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Malaria in Pregnancy

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					   Antenatal Care
   in Poor Countries


Stephen Gloyd
MCH in Developing Countries
January 2012
Antenatal Care Initiatives

MAKING PREGNANCY SAFER (WHO)
 Reduce maternal mortality 75% by 2015


SAFE MOTHERHOOD INITIATIVE (WHO-1988)
“Four Pillars”
 Family planning
 Prenatal care
 Clean birth
 Essential obstetric services at referral level
              (including availability of transport)


And…Improvement of womens' status

                           Antenatal Care             2
IMPORTANCE OF ANTENATAL CARE

 reduce high perinatal risk
 reduce high maternal risk (50x)
 major point of access to health care for
   women




                               Antenatal Care   3
Access to antenatal care

   Physical access
   Time and/or distance to facility
   Economic costs & barriers
   Cultural and social factors
   Quality of care




                      Antenatal Care   4
Trends in
Antenatal
care
1990-
2000




            Antenatal Care   5
Estimates of the proportion of pregnant women
who received some antenatal care (1996)




                    Antenatal Care              6
Number of visits to ANC by region




                Antenatal Care      7
Antenatal Care   8
Antenatal Care   9
Factors affecting the utilization of antenatal care in
developing countries: Systematic review of the literature
Bibha Simkhada Maureen PorterEdwin R. van Teijlingen Padam Simkhada. Journal
of Advanced Nursing, Jan 2008


    A systematic review of 28 papers -both quantitative and qualitative

    Factors most commonly associated with antenatal care uptake:
    Maternal education, husband's education, marital status, availability, cost,
    household income, women's employment, media exposure and having a history of
    obstetric complications. Also cultural beliefs.

    Parity had a statistically significant negative effect on adequate attendance. While
    women of higher parity tend to use antenatal care less, there is interaction with
    women's age and religion.

    Only one study examined the effect of the quality of antenatal services on
    utilization. None identified an association between the utilization of such services
    and satisfaction with them
Antenatal Care   11
Antenatal care and delivery




                 Antenatal Care   12
Timing of ANC visits
(most in 1st trimester except Africa)




                       Antenatal Care   13
Estimates of the proportion of deliveries
attended by skilled personnel (1996)




                     Antenatal Care         14
Prenatal care vs
attended birth and post partum care




                  Antenatal Care      15
Components of prenatal care:

   Health education
   Screening
   Diagnosis and treatment
   Referral

Screening/Dx
o Identify women at high risk [?usefulness]
o Intervene to prevent development of problems
o Dx and Rx pre-existing medical conditions
o Dx and Rx complications of pregnancy


                         Antenatal Care          16
Perinatal Morbidity and Mortality
                  (newborn)

   LBW
   Birth trauma, obstructed labor
   Infection
      amnionitis
      herpes
      gonorrhea
      syphilis
      streptococcus
      HIV
      Tetanus
   Abruptio Placenta
   Congenital malformations
   "other" (30%)
                      Antenatal Care   17
Maternal Morbidity and Mortality

(Five main causes)
     Hemorrhage
     Sepsis
     Eclampsia
     Obstructed Labor
     Abortion

Note: Mortality reduction requires secondary and
  tertiary care

                         Antenatal Care            18
Other Causes of
Maternal Morbidity and Mortality

         Hypertension
         Diabetes
         Heart Disease
         Hepatitis
         Anemia
         Malaria
         Tuberculosis
         STD
  Overall Morbidity: 3-12% of all pregnancies
                  (up to 37% in India)

                     Antenatal Care             19
Poor outcomes: 3465 birth registries in 30
hospitals of Cote d’Ivoire (1997)


Condition                       Rate per 1000
Normal                                     760
Stillbirth                                 44
Neonatal death                              6
LBW < 2500g                                190
 < 2000g                                    52
 <1500g                                     17
Eclampsia                                   2
Fetal disproportion                        13
Fetal distress                             15
Hemorrhage                                 22
Maternal deaths                             2
Others                                     12
Operative delivery                         36
                      Antenatal Care             20
Prevalence of low birth
weight globally




                  Antenatal Care   21
Antenatal Care   22
Sexually
transmitted
infections (STI)
among pregnant
women in
Mozambique




