The adequacy of antenatal care services among slum residents in Addis Ababa, Ethiopia

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We conducted a comprehensive systematic three-step approach search of published and unpublished sources from 2002 to 2022.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.

Does women's empowerment and socio-economic status predict adequacy of antenatal care in sub-Saharan Africa?

BACKGROUND

Quality and adequate antenatal care (ANC) are key strategies necessary to achieve Sustainable Development Goal 3.1. However, in sub-Saharan Africa (SSA), there is a paucity of evidence on the role women's empowerment and socio-economic status play in ANC attendance. This study aimed to examine whether women's empowerment and socio-economic status predict the adequacy of ANC in SSA.

METHODS

Data from the recent Demographic and Health Surveys (DHSs) of 10 countries in SSA were used for the study. We included countries with a survey dataset compiled between 2018 and 2020. We included 57 265 women with complete observations on variables of interest in the study. Frequencies and percentages were used to summarize the results of the coverage of adequate ANC services across the 10 countries. A multivariable binary multilevel regression analysis was employed to examine the association between women's empowerment and socio-economic status indicators and the adequacy of ANC. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were used to present the findings of the regression analysis.

RESULTS

The average prevalence of adequate ANC in SSA was 10.4%. This ranged from 0.2% in Rwanda to 24.5% in Liberia. Women with medium (aOR 1.24 [CI 1.10 to 1.40]) and high (aOR 1.24 [CI 1.07 to 1.43]) decision-making power had higher odds of adequate ANC compared to those with low decision-making power. Women with higher levels of education (aOR 1.63 [CI 1.36 to 1.95]) as well as partners with higher education levels (aOR 1.34 [CI 1.14 to 1.56]) had the highest odds of adequate ANC compared to those with no formal education. Additionally, those working (aOR 1.35 [95% CI 1.23 to 1.49]) and those in the richest wealth category (aOR 2.29 [CI 1.90 to 2.76]) had higher odds of adequate ANC compared to those who are not working and those in the poorest wealth category. Those with high justification of violence against women (aOR 0.84 [CI 0.73 to 0.97]) had lower odds of adequate ANC compared to those with low justification of violence against women.

CONCLUSIONS

Adequacy of ANC was low across all 10 countries we included in this study. It is evident from the study that women's empowerment and socio-economic status significantly predicted the adequacy of ANC. As such, promoting women's empowerment programs without intensive improvements in women's socio-economic status would yield ineffective results. However, when women's empowerment programs are combined with active improvements in socio-economic status, then women will be encouraged to seek adequate ANC.

Missed Opportunity of Antenatal Care Services Utilization and Associated Factors among Reproductive Age Women in Eastern Hararghe Zone, Eastern Ethiopia: Mixed Methods Study

Background

Despite the enormous advantages of early pregnancy-related problem diagnosis and therapy during prenatal care visits, not all pregnant women begin antenatal care at the proper time. Thus, this study aims to identify factors associated with missed opportunities for antenatal care service utilization among reproductive-age women in Eastern Ethiopia.

Methods

A mixed methods study design (quantitative and qualitative) was conducted in Grawa, Meta, and Haramaya woredas from September 5 to December 5, 2019. The quantitative data were analyzed using SPSS version 25. A multivariable logistic regression analysis model was used to identify the predictors. Statistical software programs based on ATLAS.ti version 8.2 was were used to conduct the thematic analysis of the qualitative data.

Results

Overall, missed opportunities for antenatal care were 15.4% of 95% (12.1, 19.1%). Factors such as maternal age being 15-24 (AOR = 6.9, 95% CI: 2.89-8.81); having a college education (AOR = 0.02, 95% CI: 0.001, 0.42), elementary (AOR = 0.05, 95% CI: 0.002, 0.98), and secondary education (AOR = 0.04, 95% CI: 0.001, 0.88); having five and more parity (AOR = 0.08, 95% CI: 0.01, 0.75); three visits (AOR = 0.10, 95% CI: 0.02, 0.71); those in the first trimester (AOR = 0.02, 95% CI: 0.001, 0.35) and the second trimester (AOR = 0.01, 95% CI: 0.001, 0.26); and get information from a health facility (AOR =0.09, 95% CI: 0.01, 0.67) and traditional birth attendance (AOR = 0.02, 95% CI: 0.001, 0.74) were factors statistically associated with outcome variables.

Conclusions

According to this report, relatively high proportions of pregnant women experienced missed opportunities in antenatal care follow-up. Factors such as maternal age, education, parity, frequency, timing, and media access were statistically significantly correlated with missed antenatal care follow-up. Therefore, all stakeholders should emphasize advocating for and enhancing the benefits of antenatal care; this in turn plays a crucial role in increasing the follow-up of clients for these crucial services. Moreover, health policy implementers need to coordinate their tracking of pregnant women who missed their antenatal care session.

A secondary analysis of the factors associated with women´s adequate utilization of antenatal care services during their last pregnancy in Uganda

BACKGROUND

Adequate antenatal care services (ANC) use is critical to identifying and reducing pregnancy risks. Despite the importance placed on adequate antenatal care service utilization, women in Uganda continue to underutilize antenatal care services. The primary goal of this study is to identify the factors associated with women's adequate utilization of antenatal care services in Uganda.

