Antenatal Care in Poor Countries

1. Antenatal Care in Poor Countries MCH in Developing Countries January 2009 Stephen Gloyd

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

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11. Antenatal care and delivery Antenatal Care

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

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

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

15. Components of prenatal care: • Health education • Screening • Diagnosis and treatment • Referral Screening/Dx • Identify women at high risk • Intervene to prevent development of problems • Dx and Rx pre-existing medical conditions • Dx and Rx complications of pregnancy Antenatal Care

16. Perinatal Morbidity and Mortality • LBW • Birth trauma, obstructed labor • Infection • amnionitis • herpes • gonorrhea • syphilis • streptococcus • HIV • Tetanus • Abruptio Placenta • Congenital malformations • "other" (30%) Antenatal Care

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

18. 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

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

20. Prevalence of low birth weight globally Antenatal Care

21. Antenatal Care

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

23. 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

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

25. Risk Approach Not 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

26. 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

27. 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

28. Other interventions that need more study • STD identification and treatment • Routine anti parasite drugs • Waiting houses • Diabetes screening (depends on prevalence) • Management and treatment of HTN Antenatal Care

29. 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

30. 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

31. Prevention and Control of Malaria during Pregnancy

32. 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

33. 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

34. 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% of stillbirths attributable to prenatal 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 • 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

35. Focused Antenatal Care • Evidence-based, goal-directed actions • Individualized, woman-centered care • Quality vs. quantity of visits • Care by skilled providers An approach to ANC that emphasizes: Antenatal Care

36. Goal of Focused Antenatal Care To promote maternal and newborn health and survival through: • Early detection and treatment of problems and complications • Prevention of complications and disease • Birth preparedness and complication readiness • Health promotion Antenatal Care

37. 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

38. Antenatal Care

39. Focused Antenatal Care Services (cont’d.) Care by a skilled provider who: • Has formal training and experience • Has knowledge, skills, and qualifications to deliver safe, effective maternal and newborn healthcare • Practices in home, hospital, health center • May be a midwife, nurse, doctor, clinical officer, etc Antenatal Care

40. Focused Antenatal Care Services (cont’d.) Individualized, woman-centered care based on each woman’s: • Specific needs and concerns • Circumstances • History, physical examination, testing • Available resources Antenatal Care

41. Focused Antenatal Care Services (cont’d.) Quality vs. quantity of ANC visits: • WHO multi-center study • Number of visits reduced without affecting outcome for mother or baby • Recommendations • Content and quality vs. number of visits • Goal-oriented care • Minimum of four visits Antenatal Care

42. Activities within PNC • Minimum of 4 visits (see table) • Individualized delivery plan depending on risk profile • One PNC visit at referral hospital • Health promotion (to individual and community) • Emergency transport Antenatal Care

43. 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

44. Basic components of the WHO antenatal care program (1994) Antenatal Care

45. Antenatal Care

46. 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

47. 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

48. Safe childbirth care Antenatal Care

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50. 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