Acta Obstetricia et

Gynecologica Scandinavica
1SS.V 0001-6349

ACTA REVIEW

Scientrfic basis for the content of routine

antenatal care
I. Philosophy, recent studies, and power to eliminate or alleviate adverse
maternal outcomes
JOSE VILLAR' AND PER BERGSJ0'

From the 'Special Programme of Research, Development & Research Training in Human Reproduction, World Health
Organization, Geneva, Switzerland and the 2Centre for International Health, and Department of Obstetrics and Gynecology,
University of Bergen, Bergen, Norway

Actu Ohstet G j m d Scund 1997: 76: 1-14. 0 Acta Obstet Gynecol Scand 1997

Brickground. Scope and content of antenatal care programs are ritualistic rather than evi-
dence-based. We wanted to identify elements of antenatal care which are of proven benefit in
preventing or ameliorating specific adverse outcomes in the mother: bleeding, anemia, pre-
eclampsia. sepsis and genito-urinary infection and obstructed labor.
;21'ethorls. Review of recent literature, especially randomized controlled trials.
Resirlts and conclu.sions. Recent trials indicate that fewer routine visits for low-risk women d o
not put pregnancies at increased risk but may lessen patient satisfaction. Bleeding in preg-
nancy has many causes. none of which can be eliminated through antenatal care. Risk factors
can be identified by history-taking. Counselling and advice on what to d o is the best option.
Anemia in pregnancy is common, especially in developing countries. Routine iron supple-
mentation is not necessary in well-nourished populations, but iron and folate should be pro-
vided for every pregnant woman in areas of high anemia prevalence; based on circumstantial
evidence. Hemoglobin (Hb) determination as a routine test is more important late (around
week 30) than early in pregnancy: high H b is a danger signal. It is uncertain whether early
detection of pre-eclampsia will reduce the incidence of eclampsia. Recent trials d o not support
routine aspirin to prevent pre-eclampsia among low risk women, nor is there evidence that
anti-hypertensive treatment of mild pre-eclampsia will prevent more severe disease, but im-
proved detection and care may still lead to better outcome. As to infections, urine culture
and dipstick for leucocyte esterase and nitrite with subsequent treatment of positive cases will
reduce the risk of pyelonephritis and appears to be cost-effective. Serological screening and
treatment of syphilis is inexpensive and cost-effective. Obstructed labor can be anticipated in
multiparas based on obstetrical history. Hospital delivery should be secured. Height of nulli-
paras should be recorded where hospital birth is not routine and a discriminatory level for
hospital delivery decided locally. External version of breech lie does reduce the incidence of
breech births and cesarean delivery.

Kej. n,ol-ds: anemia: antenatal care; bleeding in pregnancy; evidence-based medicine; ob-
structed labor; pre-eclampsia; urinary infection

Sirhtnirted 22 Airgust, 1996

Accepted 22 ilugust. 1996

A bbreriutions: Antenatal care programs, as currently practised,

CI: confidence interval: Hb: hemoglobin; OR: odds ratio; HDP:
hypertensive diseases of pregnancy; STD: sexually transmitted
diseases; CLASP: collaborative Low-dose Aspirine Study in
Pregnancy Collaborative Group; BP: blood pressure; RPR:
rapid plasma regression.
originate from models developed in the early dec-
ades of this century in Europe, notably the United
Kingdom. The core of these early models remains
practically unchanged in current programs, al-
0 Actri Ohstet Gynecol Scrnid 76 ( 1 9 9 7 )
2 J . l.illw irriil P. Btlrgsjo
though. as medical knowledge and technology
I i a e evolved. new technologies for screening for
disease and primary and secondary prevention
ha\e been added to routine antenatal care in de-
\eloped countries. Unfortunately. these new com-
poticiits and the timing of visits have most often
been introduced without proper scientific evalu-
ation ( I 3 ) .~
These models for antenatal care contain a sub-
stantial number of visits for the mothers - up to as
man> as 16 with little or no distinction between
~ dard care (19).
high and low-risk mothers. Recently, cost-benefit
aspects of antenatal care have been addressed in sev-
eral countries, and attempts are being made to re-
duce costs for clients and the health care services (1.
4).Thc need for change is recognized and consider-
able (Isbare is ongoing ( 5 . 6).
To ;I hrge extent, developing countries have
adopted the antenatal programs of developed
countries \\ i t h only minor adjustments pertaining
t o endemic disease. However, in many of these
countrioi \\,here resources for reproductive health
care arc sparse or used less than efficiently (7. 8).
the care often consists of irregularly spaced visits
v-ith long waiting time and poor feedback to
mothers. There is little communication between
the antenatal care clinics and the obstetric depart-
mcnts and maternity iinits.
The \.isits tend to be of a ritualistic nature rather
than rational health care. In three large maternity
units in Latin America, normal pregnant women
y x n t a n average of62 to 228 minutes in the clinics,
\\.it11 only nine t o twehe of those minutes with the
doctor. The doctor's interview lasted a mean of five
minutes (9). N o time is routinely devoted to activi-
tics IJt' \{omen's most important concerns, such as
ezp1:tnalic)n ot' procedures and involvement of
mothcrs i n these procedures (10). In most develop-
ing countries. even those women attending prenatal
care clo nor receive all the benefits possible from
these isitc. For example. tetanus immunization is
not pro\ided to a large proportion of them. al-
thoiigh this is recommended in all programs and has
pro\-en effective in preventing neonatal death ( 1 1-
13). 111 general. the validity of the content and the
rationale for frequency and timing of visits have not
been c\aliiated at all. The few observations made
ha\^ qucstioned the impact of antenatal care on ma-
ternal and perinatal morbidity and mortality (14,
15).This lack of evaluation is not exclusive to devel-
oping countries (16). The recent US Public Health
Ser\.ice Expert Panel on the Content of Prenatal
Care noted in its review that 'the literature on pre-
natal care activities was often limited, and many
studies were conducted without maximal scientific
rigour' ( 1 ). Similar conclusions were made by an in-
ternational panel in Sweden (17).
!<!I/ Oh.\/('/ G l . / l c , c o / S(.r/IltI 76 / 19971
The need for randomized controlled trials on
procedures and examinations included in antenatal
care has been emphasized (4, 18). A recent exten-
sive review of the literature concluded that 'care-
fully controlled evaluations of the content. number
and timing of prenatal care visits for women with
differing medical and social risk are essential' (2).
Such trials can establish minimal levels of care for
women at low risk through comparison of less fre-
quent or less intense prenatal care with the stan-
Assuming that antenatal care does confer health
benefits, how it prevents maternal and perinatal
mortality and morbidity is logically complex. Few
of the procedures commonly undertaken have a
major impact on morbidity or mortality. and some
may have no effect. For others. there can be no
impact unless other elements are also in place and
functional; for example, identifying pre-eclampsia
has no impact unless affordable and effective treat-
ment is instituted or available: identifying the risk
of post partum hemorrhage has no impact if insti-
tutional delivery is not sought. is unavailable or
ineffective. To further complicate the evaluation of
prenatal care on perinatal mortality. there is a dif-
ferent effect across populations. Among normal
birthweight infants in Indonesia, prenatal care had
more impact on perinatal mortality than maternal
education, when used as a proxy-indicator for
socioeconomical level (20). Conversely, prenatal
care in New York City had less impact on perinatal
mortality than maternal education (21).
Epidemiological studies tend to show that
women who receive antenatal care have lower ma-
ternal and perinatal mortality (19. 22, 23), and
that there is an association between the number of
prenatal visits or gestational age at the initiation
of care and pregnancy outcomes after controlling
for confounding factors, such as length of ges-
tation (24-26). Because of this suggested dose-re-
sponse effect in non-controlled studies, many ma-
ternal health programs seek to increase the quan-
tity of antenatal care provided. This has been done
without regard to the fact that, in general, lower
risk women are more likely to seek care earlier. The
general belief of obstetricians is exemplified in this
opening sentence of an article: 'It is now univer-
sally accepted that antenatal care is probably the
most important factor which determines the out-
come of pregnancy' (27). Although this may be
true for very high-risk women, parallel or oppos-
ing trends in time do not. in themselves. imply a
causal relationship for the overall population. This
particular claim has never been evaluated scien-
tifically. Recently, however. attention has been di-
rected to the essential elements of the prenatal care
package, in an effort to ensure that quality is not

