Health system and community level interventions for improving antenatal care coverage and health outcomes

Lawrence Mbuagbaw, Nancy Medley, Andrea J Darzi, Marty Richardson, Kesso Habiba Garga, Pierre Ongolo-Zogo, Lawrence Mbuagbaw, Nancy Medley, Andrea J Darzi, Marty Richardson, Kesso Habiba Garga, Pierre Ongolo-Zogo

Abstract

Background: The World Health Organization (WHO) recommends at least four antenatal care (ANC) visits for all pregnant women. Almost half of pregnant women worldwide, and especially in developing countries do not receive this amount of care. Poor attendance of ANC is associated with delivery of low birthweight babies and more neonatal deaths. ANC may include education on nutrition, potential problems with pregnancy or childbirth, child care and prevention or detection of disease during pregnancy.This review focused on community-based interventions and health systems-related interventions.

Objectives: To assess the effects of health system and community interventions for improving coverage of antenatal care and other perinatal health outcomes.

Search methods: We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (7 June 2015) and reference lists of retrieved studies.

Selection criteria: We included randomised controlled trials (RCTs), quasi-randomised trials and cluster-randomised trials. Trials of any interventions to improve ANC coverage were eligible for inclusion. Trials were also eligible if they targeted specific and related outcomes, such as maternal or perinatal death, but also reported ANC coverage.

Data collection and analysis: Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked them for accuracy.

Main results: We included 34 trials involving approximately 400,000 women. Some trials tested community-based interventions to improve uptake of antenatal care (media campaigns, education or financial incentives for pregnant women), while other trials looked at health systems interventions (home visits for pregnant women or equipment for clinics). Most trials took place in low- and middle-income countries, and 29 of the 34 trials used a cluster-randomised design. We assessed 30 of the 34 trials as of low or unclear overall risk of bias. Comparison 1: One intervention versus no interventionWe found marginal improvements in ANC coverage of at least four visits (average odds ratio (OR) 1.11, 95% confidence interval (CI) 1.01 to 1.22; participants = 45,022; studies = 10; Heterogeneity: Tau² = 0.01; I² = 52%; high quality evidence). Sensitivity analysis with a more conservative intra-cluster correlation co-efficient (ICC) gave similar marginal results. Excluding one study at high risk of bias shifted the marginal pooled estimate towards no effect. There was no effect on pregnancy-related deaths (average OR 0.69, 95% CI 0.45 to 1.08; participants = 114,930; studies = 10; Heterogeneity: Tau² = 0.00; I² = 0%; low quality evidence), perinatal mortality (average OR 0.98, 95% CI 0.90 to 1.07; studies = 15; Heterogeneity: Tau² = 0.01; I² = 58%; moderate quality evidence) or low birthweight (average OR 0.94, 95% CI 0.82 to 1.06; studies = five; Heterogeneity: Tau² = 0.00; I² = 5%; high quality evidence). Single interventions led to marginal improvements in the number of women who delivered in health facilities (average OR 1.08, 95% CI 1.02 to 1.15; studies = 10; Heterogeneity: Tau² = 0.00; I² = 0%; high quality evidence), and in the proportion of women who had at least one ANC visit (average OR 1.68, 95% CI 1.02 to 2.79; studies = six; Heterogeneity: Tau² = 0.24; I² = 76%; moderate quality evidence). Results for ANC coverage (at least four and at least one visit) and for perinatal mortality had substantial statistical heterogeneity. Single interventions did not improve the proportion of women receiving tetanus protection (average OR 1.03, 95% CI 0.92 to 1.15; studies = 8; Heterogeneity: Tau² = 0.01; I² = 57%). No study reported onintermittent prophylactic treatment for malaria. Comparison 2: Two or more interventions versus no interventionWe found no improvements in ANC coverage of four or more visits (average OR 1.48, 95% CI 0.99 to 2.21; participants = 7840; studies = six; Heterogeneity: Tau² = 0.10; I² = 48%; low quality evidence) or pregnancy-related deaths (average OR 0.70, 95% CI 0.39 to 1.26; participants = 13,756; studies = three; Heterogeneity: Tau² = 0.00; I² = 0%; moderate quality evidence). However, combined interventions led to improvements in ANC coverage of at least one visit (average OR 1.79, 95% CI 1.47 to 2.17; studies = five; Heterogeneity: Tau² = 0.00; I² = 0%; moderate quality evidence), perinatal mortality (average OR 0.74, 95% CI 0.57 to 0.95; studies = five; Heterogeneity: Tau² = 0.06; I² = 83%; moderate quality evidence) and low birthweight (average OR 0.61, 95% CI 0.46 to 0.80; studies = two; Heterogeneity: Tau² = 0.00; I² = 0%; moderate quality evidence). Meta-analyses for both ANC coverage four or more visits and perinatal mortality had substantial statistical heterogeneity. Combined interventions improved the proportion of women who had tetanus protection (average OR 1.48, 95% CI 1.18 to 1.87; studies = 3; Heterogeneity: Tau² = 0.01; I² = 33%). No trial in this comparison reported on intermittent prophylactic treatment for malaria. Comparison 3: Two interventions compared head to head. No trials found. Comparison 4: One intervention versus a combination of interventionsThere was no difference in ANC coverage (four or more visits and at least one visit), pregnancy-related deaths, deliveries in a health facility or perinatal mortality. No trials in this comparison reported on low birthweight orintermittent prophylactic treatment of malaria.

