3.1 PCC and ANC Contact-2021

PRESENTATION 3.
Preconception Care and ANTENATAL CARE
CONTACT
RATIONAL, COMPONENTS AND TOOLS
Federal Democratic Republic of Ethiopia

Ministry of Health
BEmONC – LRP
ETHIOPIA Best Practices in Maternal and Newborn Care
Session Objectives
 Describe Preconception Care

 Describe basic elements of Preconception Care
 Describe Antenatal care Contact (ANCC)
 Describe basic elements of ANC assessment and care
 Define the elements of effective counseling
 Describe the preventive measures given during ANC
 Describe the elements of Birth Preparedness and
Complication Readiness
 Demonstrate the provision of antenatal care contact
BEmONC – LRP: Ethiopia Focused antenatal care
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Best Practices in Maternal and Newborn
Preconception Care as a Basis For ANC

Preconception Care
preconception/pre-pregnancy care is the most ignored,

but equally important service for improving the outcome
of pregnancy
The provision of biomedical, behavioral and social


health interventions to women and couples before

Risk assessment
conception occurs.
Preconception care involves Prevention and treatment
Psychosocial support
Brain storming session
 Discuss on importance of Preconception care

Preconception Care
Is a comprehensive care in the continuum which

involves:-
 Risk assessment
 Prevention and treatment and
 Psychosocial support that begins pre-pregnancy to postpartum period.

Preconception care con…
Helps to
Achieve good health during pregnancy

Make good preparation for child-birth and parenting.


Early identification and management of conditions that


can worse or recur during pregnancy(medical disorder,

obstetric complication, malnutrition and substance
abuse)
Preconception assessment, intervention, and
preparation
Assessment:
Potentially recurring obstetric complications experienced
during previous pregnancies:- recurrent pregnancy loss,
preterm labor, pre-eclampsia/eclampsia, gestational diabetes,
congenital anomaly, puerperal psychosis
Obstetric and gynecologic surgery:-operative delivery,
cerclage, loop electrosurgical excision procedure (LEEP),

cone biopsy, myomectomy
Immunologic disorders (autoimmune diseases)

Assessment…
 Medical and mental health disorders:-diabetes mellitus,

thyroid disorders, hypertension, anemia, deep vein
thrombosis, asthma, epilepsy, depression, anxiety disorder,
etc.
 Infectious diseases:-sexually transmitted infections (STIs)
including HIV, gonococcal, chlamydial; hepatitis virus
other infectious disease like malaria and tuberculosis
 Physical disability, developmental disorders
 Vulnerability to domestic violence, social discrimination
and stigma

Preconception assessment may lead to :-
Delaying the pregnancy (until the identified disorder is


treated, controlled, or becomes less risky to the pregnancy)
or
Completely avoiding pregnancy if the pregnancy is likely to


endanger the life of the woman

Preconception assessment, intervention, and preparation con…
Interventions:
Counseling on the risk of pregnancy with uncontrolled medical
conditions
Counseling and providing appropriate contraception for women
who are not eligible for pregnancy are parts of preconception

care
Micronutrient supplementation (iron, folic acid, calcium, zinc)
Promote consumption of the fortified and biofortified foods,
diversified and nutrient dense foods.

Counseling on the adverse effect of substance use (serious
neural tube defects)

Intervention …
 Pre-pregnancy nutritional assessment using the body

mass index (BMI) scale :-
 Maintaining body weight to the normal range and
 Advising uptake of folic acid 400 µgm/0.4 mg daily
starting three months ahead of the planned conception are
basic components of preconception care.
 In case of previous delivery of a baby with neural tube
defect, diabetics and on antiepileptic high dose folic acid
dose needs to be increased to 4–5 mg per day
 Pre-pregnancy vaccination (Td )
 Lifestyle modification
 Ensuring linkages to locally available services,
(domestic violence, social discrimination and stigma)
ANTENATAL CARE CONTACT

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OBJECTIVES OF ANC
 A healthy pregnancy
 A healthy outcome for mother and newborn
 Promotion of physical, mental, and social health

