This document discusses the history and development of antenatal care (ANC) models. It outlines the traditional ANC model which involved frequent visits and classifying women as high or low risk. Issues with this model led to the focused ANC model promoted by WHO, which recommends 4 visits and focuses on essential services. The 2016 WHO ANC guideline further refined this, recommending a minimum of 8 contacts to provide integrated care throughout pregnancy. The document details the recommended components, timing and interventions for each contact to promote positive pregnancy outcomes.

1. By: Dr Bethelhem .T
Antenatal care

2. Outline
 Introduction
 Traditional ANC
 Making ANC effective
 Principles of Focused ANC
 Development of the WHO ANC guideline

3. INTRODUCTION
 ANC is a care given to pregnant women with the
aim of improving the maternal and perinatal out
come.
 Components of ANC:-
 Evaluation of health status of the mother
and fetus
 Identification of mothers at risk of
complications
 Anticipation and prevention of problems
 Patient education and communication.
 Health promotion
 Risk assessment
 Care provision.

4. It decreases perenatal & maternal mortality with better
pregnancy out come .
ANC has been effective in the treatment of;
Anemia
Hypertension
STDs

5. Cont...
History
 1901 - Mrs William Lowel putnam of Boston
started nurse visits to home
 1911 - out patient ANC clinic
 1920 - Edinburgh Dame Janet Campbell, started
national system of ANC
 1970 - Risk assessment approach introduced,
Focused ANC approach
 2016 WHO ANC Model

6. Cont...
 Historically the practice of a comprehensive and
organized delivery of antenatal care passed
through three phases:
1. Traditional ANC model
2. Focused ANC model
3. ANC for positive pregnancy experience

7. Traditional ANC model
 Developed in the early 1990s
 Frequent visit
 Classifying pregnant women into low and high
risk by predicting the complication
 Visit pattern
Every 4 weeks till 28 weeks
Every 2 weeks from 28-36 weeks
Every week from 36 weeks till delivery
 Total number of visits 12-14

8. Basic Problems in Traditional
Approach
 The model resulted in insignificant gains
 It was not applicable in the low resource context
 Assumes that more frequent ANC visit is better
 Quantity of care is emphasized rather than the essential
elements of care
 It has developed/changed very little despite increasing
medical knowledge

9. Why the Risk Assessment Approach
has Not Worked
 Top five causes of maternal death:
 Hemorrhage – difficult to predict
 Obstructed labor – difficult to predict
 PIH - no way to predict
 Puerperal sepsis
 Complications of unsafe abortion

10. Focused ANC
 Focused four ANC visit by skilled provider
 Birth preparedness & complications readiness
planning with family
 Detection & management of coexisting condition
 HIV test
 Counseling on BF, FP, Danger signs, STI, Nutrition.
 Treatment of diagnosed infection

11. Behavioral Change Messages &
Advocacy
 Every pregnancy is at risk.
 Pregnant women need four ANC visits
 If you have problem don't wait for next visits
 Practices are based on scientific evidences.
 Best practices save recourses, save lives

12. Cont...
FOCUSED ANC Recognizes Three Key Realities:
1. ANC visits are unique opportunity for early
diagnosis & treatment of problems in the mother
& newborns
2. Majority of pregnancies progress without
complications
3. All women are considered at risk of complications
because most complications cannot be predicted by
any type of risk categorization.
 Therefore, all woman should receive essential
care & monitoring for complications that are
focused on individual needs.