Authors' conclusions: Implications for practice - Single interventions may improve ANC coverage (at least one visit and four or more visits) and deliveries in health facilities. Combined interventions may improve ANC coverage (at least one visit), reduce perinatal mortality and reduce the occurrence of low birthweight. The effects of the interventions are unrelated to whether they are community or health system interventions. Implications for research - More details should be provided in reporting numbers of events, group totals and the ICCs used to adjust for cluster effects. Outcomes should be reported uniformly so that they are comparable to commonly-used population indicators. We recommend further cluster-RCTs of pregnant women and women in their reproductive years, using combinations of interventions and looking at outcomes that are important to pregnant women, such as maternal and perinatal morbidity and mortality, alongside the explanatory outcomes along the pathway of care: ANC coverage, the services provided during ANC and deliveries in health facilities.

Conflict of interest statement

Lawrence Mbuagbaw ‐ none known.

Nancy Medley ‐ none known.

Andrea J Darzi ‐ none known.

Marty Richardson ‐ none known.

Theresa A Lawrie ‐ none known.

Kesso Habiba Garga ‐ none known.

Pierre Ongolo‐Zogo ‐ the Centre for the Development of Best Practices receives funding from UKaid through the Effective Health Care Research Consortium, UK to promote and support evidence based health care.

Figures

1
1
Study flow diagram.
2
2
'Risk of bias' graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
'Risk of bias' summary: review authors' judgements about each risk of bias item for each included study.
4
4
Funnel plot of comparison: 1 One intervention versus no intervention, outcome: 1.1 ANC coverage: four or more visits.
5
5
Funnel plot of comparison: 1 One intervention versus no intervention, outcome: 1.2 Pregnancy‐related deaths.
6
6
Funnel plot of comparison: 1 One intervention versus no intervention, outcome: 1.6 Deliveries in a health facility.
7
7
Funnel plot of comparison: 1 One intervention versus no intervention, outcome: 1.13 Perinatal mortality.
1.1. Analysis
1.1. Analysis
Comparison 1 One intervention versus no intervention, Outcome 1 ANC coverage: four or more visits.
1.2. Analysis
1.2. Analysis
Comparison 1 One intervention versus no intervention, Outcome 2 Pregnancy‐related deaths.
1.3. Analysis
1.3. Analysis
Comparison 1 One intervention versus no intervention, Outcome 3 ANC coverage: one or more visits.
1.4. Analysis
1.4. Analysis
Comparison 1 One intervention versus no intervention, Outcome 4 Pregnant women initiating ANC in first trimester.
1.5. Analysis
1.5. Analysis
Comparison 1 One intervention versus no intervention, Outcome 5 Pregnant women receiving ANC from health professional.
1.6. Analysis
1.6. Analysis
Comparison 1 One intervention versus no intervention, Outcome 6 Deliveries in a health facility.
1.8. Analysis
1.8. Analysis
Comparison 1 One intervention versus no intervention, Outcome 8 Proportion of women with tetanus protection at birth.
1.9. Analysis
1.9. Analysis
Comparison 1 One intervention versus no intervention, Outcome 9 Proportion of women treated for syphilis.
1.10. Analysis
1.10. Analysis
Comparison 1 One intervention versus no intervention, Outcome 10 Proportion of women with HIV who receive a complete antiretroviral course for prevention of mother‐to‐child transmission of HIV.
1.11. Analysis
1.11. Analysis
Comparison 1 One intervention versus no intervention, Outcome 11 Preterm labour.
1.12. Analysis
1.12. Analysis
Comparison 1 One intervention versus no intervention, Outcome 12 Low birthweight.
1.13. Analysis
1.13. Analysis
Comparison 1 One intervention versus no intervention, Outcome 13 Perinatal mortality.
2.1. Analysis
2.1. Analysis
Comparison 2 Combination of interventions versus no intervention, Outcome 1 ANC coverage: four or more visits.
2.2. Analysis
2.2. Analysis
Comparison 2 Combination of interventions versus no intervention, Outcome 2 Pregnancy‐related deaths.
2.3. Analysis
2.3. Analysis
Comparison 2 Combination of interventions versus no intervention, Outcome 3 ANC coverage: one or more visits.
2.4. Analysis
2.4. Analysis
Comparison 2 Combination of interventions versus no intervention, Outcome 4 Pregnant women initiating ANC in first trimester.
2.5. Analysis
2.5. Analysis
Comparison 2 Combination of interventions versus no intervention, Outcome 5 Pregnant women receiving ANC from health professional.
2.6. Analysis
2.6. Analysis
Comparison 2 Combination of interventions versus no intervention, Outcome 6 Deliveries in a health facility.
2.8. Analysis
2.8. Analysis
Comparison 2 Combination of interventions versus no intervention, Outcome 8 Proportion of women with tetanus protection at birth.
2.9. Analysis
2.9. Analysis
Comparison 2 Combination of interventions versus no intervention, Outcome 9 Preterm labour.
2.10. Analysis
2.10. Analysis
Comparison 2 Combination of interventions versus no intervention, Outcome 10 Low birthweight.
2.11. Analysis
2.11. Analysis
Comparison 2 Combination of interventions versus no intervention, Outcome 11 Perinatal mortality.
4.1. Analysis
4.1. Analysis
Comparison 4 Combination of interventions versus one intervention, Outcome 1 ANC coverage: four or more visits.
4.2. Analysis
4.2. Analysis
Comparison 4 Combination of interventions versus one intervention, Outcome 2 Pregnancy‐related deaths.
4.3. Analysis
4.3. Analysis
Comparison 4 Combination of interventions versus one intervention, Outcome 3 ANC coverage: one or more visits.
4.4. Analysis
4.4. Analysis
Comparison 4 Combination of interventions versus one intervention, Outcome 4 Deliveries in a health facility.
4.5. Analysis
4.5. Analysis
Comparison 4 Combination of interventions versus one intervention, Outcome 5 Perinatal mortality.
4.6. Analysis
4.6. Analysis
Comparison 4 Combination of interventions versus one intervention, Outcome 6 Proportion of women with tetanus protection at birth.
5.1. Analysis
5.1. Analysis
Comparison 5 Different combinations of interventions, Outcome 1 ANC coverage: four or more visits.
5.4. Analysis
5.4. Analysis
Comparison 5 Different combinations of interventions, Outcome 4 Deliveries in a health facility.
6.1. Analysis
6.1. Analysis
Comparison 6 Subgroup analysis, Outcome 1 Health systems vs Population ANC coverage: four or more visits.
6.2. Analysis
6.2. Analysis
Comparison 6 Subgroup analysis, Outcome 2 Health systems vs Population Pregnancy‐related deaths.
6.3. Analysis
6.3. Analysis
Comparison 6 Subgroup analysis, Outcome 3 Country Income Low vs High ANC at least 4 visits.
7.1. Analysis
7.1. Analysis
Comparison 7 One intervention versus no intervention ‐ Sensitivity analysis by risk of bias, Outcome 1 ANC coverage: four or more visits.
8.1. Analysis
8.1. Analysis
Comparison 8 Combination of interventions versus no intervention ‐ Sensitivity analysis by risk of bias, Outcome 1 ANC coverage: four or more visits.

