Antenatal Health Services Research Articles

Changes in the inequalities in antenatal health service utilization in Serbia from 2005 to 2014

Changes in the inequalities in antenatal health service utilization in Serbia from 2005 to 2014

The MONARCH intervention to enhance the quality of antenatal and postnatal primary health services in rural South Africa: protocol for a stepped-wedge cluster-randomised controlled trial

BackgroundGaps in maternal and child health services can slow progress towards achieving the Sustainable Development Goals. The Management and Optimization of Nutrition, Antenatal, Reproductive, Child Health & HIV Care (MONARCH) study will evaluate a Continuous Quality Improvement (CQI) intervention targeted at improving antenatal and postnatal health service outcomes in rural South Africa where HIV prevalence among pregnant women is extremely high. Specifically, it will establish the effectiveness of CQI on viral load (VL) testing in pregnant women who are HIV-positive and repeat HIV testing in pregnant women who are HIV-negative.MethodsThis is a stepped-wedge cluster-randomised controlled trial (RCT) of 7 nurse-led primary healthcare clinics to establish the effect of CQI on selected routine antenatal and postnatal services. Each clinic was a cluster, with the exception of the two smallest clinics, which jointly formed one cluster. The intervention was applied at the cluster level, where staff received training on CQI methodology and additional mentoring as required. In the control exposure state, the clusters received the South African Department of Health standard of care. After a baseline data collection period of 2 months, the first cluster crossed over from control to intervention exposure state; subsequently, one additional cluster crossed over every 2 months. The six clusters were divided into 3 groups by patient volume (low, medium and high). We randomised the six clusters to the sequences of crossing over, such that both the first three and the last three sequences included one cluster with low, one with medium, and one with high patient volume.The primary outcome measures were (i) viral load testing among pregnant women who were HIV-positive, and (ii) repeat HIV testing among pregnant women who were HIV-negative. Consenting women ≥18 years attending antenatal and postnatal care during the data collection period completed outcome measures at delivery, and postpartum at three to 6 days, and 6 weeks. Data collection started on 15 July 2015. The total study duration, including pre- and post-exposure phases, was 19 months. Data will be analyzed by intention-to-treat based on first booked clinic of study participants.DiscussionThe results of the MONARCH trial will establish the effectiveness of CQI in improving antenatal and postnatal clinic processes in primary care in sub-Saharan Africa. More generally, the results will contribute to our knowledge on quality improvement interventions in resource-poor settings.Trial registrationThis trial was registered on 10 December 2015: www.clinicaltrials.gov, identifier NCT02626351.

Small for gestational age babies and depressive symptoms of mothers during pregnancy: Results from a birth cohort in India

Background: More than one million babies are born with Low birthweight (LBW) in India every year, often afflicting disadvantaged families. Earlier studies on LBW in India have mostly focused on addressing poverty, nutritional status, and obstetric factors for LBW babies, comprising of preterm babies (<37 weeks) or small for gestational age (SGA) or both. We aim to find the association between antepartum depression and SGA in a public hospital. Methods: Pregnant women with gestational age between 14 to 32 weeks were recruited. The Edinburgh Postnatal Depression Scale (EPDS) was administered to assess depression. Newborn anthropometry was performed soon after delivery. Birth weight less than 10 percentile were classified as SGA, between 10 to 90th percentile was appropriate for gestational age (AGA), and greater than 90th percentile was large for gestational age (LGA). Results: We found that 16.51% (108) of the antenatal mothers had depressive symptoms (EPDS score >11). The women with depressive symptoms delivered a greater proportion of SGA babies (21.3 v/s 15.8) and LGA (9.3 v/s 3.3) compared to women with no symptoms. The odds of women giving birth to a child with SGA were twice as high for women with EPDS scores >11 (adjusted OR = 2.18; 95% CI = 1.23 – 3.87) compared to the women with EPDS scores of ≤11. In terms of Area under curve (AUC), EPDS 11 cut off (AUC: 0.533) narrowly outperformed EPDS 12 cut-off (AUC: 0.4738), which in turn was better than EPDS 13 cut off (AUC: 0.4687) for screening depression in mothers. Conclusions: We have demonstrated the usefulness of the 10-item EPDS screening tool in screening for symptoms of antenatal depression. There is a need to explore implementation of screening, diagnostic services and evidence-based antenatal mental health services by modifying the provisions of ongoing national programs.

