WHO guidelines not feasible for Malawi

In 2015, an estimated 303 000 women died from pregnancy and childbirth related causes, globally. About 99 percent of maternal and perinatal mortality occur in low and middle-income countries (LMICs) with almost two-thirds occurring in sub-Saharan Africa.

According to the Malawi Demographic Health Survey (MDHS 2015-16), 497 women per 100 000 live births in Malawi died due to pregnancy and childbirth related reasons. Even though this is a significant decline from 1 120 deaths per 100 000 in the year 2000, the figure is high in comparison to other countries in the sub-Saharan region.  As such, Malawi failed to achieve the Millennium Development Goal of reducing maternal mortality rate (MMR) by 75 percent in 2015.

Perhaps the most compelling reason to address most adverse maternal and perinatal outcomes is that with good quality care including antenatal care (ANC) they can be prevented.

In November 2016, the World Health Organisation (WHO) released new comprehensive ANC guidelines for women and adolescent girls. In these guidelines, the WHO recommended increasing the minimum number of ANC visits for women with uncomplicated pregnancies, from four to eight. The first visit must take place in the first trimester (up to 12 weeks of pregnancy) and increased contacts (seven) later in pregnancy up to 40 weeks. Furthermore, the guidelines include 49 pregnancy care recommendations.

Ideally, given the high MMR in Malawi, increasing ANC visits should be a welcome idea. However, the 2016 WHO guidelines are not feasible for Malawi. Here is why: The traditional and more frequent visit model (7-12 visits) of ANC has failed before in most LMICs including Malawi. Many women who attended ANC clinics come only once or twice and sometimes late in pregnancy. It is for this reason that WHO, in 2002, begun promoting the new model of ANC called focused antenatal care (FANC). FANC recommended four ANC visits for women with uncomplicated pregnancies and more for otherwise. It provided goal-oriented and targeted care aimed at increasing the identification and management of complications during pregnancy.

In one of my forthcoming PhD publication, I looked at the impact of the four-visit model on quality and use of ANC services in Malawi. Results showed that FANC was associated with improvement in the quality of ANC, early access and overall reduction in unnecessary visits among women with uncomplicated pregnancies.

Similar results were found in Kenya, Ghana and Thailand. Now the question is, why would WHO recommend going back to the more frequent visit ANC model?

The successful implementation of the new ANC model will require significant investments in human resources, infrastructure, and equipment. For low resourced settings, this is a persistent challenge.

Besides financial resources, the Malawian health system also faces chronic shortages in health workers. This capacity deficiency within the health care system creates a very challenging environment for the new ANC guidelines to be successfully implemented.

According to the MDHS 2015-2016, while over 90 percent of pregnant women who access ANC are served by a skilled healthcare worker at least once, only 52 percent of women received the required minimum number of four visits.

Furthermore, a recent multi-country level study in LMICs showed lower levels of quality ANC service provision even among women who had the minimum number of visits recommended by FANC. The question now becomes, if LMICs struggled to effectively implement the four-visit model, how will they then be able to implement and afford the eight-visit model? There are stakeholders who argue that a possible outcome of the reduced number of visits could be an increase in the number of missed diagnoses or pregnancy complications. Studies in Zimbabwe and Thailand, however, found no significant differences in maternal and perinatal outcomes between the four-visit and the more frequent visit ANC models. The results of these studies indicate that, increasing the number of visits is not the solution. Rather, existing health systems capacity should be strengthened to effectively deliver quality healthcare aligned with existing ANC guidelines.