In 2016, at the start of the Sustainable Development Goals (SDGs) era, pregnancy-related preventable morbidity and mortality remains unacceptably high. While substantial progress has been made, countries need to consolidate and increase these advances, and to expand their agendas to go beyond survival, with a view to maximizing the health and potential of their populations.# Introduction
The World Health Organization (WHO) envisions a world where every pregnant woman and newborn receives quality care throughout the pregnancy, childbirth and the postnatal period. Within the continuum of reproductive health care, antenatal care (ANC) provides a platform for important health-care functions, including health promotion, screening and diagnosis, and disease prevention. It has been established that by implementing timely and appropriate evidence-based practices, ANC can save lives. Crucially, ANC also provides the opportunity to communicate with and support women, families and communities at a critical time in the course of a woman's life. The process of developing these recommendations on ANC has highlighted the importance of providing effective communication about physiological, biomedical, behavioural and sociocultural issues, and effective support, including social, cultural, emotional and psychological support, to pregnant women in a respectful way. These communication and support functions of ANC are key, not only to saving lives, but to improving lives, healthcare utilization and quality of care. Women's positive experiences during ANC and childbirth can create the foundations for healthy motherhood. This is a comprehensive WHO guideline on routine ANC for pregnant women and adolescent girls. The aim is for these recommendations to complement existing WHO guidelines on the management of specific pregnancyrelated complications. The guidance is intended to reflect and respond to the complex nature of the issues surrounding the practice and delivery of ANC, and to prioritize person-centred health and well-beingnot only the prevention of death and morbidity -in accordance with a human rights-based approach.
The scope of this guideline was informed by a systematic review of women's views, which shows that women want a positive pregnancy experience from ANC. A positive pregnancy experience is defined as maintaining physical and sociocultural normality, maintaining a healthy pregnancy for mother and baby (including preventing or treating risks, illness and death), having an effective transition to positive labour and birth, and achieving positive motherhood (including maternal self-esteem, competence and autonomy).
Recognizing that a woman's experience of care is key to transforming ANC and creating thriving families and communities, this guideline addresses the following questions:
What are the evidence-based practices during ANC that improve outcomes and lead to a positive pregnancy experience?
How should these practices be delivered?

# Guideline development methods
These ANC recommendations are intended to inform the development of relevant health-care policies and clinical protocols. The guideline was developed using standard operating procedures in accordance with the process described in the WHO handbook for guideline development. Briefly, these procedures include: (i) identification of priority questions and outcomes; (ii) evidence retrieval and synthesis; (iii) assessment of the evidence; (iv) formulation of the recommendations; and (v) planning for implementation, dissemination, impact evaluation and updating of the guideline. The quality of the scientific evidence underpinning the recommendations was graded using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) and Confidence in the Evidence from Reviews of Qualitative research (GRADE-CERQual) approaches, for quantitative and qualitative evidence, respectively. Up-to-date systematic reviews were used to prepare evidence profiles for priority questions. The DECIDE (Developing and Evaluating Communication Strategies to support Informed Decisions and Practice based on Evidence) framework, an evidence-to-decision tool that includes intervention effects, values, resources, equity, acceptability and feasibility criteria, was used to guide the formulation and approval of recommendations by the Guideline Development Group (GDG) -an international group of experts assembled for the purpose of developing this guideline -at three Technical Consultations between October 2015 and March 2016.
The WHO Technical Consultations led to the development of 39 recommendations related to five types of interventions: A. Nutritional interventions, B. Maternal and fetal assessment, C. Preventative measures, D. Interventions for common physiological symptoms, and E. Health systems interventions to improve utilization and quality of antenatal care. Interventions were either recommended, not recommended, or recommended under certain conditions based on the GDG's judgements according to the DECIDE criteria, which informed both the direction and context, if any, of the recommendation. To ensure that each recommendation is correctly understood and applied in practice, the context of all context-specific recommendations is clearly stated within each recommendation, and the contributing experts provided additional remarks where needed. Users of the guideline should refer to these remarks, which are presented along with the evidence summaries in the full version of the guideline. In addition, ANC-relevant recommendations from current guidance produced by other WHO departments were systematically identified and 10 such recommendations were consolidated into this guideline for the purpose of providing a comprehensive document for end-users. All 49 recommendations on ANC for a positive pregnancy experience are summarized in Table 1.
In accordance with WHO guideline development standards, these recommendations will be reviewed and updated following the identification of new evidence, with major reviews and updates at least every five years. WHO welcomes suggestions regarding additional questions for inclusion in future updates of the guideline.
At the Technical Consultations, the implementation considerations of individual recommendations and of the guideline as a whole were discussed. The GDG, emphasizing the evidence indicating increased fetal deaths and lesser satisfaction of women with the four-visit model (also known as focused or basic ANC), decided to increase the recommended number of contacts between the mother and the health-care providers at time points that may facilitate assessment of well-being and provision of interventions to improve outcomes if problems are identified (see Recommendation E.7 in Table 1). The recommendations in this guideline should be implemented alongside other quality-improvement activities. Derivative products of this guideline will include a practical implementation manual for health-care practitioners, which will incorporate ANC recommendations and established good clinical practices. Table 1   These recommendations apply to pregnant women and adolescent girls within the context of routine ANC

