A framework for a new approach to antenatal care.

A framework for a new approach to antenatal care (ANC) is presented to improve maternal health. Based on evaluations of ANC, safe motherhood programs, gender and social theory, it suggests that managers should draw upon existing family and community support systems, and develop partnerships beyond the health service. Policy and program changes are required in: professional mandates for ANC providers, organization of ANC services, service protocols, training programs, policy towards TBAs, referral care, and service support systems.     

The effectiveness of a perinatal education programme on smoking, infant care, and psychosocial health for ethnic Turkish women

Objective

antenatal programmes might be effective in preventing unhealthy lifestyles, poor maternal infant care practices, and poor psychosocial health in ethnic minority women, but there are few evidence-based interventions. For this reason an antenatal education programme, called ‘Happy Mothers, Happy Babies’ (HMHB) was systematically designed for ethnic Turkish women in the Netherlands.

Design

in a non-randomised trial Turkish women attending HMHB (HMHB group) were compared with those receiving care as usual (control group).

Setting

Parent–Child Centres, which provide integrated maternity and infant care.

Participants

in both the HMHB (n=119) and the control (n=120) group, questionnaires were administered by ethnic Turkish interviewers at three (T0) and eight (T1) months of pregnancy, and two (T2) and six (T3) months after birth.

Findings

at baseline, women in the HMHB group had significantly lower educational levels, were less frequently in paid employment, had less knowledge about smoking, and showed more often mildly depressive symptoms. Adjusted analyses showed that HMHB was effective in improving knowledge about smoking (OR=2.73; 95% CI 1.40, 5.31), intention to engage in prevention of sudden infant death syndrome (SIDS) (OR=8.08; 95% CI 3.34, 19.56) and short-term SIDS prevention behaviour (OR=2.22; 95% CI=1.18, 4.19). However, no intervention effect was found for smoking during pregnancy, SIDS prevention behaviour on the long term, soothing behaviour, serious depressive symptoms, and parent–child attachment.

Key conclusions

although we could not demonstrate intervention effects on all outcome measures, the HMHB programme appears to be highly welcome, and reaches an underserved minority group at increased risk for adverse perinatal outcomes.

Implications for practice

the HMHB programme is one of the first systematically developed antenatal interventions for ethnic minority women. The programme can be used as a basic antenatal programme, and as a screening opportunity for women who smoke or show serious depressive symptoms.     

CenteringPregnancy-Africa: A pilot of group antenatal care to address Millennium Development Goals

Background

severe health worker shortages and resource limitations negatively affect quality of antenatal care (ANC) throughout sub-Saharan Africa. Group ANC, specifically CenteringPregnancy (CP), may offer an innovative approach to enable midwives to offer higher quality ANC.

Objective

our overarching goal was to prepare to conduct a clinical trial of CenteringPregnancy-Africa (CP-Africa) in Malawi and Tanzania. In Phase 1, our goal was to determine the acceptability of CP as a model for ANC in both countries. In Phase 2, our objective was to develop CP-Africa session content consistent with the Essential Elements of CP model and with national standards in both Malawi and Tanzania. In Phase 3, our objective was to pilot CP-Africa in Malawi to determine whether sessions could be conducted with fidelity to the Centering process.

Setting

Phases 1 and 2 took place in Malawi and Tanzania. Phase 3, the piloting of two sessions of CP-Africa, occurred at two sites in Malawi: a district hospital and a small clinic.

Design

we used an Action Research approach to promote partnerships among university researchers, the Centering Healthcare Institute, health care administrators, health professionals and women attending ANC to develop CP-Africa session content and pilot this model of group ANC.

Participants

for Phases 1 and 2, members of the Ministries of Health, health professionals and pregnant women in Malawi and Tanzania were introduced to and interviewed about CP. In Phase 2, we finalised CP-Africa content and trained 13 health professionals in the Centering Healthcare model. In Phase 3, we conducted a small pilot with 24 pregnant women (12 at each site).

Measurements and findings

participants enthusiastically embraced CP-Africa as an acceptable model of ANC health care delivery. The CP-Africa content met both CP and national standards. The pilot established that the CP model could be implemented with process fidelity to the 13 Essential Elements. Several implementation challenges and strategies to address these challenges were identified.

Key conclusions

preliminary data suggest that CP-Africa is feasible in resource-constrained, low-literacy, high-HIV settings in sub-Saharan Africa. By improving the quality of ANC delivery, midwives have an opportunity to make a contribution towards Millennium Development Goals (MDG) targeting improvements in child, maternal and HIV-related health outcomes (MDGs 4, 5 and 6). A clinical trial is needed to establish efficacy.