METHODS

Secondary data from the 2016 Uganda Demographic and Health Survey were used in this study. The study sample consists of 9,416 women aged 15 to 49 who reported giving birth in the five years preceding the survey. The adequate use of antenatal care services is the dependent variable. A woman who used antenatal care services at least four times is considered to have adequately used antenatal care services. We used univariate, bivariate, and multilevel logistic regression modelling to identify the factors associated with adequate utilization of antenatal care services. STATA version 14.2 was used to analyze the data.

RESULTS

The prevalence of adequate utilization of antenatal care services in Uganda was found to be 61.4%. Women with secondary or higher education were 32.0% (AOR = 1.32, 95% CI;1.07-1.63), employed women were 26.0% (AOR = 1.26, 95% CI;1.10-1.44), women who received high-quality antenatal care content were 78.0% (AOR = 1.78, 95% CI;1.58-2.02), and women who belong to the rich category of the wealth index bracket were 27.0% (AOR = 1.27, 95% CI;1.09-1.49), more likely to use antenatal care services adequately. Finally, the study discovered that women from less diverse ethnic communities were 15.0% (AOR, 0.85, 95%CI; 0.73-0.99) less likely to use antenatal care services adequately.

CONCLUSION

Women's adequate utilization of antenatal care was influenced by both community and individual-level characteristics. Policymakers must use a multi-sectoral approach to develop policies that address both individual and community-level characteristics.

Neonatal and perinatal mortality in the urban continuum: a geospatial analysis of the household survey, satellite imagery and travel time data in Tanzania

INTRODUCTION

Recent studies suggest that the urban advantage of lower neonatal mortality in urban compared with rural areas may be reversing, but methodological challenges include misclassification of neonatal deaths and stillbirths, and oversimplification of the variation in urban environments. We address these challenges and assess the association between urban residence and neonatal/perinatal mortality in Tanzania.

METHODS

The Tanzania Demographic and Health Survey (DHS) 2015-2016 was used to assess birth outcomes for 8915 pregnancies among 6156 women of reproductive age, by urban or rural categorisation in the DHS and based on satellite imagery. The coordinates of 527 DHS clusters were spatially overlaid with the 2015 Global Human Settlement Layer, showing the degree of urbanisation based on built environment and population density. A three-category urbanicity measure (core urban, semi-urban and rural) was defined and compared with the binary DHS measure. Travel time to the nearest hospital was modelled using least-cost path algorithm for each cluster. Bivariate and multilevel multivariable logistic regression models were constructed to explore associations between urbanicity and neonatal/perinatal deaths.

RESULTS

Both neonatal and perinatal mortality rates were highest in core urban and lowest in rural clusters. Bivariate models showed higher odds of neonatal death (OR=1.85; 95% CI 1.12 to 3.08) and perinatal death (OR=1.60; 95% CI 1.12 to 2.30) in core urban compared with rural clusters. In multivariable models, these associations had the same direction and size, but were no longer statistically significant. Travel time to the nearest hospital was not associated with neonatal or perinatal mortality.

CONCLUSION

Addressing high rates of neonatal and perinatal mortality in densely populated urban areas is critical for Tanzania to meet national and global reduction targets. Urban populations are diverse, and certain neighbourhoods or subgroups may be disproportionately affected by poor birth outcomes. Research must capture, understand and minimise risks specific to urban settings.

Utilization of optimal antenatal care, institutional delivery, and associated factors in Northwest Ethiopia

Optimal antenatal care visits (ANC4+) and institutional delivery are essentials to save lives of the women and the baby during pregnancy and delivery. Though focused antenatal care visits and institutional delivery is recommended by World Health Organization, Ethiopia has sub-optimal antenatal care and lagged facility delivery. A community-based cross-sectional study was conducted among 811 lactating women in Northwest Ethiopia. Multivariable logistic regression analysis was performed using 95% confidence level and p < 0.05. The prevalence of optimal antenatal care visits and institutional delivery were 39.6% (95%CI: 36.2-43) and 62.6% (95%CI: 59.2-66), respectively. Maternal education (AOR = 2.05; 95%CI: 1.14, 3.69), home visiting by health extension workers (AOR = 1.57; 95%CI: 1.01, 2.29), and early antenatal care booking (AOR = 11.92; 95%CI: 8.22, 17.31) were significant predictors of optimal antenatal care. Exposure to mass media (AOR = 1.65; 95% CI: 1.02, 2.65); intended pregnancy(AOR = 1.68; 95%CI:1.12, 3.63); parity of one (AO = 3.46; 95% CI: 1.73, 6.89); 1-3 antenatal care visits (AOR = 2.17; 95% CI: 1.29, 3.63); and ANC4 + (AOR = 3.57; 95% CI: 2.07, 6.14); history of pregnancy-related complications(AOR = 1.63; 95%CI: 1.04, 2.57), and access to transportation to reach a health facility(AOR = 1.58; 95%CI: 1.00, 2.45) were significant predictors of institutional delivery. Addressing the modifiable factors identified in this study could improve optimal antenatal care visit and institutional delivery.

