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Introduction: The use of antenatal care (ANC) plays a major role in minimizing maternal and child mortality through effective and appropriate screening, preventive, or treatment intervention. Even though almost all pregnancy-related mortalities are largely preventable through adequate use of ANC, sub-Saharan Africa (SSA), particularly East African Countries, continues to share the largest share of global maternal, and newborn mortality. Therefore, this study assesses if educational attainment is associated with optimal ANC utilization in East Africa. Methods: A secondary data analysis was done based on Demographic and Health Surveys (DHS) from 2010 to 2018 in the 11 East African Countries. A total weighted sample of 84,660 women who gave birth in the 5 years preceding each country's DHS survey and had ANC visits were included in this study. Data processing and analysis were performed using STATA 15 software. A multilevel mixed-effect logistic regression model was fitted to examine the association of educational attainment and ANC utilization. Variables with a p-value < 0.05 were declared as significant factors associated with ANC utilization. Model comparison was done based on Akaike and Bayesian Information Criteria (AIC and BIC). Results: The magnitude of optimal ANC utilization in East African Countries was 56.37% with 95% CI (56.03, 56.69) with the highest optimal ANC utilization in Zimbabwe (80.96%) and the lowest optimal ANC utilization in Rwanda (44.31%). Women who had higher education levels were more likely to have optimal ANC utilization, compared to those with no education (AOR = 2.34; 95 and CI; 2.11– 2.59). Women who had media exposure were more likely to have optimal ANC utilization than those who have no media exposure (AOR = 1.07; 95% CI; 1.03, 1.10). Conclusion: Antenatal care utilization was low in East African countries. Educational attainment, maternal age, wealth index, birth order, media exposure, and living countries were factors associated with ANC utilization. Efforts to improve antenatal care and other maternal health service utilization in East Africa must take into account these factors. Specifically, working on the access to mass media by women may also improve antenatal care utilization. [ABSTRACT FROM AUTHOR]

Introduction: early commencement of antenatal care by pregnant women as well as regular visits has the potential to affect maternal and fetal outcomes positively. Even with antenatal care, the intervention requires fewer resources; however, most pregnant women in sub-Saharan Africa have begun late for antenatal care services. This study aimed to assess the magnitude and contributors of late antenatal care initiation among pregnant women at selected public health institutions of the Bench-Sheko Zone in southwest Ethiopia. Methods: a cross-sectional study was conducted among 509 pregnant women attending the Antenatal Care (ANC) service at selected public health institutions. The data were collected using a structured and pre-tested questionnaire. The data were entered using Epi-data version 3.1 and analyzed using SPSS version 22. A binary logistic regression analysis was computed to determine the association using crude and adjusted odds ratios at 95% confidence intervals. Independent variables with a p-value of less than 0.05 in the multivariable logistic regression model were considered significant. Results: of the 509 respondents interviewed, 337 (66%) reported late antenatal care initiation. The factors associated with late antenatal care initiation were mothers aged 25 years and above (AOR = 1.59, 95% CI [1.02, 2.48]), attended below secondary school (AOR =2.33, 95% CI [1.05, 5.19]), unplanned pregnancy (AOR=2.25, 95%CI [1.34, 3.77]), pregnancy recognition by missing period (AOR=0.61, 95%CI [0.39, 0.93]), perceived right time of ANC after 4 months (AOR=2.29, 95% CI [1.36, 3.85]), and did not get advice to have ANC (AOR=1.64, 95% CI [1.10, 2.45]). Conclusion: the majority of pregnant women initiate their first antenatal care lately. We can conclude that late antenatal care initiation is a major problem in the study area. Therefore, providing continuous health education on the importance of initiating antenatal care visits early to prevent unwanted pregnancy outcomes is an important segment of intervention that can be done through health extension workers. [ABSTRACT FROM AUTHOR]

