What are the components of good antenatal care?

Components of Good Antenatal Care

Good antenatal care should include comprehensive preconception counseling, risk-stratified visit schedules (8-15 visits depending on risk level), systematic screening for medical and psychosocial conditions, targeted interventions including aspirin prophylaxis for preeclampsia prevention, fetal surveillance, and patient education—all delivered through a structured, evidence-based approach rather than ritualistic protocols. 1, 2

Preconception and Early Pregnancy Care (Before 16 Weeks)

Preconception counseling is critical and should not be delayed, as organogenesis begins before many women have their first prenatal visit. 3

• Folic acid supplementation (400-800 mcg daily) must be started before conception to prevent neural tube defects, as neural tube closure occurs at 6 weeks gestation (28 days after conception). 3, 1
• Medication review to identify and discontinue teratogenic agents including ACE inhibitors, ARBs, statins, isotretinoin, warfarin, and certain antiseizure medications. 3, 1
• Optimize chronic conditions before conception, particularly diabetes (target A1C <6.5%), hypertension, and thyroid disorders. 3, 1
• Genetic and carrier screening based on family history, ethnic background, and maternal age, including cystic fibrosis screening as indicated. 3
• Infectious disease screening including HIV, syphilis, hepatitis B, gonorrhea, chlamydia, and rubella immunity status. 3, 2
• Immunization updates with hepatitis B, rubella, varicella, Tdap, HPV, and influenza vaccines as needed. 3
• Low-dose aspirin (81-150 mg daily) initiated before 16 weeks for women with preeclampsia risk factors including prior preeclampsia, chronic hypertension, pregestational diabetes, BMI >30, chronic kidney disease, or antiphospholipid syndrome. 1
• Calcium supplementation (1200 mg daily) if dietary intake is inadequate. 1

Visit Schedule and Frequency

The traditional U.S. schedule of 12-14 visits originated in 1930 without supporting evidence and has remained largely unchanged despite technological advances. 3

• For low-risk women: Evidence supports reduced visit schedules of 8-9 visits with equivalent maternal and neonatal outcomes compared to 12-14 visits. 3
• WHO recommends a minimum of 8 antenatal contacts with midwife-led continuity of care. 1
• International variation ranges from 7.5 visits (France, Netherlands) to 15 visits (Japan), with most peer countries recommending fewer visits than the U.S. 3
• Visit intervals should be monthly until 28 weeks, biweekly until 36 weeks, then weekly until delivery for standard-risk pregnancies, though this can be modified based on individual risk assessment. 3

Second Trimester Care (14-28 Weeks)

• Detailed fetal anatomy ultrasound to screen for structural anomalies. 3, 1
• Fetal echocardiogram for women with pregestational diabetes due to increased risk of cardiac anomalies. 3, 1
• Continue aspirin prophylaxis for preeclampsia prevention through delivery. 1
• Screening for gestational diabetes using oral glucose tolerance test, though timing and universal application remain somewhat controversial across guidelines. 4
• Dilated eye examination for women with preexisting diabetes to monitor for diabetic retinopathy. 3, 1

Third Trimester Care (28 Weeks to Delivery)

• Antepartum fetal surveillance beginning at 32-34 weeks for high-risk pregnancies including pregestational diabetes, using nonstress tests, amniotic fluid assessment, or biophysical profiles. 3, 1
• Preeclampsia monitoring with blood pressure and proteinuria screening, particularly in women with risk factors. 1, 2
• Fetal growth assessment via ultrasound, though routine symphysis-fundal height measurement remains controversial. 4
• Anemia screening around 30 weeks gestation, noting that high hemoglobin is a danger signal rather than reassurance. 5
• Group B Streptococcus screening at 35-37 weeks. 2

Essential Screening and Management Components

Infectious Disease Prevention and Management (apply based on population burden):

• Syphilis screening and treatment is inexpensive and cost-effective. 5
• Urine culture or dipstick for leucocyte esterase and nitrite with treatment of positive cases reduces pyelonephritis risk. 5
• HIV, tuberculosis, malaria, and tetanus prevention and screening as indicated by local epidemiology. 2

Medical Condition Screening:

• Anemia assessment with hemoglobin determination, particularly important around 30 weeks; routine iron supplementation not necessary in well-nourished populations but essential in areas of high anemia prevalence. 5, 2
• Gestational diabetes screening though optimal timing and universal application debated. 4
• Thyroid function screening for women with preexisting thyroid disease or risk factors. 3

Psychosocial Assessment:

• Mental health screening for depression and anxiety using validated tools. 3, 2
• Intimate partner violence screening and appropriate referral. 2
• Substance use assessment including tobacco, alcohol, and drugs using CAGE or T-ACE questionnaires. 3
• Social determinants including housing insecurity, though this is commonly omitted from guidelines. 3

Patient Education and Counseling

• Nutrition counseling assessing anthropometric factors (BMI), biochemical factors (anemia), clinical factors, and dietary risks. 3, 2
• Birth preparedness including recognition of danger signs and when to seek care. 2
• Breastfeeding promotion and infant safe sleep practices. 3
• Family planning for interpregnancy interval optimization. 2
• Avoidance of teratogens including alcohol, tobacco, certain fish with high mercury content, and workplace/environmental toxins. 3

Care Delivery Models

• Provider type: Most peer countries recommend general practitioners or midwives as primary maternity care providers for low-risk women, while U.S. guidelines offer choice between obstetrician-gynecologists, general practitioners, or midwives. 3
• Telemedicine and hybrid models have demonstrated feasibility and acceptability, particularly since the COVID-19 pandemic forced reconsideration of traditional visit schedules. 3
• Risk stratification is essential—care should be tailored based on individual risk factors rather than applying a one-size-fits-all approach. 3

Common Pitfalls to Avoid

• Failing to initiate aspirin prophylaxis before 16 weeks in women with preeclampsia risk factors, missing the critical window for prevention. 1
• Delaying preconception care until just before attempting pregnancy, when organogenesis may already be underway. 3, 6
• Ritualistic adherence to the 1930 visit schedule without evidence-based risk stratification, leading to unnecessary visits for low-risk women and potentially inadequate care for high-risk women. 3
• Overlooking psychosocial factors including mental health, intimate partner violence, and social determinants of health. 3, 2
• Inadequate patient education about danger signs, birth preparedness, and self-care, leading to poor patient satisfaction despite frequent visits. 3, 2
• Missing the late pregnancy anemia screen around 30 weeks, which is more clinically significant than early pregnancy screening. 5