**7. Discussion**

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

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

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].

BANC guidelines in order to ensure the correct timing of repeat tests.

with high-risk factors, should have four to five routine ANC visits.

8 Selected Topics in Midwifery Care

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 of management support [35].

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

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 (three more visits than the current five contact Basic Antenatal Care (BANC) policy) [38]. It is envisaged that this intervention will improve the pregnancy experience as well as the outcomes of pregnant women and their babies in South Africa. The BANC + continues to emphasise the importance of conducting the first visit as early as possible, with the next visit scheduled at 20 weeks and then repeat visits at 26 weeks. The adjustments include the 30 weeks and 34 weeks and then a 2-week visit until delivery. An audit of the current BANC system has shown that two important principles of good care were often missing: a plan for further antenatal care and the delivery plan (including delivery at the appropriate level of care or hospital). Therefore, appropriate planning for the pregnancy as well as for the delivery, based on information obtained and correctly interpreted at every visit, will ensure that women and their families are ready and prepared when the big day arrives. The purpose of BANC+ is not just to increase the number of visits but also an opportunity to look again at how that care is given [38].

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