CHAPTER 1

1. Introduction

1.1Background

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.

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 (http://www2.ohchr.org/english/issues/women/docs/A.HRC ). 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” (Tunçalp et al., 2015). However, approximately 303 000 women

and adolescent girls died as a result of pregnancy and childbirth-related

complications in 2015 (Alkema et al., 2014). Around 99% of maternal deaths

occur in low-resource settings and most can be prevented (WHO 2014). Similarly,

approximately 2.6 million babies were stillborn in 2015, also mainly in low-

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resource settings (Blencowe H et al., 2016). Nevertheless, there is evidence that

effective interventions exist at reasonable cost for the prevention or treatment of

virtually all life-threatening maternal complications (Campbell et al., 2006), and

almost two thirds of the global maternal and neonatal disease burden could be

alleviated through optimal adaptation and uptake of existing research findings

(Fisk et al., 2011). 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.

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 labor and delivery, thus ensuring referral to an appropriate

level of care (Carroli et al., 2001). 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 (Souza et al., 2013), ANC

also provides an important opportunity to prevent and manage concurrent diseases

through integrated service delivery (WHO 2016).

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 (WHO 2016) does
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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.

Key events in the evolution of prenatal care delivery guideline

Early 1800s: Prenatal care relatively unstructured and delivered by laypeople.

Mid-1800s: Recognition of association among blood pressure, proteinuria, and

preeclampsia or eclampsia.

Late 1800s: Increasing organization of the medical profession.

1901: John Ballantyne (Edinburgh General Hospital) introduced “promaternity

wards”; first home prenatal visits conducted by the Boston Lying-in Hospital.

1909: White House Conference on the Care of Dependent Children.

1912: The Children’s Bureau was formed.

1913: The Children’s Bureau released the first prenatal care booklet,

recommending consultation with a physician early in pregnancy.

1914: John Whitridge Williams (Johns Hopkins Hospital) presented data

suggesting that prenatal care can reduce infant mortality.

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1915: The national birth-registration area was formed, providing national data on

maternal and infant deaths.

1921: The Sheppard-Towner Bill was passed, providing federal funding for

prenatal care.

1930: The Children’s Bureau released a second prenatal care booklet, with specific

recommendations for physician visit schedule; the American Board of

Obstetricians and Gynecologists first provides specialty certification.

1951: AAOG was formed.

1955: The ACNM was founded.

1957: The AAOG changed its name to the ACOG.

1959: The ACOG released the first “Manual of standards in obstetric-gynecologic

practice,” which maintains the original prenatal visit schedule.

1970: The Kessner Index was introduced to assess the adequacy of prenatal care.

1985: Findings from the Institute of Medicine Committee to Study the Prevention

of Low Birth weight were released, supporting the causal relationship between

prenatal care and reduction of low birth weight infants.

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1989: NIH Public Health Service Expert Panel on the Content of Prenatal Care that

recommended a schedule of prenatal visits based on medical and social risk

factors; Medicaid expansion occurred to improve prenatal care access.

1990s: Clinical trials demonstrated the safety of reduced visit schedules for low-

risk patients; group prenatal care was first introduced.

2019: The first RCT of the prenatal care model integrating telemedicine was

published.

AAOG, American Academy of Obstetrics and Gynecology;

ACNM, American College of Nurse Midwives;

ACOG, American College of Obstetricians and Gynecologists;

NIH, National Institutes of Health;

RCT, randomized clinical trial.

Peahl. Evolution of prenatal care guidelines. Am J Obstet Gynecol 2021.

1.2 Objectives

 To ensure that the pregnant woman and her unborn child are in the best

possible health prior to delivery.

 To ensure that all pregnant women understand:

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(i) the complications of pregnancies that may lead to death,

(ii) the best approach to safe delivery, and

(iii) the best way of bringing up their babies

1.3 Principle and scope of services

Antenatal care provides an essential link between women and the health system

and offers essential health care services in line with national policies, including:

 Counseling about the danger signs of pregnancy and delivery complications

and where to seek care in case of emergency.

 Counseling on birth preparedness, emergency readiness, and the

development of a birth plan.

 Providing advice on proper nutrition during pregnancy.

 Detecting conditions that require additional care and providing appropriate

treatment for those conditions.

 Detecting complications that influence choice of birthing location.

 Supplying Iron and Folate supplement.

 Supplying low dose supplement of vitamin A.

 In certain settings, providing treatment for conditions that affect women’s

pregnancies, such as malaria, tuberculosis, hookworm infection, iodine

deficiency, and sexually transmitted infections, including HIV/AIDS.

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  Providing tetanus toxoid immunization, Rapid test for Syphilis.

 Providing voluntary HIV testing and counseling.

 Providing information about breastfeeding and contraceptive.

