Overview of Global Recommendations for Antenatal Care for a Positive Pregnancy Experience

1. Overview of Global Recommendations for Antenatal Care for a Positive Pregnancy Experience Module 1 Version 2

2. Learning objectives By the end of this module, learners will be able to: • Recognize pregnant women in the community • Assess gestational age in pregnant women* • Educate pregnant women about the benefits of antenatal care (ANC) • Describe recommended timings for ANC visits • Enumerate the nutritional recommendations for quality ANC

3. Learning objectives, cont. • List recommended approaches for maternal and fetal assessment in pregnancy* • Describe recommended preventive measures for best pregnancy outcome • List interventions for common physiological symptoms in pregnancy* • Describe health system interventions to improve ANC utilization and quality* *Health care workers only

4. Exercise 1: How do you know that a woman is pregnant?

5. 1. Pregnancy symptoms/complaints • Missed period (amenorrhea) • Morning sickness (nausea/vomiting) • Fatigue or weakness • Breast changes (fullness, pain) • Urinary symptoms (increased frequency, feeling of pressure, etc.) • Constipation • Enlarging abdomen

6. 2. Signs of pregnancy (elicited during physical examination) • Uterine enlargement • Pelvic examination (before 12 weeks) • Abdominal examination (from 12 weeks) • Presence of fetal heart sounds • Detected by Doppler ultrasound from 10–12 weeks • Detected by fetoscope from 17–20 weeks Photo by Karen Kasmauski

7. 2. Signs of pregnancy (elicited during physical examination), cont. • Presence of fetal movements (quickening) • Primigravida feel quickening from 18–20 weeks • Multigravida feel quickening from 16–18 weeks

8. 3. Tests to detect pregnancy • Pregnancy tests: All pregnancy tests measure levels of circulating beta human chorionic gonadotrophins (also called pregnancy hormone) • Urine tests are qualitative and can detect pregnancy from 5–6 weeks after last normal menstrual period (LNMP)

9. 3. Tests to detect pregnancy, cont. • Blood tests are quantitative and can detect pregnancy from 6–8 days after ovulation (before missed period) • Ultrasound scan/examination: An ultrasound scan can detect an intrauterine gestational sac from 6 weeks pregnancy and detect fetal heart activity by 8 weeks

10. Benefits of ANC Photo by Emmanuel Otolorin, Jhpiego

11. Focused ANC is an entry point to other critical services

12. Exercise 2: Why do some pregnant women fail to attend ANC clinics and/or deliver outside health facilities? • Duration: 10 minutes • Work in pairs • List five reasons why some pregnant women in your subnational area do not attend ANC clinics and/or deliver outside health facilities • Share your list with the rest of the class

13. Some factors causing late ANC attendance and delivery outside health facilities Can you think of any other reasons?

14. Therefore... We need to make ANC attendance a pleasurable, rewarding, assuring, empatheticexperience for ALLclients

15. Women need: Medical care Relevant and timely information Emotional support and advice Women want a positive pregnancy experience: A healthy pregnancy for mother and baby (including preventing or treating risks, illness, and death) Physical and sociocultural normality during pregnancy Effective transition to positive labor and birth Positive motherhood (including maternal self-esteem, competence, and autonomy) Women’s goals in attending ANC

16. Goals of ANC • Prevention of complications and disease: • Tetanus • Malaria • Severe anemia • Hookworm infestation • Birth preparedness and complication readiness • Provision of information and advice on lifestyle: • Nutrition (balanced diet and supplements) • Exclusive breastfeeding practices • Exercise and sexual intercourse in pregnancy • Need to avoid smoking, alcohol, use of harmful drugs, etc. • Early detection and treatment of problems and complications: • Anemia • Malaria • Urinary tract infections • Sexually transmitted infections including syphilis and HIV • Pre-eclampsia • Diabetes

17. New World Health Organization (WHO) recommendations for ANC 2016

18. Purpose of 2016 WHO recommendations for ANC • Put women at the center of care • Promote innovative, evidence-based approaches to ANC • Enhance the woman’s experience of pregnancy • Ensure that babies have the best possible start in life • Align with Sustainable Development Goals: expand care beyond survival • Complement existing WHO guidelines on the management of specific pregnancy complications • Promote a human rights–based approach to care

19. A. Nutritional interventions

20. Nutrition: All ANC settings Daily oral iron and folic acid (IFA): • 30 to 60 mg of elemental iron and • 400 μg (0.4 mg) of folic acid

21. Nutrition: Context-specific Women intolerant of IFA side effects: • Intermittent oral IFA with 120 mg of elemental iron and 2,800 μg (2.8 mg) of folic acid once weekly Populations with low dietary calcium intake: • Daily calcium supplementation (1.5–2.0 g oral elemental calcium) to reduce risk of pre-eclampsia

22. Nutrition: Context-specific, cont. Areas where vitamin A deficiency is a severe public health problem: • Vitamin A supplementation for pregnant women to prevent night blindness. • Not recommended to improve maternal and perinatal outcomes • Dose: daily up to 10,000 IU or weekly up to 25,000 IU vitamin A

23. B. Maternal and fetal assessment

24. Maternal and fetal assessment: All ANC settings One ultrasound scan before 24 weeks is recommended to estimate gestational age, improve detection of fetal anomalies and multiple pregnancies, reduce induction of labor for post-term pregnancy, and improve a woman’s pregnancy experience.

