Client Factors Affect Provider Adherence to Clinical Guidelines during First Antenatal Care

Self-reported continuity and coordination of antenatal care and its association with obstetric near miss in Uasin Gishu county, Kenya

BACKGROUND

Continuity and coordination of care are core principles of high-quality primary health care. Optimising continuity and coordination improves maternal satisfaction. However, their association with morbidity and mortality outcomes is unclear. The obstetric near-miss approach can be used to investigate whether continuity and coordination influences the occurrence of a severe maternal outcome.

AIM

To compare self-reported continuity and coordination of care between obstetric near-miss survivors and those without near miss during pregnancy, delivery and postpartum.

SETTING

Uasin Gishu county, Rift Valley region, Kenya.

METHODS

A cross-sectional survey targeting 340 postnatal mothers. Continuity of care index (COCI) and modified continuity of care index (MCCI) were used to estimate longitudinal continuity. The Likert scale was administered to measure perceived continuity and coordination of care. Mann-Whitney U test and binomial logistic regression were used for hypothesis testing.

RESULTS

COCI and MCCI were lower among near-miss survivors (COCI = 0.80, p = 0.0026), (MCCI = 0.62, p = 0.034). Near-miss survivors scored lower on items assessing coordination between a higher-level provider and usual antenatal clinic (mean = 3.6, p = 0.006) and general coordination of care during pregnancy (mean = 3.9, p = 0.019). Presence of a non-life-threatening morbidity in pregnancy was associated with occurrence of near miss (aOR = 4.34, p = 0.001).

CONCLUSION

Near-miss survivors scored lower on longitudinal continuity and coordination of care across levels. Further research should focus on strengthening coordination, determining the optimal level of longitudinal continuity and improving systems for early identification and management of morbidities in pregnancy.Contribution: The results of this study show that while longitudinal and relational COC is important during the antenatal period, the presence of a non-life-threatening condition in pregnancy remains the most important predictor of the occurrence of a near miss.

Factors influencing quality nutrition service provision at antenatal care contacts: Findings from a public health facility-based observational study in 21 districts of Bangladesh

Malnutrition during pregnancy is associated with increased maternal morbidity and mortality and has a long-term negative impact on child growth and development. Antenatal care (ANC) is the formal point of contact for pregnant women to receive preventive health and nutrition services. We assessed the quality of nutrition service delivery during ANC and examined its influencing factors related to the health facility, health care provider (HCP) and client characteristics. We conducted a cross-sectional assessment in 179 facilities, including 1,242 ANC observations and exit interviews of pregnant women from 21 districts in Bangladesh. We considered four essential nutrition services at each ANC contact including maternal weight measurement, anaemia assessment, nutrition counselling and iron-folic acid (IFA) supplement provision. We defined a composite ‘quality nutrition service’ outcome by counting the number of services (out of four) provided at each ANC from observation data. We explored both the supply-side and the client-level factors of quality nutrition service using multilevel Poisson regression. Overall, only 15% of clients received all four nutrition services. Performance of weight measurement (79%) was higher than IFA provision (56%), anaemia assessment (52%) and nutrition counselling (52%). The multivariable analysis showed that quality nutrition service delivery is positively associated with good logistical readiness of the facilities (aIRR: 1.23, 95% CI: 1.08–1.39), consultation by paramedics (aIRR 1.23, 95% CI: 1.06–1.42) and community health care providers (aIRR 1.32, 95% CI: 1.12–1.57), HCPs’ knowledge on maternal nutrition (aIRR 1.04; 95% CI: 1.01–1.08), better HCP-client communication (aIRR 1.14; 95% CI: 1.04–1.26) and use visual aids or ANC card (aIRR 1.18; 95% CI: 1.11–1.27). We found limited associations between HCP training and external supervision with the quality of nutrition services. In conclusion, the quality of nutrition service provision during ANC is suboptimal. Public health nutrition programmers should ensure the facilities’ logistical readiness, and revisit and reinforce the content and modality of training and supportive supervision of the HCPs. They should also emphasize positive HCP-client communication and the use of job aids to improve the quality of nutrition service provision during ANC.

