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 Additional considerations • nIn absolute numbers, the data mean that in settings with an anaemia prevalence of 38%, the haemoglobinometer test will probably miss about 57 anaemic women (95% CI: 38–80) out of every 1000 women tested, whereas the HCS method will probably miss about 95 anaemic women (95% CI: 76–110) out of every 1000 women tested. For populations with a severe anaemia prevalence of 5%, the haemoglobinometer test will probably miss about nine women with severe anaemia (95% CI: 2–27) out of every 1000 women tested, whereas the HCS method will probably miss about 25 women with severe anaemia (95% CI: 3–43) out of every 1000 women tested. • nThe main limitation of the evidence is the low number of women identified with severe anaemia, which affects the precision of the estimates. However, the evidence suggests that the haemoglobinometer test is probably more accurate than the HCS method. As there are no direct comparisons in test accuracy studies and, as confidence intervals for sensitivity and specificity of the two methods overlap, there is some uncertainty about the relative accuracy of these tests. • nThe review also evaluated the test accuracy of clinical assessment (4 studies, 1853 women), giving a sensitivity for clinical assessment of 0.64 (95% CI: 22–94) and a specificity of 0.63 (95% CI: 23–91) for detecting anaemia (Hb < 110 g/L). Thus, the HCS method might be more sensitive but less specific than clinical assessment. • nIn settings where iron supplementation is routinely used by pregnant women, the consequence of missing women with severe anaemia is more serious than that of missing women with mild or moderate anaemia, as women with severe anaemia usually require additional treatment. Therefore, the accuracy of on-site Hb tests to detect severe anaemia in pregnancy is probably more important than the ability to detect Hb below 110 g/L. • nA study of various Hb testing methods in Malawi found the haemoglobinometer method to be the most user-friendly method (82). Values Please see “Women’s values” in section 3.B.1: Maternal assessment: Background (p. 41). Resources Any health-care provider can perform both the haemoglobinometer and HCS methods after minimal training. The haemoglobinometer and HCS methods have been estimated to cost approximately US$ 0.75 and US$ 0.12 per test, respectively (82). Both methods require needles for finger pricks, cotton balls, gloves and Sterets® skin cleansing swabs; however, the higher costs associated with haemoglobinometer tests are mainly due to supplies (cuvettes and controls), equipment costs and maintenance. Equity The highest prevalence of maternal anaemia occurs in Africa and South-East Asia, where parasitic infections are major contributory factors (33). Anaemia increases perinatal risks for mothers and newborns and contributes to preventable mortality. Accurate, low-cost, simple-to-use tests to detect anaemia might help to address health inequalities by improving the detection and subsequent management of women with anaemia, particularly severe anaemia, in low-resource settings. Acceptability Qualitative evidence from a variety of settings indicates that women generally appreciate clinical tests that support their well-being during pregnancy (moderate confidence in the evidence) (22). However, evidence from LMICs indicates that where there are likely to be additional costs associated with tests, or where the recommended interventions are unavailable because of resource constraints, women may be less likely to engage with ANC services (high confidence in the evidence). Feasibility Qualitative evidence from providers in various LMICs indicates that a lack of resources, both in terms of the availability of the diagnostic equipment and potential treatments, as well as the lack of suitably trained staff to deliver the service, may limit implementation of recommended interventions (high confidence in the evidence) (45). 42
B.1.2: Asymptomatic bacteriuria (ASB) RECOMMENDATION 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 Gram-staining is recommended over the use of dipstick tests as the method for diagnosing ASB in pregnancy. (Context-specific recommendation) Remarks • This recommendation should be considered alongside Recommendation C.1 on ASB treatment (see section C: Preventive measures). • The GDG agreed that the higher resource costs associated with Gram stain testing might reduce the feasibility of this method in low-resource settings, in which case, dipstick tests may be used. • The GDG agreed that ASB is a priority research topic, given its association with preterm birth and the uncertainty around urine testing and treatment in settings with different levels of ASB prevalence. Specifically, studies are needed that compare on-site testing and treatment versus testing plus confirmation of test with treatment on confirmatory culture, to explore health and other relevant outcomes, including acceptability, feasibility and antimicrobial resistance. In addition, better on-site tests need to be developed to improve accuracy and feasibility of testing and to reduce overtreatment of ASB. Research is also needed to determine the prevalence of ASB at which targeted testing and treatment rather than universal testing and treatment might be effective. Summary of evidence and considerations Test accuracy of on-site urine Gram staining and dipsticks to detect ASB (EB Table B.1.2) The evidence was derived from a test accuracy review of on-site urine tests conducted to support the ANC guideline (88). Four studies (1904 pregnant women) contributed data on urine Gram staining and eight studies (5690 pregnant women) contributed data on urine dipsticks. Most of the studies were conducted in LMICs. The average prevalence of ASB in the studies was 8%. A Gram stain was positive if one or more bacteria were detected per oilimmersed field, and a dipstick test was positive if it detected either nitrites or leucocytes. The reference standard used was urine culture with a threshold of 10 5 cfu/mL. However, the certainty of the evidence on the accuracy of both Gram stain tests and dipstick tests is very low, with pooled sensitivity and specificity of the Gram stain test estimated at 0.86 (95% CI: 0.80– 0.91) and 0.97 (95% CI: 0.93–0.99), respectively, and pooled sensitivity and specificity for urine dipsticks estimated at 0.73 (95% CI: 0.59–0.83) and 0.89 (95% CI: 0.79–0.94), respectively. A positive nitrite test alone on dipsticks was found to be less sensitive but more specific than when urine leucocytes were also considered. Additional considerations • nA high level of accuracy in detecting ASB is important to avoid treating women unnecessarily, particularly in view of increasing antimicrobial resistance. Based on the uncertain evidence above, and assuming a prevalence of ASB of 9%, there would be 18 and 118 false-positive tests per 1000 women tested with Gram stain and dipstick tests, respectively. This suggests that, in settings where pregnant women are treated for ASB, dipstick diagnosis of ASB might lead to many women receiving unnecessary treatment. • nDipstick tests are multi-test strips that, in addition to testing for nitrites and leucocytes, may also include detection of urine protein and glucose. However, the accuracy of dipsticks to detect conditions associated with proteinuria (preeclampsia) and glycosuria (diabetes mellitus) is considered to be low. Values Please see “Women’s values” in section 3.B.1: Maternal assessment: Background (p. 41). Resources Dipsticks are relatively low cost compared with the Gram stain test, as the latter requires trained staff and laboratory equipment and supplies (microscope, glass slides, reagents, Bunsen burner or slide warmer). Gram stain tests take longer to perform and Chapter 3. Evidence and <strong>recommendations</strong> 43
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WHO recommendations on antenatal care for a positive pregnancy experience

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