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Prenatal Care in Poor Countries

Prenatal Care in Poor Countries. Stephen Gloyd MCH in Developing Countries January 2008. Prenatal Care Initiatives. MAKING PREGNANCY SAFER (WHO) Reduce maternal mortality by 75% by 2015 SAFE MOTHERHOOD INITIATIVE (WHO-1988) “Four Pillars” Family planning Prenatal care Clean birth

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Prenatal Care in Poor Countries

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  1. Prenatal Care in Poor Countries Stephen Gloyd MCH in Developing Countries January 2008

  2. Prenatal Care Initiatives MAKING PREGNANCY SAFER (WHO) • Reduce maternal mortality by 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 women’s status Prenatal Care

  3. IMPORTANCE OF PRENATAL CARE • Reduce high perinatal risk • Reduce high maternal risk (50x) • Major point of access to health care for women Prenatal Care

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

  5. Trends in Prenatal care 1990-2000 Prenatal Care

  6. Estimates of the proportion of pregnant women who received some prenatal care (1996) Prenatal Care

  7. Number of visits to ANC by region Prenatal Care

  8. Prenatal Care

  9. Prenatal Care

  10. Prenatal Care

  11. Prenatal care and delivery Prenatal Care

  12. Timing of PNC visits (most in 1st trimester except Africa) Prenatal Care

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

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

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

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

  18. Other Causes of Maternal Morbidity and Mortality • Hypertension • Diabetes • Heart Disease • Hepatitis • Anemia • Malaria • Tuberculosis • STD Overall Morbidity: 3-12% of all pregnancies (up to 37% in India) Prenatal Care

  19. Poor outcomes: 3465 birth registries in 30 hospitals of Cote d’Ivoire (1997) Prenatal Care

  20. Prevalence of low birth weight globally Prenatal Care

  21. Prenatal Care

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

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

  25. Risk Approach Not an effective PNC 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 Prenatal 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 Prenatal Care Randomized Trial (Villar et al 2001) • Manual for the Implementation of the New Model Prenatal 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 Prenatal 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 Prenatal 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 Prenatal 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 Prenatal 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 Prenatal Care

  33. Malaria Prevention and Treatment during Pregnancy • Focused prenatal care (PNC) 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 Prenatal 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$0.25-0.35, takes 15-20 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 Prenatal Care

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

  38. Prenatal Care

  39. Focused Prenatal Care Services (cont.) 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 Prenatal Care

  40. Focused Prenatal Care Services (cont.) Individualized, woman-centered care based on each woman’s: • Specific needs and concerns • Circumstances • History, physical examination, testing • Available resources Prenatal Care

  41. Focused Prenatal Care Services (cont.) Quality vs. quantity of PNC 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 Prenatal 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 Prenatal Care

  43. Scheduling and Timing of PNC 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 • Othervisits: 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 Prenatal Care

  44. Basic components of the WHO prenatal care program (1994) Prenatal Care

  45. Prenatal 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 Prenatal 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 Prenatal Care

  48. Safe childbirth care MMR has not improved in 20 years • Critical importance of skilled birth attendants (midwives, physicians) • Need for facility improvement • Access to care • Transport • Costs of care • Prenatal care improves institutional births Prenatal Care

  49. Prenatal 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) Prenatal Care

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