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

Multilevel modelling of factors associated with eight or more antenatal care contacts in low and middle-income countries: findings from national representative data

Background

Antenatal care (ANC) is the care provided by skilled healthcare professionals to pregnant women in order to ensure the best health conditions for both mother and baby. Antenatal care provides a platform for important healthcare functions including risk identification, prevention and management of pregnancy-related diseases. Inadequate ANC utilization is a global problem especially for low and middle-income countries. The 2016 WHO ANC model with a minimum of eight ANC visits was aimed to provide pregnant women with person specific care at every contact. However, there are limited studies that investigate the associated factors of inadequate ANC after the endorsement of the WHO 2016 guideline. Therefore, to enrich the evidence in the low and middle-income countries (LMICs), this study aimed to determine the pooled prevalence and associated with eight or more ANC contacts during pregnancy.

Methods

This study used data from 20 LMICs that have a recent Demographic and Health Survey. About 43 720 women aged 15-49 years who had live births within the year prior to the surveys were included. To identify associated factors of 8 or more ANC contacts, we used multilevel binary logistic regression, and four models were constructed. The results have been presented as odds ratios with 95% CIs, and P values less than 0.05 were considered significant factors for greater than or equal to 8 ANC contacts.

Results

In LMICs, the pooled utilization of 8 or more ANC contact was 18.11% (95% CI: 12.64, 23.58), and it ranged from 0.27% in Rwanda to 76.62% in Jordan. In the final multilevel logistic regression model, women with higher education [adjusted odds ratio (AOR)=3.83, 95% CI: 3.32, 4.41], husbands with higher education (AOR=1.98, 95% CI: 1.72, 2.28), women who have access to media (AOR=1.32, 95% CI: 1.19, 1.45), women with decision-making autonomy (AOR=1.52, 95% CI: 1.39, 1.66), women aged 35-49 years (AOR=1.70, 95% CI: 1.5, 1.91), women from communities with high media access (AOR=1.38, 95% CI: 1.23, 1.53), and husbands residing in communities with high literacy (AOR=1.76, 95% CI: 1.55, 1.98) were associated with higher odds of greater than or equal to 8 ANC contacts. Conversely, women with a birth order of greater than or equal to 6 (AOR=0.65, 95% CI: 0.56, 0.76), women who perceive the distance to a health facility as a significant problem (AOR=0.90, 95% CI: 0.83, 0.96), those with unwanted pregnancies (AOR=0.85, 95% CI: 0.78, 0.93), delayed initiation of ANC (AOR=0.26, 95% CI: 0.23, 0.3), women from households with the richest wealth index (AOR=0.45, 95% CI: 0.40, 0.52), and rural residents (AOR=0.47, 95% CI: 0.43, 0.51) were associated with lower odds of ≥8 ANC contacts.

Conclusion and recommendations

In compliance with the WHO guideline, the number of ANC contacts is low in LMICs. Individual-level, household-level, and community-level variables were associated with greater than or equal to 8 ANC contacts. Therefore, implementation strategies should focus on the identified factors in order to achieve the new WHO recommendation of greater than or equal to 8 ANC contacts.

Pelvic organ prolapse: Women's experiences of Accessing Care & Recommendations for improvement

Up to 50% of women will develop pelvic organ prolapse (POP) over their lifetime. Symptoms include pain, bulge, urinary, bowel and sexual symptoms affecting all aspects of a woman's life.Many women with POP symptoms present initially to primary care settings. Research has shown these interactions are often unsatisfactory, with women reporting their health care professional (HCP) trivialized their symptoms or appeared to have poor knowledge about pelvic floor dysfunction (PFD).Aim The aim of this qualitative study was to explore experiences of younger women seeking treatment for POP and their recommendations for improvements.Methods Ethics approval was obtained (LS-21-01-Carroll-Ful). Women with POP were recruited from an online support group (n = 930 members). Inclusion criteria: adult women, diagnosed with POP and aware of their POP stage. Following informed consent, a demographic questionnaire, interview questions and the Central Sensitization Inventory (CSI) were forwarded. Semi-structured zoom audio-recorded interviews were conducted. Thematic analysis was undertaken; transcripts coded, and themes identified.Results Fourteen women aged 32-41, parity 1-3, with POP Grade 1-3 participated. Many women reported HCPs as dismissive or not appreciative of the impact of their condition. Others described interactions with HCPs who they felt listened, understood the impact of their POP, gave simple explanations, a positive prognosis and outlined a realistic treatment plan.Current antenatal education, post-partum care and primary HCP screening for PFD were identified by women as deficient. Many highlighted delays in accessing specialist care for POP. Women made several recommendations for improvements to the current model of care.Conclusions Increased focus on person-centred care, particularly emotional support, information and education may improve younger women's experiences when seeking care for POP.

Adoption of antenatal care conversation mapping among health care providers in Saudi Arabia: Application of the diffusion innovation theory

AIM

To measure the factors influencing on the adoption of antenatal care conversation mapping among health care providers in Riyadh (Saudi Arabia), using the diffusion innovation theory.

METHODS

88 healthcare providers (Riyadh) were recruited using a non-probability convenient sampling technique were trained on how to use a newly developed antenatal care conversation map. Data was collected by self-administrated questionnaire on health education services, adoption of conversation map and diffusion of innovation variables. The JMP statistical software from SAS version 14 was used to perform data analysis.

RESULTS

Printable tools were most common as used by 72.7% of participants and 83.0% of them did not hear about conversation map. The total mean score of diffusion of innovation variables showed was in general high. The total mean score of relative advantage and observability was high in participants aged between 40 to less than 50 years, while the total mean score of compatibility, complexity, and trialability was high in participants aged from 50 years and more. Significant differences were obtained in both compatibility and trialability considering the health educators specialty, p = 0.03 and p = 0.027 respectively. The linear correlations between diffusion of innovation variables was significantly positive (p-value <0.01).

CONCLUSION

All of diffusion of innovation variables were positive as per the opinion of the participants. Applying the conversation map on other health topics in Saudi Arabia and other Arabic-speaking countries is warranted. Measuring and evaluating the adoption rate of conversation mapping among health care providers on other health topics should be explored.

Self-care interventions for preconception, antenatal, intrapartum and postpartum care: a scoping review

OBJECTIVE

To identify current and emerging self-care interventions to improve maternity healthcare.

DESIGN

Scoping review.

DATA SOURCES

MEDLINE, Embase, EmCare, PsycINFO, Cochrane CENTRAL/CDSR, CINAHL Plus (last searched on 17 October 2021).

ELIGIBILITY CRITERIA

Evidence syntheses, interventional or observational studies describing any tool, resource or strategy to facilitate self-care in women preparing to get pregnant, currently pregnant, giving birth or post partum.

DATA EXTRACTION/SYNTHESIS

Screening and data collection were conducted independently by two reviewers. Self-care interventions were identified based on predefined criteria and inductively organised into 11 categories. Characteristics of study design, interventions, participants and outcomes were recorded.

