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Antenatal Care in Poor Countries

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Title: Antenatal Care in Poor Countries


1
Antenatal Care in Poor Countries
  • Stephen Gloyd
  • MCH in Developing Countries
  • February 2007

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)
  • AndImprovement of womens' status

3
IMPORTANCE OF PRENATAL CARE
  • reduce high perinatal risk
  • reduce high maternal risk (50x)
  • major point of access to health care for women

4
Access to prenatal care
  • Physical access
  • Time and/or distance to facility
  • Economic costs barriers
  • Cultural and social factors
  • Quality of care

5
Trends in Antenatal care 1990-2000
6
Estimates of the proportion of pregnant women who
received some antenatal care (1996)
7
Number of visits to ANC by region
8
(No Transcript)
9
Antenatal care and delivery
10
Timing of ANC visits (most in 1st trimester
except Africa)
11
Estimates of the proportion of deliveries
attended by skilled personnel (1996)
12
Prenatal care vs attended birth and post partum
care
13
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

14
Perinatal Morbidity and Mortality
  • LBW
  • Birth trauma, obstructed labor
  • Infection
  • amnionitis
  • herpes
  • gonorrhea
  • syphilis
  • streptococcus
  • HIV
  • Tetanus
  • Abruptio Placenta
  • Congenital malformations
  • "other" (30)

15
Maternal Morbidity and Mortality
  • (Five main causes)
  • Hemorrhage
  • Sepsis
  • Eclampsia
  • Obstructed Labor
  • Abortion
  • Note Mortality reduction requires secondary and
    tertiary care

16
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)

17
Poor outcomes 3465 birth registries in 30
hospitals of Cote dIvoire (1997)
18
Prevalence of low birth weight globally
19
(No Transcript)
20
Sexually transmitted infections (STI) among
pregnant women in Mozambique
21
Preventability
  • Overall Infant Deaths - 33 preventable
    (Nairobi)
  • Syphilis 100 preventable
  • 10 stillbirths
  • 20 Infant Mortality
  • 20 Congenital Syphilis
  • Other causes preventable not clear

22
Risk Approach
  • Identification of high risk factors
  • Predictive (Previous fetal loss)
  • Contribution (Grand multipara, young or old)
  • Causation (syphilis, HIV, maternal malnutrition)

23
Risk Approach
  • Not an effective ANC strategy because
  • Complications cannot be predictedall 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

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

25
Focused Antenatal Care
An approach to ANC that emphasizes
  • Evidence-based, goal-directed actions
  • Individualized, woman-centered care
  • Quality vs. quantity of visits
  • Care by skilled providers

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

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

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

29
Focused Antenatal Care Services (contd.)
  • 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

30
Focused Antenatal Care Services (contd.)
  • Individualized, woman-centered care based on each
    womans
  • Specific needs and concerns
  • Circumstances
  • History, physical examination, testing
  • Available resources

31
Focused Antenatal Care Services (contd.)
  • 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

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

33
Scheduling and Timing of ANC Visits
  • First visit By 16 weeks or when woman first
    thinks she is pregnant
  • Second visit At 2428 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

34
Basic components of the WHO antenatal care
program (1994)
35
(No Transcript)
36
Problems with interventions (general)
  • Utilization is often low/widely 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

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

38
Issues in Prenatal Care Impact
  • 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
  • Malaria IPT
  • Syphilis ID and Rx
  • Iron therapy
  • Tetanus immunization
  • Family planning
  • Nutritional supplementation

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

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

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

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

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 US0.25-0.35,
    takes 15-20 minutes
  • Treatment 3 doses (1 per week) of Benzathine
    Penicillin at US1.00 per dose
  • Estimated screening of women in ANC in Africa -
    38
  • Obstacles cost, organization of services
  • Missed opportunities for screening 1 million

44
Prevention and Control of Malaria during Pregnancy
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

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

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)

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

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
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