**3. Approaches to antenatal care**

the pregnant woman and/or her unborn child [2]. The care includes various screening tests, diagnostic procedures, prophylactic treatments, some of which are done routinely, and oth-

According to Pattinson [2], ANC benefits both the mother and the baby; it assists in screening, diagnosing and managing or controlling the risk factors that might adversely affect the pregnant women and/or the pregnancy outcome. Maternal and perinatal death rates remain the major challenge of health care in South Africa. During 2005–2007, triennium maternal deaths had increased by 20% when comparing them to the 2002–2004 triennium [3]. However, due to changes in the treatment programmes for HIV-positive pregnant women and the focus on reducing deaths in specific categories such as obstetric haemorrhage, a significant fall in both the numbers of maternal deaths and mortality ratios has since been reported in South Africa. An overall reduction of 24% (1152 from 2008–2010 to 2014–2016) has been achieved [4]. Nevertheless, much more still needs to be done for the country to be able to maintain this fall and to obtain an exponential fall. Several major challenges still remain mainly relating to the quality of care, inter-facility transport, and knowledge and skills of health professionals [4]. Furthermore, the majority of preventable deaths during pregnancy and childbirth have been attributed to poor ANC [5]. According to these authors, non-attendance of ANC clinics carries an approximately four times increased risk of maternal deaths compared with the general pregnant population who attend ANC clinics. The provision of adequate ANC is advocated by most authors worldwide as the cornerstone for maternal and perinatal care. The detection of high-risk pregnancies through ANC has been advocated as a good tool for reducing

The purpose of ANC is to screen, diagnose and manage or control the risk factors that might adversely affect the pregnant woman and/or the pregnancy outcome. Both Pattinson and Snyman [2, 7] attest to this by saying: 'The quality of health care that a pregnant woman receives during ANC has an impact on the health of the woman and on the outcome of pregnancy'. Ekabua et al. [1] highlight the four major goals of ANC as being (a) promotion and maintenance of the physical and social health of the mother and the baby, (b) detection and management of complications during pregnancy, (c) development of birth preparedness and complication readiness plan and (d) preparation of the women for normal puerperium. The World Health Organisation (WHO) identifies ANC as one of the most widely used strategies to improve maternal and child health [8]. It was also one of the worldwide strategies towards the achievement of millennium development goal (MDGs numbers 4 and 5, which were to reduce child

Three South African reports, namely the Saving Mothers report by the National Committee on Confidential Enquiry into Causes of Maternal Deaths (NCCEMD), Saving Babies report for the Perinatal Problem Identification Programme (PPIP) and Saving Children report for the Child Health Problem Identification Programme (CHPIP), review the health care provided to the mothers, babies and children in South Africa [10]. The findings of these reports highlight

ers are provided to the women based on identified problems and risk factors.

**2. Importance of antenatal care**

2 Selected Topics in Midwifery Care

maternal and perinatal mortality rates [6].

deaths by 75% and improve maternal health by 50% by 2015 [9].

Several approaches to ANC are used in different countries including the traditional approach, goal-directed ANC, focussed ANC (FANC) and the basic ANC (BANC) approach. While some countries structure and develop their own approaches to suit their unique circumstances, other countries might simply adopt an approach existing elsewhere. This could create problems if the situations in the two countries differ. Developing countries (like South Africa, Botswana, Swaziland, Kenya and Zimbabwe) adopted ANC programmes modelled on the approaches used in developed countries [15]. These approaches use risk assessments to identify women who are likely to experience complications during their pregnancies and assume that more clinic visits imply better pregnancy outcomes. In these approaches, scarce resources of developing countries might be devoted to women with high-risk pregnancies, implying that women with low-risk pregnancies might not receive optimal care [16]. This approach has been challenged by the WHO [17]. The Maternal and Neonatal Programme [18] argues that frequent ANC visits are often logically and financially impossible for women to manage and place additional burdens on the healthcare system. Frequent ANC visits do not necessarily improve pregnancy outcomes [1]. The WHO realised that traditional ANC programmes, meant for developed countries, were poorly implemented and largely ineffective when used in developing countries [16].

suit the circumstances of the specific country. The WHO indicates that it might be necessary, when introducing the FANC package in practice (depending on the specific country), that the country's national clinical standards and guidelines for ANC might require updating, the pre-service training curricula in ANC and in-service training for ANC providers and their supervisors might need to be modified, and a plan for implementing changes with regard to medications, equipment and supplies to implement the package should be assessed [21].

