1. Basic Antenatal Care Package in South Africa

2. Antenatal Care The health care of pregnant women.
The care is aimed at detecting problems.
Once problems are detected they can be addressed.
Interventions during pregnancy can have beneficial effects later in life.
ANC has a further role of improving the general health of the woman.
Not only is the pregnancy examined, but also the general health and habits of the woman.
Interventions during pregnancy can have permanent beneficial effects later in the woman’s life.
ANC can screen for, detect, and thus prevent many maternal complications occurring
before childbirth

3. Routine antenatal care
12 visits: Traditional schedule
2001: RCT showed no difference between the standard Western model of antenatal care and a model that limited the number of visits.
Introduced into practice without much evidence for its effectiveness in reducing maternal and neonatal morbidity and mortality.
What can antenatal care achieve?
Improve maternal health
Improve the health and survival of the baby
Provide the pregnant woman with information on:
Warning signs during pregnancy and how to respond
Bad habits such as drinking alcohol and smoking
Nutrition
Contraception
Feeding her infant
HIV
ANC can screen for, detect, and thus prevent many maternal complications occurring
before childbirth

4. Routine antenatal care
Focused ANC introduced in SA in 2008 (BANC)
Specifically designed for non-midwife ANC providers.
5 critically timed visits.
Antenatal visits integrated multiple evidence-based interventions (1st visit, 20, 28, 34, 38 weeks)
(primary health care facilities that performed basic antenatal care as part of the complete package of care rendered at that level)
3000+ PHC clinics
Supermarket approach
Knowledge and skills poor
Problem with referrals of women with high risk factors

5. Why is improvement in antenatal care needed?
The stillbirth rate is a reflection of the quality of antenatal care.
Surveys have indicated shortcomings in the performance of antenatal care.
Patient factors? -95% of pregnant women attend antenatal care-
2,6 mil stillbirths globally.
Majority in the developing countries.
98% in low middle income countries
Sub Saharan Africa has 10 times higher than the developed counties
29 vs 3 per 1000
Recommendations have included improving antenatal care as one of the key points.
the problem is not women not attending antenatal care, but rather the quality of care given.

6. Mpumalanga audit (BANC model)
Most common cause of stillbirths
Hypertensive disorders
Unexplained (IUGR)
Third trimester- greatest risk
Failure to measure or respond to maternal hypertension
Poor knowledge and skills
Delay in referral to expert care
Failure to detect risk factors

7. Comparison with Western Cape
perinatal mortality rate was significantly higher in the reduced visit group.

8. BANC: Reduced number of visits
An updated Cochrane review was published in 2015.
For low and middle income countries, the perinatal mortality rate was significantly higher in the reduced visit group.
WHO: 5-visit FANC model no longer recommended.
No difference between models with 8 visits when compared to visits.
Better monitoring of maternal and fetal well being
Timely detection of risk factors and complications.
Number of visits as well as quality of care during each visit.
Aim to reduce preventable morbidity and mortality.
A reduced number of antenatal visits (<5) may lead to:
An increased number of stillbirths and deaths from undetected growth restriction and/or hypertensive conditions

9. What should antenatal care do?
Evidence based interventions that leads to improved outcomes.
How can these practices be delivered?

10. BANC Plus BANC visits to 8 (booking plus 7)
Improve the quality of antenatal care package
Provide support for primary care clinics performing basic antenatal care.
Reduce preventable morbidity and mortality
BANC-Plus is the minimum antenatal care that every pregnant woman should receive.
The ‘Plus’ refers to the recent introduction of additional antenatal care visits –
a change that was necessary because
research around the world has shown that few visits, as was the case with BANC previously, resulted in increased death rates in the babies (increased perinatal mortality). Every aspect of BANC-Plus is based on best evidence,
only aspects that have been shown to be effective are included.
This includes the need for additional antenatal care visits as compared with the original BANC programme.
booking visit plus 7 more visits: a 20 weeks visit, and then visits at weeks, weeks and thereafter every 2 weeks until term (booking, 20, 26-28, 30-32, 34, 36, 38, 40
The support could be on a rotation basis allowing one professional nurse/medical officer with specific training to service a number of primary care clinics

11. BANC Plus The care has been simplified to a minimum.
Use of flow charts and Protocols
Use of Checklists: demonstrated to improve the quality of care.
Women requiring additional care should be identified and referred to the next level.
Every clinic midwife should be able to perform BANC Plus.

