Determinants And Implications For Focused Antenatal Care Interventions

Determinants And Implications For Foc utilise Antenatal C ar InterventionsThe cover date of antepartum complaint (ANC) in many atomic number 18as is cognise and in that location are a number of interventions to encourage use of ANC go by with child(predicate) women. However, for women who attend ANC, it is important that they register at the enamor sentence and conciliate a given number of reprimands over the motherhood achievement to ensure that they receive the interventions recommended for the prenatal period at the right time. When a pregnant cleaning lady makes regular contact which her skilled antenatal burster provider, she is in a position to receive various services such as those meant for prevention of eclampsia, intermittent preventive treatment for malaria, early detection of human immunodeficiency virus/AIDS infection and prevention of mother-to-child transmission, micronutrient supplementation, birth preparedness and provision of information on danger s igns occurring spell she is pregnant or during delivery.1 Presently, Nigeria is transiting to the Focused Antenatal Care (FANC) approach promoted by the World Health Organization (WHO) which is aimed at ensuring that each antenatal visit counts and that antenatal headache interventions are delivered at the appropriate time.2FANC is one of the pillars of safe motherhood. The goal of FANC is to ensure that pregnancy is normal through for major actions identification of pre-existing wellness conditions, early detection of complications arising during the pregnancy, health promotion and disease prevention and birth preparedness and complication readiness planning.3The interventions are deployed in such a flair that they are appropriate for the womans stage of pregnancy.4 Unlike the previously used r bug fall outine care which was ritualistic and frequent visits, the FANC approach emphasizes evidence- order goal-directed actions, family-centred care, quality, rather than quantity o f visits as well as care by skilled providers.3 4 Thus, numerous routine visits are no longer recommended and are considered a burden to women and the health care system.The FANC approach withal deemphasizes the routine risk assessment approach for menageifying women into high and low risks groups.2 With the risk assessment approach, women attention antenatal care were spined services which include blood pressure check, urinalysis to detect protein or bacteria, and blood test to rule out syphilis or anaemia.5 However many women sort as low risk end up having a false sense of security, are unable to recognize and respond to problems and end up exploitation complications. In addition, or so high risk women give birth without complications and the excess care provided constitutes an inefficient use of scarce resources.The FANC approach in Nigeria awaits that pregnant women would direct paid the offset printing visit for ANC by the 16 workweek of pregnancy or earlier when the women premiere thinks she is pregnant, the second between the 24th to 28th week, the troika at the 32nd week and the 4th at the 36th week of pregnancy.2 Some authors use up considered early booking to mean that a woman pays her first base visit before the 14th week to achieve the aim of improved outcome of pregnancy both for a mother and her unborn child.6 Thus, by 36 weeks, a pregnant woman should have made the required minimum of four visits while those with risk of complications of conditions that give the sack impact on pregnancy would require additional visits.The time of booking and ANC attendance can affect the tellingness of interventions recommended for pregnant women and thus the goals of FANC. Early booking helps ensure that problems are detected and managed early.2 The first visit gives the opportunity to record information on family, maternal and medical history, carry out a physical examination, request laboratory tests, provide care including intermittent preve ntive treatment (IPT) for malaria in pregnancy (if beyond first trimester), provide counselling including birth plan, use of insecticide treated bed nets (ITN), HIV counselling and testing and to discuss the schedule for care. The subsequent visits are necessary for noting complaints, targeted physical examination, reviewing test results, providing care including IPT for malaria, obtaining information on use of ITN, birth plans and carrying out HIV counselling.Justification for the debateInterventions for pregnant women aim protect the woman and her unborn baby for the remaining period of the pregnancy and their provision should be timely. The subsequent the measure of first visit the shorter the period of cover and the higher the risk of development of problems and complications for the woman and her baby. Thus it is not just important to know the counterweight of pregnant women attending ANC, it is also important to know when attendees commence such visits and whether they pay an adequate number of visits.Although a number of studies have documented the timing of first visit and number of visits to ANC in the south-west region of Nigeria, little is known about the pattern in the south eastern region of the country. Additionally, most of the studies are limited in scope as they are facility based (usually ordinal infirmary based) and thus reflect experience amongst pregnant women who are able to access such facilities even though primary quill health centres are the closest to people and usually the scarcely available point of care in plain areas.Aim This study is aimed at documenting the socio-demographic predictors of timing of ANC booking and subsequent attendance amongst pregnant women in order to understand the impact these can have on deployment of focused antenatal care interventions for pregnant women.ObjectivesTo determine the timing of booking and pattern of subsequent ANC attendance among pregnant women attending primary