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Antenatal Care in Poor Countries
4/19/2017 Antenatal Care in Poor Countries Stephen Gloyd MCH in Developing Countries January 2012 Malaria in Pregnancy
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Antenatal Care Initiatives
4/19/2017 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 Malaria in Pregnancy
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IMPORTANCE OF ANTENATAL CARE
4/19/2017 IMPORTANCE OF ANTENATAL CARE reduce high perinatal risk reduce high maternal risk (50x) major point of access to health care for women Antenatal Care Malaria in Pregnancy
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Access to antenatal care
4/19/2017 Access to antenatal care Physical access Time and/or distance to facility Economic costs & barriers Cultural and social factors Quality of care Antenatal Care Malaria in Pregnancy
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Trends in Antenatal care 1990-2000
4/19/2017 Trends in Antenatal care Antenatal Care Malaria in Pregnancy
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4/19/2017 Estimates of the proportion of pregnant women who received some antenatal care (1996) Antenatal Care Malaria in Pregnancy
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Number of visits to ANC by region
4/19/2017 Number of visits to ANC by region Antenatal Care Malaria in Pregnancy
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4/19/2017 Factors affecting the utilization of antenatal care in developing countries: Systematic review of the literature Bibha Simkhada Maureen PorterEdwin R. van Teijlingen Padam Simkhada. Journal of Advanced Nursing, Jan 2008 A systematic review of 28 papers -both quantitative and qualitative Factors most commonly associated with antenatal care uptake: Maternal education, husband's education, marital status, availability, cost, household income, women's employment, media exposure and having a history of obstetric complications. Also cultural beliefs. Parity had a statistically significant negative effect on adequate attendance. While women of higher parity tend to use antenatal care less, there is interaction with women's age and religion. Only one study examined the effect of the quality of antenatal services on utilization. None identified an association between the utilization of such services and satisfaction with them Malaria in Pregnancy
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4/19/2017 Antenatal Care Malaria in Pregnancy
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Antenatal care and delivery
4/19/2017 Antenatal care and delivery Antenatal Care Malaria in Pregnancy
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Timing of ANC visits (most in 1st trimester except Africa)
4/19/2017 Timing of ANC visits (most in 1st trimester except Africa) Antenatal Care Malaria in Pregnancy
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4/19/2017 Estimates of the proportion of deliveries attended by skilled personnel (1996) Antenatal Care Malaria in Pregnancy
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Prenatal care vs attended birth and post partum care
4/19/2017 Prenatal care vs attended birth and post partum care Antenatal Care Malaria in Pregnancy
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Components of prenatal care:
4/19/2017 Components of prenatal care: Health education Screening Diagnosis and treatment Referral Screening/Dx Identify women at high risk [?usefulness] Intervene to prevent development of problems Dx and Rx pre-existing medical conditions Dx and Rx complications of pregnancy Antenatal Care Malaria in Pregnancy
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Perinatal Morbidity and Mortality (newborn)
4/19/2017 Perinatal Morbidity and Mortality (newborn) LBW Birth trauma, obstructed labor Infection amnionitis herpes gonorrhea syphilis streptococcus HIV Tetanus Abruptio Placenta Congenital malformations "other" (30%) Antenatal Care Malaria in Pregnancy
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Maternal Morbidity and Mortality
4/19/2017 Maternal Morbidity and Mortality (Five main causes) Hemorrhage Sepsis Eclampsia Obstructed Labor Abortion Note: Mortality reduction requires secondary and tertiary care Antenatal Care Malaria in Pregnancy
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Other Causes of Maternal Morbidity and Mortality
4/19/2017 Other Causes of Maternal Morbidity and Mortality Hypertension Diabetes Heart Disease Hepatitis Anemia Malaria Tuberculosis STD Overall Morbidity: % of all pregnancies (up to 37% in India) Antenatal Care Malaria in Pregnancy
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4/19/2017 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 Malaria in Pregnancy
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Prevalence of low birth weight globally
4/19/2017 Prevalence of low birth weight globally Antenatal Care Malaria in Pregnancy
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4/19/2017 Sexually transmitted infections (STI) among pregnant women in Mozambique Antenatal Care Malaria in Pregnancy
