Antenatal Care: Eight ANC Contacts Protocol
Enhancing the Quality and Continuity of Antenatal Care
Antenatal care (ANC) is a critical component of the maternal, newborn, and child health (MNCH) continuum. It refers to the routine health care provided to pregnant individuals from conception until the onset of labor. ANC plays a vital role in detecting complications early, promoting healthy behaviors, and ensuring both the mother and fetus are monitored and supported throughout pregnancy.
Previously, the World Health Organization (WHO) recommended a four-visit focused antenatal care (FANC) model, but emerging evidence showed that four visits were not sufficient to effectively address the full range of maternal and perinatal health risks. In response, WHO released updated guidelines in 2016 recommending a minimum of eight ANC contacts during pregnancy to improve health outcomes and patient satisfaction.
The Eight ANC Contacts Protocol promotes a more person-centered, evidence-based approach to care. It includes enhanced screening, counseling, and preventive interventions, such as nutritional supplementation, vaccination, mental health support, and screening for infections and pregnancy complications. More frequent contact allows for stronger provider-patient relationships, earlier detection of risks, and timely referrals.
This intervention equips local government leaders, health managers, and frontline healthcare providers with the tools and guidance needed to implement and scale the Eight ANC Contacts model. By adopting this protocol, health systems can offer comprehensive, high-quality, and respectful care that improves maternal and newborn survival and well-being.
What Are the Benefits of the Eight ANC Contacts Protocol?
WHO FANC Model
First Trimester
Visit 1: 8-12 weeks
Second Trimester
Visit 2: 24-26 weeks
Third Trimester
Visit 3: 32 weeks
Visit 4: 35-38 weeks
Return for delivery at 41 weeks if not given birth
2016 WHO ANC Model
Contact 1: up to 12 weeks
Contact 2: 20 weeks
Contact 2: 26 weeks
Contact 4: 30 weeks
Contact 5: 34 weeks
Contact 6: 36 weeks
Contact 7: 38 weeks
Contact 8: 40 weeks
How to Implement
1. Establish a System of Contact
- Implement a system for early registration of pregnant women.
- Establish clear referral pathways for women with high-risk pregnancies.
- Utilize community health workers to identify and register pregnant women.
2. Provide a Package of Essential Services
- Initial Assessment: Comprehensive history taking, physical examination, and risk assessment.
- Laboratory Investigations: Hemoglobin level, blood group, Rh factor, syphilis screening, HIV testing, and urine analysis.
- Nutritional Counseling: Guidance on a balanced diet, iron and folic acid supplementation, and multiple micronutrient supplementation intake.
- Immunization: Tetanus toxoid vaccination.
- Malaria Prevention: Intermittent preventive treatment in malaria-endemic areas.
- Blood Pressure Monitoring: Regular monitoring to detect pre-eclampsia.
- Fetal Monitoring: Assessment of fetal growth and well-being.
- Health Education: Information on danger signs, birth preparedness, and postpartum care.
- Mental Health Screening: Assess for depression and anxiety.
3. Ensure Continuity of Care
- Establish a schedule of ANC visits based on the WHO eight-contact recommended model.
- Maintain accurate and up-to-date records.
- Facilitate smooth transitions between ANC, delivery, and postpartum care.
4. Strengthen Community Engagement
- Involve community leaders and members in promoting ANC services.
- Conduct community outreach activities to raise awareness about the importance of ANC.
- Establish support groups for pregnant women.
5. Pursue Quality Improvement
- Regularly monitor and evaluate the quality of ANC services.
- Conduct audits and reviews to identify areas for improvement.
- Provide ongoing training and support to healthcare workers.
6. Monitor and Strengthen Logistics and Supply Chain
- Ensure constant supply of essential medications and supplies.
- Maintain a system for proper storage and distribution of supplies.
Danger Signs in Pregnancy
Laboratory Investigations
• Vaginal bleeding at any gestation
• Reduced fetal movement
• Draining liquor
• Feeling unwell
• Severe epigastric pain
• Severe headache and blurred vision
• Severe abdominal pain
• Fever
• Convulsions
• Blood group and Rhesus factor
• Hemoglobin level (repeated every trimester)
• Urinalysis (every visit)
• HIV Counseling and Testing (retest at term)
• Syphilis testing (VDRL)
• Blood Sugar (every visit)
• Hepatitis B screening
• TB screening
• Malaria Blood Slide or RDT (based on local epidemiological situation)
Key Indicators
- Proportion of pregnant women who receive at least one ANC contact.
- Proportion of pregnant women who receive the first ANC contact with 12 weeks of gestation.
- Proportion of pregnant women receiving at least eight ANC contacts.
- Percentage of women screened for infections (HIV, syphilis, malaria, tuberculosis).