Determinants of early initiation of first antenatal care visit in Ethiopia based on the 2019 Ethiopia mini-demographic and health survey: A multilevel analysis

BACKGROUND

Early initiation of the first antenatal care visit provides a critical opportunity for health promotion, disease prevention, and curative care for women and their unborn fetuses. However, in developing countries, including Ethiopia, it is underutilized and most of the pregnant women didn't attend antenatal care visits during the first trimester (early). Therefore, the objective of this study was to estimate the prevalence of early initiation of antenatal care visits and its determinants among reproductive-age women in Ethiopia.

METHODS

A secondary data analysis was done based on the 2019 intermediate Ethiopian demographic health survey. The data were weighted by sampling weight for probability sampling and non-response to restore the representativeness of the data and have valid statistical estimates. Then, a total weighted sample of 2,935 women aged 15-49 years who gave birth in the five years preceding the survey and who had antenatal care visits for their last child was included. A multilevel mixed-effects logistic regression model was fitted to examine the determinants of early initiation of first antenatal care visits. Finally, statistical significance was declared at a p-value < 0.05.

RESULTS

In this study, the overall magnitude of early initiation of the first antenatal care visit was 37.4% (95%CI: 34.6-40.2%). Women who attend higher education (AOR = 2.26: 95%CI; 1.36-3.77), medium wealth status (AOR = 1.80: 95%CI; 1.17-2.76), richer wealth status (AOR = 1.86: 95%CI; 1.21, 2.85), richest wealth status (AOR = 2.34: 95%CI; 1.43-3.83), living in Harari region (AOR = 2.24: 95%CI; 1.16-4.30), and living at Dire-Dawa city (AOR = 2.24: 95%CI; 1.16-4.30) were higher odds of early initiation of first ANC visits. However, women who were rural resident (AOR = 0.70: 95%CI; 0.59-0.93), household headed by male (AOR = 0.87: 95%CI; 0.72, 0.97), having ≥ 5 family size (AOR = 0.71: 95%CI; 0.55-0.93), and living in SNNPRs (AOR = 0.44: 95%CI; 0.23-0.84) were lower odds of early initiation of first ANC visits.

CONCLUSION

The prevalence of early initiation of first antenatal care remains low in Ethiopia. Women's education, residence, wealth status, household head, having ≥ 5 family sizes, and region were determinants of early initiation of first antenatal care visits. Improving female education and women's empowerment through economic transitions with special attention given to rural and SNNPR regional state residents could maximize the early initiation of first antenatal care visits. Furthermore, to increase early antenatal care uptake, these determinants should be considered when designing new policies or updating policies and strategies on antenatal care uptake to help increase early attendance, which can help in the reduction of maternal and neonatal mortality and to achieve sustainable development goals 3 by 2030.

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.

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.

The moderating role of partners' education on early antenatal care in northern Ghana

BACKGROUND

Early antenatal care (ANC) is essential for improving maternal and child health outcomes. The primary aims of this study were to 1) estimate the association between partners' education attainment and early ANC, and 2) determine whether partners' level of education modified the relationship between mothers' education, mothers' age, planned pregnancy, employment status and early ANC.

METHODS

Data were obtained from a cross-sectional study conducted from April to May 2021 among 519 mothers with a live birth in the past year in the Nabdam district in the Upper East Region in northern Ghana. Generalized estimating equations were used to assess whether partners' level of education modified the relationship between mothers' education, mothers' age, planned pregnancy, employment status and early ANC. Effect modification was assessed on the additive and multiplicative scales using adjusted prevalence ratios (aPR) and corresponding 95% confidence intervals.

RESULTS

Mothers whose partners had secondary or higher education had a 26% higher prevalence of early ANC compared to mothers whose partners had less than a secondary level of education (aPR: 1.26, 95% CI: 1.05,1.51). There was evidence of effect modification by partners' education on the relationship between planned pregnancy and early ANC on both the additive (Relative excess risk due to interaction [RERI]: 0.61, 95% CI: 0.07,0.99), and multiplicative (ratio of PRs: 1.64, 95% CI: 1.01,2.70) scales. Among mothers whose partners had less than secondary education, mothers who had teenage pregnancy (i.e., aged 18-19 years old during pregnancy) were less likely to have early ANC compared to those who did not have teenage pregnancy (aPR: 0.71, 95% CI: 0.53,0.97). Among mothers whose partners had a secondary or higher education, early ANC was more prevalent among employed mothers compared to those who were unemployed (aPR: 1.27, 95% CI: 1.02,1.57).

CONCLUSIONS

Our findings suggest that whilst mothers whose partners had a secondary or higher education were more likely to initiate early ANC, supporting such women to plan their pregnancies can further increase the coverage of early ANC.

Influence of women's decision-making autonomy on antenatal care utilisation and institutional delivery services in Nigeria: evidence from the Nigeria Demographic and Health Survey 2018

BACKGROUND

In the context of global health priority, understanding the role of power dynamics among women as an important intervention required towards achieving optimum maternal and child health outcomes is crucial. This study examined the influence of women's decision-making autonomy on antenatal care utilisation and institutional delivery services in Nigeria.

