Antenatal Care Program Research Articles

Survey of the Relationship Between Mother’s Chronic Diseases and Low Birth Weight in Infants, Ahvaz, South of Iran, 2014

Background: Birth weight is the most important indicator of infant’s health, and this critical index is directly related to mother’s health. Hence, knowledge of the maternal chronic disease before and during the pregnancy can be considered as an effective factor in maintaining the infant’s ideal weight. Babies with low birth weight are more susceptible to risks such as disabilities of neurological, respiratory diseases and sudden infant death syndrome. Therefore, identifying and modifying the risk factors can control and prevent low birth weight. Objectives: This study was performed to determine the association between mothers’ chronic diseases and low birth weight in infants. Methods: In this descriptive study, 1500 infants from 12 health centers in east and west areas of Ahvaz were selected using the random cluster sampling method. The developed researcher checklist was used for data gathering. The data was analyzed with SPSS version 20, using descriptive indexes and Chi-square, t-test and ANOVA while P ≤ 0.05 was considered as significant. Results: The prevalence of LBW in Ahvaz from the beginning to the end of the year 2015 has been 9.5%. There is a significant relationship between the cardiovascular disease before pregnancy (P ≤ 0.003), anemia before pregnancy (P ≤ 0.001), hypertensive pregnancy (P ≤ 0.001), urinary tract infection during pregnancy (P ≤ 0.001), gestational diabetic in the mother (P ≤ 0.003) and LBW. Conclusions: Our study showed that many mothers' schronic disease such as cardiovascular disease, anemia, hypertensive, gestational diabetic and UTI have relationship with LBW. Therefore it seems essential to design and implement a detailed antenatal care program for mothers with chronic disease to reduce LBW, infant mortality and defects.

Trends of preeclampsia/eclampsia and maternal and neonatal outcomes among women delivering in addis ababa selected government hospitals, Ethiopia: a retrospective cross-sectional study.

IntroductionThe burden of preeclampsia has been a major concern worldwide, particularly in developing countries such as Ethiopia. Preeclampsia is associated with substantial maternal complications, both acute and long-term. The aim of this research was to determine the magnitude and trends of preeclampsia/ eclampsia, maternal complications, and neonatal complications among women delivering babies at selected government hospitals in Ethiopia.MethodsData were collected retrospectively by reviewing the five-year medical records for 2009 to 2013, using data abstraction tools, to identify mothers with preeclampsia/eclampsia. A total of 1,809 cases were reviewed for general characteristics of the mother, delivery details, and any complications. Descriptive analyses were employed. In addition, extended Mantel Haenszel chi square for linear trend was used to check for significance of the trends.ResultsThe five year average proportion of preeclampsia/eclampsia was 4.2% (95%CI 4.02%, 4.4%). The proportion of women with preeclampsia was 2.2% in 2009 and increased to 5.58% in 2013 (p<0.001), which was a 154% increase. Of the 1,809 mothers with preeclampsia/eclampsia, 36% (95%CI 33.85%, 38.28%) experienced at least one maternal complication; there was an increase of 26.5% (p<0.01) over the five year period. The main complications were HELLP (variant of preeclampsia with hemolysis, elevated liver enzymes, and low platelet count) syndrome, 257 (39.5%); aspiration pneumonia, 114 (17.5%); pulmonary edema, 114 (17.5%); and abruption placentae, 100 (15.3%). At least one neonatal complication occurred in 66.4% (95%CI 64.24%, 68.59%) of deliveries during the five-year study. A decreasing trend in neonatal complications was observed from 2009 (76%) to 2013 (66%), which showed a percentage change over time of negative 13.2%. The most common neonatal complications were stillbirths, which accounted for 363 (30.2%); prematurity, with 395 (32.8%); respiratory distress syndrome, with 456 (37.9%); and low birth weight, with 363 (30.2%).ConclusionThere was an increasing trend of preeclampsia/eclampsia and maternal complications over a five year period in selected maternity governmental hospitals. In contrast, neonatal complications experienced a significant decrease over the five-year period. It is essential to raise awareness among mothers in the community regarding early signs and symptoms of preeclampsia/eclampsia and to design a better tracking system for antenatal care programs.

