Antenatal care strengthening for improved quality of care in Jimma, Ethiopia: an effectiveness study

Interventions to improve the quality of maternal care in Ethiopia: a scoping review

Introduction

Quality improvement interventions have been part of the national agenda aimed at reducing maternal and neonatal morbidities and mortality. Despite different interventions, neonatal mortality and morbidity rates remain steady. This review aimed to map and synthesize the evidence of maternal and newborn quality improvement interventions in Ethiopia.

Methods

A scoping review was reported based on the reporting items for systematic reviews and meta-analysis extensions for the scoping review checklist. Data extraction, collation, and organization were based on the Joanna Briggs Institute manual of the evidence synthesis framework for a scoping review. The maternal and neonatal care standards from the World Health Organization and the Donabedian quality of health framework were used to summarize the findings.

Results

Nineteen articles were included in this scoping review. The review found that the studies were conducted across various regions of Ethiopia, with the majority published after 2013. The reviewed studies mainly focused on three maternal care quality interventions: mobile and electronic health (eHealth), quality improvement standards, and human resource mobilization. Moreover, the reviewed studies explored various approaches to quality improvement, such as providing training to healthcare workers, health extension workers, traditional birth attendants, the community health development army, and mothers and supplying resources needed for maternal and newborn care.

Conclusion

In conclusion, quality improvement strategies encompass community involvement, health education, mHealth, data-driven approaches, and health system strengthening. Future research should focus on the impact of physical environment, culture, sustainability, cost-effectiveness, and long-term effects of interventions. Healthcare providers' knowledge, skills, attitudes, satisfaction, and adherence to guidelines should also be considered.

A systematic review of behaviour change interventions to improve maternal health outcomes in sub-Saharan Africa

The rate of decline in the global burden of avoidable maternal deaths has stagnated and remains an issue of concern in many sub-Saharan Africa countries. As per the most recent evidence, an average maternal mortality ratio (MMR) of 223 deaths per 100,000 live births has been estimated globally, with sub-Saharan Africa's average MMR at 536 per 100,000 live births-more than twice the global average. Despite the high MMR, there is variation in MMR between and within sub-Saharan Africa countries. Differences in the behaviour of those accessing and/or delivering maternal healthcare may explain variations in outcomes and provide a basis for quality improvement in health systems. There is a gap in describing the landscape of interventions aimed at modifying the behaviours of those accessing and delivering maternal healthcare for improving maternal health outcomes in sub-Saharan Africa. Our objective was to extract and synthesise the target behaviours, component behaviour change strategies and outcomes of behaviour change interventions for improving maternal health outcomes in sub-Saharan Africa. We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Our protocol was published a priori on PROSPERO (registration number CRD42022315130). We searched ten electronic databases (PsycINFO, Cochrane Database of Systematic Reviews, International Bibliography of Social Sciences, EMBASE, MEDLINE, Scopus, CINAHL PLUS, African Index Medicus, African Journals Online, and Web of Science) and included randomised trials and quasi-experimental studies. We extracted target behaviours and specified the behavioural interventions using the Action, Actor, Context, Time, and Target (AACTT) framework. We categorised the behaviour change strategies using the intervention functions described in the Behaviour Change Wheel (BCW). We reviewed 52 articles (26 randomized trials and 26 quasi-experimental studies). They had a mixed risk of bias. Out of these, 41 studies (78.8%) targeted behaviour change of those accessing maternal healthcare services, while seven studies (13.5%) focused on those delivering maternal healthcare. Four studies (7.7%) targeted mixed stakeholder groups. The studies employed a range of behaviour change strategies, including education 37 (33.3%), persuasion 20 (18%), training 19 (17.1%), enablement 16 (14.4%), environmental restructuring 8 (7.2%), modelling 6 (5.4%) and incentivisation 5 (4.5%). No studies used restriction or coercion strategies. Education was the most common strategy for changing the behaviour of those accessing maternal healthcare, while training was the most common strategy in studies targeting the behaviour of those delivering maternal healthcare. Of the 52 studies, 40 reported effective interventions, 7 were ineffective, and 5 were equivocal. A meta-analysis was not feasible due to methodological and clinical heterogeneity across the studies. In conclusion, there is evidence of effective behaviour change interventions targeted at those accessing and/or delivering maternal healthcare in sub-Saharan Africa. However, more focus should be placed on behaviour change by those delivering maternal healthcare within the health facilities to fast-track the reduction of the huge burden of avoidable maternal deaths in sub-Saharan Africa.

