Republic of the Philippines

Department of Health
OFFICE OF THE SECRETARY

sFP 1 $ ?0t6
ADMINISTRATIVE ORDER
No. 2o16 - ooo-r

SUBJECT: Guidelines on the Provision of Ouality Antenatal Care in All Birthine

Centers and Health Facilities Providins Maternity Care Services.

I. Background and Rationale

Pregnancy is a time to promote healthy behavior and parenting skills. Good

antenatal care (ANC) is important in the development of the unbom and links the
woman and her family with the formal health system. Inadequate care during the
antenatal period breaks the continuum of care which can compromise health of both
mothers and newborns. While ANC indirectly saves the lives of mothers by
promoting and establishing good health during pregnancy and the postnatal period the
time periods of highest risk, it improves the health and survival of the newborns
directly by reducing stillbirths and neonatal deaths.

Antenatal Care (ANC) coverage in the country can be considered a success

story with 78Yo of women having at least 4 ANC visits recorded in 2014 (National
Safe Motherhood Program Report). However, to achieve the full life-saving potential
that ANC promises to mothers and babies, an enhancement of the current ANC
practice is necessary along with strict compliance to protocol by health professionals
attending to births at all levels of the health system.

II. Objectives

This Order seeks to improve the quality of antenatal care through the provision
of technical guidance in the shift in ANC concept from the high risk approach to the
four-visit model of focused ANC and the consequent service delivery scheme of the
ANC package.

III. Scope of Application

This Order shall apply to all providers of matemal and newborn care services
in the public and private sector and at all levels of the health care delivery system.

IV.Definition of Terms and Acronyms

I. Antenatal Care (ANC) also known as prenatal care is a type of preventive

healthcare accorded to pregnant women with the goal of providing regular check-
ups that allow doctors, nurses and midwives to identiff, prevent and treat potential
health problems throughout the course of the pregnancy while promoting healthy
lifestyles that benefit both mother and child. /
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 2. High Risk ANC is a method of providing antenatal care with the objective of
classifying pregnant women as low risk or high risk based on pre-determined
criteria. This approach is hard to implement effectively since a woman may have
more than 1 risk factors and not all high risk develop complications in like manner
that some low risk women develop complications particularly during childbirth.

3. Focused ANC is an individualized goal oriented ANC that provide specific

evidence-based interventions to women, carried out at certain critical times in the
pregnancy. This comprise the following essential elements:

Pregnancy Tracking or the identification and surveillance of the pregnant

woman and her expected child.
b. Screening for conditions and diseases such as anemia, STIs (sexually
transmitted infections) particularly syphilis, HtV (human
immunodeficiency virus) infection, Hepatitis B infection, mental health
problems, andlor signs of stress or domestic violence.
Recognition and management of pregnancy-related complications,
particularly hypertensive disorders of pregnancy.
d. Recognition and treatment of underlying and concurrent illness.
e. Preventive measures, including tetanus toxoid immunization, deworming,
iron and folic acid supplementation, calcium carbonate supplementation,
iodine oil capsule supplementation in areas with low urinary iodine
excretion levels; and, in malaia endemic areas, intermittent preventive
treatment of malaria in pregnancy (IPTp) and insecticide treated bed nets
(rTN).
f. Advice and support to the woman and her family for developing healthy
home behaviors and a Birth Plan.

4. Birthing Center is a healthcare facility also known as birthing home, lying -in and
puericulture center. It can be a Rural Health Unit, Health Center, City/
Municipal/ Community/Medicare/District Hospitals that provide birthing services.
It can also be the unit in secondary and tertiary hospitals where maternity care
services are provided such as the out-patient obstetrics department, delivery room
and maternity ward. It provides antenatal care, birthing care and postnatal care. It
is staffed by doctors who are general practitioners or with specialization in
obstetrics, nurses or nurse-midwives and midwives trained on basic emergency
obstetrics and newborn care.

5. Muternal Health Services refer to a range of services that covers care during the
periods that include, but are not limited to, antenatal, delivery, and postpartum
periods. (RPRH Law IRR).

