A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and
vulnerable women
Final Report
Laura Oakley, Ron Gray, Jennifer J Kurinczuk, Peter Brocklehurst, Jennifer Hollowell
National Perinatal Epidemiology Unit, University of Oxford
October 2009
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women
ContentsExecutive summary .....................................................................................1
1 Background ...........................................................................................4
1.1 Aims of the review ..........................................................................6
2 Definitionsandscopeofthereview ...........................................................6
2.1 Operationaldefinitionofcomprehensiveantenatalcare ........................6
2.2 ‘Early’ initiation of antenatal care ......................................................6
2.3 Typesofintervention .......................................................................7
2.4 NHS relevance ................................................................................7
2.5 Disadvantagedandvulnerablegroups................................................7
3 Methods ................................................................................................8
3.1 Inclusion Criteria ............................................................................8
3.1.1 Study design ......................................................................8
3.1.2 Population ..........................................................................8
3.1.3 Intervention .......................................................................8
3.1.4 Comparatorgroup ...............................................................8
3.1.5 Outcome measure ...............................................................8
3.1.6 Language ...........................................................................9
3.1.7 Timeperiod ........................................................................9
3.1.8 Geographicalareas ..............................................................9
3.1.9 Typesofpublication .............................................................9
3.2 Exclusions .....................................................................................9
3.3 Methodsforidentificationofstudies ..................................................9
3.3.1 Overview of strategy to identify relevant studies ......................9
3.3.2 Bibliographicdatabases ......................................................10
3.3.3 Other online searchable resources .......................................10
3.3.4 Itemsidentifiedinscopingexerciseandantenatalcarereview .............................................................................11
3.3.5 Reference lists and citations ................................................11
3.4 Review methods ...........................................................................11
3.4.1 Screening .........................................................................11
3.4.2 Quality assessment ............................................................13
3.4.3 Data extraction .................................................................14
3.4.4 Assessment of effectiveness ................................................14
4 Results ................................................................................................14
4.1 Overview of included studies ..........................................................16
4.1.1 Countries .........................................................................16
4.1.2 Yearofpublication/study ....................................................16
4.1.3 Study design ....................................................................17
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women
4.1.4 Outcome measure .............................................................17
4.1.5 Quality .............................................................................18
4.1.6 Assessment of whether timing of initiation of antenatal care was an outcome measure ............................................19
4.2 Interventions studied ....................................................................19
4.2.1 Interventionrecipients/targetpopulations .............................19
4.2.2 Intervention content ..........................................................19
4.3 Effectiveness ................................................................................24
4.3.1 Outreach or other community-based interventions .................24
4.3.2 Alternative models of clinic-based antenatal care ...................25
5 Discussion ...........................................................................................29
5.1 Principalfindings ..........................................................................29
5.2 Strengths and limitations of this systematic review............................30
5.3 Findingsinrelationtootherpublishedevidence ................................31
5.4 Implicationsandrecommendations .................................................32
5.5 Conclusion ...................................................................................33
Acknowledgement .....................................................................................33
References ...............................................................................................34
Annex A: Medline search strategy ................................................................40
Annex B: Named intervention searches ........................................................42
Annex C: Characteristics and results of included studies .................................43
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women
TablesTable 1. Exclusion criteria ...........................................................................12
Table 2. Reasons for exclusion .....................................................................16
Table3.Majorflawsidentifiedinincludedstudies ...........................................18
Table 4. Effectiveness of outreach or other community-based interventions ............................................................................................26
Table 5. Effectiveness of interventions involving alternative models of clinic-based antenatal care .........................................................................28
FiguresFigure1.Barrierstoequitablehealthcareforracialandethnicgroups .................5
Figure2.Screeningprocess ........................................................................15
Figure3.Yearofpublicationofincludedstudies .............................................17
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women 1
Executive summaryThesystematicreviewdescribedinthisreportispartofaprogrammeofwork,commissionedbytheDepartmentofHealth,tostrengthentheevidencebaseoninterventionstoreduceinfantmortality,withaparticularfocusonreducinginequalitiesininfant mortality.
Aim
Thepurposeofthisreviewwastosystematicallyidentifyandevaluatetheevidencerelatingtotheeffectivenessofinterventions,relevantinthecontextoftheNationalHealthService(NHS),whichaimtoincreasetheearlyinitiationofcomprehensiveantenatalcarein socially disadvantaged and vulnerable women.
Methods
Searches
Wesearchedthemajorbibliographicdatabasesusingatwostagestrategy:weinitiallyranacomprehensive‘generic’searchandthenranfurthersearchesincorporatingtextsearchtermsrelatingtointerventionsidentifiedintheinitialsearches.Wealsosearchedotheronlinelibrariesandresources(e.g.CochraneLibrary,NationalGuidelinesClearingHouse)forrelevantsecondaryreports.Thereferencesandcitationsofincludedstudiesandrelevantsecondaryreportswerechecked.
Inclusion criteria
Studies which met the following “PICO” criteria were eligible for inclusion:
Population
Interventionevaluatedinarelevantdisadvantagedorvulnerablepopulation.•
PopulationrecruitedinanOECDcountry(excludingTurkeyandMexico).•
Intervention
Wedidnotplaceanyrestrictiononthetypeofintervention.Werequiredonlythat•studiesreportedthetimingofinitiationofantenatalcareasanoutcomemeasure.
Comparator
Studyincludedacontrol/comparatorgroup(s)whichdidnotreceiveorhaveaccessto•the intervention.
Interventionandcomparatorgroupwereselectedusingthesameand/orsimilar•samplingframesandbothgroupsdrawnfrombroadlysimilarpopulations.
Outcome
Theproportionofwomeninitiatingcomprehensiveantenatalcarebyagivenweek/•month(<=20weeksorbeforethefifthmonthofgestation).
Studiesrelatingsolelytotheprovisionorextensionofhealthinsurancecoverage,alongwith studies relating to models of insurance coverage or reimbursement were excluded. Wealsoexcludedstudiesprimarilyaddressingbarrierstoantenatalcareaccessthatrelatedtostructuralorfinancialaspectsofthelocalhealthcaresystemnotconsideredtoapplyinapredominantlygovernment-fundeduniversalhealthcaresystemsuchastheNHS.
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women2
Quality assessment
TworeviewersindependentlyappliedtheGATEchecklisttoassesstheinternalvalidityofeachstudy,focusingonthevalidityoftheestimatedeffectonthetimingofinitiationofantenatalcare.Usingthischecklist,theinternalvalidityofeachincludedstudywasratedas‘good’,‘mixed’or‘poor’.
Assessment of effectiveness
Tworeviewersindependentlycodedtheauthors’conclusionsregardingtheeffectoftheinterventionontimingofinitiationofantenatalcare,andindependentlyassessedandcodedtheevidenceofeffectiveness,takingintoaccountthestrengthsandlimitationsnoted in the GATE checklist.
Results
Overthreethousandcitationswerescreenedofwhichsixteenreports(eachrelatingtoadistinct intervention) met the inclusion criteria.
Fourteen(87%)ofthestudieswereconductedintheUS,1inAustraliaand1intheUK.
Thirteen of the sixteen included studies were observational cohort studies (10 were prospective,andthreewereretrospective;oneoftheretrospectivecohortstudiesalsoincludedapre-interventioncomparatorgroup);andthreewerebeforeandafterstudies.Allbutoneofthestudieswereassessedashaving‘poor’internalvalidity;onestudy(aretrospectivecohortstudy)wasratedashaving‘mixed’internalvalidity.
Twelvestudiesfocussedonspecificdisadvantagedorvulnerablesubgroupsofthepopulation.Thisincludedsixinterventionsthatweretargetedatand/orevaluatedinethnicminoritywomen,onethatfocussedonindigenousAustralianwomen,fourthattargetedteenagers,andonethatwasevaluatedinsubstanceabusingHIV-positivewomen.The remaining studies evaluated interventions in more generally socioeconomically disadvantagedpopulations.
Eleven studies evaluated interventions that involved outreach or other community-based services,andfivestudiesevaluatedinterventionsthatinvolvedalternativemodelsofclinic-basedantenatalcare.Themaincomponentsofeachinterventionandthetargetpopulationaresummarisedbelow.
Type of intervention Target population (number of studies)
Outreach or other community-based interventions
Layorparaprofessionalhomevisitingandsupport
Teenagers (n=2)
Socioeconomically disadvantaged women (n=1)
Linkworkers Ethnicminoritywomen/non-nativelanguagespeakers(n=1)
Mobile health clinics Socioeconomically disadvantaged women (n=1)
Multi-componentinterventions,includingtwoormoreofthefollowing:outreach,casemanagement,homevisiting,riskscreening,helpwithtransportationtoappointments,advocacyandsocialsupport
Ethnic minority women (n=5)
Indigenous women (n=1)
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women 3
Type of intervention Target population (number of studies)
Interventions involving alternative models of clinic-based antenatal care
Teen clinics Teenagers (n=2)
Collaborative antenatal care Socioeconomically disadvantaged women (n=1)
Enhanced antenatal care Socioeconomically disadvantaged women (n=1)
Socioeconomicallydisadvantaged,HIV-positivesubstanceabusingwomen(n=1*)
*Interventiontargetedatsocioeconomicallydisadvantagedwomen;studyevaluatestheinterventioninHIV-positivesubstanceabusingwomen
Effectiveness
Outreach or other community-based interventions
Of the eleven studies evaluating the effect of outreach or other community-based interventionsonthetimingofinitiationofantenatalcare,onlyone(aparaprofessionalhome visiting intervention described below) was assessed as having adequate internal validity in relation to the estimated effect on the timing of initiation of antenatal care. The qualityofevidencerelatingtotheothercommunity-basedinterventionswaspoor.
Rogers and colleagues assessed the effectiveness of a home visiting intervention delivered byparaprofessionalwomen(‘resourcemothers’)onthetimingofinitiationofantenatalcareamongpregnantteenagers(agedlessthan18),usingaretrospectiveobservationaldesign.Theevaluationusedtwodifferentcomparisongroups,onedrawnfromdifferentbutbroadlysimilargeographicalareas,andtheseconddrawnfromadolescentswhoresidedintheinterventionareasbeforetheinterventionwasimplemented.Thestudywastheonlystudyincludedinthereviewwhichadjustedforpotentialconfoundingintheanalysisoftimingofinitiationofantenatalcare.Theevaluationreportedastatisticallysignificantincreaseintheproportionofinterventionteenagersinitiatingantenatalcarebeforethefourthmonthofpregnancyrelativetobothcomparatorgroups(interventiongroupvs.geographicalcomparatorgroup,45%vs.41%,adjustedoddsratio1.48(95%CI1.32,1.66);interventiongroupvs.‘pre-intervention’comparatorgroup,45%vs.40%,adjustedoddsratio1.39(95%CI1.16,1.66)).Theauthorsconcludedthatthestudydemonstratedabeneficialeffectonthetimingofinitiationofantenatalcare.Becauseofthepotentialforselectionbiasandnon-randomassignmentofparticipants,thereviewersconsideredthestudyinconclusivebutconsistentwithapossiblebeneficialeffect.
Interventions involving alternative models of clinic-based antenatal care
The quality of evidence relating to interventions involving alternative models of clinic-basedantenatalcarewaspoor.Allfiveoftheincludedstudieswereassessedashavingpoorinternalvalidityinrelationtotheestimatedinterventioneffect on the timing of initiation of antenatal care.
Conclusions
Inacomprehensivereviewofthepublishedliteratureontheeffectivenessofinterventionstoincreasetheearlyinitiationofantenatalcare,wefoundinsufficientevidenceofadequatequalitytomakeanyfirmrecommendations.However,oneincludedinterventionwasconsidered‘promising’;andthreeotherinterventionstrategieswereidentifiedthatwereconsideredpotentiallyrelevanttotheNHSandworthyoffurtherconsiderationandevaluation.
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women4
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in
socially disadvantaged and vulnerable women
Thesystematicreviewdescribedinthisreportispartofaprogrammeofwork,commissionedbytheDepartmentofHealth,tostrengthentheevidencebaseoninterventionstoreduceinfantmortality,withaparticularfocusonreducinginequalitiesin infant mortality. The review focuses on interventions to increase the early initiation of comprehensiveantenatalcareinsociallydisadvantagedandvulnerablewomen.
Background1 Antenatalcareisconsideredtobeeffectiveinimprovingoutcomesforpregnantwomenand their infants.1 Evidence suggests that there is an association between under-utilisation ofantenatalcareandperinatalandinfantmortality.2 Early access to antenatal care is considered a key strategy in meeting targets to reduce inequalities in infant mortality in theUK,3andimprovingaccesstomaternityservicesisanongoingpriorityintheUK,4,5 witharecentGovernmentPSAtargetfocussingontheproportionofwomen‘booking’forantenatal care before 12 weeks.6,7
Initiationofantenatalcarewithinthefirsttrimesterisdesirable,withthemostrecentUKguidelines recommending initiation by 10 weeks gestation.1However,arecentUKsurveyfoundthatonly56%ofwomenhada‘booking’appointmentby12weeksgestation.8 Womenwhoinitiateantenatalcarelaterhaveareducedopportunitytofullybenefitfromtherangeofinterventionsofferedtopregnantwomen,forexampleearlyidentificationofriskfactorsforpre-eclampsiaandgestationaldiabetes,smokingcessationadvice,screeningforasymptomaticbacteriuria,1 and other screening tests offered to women in earlypregnancy.Thereisnoconsensusastowhatconstitutes‘late’booking.Asystematicreviewofsocialclass,ethnicityandantenatalcareattendance9 included studies in which thedefinitionoflateattendancevariedfrom14to20weeks;andareviewofbarrierstoaccess to antenatal care10founddefinitionsof‘latebooking’rangingfrom17to28weeks.
