The strategy of risk approach in antenatal care: evaluation of the referral compliance

Average Time Spent in Referral Process and its Determinants Among Clients of Maternal and Child Health Service in 2 Districts of Jimma Zone, Ethiopia

Background: The time spent between referring and receiving health facilities is an important determinant of the outcome of the referred patients/clients especially among women in low-income countries due to poor access to early and appropriate referrals. Thus, the aim of this study is to assess the average time spent between referring and service utilization at receiving health facility. Methods: A cross-sectional study was employed by using time and motion approach. Structured questionnaire and observation checklist were used for collecting data. SPSS 21 version was used for data analysis and binary and multivariable logistic regression analysis was carried out to identify a variable that has a significant association on the basis of OR, 95% confidence interval, and a P value of less than .05. Result: A total of 266 women participated in the study with the mean age of the study population is 24.65 (±5.03) years. The majority, (223 (83.8%)) of the participants came for maternal health services and more than half, (143 (53.8%)) of the respondents were self-referrals. Among the referred cases, the main reason for the referral was for further evaluation and management. Women spent a maximum of 540 min on the way to arrive at receiving health facility. Residence and distance were the predictor variables for average time spent. Conclusion: In general, women wait a maximum of one and half hours to contact health care providers for assessment and more than two-fifth of the women wait more than 3 h to get the service at receiving health facility.

Risk perceptions among high-risk pregnant women in Nepal: a qualitative study

BACKGROUND

A woman's perception of risk affects her decisions about seeking obstetric care and following prescribed regimens of care. This study explored the perceptions of high-risk pregnancy among women with high-risk factors.

METHODS

A qualitative study was conducted in the Morang district, Nepal. A phenomenological approach was used. In-depth interviews were conducted with 14 participants. Postpartum women with one risk factor for high-risk pregnancy who non-adhere to referral hospital birth were selected purposively. Thematic analysis was done to generate themes and categories.

FINDINGS

Two main themes emerged in this study: (i) knowledge and understanding of risk and (ii) normalizing and non-acceptance of risk. The participants had inadequate knowledge of risk in pregnancy and childbirth. Their information source was their personal experiences of risk, witnessing their close relatives, and community incidents. The participants perceived pregnancy as a normal event and did not consider themselves as at risk. They tended to deny risk and perceived that everything was fine with their pregnancy.

CONCLUSIONS

The findings of this study provide a glimpse into how women perceived risk and the reasons that lead them to deny the risks and gave home birth. In the presence of risk factors in pregnancy, some women were not convinced that they were at risk. An antenatal check-up should be utilized as a platform to educate women, explore their intentions, and encourage safer births.

A Qualitative Study to Explore the Barriers for Nonadherence to Referral to Hospital Births by Women with High-Risk Pregnancies in Nepal

Maternal and neonatal morbidity and mortality tend to decrease if referral advice during pregnancy is utilized appropriately. This study explores the reasons for nonadherence to referral advice among high-risk pregnant women. A qualitative study was conducted in Morang District, Nepal. A phenomenological inquiry was used. Fourteen participants were interviewed in-depth. High-risk women who did not comply with the referral to have a hospital birth were the study participants. Participants were chosen purposively until data saturation was achieved. The data were generated using thematic analysis. Preference of homebirth, women's diminished autonomy and financial dependence, conditional factors, and sociocultural factors were the four major themes that hindered hospital births. Women used antenatal check-ups to reaffirm normalcy in their current pregnancies to practice homebirth. For newly-wed young women, information barriers such as not knowing where to seek healthcare existed. The poorest segments and marginalized women did not adhere to referral hospital birth advice even when present with high-risk factors in pregnancy. Multiple factors, including socioeconomic and sociocultural factors, affect women's decision to give birth in the referral hospital. Targeted interventions for underprivileged communities and policies to increase facility-based birth rates are recommended.

The effect of antenatal care on perinatal outcomes in Ethiopia: A systematic review and meta-analysis

BACKGROUND

The estimated annual global perinatal and neonatal death is four million. Stillbirths are almost equivalent to neonatal mortality, yet they have not received the same attention. Antenatal care is generally thought to be an effective method of improving pregnancy outcomes, but its effectiveness as a means of reducing perinatal mortality has not been evaluated in Ethiopia. Therefore, we will identify the pooled effect of antenatal care on perinatal outcomes in Ethiopia.

METHODS

Medline, Embase, Cinahl, African journal online and Google Scholar was searched for articles published in English language between January 1990 and May 2020. Two independent assessors selected studies and extracted data from eligible articles. The Risk of Bias Assessment tool for Non-Randomized Studies was used to assess the quality of each included study. Data analysis was performed using RevMan 5.3. Heterogeneity and publication bias were assessed using I2 test statistical significance and Egger's test for small-study effects respectively. The random effect model was employed, and forest plot was used to present the risk ratio (RR) with 95% confidence interval (CI).