Effect of complete adherence to antenatal care guideline during first visit on maternal and neonatal complications during the intrapartum and postpartum periods: a prospective cohort study in Northwest Ethiopia

OBJECTIVES

To examine the relationship between complete of providers' adherence to antenatal care (ANC) guideline during first visit and maternal and neonatal complications during intrapartum and postpartum periods.

DESIGN

Prospective cohort study.

SETTING

Gondar town public health facilities in Northwest, Ethiopia.

PARTICIPANTS

A total of 832 pregnant women with gestational age <28 weeks who came for first ANC visit were enrolled and followed up to the first 6 hours of the postpartum periods.

EXPOSURE

Providers' adherence to ANC guideline during first visit was the exposure variable. An 18-point checklist was used to record the level of providers' adherence. Clients who received care from providers who adhered completely to the guideline constituted the 'exposed group', and those who did not receive such care constituted the 'unexposed group'.

MAIN OUTCOMES

Maternal and neonatal complications occurred during the intrapartum and postpartum periods.

DATA ANALYSIS

Negative binomial regression model was used to analyse the data. The adjusted incidence risk ratio (AIRR) with 95% CI was reported in the final model.

RESULTS

A total of 782 pregnant women were followed up and included in the final analysis (254 in the exposed group and 528 non-exposed). Complete adherence to the guidelines during first visit reduced the risk of neonatal complications (AIRR 0.56; 95% CI 0.39 to 0.79). However, complete adherence to the guidelines was not found to have a statistically significant effect on maternal complications (AIRR 0.84; 95% CI 0.67 to 1.05) during the intrapartum and the postpartum periods.

CONCLUSIONS

The group that received care from providers who completely adhered to the ANC guidelines during the first antenatal visit showed significantly improved neonatal outcomes. However, it did not show a significant improvement in maternal outcomes. Hence, focusing on safe motherhood programmes like training that gears provider's conformity to ANC guideline is quite crucial to improve neonatal outcomes.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Emerging and Public Health Challenges Existing in Gestational Diabetes Mellitus and Diabetes in Pregnancy

We review the evidence available worldwide on the various challenges in the screening, management, prevention of gestational diabetes mellitus and diabetes in pregnancy. The use of multiple screening and diagnostic tests prescribed by numerous guidelines is challenging for practitioners. Also, sociocultural, demographic and economic challenges affect the prevention and care. Life-course perspectives need to be adopted, as well as an integrated approach in public health care is essential. Tackling these challenges at each phase of life-course, with development and adherence to the country-specific guidelines by practitioners can decrease the burden of gestational diabetes mellitus and diabetes in pregnancy.

Client Factors Affect Provider Adherence to Guidelines during First Antenatal Care in Public Health Facilities, Ethiopia: A Multi-Center Cross-Sectional Study

Background

Timely entry to an antenatal care with a healthcare provider who follows a set of national guidelines is assumed to ensure higher levels of client satisfaction. It is also expected to improve perinatal outcomes. Little is known about the level of adherence of Ethiopian providers to these guidelines. Therefore, this study aims to assess the proportion of clients who received complete (100%) provider adherence to antenatal care guidelines at the first visit and client associated factors in Gondar Town.

Methods

A cross-sectional study of 834 study participants was conducted in public health facilities of Gondar Town in Ethiopia. An 18 point checklist was used to observe provider adherence to the first antenatal care visit guidelines. Descriptive statistics and multivariable binary logistic regression model were done by using STATA 14 software.

Result

The proportion of clients who received the complete provider's adherence to the first antenatal care guideline was 32.25% (95% CI: 29.1–35.5). The mean adherence score was 16.78%. Women who had prior history of pregnancy and/or birth-related complications (AOR = 1.58; 95%CI: 1.04–2.04) and late antenatal care booking at gestational week 16 or greater (AOR = 1.45; 95%CI: 1.03–2.03) were significantly associated with clients receiving complete providers' adherence to the first antenatal guideline.

