Fetal and Neonatal Outcomes in Booked vs. UnBooked Deliveries: A Systematic Review and Meta-analysis of the Global Literature

Abstract Purpose A booked case is an indicator of antenatal care (ANC), embodying a proactive approach to pregnancy care, whereas unbooked deliveries describe scenarios in which pregnant women delay seeking ANC, which may cause adverse fetal outcomes and lead to neonatal morbidity and mortality. Despite extensive exploration of the effects of ANC on maternal and fetal health, a detailed review comparing fetal outcomes in booked versus unbooked cases was lacking. Our study aimed to quantify the effects of ANC on fetal and neonatal outcomes through a comprehensive meta-analysis of booked and unbooked cases. Methodology This review was registered in PROSPERO (Registration No: CRD42024526568). Two databases were systematically searched, PubMed and Google Scholar, with a time filter of 2003–2023. Quality was assessed on the basis of the Newcastle‒Ottawa scale for cohort studies and the modified version for cross-sectional studies. The main outcomes were neonatal mortality, low Apgar scores, low birth weight (LBW), macrosomia, meconium aspiration and birth asphyxia. The secondary outcomes were neurological symptoms, neonatal intensive care unit (NICU) admissions, congenital anomalies, jaundice and neonatal sepsis. A random-effects model was used to evaluate the pooled effect size of the odds ratio (OR). Results In total, 28 studies were included in the final review, with the majority (n = 24) originating from low to middle-income countries. For the majority of the outcomes, being booked was found to be protective on the basis of pooled ORs, i.e., neonatal mortality (OR 0.30; 95% CI 0.15–0.63, I² = 96%), low APGAR scores at 1 minute (OR 0.33; 95% CI 0.29–0.38, I2 = 92% and 5 minutes (OR 0.16; 95% CI 0.08–0.32, I2 = 91%), LBW (OR 0.36; 95% CI 0.30–0.43, I2 = 46%), jaundice (OR 0.48; 95% CI 0.19–1.25, I2 = 74%), MAS (OR 0.36; 95% CI 0.18–0.70, I2 = 64%), neurological symptoms (OR 0.34; 95% CI 0.13–0.85, I²=20%), neonatal sepsis (OR 0.56; 95% CI 0.37–0.86, I2 = 17%), asphyxia (OR 0.39; 95% CI: 0.32–0.49; I2 = 0%) and however, we did not find any difference between booked and unbooked deliveries in terms of macrosomia (OR 0.99; 95% CI: 0.53–1.83, I² = 32%) and congenital anomalies (OR 0.09; 95% CI 0.35–2.29 I2 = 83%). The publication bias was minimal. Conclusion This meta-analysis provides substantial evidence that booked deliveries have significantly better fetal outcomes across a broad spectrum than unbooked deliveries do; therefore, interventions that improve ANC coverage need to be implemented to reduce adverse fetal outcomes.