Status of the latest 2016 World Health Organization recommended frequency of antenatal care contacts in Sierra Leone: a nationally representative survey

BMC Health Services Research, Volume 22, No. 1, Year 2022

Interpretation

Background: Timely and increased frequency of quality antenatal care (ANC) contacts is one of the key strategies aimed at decreasing maternal and neonatal deaths. In 2016, the World Health Organization (WHO) revised the ANC guidelines to recommend at least eight ANC contacts instead of four. This study aimed to determine the proportion of women who received eight or more ANC contacts and associated factors in Sierra Leone. Methods: We used Sierra Leone Demographic and Health Survey (UDHS) 2019 data of 5,432 women aged 15 to 49 years who had a live birth, within three years preceding the survey. Multistage stratified sampling was used to select study participants. We conducted multivariable logistic regression to identify factors associated with utilisation of eight or more ANC contacts using SPSS version 25 complex samples package. Results: Out of 5,432 women, 2,399 (44.8%) (95% CI: 43.1–45.7) had their first ANC contact in the first trimester and 1,197 (22.0%) (95% CI: 21.2–23.4) had eight or more ANC contacts. Women who had their first ANC contact after first trimester (adjusted odds ratio, aOR, 0.58, 95% CI 0.49–0.68) and women aged 15 to 19 years had less odds of having eight or more contacts (aOR 0.64, 95% CI 0.45 to 0.91). Working (aOR 1.33, 95%CI 1.10 to 1.62) and wealthier women had higher odds of having eight or more contacts compared to poorer ones and those not working respectively. Women residing in the southern region, those using internet and less parous (less than five) women were associated with higher odds of having eight or more ANC contacts. Women who had no big problem obtaining permission to go health facilities also had higher odds of having eight or more ANC contacts compared to those who had big problems. Conclusion: Sierra Leone’s adoption of eight or more ANC contacts is low and less than half of the women initiate ANC in the first trimester. To ensure increased access to recommended ANC visits, timely ANC should be encouraged. Attributes of women empowerment such as workings status, socio-economic status, and decision-making should also be emphasized. This study used secondary data from the 2019 SLDHS. Data were accessed from MEASURE DHS database at http://dhsprogram.com/data/available-datasets.cfm. SLDHS was a nationally representative cross-sectional survey implemented by Statistics Sierra Leone (Stats SL) with technical assistance from ICF intern through the DHS Program and funded by the United States Agency for International Development (USAID). The Demographic and Health Survey datasets are freely available to the public though researchers must register with MEASURE DHS and submit a request before accessing them. The 2016 SLDHS samples were selected using a stratified, two-stage cluster sampling design that resulted in the random selection of 13,872 households [2]. The primary sampling unit (PSU), referred to as a cluster was based on enumeration areas (EAs) from the 2015 EA population census frame [2]. Stratification was achieved by separating districts into urban and rural areas with a total of 31 sampling strata created. In the first stage, 578 EAs were selected with probability proportional to EA size which was the number of households with in the EA [2]. Detailed sampling procedures were published in the final report [2]. DHS uses different questionnaires. Household questionnaire collects data on household environment, assets and basic demographic information of household members while women’s questionnaire collects data about women’s reproductive health, domestic violence and nutrition indicators. This secondary analysis included women aged 15 to 49 years who had a live birth within three years preceding the survey and were either permanent residents or slept in the selected household the night preceding the survey. Out of the total weighted sample of 15,574 women in the data set, only 7,326 and 5,432 had given birth within five and three years preceding the survey respectively. Of the 5,432 women that had a live birth within three years preceding the survey, 82 women had missing data on the timing of ANC first contact leading to a total of 5,350 women for logistic regression analyses. We chose women who had given birth within three years preceding the survey because the WHO new ANC guidelines were introduced in November 2016 [15] and the SLDHS was carried out in May 2019. The outcome variable was the total number of ANC contacts. These were categorized into dichotomous variables: total number of ANC contacts (less than 8 contacts as inadequate and coded as 0 and 8 contacts and above as adequate and coded as 1). Similar analysis was done with timing of ANC initiation as the outcome (initiation within the first trimester as early initiation coded as 1 and initiation after first trimester as delayed initiation coded as 0) as shown in supplementary file 1. This study included determinants of ANC frequency based on evidence from available literature and data [3, 13, 26–28]. Nineteen explanatory variables were used: (1) maternal age, (2) wealth index, (3) level of education, (4) place of residence, (5) region, (6) marital status, (7) working status, (8) ANC timing of first contact, (9) sex of household head, (10) household size, (11) woman’s religion, (12) parity, (13) exposure to newspapers, (14) exposure to television (TV), (15) exposure to radio, (16) internet use, (17) having problems with getting permission to seek help, (18) having problems with distance to the nearby health facility and (19) being visited by a fieldworker. Maternal age was categorised as; (15–19 years, 20–34 years and 35–49 years). Wealth index is a measure of relative household economic status and was calculated by UDHS from information on household asset ownership using Principal Component Analysis, which was further categorised into poorest, poorer, middle, richer and richest quintiles [29]. Place of Residence was categorised into urban and rural. Region was categorised into four; Northern, Eastern, Southern, Western and Northwestern while level of Education was categorised into no education, primary education, secondary and tertiary education. Household Size was categorised as less than seven members and seven and above members (based on the dataset average of seven members per household). Sex of household head was categorised as male or female, working status categorized as: not working and working while marital status as married (this included those in formal and informal unions) and not married. Religion was categorised as Muslims and Christians and others, problems seeking permission and distance to health facility were categorised as big problem and no big problem while exposure to mass media and internet use (TV, radio, and newspapers) were categorised as yes and no. In the questionnaire, seeking permission to access healthcare and distance to health facility had three original responses: no problem, no big problem and big problem. However, none of the study participants reported no problem hence we only had two responses. In order to account for the multi-stage cluster study design, we used SPSS version 25.0 statistical software complex samples package incorporating the following variables in the analysis plan to account for the multistage sample design inherent in the DHS dataset: individual sample weight, sample strata for sampling errors/design, and cluster number [29, 30]. Analysis was carried out based on the weighted count to account for the unequal probability sampling in different strata and to ensure representativeness of the survey results at the national and regional level. Before logistic regression, each exposure/predictor (independent variable) was assessed separately for its association with the outcome variable using bivariable logistic regression and we presented the crude odds ratio (COR), 95% confidence interval (CI) and p-values. Independent variables associated with frequency of ANC from literature and those with a p-value ≤ 0.25 at the bi-variable level, and not strongly collinear with other independent variables were included in the final multivariable logistic regression model to assess the independent effect of each variable on the timing and frequency of ANC. Multi-collinearity was assessed using variance inflation factor (VIF) and no VIF was above 3. Adjusted odds ratios (AOR), 95% confidence intervals (CI) and p-values were calculated with statistical significance level set at p-value < 0.05.

