Antenatal care in developing countries: The need for a tailored model

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Summary

In developed countries, 98% of all women receive prenatal care and 94% give birth under the supervision of skilled healthcare practitioners with timely access to appropriate emergency treatment if complications arise. In contrast, large numbers of pregnant women in Africa and Asia do not receive adequate prenatal care and lack skilled attendance at birth. In developing countries quality of prenatal care is often scarce: models of care adopted in the western world and exported to the developing world have not been monitored early enough to discover their weak points promptly. This blind attitude has transformed antenatal care into an empty and useless ritual, and explains why antenatal care programmes continue to be unsuccessful, being inappropriate to the specific situation. A mix of educational and cultural factors together with persistent lack of resources in a global critical situation all contribute to the poor results of antenatal care programmes. Antenatal care services should be free of charge, planned and implemented within the community, cost-effective, and should yield evidence-based quality care. They should also include information for the patient and family members, provide affordable treatment of existing conditions, and warrant referral for complications.

Introduction

Among women's fundamental rights listed in the World Health Organization (WHO) definition of reproductive and sexual health, access to appropriate healthcare services during pregnancy and childbirth is mentioned as one of the means that will provide couples with the best chance of having a healthy infant. According to the WHO declaration, reproductive health care should warrant preventive action and solution of reproductive health problems with the goal of preserving maternal and neonatal well-being.1

Together with other functions and services, Antenatal care has long been considered a basic component of any reproductive health care programme, and all around the world different models of it have been put into practice. Each of these is a result of contributing factors of socio-cultural, historical and traditional nature, others related to the economy of the country, to the human and financial resources of the specific health system involved, at times to the economic convenience of the providers wherever private practice has stepped in.

In various European countries the traditional late 20th century model of prenatal care has been based on a large number of visits, starting as early in pregnancy as possible, continuing monthly until the last 2–3 months, when the rhythm of consultations increases to become weekly at the end of pregnancy, often accompanied by frequent blood and urine testing and, in more recent years, also by numerous ultrasound evaluations. In developed countries, such a model may be called a programme of prophylactic care,2 sustained by a large number of interacting roles, certainly redundant with regard to the real needs of the pregnant woman: nurses and midwives, general practitioners and specialists entering the scene, not always in a coordinated plot.

Until recent times, a close look at European maternity services would have shown what was already found some 25 years ago, when a WHO survey revealed extremely wide variations in the number of antenatal visits and in the content of the care given to the pregnant woman.3 Not only that, very often what was recommended was actually very different from what was really done in practice. Nevertheless, the European model of antenatal care has been successfully implemented within a functioning health system, in a general situation of widespread welfare, benefiting from the most recent scientific and technological developments. As a result, almost all women in western countries receive prenatal care, give birth under the supervision of medically trained personnel and have prompt access to emergency treatment if complications arise.4 This package of services has contributed to the reduction of maternal and neonatal morbidity and mortality coincident with the improvements seen in all sectors of life.

The situation in low-income countries is quite different. A substantial proportion of pregnant women in Africa and in most countries of the southern hemisphere do not receive antenatal care at present (Fig. 1). A WHO compilation on maternity care showed that in most countries in Africa, less than 70% of the pregnant women get proper care throughout pregnancy. Many of those who attend antenatal clinics come only once or twice and sometimes late in pregnancy; when this happens, the quality of the care provided is inevitably poor. Among women who do not have access to prenatal care, many belong to the group that would need it most, that is, poor women in rural areas and urban slums.2, 4 Many factors interfere with satisfactory implementation of antenatal care in poor countries: inadequate resources, illiteracy, poverty, and cultural and traditional practices. The question is how to re-structure Maternal and Child Health (MCH) programmes inclusive of prenatal care and make them work in developing countries; how to ensure that women go safely through pregnancy and childbirth, deliver healthy infants and avoid the threat of severe morbidity and death.

