WHO recommendations on antenatal care for a positive pregnancy experience

E. Health systems interventions to
improve the utilization and quality
of ANC
Background
There is a multitude of interventions that can be
employed to improve the utilization and quality of
ANC depending on the context and setting. For the
purposes of this guideline, the GDG considered the
following interventions:
1. Women-held case notes (home-based records)
2. Midwife-led continuity of care models
3. Group ANC
4. Community-based interventions to improve
communication and support
5. Task shifting
6. Recruitment and retention of staff
7. ANC contact schedules.
How to deliver the type and quality of ANC that
women want is a vast and complex field of research.
Interventions designed to increase staff competency,
to improve staff well-being, and other interventions
(e.g. financial incentives) to increase access and use
of ANC are broad topics that were considered beyond
the scope of this guideline.
• nWomen-held case notes: In many countries,
women are given their own case notes (or homebased
records) to carry during pregnancy. Case
notes may be held in paper (e.g. card, journal,
handbook) or electronic formats (e.g. memory
stick), and women are expected to take them
along to all health visits. If women then move, or
are referred from one facility to another, and in the
case of complications where immediate access
to medical records is not always possible, the
practice of women-held case notes may improve
the availability of women’s medical records
(168). Women-held case notes might also be an
effective tool to improve health awareness and
client–provider communication (169). Inadequate
infrastructure and resources often hamper efficient
record-keeping, therefore, case notes may be
less likely to get lost when held personally. In
addition, the practice may facilitate more accurate
estimation of gestational age, which is integral to
evidence-based decision-making, due to improved
continuity of fetal growth records (170).
• nMidwife-led continuity of care (MLCC) models:
Midwives are the primary providers of care in
many ANC settings (171). In MLCC models, a
known and trusted midwife (caseload midwifery),
or small group of known midwives (team
midwifery), supports a woman throughout the
antenatal, intrapartum and postnatal period, to
facilitate a healthy pregnancy and childbirth, and
healthy parenting practices (172). The MLCC
model includes: continuity of care; monitoring
the physical, psychological, spiritual and social
well-being of the woman and family throughout
the childbearing cycle; providing the woman with
individualized education, counselling and ANC;
attendance during labour, birth and the immediate
postpartum period by a known midwife; ongoing
support during the postnatal period; minimizing
unnecessary technological interventions; and
identifying, referring and coordinating care for
women who require obstetric or other specialist
attention (173). Thus, the MLCC model exists
within a multidisciplinary network in which
consultation and referral to other care providers
occurs when necessary. The MLCC model is
usually aimed at providing care to healthy women
with uncomplicated pregnancies.
n • Group ANC: ANC conventionally takes the form
of a one-on-one consultation between a pregnant
woman and her health-care provider. However,
group ANC integrates the usual individual
pregnancy health assessment with tailored group
educational activities and peer support, with
the aim of motivating behaviour change among
pregnant women, improving pregnancy outcomes,
and increasing women’s satisfaction (174). The
intervention typically involves self-assessment
activities (e.g. blood pressure measurement),
group education with facilitated discussion, and
Chapter 3. Evidence and <strong>recommendations</strong> 85