Quality of antenatal care in Zambia: a national assessment

Magnitude, disparity, and predictors of poor-quality antenatal care service: A systematic review and meta-analysis

Background

Antenatal care is directed toward ensuring healthy pregnancy outcomes. Quality antenatal care increases the likelihood of receiving an effective intervention to maintain maternal, fetal, and neonatal well-being, while poor quality is linked to poor pregnancy outcomes. However, owing to the complex nature of quality, researchers have followed several approaches to systematically measure it. The evidence from these variable approaches appears inconsistence and poses challenges to programmers and policymakers. Hence, it is imperative to obtain a pooled estimate of the quality of antenatal care. Therefore, considering the scarcity of evidence on the quality of antenatal care, this study aimed to review, synthesize, and bring pooled estimates of accessible evidence.

Objective

This study aimed to estimate the pooled magnitude and predictors of quality of antenatal care services and compare regional disparity.

Method

We conducted a comprehensive systematic three-step approach search of published and unpublished sources from 2002 to 2022. The methodological quality of eligible studies was checked using Joanna Briggs Institute critical appraisal tool for cross-sectional studies. Meta-analysis was carried out using STATA version 16. Statistical heterogeneity was assessed using Cochran's Q test. In the presence of moderate heterogeneity (I2 more than 50%), sensitivity and subgroup analyses were conducted and presented in a forest plot. Effect size was reported using standardized mean difference and its 95% confidence interval. Funnel plots and Egger's regression test were used to measure publication bias at the 5% significance level. A trim-and-fill analysis was conducted to adjust for publication bias. Pooled estimates were computed using random-effects models and weighted using the inverse variance method in the presence of high heterogeneity among studies. A 95% CI and 5% significance level were considered to declare significance variables.

Results

The global pooled poor-quality antenatal care was 64.28% (95% CI: 59.58%-68.98%) (I2 = 99.97%, p = 0.001). The identified pooled predictors of good-quality antenatal care service were: number of antenatal care visits (fourth and above antenatal care visit) (Adjusted odds ratio (AOR) = 2.6, 95% CI: 1.37-3.84), family wealth index (AOR = 2.72, 95% CI: 1.89-3.55), maternal education attainment (AOR = 3.03, 95% CI: 2.24-3.82), residence (urban dwellers) (AOR = 4.06, 95% CI: 0.95-7.17), and confidentiality antenatal care (AOR = 2.23, 95% CI: -0.36 to -4.82).

Conclusions

The study found regional and country-level disparities in the quality of antenatal care services for pregnant women, where poor-quality antenatal care services were provided for more than two-thirds to three-fourths of antenatal care attendants. Therefore, policymakers and health planners should put a great deal of emphasis on addressing the quality of antenatal care services.

Mapping the Role of Digital Health Interventions to Enhance Effective Coverage of Antenatal Care: A Scoping Review

Background

Antenatal care (ANC) is a core component of maternal health services. However, only half of the pregnant women in LMICs obtain WHO recommended minimum of four antenatal contacts. In addition, ANC 4+ is a commonly used indicator in monitoring ANC utilization. However, contact coverage alone provides no indications of service quality. In recent years, digital health interventions bring opportunities to provide quality maternal health care. Yet, there are few reviews on how digital health interventions contribute to improving effective coverage of antenatal care. A rigorous review that examines the role of digital health interventions in improving effective coverage of antenatal care is needed to examine how digital health solutions were rapidly deployed to support quality antenatal care service delivery.

Objective

This review aimed to map evidence on the role of digital health solutions on quality of antenatal care service to enhance effective ANC coverage.

Methods

A scoping review approach was used and four Databases (PubMed, Cochrane Library, Scopus and Embase) as well as search engines like Advanced Google Search and Google Scholar were searched from September 1 to 8, 2022. Thematic content analysis was used to present the findings.

Results

A total of 1701 articles were searched. A total of 27 full-text studies were included in the final analysis. The most reported use of digital health was for client education and behavior change communication. Most studies showed that digital health interventions have proven effective in improving antenatal care. However, most of the studies did not address to assess the quality of ANC services.

Conclusion

In this review, we found out that digital health solutions targeted at pregnant women can improve antenatal care services. There is body of evidence showing the effectiveness of digital health interventions on a range of maternal health outcomes. Few pieces of literature exist on the use of digital health interventions on the quality of antenatal care services. There is a need for more trial and program evaluation studies that examine the role of digital health interventions on the quality of ANC.

Pregnant women's satisfaction with the quality of antenatal care and the continued willingness to use health facility care in Lusaka district, Zambia

BACKGROUND

Antenatal healthcare (ANC) reduces maternal and neonatal deaths in low-middle-income countries. Satisfaction with ANC services and perception of quality of care are critical determinants of service utilization. The study aimed to assess pregnant women's satisfaction with ANC and identify sociodemographic factors associated with satisfaction and their continued willingness to use or recommend the facility to relatives or friends, in Lusaka district, Zambia.

METHODS

This was a cross-sectional study involving 499 pregnant women in Lusaka district. A combination of stratified, multistage, and systematic sampling procedures was used in selecting health facilities and pregnant women. This allowed the researcher to assess exposure and status simultaneously among individuals of interest in a population. Structured survey instruments and face-face-interview techniques were used in collecting data among pregnant women who were receiving ANC in selected health facilities.

RESULTS

Overall, the proportion of pregnant women who were fully satisfied with ANC was 58.9% (n = 292). Pregnant women's satisfaction score ranged from physical aspects (40.9 - 58.3%), interpersonal aspects (54.3 - 57.9%) to technical aspects of care (46.9 - 58.7%). Husbands' employment status (OR = 0.611, 95%CI = 0.413 - 0.903, p = 0.013), monthly household income level of > 3000 - ≤6000 Kwacha (OR = 0.480, 95%CI = 0.243 - 0.948, p = 0.035 were significantly associated with the interpersonal aspects and the physical aspects of care, respectively. Besides, pregnant women who were in their third trimester (above 33 weeks), significantly predicted satisfaction with the physical environment of antenatal care (OR = 3.932, 95%CI = 1.349 - 11.466, p = 0.012). In terms of the type of health facility, women who utilized ANC from Mtendere (OR = 0.236, 95% CI = 0.093 - 0.595, p = 0.002) and N'gombe (OR = 0.179, 95% CI = 0.064 - 0.504, p = 0.001) clinics were less satisfied with the physical environment of care. Place of residence and educational attainment showed significant association with 'willingness to return'. N'gombe clinic (n = 48, 77.4%) received the lowest consideration for 'future care'.

CONCLUSION

Drawing on Donabedian framework on assessing quality of healthcare, we posit that pregnant women's satisfaction with the quality of antenatal care was low due to concerns about the physical environment of health facilities, the interpersonal relationships between providers and pregnant women as well as the technical aspects of care. All these accounted for pregnant women's dissatisfaction with the quality of care, and the indication of unwillingness to return or recommend the health facilities to colleagues. Consistent with Donabedian framework, we suggest that the codes and ethics of healthcare must be upheld. We also call for policy initiatives to reshape the physical condition of ANC clinics and to reinforce healthcare providers' focus on the 'structures' and the 'processes' relevant to care in addition to the 'outcomes'.

Determinants of early antenatal care booking among pregnant mothers attending antenatal care at public health facilities in the Nole Kaba district, western Ethiopia: unmatched case-control study

BACKGROUND

Early initiation of antenatal care (ANC) is vital for the early detection and treatment of adverse pregnancy outcomes. Despite the widespread convenience of free ANC services, most women in Ethiopia attend their initial antenatal clinic late and fail to come back for follow-up care, which results in both maternal and fetal complications. Despite the fact that assessing the determinants of early ANC booking based on the local context is advised, it is not well studied in the study area.

OBJECTIVE

This study aimed to assess determinants of early ANC booking among pregnant women attending ANC at public health facilities in the Nole Kaba district, western Ethiopia.

METHODS

Facility-based unmatched case-control study design was conducted from April to June 2020. Systematic random sampling was used to select a total of 297 participants. A validated, pretested and structured instrument was used to interview the participants. The data were cleaned and coded before being entered into Epi-Info V.7.2.2.6 and exported to SPSS V.25 for analysis. The logistic regression analyses were done to assess the determinants of early ANC booking. Adjusted odds ratio (AOR) with 95% CI was estimated to measure the strength of the association. The level of statistical significance was set at a p value <0.05.

RESULT

A total of 297 pregnant women participated in the study (99 cases and 198 controls), with a 100% response rate. Place of residence (AOR=2.21, 95% CI 1.11, 2.72), level of education (AOR=3.42, 95% CI 1.01, 6.04), planned pregnancy (AOR=8.01, 95% CI 2.79, 23.03), history of abortion (AOR=5.96, 95% CI 2.07, 17.13), places of previous delivery (AOR=4.57, 95% CI 1.09, 19.12), presence of accompanied by husband during ANC visit (AOR=2.48, 95% CI 2.77, 7.98) and media exposure (AOR=6.95, 95 CI 2.68, 18.02) were found statistically significant.

CONCLUSION AND RECOMMENDATIONS

Places of residence, educational level, pregnancy, having a history of abortion, accompanied by the husband during ANC visit, place of previous delivery and media exposure were significantly associated with early initiation of ANC. Therefore, health extension programmes on early ANC initiation should be strengthened by giving priority to less educated women and living in rural areas.

Can women's reports in client exit interviews be used to measure and track progress of antenatal care services quality? Evidence from a facility assessment census in Malawi

INTRODUCTION

Unlike household surveys, client exit interviews are conducted immediately after a consultation and therefore provides an opportunity to capture routine performance and level of service quality. This study examines the validity and reliability of women's reports on selected ANC interventions in exit interviews conducted in Malawi.

METHODS

Using data from the 2013-2014 Malawi service provision facility census, we compared women's reports in exit interviews regarding the contents of ANC received with reports obtained through direct observation by a trained healthcare professional. The validity of six indicators was tested using two measures: the area under the receiver operating characteristic curve (AUC), and the inflation factor (IF). Reliability of women's reports was measured using the Kappa coefficient (κ) and the prevalence-adjusted bias-adjusted kappa (PABAK). Finally, we examined whether reporting reliability varied significantly by individual and facility characteristics.