Onesystematicreviewhasconsideredtheassociationbetweensocio-demographicfactorsandattendanceforantenatalcareintheUK.9TheauthorsofthereviewidentifiedfiveUKstudieslookingatsocialclass,threeofwhichreportedanassociationbetweenmanualsocialclassandlateinitiationand/orunder-utilisationofantenatalcare.AllfourofthestudiesthattheyreviewedwhichconsideredethnicityreportedthatwomenofAsian origin were more likely to have delayed initiation of antenatal care. Other socio-demographicfactorsassociatedwithlateinitiationofantenatalcareintheUKincludeyoungerage,11smoking,11non-UKmaternalplaceofbirth,12 and single status (not married or cohabiting).12
Evidencefromotherdevelopedcountrieshasconfirmedassociationsbetweenlateinitiationofcareandlowersocio-economicstatus,13,14 belonging to an ethnic minoritygroup,14,15youngermaternalage,13–17smoking,15,17 and marital status.13,14,17 Inaddition,somestudieshavereportedassociationsbetweendelayedinitiationofcareandthefollowingsocio-demographicfactors:refugeestatus,18 low educational attainment,13,14,16,17,19highparity,13–15 alcohol use17andunplannedpregnancies.14,19
Both the characteristics of users and those of the health services themselves may affect access to care.20AmodeldevelopedbyCoopertoconceptualisebarrierstoequitablehealthcareforracialandethnicgroupsintheUSA(Figure1)21classifiespotentialbarriersintothreegroups:personal/familybarriers;structuralbarriers;andfinancialbarriers.Thismodelcanbeusedasastartingpointtoconceptualisebarrierstoantenatalcare,withsomebarriersrelatingtothe‘demandside’(forexamplehealthbeliefs,implicitorexplicitcostsofcare),andothersrelatingtothe‘supplyside’(e.g.qualityandavailabilityof services).22Significantly,thismodelwasdevisedforaUSsettingandfinancialbarriers
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women 5
tocarearelikelytobedifferentintheUKsettingwithpubliclyfundedhealthcarewhichisfreeatthepointofaccessforthoseconsidered‘ordinarilyresident’.However,althoughthenumberofmigrantwomenintheUKineligibleforfreematernitycareisprobablysmall,thereisevidenceofconfusionamonghealthcarestaffevenwhenguidanceisclearthat women are entitled to National Health Service (NHS) care.23 For the majority of womenintheUK,financialcostsincurredinthereceiptofantenatalcarearelimitedto‘outofpocket’expensessuchastransportation,childcare,andpotentiallossofearnings,particularlyfor‘vulnerableworkers’suchashourlypaidcasualworkersandthoseinthe’informaleconomy’.However,thesemaybetangiblebarrierstocareforsomegroupsofwomen,e.g.thoselivinginruralareaswithoutadequatepublictransportation,thosecaringforotherchildrenandthoseininsecureemployment.24
Figure 1. Barriers to equitable healthcare for racial and ethnic groups (adapted from Cooper21)
Personal/family Structural Financial
Acceptability
Cultural
Language/literacy
Attitudes,beliefs
Preferences
Involvement in care
Health behaviour
Education/income
Health status
Availability
Appointments
How organized
Transportation
Eligibility
Insurance coverage
Reimbursement levels
Publicsupport(i.e.publicfunding)
Theprecisebarrierstocareexperiencedbywomenmayvaryaccordingtotheirsocio-demographiccharacteristics.NealeidentifiedarangeofbarriersexperiencedbyinjectingdrugusersintheUKastheyattempttoaccessgeneralhealthcareandsupportservices,andmanyofthesemaybesharedbyothervulnerableanddisadvantagedgroupsofwomenaddressedinthepresentreview.25 Although Neale’s study concluded that some barriersvariedaccordingtothesocio-demographiccharacteristicsofparticipants,others,forexamplestigmaandnegativeattitudesfromstaff,werereportedasexperiencedbyallinterviewees.Inaddition,asystematicreviewofaccesstoantenatalcareindevelopedcountrieshighlightsthe“varietyofsocio-demographic,economic,culturalandpersonalfactors” that affect the correlation between delayed or infrequent antenatal care and outcomes.10 A review of the qualitative literature by Lavender et al. suggests that for somehigh-riskmarginalisedwomen,simplyprovidingappropriateservicesislikelytobeinsufficientaswomenmaynotbehealthliterateandlackthepersonalautonomy,supportand/orabilitytomakeuseofthecarewhichismadeavailabletothem.26 These findingsaresupportedbyworklookingatwiderissuesofaccesstogeneralhealthcare,withonereviewemphasisingtheneedtoaddresssourcesofinequalitiesincare,with“keybarriers…unlikelytobeuniformacrosssectors,services,andgroupsofpeople”.22 Thisapproachissupportedbythenotionof‘candidacy’,asyntheticconstructdevelopedtodescribe“thewaysinwhichpeople’seligibilityformedicalattentionandinterventionisjointlynegotiatedbetweenindividualsandhealthservices”andusedtoemphasisethattheuse of health services requires considerable work by individuals.24,27 Dixon-Woods gives as anexampletheevidencesuggestingthatpeoplefrommoredeprivedbackgroundshavealowertake-upofpreventiveservices(the“inversepreventionlaw”28). Although this may beinpartattributabletostructuralbarriers,itmayalsoresultfromalackof“positiveconceptualisationofhealth”,andthetendencytomanagehealthanddiseaseasseriesofmajor and minor crises.27Thisexplanationmaybeparticularlyrelevanttothediscussionofantenatalcare,oftendescribedasoneoftheclassicexamplesofpreventivemedicine.29
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women6
Despitethepriorityplacedonearlyinitiationofantenatalcareandadevelopingbodyofevidenceonfactorsinfluencingcare,fewstudieshaveevaluatedstrategieslikelytoinfluencethetimingofinitiationofantenatalcare.Inourscopingwork,wedidnotidentifyanypublishedsystematicreviewsthatlookedexclusivelyatstrategiesforincreasingearlyinitiationofantenatalcare.However,wedididentifythreerelevantreviews,primarilyfocussingonperinataloutcomesbutwhichalsosynthesiseddataontheeffectsofincludedinterventions on the timing of antenatal care initiation:
One literature review evaluated changes in the delivery of antenatal care for •Australianindigenouswomen.Thereviewlookedatcareutilisationalongsidehealth/birthoutcomes.Tenevaluationswereincluded,fourofwhichreportedtimingofinitiation of antenatal care as an outcome measure.30
Oneliteraturereviewlookedattheeffectoflayhomevisitingonpregnancy•outcomes. The author synthesised the effect of included interventions on utilisation of antenatalcareforeightstudieswherethesedatawerereported.31
Oneliteraturereviewfocussedonevidenceaboutimprovingservicesfor•disadvantagedchildbearingwomenintheUK.Anumberofprimarystudiesandsystematicreviewswereidentified,reportingavarietyofdifferentoutcomesrelatingtotheperinatalperiod.Onlyoneintervention,focussingonethnicminoritywomen,reportedontimingofantenatalcarebooking.32
Aims of the review1.1
Thepurposeofthisreviewwastosystematicallyidentifyandevaluatetheevidencerelatingtotheeffectivenessofinterventions,relevantinthecontextoftheNHS,whichaimtoincreasetheearlyinitiationofcomprehensiveantenatalcareinsociallydisadvantaged and vulnerable women.
Definitions and scope of the review2 Weoperationalisedconceptsanddefinitionsasfollows.
Operational definition of comprehensive antenatal care2.1
Antenatalcarereferstopregnancy-relatedservicesprovidedbetweenconceptionandtheonsetoflabourencompassingmonitoringofthehealthstatusofthewomanandthefetus,provisionofmedicalandpsychosocialinterventionsandsupport,andhealthpromotion.33 Suchservicesaretypicallyprovidedasapackageofcare,whichweterm‘comprehensiveantenatalcare’,althoughsometimeselementsofantenatalcaremaybedeliveredseparately,forexamplehomevisitingprogrammestargetingpregnantwomen.34,35 In this reviewwefocusonthetimingofinitiationof‘comprehensiveantenatalcare’.
‘Early’ initiation of antenatal care2.2
CurrentUKguidelinesrecommendthatwomenreceivetheirbookingappointmentforantenatal care before 10 weeks.1Cut-offsusedtodefine‘late’bookingrangebetween14-28weeks,9,10withnoclearconsensusregardingtheoptimaldefinition.Twentyweeksmayberegardedasanuppercut-offpointbasedontheopportunitytoreceiveanultrasoundanomalyscanwithintherecommendedtimeperiod(18-20weeksintheUK1),althoughlatercut-offpoints(22weeks,26weeks,28weeks)arealsousedforthepurposesofmonitoringuptakeofcare.
Forthepurposesofthisreview,weconsideredtheeffectofinterventionsonthetimingofinitiationofantenatalcareuptoandincluding20weeksofgestation.
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women 7
Types of intervention2.3
We were interested in any intervention which might be delivered to increase the early initiation of antenatal care by socially disadvantaged and vulnerable women. We envisaged that the majority of such interventions would be stand alone interventions or ‘outreach’ services attached to antenatal care services. However we also considered antenatal care serviceswithoutspecificoutreachserviceswithinthescopeofthereviewprovidedthatsome element of the intervention could be considered to address barriers to care.
NHS relevance2.4
InlinewiththeaimsoftheInfantMortalityProject,wedecidedtofocusoninterventionsthatwouldbeconsideredrelevantinthecontextoftheNHS.Inparticular,giventhepreponderanceofUS-basedresearchintheliterature,wespecificallywishedtoavoidtheinclusionofasubstantialvolumeofresearchrelatingtointerventionswhichprimarilyaddressedfinancialbarriersarisingfromlackofhealthcareinsuranceorinterventionsrelatingtostructuralorfinancialaspectsoftheUShealthcaresystemswhichwerenotapplicableintheUKcontext.Wewereunabletoidentifyanypublishedtypologyofinterventionsoraconceptualmodelwhichadequatelycapturedthisideaof‘NHSrelevance’.ThereforeweusedtheconceptsandcategoriesunderpinningthebarrierstohealthcareaccessmodeldevelopedbyCooper21 (discussed in Section 1 above) to operationaliseourinclusioncriteriarelatingtoNHSrelevance.
Usingthismodel,anyinterventionaddressingpersonal/familybarrierswasconsideredtobeofpotentialrelevancetotheNHS;interventionswhichwere‘primarily’structuralorfinancialwerenotconsideredrelevantunlesscomponentsoftheinterventionaddressedbarriersrelevanttowomenintheUKthatwerepotentiallytransferabletotheUKhealthcare setting.
Disadvantaged and vulnerable groups2.5
Wesoughtinterventionstargetingorevaluatedinthefollowinggroups.
Specificdisadvantagedandvulnerablegroupsofwomenatriskofaccessingantenatal•carelate,including:
Womeninprison ○Travellers ○Homeless women ○Asylum seekers and refugees ○Recently arrived migrants ○Otherimmigrantgroups ○Non-nativelanguagespeakers ○Victimsofabuse ○Womenwithmentalillness/mentalhealthproblems ○Women with learning disabilities ○Sex workers ○Victimsoffemalegenitalmutilation/cutting ○Teenagers ○WomenwhoareHIVpositive ○Substance users ○Alcohol misusers ○
Moregeneralgroupsofdisadvantagedwomen,including:•Women of low-socioeconomic status ○Womenlivingindeprivedareas ○Sociallydisadvantagedethnicminoritygroups ○
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women8
Methods3
Inclusion Criteria3.1
The following inclusion criteria were used:
Study design3.1.1
Norestrictionwasimposedonstudydesignotherthanthatthestudyhadtoincludeacontrolorcomparatorgroupandthestudymustbeanevaluationbroadlydesignedtocompareoutcomesintheinterventiongroupvs.thecontrol/comparatorgroup.Thusbothexperimentalandobservationalstudieswereeligibleforinclusion.
Population3.1.2
We required that the study evaluated the intervention in a socially disadvantaged or vulnerablepopulation,including,butnotlimitedtothegroupslistedinsection2.5above.Studiesthatevaluatedtheinterventioninamoregeneralpopulationbutprovidedsubgroupanalysisrelatingtorelevantsub-groupswerealsoeligibleforinclusion.
Intervention3.1.3
Wedidnotplaceanyrestrictiononthetypeofintervention.Werequiredonlythatstudiesreportedthetimingofinitiationofantenatalcareasanoutcomemeasure.
Comparator group3.1.4
We required that:
thestudyincludedacontrolorcomparatorgroupthatdidnotreceive,and/orhave•accessto,theintervention.
theinterventionandcomparatorgroupwereselectedusingthesameand/orsimilar•samplingframesi and that
theselectioncriteriaweresuchthatthetwogroupsweredrawnfrombroadlysimilar•populations.
Outcome measure3.1.5
Weincludedstudieswhichevaluatedtheeffectoftheinterventionontheproportionofwomeninitiatingcomprehensiveantenatalcarebyagivenweekormonthofpregnancyuptoandincluding20weeksofgestationorbeforethefifth,monthofpregnancy.
Somestudiesassessedtheeffectoftheinterventiononothercompositemeasuresofutilisationofantenatalcare,forexampletheKotelchuck Adequacy of Prenatal Care Utilization Index36 (a measure which takes account of both the timing of initiation of antenatalcareandthenumberofantenatalcarevisits,adjustedforthedurationofantenatal care). Such studies were eligible for inclusion if the timing of initiation of antenatalcarecomponentoftheindexwasreportedseparately.
Studiesthatreportedthetimingofinitiationofantenatalcareasabaselinecharacteristicwere excluded.
Language3.1.6
WeincludedonlyarticlespublishedinEnglish.
i Samplingframeswerenotconsideredcomparableif,forexample,oneincludedwomenwithnoantenatalcare(e.g.sampledfromabirthregister)andtheotherincludedonlywomenwithsomeantenatalcare(e.g.sampledfromaclinicpopulation)
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women 9
Time period3.1.7
Modelsofantenatalcarehaveshiftedinrecentdecadesfrompredominantlyobstetrician-led/hospital-basedmodelsofcaretomorediversemodelswithgreaterinvolvementofmidwives,primarycarephysiciansandothersintheprovisionofantenatalcarefornon-highriskpregnancies.
Inordertofocusonmodelsofantenatalcarethatarerelevantinthecurrentcontext,weincludedonlystudiespublishedfrom1990onwards.
Geographical areas3.1.8
Welimitedthereviewtostudiescarriedoutinhighincomecountrieswithwelldevelopedhealthcare systems and relatively low infant mortality rates. We included interventions evaluatedinmembercountriesoftheOrganisationforEconomicCo-operationandDevelopment(OECD),exceptforMexicoandTurkey,bothofwhichhavemarkedlyhigherinfant mortality rates than the rest of the OECD.37
Types of publication3.1.9
Weincludedjournalarticlesreportingprimaryresearch,withorwithoutanabstract.
Exclusions3.2
InordertofocusoninterventionsrelevantinthecontextoftheNHS,weexcludedinterventions that related solely to:
theprovisionorextensionofhealthinsurancecoverage,orsimilar,forexample,•changesintheeligibilitycriteriaforMedicaid;
amodelofinsurancecoverageorreimbursement,forexample‘managedcare’or‘fee-•for-service’.
Wealsoexcludedinterventionsthatprimarilyaddressedotherbarrierstoantenatalcareaccessthatrelatedtostructuralorfinancialaspectsofthelocalhealthcaresystemwhichwerenotconsideredtoapplyinapredominantlygovernment-fundeduniversalhealthcaresystemsuchastheNHS(seediscussionofCooper’sbarriersmodel21 in Section 1 above).
Methods for identification of studies3.3
Overview of strategy to identify relevant studies3.3.1
Because of the diversity of the interventions which might be relevant and the absence of specificMESH/indextermsrelatingspecificallytouptakeofantenatalcare,weadopteda multi-stage strategy to identify relevant material. We initially carried out a range of scopingsearches,includinginternetsearches,toidentifypotentiallyeligibleinterventions.Basedonthis,wedevelopedalistofpotentiallyrelevanttextsearchtermsrelatingtospecificinterventionsandtypesofinterventions,whichwethenincorporated,togetherwithMESHandindexterms,inthesearchesrunonthemajorbibliographicdatabases(seesection3.3.2).Thetitlesandabstractsofstudiesidentifiedinthesesearcheswerescreened,asdescribedinsection3.4.1below.Duringscreeningonerevieweradditionallyflaggedstudiesrelatingtopotentiallyrelevantinterventions,irrespectiveofwhetherthestudymetthereviewinclusioncriteria.Basedontheflaggedinterventions,afurtherlistofinterventionswasdeveloped(listedinAnnexB)andthemajorbibliographicdatabaseswere again searched using these additional ‘free text’ terms relating to interventions of interest.
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women10
Bibliographic databases3.3.2
Thefollowingbibliographicdatabasesweresearchedinordertoidentifyreportsofprimarystudies using a combination of text terms and MESH headings relevant to the review (AnnexA).WesearchedforreportspublishedbetweenJanuary1990andApril2009,included in the following databases:
Medline (Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid •MEDLINE(R)1950toPresent,searchedviatheOvidSPinterface)
Embase(EMBASE1988to2009Week15,searchedviatheOvidSPinterface)•
Cinahl (searched via the EBSCO interface)•
PsycINFO(PsycINFO1987toAprilWeek22009,searchedviatheOvidSPinterface)•
HMIC(HMICHealthManagementInformationConsortiumMarch2009,searchedvia•the OvidSP interface)
CENTRAL (searched via the Cochrane Library)•
Initial searches were carried out on 16thApril2009.
AfurtherroundofsearcheswascarriedoutusingthesedatabasesinMay2009,usingfreetextsearchstringsrelatingtoany‘named’interventionsidentifiedduringthefirstroundofscreening,asdescribedinsection3.3.1above.
Whereavailable,weappliedlimitsandfilterstorestrictthesearchresultsbypublicationyear(1990onwards),topic(humans),andlanguage(Englishlanguageonly).ThemainMedlinesearchwasadditionallyrestrictedonpublicationtypetoexcludeletters,news,editorials and commentaries.
AcopyofthemainMedlinesearchstrategyisprovidedinAnnexA.Alistofthe‘named’interventionsthatweincludedinthesecondroundofsearchesisgiveninAnnexB.Copiesof search strategies relating to other databases are available from the authors on request.
