literature review on antenatal care

What are the essential components of antenatal care? A systematic review of the literature and development of signal functions to guide monitoring and evaluation

Affiliations.

1 Centre for Maternal and Newborn Health, Liverpool School of Tropical Medicine, Liverpool, UK.
2 The Global Fund for Aids Tuberculosis and Malaria, Geneva, Switzerland.
3 Department of Government, Health and Not for Profit, SDA Bocconi School of Management, Bocconi University, Milan, Italy.
PMID: 34839568
DOI: 10.1111/1471-0528.17029

Background: Antenatal care (ANC) is one of the key care packages required to reduce global maternal and perinatal mortality and morbidity.

Objectives: To identify the essential components of ANC and develop signal functions.

Search strategy: MESH headings for databases including Cinahl, Cochrane, Global Health, Medline, PubMed and Web of Science.

Selection criteria: Papers and reports on content of ANC published from 2000 to 2020.

Data collection and analysis: Narrative synthesis of data and development of signal function through 7 consensus-building workshops with 184 stakeholders.

Main results: A total of 221 papers and reports are included from which 28 essential components of ANC were extracted and used to develop 15 signal functions with the equipment, medication and consumables required for implementation of each. Signal functions for the prevention and management of infectious diseases (malaria, HIV, tuberculosis, syphilis and tetanus) can be applied depending on population disease burden. Screening and management of pre-eclampsia, gestational diabetes, anaemia, mental and social health (including intimate partner violence) are recommended universally. Three signal functions address monitoring of fetal growth and wellbeing, and identification and management of obstetric complications. Promotion of health and wellbeing via education and support for nutrition, cessation of substance abuse, uptake of family planning, recognition of danger signs and birth preparedness are included as essential components of ANC.

Conclusions: New signal functions have been developed which can be used for monitoring and evaluation of content and quality of ANC. Country adaptation and validation is recommended.

Keywords: Global health; health services; maternal morbidity; prenatal care.

Publication types

Systematic Review
Delivery of Health Care
Infant, Newborn
Maternal Mortality
Perinatal Mortality
Pregnancy Complications* / diagnosis
Pregnancy Complications* / epidemiology
Pregnancy Complications* / prevention & control
Prenatal Care*

Grants and funding

Global Fund to Fight AIDS, Tuberculosis and Malaria

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Cover of Referral and delivery of antenatal care

Referral and delivery of antenatal care

Evidence review J

NICE Guideline, No. 201

National Guideline Alliance (UK) .

Review question

What aspects of (referral to and delivery of) antenatal care are valued by women?

Introduction

This review gathers evidence of women’s views on how, where and by who antenatal care should be delivered. The committee agreed it was important to ask a qualitative question that captures women’s experiences of and preferences for different aspects of delivery of antenatal care. This review is intended to help tailor recommendations in a way that improve women’s experiences and identify opportunities to organise care more efficiently or effectively. The review is also intended to understand whether there are any gaps or issues in women’s experiences of care that are not being addressed in other sections, or whether specific actions are required to improve the experiences of some groups of women. The aim of this review is to explore what aspects of referral to and delivery of antenatal care are valued by women.

Summary of the protocol

Please see Table 1 for a summary of the Population, Phenomenon of interest, and Context of this review

Summary of the protocol (PICo table).

For further details see the review protocol in appendix A .

Methods and process

This evidence review was developed using the methods and process described in Developing NICE guidelines: Developing NICE guidelines: the manual 2014 . Methods specific to this review question are described in the review protocol in appendix A .

Declarations of interest were recorded according to NICE’s conflicts of interest policy .

Clinical evidence

Included studies.

Fifteen qualitative studies were included in this review ( Alshawish 2013 , Aquino, 2018 , Beake 2013 , Binder 2012 , Boyle 2016 , Crowther 2019 , Docherty 2012 , Goodwin 2018 , Hatherall 2016 , Hunter 2018 , Puthussery 2010 , Raine 2010 , Symon 2019 , Thomson 2013 and Young 2008 ).

All the studies focused on the views and experiences of women on antenatal care services. However, 9 studies presented additional data relating to views on and experiences of women during the intrapartum and/or postpartum care but this was not considered for this review ( Alshawish 2013 , Aquino 2018 , Beake 2013 , Binder 2012 , Boyle 2016 , Crowther 2019 , Puthussery 2010 , Symon 2019 and Young 2008 ).

The included studies are summarised in Table 2 .

All the studies were conducted in the UK. Ten of the studies were conducted in England ( Alshawish 2013 , Aquino 2018 , Beake 2013 , Binder 2012 , Boyle 2016 , Hatherall 2016 , Puthussery 2010 , Raine 2010 , Thomson 2013 and Young 2008 ), 3 in Scotland ( Crowther 2019 , Docherty 2012 and Symon 2019 ), and 2 in Wales ( Goodwin 2018 and Hunter 2018 ).

Four studies used semi-structured interviews for data collection ( Alshawish 2013 , Beake 2013 , Crowther 2019 and Puthussery 2010 ), whilst 1 study ( Boyle 2016 ) used diary interviews with semi-structured interviews. In the study, some information from the diary were used to generate additional prompts to enrich the semi-structured interview. Two studies used focus group discussions ( Aquino 2018 and Symon 2019 ), whilst 5 studies used a combination of semi-structured interviews and focus group discussions ( Binder 2012 , Hatherall 2016 , Raine 2010 , Thomson 2013 and Young 2008 ). One study ( Goodwin 2018 ) used a combination of observations with semi-structured interviews, whilst 1 study ( Hunter 2018 ) combined semi-structured interviews with focus groups and observations. Finally, 1 study ( Docherty 2012 ) combined observations of geographical locality and semi-structured interviews and matched the data with the Scottish Index of Multiple Deprivation (SIMD).

A total of 459 women participated in the 15 studies, with 13 men in 1 of the studies ( Thomson 2013 ). There were also 113 health providers who participated in 4 studies ( Binder 2012 , Goodwin 2018 , Hatherall 2016 and Young 2008 ), while 2 interpreters contributed to the data reported in 1 of the studies ( Goodwin 2018 ).

Four studies explored the views of women from minority ethnic groups living in the UK. One of the studies was focused on women originally from Palestine ( Alshawish 2013 ), another study was focused on female migrants from Poland ( Crowther 2019 ), whilst another study was on women originally from Pakistan ( Goodwin 2018 ). The fourth study recruited a diverse group of minority ethnic women ( Puthussery 2010 ) who were born in the UK to parents who were born outside of the UK.

See the literature search strategy in appendix B and study selection flow chart in appendix C .

Excluded studies

Studies not included in this review are listed, and reasons for their exclusion are provided in appendix K .

Summary of included studies

Summaries of the studies that were included in this review are presented in Table 2 .

Summary of included studies.

See the full evidence tables in appendix D . No meta-analysis was conducted (and so there are no forest plots in appendix E ). See appendix M for a full table of quotes supporting the themes identified in this review.

Quality assessment of studies included in the evidence review

See the evidence profiles in appendix F for GRADE-CERQual tables.

The evidence was categorised into 4 levels using Brofenbrenner’s socioecological model ( Brofenbrenner’s 1979 ). Framework analysis was used to identify themes, presented as a theme map in Figure 1 . For further details about the methods, see Supplement 1: methods .

Theme map for referral and delivery.

Economic evidence

This review question is not relevant for economic analysis. Therefore, no economic studies on this topic were identified by the global guideline systematic search of the economic literature and no primary economic modelling was undertaken.

A single economic search was undertaken for all topics included in the scope of this guideline. See supplementary material 2 for details.

Economic studies not included in this review are listed, and reasons for their exclusion are provided in appendix K .

Summary of studies included in the economic evidence review

See the economic evidence tables in appendix H and economic evidence profiles in appendix I .

Economic model

No economic modelling was undertaken for this review because the committee agreed that other topics were higher priorities for economic evaluation.

Qualitative evidence statements

See appendix M for a full table of quotes supporting the themes identified in this review.

Level 1. Individual level

Theme 1. building relationships.

High quality evidence from 5 studies reported on this theme. This finding revealed that women want to be known by their antenatal care providers to build trusting relationship with the carers. Moreover, the women also want to have continuity of care and of carers for their antenatal care.

Sub-theme 1a. Being known by care provider

High quality evidence from 1 study reported on this sub-theme. The evidence revealed that women valued being known by their midwives in order to form a relationship that is similar to those with family members. Some of the benefits that the women valued in being known by their carers include the feeling of being safe and relaxed with the carer and the ability to confide in them. This relationship was particularly important to vulnerable women who were able to discuss important issues with their midwives even though they could not discuss such issues with anyone else. The women also valued being known by their carer because it allowed them to avoid repeating their histories every time they meet someone new. This was particularly important to women with complicated obstetric histories.

Sub-theme 1b. continuity of care

Moderate quality evidence from 5 studies reported on this sub-theme. Women desire continuity of care and of carers because it allows them to build trusting relationships with their midwives and makes them feel like being cared for as an individual. The women want to be cared for by a named midwife or group of antenatal care providers so that they could avoid variations in the quality of care and conflicting advice on the pregnancy. The women also do not want to have fragmented care, to avoid repeating their histories. Therefore, some of the women reported that being with same midwives allowed them to develop trust and confidence in their carer, and described changing midwives as confusing. While it was important to women to have continuity of care and of carer, they emphasised that it is also important for them to have their emotional needs met through the contact with the midwives and that this is not automatically addressed merely by having the same midwives or group of carers.

Theme 2. Empowerment

Low quality evidence from 3 studies reported on this theme. The finding shows that women value being able to contribute to decision making and choices about their antenatal care. The women therefore want to be provided with adequate information or support to aid them in decision making. Some of the women appreciated being guided by the midwives to make decisions largely because they felt that they did not have the knowledge and experience to decide for themselves. However, the evidence further revealed that there were instances where decisions were made for these women without an opportunity to discuss alternatives with them. This approach was unpleasant to some women who reported that they sometimes feel pressured when midwives made decisions for them based on the assumption of what they would want.

In respect of information support, consistent evidence from the reviewed studies showed that women felt empowered to contribute to the decision making and informed choices when they are provided with sufficient information to make judgements. However, provision of such information to contribute to decision making does not often occur and were sometimes not provided for the women in a timely manner. Hence, the women reported that they would appreciate if they were provided with written information in advance and supported with discussion with the midwives.

Furthermore, the evidence showed that women would like to make certain decisions at different stages in the pregnancy continuum, when they would have had sufficient knowledge about the options that they could have. For instance, some women were concerned that they were asked to make decisions about the place of birth at the initial antenatal care booking appointment, without any information on which to make such decision. Hence, the women emphasised that they would like to revisit such discussions later in the pregnancy.

Level 2. Family level

Theme 3. involving family.

Very low quality evidence from 1 study reported on this theme: The finding shows that some minority ethnic women value the involvement of their family members in their antenatal care. Evidence from the reviewed study showed that mothers-in-law and domestic partners play significant roles in the antenatal care of some minority ethnic women. Despite the value placed on the role of the family members, the women reported that they sometimes struggle to balance the contradictory traditional advice given to them by mothers-in-law with the professional advice from the midwives. Meanwhile, the study further revealed that the presence of family members such as the domestic partners and mothers-in-law at antenatal appointments could be a barrier for midwives to establish relationships with the women, because the family members have the tendency to dominate the appointment. For instance, the male partners of the women were reported in the study to speak for the women even when the latter have sufficient English language skills to adequately communicate. Yet, the women were reported to view the behaviours of their partners positively. The minority ethnic women emphasised that they prefer family members to speak on their behalf because they rely on the greater experience and knowledge of the family members instead of having a direct communication with the midwives.

Level 3. Community level

Theme 4. female care provider preference.

