Timing Of Antenatal Care Visit Research Articles

Socioeconomic inequality in timing of ANC visit among pregnant women in Ethiopia, 2019.

Antenatal care (ANC) remains an invaluable approach to preventive care for ensuring maternal and infant health outcomes. Women in sub-Saharan Africa tend to delay their first antenatal care visits. In Ethiopia, only 20% of women received their first antenatal care during the first trimester of pregnancy. Timely and appropriate antenatal care practices can potentially save the lives of both mothers and children. Understanding socioeconomic inequality in the timing of antenatal care visits and its determinants may contribute to tackling disparities and achieving the sustainable development goals for maternal health. This study aimed to assess the socioeconomic inequality in the timing of antenatal care visit. Secondary data sourced from the Mini Ethiopian Demographic Health Survey 2019 were used for this study. A total of 2,906 pregnant women were included in the study, and concentration curves were used to show inequality among sociodemographic and economic variables. Decomposition analysis was performed to estimate the contribution of each independent variable to the inequality in the timing of antenatal care visits. The estimate of early initiation of antenatal care was 63%. The concentration index was 0.18 (P < 0.001). The inequality in the timing of antenatal care visit was more concentrated among the wealthiest pregnant women with a concentration index value of 0.18 (P < 0.001). Based on decomposition analysis results, the wealth index (81.9%.), education status (22.29%), and region (0.0642%) were identified as contributing factors to the inequality in the timing of antenatal care visits among women. The wealth index, educational status, and region were significant contributors to inequality in the early initiation of antenatal care visit. Improving women's wealth and education and narrowing the inequality gap are crucial for improving the health status of women and their children. We should focus on interventions targeted at early antenatal care visit to address the determinants of socioeconomic inequities.

Individual and community-level determinants of skilled birth attendant delivery in Ethiopia; multilevel analysis.

Skilled birth attendant (SBA) delivery is defined as assisting birth by a trained healthcare provider, which is vital for the health of mothers and newborns. Improving maternal health is one of the world health organization's (WHO) key priorities and skilled birth attendant delivery is one of the four pillars of the initiative for safe motherhood to reduce maternal mortality. Therefore, this study aimed to assess the individual and community-level factors associated with SBA delivery in Ethiopia. A secondary data analysis was conducted using the 2019 Mini Ethiopian demographic and health survey. A total of 5,527 (weighted) live births were included in the analysis. A multi-level logistic regression model was fitted using Stata 14.0 to identify individual and community-level factors associated with SBA delivery. Finally, AOR with 95% CI and random effects were reported. In this study after fitting a multilevel model, women with poor (AOR = 0.44 95%CI 0.32-0.61) and middle wealth index (AOR = 0.64;95% CI 0.46-0.87), multipara (AOR = 0.39;95% CI 0.28-0.55) and grand multipara (AOR = 0.46;95% CI 0.29-0.72), women from rural areas (AOR = 0.34;95% CI 0.16-0.72) and high community poverty level (AOR = 0.40;95% CI 0.21-0.76) had decreased odds of having SBA delivery. Whereas those who initiated Antenatal care (ANC) visits in the first trimester (AOR = 2.65; 95% CI 1.52-4.65) and second trimester (AOR = 1.87:95%CI 1.09-3.20) had increased odds of having SBA delivery in Ethiopia. In this study socioeconomic factors like wealth index, parity, the timing of ANC visits, place of residency, and community poverty level were significantly associated with SBA delivery. Therefore, it is better to increase timely ANC initiation particularly for women with low levels of income to improve skilled birth attendant delivery.

Survival Analysis and Factors of the Timing of Antenatal Care Visit in Ethiopia: Accelerated Failure Time Shared Frailty Models

Antenatal care is the care given to pregnant women and adolescent girls by trained healthcare professionals. In 2017, almost 295,000 women lost their lives during, immediately after, or soon after childbirth in Ethiopia. The time of the first antenatal visit must be determined in order to enhance the health of pregnant women and their infants. The most recent Demographic and Health Survey (DHS) survey datasets from 2019 are used in this study.

Impact of Antenatal Care on Perinatal Outcomes in New South Wales, Australia: A Decade-Long Regional Perspective.