Implications for practice

CP-Africa also has the potential to reduce job-related stress and enhance job satisfaction for midwives in low income countries. If CP can be transferred with fidelity to process in sub-Saharan Africa and retain similar results to those reported in clinical trials, it has the potential to benefit pregnant women and their infants and could make a positive contribution to MGDs 4, 5 and 6.     

Men's involvement in antenatal care and labour: Rethinking a medical model

In the UK, putative fathers are encouraged to be involved in antenatal and maternal health care, in the belief that involving men as early as possible lays the foundation for better, more involved fatherhood. Integrating men into maternity care can, however, have hitherto unexplored ethical complexities.     

Ethnic differences in antenatal care use in a large multi-ethnic urban population in the Netherlands

Objective

to determine differences in antenatal care use between the native population and different ethnic minority groups in the Netherlands.

Design

the Generation R Study is a multi-ethnic population-based prospective cohort study.

Setting

seven midwife practices participating in the Generation R Study conducted in the city of Rotterdam.

Participants

in total 2093 pregnant women with a Dutch, Moroccan, Turkish, Cape Verdean, Antillean, Surinamese-Creole and Surinamese-Hindustani background were included in this study.

Measurements

to assess adequate antenatal care use, we constructed an index, including two indicators; gestational age at first visit and total number of antenatal care visits.Logistic regression analysis was used to assess differences in adequate antenatal care use between different ethnic groups and a Dutch reference group, taking into account differences in maternal age, gravidity and parity.

Findings

overall, the percentages of women making adequate use are higher in nulliparae than in multiparae, except in Dutch women where no differences are present.Except for the Surinamese-Hindustani, all women from ethnic minority groups make less adequate use as compared to the native Dutch women, especially because of late entry in antenatal care. When taking into account potential explanatory factors such as maternal age, gravidity and parity, differences remain significant, except for Cape-Verdian women. Dutch-Antillean, Moroccan and Surinamese-Creole women exhibit most inadequate use of antenatal care.

Key conclusions

this study shows that there are ethnic differences in the frequency of adequate use of antenatal care, which cannot be attributed to differences in maternal age, gravidity and parity. Future research is necessary to investigate whether these differences can be explained by socio-economic and cultural factors.

Implications for practise

clinicians should inform primiparous women, and especially those from ethnic minority groups, on the importance of timely antenatal care entry.     

'Weighing up and balancing out': a meta-synthesis of barriers to antenatal care for marginalised women in high-income countries

Background  In high-resource settings around 20% of maternal deaths are attributed to women who fail to receive adequate antenatal care. Epidemiological evidence suggests many of these women belong to marginalised groups often living in areas of relative deprivation. Reasons for inadequate antenatal attendance have yet to be fully evaluated.
Objectives  To identify the factors affecting access to antenatal care for marginalised pregnant women living in developed countries.
Search strategy  We included qualitative studies from developed countries published in English language journals (1980–2007).
Selection criteria  Qualitative studies exploring the views of marginalised women living in developed countries who either failed to attend for any antenatal care or did so late or irregularly.
Data collection and analysis  Eight studies fulfilled the selection criteria and were synthesised in accord with the techniques derived from meta-ethnography.
Main results  Initial access is influenced by late pregnancy recognition and subsequent denial or acceptance. Continuing access appears to depend on a strategy of weighing up and balancing out of the perceived gains and losses. Personal resources in terms of time, money and social support are considered alongside service provision issues including the perceived quality of care, the trustworthiness and cultural sensitivity of staff and feelings of mutual respect.
Conclusions  A nonthreatening, nonjudgemental antenatal service run by culturally sensitive staff may increase access to antenatal care for marginalised women. Multiagency initiatives aimed at raising awareness of, and providing access to, antenatal care may also increase uptake.     

Factors affecting the quality of antenatal care provided to remote dwelling Aboriginal women in northern Australia

Objective: there is a significant gap in pregnancy and birth outcomes for Australian Aboriginal and Torres Strait Islander women compared with other Australian women. The provision of appropriate and high quality antenatal care is one way of reducing these disparities. The aim of this study was to assess adherence to antenatal guidelines by clinicians and identify factors affecting the quality of antenatal care delivery to remote dwelling Aboriginal women.Setting and design: a mixed method study drew data from 27 semi-structured interviews with clinicians and a retrospective cohort study of Aboriginal women from two remote communities in Northern Australia, who gave birth from 2004–2006 (n=412). Medical records from remote health centres and the regional hospital were audited.Measurements and findings: the majority of women attended antenatal care and adherence to some routine antenatal screening guidelines was high. There was poor adherence to local guidelines for follow-up of highly prevalent problems including anaemia, smoking, urinary tract infections and sexually transmitted infections. Multiple factors influenced the quality of antenatal care.Key conclusions and implications for practice: the resourcing and organisation of health services and the beliefs, attitudes and practices of clinicians were the major factors affecting the quality of care. There is an urgent need to address the identified issues in order to achieve equity in women's access to high quality antenatal care with the aim of closing the gap in maternal and neonatal health outcomes.     

