Antenatal care packages with reduced visits and perinatal mortality: a secondary analysis of the WHO Antenatal Care Trial
Identifieur interne : 001521 ( Pmc/Curation ); précédent : 001520; suivant : 001522Antenatal care packages with reduced visits and perinatal mortality: a secondary analysis of the WHO Antenatal Care Trial
Auteurs : Joshua P. Vogel [Australie, Suisse] ; Ndema Abu Habib [Suisse] ; João Paulo Souza [Suisse] ; A Metin Gülmezoglu [Suisse] ; Therese Dowswell [Royaume-Uni] ; Guillermo Carroli [Argentine] ; Hassan S. Baaqeel [Arabie saoudite] ; Pisake Lumbiganon [Thaïlande] ; Gilda Piaggio [France] ; Olufemi T. Oladapo [Nigeria]Source :
- Reproductive Health [ 1742-4755 ] ; 2013.
Abstract
In 2001, the WHO Antenatal Care Trial (WHOACT) concluded that an antenatal care package of evidence-based screening, therapeutic interventions and education across four antenatal visits for low-risk women was not inferior to standard antenatal care and may reduce cost. However, an updated Cochrane review in 2010 identified an increased risk of perinatal mortality of borderline statistical significance in three cluster-randomized trials (including the WHOACT) in developing countries. We conducted a secondary analysis of the WHOACT data to determine the relationship between the reduced visits, goal-oriented antenatal care package and perinatal mortality.
Exploratory analyses were conducted to assess the effect of baseline risk and timing of perinatal death. Women were stratified by baseline risk to assess differences between intervention and control groups. We used linear modeling and Poisson regression to determine the relative risk of fetal death, neonatal death and perinatal mortality by gestational age.
12,568 women attended the 27 intervention clinics and 11,958 women attended the 26 control clinics. 6,160 women were high risk and 18,365 women were low risk. There were 161 fetal deaths (1.4%) in the intervention group compared to 119 fetal deaths in the control group (1.1%) with an increased overall adjusted relative risk of fetal death (Adjusted RR 1.27; 95% CI 1.03, 1.58). This was attributable to an increased relative risk of fetal death between 32 and 36 weeks of gestation (Adjusted RR 2.24; 95% CI 1.42, 3.53) which was statistically significant for high and low risk groups.
It is plausible the increased risk of fetal death between 32 and 36 weeks gestation could be due to reduced number of visits, however heterogeneity in study populations or differences in quality of care and timing of visits could also be playing a role. Monitoring maternal, fetal and neonatal outcomes when implementing antenatal care protocols is essential. Implementing reduced visit antenatal care packages demands careful monitoring of maternal and perinatal outcomes, especially fetal death.
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DOI: 10.1186/1742-4755-10-19
PubMed: 23577700
PubMed Central: 3637102
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Vogel</name><affiliation wicri:level="1"><nlm:aff id="I1">School of Population Health, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, 35 Stirling Highway, Crawley, 6009, Australia</nlm:aff><country xml:lang="fr">Australie</country><wicri:regionArea>School of Population Health, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, 35 Stirling Highway, Crawley, 6009</wicri:regionArea></affiliation><affiliation wicri:level="1"><nlm:aff id="I2">UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, CH-1211, Switzerland</nlm:aff><country xml:lang="fr">Suisse</country><wicri:regionArea>UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, CH-1211</wicri:regionArea></affiliation></author><author><name sortKey="Habib, Ndema Abu" sort="Habib, Ndema Abu" uniqKey="Habib N" first="Ndema Abu" last="Habib">Ndema Abu Habib</name><affiliation wicri:level="1"><nlm:aff id="I2">UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, CH-1211, Switzerland</nlm:aff><country