CHAPTER 2

2. Antenatal services
a) The Booking Visit at 12 Weeks

Early initiation of antenatal care (ANC) is crucial for ensuring positive maternal

and fetal outcomes. The World Health Organization (WHO) recommends that the

first ANC visit known as the booking visit should occur before 12 weeks of

gestation (WHO., 2016)1. Creating a rapport between the ANC provider and the

pregnant women with a welcoming Environment and respectful reception is

critically important to get full information about her Pregnancy history, make her

comfortable for physical examination and investigations, and, above all, to create a

comfort zone for the continuity of the woman in the health service. Once

communication is established, pregnancy-specific assessment can be started. The

end goal of the first contact assessment is identifying clinical evidence to classify

the woman as deserving Routine or special care/referral.

b) History taking

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 Identification, Record name, age, address, phone number, occupation, and

marital status.

 Menstrual History: Note date of last normal menstrual period (LNMP), cycle

regularity, contraceptive use, breastfeeding status, gestational age, and EDD.

 Current Pregnancy: Document symptoms, fetal movements, complications, and

whether pregnancy was planned or wanted.

 Obstetric History: Include number and outcomes of previous pregnancies,

cesarean sections, and any complications (e.g., bleeding, stillbirths, and

hypertension).

 Medical History: Review conditions like cardiovascular disease, diabetes, TB,

seizures, and current/past illnesses.

 Medications: List all current drugs, including herbal remedies and known

allergies.

 Gynecologic History: Record past STIs, cervical cancer screening, and

gynecologic surgeries.

 Nutrition: Assess diet diversity, meal frequency, appetite, food cravings, and

vomiting.

 Social History: Screen for use of tobacco, alcohol, caffeine, and exposure to

second-hand smoke or violence.

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 Mental Health: Evaluate for signs of depression, anxiety, irritability, or loss of

interest.

c) Physical examination

 Check the mother’s general appearance for signs of illness or tiredness.

 Measure blood pressure, pulse, breathing rate, and temperature.

 Record weight and height; check for signs of poor nutrition.

 Look at eyes, mouth, and nails for signs of anemia (paleness).

 Listen to the chest and heart for any unusual sounds.

 Check the tummy to feel the baby’s position and size, and listen to the

baby’s heartbeat.

 Look at the legs or feet for swelling or edema

d) Laboratory investigations

 Blood group and Rhesus factor testing (to identify Rh incompatibility and

need for Anti-D prophylaxis).

 Full blood count to detect anemia.

 HIV testing for early treatment and prevention of mother-to-child

transmission.

 Hepatitis B screening (especially in high-risk populations).

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  Urinalysis to detect urinary tract infections or proteinuria (a potential sign of

preeclampsia).

 Malaria testing and preventive treatment especially in endemic regions.

 Toxoplasmosis test Screens for Toxoplasma gondii, which can cause

congenital infection and fetal harm.

 Hepatitis B & C test Detects risk of vertical transmission; crucial for

neonatal protection.

 Chlamydia and syphilis test Identifies sexually transmitted infection that can

affect both mother and newborn.

 Typhoid test especially in endemic areas to manage systemic infection risks

during pregnancy.

 Rheumatoid Factor (RF): Assesses for autoimmune conditions that may

impact pregnancy

 Ultrasound scan to confirm gestational age, detect multiple gestations, and

assess fetal viability.

e) Routine test in ANC

After the initial ANC booking visit, routine tests are carried out throughout

pregnancy to monitor the health of both the mother and the baby. They include;

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  Blood Glucose Level Which Screens for gestational diabetes, which can

affect fetal growth and lead to complications during delivery.

 Urinalysis which Detects proteinuria (a sign of pre-eclampsia), urinary tract

infections, and glucose in urine, supporting early diagnosis and treatment.

 Ultrasound scan to confirm gestational age, detect multiple gestations, and

assess fetal viability.

 Hemoglobin level to detect anemia.

f) Maternal and Fetal Assessment

Regular ANC enables healthcare professionals to systematically monitor maternal

health parameters such as blood pressure, weight gain, and hemoglobin levels.

These assessments help in early detection of life-threatening conditions like

preeclampsia, gestational diabetes, and anemia. Repeated measurements over time

also provide a clearer picture of trends that may indicate underlying issues (WHO.

2016) similarly; fetal development is also closely monitored through abdominal

measurements, fetal heartbeat checks, fetal kicks and ultrasound assessments.

These evaluations help detect growth restrictions, multiple pregnancies, or

congenital abnormalities, allowing for early referrals and specialized care where

needed (Villar et al., 2001) [2].

