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  • .
  • Seldom done in most developing countries
  • Key Behavior Change Messages
  • Advocacy Messages• Current best practices are based on the most up to date scientific evidence of what works• Best practices save resources in the long run by eliminating unnecessary practices and makingthe best of limited resources• Implementing best practices saves lives of mothers and newborns• Skilled providers must be made available for ANC• Even skilled providers require technical updates so they can provide effective focused ANCbased on the most recent evidence of what works
  • In low- and middle-income countries, compared with standard antenatal care, the goal-oriented, reduced-visits approach was associated with a 15% higher risk of perinatal mortality
  • Possible reasons:Health-care workers are less able to give sufficient time to each woman, and hence the quality of care is lowered and there is an increased chance of missing potential problemsThe reduced-visits package was quickly adopted by health-care services as a way of improving the quality of care for womenThe antenatal care package may have to be adapted in each country prior to implementation in order to address relevant background health risks
  • At present, the reason for increased perinatal mortality is unknown. It is possible that differences in background risks in the populations have differential effects on fetal health and well-being. Another possibility is that the gap between the visits in the second and third trimester of pregnancy may have been too wide for timely identification of fetal ill-health and action when these problems occurred.
  • plans to produce an updated evidence-based guideline on antenatal care that will be informed by these findings and other systematic reviews of interventions that may be effective in improving perinatal outcome during antenatal care.
  • Focused Antenatal Care-Planning and Providing Care During Pregnancy –MNH (www.mnh.jhpiego.org)

Routine & focused ANC Routine & focused ANC Presentation Transcript

  • Routine & Focused
    Berhanu Mohammed
    May 3, 2011
    Berhanu M
  • Topics
    Routine ANC
    Why it failed
    Berhanu M
  • Introduction
    In the USA, the first organized prenatal care programs began in 1901 with home nurse visits & The first prenatal clinic was established in 1911
    The introduction of antenatal care in 1913 has been widely attributed to the efforts of Ballantyne at the University of Edinburgh
    During the 1920s Dame Janet Campbell played great role and her ideas became the clinical obstetric screening service of the 1930s
    ? By the 1950s, a schedule of monthly visits to 28 weeks, fortnightly visits to 36 weeks, and then weekly visits until birth had become standard
    Berhanu M
  • ….History
    1978 WHO had developed the “risk approach” concept
    1980 WHO survey showed that No. of visit ranges from 5-14 in Europe
    Focused ANC approach introduced in 2001/2
    It is one of the pillar of safe mother hood (1/4)
    Dame Janet Campbell
    Berhanu M
  • Uptake
    Berhanu M
  • …Uptake Ethiopia
    Birth Preparedness and Maternity Services
    Percent of women with at least one antenatal care (ANC) visit 28%
    Percent of women with at least four antenatal care (ANC) visits 12%
    Percent of women with a skilled attendant at birth 6%
    Percent of women receiving postpartum visit within 3 days of birth 5%
    Berhanu M
  • 7
    Berhanu M
  • ANC
    General health care given to pregnant women to promote and maintain optimal health of the mother throughout the pregnancy, labor and puerperium with having and rearing of healthy baby
    Two Models : Routine and Focused
    Berhanu M
  • The Routine ANC
    The Antenatal Period:
    Based on high risk / low risk approach.
    Emphasis on frequent visits:
    For high risk mothers
    • Till 28 wks GA ,every 4 weeks~ 5-6 visits
    • Till 36 wks of GA, every 2 weeks~ 4 visits
    • Till delivery , weekly ~ 4 visits
    Berhanu M
  • Risk approach
    A strategy to identify risk factors for undesirable outcomes, with care to be delivered according to individual needs
    high levels of false positive and false negative
    No amount of screening will separate those women who will from those who will not need emergency medical care .
    Deborah Maine, et al, Columbia University, 1991
    Berhanu M
  • “Whatever the usefulness may be for other purposes, some of the common sense activities that had been promoted for decades risk screening at antenatal consultations, training of traditional birth attendants – proved to be of limited direct affect on maternal mortality.”
