ANTENATAL CARE

Seminar presentation to medical students.

Dr. E.I. OKORIE
13/12/2022
 INTRODUCTION
The World Health Organization (WHO) envisions a world where “every
pregnant woman and newborn receives quality care throughout the
pregnancy, childbirth and the postnatal period”

ANC is one of the components of safe motherhood. The need to provide

quality care for pregnant women has been on for decades. The latest is
the new ANC model produced by WHO in 2016 termed antenatal care
for positive pregnancy experience.
 INTRODUCTION
• Antenatal care (ANC) can be defined as the care provided by skilled
health-care professionals to pregnant women and adolescent girls in
order to ensure the best health conditions for both mother and baby
during pregnancy.

The components of ANC:

• risk identification;
• prevention and management of pregnancy-related or concurrent
diseases;
• and health education and health promotion.
 AIMS OF ANTENATAL CARE
• To prevent, detect and manage those factors that adversely
affect the health of mother and baby.
• To provide advice, reassurance, education and support for the
woman and her family.
• To deal with the ‘minor ailments of pregnancy
• To provide general health screening,
 MODELS OF ANC
• Antenatal care began as a social service in France in 1788 for the
destitute

• The original model of ANC established in the 1930s involved as many as

15 visits to a doctor or a midwife.

• Not evidence based

• Persisted for many years because of fears that reducing the number of
visits would lead to an increase in maternal and perinatal morbidity and
mortality.
GAPS IN THE TRADITIONAL ANC
• The risk approach fails to predict who will go on to develop complications of
pregnancy and delivery.

• Many women who have risk factors will not develop complications while
those without risk factors may do so.

• In using a risk approach, scarce health resources may be devoted to

unnecessary care for “high-risk” women who may not develop complications.

• “Low-risk” women may not receive essential care.

TRADITIONAL ANC
• Uses risk approach to classify women likely to experience
complications.

• Visits are scheduled as 4 weekly till 28 weeks, 2 weekly till 36 weeks

and weekly till delivery, which results in an average of 12 weeks
 GOAL ORIENTED OR FOCUSED ANC
• In 2000, WHO undertook a systematic review of randomized trials
assessing the effectiveness of different models of antenatal care.

• The interpretation of the findings was that:

A model with a reduced number of antenatal visits, with or without goal-
oriented components, could be introduced into clinical practice without
risk to mother or baby, but some degree of dissatisfaction by the mother
could be expected. Lower costs can be achieved.

Lancet 2001; 357: 1565–70.

 GOAL ORIENTED OR FOCUSED ANC
• Introduced in 2002. Is a goal orientated approach to delivering evidence-based
interventions carried out at four critical times during pregnancy: 8-12wks; 24-
26wks; 32wks; 36-38wks.

• Providers focus on assessment and actions needed to make decisions, and

provide care for each woman’s individual situation.

• Places emphasis on quality rather than on quantity.

• It includes a classifying form to help providers identify women who have

conditions requiring treatment and more frequent monitoring.
 POSTNATAL FOLLOW UP
• Family planning/Contraceptives

• Immunization for baby

 POSSIBLE DEFECTS OF FANC
• Findings suggest that fitting all the components of the FANC
model into four visits is difficult to achieve in some low
resource settings where services are already overstretched.
 POSSIBLE DEFECTS OF FANC cont.
• Findings showed that health care providers variably omit
certain practices from the FANC model, including vital signs,
provision of information on danger signs, and spend less than
15 minutes in seeing a patient.
 POSSIBLE DEFECTS OF FANC cont.
Evidence from LMIC and HIC suggests:
• Women do not like reduced visit schedule

• Would prefer more contact with antenatal services

• Reduced visit schedule may limit the ability of some women who depend
on their husbands to procure additional finances.

• Reduced visits may be appreciated by others because of potential for cost

savings, loss of domestic income from extra clinic attendance.
ANTENATAL CARE FOR POSITIVE PREGNANCY EXPERIENCE.
2016 WHO Antenatal care models with a minimum of eight contacts are recommended
to reduce perinatal mortality and improve women’s experience of care.
This GDG recommendation was informed by:
• Evidence suggesting increased perinatal deaths in 4-visit ANC model

• Evidence supporting improved safety during pregnancy through increased frequency

of maternal and fetal assessment to detect complications

• Evidence supporting improved health system communication and support around

pregnancy for women and families

• Evidence indicating that more contact between pregnant women and respectful,
knowledgeable health care workers is more likely to lead to a positive pregnancy
experience

• Evidence from HIC studies indicating no important differences in maternal and

perinatal health outcomes between ANC models that included at least eight contacts
and ANC models that included 11 to 15 contacts.
2016 WHO ANC model
 Foundation of the new model.
• positive pregnancy experience
• Overarching aim

• To provide pregnant women with respectful, individualized, person-

centred care at every contact, with implementation of effective
clinical practices (interventions and tests), and provision of relevant
and timely information, and psychosocial and emotional support,
by practitioners with good clinical and interpersonal skills within a
• well functioning health system
A positive pregnancy experience is defined as
• Maintaining physical and socio-cultural normality

• Maintaining a healthy pregnancy for mother and baby

(including preventing and treating risks, illness and death)

• Having an effective transition to positive labour and birth, and

• Achieving positive motherhood (including maternal self-
esteem, competence and autonomy)
A positive pregnancy experience is defined as
• Maintaining physical and sociocultural normality

• Maintaining a healthy pregnancy for mother and baby

(including preventing and treating risks, illness and death)

• Having an effective transition to positive labour and birth, and

• Achieving positive motherhood (including maternal self-
esteem, competence and autonomy)
Components of positive pregnancy experience.
• The provision of effective clinical practices (interventions and
tests, including nutritional supplements),

• Relevant and timely information (including dietary and

nutritional advice)

• Psychosocial and emotional support, by knowledgeable,

supportive and respectful health-care practitioners, to optimize
maternal and newborn health.
 Aims of the guideline.
• Provide evidence-based frame work for ANC practices.

