Factors associated with socio-demographic characteristics and antenatal care and iron supplement use in Ethiopia, Kenya, and Senegal

Maternal and Child Nutrition, Volume 14, Year 2018

Interpretation

Antenatal care (ANC) offers remarkable opportunities to reach a large number of women with effective nutrition and health interventions, including iron (Fe) supplementation. However, all women do not equally seek nor benefit from ANC. We aimed to identify characteristics associated with ANC and Fe use among women in hard-to-reach areas in Afar, Ethiopia; Sedhiou and Kolda, Senegal; and Kakamega, Kenya. Women who gave birth within 1 year preceding the survey (n = 4,575) from 15 different sub-regions were randomly selected and surveyed. Multivariable logistic regression was used to identify associations of socio-demographic characteristics with ANC and Fe use. Factors that showed positive associations with ANC uptake included education, income, possession of a mobile phone, and the occupation of the mother or another household member. Beginning ANC in the first trimester associated positively with achievement of 4 or more ANC visits, and having any ANC visits related positively with Fe intake. Distance to the nearest health facility was negatively associated, and type of nearest facility and counselling and health education were positively associated with some outcomes. The results from these surveys demonstrate the need to ensure access of services across all population groups and can help identify ANC programming needs. The following methods summarize those applied in the baseline survey of the three countries. Further detail is provided by Kung’u, Pendame, et al. (2018) in this supplement. Cross‐sectional surveys were conducted in selected communities in each of the three countries. Mothers with children under 12 months were eligible to participate in the baseline surveys. The surveys included five sub‐counties of Kakamega County in Kenya: Kakamega Central, Matungu, Mumias, Butere, and Khwisero; six woredas, the third‐level administrative division of Ethiopia, in Afar regional state: Dewe, Telalak, Chifra, Aura, Ewa, and Gulina; and three departments in the Kolda region and one department in the Sedhiou region of Senegal: Kolda, Medina Yoro Foula, Velingara, and Sedhiou. All households where data were collected were in rural areas. A total of 4,575 women were surveyed: 1,969 in Ethiopia from April to June 2013, 682 in Kenya in February 2013, and 1,925 in Senegal in January and February 2014. A multistage cluster approach was used. The first stage began from the primary sampling unit of district in Senegal, woreda in Ethiopia, and sub‐county in Kenya, with villages and households selected in the second and third stages. The details of the sampling and sample size calculation are described elsewhere (Kung’u, Pendame, et al., 2018). Technical teams tailored a questionnaire to the local context in each country. Individuals with data collection experience were recruited and trained on interview techniques, supervision, administration of the questionnaires, and ethical consideration of participants. Training lasted 3 days in Kenya, 5 days in Ethiopia, and 2.5 days in Senegal. The questionnaires were finalized after pretesting in similar neighbouring communities. The University of Nairobi ethics and review board in Kenya, the Ethiopian Health and Nutrition Research Institute ethical clearance committee in Ethiopia, and the National Ethics Committee for Health Research in Senegal provided ethical approval prior to the survey. Informed consent was obtained from all participants and confirmed with a signature or a fingerprint. There were no personal identifiers on the data collection forms and all data were handled with strict security to ensure confidentiality. Data entry and the initial cleaning were done using EpiData Version 3.1 in Ethiopia, Epi Info 2000 in Senegal, and Microsoft Access version 14.0 in Kenya. In all countries, data were double entered by two different data entry clerks for quality assurance and data cleaning. Analyses were conducted using IBM SPSS version 23.0. The analysis involved logistic regression using four outcome variables (1 = yes, 0 = no). Three of the outcome variables related to uptake of ANC provided by a skilled health care provider, that is, an accredited health professional proficient in the skills needed to manage uncomplicated pregnancies, childbirth, and the immediate post‐natal period, and in the identification, management, and referral of complications in women and newborns as compared to an unskilled health care provider who has no formal training (WHO, 2004). These three outcome variables showed whether the women received ANC (a) at least once during pregnancy (Any ANC), (b) during her first trimester of pregnancy (FT ANC), and (c) four or more times during her pregnancy (≥4 ANC). In Senegal, FT ANC is not presented here as the data were collected only from women who could present their health card with their pregnancy information, which was inconsistent with the other countries and outcomes. The fourth outcome variable showed whether a woman took an iron supplement at least once during her pregnancy. In Ethiopia, women were asked specifically about iron supplements. In Senegal, they were asked about supplements containing both iron and folic acid, and in Kenya, they were asked whether they took iron alone or iron combined with folic acid. In each country, conceptual frameworks were developed independently, which identified characteristics believed to relate to mothers’ access and motivation to seek care during pregnancy. Analyses were guided by grouping of these characteristics: (a) maternal, (b) household, (c) birth history, (d) advice and counselling received during pregnancy, and (e) health service access. Bivariable logistic analysis was conducted for each independent variable and the outcome variable. For categorical variables, no category with less than 30 cases was retained. To develop a best‐fit multivariable model, all independent variables that showed significant relationships (p < .10) to an outcome variable, in the bivariable analysis, were entered in a logistic regression for that outcome. Using SPSS's backward step selection based on likelihood‐ratio tests, the best fit model was chosen for each outcome. The settings at each step of these processes were p = .10 for entry and p = .11 for removal.