Resources allocation and their relation to antenatal and natal health service utilization in rural and urban primary healthcare units in Zagazig District, Sharkia Governorate, Egypt (2015/2016)

Objective The objective of this study was to assess resource allocation of antenatal and natal health services and its effect on utilization of these services among the urban and rural strata in Zagazig District, Sharkia Governorate. Background More than half of the Egyptian population (57%) living in rural areas according to Egypt Health Profile (2011), especially poor rural areas, have access to fewer healthcare resources. Improving resource allocation of healthcare greatly influences the utilization of health services. Patient and methods A cross-sectional study was conducted on 400 married women during the child bearing period. Stage 1: four primary healthcare facilities (units and centers) were chosen by simple random technique. Stage 2: from each health facility, the sample size was estimated according to the total number of registered women in each site through proportional allocation method. Women who attended to these health facilities for antenatal care or regular check-up visits (child vaccination, outpatient) were interviewed by a predesigned questionnaire. Utilization rates were estimated and compared regarding residence. Resources were assessed by the resource allocation checklist which was adapted from the Egyptian Ministry of Health. Checklist explains the minimal required resources needed to provide the service according to the Egyptian Ministry of Health instructions. Results The study revealed high utilization rate of antenatal and natal health services in urban facility than in the rural one, with availability of most of health resources needed for providing the services in urban units with their limitation and even unavailability in rural units. Conclusion Resources allocation affects greatly health services utilization. Health resources are more available in urban residences over rural ones. So urban residences are more likely to use health services more than rural one.

Integrated Care across Health District Boundaries

The Healthy Homes and Neighbourhoods (HHAN) Program provides long term care coordination to families with complex health and social needs, in the Sydney Local Health District (SLHD). Referral during the antenatal period is the preferred pathway, aiming to ensure complex families have support for themselves and their child, commencing in the period prior to birth. Previous geospatial mapping has identified two areas of clustered disadvantage within SLHD. Following identification of reduced attendance at one of two SLHD antenatal clinics, a HHAN care coordinator established communications with two hospitals in adjoining health districts to discover patterns of attendance for “out of area” pregnant women. Reasons for attendance at these “out of area” antenatal clinics is uncertain at this stage, but Local Government has identified gaps in public transport to the secondary SLHD hospital. Further research into cross boundary hospital attendance will be undertaken. By attending the adjacent Local Health District’s psychosocial meetings, HHAN aims to identify and engage with vulnerable women and their families, living with SLHD, but attending “out of area” health services. Engagement with adjoining health districts helps to integrate health and social care services beyond our local health district borders, which is vital for families living within previously identified areas of disadvantage. This initiative targeted pregnant women, and their families, with complex health and social needs residing in SLHD who were utilising antenatal health services outside SLHD boundaries. Engagement with health and social care providers across local health district boundaries is essential as HHAN aims to ensure vulnerable women and their families are not “falling through the cracks”. This presentation will focus on the initial collaboration between nurses/midwives and social workers, based in bordering health districts with the common aim of providing client focused support. Attendance at adjacent health district psychosocial meeting commenced in July 2017, following a period of discussion between health districts to acknowledge the identified gap in SLHD antenatal attendance and recognition of cross boundary health utilisation. Ongoing collaboration is planned to allow for seamless referral into the HHAN program and other health and social care services. Inter-Health District Care Coordination is a developing area within Australian public health. This Sydney-based, high-risk, antenatal pathway demonstrates to health care providers and their consumers that flexible support is possible across health boundaries. Interdisciplinary, cross health district collaboration is an essential current and future pathway to improve outcomes in the most vulnerable members of our population. The development of a trusting relationship between HHAN care coordinators, service providers and their clients has been an integral component of the success of the Healthy Homes and Neighbourhoods Program. This inter-health district liaison is enhancing communication and planning across health borders. Challenging and supporting health and social care partners to think and act outside their geographical boundaries is essential for ongoing change in these sectors, as we put the consumer and their complex lives at the forefront of our care. Whilst change is challenging, collaboration between health service providers is one step towards providing timely, integrated supportive care for vulnerable families.

Are Kazakhstani Women Satisfied with Antenatal Care? Implementing the WHO Tool to Assess the Quality of Antenatal Services.

