Moving toward a holistic model of woman-centered antenatal care

By: Sheela Sinharoy, MPH

Sunday began with a symposium titled, Delivering Nutrition Interventions to Women during Pregnancy: Beyond Individual Interventions to Comprehensive Antenatal Guidelines and Care. A series of speakers made clear that as antenatal care (ANC) models continue to evolve, there is plenty of room for improvement to provide a positive pregnancy experience for women and their families.

ANC is not meeting its potential. This was the conclusion of the first speaker, Erica Phillips. She discussed the model of focused ANC (FANC) recommended by the World Health Organization (WHO), which involves 75-80 tasks for an intake visit and 60-65 tasks for each follow-up. She explained that following these recommendations would require an estimated 30-40 minutes for a first visit and 20 minutes for a follow-up. Even when recommended tasks are completed, quality of care may still be low. Ms. Phillips stated that “where FANC has been adopted, success has been limited.”

Still, ANC can be an effective platform for breastfeeding promotion, according to the next speaker, Mduduzi Mbuya. He presented a case study from the Sanitation, Hygiene, Infant Nutrition Efficacy (SHINE) trial in Zimbabwe. The country faces a critical shortage of health workers, with only 9.8 skilled health workers per 10,000 people (as compared to a ratio of 117:10,000 in the USA). SHINE therefore engaged community-based village health workers and found that the prevalence of exclusive breastfeeding at six months of age increased from 23% to 68%. Dr. Mbuya attributed this result primarily to strong fidelity of implementation by village health workers.

Micronutrient supplementation is another important component of ANC, and Kate Dickin spoke about a trial of calcium supplementation in Kenya and Ethiopia. There, researchers found that women were motivated and willing to take calcium supplements as recommended and that most women sustained their adherence to the supplements through the six-week study period and said they would continue through the end of their pregnancies. Dr. Dickin attributed this largely to the intervention’s behavior change communication strategy, which was based on extensive formative research and addressed context-specific motivators and barriers.

Next, Catharine Taylor spoke about the way forward and the need for integrated, women-centered models of care. She said that ANC models should take the local context into account; have all goods and personnel in same physical space; provide clear and consistent guidelines, training and supervision to health workers; provide demonstrations and encourage active engagement and discussion; provide incentives and support; and implement women-held records and integrated health registers. As examples, she described the Centering Pregnancy model and women’s support groups, which have shown promise in a number of developing country settings.

Finally, Rebecca Stoltzfus closed the session, emphasizing the need for more community-based evidence, especially looking at “packages of ANC that are contextually adapted to be delivered in the most effective ways.” Thus, symposium attendees walked away with a substantial research agenda for the strengthening of antenatal guidelines and care.



A new rationale for breastfeeding – the benefits for the Mom!

By: Mary Scourboutakos

Presently in America breastfeeding rates are sub-par.

While the World Health Organization recommends exclusive breastfeeding for up to six months of age, with continued breastfeeding alongside complementary foods up to two years of age or beyond—in the US 79% of mothers initiate breastfeeding, but only 22% exclusively breastfeed to six months and only 27% are still breastfeeding (non-exclusively) at two years postpartum.1 Meanwhile in countries like Sri Lanka, 83.1% of mothers are still breastfeeding their children two years post-partum.2

So the question is…how do we get women in America to breastfeed longer?
Traditionally, when trying to promote breastfeeding, people have focused on the benefits for infants, such as improved cognitive development,3 fewer childhood infections,4 and decreased risk for obesity and chronic disease later in life.5

But when you consider current rates of breastfeeding (see above!), clearly this approach isn’t working. Nevertheless, there may be a presently unexplored way to promote breastfeeding…

Emerging research suggests that in fact, the benefits of breastfeeding for the mother may surpass the benefits of breastfeeding for the infant.6-8
In fact, research has shown that long-term breastfeeding is associated with decreased maternal risk for breast cancer,9-11 ovarian cancer,12, 13 endometrial cancer,14 diabetes,15 heart disease,16 as well as greater postpartum weight-loss,17, 18 and mental health benefits.19, 20

But how long is long? And by how much does risk decrease? In terms of breast cancer, research from China has shown that women who breastfeed for more than 24 months per child cut their risk for breast cancer in half, compared to women who breastfed for only one to six months.10 Furthermore, dose-response curves for risk of diabetes show an inverse relationship with lifetime duration of breastfeeding, which suggests that the longer you breastfeed for, the lower your risk is.15

So, my unsolicited piece of advice for public health agencies is…if you’re trying to improve rates of breastfeeding, never mind touting the benefits for the baby, maybe try promoting the benefits for the Mom!


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