AI Digest

Study Justification:

The study aimed to investigate the factors associated with socio-demographic characteristics, antenatal care (ANC), and iron supplement use among women in hard-to-reach areas in Ethiopia, Kenya, and Senegal. The justification for this study is that ANC provides an opportunity to reach women with important health interventions, including iron supplementation. However, not all women equally seek or benefit from ANC. Understanding the factors associated with ANC and iron supplement use can help identify areas for improvement in ANC programming and ensure access to services for all population groups.

Study Highlights:

– The study surveyed 4,575 women who had given birth within the year preceding the survey in 15 different sub-regions.
– Positive associations were found between ANC uptake and factors such as education, income, possession of a mobile phone, and the occupation of the mother or another household member.
– Beginning ANC in the first trimester was associated with achieving 4 or more ANC visits, and having any ANC visits related positively to iron intake.
– Distance to the nearest health facility was negatively associated with ANC and iron supplement use, while the type of nearest facility and counseling and health education were positively associated with some outcomes.
– The results highlight the need to ensure access to ANC services for all population groups and can inform ANC programming needs.

Recommendations:

Based on the study findings, the following recommendations can be made:

1. Improve access to ANC services: Efforts should be made to reduce the distance to the nearest health facility and ensure that all women, regardless of their socio-demographic characteristics, have access to ANC services.
2. Enhance health education and counseling: Providing comprehensive health education and counseling during ANC visits can positively influence ANC uptake and iron supplement use.
3. Address socio-economic disparities: Strategies should be implemented to address socio-economic disparities, such as promoting education and income-generating opportunities for women, to improve ANC and iron supplement utilization.

Key Role Players:

To address the recommendations, the following key role players are needed:

1. Ministry of Health: Responsible for developing and implementing policies and programs related to ANC and iron supplement use.
2. Health Care Providers: Involved in delivering ANC services and providing health education and counseling.
3. Community Health Workers: Play a crucial role in reaching women in hard-to-reach areas and providing information and support for ANC and iron supplement use.
4. Non-Governmental Organizations (NGOs): Can support ANC programming through advocacy, capacity building, and resource mobilization.

