[Show abstract][Hide abstract] ABSTRACT: Donors and other development partners commonly introduce innovative practices and technologies to improve health in low and middle income countries. Yet many innovations that are effective in improving health and survival are slow to be translated into policy and implemented at scale. Understanding the factors influencing scale-up is important. We conducted a qualitative study involving 150 semi-structured interviews with government, development partners, civil society organisations and externally funded implementers, professional associations and academic institutions in 2012/13 to explore scale-up of innovative interventions targeting mothers and newborns in Ethiopia, the Indian state of Uttar Pradesh and the six states of northeast Nigeria, which are settings with high burdens of maternal and neonatal mortality. Interviews were analysed using a common analytic framework developed for cross-country comparison and themes were coded using Nvivo. We found that programme implementers across the three settings require multiple steps to catalyse scale-up. Advocating for government to adopt and finance health innovations requires: designing scalable innovations; embedding scale-up in programme design and allocating time and resources; building implementer capacity to catalyse scale-up; adopting effective approaches to advocacy; presenting strong evidence to support government decision making; involving government in programme design; invoking policy champions and networks; strengthening harmonisation among external programmes; aligning innovations with health systems and priorities. Other steps include: supporting government to develop policies and programmes and strengthening health systems and staff; promoting community uptake by involving media, community leaders, mobilisation teams and role models. We conclude that scale-up has no magic bullet solution – implementers must embrace multiple activities, and require substantial support from donors and governments in doing so.
[Show abstract][Hide abstract] ABSTRACT: Background
The lack of high quality timely data for evidence-informed decision making at the district level presents a challenge to improving maternal and newborn survival in low income settings. To address this problem, the EQUIP project (Expanded Quality Management using Information Power) implemented a continuous household and health facility survey for continuous feedback of data in two districts each in Tanzania and Uganda as part of a quality improvement innovation for mothers and newborns.Methods
Within EQUIP, continuous survey data were used for quality improvement (intervention districts) and for effect evaluation (intervention and comparison districts). Over 30 months of intervention (November 2011 to April 2014), EQUIP conducted continuous cross-sectional household and health facility surveys using 24 independent probability samples of household clusters to represent each district each month, and repeat censuses of all government health facilities. Using repeat samples in this way allowed data to be aggregated at six four-monthly intervals to track progress over time for evaluation, and for continuous feedback to quality improvement teams in intervention districts.In both countries, one continuous survey team of eight people was employed to complete approximately 7,200 household and 200 facility interviews in year one. Data were collected using personal digital assistants. After every four months, routine tabulations of indicators were produced and synthesized to report cards for use by the quality improvement teams.ResultsThe first 12 months were implemented as planned. Completion of household interviews was 96% in Tanzania and 91% in Uganda. Indicators across the continuum of care were tabulated every four months, results discussed by quality improvement teams, and report cards generated to support their work.Conclusions
The EQUIP continuous surveys were feasible to implement as a method to continuously generate and report on demand and supply side indicators for maternal and newborn health; they have potential to be expanded to include other health topics. Documenting the design and implementation of a continuous data collection and feedback mechanism for prospective description, quality improvement, and evaluation in a low-income setting potentially represents a new paradigm that places equal weight on data systems for course correction, as well as evaluation.
[Show abstract][Hide abstract] ABSTRACT: Low birthweight babies need extra care, and families need to know whether their newborn is low birthweight in settings where many births are at home and weighing scales are largely absent. In the context of a trial to improve newborn health in southern Tanzania, a counselling card was developed that incorporated a newborn foot length measurement tool to screen newborns for low birth weight and prematurity. This was used by community volunteers at home visits and shows a scale picture of a newborn foot with markers for a 'short foot' (<8 cm). The tool built on previous hospital based research that found newborn foot length <8 cm to have sensitivity and specificity to identify low birthweight (<2500 g) of 87% and 60% respectively.
BMC Public Health 08/2014; 14(1):859. · 2.08 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Hypothermia contributes to neonatal morbidity and mortality in low-income countries, yet little is known about thermal care practices in rural African settings. We assessed adoption and community acceptability of recommended thermal care practices in rural Tanzania.
