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Focused Antenatal care (FANC)
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What is FANC?
 Is health care given to a pregnant woman from conception to
the onset of labour.
 It is personalised care provided to a pregnant woman which
emphasises on the woman’s overall health, her preparation for
childbirth and readiness for complications (emergency
preparedness).
 It is timely, friendly, simple and safe service to a pregnant
woman.
©MOH-DRH/DOMC/NLTP/JHPIEGO
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AIM OF FANC
 To achieve a good outcome for the mother
and baby and prevent any complications
that may occur in pregnancy, labour,
delivery and the post partum period.
©MOH-DRH/DOMC/NLTP/JHPIEGO
The approach:
3
The risk approach to ANC has not resulted in significant
improvement in maternal survival. Life threatening
Complications of pregnancy are difficult to predict with
any degree of certainty. Health care providers must,
therefore, consider the possibility of complications in
every pregnancy and prepare clients accordingly.
While risk assessment can help direct counseling and
treatment for individuals, it is important to understand that
most women who experience complications have no ‘risk
factors’ at all.
©MOH-DRH/DOMC/NLTP/JHPIEGO
4
Every pregnant, delivering or postpartum woman is
at risk of serious life threatening complications!
©MOH-DRH/DOMC/NLTP/JHPIEGO
Four comprehensive,
personalized antenatal visits:
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1 S T V I S I T: < 1 6 W E E K S
2 N D V I S I T: 1 6 - 2 8 W E E K S
3 R D V I S I T: 2 8 - 3 2 W E E K S
4 T H V I S I T: 3 2 - 4 0 W E E K S
NB: DEPENDING ON INDIVIDUAL NEED, SOME WOMEN WILL
REQUIRE ADDITIONAL VISITS.
Objectives of Focused Antenatal Care
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 Early detection and treatment of problems
 Prevention of complications using safe, simple and cost-
effective interventions
 Birth preparedness and complication readiness
 Health promotion using health messages and
counseling
 Provision of care by a skilled attendant
©MOH-DRH/DOMC/NLTP/JHPIEGO
Objective one: Early detection and treatment of Problems
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 Service providers should identify existing medical, surgical or
obstetric conditions during pregnancy. Such as:
– Severe anaemia (Hb <7gm/dl)
– Vaginal bleeding
– Pre-eclampsia (increased BP, severe oedema)
– STI’s, HIV/AIDS, TB and Malaria
– Chronic diseases (diabetes, heart or kidney problems)
– Decreased/absent foetal movement;
– foetal malpresentation after 36 weeks
©MOH-DRH/DOMC/NLTP/JHPIEGO
Why disease detection and not risk assessment?
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 Risk approach is not an efficient or effective strategy for
maternal mortality reduction.
 Every pregnancy is at risk!
– Risk factors cannot predict complications: (e.g.
young age does not predict eclampsia).
– Research showed that the majority of women
who experienced complications were considered
low risk (90% of women considered to be high
risk, gave birth without experiencing a
complication).
©MOH-DRH/DOMC/NLTP/JHPIEGO
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Why disease detection and not risk assessment cont…..
 Risk factors do not predict problems. Most high risk women
deliver without problems and most women who develop lifethreatening complications belong to the low risk group.
 Every pregnant woman should be prepared for the
possibility of complications.
©MOH-DRH/DOMC/NLTP/JHPIEGO
Objective two: Prevention of complications
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The service provider should ensure prevention/protection of
complications by providing:
 Tetanus toxoid to prevent maternal and neonatal tetanus
 Iron/folate supplementation to prevent anaemia
 Use of IPT and ITNS to prevent malaria/ anaemia
 Ensure environmental hygiene to prevent intestinal worms
 Presumptive treatment of hookworm infection with
Mebendazole 500mg STAT anytime after the first trimester*
*Basic Maternal and Newborn Care: A Guide to Skilled
Providers, Page 3-58
©MOH-DRH/DOMC/NLTP/JHPIEGO
Objective three: Birth preparedness and complications
readiness
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Service providers should discuss components of birth plan which
include:
 Is the EDD known?
 Has a facility been identified?
 Has a SBA/professional been identified?
 Has a means of Transport been identified?
 Are emergency Funds identified?
 Who is the custodian of the emergency funds?
 Has a Birth companion been identified?