                   Antenatal Care   23
Preventability


   Overall Infant Deaths - 33% preventable (Nairobi)
   Syphilis:    100% preventable
         10% stillbirths
         20% Infant Mortality
         20% Congenital Syphilis
   Other causes:       % preventable not clear




                      Antenatal Care               24
Risk Approach

Identification of high risk factors
 Predictive (Previous fetal loss)
 Contribution (Grand multipara, young or old)
 Causation (syphilis, HIV, maternal malnutrition)




                       Antenatal Care                25
Risk Approach

Not believed an effective ANC strategy because:
 Complications cannot be predicted—all pregnant women
  are at risk for developing complications
 Risk factors are usually not direct cause of complications

 Many “low risk” women develop complications
      Have false sense of security
      Do not know how to recognize/respond to problems

 Most “high risk” women give birth without complications
      Thus, an inefficient use of scarce resources

                               Antenatal Care             26
  WHO working group
  on prenatal care 1994

 PNC should be individualized
 Part of overall, functional system
 Midwife usually most appropriate
 Include empowerment


WHO Antenatal Care Randomized Trial
      (Villar et al 2001)
 Manual for the Implementation of the New
  Model
                       Antenatal Care        27
Current state of Prenatal Care 2008
Too many interventions
 Poor quality of care for interventions that work
 Need to focus on a FEW interventions based on epidemiology


Interventions that are cheap and effective
    pMTCT (HIV screening and prophylaxis)
    Malaria  IPT (Intermittent Preventive Therapy)
    Syphilis screening and Rx
    Iron therapy
    Tetanus immunization
    Family planning
    Nutritional    supplementation
                              Antenatal Care                   28
Other interventions that need more study
(though most of these are recommended)



  STD identification and treatment
  Routine anti parasite drugs
  Waiting houses
  Diabetes screening (depends on prevalence)
  Management and treatment of HTN




                    Antenatal Care              29
HIV in pregnancy
 Prevention of HIV transmission (pMTCT)
    Opt-in vs opt out
    Single dose Niverapine vs AZT vs HAART
    Efficiency of treatment



 Care for HIV positive mother during pregnancy
    Special nutritional needs
    Social needs, stigma



 HAART in pregnancy
    Toxicity (NVP, AZT)
    Patient flow and adherence

                            Antenatal Care        30
Prevention of Mother to Child
Transmission of HIV (pMTCT)

   Short term ARVs reduce transmission by > 50%
   AZT vs Nevirapine
   Cost-effectiveness based on prevalence
   Effectiveness depends on adequate follow up of women
       HIV+ to counseling
       Links between prenatal care and hospital

Implementation
 Not necessary to wait until everything is in place
 Important to involve PLWAs
 Community consultation critical
 Counselors need training
 Mothers need support and follow up (including psychosocial)
 Works best in conjunction with HAART




                               Antenatal Care                   31
Prevention and Control of
Malaria during Pregnancy
Malaria and Pregnancy

 30 million African women are pregnant yearly
 Malaria is more frequent and complicated during
  pregnancy
 In malaria-endemic areas, malaria during pregnancy
  may account for:
    Up to 15% of maternal anemia
    5–14% of low birthweight
    30% of “preventable” low birthweight




                       Antenatal Care               33
Effects of Malaria on Pregnant
Women

 All pregnant women in malaria-endemic areas are at
    risk
   Parasites attack and destroy red blood cells
   Malaria causes up to 15% of anemia in pregnancy
   Can cause severe anemia
   In Africa, anemia due to malaria causes up to
    10,000 maternal deaths per year



                       Antenatal Care                 34
Malaria Prevention and Treatment
during Pregnancy

 Focused antenatal care (ANC) with health education
  about malaria
 Use of insecticide-treated nets (ITNs)
 Intermittent preventive treatment (IPT)
 Case management of women with symptoms and
  signs of malaria




                      Antenatal Care               35
Benefits of Insecticide-Treated Nets

 Prevent mosquito bites
 Protect against malaria, resulting in less:
     Anemia
     Prematurity and low birthweight
     Risk of maternal and newborn death

 Help people sleep better
 Promote growth and development of fetus and
  newborn


                         Antenatal Care         36
Intermittent Preventive Treatment

 Every pregnant woman living in an area of high malaria
   transmission has malaria parasites in her blood or
   placenta, whether or not she has symptoms of malaria
 Although a pregnant woman with malaria may have no
   symptoms, malaria can still affect her and her unborn
   child
 Three doses of sulfadoxine-pyrimethamine (SP) should
   be given to all pregnant women after quickening and at
   least 1 month apart


