Overview of Global

Recommendations for
Antenatal Care for a
Positive Pregnancy
Experience
Module 1
Version 2
 Learning objectives
By the end of this module, learners will be able to:
• Recognize pregnant women in the community
• Assess gestational age in pregnant women*
• Educate pregnant women about the benefits of antenatal
care (ANC)
• Describe recommended timings for ANC visits
• Enumerate the nutritional recommendations for quality ANC

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

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 Exercise 1: How do
you know that a 1. Complaints

woman is pregnant?
(symptoms)

2. Examination
findings
(signs)

3. Test results

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

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

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

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

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

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 Benefits of ANC

Photo by Emmanuel Otolorin, Jhpiego

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 Birth planning and complication readiness

Focused
Skilled attendance at birth

ANC is an
Malaria prevention and treatment

Tetanus prevention

entry point Sexually transmitted infection prevention and treatment

to other Maternal and infant nutrition

critical Prevention of mother-to-child-transmission of HIV

services Tuberculosis detection and treatment

Family planning services

Child health

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

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 Some factors causing late ANC attendance and
delivery outside health facilities
Late ANC
attendance
Can you think of any
other reasons?
and delivery
outside health
Traditional beliefs and facility
practices

Lack of decision-making Negative attitudes

power of health providers

Long waiting time at public

Financial difficulties
facilities

Long
Myths and misconceptionsdistance to
service site

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 Therefore...
We need to make ANC attendance a
pleasurable, rewarding, assuring, empathetic
experience for ALL clients

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

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

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 New World Health
Organization (WHO)
recommendations for ANC
2016

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

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 A. Nutritional interventions

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 Nutrition: All ANC settings

Daily oral iron and folic acid (IFA):

• 30 to 60 mg of elemental iron and
• 400 μg (0.4 mg) of folic acid

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 Nutrition: Context-specific

Women intolerant of IFA side effects:

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

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 Nutrition: Context-specific, cont.

Areas where vitamin A deficiency is a

severe public health problem:
• Vitamin A supplementation for pregnant
women to prevent night blindness.
• Not recommended to improve maternal
and perinatal outcomes
• Dose: daily up to 10,000 IU or weekly up
to 25,000 IU vitamin A

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 B. Maternal and fetal assessment

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

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 Considerations

Ultrasound is recommended early

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

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

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 Maternal/fetal assessment: Context-specific

Where tuberculosis prevalence is high

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

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

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 C. Preventive measures

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 Preventive measures: All ANC settings

A 7-day antibiotic regimen is

recommended for all
pregnant women with
asymptomatic bacteriuria.

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

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

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 D. Interventions for common physiological
symptoms

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 Symptom Recommendation
Nausea and Ginger, chamomile, vitamin B6, and/or acupuncture for relief of nausea in early
vomiting pregnancy.
Advice on diet and lifestyle to prevent and relieve heartburn in pregnancy.
Heartburn Antacid preparations for women with troublesome symptoms not relieved by
lifestyle changes.
Magnesium, calcium, or nonpharmacological treatment options for relief of leg
Leg cramps
cramps in pregnancy.
Regular exercise throughout pregnancy to prevent low back and pelvic pain.
Low back/pelvic
pain Different treatment options can be used, such as physiotherapy, support belts,
and acupuncture.
Fiber supplements to relieve constipation in pregnancy if the condition fails to
Constipation
respond to dietary modification.
Varicose veins Nonpharmacological options, such as compression stockings, leg elevation, and
and edema water immersion, for management of varicose veins and edema in pregnancy.
Note: In general, these interventions should be adopted and adapted, based on women’s preferences
and available options.

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

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 Health systems: All ANC settings

A minimum of EIGHT ANC

contacts are recommended
to reduce perinatal mortality
and improve women’s
experience of care.