xml:lang="fr">Suisse</country><wicri:regionArea>UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, CH-1211</wicri:regionArea></affiliation></author><author><name sortKey="Souza, Joao Paulo" sort="Souza, Joao Paulo" uniqKey="Souza J" first="João Paulo" last="Souza">João Paulo Souza</name><affiliation wicri:level="1"><nlm:aff id="I2">UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, CH-1211, Switzerland</nlm:aff><country xml:lang="fr">Suisse</country><wicri:regionArea>UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, CH-1211</wicri:regionArea></affiliation></author><author><name sortKey="Gulmezoglu, A Metin" sort="Gulmezoglu, A Metin" uniqKey="Gulmezoglu A" first="A Metin" last="Gülmezoglu">A Metin Gülmezoglu</name><affiliation wicri:level="1"><nlm:aff id="I2">UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, CH-1211, Switzerland</nlm:aff><country xml:lang="fr">Suisse</country><wicri:regionArea>UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, CH-1211</wicri:regionArea></affiliation></author><author><name sortKey="Dowswell, Therese" sort="Dowswell, Therese" uniqKey="Dowswell T" first="Therese" last="Dowswell">Therese Dowswell</name><affiliation wicri:level="1"><nlm:aff id="I3">Department of Women’s Health, University of Liverpool, Liverpool Women’s Hospital, Crown Street, Liverpool 8, UK</nlm:aff><country xml:lang="fr">Royaume-Uni</country><wicri:regionArea>Department of Women’s Health, University of Liverpool, Liverpool Women’s Hospital, Crown Street, Liverpool 8</wicri:regionArea></affiliation></author><author><name sortKey="Carroli, Guillermo" sort="Carroli, Guillermo" uniqKey="Carroli G" first="Guillermo" last="Carroli">Guillermo Carroli</name><affiliation wicri:level="1"><nlm:aff id="I4">Centro Rosarino de Estudios Perinatales (CREP), Moreno 878, Rosario, 2000, Argentina</nlm:aff><country xml:lang="fr">Argentine</country><wicri:regionArea>Centro Rosarino de Estudios Perinatales (CREP), Moreno 878, Rosario, 2000</wicri:regionArea></affiliation></author><author><name sortKey="Baaqeel, Hassan S" sort="Baaqeel, Hassan S" uniqKey="Baaqeel H" first="Hassan S" last="Baaqeel">Hassan S. Baaqeel</name><affiliation wicri:level="1"><nlm:aff id="I5">King Saud bin Abdulaziz University for Health Sciences, College of Medicine, Jeddah, 21423, Saudi Arabia</nlm:aff><country xml:lang="fr">Arabie saoudite</country><wicri:regionArea>King Saud bin Abdulaziz University for Health Sciences, College of Medicine, Jeddah, 21423</wicri:regionArea></affiliation></author><author><name sortKey="Lumbiganon, Pisake" sort="Lumbiganon, Pisake" uniqKey="Lumbiganon P" first="Pisake" last="Lumbiganon">Pisake Lumbiganon</name><affiliation wicri:level="1"><nlm:aff id="I6">Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand</nlm:aff><country xml:lang="fr">Thaïlande</country><wicri:regionArea>Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002</wicri:regionArea></affiliation></author><author><name sortKey="Piaggio, Gilda" sort="Piaggio, Gilda" uniqKey="Piaggio G" first="Gilda" last="Piaggio">Gilda Piaggio</name><affiliation wicri:level="1"><nlm:aff id="I7">Statistika Consultoria, São Paulo, Brazil, Divonne-les-Bains, France</nlm:aff><country xml:lang="fr">France</country><wicri:regionArea>Statistika Consultoria, São Paulo, Brazil, Divonne-les-Bains</wicri:regionArea></affiliation></author><author><name sortKey="Oladapo, Olufemi T" sort="Oladapo, Olufemi T" uniqKey="Oladapo O" first="Olufemi T" last="Oladapo">Olufemi T. Oladapo</name><affiliation wicri:level="1"><nlm:aff id="I8">Department of Obstetrics and Gynaecology, Olabisi Onabanjo University Teaching Hospital, Sagamu, P.M.B. 2001, Nigeria</nlm:aff><country xml:lang="fr">Nigeria</country><wicri:regionArea>Department of Obstetrics and Gynaecology, Olabisi Onabanjo University Teaching Hospital, Sagamu, P.M.B. 2001</wicri:regionArea></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">23577700</idno><idno type="pmc">3637102</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3637102</idno><idno type="RBID">PMC:3637102</idno><idno type="doi">10.1186/1742-4755-10-19</idno><date when="2013">2013</date><idno