The impact of implementing the 2016 WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience on perinatal deaths: an interrupted time-series analysis in Mpumalanga province, South Africa

Late initiation of antenatal care and associated factors among pregnant women attending antenatal clinic at Hiwot Fana Comprehensive Specialized Hospital, Eastern Ethiopia: a cross-sectional study

Background

Late initiation of antenatal care (ANC) is a major public health concern. If women initiate ANC late, they do not get adequate care, reducing the chances of early detection of pregnancy-related complications. However, there is a lack of data related to the initiation of antenatal care in the study area.

Objectives

To assess the prevalence of late initiation of antenatal care and identify associated factors among pregnant women attending antenatal care at Hiwot Fana Comprehensive Specialized Hospital, Eastern Ethiopia.

Methods

An institutional-based cross-sectional study design was conducted among 454 pregnant women. All eligible participants during the study period were included. Data were collected via face-to-face interviews, were entered into Epi Data version 4.3, and analyzed using SPSS version 22 software. The results are presented using texts and tables. Logistic regression with the 95% confidence interval (CI) was used to identify factors associated with the late initiation of antenatal care. Statistical significance was declared at P < 0.05.

Results

The prevalence of late-initiation antenatal care in this study was 59.5% (95% CI 54.6-63.4). Age range of 30-34 years [adjusted odds ratio (AOR) 2.7, 95% CI 1.69-13.1] and age ≥35 years (AOR 4.2, 95% CI 1.92-9.84), rural residency (AOR 2.92, 95% CI 1.59-5.39), unplanned pregnancy (AOR 2.3, 95% CI 1.35-8.11), inability to make the decision to start ANC (AOR 2.14, 95% CI 1.18-3.89), multigravidity (AOR 1.9, 95% CI 1.13-12.4), wrong perception on the time of antenatal care initiation (AOR 5.8, 95% CI 3.71-9.34), lack of previous ANC experience (AOR 2.01, 95% CI 1.14-5.81), and more than 10 km distance from the hospital (AOR 1.36, 95% CI 0.62-2.95) were associated with late initiation antenatal care in this study.

Conclusion

More than half of the study participants were initiated into ANC after the 12th week of gestation. Moreover, rural residence, unplanned pregnancy, age ≥30 years, lack of previous antenatal care, inability to make decisions, and wrong perception on the time of initiation of ANC were found to be associated with late initiation of ANC. Educating women and involving partners and family members in discussions about ANC were recommended to build a supportive environment for pregnant mothers.

Impact of the COVID-19 pandemic on maternal, neonatal and child health service utilisation, delivery and health outcomes in Gauteng province, South Africa: an interrupted time series (ITS) analysis

BACKGROUND

Gauteng was one of the provinces in South Africa most hit by COVID-19. However, there has been no assessment of the pandemic's impact on essential maternal, neonatal and child health (MNCH) services in Gauteng, for planning against future emergencies. This study sought to assess the impact of the COVID-19 pandemic on essential MNCH service utilisation, delivery and health outcomes in Gauteng province.

METHODS

We employed a quasi-experimental interrupted time series (ITS) study design, using the District Health Information System (DHIS) data set to evaluate the impact of COVID-19 on eight key MNCH indicators between March 2019 to February 2021. Using Stata V.17.0 and 5% alpha, a segmented linear regression (ITS) model quantified the trends of the indicators before COVID-19 (March 2019 to February 2020) (β1), the immediate change in level due to the March 2020 lockdown (β2), the post-lockdown (March 2020 to February 2021) trend (β4) and the change in gradient from before to after the lockdown (β3).

RESULTS

COVID-19 lockdown exerted a significant decline in primary healthcare headcount<5 years (n) (β2= -60 106.9 (95% CI, -116 710.4; -3503.3), p=0.039); and postnatal care visits within 6 days (rate) (β2=-8.2 (95% CI, -12.4; -4.1), p=0.001). Antenatal care first visits before 20 weeks (rate) declined during COVID-19 (β3=-0.4 (95% CI, -0.7; -0.1), p=0.013) compared with the pre-COVID-19 period. COVID-19 adverse effects on service delivery (measles second dose coverage and fully immunised<1 year) and health outcomes (facility deaths 0-6 days, maternal mortality ratio and pneumonia case fatality<1 year) were insignificant. While some indicators post-lockdown attempted to recover, others deteriorated.

CONCLUSION

In Gauteng province, the COVID-19 pandemic significantly disrupted essential MNCH service utilisation, particularly during the March 2020 lockdown. The mechanism of MNCH service disruption by COVID-19 was induced by both supply and demand services. It is imperative to strike a balance between maintaining routine healthcare services and managing an outbreak.

Perinatal care and its association with perinatal death among women attending care in three district hospitals of western Uganda

BACKGROUND

Provision of effective care to all women and newborns during the perinatal period is a viable strategy for achieving the Sustainable Development Goal 3 targets on reducing maternal and neonatal mortality. This study examined perinatal care (antenatal, intrapartum, postpartum) and its association with perinatal deaths at three district hospitals in Bunyoro region, Uganda.

