National

Antenatal Care
Guideline
Ensuring Positive Pregnancy Experience!

February 2022
Table of Contents
Acronyms
Foreword
Acknowledgement
Executive Summary...................................................................................................................... 1
How the guideline was developed? ................................................................................................... 4

1. Introduction ............................................................................................................................. 5
1.1. Background ................................................................................................................................. 5
1.2. Rationale ..................................................................................................................................... 5
1.3. Aim .............................................................................................................................................. 5
1.4. Scope ........................................................................................................................................... 6
1.5. Users............................................................................................................................................ 6
1.6. Outcomes of interest to this guideline ....................................................................................... 6

2. Key Principles of Antenatal Care ............................................................................................... 8

3. Principles of Preconception Care as a Basis for ANC ................................................................... 9
4. Maternal and Fetal Assessment .............................................................................................. 11
4.1. ANC contact schedule ............................................................................................................... 11
4.2. Maternal and fetal assessment at first ANC contact ................................................................ 12

5. Health Promotion, Disease Prevention, and Treatment during Pregnancy ................................ 17

5.1. Counseling and health promotion ............................................................................................ 17
5.2. Nutritional interventions .......................................................................................................... 21
5.3. Other preventive antepartum interventions ............................................................................ 24
5.4. Treatment of common antepartum problems ......................................................................... 27
5.5. Interventions for common pregnancy conditions .................................................................... 30

6. Health Systems Interventions to Improve the Utilization and Quality of Antenatal Care ........... 34
6.1. Introducing woman-held case notes......................................................................................... 34
6.2. Creating a woman-friendly environment.................................................................................. 34
6.3. Pregnancy support during public health emergencies ............................................................. 34
6.4. Caring for women with special needs ....................................................................................... 35
6.5. Digitizing the health system ...................................................................................................... 36
6.6. Enhancing the capacity of ANC providers ................................................................................. 36
6.7. Integrating other RH services within the ANC package ............................................................ 36
6.8. Community engagement to increase ANC coverage ................................................................ 36
6.9. Continuous quality improvement ............................................................................................. 36
6.10. ANC guideline implementation considerations ...................................................................... 37
6.11. Roles and responsibilities........................................................................................................ 38
6.12. ANC monitoring and evaluation .............................................................................................. 40

National Antenatal Care Guideline | February 2022

ANNEXES
Annex 1. Glossary ...................................................................................................................... 43
Annex 2. Medical, Surgical, Psychiatric, and Obstetric Problems Requiring specialized ANC ......... 44
Annex 3. Reproductive Health Services That Can Be Integrated into ANC ..................................... 45
Annex 4. Key Activities in the Continuum of Maternity Care ........................................................ 46
Annex 5. Checklist for Counseling Danger Symptoms and Signs of Pregnancy During ANC ............ 47
Annex 6. Four Page ANC Card (baseline and follow-up sheet) ...................................................... 48
Annex 7: The BMI Scale (to check pre-pregnancy BMI) ................................................................ 52
Annex 8. Common Macro and Micro Nutrient Sources ................................................................ 53
Annex 9. Principles of ANC ......................................................................................................... 54
Annex 10: AUDIT TOOL: ANC for Health Center .......................................................................... 55
Annex 11. Woman-Held Case Note Template .............................................................................. 58
Annex 12: ANC Services by Level of Health Facility and Provider Category ................................... 60
Annex 13. List of ANC Indicators with Definitions, Frequency, and Source (M&E) ......................... 62
References................................................................................................................................. 64

List of Boxes and Tables

Box 1. Primary clinical and public health outcomes of interest to the guideline ........................................... 6
Box 2. Summary of the pre-pregnancy assessment, counseling, and preparation ........................................ 9
Box 3. Summary of ANC history and physical examination during first contact .......................................... 12
Box 4: Checklist for counseling danger symptoms and signs for common problems of pregnancy, starting from
the first ANC contact ......................................................................................................... 19

Table 1. Summary of ANC recommendations........................................................................................ 2

Table 2. ANC contact schedule......................................................................................................... 11
Table 3. Selected clinical conditions (screening from clinical data) and methods of screening when indicated. 14
Table 4. Sample of existing and newly developed high-risk conditions for pregnancy ................................. 14
Table 5. Focus areas of assessment and interventions in subsequent ANC contacts, after comprehensive
evaluation at first ANC contact (additional interventions are included in section 6) ....................... 15
Table 6. Recommended maternal weight gain during pregnancy and dietary diversification ........................ 22
Table 7. Degree of anemia and possible treatment options ................................................................... 23
Table 8. Tetanus–diphtheria vaccination schedule during pregnancy and beyond ..................................... 24
Table 9. Treatment protocol for HIV, syphilis, and HBV during pregnancy ................................................ 29

National Antenatal Care Guideline | February 2022

Acronyms
ANC Antenatal care
BEmONC Basic emergency obstetric and newborn care
BMI Body mass index
CEmONC Comprehensive emergency obstetric and newborn care
CQI Continuous quality improvement
EDD Estimated due date/expected date of delivery
EmONC Emergency obstetric and newborn care
eMTCT Elimination of mother-to-child transmission
FANC Focused antenatal care
FGM Female genital mutilation
Hb Hemoglobin
HBV Hepatitis B virus
Hct Hematocrit
HDP Hypertensive diseases in pregnancy
HEP Health extension program
HEW Health extension worker
HMIS Health management information system
IDP Internally displaced persons
IFA Iron-folate acid
IPTp Intermittent preventive treatment in pregnancy
LEEP Loop electrosurgical excision procedure
LNMP Last normal menstrual period
MCH Maternal and child health
MCV Mean corpuscular volume
M&E Monitoring and evaluation
MoH Ministry of Health
MUAC Mid-upper arm circumference
OGTT Oral glucose tolerance test
PMTCT prevention of mother-to-child transmission
PrEP Pre-exposure prophylaxis
RBC Red blood cell
RH Reproductive health
STI Sexually transmitted infection
TDF Tenofovir disoproxil fumarate
TT Tetanus toxoid
Td Tetanus–diphtheria
Tb Tuberculosis
UTI Urinary tract infection
WHO World Health Organization
3TC Lamivudine
-ve Negative
+ve Positive
Acknowledgement
The Ministry of Health (MoH) would like to thank Jhpiego in Ethiopia for technically and financially
supporting the development of this guideline through funding from the Children's Investment Fund
Foundation (CIFF) and The ELMA Foundation, Nutrition International, and WHO. The MoH especially
acknowledges the consultant for developing the first ANC guideline for Ethiopia and the following
technical working group members for their huge contribution.

Sr. Name of Qualification/ Organization

No participants highest level of expertise
1 Dr. Meseret Zelalem MD, Ped Ministry of Health

2 Zenebe Akale BSC, MSC Ministry of Health

3 Dr. Yenealem Tadesse MD, Ped, MPH Jhpiego
4 Sheleme Humnessa Public health expert Ministry of Health
5 Dr. Delayehu Bekele MD, OB-GYN, MPH, MFM St. Paul's Hospital Millennium Medical
College

6 Hinsermu Bayu MSC. Clinical Midwife Ethiopian Midwives Association

7 Zemzem Mohamed Public health expert Ministry of Health

8 Likelesh Lemma Public health Expert Ministry of Health

9 Dr. Dereje Nigussie MD, OB-GYN, MPH Ethiopian Society of Obstetricians &
Gynecologists

10 Dawit G/Selassie Senior Midwife Ethiopian Midwives Association

11 Dr. Hailemariam Segni MD, OB-GYN, MPH JSI/Transform Primary Health Care
12 Prof. Yifru Berhan MD, OB-GYN, Consultant St. Paul's Hospital Millennium Medical
College

13 Etenesh G/Yohannes Public health specialist Ministry of Health

14 Takele Yeshiwas Public health expert Ministry of Health

15 Dr. Eyasu Mesfin MD, OB-GYN, REI Ethiopian Society of Obstetricians &
Gynecologists

16 Aregash Molla Public health specialist Ministry of Health

17 Melese Takele BSC, MSc/IESO Professional Association of Emergency
Surgical Officers of Ethiopia
18 Dr. Mulat Adefris MD, OB-GYN, MPH,GYN-ONC Ministry of Health
19 Melkamu Ayalew EPI expert Ministry of Health

20 Kefale Meresa Pharmacy specialist Ethiopian Pharmaceuticals Supply Agency

21 Abrham Kasahun M and E expert Ministry of Health

22 Dr. Fikremelekot MD, OB-GYN, MFM Ethiopian Society of Obstetricians &

Temesgen Gynecologists
23 Dr. Haimanot Ambelu MD, MPH (RH) WHO
24 Dr. Nega Tesfaw MD, OB-GYN Marie Stopes International Ethiopia
 Sr. Name of Qualification/ Organization
No participants highest level of expertise
25 Dr. Tesfaye Hurissa MD, OB-GYN, FP and RH Ethiopian Society of Obstetricians &
Gynecologists
26 Zewuge Moges BSc, MSc Ethiopian Medical Association

27. Hiwot Darsene BSc, MSc-Nutritionist Ministry of Health

28 Gelila Zewudie BSc, MPH-Nutritionist Ministry of Health
29 Birara Melese BSc, MSc-Nutritionist Ministry of Health

30 Abera Dibabe BSc, MPH-Nutritionist Ministry of Health

31 Tesfaye chuko BSc, MSc-Nutritionist UNICEF

32 Zenebu Ahmmed BSc, MSc-Nutritionist Save the Children International

33 Tamirate Tafesse BSc, MSc-Nutritionist Alive & Thrive
34 Dr Mahbub Ali MD, MPH UNFPA
35 Aschale Worku BSc, MPH Ministry of Health

36 Netsanet Belete Public Health Expert Ministry of Health

37 Netsanet H/Silassie Public Health Expert Ministry of Health
Executive Summary
Within the continuum of reproductive health care, antenatal care (ANC) provides a platform for
important health care functions, including health promotion and disease prevention, and screening,
diagnosis, and management. By implementing timely and appropriate evidence-based practices,
ANC can improve maternal and perinatal outcomes and provide an opportunity to communicate
with and support pregnant women and their families.

In 2016, the World Health Organization (WHO) released comprehensive recommendations on ANC
for a positive pregnancy experience. This new model for delivering ANC is a goal-oriented approach
to delivering evidence-based interventions focusing on the quality and content of care
The objective of this document is, therefore, to provide evidence-based guidance for policy makers,
health programmers and health workers on comprehensive, integrated, and effective ANC service
modality and thereby improve maternal and fetal-neonatal health. In line with the WHO
recommendation, they will facilitate a positive pregnancy experience by providing quality,
integrated, comprehensive, and women-centered care.

The guideline has both clinical and public health outcomes of interest. This guideline replaces
focused antenatal care (FANC), which has been in use for more than a decade. As a result, the
number of recommended visits for routine ANC (for all women without specific pregnancy-related
complications) changed from four visits to eight contacts.

The guideline focuses on key guiding ANC principles, pregnant-woman-centered care, maternal and
fetal assessment during initial and subsequent contacts, prevention and treatment of common
pregnancy problems, counseling and health promotion during ANC, as well as strengthening the
health system for effective ANC coverage. The table below summarizes the key interventions in the
guideline (Table 1).

How the guideline was developed?

This guideline was developed as per the WHO ANC recommendations adaptation toolkit, referring to
the WHO 2016 comprehensive recommendations on ANC for pregnant women and adolescent girls.
The working group has also given due consideration to the WHO expert opinion on how to develop
country-specific ANC guideline.

A technical working group composed of gynecologists and obstetricians, midwives, pediatricians, and
public health specialists from partners, safe motherhood technical working group, universities,
Ministry of Health (MoH), and professional associations had undergone a two-day workshop on
situational analysis using the format in the ANC adaptation toolkit. Taking the situational analysis
finding as background information on the feasibility, equity, and acceptability of the WHO
recommendations, the group reconvened and outlined the ANC guideline for Ethiopia and
thoroughly examined the draft ANC guideline.

Available human resource for health, health facilities capacity, availability and affordability of
commodities and supplies, and magnitude of pregnancy-related health problems were thoroughly
discussed and consultation sought with experts from MoH for inclusion or exclusion of some of the
interventions. Further, local, regional, and international studies specific to the interventions were
rigorously reviewed. This guideline was aligned with HSTP-II, National Reproductive Health Strategy;
Triple Elimination of Mother-to-Child Transmission of HIV, HBV, and Syphilis; and National Obstetric
Protocols. Overall, in due course of the ANC guideline development, a series of consultative
workshops was conducted by involving multidisciplinary experts and interventions were
contextualized to the country’s context.

National Antenatal Care Guideline | February 2022 1

Table 1. Summary of core packages of ANC interventions
Package Interventions
1. Maternal and  Institute ANC models with 8 contacts for all women without specific pregnancy-
fetal assessment related complications at all levels of care.

 Promote early initiation and adherence to the ANC schedule.

 Provide universal testing for hemoglobin (Hb)/hematocrit (Hct), blood group and
Rh, urine analysis, HIV, hepatitis B virus (HBV), and syphilis for all pregnant women.

 Provide one ultrasound scan before 24 weeks of gestation (early ultrasound) for all
pregnant women
2. Health  Counsel pregnant women for optimal nutrition to achieve appropriate weight gain
promotion, and improve her and the fetus’ nutritional status for improved birth outcome.
prevention, and
treatment during  Counsel all pregnant women to take safe and diversified diet and avoid unhealthy
pregnancy diet.

 Counsel pregnant women to maintain regular personal hygiene and environmental

sanitation.

 Counsel all pregnant women to engage in regular work and nonstrenuous physical
activity provided that the pregnant woman is capable.

 Counsel all pregnant women to avoid alcohol, khat, smoking ( active and passive),
and other illicit drugs, throughout the pregnancy.

 Counsel all pregnant women, and any of her family members attending ANC, on
danger symptoms and signs during each contact as per the checklist and timing
presented in Annex 5.

 All pregnant women attending ANC should be counseled on birth preparedness

and complication readiness starting from the first contact and ensure that the
partner/family is involved.

 Counsel pregnant woman on consumption of quality, safe, nutrient-dense,

diversified food, and micronutrient supplementation to improve maternal and
fetal nutritional status and health outcome.

 Counsel on healthy eating habits and aerobic physical exercise to prevent maternal
overweight and obesity during pregnancy and lactation to reduce the risk of
macrosomia and avoid any additional weight gain among overweight and obese
pregnant women.

 Assess compliance and counsel for adherence of iron, folic acid, and calcium intake
during each contact.

 Counsel the woman on consumption of at least one additional diversified and

nutrient-dense (rich) meal on a daily basis; and promote consumption of
adequately iodized salt intake (at least 15 parts per million [PPM]).

 Conduct nutritional assessment (dietary, clinical, and anthropometry) using mid-

upper arm circumference (MUAC) measurement and weight gain monitoring for all
pregnant women in every ANC contact to assess maternal nutritional status.

 Provide daily oral iron and folic acid supplementation (60 mg elemental iron and
0.4 mg folic acid) to all pregnant women to prevent maternal anemia, puerperal
sepsis, low birth weight, and preterm birth (at least 90 tabs to the maximum 180
tabs; assess compliance and counsel for adherence during each contact).

 Investigate all pregnant women attending ANC for anemia and provide appropriate
treatment (based on the level of Hb/Hct).

2 National Antenatal Care Guideline | February 2022

 Package Interventions
 Treat all pregnant women with acute malnutrition (MUAC <23 cm) as
recommended by the national guideline for the management of acute
malnutrition.

 Provide calcium supplementation with daily 1.5–2.0 gm oral elemental calcium for
all pregnant women starting from 14 weeks of gestation

 Administer at least Td-1 and Td-2 during pregnancy to all pregnant women (unless
certified with Td-5) to prevent maternal and neonatal tetanus..

 Women should be counseled on the importance of continuing the remaining

doses of Td vaccine following delivery.

 Screen the mother, the father, and the baby for Rh antigen and providing anti-D
immunoglobulin 300 microgram for all Rh negative and Coomb’s negative women
at 28 weeks and soon after birth for women who give birth to Rh positive
newborns.

 Referring all Rh negative and Coomb’s positive women, preferably before

conception or early in pregnancy, to a tertiary hospital.

 Deworm all pregnant women with a single dose of Albendazole (400 mg) or
Mebendazole (500 mg) after the first trimester.

 Counsel and Provide TDF and 3TC as PrEP for pregnant women who are at
substantial risk for acquiring HIV.

 Counseling should be done on correct and consistent use of condoms, routine

screening of STIs, HIV testing, assessments of adherence and retention as part of
combination HIV prevention package.

 Low dose aspirin is recommended for prevention of pre-eclampsia in women at

high-risk of developing pre-eclampsia.

