Prenatal Visits Linked to Decreased Risk for Neonatal Death

Joe Barber Jr, PhD

April 12, 2013

Prenatal care packages featuring fewer physician visits may increase the risk for neonatal mortality, according to the findings of a secondary analysis of the World Health Organization Antenatal Care (WHO ANC) Trial.

Joshua P. Vogel, MBBS, from the University of Western Australia in Crawley and the World Health Organization in Geneva, Switzerland, and colleagues published their findings online April 12 in Reproductive Health.

"This paper provides sound information to guide the decisions of policymakers regarding the number of antenatal visits which should be offered with the available resources," write G. Justus Hofmeyr, MBBCh, MRCOG, from the University of the Witwatersrand/Fort Hare in Eastern Cape, South Africa, and Ellen D. Hodnett, PhD, RN, from the University of Toronto, Ontario, Canada, in a linked commentary.

"Most importantly, after a century of blind faith, this paper provides probably the first direct evidence from a randomized trial that routine antenatal visits for healthy pregnant women do make a difference."

The study authors note that a 2010 Cochrane review evaluated the effects of reduced antenatal visits using 7 trials, including the WHO ANC Trial and 2 other trials with cluster randomization. "[T]he three cluster-randomized trials consistently showed slightly higher perinatal mortality in the reduced visits group," the authors write.

In this study, the researchers performed a secondary analysis of the WHO ANC trial to determine whether reduced visits were associated with a higher risk for neonatal and/or maternal morbidity and mortality for singleton births. Using multivariate analysis adjusted for risk strata, smoking, education level, and other variables, the authors identified an increased risk for perinatal mortality associated with reduced visits (adjusted risk ratio [RR], 1.18; 95% confidence interval [CI], 1.01 - 1.37).

The increased risk for perinatal mortality appeared to be a result of the increased risk for fetal death (adjusted RR, 1.27; 95% CI, 1.03 - 1.58), which was itself potentially attributable to the increased risk for fetal death at gestational ages of 36 weeks or less (adjusted RR, 1.64; 95% CI, 1.27 - 2.11). When stratified by risk, significantly increased risks for fetal death (adjusted RR, 1.78; 95% CI, 1.33 - 2.39) and fetal death at gestational ages of 36 weeks or less (adjusted RR, 1.48; 95% CI, 1.17 - 1.89) were observed in the low-risk group, but only a significantly higher risk for fetal death at gestational ages of 36 weeks or less was noted in the high-risk group (adjusted RR, 1.56; 95% CI, 1.05 - 2.31).

An analysis of the risk for fetal death by gestational age revealed an increased risk only for 32 to 36 weeks (crude RR, 2.24; 95% CI, 1.42 - 3.53; P = .0005).

The limitations of the study included differences in visit frequency among control clinics and an inability to account for all confounders.

"It is critical to monitor maternal, fetal and neonatal indicators when implementing antenatal care protocols in any setting," the authors write. "Further research on rates of fetal death in centers using reduced antenatal care packages would also be of benefit."

Dr. Vogel received support from the Australian Postgraduate Award and the A & A Saw Scholarship. The WHO ANC Trial was supported by the United Nations Development Programme/United Nations Population Fund/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction of WHO. The study was supported by the Municipal Government, City of Rosario, Argentina; Ministry of Health, Cuba; National Institute of Public Health, Mexico; The Population Council—Regional Office for Latin America and the Caribbean; Ministry of Health, Saudi Arabia; Swedish Agency for Research Cooperation With Developing Countries; Ministry of Public Health and Faculty of Medicine, Khon Kaen University; Department for International Development, United Kingdom; Mother Care—John Snow Inc; National Institutes of Health; World Bank; University of Western Ontario; National Institute of Public Health, Norway; United Nations Development Programme; and University of Uppsala. The authors and commentators have disclosed no relevant financial relationships.

Reprod Health. Published online April 12, 2013. Article abstract, Commentary extract