Use of antenatal care, maternity services, intermittent presumptive treatment and insecticide treated bed nets by pregnant women in Luwero district, Uganda

Variations in the use of malaria preventive measures among pregnant women in Guinea: a secondary analysis of the 2012 and 2018 demographic and health surveys

BACKGROUND

Despite its effectiveness, the optimal use of the combination of insecticide-treated nets (ITN) and intermittent preventive treatment during pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) remains low in malaria-endemic areas. Therefore, this study analyzed its variations and predictors in Guinea.

METHODS

This study was a secondary analysis of the 2012 and 2018 Guinea Demographic and Health Surveys (DHS). It included women who had given birth 3 years before each DHS, slept on ITN and took at least one dose of SP. Use was complete if a pregnant woman slept on ITNs and took SP (at least two doses in 2012; at least three doses in 2018). Moran indices were used to determine spatial autocorrelation and classification methods to identify malaria preventive measures (MPM) predictors.

RESULTS

In 2012, 60.88% of pregnant women had incomplete use of MPMs compared with 79.11% in 2018. Associated factors with incomplete MPMs in 2012 were as follows: having an indirect link with the head of household (AOR = 2.23, 95% CI 1.08-4.61) and performing at least 4 ANC visits (AOR = 0.66, 95% CI 0.44-0.99). In 2018: Living in households of 2 to 5 people (AOR = 0.54, 95% CI 0.36-0.80), have a man as the head of the household (AOR = 0.56, 95% CI 0.35-0.89), perform the first ANC in the second trimester of pregnancy (AOR = 0.74, 95% CI 0.54-0.99), perform at least 4 ANC visits (AOR = 0.47, 95% CI 0.36-0.62), have a job (AOR = 0. 67, 95% CI 0.50-0.88), give birth in a public health facility (AOR = 0.53, 95% CI 0.39-0.72) and the middle wealth quintile (AOR = 1.56, 95% CI 1.07-2.26). Analyses revealed a global autocorrelation (Moran index = 0.0009, p = 0.2349) and high-high clusters in Mamou in 2012. In 2018, autocorrelation was found (I Moran = 0.0169, p ≤ 0.05), with spatial clusters in 4 regions.

CONCLUSION

The link with the head of household and the number of ANC visits were the main factors in MPMs. It is essential to implement strategies at the household level and health system level and monitor them to reduce inequality across regions.

Effectiveness and compliance to the use of sulphadoxine-pyrimethamine as a prophylaxis for malaria among pregnant women in Port Harcourt, Rivers State, Nigeria

Background

Malaria during pregnancy escalates the damaging consequence to the mother and neonate. The usage of intermittent preventive treatment of malaria (IPTp) with sulfadoxine-pyrimethamine (SP) is recommended for averting the deleterious consequences of malaria in pregnancy. This study evaluated the effectiveness of, and compliance with the use of SP for malaria among pregnant women in Port Harcourt Rivers State, Nigeria.

Method

A total of 300 samples of maternal peripheral blood (MPB), 84 neonatal cord blood (NCB) and 84 placental blood (PLB) were collected from consenting mothers. Malaria parasitaemia were analysed using standard parasitological methods, and bio-data of consenting mothers were collected through questionnaires and from ANC records.

Results

Out of the samples examined for MPB, 59(19.7%) tested positive to malaria. Those with only primary education (57.1%) and women of age ≤ 20yrs (25%) had higher prevalence. Women who took SP had significantly lower prevalence (17.6%) than those that took other drugs (36.4%) (p < 0.05). Malaria prevalence was highest among women who had 3 months interval between each dose (39.1%), followed by those of 2months (23.7%) and those of 1 month (7.0%) (p < 0.05). The primigravidaes (22.8%) had an insignificantly higher prevalence than secundigravidae (19.4%) and multigravidae (15.9%). Also, 30.5% of women who registered in their third trimester of pregnancy had a significantly higher malaria parasitaemia than those who registered during their first 8.10%, or second trimesters, 19.4%. Of the 84 MPB-NCB-PLB pairedamples examined, 16.7%, 8.3% and 25% respectively were infected with malaria parasitaemia. On frequency of compliance, mothers who took SP once (37.5%) had a significantly higher MPB parasitaemia than those who took it twice (7.84%) and those of thrice (6.25%). Neonatal cord blood parasitaemia prevalence revealed that those that took SP once, that is, 25%, had a higher prevalence than others like those of twice (5.88%) and thrice (0%) respectively.

Conclusion

The use and compliance of SP reduced the prevalence of malaria among pregnant women and their new-borns.

Determinants of intermittent preventive treatment with sulfadoxine-pyrimethamine in pregnant women (IPTp-SP) in Mali, a household survey

Background

In malaria endemic regions, intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) is recommended for all pregnant women during prenatal consultation, from the fourth month of pregnancy up to the time of delivery. The Government of Mali is aiming for universal coverage of IPTp-SP. However, coverage is still low, estimated to be 18% for completion of three doses (IPTp-SP3). The objective of this study was to identify the factors that influence IPTp-SP adherence in the Health District of Sélingué, Mali.

Methods

This was a cross-sectional survey with 30 clusters, proportional to village size, with two stages of sampling. Data were collected electronically with Magpi software during face-to-face interviews/surveys. The data were analysed with SPSS version 20. A descriptive analysis and bivariate and multivariate logistic regression were performed. An equity analysis examined the effect of distance from health care facility on completion of three or more antenatal visits (ANC3 +) and three or more doses of intermittent preventive treatment (IPTp-SP3 +).

Results

Of the 1,021 women surveyed, 87.8% (n = 896) attended at least one ANC visit. Of these, 86.3% (n = 773) received at least one dose of IPTp-SP. Compliance with three or more doses of IPTp-SP was 63.7%. The determinants statistically related to ANC3 + were the early initiation of ANC (OR = 3.22 [1.22, 10.78]), and the presence of a community health centre (CHC) in the village (OR = 9.69 [1.09, 86.21]). The ability to read (OR = 1.60 [1.01, 2.55]), the early initiation of ANC (OR = 1.46 [1.06, 2.00], knowledge of the utility of the drug (OR = 2.38 [1.24, 4.57]), and knowledge of the recommended dose of the drug (OR = 6.11 [3.98, 9.39]) were related to completion of three or more treatments (IPTp-SP3 +).

Conclusion

The early initiation of ANC was a positive determinant of the completeness of both ANC3 + and IPTp-SP3 + . This study shows that a successful implementation of the IPTp strategy can be achieved by improving access to prenatal care at community health facilities, and strengthening patient-provider communication to ensure adequate knowledge on dosing of IPTp-SP and the benefits to mother and child.

Factors for late initiation of antenatal care in Dar es Salaam, Tanzania: A qualitative study

Background

Antenatal care (ANC) provided by a trained health care provider is important for monitoring pregnancy thereby reducing potential risks for the mother and child during pregnancy and delivery. The World Health Organization (WHO) recommends at least four ANC visits to all pregnant women. While the proportion of women who attend at least one ANC in low-income countries is high, most pregnant women start their first ANC attendance very late. In Tanzania only 24% of pregnant women start their first ANC attendance before the fourth month of pregnancy. While factors for the utilization of antenatal care in general have been widely studied, there is paucity of studies on the factors affecting timing of the first ANC attendance. This study aimed to understand individual, community, and health system factors that lead to the delay in seeking ANC services among pregnant women in Ilala Municipal in Dar es Salaam region, Tanzania.

Methods

A qualitative exploratory study, using in-depth interviews with 20 pregnant women and five health care workers was conducted in three different health facilities in Dar es Salaam Tanzania. Thematic analysis approach was used to analyse the data.

Results

Individual perceptions of antenatal care, past experience with pregnancy, fear of pregnancy disclosure, and socio-cultural beliefs were the key individual and social factors for late ANC attendance. Shortage of trained health care workers, lack of spouse’s escort and health providers’ disrespect to pregnant women were the main health system barriers to early ANC attendance.

Conclusions

This study concludes that community members should be sensitized about the importance of early ANC attendance. Additionally, while spouse’s escort policy is important for promoting PMTCT, the interpretation of the policy should not solely be left to the health providers. District and regional health officials should provide correct interpretation of this policy.

Intermittent preventive treatment of pregnant women in Kintampo area of Ghana with sulphadoxine-pyrimethamine (SP): trends spanning 2011 and 2015

OBJECTIVE

In Ghana, intermittent preventive treatment during pregnancy with sulphadoxine-pyrimethamine (IPTp-SP) is recommended for the prevention of malaria-related adverse outcomes. This study demonstrates the coverage of IPTp-SP use among pregnant women over a period (2011-2015) and the impact of various sociodemographic groups on the uptake of IPTp-SP.

DESIGN

Retrospective analysis using data from all pregnant women in the Kintampo Health and Demographic Surveillance System area on the uptake of IPTp-SP.

SETTING

Kintampo North Municipality and Kintampo South District of Ghana.

PARTICIPANTS

All pregnant women in the Kintampo Health and Demographic Surveillance System area.

PRIMARY AND SECONDARY OUTCOME MEASURES

The number of doses of IPTp-SP taken by pregnant women were examined. Logistic regression was used to assess the determinant of uptake of IPTp-SP while adjusting for within-subject correlation from women with multiple pregnancies.

