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It is estimated that over 1 billion people worldwide have a disability. In Australia, 9% of women of childbearing age have a disability, but data on disability status for women accessing maternity services are not routinely collected and data collection processes are inconsistent. Maternal disability may affect perinatal outcomes, but to understand what factors might be amenable to interventions to improve outcomes, accurate data collection on disability status is essential. This opinion piece reflects on disability identification within maternity services in Australia, identifying areas for policy and practice change. [ABSTRACT FROM AUTHOR]

Little is published on cytomegalovirus (CMV) serological screening at the first antenatal visit or the contemporary CMV seroprevalence rates among the Australian pregnant population. We performed a retrospective analysis of public hospital births in a major tertiary centre (n = 840) over a two month period. We found that 13.6% (95% confidence interval (CI) 11.4–16.1%) of women had been screened for CMV at their first antenatal visit with their general practitioner. Of these, 43.0% (95% CI 34.3–52.1%) were CMV seronegative and therefore susceptible to primary infection. Seronegative women were also more likely to have been born in an economically developed country, to live in a socio‐economically advantaged postcode and to be nulliparous. The information from this study may help guide future studies of congenital CMV risk reduction strategies. [ABSTRACT FROM AUTHOR]

Background: On 9 June 2021, the Australian Technical Advisory Group on Immunisation and Royal Australian and New Zealand College of Obstetricians and Gynaecologists recommended that pregnant women receive Comirnaty (Pfizer) messenger RNA vaccine at any stage of pregnancy. Aim: This multi‐centre study aimed to assess vaccine acceptance, reasons for hesitancy and determine if differences exist between health districts, to inform future policy strategies for COVID‐19 vaccination in pregnancy. Materials and methods: An online survey (developed based on the World Health Organization Behavioural and Social Drivers survey and modified for the pregnant population) was administered to a sample population of pregnant women attending antenatal clinics at two metropolitan hospitals (Westmead and Royal North Shore Hospital (RNSH)) in New South Wales between 15 September 2021 and 22 October 2021. Results: There were 287 pregnant women surveyed (Westmead 198 (69%), RNSH 66 (23%), no site 23 (8%)). There was a significantly lower Socio‐Economic Indexes for Areas score (5.66 vs 9.45, P = 0.001), fewer women born in Australia (37% vs 53%, P = 0.02) and higher number of children (0.77 vs 0.41, P = 0.01) among Westmead respondents. There was lower vaccination uptake (68% vs 86%, P = 0.01) and willingness to receive vaccine (68% vs 88% P = 0.01) at Westmead compared to RNSH. There was an increased proportion of respondents who were concerned that the vaccine could cause harm to the unborn baby at Westmead (38% vs 11%, P = 0.01). Conclusions: Along with healthcare provider recommendation for vaccination in pregnancy, materials should be targeted to specific safety concerns of pregnant women. [ABSTRACT FROM AUTHOR]

Background: The World Health Organization (WHO) recommends that antenatal care (ANC) commence before 12 weeks' gestation to reduce the risk of obstetric and perinatal complications. Immigrants, refugees, and asylum seekers are at higher risk for late or non‐initiation of ANC, and exclusion from universal healthcare (UHC) may be a contributing factor. Aims: The aims were to synthesise evidence regarding uptake of ANC and to examine if this is associated with inadequate access to UHC and to evaluate the link between ANC and the risk of pregnancy outcomes in the immigrant, refugee and asylum seeker population. Methods: The review was performed according to meta‐analysis of observational studies in epidemiology (MOOSE) guidelines. Five databases were systematically searched. Abstracts were screened against inclusion criteria, and eligible papers underwent data extraction by two independent reviewers per paper. The ROBINS‐I tool was used to assess risk of bias. Results: Twelve studies were included in the final review. All studies reported that ANC was delayed for women who were classified as immigrants, refugees, and asylum seekers as per the WHO recommendations, and this was statistically significant compared to controls in 11 of 12 studies (P < 0.05). Findings regarding ANC uptake and pregnancy complications were too heterogeneous to conclusively report an association. Conclusion: Immigrants, refugees and asylum seekers who are excluded from UHC present significantly later to ANC than receiving‐country‐born women with full access to UHC. The link between delayed ANC due to inadequate UHC access and pregnancy complications remains unclear due to the heterogeneous nature of the studies. [ABSTRACT FROM AUTHOR]