Low birth weight (LBW) and preterm birth are adverse perinatal outcomes that pose a significant risk to a child's healthy beginning. While antenatal care (ANC) is an established intervention for pregnancy care, little is understood about how the number and timing of ANC visits can impact these adverse health outcomes. This study aimed to examine the impact of the number and timing of ANC visits on LBW and preterm birth in a regional setting. A decade-long perinatal dataset related to singleton live births that took place in the Southern New South Wales Local Health District (SNSWLHD) was utilized. The outcomes of interest were LBW and preterm birth, and the exposure variables were based on the Australian pregnancy guidelines on the number and timing of ANC visits. A multivariable logistic regression was performed to measure the association between outcome and exposure while adjusting for potential confounders. A greater level of protection against LBW and preterm birth was observed among mothers who had an adequate number of visits, with early entry (first trimester) into ANC. The protective effect of an adequate number of ANC visits against LBW and preterm birth among mothers with late entry into ANC (third trimester) was found to be statistically non-significant.

Modeling the Ranked Antenatal Care Visits Using Optimized Partial Least Square Regression.

The frequency and timing of antenatal care visits are observed to be the significant factors of infant and maternal morbidity and mortality. The present research is conducted to determine the risk factors of reduced antenatal care visits using an optimized partial least square regression model. A data set collected during 2017-2018 by Pakistan Demographic and Health Surveys is used for modeling purposes. The partial least square regression model coupled with rank correlation measures are introduced for improved performance to address ranked response. The proposed models included PLSρs, PLSτA, PLSτB, PLSτC, PLS D, PLSτGK, PLS G, and PLS U. Three filter-based factor selection methods are executed, and leave-one-out cross-validation by linear discriminant analysis is measured on predicted scores of all models. Finally, the Monte Carlo simulation method with 10 iterations of repeated sampling for optimization of validation performance is applied to select the optimum model. The standard and proposed models are executed over simulated and real data sets for efficiency comparison. The PLSρs is found to be the most appropriate proposed method to model the observed ranked data set of antenatal care visits based on validation performance. The optimal model selected 29 influential factors of inadequate use of antenatal care. The important factors of reduced antenatal care visits included women's educational status, wealth index, total children ever born, husband's education level, domestic violence, and history of cesarean section. The findings recommended that partial least square regression algorithms coupled with rank correlation coefficients provide more efficient estimates of ranked data in the presence of multicollinearity.

Health insurance coverage and maternal healthcare services utilization in Jordan: evidence from the 2017\u201318 Jordan demographic and health survey

BackgroundDespite the relationship between health insurance coverage and maternal healthcare services utilization, previous studies in Jordan on the use of maternal healthcare services have mainly focused on patterns and determinants of maternal healthcare services utilization in Jordan. Therefore, this study investigated the relationship between health insurance coverage and maternal healthcare services utilization in Jordan.MethodsThis study used secondary data published in 2017-18 Jordan Demographic and Health Survey on 4656 women of reproductive age (15–49 years). The independent variable was health insurance coverage and the outcome variable was maternal healthcare services utilization, measured through timing of first antenatal visit, four or more antenatal care visits, and skilled birth attendance. The data were analyzed using descriptive statistics and binary logistic regression.ResultsOut of the total number of women who participated in the study, 38.2% were not covered by health insurance. With maternal healthcare utilization, 12.5%, 23.2%, and 10.1% respectively, failed to make early first antenatal care visit, complete four or more antenatal care visits and have their delivery attended by a skilled worker. After controlling for the socio-demographic factors, health insurance coverage was associated with increased odds of early timing of first antenatal care visits and completion of four or more antenatal care visits (aOR = 1.33, p < 0.05, aOR = 1.25, p < 0.01, respectively). However, women who were covered by health insurance were less likely to use skilled birth attendance during delivery (aOR = 0.72 p < 0.001).ConclusionsJordanian women with health insurance coverage were more likely to have early first antenatal care visits and complete four or more antenatal care visits. However, they were less likely to have their delivery attended by a skilled professional. This study provides evidence that health insurance coverage has contributed to increased maternal healthcare services utilization, only in terms of number and timing of antenatal care visits in Jordan. It is recommended that policy makers in Jordan should strengthen the coverage of health insurance in the country, especially among women of reproductive age in order to enhance the use of maternal healthcare services in the country.