BMC Pregnancy and Childbirth 08/2014; 14(1):267. · 2.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Each year almost 3 million newborns die within the first 28 days of life, 2.6 million babies are stillborn, and 287,000 women die from complications of pregnancy and childbirth worldwide. Effective and cost-effective interventions and behaviours for mothers and newborns exist, but their coverage remains inadequate in low- and middle-income countries, where the vast majority of deaths occur. Cost-effective strategies are needed to increase the coverage of life-saving maternal and newborn interventions and behaviours in resource-constrained settings.
BMC Pregnancy and Childbirth 07/2014; 14(1):243. · 2.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: In Sub-Saharan Africa over one million newborns die annually. We developed a sustainable and scalable home-based counselling intervention for delivery by community volunteers in rural southern Tanzania to improve newborn care practices and survival. Here we report the effect on newborn care practices one year after full implementation.
[Show abstract][Hide abstract] ABSTRACT: Home visits by community health workers may help to improve newborn survival, but sustained high-quality supervision of community volunteers is challenging.
To compare facility-led and community-linked supervision approaches of 824 community health volunteers working to improve newborn care in Southern Tanzania.
Using a before-after design, we compared 6 months of supervision reports from each approach.
During the community-linked approach over 50 times more supervision contacts were recorded than during the facility-only supervision approach (1.04 contacts per volunteer per month vs 0.02), and the volunteer-supervisor ratio reduced from 7.8 to 1.6.
Involving community leaders has the potential to improve supervision of community health volunteers.ClinicalTrials.gov Identifier: NCT01022788; http://clinicaltrials.gov/ct2/show/NCT01022788?term=INSIST&rank=1.
International Health 04/2014; · 1.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Maternal and newborn mortality remain unacceptably high in sub-Saharan Africa. Tanzania and Uganda are committed to reduce maternal and newborn mortality, but progress has been limited and many essential interventions are unavailable in primary and referral facilities. Quality management has the potential to overcome low implementation levels by assisting teams of health workers and others finding local solutions to problems in delivering quality care and the underutilization of health services by the community. Existing evidence of the effect of quality management on health worker performance in these contexts has important limitations, and the feasibility of expanding quality management to the community level is unknown. We aim to assess quality management at the district, facility, and community levels, supported by information from high-quality, continuous surveys, and report effects of the quality management intervention on the utilization and quality of services in Tanzania and Uganda.
In Uganda and Tanzania, the Expanded Quality Management Using Information Power (EQUIP) intervention is implemented in one intervention district and evaluated using a plausibility design with one non-randomly selected comparison district. The quality management approach is based on the collaborative model for improvement, in which groups of quality improvement teams test new implementation strategies (change ideas) and periodically meet to share results and identify the best strategies. The teams use locally-generated community and health facility data to monitor improvements. In addition, data from continuous health facility and household surveys are used to guide prioritization and decision making by quality improvement teams as well as for evaluation of the intervention. These data include input, process, output, coverage, implementation practice, and client satisfaction indicators in both intervention and comparison districts. Thus, intervention districts receive quality management and continuous surveys, and comparison districts-only continuous surveys.
EQUIP is a district-scale, proof-of-concept study that evaluates a quality management approach for maternal and newborn health including communities, health facilities, and district health managers, supported by high-quality data from independent continuous household and health facility surveys. The study will generate robust evidence about the effectiveness of quality management and will inform future nationwide implementation approaches for health system strengthening in low-resource settings.Trial registration: PACTR201311000681314.
[Show abstract][Hide abstract] ABSTRACT: Achievement of Millennium Development Goal (MDG) 4 for child survival requires acceleration of gains in newborn survival, and current trends in improving maternal health will also fall short of reaching MDG 5 without more strategic actions. We present a Maternal Newborn and Child Health (MNCH) strategy for accelerating progress on MDGs 4 and 5, sustaining the gains beyond 2015, and further bringing down maternal and child mortality by two thirds by 2030.
The strategy takes into account current trends in coverage and cause-specific mortality, builds on lessons learned about what works in large-scale implementation programs, and charts a course to reach those who do not yet access services. A central hypothesis of this strategy is that enhancing interactions between frontline workers and mothers and families is critical for increasing the effective coverage of life-saving interventions. We describe a framework for measuring and evaluating progress which enables continuous course correction and improvement in program performance and impact.
