Review article Is antenatal care effective in reducing maternal morbidity and mortality? · ·...

HEALTH POLICY AND PLANNING; 11(1): 1-15 © Oxford University Press 1996

Review article

Is antenatal care effective in reducing maternalmorbidity and mortality?MARILYN MCDONAGH

Save the Children Fund, London

Women in developing countries are dying from simple preventable conditions but what impact canthe procedures collectively called antenatal care have in reducing maternal mortality and morbidity?More importantly what is antenatal care? This review found that questions have been raised aboutthe impact of antenatal care (specifically on maternal mortality) since its inception in developed coun-tries, and that although the questions continue to be asked there is very little research trying to findanswers. Many antenatal procedures are essentially screening tests yet it was found that there werevery few results showing sensitivity and specificity, and that they rarely complied with the estab-lished criteria for the effectiveness of a screening test. The acknowledged gold standard measure-ment of effectiveness is the randomized controlled trial, yet the only results available referred tonutritional supplementation. This service of flawed methodology has been exported to developingcountries and is being promoted by WHO and other agencies. This paper argues that there is insuffi-cient evidence to reach a firm decision about the effectiveness of antenatal care, yet there is sufficientevidence to cast doubt on the possible effect of antenatal care. Research is urgently required in orderto identify those procedures which ought to be included in the antenatal process. In the final analysisthe greatest impact will be achieved by developing a domiciliary midwifery service supported byappropriate local efficient obstetric services. That this domiciliary service should provide care for womenin pregnancy is not disputed but the specific nature of this care needs considerable clarification.

IntroductionIn the 1990s most developing countries are faced withrecession and imposed structural adjustment policies,resulting in restrictions on public sector spendingwhich make it vital that services are both appropriateto the needs of the people and are cost effective(Green 1992). Antenatal care is an umbrella termused to describe the medical procedures and care thatare carried out during pregnancy. In promotingantenatal care, it is essential that the effectiveness ofthis service leaves no room for doubt. However, whatevidence do we have that the service we areadvocating is effective?

Maternal mortality is generally estimated as 500 000maternal deaths each year, of which 99% occur indeveloping countries (Royston and Armstrong 1989).

The range in developing countries is 40-800 mater-nal deaths per 100 000 live births, with an averageof 450 maternal deaths per 100 000 live births(Royston and Armstrong 1989). The main causes ofdirect maternal mortality suggested by Maine (1991)are:

haemorrhage 28%sepsis 11 %hypertension 17%abortion 19%obstructed labour 11 %other 15%

The overall aim of antenatal care is to produce ahealthy mother and baby at the end of pregnancy(Lindmark and Cnattingius 1991). Using the availableliterature this paper examines the effectiveness of

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antenatal care as it relates to the outcome for themother. There are methodological limitations in thisprocess. For example, although the aim of this paperis to look at maternal outcome, maternal and babyrisk factors are so interlinked that the literature oftendoes not distinguish between the two. Many papersstudy child outcomes (e.g. low birth-weight), ratherthan maternal outcomes, which may be influenced byfactors other than those which can be acted upon inthe antenatal period.

There are no agreed criteria about what exactlyconstitutes antenatal care. There is considerablevariation in the content of antenatal care world wide(Lehrman 1981; Royston and Ferguson 1985;Royston and Armstrong 1989; Nagey 1989; Field1990; Rooney 1992; Gertler et al. 1993). Thispresented the problem of defining the most commoncomponents that collectively make up the servicecalled antenatal care at primary level in developingcountries. Bearing in mind all the possible permuta-tions that exist, the author decided to look at the pro-cedures that were routinely carried out in developingcountries during an antenatal visit at primary level,with emphasis given to those procedures that werescreening for risk factors. It was therefore decidedto consider screening for risk factors which included:

• routine measurement of weight,• routine measurement of blood pressure,• abdominal examination.

In addition, nutritional interventions were examinedas they represent one of the few tangible responsesavailable if certain risk factors are identified. It is ap-preciated that this list excludes immunization againsttetanus, testing for syphilis and the treatment ofmedical conditions. The reason for the exclusion oftetanus is that it falls under the responsibility of theexpanded programme of immunization (EPI) whichover the last few years has had an extremely high pro-file - much higher than that of maternal services. Thismeans that any figures presented for tetanus vaccina-tion would not have been solely obtained by atten-dance at antenatal clinic. As testing for syphilis cannotbe offered in the majority of clinics at primary levelit was excluded. The treatment of medical conditionswas also excluded, as medical care is not always of-fered as part of antenatal care due to the verticalnature of women's care services in many develop-ing countries.

From the point of view of this paper, the ultimateobjective of antenatal care is to improve maternal

mortality and morbidity in developing countries. Thispaper reviews the literature from developed anddeveloping countries with the intention of examin-ing the effectiveness of the screening procedures thathave been identified as collectively making upantenatal care. The weight given to each sectionreflects the available literature, thus demonstratinginternational interest in that subject and/or the easeby which it can be examined. It does not representany personal weighting placed on the procedure bythe author. The discussion will examine the role thatthese procedures can play in achieving the objective,with the final part of the discussion examiningsome of the practical problems that are faced whenattempting to measure the effectiveness of antenatalcare.

The paper looks at effectiveness from the limitedperspective of whether the procedure can tech-nically achieve its objective using the randomizedcontrolled trial (RCT) as the gold standard. It isacknowledged that this provides only one measureof effectiveness and does not take account of con-straining factors. Although reference is made topotential operational problems in respect to certainprocedures, other issues related to effectiveness ofa service, such as cost analysis, are not considered.However, the author feels that the priority should beto first examine whether we are advocating effectivetechnical services to women.