RESULTS

Thirteen out of seventeen included studies revealed antenatal care utilization had a significant association with perinatal outcomes. The pooled risk ratio by the random-effects model for perinatal death was 0.42 (95% CI: 0.34, 0.52); stillbirth 0.34 (95% CI: 0.25, 0.46); early neonatal death 0.85 (95% CI: 0.21. 3.49).

CONCLUSION

Women who attended at least one antenatal care visit were more likely to give birth to an alive neonate that survives compared to their counterpart. Therefore, the Ethiopian Ministry of health and other stakeholders should design tailored interventions to increase antenatal care utilization since it has been shown to reduce perinatal mortality.

High-risk pregnancies and their association with severe maternal morbidity in Nepal: A prospective cohort study

Background

The early identification of pregnant women at risk of developing complications at birth is fundamental to antenatal care and an important strategy in preventing maternal death. This study aimed to determine the prevalence of high-risk pregnancies and explore the association between risk stratification and severe maternal morbidity.

Methods

This hospital-based prospective cohort study included 346 pregnant women between 28–32 gestational weeks who were followed up after childbirth at Koshi Hospital in Nepal. The Malaysian antenatal risk stratification approach, which applies four color codes, was used: red and yellow denote high-risk women, while green and white indicate low-risk women based on maternal past and present medical and obstetric risk factors. The World Health Organization criteria were used to identify women with severe maternal morbidity. Multivariate confirmatory logistic regression analysis was performed to adjust for possible confounders (age and mode of birth) and explore the association between risk stratification and severe maternal morbidity.

Results

The prevalence of high-risk pregnancies was 14.4%. Based on the color-coded risk stratification, 7.5% of the women were categorized red, 6.9% yellow, 72.0% green, and 13.6% white. The women with high-risk pregnancies were 4.2 times more likely to develop severe maternal morbidity conditions during childbirth.

Conclusions

Although smaller in percentage, the chances of severe maternal morbidity among high-risk pregnancies were higher than those of low-risk pregnancies. This risk scoring approach shows the potential to predict severe maternal morbidity if routine screening is implemented at antenatal care services. Notwithstanding, unpredictable severe maternal morbidity events also occur among low-risk pregnant women, thus all pregnant women require vigilance and quality obstetrics care but high-risk pregnant women require specialized care and referral.

The effect of antenatal care on use of institutional delivery service and postnatal care in Ethiopia: a systematic review and meta-analysis

Background

Although there are many initiatives to improve maternal health services use, utilization of health facility delivery and postnatal care services is low in Ethiopia. Current evidence at global level showed that antenatal care increases delivery and postnatal care services use. But previous studies in Ethiopia indicate contrasting results. Therefore, this meta-analysis was done to identify the effect of antenatal care on institutional delivery and postnatal care services use in Ethiopia.

Methods

Studies were searched from databases using keywords like place of birth, institutional delivery, and delivery by a skilled attendant, health facility delivery, delivery care, antenatal care, prenatal care and postnatal care and Ethiopia as search terms. The Joanna Briggs Critical Appraisal Tools and the Preferred Reporting Items for Systematic Review and Meta-Analyses were used for quality assessment and data extraction. Data analysis was done using STATA 14. Heterogeneity and publication bias were assessed using I² test statistic and Egger’s test of significance. Forest plots were used to present the odds ratio (OR) with 95% confidence interval (CI).

Result

A total of 40 articles with a total sample size of 26,350 were included for this review and meta-analysis. Mothers who had attended one or more antenatal care visits were more likely (OR = 4.07: 95% CI 2.75, 6.02) to deliver at health institutions compared to mothers who did not attend antenatal care. Similarly, mothers who reported antenatal care use were about four times more likely to attend postnatal care service (OR 4.11, 95% CI: 3.32, 5.09).

Conclusion

Women who attended antenatal care are more likely to deliver in health institutions and attend postnatal care. Therefore, the Ethiopian government and other stakeholders should design interventions that can increase antenatal care uptake since it has a multiplicative effect on health facility delivery and postnatal care services use. Further qualitative research is recommended to identify why the huge gap exists between antenatal care and institutional delivery and postnatal care services use in Ethiopia.

Patterns and determinants of pathways to reach comprehensive emergency obstetric and neonatal care (CEmONC) in South Sudan: qualitative diagrammatic pathway analysis

Background

Maternity referral systems have been under-documented, under-researched, and under-theorised. Responsive emergency referral systems and appropriate transportation are cornerstones in the continuum of care and central to the complex health system. The pathways that women follow to reach Emergency Obstetric and Neonatal Care (EmONC) once a decision has been made to seek care have received relatively little attention. The aim of this research was to identify patterns and determinants of the pathways pregnant women follow from the onset of labour or complications until they reach an appropriate health facility.

Methods

This study was conducted in Renk County in South Sudan between 2010 and 2012. Data was collected using Critical Incident Technique (CIT) and stakeholder interviews. CIT systematically identified pathways to healthcare during labour, and factors associated with an event of maternal mortality or near miss through a series of in-depth interviews with witnesses or those involved. Face-to-face stakeholder interviews were conducted with 28 purposively identified key informants. Diagrammatic pathway and thematic analysis were conducted using NVIVO 10 software.

