Antenatal Care Providers Research Articles

Rural women's perspectives of maternity services in the Midland Region of New Zealand.

INTRODUCTION Rural women face many challenges with regards to maternity services. Many rural primary birthing facilities in New Zealand have closed. The Lead Maternity Carer (LMC) model of maternity care, introduced in 1990, has moved provision of rural maternity care from doctors to independent midwifery services. Shortages of rural midwives in the Midland region led to rural maternity care being seen as a vulnerable service. AIM To understand the views and experiences of rural women concerning maternity care, to inform the future design and provision of rural maternity services. METHODS Participants were drawn from areas purposively selected to represent the five District Health Boards comprising the Midland health region. A demographic questionnaire, focus groups and individual interviews explored rural women's perspectives of antenatal care provision. These were analysed thematically. RESULTS Sixty-two women were recruited. Key themes emerging from focus groups and interviews included: access to services, the importance of safety and quality of care, the need for appropriate information at different stages, and the role of partners, family and friends in the birthing journey. While most women were happy with access to services, quality of care, provision of information, and the role of family in their care, for some women, this experience could be enhanced. CONCLUSION Midwives are the frontline service for women seeking antenatal services. Support for rural midwives and for local birthing units is needed to ensure rural women receive services equal to that of their urban counterparts.

What matters to women: a systematic scoping review to identify the processes and outcomes of antenatal care provision that are important to healthy pregnant women.

Global uptake of antenatal care (ANC) varies widely and is influenced by the value women place on the service they receive. Identifying outcomes that matter to pregnant women could inform service design and improve uptake and effectiveness. To undertake a systematic scoping review of what women want, need and value in pregnancy. Eight databases were searched (1994-2015) with no language restriction. Relevant journal contents were tracked via Zetoc. An initial analytic framework was constructed with findings from 21 papers, using data-mining techniques, and then developed using meta-ethnographic approaches. The final framework was tested with 17 more papers. All continents except Australia were represented. A total of 1264 women were included. The final meta-theme was: Women want and need a positive pregnancy experience, including four subthemes: maintaining physical and sociocultural normality; maintaining a healthy pregnancy for mother and baby (including preventing and treating risks, illness and death); effective transition to positive labour and birth; and achieving positive motherhood (including maternal self-esteem, competence, autonomy). Findings informed a framework for future ANC provision, comprising three equally important domains: clinical practices (interventions and tests); relevant and timely information; and pyschosocial and emotional support; each provided by practitioners with good clinical and interpersonal skills within a high quality health system. A positive pregnancy experience matters across all cultural and sociodemographic contexts. ANC guidelines and services should be designed to deliver it, and those providing ANC services should be aware of it at each encounter with pregnant women. Women around the world want ANC staff and services to help them achieve a positive pregnancy experience.

A Multifaceted Strategy to Implement Brief Smoking Cessation Counseling During Antenatal Care in Argentina and Uruguay: A Cluster Randomized Trial.

