7

SECTION 1: SCALING UP PROVISION OF ANC SERVICES

Scaling up the provision of Antenatal care (ANC) is recommended to cognizant of the individuality of each pregnant woman or adolescent as
facilitate a positive pregnancy experience for all pregnant women and proposed in the Integrated ANC Package (see annex 1).
adolescents. ANC is one of the recommended interventions to reduce
The integrated ANC package comprises of a mix of known effective
maternal and neonatal mortality. It is defined as a package of regular
interventions that are linked to other services in order to safeguard and
medical and nursing care services prioritise the health and wellbeing of the
recommended during pregnancy that ANC is defined as a package of regular medical and nursing pregnant person and growing fetus.
comprise of preventative strategies aimed care services recommended during pregnancy that comprise of Facility level operationalization of the
at providing regular checkups that allow preventative strategies aimed at providing regular checkups integrated ANC package requires scaling
skilled personnel to identify, treat, and that allow skilled personnel to identify, treat, and prevent up of eight (8) key areas of ANC service
prevent potential health problems potential health problems throughout the progression of
delivery. These include:- 1. ANC service
throughout the progression of pregnancy pregnancy while promoting a healthy lifestyle.
provision; 2. Community engagement; 3.
while promoting a healthy lifestyle.
Organisation of ANC services; 4. Essential
ANC reduces maternal and perinatal Strengthen ANC governance and coordination
practices in ANC; 5. Ailment
ANC SERVICE mechanisms Prevention; 6. Nutrition; 7.
morbidity and mortality both directly, PROVISION
Complication management; and
through detection and treatment of Establish appropriate channels for ANC communication 8. ANC monitoring and
COMMUNITY
pregnancy-related complications, and ENGAGEMENT
and support at community level
evaluation systems.
indirectly, through the identification of
women and girls who are at increased risk of ORGANISATION
Increase the number of ANC contacts to eight (8)
OF ANC Focus on these 8 key
developing complications during labour and SERVICES areas will result in
delivery, thus ensuring referral to an appropriate ESSENTIAL Strengthen facility level capacity to conduct all essential well-coordinated,
level of care. It (ANC) also provides an important PRACTICES ANC practices
equipped and
opportunity to manage concurrent diseases, Strengthen the delivery of standard precautions for the managed
including HIV, tuberculosis (TB) and malaria, through PREVENTION prevention of infections and non-communicable
OF diseases maternity units
integrated service delivery. AILMENTS
that will provide
Therefore, scaling up of ANC services entails a positive
Strengthen nutritional counseling services
enhancing the provision of known effective ANC NUTRITION pregnancy
interventions and delivering them in a experience for all
personalized client centred manner. This can COMPLICATION Establish efficient and timely protocols for referral pregnant women
MANAGEMENT systems and mechanisms for follow up on all referrals
and adolescents.
be achieved through the establishment of MONITORING
a model of care strategy that includes AND Strengthen facility level ANC monitoring and
EVALUATION evaluation systems
health information, medical assessment
and intra-personal support that is
adapted to the local context and is

KEY MESSAGE
Scaling up of antenatal care (ANC) services at all levels of health service delivery is recommended to facilitate a positive pregnancy experience for all
pregnant women and adolescents and contribute to the reduction of maternal, newborn and child deaths.

BOX 1: INTERVENTIONS FOR SCALING UP ANC SERVICES
INTERVENTION NEED TO KNOW
Midwife- led In MLCC models a midwife (or team of
continuity of midwives) supports a woman throughout
care (MLCC) the antenatal, intrapartum and postnatal
period to facilitate a healthy pregnancy and
childbirth, and healthy parenting practices.
It is designed for healthy women with
uncomplicated pregnancies and comprises
of continuity of care, monitoring the
physical, psychological, spiritual and social
wellbeing of the woman and family
throughout the childbearing cycle.
Women held It is recommended that each pregnant
case notes woman carries her own case notes during
pregnancy to improve continuity, quality of
care and her pregnancy experience.
Community Community mobilisation through facilitated
based (health care providers and midwives)
interventions participatory learning within the
to improve community can be used to create
communicatio awareness on ANC to increase support to
n and support pregnant women and improve ANC uptake
and attendance.
ANC contact The 2016 WHO ANC model recommends a
schedules minimum of 8 ANC contacts with the first
contact scheduled to take place in the first
trimester, two contacts in the second
trimester and five contacts scheduled in
the third trimester.
8
NEED TO DO
 Set up a midwife led ANC unit
 Provide individualized ANC including
education and counseling.
 Provide ongoing support during the
postpartum period.
 Be present during labour, birth and the
immediate postpartum period.
 Identify, refer and coordinate care for women
who require obstetric and other specialist
attention (complicated pregnancies).
 Provide each pregnant woman and
adolescents with (an ANC Card/ MCH
Handbook).
 Update the card at each contact and the
appropriate registers.
 Counsel the client on safe keeping of ANC
card and the need to carry it for ANC contact
and any other visit to the health facility
● Train staff in group facilitation, convening
public meetings and communication
techniques.
● Establish relationships with key stakeholders
within the community (e.g. Traditional
leadership, influential people, traditional
doctors, traditional counselors)
● Train community volunteers/ CHAs to identify
pregnant women in the community and
encourage their attendance.
 Increase the number of ANC contacts to a
minimum of 8 contacts and provide
appropriate sensitisation.
 Integrate pregnancy screening with other
curative services
 Build capacity for pregnancy testing at various
levels
 Engage pre-service training institutions and
professional bodies on change of guidelines (8
Contacts)
 Reorganize ANC services to improve
efficiency and reduce waiting time
NEED TO HAVE
 Adequate number of midwives at
each facility at every level of care
 Midwife mentorship and internships
programmes
 Multidisciplinary networks in which
consultations and referrals to other
care providers can be made.
 Mechanisms for monitoring midwife
case loads
 Commodity management system
(ANC card / MCH handbook,
registers)
 Resources for sustained production
of cards and registers
 Methods for retaining a facility copy
(Consider digitalizing the card/ MCH
Handbooks)
 Durable and waterproof case note
carriers
 Culturally appropriate educational
materials (including job aids)
 Trained CBVs (SMAGs)
 CHA
 Adequate number of trained
facilitators per zone and resources
to support them
 Provider training and supervision for
newly introduced interventions (e.g.
Ultrasound).
 Updated j o b aids t h a t
reflect changes.
 Updated ANC curricula and clinical
manuals
 Ongoing s u p e r v i s i o n ,
m o n i t o r i n g and mentorship.
 Well-equipped maternity waiting
homes.
CONSIDER
 Midwives are the primary providers of
care in many ANC settings, hence they
must actively engage with the client to
improve ultilisation and quality of ANC,
and improve maternal and neonatal
outcomes.
 MLCC approach helps build rapport and
continuity of care as the same midwife/
group of midwives is responsible for the
woman’s ANC. Throughout the pregnancy
cycle.
 Women held case notes are essential to
continuity of ANC as they may be an
effective tool to improve health
awareness and client provider
communication. In addition, they help
improve the availability of medical
records especially in situations where
poor infrastructure and resources hamper
efficient record keeping. In addition, the
practice may facilitate more accurate
estimation of gestational age which is
integral to decision making.
 Access to appropriate communication and
support is a key element of quality ANC
services hence it is essential to actively
engage with the community to increase
awareness on ANC to improve uptake.
 Community demographics and cultural
norms
Increased ANC contacts will enable regular and
close contact between pregnant women and
midwives for improved service delivery and
pregnancy monitoring. The aim is to reduce
preventable morbidity and mortality through
systematic monitoring of maternal and foetal
wellbeing, particularly in relation to
hypertensive disorders and other complications
that may be asymptomatic but detectable.
 9

INTERVENTION NEED TO KNOW NEED TO DO NEED TO HAVE RATIONALE

Referral To ensure positive maternal and  Identify, refer and coordinate care for women  Next level of care contact  Timely and appropriate referrals to
mechanisms neonatal outcomes, referral who require obstetric and other specialist details, including which facilities higher levels of ANC is key to saving
mechanisms must be strengthened to attention provide EmONC the pregnant woman and unborn
make them more effective and child and can significantly contribute
 Conduct training on emergency response  Feedback and follow up
efficient in order to ensure to achieving positive maternal and
procedures, including which facilities to mechanisms
continuity of care for all ANC clients neonatal outcomes.
refer clients to for Emergency Obstetric and
from one health care provider to  Reliable and readily available
Newborn Care (EmONC)
another and from one facility to the well- e q u i p p e d ambulance  Up- to- date referral protocols and
next level of service delivery.  Establish information exchange and feedback services guidelines are necessary to ensure
mechanisms within and between health that every patient receives timely,
 Adequate number of EmONC
The Zambian referral system is facilities appropriate care and that
trained staff
structured according to the service unnecessary complications are
levels with the following  Up to date protocols for avoided.
structures; community, health post, referrals and emergency
health centre, level 1, 2, 3 and management  Appropriate information exchange and
specialized hospitals, including feedback mechanisms within and
ambulance services. between health facilities improves patient
care, increases motivation of health care
workers, helps learning from experience
and leads to improved patient care.
 10

SECTION 2: COMMUNITY ENGAGEMENT FOR ANC

Community engagement in ANC is recommended for the improvement of health, disease prevention and control, curative services, rehabilitation
ANC utilization and perinatal outcomes. Community involvement in ANC and palliative care within the community, it can be strengthened by
creates a platform on which health care providers can actively interact including an ANC component.
with the community to identify, prioritise and address problems women The ANC component should be aimed at creating awareness on pregnant
face around pregnancy, childbirth and after birth and empower women to women’s rights to attend ANC for their health and wellbeing and the
seek care and choose healthy pregnancy and newborn health of the unborn child, the importance
care behaviours. and role of male involvement in pregnancy,
promotion of sexual and reproductive
By involving the community in ANC, the aim is
rights, partnerships with TBAs, birth
to improve maternal and neonatal
preparedness and complication
outcomes and facilitate a positive
readiness, including community
pregnancy experience for all
participation in quality of care.
pregnant women and adolescents.
Additionally, community COMMUNITY SENSITISATION FOCUS AREAS
participation in ANC is necessary for
Women’s right to attend ANC
equitable distribution of health
services and improved health Male involvement in pregnancy
outcomes for all in the community. Promotion of sexual and reproductive rights
Community engagement and
Partnerships
participation in ANC can be
achieved through multi-level Birth preparedness and complication
community mobilisation strategies readiness
that include advocacy with community Community participation in quality of ANC
stakeholders (community leaders, services
teachers, and other respected members),
TBA, husbands or partners, and households.
This should include appropriately packaged group These can be implemented through
educational sessions on key knowledge and behaviours strengthening existing networks at outreach
around pregnancy and early neonatal care including the importance posts, health posts, health centres, and district hospitals
of each component of ANC. Particular emphasis should be on how the which are linked to the communities through NHCs. This should be
community can support pregnant women in facilitating a positive supported by a well-functioning referral system across the health delivery
pregnancy experience. stratum if community mobilisation is to contribute to improved maternal
Though the current primary health care (PHC) approach already lays and neonatal outcomes and contribute to facilitating a positive pregnancy
emphasis on people’s participation in addressing health problems within experience for all pregnant women and adolescents.
their own community by using a proactive approach to promotion of good