Conclusions

We found the level of adherence to national antenatal care guidelines during first visit as surprisingly low. When considering to upgrade the guidelines to the actual WHO guideline of eight visits, we recommend that refresher training be provided regularly to help staff understand the importance of following the guidelines as closely as possible. Perhaps, we need to learn more from the health care providers themselves about their reasons for not following the guidelines.

Provider-perceived benefits and constraints of complete adherence to antenatal care guideline among public health facilities, Ethiopia: A qualitative study

BACKGROUND

In Ethiopia, health care providers' level of adherence to the national Antenatal Care (ANC) guideline is relatively low. The reasons why they do not follow the guidelines are not well known. Therefore, this study aimed to explore the provider-perceived benefits and constraints associated with using the guideline for ANC in public health facilities in Gondar town.

METHODS

A qualitative study was conducted using a semi-structured interview guide. The interview was conducted among a purposive sample of nine health care providers working in four public health facilities in Gondar town. After the interviews were transcribed and coded, a content analysis was done using Atlas ti version 7.5 software packages.

RESULT

Decreasing provider's workload and maximizing performance, improving safe motherhood, and improving the process of service delivery were reported as the perceived benefits of following ANC guideline. Organizational problems, care providers' existing knowledge, attitude, and skills and availability of training and mentorship were the three main identified groups of factors that hinder complete providers' adherence to ANC guideline.

CONCLUSION

Although providers acknowledged the benefits of following ANC guideline, the guideline is not fully implemented. Refresher training should be given at the start of the updated eight-contact ANC guideline and continuing education and supervision throughout the implementation process. Health care providers call for profound and urgent revisions of the supply chain system for supplies and equipment.

Factors influencing implementation of an insulin patient decision aid at public health clinics in Malaysia: A qualitative study

BACKGROUND

Many patient decision aids (PDAs) are developed in academic settings by academic researchers. Academic settings are different from public health clinics where the focus is on clinical work. Thus, research on implementation in public health settings will provide insights to effective implementation of PDA in real-world settings. This study explores perceived factors influencing implementation of an insulin PDA in five public health clinics.

METHODS

This study adopted a comparative case study design with a qualitative focus to identify similarities and differences of the potential barriers and facilitators to implementing the insulin PDA across different sites. Focus groups and individual interviews were conducted with 28 healthcare providers and 15 patients from five public health clinics under the Ministry of Health in Malaysia. The interviews were transcribed verbatim and analysed using the thematic approach.

RESULTS

Five themes emerged which were: 1) time constraint; 2) PDA costs; 3) tailoring PDA use to patient profile; 4) patient decisional role; and 5) leadership and staff motivation. Based on the interviews and drawing on observations and interview reflection notes, time constraint emerged as the common prominent factor that cut across all the clinics, however, tailoring PDA use to patient profile; patient decisional role; leadership and staff motivation varied due to the distinct challenges faced by specific clinics. Among clinics from semi-urban areas with more patients from limited education and lower socio-economic status, patients' ability to comprehend the insulin PDA and their tendency to rely on their doctors and family to make health decisions were felt to be a prominent barrier to the insulin PDA implementation. Staff motivation appeared to be stronger in most of the clinics where specific time was allocated to diabetes team to attend to diabetes patients and this was felt could be a potential facilitator, however, a lack of leadership might affect the insulin PDA implementation even though a diabetes team is present.

CONCLUSIONS

This study found time constraint as a major potential barrier for PDA implementation and effective implementation of the insulin PDA across different public health clinics would depend on leadership and staff motivation and, the need to tailor PDA use to patient profile. To ensure successful implementation, implementers should avoid a 'one size fits all' approach when implementing health innovations.

Determinants of Low Birth Weight in Ghana: Does Quality of Antenatal Care Matter?

OBJECTIVES

Low birth weight is a public health issue that contributes to perinatal and infant mortality, especially in limited-resource settings, but there is limited understanding of the determinants of low birth weight and the contributions of quality antenatal care to maintaining healthy birth weights for newborns in such settings. This study aims at establishing links between birthweight and quality antenatal care in Ghana.