RESULTS

We identified eligible 580 studies. Many included studies evaluated interventions in high-income countries (45%) and during antenatal care (76%). Self-care categories featuring highest numbers of studies were diet and nutrition (26% of all studies), physical activity (24%), psychosocial strategies (18%) and other lifestyle adjustments (17%). Few studies featured self-care interventions for sexual health and postpartum family planning (2%), self-management of medication (3%) and self-testing/sampling (3%). Several venues to introduce self-care were described: health facilities (44%), community venues (14%), digital platforms (18%), partner/peer support (7%) or over-the-counter products (13%). Involvement of health and community workers were described in 38% and 8% of studies, who supported self-care interventions by providing therapeutics for home use, training or counselling. The most common categories of outcomes evaluated were neonatal outcomes (eg, birth weight) (31%), maternal mental health (26%) and labour outcomes (eg, duration of labour) (22%).

CONCLUSION

Self-care interventions in maternal care are diverse in their applications, implementation characteristics and intended outcomes. Many self-care interventions were implemented with support from the health system at initial stages of use and uptake. Some promising self-care interventions require further primary research, though several are matured and up-to-date evidence syntheses are needed. Research on self-care in the preconception period is lacking.

Incidence and causes of stillbirth in the only tertiary referral hospital in the Solomon Islands: a hospital-based retrospective cohort study

OBJECTIVES

Stillbirth is a major global health issue, which disproportionately affects families living in low-income and middle-income countries. The Solomon Islands is a Pacific nation with poor perinatal outcomes, however research investigating stillbirth is lacking. Thus, we aimed to investigate the incidence and cause of stillbirth occurring at the National Referral Hospital, Solomon Islands.

DESIGN

We conducted a retrospective cohort study from January 2017 to December 2018.

SETTING

At the only tertiary referral hospital in the Solomon Islands, on the main island of Guadalcanal.

PARTICIPANTS

All births occurring in the hospital during the study period.

OUTCOME MEASURES

Number of, causes and risk factors for stillbirths (fetal deaths before birth at ≥20 estimated gestational weeks, or ≥500 g in birth weight).

RESULTS

Over 2 years 341 stillbirths and 11 056 total births were recorded, giving an institutional incidence of 31 stillbirths per 1000 births. Of the cases with a recorded cause of death, 72% were deemed preventable. Most stillbirths occurred antenatally and 62% at preterm gestations (<37 weeks). 59% had a birth weight below 2500 g and preventable maternal conditions were present in 42% of the cases. 46% of the cases were caused by an acute intrapartum event, and among these 92% did not receive intrapartum monitoring.

CONCLUSIONS

Stillbirth affects 31 in every 1000 births at the National Referral Hospital in the Solomon Islands and many cases are preventable. Our findings highlight the urgent need for increased focus on perinatal deaths in the Solomon Islands with universal classification and targeted training, improved quality of obstetrical care and community awareness.

Maternal Well-Being and Stage of Behaviour Change during Pregnancy: A Secondary Analysis of the PEARS Randomised Controlled Trial

We aimed to determine whether early pregnancy well-being was associated with the stage of behaviour change during an antenatal lifestyle intervention using a secondary analysis of data from the Pregnancy Exercise and Nutrition Research Study (PEARS). Pregnant women (n = 277) with well-being data in early pregnancy were included. Maternal well-being was measured using the World Health Organisation Five-Item Well-Being Index. The intervention consisted of a mobile health (mHealth) phone application, supported by antenatal education and exercise, to prevent gestational diabetes in a population with overweight. Stage of behaviour change was measured in late pregnancy using a five-stage classification. Ordinal logistic regression was used to examine if well-being, the study group, or their interaction, were related to behaviour change. Maternal well-being (OR 1.03, 95% CI 1.01, 1.04, p < 0.01) and the study group (OR 2.25, 95% CI 1.44, 3.51, p < 0.01) both significantly influenced the positive stage of behaviour change. The probability of being at stage 5 increased from 43 to 92% as well-being increased from 0 to 100% and was higher in the intervention (53%) compared to the control (34%) group (p ≤ 0.01 (8.65, 29.27). This study demonstrates the potential importance of well-being in enabling women to engage with a healthy lifestyle, and the role that mHealth technology has in facilitating beneficial behaviour change.

Measurement of symphysis fundal height for gestational age estimation in low-to-middle-income countries: A systematic review and meta-analysis

In low- and middle-income countries (LMIC), measurement of symphysis fundal height (SFH) is often the only available method of estimating gestational age (GA) in pregnancy. This systematic review aims to summarize methods of SFH measurement and assess the accuracy of SFH for the purpose of GA estimation. We searched PubMed, EMBASE, Cochrane, Web of Science, POPLINE, and WHO Global Health Libraries from January 1980 through November 2021. For SFH accuracy, we pooled the variance of the mean difference between GA confirmed by ultrasound versus SFH. Of 1,003 studies identified, 37 studies were included. Nineteen different SFH measurement techniques and 13 SFH-to-GA conversion methods were identified. In pooled analysis of five studies (n = 5838 pregnancies), 71% (95% CI: 66-77%) of pregnancies dated by SFH were within ±14 days of ultrasound confirmed dating. Using the 1 cm SFH = 1wk assumption, SFH underestimated GA compared with ultrasound-confirmed GA (mean bias: -14.0 days) with poor accuracy (95% limits of agreement [LOA]: ±42.8 days; n = 3 studies, 2447 pregnancies). Statistical modeling of three serial SFH measurements performed better, but accuracy was still poor (95% LOA ±33 days; n = 4 studies, 4391 pregnancies). In conclusion, there is wide variation in SFH measurement and SFH-to-GA conversion techniques. SFH is inaccurate for estimating GA and should not be used for GA dating. Increasing access to quality ultrasonography early in pregnancy should be prioritized to improve gestational age assessment in LMIC.

Factors affecting the duration of gestation among women taking prenatal care at Gondar referral hospital, Ethiopia

Background

Pregnant women taking prenatal care is vital for the health of the mother and the fetus. The duration of pregnancies provides a useful measure of a woman's natural length of pregnancy and may help in predicting an individual woman's due date. The objective of this study was to understand the factors affecting the duration of gestation among women taking prenatal care in Gondar referral hospital, Ethiopia.

Methods

A quantitative research design using secondary data available in the form of antenatal care (ANC) cards in the Gondar teaching referral hospital data set. Kaplan–Meier estimate was used to explain the median survival time of duration of gestation. A multivariate AFT model was performed to identify the factors related to the duration of gestation among women.

Results

The mean time of the length of pregnancy was 39.5 weeks. The factors such as, the age of women, number of children, number of doctor consultations, and the stage of gestation were found to be statistically significant (p < 0.05) for the survival time of time to birth of pregnant women in Ethiopia. Weibull AFT model was found to be the best model for predicting the time to birth of pregnant women in Ethiopia.

Conclusion

We did not see associations between length of gestation and blood pressure and bleeding during early pregnancy. We also did not find an association with the presence of disease, which has been associated with the length of pregnancy. The frequency of visiting a doctor during the gestation period enhances the length of the gestation period. The shorter gestation period from the due date is dangerous to the health of both mother and her fetus.