overlooked in favor of quantity. Perhaps more ef-
fective antenatal care could be provided with fewer
visits, especially when these fewer visits are fo-
cussed on the elements most likely to have an im-
pact on mortality and morbidity? In principle, this
approach should be more effective as well as less
expensive.
It is also important to evaluate a comprehensive
package of antenatal care, rather than individual
clinical interventions, because evidence demon-
strates that disparities in pregnancy outcomes be-
tween social groups embrace all major maternal
conditions and not single pathologies (28). Fur-
thermore, the interactive nature of antenatal inter-
ventions and the multicausal characteristics of the
leading negative outcomes point toward a multipli-
cative effect of the components of antenatal care.
Philosophy of antenatal care
The concept of antenatal care has been generally
recognized as a very good model of preventive
health care. In theory, a series of health examin-
ations with predefined content should enable health
personnel to uncover ailments and other conditions
in the mother and her fetus(es) which may threaten
the pregnancy. The conditions may then be treated
or monitored to secure a better outcome. Planning
for a safe delivery is an integral part of antenatal
care. In a wider context, antenatal care should em-
brace the social environment, as well as the medical
aspects of pregnancy. It is also one of the few situ-
ations in which healthy women may have contact
with the health care system, allowing for other pre-
ventive interventions (1).
In currently applied antenatal care programs,
the basic philosophy is that, in normal cases, the
visits should become gradually more frequent as
pregnancy advances, starting with monthly check-
ups to week 28, followed by visits at two-weekly
intervals up to week 36, and weekly visits there-
after. The basic content of care at each visit has
not changed substantially over the years, although
modern technology has led to the introduction
(not always rigorously evaluated) of several new
elements in pregnancy surveillance, the typical
examples being sonographic imaging of the uterus
and its contents, Doppler blood flow velocity
waveform analysis, and biochemical and cell cul-
turing techniques for the identification of abnor-
mal fetuses or those threatened by growth retar-
dation.
The current situation
‘It amazes me that women come for. pvenatal
cave at all. They sit in these clinics for. two
Scientijc basis f o s antencrtal CNW 3
houvs to be seen for two minutes, with someone
laying on their hand and they leave. We should
be looking at why they come at all’.
McIlwaine, 1980 (29)
~
Industrialized countries
In countries where women traditionally or on ad-
vice attend the antenatal services early in preg-
nancy, the average number of visits is ten to twelve,
and attendance rates are nearly 1000/0 (30). In the
European Union countries, Luxembourg is an ex-
ception with an average of only five visits, while its
neighbor, The Netherlands, has between 12 and 14
(31). A recent survey in Scotland revealed that the
average number of antenatal visits for women with
low-risk pregnancies was 14 (32). In Sweden, the
recommended number used to be 16 (33) and in
Finland women make 15.2 antenatal visits, of
which 2.2 visits are to a hospital clinic (34). Pro-
viders in the USA, including midwives, tend to ex-
ceed the American College of Obstetricians and
Gynecology’s guidelines for the recommended
number of prenatal visits (35). Incentives to en-
courage participation in prenatal care have been
suggested, although they do not seem to have an
impact on the number of kept prenatal appoint-
ments or the level of satisfaction (36).
In spite of the similarity of antenatal care pro-
grams, surveys reveal that both the quantity and
the quality vary. Services are, in theory, available
to all pregnant women, either through private
health care or through public programs. However,
social inequality has been demonstrated in Eng-
land, Wales, and France, for late attendance and
number of antenatal care visits (37). In the USA,
there are several barriers to utilization of services
by women with low socioeconomic status (12).
Considerable resources are spent on medications
during pregnancy, as up to 70%~of low-risk pa-
tients used treatments other than iron supplements
(38, 39).
In recent years, voices have been raised to rede-
fine the quality of care rather than increasing
quantity (37, 40, 41). The necessity of the frequent
visits (42), as well as the screening ability of several
obstetrical procedures and routine laboratory
screening (4345) have also been questioned. In
1992, funds were granted in Scotland to compare
alternative models of antenatal care delivery (46)
and the results have now been published (see sec-
tion on Recent controlled studies) (47). In The
Netherlands, a controlled trial was proposed to
test the effect of fewer visits in a low risk popula-
tion (van Roosmalen J & Gravenhorst JB (1992)
Research protocol: The effect of the frequency of
antenatal care visits on the well-being of mother
0 Actri Ohstet G i i ~ e c oSccirzd
l 76 i l Y 9 7 )
1 .I. l'illor ~ P. Bcrgsjo
i i d
and infant. Leiden University Hospital, Depart-
nient of Obstetrics. Leiden, The Netherlands (un-
published) 1.
The key issue is not more or less antenatal care
or reducing the number of visits. but implementing
onl! those activities proven to be effective; the fre-
quency and timing of visits can then be planned
accordinglq:
D ~ivlop
J ii i g cow1tries
The situation is obviously different between de-
\)eloped and developing countries. In the latter,
conditions vary greatly in both quality and quan-
tity of care. and improvement of services should be
a matter of high priority, With the deplorably high
maternal and perinatal mortality and morbidity
pre\niling in many of the poorest countries and
regions of' the world. any improvement would be
expected to have a significant impact.
According to the World Health Organization,
there is wide variation in the proportion of women
\vho I-ecei1.e antenatal care. both between and
within geographic areas (30). In Africa, the figures
range from ?'!A to 99'>/;iand in Asia from 8% to
98'!;!. Sur\.eys from a number of developing coun-
tries from 1986 to 1989 revealed figures for ante-
natal coverage ranging from 50% to 90% (12).
Anallses demonstrated that in most of these coun-
tries. the more care provided, the better the peri-
natal outcome. While social and cultural con-
straints m a y be an obstacle to attendance in some
instances. the major reason for non-attendance is
lack of resources (skilled personnel and money),
quality of care on the part of care-providing au-
thorities. and lack of money among care-receivers
( 7 ) . I n urban areas where there are usually several
levels of antenatal care provision, each program is
aimed at the traditional pattern. Still, many
\vomen are seen only once or a few times before
the! .go into labor. The smaller average number of
\ isit>. e\wi where services are available, is largely
dut. to late initiation of antenatal care rather than
non-adherence to the recommended standards
( 2 7 ) . I n rural areas, the distance from home to the
health care center may also play a part.
Recent controlled studies
Although recent attetnpts were made to evaluate
antenatal care programs for low-risk women (34,
38 50). no randomized controlled study with 'in-
tention to treat' analysis comparing two distinct
model\ of antenatal care which differ in both
quantity and quality of care, has been published to
our knowledge. It has recently been concluded that
flit) i i h \ e r i c ti of direct. rmidoniized, controlled trials
precludes a straightjiorward ewluation o j the inipact
of prenatal care 011 birth outcorneJ (19). There have
been six randomized trials evaluating the effect of
enhanced prenatal care by relatively broad-based
interventions, as compared with standard of care,
on birthweight. This expanded antenatal care in-
cludes strong psychosocial support and educa-
tional activities at the clinics or in home visits.
Four of these studies, with a total sample close to
7,000 women, conducted in different countries,
showed no demonstrable effect on birthweight or
gestational age (40, 51-53). It should be noted,
however, that in the Study by Heins et al. (52)
midwives were able to care for high risk popula-
tions as compared with highly trained obstet-
ricians, without differences in the outcome vari-
ables. The other two, although reporting no overall
effect on birthweight and the rate of low birth-
weight (54, 5 3 , demonstrated a small positive ef-
fect in a subgroup analysis. In the Study by Olds
et al. (55), an improvement in birthweight was ob-
served among 21 teenagers. as compared with el-
even 'comparable' control mothers. In the strati-
fied analysis of 86 primiparous mothers assigned
to the comprehensive program, an increase of 144
gm was seen (54). No effect was present among
multiparae. The results of these small stratified
analyses were not corroborated by a larger multi-
center study (53).
Overall, there were ten studies that provided
data on preterm delivery and eleven that included
low birth weight and type of delivery as outcome
variables. The meta-analysis of these studies
yielded odds ratios of 0.93 (95% CI 0.82 to 1.05)
for preterm delivery, 0.93 (95% CI 0.80 to 1.07) for
low birth weight and 0.96 (95%)CI 0.86 to 1.07)
for forceps delivery or cesarean section. In other
words, the expanded care programs did not affect
these three outcomes.
Furthermore, two randomized controlled trials
evaluating preterm deliverj prevention programs
that included weekly or biweekly visits. cervical
examination and education, with a total sample
size close to 3,300 women, did not demonstrate a
protective effect for preterm delivery or low birth
weight (56, 57).
Conversely, it has been suggested that 'simpler'.
'less technology-oriented' prenatal care would be
less demanding to women and the health system
without compromising pregnancy outcome. Four
controlled trials have recently been published and
a trial in Harare, Zimbabwe has been completed
and is expected to be published soon. In the first
trial 549 women were randomized to either the
usual form of prenatal care (13 expected visits) or
to a program of eight expected visits (58). There
are several major methodological limitations in