RESULTS

Data from 2011 to 2015 with a total of 17 484 pregnant women were used. The coverage of the recommended three or more doses of IPTp-SP among all pregnant women was 40.6%, 44.0%, 45.9%, 20.9% and 32.4% in 2011, 2012, 2013, 2014 and 2015, respectively. In the adjusted analysis, age, household size, education, religion, number of antenatal care visits, ethnicity, marital status, wealth index and place of residence were significantly associated with the uptake of three or more doses of IPTp-SP. Having middle school education or higher, aged 20 years and above, visiting antenatal care five times or more (OR 2.83, 95% CI 2.64 to 3.03), being married (OR 1.10, 95% CI 1.02 to 1.19) and those in higher wealth quintiles were significantly more likely to take three or more doses of IPTp-SP.

CONCLUSION

The uptake of the recommended three or more doses of IPTp-SP is low in the study area. We recommend a community-based approach to identify women during early pregnancy and to administer IPTp-SP.

Regular Antenatal Attendance and Education Influence the Uptake of Intermittent Preventive Treatment of Malaria in Pregnancy: A Cross-Sectional Study at the University Hospital, Kumasi, Ghana

Background

The World Health Organization (WHO) recommends the use of Insecticide Treated Bed-Nets and Intermittent Preventive Treatment (IPT) with Sulphadoxine-Pyrimethamine (SP) as interventions in curbing malaria during pregnancy. However, increasing evidence shows a gap in coverage where not all pregnant women receive the recommended SP dose. This study evaluated the factors influencing uptake of IPTp-SP among pregnant women in Kumasi, Ghana.

Methodology

This cross-sectional study was conducted among 280 pregnant women attending the Kwame Nkrumah University of Science and Technology Hospital in Kumasi, Ghana. Validated structured questionnaires were administered to obtain sociodemographic, medical/reproductive information, and IPTp-SP uptake among participants. Statistical analyses were performed using IBM SPSS 25.0 statistics.

Results

The mean age of respondents was 29.7±4.9 years. Of the 280 women interviewed, 74.6% attended the antenatal care (ANC) clinic at least four times with only 31.8% completing the recommended doses. Tertiary education [aOR=3.15, 95% CI (0.94 -10.97), and p=0.042] and ≥ 4 ANC visits [aOR=24.6, 95% CI (5.87-103.07), p<0.0001] had statistically significant higher odds of completing the recommended IPTp-SP dose. However, participants employed by the formal sector [aOR=0.28, 95% CI (0.09 - 0.79), p=0.016] and participants with more than four children [aOR=0.14, 95% CI (0.03 - 0.63), and p=0.011] had statistically significant lower odds of completing the recommended IPT dose.

Conclusion

ANC attendance is critical in IPTp uptake. The results emphasize the need for the Health Policy Makers in Kumasi to encourage pregnant women, especially women working in the formal sector and women having more than four children to patronize ANC attendance to ensure high coverage of the recommended IPTp dose.

Effectiveness of antenatal care services in reducing neonatal mortality in Kenya: analysis of national survey data

BACKGROUND

Although global neonatal mortality declined by about 40 percent from 1990 to 2013, it still accounted for about 2.6 million deaths globally and constituted 42 percent of global under-five deaths. Most of these deaths occur in developing countries. Antenatal care (ANC) is a globally recommended strategy used to prevent neonatal deaths. In Kenya, over 90 percent of pregnant women attend at least one ANC visit during pregnancy. However, Kenya is currently among the 10 countries that contribute the most neonatal deaths globally.

OBJECTIVE

The aim of this study is to examine the effectiveness of ANC services in reducing neonatal mortality in Kenya.

METHODS

We used binary logistic regression to analyse cross-sectional data from the 2014 Kenya Demographic and Health Survey to investigate the effectiveness of ANC services in reducing neonatal mortality in Kenya. We determined the population attributable neonatal mortality fraction for the lack of selected antenatal interventions.

RESULTS

The highest odds of neonatal mortality were among neonates whose mothers did not attend any ANC visit (adjusted odds ratio [aOR] 4.0, 95% confidence interval [CI] 1.7-9.1) and whose mothers lacked skilled ANC attendance during pregnancy (aOR 3.0, 95% CI 1.4-6.1). Lack of tetanus injection relative to one tetanus injection was significantly associated with neonatal mortality (aOR 2.5, 95% CI 1.0-6.0). About 38 percent of all neonatal deaths in Kenya were attributable to lack of check-ups for pregnancy complications.

CONCLUSIONS

Lack of check-ups for pregnancy complications, unskilled ANC provision and lack of tetanus injection were associated with neonatal mortality in Kenya. Integrating community ANC outreach programmes in the national policy strategy and training geared towards early detection of complications can have positive implications for neonatal survival.

Assessment of coverage of preventive treatment and insecticide-treated mosquito nets in pregnant women attending antenatal care services in 11 districts in Mozambique in 2011: the critical role of supply chain

Background

Malaria during pregnancy is associated with poor maternal and pregnancy outcome and the World Health Organization recommends the administration of intermittent preventive treatment in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP) and distribution of insecticide-treated mosquito nets (ITNs) to all pregnant women attending antenatal care (ANC) services. This study was conducted with the aim to assess the uptake of IPTp and ITNs in pregnant women attending ANC services and correlate with ANC attendance and frequency of stock-outs in 22 health facilities Mozambique.

Methods

A cross-sectional study was conducted between July and December 2011 in 22 health units in 11 districts situated in 11 provinces in Mozambique. Two health facilities were selected per district (one urban and one rural). Data were collected by reviewing logbooks of antenatal consultations as well as from monthly district reports.

Results

During the period under investigation, a total of 23,524 pregnant women attended their 1st antenatal care visits, of which 12,775 (54.3%) and 7581 (32.2%) received one and two doses of IPTp, respectively. In regard to ITNs, a total of 16,436 (69.9%) pregnant women received ITNs. Uptake of IPTp and ITNs by pregnant women at ANC services was higher in southern Mozambique and lower in districts situated in the northern part of the country. Stock-outs of SP and ITNs were reported in 50.0% (11/22) and 54.5% (12/22) of the health facilities, respectively. Coverage of IPTp and ITN in health facilities with stock-outs of SP and ITNs was much lower as compared to health facilities with no stock-outs.

Conclusions

Altogether, data from this study shows that coverage of the 2nd dose of IPTp, as well as ITNs, was low in pregnant women attending ANC services in Mozambique. In addition, this data also shows that stock-outs of SP and ITNs were frequent and led to lower coverage of IPTp and ITN, representing a serious barrier for the accomplishment of targets. In conclusion, this study recommends that efforts should be made to improve the supply chains of SP and ITNs.

Effectiveness of advertising availability of prenatal ultrasound on uptake of antenatal care in rural Uganda: A cluster randomized trial

In rural Uganda pregnant women often lack access to health services, do not attend antenatal care, and tend to utilize traditional healers/birth attendants. We hypothesized that receiving a message advertising that "you will be able to see your baby by ultrasound" would motivate rural Ugandan women who otherwise might use a traditional birth attendant to attend antenatal care, and that those women would subsequently be more satisfied with care. A cluster randomized trial was conducted across eight rural sub-counties in southwestern Uganda. Sub-counties were randomized to a control arm, with advertisement of antenatal care with no mention of portable obstetric ultrasound (four communities, n = 59), or an intervention arm, with advertisement of portable obstetric ultrasound. Advertisement of portable obstetric ultrasound was further divided into intervention A) word of mouth advertisement of portable obstetric ultrasound and antenatal care (one communitity, n = 16), B) radio advertisement of only antenatal care and word of mouth advertisement of antenatal care and portable obstetric ultrasound (one community, n = 7), or C) word of mouth + radio advertisement of both antenatal care and portable obstetric ultrasound (two communities, n = 75). The primary outcome was attendance to antenatal care. 159 women presented to antenatal care across eight sub-counties. The rate of attendance was 65.1 (per 1000 pregnant women, 95% CI 38.3-110.4) where portable obstetric ultrasound was advertised by radio and word of mouth, as compared to a rate of 11.1 (95% CI 6.1-20.1) in control communities (rate ratio 5.9, 95% CI 2.6-13.0, p<0.0001). Attendance was also improved in women who had previously seen a traditional healer (13.0, 95% CI 5.4-31.2) compared to control (1.5, 95% CI 0.5-5.0, rate ratio 8.7, 95% CI 2.0-38.1, p = 0.004). By advertising antenatal care and portable obstetric ultrasound by radio attendance was significantly improved. This study suggests that women can be motivated to attend antenatal care when offered the concrete incentive of seeing their baby.

Pattern of utilization of ante-natal and delivery services in a semi-urban community of North-Central Nigeria

BACKGROUND

Nigeria accounts for only 2% of the world's population, but contributes up to 10 % of the global estimates of maternal deaths. The study assesses the utilization of antenatal and delivery services by women of reproductive age in Afon community.

METHODOLOGY

It was a descriptive cross-sectional study that collected both quantitative and qualitative data using semi-structured interviewer administered questionnaire and focus group discussions (FGD). Interviews were house-hold based. FGD had two homogenous groups. Data was analysed using Epi-info version 3.5.1 software package. Level of statistical significance was set at p <0.05.

RESULTS

There was a high level of utilization of antenatal/delivery services in the community. Barriers to utilization of ANC/delivery services include lack of money, distance from health facility, long waiting time, poor attitude of health workers and no permission from husbands. Level of education and employment status were significantly associated with utilization of ANC/delivery services.

CONCLUSION

Girl-child education and women empowerment are required to improve utilization of services. Ante-natal care providers need to be trained to improve quality of care in the discharge of their duties.