RESULTS

Of the six indicators, two concrete and observable measures had high reporting accuracy and met the validity criteria for both AUC ≥ 0.7 and 0.75>IF>1.25, namely whether the provider prescribed or gave malaria prophylaxis (AUC: 0.84, 95% CI: 0.83-0.86; IF: 0.96) or iron/folic tablets (AUC: (0.84 95% CI: 0.81-0.87; IF:1.00). Whereas four measures related to counselling had lower reporting accuracy: whether the provider offered counselling about nutrition in pregnancy (AUC: 0.69, 95%CI: 0.67-0.71; IF = 1.26), delivery preparation (AUC: 0.62, 95% CI: 0.60-065; IF = 0.99), pregnancy related complications (AUC: 0.59, 95%CI: 0.56-0.61; IF = 1.11), and iron/folic acid side effects (AUC:0.58, 95% CI: 0.55-0.60; IF = 1.42). Similarly, the observable measures had high reliability with both κ and PABAK values in the ranges of ≥ 0.61 and ≥ 0.80. Respondent's age, primiparous status, number of antenatal visits, and the type of health provider increased the likelihood of reporting reliability.

CONCLUSION

In order to enhance the measurement of quality of ANC services, our study emphasizes the importance of carefully considering the type of information women are asked to recall and the timing of the interviews. While household survey programmes such as the demographic health survey and multiple indicator cluster survey are commonly used as data sources for measuring intervention coverage and quality, policy makers should complement such data with more reliable sources like routine data from health information systems.

Inadequate receipt of ANC components and associated factors among pregnant women in Northwest Ethiopia, 2020-2021: a community-based cross-sectional study

BACKGROUND

Women's health and pregnancy outcomes are directly depends on the extent of ANC components received during their ANC visits. There are limited information about the components of ANC and associated factors. Therefore, the aim of this study was to assess the magnitude of inadequate recipient of ANC components and associated factors in northwest Ethiopia.

METHODS

This is a community based cross sectional survey conducted in Dabat Demographic and health survey from December 10/2020 to January 10/2021 among women who gave birth within two years before the survey. This study applied a census method to identify and select eligible pregnant women. A structured and pretested questionnaire was used to collect the data. The data was entered into Epi-data version 3.1 and exported to STATA version 14 for analysis purpose. Adjusted Odds Ratio at 95% confidence interval was used to show the association between dependent and independent variables. Statistical significance was declared at a P value less than 0.05.

RESULTS

A total of 871 pregnant women were identified from the survey and included in this study. Overall, 96.67% (95% CI: 95.24, 97.67) had not get adequate (all components) ANC. The components of ANC services were increased from 3.35 to 32.34%, 2.52 to 46.33% 1.96 to 55.8%, 2.31 to 46.53%, 3.54 to 55.75%, 2.46 to 44.62%, 1.18 to 45.96%, and 2.45 to 54.6% for tetanus toxoid Vaccine, HIV/AIDS testing and counseling, danger sign, place of delivery, deworming, iron folic acid, family planning, and breast feeding counseling, from first ANC visit to fourth ANC visit, respectively. Rural residence (AOR = 4.89, 95% CI: 1.21, 19.86), and less than four number of ANC visit (AOR = 5.15, 95% CI: 2.06, 12.86) were significantly associated with inadequate uptake of ANC components.

CONCLUSION

Only three in hundred pregnant women were received adequate ANC components in the study area. Rural residence and less than four number of ANC visit were factors significantly associated with inadequate ANC uptake. Therefore, the district health department managers and program implementers need to train the health care providers about the components of ANC. As well, increasing community and facility awareness of WHO recommendations on ANC visits focusing on rural women is needed.

Assessment of the quality of antenatal care in Mozambique

OBJECTIVE

To assess the quality of antenatal care and its covariates among postpartum women in Mozambique.

DESIGN

Cross-sectional study.

SETTING

The study was undertaken either at the maternity hospital or at home, in Mozambique, in 2019.

PARTICIPANTS

A total of 393 women aged 18 to 49 years were interviewed immediately after giving birth.

MEASUREMENTS

The quality of antenatal care was analysed based on the guidelines of the Ministry of Health of Mozambique: antenatal appointment in the first 16 weeks of gestation, 4 or more antenatal appointments, at least one laboratory test, at least 4 or more clinical-obstetric procedures, 3 doses of the prophylactic intermittent treatment for malaria, 2 doses of the tetanus vaccine, and counselling related to general health care. Women who reported all of these situations were classified as having had quality antenatal care.

FINDINGS

All women reported at least one antenatal care visit, but only 13.0% were classified as having had quality antenatal care. Women who underwent antenatal care in previous pregnancies (aOR=4,28; 95% CI=1,45-12,62) and whose current pregnancy was planned (aOR=2,51; 95% CI=1,11-5,68) were more likely to have quality antenatal care than those who had never had access to antenatal care in previous pregnancies and those who currently had an unplanned pregnancy. It was observed that the criteria recommended by the Ministry of Health were not followed during antenatal care, especially regarding the gestational age at the beginning of antenatal care, the minimum number of consultations, performing blood tests (complete blood count, blood glucose, blood typing and Rh factor) and guidance on signs of risk in pregnancy and childbirth.

KEY CONCLUSIONS

In general, the criteria recommended for quality antenatal care are not incorporated into clinical practice in Mozambique.

IMPLICATIONS FOR PRACTICE

While quality antenatal care is essential to reduce maternal morbidity and mortality, many sub-Saharan countries still have low-quality antenatal care services, which is one of the reasons why these countries have the highest maternal mortality rates worldwide.

Input, process, and output factors contributing to quality of antenatal care services: a scoping review of evidence

BACKGROUND

High-quality antenatal care (ANC) provides a lifesaving opportunity for women and their newborns through providing health promotion, disease prevention, and early diagnosis and treatment of pregnancy-related health issues. However, systematically synthesised evidence on factors influencing the quality of ANC services is lacking. This scoping review aims to systematically synthesize the factors influencing in provision and utilisation of quality ANC services.

METHODS

We conducted a scoping review of published evidence on the quality of ANC services. We searched records on four databases (PubMed, Scopus, Embase, and Google scholar) and grey literature from 1 to 2011 to 30 August 2021. We analysed data using Braun and Clarke's thematic analysis approach. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guideline for the review. We explained themes using the Donabedian healthcare quality assessment model (input-process-output).

RESULTS

Several inputs- and process-related factors contributed to suboptimal quality of ANC in many low and lower- or middle-income countries. Input factors included facility readiness (e.g., lack of infrastructure, provision of commodities and supplies, health workforce, structural and intermediary characteristics of pregnant women, and service delivery approaches). Processes-related factors included technical quality of care (e.g., lack of skilled adequate and timely care, and poor adherence to the guidelines) and social quality (lack of effective communication and poor client satisfaction). These input and process factors have also contributed to equity gaps in utilisation of quality ANC services.

CONCLUSION

Several input and process factors influenced the provision and utilization of optimum quality ANC services. Better health system inputs (e.g., availability of trained workforces, commodities, guidelines, context-specific programs) are essential to creating enabling facility environment for quality ANC services. Care processes can be improved by ensuring capacity-building activities for workforces (training, technical support visits), and mentoring staff working at peripheral facilities. Identifying coverage of quality ANC services among disadvantaged groups could be the initial step in designing and implementing targeted program approaches.

Universal health coverage of five essential health services in mothers before and after the Haiti 2010 earthquake: a retrospective cohort study using difference-in-difference

BACKGROUND

In January 2010, Haiti was hit by a 7.0-magnitude earthquake. The impact of the earthquake on Universal Health Coverage in mothers remains unclear. This study explores the association between the 2010 Haiti earthquake and access to the five quality essential health services among women who gave birth in the two years before and after the earthquake.

METHODS

From the Sixth Demographic and Health Survey in Haiti, we extracted data for women aged 15-49 who had reported a live birth in the two years before and after the 2010 Haiti earthquake. We used difference-in-difference analyses for antenatal care, delivery care, and vaccination, and multivariate logistic regression analyses for family planning and malaria prevention, to assess the impact of the acute damage (household-level damage, such as housing damage and/or loss of a family member, or region-level damage, such as living in a region where 50% or more of the houses were damaged) of the earthquake on these mothers' access to quality essential health services.

RESULTS

Mothers who had not suffered acute earthquake damage were more likely to live in rural areas and had less education and household wealth. The difference-in-difference and multivariate logistic regression analyses did not show strong evidence of any significant association between acute earthquake damage and access to quality health services. However, after the earthquake, access to quality health services deteriorated for both mothers with and without acute earthquake damage (-5.6% and -6.2% for antenatal care, -6.5% and 0% for delivery care, and -9.5% and -13.1% for vaccination, respectively).

CONCLUSIONS

The earthquake adversely affected mothers' access to quality essential health services regardless of their exposure to acute earthquake damage. Mothers in rural areas who avoided such damage might also have experienced long-term negative effects from the earthquake, which was likely exacerbated by other structural factors such as lower education and economic status.

Assessment of quality of antenatal care services in public sector facilities in India

OBJECTIVES

We undertook assessment of quality of antenatal care (ANC) services in public sector facilities in the Indian state of Bihar state delivered under the national ANC programme (Pradhan Mantri Surakshit Matritva Abhiyan, PMSMA).

SETTING

Three community health centres and one subdistrict hospital each in two randomly selected districts of Bihar.

PARTICIPANTS

Pregnant women who sought ANC services under PMSMA irrespective of the pregnancy trimester.

PRIMARY AND SECONDARY MEASURES

Quality ANC services were considered if a woman received all of these services in that visit-weight, blood pressure and abdomen check, urine and blood sample taken, and were given iron and folic acid and calcium tablets. The process of ANC service provision was documented.

