Is Antenatal Care Worthwhile?

Max Brinsmead MB BS PhD

May 2015
I will not directly answer this
because:
 There are no trials of AN care vs no AN
care
 Instead I will…
 Look at what we are we doing in AN care
 This requires a diversion into epidemiology
 Review those parts of AN care that has
been tested by rigorous RCT?
 What will AN care look like in the future?
Why do we:

 Take a history?
 Perform blood tests?
 Measure BP?
 Perform ultrasound?
 Palpate the abdomen?
 Weigh patients?
 Test urine?
Antenatal care is designed to:
 Single out pregnancies that are abnormal,
disordered or high risk…

 In order to provide interventions that will

optimise an outcome

 Provide preparation for childbirth and

parenting
Screening is:

 The application of a TEST to an

ASYMPTOMATIC population in order to
FIND cases of DISEASE or
ABNORMALITY.
The objective of screening:

x = N o rm a l
0 = D is e a s e

x x x 0 x x x 0 x x x 0
x x x 0 x x x 0 x x x 0
x x x 0 x x x 0 x x x 0
x x x 0 x x x 0 x x x 0
The objective of screening:
x = N o rm a l
0 = D is e a s e

x x x 0 x x x 0 x x x 0
x x x 0 x x x 0 x x x 0
x x x 0 x x x 0 x x x 0
x x x 0 x x x 0 x x x 0

x x x x x x x x x 0 0 0
x x x x x x x x x 0 0 0
x x x x x x x x x 0 0 0
x x x x x x x x x 0 0 0
A good screening test
x = N o rm a l
0 = D is e a s e

x x x 0 x x x 0 x x x 0
x x x 0 x x x 0 x x x 0
x x x 0 x x x 0 x x x 0
x x x 0 x x x 0 x x x 0

x x x 0 0 0 x x x x x x
x x x 0 0 0 x x x x x x
x x x 0 0 0 x x x x x x
x x x 0 0 0 x x x x x x
A typical screening scenario:
x = N o rm a l
0 = D is e a s e

x x x x x x x x x x x x
x x x 0 x x x x x x x x
x x x x x x 0 x x x x x
x x x x 0 x x x x x x x

0 0 x x x x x x x x x x x 0
x x x x x x x x x x x x x x
x x x x x x x x x x x x x x
x x x x x x x x x x x x x x
 Characteristics of a Test

 Sensitivity = the chance that the disease

will be detected

 Positive predictive value = the chance that

a screen positive individual will have the
disease
Down syndrome detection:

 Sensitivity based on age = 30%

 Based on 2nd trimester triple test = 60%
 Based on 1st trimester combined test = 88%

and
 Positive predictive value = 1:10
 Antenatal Care as Screening
 Urinalysis
 Antenatal Care as Screening
 Urinalysis  Pre eclampsia
 Antenatal Care as Screening
 Urinalysis  Pre eclampsia
 BP measures
 Antenatal Care as Screening
 Urinalysis  Pre eclampsia
 BP measures  Pre eclampsia
 Antenatal Care as Screening
 Urinalysis  Pre eclampsia
 BP measures  Pre eclampsia
 Detection of oedema
 Antenatal Care as Screening
 Urinalysis  Pre eclampsia
 BP measures  Pre eclampsia
 Detection of oedema  Pre eclampsia
 Antenatal Care as Screening
 Urinalysis  Pre eclampsia
 BP measures  Pre eclampsia
 Detection of oedema  Pre eclampsia
 Maternal weight gain
 Antenatal Care as Screening
 Urinalysis  Pre eclampsia
 BP measures  Pre eclampsia
 Detection of oedema  Pre eclampsia
 Maternal weight gain  Fetal growth
 Antenatal Care as Screening
 Haemaglobin  Anaemia
 Red cell indices  Thalassaemia
 RBC antibodies  Fetal isoimmunisation
 Reagin tests  Syphilis
 Antenatal Care as Screening
 Glucose challenge test  Gestational diabetes
 Vaginal swab  Group B Streptococci
 Hep C testing  Hep C infection
 7 Criteria to test a screening
program
 Is there a good screening test available?
 Is there an intervention available?
 Is the disease worth detecting?
 Will screen positive patients comply?
 Will the test reach those applicable?
 Has the program been tested by RCT?
 Can the health system cope with the program?
 Problems with Screening:

 FALSE POSITIVES
– And the resources required to deal with them

 UNREALISTIC EXPECATATIONS
– ie misunderstanding about the sensitivity of the
test
An Evidence Base for Antenatal
Care
The Cochrane Library
 The Cochrane Library on
Antenatal Care
 64 Analyses of which:

– 7 evaluate routine antenatal care

– 15 evaluate routine advice during pregnancy
– 16 evaluate management of common minor
problems
– 26 evaluate management of high risk
pregnancies
Trials of care for low risk women

 Ten trials with >60,000 women

– Fewer visits not associated with adverse

outcome
– But women less satisfied
– Midwife or GP care as good as Specialist care
– And women more satisfied
 Continuity of care
 Two trials with 1815 women cared for by a
team of midwives vs traditional care

– Fewer hospital admissions

– More likely to attend antenatal education
– Used less analgesic drugs in labour
– Less requirement for neonatal resuscitation.
– No difference for other obstetric outcomes
 Women who carry their own
record
 Three trials with 675 women

– More likely to feel in control

– Insignificant risk of lost or left records
– More likely to deliver operatively
– No difference for other obstetric outcomes
 Measuring symphysis fundal
height
 1639 women recruited

No difference for any obstetric outcomes

 Psychosocial support and
postpartum depression
 7600 women studied:

– No benefit if provided antenatally

– Postpartum support is required
 So, in your antenatal clinic will you:
 Weigh your patients at every visit?
 Record their height?
 Urine test every visit?
 Measure symphysis fundal height?
 Record presentation and engagement?
 Screen for depression?
 Screen for domestic abuse?
 Screen for thalassaemia?
 Offer Down’s Risk testing?
 Screen for diabetes?
 Screen for GBS colonisation?
 A New Model of Antenatal Care?
 12w
 History for risk factors
 Check weight, BP and urine
 Scan for dates, NT (and more?)
 Blood for routine tests + aneuploidy markers
 A New Model of Antenatal Care?
 12w
 History for risk factors
 Check weight, BP and urine
 Scan for dates, NT (and more?)
 Blood for routine tests + aneuploidy markers
 20w
 Scan for morphology, placenta, check uterine artery
Dopplers and cervical length
 A New Model of Antenatal Care?
 12w
 History for risk factors
 Check weight, BP and urine
 Scan for dates, NT (and more?)
 Blood for routine tests + aneuploidy markers
 20w
 Scan for morphology, placenta, check uterine artery
Dopplers and cervical length
 28w
 Screen for gestational diabetes
 Anti D for Rh negative
 34w
 Anti D for Rh negative
 A New Model of Antenatal Care?
 12w
 History for risk factors
 Check weight, BP and urine
 Scan for dates, NT (and more?)
 Blood for routine tests + aneuploidy markers
 20w
 Scan for morphology, placenta, check uterine artery
Dopplers and cervical length
 28w
 Screen for gestational diabetes
 Anti D for Rh negative
 34w
 Anti D for Rh negative
 36w
 Scan to exclude breech
 A New Model of Antenatal Care?
 12w
 History for risk factors
 Check weight, BP and urine
 Scan for dates, NT (and more?)
 Blood for routine tests + aneuploidy markers
 20w
 Scan for morphology, placenta, check uterine artery
Dopplers and cervical length
 28w
 Screen for gestational diabetes
 Anti D for Rh negative
 34w
 Anti D for Rh negative
 36w
 Scan to exclude breech
 38 & 40w
 Check primigravida for late onset pre eclampsia
 A New Model of Antenatal Care?
 12w
 History for risk factors
 Check weight, BP and urine
 Scan for dates, NT (and more?)
 Blood for routine tests + aneuploidy markers
 20w
 Scan for morphology, placenta, check uterine artery Dopplers
and cervical length
 28w
 Screen for gestational diabetes
 Anti D for Rh negative
 34w
 Anti D for Rh negative
 36w
 Scan to exclude breech
 38 & 40w
 Check primigravida for late onset pre eclampsia
 41W
 Sweep membranes. Arrange induction of labour