 Counsel on use of long lasting insecticidal treated bed nets, provided at the
community level, and prompt diagnosis and treatment of malaria infection.

 Test all pregnant women living in malaria endemic areas for malaria parasites and
treating accordingly.

 Perform gram stain of midstream urine to increase the detection of asymptomatic

bacteriuria.

 Treat asymptomatic bacteriuria with amoxicillin, or cephalexin tablets to reduce

the risk of urinary tract infections and associated obstetric complications.

 Screen, diagnose and treat/refer diabetes mellitus during pregnancy for

specialized care.

 Provide antihypertensive and anticonvulsant drugs to all pregnant women with

severe hypertensive diseases in pregnancy (HDP) at all health facilities.

 Apply all necessary precautions during ANC to reduce the vertical transmission of
HIV, syphilis, and HBV.

 Retest pregnant women for HIV every 3 months and for syphilis every 6 months,
for those with substantial risk who were previously negative.

 Provide screening, confirmatory Tb diagnostic test or refer to a hospital and

initiate anti-Tb treatment when active Tb cases are found.

 Provide Tb screening and diagnostic tests for family members of pregnant women
diagnosed to have Tb infection.

National Antenatal Care Guideline | February 2022 3

 Package Interventions
 Use ginger and vitamin B6 for the relief of mild nausea and vomiting in pregnancy,
based on a woman’s preferences and available options.

 Refer moderate to severe nausea and vomiting to specialized care center for
possible inpatient treatment.

 Provide magnesium and calcium containing antacids for persistent heartburn for
pregnant women (i.e., for those who could not respond to modified sleeping
position, diet content, and meal-time).

 Prevent constipation by increasing the high-fiber diet in the meal and frequency of
water intake.

 Encourage pregnant women to make dietary and lifestyle modifications to prevent

occurrence of hemorrhoid and varicose veins.

 Use simple and locally available methods (like compression stockings) to ease the
leg cramps and improve the physical appearance of varicose veins.

 Assess, investigate, and treat pregnant women thoroughly for abnormal vaginal
discharge to alleviate disturbing symptoms and prevent obstetric and perinatal
complications.

 Investigate new onset of headache that is not responding to simple analgesics and
is progressing, as it may be a symptom of an underlying serious disorder deserving
thorough investigation or referral.

 Use paracetamol as the drug of choice for treatment of headache during

pregnancy.

 Reassure the pregnant women that low-back pain, joint pain, and abdominopelvic
pain are temporary problems and can be soothed with non-pharmacological
methods and simple analgesics.

 Create awareness of the risks of use of unverified over-the-counter medicines for

minor pregnancy-related pains.

 Introduce woman-held case notes, create a welcoming health facility’s

environment, care for women with special needs, digitalize the health system to
improve the quality and utilization of ANC.

3. Strengthening  Avail all the required infrastructure, drugs, equipment, supplies, and personnel to
the health care implement the new recommendations
system for ANC
 Strengthen pre-service training, on-the-job training, mentorship, and supervision
focusing on the recommendations of this guideline.

 Introduce reproductive health services integration into routine ANC to use the
opportunity to address common reproductive health problems of women.

 Strengthen/reactivate the women health development group, community-based

joint forum, and family/partner engagement to increase public awareness and
increase demand for ANC and delivery services.

 Instituting continuous quality improvement and improving the documentation and

reporting of ANC.

4 National Antenatal Care Guideline | February 2022

1. Introduction
1.1. Background
Antenatal care (ANC) is a health service provided to pregnant women in the continuum of maternity
care. The WHO defines ANC as the care provided by skilled health care professionals to pregnant
women and adolescent girls to ensure the best health conditions for both mother and baby during
pregnancy. The components of ANC include: risk identification, prevention and management of
pregnancy-related or concurrent diseases, health education and health promotion. Additionally, it
provides an opportunity for reproductive health service integration. Making adequate preparation
for birth and emergencies is also an important ANC intervention to end preventable maternal and
perinatal mortality and morbidity.

The ANC also serves as a platform for pregnant women and adolescents to have access to
comprehensive reproductive health (RH) services. Thus, the ANC is not only destined to ensure a
healthy mother and a healthy baby by providing quality ANC, but also to make pregnancy a healthy
and positive experience for a woman and her family. These can be achieved by ensuring the physical,
emotional, and mental wellbeing of pregnant women, and creating an opportunity to link ANC to
other health services.

Historically, the ANC service was initiated in the 1900s in the United Kingdom. Traditional ANC was
practiced until focused antenatal care (FANC) was introduced in 2002. Recent evidence noted that
when compared to the previous model, the FANC model was associated with more adverse events,
especially increased perinatal mortality. These findings informed the review of the ANC contact
schedule, which was increased to eight contacts rather than four visits, among other interventions.

The maternal mortality ratio (401/100,000 live births) and neonatal mortality rate (33/1000 live
births) in Ethiopia are among the highest in the world and Ethiopia adopted the 2016 WHO model of
eight contacts to reduce maternal and perinatal mortality and morbidities.

Specific to the current guideline, within the continuum of RH care, ANC provides a platform for
important health care functions, including health promotion and disease prevention, screening,
diagnosis, and management. It has been established that by implementing timely and appropriate
evidence-based practices, ANC can save lives. Crucially, ANC also provides the opportunity to
communicate with and support women, families, and communities at a critical time in the course of
a woman’s life.

1.2. Rationale
Ethiopia has never had standalone ANC guideline although there is extensive evidence urging
development of this guideline. Furthermore, this guideline is needed to address equity, quality, and
standardization of ANC in Ethiopia. Moreover, it helps to increase ANC service demand and
utilization to ensure maternal-perinatal health and wellbeing. The guideline also enables integration
of other RH services with ANC.

1.3. Aim
The main aim of this guideline is to provide evidence-based guidance to policy makers, health
programmers and health workers on comprehensive, integrated, and effective ANC service modality,
thereby improving maternal and fetal-neonatal health. The guideline specifically aims at:
 Upholding health managers’ capacity in ANC program planning, implementation, monitoring,
and evaluation

National Antenatal Care Guideline | February 2022 5

  Enhancing ANC service quality by strengthening the health system, including capacity of
health care providers
 Giving due emphasis to ANC as the main gate to comprehensive RH services and services
integration
 Aligning the national ANC practice with the WHO recommendations for interventions and
good clinical practices, and other emerging evidences
 Accelerating the progress toward the Health Sector Transformation Plan II targets
 Ensuring a healthy and positive pregnancy experience

1.4. Scope
The scope of this guideline defines the level of care. The overarching intent of this guideline is,
therefore, to provide standardized ANC services for health promotion, prevention of pregnancy-
related complications, early detection of pregnancies with problems, treatment at outpatient level
and facilitate timely referral for those who require specialty care. This guideline complements other
current national guidelines, protocols, and strategy documents.

1.5. Users
The primary users of this guideline are providers of ANC services at all levels (including
obstetricians/gynecologists, integrated emergency surgical officers, general practitioners, health
officers, midwives, nurses, health extension workers (HEWs), mentors, and supervisors) both at
public and private health facilities. It also serves as a reference for policymakers, managers, partners,
professional associations/societies, researchers university/college instructors in the health related
fields and others.

1.6. Outcomes of interest to this guideline

This guideline has both clinical and public health outcomes of interest (Box 1). In essence, when ANC
improves at individual and family level, by implementing the core principle of this guideline, it
encourages more pregnant women in the community to attend ANC and helps to retain them in the
continuum of care. The cumulative advantage is that ANC coverage and births at the health facility
will increase, and ultimately result in a significant reduction in maternal and perinatal morbidity and
mortality.

Box 1. Primary clinical and public health outcomes of interest to the guideline

A. Maternal outcomes:

 Increased maternal and family satisfaction with ANC services provided

 Universal screening of Hb/Hct, blood group and RH, HIV, syphilis, hepatitis B virus (HBV),
urinalysis and tuberculosis is instituted in all health facilities
 Pregnancy-related nutritional problems (under and over nutrition) are prevented and/or
corrected
 Common pregnancy-related conditions are prevented or detected early and treated
 Pregnant women are counseled to have safe and successful pregnancy outcomes
 Pregnant women are counseled on postpartum family planning

6 National Antenatal Care Guideline | February 2022

B. Fetal and neonatal outcomes:

 Preventable early pregnancy losses are prevented and associated complications are
managed
 Congenital anomalies are prevented and pregnancies with congenital anomalies are
managed timely
 Fetuses with problems are timely detected and delivered in a setting where neonatal care is
optimal
 Premature deliveries due to preventable causes are reduced
 Perinatal mortality is reduced
 Mother-to-child transmissions of HIV, syphilis, and HBV during pregnancy, delivery, and
lactation are eliminated

C. Health system outcomes:

 Quality of ANC is improved

 ANC attendees are maintained in the continuum of care with increase in ANC, skilled birth
attendance and postpartum care coverage with reduced dropout

National Antenatal Care Guideline | February 2022 7

2. Key Principles of Antenatal Care
1.Implementing the new ANC model of eight contacts schedule: ANC services should be
provided through the eight contacts schedule for all pregnant women who do not have
any pregnancy-associated complications.
2.ANC care should be woman-centered: woman-centered care is a term that describes a
philosophy of maternity care that promotes a holistic approach by recognizing and
addressing each woman’s social, emotional, physical, psychological, spiritual, and cultural
needs and expectations. Woman-centered care should focus on the woman's unique
needs, expectations and aspirations; recognizes her right to self-determination in terms of
choice, control, and continuity of care.
3.De-medicalized ANC: care for normal pregnancy and birth should be de-medicalized and
avoid over medicalization, meaning that essential care should be provided with the
minimum set of interventions necessary and that less rather than more technology be
applied whenever possible, and avoiding unnecessary clinical interventions.
4.ANC should be providing efficient and timely care to all pregnant women.
5.ANC should be evidence-based: meaning supported by the best available evidence.
6.ANC should be multidisciplinary: involving contribution from health professionals such as
midwives, obstetricians, maternal-fetal medicine subspecialists, nurses, health officers,
etc.
7.ANC should be holistic and concerned with intellectual, emotional, social, and cultural needs
of women, their babies, and families and not only with their biological care.
8.ANC should respect the privacy, dignity, and confidentiality of women.
9.ANC providers should be motivated, competent, and compassionate.
10. Women with special needs require care in addition to the core components of basic care.

8 National Antenatal Care Guideline | February 2022

3. Principles of Preconception Care as a Basis for ANC
In the continuum of care, preconception/pre-pregnancy care is the most ignored, but equally
important service for improving the outcome of pregnancy. Comprehensive care in the continuum
involves risk assessment, prevention, treatment, and psychosocial support that begins pre-
pregnancy and extends to the antepartum and postpartum periods. The implication is that the pre-
pregnancy assessment and preparation is not limited to achieving good health during pregnancy, but
also includes making good preparation for childbirth and parenting.

There is a long list of medical disorders that can worsen during pregnancy. There are also several
obstetric complications that can recur in subsequent pregnancies. Undernutrition or obesity is
known to affect pregnancy and pregnancy outcomes. Conceiving while using a substance, especially
alcohol, tobacco, and drugs (whose teratogenic effect to the neural tube is in the first two weeks of
embryonic age), is known to increase the risk of congenital anomalies and early pregnancy loss.
Professional or environmental exposure to teratogenic chemicals and/or radiation increases adverse
pregnancy outcomes.

The purpose of preconception care is to clinically evaluate, provide basic laboratory and imaging
investigations, and treat/correct identified disorders for women (preferably in a couple) who are
planning pregnancy, and avoid fetotoxic exposures. The preconception assessment (Box 2) may lead
to delaying the pregnancy (until the identified disorder is treated, controlled, or becomes less risky
to the pregnancy) or completely avoiding pregnancy if the pregnancy is likely to endanger the life of
the woman. Pregnancy is not recommended for a woman who is diagnosed to have a life-
threatening disorder (such as severe types of cardiac disease, advanced malignancy, severe
obstructive lung disease, recurrent deep vein thrombosis).

Thoroughly counseling on the maternal and fetal risks of poorly controlled medical disorders,
teratogenic infections and substances and providing contraception for women who are not eligible
for pregnancy are parts of preconception care. Pre-pregnancy nutritional assessment using the body
mass index (BMI) scale (Annex 7), maintaining e body weight to the normal range, and advising
uptake of folic acid 400 µgm/0.4 mg daily starting three months ahead of the planned conception
are basic components of preconception care. In case of previous delivery of a baby with neural tube
defect, folic acid dose needs to be increased to 4–5 mg per day.

Box 2. Summary of pre-pregnancy assessment, counseling, and preparation

A. Assessment:

 Potentially recurring obstetric complications experienced during previous pregnancies:

recurrent pregnancy loss, preterm labor, pre-eclampsia/eclampsia, gestational diabetes,
congenital anomaly, puerperal psychosis
 Obstetric and gynecologic surgery: operative delivery, cerclage, loop electrosurgical excision
procedure (LEEP), cone biopsy, myomectomy
 Immunologic disorders: autoimmune diseases
 Medical and mental health disorders: diabetes mellitus, thyroid disorders, hypertension,
anemia, deep vein thrombosis, asthma, epilepsy, depression, anxiety disorder, etc.
 Infectious diseases: sexually transmitted infections (STIs) including HIV, gonococcal,
chlamydial; hepatitis virus other infectious disease like malaria and tuberculosis.
 Physical disability and developmental disorders

National Antenatal Care Guideline | February 2022 9

B. Interventions:

 Counseling on the risk of pregnancy with uncontrolled medical conditions (anemia, diabetes
mellitus, cardiac disease, renal disease, hypertension, etc.) and substance use
 Counseling and providing appropriate contraception for those not desiring pregnancy or
until chronic medical conditions are stabilized
 Promoting micronutrient supplementation (iron, folic acid, calcium), promote consumption
of fortified and biofortified foods, diversified and nutrient-dense foods
 Monitoring weight gain during pregnancy, body weight adjustment (overweight and obese;
underweight)
 Counseling on the increased risk to the fetus (including neural tube defects) of using alcohol
and illicit drugs immediately after conception and throughout pregnancy
 Counseling women at increased risk of having a fetus with a neural tube defect (those who
gave birth a baby with a neural tube defect, women taking antiepileptics, and diabetics) to
take high-dose supplementation of folic acid and be advised to increase their food intake
of folate
 Providing pre-pregnancy vaccination (Td for all)
 Counseling on lifestyle modification (avoiding use of substances, including alcohol, tobacco,
khat, illicit drugs; limiting caffeine intake; avoiding exposure to environmental hazards)
 Adjusting medications: using relatively safe medicines and discontinuing drugs
contraindicated during pregnancy like angiotensin converting enzyme (ACE) inhibitors,
isotretinoin (Accutane), and some anticonvulsant therapy like hydantoin or valproic acid]
 Counseling on the increased risk of carrying a fetus with a chromosomal abnormality after
the age of 35 years

C. Socioeconomic status:

 Assessing vulnerability to domestic violence, social discrimination and stigma, and ensuring
linkages to locally available services

10 National Antenatal Care Guideline | February 2022

4. Maternal and Fetal Assessment
4.1. ANC contact schedule
As per the 2016 WHO recommendation, Ethiopia is replacing the previous four-visit FANC model
with the new ANC eight-contact model. In order to reduce perinatal mortality and improve the
pregnancy experience of women, a minimum of eight contacts is required. For those pregnant
women with identified problems, additional contacts may be scheduled as necessary.

Accordingly, the first contact is recommended to be a single contact in the first trimester (up to 12
weeks), two contacts in the second trimester (at 20 and 26 weeks of gestation), and five contacts in
the third trimester (at 30, 34, 36, 38, and 40 weeks) (Table 2). The appointment schedule is: first
appointment during the first trimester, second appointment 8 weeks later; the third, 6 weeks later;
fourth and fifth 4 weeks apart; and then the rest every 2 weeks.

The reason for increasing the number of contacts in the third trimester is considering the increased
risk of complications to the mother and the fetus during this period of gestation. This schedule
enables the ANC provider to early detect and treat potential maternal and fetal complications before
advancing to a severe or irreversible stage. It also gives room for the pregnant woman to share her
symptoms and worries with her care provider before worsening.

In the current model, the word “visit” is replaced with “contact” as the connotation of the latter
indicates an active connection between a pregnant woman and a health care provider.

Table 2. ANC contact schedule

Contacts Gestational age of contact in weeks Schedule of next appointment

First trimester

1st Up to 12 After 8 weeks

Second trimester
2nd 20 After 6 weeks

3rd 26 After 4 weeks

Third trimester
4th 30 After 4 weeks

5th 34 After 4 weeks

6th 36 After 2 weeks
7th 38 After 2 weeks

8th 40

Key Interventions:
4.1a. Institute ANC models with a minimum of 8 contacts for all women without specific pregnancy-
related complications at all levels of care.
4.1b. Promote early initiation and adherence to the ANC schedule.

