WHO recommendation on antenatal care contact schedules

WHO recommendation on antenatal care contact schedules

 

Recommendation

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

(Recommended)

 

Publication history

First published: November 2016

Updated: No update planned

Assessed as up-to-date: November 2016

                

Remarks

  • The GDG stresses that the four-visit focused ANC (FANC) model does not offer women adequate contact with health-care practitioners and is no longer recommended. With the FANC model, the first ANC visit occurs before 12 weeks of pregnancy, the second around 26 weeks, the third around 32 weeks, and the fourth between 36 and 38 weeks of gestation. Thereafter, women are advised to return to ANC at 41 weeks of gestation or sooner if they experience danger signs. Each ANC visit involves specific goals aimed at improving triage and timely referral of high-risk women and includes educational components (1). However, up-to-date evidence shows that the FANC model, which was developed in the 1990s, is probably associated with more perinatal deaths than models that comprise at least eight ANC visits. Furthermore, evidence suggests that more ANC visits, irrespective of the resource setting, is probably associated with greater maternal satisfaction than less ANC visits.
  • The GDG prefers the word “contact” to “visit”, as it implies an active connection between a pregnant woman and a health-care provider that is not implicit with the word “visit”. In terms of the operationalization of this recommendation, “contact” can be adapted to local contexts through community outreach programmes and lay health worker involvement.
  • The decision regarding the number of contacts with a health system was also influenced by the following:

– evidence supporting improving safety during pregnancy through increased frequency of maternal and fetal assessment to detect problems;

– evidence supporting improving health system communication and support around pregnancy for women and families;

– evidence from HIC studies indicating no important differences in maternal and perinatal health outcomes between ANC models that included at least eight contacts and ANC models that included more (11–15) contacts (2);

– evidence indicating that more contact between pregnant women and knowledgeable, supportive and respectful health-care practitioners is more likely to lead to a positive pregnancy experience.

 

Background

In 2002, the WHO recommended a focused or goal-orientated approach to ANC to improve quality of care and increase ANC coverage, particularly in LMICs (1). The focused ANC (FANC) model, also known as the basic ANC model, includes four ANC visits occurring between 8 and 12 weeks of gestation, between 24 and 26 weeks, at 32 weeks, and between 36 and 38 weeks. Guidance on each visit includes specific evidence-based interventions for healthy pregnant women (called “goal-oriented”), with appropriate referral of high-risk women and those who develop pregnancy complications. The number of visits in this model is considerably fewer than in ANC models used in HICs. The GDG considered the available evidence and other relevant information on these interventions to determine whether they should be recommended for ANC. The GDG also considered existing recommendations from other WHO guidelines on task shifting and recruitment and retention of staff in rural areas.

 

Methods

The ANC recommendations are intended to inform the development of relevant health-care policies and clinical protocols. These recommendations were developed in accordance with the methods described in the WHO handbook for guideline development (3). In summary, the process included: identification of priority questions and outcomes, retrieval of evidence, assessment and synthesis of the evidence, formulation of recommendations, and planning for the implementation, dissemination, impact evaluation and updating of the guideline.

The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) (4) and Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) (5) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions. The DECIDE (Developing and Evaluating Communication Strategies to support Informed Decisions and Practice based on Evidence) (6) framework, an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation and approval of recommendations by the Guideline Development Group (GDG) – an international group of experts assembled for the purpose of developing this guideline – at three Technical Consultations between October 2015 and March 2016.

To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed.

In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years.

Further information on procedures for developing this recommendation are available here.

 

Recommendation question

For this recommendation, we aimed to answer the following question:

  • Should alternative models of ANC with four visits (FANC) be recommended instead of standard care of eight visits for the ANC of healthy pregnant women?

 

Evidence summary

The evidence on the effects of FANC (the four-visit ANC model) was derived from a Cochrane review on “reduced-visit” ANC models versus “standard” care models (with at least eight ANC visits planned) that included seven RCTs (2). Four individual RCTs were conducted in HICs (the United Kingdom and the USA) and three large cluster-RCTs were conducted in LMICs, including one conducted in Argentina, Cuba, Saudi Arabia and Thailand (7), and two conducted in Zimbabwe. The LMIC trials evaluated the FANC model compared with “standard” ANC models that planned for at least eight visits (1). Three clusterRCTs involving more than 50 000 women contributed data. The median number of visits achieved in the FANC arms of these trials ranged from four to five visits and the median number of visits achieved in the standard ANC arms ranged from four to eight visits.