type="wicri:Area/Pmc/Corpus">001661</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">001661</idno><idno type="wicri:Area/Pmc/Curation">001521</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Curation">001521</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Antenatal care packages with reduced visits and perinatal mortality: a secondary analysis of the WHO Antenatal Care Trial</title><author><name sortKey="Vogel, Joshua P" sort="Vogel, Joshua P" uniqKey="Vogel J" first="Joshua P" last="Vogel">Joshua P. Vogel</name><affiliation wicri:level="1"><nlm:aff id="I1">School of Population Health, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, 35 Stirling Highway, Crawley, 6009, Australia</nlm:aff><country xml:lang="fr">Australie</country><wicri:regionArea>School of Population Health, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, 35 Stirling Highway, Crawley, 6009</wicri:regionArea></affiliation><affiliation wicri:level="1"><nlm:aff id="I2">UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, CH-1211, Switzerland</nlm:aff><country xml:lang="fr">Suisse</country><wicri:regionArea>UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, CH-1211</wicri:regionArea></affiliation></author><author><name sortKey="Habib, Ndema Abu" sort="Habib, Ndema Abu" uniqKey="Habib N" first="Ndema Abu" last="Habib">Ndema Abu Habib</name><affiliation wicri:level="1"><nlm:aff id="I2">UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, CH-1211, Switzerland</nlm:aff><country xml:lang="fr">Suisse</country><wicri:regionArea>UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, CH-1211</wicri:regionArea></affiliation></author><author><name sortKey="Souza, Joao Paulo" sort="Souza, Joao Paulo" uniqKey="Souza J" first="João Paulo" last="Souza">João Paulo Souza</name><affiliation wicri:level="1"><nlm:aff id="I2">UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, CH-1211, Switzerland</nlm:aff><country xml:lang="fr">Suisse</country><wicri:regionArea>UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, CH-1211</wicri:regionArea></affiliation></author><author><name sortKey="Gulmezoglu, A Metin" sort="Gulmezoglu, A Metin" uniqKey="Gulmezoglu A" first="A Metin" last="Gülmezoglu">A Metin Gülmezoglu</name><affiliation wicri:level="1"><nlm:aff id="I2">UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, CH-1211, Switzerland</nlm:aff><country xml:lang="fr">Suisse</country><wicri:regionArea>UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, CH-1211</wicri:regionArea></affiliation></author><author><name sortKey="Dowswell, Therese" sort="Dowswell, Therese" uniqKey="Dowswell T" first="Therese" last="Dowswell">Therese Dowswell</name><affiliation wicri:level="1"><nlm:aff id="I3">Department of Women’s Health, University of Liverpool, Liverpool Women’s Hospital, Crown Street, Liverpool 8, UK</nlm:aff><country xml:lang="fr">Royaume-Uni</country><wicri:regionArea>Department of Women’s Health, University of Liverpool, Liverpool Women’s Hospital, Crown Street, Liverpool 8</wicri:regionArea></affiliation></author><author><name sortKey="Carroli, Guillermo" sort="Carroli, Guillermo" uniqKey="Carroli G" first="Guillermo" last="Carroli">Guillermo Carroli</name><affiliation wicri:level="1"><nlm:aff id="I4">Centro Rosarino de Estudios Perinatales (CREP), Moreno 878, Rosario, 2000, Argentina</nlm:aff><country xml:lang="fr">Argentine</country><wicri:regionArea>Centro Rosarino de Estudios Perinatales (CREP), Moreno 878, Rosario, 2000</wicri:regionArea></affiliation></author><author><name sortKey="Baaqeel, Hassan S" sort="Baaqeel, Hassan S" uniqKey="Baaqeel H" first="Hassan S" last="Baaqeel">Hassan S. Baaqeel</name><affiliation wicri:level="1"><nlm:aff id="I5">King Saud bin Abdulaziz University for Health Sciences, College of Medicine, Jeddah, 21423, Saudi Arabia</nlm:aff><country xml:lang="fr">Arabie saoudite</country><wicri:regionArea>King Saud bin Abdulaziz University for Health Sciences, College of Medicine, Jeddah, 21423</wicri:regionArea></affiliation></author><author><name