Factors determining antenatal care utilization among mothers of deceased perinates in Ethiopia

Introduction

Receiving adequate antenatal care (ANC) had an integral role in improving maternal and child health outcomes. However, several factors influence the utilization of ANC from the individual level up to the community level factors. Thus, this study aims to investigate factors that determine ANC service utilization among mothers of deceased perinate using the proper count regression model.

Method

Secondary data analysis was performed on perinatal death surveillance data. A total of 3,814 mothers of deceased perinates were included in this study. Hurdle Poisson regression with a random intercept at both count-and zero-part (MHPR.ERE) model was selected as a best-fitted model. The result of the model was presented in two ways, the first part of the count segment of the model was presented using the incidence rate ratio (IRR), while the zero parts of the model utilized the adjusted odds ratio (AOR).

Result

This study revealed that 33.0% of mothers of deceased perinates had four ANC visits. Being in advanced maternal age [IRR = 1.03; 95CI: (1.01-1.09)], attending primary level education [IRR = 1.08; 95 CI: (1.02-1.15)], having an advanced education (secondary and above) [IRR = 1.14; 95 CI: (1.07-1.21)] and being resident of a city administration [IRR = 1.17; 95 CI: (1.05-1.31)] were associated with a significantly higher frequency of ANC visits. On the other hand, women with secondary and above education [AOR = 0.37; 95CI: (0.26-0.53)] and women who live in urban areas [AOR = 0.42; 95 CI: (0.33-0.54)] were less likely to have unbooked ANC visit, while women who resided in pastoralist regions [AOR = 2.63; 95 CI: (1.02-6.81)] were more likely to have no ANC visit.

Conclusion

The uptake of ANC service among mothers having a deceased perinate was determined by both individual (maternal age and educational status) and community (residence and type of region) level factors. Thus, a concerted effort is needed to improve community awareness through various means of communication by targeting younger women. Furthermore, efforts should be intensified to narrow down inequalities observed in ANC service provision due to the residence of the mothers by availing necessary personnel and improving the accessibility of service in rural areas.

Input, process, and output factors contributing to quality of antenatal care services: a scoping review of evidence

BACKGROUND

High-quality antenatal care (ANC) provides a lifesaving opportunity for women and their newborns through providing health promotion, disease prevention, and early diagnosis and treatment of pregnancy-related health issues. However, systematically synthesised evidence on factors influencing the quality of ANC services is lacking. This scoping review aims to systematically synthesize the factors influencing in provision and utilisation of quality ANC services.

METHODS

We conducted a scoping review of published evidence on the quality of ANC services. We searched records on four databases (PubMed, Scopus, Embase, and Google scholar) and grey literature from 1 to 2011 to 30 August 2021. We analysed data using Braun and Clarke's thematic analysis approach. We followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guideline for the review. We explained themes using the Donabedian healthcare quality assessment model (input-process-output).

RESULTS

Several inputs- and process-related factors contributed to suboptimal quality of ANC in many low and lower- or middle-income countries. Input factors included facility readiness (e.g., lack of infrastructure, provision of commodities and supplies, health workforce, structural and intermediary characteristics of pregnant women, and service delivery approaches). Processes-related factors included technical quality of care (e.g., lack of skilled adequate and timely care, and poor adherence to the guidelines) and social quality (lack of effective communication and poor client satisfaction). These input and process factors have also contributed to equity gaps in utilisation of quality ANC services.

CONCLUSION

Several input and process factors influenced the provision and utilization of optimum quality ANC services. Better health system inputs (e.g., availability of trained workforces, commodities, guidelines, context-specific programs) are essential to creating enabling facility environment for quality ANC services. Care processes can be improved by ensuring capacity-building activities for workforces (training, technical support visits), and mentoring staff working at peripheral facilities. Identifying coverage of quality ANC services among disadvantaged groups could be the initial step in designing and implementing targeted program approaches.

The effect of national antenatal care guidelines and provider training on obstetric danger sign counselling: a propensity score matching analysis of the 2014 Ethiopia service provision assessment plus survey

Background

Most pregnant women in low and lower-middle-income countries do not receive all components of antenatal care (ANC), including counselling on obstetric danger signs. Facility-level ANC guidelines and provider in-service training are major factors influencing ANC counselling. In Ethiopia, little is known about the extent to which guidelines and provider in-service training can increase the quality of ANC counselling.

