visits of antenatal care

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Notes on the data

Antenatal care is essential for protecting the health of women and their unborn children.

Through this form of preventive health care, women can learn from skilled health personnel about healthy behaviours during pregnancy, better understand warning signs during pregnancy and childbirth, and receive social, emotional and psychological support at this critical time in their lives. Through antenatal care, pregnant women can also access micronutrient supplementation, treatment for hypertension to prevent eclampsia, as well as immunization against tetanus. Antenatal care can also provide HIV testing and medications to prevent mother-to-child transmission of HIV. In areas where malaria is endemic, health personnel can provide pregnant women with medications and insecticide-treated mosquito nets to help prevent this debilitating and sometimes deadly disease.

Globally, while 88 per cent of pregnant women access antenatal care with a skilled health personnel at least once, only two in three (69 per cent) receive at least four antenatal care visits. In regions with the highest rates of maternal mortality, such as Western and Central Africa and South Asia, even fewer women received at least four antenatal care visits (56 per cent and 55 per cent, respectively). In viewing these data, it is important to remember that the percentages do not take into consideration the skill level of the healthcare provider or the quality of care, both of which can influence whether such care succeeds in bringing about improved maternal and newborn health.

Historical data show that the proportion of women receiving at least four antenatal care visits has increased globally over the last decade. The scale and pace of this progress, however, differs greatly by region. In Western and Central Africa, for example, only about half of pregnant women received four or more antenatal care visits between 2015 and 2021 (5 6 per cent). Stronger and faster progress is needed across all higher burden regions to drastically improve maternal and newborn outcomes.  

Disparities in antenatal care coverage

Despite progress being made, large regional and global disparities in women receiving at least four antenatal care visits are observed by residence and wealth. Women living in urban areas are more likely to receive at least four antenatal care visits than those living in rural areas, with an urban-rural gap of 20 percentage points (79 per cent and 59 per cent, respectively). In addition, antenatal care coverage increases with wealth, with those in the richest quintile being almost twice as likely to receive at least four antenatal care visits than those in the poorest quintile, with a wealth gap of 29 percentage points (78 per cent and 49 per cent, respectively).

UNICEF, 2019, Health y Mothers, Healthy Babies: Taking stock of maternal health , New York 2019.  

World Health Organization, 2016, WHO recommendations on antenatal care for a p ositive pregnancy ex p erience 2016.  

UNICEF, The State of the World’s Children 2023 , UNICEF, New York, 2023.  

  WHO, UNICEF, UNFPA, The World Bank and the United Nations Population Division, Trends in Maternal Mortality: 2000 to 2020 , WHO, Geneva, 2023.  

Antenatal care coverage

Maternal and newborn health coverage, build and download your own customisable dataset, women’s, children’s and adolescents’ health country profiles and dashboards.

Renewing progress on women’s, children’s and adolescents’ health in the era of COVID-19

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Maternal and Newborn Health Disparities country profiles

Every Newborn Action Plan: Country implementation tracking tool guidance note

Pregnancy, Childbirth, Postpartum and Newborn Care: A guide for essential practice

Trends in Maternal Mortality: 1990 to 2015

Definition of indicators

Antenatal care coverage (at least one visit) is the percentage of women aged 15 to 49 with a live birth in a given time period that received antenatal care provided by skilled health personnel (doctor, nurse or midwife) at least once during pregnancy.

Skilled health personnel refers to workers/attendants that are accredited health professionals – such as a midwife, doctor or nurse – who have been educated and trained to proficiency in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns. Both trained and untrained traditional birth attendants are excluded.

Antenatal care coverage (at least four visits) is the percentage of women aged 15 to 49 with a live birth in a given time period that received antenatal care four or more times. Available survey data on this indicator usually do not specify the type of the provider; therefore, in general, receipt of care by any provider is measured.

Antenatal visits present opportunities for reaching pregnant women with interventions that may be vital to their health and well-being and that of their infants. WHO recommends a minimum of four antenatal visits based on a review of the effectiveness of different models of antenatal care. WHO guidelines are specific on the content of antenatal care visits, which should include:

• blood pressure measurement
• urine testing for bacteriuria and proteinuria
• blood testing to detect syphilis and severe anaemia
• weight/height measurement (optional).

Measurement limitations.   Receiving antenatal care during pregnancy does not guarantee the receipt of interventions that are effective in improving maternal health. Receiving antenatal care at least four times, which is recommended by WHO, increases the likelihood of receiving effective maternal health interventions during antenatal visits. Importantly, although the indicator for ‘at least one visit’ refers to visits with skilled health providers (doctor, nurse or midwife), ‘four or more visits’ refers to visits with any provider, since standardized global national-level household survey programmes do not collect provider data for each visit. In addition, standardization of the definition of skilled health personnel is sometimes difficult because of differences in training of health personnel in different countries.

Related Topics

• Delivery care
• Maternal mortality
• Newborn care

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TYLER S. ROGERS, MD, MBA, FAAFP, AND BRENDAN LUSHBOUGH, DO, Martin Army Community Hospital, Fort Benning, Georgia

Am Fam Physician. 2023;107(2):187-190

Author disclosure: No relevant financial relationships.

Key Clinical Issue

What are the risks and benefits of less frequent antenatal in-person visits vs. traditional visit schedules and televisits replacing some in-person antenatal appointments?

Evidence-Based Answer

Compared with traditional schedules of antenatal appointments, reducing the number of appointments showed no difference in gestational age at birth (mean difference = 0 days), likelihood of being small for gestational age (odds ratio [OR] = 1.08; 95% CI, 0.70 to 1.66), likelihood of a low Apgar score (mean difference = 0 at one and five minutes), likelihood of neonatal intensive care unit (NICU) admission (OR = 1.05; 95% CI, 0.74 to 1.50), maternal anxiety, likelihood of preterm birth (nonsignificant OR), and likelihood of low birth weight (OR = 1.02; 95% CI, 0.82 to 1.25). (Strength of Recommendation [SOR]: B, inconsistent or limited-quality patient-oriented evidence.) Studies comparing hybrid visits (i.e., televisits and in-person) with in-person visits only did not find differences in rates of preterm births (OR = 0.93; 95% CI, 0.84 to 1.03; P = .18) or rates of NICU admissions (OR = 1.02; 95% CI, 0.82 to 1.28). (SOR: B, inconsistent or limited-quality patient-oriented evidence.) There was insufficient evidence to assess other outcomes. 1

Practice Pointers

Antenatal care is a cornerstone of obstetric practice in the United States, and millions of patients receive counseling, screening, and medical care in these visits. 2 , 3 There is clear evidence supporting the benefits of antenatal care; however, the number of appointments needed and setting of visits is less understood.

The American College of Obstetricians and Gynecologists recommends antenatal visits every four weeks until 28 weeks' gestation, every two weeks until 36 weeks' gestation, and weekly thereafter, which typically involves 10 to 12 visits. 4

Expert consensus and past meta-analyses have favored fewer antenatal care visits given similar maternal and neonatal outcomes. In 1989, the U.S. Public Health Service suggested a reduction in the antenatal visit schedule based on a multidisciplinary panel and expert opinion in conjunction with a literature review; however, the American College of Obstetricians and Gynecologists has not updated its guidelines, and practices have not changed. 5 A 2010 Cochrane review found no differences in perinatal mortality between patients randomized to higher vs. reduced antenatal care groups in high-income countries, and a 2015 Cochrane review showed no difference in neonatal outcomes for women in high-income countries. 6 , 7

The Agency for Healthcare Research and Quality (AHRQ) review showed moderate- and low-strength evidence and did not find significant differences between traditional and abbreviated schedules when looking at many outcomes, such as gestational age at birth, low birth weight, Apgar scores, NICU admission, preterm birth, and maternal anxiety. The review was limited by a small evidence base with studies that are difficult to compare. The randomized controlled trials that were eligible were adjusted for confounding, whereas the nonrandomized controlled studies were not adjusted and were at high risk for confounding.

Telemedicine, defined as the use of electronic information and telecommunication to support health care among patients, clinicians, and administrators, is a new option for antenatal care delivery. 8 Televisits, the real-time communication between patients and clinicians via phone or the internet, are the specific interactions that encompass telemedicine. Recent literature suggests that supplementing in-person visits with televisits in low-risk pregnancies resulted in similar clinical outcomes and higher patient satisfaction scores. 9 The AHRQ review found no significant differences between rates of preterm births or NICU admissions for a hybrid model of televisits and in-person visits compared with in-person visits only. The review was limited due to the lack of adjustments for potential confounders in the study. For example, some of the studies were conducted during the COVID-19 pandemic, which adds multiple confounders and potential for bias.

The AHRQ review offers limited opportunity for conclusions to suggest changes in current practice. The current evidence supports past evidence, suggesting that fewer visits are not associated with neonatal or maternal harm, and televisits may have a role in antenatal care. Many of the other outcomes of interest had insufficient evidence to generate conclusions.

Editor's Note:   American Family Physician SOR ratings are different from the AHRQ Strength of Evidence ratings.

The opinions and assertions contained herein are the private views of the authors and are not to be construed as official or as reflecting the views of the U.S. Army, the U.S. Department of Defense, or the U.S. government.

For the full review, go to https://effectivehealthcare.ahrq.gov/sites/default/files/product/pdf/cer-257-antenatal-care.pdf .

Balk EM, Konnyu KJ, Cao W, et al. Schedule of visits and televisits for routine antenatal care: a systematic review. Comparative effectiveness review no. 257. (Prepared by the Brown Evidence-Based Practice Center under contract no. 75Q80120D00001.) AHRQ publication no. 22-EHC031. Agency for Healthcare Research and Quality; June 2022. Accessed October 1, 2022. https://effectivehealthcare.ahrq.gov/sites/default/files/related_files/cer-257-antenatal-care-evidence-summary.pdf

Kirkham C, Harris S, Grzybowski S. Evidence-based prenatal care: part I. General prenatal care and counseling issues. Am Fam Physician. 2005;71(7):1307-1316.

Zolotor AJ, Carlough MC. Update on prenatal care. Am Fam Physician. 2014;89(3):199-208.

Kriebs JM. Guidelines for perinatal care, sixth edition: by the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists. J Midwifery Womens Health. 2010;55(2):e37.

Rosen MG, Merkatz IR, Hill JG. Caring for our future: a report by the expert panel on the content of prenatal care. Obstet Gynecol. 1991;77(5):782-787.

Dowswell T, Carroli G, Duley L, et al. Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane Database Syst Rev. 2010(10):CD000934.

Dowswell T, Carroli G, Duley L, et al. Alternative versus standard packages of antenatal care for low-risk pregnancy. Cochrane Database Syst Rev. 2015(7):CD000934.

Fatehi F, Samadbeik M, Kazemi A. What is digital health? Review of definitions. Stud Health Technol Inform. 2020;275:67-71.

Cantor AG, Jungbauer RM, Totten AM, et al. Telehealth strategies for the delivery of maternal health care: a rapid review. Ann Intern Med. 2022;175(9):1285-1297.

The Agency for Healthcare Research and Quality (AHRQ) conducts the Effective Health Care Program as part of its mission to produce evidence to improve health care and to make sure the evidence is understood and used. A key clinical question based on the AHRQ Effective Health Care Program systematic review of the literature is presented, followed by an evidence-based answer based on the review. AHRQ’s summary is accompanied by an interpretation by an AFP author that will help guide clinicians in making treatment decisions.

This series is coordinated by Joanna Drowos, DO, MPH, MBA, contributing editor. A collection of Implementing AHRQ Effective Health Care Reviews published in AFP is available at https://www.aafp.org/afp/ahrq .

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Appointments at Mayo Clinic

• Pregnancy week by week

Prenatal care: 1st trimester visits

Pregnancy and prenatal care go hand in hand. During the first trimester, prenatal care includes blood tests, a physical exam, conversations about lifestyle and more.

Prenatal care is an important part of a healthy pregnancy. Whether you choose a family physician, obstetrician, midwife or group prenatal care, here's what to expect during the first few prenatal appointments.

The 1st visit

When you find out you're pregnant, make your first prenatal appointment. Set aside time for the first visit to go over your medical history and talk about any risk factors for pregnancy problems that you may have.

Medical history

Your health care provider might ask about:

• Your menstrual cycle, gynecological history and any past pregnancies
• Your personal and family medical history
• Exposure to anything that could be toxic
• Medications you take, including prescription and over-the-counter medications, vitamins or supplements
• Your lifestyle, including your use of tobacco, alcohol, caffeine and recreational drugs
• Travel to areas where malaria, tuberculosis, Zika virus, mpox — also called monkeypox — or other infectious diseases are common

Share information about sensitive issues, such as domestic abuse or past drug use, too. This will help your health care provider take the best care of you — and your baby.

Your due date is not a prediction of when you will have your baby. It's simply the date that you will be 40 weeks pregnant. Few people give birth on their due dates. Still, establishing your due date — or estimated date of delivery — is important. It allows your health care provider to monitor your baby's growth and the progress of your pregnancy. Your due date also helps with scheduling tests and procedures, so they are done at the right time.

To estimate your due date, your health care provider will use the date your last period started, add seven days and count back three months. The due date will be about 40 weeks from the first day of your last period. Your health care provider can use a fetal ultrasound to help confirm the date. Typically, if the due date calculated with your last period and the due date calculated with an early ultrasound differ by more than seven days, the ultrasound is used to set the due date.

Physical exam

To find out how much weight you need to gain for a healthy pregnancy, your health care provider will measure your weight and height and calculate your body mass index.

Your health care provider might do a physical exam, including a breast exam and a pelvic exam. You might need a Pap test, depending on how long it's been since your last Pap test. Depending on your situation, you may need exams of your heart, lungs and thyroid.

At your first prenatal visit, blood tests might be done to:

• Check your blood type. This includes your Rh status. Rh factor is an inherited trait that refers to a protein found on the surface of red blood cells. Your pregnancy might need special care if you're Rh negative and your baby's father is Rh positive.
• Measure your hemoglobin. Hemoglobin is an iron-rich protein found in red blood cells that allows the cells to carry oxygen from your lungs to other parts of your body. Hemoglobin also carries carbon dioxide from other parts of your body to your lungs so that it can be exhaled. Low hemoglobin or a low level of red blood cells is a sign of anemia. Anemia can make you feel very tired, and it may affect your pregnancy.
• Check immunity to certain infections. This typically includes rubella and chickenpox (varicella) — unless proof of vaccination or natural immunity is documented in your medical history.
• Detect exposure to other infections. Your health care provider will suggest blood tests to detect infections such as hepatitis B, syphilis, gonorrhea, chlamydia and HIV , the virus that causes AIDS . A urine sample might also be tested for signs of a bladder or urinary tract infection.

Tests for fetal concerns

Prenatal tests can provide valuable information about your baby's health. Your health care provider will typically offer a variety of prenatal genetic screening tests. They may include ultrasound or blood tests to check for certain fetal genetic problems, such as Down syndrome.

Lifestyle issues

Your health care provider might discuss the importance of nutrition and prenatal vitamins. Ask about exercise, sex, dental care, vaccinations and travel during pregnancy, as well as other lifestyle issues. You might also talk about your work environment and the use of medications during pregnancy. If you smoke, ask your health care provider for suggestions to help you quit.

Discomforts of pregnancy

You might notice changes in your body early in your pregnancy. Your breasts might be tender and swollen. Nausea with or without vomiting (morning sickness) is also common. Talk to your health care provider if your morning sickness is severe.

Other 1st trimester visits

Your next prenatal visits — often scheduled about every four weeks during the first trimester — might be shorter than the first. Near the end of the first trimester — by about 12 to 14 weeks of pregnancy — you might be able to hear your baby's heartbeat with a small device, called a Doppler, that bounces sound waves off your baby's heart. Your health care provider may offer a first trimester ultrasound, too.

Your prenatal appointments are an ideal time to discuss questions you have. During your first visit, find out how to reach your health care team between appointments in case concerns come up. Knowing help is available can offer peace of mind.

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• Lockwood CJ, et al. Prenatal care: Initial assessment. https://www.uptodate.com/contents/search. Accessed July 9, 2018.
• Prenatal care and tests. Office on Women's Health. https://www.womenshealth.gov/pregnancy/youre-pregnant-now-what/prenatal-care-and-tests. Accessed July 9, 2018.
• Cunningham FG, et al., eds. Prenatal care. In: Williams Obstetrics. 25th ed. New York, N.Y.: McGraw-Hill Education; 2018. https://www.accessmedicine.mhmedical.com. Accessed July 9, 2018.
• Lockwood CJ, et al. Prenatal care: Second and third trimesters. https://www.uptodate.com/contents/search. Accessed July 9, 2018.
• WHO recommendations on antenatal care for a positive pregnancy experience. World Health Organization. http://www.who.int/reproductivehealth/publications/maternal_perinatal_health/anc-positive-pregnancy-experience/en/. Accessed July 9, 2018.
• Bastian LA, et al. Clinical manifestations and early diagnosis of pregnancy. https://www.uptodate.com/contents/search. Accessed July 9, 2018.

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• Open access
• Published: 24 April 2024

Determinants of early antenatal care visits among women of reproductive age in Ghana: evidence from the recent Maternal Health Survey

• Aaron Asibi Abuosi 1 ,
• Emmanuel Anongeba Anaba 2 ,
• Anita Anima Daniels 1 ,
• Anita Asiwome Adzo Baku 1 &
• James Akazili 3 , 4  

BMC Pregnancy and Childbirth volume  24 , Article number:  309 ( 2024 ) Cite this article

Metrics details

Antenatal care services play a crucial role in promoting positive pregnancy outcomes by facilitating the early identification of pregnancy risk factors and early diagnosis of pregnancy-related complications. This study aimed to assess the frequency and timing of ANC attendance of mothers in Ghana as well as determine the predictors of early ANC attendance.

