Protocol · WHO antenatal care
Routine antenatal contacts
Antenatal care is the chance to find problems before they become emergencies and to help a woman have a safe and positive pregnancy. WHO now recommends at least eight contacts, starting in the first 12 weeks. Each contact has the same core: listen, check for danger signs, measure blood pressure, give the preventive package, and agree a birth and emergency plan.
- Based on WHO antenatal care
- For midwives, nurses, clinical officers and doctors
- Reviewed October 2026
1Who / 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.
WHO uses the word "contact" rather than "visit": a contact can be in the clinic or through outreach and community health workers, as your national programme allows.
2Red 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.
3Assess
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.
4Classify
| 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 |
5Treat
The preventive package (adapted from WHO ANC 2016)
| 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 |
- Low-dose aspirin (75 mg daily from before 20 weeks) for women at high risk of pre-eclampsia: see the pre-eclampsia protocol.
- Asymptomatic bacteriuria: a seven-day antibiotic course (choice per national formulary).
- HIV or syphilis positive: start treatment and prevention of transmission to the baby per national guideline.
WHO does not recommend routine multiple micronutrients, vitamin B6, C, D or E, or high-protein supplements for all pregnant women. Vitamin A only where deficiency is a severe public health problem.
6Follow-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.
7Counsel
- 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.
8When 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.
9Sources
- World Health Organization. WHO recommendations on antenatal care for a positive pregnancy experience. 2016 (ISBN 9789241549912).
- World Health Organization. Pregnancy, childbirth, postpartum and newborn care: a guide for essential practice, 3rd edition. 2015. Used for danger signs and the anaemia check.
- 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.