Evidence for the hypothesis and impact of this strategy is being gathered and will be synthesized and disseminated in order to advance global learning and to maximise the potential to improve maternal and neonatal survival.
BMC Pregnancy and Childbirth 11/2013; 13(1):216. · 2.52 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Progress towards reaching Millennium Development Goals four (child health) and five (maternal health) is lagging behind, particularly in sub-Saharan Africa, despite increasing efforts to scale up high impact interventions. Increasing the proportion of birth attended by a skilled attendant is a main indicator of progress, but not much is known about the quality of childbirth care delivered by these skilled attendants. With a view to reducing maternal mortality through health systems improvement we describe the care routinely offered in childbirth offered at dispensaries, health centres and hospitals in five districts in rural Southern Tanzania. We use data from a health facility census assessing 159 facilities in five districts in early 2009. A structural and operational assessment was undertaken based on staff reports using a modular questionnaire assessing staffing, work load, equipment and supplies as well as interventions routinely implemented during childbirth.
Health centres and dispensaries attended a median of eight and four deliveries every month respectively. Dispensaries had a median of 2.5 (IQR 2--3) health workers including auxiliary staff instead of the recommended four clinical officer and certified nurses. Only 28% of first-line facilities (dispensaries and health centres) reported offering active management in the third stage of labour (AMTSL). Essential childbirth care comprising eight interventions including AMTSL, infection prevention, partograph use including foetal monitoring and newborn care including early breastfeeding, thermal care at birth and prevention of ophthalmia neonatorum was offered by 5% of dispensaries, 38% of health centres and 50% of hospitals consistently. No first-line facility had provided all signal functions for emergency obstetric complications in the previous six months.
Essential interventions for childbirth care are not routinely implemented in first-line facilities or hospitals. Dispensaries have both low staffing and low caseload which constraints the ability to provide high-quality childbirth care. Improvements in quality of care are essential so that women delivering in facility receive "skilled attendance" and adequate care for common obstetric complications such as post-partum haemorrhage.
[Show abstract][Hide abstract] ABSTRACT: To review evidence from sub-Saharan Africa for the association between the practice or promotion of essential newborn care behaviours and neonatal survival.
We searched MEDLINE for English language, peer-reviewed literature published since 2005. The study population was neonates residing in a sub-Saharan Africa country who were not HIV positive. Outcomes were all-cause neonatal or early neonatal mortality or one of the three main causes of neonatal mortality: complications of preterm birth, infections and intrapartum-related neonatal events. Interventions included were the practice or promotion of recommended newborn care behaviours including warmth, hygiene, breastfeeding, resuscitation and management of illness. We included study designs with a concurrent comparison group. Study quality was assessed using the Cochrane EPOC or Newcastle-Ottawa tools and summarised using GRADE.
Eleven papers met the search criteria and most were at low risk of bias. We found evidence that delivering on a clean surface, newborn resuscitation, early initiation and exclusive breastfeeding, Kangaroo Mother Care (KMC) for low-birthweight babies, and distribution of clean delivery kits were associated with reduced risks of neonatal mortality or the main causes of neonatal mortality. There was evidence that training community birth attendants in resuscitation and administering antibiotics, and establishing women's groups can improve neonatal survival.
There is a remarkable lack of robust evidence from sub-Saharan Africa on the association between practice or promotion of newborn care behaviours and newborn survival.
Tropical Medicine & International Health 09/2013; · 2.94 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We studied coverage and timeliness of vaccination and risk factors for low and delayed vaccine uptake in children aged <2 years in rural Tanzania.
We used data from a cluster survey conducted in 2004, which included 1403 children. Risk factors were analysed by log-binomial regression adjusted for the clustering. The analysis was restricted to BCG, first and third dose of Diphtheria-Tetanus-Pertussis vaccines (DTP-1 and DTP-3) and first dose of measles-containing vaccine (MCV-1).
Coverage for BCG, DTP-1, DTP-3 and MCV-1 was 94%, 96%, 90% and 86%, respectively. Delayed vaccination (>1 month after the recommended age) occurred in 398/1205 (33%) children for BCG, 404/1189 (34%) for DTP-1, 683/990 (69%) for DTP-3 and 296/643 (46%) for MCV-1. Coverage was lower for all vaccines except DTP-1 in children living ≥5 km from a healthcare facility. Delayed uptake was associated with poverty. Low and delayed MCV-1 vaccination was associated with low maternal education. Delayed BCG vaccination was associated with ethnicity and rainy season.
