First Antenatal Appointment Analysis Paper.
Antenatal care is generally acknowledged as an effective method of preventing adverse outcomes in pregnant women and their babies, although many specific antenatal care practices have not been subject to rigorous evaluation.
Antenatal care may be broadly defined as encompassing pregnancy-related services
provided between conception and the onset of labour with the aim of improving
pregnancy outcome and/or the heath of the mother or child. This care involves a series of
assessments and appropriate treatments covering three components:
• monitoring of the health status of the woman and the fetus; First Antenatal Appointment Analysis Paper.
• provision of medical and psychosocial interventions and support;
• health promotion.
Given the context of the Infant Mortality Project, we were primarily interested in
interventions which might be implemented in the context of the NHS. We therefore
restricted the review to antenatal care interventions involving the delivery or organisation
of health or social care to pregnant women.
8 A systematic review of antenatal care programmes to reduce infant mortality and its major causes in socially disadvantaged and vulnerable women
Additionally, because we were primarily interested in interventions which might
strengthen or enhance antenatal health care, we considered ‘stand alone’ antenatal care
interventions, such as social support programmes, only where they were delivered and/or
evaluated in conjunction with some form of normal antenatal health care.
Clinical interventions, such as drug therapies (for example, to treat genito-urinary
infections, to prevent or delay labour or for fetal maturation, vitamins and nutritional
supplements have been extensively reviewed26 so were excluded unless they formed part
of a broader package of antenatal care. First Antenatal Appointment Analysis Paper.
Methadone/opiate substitution programmes were also explicitly excluded since an initial
scoping review of the literature indicated that many of the evaluations concerned the
safety of such programmes rather than their effectiveness in terms of improving infant
outcomes.
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Finally, because some interventions may be initiated pre-conceptionally but continue
through into pregnancy, and others may commence prior to the onset of labour but be
primarily concerned with labour and delivery, we explicitly excluded peri-conceptional
interventions and interventions with a focus on labour and birth.
Standard antenatal care
Our aim was to evaluate interventions against ‘standard antenatal care’ (typically involving
periodic attendance at a hospital or office based ambulatory clinic). However, because of
the range of different healthcare systems covered and the nature of some of the target
populations (e.g. substance users) we did not attempt to further define what constituted
‘standard care’: we required only that the control/comparator group received some form of
comprehensive antenatal care or a specified alternative model of comprehensive antenatal
care.
3.3 Disadvantaged and vulnerable groups
Our aim was to cover interventions targeting and/or evaluated in disadvantaged
populations at high risk of adverse perinatal outcomes, including both socioeconomically
deprived and vulnerable groups of women and specific groups such as teenagers,
women with mental illness and women with substance use problems who also suffer
disproportionately high rates of infant mortality and other adverse perinatal outcomes.4
These groups included:
a) Disadvantaged and vulnerable women:
• Disadvantaged minority ethnic/racial groups
• Women in prison
• Travellers
• Homeless women
• Asylum seekers and refugees
• Recently arrived migrants
• Other immigrant groups
• Victims of abuse
• Women living in deprived areas
• Women with mental illness/mental health problems
• Women with learning disabilities
• Sex workers
b) Specific groups with risk factors for adverse birth outcomes that are strongly
associated with social disadvantage:
• Teenagers
• Obese pregnant women
• Women who are HIV positive
• Substance users
A systematic review of antenatal care programmes to reduce infant mortality and its major causes in socially disadvantaged and vulnerable women
• Alcohol misusers
We did not include pregnant smokers as a group of interest. However, a recent Cochrane
review is available covering smoking cessation interventions during pregnancy. First Antenatal Appointment Analysis Paper.
The present pattern of routine antenatal care in the UK consists of a first
antenatal or ‘booking’ visit at around 12 weeks gestation, fol-lowed by monthly visits up to 28 weeks, fortnightly visits up to 36 weeks and weekly visits thereafter. Both the pattern and the basic content of antenatal care are largely historically determined and have not changed significantly over the years.
Observational studies suggest an association between gestational age at initiation of antenatal care and outcomes for mothers and babies.
