Unintended pregnancy and women's use of prenatal care in Ecuador

This paper assesses the relationship between unintended pregnancy--both unwanted and mistimed and several dimensions of use of prenatal care among women in Ecuador, where the level of unintended pregnancy has risen considerably in recent years. Data were collected from a nationally representative sample of 3988 women interviewed in the 1994 Demographic and Maternal-Child Health Survey. Multivariate logistic regression was used to assess jointly the effect of pregnancy intention status (unwanted, mistimed, planned) on three aspects of prenatal care use while controlling for potential confounders. Women with unwanted pregnancies were 32% less likely than women with planned pregnancies to seek out prenatal care. Women with unwanted pregnancies were also 25% less likely to initiate care in the first trimester and 29% less likely to receive at least an adequate number of visits. Mistimed pregnancy was not associated with receiving care, timely initiation of care or receiving an adequate number of visits.     

Intendedness of Pregnancy and Other Predictive Factors for Symptoms of Prenatal Depression in a Population-Based Study

Prenatal depression (PD) as a risk factor for adverse birth outcomes is well documented. Less is known about maternal risks for PD, which could inform preventive strategies for perinatal and interconceptional care. This exploratory study investigates associations between prenatal depression symptoms and unintended and mistimed pregnancies and other maternal risk factors for PD. A subset of birth records from the New York Statewide Perinatal Data System (n = 19,219) was used in this secondary analysis of cross-sectional data. Univariate and multivariate multinomial regression was used to identify factors that are independently associated with four self-reported levels of prenatal depression symptoms. Women with unintended pregnancies were more likely (AOR, 95 % CI) to report severe (3.6, 2.6–5.1) or moderate (2.0, 1.6–2.5) prenatal depression symptoms and less likely to report no symptoms, compared to women with intended pregnancies. Likewise, women with mistimed pregnancies were more likely to report severe (2.7, 2.2–3.5) or moderate (1.7, 1.5–2.1) prenatal depression symptoms than no symptoms, compared to women with intended pregnancies. Low education, drug use, smoking, minority race, being unmarried and having Medicaid insurance were also significant, independent predictors of PD symptoms. Results suggest that routine screening for depression, intendedness of pregnancy and other associated risk factors such as smoking and drug use during prenatal and interconceptional care visits may enable coordinated interventions that can reduce prenatal depression and unintended and mistimed pregnancies and improve pregnancy outcomes.     

Unintended pregnancies and the use of maternal health services in southwestern Ethiopia

Background

The benefits of maternal health care to maternal and neonatal health outcomes have been well documented. Antenatal care attendance, institutional delivery and skilled attendance at delivery all help to improve maternal and neonatal health. However, use of maternal health services is still very low in developing countries with high maternal mortality including Ethiopia. This study examines the association of unintended Pregnancy with the use of maternal health services in Southwestern Ethiopia.

Methods

Data for this study come from a survey conducted among 1370 women with a recent birth in a Health and Demographic Surveillance Site (HDSS) in southwestern Ethiopia. An interviewer administered questionnaire was used to gather data on maternal health care, pregnancy intention and other explanatory variables. Data were analyzed using STATA 11, and both bivariate and multivariate analyses were done. Multivariate logistic regression was used to assess the association of pregnancy intention with the use of antenatal and delivery care services. Unadjusted and adjusted odds ratio and their 95% confidence intervals are reported.

Results

More than one third ( 35%) of women reported that their most recent pregnancy was unintended. With regards to maternal health care, only 42% of women made at least one antenatal care visit during pregnancy, while 17% had four or more visits. Institutional delivery was only 12%. Unintended pregnancy was significantly (OR: 0.75, 95% CI, 0.58-0.97) associated with use of antenatal care services and receiving adequate antenatal care (OR: 0.67, 95% CI, 0.46-0.96), even after adjusting for other socio-demographic factors. However, for delivery care, the association with pregnancy intention was attenuated after adjustment. Other factors associated with antenatal care and delivery care include women’s education, urban residence, wealth and distance from health facility.

Conclusions

Women with unintended pregnancies were less likely to access or receive adequate antenatal care. Interventions are needed to reduce unintended pregnancy such as improving access to family planning information and services. Moreover, improving access to maternal health services and understanding women’s pregnancy intention at the time of first antenatal care visit is important to encourage women with unintended pregnancies to complete antenatal care.

