Geneva, 18 Sep 17

WHO Guideline on
Antenatal Care (2016)

Ӧzge Tunçalp, MD PhD

Scientist, HRP/RHR
Reproductive Health and Research (RHR)
Nutrition for Health and Development (NHD)
Maternal, Newborn, Child and Adolescent Health (MCA)

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 Outline

 Background
 Development of the WHO ANC guideline
 Recommendations
 What's new – Malaria in the context of ANC

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 BACKGROUND

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 ANC is critical

Through timely and appropriate evidence-based

actions related to health promotion, disease
prevention, screening, and treatment

 Reduces complications  Reduces stillbirths and

from pregnancy and perinatal deaths
childbirth

 Integrated care delivery throughout pregnancy

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 Previously: The 4-visit
WHO ANC model
 Involves specific evidence-
based interventions for all
women

 Carried out at four critical

times

 Also known as the Focused

Antenatal Care Model (FANC)

 Part of Pregnancy, Childbirth,

Postpartum and Newborn
Care (PCPNC)

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 QUALITY throughout the continuum of care
WHO envisions a world where “every pregnant woman and newborn receives
quality care throughout the pregnancy, childbirth and the postnatal period”.

 Prioritizes person-centred
health and well-being:

 Reducing mortality and

morbidity

 Providing respectful care that

takes into account woman’s
views

 Optimizing service delivery

within health systems

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 Women’s views

 A healthy pregnancy for mother and

Women want a baby (including preventing or
treating risks, illness and death)
Positive  Physical and sociocultural normality
during pregnancy
Pregnancy  Effective transition to positive labour
and birth
Experience  Positive motherhood (including
maternal self-esteem, competence
from ANC and autonomy)

Medical care; relevant and timely information; emotional support and advice
Downe S, Finlayson K, Tunçalp Ӧ, Metin Gülmezoglu A. What matters to women: a systematic scoping review to identify the processes and outcomes
of antenatal care provision that are important to healthy pregnant women. BJOG. 2016 Mar;123(4):529-39.
Abalos
7 E, Chamillard M, Diaz V, Tuncalp Ӧ, Gülmezoglu AM. Antenatal care for healthy pregnant women: a mapping of interventions from existing guidelines
to inform the development of new WHO guidance on antenatal care. BJOG. 2016 Mar;123(4):519-28.
 DEVELOPMENT OF THE GUIDELINE

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 The 2016 ANC guideline

 Essential core package of ANC Overarching questions

that all pregnant women and
adolescent girls should receive  What are the evidence-

based practices during ANC

 With the flexibility to employ
different options based on the that improved outcomes
context of different countries and lead to positive
• What is the content of the
model/package? pregnancy experience?
• Who provides care?
• Where is the care provided?
• How is the care provided to meet the
needs of the users?  How should these practices
 Complement existing WHO
be delivered?
guidance on complications during
pregnancy

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 Methodology and assessment of evidence
Work streams Methodology Assessment of
evidence
Individual interventions for Effectiveness reviews, GRADE
clinical practices (n=37) systematic reviews

Antenatal testing (n=2) Test accuracy reviews GRADE

Barriers and facilitators to access Qualitative evidence GRADE-CERQual

to and provision of ANC (n=2) synthesis
Health systems interventions to Effectiveness reviews GRADE
improve the utilization and
quality of ANC (n=6)
Large scale WHO ANC model (4- Mixed-methods review, N/A
visit) case studies focusing on contextual and
health system factors
affecting implementation

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 The DECIDE framework

Resource use  Three technical

consultations with
guideline
Equity Values
development group
(October 2015-March 2016)

RECOMMENDATION
 Collaborative effort
between WHO
Benefits and
departments,
Acceptability
harms methodologists and
different groups of
Feasibility experts

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http://ietd.epistemonikos.org/
 Types of recommendations

 We recommend the option

 We recommend this option under certain conditions
 Only in the context of rigorous research
 Only with targeted monitoring and evaluation
 Only in specific contexts
 We do not recommend this option

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 Recommendations on ANC
49 recommendations were grouped into five
topic areas:
A. Nutritional interventions (14)
B. Maternal and fetal assessment (13)
C. Preventive measures (7)
D. Interventions for common physiological
symptoms (6)
E. Health systems interventions to improve
the utilization and quality of ANC (9)
Including 10 recommendations relevant to
routine ANC from other WHO guidelines
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 RECOMMENDATIONS

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 A. Nutritional interventions - 1
A.1.1: Counselling about healthy eating and keeping physically active Recommended
during pregnancy is recommended for pregnant women to stay
healthy and to prevent excessive weight gain during pregnancy.

