Pregnant woman awareness of obstetric danger signs in developing country: systematic review

Impact evaluation of a digital health platform empowering Kenyan women across the pregnancy-postpartum care continuum: A cluster randomized controlled trial

BACKGROUND

Accelerating improvements in maternal and newborn health (MNH) care is a major public health priority in Kenya. While use of formal health care has increased, many pregnant and postpartum women do not receive the recommended number of maternal care visits. Even when they do, visits are often short with many providers not offering important elements of evaluation and counseling, leaving gaps in women's knowledge and preparedness. Digital health tools have been proposed as a complement to care that is provided by maternity care facilities, but there is limited evidence of the impact of digital health tools at scale on women's knowledge, preparedness, and the content of care they receive. We evaluated a digital health platform (PROMPTS (Promoting Mothers in Pregnancy and Postpartum Through SMS)) composed of informational messages, appointment reminders, and a two-way clinical helpdesk, which had enrolled over 750,000 women across Kenya at the time of our study, on 6 domains across the pregnancy-postpartum care continuum.

METHODS AND FINDINGS

We conducted an unmasked, 1:1 parallel arm cluster randomized controlled trial in 40 health facilities (clusters) across 8 counties in Kenya. A total of 6,139 pregnant individuals were consented at baseline and followed through pregnancy and postpartum. Individuals recruited from treatment facilities were invited to enroll in the PROMPTS platform, with roughly 85% (1,453/1,700) reporting take-up. Our outcomes were derived from phone surveys conducted with participants at 36 to 42 weeks of gestation and 7 to 8 weeks post-childbirth. Among eligible participants, 3,399/3,678 women completed antenatal follow-up and 5,509/6,128 women completed postpartum follow-up, with response rates of 92% and 90%, respectively. Outcomes were organized into 6 domains: knowledge, birth preparedness, routine care seeking, danger sign care seeking, newborn care, and postpartum care content. We generated standardized summary indices to account for multiple hypothesis testing but also analyzed individual index components. Intention-to-treat analyses were conducted for all outcomes at the individual level, with standard errors clustered by facility. Participants recruited from treatment facilities had a 0.08 standard deviation (SD) (95% CI [0.03, 0.12]; p = 0.002) higher knowledge index, a 0.08 SD (95% CI [0.02, 0.13]; p = 0.018) higher birth preparedness index, a 0.07 SD (95% CI [0.03, 0.11]; p = 0.003) higher routine care seeking index, a 0.09 SD (95% CI [0.07, 0.12]; p < 0.001) higher newborn care index, and a 0.06 SD (95% CI [0.01, 0.12]; p = 0.043) higher postpartum care content index than those recruited from control facilities. No significant effect on the danger sign care seeking index was found (95% CI [-0.01, 0.08]; p = 0.096). A limitation of our study was that outcomes were self-reported, and the study was not powered to detect effects on health outcomes.

CONCLUSIONS

Digital health tools indicate promise in addressing shortcomings in pregnant and postpartum women's health care, amidst systems that do not reliably deliver a minimally adequate standard of care. Through providing women with critical information and empowering them to seek recommended care, such tools can improve individuals' preparation for safe childbirth and receipt of more comprehensive postpartum care. Future work is needed to ascertain the impact of at-scale digital platforms like PROMPTS on health outcomes.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT05110521; AEA RCT Registry ID: R-0008449.

Barriers and facilitators to maternal healthcare in East Africa: a systematic review and qualitative synthesis of perspectives from women, their families, healthcare providers, and key stakeholders

BACKGROUND

In East Africa, women face significant challenges accessing maternal healthcare during pregnancy, childbirth, and the postnatal period. While several studies have examined barriers and facilitators to maternal care, there is no comprehensive review reflecting the various perspectives of women, their families, healthcare providers, and key stakeholders. We systematically reviewed qualitative literature on maternal healthcare in East Africa, synthesizing insights from multiple perspectives and exploring barriers and facilitators across socioecological levels.

METHODS

A qualitative evidence synthesis focused on studies from East Africa published between January 2015 and June 2024. We searched electronic databases, including PubMed, Embase, Scopus, Cochrane, Web of Science, and ProQuest, and used citation tracking to find additional references. Eligible studies were critically appraised using the Critical Appraisal Skills Program, and a thematic synthesis was performed to identify barriers and facilitators.