     

Factors related to the use of antenatal care services in Ethiopia: Application of the zero-inflated negative binomial model

The major causes for poor health in developing countries are inadequate access and under-use of modern health care services. The objective of this study was to identify and examine factors related to the use of antenatal care services using the 2011 Ethiopia Demographic and Health Survey data. The number of antenatal care visits during the last pregnancy by mothers aged 15 to 49 years (n = 7,737) was analyzed. More than 55% of the mothers did not use antenatal care (ANC) services, while more than 22% of the women used antenatal care services less than four times. More than half of the women (52%) who had access to health services had at least four antenatal care visits. The zero-inflated negative binomial model was found to be more appropriate for analyzing the data. Place of residence, age of mothers, woman’s educational level, employment status, mass media exposure, religion, and access to health services were significantly associated with the use of antenatal care services. Accordingly, there should be progress toward a health-education program that enables more women to utilize ANC services, with the program targeting women in rural areas, uneducated women, and mothers with higher birth orders through appropriate media.     

Differences between mistimed and unwanted pregnancies among women who have live births

CONTEXT: Mistimed and unwanted pregnancies that result in live births are commonly considered together as unintended pregnancies, but they may have different precursors and outcomes. METHODS: Data from 15 states participating in the 1998 Pregnancy Risk Assessment Monitoring System were used to calculate the prevalence of intended, mistimed and unwanted conceptions, by selected variables. Associations between unintendedness and women's behaviors and experiences before, during and after the pregnancy were assessed through unadjusted relative risks. RESULTS: The distribution of intended, mistimed and unwanted pregnancies differed on nearly every variable examined; risky behaviors and adverse experiences were more common among women with mistimed than intended pregnancies and were most common among those whose pregnancies were unwanted. The likelihood of having an unwanted rather than mistimed pregnancy was elevated for women 35 or older (relative risk, 2.3) and was reduced for those younger than 25 (0.8); the pattern was reversed for the likelihood of mistimed rather than intended pregnancy (0.5 vs. 1.7-2.7). Parous women had an increased risk of an unwanted pregnancy (2.1-4.0) but a decreased risk of a mistimed one (0.9). Women who smoked in the third trimester, received delayed or no prenatal care, did not breast-feed, were physically abused during pregnancy, said their partner had not wanted a pregnancy or had a low-birth-weight infant had an increased risk of unintended pregnancy; the size of the increase depended on whether the pregnancy was unwanted or mistimed. CONCLUSION: Clarifying the difference in risk between mistimed and unwanted pregnancies may help guide decisions regarding services to women and infants.     

Pregnancy Outcomes by Pregnancy Intention in a Managed Care Setting

Objectives Published studies show poor pregnancy outcomes associated with unintended pregnancies are disproportionately higher than in planned pregnancies and place a burden on the health care system. This study was designed to compare pregnancy intention rates, compare sociodemographic characteristics of women by pregnancy intention and compare pregnancy outcomes in a managed care setting. Methods A large managed health care organization in California conducted a retrospective medical record review of 1,784 women seeking prenatal care in 2002 to learn how women self-reported their pregnancy intention, compare pregnancy intention rates between this health plan to the national data, and to compare antecedents and pregnancy outcomes based on pregnancy intention. Results Overall, 62.1% of pregnancies were self-reported as intended with 26.4% mistimed and 11.4% unwanted. Being young, single, having lower educational attainment, having other living children, consuming alcohol and being a woman of color were the greatest predictors of having an unintended pregnancy. Despite these predictors, birth outcomes for unintended pregnancies in this setting showed no statistical difference from planned pregnancies. Conclusion Awareness of pregnancy intention of the women who are at greatest risk may be an important contributor to improving birth outcomes and health plan decisions about reproductive care services. Early entry to prenatal care and integrated services that decrease substance abuse and support high-risk pregnancy management are important contributors to reducing poor pregnancy outcomes.     

