1.1. Background
International human rights law includes fundamental commitments of states to enable women and adolescent girls to survive pregnancy and childbirth as part of their enjoyment of sexual and reproductive health and rights and living a life of dignity (1). The World Health Organization (WHO) envisions a world where “every pregnant woman and newborn receives quality care throughout the pregnancy, childbirth and the postnatal period” (2). However, approximately 303 000 women and adolescent girls died as a result of pregnancy and childbirth-related complications in 2015 (3). Around 99% of maternal deaths occur in low-resource settings and most can be prevented (4). Similarly, approximately 2.6 million babies were stillborn in 2015, also mainly in low-resource settings (5). Nevertheless, there is evidence that effective interventions exist at reasonable cost for the prevention or treatment of virtually all life-threatening maternal complications (6), and almost two thirds of the global maternal and neonatal disease burden could be alleviated through optimal adaptation and uptake of existing research findings (7). But a human rights-based approach is not just about avoiding death and morbidity – it is about enabling health and well-being while respecting dignity and rights.
Antenatal care (ANC) can be defined as 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 baby during pregnancy. The components of ANC include: risk identification; prevention and management of pregnancy-related or concurrent diseases; and health education and health promotion.
ANC reduces maternal and perinatal morbidity and mortality both directly, through detection and treatment of pregnancy-related complications, and indirectly, through the identification of women and girls at increased risk of developing complications during labour and delivery, thus ensuring referral to an appropriate level of care (8). In addition, as indirect causes of maternal morbidity and mortality, such as HIV and malaria infections, contribute to approximately 25% of maternal deaths and near-misses (9), ANC also provides an important opportunity to prevent and manage concurrent diseases through integrated service delivery (10).
In low- and middle-income countries (LMICs), ANC utilization has increased since the introduction in 2002 of the WHO ANC model, known as focused ANC (FANC) or basic ANC, which is a goal-orientated approach to delivering evidence-based interventions carried out at four critical times during pregnancy (11, 12). However, globally, during the period 2007–2014, only 64% of pregnant women attended the WHO-recommended minimum four contacts for ANC, suggesting that much more work needs to be done to address ANC utilization and quality.
Currently, WHO guidance on routine ANC is fragmented, with related recommendations published across several different WHO guidelines and practical manuals. The 2002 FANC implementation manual, for example (12), does not contain relevant context-specific guidance, which needs to be sought elsewhere. In addition, evidence on the possible harm of the FANC model has recently become available, necessitating a review.
This up-to-date, consolidated guideline for routine ANC has been produced by the WHO Department of Reproductive Health and Research (RHR), in collaboration with the Department of Nutrition for Health and Development (NHD) and the Department of Maternal, Newborn, Child and Adolescent Health (MCA), as part of WHO’s normative work on supporting evidence-informed policies and practices. By reviewing, updating and bringing together ANC-related WHO recommendations regarding “what” should be offered and “how” it should be delivered in the form of this guideline, it is hoped that policy-makers will more easily be able to adapt, adopt and implement these new ANC recommendations, presented in Chapter 3, which have also been configured to form the 2016 WHO ANC model, presented in Chapter 4.
A scoping review was conducted to inform this guideline, and it revealed that what women want and expect from ANC is to have a “positive pregnancy experience”.
A positive pregnancy experience is defined as:
maintaining physical and sociocultural normality
maintaining a healthy pregnancy for mother and baby (including preventing and treating risks, illness and death)
having an effective transition to positive labour and birth, and
achieving positive motherhood (including maternal self-esteem, competence and autonomy) (
13).
The emotional, psychological and social needs of adolescent girls and vulnerable groups (including women with disabilities, women with mental health concerns, women living with HIV, sex workers, displaced and war-affected women, ethnic and racial minorities, among others) can be greater than for other women. Therefore, the aim of this guideline is to provide a clear, evidence-based framework for ANC practices that empowers all pregnant women and adolescent girls to access the type of person-centred care that they want and need, in accordance with a human rights-based approach. This ANC guideline is part of the ongoing work of WHO in developing evidence-based guidelines to improve quality of care for mothers and their babies throughout the antenatal, intrapartum and postnatal continuum.
