proposal nada
TRANSCRIPT
Introduction:
The fifth millennium development goal aims at reducing maternal mortality by
75% by the year 2015[1]. According to the WHO, there was an estimated 358,000
maternal deaths globally in 2008. Developing countries accounted for 99% of these
deaths of which three fifths occurred in Sub-Saharan Africa where Uganda lies [2].
Abortion, obstetric complications such as hemorrhage, dystocia, eclampsia, sepsis
and infections such as tuberculosis and HIV are the major causes of maternal
deaths in developing countries[3]. Although antenatal care (ANC) is not in itself
very effective in reducing maternal mortality, it provides an entry for interventions
which give health workers the opportunity to detect these risky conditions and
therefore refer them for early management leading to better maternal outcomes[4].
ANC involves screening for health and socioeconomic conditions likely to
increase the possibility of specific adverse pregnancy outcomes, providing
therapeutic interventions known to be effective and educating pregnant women
about planning for safe birth, emergencies during pregnancy and how to deal with
them [5]. ANC is therefore relevant for the improvement of maternal health as it
enables the monitoring of the health of the mother and anticipation of any
difficulties during pregnancy, labor and birth [6]. Some studies have estimated that
ANC alone can reduce maternal mortality by 20% [7] given good quality and
regular attendance. In addition ANC attendance during pregnancy has been shown
to have a positive impact on the use of postnatal healthcare services, which also
play a key role in detecting risky conditions after child birth consequently leading
to better maternal health outcomes[8].
WHO evidence shows that four ANC visits are sufficient for uncomplicated
pregnancies and more are necessary only in cases of complications[9]. The WHO,
therefore recommends four visits, however in developing countries, many women
do not attend all the four visits [10] [11]. This has been attributed to poor
accessibility, inability to afford the costs of seeking care, cultural barriers and lack
of knowledge or illiteracy [12] [13].
The quality of ANC is critical in enabling women and health workers identify
risks and danger signs during pregnancy which should lead to appropriate
action[14]. Whether or not women can identify danger signs during pregnancy and
act appropriately depends on quality aspects such as the depth of the information
and counseling given during an ANC visit[15].
Provision of quality ANC service requires the presence of relevant Infrastructure,
adequate trained health workers, infection control facilities, diagnostic equipment,
supplies and essential drugs. Furthermore, the ANC process requires the use of
guidelines that health providers should follow while offering care to ensure
prevention, diagnosis and treatment of complications[16].
This study assessed the quality of ANC services by looking at the health facilities
capacity to deliver ANC services, the completeness of the ANC consultation
process and patient satisfaction with ANC services offered. maternal health
services using vouchers.
Previous studies:
Christoph Boller et al (2003) in Tanzania compare the quality of public and
private first-tier antenatal care services using defined criteria Structural attributes
of quality were assessed through a checklist, and process attributes, including
interpersonal and technical aspects, through observation and exit interviews. A
total of 16 health care providers, and 166 women in the public and 188 in the
private sector, were selected by systematic random sampling for inclusion in the
study. Quality was measured against national standards, and an overall score
calculated for the different aspects to permit comparison. Findings The results
showed that both public and private providers were reasonably good with regard to
the structural and interpersonal aspects of quality of care.
However, both were poor when it came to technical aspects of quality. For
example, guidelines for dispensing prophylactic drugs against anemia or malaria
were not respected, and diagnostic examinations for the assessment of gestation,
anemia, and malaria or urine infection were frequently not performed. In all
aspects, private providers were significantly better than public ones. [17]
Nicholas N A Kyei1,3 et al ( 2005) Zambia in analyzed two national
datasets with detailed antenatal provider and user information, to describe the
level of ANC service provision at 1,299 antenatal facilities and the quality of ANC
received by 4,148 mothers Between 2002 and 2007. Results: We found that only
45 antenatal facilities (3%) fulfilled our developed criteria for optimum ANC
service, while 47% of facilities provided adequate service, and the remaining 50%
offered inadequate service. Although 94% of mothers reported at least one ANC
visit with a skilled health worker and 60% attended at least four visits, only 29% of
mothers received good quality ANC, and only 8% of mothers received good
quality ANC and attended in the first trimester.
Br J Obstet Et al (1999) in UK a pilot list of indicators of quality of antenatal
care across a range of maternity care settings. For each indicator to determine what
is achieved in current clinical practice, to facilitate the setting of audit standards
and calculation of appropriate sample sizes for audit. RESULTS: Nine of the
eleven suggested indicators were successfully piloted. Two indicators require
further development. In seven of the nine hospitals external cephalic version was
not commonly performed. There were wide variations in the proportions of women
screened for asymptomatic bacteriuria. Screening of women from ethnic minorities
for haemoglobinopathy was more likely in hospitals with a large proportion of
non-caucasian women. A large number of Rhesus negative women did not have a
Rhesus antibody check performed after 28 weeks of gestation and did not receive
anti-D immunoglobulin after a potentially sensitising event during pregnancy. As a
result of the study appropriate sample sizes for future audit could be calculated.
