Clinical, provider and sociodemographic determinants of the number of antenatal visits in England and Wales
Introduction
Every year over 650,000 pregnant women in England and Wales receive some form of antenatal care (Office of Population Censuses and Surveys, 1996). This can be defined as the care of pregnant women by one or more professional group including obstetricians, midwives and general practitioners. Its purpose is to monitor the health of pregnant women and their unborn babies, advise, educate, reassure and provide treatment if appropriate. Antenatal care is still considered essential to the health of mother and baby. However, many current antenatal care practices are not evidence-based. Current provision has arisen historically and does not necessarily reflect the needs of the population (Oakley, 1982).
In the 1920s, Dame Janet Campbell introduced a fixed pattern of antenatal visits, with women being seen every four weeks until the 28th week of pregnancy, every two weeks until the 36th week and weekly thereafter. A higher standard of living, better education and wider reproductive choice means that women, in general, have less obstetric risk than previously. Hall, Chng & MacGillivray (1980) questioned established patterns of antenatal care and recommended a new pattern of eight routine visits for ‘normal’ primiparae and five for normal multiparae. However, this view has not gone unchallenged. Concern has been expressed that fewer antenatal visits may cause a delay in the detection of pregnancy-induced hypertensive disease, with its significant risks to mother and baby (Redman, 1982). Whilst routine antenatal screening for hypertensive disorders before 28 weeks gestation may have a low productivity in terms of the number of positive diagnoses per visit, it has great potential in terms of prevention of maternal and fetal morbidity and mortality (Wallenburg, 1989).
Five prospective randomised controlled trials have compared a reduced schedule of antenatal visits with an existing schedule (Binstock & Wolde-Tsadik, 1995; McDuffie, Beck, Bischoff, Cross & Orleans, 1996; Munjanja, Lindmark & Nystrom, 1996; Sikorski, Wilson, Clement, Das & Smeeton, 1996; Walker & Koniak-Griffin, 1997). A recent systematic review of these trials (Khan-Neelofur, Gulmezoglu & Villar, 1998) revealed that no significant differences were observed in the two arms of the trials when low birthweight, small for gestational age, caesarean section, induction of labour, antepartum haemorrhage and postpartum haemorrhage were considered as outcome measures. The trials provided conflicting evidence concerning the impact of a reduced schedule of antenatal visits on preterm delivery. Three of the trials demonstrated a tendency towards an increased rate of preterm delivery in the reduced schedule group (Binstock & Wolde-Tsadik, 1995; McDuffie et al., 1996; Walker & Koniak-Griffin, 1997). Conversely, the largest trial, which was conducted in Harare, Zimbabwe (Munjanja et al., 1996), demonstrated a statistically significant reduction in preterm delivery in the reduced schedule group (relative risk=0.88, 95% confidence interval=0.80, 0.96). When perception of care was addressed, Sikorski et al. (1996) showed that women tend to be more dissatisfied with fewer antenatal visits as a result of increased worries about fetal well-being. Three trials also revealed the widespread dissatisfaction with the quality of reduced visiting schedules (Binstock & Wolde-Tsadik, 1995; McDuffie et al., 1996; Sikorski et al., 1996).
During the 1990s, greater emphasis has been placed on woman-centred care. Both the Changing Childbirth Report (Department of Health, England and Wales, 1993) and the report by the Audit Commission (Audit Commission, 1997) recommended that antenatal care should be tailored to meet the specific needs of women. The report by the Audit Commission, in addition, emphasised the need for antenatal care to be cost-effective and postulated that £10 million of savings could be made if antenatal care in England and Wales reflected the needs of women rather than historically-determined patterns.
In order to tailor antenatal care to the specific needs of women, a clearer understanding is required of the factors that currently influence the care delivery process. The limited evidence that is available suggests that the level of antenatal care may be influenced by a range of clinical and non-clinical factors (Tucker et al., 1994; Sanders, Somerset, Jewell & Sharp, 1999). The study reported in this paper uses a recently collected data set to identify, for the first time, the independent effects of clinical factors and non-clinical factors, such as provider and sociodemographic characteristics, on the number of antenatal visits in England and Wales. In so doing, it illustrates the dynamics involved in the delivery and consumption of antenatal care, and highlights specific problems that may need to be tackled if a woman-centred approach to care is to be achieved.
Section snippets
Data
This study uses the data from a survey of the secondary case records of antenatal care resources consumed by women (Vause & Maresh, 1999). The women in the survey attended one of nine maternity units in Northern England and North Wales selected within those areas to reflect geographical variations, as well as variations in the size and teaching status of the institution. The maternity units delivered between 200 and 6000 women annually. Care was taken to ensure that different management
Characteristics of women
A total of 20,771 women were included in the survey. An analysis of basic obstetric data revealed that women whose notes were missing, and therefore not included in the survey, did not experience more complicated pregnancies. Among women included in the survey, the mean concordance rate for the cases on which double-data entry was performed was 94.6%, with a mean number of 186 data items per case. All analyses were based on the 17,978 women for whom a complete record of antenatal care was
Discussion
This is the first study, to our knowledge, that examines the influence of clinical, provider and sociodemographic factors on the number of antenatal visits made by women in England and Wales. Although clinical criteria used to define the risk status of women had a considerable impact upon the number of antenatal visits, this study suggests a prominent role for provider and sociodemographic factors. The type of hospital at booking, the planned pattern of antenatal care, changes in care plans,
Acknowledgements
We would like to thank the staff and patients of the hospitals involved in the survey. The participating hospitals were: Airedale Hospital, Bradford Royal Infirmary, Corbar Maternity Unit in Buxton, Glan Clwyd Hospital, North Manchester General Hospital, North Staffordshire Hospital, Northern General Hospital in Sheffield, Penrith Maternity Hospital, and Stepping Hill Hospital in Stockport. We would also like to thank Peter Brocklehurst, Leslie Davidson and Jo Garcia for their comments on
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