Background: In November 2016, the WHO four-visit focused antenatal care (FANC) model adopted in sub-Saharan Africa (SSA) was reverted to eight contacts or more as a response to reducing the global perinatal and maternal deaths and in achieving the sustainable development goal (SDG) 3. Women's empowerment, which connote the social standing, position and the ability of women to make life decisions and choices has been associated with the maternal health seeking behaviour and outcomes. This study examined the association between women's empowerment and the WHO ANC model of eight visits or more, and early first antenatal visit among pregnant women. In addition, we explored the association between women's empowerment and the WHO FANC model to allow for comparison for countries that have not adopted the recent WHO ANC model.Methods: The most recent (2018) Demographic and Health Survey (DHS) datasets conducted in SSA were used for analyses. We used all available indicators of women's empowerment captured in the DHS. The 30 variables on women's empowerment were classified into eight components using exploratory factor analysis. We fitted separate ordinal logistic regression to assess association between antenatal care utilization (number of visits and time of first antenatal visit) and women empowerment factors while adjusting for other covariates. Analysis was performed with STATA 15.0 and adjusted for complex survey design, p-value< 0.05 were used for interpretation of results.Results: The proportion of women who attended eight or more ANC visits were 1.4, 2.7 and 3.5% in Zambia, Guinea and Mali, respectively. Zambia had the lowest prevalence of 8 or more ANC visits also had the highest prevalence of at least 4 visits (63.8%) and early first ANC visit (38.2%), while Nigeria with the highest prevalence of women with at least 8 visits (17.7%) had the lowest prevalence (17.6%) of women that attended ANC visit in their first trimester. Women's empowerment was associated with more ANC visits and attending first ANC visit in the first trimester. However, these association with the women empowerment components varied significantly across the four SSA countries.Conclusion: This study highlights the significant impact of women's empowerment as a key factor for improving maternal health outcomes in SSA. It is imperative that government and development partners invest more on empowerment of women as part of strategic intervention to improve maternal health outcomes. [ABSTRACT FROM AUTHOR]

Background: There is plenitude of information on HIV infection among pregnant mothers attending antenatal care (ANC) in sub-Saharan Africa. However, the epidemiology of HBV–HIV co-infections in the same cohort is not clear despite the common route of transmission of both viruses. The aim of our study was to synthesize data on the prevalence of HBV–HIV co-infection among pregnant women attending ANC in Sub-Saharan Africa to assist in the design of public health interventions to mitigate the challenge. Methods: The study was done in tandem with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) standards and the Cochran's Q test, I2 statistics for heterogeneity and the prevalence were calculated using commercially available software called MedCalcs (https://www.medcalc.org). A random effect model was used to pool the prevalence since all the heterogeneities were high (≥ 78%) and Phet < 0.05 indicated significant heterogeneities. The risk factors and risk differences for HBV–HIV co-infection were analyzed. Any likely sources of heterogeneity were analyzed through sensitivity analysis, meta-regression and sub-group analysis. All analyses were done at 95% level of significance and a P < 0.05 was considered significant. Results: The overall pooled prevalence of HBV–HIV co-infection among pregnant mothers in sub-Saharan Africa was low 3.302% (95%CI = 2.285 to 4.4498%) with heterogeneities (I2) of 97.59% (P > 0.0001). Within regional sub group meta-analyses, West Africa had significantly higher prevalence of 5.155% (95% = 2.671 to 8.392%) with heterogeneity (I2) of 92.25% (P < 0.0001) than any other region (P < 0.001). Articles published from 2004–2010 had significantly higher prevalence of 6.356% (95% = 3.611 to 9.811%) with heterogeneity (I2) 91.15% (P < 0.0001) compared to those published from 2011 to 2019 (P < 0.001). The HIV positive cohort had significantly higher prevalence of HBV–HIV co-infection of 8.312% (95% CI = 5.806 to 11.22%) with heterogeneity (I2)94.90% (P < 0.0001) than the mothers sampled from the general population with a prevalence of 2.152% (95% CI = 1.358 to 3.125%) (P < 0.001). The overall and sub group analyses had high heterogeneities (I2 > 89%, P < 0.0001) but was reduced for South Africa (I2) = 78.4% (P = 0.0314). Age, marital status and employment were independent factors significantly associated with risk of HBV–HIV co-infection (P < 0.001) but not extent of gravidity and education level (P > 0.05). After meta-regression for year of publication and sample size for HBsAg positivity, the results were not significantly associated with HBV pooled prevalence for sample size (P = 0.146) and year of publication (P = 0.560). Following sensitivity analysis, the HBsAg pooled prevalence slightly increased to 3.429% (95% CI = 2.459 to 4.554%) with heterogeneity I2 = 96.59% (95% CI = 95.93 to 97.14%), P < 0.0001 Conclusion: There is an urgent need for routine HBV screening among HIV positive pregnant mothers attending antenatal care in sub-Saharan Africa to establish the extent of HBV–HIV co-infection in this cohort. Future studies need to investigate the putative risk factors for HBV–HIV co-infection and prioritize plausible control strategies. [ABSTRACT FROM AUTHOR]