Assessing demand-side barriers to uptake of intermittent preventive treatment for malaria in pregnancy: a qualitative study in two regions of Uganda

Background

To prevent malaria infection during pregnancy in endemic areas in Africa, the World Health Organization recommends the administration of intermittent preventive treatment in pregnancy (IPTp) as part of the focused antenatal care package. However, IPTp uptake in most countries remains low despite generally high antenatal care coverage and increased efforts by governments to address known bottlenecks such as drug stock-outs. The study explored factors that continue to impede uptake of IPTp among women who attend antenatal care. This paper focuses on demand-side barriers with regard to accessibility, affordability and acceptability.

Methods

The research was conducted in 2013/2014 and involved 46 in-depth interviews with four types of respondents: (i) seven district health officials; (ii) 15 health workers; (iii) 19 women who attended antenatal care; (iv) five opinion leaders. Interviews were conducted in Eastern and West Nile regions of Uganda. Data was analysed by thematic analysis.

Results

District health officials and health workers cited a range of barriers relating to knowledge and attitudes among pregnant women, including lack of awareness of pregnancy-related health risks, a tendency to initiate antenatal care late, reluctance to take medication and concerns about side effects of IPTp. However, women and opinion leaders expressed very positive views of antenatal care and IPTp. They also reported that the burden of travel and cost associated with antenatal care attendance was challenging, but did not keep them from accessing a service they perceived as beneficial. The role of trust in health workers’ expertise was highlighted by all respondents and it was reported that women will typically accept IPTp if encouraged by a health worker.

Conclusions

Given the positive views of antenatal care and IPTp, high antenatal care coverage and reported low refusal rates for IPTp, supply-side issues are likely to account for the majority of missed opportunities for the provision of IPTp when women attend antenatal care. However, to increase uptake of IPTp on the demand side, health workers should be encouraged to reassure eligible women that IPTp is safe.

Electronic supplementary material

The online version of this article (doi:10.1186/s12936-016-1589-7) contains supplementary material, which is available to authorized users.

Relationship between maternal pelvis height and other anthropometric measurements in a multisite cohort of Ugandan mothers

INTRODUCTION

In sub Saharan Africa, childbirth remains a challenge that creates the need for additional screening tools. Maternal pelvis height, which is currently in use by automotive engineers has previously been shown to have significant associations with various childbirth related outcomes and events. This study set out to determine the associations between maternal: Age, height, weight and number of pregnancies with maternal pelvis height in Ugandan mothers.

METHODS

This was a secondary analysis of maternal birth records from nine Ugandan hospitals, of mothers with singleton pregnancies. Data was analyzed using multilevel regression with respect to maternal pelvis height and additional analysis for tribe and site of childbirth intraclass correlations (ICCs).

RESULTS

The mean maternal pelvis height was 7.30cm for the 2068 records. Maternal pelvis height was associated with: a 0.01cm reduction per centimeter of maternal height (P=0.02), 0.01cm increase per kg of maternal weight (P<0.01), 0.04cm increase for each additional pregnancy (P=0.03) and 0.03cm increase with respect to tribe of mother (P=0.27), for a constant of 7.97cm (P<0.01). The ICC for tribe was 0.20 (SE=0.08) and 0.37 (SE=0.11) for site.

CONCLUSION

Maternal pelvis height was associated with maternal height, maternal weight and number of pregnancies. The site of childbirth had a moderate effect on the above associations with maternal pelvis height. More study on the public health screening value of these measurements in these settings is required.

Factors influencing dropout rate of intermittent preventive treatment of malaria during pregnancy

BACKGROUND

The burden of malaria in terms of morbidity and mortality is huge is Sub-Saharan Africa, particularly among pregnant women. Among the measures to curb down this burden include intermittent preventive treatment (IPT) and effective case management. These strategies were adopted by Ghana and implemented since 2003; however, there is still high dropout rate in IPT coverage. This study sought to investigate factors contributing to high dropout rate between IPT1 and IPT3 in the Tamale Metropolis, one of the health facilities with the highest IPT dropout rates in Ghana.

METHODS

Survey, in-depth interviews and short ethnographic techniques were conducted among pregnant women, antenatal care (ANC) health workers and heads of health facilities to investigate factors which account for dropout rate of intermittent treatment of malaria.

RESULTS

Shortage of sulphadoxine pyrimethamine (SP), inadequate supply of portable water for administration of SP, unavailability of IPT during outreach services, lack of knowledge by ANC staff about the dropout rate in their area of jurisdiction and poor attitude of some health workers were identified as barriers to achieving high IPT3 coverage.

CONCLUSIONS

Late ANC visit, provider and logistical barriers account for the women's missed opportunities to prevent malaria in pregnancy through IPT. Addressing the above barriers will contribute to saving lives and ensuring progress towards the goal of combating malaria as well as reducing maternal, neonatal and child mortalities.

Factors associated with use of malaria control interventions by pregnant women in Buwunga subcounty, Bugiri District

BACKGROUND

In Uganda, the Government has promoted the use of intermittent preventive treatment of malaria in pregnancy (IPTp) and insecticide-treated bed nets (ITNs) as malaria control strategies for pregnant women. However, their utilization among pregnant women is low. This study aimed at assessing factors associated with use of IPTp for malaria and ITNs by pregnant women in Buwunga sub-county, Bugiri District.

METHODS

This was a cross-sectional study, conducted in Buwunga sub-county, Bugiri District, employing quantitative data collection tools. A total of 350 household members were randomly selected to participate in the study. Data were entered and analysed using Epi info version 3.5.1; bivariable and multivariable analysis was done to assess the factors associated with use of IPTp and ITNs among pregnant women.

RESULTS

The level of uptake of IPTp1 (at least one dose) was 63.7 % while IPTp2 (at least two doses) was 42.0 %. More than half (58.6 %) of the mothers had slept under an ITN the night before the survey. Slightly more than half (51.9 %) of the mothers mentioned stock outs as the major reason for not accessing IPTp and ITNs. The main factors that were statistically significant for IPTp2 uptake were the knowledge of mothers on IPTp2 (AOR 2.48 95 % CI 1.53-4.02) and providing women with free clean water at the antenatal care (ANC) clinic (AOR 3.63 95 % CI 2.06-6.39). Factors that were significant for ITN utilization included education level of mothers (AOR 2.03 95 % CI 1.09-3.78), ease of access (AOR 2.74 95 % CI 1.65-4.52), and parity (AOR 1.71 95 % CI 1.01-1.29).

CONCLUSION

The level of uptake of the two recommended doses of sulfadoxine-pyrimethamine (SP) tablets for malaria prevention (IPTp2) was low, slightly more than half of the mothers slept under an ITN the night before the survey. Appropriate measures to increase the level of uptake of IPTp2 and coverage of ITNs among pregnant women should be implemented, and these include providing health education about IPTp and ITNs, and ensuring that mothers are provided with free safe clean water at ANC clinic.

Knowledge, attitude and practice on malaria prevention and sulfadoxine-pyrimethamine utilisation among pregnant women in Badagry, Lagos State, Nigeria

Background

Malaria in pregnancy is one of the major causes of mater nal morbidity and mortality as well as of poor pregnancy outcomes. We studied the knowledge, attitude and practices of pregnant women on malaria prevention, assessed their knowledge of sulfadoxine-pyrimethamine (SP) for intermittent preventive therapy in pregnancy (IPTp-SP), and used the outcomes to create awareness on malaria prevention with IPTp-SP.

Materials and methods

A structured questionnaire on malaria prevention and SP utilisation was administer ed to 450 pregnant women attending antenatal clinics in both government and private health facilities in Badagry, Lagos State, Nigeria.

Results

355 (78.8% ) of the pregnant women perceived malaria as a serious illness. Other responses by the respondents included: parasitic disease (13; 2.9%); caused by mosquito (5; 1.9%), while 77 (17%) said they did not know. The signs and symptoms of malaria mentioned included headache (109; 24.2%), weakness (77; 17.1%), fever (77; 17.1%) and body pains (44; 10%). 174 (58%) women indicated that they would go to a hospital when having malaria, 54 (17%) indulged in self-medication, while 32 (11%) took herbs. 43 (14%) did nothing. Malaria prevention was performed by taking herbs (134; 30%); artemisinin-based combination therapy (ACT) (123; 27%); daraprim (104; 23%); blood tonic (51; 11%); paracetamol (21; 5%) and SP (17; 4%). Mosquito control was mainly carried out by the use of insecticide spray (215; 47.7%), followed by anti-mosquito coils (95; 21%). Out of the 450 pregnant women interviewed, 350 (84.5%) said that SP was for the treatment of malaria, while 69 (15.2%) said that it was for malaria prevention. Knowledge of SP was influenced by both education (P<0.05) and parity (P<0.001).

Conclusion

The majority of the pregnant women had knowledge of SP but did not know that it is used for malaria prevention. Most of the respondents took malaria-preventive measures by taking herbs but preferred to go to the hospital when suspecting that they had malaria.

Intermittent use of sulphadoxine-pyrimethamine for malaria prevention: a cross-sectional study of knowledge and practices among Ugandan women attending an urban antenatal clinic

Background

The WHO recommends supervised administration of sulphadoxine-pyrimethamine (SP) as intermittent preventive treatment for malaria (IPTp) during pregnancy. Logistical constraints have however favoured unsupervised intake of SP-IPTp, casting doubts whether recent guidelines requiring more frequent intake can be effectively implemented. To propose strategies for enhancing compliance under limited supervision, this study sought to identify pregnant women’s knowledge and practices gaps as well as determine predictors of compliance with SP-IPTp, given under limited supervision.