 Are Items for clean safe©MOH-DRH/DOMC/NLTP/JHPIEGO
birth and for the newborn been
identified?
Objective three cont…Complication Readiness
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 Knowledge of danger signs; what to do if
they arise
 Has a decision maker been identified?
 Has a Blood donor been identified?
©MOH-DRH/DOMC/NLTP/JHPIEGO
Individual birth plan ensures that the client:
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Knows when her baby is due
Identifies a skilled birth attendant
Identifies a health facility for delivery/emergency
Can list danger signs in pregnancy and delivery and
knows what to do if they occur
Identifies a decision-maker in case of emergency
Knows how to get money in case of emergency
Has a transport plan in case of emergency
Has a birth partner/companion for the birth
Has collected the basic supplies for the birth
©MOH-DRH/DOMC/NLTP/JHPIEGO
Danger signs in pregnancy
 Any vaginal bleeding in pregnancy( APH,
Abortion)
 Severe headache or blurred vision (high blood
pressure, eclampsia)
 Swelling on the face and hands (high blood pressure,
eclampsia)
 Convulsions or fits (high blood pressure, eclampsia)
 High fever ( infection)
 Drainage of liqour
 Laboured breathing ( pneumonia, heart problems,
severe anemia)
 Premature labour pains
 Noticed that the baby is moving less or not moving
©MOH-DRH/DOMC/NLTP/JHPIEGO
at all (fetal distress,
IUD ).
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Other danger signs in pregnancy
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 Feeling very weak or tired (anemia, severe disease, multiple
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pregnancy)
Vaginal discharge (STI)
Abdominal pain (STI, early labor)
Genital ulcers (STI)
Painful urination (STI)
Persistent vomiting( severe malaria etc)
©MOH-DRH/DOMC/NLTP/JHPIEGO
Danger signs in labour:
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 Labour pains for more than 12 hrs (sun rise to sunset)
 Excessive bleeding
 Ruptured membranes without labour for more than 12 hrs
 Convulsions during labour
 Loss of consciousness
 Cord, arm or leg prolapse
©MOH-DRH/DOMC/NLTP/JHPIEGO
Danger signs in postpartum period (Mother):
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 Excessive bleeding
 Fever
 Foul smelling discharge
 Abdominal cramps or pains
 Painful breasts or cracked nipples
 Mental disturbances
 Extreme fatigue
 Facial or hand swelling
 Headaches
 Convulsions
 Painful calf muscles
©MOH-DRH/DOMC/NLTP/JHPIEGO
Danger signs in postpartum period
 Fast breathing(more than 6018breaths/minute)
 Slow breathing less than 30 breaths/minute
 Severe chest in-drawing
 Grunting
 Umbilicus draining pus/redness extending to skin
 Floppy or stiff
 Fever (temp 38 degrees celsius and above
 Convulsions
 More than 10 skin pustules
 Bleeding from stump/cut
©MOH-DRH/DOMC/NLTP/JHPIEGO
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Give advice on whom to call or where to go
in case of the above
complications/emergencies.
©MOH-DRH/DOMC/NLTP/JHPIEGO
Objective four: Health promotion using health messages and
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counseling
Encourage dialogue on the following:
 Nutrition
 Rest and hygiene
 Safer sex
 Care for common
discomforts
 Use of IPT and
ITNs/LLINs
 Drug compliance
 Family planning/ health
timing and spacing of
pregnancy
 Early and exclusive
Breastfeeding
 Newborn care
©MOH-DRH/DOMC/NLTP/JHPIEGO
Maintain the woman’s health and survival through:
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Health education and counselling on:
 Danger signs in pregnancy
 Adequate nutrition and hydration
 Early and exclusive breastfeeding
 Prevention and treatment of sexually transmitted infections
(STIs) and worm infestation
 Avoidance of alcohol and tobacco
 Individual Birth Plan (IBP)
 Complication readiness plan
©MOH-DRH/DOMC/NLTP/JHPIEGO
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To come to postpartum clinic :Immediately,48hours, 2
weeks, at 6 weeks,6months and one year.
To visit well baby clinic (MCH/FP Clinic) for
immunizations
Follow up for exposed babies to TB and HIV.
