• l develop a kind and respectful relationship between each woman and the health workers, so that she will attend for antenatal care and be more likely to talk about any problems. She may also be more accepting of any advice given
• l find and treat any illnesses the woman already has
• l identify which women can safely deliver at home and which women are more likely to have complications and should deliver in a health centre or hospital
• l explain to women the danger signs that can occur during pregnancy, labour and delivery so that they seek help early.

How many antenatal visits?
A few antenatal visits for many women are far better than many antenatal visits for a few women. It is difficult to make sure that poor women and rural women get their share of the maternity services. A real effort must be made to reach beyond the urban centres, to reach the women who need care the most. This may require mobile units, or regular visits to areas without health centres and clinics. Aim to give something to everyone; in reality this may mean only two antenatal visits per woman.
If a pregnant woman does not come for antenatal care, do you blame her – do you think she is ignorant or lazy? If so – WAIT! Ask yourself: Why is she not coming? How can I make the service more acceptable to this woman? Where should I go to give care? On which days and at what times? When antenatal care is accessible, affordable and respectful pregnant women do attend. Don’t blame women – first try to understand their lives.
Women should be encouraged to start their antenatal care early in pregnancy. The quality of care is more important than the number of times they are seen. Make sure that you can talk to the woman privately. Take time to listen to her. Find out about her problems and her fears. if she trusts you and knows you care about her, she is more likely to come back again and to believe what you say. if there is a traditional birth attendant in the area, invite her to sit with you while you give antenatal care (if the woman is happy for her to do so).

Take a history
The first visit is the time to find out if the woman has any medical problems, and to begin treatment. If she has had a baby before, ask her carefully about what happened during her last pregnancy and birth. This will give an idea about the likelihood of her developing complications, and the level of care she will require. Record this information on a card which the woman keeps and use it to decide whether or not she should be advised to deliver in hospital.

Check for anaemia
Anaemia is the most common, and one of the most serious problems in preg-nancy. Look for paleness under the lower eyelid or take blood for laboratory examination, if you have the facilities. If the woman has anaemia, think about what may have caused it. Malaria? Hookworm? You will need to treat the cause of the anaemia as well as the symptoms. Treat the symptoms by giving the woman iron and folic acid tablets, using the dose recommended in national or local guidelines. Give a double dose if her anaemia is severe. Is her anaemia caused by malnu-trition? If she is anaemic because she cannot afford to eat enough, or because her husband eats first, there is little point in giving her nutrition advice. It might be more useful to speak to her husband about her diet. Any woman who is still severely anaemic at the end of her pregnancy should be advised to go to a hospital where she can be carefully tested.
In areas where malaria is ende-mic, aim to give all women antimalarial tablets throughout their pregnancy, in line with national guidelines.

Protect against tetanus
Every pregnant woman living in an area where there is neonatal tetanus should be vaccinated against tetanus at the first antenatal visit of every pregnancy. If she has not previously had the full course of tetanus protection, she should be vaccinated again 1-2 months later, then again
6 months after that.

Look for high blood pressure
High blood pressure during pregnancy is a danger sign. You should measure the blood pressure at every antenatal visit, but only if you have properly working equipment and you are experienced in using it. It is difficult to detect pre-eclampsia early enough if antenatal visits are not close together.
It may be more important to educate the women (and traditional birth atten-dants) about the danger signs. Advise them to seek help urgently if swelling suddenly develops, especially if it is in the face or it is severe. Other danger signs are sudden pain in the stomach area (because of swelling in the liver), very severe headaches and flashing lights in front of the eyes. These symptoms are an emergency–get the woman to hospital as soon as possible.

Look for, and treat, infections
What you look for will depend on the laboratory facilities you have available, the medicines you have for treatment and the problems which are common in the area. Infections to look for might include gonorrhoea, syphilis, urinary infection, malaria, hookworm, tubercu-losis. Treating infections in pregnancy is a very effective way of improving the health of both mother and baby.
Think very carefully before you offer a pregnant woman a test for HIV. Will you, and she, be able to make constructive use of the information? What harm might be done?

Find the baby’s position
Many unnecessary deaths could be prevented if every pregnant woman were examined after the 36th week of pregnancy to determine the position of the baby. The baby should be lying in the head down position. If the baby is lying sideways, or with the shoulder coming first, it should be turned around by somebody who knows how to do this safely, or the woman should deliver in a hospital where a caesarean section can be performed. if the baby is lying in the breech position – with the head up – the baby should be turned if possible. Otherwise the woman should be advised to deliver in a hospital where there is skilled help.

Reasons for advising a woman to give birth in a hospital

• severe anaemia
• previous postpartum haemorrhage
• previous caesarean section
• bleeding towards the end of pregnancy
• high blood pressure
• twin pregnancy
• baby’s position is not head first.

In addition, if a woman is very young (16 or under) and very poor, she is at high risk.
Similarly, if a woman has had six or more babies and she is very poor, she is at high risk. If you believe that a woman should have her baby in hospital it is not enough just to tell her so. Ask her whether she is willing to go; whether any transport is available from her home to the hospital (what about at night or in the rainy season?); does she need the permission of her husband or mother-in-law? Will she have enough money?; does she have young children that she can’t leave? Once you understand her responsibi-lities and the difficulties in her life, you can plan with her what she can do.
Women who give birth at home still need a skilled helper with them; this could be a trained traditional birth- attendant or a midwife. Even those women who are at no special risk of having a complication during delivery can suddenly develop problems.
Many risk factors get mentioned in regard to childbirth. But it is not often made clear that the women whose lives are most in danger are those who live in poverty. If there is violence in their home, they are even more at risk of having a difficult pregnancy and birth. Is there anything you can do to make sure these high risk women get the care they need – for instance, could you run a clinic close to their home, at a time when they could easily attend?

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