1 Mother friendly care during pregnancy

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Mother friendly care for pregnant women

1-1 What is mother friendly care during pregnancy?

This is the modern method of caring for women during pregnancy, where the best interests of the woman and her fetus are considered above those of the hospital or clinic staff. Mother friendly care is good care.

1-2 What are the principles of mother friendly care during pregnancy?

  1. Each woman is welcomed and given individualised care, paying special attention to her own wishes and needs. Always call a mother by her name.
  2. Women are treated with kindness, compassion, patience and gentleness.
  3. Care should be sensitive, responsive and supportive to the needs, values and customs of each woman’s culture and home background.
  4. Women are encouraged and helped to play an important role in their own care and decision making.
  5. The woman’s physical and emotional needs are considered.
  6. Women are informed about their condition and that of the unborn infant in a way that they will understand.
  7. Health workers give women opportunities to voice their feelings, needs and questions.
  8. Wherever possible, care should be evidence based.

Maternal care during pregnancy should be individualised.

1-3 What is meant by individualised antenatal care?

With individualised (personalised) care, every effort is made to ensure that the same health worker sees the same patient at each visit. This may be easy to achieve in rural areas with few health workers and smaller numbers of pregnant women. However in peri-urban and urban areas with many health workers and large numbers of patients, good organisation is required to achieve this goal.

Individualised care also means that the specific needs of each woman are considered when her antenatal care is planned. The needs of all pregnant women are not the same. The needs of different individuals often vary.

1-4 What are the benefits of individualised care?

  1. A relationship of trust and respect develops between the patient and health worker. Pregnant women are more likely to ask questions and speak openly with someone they get to know.
  2. The health worker knows that observations at a visit are done in exactly the same way as during the previous visits (i.e. interobserver variation is ruled out).
  3. Abnormal observations will be identified and reacted upon and not thought to be the result of the previous person doing observations incorrectly.
  4. Patients feel they are receiving better care.
  5. Health care workers experience more job satisfaction as they get to know the women they are taking care of.

Individualised care results in better care.

1-5 What personal history should be taken during antenatal care?

In addition to the medical history routinely taken during antenatal care, attending an antenatal clinic provides a woman with the opportunity to talk about her home, partner, fears and wishes. Assessing the woman’s emotional status is important as it may identify women at increased risk of postnatal depression and anxiety. Emotional or physical abuse, economic problems or drug abuse may also be identified.

Excessive fear and anxiety during a vaginal examination may suggest previous bad experiences. It is important to allow women to speak about any previous births. Taking a brief psychiatric history is important, especially to screen women for features of anxiety or depression. Most women at risk of postpartum depression will have warning symptoms during their pregnancy. Early diagnosis and treatment of depression gives a better outcome. Women on antidepressants must not stop their treatment because they are pregnant.

1-6 How can pregnant women play a greater roll in their own care?

  1. By being allowed and encouraged to speak about their needs and fears.
  2. By learning more about the physical and emotional changes that take place during pregnancy.
  3. By understanding the care they are being given.
  4. By understanding the importance of a good diet during pregnancy.
  5. By understanding that care of themselves will improve the health of their infant.
  6. By not smoking or drinking alcohol during pregnancy.
  7. By helping to monitor their own pregnancy.

Women should be encouraged to play a more active roll in the management of their pregnancies.

1-7 How can women be helped to monitor their own pregnancy?

  1. Women should be taught to be aware for danger signs during pregnancy, such as bleeding, severe headache or abdominal pain and visual disturbances (in severe pre-eclampsia).
  2. Being aware of fetal movements can help mothers to also monitor the well being of their unborn infant.
  3. Women should know the early signs of labour.

Women should contact or go to the delivery centre as soon as they recognise danger signs or go into labour.

1-8 What is evidenced based care in pregnancy?

Evidence based care is the clinical management of a patient where the treatment is decided by the results of carefully done clinical trials. This is far better than care based on prejudices, unconfirmed beliefs and traditions. It is important to question every aspect of patient care. Only in this way can unhelpful practices be rejected and effective care introduced.

Whenever possible, care in pregnancy should be evidence based.

Women and their pregnancies

1-9 How can women be helped to enjoy their pregnancies?

Pregnancy should be an exciting time for women and their partners. The best way of enjoying a pregnancy is to keep physically and emotionally well, and to share the experience with others. To build confidence and understand the changes taking place in her body, women should learn as much as they can about pregnancy.

1-10 How can women learn more about their pregnancies?

All mothers should be encouraged to learn about the changes that are taking place in their bodies during pregnancy. Most mothers learn from speaking to their friends and family members. Books, magazines, the radio and TV are also sources of information. One of the best ways of learning about one’s pregnancy is to attend antenatal classes.