Maternal outcomes

High-certainty evidence shows that FANC had little or no effect on caesarean section rates (1 trial, 24 526 women; RR: 1.00, 95% CI: 0.89–1.11), and low-certainty evidence suggests that it may make little or no difference to maternal mortality (3 trials, 51 504 women; RR: 1.13, 95% CI: 0.5–2.57). With regard to maternal satisfaction, outcomes were reported narratively in the review, as data were sparse. In a survey conducted among a subset of WHO recommendations on antenatal care for a positive pregnancy experience 102 women participating in the WHO trial, fewer women were satisfied with the frequency of visits in the FANC model than in the standard model (77.4% versus 87.2%) and women in the FANC model were less likely to be satisfied with the spacing between visits compared with the standard model (72.7% versus 81%). This evidence was not formally graded due to insufficient data.

Fetal and neonatal outcomes

Moderate-certainty evidence indicates that FANC probably increases perinatal mortality compared with “standard” ANC with more visits (3 trials, 51 323 women; RR: 1.15, 95% CI: 1.01–1.32). Based on this RR, the illustrative impact on perinatal mortality rates are shown in Box 4. Moderate-certainty evidence indicates that FANC probably has little or no effect on preterm birth (3 trials, 47 094 women; RR: 0.99, 95% CI: 0.91–1.08) and low birth weight (3 trials, 46 220 women; RR: 1.04, 95% CI: 0.97–1.12) compared with “standard” ANC. In addition, low-certainty evidence suggests that FANC probably makes little or no difference to SGA (3 trials, 43 094 women; RR: 1.01, 95% CI: 0.88–1.17).

Additional considerations

The GDG noted that the review authors explored reasons for the effect on perinatal mortality and the effect persisted in various exploratory analyses. In 2012, the WHO undertook a secondary analysis of perinatal mortality data from the WHO FANC trial (8). This secondary analysis, which included 18 365 low-risk and 6160 high-risk women, found an increase in the overall risk of perinatal mortality between 32 and 36 weeks of gestation with FANC compared with “standard” ANC in both low- and high-risk populations. It is not clear whether the philosophy of the FANC approach, with regard to improving quality of care at each ANC visit, was implemented effectively in the trials. However, if this element is neglected, a poorly executed FANC model may then simply represent reduced health provider contact, and a reduced opportunity to detect risk factors and complications, and to address women’s concerns.

The GDG panel considered unpublished findings of a two-year audit of perinatal mortality from the Mpumalanga region of South Africa that has implemented the FANC model (9). The audit from September 2013 to August 2015 comprised data of 149 308 births of neonates weighing more than 1000 g, among which there were 3893 perinatal deaths (giving a PMR of 24.8 per 1000 births). Stillbirth risk was plotted according to gestational age and three peaks in the occurrence of stillbirths were noted, one at around 31 weeks of gestation, another at around 37 weeks, and the third occurring at 40 weeks or more. When these data were compared with stillbirth data from another South Africa province, which uses a model of ANC that includes fortnightly ANC visits from 28 weeks of gestation, the latter showed a gradual rise in the overall stillbirth risk from 28 weeks, with a single (and lower) peak at 40 weeks or more, i.e. no additional peaks at 30 and 37 weeks. These data are consistent with those from the secondary analysis of the WHO trial and suggest that additional visits in the third trimester may prevent stillbirths.

The GDG also considered the evidence from the Cochrane review on reduced visit ANC models of at least eight visits versus “standard” ANC models with 11–15 visits from four RCTs in HICs (2). Low-certainty evidence suggested that the reduced-visit model (with at least eight visits) may be associated with increased preterm birth (3 trials; RR: 1.24, 1.01–1.52), but no other important effects on health outcomes were noted. In general, however, evidence from these individual studies also suggests that the reduced-visit models may be associated with lower women’s satisfaction.

The GDG considered unpublished evidence from four country case studies (Argentina, Kenya, Thailand and the United Republic of Tanzania) where the FANC model has been implemented (10). Provider compliance was noted to be problematic in some settings, as were shortages of equipment, supplies and staff. Integration of services was found to be particularly challenging, especially in settings with a high prevalence of endemic infections (e.g. malaria, TB, sexually transmitted infections, helminthiasis). Guidance on implementation of the FANC model in such settings was found to be inadequate, as was the amount of time allowed within the four-visit model to provide integrated care. Findings on provider compliance from these case studies are consistent with published findings from rural Burkina Faso, Uganda and the United Republic of Tanzania (11). Health-care providers in this study were found to variably omit certain practices from the FANC model, including blood pressure measurement and provision of information on danger signs, and to spend less than 15 minutes per ANC visit. Such reports suggest that fitting all the components of the FANC model into four visits is difficult to achieve in some low-resource settings where services are already overstretched. In addition, in low-resource settings, when the target is set at four ANC visits, due to the various barriers to ANC use, far fewer than four visits may actually be achieved.