References

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Lewycka 2013b {published data only}
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Lund 2012 {published data only}
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Majoko 2007 {published data only}
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Manandhar 2004 {published data only}
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More 2012 {published data only}
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Mullany 2007 {published data only}
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Persson 2013 {published data only}
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Richter 2014 {published data only}
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    1. Langer A, Farnot U, Garcia C, Barros F, Victora C, Belizan JM, et al. The Latin American trial of psychosocial support during pregnancy: effects on mother's wellbeing and satisfaction Latin American Network For Perinatal and Reproductive Research (LANPER). Social Sciences and Medicine 1996;42(11):1589‐97.
    1. Langer A, Garcia C, Leis T, Reynoso S, Hernandez B. Pyschosocial support as a strategy to promote the health of the newborn. Revista de Investigacion Clinica 1993;45:317‐28.
    1. Langer A, Victora C, Victora M, Barros F, Farnot U, Belizan J, et al. The Latin American trial of psychosocial support during pregnancy: a social intervention evaluated through an experimental design. Social Sciences and Medicine 1993;36:495‐507.
    1. Victora CG, Langer A, Barros F, Belizan J, Farnot U, Villar J, et al. The Latin American multicenter trial on psychosocial support during pregnancy: methodology and baseline comparability. Controlled Clinical Trials 1994;15:379‐94.
    1. Villar J, Farnot U, Barros F, Victoria C, Langer A, Belizan J. A randomized trial of psychosocial support during high‐risk pregnancies. New England Journal of Medicine 1992;327:1266‐71.
Villar 2001 (WHO 2001) {published data only}
    1. Villar J, Ba'aqeel H, Piaggio G, Lumbiganon P, Belizan JM, Farnot U, et al. Who antenatal care randomised trial for the evaluation of a new model of routine antenatal care. The WHO Antenatal Care Trial Research group. Lancet 2001;357(9268):1551‐64.
    1. Villar J, Bakketeig L, Donner A, Al‐Mazrou Y, Ba'aqeel H, Belizan M, et al. The WHO Antenatal Care Randomised Controlled Trial: rationale and study design. Paediatric and Perinatal Epidemiology 1998;12(Suppl 2):27‐58.
    1. Villar J, Merialdi M, Ba'aqeel H, Piaggio G, Lumbiganon P, Belizan JM, et al. Developments in antenatal care [abstract]. XVIIIth European Congress of Obstetrics and Gynaecology; 2004 May 12‐15; Athens, Greece. 2004:82.
    1. Vogel JP, Ndema HA, Souza JP, Gulmezoglu MA, Dowswell T, Carroli G, et al. Antenatal care packages with reduced visits and perinatal mortality: a secondary analysis of the WHO Antenatal Care Trial. Reproductive Health 2013;10(1):19.
Wahlstrom 2011 {published data only}
    1. Wahlstrom R. Improving antenatal care utilization through a low cost community intervention which includes community participation combined with the provision of basic ANC equipment to health centers and a refresher course for healthcare providers: a pragmatic randomized trial in two provinces in rural Laos People's Democratic Republic. Current Controlled Trials (www.controlled‐) [accessed 11 November 2013] 2011.
Waiswa 2015 {published data only}
    1. Pariyo G. Improving newborn health and survival through a community based intervention linked to health facilities: a randomised controlled cluster trial. Current Controlled Trials (www.controlled‐) (accessed 12 May 2010) 2010.
    1. Waiswa P, Namazzi G, Kerber K, Peterson S. Designing for action: adapting and implementing a community‐based newborn care package to affect national change in Uganda. Global Health Action 2015;8:24250.
    1. Waiswa P, Pariyo G, Kallander K, Akuze J, Namazzi G, Ekirapa‐Kiracho E, et al. Effect of the Uganda Newborn Study on care‐seeking and care practices: a cluster‐randomised controlled trial. Global Health Action 2015; Vol. 8:24584.
    1. Waiswa P, Peterson SS, Namazzi G, Ekirapa EK, Naikoba S, Byaruhanga R, et al. The Uganda Newborn Study (UNEST): an effectiveness study on improving newborn health and survival in rural Uganda through a community‐based intervention linked to health facilities ‐ study protocol for a cluster randomized controlled trial. Trials 2012;13(1):213.
Walker 2013 {published data only}
    1. Walker D, Demaria L, Gonzalez‐Hernandez D, Padron‐Salas A, Romero‐Alvarez M, Suarez L. Are all skilled birth attendants created equal? A cluster randomised controlled study of non‐physician based obstetric care in primary health care clinics in Mexico. Midwifery 2013;29(10):1199‐205.
    1. Walker DM, DeMaria L, Suarez L, Gonzales D, Romero M, Padron A. Are all skilled birth attendants created equal? evidence from Mexico. International Journal of Gynecology and Obstetrics 2012;119(Suppl 3):S516‐S517.
