1
|
Abdissa Z, Alemu K, Lemma S, Berhanu D, Defar A, Getachew T, Schellenberg J, Marchant T, Shiferaw S, Tariku A, Guadu T, Taye G, Zelalem M, Persson LA. Effective coverage of antenatal care services in Ethiopia: a population-based cross-sectional study. BMC Pregnancy Childbirth 2024; 24:330. [PMID: 38678206 PMCID: PMC11055385 DOI: 10.1186/s12884-024-06536-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 04/21/2024] [Indexed: 04/29/2024] Open
Abstract
BACKGROUND Antenatal care (ANC) is a principal component of safe motherhood and reproductive health strategies across the continuum of care. Although the coverage of antenatal care visits has increased in Ethiopia, there needs to be more evidence of effective coverage of antenatal care. The 'effective coverage' concept can pinpoint where action is required to improve high-quality coverage in Ethiopia. Effective coverage indicates a health system's performance by incorporating need, utilization, and quality into a single measurement. The concept includes the number of contacts, facility readiness, interventions received, and components of services received. This study aimed to measure effective antenatal care coverage in Ethiopia. METHODS A two-stage cluster sampling method was used and included 2714 women aged 15-49 years and 462 health facilities from six Ethiopian regions from October 2019 to January 2020. The effective coverage cascade was analyzed among the targeted women by computing the proportion who received four or more antenatal care visits where the necessary inputs were available, received iron-folate supplementation and two doses of tetanus vaccination according to process quality components of antenatal care services. RESULTS Of all women, 40% (95%CI; 38, 43) had four or more visits, ranging from 3% in Afar to 74% in Addis Ababa. The overall mean health facility readiness score of the facilities serving these women was 70%, the vaccination and iron-folate supplementation coverage was 26%, and the ANC process quality was 64%. As reported by women, the least score was given to the quality component of discussing birth preparedness and complication readiness with providers. In the effective coverage cascade, the input-adjusted, intervention-adjusted, and quality-adjusted antenatal coverage estimates were 28%, 18%, and 12%, respectively. CONCLUSION The overall effective ANC coverage was low, primarily due to a considerable drop in the proportion of women who completed four or more ANC visits. Improving quality of services is crucial to increase ANC up take and completion of the recommended visits along with interventions increasing women's awareness.
Collapse
Affiliation(s)
- Zewditu Abdissa
- Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
- Department of Anesthesia, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
- Department of Environmental Health, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia.
| | - Kassahun Alemu
- Department of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Seblewengel Lemma
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Della Berhanu
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Atkure Defar
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Theodros Getachew
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Joanna Schellenberg
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Tanya Marchant
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| | - Solomon Shiferaw
- School of Public Health, Addis Ababa University, Addis Ababa, Ethiopia
| | - Amare Tariku
- Department of Nutrition, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Tadesse Guadu
- Department of Nutrition, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Girum Taye
- Health System and Reproductive Health Research Directorate, Ethiopian Public Health Institute, Addis Ababa, Ethiopia
| | - Meseret Zelalem
- Maternal, Child and Adolescent Health Service Lead Executive Office, Federal Ministry of Health, Addis Ababa, Ethiopia
- Department of Pediatrics and Child Health, School of Medicine, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
| | - Lars Ake Persson
- Department of Disease Control, Faculty of Infectious and Tropical Diseases, London School of Hygiene and Tropical Medicine, London, UK
| |
Collapse
|
2
|
Xie X, Munos MK, Lama TP, Bryce E, Khatry SK, LeClerq SC, Katz J. Validation of maternal recall of number of antenatal care visits attended in rural Southern Nepal: a longitudinal cohort study. BMJ Open 2023; 13:e079029. [PMID: 38072474 PMCID: PMC10729047 DOI: 10.1136/bmjopen-2023-079029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 11/23/2023] [Indexed: 12/18/2023] Open
Abstract
OBJECTIVES This study aimed to examine the validity of maternal recall of total number of antenatal care (ANC) visits during pregnancy and factors associated with the accuracy of maternal recall. DESIGN This was a longitudinal cohort study conducted from December 2018 through November 2020. SETTING Five government health posts in the Sarlahi district of Southern Nepal. PARTICIPANTS 402 pregnant women between ages 15 and 49 who presented for their first ANC visit at the study health posts. MAIN OUTCOMES The observed number of ANC visits (gold standard) and the reported number of ANC visits at the postpartum interview (maternal recall). RESULTS On average, women in the study who had a live birth attended 4.7 ANC visits. About 65% of them attended four or more ANC visits during pregnancy as recommended by the Nepal government, and 38.3% of maternal report matched the categorical ANC visits as observed by the gold standard. The individual validity was poor to moderate, with the highest area under the receiver operating characteristic curve (AUC) being 0.69 (95% CI: 0.65 to 0.74) in the 1-3 visits group. Population-level bias (as distinct from individual-level bias) was observed in the 1-3 visits and 4 visits groups, where 1-3 visits were under-reported (inflation factor (IF): 0.69) and 4 ANC visits were highly over-reported (IF: 2.12). The binary indicator ANC4+ (1-3 visits vs 4+ visits) showed better population-level validity (AUC: 0.69; IF: 1.17) compared with the categorical indicators (1-3 visits, 4 visits, 5-6 visits and more than 6 visits). Report accuracy was not associated with maternal characteristics but was related to ANC frequency. Women who attended more ANC visits were less likely to correctly report their total number of visits. CONCLUSION Maternal report of number of ANC visits during pregnancy may not be a valid indicator for measuring ANC coverage. Improvements are needed to measure the frequency of ANC visits.