1-11 Why should pregnant women attend antenatal classes?

There are many advantages of attending ante­natal classes, including:

  1. Learning about pregnancy, labour and delivery. Knowing what to expect and being able to ask questions.
  2. Learning physical excises which help a woman to keep fit and prepare for labour. Also learning the importance of adequate rest.
  3. Learning about the most suitable diet in pregnancy.
  4. Learning about dangerous practices such as smoking, drinking alcohol and taking illegal drugs.
  5. Overcoming fear and anxiety and building confidence.
  6. Learning how to care for the infant and how to breastfeed successfully.
  7. Meeting other women who are pregnant. Mutual support is most important.

Education is a very important part of good antenatal care.

1-12 Should women bring their partners to antenatal classes?

Women must be encouraged to share their pregnancies with their partner and support one another during this special time. Therefore, it is important that partners also learn about pregnancy, labour and delivery. If they are unable to bring a partner, they should invite a family member or friend who could be with them during labour.

Emotional support from a friend or family member is important in pregnancy.

1-13 Should women continue working and exercising during pregnancy?

It is important to keep physically active during pregnancy. Most women are able to continue their routine activities throughout most of pregnancy. Keeping fit through mild to moderate exercise is recommended.

Many women continue to work until the last weeks of pregnancy. The social support and financial income are benefits. Some women feel very tired during the first and last weeks of pregnancy, and a rest during the day may help. Long periods of standing should be avoided in the last trimester.

1-14 Is a sexual relationship safe during pregnancy?

Many women worry that sexual intercourse will harm their unborn infant. However, full sexual relations can usually be enjoyed by most pregnant women unless there is a risk of preterm labour.

Multiple partners and unsafe sex are particularly dangerous as HIV infection acquired during pregnancy carries a high risk of transmission to the fetus.

1-15 What is the value of written material at an antenatal clinic?

Many women find is very helpful to receive written material which gives the information discussed at antenatal clinics. Sometimes it is easier to understand if a message is read. A lot of what is spoken about in a class is forgotten unless reinforced by information sheets or leaflets. Pamphlets should list the danger signs in pregnancy and stress the importance of breastfeeding, and giving kangaroo mother care in low birth weight infants. Information must be presented in a simple, clear way.

Managing pregnant women in a mother friendly way

1-16 What is the mother friendly way to book a new patient?

  1. All patients must be greeted by name. A smile makes a huge difference.
  2. Patients should not be kept waiting longer than absolutely necessary.
  3. Patients should not be scolded for booking late. Instead they should be told the advantages of early booking and be encouraged to book early with their next pregnancy.
  4. Patients who come to book for the first time must be seen on that day.

1-17 When should women book for antenatal care?

As soon as the pregnancy is confirmed. One of the common errors made by both women and health care workers is to delay booking for antenatal care for weeks or months after the pregnancy is confirmed. Early booking helps to establish the correct gestational age, enables problems to be identified as early as possible, and enables women to get the information they need during pregnancy.

Women should book for antenatal care as soon as their pregnancy is confirmed.

1-18 Why must all women presenting for the first time during pregnancy be seen on that day?

Patients that appear healthy and are asymptomatic may already have a dangerous pregnancy complication that will become worse with time, e.g. untreated syphilis or pre-eclampsia. It is important that the first contact with the antenatal clinic is a positive experience. This will help to get the woman to attend regularly.

1-19 Why are some women who present for the first time at an antenatal clinic not immediately booked for care?

Sometimes pregnant women are not seen at a clinic because only a fixed number of patients are allowed to book for antenatal care on each day. Even arriving very early for the clinic may not guarantee that they will be seen while an unfriendly reception at an antenatal clinic may result in late booking or infrequent visits.

1-20 What are the disadvantages if women are not seen at a clinic when they come to book for antenatal care?

  1. The number of women that require booking steadily increases, resulting in a huge backlog.
  2. Women often have to arrive at the clinic in the early hours of the morning in order to be seen.
  3. Women needing antenatal care are often forced to go to other district clinics, which are far from their homes, where queues and waiting times are shorter.
  4. In the event of an emergency, women booked in another district often have problems with district based ambulance services.
  5. Women who have booked at a distant clinic often present with pregnancy complications at the local clinic where they have no clinical records and, therefore, are blamed for not booking.
  6. Women ultimately lose faith in the health service.
  7. If they are told to come back on another day they may not return for weeks or months.

1-21 What must be done if the number of patients seen at an antenatal clinic becomes too large and unmanageable?

