oedema compared with other, no or placebo interventions (EB Table D.6)
The evidence on the effects of various interventions for varicose veins in pregnancy was derived from a Cochrane review that included seven small trials involving 326 women with varicose veins and/or oedema, and various types of interventions, including rutoside (a phlebotonic drug) versus placebo (two trials), foot massage by a professional masseur for five days versus no intervention (1 trial, 80 women), intermittent external pneumatic compression with a pump versus rest (1 trial, 35 women), standing in water at a temperature between 29°C and 33°C for 20 minutes (water immersion) versus leg elevation (1 trial, 32 women) and reflexology versus rest (1 trial, 55 women) (160). Another trial comparing compression stockings with rest in the left lateral position did not contribute any data. Fetal and neonatal outcomes relevant to the ANC guideline were not reported in these studies.
Pharmacological interventions versus placebo or no intervention
Only one small trial conducted in 1975 (69 women) contributed data. Low-certainty evidence from this
trial suggests that rutoside may reduce symptoms (nocturnal cramps, paraesthesia, tiredness) associated with varicose veins compared with placebo (69 women; RR: 1.89, 95% CI: 1.11–3.22).
However, no side-effect data were reported.
Non-pharmacological interventions versus placebo or no intervention
Low-certainty evidence suggests that reflexology may reduce oedema symptoms compared with rest only (55 women; RR: 9.09, 95% CI: 1.41–58.54) and that water immersion may reduce oedema symptoms (leg volume) compared with leg elevation (32 women; RR: 0.43, 95% CI: 0.22–0.83). Low-certainty evidence suggests that there may be little or no difference in oedema symptoms (measured as lower leg circumference in centimetres) between foot massage and no intervention (80 women; MD in cm: 0.11 less, 95% CI: 1.02 less to 0.80 more) and between intermittent pneumatic compression and rest (measured as mean leg volume, unit of analysis unclear) (35 women; MD: 258.8lower, 95% CI: 566.91 lower to 49.31 higher). Only one study (reflexology versus rest) evaluated women’s satisfaction, but the evidence is of very low certainty.
WHO recommendations on antenatal care for a positive pregnancy experience
Additional considerations n
n Compression stockings combined with leg elevation is the most common non-surgical management for varicose veins and oedema;
however, the Cochrane review found no evidence on this practice in pregnancy (160). Compression stockings are also widely used to prevent morbidity in non-pregnant people with varicose veins and the evidence for this practice in a related Cochrane review of compression stockings was generally very uncertain (167).
Values
See “Women’s values” at the beginning of section 3.D: Background (p. 74).
Resources
Postural interventions are low-cost interventions.
The cost of compression stockings varies but they can cost more than US$ 15 per pair. Reflexology and professional massage require specialist training, and are, therefore, likely to be more costly.
Equity
It is not known whether interventions to relieve varicose veins and oedema might impact inequalities.
Acceptability
Qualitative evidence from a range of LMICs suggests that women may be more likely to turn to traditional healers, herbal remedies or TBAs to treat these symptoms (moderate confidence in the evidence) (22). In addition, evidence from a diverse range of settings indicates that while women generally appreciate the interventions and information provided during antenatal visits, they are less likely to engage with services if their beliefs, traditions and socioeconomic circumstances are ignored or overlooked by health-care providers and/or policy-makers (high confidence in the evidence). This may be particularly pertinent for an intervention like reflexology, which may be culturally alien and/or poorly understood in certain contexts. Qualitative evidence shows that, where there are likely to be additional costs associated with treatment or where the treatment may be unavailable (because of resource constraints), women are less likely to engage with health services (high confidence in the evidence).
Feasibility
The evidence also suggests that a lack of resources may limit the offer of treatment for varicose veins and oedema (high confidence in the evidence) (45).
E. Health systems interventions to improve the utilization and quality of ANC
Background
There is a multitude of interventions that can be employed to improve the utilization and quality of ANC depending on the context and setting. For the purposes of this guideline, the GDG considered the following interventions:
1. Women-held case notes (home-based records) 2. Midwife-led continuity of care models
3. Group ANC
4. Community-based interventions to improve communication and support
5. Task shifting
6. Recruitment and retention of staff 7. ANC contact schedules.
How to deliver the type and quality of ANC that women want is a vast and complex field of research.
Interventions designed to increase staff competency, to improve staff well-being, and other interventions (e.g. financial incentives) to increase access and use of ANC are broad topics that were considered beyond the scope of this guideline.
n
n Women-held case notes: In many countries, women are given their own case notes (or home-based records) to carry during pregnancy. Case notes may be held in paper (e.g. card, journal, handbook) or electronic formats (e.g. memory stick), and women are expected to take them along to all health visits. If women then move, or are referred from one facility to another, and in the case of complications where immediate access to medical records is not always possible, the practice of women-held case notes may improve the availability of women’s medical records (168). Women-held case notes might also be an effective tool to improve health awareness and client–provider communication (169). Inadequate infrastructure and resources often hamper efficient record-keeping, therefore, case notes may be less likely to get lost when held personally. In addition, the practice may facilitate more accurate
estimation of gestational age, which is integral to evidence-based decision-making, due to improved continuity of fetal growth records (170).
