What is a Booked Pregnancy?
A booked pregnancy refers to a pregnancy in which the woman has registered for and is receiving formal antenatal care at a healthcare facility, typically initiated in the first or early second trimester. This term is primarily used in international healthcare settings, particularly in developing countries and the United Kingdom, to distinguish women who are enrolled in prenatal care systems from those who present for delivery without prior antenatal surveillance ("unbooked" patients) 1, 2.
Clinical Definition and Timing
Booking specifically refers to the initial registration visit for antenatal care, during which a comprehensive risk assessment is performed and an individualized care plan is developed 3.
The booking visit should ideally occur before 10 weeks gestation to allow for optimal risk stratification and appropriate care pathway determination 4.
At booking, key baseline measurements are obtained including booking blood pressure and booking proteinuria assessment, which serve as reference points for detecting pregnancy complications like pre-eclampsia 3.
Women who book before 22 weeks gestation are typically classified as "booked," while those presenting after this timepoint or only at delivery are considered "unbooked" 5.
Risk Assessment at Booking
The booking visit involves systematic evaluation of risk factors that influence pregnancy management 3:
- Demographic factors: Age ≥40 years, body mass index ≥35, nulliparity 3
- Medical history: Pre-existing hypertension, renal disease, diabetes, antiphospholipid antibodies 3
- Obstetric history: Previous pre-eclampsia, ≥10 years since last pregnancy, family history of pre-eclampsia 3
- Current pregnancy factors: Multiple pregnancy, booking diastolic blood pressure ≥80 mm Hg 3
Clinical Significance and Outcomes
The distinction between booked and unbooked status has profound implications for maternal and perinatal outcomes:
Unbooked mothers have three times higher neonatal mortality rates compared to booked mothers 5.
Unbooked women are 13 times more likely to die during hospitalization compared to booked patients (OR: 13.54; 95%CI: 6.89-27.03) 6.
Unbooked mothers have significantly higher rates of pre-eclampsia/eclampsia (OR 3.88; 95%CI 2.61-5.77), uterine rupture requiring emergency laparotomy (OR 8.80; 95%CI 3.84-20.55), and birth asphyxia (nine times more likely) 6.
Among unbooked patients, 36% of babies weigh less than 2,500g compared to only 12.5% in booked groups 5.
Common Reasons for Multiple or Late Booking
Research identifies several patterns that compromise effective antenatal care 1, 7:
Multiple concurrent bookings occur in up to 69.5% of women in some settings, driven by desires to select facilities with affordable prices (43.9%), facilities promising vaginal delivery (35.3%), or to avoid HIV testing (17.9%) 1.
Late booking (≥17 weeks) is significantly influenced by lower educational level and occurs for reasons including: not feeling sick (26.1%), lack of knowledge about appropriate booking time (22.8%), financial constraints (9.2%), and fear of too many follow-up visits (4.9%) 7.
Practical Implications for Care Delivery
Women with high-risk factors identified at booking (previous pre-eclampsia, multiple pregnancy, pre-existing hypertension ≥90 mm Hg, pre-existing renal disease, diabetes, or antiphospholipid antibodies) should be referred for specialist input before 20 weeks gestation 3, 4.
After 20 weeks, booked women receive stratified monitoring schedules based on their risk profile: Level 1 (no risk factors) follows standard low-risk protocols, while Level 2 (one risk factor) requires assessments at minimum 3-week intervals from 24-32 weeks and 2-week intervals from 32 weeks to delivery 3.
The booking system enables systematic screening for pre-eclampsia through regular assessment of blood pressure, proteinuria, and symptoms (headache, visual disturbance, epigastric pain, reduced fetal movements) after 20 weeks 3.