Focused Antenatal care (FANC)

1. Focused Antenatal care (FANC) What is FANC? • Is health care given to a pregnant woman from conception to the onset of labour. • It is personalised care provided to a pregnant woman which emphasises on the woman’s overall health, her preparation for childbirth and readiness for complications (emergency preparedness). • It is timely, friendly, simple and safe service to a pregnant woman.

2. AIM OF FANC • To achieve a good outcome for the mother and baby and prevent any complications that may occur in pregnancy, labour, delivery and the post partum period.

3. The approach: The risk approach to ANC has not resulted in significant improvement in maternal survival. Life threatening Complications of pregnancy are difficult to predict with any degree of certainty. Health care providers must, therefore, consider the possibility of complications in every pregnancy and prepare clients accordingly. While risk assessment can help direct counseling and treatment for individuals, it is important to understand that most women who experience complications have no ‘risk factors’ at all.

4. Every pregnant, delivering or postpartum woman is at risk of serious life threatening complications!

5. Four comprehensive, personalized antenatal visits: 1st visit: <16 weeks 2nd visit: 16-28 weeks 3rd visit: 28-32 weeks 4th visit:32-40 weeks NB: Depending on individual need, some women will require additional visits.

6. Objectives of Focused Antenatal Care • Early detection and treatmentof problems • Prevention of complications using safe, simple and cost-effective interventions • Birth preparedness and complication readiness • Health promotion using health messages and counseling • Provision of care by a skilled attendant

7. Objective one: Early detection and treatment of Problems • Service providers should identify existing medical, surgical or obstetric conditions during pregnancy. Such as: • Severe anaemia (Hb <7gm/dl) • Vaginal bleeding • Pre-eclampsia (increased BP, severe oedema) • STI’s, HIV/AIDS, TB and Malaria • Chronic diseases (diabetes, heart or kidney problems) • Decreased/absent foetal movement; • foetal malpresentation after 36 weeks

8. Why disease detection and not risk assessment? • Risk approach is not an efficient or effective strategy for maternal mortality reduction. • Every pregnancy is at risk! • Risk factors cannot predict complications: (e.g. young age does not predict eclampsia). • Research showed that themajority of women who experienced complications were considered low risk (90% of women considered to be high risk, gave birth without experiencing a complication).

9. Why disease detection and not risk assessment cont….. • Risk factors do not predict problems. Most high risk women deliver without problems and most women who develop life-threatening complications belong to the low risk group. • Every pregnant woman should be prepared for the possibility of complications.

10. Objective two: Prevention of complications The service provider should ensure prevention/protection of complications by providing: • Tetanus toxoid to prevent maternal and neonatal tetanus • Iron/folate supplementation to prevent anaemia • Use of IPT and ITNS to prevent malaria/ anaemia • Ensure environmental hygiene to prevent intestinal worms • Presumptive treatment of hookworm infection with Mebendazole 500mg STAT anytime after the first trimester* *Basic Maternal and Newborn Care: A Guide to Skilled Providers, Page 3-58

11. Objective three: Birth preparedness and complications readiness Service providers should discuss components of birth plan which include: • Is the EDD known? • Has a facility been identified? • Has a SBA/professional been identified? • Has a means of Transport been identified? • Are emergency Funds identified? • Who is the custodian of the emergency funds? • Has a Birth companion been identified? • Are Items for clean safe birth and for the newborn been identified?

12. Objective three cont…Complication Readiness • Knowledge of danger signs; what to do if they arise • Has a decision maker been identified? • Has a Blood donor been identified?

13. Individual birth plan ensures that the client: • Knows when her baby is due • Identifies a skilled birth attendant • Identifies a health facility for delivery/emergency • Can list danger signs in pregnancy and deliveryand knows what to do if they occur • Identifies a decision-maker in case of emergency • Knows how to get money in case of emergency • Has a transport plan in case of emergency • Has a birth partner/companion for the birth • Has collected the basic supplies for the birth

14. Danger signs in pregnancy • Any vaginal bleeding in pregnancy( APH, Abortion) • Severe headache or blurred vision (high blood pressure, eclampsia) • Swelling on the face and hands (high blood pressure, eclampsia) • Convulsions or fits (high blood pressure, eclampsia) • High fever ( infection) • Drainage of liqour • Laboured breathing ( pneumonia, heart problems, severe anemia) • Premature labour pains • Noticed that the baby is moving less or not moving at all (fetal distress, IUD ).

