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Standards

Provision of effective
antenatal care

for Maternal and
Neonatal Care

INTEGRATED MANAGEMENT OF PREGNANCY AND CHILDBIRTH (IMPAC)

The standard
All pregnant women should have at least four antenatal care (ANC)
ŠœœŽœœ–Ž—œȱ‹¢ȱ˜›ȱž—Ž›ȱ‘Žȱœž™Ž›Ÿ’œ’˜—ȱ˜ȱȱŠȱœ”’••ŽȱŠĴŽ—Š—ǯȱ‘ŽœŽȱ
should, as a minimum, include all the interventions outlined in the new
WHO antenatal care model and be spaced at regular intervals throughout
™›Ž—Š—Œ¢ǰȱŒ˜––Ž—Œ’—ȱŠœȱŽŠ›•¢ȱŠœȱ™˜œœ’‹•Žȱ’—ȱ‘Žȱꛜȱ›’–ŽœŽ›ǯ

Aim
To prevent, alleviate or treat/manage health problems/diseases (including
‘˜œŽȱ’›ŽŒ•¢ȱ›Ž•ŠŽȱ˜ȱ™›Ž—Š—Œ¢Ǽȱ‘ŠȱŠ›Žȱ”—˜ —ȱ˜ȱ‘ŠŸŽȱŠ—ȱž—ŠŸ˜ž›Š‹•Žȱ
outcome on pregnancy, and to provide women and their families/partners with
appropriate information and advice for a healthy pregnancy, childbirth and
postnatal recovery, including care of the newborn, promotion of early exclusive
breastfeeding and assistance with deciding on future pregnancies in order to
improve pregnancy outcomes.

Requirements
A national policy and locally adapted guidelines are in place that protect the rights of
all women, regardless of their socioeconomic status or place of residence, to access good
quality ANC services.
National evidence-based guidelines exist detailing the essential minimum components
˜ȱǰȱ’—ȱ•’—Žȱ ’‘ȱ‘ŽȱŒ˜ž—›¢ȱŽ™’Ž–’˜•˜’ŒŠ•ȱ™›˜ę•ŽȱŠ—ȱŒ˜ž—›¢ȱ™›’˜›’’ŽœȱŠ—ȱȱ
based on WHO guidelines and recommendations.
ȱ ‘Žȱ‘ŽŠ•‘ȱœ¢œŽ–ȱŽ—œž›Žœȱ‘ŠȱœžĜŒ’Ž—ȱœ”’••ŽȱŠĴŽ—Š—œȱŠ›Žȱ›ŽŒ›ž’ŽȱŠ—ȱŽ™•˜¢Žȱ
to be able to provide all women with good quality ANC.
Services and care are organized to ensure that ANC is available and acceptable to all the
 ˜–Ž—ȱ’—ȱ‘ŽȱœŽ›Ÿ’ŒŽȱŠ›ŽŠǰȱ›ŽŠ›•Žœœȱ˜ȱœ˜Œ’Š•ǰȱ›Ž•’’˜žœȱ˜›ȱŽ‘—’Œȱ‹ŠŒ”›˜ž—ǯȱ

Each pregnant woman receives an individual record card on which details of ANC are
’ŸŽ—ǰȱ’—Œ•ž’—ȱŠ••ȱŠŒ’˜—ȱŠ”Ž—ǰȱŠŸ’ŒŽȱŠ—ȱ›ŽŠ–Ž—ȱ’ŸŽ—ǰȱ‘Žȱ›Žœž•œȱ˜ȱŠ••ȱŽœœȱŠ—ȱ
examinations and proposed plans for the actual birth; ideally, this record is held by the
woman.
ȱ ••ȱœ”’••ŽȱŠĴŽ—Š—œȱŠ›Žȱ•’—”Žȱ˜ǰȱŠ—ȱ‘ŠŸŽȱ‘ŽȱŒŠ™ŠŒ’¢ȱ˜ȱ›ŽŽ›ȱŠ—¢ȱ™›Ž—Š—ȱ ˜–Š—ȱ
to, a facility capable of managing obstetrical and neonatal complications.

2006

National or locally-adapted evidence-based protocols and/or guidelines for the
management of pregnancy-related complications are available and are widely
’œ›’‹žŽȱ˜ȱŠ••ȱœ”’••ŽȱŠĴŽ—Š—œȱŠ—ȱ˜‘Ž›ȱ‘ŽŠ•‘ȱŒŠ›Žȱ™›˜Ÿ’Ž›œȱ˜ěŽ›’—ȱǯ

World Health Organization

The health system ensures that all necessary equipment and drugs to provide essential 
ȱŠ›Žȱ’—ȱ™•ŠŒŽȱŠ—ȱŠ›Žȱ’—ȱ˜˜ȱ ˜›”’—ȱ˜›Ž›ǯ