Women’s satisfaction is a part of the quality assurance process with potential to improve antenatal health services. The objective of this study was to assess the prevalence of women’s satisfaction with antenatal care in an urban Kazakhstani setting and investigate associated factors. A total of 1496 women who delivered in all maternity clinics from 6 February through 11 July 2013 in Semey, East Kazakhstan, filled out a standardized pretested questionnaire on satisfaction with antenatal care. Independent associations between dissatisfaction and its correlates were studied by logistic regression. Ninety percent of the women were satisfied with the antenatal care. Women who were dissatisfied had lower education. These women would have preferred more checkups, shorter intervals between checkups, more time with care providers, and shorter waiting times. The overall dissatisfaction was associated with long waiting times and insufficient information on general health in pregnancy, results of laboratory tests, treatment during pregnancy, and breastfeeding. Although most of the women in the study setting were satisfied with the new antenatal care model, we identified the main sources of dissatisfaction that should be addressed. Given that Semey is a typical Kazakhstani city, the results can be generalized to other Kazakhstani urban settings.

Walk the talk: Leader behavior in parental education groups.

Expectant and new parents are offered parental education groups as a way to support their transition to parenthood. Group leadership in these groups has been found to be challenging. Using a qualitative and summative design, the aim of the present study was to investigate how health professionals describe their role in parental education groups compared to their actual behavior. Thirteen health professional leaders in antenatal and child health services were interviewed. These descriptions were compared with the leaders' actual behavior in video and audio-recordings of 16 different group sessions. The results revealed that regardless of how the leaders described their role, they acted as experts and left little time to parents for discussions and active participation. In particular, leaders who described themselves as discussion leaders did not "walk the talk"; that is, they did not do what they said they do when leading groups. That could be explained by lack of professional awareness, group leadership, and pedagogical skills. In order to provide high-quality parental support, leaders need training in group leadership and pedagogy combined with supervision and support on a regular basis.

Assessment of utilization of maternal health care services in rural field practice areas of VIMS, Ballari

Background: Maternal mortality and morbidity remains high even though national programs exist for improving maternal and child health in India. This could be related to several factors, an important one being non-utilization or delay in seeking care of maternal health-care services, especially amongst the rural poor and urban slum population due to either lack of awareness or access to health-care services. Our study was aimed to know the utilization of maternal health care services during antenatal and post natal period and factors affecting them.Methods: A Community based cross sectional study was carried in the rural field practice areas of VIMS, Ballari (three primary health centres (PHC) Kudithini, Koluru, Kurugodu) among all married women in the age group of 15-45 years who were in the post natal period (less than 2 months) at time of interview. A total 152 women were included in the study by door to door survey, among all the 3 PHC’s. The women absent during the survey were excluded.Results: Only 101 (66.44%) of women utilized antenatal care and 18 (11.8%) utilized post natal care (at least three postnatal visits) from the health care facility. Mothers who were of Muslim religion, <20 years of age, higher education of participant as well as husband, higher occupation status, high SES, less parity had higher odds of utilizing antenatal care. Health education by the health worker regarding post natal services to women ranged from 62.5-90.8%. Mothers of Muslim religion, higher education, higher occupation status, normal vaginal delivery and home delivery had higher odds of utilizing postnatal servicesConclusions: The study shows unacceptably low utilization of postnatal care services. It shows the coverage of postnatal care services is inadequate. This is an important message to health service providers and policy makers to strengthening not only antenatal health services and institutional deliveries but also postnatal care services to reduce maternal and neonatal morbidity and mortality.

Maternal Health Care Utilization Among Syrian Refugees in Lebanon and Jordan.