Assessing the Evidence for Maternal Pertussis Immunization: A Report From the Bill & Melinda Gates Foundation Symposium on Pertussis Infant Disease Burden in Low- and Lower-Middle-Income Countries.

Implementation of effective interventions has halved maternal and child mortality over the past 2 decades, but less progress has been made in reducing neonatal mortality. Almost 45% of under-5 global mortality now occurs in infants <1 month of age, with approximately 86% of neonatal deaths occurring in low- and lower-middle-income countries (LMICs). As an estimated 23% of neonatal deaths globally are due to infectious causes, maternal immunization (MI) is one intervention that may reduce mortality in the first few months of life, when direct protection often relies on passively transmitted maternal antibodies. Despite all countries including pertussis-containing vaccines in their routine childhood immunization schedules, supported through the Expanded Programme on Immunization, pertussis continues to circulate globally. Although based on limited robust epidemiologic data, current estimates derived from modeling implicate pertussis in 1% of under-5 mortality, with infants too young to be vaccinated at highest risk of death. Pertussis MI programs have proven effective in reducing infant pertussis mortality in high-income countries using tetanus-diphtheria-acellular pertussis (Tdap) vaccines in their maternal and infant programs; however, these vaccines are cost-prohibitive for routine use in LMICs. The reach of antenatal care programs to deliver maternal pertussis vaccines, particularly with respect to infants at greatest risk of pertussis, needs to be further evaluated. Recognizing that decisions on the potential impact of pertussis MI in LMICs need, as a first step, robust contemporary mortality data for early infant pertussis, a symposium of global key experts was held. The symposium reviewed current evidence and identified knowledge gaps with respect to the infant pertussis disease burden in LMICs, and discussed proposed strategies to assess the potential impact of pertussis MI.

Maternal vitamin D supplementation during pregnancy and lactation to prevent acute respiratory infections in infancy in Dhaka, Bangladesh (MDARI trial): protocol for a prospective cohort study nested within a randomized controlled trial.

BackgroundEarly infancy is a high-risk period for severe acute respiratory infection (ARI), particularly in low-income countries with resource-limited health systems. Lower respiratory tract infection (LRTI) is commonly preceded by upper respiratory infection (URTI), and often caused by respiratory syncytial virus (RSV), influenza and other common community-acquired viral pathogens. Vitamin D status is a candidate modifiable early-life determinant of the host antiviral immune response and thus may influence the risk of ARI-associated morbidity in high-risk populations.Methods/DesignIn the Maternal Vitamin D for Infant Growth (MDIG) study in Dhaka, Bangladesh (NCT01924013), 1300 pregnant women are randomized to one of five groups: placebo, 4200 IU/week, 16,800 IU/week, or 28,000 IU/week from 2nd trimester to delivery plus placebo from 0–6 months postpartum; or, 28,000 IU/week prenatal and until 6-months postpartum. In the Maternal Vitamin D for ARI in Infancy (MDARI) sub-study nested within the MDIG trial, trained personnel conduct weekly postnatal home visits to inquire about ARI symptoms and conduct a standardized clinical assessment. Supplementary home visits between surveillance visits are conducted when caregivers make phone notifications of new infant symptoms. Mid-turbinate nasal swab samples are obtained from infants who meet standardized clinical ARI criteria. Specimens are tested by polymerase chain reaction (PCR) for 8 viruses (influenza A/B, parainfluenza 1/2/3, RSV, adenovirus, and human metapneumovirus), and nasal carriage density of Streptococcus pneumoniae. The primary outcome is the incidence rate of microbiologically-positive viral ARI, using incidence rate ratios to estimate between-group differences. We hypothesize that among infants 0–6 months of age, the incidence of microbiologically-confirmed viral ARI will be significantly lower in infants whose mothers received high-dose prenatal/postpartum vitamin D supplements versus placebo. Secondary outcomes include incidence of ARI associated with specific pathogens (influenza A or B, RSV), clinical ARI, and density of pneumococcal carriage.DiscussionIf shown to reduce the risk of viral ARI in infancy, integration of maternal prenatal/postpartum vitamin D supplementation into antenatal care programs in South Asia may be a feasible primary preventive strategy to reduce the burden of ARI-associated morbidity and mortality in young infants.Trial registration NCT02388516, registered March 9, 2015.