Wu 2011 {published data only}
    1. Wu Z, Viisainen K, Wang Y, Hemminki E. Evaluation of a community‐based randomized controlled prenatal care trial in rural China. BMC Health Services Research 2011;11:92.
References to studies excluded from this review Alisjahbana 1995 {published data only}
    1. Alisjahbana A, Williams C, Dharmayanti R, Hermawan D, Kwast BE, Koblinsky M. An integrated village maternity service to improve referral patterns in a rural area in West‐Java. International Journal of Gynecology & Obstetrics 1995;48 Suppl:S83‐S94.
Baqui 2009 {published data only}
    1. Baqui AH, Arifeen SE, Rosen HE, Mannan I, Rahman SM, Al‐Mahmud AB, et al. Community‐based validation of assessment of newborn illnesses by trained community health workers in Sylhet district of Bangladesh. Tropical Medicine and International Health 2009;14(12):1448‐56.
Bhutta 2008 {published data only}
    1. Bhutta ZA, Memon ZA, Soofi S, Salat MS, Cousens S, Martines J. Implementing community‐based perinatal care: results from a pilot study in rural Pakistan. Bulletin of the World Health Organization 2008;86(6):452‐9.
Colbourn 2013 {published data only}
    1. Colbourn T, Nambiar B, Bondo A, Makwenda C, Tsetekani E, Makonda‐Ridley A, et al. Effects of quality improvement in health facilities and community mobilization through women's groups on maternal, neonatal and perinatal mortality in three districts of Malawi: MaiKhanda, a cluster randomized controlled effectiveness trial. International Health 2013;5(3):180‐95.
Dance 1987 {published data only}
    1. Dance J. A social intervention by linkworkers to Pakistani women and pregnancy outcome [MA thesis]. Warwick: University of Warwick, 1987.
Doyle 2014 {published data only}
    1. Doyle O, McGlanaghy E, Palamaro‐Munsell E, McAuliffe F. Home based educational intervention to improve perinatal outcomes for a disadvantaged community: a randomised control trial. European Journal of Obstetrics, Gynecology, and Reproductive Biology 2014;180:162‐7.
Ellard 2012 {published data only}
    1. Ellard D, Simkiss D, Quenby S, Davies D, Kandala NB, Kamwendo F, et al. The impact of training non‐physician clinicians in Malawi on maternal and perinatal mortality: a cluster randomised controlled evaluation of the enhancing training and appropriate technologies for mothers and babies in Africa (ETATMBA) project. BMC Pregnancy and Childbirth 2012;12:116.
Foord 1995 {published data only}
    1. Foord F. Gambia: evaluation of the mobile health care service in West Kiang district. World Health Statistics Quarterly 1995;48(1):18‐22.
Ford 2001 {published data only}
    1. Ford K, Hoyer P, Weglicki L, Kershaw T, Schram C, Jacobson M. Effects of a prenatal care intervention on the self‐concept and self‐efficacy of adolescent mothers. Journal of Perinatal Education 2001;10(2):15‐22.
    1. Ford K, Weglicki L, Kershaw T, Schram C, Hoyer PJ, Jacobson ML. Effects of a prenatal care intervention for adolescent mothers on birth weight, repeat pregnancy, and educational outcomes at one year postpartum. Journal of Perinatal Education 2002;11(1):35‐8.
Gokcay 1993 {published data only}
    1. Gokcay G, Bulut A, Neyzi O. Paraprofessional women as health care facilitators in mother and child health. Tropical Doctor 1993;23:79‐81.
Homer 2001 {published data only}
    1. Homer C. Incorporating cultural diversity in randomised controlled trials in midwifery. Midwifery 2000;16:252‐9.
    1. Homer CS, Davis GK, Brodie PM. What do women feel about community‐based antenatal care?. Australian & New Zealand Journal of Public Health 2000;24:590‐5.
    1. Homer CS, Davis GK, Cooke M, Barclay LM. Women's experiences of continuity of midwifery care in a randomised controlled trial in Australia. Midwifery 2002;18(2):102‐12.
    1. Homer CS, Matha DV, Jordan LG, Wills J, Davis GK. Community‐based continuity of midwifery care versus standard hospital care: a cost analysis. Australian Health Review 2001;24(1):85‐93.
    1. Homer CSE, Davis GK, Brodie PM, Sheehan A, Barclay LM, Wills J, et al. Collaboration in maternity care: a randomised controlled trial comparing community‐based continuity of care with standard hospital care. BJOG: an international journal of obstetrics and gynaecology 2001;108:16‐22.
Ickovics 2007 {published data only}
    1. Ickovics JR, Kershaw TS, Westdahl C, Magriples U, Massey Z, Reynolds H, et al. Group prenatal care and perinatal outcomes: a randomized controlled trial. Obstetrics & Gynecology 2007;110(2 Pt 1):330‐9.
    1. Novick G, Reid E, Lewis J, Kershaw S, Rising SS, Ickovics R. Group prenatal care: model fidelity and outcomes. American Journal of Obstetrics and Gynecology 2013;209(2):112.e1‐112.e6.
    1. Novick G, Reid E, Lewis J, Kershaw T, Rising S, Ickovics R. Group prenatal care: model fidelity and outcomes. Journal of Midwifery & Women's Health 2013;58(5):586‐7.
