Ante-Natal careAnte-Natal careEvidence-Based Evidence-Based
Perspective Perspective
Ante-Natal careAnte-Natal careEvidence-Based Evidence-Based
Perspective Perspective
Alaa Eldin Hamed Alaa Eldin Hamed
ELFEKYELFEKYProfessor of Obstetrics & Gynecology
ASU-EBM GROUP
Faculty of Medicine, Ain Shams University
Effective careEffective careEffective careEffective care
The Care that women and their The Care that women and their
babies receive during pregnancy babies receive during pregnancy
and childbirth must be and childbirth must be effectiveeffective
BENEFICIALBENEFICIAL HARMFULHARMFUL
COSTCOSTCOSTCOST CONVENIECECONVENIECECONVENIECECONVENIECE
Impressions or Facts?Impressions or Facts?Impressions or Facts?Impressions or Facts?
The belief that one form of care is better than The belief that one form of care is better than
the other is usually based on an the other is usually based on an IMPRESSIONIMPRESSION, ,
derived from personal experience or previous derived from personal experience or previous
teaching.teaching.
These may be correct or incorrectThese may be correct or incorrect ..
Unless the validity of these impressions is Unless the validity of these impressions is
assessed, assessed, HARMHARM may occur. may occur.
Goals of ANCGoals of ANCGoals of ANCGoals of ANC• PromotePromote and and maintainmaintain
– the physical, mental and social health the physical, mental and social health
of mother and babyof mother and baby
– by providing educationby providing education
– on nutrition, personal hygiene and birthing on nutrition, personal hygiene and birthing process.process.
• Help prepareHelp prepare mothers to mothers to – breastfeed successfullybreastfeed successfully
– experience normal puerperiumexperience normal puerperium
– take good care of the child physically, take good care of the child physically, psychologically and sociallypsychologically and socially
Goals of ANCGoals of ANCGoals of ANCGoals of ANC
• Develop Develop birth preparednessbirth preparedness and and complication readinesscomplication readiness plan. plan.
• DetectDetect and and managemanage complications complications during pregnancy, whether during pregnancy, whether medical, surgical or obstetrical.medical, surgical or obstetrical.
Disease Detection : Risk Disease Detection : Risk AssessmentAssessmentDisease Detection : Risk Disease Detection : Risk AssessmentAssessment
Risk approach has not proven to be an efficient
or effective strategy for maternal mortality
reduction:
“Risk factors”
• Cannot predictCannot predict complications
• Not a direct causeNot a direct cause of complication
• Statistically associatedStatistically associated with the outcome. Fortney 1995; Yuster 1995.
Most risk factors cannot be changed:
Parity
Age
Weight
Family history
Past reproductive performance.
Disease Detection : Risk Disease Detection : Risk AssessmentAssessmentDisease Detection : Risk Disease Detection : Risk AssessmentAssessment
Majority of women who experienced Majority of women who experienced
complication were considered “low risk”complication were considered “low risk”
Disease Detection : Risk Disease Detection : Risk AssessmentAssessmentDisease Detection : Risk Disease Detection : Risk AssessmentAssessment
Evidence-Based/Goal-Directed Evidence-Based/Goal-Directed ANC ANC Evidence-Based/Goal-Directed Evidence-Based/Goal-Directed ANC ANC
• Increasing use of systematic Increasing use of systematic
reviews to evaluate effectiveness reviews to evaluate effectiveness
of interventions.of interventions.
• Goal-directed interventions.Goal-directed interventions.
Let us Let us learn from learn from football !!!football !!!
Effective football
The English PlanThe English Plan
Depending on the wind, the striker’s position may vary…
The German PlanThe German Plan
Radical, efficient, unstoppable… (ball’s speed may reach 297 km/h)
The Italian PlanThe Italian Plan
Iron defense, small ideas in midfield, passes to striker..and…Penalty
The Brasilian PlanThe Brasilian Plan
… no comments!
Ineffective football
The Swiss PlanThe Swiss Plan
They manage to lose the game by themselves, no help needed.
The French PlanThe French Plan
In their plan, they try all possible hypotesis.
Shit! They forgot the goalShit! They forgot the goal
The Egyptian PlanThe Egyptian Plan
No Plan…but we are trying hard!!!No Plan…but we are trying hard!!!
