3. Introduction History In the USA, the first organized prenatal care programs began in 1901 with home nurse visits & The first prenatal clinic was established in 1911 The introduction of antenatal care in 1913 has been widely attributed to the efforts of Ballantyne at the University of Edinburgh During the 1920s Dame Janet Campbell played great role and her ideas became the clinical obstetric screening service of the 1930s ? By the 1950s, a schedule of monthly visits to 28 weeks, fortnightly visits to 36 weeks, and then weekly visits until birth had become standard 3 Berhanu M
4. ….History 1978 WHO had developed the “risk approach” concept 1980 WHO survey showed that No. of visit ranges from 5-14 in Europe Focused ANC approach introduced in 2001/2 It is one of the pillar of safe mother hood (1/4) Dame Janet Campbell 4 Berhanu M
6. …Uptake Ethiopia Birth Preparedness and Maternity Services Percent of women with at least one antenatal care (ANC) visit 28% Percent of women with at least four antenatal care (ANC) visits 12% Percent of women with a skilled attendant at birth 6% Percent of women receiving postpartum visit within 3 days of birth 5% 6 Berhanu M
8. ANC Definition: General health care given to pregnant women to promote and maintain optimal health of the mother throughout the pregnancy, labor and puerperium with having and rearing of healthy baby Two Models : Routine and Focused 8 Berhanu M
12. Risk approach A strategy to identify risk factors for undesirable outcomes, with care to be delivered according to individual needs high levels of false positive and false negative No amount of screening will separate those women who will from those who will not need emergency medical care . Deborah Maine, et al, Columbia University, 1991 10 Berhanu M
13. “Whatever the usefulness may be for other purposes, some of the common sense activities that had been promoted for decades risk screening at antenatal consultations, training of traditional birth attendants – proved to be of limited direct affect on maternal mortality.” Wim Van Lerberghe and Vincent De Brouwere, 2001 11 Berhanu M
14. Why it Hasn’t Worked More frequent ANC is better and Quantity is emphasized rather than the essential elements of care The model resulted in insignificant gains & it was not applicable in the low resource context 12 Berhanu M
15. …why Even when women go for ANC, they do not receive the full care as prescribed in national guidelines ,Among women who attended ANC: 37% never had their blood pressure checked, 41% never had their blood tested, 45% never had their urine tested, 25% never had their abdomen examined, and 63% were never informed of any danger signs The services in antenatal clinics in Arusha, Tanzania, (Eseko 1998). 13 Berhanu M
16. …why no enough time to handle each visit properly! Lacks due attention to client counseling, preparation for delivery, anticipation of complications, … 14 Berhanu M
17. ….Why In Kasongo, Zaire, 71 percent of the women who developed obstructed labor were not identified as at risk, while 90 percent of the women identified as “at risk” did NOT develop obstructed labor. Data from around the world has now pointed out that risk assessment does not predict who will and who will not have an obstetric emergency. Risk factors are usually not direct cause of complications 15 Berhanu M
18. Evidence suggests that the high-risk approach has failed because Most women who experience an obstetric emergency are assessed as not at risk It fails to distinguish who will develop complications and who will not women may have a false sense of security and may not be prepared for an emergency 16 Berhanu M
19. utilize scarce resources (e.g., mandated hospital deliveries for women who don’t really need them) Identification of special medical needs does not guarantee appropriate action at the referral site 17 Berhanu M
20. ….cnt’d 1. Haemorrhage – can occur anytime , difficult to predict. 2. Obstructed labor - difficult to predict. 3. PIH disorders (Eclampsia/pre-eclamsia) – there is no way to predict who will develop PIH 18 Berhanu M
21. For ANC to be effective in reducing maternal mortality, it must be goal oriented and focused on “screening to detect a problem rather than screening to predict a problem” and on treating any problem that can complicate a pregnancy. 19 Berhanu M
22. No longer recommended during ANCs Numerous visits Measurement of Maternal height Examination for Ankle edema Examination of fetal position before 36 weeks Care based on risk assessment 20 Berhanu M
24. Introduction Intended for managing non complicated pregnancies Based on multi center randomized controlled trials to compare standard “Western” model with new WHO model In total 24678 women were enrolled over 18 month between 1996 -1998, 53 clinics in four countries The new model had median of 5 visits vs 12 visits in the standard. Hospital admission diagnosis rate of LBW, UTI, Eclampsia, PE similar between the two groups. 22 Berhanu M
25. …Introduction FANC not associated with an increase in any of the negative maternal and perinatal outcomes women can be less satisfied and feel that their expectations with care are not fulfilled Care provided by midwife/general practitioner was associated with improved perception by women Lower costs for the mothers and providers Effectiveness of midwife/general practitioner managed care was similar to that of obstetrician /gynecologist led shared care 2001, Reprint 2007 23 Berhanu M
26. Principles of the new WHO ANC model The model should include simple format Identification of women with special health conditions or risk factors should be done very carefully Health care providers should make all pregnant women feel welcome at their clinic Only examinations & tests that serve an immediate purpose that have been proven to be beneficial should be performed. Whenever possible rapid & easy to perform test should be used, treatment should be initiated at the clinic the same day. 24 Berhanu M