Other online searchable resources3.3.3
We searched the following databases through the Cochrane library interface to identify systematicreviews,guidelines,healthtechnologyassessmentsandeconomicevaluationsdealingwithaccesstoantenatalcareorrelatedtopics:
Cochrane Database of Systematic Reviews•
Database of Abstracts of Reviews of Effects (DARE)•
Health Technology Assessment Database•
These databases were searched on 28thApril2009.ThestrategyusedtosearchthesedatabaseswasidenticaltothatusedtosearchCENTRAL,andusedacombinationoftextterms and MESH headings relevant to the review.
Weadditionallysearchedthefollowingspecialistdatabasesandonlineresourcesinordertoidentifyanyfurtherprimaryreports,orguidelines,reviewsandreportswithrelevantcitations:
The National Guideline Clearing House•
The National Library for Health•
The National Institute for Health Research Service Delivery and Organisation •Programme
OpenSIGLE•
TRoPHI•
TheHealthDevelopmentAgency(HDA)•
The National Institute for Health and Clinical Excellence (NICE)•
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These databases and online resources were searched between 23rd and 30thApril2009.Whereasearchfacilityexistedwithinaparticulardatabase,abasicsearchwasconductedusing text terms relevant to the review. The reference lists of the relevant systematic reviews,guidelines,etc.werecheckedtoidentifyanyadditionaleligiblestudies.
Items identified in scoping exercise and antenatal care review3.3.4
Weincludedrelevantstudiesidentifiedduringinitialscopingworkdescribedabove(section3.3.1)Additionally,asmallnumberofitemsevaluatingrelevantinterventionswereidentifiedduringtheconductofarelatedsystematicreviewfocussingonantenatalcareinterventions.38Theitemswereincludedforscreeningalongsidematerialidentifiedfromothersourcestoensurethatinclusioncriteriawereappliedconsistently.
Reference lists and citations3.3.5
Followingthefulltextscreeningstage,thereferencelistsofallincludedstudieswerecheckedandfulltextversionsofanypossiblyrelevantcitationswereretrievedandscreened. We also searched the Science Citation Index via the Web of Science to recover anyrelevantpapersthatcitedanyitemsalreadyscreenedaseligibleforinclusion.
Review methods3.4
Screening3.4.1
Forthepurposesofscreening,theeligibilitycriteriadescribedinsection3.1and3.2abovewere reformulated as a set of exclusion criteria as shown in Table 1.
Abstract screening3.4.1.1
Titlesandabstracts(whereavailable)werescreenedindependentlybytworeviewersusing the exclusion criteria listed in Table 1. Articles were included for full-text review if eitherofthereviewersconsideredthestudypotentiallyeligibleonthebasisofthetitle/abstract.
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women12
Table 1. Exclusion criteria
Stage 1: Abstract/title screening Stage 2: Full-text screening
Stage 1 criteria PLUS:
General Not English language•
Notprimaryresearch•
Noteligiblepublicationtype•Not journal article – e.g. dissertation, book, conference abstract
Population Not conducted in an eligible •OECD country
Notpregnantwomenorstudy•populationnotrelevant
Intervention No relevant intervention•Study does not evaluate any form of intervention OR evaluated intervention could not reasonably be expected to influence the timing of antenatal care initiation
Ineligible intervention•Study intervention relates only to the provision or extension of health insurance coverage or similar, OR the study intervention relates only to the model of insurance coverage/ reimbursement, OR study relates only to other non-relevant structural or financial interventions, for example healthcare fees, cost of malpractice suits, liability cover etc.
Comparator Nocomparator/controlgroup• Controlgroupnoteligible•Inappropriate comparator/control group i.e. the comparator/control group is not drawn from a population of interest and/or the intervention and control group are drawn from different and non-comparable populations
Outcome No relevant outcome• No relevant outcome•Timing of initiation of antenatal care reported but not an outcome measure
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Stage 1: Abstract/title screening Stage 2: Full-text screening
Stage 1 criteria PLUS:
Other Not an effectiveness evaluation•Study does not report an effectiveness evaluation of a relevant intervention with an eligible control group and a relevant outcome measure reported
Selection criteria for study •groupsnotappropriateFor example, - RCTs where women were randomised after entry into antenatal care - Studies where inclusion/exclusion criteria were based on the timing of initiation of antenatal care, e.g. studies which excluded ‘late bookers’ - Studies where the intervention and control/comparator groups were sampled from non-comparable sampling frames (e.g. antenatal care clinic records vs. birth records)
Full text screening3.4.1.2
Thefulltextarticlesofallitemsincludedattheabstract/titlescreeningstagewereretrievedandscreenedindependentlybytworeviewersusingtheexclusioncriteriausedpreviouslyandadditionalmorespecificcriteria(Table1).Reviewerswereaskedtousetheirjudgementincaseswhereanitemwasnotexplicitlyreported.Althoughwedidnotrestrictbyinterventiontype,studieswereexcludedatthetitle/abstractstageiftherewasnoevidencethattimingofinitiationofantenatalcarewasreportedandreviewersconsideredthattheinterventioncouldnotfeasiblybeexpectedtoinfluencetimingofinitiationofantenatalcare.Whereitwasnotexplicitlystatedthatthetimingofinitiationofantenatalcarewasastudyoutcome,reviewerswereaskedtoassesswhetherthiswasreportedasabaselinecharacteristicorasanoutcomemeasure.
Wheretherewaslackofagreementbetweenthereviewerstheopinionofathirdreviewerwas sought and a decision reached following discussion. It was found that the reviewers were sometimes unable to reach a clear consensus as to whether the timing of initiation ofantenatalcarewasanoutcomemeasure;toavoidtheexclusionofpotentiallyrelevantmaterial,thesestudieswereincludedbutthisaspectofthestudywascodedas‘unclear’.
Quality assessment3.4.2
An assessment of internal validity was carried out using the GATE checklist.39 Two reviewersindependentlyassessedeachstudy,andawardedanoverallgrade:++ Good:wellreportedandreliable;
+ Mixed:someweaknessesbutinsufficienttohaveanimportanteffectonusefulnessofstudy;
- Poor:studynotreliable,notuseful.
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women14
Wherethetwoassessmentsdidnotagree,theopinionofathirdreviewerwassoughtandafinalgradewasassignedfollowingdiscussion.
Foranalysispurposes,studiesassessedas‘mixed’or‘good’werecombinedtoprovidean‘adequate’ category.
PriortoundertakingthestudyGATEassessments,reviewerscompletedanddiscussedaminimumoffive‘trainingassessments’toensurethatthetoolwasbeingcorrectlyandconsistentlyapplied.
Data extraction3.4.3
AdataextractionandcodingformwasdevelopedandloadedintoEppi-Reviewer,40 customisedsoftwaredesignedtomanagescreening,dataextractionandanalysisforsystematic reviews.
Basicdescriptivedatawerecodedbyonerevieweronly;otherinformation,e.g.relatingtotheaims,studydesign,resultsandconclusions(assessmentofeffectiveness,seebelow)oftheevaluationwasindependentlycodedbytworeviewersandresultscompared.Discrepancieswereresolvedbydiscussionwithathirdreviewerconsultedifnecessary.
Assessment of effectiveness3.4.4
Authors’ conclusions3.4.4.1
Authors’ conclusions on the effect of the intervention on the timing of initiation of antenatalcarewereindependentlyassessedbytworeviewersandcodedasfollows:
+ Statisticallysignificantbeneficialeffect
(+) Effectconsistentwithbeneficialeffectbuteffectnotstatisticallysignificantand/orcautiousinterpretationoffindingsuggested
X Noevidenceofbeneficialeffect
0 No conclusion stated
Wherethereviewersdisagreed,athirdreviewerassessedthestudyandadecisionwasreached following discussion.
Reviewers’ assessment of effectiveness3.4.4.2
Tworeviewersassessedandindependentlycodedtheevidenceofeffectiveness,takingintoaccountthestrengthsandlimitationsnotedintheGATEchecklist,withinputfromathirdreviewerasdescribedpreviously.Studiesweregradedusingthefollowingcategories:
+ Studydemonstratesabeneficialeffect
(+?) Studyinconclusivebutmaydemonstrateabeneficialeffect
X Studydoesnotprovideconvincingevidenceofabeneficialeffect
Studiesratedashavingpoorinternalvalidity(i.e.GATEqualityassessment‘Poor:studynotreliable,notuseful’)werenotconsideredfurther.
Results4 ThenumberofitemsincludedateachstageofthereviewispresentedinFigure2.
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Figure 2. Screening process
Citations identified from initial search of major
bibliographic databasesn=3069
Stage 2 full-text screening
n=125
Stage 1 abstract/title screeningn=2100
Duplicatesn=1166
Excluded on abstract/title
n=1975
Excluded on full-text review
n=109
Included in reviewn=16
Citations identified from other sources
n=197
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women16
Initialsearchesofthemajorbibliographicdatabasesidentified3069citations,ofwhich1062wereduplicates.Afurther197citationswereidentifiedfromothersources:fromnamedinterventionsearches,scopingsearches,theantenatalcaresystematicreview,andfromcheckingthereferencelistsandcitationsofstudiesidentifiedforinclusion.Onehundredandfourofthiscitationsidentifiedfromothersourceswereexcludedasduplicates.Overall,2100itemswerescreenedontitle/abstract(stage1),ofwhich1975wereexcluded.Ofthe125progressingtofulltextreview,109wereexcludedasaresultof full-text screening (stage 2). Further information about reasons for exclusion are presentedinTable2.
Table 2. Reasons for exclusion
Reason for exclusion
Excluded at stage 1: Abstract/title screening (n=1975)
Excluded at stage 2: Full-text screening (n=109)
General Notprimaryresearch
Noteligiblepublicationtype
259 52
16 3
Population Not conducted in an eligible OECD country
Notpregnantwomenorstudypopulationnotrelevant
627
149
0
0
Intervention No relevant intervention
Ineligible intervention
827 35
0 1
Comparator Nocomparator/controlgroup
Controlgroupnoteligible
5 0
20 11
Outcome No relevant outcome 18 49
Other Not an effectiveness evaluation
Selectioncriteriaforstudygroupsnotappropriate
3
0
4
5
Overview of included studies4.1
Weidentified16eligibleevaluationsrelatingto16distinctinterventions.Thefollowingsectionsdescribethese16primarystudies.
Countries4.1.1
FourteenoftheincludedstudieswereconductedintheUSA,onewascarriedoutinAustralia,41andoneintheUK.42
Year of publication/study4.1.2
Thesearchesidentifiedstudiespublishedbetween1990and2009.Themostrecentstudyincludedinthereviewwaspublishedin2007.Themajorityofstudieswerepublishedbetween1996and2001.ThedistributionofstudiesbyyearofpublicationispresentedinFigure 3.
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Figure 3. Year of publication of included studies
0
1
2
3
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
Num
ber o
f stu
dies
Year of publication
Fourteenstudiesexplicitlystatedthestudytimeperiodfortheevaluation.Ofthesefourteenstudies,fourwerecompletedbefore1990,fivewerecompletedbefore1995,onewascompletedbefore2000,andthreewerecompletedbefore2005.Fortheremainingthreestudies,thetimeperiodoftheevaluationwasnotstatedorwasunclear.
Study design4.1.3
All the included evaluations used observational study designs. Two were before and after studieswithoutacontemporaneouscomparisongroup,43,44 and one was a before and after studywhichincludedacontemporaneouscomparatorgroupbutdidnotreportdataonthetimingofinitiationofantenatalcareforthisgroup.41Onestudywasaretrospectiveobservationalcohortstudywithanadditionalpre-interventioncomparatorgroup.45 The remaining12studieswerecohortstudies,ofwhichninewereclassifiedasretrospectiveandthreeasprospective.Oneoftheseincludedamatchedcomparatorgroup.46
Outcome measure4.1.4
Justoverhalfofthestudies(n=9)reportedtheproportionofwomeninitiatingcareinthefirsttrimester.41,46–53Twostudiesreportedmeasuresbasedoninitiationofantenatalcareby 12 weeks42orby14weeks,54andfivestudiesreportedthemonthofpregnancywhenantenatal care started (before the fourth44,45,55andfifthmonth43,56ofpregnancy).Thesource of data on gestation at initiation of antenatal care varied: six studies (all US-based) usedinformationrecordedonthebirthcertificate,43,45–47,50,56 three used clinical records only,41,42,44andone,whichrecruitedrecipientsofthe“SpecialSupplementalFoodProgramforWomen,InfantsandChildren”(WIC)services,usedtheWICrecordsasthesourceofdata.48Intheremainingsixstudies,thesourceofinformationongestationatinitiationof antenatal care was not clearly stated.49,51–55Onlytwostudiesexplicitlyreportedtheprocessbywhichgestationalagewasascertained.41,54
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Quality4.1.5
Inter-raterreliabilityoftheGATEtoolwaslow(Kappa=0.18),with25%ofinitialassessmentsdiscordant(n=4).Fifteenoutofsixteenstudiesweregivenafinalratingof“poor”,andonestudywasratedashaving“mixed”internalvalidity.45Thepoorinternalvalidityoftheincludedstudiespartlyreflectedtheinclusionofanumberofstudiesinwhichinitiationofantenatalcarewasnottheprimaryfocusoftheevaluation.Thereviewers assessed internal validity in relation to the evaluation of effects on the timing ofinitiationofantenatalcare;incaseswherethiswasnottheprimarystudyoutcome,thisratingdoesnotnecessarilyreflectthevalidityofestimatedeffectsonotherstudyoutcomes.
Themostcommonlyreportedflaw(15studies)wasalackofadjustmentforpotentialconfounding in the analysis of the effect of the intervention on the timing of initiation of antenatalcare(somestudiesreportedadjustedanalysesforotheroutcomemeasures).Thiswasaseriousproblemasmanystudiesalsoreportedsignificantbaselinedifferencesbetweentheinterventionandcomparatorgroups,oftenaresultoftheinterventiontargetinggroupswithahigherriskprofile.SomekeyflawsidentifiedintheincludedstudiesarereportedinTable3.
Table 3. Major flaws identified in included studies
FlawNumber of studies affected*
Reporting of the study
Nodatapresentedonbaselinecharacteristicsbyintervention/comparatorstatus
3
Insufficientdatapresentedonbaselinecharacteristicsbyintervention/comparatorstatus
1
Outcomedatapresentedonlyingraphicalform,nonumericresultsprovided
2
Design of the study
Interventionandcontrolgroupsknown to differ at baseline with regard to importantcharacteristics,andnoadjustmentforknowndifferencesattheanalysis stage
8
Interventionandcontrolgroups likely to differ at baseline with regard to importantcharacteristics(insufficientdatapresentedtoassess),andnoadjustment for likely differences at the analysis stage
2
Smallsamplesize(n=<200) 4
Noprotectionagainstsecularchanges(beforeandafterstudywithoutcontemporaneouscomparisongroup)
3
Atleastonecomparatorgroupincludeswomenwhomayhavereceivedthe intervention under study (contamination)
2
Analysis of the study
Noadjustmentforpotentialconfoundinginanalysisoftimingofinitiationof antenatal care
15
Inappropriateanalysismethod(unmatchedanalysisformatcheddesign) 1
*Numbersdonotaddupton=15,moststudieshadmultipleflaws
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Assessment of whether timing of initiation of antenatal care was 4.1.6 an outcome measure
Overall,eightstudieswereconsideredtoclearlyreporttimingofinitiationofantenatalcare as an outcome measure. In the remaining eight studies it was considered unclear as towhethertimingofinitiationofantenatalcarewasreportedasanoutcomemeasureasopposedtoabaselinecharacteristic.