Evidence-based ANC Evidence-based ANC Evidence-based ANC Evidence-based ANC
Beneficial forms of careBeneficial forms of care
Forms of care likely to be beneficialForms of care likely to be beneficial
Forms of care with trade-off between benefit Forms of care with trade-off between benefit
and harmand harm
Forms of care unlikely to be beneficialForms of care unlikely to be beneficial
Forms of care that are ineffective or harmfulForms of care that are ineffective or harmful
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What is Effective ANC?What is Effective ANC?What is Effective ANC?What is Effective ANC?
Continuous Care from a skilled Continuous Care from a skilled
attendant:attendant: Care must meet the social and psychological needs Care must meet the social and psychological needs
of women.of women.
Women who had continuity of caregivers were less Women who had continuity of caregivers were less
likely to use pharmacologic analgesia during birth:likely to use pharmacologic analgesia during birth:
Cochrane reviews of multiple controlled trials:Cochrane reviews of multiple controlled trials:
07672 / 07674 / 04169 / 03776 / 0377607672 / 07674 / 04169 / 03776 / 03776
What is Effective ANC?What is Effective ANC?What is Effective ANC?What is Effective ANC?
Preparation for birth and potential Preparation for birth and potential
complications:complications:
The benefits of Ante-natal classes as regards less The benefits of Ante-natal classes as regards less
need for analgesia and better satisfaction are well need for analgesia and better satisfaction are well
documented.[Review 05620]documented.[Review 05620]
The extent to which these classes may contribute The extent to which these classes may contribute
to feelings as fear or affect the decision making to feelings as fear or affect the decision making
process of the mother are not well studied .process of the mother are not well studied .
What is Effective ANC?What is Effective ANC?What is Effective ANC?What is Effective ANC?
Promoting health and preventing Promoting health and preventing
disease:disease:
Folate supplementation.Folate supplementation.
[RCT:4mg/day for +ve history of NTD; 0.8mg for [RCT:4mg/day for +ve history of NTD; 0.8mg for
others][Reviews 06488;06489]others][Reviews 06488;06489]
Tetanus toxoid.Tetanus toxoid.
Restricting Tobacco and alcohol use.Restricting Tobacco and alcohol use.
What is Effective ANC?What is Effective ANC?What is Effective ANC?What is Effective ANC?
Detection of existing diseases and Detection of existing diseases and
treatment:treatment:
HIV, syphilis, HIV, syphilis, TuberculosisTuberculosis, other co-, other co-
existing medical diseases (e.g., existing medical diseases (e.g.,
HypertensionHypertension, , DiabetesDiabetes) )
Early detection and management of Early detection and management of
complicationscomplications
Beneficial forms of care:Beneficial forms of care:Beneficial forms of care:Beneficial forms of care:
• Folic acid supplementation.Folic acid supplementation.
• Iodine supplementation.Iodine supplementation.
Effectiveness demonstrated by clear Effectiveness demonstrated by clear evidence from controlled trials [Grade Ia]evidence from controlled trials [Grade Ia]
Beneficial forms of care:Beneficial forms of care:Beneficial forms of care:Beneficial forms of care:
• Antihistamines for nausea and Antihistamines for nausea and
vomitingvomiting
• Local imidazoles for candida infection.Local imidazoles for candida infection.
• Anti-D postpartum for Rh –ve women.Anti-D postpartum for Rh –ve women.
• Antibiotic treatment for asymptomatic Antibiotic treatment for asymptomatic
bacteriuria.bacteriuria.
• Tight as opposed to strict or moderate Tight as opposed to strict or moderate
control of blood glucose levels in control of blood glucose levels in
diabetic women. diabetic women.
Beneficial forms of care:Beneficial forms of care:Beneficial forms of care:Beneficial forms of care:
• External cephalic version at term to External cephalic version at term to
avoid breech presentation at birth.avoid breech presentation at birth.
• Corticosteroids to promote fetal lung Corticosteroids to promote fetal lung
maturation before preterm birth.maturation before preterm birth.
