**2. Importance of antenatal care**

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 maternal and perinatal mortality rates [6].

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

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 avoidable causes of the deaths of mothers, babies and children and make recommendations to improve the quality of care provided to mothers, babies and children at the time when they need it most. All three committees highlight, in their triennial reports, the importance of ANC for reducing maternal, perinatal and children's deaths. Bradshaw et al. [10] further emphasise that addressing the health challenges should involve strengthening the provision of healthcare packages within the continuum of care and recognise that the effectiveness of each package depends on whether it provides high-impact, evidence-based interventions and also on the coverage and quality of the service rendered. ANC can screen for, detect and thus prevent many maternal complications that might occur before childbirth and could significantly improve the outcomes for unborn infants [2].

The one document by the NCCEMD, which might appear old but which conveys a very important message for South Africa, is the Saving Mothers Policy and Management Guidelines for Common Causes of Maternal Deaths [11]. This policy document highlights that one of the major areas of substandard care identified in South Africa is the poor initial assessment of patients during ANC visits. The authors attribute this to the fact that the midwives are trained in the traditional method of history taking, clinical examination and special investigations when assessing patients. This might make it difficult to assimilate the multiple abnormalities found and to formulate a management plan for a patient with multiple organ disease, the very type of cases described in the maternity mortality reports [12].

South Africa has a burden of high maternal and perinatal mortality rates and therefore needs to work very hard to address this problem. The number of reported maternal mortalities had increased by 20% during the 2005–2007 triennium compared to the 2002–2004 trienniums [3]. The constant rise in maternal and perinatal mortality rates resulted in South Africa's inclusion of the MNCWH programme as one of the priority programmes in the 10-year strategic plan for the country [12]. The majority of the provider-related preventable deaths in South Africa have been attributed to poor ANC.

South Africa can address the problem of the constantly rising maternal and perinatal mortality rates because the majority of avoidable provider-related maternal deaths can be avoided through providing proper and good-quality ANC services [13]. The Saving Mothers Report 2008–2010 indicates that a total of (16.6%, n = 713) of women who died during this triennium did not attend ANC clinics and (7.0%, n = 300) attended ANC clinics infrequently [14]. The Saving Mothers' Report indicates that the avoidable causes of maternal deaths included a number of health provider-related issues such as poor initial assessments, problems with recognising problems, delays in referring the pregnant women to different healthcare facilities causing pregnant women to be managed at inappropriate healthcare levels, incorrect management, substandard management/care and failure to take actions when abnormalities were found [14].