A.1.2: In undernourished populations, nutrition education on Context-specific

increasing daily energy and protein intake is recommended for recommendation
pregnant women to reduce the risk of low-birth-weight neonates.
A.1.3: In undernourished populations, balanced energy and protein Context-specific
dietary supplementation is recommended for pregnant women to recommendation
reduce the risk of stillbirths and small-for-gestational-age neonates.

A.1.4: In undernourished populations, high-protein supplementation Not recommended

is not recommended for pregnant women to improve maternal and
perinatal outcomes.

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 A. Nutritional interventions -2
A.2.1: Daily oral iron and folic acid supplementation with 30 mg to Recommended
60 mg of elemental iron and 400 µg (0.4 mg) of folic acid is
recommended for pregnant women to prevent maternal anaemia,
puerperal sepsis, low birth weight, and preterm birth.
A.2.2: Intermittent oral iron and folic acid supplementation with 120 Context-specific
mg of elemental iron and 2800 µg (2.8 mg) of folic acid once weekly is recommendation
recommended for pregnant women to improve maternal and neonatal
outcomes if daily iron is not acceptable due to side-effects, and in
populations with an anaemia prevalence among pregnant women of
less than 20%.
A.3: In populations with low dietary calcium intake, daily calcium Context-specific
supplementation (1.5–2.0 g oral elemental calcium) is recommended recommendation
for pregnant women to reduce the risk of pre-eclampsia.

A.4: Vitamin A supplementation is only recommended for pregnant Context-specific

women in areas where vitamin A deficiency is a severe public health recommendation
problem, to prevent night blindness.

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 Nutritional interventions - 3
A.5: Zinc supplementation for pregnant women is only recommended Context-specific
in the context of rigorous research. recommendation
(research)
A.6: Multiple micronutrient supplementation is not recommended for Not recommended
pregnant women to improve maternal and perinatal outcomes.

A.7: Vitamin B6 (pyridoxine) supplementation is not recommended Not recommended

for pregnant women to improve maternal and perinatal outcomes.

A.8: Vitamin E and C supplementation is not recommended for Not recommended

pregnant women to improve maternal and perinatal outcomes.

A.9: Vitamin D supplementation is not recommended for pregnant Not recommended

women to improve maternal and perinatal outcomes.

A.10: For pregnant women with high daily caffeine intake (more than Context-specific
300 mg per day), lowering daily caffeine intake during pregnancy is recommendation
recommended to reduce the risk of pregnancy loss and low-birth-
weight neonates.
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 B.1. Maternal assessment - 1
B.1.1: Full blood count testing is the recommended method for Context-specific
diagnosing anaemia in pregnancy. In settings where full blood count recommendation
testing is not available, on-site haemoglobin testing with a
haemoglobinometer is recommended over the use of the haemoglobin
colour scale as the method for diagnosing anaemia in pregnancy.
B.1.2: Midstream urine culture is the recommended method for Context-specific
diagnosing asymptomatic bacteriuria (ASB) in pregnancy. In settings recommendation
where urine culture is not available, on-site midstream urine Gram-
staining is recommended over the use of dipstick tests as the method
for diagnosing ASB in pregnancy.

B.1.3: Clinical enquiry about the possibility of intimate partner Context-specific

violence (IPV) should be strongly considered at antenatal care visits recommendation
when assessing conditions that may be caused or complicated by IPV
in order to improve clinical diagnosis and subsequent care, where
there is the capacity to provide a supportive response (including
referral where appropriate) and where the WHO minimum
requirements are met.
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 B.1. Maternal assessment - 2
B.1.4: Hyperglycaemia first detected at any time during pregnancy should be Recommended
classified as either gestational diabetes mellitus (GDM) or diabetes mellitus in
pregnancy, according to WHO criteria.

B.1.5: Health-care providers should ask all pregnant women about their tobacco Recommended
use (past and present) and exposure to second-hand smoke as early as possible in
the pregnancy and at every antenatal care visit.