• Offering induction of labor at 41+ Offering induction of labor at 41+
weeks of gestationweeks of gestation
Ineffective or Harmful forms of Ineffective or Harmful forms of care:care:Ineffective or Harmful forms of Ineffective or Harmful forms of care:care:
• Dietary restriction to prevent pre-Dietary restriction to prevent pre-
eclampsia (including caloric eclampsia (including caloric
restriction; salt restriction).restriction; salt restriction).
• Ante-natal breast or nipple care for Ante-natal breast or nipple care for
women who plan breast feeding.women who plan breast feeding.
Ineffectiveness or Harm demonstrated by clear evidence
Ineffective or Harmful forms of Ineffective or Harmful forms of care:care:Ineffective or Harmful forms of Ineffective or Harmful forms of care:care:
• Contraction stress test .Contraction stress test .
• Non-stress test.Non-stress test.
Ineffectiveness or Harm demonstrated by clear evidence
Ineffective or Harmful forms of Ineffective or Harmful forms of care:care:Ineffective or Harmful forms of Ineffective or Harmful forms of care:care:
• DES during pregnancy.DES during pregnancy.
• External cephalic version before term to External cephalic version before term to
avoid breech presentation at birth.avoid breech presentation at birth.
• Progestogens to stop preterm labor.Progestogens to stop preterm labor.
• Routine enema in labor.Routine enema in labor.
• Routine pubic shaving in preparation for Routine pubic shaving in preparation for
delivery.delivery.
Forms of care unlikely to be Forms of care unlikely to be beneficial:beneficial:Forms of care unlikely to be Forms of care unlikely to be beneficial:beneficial:
• Advise to restrict sexual activity Advise to restrict sexual activity during pregnancy.during pregnancy.
• Imposing dietary restrictions during Imposing dietary restrictions during pregnancy.pregnancy.
• Routine vitamin supplementation in Routine vitamin supplementation in well nourished populations.well nourished populations.
• Routine Hematinic supplementation in Routine Hematinic supplementation in well nourished populations.well nourished populations.
• Routine ultrasound use in late Routine ultrasound use in late pregnancypregnancy
No evidence for, with some possible adverse effects
Forms of care unlikely to be Forms of care unlikely to be beneficial:beneficial:Forms of care unlikely to be Forms of care unlikely to be beneficial:beneficial:
Screening for pre-eclampsia by:Screening for pre-eclampsia by:
Roll-over test, Cold-pressor test, Edema, Roll-over test, Cold-pressor test, Edema,
Isometric exercise, Measuring uric Isometric exercise, Measuring uric
acid.acid.
Diuretics or Diazoxide for pre-eclampsia.Diuretics or Diazoxide for pre-eclampsia.
Screening for gestational diabetes:Screening for gestational diabetes:
Routine glucose challenge test, routine Routine glucose challenge test, routine
measurement of blood glucose.measurement of blood glucose.
Forms of care unlikely to be Forms of care unlikely to be beneficial:beneficial:Forms of care unlikely to be Forms of care unlikely to be beneficial:beneficial:
• Calcium supplementation for leg Calcium supplementation for leg
cramps.cramps.
• Bed rest for threatened abortion.Bed rest for threatened abortion.
• Hospitalization or cervical cerclage for Hospitalization or cervical cerclage for
twin pregnancy.twin pregnancy.
• Prophylactic tocolysis with preterm Prophylactic tocolysis with preterm
premature rupture of membranes.premature rupture of membranes.
Forms of care unlikely to be Forms of care unlikely to be beneficial:beneficial:Forms of care unlikely to be Forms of care unlikely to be beneficial:beneficial:
• Regular leucocyte counts for Regular leucocyte counts for
PROM.PROM.
• Beta-mimetic for preterm labor in Beta-mimetic for preterm labor in
women with heart disease or DM.women with heart disease or DM.
• Hydration to arrest preterm labor.Hydration to arrest preterm labor.
• Diazoxide for preterm labor.Diazoxide for preterm labor.
SummarySummarySummarySummary
Antenatal care includes goal-directed Antenatal care includes goal-directed interventionsinterventions
• Skilled attendant.Skilled attendant.• Preparation for birth and Preparation for birth and
complications.complications.• Health promotion.Health promotion.• Detection of complications.Detection of complications.• Guided by Evidence.Guided by Evidence.