Argentina and Uruguay have a high prevalence of smoking during pregnancy. However, and despite national recommendations, pregnant women are not routinely receiving cessation counseling during antenatal care (ANC). We evaluated a multifaceted strategy designed to increase the frequency of pregnant women who received a brief smoking cessation counseling based on the 5As (Ask, Advise, Assess, Assist, and Arrange). We randomly assigned (1:1) 20 ANC clusters in Buenos Aires, Argentina and Montevideo, Uruguay to receive a multifaceted intervention to implement brief smoking cessation counseling into routine ANC, or to receive no intervention. The primary outcome was the frequency of women who recalled receiving the 5As during ANC at more than one visit. Frequency of women who smoked until the end of pregnancy, and attitudes and readiness of ANC providers towards providing counseling were secondary outcomes. Women's outcomes were measured at baseline and at the end of the 14- to 18-month intervention, by administering questionnaires at the postpartum hospital stay. Self-reported cessation was verified with saliva cotinine. The trial took place between October 03, 2011 and November 29, 2013. The rate of women who recalled receiving the 5As increased from 14.0% to 33.6% in the intervention group (median rate change, 22.1%), and from 10.8% to 17.0% in the control group (median rate change, 4.6%; P = .001 for the difference in change between groups). The effect of the intervention was larger in Argentina than in Uruguay. The proportion of women who continued smoking during pregnancy was unchanged at follow-up in both groups and the relative difference between groups was not statistically significant (ratio of odds ratios 1.16, 95% CI: 0.98-1.37; P = .086). No significant changes were observed in knowledge, attitudes, and self-confidence of ANC providers. The intervention showed a moderate effect in increasing the proportion of women who recalled receiving the 5As, with a third of women receiving counseling in more than one visit. However, the frequency of women who smoked until the end of the pregnancy was not significantly reduced by the intervention. No implementation trials of smoking cessation interventions for pregnant women have been carried out in Latin American or in middle-income countries where health care systems or capacities may differ. We evaluated a multifaceted strategy designed to increase the frequency of pregnant women who receive brief smoking cessation counseling based on the 5As in Argentina and Uruguay. We found that the intervention showed a moderate effect in increasing the proportion of women receiving the 5As, with a third of women receiving counseling in more than one visit. However, the frequency of women who smoked until the end of the pregnancy was not significantly reduced by the intervention.

Development of a scale to evaluate midwives' beliefs about assessing alcohol use during pregnancy.

BackgroundPrenatal alcohol exposure is an important modifiable cause of adverse fetal outcomes during and following pregnancy. Midwives are key providers of antenatal care, and it is important to understand the factors which influence their ability to provide appropriate advice and support to women about alcohol use in pregnancy. The main aim of this study was to develop a psychometrically valid scale to evaluate midwives’ beliefs about assessing alcohol use during pregnancy.MethodA self-administered questionnaire was developed to evaluate midwives’ beliefs about assessing alcohol use during pregnancy, including beliefs about positive and negative consequences of asking about alcohol use, and beliefs about capacity to assess alcohol use. The questionnaire was sent to 245 midwives working for a state-wide country health service in Western Australia. Exploratory factor analysis was used to identify the latent constructs assessed by the 36 belief items and provide initial construct validation of the Asking About Alcohol (AAA) Scale.ResultsOf the 166 (67.8 %) midwives who responded to the survey, 160 (96.4 %) completed one or more of the belief items and were included in this analysis. Factor analysis identified six subscales which assessed beliefs about discomfort, capacity, effectiveness, role, trust and knowledge. Midwives held the most positive beliefs about their capacity to ask and the effectiveness of asking about alcohol use, and the least positive beliefs about women’s knowledge about alcohol use and discomfort associated with asking about alcohol use in pregnancy. Midwives’ beliefs about their role and the effectiveness of asking were most strongly associated with the intention to ask all pregnant women about alcohol use during pregnancy (r = −0.59, p < 0.001 and r = −0.52, p < 0.001).ConclusionsOur analysis has identified key constructs underlying midwives’ beliefs about the assessment of alcohol use during pregnancy. The AAA Scale provides a basis for improved clarity and consistency in the conceptualisation and measurement of midwives’ beliefs which can be used to enhance our understanding of factors influencing midwives’ ability to deliver interventions to prevent alcohol use during pregnancy. The constructs identified in this exploratory analysis require confirmatory analysis to support their validity and generalizability.Electronic supplementary materialThe online version of this article (doi:10.1186/s12884-015-0779-6) contains supplementary material, which is available to authorized users.

A cross-sectional assessment of primary healthcare facilities for provision of antenatal care: calling for improvements in Basic Health Units in Punjab, Pakistan.

