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Focused Antenatal Care: Planning and Providing Care During Pregnancy - A Maternal And Neonatal Health Program Best Practice (December 2001)
The MNH approach emphasizes quality over quantity in antenatal visits.
At the core of the MNH Program's approach to antenatal care are focused visits with a skilled provider, aimed at ensuring the healthiest possible outcome for every mother and baby.
Antenatal care, the care a woman receives throughout her pregnancy, is important in helping to ensure that women and newborns survive pregnancy and childbirth. The traditional approach to antenatal care, which is based on European models developed in the early 1900s, assumes that more is better in care for pregnant women. Frequent routine visits are the norm, and women are classified by risk category to determine their chances of complications and the level of care they need. Many developing countries have adopted this approach without adjusting the interventions to meet the needs of their particular populations, taking into account their available resources or evaluating the scientific basis for specific practices.
The Maternal and Neonatal Health (MNH) Program promotes an updated approach to antenatal care that emphasizes quality over quantity of visits. The approach, focused antenatal care, recognizes two key realities. First, frequent visits do not necessarily improve pregnancy outcomes, and in developing countries they are often logistically and financially impossible for women. Second, many women who have risk factors never develop complications, while women without risk factors often do. So, when antenatal care is planned using a risk approach, scarce healthcare resources may be devoted to unnecessary care for "high-risk" women who never develop complications, and "low-risk" women may be unprepared to recognize or respond to signs of complications.
Following the World Health Organization's lead, the MNH Program takes the view that every pregnant woman is at risk for complications and that all women should therefore receive the same basic care and monitoring for complications. The Program does not recommend relying on certain measures and risk indicators that are routine in traditional antenatal care (such as height, ankle edema and fetal position before 36 weeks), because they have not been proven to be effective in improving pregnancy outcomes.
Goal-Directed Interventions
The MNH Program's approach focuses on evidence-based interventions that address the most prevalent health issues that affect mothers and newborns. Each focused antenatal care visit includes interventions that are appropriate to the woman's stage of pregnancy and that address her overall health and preparation for birth and care of the newborn.
Detection and Prevention
When the Kasongo Project Team studied 3,614 women in an antenatal clinic in Kasongo, Zaire, in 1984, they found that 71% of the women who developed obstructed labor were not identified as "at risk," while 90% of women who were identified as "at risk" did not develop obstructed labor.
The skilled provider interviews and examines the woman to detect problems that might affect the woman's pregnancy and require additional care. Conditions that could severely affect the mother or baby if they are left untreated include HIV, syphilis and other sexually transmitted diseases, malnutrition and tuberculosis (especially in populations where HIV is common). Also, conditions such as severe anemia, vaginal bleeding, pre-eclampsia/eclampsia, fetal distress and abnormal fetal position after 36 weeks may cause or be indicative of a life-threatening complication. Early treatment of these conditions can mean the difference between death and survival for the woman and her newborn.
In addition to early detection and treatment of problems, two simple preventive interventions have proven effective in reducing maternal and neonatal deaths. The first, tetanus toxoid, is a stable, inexpensive vaccine that helps to prevent neonatal and maternal tetanus. Tetanus causes about 500,000 neonatal deaths and 30,000 maternal deaths each year. The second intervention, iron and folate supplementation, helps to prevent iron deficiency, the single most prevalent nutritional deficiency affecting pregnant women. Iron deficiency can lead to severe anemia, which is associated with preterm delivery, inadequate intrauterine growth, and maternal and fetal deaths.
The MNH Program also supports the following preventive treatments in areas where the diseases or deficiencies are common: intermittent preventive treatment for malaria, presumptive treatment for hookworm, vitamin A supplementation and iodine supplementation.
Counseling and Health Promotion
Focused antenatal care visits should include time for providers and women to talk about important issues related to nutrition and health during pregnancy, including the following:
- Danger signs of complications during pregnancy and labor: how to recognize them, what to do and where to get help
- Nutrition: the importance of good nutrition to the health of the mother and baby; how to get enough calories and essential nutrients for a healthy pregnancy; micronutrient supplements; importance of iron intake
- Risks of using tobacco, alcohol, medications and local drugs
- Rest and avoidance of heavy physical work
- Family planning: benefits of child spacing to mother and child; options for family planning services following the baby's birth
- Breastfeeding: health and practical benefits; exclusive breastfeeding; importance of immediate breastfeeding after birth
- HIV and other sexually transmitted diseases: the use of condoms for dual protection from pregnancy and disease; other measures for prevention; availability and benefits of testing; and specific issues related to mother-to-child transmission and living with AIDS (after a positive test result)
Birth Preparedness and Complication Readiness
Focused antenatal care includes attention to a woman's preparations for childbirth, such as getting the support she will need from her provider, family and community, and making arrangements for her newborn. The skilled provider and the woman should plan for the following:
- A skilled provider to be at the birth
- The site for the birth and how to get there
- Items needed for the birth, whether it will be at home or in a healthcare facility
- Money to pay for the skilled attendant and any needed medications
- Support after the birth, including someone to accompany the woman during the birth and someone to take care of her family while she is away
In addition, since 15 percent of all pregnant women develop a life-threatening complication and most of these complications cannot be predicted, every woman and her family must be ready to respond to such a problem. Every woman should have a plan for the following:
- A person designated to make decisions on her behalf, in case she is unable to make them
- A way to communicate with a source of help (skilled attendant, facility, transportation)
- A source of emergency funds
- Emergency transportation
- Blood donors
Focused Antenatal Care in the MNH Program
The MNH Program promotes focused antenatal care as one of a group of essential maternal and neonatal care interventions that are evidence-based and that build on global lessons learned about what works to save the lives of mothers and newborns. Focused antenatal care is an integral part of the Program's learning materials, including two technical manuals endorsed by the global health community: "Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and Doctors" (published by the World Health Organization) and "Basic Maternal and Newborn Care" (forthcoming from JHPIEGO with substantial contributions by the American College of Nurse-Midwives and BASICS). The important role of antenatal care in helping women prepare for birth and possible complications is illustrated in the MNH Program's behavior change intervention aid, "Birth Preparedness and Complication Readiness: A Matrix of Shared Responsibility" (available on the MNH Program website).
For more information about the MNH Program visit their website: www.mnh.jhpiego.org
This publication was made possible through support provided by the Office of Health and Nutrition, Center for Population, Health and Nutrition, Bureau for Global Programs, Field Support and Research, U.S. Agency for International Development, under the terms of Award No. HRN-A-00-98-00043-00. The opinions expressed herein are those of the author(s) and do not necessarily reflect the views of the U.S. Agency for International Development.