Why anc need never worry about losing

Study staff completed semi-structured environmental tracking forms during each site visit to record potential sources of bias or confounding. Limited stock-outs of LLINs and IPTp were noted and may have occurred unevenly between the study arms as intervention sites could more easily earmark supplies for study participants.

Additionally, as commodity availability impacts quality of care, and previous literature has shown quality impacts attendance [ 22 , 23 ], results may not be replicable in contexts where key commodities are not available. Study staff also noted that as the study progressed, providers reported that new ANC clients initiating care at intervention sites began to request participation in groups, indicating that self-selection bias may have strengthened as the study progressed.

In Kenya, the availability of ANC services in intervention and control arms was disrupted by four national health care worker strikes. With few exceptions, in intervention facilities, facilitators continued to offer G-ANC, while in control facilities, individual ANC services were sometimes unavailable.

In Nigeria, both intervention and control sites participated in a concurrent World Bank performance-based financing program that rewarded facility-based delivery. This may have provided a synergistic effect, enhancing the observed effect size for facility-based delivery and G-ANC. We include frequencies for these data in S5 Table. However, generalizability of findings to other locations requires consideration of several factors: frequency of health service disruptions, freedom of movement of the pregnant population, average gestation at entry to ANC and monthly census of women attending ANC1, availability of key ANC commodities, availability of additional staff to attend to non-G-ANC clients during meetings, availability and quality of G-ANC mentorship, and access to mobile phones and airtime by both G-ANC participants and providers increasingly available in many low-resource settings.

Our results, from a pragmatic study, suggest that a G-ANC model purposefully built for the context, which integrates social and behavioral change and focuses on issues common to LMICs, can improve the quality of and attendance at facility-based ANC as well as raise low facility-based delivery rates. For a new service delivery model to have a transformational influence on maternal health care, it needs to be available to a large portion of the population. As such, future research should explore both the feasibility and impact of G-ANC adaptations in a variety of contexts e.

In addition, future studies should be undertaken and reported with careful recognition that both specifics of the individual model being tested and implementation quality may alter results. Additional data on clinical outcomes are also still needed, ideally incorporating outcomes from subsequent births to capture potential gains related to G-ANC participation in the index birth. Finally, if G-ANC is to provide a substantial, sustained benefit, there must be a continued commitment to widespread health system strengthening.

We thank the Nasarawa State Primary Healthcare Agency for providing the study staff with office space. We acknowledge Prof. Browse Subject Areas? Click through the PLOS taxonomy to find articles in your field. Abstract Background Low quality and frequency of antenatal care ANC are associated with lower uptake of facility-based deliveries—a key intervention to reduce maternal and neonatal mortality. Introduction As evidenced in the Sustainable Development Goals [ 1 ], ending preventable maternal and neonatal mortality remain global priorities, as do improvements in the overall health and well-being of women and children [ 2 ].

Participants, randomization, and masking Study facilities had to have an adequate monthly number of new ANC ANC1 clients to form gestationally matched cohorts of at least eight women, as well as two or more clinical providers available during ANC clinic hours. Procedures Before enrollment, all intervention and control clusters received equal quantities of ANC-related commodities and clinical supplies to supplement existing stock, and ANC providers participated in a 2-day clinical update.

Outcomes The primary outcome was the proportion of women reporting facility-based delivery for the index pregnancy, which was measured by self-report during the postpartum survey. Sample size and statistical analysis The sample size was calculated to detect a percentage point difference in the facility-based delivery rates between the treatment arms. Results Participant characteristics We selected, matched, and randomized 20 eligible clusters in each country.

Download: PPT. Table 1. Demographic characteristics of enrolled women at baseline. Table 2. ANC Attendance Women in the intervention arms in both countries were significantly more likely than those in the control arms to attend ANC four or more times, with a larger adjusted effect size in Nigeria aOR Quality of care Women in G-ANC in both countries received higher quality of care, based on the composite measure of ANC quality, with women in the intervention arm more likely to receive all eight ANC interventions compared to those in the control arm Nigeria: adjusted odds ration [aOR] 5.

Discussion In this pragmatic cRCT, women enrolled in G-ANC were more likely to deliver in a facility than women in the control arm in Nigeria, but not in Kenya where facility delivery associated with individual care was equally high. Strengths This study has several notable strengths, particularly its randomized, prospective, and pragmatic design.