13. Objectives of Focused ANC
The major goal of ANC is to help women maintain
normal pregnancies through:
1. Health promotion and disease prevention
2. Early detection and treatment of complications and
existing diseases
3. Birth preparedness and complication readiness
planning

14. CONT
Health Promotion and Disease Prevention:
Immunization against tetanus
Iron and folate supplementation
How to recognize danger signs, what to do, and where to
get help
Voluntary counseling and testing for HIV
The benefit of skilled attendance at birth
Breastfeeding
Establish access to family planning

15. CONT
Protection against malaria with insecticide-treated bed
nets
Good nutrition and the importance of rest
Protection against iodine deficiency
Risks of using tobacco, alcohol, local stimulants, and
traditional remedies
Hygiene and infection prevention practices
Defibulation – for women with type-III female genital
cutting

16. CONT
Birth Preparedness and Complication Readiness:
 Approximately 15% of women will develop a life-
threatening complication.
 Every woman and her family should have a plan for:
 A skilled attendant at birth
 The place of birth and how to get there including how to access
emergency transportation if needed
 Items needed for the birth
 Money saved to pay for transportation, the skilled provider and
for any needed medications and supplies that may not been
provided for free
 Support during and after the birth (e.g., family, friends)
 Potential blood donors in case of emergency

17. Principles of Focused ANC
 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; and treatment should be initiated at the clinic
the same day.

18. Overview of Focused ANC
 Segregate pregnant women in to two groups
 Those eligible to receive basic ANC component - 75%
 Those who need special care - 25%
 This classification based on the risk scoring form used
at first visit to the clinic.

19. CONT
 The activities in the basic component fall within 3
general areas.
1. Screening for health & socio-economic conditions.
2. Providing therapeutic interventions.
3. Educating pregnant women.
 These activities are distributed over four visits.

20. Basic Component Focused ANC
The first visit
 Should occur in the first trimester (ideally before 12
wks but no later than 16wks)
 Expected to take 30-40 minutes.
 Emphasis on medical & obstetric history.
 Physical & Bio-Chemical examinations are few &
less resource demanding.
 Only one routine Vaginal Examination is
recommended
 Routine iron supplementation.
 Individual interaction, general information about
pregnancy & delivery, related complications

21. CONT
Content of first visit
1.History –personal ,medical, obstetric history
2.Physical examination
3.Tests : Hgb, BG & RH, U/A, VDRL/RPR, HIV, Stool Ex
4.Interventions  Iron & Folate to all women 60mg
elemental iron and 400microgram folate per day if the
side effect un tolerable 120mg and 2800microgram (Fe
and Folate weekly ) , TT1, referral accordingly .Ca, I2,
and VitA supplementation where shortage
5.Advice, questions, scheduling
6.Complete record.

22. CONT
The second visit
 At 24 to 28 weeks
 expected to take 20 minutes
Contents
1. History review
2. Physical examination
3. Tests-
U/A, Hgb if the previously anemic
GTD-OGTT
first trimester in women with significant risk factors (eg, body
mass
index >30 kg/m 2 , gestational diabetes or baby >4500 g in a
prior
pregnancy, family history of diabetes in a first degree relative
4.Assess for referral
5.Interventions-iron-

23. CONT
The Third visit
Should take place at around 32 weeks(30-32)
Expected to take 20minutes
Contents
1.History
2.Physical examination
3.Tests- U/A, Hemoglobin test for all women,
 CDC recommends testing for sexually transmitted diseases (STDs, eg,
HIV, syphilis, hepatitis B surface antigen, Chlamydia, gonorrhea) in the
third trimester (28 to 36 weeks) in women who
 Were diagnosed with a STD earlier in pregnancy
 Continue to have risk factors for acquiring a STD
 Acquired a new risk factor during pregnancy (eg, a new or more than
one sex partner, evaluation or treatment for a STD, injection of
nonprescription drugs)

24. CONT
4.Group B beta-hemolytic streptococcus testing all women
at 35-37 weeks gestation
5.Ultrasound examination (Fetal Presentation , ESFW, in
risk mother IUGR,BPP)
6.Interventions-iron, TT2.
7.Advice –ensure availability of transports
8.Maintain records & appointment

25. CONT
The fourth visit
 Should be the final visit
 Between 36 - 38 weeks. Or 37-41
 Breech should be discovered.
Content
1. Review history
2. Physical examination
3. Test-U/A
4. Interventions-iron
5. Advice - Post partum visit, BF, Contraception,
Delivery plan, Danger sign