Interventions studied4.2
Intervention recipients/target populations4.2.1
Bydefinition,allincludedstudiescoveredinterventionsthatweretargetedatand/orevaluatedinoneormoreofthedisadvantagedorvulnerablegroupslistedpreviously.Twelvestudiesfocussedonspecificsubgroupsofinterest.Thisincludedsixinterventionsthatweretargetedatand/orevaluatedinethnicminoritywomen(“womenfrom‘minority’backgrounds”,46Mexican-American,43African-American,47,50,53 Asian-British42),onethatfocussedonindigenousAustralianwomen,41fourthattargetedteenagers,44,45,51,55 andonethatwasevaluatedinsubstanceabusingHIV-positivewomen.56 Four studies coveredinterventionstargetedatand/orevaluatedinmoregenerallysocioeconomicallydisadvantagedpopulations,49,52,54oneofwhichsimplydescribedtheinterventiontobetargeted at “at risk families”.48
Intervention content4.2.2
The16includedinterventionswerebroadlyclassifiedaccordingtowhethertheywereoutreach or other community-based interventions (11 studies41–43,45–50,53,55);orwhetherthey were interventions involving alternative models of clinic-based antenatal care (5 studies44,51,52,54,56).
Outreach or other community-based interventions4.2.2.1
Eleven studies evaluated outreach or other community-based interventions. Three of theseinterventionsconsistedprimarilyofsocialsupportand/orhomevisitsdeliveredbyparaprofessionalorlaywomen.45,48,55Ofthesestudies,twoevaluatedinterventionsbasedontheconceptof‘resourcemothers’–trainedparaprofessionalwomenrecruitedfromthelocalcommunity-providingsupporttopregnantteenagers.45,55 The third intervention encompassedhomevisitingforsocioeconomicallydisadvantaged“atrisk”families.48 One interventionconsistedoftheprovisionof‘linkworkers’inprimarycareandantenatalcaresettings,42 and in another study the intervention was a mobile health clinic offering basic antenatal services.49Theremainingsixstudiesallevaluatedmulti-componentinterventionsincludingtwoormoreofthefollowingcomponents:outreach,casemanagement,homevisiting,riskscreening,helpwithtransportationtoappointments,advocacyandsocialsupport.41,43,46,47,50,53 Five of the interventions 41,43,46,47,50 involved lay workersorparaprofessionalstaffindigenoustothetargetedcommunity.
Lay or paraprofessional home visiting and support
RogersandcolleaguesevaluatedtheimpactofaResource Mothers Program (RMP) in a sampleofruralandmoderatelyurbancountiesinSouthCarolina,USA.45 The intervention wasdeliveredbyresourcemothers(paraprofessionalwomenwhoprovidedsocialsupportthrough home visits). These women were recruited from the local community and received threeweeksofintensivetrainingonarangeofsubjectsincludingpregnancyandinfantcare,nutritionandcommunicationskills.Pregnantteenageparticipants(<18years),whowerepredominantlyBlack,wererecruitedthroughoutreachactivitiesorthroughpeer-referral or referral from other agencies such as the Special Supplemental Food Program for Women, Infants and Children (WIC),schools,antenatalcareclinicsandchurches.Theresourcemothersprovided“supportive,educationalhomevisits”andhelpedtheteenager“usethehealthcaresystem”.Afterenrolment,teenagerswerevisitedmonthlyduringpregnancy,afterdeliveryinhospital,andmonthlyforthefirstyearoftheirinfant’slife.
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“Each visit was structured, with specific goals and learning objectives. Prenatally, emphasis was on the need for early and regular prenatal care and reduction of risk factors, such as smoking, drug use, and poor nutrition.”
“Resource mothers facilitated the teenagers’ use of prenatal care and support services by following up on any missed appointments, arranging transportation, and assisting with referrals to community and health services. The resource mother acted as an advocate for the participant by bringing attention to her needs within health and community agencies.” 45
JulnesandcolleaguesevaluatedanotherResource Mothers Program,basedinNorfolk,Virginia,USA.55Theinterventionwastargetedatpregnantteens(<18years)withcertainriskfactors:youngmaternalage,black,residingintargetneighbourhoodswithlowfamilyincomelevels,lessthanahighschooleducation,andnopriorpregnancies.AswiththeinterventionevaluatedbyRogers,resourcemotherswererecruitedfromthecommunityandprovidedwithintensivetrainingtoenablethemtosupportpregnantteenagersfromdisadvantaged backgrounds.
“This program utilizes “resource mothers” to reach out to adolescents considered at high risk for inadequate prenatal care and poor pregnancy outcomes. A resource mother is a lay person – often indigenous to the culture of the adolescents – trained to assist adolescent parents and their families with the non-medical dimensions of pregnancy and child care. The resource mother is responsible for recruiting teens for the program, encouraging them to get prenatal care, providing practical assistance to the teens and their families, and acting as a liaison between the teens and the relevant public agencies.” 55
Daaleman evaluated the Kansas Healthy Start Home Visiting (HSHV) Programme.48 This programmewasdesignedtoenableat-riskfamiliestobecomehealthierandmoreself-sufficientbyimprovingaccesstoearlyinterventionservices.Thisevaluationwasdesignedtoinvestigatewhetherpriorexposuretothisprogramme(i.e.beforepregnancy)hadaneffectontheuseofantenatalcareinthecurrentpregnancy.TheevaluationwasconductedusingasmallsampleofmultiparouswomeninreceiptofWICservices.HSHVwasacommunity-basedlayhomevisitingprogramme,availableto“allpregnantwomen,infants,adoptivefamilies,andfamilieswhohavelostanewborn”.Participantswerereferredbytheirphysician,careproviderorsocialserviceagency.
“The home visitor is an experienced parent with a minimum of a high school diploma or GED, who has undergone an orientation to home visiting under the supervision of a public health nurse. The role of the home visitor is to provide education, support, resource information and referrals to the family, in addition to screening for any current or potential problems. No childcare or transportation services are provided by the home visitor. All visits are reviewed with a public health nurse to assess for any necessary follow-up or referral.” 48
Linkworkers
Mason evaluated the Asian Mother and BabyprojectinLeicester,UK.42Theproject(whichwaspartiallyhospital-based)involvedeightAsianlinkworkersbasedacrossthetwomaincity maternity units (two linkworkers on each site) and four selected GP surgeries (one linkworkerateachsurgery).GPpracticeswereselectedfromthosewhichhadatleastonegeneralpractitionernotonthe‘obstetriclist’i. The linkworkers were “women aged between 20and45whowereabletospeakfluentEnglishandatleastoneAsianlanguage”.Thelinkworkers“workedalongsidehealthprofessionals,inbothhospitalandcommunityantenatalclinics,as‘facilitators’and‘interpreters’whilealsofulfillinganeducativerole”.Theaimoftheinterventionwastoimprovebirthoutcomes,aidcommunicationwithprofessionals,andtoimparthealtheducation.
i Aregisterofgeneralpractitionerswhohavecompletedaspecifiedleveloftraininginobstetricsandgynaecology
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Mobile health clinics
OnestudyevaluatedamobilehealthclinicforwomeninCalifornia,USA.49 The Women’s Health Vanwasstaffedbyanobstetrician-gynaecologistandnursepractitionerandprovidedavarietyofservicesforwomen,includingpregnancytesting,sexuallytransmittedinfection(STI)screening,breastexamsandcontraceptiveservices.Thestaffonthevanwerebilingual(English/Spanish)andthehealtheducationliteraturetheyprovidedwasavailableinbothlanguages.Thevanaimed“toaddressbarrierstohealthcareaccesssuchaslanguage,transportation,andcostforundocumentedimmigrantsandthe uninsured”. Two days a week the van travelled to low-income neighbourhoods and providedfreewalk-inorappointmentservicestolocalwomen.
“Women with positive urine pregnancy tests received a dating ultrasound on the van, initial prenatal care, counseling regarding healthy pregnancy, and are given a packet of information and prenatal vitamins. The van acts as a bridging device as the women are then referred to local community clinics for further prenatal visits” 49
Multi-component interventions
Cramerandcolleaguesreportanevaluationofacommunity-basedantenatalcareprogrammecalledOmaha Healthy Start,implementedinNebraska,USA.47 The setting wasspecificcensustractsinDouglasCounty,where46%ofthepopulationwereBlack.Theinterventionwasdesignedto“reducelocalracialdisparitiesinbirthoutcomes”.The intervention was delivered by outreach workers (indigenous to the targeted Black community),socialworkersandpublichealthnurses.Outreachworkerswereresponsibleforrecruitingpregnantwomentotheintervention,achievedthroughcommunityoutreachamong“localchurches,clinics,socialserviceagencies,communitygroups,communityleaders,andbusinesses”.Onceenrolledintheprogramme,womenwereassignedacasemanager(asocialworkerorpublichealthnurse)whoprovided“weeklycontact,throughhomevisits,officevisits,ortelephonecalls”.Casemanagersscheduledmedicalandothervisits,helpedtoarrangetransportationtoappointments,andscreenedandreferredparticipantsforriskfactors.CasemanagersalsodeliveredantenataleducationaccordingtotheprogrammedevelopedbytheNationalHealthy Startprogramme.
An effectiveness evaluation of the Rural Oregon Minority Prenatal Program (ROMPP) is reportedbyThompsonetal.43Thisinterventionwastargetedatlow-income,Mexican-AmericanwomenatriskofpoorbirthoutcomesinaruralOregoncommunityintheUSA.ROMPPattemptedtodeliver“culturallyappropriatecare,outreach,nursingcasemanagement,andhomevisitation”tothisgroupofwomen,manywhomwereundocumented immigrants and ineligible for Medicaid. The intervention was delivered byacommunityhealthnurse/casemanagerandoutreachworkers.Thecommunityhealthnurse/casemanager“wasresponsibleforassessment,planning,coordinationandevaluationofnursingcare”.Aswellasfacilitatingaccesstoantenatalcare,thenurse/casemanager was able to refer and liaise with other community services (e.g. WIC) as needed. TheoutreachworkerwasdrawnfromthelocalMexican-Americanfarmworkercommunity,and“wasresponsibleforcase-findingandrecruitment,follow-uptoensurecontinuityofcareandreducesocialisolation,andadvocacytolowerbarriersandincreasetheacceptabilityandaccessibilityofcare”.ROMPPreferredwomentothirdpartysourcesoffinancialhelpwithcarecosts,andnegotiatedpaymentarrangementsforwomenfundingtheirowncare.MostROMPPvisitsoccurredinparticipants’homes,withthenumberofoverallvisitsdependentontheneedsofthewomen.Theoutreachworkerprovidedtransportationtoantenatalcareappointmentsandinterpretingserviceswherenecessary.
WillisandcolleaguesreportanevaluationoftheBlack Infant Health (BIH)programme,targetedatAfrican-AmericawomenlivinginCalifornia,USA.53 BIH included “augmented servicesduringtheprenatalperiod,servicesdesignedspecificallyforAfrican-Americanwomen,outreachandtracking,office-basedservicesenhancedbytelephoneandin-homecontacts,andpreserviceriskscreening”.Itwasseparatetoantenatalcare“butconsistentlyenabledandsupportedclientswithprenatalcareentryandcontinuance”.ExactservicesprovidedbyBIHvariedbyprogrammesite.Allprogrammesitesimplementedthe‘PrenatalCareOutreach’model:
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women22
“The Prenatal Care Outreach model utilizes community health outreach workers to conduct intensive outreach to identify and link pregnant African-American women to BIH, general prenatal care, and other appropriate services” 53
Uptothreeothermodelswereimplementedaspartoftheprogramme,dependingon the results of local needs assessment. These models of care included the “Case Management”model(“utilizespublichealthnursestoconducthomevisitsforthepurposeofassessments,referrals,provisionandcoordinationofservices,monitoring,andfollow-up”),the“SocialSupportandEmpowerment”model,andthe“RoleofMen”model.
An evaluation of the Minority Health Coalitions Early Pregnancy Project was carried out byJewellandRussell.46Theintervention,implementedinIndiana,USA,evolvedfromtheIndianaMinorityHealthCoalitionswiderbriefto“eliminatehealthdisparitiesforracialandethnicminorities”.Theinterventionthatformsthefocusoftheirreportwasdesignedtoincreaseaccesstoearlyantenatalcare.Theprojectaimedto“eliminateculturalbarrierstocare”.
“The cultural aspect of care was emphasized in the projects as demonstrated by the use of minority professional and paraprofessional staff and the monitoring of the projects by the minority health coalitions boards [...] Staff provided social support in varying ways from individual support via contact with mothers in the project offices and on home visits, to group support by facilitating linkages of social support with significant others and holding support group meetings of the project mothers. Other interventions included referrals to community services, health education and transportation. The staff also provided advocacy for the mothers if barriers occurred in navigating health and social service systems in their communities.” 46
The Maternal Infant Health Advocate ServiceprogrammewasimplementedintheurbanareaofFlint,GenesseeCountyinMichigan,USA.50 Hunte and colleagues conducted an effectivenessevaluationofthisintervention,targetedat,andevaluatedamong,African-Americanwomen.Theauthorsreporttheobjectivesoftheinterventionasfollows:
“1) to identify pregnant African-American women early in their pregnancies; 2) to assist identified participants in navigating the prenatal care system; 3) to identify resources that assure services are adequate to reduce the stress associated with health barriers; and 4) to engage participants in other activities that assist in addressing issues of race and ethnicity as they relate to infant mortality.” 50
Participantsintheintervention(clients)wereidentifiedthroughself-referral,advocatecase-finding,andthroughreferralfromotherservicesandsettings(clinics,WIC,localhealthdepartmentsetc.).
“Upon entering the MIHAS program, clients meet face-to-face with their advocates to set specific goals to be addressed during their enrolment. While enrolled in the program all clients must be actively working towards their goals.” 50
Becauseclientsreportedthatphysicians“talked-down”tothem,advocatesalsoaccompaniedwomentoantenatalandpostnatalvisits,andinfantcheck-ups.
“[Advocates also provide] supportive services ranging from providing assistance when seeking employment, and help with school enrolment, to continuing their educational goals. Poor reading skills among many of the clients is a known barrier therefore advocates often accompany their clients to provide assistance and support with filling out necessary paperwork.” 50
TheinterventionevaluatedbyMackerrasandcolleagues“hadspecificgoalstoincreaseinfantbirthweightsbyearlierattendanceforantenatalcareandimprovedmaternalweight status”.41Theintervention,namedStrong Women Strong Babies Strong Culture wasevaluatedinruralAboriginalcommunitiesintheNorthernTerritory,Australia.TheinterventionwasdevelopedinconsultationwiththelocalAboriginalpopulation,andlaywomen indigenous to the community were trained as “Strong Women Workers” (SWWs).
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women 23
“…a well respected Aboriginal woman was employed to develop the project. She worked with women selected by the communities (the SWWs) to implement a program that included traditional cultural practices related to childbirth as well as informing pregnant women about Western health and medical practices related to pregnancy and encouraging greater use of antenatal health care.” 41
Theinterventionalsotargetedwomennotyetpregnant,andthosewomenwhowerepregnantbutnotyetreceivingantenatalcare.
Alternative models of clinic-based antenatal care4.2.2.2
Fivestudiesreportedinterventionsthatinvolvedalternativemodelsofclinic-basedantenatalcare.Twoofthereportedinterventionswereteenantenatalclinics,44,51 one studyevaluatedacollaborativecareinitiative,54andtworeportedevaluationsofenhancedantenatal care services.56,52
Teen pregnancy clinics
MartinandcolleaguesevaluatedtheimplementationofateenpregnancyclinicinCincinnati,Ohio,USA.44 The evaluation was conducted through a small before and afterstudy.Theclinicwassetuptoprovidecomprehensiveantenatalcaretopregnantteenagerswhowerepreviouslyonlyabletoreceivenon-specificcarethroughthetraditional antenatal clinic.
“The operational objectives of the teen pregnancy clinic were to increase compliance among teen patients receiving care through GHA in attending prenatal appointments, educational classes and postpartum checkups. Some broader objectives of the clinic included reducing the number of teens who deliver low birth weight and premature infants, improving neonatal outcomes, decreasing the number of repeat pregnancies, decreasing the incidence of sexually transmitted diseases, and ensuring compliance with contraceptive care.” 44
Allteenagersparticipatingintheevaluationwereaged<18yearsandthemajorityhadtheircarefundedviaprivatehealthinsurance.