sortKey="Lumbiganon, Pisake" sort="Lumbiganon, Pisake" uniqKey="Lumbiganon P" first="Pisake" last="Lumbiganon">Pisake Lumbiganon</name><affiliation wicri:level="1"><nlm:aff id="I6">Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand</nlm:aff><country xml:lang="fr">Thaïlande</country><wicri:regionArea>Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002</wicri:regionArea></affiliation></author><author><name sortKey="Piaggio, Gilda" sort="Piaggio, Gilda" uniqKey="Piaggio G" first="Gilda" last="Piaggio">Gilda Piaggio</name><affiliation wicri:level="1"><nlm:aff id="I7">Statistika Consultoria, São Paulo, Brazil, Divonne-les-Bains, France</nlm:aff><country xml:lang="fr">France</country><wicri:regionArea>Statistika Consultoria, São Paulo, Brazil, Divonne-les-Bains</wicri:regionArea></affiliation></author><author><name sortKey="Oladapo, Olufemi T" sort="Oladapo, Olufemi T" uniqKey="Oladapo O" first="Olufemi T" last="Oladapo">Olufemi T. Oladapo</name><affiliation wicri:level="1"><nlm:aff id="I8">Department of Obstetrics and Gynaecology, Olabisi Onabanjo University Teaching Hospital, Sagamu, P.M.B. 2001, Nigeria</nlm:aff><country xml:lang="fr">Nigeria</country><wicri:regionArea>Department of Obstetrics and Gynaecology, Olabisi Onabanjo University Teaching Hospital, Sagamu, P.M.B. 2001</wicri:regionArea></affiliation></author></analytic><series><title level="j">Reproductive Health</title><idno type="eISSN">1742-4755</idno><imprint><date when="2013">2013</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec><title>Background</title><p>In 2001, the WHO Antenatal Care Trial (WHOACT) concluded that an antenatal care package of evidence-based screening, therapeutic interventions and education across four antenatal visits for low-risk women was not inferior to standard antenatal care and may reduce cost. However, an updated Cochrane review in 2010 identified an increased risk of perinatal mortality of borderline statistical significance in three cluster-randomized trials (including the WHOACT) in developing countries. We conducted a secondary analysis of the WHOACT data to determine the relationship between the reduced visits, goal-oriented antenatal care package and perinatal mortality.</p></sec><sec><title>Methods</title><p>Exploratory analyses were conducted to assess the effect of baseline risk and timing of perinatal death. Women were stratified by baseline risk to assess differences between intervention and control groups. We used linear modeling and Poisson regression to determine the relative risk of fetal death, neonatal death and perinatal mortality by gestational age.</p></sec><sec><title>Results</title><p>12,568 women attended the 27 intervention clinics and 11,958 women attended the 26 control clinics. 6,160 women were high risk and 18,365 women were low risk. There were 161 fetal deaths (1.4%) in the intervention group compared to 119 fetal deaths in the control group (1.1%) with an increased overall adjusted relative risk of fetal death (Adjusted RR 1.27; 95% CI 1.03, 1.58). This was attributable to an increased relative risk of fetal death between 32 and 36 weeks of gestation (Adjusted RR 2.24; 95% CI 1.42, 3.53) which was statistically significant for high and low risk groups.</p></sec><sec><title>Conclusion</title><p>It is plausible the increased risk of fetal death between 32 and 36 weeks gestation could be due to reduced number of visits, however heterogeneity in study populations or differences in quality of care and timing of visits could also be playing a role. Monitoring maternal, fetal and neonatal outcomes when implementing antenatal care protocols is essential. Implementing reduced visit antenatal care packages demands careful monitoring of maternal and perinatal outcomes, especially fetal death.