Methods

We examined the effect of national ANC guidelines and ANC provider in-service training on obstetric danger sign counselling for pregnant women receiving ANC using the 2014 Ethiopian service provision assessment plus (ESPA +) survey data. We created two analysis samples by applying a propensity score matching method. The first sample consisted of women who received ANC at health facilities with guidelines matched with those who received ANC at health facilities without guidelines. The second sample consisted of women who received ANC from the providers who had undertaken in-service training in the last 24 months matched with women who received ANC from untrained providers. The outcome variable was the number of obstetric danger signs described during ANC counselling, ranging from zero to eight. The covariates included women’s socio-demographic characteristics, obstetric history, health facility characteristics, and ANC provider characteristics.

Results

We found that counselling women about obstetric danger signs during their ANC session varied according to the availability of ANC guidelines (61% to 70%) and provider training (62% to 68%). After matching the study participants by the measured covariates, the availability of ANC guidelines at the facility level significantly increased the average number of obstetric danger signs women received during counselling by 24% (95% CI: 12–35%). Similarly, providing refresher training for ANC providers increased the average number of obstetric danger signs described during counselling by 37% (95% CI: 26–48%).

Conclusion

The findings suggest that the quality of ANC counselling in Ethiopia needs strengthening by ensuring that ANC guidelines are available at every health facility and that the providers receive regular ANC related in-service training.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-022-01442-6.

Maternal death from preventable pregnancy-related complications remains a global health challenge. In 2017, there were 295,000 maternal deaths worldwide, and about two-thirds of these deaths were from Sub-Saharan Africa. Ethiopia is a Sub-Saharan African country with 401 maternal deaths per 100,000 live births in 2017, and this rate is higher than the target indicated in sustainable development goals. Most maternal deaths are due to obstetric complications and could have been averted through early detection and treatment. Providing antenatal care counselling about obstetric danger signs enhances women’s awareness of obstetric complications and encourages women to seek treatment from a skilled care provider. However, most women from low-income settings, including Ethiopia, do not receive counselling about obstetric danger signs. Facility-level antenatal care guidelines and provider in-service training improve antenatal care counselling. In Ethiopia, little is known to what extent antenatal care guidelines and provider training increase counselling on obstetric danger signs. The present study used the 2014 Ethiopian service provision assessment data and estimated the effect of antenatal care guidelines and provider training on counselling about obstetric danger signs. The analysis involved a propensity score matching method and included 1725 pregnant women. The study found that antenatal care guidelines at health facilities and antenatal care provider in-service training significantly increase counselling on obstetric danger signs by 24% and 37%, respectively. The finding suggests improving the quality of antenatal care counselling in Ethiopia needs antenatal care guidelines at each antenatal care clinic and refresher training for the providers.

Antenatal Care Research in East Africa During the Millennium Development Goals Initiative: A Scoping Review

INTRODUCTION

The global burden of maternal mortality remains high and inequitably distributed between countries. Antenatal care (ANC) was identified as critical component in achieving the Millennium Development Goal of improving maternal health. This scoping review aimed to summarize trends and critically explore research about ANC attendance for East African women conducted during the Millennium Development Goals initiative, with a specific focus on barriers to ANC access.

METHODS

Using a scoping review methodology, aggregator databases were searched for relevant articles. Articles were screened by independent reviewers using a priori inclusion criteria. Eligible articles were retained for data charting and analysis.

RESULTS

Following screening, 211 articles were analyzed. The number of relevant articles increased over time; utilized primarily quantitative methods; and involved authors with affiliations from various African countries. Many interrelated physical, social, and cultural factors influenced women's seeking, reaching, and receiving of quality ANC. The extent of studies identified suggest that ANC is a priority research area, yet key gaps in the literature exist. Limited qualitative research, and few articles examining ANC experiences of women from vulnerable groups (e.g. adolescents, women with a disability, and Indigenous women) were identified.

DISCUSSION

These context-specific findings are important considering the Sustainable Development Goals aim to nearly triple the maternal mortality reductions by 2030. In order to achieve this goal, interventions should focus on improving the quality of ANC care and patient-provider interactions. Furthermore, additional qualitative research examining vulnerable populations of women and exploring the inclusion of men in ANC would help inform interventions intended to improve ANC attendance in East Africa.

Provider-perceived benefits and constraints of complete adherence to antenatal care guideline among public health facilities, Ethiopia: A qualitative study

BACKGROUND

In Ethiopia, health care providers' level of adherence to the national Antenatal Care (ANC) guideline is relatively low. The reasons why they do not follow the guidelines are not well known. Therefore, this study aimed to explore the provider-perceived benefits and constraints associated with using the guideline for ANC in public health facilities in Gondar town.