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 g) ANC Contact and the recommended schedule

The Focused Antenatal Care (FANC) model promoted a minimum of four ANC

visits for low-risk pregnancies. However, research and observational studies

showed that the four visits were not sufficient to address the health needs of

pregnant women and their babies. In 2016, WHO updated its guidelines to

recommend at least eight ANC contacts during pregnancy (WHO., 2016) [1]. This

shift was aimed at improving the quality of maternal health services and ensuring a

positive pregnancy experience for all women.

Accordingly, the first contact is recommended to be a single contact in the first

trimester (up to 12 Weeks), two contacts in the second trimester (at 20 and 26

weeks of gestation), and five contacts in the third trimester (at 30, 34, 36, 38, and

40 weeks). The appointment schedule is: first Appointment during the first

trimester, second appointment 8 weeks later; the third, 6 weeks later; fourth and

fifth 4 weeks apart; and then the rest every 2 weeks. The reason for increasing the

number of contacts in the third trimester is considering the increased Risk of

complications to the mother and the fetus during this period of gestation (WHO

2016) [1]. This schedule enables the ANC provider to early detect and treat

potential maternal and fetal complications before advancing to a severe or

irreversible stage. It also gives room for the pregnant woman to share her

Symptoms and worries with her care provider before worsening. In the current
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model, the word “visit” is replaced with “contact” as the connotation of the latter

Indicates an active connection between a pregnant woman and a health care

provider.

h) Table: ANC contact schedule

Contacts Gestational age of Schedule of next

contact in weeks appointment

First Trimester

1st Up to 12 After 8 weeks

Second Trimester

2nd 20 After 6 weeks

3rd 26 After 4 weeks

Third Trimester

4th 30 After 4 weeks

5th 34 After 4 weeks

6th 36 After 2 weeks

7th 38 After 2 weeks

8th 40

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  First contact (before 12 weeks): Includes comprehensive risk assessment,

baseline investigations, initiation of folic acid and iron supplementation, and

counseling.

 Second and third contacts (20–26 weeks): Monitor maternal and fetal

development; administer tetanus toxoid vaccination and screen for

gestational diabetes and anemia.

 Fourth to sixth contacts (30–36 weeks): Assess fetal growth and position;

prepare mother for childbirth; initiate birth planning.

 Seventh and eighth contacts (38–40 weeks): Final assessments for delivery

readiness; detect post-term risks; reinforce postpartum care planning

i) Importance of Early and Regular ANC Attendance

Antenatal care (ANC) is a cornerstone of maternal and newborn health, and its

effectiveness is greatly influenced by both the timing of initiation and the

regularity of visits. Beginning ANC early and maintaining consistent attendance

throughout pregnancy not only enables timely detection and management of health

issues but also supports positive health behaviors and birth outcomes.

Studies consistently show that women who attend ANC regularly are more likely

to receive skilled birth attendance, have improved pregnancy outcomes, and are

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less likely to experience perinatal complications (WHO 2016)[1]. Also, from a

systematic review by Kuhnt and Vollmer (2017) demonstrated that regular ANC

attendance significantly reduces neonatal mortality and improves maternal health

behaviors (Kuhnt et al., 2017) [3]. Another study in sub-Saharan Africa revealed

that early and frequent ANC visits are associated with increased institutional

delivery rates and better uptake of interventions like malaria prophylaxis and HIV

testing (Lincetto et al., 2006) [4].

The importance of early and regular ANC attendance includes;

 Accurate Dating of the Pregnancy: Early ultrasound and clinical assessments

determine the estimated due date, critical for interpreting later fetal growth and

planning for delivery (Imdad et al., 2012) [5].

 Initial Screenings: Screening for infections (e.g., HIV, syphilis, and malaria),

anemia, and hypertension can identify conditions that pose significant risks if

left untreated ((Imdad et al., 2012 [5].

 Initiation of Preventive Interventions: Folic acid and iron supplementation,

deworming, and vaccinations (such as tetanus toxoid) are most effective when

started early (Duley et al., 2009) [6].

 Health Education: Women are counseled on danger signs in pregnancy,

healthy lifestyle choices, nutrition, birth preparedness, and breastfeeding.

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 Early engagement also fosters trust between the mother and healthcare provider,

which encourages continued care and open communication.

 Ongoing Monitoring: Repeated assessments of maternal blood pressure,

weight, fetal growth, and fetal heart rate allow early detection of developing

complications such as preeclampsia, gestational diabetes, or intrauterine growth

restriction (IUGR) (Carroli et al., 2001)[7].

 Follow-Up on Abnormal Findings: Conditions flagged during earlier visits

(e.g., low hemoglobin levels or infections) can be managed and monitored

effectively.

 Nutritional Counseling and Support: With each visit, healthcare providers

can reinforce dietary advice, monitor weight gain, and adjust supplements if

needed (Tessema et al., 2017) [8].

 Preparation for Labor and Delivery: Women receive counseling on signs of

labor, preferred place of delivery, transportation planning, and newborn care.