Each procedure is considered using three dimensionsof effectiveness:

i. Do the procedures and the service calledantenatal care achieve their stated objectives(Basch 1990)?

ii. Since the randomized controlled trial (RCT) isacknowledged as the most rigorous evaluationof effectiveness, what results of any such trialsare available (Cochrane 1972; Enkin 1992)?

iii. If the procedure is a screening test, how doesit conform to the established criteria for thepotential effectiveness of a screening test(Wilson and Junger 1969, cited in Rooney 1992:10) (Appendix I)?

The concept that women require some form ofextra care during pregnancy is not being doubted.However, what needs to be questioned is what thiscare should be.

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The effectiveness of antenatal care

Evidence for the effectiveness of theprocedures that collectively make upantenatal care

Screening for 'at risk' factorsThe objective of antenatal care is to screen popu-lations of pregnant women regularly duringpregnancy (Llewellyn-Jones 1990). There are twogroups of antenatal risk factors screened for duringpregnancy:

i. those associated with the women's medical,obstetrical and social history or circumstances;

ii. those arising during the antenatal period (Hartet al. 1990).

The concept of 'risk factors' and the first group ofpre-existing factors will be considered in this section;the second group in the subsequent sections.

The objective of screening for 'at risk factors' is toidentify any pre-existing factors that could increasethe risk of complications during pregnancy ordelivery to the mother or the infant (Hart et al. 1990).The problem with screening is that it requires volun-tary participation but the very nature of risk factorsmake the women at greatest risk the most likely notto attend (Strachan 1987; Gertler et al. 1993). Theeffectiveness of a screening test is measured by itssensitivity and specificity, which are then comparedto a 'gold standard' if it exists (Grant and Mohide1982). Definitions of these terms can be found inAppendix n .

A definition of a risk factor is 'one link in a chainof associations leading to an illness of an indicatorof link. The important fact is that they are identifiableprior to the event they predict' (Backett et al. 1986:9). For this reason a medical history is obtained atthe first antenatal visit in order to identify risk fac-tors. However, WHO (1985) point out that 'abnor-mality has eluded prediction and because of that thetendency has been to define more and more riskfactors' (WHO 1985: 74).

There does however seem to be agreement over abasic core of risk factors relating to parity, age, heightand birth interval (Harrison et al. 1985; Greenwoodet al. 1987; Kwast 1989; Royston and Armstrong1989; Hall 1990; Maine 1991). The following listrepresents the risk factors generally used in EastAfrica:

Age

ParityDisability

Short staturePrevious historyPregnancy interval

risk under 15, over 35yearsmore than 8 pregnancieslimp or leg affected byPolioless than 150 cmmiscarriage or still birthless than a year (Hart etal. 1990: 44).

The differences occur when defining what limits touse within the category. In Tanzania, parity was 10 +,height 146cm (Essex and Everett 1977); Williams etal. (1985) used a parity of 4-6 and a height of 150cm.These variations arise more from operational con-straints and a fear of over burdening the maternalhealth facilities than from a scientific basis (Hart etal. 1990). The recommendation from Winkoff et al.(1991) is for more specific indicators.

Published results of the sensitivity and specificity ofthe risk approach are very sparse making it difficultto evaluate whether risk screening achieves its ob-jective. This is exacerbated by the variations betweenthe protocols currently in use, making comparisondifficult. Studies that have been carried out show thatmost risk assessments classify a high percentage ofpatients as at risk (Fortney and Whitehorne 1982;Tew 1990). Work from Tanzania stated that 81 % ofrisk factors could be identified in the antenatal periodbut there were no figures for the number of falsepositives that would be identified at the same time(Essex and Everett 1977). A study in India found that87.2% of high risk pregnancies delivered normally

but that 15% of the high risk cases were not iden-tified during the antenatal period (Abraham andJoseph 1985).

Studies have shown that one-quarter of all significanthistories were missed: retained placenta was notedin only 68% of women who had previously ex-perienced this problem and only 15% of previouspost-partum haemorrhage were picked up (Chng etal. 1980). The Kasonga Team found that a badobstetric history, compared to a good, had a relativerisk of 9.2 of producing an obstructed labour.However, the sensitivity of the test was very low at29%, due to the large number of women not at risk(Kasonga Project Team 1984; Maine 1991).

In Kenya Nordbeck et al. (1984) found a sensitivityof 41%, a specificity of 87 %, and a predictive value

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of 13%, using four maternal risk factors to identifyperinatal mortality. They felt that none of the screen-ing tests were entirely satisfactory and recommend-ed concentrating on selected factors depending oncircumstances in the area.

Various trials have been undertaken with speciallydesigned antenatal cards in an attempt to see if theycould improve the recognition of risk factors and soimprove overall care (Sims 1978; Abraham andJoseph 1985; Bullough et al. 1990). Results fromAbraham and Joseph (1985) found that 70% of at riskfactors were identified using the card, yet problemswere found to be similar to the growth card (Gerienand Ross 1991) in that cards were frequently filledin correctly but no further action was taken(Chiphangwi 1987). A paper researching the 'at risk'approach stated that 'the risk approach can only beconsidered effective if it not only encourages atten-dance and gives adequate support but also if thoseidentified to be at risk are referred to the appropriatelevel of care' (Jelley and Madeley 1983: 115). Thisstudy found that only 50% of those identified as atrisk were referred and then 89 % of those referreddid not attend the recommended centre. Added to thisis the prerequisite that there are centres to whichreferrals can be made (Hart et al. 1990; Rooney1992), and further that once at those centres thenecessary procedures can and are implemented(Sundari 1992).

Finally, the problem remains that identification of riskdoes not eliminate or alter the possibility of an adverseoutcome nor does low risk mean the pregnancy willbe totally safe (Lilford and Chard 1983; Hall 1990).Zander and Chamberlain (1984) remarked that it waslike betting on a horse, the favourite does not alwayswin. In Britain risk factors identified at the bookingclinic increased relative risk by a factor of three andit was found that the most adverse outcomes occur-red in low risk women (Hall 1990). This has also beenfound in other studies (Nordbeck et al. 1984; Winkoffet al. 1991; Gertler et al. 1993).