V. Guiding Principles
All health workers in Birthing Centers shall be guided by the following principles
in the provision of ANC:

1. ANC is an important entry point in the provision of integrated care. Conditions

such as sexually transmitted infections, tetanus, HIV, tuberculosis, malaia,
 Prevention of Maternal and Neonatal Tetanus. ANC provides an opportunity
to immunize pregnant women with the recommended (at least) 2 doses of
tetanus toxoid and provide advice and schedule towards the completion of the
immunization at postpartum.

Prevention and case management of maternal malaria in endemic areas.

Asymptomatic malaria infection of the placenta can result to maternal anemia
and contribute to low birth weight and preterm birth. ANC offers a means to
increase the coverage of key interventions for malaria in pregnancy: IPTp
(intermittent prevention and treatment of malaria in pregnancy) and ITN
(insecticide treated bed nets).

Prevention of maternal anemia, neural tube defects and malnutrition. Anemia

during pregnancy increases the risk of dying from hemorrhage. It is also
associated with an increased risk of stillbirth, low birthweight, prematurity and
neonatal death. Thus, iron and folic acid supplementation, deworming,malaia
prevention, improved obstetric care, and management of severe anemia are
essential in the prevention of neural tube defects and control of maternal
anemia and malnutrition during pregnancy.

Prevention of sexually transmitted infections (STII) and mother-to-child

transmission of HIV eMfCD Universal syphilis screening and treatment
during ANC has been established to be feasible and cost effective intervention
since syphilis complications are severe yet therapy is cheap and effective. On
the other hand, through the opt-out system or the health worker initiated HIV
counseling and testing, ANC is a key entry point for the prevention of mother-
to-child transmission of HIV (PMTCT) services.

2. ANC offers qn opportunity to develop a Birth Plan. The National Safe

Motherhood Program recommends that health workers assist all pregnant women
to have a written plan for dealing with childbirth and any unexpected adverse
event such as obstetric complications that may occur anytime during pregnancy,
childbirth and the immediate postnatal period.

3. ANC visits provide opportunities to promote lasting health, offering benefits that
continue beyond the pregnancy period. This includes birth preparedness and
extends to cover health information and counselling for pregnant women, their
families and communities.

VI. Specific Guidelines

ANC presents the first opportunity for a woman to connect with the health
system and thus an entry point for integrated care. To ensure that women and
newborns benefit from ANC the followins shall guide skilled health professionals in
the provision ofantenatal care:

l. Pregnancy Tracking shall be done in all communities by the Barangay Health

Workers (BHWs) and shall be used as an opportunity to encourage women to
access antenatal care at the nearest birthine center.

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Z. All pregnant women shall be provided with focused antenatal care (ANC).

a. The first ANC visit shall be considered crucial for early identification of
underlying conditions such as chronic hypertension, diabetes, anemia and
the like and shall be done as early as possible preferably during the first
trimester. Likewise, this visit shall distinguish women who require the
standard 4-visit model from those requiring special attention and more
visits.

b. The last visit shall be at around the 37 weeks or near the expected date of
delivery to ensure that appropriate advice and care have been provided to
prevent and manage difficult labor and problems such as multiple births,
post-maturity and mal-presentation.

J. Focused antenatal care interventions for healthy women with no underlying

medical problems shall be provided over 4 visits at specified interval: 1 visit
during the 1't trimester (8-12 weeks), 1 visit during the 2no trimester (24-26 weeks)
and 2 visits during the 4th trimester at 2 weeks interval (32 weeks and 36-38
weeks). For women with underlying medical conditions, focused antenatal care
may require more visits upon doctor's advice.