Factors associated with the number and timing of antenatal care visits among married women in Cameroon: evidence from the 2018 Cameroon Demographic and Health Survey.

Utilization of antenatal care (ANC) services, as part of reproductive health care, presents a lifesaving chance for health promotion and the early diagnosis and treatment of illnesses throughout pregnancy. This study examines the factors associated with the number and timing of ANC visits among married women in Cameroon using data from the 2018 Cameroon Demographic and Health Survey. The outcome variables were number of ANC visits, categorized as <8 visits or ≥8 visits, and the timing of first ANC visit, categorized as ≤3 months (early) or >3 months (late) (as per the new 2016 WHO recommendations). Descriptive statistics and binary logistic regression were used to analyse the data. Crude odds ratios (cOR) and adjusted odds ratios (aOR) and p-values with significance at <0.05 were used to interpret the results. The proportions of women who had ≥8 ANC visits and first ANC visit at ≤3 months gestation were 6.3% and 35.6% respectively. Women aged 35-39 at childbirth (aOR=3.99, 95% CI=1.30-12.23), middle wealth quintile women (aOR=3.22, 95% CI=1.01-10.27), women whose husbands had secondary (aOR=7.00, 95% CI=2.26-21.71) or higher (aOR=16.93, 95% CI=4.91-58.34) education were more likely to have ≥8 ANC visits. Early timing of first ANC visit was low among women with birth order 3-4 (aOR=0.63, 95% CI=0.46-0.85). Conversely, the likelihood of having early ANC visits was high among women whose pregnancies were intended (aOR=1.32, 95% CI=1.01-1.74), the richest women (aOR=3.89, 95% CI=2.30-6.57) and women whose husbands had secondary (aOR=2.41, 95% CI=1.70-3.64) or higher (aOR=3.12, 95% CI=2.40-7.46) education. The study highlights that age at childbirth, wealth, husband's educational attainment, birth order and pregnancy intention could influence the utilization of ANC services among married women in Cameroon. Hence, to improve attendance and early initiation of ANC, interventions should be targeted at empowering women financially and removing all financial barriers associated with accessing ANC, improving ANC education among women and encouraging male involvement in ANC education.

Examining barriers to healthcare access and utilization of antenatal care services: evidence from demographic health surveys in sub-Saharan Africa

BackgroundAntenatal care utilization is one of the means for reducing the high maternal mortality rates in sub-Saharan Africa. This study examined the association between barriers to healthcare access and implementation of the 2016 WHO antenatal care services model among pregnant women seeking antenatal care in selected countries in sub-Saharan Africa.MethodsThis study considered only Demographic and Health Survey data collected in 2018 in sub-Saharan Africa. Hence, the Demographic and Health Survey data of four countries in sub-Saharan Africa (Nigeria, Mali, Guinea and Zambia) were used. A sample of 6761 from Nigeria, 1973 from Mali, 1690 from Guinea and 1570 from Zambia was considered. Antenatal care visits, categorized as < 8 visits or ≥8 visits, and time of the first antenatal care visit, categorized as ≤3 months or > 3 months (as per the WHO recommendations) were the outcome variables for this study. Both descriptive statistics and ordinal logistic regression were used to analyze the data. Crude odds ratios (cOR) and adjusted odds ratios (aOR) and p-values < 0.05 were used for the interpretation of results.ResultsWith timing of antenatal care visits, getting money needed for treatment (aOR = 1.38, 95% CI = 1.03–1.92) influenced early timing of antenatal care visits in Mali whereas getting permission to visit the health facility (aOR = 1.62, 95% CI = 1.15–2.33) motivated women to have early timing of antenatal care visits in Guinea. We found that women who considered getting money needed for treatment as not a big problem in Nigeria were more likely to have the recommended number of antenatal care visits (aOR = 1.38, 95% CI= 1.11–1.73). On the contrary, in Guinea, Zambia and Mali, getting permission to visit health facilities, getting money for treatment, distance to the health facility and not wanting to go alone were not barriers to having ≥ 8 antenatal care visits.ConclusionOur study has emphasized the role played by barriers to healthcare access in antenatal care utilization across sub-Saharan African countries. There is the need for governmental and non-governmental organizations to ensure that policies geared towards improving the quality of antenatal care and promoting good interaction between health care seekers and health care providers are integrated within the health system.