# A. Nutritional interventions

# Type of recommendation

# Dietary interventions
A.1.1: Counselling about healthy eating and keeping physically active during pregnancy is recommended for pregnant women to stay healthy and to prevent excessive weight gain during pregnancy. 1 Recommended
In undernourished populations, nutrition education on increasing daily energy and protein intake is recommended for pregnant women to reduce the risk of low-birth-weight neonates.

# Context-specific recommendation
A.1.3: In undernourished populations, balanced energy and protein dietary supplementation is recommended for pregnant women to reduce the risk of stillbirths and small-for-gestational-age neonates.

# Context-specific recommendation
A.1.4: In undernourished populations, high-protein supplementation is not recommended for pregnant women to improve maternal and perinatal outcomes.

# Not recommended
Iron and folic acid supplements A.2.1: Daily oral iron and folic acid supplementation with 30 mg to 60 mg of elemental iron 2 and 400 g (0.4 mg) of folic acid 3 is recommended for pregnant women to prevent maternal anaemia, puerperal sepsis, low birth weight, and preterm birth. 4 Recommended
Intermittent oral iron and folic acid supplementation with 120 mg of elemental iron 5 and 2800 g (2.8 mg) of folic acid once weekly is recommended for pregnant women to improve maternal and neonatal outcomes if daily iron is not acceptable due to side-effects, and in populations with an anaemia prevalence among pregnant women of less than 20%. 6 Context-specific recommendation Calcium supplements
In populations with low dietary calcium intake, daily calcium supplementation (1.5-2.0 g oral elemental calcium) is recommended for pregnant women to reduce the risk of pre-eclampsia. 7

# Context-specific recommendation Vitamin A supplements
A.4: Vitamin A supplementation is only recommended for pregnant women in areas where vitamin A deficiency is a severe public health problem, 8 to prevent night blindness. 9

# Context-specific recommendation 1
A healthy diet during pregnancy contains adequate energy, protein, vitamins and minerals, obtained through the consumption of a variety of foods, including green and orange vegetables, meat, fish, beans, nuts, whole grains and fruit.
The equivalent of 60 mg of elemental iron is 300 mg of ferrous sulfate hepahydrate, 180 mg of ferrous fumarate or 500 mg of ferrous gluconate.
3 Folic acid should be commenced as early as possible (ideally before conception) to prevent neural tube defects.
This recommendation supersedes the previous WHO recommendation (1).
The equivalent of 120 mg of elemental iron equals 600 mg of ferrous sulfate heptahydrate, 360 mg of ferrous fumarate or 1000 mg of ferrous gluconate.
This recommendation supersedes the previous WHO recommendation (2).
This recommendation is consistent with the 2011 WHO recommendations on pre-eclampsia and eclampsia (3) and supersedes the 2013 WHO recommendation on calcium supplementation (4).
Vitamin A deficiency is a severe public health problem if  5% of women in a population have a history of night blindness in their most recent pregnancy in the previous 3-5 years that ended in a live birth, or if  20% of pregnant women have a serum retinol level < 0.70 mol/L. Determination of vitamin A deficiency as a public health problem involves estimating the prevalence of deficiency in a population by using specific biochemical and clinical indicators of vitamin A status.
This recommendation supersedes the previous WHO recommendation (5).
Zinc supplements A.5: Zinc supplementation for pregnant women is only recommended in the context of rigorous research.

# Context-specific recommendation (research)
Multiple micronutrient supplements A.6: Multiple micronutrient supplementation is not recommended for pregnant women to improve maternal and perinatal outcomes.

# Not recommended
Vitamin B6 (pyridoxine) supplements A.7: Vitamin B6 (pyridoxine) supplementation is not recommended for pregnant women to improve maternal and perinatal outcomes.