Purpose The influx of Syrian refugees into Jordan and Lebanon over the last 5 years presents an immense burden to national health systems. This study was undertaken to assess utilization of maternal health services among Syrian refugees in both countries. Description A cross-sectional survey of Syrian refugees living in urban and rural (non-camp) settings was conducted using a two-stage cluster survey design with probability proportional to size sampling in 2014-2015. Eighty-six percent of surveyed households in Lebanon and 88% of surveyed households in Jordan included women with a live birth in the last year. Information from women in this sub-set of households was analyzed to understand antenatal and intrapartum health service utilization. Assessment A majority of respondents reported seeking antenatal care, 82% and 89% in Jordan and Lebanon, respectively. Women had an average of at least six antenatal care visits. Nearly all births (98% in Jordan and 94% in Lebanon) took place in a health facility. Cesarean rates were similar in both countries; approximately one-third of all births were cesarean deliveries. A substantial proportion of women incurred costs for intrapartum care; 33% of Syrian women in Jordan and 94% of Syrian women in Lebanon reported paying out of pocket for their deliveries. The proportion of women incurring costs for intrapartum care was higher in Jordan both countries for women with cesarean deliveries compared to those with vaginal deliveries; however, this difference was not statistically significant in either country (Jordan p-value = 0.203; Lebanon p-value = 0.099). Conclusion Syrian refugees living in Jordan and Lebanon had similar levels of utilization of maternal health services, despite different health systems and humanitarian assistance provisions. As expected, a substantial proportion of households incurred out-of-pocket costs for essential maternal and newborn health services, making cost a major factor in care-seeking decisions and locations. As health financing policies shift to account for the continued burden of refugee hosting on the health system, sustained attention to the availability and quality of essential maternal and newborn health services is needed to protect both refugee and host populations women's rights to health and health care during pregnancy, childbirth, and the postpartum period.

Perceptions of Antenatal Women, Husband and Health Service Providers on Husband being Birth Companion during Childbirth: A Qualitative Study

Perceptions of Antenatal Women, Husband and Health Service Providers on Husband being Birth Companion during Childbirth: A Qualitative Study

Utilization of Antenatal HealthCare Services among Fishermen Population in Kanchipuram District, Tamil Nadu: A Cross-sectional Study.

Background:Considering the global and national level commitments in improving the maternal health as well as reducing the maternal mortality, assessment of factors influencing the delivery of antenatal healthcare services becomes essential.Objectives:The aim is to assess the utilization of antenatal health services and to identify the factors influencing their utilization among women of fishermen population in Kanchipuram district, Tamil Nadu.Materials and Methods:The cross-sectional study was carried out among the mothers in Kovalam area of Kanchipuram district. Details were collected using a pretested questionnaire and analyzed using statistical software.Results:The study included 284 mothers, of which 35% were illiterates. Nearly 60.21% have got registered with the Government sector, 59.51% of the mothers had three or more antenatal visits, 64.08% have received two doses of tetanus toxoid, and 73.24% have taken iron and folic acid tablets. Factors which were identified to have statistically significant association with better utilization of antenatal health services were age >30 years, higher educational status, skilled workers, those having their first child, and higher socioeconomic class.Conclusion:This study has reported the fact that antenatal healthcare services were not utilized fully by the community and the fishermen population being a special group has to be given the needed attention from the healthcare delivery system.

The WA Goldfields Aboriginal Community Antenatal Program—A community midwifery initiative

AimTo investigate the acceptability and satisfaction with the Aboriginal Community Antenatal Program by staff in the program and partner agencies. DesignA Strengths, Weaknesses, Opportunities and Threats framework guided the research and data collection methods. Mixed methodology was used, accessing qualitative and quantitative information from data bases, program and supporting agency staff. Quantitative data were analysed through a social sciences statistical package. Qualitative data were identified through questionnaires and analysed using thematic analysis. SettingRemote Aboriginal communities in the Goldfields region of Western Australia. Participant sourcesTwenty two participants including program and supporting agency staff. Main outcome measuresThis study measures acceptability and satisfaction of program antenatal and pre-conception activities by program staff and partner agencies. ResultsQualitative results indicate acceptability and satisfaction with the program, identifying a range of organisational, staffing, cultural and interagency issues relating to a model of service provision. Quantitative data suggested positive program outputs from service delivery. ConclusionFindings suggest the Aboriginal Community Antenatal Program and partner agencies are increasing provision of community based pre-conception and antenatal health services and enhancing collaboration between a range of health provider agencies, with partnerships between Aboriginal and non-Aboriginal program staff contributing to an emerging model of community antenatal care.

Financing Maternal Health and Family Planning: Are We on the Right Track? Evidence from the Reproductive Health Subaccounts in Mexico, 2003-2012.

