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Realizing the Potential of Antenatal Care
Meeting expectations in pregnancy
A pregnancy brings with it great hope for the future, and can give women a special and highly appreciated social status. It also brings great expectations of health care that is often willingly sought at this time. This explains, at least in part, the extraordinary success of antenatal care consultations. Women want confirmation that they are pregnant. At the same time they know that pregnancy can be dangerous, particularly in the developing world. In many countries pregnant women are likely to know of maternal deaths, stillbirths or newborn deaths among their own extended family or in their community. It is natural that demand is high for health care that can provide reassurance, solve problems that may arise and confirm the status conferred by pregnancy.
In high-income and middle-income countries today, use of antenatal care by pregnant women is almost universal – except among marginalized groups such as migrants, ethnic minorities, unmarried adolescents, the very poor and those living in isolated rural communities. Even in low-income settings, coverage rates for antenatal care – at least for one visit – are often quite high, certainly much higher than use of a skilled health care professional during childbirth.
There were noticeable increases in the use of antenatal care in developing countries during the 1990s. The greatest progress was seen in Asia, mainly as a result of rapid changes in a few large countries such as Indonesia (see Figure 3.1). Significant increases also took place in the Caribbean and Latin America, although countries in these areas already had relatively high levels of antenatal care. In sub-Saharan Africa, by contrast, antenatal care use increased only marginally over the decade (although levels in Africa are relatively high compared with those in Asia).
While antenatal care coverage has improved significantly in recent years, it is generally recognized that the antenatal care services currently provided in many parts of the world fail to meet the recommended standards. A huge potential thus remains insufficiently exploited. Although progress has been made globally in terms of increasing access and use of one antenatal visit, the proportion of women who are obtaining the recommended minimum of four visits is too low ( 1 ). The first consultation is often late in pregnancy, whereas maximum benefit requires an early initiation of antenatal care. Antenatal care is given by doctors, midwives and nurses and many other cadres of health workers ( 2 ). Little is known about the capacities of non-professional workers such as traditional birth attendants to deliver the known effective interventions during pregnancy.
Pregnancy – a time with its own dangers
Antenatal care is not just a way to identify women at risk of troublesome deliveries ( 3 , 4 ). While less prominent than the dangers that can occur during childbirth, those surrounding pregnancy are far from being negligible. Women expect that antenatal care will help them deal with the health problems that can occur during pregnancy itself. If left unchecked, some of these may threaten health and survival before the child is due to be born.
A substantial proportion of maternal deaths – perhaps as many as one in four – occur during pregnancy. Data on mortality during pregnancy, however, are very fragmentary ( 5 ). The proportion of maternal deaths during pregnancy varies significantly from country to country according to the importance of unsafe abortion, violence, and disease conditions in the area ( 6 , 7 ). In Egypt 9% of all maternal deaths occur during the first six months of pregnancy and a further 16% during the last three months ( 8 ).
Apart from complications of unsafe abortion, which can be prevented or dealt with by good post-abortion care, three types of health problems exist in pregnancy. First, the complications of pregnancy itself, second, diseases that happen to affect a pregnant woman and which may or may not be aggravated by pregnancy, and third, the negative effects of unhealthy lifestyles on the outcome of pregnancy. All have to be tackled by antenatal care.
Pregnancy has many complications that require care ( 9 ). In Lusaka, Zambia, nearly 40% of pregnancy-related referrals to the university teaching hospital were related to problems of the pregnancy itself, rather than to childbirth: 27% for threatened abortion or abortion complications, 13% for illness not specific to pregnancy such as malaria and infections, and 9% for hypertensive disorders of pregnancy ( 10 ). In a recent study of six west African countries, a third of all pregnant women were shown to experience some illness during pregnancy, (not including problems related to unsafe abortion) of whom 2.6% needed to be hospitalized ( 11 ).
Classic complications of pregnancy include pre-eclampsia and eclampsia which affect 2.8% of pregnancies in developing countries and 0.4% in developed countries ( 12 ), leading to many life-threatening cases and over 63 000 maternal deaths worldwide every year. Haemorrhage following placental abruption or placenta praevia affects about 4% of pregnant women ( 13 ). Less common, but very serious complications include ectopic pregnancy and molar pregnancy.
Diseases and other health problems can often complicate, or become more severe during, pregnancy. Malaria worsens during pregnancy, for example, and together with anaemia is responsible for 10 000 maternal deaths and 200 000 infant deaths per year (see Boxes 3.1 and 3.2). Mortality from HIV/AIDS during pregnancy can be significant in areas where prevalence is high. Tuberculosis is frequently encountered among pregnant women and is responsible for 9% of all deaths of women of reproductive age. Maternal malnutrition is a huge global problem, both as protein-calorie deficiency and as micronutrient deficiency. Paradoxically, obesity is also increasingly becoming an issue and leads to diabetes and birthing difficulties ( 45 ).
Mental ill-health in pregnancy appears to be more common than previously recognized. Although pregnancy has been regarded as a period of general psychological well-being for women ( 46 ), high rates of psychiatric morbidity in pregnant women have been reported, for example in Uganda ( 47 ). Pre-existing psychological disturbances can easily surface as depression, substance abuse or attempts at suicide, particularly when combined with a pregnancy that is unwanted. Rates of depression are at least as high, or higher, in late pregnancy than during the postpartum period ( 48 – 51 ).
In addition, many pregnant women are exposed to risks that are directly related to their way of life. Unhealthy lifestyles, including consumption of alcohol, tobacco and drugs, are dangerous for both mother and fetus, as they may lead to problems such as premature detachment of the placenta, sudden infant death syndrome, fetal alcohol syndrome and childhood developmental problems ( 52 ). Gender-based violence or exposure to hazards in the workplace may not be readily recognized by pregnant women as problems that health workers can help to resolve, but constitute major and underestimated public health problems (see Box 3.3).