BackgroundThere are two types of barriers to the utilisation of maternal health and antenatal care (ANC) services, including the supply-side barriers operating at the health facility level and demand-side, affecting the utilisation ANC services by pregnant women. The purpose of the study was to assess the essential resources required for the provision of ANC services in primary healthcare facilities in Punjab, Pakistan.MethodsA cross-sectional facility assessment was conducted in primary healthcare facilities across Punjab. A multi-stage sampling was used to randomly select nine districts from three stratifications and 19 primary healthcare facilities in the public sector (17 Basic Health Units (BHUs) and two Rural Health Centres (RHCs)) from each district. A total of 171 health facilities were included. Data on infrastructure and availability of equipment, essential supplies, medicines, treatment protocols, and infection control items was collected through pre-tested, semi-structured questionnaires. Univariate analysis was carried out to describe the frequency and percentages of facilities across three ratings (good, average, and poor) by type of facility.ResultsOverall, 28% of facilities had poor infrastructure and the availability of equipment was poor in 16% of the health facilities. Essential supply items, such as urine strips for albumin, blood sugar testing strips, and haemoglobin reagents, were particularly poorly stocked. However, infrastructure and the availability of equipment and supplies were generally better in RHCs compared to BHUs.ConclusionHealth facilities lacked the resources required to provide quality ANC services, particularly in terms of infrastructure, equipment, supply items, and medicines. The availability of these resources needs to be urgently addressed.

Acceptability of provider-initiated HIV testing as an intervention for prevention of mother to child transmission of HIV and associated factors among pregnant women attending at Public Health Facilities in Assosa town, Northwest Ethiopia.

BackgroundDespite more efforts for prevention of mother to child HIV transmission, still there are problems with provider-initiated HIV testing. This study was done to assess the acceptance rate of provider-initiated HIV testing among antenatal care attendants and its associated factors.MethodsInstitutions based cross sectional study with a sample size of 398 was conducted from February to March 2014 in two health facilities in Assosa town. Proportional allocation of the sample size of health facilities followed by systematic sampling method was done; data were collected using an interviewer administered questionnaire. Bivariate and multivariate regression analysis was employed using SPSS version 20.ResultsA total of 386 pregnant women participated with response rate 97 % and 312 (80.8 %) of them accepted provider-initiated HIV testing. The odds of acceptance of provider-initiated HIV testing was higher among rural residents (AOR 4.04; 95 % CI 1.24–13.11) than urban. It was also higher among students (AOR 6.00; 95 % CI 1.45–24.75), merchants (AOR 4.43; 95 % CI 1.18–16.68) and employed women (AOR 2.15; 95 % CI 1.08–4.30) than housewives. Pregnant women who had no stigmatized attitude towards people living with HIV/AIDS were more likely to accept testing (AOR 3.54; 95 % CI 1.23–10.16) than who had a strong stigmatized attitude. In addition, those who planned to disclose their test results from their husbands were higher odd of acceptance (AOR 14.85; 95 % CI 4.60–47.94) than who secreted.ConclusionAcceptance of provider-initiated HIV testing among pregnant women attending for antenatal care services was relatively high. Mothers from urban residence, occupational satus being housewives, stigmatization and not having a plan to disclose the status of test results were negatively affect the acceptance of provider-initiated HIV testing. During counselling sessions, antenatal care providers should focus on barriers of provider-initiated HIV testing such as residence, occupational status, stigmatized attitudes and disclosure status of results of HIV tests.

The evaluation of an oral health education program for midwives in Australia

Antenatal care providers are now recommended to promote oral health during pregnancy and provide dental referrals. However, midwives in Australia are not trained to undertake this role. To address this shortcoming, an online evidence based midwifery initiated oral health (MIOH) education program was systematically developed as a professional development activity. This study aimed to evaluate the effectiveness of the program in improving the oral health knowledge of midwives and assess their confidence to promote maternal oral health post training. The program was evaluated using a pre-post test design involving 50 midwives purposively recruited from two states in Australia. The pre-post questionnaire contained 24 knowledge items previously pilot tested as well as items exploring confidence in promoting oral health and perceptions of the program. The results showed a significant improvement in the oral health knowledge (↑21.5%, p<0.001) of midwives after completion of the program. The greatest improvement in knowledge occurred in key areas vital in promoting maternal oral health namely the high prevalence of dental problems and its impact on birth and infant outcomes. The majority also reported being confident in introducing oral health into antenatal care (82%) and referring women to dental services (77.6%) after undertaking the education program. The MIOH education program is a useful resource to equip midwives with the necessary knowledge and skills to promote oral health during pregnancy. The program is accessible and acceptable to midwives and can potentially be transferable to other antenatal care providers.

