1. Antenatal Care in Poor Countries
4/17/2017
Antenatal Care in Poor Countries
MCH in Developing Countries
January 2009
Stephen Gloyd
Malaria in Pregnancy

2. 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 Care

3. IMPORTANCE OF ANTENATAL CARE
reduce high perinatal risk
reduce high maternal risk (50x)
major point of access to health care for women
Antenatal Care

4. Access to antenatal care
Physical access
Time and/or distance to facility
Economic costs & barriers
Cultural and social factors
Quality of care
Antenatal Care

5. Trends in Antenatal care 1990-2000

6. Estimates of the proportion of pregnant women who received some antenatal care (1996)

7. Number of visits to ANC by region
Antenatal Care

8. Antenatal Care

9. Antenatal Care

10. Antenatal Care

11. Antenatal care and delivery

12. Timing of ANC visits (most in 1st trimester except Africa)
Antenatal Care

13. Estimates of the proportion of deliveries attended by skilled personnel (1996)
Antenatal Care

14. Prenatal care vs attended birth and post partum care
Antenatal Care

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

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

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

18. Other Causes of Maternal Morbidity and Mortality
Hypertension
Diabetes
Heart Disease
Hepatitis
Anemia
Malaria
Tuberculosis
STD
Overall Morbidity: % of all pregnancies
(up to 37% in India)
Antenatal Care

19. 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
Others 12
Operative delivery 36
Antenatal Care

20. Prevalence of low birth weight globally
Antenatal Care

21. Antenatal Care

22. Sexually transmitted infections (STI) among pregnant women in Mozambique
Antenatal Care

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

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

25. 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
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
Antenatal Care

26. 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 Care

27. 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
Antenatal Care

28. Other 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 Care

29. 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
Antenatal Care

30. 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
Antenatal Care

31. Prevention and Control of Malaria during Pregnancy

32. 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 Care

33. 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 Care

34. 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
Basic Screening Test (RPR) costs US$ , takes 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
Antenatal Care

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

36. 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 Care

37. 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
Antenatal Care

38. Antenatal Care

39. 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 Care

40. 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 Care

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

42. 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 Care

43. 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
Antenatal Care

44. Basic components of the WHO antenatal care program (1994)

45. Antenatal Care

46. 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
Antenatal Care

47. 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 Care

48. Safe childbirth care
Antenatal Care

49. Antenatal Care

50. 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 Care

51. 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
Antenatal Care

52. 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
Antenatal Care

53. 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 Care