Collapse
Affiliation(s)
- Xinyu Xie
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Melinda K Munos
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Tsering P Lama
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Emily Bryce
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Subarna K Khatry
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Nepal Nutrition Intervention Project Sarlahi, Lalitpur, Nepal
| | - Steven C LeClerq
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Nepal Nutrition Intervention Project Sarlahi, Lalitpur, Nepal
| | - Joanne Katz
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| |
Collapse
|
3
|
Thorne-Lyman AL, Lama TP, Heidkamp RA, Munos MK, Manandhar P, Khatry SK, Bryce E, LeClerq SC, Katz J. How does social desirability bias influence survey-based estimates of the use of antenatal care in rural Nepal? A validation study. BMJ Open 2023; 13:e071511. [PMID: 37495390 PMCID: PMC10373690 DOI: 10.1136/bmjopen-2022-071511] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/28/2023] Open
Abstract
OBJECTIVES Social desirability bias is often speculated to influence survey responses but seldom studied in healthcare. The objective was to explore whether social desirability scores (SDS) or the presence of interview observers is associated with inaccurate recall and overestimation of antenatal care (ANC) services. DESIGN Longitudinal validation study comparing recalled receipt of ANC services and nutrition components of ANC against direct observations of care. An adapted short form Marlowe-Crowne questionnaire was used to generate an SDS, and the presence of interview observers was treated as a separate exposure. We assessed accuracy and overestimation of recalled receipt of ANC services against observed receipt using log-binomial regression, adjusting for age, education, first-pregnancy and socioeconomic status. SETTING Rural Southern Nepal with recruitment from five government health posts. PARTICIPANTS 401 pregnant women. RESULTS Social desirability scores did not significantly predict accuracy or overestimation of most types of ANC care except counselling on nausea. Higher SDS was associated with more accurate recall (adjusted RR, aRR 1.08 (95% CI 1.03, 1.12)) and less overestimation (aRR 0.85 (0.80, 0.91)). The presence of mothers-in-law or husbands during interviews was associated with greater overestimation of the number of ANC visits received by more than three visits (aRR 2.07 (1.11, 3.84)) and (aRR 4.19 (2.17, 8.10)), respectively. Those interviewed with friends present tended to overestimate the receipt of counselling on nausea, avoiding alcohol and not smoking. CONCLUSION The presence of observers can lead to overestimation of the receipt of ANC care and support the conduct of interviews in private settings despite challenges of doing so in village contexts. Findings that the SDS did not predict the accuracy of most types of ANC care might reflect a reality that such questions may not be sensitive from a social-norms perspective. Additional local adaptation of SDS is recommended.
Collapse
Affiliation(s)
- Andrew L Thorne-Lyman
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Tsering P Lama
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Nepal Nutrition Intervention Project, Sarlahi, Kathmandu, Nepal
| | - Rebecca A Heidkamp
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Melinda K Munos
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Porcia Manandhar
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Subarna K Khatry
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Nepal Nutrition Intervention Project, Sarlahi, Kathmandu, Nepal
| | - Emily Bryce
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Jhpiego, Baltimore, MD, USA
| | - Steven C LeClerq
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
- Nepal Nutrition Intervention Project, Sarlahi, Kathmandu, Nepal
| | - Joanne Katz
- Department of International Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| |
Collapse
|
4
|
Kim SS, Ashok S, Avula R, Mahapatra T, Gokhale P, Walton S, Heidkamp RA, Munos MK. Moderate Accuracy of Survey Responses about Infant and Young Child Feeding Counseling Reported by Mothers with Children Less than 1 Year of Age in India. J Nutr 2023; 153:1220-1230. [PMID: 36796483 DOI: 10.1016/j.tjnut.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 02/03/2023] [Accepted: 02/09/2023] [Indexed: 02/16/2023] Open
Abstract
BACKGROUND Counseling on infant and young child feeding (IYCF) to support optimal breastfeeding and complementary feeding practices is an essential intervention, and accurate coverage data is needed to identify gaps and monitor progress. However, coverage information captured during household surveys has not yet been validated. OBJECTIVES We examined the validity of maternal reports of IYCF counseling received during community-based contacts and factors associated with reporting accuracy. METHODS Direct observations of home visits conducted by community workers in 40 villages in Bihar, India served as the "gold standard" to maternal reports of IYCF counseling received during 2-wk follow-up surveys (n = 444 mothers with children less than 1 y of age, interviews matched to direct observations). Individual-level validity was assessed by calculating sensitivity, specificity, and AUC. Population-level bias was measured using the inflation factor (IF). Multivariable regression models were used to examine factors associated with response accuracy. RESULTS Prevalence of IYCF counseling during home visits was very high (90.1%). Maternal report of any IYCF counseling received in the past 2 wk was moderate (AUC: 0.60; 95% CI: 0.52, 0.67), and population bias was low (IF = 0.90). However, the recall of specific counseling messages varied. Maternal report of any breastfeeding, exclusive breastfeeding, and dietary diversity messages had moderate validity (AUC > 0.60), but other child feeding messages had low individual validity. Child age, maternal age, maternal education, mental stress, and social desirability were associated with reporting accuracy of multiple indicators. CONCLUSIONS Validity of IYCF counseling coverage was moderate for several key indicators. IYCF counseling is an information-based intervention that may be received from various sources, and it may be challenging to achieve higher reporting accuracy over a longer recall period. We consider the modest validity results as positive and suggest that these coverage indicators may be useful for measuring coverage and tracking progress over time.