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Introduction
Antenatal care (ANC)
The care provided by skilled health-care professionals to pregnant women and


adolescent girls in order to ensure the best health conditions for both mother and
foetus during pregnancy
It is one of the intervention of safe motherhood to reduces maternal and perinatal


morbidity and mortality both directly and indirectly

Introduction…..
 ANC is not only destined a healthy mother and a healthy

baby, but also to make pregnancy a healthy and positive
experience for a woman and her family.
A positive pregnancy experience:

 Maintaining sociocultural normality
 Maintaining a health pregnancy for mother and baby
(including preventing or treating risks, illness and death),
 Having an effective transition to positive motherhood
(including maternal self esteem, competence and
autonomy).
 Pregnancy should be a positive experience for all women
and they should receive care that respects their dignity.”
Introduction…..
 Changes of ANC overtime: From traditional approach to
FANC(2002),
 The FANC model was associated with more adverse events,
especially increased perinatal mortality.
 Eight or more contacts for antenatal care can reduce perinatal
deaths by up to 8 per 1000 births when compared to 4 visits.
 ‘contact’ as it implies an active connection between a pregnant
woman and a health care provider that is not implicit with the
word ‘visit’.
 More contact between pregnant women and respectful,
knowledgeable health care workers is more likely to lead to a
positive pregnancy experience
Introduction...
 The maternal mortality ratio (401/100,000 live births) and

perinatal mortality rate (33/1000 live births) in Ethiopia are
among the highest in the world.
 Ethiopia adopted the 2016 WHO model with a minimum of
eight contacts to reduce maternal and perinatal mortality
and morbidities
 Ethiopia has never had ANC guideline
 This guideline is urgently needed to address the issue of
equity, quality, and standardization of the ANC in Ethiopia.
KEY PRINCIPLES OF ANC
1. Implementing the new ANC model of eight contacts schedule.
2. ANC care should be woman-centered(holistic approach) by recognizing and
addressing each woman’s social, emotional, physical, psychological, spiritual, and cultural needs and
expectations
3. De-medicalized ANC: avoid over medicalization, meaning that essential care
should be provided with the minimum set of interventions.
4. ANC should be providing efficient and timely care to all pregnant women.
5. ANC should be evidence-based
6. ANC should be multidisciplinary
7. ANC should respect the privacy, dignity, and confidentiality of women.
8. ANC providers should be motivated, competent, and compassionate
9. Women with special needs require care in addition to the core components of
basic care
Benefits of ANC
ANC visits are unique opportunities for early diagnosis

and treatment of problems:
 Maternal problems: anemia, vaginal bleeding, pre-
eclampsia/eclampsia, infection, abnormal fetal
presentation after 36 weeks
 Fetal/newborn problems: abnormal fetal growth or
movement, HIV, syphilis, malaria, malnutrition

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Benefits to newborn may be even greater than
benefits to mother
Antenatal Care action Problems that may be prevented
Tetanus immunization Neonatal tetanus
Syphilis screening (RPR or VDRL) Abortion, stillbirth, congenital
syphylis
Screening and treatment of other STIs Newborn gonococal or chlamydial
infection
Malaria prevention (ITNs) Abortion, prematurity, low birth
weight
Screening and ARVs for HIV HIV transmission to the
fetus/newborn
Screening and treatment for anemia and Low birth weight
hookworm
Micronutrient supplementation: Vitamin A, Low birth weight, prematurity, spinal
Iron, Folate (pre-conceptional), Iodine cord defects, cretinism
Danger signs and complication readiness Delays in obtaining treatment if a
plan problem arises Source: Beck et al. 2004
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QUESTION ????
 What problems have you seen with the

antenatal care?
 Why are there problems with antenatal
care?