The data for this study was extracted from the 2017 Ghana Maternal Health Survey (GMHS). The study population was women aged 15–49 years with a live birth or stillbirth in the 5 years preceding the survey. Data was analysed using STATA/SE version 17, using descriptive statistics and multiple binary logistic regression analysis.

It was found that 44.4% of the women obtained eight (8) + ANC visits. A majority of the women (66%) initiated ANC visits in the first trimester of pregnancy. Early ANC visit was significantly associated with age of the respondent, education, wealth index, religion, region and reason for first ANC visit. For instance, women between the ages of 25–29 years (aOR = 1.75, 95% CI: 1.31–2.33) had increased odds of early ANC visit compared to those aged 15–19 years. Women with higher education (aOR = 1.83, 95% CI: 1.27–2.64) were about twice as likely to initiate early ANC visits compared to those with no education. Also, women in the highest wealth index (aOR = 2.43, 95% CI: 1.83–3.23) were two times more likely to initiate early ANC visits compared to those in the lowest wealth index.

This study has shown that a majority of women in Ghana start their first ANC visit during the first trimester of pregnancy. A considerable proportion of the women failed to meet the WHO’s recommendation of having a minimum of eight ANC visits throughout pregnancy. Early ANC visit was determined by socio-demographic factors. Going forward, it should be a priority for stakeholders to ensure that ANC services are accessible to all mothers in a timely manner.

Peer Review reports

Antenatal care (ANC) is the care given to pregnant women so that they have safe pregnancy and healthy baby [ 1 ]. The World Health Organization recommends a minimum of eight antenatal care visits, initiating ANC during first trimester, giving birth in facilities, and postnatal care within 24 h of birth to reduce maternal and perinatal mortality [ 2 , 3 ]. The provision of ANC services has a positive impact on pregnancy as it helps in the early identification of pregnancy risk factors and early diagnosis of complications in pregnancy such as preterm delivery [ 4 ]. The positive impact can be achieved through screening for pregnancy problems, assessing pregnancy risk, treating problems that may arise during the antenatal period, giving medication that may improve pregnancy outcomes, providing information to the pregnant woman, preparing physically and psychologically for childbirth and parenthood [ 5 ].

A number of studies have identified the lack of antenatal care as a risk factor for maternal morbidity and mortality [ 6 , 7 , 8 ]. Since inadequate ANC is associated with poor pregnancy outcomes, it is vital for health policymakers to better understand the factors influencing optimum utilization of ANC services. Utilization of ANC services during pregnancy will lead to further utilization of additional maternal services like institutional delivery and seeking assistance for complications during delivery and postnatal period [ 9 ].

Few studies have been done in developing countries to examine factors affecting early ANC attendance. In Ethiopia [ 10 ], reported that only 117 (26.2%) pregnant mothers started their first ANC visit early. Mothers with no parity before, had good knowledge on early ANC and planned pregnancy were significantly associated with early ANC visit. In South Africa [ 11 ], , revealed that 51% of rural women and 28% of peri-urban women presented late for first ANC. Rural women were more likely to present late for first ANC visit and report barriers to accessing ANC services. Late ANC presentation in rural communities was associated with being married, employed, less than 20 years of age, and reporting an unplanned pregnancy. Late presentation in peri-urban communities was associated with unplanned pregnancy, being told to come back later to initiate ANC after presenting early and being pregnant for the first time.

In Ghana, although attendance of at least one ANC visit is nearly universal and 89% of women reported having 4 or more ANC visits, only 64% of women follow the recommendation of starting ANC in the first trimester. Facility deliveries continue to hover around 57–79% [ 12 , 13 , 14 ]. Anecdotal reports suggest that these figures may be overestimates of ANC attendance, as bringing women to ANC early remains a major challenge. Many women start ANC late, do not have the required number of visits, and often have complications [ 15 ]. The remaining women who do not start ANC in first trimester and who do not receive adequate ANC visits are the hard to reach population [ 16 ].

The most commonly cited reasons for not seeking maternal health services include lack of money, the perception that obstetric care is not necessary, and transportation problems [ 13 ]. In order to encourage women to seek maternal services at health facilities, the government of Ghana has waived fees at public facilities starting in 2004 [ 17 ]. Yet a recent assessment revealed that the Free Maternal Health Care Policy (FMHCP) exists only on paper and many women have to make payments for ANC and skilled delivery services [ 13 ]. Despite the limited studies on factors affecting early ANC attendance in developing countries, to the best of the author’s knowledge, no study has been done in Ghana to examine this nagging problem. This study therefore seeks to fill this gap. The objectives of this study are to assess the frequency and timing of ANC attendance of mothers in Ghana as well as determine the predictors of early ANC visits.

Study design and data source

The data for this study was extracted from the 2017 Ghana Maternal Health Survey (GMHS). The survey was conducted by Ghana Statistical Service (GSS) with technical support from Inner City Fund (ICF) through the Demographic and Health Survey (DHS) program. GMHS used a multi-stage sampling where the first stage involved the selection of enumeration areas with probability proportional to the sizes of enumeration areas. In the second stage, households were selected from each enumeration area using systematic random sampling. Details of the sampling procedure is publicly available [ 18 ].The 2017 GMHS was conducted among women aged 15–49 years who delivered a live birth or stillbirth from the period between 2012 and 2017.

The study population were women aged 15–49 years with a live birth or stillbirth in the 5 years preceding the survey who received antenatal care from a skilled provider (doctor, nurse/midwife, or community health officer/nurse) during their most recent pregnancy. Women who did not receive ANC or received ANC from traditional birth attendants, were excluded from this study. The GMHS interviewed 25,062 women (unweighted). This study focused on women with data on ANC visits, hence a total of 13,215 women (unweighted) were excluded from the analysis. Therefore, a sample of 11,847 (unweighted) and 11,291 (weighted) women aged 15–49 years were included in this analysis.

Measurement

The outcome variable of interest was ANC attendance, a dummy variable coded 1 = early ANC visit (within the first three months of pregnancy); and 0 = otherwise. The primary independent variables of interest were all categorical variables, including getting permission to attend ANC; getting money to attend ANC; payment for ANC services; and problem during first ANC visit. The secondary independent variables of interest included health insurance status; distance to health facility; region of respondent; religion; age; educational level; wealth quintile; and type of place of residence, all categorical variables. Detail about the coding is provided elsewhere [ 18 ].

Data analysis

Data was analysed using STATA/SE version 17. At the univariate level, descriptive statistics including frequencies and percentages were analysed for the respective variables. At the multivariable level, binary logistic regression analysis, both crude and adjusted analyses, were employed to assess the relationship between independent variables and early ANC visit. The crude and adjusted odds ratios were estimated at 95% confidence interval (CI) and significance level of 0.05. The “svyset” feature in STATA 17 was used with the weighting, cluster and strata variables. The survey protocol for GMHS was reviewed and approved by the ICF Institutional Review Board. This study analyzed data from GMHS, therefore, ethical approval was not required. We received permission from the DHS Program to use the data.

Descriptive statistics

The results showed that one-fifth (23.9%) of the participants were age 25–29 years and 30–34 years (23.6%). Four in ten (40.2%) participants had completed junior high school and one-fifth (20.7%) of them were in the poorest wealth index. Seven in ten (77.7%) participants professed Christianity and majority (50.9%) of the participants resided in rural areas. In addition, more than half (57.8%) of the participants had health insurance. Exactly 44.6% of the participants paid for ANC services, and 86% of the participants made their first ANC visit for a checkup. A majority of the participants did not perceive distance to a health facility (74.6%) and getting permission to seek care (93.9%) as barriers to seeking care. A little above half of the participants (50.8%) did not face difficulties in getting money for treatment. Regarding the frequency of ANC visits, 47.5% of the participants made between four to seven visits and 44.4% made eight + visits. A majority (66%) of the participants started ANC visit in the first trimester of pregnancy (Table  1 ).

Factors associated with ANC visits among women in Ghana

The crude analysis showed that early ANC visit was significantly associated with age of the respondent, educational level, wealth index, religion, type of place of residence, geographical region, reason for first ANC visit, distance to a health facility, getting permission for treatment and getting money for treatment. For instance, women aged 30–34 years (cOR = 2.17, 95% CI: 1.65–2.84) were more likely to initiate early ANC visits compared to adolescent girls. Women with higher education (cOR = 2.54, 95% CI: 2.11–3.06) were 2.5 times more likely to initiate early ANC visits compared to those with no education. Compared to women in the lowest wealth index, those in the highest wealth index had increased odds of early ANC visit (cOR = 2.54, 95% CI: 2.11–3.06). Women who professed Islam (cOR = 0.80, 95% CI: 0.71–0.90) had decreased odds of early ANC visit compared to those who professed Christianity. Women in rural areas (cOR = 0.85, 95% CI: 0.75–0.96) were less likely to initiate early ANC visit compared to those in urban areas. Surprisingly, women in the Upper West region (cOR = 1.38, 95% CI: 1.09–1.74) had increased odds of early ANC visit compared to those in the Greater Accra region. Women who did not have a problem with distance to a health facility (cOR = 1.17, 95% CI: 1.03–1.32), getting permission for treatment (cOR = 1.22, 95% CI: 1.00-1.49) and getting money for treatment (cOR = 1.29, 95% CI: 1.17–1.43) had increased odds of early ANC visit compared to their counterparts (Table  2 ).

In the adjusted analysis, early ANC visit was significantly associated with age of the respondent, education, wealth index, religion, region and reason for first ANC visit. For example, women between the ages of 25–29 years (aOR = 1.75, 95% CI: 1.31–2.33) had increased odds of early ANC visit compared to those aged 15–19 years. Women with higher education (aOR = 1.83, 95% CI: 1.27–2.64) were about twice more likely to initiate early ANC visit compared to those with no education. Also, women in the highest wealth index (aOR = 2.43, 95% CI: 1.83–3.23) were two timely more likely to initiate early ANC visit compared to those in the lowest wealth index. Women who professed Islam (aOR: 0.83, 95% CI: 0.71–0.97) had decreased odds of initiating early ANC visit compared to those who professed Christianity. Interestingly, women in the Upper West region (aOR = 2.31, 95% CI: 1.70–3.15) had increased odds of early ANC visit compared to those in the Greater Accra region. Women who went with no reported problem but just to check up on themselves and their babies for their first ANC visit had reduced odds of early ANC visit compared to their counterparts (Table  2 ).

This study aimed to assess the frequency and timing of ANC visit among women in Ghana as well as determine the predictors of early ANC visits. The results showed that less than half of the women obtained eight + ANC visits. This finding supports evidence from previous observations in sub-Sahara Africa [ 19 ]. For example, a study that analyzed the 2019 Ghana Malaria Indicator Cluster Survey data showed that four in ten women made eight + ANC visits [ 20 ]. Another study that analyzed the 2017–2018 Ghana Multiple Indicator Cluster Survey data found that about one-third of the women obtained eight + ANC visits [ 21 ]. However, the prevalence of eight + ANC visits in Ghana is relatively higher than findings in other West Africa countries. A further analysis of the 2018 Nigeria DHS and the 2017/2018 Benin DHS found that 17.4% and 8% of women obtained eight + ANC visits respectively [ 19 , 22 ].

Regarding the timing of ANC visit, it was found that six in ten (66%) women started ANC visit in the first trimester of pregnancy. This finding is consistent with the finding of a previous study [ 20 ] who also found that 68% of women in the country started ANC in the first trimester. However, a further analysis of the Ethiopian DHS revealed that 32.7% of women initiated early ANC visit [ 23 ]. Similarly, the Myanmar DHS revealed that 47% of the women started ANC visit in the first trimester of pregnancy [ 24 ].

Possible explanations for the difference in findings include the Free Maternal Health Care Policy (FMHCP) and National Health Insurance Scheme (NHIS) in Ghana. In 2008, Ghana implemented a FMHCP which is a vital component of the NHIS. This policy ensures that all pregnant women are exempted from paying NHIS premiums when they subscribe or renew their membership. Under this policy, expectant mothers are entitled to a wide range of medical services that fall under NHIS coverage, including antenatal, delivery, and postnatal care, as well as neonatal care for infants for the first three months after birth [ 25 ]. There is evidence to show that the FMHCP and NHIS have contributed significantly to improving utilization of maternal healthcare services in Ghana [ 26 ]. A study found that women with NHIS membership were about forty times more likely to access adequate ANC services compared to their counterparts [ 25 ]. In addition, another study revealed that a majority of women reported that NHIS is increasing access to maternal healthcare services [ 27 ].

A further analysis showed that adult women were more likely to initiate early ANC visits compared to adolescent girls. This finding is expected and consistent with evidence from previous studies in sub-Sahara Africa [ 28 ]. A number of factors may explain this observation. Firstly, adolescent girls might have inadequate knowledge about the timing for ANC visit. Hence, they are less likely to know the right period to initiate ANC visit. There is evidence to show that women with knowledge of ANC timing had increased odds of early ANC visit [ 29 ]. Secondly, most adolescent pregnancies may be unwanted or unplanned. Therefore, they may hesitate to inform their parents or healthcare providers of their pregnancy, which can result in delayed initiation of ANC visits. A study showed that women who wanted a pregnancy had increase odds of early ANC visit compared to their counterparts [ 29 ]. These findings have implications for maternal and newborns health outcomes. Adolescent mothers are at a higher risk of pregnancy-related complications [ 30 ]. Additionally, children born to adolescent mothers are at a higher risk of low birth weight and severe neonatal conditions [ 31 ]. Hence, untimely initiation of ANC visit may put them at risk of complications during delivery and adverse birth outcomes.

Other expected findings were that women with higher education and those with higher socio-economic status had increased odds of early ANC visit. These findings confirm the observations of previous investigations on timing of ANC visits [ 28 ].These relationships may be partly explained by the fact that women with higher education are literate and can easily access information about early ANC services. In addition, women with higher education and higher socio-economic status are more likely to afford the expenses associated with accessing ANC services, including transportation cost and ANC service charges. It was also not surprising to observe that women who had problems with their pregnancy were more likely to initiate early ANC visit. This is because pregnancy-related problems may create a need for healthcare services, leading to early ANC visit.

Perhaps the most striking finding is that women in poor geographical regions such as Upper East and Upper West regions, were twice more likely to initiate early ANC visit compared to those in the capital city of Ghana. It is difficult to explain this result, but it might be attributed to a number of factors. First, the Upper East region has the highest ANC coverage and the Upper West region has the highest NHIS coverage in the country [ 18 ]. Health insurance coverage may increase financial access to health care services, especially under the FMHCP where NHIS subscribers have access to free maternal healthcare services. Further research that thoroughly investigate this finding can help give a comprehensive understanding.

The findings suggest that a significant proportion of mothers in Ghana failed to adhere to the World Health Organization’s 2016 recommendation of a minimum of eight antenatal care visits, as well as initiate ANC in the first trimester of pregnancy. Among other factors, the suboptimal use and late initiation of ANC visits may be due to financial constraints. Evidence from this study showed that four in ten women had difficulty in getting money for treatment or were not covered by health insurance. In addition, some women reported that they paid for ANC services. These challenges may pose as financial barriers to accessing ANC services.

These findings have implications for maternal and child health outcomes. For instance, inadequate ANC visit and late initiation of ANC visit may increase the risk of maternal and newborn deaths [ 32 ]. In the quest to achieve Sustainable Development Goal of reducing maternal mortality to less than 70 per 100,000 live births by 2030 [ 33 ], Ghana Health Service, the Ministry of Health and the National Health Insurance Authority should take proactive measures to improve ANC coverage in the country. It is a matter of concern that some mothers pay for ANC services, despite the fact that such services are intended to be provided free of charge under the FMCHP. This issue must be addressed by stakeholders in a timely and effective manner. In addition, maternal health education interventions should target adolescent girls, women with no formal education as well as those from poor socio-economic background. Also, it is important to prioritize early ANC visits among women who do not have pregnancy-related problems.

Strengths and limitation of the study

A major strength of this study is the use of nationally representative data. Also, the survey employed robust sampling techniques to recruit the participants as well employed standard instruments and trained enumerators to collect the data. The rigor in the methods has improved the validity and reliability of the findings. The findings of this study will be relevant for developing national policies regarding antenatal care services. The major limitation of this study is the absence of qualitative data exploring reasons for early or late ANC attendance to triangulate the quantitative findings.

This study has shown that a majority of women in Ghana start their first ANC visit during the first trimester of pregnancy. However, a considerable proportion of them failed to meet the WHO’s recommendation of having eight or more ANC visits throughout pregnancy. The factors that influenced early initiation of ANC visits were being an adult woman, having higher education, having a higher socio-economic status, being a Christian, living in poor geographical regions, and having pregnancy problems. Future studies should investigate the reasons behind early or late ANC visits. Going forward, it should be a priority for stakeholders to ensure that ANC services are accessible to all mothers in a timely manner. The findings of this study have significant implications for future maternal health policies and programmes.

Data availability

The data used in this study is owned by The DHS Program, therefore, the authors cannot share the data. Interested persons can contact The DHS Program for the data ( https://dhsprogram.com/data/available-datasets.cfm ). The authors confirm they did not have any special access or privileges to the data that other researchers would not have.

Abbreviations

Ghana Maternal Health Survey

• Antenatal care

National Health Insurance Scheme

Sub-Sahara Africa

Free Maternal Health Care Policy

World Health Organization

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Aaron Asibi Abuosi, Anita Anima Daniels & Anita Asiwome Adzo Baku

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AAA and JA conceptualized the topic. AAD obtained the data. AAAB and EAA performed the analysis. EAA and AAD wrote the original draft. AAA and JA supervised, reviewed and edited the paper. All authors contributed extensively to the work presented in this paper. All authors read and approved the final manuscript.

