By Pisake Lumbiganon, Faculty of Medicine, Khon Kaen University
Background
Theoretically antenatal care (ANC) should promote good pregnancy outcomes and reduce maternal and perinatal mortality and morbidity. In 1972 Archie Cochrane, the father of evidence-based medicine, highlighted the need to study ANC through randomized control trials when he said, “By some curious chance, antenatal care has escaped the critical assessment to which most screening procedures have been subjected.”
From 1996 to 1999 the World Health Organisation (WHO) conducted a multicentre cluster randomized trial in 53 clinics in Argentina, Cuba, Saudi Arabia and Thailand involving over 24,000 pregnant women. The main objectives of the study were to evaluate the effectiveness, cost and satisfaction of a new WHO model for ANC. The results of this study were published in tandem with a WHO systematic review of routine antenatal care. The WHO concluded that the new WHO model for ANC—or Focused ANC (FANC), a model with a reduced number of visits—posed little to no risk to mother and baby and cost less. Since 2002, this has been the WHO-recommended model for ANC.
Implementation in Thailand
As investigators in the WHO trial, my colleagues and I developed Thailand’s implementation plan for FANC. As the principle investigator from Khon Kaen University, I invited investigators from provincial health offices and health promotion centers who were potential users of the research results. At the national level, we informed authorities from the Division of Health Promotion and the Department of Health (DOH) at the Ministry of Public Health (MOPH) of the research.
In 2004, we did a pilot implementation of FANC in all 24 MOPH hospitals throughout Khon Kaen (KK) Province. We obtained official permission from The Royal Thai College of Obstetricians and Gynaecologists, the DOH, the MOPH and the governor of KK Province. We translated the WHO manual of implementation into Thai to overcome language barriers. We organized seven two-day workshops for doctors and nurses who were providers of ANC in these 24 hospitals. The workshops aimed at informing practitioners about the concepts, forms and procedures for providing the new ANC model. A press conference was organized to inform mass media in order to spread the message to the wider population. We also made two site visits to each of the 24 hospitals to supervise and clarify any issues that arose during the actual implementation. Importantly, the initial implementation of the new ANC model in KK province was followed by a thorough monitoring period of three years. This confirmed that pregnancy outcomes were unchanged since the implementation of this new model.
Adapting FANC to local context
After the initial pilot stage, we modified the WHO FANC model, according to both available evidence and considering local resources. In view of the big gap between the first and second visit—the booking visit should occur during the first trimester, while the second is close to 26 weeks—we added a 20-week ultrasound in order to confirm the gestational age of the baby and rule out any major congenital abnormalities. Because of a recent Cochrane review on pre-eclampsia, we also started calcium supplementation treatment at 20 weeks to reduce pre-eclampsia and eclampsia.
In August 2008—based on the success of the pilot implementation in KK province—the MOPH decided to extend the implementation of the new model in five provinces. The DOH was responsible for training nurses and doctors with an operation manual in place to guide health professionals. External reviewers from Thai universities contracted by the DOH to monitor the project were asked to submit a report within two years of implementation to the five provinces.
This evaluation was conducted by visiting 34 hospitals involving 180 ANC providers twice in these five provinces, from February to March and September to November 2009. During this time positive attitudes towards FANC rose from 54% to 94%. In addition, more than 90% of pregnant women received all the FANC interventions except a routine per vaginal examination, which was performed in 70% of women. With fewer visits through the FANC model, there was no significant difference in clients’ satisfaction. Lastly, there were no significant differences in maternal and perinatal outcomes before and after the launch of FANC in the five pilot provinces.
In 2010—in view of the continuous success of stage 2 in five provinces—the MOPH decided to expand the FANC model throughout Thailand.