• To inform the development of national and local health polices and

clinical protocols.

• To energize countries to re-think and redesign their health systems.

• Uses the word “contact” instead of “visit to imply an active

connection between a pregnant woman and a provider.
 Strength of the new model
• The recommendations allow flexibility for countries to apply
various options both for the content and delivery of ANC based
on their specific needs and context.

• In the guideline, for each recommendation and for the new

WHO ANC model as a whole, implementation considerations
have been discussed at length to facilitate the adaptation and
implementation at country level.
 Recommendations on ANC
49 recommendations were grouped into five
topic areas:
A. Nutritional interventions (14)
B. Maternal and fetal assessment (13)
C. Preventive measures (7)
D. Interventions for common physiological
symptoms (6)
E. Health systems interventions to improve
the utilization and quality of ANC (9)
Including 10 recommendations relevant to
routine ANC from other WHO guidelines
 A. NUTRITIONAL INTERVENTIONS
Recommended:
• Counselling on healthy diets and keeping physically active to avoid excessive
weight gain.
• Daily oral iron and folic acid supplementation.

Recommended in areas of low intake:

• Calcium, vitamin A.

• Not recommended for routine use:

• Micronutrients, vit 6, (pyridoxine) E, C and D.
 B.2.Fetal assessment
• Daily FMC (eg “count to 10”) recommended in the context of
rigorous research.
• SFH and abdominal palpation to assess fetal growth stays.
• USS at 24 wk GA.
• Routine doppler – not recommended.
 B.Maternal assessment cont.
• Screenings:
• Anemia, ASB, IPV.
• DM, GDM.
• Tobacco, alcohol other substance abuse.
• PITC (for HIV), syphilis, viral
• TB – where prevalence is > 100/100,000.
 D. COMMON PHYSIOLOGICAL SYMPTOMS AND
RECOMMENDED TREATMENT
• Nausea in early pregnancy: ginger, vitB6, acupunture.

• Heartburn: diets, lifestyle changes, antacids.

• Low back and pelvic pain: physio, support belts, acupuncture.

• Constipation: diets, wheat bran, fibre supplement.

• Varicose vein and oedema: stockings, leg elevation, water immersion.

 C. Preventive measures
• Intermittent preventive treatment with sulfadoxine-
pyrimethamine (IPTp-SP) - for all pregnant women in endemic
areas. Start from second trimester or after quickening, every
months till delivery.

• Seven day antibiotics for ASB.

• Antibiotic prophylaxis for UTI – only in the context of rigorous

research
 C. Preventive measures cont.
• Anti-D immunoglobulin in non-sensitised Rhesus negative at 28
and 34 – only in the context of rigorous research

• Antihelminthic treatment after first trimester in endemic areas.

• Tetanus toxoid vaccination – depending on previous

vaccination.
 EMPHASIS OF THE NEW MODEL
GDG recommendation number E. 7:
• Reducing perinatal mortality
• Improving women’s experience of care.

• Activities at each visit not specified, as provided for in the

FANC.
 Health system interventions.
• E.1: It is recommended that each pregnant woman carries her
own case notes during pregnancy to improve continuity,
quality of care and her pregnancy experience.

• Will this recommendation not expose a woman to a potential

likelihood of inadvertent revelation of confidential matters
which she may not want a third party to know?
 FUTURE MODELS.
In accordance with WHO guideline development standards,

• These recommendations will be reviewed and updated

following the identification of new evidence, with major
reviews and updates at least every five years.

• WHO welcomes suggestions regarding additional questions for

inclusion in future updates of the guideline.
 CONCLUSION
• The ultimate aim of antenatal care is to prevent and treat
possible complications while ensuring safe delivery for mother
and a healthy baby.
• The new antenatal care model has expanded on the previous
models with the ultimate aim of making pregnancy a positive
experience for the woman. The new model is a guideline which
is to be modified and is expected to be adapted by each
country to suite her purposes.
 REFERENCES
• 1. WHO recommendations on antenatal care for a positive pregnancy experience.
ISBN 978 92 4 154991 2, (http://www.who.int)

• 2. Tuncalp Ӧ, Pena-Rosas JP, Lawrie T, Bucagu M, Oladapo OT, Portela A, Metin

G€ulmezoglu A. WHO recommendations on antenatal care for a positive
pregnancy experience—going beyond survival. BJOG 2017;124:860–862

• 3. Focused Antenatal care – George Lambert.

• Obstetrics by TEN Teachers, 20th edition.