Methods

A cross-sectional study of 700 women used exit interviews at an urban clinic in Uganda to obtain a descriptive summary of demographic and obstetric characteristics, including knowledge, practice and experiences with SP. Predictors of compliance with SP intake instructions were explored using logistic regression.

Results

Median age of respondents was 25 (IQR 22–28) and median parity was two (IQR one to three) while median number of antenatal clinic (ANC) visits was 3.0 (IQR three to four). Most women had completed primary (36%) or ordinary secondary education (25.6%) while 16.1% had not completed primary education. Awareness about SP was high (99.4%) although correct knowledge regarding its use in pregnancy was low (57%), with 15.4% thinking it was used to treat malaria and 26.7% lacking any idea about its use. Correct knowledge on SP use during pregnancy significantly predicted compliance with SP-IPTp instructions (OR 1.98, C.I. 1.12-3.55), while age, education level, parity, number of ANC visits, or history of unwanted effects with SP did not. SP was mostly accessed from hospitals (64.4%) followed by private clinics (16.9%) both for preventive and treatment purposes. SP was considered safe by most women, who were willing to take it again in future, without supervision.

Conclusion

Despite high awareness, knowledge of SP as an intervention for malaria prevention in pregnancy was low. Correct knowledge on use of SP predicted compliance with SP-IPTp intake instructions. Focused malaria-related education during ANC visits may improve compliance with SP intake amidst limited supervision.

Electronic supplementary material

The online version of this article (doi:10.1186/1475-2875-13-399) contains supplementary material, which is available to authorized users.

DETERMINANTS OF FIRST ANTENATAL CARE VISIT BY PREGNANT WOMEN AT COMMUNITY BASED EDUCATION, RESEARCH AND SERVICE SITES IN NORTHERN UGANDA

BACKGROUND

Antenatal care (ANC) aims mainly at prevention, early detection and management of general medical and pregnancy associated disorders. Early booking is recommended for maximum utilisation.

OBJECTIVE

To investigate the determinants of first ANC visit and trimesters at which pregnant mothers enrol for ANC at the COBERS sites of Northern Uganda.

DESIGN

A descriptive cross-sectional study.

SETTING

Five community based Education, Research and Service sites (COBERS) of Atiak, Madi Opei, Mungula, Namukora and Pajule health centre, fours (HC IV) in the five respective districts of Amuru, Lamwo, Adjumani, Kitgum and Pader, Northern Uganda, from April to July 2013.

SUBJECTS

Four hundred and seventeen (417) pregnant women attending antenatal care (ANC) in five health centres and ten purposively selected midwives were interviewed using questionnaires.

RESULTS

Of the 417 respondents, only 11.5% (n = 48) had their first ANC at the recommended period of 0-16 weeks. Prevalence of late entry to ANC was 88.5% (n = 369). Mean gestational age at booking was 22.6 ± 5.7 weeks. Paternal level of education, outcome of previous pregnancy, previous ANC attendance, weeks of amenorrhea, convenience of opening hours at ANC facility, commuting distance from home to health facility, knowing the right time for ANC enrollment and pregnancy planning remained significant predictors governing early booking.

CONCLUSION

Late ANC booking is still a major public health concern that demands public enlightenment and paternal education coupled with women empowerment will reduce the magnitude of the problem.

Socio-demographic determinants of maternal health-care service utilization among rural women in anambra state, South East Nigeria

BACKGROUND

Although, antenatal care (ANC) attendance in sub Saharan Africa is high, however this does not always translate into quality ANC care service utilization.

AIM

This study therefore is aimed at exploring pattern of maternal health (MH) services utilization and the socio-demographic factors influencing it in Anambra State, South East Nigeria.

SUBJECTS AND METHODS

A total of 310 women of reproductive age with a previous history of gestation attending ANC services between September, 2007 and August, 2008 in selected Primary Health Centers in Anambra State were studied. Responses were elicited from the study participants using a pre-tested, semi-structured interviewer-administered questionnaire. Data collected were analyzed using Statistical Package for Social Sciences (SPSS) version 17 (SPSS Inc, Chicago Illinois, USA). Association between socio-demographic characteristics and pattern of utilization of ANC and delivery services was measured using χ(2)-test, Regression analysis was done to identify factors associated with utilization of MH services. P < 0.05 was assumed to be significant.

RESULTS

Use of health facility was 293 (97.0%) and 277 (92,7%) out 302 women for ANC and delivery services respectively. Most women attended their first ANC consultation during the preceding pregnancy was after the first trimester and about 31% (94/298) of them had <4 ANC visits prior to delivery. Socio-demographic factors were found to be significantly associated with places where MH care services are accessed. Parity was found to be associated with timing of ANC booking and number of ANC attendance (χ(2) = 9.49, P = 0.05). Odds of utilizing formal health facility for MH services were found to be significantly associated with increasing age (P < 0.01) and educational status of mothers (P < 0.001).

CONCLUSIONS

The study revealed high maternal service utilization and 10% fetal loss, hence the need to address the gaps of late ANC booking and low ANC visits.

Antenatal care visit attendance, intermittent preventive treatment during pregnancy (IPTp) and malaria parasitaemia at delivery

Background

The determinants and barriers for delivery and uptake of IPTp vary with different regions in sub-Saharan Africa. This study evaluated the determinants of ANC clinic attendance and IPTp-SP uptake among parturient women from Mount Cameroon Area and hypothesized that time of first ANC clinic attendance could influence uptake of IPTp-SP/dosage and consequently malaria parasite infection status at delivery.

Methods

Two cross sectional surveys were carried out at the Government Medical Centre in the Mutengene Health Area, Mt Cameroon Area from March to October 2007 and June 2008 to April 2009. Consented parturient women were consecutively enrolled in both surveys. In 2007, socio-demographic data, ANC clinic attendance, gestational age, fever history and reported use/dosage of IPTp-SP were documented using a structured questionnaire. In the second survey only IPT-SP usage/dosage was recorded. Malaria parasitaemia at delivery was determined by blood smear microscopy and placental histology.

Results and discussion

In 2007, among the 287 women interviewed, 2.2%, 59.7%, and 38.1% enrolled in the first, second and third trimester respectively. About 90% of women received at least one dose SP but only 53% received the two doses in 2007 and by 2009 IPTp-two doses coverage increased to 64%. Early clinic attendance was associated (P = 0.016) with fever history while being unmarried (OR = 2.2; 95% CI: 1.3-3.8) was significantly associated with fewer clinic visits (<4visits). Women who received one SP dose (OR = 3.7; 95% CI: 2.0-6.8) were more likely not to have attended ≥ 4visits. A higher proportion (P < 0.001) of women with first visit during the third trimester received only one dose, meanwhile, those who had an early first ANC attendance were more likely (OR = 0.4; 95% CI = 0.2 - 0.7) to receive two or more doses. Microscopic parasitaemia at delivery was frequent (P = 0.007) among women who enrolled in the third trimester and had received only one SP dose than in those with two doses.

Conclusion

In the study area, late first ANC clinic enrolment and fewer clinic visits may prevent the uptake of two SP doses and education on early and regular ANC clinic visits can increase IPTp coverage.

Knowledge and Attitude of Nigerian Pregnant Women towards Antenatal Exercise: A Cross-Sectional Survey

Background. Engagement in physical exercise in pregnancy is hamstrung by safety concerns, skepticism about usefulness, and limited individualized prescription guidelines. This study assessed knowledge and attitude of pregnant women towards antenatal exercises (ANEx). Methods. The cross-sectional study recruited 189 pregnant women from six selected antenatal clinics in Ile-Ife, South-West, Nigeria. Data were obtained on maternal characteristics, knowledge, and attitude towards ANEx. Results. Relaxation and breathing (59.8%), back care (51.3%), and muscle strengthening (51.3%) exercises were the most commonly known ANEx. Prevention of back pain risk (75.9%) and excess weight gain (69.1%) were perceived as benefits, while lower extremities swelling (31.8%) and extreme weight gain or loss (30.7%) were considered as contraindications to ANEx. 15.8% of the respondents had negative attitude towards ANEx resulting from insufficient information on exercise (83.3%) and tiredness (70.0%). Age significantly influences knowledge about contraindications to ANEx (P = 0.001), while attitude was influenced by age and occupation, respectively (P < 0.05). There was significant association between attitude and knowledge about benefits and contraindications to ANEx (P < 0.05). Conclusion. A majority of Nigerian pregnant women demonstrated inadequate knowledge but had positive attitude towards ANEx. Knowledge about benefits and contraindications to ANEx significantly influenced the attitude towards exercise in pregnancy.

Spatial autocorrelation in uptake of antenatal care and relationship to individual, household and village-level factors: results from a community-based survey of pregnant women in six districts in western Kenya

Background

The majority of maternal deaths, stillbirths, and neonatal deaths are concentrated in a few countries, many of which have weak health systems, poor access to health services, and low coverage of key health interventions. Early and consistent antenatal care (ANC) attendance could significantly reduce maternal and neonatal morbidity and mortality. Despite this, most Kenyan mothers initiate ANC care late in pregnancy and attend fewer than the recommended visits.