The use of midwife-led primary antenatal care by obese women in The Netherlands: An explorative cohort study

Objectiveto study the effect of body mass index (BMI) on the use of antenatal care by women in midwife-led care.Designan explorative cohort study.Setting11 Dutch midwife-led practices.Participantsa cohort of 4421 women, registered in the Midwifery Case Registration System (VeCaS), who received antenatal care in midwife-led practices in the Netherlands and gave birth between October 2012 and October 2014.Findingsthe mean start of initiation of care was at 9.3 (SD 4.6) weeks of pregnancy. Multiple linear regression showed that with an increasing BMI initiation of care was significantly earlier but BMI only predicted 0.2% (R²) of the variance in initiation of care. The mean number of face-to- face antenatal visits in midwife-led care was 11.8 (SD 3.8) and linear regression showed that with increasing BMI the number of antenatal visits increased. BMI predicted 0.1% of the variance in number of antenatal visits. The mean number of antenatal contacts by phone was 2.2 (SD 2.6). Multiple linear regression showed an increased number of contacts by phone for BMI categories 'underweight' and 'obese class I'. BMI categories predicted 1% of the variance in number of contacts by phone.Key conclusionsBMI was not a relevant predictor of variance in initiation of care and number of antenatal visits. Obese pregnant women in midwife-led practices do not delay or avoid antenatal care.Implications for practiceTaking care of pregnant women with a high BMI does not significantly add to the workload of primary care midwives. Further research is needed to more fully understand the primary maternal health services given to obese women.     

Antenatal care for first time mothers: a discrete choice experiment of women's views on alternative packages of care

Objective

To investigate the views of women in relation to the provision of antenatal care.

Methods

A discrete choice experiment using a sample of 100 women who were nulliparous (pregnant for the first time) and attending for routine ultrasound scan in the 20th week of their pregnancy.

Results

Women preferred antenatal care visits to be provided by a community midwife at a local clinic and to have 10 visits rather than 7. In addition they favoured the provision of education/preparation for birth, the use of uterine artery Doppler screening, and the provision of a telephone advice line. The results show that women were prepared to trade-off fewer antenatal care visits to ensure access to their packages of antenatal care that reflected their preferences.

Conclusions

Whilst the number of antenatal care visits is important to women they may accept fewer visits if antenatal care is provided by midwives and they receive enhanced service provision such as a telephone advice line and uterine artery Doppler screening.     

Barriers and solutions for timely initiation of antenatal care in Kigali,Rwanda: Health facility professionals' perspective

Objective

timely initiation of antenatal care (i.e. within the first trimester) is associated with attendance of the full recommended regimen of antenatal visits. This study assessed social and behavioural factors that affect timely initiation of antenatal care in Kigali, Rwanda from the perspective of health facility professionals.

Design

health facility professionals involved in antenatal care provision were interviewed on their perceptions about untimely initiation of antenatal care based on open-ended questions. These one-on-one interviews were tape recorded and transcribed for analysis.

Setting

interviews were performed in June and July 2011 at Muhima Health Center in Kigali, Rwanda.

Participants

17 health facility professionals with a wide range of skills and experience levels were selected from the 36 total staff members of Muhima Health Center based on their participation in and knowledge of antenatal care.

Measurements and findings

inductive content analysis was used to group responses from these qualitative interviews with the goal of creating a conceptual map around barriers and solutions for untimely antenatal care. Qualitative responses were coded to identify the most common themes and sub-themes following a consensus methodology. The health-care professional interviews identified five themes as barriers to timely initiation of antenatal care: (1) lack of knowledge; (2) experience with previous births; (3) issues with male partners not willing/able to attend the clinic; (4) poverty or problems with health insurance; and (5) antenatal care culture. As potential solutions to these hurdles, the following themes were identified: (1) maternal/community education and sensitisation; (2) incentives to attend antenatal care visits; and (3) tracking the content and recommended number of antenatal visits.