National Antenatal Care Guideline | February 2022 11

4.2. Maternal and fetal assessment at first ANC contact
4.2.1. History and physical examination
Creating a rapport between the ANC provider and the pregnant women with a welcoming
environment and respectful reception is critically important to get full information about her
pregnancy history, make her comfortable for physical examination and investigations, and, above all,
to create a comfort zone for the continuity of the woman in the health service.
Once communication is established, pregnancy-specific assessment can be started. The end goal of
the first contact assessment is identifying clinical evidence to classify the woman as deserving
routine or special care/referral. To reach either conclusion, the summary of a systematic approach is
presented in Box 3.

Box 3. ANC history and physical examination during first contact

 Identification: name, age, address, phone number, occupation, and marital status
 Menstrual history: date of first last normal menstrual period and regularity of the menses;
current or previous breastfeeding, use of contraception; determining the gestational age and
EDD
 History of present pregnancy: including pregnancy symptoms, fetal kicks, and any complication
to date
 Intention of the present pregnancy: planned/unplanned; if unplanned, wanted/unwanted
 Past obstetric history: number of pregnancies and outcome of each; cesarean sections;
problems and complications, including bleeding, preterm births, stillbirths, and high blood
pressure during pregnancy
 Medical history: including cardiovascular disease, renal disease, diabetes mellitus, convulsion,
tuberculosis, and other past and current medical problems
 Current medication: including therapeutic medicines, illicit drugs, herbal/traditional remedies,
drug allergy
 Gynecologic history: including screening for cervical cancer, gynecologic surgery, STI
 Nutritional history: number of food groups and frequency of meals consumed per day, craving
for unusual food type, appetite, emesis
 Social and personal history: including use of alcohol, tobacco, exposure to second-hand smoke,
khat, caffeine in large quantity (>300 mg/day or >3 small cups of Ethiopian coffee), or other
harmful substances, assessing for intimate partner violence, female genital mutilation (FGM)
 Mental health: ask if pregnant woman felt depressed, sad, hopeless, irritable, worried a lot,
had multiple physical complaints, felt little interest or pleasure in doing things
 Intimate partner violence: have you been hit, kicked, slapped or insulted, threatened,
screamed, cursed at by your husband or somebody close?

12 National Antenatal Care Guideline | February 2022

Physical examination

 General appearance for pallor, respiratory distress

 Vital signs: blood pressure in left lateral or sitting comfortable position, pulse rate,
respiratory rate, temperature
 Weight and height: height as a baseline and weight measurement for weight gain
monitoring during pregnancy
 Acute malnutrition screening: using MUAC
 Examining the conjunctiva, oral mucosa, and nail beds for pallor
 Auscultating the chest for breathing sounds and heart sounds, any additional sounds
 Obstetric examination: Measuring the symphysis fundal height and doing the Leopold
maneuvers
 Auscultating the fetal heartbeat with Doppler (12+ weeks), Pinard fetoscope (20+ weeks),
palpating the abdomen for any mass or organomegaly
 Examining the musculoskeletal system for any gross deformity/swelling, varicose veins in the
lower limb
 Examine for any sign of trauma like bruises that would indicate intimate partner violence
 Examining the FGM scar after consultation and deciding on the need of deinfibulation (in
high prevalence areas)

Vaginal examination is not a routine practice during ANC. The most common indications are
symptoms of STI, vulvovaginal candidiasis, bacterial vaginosis, history of FGM, screening for
precancerous cervical lesion, vaginal bleeding (speculum after 28 weeks of gestation), suspected
leakage of amniotic fluid (speculum), and suspected preterm labor.

4.2.2. Basic and case-specific ANC screening

The following tests should be done for all pregnant women.
 Hemoglobin (Hb) or hematocrit (Hct), blood group, and Rh
 Urine analysis: dipstick, microscopy and gram stain
 Tests for HIV, HBV, syphilis
 Ultrasound before 24 weeks: One ultrasound scan before 24 weeks of gestation (early
ultrasound) is for all pregnant women to estimate gestational age, improve detection of
fetal anomalies and multiple pregnancies, placentation, reduce induction of labor for post-
term pregnancy, and improve a woman’s pregnancy experience.

Selective or case-specific screening is recommended for gestational diabetes mellitus, Tb, and group
B streptococcus (GBS). Table 3 summarizes the first three (further note is available in the next
section).

National Antenatal Care Guideline | February 2022 13

Table 3. Selected clinical conditions (screening from clinical data) and methods of screening when indicated.

Clinical condition Suggestive evidence Methods of screening

Gestational diabetes Personal or family history, previous 75 gm 2-hour OGTT (oral glucose
mellitus macrosomia or stillbirth, obese, large-for- tolerance test; details are in the
date uterus, family history, glycosuria national management protocol)

Tuberculosis (TB) Current cough, weight loss/failure to gain Symptom-based screening and
weight, night sweats, and fever performance of diagnostic test

Group B Previous perinatal infection with Group B Vaginal swab culture

streptococcus streptococcus

Key interventions
4.2.2a. Provide testing for hemoglobin (Hb)/hematocrit (Hct), blood group and RH, urine analysis,
HIV, hepatitis B virus (HBV), and syphilis for all pregnant women
4.2.2b. Provide one ultrasound scan before 24 weeks of gestation (early ultrasound) for all pregnant
women

4.2.3. Pregnancy risk identification

While all pregnancies are potentially at risk (complications often occur in pregnant women with no
known risk conditions), it is important to do risk identification and stratification at first contact and
in subsequent visits. Multiple assessment methods (past and present obstetric history, medical and
surgical history, systematic physical examination, laboratory, and imaging) are applied to assess the
health and wellbeing of the mother and the fetus as indicated above and in Table 4 below.

Table 4. Existing and newly developed high-risk conditions during pregnancy

Existing conditions Newly developed conditions

 Age <19 and >35 years  Threatened abortion

 Elderly primigravida  History of exposure to teratogenic drugs,
 Short stature chemicals, or radiation
 Overweight/obese (BMI >25 kg/m2) or underweight  Pregnancy after sexual assault
(BMI <18.5 kg/m2)  Multiple pregnancy
 Severe physical deformity/disability  Antepartum hemorrhage
 Multiple pregnancy  New onset or superimposed hypertension
 History of three or more abortions or one or more  Oligohydramnios or polyhydramnios
stillbirths  Lack of uterine growth or confirmed fetal
 Birth weight of previous baby <2500 or >4000 gm growth restriction
 Previous manual removal of placenta,  Large for date uterus
malpresentation, malposition, post-term, pre-  Anemia
eclampsia/eclampsia, operative delivery
 Rh-sensitized mother
 Rh-sensitized mother
 Systemic infection
 Anemia, chronic medical diseases, including diabetes
mellitus, renal, cardiac disease and chronic
 Acute pyelonephritis
hypertension  Recurrent lower urinary tract infection
 Psychiatric illness  Bacterial vaginosis
 Unplanned and/or unwanted pregnancy  Gestational diabetes mellitus
 High HIV viral load, acute viral hepatitis, syphilis, TB,  Preterm labor
malaria, and other systemic infections  Post-term pregnancy
 Imprisoned pregnant women  Abnormal presentation or abnormal lie

14 National Antenatal Care Guideline | February 2022

 Existing conditions Newly developed conditions

 Homeless pregnant women  Prelabor rupture of fetal membranes

 On chronic treatment for certain disease  Chorioamnionitis
 Short cervix

4.2.4. Maternal and fetal assessment during subsequent contacts

In subsequent ANC contacts, the focus of assessment is to reevaluate the changes from the previous
status and to look for new developments. Therefore, gestational age-based assessment in
subsequent visits is to assess maternal wellbeing, fetal growth and wellbeing. When there are
doubtful conditions, additional investigations could be requested.

On top of making a thorough assessment in every subsequent contacts (as described in Table 5),
instructing the woman on how to detect her and the wellbeing of the fetus is critical. Warning about
danger symptoms and signs of pregnancy is included in the counseling section.

Table 5. Assessment and interventions in subsequent ANC contacts (additional interventions are
included in section 6)

Gestational
Specific activities
age in weeks

20  Review the history, physical findings and laboratory results at first contact
(2nd contact)
 Ask about fetal movement
 Enquire about any complaint or concern
 Determine the gestational age
 Observe her general appearance
 Measure blood pressure
 Measure weight check for weight gain
 Look for pallor
 Measure arm for acute malnutrition screening using MUAC
 Measure the uterine fundal height
 Listen for fetal heartbeat
 Perform ultrasound scanning
 Initiate iron-folate and calcium supplementation and counsel on adherence
 Provide preventive chemotherapy(deworming)
 Check for other danger signs and symptoms
 Assess feeding practices and counsel on optimal maternal nutrition; extra
meal/feeding frequency, diet diversity, including fruit and vegetables, animal
source feeding
 Assess for mental health and intimate partner violence

26  Conduct same activities as week 20 except for ultrasound scanning

(3rd contact)
 Conduct urinalysis for proteinuria and urine gram stain
 Test for gestational diabetes for high-risk pregnant women

National Antenatal Care Guideline | February 2022 15

 Gestational
Specific activities
age in weeks

30  Conduct same activities as week 20 except for ultrasound scanning

(4th contact)
 Repeat testing for syphilis and HIV if earlier test results are negative
 Repeat Hb test
 Perform fetal wellbeing assessment if there is a discrepancy between fundal height
and gestational age or if there is a reduction in fetal movement
 Counsel on birth preparedness and complication readiness
 Counsel on optimal breastfeeding practices

34  Repeat all activities done at 30 weeks

(5th contact)
 Determine fetal presentation
 Test urine for proteinuria for high-risk women
 Repeat testing for syphilis and HIV if not done at 30 weeks
 Counsel on breastfeeding and immunization
 Counsel on stimulation for early childhood development

36  Conduct all activities done at 34 weeks

(6th contact)
 Assess mental health

38  Conduct all activities done at 36 weeks

(7th contact)
 Inquire any fears, myths, worries about labor and delivery
 Repeat Hb test
 Advise the pregnant woman on fetal movement counting

40  Repeat all activities done at 38 weeks

(8th contact)
 Review fetal movement counting
 Ultrasound scanning for fetal wellbeing assessment

16 National Antenatal Care Guideline | February 2022

5. Health Promotion, Disease Prevention and Treatment
During Pregnancy
Comprehensive ANC service includes counseling and health promotion, disease prevention, and
treatment during pregnancy.

5.1. Counseling and health promotion

Counseling during ANC involves a two-way confidential communication process to help pregnant
women examine their personal issues, make decisions, and make plans for acting if they develop
danger symptoms.

When pregnant women come to a health facility for the first time, they may be confused with myths
about pregnancy and delivery and would like to clear their confusion. Some may have already
experienced a bad outcome in a previous pregnancy, witnessed others having serious pregnancy-
related problems, or have an established problem in the index pregnancy. Studies have shown that if
pregnant women are encouraged to express their feelings, they may have a lot of questions and
concerns. Therefore, they should be encouraged to ask any questions or concerns they may have.

From the provider side, using the opportunity to counsel on early detection of pregnancy-related
problems, promote lifestyle modifications, make preparation for birth and any possible
complications makes the ANC service impactful. Counseling should include discussion of any major
problem identified with the woman and her partner, generate solutions, make decisions, plan for
future regular contacts and emergencies.

In this section, three major areas of counseling and health promotion services are considered: 1)
counseling on lifestyle modification throughout pregnancy, 2) counseling on danger signs and
symptoms (throughout pregnancy, but tailored to the gestational age), and 3) counseling on birth
preparedness and complication readiness.

5.1.1. Counseling on lifestyle modification

The need for counseling on lifestyle modification is to optimize the maternal adaptation to
physiologic and anatomic changes. It also helps to maximize fetal growth.

Counseling during ANC should focus on healthy diet, maintaining hygiene; avoiding use of tobacco,
alcohol, illicit drugs, and certain over-the-counter medications; getting regular exercise, sexual
activity, adequate sleep and reducing stress.

Diet
Counseling on adequate, safe, nutrient rich, dense, and diversified diet with available foodstuff in
the house is important. Pregnant women should take one additional meal daily during pregnancy
and two extra meals daily during lactation.

Substances
Pregnant women should completely avoid the use of illicit substances (any amount of alcohol,
tobacco, recreational drugs, khat, excessive caffeine intake). They should also be aware of the
impact of second-hand smoking (living with a partner or family member who smokes) to the
pregnancy, implying that the partner has to be involved in the counseling process for being aware of
the fetal risk and avoiding smoking around the mother. The counseling should also include on
avoiding over-the-counter medicines unless otherwise proved to be safe for pregnancy. Daily
caffeine intake should not exceed 300 mg, which is equivalent to three small cups of Ethiopian
coffee.

National Antenatal Care Guideline | February 2022 17

Exercise
During ANC contacts, pregnant women should be encouraged to have daily routine physical activity
like walking for half an hour daily but it should not be strenuous. Exercises should not be practiced in
supine position. Employed pregnant women have the right to use their maternity leave, but that
does not mean it is a leave for physical rest.

Sexual activity
Pregnant women should also be aware of that sexual intercourse during pregnancy is not associated
with adverse pregnancy outcome. However, contraindications for sexual intercourse, including
vaginal bleeding, leakage of liquor, and preterm labor should be informed.

Hygiene and sanitation for infection prevention

During pregnancy, women should be especially careful about personal hygiene and environmental
sanitation. Keeping the body clean helps prevent infection. Handwashing with soap is the most
important hygiene action she can take, especially before preparing food and after going to the toilet.
A pregnant woman should wash her body regularly with clean water. Dental hygiene is important
during pregnancy and counseling on hygiene includes regular cleaning of the teeth with a dental
stick or a toothbrush and toothpaste. Promoting the use of safe water, sanitation, and hygiene
services is fundamental to break the cycle of infection and reinfection and sustainable control of soil-
transmitted helminth infection.

Key Interventions
5.1.1a. Counseling pregnant women for optimal nutrition to achieve appropriate weight and
improve her and the fetus’ nutritional status for improved birth outcome.
5.1.1b. Counsel all pregnant women to take safe and diversified diet and avoid unhealthy diet.
5.1.1c. Counsel pregnant women to maintain regular personal hygiene and environmental
sanitation.
5.1.1d. Counsel all pregnant women to engage in regular work and nonstrenuous physical activity,
provided that the pregnant woman is capable.
5.1.1e. Counsel all pregnant women to avoid alcohol, khat, smoking (active and passive), and other
illicit drugs, throughout the pregnancy.

5.1.2. Counseling on danger symptoms and signs

Since most women have uneventful pregnancies and childbirths, pregnant women may overlook
symptoms and signs of serious maternal and fetal complications during pregnancy. Moreover,
pregnant women should be aware that having previous uneventful pregnancies does not guarantee
the normality of the index pregnancy. Sudden and unpredictable complications can occur at any
time in any woman during any pregnancy. Therefore, the ANC provider should ensure that the
pregnant woman and her family are aware of the common danger symptoms and signs and are
ready to act without delay to seek health care (Box 4).

18 National Antenatal Care Guideline | February 2022

Box 4: Checklist for counseling danger symptoms and signs for common problems of
pregnancy, starting from the first ANC contact
Counsel the pregnant woman and any of her family members to report as soon as possible any of
the following conditions:
 Vaginal bleeding of any amount and anytime during pregnancy
 Sudden gush of fluid or leaking of fluid from the vagina
 Offensive vaginal discharge
 Chills, rigor, or fever
 Severe headache not relieved by simple analgesics (e.g. paracetamol)
 Dizziness and blurring of vision
 Persistent nausea and vomiting
 Persistent cough (dry or productive)
 Swelling (hand and face)
 Decreased or loss of fetal movement
 Convulsions and/or loss of consciousness
 Premature onset of contractions/pushing down pain (before 37 weeks)
 Severe or unusual abdominal pain (flank, epigastric, or right upper quadrant pain)
 Skin rash

Recommendation:
5.1.2a. Counsel all pregnant women and any of her family member attending ANC on danger
symptoms and signs during each contact as per the checklist and timing presented in Annex 5.

5.1.3. Counseling on birth preparedness and complication readiness

Preparing the woman and her family for childbirth and parenthood should begin from the first ANC
contact. This is applicable to both first-time pregnant and experienced women. The complication
readiness is a continuation of creating awareness of danger symptoms and signs. Every pregnancy is
at risk until proven otherwise, therefore, all pregnant women and their family members have to be
ready to take essential actions and make multifaceted preparations to respond to the complications
that might occur during childbirth.

