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Antenatal Care in Poor Countries. Stephen Gloyd MCH in Developing Countries January 2012. 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

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antenatal care in poor countries

Antenatal Care in Poor Countries

Stephen Gloyd

MCH in Developing Countries

January 2012

antenatal care initiatives
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

importance of antenatal care
IMPORTANCE OF ANTENATAL CARE
  • reduce high perinatal risk
  • reduce high maternal risk (50x)
  • major point of access to health care for women

Antenatal Care

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

Antenatal Care

slide6

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

Antenatal Care

slide10

Factors affecting the utilization of antenatal care in developing countries: Systematic review of the literatureBibha Simkhada Maureen PorterEdwin R. van Teijlingen Padam Simkhada. Journal of Advanced Nursing, Jan 2008

A systematic review of 28 papers -both quantitative and qualitative

Factors most commonly associated with antenatal care uptake:

Maternal education, husband's education, marital status, availability, cost, household income, women's employment, media exposure and having a history of obstetric complications. Also cultural beliefs.

Parity had a statistically significant negative effect on adequate attendance. While women of higher parity tend to use antenatal care less, there is interaction with women's age and religion.

Only one study examined the effect of the quality of antenatal services on utilization. None identified an association between the utilization of such services and satisfaction with them

slide14

Estimates of the proportion of deliveries attended by skilled personnel (1996)

Antenatal Care

components of prenatal care
Components of prenatal care:
  • Health education
  • Screening
  • Diagnosis and treatment
  • Referral

Screening/Dx

  • Identify women at high risk [?usefulness]
  • Intervene to prevent development of problems
  • Dx and Rx pre-existing medical conditions
  • Dx and Rx complications of pregnancy

Antenatal Care

perinatal morbidity and mortality newborn
Perinatal Morbidity and Mortality (newborn)
  • LBW
  • Birth trauma, obstructed labor
  • Infection
    • amnionitis
    • herpes
    • gonorrhea
    • syphilis
    • streptococcus
    • HIV
    • Tetanus
  • Abruptio Placenta
  • Congenital malformations
  • "other" (30%)

Antenatal Care

maternal morbidity and mortality
Maternal Morbidity and Mortality

(Five main causes)

  • Hemorrhage
  • Sepsis
  • Eclampsia
  • Obstructed Labor
  • Abortion

Note: Mortality reduction requires secondary and tertiary care

Antenatal Care

other causes of maternal morbidity and mortality
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)

Antenatal Care

preventability
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

risk approach
Risk Approach

Identification of high risk factors

  • Predictive (Previous fetal loss)
  • Contribution (Grand multipara, young or old)
  • Causation (syphilis, HIV, maternal malnutrition)

Antenatal Care

risk approach1
Risk Approach

Not believed 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

who working group on prenatal care 1994
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

current state of prenatal care 2008
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

o ther interventions that need more study though most of these are recommended
Other interventions that need more study(though most of these are recommended)
  • STD identification and treatment
  • Routine anti parasite drugs
  • Waiting houses
  • Diabetes screening (depends on prevalence)
  • Management and treatment of HTN

Antenatal Care

hiv in pregnancy
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

prevention of mother to child transmission of hiv pmtct
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

malaria and pregnancy
Malaria and Pregnancy
  • 30 million African women are pregnant yearly
  • Malaria is more frequent and complicated during pregnancy
  • In malaria-endemic areas, malaria during pregnancy may account for:
    • Up to 15% of maternal anemia
    • 5–14% of low birthweight
    • 30% of “preventable” low birthweight

Antenatal Care

effects of malaria on pregnant women
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

malaria prevention and treatment during pregnancy
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

benefits of insecticide treated nets
Benefits of Insecticide-Treated Nets
  • Prevent mosquito bites
  • Protect against malaria, resulting in less:
      • Anemia
      • Prematurity and low birthweight
      • Risk of maternal and newborn death
  • Help people sleep better
  • Promote growth and development of fetus and newborn