    Wim Van Lerberghe and Vincent De Brouwere, 2001
    Berhanu M
  • Why it Hasn’t Worked
    More frequent ANC is better and
    Quantity is emphasized rather than the essential elements of care
    The model resulted in insignificant gains &
    it was not applicable in the low resource context
    Berhanu M
  • …why
    Even when women go for ANC, they do not receive the full care as prescribed in national guidelines ,Among women who attended ANC:
    37% never had their blood pressure checked,
    41% never had their blood tested,
    45% never had their urine tested,
    25% never had their abdomen examined, and 63% were never informed of any danger signs
    The services in antenatal clinics in Arusha, Tanzania, (Eseko 1998).
    Berhanu M
  • …why
    no enough time to handle each visit
    Lacks due attention to client counseling, preparation for delivery, anticipation of complications, …
    Berhanu M
  • ….Why
    In Kasongo, Zaire, 71 percent of the women who developed obstructed labor were not identified as at risk, while 90 percent of the women identified as “at risk” did NOT develop obstructed labor.
    Data from around the world has now pointed out that risk assessment does not predict who will and who will not have an obstetric emergency.
    Risk factors are usually not direct cause of complications
    Berhanu M
  • Evidence suggests that the high-risk approach has failed because
    Most women who experience an obstetric emergency are assessed as not at risk
    It fails to distinguish who will develop complications and who will not
    women may have a false sense of security and may not be prepared for an emergency
    Berhanu M
  • utilize scarce resources (e.g., mandated hospital deliveries for women who don’t really need them)
    Identification of special medical needs does not guarantee appropriate action at the referral site
    Berhanu M
  • ….cnt’d
    1. Haemorrhage – can occur anytime , difficult to predict.
    2. Obstructed labor - difficult to predict.
    3. PIH disorders (Eclampsia/pre-eclamsia) – there is no way to predict who will develop PIH
    Berhanu M
  • For ANC to be effective in reducing maternal mortality, it must be
    goal oriented and
    focused on “screening to detect a problem rather than screening to predict a problem” and on treating any problem that can complicate a pregnancy.
    Berhanu M
  • No longer recommended during ANCs
    Numerous visits
    Measurement of Maternal height
    Examination for Ankle edema
    Examination of fetal position before 36 weeks
    Care based on risk assessment
    Berhanu M
  • Focused ANC
    Berhanu M
  • Introduction
    Intended for managing non complicated pregnancies
    Based on multi center randomized controlled trials to compare standard “Western” model with new WHO model
    In total 24678 women were enrolled over 18 month between 1996 -1998, 53 clinics in four countries
    The new model had median of 5 visits vs 12 visits in the standard.
    Hospital admission diagnosis rate of LBW, UTI, Eclampsia, PE similar between the two groups.
    Berhanu M
  • …Introduction
    FANC not associated with an increase in any of the negative maternal and perinatal outcomes
    women can be less satisfied and feel that their expectations with care are not fulfilled
    Care provided by midwife/general practitioner was associated with improved perception by women
    Lower costs for the mothers and providers
    Effectiveness of midwife/general practitioner managed care was similar to that of obstetrician /gynecologist led shared care
    Reprint 2007
    Berhanu M
  • Principles of the new WHO ANC model
    The model should include simple format
    Identification of women with special health conditions or risk factors should be done very carefully
    Health care providers should make all pregnant women feel welcome at their clinic
    Only examinations & tests that serve an immediate purpose that have been proven to be beneficial should be performed.
    Whenever possible rapid & easy to perform test should be used, treatment should be initiated at the clinic the same day.
