Standards › Standard 12 › Policies
Policy · OBS-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: Standard 12 (Obstetrics and Gynaecology), criterion 12.1
At a glance
- Each pregnant woman has antenatal care on the WHO schedule, recorded on OBS-FRM-001.
- Results are reviewed at each visit, and risks are re-scored.
- A woman found to be high risk has a written plan and a named clinician.
- A missed visit is followed up within the set time.
- Stop and get help straight away if: a woman with a high-risk finding has no written plan, or antenatal checks are missed with no follow-up.
1. Purpose
To find and act on pregnancy problems early, on schedule (12.1).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Most problems in pregnancy can be found early if the checks happen on time. An antenatal schedule that follows current guidance, and is kept, catches the problems that a missed visit would hide.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Lead obstetrician or midwife | Owns the schedule and the risk plan | Clinician |
| Midwife | Runs visits and records results | Midwife |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Schedule.
- Book each visit on the schedule, and record it on OBS-FRM-001.
Key point: On schedule.
Step 2. Review.
- Review results and re-score risk at each visit.
Key point: Each visit.
Step 3. Follow up.
- Follow up each missed visit within the set time and write a plan for any high-risk woman.
Key point: Missed means followed up.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Visits completed on schedule | 90% | Monthly | Lead obstetrician or midwife | Escalate to medical director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| OBS-FRM-001 | Antenatal care record | Record |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the WHO recommendations on antenatal care for a positive pregnancy experience (2016) and the WHO Standards for improving quality of maternal and newborn care in health facilities (2016). |
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
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References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)