Antenatal Care: Old Myths, New Realities. MAQ Mini-University April 20, 2001. Theresa Shaver NGO Networks. Barbara Kinzie MNH Program. Traditional ANC What it looks like. Originated from models developed in Europe in early decades of the century Ritualistic rather than rational
Antenatal Care: Old Myths, New Realities MAQ Mini-University April 20, 2001 Theresa Shaver NGO Networks Barbara Kinzie MNH Program
Traditional ANCWhat it looks like • Originated from models developed in Europe in early decades of the century • Ritualistic rather than rational • Emphasis of visits is on frequency and numbers, rather than on essential elements
No longer recommended • Numerous routine visits • Burden to health system • Study of reduced visits program in Zimbabwe
No longer recommended • Risk approach • Kasango, Zaire study • 71% of women who did develop obstructed labor were not predicted • 90% of women identified as “at risk” never developed complications • Problems with risk approach • Poor predictive value • Failed to distinguish those who would develop complications from those who would not • Many women categorized as high risk never develop complications but consume scarce resources (e.g., hospital deliveries) • Many women categorized as low risk do develop complications but are never told how to recognize or respond to them (i.e., false security) • Identification of special need does not guarantee appropriate action
Lessons from Risk Approach • Every pregnant woman is at risk of complications and must have access to quality maternity care. • Even low-risk women may develop complications. • No amount of screening will separate out those women who will need emergency care from those who will not need such care.
No longer recommended • Routine/ritual measurements and examinations • Height • Ankle edema • Fetal position below 36 weeks
Recommended • Goal-directed visits by skilled provider • WHO recommends four focused visits as sufficient for normal pregnancy
Preparing for Normal birth Skilled attendant Place of delivery Finance Nutrition Essential items Readiness for complications Early detection Designated decision maker(s) Emergency funds Communication Transport Blood donors RecommendedBirth Preparedness, including Complication Readiness
Recommended • Counseling • Nutrition • Family planning • Breastfeeding • Danger signs • HIV/MTCT
Recommended • Detection and management of existing diseases and conditions: • HIV – Voluntary counseling and testing • STIs, including Syphilis • Tuberculosis
Recommended • Detection and management of complications: • Severe anemia • Vaginal bleeding • Pre-eclampsia/eclampsia
RecommendedPrevention • Tetanus toxoid • Iron and folate supplementation
RecommendedPrevention • In select populations • Iodine supplementation • Malaria - intermittent presumptive treatment • Routine hookworm treatment
Not recommended Numerous routine visits High risk approach Routine measurement: Height Fetal position before 36 weeks Ankle edema Recommended Focused antenatal visits by skilled provider Birth preparedness and complication readiness planning FP, breastfeeding, danger signs, HIV/STDs, and nutrition counseling Detection and management of co-existing conditions and complications Tetanus toxoid Iron and folate In selected populations Iodine Malaria presumptive treatment Helminth presumptive treatment ANC: Best Practices
REFERENCES • Ahmed, Y. et.al., “A study of maternal mortality at the University Teaching Hospital, Lusaka, Zambia: the emergence of tuberculosis as a major non-obstetric cause of maternal death,” Int’l Journal of Tubercular Lung Disease, Vol. 3 (8); 675-80, August 1999. • Bergsjo, P. and Villar, J. “Scientific basis for the content of routine antenatal care,” Vol. 1 & 2, Acta Obstericia et Gynecologica Scandinavica, 1997 • Chung, P.K., et.al, “An audit of antenatal care: the value of the first antenatal visit. British Medical Journal, 280, 1980. • The Cochrane Library, Issue 1, 2001. Oxford: Update Software.
REFERENCES • Figueroa-Damian R and Arrendondo-Garcia JL. “Neonatal Outcome of Children Born to Women with Tuberculosis,” Archives of Medical Research, Vol 32 (1); 66-69, January 2001. • Hira, et.al. “Syphilis intervention in pregnancy; Zambian demonstration project.,” Cochrane Library Document • Hofmyer, G.J. (1989). Suspected fetopelvic disproportion. Effective care in Pregnancy and Childbirth (Eds. I. Chalmers, M. Enkin, and MJNC Keirse.) Oxford: Oxford Univ. Press, pp. 493-498 • Kasonga Project Report, Journal of Tropical Medicine and Hygiene, Vol 87, 1984
REFERENCES • Looaresuwn S., et al. “Quine and severe falciparum malaria in late pregnancy,” The Lancet, 2:4-7 (1985) • Maine, Deborah, “Safe Motherhood Programs: Options and Issues,” 1991 • MotherCare, “Issues in Programming for Maternal Anemia,” September 2000. • Ministry of Health, His Majesty’s Government of Nepal, “Maternal Mortality and Morbidity Study, p. 29, 1998 • Munjanja, et.al. Randomised controlled trial of a reduced-visits programme of antenatal care in Harare, Zimbabwe. The Lancet, Vol. 348. August 10, 1996. Pp. 364-369
REFERENCES • Stoltzfus, RJ, Dreyfuss, ML, Chwaya HM, Albonico M. “Hookworm control as a strategy to prevent iron deficiency.” Nutrition Reviews, Vol 55. No. 6, 1997 • Tinker and Koblinsky, Making Motherhood Safe, World Bank, 1993 • UNAIDS and WHO, “HIV in Pregnancy: A Review,” 1999 • Villar J. and Khan-Neelofur D. “Patterns of Routine Antenatal Care for Low-risk Pregnancy,” Cochrane Library, Issue 1, 2001.
REFERENCES • Wang and Smaill; “Infection in Pregnancy” from I Chalmers, et.al. Effective Care in Pregnancy and Childbirth, pp. 534-64 • WHO, “Antenatal Care: report of a technical working group,” 1996 • WHO, “Antenatal Care and Maternal Health: how effective is it?: A review of the evidence,” 1992.