Community-based Antenatal Care Research Articles

Integration of a tobacco cessation program into a rural community-based maternal and child health program in India: A stakeholders' perspective on task shifting.

According to the Global Adult Tobacco Survey-2, India, 7.5% of pregnant women are tobacco users with a high prevalence of smokeless tobacco use in rural India. Although pregnant women may receive advice to quit tobacco, lack of knowledge on providing cessation support among healthcare workers results in missed opportunities. Community Health Workers (CHWs) play a significant role in maternal and child health (MCH) programs. Thus, task-shifting for providing cessation support by CHWs was planned and the perceptions and attitudes of concerned stakeholders were explored. A pre-implementation qualitative study was conducted in four states of India within existing rural, community-based MCH program settings. Implementation research frameworks were used to develop data collection tools and for inductive and deductive thematic analysis. In-depth interviews were conducted with stakeholders (n=28) like coordinators, pregnant women and village functionaries of the government health system. Four focus groups were conducted with female CHWs (n=24). Stakeholders intended to adopt the intervention as objectives of the cessation intervention were aligned with the aims of the MCH program. CHWs related to their role in task-shifting and understood the context for implementing the intervention within the MCH program. Pregnant women expressed openness to receiving cessation support from CHWs acting as a facilitator for task-shifting. Barriers anticipated were the additional workload and time required for CHWs to implement the intervention. Task-shifting to female CHWs for screening tobacco users, providing brief advice and cessation support within the MCH program was perceived to be acceptable, adoptable and feasible. The study builds insight into the process of developing a grounded approach for the integration of tobacco cessation intervention into a rural, community-based antenatal care setting by task shifting to female community health workers for providing cessation support to pregnant women. The study fills gaps in the literature related to establishing tobacco cessation interventions for pregnant women. The delineated efforts in integration of the intervention and task shifting can be replicated in other developing countries, especially in rural communities within South Asian and Southeast Asian regions having cultural practices, community-based healthcare structures and tobacco consumption patterns that are comparable to India.

Migrant women’s experiences of an individual language-assisted information and support visit to the labor ward before giving birth – A qualitative study from Sweden

BackgroundMigrant women are less likely to receive an individualized maternal care where they feel safe, informed and supported but few measures have been undertaken to meet their needs. In Södertälje municipality in Sweden, community-based antenatal care midwives identify migrant women and offer them and their partners language-assisted information and support through an individual two-hour-visit to the labor ward. The aim of the present study was to explore migrant women’s experiences of antenatal care including receiving language-assisted information and support during pregnancy through a two-hour INFOR-visit to the labor ward. MethodsSemi-structured interviews were conducted with 10 non-Swedish speaking migrant women, using an interpreter. Interview analysis was conducted using reflexive thematic analysis. ResultsThe individualized support, including thorough information given with language support available, sufficient time for questions and discussion, and a caring approach – did appear to inform and reassure the women. Overall, they felt that they were seen and treated as individuals during both pregnancy and birth and that their specific needs were listened to and met by the health care providers. Having professional interpreters was seen as essential for receiving the right information, something achieved at the individual visit. ConclusionsThe findings from this study provide evidence that a two-hour-visit to the labor ward during pregnancy has potential to empower migrant women during pregnancy and birth and to improve their experiences of maternity care. The two-hour-visit is a relatively simple intervention with the potential of not only improving migrant women’s experiences of pregnancy and birth, but also their medical outcomes.

Project20: Does continuity of care and community-based antenatal care improve maternal and neonatal birth outcomes for women with social risk factors? A prospective, observational study.

Social factors associated with poor childbirth outcomes and experiences of maternity care include minority ethnicity, poverty, young motherhood, homelessness, difficulty speaking or understanding English, migrant or refugee status, domestic violence, mental illness and substance abuse. It is not known what specific aspects of maternity care work to improve the maternal and neonatal outcomes for these under-served, complex populations. This study aimed to compare maternal and neonatal clinical birth outcomes for women with social risk factors accessing different models of maternity care. Quantitative data on pregnancy and birth outcome measures for 1000 women accessing standard care, group practice and specialist models of care at two large, inner-city maternity services were prospectively collected and analysed using multinominal regression. The level of continuity of care and place of antenatal care were used as independent variables to explore these potentially influential aspects of care. Outcomes adjusted for women's social and medical risk factors and the service attended. Women who received standard maternity care were significantly less likely to use water for pain relief in labour (RR 0.11, CI 0.02-0.62) and have skin to skin contact with their baby shortly after birth (RR 0.34, CI 0.14-0.80) compared to the specialist model of care. Antenatal care based in the hospital setting was associated with a significant increase in preterm birth (RR 2.38, CI 1.32-4.27) and low birth weight (RR 2.31, CI 1.24-4.32), and a decrease in induction of labour (RR 0.65, CI 0.45-0.95) compared to community-based antenatal care, this was despite women's medical risk factors. A subgroup analysis found that preterm birth was increased further for women with the highest level of social risk accessing hospital-based antenatal care (RR 3.11, CI1.49-6.50), demonstrating the protective nature of community-based antenatal care. This research highlights how community-based antenatal care, with a focus on continuity of carer reduced health inequalities and improved maternal and neonatal clinical outcomes for women with social risk factors. The findings support the current policy drive to increase continuity of midwife-led care, whilst adding that community-based care may further improve outcomes for women at increased risk of health inequalities. The relationship between community-based models of care and neonatal outcomes require further testing in future research. The identification of specific mechanisms such as help-seeking and reduced anxiety, to explain these findings are explored in a wider evaluation.