Barriers to uptake of antenatal maternal screening tests in Senegal

BackgroundEvidence exists that selective antenatal maternal screening tests contribute to the reduction of maternal morbidity and mortality. However, data are lacking on coverage with the complete set of recommended tests. The study aimed to identify barriers to uptake of the complete set of tests recommended by the Ministry of Health in Senegal. MethodsData were collected in communities, antenatal care (ANC) clinics and the laboratories of 11 public health care facilities across Senegal. Mixed-methods included ethnography (observations and informal conversations), in-depth interviews and workshops at the health facilities; structured interviews with 283 women receiving antenatal tests (“women in the lab”); in-depth interviews with 81 women in communities who were pregnant or had recently delivered (“community women”). ResultsOnly 13% of community women and 22% of women in the lab had received the complete set of tests. For various social, financial and antenatal care-related reasons 38% of community women who visited antenatal care facilities did not access a laboratory. The lowest test uptake was in women receiving antenatal care at health posts. Barriers at the laboratory level were the cost of the test, stock-outs of reagents, and broken equipment. Midwives were the main gatekeepers of the laboratory, not requesting (all) tests because of assumptions about women's financial problems and reliance on clinical symptoms. ConclusionIn Senegal, recommended antenatal maternal screening tests are substantially underutilized. Efforts to increase test uptake should include accessible testing guidelines, reducing the cost of tests, raising awareness about the reasons for tests, and making the complete test set in point-of-care format accessible in peripheral health posts. National and international antenatal care policies and programs should facilitate access to maternal screening tests as a contribution to reducing maternal and infant morbidity and mortality.

88 Development of a next-generation point-of-care biomarker-based diagnostic for detection of preeclampsia

Author Rebecca Barney, Arthur Lee, Brandon T. Leader. PATH, 2201 Westlake Avenue, Seattle, Washington. Introduction Accurate and timely diagnosis of women at high risk for preeclampsia (PE) is key to accessing proper interventions and improving clinical outcomes. New biomarkers for PE have shown potential for earlier and more accurate identification of women at increased risk. While a few biomarkers exist in commercially available diagnostics, these products are often expensive and too complex for use outside of a hospital setting. PATH has developed a point-of-care, field-friendly diagnostic for use in low-resource settings, specifically in regional and local antenatal care programs. Objectives PATH conducted research and development (RD54(1):17-27

Operational challenges to continuous LLIN distribution: a qualitative rapid assessment in four countries.

BackgroundThe World Health Organization recommends that long-lasting insecticidal nets (LLINs) for malaria prevention should be distributed continuously through antenatal care (ANC) and the expanded programme on immunization (EPI) in addition to mass campaigns. Despite these recommendations, the continuous distribution (CD) of LLIN distribution through ANC and EPI is not policy in many countries, and where there is a policy, implementation is incomplete. This study aims to identify the operational strengths and weaknesses of LLINs CD in four country programmes in sub-Saharan Africa.MethodsA qualitative rapid assessment process was conducted using semi-structured individual and group interviews at the national, sub-national, and facility level in four countries. Seventy participants were included (23 in Kenya, 13 in Malawi, 18 in Mali and 16 in Rwanda), drawn from malaria programmes, ANC and EPI programmes, government logistics units, and partner organizations. Interviews were structured to identify themes within a health systems approach. Policy and guideline documents and data collection tools were reviewed as a means of triangulation. Data analysis focused on pre-determined and emergent themes.ResultsThe four countries used a wide variety of management systems for the supply of LLINs to routine services. Issues related to quantification, supply logistics and data collection all contributed to stock-outs at facility level. None of the four countries had guidelines for responding to stock-outs or system enabling local staff to request additional supplies of LLINs. In all four countries, data collection of LLIN distribution was incomplete or absent at facility level, and such data were not used for planning. Training of staff at the facility level was implemented less frequently than national and sub-national staff would have preferred. Logistics systems, independent of other commodities, and in-country partner support strengthened the continuous distribution of LLINs.ConclusionsIn these countries, stock-outs were the most important single obstacle to the smooth operations of continuous LLIN distribution. Stock-outs can be avoided if facilities have the capacity to place orders for LLIN resupply as needed. Revised data collection and management systems for LLIN distribution have the potential to increase coverage of the target populations by improving LLIN stock-out response, and strengthening monitoring and evaluation of distribution.Electronic supplementary materialThe online version of this article (doi:10.1186/s12936-016-1184-y) contains supplementary material, which is available to authorized users.