METHODS

A qualitative study was conducted using a semi-structured interview guide. The interview was conducted among a purposive sample of nine health care providers working in four public health facilities in Gondar town. After the interviews were transcribed and coded, a content analysis was done using Atlas ti version 7.5 software packages.

RESULT

Decreasing provider's workload and maximizing performance, improving safe motherhood, and improving the process of service delivery were reported as the perceived benefits of following ANC guideline. Organizational problems, care providers' existing knowledge, attitude, and skills and availability of training and mentorship were the three main identified groups of factors that hinder complete providers' adherence to ANC guideline.

CONCLUSION

Although providers acknowledged the benefits of following ANC guideline, the guideline is not fully implemented. Refresher training should be given at the start of the updated eight-contact ANC guideline and continuing education and supervision throughout the implementation process. Health care providers call for profound and urgent revisions of the supply chain system for supplies and equipment.

Quality assessment indicators in antenatal care worldwide: a systematic review

PURPOSE

To describe indicators used for the assessment of antenatal care (ANC) quality worldwide under the World Health Organization (WHO) framework and based on a systematic review of the literature.

DATA SOURCES

Searches were performed in MEDLINE, SciELO, BIREME and Web of Science for eligible studies published between January 2002 and September 2016.

STUDY SELECTION

Original articles describing women who had received ANC, any ANC model and, any ANC quality indicators were included.

DATA EXTRACTION

Publication date, study design and ANC process indicators were extracted.

RESULTS OF DATA SYNTHESIS

Of the total studies included, 69 evaluated at least one type of ANC process indicator. According to WHO ANC guidelines, 8.7% of the articles reported healthy eating counseling and 52.2% iron and folic acid supplementation. The evaluation indicators on maternal and fetal interventions were: syphilis testing (55.1%), HIV testing (47.8%), gestational diabetes mellitus screening (40.6%) and ultrasound (27.5%). Essential ANC activities assessment ranged from 26.1% report of fetal heart sound, 50.7% of maternal weight and 63.8% of blood pressure. Regarding preventive measures recommended by WHO, tetanus vaccine was reported in 60.9% of the articles. Interventions performed by health services to improve use and quality of ANC care, promotion of maternal and fetal health, and the number of visits to the ANC were evaluated in 65.2% of the studies.

CONCLUSION

Numerous ANC content indicators are being used to assess ANC quality. However, there is a need to use standardized indicators across countries and efforts to improve quality evaluation.

Promoting and delivering antenatal care in rural Jimma Zone, Ethiopia: a qualitative analysis of midwives' perceptions

BACKGROUND

Despite improvements in recent years, Ethiopia faces a high burden of maternal morbidity and mortality. Antenatal care (ANC) may reduce maternal morbidity and mortality through the detection of pregnancy-related complications, and increased health facility-based deliveries. Midwives and community-based Health Extension Workers (HEWs) collaborate to promote and deliver ANC to women in these communities, but little research has been conducted on the professional working relationships between these two health providers. This study aims to generate a better understanding of the strength and quality of professional interaction between these two key actors, which is instrumental in improving healthcare performance, and thereby community health outcomes.

METHODS

We conducted eleven in-depth interviews with midwives from three rural districts within Jimma Zone, Ethiopia (Gomma, Kersa, and Seka Chekorsa) as a part of the larger Safe Motherhood Project. Interviews explored midwives' perceptions of strengths and weaknesses in ANC provision, with a focus as well on their engagement with HEWs. Thematic content analysis using Atlas.ti software was used to analyse the data using an inductive approach.

RESULTS

Midwives interacted with HEWs throughout three key aspects of ANC promotion and delivery: health promotion, community outreach, and provision of ANC services to women at the health centre and health posts. While HEWs had a larger role in promoting ANC services in the community, midwives functioned in a supervisory capacity and provided more clinical aspects of care. Midwives' ability to work with HEWs was hindered by shortages in human, material and financial resources, as well as infrastructure and training deficits. Nevertheless, midwives felt that closer collaboration with HEWs was worthwhile to enhance service provision. Improved communication channels, more professional training opportunities and better-defined roles and responsibilities were identified as ways to strengthen midwives' working relationships with HEWs.

CONCLUSION

Enhancing the collaborative interactions between midwives and HEWs is important to increase the reach and impact of ANC services and improve maternal, newborn and child health outcomes more broadly. Steps to recognize and support this working relationship require multipronged approaches to address imminent training, resource and infrastructure deficits, as well as broader health system strengthening.

