WHO recommendations on antenatal care for a positive pregnancy experience

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are willing to be screened and tested for a variety of conditions, provided the information and procedures are explained properly and delivered in a caring and culturally sensitive manner (high confidence in the evidence) (22). Evidence also shows that, in some LMICs, the lack of modern technology (like ultrasound equipment) at ANC facilities discourages some women from attending (high confidence in the evidence) (22). Qualitative evidence from health-care providers shows that they generally want to provide screening and testing procedures, but sometimes don’t feel suitably trained to do so (high confidence in the evidence) (45). This suggests that they might welcome Doppler ultrasound scans to identify potential risk factors, if appropriately trained and supported. Feasibility Feasibility challenges of Doppler ultrasound scans in LMICs include equipment procurement and staff training, ensuring a power supply (via a power point or rechargeable batteries) and secure storage, regular equipment maintenance, maintaining adequate and continual supplies of ultrasound gel, and ongoing technical support and supervision. <strong>WHO</strong> <strong>recommendations</strong> on antenatal care for a positive pregnancy experience 62
C. Preventive measures Background The GDG considered the evidence and other relevant information to inform <strong>recommendations</strong> on antenatal interventions to prevent the following conditions. • nAsymptomatic bacteriuria (ASB): Defined as true bacteriuria in the absence of specific symptoms of acute urinary tract infection, ASB is common in pregnancy, with rates as high as 74% reported in some LMICs (125). Escherichia coli is associated with up to 80% of isolates (83). Other pathogens include Klebsiella species, Proteus mirabilis and group B streptococcus (GBS). While ASB in nonpregnant women is generally benign, in pregnant women obstruction to the flow of urine by the growing fetus and womb leads to stasis in the urinary tract and increases the likelihood of acute pyelonephritis. If untreated, up to 45% of pregnant women with ASB may develop this complication (126), which is associated with an increased risk of preterm birth. • nRecurrent urinary tract infections: A recurrent urinary tract infection (RUTI) is a symptomatic infection of the urinary tract (bladder and kidneys) that follows the resolution of a previous urinary tract infection (UTI), generally after treatment. Definitions of RUTI vary and include two UTIs within the previous six months, or a history of one or more UTIs before or during pregnancy (127). RUTIs are common in women who are pregnant and have been associated with adverse pregnancy outcomes including preterm birth and small-forgestational-age newborns (127). Pyelonephritis (infection of the kidneys) is estimated to occur in 2% of pregnancies, with a recurrence rate of up to 23% within the same pregnancy or soon after the birth (128). Little is known about the best way to prevent RUTI in pregnancy. • nRhesus D alloimmunization: Rhesus (Rh) negative mothers can develop Rh antibodies if they have an Rh-positive newborn, causing haemolytic disease of the newborn (HDN) in subsequent pregnancies. Administering anti-D immunoglobulin to Rhnegative women within 72 hours of giving birth to an Rh-positive baby is an effective way of preventing RhD alloimmunization and HDN (129). However, Rhesus alloimmunization occurring in the third trimester due to occult transplacental haemorrhages will not be prevented by postpartum anti-D. • nSoil-transmitted helminthiasis: Over 50% of pregnant women in LMICs suffer from anaemia, and helminthiasis is a major contributory cause in endemic areas (33). Soil-transmitted helminths are parasitic infections caused mainly by roundworms (Ascaris lumbricoides), hookworms (Necator americanus and Ancylostoma duodenale), and whipworms (Trichuris trichiura). These worms (particularly hookworms) feed on blood and cause further bleeding by releasing anticoagulant compounds, thereby causing iron-deficiency anaemia (130). They may also reduce the absorption of iron and other nutrients by causing anorexia, vomiting and diarrhoea (131). • nNeonatal tetanus: Tetanus is an acute disease caused by an exotoxin produced by Clostridium tetani. Neonatal infection usually occurs through the exposure of the unhealed umbilical cord stump to tetanus spores, which are universally present in soil, and newborns need to have received maternal antibodies via the placenta to be protected at birth. Neonatal disease usually presents within the first two weeks of life and involves generalized rigidity and painful muscle spasms, which in the absence of medical treatment leads to death in most cases (132). Global vaccination programmes have reduced the global burden of neonatal tetanus deaths and continue to do so; estimates show a reduction from an estimated 146 000 in 2000 to 58 000 (CI: 20 000–276 000) in 2010 (133). However, because tetanus spores are ubiquitous in the environment, eradication is not biologically feasible and high immunization coverage remains essential (134). In addition to GDG <strong>recommendations</strong> on the above, this section of the guideline includes two <strong>recommendations</strong> on disease prevention in pregnancy that have been integrated from <strong>WHO</strong> guidelines on malaria and HIV prevention that are relevant to routine ANC. Chapter 3. Evidence and <strong>recommendations</strong> 63
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Zinc supplements Multiple micronutr
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Ultrasound scan Doppler ultrasound
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WHO recommendations on antenatal care for a positive pregnancy experience

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