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Antenatal care policies for low-risk pregnant women in high-income countries with a universal health system: a scoping review protocol

Goncalves, Andreia Soares1; Ferreira, Isabel Maria1; Pestana-Santos, Márcia1,2,3; Prata, Ana Paula4,5; McCourt, Christine6

Author Information
doi: 10.11124/JBISRIR-D-19-00197
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The previous century showed a dramatic improvement in maternal and perinatal outcomes as well as the care of women and babies in high-income countries where pregnancy, childbirth, and the neonatal period are monitored by qualified professionals.1 The challenges in these countries have shifted and currently the focus is on low birth rates, increased maternal age, infertility, obesity and other associated diseases, pre-term and low-birth-weight babies, the medicalization of normal pregnancy, and unnecessary interventions.1 Care in high-income countries has been described as “too much too soon.”2(p.2176) Excessive care, although well-intentioned, can be harmful, cost ineffective, and disrespectful towards women.2 Intervention often leads to further intervention, and there is good evidence supporting the association between unnecessary clinical interventions, which are not evidence based, and increased morbidity.3,4 Examples include routine cardiotocography, enemas, episiotomies, ultrasound examinations, as well as non-indicated inductions, cesarean sections, and augmentations.2 Routine use of unnecessary interventions is costly, wastes significant resources, and harms the health of populations, destroying human capital and reducing productivity.5

Optimal care should always avoid unnecessary interventions that risk harm.5 Although today more mothers’ and babies’ lives are saved than ever before, there is an increase in morbidity as well as short- and long-term disability that has implications at all levels: families, the health care system, and society as a whole.6,7 The World Health Organization (WHO) urges countries to expand their agendas to look beyond survival, with a view to maximizing the health and potential of their populations.5 Sustainable and adequate health policies are key to delivering the best possible care to a population, responding adequately to its changing needs.5

Some authors argue that the quality of perinatal care is not only influenced by health care expenditure, technology, and societal factors, but also by the organization of the health care system itself.8,9 An example of this is the United States of America, where, despite having some of the highest economic spending in maternity care in the world, it falls significantly behind the Organization for Economic Co-operation and Development (OECD) averages on important indicators of health-system performance such as maternal and neonatal mortality, pre-term births, and low-weight births.1

All over the world, the provision of antenatal care varies according to different health care and political realities, yet several examples have shown that the organization of health systems and models of care are paramount in the results obtained and can affect the health and well-being of women and their babies.10 As an example, a recent Cochrane review11 compared midwife-led continuity models of care with other models of care, such as doctor-led care models, and concluded that women cared for by midwives under this model are less likely to experience intervention and more likely to experience positive outcomes. Adverse outcomes, such as fetal or neonatal deaths, admissions to the neonatal unit, antepartum and postpartum hemorrhage, were comparable between the models, but the benefits in the midwife-led continuity models of care group exceeded the outcomes of other models of care. Women randomized to midwife-led continuity models of care were, on average, more likely to have spontaneous vaginal births, to not require intrapartum analgesia/anesthesia, and be attended to at birth by a known midwife. These women were also less likely to experience amniotomies, episiotomies, instrumental births, fetal loss before 24 weeks’ gestation, neonatal deaths, and pre-term birth before 37 weeks’ gestation. Other studies support these findings and conclude that midwife care for low-risk women is also more sustainable, carrying fewer costs.12,13 Given these additional benefits with no additional adverse outcomes, midwifery-led models of care, and in particular the continuity of care midwifery models, could help achieve normalization of pregnancy and childbirth practices as well as an improvement in morbidity outcomes such as prematurity and low-birth-weight babies.

Portugal is a high-income country where some practitioners are attempting to reduce unnecessary interventions and introduce guidance on normalization of pregnancy and childbirth practices.14-16 In a climate where sustainability of the national health service is a governmental concern and compromise17; where improvement of childbirth practices, and women's birth experience and outcomes are sought; and since pregnancy is a normal physiological process that should ideally require minimal intervention, it is pertinent to map key concepts of the current antenatal care guidance for low-risk women in Portugal and in countries with similar characteristics.16,18,19 In Europe and other high-income countries, there are still some perinatal health disparities that highlight both the need and opportunity for improvement.7 Are these discrepancies related to organization of care, and could countries learn from and with each other?