RESULTS

Eight hundred and fourteen (94.5% participation) women participated. Coverage of quality ANC services was 30.4% (95% CI 27.3% to 33.7%) irrespective of pregnancy trimester, and was similar in both districts and ranged 3%-83.1% across the facilities. Quality ANC service coverage was significantly lower for women in the first trimester of pregnancy (6.8%, 95% CI 3.3% to 13.6%) as compared with those in the second (34.4%, 95% CI 29.9% to 39.1%) and third (32.9%, 95% CI 27.9% to 38.3%) trimester of pregnancy. Individually, the coverage of weight and blood pressure check-up, receipt of iron folic acid (IFA) and calcium tablets, and blood sample collection was >85%. The coverage of urine sample collection was 46.3% (95% CI 42.9% to 49.7%) and of abdomen check-up was 62% (95% CI 58.6% to 65.3%). Poor information sharing post check-up was done with the pregnant women. Varied implementation of ANC service provision was seen in the facilities as compared with the PMSMA guidelines, in particular with laboratory diagnostics and doctor consultation. Task shifting from doctors to ANMs was observed in all facilities.

CONCLUSIONS

Grossly inadequate quality ANC services under the PMSMA needs urgent attention to improve maternal and neonatal health outcomes.

An assessment of the quality of antenatal care and pregnancy outcomes in a tertiary hospital in Ghana

Background

Antenatal care (ANC) is imperative to decreasing adverse pregnancy outcomes and their related maternal mortality. However, in sub-Saharan Africa, increases in ANC coverage have not correlated well with improved maternal and fetal outcomes suggesting the quality of ANC received could be the missing link. This study assessed ANC quality and its effect on adverse pregnancy outcomes among women who delivered at Komfo Anokye Teaching Hospital.

Methods

A cross-sectional study was conducted among women who delivered at Komfo Anokye Teaching Hospital within the study period. Women were selected through systematic sampling and interviewed using a pretested structured questionnaire as well as review of their medical records. Data were collected on their sociodemographic and reproductive characteristics, care provided during ANC and delivery outcomes. Categorical variables were compared using the χ² test. Factors associated with quality of ANC and adverse pregnancy outcomes were assessed using univariate and multivariate logistic regression to generate crude and adjusted odds ratios (ORs) with 95% confidence intervals (CIs). Statistical analyses were performed using SPSS and GraphPad Prism. P-values of < 0.05 were considered statistically significant.

Results

950 women were recruited into the study with mean age of 30.39±5.57 years. Less than one-tenth (7.6%) of the women received good quality ANC, 63.4% had average quality ANC, and 29.0% received poor quality ANC. Increasing educational level and initiating ANC in the first trimester [aOR 0.2; 95%CI 0.08–0.68; p<0.001] increased the odds of receiving good quality ANC while being unemployed decreased the odds of receiving good quality ANC [aOR 0.3; 95% CI 0.12–0.65; p = 0.003]. Receiving poor and average quality of ANC were significantly associated with increased likelihood of developing anaemia during pregnancy, preeclampsia with severe features or delivering a low birth weight baby.

Conclusion

Most women did not receive good quality ANC. High quality ANC should be provided while the women are encouraged to comply with the recommendations during ANC.

Assessment of Effective Coverage of Antenatal Care and Associated Factors in Squatter Settlements of Islamabad Capital Territory, Pakistan: An Analytical Cross-Sectional Study

Background: Effective coverage of antenatal care (ANC) goes beyond contact coverage and assesses the quality of service provided. We used World Health Organization’s recommended positive pregnancy guidelines to assess effective coverage and factors associated with the utilization of ANC among women in squatter settlements of Islamabad Capital Territory.

Methods:We conducted a household survey in the study area with 416 women who had given birth in the past one year. Face-to-face interviews were conducted after the selection of study subjects was done through a systematic random sampling approach. Statistical analysis was carried out using Statistical Package for the Social Sciences 22 (SPSS 22; IBM corp. Armonk, NY). Effective ANC coverage was defined as four or more ANC visits along with all WHO-recommended interventions received at least once during ANC. Adjusted odds ratios (adjOR) with 95% CI were calculated using binary logistic regression to determine the independent effects of all associated factors on the outcome.

Results: Of the 416 women interviewed, 399 (95.6%) had availed ANC services at least once. The coverage of 4+ ANC visits was 92% but effective coverage was only received by 35% women. The proportion of women who received nutritional interventions, maternal and fetal assessment and other preventive measures was 68%, 51% and 80.8% respectively. Maternal education (adjOR, 95% CI = 4.8[2.4-9.3]), family income (2.3[1.1-5.1]), multiparity (1.7[1.1-2.9]), place of first ANC visit (4.2[1.7-10.5]) and distance from a health facility (2.2[1.3-3.6]) were independently associated with the non-utilization of effective ANC.

Conclusion: Despite a very high crude coverage of ANC services, the study shows a very low proportion of women receiving effective coverage. This stresses the importance of measuring the proportion of the population that receives health services with quality to monitor progress toward achieving universal health coverage.

Evaluations of effective coverage of maternal and child health services: A systematic review

Conventionally used coverage measures do not reflect the quality of care. Effective coverage (EC) assesses the extent to which health care services deliver potential health gains to the population by integrating concepts of utilization, need and quality. We aimed to conduct a systematic review of studies evaluating EC of maternal and child health services, quality measurement strategies and disparities across wealth quantiles. A systematic search was performed in six electronic databases [MEDLINE, EMBASE, Cumulative Index of Nursing and Allied Health (CINAHL), Scopus, Web of Science and Maternity and Infant Care] and grey literature. We also undertook a hand search of references. We developed search terms having no restrictions based on publication period, country or language. We included studies which reported EC estimates based on the World Health Organization framework of measuring EC. Twenty-seven studies, all from low- and middle-income settings (49 countries), met the criteria and were included in the narrative synthesis of the results. Maternal and child health intervention(s) and programme(s) were assessed either at an individual level or as an aggregated measure of health system performance or both. The EC ranged from 0% for post-partum care to 95% for breastfeeding. When crude coverage measures were adjusted to account for the quality of care, the EC values turned lower. The gap between crude coverage and EC was as high as 86%, and it signified a low quality of care. The assessment of the quality of care addressed structural, process and outcome domains individually or combined. The wealthiest 20% had higher EC of services than the poorest 20%, an inequitable distribution of coverage. More efforts are needed to improve the quality of maternal and child health services and to eliminate the disparities. Moreover, considering multiple dimensions of quality and the use of standard measurements are recommended to monitor coverage effectively.

Coverage of Quality Maternal and Newborn Healthcare Services in India: Examining Dropouts, Disparity and Determinants

Background:

Abundant research studies has recorded availability, accessibility and quality of antenatal care and safe delivery in India but comparatively less information is known for postnatal care and furthermore limited attempts at capturing the whole spectrum of obstetric and newborn health services. Assessing discontinuity in maternal and child health service utilization provides us holistic information about existing health inequities and barriers in service provision.

Objective:

Current study evaluated the coverage of quality antenatal care (QANC), delivery care (QDC) and postnatal care (QPNC) in India as a part of a single continuum accounting for significant regional and sub-regional disparities.

Methods:

This study analyzed nationally representative data obtained from NFHS-4 (2015–16). Included in the data, were 190 898 Indian women who had a recent birth in last five years. Coverage of QANC, QDC and QPNC was examined at the national, state and district level. Bivariate association of key sociodemographic variables with coverage of services was assessed during chi-squared analysis. Multilevel logistic regression analysis examined correlates associated with coverage of services. The output was presented using odds ratios (OR) with 95% CI.

Findings:

About 23.5% women utilized QANC out of which 92.9% opted for QDC and 35.1% of newborns received QPNC. About 400 and 471 districts out of 640 had less than 30% coverage of QANC and QPNC, respectively. Women residing in rural regions of Bihar and Northeastern states were found with less than 10% coverage of QANC. Regression analysis shows that women with more than 12 years of education and belonging to richest households had increased odds of availing QANC (OR 1.95; 95%CI: 1.84–2.06) and QDC (OR: 2.86; 95%CI: 2.27–3.60), respectively.

Conclusion:

Focused interventions targeting the delivery of quality services especially ANC and PNC among newborns are imperative to achieve SDG-3 goals to achieve improvement in maternal and newborn health.

Dimensions of women empowerment on access to antenatal care in Uganda: A further analysis of the Uganda demographic health survey 2016

BACKGROUND

Women empowerment has been viewed as a good strategy in the reduction of global maternal morbidity and mortality. Most of the recent studies in Uganda have focussed on antenatal care (ANC) frequency and the associated factors with no focus on the effect of women empowerment. Our study aims at examining the prevalence of optimal access to ANC by considering the timing of initiation, type of ANC provider and ANC frequency and their association with women empowerment.

METHODS

We used Uganda Demographic and Health Survey 2016 data of 9957 women aged 15-49 years. Multistage stratified sampling was used to select study participants and we conducted multivariable logistic regression to establish the association between women empowerment and access to ANC using Statistical package for the social sciences version 25.

RESULTS

Out of 9957 women, 2953 (29.7%: 95% CI: 28.5.0-30.2) had initiated ANC in first trimester, 6080 (61.1%: 95% CI: 60.4-62.3) had 4 or more ANC contacts, and 9880 (99.2%: 95% CI: 99.0-99.3) had received ANC from a skilled provider. Overall, 2399 (24.1%: 95% CI: 23.0-24.6) had optimal access to ANC. Economic empowerment and exposure to media were the only women empowerment indices that were positively associated with optimal access to ANC. Other factors that were significant include; region, wealth index, age, level of education and working status.

CONCLUSION

To ensure increased access to ANC, policy-makers and other stakeholders should prioritise the use of mass media in maternal health programs, equitable allocation of the limited financial resources with a focus on older, poor and uneducated women.