To chose a postpartum family planning method:
- LAM (exclusive breastfeeding)
- Progesterone only pills
- Condoms
- Post partum IUCD
- feeding options
©MOH-DRH/DOMC/NLTP/JHPIEGO
Teach mothers about the importance of
immunizations: 23
 Inform her about the first-year immunization schedule to protect
children from TB, polio, tetanus, diphtheria, pertussis, hepatitis B
and measles.
 Immunize baby with BCG, HBV, OPV birth dose before the
mother leaves the health facility.
 Ensure all babies delivered at home are taken to the health facility
for immunization.
©MOH-DRH/DOMC/NLTP/JHPIEGO
National guidelines for IPT
 IPT is an effective approach to preventing malaria in
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pregnant women by giving anti
malarial drugs in treatment
doses at defined intervals after quickening to clear a
presumed burden of parasites
 The MOH Guidelines on Malaria directs us to give SP to
pregnant women in endemic malaria areas, at least twice
during each pregnancy, even if she has no physical signs
and her hemoglobin is within normal range.
 Administer IPT with each scheduled visit after quickening
(16 wks) to ensure women receive at least 2 doses at an
interval of at least 4 weeks.
 IPT should be given under Directly Observed Therapy
(DOT) in the ANC and ©MOH-DRH/DOMC/NLTP/JHPIEGO
can be given on an empty stomach.
National guidelines for Tetanus toxoid
Dose of TT When to give
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1
At first contact or as early as possible in pregnancy
2
At least 4 wks after TT1
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At least 6 months after TT2 or during subsequent
pregnancy
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At least 1 yr after TT3 or during subsequent
pregnancy
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At least 1 yr after TT4 or during subsequent
pregnancy
©MOH-DRH/DOMC/NLTP/JHPIEGO
Objective 5: Provision of Skilled Care at Birth
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 Currently only 41% of pregnant
women receive skilled care at
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birth
By 2015, it is expected that three quarters of pregnant women
should receive skilled care at birth
A skilled attendant offers services either at the health facility
or within the community (domiciliary practice)
FANC provides an opportunity to increase skilled care
Brainstorm strategies in your catchment area in support of
increased skilled care
©MOH-DRH/DOMC/NLTP/JHPIEGO
During FANC visits, ensure that the following have
been accomplished
History taking:

Current complaints/identify danger
signs
Dietary history
Tetanus vaccination status
Reproductive history
History of medical illness e.g. TB
27Provide:
 Iron, folate , IPT*(SP is the currently
recommended) tetanus toxoid and
Nevirapine if recommended
Counselling on:
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 Danger signs
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 Individual birth plan (IBP)
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 Complication readiness
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 Nutrition, breastfeeding, family
Physical exam:
planning, safer sex, hygiene, etc.
 Physical assessment of general health
 PMTCT
 Return date
 Swollen glands
ANC Profile
 Genital inspection, including sexually
Most of the lab work should be done
transmitted infections
during the first visit
 Check for blood pressure, edema and
 Sputum for AFB
proteinuria to rule out pre-eclampsia
 Urinalysis
 Check for anaemia
 Hb, grouping and Rh factor
 Check baby’s growth
 VDRL/RPR
 Sickle cell, Stool and Hepatitis B
©MOH-DRH/DOMC/NLTP/JHPIEGO
(if indicated)
The role of fathers in antenatal care
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MANY MEN ARE UNCERTAIN
ABOUT HOW THEY CAN
CONTRIBUTE TO A WOMAN’S
HEALTHY PREGNANCY
Service providers should educate fathers about antenatal care
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 Fathers should make sure that the woman:
– has enough nutritious food to eat and that she has taken iron and folate
tablets.
– is sleeping under a treated net and is able to get plenty of rest.
– has had 2 doses of SP and tetanus toxoid.
 Make sure that the couple has an individual birth plan.
 Make sure that the couple know the danger signs in
pregnancy and labour.
©MOH-DRH/DOMC/NLTP/JHPIEGO
Adolescents and pregnancy
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 In Kenya, 17-18% of all births
are to women under the age
of 20 years*
 Pregnant youth are entitled to the same quality of care that
older women are
 Research has shown that adolescents tend to delay seeking
care due to social and cultural practices and as such more
attention should be directed to them
 Services should be provided in an acceptable, nonjudgmental manner, convenient and offer confidentiality to
the adolescents.