6 Provi si o n o f e f fe c ti ve ant enat al c are 2 National and local health education activities and programmes are in place to promote the need ˜›ȱŠ••ȱ ˜–Ž—ȱ˜ȱŠŒŒŽœœȱǰȱŠ—ȱ˜›ȱŠ••ȱ™›Ž—Š—ȱ ˜–Ž—ǰȱ‘Ž’›ȱ™Š›—Ž›œȱŠ—ȱŠ–’•’Žœȱ˜ȱ–Š”ŽȱŠȱ birth and emergency preparedness plan.2). ’—Œ•ž’—ȱ‘ŽŠ•‘¢ȱ•’Žœ¢•Žœǰȱ‘ŽŠ•‘¢ȱ’Žǰȱœ–˜”’—ȱŒŽœœŠ’˜—ȱ ‘Ž›Žȱ›Žšž’›Žǰȱ™›Ž™Š›Š’˜—ȱ˜›ȱ parenthood. at some point in the pregnancy. Applying the standard ”’••ŽȱŠĴŽ—Š—œǰȱŠ—ȱ˜‘Ž›ȱ‘ŽŠ•‘ȱŒŠ›Žȱ™›˜Ÿ’Ž›œȱ˜ěŽ›’—ȱŠ—Ž—ŠŠ•ȱŒŠ›ŽȱœŽ›Ÿ’ŒŽœǰȱ–žœDZ ȱ ›Š—’£ŽȱȱœŽ›Ÿ’ŒŽœǰȱ’—Œ•ž’—ȱœŒ‘Žž•’—ȱŒ•’—’ŒȱŠĴŽ—Š—ŒŽȱ ‘Ž›ŽȱŠ™™›˜™›’ŠŽǰȱ˜ȱŽ—œž›Žȱ that all pregnant women in the locality can access the services. increased from the baseline value. Ensure that. ȱ ˜›”ȱ ’‘ȱŒ˜––ž—’¢ȱ•ŽŠŽ›œȱŠ—ȱ˜‘Ž›ȱ’—ĚžŽ—’Š•ȱ™Š›’Žœȱ˜ȱŽ—œž›Žȱ‘Šȱ‘ŽȱŒ˜––ž—’¢ȱ ž—Ž›œŠ—œȱ‘Žȱ‹Ž—Žęœȱ˜ȱȱŠ—ȱŽœ™ŽŒ’Š••¢ȱ‘Žȱ—ŽŽȱ˜›ȱŽŠ›•¢ȱǯ ȱ ™™•¢ȱŠŒŒž›ŠŽ•¢ȱŠ••ȱŒ˜–™˜—Ž—œȱ˜ȱ‘Žȱ—Š’˜—Š•ȱŠ—Ž—ŠŠ•ȱŒŠ›Žȱ–˜Ž•ȱ’Ž—’ꮍȱ˜›ȱ‘Žȱ™Ž›’˜ȱ of gestation in question. or as outlined by WHO (1. ȱ ‘Žȱ™›˜™˜›’˜—ȱ˜ȱ™›Ž—Š—ȱ ˜–Ž—ȱŠ‹•Žȱ˜ȱŠŒŒŽœœȱȱ ’‘’—ȱŠȱœ™ŽŒ’ꮍȱ’œŠ—ŒŽȱ˜›ȱ’–Žȱœ™Š—ǯ The proportion of pregnant women immunized against tetanus. ȱ ‘ŽȱŠŸŠ’•Š‹’•’¢ȱ˜ȱœ”’••ŽȱȱŠĴŽ—Š—œǯ Process and output indicators The proportion of pregnant women having at least one ANC visit.Standards 1. The proportion of pregnant women having four or more ANC visits. ȱ —œž›Žȱ‘Šȱȱ’œȱŒ˜—žŒŽȱ’—ȱŠȱœž’Š‹•ŽȱŽ—Ÿ’›˜—–Ž—ȱ‘ŠȱŠě˜›œȱ™›’ŸŠŒ¢ǯ Provide information and counselling to both partners on postpartum family planning methods. all women have the opportunity to discuss their ™›Ž—Š—Œ¢ȱŠ—ȱ™Ž›œ˜—Š•ȱŒ˜—ŒŽ›—œȱŒ˜—ꍮ—’Š••¢ǰȱ ’‘ȱ˜›ȱ ’‘˜žȱ‘Žȱ™›ŽœŽ—ŒŽȱ˜ȱ‘Žȱ™Š›—Ž›ǯ Refer all pregnant women requiring specialized medical care/treatment and all women with signs of complications of pregnancy. . and record these on the home-based ANC record card. Proportion of pregnant women with a major complication of pregnancy directly referred by the œ”’••ŽȱŠĴŽ—Š—ǰȱ’—Œ›ŽŠœŽȱ›˜–ȱ‘Žȱ‹ŠœŽ•’—ŽȱŸŠ•žŽǯ Proportion of pregnant women referred who are assessed by the referral facility as having ›ŽŒŽ’ŸŽȱŠ™™›˜™›’ŠŽȱꛜȬ•’—Žȱ–Š—ŠŽ–Ž—ȱŠœȱ’Ž—’ꮍȱ‹¢ȱ ȱ(2). ȱ ŽŒ˜›ȱꗍ’—œȱ˜—ȱ‘Žȱ–ŠŽ›—Š•ȱŒŠ›ǯ Audit Input indicators A national ANC policy and locally adapted guidelines are in place. relaxation therapy and/or other activities as required. Refer women with social and/or psychological problems or concerns to an appropriate advice/ service agency. such as exercises to prepare the woman for the process of birth. Provide appropriate health education to all pregnant women and their partners and families. ȱ ‘Žȱ™›˜™˜›’˜—ȱ˜ȱ™›Ž—Š—ȱ ˜–Ž—ȱ ’‘ȱŠȱ ›’ĴŽ—ȱ‹’›‘ȱ™•Š—ȱ‹¢ȱřŝȱ ŽŽ”œȱ˜ȱ™›Ž—Š—Œ¢ǯ Outcome indicators ȱ ›˜™˜›’˜—ȱ˜ȱ™›Ž—Š—ȱ ˜–Ž—ȱœŠ’œęŽȱ ’‘ȱ‘ŽȱȱœŽ›Ÿ’ŒŽœȱ‘Ž¢ȱ›ŽŒŽ’ŸŽǰȱ’—Œ›ŽŠœŽȱ›˜–ȱ‘Žȱ baseline value. The proportion of pregnant women screened for syphilis.

