Objective
In response to worsening maternal-infant outcomes in the United States (U.S.), key policymakers have called for maternity care reform, including changes to prenatal care.
1
However, there is limited evidence linking outcomes to specific aspects of prenatal care, including prenatal education (ie, anticipatory guidance about pregnancy, delivery, and the postpartum period), support services (eg, screening and management of psychosocial risk factors), and care delivery (ie, when, where, and by whom prenatal care is provided). Recognizing that peer countries have experienced improvements in maternity outcomes in recent decades, even while pregnancy has become more deadly in the U.S.,
- Peahl A.F.
- Kozhimannil K.B.
- Admon L.K.
Addressing the US Maternal Health Crisis: Policies of 2020 Presidential Candidates.
https://www.healthaffairs.org/do/10.1377/hblog20190625.583781/full/
Date: 2019
Date accessed: December 8, 2019
2
we compared U.S. to international prenatal care consensus guidelines for low-risk women to inform care delivery reforms.
World Health Organization
Trends in Maternal Mortality: 1990-2015: Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division: Executive Summary.
Trends in Maternal Mortality: 1990-2015: Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division: Executive Summary.
https://apps.who.int/iris/bitstream/handle/10665/193994/WHO_RHR_15.23_eng.pdf?sequence=1
Date: 2015
Date accessed: May 22, 2019
Methods
We performed a scoping review (PROSPERO/CRD42018114705) of national prenatal care guidelines for low-risk women from 17 peer nations identified by the National Academy of Medicine for health comparisons to the U.S.
3
We conducted a systematic literature search of MEDLINE, CINHAL, SCOPUS, Google, Google Scholar, GlobalHealth, and select websites of national professional organizations. Guidelines published after 2010 for low-risk pregnancies were included. Guideline quality was assessed using the AGREE-II checklist.
4
We assessed guidelines’ recommendations for 6 prenatal care education topics (nutrition, exercise, weight gain, preparation for labor and delivery, family planning, breastfeeding), 7 psychosocial services (screening for and management of tobacco use, alcohol use, substance use, intimate partner violence, mental health disorders, housing insecurity, and nutritional needs), and care delivery (visit frequency, interval between visits, and recommended maternity care provider). Data were summarized using descriptive statistics.
Results
Guidelines from 9 of 17 countries met eligibility criteria. Guidelines met 88% of AGREE-II checklist requirements on average (range, 75–100%).
Recommendations for prenatal care education and psychosocial services were similar across countries (median recommended topics: education 6/6 (interquartile range [IQR], 6–6), psychosocial services screening 7/7 (IQR, 6–7), and psychosocial services management 6/7 (IQR, 5–6) (Table 1). The content most commonly omitted from guidelines were family planning (recommended in 7/9 countries) and housing insecurity (screening recommended in 6/9 countries; management recommended in 2/9 countries).
TableNational prenatal care guidelines’ characteristics and recommendations for visit number, educational topics, and psychosocial services
| Guideline characteristics | Prenatal care content recommendations | Prenatal care delivery recommendations | |||||||
|---|---|---|---|---|---|---|---|---|---|
| Country | Year | AGREE-II checklist items (%) | Education topics | Psychosocial services: screening | Psychosocial services: management | Visit number, median (range) | Weeks between visits: 1st TM | Weeks between visits: 2nd TM | Weeks between visits: 3rd TM |
| Australia
8
|
2017 | 95 | 6/6 | 7/7 | 6/7 | 8.5 (7–10) | 4 | 4 | 3–4 |
| Canada
7
|
2017 | 88 | 6/6 | 7/7 | 7/7 | 11.5 (11–12) | 4 | 2–4 | 2 |
| Finland
9
Health Library
https://www.terveyskirjasto.fi/terveyskirjasto/tk.koti
Date accessed: August 22, 2019
|
2018 | 84 | 6/6 | 5/7 | 5/7 | 2 (12–17) | 4 | 2–3 | 1 |
| France
10
Monitoring and Guidance of Pregnant Women Based on the Identified Risk of the Situation.
https://www.cngof.fr/
Date accessed: May 8, 2019
|
2016 | 85 | 6/6 | 6/7 | 4/7 | 7.5 (7–8) | 4 | 4 | 2–4 |
| Japan
5
|
2014 | 87 | 4/6 | 3/7 | 2/7 | 15 (15–15) | 4 | 2 | 1 |
| Netherlands
11
|
2017 | 98 | 6/6 | 7/7 | 6/7 | 7.5 (6–9) | 6 | 4 | 3–4 |
| Sweden
12
SFOG
Mödrahälsovård, Sexuell och Reproduktiv Hälsa.
https://www.sfog.se/natupplaga/ARG76web4a328b70-0d76-474e-840e-31f70a89eae9.pdf
Date accessed: May 8, 2017
|
2016 | 81 | 6/6 | 7/7 | 5/7 | 10 (10–10) | 4 | 4 | 2–4 |
| United Kingdom
13
|
2017 | 100 | 4/6 | 6/7 | 6/7 | 9 (7–10) | 4 | 4 | 2–4 |
| United States
6
|
2017 | 75 | 6/6 | 7/7 | 6/7 | 13 (12–14) | 4 | 2 | 1–2 |
TM, trimester.