Utilisation of supplementary prenatal screening and diagnostics in Germany: cross-sectional study using data from the KUNO Kids Health Study

BACKGROUND

Appropriate health system utilisation during pregnancy is fundamental for maintaining maternal and child's health. To study the use and determinants of supplementary prenatal screening and diagnostics in Germany this study provides comprehensive data.

METHODS

We obtained data from a recently established prospective German birth cohort study, the KUNO Kids Health Study. Analyses are based on Andersen's Behavioural Model of health system use, which distinguishes between predisposing (e.g. country of birth), enabling (e.g. health insurance) and need factors (e.g. at-risk pregnancy). We examined bi- and multivariate association with the use of supplementary prenatal screening and diagnostics using logistic regression.

RESULTS

The study has a sample size of 1886 participating mothers. One fifth of the mothers investigated did not use any supplementary prenatal screening or diagnostics. Notably, the chance of using supplementary prenatal screening and diagnostics more than doubled if the pregnant woman had a private health insurance (OR 2.336; 95% CI 1.527-3.573). Higher maternal age (OR 1.038; 95% CI 1.006-1.071) and environmental tobacco smoke exposure (OR 1.465 95% CI 1.071-2.004) increased the use of supplementary prenatal screening and diagnostics. However, regarding need factors only having an at-risk-pregnancy (OR 1.688; 95% CI 1.271-2.241) showed an independent association.

CONCLUSION

The important role of the type of health insurance and the relatively small influence of need factors was surprising. Especially with respect to equity in accessing health care, this needs further attention.

What are the essential components of antenatal care? A systematic review of the literature and development of signal functions to guide monitoring and evaluation

BACKGROUND

Antenatal care (ANC) is one of the key care packages required to reduce global maternal and perinatal mortality and morbidity.

OBJECTIVES

To identify the essential components of ANC and develop signal functions.

SEARCH STRATEGY

MESH headings for databases including Cinahl, Cochrane, Global Health, Medline, PubMed and Web of Science.

SELECTION CRITERIA

Papers and reports on content of ANC published from 2000 to 2020.

DATA COLLECTION AND ANALYSIS

Narrative synthesis of data and development of signal function through 7 consensus-building workshops with 184 stakeholders.

MAIN RESULTS

A total of 221 papers and reports are included from which 28 essential components of ANC were extracted and used to develop 15 signal functions with the equipment, medication and consumables required for implementation of each. Signal functions for the prevention and management of infectious diseases (malaria, HIV, tuberculosis, syphilis and tetanus) can be applied depending on population disease burden. Screening and management of pre-eclampsia, gestational diabetes, anaemia, mental and social health (including intimate partner violence) are recommended universally. Three signal functions address monitoring of fetal growth and wellbeing, and identification and management of obstetric complications. Promotion of health and wellbeing via education and support for nutrition, cessation of substance abuse, uptake of family planning, recognition of danger signs and birth preparedness are included as essential components of ANC.

CONCLUSIONS

New signal functions have been developed which can be used for monitoring and evaluation of content and quality of ANC. Country adaptation and validation is recommended.

Determinants of Utilization and Quality of Antenatal Care Services in Lubumbashi, in the Democratic Republic of the Congo

Objectives:

Maternal and perinatal mortality is one of the best indicators of a society’s health status and development level. In the Democratic Republic of the Congo, antenatal care (ANC) utilization is generally low, and delayed initiation of care is very common. It is in this context that the present study on the utilization and quality of ANC carried out among women in Lubumbashi city aimed to identify determinants of the utilization and quality of ANC services.

Material and Methods:

This was a cross-sectional study conducted in Lubumbashi, relating to 1472 women who had given birth during the 12 months preceding the survey, selected by cluster sampling. Logistic regression was used to identify the relative effects of socio-demographic risk factors and all statistical tests were declared significant at a P < 0.05.

Results:

One tenth (10.5%) of the women in the sample did not attend ANC during their most recent pregnancy and 89.5% had attended ANC at least once. Of the 1318 women with at least one ANC visit, 55.9% had an early initiation of ANC and 53.2% received high quality ANC. Women aged 20–29 years (adjusted odds ratios [aOR] = 2.8 [1.6–5.1]), 30–39 years (aOR = 4.3 [2.1–8.9]) and ≥40 years (aOR = 6.5 [2.6–16.2]), married women (aOR = 1.9 [1.1–3.2]), women with secondary educational level (aOR = 4.9 [3.4–7.2]), and women with higher educational level (aOR = 15.3 [5.3–43.8]) were more likely to have at least one ANC during their pregnancy. Factors contributing to attend four or more ANC visits were secondary educational level (aOR = 1.4 [1.0–2.0]) and higher educational level (aOR = 1.9 [1.2–2.9]), primiparity (aOR = 1.5 [1.1–2.1]), and doing business activities (aOR = 1.4 [1.0–1.8]). Determinant of early initiation ANC was only the higher educational level (aOR = 2.2 [1.4–3.4]). Factors associated with high quality ANC were secondary educational level (aOR = 3.0 [2.1–4.3]) and higher educational level (aOR = 6.2 [3.8–9.9]), and receiving ANCs in a general referral hospital (aOR = 1.5 [1.2–2.0]).

Conclusion:

The use and quality of ANC services remain a serious problem in Lubumbashi city. This situation hampers the achievement of maternal and child health goals. Health education can help reduce this in our context.

Tocolytic Treatment for the Prevention of Preterm Birth from a Taiwanese Perspective: A Survey of Taiwanese Obstetric Specialists

Preterm birth represents a great burden to the healthcare system, resulting in the consideration for the use of tocolytic therapy to provide a "better time" for delivery in order to buy time to accelerate fetal lung maturity, thereby minimizing prematurity-related morbidity and mortality. However, the benefits and potential side effects and risks of tocolytic treatment for preterm birth should be carefully balanced. Although many countries and societies provide guidelines or consensuses for the management for preterm birth, there is no standardized national guideline or consensus in Taiwan. As such, great heterogeneity is suspected in preterm labor management, contributing to the uncertainty of attitudes and practice patterns of obstetric specialists in Taiwan. This study attempts to understand the attitudes and practice patterns regarding tocolytic therapy in Taiwan. A paper-based survey was conducted at the 2020 Taiwan Society of Perinatology Conference on 8 December 2020, exploring how obstetric specialists would use tocolytics under nine different clinical scenarios, such as a short cervix, preterm labor, maintenance tocolysis, preterm premature rupture of membranes, etc. Three hundred ten specialists attended the conference, and 77 responded to the survey with a response rate of 24.8%. According to the survey, many of these specialists would prescribe tocolytics for less evidence-based indications, including 22% for abdominal tightness, 46% for a short cervix, 60% for maintenance tocolysis, and 89% for repeat tocolysis, with the preferred first line medication being ritodrine and nifedipine. We concluded that tocolysis is widely accepted and practiced in Taiwan. More research is needed to include Taiwan-specific economic and cultural factors as well as associated adverse effects and patients' outcomes.

