WHO recommendations on antenatal care for a positive pregnancy experience

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<strong>WHO</strong> <strong>recommendations</strong> on antenatal care for a positive pregnancy experience Implementation considerations for ANC guideline <strong>recommendations</strong> Need to know Need to do Need to have Consider B.2.3. Routine antenatal cardiotocography (CTG) • If routine antenatal CTG is being conducted • If being conducted, instruct providers to omit this from practice, due to lack of evidence. • N/A • N/A B.2.4. Routine ultrasound scans • Health system level – – Number and capacity of ultrasound providers to act as providers and trainers/ mentors – – Number of functional machines available and geographic distribution – – Regulations around ultrasound use – – Cadres – who can perform? – – Available pre-service education and other certification • Provider level – – Training to do anatomy scan or on referral – – How to interpret results and do counselling • Health system level • Health system level (AIUM) guidelines f – – Determine appropriate settings and timeline for introduction of ultrasound – – Transportation for women if services are not sufficiently decentralized – – Cadres with skills to provide quality – – Obtain machines services – – Capacity-building plan • Facility level • Provider level – – Machines – – Conduct or refer – – Mechanism to review results and get – – Document results reports – – Provide guidance on how to – – Service contracts for machines estimate GA and delivery – – Surge protection date (EDD), depending on – – Power supply certainty of last menstrual – – Counselling skills period (LMP) and estimated – – Security and environmental GA at time of ultrasound, protection for costly machine e.g. <strong>WHO</strong>’s Manual of – – Space for machine diagnostic ultrasound e and – – Ultrasound gel supply the American Institute of – – Staff and supplies to keep equipment Ultrasound in Medicine clean • Cost – of purchase, maintenance, training, impact of shifting resources to ultrasound from other key costs • Local availability/feasibility of service contracts to support machine maintenance, especially in areas not previously prioritized for ultrasound market development • Power supply – availability and stability • Protection from power surges, which can permanently damage machines • Extreme fragility of ultrasound transducers (one drop on a concrete floor may necessitate purchase of a new transducer, costing thousands of dollars) • Relative benefits compared to other interventions • Burden to mother • Burden to providers and facility • Creative, alternative models of service delivery that do not burden women with travel and related costs • Feasibility studies in settings without widely available ultrasonography • Studies on quality of ultrasound B.2.5. Routine Doppler ultrasound • If routine Doppler ultrasound is being conducted • If being conducted, instruct providers to omit or consider in the context of research • N/A • Research context e. Manual of diagnostic ultrasound, second edition. Geneva: World Health Organization; 2013 (http://www.who.int/medical_devices/publications/manual_ultrasound_pack1-2/en/, accessed 21 October 2016). f. AIUM practice parameter for the performance of obstetric ultrasound examinations. Laurel (MD): American Institute of Ultrasound in Medicine (AIUM); 2013 (http://www.aium.org/resources/guidelines/ obstetric.pdf, accessed 21 October 2016). 148
Implementation considerations for ANC guideline <strong>recommendations</strong> Need to know Need to do Need to have Consider C. Preventive measures C.1. Antibiotics for ASB • What ASB is and how to diagnose it • Prescribing • Counselling • Commodity management • Counselling skills • Time and space for counselling • Capacity-building for providers in contexts where this is an unfamiliar concept and practice – value of treatment, risk of non-treatment, antibiotic stewardship/avoidance of resistance C.2. Antibiotic prophylaxis to prevent recurrent urinary tract infections • Whether currently being performed • Instruct to omit, if necessary • Research context C.3. Antenatal anti-D immunoglobulin administration • What is practised in the context • Context-specific • Availability of blood-typing • Research context • Recognize that this practice is routine in many high-resource settings; however, more evidence may be needed C.4. Preventive anthelminthic treatment • Local endemicity of helminth infections • Local status of worm infestation-reduction programmes • Provide or omit, depending on context • Commodities management • Task shifting • Community-based distribution C.5. Tetanus toxoid vaccination • That this practice is still recommended • Local prevalence of neonatal tetanus • Provide vaccine according to established guidance • Commodities management • Consider quality improvement (QI) activities if gaps in coverage • NOTE: Refer to dosing schedule in <strong>WHO</strong> 2006 guideline on maternal immunization against tetanus g C.6. Intermittent preventive treatment in pregnancy • See detailed implementation guidance in the specific <strong>WHO</strong> guideline on malaria h • Emerging evidence on task shifting to community-based distribution • Ways of ensuring that women receive the first dose at 13 weeks of gestation g. Maternal immunization against tetanus: integrated management of pregnancy and childbirth (IMPAC). Standards for maternal and neonatal care 1.1. Geneva: Department of Making Pregnancy Safer, World Health Organization; 2006 (http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/immunization_tetanus.pdf, accessed 28 September 2016). h. Guidelines for the treatment of malaria, third edition. Geneva: World Health Organization; 2015 (http://www.who.int/malaria/publications/atoz/9789241549127/en/, accessed 10 October 2016). Annex 4: Implementation considerations 149
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« To achieve the Every Woman Every
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Funding was provided for this guide
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WHO recomm
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Evaluation (GRADE) and Confidence i
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Zinc supplements Multiple micronutr
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Ultrasound scan Doppler ultrasound
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Task shifting components of antenat
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expect from ANC is to have a “pos
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2. Methods WHO <st
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a list of ANC outcomes was prioriti
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content experts among the GDG membe
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• nFeasibility: Feasibility is in
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are indicated by a footnote in the
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A. Nutritional interventions <stron
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A.1.2: Nutrition education on energ
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A.1.3: Energy and protein dietary s
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A.1.4: High-protein supplements REC
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Summary of evidence and considerati
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Equity Effective interventions to i
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A.7: Vitamin B6 (pyridoxine) supple
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only a quarter of the planned sampl
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A.10: Restricting caffeine intake R
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B. Maternal and fetal assessment B.
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to produce results than urine dipst
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B.1.4: Gestational diabetes mellitu
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B.1.6: Substance use RECOMMENDATION
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on screening, please refer to the 2
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Women’s values A scoping review o
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B.2.2: Symphysis-fundal height (SFH
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B.2.4: Ultrasound scan RECOMMENDATI
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are willing to be screened and test
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Women’s values A scoping review o
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C.4: Preventive anthelminthic treat
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C.5: Tetanus toxoid vaccination REC
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C.6: Intermittent preventive treatm
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D. Interventions for common physiol
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Values See “Women’s values” a
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D.4: Interventions for low back and
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Acceptability Qualitative evidence
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Additional considerations • nComp
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Senegal, Sri Lanka, Yemen and Zambi
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WHO recommendations on antenatal care for a positive pregnancy experience

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