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Until 2007, South Africa used the traditional approach to ANC. Historically, this traditional ANC service model was developed in the early 1900s. This model assumed that frequent ANC visit, and classifying pregnant women into low- and high-risk groups by predicting potential obstetric complications, was the best way to care for the mother and the foetus [22]. The use of the traditional ANC approach in South Africa was prescribed by the South African Nursing Council (SANC) in the scope of practice for midwives [23]. The SANC prescribed that the midwives should ensure that pregnant women attend ANC clinics once a month until 28 weeks' gestation and thereafter every fortnight until 36 weeks' gestation. Thereafter, a pregnant woman should continue attending the clinic at PHC level every week until her baby is born or until she reached 42 weeks' gestation whichever comes first. Should the woman not give birth by 42 weeks' gestation, she had to be referred for hospital management [23]. With the traditional approach, a pregnant woman could have up to 12 ANC visits conducted at a PHC clinic level during one pregnancy. This is one of the aspects that have been challenged

The traditional ANC approach was replaced by the FANC approach which is a goal-oriented ANC approach that was recommended by researchers during 2001 and adopted by the WHO in 2002 [21]. The NDoH identified BANC as the ideal approach to ensure that quality and effective ANC is provided [25]. According to the Saving Babies Report 2008–2009, improvement in access to good-quality ANC services could make a major contribution towards reduc-

South Africa adopted and modified the FANC model to suit the South African circumstances and referred to it as the BANC approach [27, 28]. This followed the realisation by the NDoH that the traditional ANC approach was not working well for South Africa. Midwives, the key providers of ANC services, requested for a programme based on the principles used in the Integrated Management of Childhood Illnesses (IMCI) programme with flow diagrams and protocols [2]. In 2007, the NDoH advised that all health facilities providing ANC services had to adopt the BANC approach by the end of 2008 [29]. The BANC approach is used in the public health institutions of South Africa to provide healthcare services to pregnant women and is listed as one of the priority interventions for reducing maternal and child mortality in this country [25]. South Africa's NDoH introduced the BANC approach in 2007 and advised that all health facilities providing antenatal care (ANC) services should have adopted this approach by the end of 2008 [29]. The NDoH provided training for the lead trainers from all

**4. Approaches to antenatal care services in South Africa**

by the WHO [24].

ing perinatal and child deaths [26].

The WHO designed and tested an FANC package that included only counselling, examinations and tests serving an immediate purpose and having a proven health benefit as an ideal approach to be used by developing countries [19]. In the FANC approach, the WHO recommends reducing the number of ANC visits to four, and this has not been found to pose risks to the health of mothers or babies [19]. The FANC approach recognises that every pregnant woman is at risk of experiencing complications and therefore emphasises that all pregnant women should receive the same basic care and monitoring for complications [18]. However, the WHO emphasises that once a pregnant woman has been identified to have high-risk factors, she should be referred to a higher level of care [18]. The WHO therefore advocates that after the initial assessment, pregnant women should be categorised into two groups: those who have low-risk factors who should follow the FANC reduced number of ANC visits approach and those who have high-risk factors who should be referred for hospital management of their pregnancies [19]. The Maternal, Child and Women's Health Unit of the KwaZulu-Natal (KZN) Department of Health reviewed and revised its ANC guidelines on the basis of the WHO's model of FANC to improve the quality of ANC provided at the clinics in the KZN province [20].

According to the MNH Programme [18], the FANC approach is one of several essential maternal and neonatal care interventions that are evidence-based and that build on global lessons learned about saving the lives of mothers and newborn babies. The FANC approach also includes a classifying form designed to assist ANC health-care providers to identify women who have conditions requiring treatment and more frequent monitoring. It also includes classifying forms needed to implement the package and instructions for its use [19].