and use of insecticide-treated bednets). A recent study on antenatal care estimated that  ˜›• ’Žȱ˜—•¢ȱŝŖƖȱ˜ȱ ˜–Ž—ȱŽŸŽ›ȱ›ŽŒŽ’ŸŽȱ any ANC. This uncertainty leads to the adoption of antenatal practices that are not comparable and are largely inconsistent between and within countries (5.8). The optimum number of ANC visits for countries with limited resources is still the subject of Œ˜—œ’Ž›Š‹•ŽȱŽ‹ŠŽǰȱ‘Žȱ™›˜‹•Ž–ȱ‹Ž’—ȱ•’—”Žȱ —˜ȱ˜—•¢ȱ ’‘ȱŽěŽŒ’ŸŽ—Žœœȱ‹žȱŠ•œ˜ȱ ’‘ȱ costs and other barriers to ANC access (5). including healthy lifestyles. there is growing agreement that ANC should be limited to a small —ž–‹Ž›ȱ˜ȱœ™ŽŒ’ęŒȱŽœœȱŒŠ››’Žȱ˜žȱŠȱŒŽ›Š’—ȱ critical times in the pregnancy (4. supporters for birth.8. including immunization (especially with tetanus toxoid) and screening for ž—Ž›•¢’—ȱŒ˜—’’˜—œȱŠ—ȱ’œŽŠœŽœȱœžŒ‘ȱŠœȱŠ—ŠŽ–’Šǰȱ–Š•Š›’ŠǰȱœŽ¡žŠ••¢ȱ›Š—œ–’ĴŽȱ’—ŽŒ’˜—œȱǻ˜ȱ which syphilis is particularly important owing to its negative impact on maternal and neonatal health Š—ȱ‘Žȱ•’—”œȱ˜ȱŠȱ‘’‘ȱ’—Œ’Ž—ŒŽȱ˜ȱœ’••‹’›‘ȱŠ—ȱ•˜ ȱ‹’›‘ȱ Ž’‘Ǽǰȱ ȱ’—ŽŒ’˜—ǰȱŠ—ȱž—Ž›•¢’—ȱ mental health problems and/or symptoms of stress or domestic violence. where required. whereas in industrialized countries –˜›Žȱ‘Š—ȱşśƖȱ˜ȱ™›Ž—Š—ȱ ˜–Ž—ȱ›ŽŒŽ’ŸŽȱ ANC (3).7). and support and care in the home (including adherence to advice on prophylactic treatments such as iron supplementation. Nevertheless. and to prepare emotionally and physically the pregnant woman and her partner and.9). . The results ˜ȱ‘’œȱ›ŽŸ’Ž ȱ™›˜–™Žȱ ȱ˜ȱŽę—ŽȱŠȱ Box 1. health and safety/injury prevention. Preventive measures. true progress has been made globally in terms of increasing access and use. healthy diet. Recognition and management of pregnancy-related complications. Also. The essential elements of care in pregnancy The essential elements of care in pregnancy are as follows. ȱ ŽŠ•‘ȱŽžŒŠ’˜—ȱŠ—ȱ™›˜–˜’˜—ȱ˜›ȱ‘Žȱ ˜–Š—ȱŠ—ȱ‘Ž›ȱŠ–’•¢DZ to increase awareness of maternal and neonatal health needs and self-care during pregnancy and ‘Žȱ™˜œ—ŠŠ•ȱ™Ž›’˜ǰȱ’—Œ•ž’—ȱ‘Žȱ—ŽŽȱ˜›ȱœ˜Œ’Š•ȱœž™™˜›ȱž›’—ȱŠ—ȱŠĞŽ›ȱ™›Ž—Š—Œ¢Dz to increase health in the home. Pregnancy surveillance of the woman and her unborn child. Advice and support to the woman and her family in developing a birth and emergency preparedness plan. a recent systematic review (7) showed that essential interventions required by healthy women with no underlying medical problems can be provided over ˜ž›ȱŸ’œ’œȱŠȱœ™ŽŒ’ꮍȱ’—Ž›ŸŠ•œǯȱ‘Žȱ›Žœž•œȱ of the review also revealed that women in developed countries receiving ANC through ‘’œȱ˜ž›ȬŸ’œ’ȱ–˜Ž•ȱ Ž›Žȱ•ŽœœȱœŠ’œęŽȱŠ—ȱ felt their expectations were not met. Recognition and treatment of underlying or concurrent illness or disease.6).Standards 1. ĜŒŠŒ¢ȱŠ—ȱŽěŽŒ’ŸŽ—Žœœ Epidemiological studies have demonstrated ‘Žȱ‹Ž—Žęœȱ˜ȱȱ’—ȱ›ŽžŒ’—ȱ–ŠŽ›—Š•ȱ and perinatal complications.6 Provi si o n o f e f fe c ti ve ant enat al c are 3 Rationale ž›Ž—ȱ˜ȱœžěŽ›’— Many maternal and perinatal deaths occur in women who have received no ANC. ȱ ˜ȱœž™™˜›ȱŒŠ›ŽȬœŽŽ”’—ȱ‹Ž‘ŠŸ’˜ž›ǰȱ’—Œ•ž’—ȱ›ŽŒ˜—’’˜—ȱ˜ȱŠ—Ž›ȱœ’—œȱ˜›ȱ‘Žȱ ˜–Š—ȱŠ—ȱ‘Žȱ newborn. although the exact components and timing of such ANC ‘Šœȱ‹ŽŽ—ȱ’ĜŒž•ȱ˜ȱŽ–˜—œ›ŠŽȱ(4). to promote postpartum family planning/birth spacing. whilst some long-held ›Š’’˜—Š•ȱŒ˜–™˜—Ž—œȱ‘ŠŸŽȱ•’Ĵ•ŽȱœŒ’Ž—’ęŒȱ basis (4. Nevertheless. although they did not perceive that the care they received was of lower quality (4. There is evidence to show that certain components of care appear to be more critical than others.