                       Antenatal Care                  37
Intermittent Preventive Treatment:
Dose and Timing

 Each dose is three tablets of sulfadoxine 500 mg +
  pyrimethamine 25 mg
 Ideally, a dose is given at each ANC visit after
  quickening, but at least 1 month apart
 Healthcare provider should dispense dose and
  directly observe client taking dose




                        Antenatal Care                 38
Intermittent Preventive Treatment:
Contraindications to Using SP

 First trimester: Be sure quickening has occurred and
  woman is at least 16 weeks pregnant
 Allergy to SP or other sulfa drugs: Ask about sulfa drug
  allergies before giving SP
 Taking co-trimoxazole, or other sulfa-containing drugs:
  Ask about use of these medicines before giving SP
 Not more frequently than monthly: Be sure at least 1 month
  has passed since the last dose of SP




                               Antenatal Care                  39
Managing Uncomplicated Malaria

  Provide first-line anti-malarial drugs
     Follow country guidelines

  Manage fever
    Analgesics, tepid sponging

  Diagnose and treat anemia
  Provide fluids




                        Antenatal Care      40
Active Syphilis Infection in Pregnancy

 Adverse outcome in 50-70% of infected pregnancies
 In sub-Saharan Africa, prenatal syphilis positivity varies
  between 4-16% (average ~ 9%)
 In Zambia & Malawi, 26-42% stillbirths attributed to syphilis
 8% of IMR due to syphilis
 Screening is effective & inexpensive
      Basic Screening Test (RPR) costs US$0.25-0.35, takes 15-20
       minutes. ICS (Rapid test) ~$0.50, 2 minutes.
      Treatment: 3 doses (1 per week) of Benzathine Penicillin at
       US$1.00 per dose
 Estimated screening of women in ANC in Africa - 38%
 Obstacles: cost, organization of services
 Missed opportunities for screening >1 million
                                                                     41
                              Antenatal Care
      Focused Antenatal Care

  An approach to ANC that emphasizes:
 Evidence-based, goal-directed actions
 Individualized, woman-centered care
 Early detection and treatment of problems and complications
 Prevention of complications and disease
 Quality vs. quantity of visits
 Care by skilled providers
 Birth preparedness & complication
  readiness
 Health promotion




                                   Antenatal Care               42
No Longer Recommended

 Numerous, routine visits
    Burden to women and healthcare system



 Routine measurements and examinations:
    Maternal height and weight
    Ankle edema
    Fetal position before 36 weeks



 Care based on risk assessment

                       Antenatal Care        43
Antenatal Care   44
 Number of antenatal care visits

WHO multi-center study - number of visits reduced
  without affecting outcome for mother or baby
Recommendations
 Minimum of 4 visits (see table) – with quality
  services
 Individualized delivery plan depending on risk
  profile
 One PNC visit at referral hospital
 Health promotion (to individual and community)
 Emergency transport
                    Antenatal Care              45
Scheduling and Timing of ANC Visits

 First visit: By 16 weeks or when woman first thinks she
  is pregnant
 Second visit: At 24–28 weeks or at least once in
  second trimester
 Third visit: At 32 weeks

 Fourth visit: At 36 weeks

 Other visits: If complication occurs, followup or
  referral is needed, woman wants to see provider, or
  provider changes frequency based on findings (history,
  exam, testing) or local policy
                         Antenatal Care                    46
  WHO MNH
  guidelines

5 pages of tables
Table 1 lists interventions delivered to
the mother during pregnancy, childbirth
and in the postpartum period, and to the
newborn soon after birth.
Table 2 lists the places where care
should be provided through health
services, the type of providers required
and the recommended interventions and
commodities at each level.
Table 3 lists practices, activities and
support needed during pregnancy and
childbirth by the family, community and
workplace.
Table 4 lists key interventions provided
to women before conception and
between pregnancies.
Table 5 addresses unwanted
pregnancies.
                                                  Antenatal Care
                 http://whqlibdoc.who.int/hq/2007/WHO_MPS_07.05_eng.pdf   47
Antenatal Care   48
                                                                IMPAC
                                                                Manual