ObjectiveTo analyze whether the changes observed in the level and distribution of resources for maternal health and family planning (MHFP) programs from 2003 to 2012 were consistent with the financial goals of the related policies.Materials and MethodsA longitudinal descriptive analysis of the Mexican Reproductive Health Subaccounts 2003–2012 was performed by financing scheme and health function. Financing schemes included social security, government schemes, household out-of-pocket (OOP) payments, and private insurance plans. Functions were preventive care, including family planning, antenatal and puerperium health services, normal and cesarean deliveries, and treatment of complications. Changes in the financial imbalance indicators covered by MHFP policy were tracked: (a) public and OOP expenditures as percentages of total MHFP spending; (b) public expenditure per woman of reproductive age (WoRA, 15–49 years) by financing scheme; (c) public expenditure on treating complications as a percentage of preventive care; and (d) public expenditure on WoRA at state level. Statistical analyses of trends and distributions were performed.ResultsPublic expenditure on government schemes grew by approximately 300%, and the financial imbalance between populations covered by social security and government schemes decreased. The financial burden on households declined, particularly among households without social security. Expenditure on preventive care grew by 16%, narrowing the financing gap between treatment of complications and preventive care. Finally, public expenditure per WoRA for government schemes nearly doubled at the state level, although considerable disparities persist.ConclusionsChanges in the level and distribution of MHFP funding from 2003 to 2012 were consistent with the relevant policy goals. However, improving efficiency requires further analysis to ascertain the impact of investments on health outcomes. This, in turn, will require better financial data systems as a precondition for improving the monitoring and accountability functions in Mexico.

Utilization of maternal health services among Janani Suraksha Yojana beneficiaries in Puducherry, India

Background: Utilization of maternal health services among Janani Suraksha Yojana (JSY) beneficiaries is an important aspect to improve maternal health. Aims: This study aims to assess the antenatal, intranatal, and postnatal maternal health services received by JSY beneficiaries. Materials and Methods: A community-based cross-sectional study was conducted among 152 JSY beneficiaries in the rural and urban field practice area attached to a tertiary care institution in Puducherry, India. Antenatal, intranatal, and postnatal services received by the mothers were assessed by a pretested structured questionnaire. Results: About 144 subjects participated in the study (response rate - 94.7%). About half (79, 54.9%) of subjects belonged to 19–25 years age group. About 82.6% (119) of subjects were registered in the first trimester. The majority (142, 98.6%) had institutional delivery. All had received tetanus toxoid immunization. About 3.5% (5) of beneficiaries were sent for high-risk referral. About 77.8% (112/144) of beneficiaries had consumed at least 100 iron and folic acid (IFA) tablets. About 98.6% (142) had more than three visits. The majority of them (138, 95.7%) reached hospital within 1 h. Around 62% of women breastfed their child within 1 h after birth. The postnatal visit by health worker was 54.2% (78), and minimum one postnatal visit by postnatal mother was 48.6% (70). Conclusions: Overall maternal health services are good for JSY beneficiaries in this area. Efforts should be made to improve the quality of services for early registration of pregnancies, IFA tablet intake, early breastfeeding after birth and postnatal care services.

The first antenatal appointment: An exploratory study of the experiences of women with a diagnosis of mental illness

Objectiveto explore and gain insight into the expectations and experiences of women with a pre-existing diagnosis of mental illness, of their first booking appointment; to make recommendations for practice development and collaborative partnership working between healthcare professionals. Designa qualitative design using semi structured interviews and thematic analysis of the data. QSR NVivo 10 software is used to organise the data into themes. Settingthe interviews took place either at the women׳s homes, or within the antenatal service with the consent of the woman and relevant practitioners. Participantstwelve participants were selected from one antenatal clinic and one perinatal mental health service. Findingsthe themes identified within the data included the lack of information prior to the initial midwife booking appointment; the perception of too much information at the initial booking appointment and women not being clear about their mental health needs at this time; a general positivity about disclosing mental illness diagnoses; overall positive thoughts about midwives although some midwives appeared less knowledgeable about bipolar disorder, and perceptions about a lack of joined up working between antenatal and perinatal mental health services. Key conclusions and implications for practiceit is recommended that GPs receive adequate training in order to equip them with the skills needed to discuss sensitive issues around perinatal mental illness and the impact on pregnancy and childbirth. Women require more information about their booking appointment, and it would be beneficial for their emotional and physical health needs to be assessed at each follow-up antenatal appointment. Midwives need to be facilitated to receive up-to-date knowledge of antenatal and postnatal mental illness and treatments, and the referral process to perinatal mental health services.