KEY MESSAGE
ANC programmes that include household and community mobilisation are recommended to improve ANC utilization and perinatal health outcomes

BOX 2: INTERVENTIONS FOR COMMUNITY AWARENESS AND ENGAGEMENT FOR ANC
INTERVENTION NEED TO KNOW
Community  Community demographics and
Mobilisation cultural norms
 The key stakeholders in the
community
 Nature and type of community
health groups and volunteers
within the community
. traditional
Antenatal home Antenatal home visits are an advocacy
visits strategy aimed at promoting maternal
health education, ANC attendance and
other health seeking behaviour. They
can provide, early intervention and
primary prevention in the antenatal
period and may be useful for ensuring
continuity of care across the antenatal,
intrapartum, and postnatal period.
However, antenatal home visits do not
replace the recommended 8 ANC
contacts
Male Interventions to promote male
involvement in involvement in pregnancy are aimed at
ANC facilitating support and improved self-
care of women, improved home care
practices for women and newborns, and
improved use of skilled care during
pregnancy, childbirth and postnatal
period.
11
NEED TO DO
 Train facilitators in group facilitation, convening
public meetings, and communication
techniques.
 Train community volunteers/ lay health
workers to identify pregnant women in the
community and encourage their ANC
attendance
 Coordinate with other healthcare providers and
community health groups
 Establish links or relationships with key
stakeholders within the community (e.g.
Traditional leadership, influential people,
traditional doctors, traditional counselors, TBA)
etc.
 At least one home visit should be conducted
during the pregnancy.
 Asses the social and environmental factors
prevailing at home and give necessary advice
and suggestions.
 Provide referral to other ANC services if
necessary
 Link ANC home visits to maternity shelters.
 Ensure that the individual woman’s preferences
are respected, e.g. with regard to partner
involvement.
 Interventions to engage male partners/
husbands to support women to make health
choices during pregnancy are recommended.
 Encourage men to be involved in ensuring that
all ANC appointments are attended.
NEED TO HAVE CONSIDER
 Group spaces to hold meetings  Whether meetings should include
men and women together or
 Culturally and educationally
separately
appropriate educational material, e.g.
videos, flip charts, pictorial booklets  Offering women a range of
and/or cards opportunities for communication
and support, so that their individual
 Ongoing supervision and monitoring
preferences and circumstances can
of facilitators
be catered for
 Resources, e.g. additional staff,
 Implementing health system
transport and budget for material, for
strengthening interventions, such as
community mobilization initiatives
staff training, and improving
 Register of Religious leaders, equipment, transport, supplies, etc.
leaders, alangizi,
 Participatory women’s groups as
traditional healers
they present an opportunity for
 Advocacy strategy to engage women to discuss their needs during
community leadership. pregnancy including barriers to
reaching care and to increase
support to pregnant women.
 Lay health workers or community  Offering women a range of
volunteers with a strong linkage to opportunities for communication
the health facility to manage this and support, so that their individual
component. preferences and circumstances can
be catered for
 Standards TORs for management of
maternity shelters and making them  Home visits must be implemented in
part of the health facility. a manner that respects and
facilitates women’s need for privacy
 Health system strengthening as well as their choice and
interventions, such as staff training, autonomy in decision making.
and improving equipment, transport,
supplies, etc to support the home
visits.
 Culturally and educationally Men are an important support system in
appropriate educational material, e.g. pregnancy as they are with their partners
videos, flip charts, pictorial booklets every day and may notice changes in their
and/or cards. pregnant partners that others may not
see. Further, male involvement is
 Advocacy strategy to engage men in recommended in order to facilitate and
ANC. support improved care for women, and
children, improved use of skilled care
during pregnancy, childbirth and
postnatal period for women and
newborns.
 12

INTERVENTION NEED TO KNOW NEED TO DO NEED TO HAVE CONSIDER

Strengthen existing Community outreach programs form an  Strengthen existing partnerships with  Resources, e.g. additional community Community outreach programmes act as
community integral component of the public health community based CHAs, NHCs, and SMAGs, volunteers, transport and budget for an entry point into the public health care
outreach service delivery system , hence material, for community outreach system at the community level hence
programmes strengthening processes and coverage  Coordinate ANC activities/ programs with other activities. strengthening their delivery could
provides a platform for incorporation of healthcare providers and community health significantly contribute to positive
community engagement in ANC. groups  Register of existing community maternal and neonatal outcomes.
outreach programs
 Establish linkages between facility level
activities and community outreach  Strengthen coordination, organisation
programmes. and general management of
outreach programmes
 Incorporate ANC outreach into existing
community outreach programmes (e.g. Child  Standardize organisation of outreach
health, programmes
Involve the Involvement of the community in quality  Different groups should be asked to provide  Mechanisms in place to actively Community involvement in quality
community in of ANC services ensures accountability feedback and suggestions on how to improve engage with the community to enable improvement processes is necessary for
quality of services. of healthcare services and providers. the ANC services. them provide constructive feedback. the improvement of quality of ANC
awareness and services as it provides feedback from the
engagement for  Introduce opinion/suggestion boxes at the perspectives of women, communities and
ANC health care facility health care providers.
 Conduct periodic client satisfaction surveys.
 13

SECTION 3: ORGANISATION OF ANC SERVICES

A minimum of eight (8) ANC contacts are recommended throughout the between the pregnant woman and the
pregnancy period in order to reduce perinatal mortality and improve health-care provider that is not implicit
women’s experience of care. The first contact should take place in the first with the word “visit”. An active
trimester (up to 12 weeks of gestation), two contacts scheduled in the engagement can be
second trimester (at 20 and 26 weeks of gestation) and five contacts established through
scheduled in the third trimester (30, 34, 36, 38, and 40 weeks). The timings the provision of an
of the 8 contacts are aimed at optimizing the delivery of specific essential package of
interventions in order to achieve maximum impact of ANC. This new ANC that is
model, presents a shift from the focused antenatal care (FANC) model
which recommended 4 visits. characterized by
effective clinical
WHO FANC Model 2016 WHO ANC model practices
First Trimester (interventions and
Visit 1: 8 – 12 weeks Contact 1: Up to 12 weeks tests), and the provision of relevant
Second Trimester and timely information, and
Contact 2: 20 weeks psychosocial and emotional support
Visit 2: 24 – 26 weeks Contact 3: 26 weeks with good clinical and interpersonal
Third Trimester skills within a well-functioning health system.
Visit 3: 32 weeks Contact 4: 30 weeks
Each ANC contact comprises of three key elements: 1. Health information;
Contact 5: 34 weeks
CONTACT FOCUS 2. Medical assessment; and
Visit 4: 36 – 38 weeks Contact 6: 36 weeks
COMPONENTS 3. Intra-personal support
Contact 7: 38 weeks
Health Information Provision of relevant and timely
Contact 8: 40 weeks The proposed interventions
ANC information
Return for delivery at 41weeks if not given birth Medical Implementation of effective
at each contact and by
Assessment clinical practices whom (see Box 3) are not
(including
The 2016 WHO ANC model is supported by strong evidence that suggests
interventions and tests) meant to be prescriptive
that systematic monitoring of maternal and fetal well-being particularly in Intra-personal Provision of psychosocial and but rather adaptable to the
relation to hypertensive disorders and other complications that may be Support emotional support individual woman and the
asymptomatic, as can be achieved through more visits (especially in the
local context to allow for flexibility in the delivery of ANC. This allows for
third trimester), is key in reducing preventable morbidity and mortality.
the provision of a personalized, respectful service that focuses on
It should also be noted that within this new model of ANC the word facilitating a positive pregnancy experience for all pregnant women and
“contact” is used instead of ‘visit’ to emphasise an active connection adolescents.

KEY MESSAGE
A minimum of eight (8) ANC contacts are recommended throughout the pregnancy period. This allows for an active engagement between the pregnant woman and
health care provider and facilitates increased maternal and fetal monitoring and assessments to support a healthy pregnancy and early detection of problems

BOX 3: ANC CONTACT INTERVENTIONS
CONTACT GESTATION FOCUS*
PERIOD
 ANC counselling (Nutrition,
birth preparedness and danger
signs and pregnancy to be
introduced early enough)
Up to 12
Contact 1  Medical assessment and
Weeks
management
 Clinical inquiry on IPV/ SGVB
 ANC counselling including birth
plan and preparedness, danger
signs in pregnancy
(Family planning should be
introduced at this stage. All
Contact 2 13 to 20 Weeks the available methods should be
taught for a women to have a
wider choice)
 Medical assessment and
management
 ANC counselling including birth
plan and preparedness, danger
signs in pregnancy
 Medical assessment and
management
Contact 3 21 to 26 Weeks
 Counselling for Family
Planning and breast feeding
 Management of pain during
labour
 ANC counselling including birth
plan and preparedness, danger
signs in pregnancy
 Medical assessment and
Contact 4 27 to 31 Weeks management
 Counselling for Family
Planning and breast feeding
 Management of pain during
labour
14
NEED TO DO**
 Counselling
 Medical assessment and
management/ referral
 Create rapport with clients
 Enquiry and make appropriate
referral of IPV/ SGVB
 Counselling
 Medical assessment and
management/ referral
 Create rapport with clients
 Ultras ound scan
 Home visits
 Enquiry and referral of
IPV/ SGVB
 Counselling
 Medical assessment and
management/ referral
 Create rapport with clients
 Home visits
 Enquiry and referral of
IPV/ SGVB
 Ultras o u n d scan if not done
insecond contact
 Counselling
 Medical assessment and
management/ referral
 Create rapport with clients
 Home visits
 Enquiry and referral of
IPV/ SGVB
NEED TO HAVE BY WHOM
 Counselling kits, guidelines,  SMAGs and CHAs to
test kits(HIV, RPR, urinistix), do counseling only
medical equipment (B P and refer
machines, bathroom scales, appropriately
glucometers, glucostix,