Pregnancy intention data completeness, quality and utility in population-based surveys: EN-INDEPTH study

BackgroundAn estimated 40% of pregnancies globally are unintended. Measurement of pregnancy intention in low- and middle-income countries relies heavily on surveys, notably Demographic and Health Surveys (DHS), yet few studies have evaluated survey questions. We examined questions for measuring pregnancy intention, which are already in the DHS, and additional questions and investigated associations with maternity care utilisation and adverse pregnancy outcomes.MethodsThe EN-INDEPTH study surveyed 69,176 women of reproductive age in five Health and Demographic Surveillance System sites in Ghana, Guinea-Bissau, Ethiopia, Uganda and Bangladesh (2017–2018). We investigated responses to survey questions regarding pregnancy intention in two ways: (i) pregnancy-specific intention and (ii) desired-versus-actual family size. We assessed data completeness for each and level of agreement between the two questions, and with future fertility desire. We analysed associations between pregnancy intention and number and timing of antenatal care visits, place of delivery, and stillbirth, neonatal death and low birthweight.ResultsMissing data were <2% in all questions. Responses to pregnancy-specific questions were more consistent with future fertility desire than desired-versus-actual family size responses. Using the pregnancy-specific questions, 7.4% of women who reported their last pregnancy as unwanted reported wanting more children in the future, compared with 45.1% of women in the corresponding desired family size category. Women reporting unintended pregnancies were less likely to attend 4+ antenatal care visits (aOR 0.73, 95% CI 0.64–0.83), have their first visit during the first trimester (aOR 0.71, 95% CI 0.63–0.79), and report stillbirths (aOR 0.57, 95% CI 0.44–0.73) or neonatal deaths (aOR 0.79, 95% CI 0.64–0.96), compared with women reporting intended pregnancies. We found no associations for desired-versus-actual family size intention.ConclusionsWe found the pregnancy-specific intention questions to be a much more reliable assessment of pregnancy intention than the desired-versus-actual family size questions, despite a reluctance to report pregnancies as unwanted rather than mistimed. The additional questions were useful and may complement current DHS questions, although these are not the only possibilities. As women with unintended pregnancies were more likely to miss timely and frequent antenatal care, implementation research is required to improve coverage and quality of care for those women.

Uptake of maternal services and associated factors in the western region of Kenya.

Introductionthe western region of Kenya has high early childhood mortality and maternal mortality. Maternal services have been shown to an effective strategy for reducing early childhood mortality and maternal mortality.Methodsthe study used data drawn from the 2014 Kenya Demography and Health Survey. It focuses on 1397 women who had a live birth in the five years preceding the survey. The study is guided by Anderson behavioural model. Descriptive statistics and logistic regression are used to analysis the data.Resultsalmost all the women sought antenatal care (ANC) services during their most recent pregnancy. Only 20% of the women initiated ANC visits during the first trimester and 54% of the women made at least four ANC visits. Mother's education, household wealth index, county of residence and the timing of ANC visits were strongly associated with making at least four ANC visits. About 55% of the women had skilled attendance at delivery and 54% delivered in a health facility. Delivery in a health facility was influenced by the mother's education, household wealth index, type of place of residence, county of residence, timing of ANC visits and whether or not a women made at least four ANC visits.Conclusionthe uptake of ANC services is universal in the region. However majority of the women do not start ANC visits early and do not make at least four ANC visits as recommended. Slightly over half of the women receive skilled attendance at delivery and deliver in health facilities. A number of factors are closely associated with the uptake of maternal services in the region. Concerted efforts should be made to have the majority of the women in the region to initiate ANC visits early, to make at least 4 ANC visits and to deliver in health facilities.