27. Objectives Describe four main components of focused antenatal care (ANC) Discuss frequency and timing of ANC visits Describe essential elements of a birth plan that includes complication readiness Describe interpersonal skills for effective ANC Describe components of record keeping for ANC 25 Berhanu M
28. FANC An approach to ANC that emphasizes: Evidence-based, goal-directed actions Individualized, woman-centered care Quality vs. quantity of visits Care by skilled providers 26 Berhanu M
29. Goal of FANC To promote maternal and newborn health and survival through: Early detection and treatment of problems and complications Prevention of complications and disease Birth preparedness and complication readiness Health promotion 27 Berhanu M
30. FANC Evidence-based, goal-directed actions: Address most prevalent health issues affecting women and newborns Adjusted for specific populations/regions Appropriate to gestational age Based on firm rationale 28 Berhanu M
31. …FANC Individualized, woman-centered care based on each woman’s: Specific needs and concerns Circumstances History, physical examination, testing Available resources 29 Berhanu M
32. …FANC Quality vs. quantity of ANC visits: WHO multi-center study Number of visits reduced without affecting outcome for mother or baby Recommendations Content and quality vs. number of visits Goal-oriented care Minimum of four visits 30 Berhanu M
33. …FANC Care by a skilled provider who: Has formal training and experience Has knowledge, skills, and qualifications to deliver safe, effective maternal and newborn healthcare Practices in home, hospital, health center May be a midwife, nurse, doctor, clinical officer, etc. 31 Berhanu M
34. Timing of ANC Visits First visit: By 12 weeks or when woman first thinks she is pregnant Second visit: At 24–28 weeks or at least once in second trimester Third visit: At 32 weeks Fourth visit: At 36 weeks Othervisits: If complication occurs, follow up or referral is needed, woman wants to see provider, or provider changes frequency based on findings (history, exam, testing) or local policy 32 Berhanu M
38. Early Detection and Treatment Severe anemia—physical exam, testing Pre-eclampsia/eclampsia—measurement of blood pressure HIV—voluntary counseling and testing Sexually transmitted infections, including syphilis— testing Malaria—history and physical exam Fever and accompanying signs/symptoms Region Complicated vs. uncomplicated cases 36 Berhanu M
39. Prevention: Key Preventive Measures Tetanus toxoid, iron/folatesupplements PMTCT Country/region-specific interventions as appropriate Iodine supplements Presumptive treatment for hookworm Malaria: Intermittent preventive treatment (IPT) Use of insecticide-treated nets (ITNs) 37 Berhanu M
40. Birth Preparedness and Complication Readiness Objectives Develop birth plan—exact plan for normal birth and possible complications: Arrangements made in advance by woman and family (with help of skilled provider) Usually not a written document Reviewed/revised at every visit Minimize disorganization at time of birth or in an emergency Ensure timely and appropriate care 38 Berhanu M
41. …Birth Plan Family and Community Support: Care for family in woman’s absence and birth companion during labor Blood Donor: In case of emergency Needed Items: For clean and safe birth and for newborn care Danger Signs/Signs of Advanced Labor 39 Berhanu M
42. Essential Elements of a Birth Plan Facility or Place of Birth: Home or health facility for birth, appropriate facility for emergencies Skilled Provider: To attend birth Provider/Facility Contact Information Transportation: Reliable, accessible, especially for odd hours Funds: Personal savings, emergency funds Decision-Making: Who will make decisions, especially in an emergency 40 Berhanu M
43. Danger Signs of Pregnancy Vaginal bleeding Difficulty breathing Fever Severe abdominal pain Severe headache/blurred vision Convulsions/loss of consciousness Labor pains before 37 weeks 41 Berhanu M
44. Health Education: Objectives Inform and educate the woman with health messages and counseling appropriate to: Individual needs, concerns, circumstances Gestational age Most prevalent health issues Support the woman in making decisions and solving actual or anticipated problems Involve partner and family in supporting/adopting healthy practices 42 Berhanu M
45. Health Education: Topics Addressed Other important issues to be discussed include: Nutrition Care for common discomforts Use of potentially harmful substances Hygiene Rest and activity 43 Berhanu M
46. ….cont’d Sexual relations and safer sex Early and exclusive breastfeeding Prevention of tetanus and anemia Voluntary counseling and testing for HIV Prevention of other endemic diseases/deficiencies PMTCT 44 Berhanu M
47. Interpersonal Skills Speak in a quiet, gentle tone of voice Listen to woman/family and respond appropriately Encourage them to ask questions and express concerns Allow them to demonstrate understanding of information provided Explain all procedures/actions and obtain permission before proceeding Show respect for cultural beliefs and social norms Be empathetic and nonjudgmental Avoid distractions while conducting the visit 45 Berhanu M
48. Record Keeping Record all information on the ANC chart and clinic card: Subsequent ANC Visits Interim history Targeted physical examination, testing Care provision, Counseling, including birth plan and use of ITNs (and relevant information on how client obtained and used ITN) Date of next ANC visit First ANC Visit History Physical examination Testing Care provision Counseling, including birth plan Date of next ANC visit 46 Berhanu M