Many antenatal screening tests, including ultrasonography for the detection of fetal anomalies and biochemical screening for neural tube defects and Down’s syndrome, take
place during the first trimester or early in the second trimester.
Women who initiate antenatal care after this time may be denied the opportunity to benefit from these screening tests. First Antenatal Appointment Analysis Paper.
The established pattern of antenatal care has been challenged and a number of randomized controlled trials of reduced
schedules of antenatal visits have been carried out. A recent
Cochrane review of these trials concluded that a reduction in the
number of routine antenatal visits by one or two could be implemented without increasing adverse outcomes for mothers and babies.
Women, however, particularly in developed countries,
might be less satisfied with their care as a result.
The reduction in the number of antenatal visits evaluated in
these trials took place in a managed way, with care provided in
response to clinical need. Evidence from Europe, the USA and
elsewhere points to a number of socio-demographic factors that
are related to late initiation of antenatal care or having fewer
antenatal visits. These include young maternal age,
7–12
non- white ethnic group,
11–15
low income,
10,14,16
, high parity,
8,9
low
level of education,
10,12,14
low socio-economic status
12,17,18
and
unmarried status. First Antenatal Appointment Analysis Paper.
12
Other financial barriers to adequate ante-
natal care, such as having no health insurance, are also influential.
7–9,11,14,18–20
Women from many of the social sub-groups
associated with poor attendance for antenatal care also have an
established increased risk of poor pregnancy outcomes.
21
These
studies do not imply a causal link between attendance for
antenatal care and outcome of pregnancy. They are evidence,
Social class, ethnicity and attendance for antenatal care in the United Kingdom:
a systematic review however, that women with socio-demographic characteristics
associated with a higher risk of poor pregnancy outcome are
more likely to initiate antenatal care late and experience a fragmented pattern of antenatal visits. First Antenatal Appointment Analysis Paper.
It is often assumed that similar factors are associated with
attendance for antenatal care in the United Kingdom. A recent
government paper setting out the priorities for the development
of the NHS over the next three years identified improving access
to antenatal care for women from disadvantaged groups as part
of the plan for reducing health inequalities.
22
However, it is not
clear how generalizable US and European studies are to the UK
context, given the differences in health care systems. We carried
out a systematic review of UK studies assessing the association
between women’s social class or ethnicity and attendance for
antenatal care.
Methods
Inclusion criteria
The review included studies assessing the association between
attendance for antenatal care and women’s social class or
ethnicity. Studies were eligible for inclusion if they provided
information on gestational age at initiation of antenatal care or
the number of antenatal visits attended or missed and analysed
this with respect to any individual or area-based measure of
social class, social deprivation or ethnic group. Only studies
carried out in the United Kingdom and published after 1979
were included. First Antenatal Appointment Analysis Paper.
Search methods
The electronic databases Medline, Cinahl, Embase, Sigle, Health
–
care Management Information Consortium (HMIC), ASLIB
Index to Theses, and the National Research Register (NRR)
were searched using terms drawn from a search strategy for a
review of inequalities in access to maternity care. Search terms
used on Medline included the text terms inequality, low near
income, barrier, poverty, socio-demographic, social near class,
socio-economic near factors or status or disadvantage and the
MeSH terms Health Services Accessibility, Social Class and
Poverty. First Antenatal Appointment Analysis Paper. These were combined with the MeSH term Prenatal Care and text terms antenatal near care and prenatal near care.
Further information on search strategies is available from
the authors on request. Databases were searched from 1980 onwards or from the start point of the database if this was later than 1980. Searches were carried out in September 2000 and updated in March 2002. National Perinatal Epidemiology Unit
databases and Maternity Alliance collections were also searched. First Antenatal Appointment Analysis Paper.
Reference lists of all included studies were checked for further
relevant studies and citation searches for included papers were
carried out on the Social Science and Science Citation Indexes
of BIDS. Community Health Councils (CHCs) and Maternity
Services Liaison Committees (MSLCs) were contacted via CHC
Listings and the MSLC newsletter to identify any relevant
unpublished studies.