B.1.6: Health-care providers should ask all pregnant women about their use of Recommended
alcohol and other substances (past and present) as early as possible in the
pregnancy and at every antenatal care visit.
B.1.7: In high-prevalence settings, provider-initiated testing and counselling (PITC) Recommended
for HIV should be considered a routine component of the package of care for
pregnant women in all antenatal care settings. In low-prevalence settings, PITC can
be considered for pregnant women in antenatal care settings as a key component
of the effort to eliminate mother-to-child transmission of HIV, and to integrate HIV
testing with syphilis, viral or other key tests, as relevant to the setting, and to
strengthen the underlying maternal and child health systems.
B.1.8: In settings where the tuberculosis (TB) prevalence in the general population Context-specific
is 100/100 000 population or higher, systematic screening for active TB should be recommendation
19 considered for pregnant women as part of antenatal care.
 B.2.Fetal assessment
B.2.1: Daily fetal movement counting, such as with “count-to-ten” kick Context-specific
charts, is only recommended in the context of rigorous research. recommendation
(research)
B.2.2: Replacing abdominal palpation with symphysis-fundal height Context-specific
(SFH) measurement for the assessment of fetal growth is not recommendation
recommended to improve perinatal outcomes. A change from what is
usually practiced (abdominal palpation or SFH measurement) in a
particular setting is not recommended.

B.2.3: Routine antenatal cardiotocography is not recommended for Not recommended

pregnant women to improve maternal and perinatal outcomes.

B.2.4: One ultrasound scan before 24 weeks of gestation (early Recommended

ultrasound) is recommended for pregnant women to estimate
gestational age, improve detection of fetal anomalies and multiple
pregnancies, reduce induction of labour for post-term pregnancy, and
improve a woman’s pregnancy experience.
B.2.5: Routine Doppler ultrasound examination is not recommended for Not recommended
pregnant women to improve maternal and perinatal outcomes.
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 C. Preventive measures - 1
C.1: A seven-day antibiotic regimen is recommended for all pregnant Recommended
women with asymptomatic bacteriuria (ASB) to prevent persistent
bacteriuria, preterm birth and low birth weight.

C.2: Antibiotic prophylaxis is only recommended to prevent recurrent Context-specific

urinary tract infections in pregnant women in the context of rigorous recommendation
research. (research)
C.3: Antenatal prophylaxis with anti-D immunoglobulin in non-sensitized Context-specific
Rh-negative pregnant women at 28 and 34 weeks of gestation to prevent recommendation
RhD alloimmunization is only recommended in the context of rigorous (research)
research.
C.4: In endemic areas, preventive anthelminthic treatment is Context-specific
recommended for pregnant women after the first trimester as part of recommendation
worm infection reduction programmes.
C.5: Tetanus toxoid vaccination is recommended for all pregnant women, Recommended
depending on previous tetanus vaccination exposure, to prevent
neonatal mortality from tetanus.

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 C. Preventive measures - 2
C.6: In malaria-endemic areas in Africa, intermittent preventive Context-specific
treatment with sulfadoxine-pyrimethamine (IPTp-SP) is recommended recommendation
for all pregnant women. Dosing should start in the second trimester, and
doses should be given at least one month apart, with the objective of
ensuring that at least three doses are received.

C.7: Oral pre-exposure prophylaxis (PrEP) containing tenofovir disoproxil Context-specific

fumarate (TDF) should be offered as an additional prevention choice for recommendation
pregnant women at substantial risk of HIV infection as part of
combination prevention approaches.

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 D. Common physiological symptoms
D.1: Ginger, chamomile, vitamin B6 and/or acupuncture are recommended for the relief Recommended
of nausea in early pregnancy, based on a woman’s preferences and available options.

D.2: Advice on diet and lifestyle is recommended to prevent and relieve heartburn in Recommended
pregnancy. Antacid preparations can be offered to women with troublesome symptoms
that are not relieved by lifestyle modification.
D.3: Magnesium, calcium or non-pharmacological treatment options can be used for the Recommended
relief of leg cramps in pregnancy, based on a woman’s preferences and available options.
D.4: Regular exercise throughout pregnancy is recommended to prevent low back and Recommended
pelvic pain. There are a number of different treatment options that can be used, such as
physiotherapy, support belts and acupuncture, based on a woman’s preferences and
available options.
D.5: Wheat bran or other fibre supplements can be used to relieve constipation in Recommended
pregnancy if the condition fails to respond to dietary modification, based on a woman’s
preferences and available options.
D.6: Non-pharmacological options, such as compression stockings, leg elevation and Recommended
water immersion, can be used for the management of varicose veins and oedema in
pregnancy, based on a woman’s preferences and available options.
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 E. Health systems interventions to improve the
utilization and quality of ANC – 1
E.1: It is recommended that each pregnant woman carries her own case Recommended
notes during pregnancy to improve continuity, quality of care and her
pregnancy experience.