The WHO provided key recommendations which form standards for maternal and neonatal care service delivery, providing guidance for assisting countries to improve the health and survival of women and newborn babies during pregnancy, childbirth and the postnatal period and can be modified to suit the circumstances of a specific country [21]. These WHO provisions allow each country, intending to adopt the FANC approach, to modify the guidelines to suit the circumstances of the specific country. The WHO indicates that it might be necessary, when introducing the FANC package in practice (depending on the specific country), that the country's national clinical standards and guidelines for ANC might require updating, the pre-service training curricula in ANC and in-service training for ANC providers and their supervisors might need to be modified, and a plan for implementing changes with regard to medications, equipment and supplies to implement the package should be assessed [21].

## **4. Approaches to antenatal care services in South Africa**

countries structure and develop their own approaches to suit their unique circumstances, other countries might simply adopt an approach existing elsewhere. This could create problems if the situations in the two countries differ. Developing countries (like South Africa, Botswana, Swaziland, Kenya and Zimbabwe) adopted ANC programmes modelled on the approaches used in developed countries [15]. These approaches use risk assessments to identify women who are likely to experience complications during their pregnancies and assume that more clinic visits imply better pregnancy outcomes. In these approaches, scarce resources of developing countries might be devoted to women with high-risk pregnancies, implying that women with low-risk pregnancies might not receive optimal care [16]. This approach has been challenged by the WHO [17]. The Maternal and Neonatal Programme [18] argues that frequent ANC visits are often logically and financially impossible for women to manage and place additional burdens on the healthcare system. Frequent ANC visits do not necessarily improve pregnancy outcomes [1]. The WHO realised that traditional ANC programmes, meant for developed countries, were poorly implemented and largely ineffective when used

The WHO designed and tested an FANC package that included only counselling, examinations and tests serving an immediate purpose and having a proven health benefit as an ideal approach to be used by developing countries [19]. In the FANC approach, the WHO recommends reducing the number of ANC visits to four, and this has not been found to pose risks to the health of mothers or babies [19]. The FANC approach recognises that every pregnant woman is at risk of experiencing complications and therefore emphasises that all pregnant women should receive the same basic care and monitoring for complications [18]. However, the WHO emphasises that once a pregnant woman has been identified to have high-risk factors, she should be referred to a higher level of care [18]. The WHO therefore advocates that after the initial assessment, pregnant women should be categorised into two groups: those who have low-risk factors who should follow the FANC reduced number of ANC visits approach and those who have high-risk factors who should be referred for hospital management of their pregnancies [19]. The Maternal, Child and Women's Health Unit of the KwaZulu-Natal (KZN) Department of Health reviewed and revised its ANC guidelines on the basis of the WHO's model of FANC to improve the quality of ANC provided at the clinics

According to the MNH Programme [18], the FANC approach is one of several essential maternal and neonatal care interventions that are evidence-based and that build on global lessons learned about saving the lives of mothers and newborn babies. The FANC approach also includes a classifying form designed to assist ANC health-care providers to identify women who have conditions requiring treatment and more frequent monitoring. It also includes clas-

The WHO provided key recommendations which form standards for maternal and neonatal care service delivery, providing guidance for assisting countries to improve the health and survival of women and newborn babies during pregnancy, childbirth and the postnatal period and can be modified to suit the circumstances of a specific country [21]. These WHO provisions allow each country, intending to adopt the FANC approach, to modify the guidelines to

sifying forms needed to implement the package and instructions for its use [19].

in developing countries [16].

4 Selected Topics in Midwifery Care

in the KZN province [20].

Until 2007, South Africa used the traditional approach to ANC. Historically, this traditional ANC service model was developed in the early 1900s. This model assumed that frequent ANC visit, and classifying pregnant women into low- and high-risk groups by predicting potential obstetric complications, was the best way to care for the mother and the foetus [22]. The use of the traditional ANC approach in South Africa was prescribed by the South African Nursing Council (SANC) in the scope of practice for midwives [23]. The SANC prescribed that the midwives should ensure that pregnant women attend ANC clinics once a month until 28 weeks' gestation and thereafter every fortnight until 36 weeks' gestation. Thereafter, a pregnant woman should continue attending the clinic at PHC level every week until her baby is born or until she reached 42 weeks' gestation whichever comes first. Should the woman not give birth by 42 weeks' gestation, she had to be referred for hospital management [23]. With the traditional approach, a pregnant woman could have up to 12 ANC visits conducted at a PHC clinic level during one pregnancy. This is one of the aspects that have been challenged by the WHO [24].