In 1978, the WHO supported the idea that the pregnant woman should be monitored using the so-called risk approach, foreseeing the advantage of this managerial strategy based on the measurement of individual risk to improve maternal and perinatal outcome.5 However, the simple idea of screening for risk was subsequently challenged by the evidence that most obstetric emergencies were not recognized in advance, and in fact, occurred in a low-risk group of pregnant women. After this observation a shift occurred, resulting in a re-distribution of the resources toward the improvement of the quality and accessibility of the facilities that provide emergency obstetric care. In 1987, the Safe Motherhood Initiative outlined a more complex strategy that considered integrating the risk approach with a functioning referral system. It was assumed that most deliveries could be handled safely at the community level provided that cases of obstetric emergency would be sent quickly and effectively to the appropriate health facility where operative delivery, Caesarean section and blood transfusion were all available. In 1997 again it was stated that every pregnancy faces risks and antenatal care programmes should not spend scarce resources on screening mechanisms that attempt to predict a woman's risk of developing complications. The emphasis was placed on improving the accessibility, quality and utilization of emergency obstetric care (EmOC) facilities for women who develop complications.2

Having considered different interpretations of the concept and application of antenatal care in the strategy for a safer motherhood, there are examples that show how prenatal care may be tailored to better fit the reality of a developing country, with special attention to the limited resources that usually are available, to implement and sustain it in the long-term. The international community and the researchers have already re-evaluated the traditional western model, which had been adopted in developing countries: a new modified WHO model has been tested that limits the number of visits planned for each woman at the clinic to four and restricts the tests, clinical procedures and follow-up actions to those that have been shown by research evidence to improve outcomes for women and newborns.6 The results of this trial have proved that women using the new model of antenatal care face the same risk of adverse events as those associated with the traditional model. No significant differences were seen in the prevalence of severe anaemia, pre-eclampsia, urinary tract infections or low-birth-weight infants. Incidence of secondary outcomes for either women or infants was also similar, including the rates of eclampsia and maternal and neonatal death.7

The valuable result of this initiative has been providing the evidence that for the management of a non-complicated pregnancy, a reduction in the number of visits is not associated with an increase in adverse maternal and perinatal outcomes. The objective of routine antenatal care is to deliver effective and appropriate screening, preventive and treatment interventions. Thus the number of visits should be the result of how these effective interventions can be delivered in a timely way during pregnancy. The WHO model is compatible with this assumption, does not carry any increase in the risk of adverse outcomes, but has important public health implications, especially for developing countries where resources are scarce and should be allocated in the most efficient way. It may also reduce the costs to the woman, in terms of time and money to travel, loss of working hours, and care of the children. Consequently, time and energy would be saved by the healthcare staff and the women themselves.8

The demonstration that a healthy woman needs to be monitored during pregnancy with few visits of good quality and few screening tests, is certainly a good background against which anyone can evaluate a local situation. As stated by Bergsjø, it is reasonable to propose this model as standard for antenatal care, with modifications according to local needs.2

Section snippets

Antenatal care in a specific setting

Evaluating the efficacy of a programme of antenatal care is not at all easy as numerous factors make the task hard to accomplish: a large population is needed to reach conclusive and significant results; two target populations, mothers and babies, have to be considered; antenatal care is a complex intervention, depending on overall quality of care and socio-economic context.

The present authors have worked in different sectors and with different roles to promote and improve maternal and child

Country profile

Mozambique has an estimated population of 18.5 million (projections 2002), 53% being female. The annual population growth rate is 1.5 with most of the population (65.5%) living in rural areas of a country that has one of the lowest human development indexes.9 In spite of this, recent growth of per capita income has been more than 3%, and the country achieved one of the world's sharpest reductions in hunger, diminishing the hunger rate from 69% to 55%.10 Still, the estimated life expectancy at

Provision of care

Provision of antenatal care in Mozambique and in the capital city of Maputo, in particular, is mainly provided in health centres and a few hospitals. Health centres are more accessible in the city than in the provinces. However, it is quite unusual to receive a woman in the labour ward who has not had any kind of care during her pregnancy. Low-risk women usually have their prenatal care at the health centre and those at high risk are referred to an antenatal clinic where they are seen by an

Conclusions

Antenatal care today is one of the four pillars of safe motherhood, together with family planning, clean and safe delivery, and essential obstetric care.15 Unfortunately, the situation related to pregnancy, labour and the postpartum period is still disquieting because too many mothers and newborns die annually in developing countries, and reducing these deaths must continue to be the top-priority challenge in reproductive health.2 Prenatal care is a mosaic of a variety of services that include

References (16)

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