Antenatal Care in Poor Countries 4/17/2017 Antenatal Care in Poor Countries MCH in Developing Countries January 2009 Stephen Gloyd Malaria in Pregnancy

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 Antenatal Care

IMPORTANCE OF ANTENATAL CARE reduce high perinatal risk reduce high maternal risk (50x) major point of access to health care for women Antenatal Care

Access to antenatal care Physical access Time and/or distance to facility Economic costs & barriers Cultural and social factors Quality of care Antenatal Care

Trends in Antenatal care 1990-2000

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

Number of visits to ANC by region Antenatal Care

Antenatal Care

Antenatal Care

Antenatal Care

Antenatal care and delivery

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

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

Prenatal care vs attended birth and post partum care Antenatal Care

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 Antenatal Care

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

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

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) Antenatal Care

Poor outcomes: 3465 birth registries in 30 hospitals of Cote d’Ivoire (1997) Condition Rate per 1000 Normal 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 Others 12 Operative delivery 36 Antenatal Care

Prevalence of low birth weight globally Antenatal Care

Antenatal Care

Sexually transmitted infections (STI) among pregnant women in Mozambique Antenatal Care

Preventability Overall Infant Deaths - 33% preventable (Nairobi) Syphilis: 100% preventable 10% stillbirths 20% Infant Mortality 20% Congenital Syphilis Other causes: % preventable not clear Antenatal Care

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

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 Antenatal Care

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 Antenatal Care

Current state of Prenatal Care 2008 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 (HIV screening and prophylaxis) Malaria IPT (Intermittent Preventive Therapy) Syphilis screening and Rx Iron therapy Tetanus immunization Family planning Nutritional supplementation Antenatal Care

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 Antenatal Care

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 Antenatal Care

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 Antenatal Care

Prevention and Control of Malaria during Pregnancy

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 Antenatal Care

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 Antenatal Care

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 Antenatal Care

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 Antenatal Care

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 Antenatal Care

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 Antenatal Care

Antenatal Care

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 Antenatal Care

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 Antenatal Care

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 Antenatal Care

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 Antenatal Care

Scheduling and Timing of ANC Visits 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 Antenatal Care

Basic components of the WHO antenatal care program (1994)

Antenatal Care

Problems with interventions (general): Utilization is 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 Antenatal Care

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 Antenatal Care

Safe childbirth care Antenatal Care

Antenatal Care

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) Antenatal Care

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 Antenatal Care

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 Antenatal Care

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 Antenatal Care