Data extraction and analysis
Titles and abstracts of all identified papers were checked against
the inclusion criteria by one reviewer and classified as (a)
definitely relevant, (b) probably relevant, (c) possibly relevant,
or (d) not relevant. Where there was uncertainty about classifi-
cation, the abstracts were checked independently by a second
reviewer and any difference of opinion was resolved by discus-
sion. Full copies of papers categorized as (a), (b) and (c) were
obtained. These papers were read in full by one reviewer and
classified as included, excluded or uncertain. Papers classified as
uncertain were checked for inclusion by a second reviewer and
remaining uncertainties or differences of opinion resolved by
discussion between these two reviewers. First Antenatal Appointment Analysis Paper.
Given the likely differences between these studies, we did
not consider that a statistical synthesis of their results would be
appropriate. The characteristics and results of these studies
were therefore summarized in structured tables by one reviewer,
with statistical results reported by the authors included. Where
possible, we also calculated measures of effect size in the form of
risk ratio with 95 per cent confidence intervals.
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Results
Results of the literature search
The searches described identified over 1300 papers. Of these, 20
appeared potentially relevant and were read in full. Eight stud-
ies, reported in nine papers, met the inclusion criteria. Of the 11
excluded papers, eight reported no data comparing antenatal
attendance according to social class, or focused on attendance
in low social class women only, without comparison with other
social groups. Two papers reported only on attendance for ante-
natal education and the remaining paper reported qualitative
data only. First Antenatal Appointment Analysis Paper.
Characteristics and quality of the studies
The characteristics and results of the eight included studies
are summarized in the Table. All but one of the studies
30,31
were based on data collected between the late 1970s and the
mid-1980s. Most were simple cross-sectional studies of the
association between social class and antenatal attendance using
univariate analyses. The way of assessing antenatal attendance
varied between studies. Several studies used late booking as a
measure of attendance, with the definition of ‘late’ varying from
14 to 20 weeks gestation. Others counted the number of ante-
natal visits attended or missed. In all studies where social class
was assessed, individual measures of social class based on the
woman’s or her partner’s occupation were used. No studies
used measures of area social deprivation. Three studies gave no
information about social class but reported only on antenatal
attendance according to ethnicity.
25,28,30,31
Several of these studies were limited by small numbers of
women overall or in some comparison groups. Many studies
were poorly reported, resulting in difficulties working out how
women were selected for the study or how they were classified
according to social class or ethnicity. Details of statistical
analysis were also often poorly presented and only one study
considered the effect of potential confounders such as age,
parity and clinical risk factors by controlling for these in the
analysis.
30,31
Findings
Three out of the five studies that looked at the association
between antenatal attendance and social class found that women
from manual classes were more likely to book late for antenatal
care and/or make fewer antenatal visits than other women. First Antenatal Appointment Analysis Paper.
24,26,29
In the two remaining studies, although no significant social class
differences were found, very small numbers of women in some
groups made it difficult to assess any association.
23,27
In one of
these studies almost half the women had unemployed part-
ners.
27
This meant that there were very small numbers in some
social class groupings and no significant association between
social class and antenatal attendance was found. Women with
unemployed partners were, however, significantly more likely
to book late for antenatal care than women with partners in
employment.
Four studies reported on the association between antenatal
attendance and ethnicity.
25,27,28,30,31
All found that women of
Asian origin were more likely to book late for antenatal care
than White British women. The one study that looked at the
number of antenatal visits found that women of Pakistani origin
made significantly fewer antenatal visits than White British
women.
30
Discussion
Overall, this review highlights how little good quality evidence
there is on social inequalities in attendance for antenatal care in
the United Kingdom. The studies reviewed provided some evi-
dence of social inequalities in attendance for antenatal care in
the United Kingdom and as such do not contradict findings
from research carried out in other countries. Given the charac-
teristics of the studies, however, this evidence could only be
described as weak. All but one of the studies were based on data
collected around 15–20 years ago and used statistical approaches
that did not take into account the effect of possible confounding
factors such as age, parity and clinical risk factors. We identified
no recent good quality studies that could provide evidence on
social
inequalities in attendance for antenatal care, although the
majority of the studies reviewed suggested that women from
lower social classes were more likely to initiate care late and to
have fewer antenatal visits than more affluent women.