Factors affecting the frequency and contents of routine antenatal care in remote rural China in 2009-2016: an observational study

OBJECTIVE

We assessed factors associated with frequency and contents of antenatal care (ANC) in remote rural China, including province of residence and individual level factors.

DESIGN

Survey-based cross-sectional study.

SETTING

Remote rural China, Five provinces- Jilin, Shaanxi, Hunan, Guizhou, and Ningxia.

SAMPLE

3,918 women with a live birth in 2009-2016.

METHODS

Poisson regression.

MAIN OUTCOME MEASURES

ANC frequency- 5+ visits starting in the first trimester. ANC contents- co-coverage of six care components, and overuse of ultrasound.

MAIN RESULTS

Three quarters (72.9%) of women had 5+ visits starting in the first trimester, 68.8% received all six care components, and 94.5% had 3+ ultrasounds. Only 30.9% women sought ANC from township hospitals, paying between $3.8 and 25.8 per-visit. ANC frequency and contents were associated with women's socio-economic characteristics, but provincial effects were much stronger, even after adjusting for individual factors. Women living in Guizhou and Ningxia, the two poorest provinces with high proportions of ethnic minorities, were particularly underserved. Compared to women in Shaanxi, women in Guizhou were 33% (adjusted RR 0.67, 95%CI 0.61-0.74) less likely to receive 5+ ANC starting in the first trimester; women in Ningxia were 17% less likely (adjusted RR 0.83, 95% CI 0.76-0.90) to receive all six care components.

CONCLUSION

The province of residence was a stronger predictor of ANC frequency and contents than women's individual characteristics in China, suggesting that strengthening the decentralised system of financing and organisation of ANC at province level is crucial to achieving success. Future efforts are warranted to engage sub-regional administrations.

Change in healthcare during Covid-19 pandemic was assessed through observational designs

Objective

Methodological challenges for investigating the changes in healthcare utilization during COVID-19 pandemic must be considered for obtaining unbiased estimates.

Study design and setting

A population-based study in the Lombardy region (Italy) measured the association between the level of epidemic restrictions (increasing exposure during pre-epidemic, post-lockdown, and lockdown periods) and the recommended healthcare (outcome) for patients with schizophrenia, heart failure, chronic obstructive pulmonary disease, breast cancer, and pregnancy women. Two designs are applied: the self-controlled case series (SCCS) and the usual cohort design. Adjustments for between-patients unmeasured confounders and seasonality of medical services delivering were performed.

Results

Compared with pre-epidemic, reductions in delivering recommended healthcare during lockdown up to 73% (95% confidence interval: 63%–80%) for timeliness of breast cancer surgery, and up to 20% (16%–23%) for appropriated gynecologic visit during pregnancy were obtained from SCCS and cohort design, respectively. Healthcare provision came back to pre-epidemic levels during the post-lockdown, with the exception of schizophrenic patients for whom the SCCS showed a reduction in continuity of care of 11% (11%–12%).

Conclusion

Strategies for investigating the changes in healthcare utilization during pandemic must be implemented. Recommendations for taking into account sources of systematic uncertainty are discussed and illustrated by using motivating examples.

Factors influencing health behaviour change during pregnancy: a systematic review and meta-synthesis

Pregnancy is an opportune time for women to make healthy changes to their lifestyle, however, many women struggle to do so. Multiple reasons have been posited as to why this may be. This review aimed to synthesise this literature by identifying factors that influence women's health behaviour during pregnancy, specifically in relation to dietary behaviour, physical activity, smoking, and alcohol use. Bibliographic databases (MEDLINE, PsycINFO, CINAHL-P, MIDIRS) were systematically searched to retrieve studies reporting qualitative data regarding women's experiences or perceptions of pregnancy-related behaviour change relating to the four key behaviours. Based on the eligibility criteria, 30,852 records were identified and 92 studies were included. Study quality was assessed using the CASP tool and data were thematically synthesised. Three overarching themes were generated from the data. These were (1) A time to think about 'me', (2) Adopting the 'good mother' role, and (3) Beyond mother and baby. These findings provide an improved understanding of the various internal and external factors influencing women's health behaviour during the antenatal period. This knowledge provides the foundations from which future pregnancy-specific theories of behaviour change can be developed and highlights the importance of taking a holistic approach to maternal behaviour change in clinical practice.

Adequacy of prenatal care services and associated factors in Southern Ethiopia

BACKGROUND

Prenatal care is an important component for the continuum of care in maternal and child health services. Despite increased attention on prenatal care service coverage, the adequacy of service provision has not been well addressed in Ethiopia. Therefore, this study aimed to describe the status of the adequacy of prenatal care and its associated factors in Southern Ethiopia.

METHOD

A longitudinal study done by the Performance care Monitoring and Accountability (PMA2020) project was used. The study was conducted from August 2016 to January 2017 in Southern Ethiopia. A multistage stratified cluster design in which all enumeration areas were randomly selected using probability proportional to size and all households were screened to identify 324 pregnant women of six or more months. Questions regarding early attendance of prenatal care, enough visits, and sufficient services were asked to measure the adequacy of prenatal care. Finally, an ordered logistic regression analysis was employed to assess factors associated with the adequacy of prenatal care services.

RESULTS

Of the total pregnant women 44.21 % attended enough visits, 84.10 % had early visits, and 42.03 % received sufficient services. The women residing in urban areas had 2.35 odds of having adequate prenatal care in reference to rural areas (adjusted odds ratio (aOR) 2.35 [95 % CI 1.05-5.31]). Women who attended primary and secondary education had 2.42(aOR 2.42 [95 % C.I. 1.04, 5.65]), and 4.18 (aOR 4.18 [95 % CI 1.32, 13.29]) odds of adequate prenatal care in reference with those who never attended education respectively. The women participating in one to five networks have 2.18 odds of adequate prenatal care in reference to their counterparts (aOR 2.78 [95 % CI 1.01, 7.71]).

CONCLUSIONS

The adequacy of prenatal care services in Southern Ethiopia is very low. The Ethiopian health care system should strengthen one to five networks to discuss on family health issues. Further research, should validate the tools and measure the adequacy of the services in different contexts of Ethiopia using a mixed method study for an in-depth understanding of the problem.

Suboptimal prenatal screening of Chlamydia trachomatis and Neisseria gonorrhoeae infections in a Montréal birthing and tertiary care centre: A retrospective cohort study

Background

The Canadian Paediatric Society no longer recommends the use of universal ocular prophylaxis with erythromycin ointment to prevent ophthalmia neonatorum. Screening for Chlamydia trachomatis and Neisseria gonorrhoeae in all pregnant women is considered the most effective way of preventing vertical transmission and ophthalmia neonatorum.

Objective

The aims of this study were to assess prenatal screening rates of C. trachomatis and N. gonorrhoeae and to compare sociodemographic factors between those screened and those not screened.