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Traditional ANC
PROBLEM
 Quality of care is poor
 We gather information but do not use it to manage patient eg. Anemia
 Poor clinical management of problems – eclampsia, bleeding in
pregnancy
 Failure to record relevant information
 Not woman friendly –
 Factory Assembly line ANC system
 Not client specific
 Women treated poorly so do not return
 Poor communication
 Poor counseling skills
 Information and education is not relevant to the woman
 Weak referral linkage
 Late comes for services

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ANC
An approach to ANC that emphasizes

 Individualized Care
 Client Centered
 Disease Detection Not Risk Classification
 Care by a Skilled Provider

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GOAL OF ANC
 The major goal of ANC is to help women

maintain normal pregnancies through:
 Early Detection And Treatment Of Problems
And Complications
 Prevention Of Complications And Disease
 Birth Preparedness And Complication Readiness
 Health Promotion

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Introduction cont…
Components of ANC

The 2016 WHO ANC model
 WHO recommends the new ANC care model

with minimum of eight contacts.
It helps to:
 Helps to improve quality of care
 Improve women’s experience of care
 Increase service utilization & maternal
satisfaction
 Reduce perinatal mortality
The 2016 WHO ANC model
Contact Vs visit
The term ‘contact’ – is an active connection between


a pregnant woman and a health care provider which

is implicit with the word ‘visit’
‘Contact’ can take place at the facility or at


community level

What is new on ANC schedule?
WHO FANC MODEL 2016 WHO NEW MODEL
First trimester First trimester

Contact 1: up to 12 weeks
Visit1: 8-12 weeks Second trimester
Contact 2: 20 weeks
Second trimester Contact 3: 26 weeks
Third trimester
 Visit 2: 24-28 weeks  Contact 4: 30 weeks
Third trimester  Contact 5: 34 weeks

 Contact 6: 36 weeks
 Visit 3: 32 weeks  Contact 7: 38 weeks
 Contact 8: 40 weeks
 Visit 4: 36-38 weeks
If woman not delivered until 40Wks, appoint her at 41 weeks

It means good clinical decisions
must be made at each Contact
Assessment: Clinical decision making
Gather
Step 1 • Hx, PE, Lab.Ix, US, Records
information
• Identify problem(s) and possible Dxs associated with the
Interpret
Step 2 presenting s/s
Information
• Make diagnosis
Classify type
Step 3 • Basic care or Special care
of care
• An individualized plan to meet all the woman’s needs (her
problems, risks, emotional needs, cultural beliefs,
Develop a socioeconomic status).
Step 4
Care Plan • Some women may require special care plans or urgent
referral to another facility
• Every plan must be done with input from the woman
• Give treatments and provide preventive measures, counsel
Implement on nutrition and self‐care
Step 5
Care Plan • Record findings and actions taken
• Give return appointment. Refer if necessary
• On next visit, evaluate improvements or change through
Step 6 Evaluate the Hx, PEx. or repeat lab tests.
Care PlanBEmONC • – LRP:
WasEthiopia
care plan implemented asantenatal
Focused planned? careWas it effective?
Does it need change or modification?
Group Activity
Be in groups – Work out

Basic ANC screening
1.
2. Selective ANC screening,
3. Pregnancy risk identification, ANC assessments in each contact of the

new ANC model (gallery walk)
Time: 5 minutes
Maternal and fetal assessment at first ANC contact
 Welcoming environment and respectful

reception
 Recognizing and address the pregnant woman’s
expectation, special needs, and concerns

History and Physical examination
History
Identification
Menstrual history
History of present pregnancy
Past obstetric history
Medical history
Current medication
Gynecologic history
Nutritional history
Intention of the pregnancy, Social and personal Hx

History and physical examination…
Physical Examination
General appearance

Vital signs

Weight and height


Acute malnutrition screening using mid upper arm circumference


(MUAC)
Examining the conjunctiva, oral mucosa, and nail beds for pallor

Auscultating the chest for breathing sounds and heart sounds, any

additional sounds
Physical Examination…
 Obstetric examination: Measuring the Symphysis
Fundal Height and doing the Leopold maneuvers
 Auscultating the fetal heartbeat
 Palpating the abdomen for any mass or organomegally
 Examining the FGM scar after consultation and deciding
on the need of de infibulation (in high prevalence areas)

Physical Examination…
 Examining the musculoskeletal system for any gross

deformity/swelling, varicose veins in the lower limb
 Vaginal examination if only indicated