Poor antenatal care in 20 French districts: risk factors and pregnancy outcome

STUDY OBJECTIVE: Poor attendance to antenatal visits was studied to identify risk factors and to analyse the association with adverse pregnancy outcome. DESIGN: All poor attenders and a sample of good attenders were compared within three groups of women: women < 20 years, French women > or = 20 years, and foreigners > or = 20 years. SETTING: 20 French districts including 85,000 births from January to June 1993. SUBJECTS: 848 poor attenders and 759 good attenders. Poor attenders made fewer than four antenatal visits or began care during or after the sixth month. Good attenders made at least four visits and began care before the sixth month. MAIN RESULTS: 1.1% of the women were poor attenders. Risk factors for poor attendance were single status and lack of health insurance in the group under 20; young age, high parity, and single status in the French group aged over 20; and single status and lack of health insurance in the foreign group aged over 20. For poor attenders, the odds ratios for preterm delivery were 5.8 (95% CI: 3.2, 10.5) among French women and 3.3 (95% CI: 1.5, 7.4) among foreign women with health insurance. Poor attendance was not associated with poor pregnancy outcome in the group under 20, and among foreign women over 20 without health insurance, but both groups had high rates of preterm delivery and low birth weight. CONCLUSION: Lack of health insurance is an important barrier to health care during pregnancy. Poor antenatal care is an important risk factor for adverse pregnancy outcome among women who have easy access to health care services.

 

     

Maternal Health Care Utilization Among Ever Married Youths in Kyimyindaing Township, Myanmar

This study aimed to identify maternal care services utilization among ever married female youths (15?C24?years) in Kyimyindaing Township, Yangon, Myanmar. A quantitative cross-sectional survey was conducted. A total of 196 ever married females who had delivered at least one child were included. Multistage sampling was employed. Face to face interviews using a structured questionnaire were carried out. Respondents were asked about their maternal care services utilization at the last pregnancy. Bivariate and logistic regression analyses were applied to determine the factors associated with utilization of maternal care services. Overall 96% of respondents received antenatal care (ANC) at least once and 79% had at least 4 ANC visits. The mean number of antenatal visits increased with women??s education level. The majority received late ANC regardless of residence, age, education and family income. Nearly 39% delivered at home, especially in rural areas and 79% of home deliveries were attended by traditional birth attendants (TBAs). Only 56.6% of women received at least one postnatal care visit. Inadequate postnatal care (<6 times) was identified (82.6%). Place of residence, women??s education and ANC frequency were the key determinants for a delivery place and postnatal care. Despite relatively high antenatal care attendance, most women practiced home deliveries and received inadequate postnatal care. Maternal health services need to be focused on rural women and women with little or no education. Quality ANC should be the entry point of safe delivery and postnatal care. Further intensification of information, education and communication activities on ??safe motherhood?? is needed.     

Clinical, provider and sociodemographic determinants of the number of antenatal visits in England and Wales

The objective of this study was to measure the independent effects of clinical factors and non-clinical factors, such as provider and sociodemographic characteristics, on the number of antenatal visits made by women in England and Wales. The study was based on a survey of the secondary case records of 20,771 women with singleton pregnancies who were delivered between 1 August 1994 and 31 July 1995. The women in the survey attended one of nine maternity units in Northern England and North Wales selected within those areas to reflect geographical variations, as well as variations in the size and teaching status of the institution. A multivariate Poisson regression model was developed to examine differences in the number of antenatal visits made by women with different clinical and non-clinical characteristics. After controlling for non-clinical factors, primiparous women identified as high risk at booking made 1.0% more visits than primiparous women identified as low risk at booking (p = 0.196). Multiparous women identified as high risk at booking made 3.5% more visits than their low risk counterparts (p<0.001). High risk-defining criteria during antenatal care led to a 0.3% weekly increase in the number of antenatal visits amongst primiparous women (p <0.001) and a 0.4% weekly increase in the number of antenatal visits amongst multiparous women (p < 0.001). Several notable results, not reported elsewhere in the literature, were revealed by the regression analyses. After all independent variables were controlled for, women who were booked into urban teaching hospitals made 10% fewer antenatal visits than the women who were booked into the urban non-teaching hospitals. Women of Pakistani origin made 9.1% fewer antenatal visits than women of white British origin. Similar results were revealed for women of Indian origin and women from other ethnic groups. Non-smokers made 6.0% more antenatal visits than smokers. The planned pattern of antenatal care, number of carers seen, gestation at first presentation and maternal age also had significant independent impacts on the number of antenatal visits. The study highlights the sizeable impact of non-clinical factors on the antenatal care delivery process and indicates ways in which variations in antenatal care might be reduced.     