The evidence for an association between ethnicity and late or
poor attendance for antenatal care may be slightly stronger than
for social class. One recent good quality study suggested that
women of South Asian origin are more likely to initiate ante-
natal care later and have fewer antenatal visits. First Antenatal Appointment Analysis Paper.
30,31
This finding
was supported by three other poorer quality studies carried out
between the late 1970s and the mid-1980s.
25,27,28
Considered
alongside findings from another review carried out by us, which
suggests that South Asian women are less likely to be offered
and to receive prenatal screening, this is another indication that
there may be notable inequity in the provision of antenatal care
for these women (unpublished observations). Further studies on
the barriers to equitable access to antenatal care for women
from ethnic minority communities would be valuable. These
should focus not only on barriers from the women’s perspective,
such as language and cultural issues, but also on institutional
and professional barriers to equity in the provision of care. First Antenatal Appointment Analysis Paper.
One potential source of further evidence in this area might be
unpublished local or regional studies or analyses of routinely
collected data. We aimed to identify all relevant studies for the
systematic review, but were unable to locate any unpublished
studies. Efforts to identify these studies through searching elec-
tronic databases of ‘grey literature’ and publicizing our study in
the Community Health Council and Maternity Services Liaison
Committee newsletters were unsuccessful. It is possible, there-
fore, that the review is less than comprehensive in its coverage.
Further attempts to identify whether there are social inequal-
ities in attendance for antenatal care should focus initially on
analysis of routinely collected data on antenatal care, available
in a number of hospital maternity care datasets. One obvious
limitation of this approach, however, is that data collected for
another purpose may not be best suited to answering this
specific research question. If this were the case new data collec-
tion and research would be necessary to answer these questions.
In the first instance, any new data collection should focus
on charting women’s pathways through maternity care and
assessing whether these differ by social class or ethnicity. Data
collected should include not only gestational age at booking
and the subsequent pattern of antenatal appointments, but also
gestational age at first contact with the general practitioner
(GP) for antenatal care. As one study has suggested that con-
tinuity of carer may also be associated with social class and
language,
32
it would also be useful to collect data on type or
pattern of care and continuity of carer. Qualitative research is
also needed to provide a better understanding of why some
women book late for antenatal care or do not attend antenatal
appointments.
One further possible related area for research relates to
‘unbooked’ women. Around 1 per cent of women giving birth in
the United Kingdom do so without having had any antenatal
care. First Antenatal Appointment Analysis Paper.
33
Little is known about the socio-demographic characteris-
tics of these women, but anecdotal evidence suggests that they
may come from particularly marginalized or socially excluded
groups. An audit of women giving birth at King’s College Hos-
pital in London in 2000 without having had any antenatal care
was recently carried out.
34
This showed that almost half of these
women had had some contact with antenatal services, but had
never formally ‘booked’ for care. Overall, teenagers, single, un-
supported women, and unemployed women or women with un-
employed partners were over-represented in this group
compared with other women giving birth at the same hospital. Further
study to identify the particular problems faced by women who
have very little or no antenatal care would be valuable.
Antenatal Appointment Schedule for Normal Healthy
Women with Singleton Pregnancies
Exceptional People. Exceptional Care. First Antenatal Appointment Analysis Paper.
First Antenatal Contact with the GP
Rationale for visit – Care to include:
Obtain medical and obstetric history.
Measure BP, record height and weight and calculate BMI.
Discuss antenatal screening and testing options, including Down syndrome screening with all women irrespective of
maternal age. Order 1st trimester combined screen (nuchal translucency + PAPPa, HCG) if requested at 11+0 to 13 + 6
weeks.
Order dating scan if requests serum screening for Down syndrome (triple test done at 15-20 weeks) and presents too late
for 1st trimester combined screen.
Discuss and provide referral for the18-20 week morphology scan.
Obtain MSU for microscopy and culture. Copy result to Mater Mothers’ Hospital.
Obtain routine bloods after discussion and informed consent (FBC, blood group and antibodies, Rubella antibody titre, Hep
B, Hep C, HIV, syphilis). Please ensure that all blood results are copied to the Mater Mothers’ Hospital.
Perform Pap smear if due.
Discuss available models of care and provide leaflet.