Current evidence on antenatal care provision for women with intellectual disabilities: A systematic review

Backgroundchanging attitudes, alongside integration, more independent living and recognition of rights to family life have meant a steady rise in women with intellectual disabilities becoming pregnant. However, existing evidence shows that women with intellectual disabilities are less likely to seek or attend for regular antenatal care. This population experiences poorer maternal wellbeing and worse pregnancy outcomes compared to the general population, including preterm and low-birthweight babies. Purposeto identify and review the existing evidence on the provision of antenatal care among women with intellectual disabilities. Methodsa systematic search strategy was formulated using key Medical Sub-Headings terms and related text words for pregnancy, antenatal care and intellectual disability. Comprehensive searches dating back to 1980 using pre-determined criteria followed by a hand search of reference lists and citations were undertaken. Data were extracted using a data extraction form and methodological quality assessed using the framework developed by Caldwell et al. (2011). A three stage textual narrative synthesis was used to integrate the findings from the included studies. Resultssearches identified 16 papers that met the inclusion criteria. A majority of the papers focused on women׳s experience of pregnancy and antenatal care with a paucity of papers identified on midwives knowledge and experience. The four broad themes of the analysis and synthesis performed included: In the Family Way (׳I׳ve a baby inside. I׳ve got a life inside of me.׳); Knowledge and advocacy (׳…everyone was looking at one another and no one was talking to me…׳); Midwives educational needs (׳…helpful to have guidance…׳) and Midwives Attitudes (׳…women with [intellectual disabilities]…should not be pregnant׳). Key conclusions and implications for practicesignificant gaps in the evidence base were apparent, however evidence was identified which showed that intellectually disabled pregnant women struggle to understand antenatal information communicated during pregnancy which was often text based. Maternity care providers need to make adjustments to their services so that antenatal communication, information and care is appropriate for this group of women. Midwives identified that they lacked knowledge in this area and wanted antenatal guidance on how to meet the care and communication needs of women with intellectual disabilities.

Birth preparedness among women in Tharaka Nithi County, Kenya

Background/Aim: In 2005, the sub-county health management team identified a need for information to reduce the lack of skilled attendance at birth. This study assesses the determinants of birth preparedness among women who had given birth in the last 2 years in Tharaka Nithi County, Kenya. Methods: Stratified sampling was used to select 345 pregnant women for interview. Systematic sampling was used so that every 14th client attending a maternal/child health clinic in the sampled facilities was interviewed. A descriptive cross-sectional survey design was used. A chi-squared test and logistic regression were used to analyse the data. Results: Approximately 20% of the interviewed sample were prepared for birth on all six recommended aspects of birth preparedness. The most planned for aspect of birth was hospital birth expenses (74%), followed by place of birth (69%). The least prepared for aspect was transport to a health facility (35%). Conclusions: Higher level of education, higher income, salaried occupation and at least four antenatal care visits all increased the likelihood of being more prepared for birth. A history of stillbirth reduced the likelihood of birth preparedness. It is recommended that the Kenya Ministry of Health improve levels of birth preparedness through the provision of antenatal care.

Matching comprehensive health insurance reimbursements to their real costs: the case of antenatal care visits in a region of Peru.