Ultimately the system must have credibility. Maine(1991) feels this is the fundamental problem becauserisk screening has such a low predictive power thatmany women are referred unnecessarily, causingundue stress and cost to both woman and family. Thisbrings into question the operational capacity ofany health service to deal with a burden whichultimately has a low productivity (Hall 1984).

Routine measurement of weightThere are two objectives of weighing mothersduring pregnancy:

i. to monitor excess weight gain so as to detectearly signs of pre-eclampsia (Dawes et al. 1992)

ii. to assess the nutritional status of the pregnantmother so the mother arrives in labour in op-timum health and the incidence of low birth-weight babies is reduced (Dimperio et al. 1992).

It is recommended that mothers are weighed routinelyduring pregnancy to identify poor weight gain or ex-cess weight gain. Monitoring excess weight gain isused to identify pre-eclampsia but is no longer recom-mended since high weight gain is not necessarilyassociated with pre-eclampsia (MacGillivary 1985;Dawes et al. 1992). The additional problem fordeveloping countries is that of definition. Whatconstitutes excess weight gain? (WHO 1991b).

It is felt by some obstetricians that poor weight gainin the mother is a preclinical sign of poor foetalgrowth and an indicator of poor nutritional status inthe mother (Wynn et al. 1991; Dimperio et al. 1992).However, serious doubts have arisen over the benefitof routine weighing (Durnin et al. 1985; Dawes andGrudzinskas 1991a, 1991b; Dawes et al. 1992;Hytten 1990). Their main argument is that birthweight is not, as previously believed, correlated tothe mothers' weight gain during pregnancy. It isfurther postulated that maternal nutritional state haslittle immediate effect on the foetus, except in extremecases of deprivation (Durnin et al. 1985, Dawes andGrudzinskas 1991a; Lawrence et al. 1991; Susser1991).

An RCT that found a correlation betwen maternalweight gain and birth weight pointed out that theeffect may have been produced by the height, age orparity of the women (Mara et al. 1979). A subsequentRCT did not obtain the same results (Kardjati et al.1988). The factors cited by Mara et al. (1979) werestudied further by Raman in 1981 who found that themean birth weight was lower in teenagers than olderwomen of the same economic status. He also foundthat short maternal stature contributed to low birthweight, but the effect of short stature was reduced,when women belonged to a higher economic group,postulating that better nutrition worked to balance thiseffect. Contrary to classical theory, Briend (1985)found that heavier women had smaller babies. He also

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found that although the nutritional status of womenin Senegal was similar to women in affluent societies,birth weights were significantly lower indicating otherforces at work.

The major problem arising in routine weighing is thatof definition. What is an adequate weight gain dur-ing pregnancy? (Durnin et al. 1985) 10.5-13.5 kgsis the recommended weight gain for a woman in adeveloped country but this reduces to 5-9 kgs fordeveloping countries because it is appreciated that anymore is impractical (WHO 1991b), or might not evenbe desirable. Garner et al. (1992) point out thatwomen do not want big babies because they knowthat in their circumstances, with little medical sup-port, it is dangerous for their health and subse-quently that of the baby. There are also systematicerrors incurred during weighing due to poor atten-tion to detail and inadequately maintained equipment(Gerein and Ross 1991).

It is suggested that routine weighing could create un-necessary stress and strain for the mothers (Durninet al. 1985; Dawes et al. 1992), especially in develop-ing countries where food is in short supply, par-ticularly for women (Leslie 1991). The stress andguilt that routine weighing could produce in thewoman may reduce any other benefits obtained fromvisiting the clinic and may actually deter further visits(Nabarro and Chinnock 1988).

There is general agreement in the literature that themost important factor for both mother and child isthe mothers pre-pregnancy weight (Kardjati et al.1988; Dawes et al. 1992; WHO 1991b). In aretrospective study Dawes and Grudzinskas (1991a)found that maternal booking weight had a positivepredictive value of 20% compared to routineweighing of 12.9%, for identification of poor foetalgrowth. Finally, the whole practice of routineweighing and subsequent action tends to ignore thedeterminants of malnutrition, the role of infectionssuch as malaria, and the excess work that womenare compelled to do at certain times of the year(Prentice et al. 1987; Leslie 1989, 1991; Neel andAlvarez 1991; WHO 1991b).

Nutritional interventions

Nutritional adviceThe justification for weighing is that if women havenot gained sufficient weight, nutritional advice can

then be given. It is postulated that this acts as aneffective intervention resulting in a change ofbehaviour and consequently an increase in mean birthweight and maternal nutritional status (Dimperio etal. 1992). Nagey (1989) points out that there are vastgaps in our knowledge of recommended dailyallowances. To this is compounded the fact that littleadvantage is to be gained by giving advice that can-not be implemented (Nabarro and Chinnock 1988;Tew 1990), and which will often be interpreted bythe mother as 'her fault' if she cannot implement it.In some cases medical staff will engage in victimblaming. In many countries women are of low statusand it is customary for them to eat last of whateverfood is left (Leslie 1991). This is often combined witha lack of cash to buy the necessary extra food if foodis scarce. Few.evaluations look at the impact of healtheducation on the practices of women and those thatdo are not very optimistic (Ratnaike et al. 1984; Field1990). People remain sceptical that nutritional advicedoes result in a change in behaviour, suggesting thatas yet it cannot be classified as an effective interven-tion (Nabarro and Chinnock 1988; Field 1990;Garner et al. 1992).

Food supplementsFood supplements are given during pregnancy in thebelief that this is an effective intervention to preventlow birth weight and improve maternal nutrition.

