Trends in antenatal care attendance and health facility delivery following community and health facility systems strengthening interventions in Northern Uganda

Article · October 2013with142 Reads
DOI: 10.1186/1471-2393-13-189 · Source: PubMed
Abstract
Maternal morbidity and mortality remains high in Uganda; largely due to inadequate antenatal care (ANC), low skilled deliveries and poor quality of other maternal health services. In order to address both the demand and quality of ANC and skilled deliveries, we introduced community mobilization and health facility capacity strengthening interventions. Interventions were introduced between January 2010 and September 2011. These included: training health workers, provision of medical supplies, community mobilization using village health teams, music dance and drama groups and male partner access clubs. These activities were implemented at Kitgum Matidi health center III and its catchment area. Routinely collected health facility data on selected outcomes in the year preceding the interventions and after 21 months of implementation of the interventions was reviewed. Trend analysis was performed using excel and statistical significance testing was performed using EPINFO StatCal option. The number of pregnant women attending the first ANC visit significantly increased from 114 to 150 in the first and fourth quarter of 2010 (OR 1.72; 95% CI 1.39--2.12) and to 202 in the third quarter of 2011(OR 11.41; 95% CI 7.97--16.34). The number of pregnant women counselled, tested and given results for HIV during the first ANC attendance significantly rose from 92 (80.7%) to 146 (97.3%) in the first and fourth quarter of 2010 and then to 201 (99.5%) in the third quarter of 2011. The number of male partners counseled, tested and given results together with their wives at first ANC visit rose from 13 (16.7%) in the fourth quarter of 2009 to 130 (89%) in the fourth quarter of 2010 and to 180 (89.6%) in the third quarter of 2011. There was a significant rise in the number of pregnant women delivering in the health facility with provision of mama-kits (delivery kits), from 74 (55.2%) to 149 (99.3%) in the second and fourth quarter of 2010. Combined community and facility systems strengthening interventions led to increased first ANC visits by women and their partners, and health facility deliveries. Interventions aimed at increasing uptake of maternal health services should address both the demand and availability of quality services.
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    • We would expect that in countries where access to health services is more limited and fewer national health financing schemes are in place to encourage demand, a similar intervention could yield greater increases in healthcare utilization. Health systems researchers in northern Uganda found increases in facility deliveries following a combined community-level and health facility-level intervention that occurred between January 2010 and September 2011 to improve quality of services, though they presented results from their intervention area only[55]. Our study had several limitations.
    [Show abstract] [Hide abstract] ABSTRACT: Background Evaluations of health systems strengthening (HSS) interventions using observational data are rarely used for causal inference due to limited data availability. Routinely collected national data allow use of quasi-experimental designs such as interrupted time series (ITS). Rwanda has invested in a robust electronic health management information system (HMIS) that captures monthly healthcare utilization data. We used ITS to evaluate impact of an HSS intervention to improve primary health care facility readiness on health service utilization in two rural districts of Rwanda. Methods We used controlled ITS analysis to compare changes in healthcare utilization at health centers (HC) that received the intervention (n = 13) to propensity score matched non-intervention health centers in Rwanda (n = 86) from January 2008 to December 2012. HC support included infrastructure renovation, salary support, medical equipment, referral network strengthening, and clinical training. Baseline quarterly mean outpatient visit rates and population density were used to model propensity scores. The intervention began in May 2010 and was implemented over a twelve-month period. We used monthly healthcare utilization data from the national Rwandan HMIS to study changes in the (1) number of facility deliveries per 10,000 women, (2) number of referrals for high risk pregnancy per 100,000 women, and (3) the number of outpatient visits performed per 1,000 catchment population. Results PHIT HC experienced significantly higher monthly delivery rates post-HSS during the April-June season than comparison (3.19/10,000, 95% CI: [0.27, 6.10]). In 2010, this represented a 13% relative increase, and in 2011, this represented a 23% relative increase. The post-HSS change in monthly rate of high-risk pregnancies referred increased slightly in intervention compared to control HC (0.03/10,000, 95% CI: [-0.007, 0.06]). There was a small immediate post-HSS increase in outpatient visit rates in intervention compared to control HC (6.64/1,000, 95% CI: [-13.52, 26.81]). Conclusion We failed to find strong evidence of post-HSS increases in outpatient visit rates or referral rates at health centers, which could be explained by small sample size and high baseline nation-wide health service coverage. However, our findings demonstrate that high quality routinely collected health facility data combined with ITS can be used for rigorous policy evaluation in resource-limited settings.
    Full-text · Article · Aug 2017
    • contributing to poor uptake include poor healthcare infrastructure,[6]parental education below primary school,[7,8]difficulty accessing healthcare,[7,9]reluctance to use modern medicine as opposed to traditional medicine,[10][11][12]and viewing ANC as a non-essential service.[3,12]Various methods have previously been trialed aiming to improve uptake of ANC services, such as utilizing community health networks,[13]initiating healthcare insurance,[14]and engaging male partners.[15]While these methods have demonstrated some success, attendance still remains sub-optimal in many areas.