Collapse
Affiliation(s)
- Sunny S Kim
- Poverty, Health and Nutrition Division, International Food Policy Research Institute (IFPRI), Washington, DC, USA.
| | | | | | | | - Priya Gokhale
- CARE India Solutions for Sustainable Development, Bihar, India
| | - Shelley Walton
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Rebecca A Heidkamp
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Melinda K Munos
- Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland, USA
| |
Collapse
|
5
|
L-Thorne-Lyman A, Lama TP, Heidkamp RA, Manandhar P, Subedi S, Munos MK, Bryce E, Khatry SK, LeClerq SC, Katz J. Cognitive testing of questions about antenatal care and nutrition interventions in southern Nepal. Soc Sci Med 2022; 311:115318. [PMID: 36099684 PMCID: PMC9554791 DOI: 10.1016/j.socscimed.2022.115318] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 05/31/2022] [Accepted: 08/25/2022] [Indexed: 11/16/2022]
Abstract
Large scale surveys such as the Demographic and Health Surveys (DHS) are used to measure the coverage and quality of antenatal care (ANC)-related services. Studies have increasingly validated questions from these surveys, though few have explored respondent comprehension or associated thought processes. This study aimed to use cognitive testing and validation approaches to understand how survey respondents understand questions related to ANC-related nutrition services. The study was nested within a larger validation study in southern Nepal. Pregnant women's receipt of ANC related services was directly observed at five health posts followed by a recall interview at 6 months postpartum. A week later, a survey module was re-administered to 30 women containing 15 questions about receipt of ANC care and specifically nutrition-related services. Detailed probing was used to identify cognitive challenges related to comprehension, retrieval, judgement, and response. Respondents accurately recalled the four specific ANC visits recommended by the government of Nepal but those with more visits struggled to estimate the total number of ANC visits they had made. A number of terms including "antenatal care, "nutrition" and "breastfeeding" were challenging for many respondents to understand. Visits to private providers including for ultrasounds were inconsistently included in ANC visit counts suggesting that question wording could better specify the type of care. Many respondents over-estimated the number of iron folic acid (IFA) supplements taken during pregnancy, and recall was challenging. Calculations were based on estimating the number of months between first ANC visit to delivery, and only sometimes factored in missed tablets. Opportunities exist to improve questions to facilitate better comprehension by respondents through a combination of using local terms and explanations, reordering some questions, and adapting questions to better match respondents' approaches to estimating numeric responses.
Collapse
Affiliation(s)
- Andrew L-Thorne-Lyman
- Department of International Health, 615 N. Wolfe Street E2545, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA.
| | - Tsering Pema Lama
- Department of International Health, 615 N. Wolfe Street E2545, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA; Nepal Nutrition Intervention Project-Sarlahi, Kathmandu, Nepal.
| | - Rebecca A Heidkamp
- Department of International Health, 615 N. Wolfe Street E2545, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA.
| | - Porcia Manandhar
- Department of International Health, 615 N. Wolfe Street E2545, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA.
| | - Seema Subedi
- Department of International Health, 615 N. Wolfe Street E2545, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA.
| | - Melinda K Munos
- Department of International Health, 615 N. Wolfe Street E2545, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA.
| | - Emily Bryce
- Department of International Health, 615 N. Wolfe Street E2545, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA.
| | - Subarna K Khatry
- Department of International Health, 615 N. Wolfe Street E2545, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA; Nepal Nutrition Intervention Project-Sarlahi, Kathmandu, Nepal.
| | - Steven C LeClerq
- Department of International Health, 615 N. Wolfe Street E2545, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA; Nepal Nutrition Intervention Project-Sarlahi, Kathmandu, Nepal.
| | - Joanne Katz
- Department of International Health, 615 N. Wolfe Street E2545, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, 21205, USA.
| |
Collapse
|