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Antenatal care in the European Union


National guidelines on antenatal care in the European Union: A survey of content and methodological rigour





In 2004, a survey documented and compared the content of national guidelines on antenatal care (1, 2). This study found a marked difference between guidelines from states with a gross national product above average and those states with a more restricted national budged. Differences were also observed between the ‘older’ member states and those which had just joined the Union. Until today little is known about the methodological rigour of the national guidelines, and how national guidelines develop their content further over time.




The survey aims at improving knowledge about antenatal care in Europe and the evolution of national guidelines by detailing the current content of national guidelines on antenatal care in the member states of the European Union (EU), analysing the changes in each national guideline over the past nine years, identifying patterns of care according to different geographical, financial, or other patterns of the member states, and by appraising the development processes of the national guidelines.


Materials and methods


To establish the current content of the national guidelines on antenatal care, a survey is conducted. All current 27 member states of the EU are included together with Croatia, which joins the Union on 1 July 2013. For the survey, the instrument from the 2004 survey is transferred into an electronic format (3). With the AGREE II instrument, a tool is available to appraise the quality of guidelines from different countries and on different health problems (4). It can be additionally used to guide the development process of guidelines. As the appraisal of a guideline with the full instrument takes approximately 1.5 hours and requires four appraisers for each guideline (5), it is not feasible to be completely included in a survey. Therefore only the eight questions of the AGREE II instrument’s domain ‘rigour of development’ are included to assess the methodological rigour of each guideline. An additional question on the guideline development process is included in order to clarify whether the guideline was developed genuinely, or is an adaptation of another guideline.

To receive at least one response from each state, the electronic questionnaire will be sent to all national Ministries of health, the professional organisations of obstetricians and midwives, and the national coordinators of the COST action on Childbirth Cultures Concerns and Consequences.

For data analysis, the content of each national guideline will be compared to the content of its predecessor from 2004 (1-3). Moreover, comparisons will be made between the content of the current guidelines of member states with a gross national product below, and above the EU average. The same analysis will be made for states in Eastern and Western Europe, as well as for states, which joined the Union before and after 2004.

Data on guideline quality will be appraised according to the specification of the AGREE II instrument (4). This will lead to a scaled score of the rigour of the respective guideline’s development process. The scores of each guideline are then compared to each other, trying to identify patterns according to the financial, geographical, or other characteristics of each state. If several guidelines are an adaptation of another guideline, the study will demonstrate which guideline is most influential in Europe today.




The study will contribute to map the landscape on maternity care in Europe, appraising consistently the quality of currently available national guidelines on antenatal care for the first time. In addition to this, knowledge will be added about patterns in the further development of guideline content over time.



  1. Bernloehr A, Smith P, Vydelingum V. Antenatal care in the European Union: A survey on guidelines in all 25 member states of the community. European Journal of Obstetrics Gynecology and Reproductive Biology. 2005;122(1):22-3.
  2. Bernloehr A, Smith P, Vydelingum V. National guidelines on antenatal care: A survey and comparison of the 25 member states of the European Union. European Clinics in Obstetrics and Gynaecology. 2006;2(4):213-22.
  3. Bernloehr A. Antenatal care in the European Union: Equal chances for all new citizens of the community [dissertation]. Guildford: University of Surrey; 2007.
  4. Appraisal of guidelines for research and evaluation II: AGREE II instrument [Internet].; 2009. Available from:
  5. Brouwers MC, Kho ME, Browman GP, Burgers JS, Cluzeau F, Feder G, et al. AGREE II: Advancing guideline development, reporting, and evaluation in health care. Prev Med. 2010;51(5):421-4.