Results

Once the decision is made to seek emergency obstetric care, the pregnant woman may face a series of complex steps before she reaches an appropriate health facility. Four pathway patterns to CEmONC were identified of which three were associated with high rates of maternal death: late referral, zigzagging referral, and multiple referrals. Women who bypassed nonfunctional Basic EmONC facilities and went directly to CEmONC facilities (the fourth pathway pattern) were most likely to survive. Overall, the competencies of the providers and the functionality of the first point of service determine the pathway to further care.

Conclusions

Our findings indicate that outcomes are better where there is no facility available than when the woman accesses a non-functioning facility, and the absence of a healthcare provider is better than the presence of a non-competent provider. Visiting non-functioning or partially functioning healthcare facilities on the way to competent providers places the woman at greater risk of dying. Non-functioning facilities and non-competent providers are likely to contribute to the deaths of women.

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1463-9) contains supplementary material, which is available to authorized users.

Equity in utilization of health care services: Perspective of pregnant women in southern Odisha, India

BACKGROUND & OBJECTIVES

Inequity in the use of health care services is an important factor affecting the maternal and child survival. In southern Odisha, India, the health indicators remained below compared to the State and national average. This study identifies various equity issues at individual and community levels that influence women's choice affecting the utilization of maternal health services in a district in southern Odisha.

METHODS

A qualitative study was carried out in Gajam district, rural region of south Odisha. Ten in-depth interviews were carried out till data saturation with women having less than one year child and 10 focus group discussions with the average eight women in each group having less than five year old child, community and health care providers separately. A total of 120 respondents were included in the study using in-depth interview and focus group discussions.

RESULTS

The important determinants in utilization of health care services by women emerging from the study were transportation and financial constraints. In addition, it was found that divergent aetiological concepts and low perceived hospital benefits of the women and community were equally important determinants. Further, community had different perceptions and interpretations of danger signs influencing the risk approach and health care seeking behaviour.

INTERPRETATION & CONCLUSIONS

Our findings show that to increase the utilization of health care services, the grass root health workers should be made aware of specific social determinants of risk, perceptions and preferences. m0 ore attention should be given to the transportation system, and its operational feasibility. The husband of the women and the elders of the family should be considered as an important unit of interjection. A more individualized antenatal consultation could be provided by taking into account women's perception of risk and their explanatory models.

Utilization of maternal health care services among married adolescent women: insights from the Nigeria Demographic and Health Survey, 2008

BACKGROUND

An ongoing social catastrophe of very poor performance in maternal health coupled with an unacceptably high number of maternal deaths is evident in Nigeria, especially among adolescent women. This study examines the factors associated with selected maternity services-married adolescent women who have had at least four antenatal care (ANC) visits, those who have undergone safe delivery care, and those who received postnatal care within 42 days of delivery.

METHODS

Data from Nigeria Demographic and Health Survey, 2008, were used. An eligible sample of 2,434 married adolescent (aged 15-19 years) women was included in the analysis. Pearson chi-square test and binary logistic regression were performed to fulfill the study objective.

RESULTS

It was found that about 35% of adolescent women had at least four ANC visits, a little over 25% had undergone safe delivery care, and nearly 32% received postnatal care within 42 days of delivery. Women's education, husband's education, wealth quintile, and region of residence were documented as the most important factors associated with maternal healthcare service utilization. The ANC visit was found to be vital in the utilization of safe delivery and postnatal care.

CONCLUSION

Findings indicate that programs to improve maternal healthcare have not succeeded in overcoming the socioeconomic obstacles in the way of adolescents' utilizing maternity services. In the long run, the content and service delivery strategy of maternity programs must be designed in keeping with the socioeconomic context with special attention to adolescent women who are uneducated, poor, and residing in rural areas.

How twins differ: multiple pregnancy and the use of health care in the 2008 Nigeria Demographic and Health Survey

OBJECTIVES

To (i) document the incidence of multiplicity in Nigeria, (ii) compare healthcare utilization during pregnancy and at delivery for singleton and multiple pregnancies (iii)and investigate whether antenatal care modifies the relationship between multiplicity and likelihood of having skilled attendance.

METHODS

This observational study was a secondary analysis of the 2008 Nigeria Demographic and Health Survey and included 17,635 women who gave birth to a live infant between 2003 and 2008. Multivariate logistic regression with adjustment for weighting, clustering and confounding was used to investigate associations and look for effect modification.

RESULTS

There were 18.5 multiple pregnancies per 1000 maternities. Multiple births had nearly six times the chance of neonatal mortality (AOR 5.74). Mothers with multiple births had more skilled attendance (AOR 1.75), but similar antenatal care utilization (AOR 0.95) as women with a singleton pregnancy. Women with multiple pregnancies attending antenatal care had more visits (mean 9.0 vs. 8.2), blood pressure checks (OR 1.52) and urine tests (OR 1.51). Although antenatal care was strongly associated with skilled attendance, there was no evidence that this was more so for twins than singletons.