14. The first visit (How, What, Why)
Ask
Personal History
Identify special conditions or risk factors for referral
Obstetric History
Gestational age history
Calculate EDD
Medical History
Look, Listen, Feel
Physical examination
Tests, record signs
Hb, Rh, RPR, HIV, Urine
Plan
Checklist
Qualify for BANC?
Classify, Implement, treat
Supplements, etc.
Preventing complications and improve general health
Give advice
Answer questions
Schedule next visit
Complete records, checklist
All patients should receive or be checked at every visit
Iron, folate and calcium (and multivitamins if indicated)
Nutritional advice
Advice on what to do if the warning signs in pregnancy appear
Where she plans to give birth
What transport arrangements have been made should she go into labour

16. Follow-up visits (How, what, when, why)
Rapid assessment and management
Ask
Check record
Look, listen, feel
Signs
Classify
Treat and Advise
Fill-in antenatal card and Checklist
Implement
General advice
Questions and answers
Date next visit
Complete records
The follow-up visits have been found to be most effective at 20, 26, 30, 34, 36, 38 and 40 weeks’ gestation. This coincides with performing examinations and tests at times that are of most benefit to the pregnant woman and that give the greatest chance of detecting problems that can be treated. Findings from a large international study run by the WHO have recently been updated and suggest that concentrating visits in the period from 26 to 38 weeks may reduce stillbirths related to IUGR and hypertension.

17. BANC Plus visits schedule
Performing only examinations and tests that have been proven to be beneficial, and at the most appropriate time
Wherever possible, rapid easy-to-perform tests should be used at the antenatal clinic or in a facility close to the clinic. The results should be available the same day so treatment can be initiated at the clinic without delay
Health care providers should
Task-shifting for counselling on birth preparedness, complication readiness, breast feeding
Every aspect of BANC-Plus is based on best evidence,
and only aspects that have been shown to be effective are included.
This includes the need for additional antenatal care visits as compared with the original BANC programme.
make all the pregnant women feel welcome at their clinic, and it should be convenient for the pregnant women to attend the clinic.
Timing the visits such that the maximum benefit can be obtained, without wasting human resources

18. BANC Plus Issues
Implementation: in with the new, evidence based medicine
Training: Quality improvement package
Protocol book: Ownership
Checklists
make all the pregnant women feel welcome at their clinic, and it should be convenient for the pregnant women to attend the clinic.
Timing the visits such that the maximum benefit can be obtained, without wasting human resources.
Performing only examinations and tests that have been proven to be beneficial, and at the most appropriate time
Wherever possible, rapid easy-to-perform tests should be used at the antenatal clinic or in a facility close to the clinic. The results should be available the same day so treatment can be initiated at the clinic without delay
Health care providers should
Task-shifting for counselling on birth preparedness, complication readiness, breast feeding

19. Objective Enable a positive pregnancy experience
If women’s experience of care is positive, they will attend more visits
Timing the visits such that the maximum benefit can be obtained, without wasting human resources.
Performing only examinations and tests that have been proven to be beneficial, and at the most appropriate time
Wherever possible, rapid easy-to-perform tests should be used at the antenatal clinic or in a facility close to the clinic. The results should be available the same day so treatment can be initiated at the clinic without delay
Health care providers should make all the pregnant women feel welcome at their clinic, and it should be convenient for the pregnant women to attend the clinic.
Task-shifting for counselling on birth preparedness, complication readiness, breast feeding