METHODS

We used data collected from the recent 2017 Ghana Maternal Health Survey and applied complementary log-log models to investigate relationships between the quality of antenatal care (screening/diagnostic procedures, clinical interventions, type of health provider) and low birth weight in Ghana.

RESULTS

The results reveal that compared to women who received low quality clinical interventions, those who received high quality interventions were significantly less likely to have a low birth weight baby. Similarly, women who made the recommended number of antenatal visits (at least eight) were significantly less likely to have a baby with low birth weight than women making fewer visits.

CONCLUSION

Our findings suggest that while the number of antenatal visits is important, the quality of care received during such visits is equally relevant to reducing low birth weight in Ghana.

Can an mhealth clinical decision-making support system improve adherence to neonatal healthcare protocols in a low-resource setting?

Background

This study assessed health workers’ adherence to neonatal health protocols before and during the implementation of a mobile health (mHealth) clinical decision-making support system (mCDMSS) that sought to bridge access to neonatal health protocol gap in a low-resource setting.

Methods

We performed a cross-sectional document review within two purposively selected clusters (one poorly-resourced and one well-resourced), from each arm of a cluster-randomized trial at two different time points: before and during the trial. The total trial consisted of 16 clusters randomized into 8 intervention and 8 control clusters to assess the impact of an mCDMSS on neonatal mortality in Ghana. We evaluated health workers’ adherence (expressed as percentages) to birth asphyxia, neonatal jaundice and cord sepsis protocols by reviewing medical records of neonatal in-patients using a checklist. Differences in adherence to neonatal health protocols within and between the study arms were assessed using Wilcoxon rank-sum and permutation tests for each morbidity type. In addition, we tracked concurrent neonatal health improvement activities in the clusters during the 18-month intervention period.

Results

In the intervention arm, mean adherence was 35.2% (SD = 5.8%) and 43.6% (SD = 27.5%) for asphyxia; 25.0% (SD = 14.8%) and 39.3% (SD = 27.7%) for jaundice; 52.0% (SD = 11.0%) and 75.0% (SD = 21.2%) for cord sepsis protocols in the pre-intervention and intervention periods respectively. In the control arm, mean adherence was 52.9% (SD = 16.4%) and 74.5% (SD = 14.7%) for asphyxia; 45.1% (SD = 12.8%) and 64.6% (SD = 8.2%) for jaundice; 53.8% (SD = 16.0%) and 60.8% (SD = 11.7%) for cord sepsis protocols in the pre-intervention and intervention periods respectively. We observed nonsignificant improvement in protocol adherence in the intervention clusters but significant improvement in protocol adherence in the control clusters. There were 2 concurrent neonatal health improvement activities in the intervention clusters and over 12 in the control clusters during the intervention period.

Conclusion

Whether mHealth interventions can improve adherence to neonatal health protocols in low-resource settings cannot be ascertained by this study. Neonatal health improvement activities are however likely to improve protocol adherence. Future mHealth evaluations of protocol adherence must account for other concurrent interventions in study contexts.

Assessment of Quality of Antenatal Care Services and Its Determinant Factors in Public Health Facilities of Hossana Town, Hadiya Zone, Southern Ethiopia: A Longitudinal Study

