WHO recommendations on antenatal care for a positive pregnancy experience

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B.1.6: Substance use RECOMMENDATION 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. (Recommended) <strong>WHO</strong> <strong>recommendations</strong> on antenatal care for a positive pregnancy experience Remarks • This strong recommendation based on low-quality evidence has been integrated from the 2014 <strong>WHO</strong> Guidelines for the identification and management of substance use and substance use disorders in pregnancy (97). The overarching principles of this guideline aimed to prioritize prevention, ensure access to prevention and treatment services, respect women’s autonomy, provide comprehensive care, and safeguard against discrimination and stigmatization. • The GDG responsible for the recommendation noted that asking women at every ANC visit is important as some women are more likely to report sensitive information only after a trusting relationship has been established. • Pregnant women should be advised of the potential health risks to themselves and to their babies posed by alcohol and drug use. • Validated screening instruments for alcohol and other substance use and substance use disorders are available (refer to Annex 3 of the 2014 guidelines [97]). • Health-care providers should be prepared to intervene or refer all pregnant women who are identified as using alcohol and/or drugs (past and present). • For women identified as being dependent on alcohol or drugs, further <strong>recommendations</strong> from the guideline include the following: –– Health-care providers should at the earliest opportunity advise pregnant women dependent on alcohol or drugs to cease their alcohol or drug use and offer, or refer them to, detoxification services under medical supervision, where necessary and applicable (strong recommendation based on very low-quality evidence). –– Health-care providers should offer a brief intervention to all pregnant women using alcohol or drugs (strong recommendation based on low-quality evidence). • It was decided that despite the low-quality evidence on effects of brief psychosocial interventions, the benefit (potential reduction of alcohol and substance use) outweighed any potential harms, which were considered to be minimal. • A brief intervention is a structured therapy of short duration (typically 5–30 minutes) offered with the aim of assisting an individual to cease or reduce use of a psychoactive substance. • Further guidance on interventions and strategies to identify and manage substance use and substance use disorders in pregnancy can be found in the 2014 <strong>WHO</strong> guidelines (97), available at: http://www.who.int/ substance_abuse/publications/pregnancy_guidelines/en/ 50
B.1.7: Human immunodeficiency virus (HIV) and syphilis RECOMMENDATION B.1.7: In high-prevalence settings, a provider-initiated testing and counselling (PITC) for HIV should be considered a routine component of the package of care for pregnancy 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. (Recommended) Remarks • This recommendation has been integrated from the 2015 <strong>WHO</strong> Consolidated guidelines on HIV testing services (98) (the strength of the recommendation and the quality of the evidence were not stated). • PITC denotes an HIV testing service that is routinely offered in a health-care facility and includes providing pre-test information and obtaining consent, with the option for individuals to decline testing. PITC has proved highly acceptable and has increased the uptake of HIV testing in LMICs (98). • The availability of HIV testing at ANC services is responsible for the high level of knowledge of HIV status among women in many countries, which has allowed women and infants to benefit from ART. • <strong>WHO</strong> recommends that ART should be initiated in all pregnant women diagnosed with HIV at any CD4 count and continued lifelong (99). This recommendation is based on evidence that shows that providing ART to all pregnant and breastfeeding women living with HIV improves individual health outcomes, prevents mother-to-child transmission of HIV, and prevents horizontal transmission of HIV from the mother to an uninfected sexual partner. • Other <strong>recommendations</strong> relevant to ANC services from the Consolidated guidelines on HIV testing services include the following (98): –– On disclosure: Initiatives should be put in place to enforce privacy protection and institute policy, laws and norms that prevent discrimination and promote tolerance and acceptance of people living with HIV. This can help create environments where disclosure of HIV status is easier (strong recommendation, low-quality evidence). –– On retesting: In settings with a generalized HIV epidemic: b Retest all HIV-negative pregnant women in the third trimester, during labour or postpartum because of the high risk of acquiring HIV infection during pregnancy (strength of recommendation and quality of evidence not stated). –– On retesting: In settings with a concentrated HIV epidemic: c Retest HIV-negative pregnant women who are in a serodiscordant couple or from a key population group d (strength of recommendation and quality of evidence not stated). –– On retesting before ART initiation: National programmes should retest all people newly and previously diagnosed with HIV before they enrol in care and initiate ART (strength of recommendation and quality of evidence not stated). –– On testing strategies: In settings with greater than 5% HIV prevalence in the population being tested, a diagnosis of HIV-positive should be issued to people with two sequential reactive tests. In settings with less than 5% HIV prevalence in the population being tested, a diagnosis of HIV-positive should be issued to people with three sequential reactive tests (strength of recommendation and quality of evidence not stated). –– On task shifting: Lay providers who are trained and supervised can independently conduct safe and effective HIV testing using rapid diagnostic tests (strong recommendation, moderate-quality evidence). • Further guidance on HIV testing can be found in the 2015 <strong>WHO</strong> guidelines (98), available at: http://www.who.int/hiv/pub/guidelines/hiv-testing-services/en/ • In addition, the 2015 Guideline on when to start antiretroviral therapy and on pre-exposure prophylaxis for HIV (99) is available at: http://www.who.int/hiv/pub/guidelines/earlyrelease-arv/en/ • To prevent mother-to-child transmission of syphilis, all pregnant women should be screened for syphilis at the first ANC visit in the first trimester and again in the third trimester of pregnancy. For further guidance Chapter 3. Evidence and <strong>recommendations</strong> 51
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WHO recommendations on antenatal care for a positive pregnancy experience

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