E.2: Midwife-led continuity-of-care models, in which a known midwife or Context-specific

small group of known midwives supports a woman throughout the recommendation
antenatal, intrapartum and postnatal continuum, are recommended for
pregnant women in settings with well functioning midwifery programmes.
E.3: Group antenatal care provided by qualified health-care professionals Context-specific
may be offered as an alternative to individual antenatal care for pregnant recommendation
women in the context of rigorous research, depending on a woman’s (research)
preferences and provided that the infrastructure and resources for delivery
of group antenatal care are available.

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 E. Health systems interventions to improve the
utilization and quality of ANC – 2
E.4.1: The implementation of community mobilization through facilitated Context-specific
participatory learning and action (PLA) cycles with women’s groups is recommendation
recommended to improve maternal and newborn health, particularly in rural
settings with low access to health services. Participatory women’s groups
represent an opportunity for women to discuss their needs during pregnancy,
including barriers to reaching care, and to increase support to pregnant
women.

E.4.2: Packages of interventions that include household and community Context-specific

mobilization and antenatal home visits are recommended to improve recommendation
antenatal care utilization and perinatal health outcomes, particularly in rural
settings with low access to health services.

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 E. Health systems interventions to improve the
utilization and quality of ANC – 3

E.5.1: Task shifting the promotion of health-related behaviours for maternal Recommended
and newborn health to a broad range of cadres, including lay health workers,
auxiliary nurses, nurses, midwives and doctors is recommended.

E.5.2: Task shifting the distribution of recommended nutritional Recommended

supplements and intermittent preventative treatment in pregnancy (IPTp)
for malaria prevention to a broad range of cadres, including auxiliary nurses,
nurses, midwives and doctors is recommended.

E.6: Policy-makers should consider educational, regulatory, financial, and Context-specific

personal and professional support interventions to recruit and retain recommendation
qualified health workers in rural and remote areas.

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 E. Health systems interventions to improve the
utilization and quality of ANC – 4

E.7: Antenatal care models with a minimum of eight contacts are Recommended
recommended to reduce perinatal mortality and improve women’s
experience of care.

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 WHAT’S NEW?
MALARIA IN THE CONTEXT OF ANC

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 ANC models with a minimum of 8 contacts

 E.7: Antenatal care

models with a minimum
of eight contacts are
recommended to
reduce perinatal
mortality and improve
women’s experience of
care.

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 Contact versus visit

 The guideline uses the term ‘contact’ - it implies an active

connection between a pregnant woman and a health care
provider that is not implicit with the word ‘visit’.
– quality care including medical care, support and timely and relevant
information

 In terms of the operationalization of this recommendation,

‘contact’ can take place at the facility or at community level
– be adapted to local context through health facilities or community
outreach services

 ‘Contact’ helps to facilitate context-specific recommendations

– Interventions (such as malaria, tuberculosis)
– Health system (such as task shifting)

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 ANC model – positive pregnancy experience

Overarching aim

To provide pregnant women with respectful,

individualized, person-centred care at every contact,
with implementation of effective clinical practices
(interventions and tests), and provision of relevant
and timely information, and psychosocial and
emotional support, by practitioners with good
clinical and interpersonal skills within a
well functioning health system.

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 Effective implementation of ANC requires
 Health systems approach and strengthening
o Continuity of care
o Integrated service delivery
o Improved communication with, and support for
women
o Availability of supplies and commodities
o Empowered health care providers
 Recruitment and retention of staff in rural and remote
areas
 Capacity building

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34
 Topics highlighted

 Training of IPTp-SP
 2016 ANC model contact schedule with timelines for
implementation of Mip interventions
 Frequency of IPTp-SP
 Sourcing of quality assured SP
 ITN use
 Effective case management
 Women living with HIV
 Iron and folic acid supplementation

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 Dissemination, implementation, research