CHAPTER 3

3. Medication and vaccines in ANC

Antenatal care is a critical component of maternal health, and one of its major

pillars is the appropriate use of medications and vaccines. These interventions are

designed to ensure the well-being of both the mother and the developing fetus.

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Let’s delve into some of the most commonly prescribed and recommended

medications and vaccines during pregnancy.

i. Daily Folic Acid: Benefits and Compliance

Folic acid (Vitamin B9) is one of the most essential supplements prescribed to

women during pregnancy, particularly in the first trimester.

Benefits of Folic Acid:

Neural Tube Development: Folic acid plays a key role in the formation of the

neural tube. Its deficiency during early pregnancy can lead to severe birth defects

like spina bifida and anencephaly.

Red Blood Cell Formation: It supports the production of healthy red blood cells

and helps prevent anemia.

Placental Health: It aids in proper placental development and function.

Reduced Risk of Other Birth Defects: There is also evidence linking folic acid to

a reduced risk of congenital heart defects and cleft lip/palate.

Compliance Challenges:

Forgetfulness: Pregnant women may forget to take their supplements regularly.

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Nausea: Some women experience gastrointestinal discomfort or nausea, especially

in the first trimester, which affects adherence.

Lack of Awareness: In some regions, women may not be aware of the importance

of folic acid or may begin supplementation too late.

Solution: Health workers play a critical role in educating and reminding expectant

mothers about the importance of early and consistent use of folic acid—preferably

starting at least one month before conception and continuing through the first

trimester.

ii. Iron Supplements

Iron supplementation is another cornerstone of antenatal care, particularly

important in regions where iron-deficiency anemia is prevalent.

Why Iron is Important:

Increased Blood Volume: During pregnancy, a woman’s blood volume increases

by about 50%, this raises the demand for iron.

Fetal Growth and Development: Iron supports the oxygen needs of the growing

fetus and helps prevent low birth weight and preterm delivery.

CHAPTER 4
4. Nutrition and lifestyle during pregnancy.

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Nutrition and Lifestyle during Pregnancy Taking care of yourself during pregnancy

is important for the health of both you and your baby. Eating well and staying

active can help you feel your best and reduce the risk of complications.

a. What to Eat: Nutrient-Rich Foods

During pregnancy, it’s important to eat foods that are rich in nutrients. These

include:

Fruits and vegetables: These provide important vitamins and minerals that help

your baby grow.

Whole grains: Foods like brown rice and whole wheat bread provide fiber and

other important nutrients.

Lean proteins: Foods like chicken and beans provide the protein and iron your

body needs.

Dairy products: Milk, yogurt, and cheese provide calcium and other important

nutrients.

Healthy fats: Foods like avocados and nuts provide healthy fats that are good for

both you and your baby.

b. What to Avoid: Harmful Foods and Substances

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There are certain foods and substances that should be avoided during pregnancy

because they can harm your baby. These include:

Raw or undercooked seafood: Raw fish or seafood can contain harmful bacteria or

parasites.

High-mercury fish: Fish like shark and swordfish have high levels of mercury,

which can harm your baby’s nervous system.

Unpasteurized dairy products: These can contain harmful bacteria like listeria.

Soft cheeses: Soft cheeses like brie and feta can contain listeria.

Processed meats: Foods like hot dogs and deli meats can contain harmful bacteria.

Caffeine: Limit caffeine intake to less than 200 mg per day, which is about one 12-

ounce cup of coffee.

Alcohol: No amount of alcohol is safe during pregnancy, as it can cause fetal

alcohol spectrum disorders.

c. Healthy Daily Practices

Taking care of your self during pregnancy involves more than just eating well.

Some healthy daily practices include:

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Regular exercise: Aim for at least 30 minutes of moderate-intensity exercise, like

walking or swimming, most days of the week.

Getting enough sleep: Aim for 7-9 hours of sleep per night to help your body

recover and feel rested.

Managing stress: Practice relaxation techniques like deep breathing, meditation, or

yoga to manage stress and promote relaxation.

Prenatal care: Attend regular prenatal check-ups to monitor your health and your

baby’s development.

d. Daily water intake requirements

Staying hydrated is important during pregnancy. Aim for about 10 cups (2.3 liters)

or about 3 liters of water per day. This can be achieved by drinking water,

consuming hydrating beverages like herbal teas, and eating water-rich foods like

watermelon and cucumber.