  1. The policy on the frequency of clinic visits must be reviewed. Studies have shown that the number of antenatal visits in low risk patients can be safely reduced.
  2. The number of clinic days per week must be increased, especially the number of days for booking clinics.

1-22 Should mothers be encouraged to bring a friend or family member with them to the antenatal clinic?

Yes, all pregnant women must be allowed to bring a person of their choice to the antenatal clinic. This will usually be her husband, partner, family member, friend or older child. A companion can provide important support for women who are anxious about attending an antenatal clinic.

1-23 Should the family member or friend be allowed in the cubicle while the woman is being examined?

Yes. However, the woman should first be asked whether she would like the person to be present or whether she would rather be alone. The woman should be allowed to be seen alone if she wishes. An opportunity to speak privately to the health care giver is important. Grandmothers can sometimes be very dominating and not allow the pregnant woman to speak for herself.

1-24 Why is it important to consider a woman’s feelings?

Otherwise health care workers may only focus on the medical management and not address the other needs of pregnant women. A woman’s emotion state can have an effect on the pregnancy and its outcome.

1-25 What important needs do women have during pregnancy?

  1. Research has shown that women are concerned about the health of their unborn infant and their own health.
  2. Therefore, whenever observations or an examination is done, women must be informed as to whether the findings or results indicate that she and her unborn infant are in good health.

1-26 Why should women be encouraged to speak about their fears during pregnancy?

Many women have fears or experience guilt during pregnancy. The pregnancy may not have been planned and may not be wanted. These problems can only be resolved if they are discussed. Staff should never criticise a mother.

1-27 Why are women often shy at their first antenatal visit?

  1. Unmarried women, especially young primigravidas, may be shy to reveal their pregnancies as other members of their community, church or school may be present at the clinic.
  2. Many women, especially young primigravidas, are shy and embarrassed of being exposed during a physical examination.
  3. Many have never been examined vaginally by a doctor or nurse before.
  4. They may be afraid of being scolded by the staff.

1-28 What is a teen friendly clinic?

The medical, social and emotional needs of pregnant teenagers often differ from those of older women. Therefore, there are many advantages in providing antenatal care to teenagers at a special clinic which pays more attention to their specific problems.

Both smoking tobacco and drinking alcohol are potentially harmful to the pregnant woman and her fetus. The mother should be encouraged to stop smoking and drinking. Marijuana (dagga) should be avoided although the effect on the fetus is uncertain. Hard drugs, such as ‘tik’, heroin, mandrax and cocaine, should never be used, especially during pregnancy.

Most medicines cross the placenta to the fetus. Therefore, medicine should only be taken during pregnancy if there is a good indication. Medicines known to damage the fetus must be avoided.

It is neither mother nor baby friendly to smoke or drink alcohol during pregnancy.

1-30 How can women plan for their delivery?

Towards the end of pregnancy, women should plan for their delivery and the first few days after their infant is born (‘birth preparedness’). They need to know when they should report to the clinic or hospital and where to go. A list of clothes and toiletries is very useful. Some delivery units require each woman to bring her own essentials. It is helpful to give women a list of requirements for labour and delivery. The better the woman plans for her delivery, the more relaxed and confident she will be. A visit to the birthing unit before labour will reduce her fear of what a labour ward looks like. Birth preparedness is especially important in areas where transport and communication are poor, and ambulance services limited. Women must plan how they will travel to the clinic or hospital when they go into labour.

Some women with transport problems may move in the last weeks of their pregnancy to stay with friends or family close to the clinic or hospital.

Mother friendly health workers

1-31 What are the essential factors in mother friendly health workers?

  1. Correct attitude and behavior, e.g. kindness, friendliness, politeness and respect.
  2. Acceptable appearance.
  3. Good communication skills.
  4. Team work.
  5. Providing good care.
  6. Ongoing education and training

The most important factor in mother friendly care is the correct attitude of the staff.

1-32 What staff behaviour is not considered mother friendly?

  1. Being rude, aggressive, cheeky and insensitive to the woman’s needs, feelings and wishes.
  2. Emotionally, verbally or physically abusing women.
  3. Ignoring what the woman’s says or requests.
  4. Not respecting a woman’s privacy.
  5. Not giving a woman an opportunity to ask questions.

1-33 Why are staff sometimes not mother friendly?

  1. They have not learned the correct attitudes.
  2. They have personal emotional problems.
  3. They are overworked.
  4. Chronic staff shortages and low morale.
  5. Patients and their relatives may be demanding and difficult.
  6. They are not supported by their management.
  7. They are afraid of changing outdated attitudes and practices.
  8. They may feel that patients are inferior to them.
  9. They may feel insecure due to a lack of knowledge and skills.