The components of a multifaceted birth preparedness and complication readiness plan include being
aware of the danger symptoms and signs and preparing for immediate actions. Every woman and
her family should have a plan for the following:
 Skilled attendance at birth
 Place of delivery (in consultation with the ANC provider)
 How to get to health facility (including transportation)
 Preparing essential items for childbirth
 Saving money for emergency transport (in case ambulance is not accessible)
 Preparing support during and after birth (family or friends)
 Arranging a way of communication in emergency situations
 Designating a decision-maker on the woman’s behalf (including giving consent when she is
unable to do that)

National Antenatal Care Guideline | February 2022 19

  Keeping pregnant women in the maternity waiting home to bridge the geographic gap of
accessing obstetric care during emergency situations is also an essential component of birth
preparedness and complication readiness.
 Establishing a strong inter-facility linkage and referral system is another important undertaking
for the effectiveness of birth preparedness and complication readiness efforts.

Key intervention
5.1.3a. All pregnant women attending ANC should be counseled on birth preparedness and
complication readiness starting from the first contact and ensure that the partner/family is involved
in preparations for action

5.1.4. Counseling on other issues

Counsel on the importance of family planning
 Explain that after birth, if she is sexually active and is not exclusively breastfeeding, she can
become pregnant as early as 4 weeks after delivery
 Counsel about the different family planning options including immediate postpartum
contraceptives
 Advise that waiting at least 2 years between pregnancies is healthier for the mother and the
child

Counsel on infant and young children nutrition

 Advise on optimal breastfeeding: early initiation, giving colostrum, avoiding prelacteal and bottle
feeding, and exclusive breastfeeding
 For women who are HIV positive, counsel on the options for feeding for her neonate, still
encouraging exclusive breastfeeding
 Advise on child nutrition (after 6 months), growth and development monitoring, and
immunization
 Promote deworming for children, therapeutic zinc supplements for childhood diarrhea
 Advise on danger signs and symptoms and early reporting of child illness and malnutrition

Counsel on child immunization

Immunization is one of the effective strategies in reducing child morbidity and mortality. Pregnant
women should be counseled and encouraged to vaccinate their children.

Counsel on stimulation for early childhood development

 Counsel parents to talk softly and sing to the unborn baby every day for optimal development as
the baby can hear, recognize their voice after birth, and be happy. Failing to do this will result in
poor attachment and love after birth.
 The father needs to support the mother to stay relaxed, calm, and happy during pregnancy
through stronger family relationship since stress during pregnancy can cause preterm birth, low
birth weight, or impaired brain development in the fetus.

20 National Antenatal Care Guideline | February 2022

5.2. Nutritional interventions
Maintaining good nutrition and a healthy diet during pregnancy is critical for the health of the
mother and fetus. Pregnancy requires a healthy diet that includes adequate intake of energy,
protein, vitamins, and minerals to meet maternal and fetal needs. In Ethiopia, for many pregnant
women, dietary intake of vegetables, meat, dairy products, and fruit is often insufficient. Maternal
undernutrition is highly prevalent and is recognized as a key determinant of poor perinatal
outcomes. Maternal undernutrition such as underweight or thinness (BMI<18.5kg/m2) and
micronutrient deficiencies (anemia, iodine, Vitamin A and D, Zinc, calcium, etc.) causes fetal growth
restriction and low birth weight.
In addition, overweight and obesity are becoming a public health problem in Ethiopia. Hence,
ensuring optimal maternal nutrition with appropriate counseling and providing supplements (as per
the resource allows to do so) are essential components of ANC.

5.2.1. Nutritional counseling

Nutrition education and counseling is a widely used strategy to improve the nutritional status of
women during pregnancy. Counseling primarily focuses on:
 Promoting a healthy diet by increasing the quality, quantity, and diversity of food consumed as
well as ensuring its safety
 Promoting adequate weight gain during pregnancy through weight measurement,
interpretation, and counseling
 Promoting food and micronutrient supplements during pregnancy
 Promoting healthy eating habits and physical exercise to prevent maternal overweight and
obesity during pregnancy (to reduce the risk of both small for gestational age infants,
macrosomia, neonatal hypoglycemia, gestational diabetes mellitus, and other poor obstetric
outcomes)
 Assessing compliance and counseling for adherence to iron, folic acid, and calcium
supplementation during each contact
 Promoting consumption of at least five out of the ten food groups, consumption of nutrient-
dense foods, fortified and biofortified foods, fruit and vegetables, animal source foods.
 Women with normal BMI before pregnancy should achieve 10 to 12.5 kg during pregnancy
 Counseling should also emphasize that excess weight gain is not healthy during pregnancy
 Food safety and quality is important during pregnancy. Some of food items that need to be
avoided include: raw meat (risk of toxoplasmosis, tapeworm, schistosomiasis, etc.), raw egg (risk
of salmonella food poisoning), mold-ripened soft cheese (risk of listeriosis for the fetus),
unwashed vegetables and fruits, unpasteurized or raw milk, processed and junk/packed foods
(overweight and non-communicable diseases), excess caffeine (risk of low birth weight)
Recommended food groups for pregnant women—at least five out of ten:
1. Grains, white roots and tubers, and plantains (“starchy staples”)
2. Pulses (beans, peas, and lentils)
3. Nuts and seeds
4. Dairy
5. Meat, poultry, and fish
6. Eggs
7. Dark-green leafy vegetables
8. Other vitamin A-rich fruits and vegetables
9. Other vegetables
10. Other fruits

National Antenatal Care Guideline | February 2022 21

Key Interventions:
5.2.1a. Counsel pregnant woman on consumption of quality, safe, nutrient-dense, diversified food,
and micronutrient supplementation to improve maternal and fetal nutritional status and
health outcome.
5.2.1b. Counsel on healthy eating habits and aerobic physical exercise to prevent maternal
overweight and obesity during pregnancy and lactation to reduce the risk of macrosomia.
5.2.1c. Assess compliance and counsel for adherence of iron, folic acid, and calcium intake during
each contact.
5.2.1d. Counsel the woman on consumption of at least one additional diversified and nutrient-
dense (rich) meal on a daily basis; and promote consumption of adequately iodized salt
intake (at least 15 parts per million [PPM]).

5.2.2. Prevention and treatment of maternal malnutrition during pregnancy

A healthy diet during pregnancy contains adequate energy, protein, vitamins, and minerals, which
are included in the majority of meals.

Macronutrient requirement
Women are advised to increase their daily calorie intake during pregnancy according to their pre-
pregnancy body weight, physical activity, and gestational age. Counseling mothers to get at least one
additional nutrient-dense, safe, and diverse meals per day during pregnancy to fulfill the extra
energy and protein requirement is important.

Energy requirements vary significantly depending on a woman’s age, BMI, and activity level. Caloric
intake should, therefore, be individualized based on these factors (as summarized in Table 6).

Mid-upper arm circumference (MUAC) is used to identify acute malnutrition in individual woman.
Thus, MUAC and weight measurement should be determined during each ANC contacts to assess
maternal nutritional status and to act accordingly. MUAC <23 cm indicates acute malnutrition and is
an indication for supplementation with ready-to-use foods (e.g., Plumpy’Nut, corn-soy blend
[CSB++]) until the measurement is in the normal range. Weight gain recommended during pregnancy
is based on the pre-pregnancy BMI as shown Table 6. Refer to Annex 7 to calculate BMI.

Table 6. Recommended maternal weight gain during pregnancy and dietary diversification

Baseline/ Recommended
pre-pregnancy BMI weight gain Dietary diversification
in kg/m2 in kg
Underweight (<18.5) 12.5–18 More calorie and protein diet adequate vegetables and fruits
Normal (18.5 to <25) 11.5–16 Moderate carbohydrate and protein diet adequate vegetables
and fruits
Overweight (25 to <30) 7–11.5 Normal carbohydrate and protein diet, very low fat, more
vegetables and fruits
Obese (≥30) 5–9 Lower carbohydrate and protein diet, more vegetables and
fruits, avoid fat foods
Note: Major calorie sources are carbohydrate and fat foods (see Annex 8). Steady increase of 1.5–2 kgs weight per month
is expected from 4 month of pregnancy. Cumulative average increase of 10–12 kgs weight is expected from pregnancy till
birth of a child.

22 National Antenatal Care Guideline | February 2022

Iron and folic acid supplementation
In Ethiopia nutritional (iron or folate) deficiency, malaria, and hookworm infestation are the major
causes of anemia in pregnancy. Over 50% of anemia during pregnancy is contributed by iron
deficiency, reflecting the increased demand for iron. Other causes of nutritional deficiency anemia
during pregnancy are folic acid (vitamin B9) or vitamin B12 deficiency.

The average daily requirement of elemental iron in normal pregnancy is 3.5 mg/dl. Diets that are rich
in iron include red meat, liver, poultry, fish, dried beans and peas, iron-fortified cereals, biofortified
food, etc.

Supplementary dose: All pregnant women should take 60 mg elemental iron (ferrous sulphate,
ferrous fumarate, or ferrous gluconate) and 0.4 mg folic acid daily for six months (180 tabs).

Anemia classification and treatment

Hemoglobin less than <11 g/dl defines anemia during pregnancy (Table 7). The finding of normocytic
(MCV<80) and hypochromic red blood cell (RBC) (peripheral morphology) is suggestive of iron
deficiency anemia, while macrocytic (MCV>100) and normochromic suggests folic acid or Vitamin
B12 deficiency anemia.

Use either full blood count testing or haemoglobinometer to determine hemoglobin/hematocrit

level and detect anemia.

Table 7. Degree of anemia and possible treatment options

HB level Degree of anemia Immediate action

≥ 11 gm/dl Normal Iron-folate prophylactic dose

9–10.9 gm/dl Mild Therapeutic iron dose + peripheral RBC morphology and RBC
indices*

7–8.9 gm/dl Moderate Therapeutic iron dose + peripheral RBC morphology and RBC
indices, close follow-up*
< 7 gm/dl Severe Referral to a hospital for complete investigation and possible
blood transfusion; continue therapeutic iron dose then after

 *If no adequate response to therapeutic iron dose, refer to a hospital for a complete investigation.
 Therapeutic dose: 60 mg elemental iron, BID in 24 hours until the Hb rises to ≥11gm/dl, to be followed by
prophylactic dose.

Multiple micronutrient supplementation

Micronutrients are only needed in very small quantities but are essential for normal physiological
function, growth, and development. Antenatal multiple micronutrient supplements that include iron,
folic acid, zinc, and several vitamins and minerals (13 -15 in total) can be provided as an alternative if
feasible.

Calcium supplementation as component of nutritional intervention

Dietary counseling of pregnant women should promote adequate calcium intake through locally
available, calcium-rich foods such as milk, other dairy products, and green leafy vegetables to
improve maternal nutritional status and reduce risk of pre-eclampsia/eclampsia. Calcium
supplementation reduces the risk of leg cramps. The calcium and iron tablets should not be
simultaneously taken.

National Antenatal Care Guideline | February 2022 23

Key interventions:
5.2.2a. Conduct nutritional assessment (dietary, clinical, and anthropometry) using mid-upper arm
circumference (MUAC) measurement and weight gain monitoring for all pregnant women in
every ANC contact to assess maternal nutritional status and act accordingly.
5.2.2b. Provide daily oral iron and folic acid supplementation (60 mg elemental iron and 0.4 mg folic
acid) to all pregnant women to prevent maternal anemia, puerperal sepsis, low birth weight,
and preterm birth (at least 90 tabs to the maximum 180 tabs; assess compliance and counsel
for adherence during each contact).
NB: Some women may experience GI side effect (heartburn, nausea, and vomiting) that may
affect adherence. Providers should be ready to address and respond to pregnant women’s
concern related to these side effects.
5.2.2c. Investigate all pregnant women attending ANC for anemia and provide appropriate
treatment (based on the level of Hb/Hct).
5.2.2d. Treat all pregnant women with acute malnutrition (MUAC <23 cm) as per the national
guideline for the management of acute malnutrition.
5.2.2.e. Provide calcium supplementation with daily 1.5–2.0 gm oral elemental calcium for all
pregnant women starting from 14 weeks of gestation.

5.3. Other preventive antepartum interventions

The other preventive antepartum interventions targets vaccine-preventable diseases, preventing
RhD isoimmunization, asymptomatic infections, established infections and disorders, and common
pregnancy conditions. Detail management plans for seriously complicated and emergency cases are
not included.
5.3.1 Vaccination during pregnancy
Vaccination during pregnancy has a triple life protection purpose (the mother, the fetus, and the
infant). The tetanus toxoid (TT) vaccine has been replaced with tetanus–diphtheria (Td) vaccine
(Table 8).

Live-virus vaccines for measles, mumps, and rubella are not recommended during pregnancy, but
during immediate postpartum and pre-pregnancy period is possible.

Table 8. Tetanus–diphtheria vaccination schedule during pregnancy and beyond

Dose Timing of administration* Protective effectiveness (duration of protection)
Td-1 At the first ANC contact 0%
Td-2 At least 4 weeks after Td-1 80% (1–3years)
Td-3 At least 6 months after Td-2 95% (5 years)
Td-4 At least 1 year after Td-3 99% (10 years)

Td-5 At least 1 year after Td-4 99% (all childbearing years)

* Note: For those who start ANC later, the second dose should be administered at least 2 weeks before the delivery due
date. Women who are unable to complete the Td-3 to Td-5 doses during the index pregnancy and non-pregnant state can
be provided the vaccines in subsequent pregnancies.

24 National Antenatal Care Guideline | February 2022

Key Interventions:
5.3.1a: Administer at least Td-1 and Td-2 during pregnancy to all pregnant women (unless certified
with Td-5) to prevent maternal and neonatal tetanus.
5.3.1b. Women should be counseled on the importance of continuing the remaining doses of Td
vaccine following delivery.

5.3.2. Preventing RhD isoimmunization

Rh isoimmunization is hemolytic anemia of fetus/neonate secondary to the production and passage
of antibodies against fetal Rh antigen. Rh sensitization usually occurs during labor and delivery when
there is increased risk of feto–maternal hemorrhage.

Preventing Rh isoimmunization in Rh negative pregnant women is one of the most effective

interventions in obstetrics. Administration of anti-D immunoglobulin during antepartum and
postpartum period for the prevention of Rh isoimmunization is highly effective prevention method.

Anti-D immunoglobulin is administered to unsensitized Rh negative woman whose partner is Rh

positive. It is given at 28 weeks of gestation; in the presence of risk factors for feto–maternal
hemorrhage (antepartum hemorrhage, obstetric procedures, etc.); and it is given during the
immediate postpartum period after testing the neonate’s Rh.

After delivery, the blood group of the neonate should be determined from the umbilical cord blood,
and anti-D immunoglobulin administered if the cord blood group is Rh positive. The anti-D
administration should not be delayed (as soon as possible).

NOTE: When a pregnant woman is diagnosed Rh negative, her partner’s Rh should be determined. If
he is Rh negative, there is no need to further investigate or administer anti-D. If he is Rh positive,
indirect Coomb’s test should be determined; Coomb’s positive mothers (sensitized) do not need
anti-D, but should be referred to a tertiary hospital. After birth, the neonate’s blood group should be
determined, and decision should be made accordingly. Anti-D should be administered in all
subsequent pregnancies after checking for sensitization.

Key interventions:
5.3.2a. Screen the mother, the father, and the baby for Rh antigen and provide anti-D
immunoglobulin 300 microgram for all Rh negative and Coomb’s negative women at 28
weeks and soon after birth for women who gave birth to Rh positive newborns.
5.3.2b. Refer all Rh negative and Coomb’s positive women, preferably before conception or early in
pregnancy, to a tertiary hospital.

5.3.3. Deworming during pregnancy

From different parts of Ethiopia, an overall prevalence of intestinal parasitosis ranges from 32% to
70%, which qualifies one of the WHO’s criteria (>20% prevalence) for mass deworming.

During pregnancy administer a single dose of albendazole (400 mg) or mebendazole (500 mg) after
the first trimester. Albendazole, a broad spectrum anthelmintic (including the common tapeworms),
should not be administered in the first trimester.

If the woman’s health condition is deteriorating because of massive intestinal parasitosis (usually
due to Ascariasis or tapeworm) or anemia (usually hookworm), mebendazole can be administered in
the first trimester.

National Antenatal Care Guideline | February 2022 25

If a pregnant woman is symptomatic (particularly associated with intestinal parasitosis causing
diarrheal diseases and tapeworm infestation), confirm the diagnosis with laboratory investigations
and treat the underlying cause. Promote personal hygiene and environmental sanitation.

Key interventions:
5.3.3a. Deworm all pregnant women with a single dose of albendazole (400 mg) or mebendazole
(500 mg) after the first trimester.