Meeting the World Health Organization Maternal Antenatal Care Guidelines Is Associated with Improved Early and Middle Childhood Cognition in Ethiopia

To assess the association between meeting the World Health Organization (WHO) maternal antenatal care attendance guidelines and early and middle childhood cognition among impoverished Ethiopian children. A total of 1914 impoverished Ethiopian children from the Young Lives longitudinal cohort study were included. Childhood cognition was assessed via the Cognitive Development Assessment (CDA) and Peabody Picture Vocabulary Test (PPVT) at ages 4-5years; PPVT, Early Grade Reading Assessment (EGRA), and Math Test at ages 7-8years; and PPVT, Math Test, and Reading Test at ages 11-12years. Linear regression models were used to examine the association between maternal antenatal care attendance and childhood academic achievement test scores. In the univariable analysis, children of mothers who received the WHO recommended 4+ antenatal care visits or received the WHO recommended first antenatal care visit during the first trimester scored higher on all academic achievement tests. In the multivariable analysis, children of mothers who received 4+ antenatal care visits scored significantly higher on the CDA at ages 4-5years and Math Test at ages 7-8years. Children of mothers who received antenatal care in the first trimester scored higher on the CDA at ages 4-5years and Math Test scores at ages 11-12years. Children of mothers who received both antenatal care in the first trimester and 4+ antenatal care visits scored significantly higher on the CDA at ages 4-5years and Math Test at both ages 7-8 and 11-12years. Children of mothers who received the WHO recommended number and timing of antenatal care visits had significantly higher academic achievement scores across multiple domains during early and middle childhood. Promotion of antenatal care visit attendance may improve cognition through middle childhood.

Early initiations of first antenatal care visit and associated factor among mothers who gave birth in the last six months preceding birth in Bahir Dar Zuria Woreda North West Ethiopia

BackgroundTiming of Antenatal care booking is one of the basic components of antenatal care services; that helps to early detection, managing, and prevention of problems during the pregnancy and helps the mother to receive full packages of antenatal care services. However, in the world including Ethiopia, significant numbers of pregnant mothers were not booking the follow up on the recommended time. The main aim of this study was to assess the prevalence and factors that associated with the early timing of antenatal care visit in Bahir Dar Zuria District, North West Ethiopia.MethodsA community-based cross-sectional study was conducted. A total of 410 mothers have participated. Data were collected through the interview from March 1 to 30/2018 using a structured and pre-tested questionnaire. Data were clear, code, and enter into Epi-info version 7.1 and export to SPSS for farther analysis. Both bivariate and multivariate analyses were used. On bivariate analysis p-value, less than 0.2 were used to select the candidate variable for multivariate analysis. P-value and confidence interval were used to measure the level of significance on multivariate analysis and those variables whose P-value < 0.05 were considered as statically significant.ResultsThe prevalence of early timing of ANC in the study area was 46.8%; with [95% CI 40.5, 51.8]. Distances [AOR 2.47, 95% CI; 1.4, 4.2], Knowledge on the timing of ANC [AOR 2.1; 95% CI; 1.2, 3.7], No under-five children [AOR 2.7; 95% CI; 1.3, 5.8], having one under-five children [AOR 2.2; 95% CI; 1.1, 4.5], and wanted pregnancy [AOR 2.4, 95% CI, 1.3, 4.7] were affects the early timing of ANC.ConclusionsThe prevalence of early timing of ANC was high when compared to the national figure and the Sub-Saharan country. Accessibility of health services, knowledge on the timing of ANC, under-five children, and desire for pregnancy were factors that affect the early timing of ANC.

Postnatal Care Utilization and Associated Factors among Married Women in Benchi-Maji Zone, Southwest Ethiopia: A Community Based Cross-Sectional Study.

In Ethiopia, maternal health service utilization is very low, especially postnatal care (PNC). The percentage of mothers who receive care within two days of childbirth has shown little progress, from 2.4% in 2000 to 13% in 2014. However, it is very far below the expected level as compared to other sub-Saharan regions. Therefore, the aim of this study was to assess PNC services utilization and its associated factors among married women in Benchi-Maji Zone, Southwest Ethiopia. A cross-sectional study was conducted from June 15 to August 15, 2015. A total of 801 married women was sampled from randomly selected districts in the zone. Semi-structured questionnaire was used to collect, data and informed consent was obtained from participants. The collected data were entered into the computer using Epi-data version 3.0, and then exported to SPSS Windows version 20.0 for analysis. Logistic regression was used to identify important predictors of PNC utilization. Out of 765 participants, 392(51.24%) of married women who attended PNC in this study. Out of them, more than two-third 305(77.8%) attended mainly to immunize their baby. The vast majority, 251(86.3%), of respondents mentioned lack of information as a main reason for not following PNC, and of them, the majority mentioned that they were appointed to come after 45 days for Family Planning(FP). In comparison with house wives, farmer women were less likely (AOR 0.3, 95 % CI 0.2-0.7) to attend for PNC. Awareness of problems during postnatal period showed the strongest association in which those who knew the problems were about nine times (AOR 8.7 95 % CI 5.6-13.4) more likely to attend PNC. Similarly, married women who followed antenatal care (ANC) were more likely (AOR 2.2 95 % CI 1.1-4.6) to attend PNC in comparison with those who did not attend ANC at all. Residence, ANC follow-up, maternal occupation, awareness about problems of postnatal period had effects on use of PNC. In light of this study, providing deep counselling about PNC at the time of ANC visit and discharge after delivery is strongly recommended. Furthermore, targeting more of rural married women may increase PNC utilization.