Very low quality evidence from 1 study reported on this theme. This finding showed that some minority ethnic women preferred having female caregivers for their antenatal care sessions. Evidence from the reviewed study showed that the preference for female caregivers influenced the attendance of some minority ethnic women at the antenatal clinic. Some of the women therefore reported that they did not attend the antenatal care classes because of the presence of men at the sessions.

Theme 5. Shared experience

Moderate quality evidence from 3 studies reported on this theme. This finding shows that pregnant women value the opportunity to share their own experience, and learn from other’s experiences that attending individual and group antenatal appointments affords. In this regard, the evidence showed that women valued the opportunity to socialise in group sessions. While reporting their experience, women in 1 of the studies valued the group sessions because they felt it was a safe place for sharing; where there is nothing they could not discuss. The women also appreciated the group sessions because it allowed them to learn together. Furthermore, the group sessions were particularly appreciated by the primiparous women who saw it as an opportunity to learn from multiparous women. However, the group sessions were also valuable to the multiparous women because of the respected status that their experience gave them in the sessions.

The women derived strength and reassurances from having contact with other pregnant women, and therefore they described their experience as “not being alone”. Moreover, the women in the group antenatal care sessions reported that they were able to learn new things and that being a part of a group of mixed ethnicities, nationalities, religion and cultures expanded their cultural horizons. The women also reported that they felt a sense of belonging by participating in the group session.

Sub-theme 5a. Independence from men

High quality evidence from 1 study contributed to this sub-theme. This finding suggests that some women valued the group antenatal care sessions because it afforded them the opportunity to have a sense of freedom from their male domestic partners. Whilst some of the women felt a greater sense of their own value because the partners were not involved in some of the group sessions, other women were concerned that their partners were missing out and that their needs were not being met. This is because the women believed that the partners would have had the opportunity to attend every session of a standard antenatal appointment or class.

Level 4. Policy level

Theme 6. access to information.

High quality evidence from 8 studies reported on this theme. This finding revealed that women value getting adequate information on the pregnancy and their antenatal care from the care providers in order to address concerns and for reassurances. Consistent evidence from the reviewed studies showed that women valued the antenatal care sessions because they regard it as an invaluable source of information on risks to maternal and infant health. Owing to their need for information, women in 1 of the studies were reported to value the antenatal or parentcrafts sessions conducted by UK NHS maternity units as an important source of information on pregnancy. However, due to inconsistent information, the study reported that the women confused the parentcrafts sessions with antenatal appointments.

Sub-theme 6a. Additional information opportunities

High quality evidence from 7 studies reported on this sub-theme: This finding revealed that most women often want to have the opportunities to get more information on their pregnancy and antenatal care than they usually receive from the antenatal sessions. Women therefore tend to seek additional the information from diverse sources. Evidence revealed that women sought additional information through sources such as friends who are midwives, television programmes, books, the internet, the National Childbirth Trust, and using child-birth forums or “Google”. Some minority ethnic women were also reported to value other forms of communicating information, which were often unavailable to them. This included information leaflets that are translated into the languages of the minority ethnic women. Owing to the frustration of not getting these additional useful sources of information from the antenatal care providers, the minority ethnic women also resorted to technology to get the answers that they needed. Despite the desire for these additional sources of information, women still valued the information that they considered as authoritative from the antenatal care providers. Hence, some of the women wanted to have open discussions with their antenatal care providers to appease their concerns, rather than just written information.

Theme 7. Clarity of service information

Low quality of evidence from 3 studies reported on this theme. The finding revealed that women would like to know what is going to happen at every stage of the pregnancy and want more information to help them navigate the antenatal care service better. In this regard, evidence revealed that some of the women were frustrated that the antenatal care providers did not provide them with an overall picture of the care that they could expect to receive as they progressed through their pregnancy. The women were also concerned that there was no clear explanation of the appropriate times to discuss particular aspects of care. Some of the women also emphasised that the purpose of each antenatal appointment was often unclear and the apparent duplication of visits frustrated them. Due to this lack of clear guide to the care, some women reported a reluctance to attend appointments which appeared to serve little purpose or meet their needs, while other women chose not to attend the clinic for routine ultrasound scan, because there appeared to be misunderstandings about its value and safety. Moreover, some minority ethnic women also reported that confusion regarding pre-booked appointments and poor knowledge of the UK healthcare system was preventing them from attending their antenatal appointment and sometimes led to late attendance.

Sub-theme 7a. Understanding role of care providers

Low quality evidence from 2 studies reported on this sub-theme. Some minority ethnic women were interested in knowing the role remit of their antenatal care service providers. The reviewed evidence revealed that some minority ethnic women including those who recently migrated into UK wanted to have greater clarity about the qualifications of the antenatal care providers and their professional responsibilities. While reporting their experience, some of the women in 1 of the studies reported that this lack of clarity continued until their fourth antenatal appointments.

Theme 8. Engaging and responsive communication

Low quality evidence from 10 studies reported on this theme. This finding revealed that women feel supported and respected based on the ways that their antenatal care providers communicate with them. Evidence from the review showed that women found interactions with their midwives which tended to be discourteous, abrupt or lacking in compassion as discouraging. Therefore, the women wanted to have the ability to confide in their midwives and feel responded to. Some of the women reported that they felt safe and respected when responded to by their midwives. The women also felt understood when they received responsive and caring communication approach from their midwives. The engaging and responsive approaches to communication as described by the women include being open to questions, empathic style of conversation, taking initiative to ensure the women receive prompt and appropriate healthcare, and making the women feel unrushed during antenatal appointments.

Sub-theme 8a. Adequate communication between care providers

High quality evidence from 1 study reported on this sub-theme. This finding revealed that women feel cared for when the antenatal care providers adequately share information about them for antenatal care purposes. Evidence from the reviewed study showed that women found fragmented communication between the components of the antenatal care frustrating and confusing. For instance, the study reported that the women were frustrated with failure of the General Practitioners (GPs) to exchange clinical information with other health care professionals and their inability to guide the women through the antenatal care system. Although the women acknowledged the pivotal role of the GPs, the women suggested that the disconnection between the GPs and other components of the antenatal service is a problem that should be addressed.

Sub-theme 8b. Interpreter service

Moderate quality evidence from 4 studies reported on this sub-theme. This finding showed that minority ethnic women want to have a reliable and consistent interpreter service. The reviewed evidence revealed that for some minority ethnic women, language barrier is a significant challenge to communicate with their antenatal care providers in an engaging style. To engage properly with the antenatal care providers, the minority ethnic women who were unable to speak English needed the interpreter service. The reviewed evidence showed that the interpreter service was not often available or reliable, leading to some women using their family members and friends as interpreters. However, 1 of the studies reported that the decision to use family members and friends was sometimes due to personal preferences of the women even though the interpreter service may be available. Meanwhile, some of the women in the study emphasised that they preferred having female interpreters for their antenatal care appointments. The study further reported that the strategy to use the family members or friends was not consistently reliable especially when bad news had to be relayed during routine consultations.

Moreover, evidence from 1 of the studies showed that despite the language barrier, some minority ethnic women reported how antenatal care staff helped to mitigate their challenge by speaking slowly and simply. The study further reported that some of the women valued their experiences when they were provided with the choices concerning the interpreting and translation services by the antenatal care providers. However, the women wanted to have such choices to be provided sensitively.

Meanwhile, evidence from another study suggested that women would like to know about the interpreter services before antenatal care booking appointment. According to the study, not all the women knew prior to their antenatal booking appointment that the interpreter service was available. Therefore, some minority ethnic women who were unable to speak English, experienced challenges of registering and making antenatal appointment with a GP to obtain a referral for an antenatal booking appointment. The women also reported experiencing additional difficulty of having to arrange for trusted family members and friends to accompany them to the antenatal care appointment to translate.

Sub-theme 8c. Remote contact

Low quality evidence from 2 studies reported on this sub-theme. This finding revealed that women value having remote contact with the midwives, in addition to the usual care antenatal appointments. The evidence revealed that some women appreciated the use of text message reminder that is sent to their mobile phones for antenatal care appointments by the midwives. Some women also reported valuing their interaction experiences with the midwives because they could be contacted on the phone. This approach to communication was described by the women as reassuring and responsive.

Theme 9. Frequent contact

Very low quality evidence from 4 studies reported on this theme. This finding showed that women want to have more contacts with their antenatal care service providers whenever they need it for support. Consistent evidence revealed that some women specifically want more frequent contacts during the first half of pregnancy. This was particularly noted among the multigravid women in 1 study which reported that the rigid schedule of appointments for multigravid women does not meet the needs of the women for psychological support and information. Some minority ethnic women in 1 of the studies also reported that they wanted to have more ad-hoc contacts with their midwives during the early period of pregnancy for support and cited the lack of flexibility for them to initiate the antenatal care contacts with the midwives as a potential problem for their on-going relationship with the midwives. However, women with low risk pregnancies in another study reported that they would also like to have additional contacts with the antenatal care service providers. The women in the study did not specify any particular period of the pregnancy for their desired increased antenatal care contact. The women emphasised that the anxiety and stress that they experience during pregnancy means that they should be able to access help and support from the maternity services whenever they need it. The women therefore considered more flexible access as important to ensure early identification of risks and complications and for appropriate individually determined support to be provided. Meanwhile, evidence from 1 of the studies further revealed that some women lacked adequate knowledge of how to contact the midwives in between appointments as there was no clear communication strategy informing them about what they should do if they needed to see a midwife in between visits.

Theme 10. Free service

Low quality evidence from 2 studies reported on this theme. This review finding revealed that some minority ethnic women greatly value the universal free access that women have in the UK to antenatal services which contrasted with the services in other countries.

Theme 11. Prompt and simpler referral

Very low quality evidence from 2 studies reported on this theme. This finding revealed that some minority ethnic women want a faster and less cumbersome process of referral so that they could have adequate care, especially during the early period of pregnancy. The reviewed evidence suggested that there was a low awareness of self-referral among the minority ethnic women who mostly sought referral for their antenatal care through the GP. Some of the women in 1 study were new to their communities and were therefore unaware of the local GP practices or have permanent address so they could register with the GP in time to secure referral for their antenatal care. Some of the women in both studies who were already registered with GP practices also reported delays in getting referred to the midwives. There were also reports of instances of delay in 1 study which was experienced by some of the women who were asked to return to their GPs for referral for the antenatal booking appointment after directly accessing other health services either to confirm their pregnancy or for problems early in their pregnancy.

Theme 12. Treated as an individual

Low quality evidence from 8 studies reported on this theme. This finding revealed that women want to be treated as an individual and not as a number in the antenatal care system. Evidence revealed that some women want their midwives and health visitors to be aware of their health status and relevant medical information to avoid narrating their needs repeatedly. Some women also emphasised that they wanted their antenatal care providers to pay more attention to their needs as individuals and to appreciate their perspective regarding pregnancy. Women who experienced personalised care reported that they felt like having someone there for them. According to some of the women, a personalised antenatal care is unrushed and flexible. Therefore, some women reported that they wanted an antenatal care that is flexible and fits with their individual and family needs. Hence, some of the women were dissatisfied with issues of accessibility, waiting times and restricted clinic appointments. In addition, some of the women emphasised that they would prefer that the information on risks associated with pregnancy to be tailored to individual needs instead of using a universal approach.

Moreover, the women emphasised that they wanted the midwives to discuss important issues with them rather than spending more time on completing medical records and physiological measurements. The experiences of the women in one of the studies suggested that they do not want to be treated like being on a production line, but want their emotional needs to be met during the interaction with the midwives.