Nurses, midwives,
HemoCue and microcuvettes,
reagents)
Cos, MLs, MOs (each
health provider to
 Good interpersonal and perform roles
counselling skills applicable to their
scope of practice )
 Guidelines, counseling kits test  Nurses, midwives,
kits, medical equipment (BP Cos, MLs, MOs, EHTs,
machines, bathroom scales, CHAs, SMAGs (Each
tape measure, glucometers, health provider to
glucostix, HemoCue and perform roles
microcuvettes, reagents), applicable to their
scope of practice)
 Ultras o u n d machine
 Ultrasonographer for
 Good interpersonal and
counseling skills
ultras o u n d
 Guidelines, test kits, medical
equipment (BP machines,  Nurses, midwives,
bathroom scales, tape measure, Cos, MLs, MOs, EHTs,
glucometers, glucostix, CHAs, SMAGs (Each
HemoCue and microcuvettes, health provider to
reagents), perform roles
applicable to their
 Good interpersonal and
scope)
counseling skills
 Guidelines, counselling kits test  Nurses, midwives,
kits, medical equipment (BP Cos, MLs, MOs, EHTs,
machines, bathroom scales, CHAs, SMAGs (Each
tape measure, glucometers, health provider to
glucostix, HemoCue and perform roles
microcuvettes, reagents), applicable to their
scope)
 Home visit bag and accessories
 Good interpersonal and
counseling skills
 15

CONTACT GESTATION FOCUS* NEED TO DO** NEED TO HAVE BY WHOM

PERIOD
 ANC counselling  Counselling  Guidelines, counselling kits test
kits, medical equipment (BP  nurses, midwives,
 Medical assessment and  Medical assessment and
machines, bathroom scales, Cos, MLs, MOs, EHTs,
management management/ referral
tape measure, glucometers, CHAs, SMAGs (Each
 Counselling for Family  Create rapport with clients glucostix, HemoCue and health provider to
Contact 5 30 to 33 Weeks
Planning and breast feeding microcuvettes, reagents), perform roles
 Home visits applicable to their
 Management of pain during  Home visit bag and accessories
 Enquiry and referral of scope )
labour  Good interpersonal and
IPV/ SGVB
counseling skills
 ANC counselling including birth  Counselling  Guidelines, test kits, medical
plan and preparedness and equipment (BP machines,  Nurses, midwives,
danger signs  Medical assessment and bathroom scales, tape measure, Cos, MLs, MOs , EHTs,
management/ referral glucometers, glucostix, CHAs, SMAGs (Each
 Medical assessment and
HemoCue and microcuvettes, health provider to
Contact 6 34 to 35 Weeks management
 Create rapport with clients reagents), perform roles
 Counselling for Family applicable to their
 Home visits  Home visit bag and accessories scope)
Planning and breast feeding
 Management of pain during  Enquiry and referral of  Good interpersonal relationship
labour IPV/ SGVB
 ANC counselling including birth  Counselling  Guidelines, test kits, medical
plan, preparedness and danger equipment (BP machines,  Nurses, midwives,
 Medical assessment and
sins bathroom scales, tape measure, Cos, MLs, MOs, EHTs,
management/ referral for
glucometers, glucostix, CHAs, SMAGs (Each
 Medical assessment and
36 to 37  Create rapport with clients HemoCue and microcuvettes, health provider to
Contact 7 management
Weeks reagents), perform roles
 Home visits
 Counselling for Family applicable to their
 Good interpersonal
Planning and breast feeding  Enquiry and referral of scope)
relationships
 Management of pain during IPV/ SGVB
labour
 ANC counselling including birth  Counselling  Guidelines, counseling kits test
plan and preparedness and kits, medical equipment (BP  Nurses, midwives,
danger signs  Medical assessment and machines, bathroom scales, Cos, MLs, MOs, EHTs,
management/ referral tape measure, glucometers, CHAs, SMAGs (Each
 Medical assessment and
 Create rapport with clients glucostix, HemoCue and health provider to
Contact 8 38 to 40 Weeks management
microcuvettes, reagents), perform roles
 Counselling for Family  Home visits applicable to their
 Good interpersonal relationship scope)
Planning and breast feeding
 Enquiry and referral of
 Management of pain during IPV/ SGVB
labour
* Comprehensive details of activities at each contact are outlines in the integrated ANC package presented in annex 1
**The list of interventions to be delivered at each contact and details about where they are delivered is and by whom are not meant to be prescriptive but rather adaptable to the individual woman and the local context to allow for flexibility in the
delivery of the recommended interventions.
 16
SECTION 4: ESSENTIAL PRACTICES IN PROVISION OF ANC SERVICES
An integrated ANC package that comprises essential practices in ANC
service provision is recommended to improve maternal and neonatal
outcomes (See annex 1). It integrates both clinical and non-clinical
interventions and delivers them in a manner that focuses on strengthening
and improving the quality of ANC services while encouraging a continuum
of care for all pregnant women.
The core clinical practices (medical interventions and tests) and non-
clinical practices (counseling and interpersonal support) that must be
provided at each of the recommended 8 routine ANC contacts are outlined
with details of which health provider will perform it (CHA, SMAG, midwife,
etc.), and at what health care delivery/facility level (i.e. home visit, primary
KEY MESSAGE
Effective communication and timely implementation of essential clinical practices aim to provide person centred care in order to facilitate a positive
pregnancy experience and improved outcomes for all pregnant women and adolescents.
care facility etc.). Timeliness of implementation of each component of the
package is therefore important as it has implications on the wellbeing of
the pregnant woman and the growing fetus. It is for this reason that
integrated ANC package provides for two opportunities to arrange and
conduct early ultrasound scan before 24 weeks gestation as accurate
gestational age is important in determining the exact timing of key ANC
interventions especially related to malaria, tuberculosis and HIV. Further,
accurate estimation of gestational age is important for the diagnosis and
management of pre-term birth and pre-eclampsia. It is for this reason that
accurate gestational age is vital to the successful implementation of the
model and ensuring that all 8 contacts are attended.
Creating rapport between the client and the service provider and offering
quality care is particularly important in encouraging ANC attendance as
evidence has shown that if the quality of ANC is poor and the woman’s
experience of it is negative, that woman will not attend ANC irrespective of
the number of contacts that are prescribed. Therefore respectful,
individualized and person-centered communication must be facilitated at
all ANC contacts, to cover: presence of any symptoms; promotion of
healthy pregnancies and newborns through lifestyle choices; individualized
advice and support; timely information and tests, supplements and
treatments; birth preparedness and complication readiness planning;
postnatal family planning options; and the timing and purpose of ANC
contacts. Topics for individualized advice and support can include healthy
eating, physical activity, nutrition, tobacco, substance use, caffeine intake,
physiological symptoms, malaria and HIV prevention, and blood test
results and retests, alcohol and substance abuse, intimate partner violence
foetal assessment, investigations (point of care, laboratory, radiological
birth preparedness and complications including recognition of danger
signs, and individualized birth plans.
Therefore, effective communication and timely implementations of
interventions is key to facilitating a positive pregnancy experience for all
pregnant women and adolescents.
 17

BOX 4: ESSENTIAL PRACTICES IN THE PROVISION OF ANC

INTERVENTION NEED TO KNOW NEED TO DO NEED TO HAVE CONSIDER

Communication in ANC is an integral  Counseling on birth plan and  Obstetricians, medical  Appropriate language and
component of positive pregnancy preparedness, exercise and diet, alcohol officers Nurses, Midwives, format of communication
Communication experiences. It refers to the act of tobacco and substance abuse, balanced EHTs, SMAGs, CHAs Clinical
 Staff training
sharing information and, education energy and protein supplementation, officer,
with women about timely and PMTCT, labour companion, malaria  Offering women a range of
 Effective referral systems
relevant physiological, biomedical, prevention, danger signs and family opportunities for
behavioural and sociocultural planning,  Visual aids communication and support
issues. Effective communication that take into consideration
 Inform women on their right to access  Registers
helps reduce anxiety and builds individual preferences and
quality ANC and make informed decisions
rapport between the provider and the
on their sexual and reproductive health.  Schedule for outreach and circumstances
client. information sessions
 Conducting group counseling
 Provide support for women and their
partners in addressing some of the  Good counseling and for all topics and individual
interpersonal skills counseling according to the
challenges they may face in pregnancy
needs of a client and
 Community sensitisation activities to  Guidelines for referrals (e.g. confidentiality required for
disseminate information about the IPV, SGBV) the topic
importance of each component of ANC .  Space to conduct individual
or group counseling.
Medical Medical assessment and  Measure weight, height, BP.  Medical equipment, and  In- service training
assessment management is important for the supplies
 Estimate gestational age.
and detection and treatment of pregnancy  Strategies to address staff
 Adequate skilled personnel
management related complications, minor  Conduct RPR, HIV test, TB screening, turnover and/ or inadequate
disorders and the Hb, blood group and Rh factor,  Job aids staffing
identification of women and Hepatitis, urinalysis
adolescents at risk of developing  Test kits  Availability of test kits,
 prophylaxis for HIV prevention, drugs and medical supplies
complications during pregnancy  Essential drugs (ARV,
skilled labour,
and/ labour thus ensuring referral to  Treatment of minor disorders in antibiotics, vaccines, etc.)
an appropriate level of care. pregnancy
 Clinical observation charts
 Supply iron and folic acid,
 Reliable ambulance services 
 Vaccination against tetanus,
 Effective referral systems 
 Treatment of asymptomatic bacteriuria
(ASB)
Intra- personal support refers to the  Assess for signs of SGBV/ IPV, counsel  Good interpersonal skills,  Offering women a range of
Intra- Personal provision of social, cultural and and refer, opportunities for
 Good rapport with clients,
Support psychological support throughout communication and support
 Home visits
pregnancy. It provides emotional  Guidelines for referrals that take into consideration
support to improve mental health  Prepare the woman psychologically for individual preferences and
and gives the pregnant woman a labour pain circumstances
positive outlook and improves
overall health outcomes for mother  Creating rapport between the provider
and baby and client
 18

SECTION 5: PREVENTION OF AILMENTS IN PREGNANCY

Standard precautions for the prevention of ailments in pregnancy are In the same vein non-communicable diseases or conditions that occur
recommended for the improvement of maternal and neonatal outcomes during pregnancy may also have negative maternal and neonatal effects,
and contribute to a positive pregnancy experience for pregnant women hence standard precautions measures to prevent or address them must
and adolescents. also form part of the routine ANC implementation strategy.

