WHO recommendations on antenatal care for a positive pregnancy experience

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Zinc supplements Multiple micronutrient supplements Vitamin B6 (pyridoxine) supplements Vitamin E and C supplements Vitamin D supplements Restricting caffeine intake A.5: Zinc supplementation for pregnant women is only recommended in the context of rigorous research. A.6: Multiple micronutrient supplementation is not recommended for pregnant women to improve maternal and perinatal outcomes. A.7: Vitamin B6 (pyridoxine) supplementation is not recommended for pregnant women to improve maternal and perinatal outcomes. A.8: Vitamin E and C supplementation is not recommended for pregnant women to improve maternal and perinatal outcomes. A.9: Vitamin D supplementation is not recommended for pregnant women to improve maternal and perinatal outcomes. j A.10: For pregnant women with high daily caffeine intake (more than 300 mg per day), k lowering daily caffeine intake during pregnancy is recommended to reduce the risk of pregnancy loss and low-birth-weight neonates. Context-specific recommendation (research) Not recommended Not recommended Not recommended Not recommended Context-specific recommendation B. Maternal and fetal assessment l Recommendation Type of recommendation B.1: Maternal assessment Anaemia B.1.1: Full blood count testing is the recommended method for diagnosing anaemia in pregnancy. In settings where full blood count testing is not available, on-site haemoglobin testing with a haemoglobinometer is recommended over the use of the haemoglobin colour scale as the method for diagnosing anaemia in pregnancy. Context-specific recommendation <strong>WHO</strong> <strong>recommendations</strong> on antenatal care for a positive pregnancy experience Asymptomatic bacteriuria (ASB) Intimate partner violence (IPV) B.1.2: Midstream urine culture is the recommended method for diagnosing asymptomatic bacteriuria (ASB) in pregnancy. In settings where urine culture is not available, on-site midstream urine Gramstaining is recommended over the use of dipstick tests as the method for diagnosing ASB in pregnancy. B.1.3: Clinical enquiry about the possibility of intimate partner violence (IPV) should be strongly considered at antenatal care visits when assessing conditions that may be caused or complicated by IPV in order to improve clinical diagnosis and subsequent care, where there is the capacity to provide a supportive response (including referral where appropriate) and where the <strong>WHO</strong> minimum requirements are met. m n Context-specific recommendation Context-specific recommendation j. This recommendation supersedes the previous recommendation found in the <strong>WHO</strong> publication Guideline: vitamin D supplementation in pregnant women (2012). k. This includes any product, beverage or food containing caffeine (i.e. brewed coffee, tea, cola-type soft drinks, caffeinated energy drinks, chocolate, caffeine tablets). l. Evidence on essential ANC activities, such as measuring maternal blood pressure, proteinuria and weight, and checking for fetal heart sounds, was not assessed by the GDG as these activities are considered to be part of good clinical practice. m. Minimum requirements are: a protocol/standard operating procedure; training on how to ask about IPV, and on how to provide the minimum response or beyond; private setting; confidentiality ensured; system for referral in place; and time to allow for appropriate disclosure. n. This recommendation is consistent with Responding to intimate partner violence and sexual violence against women: <strong>WHO</strong> clinical and policy guidelines (2013). xii
Recommendations integrated from other <strong>WHO</strong> guidelines that are relevant to ANC maternal assessment Gestational diabetes mellitus (GDM) Tobacco use Substance use Human immunodeficiency virus (HIV) and syphilis Tuberculosis (TB) B.1.4: Hyperglycaemia first detected at any time during pregnancy should be classified as either gestational diabetes mellitus (GDM) or diabetes mellitus in pregnancy, according to <strong>WHO</strong> criteria. o B.1.5: Health-care providers should ask all pregnant women about their tobacco use (past and present) and exposure to second-hand smoke as early as possible in the pregnancy and at every antenatal care visit. p B.1.6: 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 care visit. q B.1.7: In high-prevalence settings, r provider-initiated testing and counselling (PITC) for HIV should be considered a routine component of the package of care for pregnant women in all antenatal care settings. In low-prevalence settings, PITC can be considered for pregnant women in antenatal care settings as a key component of the effort to eliminate mother-to-child transmission of HIV, and to integrate HIV testing with syphilis, viral or other key tests, as relevant to the setting, and to strengthen the underlying maternal and child health systems. s B.1.8: In settings where the tuberculosis (TB) prevalence in the general population is 100/100 000 population or higher, systematic screening for active TB should be considered for pregnant women as part of antenatal care. t Recommended Recommended Recommended Recommended Context-specific recommendation B.2: Fetal assessment Daily fetal movement counting Symphysis-fundal height (SFH) measurement Antenatal cardiotocography B.2.1: Daily fetal movement counting, such as with “count-to-ten” kick charts, is only recommended in the context of rigorous research. B.2.2: Replacing abdominal palpation with symphysis-fundal height (SFH) measurement for the assessment of fetal growth is not recommended to improve perinatal outcomes. A change from what is usually practiced (abdominal palpation or SFH measurement) in a particular setting is not recommended. B.2.3: Routine antenatal cardiotocography u is not recommended for pregnant women to improve maternal and perinatal outcomes. Context-specific recommendation (research) Context-specific recommendation Not recommended o. This is not a recommendation on routine screening for hyperglycaemia in pregnancy. It has been adapted and integrated from the <strong>WHO</strong> publication Diagnostic criteria and classification of hyperglycaemia first detected in pregnancy (2013), which states that GDM should be diagnosed at any time in pregnancy if one or more of the following criteria are met: • fasting plasma glucose 5.1–6.9 mmol/L (92–125 mg/dL) • 1-hour plasma glucose > 10.0 mmol/L (180 mg/dL) following a 75 g oral glucose load • 2-hour plasma glucose 8.5–11.0 mmol/L (153–199 mg/dL) following a 75 g oral glucose load. Diabetes mellitus in pregnancy should be diagnosed if one or more of the following criteria are met: • fasting plasma glucose > 7.0 mmol/L (126 mg/dL) • 2-hour plasma glucose > 11.1 mmol/L (200 mg/dL) following a 75 g oral glucose load • random plasma glucose > 11.1 mmol/L (200 mg/dL) in the presence of diabetes symptoms. p. Integrated from <strong>WHO</strong> <strong>recommendations</strong> for the prevention and management of tobacco use and second-hand smoke exposure in pregnancy (2013). q. Integrated from the <strong>WHO</strong> publication Guidelines for the identification and management of substance use and substance use disorders in pregnancy (2014). r. High-prevalence settings are defined in the 2015 <strong>WHO</strong> publication Consolidated guidelines on HIV testing services as settings with greater than 5% HIV prevalence in the population being tested. Low-prevalence settings are those with less than 5% HIV prevalence in the population being tested. In settings with a generalized or concentrated HIV epidemic, retesting of HIV-negative women should be performed in the third trimester because of the high risk of acquiring HIV infection during pregnancy; please refer to Recommendation B.1.7 for details. s. Adapted and integrated from the <strong>WHO</strong> publication Consolidated guidelines on HIV testing services (2015). t. Adapted and integrated from the <strong>WHO</strong> publication Systematic screening for active tuberculosis: principles and <strong>recommendations</strong> (2013). u. Cardiotocography is a continuous recording of the fetal heart rate and uterine contractions obtained via an ultrasound transducer placed on the mother’s abdomen. Executive summary xiii
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WHO recommendations on antenatal care for a positive pregnancy experience

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