level facilitiesTo examine whether the timing of ANC booking and clinic attendance is affected by individual level socio-demographic factorsTo assess the appropriateness of timing of booking and attendance for effective delivery of focused antenatal care interventionsTo examine how the findings of the study can impact on the deployment of antenatal care interventions for pregnant women.CHAPTER TWO LITERATURE reexamineThe concept of focused antenatal care is based on the assumption that since every pregnancy faces the risk of development of complications, every pregnant woman should be monitored to avoid development of such complications.2 Lack of antenatal care is known to be a major risk factor for development of negative pregnancy outcomes. However, when antenatal care is appropriately delivered, it has the electromotive force to positively impact on maternal mortality and morbidity.7 Studies have shown that many women obtain care quite juvenile during the pregnancy period and the care obtained i s usually inadequate.2 8 9The first visit for antenatal care in Africa usually takes place around the stern to fifth month of pregnancy.5 In the African region, 73% of pregnant women aged 15 49 historic period pay at least one visit to a health care provider for antenatal care while only 44% pay at least four visits.10 A study by Al-Nasser in Saudi Arabia showed that majority (60.8%) of pregnant women attending antenatal clinic in primary health care centres were first seen before the 20th week of gestation.11 Fekede, et al noted that 42.8% of 360 pregnant women in an Ethiopian town attending antenatal clinic did so for the first time within the 3rd trimester while only 6.5% had the recommended minimum of four visits.12In Nigeria, the figures assessing antenatal care utilization are below the African regional values as 58% of women aged 15-49 years receive ANC from a skilled health provider at least once during pregnancy while 45% of women make four or more than visits for ANC.2 10 Based on the 2008 NDHS the median gestational age at booking is 5 months.2 Among 395 women attending antenatal clinic in public and private facilities showing the primary, secondary and tertiary levels of care in Ibadan, southwest Nigeria, 25.8% paid the first visit for antenatal care within the first trimester. Mean gestational age at booking was found to be 18.5 (6.3) weeks while the mean number of antenatal visits was 4.0 (2.4).13 A study carried out among 378 pregnant women attending a tertiary hospital in Edo nation Nigeria noted that the 6th month of pregnancy as the peak period of first visit for antenatal care among the women.14 Okunlola et al found a mean gestational age at booking of 21.82 (7.0) weeks with only 14.1% of the women paying attending for the first time within the first trimester.6 In a tertiary facility in Osogbo Nigeria, the mean gestational age was found to be 20.3 (6.2) weeks and 82.6% of those studied booked late.15 Amongst 400 women attending antena tal clinic at a tertiary facility in Ile Ife, Nigeria, 71% had registered by the 20th week of gestation.16 Aluko and Oluwatosin found low rates of first trimester booking and untypical visits for antenatal care among women attending clinics in a mission hospital in Ibadan south west Nigeria.17Socio-demographic factors and check bit have been found to directly settle the timing of first visit for antenatal care though the results are sometimes dissimilar. Most women (79.9%) attending antenatal clinic in a tertiary hospital in Edo state Nigeria were found to have booked late.18 However, there was no significant difference in age, parity, level of education and social class between women booking early and late. In a study carried out among pregnant women attending a the Lagos University Teaching Hospital, Adegbola found a mean gestational age at first booking of 18.5 (8.3), 18.4 (7.4) weeks for nulliparous and primiparous women respectively.19 The overall mean gestational age at book ing was 19.1(7.2) weeks. Women with parity 5 booked at significantly higher mean gestational age of 25.9 () weeks and women of lower social class tend to book earlier for antenatal care. Similarly Adeyemi, et al found that late booking was thrice as common in multiparous women compared with the nulliparous group and the difference was significant.20 Other authors have found an association between parity and timing of first visit, and number of antenatal visits.11 21A number of studies have documented the factors that affect use of ANC amongst women in the developing countries9 these determinants are also believably to affect the timeliness of attendance for ANC. Chandrashekar, et al found that women who are poor, illiterate, multiparous, unskilled and over 30 years of age were less likely to receive antenatal care in India.22 Age was found to be a significant predictor of ANC attendance in a community based study in Ethiopia where women aged 15-24 years were found 2.75 times more l ikely to attend than those aged 25-34 years.12 Geographic place of residence can also have an impact as women living in urban areas are more likely to receive antenatal care during pregnancy.Women have also been found to concurrently use multiple antenatal care providers and this can affect the timing of booking in a facility. Adeoye, et al found that 25% and 30.5% of women attending two antenatal care clinics in a tertiary facility in Ebonyi state were concurrently apply both formal and informal providers of antenatal care.23 Of 535 women attending a tertiary facility in Enugu Nigeria, 69.5% were booked in more than one facility.24The time of commencement of ANC visits has implications for the period of protection that pregnant women have from interventions. For example where women attend antenatal care late in pregnancy, they may not receive the recommended 2-3 doses of Intermittent Preventive Treatment (IPT) for malaria in pregnancy using sulphadoxine-pyrimethamine combinations. 