Thus. Ensuring the woman can hold her own records is also a way to encourage women to feel involved in their care. with appropriate remedial action or treatment of underlying medical conditions. as outlined by WHO (1. all pregnant women should be encouraged to –Š”ŽȱŠȱ‹’›‘ȱŠ—ȱŽ–Ž›Ž—Œ¢ȱ™›Ž™Š›Ž—Žœœȱ plan (see Standard 1. especially those that occur during or around birth.6 Provi si o n o f e f fe c ti ve ant enat al c are new model of ANC (1).2). there should be a general assessment of the woman’s health. especially breech ™›ŽœŽ—Š’˜—ǰȱ’—ȱ ‘’Œ‘ȱŒŠœŽȱŠ—ȱŠĴŽ–™ȱœ‘˜ž•ȱ be made at external cephalic version (9). there is general consensus that all women with an uncomplicated pregnancy should have a minimum of four visits. The best mechanism to ensure that essential information is always available is for the record to stay with the woman. home-based or hand-held records are recommended. Lone or unsupported pregnant women. A prototype form is included in the new WHO model of ANC (1). family and community membership has been shown to be a major determinant in access to antenatal care services (12).Standards 1. but should ensure that all the essential information is readily available to the caregiver. given the need for ŽŠ›•¢ȱ’Ž—’ęŒŠ’˜—ȱ˜ȱž—Ž›•¢’—ȱ™›˜‹•Ž–œȱ ˜ȱŽ—œž›ŽȱŽĜŒŠŒ’˜žœȱ›ŽŠ–Ž—ǰȱ‘Žȱꛜȱ ANC visit should be as early as possible in ™›Ž—Š—Œ¢ǰȱ™›ŽŽ›Š‹•¢ȱ’—ȱ‘Žȱꛜȱ›’–ŽœŽ›ȱ (4). Evidence suggests that. to ensure that appropriate ŠŒ’˜—ȱ’œȱŠ”Ž—ȱ˜ȱ™›ŽŸŽ—ȱ™›˜‹•Ž–œǯȱžŒ‘ȱ appropriate action should include advice on ŠŸ˜’’—ȱ™˜œ–Šž›’¢ȱŠ—ȱ‘Žȱ’Ž—’ęŒŠ’˜—ȱ of malpresentations. especially adolescents. therefore need services that are œ™ŽŒ’ęŒŠ••¢ȱŠ›ŽŽȱ˜ȱ‘Ž’›ȱ—ŽŽœDzȱœŽ›Ÿ’ŒŽȱ ™›˜Ÿ’Ž›œȱœ‘˜ž•ȱ˜ȱŠ••ȱ‘Ž¢ȱŒŠ—ȱ˜ȱœŽŽ”ȱ˜žȱ œžŒ‘ȱ ˜–Ž—ȱŠ—ȱŠ”Žȱ‘ŽȱœŽ›Ÿ’ŒŽœȱ˜ȱ‘Ž–ǰȱ’ȱ ‘Ž¢ȱŠ›Žȱž—Š‹•Žȱ˜›ȱž— ’••’—ȱ˜ȱŠĴŽ—ȱŠȱŒ•’—’Œǯ .11). Therefore. Countries may design their own antenatal care records. if required. the essential elements of which are outlined in Box 1. At this visit. 4 Evidence also indicates that good record”ŽŽ™’—ȱ’œȱŽœœŽ—’Š•ȱ˜ȱŠŒ’•’ŠŽȱŠ™™›˜™›’ŠŽȱ ŽŒ’œ’˜—Ȭ–Š”’—ȱŠ—ȱ’—Ž›ŸŽ—’˜—œǯȱ‘ŽœŽȱ records should be available at all times. Finally.9 Birth and emergency preparedness in antenatal care for further details). A number of studies have shown the ‹Ž—Žęœȱ˜ȱ‘Š—Ȭ‘Ž•ȱ˜›ȱ‘˜–ŽȬ‹ŠœŽȱŠ—Ž—ŠŠ•ȱ care records (10. Women who hold their ˜ —ȱ›ŽŒ˜›œȱŠ›Žȱ–˜›Žȱ•’”Ž•¢ȱ˜ȱ”ŽŽ™ȱ˜••˜ Ȭ ž™ȱŠ™™˜’—–Ž—œǰȱ˜ȱŠœ”ȱšžŽœ’˜—œȱŠ‹˜žȱ‘Ž’›ȱ health and to feel in control of their pregnancy (11). —ȱŠ—Ž—ŠŠ•ȱŠœœŽœœ–Ž—ȱŠȱŠ›˜ž—ȱřŝȱ ŽŽ”œȱ ˜›ȱ—ŽŠ›ȱ‘ŽȱŽ¡™ŽŒŽȱŠŽȱ˜ȱŒ˜—ę—Ž–Ž—Ȧ‹’›‘ȱ is also advisable. to try to ensure that the woman is as healthy as possible during pregnancy and for birth (4)ǯȱ ȱ’œȱŠ•œ˜ȱœžŽœŽȱ‘Šǰȱ’ŸŽ—ȱ‘Žȱ•ŠŒ”ȱ˜ȱ sensitivity in predicting problems.