Methods

The list of all women who delivered at a tertiary care hospital in Montréal, Québec, between April 2015 and March 2016, was cross-referenced with the list of samples tested for C. trachomatis and N. gonorrhoeae. Maternal medical records were reviewed for demographic, prenatal and diagnostic information.

Results

Of 2,688 mothers, 2,245 women were screened at least once, but only 2,206 women had at least one valid C. trachomatis and N. gonorrhoeae result the day of delivery (82.1%; 95% CI: 80.6%-83.5%). Infection was detected in 46/2,206 (2.1%) screened women: 42 had C. trachomatis infection, two had N. gonorrhoeae infection and two were co-infected. C. trachomatis infection was more frequent in women younger than 25 years (9.8%; 95% CI: 6.7%-13.8%) than in older women (0.8%; 95% CI: 0.4%-1.3%; p<0.001). Each increase in parity decreased the probability of being tested (adjusted odds ratio=0.89; 95% CI: 0.80%-0.97%; p=0.01). Of those with an initial negative test result, 35/267 (13.1%; 95% CI: 9.3%-17.8%) of women younger than 25 years and 122/1,863 (6.6%; 95% CI: 5.5%-7.8%; p<0.001) of women aged 25 years and older were retested. Subsequent infection was detected in 4/35 (11%) women, all younger than 25.

Conclusion

Suboptimal screening rates for C. trachomatis and N. gonorrhoeae suggest that current universal ocular prophylaxis cannot be discontinued. Repeating universal screening should be considered, especially among those younger than 25 years.

Mothers and their children's health (MATCH): a study protocol for a population-based longitudinal cohort

Background

The quality of prenatal care is critical for the prevention of adverse pregnancy outcomes. However, according to the World Health Organization (WHO), only 64 % of women worldwide have access to over four sessions of prenatal care throughout their pregnancy. Thus, studies that address factors affecting maternal and child health status before and after pregnancy are of immense importance. The primary aim of the mothers and their children’s health (MATCH) cohort study is to evaluate the effect of nutrition, sleep quality, and lifestyle on maternal and neonatal outcomes.

Methods

A prospective cohort of > 2500 pregnant women in the first trimester (before 12 weeks’ gestation) will be recruited at Arash Women’s Hospital in Tehran, Iran between February 2020 and August 2021. All eligible pregnant women will be followed from their first trimester of pregnancy until delivery at four time points and assessed through a series of in-person visits with interviewer-administered questionnaires and telephone interviews. Detailed data will be collected on maternal demographics, lifestyle, medical history, reproductive history, obstetric history, dietary intake, sleep pattern, blood specimens, and anthropometric measurements, alongside paternal demographics, lifestyle, and family history. The outcomes will include antenatal, peripartum, and postnatal maternal complications and infant growth and neurodevelopment.

Discussion

The results of the MATCH cohort study will support the development of contextual interventions that can enhance antenatal, peripartum, and postnatal status, neonatal outcomes, and longevity mother and child.

Utilization and Determinants of Antenatal Care Visits in East African Countries: A Multicountry Analysis of Demographic and Health Surveys

Background. The health care a woman receives during pregnancy is important for her survival and baby, both at the time of delivery and shortly after that. In the context of high maternal morbidity and mortality in sub-Saharan Africa, fewer than 80% of pregnant women receive antenatal care visit services. Receiving antenatal care visits at least four times increases the likelihood of receiving effective maternal health interventions through the antenatal period. This study aimed to identify the utilization and determinants of attending at least four visits in 12 East African countries. Methods. The study used the demographic and health survey data from 12 East African countries from 2008 to 2018. The DHS program adopts standardized methods involving uniform questionnaires, manuals, and field procedures to gather information comparable across countries globally. A multivariable logistic regression model was fitted to identify the determinants of completing at least four antenatal care services. With their 95% CI obtained from the adjusted multilevel logistic regression model, the adjusted odds ratio was presented to show the magnitude of the relationship between the independent variable and completing antenatal care visits. Results. The pooled utilization of attending at least four antenatal care visit in the East African region was 52.44% (95% CI: 52.13, 52.74), with the highest attending at least four or more antenatal care visit visits in Zimbabwe (75.72%) and the lowest attending at least four or more antenatal care visit visits in Ethiopia (31.82%). The significant determinants of completing at least four ANC visits were age category (24–34 (AOR = 1.24, 95% CI: 1.18, 1.31) and 35–49 (AOR = 1.42, 95% CI: 1.32, 1.53)); being married women (AOR = 1.11, 95% CI: 1.1.05, 1.16); education levels of primary education (AOR = 1.20, 95% CI: 1.13, 1.27), secondary education (AOR = 1.24, 95% CI: 1.24, 1.47), and higher education (AOR = 1.91, 95% CI: 1.62, 2.14); birth order (2–4 (AOR = 0.75, 95% CI: 0.70, 0.79) and 5+ (AOR = 0.63, 95% CI: 0.58, 0.68)); planned pregnancy (AOR = 0.81, 95% CI: 0.75, 0.86); contraceptive utilization (AOR = 1.36, 95% CI: 1.29, 1.43); wealth status of middle (AOR = 1.11, 95% CI: 1.05, 1.17) and rich (AOR = 1.25, 95% CI: 1.18, 1.32); having no problem accessing health care (AOR = 1.0.95, 95% CI: 0.89, 0.97); and living countries. Conclusions. The coverage of completing the recommended antenatal care visit was low in the region. Age, marital status, mother’s and partner’s education, women’s occupation, birth order, planned pregnancy, contraceptive utilization, wealth status, healthcare accessibility, and living countries were the major determinants of completing recommended antenatal care visits. Therefore, intersectoral collaboration to promote female education and empowerment, improve geographical access to health care, and strengthen implementation of antenatal care policies with active community participation is recommended. In addition, creating a conducive environment in entrepreneurial activities for poor women is needed.

Association between Adherence with Recommended Antenatal Care in Low-Risk, Uncomplicated Pregnancy, and Maternal and Neonatal Adverse Outcomes: Evidence from Italy

Antenatal care (ANC) aims of monitoring wellbeing of mother and foetus during pregnancy. We validate a set of indicators aimed of measuring the quality of ANC of women on low-risk, uncomplicated pregnancy through their relationship with maternal and neonatal outcomes. We conducted a population-based cohort study including 122,563 deliveries that occurred between 2015 and 2017 in the Lombardy Region, Italy. Promptness and appropriateness of number and timing of gynaecological visits, ultrasounds and laboratory tests were evaluated. We assessed several maternal and neonatal outcomes. Log-binomial regression models were used to estimate prevalence ratio (PR), and corresponding 95% confidence interval (95% CI), for the exposure→outcome association. Compared with women who adhered with recommendations, those who were no adherent had a significant higher prevalence of maternal intensive care units admission (PR: 3.1, 95%CI: 1.2-7.9; and 2.7, 1.1-7.0 respectively for promptness of gynaecological visits, and appropriateness of ultrasound examinations), low Apgar score (1.6, 1.1-1.2; 1.9, 1.3-2.7; and 2.1, 1.5-2.8 respectively for appropriateness and promptness of gynaecological visits, and appropriateness of ultrasound examinations), and low birth weight (1.8, 1.5-2.3 for appropriateness of laboratory test examinations). Benefits for mothers and newborn are expected from improving adherence to guidelines-driven recommendations regarding antenatal care even for low-risk, uncomplicated pregnancies.