Food supplements were found to be effective inGuatemala (Habicht et al. 1973) but there was no con-trol group and the results have not been repeated byother studies. An RCT carried out by Rush et al.(1980) showed that increased protein supplementa-tion actually decreased birth weight. Benefits wereonly obtained when supplements were given in theearly stages of pregnancy. It is now argued that sup-plementing food increases birth weight only duringfamine and extreme conditions (Prentice et al. 1987;Susser 1989). This is supported by an RCT trial inJava that found little benefit from supplementationof pregnant women except during the lean season(Kardjati et al. 1988). Jewell (1990) argues that thehuman race has evolved through very unfavourableperiods and that it would be remarkable if the bodyhad not developed some protective mechanism bywhich to protect the foetus, in all but the worst con-ditions. This theory is supported by the work ofDurnin et al. (1985) and Poppitt et al. (1993) whichshowed that energy saving mechanisms came intoaction during pregnancy with a reduction in basicmetabolic rate. Research by Prentice et al. (1987)

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found that supplements given during the wet season,when women were in a negative energy balance,caused an increase in birth weight. In the dry season,with women in a positive energy balance althoughconsuming only 60% of the recommended dailyallowance, no increase in birth weight was recorded.

It had been thought that food supplements to themother could have possible long-term advantages forthe children but Rush et al. (1980) found no evidencefor this hypothesis. A longitudinal study by Kusin etal. (1992), however, found that the children ofmothers who had received supplements were tallerwhen measured five years later. They go on to pro-pose that if these results are correct, supplements tothe current generation of mothers could offer long-term benefit for the next. This is backed by history;well-nourished children during the second world warlater produced well-nourished women with well-formed bones who were better prepared to cope withpregnancy. Certainly, it is only right to ensure womenare in good nutritional status at all times and especi-ally during pregnancy. But are food supplementationprogrammes the appropriate strategy to achieve this?

It is felt that food supplementation programmes hadfailed in the past because sufficient consideration hadnot been given to the recurring costs and the massivelogistics of delivery and distribution that are in-volved (Beaton and Ghassemi 1982). Such program-mes are also extremely prone to wastage, theft andleakage (Beaton and Ghassemi 1982; Kardjati et al.1988; Leslie 1991). Finally, food supplements areonly an interim strategy; the problem requiresfurther examination to seek out the root cause offemale malnutrition (Leslie 1991).

Distribution of iron and folate supplementsSince World War n it has been common practice todistribute iron and folate universally to all pregnantwomen in Britain whether needed or not (Hibbard1988; Montgomery 1990). The objective of givingiron and folate is to maintain stores throughoutpregnancy and prevent severe anaemia (Montgomery1990). The rationale of this practice is now beingquestioned in developed countries (Hibbard 1988;Montgomery 1990). Doubts have arisen because itis felt that the majority of women are not anaemicbut have a 'physiological anaemia' which occurs dueto haemodilution, a normal process (Montgomery1990). Iron is depleted whether or not iron sup-plements are given and returns to normal levels veryquickly after pregnancy (Montgomery 1990). Studies

have actually found an association between highhaemoglobin levels and unfavourable outcomes(Roller et al. 1980, cited in Montgomery 1990: 212).Consequently universal distribution is no longer seento be justified; instead, vulnerable groups shouldbe targeted (Hibbard 1988). Opponents argue thatuniversal distribution should continue as it is cheapand covers large groups of women (Horn 1988).

In developing countries the situation is very different.It is estimated that two-thirds of women are suffer-ing from anaemia and that anaemia is often theunderlying cause of maternal mortality (Royston andArmstrong 1989; WHO 1992a). Figures are generallyinaccurate as local clinics have very few facilities tomeasure anaemia. Instead they grade anaemia byobservation of the conjuctiva and buccal cavity,although the sensitivity and specificity of thesemethods is weak (Koblinsky et al. 1992; Rooney1992). The cause of anaemia is multifactorial: nutri-tional deficiency of iron and folate, malaria, sicklecell disease, intestinal parasites, infections, blood lossand poor socioeconomic conditions (Royston andArmstrong 1989). One study found that when iron,folate and malaria prophylaxis were given to preg-nant teenagers, they grew in height, reducing theirrisk of an obstructed labour (Harrison et al. 1985).

Although there is very little evidence that supplementsare effective in improving the outcome of preg-nancy for mother or baby (Hemminki 1985; Rooney1992), it is generally felt that iron supplements andfolic acid can have a profound beneficial effect indeveloping countries (Royal College of Obstetriciansand Gynaecologists 1979; Royston and Armstrong1989; Tew 1990). Some obstetricians believe that thereduction in anaemia is one of the most importantfunctions of antenatal services (Royal College ofObstetricians and Gynaecologists 1979; Royston andArmstrong 1989; WHO 1992a). Fears have been ex-pressed that routine iron supplements increase thelikelihood of infection in areas of poor hygiene.However, after a review of the literature, administra-tion of routine oral iron was deemed safe (Tomkinsand Watson 1989).

Research has shown malaria to be responsible forsevere anaemia especially in primigravidas, reduc-ing their tolerance of haemorrhage and prolongedlabour (Brabin 1991; Reubin 1993). In areas with ahigh prevalence it is recommended that malaria pro-phylaxis be given in conjunction with iron and folate

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as this has been found to be a successful intervention(Brabin 1991; Greenwood et al. 1992).

Although universal distribution is recommended indeveloping countries, there are major operationalconstraints in the successful implementation of sucha policy: attendance at the clinic early enough toreceive supplements (Shears and Mkerenga 1985;Reuben 1993), compliance in those who do receivesupplies (Schultink et al. 1993), problems of cost(Hemminki 1985) and the logistics of maintainingregular supplies (Royston and Armstrong 1989). Allthese factors affect the impact of any distribution pro-gramme. Shears and Mkerenga (1985), for example,quote figures of less than 30% of women effectivelyprotected. A cautionary note concerning universaldistribution is also expressed by Hemminki (1985)who feels that the determinants of malnutrition couldbe forgotten and complacency set in causing a failureto recognize other nutrient deficiencies often foundtogether.

