The introduction of a woman-held record into a hospital antenatal clinic: the bring your own records study. The Newbury Maternity Care Study: a randomized controlled trial to assess a policy of women holding their own obstetric records. Randomised controlled trial of a reduced-visits programme of antenatal care in Harare, Zimbabwe. A randomised controlled trial comparing two schedules of antenatal visits: the antenatal care project. Clinical, psychosocial, and economic effects of antenatal day care for three medical complications of pregnancy: a randomised controlled trial of 395 women. A group randomised trial of two methods for disseminating a smoking cessation programme to public antenatal clinics: effects on patient outcomes. Does continuity of care by well-trained breastfeeding counselors improve a mother's perception of support? Evaluation of antenatal smoking cessation programs for pregnant women. Randomised controlled trial of two antenatal care models in rural Zimbabwe.
We report the introduction of a woman-held record into an antenatal clinic in a NSW teaching hospital using a randomized controlled trial. In 1997, 150 women were randomized to either retaining their entire antenatal record through pregnancy (women-held group) or to holding a small, abbreviated card, as was standard practice (control group). A questionnaire was distributed to women to measure sense of control, involvement in care and levels of communication. Availability of records at antenatal visits was also measured. Women in both groups were satisfied with their allocated method of record keeping, however, those in the women-held group were significantly more likely to report feeling in 'control' during pregnancy. Women in the control group were more likely to feel anxious and helpless and less likely to have information on their records explained to them by their caregiver. The number of records available at each clinic was similar in both groups. To assess a policy of women holding and thus having constant access to their own obstetric records, 290 women attending a peripheral consultant clinic in Newbury, West Berkshire, were randomly allocated to hold either their full case notes, or the more usual co-operation card. Women holding their full records were significantly more likely to feel in control of their antenatal care (rate ratio 1.45; 95% confidence interval 1.08-1.95) and to feel it was easier to talk to doctors and midwives (rate ratio 1.73; 95% confidence interval 1.16-2.59). No other beneficial effects were detected. Asked about their preferences for any subsequent pregnancies, women holding their own records in the index pregnancy were more likely to say they would prefer to hold the same kind of record again in a subsequent pregnancy than were women holding a co-operation card (rate ratio 1.56; 95% confidence interval 1.34-1.81). There was no evidence of negative effects. In particular, women holding their case notes did not feel more anxious than co-operation card holders. The policy of women holding their notes resulted in savings in clerical time, without evidence of an increase in the rate of lost notes. Many of the individual components of antenatal care have been studied in randomised controlled trials, but few studies have compared whole programmes of antenatal care. Our aim was to test the hypothesis that a new programme of antenatal care with fewer goal-oriented visits would give an equivalent or better result in the outcomes associated with pregnancy and delivery.
                In a randomised clinical trial in Harare, Zimbabwe, we compared a new programme of antenatal care with the standard programme. The new programme consisted of fewer but more objectively oriented visits and fewer procedures per visit. Seven primary care clinics were randomly assigned to the two programmes-three to the standard programme and four to the new programme.
                Over a 2-year period, 15,994 women were recruited into the study at the time they booked antenatal care. 97% of the women were followed up, 9,394 who had followed the new programme, and 6,138 from clinics with the standard one. Women allocated to the new programme made, as planned, fewer visits than those in the standard programme (median 4 vs 6 visits, respectively). The proportion of antenatal referrals was also lower (13.6 vs 15.3%; odds ratio 0.87 [95% CI 0.79-0.95]) because of significantly fewer referrals for pregnancy-induced hypertension (2.5 vs 3.8%; 0.66 [0.55-0.79]). Nevertheless, there were significantly fewer labour referrals for severe hypertension or eclampsia (2.1 vs 2.6%; 0.81 [0.66-1.00]). The risk for preterm (< 37 weeks) delivery was significantly lower for women on the new programme (10.1 vs 11.5%; 0.86 [0.78-0.96]). There were no other significant differences between the programmes in other major indices of pregnancy outcome, including antenatal referrals for other causes, labour referrals, obstetric interventions, low birthweight, and perinatal and maternal mortality and morbidity.
                An antenatal care programme with fewer more objectively oriented visits can be introduced without adverse effects on the main intermediate outcome pregnancy variables. To compare the clinical and psychological effectiveness of the traditional British antenatal visit schedule (traditional care) with a reduced schedule of visits (new style care) for low risk women, together with maternal and professional satisfaction with care.
                Randomised controlled trial.
                Places in south east London providing antenatal care for women receiving shared care and planning to deliver in one of three hospitals or at home.