Decomposing socio-economic inequalities in antenatal care utilisation in 12 Southern African Development Community countries

Although many countries are making progress towards achieving the global sustainable development goals, sub-Saharan Africa (SSA) lags behind. SSA bears a relatively higher burden of maternal morbidity and mortality than other regions despite existing cost-effective interventions. This paper assesses antenatal care (ANC) service utilisation among women in the Southern African Development Community (SADC) countries, one of the four SSA regions. Specifically, it assesses socioeconomic inequality in the number of ANC visits, use of no ANC service, between one and three ANC visits and at least four ANC visits, previously recommended by the World Health Organization (WHO). Data come from the most recent Demographic and Health Surveys in twelve SADC countries. Wagstaff's normalised concentration index (CI) was used to assess socioeconomic inequalities. Factors explaining these inequalities were assessed using a standard method and similar variables contained in the DHS data. A positive CI means that the variable of interest is concentrated among wealthier women, while a negative CI signified the opposite. The paper found that wealthier women in the SADC countries are generally more likely to have more ANC visits than their poorer counterparts. Apart from Zambia, the CIs were positive for inequalities in at least 4 ANC visits and negative for between 1 and 3 ANC visits. Women from poorer backgrounds significantly report no ANC visits than wealthier women. Apart from the portion that was not explainable due to limitations in the variables included in the model, critical social determinants of health, including wealth, education and the number of children, explain socioeconomic inequalities in ANC coverage in SADC. A vital policy consideration is not to leave any woman behind. Therefore, addressing access barriers and critical social determinants of ANC inequalities, such as women's education and economic well-being, can potentially redress inequalities in ANC coverage in the SADC region.

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Wealthier women have more antenatal care (ANC) visits than their poorer counterparts.

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Women from poorer backgrounds report no ANC visits more often than wealthier women.

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Wealth and education are key drivers of socioeconomic inequalities in ANC coverage.

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Poorer women are being left behind in accessing maternal health services in Africa.

Quality of antenatal care and associated factors among pregnant women attending government hospitals in Sidama Region, Southern Ethiopia

Background:

Good-quality antenatal care improves maternal health in the least developed countries. This study was aimed at assessing the quality of antenatal care and associated factors among pregnant women attending hospitals in the Sidama Region, Southern Ethiopia.

Method:

A facility-based cross-sectional study was conducted from 1 February to 30 April 2020 among 372 pregnant women. A two-stage sampling technique—the first stage, selection of health facilities; the second stage, selection of respondents—was used. Trained data collectors administered exit interviews. Data were entered into EPI Info 7 and analyzed using IBM SPSS version 25. Quality of care was assessed using a validated questionnaire containing 68 attributes of quality. Good quality of care was determined by the proportion of respondents who scored ⩾80% of 68 variables. Bivariable and multivariable logistic regressions were used in the analysis. The outputs were presented using an adjusted odds ratio with 95% confidence intervals.

Results:

This study revealed that 41.2% (95% confidence interval: 36.2%–46.2%) of pregnant women had received good-quality antenatal care. Increased odds of the utilization of quality antenatal care were observed among women who lived in urban areas (adjusted odds ratio = 4.32, 95% confidence interval: 2.58–7.21), attained primary education and more (adjusted odds ratio = 2.68, 95% confidence interval: 1.60–4.48), earned a monthly income >3000 Ethiopia Birr (US$93.3) (adjusted odds ratio = 3.86, 95% confidence interval: 2.28–6.51), and visited hospitals for antenatal care ⩾4 times (adjusted odds ratio = 3.68, 95% confidence interval: 2.21–6.10).

Conclusions:

The proportion of women who received good-quality antenatal care was low. Good quality care was associated with residence, education status, income level, and frequency of antenatal care visits. Training care providers, strengthening counseling, and promoting women’s economic empowerment to improve the utilization of quality antenatal care are recommended.

Extent of Received Antenatal Care Components in Ethiopia: A Community-Based Panel Study

PURPOSE

This study aimed to identify the extent of antenatal care content received and associated factors among Ethiopian women.

METHODS

A nationally representative Performance Monitoring for Action 2020 Ethiopian data were used. A multistage cluster sampling design was used to select 2855 pregnant or recently postpartum women nested within 217 enumeration areas. Female resident enumerators collected the data using a semi-structured questionnaire. Researchers dichotomized the number of ANC content received greater than or equal to 75 percentiles as adequate. Otherwise, it was considered inadequate. A multilevel Poisson regression was fitted. The result was reported using an incidence rate ratio with a 95% confidence interval and a p-value less than 0.05 was considered for statistical significance.

RESULTS

The study revealed more than a quarter of pregnant women received adequate ANC content (27.8%; 95% CI: 23.8%, 32.2%). Multivariable analysis revealed urban residence (IRR = 1.09, 95% CI: 1.01, 1.21), attending secondary and above formal education (IRR = 1.08, 95% CI: 1.01, 1.16), maternal age 20-24 years (IRR = 1.10, 95% CI: 1.02, 1.19), and partner's encouragement to attend clinic for antenatal care (IRR = 1.14, 95% CI: 1.05, 1.24) was significantly associated with receiving higher numbers of antenatal care content.

CONCLUSION

The proportion of women who received adequate antenatal care content in Ethiopia was low. Despite Ethiopia's effort to improve maternal health services utilization, disparities among regions and between rural and urban exist. This study highlights the importance of ensuring high received antenatal care content, which is crucial for reducing pregnancy-related morbidity and mortality. This implies prompt intersectoral collaboration to promote female education, target older aged women, and rural resident women, encourage partner involvements during the antenatal care process, minimize regional variation, and strengthen the implementation of received ANC content policies and programs with the active participation of the stakeholders are priority issues.

Community- based maternal and newborn interventions in Africa: Systematic review

AIM AND OBJECTIVES

This review analysed the implementation and integration into healthcare systems of maternal and newborn healthcare interventions in Africa that include community health workers to reduce maternal and newborn deaths.

BACKGROUND

Most neonatal deaths (99%) occur in low- and middle-income countries, with approximately half happening at home. In resource-constrained settings, community-based maternal and newborn care is regarded as a sound programme for improving newborn survival. Health workers can play an important role in supporting families to adopt sound health practices, encourage delivery in healthcare facilities and ensure timeous referral. Maternal and newborn mortality is a major public health problem, particularly in sub-Saharan Africa, where the Millennium Development Goals 4, 5 and 6 were not achieved at the end of 2015.

METHODS

The review includes quantitative, qualitative and mixed-method studies, with a data-based convergent synthesis design being used, and the results grouped into categories and trends. The review took into account the participants, interventions, context and outcome frameworks (PICO), and followed the adapted PRISMA format for reporting systematic reviews of the qualitative and quantitative evidence guide checklist.

RESULTS

The results from the 17 included studies focused on three themes: antenatal, delivery and postnatal care interventions as a continuum. The main components of the interventions were inadequate, highlighting the need for improved planning before each stage of implementation. A conceptual framework of planning and implementation was elaborated to improve maternal and newborn health.

CONCLUSION

The systematic review highlight the importance of thoroughly planning before any programme implementation, and ensuring that measures are in place to enable continuity of services.

RELEVANT TO THE CLINICAL PRACTICE

Conceptual framework of planning and implementation of maternal and newborn healthcare interventions by maternal community health workers.

Micronutrient Powders for Infants and Young Children

Providing standalone micronutrient products for household use is not an easy strategy, but under the right conditions, it can work. To be effective, micronutrient powder programs require robust commodity logistics and support of uptake and adherence.

Late registration for antenatal care by pregnant women with previous history of caesarean section

Background

Despite good access to antenatal care (ANC) services for most women, and regular training of healthcare workers in obstetrics and gynaecology, many pregnant women with a previous history of caesarean section (C/S) still presented late for ANC services at Letsholathebe II Memorial Hospital (LIIMH) in Maun, Botswana. This may increase morbidity and mortality in women with previous C/S delivery and neonates. Knowing why women with previous C/S present late for ANC may help in the formulation of interventions that decrease morbidity and mortality amongst these women and neonates.

Aim

The aim of this study was to explore the reasons why pregnant women with a previous history of C/S registered late for ANC, at LIIMH.

Setting

This study was performed at LIIMH, a district hospital situated in Maun, Botswana.

Methods

This was a descriptive qualitative study. Consenting pregnant women with previous C/S who presented at LIIMH after the 20 weeks of pregnancy were interviewed until data saturation. The data was analysed for themes.

Results

The reasons for late registration at LIIMH include lack of information, misconception on the appropriate booking time and venue, dissatisfaction with the quality of ANC clinic services, use of alternative ANC providers, delayed referral, and pregnancy experience.

Conclusion

Lack of knowledge of ANC delivery venue, using alternative ANC providers, and dissatisfaction with ANC clinic services, contributed to late registration. Pregnant women with previous history of C/S should be informed about ANC, delivery plans, and the assistance of alternative ANC providers should be explored.

Home Birth in Rural Zambia: The Role of Intimate Partner Violence and Autonomous Decision-Making

INTRODUCTION

Skilled care is indicated as a measure to prevent the deaths of pregnant women across sub-Saharan Africa. Despite this, many women continue to give birth at home. There has been little attention as to how the experience of intimate partner violence (IPV) or autonomous decision-making about place of birth influences home births in rural Zambia. This study explores how markers of sociocultural gender inequities (prevalence of IPV and autonomous decision-making) correlate with home birth in rural Zambia.

METHODS

This secondary analysis uses quantitative data from a baseline household survey with women who had given birth within the past 13 months in rural Zambia. Control variables shown to be significant in the literature were included in the model, and binary logistic regression was used to assess the influence of IPV and autonomous decision-making on home birth.

RESULTS

This sample included 2381 women from rural Zambia, of whom 384 reported a home birth within the past 13 months. Women who were autonomously making the decision about where to give birth were more likely to have a home birth (adjusted odds ratio [AOR], 1.729; SE, 0.210; 95% CI, 1.362-2.194; P < .001). Self-report of experiencing physical IPV in the past 2 weeks was not significant in predicting home birth (AOR, 0.783; SE, 0.181; 95% CI, 0.496-1.234; P = .293). Women who self-identified as Tumbuka or other, were able to afford school fees, had completed secondary education or higher, were married, and had 4 or more antenatal care visits were significantly less likely to report a home birth.