Cost Items for Planning Recommendations:

While the actual cost will vary depending on the specific context, the following cost items should be considered in planning the recommendations:

1. Infrastructure Development: Investment may be required to improve the accessibility of health facilities in hard-to-reach areas.
2. Training and Capacity Building: Resources should be allocated for training healthcare providers and community health workers on ANC services, health education, and counseling.
3. Health Education Materials: Budget should be allocated for the development and distribution of educational materials on ANC and iron supplement use.
4. Monitoring and Evaluation: Funds should be allocated for monitoring and evaluating the implementation and impact of the recommendations.
5. Advocacy and Awareness Campaigns: Resources should be allocated for advocacy efforts and awareness campaigns to promote ANC and iron supplement utilization.
Please note that the above cost items are general suggestions and a detailed budget would require a comprehensive assessment of the specific context and needs of each country.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are some areas for improvement. The study utilized a large sample size and employed multivariable logistic regression to identify associations between socio-demographic characteristics and antenatal care and iron supplement use. The study also considered various factors such as education, income, possession of a mobile phone, occupation, and distance to the nearest health facility. However, the abstract does not provide specific effect sizes or confidence intervals for the associations found. Additionally, the abstract could benefit from including information about the representativeness of the sample and any potential limitations of the study. To improve the evidence, the authors could provide more detailed results, including effect sizes and confidence intervals, and discuss the limitations of the study, such as potential biases or generalizability issues.

Abstract

The following methods summarize those applied in the baseline survey of the three countries. Further detail is provided by Kung’u, Pendame, et al. (2018) in this supplement. Cross‐sectional surveys were conducted in selected communities in each of the three countries. Mothers with children under 12 months were eligible to participate in the baseline surveys. The surveys included five sub‐counties of Kakamega County in Kenya: Kakamega Central, Matungu, Mumias, Butere, and Khwisero; six woredas, the third‐level administrative division of Ethiopia, in Afar regional state: Dewe, Telalak, Chifra, Aura, Ewa, and Gulina; and three departments in the Kolda region and one department in the Sedhiou region of Senegal: Kolda, Medina Yoro Foula, Velingara, and Sedhiou. All households where data were collected were in rural areas. A total of 4,575 women were surveyed: 1,969 in Ethiopia from April to June 2013, 682 in Kenya in February 2013, and 1,925 in Senegal in January and February 2014. A multistage cluster approach was used. The first stage began from the primary sampling unit of district in Senegal, woreda in Ethiopia, and sub‐county in Kenya, with villages and households selected in the second and third stages. The details of the sampling and sample size calculation are described elsewhere (Kung’u, Pendame, et al., 2018). Technical teams tailored a questionnaire to the local context in each country. Individuals with data collection experience were recruited and trained on interview techniques, supervision, administration of the questionnaires, and ethical consideration of participants. Training lasted 3 days in Kenya, 5 days in Ethiopia, and 2.5 days in Senegal. The questionnaires were finalized after pretesting in similar neighbouring communities. The University of Nairobi ethics and review board in Kenya, the Ethiopian Health and Nutrition Research Institute ethical clearance committee in Ethiopia, and the National Ethics Committee for Health Research in Senegal provided ethical approval prior to the survey. Informed consent was obtained from all participants and confirmed with a signature or a fingerprint. There were no personal identifiers on the data collection forms and all data were handled with strict security to ensure confidentiality. Data entry and the initial cleaning were done using EpiData Version 3.1 in Ethiopia, Epi Info 2000 in Senegal, and Microsoft Access version 14.0 in Kenya. In all countries, data were double entered by two different data entry clerks for quality assurance and data cleaning. Analyses were conducted using IBM SPSS version 23.0. The analysis involved logistic regression using four outcome variables (1 = yes, 0 = no). Three of the outcome variables related to uptake of ANC provided by a skilled health care provider, that is, an accredited health professional proficient in the skills needed to manage uncomplicated pregnancies, childbirth, and the immediate post‐natal period, and in the identification, management, and referral of complications in women and newborns as compared to an unskilled health care provider who has no formal training (WHO, 2004). These three outcome variables showed whether the women received ANC (a) at least once during pregnancy (Any ANC), (b) during her first trimester of pregnancy (FT ANC), and (c) four or more times during her pregnancy (≥4 ANC). In Senegal, FT ANC is not presented here as the data were collected only from women who could present their health card with their pregnancy information, which was inconsistent with the other countries and outcomes. The fourth outcome variable showed whether a woman took an iron supplement at least once during her pregnancy. In Ethiopia, women were asked specifically about iron supplements. In Senegal, they were asked about supplements containing both iron and folic acid, and in Kenya, they were asked whether they took iron alone or iron combined with folic acid. In each country, conceptual frameworks were developed independently, which identified characteristics believed to relate to mothers’ access and motivation to seek care during pregnancy. Analyses were guided by grouping of these characteristics: (a) maternal, (b) household, (c) birth history, (d) advice and counselling received during pregnancy, and (e) health service access. Bivariable logistic analysis was conducted for each independent variable and the outcome variable. For categorical variables, no category with less than 30 cases was retained. To develop a best‐fit multivariable model, all independent variables that showed significant relationships (p < .10) to an outcome variable, in the bivariable analysis, were entered in a logistic regression for that outcome. Using SPSS's backward step selection based on likelihood‐ratio tests, the best fit model was chosen for each outcome. The settings at each step of these processes were p = .10 for entry and p = .11 for removal.