26. 2016 WHO ANC MODEL
 Through timely and appropriate evidence-based
actions related to :
 health promotion, disease prevention, screening, and
treatment
 Reduces complications from pregnancy and childbirth
 Reduces stillbirths and perinatal deaths
 Integrated care delivery throughout pregnancy

27. Cont...
 The guideline uses the term ‘contact’ - it implies an active
connection between a pregnant woman and a health care
provider that is not implicit with the word ‘visit’.
 quality care including medical care, support and timely and relevant
information
 In terms of the operationalization of this recommendation,
‘contact’ can take place at the facility or at community level
 be adapted to local context through health facilities or community
outreach services
 ‘Contact’ helps to facilitate context-specific recommendations
 Interventions (such as malaria, tuberculosis)
 Health system (such as task shifting)

28. Cont...
 A healthy pregnancy for mother and baby (including
preventing or treating risks, illness and death)
 Physical and sociocultural normality during pregnancy
 Effective transition to positive labour and birth
 Positive motherhood (including maternal self-esteem,
competence and autonomy)

29. CONT
 WHO recommends a minimum of eight contacts:
 Five contacts in the third trimester,
 One contact in the first trimester, and
 Two contacts in the second trimester.
 The core package of ANC services and consensus on
what care is provided at each contact, who provides
ANC care (which health cadre), where care is
provided (which system level), and how care is
provided (platforms) and coordinated across all eight
ANC contacts.

30. Cont...
2016 WHO ANC model
First trimester
Contact 1: up to 12 weeks
Second trimester
Contact 2: 20 weeks
Contact 3: 26 weeks
Third trimester
Contact 4: 30 weeks
Contact 5: 34 weeks
Contact 6: 36 weeks
Contact 7: 38 weeks
Contact 8: 40 weeks
Return for delivery at 41 weeks if not given birth.
Note: Intermittent preventive treatment of malaria in pregnancy should be started at ≥ 13 weeks

31. What shall we do at each
contact?
Week of
gestation
Intervention
Upto -12
weeks
• Baseline:
 History (Medical, Pyschological,Genetic history)
 Reproductive history(previous deliveries, abortion,mode
of deliveries)
 Previous obstetrics complications
• Physical examination
 General
 Blood pressure
 Weight
 Pelvic examination and pelvimetry
 Breast examination
 Fundal height
 Fetal position and heart rate
 Cervical examination
 Pregnancy test

32. cont
• Laboratory
 Hgb/hct
 Pap smear
 Antibody screen
 Blood and RH factor
 UA
 Urine culture
 Rubella titer
 Gonoccocal culture
 HBV
 HIV
 Toxoplasmosis
 Genetic screen
 Illicit drug use
 Nuchal translucency
 Serum marker screening for aneuploidy

33. 16-20
weeks
26-28
weeks
• Update medical and psychosocial
• Physical examination
 General
 Blood pressure
 Weight
 Fundal height
 Fetal position and heart beat
 AFP if indicate
 Multiple marker screening if indicate
 Anatomic scan upto 22wks
 Update medical and pschosocial
 Glucose tolerance test if indicate
 Hgb/hct

34. Cont...
30 weeks
34weeks
• Update medical and psychosocial
• Physical examination
 General
 Blood pressure
 Weight
 Fundal height
 Fetal position and heart beat
 Child birth education
 Risk assessment
• Update medical and psychosocial
• Physical examination
 General
 Blood pressure
 Weight
 Fundal height
 Fetal position and heart beat
 Child birth education
 Risk assessment

35. cont
36 weeks
38 weeks
• Update medical and psychosocial
• Physical examination
 General
 Blood pressure
 Weight
 Fundal height
 Fetal position and heart beat
 HBV
 HIV
 Hgb/hct
 Gbs growth
• Update medical and psychosocial
• Physical examination
 General
 Blood pressure
 Weight
 Fundal height
 Fetal position and heart beat

