Best Practices in Focused Antenatal Care: Rationale, Components and Tools

Best Practices in Maternal and Newborn Care

Jhpiego in partnership with Save the Children, Constella Futures, The Academy for Educational Development, The American College of Nurse-Midwives and IMA World Health

Session Objectives
Describe focused antenatal care (FANC)

Describe basic elements of FANC assessment and care

Describe the elements of Birth Preparedness and Complication Readiness Demonstrate the provision of focused antenatal care

Objective of ANC
A healthy pregnancy

A healthy outcome for mother and newborn

Promotion of physical, mental and social health

Benefits of FANC
ANC visits are a unique opportunity for early diagnosis and treatment of problems:
Maternal problems: anemia, vaginal bleeding, preeclampsia/eclampsia, infection, abnormal fetal position after 36 weeks Fetal/newborn problems: abnormal fetal growth or movement, HIV, syphilis, malaria, malnutrition

Benefits to Newborn May Be Even Greater than Benefits to Mother

Question ??
What problems have you seen with antenatal care? Why are there problems with antenatal care?

ANC: Why is there a problem?

Quality of care is poor:
We gather information but do not use it to manage patient e.g., anemia Poor clinical management of problems eclampsia, bleeding in pregnancy Failure to record relevant information Factory assembly-line ANC system Not client-specific Women treated poorly so do not return Poor counseling skills Information and education are not relevant to the woman

Not women-friendly:

Poor communication:

A Midwife Says:
What I dislike about the assembly line system was that I alone had to palpate about 150 pregnant women a day. There was no privacy during history taking and the women did not give us correct information . . . It was tedious work. A care provider

What FOCUSED ANC Means !

An approach to ANC that emphasizes:

Individualized care
Client-centered Fewer but comprehensive visits Disease detection, not risk Classification

Care by a skilled provider

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Four Goals of Focused ANC

Early detection and treatment of problems and complications Prevention of complications and disease Birth preparedness and complication readiness Health promotion

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The Focused ANC System

Privacy/confidentiality are assured

Continuous care provided by same provider

Promotes partner/support person involvement Adheres to national protocols

Referral facilitated
ANC, PNC and family planning services are linked and housed within the same location if possible

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High Risk Women and Low Risk Women

What are the benefits of assigning women to risk categories? What are the problems with assigning women to risk categories?

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Why Risk Approach Is Not Effective!

Complications cannot be predicted: All pregnant women are at risk Risk factors are not usually the direct cause of complications

Many low-risk women develop complications

Most high-risk women give birth without complications
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Focused ANC Visit Schedule for the Healthy Client

Four visits:
First Second Third Fourth <16 Weeks 2024 2830 36

It means good clinical decisions must be made at each visit

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Making Good Clinical Decisions at ANC

The steps:
Gathering information (history, exam, labs, etc.) Interpreting information gathered Developing a care plan Implementing care plan Evaluating care plan

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Gathering Information: History

1
Personal Hx Present Preg Hx LMP, Complaints *

2
* *

3
*

4
*

Past preg Hx
Medical Hx Family/Social Hx *

*
*

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Gathering Information: Examination

1
General Pulse, Resp, BP Breast * *

2
*

3
*

4
*

Chest
Abdomen/Preg Genital Pelvic Assess

*
* * PRN only * * *

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Gathering Information: Lab/Other Investigations, e.g., US

1
Blood Hgb, RPR, HIV Urine - according to local protocols Albumin, Sugar Ultrasound (PRN, NOT routine in FANC)

3
*

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Care Plan: Appropriate Counseling and LEC

Relevant to client needs

Relevant to gestation
Address discomforts of pregnancy

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Basic Care Plan

Minimum of four visits for the healthy client Anemia prevention Malaria prevention Prevention of HIV transmission Treatment/prevention other STIs Tetanus immunization Preparing birth and complication preparedness plan Education and counsel nutrition, family planning, infant feeding, hygiene

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Care Plan: Anemia Prevention

Iron supplementation

Folate supplementation
Treat any factors that can cause anemia: worms, malaria, schisto, etc. Nutrition foods rich in iron, folate and vitamin C

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Question ??

Why bother with a birth preparedness and complication readiness plan?

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Why Bother?
Time of labor or time of emergency is not the time to decide what to do Increase the likelihood of using a skilled attendant as arrangements have been made Frequently women/families do not seek help because they do not know they have a problem dont know danger signs Some complications, e.g., hemorrhage, take only 2 hours until death all plans must be in place

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Question ??
What are the elements of a birth preparedness and complication readiness plan?

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The Birth and Complication (BP/CR) Readiness Plan

Facility or place of birth

Skilled provider
Transportation Funds

Support person
Decision-maker Blood donor

Danger signs in labor

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Birth Preparedness and Complication Readiness Plan (cont.)

Where does she plan to deliver her baby?

Who will accompany her in labor to her chosen center?

How will she get to the health center? Does she have money and other needed items ready and accessible?

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Birth Preparedness and Complication Readiness Plan (cont.)

If she develops a complication before or during labor, how will she reach the nearest health facility? Where will she find money for any additional cost e.g., CS? If she needs blood, who will donate?

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THANK YOU FOR YOUR ATTENTION

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References
Beck D et al. 2004. Care of the Newborn Reference Manual. Save the Children: Washington, D.C. Deganus S. 2004. Improving quality of antenatal care at a district hospital in Ghana, a presentation in Accra, Ghana. (29 July) Kinzie B and Gomez P. 2004. Basic Maternal and Newborn Care: A Guide for Skilled Providers. Jhpiego: Baltimore, Maryland.

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Optional Slides
Ghana: The Tema General Hospital Experience

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Change at Tema General Hospital

Antenatal Care:
Increased attendance Booking earlier in pregnancy Average client waiting time reduced by 1hr 40 mins Individualized care: Education and counseling more tuned to client needs All care components by the same provider Improved client-provider interaction Same provider provides continuing care to the client at all visits
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Antenatal Attendance: 19992003

25,000 20,000 15,000 10,000 5,000 0 1997 1998 1999 2000 2001 2002 2003

Total Attendance

New

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The Impacts of Change (2)

Labor and delivery:
Increased use of hospital delivery facilities (skilled attendant) Decreased stillbirth rate

Postnatal care:
Enhanced use of postnatal care services

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Antenatal Booking and Skilled Attendance at Delivery: 19972003

6,000 5,000 4,000 3,000 2,000 1,000 0 1997 1998 1999 2000 2001 Deliveries 2002 2003

ANC Booking

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Stillbirths and MMR: 19972003

80 70 60 50 40 30 20 10 0 1997 1998 1999 MMR/1000 2000 2001 SBR/1000 2002 2003

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Antenatal Care Bookings and Six-Week Postnatal Care Attendance: 19972003

6000 5000 4000 3000 2000 1000 0 1997 1998 1999 PN Attend 2000 2001 2002 2003

AN Booking

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Other Benefits of This Change

Improved staff morale Improved provider skill levels More client-friendly facilities Better use of staff skills Improved status of hospital as Clinic is recognized as center of excellence Center serves as a site for introducing new ANC country programs e.g., PMTCT Commitment by care providers to continued quality improvement

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Since I started practicing individualized AN care, work has become very interesting. I know my clients better, they share their problems with me because of the privacy provided. Clients feel relaxed and at ease with me. I feel more concerned and also more obliged to address their health needs. My clients seem to appreciate more the care I give to them and sometimes shower me with thank-you cards and gifts. This makes me feel great. ANC Care Provider

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There is still more room for improvement. There is still a lot to be learnt. We have a vision and we are working towards it.
Matron in Charge

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