Methods

We used survey data from 6,200 pregnant women across six districts in western Kenya to understand demand-side factors related to use of ANC. Bayesian multi-level models were developed to explore the relative importance of individual, household and village-level factors in relation to ANC use.

Results

There is significant spatial autocorrelation of ANC attendance in three of the six districts and considerable heterogeneity in factors related to ANC use between districts. Working outside the home limited ANC attendance. Maternal age, the number of small children in the household, and ownership of livestock were important in some districts, but not all. Village proportions of pregnancy in women of child-bearing age was significantly correlated to ANC use in three of the six districts. Geographic distance to health facilities and the type of nearest facility was not correlated with ANC use. After incorporating individual, household and village-level covariates, no residual spatial autocorrelation remained in the outcome.

Conclusions

ANC attendance was consistently low across all the districts, but factors related to poor attendance varied. This heterogeneity is expected for an outcome that is highly influenced by socio-cultural values and local context. Interventions to improve use of ANC must be tailored to local context and should include explicit approaches to reach women who work outside the home.

Utilisation of insecticide treated nets among pregnant women in Gulu: a post conflict district in northern Uganda

BACKGROUND

Malaria during pregnancy causes severe anaemia, placental malaria or death to the mother while the fetus may be aborted or stillborn.

OBJECTIVE

To establish the prevalence and factors associated with Insecticide Treated Net (ITN) utilisation among pregnant women in a post conflict Internally Displaced Persons (IDP) camps of Gulu district.

METHODS

We conducted cross-sectional study in 20 IDP camps in which 769 pregnant women were interviewed for ITN utilisation the night before the survey. The 20 IDP camps were selected using simple random sampling technique as clusters. Households that had pregnant women were then consecutively selected. Data were entered in EpiData 3.1 and analyzed using STATA11.

RESULTS

35% of pregnant women (95% CI 31% - 38%) had utilised ITNs. Factors that promoted ITN utilisation includes: antenatal visit (AOR 1.90, p-value 0.000); ITN awareness (AOR 1.57, p-value 0.011), and willingness to purchase ITN (AOR 2.12, p-value 0.000). Factors which hinder ITN utilisation were: hours taken to reach health centre (AOR 0.64, p-value 0.050) and being single/widow/divorced (AOR 0.22, p-value 0.000).

CONCLUSION

Majority of the respondents were not utilising ITN. Therefore, leaders in Gulu district should encourage pregnant woman to acquire and use ITN to reduce their vulnerability to malaria.

Utilisation of skilled birth attendance in Northern Nigeria: a cross-sectional survey

OBJECTIVE

to determine the level and determinants for utilisation of Skilled Birth Attendance (SBA).

METHODS

a population-based survey using a structured questionnaire was conducted in Goya and Tundunya political wards of Katsina state from May to June 2012. Four hundred women aged 15-49 years who had delivered a baby within two years prior to the study were asked about birth attendance during antenatal care (ANC), childbirth and postnatal period of their most recent birth. Logistic regression analysis was performed to obtain independent predictors of skilled birth attendance (SBA).

FINDINGS

of the 400 women recruited for the study, 145 (36.3%) received antenatal care, 52 (13%) had their births assisted by skilled personnel and 88 (22%) received postnatal care from skilled birth attendants. Of the 52 women who had their births attended by skilled birth attendants only 29 (56%) had their births in a health facility. Maternal education, husband's occupation, presence of complication and previous place of childbirth were found to be statistically significant predictors for SBA utilisation. Barriers to SBA utilisation identified included lack of health care provider, lack of equipment and supplies and poverty. Enablers mentioned included availability of staff, husband's approval and affordable service.

CONCLUSION

women are more likely to utilise SBA with the availability of skilled personnel, strengthening of the health system and intervention to remove user fees for maternal health services. Joint effort should be made by government and community leaders to promote girl's education and to encourage men's involvement in maternal health services.

Ownership and use of insecticide-treated nets during pregnancy in sub-Saharan Africa: a review

Over the past decade, significant gains have been made in the implementation of malaria prevention measures in pregnancy in sub-Saharan Africa, including the distribution of insecticide-treated nets (ITNs). These have been shown to cause a reduction in the incidence of malaria and its consequences such as maternal anaemia, stillbirths and intrauterine growth restriction. Currently most nations in Africa have policies for distributing ITNs to pregnant women through various mechanisms, however coverage remains well below the targets. This review summarizes recent evidence regarding the correlation between ownership and use of ITNs and the determinants of both, in pregnancy in sub-Saharan Africa, and reviews interventions directed at improving coverage. A review of the literature using Pubmed, CINAHL and scanning of reference lists was conducted in October 2012 and 59 articles were selected for final review. The research obtained was a mixture of national and district level surveys, and a narrative synthesis of the data was undertaken. Ownership of ITNs varied from as low as 3% to greater than 80%, and the main determinants were found to be education level, knowledge of malaria, community involvement, socio-economic status and parity, although the significance of each varied between the different settings and studies reviewed. In more than half the settings where data were available, the combination of lack of availability and lack of use of an available net meant that less than half of all pregnancies received the recommended intervention. Supply and cost remain major barriers to achieving optimal coverage, but the additional important contributor to reduced efficiency of intervention was the clear discrepancy between ownership and use, with available ITN use below 60% in several settings. Cited reasons for not using an ITN, where one was available, included discomfort, problems with hanging up nets and lack of space, low awareness of need, and seasonal variations in use. These findings highlight the need for context-specific approaches and educational components to be incorporated into ITN distribution programmes to address some of the reasons why some pregnant women do not use the ITNs they own.

Factors affecting the delivery, access, and use of interventions to prevent malaria in pregnancy in sub-Saharan Africa: a systematic review and meta-analysis

BACKGROUND

Malaria in pregnancy has important consequences for mother and baby. Coverage with the World Health Organization-recommended prevention strategy for pregnant women in sub-Saharan Africa of intermittent preventive treatment in pregnancy (IPTp) and insecticide-treated nets (ITNs) is low. We conducted a systematic review to explore factors affecting delivery, access, and use of IPTp and ITNs among healthcare providers and women.

METHODS AND RESULTS

We searched the Malaria in Pregnancy Library and Global Health Database from 1 January 1990 to 23 April 2013, without language restriction. Data extraction was performed by two investigators independently, and data was appraised for quality and content. Data on barriers and facilitators, and the effect of interventions, were explored using content analysis and narrative synthesis. We conducted a meta-analysis of determinants of IPTp and ITN uptake using random effects models, and performed subgroup analysis to evaluate consistency across interventions and study populations, countries, and enrolment sites. We did not perform a meta-ethnography of qualitative data. Ninety-eight articles were included, of which 20 were intervention studies. Key barriers to the provision of IPTp and ITNs were unclear policy and guidance on IPTp; general healthcare system issues, such as stockouts and user fees; health facility issues stemming from poor organisation, leading to poor quality of care; poor healthcare provider performance, including confusion over the timing of each IPTp dose; and women's poor antenatal attendance, affecting IPTp uptake. Key determinants of IPTp coverage were education, knowledge about malaria/IPTp, socio-economic status, parity, and number and timing of antenatal clinic visits. Key determinants of ITN coverage were employment status, education, knowledge about malaria/ITNs, age, and marital status. Predictors showed regional variations.

CONCLUSIONS

Delivery of ITNs through antenatal clinics presents fewer problems than delivery of IPTp. Many obstacles to IPTp delivery are relatively simple barriers that could be resolved in the short term. Other barriers are more entrenched within the overall healthcare system or socio-economic/cultural contexts, and will require medium- to long-term strategies. Please see later in the article for the Editors' Summary.

Exploring the impact of targeted distribution of free bed nets on households bed net ownership, socio-economic disparities and childhood malaria infection rates: analysis of national malaria survey data from three sub-Saharan Africa countries

Background

The last decade has witnessed increased funding for malaria control. Malaria experts have used the opportunity to advocate for rollout of such interventions as free bed nets. A free bed net distribution strategy is seen as the quickest way to improve coverage of effective malaria control tools especially among poorest communities. Evidence to support this claim is however, sparse. This study explored the effectiveness of targeted free bed net distribution strategy in achieving equity in terms of ownership and use of bed nets and also reduction of malaria prevalence among children under-five years of age.

Methods

National malaria indicator survey (MIS) data from Angola, Tanzania and Uganda was used in the analysis. Hierarchical multilevel logistic regression models were used to analyse the relationship between variables of interest. Outcome variables were defined as: childhood test-confirmed malaria infections, household ownership of any mosquito net and children’s use of any mosquito nets. Marginal effects of having free bed net distribution on households with different wealth status were calculated.

Results

Angolan children from wealthier households were 6.4 percentage points less likely to be parasitaemic than those in poorest households, whereas those from Tanzania and Uganda were less likely to test malaria positive by 7 and 11.6 percentage points respectively (p < 0.001). The study estimates and present results on the marginal effects based on the impact of free bed net distribution on children's malaria status given their socio-economic background. Poorest households were less likely to own a net by 21.4% in Tanzania, and 2.8% in Uganda, whereas both poorer and wealthier Angolan households almost achieved parity in bed net ownership (p < 0.001). Wealthier households had a higher margin of using nets than poorest people in both Tanzania and Uganda by 11.4% and 3.9% respectively. However, the poorest household in Angola had a 6.1% net use advantage over children in wealthier households (p < 0.001).