 Development of tools to  Regional workshops

support adaptation and – 17 November 2016: West &
implementation at the Central Africa (Burkina Faso)
country level – 27-28 April 2017: Eastern
Europe & Central Asia
(Georgia)
 Development of indicators – 28-30 June 2017: South and
East Africa (Rwanda)
– January 2018: SEARO
 Implementation (planned)
research/design of ANC in
countries  Translation of the guideline
(Russian, French ongoing)
 Living guideline/online

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 Relevant links – 1

About the guidelines:

www.who.int/reproductivehealth/news/ant
enatal-care/en/index.html

South Africa story from the field:

www.who.int/reproductivehealth/news/ant
enatal-care-south-africa/en/index.html

The guideline
www.who.int/reproductivehealth/publicati
ons/maternal_perinatal_health/anc-
positive-pregnancy-experience/en/

Press release
www.who.int/entity/mediacentre/news/rel
eases/2016/antenatal-care-
guidelines/en/index.html

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 Relevant links – 2

Infographics
www.who.int/reproductiv
ehealth/publications/mat
ernal_perinatal_health/A
NC_infographics/en/index
.html
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 Many thanks to…
 Internal and external reviewers
 WHO Steering Group – Andrea Bosman, Maurice Bucagu, Jahnavi
– A. Metin Gülmezoglu (RHR), Matthews Daru, Claudia Garcia-Moreno, Haileyesus
Mathai (MCA), Olufemi Oladapo (RHR), Juan Getahun, Rodolfo Gomez, Tracey Goodman,
Pablo Peña-Rosas (NHD), Ӧzge Tunçalp (RHR) Tamar Kabakian, Avinash Kanchar, Philipp
Lambach, Sarah de Masi, Frances McConville,
 Members of the GDG Antonio Montresor, Justin Ortiz, Anayda
– Mohammed Ariful Aram, Françoise Cluzeau, Portela, Jeremy Pratt, Lisa Rogers, Nathalie
Luz Maria De-Regil, Aft Ghérissi, Gill Gyte, Roos, Silvia Schwarte, Maria Pura Solon, João
Rintaro Mori, James Neilson, Lynnette Paulo Souza, Petr Velebil , Ahmadu Yakubu,
Neufeld, Lisa Noguchi, Nafissa Osman, Erika Yacouba Yaro, Teodora Wi and Gerardo
Ota, Tomas Pantoja, Bob Pattinson, Kathleen Zamora
Rasmussen, Niveen Abu Rmeileh, Harshpal
Singh Sachdev, Rusidah Selamat, Charlotte  Observers
Warren, Charles Wisonge and James Neilson
– France Donnay (BMGF), Rita Borg-Xuereb
(ICM), Diogo Ayres-de-Campos and CN
 WHO regional advisors Purandare (FIGO), Luc de Bernis (UNFPA),
– Karima Gholbzouri, Gunta Lazdane, Bremen Roland Kupka (UNICEF), Deborah Armbruster
de Mucio, Mari Nagai, Leopold Ouedraogo, and Karen Fogg (USAID)
Neena Raina and Susan Serruya
 WHO ANC Technical Working Group
 Technical contributions (incl scoping) – Edgardo Abalos, Emma Allanson, Monica
– Manzi Anatole, Rifat Atun, Himanshu Chamillard, Virginia Diaz , Soo Downe, Kenny
Bhushan, Jacquelyn Caglia, Chompilas Finlayson, Claire Glenton, Ipek Gurol-Urganci,
Chongsomchai, Morseda Chowdhury, Sonja Henderson, Frances Kellie, Khalid Khan,
Mengistu Hailemariam, Stephen Hodgins, Theresa Lawrie, Simon Lewin, Nancy Medley,
Annie Kearns, Rajat Khosla, Ana Langer, Jenny Moberg, Charles O'Donovan, Ewelina
Pisake Lumbiganon, Taiwo Oyelade, Jeffrey
Smith, Petra ten Hoope-Bender, James Tielsch Rogozinska and Inger Scheel
39 and Rownak Khan
 "To achieve the Every Woman Every Child vision and the Global Strategy for
Women's Children's and Adolescents' Health, we need innovative, evidence-
based approaches to antenatal care. I welcome these guidelines, which aim to
put women at the centre of care, enhancing their experience of pregnancy and
ensuring that babies have the best possible start in life."

Ban Ki-moon, UN Secretary-General

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 For further information

Dr Özge Tunçalp in RHR at [email protected]

Dr Maurice Bucagu in MCA at [email protected]
Dr Juan Pablo Peñas-Rosas in NHD at [email protected]

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