Antenatal Care
in Poor Countries
Stephen Gloyd
MCH in Developing Countries
January 2012
Antenatal Care Initiatives
MAKING PREGNANCY SAFER (WHO)
 Reduce maternal mortality 75% by 2015
SAFE MOTHERHOOD INITIATIVE (WHO-1988)
“Four Pillars”
 Family planning
 Prenatal care
 Clean birth
 Essential obstetric services at referral level
(including availability of transport)
And…Improvement of womens' status
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IMPORTANCE OF ANTENATAL CARE
 reduce high perinatal risk
 reduce high maternal risk (50x)
 major point of access to health care for
women
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Access to antenatal care
 Physical access
 Time and/or distance to facility
 Economic costs & barriers
 Cultural and social factors
 Quality of care
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Trends in
Antenatal
care
19902000
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Estimates of the proportion of pregnant women
who received some antenatal care (1996)
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Number of visits to ANC by region
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Factors affecting the utilization of antenatal care in
developing countries: Systematic review of the literature
Bibha Simkhada Maureen PorterEdwin R. van Teijlingen Padam Simkhada. Journal
of Advanced Nursing, Jan 2008
A systematic review of 28 papers -both quantitative and qualitative
Factors most commonly associated with antenatal care uptake:
Maternal education, husband's education, marital status, availability, cost,
household income, women's employment, media exposure and having a history of
obstetric complications. Also cultural beliefs.
Parity had a statistically significant negative effect on adequate attendance. While
women of higher parity tend to use antenatal care less, there is interaction with
women's age and religion.
Only one study examined the effect of the quality of antenatal services on
utilization. None identified an association between the utilization of such services
and satisfaction with them
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Antenatal care and delivery
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Timing of ANC visits
(most in 1st trimester except Africa)
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Estimates of the proportion of deliveries
attended by skilled personnel (1996)
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Prenatal care vs
attended birth and post partum care
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Components of prenatal care:




Health education
Screening
Diagnosis and treatment
Referral
Screening/Dx
o Identify women at high risk [?usefulness]
o Intervene to prevent development of problems
o Dx and Rx pre-existing medical conditions
o Dx and Rx complications of pregnancy
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Perinatal Morbidity and Mortality
(newborn)
 LBW
 Birth trauma, obstructed labor
 Infection
 amnionitis
 herpes
 gonorrhea
 syphilis
 streptococcus
 HIV
 Tetanus
 Abruptio Placenta
 Congenital malformations
 "other" (30%)
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Maternal Morbidity and Mortality
(Five main causes)

Hemorrhage

Sepsis

Eclampsia

Obstructed Labor

Abortion
Note: Mortality reduction requires secondary and
tertiary care
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Other Causes of
Maternal Morbidity and Mortality
Hypertension

Diabetes

Heart Disease

Hepatitis

Anemia

Malaria

Tuberculosis

STD
Overall Morbidity: 3-12% of all pregnancies
(up to 37% in India)

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Poor outcomes: 3465 birth registries in 30
hospitals of Cote d’Ivoire (1997)
Condition
Rate per 1000
Normal
760
Stillbirth
44
Neonatal death
6
LBW < 2500g
< 2000g
<1500g
190
52
17
Eclampsia
2
Fetal disproportion
13
Fetal distress
15
Hemorrhage
22
Maternal deaths
2
Others
12
Operative delivery
36
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Prevalence of low birth
weight globally
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Sexually
transmitted
infections (STI)
among pregnant
women in
Mozambique
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Preventability


Overall Infant Deaths - 33% preventable (Nairobi)
Syphilis:
100% preventable




10% stillbirths
20% Infant Mortality
20% Congenital Syphilis
Other causes:
% preventable not clear
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Risk Approach
Identification of high risk factors
 Predictive (Previous fetal loss)
 Contribution (Grand multipara, young or old)
 Causation (syphilis, HIV, maternal malnutrition)
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Risk Approach
Not believed an effective ANC strategy because:
 Complications cannot be predicted—all pregnant women
are at risk for developing complications
 Risk factors are usually not direct cause of complications
 Many “low risk” women develop complications


Have false sense of security
Do not know how to recognize/respond to problems
 Most “high risk” women give birth without complications

Thus, an inefficient use of scarce resources
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WHO working group
on prenatal care 1994
 PNC should be individualized
 Part of overall, functional system
 Midwife usually most appropriate
 Include empowerment
WHO Antenatal Care Randomized Trial
(Villar et al 2001)
 Manual for the Implementation of the New
Model
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Current state of Prenatal Care 2008
Too many interventions
 Poor quality of care for interventions that work
 Need to focus on a FEW interventions based on epidemiology
Interventions that are cheap and effective
 pMTCT (HIV screening and prophylaxis)
 Malaria
IPT (Intermittent Preventive Therapy)
 Syphilis screening and Rx
 Iron therapy
 Tetanus immunization
 Family planning
 Nutritional
supplementation
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Other interventions that need more study
(though most of these are recommended)
 STD identification and treatment
 Routine anti parasite drugs
 Waiting houses
 Diabetes screening (depends on prevalence)
 Management and treatment of HTN
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HIV in pregnancy
 Prevention of HIV transmission (pMTCT)
 Opt-in vs opt out
 Single dose Niverapine vs AZT vs HAART
 Efficiency of treatment
 Care for HIV positive mother during pregnancy
 Special nutritional needs
 Social needs, stigma
 HAART in pregnancy
 Toxicity (NVP, AZT)
 Patient flow and adherence
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Prevention of Mother to Child
Transmission of HIV (pMTCT)