BackgroundPrepaid contributory systems are increasingly being recognized as key mechanisms in achieving universal health coverage in low and middle-income countries. Peru created the Seguro Integral de Salud (SIS) to increase health service use amongst the poor by removing financial barriers. The SIS transfers funds on a fee-for-service basis to the regional health offices to cover recurrent cost (excluding salaries) of pre-specified packages of interventions. We aim to estimate the full cost of antenatal care (ANC) provision in the Ventanilla District (Callao-Peru) and to compare the actual cost to the reimbursement rates provided by SIS.MethodsThe economic costs of ANC provision in 2011 in 8 of the 15 health centres in Ventanilla District were estimated from a provider perspective and the actual costs of those services covered by the SIS fee of $3.8 for each ANC visit were calculated. A combination of step-down and bottom-up costing methodologies was used. Sensitivity analysis was conducted to test the uncertainty around estimated parameters and model assumptions. Results are reported in 2011 US$,ResultsThe total economic cost of ANC provision in all 8 health centres was $569,933 with an average cost per ANC visit of $31.3 (95 % CI $29.7–$33.5). Salaries comprised 74.4 % of the total cost. The average cost of the services covered by the SIS fee was $3.4 (95 % CI $3.0–$3.8) per ANC visit. Sensitivity analysis showed that the probability of the cost of an ANC visit being above the SIS reimbursed fee is 1.4 %.ConclusionOur analysis suggests that the fee reimbursed by the SIS will cover the cost that it supposed to cover. However, there are significant threats to medium and longer term sustainability of this system as fee transfers represent a small fraction of the total cost of providing ANC. Increasing ANC coverage requires the other funding sources of the Regional Health Office (DIRESA) to adapt to increasing demand.Electronic supplementary materialThe online version of this article (doi:10.1186/s12962-015-0042-z) contains supplementary material, which is available to authorized users.

Perspectives of health care providers on the provision of intermittent preventive treatment in pregnancy in health facilities in Malawi.

BackgroundNearly 20 years after the adoption by the government of Malawi of the provision of intermittent preventive treatment in pregnancy (IPTp) for malaria, only 55 % of pregnant women received at least two doses of sulfadoxine-pyrimethamine (SP) in 2010. Although several reasons for the low coverage have been suggested, few studies have examined the views of health care providers. This study examined the experiences of the nurses and midwives in providing antenatal care (ANC) services.MethodsThis study was conducted in health facilities in Malawi that provide routine ANC services. Providers of ANC in Malawi were selected from in eight health care facilities of Malawi. Selected providers were interviewed using a semi-structured interview guide designed to address a series of themes related to their working conditions and their delivery of IPTp.ResultsNurses displayed detailed knowledge of ANC services and the rationale behind them. Nurses understood that they should provide two doses of IPTp during a pregnancy, but they did not agree on the timing of the doses. Nurses gave SP as directly observed therapy (DOT) at the clinic. Nurses did not give SP pills to women to take home with them because they did not trust that women would take the pills. Women who resisted taking SP explained they do not take drugs if they had not eaten, or they feared side effects, or they were not sick. Reasons for not giving the first or second dose of SP included a delay in the first ANC visit, testing positive for HIV, and presenting with malaria. None of the nurses were able to show any specific written guidelines on when to give SP. The challenges faced by the nurses include being overworked and persuading women to take SP under observation.ConclusionThe findings show that the nurses had gained the knowledge and technical skills to provide appropriate ANC services. With regard to IPTp, nurses need guidelines that would be available at the health facility about how and when to give SP. The adoption of the WHO guidelines and their diffusion to health care facilities could help increase the coverage of IPTp2 (at least two doses of sulfadoxine-pyrimethamine) in Malawi.

Perceptions of risk: How they influence women's and health professionals' choices

The need to ensure the survival of the species by offering pregnant and labouring women special protection has been expressed in primitive human societies through elaborate rituals and superstitions, and in contemporary society, through the provision of antenatal and intrapartum care by health professionals. Modern maternity services tend to highlight the medical risks of pregnancy and birth. Women, however, may place such risks in a broader context which includes risks to their emotional wellbeing and therefore, to their capacity to bond with their baby. Given current understanding of the importance of the first 1000 days of a baby's life, women's desire to have a labour that does not jeopardise this early relationship, is entirely logical. While both health professionals and women are dedicated to ensuring the safety of mother and baby, their definitions of ‘risk’ may sometimes lead to women's decision-making being contested and the need for ‘negotiation of disagreement’

Effects of Prepregnancy Body Mass Index and Gestational Weight Gain on Pregnancy Outcomes

To investigate the single and joint effects of prepregnancy body mass index (BMI) and gestational weight gain (GWG) on pregnancy outcomes, electronic medical records of 14,196 women who delivered singleton live infant at a maternal and child health hospital in Beijing, China, in 2012 were reviewed. Logistic regression was used to assess the associations, adjusting for maternal age, height, education, parity, and offspring sex. Women of high prepregnancy BMI or excessive GWG had higher risks of gestational diabetes mellitus, hypertensive disorders in pregnancy, postpartum hemorrhage, caesarean delivery, macrosomia, and large for gestational age infant, while women of inadequate GWG had higher risks of preterm delivery, low birth weight, and small for gestational age infant. Findings suggest that antenatal care providers should help pregnant women control their GWG to normal.