AI Digest

Study Justification:

– Timely and increased frequency of quality antenatal care (ANC) contacts is crucial for reducing maternal and neonatal deaths.
– The World Health Organization (WHO) revised the ANC guidelines in 2016 to recommend at least eight ANC contacts instead of four.
– This study aimed to assess the proportion of women in Sierra Leone who received eight or more ANC contacts and identify associated factors.

Highlights:

– Out of 5,432 women surveyed, only 22.0% had eight or more ANC contacts.
– Women who had their first ANC contact after the first trimester and women aged 15 to 19 years had lower odds of having eight or more contacts.
– Working women and wealthier women had higher odds of having eight or more contacts.
– Women residing in the southern region, those using the internet, and women with fewer previous pregnancies were associated with higher odds of having eight or more ANC contacts.
– Women who had no big problems obtaining permission to go to health facilities also had higher odds of having eight or more ANC contacts.

Recommendations:

– Encourage timely initiation of ANC to ensure increased access to recommended ANC visits.
– Emphasize women empowerment attributes such as working status, socio-economic status, and decision-making in ANC utilization.

Key Role Players:

– Ministry of Health: Responsible for implementing policies and programs related to maternal and child health, including ANC.
– Health Facilities: Provide ANC services and ensure timely and quality care.
– Community Health Workers: Promote ANC utilization and provide education and support to pregnant women.
– Non-Governmental Organizations: Support ANC programs, advocacy, and community outreach.

