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Factors Influencing Successful Implementation of Antenatal Care Services in Selected Health Centre IV’s in Jinja District Eastern Uganda

Akankwasa Prosper Kanya

Faculty of Clinical Medicine and Dentistry Kampala International University Western Campus Uganda.

ABSTRACT

Maternal mortality is a global public health issue, with an estimated 830 women dying daily due to pregnancy and childbirth-related causes, primarily in the developing world. The use of antenatal care from trained providers is crucial to monitor pregnancy and reduce morbidity and mortality risks for both mother and child during pregnancy and delivery. A prospective descriptive cross-sectional study was conducted among health workers in five health Centre IVs in Jinja district, eastern Uganda. The study found that only 17.65% of antenatal care services were implemented fairly. Factors influencing successful implementation included service duration above five years, formal training on implementing guidelines and having facility interventions in place. Factors such as seeing 30 or fewer antenatal clients on each clinic day, not attending antenatal reproductive health training, not having knowledge of antenatal care guidelines, and not using antenatal care guidelines also influenced successful implementation. However, these factors did not show statistical significance in logistic regression analysis. More efforts are needed to improve antenatal service implementation among healthcare providers to achieve the new WHO antenatal care model for a positive pregnancy experience.

Keywords: Women, Pregnancy, Antenatal care services, Antenatal health.

INTRODUCTION

The number of registered maternal deaths due to birth- or pregnancy-related complications per 100,000 registered live births[1]. Maternal mortality is a global public health problem with an estimated 830 women dying every day due to pregnancy and childbirth-related causes most of which occur in the developing world[2]. According to the United Nations Inter-agency estimates, there has been a tremendous decline in maternal mortality between 1990 and 2015, however sub-Saharan Africa (SSA) still contributes two-thirds of the world’s annual maternal deaths [3]. Most maternal deaths are preventable if women access timely and quality obstetric care provided by skilled health personnel in adequately equipped health facilities. The lifetime risk of dying due to childbirth is influenced by the number of pregnancies and the probability of experiencing a life-threatening obstetric condition [4]. Unfortunately, the lifetime risk of maternal death in low- and middle-income countries is 1 in 41 compared to 1 in 3,300 in high-income countries due to challenges in access to timely emergency obstetric care and the high fertility rates; Uganda has a lifetime risk of dying in childbirth of 1 in 49 [5]. Antenatal care (ANC), a pillar in safe motherhood is recommended as one of the strategies to reduce maternal deaths given that it provides an opportunity for the pregnant woman to interface with the health care system to identify pre-existing conditions that may complicate pregnancy and lead to morbidity and or mortality[6]. However, the coverage of ANC is low with about 78% and 49% of women in SSA attending at least one ANC and four or more visits respectively during the course of their pregnancy [7]. This implies that fewer women in SSA receive the benefits ANC. The utilization of antenatal care from a trained provider is important to monitor the pregnancy and to reduce morbidity and mortality risks for the mother and child during pregnancy and delivery. Therefore, the aim of this study was to assess the factor influencing successful implementation of ANC care services in Regional Referral Hospitals in Uganda east Africa. In 2001, a WHO study evaluated and recommended focus antenatal care (FANC) – an approach that promotes four antenatal visits that are goal oriented and personalized with guidance on the services a pregnant woman should receive when they interface with a health care worker[8]. Uganda adopted the WHO guidelines for FANC in 2003[9, 10]. Recent evidence suggests that the focused antenatal care (FANC) model is associated with more perinatal deaths than ANC models that comprise at least eight contacts between the pregnant woman or adolescent girl and the health care provider [11]. However, in a recently published document, WHO now recommends a minimum of eight visits to improve neonatal outcomes and to provide a more positive and women-centered experience for clients. Maternal mortality rate has been a challenge since the 1990s MMR has remained high in Uganda; UDHS, 2006 found that MMR declined just 14% in the past 10 years from 506 per 100,000 to 435 per 100,000 compared to 28% decline in previous 7 years[12].  And currently MMR stands at 336 per 100,000 live births[12].A pregnant woman’s chance of getting all the components of the ANC package increases with the number of visits they make to the health facility[9]. However, in Uganda, the proportion of pregnant women utilizing comprehensive ANC services is low based on the reported number of women attending four ANC visits during the last five years [13]. Some studies have shown that the more pregnant women attend ANC the more likely they will have a skilled birth attendance or health facility delivery and good health outcomes[14]. It is thus not surprising that Uganda still has a high maternal mortality rate, given the low ANC attendance and health facility deliveries. According to motivation and facilitation theory, facilitation is the goal of the clinic to create easy, open access to person-centered beneficial care. This model directs the focus of research and changes to the interface of the woman and the clinic and encourages practice-level innovations that facilitate women entering and maintaining prenatal care [8, 15]. The pregnant woman’s perception, which can be perceived susceptibility, and beliefs, about the ANC service providers may affect the motivation of pregnant mothers to attendances of ANC.