Furthermore, evidence from 1 of the studies suggested that women who have mental health concerns related to extreme anxiety or fear of the pregnancy may prefer a more personalised antenatal care appointment instead of attending the antenatal care appointment in a clinical environment. According to the study, due to the ‘stress’ and ‘pressure’ of attending a clinical environment and having clinical tests which could potentially expose concerns for their baby’s health, the women did not attend all their antenatal care appointments. The study further suggested that teenage mothers may not be motivated to access universal antenatal care appointments, because they tend to consider the antenatal care to be for the adults partly due to the experiences of being judged by the older mothers. The teenage mothers therefore reported difficulties in organising appropriate appointment times for their antenatal care.

The committee’s discussion of the evidence

Interpreting the evidence, the outcomes that matter most.

This review focused on establishing what aspects of the referral process to, and delivery of, antenatal services are valued by women.

Face to face vs. remote care (for example Skype, phone, webchat)
Gaps between visits
Group vs 1 to 1 care
Location of visit (for example home, hospital, GP practice)
Method of referral (for example self-referral, GP, healthcare worker)
Waiting time for first appointment
Who does the woman want to see

The evidence review identified data relating to these themes, for example remote contact, frequent contact, building relationships (being known by care provider and continuity of care), prompt and simpler referral, and female care provider preference. There was no evidence identified on the theme location of visit. Other themes that were identified include empowerment; involving family; shared experience (independence from men); access to information (additional information opportunities); clarity of service information (understanding role of care providers); engaging and responsive communication (adequate communication between care providers and interpreter service); free service; and treated as individual. The committee considered the evidence from all identified themes and with their own knowledge and experience, were able to draft the recommendations.

The quality of the evidence

The overall confidence in the review findings ranged from very low to high.

Concerns about the methodological limitations of the primary studies were assessed with the CASP checklist and ranged from serious to minor concerns. The most common issues identified were: no justification for research design and methods of data collection; no discussion about non-participation and data saturation; no report of the period of data collection; insufficient information to determine how informed consent was obtained; insufficient description of data analysis process; insufficient data to support findings; and insufficient description of the credibility of findings.

Concerns about the relevance for the context and populations of interest to this guideline ranged from moderate to no or very minor concerns. The common issues include uncertainty about the period of data collection for 7 studies which makes it unclear how recent the views and experiences contributing to 9 findings are in the studies were in relation to current practice. The 9 findings affected by this issue include: Building relationships; Involving family; Female care provider presence; clarity of service information; Engaging and responsive communication; Frequent contacts; Free service; Prompt and simpler referral and Treated as an individual. Another concern about some of the findings was that they were reported from studies with mainly minority ethnic women population which may limit the transferability of the views and experiences of such population to other populations. The 5 findings affected with this issue include: involving family; female care provider presence; clarity of service information; free service and prompt and simpler referral.

Concerns about coherence was no or very minor for the findings as there were no data that contradicted the findings or were there any ambiguous data.

Concerns about adequacy ranged from moderate to no or very minor concerns. The moderate concerns for 9 findings were due to the few numbers of studies ranging from 1 to 4 contributing to the findings. The affected findings are: Building relationships; Empowerment; Involving family; Female care provider presence; Shared experience; Clarity of service information; Frequent contacts; Free service and Prompt and simpler referral. The remaining findings were reported by minimum of 5 to 10 studies.

Discussion of findings

Some of the committee members noted that most of the studies in this review represent minority ethnic women and that the findings from the evidence (for example, from the theme ‘female care provider preference’ and ‘free service’) may not be experienced by the majority of women. They stated that it is possible that most women might have used the opportunity of participating in the studies to voice concerns about the antenatal care service. However, the committee was also of the opinion that although the evidence was mostly collected from minority ethnic women, that the findings of the review are still relevant to all women today.

The committee further acknowledged that because the period of data collection was not reported for some of the studies, the finding from the theme ‘prompt and simpler referral’ might have been based on studies that were conducted too early to reflect the self-referral system which has become increasingly available throughout the country.

The committee noted evidence from the theme ‘access to information’, which suggested that pregnant women value receiving information from their care providers. Evidence from the subtheme ‘additional information opportunities’ suggested that some pregnant women preferred to get more information from other sources, such as the internet, but ultimately still valued the information from antenatal care providers, which they considered as authoritative. The committee observed that evidence from the theme ‘building relationships’ and the subtheme ‘being known by care provider’ showed that women value access to their midwives. The committee noted that there is good evidence for ad hoc telephone support from midwives from the subtheme ‘remote contact’ and the theme ‘frequent contact’. The committee therefore suggested that it would be good to utilise other forms of communications rather than relying only on letters. The committee considered the need to use different methods of remote communications that are currently available such as the text messages, phone, e-mail, video calls and instant messaging.

The committee discussed that the individual needs and concerns of pregnant women are important, as supported by the evidence from the theme ‘empowerment’. The committee discussed that individual needs and concerns determine the approach towards antenatal care, which was supported by evidence from the theme ‘treated as an individual’. For example, more care might be required for women in vulnerable situations, such as if there is a health, social or emotional concern.

The committee agreed that a fundamental part of antenatal care is listening to the woman and responding to her needs and preferences. This was also highlighted by the 2020 Ockenden report . The committee also agreed that as part of informed and shared decision making, whenever offering the woman any kind of intervention, assessment or procedure, the benefits, harms and implications should be discussed and the women should be made aware of her right to decline. This is in line with the 2015 Montgomery ruling . The committee also emphasised that the healthcare professional should respect the woman’s decision even if it goes against the views or values of the healthcare professional.

The committee agreed that it is important that when women are advised to seek help or advice, urgent from non-urgent situation are distinguished. The committee agreed on the importance of tailoring the length and number of appointments to the woman’s personal needs and circumstances and cross-referred to the NICE guideline on pregnancy and complex social factors (CG110) which covers specific complex circumstances in more detail.

The committee acknowledged that the availability of interpreters is important as shown in the evidence by the theme ‘engaging and responsive communications’, and the subthemes ‘adequate communication between care providers’ and ‘interpreter service’, however they noted that it is difficult to implement in practice even though this is important for vulnerable populations and those who have hearing problems. The committee agreed it is important to ensure that the interpreter is independent of the woman and not a family member or a friend. Based on their experience, there are various concerns around having a family member or a friend as an interpreter, for example confidentiality issues, putting pressure on a family member or friend, concerns around whether a neutral message is translated. Although, it should also be noted that the evidence from the review from the theme ‘involving family’ suggests that some women do not mind having family members as interpreters. The committee also discussed that interpretation may also be required by those who use British Sign Language.

The committee discussed the evidence from the subtheme ‘continuity of care’ and acknowledged that in general women valued continuity and that there is a difference between continuity of care and continuity of carer. Although this review did not investigate the clinical or cost effectiveness of continuity of care or carer the committee agreed it was important and noted it is covered and supported by NHS Better Births . In conjunction with the NHS Better Births and the qualitative evidence the committee agreed that those providing care should aim to provide continuity of carer. This review did not investigate the effectiveness of continuity of carer or what is the best way to deliver continuity of carer.

Despite the aim for continuity of carer, there will likely be various different healthcare professionals involved in the woman’s antenatal care, either from the same team or unit or across different providers (for example primary care). The committee discussed the importance of effective and timely communication between healthcare professionals so that information is shared appropriately, concerns are not missed, and the woman does not always have to repeat the same things to various different health care professionals.

The committee agreed that the clarity of pathway of care is an important finding from the theme ‘clarity of service information’ and the subtheme ‘understanding role of care providers’ as it stopped some women from attending certain antenatal care appointments in 1 of the studies. It was therefore agreed that there should be a recommendation that involves explaining the content and timing of appointment and why it is important. The committee then suggested that the findings from this review should be referenced in [G] content of antenatal appointments.

The evidence from the theme ‘shared experience’ showed that women value group appointments. The committee agreed that while the primary mode of delivery of antenatal appointments should be one to one based, these could be supplemented by group model of care.

The committee discussed the evidence from the subtheme ‘independence from men’, which came from 1 study. Although the evidence was of high quality, the findings were contradictory and the committee agreed that it was a matter of personal preference as to whether the pregnant woman wanted their partner present at group antenatal sessions. Therefore, no recommendation was made based on this theme.

Cost effectiveness and resource use

A systematic review of the economic literature was conducted but no relevant studies were identified which were applicable to this review question.

These recommendations largely reinforce current practice or refer to existing NICE guidance and are unlikely to have any cost impact. The recommendation to offer flexibility in both length and total number of antenatal appointments will lead to more and longer appointments for some women. This to some degree will already be happening in all centres where medically indicated but this recommendation may lead to more appointments for those with social or emotional needs. The number of women is anticipated to be minimal and any increase resource use should be small. Some cost savings and health gains will also be achieved through improved birth outcomes from more intensive antenatal care.

Alshawish 2013

Aquino 2018

Binder 2012

Bronfenbrenner 1979

Crowther 2019

Docherty 2012

Goodwin 2018

Hatherall 2016

Hunter 2018

Puthussery 2010

Thomson 2013

Appendix A. Review protocol

Review protocol for review question: What aspects of (referral to and delivery of) antenatal care are valued by women? (PDF, 203K)

Appendix B. Literature search strategies

Literature search strategies for review question: What aspects of (referral to and delivery of) antenatal care are valued by women? (PDF, 336K)

Appendix C. Clinical evidence study selection

Study selection for: What aspects of (referral to and delivery of) antenatal care are valued by women? (PDF, 117K)

Appendix D. Clinical evidence tables

Evidence tables for review question: What aspects of (referral to and delivery of) antenatal care are valued by women? (PDF, 713K)

Appendix E. Forest plots

Forest plots for review question: what aspects of (referral to and delivery of) antenatal care are valued by women.

No forest plots included as this is a qualitative review.

Appendix F. GRADE-CERQual tables

GRADE-CERQual tables for review question: What aspects of (referral to and delivery of) antenatal care are valued by women? (PDF, 610K)

Appendix G. Economic evidence study selection

Economic evidence study selection for review question: what aspects of (referral to and delivery of) antenatal care are valued by women.

A single economic search was undertaken for all topics included in the scope of this guideline. No economic studies were identified which were applicable to this review question. See supplementary material 2 for details.

Appendix H. Economic evidence tables

Economic evidence tables for review question: what aspects of (referral to and delivery of) antenatal care are valued by women.

No economic evidence was identified which was applicable to this review question.

Appendix I. Economic evidence profiles

Economic evidence profiles for review question: what aspects of (referral to and delivery of) antenatal care are valued by women, appendix j. economic analysis, economic evidence analysis for review question: what aspects of (referral to and delivery of) antenatal care are valued by women.

No economic analysis was conducted for this review question.

Appendix K. Excluded studies

Excluded studies for review question: what aspects of (referral to and delivery of) antenatal care are valued by women, clinical studies, table 6 excluded studies.

View in own window

Economic studies

Appendix l. research recommendations, research recommendations for review question: what aspects of (referral to and delivery of) antenatal care are valued by women.

No research recommendations were made for this review question.

Appendix M. Quotes supporting themes

Quotes supporting themes for review question: What aspects of (referral to and delivery of) antenatal care are valued by women? (PDF, 478K)

Evidence reviews underpinning recommendations 1.1.10 to 1.1.13, 1.3.1 to 1.3.4 and 1.3.8

These evidence reviews were developed by the National Guideline Alliance, which is a part of the Royal College of Obstetricians and Gynaecologists

Disclaimer : The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.

Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government , Scottish Government , and Northern Ireland Executive . All NICE guidance is subject to regular review and may be updated or withdrawn.