Jennings 2010 {published data only}
    1. Jennings L, Yebadokpo AS, Affo J, Agbogbe M. Antenatal counseling in maternal and newborn care: use of job aids to improve health worker performance and maternal understanding in Benin. BMC Pregnancy and Childbirth 2010;10:75.
Kafatos 1989 {published data only}
    1. Kafatos AG, Tsitoura S, Pantelakis SN, Doxiadis SA. Maternal and infant health education in a rural Greek community. Hygie 1991;10(1):32‐7.
    1. Kafatos AG, Vlachonikolis IG, Codrington CA. Nutrition during pregnancy: the effects of an educational intervention program in Greece. American Journal of Clinical Nutrition 1989;50:970‐9.
Koniak‐Griffin 1991 {published data only}
    1. Koniak‐Griffin D, Verzemnieks I. Effects of nursing intervention on adolescents' maternal role attainment. Issues in Comprehensive Pediatric Nursing 1991;14:121‐38.
Koniak‐Griffin 2000 {published data only}
    1. Koniak‐Griffin D, Anderson NL, Brecht ML, Verzemnieks I, Lesser J, Kim S. Public health nursing care for adolescent mothers: impact on infant health and selected maternal outcomes at 1 year postbirth. Journal of Adolescent Health 2002;30(1):44‐54.
    1. Koniak‐Griffin D, Anderson NL, Verzemnieks I, Brecht ML. A public health nursing early intervention program for adolescent mothers: outcomes from pregnancy through 6 weeks postpartum. Nursing Research 2000;49(3):130‐8.
    1. Koniak‐Griffin D, Verzemnieks IL, Anderson NL, Brecht ML, Lesser J, Kim S, et al. Nurse visitation for adolescent mothers: two‐year infant health and maternal outcomes. Nursing Research 2003;52(2):127‐36.
Kusulasai 1993 {published data only}
    1. Kusulasai K, Somrit N. A comparative study of new antenatal care schedule versus conventional one in detection of pregnancy complications in Chon Buri Hospital. Chon Buri Hospital Journal 1993;18(2):17‐31.
Leung 2012 {published data only}
    1. Leung SSK, Lam TH. Group antenatal intervention to reduce perinatal stress and depressive symptoms related to intergenerational conflicts: a randomized controlled trial. International Journal of Nursing Studies 2012;49(11):1391‐402.
Magriples 2008 {published data only}
    1. Magriples U, Kershaw TS, Rising SS, Massey Z, Ickovics JR. Prenatal health care beyond the obstetrics service: utilization and predictors of unscheduled care. American Journal of Obstetrics and Gynecology 2008;198(1):75.e1‐75.e7.
Miller 2012 {published data only}
    1. Miller PC, Rashida G, Tasneem Z, Haque MU. The effect of traditional birth attendant training on maternal and neonatal care. International Journal of Gynecology and Obstetrics 2012;117(2):148‐52.
Munjanja 1996 {published data only}
    1. Munjanja SP. A randomized controlled trial of two programmes of antenatal care in Harare, Zimbabwe. International Journal of Gynecology & Obstetrics 1994;46:31.
    1. Munjanja SP, Lindmark G, Nystrom L. Randomised controlled trial of a reduced‐visits programme of antenatal care in Harare, Zimbabwe. Lancet 1996;348:364‐9.
    1. Murira N, Munjanja SP, Zhanda I, Nystrom L, Lindmark G. Effect of a new antenatal care programme on the attitudes of pregnant women and midwives towards antenatal care in Harare. Central African Journal of Medicine 1997;43(5):131‐5.
Olds 1986 {published data only}
    1. Eckenrode J, Ganzel B, Henderson CRJ, Smith E, Olds DL, Powers J, et al. Preventing child abuse and neglect with a program of nurse home visitation: the limiting effects of domestic violence [See comments]. JAMA 2000;284(11):1385‐91.
    1. Olds D, Henderson CRJ, Kitzman H, Cole R. Effects of prenatal and infancy nurse home visitation on surveillance of child maltreatment. Pediatrics 1995;95(3):365‐72.
    1. Olds DL. Home visitation for pregnant women and parents of young children. American Journal of Diseases of Children 1992;146:704‐8.
    1. Olds DL, Eckenrode J, Henderson CRJ, Kitzman H, Powers J, Cole R, et al. Long‐term effects of home visitation on maternal life course and child abuse and neglect. Fifteen‐year follow‐up of a randomized trial. JAMA: Journal of the American Medical Association 1997;278(8):637‐43.
    1. Olds DL, Henderson CR, Chamberlin R, Tatelbaum R. Preventing child abuse and neglect: a randomized trial of nurse home visitation. Pediatrics 1986;78:65‐78.
    1. Olds DL, Henderson CR, Phelps C, Kitzman H, Hanks C. Effect of prenatal and infancy nurse home visitation on government spending. Medical Care 1993;31:155‐74.
    1. Olds DL, Henderson CR, Tatelbaum R. Intellectual impairment in children of women who smoke cigarettes during pregnancy. Pediatrics 1994;93:221‐7.
    1. Olds DL, Henderson CR, Tatelbaum R, Chamberlin R. Improving the delivery of prenatal care and outcomes of pregnancy: a randomized trial of nurse home visitation. Pediatrics 1986;77:16‐28.
    1. Olds DL, Henderson CR, Tatelbaum R, Chamberlin R. Improving the life‐course development of socially disadvantaged mothers: a randomized trial of nurse home visitation. American Journal of Public Health 1988;78:1436‐45.