 Note: This will encourage the young women to return for
continued antenatal services.
©MOH-DRH/DOMC/NLTP/JHPIEGO
*KDHS 1998/2003
31 adolescents /youth on..
Reinforce counseling to the
 Peer influence
 Early ANC attendance
 Safer sex (ABCD)
 Drug abuse
 STI, HIV/AIDS/TB
 Family Planning
 Dangers of abortion
©MOH-DRH/DOMC/NLTP/JHPIEGO
Before the woman leaves your clinic, STOP and ask her if she:
 Has a supply of iron and folate tablets.
 Has taken her SP and has had her tetanus toxoid
injection.
 Knows the danger signs in pregnancy and child
birth.
 Knows her appointment for the next ANC visit
and SP dose.
 Has an individual birth plan.
 Has been screened for TB
 Knows the importance of using postpartum
family planning.
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©MOH-DRH/DOMC/NLTP/JHPIEGO
Integrated FANC Services
TB
FANC
STIs
PMTCT
LAB
MALARIA
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CCC
What is Tuberculosis (TB)? 34
 Tuberculosis is a chronic infectious disease caused by an organism
called mycobacterium tuberculosis, an acid fast rod shaped bacilli.
– Over 90% of new TB cases and deaths occur in developing countries
 TB is one of the leading infections causing of deaths among women
of reproductive age
 TB has increased by 10 fold over the last 15 years in Kenya
©MOH-DRH/DOMC/NLTP/JHPIEGO
Factors leading to the increase in TB
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 HIV epidemic
 Poverty
 Overcrowding
 Poor nutrition
 Limited access to health services
 Chronic diseases e.g. Diabetes,
carcinoma etc
 Immune suppressing therapy
©MOH-DRH/DOMC/NLTP/JHPIEGO
Risk of TB infection
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The risk of one being infected with the TB bacillus depends on:
 Exposure to bacilli
 Intensity of exposure
 Duration of exposure
 Presence of undetected smear positive TB
 Presence of poorly treated previous TB
©MOH-DRH/DOMC/NLTP/JHPIEGO
Types of Tuberculosis
 Pulmonary Tuberculosis (PTB)
37 is the most common and
infectious type of TB.
– It affects the lungs and causes 81% of all TB cases in Kenya
• Extra Pulmonary Tuberculosis (outside of the lungs) any organ of the body
–
–
such as the kidney, bladder, ovaries, testes, eyes, bones or joints, intestines, skin
or glands, and the meninges i.e. TB meningitis
The most common extra pulmonary TB is TB of the glands also called TB
lymphadenitis
The most severe extra pulmonary TB is pleural effusion and meningitis.
©MOH-DRH/DOMC/NLTP/JHPIEGO
Signs and Symptoms of Pulmonary
Tuberculosis (PTB)
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 Persistent cough lasting for two or more weeks with or
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without blood stained sputum
Loss of body weight
Intermittent fever
Excessive night sweats
Shortness of breath
Loss of appetite
Chest pain
Excessive tiredness and generally feeling unwell
©MOH-DRH/DOMC/NLTP/JHPIEGO
Signs and symptoms of TB of the
glands (TB lymphadenitis*)
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 Slow and painless enlargement of the lymph nodes which
then become matted and eventually discharge pus
 The most common lymph nodes: cervical (neck) lymph
nodes
 Generalised lymph node enlargement is becoming common
in HIV related TB
*Confirmed during head-to-toe examination
©MOH-DRH/DOMC/NLTP/JHPIEGO
When does TB pass from the40mother to the baby?
Pregnant women who are infected with TB can pass TB to the
baby:
 During pregnancy through the placenta barrier
causing fetal death or infection (congenital TB is
rare)
 At birth when the baby inhales or ingests infected
amniotic fluid or secretions
 After delivery when the baby inhales droplet
secretions if the mother is coughing-commonest
©MOH-DRH/DOMC/NLTP/JHPIEGO
TB affects the health of a pregnant
woman and her baby
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TB in a pregnant woman can lead to:
 Premature birth of the baby
 Low birth weight or small baby for dates
 Death of baby in the uterus
 Infecting the baby with TB
 Increased newborn deaths
©MOH-DRH/DOMC/NLTP/JHPIEGO
Screening for TB
 Ask every mother at every ANC/PNC visit the following
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questions:
symptom
YE
S
1. Have you had a persistent cough with or
without sputum for more than two weeks?