METHODS

The data for the study were derived from the 2018 Nigeria Demographic and Health Survey and comprised a weighted sample of 20,100 births in the last five years that preceded the survey among married/cohabiting childbearing women. Descriptive and analytical analyses were carried out, including frequency tables and multivariate using the binary logistic regression model.

RESULTS

The study revealed that despite a large number of women initiating antenatal care visits before 12 weeks of pregnancy (75.9%), far fewer numbers had at least eight antenatal care visits (24.2%) and delivered in a health facility (58.2%). It was established that the likelihood of having at least eight antenatal care visits was significantly increased among women who enjoyed decision-making autonomy on their healthcare (aOR: 1.24, CI: 1.02-1.51) and how their earnings are spent (aOR: 2.02, CI: 1.64-2.48). Surprisingly, women's decision-making autonomy on how their earnings are spent significantly reduced the odds of initiating antenatal care visits early (aOR: 0.75, CI: 0.63-0.89). Some socio-economic and demographic factors were observed to have a positive influence on quality antenatal care utilisation and delivery in a health facility.

CONCLUSION

In conclusion, women's decision-making autonomy on their healthcare and how their earnings are spent was significantly found to be protective factors to having eight antenatal care visits during pregnancy. Conversely, women's autonomy on how their earnings are spent significantly hindered their initiation of early antenatal care visits. There is a need for more pragmatic efforts through enlightenment and empowerment programmes of women to achieve universal access to quality maternal healthcare services in Nigeria.

Prevalence and factors affecting the utilization of antenatal care in rural areas of Southwestern Ethiopia

BACKGROUND

Antenatal care (ANC) is a health care intervention intended to ensure the safety of pregnancy. According to the World Health Organization, at least four ANC visits are recommended for a healthy pregnancy. However, whether this recommended number of visits was followed or not in the rural areas of Southwestern Ethiopia is not known. Therefore, the study aimed to investigate the prevalence of, and the associated factors of ANC utilization by pregnant women in the rural areas of Southwestern Ethiopia.

METHODS

A community-based cross-sectional study design was used in three rural zones. The data were collected from n = 978 women through a structured questionnaire with face-to-face interview. The collected data were analyzed using descriptive statistics and a multiple binary logistic regression model.

RESULTS

The results showed that 56% of women made the recommended minimum number of ANC visits and the remaining 44% of them underutilized the ANC service. The multiple binary logistic regression model identified zone, marital status of the woman, educational level of the husband, occupation of the husband, knowledge of danger signs of pregnancy, birth interval, source of information, timely visits, and transportation problem to be statistically significant factors affecting the prevalence of ANC visit utilization of women. Bench Maji zone had smaller odds ratio of ANC visit prevalence as compared to Kaffa zone. Women who lived in the rural area of Sheko zone are 2.67 times less likely to utilize ANC visit than those who lived in the rural area of Kaffa zone keeping other variables constant.

CONCLUSION

The study results highlight the need to increase the number of ANC visits, and the importance of using an appropriate model to determine the important socio-demographic factors that ANC service providers shall focus on to improve the health of the unborn baby and the mother during pregnancy.

Factors associated with the timely initiation of antenatal care: findings from a cross-sectional study in Northern Bangladesh

OBJECTIVE

This paper explored the factors that influence the timely initiation of antenatal care (ANC) in Bangladesh.

DESIGN

This was a cross-sectional survey.

SETTING

This study conducted in two rural subdistricts and one urban area from three Northern districts of Bangladesh from August to November 2016.

PARTICIPANTS

Women who had a live birth in the last 1 year prior to data collection were enrolled for this study. In each study area, around 900 women were interviewed, and finally, we completed 2731 interviews.

PRIMARY OUTCOME MEASURES

The primary outcome was timely first ANC from a Medically Trained Provider (MTP).

RESULTS

About 43% of pregnancies were detected at their earliest time. The majority of participants (82%) received at least one ANC from an MTP. Only 11% received timely first ANC from an MTP as per the WHO FANC model. The women who detected pregnancy earlier were more likely (adj.OR 1.99, 95% CI 1.31 to 3.01) to receive the timely first ANC. The urban women were more likely (adj.OR 1.78, 95% CI 1.13 to 2.80) to receive the timely first ANC from an MTP than those of the rural women. Besides, their husbands' educational status (adj.OR 1.61, 95% CI 1.0 to 2.60) was significantly associated with the timely first ANC.

CONCLUSION

Apart from sociodemographic factors, early pregnancy detection was strongly associated with the timely first ANC visit. Timely initiation of ANC is an opportunity to adhere to all the WHO recommended timely ANC visits for a pregnant woman. The findings suggest maternal, neonatal, and child health programmes to focus on the early detection of pregnancy to ensure universal ANC coverage and its timeliness.

Family context and individual characteristics in antenatal care utilization among adolescent childbearing mothers in urban slums in Nigeria

Introduction

Adolescent pregnancy contributes significantly to the high maternal mortality in Nigeria. Research evidence from developing countries consistently underscores Antenatal Care (ANC) among childbearing adolescents as important to reducing high maternal mortality. However, more than half of pregnant adolescents in Nigeria do not attend ANC. A major gap in literature is on the influence of family context in pregnant adolescent patronage of ANC services.