Background. Antenatal care is a care that links the woman and her family with the formal health system, increases the chance of using a skilled attendant at birth, and contributes to good health through the life cycle. Inadequate care during this time breaks a critical link in the continuum of care and affects both women and babies. Therefore, the main aim of this study was to determine the quality of ANC in Hadiya Zone, Southern Ethiopia. Method. A longitudinal facility-based study design was conducted among 1123 mothers whose gestational age of less than 16 weeks was identified and followed until birth and 40 days after birth to detect whether they gained the acceptable standard of quality of ANC from July 2017 to June 2018. A structured, predefined, and pretested observation check list and Likert scales were employed to obtain the necessary information after getting both written and verbal consent from the concerned bodies and study participants. Data was entered into Epi Info version 3.5 and transferred to STATA Version 14 software and cleaned by reviewing frequency tables, logical errors, and checking outliers. Generalized estimating equation (GEE) analysis was applied to get the average response observation of each visit of quality of ANC in the health facilities. Result. This study showed that the overall magnitude of good quality of antenatal care service that was provided in the whole visit at Hosanna Town’s public health facilities was 1230 (31.38%). The most frequently identified problems were inability to take full history, lack of proper counseling, poor healthcare provider and client interaction, and improper registration and there was a variation in providing quality of care in each visit. Quality of antenatal care was significantly associated with residence, educational status gravidity, parity, and visit. In conclusion, the overall quality of antenatal care is low, so the health facilities need further modification on the identified problems.

Completeness of obstetric referral letters/notes from subdistrict to district level in three rural districts in Greater Accra region of Ghana: an implementation research using mixed methods

OBJECTIVE

To assess the completeness of obstetric referral letters/notes at the district level of healthcare.

DESIGN

An implementation research within three districts in Greater Accra region using mixed methods. During baseline and intervention phases, referral processes for all obstetric referrals from lower level facilities seen at the district hospitals were documented including indications for referrals, availability and completeness of referral notes/forms. An assessment of before and after intervention availability and completeness of referral forms was carried out. Focus group discussions, non-participant observations and in-depth interviews with health workers and pregnant women were conducted for qualitative data.

SETTING

Three (3) districts in the Greater Accra region of Ghana.

PARTICIPANTS

Pregnant women referred from lower levels of care to and seen at the district hospital, health workers within the three districts and pregnant women attending antenatal clinic in the district and their family members or spouses.

INTERVENTION

An enhanced interfacility referral communication system consisting of training, provision of communication tools for facilities, formation of hospital referral teams and strengthening feedback mechanisms.

OUTCOME

Completeness of obstetric referral letters/notes.

RESULTS

Proportion of obstetric referrals with referral notes improved from 27.2% to 44.3% from the baseline to intervention period. Mean completeness (95% CI) of all forms was 71.3% (64.1% to 78.5%) for the study period, improving from 70.7% (60.4% to 80.9%) to 71.9% (61.1% to 82.7%) from baseline to intervention periods. Health workers reported they do not always provide referral notes and that most referral notes are not completely filled due to various reasons.

CONCLUSIONS

Most obstetric referrals did not have referral notes. The few notes provided were not completely filled. Interventions such as training of health workers, regular review of referral processes and use of electronic records can help improve both the provision of and completeness of the referral notes.

Antenatal care for alcohol consumption during pregnancy: pregnant women's reported receipt of care and associated characteristics

Background

Antenatal clinical guidelines recommend that during initial and subsequent antenatal visits all pregnant women: have their alcohol consumption assessed; be advised that it is safest not to consume alcohol during pregnancy and of the potential risks of consumption; and be offered referrals for further support if required. However, the extent to which pregnant women attending public antenatal services receive guideline recommended care at these visits, and the characteristics associated with its receipt, is unknown. The purpose of this study was to examine: 1) pregnant women’s reported receipt of guideline recommended care addressing alcohol consumption during pregnancy; 2) characteristics associated with the receipt of care; and 3) pregnant women’s acceptability of care.

Methods

From July 2017 – February 2018 a survey (telephone or online) was undertaken with 1363 pregnant women who had recently visited a public antenatal service in one health district in Australia. Receipt and acceptability of recommended care were assessed via descriptive statistics and associations via logistic regression analyses.