The occurrence of some infections and non- communicable diseases in NON-COMMUNICABLE STANDARD PRECAUTION
DISEASES OF CONCERN
pregnancy pose a risk to the health and wellbeing of the mother, fetus and
Anaemia  Full blood count/ on site haemoglobin
newborn as they may lead to miscarriage, preterm labour, birth defects,
testing
small for gestational age newborns, and mortality. Some infections that
 Check for iron deficiencies throughout
occur during pregnancy primarily pose a risk to the mother while others pregnancy
can be transmitted to the baby through the placenta or during birth. Viral  Provide iron and folic acid
and bacterial infections in pregnancy are of particular concern as their (supplementation)
effects tend to be more severe. Specific precautionary measures are Gestational Diabetes  Test for gestational diabetes
recommended for identified infections at specified ANC contacts (see Mellitus
Integrated ANC Package in annex 1). Pre-eclampsia  Monitor blood pressure throughout
pregnancy
VIRAL/BACTERIAL STANDARD PRECAUTION  Urinalysis (Protein) at every contact
INFECTIONS OF  Physical examination (excessive
CONCERN weight gain and edema)
Asymptomatic Test for ASB in all pregnant women High Blood Pressure Monitor blood pressure throughout
bacteriuria (ASB) pregnancy
Rh Disease  Rhesus factor test on every pregnant
Helminthiasis Administration of preventative anthelminthic
treatment
woman at first contact.
 Administration of anti D
Human Provider initiated testing and administration of immunoglobulin to non-sensitized Rh-
immunodeficiency virus pre-exposure prophylaxis negative pregnant women at 28 and 34
Syphilis Provider initiated testing weeks.
Tuberculosis TB screening for all pregnant women
Urinary tract infections Test for UTIs and provide antibiotic prophylaxis Early diagnosis and management (see section 7 for complication
for recurrent UTIs. management) of ailments in pregnancy is key to prevention of maternal
Malaria Intermittent malaria prophylaxis for all
and neonatal mortality. These standard precautionary measures must
pregnant women
however be supported by efficient and effective referral systems to ensure
Tetanus Administration of tetanus toxoid for all
pregnant women timely response. Doing so will contribute to facilitating a positive
pregnancy experience for women and adolescents.

KEY MESSAGE
Standard measures to prevent ailments in pregnancy must be implemented at each routine ANC contact to facilitate positive
pregnancy outcomes
 19

BOX 5A: INTERVENTIONS FOR INFECTION PREVENTION IN PREGNANCY

*INTERVENTION NEED TO KNOW NEED TO DO NEED TO HAVE CONSIDER

Antibiotics for ASB is a common urinary tract condition that
ASB is associated with increased risk of urinary
tract infections in pregnant women. If left
untreated, it may lead to stasis in the urinary
tract and increase the likelihood of
pyelonephritis, resulting in an increased risk
of preterm birth.
 Once detected, it can be actively
managed with antibiotics
Antibiotic Recurrent UTIs are common in pregnancy and
prophylaxis to are associated with adverse pregnancy
prevent outcomes including preterm birth and small
recurrent for gestational age newborns.
urinary tract
infections
Antenatal anti- Antenatal prophylaxis with Anti D 
D immunoglobulin in non-sensitized Rh-negative
immunoglobulin pregnant women at 28 and 34 weeks of
administration gestation is recommended to prevent RhD
alloimmunisation. Usually first child is not
affected
Preventative Worm infestation in pregnancy can lead
anthelminthic to anaemia, malnutrition and ill - health.
treatment In endemic areas preventive
antihelminthic treatment is given to
pregnant women after the 1 s t trimester
Tetanus toxoid Tetanus is an acute disease caused by an
vaccination exotoxin produced by clostridium tetani.
Tetanus in pregnancy can lead to maternal,
neonatal tetanus and death. Maternal tetanus
can be caused by unclean delivery while
neonatal infections is caused by unhygienic
care of the umbilical cord or umbilical stump
in babies. Neonates need to have received
maternal antibodies via placenta to be
protected at birth.
 Urine for microscopy
 Midstream urine for culture
 Dipstick test
 Capacity building for providers
 counseling on good hygiene and infection
prevention
 Urine for microscopy
 Counseling /IEC - hygiene need to
complete treatment
 counseling on good hygiene and infection
prevention
Rhesus Factor test on every pregnant
woman at 1st contact or at any other
contact if it was not done at 1st contact
 Administration of anti D immunoglobulin
to non-sensitized Rh- negative pregnant
women at 28, at 34 weeks and within
72hrs of giving birth to an RH positive
baby,
 Administration of preventative
anthelminthic treatment
 Stool for routine Examination
 Counseling and Health education on
Hygiene, eating habits, pica, cooking
methods,
 Administration of tetanus toxoid for all
women of childbearing age and pregnant
women
 Counseling for adherence
 Specimen bottles
 Laboratory Forms
 Antibiotics
 Medical supplies
 Guidelines and protocol on ASB
including use of antibiotics in
pregnancy
 Specimen bottles
 Medical supplies
 Laboratory Forms
 Antibiotics
 Trained staff
 Specimen bottles
 Medical supplies
 Laboratory Forms
 Trained staff
 Availability of blood-
typing
 availability of drugs
 commodities management
 Availability of the vaccine
 Storage facilities
 Medical supplies
 Availability of TT card
A high level of accuracy in detecting ASB
is required to avoid treating women
unnecessarily particularly in view of
increasing antimicrobial resistance.
Antibiotic prophylaxis is only
recommended for recurrent UTIs
Counseling and reminder in
subsequent pregnancies as Rhesus
negative mothers can develop RH
antibodies if they have an RH positive
newborn baby causing haemolytic
disease of the newborn in subsequent
pregnancies
 Affected women are often
asymptomatic therefore the
presence of soil based
helminthiasis could influence
the provision of preventative
treatment.
 Community based
distribution
 Non pregnant adolescents should
also be vaccinated and issued with
TT Cards to continue with during
pregnancy,
 TT Guidelines and protocols
 A total of 5 doses is required to be
fully immunized
 Local prevalence of neonatal
tetanus
 20

*INTERVENTION NEED TO KNOW NEED TO DO NEED TO HAVE CONSIDER

Intermittent  Give intermittent malaria prophylaxis for  constant supply of Drugs and  Strategies to ensure that women
preventative Malaria in pregnancy may lead to intense all pregnant women once a month from reagents receive the first dose at 13 weeks
treatment of inflammation of the placenta which can lead 13 weeks until delivery with at least one
 Well informed pregnant women  Those with signs and symptoms of
malaria in to miscarriage, preterm labour and foetal month apart
malaria, conduct Malaria Rapid Test
pregnancy infection  Appropriate case management
 Those with signs and symptoms of malaria, (RDT)
( IPTp)
conduct Malaria Rapid Test (RDT)  Effective and efficient referral
systems
 Counseling on keeping surroundings clean,
sleeping under treated mosquito nets and  IEC materials on prevention of
repellants malaria in pregnancy
Pre- exposure Oral pre-exposure prophylaxis should be  Counseling on the risks, benefits and  Commodities management  Stigma associated with ARV use
prophylaxis offered as an additional prevention choice for alternatives to continuing to use PrEP
 Time and space for counseling  Provider level training on how to
(PrEP) for HIV pregnant women at substantial risk of HIV during pregnancy and breastfeeding
initiate and follow up, how to
prevention infection as part of combination prevention  Confidential dispensing
 Capacity building for staff recognise renal toxicity and when to
approaches.
 Providers to counsel and train discontinue PrEP.
 Availability of ARVs
 Protocols and guidelines on
dispensing and management
* Because each of the prescribed intervention are important for maternal and foetal wellbeing, any intervention that is missed at an ANC contact, for whatever reason, should in principle be included
at the next contact