Cost Items for Planning Recommendations:

– Training and Capacity Building: Budget for training healthcare providers on updated ANC guidelines and best practices.
– Infrastructure and Equipment: Allocate funds for improving health facilities and ensuring they have the necessary equipment and supplies for ANC services.
– Outreach and Awareness Campaigns: Set aside a budget for community engagement, awareness campaigns, and health education materials.
– Monitoring and Evaluation: Allocate resources for monitoring and evaluating the implementation and impact of the recommendations.
– Research and Data Collection: Consider funding further research and data collection to monitor progress and identify areas for improvement.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is rated 7 because it provides specific data from a nationally representative survey and includes statistical analysis. However, it could be improved by providing more details on the methodology, such as the sampling procedure and data collection process. Additionally, the abstract could benefit from a clearer discussion of the limitations and implications of the findings.

Abstract

This study used secondary data from the 2019 SLDHS. Data were accessed from MEASURE DHS database at http://dhsprogram.com/data/available-datasets.cfm. SLDHS was a nationally representative cross-sectional survey implemented by Statistics Sierra Leone (Stats SL) with technical assistance from ICF intern through the DHS Program and funded by the United States Agency for International Development (USAID). The Demographic and Health Survey datasets are freely available to the public though researchers must register with MEASURE DHS and submit a request before accessing them. The 2016 SLDHS samples were selected using a stratified, two-stage cluster sampling design that resulted in the random selection of 13,872 households [2]. The primary sampling unit (PSU), referred to as a cluster was based on enumeration areas (EAs) from the 2015 EA population census frame [2]. Stratification was achieved by separating districts into urban and rural areas with a total of 31 sampling strata created. In the first stage, 578 EAs were selected with probability proportional to EA size which was the number of households with in the EA [2]. Detailed sampling procedures were published in the final report [2]. DHS uses different questionnaires. Household questionnaire collects data on household environment, assets and basic demographic information of household members while women’s questionnaire collects data about women’s reproductive health, domestic violence and nutrition indicators. This secondary analysis included women aged 15 to 49 years who had a live birth within three years preceding the survey and were either permanent residents or slept in the selected household the night preceding the survey. Out of the total weighted sample of 15,574 women in the data set, only 7,326 and 5,432 had given birth within five and three years preceding the survey respectively. Of the 5,432 women that had a live birth within three years preceding the survey, 82 women had missing data on the timing of ANC first contact leading to a total of 5,350 women for logistic regression analyses. We chose women who had given birth within three years preceding the survey because the WHO new ANC guidelines were introduced in November 2016 [15] and the SLDHS was carried out in May 2019. The outcome variable was the total number of ANC contacts. These were categorized into dichotomous variables: total number of ANC contacts (less than 8 contacts as inadequate and coded as 0 and 8 contacts and above as adequate and coded as 1). Similar analysis was done with timing of ANC initiation as the outcome (initiation within the first trimester as early initiation coded as 1 and initiation after first trimester as delayed initiation coded as 0) as shown in supplementary file 1. This study included determinants of ANC frequency based on evidence from available literature and data [3, 13, 26–28]. Nineteen explanatory variables were used: (1) maternal age, (2) wealth index, (3) level of education, (4) place of residence, (5) region, (6) marital status, (7) working status, (8) ANC timing of first contact, (9) sex of household head, (10) household size, (11) woman’s religion, (12) parity, (13) exposure to newspapers, (14) exposure to television (TV), (15) exposure to radio, (16) internet use, (17) having problems with getting permission to seek help, (18) having problems with distance to the nearby health facility and (19) being visited by a fieldworker. Maternal age was categorised as; (15–19 years, 20–34 years and 35–49 years). Wealth index is a measure of relative household economic status and was calculated by UDHS from information on household asset ownership using Principal Component Analysis, which was further categorised into poorest, poorer, middle, richer and richest quintiles [29]. Place of Residence was categorised into urban and rural. Region was categorised into four; Northern, Eastern, Southern, Western and Northwestern while level of Education was categorised into no education, primary education, secondary and tertiary education. Household Size was categorised as less than seven members and seven and above members (based on the dataset average of seven members per household). Sex of household head was categorised as male or female, working status categorized as: not working and working while marital status as married (this included those in formal and informal unions) and not married. Religion was categorised as Muslims and Christians and others, problems seeking permission and distance to health facility were categorised as big problem and no big problem while exposure to mass media and internet use (TV, radio, and newspapers) were categorised as yes and no. In the questionnaire, seeking permission to access healthcare and distance to health facility had three original responses: no problem, no big problem and big problem. However, none of the study participants reported no problem hence we only had two responses. In order to account for the multi-stage cluster study design, we used SPSS version 25.0 statistical software complex samples package incorporating the following variables in the analysis plan to account for the multistage sample design inherent in the DHS dataset: individual sample weight, sample strata for sampling errors/design, and cluster number [29, 30]. Analysis was carried out based on the weighted count to account for the unequal probability sampling in different strata and to ensure representativeness of the survey results at the national and regional level. Before logistic regression, each exposure/predictor (independent variable) was assessed separately for its association with the outcome variable using bivariable logistic regression and we presented the crude odds ratio (COR), 95% confidence interval (CI) and p-values. Independent variables associated with frequency of ANC from literature and those with a p-value ≤ 0.25 at the bi-variable level, and not strongly collinear with other independent variables were included in the final multivariable logistic regression model to assess the independent effect of each variable on the timing and frequency of ANC. Multi-collinearity was assessed using variance inflation factor (VIF) and no VIF was above 3. Adjusted odds ratios (AOR), 95% confidence intervals (CI) and p-values were calculated with statistical significance level set at p-value < 0.05.

