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Antenatal care packages with reduced visits and perinatal mortality: a secondary analysis of the WHO Antenatal Care Trial

Joshua P Vogel12*, Ndema Abu Habib2, João Paulo Souza2, A Metin Gülmezoglu2, Therese Dowswell3, Guillermo Carroli4, Hassan S Baaqeel5, Pisake Lumbiganon6, Gilda Piaggio7 and Olufemi T Oladapo8

Author Affiliations

1 School of Population Health, Faculty of Medicine, Dentistry and Health Sciences, University of Western Australia, 35 Stirling Highway, Crawley, 6009, Australia

2 UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research, World Health Organization, Avenue Appia 20, Geneva, CH-1211, Switzerland

3 Department of Women’s Health, University of Liverpool, Liverpool Women’s Hospital, Crown Street, Liverpool 8, UK

4 Centro Rosarino de Estudios Perinatales (CREP), Moreno 878, Rosario, 2000, Argentina

5 King Saud bin Abdulaziz University for Health Sciences, College of Medicine, Jeddah, 21423, Saudi Arabia

6 Department of Obstetrics and Gynaecology, Faculty of Medicine, Khon Kaen University, Khon Kaen, 40002, Thailand

7 Statistika Consultoria, São Paulo, Brazil, Divonne-les-Bains, France

8 Department of Obstetrics and Gynaecology, Olabisi Onabanjo University Teaching Hospital, Sagamu, P.M.B. 2001, Nigeria

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Reproductive Health 2013, 10:19  doi:10.1186/1742-4755-10-19

Published: 12 April 2013



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.

Antenatal care; Perinatal mortality; WHO; Developing country