Vogel Joshua P, Habib Ndema Abu, Souza João Paulo, Gülmezoglu A Metin, Dowswell Therese, Carroli Guillermo, Baaqeel Hassan S, Lumbiganon Pisake, Piaggio Gilda, Oladapo Olufemi T
Reprod Health. 2013 Apr 12;10:19. doi: 10.1186/1742-4755-10-19.
In 2001, the WHO Antenatal Care Trial (WHOACT) concluded that an antenatal care package of evidence-based screening, therapeutic interventions and education across four antenatal visits for low-risk women was not inferior to standard antenatal care and may reduce cost. However, an updated Cochrane review in 2010 identified an increased risk of perinatal mortality of borderline statistical significance in three cluster-randomized trials (including the WHOACT) in developing countries. We conducted a secondary analysis of the WHOACT data to determine the relationship between the reduced visits, goal-oriented antenatal care package and perinatal mortality.
Exploratory analyses were conducted to assess the effect of baseline risk and timing of perinatal death. Women were stratified by baseline risk to assess differences between intervention and control groups. We used linear modeling and Poisson regression to determine the relative risk of fetal death, neonatal death and perinatal mortality by gestational age.
12,568 women attended the 27 intervention clinics and 11,958 women attended the 26 control clinics. 6,160 women were high risk and 18,365 women were low risk. There were 161 fetal deaths (1.4%) in the intervention group compared to 119 fetal deaths in the control group (1.1%) with an increased overall adjusted relative risk of fetal death (Adjusted RR 1.27; 95% CI 1.03, 1.58). This was attributable to an increased relative risk of fetal death between 32 and 36 weeks of gestation (Adjusted RR 2.24; 95% CI 1.42, 3.53) which was statistically significant for high and low risk groups.
It is plausible the increased risk of fetal death between 32 and 36 weeks gestation could be due to reduced number of visits, however heterogeneity in study populations or differences in quality of care and timing of visits could also be playing a role. Monitoring maternal, fetal and neonatal outcomes when implementing antenatal care protocols is essential. Implementing reduced visit antenatal care packages demands careful monitoring of maternal and perinatal outcomes, especially fetal death.
2001年，世界卫生组织产前护理试验（WHOACT）得出结论，针对低风险女性的包括四次产前检查的循证筛查、治疗干预及教育的产前护理套餐，并不逊色于标准产前护理，且可能降低成本。然而，2010年Cochrane的一项更新综述发现，在发展中国家的三项整群随机试验（包括WHOACT）中，围产期死亡率有增加的趋势，具有临界统计学意义。我们对WHOACT数据进行了二次分析，以确定减少检查次数、以目标为导向的产前护理套餐与围产期死亡率之间的关系。
进行探索性分析以评估基线风险和围产期死亡时间的影响。根据基线风险对女性进行分层，以评估干预组和对照组之间的差异。我们使用线性模型和泊松回归来确定按孕周计算的胎儿死亡、新生儿死亡和围产期死亡的相对风险。
27家干预诊所的12,568名女性和26家对照诊所的11,958名女性参与研究。6,160名女性为高风险，18,365名女性为低风险。干预组有161例胎儿死亡（1.4%），对照组有119例胎儿死亡（1.1%），胎儿死亡的总体调整相对风险增加（调整后相对风险1.27；95%置信区间1.03, 1.58）。这归因于妊娠32至36周之间胎儿死亡相对风险的增加（调整后相对风险2.24；95%置信区间1.42, 3.53）；对于高风险和低风险组，这具有统计学意义。
妊娠32至36周之间胎儿死亡风险增加可能是由于检查次数减少，但研究人群的异质性或护理质量及检查时间的差异也可能起作用。实施产前护理方案时监测孕产妇、胎儿和新生儿结局至关重要。实施减少检查次数的产前护理套餐需要仔细监测孕产妇和围产期结局，尤其是胎儿死亡情况。
