Preconception and Antenatal Care

Why this topic?

Good care before and during pregnancy is important for the health of the mother and the development of the unborn baby.

Pregnancy is a crucial time to promote healthy behaviors and parenting skills.

Good ANC links the woman and her family with the formal health system, increases the chance of using a skilled attendant at birth and contributes to good health through the life cycle.

Inadequate care during this time breaks a critical link in the continuum of care, and affects both women and babies.

Definitions

Pre-conception: Before pregnancy

Antenatal = prenatal: occurring before or existing before birth; i.e. during pregnancy

Background

Pregnancy and childbirth are major life events.

Preconception and antenatal care improve prospects of safe motherhood.

Continuum of care: Preconception care—Antenatal care—Postnatal care—Care of the newborn

Preconception care

Specialized form of care (For who? When? Why?)

For women of reproductive age (and men) before onset of pregnancy to detect treat or counsel about pre-existing medical or social conditions that may militate against safe motherhood/delivery of a healthy baby.

Aim

To obtain the best possible pregnancy outcome by helping the mother to maintain her well-being and achieve a healthy outcome for herself and her infant.

Maternal mortality

Definition: death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes. (WHO, ICD-10)

600,000 women annually worldwide

95% in developing countries

80% of deaths are preventable

Nigeria accounts for about 20% of global maternal deaths

Preconception, ANC and maternal mortality? What is the relationship?

Causes of Maternal Deaths

Direct: As a consequence of a disorder specific to pregnancy e.g. Hemorrhage, pre-eclampsia

Indirect: resulting from previous existing disease(s) that developed during pregnancy, and which were not due to direct obstetric causes but aggravated by pregnancy e.g. Cardiac disease, DM

Coincidental: Incidental/accidental deaths/non-obstetric; deaths during pregnancy but not due to pregnancy or aggravated by pregnancy e.g. Road traffic accident.

Late: Deaths occurring > 42 days but < 1 year after the end of pregnancy.

Preconception and antenatal care can help to reduce both direct and indirect causes of maternal mortality.

Lifetime risk of maternal death

The probability that a 15-year-old girl will die from complications of pregnancy or childbirth over her lifetime.

In a high-fertility setting, a woman faces the risk of maternal death multiple times, and her lifetime risk of death will be higher than in a low-fertility setting.

Specifically;

• In South Sudan 1: 18
• Nigeria 1: 21
• Niger: 1 in 27
• In Italy 1: 51,300 (lowest in the world). ? US: 1 in 3000
• UK: 1 in 8,400

Maternal mortality ratio and rate

Maternal mortality ratio (MMR): the annual number of female deaths per 100,000 live births from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes).

Maternal mortality rate: is the number of maternal deaths (direct and indirect) in a given period per 100,000 women of reproductive age during the same time period.

Infant Mortality

Death of infant < 1 year

50% of all infant deaths occur in the first week of life

Leading causes of infant mortality are birth defects, prematurity/LBW and SIDS

Nigeria has the third highest still birth rate and neonatal death rate in the world

What is the role of preconception and ANC in reducing these adverse outcomes?

The preconception movement is based on the realization that:

• Prenatal care starts too late to prevent many of poor pregnancy outcomes.
• Women who have higher levels of health before pregnancy have healthier reproductive outcomes.
• In obstetrics, many of our outcomes or their determinants are present before we ever meet our patients.

How can preconception and antenatal care help to reduce maternal and perinatal mortality?

