Randomised controlled trial of two antenatal care models in rural Zimbabwe

OBJECTIVE: To compare a five-visit antenatal care (ANC) model with specified goals with the standard model in a rural area in Zimbabwe. DESIGN: Cluster randomised controlled trial with the clinic as the randomisation unit. SETTING: Primary care setting in a developing country where care was provided by nurse-midwives. POPULATION: Women booking for ANC in the clinics were eligible. MAIN OUTCOME MEASURES: Number of antenatal visits, antepartum and intrapartum referrals, utilization of health centre for delivery and perinatal outcomes. METHODS: Twenty-three rural health centres were stratified prior to random allocation to the new (n = 11) or standard (n = 12) model of care. RESULTS: We recruited 13,517 women (new, n = 6897 and standard, n = 6620) in the study, and 78% (10,572) of their pregnancy records were retrieved. There was no difference in median maternal age, parity and gestational age at booking between women in the standard model and those in the new model. The median number of visits was four for both models. The proportion of women with five or less visits was 77% in the new and 69% in the standard model (OR 1.5; 95% CI 1.08-2.2). The likelihood of haemoglobin testing was higher in the new model (OR 2.4; 95% CI 1.0-5.7) but unchanged for syphilis testing. There were fewer intrapartum transfers (5.4 versus 7.9% OR 0.66; 95% CI 0.44-0.98) in the new model but no difference in antepartum or postpartum transfers. There was no difference in rates of preterm delivery or low birthweight. The perinatal mortality was 25/1000 in standard model and 28/1000 in new model. CONCLUSION: In Gutu district, a focused five-visit schedule did not change the number of contacts but was more effective as expressed by increased adherence to procedures and better use of institutional health care.