Globally, maternal health outcomes have seldom improved despite improvements in other health indicators. Maternal mortality is a global public health problem with an estimated 830 women dying every day due to pregnancy and childbirth related causes most of which occur in the developing world[2], maternal mortality is unacceptably high, about 295000 women died during and following pregnancy and childbirth in 2017. The vast majority of these death (94%) occurred in low-resources settings, and most could have been prevented. Saharan Africa (SSA) still contributes two thirds of the world’s annual maternal deaths. [16].The Uganda Demographic Health Survey of 2016 reported that the maternal mortality rate (MMR) stands at 336 per 100,000 live births. Furthermore, the report also indicated that the proportion of pregnant women who attend at least four ANC visits during the course of their pregnancy is still low at 60% and only 73% of the deliveries happen at the health facility[12]. These maternal deaths could have been prevented if the pregnant women or adolescent girls had been able to access quality antenatal care[2]. Thus, understanding the factors influencing successful implementation of antenatal care services should be a matter of great policy concern to the government and other stakeholders, especially donors. Whereas studies had been done to understand the factors influencing the utilization of antenatal care services in Uganda[9, 17], no study had been carried about the factors influencing successful implementation of ANC services, using the Uganda Demographic Health Survey (UDHS) 2016 [4].

DISCUSSION

A few benefits of receiving proper prenatal care are educating women about exclusive breastfeeding and complementary feeding techniques, lowering the risk of HIV transmission from mother to child, and being aware of postpartum symptoms [18-21]. This study aimed to assess the factors influencing the successful implementation of antenatal care services in selected health Centre IV’s in Jinja district eastern Uganda. The study enrolled a total of 34 health workers. The study involved an assessment of health workers for the services they offered during antenatal care and the factors that influence the success of their implementation of these services. The findings of this study revealed that implementation of antenatal care services was evidently suboptimal in our study setting, with only about 6(17.65%) reporting a fair implementation of antenatal care services. Surprisingly, the gaps in the quality of antenatal care services have been reported in previous studies. A study conducted in eastern Uganda by[22] reported poor quality of antenatal care services. In this study, the researchers pointed out a staffing gap, inadequate infection control facilities, drugs and supplies. Additionally, the researchers also observed that counselling for risk factors and birth preparedness were poorly done. Comparably, suboptimal quality of antenatal care was also reported by studies conducted in rural health settings in Kenya[15] and in Lao[23] reported poor quality and performance of antenatal care services in rural health facilities. In these studies, pregnant mothers did not receive the recommended antenatal care services and poor performance was due to lack of routines, scarce or insufficient equipment and limited skills among providers. Our study also revealed that, duration in service above five years (OR=2.1, p- value=0.4 and CI=0.4-12.6), having had a formal training on the implementation of guidelines (OR=1.7, p-value=0.6, CI=0.3-11.1), and having facility interventions in place to successfully implement antenatal care (OR=5, p-value=0.2, CI=0.5-48.5) increased the likelihood of having a fair implementation of antenatal care guidelines. Similarly, seeing 30 or less antenatal clients on each clinic day (OR=2.7, p-value=0.3, CI=0.4-17.0), not having attended an antenatal reproductive health training (OR=2.5, p-value=0.3, CI=0.5-15.1), not having knowledge on antenatal care guidelines (OR=1.4, p-value=0.8, CI=0.11-14.0) and none use of antenatal care guidelines (OR=1.8, p-value=0.5, CI=0.3-12.5) appeared to influence fair successful implementation of antenatal care guidelines. Notably however, these factors did not show any statistical significance in logistic regression analysis. This could however be attributed to the small sample size of our study participants. Remarkably, however, similar factors have been reported to influence implementation of antennal care services across studies in different parts of the world[24–28].

CONCLUSION

Implementation of antenatal care services was strikingly suboptimal and the factors that were reported to influence antenatal care service implementation included duration in service above five years, seeing more than 30 antenatal clients on each clinic day, having had a formal training on the implementation of guidelines and having facility interventions in place to successfully implement antenatal care.

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