Antenatal Care in Poor Countries Stephen Gloyd MCH in Developing Countries February 2007.
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Antenatal Care in Poor Countries
Stephen GloydMCH in Developing CountriesFebruary 2007
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Antenatal Care 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
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Antenatal Care 3
IMPORTANCE OF PRENATAL CARE
reduce high perinatal risk reduce high maternal risk (50x) major point of access to health care for
women
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Antenatal Care 4
Access to prenatal care Physical access Time and/or distance to facility Economic costs & barriers Cultural and social factors Quality of care
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Antenatal Care 5
Trends in Antenatal care 1990-2000
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Antenatal Care 6
Estimates of the proportion of pregnant women who received some antenatal care (1996)
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Antenatal Care 7
Number of visits to ANC by region
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Antenatal Care 8
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Antenatal Care 9
Antenatal care and delivery
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Antenatal Care 10
Timing of ANC visits (most in 1st trimester except Africa)
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Antenatal Care 11
Estimates of the proportion of deliveries attended by skilled personnel (1996)
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Antenatal Care 12
Prenatal care vs attended birth and post partum care
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Antenatal Care 13
Components of prenatal care:
Health education Screening Diagnosis and treatment Referral
Screening/Dxo Identify women at high risko Intervene to prevent development of problemso Dx and Rx pre-existing medical conditionso Dx and Rx complications of pregnancy
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Antenatal Care 14
Perinatal Morbidity and Mortality
LBW Birth trauma, obstructed labor Infection
amnionitis herpes gonorrhea syphilis streptococcus HIV Tetanus
Abruptio Placenta Congenital malformations "other" (30%)
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Antenatal Care 15
Maternal Morbidity and Mortality
(Five main causes) Hemorrhage Sepsis Eclampsia Obstructed Labor Abortion Note: Mortality reduction requires secondary
and tertiary care
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Antenatal Care 16
Other Causes of Maternal Morbidity and Mortality
Hypertension Diabetes Heart Disease Hepatitis Anemia Malaria Tuberculosis STDOverall Morbidity: 3-12% of all pregnancies
(up to 37% in India)
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Antenatal Care 17
Poor outcomes: 3465 birth registries in 30 hospitals of Cote d’Ivoire (1997)
Condition Rate per 1000Normal 760
Stillbirth 44
Neonatal death 6
LBW < 2500g < 2000g <1500g
190 52 17
Eclampsia 2
Fetal disproportion 13
Fetal distress 15
Hemorrhage 22
Maternal deaths 2
Others 12
Operative delivery 36
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Antenatal Care 18
Prevalence of low birth weight globally
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Antenatal Care 19
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Antenatal Care 20
Sexually transmitted infections (STI) among pregnant women in Mozambique
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Antenatal Care 21
Preventability
Overall Infant Deaths - 33% preventable (Nairobi)
Syphilis: 100% preventable 10% stillbirths 20% Infant Mortality 20% Congenital Syphilis
Other causes: % preventable not clear
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Antenatal Care 22
Risk Approach
Identification of high risk factors Predictive (Previous fetal loss) Contribution (Grand multipara, young or old) Causation (syphilis, HIV, maternal
malnutrition)
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Antenatal Care 23
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
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Antenatal Care 24
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
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Antenatal Care 25
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:
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Antenatal Care 26
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
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Antenatal Care 27
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
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Antenatal Care 28
Focused Antenatal Care Services
Evidence-based, goal-directed actions: Address most prevalent health issues
affecting women and newborns Adjusted for specific populations/regions Appropriate to gestational age Based on firm rationale
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Antenatal Care 29
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
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Antenatal Care 30
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
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Antenatal Care 31
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
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Antenatal Care 32
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
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Antenatal Care 33
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 Other visits: 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
Scheduling and Timing of ANC Visits
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Antenatal Care 34
Basic components of the WHO antenatal care program (1994)
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Antenatal Care 35
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Antenatal Care 36
Problems with interventions (general):
Utilization is often low/widely variableGestation at first visit (after sixth month)Variable epidemiology of risk factors (Malaria, eclampsia,
Anemia, pelvic size)
Cultural barriers identification of pregnancy, taboosreluctance to use family planning
Limitations of referral and transportSensitivity and specificity of risk factors
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Antenatal Care 37
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
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Antenatal Care 38
Issues in Prenatal Care ImpactToo 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 Malaria IPT Syphilis ID and Rx Iron therapy Tetanus immunization Family planning Nutritional supplementation
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Antenatal Care 39
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
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Antenatal Care 40
Some operational issues – prenatal and birth care
Malaria in pregnancy (done by Paula Brentlinger?)
pMTCT (prevention of mother to child transmission of HIV
Antenatal syphilis screening in Mozambique
Traditional birth attendant training
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Antenatal Care 41
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
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Antenatal Care 42
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
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Antenatal Care 43
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
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Prevention and Control of Malaria during Pregnancy
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Antenatal Care 45
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
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Antenatal Care 46
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
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Antenatal Care 47
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)
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Antenatal Care 48
Impact of Traditional Birth Attendant training in Rural Mozambique (2)
A retrospective cohort study Comparison of maternal and newborn outcomes in
40 communities where TBAs had been trained 27 communities where TBAs had not yet been trained.
In each community –respondents interviewed in 30 households closest to the trained TBA (or center of the community with no trained TBA) with pregnancies in the past 3 years
Principal outcomes utilization of TBA or health facility services (delivery and ANC) outcome of pregnancy for mother and child utilization of other primary health care services
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Antenatal Care 49
Impact of Traditional Birth Attendant training in Rural Mozambique - RESULTS
In TBA trained communities 30% of these pregnant women utilized theTBAs 40% managed to deliver at health facilities
Overall, 70% of women preferred health facility midwives for their next birth (however, most users of trained TBAs preferred TBAs for their next birth)
No difference in mortality rates (perinatal, neonatal, infant)
MOH policy regarding TBA vs health facility support substantially changed after the study