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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

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antenatal care old myths new realities

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
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
No longer recommended
  • Numerous routine visits
    • Burden to health system
    • Study of reduced visits program in Zimbabwe
no longer recommended4
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
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 recommended6
No longer recommended
  • Routine/ritual measurements and examinations
    • Height
    • Ankle edema
    • Fetal position below 36 weeks
  • Goal-directed visits by skilled provider
  • WHO recommends four focused visits as sufficient for normal pregnancy
recommended birth preparedness including complication readiness
Preparing for Normal birth

Skilled attendant

Place of delivery



Essential items

Readiness for complications

Early detection

Designated decision maker(s)

Emergency funds



Blood donors

RecommendedBirth Preparedness, including Complication Readiness
  • Counseling
    • Nutrition
    • Family planning
    • Breastfeeding
    • Danger signs
    • HIV/MTCT
  • Detection and management of existing diseases and conditions:
    • HIV – Voluntary counseling and testing
    • STIs, including Syphilis
    • Tuberculosis
  • Detection and management of complications:
    • Severe anemia
    • Vaginal bleeding
    • Pre-eclampsia/eclampsia
recommended prevention
  • Tetanus toxoid
  • Iron and folate supplementation
recommended prevention13
  • In select populations
    • Iodine supplementation
    • Malaria - intermittent presumptive treatment
    • Routine hookworm treatment
anc best practices
Not recommended

Numerous routine visits

High risk approach

Routine measurement:


Fetal position before 36 weeks

Ankle edema


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


Malaria presumptive treatment

Helminth presumptive treatment

ANC: Best Practices
  • Ahmed, Y., “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.,, “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.
  • 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, “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
  • 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, Randomised controlled trial of a reduced-visits programme of antenatal care in Harare, Zimbabwe. The Lancet, Vol. 348. August 10, 1996. Pp. 364-369
  • 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.
  • Wang and Smaill; “Infection in Pregnancy” from I Chalmers, 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.