Antenatal Care in Poor Countries Stephen Gloyd MCH in Developing Countries February 2007

Antenatal Care2 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

Antenatal Care3 IMPORTANCE OF PRENATAL CARE reduce high perinatal risk reduce high maternal risk (50x) major point of access to health care for women

Antenatal Care4 Access to prenatal care Physical access Time and/or distance to facility Economic costs & barriers Cultural and social factors Quality of care

Antenatal Care5 Trends in Antenatal care

Antenatal Care6 Estimates of the proportion of pregnant women who received some antenatal care (1996)

Antenatal Care7 Number of visits to ANC by region

Antenatal Care8

9 Antenatal care and delivery

Antenatal Care10 Timing of ANC visits (most in 1 st trimester except Africa)

Antenatal Care11 Estimates of the proportion of deliveries attended by skilled personnel (1996)

Antenatal Care12 Prenatal care vs attended birth and post partum care

Antenatal Care13 Components of prenatal care: Health education Screening Diagnosis and treatment Referral Screening/Dx o Identify women at high risk o Intervene to prevent development of problems o Dx and Rx pre-existing medical conditions o Dx and Rx complications of pregnancy

Antenatal Care14 Perinatal Morbidity and Mortality LBW Birth trauma, obstructed labor Infection u amnionitis u herpes u gonorrhea u syphilis u streptococcus u HIV u Tetanus Abruptio Placenta Congenital malformations "other" (30%)

Antenatal Care15 Maternal Morbidity and Mortality (Five main causes) Hemorrhage Sepsis Eclampsia Obstructed Labor Abortion Note: Mortality reduction requires secondary and tertiary care

Antenatal Care16 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)

Antenatal Care17 Poor outcomes: 3465 birth registries in 30 hospitals of Cote d’Ivoire (1997) ConditionRate per 1000 Normal760 Stillbirth 44 Neonatal death 6 LBW < 2500g < 2000g <1500g Eclampsia 2 Fetal disproportion 13 Fetal distress 15 Hemorrhage 22 Maternal deaths 2 Others 12 Operative delivery 36

Antenatal Care18 Prevalence of low birth weight globally

Antenatal Care19

Antenatal Care20 Sexually transmitted infections (STI) among pregnant women in Mozambique

Antenatal Care21 Preventability Overall Infant Deaths - 33% preventable (Nairobi) Syphilis: 100% preventable l 10% stillbirths l 20% Infant Mortality l 20% Congenital Syphilis Other causes:% preventable not clear

Antenatal Care22 Risk Approach Identification of high risk factors Predictive (Previous fetal loss) Contribution (Grand multipara, young or old) Causation (syphilis, HIV, maternal malnutrition)

Antenatal Care23 Risk Approach Not 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 u Have false sense of security u Do not know how to recognize/respond to problems Most “high risk” women give birth without complications u Thus, an inefficient use of scarce resources

Antenatal Care24 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

Antenatal Care25 Focused Antenatal Care Evidence-based, goal-directed actions Individualized, woman- centered care Quality vs. quantity of visits Care by skilled providers An approach to ANC that emphasizes:

Antenatal Care26 Goal of Focused Antenatal Care 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

Antenatal Care27 No Longer Recommended Numerous, routine visits u Burden to women and healthcare system Routine measurements and examinations: u Maternal height and weight u Ankle edema u Fetal position before 36 weeks Care based on risk assessment

Antenatal Care28 Focused Antenatal Care Services 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

Antenatal Care29 Focused Antenatal Care Services (cont’d.) 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

Antenatal Care30 Focused Antenatal Care Services (cont’d.) Individualized, woman-centered care based on each woman’s: Specific needs and concerns Circumstances History, physical examination, testing Available resources

Antenatal Care31 Focused Antenatal Care Services (cont’d.) Quality vs. quantity of ANC visits: WHO multi-center study u Number of visits reduced without affecting outcome for mother or baby Recommendations u Content and quality vs. number of visits u Goal-oriented care u Minimum of four visits

Antenatal Care32 Activities within PNC Minimum of 4 visits (see table) Individualized delivery plan depending on risk profile One PNC visit at referral hospital Health promotion (to individual and community) Emergency transport

Antenatal Care33 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 Scheduling and Timing of ANC Visits

Antenatal Care34 Basic component s of the WHO antenatal care program (1994)

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Antenatal Care36 Problems with interventions (general): Utilization is often low/widely 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

Antenatal Care37 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

Antenatal Care38 Issues in Prenatal Care Impact 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 u pMTCT u Malaria IPT u Syphilis ID and Rx u Iron therapy u Tetanus immunization u Family planning u Nutritional supplementation

Antenatal Care39 O ther interventions that need more study STD identification and treatment Routine anti parasite drugs Waiting houses Diabetes screening (depends on prevalence) Management and treatment of HTN

Antenatal Care40 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

Antenatal Care41 HIV in pregnancy Prevention of HIV transmission (pMTCT) u Opt-in vs opt out u Single dose Niverapine vs AZT vs HAART u Efficiency of treatment Care for HIV positive mother during pregnancy u Special nutritional needs u Social needs, stigma HAART in pregnancy u Toxicity (NVP, AZT) u Patient flow and adherence

Antenatal Care42 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 u HIV+ to counseling u 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

Antenatal Care43 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% of stillbirths attributable to prenatal syphilis 8% of IMR due to syphilis Screening is effective & inexpensive u Basic Screening Test (RPR) costs US$ , takes minutes u 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

Prevention and Control of Malaria during Pregnancy

Antenatal Care45 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

Antenatal Care46 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

Antenatal Care47 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)

Antenatal Care48 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 u utilization of TBA or health facility services (delivery and ANC) u outcome of pregnancy for mother and child u utilization of other primary health care services

Antenatal Care49 Impact of Traditional Birth Attendant training in Rural Mozambique - RESULTS In TBA trained communities u 30% of these pregnant women utilized theTBAs u 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