"You cannot know if it's a baby or not a baby": uptake, provision and perceptions of antenatal care and routine antenatal ultrasound scanning in rural Kenya.

BackgroundAntenatal care early in pregnancy enables service providers to identify and manage risks to mother and fetus. In the global north, ultrasound scans are routinely offered in pregnancy to provide an accurate estimate of gestational age and identify potential problems. In sub-Saharan Africa, such services are rarely available and women often delay initiating antenatal care. This study describes the uptake and provision of antenatal care in a rural Kenyan hospital and explores how pregnant women and healthcare providers perceived the provision of ultrasound scanning, following its introduction in an international foetal growth study.MethodsA descriptive study, using qualitative and quantitative methods, was conducted in Kilifi District Hospital, Kenya, between June 2011 and April 2012. In-depth interviews were conducted with 10 nurses working in the antenatal clinic (ANC) and 59 pregnant women attending ANC. Structured observations of 357 ANC consultations and 30 ultrasound scans were made.ResultsWomen sought antenatal care for information about the health of their baby and the protection provided by the ANC services. Uncertainty about pregnancy status contributed to delay in ANC attendance; more than 78 % of women were over 20 weeks’ gestation at their first visit. Healthcare workers found it difficult to detect pregnancies below 16 weeks gestation and, accurate assessment of gestational age below 20 weeks’ gestation could be problematic. Provision of services depended on the pregnancy being detected and gestational age assessed. The “seeing”, made possible through ultrasound scanning was perceived by pregnant women and healthcare workers to be beneficial: confirming the pregnancy, and providing reassurance about the fetus’ condition. Few participants raised concerns about ultrasound scanning.ConclusionsUncertainty about pregnancy status and gestational age for women and healthcare providers is a key factor influencing timing of ANC attendance, contributing to delays and restricting early provision of ANC services. Ultrasound scanning was perceived to enhance antenatal care through confirmation of pregnancy status and enabling more accurate estimation of gestational age and the health status of the fetus. There is a need to make available more affordable means of pregnancy testing as a strategy towards encouraging early attendance, and delivery of antenatal care.

Towards biomarker-based tests that can facilitate decisions about prevention and management of preeclampsia in low-resource settings.

In recent years, an increasing amount of literature is emerging on candidate urine and blood-based biomarkers associated with incidence and severity of preeclampsia (PE) in pregnant women. While enthusiasm on the usefulness of several of these markers in predicting PE is evolving, essentially all work so far has focused on the needs of high-resource settings and high-income countries, resulting primarily in multi-parameter laboratory assays based on proteomic and metabolomics analysis techniques. These highly complex methods, however, require laboratory capabilities that are rarely available or affordable in low-resource settings (LRS). The importance of quantifying maternal and perinatal risks and identifying which pregnancies can be safely prolonged is also much greater in LRS, where intensive care facilities that can rapidly respond to PE-related health threats for women and infants are limited. For these reasons, simple, low cost, sensitive, and specific point-of-care (POC) tests are needed that can be performed by antenatal health care providers in LRS and that can facilitate decisions about detection and management of PE. Our study aims to provide a comprehensive systematic review of current and emerging blood and urine biomarkers for PE, not only on the basis of their clinical performance, but also of their suitability to be used in LRS-compatible test formats, such as lateral flow and other variants of POC rapid assays.

Is there a distinction between malaria treatment and intermittent preventive treatment? Insights from a cross-sectional study of anti-malarial drug use among Ugandan pregnant women.