Materials

https://efashare.b-cdn.net/materials/d675cf632c1600884b743a9443acc3642baf3c180a21c76336297a8b4595a27d/MCN-14-e12565-s001.zip

Innovations

Based on the provided description, here are some potential innovations that can be used to improve access to maternal health:

1. Mobile Health (mHealth) Solutions: Develop mobile applications or SMS-based systems that provide pregnant women with information about antenatal care, iron supplementation, and other relevant health interventions. These platforms can also send reminders for ANC visits and provide access to teleconsultations with healthcare providers.

2. Community Health Workers (CHWs): Train and deploy CHWs in hard-to-reach areas to provide education, counseling, and support to pregnant women. CHWs can conduct home visits, distribute iron supplements, and facilitate referrals to healthcare facilities when necessary.

3. Telemedicine: Establish telemedicine networks to connect pregnant women in remote areas with healthcare providers. This allows for remote consultations, diagnosis, and monitoring, reducing the need for women to travel long distances for ANC services.

4. Improving Transportation Infrastructure: Invest in improving transportation infrastructure, such as roads and transportation services, to ensure that pregnant women can easily access healthcare facilities for ANC visits and delivery.

5. Community-Based ANC Clinics: Set up community-based ANC clinics in hard-to-reach areas, staffed by trained healthcare providers. These clinics can provide comprehensive ANC services closer to where women live, reducing the barriers of distance and transportation.

6. Financial Incentives: Implement financial incentive programs to encourage pregnant women to seek ANC and adhere to iron supplementation. This can include cash transfers, vouchers, or subsidies for ANC visits and iron supplements.

7. Health Education and Awareness Campaigns: Conduct targeted health education and awareness campaigns to increase knowledge and understanding of the importance of ANC and iron supplementation among pregnant women and their communities.

8. Integration of ANC with Other Services: Integrate ANC services with other existing health services, such as immunization programs or family planning services. This can improve access to ANC by leveraging existing healthcare delivery platforms.

9. Public-Private Partnerships: Foster collaborations between the public and private sectors to improve access to maternal health services. This can involve leveraging private healthcare providers and facilities to expand coverage and reach in underserved areas.

10. Task-Shifting and Training: Train and empower non-specialist healthcare providers, such as nurses and midwives, to provide ANC services. This can help address the shortage of skilled healthcare providers in remote areas.

These innovations can help address the identified factors associated with ANC and iron supplement use, improve access to maternal health services, and ultimately contribute to better maternal and child health outcomes.