Previous research explored models of care (doctor versus midwife-led care),11,20 different packages of antenatal care (number of consultations and outcomes),21 characteristics of those care models that may result in improved outcomes for mothers and babies,10 and different interventions in antenatal care guidance.22 But to the authors’ knowledge, no other review has focused on mapping antenatal care policy, at a country level, from the published literature. An initial search of the JBI Database of Systematic Reviews and Implementation Reports, the Cochrane Library, MEDLINE, and CINAHL revealed no review of any type on this topic.

This review seeks to map the available evidence on the nature, extent, and range of antenatal care policies for low-risk pregnant women in high-income countries with a health care system founded on the Beveridge Model: a health system available to all citizens and financed by the government through tax payments. Ultimately, the outcomes of this review will inform future policy in antenatal care for low-risk women and help to identify if a different model of care could be an alternative to the Portuguese context.

Review questions

What are the antenatal care policies for low-risk pregnant women in high-income countries with a health care system founded on the Beveridge Model?

Additionally, the review will also address the following questions:

  • i) What are the characteristics of the antenatal care package for low-risk women in each country?
  • ii) How is the care organized for low-risk pregnant women in each country?
  • iii) Who provides care for low-risk pregnant women in each country?
  • iv) What evidence was used to inform the guidance in the field for low-risk pregnant women in each country?

Inclusion criteria


This review will consider documents that include policy or official guidance on antenatal care for low-risk pregnant women in high-income countries with a universal health system. For the purpose of this review, we will accept the definition from the National Institute for Clinical Excellence,23 which refers to low-risk pregnancy as “a normal physiological process”23(p.5) in healthy women who are not identified as having particular medical or obstetric factors that would require additional care.24,25


The concepts considered in this review are antenatal care policies and associated guidance such as guidelines and protocols. Antenatal care policies will be considered as any type of official document that aims to provide guidance on antenatal care for low-risk pregnant women in the given countries (see Context). This will include national policy documents, protocols, guidelines, and other published guidance.

We will explore the care pathways used by the countries, including the schedule of antenatal care (number of consultations and when), content of each consultation, professional providing care, setting (community or hospital setting), recommended antenatal screening (maternal and fetal), model of care, and whether recommendations are evidence-based (if available).


This review will cover countries with levels of health-financing systems comparable to Portugal. These will be defined as any high-income OECD country26 that cumulatively has a health-financing system founded on the Beveridge Model.27 The included countries will be: Australia, Denmark, Finland, Greece, Iceland, Ireland, Italy, New Zealand, Norway, Portugal, Spain, Sweden, and the United Kingdom.28

Type of sources

This scoping review will consider quantitative, qualitative, mixed method studies, and any type of study that describes official documents on antenatal care for the given country. National policy documents (policies, guidelines, protocols) will also be included. The following sources will be excluded: duplicate articles, opinion and news articles, articles without full text available, and articles that do not refer to official documents. Only the most recently published antenatal care documents will be accepted, and the search will restrict documents from 2005 to present to ensure the guidance has a certain level of currency. This date limit was set to ensure the search strategy was broad enough to capture the most recent policies from the targeted countries, and to exclude policies that might be outdated. No language restrictions will be applied as it is likely that the documents are written in the countries’ official languages. Authors will follow the normal procedure for translating a scientific document by sending it to accredited translators who are native speakers of the language of the given countries with knowledge in English.


The proposed scoping review will be conducted in accordance with JBI methodology.29 Methods for this review were developed based on Arksey and O’Malley's30 scoping review methodology with enhancement of Levac et al.31 and further developed by the JBI Reviewer's Manual for scoping reviews.29

Search strategy

The search strategy will aim to locate both published and unpublished documents. A three-step search strategy will be used in this review.29 First, an initial limited search of MEDLINE (via PubMed) and CINAHL was undertaken to identify articles on the topic. The text words contained in the titles and abstracts of relevant articles, and the index terms used to describe the articles were used to develop a full search strategy for MEDLINE via PubMed (see Appendix I). Second, the search strategy, including all identified keywords and index terms, will be adapted for each included information source. The reference lists of all studies selected will be screened for additional studies or to identify the official country documents/reports/guidelines. Third, a gray literature search for published policy documents will be undertaken. Relevant websites such as WHO, European Union official documents, ministries of health, and departments of health of the different countries will be searched. For the countries whose policies are not retrieved with the above steps, key persons at the health ministries or education/academia will be contacted and copies of the documents requested.