DISCUSSION

This quantitative analysis did not corroborate findings from other research that implicates IPV as a predictor of home birth. Additionally, autonomous decision-making was not associated with a decrease in home births. Future work should incorporate qualitative or mixed methods strategies to comprehensively explore household- and facility-level interventions to promote facility birth.

Examining barriers to healthcare access and utilization of antenatal care services: evidence from demographic health surveys in sub-Saharan Africa

Background

Antenatal care utilization is one of the means for reducing the high maternal mortality rates in sub-Saharan Africa. This study examined the association between barriers to healthcare access and implementation of the 2016 WHO antenatal care services model among pregnant women seeking antenatal care in selected countries in sub-Saharan Africa.

Methods

This study considered only Demographic and Health Survey data collected in 2018 in sub-Saharan Africa. Hence, the Demographic and Health Survey data of four countries in sub-Saharan Africa (Nigeria, Mali, Guinea and Zambia) were used. A sample of 6761 from Nigeria, 1973 from Mali, 1690 from Guinea and 1570 from Zambia was considered. Antenatal care visits, categorized as < 8 visits or ≥8 visits, and time of the first antenatal care visit, categorized as ≤3 months or > 3 months (as per the WHO recommendations) were the outcome variables for this study. Both descriptive statistics and ordinal logistic regression were used to analyze the data. Crude odds ratios (cOR) and adjusted odds ratios (aOR) and p-values < 0.05 were used for the interpretation of results.

Results

With timing of antenatal care visits, getting money needed for treatment (aOR = 1.38, 95% CI = 1.03–1.92) influenced early timing of antenatal care visits in Mali whereas getting permission to visit the health facility (aOR = 1.62, 95% CI = 1.15–2.33) motivated women to have early timing of antenatal care visits in Guinea. We found that women who considered getting money needed for treatment as not a big problem in Nigeria were more likely to have the recommended number of antenatal care visits (aOR = 1.38, 95% CI= 1.11–1.73). On the contrary, in Guinea, Zambia and Mali, getting permission to visit health facilities, getting money for treatment, distance to the health facility and not wanting to go alone were not barriers to having ≥ 8 antenatal care visits.

Conclusion

Our study has emphasized the role played by barriers to healthcare access in antenatal care utilization across sub-Saharan African countries. There is the need for governmental and non-governmental organizations to ensure that policies geared towards improving the quality of antenatal care and promoting good interaction between health care seekers and health care providers are integrated within the health system.

A new content-qualified antenatal care coverage indicator: Development and validation of a score using national health surveys in low- and middle-income countries

Background

Good quality antenatal care (ANC) helps reduce adverse maternal and newborn outcomes, especially in low and middle-income countries (LMICs). Most of the currently used ANC indicators only measure contact with services. We aimed to create and validate a new indicator measured as a score, considering both contact and content, that can be used for monitoring.

Methods

We used data from national surveys conducted in LMICs. Information on ANC was used to build an adequacy score (ANCq) that would be applicable to all women in need of ANC. Cronbach's alpha and factor analysis were used to assess the proposed indicator. We also used a convergent validation approach, exploring the association of our proposed indicator with neonatal mortality.

Results

The ANCq score was derived from seven variables related to contact with services and content of care ranging from zero to ten. Surveys from 63 countries with all variables were used. The validity assessment showed satisfactory results based on Cronbach's alpha (0.82) and factor analysis. The overall mean of ANCq was 6.7, ranging from 3.5 in Afghanistan to 9.3 in Cuba and the Dominican Republic. In most countries, the ANCq was inversely associated with neonatal mortality and the pooled for all surveys Odds Ratio was 0.90 (95% CI = 0.88-0.92).

Conclusions

ANCq allows the assessment of ANC in LMICs considering contact with services and content of care. It also presented good validity properties, being a useful tool for assessing ANC coverage and adequacy of care in monitoring and accountability exercises.

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

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

Determinants of Frequency and Content of Antenatal Care in Postnatal Mothers in Arba Minch Zuria District, SNNPR, Ethiopia, 2019

BACKGROUND

Antenatal care is one of the strategies for reducing maternal morbidity and mortality directly by affording increased chances of early detection of high-risk pregnancies. WHO recommends a minimum of four ANC visits. In order to make it effective, monitoring of the content and quality of the ANC is needed. However, a number of studies focus on the frequency of ANC, and evidence on core contents of the ANC was limited in this study area. The aim of this study was to determine factors associated with content of the ANC.

METHODS AND MATERIALS

A cross-sectional study design was employed to collect data from a total of 432 respondents by using a semi-structured questionnaire. Data were entered in EpiData version 3.1 and exported to SPSS version 20 for analysis. Both binary logistic regression and generalized linear regression with Poisson type were applied to determine factors associated with frequency of the ANC and core contents of ANC, respectively.

RESULTS

The majority of the mothers (78.7%) visited first ANC lately, and 25.2% of mothers attended ≥4 ANC visits. Only 17.1% of mothers received all the eight selected elements of ANC services. Predictors of the core contents of the ANC were the frequencies of ANC (AOR: 0.84 (95%CI: 0.76-0.93), pre-pregnancy utilization of contraception (0.63 (95%CI: 0.55-0.72)), pregnancy desire (AOR: 0.82 (95%CI: 0.71-0.94), and birth preparedness and complication readiness (AOR: 0.90 (95%CI: 0.82-0.98).

CONCLUSION

This study found that low level of WHO minimum recommended ANC and core contents of the ANC. This study suggests that identifying pregnant mothers early increases frequency of the ANC, which improves core content of care.

Interventions to improve adherence to antenatal and postnatal care regimens among pregnant women in sub-Saharan Africa: a systematic review

BACKGROUND

Pregnant women in sub-Saharan Africa tend to have low adherence to antenatal and postnatal care regimens, contributing to high infant and child mortality rates. Despite low adherence figures and the high returns from attending antenatal and postnatal care visits, research on interventions to improve adherence is in its infancy. Our aim was to determine the effectiveness of existing interventions to improve adherence to antenatal and postnatal care regimens among pregnant women in sub-Saharan Africa.

METHODS

Full text, peer-reviewed articles, published in English and listed in PubMed or PsycINFO through January 2018 were identified in a systematic review. Studies were restricted to randomized controlled trials only and had to assess intervention impact on antenatal and postnatal care adherence, operationalized as the frequency of visits attended. Two reviewers independently screened papers for inclusion and evaluated the risk of systematic error in each study using the Cochrane risk of bias tool. Any discrepancies were reconciled by a third independent reviewer.

RESULTS

The initial search generated 186 articles, of which, five met our inclusion criteria. Due to the small sample size and methodological variation across studies, a pooled effect size estimate could not be obtained. Therefore, effects on antenatal and postnatal care adherence were examined and reported at the individual study level. None of the interventions were directly aimed at improving adherence, but two of the five, both behavioral interventions, demonstrated effectiveness in increasing antenatal care (rate ratio 5.86, 95% CI 2.6-13.0, p<0.0001) and postnatal care adherence (31.3%, 95% CI 15.4-47.2, p=0.0009), respectively. Three home visit interventions had no effect on antenatal care adherence. Although the risk of bias was unclear or high in some cases, it remained low in most categories across studies.

CONCLUSIONS

Results point to a large gap in the literature on interventions to address antenatal and postnatal care adherence in sub-Saharan Africa. Interventions drawing upon the executive function literature and the promising results of the behavioral interventions reviewed here are urgently needed to address these gaps.

TRIAL REGISTRATION

The review was prospectively registered with PROSPERO, id number https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=88152, on February 7, 2018.

Measuring universal health coverage in reproductive, maternal, newborn and child health: An update of the composite coverage index

Background

Monitoring universal health coverage in reproductive, maternal and child health requires appropriate indicators for assessing coverage and equity. In 2008, the composite coverage index (CCI)–a weighted average of eight indicators reflecting family planning, antenatal and delivery care, immunizations and management of childhood illnesses–was proposed. In 2017, the CCI formula was revised to update the family planning and diarrhea management indicators. We explored the implications of adding new indicators to the CCI.

Methods

We analysed nationally representative surveys to investigate how addition of early breastfeeding initiation (EIBF), tetanus toxoid during pregnancy and post-natal care for babies affected CCI levels and the magnitude of wealth-related inequalities. We used Pearson’s correlation coefficient to compare different formulations, and the slope index of inequalities [SII] and concentration index [CIX] to assess absolute and relative inequalities, respectively.

Results

47 national surveys since 2010 had data on the eight variables needed for the original and revised formulations, and on EIBF, tetanus vaccine and postnatal care, related to newborn care. The original CCI showed the highest average value (65.5%), which fell to 56.9% when all 11 indicators were included. Correlation coefficients between pairs of all formulations ranged from 0.93 to 0.99. When analysed separately, 10 indicators showed higher coverage with increasing wealth; the exception was EIBF (SII = -2.1; CIX = -0.5). Inequalities decreased when other indicators were added, especially EIBF–the SII fell from 24.8 pp. to 19.2 pp.; CIX from 7.6 to 6.1. The number of countries with data from two or more surveys since 2010 was 30 for the original and revised formulations and 15 when all the 11 indicators were included.

Conclusions

Given the growing importance of newborn mortality, it would be desirable to include relevant coverage indicators in the CCI, but this would lead a reduction in data availability, and an underestimation of coverage inequalities. We propose that the 2017 version of the revised CCI should continue to be used.

The timing and quality of antenatal care received by women attending a primary care centre in Iquitos, Peru: A facility exit survey

Background

Maternal mortality is high in Loreto, Peru, but can be reduced by high quality antenatal care. Indicators for the quality of antenatal care received include the timing (with respect to gestational age) and number of antenatal appointments attended, the delivery of antenatal services and health information, and women’s perceptions about their care. This study investigated these indicators amongst women receiving antenatal care in predominantly the San Juan Bautista district of Iquitos, Loreto. This was to identify areas for improvement through comparison with antenatal guidelines published by the Ministry of Health, Peru, and the World Health Organization.