CHAPTER 5

5. Complication

5.1. When you don’t attend ANC

Prenatal care aims to promote maternal and fetal health, monitor risk factors, and

treat complications as early as possible. Prenatal care improves clinical and

21
psychological outcomes in pregnancy and postpartum and decreases maternal and

child morbidity and mortality( da Rosa et al., 2014)

The association between antenatal care and perinatal outcome has been examined

in many studies. Women who receive no or negligible antenatal care tend to have a

higher incidence of low birth-weight infants, preterm births, stillbirths, neonatal,

perinatal and maternal deaths( Lumbiganon et al., 1991). Antenatal care was found

to be more cost-effective than any other intervention in reducing perinatal and

maternal morbidity and mortality( Lumbiganon et al., 1991)

The deprivation of prenatal care can lead to premature pregnancy, intrauterine

growth retardation, low weight at birth, and maternal and child mortality as a result

of infections in the perinatal and postnatal periods( da Rosa et al., 2014).

Some of the major complications as a result of failure to attend ANC will be

discussed below;

1. Preeclampsia

Preeclampsia is a condition that causes dangerously high blood pressure. It can be

life-threatening if left untreated. Preeclampsia typically happens after 20 weeks of

pregnancy, often in women who have no history of high blood

pressure.(https://www.hopkinsmedicine.org/health/conditions-2025) Women with

irregular antenatal care attendance are much more prone to pregnancy

birth outcomes

2. Anemia

Late prenatal booking is associated with a high prevalence of maternal anemia in

labor, low mean maternal hemoglobin, and low birth weight compared to those of

women who booked early and the reasons for booking late are multifactorial.(Izuka

et al., 2023) In pregnancy, anemia has a significant impact on the health of the

fetus, and that of the mother. Complications are numerous and 20 percent of

maternal deaths in Africa have been attributed to anemia((Izuka et al., 2023).

3. Infection

According to Asundep et al (2016), ANC attendance varies by location. Seventy-

three percent of women in urban and 55% of women in rural areas attended ≥4

ANC visits(5). Moreso, it was suggested that 18% of preterm births could have

been prevented if blood pressure, maternal height and weight, urine and blood

samples, and pelvic examination were included in the ANC services provided.

Some antenatal measures have been shown to be effective. These include screening

for and treatment of infections (especially syphilis), malaria, anemia, bacteriuria

and proteinuria and detection and management of hypertension.(Ntui et al., 2014)

4. Limited Access to essential interventions.

services to pregnant women in an attempt to ensure, the best possible pregnancy

outcome for women and their babies. ANC provides an opportunity for essential

interventions, such as prevention of mother-to-child transmission of HIV,

prevention and treatment of sexually transmitted infections, and nutrition

counseling.

5.2 When you don't take daily folic acid

When pregnant women do not take daily folic acid, they are at a higher risk of

having a child with:

 Neural tube defects (NTDs): Folic acid prevents NTDs, such as spina

bifida and anencephaly, which occur when the neural tube does not close

properly during fetal development. (Centers for Disease Control and

Prevention. (2022). Folic Acid.)

 Increased risk of birth defects: Research suggests that folic acid

supplementation during pregnancy may reduce the risk of other birth defects,

such as heart defects and cleft lip/palate.(Wilcox et al., 2007)

 Potential cognitive and developmental delays: Some studies suggest that

maternal folate deficiency during pregnancy may be associated with

cognitive and developmental delays in children.(Schlotz et al., 2010)

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5.3 When you don't take the vaccines given

When pregnant women don't take their vaccines, they are likely to

Flu

According to the Centers for Disease Control and Prevention (CDC),that pregnant

people, recently pregnant people (including those who are breastfeeding) and those

who are trying to become pregnant get vaccinated for seasonal flu and COVID-19.

The CDC advises for vaccinations to take place as soon as possible since their

benefits greatly outweigh the risks.

If a pregnant person is vaccinated against the seasonal flu,” said William Isenberg,

M.D., PhD, Sutter Health’s chief quality and safety officer and an OB/Gyn, “The

baby will receive antibodies to the flu virus in the womb or, after they’re born,

through breast milk. These antibodies can help protect baby from flu until they

reach 6 months of age and themselves be safely vaccinated against the flu.

5.4 When you don't eat healthy food and practice a good lifestyle

A healthy diet is an important part of a healthy lifestyle at any time but is

especially vital if you're pregnant or planning a pregnancy. Eating healthily during

pregnancy will help your baby to develop and grow.

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Not washing fruits, vegetables and salads to remove all traces of soil, which may

contain toxoplasma (a parasite that can cause toxoplasmosis), can harm the unborn

baby. Good food hygiene during pregnancy can help reduce risk of listeriosis

(listeria) and salmonella.

Diet can greatly affect the health of the baby and can also influence a baby's health

into adulthood. If a growing baby is inadequately nourished in the womb, this

increases the risk of heart disease, diabetes and high blood pressure in adulthood.

Steady weight gain during pregnancy is normal and important for the health of the

mother and baby. However, it is also important not to gain too much weight.