    [Show abstract] [Hide abstract] ABSTRACT: In rural Uganda pregnant women often lack access to health services, do not attend antenatal care, and tend to utilize traditional healers/birth attendants. We hypothesized that receiving a message advertising that " you will be able to see your baby by ultrasound " would motivate rural Ugandan women who otherwise might use a traditional birth attendant to attend antenatal care, and that those women would subsequently be more satisfied with care. A cluster ran-domized trial was conducted across eight rural sub-counties in southwestern Uganda. Sub-counties were randomized to a control arm, with advertisement of antenatal care with no mention of portable obstetric ultrasound (four communities, n = 59), or an intervention arm, with advertisement of portable obstetric ultrasound. Advertisement of portable obstetric ultra-sound was further divided into intervention A) word of mouth advertisement of portable obstetric ultrasound and antenatal care (one communitity, n = 16), B) radio advertisement of only antenatal care and word of mouth advertisement of antenatal care and portable obstetric ultrasound (one community, n = 7), or C) word of mouth + radio advertisement of both antenatal care and portable obstetric ultrasound (two communities, n = 75). The primary outcome was attendance to antenatal care. 159 women presented to antenatal care across eight sub-counties. The rate of attendance was 65.1 (per 1000 pregnant women, 95% CI 38.3–110.4) where portable obstetric ultrasound was advertised by radio and word of mouth, as compared to a rate of 11.1 (95% CI 6.1–20.1) in control communities (rate ratio 5.9, 95% CI 2.6–13.0, p<0.0001). Attendance was also improved in women who had previously seen a traditional healer (13.0, 95% CI 5.4–31.2) compared to control (1.5, 95% CI 0.5–5.0, rate ratio 8.7, 95% CI 2.0–38.1, p = 0.004). By advertising antenatal care and portable obstetric ultrasound by radio attendance was significantly improved. This study suggests that women can be motivated to attend antenatal care when offered the concrete incentive of seeing their baby.
    Full-text · Article · May 2017
    • contributing to poor uptake include poor healthcare infrastructure,[6]parental education below primary school,[7,8]difficulty accessing healthcare,[7,9]reluctance to use modern medicine as opposed to traditional medicine,[10][11][12]and viewing ANC as a non-essential service.[3,12]Various methods have previously been trialed aiming to improve uptake of ANC services, such as utilizing community health networks,[13]initiating healthcare insurance,[14]and engaging male partners.[15]While these methods have demonstrated some success, attendance still remains sub-optimal in many areas.
    [Show abstract] [Hide abstract] ABSTRACT: In rural Uganda pregnant women often lack access to health services, do not attend antenatal care, and tend to utilize traditional healers/birth attendants. We hypothesized that receiving a message advertising that “you will be able to see your baby by ultrasound” would motivate rural Ugandan women who otherwise might use a traditional birth attendant to attend antenatal care, and that those women would subsequently be more satisfied with care. A cluster randomized trial was conducted across eight rural sub-counties in southwestern Uganda. Sub-counties were randomized to a control arm, with advertisement of antenatal care with no mention of portable obstetric ultrasound (four communities, n = 59), or an intervention arm, with advertisement of portable obstetric ultrasound. Advertisement of portable obstetric ultrasound was further divided into intervention A) word of mouth advertisement of portable obstetric ultrasound and antenatal care (one communitity, n = 16), B) radio advertisement of only antenatal care and word of mouth advertisement of antenatal care and portable obstetric ultrasound (one community, n = 7), or C) word of mouth + radio advertisement of both antenatal care and portable obstetric ultrasound (two communities, n = 75). The primary outcome was attendance to antenatal care. 159 women presented to antenatal care across eight sub-counties. The rate of attendance was 65.1 (per 1000 pregnant women, 95% CI 38.3–110.4) where portable obstetric ultrasound was advertised by radio and word of mouth, as compared to a rate of 11.1 (95% CI 6.1–20.1) in control communities (rate ratio 5.9, 95% CI 2.6–13.0, p<0.0001). Attendance was also improved in women who had previously seen a traditional healer (13.0, 95% CI 5.4–31.2) compared to control (1.5, 95% CI 0.5–5.0, rate ratio 8.7, 95% CI 2.0–38.1, p = 0.004). By advertising antenatal care and portable obstetric ultrasound by radio attendance was significantly improved. This study suggests that women can be motivated to attend antenatal care when offered the concrete incentive of seeing their baby.
    Full-text · Article · Apr 2017
    • While PMTCT coverage and utilization has remarkably increased over the past decade in SSA, it is still far from the recommended targets [108]. Community mobilization, as previously discussed, was employed in Uganda to encourage male partners' acceptance of HIV testing through couple attendance at ANC. Findings showed a 16 % improvement in the number of women who attended ANC together with their partners, while 95 % of male partners who attended the ANC together with their spouses were tested for HIV [54, 109, 110] . Training of health care workers to offer PMTCT services and equipping health facilities with supplies in Mali and Senegal was shown to have produced significantly better quality obstetric care results [110, 111].