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Abuosi, A.A., Anaba, E.A., Daniels, A.A. et al. Determinants of early antenatal care visits among women of reproductive age in Ghana: evidence from the recent Maternal Health Survey. BMC Pregnancy Childbirth 24 , 309 (2024). https://doi.org/10.1186/s12884-024-06490-3

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Associations between Antenatal Care Visit Attendance and Infant Mortality and Growth

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• 1 Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.
• 2 Centre de Recherche en Santé de Nouna, Nouna, Burkina Faso.
• 3 Francis I Proctor Foundation, University of California, San Francisco, San Francisco, California.
• 4 Department of Ophthalmology, University of California, San Francisco, San Francisco, California.
• PMID: 38626748
• DOI: 10.4269/ajtmh.23-0659

This study examines the association between antenatal care (ANC) attendance and infant mortality and growth outcomes. The study used data from the Nouveux-nés et Azithromycine: une Innovation dans le Traitement des Enfants (NAITRE) trial conducted in Burkina Faso. This analysis included 21,795 neonates aged 8 to 27 days who were enrolled in the trial and had ANC data available. Infants were followed until 6 months of age. The analysis adjusted for potential confounders including infant's sex, maternal age, education, urbanicity, geographic region, season (dry versus rainy), pregnancy type (singleton versus multiple), number of previous pregnancies, if the infant was breastfed, and if the facility had an onsite physician to account for level of care. We used logistic and linear regression models to evaluate the association between ANC visits and all-cause infant mortality and infant growth measurements at 6 months. There was no significant association between ANC visits and 6-month mortality. Higher ANC attendance was associated with improved growth outcomes in infants at 6 months of age. After adjusting for potential confounders, each additional ANC visit was associated with a 0.03 kg increase in mean weight, 0.07 cm increase in mean length, 0.04 SD increase in mean mid-upper-arm circumference, 0.04 SD increase in mean height-for-age, 0.04 SD mean weight-for-age, and 0.02 SD mean weight-for-length Z-scores. These mean differences were statistically significant (except for weight-for-length Z-scores) but may not be clinically meaningful. Further research is warranted to explore the relationship between ANC attendance and longer-term health outcomes among infants.

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Learn more about hyperemesis gravidarum .

Labour and birth preparation

Prepare for labour and birth by discovering what to pack in your hospital bag, understanding how labour can begin, learning about special delivery procedures, and exploring various methods to manage pain during childbirth.

• antenatal card
• loose comfortable clothing
• maternity pads
• phone charger
• snacks for labour.
• formula, bottles, teats and sterilisation equipment if you are choosing to formula feed.

Hand hygiene

Help us prevent infection by following the hand hygiene rules:

• sanitise hands upon entering hospital
• sanitise hands upon entering rooms
• sanitise hands upon exiting rooms.

Safe environment

Ensuring a safe and friendly space for our patients, visitors, and staff is our top priority. We do not tolerate any actions that put the safety and well-being of mothers, babies, or staff at risk.

Understanding induction of labour

Labour usually starts naturally between 37 and 42 weeks of pregnancy when the uterus has regular strong contractions that open the cervix, letting the baby pass down the vagina for birth. Sometimes, this doesn't happen, or there's a need to bring on labour before it starts naturally, called Induction of Labour.

Inducing labour often involves using medication (oxytocin in an Intravenous drip) along with breaking the waters in front of the baby's head (artificial rupture of membranes or ARM). This happens in the Maternity Unit birth suite.

If your cervix is ready for birth, ARM/oxytocin might be enough to start labour.

However, in many cases, there's a need for treatment the day before the induction to soften and open the cervix. This process, known as Cervical Ripening, makes the induction more successful and shortens the labour.

The usual way to ripen the cervix is by inserting a small, soft Foley catheter balloon into your cervix, causing the release of a natural hormone called prostaglandin.

Another option is to use a synthetic prostaglandin like Prostin Gel or a prostaglandin pessary (Cervadil) inserted into your vagina. Your GP, Obstetrician, and Midwife will discuss with you which method is better for you and your baby.

Monitoring your baby

Before and after inserting the balloon catheter or Prostin Gel/pessary, we'll check your baby's heartbeat with a cardiotocograph (CTG) to ensure everything is okay.

Once oxytocin is started with an intravenous drip, your baby's heartbeat will be continuously monitored during labour with a CTG.

We have wireless CTG monitoring, allowing you to be upright and mobile during labour if you choose.

For more information on Induction of Labour, please speak to your Midwife and GP Obstetrician.

Planned caesarean – meeting with the anaesthetist before the operation

If your baby is going to be born through a planned caesarean section, you'll have an appointment to visit the hospital and talk to an anaesthetist. This usually happens a week or two before the operation, and the anaesthetist will discuss the choices for your anaesthetic.

During this visit, you can ask questions about the operation, your hospital care, and receive instructions on when to stop eating and drinking before the procedure.

For a planned caesarean, you'll be admitted to the hospital on the day of your operation, specifically to the Maternity Unit, where you'll get ready to go to the Operating Theatre.

Anaesthetic options for a planned caesarean

In the operating room, before the surgery begins, an intravenous drip will be placed in your arm if you don't already have one.

Epidural or spinal anaesthetic

This is a local anaesthetic inserted into your lower back to numb the pain during surgery, allowing you to be awake. It's the most common and generally the safest option. With this choice, one person (your partner or support person) can accompany you into the operating theatre.

General anaesthetic

General anaesthetic involves being in a deep sleep throughout the procedure. While less common for a caesarean, it might be the better option in some cases. For safety reasons, your partner or support person is not allowed in the operating room. Your baby will be taken to your partner, and your midwife will stay with them until you wake up to see your baby.

When baby is born with epidural or spinal anaesthetic

Once everything is ready, the obstetrician will start the operation. If you're awake, you might feel some mild pressure as your baby is lifted out of your uterus. Your baby will be dried off and usually brought to you. Occasionally, some babies may need a bit of help getting used to breathing in air, which could delay contact with you for a few minutes.

With a planned caesarean, we aim to keep you and your baby together during the rest of the operation and in the theatre recovery room afterward. This allows for skin-to-skin contact and, if you've chosen to breastfeed, the possibility of the first breastfeed soon after birth.

Your midwife will stay with you and your baby in the operating theatre and recovery room to assist with care and breastfeeding.

After the operation, you'll spend a brief time in the recovery room before returning to your room in Maternity.

If an emergency caesarean section is needed

In most cases of an unplanned or emergency caesarean section, it will still be done under an epidural or spinal anaesthetic, and your partner will be present in the operating theatre. Additional doctors may be present based on the reason for the emergency caesarean. Efforts will be made to keep you and your baby together, but if additional care is needed, your partner will be encouraged to stay with your baby in such situations.

At Southern NSW LHD, you can decide to go through labour and give birth in water if it's deemed safe for both you and your baby. Use the details below to chat with your midwife or doctor, aiming for a positive experience.

Benefits of water immersion

Using water during labour and birth can offer you added comfort, mobility, and privacy. Evidence suggests that in uncomplicated labours:

• less need for pain-relief drugs, especially epidural analgesia
• increased relaxation and lower perceived pain levels
• fewer medical interventions for slow progress in the first stage of labour
• greater sense of control during labour.

If you have questions or want to understand our procedure for water immersion during labour and birth, talk to your midwife or doctor.

We have water immersion at certain times

Maternity services in Southern NSW LHD consider the following criteria before offering water immersion during labour:

• healthy with no pregnancy complications
• only one baby in a head-down position (not twins)
• at least 37 weeks pregnant
• no infections that may affect your baby
• able to enter and leave the bath with minimal assistance
• no use of injected pain relief in the previous four hours
• pre-pregnancy Body mass index (BMI) less than 40 for safety reasons.

It's not advisable to have water immersion in certain situations

Your midwife or doctor may advise you to leave the bath during labour in certain circumstances, including:

• concerns for your well-being (bleeding, high temperature, feeling faint or unwell)
• concerns for your baby's well-being (changes to heart rate, meconium, or blood-stained amniotic fluid when waters break)
• abnormal progress in labour; a period out of the water with walking may help contractions strengthen and progress.

Considerations when choosing water

• have support with you at all times, and assistance when entering and leaving the bath to prevent injury
• bathwater should be free from additives like oils, gels, and soap
• water temperature can be adjusted for your comfort
• stay hydrated during labour
• ensure the water level is deep enough for your body to be fully submerged at breast level when seated or kneeling
• nitrous oxide gas can be used in the bath if you choose
• gently guide your baby to the water's surface
• you can leave the bath at any time.

More information

For more details or to review our procedure for water immersion during labour and birth, talk to your midwife or doctor.

Information about epidurals to help you decide if you want one for the birth of your baby

You don't have to make a decision now. When you're admitted to the hospital, a midwife or anaesthetist will be available if you want to discuss it further.

Pain relief in labour

Every labour and birth is unique, and everyone experiences pain differently. Until you're in the midst of childbirth, you may not know how you'll cope or what will work best for you.

Your ' Having a Baby ' book, especially pages 70 to 83, contains helpful information about labour and birth, given to you by your midwife. We suggest reading it to prepare for the birth and discussing any questions with your midwife or doctor.

Various methods can help you cope with pain in labour, including staying active, changing positions, breathing techniques, water immersion (bath or shower), complementary therapies like hypnotherapy, reflexology, massage, and aromatherapy, subcutaneous sterile water injections, TENS (transcutaneous electrical nerve stimulation), Nitrous Oxide (gas and air), opioid analgesia (morphine), and epidural analgesia.

This information focuses on epidural analgesia.

If you have questions, talk to your midwife or doctor, who can arrange for you to speak with an anaesthetist. You can also request to talk to the Maternity Unit Manager at your birthing hospital. You have the right to an interpreter; please ask staff to arrange this service for you.

Frequently asked questions

What is an epidural.

Epidurals are a common way to relieve pain during childbirth. They're administered by an anaesthetist, a doctor trained to manage pain and care for patients during surgery, including caesarean sections.

Facts about epidurals

Epidurals are the most effective pain relief during childbirth. The anaesthetist inserts a small plastic tube (epidural catheter) in your lower back near spine nerves, staying in place for continuous pain medication. This can include local anaesthetic to numb nerves, small opioid doses, or a mix.

An epidural shouldn't make you feel drowsy or sick. However, it increases the chance of needing tools like a ventouse or forceps during birth, raising the risk of perineal damage for the mother and injury for the baby.

You can top up an epidural for added pain relief during procedures like ventouse, forceps, or a caesarean section. If a caesarean is needed and you don't have an epidural, the anaesthetist typically uses a spinal anaesthetic, similar to an epidural feeling.

Can everyone have an epidural?

Most people can get an epidural, but some health issues (like spina bifida, prior back surgery, or clotting problems) may make it unsuitable. It's best to know this before labour. If your labour is complicated, your midwife or obstetrician might suggest an epidural for you or your baby's benefit.

If you're overweight, placing an epidural may be trickier and take longer.

Epidurals don't harm your baby or increase the chance of emergency caesarean section.

For pain relief during labour and birth, epidurals are more effective than tablets, Nitrous Oxide gas, or injections.

What is the procedure for putting in an epidural?

First, a plastic tube (cannula) goes into a vein in your hand or arm, and a 'drip' (intravenous fluid) usually runs. During labour, you might have a drip for medication or if you're feeling sick.

Your midwife will guide you to lie on your side or sit bending forward. The anaesthetist will clean your back with an antiseptic.

Local anaesthetic is injected into your skin to numb it before placing the epidural catheter near your spine nerves. The anaesthetist must be cautious to avoid piercing the fluid bag around your spinal cord to prevent headaches.

Stay still while the anaesthetist inserts the epidural, but after securing the catheter with tape, you can move freely.

Once the catheter is in place, medication is delivered through a pump from a fluid bag. You might receive a handset to request additional doses, giving you control over pain relief with a safety lockout to prevent accidental overuse.

How long does it usually take for an epidural to work?

Setting up the epidural typically takes around 20 minutes, and it provides pain relief after another 20 minutes.

While it's taking effect, your midwife will regularly check your blood pressure. The anaesthetist ensures the medication works on the right nerves by applying ice to your tummy and legs, asking you about the cold sensation.

In some cases (about 10 to 15%), the epidural might not work well, and adjustments or reinsertion of the catheter by the anaesthetist may be necessary.

Are there any problems associated with having an epidural?

Your blood pressure may drop, making you feel light-headed or nauseated. We'll monitor your blood pressure regularly.

You might need to stay in bed as your legs could feel heavy and numb. The epidural may also remove the urge to urinate, and a catheter will be used.

You may experience shivering, fever, or itching.

The epidural may not always fully relieve pain. If uncomfortable, the anaesthetist might use more local anaesthetic, and occasionally, the epidural may need replacement.

In rare cases (less than 1 in 100), severe headaches may follow an epidural, but they can be treated.

• hyperemesis gravidarum is the same as morning sickness
• you're exaggerating
• my mum had it and is fine
• it can't be that bad
• you're weak; toughen up.

Hyperemesis gravidarum significantly affects women's physical and mental well-being. If you take one thing from this, know you don't have to endure it alone. Your struggle is tough, and you deserve supportive care and treatment.

What are the risks of an epidural?

How could an epidural be used to keep me comfortable during a caesarean section.

If you require a caesarean section, an epidural is often chosen over a general anaesthetic.

A potent local anaesthetic is injected into the epidural catheter, numbing the lower half of your body for the operation. This is safer for you and your baby compared to a general anaesthetic.

In rare cases (1 in 20 people), the epidural may not work sufficiently for a caesarean section. In such instances, another anaesthetic like a spinal or general anaesthetic may be necessary.

Consent for an epidural

NSW Health requires written consent before inserting an epidural. Understanding your pain relief choices, weighing the benefits and risks of an epidural is crucial. Please read this information and ask questions early.

While there are occasions when an obstetrician may recommend an epidural, each woman can make her own decision. If you choose an epidural, you'll sign a consent form before having it. As you may be focused on labour, in pain, or have taken pain-relieving drugs, sign and date below to confirm you received and read this info.

The anaesthetist will repeat this information verbally if you opt for an epidural during labour. Remember, the anaesthetist can answer any remaining questions during consent, but you might be distracted by pain or sedating drugs.

If you need an interpreter

Professional interpreters are available if you need help to communicate with staff. Please ask our team who can make this booking for you. The service is free and confidential. 

This information is for women who choose to go home after assessment, especially when their waters break before labour, and they don't want or need to stay in the hospital.

About 70% of women will start labour within 24 hours after their waters break.

Before you go home and wait for labour, we need to make sure:

• your baby is positioned head down
• you show no signs of infection
• you have a reliable way to get back to the hospital quickly if needed.

When you're home, take some basic precautions and know when to call and come in:

• check your temperature every 4 hours during the day
• if your temperature is 37.5 degrees or higher, contact your midwife or maternity ward
• use a sanitary pad and change it at least every 4 hours during the day
• normally, the colour of the water (amniotic fluid) is clear. If it changes to green, yellow, or blood-stained, contact your midwife or maternity ward
• if your baby moves less than usual, contact your midwife or maternity ward
• if you have regular, painful contractions, contact your midwife or maternity ward
• if you feel concerned for any reason or unwell, contact your midwife or maternity ward.

In case any of these things happen, you'll be asked to come to the hospital for review.

How you can reduce the chance of infection and help your body prepare for labour

• rest, eat, and drink normally
• take a bath or shower if you want to
• wash your hands carefully before and after using the toilet or changing your pad
• change your pad regularly
• avoid sexual intercourse
• don't go swimming
• avoid using tampons.

The Southern NSW LHD recommends inducing your labour if it hasn't started within 24 hours of your waters breaking.

If you're concerned or have questions at any time, please contact your midwife or maternity ward.

Southern NSW LHD supports your decision to hire a doula for emotional and physical support during labour.

A doula is an experienced companion who understands the needs of a woman and her family during pregnancy, birth, and the postnatal period. They provide continuous, non-medical support.

Doulas are not regulated or registered health professionals. Anyone can use the title "doula".

Some doulas undergo a doula course. You can ask about their education and experience. Your doula should share their background, abilities, education, and feedback from previous families.

It's important to clarify the roles of midwives and doulas, especially if the doula has midwifery qualifications. However, a doula cannot act as a midwife, providing clinical advice or tasks.

To avoid confusion:

• bring your doula to antenatal care appointments for information sharing
• develop your birth plan with your midwife or doctor by 36 weeks
• call the hospital or midwife if you think you're in labour.

Your doula is one of your support people in labour but cannot speak for you or make decisions with your doctor or midwife. If you can't communicate in labour, the midwife or doctor will discuss your wishes with your partner or next of kin.

Your doula cannot provide clinical care or advice. For clinical concerns, talk to your midwife or doctor.

If you need a caesarean, only one person can be with you in the operating theatre. Decide beforehand who that person will be.

Your doula, like other visitors, may be asked to leave if the focus is on your safety.

Partners in the hospital

Your partner is welcome to be with you during labour and your postnatal stay in Maternity. They should make arrangements for their meals during your stay.

Useful Information for dads and partners:

• NSW Health - Focus on New Fathers

How long will I stay in hospital after birth?

The duration of your stay depends on the type of birth and the well-being of you and your baby.

For a normal vaginal birth, the stay is usually between 6 to 48 hours.

If there are complications or your baby needs extra care, the stay may be longer.

For a caesarian section (C-section), the stay is typically around 72 hours.

Will my midwife visit me at home?

Most maternity services offer postnatal home visits, but there may be travel limits, such as a 20-to-30-minute travel distance from the service. Discuss this with your midwife.

Contact us to schedule your first antenatal (before birth) visit. We recommend women come in for their initial appointment before reaching 14 weeks of pregnancy.

Antenatal, birthing, and postnatal (after birth) care are offered at various locations within the Local Health District. Find a health service .

