Alternative versus standard packages of antenatal care for low-risk pregnancy

Evaluation of antenatal care utilization and its effects on obstetric and newborn outcomes at a public and private hospital of Karnataka: A comparative study

BACKGROUND

Neonatal outcomes and perinatal mortality are directly and significantly impacted by the use of appropriate antenatal care (ANC) during pregnancy. The objective of this study is to evaluate the association between the use of prenatal services and maternal and newborn outcomes in both public and private healthcare settings.

MATERIALS AND METHODS

This study was carried out in two tertiary healthcare setups in Mangaluru, Karnataka: Government Lady Goschen Hospital (LGH) and Kasturba Medical College Hospital (KMCH) Attavar. Data were collected from 150 women who were a part of the study. Microsoft Excel was used to compile the data, and SPSS version 25 was used to analyze it.

RESULTS

We found that 58 out of 90 women admitted to LGH went for ANC check-ups at least four times during their gestation period and the rest of them went eight times or more, compared to just 3 out of the 60 women admitted at KMCH who went at least four times, whereas the rest went eight or more. The number of checks the mother takes appears to affect the term of the gestation with fewer preterm seen in patients who have come for a minimum of eight ANC visits, a higher risk of abnormal weight gain during pregnancy, and a lower risk of giving birth to preterm babies.

CONCLUSION

The study reveals that private healthcare setups offer more antenatal services, including hospital visits, routine testing, supplements, and doctor advice. The number of antenatal visits is a significant difference between public and private healthcare setups. The public setup requires a minimum of four antenatal care visits, while the updated 2016 version requires eight. The number of antenatal visits affects both mother's and neonatal outcomes. A higher number of visits leads to fewer preterm births and a higher risk of abnormal weight gain. Education also influences the frequency of antenatal visits. The study suggests increasing the frequency of prenatal care visits and improving public education on this matter.

Modelling Prenatal Care Pathways at a Central Hospital in Zimbabwe

Background:

Maternal mortality remains a problem in low-income countries (LICs). In Zimbabwe, there has been an unprecedented increase in maternal mortality in the last 2.5 decades. Effective prenatal care delivery, particularly early visits, appropriate number of visits, and receiving recommended care is viewed as key to reducing fatal care outcomes.

Aims:

This study sought to model and identify gaps requiring service and care delivery improvement in prenatal care pathways for pregnant women visiting Mpilo Central Hospital in Bulawayo, Zimbabwe.

Methods:

This was a case study of the services offered by an antenatal care department at Mpilo Central Hospital in Bulawayo, Zimbabwe. Evidence from literature in low-income countries was used to develop prenatal care pathway guidelines as a tool to guide care delivery and identify gaps in care and service delivery. One hundred cases of prenatal care records were reviewed to determine the prenatal care pathway and care delivered to pregnant women. This data was complemented by interviews with 20 maternity care clinicians.

Results:

In 100 maternity case records studied, 53% booked for prenatal care. Of the 53% (n = 53) pregnant women who booked, their first visit on their pregnancy was late at an average gestational age of 27.1 weeks with extremes of 30 to 40 weeks in 38% (n = 20) cases. Missing scheduled prenatal care appointments was prevalent, with only 11% (n = 6) having attended all the expected 5 visits, whilst 60% (n = 32) missed 3 or more. There were inadequacies in the care delivered to women in each visit compared to that expected in such areas as obstetrics, physical examinations and haematological tests. Maternity care clinicians attributed the cost of prenatal booking fees in the background of poverty and poor family support systems as key factors hindering women’s access to prenatal services.

Conclusions:

The current prenatal care pathway at MCH requires improvement in the areas of referral, adherence to appointment by pregnant women and visiting prenatal care early. Clinicians also need to adhere to standard clinical tests recommended for each specific pregnant woman’s visit. In the Zimbabwean setting with limited resources, where the number of visits is already low, pathways with reduced visits may not be appropriate. An investment into prenatal care by the government is recommended to enable the utilisation of interventions such as e-health technologies that may improve care delivery as well as adherence to best practices. E-health and mobile health technologies involving e-referrals, e-booking, decision support, and reminder systems are recommended for clinicians to manage and deliver appropriate care to patients as well as pregnant women to adhere to scheduled visits.

Factors affecting optimal antenatal care utilization in Indonesia: implications for policies and practices

Most maternal deaths are preventable with good antenatal care. The study aimed to examine factors relevant to optimal frequency of Antenatal Care (ANC) visits in Indonesia using the Indonesian Demographic and Health Survey 2017 data. Our study outcome was optimal numbers of ANC visits (≥ 8 visits). Predictors include age, had pregnancy termination, number of children, education level, employment status, awareness of pregnancy problems, wealth index, residence, region, health insurance coverage, and barriers to reach healthcare facilities. Of 3738 participants, about 60.2% had optimal number of ANC visits. There was an association between optimal ANC utilization and: experiencing pregnancy complications, distance to the healthcare facility, health insurance coverage, residence, region, awareness of pregnancy problems, and the number of children. Policymakers should improve healthcare facilities' availability, expand health insurance coverage, and educate women about the importance of ANC. This finding might be relevant in developing countries with similar health infrastructure situation.

Effect of knowledge acquisition on gravida's anxiety during COVID-19

Objectives

Pregnant women in China are among those most affected by COVID-19. This article assesses Chinese pregnant women’s COVID-19 and pregnancy knowledge levels, including the modality through which such knowledge was acquired, the degree of difficulty in acquiring the knowledge, the means of confirming the accuracy of the knowledge, and difficulties in seeking help from people who possess relevant medical knowledge.

Method

The Mantel-Haenszel chi-square test was used to assess trends in binomial proportions. Multivariable binary logistic regression was performed to identify the association between knowledge acquisition and anxiety among pregnant women.

Results

Low scores on knowledge about pregnancy, acquiring COVID-19 and pregnancy information through communication with others, verifying COVID-19 and pregnancy information either independently or via friends, and experiencing difficulties in seeking professional help regarding COVID-19 and pregnancy significantly increased anxiety among pregnant women.

Conclusions

Pregnant women’s anxiety can be effectively reduced through developing and disseminating targeted information, including how to cope in an emergency (such as a major disease outbreak), through popular and social media, along with the provision of convenient consultation services.

Assessing the effects of disasters and their aftermath on pregnancy and infant outcomes: A conceptual model

Although many studies have examined broad patterns of effects on pregnancy and infant outcomes after disasters, the causes of adverse outcomes are not always clear. Disasters cause interrelated exposure to environmental pollutants, psychological stressors, and lack of health care, and interacts with other social determinants of health. This topical review examines the short- and long-term effects of disasters on pregnancy and how they are mediated by social, behavioral, and environmental effects. In the short term, disasters are associated with physical trauma, adverse environmental exposures, and unstable housing. In the longer term, disasters may lead to relocation, changes in family functioning, and negative economic effects. These aspects of disaster exposure, in turn, lead to lack of access to health care, increased stress and negative mental health outcomes, and negative behavioral changes, including smoking and substance use, poor nutrition, physical overexertion and limited activity, and reduction in breastfeeding. All of these factors interact with social determinants of health to worsen effects on the most vulnerable women, infants, and communities. Few interventions after disasters have been tested. With the increase in disasters due to climate change and the ongoing coronavirus pandemic, the models of effects of disasters and their human health consequences need increasing refinement, and, more importantly, should be applied to interventions that improve disaster prevention, mitigation, and response.

Association between Prenatal Care Adequacy Indexes and Low Birth Weight Outcome

OBJECTIVE

 To investigate the association between prenatal care (PNC) adequacy indexes and the low birth weigth (LBW) outcome.

METHODS

 A total of 368,093 live term singleton births in the state of Rio de Janeiro (Brazil) from 2015 to 2016 were investigated using data from the Brazilian Live Birth Information System (Sistema de Informações sobre Nascidos Vivos, SINASC, in Portuguese). Seven PNC adequacy indexes were evaluated: four developed by Brazilian authors (Ciari Jr. et al., Coutinho et al., Takeda, and an index developed and used by the Brazilian Ministry of Health - MS) and three by authors from other countries (Kessner et al., the Adequacy of Prenatal Care Utilization index - APNCU, and the Graduated Prenatal Care Utilization Index - GINDEX). Adjusted odds ratios were estimated for the PNC adequacy indexes by means of multivariate logistic regression models using maternal, gestational and newborn characteristics as covariates.

RESULTS

 When the PNC is classified as "inadequate", the adjusted odds ratios to the LBW outcome increase between 42% and 132%, depending on which adequacy index is evaluated. Younger (15 to 17 years old) and older (35 to 45 years old) mothers, those not married, of black or brown ethnicity, with low schooling (who did not finish Elementary School), primiparous, with preterm births, as well as female newborns had increasing odds for LBW. The models presented areas under the receiver operating characteristic (ROC) curve between 80.4% and 81.0%, and sensitivity and specificity that varied, respectively, between 57.7% and 58.6% and 94.3% and 94.5%.

CONCLUSION

 Considering all PNC adequacy indexes evaluated, the APNCU had the best discriminatory power and the best ability to predict the LBW outcome.

The impact of antenatal care utilization on admissions to neonatal intensive care units and perinatal mortality in Georgia

Introduction

Appropriate antenatal care (ANC) utilization has direct, significant effects on perinatal mortality (PM). Georgia has one of the highest PM rates (11.7 per 1000 births) in Europe and launched a more intensive ANC programme in 2018.

Aim

To evaluate the associations between the Adequacy of Prenatal Care Utilization (APNCU) index and neonatal intensive care unit (NICU) admission and PM in Georgia.