Methods

A total of 134 women were recruited at the Centro de Salud, San Juan—a primary care centre in Iquitos. Information about the delivery of antenatal services and the number of and gestational ages at appointments attended was collected from 121/134 women’s hand-held antenatal cards. The delivery of health information and women’s perceptions about their antenatal care were investigated through questionnaires (133/134 completed). Descriptive statistics, such as frequencies and valid percentages, were determined.

Results

Hand-held antenatal cards revealed that 52.9% of participants began their antenatal care in the first trimester. Compared to national guidelines, 42.1% attended appointments at recommended gestational ages and no women received all recommended antenatal services. Most women received information about identifying complications in pregnancy and health and lifestyle topics. Over 85% of women reported satisfaction with their antenatal care.

Conclusions

Timely antenatal attendance and delivery of services should be encouraged to meet national and global standards. Although all services were not delivered in a combined manner according to national guidelines, individual services were mostly delivered to a high standard and therefore a high proportion of women were satisfied with their antenatal care.

Quality of Prenatal Care and Associated Factors among Pregnant Women at Public Health Facilities of Wogera District, Northwest Ethiopia

Background

Prenatal care refers to services a pregnant woman receives during pregnancy to ensure a healthy outcome for herself and her newborn. However, only limited studies have so far been done to assess the quality of prenatal care in the study area. Thus, this study is aimed at assessing the quality of prenatal care and associated factors at public health facilities in Wogera district, northwest Ethiopia.

Methods

An institution-based cross-sectional study was conducted in Wogera district from March to April 2019. A total of 465 pregnant women were interviewed using a semi-structured interviewer-administered questionnaire; consecutive sampling was used to select the participants. The binary logistic regression analysis model was fitted to identify the potential predictor variables. Variables with <0.2 p values were fitted into the multivariable logistic regression analysis model; <0.05 p values and an adjusted odds ratio (AOR) with a 95% confidence interval (CI) were used to declare factors associated with the quality of prenatal care.

Results

The overall quality of prenatal care was 32.7% (95% CI: 28.1, 37.2). Four or more prenatal care visits (AOR = 2.3; 95% CI: 1.2, 4.7), high maternal education (AOR = 2.9; 95% CI: 1.03, 7.93), over USD 175.5 monthly household income (AOR = 2.8; 95% CI: 1.1, 7.8), and the availability of maternity waiting areas (AOR = 2.4; 95% CI: 1.2, 5.0) were positively associated with the quality of the care.

Conclusion

The overall quality of prenatal care in this study was low. Therefore, promoting focused prenatal care and increasing infrastructure, encouraging maternal education, and compensating for the healthcare costs for women with low household income might enhance the quality of the care.

Socioeconomic inequalities in maternal health service utilisation: a case of antenatal care in Nigeria using a decomposition approach

BACKGROUND

Antenatal care (ANC) services are critical for maternal health but Nigeria performs poorly in ANC utilisation compared to other countries in sub-Saharan Africa. This study aimed to assess socioeconomic inequalities in ANC utilisation and the determinants of these inequalities in Nigeria.

METHODS

The 2013 Nigeria Demographic and Health Survey data with 18,559 women was used for analysis. The paper used concentration curves and indices for different measures of ANC utilisation (no ANC visit, 1-3 ANC visits, at least four ANC visits, and the number of ANC visits). A positive (or negative) concentration index means that the measure of ANC utilisation was concentrated on the richer (poorer) population compared to their poorer (richer) counterparts. The concentration indices were also decomposed using standard methodologies to examine the significant determinants of the socioeconomic inequalities in no ANC visit, at least four ANC visits, and the number of ANC visits.

RESULTS

No ANC visit was disproportionately concentrated among the poor (concentration index (CI) = - 0.573), whereas at least four ANC visits (CI = 0.582) and a higher number of ANC visits (CI = 0.357) were disproportionately concentrated among the rich. While these results were consistent across all the geopolitical zones and rural and urban areas, the inequalities were more prevalent in the northern zones (which also have the highest incidence of poverty in the country) and the rural areas. The significant contributors to inequalities in ANC utilisation were the zone of residence, wealth, women's education (especially secondary) and employment, urban-rural residence, ethnicity, spousal education, and problems with obtaining permission to seek health care and distance to the clinic.

CONCLUSIONS

Addressing wealth inequalities, enhancing literacy, employment and mitigating spatial impediments to health care use will reduce socioeconomic inequalities in ANC utilisation in Nigeria. These factors are the social determinants of health inequalities. Thus, a social determinants of health approach is needed to address socioeconomic inequalities in ANC coverage in Nigeria.

Choice of birth place among antenatal clinic attendees in rural mission hospitals in Ebonyi State, South-East Nigeria

BACKGROUND

Low utilization of health facilities for delivery by pregnant women poses a public health challenge in Nigeria.

AIM

To determine the factors that influence the choice of birth place among antenatal clinic attendees.

METHODOLOGY

This was a cross-sectional study of the eligible antenatal clinic attendees recruited at Mater Misericordiae Hospital, Afikpo and Saint Vincent Hospital, Ndubia in Ebonyi State from February 1, 2016 to June 30, 2016. Analysis was done using EPI Info 7.21 software (CDC Atlanta Georgia).

RESULTS

A total of 397(99.3%) completely filled questionnaires were collated and analysed. Approximately 71% of the health facilities closest to the respondents had maternity services. It took at least 1 hour for 80.9% of the respondents to access health facilities with maternity services. Most (60.2%) of the respondents had at least one antenatal clinic attendance and majority of them did so at public hospitals. Approximately 43.8% of the respondents were delivered by the skilled birth attendants. The respondents' age and the couple's educational level, history of antenatal clinic attendance, distance of the health facility and availability of transport fare had a significant effect on delivery by skilled birth attendants. The common determinants of birth place were nearness of the health facilities, familiarity of healthcare providers, improved services, sudden labour onset and cost. Also 61.7% of the respondents chose to deliver in public health facilities due to favourable reasons but this could be hampered by the rudeness of some healthcare providers at such facilities. A significant proportion of private health facilities had unskilled manpower and shortage of drugs.

CONCLUSION

A greater proportion of women will prefer to deliver in health facilities. However there are barriers to utilization of these facilities hence the need to address such barriers.

Effect of continuum-of-care intervention package on improving contacts and quality of maternal and newborn healthcare in Ghana: a cluster randomised controlled trial

OBJECTIVE

To evaluate the effect of a continuum-of-care intervention package on adequate contacts of women and newborn with healthcare providers and their reception of high-quality care.

DESIGN

Cluster randomised controlled trial.

SETTING

32 subdistricts in 3 rural sites in Ghana.

PARTICIPANTS

The baseline survey involved 1480 women who delivered before the trial, and the follow-up survey involved 1490 women who received maternal and newborn care during the trial.

INTERVENTIONS

The intervention package included training healthcare providers, using an educational and recording tool named 'continuum-of-care card', providing the first postnatal care (PNC) by retaining women and newborns at healthcare facility or home visit by healthcare providers.

OUTCOME MEASURES

Adequate contacts were defined as at least four contacts during pregnancy, delivery with assistance of skilled healthcare providers at a healthcare facility and three timely contacts within 6 weeks postpartum. High-quality care was defined as receiving 6 care items for antenatal care (ANC), 3 for peripartum care (PPC) and 14 for PNC.

RESULTS

The difference-in-difference method was used to assess the effects of the intervention on the study outcome. The percentage of adequate contacts with high-quality care in the intervention group in the follow-up survey and the adjusted difference-in-difference estimators were 12.6% and 2.2 (p=0.61) at ANC, 31.5% and 1.9 (p=0.73) at PPC and 33.7% and 12.3 (p=0.13) at PNC in the intention-to-treat design, whereas 13.0% and 2.8 (p=0.54) at ANC, 34.2% and 2.7 (p=0.66) at PPC and 38.1% and 18.1 (p=0.02) at PNC in the per-protocol design that assigned the study sample by possession of the continuum-of-care card.

CONCLUSIONS

The interventions improved contacts with healthcare providers and quality of care during PNC. However, having adequate contact did not guarantee high-quality care. Maternal and newborn care in Ghana needs to improve its continuity and quality.

TRIAL REGISTRATION NUMBER

ISRCTN90618993. .

Proportion of pregnant women screened for hypertensive disorders in pregnancy and its associated factors within antenatal clinics of Kinshasa, Democratic Republic of Congo

Background

Screening for hypertensive disorders in pregnancy (HDP) is clinically important for identifying women at high risk, and planning early preventative interventions to improve pregnancy outcomes. Several studies in developing countries show that pregnant women are seldom screened for HDP. We conducted a study in Kinshasa, DR Congo, in order to assess the proportion of pregnant women screened for HDP, and to identify factors associated with the screening.

Methods

We conducted a facility-based cross-sectional study in a random sample of 580 pregnant women attending the first antenatal visit. Data collection consisted of a review of antenatal records, observations at the antenatal care services, and interviews. A pregnant woman was considered as screened for HDP if she had received the tree following services: blood pressure measurement, urine testing for proteinuria, and HDP risk assessment. Multivariable logistic regression, with generalized estimating equations, was used to identify factors associated with the screening for HDP.

Results

Of the 580 pregnant women, 155 (26.7%) were screened for HDP, 555 (95.7%) had their blood pressure checked, 347(59.8%) were assessed for risk factors of HDP, and 156 (26.9%) were tested for proteinuria. After multivariable analysis, screening for HDP was significantly higher in parous women (AOR = 2.09; 95% CI, 1.11–3.99; P = 0.023), in women with a gestational age of at least 20 weeks (AOR = 5.50; 95% CI, 2.86–10.89; P = 0.002), in women attending in a private clinic (AOR = 3.49; 95% CI, 1.07–11.34; P = 0.038), or in a hospital (AOR = 3.24; 95% CI, 1.24–8.47; P = 0.017), and when no additional payment was required for proteinuria testing at the clinic (AOR = 2.39; 95% CI, 1.14–5.02; P = 0.021).