RESULTS

Of the 3181 records identified, 81 studies (63 qualitative and 18 mixed method) met the inclusion criteria, representing 4816 individuals from six East African countries. This review identified barriers at various levels: individual barriers included a lack of awareness and knowledge, fear of being treated poorly, and financial constraints; interpersonal barriers comprised limited family support, communication challenges, and a lack of decision-making autonomy; health facility barriers included poor quality of healthcare, poor infrastructure, limited medical supplies, provider shortages, abusive behaviors from healthcare providers, lack of transportation, and high service costs; community-level barriers involved socio-cultural norms, societal stigma, and gender-based disparities; and policy-level barriers included poor focus on maternal health, a lack of male accompaniment policies, and conflicts. Key facilitators identified included improved healthcare understanding and women's self-efficacy at the individual level, family support and positive social influences at the interpersonal level, high-quality services, reliable transportation, compassionate care, and health education at the health facility level, community initiatives, gender equality, and maternity waiting homes at the community level, as well as free maternity services and health extension programs at the policy level.

CONCLUSION

The synthesis identified key barriers and facilitators to the maternal healthcare in East African countries, ranging from individual to policy levels. We recommend that future initiatives focus on addressing these barriers while enhancing facilitators across individual, interpersonal, health facility, community, and policy levels through woman-centered, evidence-based strategies. Moreover, fostering collaboration among governments, healthcare providers, and communities is essential for improving access to the maternal continuum of care.

Assessing awareness of danger signs of pregnancy and its associated factors among pregnant women in Libya: A cross-sectional study

BACKGROUND

The maternal mortality rate in Libya surpasses the regional average and is primarily due to sepsis, hemorrhages, hypertension, and other factors, highlighting gaps in maternal knowledge and access to quality care. This study aimed to assess the awareness of obstetric danger signs and associated factors among pregnant women attending the outpatient clinic of Tobruk Medical Center, Libya.

METHODS

An institution-based cross-sectional study was conducted from August to October 2023, involving 301 pregnant women visiting the outpatient clinic. Convenience sampling was utilized, and data were collected using structured questionnaires. Data were initially stored in Excel and then imported into R (version 4.3.1) for analysis. Descriptive statistics were applied to both categorical and continuous variables. Logistic regression was used to study the association between awareness of danger signs and socio-demographic variables, with p-values calculated and multivariate analysis performed to adjust for confounding factors.

RESULTS

Results revealed that 239 (79.4%) pregnant women were aware of danger signs. Additionally, the most cited danger signs were "fatigue" (41.5%) and "severe headache" (23.3%), whereas the least common was "sudden gush of fluids" (10.6%). Marital status was found to be an independent predictor of knowledge about pregnancy danger signs, whereby married women were more likely to have awareness than divorced women (AOR:0.16, CI: 0.04-0.71, P-value: 0.016).

CONCLUSION

To improve maternal healthcare, ANC units should focus on educating patients about under-recognized signs and encourage peer discussions through social media. These steps aim to enhance preparedness and reduce pregnancy-related complications.

Effect of community health education on mothers' knowledge of obstetric danger signs and birth preparedness and complication readiness practices in southern Ethiopia: A cluster randomized controlled trial

INTRODUCTION

Increasing knowledge of obstetric danger signs (ODS) and encouraging birth preparedness and complication readiness (BPCR) practices are strategies to increase skilled maternal health service utilization in low-income countries. One of the methods to increase mothers' knowledge about ODS and promote BPCR practice is through health education intervention (HEI). However, the effect of context-specific community-based health education led by women's groups on these outcomes has yet to be comprehensively studied, and the existing evidence is inconclusive. Thus, we aimed to evaluate the effect of a context-specific community-based HEI led by women's groups on mothers' knowledge regarding ODS and BPCR practices in southern Ethiopia.

METHODS

An open-label, two-arm parallel group cluster-randomized controlled trial was conducted from January to August 2023 on pregnant women from 24 clusters (kebeles) (12 interventions and 12 controls) in the northern zone of the Sidama region. The Open Data Kit smartphone application was utilized to collect data. The intention-to-treat analysis was used to compare outcomes between groups. We fitted multilevel mixed-effects modified Poisson regression with robust standard error to account for between and within cluster effects.

