Guidelines on Provision of Quality Antenatal Care in All Birthing Centers and Health Facilities Providing Maternity Care Services

September 19, 2016

DOH ADMINISTRATIVE ORDER NO. 2016-0035

 

I. Background and Rationale

Pregnancy is a time to promote healthy behavior and parenting skills. Good antenatal care (ANC) is important in the development of the unborn and links the woman and her family with the formal health system. Inadequate care during the antenatal period breaks the continuum of care which can compromise health of both mothers and newborns. While ANC indirectly saves the lives of mothers by promoting and establishing good health during pregnancy and the postnatal period the time periods of highest risk, it improves the health and survival of the newborns directly by reducing stillbirths and neonatal deaths.

Antenatal Care (ANC) coverage in the country can be considered a success story with 78% of women having at least 4 ANC visits recorded in 2014 (National Safe Motherhood Program Report). However, to achieve the full life-saving potential that ANC promises to mothers and babies, an enhancement of the current ANC practice is necessary along with strict compliance to protocol by health professionals attending to births at all levels of the health system.

II. Objectives

This Order seeks to improve the quality of antenatal care through the provision of technical guidance in the shift in ANC concept from the high risk approach to the four-visit model of focused ANC and the consequent service delivery scheme of the ANC package.

III. Scope of Application

This Order shall apply to all providers of maternal and newborn care services in the public and private sector and at all levels of the health care delivery system.

IV. Definition of Terms and Acronyms

1. Antenatal Care (ANC) also known as prenatal care is a type of preventive healthcare accorded to pregnant women with the goal of providing regular check-ups that allow doctors, nurses and midwives to identify, prevent and treat potential health problems throughout the course of the pregnancy while promoting healthy lifestyles that benefit both mother and child. ATICcS

2. High Risk ANC is a method of providing antenatal care with the objective of classifying pregnant women as low risk or high risk based on pre-determined criteria. This approach is hard to implement effectively since a woman may have more than 1 risk factors and not all high risk develop complications in like manner that some low risk women develop complications particularly during childbirth.

3. Focused ANC is an individualized goal oriented ANC that provide specific evidence-based interventions to women, carried out at certain critical times in the pregnancy. This comprise the following essential elements:

a. Pregnancy Tracking or the identification and surveillance of the pregnant woman and her expected child.

b. Screening for conditions and diseases such as anemia, STIs (sexually transmitted infections) particularly syphilis, HIV (human immunodeficiency virus) infection, Hepatitis B infection, mental health problems, and/or signs of stress or domestic violence.

c. Recognition and management of pregnancy-related complications, particularly hypertensive disorders of pregnancy.

d. Recognition and treatment of underlying and concurrent illness.

e. Preventive measures, including tetanus toxoid immunization, deworming, iron and folic acid supplementation, calcium carbonate supplementation, iodine oil capsule supplementation in areas with low urinary iodine excretion levels; and, in malaria endemic areas, intermittent preventive treatment of malaria in pregnancy (IPTp) and insecticide treated bed nets (ITN).

f. Advice and support to the woman and her family for developing healthy home behaviors and a Birth Plan.

4. Birthing Center is a healthcare facility also known as birthing home, lying-in and puericulture center. It can be a Rural Health Unit, Health Center, City/Municipal/Community/Medicare/District Hospitals that provide birthing services. It can also be the unit in secondary and tertiary hospitals where maternity care services are provided such as the out-patient obstetrics department, delivery room and maternity ward. It provides antenatal care, birthing care and postnatal care. It is staffed by doctors who are general practitioners or with specialization in obstetrics, nurses or nurse-midwives and midwives trained on basic emergency obstetrics and newborn care.

5. Maternal Health Services refer to a range of services that covers care during the periods that include, but are not limited to, antenatal, delivery, and postpartum periods. (RPRH Law IRR).

V. Guiding Principles

All health workers in Birthing Centers shall be guided by the following principles in the provision of ANC:

1. ANC is an important entry point in the provision of integrated care. Conditions such as sexually transmitted infections, tetanus, HIV, tuberculosis, malaria, diabetes, some nutritional deficiencies and other conditions that may arise can be addressed during ANC:

• Prevention of Maternal and Neonatal Tetanus. ANC provides an opportunity to immunize pregnant women with the recommended (at least) 2 doses of tetanus toxoid and provide advice and schedule towards the completion of the immunization at postpartum.