BOX 5B: INTERVENTIONS FOR PREVENTION 0F NON COMMUNICABLE DISEASES IN PREGNANCY
INTERVENTION NEED TO KNOW
Anaemia
 Anaemia is a common problem in
pregnancy. It is associated with iron, folate
and vitamin A deficiencies hence Iron and
folic acid supplementation is
recommended to improve maternal
and neonatal outcomes
 Major contributory factors to anaemia include
parasitic infections such as malaria, hookworm,
hence IPTp and preventative anthelminthic
treatment also contribute to preventing
anaemia.
Gestational  Gestational diabetes mellitus is diabetes that
diabetes mellitus develops during pregnancy. It can lead to pre-
term labour, intra-uterine death, obstructed
labour if not treated
 Women with hyperglycaemia detected in
pregnancy are at higher risk of adverse
pregnancy outcomes including macrosomia,
pre-eclampsia/ hypersensitive disorders in
pregnancy, and shoulder dystocia.
Pre-eclampsia Pre- eclampsia is a serious medical condition
that can lead to pre- term birth, maternal
mortality, stillbirth and neonatal mortality.
Symptoms include high blood pressure,
blurred vision, severe headaches and protein
in urine. While the exact cause is unknown
some women are at an increased risk. Risk
factors among others include; -
 High blood pressure
 Diabetes
 Kidney disease
 Obesity
 Age (younger than 20 and older than
40 women
21
NEED TO DO
 Checking for iron deficiencies
throughout pregnancy
 Counseling on good nutrition (Diverse
diet) & adherence to treatment
 Haemoglobinometer is
Prevention of infections (e.g.
malaria,hook worm, etc.)
 Daily oral iron and folic Acid
supplementation with30mg -60mg of
elemental iron
 Counseling and Testing for gestational
diabetes
 History taking for signs and symptoms
 Counseling on dietary intake
 Counseling on nutrition and healthy
lifestyle
 Refer diagnosed GDM for treatment
and management
 Monitor blood pressure throughout
pregnancy
 Test urine for protein
 Administer anti- hypertensive
agents as appropriate
 Proactive management with
cortical steroids for preterm
pregnancies i f condition is
stable
 Counseling on diet and healthy
li festyle.
NEED TO HAVE
 Availability of Testing Kits
 Availability of drugs, specimen bottles
 Treatment options and effective referral
systems
 Supplementary feeding
 Haemoglobinometer/HemoCue
 Commodities for treatment
 Testing kits and reagents
 Broad range of drugs
 Counseling spaces and skill
 Adequate information for clients
 Guidelines and protocols on GDM
 Commodity management for oral
glucose solution and testing supplies.
 Efficient and effective referral systems
 Medical supplies/ equipment
 Oral and intravenous anti-
hypertensive agents
 Guidelines and protocols on the
management of pre- eclampsia
 Effective and efficient referral
systems
CONSIDER
 Full blood count testing is the
recommended method of
diagnosing anaemia during
pregnancy. However, on site
haemoglobin testing with a
recommended in settings
where full blood count testing
is not available.
 Availability of blood
supplements such as Haem Up,
Inferon etc
 Feasibility and acceptability of
screening strategies
 If Hyperglycaemia is detected at
any time during pregnancy,
should be classified either
gestational diabetes mellitus or
diabetes mellitus in pregnancy.
 In- service training and
regular refresher sessions
on the management of
pre- eclampsia.
 Diagnosis and timely
appropriate management of
risk factors can drastically
reduce the associated
mortality andmorbidity
 Consider low dose aspirin
for pregnant women with
the r isk factors
 22

INTERVENTION NEED TO KNOW NEED TO DO NEED TO HAVE CONSIDER

High blood High blood pressure can lead to preterm  Monitor blood pressure  Adequate number of t rained  In- service training and
pressure labour, placenta abruption, organ damage throughout pregnancy staff regular refresher sessions
and impairment of baby growth i f not on the management of
 Counseling on diet and healthy  Medical supplies/ equipment
controlled. high blood pressure in
li festyle
 Oral and intravenous anti- pregnancy.
 Weight monitoring. hypertensive agents
 Diagnosis and timely
 Guidelines and protocols on the appropriate management
management of high blood of risk factors can
pressure in pregnancy drastically reduce the
 Effective and efficient referral associated mortality and
systems morbidity
Rhesus negative mothers can develop RH  Rhesus Factor test on every  Test kits
 Counselling and
antibodies if they have an RH positive pregnant woman at 1st contact
 Drugs reminder in subsequent
newborn baby causing haemolytic disease of or at any other contact if it was
Pregnancies.
Rh disease the newborn in subsequent pregnancies. Rh not done at 1 st contact  Functional laboratory
disease can lead to jaundice, heart failure,
 Administration of anti D  IEC/ Couple counseling
organ enlargement
immunoglobulin to non-
 Adequate number of t rained
sensitized Rh- negative
staff
pregnant women at 28 and 34
weeks.
 23

SECTION 6: NUTRITION IN PREGNANCY

A balanced energy and protein diet is recommended for pregnant women outcomes resulting in low-birth-weight babies and maternal mortality.
to contribute to positive maternal and neonatal outcomes. Pregnancy Anaemia is associated with iron, folate and vitamin A deficiency, while
requires a healthy diet that includes an adequate intake of energy, protein, calcium deficiency is associated with an increased risk of pre-eclampsia.
vitamins and minerals to meet maternal and foetal needs. A mixed diet is Other nutritional deficiencies have also been cited as contributing to night
therefore essential for positive maternal and neonatal outcomes as it gives blindness, impaired immunity, still births, small for gestational age
energy, builds the body and provides protection from diseases and neonates and preterm births
infections. among others.
Further, under nutrition in
ENERGY women results in reduced
Maize, Cassava PROTEIN
Sugar Sorghum Beans Chicken productivity, increased
Millet Nshima Fish Soya beans
Sweet potatoes Rice Milk Groundnuts susceptibility to infections,
Eggs Inswa
Irish Potatoes Bread
Meat Kapenta slowed recovery from illness,
and a heightened risk of

MIXED DIET

MINERALS VITAMINS adverse pregnancy

FRUITS VEGETABLES
Water Soy milk
Oranges spinach
outcomes. Nutritional
Fish Iodised salt
Milk Water melon
Mangoes Rape deficiencies in
Banana Okra
Meat Whole grains
Green leafy vegetablesa Pawpaw Pumpkin leaves pregnancies have
Guava Chinese cabbage
Pineapple Bondwe
been associated with
poor maternal and
Unfortunately for many pregnant women, dietary intake of vegetables,
neonatal outcomes.
meat, dairy products and fruit is often not sufficient to meet the nutritional
demands of pregnancy. Under nutrition in pregnancy results in conditions Nutrition counselling and related intra-personal support is important in the
that are detrimental to maternal and neonatal wellbeing mainly due to promotion of healthy pregnancies as it contributes to optimizing maternal
protein energy and micronutrient deficiencies. Protein energy and and neonatal health and facilitates a positive pregnancy experience for
micronutrient deficiencies contribute to high disease burden and less pregnant women and adolescents.
optimal maternal

KEY MESSAGE
Pregnancy requires a healthy diet that includes an adequate intake of energy, protein, vitamins and minerals to meet maternal and foetal
needs
 24

BOX 6: NUTRITIONAL INTERVENTIONS

INTERVENTION NEED TO KNOW NEED TO DO NEED TO HAVE CONSIDER

Nutritional  Culturally appropriate healthy eating  Intervention needs to be  Standardized guidance on  Normal gestational
counseling on and exercise interventions to prevent woman centred and delivered in nutrition weight gain occurs after
healthy diet and excessive weight gain in pregnancy. a non- judgmental manner to 20 weeks. However, take
 Knowledge on local nutrition
physical activity ensure appropriate weight into consideration pre
and cultural practices
 A healthy diet contains adequate gain. pregnancy weight and
surrounding nutrition and
energy, protein, vitamins and minerals BMI.
 Improve communications and exercise in pregnancy
that can be obtained through the
support  Gender issues and
consumption of various foods.  Counseling skills
cultural expectations of
 Pregnant women should be
 A healthy lifestyle includes exercise or  Designated time and place for women.
counseled on suitable
physical activity aimed at maintaining a counseling
physical exercise  Local food security
good level of fitness throughout
 Knowledge on nutritional
pregnancy. Women should choose  Demonstrate the type of  Training package for
content of various food i tems
activities with minimal risk of loss of exercises to be conducted by Health Care Providers on
balance and fetal trauma pregnant women such as taking nutrition
walks, and activity of daily
 Pregnancy may be an
living.
optimal time for
 Monthly body weight to behavior change
determine weight gain. interventions among
women with a prevalence
 Counsel pregnant women on of overweight and
mixed diet and general obesity
nutrition
Nutritional  A balanced energy and protein diet is  Establish linkages with  Weighing scales  Capacity building for ANC
education on recommended for pregnant women to nutritional programmes providers on nutrition
 Counseling skills
increasing daily reduce the risk of stillbirths and small within the community. counseling.
energy and for gestational age neonates.  Further establish nutrition  Standardized guidance on  Group- based counseling
protein intake
 Undernourishment is defined by a outreach programmes with nutrition in pregnancy
community health workers  Task shifting
low Body Mass Index. Mid Upper arm
circumference (MUAC) may also be  Strong l inkages with  Complementary balanced
used to identify protein energy  Community sensitisation and nutritionists or nutrition protein and energy
malnutrition in pregnant women and outreach programmes. programmes. supplements
to determine i ts prevalence in the
population. 
Energy and  Counseling on local food stuff  Linkages with nutrition  CBVs
protein dietary knowledge on mixed diet and local rich in Energy and Proteins programmes
supplements available foods  Cooking Demonstrations
 Counseling skills
 25

 Local grown food stuffs

INTERVENTION NEED TO KNOW NEED TO DO NEED TO HAVE CONSIDER

Iron and folic  Iron and folic acid supplementation is  Counseling on folic acid and  Availability of drugs  Intermittent oral iron and
acid recommended to prevent anaemia in iron supplementation. folic acid supplementation
supplements pregnancy once weekly is
 Dispensing recommended if daily iron is
 Daily oral Iron and folic acid not acceptable due to side
supplementation with 30 mg to 60 mg  Folic acid should be effects.
of elementary iron and 400 ug (0. 4 mg) commenced as early as
of folic Acid once weekly is possible to prevent defects  Some women experience
recommended for pregnant women to unpleasant side effects with
prevent maternal anaemia and oral iron
puerperal sepsis, low birth weight supplements, but these
and preterm birth. are not li fe threatening.
Restricting  Lowering of caffeine intake is necessary  Asses the caffeine intake of the  Counselling skills  Gender issues and cultural
caffeine intake to reduce the risk of pregnancy loss and pregnant woman (e.g. tea, norms for and
 Time and space for counseling
low birth weight neonates. coffee, energy drinks, etc. expectations of women
 Caffeine is a stimulant found in tea,  Counseling on side effects of  Task shifting
coffee, soft drinks, kola nuts and energy caffeine
drinks
 26

