Maternal and neonatal outcomes in a reduced visit antenatal care program for women at low risk for complications

Public healthcare operates with constrained resources, creating a need to reallocate capacity toward the growing population of pregnant women at high risk for complications. Therefore, a modified antenatal care program with a reduced number of in-person visits supplemented with telemedicine consultations was introduced for low-risk women in Southeast Sweden.

To evaluate whether a modified antenatal care program is non-inferior to a standard antenatal care program regarding maternal and neonatal outcomes.

A modified antenatal care program was evaluated at five antenatal care centers through a step-wedge cluster randomization design. The evaluation period extended from October 2020 to September 2024. Women at low-risk for complications were identified at gw 11-15 through comprehensive risk assessment, including risk of developing preterm preeclampsia using the Fetal-Medicine-Foundation method. The standard antenatal care program included eight in-person visits to a midwife and the modified antenatal care program comprised four in-person visits plus two telemedicine consultations. All women received two routine ultrasounds and standardized lifestyle counselling. The primary outcome was a composite of maternal outcomes (preterm birth, pregnancy-induced hypertension, preeclampsia, eclampsia and anemia). Secondary outcome was a composite of neonatal outcomes (Apgar <7 at 5 min, being small for gestational age or large for gestational age, and intrauterine fetal demise). Analyses followed the intention-to-treat principle, using logistic regression models adjusted for parity, education, and region of origin.

The study population included 5,374 women: 2,768 in the standard antenatal care program and 2,606 in the modified antenatal care program. The median number of in-person visits was 8 vs. 4 (p<0.001). No significant differences were found for the maternal composite (10.9% vs 10.5%, p=0.640) or neonatal composite (6.8% vs 6.8%, p=0.472) between the modified and standardized programs. The modified antenatal care program was associated with lower induction of labor rates (15.6% vs. 19.0%, p<0.001) and higher rates of spontaneous vaginal births (87.9% vs. 84.8%, p=0.001).

The modified antenatal care program with fewer in-person visits supplemented by telemedicine did not differ from standard care with respect to maternal and neonatal safety among women at low-risk for complications. Moreover, the modified antenatal care program was associated with fewer obstetric interventions and represented a safe and efficient alternative in a high-welfare healthcare setting.