Effect of Quality of Antenatal Care and Perinatal and
136 Indian Journal of Public Health Research & Development, April-June 2018, Vol.9, No. 2 developing countries and can be avoided as the necessary
medical interventions already exist and are well known.
The key obstacle is the lack of access to quality care by pregnant women before, during and after childbirth.1,2 The National Rural Health Mission (NRHM) has given importance to quality antenatal care as one of the key strategies for maternal and new-born health.
(Operational guidelines on Maternal and Newborn Health, NRHM).The focus on antenatal care has, till recently, been on early registration, completing at least four antenatal visits, TT injections and Iron and folic acid tablets. (UNICEF CES 2009). Under the NRHM, antenatal care services have been broadened to include laboratory investigations like haemoglobin estimation, blood sugar, HIV, blood grouping and typing. The present study therefore seeks to document perinatal and postnatal outcomes in relation to the quality of antenatal care received as well as to provide information about those components of essential antenatal care that are more strongly linked to adverse perinatal and postnatal outcomes in an Indian rural primary health care setting.
ObJeCTIVeS
To assess and compare perinatal and postnatal outcomes among pregnant women based on the quality of antenatal care at a rural primary health care setting.
MeThOd
This was a longitudinal study, carried out among mothers who had availed antenatal services at a rural hospital, covering 14 villages in Anekal Taluk of Bangalore Urban District, between 2009 to 2013. Details of antenatal care received by the mothers were taken from the hospital records. The quality of antenatal care received by the mothers was divided into 3 categories:
(i) Basic antenatal care (at least 4 Antenatal visits, tetanus vaccine and iron-folic acid tablets and health education)
(ii) Basic antenatal care and routine laboratory investigations
(iii) Basic antenatal care, routine laboratory investigations and ultrasound scan
The mothers were then contacted in person.
Mothers whose pregnancy had ended in abortion were excluded from the study. After obtaining informed
consent, a pretested semi structured questionnaire was administered to record additional socio-demographic details and perinatal & postnatal outcomes like place and mode of delivery, gestational age at delivery, birth weight, maternal complications during delivery and postpartum and neonatal complications. The data was entered and coded in Microsoft Excel and analysed using SPSS version 16 for proportions, frequencies and associations. Proportions, measures of central tendency and dispersion were used for descriptive statistics.
Chi square test and Fisher’s exact test were used for testing association between quality of antenatal care and perinatal outcomes. A p value of less than 0.05 was considered as significant.
ReSulTS
Table 1: Socio-demographic characteristics of the study population
Variable Category No (%)
Age (in Years)
< 19 4(3.1)
20–25 87(66.9)
26–30 21(16.2)
>30 18(13.8)
Religion Hindu 127(97.7)
Muslim 3(2.3)
Family
type Joint 91(70)
Nuclear 39(30)
Education
Illiterate 11(8.5)
Primary 2(1.5)
Secondary 90(69.2)
Higher secondary &
graduate 27(20.7)
Ration card BPL 111(85.4)
APL 4(3.1)
No card 15(11.5)
Marital
status Currently married 128(98.4) Divorced / Separated 2(1.6) Of the 130 mothers included in the study, majority were in the age group between 20 and 25 years. (See table 1). The mean age was 23.5 years ±2.62 (Range=18-34).
Majority of the study population were Hindu by religion.
Most of the women in the study group had received formal school education. Most women belonged to joint family and possessed a BPL card. According to the modified BG Prasad Socio-Economic Status (SES) scale, 51 (39.2%) subjects belonged to Class IV, 69(53%) in Class III SES.