                2794 women at low risk fulfilling the trial's inclusion criteria between June 1993 and July 1994.
                Measures of fetal and maternal morbidity, health service use, psychosocial outcomes, and maternal and professional satisfaction.
                Pregnant women allocated to new style care had fewer day admissions (0.8 v 1.0; P=0.002) and ultrasound scans (1.6 v 1.7; P=0.003) and were less often suspected of carrying fetuses that were small for gestational age (odds ratio 0.73; 95% confidence interval 0.54 to 0.99). They also had some poorer psychosocial outcomes; for example, they were more worried about fetal wellbeing antenatally and coping with the baby postnatally, and they had more negative attitudes to their babies, both in pregnancy and postnatally. These women were also more dissatisfied with the number of visits they received (odds ratio 2.50; 2.00 to 3.11).
                Patterns of antenatal care involving fewer routine visits for women at low risk may lead to reduced psychosocial effectiveness and dissatisfaction with frequency of visits. The number of antenatal day admissions and ultrasound scans performed may also be reduced. For the variables reported, the visit schedules studied are similar in their clinical effectiveness. Uncertainty remains as to the clinical effectiveness of reduced visit schedules for rare pregnancy problems. Day care is increasingly being used for complications of pregnancy, but there is little published evidence on its efficacy. We assessed the clinical, psychosocial, and economic effects of day care for three pregnancy complications in a randomised trial of day care versus standard care on an antenatal ward.
                395 women were randomly assigned day (263) or ward (132) care in a ratio of two to one, stratified for major diagnostic categories (non-proteinuric hypertension, proteinuric hypertension, and preterm premature rupture of membranes). The research hypothesis was that for these disorders, as an alternative to admission, antenatal day care will reduce specified interventions and investigations, result in no differences in clinical outcome, lead to greater satisfaction and psychological wellbeing, and be more cost-effective. Data were collected through case-note review, self-report questionnaires (response rates 81.0% or higher) and via the hospital's financial system. Analysis was by intention to treat.
                All participants were included in the analyses. There were no differences between the groups in antenatal tests or investigations or intrapartum interventions. The total duration of antenatal care episodes was shorter in the day-care group than in the ward group (median 17 [IQR 5-9] vs 57 [35-123] h; p=0.001). Overall stay was also significantly shorter in the day-care group (mean 7.22 [SE 0.31] vs 8.53 [0.44]; p=0.014). The median number of care episodes was three (range one to 14) in the day-care group and two (one to nine) in the ward group (p=0.01). There were no statistically or clinically significant differences in maternal or perinatal outcomes. The day-care group reported greater satisfaction, with no evidence of unintended psychosocial sequelae. There was no significant difference in either average cost per patient or average cost per day of care.
                Since clinical outcomes and costs are similar, adoption by maternity services of a policy providing specified women with the choice between admission and day-unit care seems appropriate. To assess the differential effectiveness of two methods of disseminating a smoking cessation programme to public hospital antenatal clinics.
                Group randomised trial.
                22 antenatal clinics in New South Wales, Australia.
                Clinics were allocated to a simple dissemination (SD) condition (11 clinics) which received a mail-out of programme resources or to an intensive dissemination (ID) condition (11 clinics) which included the mail-out plus feedback, training, and ongoing support with midwife facilitator.
                Independent cross sectional surveys of women on a second or subsequent visit undertaken pre-dissemination and 18 months after dissemination. Outcomes were: (1) levels of smoking status assessment by clinic staff; (2) proportion of women identifying as having been smokers at their first visit who reported receiving cessation advice; (3) proportion of these women who had quit (self report and expired air carbon monoxide (CO)); and (4) smoking prevalence among all women (self report and CO).
                5849 women pre-dissemination (2374 SD, 3475 ID) and weighted sample of 5145 women post-dissemination (2302 SD, 2843 ID).
                There were no significant differences between the groups on change on any outcome. Change in either group was minimal. In the post-dissemination survey, the cessation proportions were 6.4% (SD) and 10.5% (ID).
                Relatively modest strategies for encouraging incorporation of smoking cessation activities into antenatal care were not effective in the long term. Alternative strategies should be implemented and evaluated. The findings reinforce the importance of a whole population approach to tobacco control. Social support has been shown to be greatly important for breastfeeding success. The objective of this study was to investigate if mothers who were attended by midwives and nurses specially trained in breastfeeding counseling perceived better continuity of care and emotional and informative breastfeeding support than mothers who received only routine care.