Excess weight gain during pregnancy can increase risk of certain health issues

including gestational diabetes and high blood pressure in pregnancy. Excess weight

gain can also make it difficult to lose weight after pregnancy.

5.5 When you don't drink enough water

Mild dehydration is not typically dangerous in pregnancy as long as the woman

quickly gets enough fluids. Severe dehydration can be dangerous for both the

mother and the baby.

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Dehydration can lead to lower levels of amniotic fluid, which can influence the

baby’s development, lead to preterm labor, and can affect the production of breast

milk.

Dehydration can cause deficiencies in nutrients that are vital for the health of the

pregnant woman and the developing baby.

Maternal under-hydration during pregnancy is associated with a range of negative

birth outcomes, including low levels of adequate amniotic fluid and plasma,

disrupted fetal brain development and risk of low birth weight, according to

guidelines from the American Pregnancy Association and The American College

of Obstetricians and Gynecologists.

Meanwhile, if you are not drinking enough water to stay hydrated, you can

experience an array of uncomfortable and sometimes worrisome symptoms such

dizziness, lightheadedness, headaches, and contractions, says Ellen Smead, CNM.

CHAPTER 6

6. Health education

Health education is the process of educating individuals about healthy behaviors,

disease prevention, and management of health conditions. In the context of

antenatal care (ANC) services, health education play a vital role in empowering

27
pregnant women with the knowledge and skills necessary to maintain their health

and well-being, as well as that of their unborn babies.

6.1 Encouraging Questions from pregnant women.

Encouraging questions from pregnant women is a crucial aspect of health

education in ANC services. The reasons why it is important to encourage questions

during ANC services are as follows:

Empowerment: Encouraging questions empowers pregnant women to take an

active role in their care and make informed decisions.

Clarification: Questions help clarify any doubts or misconceptions, reducing

anxiety and stress.

Personalized care: By asking questions, women can receive personalized advice

and care tailored to their needs.

It is also important to know how to encourage pregnant women to ask questions

during ANC services. The following are points on how to encourage the questions:

Create a supportive environment: Health workers should create a welcoming and

non-judgmental atmosphere.

Active listening: Health workers should listen attentively to women's concerns and

respond thoughtfully.
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Open-ended questions: Health workers can ask open-ended questions to encourage

women to share their thoughts and concerns.

Below are some of the benefits of encouraging questions during ANC Services:

Increased patient satisfaction: Women feel heard and valued.

Improved health outcomes: Women are more likely to follow health advice and

recommendations.

Building trust: Encouraging questions helps build trust between healthcare

providers and pregnant women.

By encouraging questions, healthcare providers can foster a positive and

supportive environment, ultimately leading to better health outcomes for both

mother and baby.

6.1 Examples of useful questions to ask

Here are some examples of useful questions pregnant women can ask during ANC

visits:

I. Pregnancy-Related Questions

What are the signs of labor, and when should I seek medical attention?

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 How often should I attend ANC visits, and what will happen during each

visit?

What are the benefits and risks of different birthing options (e.g., vaginal

delivery, cesarean section)?

How can I manage common pregnancy symptoms like morning sickness and

back pain?

II. Questions on Fetal Development and Monitoring

How can I monitor my baby's movement and well-being?

What are the benefits and risks of prenatal testing (e.g., ultrasound, genetic

screening)?

How can I ensure my baby is growing and developing properly?

III. Questions on Preparation for Childbirth and Parenthood

What are the signs of complications during pregnancy or childbirth?

How can I prepare for breastfeeding, and what support will I receive?

What are the benefits and risks of different pain management options during

labor?

How can I prepare for parenthood, and what resources are available to

support me?

IV. Questions on Health and Wellness

How can I maintain a healthy diet and lifestyle during pregnancy?

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 What are the benefits and risks of exercise during pregnancy?

How can I manage stress and anxiety during pregnancy?

By asking these questions, pregnant women can gain a better understanding of

their pregnancy, childbirth options, and postpartum care, ultimately leading to

more informed decision-making and better health outcomes.

6.2 Role of health workers in supporting communication

Health workers play a vital role in supporting communication with pregnant

women during ANC visits. Effective communication between healthcare providers

and pregnant women builds trust, improves health outcomes, and increases patient

satisfaction, ultimately leading to better care and a more positive pregnancy

experience. Here are some ways health workers can play a role in supporting

communication:

o Active listening: Health workers should listen attentively to women's

concerns and respond thoughtfully.

o Clear and concise information: Health workers should provide accurate and

easy-to-understand information about pregnancy, childbirth, and postpartum

care.

o Cultural sensitivity: Health workers should be sensitive to the cultural and

individual needs of pregnant women.

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 o Encouraging open dialogue: Health workers should create a supportive

environment where women feel comfortable asking questions and sharing

their concerns.