If you're in the Yass Valley or Bombala areas, we also provide outreach services in partnership with Southern NSW Local Health District (SNSWLHD) Maternity Services for pregnancy and postnatal care.

Service contacts

Helpful information resources.

Discover helpful information about pregnancy, childbirth, and baby care. Learn about getting pregnancy support, preparing for labour, and maintaining good health during pregnancy.

• NSW Health - Having a baby
• NSW Health - Pregnancy screening for Group B Streptococcus (GBS)
• NSW Health - Pregnancy beyond 41 weeks
• NSW Health - Next birth after caesarean
• NSW Health - Breech baby at term
• Get Healthy in Pregnancy Service
• RANZCOG Pregnancy information pamphlets
• Non-Invasive Prenatal Testing (NIPT) fact sheet
• Royal Women’s Hospital - Pregnancy, labour and birth
• Royal Hospital for Women - MotherSafe fact sheets
• Information sheet - Movements matter
• Baby's Movements Matter website
• Third and fourth degree perineal tears
• NSW Health - Labour and birth fact sheets
• NSW Health - Breastfeeding and newborn care fact sheets
• Perinatal Anxiety and Depression Australia (PANDA)
• Beyond Blue - pregnancy and new parents
• Information on perinatal depression and anxiety
• National Immunisation Program
• Immunisation for mums and babies
• COVID-19 vaccine information for women who are pregnant, breastfeeding or planning pregnancy
• NSW Health - Hepatitis B Immunisation for your baby
• Vitamin K information for parents
• NSW Health - Newborn Bloodspot Screening - Information for parents
• Raising children - Newborns
• Jaundice and your newborn baby
• Neonatal Hypoglycaemia Newborn Care Guidelines  
• NSW Health - Smoking and pregnancy fact sheet
• NSW Health - Smoking and pregnancy information and resources

Visiting a dentist

On this page, eligibility direction, children upto school year 8, adolescents – up to 18th birthday, special-needs dentistry, emergency dental services for adults, dental treatments for injury.

A range of basic preventive, treatment and specialist dental services are available to eligible children and adolescents up until 18th birthday. A limited range of services for some adults is publicly funded. The main publicly funded services are outlined below.

You must meet one of the criteria in the Eligibility Direction to be considered for these publicly funded services. If you are not eligible, you are liable to be charged for the full costs of any medical treatment or disability support service you receive.

To see whether you meet the specified eligibility criteria go to the  Guide to eligibility for public health services.

Dental education, preventive and basic treatment services are provided free of charge to pre-school and primary school age children through the Community Oral Health Service. Parents can enrol their children directly or referrals can be made by Well Child providers or general practitioners.

Dental and oral therapists provide most services and dentists provide more specialised treatment if necessary. Dental assessments and treatments usually take place in community-based clinics, often located on school sites, or in mobile dental units. Some treatments are not free, such as orthodontics (including braces, for example).

Contact  0800 TALK TEETH  ( 0800 825 583 ) for enrolment information.

A range of free basic dental services is funded for adolescents until their 18th birthday. Services are usually provided by private dentists who are contracted by the local district health board to provide free services for adolescents. The Community Oral Health Service will normally provide enrolment information at the end of school year 8, or adolescents can enrol directly with a contracted dentist.

Children and adults with special medical needs (such as cleft palate) or disabilities that make them unable to access normal dental services or who require dental treatment as part of other treatment (such as for head or neck cancer) can receive free hospital dental services. Part-charges apply for outpatient services, but services are free where a patient needs to be admitted (for example, if they need a general anaesthetic).

Referrals are usually made by dental and oral health therapists, private dentists, or general practitioners.

Emergency pain relief and extractions are provided through hospital dental departments, or by contracted private dentists. These services are restricted to people on low incomes (usually demonstrated by having a Community Services Card). Part charges may apply. Contact the hospital dental department (see your   local region website   for the phone number).

Work and Income New Zealand can also provide discretionary financial assistance for   immediate and essential  dental treatment for low income adults. Contact your local Work and Income service centre for more information.

Dental treatment needed due to injury or accident is funded for all people in New Zealand and managed through the  Accident Compensation Corporation . Co-payments may be required. Contact your local ACC office for more information.

Watchdog group asks 5 attorneys general to investigate crisis pregnancy center privacy practices

A progressive watchdog group sent letters Tuesday asking attorneys general in five states to investigate the privacy practices of crisis pregnancy centers , arguing they could be misleading patients with claims that sensitive medical data is protected by health privacy laws, according to copies of the letters obtained by NBC News.

While the letters don’t allege misuse of private health information the pregnancy centers collect, they ask the attorneys general to investigate what they use the information for and whether crisis pregnancy centers are using it to further anti-abortion goals.

The letters, sent by the Campaign for Accountability, allege that the centers, which try to dissuade pregnant women from seeking abortions, gather sensitive and private medical information as part of their appointment scheduling processes. The letters asked the attorneys general of Idaho , Minnesota , New Jersey, Pennsylvania and Washington to use their investigative power to probe why crisis pregnancy centers are gathering and retaining sensitive medical information and what they do with it — and potentially charge the centers with violating state consumer protection laws. 

The centers, which provide counseling and services for women coping with unplanned pregnancies, say on their websites that they comply with the federal Health Insurance Portability and Accountability Act, known as HIPAA , as a promise that the information is protected and kept confidential.

However, because the centers offer services for free, they are not legally bound by federal health data privacy laws, creating a privacy risk that could be exploited in the wake of efforts to criminalize abortion, according to the letters.

At the time of publication, the pregnancy centers discussed in the letters from Campaign for Accountability had not responded to a list of questions. 

The letters, signed by the group’s executive director, Michelle Kuppersmith, argue “women are guaranteed no actual privacy protection when they hand over highly sensitive information about their pregnancies or reproductive health.” 

The practice is “particularly disturbing given some neighboring states’ desires to prosecute women who travel to seek abortion — including to states where abortion remains legal,” Kuppersmith writes.

Andrea Swartzendruber, an associate professor of biostatistics at the University of Georgia College of Public Health who studies crisis pregnancy centers, said: “They have so much information about the people who go to crisis pregnancy centers. There is some language in those forms that is completely problematic in the hands of crisis pregnancy centers.”

Susannah Baruch, executive director of the Petrie-Flom Center for Health Law Policy, Biotechnology and Bioethics at Harvard Law School, said claiming to be HIPAA-compliant while actually not being regulated by the federal privacy law could leave consumers whose data is shared without their consent with no recourse.

“There can be enforcement mechanisms against an entity that doesn’t do what the privacy rule requires, assuming that entity is covered by the HIPAA privacy rule,” said Baruch, who said it would be difficult for “visitors to enforce their rights, because this is not an entity against whom they can sort of claim the protections and HIPAA privacy rules.”

While many crisis pregnancy centers offer free services, such as pregnancy tests and ultrasound scans, as well as counseling, reproductive health doctors say many of them also provide misleading or false information , such as linking abortion to mental illness or infertility, meant to discourage or prevent women from receiving abortion care. 

The rise of crisis pregnancy centers

Community-based pregnancy centers began to crop up around the country in the 1960s. As the anti-abortion movement gained momentum after Roe v. Wade, religious activists began organizing them into national networks. Eventually, the centers shifted to take on the appearance of medical facilities to attract women seeking abortions and “impact a woman’s decision to choose life,” according to the National Institute of Family and Life Advocates, the organization that introduced ultrasound technology into crisis pregnancy centers.

However, the centers are not subject to the same standards as health facilities, and they are often unregulated by state health departments, which can lead to confusion over what services they actually offer: Women who are seeking abortions mistakenly schedule appointments at facilities that will try to counsel them against the procedure.

There are more than 2,500 crisis pregnancy centers across the country, compared to just over 800 abortion clinics, according to the Guttmacher Institute, a research group that supports access to abortion. There have been attempts to restrict the centers by requiring them to display written notices informing women about abortion access. In 2018, the Supreme Court ruled the efforts violated the First Amendment .

Questioning whether crisis pregnancy centers engage in deceptive privacy practices is an approach that the Campaign for Accountability hopes will prove more effective.

“CPCs are playing an increasing role in the anti-choice movement’s strategy,” Kuppersmith said. “Given the prevalence of these centers and their efforts to reach minors and other often low-income women, their activities merit close scrutiny.”

Collecting data

The crisis pregnancy centers discussed in the letters, like many across the country, are affiliated with Care Net and Heartbeat International, major pregnancy-center networks that describe themselves as religious ministries. In return for affiliation fees, pregnancy centers receive training, digital support and digital forms used to collect client information from women who interact with their facilities.

“We believe we are better together, and our center management software reflects that by collecting data, across the pregnancy help movement, on critical metrics to provide powerful, actionable insights at the local level,” Heartbeat International writes on its website.

Baruch, of Harvard Law School, said: “Many of the crisis pregnancy centers are part of networks, and they’re sharing the information up to the networks, which are there to try to reduce the number of people accessing abortion. We don’t know exactly what they would do with the information.”

The Campaign for Accountability asks the same question in the letters, writing, “This raises the question of why” crisis pregnancy centers are “gathering and retaining this highly sensitive medical and personal information and what the group does with this information.”

Much of the data is collected on pregnancy centers’ websites, which prompt prospective clients to make appointments, much as they would for doctors’ visits. 

The online intake forms ask for private information such as first and last name, phone number, email address, date of birth, first day of last period and, in some cases, interest in obtaining abortion care and interest in specific pregnancy services. 

Voluntary compliance

Websites for the centers say they are “fully HIPAA-compliant.” Some of the centers discussed in the letters say in their privacy policies that they are “required by law to maintain the privacy and security of your protected health information” and instruct clients that if they believe their data has been compromised, they can “file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights.”

However, in a blog post, Care Net acknowledges that compliance is voluntary, because the pregnancy centers are not actually bound by the federal privacy law.

“Most centers do not meet the legal definition of a covered entity under the HIPAA regulation because they do not furnish, bill, or are paid for health care in the normal course of business and do not transmit health information in electronic form in connection with a transaction for which a HIPAA standard has been adopted by HHS,” the blog post says.

That is also acknowledged in the privacy practices of some of the clinics discussed in the letters from Campaign for Accountability.

Sage Women’s Center in Twin Falls, Idaho, writes on its website that “any transactions that invoke coverage of the HIPAA Privacy  Act” and therefore its privacy practices are “voluntarily undertaken.”  

“Therefore, nothing in this notice should be construed as creating any contractual or legal rights on behalf of patients,” the privacy policy says.

Privacy policies for two of the pregnancy centers say personal data can be disclosed without consent “when required by law, when required for public health reasons” or “when necessary to avert a threat of harm to you or a third person.” Privacy policies for the three others say personal data can be disclosed “as required by law” or “when required to protect our rights or your safety or the safety of others.”

In the letters, Kuppersmith urges the attorneys general to investigate whether pregnancy centers could consider “a woman’s decision to seek abortion care as a ‘threat’ to the safety of a fetus and a ‘morally compelling’ reason to break confidentiality.”

In their advertising and legal materials, Care Net and Heartbeat International maintain that confidentiality is a priority. 

“Personal and health information is treated highly confidentially,” Care Net writes on its website. “Except in rare cases where information must be shared in compliance with state law for the protection of an endangered child, or to protect the client or others from physical harm, client information is held in the strictest confidence.”

A legal manual for Care Net and Heartbeat International pregnancy centers obtained by NBC News says: “For non-medical pregnancy centers, the confidentiality policy is primarily ethical, not legal.  “Nevertheless, because centers voluntarily promise confidentiality, centers could be held legally liable should such confidentiality be breached for inappropriate reasons.”

In a blog post , Care Net says its “pregnancy centers agree to respect client/patient privacy, and medical centers adhere to and distribute a notice of privacy practices modeled on HIPAA.” 

“Centers readily comply with all applicable confidentiality and HIPAA regulations that apply to many abortion clinics, retail clinics, and other physician’s offices,” the blog post says. “Care Net will disaffiliate any center that persists in violating or is unwilling to comply with our standards of affiliation.”

In a statement to NBC News, Jor-El Godsey, president of Heartbeat International, said, “Pregnancy help organizations comply with all applicable laws, including state-level data privacy laws and applicable HIPAA provisions.”

“For centers, confidentiality is so much more than merely complying with the law. It’s about serving her well, which includes safeguarding her private information and honoring her trust — hence the ethical duty to maintain confidentiality,” Godsey said. “Because our services are free of charge making HIPAA not applicable, confidentiality is of the utmost importance.”  

At the time of publication, Care Net had not responded to a list of questions.

On Monday, the Biden administration announced new rules to strengthen HIPAA to offer more legal protections for people who obtain or provide abortion care in states where it is legal to do so. The final policy prohibits health care organizations from disclosing private health information to state officials to conduct investigations or prosecute patients or providers. 

The new rule does not apply to crisis pregnancy centers, a Department of Health and Human Services official said.

“Generally, a crisis pregnancy center that provides services for free and does not bill health insurance does not meet the definition of a covered entity under HIPAA and therefore the HIPAA Privacy, Security, and Breach Notification Rules (‘HIPAA Rules’) do not apply,” the official told NBC News in an email.

There is precedent for penalizing companies for misleading consumers about why their reproductive health information is being collected and how it is being shared. In 2021, the Federal Trade Commission filed a complaint alleging Flo, a period- and pregnancy-tracking app, shared millions of users’ data with third-party companies, despite having promised users their data would stay private.

A group of Senate Democrats has tried to get answers about how crisis pregnancy center networks use and protect such data before, having sent a letter to Heartbeat International highlighting concerns that the data could be used in abortion-related prosecutions. In response, the organization declined to “respond materially” to questions about how and with whom it shares client data, Sen. Elizabeth Warren, D-Mass., said in a news release, but it posted on its website that it has never “had a security breach related to client information,” maintaining that “any data we collect has always been secure, safe, and legal.”

Abigail Brooks is a producer for NBC News.

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Antenatal care

NICE Guideline, No. 201

• Copyright and Permissions

This guideline replaces CG62.

This guideline is the basis of QS22, QS35, QS98 and QS105.

This guideline covers the routine antenatal care that women and their babies should receive. It aims to ensure that pregnant women are offered regular check-ups, information and support. We have also published a guideline on postnatal care, which covers the topics of emotional attachment and baby feeding.

The guideline uses the terms ‘woman’ or ‘mother’ throughout. These should be taken to include people who do not identify as women but who are pregnant. Similarly, where the term ‘parents’ is used, this should be taken to include anyone who has main responsibility for caring for a baby.

The Royal College of Obstetricians and Gynaecologists has produced guidance on COVID-19 and antenatal care for all midwifery and obstetric services.

Who is it for?

• Healthcare professionals
• Commissioners of antenatal care services
• Women using antenatal services, their partners, their families, and the public
• Recommendations

People have the right to be involved in discussions and make informed decisions about their care, as described in NICE’s information on making decisions about your care .

Making decisions using NICE guidelines explains how we use words to show the strength (or certainty) of our recommendations, and has information about prescribing medicines (including off-label use), professional guidelines, standards and laws (including on consent and mental capacity), and safeguarding.

Supporting women to make decisions about their care is important during pregnancy. Healthcare professionals should ensure that women have the information they need to make decisions and to give consent in line with General Medical Council (GMC) guidance , the Nursing and Midwifery Council (NMC) Code and the 2015 Montgomery ruling .

Please note that the Royal College of Obstetricians and Gynaecologists has produced guidance on COVID-19 and pregnancy for all midwifery and obstetric services.

1.1. Organisation and delivery of antenatal care

Starting antenatal care.

Ensure that antenatal care can be started in a variety of straightforward ways, depending on women’s needs and circumstances, for example, by self-referral, referral by a GP, midwife or another healthcare professional, or through a school nurse, community centre or refugee hostel.

• Provide an easy-to-complete referral form.
• Offer early pregnancy health and wellbeing information before the booking appointment. This should include information about modifiable factors that may affect the pregnancy, including stopping smoking, avoiding alcohol, taking supplements, and eating healthily. See also recommendation 1.3.9 and the NICE guidelines on maternal and child nutrition , vitamin D , and smoking: stopping in pregnancy and after childbirth .
• Ensure that the materials are available in different languages or formats such as digital, printed, braille or Easy Read.

specific health and social care needs

risk factors, including those that can potentially be addressed before the booking appointment, for example, smoking

• include contact details about the woman’s GP.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on starting antenatal care .

Full details of the evidence and the committee’s discussion are in evidence review F: accessing antenatal care .

Antenatal appointments

Offer a first antenatal (booking) appointment with a midwife to take place by 10+0 weeks of pregnancy.

If women contact or are referred to maternity services later than 9+0 weeks of pregnancy, offer a first antenatal (booking) appointment to take place within 2 weeks if possible.

If a woman books late in pregnancy, ask about the reasons for the late booking because it may reveal social, psychological or medical issues that need to be addressed.

Plan 10 routine antenatal appointments with a midwife or doctor for nulliparous women. (See schedule of appointments .)

Plan 7 routine antenatal appointments with a midwife or doctor for parous women. (See schedule of appointments .)

• women who misuse substances
• recent migrants, asylum seekers or refugees, or women who have difficulty reading or speaking English
• young women aged under 20
• women who experience domestic abuse.

Offer additional or longer antenatal appointments if needed, depending on the woman’s medical, social and emotional needs. Also see the NICE guidelines on pregnancy and complex social factors , intrapartum care for women with existing medical conditions or obstetric complications and their babies , hypertension in pregnancy , diabetes in pregnancy and twin and triplet pregnancy .

Ensure that reliable interpreting services are available when needed, including British Sign Language. Interpreters should be independent of the woman rather than using a family member or friend.

Those responsible for planning and delivering antenatal services should aim to provide continuity of carer .

Ensure that there is effective and prompt communication between healthcare professionals who are involved in the woman’s care during pregnancy.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on antenatal appointments .