Basic and Selective/case-specific ANC screening
Case specific ANC screening

Basic ANC
Clinical Suggestive evidence
screenings condition
• Hemoglobin (Hb) or hematocrit Gestational Personal or family history, previous macrosomia or

(HCt), blood group, and Rh diabetes stillbirth, obese, large for date uterus, family history,
mellitus glycosuria
• Urine analysis: Dipstick, Tuberculosis Current cough, weight loss/failure to gain weight,
microscopy/gram stain night sweats, and fever
• Tests for HIV, HBV, syphilis
Group B Previous perinatal infection with GBS
• Ultrasound before 24 weeks
streptococcu
Best Practices in Maternal and sNewborn
Pregnancy risk identification
 Risk identification and stratification at first contact

and refresh in subsequent contact
 Multiple assessment methods
 Past and present obstetric history,
 Medical and surgical history
 Systematic physical examination, laboratory, and imaging

Exercise
 Show revised Federal Ministry of Health Integrated

Antenatal, Labor, Delivery, Newborn and Postnatal
Care Card
 Ask the group to summarize what to do and when to
act.

Classify type of Care
Gather information ( All women)
Interpret
Identify preexisting or developing problems
Classify
Specialized care needed?
Yes
NO
Specialized Care
Additional IX and follow
Basic care up including referral

CARE PLAN: APPROPRIATE COUNSELING AND IEC
 Relevant to CLIENT NEEDS
 Relevant to GESTATION
 Address DISCOMFORTS of pregnancy

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BASIC CARE PLAN
 Minimum Of eight Contacts For The Healthy Client
 Anemia Prevention
 Malaria Prevention
 Pre-eclampsia/Eclampsia Prevention
 Prevention Of HIV Transmission
 Treatment/Prevention Tuberculosis
 Treatment/Prevention Other STIs
 Tetanus Immunization
 Preparing Birth And Complication Preparedness Plan
 Health promotion And Counseling – nutrition, family planning, infant
feeding, hygiene and Counsel on the importance of PNC 24 hr stay and
etc.
42
BASIC CARE …
Vaccination during pregnancy
 Vaccination during pregnancy has a triple life protection
purpose (the mother, the fetus, and the infant).
 In Ethiopia, the use of tetanus toxoid (TT) vaccine is replaced
with tetanus-diphtheria (Td) vaccine.
Timing of administration* Protective effectiveness
Dose
(duration of protection)
Td-1 At the first ANC contact 0%
Td-2 At least 4 weeks after Td-1 80% (1-3years)
Td-3 At least 6 months after Td-2 95% (5 years)
Td-4 At least 1 year after Td-3 99% (10 years)
Td-5 At least 1 year after Td-4 99% (all child-bearing years)

BASIC CARE …
Preventing RhD Isoimmunization
 RH isoimmunization is hemolytic anemia of fetus/neonate
secondary to the production and passage of antibodies against
fetal Rh antigen.
 Administer 300 mc anti-D immunoglobulin during
antepartum (28 wks) and immediate postpartum period (if
the cord blood group is Rh positive)
 It is administered to unsensitized Rh negative woman whose
partner is Rh positive.
BASIC CARE …
RhD Isoimmunization Cont…
 Those mothers who cannot get the Anti-D early, should be
advised to take the injection within 3-4 weeks after birth.
 Coomb’s +ve mothers do not need Anti-D, but should be
referred to a tertiary hospital
 Anti-D should be administered in all subsequent pregnancies

BASIC CARE …
Deworming during pregnancy
 WHO recommends mass deworming if prevalence is >20%
 In Ethiopia, prevalence of intestinal parasitosis ranges from
32% to 70%
 Administer single dose of either albendazole (400 mg) or
mebendazole (500 mg) after the first trimester.
 Mebendazole can be administered in the first trimester if the
woman’s health condition is deteriorating because of massive
intestinal parasitosis or anemia
 Perform lab test if the woman is symptomatic and treat
accordingly
 Encourage personal hygiene and environmental sanitation
BASIC CARE …
Pre-exposure Prophylaxis for HIV
 PrEP prophylaxis is highly recommended when there is a substantial
risk of acquiring HIV.
o Sero-discordant couple
o Risky sexual practice
o Not using condoms while having sex with with a person of
unknown HIV sero-status.
 Administer a combination of Tenofovir disoproxil fumarate (TDF) +
lamivudine (3TC)/ dolutegravir (DTG) regardless of gestational age.

