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

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

Pattinson [28] describes the BANC approach as the minimum level of ANC that every pregnant woman should receive. Every aspect of the BANC approach has been developed from the best research evidence, and the only aspects of ANC that have been shown to be effective are included in the BANC approach [28]. The BANC approach does not intend to replace any existing programme but aims to combine all resources and to facilitate their use [28]. The BANC approach was introduced as a quality improvement strategy based on the belief that good-quality ANC could reduce maternal and perinatal mortalities and improve maternal health, aiming to achieve MDGs 4 and 5 [30]. This then led to the introduction of the BANC approach in the PHC clinics. Thus, the BANC was an approach being used in South Africa to

The BANC approach has been simplified to the bare minimum so that ANC services can be provided by every PHC clinic's midwives [28]. Because the BANC approach is a modified version of the FANC approach, it has many characteristics similar to the FANC approach. These include the approach focusing on early ANC attendance by all pregnant women and on limiting the total number of ANC visits to a minimum of four or five visits per pregnancy for low-risk women. This requires that ANC services should be provided daily at every facility frequented by pregnant women so that the first ANC visit takes place as soon as the pregnancy has been confirmed or the very first time that a pregnant woman visits a health facility [28]. If a pregnant woman is brought into the health system early, her health problems could be detected and managed or controlled early and treatment then has a greater chance of success. Pattinson [28] also states that all pregnant women with high-risk factors should be referred to the next level of care so that nurses at PHC level have sufficient time to attend to women with low-risk factors. Every site where pregnant women make contact with health services should be utilised because if all PHC clinics are providing BANC, then ANC could

The BANC approach requires that two sets of checklists be used for recording purposes during ANC visits: one checklist to record the first visit and the other to use during subsequent follow-up visits. Pattinson [28] recommends that before commencing implementation of the BANC approach, each facility has to develop its own specific protocols for the management of obstetric conditions which must be in line with the South African National Maternity Care Guidelines and should be displayed in the facility. All the protocols should be counter-signed by the head of the obstetric unit from the hospital to which the facility refers the women with high-risk factors or complications during pregnancy. The protocols should be reviewed annually. Regular auditing of the ANC service should be an on-going process to ensure continuous

improvement based on identifying and addressing potential shortcomings [2].

**5. The basic antenatal care (BANC) approach**

render ANC services during the time of this study.

be started as soon as the pregnancy had been confirmed [2].

approach.

6 Selected Topics in Midwifery Care

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 childbirth [2, 33].

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 outcomes of pregnancies [7].

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

It is stated in the guidelines that communication, privacy and confidentiality during examination and counselling should be ensured at each ANC visit [28]. The importance of service hours, the availability of equipment and drugs, record keeping, and infection prevention and control are highlighted as part of the workplace and administrative procedures [28]. The guidelines describe how the ANC visits should be organised, highlighting that ANC should always begin with rapid assessment and management. All pregnant women, except those with high-risk factors, should have four to five routine ANC visits.

All information regarding pregnancy and consultation should be recorded in an ANC card which should not be filed at the clinic but which should be kept by the pregnant woman. The woman is advised to always carry the ANC card with her, wherever she goes, and to produce the card each time she visits any health-care institution. This practice facilitates communication between the different health-care providers involved in the care of women during

Basic Antenatal Care Approach to Antenatal Care Service Provision

http://dx.doi.org/10.5772/intechopen.79361

9

Several factors have been identified to be positively influencing the implementation of the BANC approach. These include the availability and accessibility of BANC services, policies, guidelines and protocol; various means of communication; a comprehensive package of and the integration of primary healthcare services; training and in-service education; human and material resources; the support and supervision offered to the midwives by the primary health-care supervisors; supervisors' understanding of the approach and the levels of experience of midwives involved in the implementation of the BANC approach [34] Nevertheless, evidence still shows that not all PHC clinics have been able to successfully implement and sustain the BANC approach [35]. Ngxongo [35] discovered that out of 59 Municipal PHC clinics in eThekwini District in KwaZulu-Natal, 46% (n = 27) were successfully implementing the BANC approach. Midwives face various challenges during the implementation of the BANC approach which has resulted in some PHC clinics abandoning the BANC approach and reverting to the traditional approach to ANC [35]. These challenges include shortage of staff, lack of cooperation from referral hospitals, lack of in-service training, problems with transportation of specimens to laboratories, lack of material resources, unavailability of Basic Antenatal Care programme guidelines and lack