METHODS

A cross-sectional study was conducted in which a questionnaire was administered consecutively to 872 postpartum women before discharge who had attended antenatal care and given birth in the study hospitals. Data on care received during antenatal, labour, delivery, and postpartum period, and perinatal outcome were extracted from medical records of the enrolled postnatal women using a pre-tested structured tool. The care received from antenatal to 24 h postpartum period was assessed against the standard protocol of care established by World Health Organization (WHO). Poisson regression was used to assess the association between care received and perinatal death.

RESULTS

The mean age of the women was 25 years (standard deviation [SD] 5.95). Few women had their blood tested for hemoglobin levels, HIV, and Syphilis (n = 53, 6.1%); had their urine tested for glucose and proteins (n = 27, 3.1%); undertook an ultrasound scan (n = 262, 30%); and had their maternal status assessed (n = 122, 14%) during antenatal care as well as had their uterus assessed for contraction and bleeding during postpartum care (n = 63, 7.2%). There were 19 perinatal deaths, giving a perinatal mortality rate of 22/1,000 births (95% Confidence interval [CI] 8.1-35.5). Of these 9 (47.4%) were stillbirths while the remaining 10 (52.6%) were early neonatal deaths. In the antenatal phase, only fetal examination was significantly associated with perinatal death (adjusted prevalence ratio [aPR] = 0.22, 95% CI 0.1-0.6). No significant association was found between perinatal deaths and care during labour, delivery, and the early postpartum period.

CONCLUSION

Women did not receive all the required perinatal care during the perinatal period. Perinatal mortality rate in Bunyoro region remains high, although it's lower than the national average. The study shows a reduction in the proportion of perinatal deaths for pregnancies where the mother received fetal monitoring. Strategies focused on strengthened fetal status monitoring such as fetal movement counting methods and fetal heart rate monitoring devices during pregnancy need to be devised to reduce the incidence of perinatal deaths. Findings from the study provide valuable information that would support the strengthening of perinatal care services for improved perinatal outcomes.

The prevalence of abnormal Doppler's of the umbilical artery in a low-risk pregnant population in South Africa

BACKGROUND

The assessment of fetal blood flow using Doppler waveform can be used to identify placental insufficiency, and hence is a tool to identify fetuses at risk of stillbirth due to fetal growth restriction (FGR). In South Africa the largest category of perinatal deaths is 'unexplained intrauterine death'. The majority of the mothers are clinically healthy women. This study was performed to determine the prevalence of abnormal umbilical resistance indices (abnormal RI) to see if screening a low-risk pregnant population is worthwhile.

METHODS

A descriptive study across 9 sites in 8 provinces of South Africa was performed to determine the prevalence of abnormal RI of the umbilical artery in women classified as having a low-risk pregnancy. The study was conducted from 1st September 2017- February 2020.The pregnant women classified were screened using a continuous wave Doppler ultrasound apparatus (Umbiflow™) between 28 and 34 weeks' gestation. Women with fetuses with an abnormal RI were referred to a high-risk clinic and were managed according to standard protocol. The outcomes of all the deliveries were recorded.

FINDINGS

Umbiflow™ screening of the umbilical artery was performed in 7088 women across nine sites; 919 (13·0%) fetuses had an abnormal RI. Absent end diastolic flow (AEDF) was found in 87 (1·2%) fetuses. The prevalence of small for gestational ages (SGA) babies was 23·1% in the normal RI group and was significantly higher in the abnormal RI group 32·1% (p<0·0001). There was a statistical difference in the perinatal mortality rate between the normal RI (9.8/1000) and abnormal RI group (21.4/1000) [RR 0·046; 95% CI -0·06-0·98].

INTERPRETATION

The prevalence of abnormal RI and AEDF in this screened low-risk population was about ten times higher than that previously recorded in high income countries. Continuous wave Doppler ultrasound screening detected previously undiagnosed growth restricted babies. The prevalence of AEDF warrants continuous wave Doppler ultrasound screening of the low-risk pregnant population in South Africa.

FUNDING

This study was funded by the South African Medical Research Council (SAMRC) and the Council for Scientific and Industrial Research (CSIR).

Implementing antenatal care recommendations, South Africa

Despite progress in reduction in maternal deaths in South Africa, deaths due to complications of hypertension in pregnancy remain high at 26 deaths per 100 000 live births in 2016. The South African health ministry modified its existing four-visit antenatal care model to align with the World Health Organization’s (WHO) 2016 recommendations for the number and content of antenatal care contacts. Implementation of the eight-contact antenatal care recommendations began in April 2017, after adaptation to the national context and nationwide trainings. In this article, we describe the stages of implementation and the monitoring of key indicators. We share lessons, particularly from the important early stages of nationwide scale-up and an analysis of the early results. We analysed samples of maternity case records in four catchment areas in the first year of the updated care model. The mean number of antenatal care contacts among five monthly samples of 200 women increased steadily from 4.76 (standard deviation, SD: 2.0) in March 2017 to 5.90 (SD: 2.3) in February 2018. The proportion of women with hypertension detected who received appropriate action (provision of medical treatment or referral) also increased from 83.3% (20/24) to 100.0% (35/35) over the same period. South Africa’s experiences with implementation of the updated antenatal care package shows that commitment from all stakeholders is essential for success. Training and readiness are key to identifying and managing women with complications and developing an efficient antenatal care system accessible to all women.