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 ANC contacts schedule

• Previously recommended four visits not enough:

• Inadequate contact with health care providers
• Less maternal satisfaction with care
• More perinatal deaths
• Minimum EIGHT contacts improves quality:
• Focus on timely detection of risk factors and
complications
• More contact between pregnant women and
knowledgeable, respectful, supportive providers more
likely to lead to positive pregnancy experience

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 Contact versus visit

• The new WHO guideline uses the term “contact” to imply an

active connection between a pregnant woman and a health
care provider.
• “Contact” can take place at the facility or at community
level.
• “Contact” helps to facilitate context-specific
recommendations (e.g., malaria, tuberculosis interventions) or
health system interventions (e.g., task-shifting).

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 Considerations in areas with moderate to high
malaria transmission
ANC contact schedule IPTp with SP schedule Other interventions and considerations
 In areas where IPTp with SP is policy, a contact should be made as early in the second trimester as
Contact 1: 13–16 weeks   IPTp with SP dose 1 possible to administer SP (see considerations below).
 Register pregnant women.
 Provide insecticide-treated bed nets or long-lasting insecticidal nets and counsel on their use.
Contact 2: 20 weeks IPTp with SP dose 2  Screen for HIV.
 If not administering IPTp with SP, administer 30 to 60 mg of elemental iron and 400 μg (0.4 mg) of folic
acid and prescribe same for daily intake. These supplements should be given as early as possible in
pregnancy and continue throughout pregnancy. If administering IPTp with SP, instruct woman to wait 7
Contact 3: 26 weeks IPTp with SP dose 3 days before she resumes taking folic acid.
 Counsel on prompt diagnosis and effective treatment/case management of malaria during pregnancy.

Contact 4: 30 weeks IPTp with SP dose 4 Considerations for administering IPTp with SP
 Do not administer IPTp with SP before week 13 (the beginning of the second trimester) of pregnancy.
 SP can be safely administered from the beginning of the second trimester until the time of delivery.
Contact 5: 34 weeks  One full dose of IPTp with SP consists of 1,500 mg/75 mg SP (i.e., three tablets of 500 mg/25 mg SP). When
providing IPTp with SP, directly observe the woman swallowing the tablets.
IPTp with SP dose 5  Administer the first IPTp with SP dose as early as possible in the second trimester so the woman fully
Contact 6: 36 weeks benefits from its protective capacity in this critical period of pregnancy.
 Administer the following doses of IPTp with SP starting from the scheduled contact at 20 weeks, observing at
least 4-week intervals between SP doses.
 Pregnant women on co-trimoxazole should not receive IPTp with SP due to an increased risk of adverse
Contact 7: 38 weeks events when both drugs are given in parallel. A pregnant woman on co-trimoxazole should be referred to ANC
IPTp with SP dose 6
  for further screening and management.
Contact 8: 40 weeks

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 Recommended ANC contacts and IPTp doses

IPTp1 IPTp2 IPTp3 IPTp4 IPTp5 IPTp6

1st
2nd 3rd 4th 5th 6th 7th 8th
13–
20 26 30 34 36 38 40
16
wks wks wks wks wks wks wks
wks

Photo by Emmanuel
Otolorin, Jhpiego

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 ANC coverage in Transforming Intermittent
Preventive Treatment for Optimal Pregnancy project
countries
100% 91%
90% 88%
82%
Percentage of women aged

80%
70% 66%
15–49 years

60% 51% 51%

48% 49%
50%
40%
30%
20%
10%
0%
Democratic Republic of Madagascar (2012–13) Mozambique (2011) Nigeria (2016–2017)
the Congo (2013–14)

At least 1 ANC contact At least 4 ANC contacts

Source: UNICEF 2018

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Conclusion

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 Additional slides for health care
workers
Estimation of gestational age

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

History Exam Scan

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 Client’s history

Parameter Comment Margin of error

 Nägele rule: To determine expected date of delivery
(EDD), add 9 months and 7 days to the first day of
Sure of LNMP LNMP. For example, if LNMP = January 2, 2017, then ± 2 weeks
EDD = October 9, 2017.
 Use pregnancy wheel to determine gestational age.
“Quickening” (i.e., Usually first noticed between 16 and 20 weeks
± 2–4 weeks
baby’s movements) (primipara: 18–20; multipara: 16–18)