Evaluation of a pilot program that integrated prenatal screening into routine antenatal care in western rural China: an interrupted time-series study

Background

We evaluated a large-scale pilot program in Shaanxi Province, western rural China, which integrated prenatal screening interventions for congenital abnormalities into routine antenatal programs.

Methods

We surveyed 1,597 mothers who gave birth between 2009 and 2016. Adopting the interrupted time-series design, we evaluated the program's impact on awareness, coverage, and cost, by comparing two counties with only supply-side policies, and two counties from the neighbouring province with no policies; and among the two counties with both supply- and demand-side policies and the two counties with only supply-side policies. We adjusted the sampling procedure and women's background characteristics. We conducted subgroup analyses by women's education.

Findings

After one year of implementation, the coverage of prenatal foetal aneuploidies and B-ultrasound screening rose by 25.0% and 23.5%. The program's supply-side policies attributed to 17.2 percentage points (90%CI 7.8–26.6%) and 27.3 percentage points (90%CI 16.2–38.5%) in coverage, and contributed to a higher median cost of 796.5RMB (90%CI 595.5–997.5). These significantly affected women with secondary education and above. However, the program's demand-side measures, that is, vouchers, seemed to be effective only in the mountainous regions, which raised awareness, and increased coverage of prenatal foetal aneuploidies screening by 28.6 percentage points (90%CI 13.4–43.8%), while not increasing costs. These significantly affected women with primary education and below. Education-related inequalities widened post-program in counties with only supply-side policies, but no inequalities existed in counties with demand-side policies.

Interpretation

Shaanxi's program made a pilot study to other provinces of China to integrate antenatal services. Government subsidies might be more effective in targeting specific geographic locations and people with primary education and lower.

[Acceptability and satisfaction with pregnancy and newborn diagnostic assessment (PANDA) system providing prenatal care in Burkina Faso]

Introduction

les technologies mobiles en santé sont de plus en plus utilisées comme solutions innovantes pour améliorer les services de soins prénatals (SPN) dans les soins de première ligne. Cette étude a évalué l´acceptabilité et la satisfaction de l´utilisation du système Pregnancy and Newborn Diagnostic Assessment (PANDA) lors des SPN au Burkina Faso.

Méthodes

une étude transversale utilisant une approche mixte a été menée auprès de 35 utilisatrices des SPN et de 35 agents de santé dans le district sanitaire de Koupéla, dans la région du Centre-Est du Burkina Faso en septembre 2017. Des entretiens et 4 focus groups ont été réalisés auprès des utilisatrices des SPN et des d´entretiens semi-structurés auprès des professionnels de soin. Une analyse descriptive des données quantitatives a été effectuée avec le logiciel SPSS et les données qualitatives ont fait l’objet d´une analyse thématique avec NVivo 10.

Résultats

le système PANDA a été très bien accepté et très apprécié par les utilisatrices et les prestataires de soins. Les motifs de satisfaction chez les utilisatrices étaient l´amélioration des échanges avec les prestataires de soin et l´accès à des soins de meilleure qualité à moindre coût. Les agents de santé ont apprécié la pertinence du système PANDA et l´amélioration des prestations fournies, du suivi et de la prise en charge des femmes enceintes.

Conclusion

le système PANDA est très bien accepté et apprécié au niveau des soins primaires aussi bien par les prestataires de soins que par les utilisatrices de services de soins prénataux au Burkina Faso.

Determinants of Low Birth Weight in Ghana: Does Quality of Antenatal Care Matter?

OBJECTIVES

Low birth weight is a public health issue that contributes to perinatal and infant mortality, especially in limited-resource settings, but there is limited understanding of the determinants of low birth weight and the contributions of quality antenatal care to maintaining healthy birth weights for newborns in such settings. This study aims at establishing links between birthweight and quality antenatal care in Ghana.

METHODS

We used data collected from the recent 2017 Ghana Maternal Health Survey and applied complementary log-log models to investigate relationships between the quality of antenatal care (screening/diagnostic procedures, clinical interventions, type of health provider) and low birth weight in Ghana.

RESULTS

The results reveal that compared to women who received low quality clinical interventions, those who received high quality interventions were significantly less likely to have a low birth weight baby. Similarly, women who made the recommended number of antenatal visits (at least eight) were significantly less likely to have a baby with low birth weight than women making fewer visits.

CONCLUSION

Our findings suggest that while the number of antenatal visits is important, the quality of care received during such visits is equally relevant to reducing low birth weight in Ghana.

Are antenatal interventions effective in improving multiple health behaviours among pregnant women? A systematic review protocol

BACKGROUND

Maternal behaviours in pregnancy associated with adverse pregnancy, birth and health outcomes include tobacco smoking, poor nutrition, alcohol consumption and low physical activity, collectively referred to as the SNAP risk factors. Due to the high prevalence, co-occurrence and possible interactive health effects of such health behaviours in pregnancy, antenatal interventions that support pregnant women to improve multiple SNAP behaviours have a greater potential impact on the health outcomes of women and their children than interventions addressing single behaviours. The objective of this review is to determine the effectiveness of interventions delivered as part of antenatal care that aim to improve multiple SNAP behaviours among pregnant women.

METHODS

Seven electronic databases will be searched for potentially eligible studies. Eligible studies will include those where pregnant women are attending antenatal care. Studies that examine the effect of an intervention that addresses multiple SNAP behaviours (≥ 2 behaviours) during pregnancy and are delivered or instigated through antenatal care in a healthcare service will be included. Systematic reviews of randomised controlled trials (RCTs), RCTs, cluster RCTs, stepped-wedge RCTs and non-randomised control trials will be eligible. Studies that include a no-intervention control, wait-list control group, standard/usual care, or another active single behavioural intervention (e.g. addressing one behaviour only) will be considered. Two independent reviewers will conduct study screening, data extraction and risk of bias assessment. Discrepancies will be resolved by consensus or a third reviewer if required. A random effects model will be used to synthesise the results. Alternative synthesis methods will be investigated in instances where a meta-analysis is not appropriate, such as summarising effect estimates, combining P values, vote counting based on direction of effect, or synthesis in narrative form.

DISCUSSION

The review will synthesise the evidence on the effect of interventions that address multiple SNAP behaviours in antenatal care and will help researchers, policy-makers and health services to develop and deliver best practice integrated models of antenatal care that have the potential to impact on both the short- and long-term health outcomes for women and their children.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018095315.

Quality assessment indicators in antenatal care worldwide: a systematic review

PURPOSE

To describe indicators used for the assessment of antenatal care (ANC) quality worldwide under the World Health Organization (WHO) framework and based on a systematic review of the literature.