Methods

The Georgian Birth Registry (GBR), with linkage to the Vital Registration System, was used as the main data source; 148,407 eligible mothers and singleton newborns were identified during the observation period (2017–2019). The main exposure was ANC utilization, measured by the APNCU index, and the hospitalization registry was used to validate NICU admissions. Logistic regression analysis was used to assess the associations between the exposure and outcomes while controlling for potential confounders.

Results

The overall PM rate was 11.6/1000 births, and the proportion of newborns with a NICU admission was 7.8%. 85% of women initiated ANC before gestational age week 12. According to the APNCU index, 16% of women received inadequate, 10% intermediate, 38% adequate, and 36% intensive care. Women who received intermediate care had the lowest odds of PM (adjusted odds ratio [AOR] = 0.56, 95% confidence interval [CI] 0.45–0.70), and newborns of women who received inadequate care had the highest odds of NICU admission (AOR = 1.16, 95% CI 1.09–1.23) and PM (AOR = 1.18, 95% CI 1.02–1.36).

Conclusion

ANC utilization is significantly associated with newborn asmissions to NICU and PM in Georgia. Women received inadequate care experienced the highest odds of newborn admissions to NICU and PM.

Comparative risks and predictors of preeclamptic pregnancy in the Eastern, Western and developing world

Preeclampsia (PE) is a complication of pregnancy characterized by hypertension (HTN-Preg), and often proteinuria. If not managed promptly, PE could lead to eclampsia and seizures. PE could also lead to intrauterine growth restriction (IUGR) and prematurity at birth. Although PE is a major cause of maternal and fetal morbidity and mortality, the underlying mechanisms are unclear. Also, there is a wide variability in the incidence of PE, ranging between 2 and 8% of pregnancies in the Eastern, Western and Developing world, suggesting regional differences in the risk factors and predictors of the pregnancy-related disorder. Several demographic, genetic, dietary and environmental factors, as well as maternal circulating biomarkers have been associated with PE. Demographic factors such as maternal race and ethnicity could play a role in PE. Specific genetic polymorphisms have been identified in PE. Maternal age, parity, education and socioeconomic status could be involved in PE. Dietary fat, protein, calcium and vitamins, body weight, and environmental factors including climate changes and air pollutants could also play a role in PE. Several circulating cytoactive factors including anti-angiogenic factors and cytokines have also been associated with PE. Traditional midwifery care is a common practice in local maternity care units, while advanced perinatal care and new diagnostic tools such as uterine artery Doppler velocimetry have been useful in predicting early PE in major medical centers. These PE risk factors, early predictors and diagnostic tools vary vastly in different regions of the Eastern, Western and Developing world. Further understanding of the differences in the demographic, genetic, dietary and environmental factors among pregnant women in different world regions should help in designing a region-specific cluster of risk factors and predictors of PE, and in turn provide better guidance for region-specific tools for early detection and management of PE.

From Midwife-Dominated to Midwifery-Led Antenatal Care: A Meta-Ethnography

Provision of antenatal care includes risk identification, prevention and management of pregnancy-related diseases, but also health education, health promotion, support and guidance to smooth the transition to parenthood. To ensure good perinatal health, high-quality, free and easily accessed antenatal care is essential. The aim of this study was to identify, integrate and synthesize knowledge of midwives' experiences of providing antenatal care, attending to clients' individual needs whilst facing multiple challenges. We conducted a meta-ethnography, which is a seven-step grounded, comparative and interpretative methodology for qualitative evidence synthesis. A lines-of-argument synthesis based on two metaphors was developed, based on refutational themes emerging from an analogous translation of findings in the included 14 papers. The model reflects midwives' wished-for transition from a midwife-dominated caring model toward a midwifery-led model of antenatal care. Structural, societal and personal challenges seemingly influenced midwives' provision of antenatal care. However, it emerged that midwives had the willingness to change rigid systems that maintain routine care. The midwifery-led model of care should be firmly based in midwifery science and evidence-based antenatal care that emphasize reflective practices and listening to each woman and her family. The change from traditional models of antenatal care towards increased use of digitalization no longer seems to be a choice, but a necessity given the ongoing 2020 pandemic.

Attitude and practices related to coronavirus disease (COVID-19) pandemic among pregnant women attending family welfare clinic amid Phase-2 lock down

BACKGROUND

The antenatal period is an important landmark where the services provided to mothers through antenatal care (ANC) checkups also act as a way for additional interventions influencing maternal and child health. This study aimed to know about the perception and practice among the patients of ANC checkups (ANCs) regarding COVID-19 and what are the implications of it on their routine check-ups.

METHODS

We conducted this study from 15 April, 2020 to 03 May, 2020, Phase 2 {Country wide lockdown in India}, which was imposed for over 19 days. The sample size was kept open and we used convenient type of sampling and included all those pregnant women who attended the clinic for ANC checkup amid the countrywide lock down. Each patient of ANC checkup was interviewed by the treating doctor using a predesigned structured questionnaire containing questions based on demographic information and the perception and practices regarding corona virus infection.

RESULTS

The majority, 66 (79.5%) were in the age group of 26-35 years, 63 (75.9%) were in the second and third trimester of their pregnancy, 72 (86.7%) were from urban areas, 26 (31.3%) and 17 (20.5%) were having education level of bachelor's and higher, respectively. The majority 39 (47%) reported that they are worried that someone they know may have the coronavirus infection and they are unaware about it, 57 (68.7%) feel the nature of the disease as fatal, all ANCs reported that their families are taking initiatives to prevent corona virus infection and they should take extra precautions for corona virus infection, 6 (7.2%) reported that any member of their family has been quarantined during the period, 81 (97.6%) feel that primary precautions like hand washing, social distancing, wearing a face mask, and isolation and quarantine will help in the reduction of infection, 69 (83.1%) choose to report to hospital if any of their close relatives are down with symptoms of corona virus.

CONCLUSION

Our study showed that the respondents had a good attitude, perception, and were following sensible positive practices regarding COVID-19 prevention.

Women's Empowerment as a Mitigating Factor for Improved Antenatal Care Quality despite Impact of 2014 Ebola Outbreak in Guinea

Improving maternal outcomes and reducing pregnancy morbidity and mortality are critical public health goals. The provision of quality antenatal care (ANC) is one method of doing so. Increasing women’s empowerment is associated with positive women’s health outcomes, including the adequate timing and amount of ANC use. However, little is known about the relationship between women’s empowerment and quality ANC care. Despite a history of political instability, low women’s equality and poor maternal health, the Republic of Guinea has committed to improving the status of women and access to health. However, the 2014 Ebola outbreak may have had a negative impact on achieving these goals. This study sought to examine factors in the relationship between women’s empowerment and the receipt of quality ANC (indicated by the number of health components) within the context of the Ebola outbreak. This study conducted multiple logistic regressions examining associations between covariates and the number of ANC components received using data from the 2012 and 2018 Guinea Demographic Health Surveys. Several aspects of women’s empowerment (healthcare decision-making, literacy/access to magazines, monogamous relationship status, contraceptive use, socio-economic status/employment) were significantly linked with the receipt of a greater number of ANC components, highlighting the importance of women’s empowerment in accessing quality maternity care.

Evaluating the effect of maternal mHealth text messages on uptake of maternal and child health care services in South Africa: a multicentre cohort intervention study

Background

There are high expectations that mobile health (mHealth) strategies will increase uptake of health care services, especially in resource strained settings. Our study aimed to evaluate effects of an mHealth intervention on uptake of maternal health services.

Methods

This was an intervention cohort study conducted at six public antenatal and postnatal care clinics in inner-city Johannesburg, South Africa. The intervention consisted of twice-weekly informative and pregnancy stage-based maternal health information text messages sent to women during pregnancy until their child was one year of age. The intervention arm of 87 mother-infant pairs was compared to a control arm of 90 pairs. Univariate and multivariate analyses were used to compare the probability of the outcome between the two groups.

Results

Intervention participants had higher odds of attending all government-recommended antenatal and postnatal visits, all recommended first year vaccinations (OR: 3.2, 95% CI 1.63–6.31) and had higher odds of attending at least the recommended four antenatal visits (OR: 3.21, 95% CI 1.73–5.98).

Conclusion

We show an improvement in achieving complete maternal-infant continuum of care, providing evidence of a positive impact of informative maternal mHealth messages sent to pregnant women and new mothers.

Trial registration ISRCTN, ISRCTN41772986. Registered 13 February 2019—Retrospectively registered, https://www.isrctn.com/ISRCTN41772986

Women's enlightenment and early antenatal care initiation are determining factors for the use of eight or more antenatal visits in Benin: further analysis of the Demographic and Health Survey

Background

Within the continuum of reproductive health care, antenatal care (ANC) provides a platform for vital health care functions, such as disease prevention, health promotion, screening, and diagnosis. It has been widely confirmed that by implementing appropriate evidence-based practices, ANC can save lives. Previous studies investigated the utilization of ANC based on the four visits model. The new guidelines set by the World Health Organization 2016 recommended increasing contacts with health providers from four to eight contacts. The present study aims to determine the frequency, determinants, and socioeconomic inequalities of ANC utilization based on the eight or more contacts in Benin. This will provide information for policy makers to improve ANC utilization.

Methods

We used a population-based cross-sectional data from Benin Demographic and Health Survey (BDHS)—2017–2018. The outcome variable considered for this study was coverage of ≥ 8 ANC contacts. About 1094 women of reproductive age who became pregnant after the new guideline of ≥ 8 ANC contacts was endorsed were included in this study. The determinants for ≥ 8 ANC contacts were measured using multivariable logistic regression. Concentration (Conc.) Index and Lorenz curves were used to estimate the socioeconomic inequalities of ≥ 8 ANC contacts. The level of significance was set at P < 0.05.