AnotherevaluationofteenpregnancyclinicswasconductedbyMorrisandcolleaguesinTexas,USA.51Thesettingwasapublichealthclinicservingamulti-ethniclow-incomepopulation,themajorityofwhomweremedicallyindigent.Theclinicwasdesignedforpregnantteenagers<18yearsandprovided:
“…general monitoring of the course of pregnancy, in addition to special emphasis on educational, social and nutritional support. The care was provided by a team of nurses, physician assistants, obstetrician-gynecologist residents, a social worker, and a nutritionist.” 51
Collaborative antenatal care
MvulaandMillerevaluatedacollaborativeantenatalcareprogrammeinLouisiana,USA.54 Theclinic,Neighbourhood Pregnancy Care, was situated next to low-income housing projectsinNewOrleansandprovidedcontraceptiveservicesalongsideantenatalcare.Theclinicfocussedon“continuityofprenatalcarebyspecificproviders,individualizedperinataleducation,andnursingcasemanagement...”.Servicesweredeliveredbyteamsofobstetriciansand‘advancedpracticenurses’(clinicalnursespecialists,nursepractitioners,andnursemidwives).Tomaximisecompliance“patientsareremindedthedaybeforescheduledappointments”.
Enhanced antenatal care services
One study evaluated the Prenatal Care Assistance Program (PCAP).56 PCAP was a combined state-federal intervention delivered through selected Medicaid clinics in NewYorkState,USA.ClinicswereeligibletobepartofthePCAPiftheydeliveredspecificservicesalongside“comprehensiveprenatal,diagnosisandtreatmentservices”.
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women24
Thespecificservicesincludedcarecoordination,referralstootherservices(HIVmanagement,mentalhealthservices,andsubstanceabuseprogrammes),andhealthandnutritioneducation.ClinicsdesignatedaspartofPCAPwereabletobillforantenatalandpostpartumcareservicesatenhancedratescomparedtousualMedicaidcosts.Newschaffer and colleagues conducted an evaluation of PCAP concentrating on the outcomesinsubstance-usingHIV-positivewomen.
ReichmanandFlorioreportanevaluationofNewJersey’sHealthStart program (New Jersey,USA).52 This enhanced antenatal care intervention was designed to increase the quantityandqualityofantenatalcare,withtheaimofincreasingbirthweightamongsocioeconomicallydisadvantagedwomen.TheprogrammedeliveredantenatalcaretoMedicaideligiblewomen,alongsideenhancedservicessuchascarecoordination.
“The key features of this program, available to pregnant Medicaid recipients, are an increased number of prenatal visits, increased provider reimbursement, case coordination with other social programs and integrated health support services such as psychological counselling and health education. Case managers, trained in cultural sensitivity, provide individualized plans of care and follow-up consultations through the pregnancy and for 60 days postpartum. To encourage women to get prenatal care early, community outreach efforts are mandated for all HealthStart providers. A system of presumptive eligibility, not part of the HealthStart program per se, was also established to enable financially eligible unenrolled pregnant women to obtain early care. The combination of provider supply incentives, enhanced services, and streamlined enrolment procedures was expected to increase the use of prenatal care and improve birth outcomes among Medicaid women in New Jersey.” 52
Effectiveness4.3
Outreach or other community-based interventions4.3.1
Theoverallstrengthandqualityofevidencerelatingtothesestudieswaspoor.Alloftheeleven studies evaluating the effect of outreach or other community-based interventions on the timing of initiation of antenatal care were observational study designs (nine cohortstudiesandtwobeforeandafterstudies),andonlyoneoftheelevenevaluationswas assessed as having adequate internal validity in relation to the outcome relevant to thisreview.Eightstudieswereassessedasclearlyreportingthetimingofinitiationofantenatalcareasanoutcomemeasure;intheremainingthreestudiesitwasunclearastowhetherthismeasurewasreportedasanoutcomemeasure.
Lay or paraprofessional home visiting and support
Rogers and colleagues assessed the effectiveness of a Resource Mothers intervention onthetimingofinitiationofantenatalcareamongpregnantteenagers,usingaretrospectiveobservationaldesign.Theevaluationusedtwodifferentcomparisongroups,onedrawnfromdifferentbutbroadlysimilargeographicalareas,andtheseconddrawnfrom adolescents who resided in the intervention areas before the intervention was implemented.Thestudywasconsideredtohavenomajorweaknesses,andwastheonlystudyincludedinthereviewtoadjustforpotentialconfoundingintheanalysisoftimingofinitiationofantenatalcare.Theevaluationreportsthatahigherproportionofinterventionadolescentsinitiatedantenatalcarebeforethefourthmonthofpregnancy(45%oftheinterventiongroupvs.41%inthegeographicalcomparatorgroupand40%inthe‘pre-intervention’comparatorgroup),withthisincreasesignificantincomparisontobothcontrolgroups.Anadjustedoddsratioforearlyinitiationofantenatalcareisreportedfortheinterventiongroupcomparedtothegeographicalcomparatorgroup(1.48,95%CI1.32,1.66)and‘pre-intervention’comparatorgroup(1.39,95%CI1.16,1.66).Theauthorsconcludedthatthestudydemonstratedastatisticallysignificantbeneficialeffectonthetimingofinitiationofantenatalcare.Becauseofpotentialforselectionbiaslargelyattributabletotheobservationalstudydesignandnon-randomassignmentofparticipants,thereviewersconsideredthestudyinconclusivebutconsistentwithapossiblebeneficialeffect.
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women 25
Results are summarised in Table 4.
Alternative models of clinic-based antenatal care4.3.2
The quality of evidence relating to interventions involving alternative models of clinic-basedantenatalcarewasalsopoor.Fourofthefivestudiesinthiscategorywereobservationalcohortstudies,andonewasabeforeandafterstudywithoutacontemporaneouscomparatorgroup.Allfiveofthesestudieswereassessedashavingpoorinternalvalidityinrelationtotheoutcomerelevanttothisreview.However,thereviewers considered that in none of these studies was it clear whether timing of initiation ofantenatalcarewasreportedasanoutcomemeasure.Thisreflectedthefactthatmanyoftheseinterventionswereprimarilydesignedtoimproveantenatalcareutilisationasmeasuredbyattendanceforappointmentsratherthantimingofinitiation.
Results are summarised in Table 5.
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women26
Tab
le 4
. Eff
ect
iven
ess
of
ou
treach
or
oth
er
com
mu
nit
y-b
ase
d i
nte
rven
tio
ns
Au
tho
r an
d y
ear
Desi
gn
Ass
ess
men
t o
f in
tern
al
valid
ity
(1)
Tim
ing
of
an
ten
ata
l ca
re
init
iati
on
cl
earl
y a
n
ou
tco
me
measu
re?
Eff
ect
of
inte
rven
tio
n
on
tim
ing
of
init
iati
on
of
an
ten
ata
l ca
reR
evie
wer
com
men
ts
Au
tho
rs’
con
clu
sio
n (
2)i
Revie
wer
ass
ess
men
t (3
)
Cra
mer
2007
Retrospective
obse
rvat
ional
co
hort
stu
dy
Poor
Yes
XX
Nodatapresentedonbaselinecharacteristics,intervention
andcontrolgroupslikelytodifferwithrespecttoimportant
riskfactorsduetotargetingofintervention,noadjustment
forpotentialconfoundinginanalysisoftimingofinitiationof
ante
nat
al c
are.
Daa
lem
an
1997
Retrospective
obse
rvat
ional
co
hort
stu
dy
Poor
Yes
(+)
XNodatapresentedonbaselinecharacteristicsbyintervention/
controlstatus,interventionandcontrolgroupslikelyto
differwithrespecttoimportantriskfactorsduetotargeting
ofintervention,noadjustmentforpotentialconfoundingin
analysisoftimingofinitiationofantenatalcare,smallsample
size,outcomedataonlypresentedingraphicalform,authors’
conclusionsdonotappeartocorrespondtodatapresented.
Edger
ley
2007
Retrospective
obse
rvat
ional
co
hort
stu
dy
Poor
Yes
+X
Noadjustmentforpotentialconfoundinginanalysisoftiming
ofinitiationofantenatalcare,insufficientdatapresentedon
bas
elin
e ch
arac
terist
ics.
Hunte
2004
Retrospective
obse
rvat
ional
co
hort
stu
dy
Poor
Uncl
ear
XX
Interventionandcontrolgroupsdifferwithrespectto
importantriskfactors,noadjustmentforpotentialconfounding
in a
nal
ysis
of
tim
ing o
f in
itia
tion o
f an
tenat
al c
are.
Jewell2000
Retrospective
obse
rvat
ional
co
hort
stu
dy
Poor
Yes
+X
Noadjustmentforpotentialconfoundinginanalysisoftiming
ofinitiationofantenatalcare,inappropriatestatisticalanalysis
(matcheddata,unmatchedanalysis),unclearwhether
indiv
idual
s m
ay h
ave
bee
n r
efer
red b
y th
eir
ante
nat
al c
are
provider.
Julnes1994
Retrospective
obse
rvat
ional
co
hort
stu
dy
Poor
Yes
+X
Interventionandcontrolgroupsdifferwithrespectto
importantriskfactors,noadjustmentforpotentialconfounding
inanalysisoftimingofinitiationofantenatalcare,small
samplesize.
Mac
kerr
as
2001
Bef
ore
and
afte
r st
udy
Poor
Yes
(+)
XNodatapresentedonbaselinecharacteristicsofcontrol(pre-
phase)andintervention(post-phase)groups,noadjustment
forpotentialconfoundinginanalysisoftimingofinitiationof
antenatalcare,noprotectionagainstsecularchanges.
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women 27
Au
tho
r an
d y
ear
Desi
gn
Ass
ess
men
t o
f in
tern
al
valid
ity
(1)
Tim
ing
of
an
ten
ata
l ca
re
init
iati
on
cl
earl
y a
n
ou
tco
me
measu
re?
Eff
ect
of
inte
rven
tio
n
on
tim
ing
of
init
iati
on
of
an
ten
ata
l ca
reR
evie
wer
com
men
ts
Au
tho
rs’
con
clu
sio
n (
2)i
Revie
wer
ass
ess
men
t (3
)
Mas
on 1
990
Prospective
obse
rvat
ional
co
hort
stu
dy
Poor
Uncl
ear
XX
Interventionandcontrolgroupsdifferwithrespectto
importantriskfactors,noadjustmentforpotentialconfounding
in a
nal
ysis
of
tim
ing o
f in
itia
tion o
f an
tenat
al c
are.
Roger
s 1996
Retrospective
obse
rvat
ional
co
hort
st
udy
with
additio
nal
pre-
inte
rven
tion
comparator
group
Mix
edYe
s+
(+?)
Generallywelldesigned/reportedstudy,althoughsome
potentialforselectionbias.
Thompson
1998
Bef
ore
and
afte
r st
udy
Poor
Yes
XX
Noadjustmentforpotentialconfoundinginanalysisoftiming
ofinitiationofantenatalcare,smallsamplesize,outcomedata
onlypresentedingraphicalform,noprotectionagainstsecular
chan
ges
.
Will
is 2
004
Prospective
obse
rvat
ional
co
hort
stu
dy
Poor
Uncl
ear
XX
Interventionandcontrolgroupsdrawnfromdifferentsampling
frames,interventionandcontrolgroupsdifferwithrespectto
importantriskfactors,noadjustmentforpotentialconfounding
inanalysisoftimingofinitiationofantenatalcare,intervention
groupincludedincomparisongroup.
(1) Q
uali
ty a
ssess
men
t (G
ATE c
rite
ria)
(2) A
uth
ors
’ co
ncl
usi
on
(3) R
evie
wers
’ ass
ess
men
tGoodWellreportedandreliable;
MixedSomeweaknessesbutinsufficient
tohaveanimportanteffecton
usefulnessofstudy;
Poor
Studynotreliable,notuseful
+
StatisticallysignificantbeneficialeffectonPTB/IM
(+)
Effectconsistentwithbeneficialeffectbuteffectnotstatistically
significantand/orcautiousinterpretationoffindingsuggested
X
Noevidenceofbeneficialeffect
0
No c
oncl
usi
on s
tate
dN/ANotapplicable–outcomenotassessed
+
Studydemonstratesabeneficialeffect
(+?)
Stu
dy
inco
ncl
usi
ve b
ut
may
dem
onst
rate
abeneficialeffect
X
Studydoesnotprovideconvincing
evidenceofabeneficialeffect
N/ANotapplicable–outcomenotassessed
i Anumberoftheincludedstudiesreportedtimingofinitiationofantenatalcarebytrimesterorothersimilarmeasureandassessedwhethertherewasatrendtowardsearlierinitiation.The
conclusionreportedhererelatestothetestofeffectivenessreportedbytheauthor.
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women28
Tab
le 5
. Eff
ect
iven
ess
of
inte
rven
tio
ns
invo
lvin
g a
ltern
ati
ve m
od
els
of
clin
ic-b
ase
d a
nte
nata
l ca
re
Au
tho
r an
d y
ear
Desi
gn
Ass
ess
men
t o
f in
tern
al
valid
ity (
1)
Tim
ing
of
an
ten
ata
l ca
re
init
iati
on
cl
earl
y a
n
ou
tco
me
measu
re?
Tim
ing
of
an
ten
ata
l ca
re
init
iati
on
ou
tco
me r
esu
lts
Co
mm
en
ts
Au
tho
rs’
con
clu
sio
n (
2)
Revie
wer
ass
ess
men
t (3
)
Mar
tin 1
997
Bef
ore
and
afte
r st
udy
Poor
Uncl
ear
XX
Interventionandcontrolgroupsdifferwithrespectto
importantriskfactors,noadjustmentforpotentialconfounding
inanalysisoftimingofinitiationofantenatalcare,small
samplesize,noprotectionagainstsecularchanges.
Morr
is 1
993
Retrospective
obse
rvat
ional
co
hort
stu
dy
Poor
Uncl
ear
+X
Interventionandcontrolgroupsdifferwithrespectto
importantriskfactors,noadjustmentforpotentialconfounding
in a
nal
ysis
of
tim
ing o
f in
itia
tion o
f an
tenat
al c
are.
Mvu
la 1
998
Prospective
obse
rvat
ional
co
hort
stu
dy
Poor
Uncl
ear
XX
Interventionandcontrolgroupsdifferwithrespectto
importantriskfactors,noadjustmentforpotentialconfounding
in a
nal
ysis
of
tim
ing o
f in
itia
tion o
f an
tenat
al c
are.
New
schaf
fer
1998
Retrospective
obse
rvat
ional
co
hort
stu
dy
Poor
Uncl
ear
(+)
XNoadjustmentforpotentialconfoundinginanalysisoftiming
of
initia
tion o
f an
tenat
al c
are.
Rei
chm
an
1996
Retrospective
obse
rvat
ional
co
hort
stu
dy
Poor
Uncl
ear
0X
Interventionandcontrolgroupsdifferwithrespectto
importantriskfactors,noadjustmentforpotentialconfounding
in a
nal
ysis
of
tim
ing o
f in
itia
tion o
f an
tenat
al c
are.
(1) Q
uali
ty a
ssess
men
t (G
ATE c
rite
ria)
(2) A
uth
ors
’ co
ncl
usi
on
(3) R
evie
wers
’ ass
ess
men
tGoodWellreportedandreliable;
MixedSomeweaknessesbutinsufficient
tohaveanimportanteffecton
usefulnessofstudy;
Poor
Studynotreliable,notuseful
+
StatisticallysignificantbeneficialeffectonPTB/IM
(+)
Effectconsistentwithbeneficialeffectbuteffectnotstatistically
significantand/orcautiousinterpretationoffindingsuggested
X
Noevidenceofbeneficialeffect
0
No c
oncl
usi
on s
tate
dN/ANotapplicable–outcomenotassessed
+
Studydemonstratesabeneficialeffect
(+?)