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 Exercise 3: Calculating gestational age and EDD
Using Nägele rule
LNMP =
Add 9 months

Calculate EDD and gestational

September 21,
= June 21, 2017
2016

A
d
d
age for the following LNMPs:
7
d 1. February 23, 2016
ay
s
=
2. May 30, 2015
J
u 3. April 14, 2017
n
e
28
4. July 26, 2017
,
20 5. September 8, 2010
17

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 Using a pregnancy wheel

Calculate the gestational age

for the following LNMPs:
1. February 23, 2016
2. May 30, 2015
3. April 14, 2017
4. July 26, 2017
5. September 8, 2010

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 Physical examination

Parameter Comment Margin of error

Increases from 37°C to 37.8°C due to increased
Increased basal body
blood flow. Noticeable from about 6 weeks ± 4–6 weeks
temperature
gestational age.
Bimanual pelvic Performed before the uterus is palpable in the
± 2 weeks
examination abdomen
Modern fetal Doppler instrument can detect fetal
First fetal heart tones
heart sounds by 8–12 weeks; manual fetoscope ± 2 weeks
by Doppler
can detect heart sounds by 17–20 weeks

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 Physical examination, cont.
Parameter Comment Margin of error
Symphysis- Uterine fundus is: ± 4 wks
fundal height  Palpable at (between 18 and
measurement symphysis pubis at 32 wks)
(cm) 12 wks ± 4–6 wks
 Midway between (after 32 wks)
symphysis and
umbilicus at 16
wks
 At umbilicus at
20–22 wks
 At xiphisternum at
36 wks

A uterine fundus that is at least three finger breadths

above the symphysis pubis is in the second trimester

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 Ultrasound scan
Parameter Comment Error margin
10 mm = 5 weeks
Measurement of gestational
20 mm = 6.5 weeks
A. Gestational sac sac diameter
40 mm = 9.3 weeks
(in mm)
49 mm = 10.6 weeks
1 cm = 7 weeks
Measurement of the crown-
B. Crown-rump 2 cm = 8 weeks 4 days
rump length (in cm) in the
length 3 cm = 9 weeks 5 days
first trimester
5 cm = 11 weeks 4 days
3 cm = 14.4 weeks
Measurement of the fetal 5 cm = 20.7 weeks
C. Biparietal
skull biparietal diameter in 8 cm = 31 weeks
diameter
the second trimester 9 cm = 36 weeks
10 cm = 42 weeks
 Head circumference
D. Others
 Abdominal circumference

Adapted from: MacGregor and Sabbagha 2008.

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 References
• MacGregor SN, Sabbagha RE. 2008. Assessment of gestational age by ultrasound. Global Library of Women’s Medicine
website. doi: 10.3843/GLOWM.10206. Accessed October 18, 2018.
• UNICEF. 2018. Antenatal care. UNICEF data website. https://data.unicef.org/topic/maternal-health/antenatal-care/. Published
June. Accessed October 18, 2018.
• WHO. 2011. WHO Recommendations for Prevention and Treatment of Pre-eclampsia and Eclampsia. Geneva, Switzerland:
WHO. http://apps.who.int/iris/bitstream/handle/10665/44703/9789241548335_eng.pdf. Accessed September 18, 2018.
• WHO. 2013. Guideline: Calcium Supplementation in Pregnant Women. Geneva, Switzerland: WHO.
http://apps.who.int/iris/bitstream/handle/10665/85120/9789241505376_eng.pdf?sequence=1. Accessed September 18, 2018.
• WHO. 2016. WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience. Geneva, Switzerland: WHO.
http://apps.who.int/iris/bitstream/10665/250796/1/9789241549912-eng.pdf?ua=1. Accessed September 18, 2018.

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 Thank you!
Any questions or comments?

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