    1. Olds DL, Henderson CRJ, Kitzman H. Does prenatal and infancy nurse home visitation have enduring effects on qualities of parental caregiving and child health at 25 to 50 months of life?. Pediatrics 1994;93(1):89‐98.
Olds 1995a {published data only}
    1. Olds DL, Kitzman H, Cole R, Robinson J, Sidora K, Luckey DW, et al. Effects of nurse home‐visiting on maternal life course and child development: age 6 follow‐up results of a randomized trial. Pediatrics 2004;114(6):1550‐9.
    1. Olds DL, Kitzman H, Hanks C, Cole R, Anson E, Sidora‐Arcoleo K, et al. Effects of nurse home visiting on maternal and child functioning: age‐9 follow‐up of a randomized trial. Pediatrics 2007;120(4):e832‐45.
    1. Olds DL, Kitzman HJ, Cole RE. Effect of home visitation by nurses on caregiving and maternal life‐course. Archives of Pediatrics and Adolescent Medicine 1995;149:P76.
    1. Olds DL, Kitzman HJ, Cole RE, Hanks CA, Arcoleo KJ, Anson EA, et al. Enduring effects of prenatal and infancy home visiting by nurses on maternal life course and government spending: follow‐up of a randomized trial among children at age 12 years. Archives of Pediatrics & Adolescent Medicine 2010;164(5):419‐24.
Rodriguez‐Angulo 2012 {published data only}
    1. Rodriguez‐Angulo E, Andueza‐Pech G, Rosado‐Alcocer L, Ortiz‐Panozo E, Hernandez‐Prado B. Effect of a community‐based intervention to improve the knowledge on the warning signs of maternal complications among Mayan women from Yucatan randomized controlled trial [Spanish] [Efecto de una intervencion comunitaria para mejorar conocimientos sobre signos de alarma de complicaciones maternas en mujeres mayas de Yucatan, ensayo controlado, aleatorizado]. Revista de Investigacion Clinica 2012;64(2):154‐63.
Schellenberg 2011 {published data only}
    1. Schellenberg D, Mshinda H, Tanner M. Improving newborn survival in rural southern Tanzania: a study to evaluate the impact and cost of a scaleable package of interventions at community level with health system strengthening. (accessed 25 November 2011) 2011.
Srinivasan 1995 {published data only}
    1. Srinivasan V, Radhakrishna S, Sudha R, Malathi MV, Jabbar S, Ramakrishnan R, et al. Randomised controlled field trial of two antenatal care packages in rural south India. Indian Journal of Medical Research 1995;102:86‐94.
Tomlinson 2014 {published data only}
    1. Tomlinson M. An effectiveness study of an integrated, community based package for maternal, newborn, child and HIV care in a disadvantaged community in South Africa. Current Controlled Trials (www.controlled‐) (accessed 12 May 2010) 2010.
    1. Tomlinson M, Doherty T, Ijumba P, Jackson D, Lawn J, Persson LA, et al. Goodstart: a cluster randomised effectiveness trial of an integrated, community‐based package for maternal and newborn care, with prevention of mother‐to‐child transmission of HIV in a South African township. Tropical Medicine & International Health 2014;19(3):256‐66.
    1. Tomlinson M, Doherty T, Jackson D, Lawn JE, Ijumba P, Colvin M, et al. An effectiveness study of an integrated, community‐based package for maternal, newborn, child and HIV care in South Africa: study protocol for a randomized controlled trial. Trials 2011;12:236.
Tough 2006 {published data only}
    1. Johnston D, Tough S, Siever J. The Community Perinatal Care Study: home visiting and nursing support for pregnant women. Zero to Three 2006;27(2):11‐7.
    1. Tough SC, Johnston DW, Siever JE, Jorgenson G, Slocombe L, Lane C, et al. Does supplementary prenatal nursing and home visitation support improve resource use in a universal health care system? A randomized controlled trial in Canada. Birth 2006;33(3):183‐94.
    1. Tough SC, Johnston DW, Siever JE, Jorgenson G, Slocombe L, Lane C, et al. Does supplementary prenatal nursing and home visitation support improved resource utilization in a system of univeral health care? Results from a randomized controlled trial in Canada [abstract]. Pediatric Academic Societies Annual Meeting; 2006 April 29‐May 2; San Fransisco, CA, USA. 2006.
    1. Tough SC, Siever JE, Johnston DW. Retaining women in a prenatal care randomized controlled trial in Canada: implications for program planning. BMC Public Health 2007;7:148.
Tough 2007 {published data only}
    1. Tough S. A randomised controlled trial comparing group to individual prenatal care. Current Controlled Trials (www.controlled‐) (accessed 30 October 2007) 2007.
Turan 2001 {published data only}
    1. Turan JM, Nalbant H, Bulut A, Sahip Y. Including expectant fathers in antenatal education programmes in Istanbul, Turkey. Reproductive Health Matters 2001;9(18):114‐25.
References to ongoing studies Bhandari 2014 {published data only}