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Preventability Overall Infant Deaths - 33% preventable (Nairobi)
4/19/2017 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 Malaria in Pregnancy
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Risk Approach Identification of high risk factors
4/19/2017 Risk Approach Identification of high risk factors Predictive (Previous fetal loss) Contribution (Grand multipara, young or old) Causation (syphilis, HIV, maternal malnutrition) Antenatal Care Malaria in Pregnancy
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Risk Approach Not believed an effective ANC strategy because:
4/19/2017 Risk Approach Not believed 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 Malaria in Pregnancy
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WHO working group on prenatal care 1994
4/19/2017 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 Malaria in Pregnancy
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Current state of Prenatal Care 2008
4/19/2017 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 Malaria in Pregnancy
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4/19/2017 Other interventions that need more study (though most of these are recommended) STD identification and treatment Routine anti parasite drugs Waiting houses Diabetes screening (depends on prevalence) Management and treatment of HTN Antenatal Care Malaria in Pregnancy
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HIV in pregnancy Prevention of HIV transmission (pMTCT)
4/19/2017 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 Malaria in Pregnancy
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Prevention of Mother to Child Transmission of HIV (pMTCT)
4/19/2017 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 Malaria in Pregnancy
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Prevention and Control of Malaria during Pregnancy
4/19/2017 Prevention and Control of Malaria during Pregnancy Malaria in Pregnancy
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Malaria and Pregnancy 30 million African women are pregnant yearly
4/19/2017 Malaria and Pregnancy 30 million African women are pregnant yearly Malaria is more frequent and complicated during pregnancy In malaria-endemic areas, malaria during pregnancy may account for: Up to 15% of maternal anemia 5–14% of low birthweight 30% of “preventable” low birthweight Antenatal Care Malaria in Pregnancy
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Effects of Malaria on Pregnant Women
4/19/2017 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 in Pregnancy
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Malaria Prevention and Treatment during Pregnancy
4/19/2017 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 Malaria in Pregnancy
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Benefits of Insecticide-Treated Nets
4/19/2017 Benefits of Insecticide-Treated Nets Prevent mosquito bites Protect against malaria, resulting in less: Anemia Prematurity and low birthweight Risk of maternal and newborn death Help people sleep better Promote growth and development of fetus and newborn Antenatal Care Malaria in Pregnancy
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Intermittent Preventive Treatment
4/19/2017 Intermittent Preventive Treatment Every pregnant woman living in an area of high malaria transmission has malaria parasites in her blood or placenta, whether or not she has symptoms of malaria Although a pregnant woman with malaria may have no symptoms, malaria can still affect her and her unborn child Three doses of sulfadoxine-pyrimethamine (SP) should be given to all pregnant women after quickening and at least 1 month apart Antenatal Care Malaria in Pregnancy
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Intermittent Preventive Treatment: Dose and Timing
4/19/2017 Intermittent Preventive Treatment: Dose and Timing Each dose is three tablets of sulfadoxine 500 mg + pyrimethamine 25 mg Ideally, a dose is given at each ANC visit after quickening, but at least 1 month apart Healthcare provider should dispense dose and directly observe client taking dose Antenatal Care Malaria in Pregnancy
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Intermittent Preventive Treatment: Contraindications to Using SP
4/19/2017 Intermittent Preventive Treatment: Contraindications to Using SP First trimester: Be sure quickening has occurred and woman is at least 16 weeks pregnant Allergy to SP or other sulfa drugs: Ask about sulfa drug allergies before giving SP Taking co-trimoxazole, or other sulfa-containing drugs: Ask about use of these medicines before giving SP Not more frequently than monthly: Be sure at least 1 month has passed since the last dose of SP Antenatal Care Malaria in Pregnancy
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Managing Uncomplicated Malaria
4/19/2017 Managing Uncomplicated Malaria Provide first-line anti-malarial drugs Follow country guidelines Manage fever Analgesics, tepid sponging Diagnose and treat anemia Provide fluids Antenatal Care Malaria in Pregnancy
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Active Syphilis Infection in Pregnancy