Determinants of poor utilization of antenatal care services among recently delivered women in Rwanda; a population based study

BackgroundIn Rwanda, a majority of pregnant women visit antenatal care (ANC) services, however not to the extent that is recommended. Association between socio-demographic or psychosocial factors and poor utilization of antenatal care services (≤2 visits during the course of pregnancy irrespective of the timing) among recently pregnant women in Rwanda were investigated.MethodsThis population-based, cross sectional study included 921 women who gave birth within the past 13 months. Data was obtained using an interviewer-administered questionnaire. For the analyses, bi-and multivariable logistic regression was used and odds ratios were presented with their 95% confidence intervals.ResultsAbout 54% of pregnant women did not make the recommended four visits to ANC during pregnancy. The risk of poor utilization of ANC services was higher among women aged 31 years or older (AOR, 1.78; 95% CI: 1.14, 2.78), among single women (AOR, 2.99; 95% CI: 1.83, 4.75) and women with poor social support (AOR, 1.71; 95% CI: 1.09, 2.67). No significant associations were found for school attendance or household assets (proxy for socio-economic status) with poor utilization of ANC services.ConclusionOlder age, being single, divorced or widowed and poor social support were associated with poor utilization of ANC services. General awareness in communities should be raised on the importance of the number and timing of ANC visits. ANC clinics should further be easier to access, transport should be available, costs minimized and opening hours may be extended to facilitate visits for pregnant women.

Frequency and Timing of Antenatal Care Visits and Its Impact on Neonatal Mortality in EAG States of India

The study aims to examine the association between frequency of antenatal care visits and neonatal mortality in EAG states and to explore the relationship between the timing of first antenatal care visit in the trimester and neonatal mortality in EAG states of India. The study uses data from the third round of National Family Health Survey NFHS-3. The timing of the first antenatal visit and the relative number of ANC visits received by the women is studied separately. Logistic regression is applied to find an association between continuity, the timing of ANC received and neonatal birth outcome. Results explain significant association between mothers receiving ANC 4-9 visits had experienced a lower risk of neonatal mortality. Mothers who received antenatal care visit from the first trimester experienced lest pregnancy outcomes and neonatal deaths.

Pregnancy wantedness, frequency and timing of antenatal care visit among women of childbearing age in Kenya.

BackgroundA woman’s health seeking behaviour during pregnancy has been found to have significant repercussions on her wellbeing and that of her unborn child. For example, the risk of poor pregnancy outcomes and maternal death is higher among women who do not receive antenatal care.MethodsThe study described the characteristics of women who reported wanted, unwanted and mistimed pregnancies from their last birth at the time of the survey; the linkage between frequency of antenatal care visits and pregnancy wantedness and the relationship between timing of the first antenatal care visit and pregnancy wantedness since maternal morbidity and mortality are higher among women who do not receive antenatal care. The 2008-09 Kenya Demographic and Health Survey data is used and multinomial logistic regression and logistic regression informed the study analysis.ResultsResults showed that women, who reported wanted pregnancy were more likely to receive antenatal care while those who reported unwanted pregnancy were less likely to receive antenatal care, but more likely to attend late the first time and have fewer than four antenatal care visits. Also, mistimed pregnancies were associated with low frequency of antenatal care visit and late timing of the first visit.ConclusionOur findings confirm an association between pregnancy wantedness, frequency of antenatal care visits and timing of the first antenatal care visit. Women whose pregnancy was reported as mistimed and unwanted were more likely not to receive any antenatal care and when they did; they went for fewer than the recommended four visits with late timing. Health policy and strategies should ensure that all pregnant women regardless of their pregnancy status at the time of conception first receive antenatal care, and receive it in a timely manner and make at least four antenatal care visits before delivery. This will help to identify health complications that may arise during and after delivery and reduce maternal, new-born and infant mortality. Information, education and communication campaigns on family planning especially for spacing and matters related to antenatal care visits, timing and frequency should be intensified nationally.