4. All pregnant women shall be required to have a written Birth Plan (contained in
Mother-Baby Book, Mother and Child Book, Rekord ni Nanay, Nanay and Baby
Book, other similar health records) at the first ANC visit. The women should
discuss and review this plan with a health worker at every ANC visit and I month
before the expected date of delivery. The birth center nurse or midwife shall
ensure the identification of the following elements in the plan:

a. Desired place of delivery;

b. Name and location of the nearest birthing center;
c. Name of birth attendant;
d. Name and location of the nearest referral hospital;
e. Funds for birth-related and emergency expenses;
The birthing center staff should orient the woman about Philhealth
membership benefits and enrolment at the point of care in case she is not a
member yet.

f. Desired birth companion;

g, Things to prepare for the newborn and things to bring on delivery date;
h. Available support from community workers, e.g. BHWs in looking after
the home and children while the woman is away to give birth;
i. Transport from home to a health facility, including contact person, contact
number and cost;
j. Transport from the birthing center to a referral facility in case of obstetric
emergency, including contact person, contact number and cost;
k. Identification of at least 2 blood donors in case of emergency including
contact numbers.

5. Health professionals in birthing centers shall effectively use each visit to provide
opportunities to promote lasting health and offer benefits that continue beyond
pi"gnutr"y and delivery. Thus, eich woman accessing antenatal care shall be given
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 a Mother and Child Book.The Mother end Child Book shall be used not only as a
tool to prepare for birth but also to provide information and learning about
pregnancy and child care. With the aid of the Mother and Child Book health
workers should be able to inform, educate and give advice about -
a. Proper nutrition and rest
b. Promotion of early and exclusive breastfeeding
c. Smoking cessation
d. Avoidance of alcohol and drugs
e. Personal hygiene including oral health
f. Guidance about family planning
g. Newborn and child care including immunization schedule
h. Child nutritional status through the growth monitoring chart that includes
weight and height monitoring

Likewise, all essential information and birth center visit findings shall be
accurately recorded in the Mother and Child Book. The coverage of 4 or more
ANC visits disaggregated by trimester is important because the effectiveness of
certain interventions such as iron with folic acid and calcium carbonate
supplementation, tetanus toxoid vaccination and provider initiated counselling and
testing (PICT) for HIV, syphilis and hepatitis B depend on repeated visits and the
trimester in which they occur. This guides the woman and health providers as well
on actions to take and make referrals efficient.

T\e Mother and Child Book is a record that should be held by the woman. The
Birthing Center nurse or midwife should instruct the woman to bring the Book
during every health center visit and at the time of delivery.

6. All birthing centers shall guarantee the provision of focused ANC by establishing
and maintaining a network of service providers (service delivery network) as
necessary to ensure that all the essential services are delivered to every pregnant
woman. The network of service providers may include hospitals, specialized
clinics such as the Social Hygiene Clinic and laboratories both in the public and
private sector.

7. All birthing center staff at each level of the health care delivery system shall
comply with the ANC goals and activities at each visit based on the 4-visit model
as applied in focused ANC:

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 > basic ANC (4 measures measures measures
visits) or
> more specialized
care (more visits)
Screen, treat and Review and modify Review and modifl, Review and modify
give advice on Birth Plan Binh Plan Birth Plan
preventive measures
Together with the Advice and counsel Advice and counsel Advice and counsel
woman, develop a
Birth Plan
Advice and counsel.
Activities: Rapid ass essment and management for emergency signs and symptoms, give appropriate treatment
and refer to hospital i fneeded.
History Assess signifrcant Assess significant Assess significant Assess significanl
(ask, check signs and symptoms signs and symptoms signs and symptoms signs and
records) symptoms
Take psychosocial, Check records for Check records for Check records for
medical and previous previous previous
obstetric history complications & complications & complications &
treatments during treatments during treatments during
the oresnancv the oresnancv the oresnancv
Confirm pregnancy Re-classify as Re-classifu as Re-classiff as
and calculate EDD needed needed needed
Classify women for
basic ANC (4 visits)
or more specialized
care (in some cases,
this may come after
the tests results are
made available).
Examination Complete general Check for anemia Check for anemia Check for anemia
(look,listen, feel) and obstetrical and thyroid and thyroid and thyroid
examination enlargement enlargement enlargement
including nutritional
assessment:
compute for body
mass index (BMI)
and monitor weight
gain based on pre-
Dresnant weisht
Check the blood Check BP check BP check BP
pressure (BP) Check for weight Check for weight Check for weight
gain based on first gain based on frrst gain based on first
trimester BMI trimester BMI trimester BMI
Assess fetal growth Assess fetal growth Assess fetal growth
and movement and movement and movement

