On 7th November 2016, the World Health Organization (WHO) released new guidelines on access to antenatal care for pregnant women. The revision was necessitated by the persistently high maternal deaths globally, particularly in developing countries where deaths are still 14 times higher than in the developed regions.
The WHO recommended increasing antenatal care visits from the current four to eight fundamental visits, to ensure a continuum of care during pregnancy, labour and delivery, and the postnatal period. The four-visit model (focused antenatal care) being replaced was adopted by WHO in 2002, and has been in use since then, providing goal-oriented and targeted care aimed at increasing the detection and management of complications during pregnancy.
However, growing evidence shows that a higher frequency of antenatal contacts by women and adolescent girls with the health system is associated with a reduced likelihood of stillbirths. A minimum of eight contacts for antenatal care can reduce perinatal deaths by up to 8 per 1000 births when compared to a minimum of four visits.
Under the new guidelines, the first visit is recommended at 12 weeks of gestation, with subsequent visits at 20, 24, 28, 32, 36, 38 and 40 weeks of gestation. The new guidelines also provide details on the care that should be provided during each of the eight visits. Under the focused antenatal care model, the first visit was recommended at 16 weeks, the second at 24 to 28 weeks of gestation, and the 3rd and 4th visits were at 32 weeks and at 36 weeks of gestation.
The release of the new guidelines is a step towards implementation of the Sustainable Development Goals (SDGs). Goal three aims at reducing global maternal mortality ratio to less than 70 per 100,000 live births, and reducing neonatal mortality to at least as low as 12 per 1,000 live births by 2030.
Increasing antenatal care visits should thus be a welcome move in Kenya where maternal and neonatal deaths remain unacceptably high. Frequent visits provide a critical opportunity for health providers to deliver care, support and information to pregnant women, and identify and prevent adverse pregnancy outcomes.
According to the Kenya Demographic and Health Survey (KDHS) 2014, the average national maternal mortality ratio was 362 deaths per 100,000 live births, a decrease from 488 per 100,000 in 2008. In other words, for every 1,000 live births, approximately four women die during pregnancy, childbirth, or following childbirth. In addition, the deaths that occur in the first month of life contribute to nearly half (42 percent) of all deaths occurring among children aged under five years. The irony is that almost all these deaths are entirely preventable given proper medical surveillance and intervention.
However, Kenya and other developing countries have struggled to effectively implement the four-visit program. The question thus becomes: will the new eight-visit program be feasible?
The 2014 KDHS showed that slightly more than half (58 percent) of pregnant women made four or more antenatal care visits during their pregnancy, an increase from 47 percent since the 2008-09 KDHS. In the North Eastern region which has the highest maternal and neonatal mortality rates, only about one in every three women (37 percent) made four visits, compared with over 50 percent in the other regions. North Eastern counties recorded the highest maternal mortality ratios, at 3,795 deaths per 100,000 live births in Mandera, 1,683 in Wajir, 1,594 in Turkana and 1,127 in Marsabit. Indeed, 98.7 percent of the total maternal deaths in the country occur in only 15 out of 47 counties, most them in the northern and coastal parts of the country. Increasing antenatal visits is bound to reduce maternal deaths, because it will increase contact between health workers and pregnant women. But what will make the eight-visit model work where the four-visit model has failed?
While there are obvious benefits of increasing antenatal visits, implementing the new guidelines is going to be much more difficult to achieve given current resources constraints. There is therefore need for careful considerations of the extra challenge the new guidelines pose and to understand the implications on the resources needed including among others: human resources, infrastructure, and equipment.
Given the sub-national disparity and inequity in access to critical health services and in health outcomes, the salient question remains whether the government should increase resources countrywide to implement the new guidelines, or focus its efforts on strengthening the current interventions, including the focused antenatal care model and free maternal health services in the 15 counties with the highest maternal death burden. This will call for collaborative efforts among all stakeholders to determine the extent to which the new WHO guidelines can be implemented.
Eunice Mueni is a Knowledge Translation Officer at the African Institute for Development Policy (AFIDEP). Eunice.email@example.com.
This article was initially published in the Daily Nation, Tuesday 29th November 2016