Assessment of Timing of First Antenatal Care Booking and Associated Factors among Pregnant Women who attend Antenatal Care at Health Facilities in Dilla town, Gedeo Zone, Southern Nations, Nationalities, and Peoples Region, Ethiopia, 2014

Introduction: Yet in developing regions overall, only half of all pregnant women receive the minimum recommended number of antenatal visits four and lately timing of ANC booking. Objective: The main objective of this study was assessing timing of first ANC booking and associated factors among pregnant women in Dilla town, SNNPR, 2014. Methods: Facility based Cross-Sectional study design was conducted to assess the timing of first ANC booking and associated factors. Study subjects were selected using systematic random sampling. Data were entered onto a computer using Epi-info 3.5.1 statistical program then exported to SPSS version 20 for analysis. Logistic regression model was used to predict timing of first ANC booking and associated factors. Significance of association was declared if p value is < 0.05 and also OR was calculated to determine strength of association. Result: The study finding revealed that 35.4% respondents were booked first Antenatal care timely. The mean gestational age of timing of first ANC booking was 4 + 1.4 months. Binary logistic regression analysis revealed that respondents age(OR=0.2, 95% CI, 0.03-0.5, P=0.005), Education (OR=0.4, 95% CI, 0.2-0.9, P=0.04), Parity(OR=1.8, 95% CI, 1.1-3, P=0.01), knowledge on importance timely booking (OR=2, 95% CI, 1.3-3.3, P=0.003), those informed before to book ANC(OR=3, 95%CI, 1.1-9, P=0.03) and past ANC experience (OR=1.7, 95%CI, 1.1-2.8, P=0.022) were found as significant factors that influence timing of first Antenatal care booking. Conclusion and Recommendation: The findings of this study showed that 35.4% were booked timely. Thus, women’s educational status, knowledge of women on importance of timely booking, quality of ANC have to be considered when antenatal care programs are planned, implemented and evaluated to ensure timely booking of first ANC.

Sociodemographic correlates of smoking in pregnancy and antenatal-care attendance in Indigenous and non-Indigenous women in South Australia.

Smoking in pregnancy is a key health issue in Australia, particularly among Indigenous women. However, few studies have examined the sociodemographic factors associated with smoking in pregnancy or the predictors of antenatal-care attendance among Indigenous and non-Indigenous Australian women who smoke. Data from the South Australian perinatal statistics collection of all births from 2000-2010 (n=197538) were analysed separately by Indigenous status to determine the sociodemographic factors associated with smoking in pregnancy and antenatal-care attendance by women who smoke. For Indigenous and non-Indigenous women, smoking in pregnancy was significantly independently associated with socioeconomic disadvantage, residing in regional or remote areas, increased parity, unemployment, being a public patient and attending fewer antenatal care visits. Smoking in pregnancy was associated with younger age and not being partnered only for non-Indigenous women. For Indigenous and non-Indigenous pregnant women who smoked, antenatal-care attendance was lower among women who were of younger age, higher parity, unemployed and not partnered. Differences in attendance within sociodemographic factors were greater for Indigenous women. Therefore, while sociodemographic correlates of smoking in pregnancy and antenatal-care attendance are largely similar for Indigenous and non-Indigenous women, tailored cessation and antenatal-care programs that reflect the differences in sociodemographic groups most at risk may be beneficial.

Multiple-micronutrient supplementation for women during pregnancy.

The aim of this bi-monthly column is to highlight Cochrane Systematic Reviews of relevance to pregnancy and childbirth and to stimulate discussion on the relevance and implications of the review for practice. The Cochrane Collaboration is an international organisation that prepares and maintains high quality systematic reviews to help people make well-informed decisions about healthcare and health policy. A systematic review tries to search for, appraise and bring together existing research to answer a specific research question. The Cochrane Database of Systematic Reviews (CDSR) is published monthly online. Residents in countries with a national licence to The Cochrane Library, including the UK and Ireland, can access the Cochrane Library online, free of charge, through www.thecochranelibrary.com.