To communicate effectively, health workers can use plain language, avoiding

technical jargon, and utilize visual aids like diagrams or videos to help women

understand complex information. They should also check for understanding to

ensure women grasp the information provided. By supporting effective

communication, health workers can empower pregnant women to take an active

role in their care, leading to better health outcomes for both mother and baby.

6.3 Using songs to promote ANC

Using songs to promote ANC can be an effective way to convey important health

messages, engage and educate pregnant women, and create a memorable and

enjoyable learning experience. Songs can be particularly effective in reaching a

wider audience, including those with limited literacy, as music can transcend

language and cultural barriers. Some of the benefits of using songs to promote

ANC include:

Improved retention: Songs can help pregnant women remember important health

information.

Increased engagement: Music can make learning more enjoyable and interactive.
32
Cultural relevance: Songs can be tailored to specific cultural contexts, making

them more relatable and effective.

Songs can cover topics like ANC visits, healthy behaviors, and danger signs. To

implement, collaborate with local musicians, use simple melodies, and disseminate

through various channels like clinics, community gatherings, and media. By

incorporating songs into ANC promotion, healthcare providers can create a more

engaging and effective health education experience for pregnant women.

6.4 Messages delivered through ANC songs

ANC songs can deliver various messages, including:

Importance of regular ANC visits

Healthy behaviors during pregnancy (e.g., nutrition, exercise)

Danger signs and symptoms to watch out for

Benefits of skilled birth attendance

Preparation for childbirth and parenthood

These messages can be conveyed in a way that is engaging, memorable, and

culturally relevant, helping pregnant women to better understand and adopt healthy

practices.

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 6.5 Benefits of using song based education

As already mentioned above, song-based education improves retention,

engagement, and accessibility, while fostering emotional connections and cultural

relevance, ultimately leading to more effective health education and better

outcomes.

Conclusively, by encouraging open communication and using creative approaches

like song-based education, health workers can empower pregnant women, improve

health outcomes, and create a more positive ANC experience.

CHAPTER 7
7. Preparation for delivery

As you approach the final stages of pregnancy, preparation is key to a smooth and

empowering experience. This involves emotional, physical and logistical readiness.

By focusing on these areas, you will be better equipped to handle the challenges

and joys of childbirth.

7.1 Emotional preparation

1) Childbirth Education Classes: Attend classes to learn about labor, delivery

and post-partum care. This is so that you don’t get overwhelmed by so many

emotions at the thought of labor pains and others

34
 2) Building a support network: Identify a birth partner or a support person to

provide you with emotional support. This person will be the one to comfort

and encourage you during labor.

3) Managing anxiety and fear: Always try to practice some relaxation

techniques like deep breathing, meditation or yoga to manage stress. Deep

breathing will help slow down your heart rate and deal with nervousness and

anxiousness.

4) Positive birth affirmations: It is important to repeat affirmations in order to

build confidence and positivity. Examples of such affirmations are “I am

strong and capable of giving birth”, “Each contraction brings my baby closer

to me”, “and my body is designed to birth my baby”.

7.2 Physical preparation

1) Regular Prenatal Check-ups: You have to schedule regular appointments

with your healthcare provider.

2) Exercise and physical activity: Engage in activities that are pregnancy

friendly such as prenatal yoga or swimming.

3) Healthy Nutrition: Focus on a balanced diet rich in essential nutrients

4) Rest and Sleep: Prioritize getting enough rest and managing fatigue.

35
 7.3 Hospital Bag Checklist

Packing your hospital bag ahead of time ensures that you are prepared for a

smooth and comfortable experience. A well-stocked bag should include essentials

for the mother, the baby and some important documents

1) Mother’s essentials:

- Comfortable clothes for labor and postpartum

- Toiletries (tissue, toothbrush, postpartum pads, hairbrush etc)

- Pillow and blanket(if desired)

- Snacks and drinks

2) Baby’s essentials

- Warm baby clothes(with caps, socks)

- Swaddle blankets

- Diapers

- Baby’s Vaseline

3) Important documents

- Insurance cards(if any)

- National Identity Card

- Birth plan
36
 - Contact information for healthcare provider

7.4 Birth planning and family involvement

Birth planning involves outlining your preferences for labor, delivery and

postpartum care. This plan serves as a guide for your healthcare provider and

support team, ensuring your wishes are respected. There are important key aspects

to consider:

1) Labor Preferences

Labor preferences outline your wishes for the labor process. It has some key

considerations:

Pain Management: Specify your preferred pain relief options, such as:

- Epidural anesthesia

- Natural methods (Breathing techniques, massage, water immersion)

- Other options (nitrous oxide, etc)

Monitoring and interventions: Decide on your preferences for:

- Fetal monitoring (continuous or intermittent)

- Intravenous fluids (routine or as needed)

- Other interventions (amniotomy, etc)