Cite this Page National Guideline Alliance (UK). Referral and delivery of antenatal care: Antenatal care: Evidence review J. London: National Institute for Health and Care Excellence (NICE); 2021 Aug. (NICE Guideline, No. 201.)
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A Literature Review on Emerging Factors Affecting Antenatal Care Utilization of Pregnant Women

2022, International Journal of Food and Nutritional Sciences

Antenatal Care (ANC) is the care given to pregnant women so that they have a safe pregnancy and a healthy baby. It helps in the identification of early pregnancy complications and adverse pregnancy outcomes. The present paper is focused on the review of ANC services utilization and analyzes determinants that affect the utilization of ANC services. In this literature review, studies published in the years 2011-2021 were evaluated. For this purpose, electronic databases, i.e., Google Scholar, Science Direct, Scopus and PubMed, were explored to find English-language articles by using relevant keywords; moreover, the reference lists of the articles were searched. A systematic scoping review of studies focused on factors associated with the use of antenatal care services by pregnant women was done. In total, 30 relevant articles were included for review. The results exhibited that the late initiation and inadequate use of antenatal care services are associated with multiple variables, including demographic characteristics, socio-economic factors, literacy rate, accessibility, parity, decision-making power, massmedia, etc. The paper infers that optimum use of antenatal care cannot be achieved merely by establishing healthcare centers as various hurdles need to be addressed on the axis of socio-demographic, economic and education. Further, it suggests that the number of ANC visits can be enhanced by creating awareness among women regarding the significance of ANC services during their pregnancy

Antenatal care services and its implications for vital and health outcomes of children: evidence from 193 surveys in 69 low-income and middle-income countries

Sebastian vollmer.

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Article notes
Copyright and License information

Correspondence to Professor Sebastian Vollmer; [email protected]

Received 2017 May 2; Revised 2017 Aug 15; Accepted 2017 Sep 26; Collection date 2017.

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

Antenatal care (ANC) is an essential part of primary healthcare and its provision has expanded worldwide. There is limited evidence of large-scale cross-country studies on the impact of ANC offered to pregnant women on child health outcomes. We investigate the association of ANC in low-income and middle-income countries with short- and long-term mortality and nutritional child outcomes.

We used nationally representative health and welfare data from 193 Demographic and Health Surveys conducted between 1990 and 2013 from 69 low-income and middle-income countries for women of reproductive age (15–49 years), their children and their respective household.

Participants

The analytical sample consisted of 752 635 observations for neonatal mortality, 574 675 observations for infant mortality, 400 426 observations for low birth weight, 501 484 observations for stunting and 512 424 observations for underweight.

Main outcomes and measures

Outcome variables are neonatal and infant mortality, low birth weight, stunting and underweight.

At least one ANC visit was associated with a 1.04% points reduced probability of neonatal mortality and a 1.07% points lower probability of infant mortality. Having at least four ANC visits and having at least once seen a skilled provider reduced the probability by an additional 0.56% and 0.42% points, respectively. At least one ANC visit is associated with a 3.82% points reduced probability of giving birth to a low birth weight baby and a 4.11 and 3.26% points reduced stunting and underweight probability. Having at least four ANC visits and at least once seen a skilled provider reduced the probability by an additional 2.83%, 1.41% and 1.90% points, respectively.

Conclusions

The currently existing and accessed ANC services in low-income and middle-income countries are directly associated with improved birth outcomes and longer-term reductions of child mortality and malnourishment.

Keywords: epidemiology, perinatology

Strengths and limitations of this study.

This is the first study on the association of antenatal care (ANC) with child health and vital outcomes for all low-income and middle-income countries for which high-quality and comparable data are available.

This is the first study investigating the possible long-term effects of the utilisation of ANC on children’s nutritional and vital status.

The study focuses on the association between the ANC services effectively available and accessible to women in low-income and middle-income countries and hence, generates knowledge on the current status quo and effect of the ANC services on child health.

The analysis does not allow a causal interpretation of the results.

Data availability limits the investigation of the association of more disaggregated quality indicators of ANC with the outcome variables.

Introduction

Despite strong international efforts to expand the worldwide coverage of basic primary health services for women, pregnancy and childbirth still represent a high-risk period for mother and child; especially in low-income and middle-income countries. Reductions in maternal and early child mortality remain high on the global development policy agenda, which can be seen in its inclusion in the Sustainabile Development Goal 3. 1 However, nearly 3 million babies die every year during their first month of life, and in low-income and middle-income countries, many of those deaths and morbidities are due to easily preventable causes. 2 3 Undetected infections during pregnancy, such as malaria, syphilis, tuberculosis, tetanus or HIV/AIDS, as well as high blood pressure, diabetes and other pre-existing health conditions often complicate or aggravate pregnancy and pose significant risk for mother and child. Antenatal care (ANC)—the services offered to mother and unborn child during pregnancy—is an essential part of basic primary healthcare during pregnancy, and offers a mosaic of services that can prevent, detect and treat risk factors early on in the pregnancy. The detection of high-risk pregnancies through the analysis of socioeconomic, medical and obstetrical factors represents a key element of ANC. It is also often used as a platform for additional interventions that have been shown to positively influence the maternal and child health status, such as immunisation and nutrition programmes and breastfeeding counselling, or to educate women about the possibilities of family planning and birth spacing. 4–13 In addition, ANC programmes are used to provide care and information that is not directly related to pregnancy but can reduce the possible maternal risk factors, such as promoting healthy lifestyles, tackle malnutrition or inform about gender-based violence. Hence, ANC is a potentially important determinant in reducing maternal and child morbidity and mortality. 14–22

Within the last decades, the provision of ANC services has increased worldwide. During 2010–2015, the ANC coverage, defined as the percentage of women aged 15–49 years who attended at least one ANC visit with a skilled provider, was around 85% globally and approximately 77% in the least developed countries. 23 24 To our knowledge, there exists no global study for all low-income and middle-income countries, which analyses the association of existing ANC services that are offered to pregnant women in low-income and middle-income countries on child health outcomes.

Numerous studies have helped to develop an internationally accepted set of so-called essential ANC services by evaluating the effects of single interventions, such as tetanus and malaria prevention programmes, on maternal and neonatal health 25–30 or by studying the optimal number and content of ANC visits. 31–34 However, the de facto offered and used set of ANC services can deviate greatly from the recommended ANC interventions. A couple of studies evaluate the relationship between the utilisation of ANC services and perinatal outcomes in individual low-income and middle-income countries. The majority have shown the positive effects of ANC on newborn mortality, the occurrence of stillbirth and preterm labour and low birth weight. 35–43 However, they exclusively focus on single countries, are often conducted at the clinic level and have small sample sizes. This limits their external validity. We identified only one study that focuses on a larger regional sample. Conde-Agudelo et al studied 837 232 births in Latin America between 1985 and 1997. 44 One major risk factor associated with fetal death was the lack of ANC. We could not find a study that took into account the possible long-term effects of the utilisation of ANC services on children’s nutritional and vital status.

With up to 193 Demographic and Health Surveys (DHS) from 69 low-income and middle-income countries, we use the most comprehensive data for low-income and middle-income countries that currently exist. Specifically, we investigate whether the attendance of mothers at ANC services was associated with improved short-term and long-term survival rates or reductions in the prevalence of low birth weight, stunting and underweight in their children.

We used data from the DHS, which are publicly available online ( http://dhsprogram.com ). The DHS are cross-sectional household surveys that use a harmonised questionnaire to facilitate between-country comparisons. The DHS collect nationally representative health and welfare data for women of reproductive age (15–49 years), their children and their respective household.

They have been conducted at different time intervals in 90 low-income and middle-income countries since 1985. We included all surveys, which have information for the relevant outcome and explanatory variables. The final sample consists of pooled data from up to 193 surveys in 69 low-income and middle-income countries worldwide, conducted between 1 January 1990 and 31 December 2013. The DHS used a multistage stratified sampling. Countries were divided into regions, within which populations were stratified by area of residence and from which a random sample was taken according to the most recent population census. Those are the primary sampling units (clusters with an average of 250 households), which are equally likely to be selected to the proportion of the specific cluster’s population that contributed to the total population. At the second stage, after a complete listing of all households within the cluster, an average of 20–30 households were randomly selected by equal probability. Sampling weights in order to calculate nationally representative statistics are provided by the DHS.

Women were, among other things, asked for each live birth within 5 (or in some cases 3) years prior to the survey about date of birth, birth weight, vital status at the time of the interview and either current age or age at death of the child. Furthermore, the DHS collected information on the height and weight of the children born during the last 3 or 5 years.

For each last-born live birth of the previous 3 or 5 years, there is information on the attendance rates and quality of ANC visits during the last pregnancy that led to a live birth. Considering the ongoing debates on the importance of the quality and number of ANC visits, 31 45–48 we specified two different main explanatory variables. First, the mere attendance of ANC (a dummy variable indicating whether the woman attended at least one ANC visit during her last pregnancy leading to a live birth) irrespective of the total number of visits and the type of provider. To proxy WHOrecommendations regarding prenatal care (at least four visits at a skilled provider 1 ), we specified a variable indicating whether the woman saw at least once a skilled provider during her at least four ANC visits. Unfortunately, we were unable to identify whether all ANC visits were provided by a skilled professional. ANC visits to a doctor, midwife, nurse, auxiliary midwife, obstetrician, health professional or trained (traditional) birth attendant were considered as skilled ANC services, whereas ANC with a traditional birth attendant, relatives, any other person or none of the mentioned was classified as unskilled ANC.

We analysed the data for short-term and long-term vital outcomes and low birth weight of all last-born live births as well as stunting and underweight for the last-born children aged 0–59 months (in some surveys 0–36 months) at the time of the interview. Hence, each woman is represented only once in the dataset with the information of her last-born child (in case of a live birth). Mortality outcomes were neonatal death, defined as death of a live birth within the first month of life, and infant death, defined as death after the first month but within the first year of life. The latter excludes neonatal deaths and is restricted to children aged at least 1 year. Nutritional outcomes were low birth weight, stunting and underweight. We used WHO classification that defines low birth weight as a birth weight below 2500 g at birth. Following WHO and Unicef suggestions, we only included biologically plausible birth weights from 500 to 5999 g. To calculate stunting and underweight, we used anthropometric data defined by WHO standards and classifications (using the Stata package ‘igrowup_stata’). Comparing the child’s height and weight to those of a well-nourished reference population of the same age and sex allows us to calculate the z-scores of height-for-age and weight-for-age. Stunting is defined by a height-for-age z-score of less than −2, and underweight is defined by a weight-for-age z-score of less than −2. Biologically implausible values of the z-scores were excluded following WHO guidelines.

Statistical analysis

We used linear probability regression models to investigate the association between ANC services and short-term and long-term vital and health outcomes of children. We adjusted the regressions for confounding factors and controlled for primary sampling unit (PSU) fixed effects. The PSU fixed effects are survey specific and herewith, we control for common factors faced by households in the same PSU at one point in time, such as the local availability and quality of health providers and other local factors. SEs were clustered at the PSU level as respondents in the same PSU might experience common shocks. They capture characteristics of local enumeration areas that are common to all respondents from that area. We used sex, birth order (five categories: ranging from ‘first born’ to ‘fifth or later born’ child), birth spacing (five categories: ranging from ‘no preceding birth’ to ‘equal or more than 36 months’), birth month and whether the child was a multiple birth, the mother’s age at birth (five categories: ranging from ‘below 17’ to ‘equal or above 30’ years), education (five categories: ranging from ‘no education’ to ‘higher education’), work status, relation to the household head (dummy indicating whether the mother is the household head) and her marital status and household wealth quintile as covariates. The wealth quintile variable is constructed by using a principal component analysis, is based on the ownership of household assets (eg, electricity, television and quality of dwelling) and indicates the household’s wealth relative to other households within the respective country in that survey. Additionally, by including variables indicating the place of delivery, mode of delivery (vaginal or caesarean), status of tetanus injection of mother before birth and if the mother breastfed at least 1 month after birth (several only applicable for long-term outcomes), we inspected the possible mediator variables, meaning that the uptake of ANC services might starkly influence those variables, which themselves might affect the outcome variables.