5.3.4. Pre-exposure prophylaxis for HIV prevention

Taking an antiretroviral for pre-exposure prophylaxis (PrEP) is highly recommended when there is a
substantial risk of acquiring HIV.

The target beneficiaries for PrEP service are:

 Consenting HIV negative female sex workers

 HIV negative partners of sero-discordant couples
 HIV negative pregnant and breastfeeding women at substantial risk of HIV infection during
antenatal and postnatal follow-up visits with HIV-positive partner, which also required
conducting routine partner testing for HIV

PrEP is not an emergency intervention; it requires consistent, daily use for people who have sexual
intercourse with a known HIV-positive person or person of unknown status, but at high risk of
acquiring the virus.

Pregnant women should receive PrEP regardless of gestational age with a combination of tenofovir
disoproxil fumarate (TDF) + lamivudine (3TC). When PrEP is taken daily, it is highly effective in
preventing HIV infection. If the pregnant woman is HIV positive and her husband/partner is negative,
he should be counseled to use condoms and PrEP.

Key interventions:
5.3.4a. Counsel and provide TDF and 3TC as PrEP for pregnant women who are at substantial risk for
acquiring HIV.

5.3.4b. Counseling should be done on correct and consistent use of condoms, routine screening of
STIs, HIV testing, assessments of adherence and retention as part of combination HIV
prevention package.

5.3.5. Prevention of pre-eclampsia

The Ethiopia Public Health Institute study has concluded that the dietary calcium intake of
childbearing age women in Ethiopia is very low (nearly 60–70% less than the recommended
amount).

Dietary counseling of pregnant women should promote adequate calcium intake through locally
available, calcium-rich foods. The recommended daily calcium supplementation is 1.5–2.0 g oral
elemental calcium starting from 14 weeks of gestation.

Dividing the dose of calcium may improve adherence, preferably taken at mealtimes.

Low dose aspirin is recommended for prevention of pre-eclampsia in women at high risk of
developing pre-eclampsia. After risk stratification, women with high risk of pre-eclampsia should be
referred to hospital for initiation of aspirin.

26 National Antenatal Care Guideline | February 2022

Negative interactions between iron and calcium supplements may occur. Therefore, the two
nutrients should preferably be administered at least 3 hours apart rather than concomitantly.
Pregnant women with high risk of pre-eclampsia should be referred to a hospital for further
management.

Key interventions:
5.3.5a. Low dose aspirin is recommended for prevention of pre-eclampsia in women at high risk of
developing pre-eclampsia.

5.3.6. Prevention of malaria

Ethiopia is generally considered as a low-to-moderate malaria transmission intensity country.

Malaria infection during pregnancy is a major public health problem, with substantial risks for the
mother, her fetus, and the newborn. It is recommended to use a package of interventions for
preventing and controlling malaria during pregnancy, which includes promotion and use of
insecticide-treated nets and appropriate case management with prompt and effective treatment.

WHO recommends administration of IPTp with sulfadoxine–pyrimethamine (IPTp-SP) in areas with

moderate to high transmission of Plasmodium falciparum starting in the second trimester with one-
month intervals. All pregnant women in malaria endemic areas should be tested for malaria.

Key interventions:
5.3.6a. Counsel on use of insecticidal treated bed nets, provided at the community level, and on
prompt diagnosis and treatment of malaria infection.
5.3.6b. Test all pregnant women living in malaria endemic areas for malaria parasites and treating
accordingly.

5.4. Treatment of common antepartum problems

Health conditions with potential to progress and cause serious maternal and fetal complications
during pregnancy include asymptomatic bacteriuria, TB, hypertension, and diabetes mellitus.

5.4.1. Asymptomatic bacteriuria during pregnancy

During pregnancy, the prevalence of asymptomatic bacteriuria ranges from 5%–20%. Asymptomatic
bacteriuria increases the risk of developing cystitis, acute pyelonephritis, and obstetric
complications, including spontaneous preterm delivery, prelabor rupture of fetal membranes
(PROM), and chorioamnionitis.

All pregnant women should be screened for asymptomatic bacteria during the first antenatal
contact.

Diagnosis of asymptomatic bacteriuria is made when the load of a single bacteria is > 100,000 colony
forming units/ml of midstream urine culture. If the midstream urine culture is not possible, the
second alternate is gram staining the midstream urine. Dipstick test (detecting nitrites and
leukocytes) alone has low sensitivity to diagnose asymptomatic bacteriuria.

Treating asymptomatic bacteriuria markedly reduces the risk of infection complications. Administer
amoxicillin, or cephalexin tablets to treat asymptomatic bacteriuria.

National Antenatal Care Guideline | February 2022 27

Key interventions:
5.4.1a. Perform gram stain of midstream urine to increase the detection of asymptomatic
bacteriuria.
5.4.1b. Treat asymptomatic bacteriuria with amoxicillin, or cephalexin tablets to reduce the risk of
urinary tract infections and associated obstetric complications.

5.4.2. Diabetes mellitus in pregnancy

The management principle of diabetes mellitus in pregnancy is primarily making early diagnosis and
providing appropriate treatment to minimize the maternal and fetal complications.

This is achieved by maintaining good glycemic control through lifestyle modifications (including
avoiding hyperglycemic diets, carrying out moderate intensity regular exercise, and avoiding chronic
stress) and/or using administration of drugs (oral hypoglycemic agents or insulin). Pregnant women
with a diagnosis of diabetes mellitus need specialized care.

Key intervention:
5.4.2a. Screen, diagnose, and treat/refer diabetes mellitus during pregnancy for specialized care.

5.4.3. Hypertensive disorders of pregnancy

In Ethiopia, the 2020 maternal perinatal death surveillance and response report has shown that
hypertensive disorders of pregnancy (HDP) is the second most common cause of maternal deaths.
HDP is also one of the most common causes of premature delivery and perinatal mortality.

Treatment of HDP includes administration of antihypertensive drugs (hydralazine, nifedipine,

methyldopa), anticonvulsants (magnesium sulphate, phenytoin, diazepam), and opening IV-line with
ringer lactate or normal saline. If the woman is convulsing, the convulsion must be controlled before
expediting the referral. Detailed description is available in the national obstetric management protocol.

Key interventions:
5.4.3a. Provide antihypertensive and anticonvulsant drugs to all pregnant women with severe HDP
at all health facilities.

5.4.4. HIV, syphilis, and/or HBV infection during pregnancy

Sexually transmitted infections during pregnancy can pose serious health risks for the mother and
the fetus. As a result, screening for human immunodeficiency virus (HIV), hepatitis B, and syphilis
should be done for all pregnant women to diagnose and treat early (Table 9). Refer to the national
guideline for prevention of mother-to-child transmission of HIV, syphilis, and hepatitis B virus.

28 National Antenatal Care Guideline | February 2022

Table 9. Treatment protocol for HIV, syphilis, and HBV during pregnancy
Diagnosis Treatment for the mother and prophylaxis for the fetus
HIV positive TDF + 3TC + DTG or
TDF + 3TC + EFV 400 mg
Syphilis Benzathine penicillin 1.8 g (2.4 million units) IM, stat (1.2 MU in each buttock) weekly for three
positive consecutive weeks
OR
Procaine penicillin 1.5 g IM daily for 10 days
OR
Erythromycin orally 500 mg, three times a day, for 7 days (for penicillin allergic)

HBV positive  For those women with positive HBSAg, HBV DNA viral load should be determined.
 HBV viral load greater than 20,000 international units per milliliter (IU/mL) of blood
indicates that the virus is active and an indication to give tenofovir for the woman starting
from 28 weeks of gestation until delivery.
 If the laboratory test for HBV viral load is not available, HBeAg should be determined to
decide on the need of maternal treatment.
 For women with detectable HBeAg, give tenofovir starting from 28 weeks of gestational
age until delivery.
 Linkage/referral for medical evaluation is also important (assessment of eligibility for life-
long treatment and follow-up).
 Take note that management of HBV for positive women requires specialized care.

Key interventions:
5.4.4a. Implement early universal testing for HIV, syphilis, and HBV, including testing and treating
partners and children.
5.4.4b. Apply all necessary precautions during ANC to reduce vertical transmission of HIV, syphilis, and
HBV.
5.4.4c. Retest pregnant women for HIV every 3 months and for syphilis every 6 months, for those with
substantial risk who were previously negative.
5.4.5. Tuberculosis
Ethiopia is one of the 22 WHO high Tb burden countries, with an estimated prevalence of active Tb
of 370/100,000 pregnant population. Tb seriously affects maternal health and pregnancy outcomes
by reducing the fetal birth weight, increasing mother-to-child transmission of HIV and maternal and
perinatal morbidity and mortality.

Considering the high burden of the disease, conduct symptom based screening of Tb for all pregnant
women with constitutional symptoms (low grade intermittent fever, night sweat, cough for more
than two weeks).

Pregnant women who are at risk for Tb infection are those who are exposed to Tb infected persons,
immunocompromised (HIV, malignancy, chemotherapy, radiotherapy), chronic steroid and cytotoxic
drug users (autoimmune disease), diabetic, malnourished, chronic stress etc.

During pregnancy, latent Tb treatment should be delayed for 2–3 months after birth unless there is a
risk for progression to active Tb (severely immunocompromised, recent contact with infectious Tb
disease). Active Tb, however, should be treated even in the first trimester. Selected anti-Tb drugs
(isoniazid, rifampin, and ethambutol) are safe during pregnancy. Other anti-Tb drugs such as
aminoglycosides (including streptomycin), fluoroquinolones, pyrazinamide (unknown effect on the
fetus) are contraindicated during pregnancy.

National Antenatal Care Guideline | February 2022 29

Key Interventions:
5.4.5a. Provide routine screening and confirmatory Tb diagnostic test or referring to a hospital and
initiating anti-Tb treatment when active Tb cases are found with isoniazid, rifampin, or
ethambutol.
5.4.5b. Provide Tb screening and diagnostic tests to the family members of pregnant women
diagnosed to have Tb infection.

5.5. Interventions for common pregnancy conditions

The anatomic and physiologic changes during pregnancy can create pain and discomfort for the
pregnant woman; these are referred to as “common pregnancy conditions.” Unlike serious illnesses
during pregnancy, common pregnancy conditions are not exceptionally harmful, rarely debilitating
condition, requiring hospitalization, or aggressive therapeutic interventions, but can be a distressing.

Many of the common pregnancy conditions are medically treatable and simple psychological
reassurance may suffice. When there is intractable pain, exaggerated pregnancy symptoms (like
persistent vomiting), and constitutional symptoms of infection, a thorough evaluation is warranted;
minor pregnancy symptoms/disorders are diagnosis of exclusion.
5.5.1. Nausea and vomiting
Nausea and vomiting of mild degree (morning sickness) is a common phenomenon experienced in
about 70% of pregnant women. It usually occurs during the first trimester of pregnancy, but up to
20% of women may experience nausea and vomiting beyond 20 weeks of gestation. Only a few
mothers (about 1%–2%) develop the severe form of nausea and vomiting (hyperemesis gravidarum)
that could result in hypotension, electrolyte imbalance, and marked weight loss in pregnant women
who are late in receiving medical treatment.
Women should be informed that symptoms of nausea and vomiting usually resolve in the second
half of pregnancy. Ginger and vitamin B6 are recommended for relief of mild degree of nausea and
vomiting in pregnancy, based on a woman’s preference and available options. Moderate to severe
degrees of nausea and vomiting need specialized care.

Key interventions:
5.5.1a. Use ginger and vitamin B6 for the relief of mild nausea and vomiting in pregnancy, based on
a woman’s preferences and available options.
5.5.1b. Refer moderate to severe nausea and vomiting to specialized care for possible inpatient
treatment.

5.5.2. Heartburn
Heartburn is one of the most common gastrointestinal problems during pregnancy and can be
experienced starting in the first trimester with increasing frequency as the pregnancy advances and
usually spontaneously ameliorates after delivery. At least 30%–50% of pregnant women experience
heartburn, mainly due to the lower esophageal sphincter relaxation effect of estrogen and
progesterone and delayed gastric emptying. It may be worsened by heavy meals, fatty and spicy
foods, chocolate, caffeine, and some drugs (such as nifedipine, chlorpromazine, promethazine,
hyoscine).

The diagnosis is based on the patient’s complaint and does not usually need further investigation.
The clinical presentation is feeling burning pain in the retrosternal area, commonly accompanied by
regurgitation, and occasionally by nausea, vomiting, indigestion, and epigastric pain.

30 National Antenatal Care Guideline | February 2022

Lifestyle modification (modifying the diet content and habit/meal frequency), not eating at bed-
time, elevating the bed/increasing pillows number, and avoiding alcohol and tobacco can improve
the heartburn episodes and severity. For persistent heartburn, antacids (the commonly available
magnesium hydroxide or magnesium trisilicate) can be prescribed. If available, calcium containing
antacids are also safe and effective. However, aluminum hydroxide antacids should not be used as
they can aggravate constipation, and there is concern of fetal neurotoxicity and developmental
delay. If the heartburn persisted after treatment with antacid, further evaluation is needed.

Key intervention:
5.5.2a. Provide magnesium and calcium containing antacids for pregnant women with persistent
heartburn (i.e., for those who do not respond to modified sleeping position, diet content,
and meal-time).

5.5.3. Constipation
Constipation is the second most common gastrointestinal disorder during pregnancy, experienced by
35%–40% of pregnant women in the first and second trimester and 20% in the third trimester, which
is also mainly associated with the bowel or smooth muscle relaxation effect of progesterone.

Mechanical causes of constipation and medical disorders predisposing to constipation (diabetes

mellitus and hypothyroidism) should be ruled out.

Adequate water intake and a high-fiber diet (wholegrain foods, fruit, and vegetables) are usually
effective in preventing constipation. Laxatives (such as lactulose, polyethylene glycol) and anti-
hemorrhoid creams should be reserved for refractory cases. Commonly used laxatives (such as
bisacodyl, mineral or castor oil) should be avoided.

Key intervention:
5.5.3a. Prevent constipation by increasing the high-fiber diet in the meal and frequency of water
intake

5.5.4. Hemorrhoid and varicose veins

Hemorrhoid (varicose veins of the lower rectum) and varicose veins of the legs are common
disorders during pregnancy. Despite the high incidence of hemorrhoids during pregnancy, many
women feel embarrassed to disclose it to their ANC providers, implying the need for enquiring about
its occurrence during ANC assessments.

Dietary modification to prevent constipation, hydrotherapy (sitz bath), avoiding prolonged sitting
and vigorous straining, and locally applying anti-hemorrhoid agents are the commonly used
conservative methods to reduce the size of hemorrhoids.

For varicose veins of the legs, mechanical compression stockings, leg elevation, not standing for long
hours, and water immersion are the recommended conservative management options.

If the above treatment options cannot bring about improvement, the woman should be referred for
further management.

Key interventions:
5.5.4a. Encourage pregnant women to make dietary and lifestyle modifications to prevent
occurrence of hemorrhoid and varicose veins.
5.5.4b. Use simple and locally available methods (like compression stockings) to ease the leg cramps
and improve the physical appearance of varicose veins.

National Antenatal Care Guideline | February 2022 31

5.5.5. Abnormal vaginal discharge
The purpose of assessing abnormal vaginal discharge is not only to alleviate the disturbing
symptoms, but also to prevent the associated pregnancy risks (preterm birth, intra-amniotic
infection, PROM, perinatal sepsis, postpartum pelvic inflammatory disease, and ophthalmia
neonatorum).

Abnormal vaginal discharge is characterized by a change in color (yellow, green, or gray), change in
odor (strong and foul odor), redness, itching, and vulval swelling or ulceration.

Syndromic management for pregnant women may increase the overtreatment and exposing the
fetus to the cocktail of drugs; therefore, if possible, etiologic diagnosis and management is
preferred.

Treatment for confirmed or suspected gonococcal infection (ceftriaxone), chlamydia (azithromycin

or erythromycin), trichomoniasis and bacterial vaginosis (metronidazole in the 2nd and 3rd
trimesters), and vulvovaginal candidiasis (miconazole, imidazole or clotrimazole) can be safely
provided to pregnant women. Simple but important is counseling pregnant women to wear loose
cotton underwear and loose-fitting clothes to reduce the risk of vulvovaginal candidiasis. For STI
suspected and confirmed cases, the partner must be treated.

Recommendation:
5.5.5a. Assess, investigate, and treat pregnant women thoroughly for abnormal vaginal discharge to
alleviate disturbing symptoms and prevent obstetric and perinatal complications.

5.5.6. Headache during pregnancy

Headache during pregnancy is a common complaint with myriad causes. More than the pain, over-
the-counter medicines use for the headache may seriously affect the pregnancy outcome,
particularly when they are taken during the first trimester.