Information sources

The databases/information sources to be searched will include: CINAHL Plus with Full Text, Cochrane Central Register of Controlled Trials, and Academic Search Complete via EBSCOhost, MEDLINE via PubMed, Scopus via Elsevier, and JBI COnNECT+ via own platform.

The search for unpublished studies will include: Health Policy Reference Centre database, RCAAP–Repositório Científico de Acesso Aberto de Portugal, OpenGrey–System for Information on Grey Literature in Europe, WHO website, European Union official documents, and ministries of health and departments of health of the included countries.

Study selection

Articles and documents identified in the search will be uploaded into Mendeley citation manager (Mendeley Ltd., Elsevier, Netherlands) and the duplicates removed. Two independent reviewers will screen titles and abstracts against the inclusion criteria. The full text will be retrieved for all studies that meet the inclusion criteria. In the case of a disagreement between the two reviewers, a third reviewer will arbitrate. Reasons to further exclude full-text documents will be recorded and described in the scoping review report.

Data extraction

The final scoping review report will present the results of the search in full and will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA-ScR) extension for scoping reviews flow diagram.32

Data will be extracted from papers included in the scoping review using a data extraction form developed by the reviewers (see Appendix II). Key items include: author, year, country, type of document, objective, schedule of antenatal care, professional providing care, antenatal care setting, content of each consultation, recommended antenatal screening, evidence to support recommendations, and model of care (if available). The form will include additional space to allow the emergence of new key themes once the authors are more familiar with the information retrieved. The data extracted will include specific details about the population, concept, context, study methods, and key findings relevant to the review objective. The data extraction tool will be modified and revised as necessary during the process of extracting data from each included study. Modifications will be detailed in the full scoping review report. Any disagreements that arise between the reviewers will be resolved through discussion or with a third reviewer. Authors of papers will be contacted to request missing or additional data, where required.

Data presentation

Extracted data will be synthesized and presented in tabular or diagrammatic form in a manner that aligns with the objective of this scoping review. Narrative description will complement the charted results and will describe how the results answer the objectives and questions of this review. Assessment of study quality is not required for scoping reviews; however, as stated above, the authors aim to retrieve official policy documents.


Anna Martin Arribas and Francisco Vieira provided guidance in this scoping review protocol. Francisco Vieira helped write the search sentence and with the search strategy. Anna Martin Arribas is a senior colleague who provided guidance on the processes and tools to conduct a scoping review. This review contributes towards a PhD degree (ASG).


This research study is funded by Fundação para a Ciência e Tecnologia through a PhD scholarship.