• evidence review H: timing of first antenatal appointment
• evidence review I: number of antenatal appointments
• evidence review J: referral and delivery of antenatal care .

Involving partners

• involve partners according to the woman’s wishes and
• inform the woman that she is welcome to bring a partner to antenatal appointments and classes.

Consider arranging the timing of antenatal classes so that the pregnant woman’s partner can attend, if the woman wishes.

• providing information about how partners can be involved in supporting the woman during and after pregnancy
• providing information about pregnancy for partners as well as pregnant women
• displaying positive images of partner involvement (for example, on notice boards and in waiting areas)
• providing seating in consultation rooms for both the woman and her partner
• considering providing opportunities for partners to attend appointments remotely as appropriate.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on involving partners .

Full details of the evidence and the committee’s discussion are in evidence review C: involving partners and evidence review B: approaches to information provision .

1.2. Routine antenatal clinical care

Taking and recording the woman’s history.

• her medical history, obstetric history and family history (of both biological parents)
• previous or current mental health concerns such as depression, anxiety, severe mental illness, psychological trauma or psychiatric treatment, to identify possible mental health problems in line with the section on recognising mental health problems in pregnancy and the postnatal period and referral in the NICE guideline on antenatal and postnatal mental health
• current and recent medicines, including over-the-counter medicines, health supplements and herbal remedies
• her occupation, discussing any risks and concerns
• her family and home situation, available support network and any health or other issues affecting her partner or family members that may be significant for her health and wellbeing
• other people who may be involved in the care of the baby
• contact details for her partner and her next of kin
• factors such as nutrition and diet, physical activity, smoking and tobacco use, alcohol consumption and recreational drug use (see also recommendations 1.3.8 and 1.3.9 ).

Consider reviewing the woman’s previous medical records if needed, including records held by other healthcare providers.

4 times higher in black women (34/100,000)

3 times higher in women with mixed ethnic background (25/100,000)

2 times higher in Asian women (15/100,000; does not include Chinese women)

more than twice as high in black babies (74/10,000)

around 50% higher in Asian babies (53/10,000)

• women living in the most deprived areas (15/100,000) are more than 2.5 times more likely to die compared with women living in the least deprived areas (6/100,000)
• the stillbirth rate increases according to the level of deprivation in the area the mother lives in, with almost twice as many stillbirths for women living in the most deprived areas (47/10,000) compared with the least deprived areas (26/10,000).

If the woman or her partner smokes or has stopped smoking within the past 2 weeks, offer a referral to NHS Stop Smoking Services in line with the NICE guideline on smoking: stopping in pregnancy and after childbirth . Also see the NICE guideline on smokeless tobacco: South Asian communities .

Ask the woman about domestic abuse in a kind, sensitive manner at the first antenatal (booking) appointment, or at the earliest opportunity when she is alone. Ensure that there is an opportunity to have a private, one-to-one discussion. Also see the NICE guideline on domestic violence and abuse and the section on pregnant women who experience domestic abuse in the NICE guideline on pregnancy and complex social factors .

Assess the woman’s risk of and, if appropriate, discuss female genital mutilation (FGM) in a kind, sensitive manner. Take appropriate action in line with UK government guidance on safeguarding women and girls at risk of FGM .

Refer the woman for a clinical assessment by a doctor to detect cardiac conditions if there is a concern based on the pregnant woman’s personal or family history. See also the section on heart disease in the NICE guideline on intrapartum care for women with existing medical conditions or obstetric complications and their babies .

Refer the woman to an obstetrician or other relevant doctor if there are any medical concerns or if review of current long-term medicines is needed.

After discussion with and agreement from the woman, contact the woman’s GP to share information about the pregnancy and potential concerns or complications during pregnancy.

• ask the woman about her general health and wellbeing
• ask the woman (and her partner, if present) if there are any concerns they would like to discuss
• provide a safe environment and opportunities for the woman to discuss topics such as concerns at home, domestic abuse, concerns about the birth (for example, if she previously had a traumatic birth) or mental health concerns
• review and reassess the plan of care for the pregnancy
• identify women who need additional care.

At every antenatal contact, update the woman’s antenatal records to include details of history, test results, examination findings, medicines and discussions.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on taking and recording the woman’s history .

Full details of the evidence and the committee’s discussion are in evidence review G: content of antenatal appointments .

Examinations and investigations

• offer to measure the woman’s height and weight and calculate body mass index
• offer a blood test to check full blood count, blood group and rhesus D status.
• NHS infectious diseases in pregnancy screening programme (HIV, syphilis and hepatitis B)
• NHS sickle cell and thalassaemia screening programme
• NHS fetal anomaly screening programme .

Inform the woman that she can accept or decline any part of any of the screening programmes offered.

• determine gestational age
• detect multiple pregnancy
• and if opted for, screen for Down’s syndrome, Edwards’ syndrome and Patau’s syndrome (see the NHS fetal anomaly screening programme ).
• screen for fetal anomalies (see the NHS fetal anomaly screening programme )
• determine placental location.
• anti-D prophylaxis to rhesus-negative women in line with NICE’s technology appraisal guidance on routine antenatal anti-D prophylaxis for women who are rhesus D negative (see also NICE’s diagnostics guidance on high-throughput non-invasive prenatal testing for fetal RHD genotype )
• a blood test to check full blood count, blood group and antibodies.

If there are any unexpected results from examinations or investigations, offer referral according to local pathways and ensure appropriate information provision and support.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on examinations and investigations .

Venous thromboembolism

Assess the woman’s risk factors for venous thromboembolism at the first antenatal (booking) appointment, and after any hospital admission or significant health event during pregnancy. Consider using guidance by an appropriate professional body, for example, the Royal College of Obstetricians and Gynaecologists’ guideline on reducing the risk of venous thromboembolism during pregnancy .

For pregnant women who are admitted to a hospital or a midwife-led unit, see the section on interventions for pregnant women and women who gave birth or had a miscarriage or termination of pregnancy in the past 6 weeks in the NICE guideline on venous thromboembolism in over 16s .

For women at risk of venous thromboembolism, offer referral to an obstetrician for further management.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on venous thromboembolism .

Full details of the evidence and the committee’s discussion are in evidence review N: risk factors for venous thromboembolism in pregnancy .

Gestational diabetes

At the first antenatal (booking) appointment, assess the woman’s risk factors for gestational diabetes in line with the recommendations on gestational diabetes risk assessment in the NICE guideline on diabetes in pregnancy .

If a woman is at risk of gestational diabetes, offer referral for an oral glucose tolerance test to take place between 24+0 weeks and 28+0 weeks in line with the recommendations on gestational diabetes risk assessment and the recommendations on gestational diabetes testing in the NICE guideline on diabetes in pregnancy.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on gestational diabetes .

Pre-eclampsia and hypertension in pregnancy

At the first antenatal (booking) appointment and again in the second trimester, assess the woman’s risk factors for pre-eclampsia, and advise those at risk to take aspirin in line with the section on antiplatelet agents in the NICE guideline on hypertension in pregnancy .

Measure and record the woman’s blood pressure at every routine face-to-face antenatal appointment using a device validated for use in pregnancy, and following the recommendations on measuring blood pressure in the NICE guideline on hypertension in adults .

For women under 20+0 weeks with hypertension, follow the recommendations on the management of chronic hypertension in pregnancy in the NICE guideline on hypertension in pregnancy .

Refer women over 20+0 weeks with a first episode of hypertension (blood pressure of 140/90 mmHg or higher) to secondary care to be seen within 24 hours. See the recommendations on diagnosing hypertension in the NICE guideline on hypertension in adults .

Urgently refer women with severe hypertension (blood pressure of 160/110 mmHg or higher) to secondary care to be seen on the same day. The urgency of the referral should be determined by an overall clinical assessment.

Offer a urine dipstick test for proteinuria at every routine face-to-face antenatal appointment.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on pre-eclampsia and hypertension in pregnancy .

Full details of the evidence and the committee’s discussion are in evidence review K: identification of hypertension in pregnancy and evidence review G: content of antenatal appointments .

Monitoring fetal growth and wellbeing

Offer a risk assessment for fetal growth restriction at the first antenatal (booking) appointment, and again in the second trimester. Consider using guidance by an appropriate professional or national body, for example, the Royal College of Obstetricians and Gynaecologists’ guideline on the investigation and management of the small-for-gestational-age fetus or the NHS saving babies’ lives care bundle version 2 .

Offer symphysis fundal height measurement at each antenatal appointment after 24+0 weeks (but no more frequently than every 2 weeks) for women with a singleton pregnancy unless the woman is having regular growth scans. Plot the measurement onto a growth chart in line with the NHS saving babies’ lives care bundle version 2 .

If there are concerns that the symphysis fundal height is large for gestational age, consider an ultrasound scan for fetal growth and wellbeing.

If there are concerns that the symphysis fundal height is small for gestational age, offer an ultrasound scan for fetal growth and wellbeing, the urgency of which may depend on additional clinical findings, for example, reduced fetal movements or raised maternal blood pressure.

Do not routinely offer ultrasound scans after 28 weeks for uncomplicated singleton pregnancies.

• ask if she has any concerns about her baby’s movements at each antenatal contact after 24+0 weeks
• advise her to contact maternity services at any time of day or night if she has any concerns about her baby’s movements or she notices reduced fetal movements after 24+0 weeks
• assess the woman and baby if there are any concerns about the baby’s movements.

Service providers should recognise that the use of structured fetal movement awareness packages , such as the one studied in the AFFIRM trial, has not been shown to reduce stillbirth rates.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on monitoring fetal growth and wellbeing .

• evidence review O: monitoring fetal growth
• evidence review P: fetal movement monitoring
• evidence review Q: routine third trimester ultrasound for fetal growth .

Breech presentation

Offer abdominal palpation at all appointments after 36+0 weeks to identify possible breech presentation for women with a singleton pregnancy.

If breech presentation is suspected on abdominal palpation, offer an ultrasound scan to determine the presentation.

external cephalic version (to turn the baby from bottom to head down)

breech vaginal birth

elective caesarean birth

• for women who prefer cephalic (head-down) vaginal birth, offer external cephalic version.

Also see the recommendations on breech presentation in the NICE guideline on caesarean birth , and the recommendations on breech presenting in labour in the NICE guideline on intrapartum care for women with existing medical conditions or obstetric complications and their babies .

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on breech presentation .

Full details of the evidence and the committee’s discussion are in evidence review L: identification of breech presentation and evidence review M: management of breech presentation .

1.3. Information and support for pregnant women and their partners

Communication – key principles.

When caring for a pregnant woman, listen to her and be responsive to her needs and preferences. Also see the NICE guideline on patient experience in adult NHS services , in particular the sections on communication and information , and the NICE guideline on shared decision making .

Ensure that when offering any assessment, intervention or procedure, the risks, benefits and implications are discussed with the woman and she is aware that she has a right to decline.

Women’s decisions should be respected, even when this is contrary to the views of the healthcare professional.

• offered on a one-to-one or couple basis
• supplemented by group discussions (women only or women and partners)
• supplemented by written information in a suitable format, for example, digital, printed, braille or Easy Read
• offered throughout the woman’s care
• individualised and sensitive
• supportive and respectful
• evidence-based and consistent
• translated into other languages if needed.

For more guidance on communication, providing information (including different formats and languages), and shared decision making, see the NICE guideline on patient experience in adult NHS services and the NHS Accessible Information Standard .

Explore the knowledge and understanding that the woman (and her partner) has about each topic to individualise the discussion.

Check that the woman (and her partner) understands the information that has been given, and how it relates to them. Provide regular opportunities to ask questions, and set aside enough time to discuss any concerns.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on communication – key principles .

• evidence review B: approaches to information provision
• evidence review A: information provision

Information about antenatal care

At the first antenatal (booking) appointment, discuss antenatal care with the woman (and her partner) and provide her schedule of antenatal appointments .

• what antenatal care involves and why it is important
• the planned number of antenatal appointments
• where antenatal appointments will take place
• which healthcare professionals will be involved in antenatal appointments
• how to contact the midwifery team for non-urgent advice
• how to contact the maternity service about urgent concerns, such as pain and bleeding
• screening programmes: what blood tests and ultrasound scans are offered and why
• how the baby develops during pregnancy
• what to expect at each stage of the pregnancy
• physical and emotional changes during the pregnancy
• mental health during the pregnancy
• relationship changes during the pregnancy
• how the woman and her partner can support each other
• immunisation for flu, pertussis (whooping cough) and other infections (for example, COVID-19) during pregnancy, in line with the NICE guideline on flu vaccination and the Public Health England Green Book on immunisation against infectious disease
• infections that can impact on the baby in pregnancy or during birth (such as group B streptococcus, herpes simplex and cytomegalovirus)
• reducing the risk of infections, for example, encouraging hand washing
• safe use of medicines, health supplements and herbal remedies during pregnancy
• resources and support for expectant and new parents
• how to get in touch with local or national peer support services.

At the first antenatal (booking) appointment, and later if appropriate, discuss and give information about nutrition and diet, physical activity, smoking cessation and recreational drug use in a non-judgemental, compassionate and personalised way. See the NICE guidelines on maternal and child nutrition , vitamin D , weight management before, during and after pregnancy , smoking: stopping in pregnancy and after childbirth , and the section on pregnant women who misuse substances (alcohol and/or drugs) in the NICE guideline on pregnancy and complex social factors .

• there is no known safe level of alcohol consumption during pregnancy
• drinking alcohol during the pregnancy can lead to long-term harm to the baby
• the safest approach is to avoid alcohol altogether to minimise risks to the baby.
• how the parents can bond with their baby and the importance of emotional attachment (also see the section on promoting emotional attachment in the NICE guideline on postnatal care )
• the results of any blood or screening tests from previous appointments.

After 24 weeks, discuss babies’ movements (see also recommendation 1.2.34 ).

Before 28 weeks, start talking with the woman about her birth preferences and the implications, benefits and risks of different options (see the section on choosing planned place of birth in the NICE guideline on intrapartum care for healthy women and babies and the section on planning mode of birth in the NICE guideline on caesarean birth ).

• preparing for labour and birth, including information about coping in labour and creating a birth plan
• recognising active labour

care of the new baby

the baby’s feeding

vitamin K prophylaxis

newborn screening

postnatal self-care, including pelvic floor exercises

awareness of mood changes and postnatal mental health.

Also see the NICE guideline on postnatal care .

From 28 weeks onwards, as appropriate, continue the discussions and confirm the woman’s birth preferences, discussing the implications, benefits and risks of all the options.

From 38 weeks, discuss prolonged pregnancy and options on how to manage this, in line with the NICE guideline on inducing labour .

See the NICE guideline on preterm labour and birth for women at increased risk of, or with symptoms and signs of, preterm labour (before 37 weeks), and women having a planned preterm birth.

Provide appropriate information and support for women whose baby is considered to be at an increased risk of neonatal admission.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on information about antenatal care .

• evidence review C: involving partners
• evidence review D: peer support
• evidence review G: content of antenatal appointments
• evidence review J: referral and delivery of antenatal care
• evidence review P: fetal movement monitoring .

Antenatal classes

• preparing for labour and birth
• supporting each other throughout the pregnancy and after birth
• common events in labour and birth
• how to care for the baby
• planning and managing their baby’s feeding (also see the section on planning and supporting babies’ feeding in the NICE guideline on postnatal care ).

Consider antenatal classes for multiparous women (and their partners) if they could benefit from attending (for example, if they have had a long gap between pregnancies, or have never attended antenatal classes before).

Ensure that antenatal classes are welcoming, accessible and adapted to meet the needs of local communities. Also see the section on young pregnant women aged under 20 in the NICE guideline on pregnancy and complex social factors .

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on antenatal classes .

Full details of the evidence and the committee’s discussion are in evidence review E: antenatal classes and evidence review B: approaches to information provision .

Peer support

• provide practical support
• help to build confidence
• reduce feelings of isolation.

Offer pregnant women (and their partners) information about how to access local and national peer support services.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on peer support .

Full details of the evidence and the committee’s discussion are in evidence review D: peer support .

Sleep position

Advise women to avoid going to sleep on their back after 28 weeks of pregnancy and to consider using pillows, for example, to maintain their position while sleeping.

Explain to the woman that there may be a link between going to sleep on her back and stillbirth in late pregnancy (after 28 weeks).

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on sleep position .

Full details of the evidence and the committee’s discussion are in evidence review W: maternal sleep position during pregnancy .

1.4. Interventions for common problems during pregnancy

Nausea and vomiting.

Reassure women that mild to moderate nausea and vomiting are common in pregnancy, and are likely to resolve before 16 to 20 weeks.

Recognise that by the time women seek advice from healthcare professionals about nausea and vomiting in pregnancy, they may have already tried a number of different interventions.

For pregnant women with mild-to-moderate nausea and vomiting who prefer a non-pharmacological option, suggest that they try ginger.

When considering pharmacological treatments for nausea and vomiting in pregnancy, discuss the advantages and disadvantages of different antiemetics with the woman. Take into account her preferences and her experience with treatments in previous pregnancies. See table 1 on the advantages and disadvantages of different pharmacological treatments for nausea and vomiting in pregnancy to support shared decision making .

For pregnant women with nausea and vomiting who choose a pharmacological treatment, offer an antiemetic (see table 1 on the advantages and disadvantages of different pharmacological treatments for nausea and vomiting in pregnancy ).

• consider intravenous fluids, ideally on an outpatient basis
• consider acupressure as an adjunct treatment.

Consider inpatient care if vomiting is severe and not responding to primary care or outpatient management. This will include women with hyperemesis gravidarum. Also see the section on venous thromboembolism .

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on nausea and vomiting .

Full details of the evidence and the committee’s discussion are in evidence review R: management of nausea and vomiting in pregnancy .