Recommendations for the Eight Contacts Protocol for ANC
Contact
1
2
3
4
5
6
7
8
Gestation in weeks
0-12 weeks
20 weeks
26 weeks
30 weeks
34 weeks
36 weeks
38 weeks
40 weeks
Interventions
- History taking, mental health assessment, and physical examination
- Vital signs measurements, weight & height measurement
- Baseline laboratory investigations and ANC profile (including HIV counseling and HPV testing)
- *Early obstetric ultrasound - One ultrasound scan before 24 weeks’ gestation is recommended for all pregnant women to:
- estimate gestational age
- detect fetal anomalies and multiple pregnancies
- and enhance the maternal pregnancy experience
- Malaria prevention: Provision of Long Lasting Insecticide treated Net in malaria endemic areas
- Education on danger signs in pregnancy
- Maternal Nutritional assessment and counseling
- Nutritional supplementation- multiple micronutrient supplementation or iron and folic acid for all mothers vitamin D, calcium
- Aspirin 150 mg od (mothers with HTN-to prevent pre-eclampsia /eclampsia up to 36 weeks gestation then stop)
- Breastfeeding counseling
- Counseling on hygiene and common discomforts, minor disorders/symptoms during pregnancy
- Counseling on routine immunization schedule during pregnancy eg; Tetanus toxoid D injection
- Recruitment into the group Antenatal care(GANC)
- Physical examination
- Vital signs measurements, and weight
- *Obstetric ultrasound at 18-20 weeks - One ultrasound scan before 24 weeks’ gestation is recommended for all pregnant women to:
- estimate gestational age
- detect fetal anomalies and multiple pregnancies
- and enhance the maternal pregnancy experience
- Malaria Prevention: Intermittent Preventive Treatment of malaria in pregnancy using Sulfadoxine Pyrimethamine (IPTp - SP) from 13 weeks
- Breastfeeding counseling
- Urinalysis/+/-Midstream urine culture
- Deworming
- Repeat hemoglobin levels
- Screen for Mental Health, intimate Partner Violence and Reproductive Cohesion at every contact
- Discuss Birth preparedness and Partner involvement
- Educate on danger signs in pregnancy
- Physical examination, Abdominal palpation, Fetal assessment and well being
- Vital signs measurements, and weight
- Malaria prevention: IPTp-SP
- ICT (Indirect Coombs Test) for Rh-ve mothers prior to anti-D administration
- Breastfeeding counseling
- Urinalysis and/or Midstream urine culture
- Educate on danger signs
- Physical exam
- Vital signs and weight
- Malaria prevention: IPTp-SP
- Obstetric abdominal examination and fetal assessment
- Lab exam- Repeat HB, blood glucose and Urinalysis/culture
- Breastfeeding counseling
- Prophylactic anti-D at 28 weeks for Rh-ve women
- Educate on danger signs
- Physical examination
- Vital signs measurements including weight
- Rule Out Pre-eclampsia
- Malaria prevention: IPTp-SP
- Clinical examination, obstetric abdominal examination, breast examination and risk assessment
- Urinalysis and/or Midstream urine culture
- Birth preparedness assessment
- Educate on danger signs
- Partner involvement discussion
- Clinical and physical examination, obstetric abdominal examination, fetal assessment and risk assessment
- Birth preparedness advice
- Strengthen partner involvement
- Repeat Hemoglobin levels
- Obstetric ultrasound
- Educate mother on essential newborn care
- Urinalysis
- Educate on danger signs
- Physical examination
- Abdominal palpation and fetal assessment
- Malaria prevention: IPTp-SP
- Vital signs measurements including weight
- Rule out Pre-eclampsia
- Urinalysis/urine culture
- Repeat hemoglobin/ Full Blood Count
- HIV test (if previously negative)
- Blood glucose
- Breastfeeding counseling
- Educate on danger signs
- Educate mother on essential newborn care
- Review birth plan and preparedness
- Discuss Birth Spacing and Postpartum FP counselling
- Clinical and physical examination; obstetric abdominal examination and risk assessment
- Birth preparedness
- Counsel on signs of true labor, exercise
- Postpartum Family Planning counselling
- Educate mother on essential newborn care
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Tips
- Person-Centered Care: Provide respectful and culturally sensitive care.
- Effective Communication: Build rapport with pregnant women and their families.
- Empowerment: Empower women to make informed decisions about their health.
- Collaboration: Foster collaboration between healthcare workers, community health workers, and other stakeholders.
- Utilize Technology: Use mobile health (mHealth) tools to improve access to information, follow-ups, and services.
- Focus on Equity: Ensure that ANC services are accessible to all pregnant women, regardless of their socioeconomic status.
- Continuous Training: Regularly update healthcare workers on the latest evidence-based practices.
Challenges
- Limited Access to Services: Geographical barriers, financial constraints, and cultural factors can limit access to ANC.
- Shortage of Skilled Healthcare Workers: A lack of trained healthcare workers can compromise the quality of ANC.
- Inadequate Infrastructure: Poor infrastructure can hinder the delivery of essential services.
- Cultural Beliefs and Practices: Harmful cultural beliefs and practices can affect women's health-seeking behavior.
- Lack of Resources: Insufficient funding and resources can limit the availability of essential supplies and services.
- Low Community Awareness: Lack of understanding of the importance of ANC.