Table 4 Studies evaluating programmes provided as an adjunct to comprehensive antenatal care

a) Interventions aimed at socioeconomically disadvantaged women

Home visiting

Kafatos, 1991/Greece

Rural primary health

care clinics in

Florina, a

socioeconomically

disadvantaged rural

region in Northern

Greece.

Women living in a

socioeconomically

disadvantaged

rural area

Cluster

randomised

controlled

trial

An outreach health education/counselling service provided by nurses

attached to rural primary health clinics. Women receive regular

(fortnightly) nurse home visits with an emphasis on nutritional

counseling covering food sources and the methods for selecting a

balanced diet; instruction in practical techniques to improve the

quality of the woman's diet including selection of foods with a high

nutrient value and preparation/preservation techniques to reduce the

loss of nutrients). Other themes covered during pregnancy included

general hygiene, preparation for delivery, breastfeeding and care of

the newborn. Home visits continued after delivery until the infant

was 12 months old; these visits focused on infant health topics.

Kitzman, 1997/USA

Public system of

obstetric care,

Memphis,

Tennessee.

Predominantly African-

American, low-income

women with multiple

socio-demographic risk

factors (unmarried,

unemployed and/or less

than 12 years education)

Randomised

controlled

trial

A programme based on the 'Elmira'/Family Nurse Partnership model.

The antenatal aspect of the interventions (which also includes

post natal home visits) involves an average of 7 home visits

focusing on improving health-related behaviour (nutrition,

smoking, alcohol and illegal drug use). Women are also taught

to recognize the signs and symptoms of pregnancy complications

and to act appropriately if these occur; and attention is paid

to compliance with treatment and to urinary tract infections

(UTIs) and sexually transmitted diseases (STDs).

Maternity care co-ordination

Buescher,

1991/USA

Services for Medicaid

eligible women, North

Carolina.

Low-income women

Retrospective

cohort

study

The care coordinators help Medicaid-eligible women receive services

and also provide to provide social and emotional support. The

programme includes outreach, to help women apply for Medicaid,

assessment (psychosocial, nutritional, medical, educational and

financial), service planning (development of an individualized plan

and provision of assistance to access services), coordination and

referral, follow up and monitoring and education and counselling.

b) Interventions aimed at or evaluated in socioeconomically disadvantaged women with additional risk factors for PTB/LBW

Home visiting/telephone support

Bryce,

1991/Australia

Three public hospital

antenatal clinics in

Perth and the offices

of 87 obstetricians

and general

practitioners in

western Australia.

Women with a prior PTB or

other specified risk

factors for adverse

pregnancy outcome.

Intervention not

restricted to

socioeconomically

disadvantaged women but

stratified analysis of

intervention effect by

social class reported

Randomised

controlled

trial

Higher-risk women receive home visits from midwives at roughly

4-6 weekly intervals (more frequently if requested by the woman)

with intervening telephone calls. The midwives provide expressive

support ("empathy, understanding, acceptance, ...") and are

instructed to provide instrumental support ("information, advice

and material aid") only on request. Physical antenatal care is

provided only in an emergency.

Moore, 1998/USA

Public health clinic,

Winston-Salem,

North Carolina

Low-income African-

American women and

low-income white

women with

additional risk

factors for PTB

Randomised

controlled

trial

Higher-risk women receive a booklet and additional instruction about

the signs and symptoms of preterm labour followed by three scheduled

nurse phone calls per week. Each call includes an assessment of health

status ("perception of uterine contractions and other pregnancy

changes, color of urine as an assessment of hydration, number of

meals eaten, number of cigarettes smoked, alcohol and drug use, and

ingestion of a prenatal vitamin capsule on the previous day");

recommendations based on the assessment; and a discussion of any

additional issues important to the mother

Oakley 1990/UK

Four hospital

antenatal clinics

Disadvantaged,

predominantly

'working class'

women with a prior

LBW birth.

Randomised

controlled

trial

A structured social support intervention consisting of a minimum of

three antenatal home visits at 14, 20 and 28 weeks, plus two

telephone contacts. Midwives engage in a semi-structured, open

ended discussion with mothers on topics of the mother's choice;

the midwives provide advice or information only if requested and

do not provide clinical care (but may refer a mother for care if

required)

c) Interventions evaluated in other vulnerable/at risk groups

Higgins Nutrition Intervention Program

Dubois,

1997/Canada

Subjects recruited

from 15 Montreal

area hospitals but

location/setting

of the Montreal

Diet Dispensary

unclear.

Pregnant adolescents

Retrospective

cohort

study

A nutritional programme delivered by trained dieticians as an adjunct

to routine antenatal care. The programme has four elements:

assessment of risks for the pregnancy; determination of an

individualized "dietary prescription"; teaching of food consumption

patterns that meet the individual's requirements while respecting

pre-existing food habits; and follow-up and supervision by the same

dietician at 2-week intervals.