Methods

The study utilized a cross-sectional survey with data collected among adolescent mothers in urban slums in three Nigerian states namely, Kaduna, Lagos, and Oyo. The survey used a multi-stage sampling design. The survey covered a sample of 1,015, 1,009 and 1,088 childbearing adolescents from each of Kaduna, Lagos, and Oyo states respectively. Data were analyzed at the three levels: univariate, bivariate and multivariate.

Results

Overall, about 70 percent of female adolescents in our sample compared with 75 percent in the Demographic and Health Survey (DHS) had any antenatal care (ANC) visit. About 62 percent in our sample compared with 70 percent in the DHS had at least 4 ANC visits, and, about 55 percent in our sample compared with 41 percent of the DHS that had 4 ANC visits in a health facility with skilled attendant (4ANC+). Those who have both parents alive and the mother with post-primary education have higher odds of attending 4ANC+ visits. The odds of attending 4ANC+ for those who have lost both parents is almost 60% less than those whose parents are alive, and, about 40% less than those whose mothers are alive. The influence of mother’s education on 4ANC+ attendance is more significant with large disparity when both parents are dead.

Conclusion

The study concludes that identifying the role of parents and community in expanding access to ANC services among adolescent mothers is important in improving maternal health in developing countries.

A multinomial regression analysis of factors associated with antenatal care attendance among women in Papua New Guinea

Objectives

This study sought to assess the prevalence and factors associated with antenatal care (ANC) uptake among women in Papua New Guinea.

Study design

This is a secondary data analysis of a nationally representative population based cross-sectional survey of households in Papua New Guinea conducted from 2016 to 2018.

Methods

Descriptive statistics in the form of frequencies and percentages and multinomial logistic regression analysis were done to assess the factors associated with ANC uptake and statistical significance was set at p<0.05.

Results

The prevalence of 4 or more ANC visits was 51.4%. The multinomial logistic regression analysis showed that women aged 35–39 [ARRR = 1.630, 95% CI = 1.016,2.615], those in the richest wealth quintile [2.361, 95% CI = 1.595,3.496], women who had secondary/higher level of education [ARRR = 3.644, 95% CI = 2.614,5.079], and those whose partners had secondary/higher education [ARRR = 1.706, 95% CI = 1.310,2.223] were more likely to attain 4 or more ANC visits. The likelihood of 4 or more ANC visits increased among women in Momase region [ARRR = 3.574, 95% CI = 2.683,4.762], those with parity 1 [ARRR = 2.065, 95% CI = 1.513,2.816], women who did not have a big problem with permission to go to the hospital for care [ARRR = 1.331, 95% CI = 1.110,1.597] and distance to health facility [ARRR = 1.970, 95% CI = 1.578,2.458]. However, women who were not working [ARRR = 0.756, 95% CI = 0.630,0.906], those in rural areas [ARRR = 0.712, 95% CI = 0.517,0.980] and those who do not take healthcare decisions alone [ARRR = 0.824, 95% CI = 0.683,0.994] were less likely to attain 4 or more ANC visits.

Conclusion

It was found that 51.4% of women have attained 4 or more ANC visits. Age, wealth status, employment, maternal and partner’s education, region and place of residence, parity, exposure to mass media, problem with distance and getting money needed for treatment and decision making on healthcare are associated with 4 or more ANC uptake among women in Papua New Guinea. To promote optimal number of ANC visits, there is the need for a multi-sectorial collaboration. For example, the various ministries such as the Ministry of Labour/Employment, Education, Development, Women affairs and Finance could collaborate with the Ministry of Health to achieve universal ANC coverage.

Inequalities in Access and Utilization of Maternal, Newborn and Child Health Services in sub-Saharan Africa: A Special Focus on Urban Settings

OBJECTIVES

The aim of this paper is to share the results of a systematic review on the state of inequalities in access to and utilization of maternal, newborn and child health (MNCH) services in the sub-Saharan African region. The focus of the review was on urban settings where growing needs and challenges have been registered over the past few years due to rapid increase in urban populations and urban slums.

METHODS

The review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines. Studies published in English between 2000 and 2019 were included. A narrative synthesis of both qualitative and quantitative data was undertaken. The record for registration in PROSPERO was CRD42019122066.

RESULTS

The review highlights a great variation in MNCH services utilization across urban sub-Saharan Africa (SSA). The main aspects of vulnerability to unequal and poor MNCH services utilization in urban settings of the region include poverty, low level of education, unemployment, lower socioeconomic status and poor livelihoods, younger maternal age, low social integration and social support, socio-cultural taboos, residing in slums, and being displaced, refugee, or migrant. At the health system level, persistent inequalities are associated with distance to health facility, availability of quality services and discriminating attitudes from health care personnel.

CONCLUSION

Context-specific intervention programs that aim at resolving the identified barriers to access and use MNCH services, particularly for the most vulnerable segments of urban populations, are essential to improve the overall health of the region and universal health coverage (UHC) targets.

Women's perspectives on the measures that need to be taken to increase the use of health-care facility delivery service among slums women, Addis Ababa, Ethiopia: a qualitative study

BACKGROUND

Global strategies to target high maternal mortality ratios are focused on providing skilled attendance at delivery along with access to emergency obstetric care. Research that examines strategies to increase facility-based skilled birth attendance among slum residents in Addis Ababa, Ethiopia, is limited.