    1. Bhandari GP, Subedi N, Thapa J, Choulagai B, Maskey MK, Onta SR. A cluster randomized implementation trial to measure the effectiveness of an intervention package aiming to increase the utilization of skilled birth attendants by women for childbirth: study protocol. BMC Pregnancy and Childbirth 2014;14(1):109.
Chavane 2014 {published data only}
    1. Chavane L, Merialdi M, Betran AP, Requejo‐Harris J, Bergel E, Aleman A, et al. Implementation of evidence‐based antenatal care in Mozambique: a cluster randomized controlled trial: study protocol. BMC Health Services Research 2014;14(1):228.
Kestler 2013 {published data only}
    1. Kestler E, Walker D, Bonvecchio A, Saenz de Tejada S, Donner A. A matched pair cluster randomized implementation trial to measure the effectiveness of an intervention package aiming to decrease perinatal mortality and increase institution‐based obstetric care among indigenous women in Guatemala: study protocol. BMC Pregnancy and Childbirth 2013;13(1):73.
Khan 2012 {published data only}
    1. Khan MA, Mirza S, Ahmed M, Rasheed A, Khan A, Walley J, et al. Making birthing safe for Pakistan women: A cluster randomized trial. BMC Pregnancy and Childbirth 2012;12:67.
Kikuchi 2015 {published data only}
    1. Kikuchi K, Ansah E, Okawa S, Shibanuma A, Gyapong M, Owusu‐Agyei S, et al. Ghana's Ensure Mothers and Babies Regular Access to Care (EMBRACE) program: study protocol for a cluster randomized controlled trial. Trials 2015;16:22.
Morrison 2011 {published data only}
    1. Morrison J, Tumbahangphe KM, Budhathoki B, Neupane R, Sen A, Dahal K, et al. Community mobilisation and health management committee strengthening to increase birth attendance by trained health workers in rural Makwanpur, Nepal: Study protocol for a cluster randomised controlled trial. Trials 2011;12:128.
Owen‐Jones 2013 {published data only}
    1. Owen‐Jones E, Bekkers MJ, Butler CC, Cannings‐John R, Channon S, Hood K, et al. The effectiveness and cost‐effectiveness of the Family Nurse Partnership home visiting programme for first time teenage mothers in England: a protocol for the Building Blocks randomised controlled trial. BMC Pediatrics 2013;13:114.
Ramsey 2013 {published data only}
    1. Ramsey K, Hingora A, Kante M, Jackson E, Exavery A, Pemba S, et al. The Tanzania Connect Project: a cluster‐randomized trial of the child survival impact of adding paid community health workers to an existing facility‐focused health system. BMC Health Services Research 2013;13(Suppl 2):S6.
Richter 2013 {published data only}
    1. Richter SM, Leroy JL, Olney D, Quinones E, Ruel M. Strengthening and evaluating the preventing malnutrition in children under 2 approach in Guatemala: Report of the enrollment survey. Strengthening and Evaluating the Preventing Malnutrition in Children under 2 Approach in Guatemala: Report of the Enrollment Survey. Washington DC: FHI 360, 2013.
Sando 2014 {published data only}
    1. Sando D, Geldsetzer P, Magesa L, Andrew I, Machumi L, Mwanyika‐Sando M, et al. Evaluation of a community health worker intervention and the World Health Organization's option B versus option A to improve antenatal care and PMTCT outcomes in Dar es Salaam, Tanzania: study protocol for a cluster‐randomized controlled health systems implementation trial. Trials 2014;15(1):359.
Shepard 2014 {published data only}
    1. Shepard D. Impact evaluation of the pilot SMS mother reminder system. () [accessed 2 September 2014] 2014.
Shrestha 2011 {published data only}
    1. Shrestha BP, Bhandari B, Manandhar DS, Osrin D, Costello A, Saville N. Community interventions to reduce child mortality in Dhanusha, Nepal: study protocol for a cluster randomized controlled trial. Trials 2011;12:136.
Vos 2015 {published data only}
    1. Vos AA, Voorst SF, Waelput AJ, Jong‐Potjer LC, Bonsel GJ, Steegers EA, et al. Effectiveness of score card‐based antenatal risk selection, care pathways, and multidisciplinary consultation in the Healthy Pregnancy 4 All study (HP4ALL): study protocol for a cluster randomized controlled trial. Trials 2015;16(1):8.
Additional references Agus 2012
    1. Agus Y, Horiuchi S, Porter SE. Rural Indonesia women's traditional beliefs about antenatal care. BMC Research Notes 2012;5:589. [PUBMED: 23106915]
Ballard 2013
    1. Ballard K, Gari L, Mosisa H, Wright J. Provision of individualised obstetric risk advice to increase health facility usage by women at risk of a complicated delivery: a cohort study of women in the rural highlands of West Ethiopia. BJOG: an international journal of obstetrics and gynaecology 6 March 2013;120(8):971‐978. [DOI: 10.1111/1471-0528.12190; PUBMED: 23464619]
Barber 2009
    1. Barber SL, Gertler PJ. Empowering women to obtain high quality care: evidence from an evaluation of Mexico's conditional cash transfer programme. Health Policy and Planning 2009;24(1):18‐25.
Bloom 1999
    1. Bloom SS, Lippeveld T, Wypij D. Does antenatal care make a difference to safe delivery? A study in urban Uttar Pradesh, India. Health Policy and Planning 1999;14(1):38‐48. [PUBMED: 10351468]