CONCLUSIONS

Multiplicity in Nigeria is not just a common occurrence, but an indicator of a high-risk pregnancy. The fact that the use of antenatal care by women with a multiple pregnancy is not associated with a disproportionately greater use of skilled delivery care raises questions about the quality of antenatal services. Services should encourage and link all women and especially high-risk women to skilled attendance at delivery.

Reproductive health care utilization among young mothers in Bangladesh: does autonomy matter?

OBJECTIVE

To examine the linkage between the possible influences of the extent of autonomy on young mothers use of reproductive health care services.

METHODS

This paper used data from the 2007 Bangladesh Demographic Health Survey. The analyses were based on responses of 1,778 currently married women aged 15 to 24 years, living with at least one 0- to 35-month-old child. Utilization of antenatal health services (ANC) services by amount and type of provider, and utilization of delivery assistance according to provider type were used as proxy outcome variables of reproductive health care utilization. Descriptive statistics and multivariate logistic regression methods were employed in the analysis.

RESULTS

Approximately one third (31%) of the currently married young women in Bangladesh had a higher level of overall decision-making autonomy. Only 24.0% of the sampled women received sufficient ANC; 54% and 18% received ANC and assisted deliveries from a medically trained provider. respectively. In adjusted models, young women who had a higher level of overall autonomy were more likely to receive sufficient ANC (adjusted odds ratio [AOR], 1.64; 95% confidence interval [CI], 1.17-2.23) and receiving ANC from medically trained provider (AOR, 1.91; 95% CI, 1.42-2.45). Women who had medium overall autonomy were 1.40 times more likely (95% CI, 1.03-1.98) to have deliveries assisted by a medically trained provider than women who had low autonomy.

CONCLUSION

Association between young mother's autonomy and reproductive health care utilization suggest that maternal autonomy needs to be considered as an important sociocultural determinant for the higher utilization of reproductive health care services for young mothers in Bangladesh.

Compliance with referral for curative care in rural Burkina Faso

BACKGROUND

The goal of this study is to contribute to improving the functioning of the referral system in rural Burkina Faso. The main objective is to ascertain the compliance rate for referral and to identify the factors associated with successful referral.

METHODS

A record review of 12 months of curative consultations in eight randomly selected health centres was conducted to identify referral cases. To assess referral compliance, all patient documents at referral hospitals from the day of the referral up to 7 days later were checked to verify whether the referred case arrived or not. Descriptive statistics were then used to compute the compliance rate. Hierarchical modelling was performed to identify patient and provider factors associated with referral compliance.

RESULTS

The number of visits per person per year was 0.6 and the referral rate was 2.0%. The compliance rate was 41.5% (364/878). After adjustment, females (OR = 0.71; 95% CI = 0.52-0.98), patients referred during the rainy seasons (OR = 0.56; 95% CI = 0.40-0.78), non-emergency referrals (OR = 0.47; 95% CI = 0.34-0.65) and referrals without a referral slip (OR = 0.30; 95% CI = 0.21-0.43) were significantly less likely to comply. Children between 5 and 14 years old (OR = 0.61; 95% CI = 0.35-1.06) were at a higher risk of non-compliance, but the difference did not reach statistical significance. Moreover, none of provider characteristics was statistically significantly associated with non-compliance. CONCLUSIONS In a rural district of Burkina Faso, we found a relatively low compliance with referral after the official referral system was organized in 2006. Patient characteristics were significantly associated with a failure to comply. Interventions addressing female patients' concerns, increasing referral compliance in non-emergency situations, reducing inconvenience and opportunity costs due to seasonal/climate factors, and assuring the issue of a referral slip when a referral is prescribed may effectively improve referral compliance.

Factors affecting the utilisation of postpartum care among young mothers in Bangladesh

This article addresses the hypothesis that predisposing, enabling and need factors of households influence utilisation of postpartum care among the young mothers according to the timing and type of providers. To reach our goal Bangladesh Demographic and Health Survey of 2007 data (n = 2376) were used. Findings revealed that only one-third of the young mothers received postpartum care. Postpartum care by medically trained personnel and within the most critical period (within 48 h after delivery) was found to be very low (25.5 and 16.6%). Regarding postpartum morbidities, only one-fifth to one-half of the women reporting a complication consulted medically trained providers. Indeed, between one third and two thirds did not seek any postpartum care. The highest percentages contacting healthcare providers were for convulsions and the lowest was when the baby's hands or feet came first. The stronger influence of the mother's education and antenatal care on the utilisation of postpartum care is consistent with findings from other studies. Concern of the husband or family about pregnancy complications showed a significant and positive impact on the utilisation of postpartum care. Multivariate analysis showed that mother's age at delivery, residence, education, antenatal care, place of delivery, wealth, husband's occupation, husband's concern about pregnancy complications and mother's permission to go to a health centre alone were likely to affect utilisation of postpartum care services. The results indicate urgent needs in Bangladesh for an awareness-raising program highlighting the importance and availability of postpartum care; for strategies to improve the availability and accessibility of antenatal care services and skilled birth attendance, including focused financial support; for women's education to be given high priority; and to enable women to exercise their rights to control their freedom of movement, own health care and access to economic resources.

