Antenatal Care in Poor Countries

Stephen GloydMCH in Developing CountriesFebruary 2007

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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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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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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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Trends in Antenatal care 1990-2000

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Estimates of the proportion of pregnant women who received some antenatal care (1996)

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Number of visits to ANC by region

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Antenatal care and delivery

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Timing of ANC visits (most in 1st trimester except Africa)

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Estimates of the proportion of deliveries attended by skilled personnel (1996)

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Prenatal care vs attended birth and post partum care

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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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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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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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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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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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Prevalence of low birth weight globally

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Sexually transmitted infections (STI) among pregnant women in Mozambique

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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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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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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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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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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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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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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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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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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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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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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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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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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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Basic components of the WHO antenatal care program (1994)

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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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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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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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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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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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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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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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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

Prevention and Control of Malaria during Pregnancy

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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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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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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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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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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