25 Data from the 2008 National Demographic and Health Survey (NDHS) shows that among 11,027 women aged 15 49 years with a live birth within a period of 2 years preceding the survey, only 8.0% received at least one dose of IPT while 4.9% received 2 or more doses.2 The similitude was 9.9% and 5.4% respectively for the south east region of Nigeria. It is important that pregnant women are available at the appropriate time for delivery of IPT which is best given when the harvest-tide of the foetus is occurring at its highest velocity (16th 24th week) as this helps to reduce placental parasitaemia, foetal growth reduction and the resultant low birth weight.26It is also known that the negative impact of malaria is worse among women with their first and second pregnancies compared to those that have had more than two pregnancies.27-29 Thus primi and secundi-gravidae need to pay their first visit early nice to ensure adequate protection through the pregnancy period. The same considerati on holds sway for interventions such as insecticide treated nets for which the potential protective time period depends on how early in pregnancy a woman starts sleeping under the net.All it all, timely attendance to ANC is important to enhance the potential for positive pregnancy outcomes since it provides pregnant women with the opportunity to receive recommended interventions and the protection from problems and complications. Socio-demographic and maternal factors such as parity can affect the timeliness of ANC visits by pregnant women.CHAPTER THREE METHODOLOGYStudy area This study will be carried out in Enugu State, southeast-East Nigeria. Enugu state comprises of 17 Local Government Areas (LGAs), has a total population of 3,257,298 people and an annual growth rate of 3.0.30 Three of the 17 LGAs (Enugu North, Enugu South and Nsukka) are urban, one (Enugu East) has a mix of urban and rural areas while the remaining 13 LGAs are rural. The people of Enugu are of Igbo ethnicity an d are predominantly Christians. A substantial proportion of the working population in the state is engaged in farming, trading, and public service employment.Study site Two areas will be purposively selected for the study to enable collection of entropy across for those in both urban and rural areas of the state. These are Udi LGA comprising Udi North and South Development Councils will be used to represent the rural areas while Enugu North and South LGAs will represent the urban areas. Udi has a population of 234,002 while Enugu North and South have a population of 244,852 and 198,723 respectively.30 Udi LGA has 14 primary health facilities that offer ANC services while Enugu North and South (referred to as Enugu) together have 12 primary facilities that offer ANC (appendix 1).Study design This will be a cross-sectional study involving eliciting of information from pregnant women attending primary health centres for antenatal care through exit interviews using a pre-tested questio nnaire.Sampling and archetype size All the primary health care facilities providing ANC in the study LGAs will be used for the study. Since the level of attendance of ANC varies for different facilities, a symmetrical method will be used for determining the strain size for each facility. The proportion will be determined by considering the average hebdomadary number of antenatal clinic attendees to the facility relative to the total from all facilities as reported by the heads of the facilities and the relative proportion will be computed.The minimum sample size required for the study is 374. This was determined using the formula for determination of sample size for population proportion,31 an ANC coverage level of 58%,2 a bureau level of 95% and an error margin of 0.05.Z= 1.96 at 95% confidence level, (two-sided).p=ANC coverage = 58%d=margin of error tolerated = 0.05Considering a potential refusal rate of 10%, 411 women will be sampled.Study tools Data will be collected using a pre-tested interviewer administered questionnaire (appendix 2) which will be administered by trained field workers. The questionnaire will be pre-tested amongst pregnant women attending ANC at the Primary Health Centre Abakpa, Enugu East LGA which will not be used for the study.Data epitome Epi Info statistical software will be used for data entry while SPSS and Stata Softwares will be used for data analysis. Data will initially aim to elicit the determinants of timing of booking of ANC. Subsequently, a continuous socio-economic status index will be generated using the principal component analysis technique in STATA software package 32 to enable disaggregation of data into socio-economic quintiles. Information that will be used include households summation holdings including television, radio, refrigerator, car, bicycle, rechargeable lamp, kerosene lamp, electric fan, air conditioner, motorcycle.33 The SES quintiles generated will be used in assessing differences in timing of boo king for women of various SES groups. Logistic regression analysis will be employed for examination of the determinants of the timing of booking. Data analysis will also aim to estimate the proportion of women attending at the appropriate time for delivery of recommended interventions. Chi squared test will be used to test for significance of differences observed for categorical data while chi squared for trend test will be employed for ordered categorical data. All tests of significance will be done a p value of 0.05.Ethical considerations Ethical clearance will be obtained from the Research Ethics Committee of the University of Nigeria Teaching Hospital Enugu, while permission to carry out the study will be obtained from the Primary Health Care Coordinator of the LGAs as well as from the heads of facilities to be used. Written consent will be obtained from patients who are interviewed after they have been informed of the objectives of the study and the voluntary nature of their pa rticipation.