AI Innovations Description

Based on the description provided, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Mobile Health (mHealth) Interventions: Since possession of a mobile phone was positively associated with ANC uptake, developing mHealth interventions can help improve access to maternal health. These interventions can include sending reminders for ANC appointments, providing health education and counseling through mobile apps or text messages, and facilitating communication between pregnant women and healthcare providers.

2. Community-Based ANC Services: Given that distance to the nearest health facility was negatively associated with ANC uptake, implementing community-based ANC services can help overcome geographical barriers. This can involve setting up mobile clinics or outreach programs in hard-to-reach areas, where healthcare providers can offer ANC services closer to the women’s homes.

3. Targeted Education and Awareness Campaigns: Since education was positively associated with ANC uptake, implementing targeted education and awareness campaigns can help improve knowledge and understanding of the importance of ANC among women in hard-to-reach areas. These campaigns can be conducted through community health workers, local leaders, and mass media to reach a wider audience.

4. Income Generation Programs: Income was positively associated with ANC uptake, suggesting that financial constraints may hinder access to maternal health services. Implementing income generation programs, such as microfinance initiatives or vocational training, can help empower women economically, enabling them to afford ANC services and related expenses.

5. Strengthening Health Facilities and Services: The type of nearest facility and counseling and health education were positively associated with ANC uptake. Therefore, investing in improving the quality and availability of ANC services at health facilities, as well as providing comprehensive counseling and health education during ANC visits, can contribute to better access and utilization of maternal health services.

By implementing these recommendations as innovative solutions, access to maternal health can be improved, ensuring that all women, regardless of their socio-demographic characteristics, can benefit from ANC and related interventions for a healthier pregnancy and childbirth.

AI Innovations Methodology

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

1. Mobile Health (mHealth) Solutions: Utilize mobile technology to provide maternal health information, reminders for antenatal care visits, and access to telemedicine consultations.

2. Community Health Workers (CHWs): Train and deploy CHWs to provide education, counseling, and basic healthcare services to pregnant women in hard-to-reach areas.

3. Telemedicine: Establish telemedicine networks to connect pregnant women in remote areas with healthcare providers for consultations and monitoring.

4. Transportation Support: Implement transportation programs to ensure that pregnant women have access to healthcare facilities for antenatal care and delivery.

5. Financial Incentives: Provide financial incentives or subsidies to encourage pregnant women to seek antenatal care and deliver in healthcare facilities.

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 (e.g., pregnant women in hard-to-reach areas) that will be the focus of the simulation.

2. Collect baseline data: Gather data on the current access to maternal health services, including ANC uptake, iron supplement use, distance to the nearest health facility, and other relevant factors.

3. Develop a simulation model: Create a mathematical model that represents the relationships between the different factors influencing access to maternal health. This model should incorporate the potential impact of the recommended interventions.

4. Input intervention parameters: Specify the parameters of the recommended interventions, such as the coverage and effectiveness of mHealth solutions, the number and training of CHWs, the availability of telemedicine services, and the extent of transportation support and financial incentives.

5. Run the simulation: Use the simulation model to project the potential impact of the interventions on improving access to maternal health. This could include estimating the increase in ANC uptake, iron supplement use, and reduction in distance to the nearest health facility.

6. Analyze the results: Evaluate the outcomes of the simulation, such as the predicted changes in access to maternal health services. Assess the effectiveness and cost-effectiveness of the recommended interventions.

7. Refine and iterate: Based on the simulation results, refine the intervention parameters and re-run the simulation to explore different scenarios and optimize the strategies for improving access to maternal health.

It is important to note that the accuracy of the simulation results will depend on the quality and representativeness of the baseline data, as well as the assumptions and limitations of the simulation model. Regular monitoring and evaluation of the implemented interventions will help validate and refine the simulation findings.

Author

Dima Health

Statistics:

Citations: 8

Identifiers:

DOI: 10.1111/mcn.12565

ISSN: 17408695

Research Areas:

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

Study Countries:

Ethiopia, Kenya, Multi-Countries, Senegal

Study Design:

Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Female