Results

The coverage of ≥ 8 ANC contacts was 8.0%; 95%CI 6.5%, 9.7%. The results of timing of antenatal care initiation showed that women who had late booking (after 1st trimester) had 97% reduction in ≥ 8 ANC contacts compared with women who initiated ANC contacts within the first trimester (adjusted odds ratio (AOR) = 0.03; 95% CI 0.00, 0.21). In addition, women with medium or high enlightenment were 4.55 and 5.49 as more likely to have ≥ 8 ANC contacts, compared with women having low enlightenment (AOR = 4.55; 95% CI 1.41, 14.69 and AOR = 5.49; 95% CI 1.77, 17.00, respectively). Conc. Index for the household wealth-related factor was 0.33; p < 0.001 for urban women and 0.37; p < 0.001 for the total sample. Similarly, Conc. Index for maternal education was 0.18; p = 0.006 for urban women and 0.21; p < 0.001 for the total sample.

Conclusion

Secondary analysis of the BDHS showed low coverage of ≥ 8 ANC contacts in Benin. In addition, women’s enlightenment, early ANC initiation, and socioeconomic inequalities determined the coverage of ≥ 8 ANC contacts. The findings bring to limelight the need to enhance women’s enlightenment through formal education, exposure to mass media, and other channels of behavior change communication. Health care programs which encourage early antenatal care initiation should be designed or strengthened to enhance the coverage of ANC contacts in Benin.

Unattended Pregnancies and Perinatal Mortality in Georgia

Introduction

The majority of pregnant women in Georgia attend the free-of-charge, national antenatal care (ANC) programme, but over 5% of pregnancies in the country are unattended. Moreover, Georgia has one of the highest perinatal mortality (PM) rates in Europe (11.7/1000 births).

Purpose

To assess the association between unattended pregnancies and the risk of PM.

Methods

Data were extracted from the Georgian Birth Registry (GBR) and the national vital registration system. All mothers who had singleton births and delivered in medical facilities in Georgia in 2017–2018 were included in the study and categorised into attended pregnancies (at least one ANC visit during pregnancy) and unattended pregnancies (no ANC visits during pregnancy). After exclusions, the study sample included 101,663 women and their newborns, of which 1186 were either stillborn or died within 7 days. Logistic regression analysis was used to assess the effect of unattended pregnancies on PM.

Results

During the study period, the PM rate was 12.9/1000 births. In total, 5.6% of women had unattended pregnancies. The odds of PM among women with unattended pregnancies were more than double those among women with attended pregnancies (odds ratio=2.21, [95% confidence interval: 1.81–2.70]). Multiparous women with higher education and who resided/delivered outside of Tbilisi were significantly less likely to experience PM.

Conclusion

The risk of PM doubled among women with unattended pregnancies. Six percent of PM cases were attributable to unattended pregnancies. Targeting women with previous unattended pregnancies will likely reduce the PM rate in Georgia.

Spatial distribution and determinants of an optimal ANC visit among pregnant women in Ethiopia: further analysis of 2016 Ethiopia demographic health survey

BACKGROUND

Antenatal care (ANC) is essential to improve maternal and newborn health and wellbeing. Antenatal care coverage is improving in Africa since over two-thirds of pregnant women have at least one ANC contact. However, to realize the complete life-saving potential that ANC guarantees for mothers and babies, at least four visits providing essential evidence-based interventions are required.. Therefore, this study was conducted to identify determinants of an optimal ANC visit and its spatial distribution in Ethiopia.

METHODS

This study is a secondary data analysis of the 2016 Ethiopian Demographic and Health Survey (EDHS). A total of 8025 women who had a live birth in the five years preceding the survey were included in this study. STATA 14 software and ArcGIS10.7 software were used for analysis. The generalized estimating equation (GEE) model was fitted to identify factors associated with an optimal ANC visit. Crude and Adjusted odds ratio with a 95% CI computed to assess the strength of association between explanatory and outcome variables.

RESULTS

This study revealed that rural residence (AOR = 0.59, 95%CI: 0.45-0.77),male partners educational status [secondary school (AOR = 1.33, 95%CI: 1.05-1.67)], distance to the health institutions [not a big problem (AOR = 1.21, 95%CI: 1.04-1.39)], community-level literacy (AOR = 1.07, 95%CI: 1.03-1.12), and community level service utilization (AOR = 2.67,95%CI:2.21-3.24) were significantly associated with optimal ANC visits. From the spatial analysis result, an Optimal ANC visit was observed in Addis Ababa, Tigray, Harari, and Dire Dawa regions whereas areas with no optimal ANC visit were Afar, Amhara, Oromia Benishangul, SNNP, and Somalia regions.

CONCLUSION

Living in peripheral regions of the country and in rural areas, lower educational status of male partners and distance to health institutions were prohibiting factors for an adequate number of visits. In this study, community-level literacy and community level service utilizations were were also affect womens' ANC utilization which implies community-level interventions should be considered for improving antenatal care utilization and better health outcomes. The government should give special attention to the regions like Afar, Amhara, Oromia, Benishangul, SNNP, and Somalia which had low optimal ANC visits.

Impacto de las condiciones sociodemográficas sobre el control prenatal en Latinoamérica

Introducción. El control prenatal corresponde a una estrategia encaminada a prevenir las posibles complicaciones del embarazo, el parto y el puerperio. Diversos estudios aislados se han realizado para identificar factores que pueden afectar de forma negativa el control prenatal.Objetivo. Realizar una síntesis cualitativa de la literatura respecto al impacto de las condiciones sociodemográficas sobre el control prenatal en Latinoamérica.Materiales y métodos. Se realizó una búsqueda de la literatura a junio de 2018 en las bases de datos EBSCO, Embase, ScienceDirect, LILACS, SciELO, Cochrane Library, MEDLINE-PubMed y Google Scholar, con los términos “prenatal care” AND “Health services accessibility” AND “Pregnancy, Health services accessibility” AND “Pregnancy, prenatal care” AND “Health services accessibility” y sin límite de tiempo.Resultados. Se encontraron 13 artículos con información relevante para el desarrollo de la presente revisión.Conclusiones. La literatura disponible sugiere que condiciones sociodemográficas desfavorables podrían incidir de manera negativa sobre el control prenatal. El cuidado del hogar, la atención de otros hijos, la afiliación al sistema de seguridad social, la obligación laboral y el desempleo parecen ser los principales factores que afectan la calidad del mismo.

A Mobile Prenatal Care App to Reduce In-Person Visits: Prospective Controlled Trial

Background

Risk-appropriate prenatal care has been asserted as a way for the cost-effective delivery of prenatal care. A virtual care model for prenatal care has the potential to provide patient-tailored, risk-appropriate prenatal educational content and may facilitate vital sign and weight monitoring between visits. Previous studies have demonstrated a safe reduction in the frequency of in-person prenatal care visits among low-risk patients but have noted a reduction in patient satisfaction.

Objective

The primary objective of this study was to test the effectiveness of a mobile prenatal care app to facilitate a reduced in-person visit schedule for low-risk pregnancies while maintaining patient and provider satisfaction.

Methods

This controlled trial compared a control group receiving usual care with an experimental group receiving usual prenatal care and using a mobile prenatal care app. The experimental group had a planned reduction in the frequency of in-person office visits, whereas the control group had the usual number of visits. The trial was conducted at 2 diverse outpatient obstetric (OB) practices that are part of a single academic center in Washington, DC, United States. Women were eligible for enrollment if they presented to care in the first trimester, were aged between 18 and 40 years, had a confirmed desired pregnancy, were not considered high-risk, and had an iOS or Android smartphone that they used regularly. We measured the effectiveness of a virtual care platform for prenatal care via the following measured outcomes: the number of in-person OB visits during pregnancy and patient satisfaction with prenatal care.

Results

A total of 88 patients were enrolled in the study, 47 in the experimental group and 41 in the control group. For patients in the experimental group, the average number of in-person OB visits during pregnancy was 7.8 and the average number in the control group was 10.2 (P=.01). There was no statistical difference in patient satisfaction (P>.05) or provider satisfaction (P>.05) in either group.

Conclusions

The use of a mobile prenatal care app was associated with reduced in-person visits, and there was no reduction in patient or provider satisfaction.

Trial Registration

ClinicalTrials.gov NCT02914301; https://clinicaltrials.gov/ct2/show/NCT02914301 (Archived by WebCite at http://www.webcitation.org/76S55M517)

Incremental cost and health gains of the 2016 WHO antenatal care recommendations for Rwanda: results from expert elicitation

OBJECTIVES

High-quality evidence of effectiveness and cost-effectiveness is rarely available and relevant for health policy decisions in low-resource settings. In such situations, innovative approaches are needed to generate locally relevant evidence. This study aims to inform decision-making on antenatal care (ANC) recommendations in Rwanda by estimating the incremental cost-effectiveness of the recent (2016) WHO antenatal care recommendations compared to current practice in Rwanda.

METHODS

Two health outcome scenarios (optimistic, pessimistic) in terms of expected maternal and perinatal mortality reduction were constructed using expert elicitation with gynaecologists/obstetricians currently practicing in Rwanda. Three costing scenarios were constructed from the societal perspective over a 1-year period. The two main inputs to the cost analyses were a Monte Carlo simulation of the distribution of ANC attendance for a hypothetical cohort of 373,679 women and unit cost estimation of the new recommendations using data from a recent primary costing study of current ANC practice in Rwanda. Results were reported in 2015 USD and compared with the 2015 Rwandan per-capita gross domestic product (US$ 697).

RESULTS

Incremental health gains were estimated as 162,509 life-years saved (LYS) in the optimistic scenario and 65,366 LYS in the pessimistic scenario. Incremental cost ranged between $5.8 and $11 million (an increase of 42% and 79%, respectively, compared to current practice) across the costing scenarios. In the optimistic outcome scenario, incremental cost per LYS ranged between $36 (for low ANC attendance) and $67 (high ANC attendance), while in the pessimistic outcome scenario, it ranged between $90 (low ANC attendance) and $168 (high ANC attendance) per LYS. Incremental cost effectiveness was below the GDP-based thresholds in all six scenarios.