Cesar 2012
    1. Cesar JA, Sutil AT, Santos GB, Cunha CF, Mendoza‐Sassi RA. Prenatal care in public and private health services: a population‐based survey in Rio Grande, Rio Grande do Sul State, Brazil [Assistencia pre‐natal nos servicos publicos e privados de saude: estudo transversal de base populacional em Rio Grande, Rio Grande do Sul, Brasil]. Cadernos de Saude Publica 2012;28(11):2106‐14. [PUBMED: 23147952]
Darmstadt 2005
    1. Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, Bernis L. Evidence‐based, cost‐effective interventions: how many newborn babies can we save?. Lancet 2005;365(9463):977‐88. [PUBMED: 15767001]
Delgado‐Rodriguez 1996
    1. Delgado‐Rodriguez M, Gomez‐Olmedo M, Bueno‐Cavanillas A, Galvez‐Vargas R. A comparison of two indices of adequacy of prenatal care utilization. Epidemiology 1996;7(6):648‐50.
Dettrick 2013
    1. Dettrick Z, Firth S, Jimenez Soto E. Do strategies to improve quality of maternal and child health care in lower and middle income countries lead to improved outcomes? A review of the evidence. PloS One 2013;8(12):e83070. [PUBMED: 24349435]
Dogba 2009
    1. Dogba M, Fournier P. Human resources and the quality of emergency obstetric care in developing countries: a systematic review of the literature. Human Resources for Health 2009;7:7. [PUBMED: 19200353]
Dowswell 2015
    1. Dowswell T, Carroli G, Duley L, Gates S, Gulmezoglu AM, Khan‐Neelofur D, Piaggio G. Alternative versus standard packages of antenatal care for low‐risk pregnancy. Cochrane Database of Systematic Reviews 2015, Issue 7. [DOI: 10.1002/14651858.CD000934.pub3]
Edgerley 2007
    1. Edgerley L. Use of a community mobile health van to increase early access to prenatal care. Maternal and Child Health Journal 2007;11(3):235‐9. [DOI: 10.1007/s10995-006-0174-z]
Gertler 2000
    1. Gertler, Paul. Final report: The impact of Progressa on health. International Food Policy Research Institute Nov 2000.
Grilli 2002
    1. Grilli R, Ramsay C, Minozzi S. Mass media interventions: effects on health services utilisation. Cochrane Database of Systematic Reviews 2002, Issue 1. [DOI: 10.1002/14651858.CD000389]
Haider 2012
    1. Haider BA, Bhutta ZA. Multiple‐micronutrient supplementation for women during pregnancy. Cochrane Database of Systematic Reviews 2012, Issue 11. [DOI: 10.1002/14651858.CD004905.pub3]
Hawkes 2013
    1. Hawkes SJ, Gomez GB, Broutet N. Early antenatal care: does it make a difference to outcomes of pregnancy associated with syphilis? A systematic review and meta‐analysis. PloS One 2013;8(2):e56713. [PUBMED: 23468875]
Higgins 2011
    1. Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane‐.
Khan‐Neelofur 1998
    1. Khan‐Neelofur D, Gulmezoglu M, Villar J. Who should provide routine antenatal care for low‐risk women, and how often? A systematic review of randomised controlled trials. WHO Antenatal Care Trial Research Group. Paediatric and Perinatal Epidemiology 1998;12(Suppl 2):7‐26. [PUBMED: 9805721]
Kidney 2009
    1. Kidney E, Winter HR, Khan KS, Gulmezoglu AM, Meads CA, Deeks JJ, et al. Systematic review of effect of community‐level interventions to reduce maternal mortality. BMC Pregnancy and Childbirth 2009;9:2. [PUBMED: 19154588]
Kinzie 2004
    1. Kinzie B, Gomez P. Basic maternal and newborn care: a guide for skilled providers. (JHPIEGO/MNH Program: Baltimore, MD) 2004.
Langer 1993
    1. Langer A, Victora C, Victora M, Barros F, Farnot U, Belizan J, et al. The Latin American trial of psychosocial support during pregnancy: a social intervention evaluated through an experimental design. Social Sciences and Medicine 1993;36:495‐507.
Lassi 2015
    1. Lassi ZS, Bhutta ZA. Community‐based intervention packages for reducing maternal and neonatal morbidity and mortality and improving neonatal outcomes. Cochrane Database of Systematic Reviews 2015, Issue 3. [DOI: 10.1002/14651858.CD007754.pub3]
Liberati 2009
    1. Liberati A, Altman DG, Tetzlaff J, Mulrow C, Gotzsche PC, Ioannidis JP, et al. The PRISMA statement for reporting systematic reviews and meta‐analyses of studies that evaluate healthcare interventions: explanation and elaboration. BMJ (Clinical Research ed.) 2009;339:b2700. [PUBMED: 19622552]
Mangham‐Jefferies 2014
    1. Mangham‐Jefferies L, Pitt C, Cousens S, Mills A, Schellenberg J. Cost‐effectiveness of strategies to improve the utilization and provision of maternal and newborn health care in low‐income and lower‐middle‐income countries: a systematic review. BMC Pregnancy and Childbirth 2014;14:243. [PUBMED: 25052536]
Marteau 2006
    1. Marteau T, Dieppe P, Foy R, Kinmonth A, Schneiderman N. Behavioural medicine: changing our behaviour. BMJ 2006;332(7539):437‐8.
Marteau 2009
    1. Marteau TM, Ashcroft RE, Oliver A. Using financial incentives to achieve healthy behaviour. BMJ 2009;338:b1415.
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Source: PubMed

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