The World Health Organization has issued a new series of recommendations to improve quality of antenatal care to reduce the risk of stillbirths and pregnancy complications and give women a positive pregnancy experience. By focusing on a positive pregnancy experience, these new guidelines seek to ensure not only a healthy pregnancy for mother and baby, but also an effective transition to positive labour and childbirth and ultimately to a positive experience of motherhood.
Pregnancy-related deaths and diseases remain unacceptably high. In 2015, an estimated 303 000 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. While substantial progress has been made over the past two decades, increased access to, and use of, higher-quality health care during pregnancy and childbirth can prevent many of these deaths and diseases, as well as improve women and adolescent girls’ experience of pregnancy and childbirth. Globally, however, only 64% of women receive antenatal care four or more times throughout their pregnancy.
An important feature of these guidelines is their comprehensiveness. Not only do they provide recommendations on standard maternal and foetal assessments, but also on nutrition during pregnancy, on prevention and treatment of physiological problems commonly experienced during pregnancy (e.g. nausea, heartburn, etc.), and on preventative interventions for certain contexts (e.g. malaria and/or HIV endemic areas). The guidelines also include recommendations on counselling and supporting women who may be experiencing intimate partner violence. Guidance on how antenatal care services can be provided more effectively and in different contexts is also included.
“If women are to use antenatal care services and come back when it is time to have their baby, they must receive good quality care throughout their pregnancy.” says Dr Ian Askew, Director of Reproductive Health and Research, WHO. “Pregnancy should be a positive experience for all women and they should receive care that respects their dignity.”
WHO recommendations on antenatal care
"To achieve the Every Woman Every Child vision and the Global Strategy for Women's Children's and Adolescents' Health, we need innovative, evidence-based approaches to antenatal care. I welcome these guidelines, which aim to put women at the centre of care, enhancing their experience of pregnancy and ensuring that babies have the best possible start in life."
Ban Ki-moon, UN Secretary-General
In developing these guidelines, WHO brought together global experts to assess evidence from different sources (effectiveness reviews, qualitative evidence synthesis, test accuracy review and mixed method reviews) and 49 recommendations to guide countries on how to provide antenatal care services with proven effectiveness were identified.
The new guidance increases the number of contacts a pregnant woman has with health providers throughout her pregnancy from four to eight. Recent evidence indicates that a higher frequency of antenatal contacts by women and adolescent girls with a health provider is associated with a reduced likelihood of stillbirths. This is because of the increased opportunities to detect and manage potential complications. Eight or more contacts for antenatal care can reduce perinatal deaths by up to 8 per 1000 births when compared to 4 visits.
A woman’s ‘contact’ with her antenatal care provider should be more than a simple ‘visit’ but rather the provision of care and support throughout pregnancy. The guideline uses the term ‘contact’ as it implies an active connection between a pregnant woman and a health care provider that is not implicit with the word ‘visit’. The new model increases maternal and fetal assessments to detect complications, improves communication between health providers and pregnant women, and increases the likelihood of positive pregnancy outcomes. It recommends pregnant women to have their first contact in the first 12 weeks’ gestation, with subsequent contacts taking place at 20, 26, 30, 34, 36, 38 and 40 weeks’ gestation.
“More and better quality contacts between all women and their health providers throughout pregnancy will facilitate the uptake of preventive measures, timely detection of risks, reduces complications and addresses health inequalities,” says Dr Anthony Costello, Director of Maternal, Newborn, Child and Adolescent Health, WHO. “Antenatal care for first time mothers is key. This will determine how they use antenatal care in future pregnancies.”
The new guidelines outline what care pregnant women should receive at each of the contacts with the health provider, including counselling on healthy diet and optimal nutrition, physical activity, tobacco and substance use; malaria and HIV prevention; blood tests and tetanus vaccination; fetal measurements including use of ultrasound; and advice for dealing with common physiological symptoms such as nausea, back pain and constipation.
“Counselling about healthy eating, optimal nutrition and what vitamins or minerals women should take during pregnancy can go a long way in helping them and their developing babies stay healthy throughout pregnancy and beyond,” says Dr Francesco Branca, Director Department on Nutrition for Health and Development, WHO.
WHO recommendations on antenatal care for a positive pregnancy experience
Delivering antenatal care through the health system
By recommending an increase in the amount of contact a pregnant woman has with her health provider and by changing the way in which antenatal care can be delivered, WHO is seeking to improve the quality of antenatal care and reduce maternal and perinatal mortality among all populations, including adolescent girls and those in hard-to-reach areas or conflict settings.
In addition to clinical guidance, the new guidelines contain recommendations on health system interventions to improve the utilization and quality of antenatal care. The recommendations allow flexibility for countries to employ different options for the delivery of antenatal care based on their specific needs. This means, for example, care can be provided through midwives or other trained health personnel, delivered at health facilities or through community outreach services. The guidelines also incorporate recommendations on task shifting for the promotion of health-related behaviours as well as for the distribution of recommended nutritional supplements and malaria prevention.
Sample 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.
WHO recommendations on antenatal care for a positive pregnancy experience