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

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We conducted a comprehensive systematic three-step approach search of published and unpublished sources from 2002 to 2022.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

A systematic scoping review of medicine availability and affordability in Africa

BACKGROUND

The most recent World Medicines Situation Report published in 2011 found substantial medicine availability and affordability challenges across WHO regions, including Africa. Since publication of the 2011 report, medicine availability and affordability has risen on the international agenda and was included in the Sustainable Development Goals as Target 3.8. While numerous medicine availability and affordability studies have been conducted in Africa since the last World Medicines Situation Report, there has not been a systematic analysis of the methods used in these studies, measures of medicine availability and affordability, categories of medicines studied, or geographic distribution. Filling this knowledge gap can help inform future medicine availability and affordability studies, design systems to monitor progress toward Sustainable Development Goal Target 3.8 in Africa and beyond, and inform policy and program decisions to improve medicine availability and affordability.

METHODS

We conducted a systematic scoping review of studies assessing medicine availability or affordability conducted in the WHO Africa region published from 2009-2021.

RESULTS

Two hundred forty one articles met our eligibility criteria. 88% of the articles (213/241) reported descriptive studies, while 12% (28/241) reported interventional studies. Of the 198 studies measuring medicine availability, the most commonly used measure of medicine availability was whether a medicine was in stock on the date of a survey (124/198, 63%). We also identified multiple other availability methods and measures, including retrospective stock record reviews and self-reported medicine availability surveys. Of the 59 articles that included affordability measures, 32 (54%) compared the price of the medicine to the daily wage of the lowest paid government worker. Other affordability measures were patient self-reported affordability, capacity to pay measures, and comparing medicines prices with a population-level income standard (such as minimum wage, poverty line, or per capita income). The most commonly studied medicines were antiparasitic and anti-bacterial medicines. We did not identify studies in 22 out of 48 (46%) countries in the WHO Africa Region and more than half of the studies identified were conducted in Ethiopia, Kenya, Tanzania, and/or Uganda.

CONCLUSION

Our results revealed a wide range of medicine availability and affordability assessment methodologies and measures, including cross-sectional facility surveys, population surveys, and retrospective data analyses. Our review also indicated a need for greater focus on medicines for certain non-communicable diseases, greater geographic diversity of studies, and the need for more intervention studies to identify approaches to improve access to medicines in the region.

Community-based newborn care intervention fidelity and its implementation drivers in South Wollo Zone, North-east Ethiopia

Community-based newborn care (CBNC) has been implemented in Ethiopia across the maternal, neonatal, and child health continuum of care with the goal of lowering newborn mortality. However, neonatal mortality rate in Ethiopian is among the highest in the world. Why neonatal mortality remains high in the face of such effective interventions is the issue. As a result, the authors claim that it is unknown whether the planned intervention is carried out effectively or not. The purpose of this study was to investigate the fidelity of community-based newborn care intervention and its implementation drivers. Multicenter community-based mixed method study was employed on 898 postpartum women, 16 health extension workers (HEWs) and 10 health posts to evaluate CBNC intervention fidelity. Structured questionnaire and facility audit checklist was used to collect quantitative data. In-depth interview technique was used to explore lived experiences of HEWs on CBNC implementation. CBNC intervention fidelity was computed as a composite index of the product of program coverage, frequency and contents. Multilevel linear regression model with adjusted β-coefficients at P-value of 0.05 and a 95% confidence interval (CI) were used to declare a significant relation between CBNC intervention fidelity and its implementation drivers. Interpretative phenomenological analysis was employed for qualitative data analysis. CBNC intervention fidelity was found to be 4.5% (95% CI: 3.6-5.4) with only two women received the intervention with full fidelity. The overall CBNC intervention coverage was 38.4% (95% CI: 35.2-41.6). Only 8.1% and 1.5% of women received all CBNC interventions with recommended frequency and content, respectively. HEWs knowledge of danger sign was significant facilitator while lack of: health center's feedback, related short-term training, health development army support, health center staff's technical assistance to HEWs and shortage of medical equipment supply were barriers for CBNC intervention fidelity. In conclusion the CBNC intervention fidelity was too low in this study. This indicates that CBNC intervention package was not implemented as envisioned implying an implementation gap. All implementation drivers were poorly implemented to result in improved fidelity and intervention outcomes.