S08.4 What is ‘sustainable’: the costs and cost-savings of strategies to expand services

<h3>Background</h3> Congenital syphilis imposes a significant global health and economic burden. Serious adverse events, including infant mortality and infection, occur in more than half of cases. The annual global medical cost burden exceeds $300 million. Syphilis screening and treatment, though simple, effective, and affordable, fails to reach most pregnant women. In this presentation we examine the financial sustainability of scaling-up syphilis screening and treatment in existing antenatal care (ANC) programs in diverse programmatic, epidemiologic, and economic contexts. <h3>Methods</h3> We modeled the program cost, health impact, and net cost of expanded syphilis screening and treatment in ANC, for 1,000,000 pregnancies per year over four years. We described 8 generic country scenarios by varying three factors: current maternal syphilis testing and treatment coverage, syphilis prevalence in pregnant women, and the cost of healthcare. <h3>Findings</h3> Program costs are estimated at $4,142,287 – $8,235,796 per million pregnant women. Net costs, adjusted for averted medical care and current services, range from net savings of $12,261,250 to net costs of $1,736,807. The program yields net savings in four scenarios, and has low net costs in the other four. <h3>Conclusions</h3> Eliminating vertical transmission of syphilis through expanded screening and treatment in ANC appears highly sustainably in economic terms for varied settings. Countries with high prevalence, low current service coverage, and high healthcare cost would be most likely to realize net savings. This analysis approach can be adapted to other conditions.

Alternative versus standard packages of antenatal care for low-risk pregnancy.

The number of visits for antenatal (prenatal) care developed without evidence of how many visits are necessary. The content of each visit also needs evaluation. To compare the effects of antenatal care programmes with reduced visits for low-risk women with standard care. We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (23 March 2015), reference lists of articles and contacted researchers in the field. Randomised trials comparing a reduced number of antenatal visits, with or without goal-oriented care, versus standard care. Two review authors independently assessed trials for inclusion and risk of bias, extracted data and checked for accuracy. We assessed studies for risk of bias and graded the quality of the evidence. We included seven trials (more than 60,000 women): four in high-income countries with individual randomisation; three in low- and middle-income countries with cluster randomisation (clinics as the unit of randomisation). Most of the data included in the review came from the three large, well-designed cluster-randomised trials that took place in Argentina, Cuba, Saudi Arabia, Thailand and Zimbabwe. All results have been adjusted for the cluster design effect. All of the trials were at some risk of bias as blinding of women and staff was not feasible with this type of intervention. For primary outcomes, evidence was graded as being of moderate or low quality, with downgrading decisions due to risks of bias and imprecision of effects.The number of visits for standard care varied, with fewer visits in low- and middle- income country trials. In studies in high-income countries, women in the reduced visits groups, on average, attended between 8.2 and 12 times. In low- and middle- income country trials, many women in the reduced visits group attended on fewer than five occasions, although in these trials the content as well as the number of visits was changed, so as to be more 'goal-oriented'.Perinatal mortality was increased for those randomised to reduced visits rather than standard care, and this difference was borderline for statistical significance (risk ratio (RR) 1.14; 95% confidence interval (CI) 1.00 to 1.31; five trials, 56,431 babies; moderate-quality evidence). In the subgroup analysis, for high-income countries the number of deaths was small (32/5108), and there was no clear difference between the groups (RR 0.90; 95% CI 0.45 to 1.80, two trials); for low- and middle-income countries perinatal mortality was significantly higher in the reduced visits group (RR 1.15; 95% CI 1.01 to 1.32, three trials).There was no clear difference between groups for our other primary outcomes: maternal death (RR 1.13, 95%CI 0.50 to 2.57, three cluster-randomised trials, 51,504 women, low-quality evidence); hypertensive disorders of pregnancy (various definitions including pre-eclampsia) (RR 0.95, 95% CI 0.80 to 1.12, six studies, 54,108 women, low-quality evidence); preterm birth (RR 1.02, 95% CI 0.94 to 1.11; seven studies, 53,661 women, moderate-quality evidence); and small-for-gestational age (RR 0.99, 95% CI 0.91 to 1.09, four studies 43,045 babies, moderate-quality evidence).Reduced visits were associated with a reduction in admission to neonatal intensive care that was borderline for significance (RR 0.89; 95% CI 0.79 to 1.02, five studies, 43,048 babies, moderate quality evidence). There were no clear differences between the groups for the other secondary clinical outcomes.Women in all settings were less satisfied with the reduced visits schedule and perceived the gap between visits as too long. Reduced visits may be associated with lower costs. In settings with limited resources where the number of visits is already low, reduced visits programmes of antenatal care are associated with an increase in perinatal mortality compared to standard care, although admission to neonatal intensive care may be reduced. Women prefer the standard visits schedule. Where the standard number of visits is low, visits should not be reduced without close monitoring of fetal and neonatal outcome.