OBJECTIVE

The study aimed to explore women's perspectives on the measures that need to be taken to increase the use of the facility-delivery service among slums women, Addis Ababa, Ethiopia METHODS: Qualitative exploratory and descriptive research designs were used. Participants in the study were women in the reproductive age group (18-49 years of age) living in the slum areas of Addis Ababa, Ethiopia. A purposive sampling strategy was used to select study participants. Potential participants' names were gathered from health facilities and followed to their homes for the study. Four audio-recorded focus group discussions [FGDs] were conducted with 32 participants from the three public health centers and one district hospital. The number of participants in FGDs was between 6 and 10 women. Data were analyzed simultaneously with data collection. Thematic analysis was used in data analysis, which entails three interconnected stages: data reduction, data display, and data conclusion. In addition, thematic analysis entailed evaluating the structure and content of textual data, identifying data themes, coding the themes, and then interpreting the structure and content of the themes. A codebook was first devised, discussed, and adopted by the writers before they could use this technique. Using the codebook, the theme codes were then manually produced. To explain the study results, verbatim excerpts from participants were given. The researcher used Techs' eight steps of qualitative data analysis method for analyzing the data. A multi-level life-course framework of facility-based delivery in low- and middle-income countries (LMICs) developed by Bohren et al. was used to frame the current study and link the findings of the study to the body of knowledge.

RESULTS

The FGDs included a total of 32 participants. The mean age of the overall sample was 32.6 years (± SD = 5.2). Participants' educational characteristics indicate that the majority (24 out of 32) was found to have no formal education, and two-thirds of participants were found to have one to five children. Three-fourths of them attended the ANC twice and they all gave birth to their last child at home. Two themes emerged from the analysis of focus group data, namely provision of quality, respectful and dignified midwifery care, and lack of awareness about facility delivery. These themes were described as a rich and comprehensive account of the views and suggestions made by focused antenatal care [FANC] participants on measures required to improve the use of the facility-delivery services. The findings of the study raise concerns about the effectiveness of FANC in encouraging facility-deliveries since FANC participants had not used health facilities for their last childbirth. According to the findings of the focus groups, women who took part in this study identified measures required to increase the use of health facility-delivery services among FANC participants in Addis Ababa's slum residents. It is to be expected that diligent counseling during antenatal care about birth plans would facilitate prompt arrival at facilities consistent with the desires of women.

Magnitude and determinants of adequate antenatal care service utilization among mothers in Southern Ethiopia

BACKGROUND

Mortality from preventable pregnancy-related complications remains high in Ethiopia. Antenatal care remains a major public health intervention that prevents maternal and neonatal mortality. Thus, this study aimed to assess the magnitude and determinants of adequate antenatal care utilization in Southern Ethiopia.

METHODS

A community-based cross-sectional study was conducted between November and December 2019. A systematic random sampling technique was used to select 670 women. Data were collected using a pre-tested structured questionnaire administered with a digital survey tool (open data kit) and directly exported to STATA version 15 for analysis. Descriptive statistics followed by a multivariable logistic regression analysis were performed. Both crude and adjusted odds ratios (ORs) with 95% confidence intervals were reported.

RESULTS

The magnitude of adequate antenatal care utilization was 23.13%. Tertiary and above education (AOR,4.15;95%CI: 1.95, 8.83), having the best friend who used maternal care (AOR,2.01;95%CI: 1.18,3.41), husband support (AOR,3.84; 95%CI: 1.05, 14.08), high wealth index (AOR,3.61; 95%CI: 1.86, 6.99), follow-up in private health facilities (AOR, 2.27;95% CI:1.33, 3.88), having a history of risky pregnancy (AOR,2.59; 95%CI: 1.55, 4.35), and planned pregnancy (AOR,2.60;95% CI: 1.35, 4.99) were significant determinants of overall adequate ANC service utilization.

CONCLUSION

The utilization of adequate antenatal care services is quite low. The study findings suggest that interventions should be in place to improve husband's support, social networks, and women's education. There is also a need to counsel women to utilize family planning.

Adequacy of prenatal care considering nutritional assistance in Southern Brazil: Maternar Cohort Study

