Antenatal Care

1. What is the decision or change you are facing or struggling with where a summary of the evidence would be helpful?

We are interested in the relationship between the number and frequency of antenatal care visits and obstetric outcomes in uncomplicated pregnancies. Typically, for an uncomplicated pregnancy, a woman is examined every four weeks for the first 28 weeks of gestation, every two weeks until 36 weeks of gestation, and weekly thereafter (1). The currently used antenatal care pathway in the US is largely based on tradition without an evidence base. As evidence-based clinical assessments have been integrated into antenatal care (such as prenatal genetic screening, screening for gestational diabetes, anatomic ultrasound), these assessments have been "inserted" into the current traditional pathway, as opposed to having the antenatal care pathway (number and frequency of visits) determined by the indicated assessments, including education and counseling.

Questions:

1. What is the relationship between prenatal care for women with uncomplicated pregnancies and adverse outcomes?
2. What is the relationship between fewer than “routine” antenatal care visits and maternal/fetal/neonatal outcomes?
3. What is the relationship between frequency of antenatal care visits and maternal/fetal/neonatal outcomes?

Population: women with low-risk (uncomplicated) pregnancies Interventions and Comparators: "poor" or "inadequate" antenatal care versus "adequate" care, decreased and/or increased number of antenatal care visits versus routine number of antenatal care visits, alternative frequency or spacing of visits versus routine frequency or spacing of visits Outcomes: maternal morbidity, maternal mortality, fetal/neonatal morbidity and mortality, NICU, preterm birth, patient satisfaction, provider efficiency (cost, time, resources)

2. Why are you struggling with this issue?

We are struggling with this issue because current uncomplicated pregnancy guidelines regarding number and frequency of prenatal visits are very much based on tradition without a significant amount of evidence leading to a pre-determined pathway. However, emerging evidence suggests that reducing the number of prenatal visits for low-risk women in high, middle, and low-income countries does not increase adverse outcomes, with mixed findings about how it may impact patient satisfaction with care (2)(3)(4). Some studies even suggest that low-risk women with a higher than normal number of prenatal visits may have higher rates of interventions without improvement in outcomes (4). Some systems within the US, such as the Department of Defense/Veterans Administration, have already begun to successfully implement modified prenatal care visits schedule (5); this, along with an increase use of telehealth, alternative models of prenatal care, and evolving diagnostic and screening test, suggest that there is wide variation in practice.

3. What do you want to see changed? How will you know that your issue is improving or has been addressed?

We want to see recommendations for prenatal care visits in uncomplicated pregnancies become evidence based. We will know the issue has been addressed when the American College of Obstetricians and Gynecologists (ACOG) and other relevant organizations' members are provided with timely evidence-based guidance with the potential to increase efficiency and patient satisfaction in clinical care and decrease adverse obstetric outcomes.

4. When do you need the evidence report?

Thu, 10/07/2021

5. What will you do with the evidence report?

The evidence report will be used by ACOG and the Society for Maternal-Fetal Medicine (SMFM), in collaboration with several organizations representing obstetric care providers, patients, and key stakeholders, to develop a future Clinical Consensus statement with recommendations on the number and frequency of prenatal visits. Given the potential impact on patients, providers, systems, policies, and payers, it is critical that these recommendations are developed based on full review of the available evidence.

References

1. American Academy of Pediatrics, American College of Obstetricians. Guidelines for perinatal care. 8th ed. Elk Grove Village (IL): AAP; Washington, DC: American College of Obstetricians and Gynecologists; 2017.
2. Dowswell T, Carroli G, Duley L, et al. Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane Database Syst Rev. 2010;(10):CD000934. Published 2010 Oct 6. doi:10.1002/14651858.CD000934.pub2
3. Butler Tobah YS, LeBlanc A, Branda ME et al. Randomized comparison of a reduced-visit prenatal care model enhanced with remote monitoring. Am J Obstet Gynecol. 2019 Jun 19.
4. Carter EB, Tuuli MG, Caughey AB et al. Number of prenatal visits and pregnancy outcomes in low-risk women. J Perinatol. 2016 Mar; 36(3):178-181.
5. https://www.healthquality.va.gov/guidelines/WH/up/VADoDPregnancyCPG4102018.pdf

(Optional) About You

What is your role or perspective? Professional Society.