Antenatal care in Nigeria
Antenatal period is the interval from conception to the delivery of the fetus. This period is usually associated with physiological as well as psychological changes in the Nigerian woman. The psychological changes are dependent to a large extent on whether or not the pregnancy is wanted, the social circumstances around the you and how your body responds to normal physiological changes in pregnancy. The physiological changes in pregnancy are mostly aimed at creating effective changes in the mother’s body; hormonal, cardiovascular, renal among others in order to ensure that the baby is adequately catered for while in the womb.
Meaning of antenatal care
Antenatal care is the process whereby mother and the growing foetus are systematically examined throughout the antenatal period. It is a form of preventive medicine in which risk factors are recognized early in the antenatal period and specific interventional measures are instituted. Pregnancy is a special event and the family and community should treat a pregnant woman with particular care.
The World Health Organization technical working group in charge of antenatal care in Nigeria are of the opinion that antenatal care makes a significant contribution to maternal and perinatal health and is therefore an essential component of care for mothers and babies together with family planning, clean and safe delivery and essential obstetric care.
Aims of antenatal care in Nigeria
The main aim of antenatal care is to ensure a healthy mother and infant at the end of the pregnancy. It reduces maternal and child mortality rates. To attain this objective, antenatal care should be seen as a major preventive health measure which guarantees that the mother remains healthy throughout pregnancy. Antenatal care should have well defined measures aimed at preventing the development of any pregnancy disorders or complications. Antenatal care should address the psychosocial and medical needs of the woman within the context of the health care delivery system and the culture in which she lives.
Visits to antenatal clinic- focused antenatal care in Nigeria
The concept of antenatal care in Nigeria has now shifted from providing medical management of pregnant woman to a combination of information sharing, medical care and helping the pregnant woman make informed decisions about life in general and the pregnancy in particular. The pregnant woman should no longer be a passive receiver of medical care, rather she should participate actively in the care of herself and the fetus.
For this reason emphasis has now shifted from issues such as the number of times of antenatal visits to the concept of the quality of the care given at each visit. This concept is even more important in developing countries where there are a few doctors attending to a large number of pregnant women. The WHO has recommended a minimum of 4 visits for a woman with a normal pregnancy. This is not to imply that where more visits are practicable, it should be reduced to the minimum. Rather, it is to focus on the content of care and to set a basic essential standard for quality of care for all pregnant women particularly in developing countries. This WHO new concept of antenatal care is known as the focused antenatal care and Nigeria has adopted it.
Summary of focused antenatal care in Nigeria
1. First Visit (between 14-16 weeks)
Screen and treat anemia
Screen for risk factors and medical conditions that can be addressed early in pregnancy
Initiate prophylaxis for malaria and place on hemanitics (blood boosters)
Plan individualized antenatal care and delivery.
2. Second visit (between 24-28 weeks)
Screen for anemia
Listen to woman’s complaints if any
The woman will be requested to do an ultrasound scan to check foetal well being, multiple pregnancy, and to rule out any foetal abnormalities
3.Third visit (around 32 weeks)
Screen for pre-eclampsia, multiple pregnancy, and anemia
Review birth plans
4. Fourth visit (at 36 weeks)
Screen for anemia
Identify fetal lie and presentation
Assess if the pelvis is adequate
Update the individualized birth plans.
Above is a summary of the care most teaching hospitals and federal medical centres in Nigeria give to pregnant woman- Focused Antenatal Care in Nigeria.
Traditional antenatal care in Nigeria
Still practised by most private hospitals and primary health care centres in Nigeria. In this method of pregcare, visits to the antenatal clinics in normal pregnancy are regimental depending on the gestational age, so that women attend antenatal clinic every 4 weeks until 28 weeks then every two weeks until 36 weeks, then every week until delivery. Unlike in focused antenatal care which is 4 visits, the total number of visits in traditional antenatal care is 13. This is excellent when there are adequate numbers of health care providers to attend to these pregnant women. In situations where there are few health care providers to attend to a large number of pregnant women, this method may overload the service provided.
Who provides antenatal care in Nigeria?
The midwife,general practitioner and obstetrician provides antenatal care. The antenatal clinic must adequately provide health promotion and care.
First antenatal visit (Booking visit)
This is important as it is the visit at which the medical risk factors are ascertained. Ideally, there should be a preconception visit, which should be the first visit. This visit should provide information to women on health education, risk assessment, nutrition and lifestyle (smoking, alcohol, use of drugs) which may affect the fetus. For some medical diseases such as diabetes mellitus, preconception control would reduce the effect of the disease on the fetus. In Nigeria, very few hospitals run preconception clinic.
The booking visit traditionally occurs at about 16 to 18 weeks, although booking earlier is advisable as some obstetric interventions such as cervical cerclage and amniocentesis are required at an earlier gestational date.
The first antenatal visit consists of three components: history taking, physical examination and special tests.
