By Kelli Rogers | Devex | 20 December 2016

One of the core recommendations of focused antenatal care for the last 15 years has been reworked in the World Health Organization’s newly released guidelines.

In the guidelines released in November, the WHO now recommends eight contacts with health services instead of four over the course of a woman’s pregnancy.

This shift provides more opportunity for women to meet with medical professionals throughout their pregnancies to reduce stillbirths and complications and represents renewed focus on women’s overall experience of care, said Ӧzge Tunçalp, the lead scientist on WHO’s antenatal care guideline development.

Tunçalp says the change emphasizes “women-centered antenatal care throughout the entire pregnancy.”

Previously a pregnant woman might visit her health care provider for the first time and not be asked to return for another two months: “You didn’t know how your baby was doing, but because there wasn’t a checklist item to check off during that time, there was no visit scheduled,” explained Katie Hutchinson, senior technical adviser for sexual and reproductive health and rights at Pathfinder International. Hutchinson sees the new recommendation as the future of women’s maternal health programs.

The practice of only recommending four visits was integral to the focused antenatal care — an umbrella term used to describe medical procedures and care performed during pregnancy — strategy adopted by the WHO in the early 2000s. It stressed targeted assessments and recognized several realities in the developing world after many programs had initially sought to recreate the frequent visits women underwent in the United States and elsewhere: frequent visits didn’t necessarily improve pregnancy outcomes in developing countries. They were logistically and financially challenging for women to manage, and they were often taxing on the health care system, according to a 2004 U.S. Agency for International Development program brief.

So, the four antenatal visits recommendation was born.

But women around the world have for years expressed displeasure with the antenatal care practices that many maternal health-focused organizations have stuck to, Hutchinson said.

The goal of less frequent visits was to provide women the life saving care that would keep them and their babies safe yet avoid burdening them with logistical hassles, but “what we found after doing this for 15 years was that it’s not only about those mortality reduction measures that were included in the focused antenatal care,” Hutchinson said. “Women want more than that, whether they live in the U.S. or in Burundi.”

Instead, in Hutchinson’s experience, women displeased with the lack of more personal, regular care often wouldn’t return for a facility based delivery. And the gains the sector has celebrated in terms of reductions in maternal mortality have not necessarily come from antenatal interventions.

It turns out, fewer antenatal visits wasn’t the panacea. Research undertaken in the 2.5 years of guideline preparation supports this, Tunçalp said. A 2015 Cochrane review on “reduced-visit” care models versus models with at least eight visits, for example, indicated that the fewer visit model increases perinatal deaths.

Now, four more visits to a doctor or skilled health worker “means four more chances to detect and address potential problems early on — critical issues like diabetes, high blood pressure, obesity, cardiovascular disorders or metabolic syndrome,” Women Deliver CEO Katja Iversen told Devex. “It’s a small price to pay for a healthy future.”

Currently, millions of births remain unassisted by a midwife, a doctor or a trained nurse, according to the WHO. Focusing on women’s experiences of care will lead to increased utilization of health clinics, which will only increase the need for more staff, Hutchinson said. She also expects to see an increase in programs that combine maternal health care with counseling and discussion around healthy timing and spacing of pregnancies.

Guideline adaptation and implementation at the country level “may take time and will probably be in phases during the transition period,” Tunçalp said of further expected changes.

As for more visits burdening already stretched health care providers, Hutchinson hopes to see the new WHO guidelines instead spur increased investments in health services’ human resources.

“That’s something we know already — that most countries with high maternal mortality ratios need more staff … that will not change,” Hutchinson said. “I think that this will help national governments and NGOs like ours make some investments in thinking and talking about women’s experience in pregnancy instead of a checklist of activities to make sure people don’t die.”

The revised WHO guidelines on antenatal care include 49 recommendations regarding nutrition, maternal and fetal assessment, preventative measures and health systems interventions to improve utilization and quality of antenatal care.

The guidelines also for the first time include advice on nausea, back pain and constipation, an addition Hutchinson said “is not going to improve maternal mortality, but it recognizes that these are things that are important for women themselves.”