Determinants And Implications For Focused Antenatal Care Interventions

Determinants And Implications For Foc utilizationd Antenatal Cargon InterventionsThe c everywhereage of prenatal att fetch uping (ANC) in many another(prenominal) beas is known and there argon a get along of interventions to encourage use of ANC service by think ofing(a) women. However, for women who attend ANC, it is serious that they register at the appropriate time and honorarium a accustomed number of be dictates over the enate quality period to ensure that they receive the interventions recommended for the antepartum period at the right time. When a enceinte cleaning lady introduces even contact which her skilled antepartum trade provider, she is in a rig to receive various services such as those specifyt for prevention of eclampsia, intermittent preventive treatment for malaria, other(a) detection of HIV/AIDS contagion and prevention of mother-to-child transmission, micronutrient supplementation, pay prep atomic number 18dness and provision of schooling on riskiness signs occurring speckle she is pregnant or during talking to.1 Presently, Nigeria is transiting to the Foc utilise Antenatal Cargon (FANC) arise promoted by the World Health Organization (WHO) which is becomeed at ensuring that each antepartum visit counts and that antepartum help interventions atomic number 18 delivered at the appropriate time.2FANC is nonpareil of the pillars of safe motherhood. The goal of FANC is to ensure that motherhood is normal finished for major(ip) actions identification of pre-existing health conditions, primaeval detection of complications arising during the maternal quality, health procession and disease prevention and birth preparedness and complication readiness planning.3The interventions are deployed in such a way that they are appropriate for the cleaning womans pointedness of gestation.4 Unlike the previously employ r byine perplexity which was ritualistic and patronize visits, the FANC entree emphasizes evidence-base d goal-directed actions, family-centred fear, quality, rather than quantity of visits as well as share 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 alike deemphasizes the routine risk assessment approach for classifying women into soaring and low risks groups.2 With the risk assessment approach, women go to antepartum care were offered services which include rake pressure check, urinalysis to detect protein or bacteria, and blood establish to rule out syphilis or anaemia.5 However many women classified as low risk end up having a false sense of security, are unable to recognize and respond to problems and end up developing complications. In addition, most high risk women gift birth without complications and the excess care provided constitutes an inefficient use of scarce resources.The FANC approach in Nigeria guides that pregnant women would have paid the freshman visit for ANC by the 16 calendar hebdomad of pregnancy or earlier when the women commencement ceremony thinks she is pregnant, the back betwixt the 24th to 28th week, the third at the 32nd week and the 4th at the 36th week of pregnancy.2 Some authors have considered early interlocking to mean that a woman pays her first visit forwards the 14th week to achieve the aim of improved outcome of pregnancy both(prenominal) for a mother and her unborn child.6 Thus, by 36 weeks, a pregnant woman should have made the required minimum of quartet visits composition those with risk of complications of conditions that provide preserve on pregnancy would require additional visits.The time of conflict and ANC attendance can impress the forte of interventions recommended for pregnant women and thus the goals of FANC. Early booking helps ensure that problems are observe and managed early.2 The first visit gives the opportunity to record information on family, maternal and med ical history, stop out a physical examination, request laboratory tests, provide care including intermittent preventive treatment (IPT) for malaria in pregnancy (if beyond first trimester), provide counselling including birth plan, use of insect powder treated bed nets (ITN), HIV counselling and testing and to discuss the agenda for care. The subsequent visits are necessary for noting complaints, targeted physical examination, reviewing test results, providing care including IPT for malaria, nurseing information on use of ITN, birth plans and carrying out HIV counselling.Justification for the subject areaInterventions for pregnant women aim protect the woman and her unborn baby for the rest period of the pregnancy and their provision should be timely. The later the time of first visit the shorter the period of cover and the higher the risk of instruction of problems and complications for the woman and her baby. Thus it is not just important to know the attribute of pregnant women attending ANC, it is similarly 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 measure of first visit and number of visits to ANC in the south-west theatrical role of Nigeria, bantam is known about the figure of speech in the south eastern region of the country. Additionally, most of the studies are limited in scope as they are set based ( usually tertiary hospital based) and thus reflect bugger off amongst pregnant women who are able to access such facilities even though primary(a) health centres are the closest to people and usually the further available point of care in rural areas.Aim This area 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 concentrate antenatal care interventions for pregnant women.ObjectivesT o determine the timing of booking and pattern of subsequent ANC attendance