Background: The estimated burden of maternal morbidities in lower-income countries, such as Madagascar, is high. However, there is still a lack of data on maternal morbidities, in part due to an absence of standardized assessment tools. This cross-sectional study aims to report maternal morbidities among 1015 women in the district of Ambanja, Madagascar, and to describe the advantages and limitations of a mHealth system. Methods: Data were collected using the PANDA (pregnancy and newborn diagnosis assessment) system, an mHealth device that incorporates the WHO recommendations for antenatal care (ANC). Data, including personal and medical information, but also clinical data such as hypertension, anemia or HIV were collected from more than 1000 women attending ANC. Results: A total of 1015 pregnant women were recruited from January 2015 to August 2018. The average age was 24.6 years old, and most women were married (82.3%). The majority lived in urban areas and were unemployed. Prevalence of hypertension and gestational diabetes was relatively low (4% vs 2.2%). Malaria infection was diagnosed in 2.2% and HIV was diagnosed in 1.2% of pregnant women. The most common morbidity was anemia (68.4%) and the only significant factor associated was being single compared to being married (OR 1.68, 95% CI 1.05– 2.70, p-value 0.032). Discussion: The prevalence of anemia in our study population was much higher than previously reported in Sub-Saharan Africa. This finding highlights the need for regular iron supplementation during pregnancy, especially in vulnerable (eg, single) women. The PANDA mHealth system provides unique opportunities due to its standardization of ANC and creation of a digital database accessible from a distance. However, one of the main challenges was that even a mHealth system such as the PANDA remains dependent on the local procurement chain. Therefore, future studies need to access opportunities of mHealth systems to support health service delivery. Trial Registration: Registered on ISRCTN on 14th October 2015, number ISRCTN18270380. Retrospectively registered. [ABSTRACT FROM AUTHOR]

Background: Anaemia and malaria are both major contributors to maternal and child mortality, and morbidity, with some of the worst outcomes occurring in sub-Saharan Africa. Point of care tests (POCT), if used appropriately, provide a simple, inexpensive form of diagnostic testing, as a reliable alternative when laboratory tests are not readily available. In such resource limited settings, clinical staff tend to rely on symptom-based diagnosis and presumptive treatment. This study uses qualitative methods to identify the current practice of POCT use for malaria and anaemia, to explore the enablers and barriers to effective implementation of these POCT, and to determine how relationships between each of the stakeholder groups may impact on POCT use.Methods: Staff (clinical and laboratory) and patients (pregnant women) at three antenatal care facilities within the Ashanti Region of Ghana participated in interviews and focus group discussions (FGDs). An initial coding framework was developed based on the pre-defined objectives of the study. Thematic analysis was used to identify subthemes and categories within each of the key themes.Results: At the time data were collected all three facilities used malaria POCT either as an adjunct to microscopy, or as their only form of malaria testing. Although all three facilities were familiar with haemoglobin colour scale (HCS), none of the facilities used them routinely. Clinical staff perceived symptom-based diagnosis was a quick way to diagnosis because access to POCT during consultations was unreliable, but recognized disadvantages associated with symptom-based diagnosis. Perceived advantages of malaria and anaemia POCT were user-friendliness, improved diagnosis and opportunity for patient engagement, as well as lower cost implication for patients. Perceived disadvantages included likelihood of missed diagnosis of mild anaemia, as well as likelihood of human error leading to in accurate diagnosis which could impact on patient trust. Poor communication and lack of trust between staff groups was also identified as a barrier to effective uptake of POCT.Conclusions: Consistent supply of POCT as well as staff training and staff and patient engagement, are fundamental to successful uptake of POCT for effective malaria and anaemia management. [ABSTRACT FROM AUTHOR]