The role of nurse-client relationships in maternal and child healthcare: a qualitative study in rural Tanzania

Background

The literature suggests that poor provider-client relationships in maternal and child healthcare (MCH) continue to impact healthcare service uptake, continuity of care, and MCH outcomes. However, there is a paucity of literature on the benefits of the nurse-client relationship for clients, nurses, and the health system, particularly in rural African contexts.

Objective

This study examined the perceived benefits and disadvantages of good and poor nurse-client relationships in rural Tanzania respectively. We present the findings of a community-driven inquiry that was the first step of a broader study that sought to co-design an intervention package for strengthening nurse-client relationships in MCH in rural contexts using a human-centred design approach.

Methods

This study used a qualitative descriptive design. Nine focus group discussions and 12 key informant interviews were conducted using semi-structured interview guides. Participants were purposefully selected nurses/midwives and clients attending MCH services, and MCH administrators. Data were managed using NVivo and analysed thematically.

Results

A range of perceived benefits of good nurse-client relationships and disadvantages of poor relationships emerged. Perceived benefits of good nurse-client relationships included: (i) benefits to clients (increased healthcare-seeking behaviours, disclosure, adherence, return to care, positive health outcomes, and referral tendencies); (ii) benefits to nurses (increased confidence, efficiency, productivity, job satisfaction, trust, and community reputation and support); and (iii) benefits to healthcare facilities/systems (increased client load and consequently income, fewer complaints and legal disputes, increased trust and facility delivery, and reduced maternal and child deaths). The disadvantages of poor nurse-client relationships were basically the opposite of their benefits.

Conclusion

The benefits of good nurse-client relationships and the disadvantages of poor relationships extend beyond patients and nurses to the healthcare system/facility level. Therefore, identifying and implementing feasible and acceptable interventions for nurses and clients could pave the way for good nurse-client relationships, leading to improved MCH outcomes and performance indicators.

Composite measures of quality of health care: Evidence mapping of methodology and reporting

Background

Quality indicators are used to quantify the quality of care. A large number of quality indicators makes assessment of overall quality difficult, time consuming and impractical. There is consequently an increasing interest for composite measures based on a combination of multiple indicators.

Objective

To examine the use of different approaches to construct composite measures of quality of care and to assess the use of methodological considerations and justifications.

Methods

We conducted a literature search on PubMed and EMBASE databases (latest update 1 December 2020). For each publication, we extracted information on the weighting and aggregation methodology that had been used to construct composite indicator(s).

Results

A total of 2711 publications were identified of which 145 were included after a screening process. Opportunity scoring with equal weights was the most used approach (86/145, 59%) followed by all-or-none scoring (48/145, 33%). Other approaches regarding aggregation or weighting of individual indicators were used in 32 publications (22%). The rationale for selecting a specific type of composite measure was reported in 36 publications (25%), whereas 22 papers (15%) addressed limitations regarding the composite measure.

Conclusion

Opportunity scoring and all-or-none scoring are the most frequently used approaches when constructing composite measures of quality of care. The attention towards the rationale and limitations of the composite measures appears low.

Discussion

Considering the widespread use and the potential implications for decision-making of composite measures, a high level of transparency regarding the construction process of the composite and the functionality of the measures is crucial.

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.

Implementing standard antenatal care interventions: health system cost at primary health facilities in Tanzania

Background

Since 2002, Tanzania has been implementing the focused Antenatal Care (ANC) model that recommended four antenatal care visits. In 2016, the World Health Organization (WHO) reintroduced the standard ANC model with more interventions including a minimum of eight contacts. However, cost-implications of these changes to the health system are unknown, particularly in countries like Tanzania, that failed to optimally implement the simpler focused ANC model. We compared the health system cost of providing ANC under the focused and the standard models at primary health facilities in Tanzania.

Methods

We used a micro-costing approach to identify and quantify resources used to implement the focused ANC model at six primary health facilities in Tanzania from July 2018 to June 2019. We also used the standard ANC implementation manual to identify and quantify additional resources required. We used basic salary and allowances to value personnel time while the Medical Store Department price catalogue and local market prices were used for other resources. Costs were collected in Tanzanian shillings and converted to 2018 US$.

Results

The health system cost of providing ANC services at six facilities (2 health centres and 4 dispensaries) was US$185,282 under the focused model. We estimated that the cost would increase by about 90% at health centres and 97% at dispensaries to US$358,290 by introducing the standard model. Personnel cost accounted for more than one third of the total cost, and more than two additional nurses are required per facility for the standard model. The costs per pregnancy increased from about US$33 to US$63 at health centres and from about US$37 to US$72 at dispensaries.