Programmatic evidence from Ghana and Kenya indicates similar levels of satisfaction between FANC and standard ANC, with sources of dissatisfaction with both models being long waiting times and costs associated with care (12, 13). Emotional and psychosocial needs are variable and the needs of vulnerable groups (including adolescent girls, displaced and war-affected women, women with disabilities, women with mental health concerns, women living with HIV, sex workers, ethnic and racial minorities, among others) can be greater than for other women. Therefore, the number and content of visits should be adaptable to local context and to the individual woman.

Resources

Two trials evaluated cost implications of two models of ANC with reduced visits, one in the United Kingdom and one in two LMICs (Cuba and Thailand). Costs per pregnancy to both women and providers were lower with the reduced visits models in both settings. Time spent accessing care was also significantly shorter with reduced visits models. In the United Kingdom trial, there was an increase in costs related to neonatal intensive care unit stays in the reduced visit model.

Equity

Preventable maternal and perinatal mortality is highest among disadvantaged populations, which are at greater risk of various health problems, such as nutritional deficiencies and infections, that predispose women to poor pregnancy outcomes. This suggests that, in LMICs, more and better quality contact between pregnant women with health-care providers would help to address health inequalities.

Acceptability

Evidence from high-, medium- and low-resource settings suggests that women do not like reduced visit schedules and would prefer more contact with antenatal services (moderate confidence in the evidence) (14). Women value the opportunity to build supportive relationships during their pregnancy (high confidence in the evidence) and for some women, especially in LMIC settings, the reduced visit schedule may limit their ability to develop these relationships, both with health-care professionals and with other pregnant women (low confidence in the evidence). In some low-income settings where women rely on husbands or partners to financially support their antenatal visits, the reduced visit schedule limits their ability to procure additional finance (low confidence in the evidence). However, the reduced visit schedule may be appreciated by some women in a range of LMIC settings because of the potential for cost savings, e.g. loss of domestic income from extra clinic attendance and/or associated travel costs (low confidence in the evidence). Indirect evidence also suggests that women are much more likely to engage with antenatal services if care is provided by knowledgeable, kind health-care professionals who have the time and resources to deliver genuine woman-centred care, regardless of the number of WHO recommendations on antenatal care for a positive pregnancy experience 104 visits (high confidence in the evidence). Specific evidence from providers relating to reduced visit schedules or the adoption of FANC is sparse and, in some LMICs, highlights concerns around the availability of equipment and resources, staff shortages and inadequate training – issues that are pertinent to all models of ANC delivery in low-resource settings.

Feasibility

Qualitative evidence suggests that some providers in LMICs feel that the reduced visit schedule is a more efficient use of staff time and is less likely to deplete limited supplies of equipment and medicine (moderate confidence in the evidence) (15). Programme reports from Ghana and Kenya stress that inadequate equipment, supplies, infrastructure and training may hamper implementation (12, 13). Providers have also raised concerns about the difficulty of incorporating all of the FANC components into relatively short appointments, especially in LMICs (Burkina Faso, Uganda and the United Republic of Tanzania) where services are already stretched (11, 15).

Further information and considerations related to this recommendation can be found in the WHO guidelines, available at:

http://apps.who.int/iris/bitstream/10665/250796/8/9789241549912-websupplement- eng.pdf?ua=1

 

Implementation considerations

  • The successful introduction of evidence-based policies related to antenatal care into national programmes and health care services depends on well-planned and participatory consensus-driven processes of adaptation and implementation. These processes may include the development or revision of national guidelines or protocols based on this recommendation.
  • The recommendation should be adapted into locally-appropriate documents and tools that are able to meet the specific needs of each country and health service. Modifications to the recommendation, where necessary, should be justified in an explicit and transparent manner.
  • An enabling environment should be created for the use of this recommendation, including changes in the behaviour of health care practitioners to enable the use of evidence-based practices.
  • Local professional societies may play important roles in this process and an all-inclusive and participatory process should be encouraged.
  • Antenatal care models with a minimum of eight contacts are recommended to reduce perinatal mortality and improve women’s experience of care. Taking this as a foundation, the GDG reviewed how ANC should be delivered in terms of both the timing and content of each of the ANC contacts, and arrived at a new model – the 2016 WHO ANC model – which replaces the previous four-visit focused ANC (FANC) model. For the purpose of developing this new ANC model, the ANC recommendations were mapped to the eight contacts based on the evidence supporting each recommendation and the optimal timing of delivery of the recommended interventions to achieve maximal impact.