2. Have you experienced excessive sweating or
fever at night?
3. Have you lost any weight?
4. Do you have any chest pain?
5. Have you been in contact with any one who has
TB?
6. Do you have any swollen glands?
(Confirm during physical examination)
©MOH-DRH/DOMC/NLTP/JHPIEGO
NO
Investigations
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 Smear positive TB cases are the most infectious both to the
new born and other children in the household
 These are diagnosed through sputum examination
 Smear negative cases and Extra-pulmonary are diagnosed
through history, physical examination, radiography and
histology
©MOH-DRH/DOMC/NLTP/JHPIEGO
Why integration…TB/FANC
 Since the onset of the HIV epidemic in the early
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eighties in Kenya, the prevalence of TB has risen
sharply
 HIV increases the likelihood of developing tuberculosis
 Pregnancy also increases the risk of developing TB
 TB is the major opportunistic infection in HIV and the
leading killer of PLWHA
 More than 50% of TB clients in Kenya are also HIV
positive
 At least one out of eight of HIV+ pregnant women
could also have TB*
*USAID Bureau for Africa, 2000
©MOH-DRH/DOMC/NLTP/JHPIEGO
Integration of HIV, TB and malaria interventions into MCH
services:
 Ensures that women receive targeted care according to
their needs with appropriate linkages and referral
structures are in place
 Involves the reorganization and re-orientation of health
systems to ensure the delivery of a set of interventions
or targeted package as part of the continuum of care
 Involves integrated procurement of commodities
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Integration addresses structural , managerial and
operational issues at all levels of the health system
in order to:
 Create effective coordination mechanisms between
departments, programs and other stakeholders
 Support integrated training and capacity planning,
management and joint supervision
 Harmonize efforts to support targeted service delivery
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Intensified TB case finding
in FANC
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 All pregnant women should be screened for TB
 Pregnant women suspected to have TB should have their
sputum collected and tested for TB
 Pregnant women found to have TB should be referred to
the TB clinic for treatment
NB: Negative Sputum result does not exclude TB!
©MOH-DRH/DOMC/NLTP/JHPIEGO

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Symptoms
of TB ?
 C (Coughing)
 W (Weight loss)
 F (Fever)
 N (Night sweats)
 G (enlarged Glands)
©MOH-DRH/DOMC/NLTP/JHPIEGO
Refer to Lab:
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 If the pregnant woman has a cough for two weeks or
more, explain that three specimens of her sputum must
be collected to help confirm the presence or absence of
TB
 Explain that testing and treatment for TB is free
©MOH-DRH/DOMC/NLTP/JHPIEGO
Collection of sputum specimen: laboratory
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 Ask the pregnant woman to cough deeply to produce
sputum in an open place
 Ensure that nobody is standing nearby during the
cough
 Avoid contaminating the outside of the container
with sputum
 Ensure that an adequate amount of sputum is
collected in the specimen pot
©MOH-DRH/DOMC/NLTP/JHPIEGO
PTB confirmation is based on 3 sputum specimens
collected within a 24-hour period
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 3 specimens are collected and
examined by direct smear for
acid fast bacilli (AFB)
 “Spot” refers to a specimen
obtained right there in the
clinic
 The process goes: SMS
Spot
Morning plus
Spot
 #1 specimen at the lab, or “on the
spot”
Provide container for next
day home collection
 #2 early morning the following
day client brings to Lab
 #3 specimen “spot” at the Lab
right after she drops off the one
from home
©MOH-DRH/DOMC/NLTP/JHPIEGO
Refer to TB clinic:
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 Explain that TB can be treated over a 6-8 month period and the
drugs are safe to use during pregnancy and breastfeeding
 If the sputum is positive
– Send the woman to the TB clinic directly
– Document the positive results in the register
 If the sputum is negative, but the woman is symptomatic, send
her to the TB clinic anyway
– Note: Negative smear test for TB does NOT exclude TB
– Explain that after delivery, barrier methods of family planning are necessary
as some TB drugs interfere with the absorption of hormonal contraceptives.