Although the BANC approach emphasises quality over quantity of visits [36], reducing the number of ANC visits has posed numerous challenges in the pregnancy outcomes. According to Hofmeyr and Mentrop [37], too few visits and the long interval between routine ANC visits in late pregnancy in the BANC approach have been responsible for a number of maternal and perinatal deaths. Hofmeyr and Mentrop [37] argue that the more frequent and closely spaced ANC visits as pregnancy advances in the traditional approach assisted in early diagnosis and management of selected ANC problems such as preeclampsia, foetal growth impairment and others and that too few visits result in missed opportunities to detect and treat asymptomatic pregnancy complications. These authors recommend modification of the BANC approach into what they call 'BANC plus'. Their proposal is that a reasonable compromise for a middleincome country such as South Africa would be to continue to implement the WHO BANC approach with reduced, goal-orientated visits up to 32 weeks' gestation and thereafter to

The international evidence supports a more regular contact between healthcare workers and pregnant women. Therefore, South Africa is gradually switching to an eight-contact model

revert to routine visits every 2–36 or 38 weeks, followed by weekly checks.

pregnancy and childbirth [2].

of management support [35].

**7. Discussion**

A pregnancy status and birth plan chart, which should be used to assess the pregnant women at each of the four ANC visits, are provided [28]. The chart is used during the first ANC visit to prepare the birth and emergency plan and reviewed and modified according to the need at each subsequent ANC visit. 'Ask, check, look listen and feel' criteria should always be followed during assessments of pregnant women. All pregnant women should be screened for preeclampsia, anaemia, foetal growth and post-maturity at all ANC visits [28]. All women should also be screened for syphilis, Human Immunodeficiency Virus (HIV) and Rhesus factor (RH) [28]. All routine investigations, including the rapid plasma reagent (RPR) test, haemoglobin (Hb) level test, HIV and RH tests should be done using rapid test kits. The guidelines highlight the importance of responding to observed signs and/or problems reported by the pregnant women and contain a guide on how to respond to these signs [28].

Standard preventative therapy, including tetanus toxoid injections, iron preparations and calcium supplements, should be issued to all pregnant women at each ANC [28]. A guide is included on how to advise women about nutrition and self-care [28]. The guidelines highlight the importance of preparing individualised ANC and delivery plans for each woman at the first ANC visit and that the plans should be reviewed during each subsequent visit and adjusted based on the identified needs. The plan should be prepared in consultation with the woman concerned. This ensures that the woman is involved in her own care. The plans should also include transport arrangements, infant feeding options and future contraception. A description of how the first and the follow-up visits should be conducted is provided [28].

The guidelines state that the first ANC visit should take place as early in pregnancy as possible, before 12 weeks' gestation, preferably at the confirmation of pregnancy [28]. During the first ANC visit, all women should be classified for BANC using the classifying form/first visit checklist provided. Only women with low-risk factors should follow the BANC approach. All women with risk factors should either be referred to an appropriate level of care or follow a specially prepared schedule based on the risk factors identified. Four follow-up visits should be scheduled at 20, 26, 32 and 38 weeks' gestation. Specific times are scheduled for performing repeat routine tests such as Hb, HIV and RPR, and these times coincide with specific routine follow-up visits. It is therefore important to schedule the follow-up visits as specified by the BANC guidelines in order to ensure the correct timing of repeat tests.

Pattinson [2] suggests that each PHC clinic should have one or more people in the role of ANC supervisor to ensure clinical and administrative supervision. The clinical supervisor should be the person with most ANC skills and should check each pregnant woman's ANC card at the first visit and again at the 32 weeks' visit to ensure that the clinic provides adequate care [2].

All information regarding pregnancy and consultation should be recorded in an ANC card which should not be filed at the clinic but which should be kept by the pregnant woman. The woman is advised to always carry the ANC card with her, wherever she goes, and to produce the card each time she visits any health-care institution. This practice facilitates communication between the different health-care providers involved in the care of women during pregnancy and childbirth [2].