Effectiveness of maternal referral system in a rural setting: a case study from Rufiji district, Tanzania

Background

The functional referral system is important in backing-up antenatal, labour and delivery, and postnatal services in the primary level of care facilities. The aim of this study was to evaluate the effectiveness of the maternal referral system through determining proportion of women reaching the hospitals after referral advice, appropriateness of the referral indications, reasons for non-compliance and to find out if compliance to referrals makes a difference in the perinatal outcome.

Methods

A follow-up study was conducted in Rufiji rural district in Tanzania. A total of 1538 women referred from 18 primary level of care facilities during a 13 months period were registered and then identified at hospitals. Those not reaching the hospitals were traced and interviewed.

Results

Out of 1538 women referred 70% were referred for demographic risks, 12% for obstetric historical risks, 12% for prenatal complications and 5.5% for natal and immediate postnatal complications. Five or more pregnancies as well as age <20 years were the most common referral indications. The compliance rate was 37% for women referred due to demographic risks and more than 50% among women referred in the other groups. Among women who did not comply with referral advice, almost half of them mentioned financial constraints as the major factor. Lack of compliance with the referral did not significantly increase the risk for a perinatal death.

Conclusion

Majority of the maternal referrals were due to demographic risks, where few women complied. To improve compliance to maternal referrals there is need to review the referral indications and strengthen counseling on birth preparedness and complication readiness.

Seeking treatment for symptomatic malaria in Papua New Guinea

BACKGROUND

Malaria places a significant burden on the limited resources of many low income countries. Knowing more about why and where people seek treatment will enable policy makers to better allocate the limited resources. This study aims to better understand what influences treatment-seeking behaviour for malaria in one such low-income country context, Papua New Guinea (PNG).

METHODS

Two culturally, linguistically and demographically different regions in PNG were selected as study sites. A cross sectional household survey was undertaken in both sites resulting in the collection of data on 928 individuals who reported suffering from malaria in the previous four weeks. A probit model was then used to identify the factors determining whether or not people sought treatment for presumptive malaria. Multinomial logit models also assisted in identifying the factors that determined where people sought treatments.

RESULTS

Results in this study build upon findings from other studies. For example, while distance in PNG has previously been seen as the primary factor in influencing whether any sort of treatment will be sought, in this study cultural influences and whether it was the first, second or even third treatment for a particular episode of malaria were also important. In addition, although formal health care facilities were the most popular treatment sources, it was also found that traditional healers were a common choice. In turn, the reasons why participants chose a particular type of treatment differed according to the whether they were seeking an initial or subsequent treatments.

CONCLUSIONS

Simply bringing health services closer to where people live may not always result in a greater use of formal health care facilities. Policy makers in PNG need to consider within-country variation in treatment-seeking behaviour, the important role of traditional healers and also ensure that the community fully understands the potential implications of not seeking treatment for illnesses such as malaria at a formal health care facility.

A risk assessment for pregnancy using the World Health Organization classifying form in primary health-care facilities in Enugu, Nigeria

We present a cross-sectional survey of the pattern of high-risk pregnancies in randomly selected primary health-care facilities in Enugu, Nigeria, using the World Health Organization's classifying form. None of the 10 maternity homes studied had a standard risk screening tool. The age of the 299 women studied ranged from 16 to 42 years with a mean of 27.8 +/- 6.7 years. Eighty-eight (29.4%) of them were nulliparous, 160 (53.5%) were multiparous and 51 (17.1%) grandmultiparous. One hundred and twenty (40.1%) respondents were in the high-risk category. Rhesus D-negative blood group parturients (42, 35.0%), previous perinatal deaths (29.2%) and multiple pregnancies (9.2%) were the most common risk factors. The prevalence of high-risk pregnancies significantly increased with maternal age and parity and was not influenced by an improved maternal educational attainment. The institution of screening for high-risk pregnancies is vital at the primary health-care level and must be emphasized and must be regularly audited.

Mainstreaming nutrition in maternal, newborn and child health: barriers to seeking services from existing maternal, newborn, child health programmes

In the light of mainstreaming nutrition programs into health services, this review article approaches the issue of barriers to existing maternal child health programs from both theoretical and applied perspectives. It begins with a discussion of salient literature on models of health service utilization. The mid-section of the paper presents the results of a review of research studies that illuminate the barriers to care. Categorical themes emerged from the review of studies in the form of barriers based on geographic factors, temporal factors, a myriad of socio-cultural factors, financial factors and quality of care. The discussion focuses on the need to overcome existing restrictions to health services in order to facilitate initiatives to mainstream nutrition and achieve Millennium Development Goal #1.