Stu
dy
inco
ncl
usi
ve b
ut
may
dem
onst
rate
abeneficialeffect
X
Studydoesnotprovideconvincing
evidenceofabeneficialeffect
N/ANotapplicable–outcomenotassessed
i Anumberoftheincludedstudiesreportedtimingofinitiationofantenatalcarebytrimesterorothersimilarmeasureandassessedwhethertherewasatrendtowardsearlierinitiation.The
conclusionreportedhererelatestothetestofeffectivenessreportedbytheauthor.
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women 29
Discussion5
Principal findings5.1
Thepurposeofthisreviewwastosystematicallyidentifyandevaluatetheevidencerelatingtotheeffectivenessofinterventions,relevantinthecontextoftheNHS,whichaimtoincreasetheearlyinitiationofcomprehensiveantenatalcareinsociallydisadvantaged and vulnerable women.
Weidentifiedoverthirtypotentiallyrelevantinterventions(seeAnnexB)butonly16eligible evaluation studies: eleven of the sixteen related to community-based interventions involving outreach or community based services designed to increase the early initiation ofantenatalcare;andfivestudiesevaluatedtheeffectofalternativemodelsoforganisingand delivering antenatal care on the timing of initiation of antenatal care.
Oftheelevenstudiesrelatingtocommunity-basedinterventions,threeevaluatedinterventionswhichconsistedsolelyofsocialsupportand/orhomevisitsdeliveredbylayorparaprofessionalworkers,oneevaluatedtheprovisionofbilingual‘linkworkers’(workinginbothprimarycareandobstetricclinics),oneevaluateda‘mobilewomen’shealthbus’,andsixevaluatedother,multi-componentinterventions.
Ofthefivestudiesrelatingtoalternativemodelsoforganisinganddeliveringantenatalcare,twoevaluated‘teenclinics’,oneevaluateda‘neighbourhoodclinic’andtwoevaluated‘enhancedprenatalcare’models.
We found eligible studies relating to only a few of the disadvantaged and vulnerable groupsofinterest:fourinterventionstargetedpregnantteenagers,seventargetedand/orwereevaluatedinsociallydisadvantaged‘ethnicminority’populations(includingAustralianindigenouswomenandnon-nativelanguagespeakers),andfivewereaimedatsocio-economicallydisadvantagedwomen.Wedidnotfindeligiblestudiesrelatingtointerventions seeking to increase early initiation of antenatal care in other vulnerable or ‘atrisk’subgroupssuchashomelesswomen,travellers,refugees,substanceandalcoholusersandwomenwithmentalhealthproblemsorlearningdisabilities.
Overall,thequalityofevidencewaspoor.Wedidnotidentifyanyeligiblerandomisedcontrolledtrials(RCTs)andonlyonestudy-aretrospectivecohortstudywithanadditionalpre-interventioncomparatorgroup-wasassessedashavingadequateinternalvalidity.45 This study evaluated a Resource Mothers Program,whichusedparaprofessionalwomentodeliversocialsupport,healthpromotion/educationandotherassistancetopregnantadolescentsathomeandforoneyearafterdelivery.Theevaluation,whichwasconductedinapredominantlyblack,non-urbanUSpopulationfoundthattheinterventionwaseffectiveinincreasingtheproportionofpregnantadolescentsinitiatingantenatalcarebythefourthmonthofpregnancy.ThisinterventioncouldbeconsideredtoaddressbarrierstocaregroupedundertwoofthethreeheadingssuggestedbyCooper’saccessmodel.21Personalandfamilybarrierswereaddressedbytheprovisionofculturally-appropriateantenataleducationandsocialsupport,deliveredbythe‘resourcemothers’,many of whom had been teenage mothers themselves. The resource mothers facilitated access to antenatal care by acting as an advocate and drawing attention to the needs of the adolescents within the healthcare system. Structural barriers to care were attenuated bytheresourcemotherfollowingupappointmentsandarrangingtransportation.Therefore,thisinterventionmovedbeyondsimplyprovidingservices,anapproachcriticisedbyLavenderandcolleagues,10whilealsotakingintoaccountthecomplexinterplaybetweenindividualsandhealthcareservices.27,57ItwouldalsoappeartoaddressthedifferentialconceptualisationofhealthdescribedbyDixon-Woodsasassociatedwithsociallydisadvantagedgroups,27inparticularthelackofappreciationofpreventivecare,asoneoftherolesoftheresourcemotherwastoemphasisetheneedfor“earlyandregularprenatalcare”.TheinterventionwasadequatelydescribedandcontainedsomepotentiallytransferableelementsbutthegeneralisabilityofthefindingstoaUKpopulationisunknown.Forexample,routesofreferralintotheprogrammeincludedWIC(aUSspecificwelfareprogramme)andchurches.
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women30
Evidence relating to other interventions was inconclusive due to the methodological limitationsoftheincludedstudies.However,althoughtheireffectivenessisunproven,someoftheinterventionsidentifiedinthisreviewincludedelementsofpotentialrelevanceintheUKwhichthereviewersconsideredmightplausiblyaffectthetimingofinitiationofantenatalcareinsociallydisadvantagedandvulnerablegroups.Theseincluded:
Mobilehealthclinics,providingfreewalk-inorappointmentservicesincludinginitial•antenatal care.49 This intervention strategy may address structural barriers to care suchaslackoftransportationortheneedtonegotiateanappointmentsystem.Another outcome evaluation of a similar intervention in the USA has recently been published58(outsidethetimeperiodofthisreview),reportingabeneficialeffectoftheinterventionconsistentwiththeconclusionsoftheevaluationincludedinthepresentreview.
LinkworkerssituatedinGPsurgeries,actingas“‘facilitators’and‘interpreters’whilst•alsofulfillinganeducativerole”.42 This form of intervention may work well for some ethnicminoritygroupsandwomenforwhomlanguagedifficultiesmaybeabarriertoantenatalcare.Theincludedevaluationshowednoeffectontheproportionofwomenbookingbefore12weeks.However,theincludedstudywasnotwelldesignedtoevaluate the effect on this outcome.
Culturallyappropriatecommunity-basedprogrammes,wherelaywomenencourage•greateruseofantenatalcarethroughintegratingtraditionalbeliefsandpracticesalongside more conventional antenatal education.41 Programmes such as this are most likelytoinfluencepersonalbarrierstocaresuchasacceptability,attitudes/beliefsandculturalpreferences.AlthoughthisinterventiontargetsasubgroupwhichhasnodirectlyequivalentgroupintheUK,theemphasisonaddressingculturalbeliefsandpracticesisconsideredrelevanttoethnicminoritygroupsintheUK.
Theseinterventionsmeritfurtherconsiderationandpossiblyfurther,morerobustevaluationinaUKsetting.
Strengths and limitations of this systematic review5.2
Weusedacomprehensive,multi-stagesearchstrategywhichenabledustoidentifyawiderange of relevant interventions described in the literature. The relatively small number of studieseligibleforinclusioninthissystematicreviewreflectsthepaucityofeffectivenessevaluations in this area.
Wedidnotrestrictinclusiontospecificstudydesigns,otherthanrequiringsomeformofcomparator/controlgroup,andhencethematerialdescribedherereflectsthebreadthoftheeffectivenessevidenceavailableinthescientificliterature.Givensomeofthereportinglimitationsoftheincludedmaterial,wefounditchallengingtodevelopreproducibleinclusion/exclusioncriteriarelatingtotheaimsoftheintervention/evaluation.Weresolvedthis by including studies where the reviewers could not easily reach a consensus as to whetherornotthetimingofinitiationofantenatalcarewasreportedasanoutcomemeasure.Weconsideredthatthisinclusiveapproachwaspreferabletoexcludingpotentiallyrelevantstudiesbutaconsequenceisthatwehaveincludedsomestudies–particularlythoserelatingtoalternativemodelsoforganisinganddeliveringclinic-basedantenatal care – of questionable relevance. A further consequence of this was that we assessed internal validity of the study in relation to the estimated effect of the intervention onthetimingofinitiationofantenatalcare,evenwhenthiswasnotnecessarilytheaimofthestudy.Thisenabledustoassesswhetherthestudyprovidedrobustevidenceofaneffectontimingofinitiationofantenatalcare.However,ourqualityassessmentsshouldnotbeinterpretedasreflectingthequalityofthestudyinrelationtotheaimsstatedbythe author where these are different from the effectiveness question addressed by this review.
Forpragmaticreasons,wedidnotincludeevaluationsreportedinthegreyliterature.Weidentifiedbutdidnotincludeasmallnumberofpotentiallyrelevantstudiesinthegreyliterature:thesewerepredominantlyidentifiedthroughscreeningreferencesof
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women 31
includedstudies,ratherthanthroughthebibliographicdatabasesearches,andmostrelated to interventions targeting Australian indigenous women. Although the inclusion ofsuchstudieswouldpotentiallyhaveaddedtothedescriptiveelementsofthisreview,weconsideritunlikelythattheinclusionofsuchreportswouldhaveinfluencedourconclusions regarding effectiveness.
Thegeneralisabilityoffindingsandthetransferabilityofinterventionspresentamethodologicalchallengeinreviewsofthiskind.Bydevelopinginclusioncriteriabasedonaconceptual‘barrierstocare’model21wewereabletooperationalisecriteriathatenabledustoexcludeanumberofstructuralandfinancialinterventionsnotrelevantinthecontextofapubliclyfundeduniversalhealthcaresystem.Wewerethusabletofocuson interventions most likely to be relevant in the context of the NHS. We note above some issuesrelatingtobothtransferabilityandgeneralisabilityoffindingstootherpopulationsbutthisisanareawherefurthertheoreticalworktodevelopaconceptualframeworkmightbehelpful.
Findings in relation to other published evidence5.3
Threepublishedliteraturereviewshaveevaluatedtheeffectofdifferentantenatalintervention strategies on a range of outcomes and have included results relating to the timing of initiation of antenatal care. Rumbold and Cunningham evaluated the effect of changes in the delivery of antenatal care on outcomes for Australian indigenous women.30Fouroftheteninterventionsincludedinthisreviewreportedtimingofinitiationof antenatal care as an outcome.59–62Twoofthesereportedastatisticallysignificantbeneficialeffectontimingofinitiationofantenatalcare:onewasacommunitybasedsupportprogrammeforpregnantwomen(includedinthepresentreview),60 and the other a“culturallyappropriatemidwiferyprogram”.59 The latter intervention was not included inthepresentreviewastherelevantresultswerereportedonlyinthegreyliterature.NeitherofthetwointerventionsidentifiedintheRumboldreviewashavingnoeffectontimingofinitiationwereincludedinthepresentreview,bothbecausethecomparatorgroupsdidnotmeetoureligibilitycriteria.62,63Indiscussingtheirresults,theauthorscommentonthechallengesofsynthesisingresultsacrossdifferentstudies,referringinparticulartothelackofconsistencyinoutcomesandthediversityofcomparisongroups.However,theyconcludethattheresultssuggest“modestincreasesinindicatorsofantenatalcareutilization,mostnotablyincreasesintheproportionofwomenaccessingantenatalcareinthefirsttrimester”.30
A second relevant literature review by Persily evaluated the effect of lay home visiting onpregnancyoutcomes.31InPersily’sreview,alleightstudiesthatreportedaneffectonantenatalcareusefoundabeneficialeffectoftheintervention.However,onlyfourofthesestudieslookedspecificallyattimingofinitiationofantenatalcare.Threeofthesestudiesareincludedinthepresentreviewanddescribedinsomedetailinearliersections.45,48,55ThefourthstudyevaluatedtheeffectofalayhomevisitingprogrammetargetedatHispanicpregnantwomeninanurbanarea,64andwasexcludedinthepresentreviewbecauseitusedanineligiblecontrolgroup.Theauthorofthisreviewhighlightedthemethodologicalweaknessesofincludedstudies,butneverthelessconcludedthat“layworkersmaybeespeciallysuccessfulin…impactingonsocialandenvironmentalriskfactors as well as on health care utilization”.31
The review conducted by D’Souza and Garcia32 considered a variety of different interventionstoimproveperinataloutcomes,evaluatedindifferentsubgroupsofdisadvantagedwomen.Onlyoneinterventiondescribedintheirreportlookedattimingof initiation of antenatal care. This intervention - health advocacy for ethnic minority women65-wasassessedasunlikelytohaveabeneficialimpactonlatebookingforantenatalcare.Thisinterventionwasnotincludedinthepresentreviewbecausethetimingofinitiationofantenatalcarewasreportedasacontinuousmeasure(meangestationalageat‘booking’),anditwasnotpossibletoderivetheproportionofwomenbookingbyagivendatefromthedatareported.D’SouzaandGarciacommentonthe
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women32
limitedevidenceofeffectivenessacrossallthestudiesreviewed,concludingthatlittleornoreliableevidenceisavailableregardingpromisinginterventionsapplicabletodisadvantagedgroupsofpregnantwomenintheUK.32
Overall,ourfindingsarebroadlyconsistentwiththeresultsofthesepreviousreviews,and echo the authors’ conclusions about the methodological limitations of the available evidence.
Implications and recommendations5.4
Theresultsofthisreview,consideredalongsidetheexistingliteratureonthistopic,suggestthatthereisinsufficientevidencetorecommendthatanyoftheinterventionsdescribedintheliteratureshouldbeimplementedasameansofincreasingtheearlyinitiationofantenatalcareinsociallydisadvantagedandvulnerablegroupsofpregnantwomen.Inreviewingtheincludedstudies,wefocussedspecificallyonthetimingofinitiationofantenatalcare,althoughthiswasnottheprimaryoutcomeofmanyoftheincludedstudies.Ourfindingsdonotthereforenecessarilyindicatethattheincludedinterventionsdonothaveabeneficialeffectonotheroutcomes,forexampleimprovedadherencetoarecommendedscheduleofappointmentsonceantenatalcareisinitiated.
Majormethodologicaland/orreportingweaknesseswereidentifiedinmanyoftheincludedstudies.Suchfundamentalmethodologicalflawsneedtobeavoidedthroughthecarefuldesignoffutureevaluations.Poorreporting,anotherweaknessobservedinmanyofthestudies,mightbeminimisedbyadherencetorelevantreportingguidelinessuch as SQUIRE66(qualityimprovementstudies)andSTROBE67 (observational studies in epidemiology).
Alloftheevaluationsincludedinthisreviewwereobservationalstudies.Thepotentialweaknesses of such study designs have been well documented. RCTs are considered themostrobustdesignforassessingeffectiveness,althoughweareawarethatmanyof the interventions considered in this review would have been challenging to evaluate usingstandardrandomisedapproachessuchasclusterorindividuallyrandomisedRCTs.However,avarietyofexperimentalmethodspotentiallysuitablefor‘complex’interventionshavebeenproposed.68Furthermore,itmaybepossibletogreatlyimprovethequalityofevaluationswithoutrecoursetostandardrandomiseddesigns.Forexampleacontrolledbeforeandafterstudy(CBA)canprovidemoderatelyrobustevidenceprovidedthatthestudyiscarefullyplannedandconductedandthecontrolgroupisappropriatelyselectedtocreatestudygroupswithsimilar‘baseline’characteristics.
Although we did not identify interventions for which there was sound evidence of effectiveness,ourreviewneverthelessidentifiedanumberofinterventionsthatcouldplausiblyaffectthetimingofinitiationofantenatalcareandwhichwereconsideredtobepotentiallyrelevantintheUKcontext.Someofthesemightprovideameansofaddressingthe concern raised by Dixon-Woods et al. in their review on access to healthcare for vulnerablegroupsthat“manyinterventionsandpoliciesarenotwellmatchedtowhatwehaveidentifiedasthemajorbarrierstoaccess”.24Thematerialidentifiedduringthis review (including the interventions described in the literature for which no eligible evaluationswerefound)providesasourceofdatathatmightbefurther‘mined’toidentifytheinterventionswhichmostplausiblyaddressthebarrierstoaccessingantenatalcareexperiencedbysociallydisadvantagedandvulnerablegroupsintheUK.Inparticular,furtherworkmightusefullybeundertakentoexploreanddescribethemechanismsofactionandbarriersaddressedbysomeofthemorerelevantinterventions,incombinationwith a synthesis of the qualitative literature aimed at identifying the barriers to and facilitatorsofantenatalcareuptakebysociallydisadvantagedandvulnerablesubgroupsintheUK.Asynthesisofthesetwosetsoffindingscouldpotentiallyguidefutureservicedevelopmentandresearchprioritiesbyidentifyingtheinterventionswhichbestaddressthe‘barriersandfacilitators’relevantintheUKcontext.