Routine measurement of blood pressureThe objective of measuring blood pressure during theantenatal period is to screen for hypertension whichacts as an early and detectable sign of toxaemia(Rosenberg and Twaddle 1990). However, themeasurement of blood pressure as a screening testfor eclampsia is flawed: the natural history of the con-dition is not known (Rosenberg and Twaddle 1990)and there is a problem of defining the limits(Redman 1982a; Cuckle and Wood 1984). Thepreclinical state of pre-eclampsia has been definedas a blood pressure reading of 140/90 mmHg but ithas been suggested that in developing countries,where women start pregnancy undernourished, thediastolic limit should be reduced (Koblinsky et al.1992).

The incidence of eclampsia in Britain ranges from10 to 1.3 per 10 000 maternities, accounting for one-fifth of maternal deaths (Redman 1982a). It is morecommon in primigravidas (MacGillivary 1985). Thefigures for developing countries are difficult toobtain but one study found 5.4-33.2% of womenpresenting with a diastolic blood pressure over90 mmHg during pregnancy (Koblinsky et al. 1992),and mortality ranges from 7% to 25% (Rooney1992).

As with routine weighing, there are intrinsicsystematic and random errors in recording bloodpressure (Redman 1982a). Observation of blood

pressure recording (MacGillivary et al. 1969; Villaret al. 1989) found a wide range of values and littlestandard practice even in a supervised clinical set-ting. Finally, due to the errors and the transient natureof blood pressure, frequent readings are required,although studies suggest that screening before 32weeks gestation is not cost-effective (Hall 1990). Thishas been supported by studies in Sweden where 80%of hypertensive cases occurred after 32 weeksgestation (Lindmark and Cnattingius 1991).

Research examining blood pressure screening for pre-eclampsia found that 30% of cases were not detectedduring routine antenatal visits. Results obtained a sen-sitivity of 71 %, specificity of 95 %, and a positivepredictive value of 40% for pre-eclampsia duringpregnancy, labour and the puerperium (Hall et al.1980). Hall and Chng (1982) point out a problem ofover-diagnosis. Their study found that 13.5% of thewomen diagnosed had transient hypertension or couldbe classed as false positives, and this increased withgestation producing a ratio of false positives to casesof 1.3:1 (Rosenberg and Twaddle 1990).

Routine blood pressure reading is carried out in con-junction with examination for the presence or absenceof oedema and proteinuria. A study using onlyoedema and proteinuria to screen for pre-eclampsiafound a sensitivity of 43% for detecting diastolichypertension and 35% for eclampsia (Rooney 1992).The presence of oedema is not a reliable pre-clinicalsign as 80% of oedema can be found in normoten-sive women (Roberts 1971, cited in Redman 1982a:75). Proteinuria is a late sign in the development ofpre-eclampsia and therefore not a useful sign,although a combination of hypertension and pro-teinuria is certainly significant (Redman 1982a). Theresults of testing for proteinuria found 25% falsepositives and 6% false negatives using 'urine stixs'(Enkin et al. 1989).

Once identified there is still no clearly defined treat-ment schedule or effective intervention to prevent pre-eclampsia becoming eclampsia (Rosenberg andTwaddle 1990). Treatment remains induced labour,but this may not be possible depending on the gesta-tion of the pregnancy (MacGillivary 1985). The in-terim solution is rest with regular monitoring. Dietaryrestrictions and diuretics have not been found to beeffective (MacGillivary 1985; Redman 1982b). Seda-tion has been used successfully to prevent eclampsiabut it requires good technical expertise (MacGillivary1985). Several studies are being carried out in

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developing countries using anti-hypertensive (OxfordPerinatal Data Base) with the view to controlling pre-eclampsia until the baby can be born with a chanceof surviving.

Abdominal examinationThe objective is 'to predict and efficiently detect thoseconditions that may adversely affect the health ofthe pregnant mother or her child and then guide thesubsequent management' (Godfrey 1981: 1253). Inmost developing and developed countries this isachieved by measuring fundal height using a tapemeasure, listening for foetal heart sounds andmanually palpating to feel the position of the foetus.The limitations of these screening examinations is thatthey must be carried out regularly throughoutpregnancy to be useful. The transitory nature of thesemeasurements makes evaluation of effectiveness verydifficult (Hall 1990).

Palpating is the main method of estimating foetal posi-tion and wellbeing but the method has never beenproven useful (Godfrey 1981; Grant and Mohide1982). One study from Aberdeen found that breechposition had been detected in 88 % of cases beforelabour (Hall et al. 1985). In studies from Kasongaand The Gambia malposition was rarely identifiedcorrectly (Greenwood et al. 1987; Rooney 1992). InKenya a risk system which included identification offoetal position produced a sensitivity of 41%,specificity of 87% and a predictive value of 13%(Nordbeck et al. 1984). Finally, the identification ofmalposition will never alter the position of the foetus.The eventual outcome is dependent on the availabilityof efficient obstetric facilities with staff who can carryout caesarian sections (Kwast 1992).

Measurement of foetal growth does not directlyaffect the mother, but if poor growth is identified itwill inevitably result in stress and perhaps guilt forthe mother, indirectly affecting her health. For thisreason its effectiveness will be discussed. As a pro-cedure, some have found it difficult to do well(Chiphangwi 1987) and an inadequate measure offoetal growth (Sims 1978). In contrast, others foundit an excellent method (Kestler et al. 1991). Figuresare scarce, intra-uterine growth retardation wassuspected or diagnosed in less than half the womenwho subsequently delivered a small for gestationalage baby, a ratio of 1:2.5 of correct prediction to in-correct (Hall et al. 1980: 79). The large number offalse positives places a load on the system and in-creases both the tendency to unnecessary interven-

tions (Hall et al. 1980; Tew 1990) and the stress onwomen.