25. Considerations Ultrasound is recommended early (<24 weeks) • Additional scans later in pregnancy not recommended • Effects of introducing antenatal ultrasound on population health outcomes and health systems in rural, low-resource settings are unproven

26. Maternal/fetal assessment: All ANC settings, cont. • Classify hyperglycemia (high blood sugar) first detected at any time during pregnancy as either gestational diabetes mellitus (GDM) or diabetes mellitus in pregnancy, according to WHO criteria. • No recommendation for routine screening for diabetes in pregnancy

27. Maternal/fetal assessment: Context-specific Where tuberculosis prevalence is high (≥100/100,000): • Consider symptomatic screening for active tuberculosis in ANC. Where abdominal palpation is used to assess fetal growth: • Not recommended to change to symphysis-fundal height measurement

28. Maternal/fetal assessment: Context-specific, cont. Where full blood count testing is not available for anemia testing: • Onsite Hb testing with a hemoglobinometer is recommended (over the Hb color scale). Where urine culture is not available for diagnosis of asymptomatic bacteriuria: • Onsite midstream urine Gram stain is recommended (over dipstick tests)

29. C. Preventive measures

30. Preventive measures: All ANC settings A 7-day antibiotic regimen is recommended for all pregnant women with asymptomatic bacteriuria.

31. Preventive measures: Context-specific In malaria-endemic areas in Africa: • Start intermittent preventive treatment in pregnancy with sulfadoxine-pyrimethamine (IPTp with SP) in the second trimester. Give at least three doses, each 1 month apart. • IPTp can start as early as possible in the second trimester (best between 13 and 16 weeks) and then at least 1 month apart • New ANC schedule should be aligned with new approach of community-based distribution of IPTp

32. Preventive measures: Context-specific, cont. For pregnant women at substantial risk of acquiring HIV infection:* • Offer oral pre-exposure prophylaxis (PrEP) containing tenofovirdisoproxil fumarate

33. D. Interventions for common physiological symptoms

35. E. Health system interventions to improve the utilization and quality of ANC

36. Health systems: All ANC settings A minimum of EIGHT ANC contacts are recommended to reduce perinatal mortality and improve women’s experience of care.

37. ANC contacts schedule • Previously recommended four visits not enough: • Inadequate contact with health care providers • Less maternal satisfaction with care • More perinatal deaths • Minimum EIGHT contacts improves quality: • Focus on timely detection of risk factors and complications • More contact between pregnant women and knowledgeable, respectful, supportive providers more likely to lead to positive pregnancy experience

38. Contact versus visit • The new WHO guideline uses the term “contact” to imply an active connection between a pregnant woman and a health care provider. • “Contact” can take place at the facility or at community level. • “Contact” helps to facilitate context-specific recommendations (e.g., malaria, tuberculosis interventions) or health system interventions (e.g., task-shifting).

39. Considerations in areas with moderate to high malaria transmission

40. Recommended ANC contacts and IPTpdoses IPTp1 IPTp2 IPTp3 IPTp4 IPTp5 IPTp6 Photo by Emmanuel Otolorin, Jhpiego

41. ANC coverage in Transforming Intermittent Preventive Treatment for Optimal Pregnancy project countries Percentage of women aged15–49 years Source: UNICEF 2018

42. Conclusion

43. Additional slides for health care workers Estimation of gestational age

44. How can you determine the gestational age in a pregnant woman?

45. Client’s history

46. Exercise 3: Calculating gestational age and EDD Using Nägele rule Calculate EDD and gestational age for the following LNMPs: • February 23, 2016 • May 30, 2015 • April 14, 2017 • July 26, 2017 • September 8, 2010

47. Using a pregnancy wheel Calculate the gestational age for the following LNMPs: • February 23, 2016 • May 30, 2015 • April 14, 2017 • July 26, 2017 • September 8, 2010

48. Physical examination

49. Physical examination, cont. A uterine fundus that is at least three finger breadths above the symphysis pubis is in the second trimester

50. Ultrasound scan Adapted from: MacGregor and Sabbagha 2008.