Short term ARVs reduce transmission by > 50%
AZT vs Nevirapine
Cost-effectiveness based on prevalence
Effectiveness depends on adequate follow up of women


HIV+ to counseling
Links between prenatal care and hospital
Implementation
 Not necessary to wait until everything is in place
 Important to involve PLWAs
 Community consultation critical
 Counselors need training
 Mothers need support and follow up (including psychosocial)
 Works best in conjunction with HAART
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Prevention and Control of
Malaria during Pregnancy
Malaria and Pregnancy
 30 million African women are pregnant yearly
 Malaria is more frequent and complicated during
pregnancy
 In malaria-endemic areas, malaria during pregnancy
may account for:
 Up
to 15% of maternal anemia
 5–14% of low birthweight
 30% of “preventable” low birthweight
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Effects of Malaria on Pregnant
Women
 All pregnant women in malaria-endemic areas are at




risk
Parasites attack and destroy red blood cells
Malaria causes up to 15% of anemia in pregnancy
Can cause severe anemia
In Africa, anemia due to malaria causes up to
10,000 maternal deaths per year
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Malaria Prevention and Treatment
during Pregnancy
 Focused antenatal care (ANC) with health education
about malaria
 Use of insecticide-treated nets (ITNs)
 Intermittent preventive treatment (IPT)
 Case management of women with symptoms and
signs of malaria
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Benefits of Insecticide-Treated Nets
 Prevent mosquito bites
 Protect against malaria, resulting in less:
Anemia
 Prematurity and low birthweight
 Risk of maternal and newborn death

 Help people sleep better
 Promote growth and development of fetus and
newborn
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Intermittent Preventive Treatment
 Every pregnant woman living in an area of high malaria
transmission has malaria parasites in her blood or
placenta, whether or not she has symptoms of malaria
 Although a pregnant woman with malaria may have no
symptoms, malaria can still affect her and her unborn
child
 Three doses of sulfadoxine-pyrimethamine (SP) should
be given to all pregnant women after quickening and at
least 1 month apart
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Intermittent Preventive Treatment:
Dose and Timing
 Each dose is three tablets of sulfadoxine 500 mg +
pyrimethamine 25 mg
 Ideally, a dose is given at each ANC visit after
quickening, but at least 1 month apart
 Healthcare provider should dispense dose and
directly observe client taking dose
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Intermittent Preventive Treatment:
Contraindications to Using SP
 First trimester: Be sure quickening has occurred and
woman is at least 16 weeks pregnant
 Allergy to SP or other sulfa drugs: Ask about sulfa drug
allergies before giving SP
 Taking co-trimoxazole, or other sulfa-containing drugs:
Ask about use of these medicines before giving SP
 Not more frequently than monthly: Be sure at least 1 month
has passed since the last dose of SP
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Managing Uncomplicated Malaria
 Provide first-line anti-malarial drugs
 Follow country guidelines
 Manage fever
 Analgesics, tepid sponging
 Diagnose and treat anemia
 Provide fluids
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Active Syphilis Infection in Pregnancy
 Adverse outcome in 50-70% of infected pregnancies
 In sub-Saharan Africa, prenatal syphilis positivity varies
between 4-16% (average ~ 9%)
 In Zambia & Malawi, 26-42% stillbirths attributed to syphilis
 8% of IMR due to syphilis
 Screening is effective & inexpensive

Basic Screening Test (RPR) costs US$0.25-0.35, takes 15-20
minutes. ICS (Rapid test) ~$0.50, 2 minutes.