among pregnant women attending primary take aim facilitiesTo experience 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 speech communication of focused antenatal care interventionsTo examine how the findings of the con can impact on the deployment of antenatal care interventions for pregnant women.CHAPTER TWO LITERATURE analyseThe concept of focused antenatal care is based on the presumptuousness 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 potential to positively impact on ma ternal mortality and morbidity.7 Studies have shown that many women obtain care quite late during the pregnancy period and the care obtained is usually inadequate.2 8 9The first visit for antenatal care in Africa usually takes place around the fourth to fifth month of pregnancy.5 In the African region, 73% of pregnant women aged 15 49 long time pay at least atomic number 53 visit to a health care provider for antenatal care while only 44% pay at least four visits.10 A admit 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 inwardly the 3rd trimester while only 6.5% had the recommended minimum of four visits.12In Nigeria, the figures assessing antenatal care work are below the African regional values as 58% of women age d 15-49 years receive ANC from a skilled health provider at least once during pregnancy while 45% of women make four or more visits for ANC.2 10 Based on the 2008 NDHS the median value gestational age at booking is 5 months.2 Among 395 women attending antenatal clinic in public and private facilities covering the primary, mhoary 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 appoint 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 capital of Japan state 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 form 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 f acility in Osogbo Nigeria, the mean gestational age was found to be 20.3 (6.2) weeks and 82.6% of those studied schedule late.15 Amongst four hundred women attending antenatal clinic at a tertiary facility in Ile Ife, Nigeria, 71% had registered by the 20th week of gestation.16 Aluko and Oluwatosin found low grade of first trimester booking and irregular visits for antenatal care among women attending clinics in a mission hospital in Ibadan south west Nigeria.17Socio-demographic factors and proportion have been found to directly influence 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 real 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 f ound 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 booking was 19.1(7.2) weeks. Women with parity 5 booked at evidentiaryly higher mean gestational age of 25.9 () weeks and women of glower social class tend to book earlier for antenatal care. in like manner Adeyemi, et al found that late booking was thrice as usual 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 plausibly 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 antena tal 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 likely 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 using 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 send-off 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 issue 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 proportion 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 devoted when the growth of the foetus is occurring at its highest velocity (16th 24th week) as this helps to adulterate 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 enough to ensure adequate protection through the pregnancy period. The same consideration 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. every last(predicate) 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 leash METHODOLOGY knowledge area This study impart be carried out in Enugu State, South-East Nigeria. Enugu state comprises of 17 Local Government Areas (LGAs), has a union tribe of 3,257,298 people and an annual growth rate of 3.0.30 iii of th e 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 and 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 leave alone be purposively selected for the study to enable allurement of data 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 play 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 questionn communicatee.Sampling and try 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 proportionate method will be used for determining the try on size for each facility. The proportion will be fixed by considering the average weekly 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 reporting level of 58%,2 a confidence level of 95% and an break margin of 0.05.Z= 1.96 at 95% confidence level, (two-sided).p=ANC reporting = 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 teach field workers. The questionnaire will be pre-tested amongst pregnant women attending ANC at the firsthand Health Centre Abakpa, Enugu East LGA which will not be used for the study.Data analysis Epi Info statistical software system 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 asset holdings including tele vision, 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 booking for women of various SES groups. Logistic regression analysis will be employ 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 form test will be used to test for significance of differences observed for savorless 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 enquiry Ethics Committee of the University of Nigeria Teaching Hospital Enugu, while permission to carry out the study will be obtained from the Primary Health safekeeping Coordinator of the LGAs as well a s 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 intended nature of their participation.