It involves an interview section with your doctor. You will be asked certain questions and you will be expected to provide some answers. The question and answer section will involve topics ranging from below:
Demographic details (biodata)
Past Obstetric history
Past medical and surgical history
Family and social history
History of present pregnancy
Information from history taking will help the doctor make useful decisions on the best management for the pregnant woman.
Physical Examination is a key component of antenatal care in Nigeria
Your height, weight, blood pressure will be measured. A midstream sample of your urine will be examined for protein, glucose and acetone.
A thorough physical examination will be carried our on you. You will be examined for pallor, jaundice, cyanosis, and leg swelling. Your neck will be examined for thyroid and lymph node enlargement. Your breasts will be examined for lumps and normal nipples preparatory for breast feeding.
Your cardiovascular and respiratory systems will be examined. The abdomen will be checked for liver, spleen and kidney enlargements. The fundal height (a tape rule running from top of your womb to your pubic region) of the uterus will ascertained. This helps the doctor know how well your baby is growing and to determine its gestational age.
Sometimes, a pelvic examination will be done to ascertain how adequate your pelvis is for vaginal delivery.
Your blood will be taken for routine tests like hemoglobin or packed cell volume estimation, complete blood count, blood grouping and genotype, Rhesus group, test for syphilis etc.
These tests are done routinely in Nigeria. Screening for rubella, is done routinely in some centres in Lagos. It has become necessary for you to be screened for HIV and Hepatitis B virus during booking because of the high positive rates in Nigeria and to reduce transmission from mothers to their babies.
Your urine will be tested on every visit for proteins, glucose and acetone. It may be sent for microscopy and culture if urinary tract infection which is common in pregnancy is suspected. Where glucose is present in your urine, your fasting blood sugar will be tested.
Ultrasound scanning has now become part of the booking investigations. It is offered routinely to all women at booking. In Nigeria, where facilities are available, it is done at 20-25 weeks or earlier for dating and suspected multiple pregnancy. Obstetric ultrasound scan is used to to check for fetal abnormalities. In later pregnancy, ultrasound scan is done for specific indications like: antepartum hemorrhage, big babies, intrauterine growth restriction, reduced fetal movements, and premature rupture of membranes.
Depending on the hospital or diagnostic centre, the price/cost of pregnacy ultrasound scan in Nigeria is around #2,500- #4,000 naira.
Prophylaxis for malaria and anemia in pregnancy in Nigeria
In Nigeria, it is still the common practice for all pregnant women to receive drugs for prevention of malaria and anemia.
Chloroquine is no longer used for malaria prophylaxis is Nigeria. It has been banned.
Oral proguanil 200mg called “sunday sunday medicine” is taken every 7 days by pregnant women for malaria prevention.
Intermittent preventive treatment is now the recommended method of preventing malaria in pregnancy by the WHO. Intermittent preventive treatment (IPT) of malaria in pregnancy is a full therapeutic course of antimalarial medicine given to pregnant women in Nigeria at routine antenatal visits regardless of whether she is infected or not. The recommended IPT drug is sulphadoxine-pyrimethamine (fansidar). Each satchet contains 3 tablets and you will be required to take the 3 tablets once starting from the second trimester. Each dose taken should be at least one month apart. You are expected to 3 doses in one pregnancy.
Anaemia prevention is provided by prophylactic medication with iron (fesolate) and folic acid throughout pregnancy and for two months after delivery. In women with sickle cell anemia, only folic acid supplementation is necessary unless there is laboratory evidence of iron deficiency anemia
Antenatal care services in Nigeria
Antenatal care in Nigeria have come of age and there is still much room for improvement. A list of antenatal services you will be offered or provided for every antenatal care visits in Nigeria are below.
- Health education
- Immunization against tetanus
- Physical examination of mother and foetus
- Malaria prophylaxis
- Anemia prophylaxis
- Basic investigation for HIV, Hepatitis B, syphilis etc and urinalysis
- Assessment of foetal well -being via ultrasound scan
- Counselling services
- Screening for hypertension in pregnancy, diabetes mellitus.
- Prepare you for safe delivery
- The doctor will listen to and answer your questions.
Subsequent antenatal visit
In Nigeria, visits to antenatal clinics remain regimental, so that women attend every 4 weeks until 28 weeks, then every 2 weeks, until 36 weeks and then every week until delivery.
At each subsequent antenatal visit your weight and blood pressure measurements are taken and your urine is checked for protein, sugar and acetone. Gestational age estimate and fundal height measurement are also taken and recorded.
Cost of antenatal care in Nigeria
Antenatal care cost in Nigeria is highly subsidized by both the states and federal government. In University of Benin Teaching Hospital, Benin-city for example, the cost of antenatal care is #30,000 naira, this is for the whole duration of pregnancy. In Lagos University Teaching Hospital, antenatal care cost is #32,000 naira, in National Hospital Abuja, antenatal care cost is #27,000 naira. Some private hospitals may charge higher or lower amounts.
Textbook of Obstetrics and Gynaecology by Dr Akin Agboola