36. cont
40 weeks • Update medical and psychosocial
• Physical examination
 General
 Blood pressure
 Weight
 Fundal height
 Fetal position and heart beat
 Risk assessment
• Return for delivery at 41 weeks if not given birth.
• Update medical and psychosocial
• Assess risk and BPP 2x/week
• Admit at 41wks +6days

37. Early ultrasound
 In the new WHO ANC guideline, an ultrasound scan before 24
weeks’ gestation is recommended for all pregnant women to:
 Estimate gestational age
 Detect fetal anomalies and multiple pregnancies
 Enhance the maternal pregnancy experience
 An ultrasound scan after 24 weeks’ gestation (late ultrasound) is
not recommended for pregnant women who have had an early
ultrasound scan.
 Stakeholders should consider offering a late ultrasound scan to
pregnant women who have not had an early ultrasound scan.
 Ultrasound equipment can also used for other indications (e.g.
obstetric emergencies) or by other medical departments

38. Recommendations on ANC
 49 recommendations were grouped into five topic
areas:
A. Nutritional interventions (14)
B. Maternal and fetal assessment (13)
C. Preventive measures (7)
D. Interventions for common physiological symptoms
(6)
E. Health systems interventions to improve the
utilization and quality of ANC (9)

39. Nutritional intervention
A.1.1: Counselling about healthy eating and
keeping physically active during pregnancy is
recommended for pregnant women to stay healthy and
to prevent excessive weight gain during pregnancy.
Recommended
A.1.2: In undernourished populations, nutrition
education on increasing daily energy and protein
intake is recommended for pregnant women to reduce
the risk of low-birth-weight neonates.
Context-specific
recommendation
A.1.3: In undernourished populations, balanced
energy and protein dietary supplementation is
recommended for pregnant women to reduce the risk
of stillbirths and small-for-gestational-age neonates.
Context-specific
recommendation
A.1.4: In undernourished populations, high-protein
supplementation is not recommended for pregnant
women to improve maternal and perinatal outcomes.
Not
recommended

40. Cont...
A.2.1: Daily oral iron and folic acid supplementation
with 30 mg to 60 mg of elemental iron and 400 µg
(0.4 mg) of folic acid is recommended for pregnant
women to prevent maternal anaemia, puerperal sepsis,
low birth weight, and preterm birth.
Recommende
d
A.2.2: Intermittent oral iron and folic acid
supplementation with 120 mg of elemental iron and
2800 µg (2.8 mg) of folic acid once weekly is
recommended for pregnant women to improve maternal
and neonatal outcomes if daily iron is not acceptable due
to side-effects, and in populations with an anaemia
prevalence among pregnant women of less than 20%.
Context-
specific
recommendati
on
A.3: In populations with low dietary calcium intake, daily
calcium supplementation (1.5–2.0 g oral elemental
calcium) is recommended for pregnant women to reduce
the risk of pre-eclampsia.
Context-
specific
recommendati
on
A.4: Vitamin A supplementation is only recommended
for pregnant women in areas where vitamin A deficiency
is a severe public health problem, to prevent night
blindness.
Context-
specific
recommendati
on

41. Cont...
A.5: Zinc supplementation for pregnant women is only
recommended in the context of rigorous research.
Context-
specific
recommendati
on (research)
A.6: Multiple micronutrient supplementation is not
recommended for pregnant women to improve maternal
and perinatal outcomes.
Not
recommended
A.7: Vitamin B6 (pyridoxine) supplementation is not
recommended for pregnant women to improve maternal
and perinatal outcomes.
Not
recommended
A.8: Vitamin E and C supplementation is not
recommended for pregnant women to improve maternal
and perinatal outcomes.
Not
recommended
A.9: Vitamin D supplementation is not recommended
for pregnant women to improve maternal and perinatal
outcomes.
Not
recommended
A.10: For pregnant women with high daily caffeine intake
(more than 300 mg per day), lowering daily caffeine
intake during pregnancy is recommended to reduce the
Context-
specific
recommendati