Conclusion

Introduction of a standard ANC model at primary health facilities in Tanzania may double resources requirement compared to current practice. Resources availability has been one of the challenges to effective implementation of the current focused ANC model. More research is required, to consider whether the additional costs are reasonable compared to the additional value for maternal and child health.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12962-021-00325-0.

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.

Twelve-year persistence of inequalities in antenatal care utilisation among women in Tanzania: a decomposition analysis of population-based cross-sectional surveys

OBJECTIVE

This study was undertaken to assess the trend and contributors of socioeconomic inequalities in antenatal care (ANC) utilisation among women of reproductive age in Tanzania from 2004 to 2016.

DESIGN

Population-based cross-sectional surveys.

SETTING

This study analysed nationally representative data for women of reproductive age obtained from the 2004-2016 Tanzania Demographic Health Surveys.

PRIMARY OUTCOME MEASURE

The outcome variables analysed in this study are: (1) attendance of ANC and (2) accessing adequate antenatal care.

ANALYTICAL METHODS

The concentration curve and the concentration index were used to measure socioeconomic inequality in attending and accessing adequate ANC. The concentration index was decomposed to identify the factors explaining the observed socioeconomic inequality of these two outcomes.

RESULTS

The concentration index for attending at least four ANC visits increased from 0.169 in 2004 to 0.243 in 2016 (p<0.01). Similarly, for accessing adequate care, the index increased from 0.147 in 2004 to 0.355 in 2016 (p<0.01). This indicates the significant increase in socioeconomic inequalities (favouring wealthier women) for these two outcomes over time. Furthermore, the results show that wealth status was the largest contributor to inequality in both attending at least four visits (71%, 50% and 70%) and accessing adequate ANC (50%, 42% and 51%) in 2004, 2010 and 2016, respectively, in favour of wealthier women (p<0.05). The other contributors to socioeconomic inequalities in ANC utilisation were maternal education and type of residence.

CONCLUSION

Over the 12 years of surveys, there was no reduction in socioeconomic inequalities in ANC utilisation in Tanzania. Therefore, the efforts of achieving universal health coverage should focus on reducing wealth-related inequality and improving women's education from poor households.

High dropout rate from maternity continuum of care after antenatal care booking and its associated factors among reproductive age women in Ethiopia, Evidence from Demographic and Health Survey 2016

Background

Maternal continuums of care were vital to reducing maternal and neonatal mortalities. While the dropout rate remains high and limited studies were found on risk factors associated with a high dropout rate of the maternal continuum of care.

Objective

This study aimed to assess the magnitude of dropout rate and its associated factors of maternity continuum of care in Ethiopia, 2016

Methods

An in-depth secondary data analysis was conducted from the Ethiopian Demographic and Health Survey 2016 data. A total of 4,693 women who were booked for antenatal care visit were included to the final analysis. A community-based cross-sectional study design and a pre-tested and standardized questionnaire were used to collect the survey data. Data were weighted using women data weighting variables. Chi-square and multicollinearity assumptions were checked for independent variables. Bi-variable and multivariable logistics regression used to identify associated factors with a cut of the p-value of 0.2 and 0.05 respectively. Adjusted Odds Ratio (AOR) with 95%CI was reported for the final model.

Results

Of the total 4,693 women who were booked for antenatal care visits, 2,092(44.58%), 2,183 (46.52%), and 4,086(87.07%) dropped from a recommended number of ANC, Institutional delivery and postnatal care visit respectively. Only 308 (6.56%, 95%CI: 5.89, 7.31) women used all the complete continuum of care. Not married, and poorest wealth index were significantly associated with dropout from ANC visit. Being a protestant religious follower was significantly associated with dropout from PNC after antenatal care booking. While not exposed to media, distance from health facility as a big problem, protestant affiliation, parity of 2 to 4 and above4, Wealth index of the poorest, poorer, middle, and richer significantly associated with dropout from institutional delivery. Not being informed about pregnancy complications during their ANC visit was significantly associated with dropout from ANC, PNC, and institutional delivery.

Conclusions

Dropout of women from the maternity continuum of care after antenatal care booking was a public health problem in Ethiopia. Socio-demographic, pregnancy, and health service-related factors were significant determinants of dropout from the maternity continuum of care. Improving the family wealth index, increasing access to health facilities, media exposure, and giving more information during the antenatal care visit is important to reduce the dropout rate from the maternity continuum of care.