DATA SOURCES

Searches were performed in MEDLINE, SciELO, BIREME and Web of Science for eligible studies published between January 2002 and September 2016.

STUDY SELECTION

Original articles describing women who had received ANC, any ANC model and, any ANC quality indicators were included.

DATA EXTRACTION

Publication date, study design and ANC process indicators were extracted.

RESULTS OF DATA SYNTHESIS

Of the total studies included, 69 evaluated at least one type of ANC process indicator. According to WHO ANC guidelines, 8.7% of the articles reported healthy eating counseling and 52.2% iron and folic acid supplementation. The evaluation indicators on maternal and fetal interventions were: syphilis testing (55.1%), HIV testing (47.8%), gestational diabetes mellitus screening (40.6%) and ultrasound (27.5%). Essential ANC activities assessment ranged from 26.1% report of fetal heart sound, 50.7% of maternal weight and 63.8% of blood pressure. Regarding preventive measures recommended by WHO, tetanus vaccine was reported in 60.9% of the articles. Interventions performed by health services to improve use and quality of ANC care, promotion of maternal and fetal health, and the number of visits to the ANC were evaluated in 65.2% of the studies.

CONCLUSION

Numerous ANC content indicators are being used to assess ANC quality. However, there is a need to use standardized indicators across countries and efforts to improve quality evaluation.

Recommendations of physical activity and rest in a Colombian prenatal control program

OBJECTIVE

To determine the frequency of the registry of physical activity and rest recommendations made to pregnant women and to explore their associated factors in a prenatal care program of primary care public institutions in Bucaramanga, Colombia.

METHODS

An observational study was conducted. The sampling frame consisted of the medical records of the pregnant women who attended at least one prenatal care program between January 1 and December 31, 2012 (n = 2.932), in 21 primary care health centers. We analyzed sociodemographic variables, prenatal and clinical antecedents, and information related to health personnel and the organization of health centers as possible factors associated with the recommendations of physical activity and rest recorded in the clinical history. Logistic regression models were applied to explore associations with α = 0.10.

RESULTS

There was a frequency of 26.1% of PA recommendations and 3.6% of rest recommendation on record, issued by nutrition (97.3%) and medical (86.7%) professionals, respectively. The factors associated with the registration of physical activity recommendations were: being nulliparous pregnant (OR = 1.7), attending more than four Prenatal Care Attention Programs (OR = 2.2), having high or medium obstetric risk in the first prenatal care program (OR = 0.6), and being attended in the western (OR = 0.5) and eastern (OR = 0.2) administrative areas health centers.

CONCLUSIONS

The low frequency of physical activity recommendations found in the records makes it necessary to reinforce the management strategies of health centers and strengthen the monitoring and accompaniment to comply with the care protocols. In addition, it is necessary to train health teams on the benefits of physical activity and their proper prescription, considering the multiple benefits derived from their practice on the maternal-fetal health.

HIV Infection: Antepartum Treatment and Management

Human immunodeficiency virus (HIV) is a retrovirus which became pandemic in the early 1980s. Since its initial characterization, advancements in diagnosis and management have transformed HIV infection from a terminal diagnosis to a chronic, manageable condition. Effective antiretroviral therapy, acting at multiple steps in the viral lifecycle, durably suppresses viral replication, preserves maternal health and prevents mother to child HIV transmission. Here, we review the salient clinical and ethical considerations of managing HIV infection during pregnancy and delivery.

Mobile Phone Access and Willingness Among Mothers to Receive a Text-Based mHealth Intervention to Improve Prenatal Care in Northwest Ethiopia: Cross-Sectional Study

BACKGROUND

Maternal mortality remains high in many low- and middle-income countries where limited access to health services is linked to low antenatal care utilization. Effective communication and engagement with care providers are vital for the delivery and receipt of sufficient health care services. There is strong evidence that simple text-based interventions can improve the prenatal care utilization, but most mobile health (mHealth) interventions are not implemented on a larger scale owing to the lack of context and preliminary evidence on how to make the transition.

OBJECTIVE

The objective of this study was to determine access to mobile phones by pregnant women attending antenatal care as well as willingness to receive a text message (short message service, SMS)-based mHealth intervention for antenatal care services and identify its associated factors among pregnant women attending an antenatal care clinic in Gondar Town Administration, Northwest Ethiopia, Africa.

METHODS

A cross-sectional quantitative study was conducted among 422 pregnant women attending antenatal care from March 27 to April 28, 2017. Data were collected using structured questionnaires. Data entry and analysis were performed using Epi-Info version 7 and SPSS version 20, respectively. In addition, descriptive statistics and bivariable and multivariable logistic regression analyses were performed. Furthermore, odds ratio with 95% CI was used to identify factors associated with the willingness to receive a text message-based mHealth intervention.

RESULTS

A total of 416 respondents (response rate 98.6%, 416/422) were included in the analysis. About 76.7% (319/416) of respondents owned a mobile phone and 71.2% (296/416) were willing to receive an SMS text message. Among the mobile phone owners, only 37.6% (120/319) were having smartphones. Of all women with mobile phones, 89.7% (286/319) described that they are the primary holders of these phones and among them, 85.0% (271/319) reported having had the same phone number for more than a year. Among the phone owners, 90.0% (287/319) described that they could read and 86.8% (277/416) could send SMS text messages using their mobile phones in their day-to-day activities. Among pregnant women who were willing to receive SMS text messages, about 96.3% (285/296) were willing to receive information regarding activities or things to avoid during pregnancy. Factors associated with willingness were youth age group (adjusted odds ratio [AOR] 2.869, 95% CI 1.451-5.651), having attained secondary and higher educational level (AOR 4.995, 95% CI 1.489-14.773), and the frequency of mobile phone use (AOR 0.319, 95% CI 0.141-0.718).

CONCLUSIONS

A high proportion of pregnant women in an antenatal care clinic in this remote setting have a mobile phone and are willing to receive an SMS text message-based mHealth intervention. Age, educational status, and the frequency of mobile phone use are significantly associated with the willingness to receive SMS text message-based mHealth interventions.

Clinical guidelines for prevention and management of preterm birth: a systematic review

BACKGROUND

Clinical practice guidelines (CPG) endorse multiple strategies to prevent or manage preterm birth (PTB).

OBJECTIVES

To summarise CPG recommendations for PTB and identify areas of international consensus.

SEARCH STRATEGY

In May 2017 we searched for all CPG relevant to PTB without language restrictions.

SELECTION CRITERIA

CPG were eligible if the following criteria were met: (1) the guideline was published or current from June 2013; (2) the guideline recommended practices for the prevention or management of PTB relevant to our prespecified clinical questions for screening, medications or surgery and other interventions; (3) publications on methods of guideline development for eligible CPG were included to enable quality assessment.

DATA COLLECTION AND ANALYSIS

Two authors classified CPG recommendations relevant to prespecified clinical questions. When more than 70% of CPGs reporting on a topic recommended or rejected an intervention, we regarded this as consensus. We summarised recommendations in tables.