Background: Peripartum antibiotics are commonly administered. Little is known of the attitudes of pregnant women toward peripartum antibiotics. Aim: We aimed to assess the awareness of and attitudes toward peripartum antibiotic use in Australian women. Materials and Methods: We surveyed post‐partum women at three hospitals over six months. Women reported if they received antibiotics 48 h either side of delivery and responded to statements assessing attitudes to peripartum antibiotic use. Administered antibiotics were recorded. We reported the proportion receiving antibiotics and the proportion aware of receiving them. Participants responded on five‐point Likert scales and selected side effects of concern. Results: Participants responding were 248 of 299 (83%, Royal Brisbane and Women's Hospital), 56 of 106 (53%, Caboolture Hospital) and 17 (Redcliffe Hospital, denominator not recorded). Of 183 (57%) receiving antibiotics, 134 (73%) received them pre‐delivery only, 18 (10%) post‐delivery only and 31 (17%) pre‐ and post‐delivery. Pre‐delivery, the most common indication was pre‐incisional prophylaxis for caesarean delivery (93 of 160 responses, 58%). Seventy‐nine (51%, 156 responses) of those receiving pre‐delivery antibiotics were aware. Of 49 women receiving post‐delivery antibiotics, 36 (73%) were aware. Most agreed they were worried that pre‐delivery antibiotics would affect their baby (198, 62%) and 160 (50%) were concerned about effects on their own microbiome. Most (204, 65%) agreed they would rather not take antibiotics while breastfeeding. Conclusion: Many women were unaware of receiving pre‐delivery antibiotics. Most had concerns about side effects. Improved communication regarding peripartum antibiotic use would improve patient‐centred care. [ABSTRACT FROM AUTHOR]

Pregnancy is a risk factor for the development and progression of diabetic retinopathy (DR) in women with pre‐gestational diabetes. However, a minority of pregnant women with diabetes adhere to retinal screening recommendations. The introduction of an onsite retinal camera at our tertiary maternity hospital significantly increased the proportion of women who received at least one retinal screen during pregnancy (93.0% vs 54.3%, P < 0.001) and the identification of both DR and DR progression. We conclude that the use of a retinal camera in similar clinics is a feasible option to improve DR screening and diagnosis rates in pregnancy. [ABSTRACT FROM AUTHOR]

Background: Severe maternal morbidity (SMM) occurs in 1–2% of pregnancies. Despite the knowledge that a SMM event can contribute to poor fetal/neonatal outcomes, little is known about the preventability of these adverse outcomes. Aims: To examine adverse fetal/neonatal outcomes associated with SMM to determine if these outcomes were potentially preventable. Materials and Methods: A New Zealand national retrospective cohort study examining cases of SMM with an adverse fetal/neonatal outcome. Maternity and initial neonatal care were explored by multidisciplinary panels utilising a preventability tool to assess whether the fetal/neonatal harm was potentially preventable. Adverse fetal/neonatal outcomes were defined as fetal or early neonatal death, Apgar score <7 at five minutes, admission to neonatal intensive care unit or special care baby unit and neonatal encephalopathy. Results: Of 85 cases reviewed, adverse fetal/neonatal outcome was deemed potentially preventable in 55.3% of cases (n = 47/85). Preventability was related to maternal antenatal/peripartum care (in utero) in 39% (n = 33/85), to initial neonatal care (ex utero) in 36% (n = 29/80), and to both maternal and neonatal care in 20% (16/80) of cases. Main contributors to potential preventability were factors related to healthcare providers, particularly lack of recognition of high risk, delayed or failure to diagnose, and delayed or inappropriate treatment. Conclusions: Multidisciplinary panels found that over half of adverse fetal/neonatal harm associated with SMM was potentially preventable. The novel approach of examining both maternal and neonatal care identifies opportunities to improve fetal/neonatal outcomes associated with SMM at multiple points on the perinatal continuum of care. [ABSTRACT FROM AUTHOR]

COVID‐19 has resulted in unprecedented changes to maternity care across Australia. This study aims to analyse trends in maternity consultations and the uptake of telehealth in Victoria and New South Wales (NSW) since the first restrictions to reduce COVID‐19 transmission were implemented. From March 2020 to April 2021, a higher proportion of antenatal care consultations was delivered via telehealth in Victoria compared to NSW (13.8% vs 7.4%, P < 0.0001). Uptake of telehealth and a shift from in‐person care has been a major contributor to maintaining pregnancy care during pandemic restrictions. However, further research is required to understand women's perspectives and health outcomes. [ABSTRACT FROM AUTHOR]

