Is antenatal care apportioned according to obstetric risk? The Scottish antenatal care study

A retrospective cohort study of case records of antenatal care was carried out to describe and compare antenatal services in Scotland according to type of hospital and risk category of women. The study took place at 15 randomly selected maternity hospitals which were divided into teaching hospitals (n = 5), rural catchment hospitals (n = 2), and district general hospitals divided by size as those with 1000-1699 deliveries per year (n = 4), and those with > or = 1700 deliveries per year (n = 4). The subjects were 3574 (87.7 per cent) of 4069 eligible women who delivered in the last quarter of 1989 at these hospitals. Of those 3574, 19 per cent (675) were considered to be high risk at booking, 64 per cent (2899) continued low risk throughout their pregnancy and the remaining 17 per cent (608) changed from low risk to high risk during pregnancy. The main outcome measures were the number, timing, location and supervision of antenatal visits and antenatal admissions in relation to hospital types and obstetric risk categories, and adverse pregnancy outcomes in relation to risk categories. It was found that 97 per cent of all women had care shared by general practitioner (GP) and hospital specialist agreement. The majority (64 per cent) of antenatal visits took place away from the hospital of delivery, with GPs responsible for the largest proportion of all antenatal visits (43.5 per cent) compared with specialist hospital doctors (36 per cent) and midwives (11.5 per cent). Wide variations in the use of different personnel groups to deliver antenatal care were observed between hospitals, particularly in the use of midwives to supervise visits (4-34 per cent). The median number of antenatal visits was 14 (mean 13.9, SD 3.9). Within hospital types the differences in the mean number of antenatal visits between the three risk categories were small (one to two visits) and the direction inconsistent. In all types of hospital, outset high-risk women and those who changed to high risk were more likely to have hospital admission than those who continued as low risk. Significantly more women in the high-risk categories experienced adverse pregnancy outcomes than women who continued at low risk.(ABSTRACT TRUNCATED AT 400 WORDS)