Despite reasonably high vaccination coverage, we observed substantial vaccination delays, particularly for DTP-3 and MCV-1. We found specific factors associated with low and/or delayed vaccine uptake. These findings can help to improve strategies to reach children who remain inadequately protected.
International Health 06/2013; 5(2):139-47. · 1.01 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The study explored the childbirth-related hygiene and newborn care practices in home-deliveries in Southern Tanzania and barriers to and facilitators of behaviour change. Eleven home-birth narratives and six focus group discussions were conducted with recently-delivering women; two focus group discussions were conducted with birth attendants. The use of clean cloth for delivery was reported as common in the birth narratives; however, respondents did not link its use to newborn's health. Handwashing and wearing of gloves by birth attendants varied and were not discussed in terms of being important for newborn's health, with few women giving reasons for this behaviour. The lack of handwashing and wearing of gloves was most commonly linked to the lack of water, gloves, and awareness. A common practice was the insertion of any family member's hands into the vagina of delivering woman to check labour progress before calling the birth attendant. The use of a new razor blade to cut the cord was near-universal; however, the cord was usually tied with a used thread due to the lack of knowledge and the low availability of clean thread. Applying something to the cord was near-universal and was considered essential for newborn's health. Three hygiene practices were identified as needing improvement: family members inserting a hand into the vagina of delivering woman before calling the birth attendant, the use of unclean thread, and putting substances on the cord. Little is known about families conducting internal checks of women in labour, and more research is needed before this behaviour is targeted in interventions. The use of clean thread as cord-tie appears acceptable and can be addressed, using the same channels and methods that were used for successfully encouraging the use of new razor blade.
Journal of Health Population and Nutrition 03/2013; 31(1):110-7. · 1.12 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: The poor maintenance of equipment and inadequate supplies of drugs and other items contribute to the low quality of maternity services often found in rural settings in low- and middle-income countries, and raise the risk of adverse maternal outcomes through delaying care provision. We aim to describe staff experiences of providing maternal care in rural health facilities in Southern Tanzania, focusing on issues related to equipment, drugs and supplies. METHODS: Focus group discussions and in-depth interviews were conducted with different staff cadres from all facility levels in order to explore experiences and views of providing maternity care in the context of poorly maintained equipment, and insufficient drugs and other supplies. A facility survey quantified the availability of relevant items. RESULTS: The facility survey, which found many missing or broken items and frequent stock outs, corroborated staff reports of providing care in the context of missing or broken care items. Staff reported increased workloads, reduced morale, difficulties in providing optimal maternity care, and carrying out procedures that carried potential health risks to themselves as a result. CONCLUSIONS: Inadequately stocked and equipped facilities compromise the health system's ability to reduce maternal and neonatal mortality and morbidity by affecting staff personally and professionally, which hinders the provision of timely and appropriate interventions. Improving stock control and maintaining equipment could benefit mothers and babies, not only through removing restrictions to the availability of care, but also through improving staff working conditions.
BMC Health Services Research 02/2013; 13(1):61. · 1.77 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background. Intermittent preventive treatment in infants (IPTi) is the administration of sulfadoxine-pyrimethamine (SP) at 2, 3, and 9 months of age to prevent malaria. We investigated the influence of IPTi on drug resistance. Methods. Twenty-four areas were randomly assigned to receive or not receive IPTi. Blood collected during representative household surveys at baseline and 15 and 27 months after implementation was tested for SP and resistance markers. Results. The frequency of SP in blood was similar in the IPTi and comparison areas at baseline and at 15 months. dhfr and dhps mutations were also similar at baseline and then increased similarly in both arms after 15 months of SP-IPTi. First-line treatment was switched from SP to artemether-lumefantrine before the final survey, when SP positivity fell among infants in comparison areas but increased in IPTi areas. This was accompanied by an increase in dhfr but not dhps mutations in IPTi areas (P = .004 and P = .18, respectively). Conclusions. IPTi did not increase drug pressure or the selection on dhfr and dhps mutants, when SP was the first-line malaria treatment. Introduction of artemether-lumefantrine was followed by an increase in dhfr mutations, consistent with weak selection attributable to SP-IPTi, but not by an increase in dhps mutations, suggesting a fitness cost of this mutation.