Among widely available analgesics, paracetamol is the drug of choice for treatment of headache.
Diclofenac, ibuprofen, indomethacin, and naproxen should not be given to pregnant women in the
first and third trimester. Take note that untreated headache may cause depression and hypertension.

Also note that until proved otherwise, worsening of headache, headache not responding to simple
analgesics, and new onset headache during pregnancy require thorough evaluation.

Key interventions:
5.5.6a. Investigate new onset of headache that is not responding to simple analgesics and is
progressing, as it may be a symptom of an underlying serious disorder deserving thorough
investigation or referral.
5.5.6b. Paracetamol is the drug of choice for treatment of headache during pregnancy.

5.5.7. Treatment of low-back pain, pelvic pain, and leg cramps

Low-back and pelvic pain are very common during pregnancy, even more common among women
with a history of low-back pain in the previous pregnancy and in non-pregnant state. The lumbar
lordosis to balance the growing uterus, increasing body-weight gain, and ligamentous laxity (relaxin,
estrogen, progesterone effect) impact gravitational and mechanical load to the lumbosacral strain,
can cause pain in some women.

32 National Antenatal Care Guideline | February 2022

In the management of low-back and pelvic pain during pregnancy, prevention through ergonomics
(teaching the correct posture for standing, walking, bending and type of shoes) is recommended.
There are several treatment options that can be used, such as physiotherapy and support belts,
based on a woman’s preference and available options.

Note: While exercise is helpful to relieve low-back pain, it could exacerbate pelvic pain associated
with symphysis pubis dysfunction and is not recommended for this condition.

Leg cramps often occur at night and can be very painful, affecting sleep and daily activities. The
potential etiology attributed to leg cramps is nutritional deficiency. Magnesium, calcium, or non-
pharmacological treatment options can be used for the relief of leg cramps in pregnancy, based on a
woman’s preference and available options.

Wearing low-heeled shoes, sitting with the knee flexed and back straight with good support,
avoiding weight-bearing activities and climbing stairs, and applying heat or massage to painful areas
are also recommended.

Above all, the musculoskeletal pains are a diagnosis of exclusion; therefore, other serious disorder or
infection should be excluded with meticulous evaluation before embarking on the diagnosis of
pregnancy-related low-back or pelvic pain.

Key interventions:
5.5.7a. Reassure the pregnant women that low-back pain, joint pain, and abdominopelvic pain are
temporary problems and can be soothed with non-pharmacological methods and simple
analgesics.
5.5.7b. Create awareness of the risks of use of unverified over-the-counter medicines for minor
pregnancy-related pains.

National Antenatal Care Guideline | February 2022 33

6. Health Systems Interventions to Improve the Utilization
and Quality of Antenatal Care
Implementing evidence based health system interventions is needed to increase ANC service
utilization, ensure equity and quality as well as an effective referral system, and improve clients’
satisfaction. The health system is not limited to availing and sustaining the required resources and
systems at the health facility level, but it includes community and program design, implementation,
follow-up, and performance evaluation.

6.1. Introducing woman-held case notes

Pregnant woman attending ANC should be given their own case notes (home-based records) to carry
during pregnancy. Women are expected to bring them to each ANC visits. If women 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. Women-held case notes might also be an effective tool to
improve health awareness and client–provider communication. Inadequate infrastructure and
resources often hamper efficient recordkeeping; 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. A separate A4 size, double-sided piece of card has been prepared to document
summary findings and interventions at each ANC contacts (Annex 12).

6.2. Creating a woman-friendly environment

Pregnant women coming for ANC require a welcoming environment at health facilities in addition to
the actual medical service. Reducing waiting time, arranging convenient time for service, flexible
time for reception and culturally sensitive environment are useful to encourage women to initiate
ANC and remain in follow-up. In rural areas, in particular, pregnant women like to use the
opportunity of a market day for ANC service utilization.

Therefore, adjusting timing to the majority of pregnant women’s preferences and at least ensuring
ANC services 8-hours a day on all working days is a strategic decision health facilities need to
undertake.

6.3. Pregnancy support during public health emergencies

Public health emergencies such as pandemics can affect provision of essential services. The recent
COVID-19 pandemic resulted in disruption of essential services due to shortages of human resource,
disruption of supply chain, overstretching health facilities, and reduced demand of services due to
fear of infection. Evidence in West Africa during Ebola virus epidemic showed that the number of
deaths due to measles, malaria, HIV/AIDS, Tb, and among mothers, infants, and newborns,
attributed to health system failure, were much higher than those who died from Ebola virus. Hence,
it is important to ensure continuity of essential services including ANC for women during public
health emergencies. For ANC contacts, this can be ensured by extending dates of appointments for
pregnant women who do not have danger signs and pregnancy-related problems, remote
monitoring by phone as needed at the time of their regular appointment date, or HEWs can provide
services for healthy pregnant mothers and can refer to the health facility for any problem, until the
pandemic gets controlled. It is also important to ensure that pregnant women are protected from
being infected and should be screened during their ANC follow-up.

34 National Antenatal Care Guideline | February 2022

6.4. Caring for women with special needs
Women with mental or physical disabilities, adolescents, survivors of gender-based violence, FGM,
and women with physical disabilities have special needs and require care in addition to the core
components of basic care. They may need help in communication, self-care, movement and decision
making.

An important goal in caring for women with special needs during pregnancy is to determine whether
their needs require specialized care/referral or whether the service provider can address them
appropriately during the ANC contacts. It is the service provider’s responsibility to ensure that all
relevant information is made available to other providers in the same health facility or in another
level of care if she is referred. This may include:
 Providing all information related to the special needs that have been identified.
 Counseling and making special recommendations about the woman’s care during the antenatal,
labor/birth, and postpartum periods; referral to specialized care; or supportive services as
indicated.
 Facilitating linkages as appropriate with local sources of support (adolescent/youth corners, one-
stop crisis center, social welfare, peer support groups, community service organizations, etc.). A
key role of the health worker includes linking the health services with the community and other
available support services. Maintaining existing links and, when possible, exploring needs and
alternatives for support through community groups, women groups, leaders, peer support
groups, other health service providers and community counselors.
6.4.1. Supporting pregnant women during humanitarian crisis
In humanitarian/emergency settings apart from providing shelter, nutrition, water, sanitation, and
essential health care, including treatment of injuries to affected community, special attention must
be paid to pregnant women and newborn babies, who are the most vulnerable in such
circumstances. Pregnancy is a period of transition with important physical and emotional changes.
Even in uncomplicated pregnancies, these changes can affect the quality of life for pregnant women,
affecting both maternal and infant health. Hence, pregnant women are even more vulnerable during
crisis situations and need to be provided with an appropriate support for safe pregnancy and
delivery.

The assigned responsible health personnel in internally displaced people (IDP) sites should register
pregnant women and remind them their appointment time and ensure follow-up by available
personnel, including HEWs with available materials and counseling on nutrition and danger
symptoms and signs. Moreover, additional rations of food, clean drinking water, and warm clothes
to pregnant women should be availed. The register should include estimated date of delivery to
facilitate referral or linkage to nearby health facility during onset of labor. Additionally, the
responsible person in the IDP site should have ambulance address or contact for emergency referral.
Information should be provided about availability of safe delivery and emergency obstetric and
newborn care (EmONC) services and the need to seek care from facilities with a 24 hours per day, 7
days per week referral system to facilitate transport for delivery.

During humanitarian crisis, home delivery and unhygienic delivery is common, which potentially
expose mothers and newborns to postpartum infections. To avert this, it is important to avail
essential supplies at the IDP site in the form of kits such as clean delivery kits containing sterile
supplies such as razors, plastic sheet, gloves, and other essential items to facilitate safe births, as
well as “dignity kits” that contain hygiene materials such as sanitary napkins, underwear, soap and
shampoo. Clean delivery kits have been a great help in decreasing incidences of infection for
mothers and their babies if health facility delivery services are not available nearby. It is important to
work with pregnant women on birth plans, including support for an evacuation plan in case of
pregnancy or delivery related complications.

National Antenatal Care Guideline | February 2022 35

6.5. Digitizing the health system
Digitalizing the health system can increase the quality and utilization of ANC. Strengthening and
expanding the ongoing momentum and piloting efforts to use electronic medical records to include
secondary data sources (detailed medical records) can improve ANC and improve the health facility
data documentation and ease of access for service and analysis. The electronic medical records will
also be an advantage for establishing an electronic inter and intra-facility referral and feedback
system.

6.6. Enhancing the capacity of ANC providers

To enhance the competence of health care providers, this guideline must be part of the trainings
packages such as BEmONC, CEmONC, and Catchment Based Clinical Mentoring for Reproductive,
Maternal, Newborn, Child, Adolescent and Youth Health Program as well as all relevant management
protocols. Additionally, the guideline must be accessible to all providers and stakeholders in the
form of hard copy, electronically, and uploaded on websites, such as the MoH and others.
Furthermore, on-the-job training, mentorship and other relevant trainings such ultrasound trainings
for middle level health care providers need to be strengthened as part of quality improvement
efforts.

6.7. Integrating other RH services within the ANC package

ANC is a golden opportunity for women to get information and RH and non-RH services for
themselves and their families. The ANC providers can use the opportunity to give an overview of the
RH services that are available during and after the pregnancy (Annex 3).

6.8. Community engagement to increase ANC coverage

Community engagement is effective in promoting the quality of ANC services when the right
strategies are used. Community engagement for ANC is mainly aimed to create demand for ANC,
reduce dropout rates, promote service utilization, and enhance partner/male/ involvement. The
approach includes strengthening/reactivating:
 Strengthening women development army
 Strengthening health extension program
 Applying community score card
 Regularly conducting pregnant women’s conferences
 Pregnant women mapping and tracing
 Partner/male engagement in the continuum of care

Essentially, the future community mobilization initiatives have to be innovative, preferably

technology-driven, and affordable.

6.9. Continuous quality improvement

Quality improvement (QI) is a continuous process whereby organizations iteratively test and
measure changes in work routines, set and achieve ambitious aims, shift whole-system performance,
and spread best practices for rapid uptake at a larger scale to address a specific issue or suite of
issues they have determined to improve.

Continuous quality improvement (CQI) is one of the main means to achieve the intended goal of
ANC—positive pregnancy experience. Poor quality of ANC could create a negative experience for a
pregnant woman, which leads to poor demand and utilization of services. In addition, the quality of
ANC service influences women’s health care seeking behavior. Effective communication skills would

36 National Antenatal Care Guideline | February 2022

help to improve health care delivery. Receiving good quality ANC is an important factor to complete
eight or more ANC contact. Hence, it is advised to continuously monitor the quality of ANC service to
institute further improvements as required using a standardized tool (Annex 10).

ANC is expected to fulfill the principles of client satisfaction, scientific, and team approaches.
Important considerations in QI of ANC service include:
 Ensure MCH head is member of the QI committee of the health facility
 Establish QI team at ANC or MCH department
 Use kaizen and model for improvement methods to improve ANC service
 Conduct clinical audit regularly using national clinical audit tool and design QI projects based on
identified gaps (Annex 10 national clinical audit tool for hospital [HSTQ] and health center)
 Identify gaps and prioritize depending on the findings of HMIS, KPI, administratively tracked
evidences and surveys
 Design QI projects, test, implement and monitor using appropriate quality measures based on the
quality gap assessment.
 Select quality indicators for ANC, display using dashboard and monitor the selected indicators
 Participate and present QI projects on learning sessions and review meetings

The CQI assessment can be done at the facility or at the client's level. In this case, facility-based CQI
assessment is crucial, as the health care provider can use the facility-based checklist to assess health
professionals' performance against the minimum standard of ANC service, either as a team within
the health facility or by an external team, to track the health services' progress.

6.10. ANC guideline implementation considerations

The major purpose of pre-service education and in-service training (basically, in the form of basic
and comprehensive emergency obstetric and newborn care [BEmONC/CEmONC]) is to improve
clinical evaluation and develop decision-making capacity in ancillary investigation and treatment
plan. By updating this guideline for those who are on job and incorporating it into the pre service-
curriculum, ANC programmers and service providers will be familiar with the ANC guideline. In due
course, it will be fully implemented in the Ethiopian health system.

All stakeholders in RH service delivery should be committed and actively involved in fully
implementing this guideline to achieve the expected outcomes. The roles and responsibilities of
each stakeholder are stated below in Section 6.11.

Therefore, considerations in implementing the guideline include:

 Identifying and mobilizing all the required resources and stakeholders necessary to
implement the guideline;
 Availing all the required infrastructure, drugs, equipment, supplies, and personnel
 Introducing and disseminating the guideline to all relevant health care providers and
stakeholders at all levels through in-service trainings (on-site and off-site), workshops, and
web-based platforms;
 Creating easy and continuous access to hard copy and soft copy of the guideline for all
stakeholders involved in implementation of ANC;
 Ensuring appropriate implementation of ANC interventions at all service delivery points
through a continuous quality improvement process.

National Antenatal Care Guideline | February 2022 37

6.11. Roles and responsibilities
6.11.1. Ministry of Health
 Disseminate ANC guideline, develop standardized job aids, and standard operating
procedures that emphasize eight contacts in a health facility.
 Ensure coordination among responsible directorates and supporting the implementation of
the guideline.
 Monitor the implementation status of ANC interventions through regular supportive
supervision, review meeting, evidence generation and program evaluation.
 Update training materials and provide integrated refresher training as per the guideline.
 Mobilize resource for the implementation of ANC interventions.
6.11.2. Regional health bureaus, zonal health departments, and woreda health offices
 Coordinate and monitor the role of government organizations, non-governmental
organizations, faith-based and community-based organizations, and private sector to
implement the guideline.
 Cascade dissemination of guideline to stakeholders.
 Provide training of health care workers.
 Improve human resource, supplies, and equipment in health facility to provide quality ANC
and increase uptake of ANC.
 Increase community engagement through available communication channels.
 Ensure coordination among responsible core processes/programs and coordinators to
support health facilities in the implementation of the guideline.
 Monitor the implementation status of the guideline through regular supportive supervision
and review meeting
 Coordinate and expand maternity waiting home
 Strengthen referral linkage from health post to health center, and from health center to a
hospital.
6.11.3. Health facilities
 Ensure facility readiness and preparedness (facility set up with clean and well equipped
facilities with uninterrupted supply of water and electricity, human resource, supplies, and
equipment) to implement the guideline.
 Avail ANC guideline and relevant protocols, job aids, and information, education, and
communication materials.
 Strengthen referral linkage with catchment health posts (health centers), and catchment
health centers (hospitals).
 Coordinate community participation and engagement to strengthen the implementation of
ANC guideline.
 Conduct regular clinical audit

6.11.4. Partners and professional associations

 Support financially and technically the government’s efforts at all levels in disseminating and
implementing the guideline.

38 National Antenatal Care Guideline | February 2022

  Coordinate their effort with government, non-governmental, faith-based and community-
based organizations, and private sector to fully and effectively implement the all over the
country.
 Participate actively in the CQI process
 Advocate for and conduct sensitization on ANC guideline.

6.11.5. Health care providers

 Ensure the provision of ANC as per the recommendation of the guideline.
 Update themselves regularly on the ANC guideline and related protocols.
 Ensure availability of the new guideline, relevant protocols, and job aids
 Ensure availability of adequate supplies and materials required to implement the ANC
interventions in collaboration with their respective managers.
 Participate actively in community engagement for ANC.
 Ensure timely documentation and reporting of ANC service indicators.

6.11.6. Health post

The type and number of service packages and interventions to be delivered through the Health
Extension Program (HEP) vary depending on the health post categories, i.e., comprehensive, basic,
and integrated health posts.

Comprehensive health post

According to the list of HEP service packages and interventions by service delivery outlets on the
Implementation Manual for Optimizing Health Extension Program, maternal health services related
to ANC that are delivered at a comprehensive health post include promotion of early ANC, PMTCT,
maternal nutrition, birth preparedness and complication readiness, danger signs, and maternal
waiting home services. Human resource have been planned accordingly, until 2025, to include teams
of different professions such as health officer, midwives, nurses, and Level 4 HEWs with availability
of laboratory tests as described in detail in the implementation manual. Therefore, all components
of new ANC guideline, in particular to eight contacts, will be provided at this category of health post
if the basic conditions such as availability of lab services, aforementioned human resources, etc. are
fulfilled.

Basic health post

Among the major packages and interventions outlined for basic health post, promotion of early ANC,
maternal nutrition, birth preparedness, complication readiness, danger signs, maternity waiting
services, skill delivery, and postpartum care are well addressed in the implementation manual for
optimizing the HEP and will be delivered by two level-IV HEWs and a nurse or family health
professional.