Conclusion

This is the first study to use nationally representative data to explore inequalities in bed net ownership and related consequences on childhood malaria infection rates across different countries. While targeted distribution of free bed nets improved overall bed net ownership, it did not overcome ownership inequalities as measured by household socioeconomic status. Use of bed nets was disproportionately lower among poorest children, except for Angola where bed net use was higher among poorest households when compared to children in wealthier households. The study highlights the need for malaria control world governing bodies and policy makers to continue working on finding appropriate strategies to improve access to effective malaria control tools especially by the poorest who often times bears the brunt of malaria burden than their wealthier counterparts.

Antenatal care visit attendance, intermittent preventive treatment and bed net use during pregnancy in Gabon

Background

The World Health Organization (WHO) recommends that intermittent preventive treatment with sulfadoxine-pyrimethamine (IPTp-SP) and insecticide treated bed nets (ITNs) must be provided during antenatal care (ANC) visits for malaria prevention during pregnancy. The aim of this study was to determine the level of ANC attendance and its relationship with IPTp-SP and bed net coverage in Gabonese pregnant women.

Methods

This was a cross-sectional survey performed in 2011 in sentinel sites for malaria: two ANC units (Melen and Owendo) and one delivery unit (CHL). A validated structured questionnaire was used to collect the following data: age, parity, history of the current pregnancy including gestational age at the interview, number of ANC visits already performed, date of first visit, use of malaria preventive measure and details on IPTp-SP administration.

Results

During the study, 1030 women were interviewed, 735 at their ANC visit and 295 at the delivery. Their median age was 24[20–29] years and 21.0% were primigravidae. More than 70.0% attended their first ANC visit during the second trimester. Among the 442 women who were at the end of their pregnancy, 71.5% had a correct attendance, at least four ANC visits, most frequently women with no education and older women; IPTp-SP was offered to 84.1% of them and 57.4% received at least two doses. The number of SP doses was correlated to the number of ANC visits. Bed net coverage was 59.0%, not associated with ANC attendance. Among the women with correct ANC attendance, only 49.5% had a complete IPTp-SP course associated with bed net use during pregnancy. In the site where SP administration was supervised, 80% had four ANC visits and 97.4% received a full 2-dose course of IPTp-SP.

Conclusions

Despite a high level of correct ANC attendance in Gabon, the goal of 80% of women with 2-dose IPTp-SP during pregnancy is not achieved. Evaluations, training of health workers, as well as surveys from other areas of the country are needed to further measure the implementation and the impact of these strategies.

Determinants of maternal health services utilization in urban settings of the Democratic Republic of Congo--a case study of Lubumbashi City

Background

The use of maternal health services, known as an indirect indicator of perinatal death, is still unknown in Lubumbashi. The present study was therefore undertaken in order to determine the factors that influence the use of mother and child healthcare services in Lubumbashi, Democratic Republic of the Congo.

Methods

This was transversal study of women residing in Lubumbashi who had delivered between January and December 2009. In total, 1762 women were sampled from households using indicator cluster surveys in all health zones. Antenatal consultations (ANC), delivery assisted by qualified healthcare personnel (and delivery in a healthcare facility) as well as postnatal consultations (PNC) were dependent variables of study. The factors determining non-use of maternal healthcare services were researched via logistic regression with a 5% materiality threshold.

Results

The use of maternal healthcare services was variable; 92.6% of women had attended ANC at least once, 93.8% of women had delivered at a healthcare facility, 97.2% had delivered in the presence of qualified healthcare personnel, while the rate of caesarean section was 4.5%. Only 34.6% postnatal women had attended PNC by 42 days after delivery. During these ANC visits, only 60.6% received at least one dose of vaccine, while 38.1% received Mebendazole, 35.6% iron, 32.7% at least one dose of SulfadoxinePyrimethamine, 29.2% folic acid, 15.5% screening for HIV and 12.8% an insecticide treated net.

In comparison to women that had had two or three deliveries before, primiparous and grand multiparous women were twice as likely not to use ANC during their pregnancy. Women who had unplanned pregnancies were also more likely not to use ANC or PNC than those who had planned pregnancies alone or with their partner. The women who had not used ANC were also more likely not to use PNC. The women who had had a trouble-free delivery were more likely not to use PNC than those who had complications when delivering.

Conclusion

In Lubumbashi, a significant proportion of women continue not to make use of healthcare services during pregnancy, as well as during and after childbirth. Women giving birth for the first time, those who have already given birth many times, and women with an unwanted pregnancy, made less use of ANC. Moreover, women who had not gone for ANC rarely came back for postnatal consultations, even if they had given birth at a healthcare facility. Similarly, those who gave birth without complications, less frequently made use of postnatal consultations. As with ANCs, women with unwanted pregnancies rarely went for postnatal visits.

In addition to measures aimed at reinforcing women’s autonomy, efforts are also needed to reinforce and improve the information given to women of childbearing age, as well as communication between the healthcare system and the community, and participation from the community, since this will contribute to raising awareness of safe motherhood and the use of such services, including family planning.

Timing of antenatal care for adolescent and adult pregnant women in south-eastern Tanzania

Background

Early and frequent antenatal care attendance during pregnancy is important to identify and mitigate risk factors in pregnancy and to encourage women to have a skilled attendant at childbirth. However, many pregnant women in sub-Saharan Africa start antenatal care attendance late, particularly adolescent pregnant women. Therefore they do not fully benefit from its preventive and curative services. This study assesses the timing of adult and adolescent pregnant women's first antenatal care visit and identifies factors influencing early and late attendance.

Methods

The study was conducted in the Ulanga and Kilombero rural Demographic Surveillance area in south-eastern Tanzania in 2008. Qualitative exploratory studies informed the design of a structured questionnaire. A total of 440 women who attended antenatal care participated in exit interviews. Socio-demographic, social, perception- and service related factors were analysed for associations with timing of antenatal care initiation using regression analysis.

Results

The majority of pregnant women initiated antenatal care attendance with an average of 5 gestational months. Belonging to the Sukuma ethnic group compared to other ethnic groups such as the Pogoro, Mhehe, Mgindo and others, perceived poor quality of care, late recognition of pregnancy and not being supported by the husband or partner were identified as factors associated with a later antenatal care enrolment (p < 0.05). Primiparity and previous experience of a miscarriage or stillbirth were associated with an earlier antenatal care attendance (p < 0.05). Adolescent pregnant women started antenatal care no later than adult pregnant women despite being more likely to be single.

Conclusions

Factors including poor quality of care, lack of awareness about the health benefit of antenatal care, late recognition of pregnancy, and social and economic factors may influence timing of antenatal care. Community-based interventions are needed that involve men, and need to be combined with interventions that target improving the quality, content and outreach of antenatal care services to enhance early antenatal care enrolment among pregnant women.

Birth outcomes among booked and unbooked women at a secondary health facility in southwest Nigeria: implications for strengthening perinatal health services

A case-controlled analytic study involving 406 singleton unbooked and 396 singleton booked births was conducted. Unbooked births constituted 16.6% of all births during the study. Booked births were half as likely to preterm than unbooked births (43, 10.9% vs 81, 20.0%; p<0.001). Unbooked births were seven times more likely to be stillbirth than booked births (80, 17.7% vs 13, 3.3%; p< 0.001). Booked births were a third as likely to have a low birth weight as unbooked births (36, 9.1% vs 104, 25.6%; p< 0.001). Unbooked births had a significantly lower mean birth weight of 2.95 ± 0.53 kg than 3.08 ± 0.45 kg of booked births (p< 0.001). Unbooked births had a significantly lower mean Apgar score at 1 minute and 5 minutes than booked births (6.64 ± 1.42 vs 7.08 ± 1.12 and 9.16 ± 1.40 vs 9.64 ± 1.00; p< 0.001) respectively. Unbooked births are common and their birth outcomes may result in high morbidity and disability, thereby contributing to the high child mortality in developing countries. Strengthening perinatal health services through professional skilled care at birth and providing quality services for all unbooked births may lead to improved birth outcomes.

Factors influencing the utilisation of antenatal care content in Uganda

BACKGROUND

Uganda records an inadequate utilisation of antenatal care programmes. The study set out to investigate the factors associated with the use of antenatal care content to inform policy makers of the pertinent factors that need to be influenced by policy.

METHOD

Data for the study was taken from a nationally representative Uganda Demographic and Health Survey (UDHS) 2006. The study employed both descriptive and community fixed effects approaches to examine the factors associated with the use of antenatal care content in Uganda.

RESULTS

On average, only 16% of women used the full content of antenatal care. Only 12% of women had a urine sample taken, 28% a blood sample taken, and 53% their blood pressure measured. Almost two-thirds of women (63%) took iron supplements, 77% had their weight measured, and 27% were given drugs for intestinal parasites. The utilisation of the content of care was significantly associated with education of the mother and her partner, wealth status, location disparities, timing and frequency of antenatal visits, nature of facility visited, access to media, family planning, and utilisation of professional care.

CONCLUSION

Efforts are needed to educate girls beyond secondary level, establish village outreach clinics with qualified staff to attract the hard to reach women in the rural areas, and facilitate antenatal care utilisation irrespective of the ability to pay.

The combined effect of determinants on coverage of intermittent preventive treatment of malaria during pregnancy in the Kilombero Valley, Tanzania

Background

Intermittent preventive treatment during pregnancy (IPTp) at routine antenatal care (ANC) clinics is an important and efficacious intervention to reduce adverse health outcomes of malaria infections during pregnancy. However, coverage for the recommended two IPTp doses is still far below the 80% target in Tanzania. This paper investigates the combined impact of pregnant women's timing of ANC attendance, health workers' IPTp delivery and different delivery schedules of national IPTp guidelines on IPTp coverage.