The Journal of Infectious Diseases 01/2013; 207(5):848-859. · 5.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Improving newborn survival is essential if Ethiopia is to achieve Millennium Development Goal 4. The national Health Extension Program (HEP) includes community-based newborn survival interventions. We report the effect of these interventions on changes in maternal and newborn health care practices between 2008 and 2010 in 101 districts, comprising 11.6 million people, or 16% of Ethiopia's population.
Using data from cross-sectional surveys in December 2008 and December 2010 from a representative sample of 117 communities (kebeles), we estimated the prevalence of maternal and newborn care practices, and a program intensity score in each community. Women with children aged 0 to 11 months reported care practices for their most recent pregnancy and childbirth. The program intensity score ranged between zero and ten and was derived from four outreach activities of the HEP front-line health workers. Dose-response relationships between changes in program intensity and the changes in maternal and newborn health were investigated using regression methods, controlling for secular trend, respondents' background characteristics, and community-level factors. Between 2008 and 2010, median program intensity score increased 2.4-fold. For every unit increase in the score, the odds of receiving antenatal care increased by 1.13 times (95% CI 1.03-1.23); the odds of birth preparedness increased by 1.31 times (1.19-1.44); the odds of receiving postnatal care increased by 1.60 times (1.34-1.91); and the odds of initiating breastfeeding immediately after birth increased by 1.10 times (1.02-1.20). Program intensity score was not associated with skilled deliveries, nor with some of the other newborn health care indicators.
The results of our analysis suggest that Ethiopia's HEP platform has improved maternal and newborn health care practices at scale. However, implementation research will be required to address the maternal and newborn care practices that were not influenced by the HEP outreach activities.
PLoS ONE 01/2013; 8(6):e65160. · 3.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background. Intermittent Preventive Treatment in infants (IPTi) is the administration of sulphadoxine-pyrimethamine (SP) at 2, 3 and 9 months of age to prevent malaria. We investigated the influence of IPTi on drug resistance.Methods. Twenty-four areas were randomized to IPTi or no IPTi. Blood collected during representative household surveys at baseline, then after 15 and 27 months of implementation, was tested for SP and resistance markers.Results. The frequency of SP in blood was similar in IPTi and comparison areas at baseline and at 15 months. dhfr and dhps mutations were also similar at baseline then increased similarly in both arms after 15 months of SP-IPTi. First-line treatment switched from SP to artemether-lumefantrine before the final survey, when SP positivity fell among infants in comparison areas but increased in IPTi areas. This was accompanied by an increase in dhfr, but not dhps, mutations in IPTi areas (p=0.004 and p=0.18 respectively).Conclusions. IPTi did not increase drug pressure, or the selection on dhfr and dhps mutants, when SP was first line malaria treatment. Introduction of artemether-lumefantrine was followed by an increase in dhfr mutations, consistent with weak selection attributable to SP-IPTi, but not dhps, suggesting a fitness cost of this mutation.
The Journal of Infectious Diseases 12/2012; · 5.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To synthesize findings from recent studies of strategies to deliver insecticide-treated nets (ITNs) at scale in malaria-endemic areas.
Databases were searched for studies published between January 2000 and December 2010 in which: subjects resided in areas with endemicity for Plasmodium falciparum and Plasmodium vivax malaria; ITN delivery at scale was evaluated; ITN ownership among households, receipt by pregnant women and/or use among children aged < 5 years was evaluated; and the study design was an individual or cluster-randomized controlled design, nonrandomized, quasi-experimental, before-and-after, interrupted time series or cross-sectional without temporal or geographical controls. Papers describing qualitative studies, case studies, process evaluations and cost-effectiveness studies linked to an eligible paper were also included. Study quality was assessed using the Cochrane risk of bias checklist and GRADE criteria. Important influences on scaling up were identified and assessed across delivery strategies.