DISCUSSION

Implementing the new WHO ANC recommendations in Rwanda would likely be very cost-effective; however, the additional resource requirements are substantial. This study demonstrates how expert elicitation combined with other data can provide an affordable source of locally relevant evidence for health policy decisions in low-resource settings.

Effective coverage of essential antenatal care interventions: A cross-sectional study of public primary healthcare clinics in the West Bank

BACKGROUND

The proportion of women attending four or more antenatal care (ANC) visits is widely used for monitoring, but provides limited information on quality of care. Effective coverage metrics, assessing if ANC interventions are completely delivered, can identify critical gaps in healthcare service delivery. We aimed to measure coverage of at least one screening and effective coverage of ANC interventions in the public health system in the West Bank, Palestine, and to explore associations between infrastructure-related and maternal sociodemographic variables and effective coverage.

METHODS

We used data from paper-based clinical records of 1369 pregnant women attending ANC in 17 primary healthcare clinics. Infrastructure-related variables were derived from a 2014 national inventory assessment of clinics. Sample size calculations were made to detect effective coverage ranging 40-60% with a 2-3% margin of error, clinics were selected by probability sampling. We calculated inverse probability weighted percentages of: effective coverage of appropriate number and timing of screenings of ANC interventions; and coverage of at least one screening.

RESULTS

Coverage of one screening and effective coverage of ANC interventions were notably different for screening for: hypertension (98% vs. 10%); fetal growth abnormalities (66% vs. 6%); anemia (93% vs. 14%); gestational diabetes (93% vs. 34%), and antenatal ultrasound (74% vs. 24%). Clinics with a laboratory and ultrasound generally performed better in terms of effective coverage, and maternal sociodemographic factors had no associations with effective coverage estimates. Only 13% of the women attended ANC visits according to the recommended national schedule, driving effective coverage down.

CONCLUSION

Indicators for ANC monitoring and their definitions can have important consequences for quantifying health system performance and identifying issues with care provision. To achieve more effective coverage in public primary care clinics in the West Bank, efforts should be made to improve care provision according to prescribed guidelines.

Percepción que tienen las gestantes sobre el cuidado de enfermería en la atención prenata

Introducción: Favorecer la adherencia al control prenatal es necesario para mejorar la salud materno-perinatal. El cuidado humano que ofrece enfermería es determinante. Objetivo: Describir la percepción de las mujeres gestantes frente a las competencias técnicas, cognitivas y la capacidad de los profesionales de enfermería de dar cuidado humanizado durante la atención prenatal. Método: Diseño descriptivo de corte trasversal, que empleó una muestra de 150 gestantes, abordadas de manera secuencial, seleccionadas por conveniencia, provenientes de cuatro centros de atención distintos, adscritos a un hospital de Bogotá, Colombia, durante el periodo junio-agosto de 2013. Se empleó la Escala de Cuidado Profesional fundada en la teoría El cuidado para el bienestar del otro, que permite identificar las habilidades técnicas y de cuidado humano. Resultados: El cuidado profesional fue calificado como excelente; sin embargo, existen elementos del cuidado humano que deben reconocerse. La habilidad para permitir la expresión de sentimientos, la escucha y la atención sin reproches o críticas a las condiciones particulares de las mujeres son valoradas de manera positiva y pueden modificar la percepción de la competencia cognitiva del profesional. Conclusiones: Estos atributos del cuidado humano pueden ser determinantes en la adherencia al control prenatal y su importancia debe ser reconocida por los profesionales sanitarios.

Determinants of frequency and contents of antenatal care visits in Bangladesh: Assessing the extent of compliance with the WHO recommendations

Background

In addition to the number of antenatal care (ANC) visits, the items of ANC services covered by ANC visits greatly influence the effectiveness of the ANC services. Recently the World Health Organization (WHO) recommended not only to achieve a minimum of eight ANC visits, but also to use a core set of items of ANC services for safe motherhood. This study examined the levels and determinants of frequency and contents of ANC visits in Bangladesh and thus assessed the level of compliance with the WHO recommended number and the content of ANC services during pregnancy in Bangladesh.

Methods

The data for the study come from the 2014 Bangladesh Demographic and Health Survey (BDHS), which covereda nationally representative sample of 17,863 ever-married women aged 15–49 years. Data derived from 4,627 mothers who gave birth in the three years preceding the survey constituted the study subjects. Descriptive, inferential and multivariate statistical techniques were used for data analysis.

Results

On average, mothers received less than three (2.7 visits) ANC visits and only 6% receive the recommended eight or more ANC visits. About 22% of the mothers received all the prescribed basic items of ANC services. About one-fifth (21%) of the mothers never received ANC visits and thus no items of ANC services. Measurement of blood pressure was the most common item received during ANC visit as reported by 69% mothers. Blood test was the least received item (43%). Significant positive association was found between frequency of ANC visits and receiving the increased number of items of ANC services. High socio-economic status, low parity, living in urban areas and certain administrative regions, planned pregnancies, having media exposure, visiting skilled providers for ANC services and visit to public or NGO health facilities are associated with frequent ANC visits and receiving higher number of items of ANC contents.

Conclusion

An unsatisfactory level of coverage of and content of ANC visits have been observed in Bangladesh. Further investigation is needed to identify the causes of under-utilization of ANC services in Bangladesh. A greater understanding of the identified risk factors and incorporating them into short and long term strategies would help improve the coverage and contents and thus quality of ANC services in Bangladesh.

Survival analysis of the association between antenatal care attendance and neonatal mortality in 57 low- and middle-income countries

Background

Neonatal mortality is unacceptably high in most low- and middle-income countries (LMICs). In these countries, where access to emergency obstetric services is limited, antenatal care (ANC) utilization offers improved maternal health and birth outcomes. However, evidence for this is scanty and mixed. We explored the association between attendance for ANC and survival of neonates in 57 LMICs.

Methods

Employing standardized protocols to ensure comparison across countries, we used nationally representative cross-sectional data from 57 LMICs (N = 464 728) to investigate the association between ANC visits and neonatal mortality. Cox proportional hazards multivariable regression models and meta-regression analysis were used to analyse pooled data from the countries. Kaplan-Meier survival curves were used to describe the patterns of neonatal survival in each region.

Results

After adjusting for potential confounding factors, we found 55% lower risk of neonatal mortality [hazard ratio (HR) 0.45, 95% confidence interval (CI) 0.42–0.48] among women who met both WHO recommendations for ANC (first visit within the first trimester and at least four visits during pregnancy) in pooled analysis. Furthermore, meta-analysis of country-level risk shows 32% lower risk of neonatal mortality (HR 0.68, 95% CI 0.61–0.75) among those who met at least one WHO recommendation. In addition, ANC attendance was associated with lower neonatal mortality in all the regions except in the Middle East and North Africa.

Conclusions

ANC attendance is protective against neonatal mortality in the LMICs studied, although differences exist across countries and regions. Increasing ANC visits, along with other known effective interventions, can improve neonatal survival in these countries.

Prevalence and factors associated with underutilization of antenatal care services in Nigeria: A comparative study of rural and urban residences based on the 2013 Nigeria demographic and health survey

INTRODUCTION

Antenatal care (ANC) is a major public health intervention aimed at ensuring safe pregnancy outcomes. In Nigeria, the recommended minimum of four times ANC attendance is underutilized. This study investigates the prevalence and factors associated with underutilization of ANC services with a focus on the differences between rural and urban residences in Nigeria.

METHODS

We analyzed the 2013 Nigeria Demographic and Health Survey dataset with adjustment for the sampling weight and the cluster design of the survey. The prevalence of underutilization of ANC was assessed using frequency tabulation while associated factors were examined using Chi-Square test and multivariable logistic regression analysis.

RESULTS

The prevalence of underutilization of ANC was 46.5% in Nigeria, 61.1% in rural residence and 22.4% in urban residence. The North-West region had the highest prevalence of ANC underuse in Nigeria at 69.3%, 76.6% and 44.8% for the overall, rural and urban residences respectively. Factors associated with greater odds of ANC underuse in rural residence were maternal non-working status, birth interval < 24 months, single birth type, not listening to radio at all, lack of companionship to health facility and not getting money for health services. In urban residence, mothers professing Islam, those who did not read newspaper at all, and those who lacked health insurance, had greater odds of ANC underuse. In both rural and urban residence, maternal and husband's education level, region of residence, wealth index, maternal age, frequency of watching television, distance to- and permission to visit health facility were significantly associated with ANC underuse.

CONCLUSIONS

Rural-urban differences exist in the use of ANC services, and to varying degrees, factors associated with underuse of ANC in Nigeria. Interventions aimed at addressing factors identified in this study may help to improve the utilization of ANC services both in rural and urban Nigeria. Such interventions need to focus more on reducing socioeconomic, geographic and regional disparities in access to ANC in Nigeria.

Health-related quality of life determinants among Rwandan women after delivery: does antenatal care utilization matter? A cross-sectional study

BACKGROUND

Despite the widespread use of antenatal care (ANC), its effectiveness in low-resource settings remains unclear. In this study, self-reported health-related quality of life (HRQoL) was used as an alternative to other maternal health measures previously used to measure the effectiveness of antenatal care. The main objective of this study was to determine whether adequate antenatal care utilization is positively associated with women's HRQoL. Furthermore, the associations between the HRQoL during the first year (1-13 months) after delivery and socio-economic and demographic factors were explored in Rwanda.