• Ensuring optimal health prior to pregnancy.
• Identifying and managing conditions in pre-pregnant state that may negatively affect pregnancy outcome.
• Provision of prophylaxis during pregnancy
• Early identification and appropriate management of complications
• Increasing skilled attendants at delivery

Objectives of preconception care

• Screening
• For medical conditions
• If present, ensure good control
• For viral infections like HIV, hepatitis, rubella
• Avoidance of maternal exposure to teratogens during the period of organogenesis
• Ensure healthy lifestyle
• Provide nutritional supplements
• Introduce potential mothers to social and medical interventions at a time when it will have a maximal effect on pregnancy outcome e.g. preconception folic acid to reduce NTD

4 goals of Preconception Care (Centre for disease control/select panel for preconception care (CDC/SPPC)

1. To improve the knowledge, attitudes and behavior of women and men related to preconception health
2. Ensure that all women of child-bearing age in the US receive preconception care services (i.e. evidence-based risk screening, health promotion and intervention) that will enable them to enter pregnancy in optimal health
3. Reduce risks indicated by a previous adverse pregnancy outcome through interventions during the inter-conception period, which can prevent or minimize health problems for a mother and her future children
4. Reduce disparities in adverse pregnancy outcomes

Context

Certain pre-existing conditions become worse during pregnancy and could contribute to the occurrence of adverse pregnancy outcome to the mother or the child.

• Maternal morbidity or mortality
• Perinatal morbidity or mortality

Preconception care involves—

• Early and continuous risk assessment
• Health promotion
• Medical and psychosocial interventions
• Follow up

Risk assessment

Concept of risk factors: presence of risk factors increase the probability of having an adverse outcome

• Most women with adverse outcome are high risk
• Not all women with risk factors will have an adverse outcome
• Some women without any risk factor will end up having an adverse outcome

Continuous evaluation of risk status before and during pregnancy during labor and in the puerperium will enable early detection of problems allowing timely management and improved outcome.

Examples of Risk Factors for adverse pregnancy outcome

Modifiable

• Drug use, cigarette smoking, and alcohol ingestion
• Medical conditions e.g. HTN, DM, Epilepsy, heart dx

Unmodifiable

• Age
• Parity
• Past obstetric history
• Maternal genetic constitution
• Socioeconomic status

Critical Events before ANC Begins

Placental implantation begins 5 days after fertilization and is complete by days 9-10— before most women know they are pregnant.

The most critical period for development of structural anomalies is days 17-56 after fertilization i.e. organogenesis begins just 3 days after the first missed menses—before most women can get into prenatal care.

A critical period for the prevention of poor pregnancy outcomes has already passed by the time of the first antenatal visit.

Preconception care for men

Make a plan; have a reproductive life plan

Healthy living—stop smoking, alcohol

Avoid exposure to toxic substances (including alcohol and drug)

Knowledge and information about STI/HIV; prevention and treatment

Ten recommendations to improve preconception health (CDC/SPCC)

1. Individual responsibility across the lifespan. Encourage each woman and every couple to have a reproductive life plan
2. Consumer awareness. Increase public awareness of the importance of preconception health behavior and use of preconception care services
3. Preventive visits: as part of primary care visits, provide risk assessment and counselling to all women of childbearing age to reduce risks related to pregnancy outcomes
4. Interventions for identified risks: increase the proportion of women who receive interventions as follow up to preconception risk screening focusing on high priority interventions
5. Inter-conception care: use the inter-conception period to provide intensive interventions to women who had a prior pregnancy ending in an adverse outcome (e.g. infant death, low birth weight, or preterm birth)
6. Pre-pregnancy checkups: offer as a component of maternity care, one pre pregnancy visit for couples planning a pregnancy
7. Health coverage for low income women to improve access to preventive women’s health, preconception and inter-conception care
8. Public health programs and strategies. Integrate components of preconception health into existing local public health and related programs including emphasis on women with previous adverse outcomes
9. Research
10. Monitoring improvements. Maximize public health surveillance and related research mechanisms to monitor pre-conception health

Constraints

Most pregnancies are unplanned

Lack of motivation; skepticism about the values of preconception care

Feel they are healthy

No formal setup

Time, cost, logistics

Way out

Physician’s role: active participation of all health workers because all women of reproductive age are candidates for preconception care.

Woman’s role—all women can benefit from preconception care by taking good care of their health and maintaining healthy habits irrespective of whether or not they are planning a pregnancy.

Education of stake holders

Provision of woman friendly services

Definition

Care provided by skilled health-care professionals to pregnant women in order to ensure the best health conditions for both mother and baby during pregnancy.