Friedman Peahl. Comparison of international prenatal care guidelines for low-risk women. Am J Obstet Gynecol 2020.
a Guideline translation required
b Guideline recommends only 2 provider visits, with additional visits completed with a nurse.
Guidelines for prenatal care delivery were more varied across countries. The greatest variation was observed in median number of recommended visits (France and the Netherlands: 7.5; U.S.: 13; Japan: 15) and recommended interval between visits by trimester (range between visits: first trimester, 4–6 weeks; second trimester, 2–4 weeks; third trimester, 1–4 weeks) (Table 1). Most (6/9) countries recommended that low-risk women see only general practitioners or midwives for prenatal care, while Japanese guidelines recommended obstetrician-gynecologists as primary maternity care providers
5
and U.S. and Canadian guidelines recommended that pregnant women have the option to see an obstetrician-gynecologist, general practitioner, or midwife.
6
,
7
Conclusion
U.S. and peer-country guidelines recommended similar prenatal education and psychosocial services for low-risk women. Conversely, peer countries generally recommended fewer visits, longer intervals between visits, and less reliance on obstetrician-gynecologists for routine, low-risk prenatal care. Further investigation should evaluate associations between recommended care and actual practice, as well as the effects of different components of prenatal care and delivery models on maternal-infant outcomes, patient-centeredness, and health care expenditures in the U.S.
Acknowledgments
We gratefully acknowledge Emily Ginier for her contributions to establishing our search strategy for this project and Sarah Block for her tireless work in preparing the manuscript. Ms Ginier and Ms Block are employed by the University of Michigan and did not receive any special compensation for their contributions.
References
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Addressing the US Maternal Health Crisis: Policies of 2020 Presidential Candidates.(Available at:)https://www.healthaffairs.org/do/10.1377/hblog20190625.583781/full/Date: 2019Date accessed: December 8, 2019
-
Trends in Maternal Mortality: 1990-2015: Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division: Executive Summary.(Available at:)https://apps.who.int/iris/bitstream/handle/10665/193994/WHO_RHR_15.23_eng.pdf?sequence=1Date: 2015Date accessed: May 22, 2019
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AGREE II: advancing guideline development, reporting and evaluation in health care.CMAJ. 2010; 182: E839-E842
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Guidelines for obstetrical practice in Japan: Japan Society of Obstetrics and Gynecology (JSOG) and Japan Association of Obstetricians and Gynecologists (JAOG) 2014 edition.J Obstet Gynaecol Res. 2014; 40: 1469-1499
- Kilpatrick S.J. Papile L.A. Macones G.A. Guidelines for perinatal care. 8th edition. American Academy of Pediatrics, Elk Grove, IL2017
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Ontario. Routine Prenatal Care.(Available at:)
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Updated clinical practice guidelines on pregnancy care.Med J Aust. 2018; 209: 409-412
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(Available at:)
https://www.terveyskirjasto.fi/terveyskirjasto/tk.kotiDate accessed: August 22, 2019
-
Monitoring and Guidance of Pregnant Women Based on the Identified Risk of the Situation.(Available at:)https://www.cngof.fr/Date accessed: May 8, 2019
-
Pregnant!.(Available at:)
-
Mödrahälsovård, Sexuell och Reproduktiv Hälsa.(Available at:)https://www.sfog.se/natupplaga/ARG76web4a328b70-0d76-474e-840e-31f70a89eae9.pdfDate accessed: May 8, 2017
-
NICE guidelines update antenatal care guidance.Pract Midwife. 2008; 11: 8
Article info
Publication history
Published online: January 18, 2020
Footnotes
The authors report no conflict of interest. Support for this project came from the Institute for Healthcare Policy and Innovation (IHPI) Policy Sprint Funding Award. Michele Heisler is supported by the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), grant P30 DK092926, and Michelle Moniz is supported by the Agency for Healthcare Research and Quality (AHRQ), grant K08 HS025465. IHPI, NIDDK, and AHRQ played no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; or in the decision to submit the article for publication.
The study was conducted in Ann Arbor, Michigan
Identification
Copyright
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