BackgroundIn Uganda, treatment of clinical malaria and intermittent preventive treatment with sulphadoxine-pyrimethamine (SP) are common during pregnancy. As a result, both formal and informal reports from antenatal sources suggest possible misuse of SP for malaria treatment among pregnant women. The objective of this study was to investigate anti-malarial drug use patterns among women who had recently suffered malaria illness before and during pregnancy.MethodsA cross-sectional study in which a structured questionnaire (interviewer-administered) was used to collect data from pregnant women attending an urban antenatal clinic. Details of medicines used to treat malaria episodes suffered before and during pregnancy were captured. A first order Markov probability model was used to estimate probabilities of transitioning between treatment choices made before and during pregnancy. Logistic regression was used to explore whether demographic and obstetric characteristics were associated with transition patterns.ResultsSeven hundred women were interviewed among whom 428 had suffered malaria in both instances. Three hundred thirty of these could recall the medicines used in both instances. Women who used ACT/QNN (correct choice) before pregnancy had higher probabilities of transitioning to SP than staying on ACT/QNN during pregnancy (0.463 versus 0.451). Access of medicines from private outlets (clinics and pharmacies) were more than nine times predictive of receiving correct medicines (p=0.035 and p=0.039 respectively). Access of medicines from clinics was 5.9 times protective against receiving SP for malaria treatment (p=0.033). Among those who used SP before pregnancy, there was a 0.75 probability of staying on it during pregnancy. None of the factors explored could explain this observation.ConclusionUse of SP for malaria treatment is common during pregnancy. This may be contributing to adverse pregnancy outcomes. Antenatal care providers should endeavour to emphasize the distinction between treatment and prevention of malaria during pregnancy.Electronic supplementary materialThe online version of this article (doi:10.1186/s12936-015-0702-7) contains supplementary material, which is available to authorized users.

Pathways Utilized for Antenatal Health Seeking Among Women in the Ga East District, Ghana.

Ghana's maternal mortality ratio has been declining over the last two decades but at a rather slow pace. Poor access to effective maternity care is identified as one of the key challenges of maternity care. The current study mapped out the pathways to pregnancy care seeking among urban-dwelling adult women in a peri-urban district located in the Greater Accra region of Ghana. A total of 300 women who had a live birth in the last 12 months participated in a community-based survey. They answered questions on care seeking behavior related to their last pregnancy. A multivariate Logistic regression model was used to identify factors associated with multiple care seeking behavior. Almost all women in the survey (98%) reported accessing skilled antenatal care (ANC) from a biomedical provider, although 35% begun ANC later than the first trimester. About 45% of women simultaneously utilized both ANC and alternative care providers (ACP) including traditional birth attendants, herbalists, and spiritualists. A complex pathway to antenatal care seeking behavior involving shuttling between providers was observed. Controlling for household wealth, household size, and age, seeking care from multiple providers concurrently was associated with residence in Kwabenya sub-district OR=2.13 (95% CI: 1.28, 3.55) and previous abortion OR=2.08 (95% CI: 1.11, 3.91). Urban-dwelling women in Ga East District seek antenatal care concurrently from multiple sources. Health system interventions must seek ways to integrate alternative care providers into the existing biomedical health care system.

Antenatal care strengthening for improved quality of care in Jimma, Ethiopia: an effectiveness study.