Key conclusions

qualitative results indicate that behavioural contextual interventions may help overcome antenatal care barriers. The Rwandan Government and health facilities should work together with target communities to improve antenatal care compliance, taking into account the solutions suggested by the health facility professional interviews.

Implications for practice

study findings suggest that there are specific solutions to increase adherence with timely initiation of antenatal care in Rwanda, including education and sensitisation, modifying couples' HIV testing policies, addressing costs of antenatal care, and tracking the number of recommended antenatal visits.     

Development of the Optimality Index as a new approach to evaluating outcomes of maternity care

Evaluating perinatal outcomes within a framework of normalcy is a new focus of measurement. As maternal and child health clinicians and researchers look to evaluate care practices that are both of high quality and cost-effective, it is important to have measurement tools that assess differences among all women giving birth. The Optimality Index-US shifts the focus from rare adverse events to evidence-based optimal events. This article describes the continuing development of the index and discusses clinical implications for obstetric nurse clinicians.     

An antenatal prediction model for adverse birth outcomes in an urban population: The contribution of medical and non-medical risks

Objectivesin the Netherlands the perinatal mortality rate is high compared to other European countries. Around eighty percent of perinatal mortality cases is preceded by being small for gestational age (SGA), preterm birth and/or having a low Apgar-score at 5 minutes after birth. Current risk detection in pregnancy focusses primarily on medical risks. However, non-medical risk factors may be relevant too. Both non-medical and medical risk factors are incorporated in the Rotterdam Reproductive Risk Reduction (R4U) scorecard.We investigated the associations between R4U risk factors and preterm birth, SGA and a low Apgar score.Designa prospective cohort study under routine practice conditions.Settingsix midwifery practices and two hospitals in Rotterdam, the Netherlands.Participants836 pregnant women.Interventionsthe R4U scorecard was filled out at the booking visit.Measurementsafter birth, the follow-up data on pregnancy outcomes were collected. Multivariate logistic regression was used to fit models for the prediction of any adverse outcome (preterm birth, SGA and/or a low Apgar score), stratified for ethnicity and socio-economic status (SES).Findingsfactors predicting any adverse outcome for Western women were smoking during the first trimester and over-the-counter medication. For non-Western women risk factors were teenage pregnancy, advanced maternal age and an obstetric history of SGA. Risk factors for high SES women were low family income, no daily intake of vegetables and a history of preterm birth. For low SES women risk factors appeared to be low family income, non-Western ethnicity, smoking during the first trimester and a history of SGA.Key conclusionsthe presence of both medical and non-medical risk factors early in pregnancy predict the occurrence of adverse outcomes at birth. Furthermore the risk profiles for adverse outcomes differed according to SES and ethnicity.Implications for practiceto optimise effective risk selection, both medical and non-medical risk factors should be taken into account in midwifery and obstetric care at the booking visit.     

Group antenatal care: new pedagogic method for antenatal care—a pilot study

Objective

to investigate how women who attended group antenatal care experienced the information they received, compared with women who attended traditional antenatal care, and their satisfaction with the form of care. The aim was also to determine the effect of group antenatal care on women's social networks compared with traditional antenatal care.

Design and setting

a pilot study with an intervention group (group antenatal care) and a control group (traditional antenatal care). Both groups were selected through informed choice. A questionnaire and a follow-up telephone call, using a structured questionnaire, were used to evaluate both groups.

Participants

for each woman who had chosen to be in the intervention group, two women who had chosen traditional antenatal care were selected from the same antenatal clinic and given the same questionnaire.

Findings

35/45 (77%) women in the intervention group returned a completed questionnaire, compared with 40/85 (48%) women in the control group. There was little difference in satisfaction with information between the two groups, and overall satisfaction was high.

Key conclusions

at six months post partum, the women who attended group antenatal care still met others from the group more regularly than the women who attended traditional antenatal care.

Implications for practice

group antenatal care is well accepted by women, and can better utilise midwives’ time.     

Coverage and outcomes of antenatal tests for infections: a population based survey in the Province of Trento,Italy

Background: Rubella, syphilis, toxoplasmosis, cytomegalovirus (CMV), hepatitis B (HBV) and C (HCV), HIV, and Group B Streptococcus (GBS) infections may have very severe outcomes during pregnancy, and for this reason, monitoring of infections in pregnant women is a requirement of prenatal assistance.

Aims: To describe coverage and outcome of the screening for rubella, syphilis, toxoplasmosis, CMV, HBV, HCV, HIV, and Group B Streptococcus in pregnancy in the Autonomous Province of Trento, Northern Italy (538,600 inhabitants).

