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Slide 2
Refocusing of Antenatal Care
Objectives of presentation:
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Describe and give the rationale for the number of prenatal visits;
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Describe and give the rationale for the kinds of providers competent to provide antenatal care;
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Describe and give the rationale for the recommended contents of refocused antenatal care;
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Enumerate and describe the significance of factors associated with complications and danger signals;
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Describe and give the rationale for various elements of care provision and health education.
Slide 3
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Essential for any safe motherhood interventions is the understanding that no one intervention can make a difference for maternal morbidity and mortality.
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Good antenatal care must be provided within a larger context where equity, emotional and psychological support, and a commitment to provide basic health services are priorities.
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Antenatal Care is still a big pillar of Safe Motherhood.
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Antenatal services also need to be linked with quality emergency obstetric services, should the woman experience a complication at any time during her pregnancy.
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Finally, good safe motherhood services must be part of a continuum of services in which family planning, postabortion care, intrapartum and postpartum care are all provided and support one another.
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Department of Reproductive Health and Research
Slide 4
Objectives of ANC:
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Promote and maintain the physical, mental and social well-being of both the mother and baby by providing education on danger signals, nutrition, rest, sleep and personal hygiene PLUS the environment of the pregnancy and birth; Keeping normal “normal”
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Detect and manage complications, whether medical, surgical or obstetric: current problems, not predictions
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Develop birth preparedness plan: who attends, where, communication/transportation, birth attendant, who accompanies, necessary items (blanket/towels, clean plastic cover, clean razor blade, clean setting
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Develop complication readiness plan: where, who accompanies, who stays with children, who makes decisions if primary decision-maker not available, potential blood donor, finances, transportation, communication
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Help prepare the mother to breastfeed successfully, experience normal puerperium, and take good care of the child physically, psychologically and socially
Slide 5
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Provider
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The issue of who could or should provide antenatal care continues to be widely discussed, despite the extensive implementation of Midwife managed programs or antenatal care led by providers other than Obstetrician/Gynecologists. The WHO Department of Reproductive Health and Research found that clinical effectiveness of Midwife/General Practitioner managed care is similar to that of Obstetrician/ Gynecologist led shared care. In addition, they found that lower salary costs and enhanced women's satisfaction can be attained by Midwives' clinics (Giles, 1992; Tucker, 1996; Turnbull, 1996). The most important lesson from this is that the set of competencies necessary to provide antenatal care is more important than the specific cadre of healthcare provider caring for a woman during her pregnancy.
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In addition, while women’s response to the midwives' clinic were positive, continuity of care and of care provider was a significant factor enhancing women's satisfaction and building confidence. Care providers should, therefore, seek to facilitate a system of care provision that fosters continuity of both the provider and the care
received.
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Screening and Detection of existing diseases and treatment which will have a direct impact on the pregnancy, childbirth, or perinatal outcome: HIV, Syphilis, Tuberculosis, Hypertension, Diabetes
Slide 6
In the past, healthcare services used a risk system to identify women with “high risk” pregnancies, so that they could be referred for specialized care. Unfortunately, more than 10 years of experience has shown that this system has many limitations, for example:
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“Risk factors” cannot predict complications because usually they do not directly cause the complication; (e.g., young age is associated with a higher risk of eclampsia, but does not cause it).
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Because maternal mortality is a relatively rare event in the population at risk (I.e., women of reproductive age) and the “risk factors” are relatively common in the same population, “risk factors” do not appear to be good indicators of which women will experience complications.
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The majority of women who experience a complication were considered “low risk;” while the vast majority of women considered to be “high risk” give birth without complications.
Given the limitations of the “risk approach,” what can be done? The literature strongly suggests that:
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All pregnancies should be regarded as “at risk” of developing a complication and be managed with the utmost care;
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The focus of obstetric care should be shifted from predicting complications through identification of “risk factors”
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Detecting signs and symptoms of actual problems and
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Educating women, men and family members about danger signals and complication readiness;
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“Risk factors,” should be regarded as “factors associated with complications” rather than as indicators of complications. Their importance for each pregnancy and childbirth should be considered on an individual basis.
We do not recommend abandoning antenatal care. Patients often have pre-existing disease, or develop diseases during pregnancy that require care at regular intervals, but antenatal care cannot be used to predict complications later. It is not useful as a screening tool. It is important for detecting current problems and for keeping the normal pregnancy, “normal."