Materials

https://efashare.b-cdn.net/materials/4977145b93c499c853becd8d14b5bcb5900f31e5e09d0892b593b102a312f0f7/12913_2022_8594_MOESM1_ESM.docx

Innovations

Based on the information provided, it seems that the study is focused on determining the proportion of women in Sierra Leone who received eight or more antenatal care (ANC) contacts, as recommended by the World Health Organization (WHO) in 2016. The study also aims to identify factors associated with the utilization of eight or more ANC contacts.

In terms of potential innovations to improve access to maternal health, here are some recommendations:

1. Mobile Health (mHealth) Solutions: Implementing mobile health technologies, such as text messaging or mobile apps, to provide timely and relevant information to pregnant women about ANC, pregnancy care, and maternal health services. These technologies can also be used to send reminders for ANC appointments and provide educational resources.

2. Telemedicine: Using telecommunication technologies to provide remote ANC consultations and follow-ups. This can be particularly beneficial for women in rural or remote areas who may have limited access to healthcare facilities.

3. Community Health Workers: Training and deploying community health workers to provide ANC services and education in underserved areas. These workers can conduct home visits, provide basic ANC services, and refer women to healthcare facilities when necessary.

4. Integrated Maternal Health Services: Integrating ANC services with other maternal health services, such as family planning, postnatal care, and immunization, to provide comprehensive care and improve continuity of care for women.

5. Financial Incentives: Providing financial incentives, such as conditional cash transfers or vouchers, to encourage pregnant women to attend ANC visits and incentivize healthcare providers to deliver quality ANC services.

6. Public-Private Partnerships: Collaborating with private healthcare providers and organizations to expand access to ANC services, especially in areas with limited public healthcare facilities.

7. Transportation Support: Providing transportation support, such as subsidized or free transportation, to help pregnant women overcome geographical barriers and reach healthcare facilities for ANC visits.

8. Empowering Women: Implementing interventions that empower women, such as promoting education, improving economic opportunities, and addressing gender inequalities, to enable them to make informed decisions about their maternal health and access ANC services.

These are just a few potential innovations that can be considered to improve access to maternal health. It is important to assess the feasibility, effectiveness, and sustainability of these innovations in the specific context of Sierra Leone and tailor them to the local needs and resources.

AI Innovations Description

The study mentioned focuses on the status of antenatal care (ANC) contacts in Sierra Leone and identifies factors associated with the utilization of eight or more ANC contacts. The goal is to improve access to maternal health by encouraging timely and increased frequency of quality ANC contacts.

Based on the findings of the study, the following recommendations can be developed into an innovation to improve access to maternal health:

1. Promote early initiation of ANC: Emphasize the importance of early initiation of ANC within the first trimester of pregnancy. This can be done through community awareness campaigns, education programs, and targeted messaging to pregnant women and their families.