Using Stata (V.14.0) for all statistical analyses, we also took into account the stratified survey design by using the Stata svy command. We used sampling weights provided by the DHS in all our regressions.

Our initial samples consisted of surveys for which the respective outcome variable and the information on ANC visits were collected and composed children between 0 and 59 months at the time of the interview and who were permanent members of the respective household. The total sample for neonatal and infant mortality included observations for 1 019 463 children. In some survey rounds, data on birth weight and in others on anthropometric measures were not systematically collected. This left us with data of 947 365 children, where information on their birth weight could have potentially been recorded. For stunting, this amounted up to 865 959 children and for underweight to 857 908 children.

Observations were lost due to missing data on outcome variables, missing data on the ANC variables (including the dummies indicating the mere attendance of ANC visits and the attendance of at least four ANC visits while the woman at least once saw a skilled provider) or missing data on covariates. The final analytical sample was 752 635 for neonatal mortality, 400 426 for low birth weight, 574 675 for infant mortality, 501 484 for stunting and 512 424 for underweight (see figure 1 and online supplementary table A1 ).

Sample deduction. ANC, antenatal care; LMIC, low-income and middle-income countries.

bmjopen-2017-017122supp001.pdf (467.2KB, pdf)

The prevalence of newborn death was higher among women who did not receive any ANC check-up (3.12%) compared with those attending at least one check-up (1.67%). For infant mortality, the respective numbers are 4.23% and 2.21%. Prevalence of all outcome variables was higher among women not attending any ANC visit than those attending at least one ANC check-up and to those who received at least four ANC visits while at least once having seen a skilled provider ( table 1 ). Pregnant women who did not attend ANC visits were on average less educated and poorer than those women who attended at least one ANC check-up (see online supplementary table A2 appendix ).

Descriptive statistics

n Values denote the number of observations in the neonatal mortality sample.

*Proportions to the group ‘mother did not attend ANC visit’ were significantly different from each other, p≤0.05 (Student’s t-test).

ANC, antenatal care.

In table 2 , we report the association between ANC take-up and short-term and long-term mortality outcomes. For each outcome, we show the results from three different specifications where PSU fixed effects are included in all three. The first column shows the mere association between the attendance of at least one ANC visit without controlling for any covariates. The second column shows the association adjusted for control variables, and the third column reports the coefficients while adding whether the mother has received at least four ANC visits during pregnancy while at least having once seen a skilled provider. The interpretation of this additional term follows the logic of an interaction term as it overlaps in its definition with the variable indicating the mere attendance of ANC. Hence, it shows the additional effect if the mother followed more closely WHO recommendations. In supplementary table A2 and A4 appendix ), we report the regression results where in addition to control variables, we also adjusted for potential transmission channels of ANC (place of delivery, mode of delivery, status of tetanus toxoid injection of mother before birth and whether the mother breastfed at least for 1 month after birth). We will focus on the second and third specifications adjusted for control variables and only refer to the other specifications for comparison purposes.

Associations between antenatal care visits and mortality outcomes

All regressions include PSU fixed effects.

SEs in parentheses are clustered at PSU level.

Control variables include: mother’s age, marital status and educational achievement, whether she heads the household, child’s sex and birth order and spacing, month of birth, whether it was a multiple birth and household wealth quintile.

***, ** and * Significance at the 1%, 5% and 10% levels, respectively.

Women attending at least one ANC visit have a 1.04% points reduced probability of their newborn dying within the first month after birth and a 1.07% points lower probability of experiencing death of their child within the first year of life. Following the WHO recommendations on ANC visits is significantly related to lower mortality outcomes. Compared with the mere attendance of less than four ANC visits (irrespective of the quality of the provider), having at least four ANC visits and having at least once seen a skilled provider reduce the probability of neonatal deaths by an additional 0.56% points and are associated with an additional 0.42% points reduction in the probability of infant deaths.

The DHS dataset also provides information on several variables that are well-established in the literature to impact mortality and morbidity outcomes of children and that simultaneously are potentially influenced by ANC attendance. When controlling for these potential transmission channels of ANC services, it can be seen that the majority of the ANC coefficients are somewhat attenuated when controlling for these additional variables but not by much (online supplementary table A3 ). Results for all covariates are provided in online supplementary A5 appendix .

In table 3 , we report the association between ANC and short-term and long-term nutritional outcomes of the child. If the mother attends at least one ANC visit, this is associated with a 3.82% points reduced probability of giving birth to a low birth weight baby. Stunting and underweight outcomes are reduced by 4.11% and 3.26% points, respectively. Attendance at a skilled provider during at least one of at least four ANC visits further reduces the probability of having a low birth weight baby by 2.83% points, for stunting by 1.41% points and for underweight by 1.90% points.

Associations between antenatal care visits and nutritional outcomes

***, ** and *Significance at the 1%, 5% and 10% levels, respectively.

Adding potential transmission channels of ANC services to the regression slightly attenuates the ANC coefficients in case of low birth weight and underweight (online supplementary table A4 ). Results for all covariates are provided in online supplementary table A5 .

Most existing evidence on the effect of ANC on child health is based on data from high-income countries, and their conclusions are not easily transferable to low-income and middle-income settings. The existing studies for low-income and middle-income countries often focus on individual countries. Furthermore, the studied effects of ANC have been limited to direct short-term maternal and child delivery outcomes. This is the first large-scale cross-country study for all low-income and middle-income countries with available comparable data for ANC, which systematically investigates the association of ANC with short-term and long-term mortality and nutritional child outcomes.

Using child vital data and child anthropometry from up to 193 surveys in 69 low-income and middle-income countries, we have shown that ANC is associated with reductions in neonatal and infant mortality, low birth weight, stunting and underweight. While we measure the average effects across countries and years, we find that this association remains relatively stable across survey rounds (online supplementary table A6 ) and can be seen for all outcomes in almost all world regions (online supplementary figures A1 and A2 ); though it is especially strong in Latin America and Caribbean, Sub-Saharan Africa and South and Southeast Asia (which constitute about 90% of our sample). Receiving prenatal care by skilled providers and attending at least four ANC visits is significantly associated with additional prevalence reductions of all outcome variables and hence, plays an important role in the provision of ANC services. The magnitude of the association is quantitatively important, as it varies around −1.04% and −4.11% points.

Many pregnant women in low-income and middle-income countries have no access to or do not attend ANC services regularly enough (more than four visits) and many do not see a skilled provider. 23 49 50 According to our results, improving the coverage and uptake of ANC services could be an important tool to improve short-term and even long-term mortality and nutritional outcomes of children.

There are a couple of self-selection issues and limitations that we have attempted to address. Unfortunately, we do not have disaggregated information on the type of provider (skilled/unskilled) for each ANC visit. We try to proxy this by including whether the woman has at least once seen a skilled provider during her pregnancy. Furthermore, we controlled for mother’s education and household wealth, since more educated or more affluent mothers might be more likely to seek ANC and at the same time have a better overall health status. Similarly, we adjusted for PSU fixed effects to control for community characteristics, overall health status in the region and the local availability and quality of healthcare services as well as other characteristics that are common to the local area. However, there are a few maternal characteristics, which we did not observe and therefore were not able to control for. For instance, if pregnant women feel that there could be something wrong, they might be more likely to seek ANC. Similarly, if women had negative birth outcomes in the past, they might also be more likely to seek ANC to avoid the repetition of the negative birth outcome. Both cases would downward bias our estimates and the true association would be even stronger than the association, which we found in our analysis. It is important to point out again that we are only including the outcomes of live births. The attendance at ANC services might lead to better survival chances of those babies that would have otherwise died before birth. This might impose a downward bias on our estimates. However, there are also potential selection issues, which could bias the results in the other direction. For instance, it is unclear how women would behave in case of an unwanted pregnancy. They might be less likely to seek ANC and have worse overall health behaviour compared with women in planned pregnancies. In a robustness check, we controlled for an indicator variable if the pregnancy was wanted, and this did not change the results. Additionally, we cannot further approximate the quality of care received by the women. As the quality of care will influence the effect of ANC, this limits our study. By including PSU level fixed effects, we absorb indicators that are similar across this geographical unit and survey. Assuming that the quality of ANC available to women within the same PSU is comparable, we successfully address this data limitation. We also assume that missing data in our sample was not systematically correlated with the true unobserved child health and vital outcomes and the availability and accessibility of ANC services.

In summary, our study provides evidence for the potential importance of ANC for improving child health and vital outcomes in low-income and middle-income countries and might be an important tool to reach the third Sustainable Development Goal by 2030.

Supplementary Material

Acknowledgments.

In 2016, WHO updated their recommendations to at least eight prenatal care visits at skilled providers. 51

Contributors: JK and SV conceptualised the study, developed the analytical strategy and interpreted the data. JK conducted the statistical analysis and wrote the first draft of the manuscript. SV critically revised the manuscript.

Competing interests: None declared.

Patient consent: Obtained.

Ethics approval: Procedures and questionnaires for standard DHS surveys have been approved by the ICF Institutional Review Board (IRB) and by the relevant body in each country. ICF IRB ensures that the survey complies with the US Department of Health and Human Services regulations for the protection of human subjects (45 CFR 46), while the host country IRB ensures that the survey complies with laws and norms of the nation.

Provenance and peer review: Not commissioned; externally peer reviewed.

Data sharing statement: This study used data that was collected by the Demographic and Health Surveys Program (www.dhsprogram.com), under a contract from the US Agency for International Development.

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Published: 01 October 2024

What are the mechanisms of effect of group antenatal care? A systematic realist review and synthesis of the literature

Anita Mehay 1 ,
Giordana Da Motta 1 ,
Louise Hunter 2 ,
Juliet Rayment 1 ,
Meg Wiggins 3 ,
Penny Haora 4 ,
Christine McCourt 1 &
Angela Harden 1

BMC Pregnancy and Childbirth volume 24 , Article number: 625 ( 2024 ) Cite this article

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There is growing interest in the benefits of group models of antenatal care. Although clinical reviews exist, there have been few reviews that focus on the mechanisms of effect of this model.

We conducted a realist review using a systematic approach incorporating all data types (including non-research and audiovisual media), with synthesis along Context-Intervention-Mechanism-Outcome (CIMO) configurations.

A wide range of sources were identified, yielding 100 relevant sources in total (89 written and 11 audiovisual). Overall, there was no clear pattern of ‘what works for whom, in what circumstances’ although some studies have identified clinical benefits for those with more vulnerability or who are typically underserved by standard care. Findings revealed six interlinking mechanisms, including: social support, peer learning, active participation in health, health education and satisfaction or engagement with care. A further, relatively under-developed theory related to impact on professional practice. An overarching mechanism of empowerment featured across most studies but there was variation in how this was collectively or individually conceptualised and applied.

Conclusions

Mechanisms of effect are amplified in contexts where inequalities in access and delivery of care exist, but poor reporting of populations and contexts limited fuller exploration. We recommend future studies provide detailed descriptions of the population groups involved and that they give full consideration to theoretical underpinnings and contextual factors.

Registration

The protocol for this realist review was registered in the International Prospective Register of Systematic Reviews (PROSPERO CRD42016036768).

