Antenatal care (ANC)

Antenatal care (ANC) or prenatal care is described as the routine care provided to women between conception and before the delivery of child. The overall aim of ANC is to provide holistic care to cover health promotion and education, screening, diagnosis, and treatment for the mother and fetus (World Health Organization (WHO), 2016a). The health and wellbeing of women and children remain a fragmented agenda and a global challenge where progress in the reporting of early ANC visits has been achieved, however, coverage is still far from ubiquitous (Moller et al, 2017). Increased efforts and financial commitments from the government and private medical sector are required to preserve and advance momentum if countries and the global community have to reach the Sustainable Development Goals (SDG) (United Nations (UN), 2017) and thus prevent maternal and child mortality (WHO, 2017). The SDG aim to reduce maternal and neonatal mortalities of livebirths to less than 70/1000000 and 12/1000 (UN, 2017). These goals are further supported by global initiatives including the; Global Strategy for Women’s, Children’s, and Adolescent’s Health 2016 – 2030 (WHO, 2015a), Global Financing Facility in support of Every Woman Every Child (Global Financing Facility, 2017), the Strategies towards Ending Preventable Maternal Mortality (WHO, 2015b) and Every New-born: An Action Plan to End Preventable deaths (WHO, 2015).

Carroli et al (2001a) highlight that there is a lack of robust evidence pertaining to the content, frequency, and timing of ANC assessment within the current recommended ‘Western’ ANC packages.

In the UK, the National Institute for Clinical Excellence (NICE), (2019) recommends that pregnant women should be encouraged to access maternity services early in the pregnancy and that starts with the booking a midwife appointment, it should be completed by the 10th week of pregnancy. This allows for early screening of growth of fetus and provision of care for mother and baby. Considering some demographic variations, evidence suggests that 56% of women have their booking appointment within their first 10 weeks of pregnancy (NHS Digital, 2020). Results obtained by observing the facts and research that there has been a reduction in the proportion of women reported being 0-6 weeks pregnant when they first accessed a health professional about their pregnancy (53% in 2013, 50% in 2015, 48% in 2017 and 45% in 2018). There has been a corresponding upturn in the proportion who reported being 7-12 weeks pregnant (43% in 2013, 45% in 2015, 48% in 2017 and 50% in 2018) (CQC, 2019).

Kilpatrick et al (2017) highlight that ANC or prenatal care services are evidence-based however they argue that evidence on how to deliver a baby and how to take care of them. Most global ANC care models were developed on the historical notion, which was conceived from the, then, newly-emerging belief of the possibility of avoiding maternal and neonatal deaths (Avalos et al, 2015). Zanconato et al (2005) highlight that the late 20th century ANC model, which is practised in various European countries, includes care schedules which involves numerous visits starting as early in pregnancy as possible provided mostly until about 37 weeks where the frequency increases to weekly until delivery/birth. This is further accompanied by numerous interventions such as blood and urine testing and more recently ultrasound scanning, to access the health of mother. Lobo (1998) argues that an increased number of visits does not automatically correlate with better outcomes and that this extensive use of diagnostic tools, coupled with a ‘more is safer’ mindset often forces low risk women into an over-medicalized model of care which in turn, causes a snowball effect of increased financial costs and unjustifiable maternal and neonatal risks of complications (Henderson et al, 2000). Smeenk & ten Have (2003) highlight that the medicalisation of maternal care results in an over reliance on healthcare professionals, especially obstetricians and gynaecologists, the excessive use of drug, technological interventions, and surgical procedures, including superfluous, costly, often risky and invasive obstetrical interventions in low-risk pregnancies and low -risk births (Peahl et al, 2020).

Moller et al (2017) highlight that although there is sparce evidence on the analysis of global ANC, it remains imperative that antenatal services are made accessible as early as possible starting from the first trimester to meet these targets. This initiative is also echoed by the Maternity Matters (Department of Health (DoH), 2007) document in the United Kingdom (UK). However, it is not evident that early ANC leads to continued ANC throughout pregnancy and although the recommended ANC guideline (WHO, 2016a) has a strong focus on quality of care, accessing early care or receiving all recommended visits does not guarantee high quality care (Raynes-Greenow, 2017). de Masi et al (2017) advise that this recommendation aims to improve communication with and support for women throughout the antenatal period and was also designed to be adaptable and flexible such that various care settings can tailor them to meet their population’s needs.

In 2015, WHO (2016) estimated that 303000 women succumbed to pregnancy-related causes, such as complexities and serve post-delivery pain, about 2.7 million babies died within the first 28 days of life and 2.6 million babies were stillborn. They also state that only 64% of women receive ANC four or more times during their pregnancy nevertheless, high quality care during pregnancy and childbirth can inhibit many of these deaths. The United Nations International Children’s Emergency Fund (UNICEF) (2019) adds that even though 86% of pregnant women access ANC with a skilled healthcare professional at least once, only 2/3 (65%) receive at least four antenatal visits; with fewer women receiving at least four visits (~ 49 -52%) in regions such as Sub-Saharan Africa and South Asia with increased mortality rates. WHO (2014) emphasizes that 99% of preventable deaths occur in low-resource settings, maternal mortality is higher in women living in rural areas and for those in poorer communities, young adolescents are at increased risks of complications and death as a result of pregnancy compared to older women and that the 2.6 million recorded stillbirths in 2015 were also mainly in low-income resource settings (Blencowe et al, 2016). These statistics highlight that there are global disparities in accessing ANC due to educational, socio-economic inequalities resulting in some women being at higher risk of adverse outcomes during pregnancy Further supporting the notion of the need to address accessibility to care but also to ensure high quality content in the provision of ANC.