Staff often need to be supported themselves in order to be friendly and caring towards their patients. A climate of mother friendly care has to be developed over time. Many outdated attitudes and practices have to be changed. Abusive behavior by staff should never be tolerated.

Staff often need to be taught, encouraged and supported before they can give mother friendly care.

1-34 Why is it important that staff dress in a professional manner?

Nurses and doctors should always dress in a professional manner in order for them to be recognised as professional health care workers. Sloppy dress suggests sloppy care. A professional appearance shows self respect as well as respect for colleagues and patients.

1-35 Why is a team spirit among health care providers important?

  1. Because a spirit of trust and support will result in:
    • An improved staff morale and confidence.
    • A friendly and warm atmosphere in the clinic.
    • Loyalty to the institution and colleagues.
  2. With a good team spirit it will be easy to implement activities that result in a patient friendly service.
  3. Improved self esteem among the staff results from a spirit of working well together.

All these factors will in turn results in better patient care.

1-36 What will contribute towards a better team spirit among health care providers?

  1. Group activities.
  2. Supportive leadership from the person in charge of the clinic.
  3. A single health authority that manages both the staff and the district service.
  4. A neat and well kept clinic building and surrounding area, especially the garden.
  5. A common goal that the clinic staff should strive for, decided on by the staff themselves.
  6. A commitment to upholding a high level of professionalism
  7. Opportunities for improving their knowledge and skills.
  8. Praise and encouragement for each other.

Support and care of the staff are essential for a good service.

1-37 What group activities will foster a team spirit?

  1. Regular meetings to discuss staff and operational problems (business meetings).
  2. Regular audit meetings to evaluate the quality of care, i.e. to discuss perinatal deaths, patient transfers, use of antenatal cards and partograms. Staff need to be accountable for the care they provide.
  3. Regular educational meetings with local and invited lecturers.
  4. A safe and confidential environment where real needs and problems can be discussed.

Although all the above issues can be dealt with at weekly meetings, it is wise to have a separate educational afternoon at regular intervals (i.e. monthly). As staff and management problems tend to overwhelm educational needs, a separate educational exercise solves this problem.

1-38 How will educational activities improve the team spirit?

  1. Improved knowledge and skills leads to more confidence and job satisfaction.
  2. Management protocols can be discussed and new staff members taught how patients are managed.
  3. When a uniform patient management approach is followed, trust between health workers and the level of care improve.
  4. Studying an educational manual in a group is of great value as it provides background knowledge and management guidelines.

1-39 What is the value of self-help training in building team spirit?

Enabling staff to take pride and responsibility in their own professional growth, through self-help training programmes like PEP, teaches all team members to work and learn together. The principles of peer tuition (teaching each other) and support are of great importance. Learning and agreeing to common protocols of diagnosis, management and referral build a united vision of maternal care.

Learning together teaches people how to work together.

1-40 How will audit meetings improve a team spirit?

The spirit at the meeting must be constructive and not threatening. The approach must be to learn from omissions, errors made or incorrect management or diagnosis? Blaming of staff members must never be done in a meeting.

1-41 How can the community contribute to mother friendly care?

The community should be encouraged to support both pregnant women and the services that care for them.

Family and community support for pregnant women is particularly important for teenage mothers, single mothers, working mothers and mothers with large families. The physical, emotional and time demands of pregnancy are often considerable. Help may be needed with home and work responsibilities.

The community can help make clinics and hospitals mother friendly by helping to create a warm, friendly environment. Clean and attractively painted waiting and examination rooms with colourful curtains and comfortable chairs makes the experience of an antenatal visit more enjoyable. The community can offer time, skills and collect funds. A ‘Friends of the clinic’ group can be formed with community volunteers helping with tasks such as providing tea. The community should take pride in ‘their’ clinic.

Case study 1

A young woman attends an antenatal clinic where she sees a midwife she has not met before. She is not greeted by name but simply asked to lie on the examination couch. Although asked about her health, she is not asked about her other needs. As a result, her anxieties about being thrown out of her home are not discussed. The midwife gives no explanation but says there is no reason to be worried and gives her a date for the next appointment. The woman decides not to come back for her next appointment but to look for another clinic where she is not treated as ‘just another patient’.

1. Is this young woman receiving mother friendly care?

No. She is being treated as a number rather than as an individual. She should have been greeted by name and introduced to the midwife. She is not given any details of the examination findings. One would not treat a friend or family member in this uncaring way.

2. What is individualised care?

With individualised care, the patient is seen as an individual (not just a number). She is seen by the same doctor or midwife at every visit. Although this is not easy in a busy clinic with staff shortages, it has benefits for both the patient and the health worker.