Indian Journal of Public Health Research & Development, April-June 2018, Vol.9, No. 2 137 Table 2: Quality of antenatal care
Antenatal services received No. (%) Basic Antenatal Care 78 (60) Basic antenatal care + Blood
investigations 32 (24.6)
Basic antenatal care + Blood
investigations + Obstetric ultrasound 20 (15.4) Of the 130 mothers, 111(85.4%) had registered their pregnancy before 12 weeks and 19(14.6%) had registered after that.All mothers had received at least four antenatal visits, during which height, weight and blood pressure was recorded, a general physical and obstetric examination was done by a primary care physician alongwith counselling regarding diet, rest and birth preparedness. 52 (40%) of women had undergone routine laboratory investigations (Blood group, haemoglobin, HIV, VDRL, HBsAg and Random blood sugar). Only 20 (15.4%) had undergone an obstetric ultrasound. 60 % of the women had received only Basic antenatal care (at least 4 Antenatal visits, tetanus vaccine and iron and folic acid tablets), 24.6% had received Basic antenatal care along with laboratory investigations and only 15.4% of the women underwent an ultrasound in addition to basic antenatal care and laboratory investigations.(see table 2)
Looking at perinatal and postnatal outcomes among these mothers, it was found that 10 (7.7%) had an adverse outcome in terms of either stillbirth or neonatal death. (see table 3). Also 45 (34.6%) of the births were premature, 48 (36.9%) were born with low birth weight (below 2500 grams), 36 (27.6%) mothers had an assisted
delivery or caesarean section, 6(4.6%) women delivered at home, 15 (11.5%) of the mothers reported at least one maternal intrapartum complication, commonest being pregnancy induced hypertension, 20 (15.4%) reported any one maternal postpartum complication commonest being severe bleeding. 19 (14.6%) reported at least one neonatal complication, commonest being delayed cry at birth and severe jaundice.
Adverse perinatal and neonatal outcomes like stillbirth or neonatal deaths, preterm delivery, low birth weight, maternal postpartum complications and neonatal complications were significantly lower as the quality of antenatal care improved. (see table 3) The women who had undergone ultrasound and laboratory investigations in addition to basic antenatal care had significantly lower rates of adverse perinatal and neonatal outcomes.
Adverse perinatal and post natal outcomes were not associated with socioeconomic status, family type, and religion. The quality of antenatal care was not found to be significantly associated with outcomes like mode of delivery, place of delivery and maternal intrapartum complications. Multiple logistic regression was done, adjusting for all the perinatal outcomes which were significantly associated with the quality of antenatal care. There was a significant association of quality of antenatal care with preterm delivery and maternal postpartum complications. Women who had only basic antenatal care, without any laboratory investigations and obstetric ultrasound were 9.1 times more likely to have a preterm delivery and 6.4 times more likely to have maternal intrapartum complications. (see table 4)
Table 3: Association of quality of antenatal care with various perinatal and postnatal outcomes basic antenatal
(n = 78)care
basic antenatal care + blood investigations
(n = 32)
basic antenatal care + blood investigations + Obstetric ultrasound
(n = 20)
P value
Mortality
Baby alive and well 68 32 20
Stillbirth or Neonatal death 10 0 0 0.03
gestational age at birth
Full term 40 26 19 0.0001
Preterm 38 6 1
birth Weight
≥ 2500 gms 41 25 16
< 2500 gms 37 7 4 0.03
138 Indian Journal of Public Health Research & Development, April-June 2018, Vol.9, No. 2 Contd…
Mode of delivery
Normal 51 27 16 0.09
Assisted or Caesarean 27 5 4
Place of delivery
Hospital 73 31 20
Home 5 1 0 0.42
Maternal Intrapartum complications
No 67 29 19 0.47
Yes 11 3 1
Maternal Postpartum complications
No 59 31 20
0.002
Yes 19 1 0
Neonatal complications
No 60 31 20 0.003
Yes 18 1 0
Table 4: Multivariate analysis of quality of antenatal care with perinatal and postnatal outcomes
Factors unadjusted estimates Adjusted estimates p value
OR 95% CI for OR OR 95% CI for OR
Gestational age at birth 8.3 5.6-16.9 9.1 3.4-17.7 <0.01*
Maternal postpartum complications. 5.3 4.5-18.3 6.4 3.4-20.7 <0.01*
*statistically significant at 5% level
dISCuSSION
Antenatal care is a type of preventative care with the goal of providing regular check-ups that allow doctors or midwives to treat and prevent potential health problems throughout the course of the pregnancy while promoting healthy lifestyles that benefit both mother and child.3,4 Recommendations on management and healthy lifestyle changes are also made during regular check-ups.5,6There are a number of outcome indicators used to monitor and evaluate maternal health care services internationally.7, 8 The aim of antenatal care is to ensure early registration of all pregnant women in antenatal clinics and timely identification and referral of complicated or high risk cases, thereby improving perinatal and postnatal outcomes. To this end, women are educated about hygiene, nutrition, immunization, breast-feeding, family planning, and danger signs of pregnancy and labor.9,10,11 The present study sought to identify whether there was any tangible benefit to the mother and baby by including laboratory investigations and obstetric ultrasound in the package of antenatal services.