this study, including inappropriate sample size, loss
of patients to follow-up (no ‘intention to treat
analysis’), and randomization based on mothers’
birth dates with imbalanced sample size in the
groups on an ad lzoc basis, making the results dif-
ficult to interpret. The authors claim that both pre-
natal care models produced similar results in terms
of outcome and maternal satisfaction.
In the London trial, low-risk, consenting women
were randomized to either the ‘traditional’ 13
visits, or to the ‘new style’ of seven (nulliparous)
or six (multiparous) visits. Analysis was conducted
on the ‘intention to treat’ principle. The difference
was smaller than intended (2.2 visits). Out of 2758
women with clinical data and 36 with ques-
tionnaire data available, there were no significant
differences between the groups in cesarean section
frequency, or in any other clinical outcome vari-
able. However, those in the new style schedule
complained about too few visits and too little time
to talk and being listened to at visits (59), sug-
gesting that women may not tolerate this reduc-
tion, perhaps influenced by past experience of
antenatal care (60).
The Scottish model approaches the evaluation
of a simplified system by proposing ‘only’ seven
visits for those women in the lowest risk category,
with more emphasis on ‘psychosocial midwifery
care’. The trial revealed that antenatal care pro-
vided by general practitioners and midwives re-
sulted in improved continuity of care as compared
with obstetrician led shared care. Specialist care
led to more routine visits, more antenatal admis-
sions and more frequent inductions of labor, but
the general practitioners and midwives failed to
check for rhesus antibodies at 34 weeks in a num-
ber of instances. Specialist visits for low risk
women offer little benefit, while satisfaction was
equally high in both groups (47).
In 1989, an expert panel in the United States
recommended a schedule of fewer antenatal visits
with specific advice on the contents, for low risk
women (1). The model was tested in a randomized
controlled trial in Colorado on the ‘intention to
treat’ principle, with nine visits in the experimental
group (the 12 weeks visit was replaced by a tele-
phone call for parous women), against 14 visits in
the control group. The analysis revealed on average
2.7 fewer visits in the experimental group but no
significant differences in main outcomes (preterm
delivery, low birth weight, preeclampsia, cesarean
section) or in patients’ satisfaction with the quality
of care (61).
In summary, these data support the hypothesis
that similar outcomes are achieved with simpler
antenatal care packages, although there is a note of
caution that they may be deviant from women’s cur-
Scientijic basis f o r antenatal care 5
rent expectations in developed countries. Further-
more, there is little evidence also in the literature
supporting a stronger emphasis on psychosocial
support during pregnancy on biological outcome
(53) or mother’s wellbeing and satisfaction (62,63).
Adverse outcomes:
possibility for elimination or alleviation
The basic concept for the selection of the compon-
ents to include in routine antenatal care is that ac-
tivities should be goal-oriented for specific ma-
ternal-fetal or newborn health problems and
proven to be effective in controlled trials. We will
discuss the most important adverse outcomes for
mothers and newborns and the interventions
which provide evidence of their role in prevention
or alleviation of such outcomes.
To conduct this review, we first constructed a
conceptual framework by identifying the most rele-
vant adverse outcome for the mother and fetus or
newborn. The maternal outcomes selected were:
bleeding during pregnancy, delivery and puer-
perium, maternal anemia, pre-eclampsia, sepsis
and genito-urinary infection and obstructed labor.
These outcomes are well-accepted as leading
causes of maternal morbidity and mortality in
both developed and developing countries. For the
newborn, we considered intrauterine infections,
intrauterine growth retardation and preterm birth.
Finally, other pregnancy-disturbing conditions of
relevance to a particular country or region were
identified.
The second step was to list all activities as poss-
ible factors in routine antenatal care. Finally, we
required each activity to ‘provide’ evidence (from
the literature) that it is effective in preventing or
ameliorating the outcomes identified. Evidence of
effectiveness was primarily considered as coming
from randomized controlled trials. Data were ob-
tained from the extensive literature reviews con-
ducted recently (1, 15, 17, 64), supplemented by
meta-analysis reviews included in the Cochrane
systematic reviews for pregnancy and childbirth
(65, 66) and by systematically reviewing the litera-
ture from 1993 to 1995 and early 1996. Although
randomized controlled trials provide the most
valid basis for the comparison of interventions in
health care, the quality of published trials in our
speciality is not as high as expected: of 206 studies
described as randomized control trials published
between 1990 and 1991 in four obstetrics and gyn-
ecology journals, only 32% described an adequate
method of generating random numbers and only
23% described the method used to cancel the treat-
ment assignment until the point of treatment allo-
cation (67).
0 Acta Ohstet Gjnrcol Scand 76 (1997)
6 J . l,YIus trritl P. Besg5;jo
We do not rely here on a fixed number of ante-
natal visits. rather on a series of useful activities.
These activities should be carried out during preg-
nancy at the time in which they are most effective
and most convenient to the mother and when they
ill have the best cost-effectiveness ratio. Still, the
concept of few routine visits relies strongly on the
abilit! of women to present theniselves when un-
foreseen symptoms develop and on services (emer-
gent! or routine clinics I being able to resolve these
problems and give advice accordingly.
This review does not include screening to detect
congenital malformations and genetic diseases and
consequent treatment. or termination of preg-
nancy: this represents an extensive and complex
literat itre requiring independent assessment.
Nevertheless. some interventions that can be in-
cluded in prenatal care to prevent or avoid these
diseases are reviewed here.
The present part of the review concerns adverse
maternal outcomes and obstructed labor. Adverse
ne\vborn outcomes. special conditions and tools
will be discussed in a subsequent article.
.A rh.ri..vtj n Ii I t cii.rinl oiI t cot I ic : I . Bl e di t q
Hemorrhagic complications may arise at any time
during pregnancy. delivery and the puerperium.
Causes differ. and hence the possibility for their
pre\.ention. How does routine antenatal care com-
pare with emergency attendance in contributing
towards elimination or alleviation of these coinpli-
cations'!
Blood group typing obtained during antenatal
care early in pregnancy is very useful to reduce the
time-consuming blood group matching during
emergency situations. particularly in small hospi-
tals or free-standing clinics. This is not available in
many emergency facilities in developing countries.
Spontaneous abortion will often occur before or
at the start of an antenatal care program. If the wo-
111;2n has a history of repeated spontaneous abor-
tions. or of slight bleeding in the present pregnancy,
the reasonable course would be to give advice on
how and where to seek hospital care for help in case
of syniptoins indicative of an inevitable abortion.
More frequent visits should be considered, depend-
ing on degree of symptoms and signs, as a follow-up
of the hospital consultation. N o type of treatment
has been shown to alter the course of threatening
abortion. Sonography should be used to ascertain
feral life where available.
Major separation of the placenta is life-threaten-
ing. because of acute blood loss and later coagulo-
pathy. Mothers who hake experienced this conipli-
cation in a previous pregnancy(ies) are at increased
risk. Prediction of these conditions prior to symp-
(' ti/ Oh.\ti't
.-I( (;I~I~cJc'o/ Sr.tr/lt/ 76 i 1997)
toms is very difficult if no other symptoms. such
as pre-eclampsia, are present. Advice and counsel-
ling are the key elements which may help women
secure rapid hospital treatment. More frequent
visits are advisable, and should be planned for
women with pre-eclampsia in previous pregnancq.
Placenta previa can be detected by ultrasound
early in pregnancy. Most of the suspected cases will
spontaneously 'disappear' in the later course when
the uterus enlarges. It has yet to be proven that
early recognition, before signs (bleeding) arise, is
beneficial with regard to outcome, particularly
very early in pregnancy. Advice and counselling
with specific instruction on what to do in the case
of bleeding are recommended.
Vasa previa, blood vessels in the membranes
traversing the internal cervical os, cannot be sus-
pected or detected during pregnancy. When the
membranes rupture or are artificially ruptured
such vessels may cause serious bleeding at labor.
Local causes of bleeding can be discovered at
the time of the first visit by pelvic examination.
Referral is necessary if this cannot be done at the
primary care level. Cancer of the cervix should be
treated as soon as it is detected. in exceptional
cases shortly after delivery of the baby. Women
with benign local causes of bleeding. such as cervi-
cal polyps or bacterial vaginosis, can receive reg-
ular low risk care after evaluation and treatment.
To conclude: acute bleeding will commence be-
fore or between routine visits and as a rule requires
emergency consultation. Therefore. advice and
counselling remain the key elements for these con-
ditions at routine visits.
Bleeding at or after birth is difficult to prevent
through antenatal care. Bleeding due to deep tears
may follow from instrumental delivery, notably
forceps, which may in some cases be avoided by
planning for cesarean section if there is high risk
of obstructed or prolonged labor. Post partum
bleeding is associated with previous post partum
bleeding (risk slightly increased), multiple preg-
nancy and grand multiparity. While antenatal care
cannot prevent the complication, advice on deliv-
ery in a hospital equipped for adequate treatment
should be given. Risk factors which can be iden-
tified are: history of hemorrhage in previous preg-
nancy or history of coagulopathy; grand multipar-
ity; polyhydramnios (high uterine height); hyper-
tensive disease of pregnancy, including clotting
defect; premonitory bleeding (present pregnancy)
(15).
Adverse maternal oirtconie: 2. Aneiwiii
Severe anemia may cause debilitating symptoms.
and anemia of any degree may presumably worsen