Likewise, the role of HEW in delivering ANC interventions at first ANC contact and at subsequent
contacts in this category of health post is inconsistent across the eight contacts mainly due to
unavailability of laboratory tests and imaging at this level. However, other components of ANC care
(first contact and follow up contacts) such as past and current pregnancy history, current pregnancy
follow-up, and routinely administered prophylaxis (except Anti-D for Rh negative) can be managed at

National Antenatal Care Guideline | February 2022 39

this category of health post. Besides, the essential laboratory tests and ultrasound scanning,
particularly during the first contact and during the subsequent contacts, would need to be done by
the catchment or supervisory health center, based on the existing referral system platform (Annex
11). Furthermore, HEW together with village health leaders (who are educated and at least above
6th grade) will actively participate in early identification of pregnant women and referring to the
supervisory or catchment health center. Some of highlight activities that should be delivered by
village health leaders include:

 Strengthen awareness creation to increase up take of early ANC through existing platform:
women development army, men development groups, youth groups, and social structures.
 Conduct community mobilization about the importance of early ANC attendance and follow-up.
 Create awareness about danger sign occurring during pregnancy and refer to nearest health
centers if encountered.
 Support the community in arranging available transportation of pregnant women to health
centers.
 Collaborate with local administrator to strengthen maternity waiting home (both financial and
in-kind).
 Facilitate and support regular pregnant women conference.

Merged health post

Merged HEP services are defined as HEP-essential packages that include health promotion, disease
prevention services, to be provided in integration with health centers’ routine health care services in
the areas where health post is located within the compound of, or too close to, the health center or
primary hospital. In this category of health post, promotion of early ANC, PMTCT, maternal nutrition,
birth preparedness, complication readiness, counseling on danger signs, and maternity and waiting
services are the main tasks of HEWs. However, routine ANC service delivery should be carried out in
the health center that is merged with the health post.

6.12. ANC monitoring and evaluation

6.11.1. Documentation and reporting
Documentation and reporting provide the means to assess coverage, effectiveness, and quality of
services delivered and promotes a culture of continuous quality improvement within the health
system. Through effective monitoring and evaluation, program results at all levels can be measured
to provide the basis for accountability and decision-making at both program and policy level.
There are different dimensions of data quality. To ensure appropriate targeting and planning, it is
crucial that data are precise, complete, timely, reliable, and accurate.

All ANC information and findings should be documented in the ANC card in hardcopy or electronic
record and ANC register. The task of filling each data entry should be designated to trained health
staff in each antenatal clinic. At the end of each week, the supervisor should coordinate the
completion of the ANC report and ensure that respective sections have made their submission in full
and on time. The health facility supervisor is also responsible for ensuring the completeness of
record entries and for monitoring the upkeep of the registers on a regular basis. The list of ANC
indicators for M&E as well as their definition, frequency and source are included in Annex 13 and 14
respectively.

40 National Antenatal Care Guideline | February 2022

Key intervention:
6.1–6.5. a. Introduce woman-held case notes, create a welcoming health facility’s environment, care
for women with special needs, digitalize the health system to improve the quality and
utilization of ANC
6.1-6.5. b. Avail all the required infrastructure, drugs, equipment, supplies, and personnel to
implement ANC interventions
6.7a. Strengthen pre-service training, on-job training, mentorship, and supervision focusing on the
interventions of this guideline.
6.8a. Introduce RH service integration into routine ANC to use the opportunity to address common
RH problems of women
6.9a. Strengthen women development army, community-based joint forum, and family/partner
engagement to increase public awareness and demand for ANC and delivery services
6.9–6.12. Instituting continuous quality improvement and improving documentation and reporting
of ANC.

National Antenatal Care Guideline | February 2022 41

 ANNEXES

42 National Antenatal Care Guideline | February 2022

Annex 1. Glossary
 Antenatal care (ANC) is a broad term to describe medical care provided by a skilled health care
professional for pregnant women, aiming to make every pregnancy end with a healthy mother and
baby and is positively experienced.
 ANC coverage is the proportion of pregnant women who received at least one ANC contact provided by
skilled health personnel.
 Routine ANC applies to all pregnant women without specific pregnancy-related complications.
 ANC 8 is the proportion of pregnant women who received at least eight ANC contacts provided by skilled
health personnel.
 Skilled health personnel for ANC includes medical doctors, integrated emergency surgical officers,
midwives, and nurses who are trained to provide medical services to pregnant and postpartum women
as per the guideline and minimum standard of practice.
 Effective ANC is measured by the achievement of 1) preventing, detecting, and treating concurrent
diseases and disorders; 2) linking to skilled health personnel-attended delivery; 3) ending preventable
maternal and perinatal deaths; 4) ending near-miss cases; and 5) adherence to postpartum/postnatal
counseling.
 Quality ANC provides safe, effective, timely, efficient, equitable, and pregnant woman-centered service
and achieves a healthy mother, healthy baby, and a positive pregnancy experience.
 Package of ANC is summarized as: 1) provision of effective clinical services (diagnostic and therapeutic)
to pregnancy and pregnancy-unrelated problems, 2) establishing effective communication and
providing relevant and timely information to pregnant women and accompanier, and 3) providing
psychosocial and emotional support when need arises.
 Sub-optimally dated pregnancy refers to the last normal menstrual period (LNMP)-based gestational age
determination with no ultrasound confirmation before 24 weeks’ gestation or ultrasound-based
gestational age estimation after 24 weeks.
 Woman-centered care creates a comfort zone for pregnant women to let them freely communicate with
ANC providers and have active participation in the decision-making process, by making the ANC service
provision informative, supportive, individualized, and woman-centered at every contact. Woman-
centered care is not about convincing a pregnant woman, but about encouraging and empowering her
to make the right decision by allowing her privacy for examination, agreeing on psycho-sensitive
investigations, adhering to treatment, continuing future follow-up, and making preparation for birth.
 Three-steps of ANC consultation—including introductory phase or opening the conversation, discussing
pregnancy in detail (including history taking and physical examination), and providing basic information
(counseling on danger symptoms, birth preparedness, complication readiness, companionship,
integrating to other health issues as well as promoting self-care)—primarily are intended to ease and
relax the pregnant woman, build her confidence, and end with key remarks.
 Ensuring continuity of ANC service utilization is an all-round effort to make sure that pregnant women
will be regular clients until the end of pregnancy and are prepared for health facility delivery.
 Creating a welcoming environment for ANC during each contact requires easing access; showing respect
and politeness; creating physical and psychological comfort while the pregnant woman is at the
reception and in the examination, investigation, and counseling rooms.
 Ensuring privacy and confidentiality for pregnant women—avoiding exposing private parts of her body
without her awareness and consent and assuring confidentiality.
 Showing empathy and compassion means being compassionate, respectful, and caring to build a
pregnant woman’s confidence and let her express her feelings and concerns.
 Practicing respectful maternity care is being compassionate, respectful, and caring to get full information
and allow the woman to give informed consent ahead of the examination and procedure, decline any
treatment or procedure, have privacy during examination/procedure, and freely express her views or
ask questions.

National Antenatal Care Guideline | February 2022 43

Annex 2. Medical, Surgical, Psychiatric, and Obstetric
Problems Requiring specialized ANC
Women with one or more of the following Women with one or more of the
medical, surgical, or psychiatric disorders following ob/gyn problems

 Chronic obstructive lung disease  Multiple pregnancy

 Chronic hypertension  Post-term pregnancy
 Cardiac disease  Having a previous uterine scar
 Chronic renal failure  Decreased fetal movement/growth
 Chronic hepatic disease  History of or diagnosed to have:
 Diabetes mellitus • Recurrent miscarriage, small-for-gestational-
 Thyroid dysfunction (hypo or age or preterm birth, stillbirth, antepartum
hyperthyroidism) hemorrhage, prelabor rupture of fetal
membranes
 Hematologic disorders
 Gross congenital anomaly
 Epilepsy on treatment
 Cerclage, LEEP, cone biopsy of cervix
 Autoimmune disease
 Diagnosed to have severe pre-eclampsia/eclampsia
 HBV or HCV infection
 Rh sensitized
 Severe psychiatric disorders
 Placental accreta syndrome
 Malignancy
 Puerperal psychosis
 Obesity (BMI ≥30 kg/m2)
 Pelvic mass, extensive genital wart
 Surgical problem/scar
 Mullerian anomaly
 All severe anemia, mild to moderate anemia
not responding to iron treatment  FGM (Type III scar)
 Transverse lie or breech at term
 Suspected macrosomia or fetal growth restriction

44 National Antenatal Care Guideline | February 2022

Annex 3. Reproductive Health Services That Can Be
Integrated into ANC
Gestational Possible RH services that can be integrated
age in weeks
1st contact  Better to be specific to ANC proper; adding further assessment and provision may be
overwhelming
 PMTCT for HIV
 Screening for nutrition

2nd contact  Preventing sexual and gender-based violence, discussing domestic violence
( 20 weeks)
 Screening for cervical cancer
 Screening and treating reproductive tract infection and STI
 Counseling on postpartum family planning to increase birth spacing and prevent
unplanned pregnancy
3rd, 4th contacts Counseling on:
(26–30 weeks)  Completion of the Td vaccination for herself after birth and Expanded Programme on
Immunization for her baby
 FGM prevention and management if indicated
 Prevention of child marriage and teenage pregnancy
 Obstetric fistula symptoms and availability of treatment
 Postpartum family planning

Counseling on:
5th, 6th contacts  Postpartum family planning
(32–36 weeks)
 Early initiation of breastfeeding within 1 hour after delivery and colostrum feeding
 Exclusive breastfeeding for 6 months and total breastfeeding for 2 years, and
avoiding pre-lacteal feeding

National Antenatal Care Guideline | February 2022 45

Annex 4. Key Activities in the Continuum of Maternity Care

 Screening and treating chronic medical disorders, including hypertension, diabetes

mellitus, organs dysfunction, anemia, and infection.
 Preventing vertically transmissible infections, including HIV, syphilis, hepatitis virus,
Pre-pregnancy

malaria.
 Preventing unplanned pregnancy by promoting family planning.
 Planning pregnancy with good health and good nutrition.

 Promoting early initiation and continuation of antenatal care.

 Implementing 8 ANC contacts for pregnant women with no complications.
 Improving the quality of ANC by applying all the package.
 Practicing an early detection and treatment of HIV, syphilis, HBV, and others to
Pregnancy

prevent vertical transmission and improve maternal health.

 Preparing pregnant women for health facility delivery and postnatal care and service
integration.


 Routinely follow up of active first stage of labor with partograph.

 Providing optimal and safe obstetric care, including providing operative delivery.
 Providing prophylactic antibiotics if caesarean section is indicated, and 3 rd or 4th degree
Labor and

perineal tear is encountered.

Delivery

 Testing and treating the mother and her partner for HIV, syphilis, and HBV.

 Providing basic newborn care, initiating exclusive breastfeeding, vaccination for polio,
BCG , and HBV.
 Providing HIV PCR testing for the infant of HIV positive mothers.
 Administering ARV prophylaxis for HIV and HBV exposed infants.
Post-delivery

 Treating syphilis exposed newborns (if eligible). *

 Counseling on family planning, child immunization, screening for cervical cancer.
 Providing contraceptive method of woman’s choice.

 Promoting antenatal care including early initiation of ANC, skilled delivery women’s
and girls’ rights protection, family planning, testing for HIV, syphilis, HBV, and Tb.
 Working with the community to change health seeking behavior of women during
Community

pregnancy and delivery, to eliminate home delivery, FGM, child marriage and marriage
by abduction.
 Praising advocates and practitioners against harmful traditions.

* If the mother was not treated or partially treated (<3 doses of benzathine
penicillin) or treated in <4 weeks before delivery.

46 National Antenatal Care Guideline | February 2022

Annex 5. Checklist for Counseling Danger Symptoms and
Signs of Pregnancy During ANC
Clinical ANC contacts
Symptoms/signs
problem 1 2 3 4 5 6 7 8
Spontaneous Vaginal bleeding, lower abdominal pain
abortion
Pre- Throbbing and persistent headache
eclampsia/
eclampsia Blurring of vision

Epigastric or right upper quadrant abdominal pain

Petechial rash, swelling of fingers and face

Convulsion or coma for the first time

PROM leakage of fluid per vagina

Antepartum vaginal bleeding

hemorrhage
Gonococcal Foul smelling vaginal discharge
cervicitis
Acute Flank pain, fever, dysuria, nausea and vomiting, may be
pyelonephritis hematuria

Fetal growth No or little change in abdominal growth

restriction
Fetal jeopardy Decreased or absent fetal movement

Others Yellowish discoloration of eyes and skin

Persistent cough, fast or difficult breathing

Recurrent fainting

Fast abdominal girth increment

Unilateral leg swelling

Shaded areas show the less probability of the occurrence of the specified health problem

National Antenatal Care Guideline | February 2022 47

 Annex 6. Four Page ANC Card (baseline and follow-up sheet)
Name: _______________________________Age: ___________years; Telephone________________
1. Residence: 1. Urban 2. Rural
2. Occupation: 1. Employed 2. Unemployed
3. Marital status: 1. Married 2. Divorced 3. Widowed 4. Separated 5. Single
4. Gravida _________Para_________ Abortion ________Ectopic pregnancy_______GTD_________
5. LNMP____/______/_____GA ________weeks; EDD____/___/_____. (First contact)
6. Gestational age from early ultrasound ______________weeks (Date estimated: ___/___/_____)
Put a check mark for Yes (√) and X mark for No response (First contact)
Past pregnancy history Yes No Note/Description
Did you have a history of:
 spontaneous abortion?
 induced abortion?
 stillbirth?
 congenital anomaly?
 low birth weight (<2.5 kg)?
 macrosomia (≥ 4kg)?
 preterm birth?
 early neonatal death?
 leakage of fluid per vagina (PROM)?
 vaginal bleeding after 7 months (antepartum hemorrhage)?
 hypertensive disease?
Did you deliver by cesarean section?
Did you deliver by vacuum or forceps?
Did you have another surgery on reproductive tract?
(myomectomy, LEEP, Cerclage)
Did you experience any other problem?
Current pregnancy history
Is this pregnancy planned?
Are you from malaria endemic area?
Are you diagnosed to have:
 diabetes mellitus?
 cardiac disease?
 hypertension?
 any other chronic illness?
Do you have any question before proceeding?

48 National Antenatal Care Guideline | February 2022

Date in Ethiopian calendar

Gestational age in weeks

Contacts 1st 2nd 3rd 4th 5th 6th 7th 8th
Current pregnancy follow-up sheet Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Is this pregnancy supported?
Are you feeling fetal movement well?

Is your abdominal growth good?

Is your weight gain good?

Do you have any medical problem this time?
Do you use any substance or drug?

Do you feel any pain or some other symptom?

Is your husband accompanying you today?

If yes, will you call him to come?

May I request you to express your feeling?

Do you have any more question I can answer?