BackgroundInterventions for curing most diseases and save lives of pregnant and delivering women exist, yet the power of health systems to deliver them to those in most need is not sufficient. The aims of this study were to design a participatory antenatal care (ANC) strengthening intervention and assess the implementation process and effectiveness on quality of ANC in Jimma, Ethiopia.MethodsThe intervention comprised trainings, supervisions, equipment, development of health education material, and adaption of guidelines. It was implemented at public facilities and control sites were included in the evaluation. Improved content of care (physical examinations, laboratory testing, tetanus toxoid (TT)-immunization, health education, conduct of health professionals, and waiting time) were defined as proximal project outcomes and increased quality of care (better identification of health problems and increased overall user satisfaction with ANC) were distal project outcomes. The process of implementation was documented in monthly supervision reports. Household surveys, before (2008) and after (2010) intervention, were conducted amongst all women who had given birth within the previous 12 months. The effect of the intervention was assessed by comparing the change in quality of care from before to after the intervention period at intervention sites, relative to control sites, using logistic mixed effect regression.ResultsThe continued attention to the ANC provision during implementation stimulated increased priority of ANC among health care providers. The organizational structure of the facilities and lack of continuity in care provision turned out to be a major challenge for implementation. There was a positive effect of the intervention on health education on danger signs during pregnancy (OR: 3.9, 95% CI: 2.6;5.7), laboratory testing (OR for blood tests other than HIV 2.9, 95% CI: 1.9;4.5), health problem identification (OR 1.8, 95% CI: 1.1;3.1), and satisfaction with the service (OR: 0.4, 95% CI: 0.2;0.9). There was no effect of intervention on conduct of health professionals. The effect of intervention on various outcomes was significantly modified by maternal education.ConclusionThe quality of care can be improved in some important aspects with limited resources. Moreover, the study provides strategic perspectives on how to facilitate improved quality of ANC.

Norwegian nurse-midwives' perspectives on the provision of antenatal diabetes care in an outpatient setting: A qualitative study.

There is limited research related to nurse-midwives' accounts of their provision of antenatal diabetes care in hospital outpatient settings. This study explored the perspectives and experiences of eight Norwegian nurse-midwives regarding the provision of the midwifery aspect of an antenatal consultation as part of the diabetes specialist team. A qualitative descriptive study was used. Eight nurse-midwives aged between 37 and 58 years, representing four Norwegian hospital outpatient clinics, participated in individual interviews. Transcribed interviews were analysed in accordance with a qualitative thematic analysis. Three main themes were developed: "Approaching the women as persons in order to frame strengths and normalcy", "Managing different tasks judiciously" and "Balancing conflicting values". Some of the barriers were found to be related to the organisation of care, such as short timeframes with a medical focus, which overshadowed or forced the normalcy aspects of childbearing into the background. Managing risk and evidence-based knowledge were demanding tasks to fulfil in a judicious way. Some midwives experienced ambiguity while being forced to prioritise medical factors over woman-focused care while running others' errands, an act of balancing conflicting values. The contextual conditions related to the organisation present barriers for pregnant women to receive woman-focused care beyond the medical approach. The midwifery contribution in this care setting should be clearly recognised and defined so that women can capitalise on the different professionals and their expert competencies and contributions in this setting.

Rural/urban and socioeconomic differentials in quality of antenatal care in Ghana.

BackgroundApproximately 800 women die of pregnancy-related complications every day. Over half of these deaths occur in sub-Saharan Africa (SSA). Most maternal deaths can be prevented with high quality maternal health services. It is well established that use of maternal health services vary by place of residence and socioeconomic status (SES), but few studies have examined the determinants of quality of maternal health services in SSA. The purpose of this study is to examine the determinants of antenatal care (ANC) quality in Ghana–focusing on the role of place of residence and SES (education and wealth). The analysis also examines the interactions of these variables and the mediating role of ANC timing, frequency, facility type, and provider type.MethodsThe data are from the Ghana Maternal Health Survey (N = 4,868). Analytic techniques include multilevel linear regression with mediation and moderation analysis.ResultsUrban residence and higher SES are positively associated with higher ANC quality, but the urban effect is completely explained by sociodemographic factors. Specifically, about half of the urban effect is explained by education and wealth alone, with other variables accounting for the remainder. The effects of education are conditional on wealth and are strongest for poor women. Starting ANC visits early and attending the recommended four visits as well as receiving ANC from a higher level facility and from a skilled provider are associated with higher quality ANC. These factors partially explain the SES differentials.ImplicationsGhanaian women experience significant disparities in quality of ANC, with poor illiterate women receiving the worst care. Targeted efforts to increase quality of ANC may significantly reduce maternal health disparities in Ghana and SSA. A particularly crucial step is to improve ANC quality in the lower level health facilities, where the most vulnerable women are more likely to seek ANC.