the outcome of bleeding complications and there-
fore contribute to maternal morbidity and deaths.
During pregnancy, iron is preferentially distributed
to the fetus, but severe maternal anemia is associ-
ated with low birthweight and preterm birth.
Anemia, defined here as hemoglobin (Hb) < 110
gil, is very common among women world-wide,
but especially in developing countries. Prevalence
in 1980 of anemia during pregnancy has been esti-
mated to range from 38% to 52% for pregnant
women in Sub-Saharan Africa, Latin America,
South-East Asia and Oceania (68). Among 1800
pregnant women in Moshi, Tanzania (1 99 1-1 994),
74.5% were below 110 g/l of H b concentration (69).
Dietary iron deficiency is the most common
cause of anemia, which is microcytic and hypoch-
romic in type (70). Other contributing causes to
anemia during pregnancy may be: malaria, other
parasitic diseases (especially hookworm and
schistosomiasis), AIDS and sickle cell disease.
These causes would have to be investigated if poss-
ible in areas of high prevalence. Folate deficiency
is also common in developing countries. It causes
megaloblastic anemia, and may also have indepen-
dent effects on birth weight, preterm birth, and
presumably neural tube defects in offspring (68).
There have been several randomized controlled
trials of routine prophylactic iron supplementation
during pregnancy as compared with indicated iron
treatment, most of them in populations with low
prevalence of iron deficiency. These trials demon-
strated no detectable effect on several maternal,
perinatal and long-term outcomes (71, 72). There
has been evidence of a positive relationship be-
tween higher hemoglobin concentrations and the
risk of low birth weight and preterm deliveries in
observational studies (73), although meta-analysis
of controlled trials does not support the possibility
that iron supplementation is implicated. It is there-
fore concluded that in well-nourished pregnant
populations, routine iron supplementation is un-
necessary.
However, randomized trials did demonstrate a
reduction in the proportion of women with hemo-
globin levels <lo0 gil (O.R.: 0.19; 95% confidence
limits 0.14 to 0.26) (71), increase in circulating fer-
ritin levels after mid-pregnancy (74) and a reduc-
tion in post partum blood transfusions (75), all of
which are important indicators of the mother’s nu-
tritional and health status, particularly among
women from developing countries.
As a consequence of the high prevalence of ane-
mia and folate deficiency in most developing coun-
tries and in many deprived populations in de-
veloped countries, it is felt that when such defi-
ciencies are documented (e.g. if prevalence >20%1),
iron and folate supplementation should be pro-
Scientific basis for antenatal cure 7
vided for every pregnant woman. It is expected
that this would improve the nutritional status of
the mother, reduce the need for post partum blood
transfusion, and obviate the need for hemoglobin
determination early in pregnancy as a screening
test. Iron should be given at the first visit to all
pregnant women living under these conditions as
tablets containing 60 mg elemental iron and 250
micrograms of folate twice a day. It is recognized
that compliance with this recommendation may be
low (75), particularly in developing countries, and
alternative doses now suggested (e.g. two tablets a
week) could be incorporated into programs if con-
firmatory data become available.
Unfortunately, absorption studies indicate that
there is not significant absorptive advantage in giv-
ing iron less than once daily (77). To increase ab-
sorption, iron can be given without food or if gas-
trointestinal side effects influence compliance, a
gastric delivery system could be of use (78).
Hemoglobin is more important to be deter-
mined at a later stage of pregnancy, preferably near
week 30, when physiological hemodilution is most
pronounced. High Hb concentration at this stage
could signal poor hemodilution, which has been
associated with poor placental circulation (79) and
fetal growth retardation (75, 80, 81).
Adverse maternal outcome:
3. Pre-eclmnpsiu rind eclurnpsia
Complications of hypertensive disorders of preg-
nancy (HDP) are among the most common causes
of maternal death both in developing and de-
veloped countries (82, 83). The incidence of preg-
nancy hypertension varies between countries and
populations, possibly because of different criteria
for the diagnostic label, but certainly also because
of genetic, nutritional and demographic differences
which are poorly understood (84).
Pregnancy-induced hypertension without pro-
teinuria carries little added risk for mother or
fetus, but progression of the condition to pre-ec-
lampsia is unpredictable. However, the majority of
cases will remain in the low risk category. In
women with hypertension and proteinuria (i.e. pre-
eclampsia), the prognosis is not good (85), es-
pecially in cases of early onset of pre-eclampsia
(86).
The most dreaded complication of hypertension
in pregnancy is eclampsia, which may occur at any
time during the latter half of pregnancy and in the
puerperium. It has a high fatality rate, especially
if not properly treated. It may occur in the absence
of hypertension and proteinuria, in spite of ante-
natal care and a recent visit to a doctor or widwife
(87). However, in countries where eclampsia rates
0 A i fir ObAter GI rlciol Sranil 76 (19971
8 ,I, l'i//(ir (miP. Bcrgsjo