please refer to the reference section of the standard. Study ǻ¢™ŽȱǭȱŽŸŽ•ȱ˜ȱ ŽŸ’Ž—ŒŽǼ ŝǯȱ’••Š›ȱŽȱŠ•ǯȱŘŖŖŚ Most recent substantive amendment. For an overview of a comprehensive list of evidence. USA Baseline risk Post-term delivery rate Ȯȱ–’—’–ž–ȱŖǯŚƖ Ȯȱ–Š¡’–ž–ȱŚǯŜƖ a To assess the ŽěŽŒœȱ˜ȱ›˜ž’—Žȱ late pregnancy ž•›Šœ˜ž—ȱǻŠĞŽ›ȱŘŚȱ  ŽŽ”œȂȱŽœŠ’˜—Ǽǰȱ’—ȱ women with either unselected or low›’œ”ȱ™›Ž—Š—Œ’Žœǰȱ˜—ȱ obstetric practice and pregnancy outcome —Ž›ŸŽ—’˜—DZȱ›˜ž’—Žȱ ultrasound versus no or selected or concealed ultrasound ŠĞŽ›ȱŘŚȱ ŽŽ”œȱ˜ȱ gestation Routine vs no or selective ultrasound Caesarean section NS a řȱœž’ŽœǰȱřŞŞŜȱ ˜–Ž— —œ›ž–Ž—Š•ȱ delivery NS Śȱœž’ŽœǰȱŗşȱŖřŝȱ women Post-term delivery ǻǁŚŘȱ ŽŽ”œǼ min. Norway. October 1999 ¢œŽ–Š’Œȱ›ŽŸ’Ž ȱ 1++ ŝȱ›’Š•œȱ›ŽŒ›ž’’—ȱȱȱȱȱȱȱȱȱ ŘśȱŖřŜȱ ˜–Ž—ȱ’—ȱ•ŠŽȱ ™›Ž—Š—Œ¢ȱǻŠĞŽ›ȱŘŚȱ  ŽŽ”œȂȱŽœŠ’˜—Ǽȱ Australia. United Kingdom. ANC programme based on midwife support versus programme including obstetric/ gynaecological personnel Satisfaction with care received Results Comments Fewer vs standard number of visits ˜ȱ’쎛Ž—ŒŽȱ’—ȱ any of the negative maternal and perinatal outcomes reviewed Trials from developed Œ˜ž—›’ŽœDZȱ ˜–Ž—ȱŒŠ—ȱ ‹Žȱ•ŽœœȱœŠ’œęŽȱ ’‘ȱ the reduced number of visits and feel that their expectations of ŒŠ›ŽȱŠ›Žȱ—˜ȱž•ę••Ž ANC by a midwife/ general practitioner vs obstetric/ gynaecological personnel –™›˜ŸŽȱ™Ž›ŒŽ™’˜—ȱ of care by women ˜ȱ’쎛Ž—ŒŽȱ’—ȱ Œ•’—’ŒŠ•ȱŽěŽŒ’ŸŽ—Žœœ ŗřǯȱ›’Œ”Ž›ȱǭȱ Ž’•œ˜—ȱŘŖŖř Most recent substantive amendment. The level of evidence is ™›ŽœŽ—Žȱžœ’—ȱ‘Žȱ ȱ–Ž‘˜˜•˜¢ȱ ‘’Œ‘ȱŠ™™•’ŽœȱŠȱŒ˜’—ȱ›˜–ȱŗȱǻ‘’‘ȱ•ŽŸŽ•Ǽȱ˜ȱŚȱǻ•˜ ȱ•ŽŸŽ•Ǽǯȱȱȱȱ For details.Standards 1. NNT bȱŞŖşȱ ǻśşŝȮŗřŘŖǼ –Š¡ǯȱȱŝŘȱǻśřȮŗŗşǼ Řȱœž’Žœǰȱŗŝśŗȱ neonates* ™Š›ȱœŒ˜›ŽȱǀŝȱŠȱ 5 minutes NS řȱœž’ŽœǰȱřŞşŗȱ neonates Perinatal mortality NS Ŝȱœž’ŽœǰȱŘŘȱŘŝŞȱ neonates b ȱ˜—Ȭœ’—’ęŒŠ—ȱȱȱȱȱ ž–‹Ž›ȱ—ŽŽŽȱ˜ȱ›ŽŠǯȱǻşśƖȱŒ˜—ꍮ—ŒŽȱ’—Ž›ŸŠ•Ǽ Ș’—’ęŒŠ—ȱ data only from one large study . see also the Introduction to the Standards for Maternal and Neonatal Care and the Process to develop the Standards for Maternal and Neonatal Careȱ˜—ȱ‘Ĵ™DZȦȦ   ǯ ‘˜ǯ’—Ȧ–Š”’—ȏ™›Ž—Š—Œ¢ȏœŠŽ›Ȧ publications/en. New Zealand.6 Provi si o n o f e f fe c ti ve ant enat al c are 5 The table below summarizes the evidence from the most relevant studies. žžœȱŘŖŖŗ ¢œŽ–Š’Œȱ›ŽŸ’Ž  1++ ˜™ž•Š’˜—ȱǭȱŽĴ’— ŗŖȱ›’Š•œǰȱŝȱŒ˜—žŒŽȱ in developed countries (individual randomization trials) Š—ȱřȱ’—ȱŽŸŽ•˜™’—ȱ countries (cluster randomization trials) ŸŽ›ȱŜŖȱŖŖŖȱ™›Ž—Š—ȱ  ˜–Ž—ȱŠĴŽ—’—ȱ ANC clinics and considered to be at •˜ ȱ›’œ”ȱ˜ȱŽŸŽ•˜™’—ȱ complications during pregnancy and labour ‹“ŽŒ’ŸŽȱǭȱ —Ž›ŸŽ—’˜— Outcomes linked to the Standard ˜ȱŠœœŽœœȱ‘ŽȱŽěŽŒœȱ of ANC programmes ˜›ȱ•˜ Ȭ›’œ”ȱ ˜–Ž— Neonatal and maternal outcomes —Ž›ŸŽ—’˜—DZȱȱ programme with reduced frequency and timing of visits compared with standard frequency and timing of visits.