METHODS

In 2014, we performed a cross-sectional population-based survey involving 922 women who gave birth 1-13 months prior to the data collection. The study population was randomly selected from two provinces in Rwanda, and a structured questionnaire was used. HRQoL was measured using the EQ-5D-3L and a visual analogue scale (VAS). The average HRQoL scores were computed by demographic and socio-economic characteristics. The effect of adequate antenatal care utilization on HRQoL was tested by performing two multivariable linear regression models with the EQ-5D and EQ-VAS scores as the outcomes and ANC utilization and socio-economic and demographic variables as the predictors.

RESULTS

Adequate ANC utilization affected women's HRQoL when the outcome was measured using the EQ-VAS. Social support and living in a wealthy household were associated with a better HRQoL using both the EQ-VAS and EQ-5D. Cohabitating, and single/unmarried women exhibited significantly lower HRQoL scores than did married women in the EQ-VAS model, and women living in urban areas exhibited lower HRQoL scores than women living in rural areas in the ED-5D model. The effect of education on HRQoL was statistically significant using the EQ-VAS but was inconsistent across the educational categories. The women's age and the age of their last child were not associated with their HRQoL.

CONCLUSIONS

ANC attendance of at least four visits should be further promoted and used in low-income settings. Strategies to improve families' socio-economic conditions and promote social networks among women, particularly women at the reproductive age, are needed.

Beyond coverage: improving the quality of antenatal care delivery through integrated mentorship and quality improvement at health centers in rural Rwanda

BACKGROUND

Inadequate antenatal care (ANC) can lead to missed diagnosis of danger signs or delayed referral to emergency obstetrical care, contributing to maternal mortality. In developing countries, ANC quality is often limited by skill and knowledge gaps of the health workforce. In 2011, the Mentorship, Enhanced Supervision for Healthcare and Quality Improvement (MESH-QI) program was implemented to strengthen providers' ANC performance at 21 rural health centers in Rwanda. We evaluated the effect of MESH-QI on the completeness of danger sign assessments.

METHODS

Completeness of danger sign assessments was measured by expert nurse mentors using standardized observation checklists. Checklists completed from October 2010 to May 2011 (n = 330) were used as baseline measurement and checklists completed between February and November 2012 (12-15 months after the start of MESH-QI implementation) were used for follow-up. We used a mixed-effects linear regression model to assess the effect of the MESH-QI intervention on the danger sign assessment score, controlling for potential confounders and the clustering of effect at the health center level.

RESULTS

Complete assessment of all danger signs improved from 2.1% at baseline to 84.2% after MESH-QI (p <  0.001). Similar improvements were found for 20 of 23 other essential ANC screening items. After controlling for potential confounders, the improvement in danger sign assessment score was significant. However, the effect of the MESH-QI was different by intervention district and type of observed ANC visit. In Southern Kayonza District, the increase in the danger sign assessment score was 6.28 (95% CI: 5.59, 6.98) for non-first ANC visits and 5.39 (95% CI: 4.62, 6.15) for first ANC visits. In Kirehe District, the increase in danger sign assessment score was 4.20 (95% CI: 3.59, 4.80) for non-first ANC visits and 3.30 (95% CI: 2.80, 3.81) for first ANC visits.

CONCLUSION

Assessment of critical danger signs improved under MESH-QI, even when controlling for nurse-mentees' education level and previous training in focused ANC. MESH-QI offers an approach to enhance quality of care after traditional training and may be an approach to support newer providers who have not yet attended content-focused courses.

Is the effectiveness of memory assessment services associated with their structural and process characteristics?

OBJECTIVES

The aim of this study was to investigate whether structural and process characteristics of memory assessment services (MASs) are associated with outcomes (changes in patients' health-related quality of life (HRQL), carers' HRQL and carers' burden) over the first 6 months following the first appointment.

METHODS

Data from 785 patients referred to 69 MASs and 511 of their lay carers, collected at the first appointment and 6 months later. Data on MAS characteristics were collected using a questionnaire at baseline. We used multilevel linear regression models to explore the associations of patients' HRQL and carers' outcomes with structural and process characteristics of MASs. Analyses were conducted on the full sample of patients and carers, and separately on those patients diagnosed with dementia.

RESULTS

None of the structural (skill mix, workload, volume, provision of clinical assessments and provision of psychosocial support) or process (waiting time, length and number of appointments, anti-dementia drug use and psychosocial interventions use) characteristics included in the analyses were associated with patients' or carers' outcomes at 6 months, apart from the presence of allied health professionals (AHPs), which was associated with a DEMQOL score 2.7 points higher. When only those with a diagnosis of dementia were considered, the association with presence of AHPs was no longer observed.

CONCLUSIONS

Apart from involving AHPs, alterations to the way MASs are structured or function appear unlikely to improve their effectiveness in improving patients' and carers' HRQL. It is possible that the characteristics of MASs may influence patients' and carers' experience, but this was not studied. Copyright © 2017 John Wiley & Sons, Ltd.

Antenatal care and opportunities for quality improvement of service provision in resource limited settings: A mixed methods study

Antenatal care is essential to improve maternal and newborn health and wellbeing. The majority of pregnant women in Tanzania attend at least one visit. Since implementation of the focused antenatal care model, quality of care assessments have mostly focused on utilization and coverage of routine interventions for antenatal care. This study aims to assess the quality of antenatal care provision from a holistic perspective in a rural district in Tanzania. Structure, process and outcome components of quality are explored. This paper reports on data collected over several periods from 2012 to 2015 through facility audits of supplies and services, ANC observations and exit interviews with pregnant women. Additional qualitative methods were used such as interviews, focus group observations and participant observations. Findings indicate variable performance of routine ANC services, partly explained by insufficient resources. Poor performance was also observed for appropriate history taking, attention for client's wellbeing, basic physical examination and adequate counseling and education. Achieving quality improvement for ANC requires increased attention for the process of care provision beyond coverage, including attention for response-based services, which should be assessed based on locally determined criteria.

Predictors of prenatal care satisfaction among pregnant women in American Samoa

Background

Pregnant women in American Samoa have a high risk of complications due to overweight and obesity. Prenatal care can mitigate the risk, however many women do not seek adequate care during pregnancy. Low utilization of prenatal care may stem from low levels of satisfaction with services offered. Our objective was to identify predictors of prenatal care satisfaction in American Samoa.

Methods

A structured survey was distributed to 165 pregnant women receiving prenatal care at the Lyndon B Johnson Tropical Medical Center, Pago Pago. Women self-reported demographic characteristics, pregnancy history, and satisfaction with prenatal care. Domains of satisfaction were extracted using principal components analysis. Scores were summed across each domain. Linear regression was used to examine associations between maternal characteristics and the summed scores within individual domains and for overall satisfaction.

Result

Three domains of satisfaction were identified: satisfaction with clinic services, clinic accessibility, and physician interactions. Waiting ≥ 2 h to see the doctor negatively impacted satisfaction with clinic services, clinic accessibility, and overall satisfaction. Living > 20 min from the clinic was associated with lower clinic accessibility, physician interactions, and overall satisfaction. Women who were employed/on maternity leave had lower scores for physician interactions compared with unemployed women/students. Women who did not attend all their appointments had lower overall satisfaction scores.

Conclusions

Satisfaction with clinic services, clinic accessibility and physician interactions are important contributors to prenatal care satisfaction. To improve patient satisfaction prenatal care clinics should focus on making it easier for women to reach clinics, improving waiting times, and increasing time with providers.

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1563-6) contains supplementary material, which is available to authorized users.

Survival analysis of the association between antenatal care attendance and neonatal mortality in 57 low- and middle-income countries

Background

Neonatal mortality is unacceptably high in most low- and middle-income countries (LMICs). In these countries, where access to emergency obstetric services is limited, antenatal care (ANC) utilization offers improved maternal health and birth outcomes. However, evidence for this is scanty and mixed. We explored the association between attendance for ANC and survival of neonates in 57 LMICs.

Methods

Employing standardized protocols to ensure comparison across countries, we used nationally representative cross-sectional data from 57 LMICs (N = 464 728) to investigate the association between ANC visits and neonatal mortality. Cox proportional hazards multivariable regression models and meta-regression analysis were used to analyse pooled data from the countries. Kaplan-Meier survival curves were used to describe the patterns of neonatal survival in each region.

Results

After adjusting for potential confounding factors, we found 55% lower risk of neonatal mortality [hazard ratio (HR) 0.45, 95% confidence interval (CI) 0.42-0.48] among women who met both WHO recommendations for ANC (first visit within the first trimester and at least four visits during pregnancy) in pooled analysis. Furthermore, meta-analysis of country-level risk shows 32% lower risk of neonatal mortality (HR 0.68, 95% CI 0.61-0.75) among those who met at least one WHO recommendation. In addition, ANC attendance was associated with lower neonatal mortality in all the regions except in the Middle East and North Africa.

Conclusions

ANC attendance is protective against neonatal mortality in the LMICs studied, although differences exist across countries and regions. Increasing ANC visits, along with other known effective interventions, can improve neonatal survival in these countries.

Delivery arrangements for health systems in low-income countries: an overview of systematic reviews

BACKGROUND

Delivery arrangements include changes in who receives care and when, who provides care, the working conditions of those who provide care, coordination of care amongst different providers, where care is provided, the use of information and communication technology to deliver care, and quality and safety systems. How services are delivered can have impacts on the effectiveness, efficiency and equity of health systems. This broad overview of the findings of systematic reviews can help policymakers and other stakeholders identify strategies for addressing problems and improve the delivery of services.

OBJECTIVES

To provide an overview of the available evidence from up-to-date systematic reviews about the effects of delivery arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on delivery arrangements and informing refinements of the framework for delivery arrangements outlined in the review.

METHODS

We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of delivery arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use, healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty or employment) and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the findings. Two overview authors independently screened reviews, extracted data, and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence), and assessments of the relevance of findings to low-income countries.