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Clement, S" uniqKey="Clement S">S Clement</name></author><author><name sortKey="Candy, B" uniqKey="Candy B">B Candy</name></author><author><name sortKey="Sikorski, J" uniqKey="Sikorski J">J Sikorski</name></author><author><name sortKey="Wilson, J" uniqKey="Wilson J">J Wilson</name></author><author><name sortKey="Smeeton, N" uniqKey="Smeeton N">N Smeeton</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Binstock, M" uniqKey="Binstock M">M Binstock</name></author><author><name sortKey="Woldetsadik, G" uniqKey="Woldetsadik G">G Woldetsadik</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Mcduffie, R" uniqKey="Mcduffie R">R Mcduffie</name></author><author><name 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<front><journal-meta><journal-id journal-id-type="nlm-ta">Reprod Health</journal-id><journal-id journal-id-type="iso-abbrev">Reprod Health</journal-id><journal-title-group><journal-title>Reproductive Health</journal-title></journal-title-group><issn pub-type="epub">1742-4755</issn><publisher><publisher-name>BioMed Central</publisher-name></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">23577700</article-id><article-id pub-id-type="pmc">3637102</article-id><article-id pub-id-type="publisher-id">1742-4755-10-19</article-id><article-id pub-id-type="doi">10.1186/1742-4755-10-19</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research</subject></subj-group></article-categories><title-group><article-title>Antenatal care packages with reduced visits and perinatal mortality: a secondary analysis of the WHO Antenatal Care Trial</article-title></title-group><contrib-group><contrib contrib-type="author" corresp="yes" id="A1"><name><surname>Vogel</surname><given-names>Joshua P</given-names></name><xref ref-type="aff" rid="I1">1</xref><xref ref-type="aff" rid="I2">2</xref><email>vogeljo@who.int</email></contrib><contrib contrib-type="author" id="A2"><name><surname>Habib</surname><given-names>Ndema Abu</given-names></name><xref ref-type="aff" rid="I2">2</xref><email>habibn@who.int</email></contrib><contrib contrib-type="author" id="A3"><name><surname>Souza</surname><given-names>João Paulo</given-names></name><xref ref-type="aff" rid="I2">2</xref><email>souzaj@who.int</email></contrib><contrib contrib-type="author" id="A4"><name><surname>Gülmezoglu</surname><given-names>A Metin</given-names></name><xref ref-type="aff" rid="I2">2</xref><email>gulmezoglum@who.int</email></contrib><contrib contrib-type="author" id="A5"><name><surname>Dowswell</surname><given-names>Therese</given-names></name><xref ref-type="aff" rid="I3">3</xref><email>T.Dowswell@Liverpool.ac.uk</email></contrib><contrib contrib-type="author" id="A6"><name><surname>Carroli</surname><given-names>Guillermo</given-names></name><xref ref-type="aff" rid="I4">4</xref><email>gcarroli@crep.org.ar</email></contrib><contrib contrib-type="author" id="A7"><name><surname>Baaqeel</surname><given-names>Hassan S</given-names></name><xref ref-type="aff" rid="I5">5</xref><email>baaqeelhs@ngha.med.sa</email></contrib><contrib contrib-type="author" id="A8"><name><surname>Lumbiganon</surname><given-names>Pisake</given-names></name><xref ref-type="aff" rid="I6">6</xref><email>pisake@kku.ac.th</email></contrib><contrib contrib-type="author" id="A9"><name><surname>Piaggio</surname><given-names>Gilda</given-names></name><xref ref-type="aff" rid="I7">7</xref><email>gilda.piaggio@gmail.com</email></contrib><contrib contrib-type="author" id="A10"><name><surname>Oladapo</surname><given-names>Olufemi T</given-names></name><xref ref-type="aff" rid="I8">8</xref><email>tixon_y2k@hotmail.com</email></contrib></contrib-group><aff id="I1"><label>1</label>School of Population Health, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, 35 Stirling Highway, Crawley, 6009, Australia</aff><aff id="I2"><label>2</label>UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, CH-1211, Switzerland</aff><aff id="I3"><label>3</label>Department of Women’s Health, University of Liverpool, Liverpool Women’s Hospital, Crown Street, Liverpool 8, UK</aff><aff id="I4"><label>4</label>Centro Rosarino de Estudios Perinatales (CREP), Moreno 878, Rosario, 2000, Argentina</aff><aff id="I5"><label>5</label>King Saud bin Abdulaziz University for Health Sciences, College