42. B.1. Maternal assessment - 1
B.1.1: Full blood count testing is the recommended
method for diagnosing anaemia in pregnancy. In
settings where full blood count testing is not available,
on-site haemoglobin testing with a haemoglobinometer is
recommended over the use of the haemoglobin colour
scale as the method for diagnosing anaemia in
pregnancy.
Context-
specific
recommendati
on
B.1.2: Midstream urine culture is the recommended
method for diagnosing asymptomatic bacteriuria
(ASB) in pregnancy. In settings where urine culture is not
available, on-site midstream urine Gram-staining is
recommended over the use of dipstick tests as the
method for diagnosing ASB in pregnancy.
Context-
specific
recommendati
on
B.1.3: Clinical enquiry about the possibility of
intimate partner violence (IPV) should be strongly
considered at antenatal care visits when assessing
conditions that may be caused or complicated by IPV in
order to improve clinical diagnosis and subsequent care,
where there is the capacity to provide a supportive
Context-
specific
recommendati
on

43. Cont...
B.1.4: Hyperglycaemia first detected at any time during
pregnancy should be classified as either gestational diabetes
mellitus (GDM) or diabetes mellitus in pregnancy, according to
WHO criteria.
Recom
mende
d
B.1.5: Health-care providers should ask all pregnant women
about their tobacco use (past and present) and exposure to
second-hand smoke as early as possible in the pregnancy and at
every antenatal care visit.
Recom
mende
d
B.1.6: Health-care providers should ask all pregnant women
about their use of alcohol and other substances (past and
present) as early as possible in the pregnancy and at every
antenatal care visit.
Recom
mende
d
B.1.7: In high-prevalence settings, provider-initiated testing and
counselling (PITC) for HIV should be considered a routine
component of the package of care for pregnant women in all
antenatal care settings. In low-prevalence settings, PITC can be
considered for pregnant women in antenatal care settings as a
key component of the effort to eliminate mother-to-child
transmission of HIV, and to integrate HIV testing with syphilis,
viral or other key tests, as relevant to the setting, and to
strengthen the underlying maternal and child health systems.
Recom
mende
d
B.1.8: In settings where the tuberculosis (TB) prevalence in the
general population is 100/100 000 population or higher,
Contex
t-

44. B.2.Fetal assessment
B.2.1: Daily fetal movement counting, such as with “count-to-ten” kick
charts, is only recommended in the context of rigorous research.
Context-
specific
recommendat
ion (research)
B.2.2: Replacing abdominal palpation with symphysis-fundal height
(SFH) measurement for the assessment of fetal growth is not
recommended to improve perinatal outcomes. A change from what is
usually practiced (abdominal palpation or SFH measurement) in a
particular setting is not recommended.
Context-
specific
recommendat
ion
B.2.3: Routine antenatal cardiotocography is not recommended for
pregnant women to improve maternal and perinatal outcomes.
Not
recommende
d
B.2.4: One ultrasound scan before 24 weeks of gestation (early
ultrasound) is recommended for pregnant women to estimate
gestational age, improve detection of fetal anomalies and multiple
pregnancies, reduce induction of labour for post-term pregnancy, and
improve a woman’s pregnancy experience.
Recommende
d

45. C. Preventive measures
C.1: A seven-day antibiotic regimen is recommended for all pregnant
women with asymptomatic bacteriuria (ASB) to prevent persistent
bacteriuria, preterm birth and low birth weight.
Recommend
ed
C.2: Antibiotic prophylaxis is only recommended to prevent recurrent
urinary tract infections in pregnant women in the context of rigorous
research.
Context-
specific
recommend
ation
C.3: Antenatal prophylaxis with anti-D immunoglobulin in non-
sensitized Rh-negative pregnant women at 28 and 34 weeks of
gestation to prevent RhD alloimmunization is only recommended in the
context of rigorous research.
Context-
specific
recommend
ation
C.4: In endemic areas, preventive anthelminthic treatment is
recommended for pregnant women after the first trimester as part of
worm infection reduction programmes.
Context-
specific
recommend
ation
C.5: Tetanus toxoid vaccination is recommended for all pregnant
women, depending on previous tetanus vaccination exposure, to
prevent neonatal mortality from tetanus.
Recommend
ed