Slide 7
Birth preparedness:
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Who attends, who accompanies, where, transportation, supplies
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Complication readiness (What plan does the woman/family have to manage a complication):
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Transport, decision-makers, who accompanies, finances, where potential blood donors
Slide 8
Goal-directed care:
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In many countries, the antenatal exam is divided into stations - history, blood pressure, height and weight, urine testing, abdominal palpation and fetal heart tones, etc. - with the woman moving from station to station until her antenatal exam card is filled in for the visit. When information is gathered in this way, there is a risk that the information gathered is analyzed in isolation rather than integrated.
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Goal-directed care, on the other hand, involves gathering information in such a way that certain complications are either detected or ruled out. The table shows how information can be gathered in a goal-directed way.
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Collecting information in this way forces the provider to look critically at all of the parameters that are being checked, and deciding if they mean that the woman’s pregnancy is evolving normally or that she is experiencing a complication that needs to be managed.
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The quality of antenatal care can be improved by having goal-directed care, not only because providers are processing the information they gather, but also because this way of gathering information facilitates clinical decision making.
Slide 9
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The antenatal visit can be used as one way that healthcare providers can provide information to the pregnant woman and her family
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For advice or information to be useful, staff at antenatal clinics need to have:
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adequate knowledge of the subject at hand
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enough time to give practical advice
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an understanding of local beliefs and taboos surrounding the subject during pregnancy
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adequate knowledge of locally available, culturally feasible, and financially accessible interventions.
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For nutritional advice or information to be useful, messages need to be
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simple (“increase the number of times you eat a day,” and “no foods are taboo”)
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realistic - advice will only be translated into action if women have the real possibility of implementing the advice given
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specific for the woman and her particular situation.
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Malaria prophylaxis is covered in further detail in another slide set. In addition, there are several slide sets on other topics, including headache, HIV and nutrition.
Slide 10
“Hope for the best and prepare for the worst”
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Too many women die because they suffer from serious complications during pregnancy, birth, or postpartum, but cannot get to the level of healthcare that can provide competent care for their problems:
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because the primary decision-maker is absent and no one else can make a decision to let the woman seek care,
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because they do not have access to financial assets to pay for the care, and
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because they do not have access to a means of transportation that can take them.
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A pregnant woman and her family can prepare for birth before the event occurs - she will need to choose a skilled attendant to assist her at birth and an appropriate birth setting. She will also need to have the necessary money for care, make a decision about how to get where she plans to give birth, and who will accompany her and stay behind to care for the family. She and her family can also gather supplies such as clean bed clothes, perineal pads or cloths, and a bar of soap.
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The birth plan is an action plan that has been made after discussion by the woman, her family members, and the healthcare provider. It does not need to be a written document, and usually will not be. Rather, it is an ongoing discussion between all concerned parties to ensure that the woman receives the appropriate care in a timely manner.
Slide 11
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We know that 40% of pregnant women will develop some form of a pregnancy-related complication, that 15% of all pregnant women develop a life-threatening complication requiring obstetric care, and that 1-2% of these women will die (UNICEF, 1996). Evidence has shown that it is nearly impossible to predict which women will have a complication, so it is extremely important to work with all women to recognize complications and to establish a plan of action in case they arise. This should save many women’s lives and ensure that they arrive earlier at points in the healthcare system where they can receive appropriate and competent care.
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A pregnant woman also needs to develop a plan for emergency transportation with the family in case she develops a complication and needs to seek care. It is important to discuss how families/couples make decisions about when to seek care and where to go. When only one person is responsible for making decision, it is important to establish an alternate plan for decision-making if there is an emergency when the chief decision-maker is absent. The husband or the mother-in-law may be the primary decision-maker and should make a plan for decision-making.
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The family should be encouraged to save money or learn how to access community emergency funds so that the necessary funds will be available in the case of an emergency. In too many cases, women either don’t seek care or don’t receive care because they don’t have the necessary funds.
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A major problem in many facilities is that although a facility may be able to provide a blood transfusion, there is a chronic lack of blood. Another problem, of course, is a supply of “safe” blood to be transfused. Women are at a high risk of developing blood-borne infections because they are exposed to pregnancy and potential complications leading to loss of blood. For these two reasons, it is extremely important that the woman designate blood donors that can be available should the need arise either during pregnancy, labor, birth, or in the immediate postpartum period.
Slide 12
Goal directed interventions are not risk assessment. Evidence is used to evaluate proven interventions. We continue to learn more.
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