We verified the prevalence of adequacy in prenatal care considering nutritional assistance and associated factors. It is a cross-sectional study, part of Maternar Cohort Study, conducted between 2018-2019 in Southern Brazil. Women were interviewed during hospitalization in the immediate postpartum period and data were collected from the prenatal chart. Prenatal adequacy and nutritional care were assessed according to criteria from the Brazilian Ministry of Health. Two outcome models were constructed. Outcome 1 consisted of minimal coverage (early prenatal start and minimum number of visits) and exams, and Outcome 2 comprised minimal coverage, exams, and nutritional assistance. Poisson regression was used to estimate prevalence ratios. A total of 802 women were analyzed, and we identified 57% of adequacy of Outcome 1. Unplanned pregnancy (PR = 0.76; 95%CI: 0.68-0.86), parity (PR = 0.88; 95%CI: 0.83-0.94) and prenatal care outside Porto Alegre, Rio Grande do Sul State (PR = 0.80; 95%CI: 0.69-0.92), were associated with lower prenatal adequacy frequencies. Outcome 2 was considered adequate for 10.2% of women. Follow-up by different professionals during prenatal care was associated with lower adequacy (PR = 0.49; 95%CI: 0.28-0.86). Women with high-risk pregnancies had a higher frequency of adequacy in Outcome 1 (PR = 1.21; 95%CI: 1.07-1.37) and in Outcome 2 (PR = 1.75; 95%CI: 1.16-2.64). General adequacy was considered low in both outcomes. There was a lack of nutritional assistance during prenatal care. Characteristics such as pregnancy planning, lower parity, prenatal care in Porto Alegre, follow-up by the same professional and high-risk pregnancy were predictors for the adequacy of prenatal care.

Adequacy of prenatal care services and associated factors in Southern Ethiopia

BACKGROUND

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

METHOD

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

RESULTS

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

CONCLUSIONS

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

Determinants of change in timely first antenatal booking among pregnant women in Ethiopia: A decomposition analysis

Background

Even though maternal health was highly targeted in different global strategies, maternal mortality could not be decreased as was expected. Besides this, prior decomposition analysis to the possible cause of changes to timely first antenatal booking has not been conducted. Therefore, this study aimed to assess determinants of change in timely first antenatal booking among pregnant women in Ethiopia.

Methods

The study utilized three consecutive Ethiopia Demographic and Health Survey (EDHS) datasets which were collected through cross-sectional study design. The number of pregnant women who gave birth in 2005, 2011 and 2016 survey included in the analysis was 7,307, 7,908 and 7,590 respectively. The data were analyzed by using Stata/SE version 14.0. Logit-based decomposition analysis was done to identify contributing factors for change in timely first antenatal booking and statistical significance was determined by using P-value.

Results

The trend of timely first antenatal booking was increased from 6% to 20% in the last ten years. The analysis revealed that 14% of the overall change was because of the change in women’s composition. Changes in the composition of women according to region, education and occupation status were the major sources of this change. The remaining, 86% of the change was due to differences in the coefficient. Mostly, the change in behaviors of the Oromia population, those who have lived in the rural areas and male household head were some of the contributing factors for the increase in timely first antenatal booking.

Conclusions

There was a significant increase in timely first antenatal booking among pregnant women in Ethiopia from 2005 to 2016 EDHS. The change in the women composition according to residency, education and occupation status of women and the difference in behaviors like: behavior of rural residents and male household head contributed to the majority of the change. Interventions targeting the male household head, rural residents and those women who lived in the Oromia region should be emphasized to increase further timely booking. In addition, promoting women in terms of education and creating job opportunities could be the other recalled intervention areas of the country.

Missed antenatal care follow-up and associated factors in Eastern Zone of Tigray, Northern Ethiopia

Introduction

Focused antenatal care improves the survival and health of the mother as well as the babies. However, there are real challenges in keeping the subsequent antenatal care follow up in Ethiopia. Hence, the aim of this study was to assess missed antenatal care follow up and associated factors in the Eastern zone of Tigray

Methods

Hospital based cross-sectional study was conducted among systematically selected 548 women who came for delivery services from March to April 2016. The data were collected using pre-tested and structured questionnaire through face to face exit interview. Data entry and analysis were made using EPI info version 7 software and SPSS version 20 respectively. Both binary and multiple logistic regression was performed.

Results

This study revealed that 33.4% of participants were missing their Antenatal care follow-up. Having no formal education [AOR=1.778 (1.102, 2.869)], attending primary education [AOR= 1.756 (1.040, 2.964)], self-employee [AOR=1.589 (1.030, 2.452)], government employee [AOR=0.503 (0.503, 0.953)], being unmarried [AOR=2.36 (1.11, 5.04)], didn’t informed about institutional delivery [AOR=3.34 (1.44, 7.78)], and travel distance more than two hours to hospital [AOR=1.93 (1.08, 3.44)] were factors significantly associated with missed Antenatal care follow-up.

Conclusion

The proportion of missed antenatal care follow-up was lessened as compared to local and national evidences. Nevertheless, still a coordinated effort on tracking of pregnant women who missed their antenatal care appointment is required by health policy implementers so as to increase the uptake of four complete visits.

Determinants of antenatal care utilisation in sub-Saharan Africa: a systematic review

OBJECTIVES

To identify the determinants of antenatal care (ANC) utilisation in sub-Saharan Africa.

DESIGN

Systematic review.

DATA SOURCES

Databases searched were PubMed, OVID, EMBASE, CINAHL and Web of Science.

ELIGIBILITY CRITERIA

Primary studies reporting on determinants of ANC utilisation following multivariate analysis, conducted in sub-Saharan Africa and published in English language between 2008 and 2018.

DATA EXTRACTION AND SYNTHESIS

A data extraction form was used to extract the following information: name of first author, year of publication, study location, study design, study subjects, sample size and determinants. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist for reporting a systematic review or meta-analysis protocol was used to guide the screening and eligibility of the studies. The Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies was used to assess the quality of the studies while the Andersen framework was used to report findings.