46. Cont...
C.6: In malaria-endemic areas in Africa, intermittent
preventive treatment with sulfadoxine-
pyrimethamine (IPTp-SP) is recommended for all
pregnant women. Dosing should start in the second
trimester, and doses should be given at least one month
apart, with the objective of ensuring that at least three
doses are received.
Context-
specific
recommendatio
n
C.7: Oral pre-exposure prophylaxis (PrEP) containing
tenofovir disoproxil fumarate (TDF) should be offered as
an additional prevention choice for pregnant women at
substantial risk of HIV infection as part of combination
prevention approaches.
Context-
specific
recommendatio
n

47. D.Recommended interventions for management
of common physiological symptoms in pregnancy

48. E. Health systems interventions to
improve the utilization and quality of
ANC
E.1: It is recommended that each pregnant woman carries
her own case notes during pregnancy to improve
continuity, quality of care and her pregnancy experience.
Recommend
ed
E.2: Midwife-led continuity-of-care models, in which a
known midwife or small group of known midwives supports
a woman throughout the antenatal, intrapartum and
postnatal continuum, are recommended for pregnant
women in settings with well functioning midwifery
programmes.
Context-
specific
recommenda
tion
E.3: Group antenatal care provided by qualified health-
care professionals may be offered as an alternative to
individual antenatal care for pregnant women in the
context of rigorous research, depending on a woman’s
preferences and provided that the infrastructure and
resources for delivery of group antenatal care are
available.
Context-
specific
recommenda
tion

49. cont
E.4.1: The implementation of community mobilization
through facilitated participatory learning and action
(PLA) cycles with women’s groups is recommended to
improve maternal and newborn health, particularly in rural
settings with low access to health services. Participatory
women’s groups represent an opportunity for women to
discuss their needs during pregnancy, including barriers to
reaching care, and to increase support to pregnant women.
Context-
specific
recommend
ation
E.4.2: Packages of interventions that include household and
community mobilization and antenatal home visits are
recommended to improve antenatal care utilization and
perinatal health outcomes, particularly in rural settings with
low access to health services.
Context-
specific
recommend
ation

50. Cont...
E.5.1: Task shifting the promotion of health-related
behaviours for maternal and newborn health to a broad
range of cadres, including lay health workers, auxiliary
nurses, nurses, midwives and doctors is recommended.
Recomme
nded
E.5.2: Task shifting the distribution of recommended
nutritional supplements and intermittent preventative
treatment in pregnancy (IPTp) for malaria prevention to a
broad range of cadres, including auxiliary nurses, nurses,
midwives and doctors is recommended.
Recomme
nded
E.6: Policy-makers should consider educational, regulatory,
financial, and personal and professional support interventions
to recruit and retain qualified health workers in rural and
remote areas.
Context-
specific
recomme
ndation

51. Cont...
E.7: Antenatal care models with
a minimum of eight contacts
are recommended to reduce
perinatal mortality and improve
women’s experience of care.
Recommend
ed

52. contact recommended to reduce perinatal
mortality and improve women experience
care
 Evidence suggesting increased perinatal deaths in 4-visit ANC
model
 Evidence supporting improved safety during pregnancy through
increased frequency of maternal and fetal assessment to detect
complications
 Evidence supporting improved health system communication
and support around pregnancy for women and families
 Evidence indicating that more contact between pregnant women
and respectful, knowledgeable health care workers is more likely
to lead to a positive pregnancy experience
 Evidence from HIC studies indicating no important differences in
maternal and perinatal health outcomes between ANC models
that included at least eight contacts and ANC models that
included 11 to 15 contacts.

54. THANK YOU