Utilisation of postnatal care in Bangladesh: evidence from a longitudinal study

Utilisation of health services is a complex behavioural phenomenon. Empirical studies of preventive and curative services in Bangladesh have often showed that the use of health services is related to the availability, quality and cost of services, as well as to social structure, health beliefs and personal characteristics of the users. The present paper attempts to examine factors associated with the utilisation of healthcare services during the postnatal period in Bangladesh by using prospective data from a survey on maternal morbidity in Bangladesh, conducted by the Bangladesh Institute of Research for Promotion of Essential and Reproductive Health and Technologies (BIRPERT). Both bivariate and multivariate analyses of the data confirmed that the mother's age at marriage had a significant and positive impact on the utilisation of quality healthcare services. The husband's occupation also showed a strong impact on healthcare utilisation, indicating higher use of quality care for postpartum morbidity by wives of business and service workers. The bivariate analysis showed that the number of pregnancies prior to the index pregnancy and desired pregnancies are significantly associated with the utilisation of postpartum healthcare. However, the results of this study were inconclusive on the influence of other predisposing and enabling factors, such as maternal education, the number of previous pregnancies, the occupation of the husband, antenatal care visits during pregnancy and access to health facilities. Multivariate logistic regression estimates did not show any significant impact of these factors on the use of maternal healthcare.     

The role of women’s empowerment and male engagement in pregnancy healthcare seeking behaviors in western Kenya

We sought to understand whether women’s empowerment and male partner engagement were associated with use of antenatal care (ANC). Women presenting for ANC in Nyanza province of Kenya between June 2015 and May 2016, were approached for participation. A total of 137 pregnant women and 96 male partners completed baseline assessments. Women’s empowerment was measured using the modified Sexual Relationship Power Scale. ANC use measures included timing of the first ANC visit and number of visits. Male engagement was based on whether a husband reported accompanying his wife to one or more antenatal visits during the pregnancy. Multiple linear and logistic regression analyses were used to identify factors independently related to use and timing of ANC. Women with higher mean empowerment scores were likely to have more than one ANC visit in the index pregnancy [Adjusted Odds Ratio (AOR) = 2.8, 95% Confidence Interval (CI): 1.1–7.3], but empowerment was not associated with early ANC use. Women who were more empowered were less likely to have a husband who reported attending an ANC visit with his wife (AOR = 0.1, 95% CI: 0.03–0.8). Women’s empowerment is important and may be related to ANC use and engagement of male partners in complex ways.     

Antenatal Care Attendance,a Surrogate for Pregnancy Outcome? The Case of Kumasi,Ghana

Antenatal care (ANC) has been shown to influence infant and maternal outcomes. WHO recommends 4 ANC visits for uncomplicated pregnancies. However, pregnant women in Ghana are required to attend 8–13 antenatal visits. We investigated the association of ANC attendance with adverse pregnancy outcomes (defined as low infant birth weight, stillbirth, preterm delivery or small for gestational age). A quantitative cross-sectional study was conducted on 629 women, age 19–48 years who presented for delivery at two selected public hospitals and 16 traditional birth attendants from July to November 2011. Socio-demographic and antenatal information were collected using a structured questionnaire. ANC attendance, medical and obstetric/gynecological history were abstracted from maternal antenatal records. Data were analyzed using Chi square and logistic regression. Twenty-two percent of the women experienced an adverse outcome. Eleven percent of the women attended <4 ANC visits. In an unadjusted model, these women had an increased likelihood of experiencing an adverse outcome (OR 2.27; 95 % CI 1.30–3.94; p = 0.0038). High parity (>5 children) was also associated with adverse birth outcomes. Women screened for syphilis or use of insecticide-treated bed nets had a 40 and 36 % (p = 0.0447 and p = 0.0293) reduced likelihood of experiencing an adverse pregnancy outcome respectively. After adjusting for confounders, attending <4 antenatal visits was associated with adverse pregnancy outcome compared with ≥4 ANC visits (Adjusted OR 2.55; 95 % CI 1.16–5.63; p = 0.0202). Attending <4 antenatal visits and high parity were associated with adverse pregnancy outcomes for uncomplicated pregnancies.     