6 Provi si o n o f e f fe c ti ve ant enat al c are 6 References 1.Standards 1. WHO antenatal care randomized trial: manual for implementation of the new model.ȱ Ž—ŽŸŠǰȱ˜›•ȱ ŽŠ•‘ȱ›Š—’£Š’˜—ǰȱŘŖŖŘȱǻ˜Œž–Ž—ȱ Ȧ ȦŖŗǯřŖǼȱǻ‘Ĵ™DZȦȦ   ǯ ‘˜ǯ’—Ȧ›Ž™›˜žŒ’ŸŽȬ ‘ŽŠ•‘Ȧ™ž‹•’ŒŠ’˜—œȦ ȏŖŗȏřŖȦ ȏŖŗȏřŖǯ™ǰȱŠŒŒŽœœŽȱśȱ.

Lancet. childbirth. ŗşşŖǰȱŗŖDZŚŘŖȮŚřŚǯ 6. postpartum and newborn care: a guide for essential practice. Campbell E. achievements and missed opportunities. Sanson Fisher R.ȱŘŖŖŗǰȱřśŝDZŗśŜśȮŗśŝŖǯ śǯȱ Ž›Ž£ȱ˜˜œȱǯȱŠ››’Ž›œȱ˜ȱ‘ŽȱžœŽȱ˜ȱ™›Ž—ŠŠ•ȱŒŠ›ŽDZȱŒ›’’ŒŠ•ȱŠ—Š•¢œ’œȱ˜ȱ‘Žȱ•’Ž›Šž›ŽȱŗşŜŜȮ ŗşŞŝǯȱJournal of Perinatology. An analysis ˜ȱ›Ž—œǰȱ•ŽŸŽ•œȱŠ—ȱ’쎛Ž—’Š•œǰ 1990-2001ǯȱ Ž—ŽŸŠǰȱ˜›•ȱ ŽŠ•‘ȱ›Š—’£Š’˜—ǰȱŘŖŖřǯ Śǯȱ Š››˜•’ȱ ȱŽȱŠ•ǯȱ ȱœ¢œŽ–Š’Œȱ›ŽŸ’Ž ȱ˜ȱ›Š—˜–’œŽȱŒ˜—›˜••Žȱ›’Š•œȱ˜ȱ›˜ž’—ŽȱŠ—Ž—ŠŠ•ȱ care. ŗşşşǰȱŘŜDZŘŚȮřŖǯ ŝǯȱ ’••Š›ȱ. What is recommended for healthy women during pregnancy? A comparison of seven prenatal clinical practice guideline documents. Birth.Š—žŠ›¢ȱŘŖŖśǼǯ Řǯȱ Pregnancy. Promises. Haertsch M.ȱ Ž—ŽŸŠǰȱ˜›•ȱ ŽŠ•‘ȱ›Š—’£Š’˜—ǰȱŘŖŖřȱǻ‘Ĵ™DZȦȦ ‘š•’‹˜Œǯ ‘˜ǯ’—Ȧ™ž‹•’ŒŠ’˜—œȦŘŖŖřȦşŘŚŗśşŖŞŚǯ™ǰȱ ŠŒŒŽœœŽȱŝȱŽŒŽ–‹Ž›ȱŘŖŖŚǼǯ řǯȱ Antenatal care in developing countries.

Issue 4.ȱ‘’Œ‘ŽœŽ›ǰȱ. 2004.ȱŽȱŠ•ǯȱŠĴŽ›—œȱ˜ȱ›˜ž’—ŽȱŠ—Ž—ŠŠ•ȱŒŠ›Žȱ˜›ȱ•˜ Ȭ›’œ”ȱ™›Ž—Š—Œ¢ȱǻ˜Œ‘›Š—ŽȱŽŸ’Ž Ǽǯȱ —DZȱ The Cochrane Library.