SECTION 7: MANAGING COMPLICATIONS IN PREGNANCY

Interventions for managing complications in pregnancy are recommended to diagnose, treat, or manage conditions before they become serious.
for the improvement of maternal and neonatal outcomes and contribute
to a positive pregnancy experience for pregnant women and adolescents Additionally, all pregnant women’s bodies undergo substantial changes
Complications in pregnancy are health problems that occur during during pregnancy which are brought about by both hormonal and
pregnancy. They may be caused by conditions women have before mechanical effects. These physiological changes lead to a
pregnancy or conditions women develop during pregnancy. Pregnancy variety of common symptoms – including nausea and
complications are classified as being either obstetric or non-obstetric vomiting, low back and
complications. Obstetric complications are health problems that pelvic pain, heartburn,
associated with the pregnancy. They include bleeding, high blood varicose veins,
pressure, pre-term labour, pre-eclampsia, gestational diabetes constipation and leg
and multiple pregnancies among others. cramps. Generally
symptoms associated
Non-obstetric complications with hormonal changes
are complications in settle as the pregnancy
pregnancy that occur as progresses (usually by second trimester)
a result of infections in and require minor relief, while symptoms of
pregnancy. These are mechanical effects generally worsen as the
infections which could pregnancy progresses and require management.
have occurred before or Physiological symptoms
during the pregnancy and can be managed by a
have serious consequence for variety of non-
a woman, her pregnancy and the baby. pharmacological and
Infections such as, malaria, HIV, UTIs, syphilis, TB have pharmacological options.
been associated with increase in complications such as bleeding, still
birth, pre-term labour and anaemia. Effective and high quality
care for the prevention and
Early identification and treatment / management of these complications management of complications in pregnancy are
is recommended as if left untreated or not managed can lead to negative likely to significantly reduce maternal and neonatal morbidity and
maternal and neonatal outcomes including mortality. Getting early and mortality.
regular ANC can help reduce the risk for problems by enabling health care
providers
KEY MESSAGE
Early diagnosis and referral of complications in pregnancy is important for reduction of maternal and neonatal morbidity and mortality.
 27

BOX 7A: INTRVENTIONS FOR MANAGING PHYSIOLOGICAL SYMPTOMS IN PREGNANCY

INTERVENTION NEED TO KNOW NEED TO DO NEED TO HAVE CONSIDER

Many pregnant women experience nausea and
vomiting in the first trimester of pregnancy.
Nausea and Vomiting However some women may experience nausea
and vomiting beyond 20 weeks of gestation.
 Counseling on how to manage nausea
and vomiting using non-
pharmacological methods.
 Inform women that symptoms of
nausea and vomiting often resolve in
the second half of pregnancy
 Knowledge on non-
pharmacological methods that
are unlikely to have harmful
effects on mother and baby
(e.g. Ginger, chamomile, etc.)
 Time to counsel
Pharmacological treatments for
nausea and vomiting should be
reserved for those pregnant women
experiencing distressing symptoms
that are not relieved by non-
pharmacological options under the
supervision of a doctor.

 Counseling skills,
 Counseling and advise on diet and  Time to counsel Antacid preparations can be used for
Heartburn is a common problem in pregnancy. lifestyle to relive or prevent women with symptoms that are not
Heart Burn It is often worse after eating and lying down. It heartburn.  Counseling skills relieved by lifestyle and diet
can be self-treated with over the counter modifications, under the supervision
antacids. of a doctor.
 Leg cramps often occur at night and can  Counseling on how to relieve leg  Magnesium, calcium or non- Magnesium, calcium or non-
Leg Cramps be very painful, affecting sleep and daily cramps pharmacological treatment pharmacological treatment options
activities. options can be based on a woman’s
 Dispense magnesium and calcium as preferences and available options.
 Magnesium, calcium and non-  Time to counsel
appropriate
pharmacological therapies can be used
 Counseling skills,
for the relief of leg cramps in pregnancy.
 Counseling on suitable physical  Time to counsel Though exercise may be helpful in
Lower Back and Regular exercise throughout pregnancy is exercise relieving lower back pain, it could
Pelvic Pain recommended to prevent lower back and pelvic  Counseling skills exacerbate pelvic pain associated
pain.  Demonstrate the type of exercises to with symphysis pubis dysfunction
be conducted by pregnant women and is not recommended for this
condition.
Treatment for pelvic pain is based on
severity. Mild pain will require rest,
while severe cases mobility aids and
strong analgesics

Constipation in pregnancy can be managed by
Constipation consuming foods that are high in fibre and
drinking plenty of water
Varicose Veins and Varicose veins usually occur in the legs, but can
Oedema also occur in the vulva ad rectum, and may be
associated with pain, night cramps, aching and
heaviness and worsen with long periods of
standing.
 Counseling and dietary advise
 Promote intake of dietary fibre (found
in vegetables, nuts, fruits and whole
grains) and plenty of water
 Inform women that symptoms may
worsen as the pregnancy progresses.
 Counseling and advise on rest and
pain management
 Time to counsel
 Counseling skills
 Time to counsel
 Counseling skills
Mild laxatives may be considered for
use in situations where dietary
modification or fibre
supplementation has not been
successful in relieving constipation.
Non pharmacological options such
as compression stockings, leg
elevation and water immersion can
be recommended for management
of varicose veins and oedema

BOX 7B: INTRVENTIONS FOR MANAGING OBSTETRIC COMPLICATIONS IN PREGNANCY
INTERVENTION NEED TO KNOW
Bleeding Bleeding in pregnancy can happen anytime
from conception to birth. However the timing
and severity of bleeding could be indicative of
a problem, hence all bleeding must be treated
as serious and immediately attended to.
High Blood Pressure High blood pressure in pregnancy can result in
reduced blood flow to the placenta which can
slow down the growth of fetus and places the
mother at great risk of pre-term labour,
placenta abruption, organ damage and pre-
eclampsia if not controlled. It is one of the
major causes of maternal mortality, still birth
and neonatal mortality.
Preterm labour Pre-term labour is labour that occurs after 20
weeks but before 37 weeks of pregnancy.
Preterm labour can result in premature birth.
And infants born before 37 weeks are at
increased risk for health problems. The earlier
premature birth occurs the higher the health
risks for the baby.
Multiple pregnancies Multiple pregnancies often have a higher risk
for complications. Common problems include:-
 Preterm labour and birth
 High blood pressure
 Gestational diabetes
 Anaemia
 Birth defects.
28
NEED TO DO
 Depending on gestational age, check
foetal heart rate and ask about foetal
movements.
 Counseling on bleeding in pregnancy.
 Examine and determine severity of
bleeding
 Refer accordingly
 Monitoring of BP throughout
pregnancy
 Counseling and advise on diet and
healthy lifestyle to manage BP
 Dispensing of medication
 Counseling on the importance of ANC
attendance
 Early diagnosis and treatment/
management of risk factors
 Take previous pregnancy history
 Counseling and advise on diet and
healthy lifestyle
 Counseling on the importance of ANC
attendance and signs of pre-term
labour.
 Asses for signs and symptoms of
infection
 Evaluate whether preterm birth is
imminent or can be delayed
 Counseling and advise on diet and
healthy lifestyle
 Monitoring of BP throughout
pregnancy
 Management of complications in
multiple pregnancies
 Refer accordingly
NEED TO HAVE
 Skilled/ trained staff
 Medical supplies/equipment
 Guidelines and protocol for
managing bleeding in
pregnancy
 Effective and efficient referral
systems
 Skilled/trained staff
 Medical supplies/equipment
 Guidelines and protocol for
managing high blood pressure
in pregnancy
 Blood pressure medication
 Skilled/trained staff
 Medical supplies/equipment
 Guidelines and protocol for
managing pre-term labour
 Effective and efficient referral
systems
 Skilled/ trained staff
 Medical supplies/equipment
 Guidelines and protocol for
managing multiple pregnancies
 Effective and efficient referral
systems
CONSIDER
 Virginal bleeding during
pregnancy does not always
mean that a miscarriage. will
happen or is happening.
 Bleeding in the first trimester
may not be a sign of problems
 Bleeding in the 2nd and 3rd
trimester can be a possible sign
of problems.
 Continuation of monitoring,
management and control for
women who have high blood
pressure before pregnancy
 High blood pressure that
develops in pregnancy typically
occurs during the second half
of pregnancy and goes away
after delivery.
 You might not be able to
prevent preterm labour but a
healthy lifestyle can go a long
way in promoting a health full-
term pregnancy
 Appropriate management of
imminent pre-term labour is
imperative to reduce the
associated risks to the baby
and improves the outcomes
and survival of pre-term
babies.
All multiple pregnancies must be
treated as high risk and closely
monitored through pregnancy.
 29

INTERVENTION NEED TO KNOW NEED TO DO NEED TO HAVE CONSIDER

Gestational diabetes  Gestational diabetes mellitus is diabetes
mellitus that develops during pregnancy. It can
lead to pre-term labour, intra-uterine
death, obstructed labour if not treated
 Women with hyperglycaemia detected in
pregnancy are at higher risk of adverse
pregnancy outcomes including
macrosomia, pre-eclampsia/
hypersensitive disorders in pregnancy,
and shoulder dystocia.
 Counseling and testing for gestational
diabetes
 History taking for signs and symptoms
 Counseling on dietary intake
 Counseling on nutrition and healthy
lifestyle
 Refer accordingly
 Testing kits and reagents  Feasibility and acceptability of
screening strategies
 Broad range of drugs
 If Hyperglycaemia is detected
 Counseling spaces and skill
at any time during pregnancy,
 Adequate information for should be classified either
clients gestational diabetes mellitus or
diabetes mellitus in pregnancy.
 Guidelines and protocols on
GDM
 Commodity management for
oral glucose solution and
testing supplies.
 Efficient and effective referral
systems
 30
BOX 7C: INTRVENTIONS FOR MANAGING NON OBSTETRIC COMPLICATIONS IN PREGNANCY
INTERVENTION NEED TO KNOW NEED TO DO
Anaemia  Anemia in pregnancy is  Counseling and advise on diet and
associated with iron deficiency. healthy lifestyle to improve Hb
levels
 Pregnant women with anaemia are at  Iron and folic acid supplementation
risk of pre-term labour, low birth weight,
spontaneous abortion, IUFD, PPH etc.  Monitoring of Hb levels
 Treatment
HIV  Management of HIV in pregnancy is
 Counseling and advise on diet and
aimed at reducing mother to child
healthy lifestyle to maintain good
transmission.
health
 ART is recommended for all HIV positive  Dispensing of medication
pregnant women regardless of CD4
 Counseling on the importance
count or viral load in order to reduce
of ANC attendance
perinatal transmission.
 ART and PMTCT counseling
 Retest all HIV negative pregnant
women in the 3rd trimester (for
PMTCT
Urinary Tract UTIs are common in pregnancy and are  Urine for microscopy
Infections associated with adverse pregnancy
 Counseling /IEC - hygiene need to
outcomes including preterm birth and
complete treatment
small for gestational age newborns.
 counseling on good hygiene
Syphilis Syphilis in pregnancy can cause  Skilled/ t rained staff
miscarriage, stillbirth and mental and
 Medical supplies/ equipment
physical problems. Syphilis
 Guidelines and protocols for
treatment of syphilis in
pregnancy
 Linkage to treatment
Facilities/ commodities
testing
 Refer accordingly
NEED TO HAVE CONSIDER
 Skilled/ trained staff  Daily oral iron and folic Acid
supplementation with30mg -60mg of
 Medical
elemental iron is recommended for
supplies/ equipment
pregnant women to prevent maternal
anaemia.
 Guidelines and protocol
for managing Anaemia in  Women with severe anaemia require
pregnancy further treatment hence routine
testing for Hb must be done even if
 Effective and efficient iron and folic acid supplementation is
referral systems being provided
 Skilled/ t rained staff  Continuation of monitoring