Appendix I: Search strategy

Search strategy conducted on MEDLINE (via PubMed) on 10 February 2020

Appendix II: Data extraction form


1. Shaw D, Guise JM, Shah N, Gemzell-Danielsson K, Joseph KS, Levy B, et al. Drivers of maternity care in high-income countries: can health systems support woman-centred care? Lancet 2016; 388 (10057):2282–2295.
2. Miller S, Abalos E, Chamillard M, Ciapponi A, Colaci D, Comandé D, et al. Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide. Lancet 2016; 388 (10056):2176–2192.
3. Dahlen HG, Tracy S, Tracy M, Bisits A, Brown C, Thornton C. Rates of obstetric intervention and associated perinatal mortality and morbidity among low-risk women giving birth in private and public hospitals in NSW (2000 - 2008): a linked data population-based cohort study. BMJ Open 2014; 4 (e004551):
4. WHO. WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience: Summary Highlights and Key Messages from the World Health Organization's 2016 Global Recommendations for Routine Antenatal Care. 2018;10(1):1–10.
5. WHO, OECD, The World Bank. Delivering quality health services: a global imperative for universal health coverage [Internet]. 2018 [cited 9 Sep 2019]. Available from:
6. Sandall J, Tribe RM, Avery L, Mola G, Visser GH, Homer CS, et al. Short and long-term impacts/or effects of caesarean section on the health of women and children. Lancet 2018; 392 (10155):1349–1357.
7. EURO-PERISTAT Project with SCPE and EUROCAT. European Perinatal Health Report. The health and care of pregnant women and babies in Europe in 2010. [Internet]. 2013 [cited 19 Apr 2019]. Available from:
8. Austin A, Langer A, Salam RA, Lassi ZS, Das JK, Bhutta ZA. Approaches to improve the quality of maternal and newborn health care: an overview of the evidence. Reprod Health 2014; 11: (Suppl 2): S1.
9. Koblinsky M, Moyer CA, Calvert C, Campbell J, Campbell OMR, Feigl AB, et al. Quality maternity care for every woman, everywhere: a call to action. Lancet 2016; 388 (10057):2307–2320.
10. Symon A, Pringle J, Cheyne H, Downe S, Hundley V, Lee E, et al. Midwifery-led antenatal care models: mapping a systematic review to an evidence-based quality framework to identify key components and characteristics of care. BMC Pregnancy Childbirth. 2016;16(1):168.
11. Sandall J, Soltani H, Gates S, Shennan A, Devane D. Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Rev 2016; (4):CD004667.
12. Kenny C, Devane D, Normand C, Clarke M, Howard A, Begley C. A cost-comparison of midwife-led compared with consultant-led maternity care in Ireland (the MidU study). Midwifery 2015; 31 (11):1032–1038.
13. Redshaw M, Heikkila K. Delivered with care: a national survey of women's experience of maternity care 2010 [Internet]. [cited 5 May 2019]. National Perinatal Epidemiology Unit. University of Oxford. Available from:
14. General Health Directorate. [National Programme for Antenatal Care of Low Risk Women] [Internet]. 2015; Lisbon: General Health Directorate, [cited 02 May 2019]. Available from: Portuguese.
15. Marcelino C. Message from the Secretary of State for Citizenship and Equality. Born in Love - 1st Meeting of the Portuguese Association for the Rights of the Woman in Pregnancy and Labour. 2016; 1–2.
16. Ayres de Campos D, Furtado JM, Crisóstomo MR, Carrapato R, Cunha E, Conceição MF da. Measures to reduce the cesarean section rates in northern Portugal. Ministry of Health Northern Regional Health Area. Porto; 2010; 1–18.
17. Portugal Ministry of Health. [Commitment to sustainability and development of the National Health Service] 2016-2018 [Internet]. 2016 [cited 5 May 2019] Available from: Portuguese.
18. Cruz C, Marcelino C, Falcato Simões J, António Silva J. Parliamentary Hearing No 161-CS-XIII: [For the end of obstetric violence in the labour ward of the Portuguese hospitals] [Internet]. 2018 [cited 5 May 2019] Available from: Portuguese.
19. Portuguese Observatory of Health Systems. Halfway Walked: Spring Report. 2018; 188.
20. Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2008; (4):CD004667.
21. Dowswell T, Carroli G, Duley L, Gates S, Am G, Piaggio G, et al. Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane Database Syst Rev 2015; (7):CD000934.
22. Abalos E, Chamillard M, Diaz V, Tuncalp ö, Gulmezoglub A. Antenatal care for healthy pregnant women: a mapping of interventions from existing guidelines to inform the development of new WHO guidance on antenatal care. BJOG 2015; (123):519–528.
23. National Institute for Health and Care Excellence. Antenatal care for uncomplicated pregnancies [Internet]. 2008. [cited 10 Feb 2020]. Available from:
24. National Institute for Health and Care Excellence. Antenatal care for uncomplicated pregnancies. Appendix C: women requiring additional care [Internet]. 2008 [cited 10 Feb 2020]. Available from:
25. National Institute for Health and Care Excellence. Intrapartum care for healthy women and babies [Internet]. 2014 [cited 10 Feb 2020. Available from:
26. OECD. Doing Business 2019. OECD High Income [Internet]. 2019 [cited 6 May 2019]. Available from:
27. Kulesher RR, Elizabeth Forrestal E. International models of health systems financing. J Hosp Adm 2014; 3 (4):127–139.
28. Łyszczarz B. The effect of health care model on health systems’ responses to economic crises. Ekon i Prawo Econ Law 2016; 15 (4):493–501.
29. Peters MDJ, Godfrey C, McInerney P, Baldini Soares C, Khalil H, Parker D. Aromataris E, Munn Z. Chapter 11: Scoping reviews. JBI, JBI Reviewer's Manual [Internet]. Adelaide:2017.
30. Arksey H, O’Malley L. Scoping studies: towards a methodological framework. Int J Soc Res Methodol 2005; 8 (1):19–32.
31. Levac D, Colquhoun H, O’Brien K. Scoping studies: advancing the methodology. Implement Sci 2010; 5 (69):
32. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med 2018; 169 (7):467.

low-risk pregnancy; midwifery; policy; prenatal care

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