˜‘—ȱ’•Ž¢ȱǭȱ˜—œǰȱŘŖŖŚǯ Şǯȱ Š—Ž›ȱȱŽȱŠ•ǯȱ‘ŽȱŽŸŠ•žŠ’˜—ȱ˜ȱ ˜–Ž—ȂœȱŠ—ȱ™›˜Ÿ’Ž›œȂȱ™Ž›ŒŽ™’˜—ȱ˜ȱšžŠ•’¢ȱ˜ȱŠ—Ž—ŠŠ•ȱ care in the WHO Antenatal Care Randomized Controlled Trial.ȱŗşşŞǰȱŗŘǻž™™•ǯǼDZşŞȮŗŗŘǯ şǯȱ ˜–Ž¢›ȱ . Paediatric and Perinatal Epidemiology.

ȱ‘’Œ‘ŽœŽ›ǰȱ. 2004.ǰȱ ž•’Ž›ȱǯȱ¡Ž›—Š•ȱŒŽ™‘Š•’ŒȱŸŽ›œ’˜—ȱ˜›ȱ‹›ŽŽŒ‘ȱ™›ŽœŽ—Š’˜—ȱŠȱŽ›–ȱǻ˜Œ‘›Š—Žȱ ŽŸ’Ž Ǽǯȱ —DZȱThe Cochrane Library. Issue 4.

ȱŗşşşǰȱřşDZśŚȮśŝǯ ŗŗǯȱ ›˜ —ȱ ǰȱ–’‘ȱ . Australian and New Zealand Journal of Public Health. the bring your own records study.˜‘—ȱ’•Ž¢ȱǭȱ˜—œǰȱŘŖŖŚǯ ŗŖǯȱ ˜–Ž›ȱǰȱŠŸ’œȱ ǰȱŸŽ›’Ĵȱǯȱ‘Žȱ’—›˜žŒ’˜—ȱ˜ȱ ˜–Š—Ȭ‘Ž•ȱ›ŽŒ˜›ȱ’—˜ȱŠȱ‘˜œ™’Š•ȱ antenatal clinic.

2004ǯȱ‘’Œ‘ŽœŽ›ǰȱ. Issue 4.ǯȱ ’Ÿ’—ȱ ˜–Ž—ȱ‘Ž’›ȱ˜ —ȱŒŠœŽȱ—˜Žœȱ˜ȱŒŠ››¢ȱž›’—ȱ™›Ž—Š—Œ¢ȱ ǻ˜Œ‘›Š—ŽȱŽŸ’Ž Ǽǯȱ —DZȱThe Cochrane Library.

˜‘—ȱ’•Ž¢ȱǭȱ˜—œǰȱ ŘŖŖŚǯ ŗŘǯȱ Ž‹•Ž¢ȱǰȱ ˜•–Š—ȱǰȱ˜›’žŽ£ȱ ǯȱ›Ž—ŠŠ•ȱŠ—ȱŽ•’ŸŽ›¢ȱŒŠ›ŽȱŠ—ȱŒ‘’•‘˜˜ȱ’––ž—’£Š’˜—ȱ ’—ȱ žŠŽ–Š•ŠDZȱ˜ȱŠ–’•¢ȱŠ—ȱŒ˜––ž—’¢ȱ–ŠĴŽ›ǵȱDemography.ȱŗşşŜǰȱřřDZŘřŗȮŘŚŝǯ ŗřǯȱ ›’Œ”Ž›ȱǰȱŽ’•œ˜—ȱ.

Issue 1.ǯȱ˜ž’—Žȱž•›Šœ˜ž—ȱ’—ȱ•ŠŽȱ™›Ž—Š—Œ¢ȱǻŠĞŽ›ȱŘŚȱ ŽŽ”œȱŽœŠ’˜—Ǽȱ ǻ˜Œ‘›Š—ŽȱŽŸ’Ž Ǽǯȱ —DZȱThe Cochrane Library. 2005.ȱ‘’Œ‘ŽœŽ›ǰȱ.