15. Other danger signs in pregnancy • Feeling very weak or tired (anemia, severe disease, multiple pregnancy) • Vaginal discharge (STI) • Abdominal pain (STI, early labor) • Genital ulcers (STI) • Painful urination (STI) • Persistentvomiting( severe malaria etc)

16. Danger signs in labour: • Labour pains for more than 12 hrs (sun rise to sunset) • Excessive bleeding • Ruptured membranes without labour for more than 12 hrs • Convulsions during labour • Loss of consciousness • Cord, arm or leg prolapse

17. Danger signs in postpartum period (Mother): • Excessive bleeding • Fever • Foul smelling discharge • Abdominal cramps or pains • Painful breasts or cracked nipples • Mental disturbances • Extreme fatigue • Facial or hand swelling • Headaches • Convulsions • Painful calf muscles

18. Danger signs in postpartum period • Fast breathing(more than 60 breaths/minute) • Slow breathing less than 30 breaths/minute • Severe chest in-drawing • Grunting • Umbilicus draining pus/redness extending to skin • Floppy or stiff • Fever (temp 38 degrees celsius and above • Convulsions • More than 10 skin pustules • Bleeding from stump/cut

19. Give advice on whom to call or where to go in case of the above complications/emergencies.

20. Objective four: Health promotion using health messages and counseling • Nutrition • Rest and hygiene • Safer sex • Care for common discomforts • Use of IPT and ITNs/LLINs • Drug compliance • Family planning/ health timing and spacing of pregnancy • Early and exclusive Breastfeeding • Newborn care Encourage dialogue on the following:

21. Maintain the woman’s health and survivalthrough: Health education and counselling on: • Danger signs in pregnancy • Adequate nutrition and hydration • Early and exclusive breastfeeding • Prevention and treatment of sexually transmitted infections (STIs) and worm infestation • Avoidance of alcohol and tobacco • Individual Birth Plan (IBP) • Complication readiness plan

22. To come to postpartum clinic :Immediately,48hours, 2 weeks, at 6 weeks,6months and one year.To visit well baby clinic (MCH/FP Clinic) for immunizations Follow up for exposed babies to TB and HIV. To chose a postpartum family planning method:- LAM (exclusive breastfeeding)- Progesterone only pills- Condoms- Post partum IUCD- feeding options

23. Teach mothers about the importance of immunizations: • Inform her about the first-year immunization schedule to protect children from TB, polio, tetanus, diphtheria, pertussis, hepatitis B and measles. • Immunize baby with BCG, HBV, OPV birth dose before the mother leaves the health facility. • Ensure all babies delivered at home are taken to the health facility for immunization.

24. National guidelines for IPT • IPT is an effective approach to preventing malaria in pregnant women by giving anti malarial drugs in treatment doses at defined intervals after quickening to clear a presumed burden of parasites • The MOH Guidelines on Malaria directs us to give SP to pregnant women in endemic malaria areas, at least twice during each pregnancy, even if she has no physical signs and her hemoglobin is within normal range. • Administer IPT with each scheduled visit after quickening (16 wks) to ensure women receive at least 2 doses at an interval of at least 4 weeks. • IPT should be given under Directly Observed Therapy (DOT) in the ANC and can be given on an empty stomach.

25. National guidelines for Tetanus toxoid

26. Objective 5: Provision of Skilled Care at Birth • Currently only 41% of pregnant women receive skilled care at birth • By 2015, it is expected that three quarters of pregnant women should receive skilled care at birth • A skilled attendant offers services either at the health facility or within the community (domiciliary practice) • FANC provides an opportunity to increase skilled care • Brainstorm strategies in your catchment area in support of increased skilled care

27. During FANC visits, ensure that the following have been accomplished History taking: • Current complaints/identify danger signs • Dietary history • Tetanus vaccination status • Reproductive history • History of medical illness e.g. TB Physical exam: • Physical assessment of general health • Swollen glands • Genital inspection, including sexually transmitted infections • Check for blood pressure, edema and proteinuria to rule out pre-eclampsia • Check for anaemia • Check baby’s growth Provide: • Iron, folate , IPT*(SP is the currently recommended) tetanus toxoid and Nevirapine if recommended Counselling on: • Danger signs • Individual birth plan (IBP) • Complication readiness • Nutrition, breastfeeding, family planning, safer sex, hygiene, etc. • PMTCT • Return date ANC Profile Most of the lab work should be done during the first visit • Sputum for AFB • Urinalysis • Hb, grouping and Rh factor • VDRL/RPR • Sickle cell, Stool and Hepatitis B (if indicated)

28. The role of fathers in antenatal care Many men are uncertain about how they can contribute to a woman’s healthy pregnancy

29. Service providers should educate fathers about antenatal care • Fathers should make sure that the woman: • has enough nutritious food to eat and that she has taken iron and folate tablets. • is sleeping under a treated net and is able to get plenty of rest. • has had 2 doses of SP and tetanus toxoid. • Make sure that the couple has an individual birth plan. • Make sure that the couple know the danger signs in pregnancy and labour.

30. Adolescents and pregnancy • In Kenya, 17-18% of all births are to women under the age of 20 years* • Pregnant youth are entitled to the same quality of care that older women are • Research has shown that adolescents tend to delay seeking care due to social and cultural practices and as such more attention should be directed to them • Services should be provided in an acceptable, non-judgmental manner, convenient and offer confidentiality to the adolescents. • Note: This will encourage the young women to return for continued antenatal services. *KDHS 1998/2003

31. Reinforce counseling to the adolescents /youth on.. • Peer influence • Early ANC attendance • Safer sex (ABCD) • Drug abuse • STI, HIV/AIDS/TB • Family Planning • Dangers of abortion

32. Before the woman leaves your clinic, STOP and ask her if she: • Has a supply of iron and folate tablets. • Has taken her SP and has had her tetanus toxoid injection. • Knows the danger signs in pregnancy and child birth. • Knows her appointment for the next ANC visit and SP dose. • Has an individual birth plan. • Has been screened for TB • Knows the importance of using postpartum family planning.