Iron+folic acid distribution and consumption through antenatal care: identifying barriers across countries.

The prevalence of maternal anaemia remains unacceptably high in developing countries. At the same time, the percentage of women who consume one or more Fe+folic acid (IFA) tablets during pregnancy remains persistently low. The objective of the present study was to identify where, within antenatal care (ANC) programmes, pregnant women falter in obtaining and consuming an ideal minimum of 180 IFA tablets. Data from Demographic and Health Surveys were used to develop a schematic which identifies four sequential 'falter points' to consuming 180 IFA tablets: ANC attendance, IFA receipt or purchase, IFA consumption and the number of tablets consumed. Twenty-two countries with high burdens of undernutrition. A sample of 162 958 women, 15 to 49 years of age, with a live birth in the past 5 years. Across all countries, 83 % of all pregnant women had at least one ANC visit, 81 % of whom received IFA tablets. Of those receiving IFA tablets, 95 % consumed at least one. Overall adherence to the ideal supplementation regimen, however, was extremely low: only 8 % consumed 180 or more IFA tablets. There were only two countries in which the percentage of pregnant women consuming 180 or more tablets exceeded 30 %. While most women receive and take some IFA tablets, few receive or take enough. The analysis identifies where ANC-based distribution of IFA falters in each country. It enables policy makers to design and prioritize follow-up activities to more precisely identify barriers, an essential next step to improving IFA distribution through ANC.

Bottlenecks in the implementation of essential screening tests in antenatal care: Syphilis, HIV, and anemia testing in rural Tanzania and Uganda

ObjectiveTo identify and compare implementation bottlenecks for effective coverage of screening for syphilis, HIV, and anemia in antenatal care in rural Tanzania and Uganda; and explore the underlying determinants and perceived solutions to overcome these bottlenecks. MethodsIn this multiple case study, we analyzed data collected as part of the Expanded Quality Management Using Information Power (EQUIP) project between November 2011 and April 2014. Indicators from household interviews (n=4415 mothers) and health facility surveys (n=122) were linked to estimate coverage in stages of implementation between which bottlenecks can be identified. Key informant interviews (n=15) were conducted to explore underlying determinants and analyzed using a framework approach. ResultsLarge differences in implementation were found within and between countries. Availability and effective coverage was significantly lower for all tests in Uganda compared with Tanzania. Syphilis screening had the lowest availability and effective coverage in both countries. The main implementation bottleneck was poor availability of tests and equipment. Key informant interviews validated these findings and perceived solutions included the need for improved procurement at the central level. ConclusionOur findings reinforce essential screening as a missed opportunity, caused by a lack of integration of funding and support for comprehensive antenatal care programs.

A qualitative study on barriers in the prevention of anaemia during pregnancy in public health centres: perceptions of Indonesian nurse-midwives.