In developing countries some large hospitals haveaccess to ultra-sound (Nylander and Adekunle 1990).A comparison of palpation and ultra-sound found verylittle difference between the two methods, both pro-duced over 50% false positives (Tew 1990). It is sug-gested that simple and appropriate technology shouldbe encouraged, especially when the cost-effectivenessof sophisticated high-tech equipment cannot beproven (Faundes et al. 1988; Tew 1990; Briggs andOruamabo 1991).

DiscussionThe discussion will first examine the results of studiesthat have investigated the impact of antenatal care onmaternal mortality; secondly, hypothesize from theevidence in the review on the role that each procedurecan play in reducing the direct and indirect causesof maternal mortality and morbidity; thirdly, examinethe role that actually attending antenatal care couldplay in reducing maternal mortality and morbidity;and finally, look at the scientific evidence surround-ing antenatal care and the problems in obtaining it.

The impact of antenatal care on maternal mortalityVery few scientific studies have examined the roleof antenatal care in reducing maternal mortality. Theresults of studies investigating the impact of antenatalcare are mixed. The work from Zaire found diatantenatal care reduced maternal mortality by 17-fold.The main impact had been a reduction in severeanaemia, cases of obstructed labour, and treatmentof medical conditions (Royal College of Obstetriciansand Gynaecologists 1979). In Vietnam antenatalcare was found to reduce maternal mortality byimproved nutrition and screening for high risk(Swenson et al. 1993). A prospective study in TheGambia (Greenwood et al. 1987) and a retrospectiveanalysis from Tanzania (Moller et al. 1989) foundno relationship between attendance at antenatal careand maternal mortality. Figures from Lesotho showthat although 85% of women attend antenatal care,maternal mortality has not reduced in line with thisincrease in attendance (WHO 1993). Other studiesfound that maternal mortality was lower in villagesreceiving community-based maternity services which,included antenatal care. The improvement, however,was attributed to the availability of local midwives(Lamb et al. 1984; Fauveau et al. 1991) and anefficient referral system (Fauveau et al. 1991).

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The interesting feature in all these studies was thatthe content of antenatal care was rarely mentioned;it was simply stated that antenatal care was given.With the available information it is difficult toestablish why the results from Zaire were so differentfrom the results in The Gambia and Tanzania. Tomake any inference from the information we needfirst to establish what was meant by antenatal carein each study. Then we need to know who visited theclinic, how often and the quality of the serviceoffered. It is apparent that the term 'antenatal care'is a variable itself, making the comparison ofoutcome impossible.

Antenatal care procedures and reduction of causesof maternal mortality

On a first visit to an antenatal clinic an obstetrichistory is obtained, seeking risk factors that mightaffect the outcome of pregnancy. Benefits can beobtained by screening for the 'risk factors' associatedwith obstructed labour and haemorrhage (WHO1989b), although the preceding review demonstratesthat this screening is not very sensitive. The fewresults there are range from 29-41% sensitivity(Kasonga Project Team 1984; Nordbeck et al. 1984).The major problem in evaluating 'risk factors' is thatthere is no standard.

The procedure of abdominal palpation near the endof pregnancy can identify malposition and poten-tially reduce deaths from obstructed labour and themorbidity associated with prolonged labour. Butagain research indicates low sensitivity. Ultimately,haemorrhage and obstructed labour are acuteemergencies requiring local obstetric facilities (WHO1989b). These facilities require staff trained tocarry out caesarian sections and blood transfusions(Rosenfield 1992).

Blood pressure monitoring can prevent deaths fromtoxaemia. Results from Aberdeen showed a sensi-tivity of 70% (Hall et al. 1980) but results fromTanzania were low (Moller et al. 1989). The majorproblem arising when monitoring for toxaemia is thatthe natural history of the condition is not known.What is known is that the incidence of toxaemia variesfrom country to country and within countries.

Routine weighing will have no influence on mater-nal mortality and its role in antenatal care is cer-tainly doubtful (Chalmers 1990; Dawes et al. 1992).The identification of women of low body weight will

only be beneficial if the means are available tocorrect the situation.

None of the procedures discussed in this paper willhave any effect in reducing the number of deaths fromsepsis or abortion. The major contribution to thereduction of deaths from sepsis and abortion will beto legalize abortion, with local obstetric facilitiesoffering safe legal abortions (Kwast 1989; Renfrewand Chalmers 1990). This may be an unrealistic pro-posal for many countries but local facilities shouldbe able to deal with incomplete abortions and havethe necessary supplies of antibiotics (Rosenfield1992). A contribution could be made if the antenatalvisit was used for health education which includedthe training of mothers and instruction of local tradi-tional birth attendants (TBAs) about the 'three cleans'necessary for a safe delivery (Royston and Ferguson1985; Hart et al. 1990).

The evidence seems to indicate that the most impor-tant contribution can be made by the distribution ofiron, folate and malaria prophylaxis, which can helpto improve the nutritional status of women makingthem better able to withstand haemorrhage and pro-longed labour and improve chronic anaemia (RoyalCollege of Obstetricians and Gynaecologists 1979;Sai and Measham 1992; Rooney 1992; WHO 1992a,1993). This distribution has also been found to im-prove growth in teenagers, reducing death fromobstruction (Harrison et al. 1985); but this contribu-tion is limited to the women who attend, and to thosewho attend early enough for the supplements to haveany benefit.