49. Late enrolment & Missed visits Those particularly starting after 32 weeks should have the first visit all activities recommended & those which correspond to the present visit. Take more time than regular Determine the reason for missed appointment. 47 Berhanu M
50. Spacing between Visits Timing & Spacing between visits in the basic component were decided empirically based upon the result of WHO,ANC randomized controlled trials. Incase of unexpected symptoms mother should be advised to seek care. 48 Berhanu M
51. The post partum visit Universally recommended Benefits of ANC & Determinants of outcomes seen only when they are part of program for post natal period Visit should be within 1 week 49 Berhanu M
52. Barriers to effective antenatal care • Inadequate infra-structural resources • Poor quality of care and treatment of clients • Ignorance of the importance and value of ANC • Not customary, In most societies there is no tradition of antenatal care • Cultural, traditional and religious practices 50 Berhanu M
53. ….Barriers • Lack of women’s autonomous decision-making on their own health care seeking • Poverty – fear of costs of transport and medical care • Household responsibilities • Illiteracy 51 Berhanu M
54. Key Behavior Change Messages for the mother • Every pregnancy is at risk, visit your health care provider if you suspect you are pregnant • Go for antenatal care during pregnancy to detect and treat problems – it could save your and your baby’s life • Pregnant women need four antenatal care visits (including registration) that include a physical checkup, blood and urine testing, two tetanus toxoid injections, and supply of iron folate supplementation 52 Berhanu M
55. …Key Behavior • Pregnant women need to take iron folate tablets every day for 6 months during pregnancy to save mother’s and newborn’s lives • Ask your health care provider about the signs of an emergency and what to do if they occur • If you think you have Malaria or hepatitis and you are pregnant, see your doctor immediately for treatment • If you are having health problems during your pregnancy, don’t wait – see your doctor right away 53 Berhanu M
56. Advocacy Messages Current best practices are based on the most up to date scientific evidence of what works therefore it should be implemented 54 Berhanu M
57. Update . The goal-oriented, reduced-visits approach was associated: A 15% higher risk of perinatal mortality Lower Cost women were less satisfied 2010 55 Berhanu M
58. …updates Possible reasons: Health-care workers are less able to give sufficient time to each woman The reduced-visits package was quickly adopted by health-care services 56 Berhanu M
59. Possible Explanations: Differences in background risks in the populations have differential effects on fetal health and well-being Wide gap between the visits in the second and third trimester of pregnancy January 2011 57 Berhanu M
61. References Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane Database of Systematic Reviews 2010, Issue 10. Art. No.: CD000934. DOI: 10.1002/14651858.CD000934.pub2 WHO Statement on antenatal care January 2011 ,WHO/RHR/11.12 MJA Vol 176 18 March 2002 pp 153/4 , Guiding antenatal care ABC OF ANTENATAL CARE, Fourth edition, GEOFFREY CHAMBERLAIN Professor Emeritus, Department of Obstetrics and Gynaecology, St George’s Hospital Medical School, London and Consultant Obstetrician, Singleton Hospital, Swansea and MARGERY MORGANConsultant Obstetrician and Gynaecologist, Singleton Hospital, Swansea Safe Motherhood Strategies :a Review of the Evidence Vincent De Brouwere and Wim Van Lerberghe, Studies in HSO&P,17,2001 Patterns of routine antenatal care for low-risk pregnancy , Cochrane Database of Systematic Reviews reprint 2007 www.mnh.jhpiego.orgFocused Antenatal Care-Planning and Providing Care During Pregnancy –MNH 59 Berhanu M
Advocacy Messages• Current best practices are based on the most up to date scientific evidence of what works• Best practices save resources in the long run by eliminating unnecessary practices and makingthe best of limited resources• Implementing best practices saves lives of mothers and newborns• Skilled providers must be made available for ANC• Even skilled providers require technical updates so they can provide effective focused ANCbased on the most recent evidence of what works
In low- and middle-income countries, compared with standard antenatal care, the goal-oriented, reduced-visits approach was associated with a 15% higher risk of perinatal mortality
Possible reasons:Health-care workers are less able to give sufficient time to each woman, and hence the quality of care is lowered and there is an increased chance of missing potential problemsThe reduced-visits package was quickly adopted by health-care services as a way of improving the quality of care for womenThe antenatal care package may have to be adapted in each country prior to implementation in order to address relevant background health risks
At present, the reason for increased perinatal mortality is unknown. It is possible that differences in background risks in the populations have differential effects on fetal health and well-being. Another possibility is that the gap between the visits in the second and third trimester of pregnancy may have been too wide for timely identification of fetal ill-health and action when these problems occurred.
plans to produce an updated evidence-based guideline on antenatal care that will be informed by these findings and other systematic reviews of interventions that may be effective in improving perinatal outcome during antenatal care.
Focused Antenatal Care-Planning and Providing Care During Pregnancy –MNH (www.mnh.jhpiego.org)
