Antenatal Care in Poor Countries

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

2. 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

3. IMPORTANCE OF ANTENATAL CARE • reduce high perinatal risk • reduce high maternal risk (50x) • major point of access to health care for women Antenatal Care

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

5. Trends in Antenatal care 1990-2000 Antenatal Care

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

7. Number of visits to ANC by region Antenatal Care

8. Antenatal Care

9. Antenatal Care

10. 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

11. Antenatal Care

12. Antenatal care and delivery Antenatal Care

13. Timing of ANC visits (most in 1st trimester except Africa) Antenatal Care

14. Estimates of the proportion of deliveries attended by skilled personnel (1996) Antenatal Care

15. Prenatal care vs attended birth and post partum care Antenatal Care

16. 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

17. 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

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

19. 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

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

21. Prevalence of low birth weight globally Antenatal Care

22. Antenatal Care

23. Sexually transmitted infections (STI) among pregnant women in Mozambique Antenatal Care

24. 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

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

26. 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

27. 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

28. 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

29. 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

30. 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

31. 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

32. Prevention and Control of Malaria during Pregnancy

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. 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

40. 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

41. 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

42. 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

43. 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

44. Antenatal Care

45. 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

46. 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

47. 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

48. Antenatal Care

49. IMPAC Manual Integrated Management of Pregnancy & Childbirth Guidelines WHO 2006 http://whqlibdoc.who.int/publications/2006/924159084X_eng.pdf Antenatal Care

50. IMPAC ManualGuideline detail for Antenatal Care Antenatal Care http://whqlibdoc.who.int/publications/2006/924159084X_eng.pdf