There have been numerous ways to improve access to medical care of new-born and mother globally including enabling remote or virtual delivery of ANC care to low risk pregnant women? The move to virtual care has been influenced by previous epidemic outbreaks such as the Ebola virus outbreak in Sierra Leone and the natural disasters caused by the hurricanes in the USA in 2017. These epidemics and natural disasters resulted in severe disruptions to health systems and demonstrated the potential of using remote access/telemedicine as a means of reducing infection rates and also maintaining service provision of healthcare (Ohannessian et al, 2020). A mobile app was used to successfully monitor and trace the contacts of confirmed Ebola cases where clinicians were educated and trained via virtual and telemedicine was successfully implemented for free 2-way video consultations for victims, although limited infrastructure and access to Wi-Fi deemed as grave challenges (Usher-Pines et al, 2018) and tutorial (Watson-Jones et al, 2015).

To date, the COVID-19 strain of the coronavirus has posed serious implications on accessibility to health care services worldwide. It is an infectious respiratory disease discovered by SARS as COVID-19 which spreads through droplets of saliva or discharged from the nose when an infected person coughs or sneezes. It was declared as global pandemic on March 11, 2020 after more than 118 000 cases spread over 110 countries and maintained the risk of continuing global spread (WHO, 2020). The ultimate response strategies in numerous countries for combating the pandemic included social distancing, imposing lockdowns, early diagnosis, and isolation of infected individuals and tracking and tracing of those suspected of or confirmed cases (Haug et al, 2020). In view of this, the crucial role of video consultations/virtual care or telemedicine, immediately increased in order to reduce the risks and rates of transmission – particularly in environments that did not have sufficient personal protective equipment for the health workforce (Smith et al, 2020). There was a call for global nations to utilize telehealth on a large scale, especially in high income countries with widely available technological resources by governments and health systems, as a means of responding to the pandemic whilst maintaining provision of crucial health services (Bokolo, 2020 or Bashshur et al, 2020). However, evidence is lacking in relation to the effectiveness, quality of and efficacy of telemedicine in different contexts of maternal healthcare as vital aspects of maternal and new-born care deem difficult to deliver by telemedicine (Galle, 2021).

WHO (2010) defines telehealth as the conveyance of healthcare services by health care professionals from a distance through the use of information and communication processes for the purposes of exchanging appropriate and accurate information. There is a compelling drive for the National Health Service (NHS) decision-makers at national-level to increase the use of digital technologies via virtual consultations in order to provide an improved, timely and cost-effective outpatient consultation, however, current evidence is sparse with regards to the development and use of virtual consultations in the UK (Shaw et al, 2018). Poor health outcomes and increased use of emergency care are often the results of poor patient engagement, high ‘did not attend’ (DNA) rates and constantly increasing health service costs due to increasing prevalence of diseases (Fischer et al, 2016 & NHS England, 2014). It is crucial to reduce hospital follow-up appointments in the NHS as most out-patient models of care fail to provide a responsive care model when intervention is required (Shaw et al, 2018). Current policies are placing significant faith in digital advancements and their potential to provide more efficient, effective, and patient-centred models of community care (Honeyman et al, 2016 & National Information Board, 2014). In view of the pandemic, pregnant women have been classified into a vulnerable group such that they are advised to be strict with social distancing and self-isolation in order to reduce the risk of transmission and/or exposure to the virus. This has resulted in limiting face-to-face appointments and in turn, the swift implementation of remote access to ANC in the UK (RCOG, 2020).

Subsequent studies have considered the effectiveness of a reduced ANC model and most suggest that models of care with reduced visits among low-risk women could be achieved without increasing maternal or fetal adverse outcomes (Doswell et al, 2010). The reasons for the reduced satisfaction are unclear nonetheless, there are suggestions that women who received the reduced visits felt that they needed more time to talk and be listened to and that the time span between the visits was too long (Sikorski et al, 1996). An assessment of women’s preferences for ANC included opportunities for women to communicate with other pregnant women, flexibility, developing meaningful relationships with healthcare professionals, being more involved in their care and continuity of care (Novick, 2009 NHS England (2017) describes the term ‘continuity of care’ as that where there is consistency within the midwifery or obstetric teams who provide care to a woman and her baby throughout the three phases of pregnancy – ante-/prenatal, intrapartum and postnatal periods. Homer et al (2017) highlight that continuity of carer can also improve birth outcomes for women from ethnic minority groups and/or those from deprived areas. Sandall et al (2016) suggest that women who experience the continuity of carer model are; 16% less likely to lose their baby, 19% less likely to lose their baby before 24 weeks, 24% less likely to experience pre-term birth and unquestionably experience a more improved experience across various measures of care.

The continuity of carer model Implementation guide was published in England through the Maternity Transformation Programme (NHS England, 2017) with the monitoring and evaluation framework published in 2018 (Sandall, 2018). The NHS Standard Contract 2019/2020 (NHS England, 2019) stated that by March 2020, 35% of pregnant women should be in a continuity of carer model and it may, in turn, be suggested that virtual ANC might help to achieve these goals and provide greater satisfaction for low risk women.

Villar et al (2001) conducted a study that assessed the effects of a reduced visits ANC package for low-risk women versus standard models of care. They suggested that a reduction in the number of antenatal visits was not associated with increases in maternal and neonatal outcomes and that the trials conducted in developed countries suggest that women may feel that their expectations of care were not fulfilled. However, evidence is scarce in view of women’s perceptions/satisfaction of ANC using telehealth processes (Ridgeway et al, 2015).

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