In a study conducted on Outcome of Antenatal Care in an Urban Slum of Delhi, 12it was seen that outcome of pregnancies in terms of perinatal deaths, low birth weight and maternal deaths improve significantly for women who have at least two antenatal check-ups. Other studies have also reported a higher mortality in cases with no antenatal checkup.13, 14, 15
NFHS 4 survey for Karnataka16reported thatonly 32.9% women received full ANC (at least 4 Antenatal visits, tetanus vaccine and iron-folic acid tablets) as compared tothe present study where all the 130 women had received full ANC. The proportion of women who had undergone routine laboratory investigations, however was only 40 % in our study, which was lower than the NFHS-3 rate of 59.5%. Obstetric ultrasound was undergoneby only 15.3% of women in the present study, which again was much lower than the 23.5%
ultrasound rate reported by NFHS-3. These lower rates of laboratory investigations and ultrasounds are alarming considering that our study found that women who did
Indian Journal of Public Health Research & Development, April-June 2018, Vol.9, No. 2 139 not have these investigations done had significantly
poorer perinatal outcomes. The common reason for not undergoing laboratory investigations was that the nearby primary health centre did not have stock of the kits required to perform these investigations and the women could not afford to pay for these tests at a private laboratory. Similarly, the women who did not undergo an ultrasound, stated financial difficulty as the reason.
In India, 9.7% babies are born preterm17, and over one in five (23%) babies born in rural India are of low birth weight, that is weighing less than 2.5 kg.18 However, in the present study, the proportion of low birth weight was much higher at 36.9% and mothers who had received only basic antenatal care were significantly more likely to deliver a low birth weight baby. One probable explanation is that laboratory investigations can detect anaemia, which if corrected can improve birth weight and lower the risk of preterm labour,19,20,21 Obstetric ultrasound can detect intrauterine growth retardation which can be corrected with supplementary nutrition.22
The present study found a significant reduction in perinatal mortality among women who had undergone laboratory investigations with or without an ultrasound, in addition to basic antenatal care. This finding was similar to that in a meta-analysis of 15,935 pregnancies from four randomized controlled trials, where perinatal mortality was found to be significantly lower among women who had a routine obstetric ultrasound.23 However, Cochrane database reviews of eight trials with 27,024 women24 and of eleven trials with 37,505 women25, and a study in Israel26 over a 4.5 year period, did not find any benefit of ultrasound scans in pregnancy in terms of improved perinatal outcomes.In the present study it was found that adverse perinatal and neonatal outcomes like stillbirth or neonatal deaths, preterm delivery, low birth weight, maternal postpartum complications and neonatal complications were significantly lower as the quality of antenatal care improved.
CONCluSION
Better perinatal and postnatal outcomes were found among women who had undergone laboratory investigations with or without ultrasound, in addition to basic antenatal care. It is recommended that all women must undergo basic laboratory investigations as a part of routine antenatal care. The public health system should
ensure that the required testing kits are stocked at all Primary Health Centres to increase access to laboratory investigations.
ethical Clearance: Taken from St. John’s Medical College Institutional Ethical committee
Source of support: Nil Conflict of interest: Nil
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