Limitations Limitations to our findings include potential sources of bias. Recommendations For a new service delivery model to have a transformational influence on maternal health care, it needs to be available to a large portion of the population. Supporting information. S1 Fig. S2 Fig. S1 Table. Location of current delivery compared to previous delivery by study group in Nigeria, multiparas only.

S2 Table. Location of current delivery compared to intent at entry to antenatal care by study group in Nigeria, all subjects. S3 Table. Effect of G-ANC on individual components of birth planning and complication readiness. S4 Table. Effect of intervention on individual components of comprehensive counseling received and danger signs assessed. S5 Table. Pregnancy loss and mortality by study arm.

S1 Data. G-ANC data codebook. S2 Data. S1 Checklist. References 1. United Nations. Sustainable Development Goals. Every Woman Every Child. Geneva: World Health Organization; Every Newborn: progress, priorities, and potential beyond. The Lancet. View Article Google Scholar 4. Delivery care. View Article Google Scholar 5. Moyer CA, Mustafa A. Drivers and deterrents of facility delivery in sub-Saharan Africa: a systematic review. Reproductive Health.

Health system and community level interventions for improving antenatal care coverage and health outcomes. Cochrane Database of Systematic Reviews. View Article Google Scholar 7. Berhan Y, Berhan A. Antenatal care as a means of increasing birth in the health facility and reducing maternal mortality: a systematic review. Ethiopian J Health Sci. View Article Google Scholar 8.

Quality of antenatal care predicts retention in skilled birth attendance: a multilevel analysis of 28 African countries. BMC Pregnancy Childbirth.

Effect of birth preparedness on institutional delivery in semiurban Ethiopia: A cross-sectional study. Annals of Global health. The effectiveness of birth plan in increasing use of skilled care at delivery and postnatal care in rural Tanzania: a cluster randomized trial. Tropical Medicine and International Health. Impact of birth preparedness and complication readiness interventions on birth with a skilled attendant: A systematic review.

Effectiveness of antenatal care services in reducing neonatal mortality in Kenya: analysis of national survey data. Glob Health Action. Doku DT, Neupane S. Survival analysis of the association between antenatal care attendance and neonatal mortality in 57 low-and middle-income countries.

A majority had no education There were no drop-outs during FGDs. No repeat interviews were conducted. Audio recordings in Dinka language were transcribed and translated into English by bilingual Dinka and English speakers while audio recordings of KIIs conducted in English were transcribed by CW. The transcripts were not returned to participants for review because of logistical constraints. The transcripts were then analysed using the inductive content analysis approach [ 14 ].

The analytic framework was adapted from a large systematic review [ 15 ]. Although the original framework is about barriers to childbirth service use, the themes were modified to apply to ANC use. The data for each theme and sub-theme were then pieced together to provide an overview of the content relating to that specific theme charting.

The four broad themes were: 1 access and resource availability, 2 influence of the sociocultural context and insecurity, 3 Perceptions of pregnancy, and 4 perceptions of the quality of care. Quotes were selected to represent a typical response or to illustrate a deviant opinion.

Table 1 summarises the findings of the study. The perceived barriers to utilisation of ANC services in the county are described in detail below. Long distance to health facilities was occasioned by the sparseness of the population settlements, nomadism in search for water and pasture, and the lack of enough facilities providing ANC in the county.

Some villages and payams have no health facilities and women are discouraged from visiting faraway health facilities. In the dry season, they have to go to a far place where there is water and during the rainy season, they move to a place where there are no mosquitoes because this place has a lot of mosquitoes if there is water.

Long distance and lack of means of transportation to health facilities aggravated the effect of the other barriers on ANC attendance mentioned below. Women felt that if a health facility was near, they would attend ANC and return home quickly without having to worry about insecurity. Additionally, their husbands would be less likely to restrict them from attending ANC. If you bring a hospital near, our problems will be solved. We will not be worried about our children, husbands, and cattle.

Flooding during wet seasons prevented women from accessing health facilities as highlighted below:. If you are pregnant, you cannot swim in such a place, because your heart will get tired and your thighs will be exhausted.

Additionally, flooding prevented delivery of drugs and supplies to health facilities rendering them functionless. Floods washed away parts of the main road connecting Maper centre and Rumbek town causing serious logistical challenges.