2) Delivery Preferences

37
 This focuses on your wishes for the delivery process. Some key

considerations:

Birthing positions: Specify your preferred positions such as:

- Lying down

- Sitting

- Standing

- Water birth

Family Involvement Family involvement is crucial for emotional support and

decision-making during the delivery process. This involves:

1) Partner’s role:

- Discuss expectations from your partner and his roles during labor and

delivery

- Decide on the level of involvement in decision making

2) Support System:

- Inform family and close friends about your birth plan

- Identify who will provide emotional support during labor and postpartum

3) Involvement in decision-making:

- Decide who will make decisions during labor and delivery

- Discuss preferences for communication and involvement

38
By being thoroughly prepared, you will be better equipped to navigate the delivery

process and enjoy this special moment.

CHAPTER 8
8. Socioeconomic Barriers

In Bamenda, many women face financial hardship, which makes it difficult to

access ANC services. Expenses such as consultation fees, lab tests, and

transportation often become insurmountable, especially for unemployed women or

those dependent on male partners (Ndoh et al., 2022). A study in the Northwest

Region showed that the high cost of care significantly delays ANC attendance;

women often prioritize household needs over healthcare (Sama et al., 2018).

Example: A woman from Nkwen reported missing her ANC appointments because

she couldn’t afford the transportation fee of 1,500 FCFA each way (Sama et al.,

2018)

8.2 Cultural and Religious Beliefs

Cultural norms in parts of Bamenda discourage early disclosure of pregnancy.

Some women delay seeking ANC because they fear attracting “evil eyes” or

believe it is taboo to talk about pregnancy in the first trimester (Titaley et al.,

2010). Additionally, religious beliefs influence care-seeking behavior. Certain

39
denominations promote prayer and spiritual intervention over medical care,

causing women to skip hospital visits (Van et al., 2020).

Example: A pregnant woman in Bamenda reported that her pastor advised her

against going to the hospital, saying, “God will protect your baby better than the

doctors” ((Van et al., 2020).

8.3 Lack of Awareness or Misinformation

Limited health education contributes to low ANC attendance. Many women

believe ANC is only necessary when complications arise, or they think it’s only

useful during the last months of pregnancy (Nsagha et al., 2019). This lack of

awareness is common among young or first-time mothers who may not have

received proper community sensitization or school-based health education (Fomulu

et al., 2014).

Example: A 19-year-old first-time mother in Bamenda delayed her first ANC visit

until 7 months because she thought ANC was only for women with problems

during pregnancy

8.4 Distance and Transportation Issues

While the Bamenda Regional Hospital is centrally located, many women from

surrounding villages like Bambili, Bafut, or Mbatu face challenges reaching the

40
hospital due to poor roads and high transport costs. The socio-political crisis in the

Northwest region has made road travel dangerous and unreliable (Chia et al.,

2014). Public transport is either unavailable or unaffordable for many.

Example: A woman from Bafut shared that she had to walk over an hour to find a

bike taxi willing to take her to ANC during lockdown days imposed by armed

groups (Chia et al., 2014).

8.5 Health System Limitations

The hospital itself faces several operational challenges. Staff shortages are

common, especially in the maternity unit, leading to long wait times and poor

patient-provider interactions (Acha et al., 2021). Power outages and lack of

essential medical equipment (e.g., oxygen, ultrasound machines) reduce service

quality. In addition, some women report disrespectful treatment from overworked

nurses, which discourage them from returning (Hildon et al., 2018).

Example: One woman recounted being yelled at by a nurse for arriving late for her

ANC appointment, even though her delay was due to roadblocks caused by

insecurity.

CHAPTER 9
Strategies to improve ANC

(i) Community Education and Awareness:

41
Increase awareness about the importance of early and regular ANC through health

talks, community outreach, and media campaigns. Also, Educate women on danger

signs, birth planning, and emergency preparedness to reduce maternal and neonatal

mortality.

(ii)Training and Support for Health Workers:

Provide continuous training and resources to ensure skilled and respectful care.

(iii) Accessible and Affordable Services:

Improve access by reducing cost barriers, providing services closer to

communities, and offering flexible clinic hours.

(iv) Male And family Involvement:

Encourage partner and family support and participation to improve women’s

attendance and compliance.

(v) Improved Infrastructure and Equipment:

Ensure clinics are well-equipped with essential supplies, diagnostic tools, and a

clean environment.

(vi) Integration of Services:

42
Combine ANC with other services like HIV testing, nutrition counseling, and

immunizations for efficiency.

(vii) Monitoring and Evaluation:

Regularly assess ANC service quality and outcomes to identify gaps and improve

delivery.

(viii) Strengthening Referral Systems:

Ensure timely and coordinated referrals for women who need higher-level care,

especially in high-risk pregnancies.

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