Results

At the initial antenatal visit, less than two thirds (64.3%) of pregnant women reported that they received an assessment of their alcohol consumption and just over one third (34.9%) received advice and referral appropriate to their self-reported level of alcohol consumption since pregnancy recognition. Less than 10% of women received such care at subsequent antenatal visits. Characteristics that significantly increased the odds of receiving all guideline elements at the initial antenatal visit included: less than university attainment (OR = 1.93; 95% CI:1.12, 3.34), not residing in an advantaged area (OR = 2.11; 95% CI:1.17, 3.79), first pregnancy (OR = 1.91; 95% CI:1.22, 2.99) and regional/rural service location (OR = 2.38; 95% CI:1.26, 4.48); and at subsequent visits: younger age (OR = 0.91; 95% CI:0.84, 0.99) and Aboriginal origin (OR = 3.17; 95% CI:1.22, 8.24). Each of the recommended care elements were highly acceptable to pregnant women (88.3–99.4%).

Conclusions

Although care for alcohol consumption is both recommended by clinical guidelines and highly acceptable to pregnant women, its receipt in public antenatal services is suboptimal. There is a need and an opportunity for interventions to support antenatal care providers to routinely and consistently provide such care to all pregnant women.

Adherence to the recommended timing of focused antenatal care in the Accra Metropolitan Area, Ghana

INTRODUCTION

The proportion of antenatal attendants in Ghana who had at least four antenatal visits increased from 78% in 2008 to 87% in 2014. However, it is not known whether these visits followed the recommended timing of focused antenatal clinic attendance in Ghana. We sought to assess the adherence to the clinic schedule and its determinants in the Accra Metropolis.

METHODS

A cross-sectional study was conducted. Face-to-face interviews were conducted with postpartum women. Multiple logistic regression was used in the analysis of determinants of adherence to the recommended timing of clinic attendance. A p-value of <0.05 was considered statistically significant.

RESULTS

Among 446 focused antenatal care clinic attendants, 378 (84.8%) had four or more visits. Among these, 101 (26.7%) adhered to the recommended clinic schedule. Women who adhered were more likely to have had education up to Junior High School [AOR=3.31, 95%CI (1.03-10.61)] or Senior High School [AOR=4.47, 95%CI (1.14-17.51)], or have history of abortion [(AOR=3.36, 95%CI (1.69-7.96)]. For every week increase in gestational age at booking at the antenatal clinic, respondents were 34% less likely to complete all four antenatal visits at the recommended times. [(AOR=0.66, 95% (0.60-0.73)].

CONCLUSION

Majority of women receiving focused antenatal care in the Accra Metropolis have four or more visits but only about a quarter of them adhered to the recommended clinic schedule. Having high school education, history of abortion and early initiation of antenatal care were predictors of adherence to clinic schedule. Women should be educated on early initiation of antenatal care to enhance adherence.

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Does body mass index early in pregnancy influence the risk of maternal anaemia? An observational study in Indonesian and Ghanaian women

Background

Anaemia is common among pregnant women, especially in low- and middle-income countries (LMICs). While body mass index (BMI) relates to many risk factors for anaemia in pregnancy, little is known about the direct relation with anaemia itself. This is particularly relevant in Southeast Asia and Sub-Saharan Africa where the prevalence of anaemia in pregnancy and the associated adverse outcomes is among the highest worldwide. This study aimed to assess the association between early pregnancy BMI and anaemia at first antenatal care visit in Indonesian and Ghanaian women. In addition, the associations between early pregnancy anaemia and adverse birth outcomes was assessed.

Methods

Prospective cohort studies of women in early pregnancy were conducted in Jakarta, Indonesia (n = 433) and in Accra, Ghana (n = 946), between 2012 and 2014. Linear regression analysis was used to assess relations between early pregnancy BMI and pregnancy haemoglobin levels at booking. Logistic regression analyses were used to assess associations between early pregnancy anaemia as defined by the World Health Organization (WHO) criteria and a composite of adverse birth outcomes including stillbirth, low birth weight and preterm birth.