Blood pressure (systolic/diastolic)

Mid-upper arm circumference (MUAC) in cm

Body weight in kg/height in meter

Palm and conjunctivae color (pink, pale)
Symphysis fundal height

Fetal heart beat (FHB) (+Ve/-Ve)

Presentation (cephalic/breech/transverse lie)

National Antenatal Care Guideline | February 2022 49

Laboratory tests, ultrasound scanning, and routine prophylaxis

Date in Ethiopian calendar

Gestational age in weeks <12 20 26 30 34 36 38 40

Contacts 1st 2nd 3rd 4th 5th 6th 7th 8th
Lab tests and imaging

 Hemoglobin/hematocrit

 Blood group and Rh

 Urine analysis (dipstick for protein)

 Urine gramstain

 HIV

 Syphilis

 HBV

 Obstetric ultrasound

 OGTT (selected cases)

Routinely administered prophylaxis:

 Number of iron-folic acid (IFA) tabs supplemented

 Number of IFA tabs consumed

 Calcium

 Td (at least 2–3 doses, 4 weeks interval)

 Deworming after the first trimester

 Anti-D for Rh negative and indirect Coomb’s negative

50 National Antenatal Care Guideline | February 2022

Summarizing the major findings and planning intervention in each contact
Date in Ethiopian calendar

Gestational age in weeks

Contacts 1st 2nd 3rd 4th 5th 6th 7th 8th

Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

Hyperemesis gravidarum

Anemia (Hb <11.5 gm/dl or Hct < 36%)

Thinness (MUAC < 23 cm)

Asymptomatic bacteriuria
Recurrent urinary tract infection (UTI)

HIV

Syphilis
Malaria

Tuberculosis (Tb)
Headache (H), Low-back pain (L)

Hemorrhoid (H), Varicose veins (V)

Constipation (C), Heartburn (H)

Uterus size large (L) or small (S) for date

Breech (B) or transverse lie (T) at term

Counseling on lifestyle modification

Counseling on danger symptoms

Counseling on birth preparedness and complication readiness

Counseling on optimal maternal nutrition

National Antenatal Care Guideline | February 2022 51

Annex 7: The BMI Scale (to check pre-pregnancy BMI)
Weight in kilograms
45 48 50 53 55 58 60 63 65 68 70 73 75 78 80 82.5 85 87.5 90
145 21.4 22.8 23.8 25.2 26.2 27.6 28.5 30.0 30.9 32.3 33.3 34.7 35.7 37.1 38.0 39.2 40.4 41.6 42.8
147 20.8 22.2 23.1 24.5 25.5 26.8 27.8 29.2 30.1 31.5 32.4 33.8 34.7 36.1 37.0 38.2 39.3 40.5 41.6
150 20.0 21.3 22.2 23.6 24.4 25.8 26.7 28.0 28.9 30.2 31.1 32.4 33.3 34.7 35.6 36.7 37.8 38.9 40.0
152.5 19.3 20.6 21.5 22.8 23.6 24.9 25.8 27.1 27.9 29.2 30.1 31.4 32.2 33.5 34.4 35.5 36.5 37.6 38.7
155 18.7 20.0 20.8 22.1 22.9 24.1 25.0 26.2 27.1 28.3 29.1 30.4 31.2 32.5 33.3 34.3 35.4 36.4 37.5
157.5
Height in centimeters

18.1 19.3 20.2 21.4 22.2 23.4 24.2 25.4 26.2 27.4 28.2 29.4 30.2 31.4 32.2 33.3 34.3 35.3 36.3
160 17.6 18.8 19.5 20.7 21.5 22.7 23.4 24.6 25.4 26.6 27.3 28.5 29.3 30.5 31.3 32.2 33.2 34.2 35.2
162.5 17.0 18.2 18.9 20.1 20.8 22.0 22.7 23.9 24.6 25.8 26.5 27.6 28.4 29.5 30.3 31.2 32.2 33.1 34.1
165 16.5 17.6 18.4 19.5 20.2 21.3 22.0 23.1 23.9 25.0 25.7 26.8 27.5 28.7 29.4 30.3 31.2 32.1 33.1
167.5 16.0 17.1 17.8 18.9 19.6 20.7 21.4 22.5 23.2 24.2 24.9 26.0 26.7 27.8 28.5 29.4 30.3 31.2 32.1
170 15.6 16.6 17.3 18.3 19.0 20.1 20.8 21.8 22.5 23.5 24.2 25.3 26.0 27.0 27.7 28.5 29.4 30.3 31.1
172.5 15.1 16.1 16.8 17.8 18.5 19.5 20.2 21.2 21.8 22.9 23.5 24.5 25.2 26.2 26.9 27.7 28.6 29.4 30.2
175 14.7 15.7 16.3 17.3 18.0 18.9 19.6 20.6 21.2 22.2 22.9 23.8 24.5 25.5 26.1 26.9 27.8 28.6 29.4
177.5 14.3 15.2 15.9 16.8 17.5 18.4 19.0 20.0 20.6 21.6 22.2 23.2 23.8 24.8 25.4 26.2 27.0 27.8 28.6
180 13.9 14.8 15.4 16.4 17.0 17.9 18.5 19.4 20.1 21.0 21.6 22.5 23.1 24.1 24.7 25.5 26.2 27.0 27.8
182.5 13.5 14.4 15.0 15.9 16.5 17.4 18.0 18.9 19.5 20.4 21.0 21.9 22.5 23.4 24.0 24.8 25.5 26.3 27.0
185 13.1 14.0 14.6 15.5 16.1 16.9 17.5 18.4 19.0 19.9 20.5 21.3 21.9 22.8 23.4 24.1 24.8 25.6 26.3
187.5 12.8 13.7 14.2 15.1 15.6 16.5 17.1 17.9 18.5 19.3 19.9 20.8 21.3 22.2 22.8 23.5 24.2 24.9 25.6
190 12.5 13.3 13.9 14.7 15.2 16.1 16.6 17.5 18.0 18.8 19.4 20.2 20.8 21.6 22.2 22.9 23.5 24.2 24.9

52 National Antenatal Care Guideline | February 2022

Annex 8. Common Macro and Micro Nutrient Sources

Nutrient type Some of the best sources

Grains (wheat, sorghum, corn, barley), dairy products (milk, cheese,

Calorie
butter), fruits, poultry (egg, chicken), fats and oils, sugar, honey, etc.

Beef, fish, chicken, eggs, milk, cheese, beans and peas, nuts, seeds,
Protein
etc.
Red meat, liver, poultry, fish, dried beans and peas, iron-fortified
Iron
cereals, etc.

Folate Green leafy vegetables, orange, beans, liver, folic acid, etc.

Vitamin A Carrots, sweet potatoes, green leafy vegetables, etc.

Iodine iodized salt, sea/ocean food, dairy products, etc.

Zinc Liver, kidney, red meat, poultry, fish, etc.

National Antenatal Care Guideline | February 2022 53

Annex 9. Principles of ANC
 Care for women with a normal pregnancy and birth should promote normal reproductive processes
and women’s inherent capabilities

 Pregnancy and birth should be viewed as a natural process in life and essential care should be
provided to women with the minimum set of interventions necessary.

 Care should be based on the use of appropriate technology

 Sophisticated or complex technology should not be applied when simpler procedures may suffice or
be superior.

 Care should be evidence-based

 Care should be supported by the best available research, and by randomized controlled trials where
possible and appropriate.

 Care should be local

 Care should be available as close to the woman’s home as possible and based on an efficient referral
system

 Care should be multidisciplinary

 Effective care may involve contributions from a wide range of health professionals, including
midwives, general practitioners, obstetricians, neonatologists, nurses, and childbirth and parenthood
educators.

 Care should be holistic

 Care should include consideration of the intellectual, emotional, social, and cultural needs of women,
their babies and families, and not only their physical care.

 Care should be woman-centered

 The focus of care should be meeting the needs of the woman and her baby. Each woman should
negotiate the way that her partner and family or friends are involved. Care should be tailored to any
special needs a woman may have.

 Care should be culturally appropriate and safe

 Care should consider and allow for cultural variations in meeting these expectations.

 Care should provide women with information and support so they can make decisions

 Women should be given evidence-based information that enables them to make decisions about care.
This should be provided in a format that the woman finds acceptable and can understand.

 Care should respect the privacy, dignity, and confidentiality of women

54 National Antenatal Care Guideline | February 2022

Annex 10: AUDIT TOOL: ANC for Health Center

Facility name
Audit topic Clinical audit record for ANC
Objective Ensure all pregnant women coming for ANC follow up receive appropriate
care according to national guidelines
Period of Audit
Exclusion criteria (where applicable)
If all are completed give ‘1’ if not give ‘0’

chart10

chart11

chart12

chart13

chart14

chart15

chart16

chart17

chart18

chart19
chart 1

chart 2

chart 3

chart 4

chart 5

chart 6

chart 7

chart 8

chart 9
S.N. Measurement criteria

Total
Demographic and identification information recorded
 Name
 Age
 Sex
 Address
 date of visit
 MRN
Present pregnancy, LMP, GA, Complaints including intimate partner
1.
violence
Past obstetric history as per the national guideline, Integrated client card
2.
(ANC, Delivery and PNC)
Medical History for DM, renal disease, cardiac disease, and chronic
3.
hypertension

National Antenatal Care Guideline | February 2022 55

 chart10

chart11

chart12

chart13

chart14

chart15

chart16

chart17

chart18

chart19
chart 1

chart 2

chart 3

chart 4

chart 5

chart 6

chart 7

chart 8

chart 9
S.N. Measurement criteria

Total
Mental health problem
4.
substance use (drugs and other substance use such as alcohol, Khat,
5.
tobacco)
Blood pressure taken at each visit
Weight measured at each visit
Fundal height every visit from 12 weeks
Fetal heartbeat (Every visit from 20weeks)
Fetal lie and presentation after 36 weeks
Mid upper arm Circumference (MUAC < 23cm: except for TB, HIV and
mothers on malnutrition treatment)
Ultrasound before 24 weeks
Essential laboratory tests were performed
 Hemoglobin/hematocrit
 Blood group and RH
 VDRL/RPR
 Urine for protein, microscopy
 Rapid HIV test
 HBsAg
HIV viral load at first visit if HIV positive; On ART: 3 months, then 6
monthly
Proper advice and counseling provided
 Nutrition including iodine salt, calcium, and iron rich foods
 Rest, hygiene, safe sex practice
 Family planning
 Breast feeding
 partner HIV testing

56 National Antenatal Care Guideline | February 2022

 chart10

chart11

chart12

chart13

chart14

chart15

chart16

chart17

chart18

chart19
chart 1

chart 2

chart 3

chart 4

chart 5

chart 6

chart 7

chart 8

chart 9
S.N. Measurement criteria

Total
 Birth Preparedness and complication readiness (Danger signs of
pregnancy, place of birth, emergency fund and transport)
 Provide HIV test result with posttest counseling
 Safe sex practices and encouraged repeat testing after three months,
if test result is negative.
Advised on Malaria prevention, sleeping under an ITN
Advised on Living positively, adherence to treatment, risk reduction,
partner testing and exclusive breastfeeding if test result is positive
Mother properly managed
 Identified problems (mental health risk, HIV, malaria, preeclampsia,
etc.) managed accordingly
 Oral iron and folate supplemented according to the protocol
 Deworming (single dose after 16 wks of gestation)
 Scheduled a date for the next visit according to findings and
recommended 8 antenatal visits
 Birth plan developed.
Td vaccine provided
 If up to date, given 1 dose of tetanus vaccine at 27-36 weeks
gestation
 If not up to date/unknown, given 3 doses of tetanus vaccine: at first
visit, then after 1 month and then after 6 months.
Referred timely to hospital for specialized care if a woman experienced
complications or problems
Grade Total
Average (%)

National Antenatal Care Guideline | February 2022 57

Annex 11. Woman-Held Case Note Template

Front Page
The FMoH, MCH Directorate, Maternal Health Services ANC Case Note Format.
Registration /No_______________

I. Personal information

Name_________________________________Aderss___________________Date_________
Date of Birth (Age)_____________________ Height__________ Marital Status___________
Gravida________________ Family planning method use: Method___________________
Parity_____________________ None_________________ Abortion_______________

II. Obstetrics and medical history:

Medical Yes No Obstetrics Yes No

Anemia Last normal menstrual period
(Regular 28 days)
Hypertension Multiple Pregnancy
Diabetes CS (Uterine scar)
TB Previous bad pregnancy outcome.
If yes, specify____________
________________________
Cardiac EDD

III. History of previous birth

Month/Y Duration of pregnancy ANC Delivery Complications/

delivered Full Term Preterm Yes No Type Place APH,PPH,CS etc.

58 National Antenatal Care Guideline | February 2022

Back page

IV. Current Pregnancy

Gestational age 1st 2nd 3rd 4th 5th 6th 7th 8th
in weeks (<12) 20 26 30 34 36 38 40
Date of visit
Blood group
Rh factor
HGB/HCT
HBsAg
Syphilis test
Gestational/age
Td vaccine
Iron & folic acid
Calcium sup
Abnormal lab test
Instituted treatment
Remark

Sign

National Antenatal Care Guideline | February 2022 59

Annex 12: ANC Services by Level of Health Facility and Provider
Category
Level of facility Providers category ANC service
Health post Midwifes, Health officer,  Perform ANC contacts for pregnant
(comprehensive Nurse, health extension women with no identified problem
health post with workers  Take history (past pregnancy multi gravida
lab facility) and current pregnancy history)
 Perform physical examination
o Take vital sign, measure weight
and height, measure MUAC, check
for palm or conjunctiva (pink,
pale), measure fundal height
(after 18 weeks), check for fetal
heartbeat, check for presentation
 Administer prophylaxis: (IFA and
deworming after first trimester)
 Perform counseling on life style
modification, danger signs and symptoms,
birth preparedness and complication
readiness and optimal maternal nutation
 Coordinate pregnant women conference
 Promote early ANC attendance
 Strengthen referral linkage from health
post to health center
 Closely work with women development
army
 Identify and link pregnant women to
health facilities

Health center Midwifes, Health Officer,  Perform 8 contacts as per the guideline
nurses, integrated  Take history (past pregnancy multi gravida
emergency surgical and current pregnancy history)
officer(IESO), GP,  Perform physical examination
laboratory professionals o Take vital signs, measure weight
and height, measure MUAC, check
for palm or conjunctiva (pink,
pale), measure fundal height
(after 18 weeks), check for fetal
heartbeat, check for presentation
 Perform laboratory tests
o HGB/hematocrit
o Blood group and Rh
o Indirect Coomb’s for Rh Positive
pregnant women
o Urine analysis (dipstick for
protein)
o Urine gram stain
o Test for HIV, syphilis, HBV
o OGTT

60 National Antenatal Care Guideline | February 2022

 Level of facility Providers category ANC service

 Perform obstetric U/S

 Administer prophylaxis: (IFA, calcium, TD,
deworming after first trimester and anti-D
for RH negative and Indirect Coomb’s
negative for pregnant women)
 Perform counseling on life style
modification, danger signs and symptoms,
birth preparedness and complication
readiness and optimal maternal nutrition
 Provide treatment for illness such as
asymptomatic bacteriuria, UTI, malaria,
HIV, syphilis, headache and others
 Provide emergency care and refer for
malpresentation
Hospital OBGYN, IESO, midwives, In addition to health center services
HO, nurses, GP, medical  Manage any pregnancy-related
radiology technologists, complications such as severe anemia,
laboratory professionals, hypertension, DM, any bleeding related to
radiologists pregnancy, severe infections and other
chronic illness
 Perform antepartum fetal surveillance
 Follow and manage multiple pregnancy
and hyperemesis

National Antenatal Care Guideline | February 2022 61

Annex 13. List of ANC Indicators with Definitions, Frequency,
and Source (M&E)
Sources for
Name of
Indicator Numerator Denominator Frequency monthly
Program
report
Maternal Antenatal coverage (at # of pregnant women Total number of Monthly ANC register;
health (MH) least one contact) attending ANC (new expected HMIS
ANC) pregnancy
Antenatal coverage (at # of pregnant women Total number of Monthly ANC register;
least four contact) attending ANC at least expected HMIS
four contacts pregnancy
Percentage of women # of pregnant women Total number of Monthly ANC register;
who received ANC at attending ANC at least expected Form 1
least 8 times eight contacts pregnancy
Proportion of pregnant The number of (new) Total # of (new) Monthly ANC register
women with anemia registered pregnant pregnant women
women whose registered during
hemoglobin level was the month
< 11g/dl
Nutrition Proportion of pregnant Number of pregnant Estimated # of Monthly ANC register
women receiving IFA at woman who received pregnant woman
least 90 + tabs IFA supplementation
Percentage of # of pregnant women Estimated Monthly ANC register
pregnant women who received number of
receiving deworming deworming pregnant women
drugs

Proportion of pregnant # of pregnant women Estimated # of Monthly HMIS

woman with MUAC with acute pregnant women
<23 cm malnutrition (MUAC
<23 cm)

Expanded Percent coverage of # of pregnant women # of ANC Monthly ANC register

Program on tetanus toxoid and who received attendant eligible
Immunization diphtheria (second immunization against for Td
(EPI) dose) in pregnant tetanus and
women diphtheria for the
second time
PMTCT Percentage of women # of women who were Estimated Monthly  ANC Register
who were tested and tested and know their number of
know their HIV status HIV status during pregnant women
during pregnancy, pregnancy, labor or
labor or delivery and delivery and post-
post-partum period partum period
Percentage of HIV- Number of HIV Estimated HIV Monthly  ANC Register
positive pregnant positive pregnant and positive pregnant
women who received lactating women who women in the
ART to reduce the risk received ART at ANC, year
of mother-to child- L&D and PNC for the

62 National Antenatal Care Guideline | February 2022

 Sources for
Name of
Indicator Numerator Denominator Frequency monthly
Program
report
transmission during first time and those
pregnancy, labor & women who get
delivery (L&D) and pregnant while on ART
postpartum & linked to ANC
Percentage of # of pregnant women # of pregnant Monthly  ANC register
pregnant women attending ANC whose women attending
attending ANC whose male partners were ANC
male partners were tested for HIV during
tested for HIV during pregnancy
pregnancy
Proportion of pregnant Number of pregnant Total number of Monthly DHIS2
women attending women tested for pregnant women
antenatal care tested syphilis who attended
for syphilis first ANC contact
Proportion of syphilis- # of syphilis -positive # of syphilis Monthly PMTCT
positive pregnant pregnant women who infected pregnant monthly report
women who received received antibiotics to women
syphilis treatment reduce the risk of
(eMTCT indicator) mother-to-child
transmission

National Antenatal Care Guideline | February 2022 63

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