Yeoh, Ping Ling (2016) Adequacy of antenatal care: Associated factors and pregnancy outcomes among women attending public health clinics in Selangor, Malaysia / Yeoh Ping Ling. PhD thesis, University of Malaya.
Abstract
Malaysia has remarkable achievement in maternal-child–health over past decades. Relevant tracers continue to be excellent, and there has been increasing number of antenatal visits. Recent progress in pregnancy outcomes however does not improve with equal pace: maternal mortality has been stagnant since over a decade, birth weight <2,500g was higher than neighbouring countries, and stillbirth doubling that of developed nations. These pose the questions related to limitation of coverage indicators and need for assessing adequacy of antenatal care. The purpose of this study was to determine adequacy of antenatal care, its associated factors and pregnancy outcomes. Adequacy of antenatal care included adequacy of utilisation and adequacy of content that were analysed separately. Wherein, adequacy of utilisation referred to the concept of Adequacy of Prenatal Care Utilisation Index which is defined by adequacy in initiation of care and observed-to-expected visits ratio adjusted for gestational age of delivery. Adequacy of content is defined as adequacy in compliance to recommended routine care. The study was conducted using retrospective cohort study design where data was extracted from individual records of public health clinics. The findings pointed to high proportion (63%) of intensive utilisation, with intensive utilisation noted among nearly 60% of low-risk women, while 26% of high-risk women did not have the expected intensive utilisation. The findings also highlighted inadequacy of routine care provided with 52% of women receiving <80% of recommended content; delivery of antenatal advice scored the lowest. High-risk had lower content score than low-risk (76% versus 78%, p=0.001). Women attended the smallest clinics had higher content score (80% versus 75-77%, p<0.001). Examining association between utilisation and pregnancy outcomes revealed that adequate utilisation appeared to lower the odds of preterm birth and maternal complications, compared to inadequate and intensive utilisation. Intensive utilisation however did not seem to lower the odds of preterm birth, low birth weight and maternal complications. Adequate content was significantly associated with lower odds (OR=1.00) of preterm birth than inadequate content (OR=3.72, 95%CI=1.58-8.72); but appeared to result in higher odds of stillbirth and maternal complications, indicating the influence of other aspect of care. The study presented several contributions to research on antenatal care adequacy. One, intensive utilisation does not seem to improve pregnancy outcomes. While it is justified for highrisk to have more frequent visits for additional care, there is no reason for low-risk to have higher number of visits than standard schedule. Two, over half of women had <80% of routine content indicates need to improve technical performance of care. All women should be given complete routine care. Three, the findings have resulted in an accompanying insight on the need to review the current guidelines, spinning from reviewing guidelines from countries with better pregnancy outcomes. Lastly, the methods used could be reviewed as to their utility in expanding monitoring and evaluation framework for improving quality and informing policy formulation. Further researches are required to assess how technical performance of routine antenatal care can be improved, in particular, delivery of antenatal advice. Future studies may consider qualitative study involving stakeholders responsible for guidelines and policy formulation, examining rationale of excluding and including certain practices.
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