Known Rh(D) negative women – discuss antenatal anti-D prophylaxis and the importance of seeking advice following any
potentially sensitising events.
Refer to hospital electronically / paper copy and include above information.
Document all in full in Hand Held Record (a printed computerised summary is acceptable.)
12-14 week appointment with the Midwife
Rationale for visit-Care to include:
Full booking history taken in person.
Routine antenatal assessment. Check BP and record height weight and BMI
Identify risk factors and those women requiring additional care. Consult and refer if necessary (see MMH Guidelines for
Consultation and Referral).
Confirm model of care based on MMH Guidelines for Consultation and Referral and woman’s informed choice.
Take bloods and MSU as above if not already obtained.
Dipstick urinalysis for blood, protein, nitrites and leucocytes to screen for chronic renal disease.
Check blood group result – Rh (D) negative women – discuss antenatal anti-D prophylaxis and the importance of seeking
advice following any potentially sensitising events.
If Rh (D) negative ensure 28 and 34 week anti-D appointments are booked. If GP shared care, ensure need for anti-D is
highlighted and forward appropriate letter advising of the current recommendations for anti-D prophylaxis.
Confirm that each woman understands the screening tests and answer any questions raised. If required, refer to
appropriate professional for ongoing management.
Review, discuss and document all results available. Print off results and file in chart.
Reinforce public health principles (diet, exercise, smoking cessation, domestic abuse, drug and alcohol use, social
circumstances).
Discuss parent education – invite to classes.
Discuss and plan schedule of antenatal visits with woman and complete appointment form to facilitate administration of
future appointments.
Inform about postnatal homecare and commence referral form.
Inform about dietician, social work physiotherapy services
Document in hand held and medical record
Put ID label in “named midwife” diary for timely follow up of all pathology and identified social needs.
Named midwife is responsible for obtaining all test results necessary for obstetric review, and making appropriate early
referral if necessary.
16 Weeks appointment with an Obstetrician Mater Mothers’ Hospital
Rationale for visit – Care to include:
Review results of screening tests, pathology and action as appropriate (write order for antenatal Anti D for Rh Neg
women who are not sharing care with their GP)
Initiate triple test if appropriate
Routine antenatal assessment.
Confirm EDC if information available
Obstetrician to make final recommendation regarding model of care after consideration of any risk factors.
Discuss planned schedule of antenatal visits and confirm.
Document in hand held record and medical record.
18-20 Week Morphology Ultrasound Scan followed by an appointment with the GP as soon as possible
Rationale for visit – Care to include:
Review morphology USS results and refer if necessary to Maternal Fetal Medicine or Specialist Obstetrician
Review triple test result if taken and action as appropriate
Confirm EDC if not done by obstetrician
Check placental position on 19-20 week scan and if low lying arrange a further scan for placental position at 34 weeks
gestation
Document in hand held record
24 weeks, Primigravida and Multigravida with a different partner this pregnancy
Appointment with Primary Carer (GP or Midwife)
Rationale for visit – Care to include:
Routine AN assessment.
Begin assessment of fundal height to measure fetal growth and include at each AN assessment. First Antenatal Appointment Analysis Paper.
Reinforce aspects of health promotion and parent education.
Reassess planned schedule of care and identify women who need additional care.
Midwives document in hand held record and medical record.
GPs document in hand held record
28 Week Appointment with Primary Carer (GP or Midwife)
Rationale for visit – Care to include:
Routine AN assessment as above and assessment of fetal growth and well being.
Reinforce aspects of health promotion and parent education.
Obtain blood for FBC. If Hb less than 100 for further investigation and appropriate treatment.
If Rh (D) negative, take antibody screen BEFORE offering administration of 625 IU Anti-D immunoglobulin IM.
Gestational diabetes screening offered to all women. Non-fasting 75g 1hr glucose challenge test or fasting 75g 2hr oral
glucose tolerance test if risk factors for diabetes.
Discuss infant feeding (written information has been provided at booking).
Discuss Vitamin K and Hep B vaccination (written information has been provided at booking visit).
Reassess planned schedule of care and identify women who need additional care – See MMH Guidelines for
Consultation and Referral.
Discuss & commence birth plan.
Consider discharge planning.