©MOH-DRH/DOMC/NLTP/JHPIEGO
TB treatment
 If a pregnant woman is confirmed to have TB the treatment
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will last 6-8 months :
 Intensive phase (2 months):
– Ethambutol (E) , Rifampicin ( R ), Isoniazid (H) and Pyrazinamide (Z)
Continuation phase (4-6 months)*
– Rifampicin (R) and Isoniazid (H) (4 months)
– Ethambutol (E) and Isoniazid (H) (6 Months)
 For pregnant women who are HIV+ and also have TB, the
TB treatment should be continued and client referred to the
CCC
 All co-infected patients HIV and TB should be started on
cotrimoxazole prophylaxis as it reduces mortality
*Which regimen are you using in your district
©MOH-DRH/DOMC/NLTP/JHPIEGO
What is DOT
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 DOT: Directly Observed Treatment
 Initial Phase: the first two months of TB treatment should
be administered under direct observation of either a health
worker in the facility or a member of the household or
community
 If client is too sick or observed treatment not possible the
client should be admitted to hospital
 Continuation phase: the client collects a supply four
weekly for daily self administration at home.
©MOH-DRH/DOMC/NLTP/JHPIEGO
55
What can be done to support TB control
 Adhere to the national TB control program guidelines for
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case detection, definition and management.
Provide health education for the community.
Encourage symptomatic women to come for TB testing and
treatment.
Provide counseling support so that they will complete their
treatment.
Develop a system for supervising community health workers
assisting health care providers to track and monitor treatment
compliance.
Keep accurate records. ©MOH-DRH/DOMC/NLTP/JHPIEGO
56
Follow-up visits:
 At each subsequent FANC visit the HCW inquires about TB
treatment progress, looks for TB clinic information and
documents, updates in the register
 Continue follow-up into the post natal period
©MOH-DRH/DOMC/NLTP/JHPIEGO
57
At the post partum visit
 Ask the postpartum mother if contact invitation has been
initiated
 Ask if newborn and others have been assessed and treated
for TB
 Is she still taking medications?
 Document information in record
 Explain that barrier methods of family planning are
necessary as some TB drugs interfere with the absorption
©MOH-DRH/DOMC/NLTP/JHPIEGO
of hormonal contraceptives
TB and the newborn
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 If a mother has TB and has started treatment 2 months or more
before the due date, she should have 2 sputum smear tests done
before the birth.
 If she is sputum smear negative just before delivery then she is
non-infectious and the infant does not need prophylaxis and
BCG is given at birth
 If she is sputum smear positive then the newborn must receive
daily isoniazid (5mg/kg) for 3 months and if the mothers
sputum is negative and mantoux test is non reactive (<5mm)
then isoniazid should be stopped and BCG given (3 days after
prophylaxis treatment has stopped)
©MOH-DRH/DOMC/NLTP/JHPIEGO
59
TB and newborn/child care
 If the Mantoux test is reactive (>5mm) after 3 months on
Isoniazid, then Isoniazid should be continued for another 3
months
 Breast feeding women on INH should also include diet rich
in Vitamin B6
 Any other child under five years old living in the same
household must also be given isoniazid prophylaxis if
mother is smear positive and child does not have active TB
INH given for 6 months
©MOH-DRH/DOMC/NLTP/JHPIEGO
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Integrated care model for pregnant woman
Integrated FANC Clinic
PMTCT/ other interventions e.g. MIP
Referral 2
Laboratory
©MOH-DRH/DOMC/NLTP/JHPIEGO
TB Clinic
Drug Interactions
Interacting TB Drug
drug
Streptomycin
Nevirapine
Rifampicin
Effect of interaction
In pregnancy it
causes deafness to
the unborn baby
Lowers blood levels of
Nevirapine
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Management
recommendation
Avoid in
pregnancy
Refer to/Consult
CCC
62
Caution
 If a client is on Anti-TB drugs, anti-convulsants and/or
antiretrovirals, the interactions between these drugs and
hormonal contraceptives may lower the effectiveness of the
latter. Barrier methods are preferred
©MOH-DRH/DOMC/NLTP/JHPIEGO
Treatment:
63
 The following drug regimens are used in Kenya:
For new TB case(Previously untreated):
- 2RHZE/4RH
2. For retreatment TB cases
- 3RHZE/5RHE
NB: R – Rifampicin
H – Isoniazid
Z – Pyrazinamide
E - Ethambutol
1.
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