In this clinical review we highlight aspects of the diagnosis and management of pulmonary embolism (PE) in pregnancy and post‐partum and how this may impact on antenatal and postnatal management. Investigation for PE in pregnancy is challenging and includes appropriate patient selection and knowledge of the risks and benefits of pulmonary imaging modalities. The complete Society of Obstetric Medicine of Australia and New Zealand Position Statement on Pulmonary Embolism in Pregnancy and Post‐Partum comprehensively reviews all aspects of diagnosis, investigation and management and is accessible at https://www.somanz.org/guidelines.asp. It includes a summary of all recommendations and a guide to developing a management plan for birth in women on anticoagulation. [ABSTRACT FROM AUTHOR]

Background: Timely detection of small for gestational age (SGA) fetuses is important for reducing severe perinatal morbidity and mortality, and better tools are needed to detect SGA in maternity care. Aim: We evaluated the effect of the introduction of the Perinatal Institute's Growth Assessment Protocol (GAP) in the Counties Manukau Health region, South Auckland, New Zealand, on antenatal detection of SGA and maternal and perinatal outcomes. Materials and Methods: Uncontrolled before and after study in women booked under hospital community midwife care with a singleton, non‐anomalous pregnancy. Antenatal detection of SGA (birthweight <10th customised centile) was compared pre‐GAP (2012, N = 1105) and post‐GAP (2017, N = 1082). Composite adverse neonatal outcome was defined as neonatal unit admission >48 h, five‐minute Apgar score <7, and/or any ventilation. Analyses were adjusted for maternal age, body mass index, deprivation, smoking and ethnicity. Results: SGA rates were similar across epochs (13.8% vs 12.9%) but antenatal detection of SGA increased from 22.9% (35/153) to 57.9% (81/140) post‐GAP (adjusted odds ratio (aOR) = 4.8, 95% CI 2.82–8.18). Rates of induction of labour and caesarean section increased between epochs but were similar in SGA, non‐SGA, and detected and non‐detected SGA subgroups. Among SGA babies, there was some evidence that antenatal detection of SGA may be associated with lower composite adverse neonatal outcome (detected SGA: aOR 0.44 95% CI 0.17–1.15; non‐detected SGA: aOR = 1.81 95% CI 0.73–4.48; interaction P = 0.03). Pre‐term birth did not appear to be influenced by GAP. Conclusion: Implementation of GAP was associated with a nearly five‐fold increase in SGA detection without increasing obstetric intervention for SGA. [ABSTRACT FROM AUTHOR]

Background: Haemoglobinopathies represent the most common single gene disorder worldwide; however, significant centre to centre variations in antenatal screening practices exist. Aims: To assess performance of a selective antenatal haemoglobinopathy screening policy within a presumed low‐prevalence Australian population. Primary outcome was the failure to screen rate for women with at least one identifiable risk factor. Secondary outcomes included outcomes of maternal screening and rates, gestations and outcomes of paternal, prenatal and neonatal testing. Materials and methods: A two‐year retrospective cohort study identifying all women attending for public antenatal care with at least one identifiable risk factor for haemoglobinopathy. Results: At least one risk factor for haemoglobinopathy was identified in 8.8% of the entire pregnant cohort; however, the failure to screen rate was high at 83.7% overall. Screening was significantly more likely to be undertaken in multiparous women, those with multiple risk factors and women originating from the Middle East. Twenty percent of screened women returned an abnormal result; however, this led to paternal haemoglobinopathy screening in only 66.6%. Where completed, the addition of partner screening reclassified offspring to low‐risk status in 85.7% of cases. Conclusions: This study demonstrates an 83.7% screen failure rate within a selective screening model raising concerns regarding the clinical utility and health equity of this approach. This major drawback of selective screening suggests that institution of a universal antenatal screening system for haemoglobinopathies, even in anticipated low‐prevalence areas, will improve detection rates and ensure families receive appropriate and timely counselling. [ABSTRACT FROM AUTHOR]

