What are the recent World Health Organization (WHO) guidelines on antenatal care?

Recent WHO Guidelines on Antenatal Care

The World Health Organization recommends a minimum of 8 antenatal care contacts throughout pregnancy, with midwife-led continuity of care, representing a significant shift from the previous 4-visit model. 1, 2

Core WHO Recommendations for Visit Frequency

The 2016 WHO guidelines fundamentally changed the approach to antenatal care delivery:

• Minimum of 8 ANC contacts are recommended for all pregnant women to achieve a positive pregnancy experience 1, 2, 3
• First contact should occur within the first trimester (before 12 weeks gestation), as timely initiation is a major driving force toward achieving adequate total visits 3, 4
• Women with timely first-trimester ANC initiation have 4.7 times higher odds of receiving eight contacts 3

This represents a doubling of the previous 4-visit recommendation, though implementation remains challenging globally with only 13-23% of women in low- and middle-income countries currently achieving 8+ contacts 4, 5

Health System Interventions Recommended by WHO

The WHO guidelines emphasize several structural changes to improve antenatal care quality and access:

• Midwife-led continuity of care throughout antenatal, intrapartum, and postnatal periods 1, 2
• Women-held case notes to improve communication and patient engagement 1
• Community mobilization to improve communication and support to pregnant women 1
• Task-shifting components of prenatal care to community-based health workers to improve access, particularly in low-resource settings 1
• Recruitment and retention of health workers in rural and remote areas where access to essential health services is limited 1

Essential Content of Antenatal Contacts

WHO guidelines specify that antenatal care must deliver comprehensive services beyond simple monitoring:

Education Topics (all 6 recommended):

• Nutrition and appropriate weight gain 1, 6
• Exercise during pregnancy 1, 6
• Preparation for labor and delivery 1, 6
• Breastfeeding 1, 6
• Family planning 1, 6

Psychosocial Screening and Management (all 7 areas):

• Tobacco use screening and cessation support 1, 6
• Alcohol use assessment 1, 6
• Substance use evaluation 1, 6
• Intimate partner violence screening 1, 6
• Mental health disorders 1, 6
• Housing insecurity 1, 6
• Nutritional needs assessment 1, 6

Preventive Interventions

The WHO guidelines include specific evidence-based interventions to prevent adverse outcomes:

• Low-dose aspirin (100-150 mg daily) starting before 16 weeks gestation for women with major risk factors (prior preeclampsia, chronic hypertension, pregestational diabetes, BMI >30, chronic kidney disease, antiphospholipid syndrome) or ≥2 minor risk factors 1, 2
• Calcium supplementation (1200 mg daily) if dietary calcium intake is low in the local population 1, 2
• Multiple micronutrient supplementation for pregnant women 7
• Malaria prevention in endemic areas 7
• Treatment of asymptomatic bacteriuria 7
• Syphilis screening and treatment 7

These eight proven preventive interventions, if fully implemented, could prevent 5.2 million small vulnerable newborn births and 0.566 million stillbirths annually in low- and middle-income countries 7

Implementation Challenges and Solutions

A critical pitfall is that women in low- and middle-income countries typically do not seek care until after 20 weeks gestation, missing the crucial window for aspirin and calcium prophylaxis before 16 weeks. 1

Key barriers to achieving 8+ contacts include:

• Poor knowledge of prophylactic interventions among healthcare providers, even doctors, in district health centers 1
• Limited supply and distribution of essential medications like magnesium sulfate for eclampsia prevention 1
• Women's limited comprehension of preeclampsia risks and the importance of regular monitoring 1
• Socioeconomic factors: women who fail to achieve 8+ contacts are typically poor, single, with low education, living in rural areas, with higher parity and shorter birth intervals 3

Comparison with Other International Guidelines

While WHO recommends 8 contacts, implementation varies globally:

• France and Netherlands: 7.5 visits median 1
• United Kingdom: 9 visits 1
• Sweden: 10 visits 1
• Canada: 11.5 visits 1
• United States (ACOG): 12-14 visits traditionally, though reduced schedules endorsed since 2020 1, 6
• Japan: 15 visits 1

Meta-analysis of over 5,000 patients demonstrated equivalent maternal and neonatal outcomes when visits were reduced from 12-14 to 9 visits for low-risk patients, supporting the WHO's evidence-based approach 1, 6

Evidence for Combined Interventions

Combined interventions (two or more) show stronger effects than single interventions on key outcomes:

• Improved ANC coverage of at least one visit (OR 1.79,95% CI 1.47-2.17) 8
• Reduced perinatal mortality (OR 0.74,95% CI 0.57-0.95) 8
• Reduced low birthweight (OR 0.61,95% CI 0.46-0.80) 8
• Improved tetanus protection coverage (OR 1.48,95% CI 1.18-1.87) 8

Single interventions show only marginal improvements in achieving 4+ visits (OR 1.11,95% CI 1.01-1.22) with no effect on pregnancy-related deaths or perinatal mortality 8

Common Pitfalls to Avoid

• Failing to identify high-risk women early (before 16 weeks) who would benefit from aspirin prophylaxis for preeclampsia prevention 1, 2
• Inadequate supply chain management for essential medications like magnesium sulfate, which often remains stuck at district level rather than reaching healthcare facilities 1
• Insufficient patient education about disease risks, particularly for preeclampsia, leading to poor acceptance of treatment and follow-up 1
• Not distinguishing between low-risk and high-risk pregnancies when determining visit frequency and content 6
• Overlooking socioeconomic barriers that prevent women from attending recommended contacts, particularly transportation, work conflicts, and childcare needs 1