Conclusion

Our results show that screening for HDP during the first antenatal visit in Kinshasa is not universal. The factors associated with screening included maternal as well as clinics’ characteristics. More effort should be made both at maternal and clinic levels to improve the screening for HDP in Kinshasa.

Patterns and factors affecting antenatal care utilization in Damietta Governorate, Egypt: a retrospective cross-sectional study

BACKGROUND

Timely antenatal care (ANC) has been proven to save lives and maximizes health and potential. The study aimed to assess ANC utilization rates in Damietta district, Egypt and to identify the components of ANC provided and factors affecting utilization rates.

METHODS

A cross-sectional study was conducted in four Family Health Centers (FHC) in Damietta district. The study included any mother, who gave birth within the last 6 months, after giving written consent to participate. Women were interviewed about their experience with ANC during the last pregnancy using a pre-designed questionnaire.

RESULTS

The study found that ~85% of the mothers have ever attended ANC during the last pregnancy, two-thirds were regular attendants. Urban residence, being not working, having high education and high family income were positively associated with utilization of ANC (P < 0.001). Only 30% of the mothers received ANC in FHCs, while the majority received ANC at private clinics. Rates of receiving ANC components were variable with significantly higher rates in private clinics than governmental FHCs (P < 0.001 for most components). Health education was the least ANC component to be received by mothers at governmental and private sites.

CONCLUSION

More work is needed to improve the utilization of ANC in FHCs. Providers of ANC should be trained and supervised to provide full package of ANC especially health education message, being the most neglected component of ANC.

Management and referral for high-risk conditions and complications during the antenatal period: knowledge, practice and attitude survey of providers in rural public healthcare in two states of India

BACKGROUND

Appropriate antenatal care improves pregnancy outcomes. Routine antenatal care is provided at primary care facilities in rural India and women at-risk of poor outcomes are referred to advanced centres in cities. The primary care facilities include Sub-health centres, Primary health centres, and Community health centres, in ascending order of level of obstetric care provided. The latter two should provide basic and comprehensive obstetric care, respectively, but they provide only partial services. In such scenario, the management and referrals during pregnancy are less understood. This study assessed rural providers' perspectives on management and referrals of antenatal women with high obstetric risk, or with complications.

METHODS

We surveyed 147 health care providers in primary level public health care from poor and better performing districts from two states. We assessed their knowledge, attitudes and practices regarding obstetric care, referral decisions and pre-referral treatments provided for commonly occurring obstetric high-risk conditions and complications.

RESULTS

Staff had sub-optimal knowledge of, and practices for, screening common high-risk conditions and assessing complications in pregnancy. Only 31% (47/147) mentioned screening for at least 10 of the 16 common high-risk conditions and early complications of pregnancy. Only 35% (17/49) of the staff at Primary health centres, and 51% (18/35) at Community health centres, mentioned that they managed these conditions and, the remaining staff referred most of such cases early in pregnancy. The staff mentioned inability to manage childbirth of women with high-risk conditions and complications. Thus in absence of efficient referral systems and communication, it was better for these women to receive antenatal care at the advanced centres (often far) where they should deliver. There were large gaps in knowledge of emergency treatment for obstetric complications in pregnancy and pre-referral first-aid. Staff generally were low on confidence and did not have adequate resources. Nurses had limited roles in decision making. Staff desired skill building, mentoring, moral support, and motivation from senior officers.

CONCLUSION

The Indian health system should improve the provision of obstetric care by standardising services at each level of health care and increasing the focus on emergency treatment for complications, appropriate decision-making for referral, and improving referral communication and staff support.

Advances in the measurement of coverage for RMNCH and nutrition: from contact to effective coverage

Current methods for measuring intervention coverage for reproductive, maternal, newborn, and child health and nutrition (RMNCH+N) do not adequately capture the quality of services delivered. Without information on the quality of care, it is difficult to assess whether services provided will result in expected health improvements. We propose a six-step coverage framework, starting from a target population to (1) service contact, (2) likelihood of services, (3) crude coverage, (4) quality-adjusted coverage, (5) user-adherence-adjusted coverage and (6) outcome-adjusted coverage. We support our framework with a comprehensive review of published literature on effective coverage for RMNCH+N interventions since 2000. We screened 8103 articles and selected 36 from which we summarised current methods for measuring effective coverage and computed the gaps between ‘crude’ coverage measures and quality-adjusted measures. Our review showed considerable variability in data sources, indicator definitions and analytical approaches for effective coverage measurement. Large gaps between crude coverage and quality-adjusted coverage levels were evident, ranging from an average of 10 to 38 percentage points across the RMNCH+N interventions assessed. We define effective coverage as the proportion of individuals experiencing health gains from a service among those who need the service, and distinguish this from other indicators along a coverage cascade that make quality adjustments. We propose a systematic approach for analysis along six steps in the cascade. Research to date shows substantial drops in effective delivery of care across these steps, but variation in methods limits comparability of the results. Advancement in coverage measurement will require standardisation of effective coverage terminology and improvements in data collection and methodological approaches.

Adherence to standards of first-visit antenatal care among providers: A stratified analysis of Tanzanian facility-based survey for improving quality of antenatal care

INTRODUCTION

Despite the benefits of early antenatal care visits for early prevention, detection, and treatment of potential complications in pregnancy, a high level of provider adherence to first-visit antenatal care standards is needed. However, little information is available regarding provider adherence to antenatal care in Tanzania. This study was performed to assess provider adherence to first-visit antenatal care standards and to apply stratified analysis to identify associated factors in Tanzania.

METHODS

Data from the 2014-2015 Tanzania Service Provision Assessment Survey were used in this study. Provider adherence to first-visit antenatal care standards was measured using 10 domains: client history; aspects of prior pregnancies; danger signs of the current pregnancy; physical examination; routine tests; HIV testing and counseling; maintaining a healthy pregnancy; iron/folate supplements; tetanus toxoid vaccination, and preparation for delivery. A composite score was then created in which the highest quantile (corresponding to ≥60.5%) considered to provider adhering to first-visit antenatal care standards. Initially, a series of unadjusted logistic regression analyses according to the type of facility and managing authority were performed separately at each level (i.e., facility, provider, and client). Thereafter, all variables with P < 0.2 were fitted into the respective stratified multivariable logistic regression analysis using a 5% significance level.

RESULTS

A total of 1756 first-visit antenatal care consultations performed by 822 providers in 648 health facilities were analyzed. The overall median [Interquartile range, IQR] adherence to first-visit antenatal care was relatively low at 47.1% [35.7%-60.5%]. After adjusting for selected variables from each level in specific strata, at dispensary; female providers [AOR = 5.5; 95% CI, 1.8-16.4], at health centre; performance of quality assurance [AOR = 2.2; 95% CI, 1.3-3.9], at hospital; availability of routine tests [AOR = 2.5; 95% CI, 1.3-4.8] and basic medicine [AOR = 2.8; 95% CI, 1.4-5.7], at public facilities; availability of medicine [AOR = 1.8; 95% CI, 1.1-3.2] and receiving refresher training [AOR = 1.8; 95% CI, 1.1-3.1], and at private facility; receiving external fund from government [AOR = 3.0; 95% CI, 1.1-8.4] were significantly associated with better adherence to first-visit antenatal care standards.

CONCLUSIONS

The study highlighted the important factors, including the provision of refresher training, regular distribution of basic medicines, and diagnostics equipment which may influence provider adherence to first-visit ANC standards.

Advice on healthy pregnancy, delivery, motherhood and information on non-communicable diseases in the maternal care programme in Myanmar: a cross-sectional study

OBJECTIVE

Pregnancy and delivery periods offer an opportunity for counselling women to improve behavioural risk and prevent complications, including non-communicable diseases (NCDs). However, little evidence is available on counselling offered during antenatal and postnatal care (PNC) in Myanmar. This study aimed to assess the contents of advice and information received by women during antenatal and postnatal counselling and to identify factors associated with receiving those advice and information.

DESIGN

Cross-sectional study.

SETTING

A predominantly rural township in the Ayeyawady region and a predominantly urban township in the Yangon region.

PARTICIPANTS

1500 women who had given birth in the last 6 weeks to 12 months prior to the survey.

OUTCOME MEASURES

Receiving advice on 18 items during antenatal counselling, 10 items during postnatal counselling and information on five major NCDs during antenatal care (ANC).

RESULTS

Nearly 52% of women received advice on 18 items during antenatal counselling, and 60% received advice on 10 items during postnatal counselling. About 28% received information on five NCDs during ANC. Women who were living in the Yangon site, who had primary school education or lower and who experienced complications were less likely to receive advice on all items during both antenatal and postnatal counselling. Women who received PNC outside of a healthcare facility and were primiparas were also less likely to receive advice on all items during postnatal counselling. Women living in the Yangon site and those who utilised a private care facility were less likely to receive information on NCDs.

CONCLUSIONS

Only 60% of women received advice on healthy pregnancy, delivery and motherhood, whereas 30% received information on NCDs. Although non-modifiable maternal factors were associated with these results, counselling practice can be improved and information on NCDs can be offered as the first step of integrated NCDs care in maternal care programme in Myanmar.

Quality gap in maternal and newborn healthcare: a cross-sectional study in Myanmar

Introduction

Access to maternal and newborn healthcare has improved in Myanmar. However, regular contact with skilled care providers does not necessarily result in quality care. We assessed adequate contact made by women and newborns with skilled care providers, reception of high-quality care and quality-adjusted contacts during antenatal care (ANC), peripartum care (PPC) and postnatal care (PNC) in Myanmar.