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women 33
Conclusion5.5
Insummary,wefoundinsufficientevidencetoconcludethatinterventionsthataimtoincrease the early initiation of antenatal care in socially disadvantaged and vulnerable populationsofwomenareeffective.However,theabsenceofevidenceshouldnotbeinterpretedasevidencethattheinterventionsevaluatedarenecessarilyineffective.Oneinterventionbasedonhomevisitingforpregnantadolescentswasconsidered‘promising’,and several other intervention strategies were considered to contain elements that would meritfurtherconsiderationandpossiblyevaluation.Overall,theresultsofthisreviewhighlightthepaucityofevidenceandtheneedforfurtherwelldesignedevaluationsto ensure that services designed to increase the early initiation of antenatal care are evidence based.
AcknowledgementThisisanindependentreportfromastudywhichisfundedbythePolicyResearchProgrammeintheDepartmentofHealth.TheviewsexpressedarenotnecessarilythoseoftheDepartment.
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Annex A: Medline search strategyDatabase: Ovid MEDLINE(R) In-Process & Other Non-Indexed Citations and Ovid MEDLINE(R) <1950 to Present>
Search Strategy:
--------------------------------------------------------------------------------
1expSocioeconomicFactors/orexpSocialClass/
2(equityorinequalit$orequalit$orunequal$orinequit$ordisparit$orgaporgapsorgradient$ordisadvantag$orsocioeconomic$).ti,ab.
3healthinequalit$.mp.orHealthStatusIndicators/or*HealthStatusDisparities/or*HealthcareDisparities/
4expPoverty/orexpMedicalIndigency/orvulnerablepopulations/
5expMinorityHealth/orexpMinorityGroups/orpopulationgroups/orexpethnicgroups/orhealthservices,indigenous/
6(ethnicor(blackadj2asian)).ti,ab.
7(multiethnic$ormultiethnic$ormultiracial$ormultiracial$).ti,ab.
8expPrisoners/orprison*.ti,ab.
9exprefugees/or“EmigrantsandImmigrants”/or“TransientsandMigrants”/
10(immigrant*orrefugee*ormigrant*orasylumseeker*).ti,ab.
11expgypsies/ortravel?er*.ti,ab.
12expHomelessYouth/orexpHomelessPersons/orhomeless$.ti,ab.
13expSpouseAbuse/orDomesticViolence/orexpbatteredwomen/
14((abuse$orviolen$)adj4(partner$orwifeorwivesorspouse$ordomestic)).ti,ab.
15((neighbo?rhoodoreconomicorruralorurban)adj2(depriv$orpoverty)).ti,ab.
16(disadvantag*ordeprivedarea*orinnercit*orinnercit*).ti,ab.
17MentalDisorders/orexpeatingdisorders/orexpmooddisorders/orexp“schizophreniaanddisorderswithpsychoticfeatures”/
18((mental$orpsych$)adj2(ill$ordisorder$orimpair$ordisturb$ordisabil$)).ti,ab.
19LearningDisorders/orMentalDeficiency/
20((mental$orlearningorcognitiv$)adj2(retard$orhandicap$ordisab$ordifficult$orimpair$)).ti,ab.
21expProstitution/orsexworker*.ti,ab.
22AdolescentHealthServices/orexpAdolescent/orexpPregnancyinAdolescence/
23(teen$oryouth$oradolescen$).ti,ab.
24expHIVInfections/orHIV/
25(HIVorHIV-pos$orHIV-inf$).ti,ab.
26expStreetDrugs/orexpNarcotics/orexpCocaine/orexpCrackCocaine/orexpHeroin/orexpamphetamines/orexpmethadone/27expsubstance-relateddisorders/orexpSubstanceAbuse,Intravenous/orexpamphetamine-relateddisorders/orexpcocaine-relateddisorders/orexpmarijuanaabuse/orexpopioid-relateddisorders/orexpheroindependence/orexpphencyclidineabuse/orexppsychoses,substance-induced/orexpsubstanceabuse,intravenous/orsubstancewithdrawalsyndrome/
28expalcohol-relateddisorders/orexpalcoholism/orexpalcohol-induceddisorders/
29expCircumcision,Female/
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women 41
30(femaleadj(genitalmutilationorcircumcisionorgenitalcutting)).ti,ab.
31(clitoridectomyorinfibulation).ti,ab.
32((languageadj3(secondorproblem*oradditionalorbarrier*))ortranslat*orinterpreter*).ti,ab.
33expcommunicationbarriers/orexplanguage/
34expculture/orexpculturalcharacteristics/orexpculturaldiversity/
35((cultur*orsociocultur*orsocio-cultur*)adj5(barrier*ordifferen*orpractice*orsensitiv*orappropriate*)).ti,ab.
36or/1-35
37expPrenatalCare/ormaternalhealthservices/
38((antenatalorprenatal)adj2(careorclinicorprogram*orservice*)).ti,ab.
39expMidwifery/
40or/37-39
41outreach.ti,ab.
42 41 and 40
43((utilis$orutiliz$orbarrier$oraccess$oruptakeorinitiateorinitiationorbooking)adj5(prenatalorantenatalorcare)).ti,ab.
44((lateorearly)adj5(uptakeorinitiat$orattend$orbooking)).ti,ab.
45 (43 or 44) and 40
46PrenatalCare/ut[Utilization]
47 (42 or 45 or 46) and 36
48limit47toinprocess
49 limit 47 to in data review
50limit47topubmednotmedline
51or/48-50
52 47 not 51
53 limit 52 to humans
54 51 or 53 (1622)
55 limit 54 to (english language and yr=”1990 - 2009”)
56casereports/
57(letterorrevieworcommentoreditorialorletterornews).pt.
58 55 not (56 or 57)
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women42
Annex B: Named intervention searchesInoursecondroundofsearches,weusedthefollowinglistof(potentiallyeligible)namedinterventions for text searching:
AfterCare Project 69
AsianMotherandBabyCampaign42
Baby Talk 70
California Black Infant Health Program 53
Center for Addiction and Pregnancy71
Community Health Nursing Prenatal Care Program 72
Congress Alukura 62
Daruk Antenatal Program 73
De Madres a Madres74 75 76 77
Florida Outreach Childbirth Education Project 78
HealthStart 52
Homeless Prenatal Program 79
ImprovedPregnancyOutcome80
KansasHealthyStartHomeVisitingProgram48
Maternal Infant Health Advocate Service 50
Maternal Infant Health Outreach Worker 81
Maternal Outreach Worker 82
Minority Health Coalitions’ Early Pregnancy Project 46
MumsandBabiesprogram83
NguaGundi(Mother/ChildProject)61
Omaha Healthy Start 47
OpeningDoors84
Parenting and the Community Health 85
PeerSupportProgramme86
Prenatal Care Assistance Program 56
Project MotherCare87
Resource Mothers Program 55 45
Rural Alabama Pregnancy and Infant Health 88
RuralMaternalChildHealthprogram89
Rural Oregon Minority Prenatal Progam 43
Southeast Asian Health Project 90
Strong Women Strong Babies Strong Culture 41
TeenParentingPartnership91
TempleInfantandParentSupportServices92
The Door 93
Un Comienzo Sano (A Healthy Beginning) 94
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women 43
Annex C: Characteristics and results of included studiesNotes – how to read this table
Interventiongroupsaredescribedincolumn7.Inmoststudiesthereisonlyone•interventiongroup,labelledI1,denotingInterventiongroup1;wherethereismorethanoneinterventiongroup,groupsarelabelledI1,I2,etc.
Comparator/controlgroup(s)aredescribedincolumn8.Wherethereisonlyone•comparator/controlgroupthisislabelledC1,denotingcontrol/comparatorgroup1;wheretherearemultiplecomparatorgroupsthesearelabelledC1,C2,etc.
Resultsaregenerallypresentedasacomparisonoftheoutcomesintheintervention•groupcomparedwiththecontrolgroup(s),i.e.I1vs.C1forstudieswithoneinterventiongroupandonecontrol/comparatorgroup.Wheretherearemultiplecontrol/comparatorgroups,multiplecomparisonsareshown.
Subgroupanalysesarepresentedwheretheauthorreportsondifferential•effectivenessacrosssubgroups
Bothunadjustedandadjustedresultsarepresentedwhereavailable;wherethe•authorshavefittedmultipleadjustmentmodelswepresenttheresultsconsideredmostrelevant–usuallyinvolvingadjustmentformaternalcharacteristics/riskfactorspresentatbooking.
95%confidenceinterval,‘p-values’and/orastatementthatadifferenceis“not•significant”(NS)areincludedwherereportedbytheauthors.
Forstudieswhichcompareoutcomesbeforeandaftertheimplementationofan•intervention,resultsarepresentedasC1(“before”)vs.I1(“after”)
Abbreviations
ANC=Antenatalcare; OR=Oddsratio; RR=RelativeRisk; 95%CI=95%confidenceinterval; NS=Notstatisticallysignificantatthe5%level.
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women44
Au
tho
r an
d
year
Co
un
try/
S
ett
ing
Stu
dy d
esi
gn
Stu
dy p
op
ula
tio
nTarg
et
po
pu
lati
on
(i
nte
rven
tio
n)
Meth
od
of
all
oca
tio
n t
o
stu
dy g
rou
p(s
)In
terv
en
tio
n g
rou
p(s
)C
on
tro
l/
com
para
tor
gro
up
(s)
Resu
lts
– t
imin
g o
f in
itia
tio
n o
f A
NC
Cra
mer
2007
USA,Douglas
County,
Neb
rask
a.
Retrospective
obse
rvat
ional
co
hort
stu
dy.
Wom
en g
ivin
g b
irth
in
the
study
area
s bet
wee
n 2
002 a
nd
2003.
Eth
nic
min
ority
wom
en
(“Bla
ck w
om
en”)
. N.B.studysample
not
rest
rict
ed b
y et
hnic
ity)
.
Uncl
ear.
Retrospective
assi
gnm
ent.
I1:
236 w
om
en w
ho
lived
in t
he
19 t
arget
ed
censu
s tr
acts
and w
ho
participatedinthe
programme.
C1:
1520 w
om
en w
ho
lived
in t
he
19 t
arget
ed
censu
s tr
acts
who d
id
nottakepartinthe
programme.
C2:15,949women
who g
ave
birth
in t
he
county
(in
cludes
sm
all
numberofprogramme
participants).
Unad
just
ed %
initia
ting A
NC in 1
st
trim
este
r:
2002:I167.1%,C168.0%,C285.5%
2003:I179.0%,C174.5%,C283.3%
I12002vs.C22002,p=0.01
Authorspresentarangeofother
comparisons.SeeTable3inthepaper
for
furt
her
det
ails
.
Daa
lem
an 1
997USA,Topeka-
ShawneeCounty,
Kansas.
Retrospective
obse
rvat
ional
co
hort
stu
dy.
Multiparous
wom
en a
ged
17-3
8 r
ecei
ving
WIC
ser
vice
s duringpregnancy,
whohadnoprior
participationinthe
KansasMaternal
and I
nfa
nt
Progra
m
(aseparate
comprehensive
preventative
serv
ice
that
se
rves
hig
h r
isk
child
bea
ring w
om
en
and infa
nts
).
Studyperiodnot
specified.
Soci
oec
onom
ical
ly
dis
adva
nta
ged
wom
en
(“atrisk”,andin
receiptofWIC).
Retrospective
assi
gnm
ent
bas
ed
on c
are
rece
ived
.
I1:?*womenwhohad
participatedinthe
KansasHealthyStart
HomeVisiting(HSHV)
programme(had
rece
ived
at
leas
t one
contact(phonecalland/
orhomevisit))priorto
theindexpregnancy.
*62womenwere
enro
lled in s
tudy
overall,butnumbers
in inte
rven
tion a
nd
comparatorgroupnot
separatelyreported.
Inte
rven
tion t
arget
ed
“at-
risk
” fa
mili
es.
C1:?*womenwhohad
notparticipatedinthe
HSHVprogrammeprior
totheindexpregnancy.
*seenoteinprevious
colu
mn
Numericresultsnotreported;data
derivedvisuallyfrombarcharts,
approximate.
Unad
just
ed %
initia
ting A
NC in 1
st
trim
este
r:
I1 v
s. C
1:
63%
vs.
75%
Test
for
tren
d a
cross
thre
e tr
imes
ters
andnocaregroup:p=0.36.
Stratifiedanalysis
Sin
gle
wom
en:
I1 v
s. C
1:
73%
vs.
57%
Test
for
tren
d a
cross
thre
e tr
imes
ters
andnocaregroup:NS.
Edger
ley
2007
USA,PaloAlto,
Cal
iforn
ia.
Low
-inco
me
nei
ghbourh
oods.
Retrospective
obse
rvat
ional
co
hort
stu
dy.
Wom
en w
hose
an
tenat
al a
nd
del
iver
y ca
re w
as
funded
by
Med
iCal
(M
edic
aid)
and
who d
eliv
ered
a
single
ton infa
nt
at
Sta
nfo
rd U
niv
ersi
ty
Med
ical
Cen
ter
between01/01/00
and04/07/04.
Soci
oec
onom
ical
ly
dis
adva
nta
ged
wom
en
(Medicaidrecipients).
Sel
ection b
y si
te o
f care/birth.
I1:
108 w
om
en w
ho
initia
ted a
nte
nat
al c
are
on t
he
Wom
en’s
Hea
lth
Van.
C1:
127 r
andom
ly
selectedfrom2,121
wom
en w
ho initia
ted
ante
nat
al c
are
in a
loca
l co
mm
unity
clin
ic.
Unad
just
ed %
initia
ting A
NC in 1
st
trim
este
r:
I1 v
s. C
1:
79.6
% v
s. 5
9.8
%
Testfortrendacrossthreetrimesters:p
= 0
.002.
Hunte
2004
USA,Flint,
Gen
esse
e County,Michigan.
Urb
an a
rea.
Retrospective
obse
rvat
ional
co
hort
stu
dy.
Afr
ican
-Am
eric
an
wom
en liv
ing in 4
selectedzipcodes
who g
ave
birth
duringthegroup-
specificstudy
periods.
Min
ority
eth
nic
wom
en
(“Afr
ican
-Am
eric
an
wom
en”)
.
Uncl
ear.
Retrospective
assi
gnm
ent
bas
ed
on c
are
rece
ived
?
I1:
111 w
om
en w
ho
wer
e M
IHAS c
lients
and
had
giv
en b
irth
at
the
tim
e of th
e birth
rec
ord
s ex
trac
tion in A
ugust
2003,livinginthe4
targetedzipcodes.
C1:350women,a
“uniformprobability
sample”ofallbirths
duringthefirst6months
of 2003 t
o w
om
en w
ho
wer
e not
MII
HAS c
lients
an
d w
ho liv
ed in 3
of th
e 4targetedzipcodes.
Unad
just
ed %
initia
ting A
NC in 1
st
trim
este
r:
I1vs.C1:66.7%vs.67.7%,testof
statisticalsignificancenotreported.
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women 45
Au
tho
r an
d
year
Co
un
try/
S
ett
ing
Stu
dy d
esi
gn
Stu
dy p
op
ula
tio
nTarg
et
po
pu
lati
on
(i
nte
rven
tio
n)
Meth
od
of
all
oca
tio
n t
o
stu
dy g
rou
p(s
)In
terv
en
tio
n g
rou
p(s
)C
on
tro
l/
com
para
tor
gro
up
(s)
Resu
lts
– t
imin
g o
f in
itia
tio
n o
f A
NC
Jewell2000
USA,Indiana.
Retrospective
obse
rvat
ional
co
hort
stu
dy.
M
atch
ed.
Wom
en w
ho g
ave
birth
during t
he
two y
ear
study
period(datesnot
specified).