Methods

Data on pregnant women's ANC attendance and health workers' IPTp delivery were collected from ANC card records during structured exit interviews with ANC attendees and through semi-structured interviews with health workers in south-eastern Tanzania. Women's timing of ANC visits and health worker's timing of IPTp delivery were analyzed in relation to the different national IPTp schedules and the outcome on IPTp coverage was modelled.

Results

Among all women eligible for IPTp, 79% received a first dose of IPTp and 27% were given a second dose. Although pregnant women initiated ANC attendance late, their timing was in line with the national guidelines recommending IPTp delivery between 20-24 weeks and 28-32 weeks of gestation. Only 15% of the women delayed to the extent of being too late to be eligible for a first dose of IPTp. Less than 1% of women started ANC attendance after 32 weeks of gestation. During the second IPTp delivery period health workers delivered IPTp to significantly less women than during the first one (55% vs. 73%) contributing to low second dose coverage. Simplified IPTp guidelines for front-line health workers as recommended by WHO could lead to a 20 percentage point increase in IPTp coverage.

Conclusions

This study suggests that facility and policy factors are greater barriers to IPTp coverage than women's timing of ANC attendance. To maximize the benefit of the IPTp intervention, revision of existing guidelines is needed. Training on simplified IPTp messages should be consolidated as part of the extended antenatal care training to change health workers' delivery practices and increase IPTp coverage. Pregnant women's knowledge about IPTp and the risks of malaria during pregnancy should be enhanced as well as their ability and power to demand IPTp and other ANC services.

The impact of maternal highly active antiretroviral therapy and short-course combination antiretrovirals for prevention of mother-to-child transmission on early infant infection rates at the Mulago national referral hospital in Kampala, Uganda, January 2007 to May 2009

BACKGROUND

Early HIV infant diagnosis and treatment have been shown to dramatically improve survival in infants. Despite these findings, infants accessing HIV diagnosis and treatment remain low in Uganda. We describe the antiretroviral (ARV) drugs given in the Mulago Hospital prevention of mother-to-child transmission (PMTCT) program from January 2007 to May 2009 and its impact on early infant HIV infection rates.

METHODS

Pregnant women identified as HIV infected in the Mulago antenatal clinics received one of the following regimens: short-course ARV prophylaxis plus single-dose nevirapine (sdNVP) in labor, highly active antiretroviral therapy (HAART), or sdNVP if they presented in labor. Infants received sdNVP and zidovudine (ZDV) for 1 week. Infants HIV diagnosis was done from 6 weeks after delivery.

RESULTS

62.3% of HIV-infected women received combination ARVs, including HAART. Early infection rates were highest among infants with no maternal ARV [36.4; 95% confidence interval (CI): 17.2 to 59.3] or only sdNVP (11.2; 95% CI: 8.1 to 14.8). Similar rates were observed for the group that took short-course ARVs, ZDV/sdNVP (4.6; 95% CI: 3.2 to 6.4), and ZDV/lamivudine/sdNVP (4.9; 95% CI: 3.1 to 7.2) and lowest rates for those that took HAART (1.7: 95% CI: 0.8 to 2.8). Overall infection rate was 5.0% (95% CI: 4.1 to 5.9).

CONCLUSIONS

Findings indicate low rates of infant infection for mothers receiving combination ARVs. These findings demonstrate that provision of combination ARV for PMTCT is feasible and effective in busy referral hospital's PMTCT programs in resource-limited settings.

Determinants of use of intermittent preventive treatment of malaria in pregnancy: Jinja, Uganda

Background

Maternal malaria is associated with serious adverse pregnancy outcomes. One recommended means of preventing malaria during pregnancy is intermittent preventive therapy (IPTp) with sulfadoxine/pyrimethamine (SP). We sought to identify determinants of preventive use of SP during pregnancy among recently pregnant women in Uganda. Additionally, we characterized the timing of and indications for the administration of SP at antenatal care (ANC) visits and missed opportunities for SP administration.

Methodology/Principal Findings

Utilizing a population-based random sample, we interviewed 500 women living in Jinja, Uganda who had been pregnant in the past year. Thirty-eight percent (192/500) of women received SP for the treatment of malaria and were excluded from the analysis of IPTp-SP. Of the remaining women, 275 (89.3%) reported at least two ANC visits after the first trimester and had an opportunity to receive IPTp-SP according to the Ugandan guidelines, but only 86 (31.3%) of these women received a full two-dose course of IPTp. The remaining 189 (68.7%) women missed one or more doses of IPTp-SP. Among the 168 women that were offered IPTp, 164 (97.6%) of them took the dose of SP.

Conclusions/Significance

Use of IPTp in Uganda was found to be far below target levels. Our results suggest that women will take SP for IPTp if it is offered during an ANC visit. Missed opportunities to administer IPTp-SP during ANC were common in our study, suggesting provider-level improvements are needed.

Methods for evaluating delivery systems for scaling-up malaria control intervention

Background

Despite increased resources over the past few years the coverage of malaria control interventions is still inadequate to reach national and international targets and achieve the full potential of the interventions to improve population health. One of the reasons for this inadequate coverage of efficacious interventions is the limited understanding of the optimum delivery systems of the interventions in different contexts. Although there have been debates about how to deliver interventions, the methods for evaluating the effectiveness of different delivery systems have rarely been discussed. Delivery of interventions is relatively complex and a thorough evaluation would need to look holistically at multiple steps in the delivery process and at multiple factors influencing the process. A better understanding of the strength of the evidence on delivery system effectiveness is needed in order to optimise delivery of efficacious interventions.

Methods

A literature review was conducted of methods used to evaluate delivery systems for insecticide treated nets, intermittent preventive treatment in pregnant women, and treatment for malaria in children.

Results

The methodology of delivery system evaluations varied. There were inconsistencies between objectives and methods of the evaluations including inappropriate outcome measures and unnecessary controls. There were few examples where the delivery processes were adequately described, or measured. We propose a cross sectional observational study design with attribution of the outcomes to a specific delivery system as an appropriate method for evaluating delivery systems at scale.

Conclusions

The proposed evaluation framework is adaptable to natural experiments at scale, and can be applied using data from routine surveys such as the Demographic and Health Surveys, modified by the addition of one to two questions for each intervention. This framework has the potential to enable wider application of rigorous evaluations and thereby improve the evidence base on which decisions about delivery systems for malaria control and other public health interventions are taken.

Reasons given by pregnant women for late initiation of antenatal care in the niger delta, Nigeria

BACKGROUND

Many studies show that the vast majority of Nigerian women register for antenatal care late and that the determinants may differ from those found in developed countries.

OBJECTIVE

To determine the reasons for late booking among women presenting at the antenatal clinic of a major tertiary hospital in the Niger Delta, Nigeria

DESIGN

A cross sectional questionnaire based survey.

SETTING

A large tertiary hospital in the Niger delta, Nigeria

PARTICIPANTS

Pregnant women registering for antenatal care after 14 weeks gestation.

RESULTS

The majority of respondents were aged 20-39 years (97.1%), quarters were primigravidae and 25 % of the women belonged to the upper socioeconomic class. Seventy three point six percent booked in the second trimester and 26.4% in the third trimester. Of the women who had given birth before, 80% had booked late in at least one previous pregnancy. More than three-fifth of the women (65.6%) booked late due to ignorance or misconceptions of the purpose of, and right time to commence antenatal care.

CONCLUSION

The findings of this study suggest that most women book late because of a belief that there are no advantages in booking for antenatal care in the first three months of pregnancy. This seems to be because antenatal care is viewed primarily as curative rather than preventive in the study population. Research is needed to determine the best approaches for health education programmes to correct the misconceptions about antenatal care.

Intermittent preventive treatment of malaria in pregnancy (IPTp): do frequent antenatal care visits ensure access and compliance to IPTp in Ugandan rural communities?

The relationship between antenatal care (ANC) visits and coverage of intermittent preventive treatment of malaria in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP), and barriers to IPTp-SP access were examined. Four hundred and fifty-three women who had given birth during the study period were interviewed using a semi-structured questionnaire. Of these, 425 (93.8%) attended ANC at least once, but only 90 (21.2%) made four or more visits. Primigravidae 25 (29.8%) were more likely than multigravidae 65 (17.6%) to make more than four visits (P=0.012). Only 237 (52.3%) women accessed two or more doses of IPT-SP, which increased with the number of ANC visits (X(2) for linear trends, 117.7, P<0.001). However, 131 (28.9%) women made two or more ANC visits, which were sufficient for them to access two or more doses of IPTp-SP, but they did not. The main reasons were: not given SP by the midwife for unknown reasons 36 (27.5%), SP stock-outs 34 (26%) and irregular ANC attendance 18 (13.7%). Frequent ANC visits do not seem to ensure access to IPTp-SP in the presence of other barriers. The Roll Back Malaria target of 80% of women accessing two or more doses of IPTp-SP by 2010 appears unachievable unless alternative channels of delivery are found.