MAIN RESULTS

We identified 7272 systematic reviews and included 51 of them in this overview. We judged 6 of the 51 reviews to have important methodological limitations and the other 45 to have only minor limitations. We grouped delivery arrangements into eight categories. Some reviews provided more than one comparison and were in more than one category. Across these categories, the following intervention were effective; that is, they have desirable effects on at least one outcome with moderate- or high-certainty evidence and no moderate- or high-certainty evidence of undesirable effects. Who receives care and when: queuing strategies and antenatal care to groups of mothers. Who provides care: lay health workers for caring for people with hypertension, lay health workers to deliver care for mothers and children or infectious diseases, lay health workers to deliver community-based neonatal care packages, midlevel health professionals for abortion care, social support to pregnant women at risk, midwife-led care for childbearing women, non-specialist providers in mental health and neurology, and physician-nurse substitution. Coordination of care: hospital clinical pathways, case management for people living with HIV and AIDS, interactive communication between primary care doctors and specialists, hospital discharge planning, adding a service to an existing service and integrating delivery models, referral from primary to secondary care, physician-led versus nurse-led triage in emergency departments, and team midwifery. Where care is provided: high-volume institutions, home-based care (with or without multidisciplinary team) for people living with HIV and AIDS, home-based management of malaria, home care for children with acute physical conditions, community-based interventions for childhood diarrhoea and pneumonia, out-of-facility HIV and reproductive health services for youth, and decentralised HIV care. Information and communication technology: mobile phone messaging for patients with long-term illnesses, mobile phone messaging reminders for attendance at healthcare appointments, mobile phone messaging to promote adherence to antiretroviral therapy, women carrying their own case notes in pregnancy, interventions to improve childhood vaccination. Quality and safety systems: decision support with clinical information systems for people living with HIV/AIDS. Complex interventions (cutting across delivery categories and other health system arrangements): emergency obstetric referral interventions.

AUTHORS' CONCLUSIONS

A wide range of strategies have been evaluated for improving delivery arrangements in low-income countries, using sound systematic review methods in both Cochrane and non-Cochrane reviews. These reviews have assessed a range of outcomes. Most of the available evidence focuses on who provides care, where care is provided and coordination of care. For all the main categories of delivery arrangements, we identified gaps in primary research related to uncertainty about the applicability of the evidence to low-income countries, low- or very low-certainty evidence or a lack of studies.

Household food insecurity is independently associated with poor utilization of maternal healthcare services in Bangladesh

Introduction: Food insecurity at the individual level has been shown to be associated with the adoption of risky behavior and poor healthcare-seeking behavior. However, the impact of household food insecurity (HFI) on the utilization of maternal healthcare services (MHS) remains unexplored. In this study, we aimed to investigate whether or not household food insecurity was associated with non/inadequate utilization of MHS.

Methods: Participants consisted of 3562 mothers aged between 15 and 49 years and with at least one child. The outcome variable was the utilization of MHS, e.g., institutional delivery, attendance ante-, and pre-natal visits. The explanatory variables included various sociodemographic factors (e.g., age, residence, education, wealth) apart from HFI. HFI was measured using the Household Food Insecurity Access Scale (HFIAS).

Result: The prevalence of non- and under-utilization of MHS was 5.3 and 36.5, respectively. In the multivariate analysis, HFI, wealth index, and educational level were independently associated with MHS status. The odds of non- and under-utilization of MHS were 3.467 (CI = 1.058–11.354) and 4.104 (CI = 1.794–9.388) times higher, respectively, among women from households reporting severe food insecurity.

Conclusion: Severe HFI was significantly associated with both under- and non-utilization of MHS. Interventions programs that address HFI and the empowerment of women can potentially contribute to an increased utilization of MHS.

Patient Satisfaction with Virtual Obstetric Care

Introduction The importance of patient satisfaction in US healthcare is increasing, in tandem with the advent of new patient care modalities, including virtual care. The purpose of this study was to compare the satisfaction of obstetric patients who received one-third of their antenatal visits in videoconference ("Virtual-care") compared to those who received 12-14 face-to-face visits in-clinic with their physician/midwife ("Traditional-care"). Methods We developed a four-domain satisfaction questionnaire; Virtual-care patients were asked additional questions about technology. Using a modified Dillman method, satisfaction surveys were sent to Virtual-care (N = 378) and Traditional-care (N = 795) patients who received obstetric services at our institution between January 2013 and June 2015. Chi-squared tests of association, t-tests, logistic regression, and ANOVA models were used to evaluate differences in satisfaction and self-reported demographics between respondents. Results Overall satisfaction was significantly higher in the Virtual-care cohort (4.76 ± 0.44 vs. 4.47 ± 0.59; p < .001). Parity ≥ 1 was the sole significant demographic variable impacting Virtual-care selection (OR = 2.4, 95% CI: 1.5-3.8; p < .001). Satisfaction of Virtual-care respondents was not significantly impacted by the incorporation of videoconferencing, Doppler, and blood pressure monitoring technology into their care. The questionnaire demonstrated high internal consistency as measured by domain-based correlations and Cronbach's alpha. Discussion Respondents from both models were highly satisfied with care, but those who had selected the Virtual-care model reported significantly higher mean satisfaction scores. The Virtual-care model was selected by significantly more women who already have children than those experiencing pregnancy for the first time. This model of care may be a reasonable alternative to traditional care.

Antenatal care trial interventions: a systematic scoping review and taxonomy development of care models

BACKGROUND

Antenatal care models vary widely around the world, reflecting local contexts, drivers and resources. Randomised controlled trials (RCTs) have tested the impact of multi-component antenatal care interventions on service delivery and outcomes in many countries since the 1980s. Some have applied entirely new schemes, while others have modified existing care delivery approaches. Systematic reviews (SRs) indicate that some specific antenatal interventions are more effective than others; however the causal mechanisms leading to better outcomes are poorly understood, limiting implementation and future research. As a first step in identifying what might be making the difference we conducted a scoping review of interventions tested in RCTs in order to establish a taxonomy of antenatal care models.

METHODS

A protocol-driven systematic search was undertaken of databases for RCTs and SRs reporting antenatal care interventions. Results were unrestricted by time or locality, but limited to English language. Key characteristics of both experimental and control interventions in the included trials were mapped using SPIO (Study design; Population; Intervention; Outcomes) criteria and the intervention and principal outcome measures were described. Commonalities and differences between the components that were being tested in each study were identified by consensus, resulting in a comprehensive description of emergent models for antenatal care interventions.

RESULTS

Of 13,050 articles retrieved, we identified 153 eligible articles including 130 RCTs in 34 countries. The interventions tested in these trials varied from the number of visits to the location of care provision, and from the content of care to the professional/lay group providing that care. In most studies neither intervention nor control arm was well described. Our analysis of the identified trials of antenatal care interventions produced the following taxonomy: Universal provision model (for all women irrespective of health state or complications); Restricted 'lower-risk'-based provision model (midwifery-led or reduced/flexible visit approach for healthy women); Augmented provision model (antenatal care as in Universal provision above but augmented by clinical, educational or behavioural intervention); Targeted 'higher-risk'-based provision model (for woman with defined clinical or socio-demographic risk factors). The first category was most commonly tested in low-income countries (i.e. resource-poor settings), particularly in Asia. The other categories were tested around the world. The trials included a range of care providers, including midwives, nurses, doctors, and lay workers.

CONCLUSIONS

Interventions can be defined and described in many ways. The intended antenatal care population group proved the simplest and most clinically relevant way of distinguishing trials which might otherwise be categorised together. Since our review excluded non-trial interventions, the taxonomy does not represent antenatal care provision worldwide. It offers a stable and reproducible approach to describing the purpose and content of models of antenatal care which have been tested in a trial. It highlights a lack of reported detail of trial interventions and usual care processes. It provides a baseline for future work to examine and test the salient characteristics of the most effective models, and could also help decision-makers and service planners in planning implementation.

PRIMARY CARE SENSITIVE ADMISSIONS IN PREGNANT WOMEN: ASSOCIATED FACTORS BASED ON THE PRENATAL CARE PROCESS

ABSTRACT Objective: to analyze admissions for primary care sensitive conditions among pregnant women, and the associated factors, based on the process of prenatal care, in a city of the center-west of the Brazilian State of Paraná (Brazil). Method: this is an inquiry into hospital morbidity undertaken with a sample of 86 pregnant women admitted to hospitals serving the Unified Health System. Results: the percentage of admissions was 70.97% (n=59), with emphasis placed on admissions specifically during the period of pregnancy (51.17%), among which, admissions due to infections in the genitourinary tract were the most frequent. The following were associated with the risk of admission due to a sensitive condition: incomplete records in the woman’s ‘pregnancy card’ (cartão da gestante), delayed initiation of prenatal care (after the second trimester), insufficient number of consultations and insufficient care during the consultation. Conclusion: the results suggest that a minimumlevel of care for these pregnant women would reduce the risk of unnecessary admission, evidencing that the quality of care provided during the prenatal period in this region is inadequate.

'First 1000 days' health interventions in low- and middle-income countries: alignment of South African policies with high-quality evidence

BACKGROUND

In South Africa (SA), despite adoption of international strategies and approaches, maternal, neonatal and child (MNC) morbidity and mortality rates have not sufficiently declined.

OBJECTIVES

To conduct an umbrella review (UR) that identifies interventions in low- and middle-income countries, with a high-quality evidence base, that improve MNC morbidity and mortality outcomes within the first 1000 days of life; and to assess the incorporation of the evidence into local strategies, guidelines and documents.