Peer Review reports

Antenatal care (ANC) is considered an integral component of maternity care and can make a vital contribution to improving health outcomes and reducing inequalities [ 1 ]. According to the UK’s National Institute for Clinical Excellence (NICE), pregnancy care should be woman-centred and enable informed decision making [ 2 ]. Some women are well prepared for the challenges brought on by the journey through this major life event, but many experience significant barriers to enabling optimal care for themselves and their babies [ 3 ]. There is growing evidence to suggest that care should be tailored to meet the diverse needs of women and birthing people, within sometimes complex social situations [ 4 ] but evidence on its implementation is scarce [ 3 ]. Many women report being overwhelmed with so much information and that care is not person-centred, particularly in hospital settings [ 5 ]. Within the context of hospital maternity services, in many countries, antenatal care is fragmented, leaving women feeling like ‘a number’ [ 6 ] with screening tests dominating antenatal appointments [ 7 ]. For many people from socially and ethnically diverse groups, the political, policy, clinical and philosophical contexts of maternity services make engagement with care challenging [ 8 ], leading to poorer maternity outcomes [ 9 , 10 ]. Pregnant women (and their partners) are sometimes offered antenatal education classes. However, access and provision is inequitable across the UK and many do not attend due to cost and/or other constraints. Classes are considered important for providing information and facilitating social support, which is known to be important for short- and long-term wellbeing [ 11 ]. However, there is no consistent evidence that standard (didactic) antenatal education improves birth and parenthood outcomes and/or experiences [ 12 ].

A recent UK enquiry into maternal and child health highlighted the significantly higher mortality rates among women and babies from minority ethnic groups and those affected by social or economic deprivation and identified sub-optimal care experiences as a contributing factor [ 10 ]. Systemic, structural, and institutional factors can produce these health disparities and expose a pattern whereby women from socially and ethnically diverse groups receive inadequate maternity care. Frequently, there are multiple forms of intersecting inequalities which compound and create challenges and disadvantages based on numerous factors [ 13 ].

Existing evidence on group antenatal care

Ensuring quality, equitable maternity care requires the development and evaluation of new care models and, where appropriate, scale-up and replication for maximum population health impact. Quality maternity care should incorporate medical checks, effective health information sharing, social support, and cultural safety for all women, to enable participation in timely and comprehensive care seeking. Satisfying and optimal care and outcomes may be supported with such holistic ANC models.

Group ANC is a care model combining elements of clinical assessment and learning with the aim of facilitating social connections [ 14 ]. One of the most established models is ‘Centering Pregnancy’, developed by a midwife in the US to tailor care to the needs of socially disadvantaged communities who experience poorer access and care quality [ 15 ]. Centering Pregnancy combines clinical checks with information sharing and is typically provided by the same two midwives facilitating a group of around 8–10 pregnant women. The first part of each session involves ‘self-care activities’ (individuals are taught to test their own blood pressure and urine) followed by one-to-one individual health checks with a midwife on a mat in the group space, to one side of the ‘Circle’ while other women had a group discussion facilitated by the second midwife. These clinical checks included: palpation, auscultation and fundal height measurement; discussion about blood pressure, urine, scan and blood results; and questions about foetal movements, personal concerns, mental health and domestic violence. Any general queries are discussed in the group, allowing the individual checks to remain brief (around 3–5 min). The model was developed in response to recognition of the importance of social support during pregnancy and the transition to parenthood and known limitations of didactic approaches to teaching and learning. Furthermore, women are not viewed as passive recipients of care, but are encouraged to make informed decisions, provide informed consent (or refusal), and to take an active role in their care to attain the best outcomes for themselves and their babies. This is facilitated by the longer time allocated for each session (typically 90–120 minutes compared with 20–30 in individual care) and continuity of facilitators and participants.

A 2015 Cochrane review of experimental studies concluded there is not yet sufficient evidence on group ANC to draw strong inferences about clinical outcomes [ 16 ] and a later systematic review of randomised controlled trials and cohort studies did not find significant differences in clinical outcomes [ 17 ]. However, a review focused on outcomes for women categorised as higher risk showed more variable effects, with greater benefits for specific groups including adolescents and African American women [ 18 ]. Group ANC is a complex, person-centred intervention, therefore it cannot be assumed that benefits identified in one study or setting will be scaled and replicated in others [ 19 ]; evaluations need to take account of practice variations and local contexts, including beliefs and views of local health professionals and of service users [ 20 ]. Group ANC also combines different components (i.e., continuity of midwifery carer, social support and enquiry-based learning) which in themselves may have different explanatory theories of effect. Emerging evidence suggests that empowerment and support are core principles of group ANC, which yields benefits for women in contexts with inequalities in access and delivery of care [ 21 ]. However, there are different theoretical perspectives to understanding the mechanisms of empowerment [ 22 ] and within group ANC, the concept is still under-theorised and poorly understood. Increasing our analytical understanding of the theoretical propositions that underpin group ANC, the ‘ingredients’ of the model, will help to explain any effects and the role of context, to support further developments of the model and inform scaleup and replication/adaptation. This calls for an approach rooted in critical realism [ 23 ] to better understand the underlying causal mechanisms and the interplay between observable and hidden mechanisms shaping how group ANC might work for particular groups and within different contexts.

Realist synthesis approach

Realist synthesis is an approach to systematic review which focuses on identifying and testing potential context-intervention-mechanism-outcome configurations to develop theoretical and substantive understanding of how an intervention works, for whom and in what circumstances [ 24 , 25 ]. It challenges positivist models of systematic review by positing that complex interventions do not ‘work’ in an ‘a-contextual’ and standardised fashion, replicable once subjected to rigorous evaluation. Instead, mechanisms of effect are produced by the ways in which interventions are interpreted, implemented and enacted, in particular environments and by people who may actively shape them [ 26 ]. In order to develop an appropriate experimental study, therefore, we identified a need to clearly understand potential mechanisms of effect of this care model and to develop a context-sensitive model which includes a core set of components around which local implementation would vary [ 27 ]. In this sense, realist reviews seek to provide explanations rather than measure outcomes.

This review was developed as part of a broader research programme, the REACH Pregnancy Programme [ 28 ], which sought to develop, implement and evaluate a bespoke model of group ANC (called ‘Pregnancy Circles’) for a socially and ethnically ‘superdiverse’ community [ 29 ]. The primary aim of this realist review was to articulate both implicit and explicit theories of action and key principles of group ANC (see protocol [ 30 ]). Secondary aims were to synthesise the findings/methods of the sources under review in relation to maternal and newborn health and wellbeing, and health services/service provider outcomes. The specific objectives were to:

Identify and review relevant research on/reports of implementation of group ANC models.

Articulate theories informing the models evaluated.

Identify the context and mechanisms of change in models already evaluated, recognising the likely complexity.

Synthesise and develop a set of core principles to inform the design and development of an intervention model tailored for a UK context named ‘Pregnancy Circles’.

Inform the preparations for implementing and testing the model in a planned multi-centre RCT.

Synthesise the findings of the range of the studies/sources on the subject.

This review was conducted following the RAMESES guidelines for realist synthesis, and the PRISMA guidelines for systematic reviews [ 31 , 32 ].

Eligibility criteria

We envisioned different sources would contribute different context, intervention, mechanisms and outcome (‘CIMO’) insights (with some containing several data types). We therefore sought to mine for theoretical and empirical data in a wide range of media, including clinical trials, qualitative studies, reviews, reports, commentaries and videos. We included sources describing reviews as background information to provide theoretical insights; only sources describing primary research were accessed for data extraction and analysis. Non-research sources (e.g. opinion pieces, audio-visuals) were also included as these may highlight theoretical propositions underlying model development and implementation.

Inclusion criteria:

All sources related to any outcomes of an ANC model, or ANC and postnatal care that include participants meeting in a group (at least 4 women).

All sources related to the process or implementation of an ANC model that includes women meeting in a group (at least 4 women).

All sources related to experiences of an ANC model that includes women meeting in a group (at least 4 women) (professionals’ or users’ experiences).

All national/country contexts.

Exclusion criteria:

Groups that do not include ANC.

Groups provided outside NHS/mainstream health care (e.g., by charity groups).

Groups that provide speciality rather than routine care (e.g., obesity ‘clinic’).

One-off groups.

Groups not including clinical care (e.g., classes only).

Groups not involving any health professional input (e.g., peer-led groups).

Following data extraction, a further exclusion was applied prior to analysis:

Sources relating to opinions and experiences without relevant CIMO data.

Study selection

Database searches were conducted in MEDLINE, PsychINFO, EMbase, Maternity and Infant Care, Web of Science, Cochrane library (Cochrane Central Register of Controlled Trials [CENTRAL] and Database of Systematic Reviews) (see Appendix 1 for search terms used). No language restrictions were imposed for the initial search. Sources published from and including January 1980 to March 2015 were eligible for inclusion. Grey literature was sought in sources including OpenGrey, GreySource, internal reports and non-peer reviewed journals such as Midwifery Digest). Reference chaining was undertaken on all relevant sources retrieved, and forward and back-citation searches conducted using Google Scholar. Searches were also undertaken in relevant websites such as the Centering Healthcare Institute Inc., Association for Improvements in Maternity Services, National Childbirth Trust, and Local Supervising Authority Midwifery Officers Forum. As we aimed to include audio visual media, we also searched YouTube and internet search engines (for example, Google) using key terms.

EPPI-Reviewer version 4 was utilised for data/review management. Titles and abstracts of written sources retrieved were first independently double screened by two researchers with any differences resolved through discussion or deferred to full text assessment. Full texts of included written sources were then double screened by two researchers, and any disagreements adjudicated by a third person. Audio visual media sources were screened by one reviewer using the same criteria. Realist reviewing is complex and time-consuming so following the analysis, the search was updated in April 2019 to identify any additional sources or insights (from the period of April 2015 - April 2019). These were screened and read analytically by two reviewers to identify whether any new themes should be added, or existing themes modified in light of new literature.

Data extraction and management

We developed data extraction proformas to draw out data (i.e., descriptive notes, ideas and annotations or excerpts) around the terms of what works, for whom, in what circumstances. The extracted data were then interrogated by sub-teams of researchers to answer the research aims specifically relating to:

What works , and for whom? Outcomes measured in each study were collated and compared by study population, to determine whether they were more or less successful with different groups of women (for example, vulnerable, young or socio-economically deprived groups).

How? Are any explicit theoretical claims made about how the intervention might or did achieve the intended or experienced outcomes? What can be gathered implicitly regarding theories of how the intervention might or did work?

In what circumstances? How does context at a strategic, institutional, inter-personal and individual level disrupt or support the implementation or delivery of the intervention?

The analysis was conducted inductively, with no initial attempt to impose a preconceived framework, theory or theories onto the data unless deemed appropriate. As part of the reflective process team members formulated their own logic models prior to analysis, to make their own ‘theories’ explicit; these were set aside for later reflection on the findings rather than used as a framework for analysis. Critical discussions were held within and between sub-teams during this process, and the data relevant to each question were then synthesised.

Assessment of risk of bias

Reviewers assessed and ranked source quality and relevance and provided rationales for their decisions drawing on the RAMESES Quality Standards for Realist Synthesis [ 31 ]. Key principles by which sources were assessed included: whether they contributed to the development or testing of programme theories; and, in the case of research sources, rigour: whether the studies used credible and trustworthy methods. We used an adapted checklist from the Critical Appraisal Skills Programme (CASP) to assess rigour of research-based sources. Additionally, an overall assessment rating of low, medium or high was assigned, relating to the source’s usefulness for the review, based on content with sufficient detail to inform the analysis, with ‘high’ rated sources prioritised during data synthesis.

Data synthesis

We used a two-stage approach to synthesis; an initial analysis identified themes from the review data on what works for whom, how, and in what circumstances. A second, narrative synthesis, iteratively developed overarching themes through data interrogation and review team discussions. Statistical analysis based on any group or sub-group outcomes was outside the review scope and focus.

