Routine antenatal contacts

WHO antenatal care · reviewed October 2026 · gpreasoning.uk/global

Reasoning GP
Global Primary Care

Who / when

Every pregnant woman and adolescent girl, from the first contact until birth.
Aim for at least eight contacts: the first up to 12 weeks, then at 20, 26, 30, 34, 36, 38 and 40 weeks. If she has not given birth by 41 weeks, she should come back.
A missed item at one contact should be done at the next one.

Red flags: refer now

Refer now (or, if she calls from home, tell her to come at once, day or night):

Vaginal bleeding.
Convulsions or loss of consciousness.
Severe headache with blurred vision, or BP 160/110 or higher.
Fever and too weak to get out of bed.
Severe abdominal pain.
Fast or difficult breathing; breathless at rest with pallor (possible severe anaemia).

Come soonFever, abdominal pain, feeling ill, or swelling of the fingers, face or legs: she should come to the clinic as soon as possible, not wait for her next contact.

Assess

Every contact

Ask how she feels, about bleeding, headache, fever, fetal movements, and common problems (nausea, heartburn, cramps, back pain, constipation).
Blood pressure, urine for protein when BP is 140/90 or higher, weight, signs of anaemia (palms, conjunctiva), fundal height, fetal heart.
Ask about tobacco, alcohol and other substances at every contact. Ask about violence at home where you are trained and can respond and refer safely.

Tests

Haemoglobin at the first contact (full blood count, or a haemoglobinometer if no laboratory; WHO prefers this to the colour scale), and again if pale or tired.
HIV and syphilis at the first contact (and retest for HIV late in pregnancy where HIV is common).
Urine for asymptomatic bacteriuria: culture, or Gram stain on site if no culture (not dipstick).
One ultrasound before 24 weeks where available, to date the pregnancy and find twins or anomalies.
Blood glucose if she has risk factors or symptoms; screen for TB where your programme does.

Classify

Hb thresholds from the WHO haemoglobin cut-off guideline (2024). Use your national referral criteria.
Finding	What it may mean	Action
Any danger sign above; BP 160/110 or more; Hb below 70 g/L or breathless with pallor	Emergency, severe pre-eclampsia or severe anaemia	Refer urgently (see the pre-eclampsia and anaemia protocols for first doses)
BP 140/90 or more after 20 weeks; Hb below 110 g/L (below 105 in the second trimester); positive HIV, syphilis or bacteriuria test; twins; previous caesarean	Needs extra care	Treat or refer per protocol; see more often; plan birth in a facility that can manage it
Normal BP, Hb 110 g/L or more, tests negative, no danger signs	Routine pregnancy	Preventive package, counselling, next contact as scheduled

Treat

The preventive package (adapted from WHO ANC 2016)

Folic acid at 0.4 mg daily, not 5 mg, if she is taking IPTp: high-dose folic acid may stop SP working.
What	Dose or schedule	Note
Iron and folic acid, daily	30 to 60 mg elemental iron + 400 micrograms (0.4 mg) folic acid	60 mg preferred where 40% or more of pregnant women are anaemic. 60 mg iron = ferrous sulfate 300 mg
Or iron and folic acid, weekly	120 mg iron + 2.8 mg folic acid once a week	Only if daily iron is not tolerated, and where under 20% of pregnant women are anaemic
Anaemia found	Increase to 120 mg elemental iron a day + 400 micrograms folic acid	Until Hb is 110 g/L or more, then back to the usual dose
Calcium (low-calcium diets)	1.5 to 2.0 g elemental calcium a day	To reduce pre-eclampsia. Split into three doses with meals; take several hours apart from iron
IPTp with sulfadoxine-pyrimethamine	From 13 weeks (second trimester), at scheduled contacts, at least 1 month apart	Malaria-endemic areas of Africa; aim for at least three doses. Plus a bed net
Tetanus toxoid-containing vaccine	Unvaccinated or unknown: 2 doses 1 month apart, the second at least 2 weeks before birth	1 to 4 previous doses: 1 dose this pregnancy, up to a total of 5
Deworming	One dose after the first trimester	Where over 20% of people have worm infection; per national programme

Follow-up

Next scheduled contact (20, 26, 30, 34, 36, 38, 40 weeks).
Anaemia: see again in 2 weeks if severe, or at the next contact (4 to 6 weeks) if moderate.
Raised BP without danger signs: see the pre-eclampsia protocol (usually weekly or more often).
Use a woman-held card or notes so every contact can see what has been done.

Counsel

Healthy eating and staying active. More energy and protein in undernourished settings.
Take iron and folic acid every day; tell us about side effects rather than stopping.
High caffeine intake (over 300 mg a day, from coffee, tea, cola or energy drinks): cut down.
No tobacco or alcohol; avoid second-hand smoke.
Nausea: ginger or chamomile; heartburn: small meals, antacids if needed; constipation: fibre such as wheat bran.
Birth and emergency plan: where to give birth, transport, money, a companion, a blood donor.
Danger signs, breastfeeding and family planning after birth.

Come to every check-up, even when you feel well. If you bleed, have a fit, a bad headache with blurred vision, fever with weakness, bad belly pain or trouble breathing, come to the clinic at once, day or night.

When to refer

Urgently: any danger sign, BP 160/110 or more, convulsions, severe anaemia.
BP 140/90 or more with protein in the urine, or any feature of pre-eclampsia.
Moderate anaemia not improving after treatment.
Transverse lie or other malpresentation within a month of the due date; no fetal movement; obvious twins.
Women who should give birth at a referral-level facility, such as after a previous caesarean, under 14 years old, or with a history of bleeding in this pregnancy.

Sources

World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. 2016. World Health Organization. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice, 3rd edition. 2015. World Health Organization. Guideline on haemoglobin cutoffs to define anaemia in individuals and populations. 2024. World Health Organization. WHO recommendations for prevention and treatment of pre-eclampsia and eclampsia. 2011.

Adapted from WHO guidance; not endorsed by WHO. This page paraphrases and adapts the WHO publications listed under Sources, which are licensed CC BY-NC-SA 3.0 IGO; the adapted text is shared under the same licence for non-commercial education. Reasoning GP is not affiliated with WHO or any other organisation named here. Use it alongside your national guidelines, essential medicines list and formulary, and your clinical judgement. Doses are given only where they come from a WHO source; otherwise follow your national guideline or formulary.