The only reliable method of improving nutritionalstatus is by improving the socioeconomic conditionsin the country and by advocating female education(Rossiter 1985; Caldwell 1986; World Bank 1993).It is interesting to note that in the 1930s, beforepregnancy was medicalized, 'schools for mothers'were considered the most effective method ofimproving maternal and child health.

The potential role of antenatal care.

A vital contribution could be made if attendance atan antenatal service influenced women to select atrained birth attendant. This would help reduce deathsfrom delayed referral, sepsis, obstructed labour andmorbidity associated with prolonged labour and poorobstetric technique (Greenwood et al. 1990). But thishas not been found to be the case. In one survey, 81 %of women attended antenatal care yet only 57%

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were subsequently attended by a trained attendant(Adekunle et al. 1990). These results could be duein part to a lack of trained attendants but the trendis that many more women attend antenatal care thanseek trained assistance at delivery (Leslie and Gupta1989). Research from Jamaica actually showed thatattendance at antenatal care resulted in womenhaving less chance of being delivered by a trainedperson (Gertler et al. 1993). The reasons for this areunclear but certainly cultural practices and mothers'perception of antenatal care are important factors(Paul 1993). This is compounded by a service thatprovides various 'ritually performed' diagnostic pro-cedures, leaving little time to offer a well-designedquality service which offers appropriate counsellingand empowerment to women to look after their ownhealth (Jelley and Madeley 1983: Wong et al. 1987;Hay 1990; Gertler et al. 1993).

Antenatal care as a screening programme in develop-ing countries is affected by the fact that the basic con-cept of screening procedures involved necessitatesregular attendance. The appropriate frequency andnumber of visits continues to be debated in developedcountries (Hall et al. 1980; Blondel et al. 1985;Lindmark and Cnattingius 1991). Antenatal care indeveloping countries by definition can be one visit(Royston and Ferguson 1985), which must inevitablyreduce the effectiveness of the procedures that requireregular attendance. Furthermore, timing becomes anissue (Thomas et al. 1991). To increase the possibilityof effective intervention, low body weight, risk fac-tors and medical conditions should be identified asearly as possible. Yet studies show that monitoringfor pre-eclampsia is not cost-effective until after 32weeks (Hall et al. 1980; Lindmark and Cnattingius1991) and abdominal palpation to identify malposi-tion is required as late in pregnancy as possible (Hallet al. 1980).

Evidence on antenatal care and the problems ofobtaining it

In reviewing the history of antenatal care, it wasfound that questions have been asked about antenatalcare since the 1930s when Drs Browne and Aberd(1932) asked why, although antenatal care hadbecome a routine part of obstetric practice, themassive reduction in mortality that had been en-visaged had not been seen. The paper makes in-teresting reading as the situation in 1932 is in manyways relevant to developing countries today. It statesthat although antenatal care can reduce the incidenceof complicated deliveries, many conditions go

unrecognized and there is often unnecessary in-terference. Furthermore, it can do little to preventsepsis or postpartum haemorrhage and has done verylittle for eclampsia. Finally they state 'much of whatpasses under the guise of antenatal care is tooirregular, too infrequent, too ill-organised' (Browneand Aberd 1932: 4).

In 1980, the Short Report (House of Commons SocialServices Committee 1980) expressed concern thatthere was a lack of knowledge on the practices andprocedures which form part of established antenatalcare and recommend more research on the impact ofantenatal care. In 1984 Hall asked the following ques-tion about antenatal care 'Are our accepted practicesbased on valid assumptions?' The reasons for doubtare clear. Much of the justification for antenatal carestems from studies looking at attendance at clinic, andthe timing and quantity of visits, using perinatal mor-tality and birth weight as the main outcome measures(Jelley and Madeley 1983; Strachan 1987; Nordbecket al. 1984). The methodology is often flawed aswomen who attend antenatal clinics are a self-selectedgroup or volunteers (Lederman 1985). These womenare destined to have a better outcome, a stance sup-ported by several studies (Lewis 1982; Ahmed et al.1990).

There is also a fundamental error in equating thenumber of visits made by a woman during antenatalcare with outcome, called 'the preterm bias' (Tysonet al. 1990), and a tendency to confuse quantity withquality (Enkin and Chalmers 1982). There continuesto be considerable debate over the issue of quantity;in Europe where the recommended number of visitsranges from 3-15 no significant difference in out-come was noted (Blondel et al. 1985). This is com-pounded by the lack of controlled trials to prove theeffectiveness of procedures used in antenatal care ortheir effect on maternal mortality in developing coun-tries (Cochrane 1972; Hall et al. 1980; Peoples-Shepset al. 1988; Chalmers 1990; Tew 1990; Lindmarkand Cnattingius 1991; Enkin 1992; Rooney 1992).The World Health Organization (1985) concluded thatno more than 10% of routine procedures used inobstetrics have been scientifically evaluated. Thereare those who accept that antenatal care has not beenproven scientifically but continue to believe in a per-sistent association between antenatal care and out-come (Nagey 1989; Lederman 1985). Lederman(1985) argues that clear benefit and better outcomewould be seen if all the high risk mothers attendedas recommended, but because they do not the results

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The effectiveness of antenatal care 11

are weakened. Nagey (1989) feels strongly that theword 'care' has been lost in all the analysis and the'benefits exceed the sum of the components' (p 525).

Although it is easy to criticize the lack of scientificevidence it is much more difficult to rectify the situa-tion. The major constraint is ethical; it is rarely pos-sible to carry out an RCT on a service that is alreadywell established as it would mean withdrawing theservice from one group (Peoples-Sheps et al. 1988;Bobadilla 1992). Another problem is sample sizebecause although maternal mortality is high, deathsin each community are often too small to offer signifi-cant results (Rosenfield 1992). To overcome thisproblem RCTs using geographical units have beenproposed (Lindmark and Cnattingius 1991). Therethen remains the issue of selecting a valid scientificsample due to the problem of non-attenders being dif-ferent to the attenders (Peoples-Sheps et al. 1988).Finally there is the need to match for all possiblepotential confounding variables, which are numerous.