Eth
nic
min
ority
wom
en
("m
inority
wom
en")
.U
ncl
ear.
Retrospective
assi
gnm
ent
bas
ed
on c
are
rece
ived
?
I1:
95 w
om
en r
ecei
ving
care
coord
inat
ion t
hro
ugh
enro
lmen
t in
one
of th
e th
ree
Min
ority
Hea
lth
Coalitionprojects.
Inte
rven
tion t
arget
ed a
t w
om
en fro
m m
inority
backgrounds,butsample
not
rest
rict
ed b
y ra
ce.
C1:188women,a
stratifiedrandom
sampleofwomenwho
did
not
rece
ive
care
co
ord
inat
ion.
Eac
h
inte
rven
tion b
irth
was
matchedwithapprox.
2 c
ontr
ols
fro
m b
irth
certificaterecords,
matchedon:race,age,
maritalstatus,and
educa
tion a
ttai
nm
ent.
Unad
just
ed %
initia
ting A
NC in 1
st
trim
este
r:
I1 v
s. C
1:
73.3
% v
s. 5
3.3
%
Chi sq
uar
e te
st for
tren
d a
cross
thre
e trimestersandnocaregroup:p=
0.0
10.
Julnes1994
USA,Norfolk,
Virginia.City
with h
igh r
ate
of
infa
nt
mort
ality
and a
dole
scen
t pregnancy.
Retrospective
obse
rvat
ional
co
hort
stu
dy.
Adole
scen
ts <
19
year
s w
ho g
ave
birth
during t
he
12 m
onth
stu
dy
period(datesnot
specified).
Teen
ager
s.U
ncl
ear.
Retrospective
assi
gnm
ent
bas
ed
on c
are
rece
ived
?
I1:
49 a
dole
scen
ts
who w
ere
clie
nts
of
the
Res
ourc
e M
oth
ers
Progra
m (
RM
P).
Inte
rven
tion t
arget
ed
“hig
h-r
isk”
adole
scen
ts.
C1:
46 a
dole
scen
ts w
ho
didnotparticipateinthe
RMP(instead,theywere
clie
nts
of th
e cl
inic
-basedmulti-disciplinary
programme).
Unad
just
ed %
initia
ting A
NC b
efore
the
4thmonthofpregnancy:
I1vs.C1:53.1%vs.32.6%,p<0.05
Mac
kerr
as 2
001Australia,Darwin
Rura
l an
d
Eas
t Arn
hei
m
regions,Northern
Terr
itory
.
Bef
ore
and
afte
r st
udy.
Aborigin
al w
om
en
who g
ave
birth
inthethreepilot
com
munitie
s.
Indig
enous
wom
en
(Aborigin
al w
om
en).
Sel
ection b
y ye
ar
ofcare/birth
(pre-andpost-
inte
rven
tion).
I1:
228 w
om
en w
ho
gav
e birth
bet
wee
n
1994and95,afterthe
implementationofthe
Str
ong W
om
en S
trong
Bab
ies
Str
ong C
ulture
(S
WSBSC)
inte
rven
tion.
C1:
246 w
om
en w
ho
gav
e birth
bet
wee
n 1
990
and1991,beforethe
implementationofthe
SW
SBSC inte
rven
tion.
Unad
just
ed %
initia
ting A
NC in 1
st
trim
este
r:
I1vs.C1:24.4%vs.16.7%,p=0.03
Mar
tin 1
997
USA,Cincinnati,
Ohio
.Bef
ore
and
afte
r st
udy.
Adole
scen
ts a
ged
14-1
7 y
ears
who
rece
ived
ante
nat
al
carethroughGroup
Hea
lth A
ssoci
ates
.
Teen
ager
s.Sel
ection b
y ye
ar
ofcare/birth
(pre-andpost-
inte
rven
tion).
I1:
72 a
dole
scen
ts w
ho
gav
e birth
bet
wee
n 1
992
and1994,receivingtheir
ante
nat
al c
are
afte
r th
e implementationofthe
Teen
Pre
gnan
cy P
rogra
m
(TPP
).
C1:
33 a
dole
scen
ts
whogavebirth1991,
rece
ivin
g in t
hei
r an
tenat
al c
are
bef
ore
theimplementation
oftheTPP.Allprivate
patients(clinicdidnot
acceptMedicaiduntil
1992).
Unad
just
ed %
initia
ting A
NC b
efore
4th
monthofpregnancy:
I1vs.C1:79.8%vs.69.7%,NS.
Mas
on 1
990
U.K,Leicester.
Two m
ater
nity
units
and f
our
GP
surg
erie
s.
Prospective
obse
rvat
ional
co
hort
stu
dy.
Asi
an w
om
en
regis
tering for
ante
nat
al c
are
at
selectedpractices
between01/05/85
and30/04/86.
Eth
nic
min
ority
wom
en
(Gujarati,Punjabi,
Hindi,Urduand
Bengalispeakers).
Uncl
ear. N
on-
random
sel
ection.
I1:
213 w
om
en w
ho h
ad
at lea
st o
ne
conta
ct w
ith
acommunityand/or
hospitallinkworker.
C1:
244 w
om
en w
ho d
id
not
hav
e an
y co
nta
ct
withacommunityand/
orhospitallinkworker.
Unad
just
ed %
initia
ting A
NC b
efore
12
wee
ks g
esta
tion:
I1vs.C1:70%vs.70%,NS
Morr
is 1
993
USA,Galveston,
Texa
s. C
linic
s providedbythe
Univ
ersi
ty o
f Te
xas
Med
ical
Bra
nch
.
Retrospective
obse
rvat
ional
co
hort
stu
dy.
Adole
scen
ts a
ged
<
18 y
ears
who
rece
ived
ante
nat
al
care
at
the
study
clin
ics
and g
ave
birth
bet
wee
n
1985 a
nd 1
986.
The
maj
ority
of
adole
scen
ts w
ere
med
ical
ly indig
ent.
Teen
ager
s.Sel
ection b
y si
te
ofcare/birth.Self-
sele
ctio
n.
I1:
660 a
dole
scen
ts w
ho
rece
ived
ante
nat
al c
are
attheteenpregnancy
clin
ic.
C1:
277 a
dole
scen
ts
who r
ecei
ved “
trad
itio
nal
prenatalcare”.
Unad
just
ed %
initia
ting A
NC in 1
st
trim
este
r:
I1 v
s. C
1:
45.2
% v
s. 1
9.5
%
Distributionoftrimesterofbooking,chi
squaretest:p=0.001.
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women46
Au
tho
r an
d
year
Co
un
try/
S
ett
ing
Stu
dy d
esi
gn
Stu
dy p
op
ula
tio
nTarg
et
po
pu
lati
on
(i
nte
rven
tio
n)
Meth
od
of
all
oca
tio
n t
o
stu
dy g
rou
p(s
)In
terv
en
tio
n g
rou
p(s
)C
on
tro
l/
com
para
tor
gro
up
(s)
Resu
lts
– t
imin
g o
f in
itia
tio
n o
f A
NC
Mvu
la 1
998
USA,New
Orleans,
Louis
iana.
Pu
blic
ly
funded
clin
ics
serv
ing “
low
so
cioec
onom
ic
populations,
with m
ost
bel
ow
povertylevel”.
Prospective
obse
rvat
ional
co
hort
stu
dy.
Med
ical
ly low
-ris
k w
om
en r
egis
tering
for
ante
nat
al c
are
between01/01/94
and31/12/94,
excl
udin
g w
om
en
withmultiple
pregnancies
andspecific
complications
(includingdiabetes,
hypertension,HIV,
sick
le c
ell)
.
Soci
oec
onom
ical
ly
dis
adva
nta
ged
wom
en
(low
inco
me)
.
Sel
ection b
y si
te o
f care/birth.
I1:
179 w
om
en
who r
egis
tere
d for
ante
nat
al c
are
at
the
Nei
ghbourh
ood
Preg
nan
cy C
are
(NPC
).
C1:
181 r
andom
ly
sele
cted
wom
en w
ho
regis
tere
d for
ante
nat
al
care
at
the
Louis
iana
Sta
te U
niv
ersi
ty
obst
etric
clin
ic.
Unad
just
ed %
initia
ting A
NC b
efore
14
wee
ks:
I1vs.C1:37%vs.29%,
Distributionoftrimesterofbooking,chi
squar
e te
st:
NS
New
schaf
fer
1998
USA,NewYork
Sta
te.
Med
icai
d
Ante
nat
al C
linic
s.
Retrospective
obse
rvat
ional
co
hort
stu
dy.
HIV-positive
subst
ance
abusi
ng
wom
en c
laim
ing
Med
icai
d w
ho g
ave
birth
to a
sin
gle
ton
infa
nt
bet
wee
n
January1993and
September1994.
Soci
oec
onom
ical
ly
dis
adva
nta
ged
wom
en
(Medicaidrecipients),
though inte
rven
tion
evaluatedinHIV-
positivesubstance
abusi
ng w
om
en.
Uncl
ear. S
elec
tion
bysiteofcare/
birth
?
I1:
240 w
om
en w
ho
rece
ived
ante
nat
al
care
at
a Pr
enat
al C
are
Ass
ista
nce
Pro
gra
m
(PCAP)
clin
ic (
wom
en
with a
t le
ast
one
Med
icai
d P
CAP
clai
m
duringpregnancy).
C1:
113 w
om
en w
ho
rece
ived
ante
nat
al c
are
from
a s
ourc
e oth
er
than
PCAP.
Unad
just
ed %
initia
ting A
NC b
efore
the
5thmonthofpregnancy:
I1vs.C1:76%vs.68%,p=0.11.
Rei
chm
an 1
996
USA,NewJersey.Retrospective
obse
rvat
ional
co
hort
stu
dy.
Med
icai
d c
laim
ants
w
ho h
ad a
sin
gle
ton
live
birth
bet
wee
n
1989 a
nd 1
990.
Soci
oec
onom
ical
ly
dis
adva
nta
ged
wom
en
(Medicaidrecipients).
Sel
ection b
y si
te o
f care/birth
11:24,036women
(10,908Black,13,128
White)whoparticipated
inNewJersey’s
HealthStartprogramme.
C1:16,719women
(8,671Black,8,102
White)
who d
id n
ot
participateinNew
Jersey’sHealthStart
programme.
Unad
just
ed %
initia
ting A
NC in 1
st
trim
este
r:
Onlystratifieddatareportedbyauthors.
Bla
cks:
I1
vs.
C1:
49.5
% v
s. 4
9.6
% (
NS)
Whites
: I1vs.C1:56.4%vs.59.0%,p<0.01
Roger
s 1996
USA,South
Car
olin
a. R
ura
l (<
50 %
urb
an)
and m
oder
atel
y urb
an (
bet
wee
n
50-7
5%
urb
an)
counties
.
Retrospective
obse
rvat
ional
co
hort
st
udy
with
additio
nal
pre-
inte
rven
tion
comparator
group.
Primiparous
adole
scen
ts (
<18
year
s at
del
iver
y)
who g
ave
birth
to
a s
ingle
infa
nt
between01/01/86
and31/12/89.
Teen
ager
s.U
ncl
ear.
Retrospective
assi
gnm
ent
bas
ed
on c
are
rece
ived
?
I1:
1901 a
dole
scen
ts
whoparticipatedin
the
Res
ourc
e M
oth
ers
Progra
m (
RM
P) a
nd
resi
ded
in t
he
16
counties
in w
hic
h t
he
RMPwasimplemented.
C1:
4612 a
dole
scen
ts
who r
esid
ed in 1
6
comparisoncounties
(bro
adly
mat
ched
to
the
RM
P co
unties
on
selectedsociocultural,
perinatalstatus
and h
ealth r
esourc
e in
dic
ators
) w
ho d
id n
ot
takepartintheRMP
programme.
C2:
712 a
dole
scen
ts
who r
esid
ed in 1
0 o
f th
e 16 R
MP
counties
an
d g
ave
birth
bef
ore
theRMPprogramme
wasimplemented
in t
hei
r co
unty
of
resi
den
ce (
inte
rven
tion
wasimplementedina
stepwisefashion).
Unad
just
ed %
initia
ting A
NC b
efore
the
4thmonthofpregnancy:
I145.3%,C140.9%,C240.0%
Adjusted*oddsratioforearlyinitiation
of AN
C (
1-3
month
s)
I1vs.C1,OR1.48(1.32,1.66)
I1vs.C2,OR1.39(1.16,1.66)
*adjustedforage,maritalstatus,race,
andpreviouspregnancies
A systematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women 47
Au
tho
r an
d
year
Co
un
try/
S
ett
ing
Stu
dy d
esi
gn
Stu
dy p
op
ula
tio
nTarg
et
po
pu
lati
on
(i
nte
rven
tio
n)
Meth
od
of
all
oca
tio
n t
o
stu
dy g
rou
p(s
)In
terv
en
tio
n g
rou
p(s
)C
on
tro
l/
com
para
tor
gro
up
(s)
Resu
lts
– t
imin
g o
f in
itia
tio
n o
f A
NC
Thompson1998USA,Oregon.
“Veryrural
county
”.
Bef
ore
and
afte
r st
udy.
Lo
w-i
nco
me
Mex
ican
- Am
eric
an
wom
en liv
ing in
rura
l ar
eas.
Eth
nic
min
ority
wom
en
(“M
exic
an-A
mer
ican
w
om
en”)
.
Sel
ection b
y ye
ar
ofcare/birth
(pre-andpost-
inte
rven
tion).
I1:100highrisk*
pregnantwomen
recr
uited
bet
wee
n
September1991-May
1994 w
ho r
ecei
ved
Rura
l O
regon M
inority
Pr
enat
al P
rogra
m
(RO
MPP
) se
rvic
es a
nd
wer
e co
nsi
der
ed t
o
havecompletedthe
inte
rven
tion (
rece
ived
a
min
imum
of 3 v
isits)
.
*highrisk:included
historyofpreterm
orLBW,historyof
pregnancycomplications,
pre-existingmedical
conditions,age<17
year
s.
C1:
100 w
om
en
“demographically
sim
ilar”
to inte
rven
tion
samplewhogavebirth
in t
he
study
county
bet
wee
n 1
989-9
1
(the
year
s bef
ore
the
RO
MPP
inte
rven
tion w
as
implemented).
Numericresultsnotreported;
approximatedataderivedvisuallyfrom
bar
char
ts.
Unad
just
ed %
initia
ting A
NC b
efore
the
5thmonthofpregnancy:
I1 v
s. C
1:
66%
vs.
52%
Distributionofgroupedmonthof
booking(1-2,3-4,5-6,7+ornocare),
Man
n-W
hitney
tes
t: N
S.
Will
is 2
004
USA,California.
Prospective
obse
rvat
ional
co
hort
stu
dy.
Afr
ican
-Am
eric
an
Med
icai
d c
laim
ants
w
ho g
ave
birth
during r
elev
ant
studyperiodand
resi
ded
in t
arget
ed
ZIPcodes.
Eth
nic
min
ority
wom
en
(“Afr
ican
-Am
eric
an
wom
en”)
.
Uncl
ear.
I1:2,031womenwho
had
a s
ingle
ton liv
e birth
betweenJuly1996and
September1990and
whoparticipatedinthe
Bla
ck I
nfa
nt
Hea
lth (
BIH
) programme.
C1:11,622womenwho
gav
e birth
in 1
997 a
nd
didnotparticipateinthe
BIHprogramme.
Unad
just
ed %
initia
ting A
NC in 1
st
trim
este
r:
I1vs.C1:60.8%vs.75.8%,testof
statisticalsignificancenotreported.
Please cite this document as:
LauraOakley,RonGray,JenniferJKurinczuk,PeterBrocklehurst,JenniferHollowell,Asystematic review of the effectiveness of interventions to increase the early initiation of antenatal care in socially disadvantaged and vulnerable women. Oxford: National Perinatal EpidemiologyUnit,2009
ThisreportandotherInequalitiesinInfantMortalityProjectreportsareavailableat:
www.npeu.ox.ac.uk/infant-mortality