There were also concerns about the excessive shaking that occurs when travelling by a motor vehicle on the rutted roads in the county. You can neither walk on foot nor use the car because they say that pregnant women are not supposed to get in the car if there is too much shaking due to bad roads.

Both male and female FGD participants mentioned that women were discouraged from attending ANC because of being asked by health facility staff to pay money.

It was unclear whether these payments were official or under-the-table payments. Participants, however, noted that this practice was not present at all health facilities, and was being encountered mainly at health facilities located in neighbouring counties. The experience of having been asked to pay for ANC or for treatment during pregnancy was negatively affecting the current use of ANC services. We did not even have one pound to buy soap, leave alone money to pay at the hospital.

If a pregnant woman is asked to pay money every day she goes to the hospital, but she is very poor and cannot afford to pay, do you think she will go again?

Some women who had been asked to pay for services returned home and spread this message to their friends and relatives; discouraging more women from attending ANC. Women in Rumbek North bear a heavy burden of domestic chores.

They were responsible for taking care of children, taking care of the house, and producing and preparing food for the family. Domestic chores increased substantially during planting, weeding and harvesting seasons when women were required to work on their farms besides attending to their families.

A list of the duties of women and men in Rumbek North is presented in Additional file 1. Long distance to health facilities and insecurity worsened the problem of domestic chores.

There was also the problem of lack of someone to take care of children at home if a woman wished to attend ANC. The other reason is that there is nobody to leave our children at home with.

Because of domestic chores, some women could not arrive at health facilities during the regular time of service delivery and there were concerns about being turned away for arriving too late at health facilities. So you spend time cooking in the morning until the hospital visiting time is over. If you go to the hospital late, doctors will say that the time for registration is over. Therefore, women who work in the morning may not go to the hospital because they can only arrive there late every day.

Partners of pregnant women had a great influence on utilisation of ANC and other maternal health services in Rumbek North. Because men controlled the resources of the family, they were often unwilling to pay for the costs associated with health facility visits.

Both male and female FGD participants mentioned that men were restricting their wives from attending ANC based on three main factors: 1 long distance to health facilities: men did not want their wives to travel to faraway health facilities leaving their homes and children unattended, 2 men did not want their wives to travel to health facilities because of insecurity, and 3 some men did not see the necessity of their wives attending ANC because their mothers never used to do so.

No, I am still alive. Why should you frequent the hospital? Moreover, women felt that they were not getting the encouragement and support they needed during pregnancy and that men lacked interest in maternal health; leaving the burden of taking care of the pregnancy to women.

They just leave the pregnancy for you alone. They leave you for the rest of the pregnancy. Some men encouraged their wives to attend ANC. However, this was primarily driven by the need to have their wives get tested for any disease that would affect the foetus or just to check the status of the foetus. There was little concern about the health of the mother. If the foetus has a disease, the hospital provides treatment. Rumbek North is in a state of chronic insecurity and the inhabitants live in fear of being attacked at any time by the neighbouring communities.

Although the county is known for frequent inter-clan feuds, the prevailing political and security situation in South Sudan had exacerbated the problem.

Insecurity was widely cited as the reason behind poor ANC utilisation. Do you think that if a pregnant woman had planned to come today she will come? She will not come because of fighting. Many people are attacking our village every day and for that reason, we cannot go to a distant hospital…. ANC was perceived in the county to be a new concept. The population had lived for a long time without formal health care services and some women had never visited a health facility.

Consequently, some women were not familiar with ANC and its significance. Our villages have been in the forest all along. For example, Maper never had a hospital in the past. Additionally, in the case of problems during pregnancy, some women turned to traditional remedies because they did not know about the medical treatment in health facilities. During my previous pregnancy, whenever I had any kind of illness, I went to the traditional healer.

The health facility staff felt that efforts to raise awareness, though still limited, were resulting in an increase in the number of women attending ANC. This is because previously, they were unaware of the benefits of the health facility. We have tried to create awareness in the villages and they are listening and starting to understand.

A few women came, received good care and went back to inform their colleagues to come. The risk of serious pregnancy-related complications was perceived to be low. Some women without any prior pregnancy related complication did not see the added value of ANC attendance in the context of the formidable barriers to service access.