    [Show abstract] [Hide abstract] ABSTRACT: Background Many interventions have been implemented to improve maternal health outcomes in sub-Saharan Africa (SSA). Currently, however, systematic information on the effectiveness of these interventions remains scarce. We conducted a systematic review of published evidence on non-drug interventions that reported effectiveness in improving outcomes and quality of care in maternal health in SSA. Methods African Journals Online, Bioline, MEDLINE, Ovid, Science Direct, and Scopus databases were searched for studies published in English between 2000 and 2015 and reporting on the effectiveness of interventions to improve quality and outcomes of maternal health care in SSA. Articles focusing on interventions that involved drug treatments, medications, or therapies were excluded. We present a narrative synthesis of the reported impact of these interventions on maternal morbidity and mortality outcomes as well as on other dimensions of the quality of maternal health care (as defined by the Institute of Medicine 2001 to comprise safety, effectiveness, efficiency, timeliness, patient centeredness, and equitability). ResultsSeventy-three studies were included in this review. Non-drug interventions that directly or indirectly improved quality of maternal health and morbidity and mortality outcomes in SSA assumed a variety of forms including mobile and electronic health, financial incentives on the demand and supply side, facility-based clinical audits and maternal death reviews, health systems strengthening interventions, community mobilization and/or peer-based programs, home-based visits, counseling and health educational and promotional programs conducted by health care providers, transportation and/or communication and referrals for emergency obstetric care, prevention of mother-to-child transmission of HIV, and task shifting interventions. There was a preponderance of single facility and community-based studies whose effectiveness was difficult to assess. Conclusions Many non-drug interventions have been implemented to improve maternal health care in SSA. These interventions have largely been health facility and/or community based. While the evidence on the effectiveness of interventions to improve maternal health is varied, study findings underscore the importance of implementing comprehensive interventions that strengthen different components of the health care systems, both in the community and at the health facilities, coupled with a supportive policy environment. Systematic review registrationPROSPERO CRD42015023750
    Full-text · Article · Dec 2016
    • On the other hand, other researches (Kawungezi et al. 2015; Wablembo and Doctor 2013) found that younger primigravide women are more likely to attend the routine antenatal care because the health system target them for attention due to the higher risk of complications associated with young age and first pregnancy. The researchers finding on the effects of parity on delivering the most recent birth in a health facility shows that older women were less likely to have delivered the most recent birth in a health facility, which is consistent with other studies (Choe et al. 2015; Ediau et al. 2013 ). Older multiparous women who have not experienced previous pregnancy or delivery complications are less likely to attend the antenatal care visits and to deliver in a health facility.
    [Show abstract] [Hide abstract] ABSTRACT: Disparities in the Antenatal Care (ANC) attendance and Delivery in a Health Facility (DHF) were examined in Uganda where the maternal and the new-born mortality are high. Cross-sectional data on 4818 women were obtained from the 2011 Uganda Demographic Health Survey and was used. Over half and three-fifth of the women attended the recommended 4 or more ANC visits and DHF respectively. Tertiary and secondary education, currently married status, belonging to the richer wealth index group and having daily access to the media significantly increased the attendance of the 4 or more ANC visits and DHF. Attending the 4 or more ANC visits also significantly increased DHF. The researchers conclude that increasing the demand for the continuum of care services through education, information, access to health facilities and lower costs is required to increase the attendance of the recommended number of ANC visits and delivery in health facilities.
    Full-text · Article · Oct 2016 · Global Public Health
    • Initially, the kits were intended to be distributed to women who attended at least four antenatal care visits for use during either facility or home delivery, but many districts switched to distributing the kits only when women arrived for delivery at a facility since many of the women either forgot their kit when they came to deliver at a facility or the packaging had been compromised and was no longer sterile by the time of delivery (WHO, n.d.). Additionally, the availability of CDKs varied from district to district, depending on the availability of supplies and the development partner sponsoring the kits, and there have been reports of inconsistent supply of the kits in Uganda (Ediau et al., 2013; WHO, n.d.). Launched in 2012, 'Saving Mothers, Giving Life' (SMGL) is a large-scale maternal health programme aimed to accelerate reductions in maternal mortality in select districts in Uganda and Zambia over a five-year period (Global Health Initiative, 2011).
    [Show abstract] [Hide abstract] ABSTRACT: There is growing interest in the use of incentives to increase the utilisation of maternal health services globally, including the use of in-kind goods. As part of the Saving Mothers, Giving Life (SMGL) programme, pregnant women in three districts in Uganda were incentivised to deliver in a facility by the promise of 'Mama Kits' - clean delivery kits augmented with goods for newborns. We collected and analysed qualitative data from 18 focus groups (130 women) who had a recent home (N = 9) or facility delivery (N = 9 groups) to understand their overall perceptions of the SMGL programme, and, in particular, the Mama Kit. There was a high level of awareness of Mama Kits among women who delivered in a health facility and a moderate awareness among women who delivered at home. When available, kits positively affected women's perceptions of facility delivery because they associated availability of kits with affordability of care. When not available, women's perceptions of their actual or expected delivery experience were negatively affected. When well implemented, in-kind goods can be important complements in broader efforts to incentivise facility delivery. Inconsistent implementation and an underestimation of their influence on care-seeking can undermine efforts to reduce maternal mortality and morbidity.
    Article · Mar 2016
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