Antenatal Care: Old Myths, New Realities

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Antenatal Care Old Myths, New Realities

• MAQ Mini-University
• April 20, 2001

Theresa Shaver NGO Networks
Barbara Kinzie MNH Program
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Traditional ANCWhat it looks like

• Originated from models developed in Europe in
  early decades of the century
• Ritualistic rather than rational
• Emphasis of visits is on frequency and numbers,
  rather than on essential elements

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No longer recommended

• Numerous routine visits
• Burden to health system
• Study of reduced visits program in Zimbabwe

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No longer recommended

• Risk approach
• Kasango, Zaire study
• 71 of women who did develop obstructed labor
  were not predicted
• 90 of women identified as at risk never
  developed complications
• Problems with risk approach
• Poor predictive value
• Failed to distinguish those who would develop
  complications from those who would not
• Many women categorized as high risk never develop
  complications but consume scarce resources (e.g.,
  hospital deliveries)
• Many women categorized as low risk do develop
  complications but are never told how to recognize
  or respond to them (i.e., false security)
• Identification of special need does not guarantee
  appropriate action

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Lessons from Risk Approach

• Every pregnant woman is at risk of complications
  and must have access to quality maternity care.
• Even low-risk women may develop complications.
• No amount of screening will separate out those
  women who will need emergency care from those who
  will not need such care.

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No longer recommended

• Routine/ritual measurements and examinations
• Height
• Ankle edema
• Fetal position below 36 weeks

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Recommended

• Goal-directed visits by skilled provider
• WHO recommends four focused visits as sufficient
  for normal pregnancy

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RecommendedBirth Preparedness, including
Complication Readiness

• Preparing for Normal birth
• Skilled attendant
• Place of delivery
• Finance
• Nutrition
• Essential items

• Readiness for complications
• Early detection
• Designated decision maker(s)
• Emergency funds
• Communication
• Transport
• Blood donors

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Recommended

• Counseling
• Nutrition
• Family planning
• Breastfeeding
• Danger signs
• HIV/MTCT

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Recommended

• Detection and management of existing diseases and
  conditions
• HIV Voluntary counseling and testing
• STIs, including Syphilis
• Tuberculosis

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Recommended

• Detection and management of complications
• Severe anemia
• Vaginal bleeding
• Pre-eclampsia/eclampsia

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RecommendedPrevention

• Tetanus toxoid
• Iron and folate supplementation

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RecommendedPrevention

• In select populations
• Iodine supplementation
• Malaria - intermittent presumptive treatment
• Routine hookworm treatment

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ANC Best Practices

• Not recommended
• Numerous routine visits
• High risk approach
• Routine measurement
• Height
• Fetal position before 36 weeks
• Ankle edema

• Recommended
• Focused antenatal visits by skilled provider
• Birth preparedness and complication readiness
  planning
• FP, breastfeeding, danger signs, HIV/STDs, and
  nutrition counseling
• Detection and management of co-existing
  conditions and complications
• Tetanus toxoid
• Iron and folate
• In selected populations
• Iodine
• Malaria presumptive treatment
• Helminth presumptive treatment

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REFERENCES

• Ahmed, Y. et.al., A study of maternal mortality
  at the University Teaching Hospital, Lusaka,
  Zambia the emergence of tuberculosis as a major
  non-obstetric cause of maternal death, Intl
  Journal of Tubercular Lung Disease, Vol. 3 (8)
  675-80, August 1999.
• Bergsjo, P. and Villar, J. Scientific basis for
  the content of routine antenatal care, Vol. 1
  2, Acta Obstericia et Gynecologica Scandinavica,
  1997
• Chung, P.K., et.al, An audit of antenatal care
  the value of the first antenatal visit. British
  Medical Journal, 280, 1980.
• The Cochrane Library, Issue 1, 2001. Oxford
  Update Software.

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REFERENCES

• Figueroa-Damian R and Arrendondo-Garcia JL.
  Neonatal Outcome of Children Born to Women with
  Tuberculosis, Archives of Medical Research, Vol
  32 (1) 66-69, January 2001.
• Hira, et.al. Syphilis intervention in pregnancy
  Zambian demonstration project., Cochrane Library
  Document
• Hofmyer, G.J. (1989). Suspected fetopelvic
  disproportion. Effective care in Pregnancy and
  Childbirth (Eds. I. Chalmers, M. Enkin, and MJNC
  Keirse.) Oxford Oxford Univ. Press, pp. 493-498
• Kasonga Project Report, Journal of Tropical
  Medicine and Hygiene, Vol 87, 1984

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REFERENCES

• Looaresuwn S., et al. Quine and severe
  falciparum malaria in late pregnancy, The
  Lancet, 24-7 (1985)
• Maine, Deborah, Safe Motherhood Programs
  Options and Issues, 1991
• MotherCare, Issues in Programming for Maternal
  Anemia, September 2000.
• Ministry of Health, His Majestys Government of
  Nepal, Maternal Mortality and Morbidity Study,
  p. 29, 1998
• Munjanja, et.al. Randomised controlled trial of
  a reduced-visits programme of antenatal care in
  Harare, Zimbabwe. The Lancet, Vol. 348. August
  10, 1996. Pp. 364-369

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REFERENCES

• Stoltzfus, RJ, Dreyfuss, ML, Chwaya HM, Albonico
  M. Hookworm control as a strategy to prevent
  iron deficiency. Nutrition Reviews, Vol 55. No.
  6, 1997
• Tinker and Koblinsky, Making Motherhood Safe,
  World Bank, 1993
• UNAIDS and WHO, HIV in Pregnancy A Review,
  1999
• Villar J. and Khan-Neelofur D. Patterns of
  Routine Antenatal Care for Low-risk Pregnancy,
  Cochrane Library, Issue 1, 2001.

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REFERENCES

• Wang and Smaill Infection in Pregnancy from I
  Chalmers, et.al. Effective Care in Pregnancy and
  Childbirth, pp. 534-64
• WHO, Antenatal Care report of a technical
  working group, 1996
• WHO, Antenatal Care and Maternal Health how
  effective is it? A review of the evidence,
  1992.