 

Research implications

The GDG identified this priority question related to this recommendation

  • Can the 2016 WHO ANC model with a minimum of eight contacts impact the quality of ANC in LMICs, and what is the effect on health, values, acceptability, resources, feasibility and equity parameters?

 

Related links

WHO recommendations on antenatal care for a positive pregnancy experience

(2016) - full document and evidence tables

Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

WHO Programmes: Sexual and Reproductive health

Maternal Health

 

 

References

  1. WHO antenatal care randomized trial: manual for the implementation of the new model. Geneva: World Health Organization; 2002 (http://www.who.int/reproductivehealth/ publications/maternal_perinatal_health/ RHR_01_30/en/, accessed 6 October 2016)
  2. Dowswell T, Carroli G, Duley L, Gates S, Gülmezoglu AM, Khan-Neelofur D, Piaggio G. Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane Database Syst Rev. 2015;(7):CD000934
  3. WHO handbook for guideline development, 2nd edition. Geneva: World Health Organization; 2014 (http://www.who.int/kms/handbook_2nd_ ed.pdf, accessed 6 October 2016).
  4. GRADE [website]. The GRADE Working Group; 2016 (http://gradeworkinggroup.org/, accessed 27 October 2016).
  5. GRADE-CERQual [website]. The GRADECERQual Project Group; 2016 (https://cerqual. org/, accessed 27 October 2016).
  6. The DECIDE Project; 2016 (http://www.decide-collaboration.eu/, accessed 27 October 2016).
  7. Villar J, Ba’aqeel H, Piaggio G, Lumbiganon P, Miguel Belizan J, Farnot U et al. WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care. Lancet. 2001;357(9268):1551–64.
  8. Vogel JP, Habib NA, Souza JP, Gulmezoglu AM, Dowswell T, Carroli G et al. Antenatal care packages with reduced visits and perinatal mortality: a secondary analysis of the WHO Antenatal Care Trial. Reprod Health. 2013;10:19. doi:10.1186/1742-4755-10-19.
  9. Pattinson R. 2016. Audit of Mpumalanga stillbirths. Presentation at ANC guideline development group meeting (21–23 March). Geneva: World Health Organization; 2016.
  10. Gurol I, Scheel I. Adoption and implementation of ANC guidelines at large scale. Presentation at ANC guideline development group meeting (21– 23 March). Geneva: World Health Organization; 2016.
  11. Conrad P, Schmid G, Tientrebeogo J, Moses A, Kirenga S, Neuhann F et al. Compliance with focused antenatal care services: do health workers in rural Burkina Faso, Uganda and Tanzania perform all ANC procedures? Trop Med Int Health. 2012;17:300–7. doi:10.1111/ j.1365-3156.2011.02923.x.
  12. Nyarko P, Birungi H, Armar-Klamesu M, Arhinful D, Degarnus S, Odoi-Agyarko H, Brew G. Acceptability and feasibility of introducing the WHO focused antenatal care package in Ghana. FRONTIERS final report. Washington (DC): Population Council; 2006 (http://citeseerx.ist.psu.edu/viewdoc/ download?rep=rep1&type=pdf&doi=10.1.1.175. 8828, accessed 28 September 2016).
  13. Birungi H, Onyango-Ouma W. Acceptability and sustainability of the WHO focused antenatal care package in Kenya. Frontiers in Reproductive Health Program, Population Council; 2006 (http://citeseerx.ist.psu.edu/viewdoc/ download?doi=10.1.1.175.8488&rep=rep1&type= pdf, accessed 28 September 2016).
  14. Von Both C, Fleßa S, Makuwani A, Mpembeni R, Albrecht J. How much time do health services spend on antenatal care? Implications for the introduction of the focused antenatal care model in Tanzania. BMC Pregnancy Childbirth. 2006;6:22.
  15. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Factors that influence the use of routine antenatal services by pregnant women: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2016;(10):CD012392
  16. Downe S, Finlayson K, Tunçalp Ö, Gülmezoglu AM. Factors that influence the provision of good quality routine antenatal care services by health staff: a qualitative evidence synthesis. Cochrane Database Syst Rev. 2016

 

Citation: WHO Reproductive Health Library. WHO recommendation on group antenatal care. (November 2016). The WHO Reproductive Health Library; Geneva: World Health Organization.