Medical  Task shifting,
supplies/ equipment
 Guidelines and protocols
for ART and PMTCT
 Linkage to treatment
 Facilities/ commodities
for testing
 Specimen bottles Antibiotic prophylaxis is only
recommended for recurrent UTIs
 Medical supplies
 Laboratory Forms
 Antibiotics
 Trained staff
 Skilled/ t rained staff Antibiotics approved by an
obstetrician can be u sed to prevent
 Medical
damage to the fetus
supplies/ equipment
 Guidelines and protocols
for syphilis
 Linkage to treatment
 Facilities/ commodities
for for testing
 31

INTERVENTION NEED TO KNOW NEED TO DO NEED TO HAVE CONSIDER

Tuberculosis TB increases the risk of pre-term birth,
perinatal death and other pregnancy
complications. Initiating treatment early is
associated with better maternal and infant
outcomes than late initiation.
 Systematic screening for TB
 Initiate early treatment
 Counseling and advise on diet and
healthy lifestyle
 Counseling on TB drug adherence
 Facilities/ commodities
for testing
 Time to counsel
 Counseling skills
 Guidelines and protocols
for TB treatment in
pregnancy
 Consider TB clinics tack pregnancy as a
Colum in the register to allow for
better estimation of the local burden
of TB in pregnancy
 Pregnant women living with HIV
should be periodical screened for
active TB

 Linkage to treatment
 32

SECTION 8: MONITORING AND EVALUATION OF ANC

Rigorous monitoring and evaluation (M&E) ensure the highest possible positive pregnancy experience for all pregnant women and adolescents
quality of ANC. A facility level M&E system must therefore be put in place while the external M&E should be conducted for rigorous evaluation of the
in order to audit, monitor and evaluate ANC services in line with these integrated ANC package to ensure effectiveness and economic efficiency.
guidelines and the integrated ANC package. The aim of the M&E system is
This can be achieved by using three methods; 1: Collecting and collating
to ensure that services delivered at the facility level are of quality, and are
routine ANC service statistics; 2. Documenting client information; and 3.
in line with facilitating a positive pregnancy experience for all pregnant
Periodic internal and external evaluation. The routine data collected will
women and adolescents.
be used to monitor implementation of the eight (8) areas of scaling up
By focusing on the ANC. Client
integrated ANC information is
package essential for
components of documenting the
health number of clients
information, seen, demographic
medical information,
assessment and number of
intra-personal contacts, services
support received and
recommended for referrals made.
each contact, the Periodic evaluation
M&E system must should comprise of
be tailored client and provider
towards collecting interviews,
and analysing data surveys, and
based on observations.
indicators that define safeguarding and prioritising the health and
wellbeing of the pregnant person and growing foetus. The facility must therefore define procedures for ANC data management,
operations research,
The system must therefore sentinel surveillance and
comprise of a robust KEY MESSAGE feedback mechanisms to
internal and external M&E A robust monitoring and evaluation system for the implementation of the integrated ANC inform programming, thus
plan. Internal M&E should package is recommended ensuring effective and
be integrated into each of efficient implementation of
the eight (8) areas of ANC the guidelines and the
intervention and linked to Integrated ANC Package.
the intended outcome of a
 33

BOX 8: INTERVENTIONS FOR MONITORING AND EVALUATION OF ANC

INTERVENTIONS NEED TO KNOW NEED TO DO NEED TO HAVE CONSIDER

The purpose of data  Regular data collection and  ANC registers and data collection  Training/ reorienting all staff
collection and management is aggregation (daily, weekly, monthly, tools on key health information
Data Management to provide information that quarterly, annually) data collection tools and
 Monthly report forms
can be analysed and used procedures.
 Timely reporting (weekly, monthly,
appropriately to provide  Data management skills
quarterly, etc.)  Training/ orientation on
feedback and improve service
 HMIS indicators manual HMIS indicators and their
provision and outcomes.  Analyze data and use i t for decision
related calculations
making and quality of care  Health system procedure manual
improvements  Periodic data management
 Procedures and guidelines for using
training and refresher
 Conduct regular data audits and hold data for decision making
courses
data review meetings
 Safe motherhood activity sheet
 Analysis of patterns or problems in
services using statistics

Operations research can be  Client based exit interviews,  ANC registers and activity sheets
Operations undertaken to assist in observations and questionnaires Research findings can be used
 Clinical incident reviews and
Research management of ANC services. The routinely to inform clinical and
 Provider based surveys learning
findings can be used to solve management decisions and improve
problems and influence decisions  Facility level case reviews,  data management skills quality of care.
around ANC service provision. observations and maternal death
 monthly HIA 2
audits
 Use data for performance review
 Periodic special studies (client
and systems strengthening
satisfaction, proximity of women to
facility, cost, impact, etc.)  scorecard indicators
 staffing levels
Supervision Facility managers/ staff  Observation of counseling and clinical  Data checklist
 Creating a supportive work
supervisors need to provide services to assess quality of
 Supervision schedule environment for the delivery
supervision in routine interactions with pregnant women.
of ANC services
monitoring and service  Team building and people
provision, and give suitable  Supervise data collection and ensure management skills of health care  Updating staff establishment for
recommendations or data completeness. providers midwives to ensure all facilities
guidance where appropriate have adequate numbers’
 Monitor mid wife workload and burn out  Defined roles and responsibilities
in order to maintain high
and lines of accountability for  Good managerial and clinical
standards of care.
 Facility level spot checks and feedback reporting leadership improves performance
by showing direction and inspiring
 At least two annual meetings with
subordinates and creating an
stakeholders (e.g. Community,
environment of support for staff in
service users, partners) to review
undertaking continuous quality
its performance, identify problems
improvement.
and make recommendations for
joint actions to improve quality.

INTERVENTIONS NEED TO KNOW
A well function logistics and
Supply Chain supply chain system is
necessary for the provision
of quality services as it
ensures regular supply of
equipment and consumables
34
NEED TO DO NEED TO HAVE CONSIDER
 Inventory of data management tools  Strategies to improve supply chain
management according to local Assigning an officer for the
requirements management of all data collection
tool.
 Regular monitoring of stock levels
and strengthening coordination
and follow up for medicines and
supplies required of ANC
 Stock control cards for data
management tools
 Functional logistics system to
ensure regular supply of equipment
and consumables.
 35

ANNEX 1: INTEGRATED ANC PACKAGE

CONTACT ACTIVITY BY HEALTH PROVIDER BY LEVEL PHASING IF ANY
Health information: Counseling on birth plan and preparedness, Counseling on diet
and exercise, counseling on alcohol, tobacco and substance use, restricting caffeine
intake, HIV testing and counseling (PITC), counseling on balanced energy and
All health providers All levels No phasing
protein supplementation, Labour companion, counseling on and encouraging
sleeping under insecticide treated bednets and counseling on danger signs (If
identified refer as appropriate)
Medical assessment and management: Maternal weight/ height measurement,
Contact 1
Blood pressure measurement, Clinical estimate of gestational age, syphilis Medical licentiates, Clinical No phasing ( if
(up to 12
screening, hepatitis B, urinary test for proteinuria, HIV testing, TB screening, Blood Officers, Doctors, nurses and Health Post, blood sugar is
weeks)
Hb measurement, blood group typing and Rh factor, blood sugar. Tetanus toxoid midwives. (CHAs, SMAGs, Health positive this can
vaccination. Iron/folic acid dispensing, calcium supplements, gestational diabetes EHTs will give advice related center, be repeated
mellitus, Asymptomatic bacteriuria (ASB), management of pain during labour. Pre- to heart burn, leg cramps, hospitals during other
exposure prophylaxis for HIV prevention, treatment for nausea and vomiting, varicose veins) contacts).
heartburn, low back ache and pelvic pain, leg cramps, constipation, varicose veins,
Intra-personal support: Clinical enquiry and referral of SGBV including Intimate
All health providers All levels No phasing
Partner Violence(IPV), referral to other services
Health information: Counseling on birth plan and preparedness, Counseling on diet
and exercise, counseling on alcohol, tobacco and substance use, HIV testing, safer
sex and counseling (PITC), counseling on balanced energy and protein
All health providers All levels No phasing
supplementation, Labour companion, counseling on and encouraging sleeping
under insecticide treated bednets and counseling on danger signs (If identified
refer as appropriate)
Medical licentiate, Clinical
Contact 2 Medical assessment and management: Maternal weight/ height measurement,
Officer, Doctor, nurses and
(13-20 Blood pressure measurement, Clinical estimate of gestational age, urinary test for
midwives (however, Nurses Health Post,
weeks) proteinuria, TB screening, Blood Hb measurement, tetanus toxoid vaccination.
will not prescribe Antibiotics Health
Iron/folic acid dispensing, Asymptomatic bacteriuria (ASB), management of pain No phasing
for ASB). center,
during labour. Ultrasound (18-20 weeks). Pre-exposure prophylaxis for HIV
CHAs, SMAGs, EHTs will give Hospitals
prevention, treatment for nausea and vomiting, heartburn, low back ache and
advice related to heart
pelvic pain, leg cramps, constipation, varicose veins
burn, leg cramps, varicose
veins
Health post,
Intra-personal Support: Home visits/ outreach, referral to other services Midwife, nurse, CHA No phasing
Health Centre
 36