Individual and Contextual Determinants of Adequate Maternal Health Care Services in Kenya

This study aimed to examine individual and community level factors associated with adequate use of maternal antenatal health services in Kenya. Individual and community level factors associated with adequate use of maternal health care (MHC) services were obtained from the 2008–09 Kenya Demographic and Health Survey data set. Multilevel partial-proportional odds logit models were fitted using STATA 13.0 to quantify the relations of the selected covariates to adequate MHC use, defined as a three-category ordinal variable. The sample consisted of 3,621 women who had at least one live birth in the five-year period preceding this survey. Only 18 percent of the women had adequate use of MHC services. Greater educational attainment by the woman or her partner, higher socioeconomic status, access to medical insurance coverage, and greater media exposure were the individual-level factors associated with adequate use of MHC services. Greater community ethnic diversity, higher community-level socioeconomic status, and greater community-level health facility deliveries were the contextual-level factors associated with adequate use of MHC. To improve the use of MHC services in Kenya, the government needs to design and implement programs that target underlying individual and community level factors, providing focused and sustained health education to promote the use of antenatal, delivery, and postnatal care.

Factors related to utilization of antenatal care in Nepal: A generalized linear approach

Background: Antenatal care provides an entry point for pregnant women to the health care system. Proper utilization of available health services essential for successful implementation of health programmes. Objectives: This study investigates factors associated with the use of maternal health services in terms of number of antenatal care visits. Methods: For analyzing the use of antenatal care health services in Nepal, data was extracted from individual recodes of a data file of Nepal Demographic Health Survey 2006. The unit of analysis for this study was Ever Married Woman (who had at least one live birth in the five years preceding the survey). The sample of study consisted of 4182 Ever Married Woman. The response variable has numbers as its possible outcome therefore generalized Poisson regression model was selected for establishing linkage between number of antenatal care visits and several explanatory variables. Results: The result of this study shows that women with low education level, those residing in rural areas and those with low socio-economic status are less likely to attend antenatal care visits. Conclusion: This study confirms that antenatal care visit is indeed an effective entry point for delivery care. Programmes directed at improving and increasing the accessibility of antenatal care are important to improve maternal health, especially in developing countries like Nepal.DOI: http://dx.doi.org/10.3126/jkmc.v2i2.10629Journal of Kathmandu Medical College, Vol. 2, No. 2, Issue 4, Apr.-Jun., 2013, Page: 69-74

Individual and community determinants of neonatal mortality in Ghana: a multilevel analysis

BackgroundNeonatal mortality is a global challenge; identification of individual and community determinants associated with it are important for targeted interventions. However in most low and middle income countries (LMICs) including Ghana this problem has not been adequately investigated as the impact of contextual factors remains undetermined despite their significant influence on under-five mortality and morbidity.MethodsBased on a modified conceptual framework for child survival, hierarchical modelling was deployed to examine about 6,900 women, aged 15 – 49 years (level 1), nested within 412 communities (level 2) in Ghana by analysing combined data of the 2003 and 2008 Ghana Demographic and Health Survey. The aim was to identify individual (maternal, paternal, neonatal, antenatal, delivery and postnatal) and community (socioeconomic disadvantage communities) determinants associated with neonatal mortality.ResultsThe results showed both individual and community characteristics to be associated with neonatal mortality. Infants of multiple-gestation [OR 5.30; P-value < 0.001; 95% CI 2.81 – 10.00], neonates with inadequate birth spacing [OR 3.47; P-value < 0.01; 95% CI 1.60 – 7.57] and low birth weight [OR 2.01; P-value < 0.01; 95% CI 1.23 – 3.30] had a lower chance of surviving the neonatal period. Similarly, infants of grand multiparous mothers [OR 2.59; P-value < 0.05; 95% CI 1.03 – 6.49] and non-breastfed infants [OR 142.31; P-value < 0.001; 95% CI 80.19 – 252.54] were more likely to die during neonatal life, whereas adequate utilization of antenatal, delivery and postnatal health services [OR 0.25; P-value < 0.001; 95% CI 0.13 – 0.46] reduced the likelihood of neonatal mortality. Dwelling in a neighbourhood with high socioeconomic deprivation was associated with increased neonatal mortality [OR 3.38; P-value < 0.01; 95% CI 1.42 – 8.04].ConclusionBoth individual and community characteristics show a marked impact on neonatal survival. Implementation of community-based interventions addressing basic education, poverty alleviation, women empowerment and infrastructural development and an increased focus on the continuum-of-care approach in healthcare service will improve neonatal survival.