Identification, screening and study selection

The initial electronic search in 2015 produced 2,238 records with another seven sources obtained from hand searching of reference lists. After full screening, the review included 100 sources (of which 11 were audiovisual and the remaining 89 written sources) (see Fig. 1 ). An updated search in April 2019 identified 75 additional sources, of which 48 met the inclusion criteria and 27 were excluded following full text review (two of which were study team publications). Of those 48 sources, 15 were conference abstracts or posters which did not provide sufficient detail to add new insights to the analysis. Of the remaining 33 sources, there were no additional or divergent themes identified and they were therefore not included in this synthesis (summary details are given in Supplementary file 1 and 2 ). As a result, we concluded that analytical saturation in relation to theories of effect had been reached and no further search updates were conducted.

Consort diagram

Characteristics of included sources

Most sources were either cohort studies or opinion/expert reviews. Only four sources were from the Global South. Most sources ( n = 77) related to populations and contexts in the United States. There were 14 studies or projects which had numerous sources reporting on outcomes or were commentaries, editorials or conference abstracts related to that study. The sources from the same project or study were linked for the review and data extraction to avoid data duplication.

The vast majority referred to a ‘standard’ CenteringPregnancy ( n = 62). This follows the recommended schedule of ANC visits (lasting 90 min to two hours long) with women taking and recording their own health data, facilitative discussions, and activities to address important health topics, with private time with their provider. Of the CenteringPregnancy interventions, six described the model with ‘additions’ (including dental oral health components or specific topics relating to adolescents and youth). Another six sources described CenteringPregnancy with ‘adaptations’ where the private provider time was either scheduled outside of the main group session (i.e., either side of it), or where ANC visits involved a combination of one-to-one appointments and group sessions throughout pregnancy. There were seven sources describing non-CenteringPregnancy models of group ANC, which broadly described similar models of care to standard CenteringPregnancy.

What works and for whom?

Evidence on the benefits for particular population groups was inconsistent when examining ‘what works’. We coded and categorised outcomes into four key domains: (1) experience (e.g., satisfaction), (2) clinical (e.g., mode of birth, birth weight), (3) health behaviours (i.e. smoking, breastfeeding), and (4) psychosocial (e.g. self-efficacy). We then coded population groups into 10 categories based on four population risk factors (social/demographic factors; medical, economic or none) within high income or low to middle income countries (see Table 1 ).

Mapping the outcome categories by population group categories generated no overall conclusive patterns as to what works for any particular population groups, although there were some indications of benefits for military families [ 33 ], for African American women [ 34 ] and for adolescent mothers [ 35 ].

Poor reporting and rationale for targeting particular population groups hampered comparisons. For example, some sources stated the targeted population groups were socially or medically high-risk but did not explain in detail or provide a clear rationale for why and how group ANC was expected to confer benefits. Others defined risk by the geography of an area such as where a clinic was located (i.e., low-income area) but did not explain this further in relation to the group care participants. Furthermore, being from a minority ethnic group was deemed high-risk due to the increased prevalence of poorer clinical outcomes at the population level, with little detailed understanding of how race and ethnicity were associated with poorer outcomes. For example, group ANC tended to have limited effectiveness compared with usual care in communities where women already had strong social support networks [ 36 , 37 ]. Some sources also referred to the ‘Latina paradox’ whereby group ANC had little positive effect due to the already high levels of social support found within the Latin American population [ 37 ]. No studies examined the interconnected nature of multiple and compounding risk factors (i.e., through an intersectionality lens).

How (mechanisms of effect)?

Most sources drew on implicit rather than formal explicit theories to explain how group ANC might work to improve outcomes. Most sources also described CenteringPregnancy therefore they shared common theorised mechanisms of how group ANC might work. All implicit and explicit explanations were drawn out and coded, which generated six broad mechanisms of effect: (1) Social support; (2) Peer Learning; (3) Active Participation in Health; (4) Health Education; (5) Satisfaction with care; (6) Health Professional Development and Wellbeing (see Table 2 ).

Most sources referred to a number of these mechanisms, but some focussed on one or two only; for example, transaction of knowledge and health persuasion messaging (an individualised theory) while others were instead focused on the exchange of peer knowledge and breaking down of traditional ‘expert knowledge’ sources (a collective theory of action).

Group ANC was believed to facilitate positive relationships between women and their healthcare provider where more time and continuity with midwives (and other health professionals) built additional trust leading to increased satisfaction and engagement with care, as well as management of risks that was more responsive [ 33 , 36 , 50 , 51 , 52 , 53 , 55 , 59 , 67 , 71 , 72 , 73 , 74 ]. Shared health activities and engaging in women-led, group-based discussions supported woman-midwife relationships that were more equal and trusting [ 37 , 39 , 46 , 62 ]. Additionally, it was theorised that midwives deliver richer and safer care within group ANC models through more positive relationships with women and through gaining the opportunity to develop their own knowledge with colleagues [ 50 , 75 ].

Sources referred to mechanisms relating specifically to the group element of care. For example, group modelling supported empowerment where women developed greater confidence to take control of their health by viewing others’ behaviours [ 46 , 47 , 53 , 55 , 59 , 61 , 62 , 63 , 64 , 66 , 76 ]. It was theorised that group ANC provided peer and community support, allowing women to share and normalise experiences, whilst also gaining practical and relevant psychosocial support [ 38 , 39 , 40 , 41 , 42 , 43 , 44 , 71 ]. Reduced stress and increased coping skills through pregnancy were anticipated [ 58 , 77 ]. It was expected that peer support would reduce unnecessary reliance on health services and build more resilient communities [ 36 , 41 , 45 , 46 , 47 , 50 , 51 ].

An overarching mechanism was the reoccurring concept of empowerment as related to increasing women’s knowledge, ability to make better informed decisions (and behaviour changes) and building positive support networks with healthcare providers, own peers and their communities. However, most sources poorly theorised the concept of empowerment with different underpinning assumptions from individualistic and collective perspectives. For instance, nearly all theorised a link between greater knowledge and empowerment, whereby active learning approaches (e.g., peer-led group discussions) results in more relevant and salient knowledge, leading to empowerment in decision making and positive behaviour changes. This process of empowerment was largely conceptualised through an individualistic lens relating to self-efficacy and control over one’s health rather than broader concepts of empowerment which instead encompass collective and/or group levels of empowerment and/or paradigmatic shifts in care delivery. However, there was insufficient detail in the data to enable a fuller exploration of how such differences in the hypothesised underpinning mechanisms may influence the implementation, process or outcomes of group care implemented in different settings.

In what circumstances?

There were three main context factors related to implementation and delivery of group ANC models. Factors included: (1) Focus on the community and hyper-local level; (2) Shifting care out of hospitals, (3) Adapting to a different way of working.

Focus on the community and hyper-local level

Most group ANC models of care sought to focus on the community and hyper-local level (i.e., particular populations and areas of deprivation) to signify equal partnership between women and facilitators [ 78 ]. Group ANC models needed to be easily accessible at this level to recruit and reach women whilst also working at a scale to allow for an appropriate number to form a group size of 8–10. This posed a number of practical challenges for teams, mainly recruiting a desired number of women at similar gestations within local areas which required good targeting, scheduling and organisation [ 38 , 71 ]. Focused recruitment strategies were needed to encourage women’s interest and engagement e.g., vouchers, automated reminders and involving local women in setting up and promoting groups [ 39 , 79 ]. An opt-out recruitment (rather than opt-in) was also used with success in another study [ 38 ]. There was some evidence that a lack of childcare facilities discouraged multiparous women from attending group care [ 37 , 79 ]. Engaging women in early pregnancy was considered important (particularly if any behaviour change was a desired outcome) [ 53 , 67 , 80 ], however engaging women too early could lead to high discontinuation rates for practical reasons or early pregnancy loss [ 52 ].

Shifting care outside hospitals

Most group ANC models were delivered in community settings rather than hospitals to aid accessibility, work at community and hyper-local level, and reach target populations. For example, an initiative targeting pregnant school pupils was held on a school site immediately after the end of the school day, which supported attendance [ 39 , 79 ]. Sourcing suitable community venues, and the increased time taken to transport equipment and set up venues each week, was a recurring practical challenge [ 33 , 45 , 55 , 71 , 81 ]. Many community-based venues were often not immediately appropriate for medical tasks such as routine blood tests and accessing patient records [ 39 , 75 ]. Group ANC required appropriate infrastructure and troubleshooting to manage the shift to care delivery outside of hospitals.

A different way of working

Groups were often set up and/or sustained by a small group of midwives or nurses who were committed to the concept, took ownership of the initiative and invested considerable time and effort to ensure its success [ 39 ]. The satisfaction gained from providing group ANC, working flexibly, making compromises where necessary and supporting each other enabled facilitators to sustain the model and overcome obstacles to implementation [ 38 , 82 ]. Group ANC was usually a very new way of working for teams and services and there were key points of incompatibility to overcome. For example, group facilitation was not a well-developed skill for most midwives [ 83 , 84 , 85 ]. Adequate facilitator training was essential; and in its absence, both midwifery and medical professionals tended to adopt an overly didactic style, which was unsatisfying to women, leaving them feeling their concerns had not been addressed [ 52 , 72 , 86 ]. A didactic teaching style was deeply ingrained in some physicians [ 55 ], as reported in some Swedish and Canadian studies [ 52 ]. Women also needed to have a good understanding of the model otherwise there were confusions. For example, in one study, participants were not aware that group attendance replaced standard individual appointments and women tried to attend both [ 33 ]. Group ANC models also needed to consider the value this model offered within existing care. In one study, group ANC was less well received when set against a case-loading approach [ 45 ]. There was insufficient detail on national and local policies and health system factors to enable a full exploration of these broader context issues or to identify whether group care may have different impacts in settings with or without established and autonomous midwifery care, or in health systems which are universal or with a mix of private and subsidised care.

Overall, there was no clear pattern of ‘what works for whom, in what circumstances’. Although in some studies group care was targeted to more underserved groups or in more disadvantaged areas, and some studies have identified specific benefits for these groups [ 18 ] mechanisms such as peer learning and social support appeared salient for all groups. Variation in contexts, group ANC application or interpretation as well as which communities were involved may account for the inconsistency of findings. Our analysis did reveal some other important insights. We identified six interlinking mechanisms drawn out from mainly implicit descriptions. Mechanisms included: social support, peer learning, active participation in health, health education and satisfaction or engagement with care. A further theory related to impact on professional practice but was relatively under-developed. An overarching mechanism of empowerment featured across most studies, but most models largely adopted an individualistic lens despite the group/community focused approach. For example, some focused on the role of education, peers, and social support to change actions and behaviours. Others focused on broader paradigmatic shifts in professional-client relationships and the redistribution of power to women and communities. Conceptualisation of educational mechanisms drew on two somewhat different areas of pedagogical theory: one more focused on the emancipatory potential of the group approach to information and learning, whereas the other was rooted in a more transactional concept of education. The mechanisms of effect relating to empowerment were particularly important when considering which population group(s) to target for group ANC. There was poor reporting of populations, inadequate rationales for why particular populations were targeted and how the model was expected to confer benefits. For example, limited benefits were reported where women already had strong social support networks. No studies considered intersectionality of multiple and compounding risk factors. Few studies considered wider health system factors in shaping contexts, mechanisms and outcomes and most focused on site-specific context factors relating to implementation and individual/team level cultures. Much of the early conceptualisation and implementation of group ANC took place in the US, and it is possible that the model may function differently and have varying effects in different health systems, rather than simply in different local contexts or working with different populations and communities.