Perinatal health service use by women released from jail

Few studies have examined health care access for the growing population of pregnant women who cycle in and out of urban jails. The present study compared use of Medicaid-funded perinatal services for births to women who were in jail during pregnancy and births to women who had been in jail, but not while pregnant. Jail contact during pregnancy increased the likelihood women would receive prenatal care (odds ratio [OR] = 5.95; 95% confidence interval [CI] 2.18-16.23) and maternity support services (OR = 1.80; 95% CI 1.12-2.88), but was associated with fewer total prenatal and support visits. Jail contact during a previous pregnancy was associated with fewer prenatal care visits, more support service visits, and longer time receiving case management. Jail settings can become a place of coordination between public health and criminal justice professionals to ensure that pregnant women receive essential services following release. Service coordination may increase women's engagement in health services during future pregnancies, with or without subsequent incarceration.     

An indicator of adverse pregnancy outcome in France: not receiving maternity benefits.

STUDY OBJECTIVE--The aim was to compare the social characteristics, the pregnancy outcome, and the antenatal care of women in France who did not receive maternity benefits to women who did. These benefits (860 FF, approx 86 pounds per month) are given to every pregnant woman, starting in the second trimester. Payments are made on the condition that at least three antenatal visits are made, the first being before the end of the first trimester. DESIGN--The study involved a random sample of women who were interviewed after delivery during their stay in hospital. Data on pregnancy outcome were collected from medical records. SETTING--The study was carried out in four public maternity units in different regions of France. PARTICIPANTS--1692 women were included in the analysis (86.8% of the selected sample). Of 257 exclusions, 40 had multiple pregnancies, 189 had missing data, and 28 did not answer the question concerning maternity benefits. MEASUREMENTS AND MAIN RESULTS--4.3% of the women did not receive any maternity benefits. These women lived in poorer social conditions than the women who received the benefits. They had a higher preterm delivery rate, after controlling for risk factors in a logistic regression. Women without maternity benefits were characterised by a lower level of care, yet the majority began their antenatal care during the first trimester or had more than six visits. CONCLUSIONS--Not receiving maternity benefits during pregnancy is an index of an underprivileged situation and a risk factor for pregnancy outcome.     

Provision and Use of Maternal Health Services among Urban Poor Women in Kenya: What Do We Know and What Can We Do?

In sub-Saharan Africa, the unprecedented population growth that started in the second half of the twentieth century has evolved into unparalleled urbanization and an increasing proportion of urban dwellers living in slums and shanty towns, making it imperative to pay greater attention to the health problems of the urban poor. In particular, urgent efforts need to focus on maternal health. Despite the lack of reliable trend data on maternal mortality, some investigators now believe that progress in maternal health has been very slow in sub-Saharan Africa. This study uses a unique combination of health facility- and individual-level data collected in the slums of Nairobi, Kenya to: (1) describe the provision of obstetric care in the Nairobi informal settlements; (2) describe the patterns of antenatal and delivery care, notably in terms of timing, frequency, and quality of care; and (3) draw policy implications aimed at improving maternal health among the rapidly growing urban poor populations. It shows that the study area is deprived of public health services, a finding which supports the view that low-income urban residents in developing countries face significant obstacles in accessing health care. This study also shows that despite the high prevalence of antenatal care (ANC), the proportion of women who made the recommended number of visits or who initiated the visit in the first trimester of pregnancy remains low compared to Nairobi as a whole and, more importantly, compared to rural populations. Bivariate analyses show that household wealth, education, parity, and place of residence were closely associated with frequency and timing of ANC and with place of delivery. Finally, there is a strong linkage between use of antenatal care and place of delivery. The findings of this study call for urgent attention by Kenya’s Ministry of Health and local authorities to the void of quality health services in poor urban communities and the need to provide focused and sustained health education geared towards promoting use of obstetric services. Fotso, Ezeh, and Oronje are with the African Population and Health Research Center (APHRC), Nairobi, Kenya.     