The Influence of Distance and Level of Service Provision on Antenatal Care Use in Rural Zambia

BackgroundAntenatal care (ANC) presents important opportunities to reach women with crucial interventions. Studies on determinants of ANC use often focus on household and individual factors; few investigate the role of health service factors, partly due to lack of appropriate data. We assessed how distance to facilities and level of service provision at ANC facilities in Zambia influenced the number and timing of ANC visits and the quality of care received.Methods and FindingsUsing the 2005 Zambian national Health Facility Census, we classified ANC facilities according to the level of service provision. In a geographic information system, we linked the facility information to household data from the 2007 DHS to calculate straight-line distances. We performed multivariable multilevel logistic regression on 2405 rural births to investigate the influence of distance to care and of level of provision on three aspects of ANC use: attendance of at least four visits, visit in first trimester and receipt of quality ANC (4+ visits with skilled health worker and 8+ interventions).We found no effect of distance on timing of ANC or number of visits, and better level of provision at the closest facility was not associated with either earlier ANC attendance or higher number of visits. However, there was a strong influence of both distance to a facility, and level of provision at the closest ANC facility on the quality of ANC received; for each 10 km increase in distance, the odds of women receiving good quality ANC decreased by a quarter, while each increase in the level of provision category of the closest facility was associated with a 54% increase in the odds of receiving good quality ANC.ConclusionsTo improve ANC quality received by mothers, efforts should focus on improving the level of services provided at ANC facilities and their accessibility.

The combined effect of determinants on coverage of intermittent preventive treatment of malaria during pregnancy in the Kilombero Valley, Tanzania

BackgroundIntermittent preventive treatment during pregnancy (IPTp) at routine antenatal care (ANC) clinics is an important and efficacious intervention to reduce adverse health outcomes of malaria infections during pregnancy. However, coverage for the recommended two IPTp doses is still far below the 80% target in Tanzania. This paper investigates the combined impact of pregnant women's timing of ANC attendance, health workers' IPTp delivery and different delivery schedules of national IPTp guidelines on IPTp coverage.MethodsData on pregnant women's ANC attendance and health workers' IPTp delivery were collected from ANC card records during structured exit interviews with ANC attendees and through semi-structured interviews with health workers in south-eastern Tanzania. Women's timing of ANC visits and health worker's timing of IPTp delivery were analyzed in relation to the different national IPTp schedules and the outcome on IPTp coverage was modelled.ResultsAmong all women eligible for IPTp, 79% received a first dose of IPTp and 27% were given a second dose. Although pregnant women initiated ANC attendance late, their timing was in line with the national guidelines recommending IPTp delivery between 20-24 weeks and 28-32 weeks of gestation. Only 15% of the women delayed to the extent of being too late to be eligible for a first dose of IPTp. Less than 1% of women started ANC attendance after 32 weeks of gestation. During the second IPTp delivery period health workers delivered IPTp to significantly less women than during the first one (55% vs. 73%) contributing to low second dose coverage. Simplified IPTp guidelines for front-line health workers as recommended by WHO could lead to a 20 percentage point increase in IPTp coverage.ConclusionsThis study suggests that facility and policy factors are greater barriers to IPTp coverage than women's timing of ANC attendance. To maximize the benefit of the IPTp intervention, revision of existing guidelines is needed. Training on simplified IPTp messages should be consolidated as part of the extended antenatal care training to change health workers' delivery practices and increase IPTp coverage. Pregnant women's knowledge about IPTp and the risks of malaria during pregnancy should be enhanced as well as their ability and power to demand IPTp and other ANC services.

