Addressing the maternal and neonatal adverse outcome through the implementation of the new WHO ANC guideline Joint RPA /RSOG Scientific Conference + From 11 th to 13 th Sept 2019 Presentation by Dr David Ntirushwa , Consultant Obstetrician and Gynecologist University Teaching Hospital of Kigali
+ Outlines Background What is new new and benefits compared to the FANC Sample recommendations How does the new ANC affect our current practices
+ Background Despite global efforts to improve maternal and child health and important successes in MDGs era Pregnancy related death after 2015 remained unucceptably high In 2015: 303000 women died from pregnancy related causes 2.7 million babies died during the first 28 days of life and 2.6 million babies were stillborn Globally only 64% of women receive ANC 4 or more times during their pregnancy
+ Status of maternal health indicators Trends of Maternal Mortality Ratio in Rwanda Rwanda is among few Countries which have managed to achieve MDG 4 and 5.
+ Status of maternal health indicators Trends in ANC and deliveries in Rwanda Once pregnant , women attending at least 1 ANC, Delivering at a Health facility and attended by Skilled Providers have gotten better
+ Challenge with MDG 4 and 5 Maternal death reduction has been spectacular but still high Under 5 mortality has also dramatically declined and the MDG 4 was achieved (U5MR of 54/1000LB) but neonatal mortality has been declining slowly Neonatal death represent more than 30 % of all under 5 five mortality
+ ANC is critical Enables timely and appropriate evidence-based actions related to health promotion, disease prevention, screening, and treatment Reduces complications Reduces stillbirths from pregnancy and and perinatal deaths childbirth Integrated care delivery throughout pregnancy
+ Previously: The 4-visit WHO ANC model Involves specific evidence- based interventions for all women Carried out at four critical times Also known as the Focused Antenatal Care Model (FANC) Part of Pregnancy, Childbirth, Postpartum and Newborn Care (PCPNC)
+ New 8 contacts ANC guideline Goal of the WHO 2016 recommendations is to improve utilization and quality of routine ANC care and improve maternal and neonatal outcome In Context of person –centered health and well-being as part of a broader ,right –based approach Successful implementation requires the integrated delivery of maternal , nutrition , immunization , antimalarial, TB, and HIV interventions ;ANC being the common platform. Countries vary based on: Which recommended interventions are applied Which one need to be introduced Which one need to be delivered with higher quality
+ What is the difference ? And what is new ?
+ 2016 WHO ANC model
2 + Contact versus visit The guideline uses the term ‘ contact ’ - it implies an active connection between a pregnant woman and a health care provider that is not implicit with the word ‘visit’. quality care including medical care, support and timely and relevant information In terms of the operationalization of this recommendation, ‘contact’ can take place at the facility or at community level be adapted to local context through health facilities or community outreach services ‘Contact’ helps to facilitate context-specific recommendations Interventions (such as malaria, tuberculosis) Health system (such as task shifting)
+ Comprehensiveness Provide recommendations on standard maternal and fetal assessment Nutrition during pregnancy Prevention and treatment of physiological problems commonly experienced during pregnancy And preventive interventions for certain contexts ( eg: malaria , HIV ….) The guideline also include recommendations on counseling and supporting women who may be experiencing intimate partner violence Guidance on how ANC services can be provided more effectively and in difference contexts
+ Better outcome based on evidences Recent evidences indicates that a higher frequency of ANC contacts is associated with reduced stillbirths Increased opportunity to detect and manage potential complications 8 or more contacts of ANC can reduce perinatal deaths by up to 8 per 1000 births when compared to 4 visits The new model increases maternal and fetal assessments to detect complications It improves communication between health providers and pregnant women , an therefore the likelihood of positive pregnancy outcomes The new guideline outline what care pregnant mother should receive at each of the contacts including counseling on healthy died , optimal nutrition , physical activity , tobacco and substance abuse , malaria and HIV prevention , blood tests and tetanus vaccination , fetal measurement including use of ultrasound ; and advise dealing with common physiological symptoms
1 + E.7: Antenatal care models with a minimum of eight contacts are recommended to reduce perinatal mortality and improve women’s experience of care. This GDG recommendation was informed by: Evidence suggesting increased perinatal deaths in 4-visit ANC model Evidence supporting improved safety during pregnancy through increased frequency of maternal and fetal assessment to detect complications Evidence supporting improved health system communication and support around pregnancy for women and families Evidence indicating that more contact between pregnant women and respectful, knowledgeable health care workers is more likely to lead to a positive pregnancy experience 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 11 to 15 contacts.
+ Guideline structure and sample of recommendation The guidelines is made of different recommendations which have been studies For each intervention the guideline precise whether the option is : Recommended Recommended under certain conditions : Research , targeted monitoring and evaluation or specific contexts Or whether the option is not recommended
+ Recommendations on ANC 49 recommendations were grouped into five topic areas: A. Nutritional interventions (14) B. Maternal and fetal assessment (13) C. Preventive measures (7) D. Interventions for common physiological symptoms (6) E. Health systems interventions to improve the utilization and quality of ANC (9) Including 10 recommendations relevant to routine ANC from other WHO guidelines
+ Sample of recommendations A minimum of eight contacts are recommended to reduce perinatal mortality and improve women’s experience of care. Counselling about healthy eating and keeping physically active during pregnancy. Daily oral iron and folic acid supplementation with 30 mg to 60 mg of elemental iron and 400 µg (0.4 mg) folic acid for pregnant women to prevent maternal anaemia, puerperal sepsis, low birth weight, and preterm birth. Tetanus toxoid vaccination is recommended for all pregnant women, depending on previous tetanus vaccination exposure, to prevent neonatal mortality from tetanus. One ultrasound scan before 24 weeks’ gestation (early ultrasound) is recommended for pregnant women to estimate gestational age, improve detection of fetal anomalies and multiple pregnancies, reduce induction of labour for post-term pregnancy, and improve a woman’s pregnancy experience. Health-care providers should ask all pregnant women about their use of alcohol and other substances (past and present) as early as possible in the pregnancy and at every antenatal visit.
+ What does the implementation of the guidelines brings to clinicians Improved quality of care for pregnant women Improve clinical effectiveness by implementing evidence based care in our daily practices Brings equity and hum right by offering the same minimun of care to all women Standardized practices among different health providers Improved patient satisfaction with better pregnancy experience Better maternal and neonatal outcome
+ THANK YOU
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