Table 4.

Studies evaluating programmes provided as an adjunct to comprehensive antenatal care

Study/ Country	Setting	Target population	Study design	Intervention
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.