[18]
Delvaux, T. et al (2008) in Cote d'Ivoire assess whether implementation of a
prevention of mother-to-child HIV transmission (PMTCT) programme in Cote
d'Ivoire improved the quality of antenatal and delivery care services. METHODS:
Quality of antenatal and delivery care services was assessed in five urban health
facilities before (2002-2003) and after (2005) the implementation of a PMTCT
programme through review of facility data; observation of antenatal consultations
(n = 606 before; n = 591 after) and deliveries (n = 229 before; n = 231 after) and
exit interviews of women; and interviews of health facility staff. RESULTS: HIV
testing was never proposed at baseline and was proposed to 63% of women at the
first ANC visit after PMTCT implementation. The overall testing rate was 42%
and 83% of tested HIV-infected pregnant women received nevirapine. In addition,
inter-personal communication and confidentiality significantly improved in all
health facilities. In the maternity ward, quality of obstetrical care at admission,
delivery and post-partum care globally improved in all facilities after the
implementation of the programme although some indicators remained poor, such
as filling in the partograph directly during labour. Episiotomy rates among
primiparous women dropped from 64% to 25% (P < 0.001) after PMTCT
implementation. Global scores for quality of antenatal and delivery care
significantly improved in all facilities after the implementation of the program me
[19]
Fekede, B et al(2007) in Ethiopia assess antenatal care service utilization and
factors associated with antenatal care non attendance. METHODS: A community
based cross-sectional study was conducted among pregnant women from January
26 to February 06, 2006 in Jimma Town, Jimma zonal administration south west
Ethiopia. Structured interviewer administered questionnaire was used for data
collection. The data collected on study variables were tabulated in frequency tables
and significance of association between variables was tested using chi2--test of
significance. RESULT: A total of 360 pregnant women were enrolled in the study.
The study, revealed that about 76.7% of the women have attended antenatal care
and 23.3% have not attended at all. Literacy status, income, Gravidity, Religion
and occupation showed statistically significant association (P < 0.05) with
utilization of antenatal care. But marital status, Ethnicity and parity showed no
statistically significant association (P > 0.05) with antenatal care utilization. The
study showed that about 42.8% of the attendants have made their first antenatal
visit in the 3rd trimester of pregnancy. Out of the total only 6.5% the studied
women had the recommended four visits. Women in the age group 15-24 are more
likely to attend ANC 2.75 times larger than that of women in the age group 25-34
(OR = 2.74, 95% CI: 1.37, 4.38). Similarly others (students and farmers) are about
four times likely to attend ANC than House wives (OR = 4.06. 95% CI: 1.50,
11.40). [20]
Khatun, S. et al (2008) in Dhaka, Bangladesh studied Four hundred and sixty-
five pregnant women and their newborn babies were at a maternal and child health
training institute, between July 2002 and June 2003 with the objective of (1)
examining the relationship between birth weight and maternal factors, and, if there
was a dose-response relationship between quality of antenatal care and birth
weight, (2) predicting the number of antenatal visits required for women with
different significant characteristics to reduce the incidence of low-birth-weight
babies. The study revealed that 23.2% of the babies were of low birth weight
according to the WHO cut-off point of <2500 g. Mean birth weight was 2674.19+/-
425.31 g. A low birth weight was more common in younger (<20 years) and older
(> or =30 years) mothers, the low-income group and those with little or no
education. The mean birth weight of the babies increased with an increase in
quality of antenatal care. The babies of the mothers who had 6+ antenatal visits
were found to be 727.26 g heavier than those who had 1-3 visits and 325.88 g
heavier than those who had 4-5 visits. No significant relationship was found
between number of conception, birth-to-conception interval, BMI at first visit, sex
of the newborn and birth weight. Further, from multiple regression analysis
(stepwise), it was revealed that number of antenatal visits, educational level of the
mother and per capita yearly income had independent effects on birth weight after
controlling the effect of each variable. Using multiple regression analysis, the
estimated number of antenatal visits required to reduce the incidence of low-birth-
weight babies for women with no education and below-average per capita income
status was 6; the number required for women with no education and above-average
per capita income status was 5; and that for women with education and with any
category of income status was 4 visits. [21]
General objective:
To access perception of pregnant women and providers about Quality off
Antenatal care.
Specific Objectives:
To access availability of service
To access availability of drugs
To access availability of infrastructure
To reduce infant mortality,
Preventing people from dying prematurely.