CONTACT ACTIVITY BY HEALTH PROVIDER BY LEVEL PHASING IF ANY

Health information: Counseling on birth plan and preparedness, Counseling on diet
and exercise, counseling on alcohol, tobacco and substance use, HIV testing, safe
sex and counseling (PITC), counseling on balanced energy and protein
All health providers All levels No phasing
supplementation, Labour companion, counseling on and encouraging sleeping
under insecticide treated bednets and counseling on danger signs (if identified
referimmediately) counseling for breastfeeding and postpartum family planning
ML, CO, Doctor, nurses and
Medical assessment and management: Maternal weight/ height measurement, midwives (however, No phasing
Contact 3 Health Post
Blood pressure measurement, Clinical estimate of gestational age, Fetal Heart Rate nurses/midwives will not however,
(21-26 (except
(FHR) urinary test for proteinuria, TB screening, Blood Hb measurement, tetanus prescribe Antibiotics for ASB). Ultrasound scan
weeks) ultrasound),
toxoid vaccination. Iron/folic acid dispensing, Malaria prevention (IPTp), Antibiotics CHAs, SMAGs, EHTs will give facilities can be
Health
for asymptomatic bacteriuria (ASB), Ultrasound scan, management of pain during advice related to heart burn, phased country-
center,
labour. Pre-exposure prophylaxis for HIV prevention, treatment for heartburn, low leg cramps, varicose veins, wide. (see note
hospitals
back ache and pelvic pain, leg cramps, constipation, varicose veins. Ultrasonographer for below).
Ultrasound only.
Intra-personal Support: Home visits/ outreach, Clinical enquiry and referral of
Intimate Partner Violence (IPV)/Sexual Gender Based Violence (SGBV), referral for All health providers All levels No phasing
emergencies, referral to other services
Health information: Counseling on birth plan and preparedness, Counseling on diet
and exercise, counseling on alcohol, tobacco and substance use, HIV testing, safe
sex and counseling (PITC), counseling on balanced energy and protein
All health providers All levels No phasing
supplementation, Labour companion, counseling on and encouraging sleeping
under insecticide treated bednets and counseling on danger signs (if identified
refer immediately), counseling for breastfeeding and postpartum family planning
Medical assessment and management: Maternal weight/ height measurement,
Contact 4
Blood pressure measurement, Clinical estimate of gestational age, Fetal Heart Rate
(27-31 Health Post, No phasing.
(FHR) urinary test for proteinuria, TB screening, Blood Hb measurement, tetanus Medical Licentiate, Clinical
weeks) Health (Ultrasound can
toxoid vaccination. Iron/folic acid dispensing, Malaria prevention (IPTp), Antibiotics Officer, Doctor, Midwife,
center, be done if not
for asymptomatic bacteriuria (ASB), Ultrasound scan (second scan at 28 weeks), Nurse
Hospitals done earlier)
management of pain during labour. Pre-exposure prophylaxis for HIV prevention,
low back ache and pelvic pain, leg cramps, constipation, varicose veins
Intra-personal Support: Home visits/ outreach, Clinical enquiry and referral of
Intimate Partner Violence (IPV)/Sexual Gender Based Violence (SGBV), referrals for All health providers All levels No phasing
emergencies, referral to other services
 37

CONTACT ACTIVITY BY HEALTH PROVIDER BY LEVEL PHASING IF ANY

Health information: Counseling on birth plan and preparedness, Counseling on diet

and exercise, counseling on alcohol, tobacco and substance use, HIV testing, safe
sex and counseling (PITC), counseling on balanced energy and protein
All health providers All levels No phasing
supplementation, Labour companion, counseling on and encouraging sleeping
under treated bednets and counseling on danger signs (if identified refer
immediately), counseling for breastfeeding and postpartum family planning
Contact 5 Medical assessment and management: Maternal weight/ height measurement,
(30-33 Blood pressure measurement, Clinical estimate of gestational age, Fetal Heart Rate
weeks) Health Post,
(FHR) urinary test for proteinuria, TB screening, Blood Hb measurement, tetanus Medical licentiate, Clinical
Health
toxoid vaccination. Iron/folic acid dispensing, Malaria prevention (IPTp), Antibiotics Officer, Doctor, Midwife, No phasing
center,
for asymptomatic bacteriuria (ASB), management of pain during labour. Pre- Nurse
Hospitals
exposure prophylaxis for HIV prevention, low back ache and pelvic pain, leg
cramps, constipation, varicose veins,
Intra-personal Support: Home visits/ outreach, Clinical enquiry and referral of IPV,
All health providers All levels No phasing
referrals for emergencies, referral to other services
Health information: Counseling on birth plan and preparedness, Counseling on diet
and exercise, counseling on alcohol, tobacco and substance use, HIV testing, safe
sex and counseling (PITC), counseling on (Mixed diet) balanced energy and protein
All health providers All levels No phasing
supplementation, Labour companion, counseling on and encouraging sleeping
under treated bednets and counseling on danger signs (if identified refer
immediately), counseling for breastfeeding and postpartum family planning
Medical assessment and management: Maternal weight/ height measurement,
Contact 6 Blood pressure measurement, Clinical estimate of gestational age, Abdominal
(34-35 palpation to detect breech, Fetal Heart Rate (FHR) urinary test for proteinuria, TB Health Post,
Medical licentiate, Clinical
weeks) screening, Blood Hb measurement, tetanus toxoid vaccination. Iron/folic acid Health
Officer, Doctor, Midwife, No phasing
dispensing, Malaria prevention (IPTp), Antibiotics for asymptomatic bacteriuria center,
Nurse
(ASB), management of pain during labour. Pre-exposure prophylaxis for HIV Hospitals
prevention, low back ache and pelvic pain, leg cramps, constipation, varicose veins,

Intra-personal Support: Home visits/ outreach, Clinical enquiry and referral of IPV, All health providers All levels No phasing
referral for emergencies, referral to other services
 38

CONTACT ACTIVITY BY HEALTH PROVIDER BY LEVEL PHASING IF ANY

Health information: Counseling on birth plan and preparedness, Counseling on diet

and exercise, counseling on alcohol, tobacco and substance use, safe sex and
counseling (PITC), counseling on balanced energy and protein supplementation,
All health providers All levels No phasing
Labour companion, counseling on and encouraging sleeping under treated bednets
and counseling on danger signs (if identified refer immediately), counseling for
breastfeeding and postpartum family planning
Contact 7 Medical assessment and management: Maternal weight/ height measurement,
(36-37 Blood pressure measurement, Clinical estimate of gestational age, Abdominal Health Post,
weeks) Medical Licentiate, Clinical
palpation to detect breech, Fetal Heart Rate (FHR) urinary test for proteinuria, Health
Officer, Doctor, Midwife, No phasing
Blood Hb measurement, Iron/folic acid dispensing, management of pain during center,
Nurse
labour. Pre-exposure prophylaxis for HIV prevention, low back ache and pelvic pain, Hospitals
leg cramps, constipation, varicose veins,

Intra-personal Support: Home visits/ outreach, Clinical enquiry and referral of

All health providers All levels No phasing
SGBV and IPV, referrals for emergencies, referral to other services

Health information: Counseling on birth plan and preparedness, Counseling on diet

and exercise, counseling on alcohol, tobacco and substance use, safe sex and
counseling (PITC), counseling on balanced energy and protein supplementation,
All health providers All levels No phasing
Labour companion, counseling on and encouraging sleeping under treated bednets
and counseling on danger signs (if identified refer immediately), counseling for
breastfeeding and postpartum family planning
Contact 8
(38-40 Medical assessment and management: Maternal weight/ height measurement,
weeks) Blood pressure measurement, Clinical estimate of gestational age, abdominal Health Post,
Medical Licentiate, Clinical
palpation to detect breech, Fetal Heart Rate (FHR) urinary test for proteinuria, Health
Officer, Doctor, Midwife, No phasing
Blood Hb measurement, Iron/folic acid dispensing, management of pain during center,
Nurse
labour. Pre-exposure prophylaxis for HIV prevention, low back ache and pelvic pain, Hospitals
leg cramps, constipation, varicose veins,
Intra-personal Support: Home visits/ outreach, Clinical enquiry and referral of
All health providers All levels No phasing
SGBV and IPV, referrals for emergencies, referral to other services

KEY : HEALTH PROVIDERS: CHA – Community health assistant; CO - Clinical Officer; EHT – Environmental health technician; ML – medical licentiate;
FACILITIES: HP – health post; HC – health centre
 39

ANNEX 2: EXPERTS INVOLVED IN THE PREPARATION OF THIS GUIDELINE

NO NAME ORGANISATION DESIGNATION

1. Ms. Esther Banda Eastern Province PHO MOH Acting PNO MNCH

2. Mr. Stanley Banda Ministry of Health (HQ) Health Systems Strengthening

3. Ms. Martha Chabinga Ministry of Health (Central Province) Registered Midwife

4. Ms. Wajilovia Chilambo Ministry of Health – NMEC MFO

5. Ms. Ms. Caren Chizuni Ministry of Health (HQ) Chief Safe Motherhood Officer

6. Ms. Bertha Kaluba Lusaka District Health Office Senior Nursing Officer

7. Ms. Purity Linyaku Ministry of Health (HQ) SHPO

8. Dr. Victor Liyuma Chipata Level 1 Hospital Medical Superintendent

9. Ms. Grace Malitino Sikazwe. Kabwe Health Centre Nursing Sister

10. Dr. Sarai Bvulani Malumo World Health Organisation National Programme Officer/ MPS

11. Ms. Mable Mfula Ministry of Health (HQ) Public Health Nurse

12. Ms. Jenipher Mijere UNFPA Programme Officer

13. Dr. Angel Mwiche Ministry of Health (HQ) Assistant Director – MNCH

14. Dr. Gideons Mwiche Women and Newborn Hospital – University Teaching Hospital Senior Registrar/OBGY

15. Dr. Christopher Ng’andwe Churches Health Association of Zambia Project Director

16. Ms. Dorothy Sikazwe Ministry of Health (HQ) Chief Nutrition Officer
17. Dr. Malunga Syacumpi Lumia Consultancy Consultant

18. Dr. Muriel Syacumpi WHO/Ministry of Health Consultant

19. Dr. Christopher Mlelemba CRHE/MOH Center for Reproductive Health and Education Programme Director

20. Mr. Richard Tembo Ministry of Health- Chibombo District Health Office District Health Information Officer