Responding to the Christmas Island health care crisis

To the Editor: Recent media reports of unsafe maternal and child health practices at the Christmas Island immigration detention centre suggest an alarming contrast between the care available to asylum seekers and that available to Australian nationals.1,2 The reports also appear at odds with the Department of Immigration and Border Protection's factsheet that states: “All detainees in immigration detention have access to health care at a standard generally comparable to the health care available to the Australian community”3 — though the use of “generally” allows for unqualified departure from the standard. Australia's low infant mortality rate (3.3/1000 births)4 is testament to high-quality specialist antenatal, perinatal and child health services. Yet on Christmas Island, where pregnant women are detained and for whom Australia has a duty of care, there is no sonographer. A pregnant woman who was denied an ultrasound and miscarried was apparently told: “They keep telling me that you are in detention centre and should not expect a lot”.1 This seems somewhat callous — since current policy appears designed to routinely detain pregnant women on Christmas Island. In our view, if this is to happen, then it is reasonable for a mother to expect access to appropriate antenatal and perinatal care, and for that care to be provided. Doctors providing services on the island have raised concerns that routine developmental screening and assessment does not occur for children, and that specialist paediatric mental health support is not available.2 While we oppose the detention of children, if it occurs, then adequate child health services must be provided. Remoteness is not an excuse: Australia has considerable history and expertise in providing health care services against geographical challenges, whether by specialist outreach services or by aeromedical retrieval. Australia also has one of the largest reported paediatric telemedicine services, which has provided specialist advice, including in perinatal care and child and youth mental health, throughout Queensland since 1999.5 While local clinical resources clearly need to be increased, support could and should be provided to clinicians through the appropriate use of telemedicine. It need not be technically complex or expensive, and the necessary resources exist within Australia. No relevant disclosures.

Risk Factors for Congenital Syphilis and Adverse Pregnancy Outcomes in Offspring of Women With Syphilis in Shenzhen, China

Despite existence of a highly effective intervention, maternal syphilis still causes substantial perinatal morbidity and mortality, even in China, where antenatal health services are strong. This study sought to address personal, programmatic, and other risk factors for congenital syphilis (CS) and adverse pregnancy outcomes (APOs) among pregnant women in Shenzhen, China. Pregnant women attending antenatal services were offered serologic tests, and those diagnosed as having syphilis were recruited from April 2007 to October 2012. In a nested case-control study for the pregnancy outcomes of syphilis-infected women, we assessed risk factors comparing infants born with CS (group II) and with any APOs (group III) to infants without CS or APOs (group I). During the 66-month study period, we screened 279,334 pregnant women and identified 838 (0.3%; 95% confidence interval, 0.28%-0.32%) women infected with syphilis. Among infants born to syphilitic mothers, 8.2% (34/417) were diagnosed as having CS and 24.7% (103/417) were diagnosed as having APOs. Compared with group I, maternal baseline titers of nontreponemal antibodies (adjusted odds ratio [aOR], 2.13), stage of syphilis (aOR, 21.56), length of time between the end of the first treatment to childbirth (aOR, 11.93), gestational week at treatment (aOR, 2.63), and fathers' cocaine use (aOR, 15.44) and syphilis infection status (aORpositive vs. negative, 5.84; aORunknown vs. negative, 5.55) were positively associated with CS, but prenatal care (aOR, 0.11) and complete treatment (aOR, 0.20) were negatively associated with CS. Maternal age (aOR, 1.43), marriage (aOR, 2.41), history of cocaine use (aOR, 3.79) and ectopic pregnancy (aOR, 5.91), baseline titers of nontreponemal antibodies (aOR, 1.30), stage of syphilis (aOR, 8.89), length of time between the end of the first treatment to childbirth (aOR, 2.52), gestational week at treatment (aOR, 1.78), and fathers' syphilis infection status (aORunknown vs. negative, 2.02) were also positively associated with APOs, but maternal history of syphilis (aOR, 0.44), prenatal care (aOR, 0.29), and complete treatment (aOR, 0.25) were negatively associated with APOs, Syphilis was an important cause of pregnancy loss and infant disability, particularly among women who did not receive prenatal care or had late or inadequate treatment. These study results can inform antenatal programs on the importance of early syphilis testing and prompt and appropriate treatment. Some strategies targeted at other risk factors areas may be helpful.