BASIC CARE …
Prevention of Preeclampsia
 60-70% of child bearing women in Ethiopia have less than the
recommended level of dietary calcium intake
 Daily dose of 1.5-2.0 g oral elemental calcium starting from 14
weeks of gestation is recommended to reduce risk of
preeclampsia/eclampsia
 Women should be counseled to take adequate dietary calcium
 Administer iron and calcium at least 3 hours apart to avoid
interaction
BASIC CARE …
Prevention of Malaria
 Malaria infection during pregnancy is a major public health
problem, with substantial risks for the mother, her fetus and
the newborn.
 Promote use of insecticide-treated nets
 Prompt diagnosis and treatment of malaria infection
 Test & treat all pregnant women living in malaria endemic
areas (Afar, Somali, Gambela, Benshangul-Gumz, and
selected areas of other regions)

BASIC CARE …
Tuberculosis
 Ethiopia is one of the 22 WHO high Tb burden countries, with an estimated
prevalence of active Tb of 370/100,000 pregnant population
 Tb seriously affects the maternal health and the pregnancy outcome, by
reducing the fetal birth weight, increasing MTCT of HIV
 During pregnancy, latent Tb treatment can be delayed for 2-3 months after birth
unless there is a risk for progression to active Tb
 Active Tb, however, should be treated even in the first trimester
 Streptomycin, Fluoroquinolones, Pyrazinamide contraindicated during
pregnancy

BASIC CARE …
Anemia Prevention
Iron supplementation

Folate supplementation

Treat any factors that can cause anemia: worms,


malaria, schisto etc.

Nutrition – foods rich in iron, folate, and vitamin c


51
Anemia classification and treatment
HB level Degree of anemia Immediate action
>11 gm/dl Normal Iron-folate prophylactic dose
9–10.9 gm/dl Mild Therapeutic iron dose + peripheral RBC

morphology and RBC indices*
7–8.9 gm/dl Moderate Therapeutic iron dose + peripheral RBC

morphology and RBC indices, close follow-up*
< 7 gm/dl Severe Referral to a hospital for complete investigation

and possible blood transfusion; continue
therapeutic iron dose then after
*If no adequate response to therapeutic iron dose, refer to a hospital for a complete investigation
Therapeutic dose: 60 mg elemental iron, BID in 24 hours until the Hb rises to ≥11gm/dl, to be followed
by prophylactic dose.

BASIC CARE …
Asymptomatic Bacteriuria
 Asymptomatic bacteriuria (AB) in pregnancy ranges from 5-20%
 It increases risk of developing cystitis, acute pyelonephritis,
spontaneous preterm delivery, PROM, and chorioamnionitis
 Diagnosis of AB is when the load of single bacteria is >100,000
colony forming units/ml of midstream urine culture
 Perform gram-staining of the midstream urine if urine culture is
not possible (recommended)
 Treat AB with Amoxicillin or cephalexin or Cephoxin tablets

BASIC CARE …
Asymptomatic Bacteriuria
 Asymptomatic bacteriuria (AB) in pregnancy ranges from 5-20%
 It increases risk of developing cystitis, acute pyelonephritis, spontaneous
preterm delivery, PROM, and chorioamnionitis
 Diagnosis of AB is when the load of single bacteria is >100,000 colony
forming units/ml of midstream urine culture
 Perform gram-staining of the midstream urine if urine culture is not possible
(recommended)
 Treat AB with Amoxicillin or cephalexin or Cephoxin tablets to prevent
pyelonephritis, preterm birth and low birth weight.

