WHO recommendation on task shifting components of antenatal care delivery

WHO recommendation on task shifting components of antenatal care delivery


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



2. Task shifting the distribution of recommended nutritional supplements and intermittent preventive treatment in pregnancy (IPTp) for malaria prevention to a broad range of cadres, including auxiliary nurses, nurses, midwives and doctors is recommended.



Publication history

First published: November 2016

Updated: No update planned

Assessed as up-to-date: November 2016



  • Recommendations 1 and 2 have been adapted and integrated from Optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting (OptimizeMNH) (2012) (1).
  • The GDG noted that, while task shifting has an important role to play in allowing flexibility in health-care delivery in low-resource settings, policy-makers need to work towards midwife-led care for all women.
  • Lay health workers need to be recognized and integrated into the system, and not be working alone, i.e. task shifting needs to occur within a team approach.
  • The mandate of all health workers involved in task shifting programmes needs to be clear.
  • In a separate guideline on HIV testing services (2), WHO recommends that lay providers who are trained and supervised can independently conduct safe and effective HIV testing using rapid tests.
  • The GDG noted that it may be feasible to task shift antenatal ultrasound to midwives with the appropriate training, staffing, mentoring and referral systems in place.
  • Further research is needed on the mechanism of effect of MLCC and whether continuity of care can be task shifted.
  • Further information on this recommendation can be found in the OptimizeMNH guideline (1), available at:


  • Promotion of health-related behaviours, includie promotion of the following: care-seeking behaviour and ANC utilization; birth preparedness and complication readiness; sleeping under insecticide-treated bed-nets; skilled care for childbirth; companionship in labour and childbirth; nutritional advice; nutritional supplements; HIV testing during pregnancy; exclusive breastfeeding; postnatal care and family planning; immunization according to national guidelines.



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 the optimization of health worker roles through task shifting be used to improve access to ANC?


Evidence base

Further information and considerations related to these recommendations 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 did not identify any priority question related to this recommendation.


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




  1. WHO recommendations: optimizing health worker roles to improve access to key maternal and newborn health interventions through task shifting. Geneva: World Health Organization; 2012 (http://apps.who.int/iris/ bitstream/10665/77764/1/9789241504843_ eng.pdf, accessed 28 September 2016).
  2. Consolidated guidelines on HIV testing services 2015. Geneva: World Health Organization; 2015 (http://apps.who.int/iris/ bitstream/10665/179870/1/9789241508926_ eng.pdf, accessed 29 September 2016).
  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).


Citation: WHO Reproductive Health Library. WHO recommendation on task shifting components of antenatal care delivery. (November 2016). The WHO Reproductive Health Library; Geneva: World Health Organization.