Determine multiple Determine multiple

pregnancY oregnancv
Assess for mal-
oresentation
Check for oral Assess for presence Assess for presence Assess for presence
health ofdental caries and ofdental caries and ofdental caries and
loosenine loosenine loosenine
Screening and Pregnancy Test Etilogic tests Bacteriuria as
Tests as necessary for STIs as necessary
Hemoglobin necessary Blood/RH
count Pap Smear as group as
Complete necessary necessary
Blood Count Gestational
Blood Twine diabetes (oral
 glucose
syndromic challenge test)
approach as necessary

necessary

(HBsAG)

proteinuria,
albuminuria

examination

Wash
Treatments If indicated: If indicated: If indicated:
If indicated:

(anteretroviral)

If indicated: Ifbreech, do an
external cephalic
services: version (ECV) or
permanent refer for ECV
filling and gum
treatment
Preventive Tetanus Toxoid Tetanus Toxoid
Measures immunization immunization

Iron with folic acid Iron with folic acid Iron with folic acid Iron with folic acid
supplementation supplementation supplementation suoolementation
Calcium carbonate Calcium carbonate Calcium carbonate
Oral health check- Oral health check- Oral health check- Oral health check-
up and prophylaxis up and prophvlaxis up and prophylaxis uo and oroohvlaxis
IPTp (intermittent IPTp (intermittent IPTp (intermittent
treatment for treatment for treatment for
malaria) in endemic malaria) in endemic malaria) in endemic
areas areas areas
Health Education, Self-care Birth Plan Birth Plan Birth Plan
Advice and
Counselling
Alcohol and Reinforcement of Breastfeedins Breastfeeding
tobacco use previous advice
Nutrition PosQartum and Postpartum and
counseling and postnatal care postnatal care
supplemental including follow-up
feeding program if tetanus
appropriate immunization for
TT3 after 6 months;
after I year for TT4
and TT5 after
another vear
Safe sex Presnancv soacins Pregnancy spacing
Rest and sleep Reinforcement of Reinforcement of
(under ITN - previous advice previous advice
insecticide treated
bed nets in endemic
areas)
Birth Plan

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 8. Where the required services are not available at the Birthing Center, e.g., HIV
testing, syphilis testing, etc., the Birthing Center head shall be responsible for
referring the woman to an appropriate facility for the tests and/or treatment and
ensure that the referral and the services required has been adequately served.

9. The result of the tests as well as the recommended medical management and
treatment shall be appropriately compiled in the Individual Record at the Birthing
Center. Relevant information shall be recorded in the Mother and Child Book for
future reference.

10. Antenatal care services as provided for in this Guideline shall be part of the
Maternity Care Package and shall be reimbursed by PhilHealth to appropriate
facility providing specific service(s).

I 1. The following indicators shall be the indicators for quality antenatal care and shall
be reported as part of the National Safe Motherhood Program Results Matrix
starting 2017 (Please refer to the ANC Utilization Report matrix in the attached
annex of this policy):

a. Proportion of women who gave birth with a written birth plan.

b. Proportion of women who gave birth who had at least 4 ANC visits.
c. Proportion of women who gave birth who had at least 2 tetanus toxoid
vaccination during their pregnancy.
d. Proportion of women who gave birth who receive IPTp for malaria during
their pregnancy.
e. Proportion of women who gave birth who tested positive for HIV during
their pregnancy.
f. Proportion of women who gave birth who tested positive for syphilis
during their pregnancy.
g. Proportion of women who gave birth who were referred to a treatment hub
or given treatment at the birthing center.

VII. Effectivity

This order shall take effect immediately.

PAULYN'' M'!!,h#,H,
Secretary of Health
CESO II
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