Delivery complications and healthcare-seeking behaviour: the Bangladesh Demographic Health Survey, 1999-2000

Maternal health services have a potentially critical role in the improvement of reproductive health. The use of health services is related to the availability, quality and cost of the services, as well as to social structure, health beliefs and the personal characteristics of the users. The present paper examined the factors that influence the use of maternal health services for some selected pregnancy-related complications (e.g. prolonged labour, excessive bleeding, high fever/discharge and convulsions) in Bangladesh by using data from the Bangladesh Demographic Health Survey, 1999-2000. It was found that younger mothers were significantly less likely to seek professional healthcare at the time of birth. The odds for rural women seeking healthcare services from a doctor, nurse and/or midwife were half those of urban women. The strong influence of the mothers' education and parity on the utilisation of healthcare services is consistent with findings from other studies. The possession of assets emerged as an important predictor of seeking care from health professionals at the time of birth. Another factor, i.e. a husband's concern about pregnancy complications, showed a significant and positive impact on the utilisation of healthcare services, which is very important for rural women when they are dependent on their spouses. It was observed that the respondents living in urban areas, who had higher levels of education and lower parity, and more assets (used as a proxy for income), visited trained healthcare providers more often and were more likely to use healthcare facilities provided by trained personnel at the time of delivery. This is a reflection of the fact that, irrespective of their needs, only people from higher economic or educational groups can afford to seek healthcare from trained personnel in Bangladesh. In other words, predisposing and enabling factors appear to have a strong association with women's healthcare utilisation during pregnancy.

Chikotsa--secrets, silence, and hiding: social risk and reproductive vulnerability in central Mozambique

In this article, I examine pregnancy narratives and patterns of reproductive health seeking among women of fertile age in central Mozambique. I map the interplay between gendered economic marginalization, maternal risk perceptions, and pregnancy management strategies. By interpreting my data in light of Shona illness theories, I illuminate the ways that embodied experiences of reproductive vulnerability, risk perceptions, and social inequalities are linked: women attribute the most serious maternal complications to human- or spirit-induced reproductive threats of witchcraft and sorcery. This construction of reproductive vulnerability as social threats related to material and social competition significantly influences prenatal health seeking. Data reveal the structural and cognitive gap between biomedical constructions of risk and lay social threat perceptions. Plural health care systems are strategically utilized by women seeking to minimize both social and biological harm. On-the-ground ethnography shows that maternal health initiatives must take this plurality into full and accommodative account to achieve viable improvements in reproductive care and outcomes.

Effectiveness of referral system for antenatal and intra-partum problems in Gutu district, Zimbabwe

We conducted a population-based cohort study to determine the prevalence of antenatal and intra-partum referrals, compliance with advice and perinatal outcomes in referred pregnant women in Gutu district, Zimbabwe. The cohort was composed of 10,572 women who received antenatal care in 23 rural health centres (RHC) in Gutu district between January 1995 and June 1998. Pregnancy records of women with antenatal or intra-partum referral were analysed for indication, compliance and perinatal outcomes. Using women who had no antenatal referral or those who complied as referents, the association of referral with perinatal outcome was expressed as relative risk (RR) with 95% confidence intervals (CI). A total of 30% of women (3,094/10,572) had an antenatal referral. Among women attending RHC in labour, 13% (694/5,338) were referred intra-partum. Nulliparous and women younger than 20 years were more likely to be referred. Nurse - midwives' compliance with referral recommendations was low as 59% women with historical risk factors and 52% with raised blood pressure (>140/90 mmHg) were not referred. Women complied with referral advice except when indication was high parity. Women with antenatal referral were more likely to have hospital delivery, 70% vs 18% (p < 0.001). A total of 13% (993/7,478) of women referred themselves for hospital delivery. The risk of perinatal death was elevated among intra-partum referrals (RR 3.4; 95% CI 1.7 - 6.8), self-referrals (RR 2.6; 95% CI 1.5 - 4.5) and also among women with historical risk factors who were not referred (RR 4.8; 95% CI 2.5 - 9.2). We concluded that although there was a functional referral system in Gutu district its efficiency was reduced by failure of health personnel to comply with referral recommendations. Women took appropriate action for most referral indications.

Maternity referral systems in developing countries: current knowledge and future research needs

A functioning referral system is generally considered to be a necessary element of successful Safe Motherhood programmes. This paper draws on a scoping review of available literature to identify key requisites for successful maternity referral systems in developing countries, to highlight knowledge gaps, and to suggest items for a future research agenda. Key online social science, medical and health system bibliographic databases, and websites were searched in July 2004 for evidence relating to referral systems for maternity care. Documentary evidence on implementation is scarce, but it suggests that many healthcare systems in developing countries are failing to optimise women's rapid access to emergency obstetric care, and that the poor and marginalised are affected disproportionately. Likely requisites for successful maternity referral systems include: a referral strategy informed by the assessment of population needs and health system capabilities; an adequately resourced referral centre; active collaboration between referral levels and across sectors; formalised communication and transport arrangements; agreed setting-specific protocols for referrer and receiver; supervision and accountability for providers' performance; affordable service costs; the capacity to monitor effectiveness; and underpinning all of these, policy support. Theoretically informed social and organisational research is required on the referral care needs of the poor and marginalised, on the maternity workforce and organisation, and on the implications of the mixed economy of healthcare for referral networks. Clinical research is required to determine how maternity referral fits within newborn health priorities and where the needs are different. Finally, research is required to determine how and whether a more integrated approach to emergency care systems may benefit women and their communities.