    Berhanu M
  • Objectives
    Describe four main components of focused antenatal care (ANC)
    Discuss frequency and timing of ANC visits
    Describe essential elements of a birth plan that includes complication readiness
    Describe interpersonal skills for effective ANC
    Describe components of record keeping for ANC
    Berhanu M
  • FANC
    An approach to ANC that emphasizes:
    Evidence-based, goal-directed actions
    Individualized, woman-centered care
    Quality vs. quantity of visits
    Care by skilled providers
    Berhanu M
  • Goal of FANC
    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
    Berhanu M
  • FANC
    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
    Berhanu M
  • …FANC
    Individualized, woman-centered care based on each woman’s:
    Specific needs and concerns
    History, physical examination, testing
    Available resources
    Berhanu M
  • …FANC
    Quality vs. quantity of ANC visits:
    WHO multi-center study
    Number of visits reduced without affecting outcome for mother or baby
    Content and quality vs. number of visits
    Goal-oriented care
    Minimum of four visits
    Berhanu M
  • …FANC
    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.
    Berhanu M
  • Timing of ANC Visits
    First visit: By 12 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, follow up or referral is needed, woman wants to see provider, or provider changes frequency based on findings (history, exam, testing) or local policy
    Berhanu M
  • TB, HIV, Ca,DVT…
    Berhanu M
  • 34
    Berhanu M
  • 35
    Berhanu M
  • Early Detection and Treatment
    Severe anemia—physical exam, testing
    Pre-eclampsia/eclampsia—measurement of blood pressure
    HIV—voluntary counseling and testing
    Sexually transmitted infections, including syphilis— testing
    Malaria—history and physical exam
    Fever and accompanying signs/symptoms
    Complicated vs. uncomplicated cases
    Berhanu M
  • Prevention: Key Preventive Measures
    Tetanus toxoid, iron/folatesupplements
    Country/region-specific interventions as appropriate
    Iodine supplements
    Presumptive treatment for hookworm
    Intermittent preventive treatment (IPT)
    Use of insecticide-treated nets (ITNs)
    Berhanu M
  • Birth Preparedness and Complication Readiness
    Develop birth plan—exact plan for normal birth and possible complications:
    Arrangements made in advance by woman and family (with help of skilled provider)
    Usually not a written document
    Reviewed/revised at every visit
    Minimize disorganization at time of birth or in an emergency
    Ensure timely and appropriate care
    Berhanu M
  • …Birth Plan
    Family and Community Support: Care for family in woman’s absence and birth companion during labor
    Blood Donor: In case of emergency
    Needed Items: For clean and safe birth and for newborn care
    Danger Signs/Signs of Advanced Labor
    Berhanu M
  • Essential Elements of a Birth Plan
    Facility or Place of Birth: Home or health facility for birth, appropriate facility for emergencies
    Skilled Provider: To attend birth
    Provider/Facility Contact Information
    Transportation: Reliable, accessible, especially for odd hours
    Funds: Personal savings, emergency funds
    Decision-Making: Who will make decisions, especially in an emergency
    Berhanu M
  • Danger Signs of Pregnancy
    Vaginal bleeding
    Difficulty breathing
    Severe abdominal pain
    Severe headache/blurred vision
    Convulsions/loss of consciousness
    Labor pains before 37 weeks
    Berhanu M
  • Health Education: Objectives
    Inform and educate the woman with health messages and counseling appropriate to:
    Individual needs, concerns, circumstances
    Gestational age
    Most prevalent health issues
    Support the woman in making decisions and solving actual or anticipated problems
    Involve partner and family in supporting/adopting healthy practices
    Berhanu M
  • Health Education: Topics Addressed
    Other important issues to be discussed include:
    Care for common discomforts
    Use of potentially harmful substances
    Rest and activity
    Berhanu M
  • ….cont’d
    Sexual relations and safer sex
    Early and exclusive breastfeeding
    Prevention of tetanus and anemia
    Voluntary counseling and testing for HIV
    Prevention of other endemic diseases/deficiencies
    Berhanu M
  • Interpersonal Skills
    Speak in a quiet, gentle tone of voice
    Listen to woman/family and respond appropriately
    Encourage them to ask questions and express concerns
    Allow them to demonstrate understanding of information provided
    Explain all procedures/actions and obtain permission before proceeding
    Show respect for cultural beliefs and social norms
    Be empathetic and nonjudgmental
    Avoid distractions while conducting the visit
    Berhanu M
  • Record Keeping
    Record all information on the ANC chart and clinic card:
    Subsequent ANC Visits
    Interim history
    Targeted physical examination, testing
    Care provision,
    Counseling, including birth plan and use of ITNs (and relevant information on how client obtained and used ITN)
    Date of next ANC visit
    First ANC Visit
    Physical examination
    Care provision
    Counseling, including birth plan
    Date of next ANC visit
    Berhanu M
  • Late enrolment & Missed visits
    Those particularly starting after 32 weeks should have the first visit all activities recommended & those which correspond to the present visit.