have been monitored for many years, a systematic
decline in its incidence has been observed, attri-
buted mainly to routine screening for pre-eclamp-
sia. There has been a reduction in the incidence of
eclampsia in the U.K. which paralleled the wide-
spread practice of antenatal care, while developing
countries still have high rates of eclampsia and de-
ficient prenatal care.
There is a high proportion of eclampsia cases
without previous hypertension and proteinuria in
developed countries which have very low total
rates of eclampsia. This could be due to the pre-
\lention (by early detection of pre-eclampsia) of
most of the eclampsia cases with classic clinical
symptoms remaining a proportionally greater
numbcr of atypical eclampsia cases (87). Thus, the
extrapolation of epidemiological reports from low
to high incidence populations is questionable.
The keq question is whether screening methods
and'or prophylactic measures during antenatal
care \\,ill have a n y effect on maternal and perinatal
outcomes. and if active iiiterventions in the form
of rest or medication will prevent progression of
tlie condition to more severe forms, especially
am on g 1 i gh -ri sk patients .
The methods for the prediction of hypertensive
disorders of pregnancy have been recently evalu-
ated and tlie conclusions are not encouraging. Of
all tlie risk factors usually suggested as associated
tvitli severe pre-eclampsia only severe obesity in pa-
tients of all parities and a history of pre-eclampsia
in multiparous patients were found to be indepen-
dently associated. in a multiple regression analysis
(88). I t should be remembered, however, that al-
though excessive weight gain is generally regarded
as one of the cardinal signs in severe pre-eclampsia,
both its sensitivity and specificity are so low that
weight recording among non-severely obese
\yomen would probably cause more anxiety than
benefit, Routine weight recording will therefore
not be p r t of a program for the monitoring of
pre-eclampsia. The elevation of mean arterial
blood pressure 2 8 5 mmHg) during the second tri-
mester is a poor predictor of pre-eclampsia; it only
predicts transient hypertension. Angiotension I1
sensitivity is tlie best predictor of pre-eclampsia
but is impractical for routine antenatal care (89).
There are published trials of the protective effect
of 3 g of calcium supplementation in primiparous
~vomen(90. 91). This effect is being further evalu-
ated i n ii large randomized controlled trial in the
USA to be published during 1997.
Several small trials of low dose aspirin among
high risk patients have suggested a protective effect
(93). but results from a more recent randomized
trial in Western Australia showed no benefit in the
treatment of fetal growth restriction and umbilical-
S .I( [ti OIi\ic~! G i . i i ( r o l S m i d 76 i 19971
placental insufficiency between 28 and 36 weeks'
gestation (93). Furthermore, results from more re-
cent large trials do not support the widespread use
of low dose aspirin in low risk populations (94-
96). The National Institutes of Health (USA) ran-
domized trial (95) of low dose aspirin demon-
strated that the benefit in preventing pre-eclampsia
after controlling for baseline imbalance in the trial
is marginal (not statistically significant). with no
effect on perinatal mortality. Moreover. this study
showed in the aspirin group an increase in the inci-
dence of abruptio placentae. The CLASP trial in-
volving 9000 women only demonstrated a non-
statistically significant trend to a protective effect
of aspirin (odds ratio of 0.88 95'31, CI 0.75 to 1.03)
for proteinuric pre-eclampsia (96). Thus, presently.
there is no evidence for the routine use of low-dose
aspirin among low risk women for the prevention
of pre-eclampsia.
There is no convincing data that treatment of
mild disease with antihypertensive drugs defers or
prevents more severe disease (97). However. im-
proved detection and care of women with hyper-
tensive disease of pregnancy may lead to better
maternal outcome (1 5 ) , and women who die of this
condition have had substandard antenatal care (7).
The specific objective should be to detect the
condition, to counsel the woman and her relatives
about symptoms (98), indicating the need for im-
mediate specialist or hospital care, and to refer her
for higher level of care if and when the condition
progresses beyond the 'mild' stage. There should
be blood pressure screening for chronic hyperten-
sion for all the women at the first visit because
they are at an increased risk for pre-eclampsia. It
is important also to identify the groups of mothers
at higher risk, for whoiii blood pressure measure
is especially important to be taken during all the
follow-up visits:
- age <18 or >35 years:
primigravidae;
~
- multiple pregnancy (99);
- pre-eclampsia in previous pregnancy;
severe obesity (body mass index 232.3 kg:
~
m?).
The issue of routine blood pressure measures in all
antenatal care visits is still unresolved. There is
poor quality in the blood pressure measures taken
in busy obstetrical clinics when routinely per-
formed without selecting high-risk women ( 100).
Moreover, simple blood pressure values between 28
and 31 weeks do not provide a good prediction
of pre-eclampsia later on in pregnancy (100--102).
despite clear differences in mean blood pressure
values between women who remain normal and
those who develop pre-eclampsia. This can be due