BASIC CARE …
Diabetes mellitus in pregnancy
 DM has maternal and newborn immediate and late complications
 Early diagnosis and appropriate treatment minimizes immediate
and late complications
 Maintaining good glycemic control through lifestyle modifications,
administration of insulin
 Pregnant women with a diagnosis of diabetes mellitus are
candidates for specialized care

BASIC CARE …
HIV, syphilis, and HBV infection during
pregnancy
 STI during pregnancy can pose serious health risks
for the mother and the fetus
 Screening for HIV, hepatitis B, chlamydia, and
syphilis should be taken place for all pregnant
women

BASIC CARE …
Addressing Common pregnancy conditions
 Common pregnancy conditions in pregnancy are due to anatomic and
physiologic changes
 Unlike serious illnesses during pregnancy, common pregnancy conditions are
not exceptionally harmful to the pregnancy
 However, some case may require hospitalization and aggressive therapeutic
interventions
 Common pregnancy conditions include:
• Nausea and vomiting • Abnormal vaginal discharge
• Heartburn • Headache
• Hemorrhoid & varicose • Low back pain
veins • Pelvic pain
• Leg cramp

BASIC CARE …
Counseling IN ANC:
Ask the group
Have you ever had counseling yourself?
What did you like or not like about the counseling you
received?
What are the six elements of counseling?

58
Elements of Counseling
 Greet client politely, warmly

 Ask about how she is feeling, herself, her family
 Tell her what is going to happen
 Help her to be comfortable, to understand her
situation, to make informed decisions when needed
 Explain care plans or instructions to client and
companion
 Return visit, referral, follow-up

59
Counseling Skills
What are some skills or techniques for effective

counseling?
Give some examples

60
Effective Counseling: Skills/Techniques
 Praise and encouragement

 Questioning
 Paraphrasing and summarizing
 Active listening
 Observation (client’s nonverbal clues)
 Reflection and acknowledgement
 Using appropriate level of language

61
BASIC CARE …
Counseling and Health Promotion
Major areas of counseling and health promotion services
Birth
preparedness Danger signs
Lifestyle
and and modification
complication symptoms
readiness

Lifestyle Modification
 To optimize the maternal adaptation to the

Aim physiologic and anatomic changes
 Helps to maximize the fetal growth and
tolerance

Lifestyle Modification
Focus areas
Substance use Diet Exercise
Hygiene & sanitation Sexual activity


Danger Symptoms & Signs
Sudden and unpredictable complications can occur at

any time
 Vaginal bleeding any amount and anytime

 Sudden gush or leaking of fluid per vagina
 Offensive vaginal discharge
 Chills, rigor or fever
Signs  Severe headache not relieved by simple analgesics
 Dizziness and blurring of vision
 Sustained nausea and vomiting

Danger Symptoms & Signs Cont…
• Sustained cough (dry or productive)

• Swelling (hand and face)
• Decreased or loss of fetal movement
• Convulsions and/or loss of consciousness
Signs
• Premature onset of contractions/pushing down
pain
• Severe or unusual abdominal pain and skin rash
Annex 5: Checklist for Counseling danger
Counseling and Health Promotion symptoms & signs

Birth preparedness
and complication readiness plan
QUESTION ???
Why bother with a birth preparedness
and complication readiness plan?

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Why bother?
 Time of labor or time of emergency is not the time to

decide what to do
 Increase the likelihood of using a skilled attendant as
arrangements have been made
 Frequently women/families do not seek help because
they do not know they have a problem – don’t know
danger signs
 Some complications, eg hemorrhage take only 2
hours until death – all plans must be in place

68
QUESTION?
What are the elements of a birth

preparedness and complication readiness
plan?

69
Birth preparedness & Complication Readiness
All pregnant women & their family have to be ready for birth &
complication
 Skilled attendance at birth
 Place of delivery
 How to get to health facility
 Preparing essential items for child-birth
 Saving money for emergency transport
 Preparing support during and after birth
 Arranging a way of communication in emergency situations; and
 Designating a decision maker on her behalf when she is unable to
do that Counseling and Health Promotion