Antenatal Care

intermittent preventive treatment
Intermittent Preventive Treatment
  • Every pregnant woman living in an area of high malaria transmission has malaria parasites in her blood or placenta, whether or not she has symptoms of malaria
  • Although a pregnant woman with malaria may have no symptoms, malaria can still affect her and her unborn child
  • Three doses of sulfadoxine-pyrimethamine (SP) should be given to all pregnant women after quickening and at least 1 month apart

Antenatal Care

intermittent preventive treatment dose and timing
Intermittent Preventive Treatment: Dose and Timing
  • Each dose is three tablets of sulfadoxine 500 mg + pyrimethamine 25 mg
  • Ideally, a dose is given at each ANC visit after quickening, but at least 1 month apart
  • Healthcare provider should dispense dose and directly observe client taking dose

Antenatal Care

intermittent preventive treatment contraindications to using sp
Intermittent Preventive Treatment: Contraindications to Using SP
  • First trimester: Be sure quickening has occurred and woman is at least 16 weeks pregnant
  • Allergy to SP or other sulfa drugs: Ask about sulfa drug allergies before giving SP
  • Taking co-trimoxazole, or other sulfa-containing drugs: Ask about use of these medicines before giving SP
  • Not more frequently than monthly: Be sure at least 1 month has passed since the last dose of SP

Antenatal Care

managing uncomplicated malaria
Managing Uncomplicated Malaria
  • Provide first-line anti-malarial drugs
    • Follow country guidelines
  • Manage fever
    • Analgesics, tepid sponging
  • Diagnose and treat anemia
  • Provide fluids

Antenatal Care

active syphilis infection in pregnancy
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% stillbirths attributed to 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. ICS (Rapid test) ~$0.50, 2 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

focused antenatal care
Focused Antenatal Care

An approach to ANC that emphasizes:

  • Evidence-based, goal-directed actions
  • Individualized, woman-centered care
  • Early detection and treatment of problems and complications
  • Prevention of complications and disease
  • Quality vs. quantity of visits
  • Care by skilled providers
  • Birth preparedness & complication readiness
  • Health promotion

Antenatal Care

no longer recommended
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

number of antenatal care visits
Number of antenatal care visits

WHO multi-center study - number of visits reduced without affecting outcome for mother or baby

Recommendations

  • Minimum of 4 visits (see table) – with quality services
  • Individualized delivery plan depending on risk profile
  • One PNC visit at referral hospital
  • Health promotion (to individual and community)
  • Emergency transport

Antenatal Care

scheduling and timing of anc visits
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
  • 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

Antenatal Care

who mnh guidelines
WHO MNH guidelines

5 pages of tables

Table 1 lists interventions delivered to the mother during pregnancy, childbirth and in the postpartum period, and to the newborn soon after birth.

Table 2 lists the places where care should be provided through health services, the type of providers required and the recommended interventions and commodities at each level.

Table 3 lists practices, activities and support needed during pregnancy and childbirth by the family, community and workplace.

Table 4 lists key interventions provided to women before conception and between pregnancies.

Table 5 addresses unwanted pregnancies.

Antenatal Care

http://whqlibdoc.who.int/hq/2007/WHO_MPS_07.05_eng.pdf

impac manual
IMPAC Manual

Integrated Management of Pregnancy & Childbirth

Guidelines

WHO

2006

http://whqlibdoc.who.int/publications/2006/924159084X_eng.pdf

Antenatal Care

impac manual guideline detail for antenatal care
IMPAC ManualGuideline detail for Antenatal Care

Antenatal Care

http://whqlibdoc.who.int/publications/2006/924159084X_eng.pdf

other useful who guidelines
Other useful WHO guidelines

http://whqlibdoc.who.int/hq/2010/WHO_MPS_09.04_eng.pdf

JHPEIGO. Inspired by George Povey Manual http://whqlibdoc.who.int/publications/2007/9241545879_eng.pdf

problems with interventions general
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

thank you
Thank you!

Antenatal Care

some operational issues prenatal and birth care
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

safe childbirth care
Safe childbirth care

Antenatal Care

inadequate health systems
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

impact of traditional birth attendant training in rural mozambique 1
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

impact of traditional birth attendant training in rural mozambique 2
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

impact of traditional birth attendant training in rural mozambique results
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