GPs-Document in hand held record
Midwives- Document in hand held record and medical record.
31 Week, Primigravida and Multigravida with a different partner this pregnancy
Appointment with Primary Carer (GP or Midwife)
Rationale for visit-Care to include:
Routine antenatal assessment.
Review, discuss and document results of tests taken at 28 weeks and action as required.
Reassess planned schedule of care and identify women who need additional care. See MMH Guidelines for consultation
and referral.
Discuss neonatal Vitamin K and Hep B vaccination. Obtain verbal consent and written consent if form available.
Document in hand held record and medical record.
34 Week Appointment with Primary Carer (GP or Midwife)
Rationale for visit – Care to include:
Routine antenatal assessment.
If Rh(D) negative, recommend & administer 625 IU Anti-D immunoglobulin IM.
For women not seen at 31 weeks, review as above.
Repeat ultrasound scan if low lying placenta at morphology scan
Reassess planned schedule of care and identify women who need additional care as per MMH Guidelines for
Consultation and referral.
Discuss birth plan.
GPs-Document in hand held record
Midwives- Document in hand held record and medical record.
Computerised GPs to print antenatal record summary and attach into hand held record for MMH.
36 Week Appointment with the Midwife or Obstetrician if Shared Care
Rationale for visit – Care to include:
Routine antenatal assessment. Identify and document fetal presentation.
If breech presentation discuss external cephalic version (ECV) and refer accordingly.
Reassess planned schedule of care and identify women who need additional care as per MMH Guidelines for Con and
Referral.
Obtain blood for FBC. If Hb less than 100 for further investigation and appropriate treatment.
Check follow-up ultrasound for placental position if low lying placenta at 18-20 weeks.
Review birth plan and discuss active birth / labour and pain relief, especially if has not attended parent education.
Review infant feeding discussion. First Antenatal Appointment Analysis Paper.
Attach antenatal summary from GP into medical record.
Document in hand held record and medical record.
38 Week Appointment with Primary Carer (GP or Midwife)
Rationale for visit – Care to include:
Routine antenatal assessment.
Confirm understanding of signs of labour and indications for admission to hospital.
Provide additional information as required.
GPs-Document in hand held record
Midwives- Document in hand held record and medical record.
Term – Primigravida / Multigravida with new partner
Appointment with Primary Carer (GP or Midwife)
Rationale for visit – Care to include:
Routine AN assessment.
GPs-Document in hand held record
Midwives- Document in hand held record and medical record.
Week Appointment with the Obstetrician or Midwife (MMH)
Rationale for visit – Care to include:
Routine antenatal assessment.
Ensure dates are correct. If uncertain refer for consultant opinion.
For all women who have not given birth by 41 weeks, discuss IOL and arrange as per MMH Guidelines for Consu referral
(Midwife to book IOL by T+12).
Discuss and offer membrane sweep and follow up in 2 days- Link IOL policy.
Throughout the entire antenatal period, practitioners must remain vigilant to the signs
and symptoms of conditions which affect the well being of the mother and unborn
baby.
Please note there is no conclusive evidence for the practice of weighing women at every antenatal visit as it is not a
clinically useful screening tool for the detection of growth restriction, macrosomia or pre eclampsia (Mercy Hospital
2001).
Use of dipstick measurement for routine screening of proteinuria in healthy pregnant women is not recommended (Mercy
Hospital 2001).
If midwives and doctors detect hypertension then the use of dipstick for testing urine is indicated.
If women present with urinary symptoms an MSU should be ordered
Assessment of hypertensive pregnancies requires estimation of total protein in a 24 hour collection of urine.
Blood glucose sampling has outdated glycosuria as a screening test for GDM.
Screening for Gestational Diabetes Mellitus- Routine GCT or OGTT in pregnancy is recommended between 26-28 week
gestations.
Prevention of early onset Group B Streptococcal Disease as per MMH policy
Conclusions
The findings of this review do not provide strong evidence of
social inequalities in attendance for antenatal care in the United
Kingdom. Neither do they provide any evidence to rule out the
possibility of an association between social class, ethnicity and
attendance for antenatal care. There is an apparent need for
further research in this area. First Antenatal Appointment Analysis Paper.
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