Treatment: 3 doses (1 per week) of Benzathine Penicillin at
US$1.00 per dose
 Estimated screening of women in ANC in Africa - 38%
 Obstacles: cost, organization of services
 Missed opportunities for screening >1 million
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Focused Antenatal Care
An approach to ANC that emphasizes:
 Evidence-based, goal-directed actions
 Individualized, woman-centered care
 Early detection and treatment of problems and complications
 Prevention of complications and disease
 Quality vs. quantity of visits
 Care by skilled providers
 Birth preparedness & complication
readiness
 Health promotion
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No Longer Recommended
 Numerous, routine visits
 Burden to women and healthcare system
 Routine measurements and examinations:
 Maternal height and weight
 Ankle edema
 Fetal position before 36 weeks
 Care based on risk assessment
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Number of antenatal care visits
WHO multi-center study - number of visits reduced
without affecting outcome for mother or baby
Recommendations
 Minimum of 4 visits (see table) – with quality
services
 Individualized delivery plan depending on risk
profile
 One PNC visit at referral hospital
 Health promotion (to individual and community)
 Emergency transport
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Scheduling and Timing of ANC Visits
 First visit: By 16 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
 Other visits: If complication occurs, followup or
referral is needed, woman wants to see provider, or
provider changes frequency based on findings (history,
exam, testing) or local policy
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WHO MNH
guidelines
5 pages of tables
Table 1 lists interventions delivered to
the mother during pregnancy, childbirth
and in the postpartum period, and to the
newborn soon after birth.
Table 2 lists the places where care
should be provided through health
services, the type of providers required
and the recommended interventions and
commodities at each level.
Table 3 lists practices, activities and
support needed during pregnancy and
childbirth by the family, community and
workplace.
Table 4 lists key interventions provided
to women before conception and
between pregnancies.
Table 5 addresses unwanted
pregnancies.
Antenatal Care
http://whqlibdoc.who.int/hq/2007/WHO_MPS_07.05_eng.pdf
47
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IMPAC
Manual
Integrated
Management
of Pregnancy &
Childbirth
Guidelines
WHO
2006
http://whqlibdoc.who.int/publications/2006/924159084X_eng.pdf
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IMPAC Manual
Guideline detail for Antenatal Care
1.
Assess the pregnant woman
2.
Check for pre-eclampsia
3.
Check for Anemia
4.
Check for syphilis
5.
Check for HIV status
6.
Respond to observed signs
or volunteered problems (no
fetal mvmt, ruptured
membranes, fever, disuria,
vaginal discharge, HIV,
smoking, drugs, DV, SOB, TB)
7.
Give preventive measures
(tetanus, Fe/folate,
mebendazole, malaria, ITN)
7.
Advice and counsel on
nutrition and self care
8.
Develop a birth & emergency
plan
9.
Advise and counsel on family
planning
10. Advise on routine and follow
up visits
11. Home delivery without a
skilled attendant
12. Assess feasibility of ARV for
pregnant woman
http://whqlibdoc.who.int/publications/2006/924159084X_eng.pdf
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Other useful WHO guidelines
JHPEIGO. Inspired by George Povey Manual
http://whqlibdoc.who.int/publications/2007/924
1545879_eng.pdf
http://whqlibdoc.who.int/hq/2010/WHO_MPS_
09.04_eng.pdf
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Problems with interventions
(general):
Utilization is variable
Gestation at first visit (after sixth month)
Variable epidemiology of risk factors (Malaria, eclampsia, Anemia,
pelvic size)
Cultural barriers
identification of pregnancy, taboos
reluctance to use family planning
Limitations of referral and transport
Sensitivity and specificity of risk factors
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Thank you!
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Some operational issues –
prenatal and birth care
Malaria in pregnancy (done by Paula Brentlinger?)
pMTCT (prevention of mother to child transmission of
HIV
Antenatal syphilis screening in Mozambique
Traditional birth attendant training
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Safe childbirth care
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Inadequate health systems
Emergency obstetric care (EOC) requires  Surgical facilities
 Anesthesia
 Blood transfusion
 Manual delivery tools (VE, forceps)
 Medical treatment (HTN, Sepsis, shock)
 Family Planning
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Impact of Traditional Birth Attendant training in
Rural Mozambique (1)
 MOH established a TBA program in
 Goals: reduce maternal and infant mortality & improve utilization
of primary health care
 Over 8 years MOH trained >300 TBAs - supported by quarterly
supervision, basic equipment, and annual refresher courses
 Surveys showed TBAs improved their knowledge of obstetric
emergencies and skills in how to manage them
 An evaluation was planned to assess whether the program had
met its initial goals (1995)
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Impact of Traditional Birth Attendant training in
Rural Mozambique (2)
 A retrospective cohort study
 Comparison of maternal and newborn outcomes in
40 communities where TBAs had been trained
27 communities where TBAs had not yet been trained.
 In each community –respondents interviewed in 30 households
closest to the trained TBA (or center of the community with no
trained TBA) with pregnancies in the past 3 years
 Principal outcomes

utilization of TBA or health facility services (delivery and ANC)

outcome of pregnancy for mother and child

utilization of other primary health care services
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Impact of Traditional Birth Attendant training
in Rural Mozambique - RESULTS
 In TBA trained communities

30% of these pregnant women utilized theTBAs

40% managed to deliver at health facilities
 Overall, 70% of women preferred health facility midwives for
their next birth (however, most users of trained TBAs preferred
TBAs for their next birth)
 No difference in mortality rates (perinatal, neonatal, infant)
 MOH policy regarding TBA vs health facility support substantially
changed after the study
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Basic
component
s of the
WHO
antenatal
care
program
(1994)
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