Ensuring that people have a positive experience of care.
Justification:
This study gives important baseline information that could be used in informing
the intervention design and implementation of projects that seek to improve
maternal health.
Treating and caring for people in a safe environment and protecting them from
avoidable harm.
Methodology:
Type of study:
Descriptive cross section study
Study population :
There are 1107 pregnant women in Khartoum state receiving antenatal
care services every month in public health centers
The study populations are all pregnant women in reproductive age
attending antenatal clinic in 5 public health centers (Alshajara , Alremaila, Algoz,
Alamab, Almygoma Health centers).
Sample size determination:
n=N/1+n (e) 2
n=sample size
N=population size in last month who attending antenatal care
in clinics of health centers.
5 health centers=350
e=margin of error=0, 05
n=350/1+350/,0025
n=187
Data Colletion:
Data will be collected via questionnaire.
Plan for analysis:
Data will entered spss program , statistical significant will tested by using chi
squired test and using proportion between sub groups and mean and stander
diviation.
Ethical Issues
References:
1. Bhutta ZA . Countdown to 2015 decade report (2000-10): taking stock of
maternal, newborn, and child survival. Lancet. . 2010. 5;375((9730)):
p.:2032-44. .
2. WHO. Trends in Maternal Mortality: 1990 to 2008, Estimates developed by
WHO, UNICEF, UNFPA and the World Bank. World Health Organisation. .
2010.
3. Eijk, v., . Use of antenatal services and delivery care among women in rural
western Kenya: a community based survey. Reproductive Health. 2006;
(3(1): ): p. 2.
4. MagadiM, Factors associated with unfavourable birth outcomes in Kenya.
Journal of Biosocial Science.; : . 2001. 33((02)): p. 199-225.
5. WHO. WHO, programme to map best reproductive health practices.
WHO/RHR/01. 30,(W). 2002.
6. Wirth, M., "Delivering" on the MDGs?: Equity and Maternal Health in
Ghana, Ethiopia and Kenya. East African Journal of Public Health. . 2008; .
5:((3)): p. 133-141.
7. Nikiema, Quality of Antenatal Care and Obstetrical Coverage in Rural
Burkina Faso. . . 2010. Vol. 28.
8. Chakraborty, N., et al., Utilisation of postnatal care in Bangladesh:
evidence from a longitudinal study. Health Soc Care Community, 2002.
10(6): p. 492-502.
9. Villar, J., et al., WHO antenatal care randomised trial for the evaluation of
a new model of routine antenatal care. Lancet, 2001. 357(9268): p. 1551-64.
10. TDHS., Tanzania demographic and health survey. Ministry of health, . 2005.
11. UDHS., Uganda demographic and health survey. Ministry of health, . . ,
2006
12. Chowdhury A, Skilled Attendance at Delivery in Bangladesh: An
Ethnographic Study.Research Monograph Series Research and Evaluation
Division, BRAC, Dhaka, Bangladesh. 2003. vol. 22.
13. Mathole, A qualitative study of women's perspectives of antenatal care in a
rural area of Zimbabwe. Midwifery.; :. . 2004. 20((2)): p. 122-132.
14. Sarker, . Quality of antenatal care in rural southern Tanzania: a reality
check. BMC Research Notes.; :. 2010. 3((1)): p. 209.
15. Carroli, G., C. Rooney, and J. Villar, How effective is antenatal care in
preventing maternal mortality and serious morbidity? An overview of the
evidence. Paediatr Perinat Epidemiol, 2001. 15 Suppl 1: p. 1-42.
16. Mcdonagh, Is antenatal care effective in reducing maternal morbidity and
mortality?. Health Policy and Planning. ; :. . 1996. 11((1)): p. 1-15.
17. Boller, C., et al., Quality and comparison of antenatal care in public and
private providers in the United Republic of Tanzania. Bull World Health
Organ, 2003. 81(2): p. 116-22.
18. Vause, S. and M. Maresh, Indicators of quality of antenatal care: a pilot
study. Br J Obstet Gynaecol, 1999. 106(3): p. 197-205.
19. Delvaux, T., et al., Quality of antenatal and delivery care before and after
the implementation of a prevention of mother-to-child HIV transmission
programme in Cote d'Ivoire. Trop Med Int Health, 2008. 13(8): p. 970-9.
20. Fekede, B. and G.M. A, Antenatal care services utilization and factors
associated in Jimma Town (south west Ethiopia). Ethiop Med J, 2007. 45(2):
p. 123-33.
21. Khatun, S. and M. Rahman, Quality of antenatal care and its dose-response
relationship with birth weight in a maternal and child health training
institute in Bangladesh. J Biosoc Sci, 2008. 40(3): p. 321-37.