A Safe Motherhood project in Kenya: assessment of antenatal attendance, service provision and implications for PMTCT

To investigate uptake and provision of antenatal care (ANC) services in the Uzazi Bora project: a demonstration-intervention project for Safe Motherhood and prevention of mother-to-child transmission of HIV in Kenya. Data were extracted from antenatal clinic, laboratory and maternity ward registers of all pregnant women attending ANC from January 2004 until September 2006 at three antenatal clinics in Mombasa and two in rural Kwale district of Coast Province, Kenya (n = 25 364). Multiple logistic and proportional odds logistic regression analyses assessed changes over time, and determinants of the frequency and timing of ANC visits, uptake of HIV testing, and provision of iron sulphate, folate and single-dose nevirapine (sd-NVP). About half of women in rural and urban settings (52.2% and 49.2%, respectively) attended antenatal clinics only once. Lower parity, urban setting, older age and having received iron sulphate and folate supplements during the first ANC visit were independent predictors of more frequent visits. The first ANC visit occurred after 28 weeks of pregnancy for 30% (5894/19 432) of women. By mid-2006, provision of nevirapine to HIV-positive women had increased from 32.5% and 11.7% in rural and urban clinics, to 67.0% and 74.6%, respectively. Equally marked improvements were observed in the uptake of HIV testing and the provision of iron sulphate and folate. Provision of ANC services, including sd-NVP, increased markedly over time. While further improvements in quality are necessary, particular attention is needed to implement evidence-based interventions to alter ANC utilization patterns. Encouragingly, improved provision of basic essential obstetric care may increase attendance.

A Randomized Controlled Trial of Oral Administration of Tetanus Toxoid (TT) Versus Tetanus and Reduced Diphtheria (Td) in Pregnant Women

The present study was designed as a randomized clinical trial to compare the immunogenicity, reactogenicity, and efficacy of tetanus toxoid (TT) and the combined tetanus and reduced diphtheria (Td) in pregnant women in four rural communities in Egypt. The pregnant women in each four villages received either TT or Td randomly. Both TT and Td vaccines are manufactured by the Egyptian Company for Biological Products & Vaccines (VACSERA) in Egypt. A total of 131 pregnant women were enrolled during the time of antenatal care visit (at 20 weeks gestational age of pregnancy) in one of four health units in Abu Homos district, Beheira Governorate, Egypt. Unimmunized women received two random doses of either TT or Td 8 weeks apart during their pregnancy. Outpatient follow-up for adverse reactions occurred at the third day after each vaccine dose as either local effects such as pain, redness, and swelling or systematic effects such as fever, malaise, and headache or body aches which was served as primary safety endpoint. Blood was collected three times from each woman for determination of antibody titer against tetanus and diphtheria by using enzyme-linked immunosorbent assay technique. The first sample was collected immediately before the first dose, the second before the second dose, and the third sample 1 week after delivery. Active surveillance home visits to all study participants were done twice: the first home visit during the first week after delivery and the second 1 month after labor to report the health status of the mother and the baby. A total of 122 pregnant women received two ordinary doses with interdose intervals within the allowable range and three blood samples were collected in each protocol analysis (62 in the TT group and 60 in the Td group). There was no statistically significant difference between groups in the percentage of reporting a primary safety endpoint (fever, malaise, body ache, headache) or local reactions at the site of injection as redness and swelling, at third day after each dose. While in the Td group, after doses I and II, there was significant reporting pain at injection site as compared with TT group, home visits clinical examination revealed that the mothers and children were normal on in both groups. However, in the TT group, some children suffered from physiological jaundice. In all women in the two groups, protective immunity for tetanus was acquired, which reflected in neutralization of antibodies at titer (>0.10 IU/ml) after complete vaccination; however, the tetanus geometric mean titers postdoses I and II were significantly higher in TT vaccines group (P < 0.001). The postvaccination seroprotection titer (>0.10 IU/ml) in diphtheria was significantly higher in Td group than the TT group; diphtheria geometric mean titers of postdose II were significantly higher in Td vaccines as compared to the other group (P < 0.0001). From this results, we can conclude that the use of Td vaccine improves immunogenicity for both tetanus and diphtheria more than the use of TT vaccine alone and we can recommend to replace TT in immunization of pregnant women.