# Not recommended
Vitamin E and C supplements A.8: Vitamin E and C supplementation is not recommended for pregnant women to improve maternal and perinatal outcomes.

# Not recommended
Vitamin D supplements A.9: Vitamin D supplementation is not recommended for pregnant women to improve maternal and perinatal outcomes. 10 Not recommended
Restricting caffeine intake A.10: For pregnant women with high daily caffeine intake (more than 300 mg per day), 11 lowering daily caffeine intake during pregnancy is recommended to reduce the risk of pregnancy loss and low-birthweight neonates.

# Context-specific recommendation
This recommendation supersedes the previous WHO recommendation (6).
This includes any product, beverage or food containing caffeine (i.e. brewed coffee, tea, cola-type soft drinks, caffeinated energy drinks, chocolate, caffeine tablets).
Evidence on essential ANC activities, such as measuring maternal blood pressure, proteinuria and weight, and checking for fetal heart sounds, was not assessed by the GDG as these activities are considered to be part of good clinical practice.
Minimum requirements are: a protocol/standard operating procedure; training on how to ask about IPV, and on how to provide the minimum response or beyond; private setting; confidentiality ensured; system for referral in place; and time to allow for appropriate disclosure.
This recommendation is consistent with the 2013 WHO clinical and policy guidelines (7).

# Recommendations integrated from other WHO guidelines that are relevant to ANC maternal assessment

# Gestational diabetes mellitus (GDM)
B.1.4: Hyperglycaemia first detected at any time during pregnancy should be classified as either gestational diabetes mellitus (GDM) or diabetes mellitus in pregnancy, according to WHO criteria. 15 Recommended Tobacco use B.1.5: Health-care providers should ask all pregnant women about their tobacco use (past and present) and exposure to second-hand smoke as early as possible in the pregnancy and at every antenatal care visit. 16 Recommended Substance use B.1.6: Health-care providers should ask all pregnant women about their use of alcohol and other substances (past and present) as early as possible in the pregnancy and at every antenatal care visit. 17 Recommended

# Context-specific recommendation
This is not a recommendation on routine screening for hyperglycaemia in pregnancy. This recommendation has been adapted and integrated from the 2013 WHO publication (8), which states that GDM should be diagnosed at any time in pregnancy if one or more of the following criteria are met:
- fasting plasma glucose 5.1-6.9 mmol/L (92-125 mg/dL) Diabetes mellitus in pregnancy should be diagnosed if one or more of the following criteria are met:
- fasting plasma glucose  7.0 mmol/L (126 mg/dL)
- 2-hour plasma glucose  11.1 mmol/L (200 mg/dL) following a 75 g oral glucose load
- random plasma glucose  11.1 mmol/L (200 mg/dL) in the presence of diabetes symptoms.
Integrated from the 2013 WHO recommendations (9).

# Integrated from the 2014 WHO guidelines (10).
High-prevalence settings are defined as settings with greater than 5% HIV prevalence in the population being tested. Lowprevalence settings are those with less than 5% HIV prevalence in the population being tested (11). In settings with a generalized or concentrated HIV epidemic, retesting of HIV-negative women should be performed in the third trimester because of the high risk of acquiring HIV infection during pregnancy.
Adapted and integrated from WHO's Consolidated guidelines on HIV testing services (11).
Adapted and integrated from the 2013 WHO recommendations (12).

# C. Preventive measures

# Type of recommendation
Antibiotics for asymptomatic bacteriuria (ASB)
C.1: A seven-day antibiotic regimen is recommended for all pregnant women with asymptomatic bacteriuria (ASB) to prevent persistent bacteriuria, preterm birth and low birth weight.

# Context-specific recommendation
Tetanus toxoid vaccination C.5: Tetanus toxoid vaccination is recommended for all pregnant women, depending on previous tetanus vaccination exposure, to prevent neonatal mortality from tetanus. 25
Cardiotocography is a continuous recording of the fetal heart rate and uterine contractions obtained via an ultrasound transducer placed on the mother's abdomen.
Doppler ultrasound technology evaluates umbilical artery (and other fetal arteries) waveforms to assess fetal well-being in the third trimester of pregnancy.
Areas with greater than 20% prevalence of infection with any soil-transmitted helminths.

# Consistent with the 2016 WHO guideline (13).
This recommendation is consistent with the 2006 WHO guidelines (14). The dosing schedule depends on the previous tetanus vaccination exposure. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use.

# Recommendations integrated from other WHO guidelines that are relevant to ANC