RESULTS

One thousand and seventy pregnant women (540 in the intervention and 530 in the control clusters) responded to this study, making the overall response rate 95.02%. Excessive vaginal bleeding (94.3% in the interventional group vs. 88.7% in the control group) was the commonest ODS mentioned during childbirth. Overall, 68.7% of women in the intervention group and 36.2% of mothers in the control group had good knowledge of ODS (P-value < 0.001). Saving money and materials (97.1% in the interventional group vs. 92.7% in the control group) was the most frequently practiced BPCR plan. Overall, 64.3% of women in the intervention group and 38.9% of mothers in the control group practiced BPCR (P-value < 0.001). HEI significantly increased overall knowledge of ODS (adjusted risk ratio [ARR]: 1.71; 99% CI: 1.14-2.57) and improved overall BPCR practice (ARR: 1.55; 99% CI: 1.02-2.39).

CONCLUSIONS

A community-based HEI led by women's groups improved mothers' knowledge regarding ODS and BPCR practices in a rural setting in southern Ethiopia. Interventions designed to increase women's knowledge of ODS and improve BPCR practice must implement context-specific, community-based HEI that aligns with World Health Organization recommendations.

TRIAL REGISTRATION

NCT05865873.

Midwife-Led Mobile Antenatal Clinic: An Innovative Approach to Improve Utilization of Services in Pwani, Tanzania

Participating in antenatal clinics is a major determinant in reducing poor maternal and neonatal birth outcomes. We aimed to evaluate the utilization of antenatal clinic (ANC) services provided by a mobile clinic led by skilled midwives and determine the acceptability in the Pwani region, Tanzania. For a year, the mobile clinic, nicknamed "Mkunga Kitaani" and equipped with necessary tools and staff, served seven villages in the Kisarawe district that lacked health facilities. The research was conducted using a descriptive study design, incorporating both qualitative and quantitative methods. Qualitative and quantitative data were collected through 12 interviews and 214 medical records among pregnant women, respectively. The results show that approximately 17% of the women initiated ANC early, while 36% made their visit during their third trimester. Participants generally preferred the mobile clinic over traditional facilities due to its provision of comprehensive care. However, challenges such as clinic unreliability during the rainy season and limited availability of tests, including obstetric ultrasounds, were noted. Despite hurdles, the study highlighted increased ANC access and community engagement, suggesting potential for expansion to other underserved rural areas. The findings underscore the importance of innovative approaches to ANC delivery in regions with limited healthcare infrastructure.

Predictors of antenatal care services utilization by pregnant women in Afghanistan: Evidence from the Afghanistan Health Survey 2018

BACKGROUND

Poor utilization of maternal healthcare services remains a public health concern in most low and middle-income countries (LMICs), including Afghanistan. Late, inadequate, or no utilization of antenatal care (ANC) services pose a great concern.

OBJECTIVES

This study assessed the predictors of ANC service utilization among Afghan pregnant women, using secondary data from the Afghanistan Health Survey 2018 (AHS2018).

METHODS

In this study, we used data from 10,855 ever-married women, aged 13-49 years, who gave birth in the two years prior to the survey or those women who were currently pregnant. The outcome variable was defined as a binary variable on ANC utilization (≥1 ANC visit equals 1, and zero otherwise). We fitted a binary logistic regression model and examined the associations between ANC utilization and explanatory variables, providing findings based on univariate and multivariate analysis. STATA version 17 was employed for the data analysis.

RESULTS

Overall, 63.2%, 22.0%, and 3.1% of women had at least one ANC visit, ≥4 ANC visits, and ≥8 ANC visits during their last pregnancy, respectively. Higher odds of ANC utilization were observed in women who could read and write (AOR = 1.55, 95%CI: 1.36-1.77), whose husbands could read and write (AOR = 1.42, 95%CI: 1.29-1.56), who knew 1 sign (AOR = 1.93, 95%CI: 1.74-2.14), 2 signs (AOR = 2.43, 95%CI: 2.17-2.71) and ≥ 3 signs (AOR = 1.55, 95%CI: 1.36-1.77) of complicated pregnancy, and those with almost daily access to radio (AOR = 1.19, 95%CI: 1.08-1.327) and TV (AOR = 1.92, 95%CI: 1.73-2.13). We also found that women with one (AOR = 0.64, 95%CI: 0.49-0.84) and more than one (AOR = 0.60, 95%CI: 0.47-0.76) parity status, those for whom in-laws and others decided for their birthplace [(AOR = 0.85, 95%CI: 0.74-0.97) and (AOR = 0.63, 95%CI: 0.55-0.72), respectively], and those that resided in rural areas (AOR = 0.89, 95%CI: 0.79-1.00) had reduced odds of ANC utilization.