Results

Indonesian women had lower BMI than Ghanaian women (23.0 vs 25.4 kg/m², p < 0.001) and higher mean haemoglobin levels (12.4 vs 11.1 g/dL, p < 0.001), corresponding to anaemia prevalence of 10 and 44%, respectively. Higher early pregnancy BMI was associated with higher haemoglobin levels in Indonesian (0.054 g/dL/kg/m², 95% CI 0.03 to 0.08, p < 0.001) and Ghanaian women (0.044 g/dL/kg/m², 0.02 to 0.07, p < 0.001). Accordingly, risk for anaemia decreased with higher early pregnancy BMI for Indonesians (adjusted OR 0.88, 0.81 to 0.97, p = 0.01) and Ghanaians (adjusted OR 0.95, 0.92 to 0.98, p < 0.001). No association between anaemia and the composite of adverse birth outcomes was observed.

Conclusion

Higher BMI in early pregnancy is associated with higher haemoglobin levels at antenatal booking and with a reduced risk of anaemia in Indonesian and Ghanaian women.

Electronic supplementary material

The online version of this article (10.1186/s12889-018-5704-2) contains supplementary material, which is available to authorized users.

Service providers' adherence to methadone maintenance treatment protocol in China

BACKGROUND

Methadone maintenance treatment (MMT) programs have expanded rapidly in China during the last decade. However, variance in service providers' practice may have an impact on the quality of care received by the patients. This study examined Chinese service providers' adherence to the MMT protocol and its associated factors.

METHODS

The study used baseline data from a randomized intervention trial implemented in MMT clinics in five provinces of China. The data were collected from January 2012 to August 2013. A total of 418 service providers from 68 MMT clinics participated in the study. Demographic and job-related characteristics were collected. The providers' adherence to the MMT protocol, MMT knowledge, negative attitudes towards people who use drugs (PWUD), and perceived institutional support were assessed.

RESULTS

The average adherence score was 36.7 ± 4.3 (out of 9-45). Fewer providers adhered to the protocol items where communications with patients or families were required. After controlling for potential confounders, adherence to the MMT protocol was positively associated with perceived institutional support (standardized β = 0.130; p = 0.0052), and negatively associated with prejudicial attitudes towards PWUD (standardized β = -0.357; p < 0.0001). Reception of national-level MMT training was not associated with higher level of adherence to protocol.

CONCLUSION

The findings suggest the potential benefits of providing institutional support to MMT providers to enhance their level of adherence to the MMT protocol. Intervention effort is needed to reduce negative attitudes towards PWUD among MMT service providers to achieve greater consistency with best-practice recommendations.

Provider adherence to first antenatal care guidelines and risk of pregnancy complications in public sector facilities: a Ghanaian cohort study

BACKGROUND

Guideline utilization aims at improvement in quality of care and better health outcomes. The objective of the current study was to determine the effect of provider complete adherence to the first antenatal care guidelines on the risk of maternal and neonatal complications in a low resource setting.

METHODS

Women delivering in 11 health facilities in the Greater Accra region of Ghana were recruited into a cohort study. Their first antenatal visit records were reviewed to assess providers' adherence to the guidelines, using a thirteen-point checklist. Information on their socio-demographic characteristics and previous pregnancy history was collected. Participants were followed up for 6 weeks post-partum to complete data collection on outcomes. The incidence of maternal and neonatal complications was estimated. The effects of complete adherence on risk of maternal and neonatal complications were estimated and expressed as relative risks (RRs) with their 95% confidence intervals (CI) adjusted for a potential clustering effect of health facilities.

RESULTS

Overall, 926 women were followed up to 6 weeks post-partum. Mean age (SD) of participants was 28.2 (5.4) years. Complete adherence to guidelines pertained to the care of 48.5% of women. Incidence of preterm deliveries, low birth weight, stillbirths and neonatal mortality were 5.3, 6.1, 0.4 and 1.4% respectively. Complete adherence to the guidelines decreased risk of any neonatal complication [0.72 (0.65-0.93); p = 0.01] and delivery complication [0.66 (0.44-0.99), p = 0.04].

CONCLUSION

Complete provider adherence to antenatal care guidelines at first antenatal visit influences delivery and neonatal outcomes. While there is the need to explore and understand explanatory mechanisms for these observations, programs that promote complete adherence to guidelines will improve the pregnancy outcomes.