    Take more time than regular
    Determine the reason for missed appointment.
    Berhanu M
  • Spacing between Visits
    Timing & Spacing between visits in the basic component were decided empirically based upon the result of WHO,ANC randomized controlled trials.
    Incase of unexpected symptoms mother should be advised to seek care.
    Berhanu M
  • The post partum visit
    Universally recommended
    Benefits of ANC & Determinants of outcomes seen only when they are part of program for post natal period
    Visit should be within 1 week
    Berhanu M
  • Barriers to effective antenatal care
    • Inadequate infra-structural resources
    • Poor quality of care and treatment of clients
    • Ignorance of the importance and value of ANC
    • Not customary, In most societies there is no tradition of antenatal care
    • Cultural, traditional and religious practices
    Berhanu M
  • ….Barriers
    • Lack of women’s autonomous decision-making on their own health care seeking
    • Poverty – fear of costs of transport and medical care
    • Household responsibilities
    • Illiteracy
    Berhanu M
  • Key Behavior Change Messages for the mother
    • Every pregnancy is at risk, visit your health care provider if you suspect you are pregnant
    • Go for antenatal care during pregnancy to detect and treat problems – it could save your and your baby’s life
    • Pregnant women need four antenatal care visits (including registration) that include a physical checkup, blood and urine testing, two tetanus toxoid injections, and supply of iron folate supplementation
    Berhanu M
  • …Key Behavior
    • Pregnant women need to take iron folate tablets every day for 6 months during pregnancy to save mother’s and newborn’s lives
    • Ask your health care provider about the signs of an emergency and what to do if they occur
    • If you think you have Malaria or hepatitis and you are pregnant, see your doctor immediately for treatment
    • If you are having health problems during your pregnancy, don’t wait – see your doctor right away
    Berhanu M
  • Advocacy Messages
    Current best practices are based on the most up to date scientific evidence of what works therefore it should be implemented
    Berhanu M
  • Update
    The goal-oriented, reduced-visits approach was associated:
    A 15% higher risk of perinatal mortality
    Lower Cost
    women were less satisfied
    Berhanu M
  • …updates
    Possible reasons:
    Health-care workers are less able to give sufficient time to each woman
    The reduced-visits package was quickly adopted by health-care services
    Berhanu M
  • Possible Explanations:
    Differences in background risks in the populations have differential effects on fetal health and well-being
    Wide gap between the visits in the second and third trimester of pregnancy
    January 2011
    Berhanu M
  • ...who
    Berhanu M
  • References
    Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane Database of Systematic Reviews 2010, Issue 10. Art. No.: CD000934. DOI: 10.1002/14651858.CD000934.pub2
    WHO Statement on antenatal care January 2011 ,WHO/RHR/11.12
    MJA Vol 176 18 March 2002 pp 153/4 , Guiding antenatal care
    ABC OF ANTENATAL CARE, Fourth edition, GEOFFREY CHAMBERLAIN Professor Emeritus, Department of Obstetrics and Gynaecology, St George’s Hospital Medical School, London and Consultant Obstetrician, Singleton Hospital, Swansea and MARGERY MORGANConsultant Obstetrician and Gynaecologist, Singleton Hospital, Swansea
    Safe Motherhood Strategies :a Review of the Evidence Vincent De Brouwere and Wim Van Lerberghe, Studies in HSO&P,17,2001
    Patterns of routine antenatal care for low-risk pregnancy , Cochrane Database of Systematic Reviews reprint 2007
    www.mnh.jhpiego.orgFocused Antenatal Care-Planning and Providing Care During Pregnancy –MNH
    Berhanu M
  • Thank you
    Berhanu M