METHODS

We included publications about women and children in the first 1000 days of life; healthcare professionals and community members. Comparators were those who did not receive the intervention. Interventions were pharmacological and non-pharmacological. Outcomes were MNC morbidity and mortality. Authors conducted English language electronic and manual searches (2000-2013). The quality of systematic reviews and meta-analyses (SRs/MAs) were reviewed. Interventions were ranked according to level of evidence; and then aligned with SA strategies, policies and guidelines. A tool to extract data was developed and used by two authors who independently extracted data. Summary measures from MAs or summaries of SRs were reviewed and the specificities of the various interventions listed. A search of all local high-level documents was done and these were assessed to determine the specificities of the recommendations and their alignment to the evidence.

RESULTS

In total, 19 interventions presented in 32 SRs were identified. Overall, SA's policymakers have sufficiently included high-quality evidence-based interventions into local policies. However, optimal period of birth spacing (two to five years) is not explicitly promoted nor was ante- and postnatal depression adequately incorporated. Antenatal care visits should be increased from four to about eight according to the evidence.

CONCLUSION

Incorporation of existing evidence into policies can be strengthened in SA. The UR methods are useful to inform policymaking and identify research gaps. RESPONSIBLE EDITOR Nawi Ng, Umeå University, Sweden.

Prenatal visit utilization and outcomes in pregnant women with type II and gestational diabetes

OBJECTIVE

To investigate the association between the number of prenatal visits (PNVs) and pregnancy outcomes in women with gestational diabetes (GDM) and Type 2 diabetes mellitus (DM).

STUDY DESIGN

A 4-year prospective cohort study of women with GDM and DM and was conducted. Patients ⩾75th percentile for number of PNVs were compared with those ⩽25th percentile. The primary outcomes were large for gestational age (LGA) with birth weight >90% and neonatal intensive care unit (NICU) admission for >24 h. Secondary neonatal outcomes included severe LGA (>95%), shoulder dystocia, hyperbilirubinemia requiring phototherapy, neonatal hypoglycemia, low 5 min APGAR score (<7) and preterm birth (prior to 37 weeks). Secondary maternal outcomes included mean third trimester fasting blood glucose, hemoglobin A1c (Hgb A1c) in labor, preeclampsia, gestational weight gain over Institute of Medicine recommendations, mode of delivery and maternal readmission within 30 days. Logistic regression was used to adjust for maternal race, nulliparity and body mass index.

RESULTS

Of the 305 women, 4 were excluded for unknown number of PNVs. Among the 301 included, the average number of visits was 12. Rates of LGA were similar between the high (28%) compared with low (18%) utilization groups (adjusted odds ratio (aOR) 1.69; 95% confidence interval (CI) 0.81-3.54). The high utilization group was 85% less likely to deliver an infant requiring NICU admission (aOR 0.15; 95% CI 0.04-0.53) and 59% less likely to have a preterm birth (aOR 0.41; 95% CI 0.21-0.80). A time-to-event analysis to account for the fact that patients who delivered earlier had fewer weeks to experience PNVs showed that the risk for NICU admission was still significantly lower in the high PNV utilization group (hazard ratio 0.15; 95% CI 0.04-0.51) after adjusting for confounders in a Cox proportional hazard model. The mean Hgb A1c at the time of delivery was significantly better in the high (6.4%) compared with low (6.9%) utilization groups (P=0.01). There were no differences in other maternal outcomes based on prenatal care utilization.

CONCLUSIONS

Diabetic women with high PNV utilization have better glycemic control in the 3 months prior to delivery and are significantly less likely to deliver preterm infants or infants requiring NICU admission. There may be innovative ways to provide prenatal care for GDM and DM to optimize maternal and neonatal outcomes.

Midwifery-led antenatal care models: mapping a systematic review to an evidence-based quality framework to identify key components and characteristics of care

BACKGROUND

Implementing effective antenatal care models is a key global policy goal. However, the mechanisms of action of these multi-faceted models that would allow widespread implementation are seldom examined and poorly understood. In existing care model analyses there is little distinction between what is done, how it is done, and who does it. A new evidence-informed quality maternal and newborn care (QMNC) framework identifies key characteristics of quality care. This offers the opportunity to identify systematically the characteristics of care delivery that may be generalizable across contexts, thereby enhancing implementation. Our objective was to map the characteristics of antenatal care models tested in Randomised Controlled Trials (RCTs) to a new evidence-based framework for quality maternal and newborn care; thus facilitating the identification of characteristics of effective care.

METHODS

A systematic review of RCTs of midwifery-led antenatal care models. Mapping and evaluation of these models' characteristics to the QMNC framework using data extraction and scoring forms derived from the five framework components. Paired team members independently extracted data and conducted quality assessment using the QMNC framework and standard RCT criteria.

RESULTS

From 13,050 citations initially retrieved we identified 17 RCTs of midwifery-led antenatal care models from Australia (7), the UK (4), China (2), and Sweden, Ireland, Mexico and Canada (1 each). QMNC framework scores ranged from 9 to 25 (possible range 0-32), with most models reporting fewer than half the characteristics associated with quality maternity care. Description of care model characteristics was lacking in many studies, but was better reported for the intervention arms. Organisation of care was the best-described component. Underlying values and philosophy of care were poorly reported.

CONCLUSIONS

The QMNC framework facilitates assessment of the characteristics of antenatal care models. It is vital to understand all the characteristics of multi-faceted interventions such as care models; not only what is done but why it is done, by whom, and how this differed from the standard care package. By applying the QMNC framework we have established a foundation for future reports of intervention studies so that the characteristics of individual models can be evaluated, and the impact of any differences appraised.

Patterns and determinants of antenatal care utilization: analysis of national survey data in seven countdown countries

BACKGROUND

Antenatal care (ANC) is critical for improving maternal and newborn health. WHO recommends that pregnant women complete at least four ANC visits. Countdown and other global monitoring efforts track the proportions of women who receive one or more visits by a skilled provider (ANC1+) and four or more visits by any provider (ANC4+). This study investigates patterns of drop-off in use between ANC1+ and ANC4+, and explores inequalities in women's use of ANC services. It also identifies determinants of utilization and describes countries' ANC-related policies, and programs.

METHODS

We performed secondary analyses using Demographic Health Survey (DHS) data from seven Countdown countries: Bangladesh, Cambodia, Cameroon, Nepal, Peru, Senegal and Uganda. The descriptive analysis illustrates country variations in the frequency of visits by provider type, content, and by household wealth, women's education and type of residence. We conducted a multivariable analysis using a conceptual framework to identify determinants of ANC utilization. We collected contextual information from countries through a standard questionnaire completed by country-based informants.

RESULTS

Each country had a unique pattern of ANC utilization in terms of coverage, inequality and the extent to which predictors affected the frequency of visits. Nevertheless, common patterns arise. Women having four or more visits usually saw a skilled provider at least once, and received more evidence-based content interventions than women reporting fewer than four visits. A considerable proportion of women reporting four or more visits did not report receiving the essential interventions. Large disparities exist in ANC use by household wealth, women's education and residence area; and are wider for a larger number of visits. The multivariable analyses of two models in each country showed that determinants had different effects on the dependent variable in each model. Overall, strong predictors of ANC initiation and having a higher frequency (4+) of visits were woman's education and household wealth. Gestational age at first visit, birth rank and preceding birth interval were generally negatively associated with initiating visits and with having four or more visits. Information on country policies and programs were somewhat informative in understanding the utilization patterns across the countries, although timing of adoption and actual implementation make direct linkages impossible to verify.

CONCLUSION

Secondary analyses provided a more detailed picture of ANC utilization patterns in the seven countries. While coverage levels differ by country and sub-groups, all countries can benefit from specific in-country assessments to properly identify the underserved women and the reasons behind low coverage and missed interventions. Overall, emphasis needs to be put on assessing the quality of care offered and identifying women's perception to the care as well as the barriers hindering utilization. Country policies and programs need to be reviewed, evaluated and/or implemented properly to ensure that women receive the recommended number of ANC visits with appropriate content, especially, poor and less educated women residing in rural areas.

Improving Access to Antenatal Care for Aboriginal Women in South Australia: Evidence from a Population-Based Study

INTRODUCTION

Aboriginal and Torres Strait Islander women are two to three times more likely to experience adverse maternal and perinatal outcomes than non-Aboriginal women in Australia. Persisting health inequalities are at least in part explained by late and/or inadequate access to antenatal care.

METHODS

This study draws on data collected in a population-based study of 344 women giving birth to an Aboriginal infant between July 2011 and June 2013 in South Australia to investigate factors associated with engagement in antenatal care.

RESULTS

About 79.8 percent of mothers accessed antenatal care in the first trimester of pregnancy, and 90 percent attended five or more antenatal visits. Compared with women attending mainstream regional services, women attending regional Aboriginal Family Birthing Program services were more likely to access antenatal care in the first trimester (Adj OR 2.5 [1.0-6.3]) and markedly more likely to attend a minimum of five visits (Adj OR 4.3 [1.2-15.1]). Women attending metropolitan Aboriginal Family Birthing Program services were also more likely to attend a minimum of five visits (Adj OR 12.2 [1.8-80.8]) compared with women attending mainstream regional services. Women who smoked during pregnancy were less likely to attend a visit in the first trimester and had fewer visits.

CONCLUSIONS

Scaling up of Aboriginal Family Birthing Program Services in urban and regional areas of South Australia has increased access to antenatal care for Aboriginal families. The involvement of Aboriginal Maternal Infant Care workers, provision of transport for women to get to services, and outreach have been critical to the success of this program.

Strategies for improving health care seeking for maternal and newborn illnesses in low- and middle-income countries: a systematic review and meta-analysis

BACKGROUND

Lack of appropriate health care seeking for ill mothers and neonates contributes to high mortality rates. A major challenge is the appropriate mix of strategies for creating demand as well as provision of services.