This is the full version of the Australasian Diabetes in Pregnancy Society (ADIPS) 2020 guideline for pre‐existing diabetes and pregnancy. The guideline encompasses the management of women with pre‐existing type 1 diabetes and type 2 diabetes in relation to pregnancy, including preconception, antepartum, intrapartum and postpartum care. The management of women with monogenic diabetes or cystic fibrosis‐related diabetes in relation to pregnancy is also discussed. [ABSTRACT FROM AUTHOR]

Background: Excess gestational weight gain is associated with adverse pregnancy outcomes. Addressing barriers to the provision of best practice care that supports healthy pregnancy weight gain could assist staff in clinical care; however, little is known about changes to staff practices after ameliorating barriers. Aims: To evaluate if service initiatives to promote healthy pregnancy weight gain improve weight‐related documentation by antenatal staff throughout pregnancy care. Materials and Methods: Service initiatives including staff training, familiarisation with a pregnancy weight gain chart and placement of scales in clinic rooms were introduced. Pregnancy health records were audited for deliveries pre‐ (2014) and post‐implementation (2017) to obtain weight‐related measures. Measures assessed included the documentation of pre‐pregnancy weight, height, pre‐pregnancy body mass index (BMI), referral to dietetic services (if overweight) and the accuracy of pre‐pregnancy BMI calculation. The proportion of visits with weight recorded during pregnancy was also audited. Results: A total of 1003 and 1050 records were included from the pre‐ and post‐intervention groups respectively. Significant improvements over time were observed in the documentation of pre‐pregnancy weight (P < 0.001), BMI (P < 0.001), accuracy of BMI calculation (P < 0.001) and for obese women proportion of visits with weight recorded (P = 0.02). There was a non‐significant increase in the documentation of dietetic referral for overweight women (1.1% vs 2.2%, P = 0.27) and proportion of visits with weight recorded for women across all pre‐pregnancy BMI groups (49% vs 51%, P = 0.07). Conclusions: Addressing barriers to supporting healthy pregnancy weight gain through service‐wide initiatives may improve weight‐related documentation by antenatal staff. [ABSTRACT FROM AUTHOR]

This retrospective study assessed maternal and perinatal outcomes for women with rheumatic heart disease (RHD) admitted to the largest tertiary obstetric hospital in Western Australia from 2009 to 2016. Of 54 women identified, 75.9% were Indigenous, 59.3% lived in rural areas and 40.7% had severe RHD. Heart failure developed in 10% who gave birth. Indigenous women were younger, had higher gravidity (P = 0.0305), were more likely to receive secondary prophylaxis (P = 0.0041) and have sub‐optimal antenatal clinic attendance (P = 0.0078). There were no maternal deaths and two perinatal deaths (4.0%), reflecting vigilance in the obstetric management of women with RHD in Western Australia. [ABSTRACT FROM AUTHOR]

SOMANZ (Society of Obstetric Medicine Australia and New Zealand) has written a guideline to provide evidence-based guidance for the investigation and care of women with sepsis in pregnancy or the postpartum period. The guideline is evidence-based and incorporates recent changes in the definition of sepsis. The etiology, investigation and treatment of bacterial, viral and non-infective causes of sepsis are discussed. Obstetric considerations relevant to anaesthetic and intensive care treatment in sepsis are also addressed. A multi-disciplinary group of clinicians with experience in all aspects of the care of pregnant women have contributed to the development of the guidelines. This is an executive summary of the guidelines. [ABSTRACT FROM AUTHOR]

Background New Zealand ( NZ) has a unique choice-based model of maternity care. Aims To examine how engagement in antenatal care and choice of Lead Maternity Care provider ( LMC) vary with maternal demographics. Materials and Methods Our sample consisted of 6822 women enrolled during 2009 and 2010 into a longitudinal cohort study Growing Up in New Zealand. We asked if women had engaged a LMC, the type of LMC and whether they had a choice of LMC. Associations with maternal ethnicity, age, parity and education and household deprivation were determined. Results Ninety-eight per cent of women had engaged a LMC provider. Twelve per cent reported not experiencing choice and 11% not receiving their first choice of LMC provider. The reported LMC provider type was independent midwife (66%), hospital midwife (15%), private obstetrician (8%), shared midwife and general practitioner ( GP) (5%) and GP-only care (<1%). LMC provider type and choice varied with maternal demographics. Women not engaging a LMC were more likely to be non-European, <20 years or >40 years old, with poorer educational attainment, or living in more deprived households. Women not experiencing choice of provider were more likely to be non-European, <20 years old, or living in more deprived households. Conclusions The current unequal distribution of provider engagement and choice in NZ has relevance for a number of specific maternity policies, including policies seeking to improve engagement in antenatal care. The study findings have international relevance as an example of the impact of choice policies on equity. [ABSTRACT FROM AUTHOR]