Methods

This cross-sectional study was conducted in a predominantly urban township of Yangon and a predominantly rural township of Ayeyawady in March 2016. We collected data from 1500 women. We measured quality-adjusted contact, which refers to adequate contact with high-quality care, as follows: ≥4 ANC contacts and receiving 11–14 of 14 intervention items; facility-based delivery assisted by skilled care providers, receiving 7 of 7 PPC intervention items; and receiving the first PNC contact ≤24 hours postpartum and ≥2 additional contacts, and receiving 16–17 of 17 intervention items. Using multilevel logistic regression analysis with a random intercept at cluster level, we identified factors associated with adequate contact and high-quality ANC, PPC and PNC.

Results

The percentage of crude adequate contact was 60.9% for ANC, 61.3% for PPC and 11.5% for PNC. However, the percentage of quality-adjusted contact was 14.6% for ANC, 15.2% for PPC and 3.6% for PNC. Adequate contact was associated with receiving high-quality care at ANC, PPC and PNC. Being a teenager, low educational level, multiparity and low level in the household wealth index were negatively associated with adequate contact with healthcare providers for ANC and PPC. Receiving a maternal and child health handbook was positively associated with adequate contact for ANC and PPC, and with receiving high-quality ANC, PPC and PNC.

Conclusion

Women and newborns do not receive quality care during contact with skilled care providers in Myanmar. Continuity and quality of maternal and newborn care programmes must be improved.

Developing and implementing an interventional bundle to reduce mortality from gastroschisis in low-resource settings

Background: Gastroschisis is associated with less than 4% mortality in high-income countries and over 90% mortality in many tertiary paediatric surgery centres across sub-Saharan Africa (SSA). The aim of this trial is to develop, implement and prospectively evaluate an interventional bundle to reduce mortality from gastroschisis in seven tertiary paediatric surgery centres across SSA. Methods: A hybrid type-2 effectiveness-implementation, pre-post study design will be utilised. Using current literature an evidence-based, low-technology interventional bundle has been developed. A systematic review, qualitative study and Delphi process will provide further evidence to optimise the interventional bundle and implementation strategy. The interventional bundle has core components, which will remain consistent across all sites, and adaptable components, which will be determined through in-country co-development meetings. Pre- and post-intervention data will be collected on clinical, service delivery and implementation outcomes for 2-years at each site. The primary clinical outcome will be all-cause, in-hospital mortality. Secondary outcomes include the occurrence of a major complication, length of hospital stay and time to full enteral feeds. Service delivery outcomes include time to hospital and primary intervention, and adherence to the pre-hospital and in-hospital protocols.  Implementation outcomes are acceptability, adoption, appropriateness, feasibility, fidelity, coverage, cost and sustainability. Pre- and post-intervention clinical outcomes will be compared using Chi-squared analysis, unpaired t-test and/or Mann-Whitney U test. Time-series analysis will be undertaken using Statistical Process Control to identify significant trends and shifts in outcome overtime. Multivariate logistic regression analysis will be used to identify clinical and implementation factors affecting outcome with adjustment for confounders. Outcome: This will be the first multi-centre interventional study to our knowledge aimed at reducing mortality from gastroschisis in low-resource settings. If successful, detailed evaluation of both the clinical and implementation components of the study will allow sustainability in the study sites and further scale-up. Registration: ClinicalTrials.gov Identifier NCT03724214.

Disparity in utilization and expectation of community-based maternal health care services among women in Myanmar: a cross-sectional study

BACKGROUND

Aim of this study is to assess women's utilization and expectation of community-based antenatal and delivery care services in Myanmar and determine associated factors for disparity of services received with services women expected to receive.

METHODS

A cross-sectional survey was conducted among 6-month postpartum women in three townships of Myanmar during May-September 2016. Associated factors for the services with disparity were identified using multinomial logistic regression models.

RESULTS

Of 1743 women, the percentages of antenatal care (ANC) attended by a skilled provider, at least four ANC visits, and early ANC were 89, 60 and 36%, respectively. The percentage of non-facility delivery was 65%. Many ANC services received and services expected to receive had lower than 80% coverage. Services with significant disparity included blood hemoglobin and urinary protein testing, and iron supplementation. Low access to ANC, women's socio-economic status, pregnancy and delivery complications, and out-of-pocket cost were associated with disparity of these services.

CONCLUSION

Utilization and expectation of community-based ANC services and facility delivery is low in Myanmar. Disparities of the services received with the services women expected to receive were common in ANC. Improving women's expectations on essential services during pregnancy is needed as well as strengthening community participation.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Cross-cultural adaptation and psychometric properties of the Brazilian-Portuguese version of the Quality of Prenatal Care Questionnaire (QPCQ)

OBJECTIVE

To translate and to observe the psychometric measures of the Brazilian version of the Quality of Prenatal Care Questionnaire.

METHODS

The translation protocol followed the standards of the International Society for Pharmacoeconomics and Outcomes Research. Descriptive statistics were performed to identify characteristics of 280 literate postpartum women in a public hospital. We examined the internal consistency using Cronbach's alfa. To determine the test-retest reproducibility and the instrument's stability, we performed the intraclass correlation coefficient and Bland and Altman plot between two applications. We investigated the item's properties using the item response theory.

RESULTS

The overall Cronbach's alpha index was 0.975. The intraclass correlation coefficient was 0.995 (95%CI 0.993-0.996) and a uniform distribution was visualized at the Bland and Altman plot. The item response theory identified the discriminatory power and the difficulty level of the instrument and of each item. The instrument showed acute angulation of the expected total score, and good concentrate information and good standard error curves, preserving the latent construct and its original items.

CONCLUSIONS

This analysis concluded that the Brazilian version of the Quality of Prenatal Care Questionnaire is a high-quality, reliable and valid questionnaire to determine the quality of prenatal care among Brazilian women. The questionnaire is suitable for the cultural context represented.

Antenatal care in rural Bangladesh: Gaps in adequate coverage and content

INTRODUCTION

Antenatal care (ANC) has long been considered a critical component of the continuum of care during pregnancy, with the potential to contribute to the survival and thriving of women and newborns. Although ANC utilization has increased in over the past decades, adequate coverage and content of ANC contacts have fallen under increased scrutiny. The objectives of this article are to describe the coverage and content of ANC contacts in the context of rural Bangladesh.

METHODS

A community-based, cross-sectional household survey was conducted in two sub-districts of Netrokona district, Bangladesh in 2016. A total of 737 women with a recent birth outcome were interviewed. Respondents reported on the ANC contacts and the content of these contacts. Descriptive statistics were used to report coverage and content of ANC contacts stratified by covariates. Chi-square tests were performed to explore whether the estimates are different among different categories and significant differences were reported at p<0.05.

RESULTS

Around 25% of women attended at least four ANC contacts, with only 11% initiating ANC in the first trimester of pregnancy. Blood pressure was measured in almost all of the ANC contacts (92%), and abdominal examination performed in 80% and weight measured in 85% of ANC contacts. Urine tests were conducted in less than half of the ANC contacts, whereas blood screening tests and ultrasound were conducted in 45% contacts. Health care providers counselled women on danger signs in only 66% of the ANC contacts. Overall, the content of facility-based ANC contacts were better than home-based ANC contacts across all components.

CONCLUSIONS

Adequate coverage of ANC remains poor in Netrokona, Bangladesh and important gaps remain in the content of ANC contacts when women attend these services.

Demand Side Factors Associated With Quality Antenatal Care Services: A Case Study of Lusaka District, Zambia

Background: The quality of antenatal care (ANC) a woman receives during pregnancy is crucial to both the child and the mother's life. It has been established that providing high-quality ANC can save lives and has a positive impact on postnatal health care services. However, the quality of ANC in Zambia requires attention as maternal and neonatal mortality rates are still unacceptably high with Lusaka district not being left out of the problem. Methods: Using a cross-sectional study design, the main aim of this study was to determine the demand side factors associated with high-quality antenatal care among pregnant women in Lusaka. It also estimated the proportion of women who received high-quality ANC during their last antenatal visit. Multifactorial logistic regression model was fitted in STATA version 13 to predict the demographic, socio and economic factors that influence the quality of ANC. Results: It was established that only 47.1% of pregnant women received high-quality ANC while 52.9% received low quality. Six key ANC interventions were considered, among which urine (36.7%) and blood (46.8%) testing were the least received basic components of ANC. After adjusting for the effect of other factors, women with secondary education had higher odds of receiving high-quality ANC than women with primary level of education (OR = 1.98; 95% CI: 1.24-3.14). Women staying with their husband/partners had lesser odds of receiving high quality ANC compared to those that were not staying with their partners (OR = 0.47; 95% CI: 0.28-0.79). Conclusion: The quality of antenatal care received by pregnant women in Lusaka is low. Continued efforts to improve the delivery of basic ANC services such as blood and urine testing is required to improve the quality of healthcare services provided by medical personnel at all levels.

A reassessment of global antenatal care coverage for improving maternal health using sub-Saharan Africa as a case study

BACKGROUND

Antenatal period is an opportunity for reaching pregnant women with vital interventions. In fact, antenatal care (ANC) coverage was an indicator for assessing progress towards the Millennium Development Goals. This paper applies a novel index of service coverage using ANC, which accounts for every ANC visit. An index of service coverage gap is also proposed. These indices are additively decomposable by population groups and they are sensitive to the receipt of more ANC visits below a defined threshold. These indices have also been generalised to account for the quality of services.

METHODS

Data from recent rounds of the Demographic and Health Survey (DHS) are used to reassess ANC service coverage in 35 sub-Saharan African countries. An index of ANC coverage was estimated. These countries were ranked, and their ranks are compared with those based on attaining at least four ANC visits (ANC4+).

FINDINGS

The index of ANC coverage reflected the level of service coverage in countries. Further, disparities exist in country ranking as some countries, e.g. Cameroon, Benin Republic and Nigeria are ranked better using the ANC4+ indicator but poorly using the proposed index. Also, Rwanda and Malawi are ranked better using the proposed index.

CONCLUSION

The proposed ANC index allows for the assessment of progressive realisation, rooted in the move towards universal health coverage. In fact, the index reflects progress that countries make in increasing service coverage. This is because every ANC visit counts. Beyond ANC coverage, the proposed index is applicable to assessing service coverage generally including quality education.