                Ten municipalities, each with an antenatal center and child health center, in southwest Sweden were randomized either to intervention or control municipalities. The intervention included a process-oriented training in breastfeeding counseling and continuity of care at the antenatal and child health centers. Primiparas were asked to evaluate the care given, and those living in the control municipalities were divided into control groups A and B. Data collection took place at different points in time for the two control groups. The 540 mothers responded to 3 questionnaires at 3 days and at 3 and 9 months postpartum. The perception of support provided by the health professionals and from the family classes was rated on Likert scales.
                Intervention group mothers rated the breastfeeding information given during the family class as significantly better during pregnancy than both control groups, and better than control group B mothers at 3 months postpartum; compared with both control groups, intervention group mothers perceived that they received significantly better overall support and that postnatal nurses provided better information about breastfeeding and the baby's needs. At 9 months, intervention group mothers were more satisfied with knowledge about social rights, information about the baby's needs, and their social network than control group B mothers. Both intervention group and control group B mothers perceived better overall support than control group A during pregnancy. At 3 and 9 months, intervention group mothers perceived that postnatal nurses were more sensitive and understanding compared with both control groups.
                After implementation of a process-oriented breastfeeding training program for antenatal midwives and postnatal nurses that included an intervention guaranteeing continuity of care, the mothers were more satisfied with emotional and informative support during the first 9 months postpartum. The results lend support to family classes incorporating continuity of care. Smoking during pregnancy has been linked to health problems, including the risk of low birthweight, preterm labour, spontaneous abortion and perinatal death. Two trials to investigate the efficacy of self-help materials were undertaken. During the first trial, a self-help booklet developed overseas was evaluated through a randomised controlled design to determine the effects of the booklet alone, compared with the booklet with midwife counselling for the women. We recruited 217 women into the study and followed them up at 20 weeks' gestation to ascertain smoking cessation and to measure process variables. Smoking cessation rates were lower than expected, and process measures indicated that materials were not being used. A second trial was commenced after a comprehensive review of the materials with focus groups of pregnant women and one-to-one interviews of nurses and doctors. Trial 2 was based new materials, and used a magazine-style (smoking cessation) booklet designed by the focus groups. A total of 119 women were randomly allocated into the new-materials group or a usual-care group. The materials were well received, relevant and pertinent, and were used by the women. Smoking cessation rates at 20 weeks' gestation were biochemically validated and indicated that 9 per cent in the intervention group and none in the usual-care group had stopped smoking. The use of overseas programs needs to be approached with caution. To compare a five-visit antenatal care (ANC) model with specified goals with the standard model in a rural area in Zimbabwe.
                Cluster randomised controlled trial with the clinic as the randomisation unit.
                Primary care setting in a developing country where care was provided by nurse-midwives.
                Women booking for ANC in the clinics were eligible.
                Number of antenatal visits, antepartum and intrapartum referrals, utilization of health centre for delivery and perinatal outcomes.
                Twenty-three rural health centres were stratified prior to random allocation to the new (n = 11) or standard (n = 12) model of care.
                We recruited 13,517 women (new, n = 6897 and standard, n = 6620) in the study, and 78% (10,572) of their pregnancy records were retrieved. There was no difference in median maternal age, parity and gestational age at booking between women in the standard model and those in the new model. The median number of visits was four for both models. The proportion of women with five or less visits was 77% in the new and 69% in the standard model (OR 1.5; 95% CI 1.08-2.2). The likelihood of haemoglobin testing was higher in the new model (OR 2.4; 95% CI 1.0-5.7) but unchanged for syphilis testing. There were fewer intrapartum transfers (5.4 versus 7.9% [OR 0.66; 95% CI 0.44-0.98]) in the new model but no difference in antepartum or postpartum transfers. There was no difference in rates of preterm delivery or low birthweight. The perinatal mortality was 25/1000 in standard model and 28/1000 in new model.
                In Gutu district, a focused five-visit schedule did not change the number of contacts but was more effective as expressed by increased adherence to procedures and better use of institutional health care.
The three trials are small, and not all of them reported on all outcomes. The results suggest that there are both potential benefits (increased maternal control and satisfaction during pregnancy, increased availability of antenatal records during hospital attendance) and harms (more operative deliveries). Importantly, all of the trials report that more women in the case notes group would prefer to hold their antenatal records in another pregnancy. There is insufficient evidence on health related behaviours (smoking and breastfeeding) and clinical outcomes. It is important to emphasise that this review shows a lack of evidence of benefit rather than evidence of no benefit.