Background Timely engagement in antenatal care improves maternal and child health outcomes and is an important element of healthcare performance measurement. Aims To describe the timeliness of lead maternity carer ( LMC) engagement and identify the factors associated with timely engagement. Materials and Methods The Growing Up in New Zealand longitudinal study enrolled a diverse sample of pregnant women during 2009 and 2010. Timely engagement was defined as before ten weeks gestation. Independent associations of LMC type; maternal ethnicity, age, parity and education, and household deprivation with timely engagement were described using odds ratios ( OR) and 95% confidence intervals ( CIs). Results Of the 6822 women enrolled, 6661 (98%) stated they had a LMC. Of these 6661, 6012 (90%) reported the time taken to engage a LMC. Eighty-six to 92% of women engaged a LMC in a timely manner depending upon the estimate of gestational time used. Factors independently associated with delayed engagement were Māori (odds ratio ( OR) = 0.59, 95% CI 0.44-0.80), Pacific (0.63, 0.46-0.86) or Asian (0.51, 0.39-0.67) ethnicity; first pregnancy (0.71, 0.58-0.88); age <20 years (0.62, 0.41-0.94); socio-economic deprivation (0.69, 0.52-0.92); and LMC type being a hospital midwife (0.47, 0.38-0.60), or a combination of care providers (0.60, 0.42-0.90). Conclusions Timeliness of LMC engagement in NZ is poorer for non-European women, younger women, women in their first pregnancy, and women living in more socioeconomically deprived areas. Improving the timeliness of LMC engagement for these groups of women has the potential to reduce inequalities in maternal and child health outcomes. [ABSTRACT FROM AUTHOR]

Background Pregnant women have been identified as high users of complementary and alternative medicine (CAM). However, no research to date has provided a detailed analysis of the prevalence and determinants of CAM consumption amongst pregnant women. Aim To examine the prevalence and determinants of CAM use by pregnant women, utilising a national representative sample. Methods The study sample was obtained via the Australian Longitudinal Study on Women's Health. This paper is based on a sub-study of 1,835 pregnant women, administered in 2010. The women answered questions about CAM use, demographics, pregnancy-related health concerns and health service utilisation. Results Complementary and alternative medicine use was found to be high with 48.1% ( n = 623) of pregnant women consulting a CAM practitioner and 52.0% ( n = 842) of women using CAM products (excluding vitamins and minerals) during pregnancy. CAM practitioner visits were more likely for selected pregnancy-related health concerns, namely back pain or back ache, neck pain and labour preparation. Women were less likely to consult a CAM practitioner if they suffered with headaches/migraines. Employment was also found to be predictive of pregnant women's visits to a CAM practitioner. Significant health history and demographic predictors of CAM product use were tiredness and fatigue, embarking on preparation for labour and having a university education. Conclusion Most pregnant women are utilising CAM products and/or services as part of their maternity care and obstetricians, general practitioners and midwives need to enquire with women in their care about possible CAM use to help promote safe, effective coordinated maternity care. [ABSTRACT FROM AUTHOR]

Background: The Winnunga Nimmityjah Aboriginal Health Service Aboriginal Midwifery Access Program (AMAP) was established in 2001 to provide antenatal care, birth support and postnatal care to clients in the Australian Capital Territory (ACT). Aim: To describe the uptake and impact of AMAP services on access to antenatal care, behavioural risk factors and pregnancy outcomes and to compare the characteristics of AMAP clients with other women giving birth in the ACT. Methods: A descriptive study of medical records for AMAP clients who gave birth in 2004-2008. Outcome measures: maternal and baby characteristics, antenatal visits, behavioural risk factors and complications. Characteristics of AMAP clients were compared with the ACT Maternal and Perinatal Collection. Results: Of 187 women, 11.2% were aged <20 years, 50.3% presented in the first trimester and 94.7% attended five or more antenatal visits. Of 193 babies, 17.1% were born preterm and 18.1% had low birthweight. Compared with the ACT Maternal and Perinatal Collection, Aboriginal and Torres Strait Islander AMAP clients had a higher smoking rate (63.8 vs 49.0%), a lower caesarean delivery rate (20.0 vs 27.6%), a slightly lower proportion of preterm babies (18.8 vs 21.6%) and a slightly lower proportion of low-birthweight babies (18.8 vs 21.0%). Conclusions: Aboriginal Midwifery Access Program provides high-quality antenatal care in a trusted environment. The high rate of smoking in pregnancy needs to be addressed. [ABSTRACT FROM AUTHOR]