RESULTS

74 studies that met the inclusion criteria were fully assessed. Most studies identified socioeconomic status, urban residence, older/increasing age, low parity, being educated and having an educated partner, being employed, being married and Christian religion as predictors of ANC attendance and timeliness. Awareness of danger signs, timing and adequate number of antenatal visits, exposure to mass media and good attitude towards ANC utilisation made attendance and initiation of ANC in first trimester more likely. Having an unplanned pregnancy, previous pregnancy complications, poor autonomy, lack of husband's support, increased distance to health facility, not having health insurance and high cost of services negatively impacted the overall uptake, timing and frequency of antenatal visits.

CONCLUSION

A variety of predisposing, enabling and need factors affect ANC utilisation in sub-Saharan Africa. Intersectoral collaboration to promote female education and empowerment, improve geographical access and strengthened implementation of ANC policies with active community participation are recommended.

Determinants of maternal health care and birth outcome in the Dande Health and Demographic Surveillance System area, Angola

OBJECTIVES

Maternal health care improvement and reduction of maternal and child mortality are priorities of the global health agenda. In Angola, maternal mortality remains high and the risk of pregnancy-related death was 1 in 32 during 2015. This study aims to identify demographic and social factors influencing antenatal care and health facility delivery among women in Dande and to understand their impact on birth outcomes.

METHODS

This study is based on community-based longitudinal data collected by the Dande Health and Demographic Surveillance System between 2009 and 2015. Data on pregnancy outcomes (10,289 outcomes of 8,066 women) were collected for all reported pregnancies, including sociodemographic information, health services utilisation and women's reproductive history. Logistic regression was used to investigate the determinants of birth outcomes, antenatal care attendance and institutionalised delivery.

FINDINGS

Of the 10,289 pregnancy outcomes, 98.5% resulted in live births, 96.8% attended antenatal care, and 82.5% had four or more visits. Yet, 50.7% of the women delivered outside a health facility. Antenatal care attendance was a determinant of birth outcomes (stillbirth: unadjusted OR = 0.34 95% CI = 0.16-0.70; abortion: OR = 0.07 95% CI = 0.04-0.12). Older women, with lower education, living at a greater distance of a health facility and in rural areas, were less likely to use maternal health care. Having had previous pregnancies, namely resulting in live births, also decreased the likelihood of health care utilization by pregnant women.

CONCLUSIONS

The study identifies relevant social determinants for the utilisation of antenatal care, place of delivery and their impact on birth outcome, thereby providing insight on how best to address inequities in health care utilization.

Delayed initiation of antenatal care and associated factors in Ethiopia: a systematic review and meta-analysis

BACKGROUND

Antenatal care uptake is among the key indicators for monitoring the progress of maternal outcomes. Early initiation of antenatal care facilitates the timely management and treatment of pregnancy complications to reduce maternal deaths. In Ethiopia, antenatal care utilization is generally low, and delayed initiation of care is very common. We aimed to systematically identify and synthesize available evidence on delayed initiation of antenatal care and the associated factors in Ethiopia.

METHODS

Studies published in English from 1 January 2002 to 30 April 2017 were systematically searched from PubMed, Medline, EMBASE, CINAHL and other relevant sources. Two authors independently reviewed the identified studies against the eligibility criteria. The included studies were critically appraised using the Joanna Briggs-MAStARI instrument for observational studies. Meta-analysis was conducted in RevMan v5.3 for Windows using a Mantel-Haenszel random effects model. The presence of statistical heterogeneity was checked using the Cochran Q test, and its level was quantified using the I² statistics. Pooled estimate of the proportion of the outcome variable was calculated. Pooled Odd Ratios with 95% CI were calculated to measure the effect sizes.

RESULT

The pooled magnitude of delayed antenatal care in Ethiopia was 64% (95% CI: 57%, 70%). Maternal age (OR = 0.70; 95% CI: 0.53, 0.93), place of residence (OR = 0.29, 95% CI: 0.16, 0.50), maternal education (OR = 0.49; 95% CI: 0.38, 0.63), husband's education (OR = 0.44; 95% CI: 0.23, 0.85), maternal occupation (OR = 0.75; 95% CI: 0.61, 0.93), monthly income (OR = 2.06; 95% CI: 1.23, 3.45), pregnancy intention (OR = 0.49; 95% CI: 0.40, 0.60), parity (OR = 0.46; 95% CI: 0.36, 0.58), knowledge of antenatal care (OR = 0.40; 95% CI: 0.32, 0.51), women's autonomy (OR = 0.38; 95% CI: 0.15, 0.94), partner involvement (OR = 0.24; 95% CI: 0.07, 0.75), pregnancy complications (OR = 0.23; 95% CI: 0.06, 0.95), and means of identifying pregnancy (OR = 0.50; 95% CI: 0.36, 0.69) were significantly associated with delayed antenatal care.

CONCLUSION

Improving female education and women's empowerment through economic reforms, strengthening family planning programs to reduce unintended pregnancy and promoting partner involvement in pregnancy care could reduce the very high magnitude of delayed antenatal care in Ethiopia.

TRIAL REGISTRATION

CRD42017064585 .