Assessment of Community-based Antenatal Care Services Provided by Midwives in River Nile State, Sudan, 2017

Assessment of Community-based Antenatal Care Services Provided by Midwives in River Nile State, Sudan, 2017

Exploration of preterm birth rates associated with different models of antenatal midwifery care in Scotland: Unmatched retrospective cohort analysis

Objectivespreterm birth represents a significant personal, clinical, organisational and financial burden. Strategies to reduce the preterm birth rate have had limited success. Limited evidence indicates that certain antenatal care models may offer some protection, although the causal mechanism is not understood. We sought to compare preterm birth rates for mixed-risk pregnant women accessing antenatal care organised at a freestanding midwifery unit (FMU) and mixed-risk pregnant women attending an obstetric unit (OU) with related community-based antenatal care. Methodsunmatched retrospective 4-year Scottish cohort analysis (2008–2011) of mixed-risk pregnant women accessing (i) FMU antenatal care (n=1107); (ii) combined community-based and OU antenatal care (n=7567). Data were accessed via the Information and Statistics Division of the NHS in Scotland. Aggregates analysis and binary logistic regression were used to compare the cohorts׳ rates of preterm birth; and of spontaneous labour onset, use of pharmacological analgesia, unassisted vertex birth, and low birth weight. Odds ratios were adjusted for age, parity, deprivation score and smoking status in pregnancy. Findingsafter adjustment the ‘mixed risk’ FMU cohort had a statistically significantly reduced risk of preterm birth (5.1% [n=57] versus 7.7% [n=583]; AOR 0.73 [95% CI 0.55–0.98]; p=0.034). Differences in these secondary outcome measures were also statistically significant: spontaneous labour onset (FMU 83.9% versus OU 74.6%; AOR 1.74 [95% CI 1.46–2.08]; p<0.001); minimal intrapartum analgesia (FMU 53.7% versus OU 34.4%; AOR 2.17 [95% CI 1.90–2.49]; p<0.001); spontaneous vertex delivery (FMU 71.9% versus OU 63.5%; AOR 1.46 [95% CI 1.32–1.78]; p<0.001). Incidence of low birth weight was not statistically significant after adjustment for other variables. There was no significant difference in the rate of perinatal or neonatal death. Conclusionsgiven this study׳s methodological limitations, we can only claim associations between the care model and or chosen outcomes. Although both cohorts were mixed risk, differences in risk levels could have contributed to these findings. Nevertheless, the significant difference in preterm birth rates in this study resonates with other research, including the recent Cochrane review of midwife-led continuity models. Because of the multiplicity of risk factors for preterm birth we need to explore the salient features of the FMU model which may be contributing to this apparent protective effect. Because a randomised controlled trial would necessarily restrict choice to pregnant women, we feel that this option is problematic in exploring this further. We therefore plan to conduct a prospective matched cohort analysis together with a survey of unit practices and experiences.

Factors associated with maternal health knowledge through community-based antenatal care program among pregnant women in rural Paraguay

Factors associated with maternal health knowledge through community-based antenatal care program among pregnant women in rural Paraguay

Relative Efficacy of Micronutrient Powders versus Iron—Folic Acid Tablets in Controlling Anemia in Women in the Second Trimester of Pregnancy