Methods: We analysed the coverage and outcome of the above-mentioned screenings among women who delivered in the hospitals of the Province of Trento between 2007 and 2014 (N?=?38,712). Screenings were grouped according to characteristics such as recommendation by national and local guidelines, scheduling of the tests, operating methods, and charge. We also estimated odds ratios (ORs) for missing screening for selected infections through multiple logistic regression.

Results: Estimated uptake of antenatal screening was 99.7% for rubella, 99.3% for syphilis, 99.7% for toxoplasmosis, 98.1% for HIV infection, 99.0% for HBV, 98.9% for HCV, 94.0% for GBS infection, and 75.4% for CMV infection. The overall prevalence of immunity was 94.1% for rubella, 24.2% for toxoplasmosis, and 64.2% for CMV. The rate of seroconversion in pregnant women was 0.02% for rubella, 0.29% for toxoplasmosis, and 0.75% for CMV. The overall prevalence of infection was 0.94% for HBV, 0.53% for HCV, 22.3% for GBS, 0.29% for syphilis, and 0.13% for HIV. We found a significant positive association for all screening tests, between lack of testing and late first medical examination in pregnancy (ORs ranging from 1.20 to 1.66 for the first medical visit in the second trimester and ORs ranging from 1.60 to 5.88 for the first medical visit in third trimester, compared to early medical visit in the first trimester). Compared to Italian citizenship, foreign citizenship of the mother was also positively associated with absence of screening (ORs ranging from 1.30 to 1.53). A significant inverse association was observed for calendar year of delivery (ORs ranging from 0.71 to 0.97, for 1 year increment). Less educated mothers and pluriparae were also at higher risks of not being tested. Analysis of the association with mother age showed different heterogeneous effects.

Conclusions: Our study indicates that the attention to screening and detecting infected cases is growing over the time. In addition, care delivered during pregnancy has a leading role in determining coverage of the examinations. Immigrant, pluriparous and less educated women need particular attention.     

The psychosocial outcomes of antenatal day care for three medical complications of pregnancy: a randomised controlled trial of 395 women

BACKGROUND: Although antenatal day care is becoming increasingly common, there is little evidence as to the psychosocial efficacy of this model of care. AIM: We aimed to assess the broader psychosocial impact of antenatal day care compared with admission to hospital. METHODS: We carried out a randomised trial of 395 women, randomly assigned in a 2 : 1 ratio between day care and antenatal ward, stratified for major diagnostic categories (proteinuric hypertension, non-proteinuric hypertension and preterm premature rupture of membranes). Main outcome measures--self-report questionnaires (response rates ranging from 80 to 90%) were sent to women's homes four days after randomisation and seven weeks after delivery. RESULTS: Overall, there were statistically significant differences favouring day care in 12 of 28 items at four days post-randomisation, with no differences in the two groups for the other 16 items. At seven weeks postdelivery, we found differences in eight of 28 items favouring day care, with no differences in the two groups for the other 20 items. The types of items indicating a sustained difference covered a range of aspects of care and included satisfaction with staff, continuity of carer, information transfer, and social support. There were no differences in relation to infant feeding and relationship with the baby. CONCLUSIONS: Day care has an effect on women's satisfaction with care but does not produce broader psychosocial outcomes.     

外来孕妇与本地孕妇产前检查和妊娠结局的对照研究

目的:调查上海户籍与非上海户籍孕妇围产保健方面存在的差距,分析流动人口平产分娩点对改善外来孕妇围产期保健状况、减少不良妊娠结局发生的作用。方法:回顾分析2004年7月至2005年6月在复旦大学附属上海第五人民医院浦江分院流动人口平产分娩点及上海市第五人民医院产科住院分娩的5528例孕妇。分为分娩点非上海户籍、五院非上海户籍和五院上海户籍3组。结果:分娩点外来孕妇产前检查覆盖率为92.98%,仅次于综合医院沪籍孕妇,但产检4次以上的比例不足1/3,与其他两组差异显著。分娩点调查对象的妊娠结局普遍好于综合医院的外来孕妇,剖宫产率仅为21.10%,明显低于其他两组。两组外来孕妇中,不良妊娠结局的发生随产检次数的增加而减少,来自分娩点孕妇的低体重儿、过期产的发生并未因产检次数增加而得以抑制。结论:通过普及产前检查,流动人口平产分娩点在改善外来孕产妇妊娠结局方面有成效。但外来孕产妇仍缺乏足够的围产保健,应进一步加强系统产前检查和提高质量,切实改善外来流动人口的母婴保健状况。