CONCLUSION

ANC service utilization is unacceptably low by pregnant women in Afghanistan. The predictors of ANC utilization identified by the study should be considered in the design of future interventions to enhance antenatal care utilization in Afghanistan.

A comprehensive assessment of care competence and maternal experience of first antenatal care visits in Mexico: Insights from the baseline survey of an observational cohort study

BACKGROUND

Comprehensive antenatal care (ANC) must prioritize competent, evidence-based medical attention to ensure a positive experience and value for its users. Unfortunately, there is scarce evidence of implementing this holistic approach to ANC in low- and middle-income countries, leading to gaps in quality and accountability. This study assessed care competence, women's experiences during the first ANC visit, and the factors associated with these care attributes.

METHODS AND FINDINGS

The study analyzed cross-sectional baseline data from the maternal eCohort study conducted in Mexico from August to December 2023. The study adapted the Quality Evidence for Health System Transformation (QuEST) network questionnaires to the Mexican context and validated them through expert group and cognitive interviews with women. Pregnant women aged 18 to 49 who had their first ANC visit with a family physician were enrolled in 48 primary clinics of the Instituto Mexicano del Seguro Social across 8 states. Care competence and women's experiences with care were the primary outcomes. The statistical analysis comprised descriptive statistics, multivariable linear and Poisson regressions. A total of 1,390 pregnant women were included in the study. During their first ANC visit, women received only 67.7% of necessary clinical actions on average, and 52% rated their ANC experience as fair or poor. Women with previous pregnancies (adjusted regression coefficient [aCoef.] -3.55; (95% confidence intervals [95% CIs]): -4.88, -2.22, p < 0.001), at risk of depression (aCoef. -3.02; 95% CIs: -5.61, -0.43, p = 0.023), those with warning signs (aCoef. -2.84; 95% CIs: -4.65, -1.03, p = 0.003), common pregnancy discomforts (aCoef. -1.91; 95% CIs: -3.81, -0.02, p = 0.048), or those who had a visit duration of less than 20 minutes (<15 minutes: aCoef. -7.58; 95% CIs: -10.21, -4.95, p < 0.001 and 15 to 19 minutes: aCoef. -2.73; 95% CIs: -4.79, -0.67, p = 0.010) and received ANC in the West and Southeast regions (aCoef. -5.15; 95% CIs: -7.64, -2.66, p < 0.001 and aCoef. -5.33; 95% CIs: -7.85, -2.82, p < 0.001, respectively) had a higher probability of experiencing poorer care competence. Higher care competence (adjusted prevalence ratio [aPR] 1.004; 95% CIs:1.002, 1.005, p < 0.001) and receiving care in a small clinic (aPR 1.19; 95% CIs: 1.06, 1.34, p = 0.003) compared to a medium-sized clinic were associated with a better first ANC visit experience, while common pregnancy discomforts (aPR 0.94; 95% CIs: 0.89, 0.98, p = 0.005) and shorter visit length (aPR 0.94; 95% CIs: 0.88, 0.99, p = 0.039) were associated with lower women's experience. The primary limitation of the study is that participants' responses may be influenced by social desirability bias, leading them to provide socially acceptable responses.

CONCLUSIONS

We found important gaps in adherence to ANC standards and that care competence during the first ANC visit is an important predictor of positive user experience. To inform quality improvement efforts, IMSS should institutionalize the routine monitoring of ANC competencies and ANC user experience. This will help identify poorly performing facilities and providers and address gaps in the provision of evidence-based and women-centered care.

Preventing maternal morbidity and mortality from preeclampsia and eclampsia particularly in low- and middle-income countries

Preeclampsia (PE) is a complex heterogeneous disorder with overlapping clinical phenotypes that complicate diagnosis and management. Although several pathophysiological mechanisms have been proposed, placental dysfunction due to inadequate remodelling of uterine spiral arteries leading to mal-perfusion and syncytiotrophoblast stress is recognized as the unifying characteristic of early-onset PE. Placental overgrowth and or premature senescence are probably the causes of late-onset PE. The frequency of PE has increased over the last few decades due to population-wide increases in risk factors viz. obesity, diabetes, multifetal pregnancies and pregnancies at an advanced maternal age. Whilst multimodal tools with components comprising risk factors, biomarkers and sonography are used for predicting PE, aspirin is most effective in preventing early-onset PE. The incidence and clinical consequences of PE and eclampsia are influenced by socioeconomic and cultural factors, therefore management strategies should involve multi-sector partnerships to mitigate the adverse outcomes.