MAIN RESULTS

We identified 49 guidelines from 16 guideline developers. We found consensus for several clinical practices: cervical length screening for high-risk women; short-term tocolysis; steroids for fetal lung maturation; and magnesium sulphate for fetal neuroprotection. We found discrepant recommendations for progesterone and fibronectin. No guideline identified an effective strategy for women with multiple pregnancy.

CONCLUSIONS

We identified interventions for which there is an international consensus on benefit for PTB. Systematic reviews of CPG using standardised methodology will help avoid duplication and target scarce resources for guideline developers globally.

TWEETABLE ABSTRACT

International clinical guidelines agree on the benefits and harmful effects of several important interventions to prevent preterm birth.

Framework for the establishment of a feasible, tailored and effective perinatal education programme

BACKGROUND

Antenatal education needs to be renewed and adapted to the needs of women.

OBJECTIVES

to assess women needs, identify factors that influence the desired outcomes, and propose a framework for developing new perinatal education based on the guidance published by the UK Medical Research Council for the development and evaluation of complex interventions in primary care.

METHODS

For this study: (a) four focus group sessions were held from October to November 2010 in Bizkaia (Spain) with 30 women exploring their needs during pregnancy and postpartum; (b) two literature reviews were conducted on women's needs at these times and theoretical models of healthcare education; and (c) seven discussion and consensus sessions were run with a group of experts composed of midwifes, gynaecologists, paediatricians, and paediatric and postpartum nurses.

RESULTS

Various areas for improvement were identified: needs assessment of each woman/family, consideration of pregnancy and childbirth as normal physiological processes, participation of fathers, establishment of social networks, continuity of postpartum care, better access to and training for midwives, and more flexible format and contents for the programme. We propose a woman-focused framework that includes three exploratory interviews during pregnancy, personalized interventions coordinated between professionals, empowerment to choose the type of birth, and postpartum activities.

CONCLUSION

New perinatal education should be on-going and focused on each woman. It is necessary to assess the feasibility of implementing this type of programme, depending on the context, professionals' readiness for change and characteristics of the proposed interventions. Then, its effectiveness and sustainability must be assessed.

Maternal and Newborn Health in Karnataka State, India: The Community Level Interventions for Pre-Eclampsia (CLIP) Trial's Baseline Study Results

Existing vital health statistics registries in India have been unable to provide reliable estimates of maternal and newborn mortality and morbidity, and region-specific health estimates are essential to the planning and monitoring of health interventions. This study was designed to assess baseline rates as the precursor to a community-based cluster randomized control trial (cRCT)–Community Level Interventions for Pre-eclampsia (CLIP) Trial (NCT01911494; CTRI/2014/01/004352). The objective was to describe baseline demographics and health outcomes prior to initiation of the CLIP trial and to improve knowledge of population-level health, in particular of maternal and neonatal outcomes related to hypertensive disorders of pregnancy, in northern districts the state of Karnataka, India. The prospective population-based survey was conducted in eight clusters in Belgaum and Bagalkot districts in Karnataka State from 2013–2014. Data collection was undertaken by adapting the Maternal and Newborn Health registry platform, developed by the Global Network for Women’s and Child Health Studies. Descriptive statistics were completed using SAS and R. During the period of 2013–2014, prospective data was collected on 5,469 pregnant women with an average age of 23.2 (+/-3.3) years. Delivery outcomes were collected from 5,448 completed pregnancies. A majority of the women reported institutional deliveries (96.0%), largely attended by skilled birth attendants. The maternal mortality ratio of 103 (per 100,000 livebirths) was observed during this study, neonatal mortality ratio was 25 per 1,000 livebirths, and perinatal mortality ratio was 50 per 1,000 livebirths. Despite a high number of institutional deliveries, rates of stillbirth were 2.86%. Early enrollment and close follow-up and monitoring procedures established by the Maternal and Newborn Health registry allowed for negligible lost to follow-up. This population-level study provides regional rates of maternal and newborn health in Belgaum and Bagalkot in Karnataka over 2013–14. The mortality ratios and morbidity information can be used in planning interventions and monitoring indicators of effectiveness to inform policy and practice. Comprehensive regional epidemiologic data, such as that provided here, is essential to gauge improvements and challenges in maternal health, as well as track disparities found in rural areas.

Beyond too little, too late and too much, too soon: a pathway towards evidence-based, respectful maternity care worldwide

On the continuum of maternal health care, two extreme situations exist: too little, too late (TLTL) and too much, too soon (TMTS). TLTL describes care with inadequate resources, below evidence-based standards, or care withheld or unavailable until too late to help. TLTL is an underlying problem associated with high maternal mortality and morbidity. TMTS describes the routine over-medicalisation of normal pregnancy and birth. TMTS includes unnecessary use of non-evidence-based interventions, as well as use of interventions that can be life saving when used appropriately, but harmful when applied routinely or overused. As facility births increase, so does the recognition that TMTS causes harm and increases health costs, and often concentrates disrespect and abuse. Although TMTS is typically ascribed to high-income countries and TLTL to low-income and middle-income ones, social and health inequities mean these extremes coexist in many countries. A global approach to quality and equitable maternal health, supporting the implementation of respectful, evidence-based care for all, is urgently needed. We present a systematic review of evidence-based clinical practice guidelines for routine antenatal, intrapartum, and postnatal care, categorising them as recommended, recommended only for clinical indications, and not recommended. We also present prevalence data from middle-income countries for specific clinical practices, which demonstrate TLTL and increasing TMTS. Health-care providers and health systems need to ensure that all women receive high-quality, evidence-based, equitable and respectful care. The right amount of care needs to be offered at the right time, and delivered in a manner that respects, protects, and promotes human rights.

Women's perceptions of antenatal care: are we following guideline recommended care?

Background

Detection and management of antenatal risk factors is critical for improved maternal and infant outcomes. This study describes the proportion of pregnant women who self-reported being screened for and offered advice to manage antenatal risk factors in line with antenatal care recommendations; and the characteristics associated with rates of screening.

Methods

A survey was undertaken with 223 (64 % of eligible) pregnant women recruited from an outpatient obstetrics clinic at a public hospital. Participants self-reported whether they were: (i) screened for 23 guideline-recommended risk factors during their antenatal visit; (ii) offered assistance to manage identified risk factor(s); and (iii) received assistance that was of benefit. Association between rate of screening and participant characteristics was examined using multivariate quantile regression.

Results

Overall, 23 % of women reported that they were asked about every risk factor. Weight gain (48 %), diet (60 %) and oral health (31 %) were least frequently screened risk factors. The number of women who reported they were offered advice to manage identified risks and the value of that advice was perceived by women as suboptimal. Those women receiving shared care between a midwife and general practitioner, of Aboriginal or Torres Strait Islander descent, and without private health insurance reported being screened for a greater number of risk factors.

Conclusions

Pregnant women report suboptimal rates of screening and management of antenatal risk factors. Initiatives to improve consistency in detection of antenatal risk factors and the application of appropriate interventions to manage those risk factors that are detected are required.

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.