Portrait of a lengthy vaccination trajectory in Burkina Faso: from cultural acceptance of vaccines to actual immunization

BACKGROUND

The global recognition of vaccination is strongly related to the fact that it has proved in the past able to dramatically reduce the incidence of certain diseases. Nevertheless, reactions regarding the practice of vaccination still vary among communities, affecting the worldwide vaccination coverage. Numerous studies, conducted from varying perspectives, have focused on explaining this active refusal or resistance to vaccination. Although in some cases low immunization coverage has been well explained by active refusal or resistance to vaccination, little is known about the reasons for low coverage where those reactions are absent or play a minor role, especially outside an epidemic context. This study attempts to explain this situation, which is found in the health district of Nouna in Burkina Faso.

METHODS

An in-depth ethnographic study was undertaken in the health district of Nouna in an effort to understand, from an anthropological point of view, the logic behind the parental decision-making process regarding the vaccination or non-vaccination of children, in a context where rejection of, and reservations concerning vaccination are not major obstacles.

RESULTS

Three elements emerged from the analysis: the empirical conceptions of childhood diseases, the perceived efficacy of vaccine and the knowledge of appropriate age for vaccination uptake; the gap between the decision-making process and the actual achievement of vaccination; and the vaccination procedure leading to vaccination uptake in the particular context of the health district of Nouna.

CONCLUSION

The procedures parents must follow in order to obtain vaccination for their children appear complex and constraining, and on certain points discord with the traditional systems of meaning and idioms of distress related to pregnancy, the prevention of childhood diseases and with the cultural matrix shaping decision-making and behaviour. Attention needs to be directed at certain promotional, logistical and structural elements, and at the procedure that must currently be followed to obtain vaccination for a child during routine vaccination sessions, which are currently limiting the active demand for vaccination. ABSTRACT IN FRENCH : See the full article online for a translation of this abstract in French.

Use of intermittent preventive treatment for malaria by pregnant women in Buea, Cameroon

We identified individual factors associated with IPT use, by comparing characteristics of pregnant women who use IPT to those who do not. A cross-sectional study was conducted in antenatal clinics in Buea, Cameroon, from December 2006 to December 2007. Information on factors: age, parity, gravidity, gestational age, level of education, use of insecticide treated nets (ITN), socioeconomic status and IPT use was collected through interview and filled in a questionnaire. Data was entered using EPIDATA version 3 and analysis done using STATA version 8.2. A total of 527 pregnant women were interviewed with a mean (+/-SD) age of 26.45+/-5.37 years. 69.71% of the pregnant women used at least two doses of IPT. Logistic regression revealed women with higher educational status were more likely to use IPT compared to those with lower educational status (OR=3.14, 95% CI=1.20-8.25, p=0.02). Meanwhile, multigravid women tend to use IPT less than their primigravid counterparts (OR=0.47, 95% CI=0.26-0.84, p=0.01). There was no evidence that maternal age, parity, marital status, gestational age, use of ITN and socioeconomic status were each associated to IPT use. In antenatal clinics in Buea, South Western Cameroon, educational status and gravidity are the key determinants of IPT use.

Intermittent preventive treatment of malaria in pregnancy (IPTp): participation of community-directed distributors of ivermectin for onchocerciasis improves IPTp access in Ugandan rural communities

Access and compliance to sulfadoxine-pyrimethamine (SP) for intermittent preventive treatment of malaria in pregnancy (IPTp) when delivered by community-directed drug distributors (CDDs) of ivermectin for onchocerciasis control (intervention arm) and through delivery of SP-IPTp during antenatal care visit (control arm) was investigated in western Uganda. Every woman in both arms who delivered during the study period was interviewed on access and compliance to SP-IPT during her previous pregnancy. Overall, 926 women participated in the study (473 and 453 in the intervention and control arms, respectively). There were 467 (98.7%) women who accessed SP-IPTp at least once in the intervention arm and 401 (88.5%) in the control arm (P<0.001), and 424 (89.6%) women accessed at least two doses of SP-IPTp in the intervention arm compared with 237 (52.3%) in the control arm (P<0.001). The findings of this study suggest that a strategy using community resource people such as CDDs is an effective and feasible option to deliver SP-IPTp, because it uses existing community structures and volunteers, which creates easy access of the intervention, and should complement SP-IPTp access during antenatal care visit.

A package of primary health care services for comprehensive family-centred HIV/AIDS care and treatment programs in low-income settings

Particularly in resource-limited settings, HIV/AIDS is a family concern. Separate services for children and adults may make accessing care more difficult for families than services where family members can be cared for together. Implicit in comprehensive, family-centred approaches to care are the broader notions of longitudinal primary care and linkages to other services, including those based in communities. As highly-active antiretroviral therapy becomes more available, and the direct burden of HIV-associated morbidity diminishes, HIV-infected individuals require primary care that goes beyond exclusive management of HIV and related conditions, including preventive services and the management of common medical issues. The prevention of tuberculosis, diarrhoea, and, in endemic regions, malaria; the addressing of debilitating depression; cervical screening; and the management of chronic cardiovascular disease and its risk factors are all of benefit to patients accessing HIV/AIDS care. Packaging such services is an effective means both of standardizing care within a program and of ensuring patients receives a full roster of available interventions. As family-centred care models develop in resource-limited settings, the availability of evidence-based service packages such as presented here will help program designers prioritize available human and materiel resources toward those interventions that improve patients' global health and well being.

Rural Gambian women's reliance on health workers to deliver sulphadoxine-pyrimethamine as recommended intermittent preventive treatment for malaria in pregnancy

Background

The use of most anti-malarial medications is restricted during pregnancy, but two doses of sulphadoxine-pyrimethamine are recommended after the first trimester as intermittent preventive treatment in pregnancy (IPTp). In The Gambia, only 32% of women receive two doses and very little research has been conducted on women's awareness of drug safety during pregnancy. The objective of this paper was to assess whether rural Gambian women were aware of the importance of the timing of the two-dose IPT dose schedule and its relevance to drug safety.

Methods

This was a qualitative study in which 41 interviews and 16 focus group discussions with women, adolescents, men and traditional birth attendants were conducted. A generic qualitative approach was used to generate a theory as to why women might not participate in IPTp as recommended.

Results

Although most women used calendar months to count their stage of pregnancy, these months did not correlate with their concept of foetal development. Foetal growth was described following Islamic tradition as water, clot, piece of meat and human being, although there was little consensus about the order or timing in which these stages occurred. Common signs and conditions of malaria were known. Women were anxious about miscarriage and recognized that some medicines should not be taken in the first trimester, but were urged by men and traditional birth attendants to attend for antenatal care in the first trimester to "start treatment." General knowledge about the purpose of pregnancy medications and when they should be taken was poor among both men and women. One important result was that women relied entirely on health workers to provide safe drugs, at the correct time.

Conclusion

Women did not have relevant information to judge the safety and appropriate timing of pregnancy drugs, which made them over-reliant on health workers. They should be encouraged to date their own pregnancies in culturally relevant terms and to anticipate when and which medications they should receive.

Malaria and pregnancy: a global health perspective

Malaria, a parasitic infection transmitted by mosquitoes, is one of the most devastating infectious diseases, killing more than 1 million people annually. Pregnant women, children, and immunocompromised individuals have the highest morbidity and mortality, and Africa bears the heaviest burden. The World Health Organization defines malaria as a disease of poverty caused by poverty. Pregnant women infected with malaria usually have more severe symptoms and outcomes, with higher rates of miscarriage, intrauterine demise, premature delivery, low-birth-weight neonates, and neonatal death. They are also at a higher risk for severe anemia and maternal death. Malaria can be prevented with appropriate drugs, bed nets treated with insecticide, and effective educational outreach programs.

Individual, facility and policy level influences on national coverage estimates for intermittent preventive treatment of malaria in pregnancy in Tanzania

BACKGROUND

Delivery of two doses of intermittent preventive treatment of malaria during pregnancy (IPTp) is a key strategy to reduce the burden of malaria in pregnancy in sub-Saharan Africa. However, different settings have reported coverage levels well below the target 80%. Antenatal implementation guidelines in Tanzania recommend IPTp first dose to be given at the second antenatal visit, and second dose at the third visit. This investigation measured coverage of IPTp at national level in Tanzania and examined the role of individual, facility, and policy level influences on achieved coverage.

METHODS

Three national household and linked reproductive and child health (RCH) facility surveys were conducted July-August 2005, 2006, and 2007 in 210 clusters sampled using two-stage cluster sampling from 21 randomly selected districts. Female residents who reported a livebirth in the previous year were asked questions about malaria prevention during that pregnancy and individual characteristics including education, pregnancy history, and marital status. The RCH facility serving each cluster was also surveyed, and information collected about drug stocks, health education delivery, and the timing of antenatal care delivery by clinic users.

RESULTS

The national IPTp coverage had declined over the survey period being 71% for first dose in 2005 falling to 65% in 2007 (chi2 2.9, p = 0.05), and 38% for second dose in 2005 but 30% in 2007 (chi2 4.4, p = 0.01). There was no evidence of any individual factors being associated with second dose coverage beyond living in an urban area. Availability of sulphadoxine-pyrimethamine at RCH had decreased year on year from 85% of clinics in stock in 2005 to 60% in 2007 (chi2 20.6, p < 0.001). This reduction was evident in rural but not urban clinics. If safety recommendations and national antenatal care guidelines for IPTp delivery were followed, in 2007 only 76% of pregnant women could have received IPTp first dose and only 46% could have received second dose.

CONCLUSION

There is scope to improve IPTp first and second dose coverage at national scale within existing systems by improving stock at RCH, and by revising the existing guidelines to recommend delivery of IPTp after quickening, rather than at a pre-defined antenatal visit.