Antenatal care in the capital city of Cambodia: Current situation and impact on obstetric outcome

AIMS

To analyze the situation of antenatal care (ANC) attendance in the capital of Cambodia, Phnom Penh, and the effect of ANC attendance on delivery and newborn outcome, in order to establish a strategy for ANC in the national reproductive health program in Cambodia.

METHODS

This was a health facility-based retrospective cohort study. Background factors (education, household income, and parity) were obtained through interview, and obstetric information (cesarean section, low birth-weight, and maternal complications) were collected from the medical records of women who delivered during 1 month at all the public and private health facilities in Phnom Penh. Relations were analyzed between the number of ANC visits, background factors, and obstetric outcome.

RESULTS

A total of 1204 responses were received from Phnom Penh residents, representing 84% of the estimated number of deliveries in the city. Of these, 89% were from public health facilities. Low educational level, low household income, and multiparity were risk factors for ANC attendance. There was no association between the number of ANC attendances and obstetric outcome.

CONCLUSIONS

Our study has shown that Phnom Penh residents have good access to ANC and delivery care. Low socioeconomic factors are risk factors to ANC. The number of ANC visits had no association with poor perinatal outcome, but further study on quality of ANC and its impact on obstetric outcome is needed. Within the limited resources, safe motherhood strategies need to be targeted to the rural area and to the poor in order to increase access to ANC and delivery care.

Mothers' education and childhood mortality in Ghana

The significant extent to which maternal education affects child health has been advanced in several sociodemographic-medical literature, but not much has been done in analysing the spatial dimension of the problem; and also using graphic and linear regression models of representation. In Ghana, very little has been done to relate the two variables and offer pragmatic explanations. The need to correlate the two, using a regression model, which is rarely applied in previous studies, is a methodological necessity. The paper examines the impact of mothers' education on childhood mortality in Ghana using, primarily, Ghana Demographic and Health Survey data of 1998 and World Bank data of 2000. The survey has emphatically established that there is an inverse relationship between mothers' education and child survivorship. The use of basic health facilities that relate to childhood survival shows a direct relationship with mothers' education. Recommendations for policy initiatives to simultaneously emphasise the education of the girl-child, and to ensure adequate access to maternal and child health services, have been made. The need for an experimental project of integrating maternal education and child health services has also been recommended. A linear regression model that illustrates the relationship between maternal education and childhood survival has emerged.

Changes in ante-natal care and family planning in Krakor, Pursat, Cambodia, 1996-1998

This study examines variations in ante-natal care (ANC) and family planning in Krakor, Pursat, Cambodia between 1996 and 1998. Population-based survey interviews were conducted with a total of 291 women in 1996 and 211 women in 1998. An intervention strategy designed to enhance the skills and roles of Health Centre staff, Village Health Volunteers (VHVs) and Traditional Birth Attendants (TBAs) was conducted. Over this timeframe, reported ANC access increased from 37% to 47%. Most women delivered their last child at home, usually assisted by a TBA. Few women practiced family planning, despite the fact that most reported that they did not want any further children. A range of reasons for not practicing family planning were found to be highly significant, including the lack of available services (p<0.01). The fear of side-effects decreased significantly (p<0.01), with the community education provided by the VHVs and TBAs, potentially being one contributing factor. The results of this study suggest that continual support of VHVs and TBAs will further improve the health of women in Cambodia.

A framework for a new approach to antenatal care

A framework for a new approach to antenatal care (ANC) is presented to improve maternal health. Based on evaluations of ANC, safe motherhood programs, gender and social theory, it suggests that managers should draw upon existing family and community support systems, and develop partnerships beyond the health service. Policy and program changes are required in: professional mandates for ANC providers, organization of ANC services, service protocols, training programs, policy towards TBAs, referral care, and service support systems.

Usefulness of risk scoring at booking for antenatal care in predicting adverse pregnancy outcome in a rural African setting

Antenatal care (ANC) attempts to screen and provide surveillance and treatment to individuals according to the level of need. We assessed the value of antenatal risk allocation made at the first visit in identifying women who will experience pregnancy complications in a rural area in Zimbabwe. As part of an ANC trial women were allocated into low- and high-risk categories based on medical, demographic and obstetric history. All highrisk women were recommended hospital delivery. This evaluation is based on 5223 women who received traditional care from nurse-midwives in 12 rural health centres, of whom 2890 (55%) were classified as high risk by the traditional risk markers, including 1618 nulliparous women. Complications occurred in 924 (17.7%) women 577 (62.4%) of whom had risk markers identified at booking. Twenty per cent (577/2890) of women classified as high risk developed complications. There was a high recurrence of complications, such as hypertensive disorders, operative delivery and preterm delivery. Nulliparity was a risk for low birth weight, operative delivery and hypertensive disorders, whereas grandmultiparity (> or =6) was a risk for hypertension in pregnancy. Young age (< or =16 years) was)a risk factor for low birth weight and perinatal death. Age above 35 years was not an independent risk factor. The traditional risk allocation system, with a likelihood ratio of 1.16, was not effective in identifying women at risk of pregnancy complications and resulted in too large a risk group for referral.