Give information about lifestyle and dietary changes to pregnant women with heartburn in line with the section on common elements of care in the NICE guideline on gastro-oesophageal reflux disease and dyspepsia in adults .

Consider a trial of an antacid or alginate for pregnant women with heartburn.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on heartburn .

Full details of the evidence and the committee’s discussion are in evidence review S: management of heartburn in pregnancy .

Symptomatic vaginal discharge

Advise pregnant women who have vaginal discharge that this is common during pregnancy, but if it is accompanied by symptoms such as itching, soreness, an unpleasant smell or pain on passing urine, there may be an infection that needs to be investigated and treated.

Consider carrying out a vaginal swab for pregnant women with symptomatic vaginal discharge if there is doubt about the cause.

If a sexually transmitted infection is suspected, consider arranging appropriate investigations.

Offer vaginal imidazole (such as clotrimazole or econazole) to treat vaginal candidiasis in pregnant women.

Consider oral or vaginal antibiotics to treat bacterial vaginosis in pregnant women in line with the NICE guideline on antimicrobial stewardship .

For a short explanation of why the committee made the recommendations and how they might practice, see the rationale and impact section on symptomatic vaginal discharge .

Full details of the evidence and the committee’s discussion are in evidence review T: management of symptomatic vaginal discharge in pregnancy .

Pelvic girdle pain

• exercise advice and/or
• a non-rigid lumbopelvic belt.

For a short explanation of why the committee made the recommendation and how it might affect practice, see the rationale and impact section on pelvic girdle pain .

Full details of the evidence and the committee’s discussion are in evidence review U: management of pelvic girdle pain in pregnancy .

Unexplained vaginal bleeding after 13 weeks

• rhesus D-negative and
• at risk of isoimmunisation.

Refer pregnant women with unexplained vaginal bleeding after 13 weeks to secondary care for a review.

• the risk of placental abruption
• the risk of preterm delivery
• the extent of vaginal bleeding
• the woman’s ability to attend secondary care in an emergency.

For pregnant women who present with unexplained vaginal bleeding, offer to carry out placental localisation by ultrasound if the placental site is not known.

For pregnant women with unexplained vaginal bleeding who are admitted to hospital, consider corticosteroids for fetal lung maturation if there is an increased risk of preterm birth within 48 hours. Take into account gestational age (see the section on maternal corticosteroids in the NICE guideline on preterm labour and birth ).

Consider discussing the increased risk of preterm birth with women who have unexplained vaginal bleeding.

For a short explanation of why the committee made the recommendations and how they might affect practice, see the rationale and impact section on unexplained vaginal bleeding after 13 weeks .

Full details of the evidence and the committee’s discussion are in evidence review V: management of unexplained vaginal bleeding in pregnancy .

Terms used in this guideline

This section defines terms that have been used in a particular way for this guideline.

Bonding is the positive emotional and psychological connection that the parent develops with the baby.

Emotional attachment refers to the relationship between the baby and parent, driven by innate behaviour and which ensures the baby’s proximity to the parent and safety. Its development is a complex and dynamic process that is dependent on sensitive and emotionally attuned parent interactions supporting healthy infant psychological and social development and a secure attachment. Babies form attachments with a variety of caregivers but the first, and usually most significant of these, will be with the mother and/or father.

Having continuity of carer means that a trusting relationship can be developed between the woman and the healthcare professional who cares for her. Better Births , a report by the National Maternity Review, defines continuity of carer as consistency in the midwifery team (between 4 and 8 individuals) that provides care for the woman and her baby throughout pregnancy, labour and the postnatal period. A named midwife coordinates the care and takes responsibility for ensuring that the needs of the woman and her baby are met throughout the antenatal, intrapartum and postnatal periods.

For the purpose of this guideline, definition of continuity of carer in the Better Births report has been adapted to include not just the midwifery team but any healthcare team involved in the care of the woman and her baby. It emphasises the importance of effective information transfer between the individuals within the team. For more information, see the NHS Implementing Better Births: continuity of carer .

Partner refers to the woman’s chosen supporter. This could be the baby’s father, the woman’s partner, family member or friend, or anyone who the woman feels supported by and wishes to involve in her antenatal care.

Shared decision making is a collaborative process that involves a person and their healthcare professional working together to reach a joint decision about care. It could be care the person needs straightaway or care in the future, for example, through advance care planning. See the full definition in the NICE guideline on shared decision making . In line with NHS England’s personalised care and support planning guidance: guidance for local maternity systems , in maternity services, this may be referred to as ‘informed decision making’.

• an e-learning education package for all clinical staff about the importance of a recent change in the frequency of fetal movements and how to manage reduced fetal movements
• a leaflet given to pregnant women at 20 weeks of pregnancy to raise awareness of the importance of monitoring fetal movements and reporting reduced movements
• a structured management plan for hospitals following reporting of reduction in fetal movement including cardiotocography, measurement of liquor volume and a growth scan (umbilical artery doppler was encouraged if available).
• Recommendations for research

The guideline committee has made the following recommendations for research.

Key recommendations for research

1. hospitalisation of pregnant women with unexplained vaginal bleeding.

What is the clinical and cost effectiveness of hospitalisation compared with outpatient management for pregnant women with unexplained vaginal bleeding?

For a short explanation of why the committee made this research recommendation, see the rationale section on unexplained vaginal bleeding .

Full details of the research recommendation are in evidence review V: management of unexplained vaginal bleeding in pregnancy .

2. Medications for mild to moderate nausea and vomiting in pregnancy

What is the clinical and cost effectiveness of medication for women with nausea and vomiting in pregnancy?

For a short explanation of why the committee made this research recommendation, see the rationale section on nausea and vomiting .

Full details of the research recommendation are in evidence review R: management of nausea and vomiting in pregnancy .

3. Models of antenatal care

What is the clinical and cost effectiveness of different models of antenatal care with varying numbers and times of appointment, and should different models be used for groups at risk of worse outcomes?

For a short explanation of why the committee made this research recommendation, see the rationale section on starting antenatal care .

Full details of the research recommendation are in evidence review F: accessing antenatal care .

For a short explanation of why the committee made this research recommendation, see the rationale section on antenatal appointments .

4. Identification of breech presentation

What is the clinical and cost effectiveness of routine ultrasound from 36+0 weeks compared with selective ultrasound in identifying breech presentation?

For a short explanation of why the committee made this research recommendation, see the rationale section on breech presentation .

Full details of the research recommendation are in evidence review L: identification of breech presentation .

5. Management of severe nausea and vomiting

What is the clinical and cost effectiveness of corticosteroids for women with severe nausea and vomiting in pregnancy?

• Rationale and impact

These sections briefly explain why the committee made the recommendations and how they might affect practice.

Recommendations 1.1.1 to 1.1.3

Why the committee made the recommendations

No relevant evidence was identified and so the committee made the recommendations based on their knowledge and experience, and also made a research recommendation about how to start antenatal care . The committee discussed the ways in which women should be able to access antenatal care, but agreed that the configuration details would depend on local arrangements.

The committee agreed that antenatal service planning should take into account women’s needs and circumstances, and should not discriminate against, for example, a limited ability to use and access online services, limited skills in English language or in literacy, or not being registered with a GP surgery. The committee were aware that for some women in vulnerable situations or with limited English language skills, there may be a delay in accessing and starting antenatal care.

The booking appointment should occur by 10 weeks of pregnancy but the initial contact and referral might have happened several weeks earlier, so the committee agreed that the referral contact should include provision of early pregnancy information, for example, public health messages for the woman about folic acid supplementation or stopping smoking. It is also important to identify women with specific needs or risk factors early on so that appropriate care can be provided from the beginning.

The committee agreed that it is important to have the contact details for the woman’s GP to ensure that information can be shared between primary care and maternity services so that care is provided according to the woman’s individual needs, and to identify potential safeguarding issues.

How the recommendations might affect practice

There is variation in current practice in how women access antenatal care and the time between women’s first contact with a healthcare professional and subsequent steps. Enabling women to start their antenatal care through various routes, including through school nurses, community centres or refugee hostels, may have some implications on resources; however, these should be outweighed by the benefits of timely antenatal care. The recommendations should improve timely access to antenatal care for women in various situations, and improve early recognition of specific needs and risk factors so that care can be planned.

Return to recommendations

Recommendations 1.1.4 to 1.1.13

There was no new evidence to support changing from the existing recommended practice of women having their first antenatal (booking) appointment by 10+0 weeks.

Some women only contact, or are referred to, maternity services after 9+0 weeks. This ‘late booking’ may be particularly common among some socially vulnerable women or women with limited English language skills. Based on their knowledge and experience, the committee agreed that women who contact, or are referred to, maternity services after 9+0 weeks should have a booking appointment ideally within 2 weeks so that early pregnancy care, including information provision and screenings, can happen within the right timeframe. The committee agreed that it would be helpful to identify any underlying factors that may have led to the ‘late booking’ so that the woman’s need for potential additional support or care can be considered and that any potential inequality and accessibility issues can be addressed.

There was no new evidence that led the committee to change from the existing recommended practice of arranging 10 appointments for nulliparous women and 7 appointments for parous women. Instead, the committee made a research recommendation about the ideal number and timing of antenatal appointments , including consideration for groups at higher risk of adverse outcomes.

The evidence on women’s experience and satisfaction in relation to the number of antenatal appointments was mixed, but the committee agreed the importance of being flexible to meet women’s needs.

There was evidence that women who needed to use interpreters found the service to be unreliable and inconsistent, so the committee made a specific recommendation highlighting that interpreters should always be available when needed (including, for example, at scan appointments) and that they should be independent of the woman and not, for example, a family member or a friend.

There was good evidence that women value having the same midwife throughout their antenatal care, although the review did not look at the benefits and harms of continuity of carer in relation to clinical- and cost-effectiveness outcomes. The NHS England’s report Better Births: improving outcomes of maternity services in England – a five year forward view for maternity care recommends continuity of carer by 1 midwife who is part of a small team of midwives based in the community, so that they can get to know the woman and provide support to her throughout pregnancy all the way to the postnatal period.

Various health professionals or providers may be involved throughout the pregnancy, and the committee emphasised the need for good communication between different health professionals and providers.

The timing of the booking appointment and the number of appointments reflects current clinical practice. The recommendation about women who do not have a booking appointment arranged by 9+0 weeks may lead to more women attending booking appointments before 11 weeks and it may also reduce how long it takes to secure a booking appointment. However, this may also be challenging for services to organise.

The recommendation about offering additional or longer antenatal appointments depending on need may lead to a small increase in the number of antenatal appointments, but this is likely to be negligible and potentially have benefits later on.

The recommendation on the use of interpreters is not new but is not well implemented in all units, so may involve a change in practice.

In current practice, providing continuity of carer can be difficult to achieve and there can be significant resource implications; however, the recommendation reflects NHS England’s recommendations.

The committee agreed that the recommendations would not result in a major change in practice but should reduce variation in practice and improve care for women.

Recommendations 1.1.14 to 1.1.16

The committee recognised that women’s home and family circumstances vary, and it is up to the woman to decide who she may want to involve in her antenatal care. Involving partners is an important part of antenatal care, and the World Health Organization has emphasised the importance of engaging with partners during pregnancy, childbirth and postnatally. The committee discussed the impact that a partner’s support, lack of support, or their wellbeing can have on the wellbeing of the pregnant woman. The committee recognised that the woman’s partner is often also an expectant parent and being involved in the antenatal care, if the woman so wishes, can provide information and support for them as well.

The committee discussed that partners can face many types of barriers when engaging with antenatal services. There was good quality evidence on partners’ views and experiences of antenatal care that showed that women appreciate being able to involve their partners in antenatal care, but that this can be difficult, for example, because of the partner’s work patterns. Therefore, the committee agreed that the services should consider adapting when to offer antenatal classes (for example, in the evenings or at the weekends) to enable partners to be involved if the woman wishes.

Evidence showed that partners can feel like bystanders in appointments if, for example, there is no space for them to sit with their partner. The committee agreed ways that antenatal services could promote partner involvement. The committee agreed that partners are not always given information, including on how partners can support the woman during and after pregnancy, and the general pregnancy information that women receive.

Increased use of virtual platforms for appointments may also improve partners’ involvement in antenatal care. For example, this could enable the partner to attend remotely if the woman has a face-to-face appointment, or for the couple to attend together if she has a video appointment. However, the committee recognised that evidence on video consultations and appointments was not reviewed for this guideline, and the benefits, harms and experiences related to them is important to consider when planning services. The committee also agreed that it is important to carefully assess any potential inequalities issues that could be associated with video appointments, for example, among people with sensory impairments or language barriers, minority groups, or in relation to access to devices or internet connection.

The committee agreed that the recommendations may increase and promote the involvement of partners, while respecting the woman’s decisions. The recommendations are not expected to have a large resource impact or be difficult to implement although there may be some organisational changes needed to support making the timing of antenatal classes more flexible.

Recommendations 1.2.1 to 1.2.11

The recommendations were not developed by the usual NICE guideline systematic review process. A new evidence review was not considered necessary because the issues are covered by other NICE guidelines, or there is no clinical uncertainty or significant resource impact. Where there might be a potential limited resource impact, this could be justifiably offset by improved outcomes, avoidance of serious adverse outcomes or addressing inequalities. The recommendations were based on committee consensus on what is best practice, as well as other existing NICE guidelines.

Asking the woman about her past and present conditions and experiences in relation to her physical, obstetric, psychological, emotional and social health enables potential risk factors to be identified and managed. The committee used their knowledge and experience to list the factors that should be discussed so that appropriate action can be taken, and care tailored to the woman’s needs. For example, it is important to note which pharmacological and non-pharmacological remedies the woman uses so that current medication can be reviewed in light of pregnancy. It is important that women do not automatically stop using their regular medication without consultation. This discussion also allows for individualised advice on safe medicine use during pregnancy and can help with identifying any health issues that may have otherwise not come up.

The committee also agreed that it is important to discuss the woman’s home and family situation and the available support she has. There may be issues that can impact on her wellbeing, for example, lack of support, illness in the family or a partner’s substance use issues.

Sometimes there may be a reason to review the woman’s previous medical records, for example, when her previous maternity care has been in a different organisation, she cannot recall details of a potentially significant issue, or the discussion somehow triggers a concern.

The committee agreed that healthcare professionals should be aware of the disproportionate maternal mortality and stillbirth rates among women and babies from black and Asian backgrounds and those living in deprived areas, as highlighted by the 2020 MBRRACE-UK reports on maternal mortality and perinatal mortality. This increased risk of death indicates that interventions to improve engagement, support and closer monitoring need to be explored. Future research could help understand the mechanisms underlying these disparities and what interventions could improve the outcomes. In general, action on the wider determinants of health, including different social, economic and environmental factors, is also needed to overcome such inequalities.

The committee agreed that domestic abuse puts both the woman and her baby at risk of harm, so it is important that all pregnant women are asked about it in a kind, sensitive way. Pregnancy can sometimes be a trigger for domestic abuse or existing domestic abuse can continue or worsen during pregnancy, so it is important that women feel that they can disclose it safely so that they can be supported, and interventions put in place if needed. Although partner involvement in antenatal care is welcome, it is also important to ensure that there is an opportunity to discuss domestic issues privately with the woman.

The committee recognised the need to identify women who have undergone female genital mutilation (FGM) or whose unborn baby girl might be at risk of FGM so that appropriate safeguarding can take place. In the context of this guideline, this could be the pregnant woman, or the unborn baby when there is a family history or tradition of FGM. There is a mandatory duty to report suspected or known FGM in under 18s. The Department of Health and Social Care has produced a quick guide for healthcare professionals on FGM safeguarding and risk assessment , which includes information about countries where FGM is practised, and practical advice on how to start the conversation.

Identifying underlying cardiac problems is important because cardiovascular disease is the leading cause of death among women in the UK during and after pregnancy, according to the 2019 report MBRRACE-UK: Saving lives, improving mothers’ care – lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2016–18 . Some women are at a higher risk of undiagnosed structural cardiac problems, such as women with a family history of cardiac abnormalities or women who were brought up in a country with a high incidence of rheumatic fever. Clinical assessment cannot identify all cardiac problems that cause maternal mortality, but it might pick up structural heart disease or concerns that warrant further investigations. Early identification of underlying cardiac conditions allows these women to receive appropriate care during their pregnancy, childbirth and postnatal period, and potentially avoid poor outcomes.

The committee also agreed the importance of information sharing between the maternity unit and the GP, and agreeing this with the woman. This is particularly important if the woman has self-referred (because the GP may be unaware of her pregnancy), and if women have a complex medical, psychological or social history (because different agencies may need to be involved in her and her baby’s care).

Antenatal appointments are opportunities for continued monitoring and risk assessment on the health and wellbeing of the woman and her baby. They also allow for regular reassessments of women’s antenatal care needs and plans.

The recommendations largely reflect current best practice. Clinical assessment for cardiac conditions is not always done for women who may be at an increased risk so this recommendation may change practice to some extent. The number of women this recommendation applies to is relatively small and the potentially life-saving benefit of this simple examination outweighs the potential cost and resource implications.

Recommendations 1.2.12 to 1.2.17

Most of the issues are covered by national screening programmes or other NICE guidance, so no new evidence review was needed. The committee agreed, by consensus, any other recommendations where there is no clinical uncertainty or significant resource impact.

The timing of the ultrasound scans aligns with the NHS fetal anomaly screening programme .

It is important that women understand the potential implications of each of the tests being offered so that they have the opportunity to accept or decline.

The recommendations reflect current practice and no change in practice is expected.