Background: Newborns are at greatest risk of dying at and shortly after the time of birth. Newborn mortality remains an urgent concern and is an important indicator of child health, development and well-being. Studies examining the effectiveness of antenatal care on maternal and newborn health outcomes have provided conflicting results. The aim of this review and meta-analysis was to determine the pooled effect of antenatal care on neonatal mortality in sub-Saharan Africa. Methods: We searched PubMed, Medline, EMBASE, CINAHL and Google Scholar from September to November 2016 and then updated our search on April 13, 2019. Two independent reviewers extracted data from eligible studies. The quality of each included study was assessed using the Risk of Bias Assessment tool for Non-Randomized Studies (RoBANS). The results were reported based on risk ratio (RR) with 95% confidence intervals (CI) using a random-effects model. Results: Eight hundred and ninety eight studies were initially identified. During screening, 23 studies were found to be relevant for data extraction. Of these, only twelve studies fulfilled the inclusion criteria and were included in the analysis. In five of the twelve studies included in the analysis, antenatal care service utilization had a significant association with neonatal mortality. The pooled risk ratio by the random-effects model was 0.61 (95% CI: 0.43, 0.86) for neonates born to women who received at least one antenatal care visit by a skilled provider as compared to neonates born to women who did not receive antenatal care. Conclusion: This review indicates that utilization of at least one antenatal care visit by a skilled provider during pregnancy reduces the risk of neonatal mortality by 39% in sub-Saharan African countries. Thus, in order to accelerate progress towards the reduction of newborn deaths, all pregnant women should receive antenatal care during pregnancy. [ABSTRACT FROM AUTHOR]

Abstract: Maternal and neonatal mortality are unacceptably high in developing countries. Essential nutrition interventions contribute to reducing this mortality burden, although nutrition is poorly integrated into health systems. Universal health coverage is an essential prerequisite to decreasing mortality indices. However, provision and utilization of nutrition and health services for pregnant women and their newborns are poor and the potential for improvement is limited where health systems are weak. The Community‐Based Maternal and Neonatal Health and Nutrition project was established as a set of demonstration projects in 4 countries in Africa with varied health system contexts where there were barriers to safe maternal health care at individual, community and facility levels. We selected project designs based on the need, context, and policies under consideration. A theory driven approach to programme implementation and evaluation was used involving developing of contextual project logic models that linked inputs to address gaps in quality and uptake of antenatal care; essential nutrition actions in antenatal care, delivery, and postnatal care; delivery with skilled and trained birth attendant; and postnatal care to outcomes related to improvements in maternal health service utilization and reduction in maternal and neonatal morbidity and mortality. Routine monitoring and impact evaluations were included in the design. The objective of this paper is to describe the rationale and methods used in setting up a multi‐country study that aimed at designing the key maternal and neonatal health interventions and identifying indicators related to inputs, outcomes, and impact that were measured to track change associated with our interventions. [ABSTRACT FROM AUTHOR]

