WHO recommendations on antenatal care for a positive pregnancy experience

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Ultrasound scan Doppler ultrasound of fetal blood vessels B.2.4: One ultrasound scan before 24 weeks of 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. B.2.5: Routine Doppler ultrasound examination is not recommended for pregnant women to improve maternal and perinatal outcomes. v Recommended Not recommended C. Preventive measures Antibiotics for asymptomatic bacteriuria (ASB) Antibiotic prophylaxis to prevent recurrent urinary tract infections Antenatal anti-D immunoglobulin administration Preventive anthelminthic treatment Recommendation C.1: A seven-day antibiotic regimen is recommended for all pregnant women with asymptomatic bacteriuria (ASB) to prevent persistent bacteriuria, preterm birth and low birth weight. C.2: Antibiotic prophylaxis is only recommended to prevent recurrent urinary tract infections in pregnant women in the context of rigorous research. C.3: Antenatal prophylaxis with anti-D immunoglobulin in non-sensitized Rh-negative pregnant women at 28 and 34 weeks of gestation to prevent RhD alloimmunization is only recommended in the context of rigorous research. C.4: In endemic areas, w preventive anthelminthic treatment is recommended for pregnant women after the first trimester as part of worm infection reduction programmes. x Type of recommendation Recommended Context-specific recommendation (research) Context-specific recommendation (research) Context-specific recommendation <strong>WHO</strong> <strong>recommendations</strong> on antenatal care for a positive pregnancy experience Tetanus toxoid vaccination C.5: Tetanus toxoid vaccination is recommended for all pregnant women, depending on previous tetanus vaccination exposure, to prevent neonatal mortality from tetanus. y Recommendations integrated from other <strong>WHO</strong> guidelines that are relevant to ANC Malaria prevention: intermittent preventive treatment in pregnancy (IPTp) Pre-exposure prophylaxis (PrEP) for HIV prevention C.6: In malaria-endemic areas in Africa, intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) is recommended for all pregnant women. Dosing should start in the second trimester, and doses should be given at least one month apart, with the objective of ensuring that at least three doses are received. z C.7: Oral pre-exposure prophylaxis (PrEP) containing tenofovir disoproxil fumarate (TDF) should be offered as an additional prevention choice for pregnant women at substantial risk of HIV infection as part of combination prevention approaches. aa Recommended Context-specific recommendation Context-specific recommendation v. Doppler ultrasound technology evaluates umbilical artery (and other fetal arteries) waveforms to assess fetal well-being in the third trimester of pregnancy. w. Areas with greater than 20% prevalence of infection with any soil-transmitted helminths. x. Consistent with the <strong>WHO</strong> publication Guideline: preventive chemotherapy to control soil-transmitted helminth infections in high-risk groups (2016, in press). y. This recommendation is consistent with the <strong>WHO</strong> guideline on Maternal immunization against tetanus (2006). The dosing schedule depends on the previous tetanus vaccination exposure. z. Integrated from the <strong>WHO</strong> publication Guidelines for the treatment of malaria (2015), which also states: “<strong>WHO</strong> recommends that, in areas of moderate-to-high malaria transmission of Africa, IPTp-SP be given to all pregnant women at each scheduled ANC visit, starting as early as possible in the second trimester, provided that the doses of SP are given at least 1 month apart. <strong>WHO</strong> recommends a package of interventions for preventing malaria during pregnancy, which includes promotion and use of insecticide-treated nets, as well as IPTp-SP”. To ensure that pregnant women in endemic areas start IPTp-SP as early as possible in the second trimester, policy-makers should ensure health system contact with women at 13 weeks of gestation. aa. Integrated from the <strong>WHO</strong> publication Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV (2015). Substantial risk of HIV infection is defined by an incidence of HIV infection in the absence of PrEP that is sufficiently high (> 3% incidence) to make offering PrEP potentially cost-saving (or cost-effective). Offering PrEP to people at substantial risk of HIV infection maximizes the benefits relative to the risks and costs. xiv
D. Interventions for common physiological symptoms Nausea and vomiting Heartburn Leg cramps Low back and pelvic pain Constipation Varicose veins and oedema Recommendation D.1: Ginger, chamomile, vitamin B6 and/or acupuncture are recommended for the relief of nausea in early pregnancy, based on a woman’s preferences and available options. D.2: Advice on diet and lifestyle is recommended to prevent and relieve heartburn in pregnancy. Antacid preparations can be offered to women with troublesome symptoms that are not relieved by lifestyle modification. D.3: Magnesium, calcium or non-pharmacological treatment options can be used for the relief of leg cramps in pregnancy, based on a woman’s preferences and available options. D.4: Regular exercise throughout pregnancy is recommended to prevent low back and pelvic pain. There are a number of different treatment options that can be used, such as physiotherapy, support belts and acupuncture, based on a woman’s preferences and available options. D.5: Wheat bran or other fibre supplements can be used to relieve constipation in pregnancy if the condition fails to respond to dietary modification, based on a woman’s preferences and available options. D.6: Non-pharmacological options, such as compression stockings, leg elevation and water immersion, can be used for the management of varicose veins and oedema in pregnancy, based on a woman’s preferences and available options. Type of recommendation Recommended Recommended Recommended Recommended Recommended Recommended E. Health systems interventions to improve the utilization and quality of antenatal care Woman-held case notes Midwife-led continuity of care Group antenatal care Community-based interventions to improve communication and support Recommendation E.1: It is recommended that each pregnant woman carries her own case notes during pregnancy to improve continuity, quality of care and her pregnancy experience. E.2: Midwife-led continuity-of-care models, in which a known midwife or small group of known midwives supports a woman throughout the antenatal, intrapartum and postnatal continuum, are recommended for pregnant women in settings with well functioning midwifery programmes. E.3: Group antenatal care provided by qualified health-care professionals may be offered as an alternative to individual antenatal care for pregnant women in the context of rigorous research, depending on a woman’s preferences and provided that the infrastructure and resources for delivery of group antenatal care are available. E.4.1: The implementation of community mobilization through facilitated participatory learning and action (PLA) cycles with women’s groups is recommended to improve maternal and newborn health, particularly in rural settings with low access to health services. ab Participatory women’s groups represent an opportunity for women to discuss their needs during pregnancy, including barriers to reaching care, and to increase support to pregnant women. E.4.2: Packages of interventions that include household and community mobilization and antenatal home visits are recommended to improve antenatal care utilization and perinatal health outcomes, particularly in rural settings with low access to health services. Type of recommendation Recommended Context-specific recommendation Context-specific recommendation (research) Context-specific recommendation Context-specific recommendation ab. Integrated from <strong>WHO</strong> <strong>recommendations</strong> on community mobilization through facilitated participatory learning and action cycles with women’s groups for maternal and newborn health (2014). Executive summary xv
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WHO recommendations on antenatal care for a positive pregnancy experience

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