Iron deficiency is a major cause of anemia and the most prevalent nutrient deficiency among pregnant women in developing countries. The use of iron and folic acid supplements to treat and prevent iron-deficiency anemia has limited effectiveness, mainly due to poor adherence. Home fortification with a micronutrient powder for pregnant women may be an effective and acceptable alternative to traditional drug models. To determine whether home fortification with micronutrient powders is at least as efficacious as iron and folic acid tablets for improving hemoglobin concentration in pregnant women. A cluster-randomized noninferiority trial was conducted in the rural subdistrict of Kaliganj in central Bangladesh. Pregnant women (gestational age 14-22 weeks, n=478), were recruited from 42 community-based Antenatal Care Centres. Each centre was randomly allocated to receive either a micronutrient powder (containing iron,folic acid, vitamin C, and zinc) or iron and folic acid tablets. Changes in hemoglobin from baseline were compared across groups using a linear mixed-effects regression model. At enrolment, the overall prevalence of anemia was 45% (n = 213/478). After the intervention period, the mean hemoglobin concentrations among women receiving the micronutrient powder were not inferior to those among women receiving tablets (109.5 ± 12.9 vs. 112.0 ± 11.2 g/L; 95% CI, -0.757 to 5.716). Adherence to the micronutrient powder was lower than adherence to tablets (57.5 ± 22.5% vs. 76.0 ± 13.7%; 95% CI, -22.39 to -12.94); however, in both groups, increased adherence was positively correlated with hemoglobin concentration. The micronutrient powder was at least as efficacious as the iron and folic acid tablets in controlling moderate to severe anemia during pregnancy.

Training of Healthcare Personnel to Improve Performance of Community-Based Antenatal Care Program

The present study was performed to evaluate the effectiveness of a training course designed to improve the knowledge, skills, and attitudes of healthcare personnel to allow them to provide a comprehensive community-based antenatal care (ANC) program in rural Paraguay. Sixty-eight of 110 healthcare personnel in the Caazapa Region of Paraguay participated in a nine-day training course between November 1997 and March 1998. The knowledge of the participants related to maternal healthcare services was assessed both before and after the training course, and enrollment rates of pregnant women in ANC before and after the training were compared as a measure of patient satisfaction. The participants were also asked to evaluate the appropriateness of each individual method used in the training course. The average scores of the participants' knowledge increased significantly from 41.0 before to 60.1 after training (p<0.001). The enrollment rates of pregnant women in ANC increased from 2.2 times per pregnancy in 1996 to 3.4 times in 1998 (p<0.001). The participants reported that role-playing, demonstrations using visual information, and hands-on practice at a hospital were useful training methods. Continuous training for healthcare personnel in rural Paraguay contributes to an increase in their capacity to carry out community-based ANC program. The participants reported that learning through peer-educators, interactive communications, role-playing, and supervision provided in actual community services were beneficial. Continuous supervision should be provided to enable healthcare personnel to maintain the knowledge and skills acquired in the training.

Improvement in maternal health literacy among pregnant women who did not complete compulsory education: policy implications for community care services

This paper examined factors that influence the improvement in maternal health literacy among pregnant women in Paraguay, including those who did not complete compulsory education but participated in a community-based antenatal care program. Structured interviews were conducted to evaluate the pregnant women's maternal health literacy during their first, second, and third visits to the program in the Caazapa Region. The associations between individual maternal health knowledge scores and its gains, healthcare personnel capabilities, available health facility equipment, community social network, and living environment were analyzed by multiple regression analysis. The mean maternal health knowledge score from 124 women who completed three-consecutive assessments increased between the first and third interviews. Higher capabilities of healthcare personnel and better living environment were significantly related to gains in the maternal health knowledge score ( p < 0.01). Wider application of a community-based antenatal care program to meet the needs of those who are functionally illiterate in the standard language of the country, training for community healthcare personnel to improve capabilities, and resources for social network in the community would contribute to the improvement in maternal health literacy.

Anaemia and iron deficiency during pregnancy in rural Bangladesh

To study the prevalence of anaemia and its association with measures of iron deficiency (ID) among a group of pregnant women. Cross-sectional survey. Pregnant women identified through house-to-house visits and participating in community-based antenatal care activities in a rural location of Mymensingh, Bangladesh. The estimates are based on 214 reportedly healthy pregnant women in their second trimester. Information on socio-economic status and reproductive history were obtained through home visits and venous blood samples were collected at antenatal care centres. Haemoglobin concentration (Hb) was measured by HemoCue, serum ferritin (sFt) by radioimmunoassay and serum transferrin receptor (sTfR) by enzyme-linked immunosorbent assay methods. ID was defined as presence of either low sFt (<12 microg l(-1)) or high sTfR (>8.5 mg l(-1)). The prevalence of anaemia (Hb <110 g l(-1)) was 50%, but severe anaemia (Hb <70 g l(-1)) was absent. Low sFt was observed in 42%, high sTfR in 25%, either low sFt or high TfR in 54% and both low sFt and high TfR in 13% of the pregnant women. Two out of three anaemic women had an indication of ID, which was present in 80% of women with moderate (Hb 70-99 g l(-1)) and 50% with mild (Hb 100-109 g l(-1)) anaemia. Four out of 10 non-anaemic women (Hb >/=110 g l(-1)) also had ID, but the prevalence was significantly lower than that observed in anaemic women (P=0.001). Despite the high prevalence of anaemia, severe cases were absent. The prevalence of ID increased at lower Hb. However, an increased prevalence was also found among women in the highest category of Hb.