Background: Health-related millennium development goals are off track in most of the countries in the sub-Saharan African region. Lack of access to, and low utilization of essential services and high-impact interventions, together with poor quality of health services, may be partially responsible for this lack ofprogress. We explored whether improvement approaches can be applied to increase utilization of antenatal care (ANC), health facility deliveries, prevention of mother-to-child transmission services and adherence to ANC standards of care in a rural district in Kenya. We targeted improvement of ANC services because ANC is a vital point of entry for most high-impact interventions targeting the pregnant mother. Methods: Healthcare workers in 21 public health facilities in Kwale District, Kenya formed improvement teams that met regularly to examine performance gaps in service delivery, identify root causes of such gaps, then develop and implement change ideas to address the gaps. Data were collected and entered into routine government registers by the teams on a daily basis. Data were abstracted from the government registers monthly to evaluate 20 indicators of care quality for improvement activities. For the purposes of this study, aggregate data for the district were collected from the District Health Management Office. Results: The number of pregnant mothers starting ANC within the first trimester and those completing at least four ANC checkups increased significantly (from 41 (8%) to 118 (24%) p=0.002 and from 186 (37%) to 316 (64%) p<0.001, respectively). The proportions of ANC visits in which provision of care adhered to the required standards increased from <40% to 80-100% within three to six months (X2 for trend 4.07, p<0.001). There was also a significant increase in the number of pregnant women delivering in health facilities each month from 164 (33%) to 259 (52%) (p=0.012). Conclusion: Improvement approaches can be applied in rural health care facilities in low-income settings to increase utilization of services and adherence to standards of care. Using the quality improvement methodology to target integrated health services is feasible. Longer follow-up periods are needed to gather more evidence on the sustainability of quality improvement initiatives in low-income countries. [ABSTRACT FROM AUTHOR]

Introduction Lack of information on the warning signs of complications during pregnancy, parturition and postpartum hampers women's ability to partake fully in safe motherhood initiatives. We assessed the extent to which women in 19 countries of sub-Saharan Africa recall receiving information about pregnancy complications during antenatal care for the most recent pregnancy, and examined the impact of advice receipt on the likelihood of institutional delivery. [ABSTRACT FROM PUBLISHER]

Background Iron deficiency anemia during pregnancy is a significant public health problem in sub-Saharan Africa (SSA) and is associated with serious adverse health outcomes. Although it is recommended that all women receive iron supplementation during pregnancy, little research has been conducted to measure overall compliance with this recommendation or variation across SSA countries. Objectives To assess prevalence and sociodemographic-economic factors associated with adherence to iron supplementation among pregnant women in SSA. Methods This was a weighted population-based cross-sectional study of 148,528 pregnant women aged 15–49 y in 22 SSA countries that participated in the Demographic and Health Surveys (DHS) in 2013–2018 and measured iron supplementation during pregnancy. Adherence to iron supplementation was defined as using iron supplementation for ≥90 d during pregnancy of the most recent birth. Results The overall prevalence of adherence to ≥90 d of iron supplementation during pregnancy was 28.7%, ranging from 1.4% in Burundi to 73.0% in Senegal. Factors associated with adherence included receiving ≥4 antenatal care visits [adjusted Prevalence Ratio (aPR): 25.73; 95% CI: 22.36, 29.60] compared with no antenatal visits; secondary or higher education (aPR: 1.17; 95% CI: 1.14, 1.19) compared with no education; wealthy (aPR: 1.13; 95% CI: 1.10, 1.16) compared with poor; and older women aged 35–49 y (aPR: 1.07; 95% CI: 1.05, 1.10) compared with younger women aged 15–24 y. Conclusions Adherence to iron supplementation during pregnancy in SSA is low and varies substantially across countries and in relation to factors such as number of antenatal visits, education, and level of family wealth. These results underscore the need for increased efforts to improve the uptake of iron supplementation for pregnant women in SSA. [ABSTRACT FROM AUTHOR]