to the fact that although different, most of the ab-
solute blood pressure values are usually within the
normal range and moderate elevations are usually
related to the stress response associated with hos-
pital visits (103), as well as error in measurements
(100, 104, 105).
It is therefore considered that repeated blood
pressure measures are medically necessary only for
a selected sub-group of women. There is a practical
problem, however, in the implementation of this
recommendation, which is selecting some women
for blood pressure measures and excluding others.
This will create logistic as well as possible ethical
concerns. Because of this, we recommend that all
women should have blood pressure measures dur-
ing the antenatal visits.
Blood pressure (BP) should be taken by auscul-
tation, with recording of both the systolic and the
diastolic levels. For the diastolic level, Korotkoff
phase V is recommended (79, 106), i.e. when the
sound disappears completely. If a recording of
>140/90 is made, then the blood pressure record-
ing should be repeated, preferably more than six
hours after the first. A shorter (one hour) interval
between two readings can be accepted for prag-
matic reasons. If the second recording confirms the
first, the diagnosis of hypertensive disease of preg-
nancy should be applied if the pregnancy has ad-
vanced beyond 20 weeks.
Advice and intervention will depend on the ac-
tual level of the BP and the test for proteinuria.
Unfortunately, dipstick urinalysis for proteinuria
has been shown to poorly standardize because of
large error measures, particularly at (+) level
(107), low predictability of pregnancy outcomes in
low-risk populations (44); and a positive dipstick
test for protein in a normotensive woman is often
due to contamination with vaginal discharge.
Nevertheless, because of the severity of the dis-
ease, proteinuria detection in a random urine
sample should be carried out on all pregnant
women in the first visit. It should detect any
chronic occult renal dysfunction and occasional
cases of pre-eclampsia remote from term. Al-
though the incidence of pre-eclampsia is very low
before 28 weeks of pregnancy, it represents a very
severe situation with high rates of perinatal mor-
bidity and mortality. After the first visit, dipstick
test for proteinuria should be performed during all
antenatal care visits only to nulliparous women or
those with previous pre-eclampsia or hypertension.
A positive result in a normotensive woman with
no clinical evidence of urinary tract infection is
more likely to be related to vaginal discharge. If
high blood pressure is detected or urinary tract in-
fection symptoms are observed, the patient should
be referred and/or treated according to the clinic
Scient$ic basis f o r antenatal care 9
protocol. Clinics that have the possibility of simul-
taneous determination of specific gravity should
implement it to possibly improve the reliability of
the proteinuria detection in random urine samples.
Although the use of albuminkreatinhe ratio in
random urine samples has been proposed as an
alternative to 24-hour protein excretion measures,
available data require extensive validation before
incorporating it to a routine antenatal care prac-
tice (1 08).
Moderate hypertension (< 1601110 mmHg)
without proteinuria is of little importance; for
women with non-proteinuric hypertension, con-
tinuation in the antenatal clinic is possible (109).
However, enrolment in a day care unit for hyper-
tension in pregnancy should be considered if avail-
able and if there has been no previous admission
to the hospital for this disease (1 10). However, the
option of a day care unit for the management of
hypertensive diseases needs further evaluation, as
there are no clear cost benefits or increased satis-
faction with this system (1 11).
Blood pressure >160/110 accompanied by pro-
teinuria [( +)( +) or more], requires immediate re-
ferral to a higher level of care. Proteinuria (+)
alone should be repeated following sample collec-
tion precautions and if (+) a second time, referral
for 24 hours urinary collection. If proteinuria (+)
is confirmed in a hypertensive woman, she should
be referred to a high risk unit. The advice to the
woman and her husband (or other family member)
is to be aware of signs of generalized edema, short-
ness of breath, chest pain, dizziness, fainting spells,
epigastric distress and visual sensations, all of
which require medical intervention without delay.
Adverse muternal outcome:
4. Sepsis and genito-urinary infection
The relative share of puerperal infection tends to
rise with increasing maternal mortality. This is due
to higher rates of unclean home deliveries, higher
genital pathogenic bacteria infection, and poor
cleanliness and delay after rupture of membranes.
The main preventive effort is to secure a clean de-
livery, for which trained assistance and clean deliv-
ery kits are essential. Primary detection of patho-
genic bacteria or predisposing conditions, as well
as the use of prophylactic antibiotics in deliveries
at high risk for infection and rupture of mem-
branes >12 hours (112), should be considered. An
antenatal care program may be beneficial in edu-
cating the woman about cleanliness and the need
to seek care in the event of spontaneous pre-term
rupture of the membranes.
As far as detection of infectious foci or specific
micro-organisms is concerned, there are two prac-
0 Act" Ohstet G1mcol Srmd 76 (1997)
tical options in a primary antenatal care program:
to detect chronic urinary tract infection. and to
detect s!,philis and gonorrhea. The test for pro-
teinuria could also serve as an indicator of which
wines should be cultured for urinary tract infec-
lion among women with less than 26 weeks of ges-
tation without vaginal discharge or who are nor-
motensive i n their third trimester. When this is
done at the first visit. a sample could be taken for
bacteriological culture i n those with proteinuria.
However, this screening system is far from effec-
tive. The decision t o screen all pregnant women by
culture and colony count of a clean catch urine
represenls ;i dilemma. This strategy. followed by a
single dose therapy. has been shown to reduce the
risk of pqelonephritis ( I 13) and preterm delivery
( 1 13. I 15). but the cost-effectiveness is question-
able. particularly if the incidence of overt urinary
infecticm ia low ( 1 16). Recent reports. however.
support i1s cost-effectiveness ( 1 13).
We b e h e :i strong effort should be made to per-
foi-m urine culture to all women at the first visit. If
urine culture is not available, women should be
screened b!- a urine dipstick multiple test for leuco-
cyte esterrise and nitrite ( 1 13) and possibly protein
and blood. a combination that appears to be a re-
liable iiltei'native to culture all urines ( 1 17). Treat-
ment is initiated in case of positive culture (100 mil-
lion colony-forming units per liter) when results are
available 01-ii positive dipstick. In cases of sympto-
ma tic ii r in a r > in fect i on . investigation and treat men t
should be carried out according to standard proto-
cols ( 119). There is evidence from a randomized
controlled trial that p r e p a n t women with pyelo-
nephritis a t less than 24 weeks gestational age can
successfullq be treated as outpatients with antibiotic
therap! (tn.0injections ofceftriaxone ( 1 g intramus-
culai-I! ) and a ten-day dose of oral cephalexin ( S O 0
mg t'our times a day) ( 1 18).
I n inan! countries, syphilis is still a major threat
to reproductive health and one of the major causes
of :id\wse pregnancy outcome, e.g. abortion.
stillbirth. neonatal death and congenital abnor-
malities. The sero-prevalence of syphilis in devel-
aping countries is very high. ranging from O.S'%, to
20".,, ( 119). An infected woman can transmit the
disease to her fetus as early as the ninth week of
gestation. but transmission usually takes place
after the 16th week o f pregnancy. If pregnant
w~nieiiare screened and maternal syphilis is ad-
equately treated. risk to the infant becomes mini-
mal. Screening of pregnant women for reactive
s!.philis serology followed by treatment of sero-re-
i1ctk.c women is a highly cost-effective, inexpensive
ii n d fea s i bl e i nte rven t i c) n .
A poliq of uni\,ersal screening for syphilis in
pregnant women exists in most countries. Unfortu-
.I .41 I ( / Ob\/<,!c;1~flc~Coi
S U I l l d 76 f I Y Y 7 )
nately, only a fraction are screened and. of those
who are syphilis sero-reactive. many fail to receive
treatment during that pregnancy for various rea-
sons. To increase the coverage of syphilis screening,
it is proposed to use a nontreponemal serologic
test such as a rapid plasma regression ( R P R ) or
VDRL serological test which can be performed at
the primary health care center during the first visit.
while the woman is waiting. In the event of positive
results. treatment will be given at the same visit
without any confirmatory test. Where operation-
ally possible, in case of high risk women and/or in
areas with high prevalence, a serological test could
be repeated at the last visit or at the time of deliv-
ery (120).
Infection with gonorrhea, chlamydia and other
sexually transmitted infections may have an ad-
verse effect on the mother and the newborn ( 1 14).
including higher risk of acquiring HIV infection
(121). However. screening for gonorrhea and chla-
mydia is labor- and technology-intensive, as well
as costly. Therefore, strategies to screen pregnant
women for gonorrhea and chlamydia should be
based on the available technology and resources of
the regions or countries. In most primary health
care settings. effective screening is neither available
nor operationally possible. It is. therefore. pro-
posed that all women undergo a pelvic examin-
ation at the time of first or second visit to identify
symptomatic sexually transmitted diseases (STD).
e.g. vaginal discharge (may be due to cervical or
vaginal infection), genital ulcers, inguinal swelling
etc., and be managed based on the national recom-
mendation for treatment of STD syndrome. The
'syndromic case management' approach is based
on recommendations from the World Health Or-
ganization ( 122).
There is still considerable controversy related to
screening of all pregnant women for group B strep-
tococcus at 26-28 weeks of gestation for the pre-
vention of neonatal infection or sepsis (133). The
American College of Obstetricians and Gynae-
cologists does not recommend routine universal
prenatal screening (124) although it could be justi-
fied in populations with a very high incidence. It
appears that the use of intrapartum antibiotics re-
duces the transmission of Group B streptococcus.
although the problem is how to select women for
this treatment. We conclude that. at the present
time, there is insufficient evidence to recommend
routine screening for Group B streptococcus dur-
ing pregnancy (125).
Ah1er.w outc'onie: obsrrucfed lrhor
Can obstructed labor be anticipated during preg-
nancy? The best indicator is obstructed labor in

