Basic Antenatal Care Package in South Africa

Antenatal Care The health care of pregnant women. The care is aimed at detecting problems. Once problems are detected they can be addressed. Interventions during pregnancy can have beneficial effects later in life. ANC has a further role of improving the general health of the woman. Not only is the pregnancy examined, but also the general health and habits of the woman. Interventions during pregnancy can have permanent beneficial effects later in the woman’s life. ANC can screen for, detect, and thus prevent many maternal complications occurring before childbirth

Routine antenatal care 12 visits: Traditional schedule 2001: RCT showed no difference between the standard Western model of antenatal care and a model that limited the number of visits. Introduced into practice without much evidence for its effectiveness in reducing maternal and neonatal morbidity and mortality. What can antenatal care achieve? Improve maternal health Improve the health and survival of the baby Provide the pregnant woman with information on: Warning signs during pregnancy and how to respond Bad habits such as drinking alcohol and smoking Nutrition Contraception Feeding her infant HIV ANC can screen for, detect, and thus prevent many maternal complications occurring before childbirth

Routine antenatal care Focused ANC introduced in SA in 2008 (BANC) Specifically designed for non-midwife ANC providers. 5 critically timed visits. Antenatal visits integrated multiple evidence-based interventions (1st visit, 20, 28, 34, 38 weeks) (primary health care facilities that performed basic antenatal care as part of the complete package of care rendered at that level) 3000+ PHC clinics Supermarket approach Knowledge and skills poor Problem with referrals of women with high risk factors

Why is improvement in antenatal care needed? The stillbirth rate is a reflection of the quality of antenatal care. Surveys have indicated shortcomings in the performance of antenatal care. Patient factors? -95% of pregnant women attend antenatal care- 2,6 mil stillbirths globally. Majority in the developing countries. 98% in low middle income countries Sub Saharan Africa has 10 times higher than the developed counties 29 vs 3 per 1000 Recommendations have included improving antenatal care as one of the key points. the problem is not women not attending antenatal care, but rather the quality of care given.

Mpumalanga audit (BANC model) Most common cause of stillbirths Hypertensive disorders Unexplained (IUGR) Third trimester- greatest risk Failure to measure or respond to maternal hypertension Poor knowledge and skills Delay in referral to expert care Failure to detect risk factors

Comparison with Western Cape perinatal mortality rate was significantly higher in the reduced visit group.

BANC: Reduced number of visits An updated Cochrane review was published in 2015. For low and middle income countries, the perinatal mortality rate was significantly higher in the reduced visit group. WHO: 5-visit FANC model no longer recommended. No difference between models with 8 visits when compared to 11-15 visits. Better monitoring of maternal and fetal well being Timely detection of risk factors and complications. Number of visits as well as quality of care during each visit. Aim to reduce preventable morbidity and mortality. A reduced number of antenatal visits (<5) may lead to: An increased number of stillbirths and deaths from undetected growth restriction and/or hypertensive conditions

What should antenatal care do? Evidence based interventions that leads to improved outcomes. How can these practices be delivered?

BANC Plus BANC visits to 8 (booking plus 7) Improve the quality of antenatal care package Provide support for primary care clinics performing basic antenatal care. Reduce preventable morbidity and mortality BANC-Plus is the minimum antenatal care that every pregnant woman should receive. The ‘Plus’ refers to the recent introduction of additional antenatal care visits – a change that was necessary because research around the world has shown that few visits, as was the case with BANC previously, resulted in increased death rates in the babies (increased perinatal mortality). Every aspect of BANC-Plus is based on best evidence, only aspects that have been shown to be effective are included. This includes the need for additional antenatal care visits as compared with the original BANC programme. booking visit plus 7 more visits: a 20 weeks visit, and then visits at 26-28 weeks, 30-32 weeks and thereafter every 2 weeks until term (booking, 20, 26-28, 30-32, 34, 36, 38, 40 The support could be on a rotation basis allowing one professional nurse/medical officer with specific training to service a number of primary care clinics

BANC Plus The care has been simplified to a minimum. Use of flow charts and Protocols Use of Checklists: demonstrated to improve the quality of care. Women requiring additional care should be identified and referred to the next level. Every clinic midwife should be able to perform BANC Plus.

The first visit (How, What, Why) Ask Personal History Identify special conditions or risk factors for referral Obstetric History Gestational age history Calculate EDD Medical History Look, Listen, Feel Physical examination Tests, record signs Hb, Rh, RPR, HIV, Urine Plan Checklist Qualify for BANC? Classify, Implement, treat Supplements, etc. Preventing complications and improve general health Give advice Answer questions Schedule next visit Complete records, checklist All patients should receive or be checked at every visit Iron, folate and calcium (and multivitamins if indicated) Nutritional advice Advice on what to do if the warning signs in pregnancy appear Where she plans to give birth What transport arrangements have been made should she go into labour

Follow-up visits (How, what, when, why) Rapid assessment and management Ask Check record Look, listen, feel Signs Classify Treat and Advise Fill-in antenatal card and Checklist Implement General advice Questions and answers Date next visit Complete records The follow-up visits have been found to be most effective at 20, 26, 30, 34, 36, 38 and 40 weeks’ gestation. This coincides with performing examinations and tests at times that are of most benefit to the pregnant woman and that give the greatest chance of detecting problems that can be treated. Findings from a large international study run by the WHO have recently been updated and suggest that concentrating visits in the period from 26 to 38 weeks may reduce stillbirths related to IUGR and hypertension.

BANC Plus visits schedule Performing only examinations and tests that have been proven to be beneficial, and at the most appropriate time Wherever possible, rapid easy-to-perform tests should be used at the antenatal clinic or in a facility close to the clinic. The results should be available the same day so treatment can be initiated at the clinic without delay Health care providers should Task-shifting for counselling on birth preparedness, complication readiness, breast feeding Every aspect of BANC-Plus is based on best evidence, and only aspects that have been shown to be effective are included. This includes the need for additional antenatal care visits as compared with the original BANC programme. make all the pregnant women feel welcome at their clinic, and it should be convenient for the pregnant women to attend the clinic. Timing the visits such that the maximum benefit can be obtained, without wasting human resources

BANC Plus Issues Implementation: in with the new, evidence based medicine Training: Quality improvement package Protocol book: Ownership Checklists make all the pregnant women feel welcome at their clinic, and it should be convenient for the pregnant women to attend the clinic. Timing the visits such that the maximum benefit can be obtained, without wasting human resources. Performing only examinations and tests that have been proven to be beneficial, and at the most appropriate time Wherever possible, rapid easy-to-perform tests should be used at the antenatal clinic or in a facility close to the clinic. The results should be available the same day so treatment can be initiated at the clinic without delay Health care providers should Task-shifting for counselling on birth preparedness, complication readiness, breast feeding

Objective Enable a positive pregnancy experience If women’s experience of care is positive, they will attend more visits Timing the visits such that the maximum benefit can be obtained, without wasting human resources. Performing only examinations and tests that have been proven to be beneficial, and at the most appropriate time Wherever possible, rapid easy-to-perform tests should be used at the antenatal clinic or in a facility close to the clinic. The results should be available the same day so treatment can be initiated at the clinic without delay Health care providers should make all the pregnant women feel welcome at their clinic, and it should be convenient for the pregnant women to attend the clinic. Task-shifting for counselling on birth preparedness, complication readiness, breast feeding