4/19/2017 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% stillbirths attributed to syphilis 8% of IMR due to syphilis Screening is effective & inexpensive Basic Screening Test (RPR) costs US$ , takes minutes. ICS (Rapid test) ~$0.50, 2 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 Malaria in Pregnancy
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Focused Antenatal Care
4/19/2017 An approach to ANC that emphasizes: Evidence-based, goal-directed actions Individualized, woman-centered care Early detection and treatment of problems and complications Prevention of complications and disease Quality vs. quantity of visits Care by skilled providers Birth preparedness & complication readiness Health promotion Antenatal Care Malaria in Pregnancy
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No Longer Recommended Numerous, routine visits
4/19/2017 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 Malaria in Pregnancy
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Number of antenatal care visits
4/19/2017 Number of antenatal care visits WHO multi-center study - number of visits reduced without affecting outcome for mother or baby Recommendations Minimum of 4 visits (see table) – with quality services Individualized delivery plan depending on risk profile One PNC visit at referral hospital Health promotion (to individual and community) Emergency transport Antenatal Care Malaria in Pregnancy
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Scheduling and Timing of ANC Visits
4/19/2017 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 Malaria in Pregnancy
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WHO MNH guidelines 5 pages of tables
4/19/2017 WHO MNH guidelines 5 pages of tables Table 1 lists interventions delivered to the mother during pregnancy, childbirth and in the postpartum period, and to the newborn soon after birth. Table 2 lists the places where care should be provided through health services, the type of providers required and the recommended interventions and commodities at each level. Table 3 lists practices, activities and support needed during pregnancy and childbirth by the family, community and workplace. Table 4 lists key interventions provided to women before conception and between pregnancies. Table 5 addresses unwanted pregnancies. Antenatal Care Malaria in Pregnancy
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IMPAC Manual Integrated Management of Pregnancy & Childbirth
4/19/2017 IMPAC Manual Integrated Management of Pregnancy & Childbirth Guidelines WHO 2006 Antenatal Care Malaria in Pregnancy
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IMPAC Manual Guideline detail for Antenatal Care
4/19/2017 IMPAC Manual Guideline detail for Antenatal Care Assess the pregnant woman Check for pre-eclampsia Check for Anemia Check for syphilis Check for HIV status Respond to observed signs or volunteered problems (no fetal mvmt, ruptured membranes, fever, disuria, vaginal discharge, HIV, smoking, drugs, DV, SOB, TB) Give preventive measures (tetanus, Fe/folate, mebendazole, malaria, ITN) Advice and counsel on nutrition and self care Develop a birth & emergency plan Advise and counsel on family planning Advise on routine and follow up visits Home delivery without a skilled attendant Assess feasibility of ARV for pregnant woman Antenatal Care Malaria in Pregnancy
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Other useful WHO guidelines
4/19/2017 Other useful WHO guidelines JHPEIGO. Inspired by George Povey Manual Malaria in Pregnancy
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Problems with interventions (general):
4/19/2017 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 Malaria in Pregnancy
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4/19/2017 Thank you! Antenatal Care Malaria in Pregnancy
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Some operational issues – prenatal and birth care
4/19/2017 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 Malaria in Pregnancy
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4/19/2017 Safe childbirth care Antenatal Care Malaria in Pregnancy
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Inadequate health systems
4/19/2017 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 Malaria in Pregnancy
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Impact of Traditional Birth Attendant training in Rural Mozambique (1)
4/19/2017 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 Malaria in Pregnancy
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Impact of Traditional Birth Attendant training in Rural Mozambique (2)
4/19/2017 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 Malaria in Pregnancy
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4/19/2017 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 Malaria in Pregnancy
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Basic components of the WHO antenatal care program (1994)
4/19/2017 Basic components of the WHO antenatal care program (1994) Antenatal Care Malaria in Pregnancy
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