33. TB FANC STIs PMTCT CCC LAB MALARIA Integrated FANC Services

34. What is Tuberculosis (TB)? • Tuberculosis is a chronic infectious disease caused by an organism called mycobacterium tuberculosis, an acid fast rod shaped bacilli. • Over 90% of new TB cases and deaths occur in developing countries • TB is one of the leading infections causing of deaths among women of reproductive age • TB has increased by 10 fold over the last 15 years in Kenya

35. Factors leading to the increase in TB • HIV epidemic • Poverty • Overcrowding • Poor nutrition • Limited access to health services • Chronic diseases e.g. Diabetes, carcinoma etc • Immune suppressing therapy

36. Risk of TB infection The risk of one being infected with the TB bacillus depends on: • Exposure to bacilli • Intensity of exposure • Duration of exposure • Presence of undetected smear positive TB • Presence of poorly treated previous TB

37. Types of Tuberculosis • Pulmonary Tuberculosis (PTB) is the most common and infectious type of TB. • It affects the lungs and causes 81% of all TB cases in Kenya • Extra Pulmonary Tuberculosis (outside of the lungs) any organ of the body such as the kidney, bladder, ovaries, testes, eyes, bones or joints, intestines, skin or glands, and the meninges i.e. TB meningitis • The most common extra pulmonary TB is TB of the glands also called TB lymphadenitis • The most severe extra pulmonary TB is pleural effusion and meningitis.

38. Signs and Symptoms of Pulmonary Tuberculosis (PTB) • Persistent cough lasting for two or more weeks with or without blood stained sputum • Loss of body weight • Intermittent fever • Excessive night sweats • Shortness of breath • Loss of appetite • Chest pain • Excessive tiredness and generally feeling unwell

39. Signs and symptoms of TB of the glands (TB lymphadenitis*) • Slow and painless enlargement of the lymph nodes which then become matted and eventually discharge pus • The most common lymph nodes: cervical (neck) lymph nodes • Generalised lymph node enlargement is becoming common in HIV related TB *Confirmed during head-to-toe examination

40. When does TB pass from the mother to the baby? Pregnant women who are infected with TB can pass TB to the baby: • During pregnancy through the placenta barrier causing fetal death or infection (congenital TB is rare) • At birth when the baby inhales or ingests infected amniotic fluid or secretions • After delivery when the baby inhales droplet secretions if the mother is coughing-commonest

41. TB affects the health of a pregnant woman and her baby TB in a pregnant woman can lead to: • Premature birth of the baby • Low birth weight or small baby for dates • Death of baby in the uterus • Infecting the baby with TB • Increased newborn deaths

42. Screening for TB • Ask every mother at every ANC/PNC visit the following questions:

43. Investigations • Smear positive TB cases are the most infectious both to the new born and other children in the household • These are diagnosed through sputum examination • Smear negative cases and Extra-pulmonary are diagnosed through history, physical examination, radiography and histology

44. Why integration…TB/FANC • Since the onset of the HIV epidemic in the early eighties in Kenya, the prevalence of TB has risen sharply • HIV increases the likelihood of developing tuberculosis • Pregnancy also increases the risk of developing TB • TB is the major opportunistic infection in HIV and the leading killer of PLWHA • More than 50% of TB clients in Kenya are also HIV positive • At least one out of eight of HIV+ pregnant women could also have TB* *USAID Bureau for Africa, 2000

45. Integration of HIV, TB and malaria interventions into MCH services: Ensures that women receive targeted care according to their needs with appropriate linkages and referral structures are in place Involves the reorganization and re-orientation of health systems to ensure the delivery of a set of interventions or targeted package as part of the continuum of care Involves integrated procurement of commodities

46. Integration addresses structural , managerial and operational issues at all levels of the health system in order to: Create effective coordination mechanisms between departments, programs and other stakeholders Support integrated training and capacity planning, management and joint supervision Harmonize efforts to support targeted service delivery

47. Intensified TB case finding in FANC • All pregnant women should be screened for TB • Pregnant women suspected to have TB should have their sputum collected and tested for TB • Pregnant women found to have TB should be referred to the TB clinic for treatment NB: Negative Sputum result does not exclude TB!

48. Symptoms of TB ? — • C (Coughing) • W (Weight loss) • F (Fever) • N (Night sweats) • G (enlarged Glands)

49. Refer to Lab: • If the pregnant woman has a cough for two weeks or more, explain that three specimens of her sputum must be collected to help confirm the presence or absence of TB • Explain that testing and treatment for TB is free

50. Collection of sputum specimen: laboratory • Ask the pregnant woman to cough deeply to produce sputum in an open place • Ensure that nobody is standing nearby during the cough • Avoid contaminating the outside of the container with sputum • Ensure that an adequate amount of sputum is collected in the specimen pot