Specialized care organized for pregnant women to enable them attain and maintain a state of good health throughout pregnancy and to improve their chances of having safe delivery of healthy infants at term.

According to WHO, ANC involves

• Screening for health and socioeconomic conditions likely to increase the possibility of specific adverse pregnancy outcomes;
• Providing therapeutic interventions known to be effective; and
• Educating pregnant women planning for safe birth on emergencies during pregnancy and how to deal with them.

Components of ANC

Risk identification

Prevention and management of pregnancy-related or concurrent diseases

Health education and health promotion

Involves—

• Thorough initial assessment to determine the level of risk faced by mother and fetus, and
• Continuing follow up care right throughout pregnancy.

Remember—

• Pregnancy and childbirth are major life events
• Preconception and antenatal care improve prospects of safe motherhood
• Continuum of care:
• Preconception care—Antenatal care—Postnatal care—Care of the newborn

Role of ANC in reducing maternal mortality

Ensuring optimal health prior to pregnancy

Identifying & managing conditions during pregnancy that may negatively affect outcome

Provision of prophylaxis during pregnancy

Early identification and appropriate management of complications

Increasing skilled attendants at delivery

ANC reduces maternal and perinatal mortality—

• Directly, through detection and treatment of pregnancy-related complications
• Indirectly, through identification of women at increased risk of developing complications during labor and delivery, thus ensuring referral to an appropriate level of care
• In addition, as indirect causes of maternal morbidity and mortality, such as HIV and malaria infections, contribute to approximately 25% of maternal deaths and near-misses, ANC provides an opportunity to prevent and manage concurrent diseases.
• WHO established that by implementing timely and appropriate evidence-based practices, ANC can save lives.

Within the continuum of care, ANC provides a platform for—

• Critical healthcare functions (health promotion, prevention, screening and diagnosis of diseases).
• Implementing timely and appropriate evidence-based practices which can improve maternal and fetal health.
• Communicate with and support of women, families and communities at this very pivotal time in the course of their lives.

Context:

Certain preexisting conditions become worse during pregnancy and could contribute to the occurrence of adverse pregnancy outcome to the mother or the child resulting in—

• Maternal morbidity or mortality
• Perinatal morbidity or mortality

Risk assessment

Presence of risk factors increase the probability of having an adverse outcome

Most women with adverse outcome are high risk

Not all women with risk factors will have an adverse outcome

Some women without any risk factor will end up having an adverse outcome

Continuous evaluation of risk status before and during pregnancy, during labor and in the puerperium will enable early detection of problems allowing timely management and improved outcome

Historical perspective of ANC

Steeped in rituals and taboos

• Greece: Exercise in pregnancy results in delivery of better warriors
• Rome: strong and violent movements induce membrane rupture
• Hanging clothes to dry on a clothes line increase the risk of cord wrapping round the baby’s neck

Began as a social service in France in 1788 for the destitute.

Women were housed from the 36th week until delivery in cramped hostels.

Emphasis was on treatment, not prevention.

Complicated cases were admitted into general wards.

1st organized prenatal care in US in 1901 with nurse home visits

1911: 1st prenatal clinic

Goal of early prenatal care: diagnose and treat preeclampsia in order to decrease maternal mortality.

Aims of Antenatal Care (ANC)

Prompt detection, modification or management of pre-existing conditions or risk factors that may influence the course and outcome of pregnancy and labor

Provision of health education on the events of pregnancy, labor and puerperium

Immunization and chemoprophylaxis against common diseases that may influence maternal or fetal wellbeing and pregnancy outcome

ANC helps to prepare for birth and parenthood as well as prevent, detect, alleviate, or manage the three types of health problems during pregnancy that affect mothers and babies viz:

• Complications of pregnancy itself
• Pre-existing conditions that worsen during pregnancy
• Effects of unhealthy lifestyles

ANC involves—

• Close monitoring of maternal wellbeing and fetal growth and wellbeing through-out pregnancy
• Detection and modification of conditions that may be pregnancy induced that can influence materno-fetal outcome e.g. gestational diabetes mellitus (GDM), pregnancy induced hypertension (PIH), urinary tract infection (UTI)
• Education regarding pregnancy related conditions, what to expect, danger signs
• Determination of the timing and mode of delivery of the fetus
• Healthcare functions, including health promotion, screening and diagnosis, and disease prevention

Benefits of ANC

Key entry point to receive broad range of health promotion and preventive health services.