Seizing the opportunities
Good antenatal care does more than just deal with the complications of pregnancy. Women are the largest group of health care users actively and willingly seeking care at clinics. This offers enormous opportunities to use antenatal care as a platform for programmes that tackle nutrition, HIV/AIDS, sexually transmitted infections, malaria and tuberculosis, among others. This and other opportunities have so far been insufficiently exploited. Three important opportunities during antenatal care should not be missed.
First, antenatal consultations offer an opportunity to promote healthy lifestyles that improve long-term health outcomes for the woman, her unborn child, and possibly her family. The promotion of family planning is the foremost example of this and can have a positive impact on contraceptive use after birth. Some women actually prefer to discuss family planning methods during pregnancy or as part of postnatal care ( 64 , 65 ). Another example of an opportunity for prenatal health promotion is that of smoking cessation programmes in pregnancy, which appear to be successful ( 66 ). They reduce the risks of low birth weight and preterm birth, and improve the pregnant woman’s health in the long term as well.
Second, antenatal care provides an opportunity to establish a birth plan ( 67 ). Apart from planning the birth, making the plan is a chance to inform women and their families of the potential for unexpected events. Birth preparedness itself includes planning the desired place of birth, the preferred birth attendant and birth companion, and finding out the location of the closest appropriate care facility. It also involves securing funds for birth-related and emergency expenses, finding transport for facility-based birth and identifying compatible blood donors in case of emergency. Birth planning has been used in many developed countries for more than a decade with beneficial effects ( 68 – 70 ), and has been introduced with success in developing countries as well, albeit on too limited a scale so far.
Third, the antenatal care consultation is an opportunity to prepare mothers for parenting and for what will happen after the birth. Women and their families can learn how to improve their health and seek help when appropriate, and, most importantly, how to take care of the newborn child. Advice on parenting skills is particularly important for pregnant adolescents and women with low self-esteem ( 71 ), and can improve the care that newborns and children will receive in the future ( 72 ). It helps to build a healthy family environment that is responsive to the child’s needs.
Critical directions for the future
Antenatal care started out in the first half of the 20th century as a means to educate "ignorant" women with an emphasis on the welfare of the infant and child. This was a response to what had been identified as inadequate devotion to maternal duty resulting in the poor physical stock of nations ( 73 ). In the 1950s it was used as an instrument for screening, so that women at higher risk of complications could be identified. Although antenatal care turned out to be a poor screening instrument, few people would deny that many pregnancy complications, concurrent illnesses and health problems can be dealt with in an antenatal care consultation that focuses on effective interventions.
Antenatal care has come a long way, but can go much further. Four directions are critical: to rationalize the rituals of care, to roll out antenatal care as a platform for a number of other key health programmes, to establish communication with women more effectively, and to avoid the overmedicalization that can do more harm than good. Most importantly, the unfinished agenda of reaching all women who are pregnant should be tackled.
All too often, antenatal care is still more a question of ritual than of effective interventions. Many of the tests and procedures carried out during a traditional antenatal consultation have very little scientific merit ( 74 ). Many ineffective interventions, such as routine weighing of the woman at each consultation to assess maternal well-being and fetal growth, could be dispensed with ( 75 ). They take up valuable time which could be more usefully dedicated to counselling women on healthy lifestyles and health problems such as the detection and management of existing diseases.
This interaction between antenatal care and coping with women’s circumstances and pre-existing diseases is the most underestimated aspect of care in pregnancy. The potential for antenatal care to be much more far-reaching in this respect has not been fully exploited. As a platform for other health programmes such as HIV/AIDS and other sexually transmitted infections, malaria, TB and family planning, the resource of antenatal care is invaluable. WHO guidelines are readily available ( 42 ) to advise on care, prevention and treatment of diseases during pregnancy. Moreover, pregnancy is a time when a dialogue about health and relevant social issues can be established between women and health services staff. Establishing communication with women and linking up the medical and social worlds will make care more human, and ultimately more responsive.
A frequently forgotten issue is that of supply-driven overmedicalization of normal pregnancies, sometimes for reasons of financial gain. Overmedicalized care can needlessly damage the health of both mothers and babies and expose households to unnecessary expenditure. All too often, sophisticated investigations such as ultrasound scanning are performed without justification at every antenatal visit, while useful procedures such as blood pressure measurement are neglected and the establishment of birth plans and counselling on existing health problems are omitted. This has gone to extremes in some countries, where ultrasound is used to detect female fetuses for the purposes of sex-selective abortion.
In terms of coverage, there is some way to go to provide at least four care contacts during each pregnancy, starting early enough to ensure that effective interventions are used. Women need providers who are skilled enough to offer care that is linked into a health care system that has continuity with childbirth care. The barriers to extending coverage are twofold. First, in some areas no services are offered, implying the need for outreach or services that can be physically accessed. Second, services are often not responsive enough. Complaints of unhelpful and rude health personnel, unexpected and unfair costs, unfriendly opening hours and the lack of involvement of male partners are not uncommon. Relatively straightforward changes to the arrangements of how antenatal care sessions are run (for instance not limiting antenatal care to one session per week) can sometimes make significant improvements to uptake. Adolescent girls are particularly vulnerable in this respect. Services that are responsive to them and young women will make a great contribution to the expansion of antenatal care. The question should not be "why do women not accept the service that we offer?", but "why do we not offer a service that women will accept?" ( 76 ).
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