Effect of quality antenatal care service on the continuum of maternal and newborn health care services; a follow up study at public health facilities of Bahir-dar city administration; North West Ethiopia

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Addis Ababa Universty


Background: In Ethiopia, more than 62 % of pregnant women attend antenatal care (ANC) at least once and it is an opportunity for reaching pregnant women with a number of interventions that may be vital to their health and the well-being of their infants. However data on the extent to which providers utilize these opportunities remain limited especially in developing countries. Ethiopia is one of the countries that experiences relatively high ANC coverage and high maternal and neonatal mortality. This paradox urges the need to investigate the linkage between ANC service quality and continuum of maternal and newborn health care services. Objective: To assess the effect of antenatal care service quality on the continuum of maternal and newborn health care services at public health facilities of Bahir Dar City Administration. Method: A facility based prospective follow up study was conducted among 970 first ANC visit pregnant women with gestational age ≤16weeks selected by systematic sampling technique (k=3). Women were followed from their first ANC visit till six weeks after delivery. Longitudinal data on the quality of ANC service was collected through structured observation checklist during consultation with ANC providers during each of the four ANC visits. ANC service was considered as acceptable quality if women received ≥75th percentile of the essential ANC services. Exit interview just after their fourth ANC visit was carried out to assess the satisfaction of pregnant women on ANC services they received and another exit interview was also conducted at 6 weeks after birth when women come to immunize their child to assess the essential newborn care practices that their babies received from a provider and/or woman; and whether or not they started to use postpartum modern family planning. If a woman does not come to the health facility for immunization, the data collectors traced her based on the address registered during her first ANC visit. For the assessment of health facility delivery, postpartum modern family planning use and essential newborn care practices, completed data were obtained from 823 women where as for the assessment of birth weight, it was obtained from 718 women since those women who gave birth at home and those who deliver a premature or still birth baby were excluded due to the fact that data on birth weight could not be obtained and as it might be affected by the underlying conditions respectively. XVI Generalized Estimating Equation (GEE) was carried out to control cluster effect among women who received ANC in the same facility. The model fitness was checked by observing the difference of the -2 log likelihood ratio between the null model and the model with independent variables; linear regression assumptions were also checked by graphical and/or statistical methods accordingly. In addition, Multi co linearity diagnosis was also carried out using variance inflation factor (VIF). Based on Hosmer and Lemeshow applied logistic regression guide a p-value <0.2 was considered to select eligible variables for multivariable regression analyses and p-value <0.05 was considered to identify statistically significant predictor variables for the outcome of interest. Results: Among 823 pregnant women who completed follow up, only about one-fourth (27.6%) (95% CI =24.5%, 30.5%) received acceptable quality ANC services. The odds of giving birth at health facility among pregnant women who received acceptable ANC service quality was about 3.38 times higher than pregnant women who received un acceptable quality ANC service (AOR=3.38, 95% CI: 1.67, 6.83). Being urban dweller (AOR = 9.91, 95% CI: 2.52, 38.91), being younger age (AOR = 3.69, 95% CI: 1.44, 9.49); Secondary school and above educational status of pregnant women (AOR = 6.83, 95% CI; 3.33, 13.97) were also positively associated with Health facility delivery. However, primary school educational status of women has no significant difference in the use of institutional delivery compared to those women who cannot read and write. The magnitude of low birth weight (<2500grams) among 718 babies delivered at the health facility was 7.8% (95%CI= 6.0%, 9.7%) with 1.4% versus 10.5% among those who received acceptable and not acceptable ANC services quality respectively (P-value<0.001); frequency of maternal nutritional advice (β= 0.147, 95%CI= 0.11, 0.19), iron-folic acid supplementation (β= - 0.358, 95%CI= -0.476,-0.240), tetanus toxoid vaccination (β= 0.609, 95%CI= 0.316, 0.903), maternal educational status (β= 0.079, 95%CI= 0.06, 0.10) and parity (β= -0.174, 95%CI= 0.24, 0.11) were determinants for birth weight. About 22.7% of pregnant women were counseled about postpartum family planning at least once during their four ANC visits. The magnitude of postpartum modern family planning use within 6 weeks after delivery among the study women was 157 (19.1%) with 95%CI (16.4%, 21.9%). The odds of postpartum modern family planning use within 6 weeks after birth among women who XVII were counseled about postpartum family planning at their third or fourth visit was 3.5 times higher compared to those who were not counselled at any of their visits (AOR=3.5; 95% CI:2.19,5.49). Being satisfied with ANC services received (AOR= 4.12; 95% CI: 2.55, 6.66), counseling on birth preparedness and complication readiness plan (AOR= 2.2; 95% CI: 1.32, 3.55), Being counselled on breast feeding (AOR= 1.8; 95% CI: 1.15, 2.82) and post natal care use (AOR= 13.5; 95% CI: 8.24, 22.07) had also significant positive effect on postpartum modern family planning use. The composite index for good essential newborn care practice was only 13.7%, with 95% CI (11.3%, 16.2%). About 24.7% versus 9.6% women who received acceptable and un acceptable ANC service quality had good essential newborn care practices (X2=31.668, p<0.000). ANC service quality (AOR= 2.31, 95% CI=1.47, 3.65), PNC use (AOR= 1.69, 95% CI=1.03, 2.79), parity (AOR= 0.43 95% CI=0.27, 0.69) and age (AOR=3.94 95% CI=1.12, 13.91) of the women were predictors for essential newborn care practice (ENBC) practice Conclusion and recommendation: The quality of ANC service was low and adherence to essential contents of ANC services was also heterogeneous. ANC service quality ensures normal birth weight outcome Majority of the post partum women were at risk for closely spaced pregnancy; the risk increases among those who were not counselled on FP Good ENBC practice was significantly low; mainly due to problem related to clean cord care Quality of ANC service matters continuum of maternal and newborn health care services more than frequency of visit. Therefore Maternal and newborn health programme managers and health providers need to ensure continuity of care through maintaining the quality of ANC service by integrating maternal and newborn health care services and through strengthening referral linkages between community health workers (like health extension workers and health development armies) and primary level of care for maternal and newborn care services. In addition, the local authorities at each level of health sector or the nongovernmental organizations working to improve maternal and newborn health need to provide training for ANC providers and equip the necessary supplies for the provision of quality ANC service.



newborn health,pregnant women