Should the Norwegian public prenatal care program include an ultrasound scan in the first trimester?

1. Should the Norwegian public prenatal
care program include an ultrasound
scan in the first trimester?
Siv Cathrine Høymork, Hege Wang, Vigdis Lauvrak, Ånen Ringard
Secretariat for the National Council for Priority setting in Health Care
The Norwegian Knowledge Centre for the Health Services

2. Health care in Norway
 Mainly publicly provided and
financed
 The public prenatal care
program is free of any costs for
the pregnant women

3. National Council for Priority setting in
Health Care
 Established in 2007 by the Ministry of Health
 An advisory board for assessing new technologies
 26 members
 Executives from the central health administration and regional health
authorities
 Executives from municipalities and their organisation
 Leaders from patient associations
 Representatives from universities and colleges
 Chaired by the Director-General of the Norwegian Directorate of
Health; deputy chairperson is the Director-General of the
Norwegian Institute of Public Health
 Secretariat at the Norwegian Knowledge Centre (the national HTA-
institution)

4. Framework for priority setting
 The Priority Setting Regulation is founded on the Patient’s
Rights Act
 Three criteria should be fulfilled:
 Severity
”the patient will experience a certain reduction in prognosis with
regard to life expectancy or a considerable reduction in quality of life
if the provision of a health intervention is deferred”
 Effectiveness
”the patient may expect to benefit from the health intervention”
 Cost-effectiveness
”the expected costs are in a reasonable proportion to the effects”

5. The Council’s web-site:
www.kvalitetogprioritering.no

6. Should a publicly financed early
(weeks 11-13) ultrasound scan be
offered to pregnant women?

7. Case processing in the National
council, spring 2011
 14.2.: case put forward
 11.4.: case initially discussed in the
council
 Not sufficient documentation to suggest that 2008
ultrasound provides health benefit to the mother
and/or foetus
 Case was to be further investigated, including an
assessment of effects with respect to different
medical conditions as well as health economic
effects
 Assessment was to be jointly conducted by the
Directorate of Health, the Knowledge Centre and
relevant professional groups. The case would
subsequently be re-examined by the council.

8. An HTA working-group was established
 Specialists in foetal medicine
 Gynaecologist
 Paediatrician
 Midwife
 Specialists in medical ethics
 Norwegian Birth Registry
 Systematic reviewers
 Librarians
 Health economists

9. Case handled in the National council on
December 5th
 Summary of the findings in the
HTA-report from was presented:
 No documented health benefit
 More women satisfied with
prenatal care
 Fewer children with Down
syndrome will be born
 Rise in costs not evident

11. Final resolution
The Norwegian Council for Quality Improvement and Priority
Setting in Health Care considers it essential that the publicly provided
prenatal care program should be assured, safe, and maintain a high
professional standard.
Routine ultrasound scans should be offered in weeks 11-13 and 17-19
in order to
- ensure that the objectives of ultrasound scanning in pregnancy
are attended to at the earliest possible opportunity
- ensure that the examination meets professional standards
Prior to implementation, the consequences regarding economics and
priority setting should be evaluated by means of pilot testing.

12. Final resolution - justification
 Pregnant women more satisfied - major objective within
prenatal care programme
 Better to be informed sooner rather than later if something is
wrong
 Ensure high standards to avoid unnecessary waste of
resources on follow-up
 Counteract the geographic and economic barriers to access
 Expenses not likely to rise
 Publicly provided programme in place in many other countries

13. Conclusion
 Despite the fact that the HTA revealed no health gain
for the mother or the foetus, the Council
recommended that an additional ultrasound scan
should be offered in the prenatal care programme.
 The advice challenge the official criteria stated in the
Priority Setting Regulation.
 The final decision will be made by the Parliament.