DESIGN

Systematic review and meta-analysis of experimental studies (last search: Jan 2015) to assess the impact of different strategies to improve maternal and neonatal health care seeking in low- and middle-income countries (LMIC).

RESULTS

Fifty-eight experimental [randomized controlled trials (RCTs), non-RCTs, and before-after studies] with 310,652 participants met the inclusion criteria. Meta-analyses from 29 RCTs with a range of different interventions (e.g. mobilization, home visitation) indicated significant improvement in health care seeking for neonatal illnesses when compared with standard/no care [risk ratio (RR) 1.40; 95 confidence interval (CI): 1.17-1.68, 9 studies, n=30,572], whereas, no impact was seen on health care seeking for maternal illnesses (RR 1.06; 95% CI: 0.92-1.22, 5 studies, n=15,828). These interventions had a significant impact on reducing stillbirths (RR 0.82; 95% CI: 0.73-0.93, 11 studies, n=176,683), perinatal deaths (RR 0.84; 95% CI: 0.77-0.90, 15 studies, n=279,618), and neonatal mortality (RR 0.80; 95% CI: 0.72-0.89, 20 studies, n=248,848). On GRADE approach, evidence was high quality except for the outcome of maternal health care seeking, which was moderate.

CONCLUSIONS

Community-based interventions integrating strategies such as home visiting and counseling can help to reduce fetal and neonatal mortality in LMIC.

Antenatal Care Utilisation and Content between Low-Risk and High-Risk Pregnant Women

BACKGROUND

The purpose of antenatal care is to monitor and improve the wellbeing of the mother and foetus. The World Health Organization recommends risk-oriented strategy that includes: (i) routine care to all women, (ii) additional care for women with moderately severe diseases and complications, (iii) specialised obstetrical and neonatal care for women with severe diseases and complications. Antenatal care is concerned with adequate care in order to be effective. Measurement for adequacy of antenatal care often applies indexes that assess initiation of care and number of visits. In addition, adequacy of care content should also be assessed. Results of studies in developed settings demonstrate that women without risk factors use antenatal services more frequently than recommended. Such over-utilisation is problematic for low-resourced settings. Moreover, studies show that a substantial proportion of high-risk women had utilisation or content of care below the recommended standard. Yet studies in developing countries have seldom included a comparison between low-risk and high-risk women. The purpose of the study was therefore to assess adequacy of care and pregnancy outcomes for the different risk groups.

METHODS

A retrospective study using a multistage sampling technique, at public-funded primary health care clinics was conducted. Antenatal utilisation level was assessed using a modified Adequacy of Prenatal Care Utilisation index that measures the timing for initiation of care and observed-to-expected visits ratio. Adequacy of antenatal care content assessed compliance to routine care based on the local guidelines.

RESULTS

Intensive or "adequate-plus" antenatal care utilisation as defined by the modified index was noted in over half of the low-risk women. On the other hand, there were 26% of the high-risk women without the expected intensive utilisation. Primary- or non-educated high-risk women were less likely to have a higher antenatal care utilisation level compared with tertiary educated ones (OR = 0.20, P = 0.003). Half of all women had <80% of the recommended antenatal care content. A higher proportion of high-risk than low-risk women scored <80% of the routine care content (p<0.015). The majority of the additional laboratory tests were performed on high-risk women. Provision of antenatal education showed comparatively poor compliance to guidelines, more than half of the antenatal advice topics assessed were rarely provided to the women. High-risk women were associated with a higher prevalence of adverse pregnancy outcome.

CONCLUSIONS

Disproportionate utilisation of antenatal care according to risk level of pregnancy indicates the need for better scheduling of care. The risk-oriented approach often results in a tendency to focus on the risk conditions of the women. Training interventions are recommended to improve communication and to help healthcare professionals understand the priorities of the women. Further studies are required to assess the reason for disproportionate utilisation of antenatal care according to risk level and how delivery of antenatal advice can be improved, reviewing both user and provider perspectives.

Antenatal care for healthy pregnant women: a mapping of interventions from existing guidelines to inform the development of new WHO guidance on antenatal care

BACKGROUND

The World Health Organization (WHO) is in the process of updating antenatal care (ANC) guidelines.

OBJECTIVES

To map the existing clinical practice guidelines related to routine ANC for healthy women and to summarise all practices considered during routine ANC.

SEARCH STRATEGY

A systematic search in four databases for all clinical practice guidelines published after January 2000.

SELECTION CRITERIA

Two researchers independently assessed the list of potentially eligible publications.

DATA COLLECTION AND ANALYSIS

Information on scope of the guideline, type of practice, associated gestational age, recommendation type and the source of evidence were mapped.

MAIN RESULTS

Of 1866 references, we identified 85 guidelines focusing on the ANC period: 15 pertaining to routine ANC and 70 pertaining to specific situations. A total of 135 interventions from routine ANC guidelines were extracted, and categorised as clinical interventions (n = 80), screening/diagnostic procedures (n = 47) and health systems related (n = 8). Screening interventions, (syphilis, anaemia) were the most common practices. Within the 70 specific situation guidelines, 102 recommendations were identified. Overall, for 33 (out of 171) interventions there were conflicting recommendations provided by the different guidelines.

CONCLUSION

Mapping the current guidelines including practices related to routine ANC informed the scoping phase for the WHO guideline for ANC. Our analysis indicates that guideline development processes may lead to different recommendations, due to context, evidence base or assessment of evidence. It would be useful for guideline developers to map and refer to other similar guidelines and, where relevant, explore the discrepancies in recommendations and others.

TWEETABLE ABSTRACT

We identified existing ANC guidelines and mapped scope, practices, recommendations and source of evidence.

Number of prenatal visits and pregnancy outcomes in low-risk women

OBJECTIVE

We investigated the association between number of prenatal visits (PNV) and pregnancy outcomes.

STUDY DESIGN

A retrospective cohort of 12 092 consecutive, uncomplicated term births was included. Exclusion criteria included unknown or third trimester pregnancy dating, pre-existing medical conditions and common pregnancy complications. Patients with ⩽10 PNV were compared with those with >10. The primary outcome was a neonatal composite including neonatal intensive-care unit admission, low APGAR score (<7), low umbilical cord pH (<7.10) and neonatal demise. Secondary outcomes included components of the composite as well as vaginal delivery, induction and cesarean delivery. Logistic regression was used to adjust for potential confounders.

RESULT

Of 7256 patients in the cohort meeting inclusion criteria, 30% (N=2163) had >10 PNV and the remaining 70% (N=5093) had ⩽10, respectively. There was no difference in the neonatal composite between the two groups. However, women with>10 PNV were more likely to undergo induction of labor and cesarean delivery.

CONCLUSION

Low-risk women with ⩾10 PNV had higher rates of pregnancy interventions without improvement in neonatal outcomes.

Rollout of community-based family health strategy (programa de saude de familia) is associated with large reductions in neonatal mortality in São Paulo, Brazil

Rationale

Several recent studies suggest that Brazil’s Estratégia Saude de Familia (Family Health Strategy-FHS) has contributed to declines in mortality at the national and regional level. Comparatively little is known whether this approach is effective in urban populations with relatively easy access to health services.

Objectives

To use detailed medical data collected as part of São Paulo’s Western Region project to examine whether the FHS program had an impact on child health in São Paulo, Brazil.

Results

No associations were found between FHS and birth weight (OR 1.03, 95% CI 0.93–1.29), gestational length (OR 0.98, 95% CI 0.83–1.15) or stillbirth (OR 1.51, 95% CI 0.75–3.03). FHS eligibility was associated with a 42% reduction in the odds of child mortality (OR 0.58, 95% CI 0.34, 0.91), with largest effect sizes for the early neonatal period (OR 0.18, 95% CI 0.04–0.79).

Conclusions

Community based health delivery platforms may be a highly effective way to reduce neonatal mortality in urban areas of low and middle income countries, even when access to general health services is almost universal.

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Brazil is currently transitioning from a health-center-based to a community-based model

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We find large neonatal mortality reductions in areas with the community based model.

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Community based programs may be effective even in areas with easy healthcare access.

Stillbirths: progress and unfinished business

This first paper of the Lancet Series on ending preventable stillbirths reviews progress in essential areas, identified in the 2011 call to action for stillbirth prevention, to inform the integrated post-2015 agenda for maternal and newborn health. Worldwide attention to babies who die in stillbirth is rapidly increasing, from integration within the new Global Strategy for Women's, Children's and Adolescents' Health, to country policies inspired by the Every Newborn Action Plan. Supportive new guidance and metrics including stillbirth as a core health indicator and measure of quality of care are emerging. Prenatal health is a crucial biological foundation to life-long health. A key priority is to integrate action for prenatal health within the continuum of care for maternal and newborn health. Still, specific actions for stillbirths are needed for advocacy, policy formulation, monitoring, and research, including improvement in the dearth of data for effective coverage of proven interventions for prenatal survival. Strong leadership is needed worldwide and in countries. Institutions with a mandate to lead global efforts for mothers and their babies must assert their leadership to reduce stillbirths by promoting healthy and safe pregnancies.

Perceived Barriers and Facilitators of a New Model in Managing Pregnant Women With Iron Deficiency Anemia: A Qualitative Study

A new model of antenatal care to manage pregnant women with iron deficiency anemia at public health centers in Indonesia has been studied. This study aimed to explore the facilitators and the barriers of this new model introduction by using focus group discussions to nurse-midwives and nurse-midwife coordinators. Training and information booklets, the improved confidence in providing comprehensive care, and adequate support from supervisors were perceived as facilitators of the new model. Financial support and public transportation necessary to reach the optimum treatment according to the new model, limited health insurance coverage, and shortage of staff and iron tablets were the barriers. Similar barriers should be anticipated for further implementation. A lasting support of policy and decision makers therefore is essential.