Opportunity to promote benefits of skilled attendance at birth.

Ideal opportunity to counsel women about benefits of child spacing.

Essential link in the household-to-hospital care continuum.

Reduces maternal morbidity and mortality

Improves survival and health of babies directly by reducing SBs and NNDs deaths.

Types of ANC

• Traditional ANC
• Focused ANC
• 2016 WHO ANC Model

Focused ANC

Aim was to reduce time and resources needed for ANC by

Reducing number of visits

Limiting clinical procedures to those proven to be of benefit

Definition

Provides goal-oriented care that is client centered, friendly, simple, beneficial and safe to pregnant women.

Provided by skilled birth attendants and emphasizes the woman’s overall health, preparation for childbirth, and readiness for complications that may occur in pregnancy, labor or the puerperium in order to achieve a good pregnancy outcome

Providers focus on assessment and actions needed to make decisions, and provide care for each woman’s individual situation.

Services provide specific evidence-based interventions for all women, carried out at certain critical times in the pregnancy.

Places emphasis on quality rather than on quantity of visits

It includes a classifying form to help providers identify women who have conditions requiring treatment and more frequent monitoring.

Study comparing both models; Focused ANC and traditional ANC

Multi-center randomized controlled trial (RCT) compared the standard ‘Western’ model of ANC with a new WHO model

New model limits number of ANC visits and restricts the tests, clinical procedures and follow up actions to those that have been scientifically proven to improve maternal, perinatal and neonatal outcomes.

Hypothesis: the new WHO model

• Would be as effective as the standard model in terms of specified maternal and perinatal end points among singleton pregnancies,
• Would be cheaper, and
• Acceptable to women and providers.

Results

• No significant differences, in terms of severe anemia, pre-eclampsia, urinary tract infections or low birth-weight infants.
• No significant differences in secondary outcomes for either women or infants, including rates of eclampsia, maternal and neonatal deaths
• Women in both arms equally satisfied with care received
• Women in the new model expressed some concern with timing of the visits.
• In some settings, new model decreased cost

Principles of Focused ANC

Evidence-based, goal directed actions

Family-centered care

Emphasizes quality and not quantity of visits

Provided by skilled providers

Evidence based, goal directed actions

Major goal is to help the woman maintain normal pregnancy through

• Identification of preexisting health conditions
• Early detection and treatment of problems and complications
• Birth preparedness and complication readiness i.e. Counselling for the
• Woman/family to develop a birth preparedness and complication readiness plan.
• Health promotion and disease prevention

Addresses most prevalent health issues affecting women and newborns

Adjusted for specific populations/regions (e.g. malaria prophylaxis in malaria endemic regions like Nigeria)

Appropriate to gestational age based on firm rationale

Family-centred care

Based on each woman’s

• Specific needs and concerns
• Circumstances e.g. socioeconomic, health
• History, physical examination, investigation results
• Available resources

Woman friendly:

• Clean and attractive facility, providing kind and supportive care



• Explain what is happening to the woman and family after each evaluation.
• Praises the woman/family for her/their efforts
• Empowers woman and her family to become active participants in the care.

The provider:

• Involves family, partner or other support person in the care
• Includes relevant and feasible advice
• Speaks in a language that the client understands

Considers rights of the woman:

• Respects beliefs, culture and traditions, permits cultural practices that are not harmful
• Recognizes the right to be informed about her health and what to expect during visit
• Obtains informed consent prior to exams and procedures
• Assures privacy and confidentiality.