BackgroundAnemia in pregnancy remains a major problem in Indonesia over the past decade. Early detection of anaemia in pregnancy is one of the components which is unsuccessfully implemented by nurse-midwives. This study aims to explore nurse-midwives’ experiences in managing pregnant women with anaemia in Public Health Centres.MethodsWe conducted a qualitative study with semi-structured face to face interviews from November 2011 to February 2012 with 23 nurse-midwives in five districts in Yogyakarta Special Province. Data analysis was thematic, using the constant comparison method, making comparison between participants and supported by ATLAS.ti software.ResultsTwelve nurse-midwives included in the interviews had less than or equal to 10 years’ working experience (junior nurse-midwives) and 11 nurse-midwives had more than 10 years’ working experience (senior nurse-midwives) in Public Health Centres. The senior nurse-midwives mostly worked as coordinators in Public Health Centres. Three main themes emerged: 1) the lack of competence and clinical skill; 2) cultural beliefs and low participation of family in antenatal care programme; 3) insufficient facilities and skilled support staff in Public Health Centres. The nurse-midwives realized that they need to improve their communication and clinical skills to manage pregnant women with anaemia. The husband and family involvement in antenatal care was constrained by the strength of cultural beliefs and lack of health information. Moreover, unfavourable work environment of the Public Health Centres made it difficult to apply antenatal care the pregnant womens’ need.ConclusionsThe availability of facilities and skilled staffs in Public Health Centre as well as pregnant women’s husbands or family members contribute to the success of managing anaemia in pregnancy. Nurse-midwives and pregnant women need to be empowered to achieve the optimum result of anaemia management. We recommend a more comprehensive approach in managing pregnant women with anaemia, which synergizes the available resources and empowers nurse-midwives and pregnant women.

Coverage and efficacy of intermittent preventive treatment with sulphadoxine pyrimethamine against malaria in pregnancy in Côte d'Ivoire five years after its implementation.

BackgroundThe World Health Organization (WHO) recommends for sub-Saharan Africa a package of prompt and effective case-management combined with the delivery of insecticide-treated nets (ITN) and intermittent preventive treatment during pregnancy (IPTp) with sulphadoxine-pyrimethamine (SP) through the national antenatal care (ANC) programs. Implemented in Côte d’Ivoire around 2005, few Data on IPTp coverage and efficacy in the country are available.MethodsA multicentre, cross-sectional survey was conducted in Côte d’Ivoire from September 2009 to May 2010 at six urban and rural antenatal clinics. IPTp-sp coverage, Socio-economic and obstetrical data of mothers and neonate birth weights were documented. Peripheral blood as well as placental and cord blood were used to prepare thick and thin blood films. In addition, pieces of placental tissues were used to prepare impression smears and maternal haemoglobin concentration was measured. Regression logistics were used to study factors associated with placental malaria and LBW (<2.500 grams).ResultsA total of 1317 delivered women were enrolled with a median age of 26 years. A proportion of 43.28% of the women had received at least two doses of IPTsp during the current pregnancy although a high proportion (90.4%) of women received antenatal care and made enough visits (≥2). Variability in the results was observed depending on the type of area (rural/urban). Plasmodium falciparum was detected in the peripheral blood of 97 women (7.3%) and in the placenta of 119 women (9%). LBW infants were born to 18.8% (22/107) of women with placental malaria and 8.5% (103/1097) of women without placental malaria. LBW was associated with placental malaria.ConclusionsThis study found relative low coverage of IPTp in the study areas which supported findings that high ANC attendance does not guarantee high IPTp coverage. Urgent efforts are required to improve service delivery of this important intervention.

Policy implications for multipurpose prevention technologies service delivery.

Policy implications for multipurpose prevention technologies service delivery.

A cross-sectional analytical study of geophagia practices and blood metal concentrations in pregnant women in Johannesburg, South Africa.

Geophagia, a form of pica, has been shown to be widely practised in sub-Saharan Africa, especially among pregnant women. To assess the prevalence of geophagia and examine exposure to selected metals and associated risk factors in women attending an antenatal clinic at Rahima Moosa Mother and Child Hospital, Johannesburg, South Africa, during June and July 2010. We conducted a cross-sectional study on a convenience sample of 307 pregnant women, ranging in age from 18 to 46 years. Structured interviews were conducted to understand geophagia practices. Blood samples were collected to determine haemoglobin values and concentrations of arsenic, cadmium, mercury and lead. Statistical analyses using the χ2 test, Wilcoxon's rank-sum test and logistic regression analyses were performed as appropriate. Mean parity was 1.4 and the mean (standard deviation) gestational age 30.3 (6.0) weeks. Geophagia was reported by 60 women (19.5%), and the majority purchased soil from street vendors (83.3%). The prevalence of anaemia in the study sample was 16.9% (95% confidence interval 13.1 - 21.6%). Geophagic women had significantly higher blood lead levels than non-geophagic women (2.1 v. 1.4 µg/dl; p<0.001). Anaemia, the use of African traditional medicines and craving of non-nutritive substances in a previous pregnancy were associated with geophagia. Geophagia is practised by a considerable proportion of pregnant women in Johannesburg, especially migrant women. Greater vigilance in respect of pica, especially geophagia, may be needed as part of antenatal care programmes to avoid potentially detrimental health effects of the practice.

