The Swedish routine program for antenatal care is based on a number of scheduled visits for the detection of symptomless complications, as well as psychosocial support and health education. The scientific evidence to support the present timing and contents of routine visits is unsatisfactory, and there is a great need for evaluation both of single diagnostic procedures and interventions and of programs of antenatal care.

In Britain, antenatal care is performed by specialist obstetricians, general practitioners (GPs), and midwives, often in combination. Because most women are delivered in specialist hospitals, obstetricians are involved in booking for place of delivery, and usually in delivery of specialized investigations such as ultrasonic scanning. General practitioners may independently book women for confinement under their care in Cottage Hospitals or (rarely) at home, and may provide all the medical care for those women, in addition to sharing in the antenatal care of women to be delivered at specialist units, and in fact doing most of the care for these women, unless they are very high risk or complicated.

Antenatal care was established in Norway during the 1930s. Unlike the other Nordic countries, care is provided by general practitioners, not be midwives. Guidelines were first issued in 1984 after a debate about the quality of the care. This article reports providers' compliance to important parts of the guidelines.

Swedish antenatal care is staffed by midwives working within the primary health care system, but with close collaboration with the hospital. The compliance to the program both from staff and mothers is very high, with 13.2 visits on average. There is a regional variation both in the number of visits and in the use of routine tests.

Antenatal care in Denmark is shared between general practitioners, midwives, and hospital departments. A minimum of 9 visits is officially recommended for all pregnant women. In 1987, 80% made 10 or more visits. An inadequate number of visits in relation to recommendations was most frequent in the lowest social group. Risk of stillbirth and neonatal death varied substantially between social groups even after taking account of number of visits made.

Antenatal care is evaluated based on observational trend studies, geographical comparisons, medical audits, and randomized trials. The last method is preferable and should be applied whenever feasible. Most components of antenatal care have not been properly evaluated. In order to evaluate an antenatal care program, a randomized study is suggested using geographical areas as units of randomization.

Many of the practices carried out during antenatal care improve the well-being of mother or baby and reduce the burden of adverse perinatal outcome. Other practices have either not been evaluated or have been shown to be ineffective. Evidence from randomized clinical trials provides the best evidence about the effectiveness of these practices.

The advantages and limitations of national registers containing individual identification numbers in clinical epidemiological research are reviewed. The author concludes that such registers are very valuable for epidemiological research and for formulation of research questions of public health importance.

Economic evaluations can be used to compare alternative antenatal care programs in terms of cost and outcome. The cost of routine antenatal care is small compared to the total cost associated with pregnancy and childbirth. The main problem in economic evaluations is related to outcome measurement.

Hypertension during pregnancy, defined as a diastolic blood pressure of at least 90 mm Hg, occurs in about 7% of Western countries. Primiparity and familial factors are the most important risk factors. Fifty percent of women experienced blood pressure elevation as late as the last month of pregnancy.

The literature dealing with screening for hypertension in pregnancy was reviewed. No level of blood pressure or any other factor provides a guarantee of no risk for the development of preeclampsia. However, higher blood pressure in early pregnancy and a failure to decrease blood pressure in midpregnancy are both associated with the development of preeclampsia. The development of proteinuria, rather than the level of blood pressure, is the best predictor of poor pregnancy outcome. Multiparas, especially those with severe chronic hypertension who develop preeclampsia, are at greatest risk of poor pregnancy outcome.

Standardized conditions for blood pressure measurements and strict definitions of systolic and diastolic blood pressure are essential for a consequent management of hypertension during pregnancy. In Sweden, it has been agreed to measure blood pressure with the pregnant women sitting in upright position. Home-monitoring of blood pressure is recommended in women at risk of preeclampsia.

Proteinuric hypertension is an important cause of maternal and perinatal mortality. Eclampsia cannot always be prevented. The likelihood of identifying a new case of proteinuric hypertension at any particular visit is very low using traditional antenatal care schedules, and care could be focused on women at higher risk.

The effect of various levels of both diastolic and systolic blood pressure at various times during pregnancy on the rates of intrauterine growth retardation (IUGR) and preterm delivery (PTD) were determined. Low systolic and diastolic pressures were associated with both IUGR and PTD, as were high pressures. Low pressures tended to be associated with spontaneous preterm deliveries, whereas high pressures were associated with more indicated preterm deliveries.

Maternal smoking during pregnancy is causally related to fetal growth retardation. Smoking more than doubles the risk for the birth of a small-for-gestational-age infant. About 30% of the Swedish pregnant population smoke in early pregnancy. Despite that practically all pregnant women in Sweden today are aware of the hazards of smoking, about 70% of the smokers continue to smoke during pregnancy. Women who continue to smoke during pregnancy differ in terms of socio-demographic characteristics from those who stop smoking during pregnancy.

Prevention of smoking in pregnancy is a mission of utmost importance since the fetal outcome is improved when the mother quits smoking. Methods to prevent smoking have to consider maternal attitudes and characteristics and be based on pedagogical and behavioral principles. A well-motivated staff, a self-help manual accepted by most women, and special support to those who want it are minimal requirements.

Among alcohol and narcotics, alcohol is most comprehensively documented as a teratogen. However, for all other narcotics, data are continuously accumulating, convincingly displaying the teratogenic effects. The proportions between “somatic” teratogenicity and “behavioral” teratogenicity vary between the different agents. Preventive work in prenatal clinics and among social workers, as well as objective mass media attention to the problem, seems to have lowered the incidence of severe fetal alcohol syndrome where the above-mentioned activities have been practiced. The female alcohol consumption in Sweden decreased from 1976 to 1985; thereafter, a slow continuous increase is underway again, in Sweden the number of recruits to narcotic abuse peaked in the 1970s and early 1980s. Thereafter, the number of recruits among females decreased, but abuse has continued among the members of the older age groups.

Alcoholism among women has increased during the last decades. Thus it is likely that an increasing number of pregnancies will involve risk of alcohol damage to the fetus. In this article, two antenatal programs are presented to identify pregnancies at risk. Adequate alcohol information seems to be sufficient for socially drinking women, whereas alcoholic women need extensive support to abstain from alcohol. The psychosocial support was not experienced as intrusive.

This article draws on social science evidence concerning the views and experiences of those using the antenatal services. It identifies several important themes in this evidence, including the need to consider pregnancy a normal process, to provide care that is sensitive to individual circumstances and that offers continuity of care throughout the antenatal period, and the obligation on providers to assess scientifically the effectiveness of the care they give.