Adherence to standards of first-visit antenatal care among providers: A stratified analysis of Tanzanian facility-based survey for improving quality of antenatal care

INTRODUCTION

Despite the benefits of early antenatal care visits for early prevention, detection, and treatment of potential complications in pregnancy, a high level of provider adherence to first-visit antenatal care standards is needed. However, little information is available regarding provider adherence to antenatal care in Tanzania. This study was performed to assess provider adherence to first-visit antenatal care standards and to apply stratified analysis to identify associated factors in Tanzania.

METHODS

Data from the 2014-2015 Tanzania Service Provision Assessment Survey were used in this study. Provider adherence to first-visit antenatal care standards was measured using 10 domains: client history; aspects of prior pregnancies; danger signs of the current pregnancy; physical examination; routine tests; HIV testing and counseling; maintaining a healthy pregnancy; iron/folate supplements; tetanus toxoid vaccination, and preparation for delivery. A composite score was then created in which the highest quantile (corresponding to ≥60.5%) considered to provider adhering to first-visit antenatal care standards. Initially, a series of unadjusted logistic regression analyses according to the type of facility and managing authority were performed separately at each level (i.e., facility, provider, and client). Thereafter, all variables with P < 0.2 were fitted into the respective stratified multivariable logistic regression analysis using a 5% significance level.

RESULTS

A total of 1756 first-visit antenatal care consultations performed by 822 providers in 648 health facilities were analyzed. The overall median [Interquartile range, IQR] adherence to first-visit antenatal care was relatively low at 47.1% [35.7%-60.5%]. After adjusting for selected variables from each level in specific strata, at dispensary; female providers [AOR = 5.5; 95% CI, 1.8-16.4], at health centre; performance of quality assurance [AOR = 2.2; 95% CI, 1.3-3.9], at hospital; availability of routine tests [AOR = 2.5; 95% CI, 1.3-4.8] and basic medicine [AOR = 2.8; 95% CI, 1.4-5.7], at public facilities; availability of medicine [AOR = 1.8; 95% CI, 1.1-3.2] and receiving refresher training [AOR = 1.8; 95% CI, 1.1-3.1], and at private facility; receiving external fund from government [AOR = 3.0; 95% CI, 1.1-8.4] were significantly associated with better adherence to first-visit antenatal care standards.

CONCLUSIONS

The study highlighted the important factors, including the provision of refresher training, regular distribution of basic medicines, and diagnostics equipment which may influence provider adherence to first-visit ANC standards.

Antenatal care strengthening for improved health behaviours in Jimma, Ethiopia, 2009-2011: An effectiveness study

INTRODUCTION

health systems in low-income settings are not sufficiently reaching the poor, and global disparities in reproductive health persist. The frequency and quality of health education during antenatal care is often low. Further studies are needed on how to improve the performance of health systems in low income settings to improve maternal and child health.

OBJECTIVES

to assess the effectiveness of a participatory antenatal care intervention on health behaviours and to illuminate how the different socioeconomic groups responded to the intervention in Jimma, Ethiopia. SETTING, INTERVENTION AND MEASUREMENTS: an intervention was designed participatorily and comprised trainings, supervisions, equipment, health education material, and adaption of guidelines. It was implemented at public facilities. Household surveys, before (2008) and after (2010) intervention, were conducted amongst all women who had given birth within the previous 12 months. The effect of the intervention was assessed by comparing the change in health behaviours (number of antenatal visits, health facility delivery, breast feeding, preventive infant health check, and infant immunisation) from before to after the intervention period at intervention sites, relative to control sites, using logistic mixed effect regression.

RESULTS

on the basis of 1357 women included before and 2262 after the intervention, there were positive effects of the intervention on breast feeding practices (OR 3.0, 95% CI: 1.4; 3.6) and preventive infant health check (OR 2.4, 95% CI: 1.5; 3.5). There was no effect on infant immunisation coverage and negative effect on number of antenatal visits. The effect on various outcomes was modified by maternal education, and results indicate increased health facility delivery (OR 2.4, 95% CI: 0.8; 6.9) and breast feeding practices (OR 18.2, 95% CI: 5.2;63.6) among women with no education.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

the facility based intervention improved some, but not all health behaviours. The improvements indicated amongst the most disadvantaged antenatal care attendants in breast feeding and health facility delivery are encouraging and underline the need to scale up priority of antenatal care in the effort to reduce maternal and child health inequity.