The pattern of antenatal care in the United Kingdom was originally laid down in a Report from the Ministry of Health in 1929. It stated that women should be seen every fortnight from 28 weeks of pregnancy and then weekly from 36 weeks until the baby was born. It is a pattern still familiar to many currently practising midwives. However, this regimented pattern of care was challenged by Hall et al (1980) who concluded that the detection of asymptotic problems during routine antenatal care was low and that the number of visits for low-risk women could bc considerably reduced. Sikorski et al (1996) conducted a randomized controlled trial comparing traditional care (13 visits) with ‘new style’ care (seven visits). The results demonstrated that in reality there was less difference between the mean number of visits that women actually received than anticipated (10.8 visits compared with 8.6 in the study group). They evaluated both clinical outcomes and client satisfaction. No statistical significance was found between clinical outcomes but women were more dissatisfied if they had fewer visits as they valued regular contact with professionals. Midwives also have some reservations about reduced schedules of care, in particular regarding the detection of raised blood pressure and in relation to developing a relationship with the woman (Sanders et al 1999). In a Swedish study (Hildingsson et al 2002) women preferred more antenatal visits if it was their first pregnancy or if they had a previous negative reproductive experience. Older women and those with more than two children preferred fewer visits. The World Health Organization (WHO) has taken a proactive stance regarding the scheduling of antenatal care. In a multi-centre trial involving 24678 women, a model comprising a screening checklist and a basic package of four antenatal visits was implemented and evaluated (Villar et al 2001). The content of each visit was also specified and outcomes revealed minimal differences between the study and control groups for maternal, fetal and neonatal outcomes (Villar & Bergsjo 2002). The conclusions of this trial are supported by a systematic review of antenatal care for low-risk pregnancies (Villar et al 2008) which again highlighted that maternal satisfaction is often diminished when contact with health professionals is reduced.

Schedules of antenatal care vary between individual Trusts, consultants, midwives and women. Although a general ideal pattern may be part of written guidance for practice, it is appropriate that care reflects the individual needs of women. Since 2003, national guidance has recommended seven antenatal appointments for multiparous women and 10 for primiparous women (NICE 2003; NICE 2008).

Women will have their own expectations in relation to what antenatal care can do for them. For example, Hildingsson et al (2002) in their study involving 3061 women, reported that women had high expectations of antenatal care in relation to preventing fetal morbidity. Women need to receive realistic information about the care they receive and what the limits of reproductive technologies are.

Midwives are the experts in the provision of antenatal care for low-risk women:

This care is often delivered in partnership with either a GP or an obstetrician. The maxim of the government policy document Maternity matters (Department of Health 2007a) is that ‘all women need a midwife and some need doctors too’ (p. 15). However, the role of the midwife as the lead professional for women with uncomplicated pregnancies has been recognized (Department of Health 1993, Department of Health 2007a), if not universally adopted. There is also a move to ensure that all women have access to a midwife as the first point of contact when she confirms her pregnancy (Department of Health 2004, Department of Health 2006, Department of Health 2007a, Department of Health 2007b). Community midwives generally provide the majority of antenatal care to women with uncomplicated pregnancies. This care usually takes place in community health centres or GPs’ surgeries and increasingly in children’s centres. Within most maternity systems there are midwives who work mostly either in the hospital or community setting, although some work across both primary and secondary care. Some midwives work independently from the National Health Service (NHS) and are employed by women for a fee, usually fixed. Women who are able to access the services of an independent midwife can then expect continuity of care from a known carer.

Hospital midwives provide care for women attending antenatal clinics for specialist tests and investigations or for monitoring of high-risk pregnancies. Clinics, where consultants from a range of specialisms attend, provide care for pregnant women who also have underlying medical problems. Some hospitals have antenatal day care units where women can attend for assessment and care, without having to stay in hospital. Inevitably a minority of women will need to stay in hospital at some point during their pregnancy and midwives work with obstetricians to plan care that meets their unique needs.

Most women go to their GP when they suspect they are pregnant. Redshaw et al (2007) reported that 83% of respondents presented at their GP when first pregnant and 13% to a midwife. The GP then usually refers the woman to a hospital consultant or the community midwife attached to the practice. However, the continued input of GPs into antenatal care is variable. Research undertaken by Battersby & Thomson (1997) found that no clear parameters emerged when GPs were asked to describe their role in antenatal care. Some maintain or develop a strong interest in obstetrics and continue to see women, perhaps alternating with the midwife, throughout the woman’s pregnancy. GPs are uniquely placed to offer care for women and their families over a number of years rather than just a few months (Sikorski et al 1995). However, different priorities, perspectives and geographical locations can contribute to fragmented or duplicated services (Marsh & Renfrew 1999; Renfrew et al 2008).

Although many women are booked under a particular consultant for their obstetric care, it is unlikely that they will receive much direct care from them, unless they have a high-risk pregnancy. Consultant obstetricians usually have a team of doctors working with them at varying levels of obstetric training, who assist with the management of such women’s care. Some consultants also work in private practice.

As technology advances, more women are becoming pregnant who would previously have remained childless. Conditions such as cystic fibrosis, diabetes and cardiac anomalies now complicate pregnancies that hitherto would not have been conceived. The care of such women needs to be closely coordinated and monitored and will require a plan of action that involves senior professionals including, for example, paediatricians, anaesthetists and intensive therapy staff. Care is provided in joint clinics where specialists and obstetricians can work together to provide coordinated woman-centred care.

Some women will benefit from the additional services provided by social workers, particularly those women whose social circumstances are complicated by poverty, abuse and disadvantage. Such vulnerable women may include: teenage parents, homeless women, victims of domestic violence and substance misuse. It is particularly important that their care is carefully coordinated and that they have a named midwife who has an in-depth insight into their unique history and personal challenges.