2. Increase the number of ANC contacts: Encourage women to attend at least eight ANC contacts throughout their pregnancy, as recommended by the World Health Organization. This can be achieved by providing incentives such as free transportation, flexible scheduling options, and ensuring availability of ANC services in both urban and rural areas.

3. Empower women: Focus on women’s empowerment by addressing factors such as working status and socio-economic status. Promote economic opportunities for women, provide support for working mothers, and implement policies that ensure equal access to healthcare for all women, regardless of their socio-economic background.

4. Improve decision-making: Enhance women’s decision-making power regarding their own healthcare. This can be achieved by providing information and education on the importance of ANC, involving women in the decision-making process, and addressing cultural and social barriers that limit women’s autonomy.

5. Strengthen healthcare infrastructure: Address challenges related to distance and permission to seek help by improving the accessibility of healthcare facilities. This can be done by establishing more health facilities in remote areas, improving transportation infrastructure, and addressing cultural and social norms that restrict women’s mobility.

6. Utilize mass media and technology: Utilize mass media platforms such as television, radio, and newspapers to disseminate information about ANC and its benefits. Additionally, leverage technology, such as internet use, to provide online resources, telemedicine services, and remote consultations for pregnant women.

By implementing these recommendations, it is expected that access to maternal health will be improved, leading to a reduction in maternal and neonatal deaths.

AI Innovations Methodology

To improve access to maternal health, here are some potential recommendations:

1. Strengthening healthcare infrastructure: Investing in the development and improvement of healthcare facilities, especially in rural areas, can increase access to maternal health services. This includes ensuring the availability of skilled healthcare providers, essential medical equipment, and necessary supplies.

2. Mobile health (mHealth) interventions: Utilizing mobile technology to provide maternal health information, reminders, and appointment scheduling can help overcome barriers to access. Mobile apps, SMS messaging, and interactive voice response systems can be used to reach women in remote areas and provide them with important prenatal and postnatal care information.

3. Community-based interventions: Implementing community-based programs that involve trained community health workers can improve access to maternal health services. These workers can provide education, counseling, and basic healthcare services to pregnant women and new mothers in their communities.

4. Financial incentives: Providing financial incentives, such as cash transfers or vouchers, can help overcome financial barriers and encourage pregnant women to seek and utilize maternal health services. These incentives can cover costs associated with transportation, consultations, and medications.

5. Telemedicine: Using telemedicine technologies, such as video consultations and remote monitoring, can enable pregnant women to access specialized care and consultations without the need for travel. This can be particularly beneficial for women in remote or underserved areas.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the target population: Identify the specific population group that the recommendations aim to benefit, such as pregnant women in a particular region or country.

2. Collect baseline data: Gather relevant data on the current status of access to maternal health services in the target population. This can include information on the number of ANC contacts, timing of ANC initiation, and other relevant factors.

3. Develop a simulation model: Create a mathematical or statistical model that incorporates the potential impact of the recommendations on access to maternal health services. This model should consider factors such as population size, geographical distribution, healthcare infrastructure, and the effectiveness of the proposed interventions.

4. Input data and parameters: Input the baseline data and parameters into the simulation model. This includes information on the current utilization of maternal health services, the expected impact of each recommendation, and any assumptions or constraints.

5. Run simulations: Use the simulation model to generate multiple scenarios that reflect the potential impact of the recommendations on access to maternal health services. This can involve varying the parameters and assumptions to explore different outcomes.

6. Analyze results: Analyze the simulation results to assess the potential impact of the recommendations on improving access to maternal health services. This can include evaluating changes in the number of ANC contacts, timing of ANC initiation, and other relevant indicators.

7. Validate and refine the model: Validate the simulation model by comparing the simulated results with real-world data or expert opinions. Refine the model as necessary to improve its accuracy and reliability.

8. Communicate findings: Present the findings of the simulation analysis in a clear and concise manner, highlighting the potential benefits and limitations of the recommendations. This information can be used to inform decision-making and prioritize interventions to improve access to maternal health services.

Author

Dima Health

Statistics:

Citations: 1

Identifiers:

DOI: 10.1186/s12913-022-08594-y

Research Areas:

Food Security, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Violence and Injury

Study Countries:

Sierra Leone

Study Design:

Case-Control Study, Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Male & Female