Doubts about scientific evaluation are compoundedby the practical issue that antenatal care is often theonly service provided for women, and in many casesit offers the only opportunity to reach women. Itwould seem prudent to make better use of thisopportunity and provide a service more appropriateto women's needs.

The available evidence and the preceding discussionindicates that the procedures collectively carried outduring an antenatal visit, or simply attending antenatalcare, can have very little effect on maternal mor-tality or morbidity in developing countries at thepresent time. This is exacerbated by the fact thatthe service is generally caring for those least in need.The evidence indicates that for antenatal care to haveany effect it must be part of a system of care thatculminates in good local obstetric facilities withadequately trained staff (Kwast 1989; Winkoff et al.1991; WHO 1991a). Furthermore, without theseobstetric facilities the possible impact of antenatalcare in reducing maternal mortality and morbidity isdoubtful. It is estimated that first level obstetric carecould result in a reduction of 80-85 % in maternalmortality (Belsey 1990). The single important con-tribution that obstetric facilities have to play in im-proving maternal mortality can be seen from the studyof a religious group in the USA. This group, wholived under good socioeconomic conditions, refusedany medical intervention and had a maternal mortalityrate of 850 per 100 000 compared to an average

of 6 per 100 000 live births for the rest of thepopulation (Belsey 1990).

ConclusionAll the collated evidence suggests there are substan-tial grounds to doubt the effectiveness of the pro-cedures ritually performed during an antenatal visitand that are collectively called antenatal care. It seemsas if antenatal care, as part of MCH services, wasexported from developed countries to developingcountries because it was believed to be an appropriateand beneficial service. Yet the justification for ex-porting this service to deal with the prevailing con-ditions in developing countries is not apparent.Research shows that questions were being asked aboutthe possible lack of impact of antenatal care onmaternal mortality as early as 1932 (Browne andAberd 1932). The questions have continued to beposed and have not been answered satisfactorily,especially concerning maternal mortality and mor-bidity in developing countries (Hall et al. 1980, 1985;Hall 1983; Enkin and Chalmers 1982; Tew 1990;Enkin 1992; Bobadilla 1992; Rooney 1992).

Ultimately what is required is an improvement insocioeconomic conditions, the promotion of femaleeducation simultaneously with a broader concept ofwhat constitutes women's health, and the garneringof more accurate statistics to increase understandingof the needs of women (Graham 1992; Koblinsky etal. 1992). Recent efforts have seen maternal healthmoving away from a purely pregnancy-related orien-tation to reproductive health (WHO 1992b) but thisis not far enough. A definition of woman's health byVan der Kwaak (1991) cited in Koblinsky et al.(1992:31) states 'A woman's health is her total well-being, not determined solely by biological factors andreproduction, but also the effects of work load, nutri-tion, stress, war and migration, among others'. If ser-vices were delivered based upon a broader conceptof women's health and with a view to empoweringwomen to look after their own health needs, therewould ultimately be a welcome reduction in the unac-ceptably high levels of maternal mortality and mor-bidity currently prevalent in developing countries.The ultimate bonus would be healthier families andall the attending benefits resulting from this desirableachievement.

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BiographyMarilyn McDonagh, RGN, RSCN, HV, worked for Save theChildren Fund in Upper Volta and Laos from 1980 to 1986. Shereturned to Edinburgh for a four year period working as a nightsister and then studying to be a health visitor. In 1990 she wentto Pakistan, as health adviser for SCF to a primary health careprogramme based in Peshawar. In 1993 she completed an MScin Preventive Health Care Administration for Developing Coun-tries at Cardiff Medical School. After her Masters she worked forSCF as health adviser to the South Wollo Health Programme inEthiopia and she is currently seconded by SCF to WFP as foodsecurity adviser in Burundi. The full paper was written as partof her MSc and presented as her dissertation.

Correspondence: Marilyn McDonagh, 21a Regent Street,Portobello, Edinburgh, EH15 2AY, UK.

Appendix I. Criteria for a screening testa) that the outcome in question is an important public

health problem in the population.b) that there is a detectable preclinical phase or

high risk state preceding this outcome.c) that screening tests are sufficiently sensitive and

specific to permit identification of those at risk.d) that there is an effective treatment available for

this early disease stage ande) that early intervention is more effective than

waiting and treating overt disease.(Wilson and Jungner, cited in Rooney 1992: 10).

Additional requirements that would facilitatemonitoring are:

a) the condition should be well definedb) the prevalence of the condition should be knownc) the natural history of the condition should be

knownd) the test should be cost effectivee) facilities offering the test should be easily

installed and accessiblef) the test should be simple and safe

(Cuckle and Wood 1984: 2).

Appendix II. DefinitionsThe SENSITIVITY of a test refers to its ability tosingle out those people who have the conditionbeing screened for. High sensitivity results in lownumbers of false negatives (Gehlbach 1988).

The SPECIFICITY of a test refers to its ability tosingle out those people who do not have the con-dition being screened for. High specificity results inlow numbers of false positives (Gehlbach 1988). Thedilemma faced when attempting to improve effec-tiveness is that one can only improve sensitivity atthe expense of specificity and vice versa (Fortney andWhitehorne 1982).

The POSITIVE PREDICTIVE VALUE expresses theproportion of persons with positive tests who will befound to have the disease, when the test is appliedto a population with a specified prevalence of disease(Abramson 1974). Measuring the sensitivity andspecificity of a procedure is only part of a screeningtest and it may be efficient in identifying a condition,however to be effective it must also alter the outcome.

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Review article Is antenatal care effective in reducing maternal morbidity and mortality? · ·...

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