The Cost and Cost-Effectiveness of Scaling up Screening and Treatment of Syphilis in Pregnancy: A Model

BackgroundSyphilis in pregnancy imposes a significant global health and economic burden. More than half of cases result in serious adverse events, including infant mortality and infection. The annual global burden from mother-to-child transmission (MTCT) of syphilis is estimated at 3.6 million disability-adjusted life years (DALYs) and $309 million in medical costs. Syphilis screening and treatment is simple, effective, and affordable, yet, worldwide, most pregnant women do not receive these services. We assessed cost-effectiveness of scaling-up syphilis screening and treatment in existing antenatal care (ANC) programs in various programmatic, epidemiologic, and economic contexts.Methods and FindingsWe modeled the cost, health impact, and cost-effectiveness of expanded syphilis screening and treatment in ANC, compared to current services, for 1,000,000 pregnancies per year over four years. We defined eight generic country scenarios by systematically varying three factors: current maternal syphilis testing and treatment coverage, syphilis prevalence in pregnant women, and the cost of healthcare. We calculated program and net costs, DALYs averted, and net costs per DALY averted over four years in each scenario. Program costs are estimated at $4,142,287 – $8,235,796 per million pregnant women (2010 USD). Net costs, adjusted for averted medical care and current services, range from net savings of $12,261,250 to net costs of $1,736,807. The program averts an estimated 5,754 – 93,484 DALYs, yielding net savings in four scenarios, and a cost per DALY averted of $24 – $111 in the four scenarios with net costs. Results were robust in sensitivity analyses.ConclusionsEliminating MTCT of syphilis through expanded screening and treatment in ANC is likely to be highly cost-effective by WHO-defined thresholds in a wide range of settings. Countries with high prevalence, low current service coverage, and high healthcare cost would benefit most. Future analyses can be tailored to countries using local epidemiologic and programmatic data.

Factors associated with small size at birth in Nepal: further analysis of Nepal Demographic and Health Survey 2011

BackgroundThe global Low Birth Weight (LBW) rate is reported to be 15.5% with more than 95% of these LBW infants being from developing countries. LBW is a major factor associated with neonatal deaths in developing countries. The determinants of low birth weight in Nepal have rarely been studied. This study aimed to identify the factors associated with small size at birth among under-five children.MethodsData from the 2011 Nepal Demographic and Health Survey (NDHS) were used. The association between small size at birth and explanatory variables were analysed using Chi-square tests (χ2) followed by logistic regression. Complex Sample Analysis was used to adjust for study design and sampling.ResultsA total of 5240 mother- singleton under five child pairs were included in the analysis, of which 936 (16.0%) children were reported as small size at birth. Of 1922 infants whose birth weight was recorded, 235 (11.5%) infants had low birth weight (<2500 grams). The mean birth weight was 3030 grams (standard deviation: 648.249 grams).The mothers who had no antenatal visits were more likely (odds ratio (OR) 1.315; 95% confidence interval (CI) (1.042-1.661)) to have small size infants than those who had attended four or more antenatal visits. Mothers who lived in the Far-western development region were more likely to have (OR 1.698; 95% CI (1.228-2.349)) small size infants as compared to mothers from the Eastern development region. Female infants were more likely (OR 1.530; 95% CI (1.245-1.880)) to be at risk of being small than males.ConclusionOne in every six infants was reported to be small at birth. Attendance of antenatal care programs appeared to have a significant impact on birth size. Adequate antenatal care visits combined with counselling and nutritional supplementation should be a focus to reduce adverse birth outcomes such as small size at birth, especially in the geographically and economically disadvantaged areas such as Far-western region of Nepal.