n
n Midwife-led continuity of care (MLCC) models:
Midwives are the primary providers of care in many ANC settings (171). In MLCC models, a known and trusted midwife (caseload midwifery), or small group of known midwives (team
midwifery), supports a woman throughout the antenatal, intrapartum and postnatal period, to facilitate a healthy pregnancy and childbirth, and healthy parenting practices (172). The MLCC model includes: continuity of care; monitoring the physical, psychological, spiritual and social well-being of the woman and family throughout the childbearing cycle; providing the woman with individualized education, counselling and ANC;
attendance during labour, birth and the immediate postpartum period by a known midwife; ongoing support during the postnatal period; minimizing unnecessary technological interventions; and identifying, referring and coordinating care for women who require obstetric or other specialist attention (173). Thus, the MLCC model exists within a multidisciplinary network in which consultation and referral to other care providers occurs when necessary. The MLCC model is usually aimed at providing care to healthy women with uncomplicated pregnancies.
n
n Group ANC: ANC conventionally takes the form of a one-on-one consultation between a pregnant woman and her health-care provider. However, group ANC integrates the usual individual pregnancy health assessment with tailored group educational activities and peer support, with the aim of motivating behaviour change among pregnant women, improving pregnancy outcomes, and increasing women’s satisfaction (174). The intervention typically involves self-assessment activities (e.g. blood pressure measurement), group education with facilitated discussion, and
WHO recommendations on antenatal care for a positive pregnancy experience
time to socialize. Group ANC needs to be delivered in a space large enough to accommodate a group of women, with a private area for examinations.
n
n Community-based interventions to improve communication and support: The scoping review conducted for the ANC guideline identified communication and support for women as integral components of positive pregnancy experiences. The term “communicate” refers to the act of sharing information, education and communication with women about timely and relevant physiological, biomedical, behavioural and sociocultural issues; “support” refers to social, cultural, emotional and psychological support (13).
Having access to appropriate communication and support is a key element of a quality ANC service.
A human-rights-based approach recognizes that women are entitled to participate in decisions that affect their sexual and reproductive health (1). In addition, pregnant women have a right to access quality health-care services and, particularly in low-resource settings, may need to be empowered to do so. Interventions that increase the dialogue around awareness of a women’s rights, barriers and facilitators to utilizing ANC rvices and keeping healthy during pregnancy and beyond (including dialogue around newborn care and postnatal family planning), and providing women and their partners with support in addressing challenges they may face, may lead to improved ANC uptake and quality of care.
n
n ANC contact schedules: In 2002, the WHO recommended a focused or goal-orientated approach to ANC to improve quality of care and
increase ANC coverage, particularly in LMICs (12).
The focused ANC (FANC) model, also known as the basic ANC model, includes four ANC visits occurring between 8 and 12 weeks of gestation, between 24 and 26 weeks, at 32 weeks, and between 36 and 38 weeks. Guidance on each visit includes specific evidence-based interventions for healthy pregnant women (called “goal-oriented”), with appropriate referral of high-risk women and those who develop pregnancy complications. The number of visits in this model is considerably fewer than in ANC models used in HICs.
The GDG considered the available evidence and other relevant information on these interventions to determine whether they should be recommended for ANC (Recommendations E1 to E5). The GDG also considered existing recommendations from other WHO guidelines on task shifting and recruitment and retention of staff in rural areas (Recommendations E5 and E6).
Women’s values
A scoping review of what women want from ANC and what outcomes they value informed the ANC guideline (13). Evidence showed that women from high-, medium- and low-resource settings valued having a positive pregnancy experience. Within a health systems context, this included the adoption of flexible appointment systems and continuity of provider care where women were given privacy and time to build authentic and supportive relationships with maternity-care providers (high confidence in the evidence).
E.1: Women-held case notes
RECOMMENDATION E.1: It is recommended that each pregnant woman carries her own case notes during pregnancy to improve continuity, quality of care and her pregnancy experience.
(Recommended)
Remarks
• The GDG noted that women-held case notes are widely used and are often the only medical records available in various LMIC settings.
• The GDG agreed that the benefits of women-held case notes outweigh the disadvantages. However, careful consideration should be given as to what personal information it is necessary to include in the case notes, to avoid stigma and discrimination in certain settings. In addition, health-system planners should ensure that admission to hospitals or other health-care facilities do not depend on women presenting their case notes.
• Health-system planners should consider which form the women-held case notes should take (electronic or paper-based), whether whole sets of case notes will be held by women or only specific parts of them, and how copies will be kept by health-care facilities.
• For paper-based systems, health-system planners also need to ensure that case notes are durable and transportable. Health systems that give women access to their case notes through electronic systems need to ensure that all pregnant women have access to the appropriate technology and that attention is paid to data security.
• Health-system planners should ensure that the contents of the case notes are accessible to all pregnant women through the use of appropriate, local languages and appropriate reading levels.