Considers emotional, psychological and social well-being of the woman

Quality versus Quantity of visits

WHO multi-center study showed that number of ANC visits can be reduced without affecting outcome for mother or baby

Recommendations:

• Minimum of four visits
• Extra visits if necessary
• Discuss individualized birth plan at each visit

Care by trained provider

Characteristics of a trained provider

• Has formal training and experience
• Has knowledge, skills and qualifications to deliver safe and effective maternal and newborn health care Practices in home, hospital, health center
• May be a midwife, nurse, doctor
• May be a community care providers such as Community health officers (CHO’s), community health extension workers (CHEWs)

Timing of visits in Focused ANC

1st visit: ideally before 12 weeks but no later than 16 weeks or when woman first thinks she is pregnant

2nd visit: at 24-26 weeks or at least once in 2nd trimester

3rd visit: at 28-32 weeks

4th visit: at 36 weeks

Unscheduled visits should be made if

• Complications occur
• Follow up or referral is needed
• Woman wants to see the provider
• Provider changes frequency based on findings (history, exam, testing) or local policy

Remember:

• Basic component of focused ANC is intended only for the management of pregnant women who do not have evidence of pregnancy-related complications, medical conditions or major health-related risk factors.
• Providers are advised to follow established protocols of the hospital for pregnancy related conditions.

Essential elements of Focused ANC

• Screening for/early detection and diagnosis of disease/abnormality e.g. anemia, HIV etc.
• Counselling on health promotion
• Preventive measures, including TT immunization, iron and folic acid, intermittent preventive treatment of malaria in pregnancy (IPTp), use of insecticide treated bednets (ITN)
• Advice and support to the woman and her family for developing healthy home behaviors
• Individualized birth plan
• Emergency preparedness and complication readiness plan
• Focused visits

Aims of focused ANC

• Early detection of existing diseases and treatment or referral.
• Promotion of health and to maintain well-being of mother and baby physically, mentally and socially.
• Development of Individualized Birth Plan (IBP) and complication readiness plan.
• Prevention of diseases and early detection and management of complications during pregnancy, labor/delivery and postpartum through identification of danger signs and symptoms.

Aim of visits

Health promotion and disease prevention; information provided on

• How pregnancy progresses,
• How to prepare for birth,
• Danger signs in pregnancy, what to do and where to get help,
• Importance of healthy living, care of the newborn, child spacing

Immunization against tetanus

Reduction of iron deficiency anemia through nutritional supplements and iron supplements

Protection against malaria in women living in malaria endemic zones

Prevention of Sexually transmitted infections (STI) /HIV/AIDS;

Prevention of Mother to Child Transmission (PMTCT) of HIV

Basic component checklist

• The activities distributed over the four visits are presented in a basic component checklist.
• Used to record tests and interventions performed at each visit.
• The checklist serves as a reminder of the activities that have been and must be performed.

WHO recommends that all pregnant women have a written plan for dealing with birth and any unexpected adverse events, such as complications or emergencies that may occur during pregnancy, childbirth, or the immediate postnatal period.

Birth plan should be discussed and reviewed with a skilled attendant at every ANC assessment and one month before the EDD

Components of birth plan

Identification of

• Desired place of birth;
• Preferred skilled birth attendant;
• Location of closest appropriate care facility;
• Identifying a potential blood donor
• Funds for birth-related and emergency expenses;
• Birth companion;
• Support in looking after the home and children while the woman is away;
• Transport to a health facility for the birth;
• Transport in the case of an obstetric emergency; and
• Identification of compatible blood donors in case of emergency.

Definitions

Components of ANC

Concept of maternal mortality

Role of Antenatal Care (ANC) in reducing maternal mortality

Concept of risk assessment

Models of ANC

Traditional ANC

Focused ANC

New WHO model; 2016

Birth preparedness and complication readiness

Antenatal care is an important component of the care of pregnant women and its overall aim is to improve the outcome of pregnancy….by having a healthy baby born to healthy mother at the end of pregnancy.