˜‘—ȱ’•Ž¢ȱǭȱ˜—œǰȱ ŘŖŖŚǯ This document is not a formal publication of the World Health Organization (WHO). but not for sale nor for use in conjunction with commercial purposes. be freely reviewed. in part or in whole. The funding towards the preparation and production of this document provided by the ˜ŸŽ›—–Ž—œȱ˜ȱžœ›Š•’Šǰȱ Š•¢ȱŠ—ȱȱ’œȱ›ŠŽž••¢ȱŠŒ”—˜ •ŽŽǯȱ —ȱŠ’’˜—ǰȱ Ȃœȱ Š”’—ȱ›Ž—Š—Œ¢ȱŠŽ›ȱŽ™Š›–Ž—ȱ’œȱ›ŠŽž•ȱ˜ȱ‘Žȱ ˜ŸŽ›—–Ž—œȱ˜ȱŽ—–Š›”ǰȱ ›Ž•Š—ǰȱ Ž‘Ž›•Š—œǰȱ˜› Š¢ǰȱ ŽŽ—ǰȱŠ—ȱ‘Žȱ—’Žȱ ’—˜–ǰȱŠ—ȱ˜ȱ‘Žȱ˜›•ȱŠ—”ǰȱ ȱ Š—ȱȱ˜›ȱž—œ™ŽŒ’ꮍȱ™›˜›Š––Žȱœž™™˜›ǯȱ . however. This document is part of the Standards for Maternal and Neonatal Š›ŽȱŽŸŽ•˜™Žȱ‹¢ȱ‘ŽȱŽ™Š›–Ž—ȱ of Making Pregnancy Safer. For further information please contactDZ Ž™Š›–Ž—ȱ˜ȱŠ”’—ȱ›Ž—Š—Œ¢ȱ Safer (MPS) World Health Organization (WHO) ŘŖȱŸŽ—žŽȱ™™’Š ŗŘŗŗȱ Ž—ŽŸŠȱŘŝ Switzerland Ž•DZȱƸŚŗȱŘŘȱŝşŗȱřřŝŗ Š¡DZȱƸŚŗȱŘŘȱŝşŗȱśŞśř –Š’•DZȱ’—˜ȓ ‘˜ǯ’— Ž‹ȱœ’ŽDZȱ   ǯ ‘˜ǯ’—Ȧ–Š”’—ȏ ™›Ž—Š—Œ¢ȏœŠŽ›Ȧ™ž‹•’ŒŠ’˜—œȦŽ—Ȧ Š—Š›œȱ˜›ȱŠŽ›—Š•ȱŠ—ȱŽ˜—ŠŠ•ȱŠ›ŽȱŽŽ›’—ȱ˜––’ĴŽŽȱȱ ‘Š’›DZȱŠž•ȱŠ—ȱ˜˜”ǰȱ’›ŽŒ˜›ǰȱŽ™Š›–Ž—ȱ˜ȱŽ™›˜žŒ’ŸŽȱ ŽŠ•‘ȱŠ—ȱŽœŽŠ›Œ‘Dzȱȱȱȱȱȱȱȱȱȱȱȱ ›—Ž••Šȱ’—ŒŽĴ˜ǰȱ Ž•Šȱ˜œŠǰȱŽ••Šȱ‘Ž››ŠĴǰȱ——’Žȱ˜›Ž•Šǰȱ’Šȱ Š‹›ŠȱŠ—ȱžŒȱŽȱŽ›—’œȱ ǻŽ™Š›–Ž—ȱ˜ȱŠ”’—ȱ›Ž—Š—Œ¢ȱŠŽ›Ǽǯ Œ”—˜ •Ž–Ž—œȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱȱ ‘’œȱœŠ—Š›ȱ ŠœȱŽŸŽ•˜™Žȱ‹¢ȱŽ••Šȱ‘Ž››ŠĴȱ ’‘ȱŸŠ•žŠ‹•Žȱ’—™žœȱ›˜–ȱ–Ž–‹Ž›œȱ˜ȱ‘ŽȱŠ‹˜ŸŽȱ ŽŽ›’—ȱ˜––’ĴŽŽȱŠ—ȱ ȱŽ’˜—Š•ȱĜŒŽœȱŠ—ȱ›ŽŸ’Ž ŽȱŠȱŠȱŽŒ‘—’ŒŠ•ȱ˜—œž•Š’˜—ȱ’—ȱ Ž—ŽŸŠǰȱŗŚȬŗŜȱŒ˜‹Ž›ȱŘŖŖŘǯȱŽ–‹Ž›œȱ˜ȱ‘ŽȱŽ—Ž›ȱ˜›ȱŽŸŠ•žŠ’˜—ȱ˜ȱŽěŽŒ’ŸŽ—Žœœȱ˜ȱ‘ŽŠ•‘ȱŒŠ›ŽȬ Žȱǻ’–˜—Šȱ’ȱŠ›’˜ǰȱ’Ĵ˜›’˜ȱŠœŽŸ’ǰȱ ’Š—›Š—Œ˜ȱ ˜›’ǰȱŠ—’Ž•Šȱ™ŽĴ˜•’ǰȱŠ—ŽȱŠ›˜—Œ’Š—’ȱ and Nicola Magrini) developed the table of evidence and provided additional insightful review ˜ȱ‘ŽȱŽŸ’Ž—ŒŽȱœŽŒ’˜—ǯȱŽȱ‘Š—”ȱŠĴ‘Ž œȱŠ‘Š’ȱ˜›ȱ›ŽŸ’œ’—ȱ‘Žȱꗊ•ȱ›ŠĞǰȱ›Š—”ȱŽŒ”œ˜—ȱ ˜›ȱ‘ŽȱŽ’’—ȱŠ—ȱž”Žȱ ¢Š–Ž›Š‘ȱ˜›ȱ‘Žȱ•Š¢˜žǯ  ȱŠŒ”—˜ •ŽŽœȱ‘ŽȱŽ—Ž›˜žœȱŒ˜—›’‹ž’˜—ȱ˜ȱ˜ŸŽ›ȱŞŖȱ’—’Ÿ’žŠ•œȱŠ—ȱ˜›Š—’£Š’˜—œȱ’—ȱ ‘Žȱꎕȱ˜ȱ–ŠŽ›—Š•ȱŠ—ȱ—Ž˜—ŠŠ•ȱ‘ŽŠ•‘ȱ ‘˜ȱ˜˜”ȱ’–Žȱ˜ȱ›ŽŸ’Ž ȱ‘’œȱ˜Œž–Ž—ȱŠȱ’쎛Ž—ȱ stages of its development. World Health Organization. The document may. and all rights are reserved by the Organization. reproduced and translated. abstracted.