Birth preparedness & complication
readiness Cont…
o Use maternity waiting home to bridge

geographic gaps to access obstetric care
o Establish strong inter-facility linkage and

referral system

Basic care…
Nutritional counseling
 Promoting a healthy diet by increasing the quality,
quantity, and diversity of food consumed
 Promoting adequate weight gain during pregnancy
through weight measurement
 Women with normal BMI before pregnancy should achieve
10 to 12.5 kg during pregnancy
 Counseling should also emphasize that excess weight gain is
not healthy during pregnancy
 Promoting food and micronutrient supplements during
pregnancy
 Promoting healthy eating habits and physical exercise to
prevent maternal overweight and obesity during pregnancy

Nutritional counseling…
 Promoting consumption of at least five out of the ten food groups

1.Grains, white roots and tubers, and plantains (“starchy
staples”)
2. Pulses (beans, peas, and lentil)
6. Eggs
3. Nuts and seeds 7. Dark-green leafy vegetables
4. Dairy 8. Other vitamin A-rich fruits
and vegetables
5. Meat, poultry, and fish 9. Other vegetables
10. Other fruits

Nutritional counseling ...
 Counseling for adherence to iron, folic acid, and calcium
supplementation during each contact
 Food safety and quality is important during pregnancy

Some of food items that need to be avoided include:-
 Raw meat (risk of toxoplasmosis, tapeworm, schistosomiasis, etc.)
 Raw egg (risk of salmonella food poisoning),
Mold-ripened soft cheese (risk of listeriosis for the fetus),
Unwashed vegetables and fruits,
unpasteurized or raw milk,
 processed and Junk/packed foods (overweight and non-

communicable diseases),
Excess caffeine (risk of low birth weight

Prevention and treatment of maternal malnutrition during
pregnancy
 Women are advised to increase their daily calorie intake during pregnancy according
to their pre pregnancy body weight, physical activity, and gestational age
 Counseling mothers to get at least one additional nutrient-dense, safe, and diverse
meals per day during pregnancy
 Energy requirements vary significantly depending on a woman’s age, BMI, and

activity level
 MUAC and weight measurement should be determined during each ANC contacts to
assess maternal nutritional status and to act accordingly.
 MUAC <23 cm indicates acute malnutrition and is an indication for supplementation

with ready-to-use foods (e.g., Plumpy’Nut)

Recommended maternal weight gain during pregnancy and
dietary diversification
Baseline/ Recommended Dietary diversification
pre-pregnancy BMI weight gain
in kg/m2
in kg
Recommended
weight gain
in kg
Underweight (<18.5) 12.5–18 More calorie and protein diet adequate vegetables and fruits
Normal (18.5 to <25) 11.5–16 Moderate carbohydrate and protein diet adequate vegetables
and fruits
Overweight (25 to <30) 7–11.5 Normal carbohydrate and protein diet, very low fat, more
vegetables and fruits
Obese (≥30) 5–9 Lower carbohydrate and protein diet, more vegetables and
fruits, avoid fat foods
Steady increase of 1.5–2 kgs weight per month is expected from 4 month of
pregnancy.
Cumulative average increase of 10–12 kgs weight is expected from pregnancy
till birth of a child.
Iron and folic acid supplementation
 In Ethiopia nutritional (iron or folate) deficiency, malaria, and

hookworm infestation are the major causes of anemia in
pregnancy.
 Over 50% of anemia during pregnancy is contributed by iron
deficiency, reflecting the increased demand for iron.
 Other causes of nutritional deficiency anemia during pregnancy
are folic acid (vitamin B9) or vitamin B12 deficiency.
 The average daily requirement of elemental iron in normal
pregnancy is 3.5 mg/dl.
 Diets that are rich in iron include red meat, liver, poultry, fish,
dried beans and peas, iron-fortified cereals, biofortified food
Iron and folic acid supplementation
 Supplementary dose: Provide daily oral iron and folic

acid supplementation (60 mg elemental iron and 0.4
mg folic acid) to all pregnant women to prevent
maternal anemia, puerperal sepsis, low birth weight,
and preterm birth (at least 90 tabs to the maximum
180 tabs; assess compliance and counsel for adherence
during each contact).