• Prevention and case management of maternal malaria in endemic areas. Asymptomatic malaria infection of the placenta can result to maternal anemia and contribute to low birth weight and preterm birth. ANC offers a means to increase the coverage of key interventions for malaria in pregnancy: IPTp (intermittent prevention and treatment of malaria in pregnancy) and ITN (insecticide treated bed nets).

• Prevention of maternal anemia, neural tube defects and malnutrition. Anemia during pregnancy increases the risk of dying from hemorrhage. It is also associated with an increased risk of stillbirth, low birthweight, prematurity and neonatal death. Thus, iron and folic acid supplementation, deworming, malaria prevention, improved obstetric care, and management of severe anemia are essential in the prevention of neural tube defects and control of maternal anemia and malnutrition during pregnancy.

• Prevention of sexually transmitted infections (STIs) and mother-to-child transmission of HIV (PMTCT). Universal syphilis screening and treatment during ANC has been established to be feasible and cost effective intervention since syphilis complications are severe yet therapy is cheap and effective. On the other hand, through the opt-out system or the health worker initiated HIV counseling and testing, ANC is a key entry point for the prevention of mother-to-child transmission of HIV (PMTCT) services.

2. ANC offers an opportunity to develop a Birth Plan. The National Safe Motherhood Program recommends that health workers assist all pregnant women to have a written plan for dealing with childbirth and any unexpected adverse event such as obstetric complications that may occur anytime during pregnancy, childbirth and the immediate postnatal period. TIADCc

3. ANC visits provide opportunities to promote lasting health, offering benefits that continue beyond the pregnancy period. This includes birth preparedness and extends to cover health information and counselling for pregnant women, their families and communities.

VI. Specific Guidelines

ANC presents the first opportunity for a woman to connect with the health system and thus an entry point for integrated care. To ensure that women and newborns benefit from ANC the following shall guide skilled health professionals in the provision of antenatal care:

1. Pregnancy Tracking shall be done in all communities by the Barangay Health Workers (BHWs) and shall be used as an opportunity to encourage women to access antenatal care at the nearest birthing center.

2. All pregnant women shall be provided with focused antenatal care (ANC).

a. The first ANC visit shall be considered crucial for early identification of underlying conditions such as chronic hypertension, diabetes, anemia and the like and shall be done as early as possible preferably during the first trimester. Likewise, this visit shall distinguish women who require the standard 4-visit model from those requiring special attention and more visits.

b. The last visit shall be at around the 37 weeks or near the expected date of delivery to ensure that appropriate advice and care have been provided to prevent and manage difficult labor and problems such as multiple births, post-maturity and mal-presentation.

3. Focused antenatal care interventions for healthy women with no underlying medical problems shall be provided over 4 visits at specified interval: 1 visit during the 1st trimester (8-12 weeks), 1 visit during the 2nd trimester (24-26 weeks) and 2 visits during the 4th trimester at 2 weeks interval (32 weeks and 36-38 weeks). For women with underlying medical conditions, focused antenatal care may require more visits upon doctor's advice.

4. All pregnant women shall be required to have a written Birth Plan (contained in Mother-Baby Book, Mother and Child Book, Rekord ni Nanay, Nanay and Baby Book, other similar health records) at the first ANC visit. The women should discuss and review this plan with a health worker at every ANC visit and 1 month before the expected date of delivery. The birth center nurse or midwife shall ensure the identification of the following elements in the plan:

a. Desired place of delivery;

b. Name and location of the nearest birthing center;

c. Name of birth attendant;

d. Name and location of the nearest referral hospital;

e. Funds for birth-related and emergency expenses;

 The birthing center staff should orient the woman about PhilHealth membership benefits and enrolment at the point of care in case she is not a member yet.

f. Desired birth companion;

g. Things to prepare for the newborn and things to bring on delivery date;

h. Available support from community workers, e.g., BHWs in looking after the home and children while the woman is away to give birth;

i. Transport from home to a health facility, including contact person, contact number and cost;

j. Transport from the birthing center to a referral facility in case of obstetric emergency, including contact person, contact number and cost;

k. Identification of at least 2 blood donors in case of emergency including contact numbers.

