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Ante-Natal care Evidence-Based Perspective. Alaa Eldin Hamed ELFEKY Professor of Obstetrics & Gynecology ASU-EBM GROUP Faculty of Medicine, Ain Shams University. Effective care. The Care that women and their babies receive during pregnancy and childbirth must be effective. BENEFICIAL.
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Ante-Natal careEvidence-Based Perspective Alaa Eldin Hamed ELFEKY Professor of Obstetrics & Gynecology ASU-EBM GROUP Faculty of Medicine, Ain Shams University
Effective care The Care that women and their babies receive during pregnancy and childbirth must be effective BENEFICIAL HARMFUL COST CONVENIECE
Impressions or Facts? • The belief that one form of care is better than the other is usually based on an IMPRESSION, derived from personal experience or previous teaching. • These may be correct or incorrect . • Unless the validity of these impressions is assessed, HARM may occur.
Goals of ANC • Promote and maintain • the physical, mental and social health of mother and baby • by providing education • on nutrition, personal hygiene and birthing process. • Help prepare mothers to • breastfeed successfully • experience normal puerperium • take good care of the child physically, psychologically and socially
Goals of ANC • Develop birth preparedness and complication readiness plan. • Detect and manage complications during pregnancy, whether medical, surgical or obstetrical.
Disease Detection : Risk Assessment Risk approach has not proven to be an efficient or effective strategy for maternal mortality reduction: “Risk factors” • Cannot predict complications • Not a direct cause of complication • Statistically associated with the outcome. Fortney 1995; Yuster 1995.
Disease Detection : Risk Assessment Most risk factors cannot be changed: Parity Age Weight Family history Past reproductive performance.
Disease Detection : Risk Assessment Majority of women who experienced complication were considered “low risk”
Evidence-Based/Goal-Directed ANC • Increasing use of systematic reviews to evaluate effectiveness of interventions. • Goal-directed interventions. Let us learn from football !!!
The English Plan Depending on the wind, the striker’s position may vary…
The German Plan Radical, efficient, unstoppable… (ball’s speed may reach 297 km/h)
The Italian Plan Iron defense, small ideas in midfield, passes to striker..and…Penalty
The Brasilian Plan … no comments!
The Swiss Plan They manage to lose the game by themselves, no help needed.
The French Plan In their plan, they try all possible hypotesis. Shit! They forgot the goal
The Egyptian Plan No Plan…but we are trying hard!!!
Evidence-based ANC Beneficial forms of care Forms of care likely to be beneficial Forms of care with trade-off between benefit and harm Forms of care unlikely to be beneficial Forms of care that are ineffective or harmful
What is Effective ANC? Continuous Care from a skilled attendant: • Care must meet the social and psychological needs of women. • Women who had continuity of caregivers were less likely to use pharmacologic analgesia during birth: Cochrane reviews of multiple controlled trials: 07672 / 07674 / 04169 / 03776 / 03776
What is Effective ANC? Preparation for birth and potential complications: • The benefits of Ante-natal classes as regards less need for analgesia and better satisfaction are well documented.[Review 05620] • The extent to which these classes may contribute to feelings as fear or affect the decision making process of the mother are not well studied .
What is Effective ANC? Promoting health and preventing disease: Folate supplementation. [RCT:4mg/day for +ve history of NTD; 0.8mg for others][Reviews 06488;06489] Tetanus toxoid. Restricting Tobacco and alcohol use.
What is Effective ANC? Detection of existing diseases and treatment: HIV, syphilis, Tuberculosis, other co-existing medical diseases (e.g., Hypertension, Diabetes) Early detection and management of complications
Beneficial forms of care: Effectiveness demonstrated by clear evidence from controlled trials [Grade Ia] • Folic acid supplementation. • Iodine supplementation.
Beneficial forms of care: • Antihistamines for nausea and vomiting • Local imidazoles for candida infection. • Anti-D postpartum for Rh –ve women. • Antibiotic treatment for asymptomatic bacteriuria. • Tight as opposed to strict or moderate control of blood glucose levels in diabetic women.
Beneficial forms of care: • External cephalic version at term to avoid breech presentation at birth. • Corticosteroids to promote fetal lung maturation before preterm birth. • Offering induction of labor at 41+ weeks of gestation
Ineffective or Harmful forms of care: • Dietary restriction to prevent pre-eclampsia (including caloric restriction; salt restriction). • Ante-natal breast or nipple care for women who plan breast feeding. Ineffectiveness or Harm demonstrated by clear evidence
Ineffective or Harmful forms of care: Ineffectiveness or Harm demonstrated by clear evidence • Contraction stress test . • Non-stress test.
Ineffective or Harmful forms of care: • DES during pregnancy. • External cephalic version before term to avoid breech presentation at birth. • Progestogens to stop preterm labor. • Routine enema in labor. • Routine pubic shaving in preparation for delivery.
Forms of care unlikely to be beneficial: • Advise to restrict sexual activity during pregnancy. • Imposing dietary restrictions during pregnancy. • Routine vitamin supplementation in well nourished populations. • Routine Hematinic supplementation in well nourished populations. • Routine ultrasound use in late pregnancy No evidence for, with some possible adverse effects
Forms of care unlikely to be beneficial: Screening for pre-eclampsia by: Roll-over test, Cold-pressor test, Edema, Isometric exercise, Measuring uric acid. Diuretics or Diazoxide for pre-eclampsia. Screening for gestational diabetes: Routine glucose challenge test, routine measurement of blood glucose.
Forms of care unlikely to be beneficial: • Calcium supplementation for leg cramps. • Bed rest for threatened abortion. • Hospitalization or cervical cerclage for twin pregnancy. • Prophylactic tocolysis with preterm premature rupture of membranes.
Forms of care unlikely to be beneficial: • Regular leucocyte counts for PROM. • Beta-mimetic for preterm labor in women with heart disease or DM. • Hydration to arrest preterm labor. • Diazoxide for preterm labor.
Summary Antenatal care includes goal-directed interventions • Skilled attendant. • Preparation for birth and complications. • Health promotion. • Detection of complications. • Guided by Evidence.