Background: Recent policy debates about the challenges facing maternity services in Australia provide an opportunity to reflect on current care practices. Aims: To identify the provision of primary maternity care models in two Australian states: South Australia (SA) and Victoria. Methods: All public and private hospitals with maternity facilities in SA and Victoria were mailed a survey requesting information about the organisation and provision of maternity care. Results: All hospitals in SA (35) and 99% (75/76) in Victoria completed the survey. Among public hospitals, approximately 50% (14/30 in SA and 29/56 in Victoria) reported primary care arrangements where all antenatal care is provided by medical practitioners working in the community. The vast majority of hospitals offering this type of care were located outside metropolitan areas. Twenty per cent of public hospitals in SA (6/30) and 36% in Victoria (20/59) reported offering primary midwifery models, such as team, caseload and/or birth centre care. In SA, hospitals offering these models were located in both metropolitan and regional areas. In Victoria, 60% of hospitals offering women primary midwifery care were large hospitals with more than 1000 births per annum. Conclusions: This study shows that community-based medical practitioners, general practitioners in particular, are major providers of maternity care despite the emergence of primary midwifery models of care. With 25% of the population living outside metropolitan areas in both states, providing access to choice and continuity of care for women living in regional and rural areas will be a challenge for maternity reform. [ABSTRACT FROM AUTHOR]

Background: Shared maternity care is an important model of care in Australia and overseas, but Victorian studies have shown patient dissatisfaction and widespread communication problems. Aims: This study aimed to implement and evaluate initiatives to improve communication between three maternity hospitals and general practitioners involved in shared maternity care in Melbourne. Methods: A pre- and post-design with audit of 150 hospital records at each of three hospitals plus audit of 20 general practitioner files for evidence of key communications on shared care patients, before and after a multifaceted intervention. Results: Significant improvements at individual hospitals were seen if one person was made responsible for a communication outcome. Other initiatives did not lead to improvements if they did not include individual accountability. Conclusion: The standard of integration of shared maternity care is unacceptable low. Improvements to communication are achievable but depend on the allocation of individual time and responsibility, plus a commitment by hospitals to ongoing audit of their performance. [ABSTRACT FROM AUTHOR]

To examine reasons for women not accessing antenatal care, and subsequent pregnancy outcomes for this group of women. Retrospective observational study between 1992 and 2001. Large public provincial referral obstetric unit. A total of 226 of 16 176 women (1.4%) who gave birth had not accessed antenatal care in the index pregnancy. The women who did not access antenatal care were more likely to be highly parous or young, indigenous, and users of alcohol than the women who did access antenatal care; women who lived in remote communities and women who significant medical conditions complicating their pregnancy were less likely to default on antenatal care. The women who did not access antenatal care had a higher incidence of preterm birth and post-partum haemorrhage; their babies were more likely to be of low birthweight, to be born with 5-min Apgar scores less than 5, and had a higher incidence of perinatal death. Lack of antenatal care is associated with a significant number of poor pregnancy outcomes, which are not explained by the basic epidemiological characteristics of women. As the women not accessing antenatal care tend to be from the most disadvantaged or marginalised groups in our society, a better understanding of their reasons for not accessing antenatal care is necessary so that care options can be provided which this high-risk group of women may find acceptable and use. [ABSTRACT FROM AUTHOR]

Do extra outpatient visits, in addition to regularly scheduled visits, identify a pregnancy at risk of an adverse outcome? This prospective investigation analysed additional outpatient visits, by low-risk obstetric patients. One hundred and sixty-two women were evaluated with one to two additional visits and 66 had three or more visits. Antepartum and intrapartum pregnancy complications between groups was similar suggesting that frequency of additional visits does not identify a pregnancy at risk for an adverse outcome. [ABSTRACT FROM AUTHOR]