Multiple micronutrient supplementation
 Micronutrients are only needed in very small quantities but are essential
for normal physiological function, growth, and development.
 Calcium supplementation as component of nutritional intervention
 Promote Calcium-rich foods such as milk, other dairy products, and green leafy
vegetables to improve maternal nutritional status and reduce risk of pre-
eclampsia/eclampsia.
 Calcium supplementation reduces the risk of leg cramps.
 The calcium and iron tablets should not be simultaneously taken.
 Provide calcium supplementation with daily 1.5–2.0 gm oral elemental calcium
for all pregnant women starting from 14 weeks of gestation

SUMMARY
 Preconception care:- Make good preparation for child-birth and
parenting
 Complications Cannot Be Predicted: All Pregnant Women Are
At Risk.
 ANC visits are unique opportunities for early diagnosis and
treatment of problems
 ANC is an approach to ANC that emphasizes:-
 Individualized Care
 Client Centered
 Disease Detection Not Risk Classification
 Care By a Skilled Provider
80
References
 ANC new guideline,2021, Ethiopia,

 Kinzie and Gomez, Basic Maternal and Newborn Care. 2004. JHPIEGO.
WHO 2016. WHO recommendations on antenatal care for a positive
pregnancy experience.

81

3.1 PCC and ANC Contact-2021

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PRESENTATION 3.

Preconception Care and ANTENATAL CARE

Federal Democratic Republic of Ethiopia

 Describe Preconception Care

BEmONC – LRP: Ethiopia Focused antenatal care

preconception/pre-pregnancy care is the most ignored,

The provision of biomedical, behavioral and social

health interventions to women and couples before

 Discuss on importance of Preconception care

BEmONC – LRP: Ethiopia Focused antenatal care

Is a comprehensive care in the continuum which

BEmONC – LRP: Ethiopia Focused antenatal care

Make good preparation for child-birth and parenting.

Early identification and management of conditions that

can worse or recur during pregnancy(medical disorder,

cerclage, loop electrosurgical excision procedure (LEEP),

BEmONC – LRP: Ethiopia Focused antenatal care

 Medical and mental health disorders:-diabetes mellitus,

BEmONC – LRP: Ethiopia Focused antenatal care

Delaying the pregnancy (until the identified disorder is

treated, controlled, or becomes less risky to the pregnancy)

Completely avoiding pregnancy if the pregnancy is likely to

endanger the life of the woman

BEmONC – LRP: Ethiopia Focused antenatal care

who are not eligible for pregnancy are parts of preconception

Promote consumption of the fortified and biofortified foods,

diversified and nutrient dense foods.

neural tube defects)

 Pre-pregnancy nutritional assessment using the body

BEmONC – LRP: Ethiopia Focused antenatal care

BEmONC – LRP: Ethiopia Focused antenatal care

The care provided by skilled health-care professionals to pregnant women and

It is one of the intervention of safe motherhood to reduces maternal and perinatal

morbidity and mortality both directly and indirectly

BEmONC – LRP: Ethiopia Focused antenatal care

 ANC is not only destined a healthy mother and a healthy

A positive pregnancy experience:

 The maternal mortality ratio (401/100,000 live births) and

ANC visits are unique opportunities for early diagnosis

BEmONC – LRP: Ethiopia Focused antenatal care

 What problems have you seen with the

BEmONC – LRP: Ethiopia Focused antenatal care

BEmONC – LRP: Ethiopia Focused antenatal care

An approach to ANC that emphasizes

BEmONC – LRP: Ethiopia Focused antenatal care

 The major goal of ANC is to help women

BEmONC – LRP: Ethiopia Focused antenatal care

BEmONC – LRP: Ethiopia Focused antenatal care

 WHO recommends the new ANC care model

The term ‘contact’ – is an active connection between

a pregnant woman and a health care provider which

‘Contact’ can take place at the facility or at

BEmONC – LRP: Ethiopia Focused antenatal care

First trimester First trimester

Third trimester  Contact 5: 34 weeks

If woman not delivered until 40Wks, appoint her at 41 weeks

Be in groups – Work out

2. Selective ANC screening,

3. Pregnancy risk identification, ANC assessments in each contact of the

 Welcoming environment and respectful

BEmONC – LRP: Ethiopia Focused antenatal care

History of present pregnancy

Past obstetric history