Recommendations 1.2.18 to 1.2.20

The committee based the recommendations on the evidence on independent risk factors for venous thromboembolism in pregnancy, their knowledge and experience, and the NICE guideline on venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism . The evidence on independent risk factors for venous thromboembolism during pregnancy did not assess the accuracy of tools used to measure the risk, so the committee recommended that tools should meet certain quality criteria. They agreed that an example of a tool that might be used is the risk assessment tool in the Royal College of Obstetricians and Gynaecologists’ green-top guideline on reducing the risk of venous thromboembolism during pregnancy (2015), which is commonly used in practice.

The committee highlighted some risk factors in the evidence review (blood type A or B, miscarriage after 10 weeks in the current pregnancy and history of previous blood transfusion) that are not always incorporated into commonly used venous thromboembolism tools. However, they agreed not to include them specifically in the recommendations because it could give a false impression that these factors were more important than others or lead to overtreatment.

The committee agreed that women assessed as being at an increased risk of venous thromboembolism should be offered referral to an obstetrician so that a risk management plan can be made, for example, starting thromboprophylaxis.

How the recommendation might affect practice

The recommendation reflects current practice and no change in practice is expected.

Recommendations 1.2.21 and 1.2.22

Guidance on risk assessment for and identification of gestational diabetes is covered by the NICE guideline on diabetes in pregnancy .

Recommendations 1.2.23 to 1.2.28

Guidance on risk assessment and risk reduction for pre-eclampsia is covered by the NICE guideline on hypertension in pregnancy . Although the guideline implies that pregnant women will be routinely tested for proteinuria, it does not explicitly recommend this. Therefore, the committee agreed that, in line with current practice, urine testing for proteinuria should be offered at every routine face-to-face appointment.

There was little evidence on the setting and technique for monitoring blood pressure during pregnancy, so the committee made the recommendations based on their knowledge and experience and existing NICE guidance. The committee were aware that the British and Irish Hypertension Society lists blood pressure measurement devices validated for use in pregnancy . This has also been noted in the NICE guideline on hypertension in adults .

The committee agreed that monitoring blood pressure and testing for proteinuria at every routine face-to-face antenatal appointment enables hypertension and pre-eclampsia to be identified and treated early, which is important because they can have severe consequences.

Guidance on care for pregnant women with gestational or chronic hypertension is covered by the NICE guideline on hypertension in pregnancy.

Recommendations 1.2.29 to 1.2.35

Risk assessment starting in early pregnancy enables increased monitoring of babies who are at an increased risk of fetal growth restriction, which is associated with fetal morbidity and mortality. The committee were aware of available risk assessment tools, such as those in the Royal College of Obstetricians and Gynaecologists’ guideline on the investigation and management of the small-for-gestational-age fetus or the NHS saving babies’ lives care bundle version 2 .

Evidence showed that ultrasound scans and symphysis fundal height measurement do not accurately predict a baby being born small or large for gestational age. However, the committee agreed that the current routine practice of using symphysis fundal height measurement to monitor fetal growth should be used, because it is a simple and low-cost intervention and can alert to further investigations when concerns arise about the baby being either larger or smaller than expected for gestational age. When the symphysis fundal height measurement is large for gestational age, ultrasound scans could be used to assess the size of the baby and the volume of amniotic fluid. Small-for-gestational-age babies are at an increased risk of perinatal mortality and morbidity; therefore, when this is suspected, further investigations should be done to monitor the growth and wellbeing of the baby, taking into consideration the full clinical picture.

The committee were aware that many women may request routine ultrasound scans in late pregnancy, but available evidence showed no benefit from routine ultrasound in late pregnancy (from 28 weeks) for uncomplicated singleton pregnancies. However, the absence of effect found in the evidence does not mean that there is definitely no effect. There was also no evidence on maternal anxiety in relation to routine ultrasound scanning. The committee were in favour of research on this in the future; however, a research recommendation was not prioritised because there is a good amount of evidence on other key outcomes.

The committee were aware that cases of stillbirth have been linked to reduced fetal movements. Therefore, structured fetal movement awareness packages have been trialled. Evidence on the use of a structured fetal movement awareness package , such as the one described in the UK trial Awareness of fetal movements and care package to reduce fetal mortality (AFFIRM), did not detect a reduction in stillbirths or perinatal mortality but did find that there were more interventions at birth, including more caesarean births and inductions of labour, and fewer spontaneous vaginal births. Another study from Sweden compared giving a leaflet to pregnant women teaching them a method of being aware of fetal movements, with usual care. No clinically important benefits or harms were detected, including no difference in perinatal mortality, although there was a small, but statistically significant, reduction in births after 41+6 weeks and fewer caesarean births. Health economic evaluation did not establish cost effectiveness for either of these structured awareness packages.

Although the available evidence did not support the use of structured packages, the committee agreed that fetal movements should be discussed routinely and women’s concerns should be taken seriously. The committee agreed that there is no agreed definition of normal fetal movements. Discussing the topic of babies’ movements in the womb and how they change throughout the pregnancy can help women recognise changes to their own baby’s movement patterns. When there are concerns, an assessment of the woman’s wellbeing and the baby’s wellbeing and size should be done.

The recommendations on fetal growth monitoring largely reflect current practice, although in some maternity units it is common to offer women with uncomplicated singleton pregnancies ultrasound scans after 28 weeks to monitor the baby, so there might be a change of practice for these units and some potential cost savings. On the other hand, there may be some more scans due to suspected large for gestational age.

Current practice for managing reduced fetal movements is to follow the NHS saving babies’ lives care bundle version 2 . The recommendations in this guideline similarly emphasise the importance of recognising and reporting concerns on fetal movements and acting on those concerns by assessing the woman and the baby.

Recommendations 1.2.36 to 1.2.38

There was not enough evidence to support routine ultrasound at 36+0 weeks to 39+0 weeks to identify breech presentation, so the committee did not change the current standard practice of offering abdominal palpation with selective ultrasound when breech is suspected.

Because of the lack of evidence, the committee made a research recommendation to compare routine ultrasound scans from 36+0 weeks with selective ultrasound scans .

In the case of breech presentation, the committee agreed that a discussion about the different options and their potential benefits, harms and implications is needed to ensure an informed decision. External cephalic version is standard practice for managing breech presentation in uncomplicated singleton pregnancies at or after 36+0 weeks. Head-down vaginal birth is preferred by many women and the evidence suggests that external cephalic version is an effective way to achieve this.

The recommendations reflect current clinical practice and no change in practice is expected.

Recommendations 1.3.1 to 1.3.6

The committee agreed that the key principles of care in the antenatal period are to listen to women and be responsive to their needs, in line with the findings of the Ockenden report on maternity services at the Shrewsbury and Telford hospital NHS trust , and to enable women to make informed decisions about their care, in line with the Montgomery ruling . The committee emphasised that women should be supported in their decision making even when their preferences and values differ from those of the healthcare professionals.

The evidence did not show a particular benefit from any one specific approach to giving information, although 1 study found that supplementing information provided face-to-face with online information increased knowledge. The committee based the recommendations on their knowledge and experience.

The committee agreed that information should meet the needs of the woman, for example, taking into account any language barriers, learning disabilities or other needs. Most antenatal care information is given in a one-to-one or couple discussion. Offering other formats to supplement this can help improve understanding and engagement, including written materials and group discussions in antenatal classes or, in some cases, group antenatal appointments.

There was evidence that women value information that is relevant to their own circumstances. The committee agreed that healthcare professionals should explore the level and accuracy of the woman’s (and her partner’s) existing knowledge and understanding of the topic. The committee discussed the importance of allowing sufficient time for discussions.

The recommendations largely reflect current practice.

Recommendations 1.3.7 to 1.3.18

The committee agreed, based on the evidence and their knowledge and experience, that if women are given information about antenatal care, their schedule of appointments and what happens at different appointments and stages of pregnancy, they are more likely to be engaged, follow advice and share their concerns with healthcare professionals.

There was no evidence identified to inform the timing of information provision, but the committee agreed that it is important to have a staged approach and cover topics relevant to each stage of pregnancy.

The first antenatal (booking) appointment is an opportunity to discuss and share information about various practical issues related to pregnancy and antenatal care so that the woman knows what to expect and how to get support. The evidence showed that partners also value practical information throughout the pregnancy. For example, in relation to safe use of medicines in pregnancy, the committee were aware of the UK Teratology Information Service’s information resources on best use of medicines in pregnancy (bumps) .

The evidence suggested that women want information on how behavioural factors, such as smoking, alcohol, diet and physical activity may affect them and their baby’s health. The evidence also highlighted how emotional these topics could be for women and that women may feel judged or patronised. The committee agreed that it is important to have these discussions in a sensitive manner that supports individual women. Guidance on all these issues is covered by other NICE guidelines or government documents.

The committee recognised that pregnant women and their partners often look for information and support from various sources, such as websites, and not all of them are necessarily evidence-based, so signposting to trusted resources may be helpful.

There was some evidence that women and their partners valued information and discussion around the transition to parenthood, and the changes that pregnancy and becoming a parent will bring to their life and relationship. The committee were aware of various available resources that could be helpful for parents, particularly new parents.

The evidence showed that women want information on their options for giving birth. The committee agreed that these discussions should start, at the latest, around the start of the third trimester, depending on the woman’s preferences and circumstances. The committee agreed, in line with the Montgomery ruling , that discussing the implications, benefits and risks is fundamental to making shared and informed decisions. Guidance on making decisions about place of birth, mode of birth and prolonged pregnancy are also covered by other NICE guidelines. The committee were also aware that NICE is developing a guideline on the prevention and non-surgical management of pelvic floor dysfunction .

Considering the amount of new information given at the beginning of antenatal care, discussions around practical aspects related to labour, childbirth and postnatal care are often more appropriate later on in pregnancy. There was some evidence that healthcare professionals thought that providing information on emotional attachment and bonding could improve women’s confidence and increase their preparedness for birth. Further recommendations about promoting emotional attachment and bonding, as well as planning and managing infant feeding, are covered by the NICE guideline on postnatal care .

The recommendations will improve consistency of care and reinforce best practice.

Recommendations 1.3.19 to 1.3.21

Evidence among nulliparous women showed that women who went to antenatal classes were more likely to have their cervix dilated by 3 cm or more on admission to labour. A dilated cervix on admission may reduce the need for interventions. This may indicate that women who attended antenatal classes have better coping strategies and the confidence to deal with pain at home in the early stages of labour. There was no evidence about the most effective content for antenatal classes, so the committee made the recommendations based on their experience.

The committee recognised that there may be multiparous women who could also particularly benefit from antenatal classes, so providing them for these women should be considered.

The committee recognised that some groups of women may be less likely to attend antenatal classes (for example, some women from low income or disadvantaged backgrounds or minority ethnic groups, or those for whom English is not their first language). The committee agreed that in order to increase engagement with antenatal classes, service providers should ensure that classes are accessible, welcoming and adapted to meet the needs of local communities.

The recommendations reflect current practice. However, adapting classes to the needs of the local communities might involve some reorganising of practices.

Recommendations 1.3.22 and 1.3.23

The evidence showed that peer support could offer helpful and valuable care and guidance during the antenatal period. There was evidence among women from particular subpopulations, such as migrant women, women of lower socioeconomic status, women with intellectual disabilities, or younger women, and the committee agreed that peer support groups among women in similar circumstances might be particularly helpful.

The committee discussed that peer support, including group peer support, volunteer peer support, doula support and online support, is usually provided through ‘third sector’ services, and they agreed that healthcare professionals should give women information about how to contact local and national services. Although there was little evidence on partners’ experiences of peer support, in the committee’s experience, some partners find peer support services for partners helpful.

The recommendations reflect current best practice.

Recommendations 1.3.24 and 1.3.25

The evidence suggested that there is an increased risk of stillbirth and babies being born small for gestational age after 28 weeks if women fall asleep on their backs. The committee agreed that there is some uncertainty about this risk because the evidence was from relatively small studies whose design made it difficult to assume that sleep position caused the adverse outcomes. The committee recognised that further research is unlikely because conducting sufficiently powered prospective cohort studies is not feasible given the relatively low incidence of stillbirth (1 in every 244 births in England and Wales according to 2018 Office for National Statistics [ONS] data ). The committee also noted that not all the included studies used the same definition of stillbirth and that only 1 study reported data according to whether the stillbirth occurred at term or at preterm. On balance, the committee agreed that the evidence was strong enough to advise women to try to avoid going to sleep on their back after 28 weeks.

The committee knew from their experience that providing practical advice about risk reduction is extremely important for pregnant women. They discussed reassuring women about sleep positions, aids that could make it easier for pregnant women not to go to sleep on their backs and maintain this position when sleeping, for example, by using pillows.

The committee also agreed that the reason for this advice should be explained, and they recognised the potential anxiety and feelings of guilt that women may experience, for example, if they wake up on their backs.

Healthcare professionals may need to spend more time talking to women about sleep position in pregnancy, but the recommendations are not expected to have a significant cost or resource impact.

Recommendations 1.4.1 to 1.4.7

Nausea and vomiting in pregnancy can affect daily functioning and quality of life, and can cause significant worry and upset. Based on their knowledge and experience, the committee agreed that it is important to reassure pregnant women who experience mild-to-moderate nausea and vomiting that these are common symptoms in early pregnancy and will usually settle later in the second trimester.

However, the committee recognised that many pregnant women expect nausea and vomiting in pregnancy and might even tolerate significant symptoms and try various self-help approaches before seeking medical advice. It is therefore important to take it seriously when women do seek help.

Some women prefer to use non-pharmacological treatments whereas others may prefer pharmacological treatments, so both options are recommended.

There was some evidence that ginger is effective in treating mild-to-moderate nausea and vomiting in pregnancy compared with placebo, and this may be an option particularly for women who want to try a non-pharmacological option.

There was evidence on a wide variety of pharmacological treatments, many of which are commonly used in current practice. The evidence on the medicines varied in quality and for some medicines, no evidence was found. Metoclopramide hydrochloride was supported by good quality evidence showing that it was effective in improving symptoms. Ondansetron was also found to be effective in improving symptoms. A combination drug with pyridoxine and doxylamine is currently the only drug licensed for this indication, but the evidence is very old and of low quality and did not show a convincing effect on symptom improvement. Evidence on histamine H1 receptor antagonists was of very low quality and not particularly convincing. Studies on pyridoxine hydrochloride showed differing results, with larger trials showing no improvement in symptoms. No evidence was identified on the effectiveness of cyclizine hydrochloride alone in pregnant women, so the committee made a research recommendation on the effectiveness of medication for women with nausea and vomiting in pregnancy .

The treatment options have different advantages and disadvantages, including effectiveness in relieving symptoms, safety and other considerations, which have been summarised in a table to help with decision making. The committee used information available from the British National Formulary (BNF), the UK Teratology Information Service monographs and patient information leaflets, and the manufacturers’ summaries of product characteristics to inform women about the potential effects on the baby. The committee recognised that women are often concerned about the possible adverse effects of medicines on the baby and that these should be discussed in the context of understanding the small risk of adverse outcomes unrelated to medicine use.

The evidence for treating the more severe form of nausea and vomiting in pregnancy did not generally support any different treatment options from those used for mild and moderate nausea and vomiting in pregnancy. An exception was for acupressure combined with standard care where the evidence showed benefits in relieving symptoms in women with moderate-to-severe nausea and vomiting in pregnancy, which was not shown for women with mild and moderate nausea and vomiting. Therefore, the committee recommended that acupressure could be considered for women with moderate-to-severe nausea and vomiting as an additional treatment.

No recommendation was made on the use of corticosteroids as a treatment for severe nausea and vomiting in pregnant women because, despite research in this area, no evidence was found to support its use. The committee discussed that although corticosteroids have well-known harms, the benefits can outweigh them so that some units use corticosteroids in severe cases of nausea and vomiting in pregnancy, and so a research recommendation on the effectiveness of corticosteroids for women with severe nausea and vomiting in pregnancy was made.

Some women with moderate-to-severe nausea and vomiting in pregnancy might need intravenous fluids. The evidence showed no difference in most outcomes between offering intravenous fluids in an inpatient or outpatient setting. Offering them to an outpatient is less expensive, reduces time spent in hospital and, in the committee’s experience, is generally preferred by women. Inpatient care may be needed when severe nausea and vomiting persists despite treatment. Hyperemesis gravidarum can have serious harmful consequences, and treatment and care in hospital may be needed. It should be noted that this guideline only covers treatments to manage nausea and vomiting in pregnancy and comprehensive management of hyperemesis gravidarum, which may include nutritional interventions, is not covered by this guideline on routine antenatal care.

The treatment options are all used in current practice but there may be a change in practice in encouraging shared decision making for different options. This may mean that those prescribing medicines may need to spend more time discussing the options with the woman.

An increase in giving intravenous fluids as an outpatient service instead of an inpatient service could bring cost savings.

Recommendations 1.4.8 and 1.4.9

There was no evidence on whether giving lifestyle and diet information to pregnant women with heartburn is effective, but the committee agreed, based on their own knowledge and experience, that it may help. This is supported by guidance for the general adult population in the NICE guideline on gastro-oesophageal reflux disease and dyspepsia .

The committee recommended considering either antacid or alginate therapy for women with heartburn in pregnancy because there is evidence that they are equally effective. These medicines are available over the counter. Because the studies examined various antacid and alginate remedies, the committee agreed that they could not make a more specific recommendation.

The committee did not make any recommendations about acupuncture or proton pump inhibitors (PPIs) because, although there was some evidence that acupuncture is effective in alleviating heartburn and that PPI use in the first trimester is not harmful to the baby, it was of very low quality and not good enough to support recommending them to be used routinely. In addition, there was no evidence on H2 receptor antagonist (H2RA) therapy to treat heartburn in pregnancy.

The recommendations reflect current clinical practice.

Recommendations 1.4.10 to 1.4.14

There was limited evidence on the effectiveness of treatments for symptomatic vaginal discharge in pregnant women, so the committee used their knowledge and clinical experience to make the recommendations. The committee agreed that some women can find an increase in vaginal discharge distressing or uncomfortable, so it is important to reassure women that it is a normal feature of pregnancy. However, women should also be made aware of the symptoms and signs of infection that may need further action, because there is a small chance that some infections could lead to complications.