Our findings are largely in line with other research, including a previous Cochrane review demonstrating that there is insufficient evidence of benefits from this care model [ 16 , 17 ] They are also concordant with a later scoping review to construct a conceptual framework for group well-child care [ 87 ] [where Gresh and colleagues identified guiding frameworks including adult and experiential learning theory social learning theory, Freire‘s pedagogy and several behaviour change theories]. We suggest there are inconsistencies in the evidence base due to variation in contexts, how the model is applied or interpreted as well as which communities are involved. For instance, our findings support other reviews which suggest that group ANC is likely to be most beneficial in groups and contexts with high levels of inequalities in access and experience of care, such as higher-risk or more vulnerable populations such as African American women and adolescents [ 18 ]. Another review focused on attributes that may support acceptability and effectiveness in LMICs and posited a generic model which was concordant with the mechanisms of effect we identified here, including empowerment and social support [ 21 ]. Since mechanisms of effect may have particular advantages in contexts where access and care inequalities exist, giving ‘women a voice for knowledge sharing and a sense of community support’ [ 21 ] may be of particular value. The concept of empowerment was present in a range of sources, but the meaning of empowerment was less often developed. Ongoing research by the review team suggests that empowerment may be mutually constructed through development of those facilitating as well as those participating in group care [ 21 , 22 ], which is consonant with Freire’s emancipatory pedagogy as compared with a ’banking’ model of education [ 88 ].

Strengths and weaknesses of the review

A systematic approach to searching for sources, including research and non-research literature helped to ensure a comprehensive set of sources, although inevitably some sources which may have been relevant will be missed by such a process. A realist approach helped to identify the potential mechanisms of effect for how group ANC ‘works’ with calls for more theoretical understanding about the concept of empowerment and how this relates to particular groups facing intersecting forms of inequality, disadvantage and discrimination. This approach also helped to provide more nuanced guidance on what to consider when implementing group ANC, including what features of the context are important. Our analysis however was limited by the lack of detail in study reporting, which meant some implicit understanding and insights had to be drawn out. Potential for researcher biases were handled through discussions and reviewing our own assumptions at review commencement to check how these may influence findings. In anticipation, each review team member drew a logic model at the outset, setting out their own theoretical propositions and assumptions about mechanisms of effect. For this reason, the team did not include their own developing work in the review, as we considered this may weight the analysis more heavily towards our own thinking. That said, the review work was intended to inform our thinking about possible mechanisms of effect of group care and took place over an extended period alongside our primary research, so it is likely that influences were mutual. Searches took place initially to feed into a feasibility study and development work for a bespoke model of group care to function in a UK NHS setting. A subsequent update identified no new themes relating to theories or mechanisms of effect. The team concluded that sufficient saturation was reached in the literature to inform future work to implement and evaluate this model of care (see Figs. 2 and 3 ). The review did not lead to any dissonant findings but instead provided a more developed consideration of possible mechanisms of effect for group care, as reflected in Fig. 2 and informed our Core Values and Components description for Pregnancy Circles (Fig. 3 ).

Pregnancy circles logic model

Pregnancy circles values and components

Implications for researchers, care providers, and policymakers

This review of group ANC provides important implications for researchers, care providers and policymakers. Our review was hampered by the lack of study details particularly intervention and contextual descriptions and rationales for population group targeting. There is also a need for greater reporting quality and consistency. Future research would benefit from a clearer focus on mechanisms of effect, to ensure appropriate outcome measures are used, but also a clearer focus on who is expected to benefit and in which contexts. Further trials are essential, including detailed process evaluations exploring the role of care context and process, professional preparation and attitudes, the communities involved and how they experience group care. We identified few studies or other sources that examined the effects on care providers and could not identify theories of how any impact on professionals may have an impact on service users. We did not identify any negative impacts of more interactive and active participation of service users on professionals, although this is likely to be an important line for future research (for example, see [ 89 ]).

Much of the early conceptualisation and implementation of group ANC has taken place in the US, where the health financing system is not universal, access to healthcare is inequitable and midwives remain relatively marginal rather than mainstream healthcare providers. It is possible that the model may function differently and have varying effects in different health systems, rather than simply in different local contexts or working with different populations and communities. These should be considered in more depth in future studies and reviews. This review was undertaken alongside the conduct of a qualitative feasibility study and pilot trial. Both were intended to contribute to the conceptualisation and design of a contextually adapted model to be tested formally in a trial, with integral process evaluation. The findings of both studies were utilised to develop a logic and core values model, which helped to shape the trial intervention and provide a guide for the process evaluation, through clarifying how this model of care should be implemented in the study sites (see Figs. 2 and 3 ). An RCT with nested qualitative evaluation is currently in progress [ 28 ], following a successful pilot trial [ 90 ].

For providers and policymakers, we outline some key context factors which suggest a focus on supporting staff and teams to implement group ANC at a hyper-local community level and enabling the systems, infrastructure, time and training to shift care out of hospital settings and bring on broader paradigmatic shifts in care delivery and the women-provider relationship. Group ANC facilitators required support and learning to deliver the model in non-didactic ways and to bring out the benefits of the group dynamic. Further work is needed to examine the concept of empowerment, whether and how this may operate as an overarching mechanism of effect and in what circumstances.

Data availability

All data generated or analysed during this study are included in this published article (and its supplementary information files).

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Acknowledgements

We would like to thank the EPPI-Reviewer team at the EPPI-Centre for their training and support and Silvia Potter for undertaking the initial searches and providing ongoing support.

The review was undertaken as part of the REACH Pregnancy Programme which is supported by the National Institute for health and care Research (NIHR) under NIHR grant number RP-PG-1211-20015. Angela Harden is in part supported by the NIHR ARC North Thames. The views expressed in this publication are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care.

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Oxford Brookes University, Oxford, UK

Louise Hunter

University College London, London, UK

Meg Wiggins

University of Queensland, Brisbane, Australia

Penny Haora

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AM, GDM, LH, JR, MW, CM, and AH were involved in the screening, data extraction and synthesis stages of the review. AM led the overall synthesis of findings with input from AH, CM, GDM. AH is the PI for the project, and led the conceptualisation process with input from MW, CM, and PH. All authors read and approved the final manuscript.

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Correspondence to Anita Mehay .

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Mehay, A., Motta, G.D., Hunter, L. et al. What are the mechanisms of effect of group antenatal care? A systematic realist review and synthesis of the literature. BMC Pregnancy Childbirth 24 , 625 (2024). https://doi.org/10.1186/s12884-024-06792-6

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Received : 18 September 2023

Accepted : 28 August 2024

Published : 01 October 2024

DOI : https://doi.org/10.1186/s12884-024-06792-6

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Group antenatal care
CenteringPregnancy
Realist review

BMC Pregnancy and Childbirth

ISSN: 1471-2393

Submission enquiries: [email protected]
General enquiries: [email protected]

IMAGES

Early antenatal care visit: a systematic analysis of regional and global levels and trends of
The Importance of Antenatal Care for Safe Motherhood
Antenatal Health CARE
Antenatal Care
ANTENATAL CARE
Antenatal Care

COMMENTS

A Literature Review on Emerging Factors Affecting Antenatal Care
A systematic scoping review of studies focused on factors associated with the use of antenatal care services by pregnant women was done. In total, 30 relevant articles were included for review.
What are the essential components of antenatal care? A ...
Background: Antenatal care (ANC) is one of the key care packages required to reduce global maternal and perinatal mortality and morbidity. Objectives: To identify the essential components of ANC and develop signal functions. Search strategy: MESH headings for databases including Cinahl, Cochrane, Global Health, Medline, PubMed and Web of Science.
What are the essential components of antenatal care? A systematic
Antenatal care (ANC) is one of the key care packages required to reduce global maternal and perinatal mortality and morbidity. Objectives. To identify the essential components of ANC and develop signal functions. Search strategy. MESH headings for databases including Cinahl, Cochrane, Global Health, Medline, PubMed and Web of Science. Selection ...
Input, process, and output factors contributing to quality of antenatal
Background High-quality antenatal care (ANC) provides a lifesaving opportunity for women and their newborns through providing health promotion, disease prevention, and early diagnosis and treatment of pregnancy-related health issues. However, systematically synthesised evidence on factors influencing the quality of ANC services is lacking. This scoping review aims to systematically synthesize ...
Provision and uptake of routine antenatal services: a qualitative
This review was designed to complement the existing Cochrane Reviews of the efficacy of different antenatal models of care (Catling 2015; Dowswell 2015), to inform the antenatal care recommendations in the WHO guideline for a positive pregnancy experience , and to provide insights for the design and implementation of improved antenatal care in ...
Evidence review for antenatal care planning involving a
Literature review and description of model of care implemented at the Maternal Health Clinic: Smith, M. R., Pande, B., Evaluating the requirement for a joint obstetric/cardiology clinic within NHS tayside, Archives of Disease in Childhood: Fetal and Neonatal Edition, 99, A135, 2014 ... Evidence review for antenatal care planning involving a ...
Referral and delivery of antenatal care
This review gathers evidence of women's views on how, where and by who antenatal care should be delivered. The committee agreed it was important to ask a qualitative question that captures women's experiences of and preferences for different aspects of delivery of antenatal care. This review is intended to help tailor recommendations in a ...
A Literature Review on Emerging Factors Affecting Antenatal Care
Parity The parity of women is a substantial aspect of antenatal care attendance. Literature review demonstrated that fourteen studies have observed the role of parity in influencing ANC attendance among women. Eight studies provided evidence that low parity recorded more antenatal care attendance. Older and high parity women were found to be ...
Antenatal care services and its implications for vital and health
Antenatal care (ANC) is an essential part of primary healthcare and its provision has expanded worldwide. ... The DHS dataset also provides information on several variables that are well-established in the literature to impact mortality and morbidity outcomes of children and that simultaneously are potentially influenced by ANC attendance ...
What are the mechanisms of effect of group antenatal care? A systematic
Background There is growing interest in the benefits of group models of antenatal care. Although clinical reviews exist, there have been few reviews that focus on the mechanisms of effect of this model. Methods We conducted a realist review using a systematic approach incorporating all data types (including non-research and audiovisual media), with synthesis along Context-Intervention ...

What are the essential components of antenatal care? A systematic review of the literature and development of signal functions to guide monitoring and evaluation

Publication types

Grants and funding

Review question

Introduction

Summary of the protocol

Methods and process

Clinical evidence

Excluded studies

Summary of included studies

Quality assessment of studies included in the evidence review

Economic evidence

Summary of studies included in the economic evidence review

Economic model

Qualitative evidence statements

Level 1. Individual level

Sub-theme 1a. Being known by care provider

Sub-theme 1b. continuity of care

Theme 2. Empowerment

Level 2. Family level

Level 3. Community level

Theme 5. Shared experience

Sub-theme 5a. Independence from men

Level 4. Policy level

Sub-theme 6a. Additional information opportunities

Theme 7. Clarity of service information

Sub-theme 7a. Understanding role of care providers

Theme 8. Engaging and responsive communication

Sub-theme 8a. Adequate communication between care providers

Sub-theme 8b. Interpreter service

Sub-theme 8c. Remote contact

Theme 9. Frequent contact

Theme 10. Free service

Theme 11. Prompt and simpler referral

Theme 12. Treated as an individual

The committee’s discussion of the evidence

The quality of the evidence

Discussion of findings

Cost effectiveness and resource use

Appendix A. Review protocol

Appendix B. Literature search strategies

Appendix C. Clinical evidence study selection

Appendix D. Clinical evidence tables

Appendix E. Forest plots

Appendix F. GRADE-CERQual tables

Appendix G. Economic evidence study selection

Appendix H. Economic evidence tables

Appendix I. Economic evidence profiles

Appendix K. Excluded studies

Economic studies

Appendix M. Quotes supporting themes

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A Literature Review on Emerging Factors Affecting Antenatal Care Utilization of Pregnant Women

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Antenatal care services and its implications for vital and health outcomes of children: evidence from 193 surveys in 69 low-income and middle-income countries

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Introduction

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What are the mechanisms of effect of group antenatal care? A systematic realist review and synthesis of the literature

Conclusions

Registration

Existing evidence on group antenatal care

Realist synthesis approach

Eligibility criteria

Study selection

Data extraction and management

Assessment of risk of bias