The traditional ANC approach was replaced by the FANC approach which is a goal-oriented ANC approach that was recommended by researchers during 2001 and adopted by the WHO in 2002 [21]. The NDoH identified BANC as the ideal approach to ensure that quality and effective ANC is provided [25]. According to the Saving Babies Report 2008–2009, improvement in access to good-quality ANC services could make a major contribution towards reducing perinatal and child deaths [26].

South Africa adopted and modified the FANC model to suit the South African circumstances and referred to it as the BANC approach [27, 28]. This followed the realisation by the NDoH that the traditional ANC approach was not working well for South Africa. Midwives, the key providers of ANC services, requested for a programme based on the principles used in the Integrated Management of Childhood Illnesses (IMCI) programme with flow diagrams and protocols [2]. In 2007, the NDoH advised that all health facilities providing ANC services had to adopt the BANC approach by the end of 2008 [29]. The BANC approach is used in the public health institutions of South Africa to provide healthcare services to pregnant women and is listed as one of the priority interventions for reducing maternal and child mortality in this country [25]. South Africa's NDoH introduced the BANC approach in 2007 and advised that all health facilities providing antenatal care (ANC) services should have adopted this approach by the end of 2008 [29]. The NDoH provided training for the lead trainers from all the provinces and made available various documents such as a handbook, guidelines and guides for facility managers [2, 28, 29]. The lead trainers were expected to cascade the training into their respective provinces and to institute and facilitate the implementation of the BANC approach.

The BANC approach focuses on the quality rather than on the quantity of visits, with special emphasis on the fact that every visit should be goal directed [31]. The approach is included in the list of strategies provided by the NDoH to achieve MDGs 4 and 5 which are to reduce perinatal deaths and improve maternal health by 2015 [32]. A baseline audit of the ANC service and an analysis of the strengths, weaknesses, opportunities and threats (SWOT) of the facility should be conducted before commencing the implementation of the BANC approach. This enables the midwives to compile a realistic plan and process map for the implementation of the BANC approach [2]. Documents such as the handbook, guidelines and facility manager's guides are available to be used by the midwives during the implementation of the BANC approach [2]. According to the BANC handbook, each clinic should have one or more supervisors to perform the clinical supervision and the administrative tasks [2]. The manager is responsible for providing supportive supervision to the staff members in order to ensure

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that the clinic's programmes are implemented successfully [2].

**antenatal care approach**

childbirth [2, 33].

comes of pregnancies [7].

tions, and cleanliness and organisation of ANC visits [28].

**6. Provision of antenatal care services according to the basic** 

While the BANC approach is adapted from the WHO's FANC model, it is also designed similar to the IMCI programme [2]. This decision was taken in response to the midwives' request for an ANC programme that has flow diagrams and protocols similar to the IMCI programme. The midwives hoped that having such a programme would assist them to render safer and better quality health care to the pregnant women [2]. It is for this reason that the BANC approach is sometimes referred to as the integrated management of pregnancy and

The NDoH also identified BANC as an ideal approach to ensure that quality and effective ANC is provided [25]. The implementation of BANC is seen as a positive measure to improve the quality of ANC in PHC clinics [7]. Effective and quality ANC could assist South Africa to address the problem of constantly increasing maternal and perinatal mortalities. Snyman [6] stated that the BANC quality improvement package is designed to assist ANC-related clinical management and decision-making at PHC level. This author conducted a qualitative study to assess the effectiveness of the BANC package for improving the quality of ANC services rendered at PHC facilities. With the implementation of the BANC approach, the organisational changes required at the facility level for the improvement of ANC services are facilitated with tools like the integrated flow charts for pregnant women's management, referral protocols and checklists. This could potentially have a positive impact on the out-

Guidelines on how to conduct ANC visits are detailed in the Basic Antenatal Care Principles of Good Care and Guidelines [28]. These guidelines have been adapted from a guide for essential practice by the WHO titled 'Pregnancy, Childbirth, Postpartum and Newborn Care' [28]. According to the BANC Principles of Good Care and Guidelines, the principles of good care include communication, workplace and administrative procedures, universal precau-