Referral to hospital in Nepal: 4 years' experience in one rural district

Formal referral systems have been proposed as a strategy to improve access to secondary care, yet their implementation can be problematic. This paper describes data from referrals in one rural district in Nepal over a 4-year period. Whilst the characteristics of those patients attending hospital after referral were similar to those described in other developing countries, the rate (1.0/1000 population/year) is much lower, especially when compared to estimated need. Geographical and other barriers to access to secondary care in rural Nepal are discussed.

How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of the evidence

This is an overview of evidence of the effectiveness of antenatal care in relation to maternal mortality and serious morbidity, focused in particular on developing countries. It concentrates on the major causes of maternal mortality, and traces their antecedent morbidities and risk factors in pregnancy. It also includes interventions aimed at preventing, detecting or treating any stage along this pathway during pregnancy. This is an updated and expanded version of a review first published by the World Health Organization (WHO) in 1992. The scientific evidence from randomised controlled trials and other types of intervention or observational study on the effectiveness of these interventions is reviewed critically. The sources and quality of available data, and possible biases in their collection or interpretation are considered. As in other areas of maternal health, good-quality evidence is scarce and, just as in many aspects of health care generally, there are interventions in current practice that have not been subjected to rigorous evaluation. A table of antenatal interventions of proven effectiveness in conditions that can lead to maternal mortality or serious morbidity is presented. Interventions for which there is some promising evidence, short of proof, of effectiveness are explored, and the outstanding questions formulated. These are presented in a series of tables with suggestions about the types of study needed to answer them.

Maternal morbidity and mortality in two different populations of Senegal: a prospective study (MOMA survey)

OBJECTIVE

To compare maternal morbidity and mortality in two urban populations with contrasting availability of health care, and to test the hypothesis that differences in maternal outcome result mainly from the management of delivery in health facilities.

DESIGN

A population-based study of a cohort of pregnant women which was part of a multicentre study of maternal morbidity in six countries of western Africa (MOMA).

SETTING

Two different urban areas of Senegal (Saint-Louis and Kaolack).

POPULATION

3,777 pregnant women who were followed up throughout pregnancy, delivery and puerperium.

MAIN OUTCOME MEASURES

Maternal morbidity and mortality: morbidity was assessed from women's recall at each visit by the investigator and from obstetric complications diagnosed by the birth attendant within health facilities.

RESULTS

Maternal mortality was higher in the Kaolack area where women gave birth mainly in district health care centres, usually assisted by traditional birth attendants, than in Saint-Louis where women giving birth in health facilities went principally to the regional hospital and were usually assisted by midwives (874 and 151 maternal deaths per 100,000 live births, respectively, P < 0 x 01). Maternal morbidity, however, was higher in Saint-Louis than in Kaolack area, especially for births in health facilities (9 x 50 and 4 x 84 episodes of obstetric complications per 100 live births, respectively, P < 0 x 01). Univariate and multivariate analyses showed that morbidity was mainly associated with the training of the birth attendant in facility deliveries and that antenatal care had no effect.

CONCLUSION

Midwives in health facilities appear to detect more obstetric complications than traditional birth attendants. Immediate detection leads to immediate care and to low fatality rates. This could explain differences in maternal outcome between two urban centres with contrasting health care availability. These results suggest that one of the strongest weapons in the fight against maternal mortality is the employment of the most qualified personnel possible for monitoring labour.

Obstetric care in southern Tanzania: does it reach those in need?

OBJECTIVE

To assess whether antenatal care achieves identification and timely referral of high-risk pregnancies in southern Tanzania.

METHODS

We compared the risk profiles of pregnant women in general with those attending obstetric care and investigated the reasons for seeking care. The risk profile of inpatients was drawn up through interviews with maternity cases and analysis of their antenatal records at the regional referral hospital (n = 415); population-based data on the prevalence of specific risk factors were obtained from entries in antenatal care registers (n = 1630) and from literature.

RESULTS

A significant risk selection towards obstetric referral level care was observed only for previous caesarean section (prevalence hospital 6.7%, all pregnancies 1.5%, P < 0.005) and for nulliparity (hospital 42.8%, all pregnancies 25.0%, P < 0.005). No significant differences were observed for other risk factors such as previous perinatal death, height < 150 cm, multiple gestation and breech presentation. Prevalence of the risk factors age > 34 years and grand multiparity was significantly lower among hospital users. Coverage of obstetric care was below 50% for all risk factors except previous caesarean section (91.5%).

CONCLUSION

Despite pursuing the risk approach and very good coverage, antenatal care in Tanzania has only limited effect on extending obstetric care to high-risk mothers. A critical review of the present screening and counselling practices, including a more focused and client-centred application of risk assessment, is warranted.