of Medicine, Jeddah, 21423, Saudi Arabia</aff><aff id="I6"><label>6</label>Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand</aff><aff id="I7"><label>7</label>Statistika Consultoria, São Paulo, Brazil, Divonne-les-Bains, France</aff><aff id="I8"><label>8</label>Department of Obstetrics and Gynaecology, Olabisi Onabanjo University Teaching Hospital, Sagamu, P.M.B. 2001, Nigeria</aff><pub-date pub-type="collection"><year>2013</year></pub-date><pub-date pub-type="epub"><day>12</day><month>4</month><year>2013</year></pub-date><volume>10</volume><fpage>19</fpage><lpage>19</lpage><history><date date-type="received"><day>30</day><month>1</month><year>2013</year></date><date date-type="accepted"><day>18</day><month>2</month><year>2013</year></date></history><permissions><copyright-statement>Copyright © 2013 Vogel et al.; licensee BioMed Central Ltd.</copyright-statement><copyright-year>2013</copyright-year><copyright-holder>Vogel et al.; licensee BioMed Central Ltd.</copyright-holder><license license-type="open-access" xlink:href="http://creativecommons.org/licenses/by/2.0"><license-p>This is an Open Access article distributed under the terms of the Creative Commons Attribution License (<ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/2.0">http://creativecommons.org/licenses/by/2.0</ext-link>), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</license-p></license></permissions><self-uri xlink:href="http://www.reproductive-health-journal.com/content/10/1/19"></self-uri><abstract><sec><title>Background</title><p>In 2001, the WHO Antenatal Care Trial (WHOACT) concluded that an antenatal care package of evidence-based screening, therapeutic interventions and education across four antenatal visits for low-risk women was not inferior to standard antenatal care and may reduce cost. However, an updated Cochrane review in 2010 identified an increased risk of perinatal mortality of borderline statistical significance in three cluster-randomized trials (including the WHOACT) in developing countries. We conducted a secondary analysis of the WHOACT data to determine the relationship between the reduced visits, goal-oriented antenatal care package and perinatal mortality.</p></sec><sec><title>Methods</title><p>Exploratory analyses were conducted to assess the effect of baseline risk and timing of perinatal death. Women were stratified by baseline risk to assess differences between intervention and control groups. We used linear modeling and Poisson regression to determine the relative risk of fetal death, neonatal death and perinatal mortality by gestational age.</p></sec><sec><title>Results</title><p>12,568 women attended the 27 intervention clinics and 11,958 women attended the 26 control clinics. 6,160 women were high risk and 18,365 women were low risk. There were 161 fetal deaths (1.4%) in the intervention group compared to 119 fetal deaths in the control group (1.1%) with an increased overall adjusted relative risk of fetal death (Adjusted RR 1.27; 95% CI 1.03, 1.58). This was attributable to an increased relative risk of fetal death between 32 and 36 weeks of gestation (Adjusted RR 2.24; 95% CI 1.42, 3.53) which was statistically significant for high and low risk groups.</p></sec><sec><title>Conclusion</title><p>It is plausible the increased risk of fetal death between 32 and 36 weeks gestation could be due to reduced number of visits, however heterogeneity in study populations or differences in quality of care and timing of visits could also be playing a role. Monitoring maternal, fetal and neonatal outcomes when implementing antenatal care protocols is essential. Implementing reduced visit antenatal care packages demands careful monitoring of maternal and perinatal outcomes, especially fetal death.</p></sec></abstract><kwd-group><kwd>Antenatal care</kwd><kwd>Perinatal mortality</kwd><kwd>WHO</kwd><kwd>Developing country</kwd></kwd-group></article-meta></front></pmc></record>Pour manipuler ce document sous Unix (Dilib)
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