Contextual Determinants of Maternal Health Care Service Utilization in Nigeria

Despite the high maternal mortality ratio in Nigeria, the use of maternal health care services is very poor. Attempts to explain this situation has focused on individual level factors and the influence of community contextual factors have not received much attention. This study examined the relation of community factors to the use of antenatal care in Nigeria, and explored whether community factors moderated the association between individual characteristics and antenatal care visits. Data were drawn from the 2008 Nigeria Demographic and Health Survey among 16,005 women aged 15–49 years who had had their last delivery in the five years preceding the survey. Results from multi-level models indicated that living in communities with a high proportion of women who delivered in a health facility was associated with four or more antenatal care visits. Residence in high-poverty communities decreased the likelihood of antenatal care attendance. Living in communities with a high proportion of educated women was not significantly related to antenatal care visits. Community factors acted as moderators of the association between educational attainment and antenatal care attendance. Improvement in antenatal care utilization may therefore be enhanced by targeting poverty reduction programs and increasing health facility delivery in disadvantaged communities.     

Does antenatal care make a difference to safe delivery? A study in urban Uttar Pradesh, India.

Evidence to support that antenatal screenings and interventions are effective in reducing maternal mortality has been scanty and studies have presented contradictory findings. In addition, antenatal care utilization is poorly characterized in studies. As an exposure under investigation, antenatal care should be well defined. However, measures typically only account for the frequency and timing of visits and not for care content. We introduce a new measure for antenatal care utilization, comprised of 20 input components covering care content and visit frequency. Weights for each component reflect its relative importance to better maternal and child health, and were derived from a survey of international researchers. This composite measure for antenatal care utilization was studied in a probability sample of 300 low to middle income women who had given birth within the last three years in Varanasi, Uttar Pradesh, India. Results showed that demarcating women's antenatal care status based on a simple indicator--two or more visits versus less--masked a large amount of variation in care received. Logistic regression analyses were conducted to examine the effect of antenatal care utilization on the likelihood of using safe delivery care, a factor known to decrease maternal mortality. After controlling for relevant socio-demographic and maternity history factors, women with a relatively high level of care (at the 75th percentile of the score) had an estimated odds of using trained assistance at delivery that was almost four times higher than women with a low level of care (at the 25th percentile of the score) (OR = 3.97, 95% CI = 1.96, 8.10). Similar results were obtained for women delivering in a health facility versus at home. This strong positive association between level of care obtained during pregnancy and the use of safe delivery care may help explain why antenatal care could also be associated with reduced maternal mortality.     

Measuring the adequacy of antenatal health care: a national cross-sectional study in Mexico

ObjectiveTo propose an antenatal care classification for measuring the continuum of health care based on the concept of adequacy: timeliness of entry into antenatal care, number of antenatal care visits and key processes of care.MethodsIn a cross-sectional, retrospective study we used data from the Mexican National Health and Nutrition Survey (ENSANUT) in 2012. This contained self-reported information about antenatal care use by 6494 women during their last pregnancy ending in live birth. Antenatal care was considered to be adequate if a woman attended her first visit during the first trimester of pregnancy, made a minimum of four antenatal care visits and underwent at least seven of the eight recommended procedures during visits. We used multivariate ordinal logistic regression to identify correlates of adequate antenatal care and predicted coverage.FindingsBased on a population-weighted sample of 9 052 044, 98.4% of women received antenatal care during their last pregnancy, but only 71.5% (95% confidence interval, CI: 69.7 to 73.2) received maternal health care classified as adequate. Significant geographic differences in coverage of care were identified among states. The probability of receiving adequate antenatal care was higher among women of higher socioeconomic status, with more years of schooling and with health insurance.ConclusionWhile basic antenatal care coverage is high in Mexico, adequate care remains low. Efforts by health systems, governments and researchers to measure and improve antenatal care should adopt a more rigorous definition of care to include important elements of quality such as continuity and processes of care.     

Effects of individual and neighborhood factors on maternal care in Cambodia

This study analyzed data from the 2005 Cambodia Demographic and Health Survey to examine the effects of individual- and community-level factors on the receipt of four or more antenatal care visits, receipt of antenatal care within the first trimester of pregnancy, delivery in a health facility and delivery by trained medical professional. The findings demonstrate that age at birth, parity level, educational attainment, household wealth, occupation, media exposure and counseling about pregnancy complications are significant determinants of pregnancy care. There is also a strong evidence of the impact of community-level factors on the utilization of maternal health services. Programs to improve maternal health outcomes must take into account covariates at multiple levels of influence to better address the needs of women of reproductive age in Cambodia.