Malaria in Pregnancy by malj


									   Antenatal Care
   in Poor Countries

Stephen Gloyd
MCH in Developing Countries
January 2012
Antenatal Care Initiatives

 Reduce maternal mortality 75% by 2015

“Four Pillars”
 Family planning
 Prenatal care
 Clean birth
 Essential obstetric services at referral level
              (including availability of transport)

And…Improvement of womens' status

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

                               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

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Trends in

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

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Number of visits to ANC by region

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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
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Antenatal care and delivery

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

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

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Prenatal care vs
attended birth and post partum care

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Components of prenatal care:

   Health education
   Screening
   Diagnosis and treatment
   Referral

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

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Perinatal Morbidity and Mortality

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

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

Note: Mortality reduction requires secondary and
  tertiary care

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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)

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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
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Prevalence of low birth
weight globally

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infections (STI)
among pregnant
women in

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

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Risk Approach

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

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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

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  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
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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
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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

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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

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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

 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

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Prevention and Control of
Malaria during Pregnancy
Malaria and Pregnancy

 30 million African women are pregnant yearly
 Malaria is more frequent and complicated during
 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

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Effects of Malaria on Pregnant

 All pregnant women in malaria-endemic areas are at
   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

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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

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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

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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
 Three doses of sulfadoxine-pyrimethamine (SP) should
   be given to all pregnant women after quickening and at
   least 1 month apart

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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

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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

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Managing Uncomplicated Malaria

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

  Manage fever
    Analgesics, tepid sponging

  Diagnose and treat anemia
  Provide fluids

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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
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      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
 Health promotion

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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

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 Number of antenatal care visits

WHO multi-center study - number of visits reduced
  without affecting outcome for mother or baby
 Minimum of 4 visits (see table) – with quality
 Individualized delivery plan depending on risk
 One PNC visit at referral hospital
 Health promotion (to individual and community)
 Emergency transport
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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
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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
Table 4 lists key interventions provided
to women before conception and
between pregnancies.
Table 5 addresses unwanted
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                                                                of Pregnancy &


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          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
     4.    Check for syphilis
                                                      9.   Advise and counsel on family
     5.    Check for HIV status
     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)
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  Other useful WHO guidelines

JHPEIGO. Inspired by George Povey Manual
1545879_eng.pdf                                      09.04_eng.pdf
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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

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Thank you!

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Some operational issues –
prenatal and birth care

Malaria in pregnancy (done by Paula Brentlinger?)

pMTCT (prevention of mother to child transmission of

Antenatal syphilis screening in Mozambique

Traditional birth attendant training

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Safe childbirth care

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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

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  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)

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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
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   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

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s of the

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