Candidiasis (thrush) is often an easily identifiable cause of symptomatic vaginal discharge and may not need a formal investigation. However, if there is doubt about the cause, a vaginal swab could be used. It is important that possible sexually transmitted infections are appropriately investigated so that they can be treated, because they could have an impact on the baby.

The evidence on antifungal treatment to treat symptomatic vaginal discharge because of vaginal candidiasis was very limited, imidazole being the only drug class being studied. However, imidazole (for example, clotrimazole or econazole) was consistently shown to be effective.

The evidence on the benefits and harms of antibiotics to treat symptomatic vaginal discharge due to bacterial vaginosis was also very limited. There was only evidence on oral amoxicillin (which is not commonly prescribed in current practice for this indication) and oral metronidazole. The committee were aware of evidence among asymptomatic populations that antibiotics are effective in treating the underlying infection, but the committee agreed that it cannot be assumed that they would be effective in relieving symptomatic vaginal discharge. The committee noted that it is common practice to prescribe vaginal rather than oral antibiotics for this indication – in particular, clindamycin or metronidazole. Combining this with their knowledge and experience, they recommended that either oral or vaginal antibiotics could be considered. The NICE guideline on antimicrobial stewardship gives guidance on good practice in prescribing antimicrobials.

No evidence was identified on the effectiveness of metronidazole to treat symptomatic vaginal discharge because of vaginal trichomoniasis, therefore no recommendations were made.

The committee agreed that the recommendations will reinforce current best practice and standardise care.

Recommendation 1 4.15

Why the committee made the recommendation

There was evidence of varying quality from several randomised controlled trials that exercise advice from a physiotherapist may reduce pain intensity and pelvic-related functional disability. The committee recommended referral to physiotherapy services rather than to a physiotherapist because, in some cases, information and advice could be given over the telephone or in an email or letter rather than in a face-to-face appointment.

Moderate quality evidence from 1 randomised controlled trial showed that a non-rigid lumbopelvic belt together with general information about anatomy, body posture and ergonomic advice reduced pelvic girdle pain intensity, compared with exercise advice and information, and information only. However, it did not have an impact on functional status in daily activities. No evidence was identified about adverse effects of using a lumbopelvic belt. Providing a non-rigid lumbopelvic belt was also found to be cost effective based on an economic evaluation, but because the clinical evidence base was limited, the committee agreed not to make a strong recommendation.

The committee agreed that there was not enough evidence to show that manual therapy alone had any benefits for women with pelvic girdle pain, so did not make a recommendation. The committee agreed that the evidence for acupuncture to treat pelvic girdle pain was mixed, of poor quality and therefore not adequate enough to justify a recommendation that would have a substantial resource impact.

Current practice for pregnancy-related pelvic girdle pain is to offer analgesics (for example, paracetamol) and provide information about lifestyle and health changes. Some hospitals also have access to physiotherapy services. Providing a lumbopelvic belt is not current practice in all units, so the committee recognised that the recommendation may have cost implications. However, health economic modelling showed that it is cost effective even if women are referred for physiotherapy. The recommendation may increase the number of pregnant women seeking referral to physiotherapy services.

Return to recommendation

Recommendations 1.4.16 to 1.4.21

There was very little evidence, so the committee used their knowledge and experience to make recommendations. They took into account the risks associated with a delay in assessing and treating unexplained vaginal bleeding in pregnancy, the possibility that anti-D injections may be needed for women who are rhesus D-negative, the need to exclude a low-lying placenta (placenta praevia) and that corticosteroids may be needed if there is a risk of preterm birth.

The committee agreed that a review in secondary care is needed when unexplained vaginal bleeding occurs after 13 weeks of pregnancy. Evidence on the effectiveness of hospitalisation was limited, with only 1 retrospective study that showed no difference in the number of fetal deaths whether women were admitted to hospital or discharged on the day they presented. Because of limited evidence, the committee made a research recommendation on the effectiveness of hospitalisation compared with outpatient management for pregnant women with unexplained vaginal bleeding .

The committee agreed that hospitalisation should be considered for monitoring, administering corticosteroids and neonatal unit care if the baby is born preterm. Discussion with the woman about the possibility of preterm birth may also be helpful.

The recommendations reflect current practice.

Around 660,000 women give birth in England and Wales each year. The antenatal period is an excellent opportunity to not only provide support and information to women (and their families) about pregnancy, birth and the postnatal period, but also to assess their risk of complications. Even in fit and healthy women, concerns and complications can still arise, and good quality antenatal care is vital to identify and deal with potential problems and reduce the chance of poor outcomes for both the woman and the baby.

Antenatal service delivery and provision of care have changed over time and this guideline updates and replaces the version of the NICE guideline on antenatal care (first published in 2008).

This guideline covers routine antenatal care for all women. However, it does not cover specialised care for women with underlying medical conditions or obstetric complications (once diagnosed) but refers to other NICE guidelines.

This guideline covers the organisation and delivery of antenatal care, in particular, how to initially access antenatal care and antenatal appointments, and the involvement of partners in antenatal care. Routine care and monitoring during pregnancy is covered and the guideline makes references to other guidance on risk assessment and screening. This guideline also covers providing information and support during antenatal care, and managing some of the common problems during pregnancy.

Throughout the development of this guideline, the committee has considered how antenatal care could be made accessible, fair and high quality for all women, regardless of their background or situation.

• Finding more information and committee details

You can see everything NICE says on this topic in the NICE Pathway on antenatal care .

To find NICE guidance on related topics, including guidance in development, see the NICE webpage on pregnancy .

For full details of the evidence and the guideline committee’s discussions, see the evidence reviews . You can also find information about how the guideline was developed , including details of the committee .

NICE has produced tools and resources to help you put this guideline into practice . For general help and advice on putting our guidelines into practice, see resources to help you put NICE guidance into practice .

• Update information

This guideline updates and replaces NICE guideline CG62 (published March 2008).

Your responsibility : The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian.

Local commissioners and providers of healthcare have a responsibility to enable the guideline to be applied when individual professionals and people using services wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable health and care system and should assess and reduce the environmental impact of implementing NICE recommendations wherever possible.

• Cite this Page Antenatal care. London: National Institute for Health and Care Excellence (NICE); 2021 Aug 19. (NICE Guideline, No. 201.)
• PDF version of this title (318K)

In this Page

Other titles in this collection.

• National Institute for Health and Care Excellence: Guidelines

Related NICE guidance and evidence

• Antenatal Care: Routine Care for the Healthy Pregnant Woman (NICE guideline CG62)
• Information provision: Antenatal care: Evidence review A
• Approaches to information provision: Antenatal care: Evidence review B
• Involving partners: Antenatal care: Evidence review C
• Peer support: Antenatal care: Evidence review D
• Antenatal classes: Antenatal care: Evidence review E
• Accessing antenatal care: Antenatal care: Evidence review F
• Content of antenatal appointments: Antenatal care: Evidence review G
• Timing of first antenatal appointment: Antenatal care: Evidence review H
• Number of antenatal appointments: Antenatal care: Evidence review I
• Referral and delivery of antenatal care: Antenatal care: Evidence review J
• Identification of hypertension in pregnancy: Antenatal care: Evidence review K
• Identification of breech presentation: Antenatal care: Evidence review L
• Management of breech presentation: Antenatal care: Evidence review M
• Risk factors for venous thromboembolism in pregnancy: Antenatal care: Evidence review N
• Monitoring fetal growth: Antenatal care: Evidence review O
• Fetal movement monitoring: Antenatal care: Evidence review P
• Routine third trimester ultrasound for fetal growth: Antenatal care: Evidence review Q
• Management of nausea and vomiting in pregnancy: Antenatal care: Evidence review R
• Management of heartburn in pregnancy: Antenatal care: Evidence review S
• Management of symptomatic vaginal discharge in pregnancy: Antenatal care: Evidence review T
• Management of pelvic girdle pain in pregnancy: Antenatal care: Evidence review U
• Management of unexplained vaginal bleeding in pregnancy: Antenatal care: Evidence review V
• Maternal sleep position during pregnancy: Antenatal care: Evidence review W

Supplemental NICE documents

• NICE Pathway: Antenatal care overview (PDF)
• NICE Quality Standard QS22: Antenatal care (PDF)
• NICE Quality Standard QS35: Hypertension in pregnancy (PDF)
• NICE Quality Standard QS98: Nutrition: improving maternal and child nutrition (PDF)
• NICE Quality Standard QS105: Intrapartum care (PDF)

Related information

• NLM Catalog Related NLM Catalog Entries

Similar articles in PubMed

• Review Postnatal care [ 2021] Review Postnatal care . 2021 Apr 20
• Review Neonatal infection: antibiotics for prevention and treatment [ 2021] Review Neonatal infection: antibiotics for prevention and treatment . 2021 Apr 20
• Review Intrapartum care for healthy women and babies [ 2022] Review Intrapartum care for healthy women and babies . 2022 Dec 14
• Review Fetal monitoring in labour [ 2022] Review Fetal monitoring in labour . 2022 Dec 14
• Review Preterm labour and birth [ 2022] Review Preterm labour and birth . 2022 Jun 10

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40 facts about elektrostal.

Written by Lanette Mayes

Modified & Updated: 02 Mar 2024

Reviewed by Jessica Corbett

Elektrostal is a vibrant city located in the Moscow Oblast region of Russia. With a rich history, stunning architecture, and a thriving community, Elektrostal is a city that has much to offer. Whether you are a history buff, nature enthusiast, or simply curious about different cultures, Elektrostal is sure to captivate you.

This article will provide you with 40 fascinating facts about Elektrostal, giving you a better understanding of why this city is worth exploring. From its origins as an industrial hub to its modern-day charm, we will delve into the various aspects that make Elektrostal a unique and must-visit destination.

So, join us as we uncover the hidden treasures of Elektrostal and discover what makes this city a true gem in the heart of Russia.

Key Takeaways:

• Elektrostal, known as the “Motor City of Russia,” is a vibrant and growing city with a rich industrial history, offering diverse cultural experiences and a strong commitment to environmental sustainability.
• With its convenient location near Moscow, Elektrostal provides a picturesque landscape, vibrant nightlife, and a range of recreational activities, making it an ideal destination for residents and visitors alike.

Known as the “Motor City of Russia.”

Elektrostal, a city located in the Moscow Oblast region of Russia, earned the nickname “Motor City” due to its significant involvement in the automotive industry.

Home to the Elektrostal Metallurgical Plant.

Elektrostal is renowned for its metallurgical plant, which has been producing high-quality steel and alloys since its establishment in 1916.

Boasts a rich industrial heritage.

Elektrostal has a long history of industrial development, contributing to the growth and progress of the region.

Founded in 1916.

The city of Elektrostal was founded in 1916 as a result of the construction of the Elektrostal Metallurgical Plant.

Located approximately 50 kilometers east of Moscow.

Elektrostal is situated in close proximity to the Russian capital, making it easily accessible for both residents and visitors.

Known for its vibrant cultural scene.

Elektrostal is home to several cultural institutions, including museums, theaters, and art galleries that showcase the city’s rich artistic heritage.

A popular destination for nature lovers.

Surrounded by picturesque landscapes and forests, Elektrostal offers ample opportunities for outdoor activities such as hiking, camping, and birdwatching.

Hosts the annual Elektrostal City Day celebrations.

Every year, Elektrostal organizes festive events and activities to celebrate its founding, bringing together residents and visitors in a spirit of unity and joy.

Has a population of approximately 160,000 people.

Elektrostal is home to a diverse and vibrant community of around 160,000 residents, contributing to its dynamic atmosphere.

Boasts excellent education facilities.

The city is known for its well-established educational institutions, providing quality education to students of all ages.

A center for scientific research and innovation.

Elektrostal serves as an important hub for scientific research, particularly in the fields of metallurgy, materials science, and engineering.

Surrounded by picturesque lakes.

The city is blessed with numerous beautiful lakes, offering scenic views and recreational opportunities for locals and visitors alike.

Well-connected transportation system.

Elektrostal benefits from an efficient transportation network, including highways, railways, and public transportation options, ensuring convenient travel within and beyond the city.

Famous for its traditional Russian cuisine.

Food enthusiasts can indulge in authentic Russian dishes at numerous restaurants and cafes scattered throughout Elektrostal.

Home to notable architectural landmarks.

Elektrostal boasts impressive architecture, including the Church of the Transfiguration of the Lord and the Elektrostal Palace of Culture.

Offers a wide range of recreational facilities.

Residents and visitors can enjoy various recreational activities, such as sports complexes, swimming pools, and fitness centers, enhancing the overall quality of life.

Provides a high standard of healthcare.

Elektrostal is equipped with modern medical facilities, ensuring residents have access to quality healthcare services.

Home to the Elektrostal History Museum.

The Elektrostal History Museum showcases the city’s fascinating past through exhibitions and displays.

A hub for sports enthusiasts.

Elektrostal is passionate about sports, with numerous stadiums, arenas, and sports clubs offering opportunities for athletes and spectators.

Celebrates diverse cultural festivals.

Throughout the year, Elektrostal hosts a variety of cultural festivals, celebrating different ethnicities, traditions, and art forms.

Electric power played a significant role in its early development.

Elektrostal owes its name and initial growth to the establishment of electric power stations and the utilization of electricity in the industrial sector.

Boasts a thriving economy.

The city’s strong industrial base, coupled with its strategic location near Moscow, has contributed to Elektrostal’s prosperous economic status.

Houses the Elektrostal Drama Theater.

The Elektrostal Drama Theater is a cultural centerpiece, attracting theater enthusiasts from far and wide.

Popular destination for winter sports.

Elektrostal’s proximity to ski resorts and winter sport facilities makes it a favorite destination for skiing, snowboarding, and other winter activities.

Promotes environmental sustainability.

Elektrostal prioritizes environmental protection and sustainability, implementing initiatives to reduce pollution and preserve natural resources.

Home to renowned educational institutions.

Elektrostal is known for its prestigious schools and universities, offering a wide range of academic programs to students.

Committed to cultural preservation.

The city values its cultural heritage and takes active steps to preserve and promote traditional customs, crafts, and arts.

Hosts an annual International Film Festival.

The Elektrostal International Film Festival attracts filmmakers and cinema enthusiasts from around the world, showcasing a diverse range of films.

Encourages entrepreneurship and innovation.

Elektrostal supports aspiring entrepreneurs and fosters a culture of innovation, providing opportunities for startups and business development.

Offers a range of housing options.

Elektrostal provides diverse housing options, including apartments, houses, and residential complexes, catering to different lifestyles and budgets.

Home to notable sports teams.

Elektrostal is proud of its sports legacy, with several successful sports teams competing at regional and national levels.

Boasts a vibrant nightlife scene.

Residents and visitors can enjoy a lively nightlife in Elektrostal, with numerous bars, clubs, and entertainment venues.

Promotes cultural exchange and international relations.

Elektrostal actively engages in international partnerships, cultural exchanges, and diplomatic collaborations to foster global connections.

Surrounded by beautiful nature reserves.

Nearby nature reserves, such as the Barybino Forest and Luchinskoye Lake, offer opportunities for nature enthusiasts to explore and appreciate the region’s biodiversity.

Commemorates historical events.

The city pays tribute to significant historical events through memorials, monuments, and exhibitions, ensuring the preservation of collective memory.

Promotes sports and youth development.

Elektrostal invests in sports infrastructure and programs to encourage youth participation, health, and physical fitness.

Hosts annual cultural and artistic festivals.

Throughout the year, Elektrostal celebrates its cultural diversity through festivals dedicated to music, dance, art, and theater.

Provides a picturesque landscape for photography enthusiasts.

The city’s scenic beauty, architectural landmarks, and natural surroundings make it a paradise for photographers.

Connects to Moscow via a direct train line.

The convenient train connection between Elektrostal and Moscow makes commuting between the two cities effortless.

A city with a bright future.

Elektrostal continues to grow and develop, aiming to become a model city in terms of infrastructure, sustainability, and quality of life for its residents.

In conclusion, Elektrostal is a fascinating city with a rich history and a vibrant present. From its origins as a center of steel production to its modern-day status as a hub for education and industry, Elektrostal has plenty to offer both residents and visitors. With its beautiful parks, cultural attractions, and proximity to Moscow, there is no shortage of things to see and do in this dynamic city. Whether you’re interested in exploring its historical landmarks, enjoying outdoor activities, or immersing yourself in the local culture, Elektrostal has something for everyone. So, next time you find yourself in the Moscow region, don’t miss the opportunity to discover the hidden gems of Elektrostal.

Q: What is the population of Elektrostal?

A: As of the latest data, the population of Elektrostal is approximately XXXX.

Q: How far is Elektrostal from Moscow?

A: Elektrostal is located approximately XX kilometers away from Moscow.

Q: Are there any famous landmarks in Elektrostal?

A: Yes, Elektrostal is home to several notable landmarks, including XXXX and XXXX.

Q: What industries are prominent in Elektrostal?

A: Elektrostal is known for its steel production industry and is also a center for engineering and manufacturing.

Q: Are there any universities or educational institutions in Elektrostal?

A: Yes, Elektrostal is home to XXXX University and several other educational institutions.

Q: What are some popular outdoor activities in Elektrostal?

A: Elektrostal offers several outdoor activities, such as hiking, cycling, and picnicking in its beautiful parks.

Q: Is Elektrostal well-connected in terms of transportation?

A: Yes, Elektrostal has good transportation links, including trains and buses, making it easily accessible from nearby cities.

Q: Are there any annual events or festivals in Elektrostal?

A: Yes, Elektrostal hosts various events and festivals throughout the year, including XXXX and XXXX.

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