A total of 32 papers describing 20 African studies were reviewed. Many delivery strategies involved health sectors and retail outlets (partial subsidy), antenatal care clinics (full subsidy) and campaigns (full subsidy). Strategies achieving high ownership among households and use among children < 5 delivered ITNs free through campaigns. Costs were largely comparable across strategies; ITNs were the main cost. Cost-effectiveness estimates were most sensitive to the assumed net lifespan and leakage. Common barriers to delivery included cost, stock-outs and poor logistics. Common facilitators were staff training and supervision, cooperation across departments or ministries and stakeholder involvement.
There is a broad taxonomy of strategies for delivering ITNs at scale.
Bulletin of the World Health Organisation 09/2012; 90(9):672-684E. · 5.25 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Low birth weight and prematurity are amongst the strongest predictors of neonatal death. However, the extent to which they act independently is poorly understood. Our objective was to estimate the neonatal mortality risk associated with preterm birth when stratified by weight for gestational age in the high mortality setting of East Africa.
Members and collaborators of the Malaria and the MARCH Centers, at the London School of Hygiene & Tropical Medicine, were contacted and protocols reviewed for East African studies that measured (1) birth weight, (2) gestational age at birth using antenatal ultrasound or neonatal assessment, and (3) neonatal mortality. Ten datasets were identified and four met the inclusion criteria. The four datasets (from Uganda, Kenya, and two from Tanzania) contained 5,727 births recorded between 1999-2010. 4,843 births had complete outcome data and were included in an individual participant level meta-analysis. 99% of 445 low birth weight (< 2,500 g) babies were either preterm (< 37 weeks gestation) or small for gestational age (below tenth percentile of weight for gestational age). 52% of 87 neonatal deaths occurred in preterm or small for gestational age babies. Babies born < 34 weeks gestation had the highest odds of death compared to term babies (odds ratio [OR] 58.7 [95% CI 28.4-121.4]), with little difference when stratified by weight for gestational age. Babies born 34-36 weeks gestation with appropriate weight for gestational age had just three times the likelihood of neonatal death compared to babies born term, (OR 3.2 [95% CI 1.0-10.7]), but the likelihood for babies born 34-36 weeks who were also small for gestational age was 20 times higher (OR 19.8 [95% CI 8.3-47.4]). Only 1% of babies were born moderately premature and small for gestational age, but this group suffered 8% of deaths. Individual level data on newborns are scarce in East Africa; potential biases arising due to the non-systematic selection of the individual studies, or due to the methods applied for estimating gestational age, are discussed.
Moderately preterm babies who are also small for gestational age experience a considerably increased likelihood of neonatal death in East Africa.
PLoS Medicine 08/2012; 9(8):e1001292. · 15.25 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Early and frequent antenatal care attendance during pregnancy is important to identify and mitigate risk factors in pregnancy and to encourage women to have a skilled attendant at childbirth. However, many pregnant women in sub-Saharan Africa start antenatal care attendance late, particularly adolescent pregnant women. Therefore they do not fully benefit from its preventive and curative services. This study assesses the timing of adult and adolescent pregnant women's first antenatal care visit and identifies factors influencing early and late attendance.
The study was conducted in the Ulanga and Kilombero rural Demographic Surveillance area in south-eastern Tanzania in 2008. Qualitative exploratory studies informed the design of a structured questionnaire. A total of 440 women who attended antenatal care participated in exit interviews. Socio-demographic, social, perception- and service related factors were analysed for associations with timing of antenatal care initiation using regression analysis.
The majority of pregnant women initiated antenatal care attendance with an average of 5 gestational months. Belonging to the Sukuma ethnic group compared to other ethnic groups such as the Pogoro, Mhehe, Mgindo and others, perceived poor quality of care, late recognition of pregnancy and not being supported by the husband or partner were identified as factors associated with a later antenatal care enrolment (p < 0.05). Primiparity and previous experience of a miscarriage or stillbirth were associated with an earlier antenatal care attendance (p < 0.05). Adolescent pregnant women started antenatal care no later than adult pregnant women despite being more likely to be single.
Factors including poor quality of care, lack of awareness about the health benefit of antenatal care, late recognition of pregnancy, and social and economic factors may influence timing of antenatal care. Community-based interventions are needed that involve men, and need to be combined with interventions that target improving the quality, content and outreach of antenatal care services to enhance early antenatal care enrolment among pregnant women.
BMC Pregnancy and Childbirth 03/2012; 12:16. · 2.52 Impact Factor