                                                                Integrated
                                                                Management
                                                                of Pregnancy &
                                                                Childbirth

                                                                Guidelines
                                                                WHO
                                                                2006
http://whqlibdoc.who.int/publications/2006/924159084X_eng.pdf




                                               Antenatal Care            49
          IMPAC Manual
          Guideline detail for Antenatal Care

     1.    Assess the pregnant woman                  7.   Advice and counsel on
     2.    Check for pre-eclampsia                         nutrition and self care
     3.    Check for Anemia                           8.   Develop a birth & emergency
                                                           plan
     4.    Check for syphilis
                                                      9.   Advise and counsel on family
     5.    Check for HIV status
                                                           planning
     6.    Respond to observed signs
                                                      10. Advise on routine and follow
           or volunteered problems (no
                                                          up visits
           fetal mvmt, ruptured
           membranes, fever, disuria,                 11. Home delivery without a
           vaginal discharge, HIV,                        skilled attendant
           smoking, drugs, DV, SOB, TB)
                                                      12. Assess feasibility of ARV for
     7.    Give preventive measures                       pregnant woman
           (tetanus, Fe/folate,
           mebendazole, malaria, ITN)

http://whqlibdoc.who.int/publications/2006/924159084X_eng.pdf
                                               Antenatal Care                         50
  Other useful WHO guidelines




JHPEIGO. Inspired by George Povey Manual
http://whqlibdoc.who.int/publications/2007/924   http://whqlibdoc.who.int/hq/2010/WHO_MPS_
1545879_eng.pdf                                      09.04_eng.pdf
Antenatal Care   52
Problems with interventions                        (general):

Utilization is variable
Gestation at first visit (after sixth month)
Variable epidemiology of risk factors (Malaria, eclampsia, Anemia,
   pelvic size)

Cultural barriers
    identification of pregnancy, taboos
    reluctance to use family planning

Limitations of referral and transport
Sensitivity and specificity of risk factors


                              Antenatal Care                         53
Thank you!




             Antenatal Care   54
Some operational issues –
prenatal and birth care

Malaria in pregnancy (done by Paula Brentlinger?)

pMTCT (prevention of mother to child transmission of
  HIV

Antenatal syphilis screening in Mozambique

Traditional birth attendant training


                        Antenatal Care              55
Safe childbirth care




                  Antenatal Care   56
Antenatal Care   57
Inadequate health systems

Emergency obstetric care (EOC) requires -
 Surgical facilities
 Anesthesia
 Blood transfusion
 Manual delivery tools (VE, forceps)
 Medical treatment (HTN, Sepsis, shock)
 Family Planning




                    Antenatal Care          58
  Impact of Traditional Birth Attendant training in
  Rural Mozambique (1)


 MOH established a TBA program in
 Goals: reduce maternal and infant mortality & improve utilization
  of primary health care
 Over 8 years MOH trained >300 TBAs - supported by quarterly
  supervision, basic equipment, and annual refresher courses
 Surveys showed TBAs improved their knowledge of obstetric
  emergencies and skills in how to manage them
 An evaluation was planned to assess whether the program had
  met its initial goals (1995)




                                 Antenatal Care                  59
Impact of Traditional Birth Attendant training in
Rural Mozambique (2)


 A retrospective cohort study
 Comparison of maternal and newborn outcomes in
   40 communities where TBAs had been trained
   27 communities where TBAs had not yet been trained.
 In each community –respondents interviewed in 30 households
  closest to the trained TBA (or center of the community with no
  trained TBA) with pregnancies in the past 3 years
 Principal outcomes
      utilization of TBA or health facility services (delivery and ANC)
      outcome of pregnancy for mother and child
      utilization of other primary health care services
                                 Antenatal Care                            60
   Impact of Traditional Birth Attendant training
   in Rural Mozambique - RESULTS


 In TBA trained communities
      30% of these pregnant women utilized theTBAs
      40% managed to deliver at health facilities
 Overall, 70% of women preferred health facility midwives for
  their next birth (however, most users of trained TBAs preferred
  TBAs for their next birth)
 No difference in mortality rates (perinatal, neonatal, infant)
 MOH policy regarding TBA vs health facility support substantially
  changed after the study



                                Antenatal Care                     61
Basic
component
s of the
WHO
antenatal
care
program
(1994)




            Antenatal Care   62
Antenatal Care   63

				
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