the previous delivery. For primigravidae, maternal
height has been used to select those of low stature
for hospital birth. The test sensitivity is low but
obviously increases with decreasing cut-off levels
of height. Recent data from a Guatemalan urban
population have provided information on the use
of height as a screening tool for selection of pa-
tients at higher risk of a cesarean section (126).
For populations with all hospital deliveries, even if
obstruction is detected during labor, cesarean sec-
tion should be performed before any harm is done,
and therefore measuring height during pregnancy
is not necessary. Towards the end of pregnancy, ab-
dominal examination with symphysis-to-fundus
height measurement and palpation by 37 weeks of
the presenting fetal part with the women sitting in
60 degrees from the horizontal may indicate im-
pending obstruction (127). In cases of term breech
presentation, pre-labor referral for external ver-
sion after 37 weeks is recommended.
Based on these considerations, it is recom-
mended:
- to measure maternal height of nulliparae at
first examination, only in settings where hos-
pital birth is not routine. Discriminatory level
for securing hospital birth must be decided
locally;
- to measure symphysis-to-fundus distance at
every visit for all women. Deviation more
than 2 s.d. above normal at the end of preg-
nancy requires referral for hospital delivery
or evaluation for twin pregnancies;
- if breech presentation is suspected after the
37th week, the mother should be referred for
external version. Randomized controlled tri-
als of external version have clearly demon-
strated that the procedure reduces breech
births and cesarean sections (128). The ex-
pected probability of a successful version is
estimated from four studies at 0.78 (95%)con-
fidence interval 0.72 to 0.84) (129);
~ a history of previous cesarean section or of
prolonged labor, with or without instrumen-
tal delivery, requires referral for hospital de-
livery.
In all of these cases, the routine antenatal care can
be followed until 36 weeks of gestation, as these
women are not at a higher risk for pregnancy com-
plications before that time.
Addendum
A further trial evaluating a reduced-visits program
of antenatal care in Zimbabwe has become avail-
able since this review was prepared (1 30).
Scientijic basis.for untenutal care 11
Acknowledgments
Support for this review was provided by the United Nations
Development Programme (UNDP), the United Nations Fund
for Population Activities (UNFPA). the Swedish International
Development Authority (SIDA), the Swedish Agency for Re-
search Cooperation with Developing Countries (SAREC). and
the Division of Family Health of the World Health Organiza-
tion (WHO). The following colleagues provided very useful
comments to earlier versions of this document: L. Bakketeig.
R. Guidotti, Q. Islam, G. Lindinark, S. Mehta, 0. Meirik. G.
Walker.
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4 rltlres.s f i w corrcs/~orrrli~?I~~f~:
Josk Villar, M. D.
Human Reproduction Programme
World Health Organization
CH-1211 Geneve 27
Switzerland