Similarly, those with a health concern did not perceive the problem to be a major threat to the pregnancy. We reason that the present pregnancy will be like the first one. On the other hand, women with prior pregnancy-related complications were more likely to attend ANC because of their higher risk perception.

From there, I said to myself that for my second pregnancy, I would not want my baby to die again. I went to the hospital for check-up and treatment, came back home and delivered safely to a life child.

Attending ANC was often associated with medical treatment. On one hand this promoted ANC attendance for women with health problems but on the other hand, it was a potential reason to avoid service use for women who did not feel any discomfort. While there, I was injected with medicine and then I felt well. Some male participants had a positive perception toward ANC especially the medical care received at health facilities—which they felt sometimes benefited them too. Accompanying a woman may encourage her to attend the clinic.

Both of you will be tested together. You may be suffering from a sexually transmitted disease and this will require the doctor to treat both of you. Because ANC was perceived be a curative service, some women felt unsatisfied if treatment was not provided during ANC while others were unsatisfied with the quality of treatment provided if it did not include an injection or if the treatment did not relieve the symptoms experienced.

These issues seemed to affect decisions on future ANC attendance. Even if you go to the hospital, you will not be given medicine. I have gone to the hospital twice but nothing has happened. Now I have decided to go to Marial lou hospital because this medicine of Maper hospital is not helping. In general, the barriers to utilisation of ANC services identified in the present study have also been reported in other studies [ 16 ].

Some of them, such as transportation problems and insecurity, affect both service provision and utilisation; aggravating the problem of poor access to maternal health services. In this setting, geographical barriers and insecurity made it difficult and dangerous for women to travel to health facilities thereby negatively influencing the decision to attend ANC.

Although maternal health services were officially free-of-charge in Rumbek North, women were discouraged from utilising ANC services because health workers at some health facilities were demanding for payment. Any out-of-pocket payment requested, either official or illegal, has a considerable negative impact and dramatically hinders the delivery of ANC in this setting.

Both of these issues are reflective of the women's empowerment situation in this community. The party faced a difficult election campaign, marred by accusations of racism. Over the past few years, a number of senior black members within the DA have been pushed out of the party, and the DA was criticized for putting up racially tinged posters in Phoenix, an area populated predominantly by the Indian community and where 36 black people were killed during the July riots.

The posters caused serious tensions, and raised fears that open racism might be ignited or accelerated by such a campaign tool. The DA was ultimately forced to pull down the posters. The DA were desperate for votes in these elections, as they have lost part of the middle class vote and the black vote.

They have also lost some of the white vote to the Freedom Front Plus, an Afrikaner party, because some white people feel that the DA does not protect their interests. The party seems to lack a clear orientation with regard to its voter base. In certain business quarters they are not trusted anymore, as they worked side-by-side with the radical EFF just to get into power. The EFF has been growing in every election since its formation in , although they did not win a single ward in , but got good results in the proportional representation vote.

This made them kingmakers during negotiations for coalitions in the key municipalities in All three did not last long. The EFF cannot be evaluated in terms of good or bad governance as the party have never been in government in any municipality in the country. It remains to seen whether they could work with the ANC in the future, the party from which they split off.

Yet this time around, the IFP contested local elections in Limpopo province, home province of President Ramaphosa, for the first time. While on the campaign trail, party leaders also met with some of the royal houses. This is common in South Africa during elections, as most of the royal houses are influential in the rural areas. Formally, however, those structures are not to be used openly for party politics. Coalition governments at various levels are not new in South Africa, even the first national government of democratic South Africa was a coalition including the National Party.

Yet these coalitions have a fairly negative track record. Looking back on the LGE results and the coalitions or minority local governments which formed in four out of eight metropolitan municipalities, quite a lot of instability was the result. Initially, the DA and the EFF voted together in Tshwane, Johannesburg, and Nelson Mandela Bay, thus enabling the DA to form a minority government in these municipalities—despite the fact that, ideologically, it made no sense for these two parties to vote together.

The Ekurhuleni municipality was the only stable coalition government from up to All the other aforementioned municipalities were not stable at all. Some have had five or more mayors in the last five years. According to political analysts, this was largely the result of a lack of experience with forming a stable coalition government at the local level.

In most cases, no formal coalition agreement was negotiated, nor was anything communicated to the public. These developments resulted in a very negative attitude towards coalitions at the metropolitan level. Given the current results, it is clear that coalitions will have to be formed once again.