3. What are the benefits of individualised care?

A relationship of trust and respect develops between the patient and health worker and there is continuity of care. Patients feel they are getting better care and the health worker has more job satisfaction.

4. Why is a personal history important?

The needs of this woman were not addressed as a personal history was not taken. Only taking a medical history may miss important problems, such as social, emotional or financial difficulties.

5. How can a pregnant woman be encouraged to speak about her fears and anxieties?

She could be asked how she feels about her pregnancy and whether she receives support from her family at home.

6. Which specific need was not addressed during the antenatal visit?

The woman wants to know whether she and her fetus are in good health. To merely state that there is no reason to be worried in an incorrect and negative approach.

7. Are you surprised that she decides to try another clinic for her next antenatal care visit?

No. She wants a clinic where she is made to feel that the staff are interested in providing her with good care. She needs mother friendly pregnancy care.

8. What may result from her unsatisfactory clinic visit?

She may decide not to have any more antenatal care or only attend another clinic late in her pregnancy. She may also tell her friends about her experience and, as a result, they may not go for antenatal care in their pregnancies.

Case study 2

A primigravid woman and her husband attend an antenatal clinic for the first time. She wants to know more about pregnancy and delivery, and asks where she can get more information. She needs to know about diet, working, exercise and sex during her pregnancy. The midwife is very helpful and refers her to antenatal classes. She is very excited about being pregnant and wants to enjoy her pregnancy and play an active role in her management.

1. How should women be education during antenatal care?

General health education, and in particular education about pregnancy, labour and delivery, is a very important part of good antenatal care. Talks, videos, CDs, books, magazines and pamphlets can all be used for antenatal education. However, antenatal classes are the best way of providing education for pregnant mothers.

2. What are the benefits of women attending antenatal classes?

Not only do they become more knowledgeable about their pregnancies, but they build their confidence and lose many of their anxieties. She will be able to discuss the important topics of diet, weight, exercise and sex during pregnancy. Meeting and talking to other pregnant women provides an emotional support. This enables women to enjoy their pregnancies. Many of the benefits gained from antenatal classes can still be provided at a routine antenatal clinic.

3. Can her husband also attend the antenatal class?

Yes. He will be able to support her better both during the pregnancy and labour, but also with their newborn infant, if he joins her in the antenatal classes.

4. How can a woman play an active role in the management of her pregnancy?

By learning how to monitor her own pregnancy. She should be taught the danger symptoms and also how to become aware of fetal movements.

5. Should women continue to exercise and work during pregnancy?

Yes. It is important that women keep fit during pregnancy. Most women can continue to work until the last weeks of pregnancy. However, they often get tired and need to have extra rest during the day.

Case study 3

A teenage girl attends a local clinic to have a pregnancy test as she has missed her period for two months. Her pregnancy is confirmed and she is told to return to book for antenatal care when she reaches 20 weeks of gestation. However, when she returns to book there is a long queue and, after waiting all morning, she is asked to come back the next day. When she is finally seen, the staff are rude. She notices that their uniforms are dirty and they appear uninterested in the care of their patients.

1. How soon should pregnant women book for antenatal care?

As soon as the pregnancy is confirmed. She should have booked the same day as the positive pregnancy test.

2. What was the problem at the booking clinic?

The staff were not able to see all the patients wanting to book. This is a common problem in many clinics, with a shortage of staff, when all new bookings are only done on a single day of the week. Long queues often lead to women booking late or not at all. An urgent plan is needed to clear the backlog of patients as postponing booking does not solve the problem.

3. Does it matter that the patient is still a teenager?

Yes. Pregnant teenagers often have social and emotional problems. They are best cared for at a special antenatal clinic for teenagers. The unfriendly way that this patient was managed would be especially stressful for a young woman.

4. Are you surprised the staff were rude?

Not really, although health care workers should always treat patient with courtesy and respect. Inadequate staffing rapidly leads to stress, exhaustion and poor staff morale. The poor standard of dress and bad attitude of the staff support the conclusion that there was a poor team spirit.

5. How could you improve the poor team spirit of the staff?

The staff need help and support. They should be given an opportunity to speak about the problems at the clinic. With good leadership training and encouragement the team spirit can be rebuilt. This will result in better patient care. Group activities such as audit meetings and self-help learning in groups would be very helpful. The staff need to be educated in the principles of mother friendly care.

6. How could the community help to develop mother friendly care at the clinic?

They should form a ‘Friends of the Clinic’ committee to help raise funds to improve the appearance and facilities of the clinic. Community support, encouragement and pride in the clinic and staff will help to maintain a high standard of care.

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