5. Health professionals in birthing centers shall effectively use each visit to provide opportunities to promote lasting health and offer benefits that continue beyond pregnancy and delivery. Thus, each woman accessing antenatal care shall be given a Mother and Child Book. The Mother and Child Book shall be used not only as a tool to prepare for birth but also to provide information and learning about pregnancy and child care. With the aid of the Mother and Child Book health workers should be able to inform, educate and give advice about —

a. Proper nutrition and rest

b. Promotion of early and exclusive breastfeeding

c. Smoking cessation

d. Avoidance of alcohol and drugs AIDSTE

e. Personal hygiene including oral health

f. Guidance about family planning

g. Newborn and child care including immunization schedule

h. Child nutritional status through the growth monitoring chart that includes weight and height monitoring

Likewise, all essential information and birth center visit findings shall be accurately recorded in the Mother and Child Book. The coverage of 4 or more ANC visits disaggregated by trimester is important because the effectiveness of certain interventions such as iron with folic acid and calcium carbonate supplementation, tetanus toxoid vaccination and provider initiated counselling and testing (PICT) for HIV, syphilis and hepatitis B depend on repeated visits and the trimester in which they occur. This guides the woman and health providers as well on actions to take and make referrals efficient.

The Mother and Child Book is a record that should be held by the woman. The Birthing Center nurse or midwife should instruct the woman to bring the Book during every health center visit and at the time of delivery.

6. All birthing centers shall guarantee the provision of focused ANC by establishing and maintaining a network of service providers (service delivery network) as necessary to ensure that all the essential services are delivered to every pregnant woman. The network of service providers may include hospitals, specialized clinics such as the Social Hygiene Clinic and laboratories both in the public and private sector.

7. All birthing center staff at each level of the health care delivery system shall comply with the ANC goals and activities at each visit based on the 4-visit model as applied in focused ANC:

Goals
	First Visit	Second Visit	Third Visit	Fourth Visit
8-12 weeks	24-26 weeks	32 weeks	36-38 weeks
	Confirm pregnancy	Assess maternal and fetal well-being	Assess maternal and fetal well-being	Assess maternal and fetal well-being
	Determine expected date of delivery (EDD)	Rule out hypertensive disorder in pregnancy and anemia	Rule out hypertensive disorder in pregnancy, anemia and multiple pregnancy	Rule out hypertensive disorder in pregnancy, anemia, multiple pregnancy and mal-presentation.
	Classify women for	Give preventive measures	Give preventive measures	Give preventive measures
> basic ANC (4 visits) or
> more specialized care (more visits)
	Screen, treat and give advice on preventive measures	Review and modify Birth Plan	Review and modify Birth Plan	Review and modify Birth Plan
	Together with the woman, develop a Birth Plan	Advice and counsel	Advice and counsel	Advice and counsel
	Advice and counsel.
Activities: Rapid assessment and management for emergency signs and symptoms, give appropriate treatment and refer to hospital if needed.
History (ask, check records)	Assess significant signs and symptoms	Assess significant signs and symptoms	Assess significant signs and symptoms	Assess significant signs and symptoms
Take psychosocial, medical and obstetric history	Check records for previous complications & treatments during the pregnancy	Check records for previous complications & treatments during the pregnancy	Check records for previous complications & treatments during the pregnancy
Confirm pregnancy and calculate EDD	Re-classify as needed	Re-classify as needed	Re-classify as needed
Classify women for basic ANC (4 visits) or more specialized care (in some cases, this may come after the tests results are made available).
Examination (look, listen, feel)	Complete general and obstetrical examination including nutritional assessment: compute for body mass index (BMI) and monitor weight gain based on pre-pregnant weight	Check for anemia and thyroid enlargement	Check for anemia and thyroid enlargement	Check for anemia and thyroid enlargement
Check the blood pressure (BP)	Check BP	Check BP	Check BP
Check for weight gain based on first trimester BMI	Check for weight gain based on first trimester BMI	Check for weight gain based on first trimester BMI
	Assess fetal growth and movement	Assess fetal growth and movement	Assess fetal growth and movement
		Determine multiple pregnancy	Determine multiple pregnancy
			Assess for mal-presentation
Check for oral health	Assess for presence of dental caries and loosening	Assess for presence of dental caries and loosening	Assess for presence of dental caries and loosening
Screening and Tests	➢Pregnancy Test as necessary	➢Etilogic tests for STIs as necessary	➢Bacteriuria as necessary
➢ Hemoglobin count	➢Pap Smear as necessary	➢Blood/RH group as necessary
➢ Complete Blood Count	➢Gestational diabetes (oral glucose challenge test) as necessary
➢Blood Typing	➢Bacteriuria as necessary
➢STIs using syndromic approach
➢ Syphilis
➢HIV
➢ Hepatitis B (HBsAG)
➢ Urinalysis for proteinuria, albuminuria
➢Stool examination
➢ Acetic Acid Wash
Treatments	If indicated:	➢Deworming	If indicated:	If indicated:
➢ Syphilis	If indicated:	➢ARV	➢ARV
➢ ARV (anteretroviral)	➢ARV	➢Bacteriuria	➢Bacteriuria
➢ Bacteriuria	➢Bacteriuria	➢Anemia	➢Anemia
➢Anemia	➢Anemia
	If indicated:		If breech, do an external cephalic version (ECV) or refer for ECV
➢Oral curative services: permanent filling and gum treatment
Preventive Measures	Tetanus Toxoid immunization	Tetanus Toxoid immunization
Iron with folic acid supplementation	Iron with folic acid supplementation	Iron with folic acid supplementation	Iron with folic acid supplementation
	Calcium carbonate	Calcium carbonate	Calcium carbonate
Oral health check-up and prophylaxis	Oral health check-up and prophylaxis	Oral health check-up and prophylaxis	Oral health check-up and prophylaxis
	IPTp (intermittent treatment for malaria) in endemic areas	IPTp (intermittent treatment for malaria) in endemic areas	IPTp (intermittent treatment for malaria) in endemic areas
Health Education, Advice and Counselling	Self-care	Birth Plan	Birth Plan	Birth Plan
Alcohol and tobacco use	Reinforcement of previous advice	Breastfeeding	Breastfeeding
Nutrition counseling and supplemental feeding program if appropriate		Postpartum and postnatal care	Postpartum and postnatal care including follow-up tetanus immunization for TT3 after 6 months; after 1 year for TT4 and TT5 after another year
Safe sex		Pregnancy spacing	Pregnancy spacing
Rest and sleep (under ITN — insecticide treated bed nets in endemic areas)		Reinforcement of previous advice	Reinforcement of previous advice
Birth Plan

8. Where the required services are not available at the Birthing Center, e.g., HIV testing, syphilis testing, etc., the Birthing Center head shall be responsible for referring the woman to an appropriate facility for the tests and/or treatment and ensure that the referral and the services required has been adequately served.

9. The result of the tests as well as the recommended medical management and treatment shall be appropriately compiled in the Individual Record at the Birthing Center. Relevant information shall be recorded in the Mother and Child Book for future reference.

10. Antenatal care services as provided for in this Guideline shall be part of the Maternity Care Package and shall be reimbursed by PhilHealth to appropriate facility providing specific service(s).

11. The following indicators shall be the indicators for quality antenatal care and shall be reported as part of the National Safe Motherhood Program Results Matrix starting 2017 (Please refer to the ANC Utilization Report matrix in the attached annex of this policy):

a. Proportion of women who gave birth with a written birth plan.

b. Proportion of women who gave birth who had at least 4 ANC visits.

c. Proportion of women who gave birth who had at least 2 tetanus toxoid vaccination during their pregnancy.

d. Proportion of women who gave birth who receive IPTp for malaria during their pregnancy.

e. Proportion of women who gave birth who tested positive for HIV during their pregnancy.

f. Proportion of women who gave birth who tested positive for syphilis during their pregnancy.

g. Proportion of women who gave birth who were referred to a treatment hub or given treatment at the birthing center.

VII. Effectivity

This order shall take effect immediately. AaCTcI

(SGD.) PAULYN JEAN B. ROSELL-UBIAL, MD, MPH, CESO IISecretary of Health

ANNEX 1