We approach the countdown for the MDG5 for improved maternal health [
Generally, guidelines for FANC have not been fully implemented in low-income settings [
In Ethiopia, maternal mortality rates have been among the highest in the world, although currently there are indications of a marked decline [
The aims of this study were to analyse if the health system priorities matched the user expectation and to assess the needs for ANC strengthening for improved maternal health in the Jimma area of Ethiopia. The specific objectives of the quantitative component were to analyse the content of ANC and to identify the predictors of low ANC satisfaction, while the specific objectives of the qualitative component were to understand perceptions, practices, and policies of ANC.
The study was a needs assessment aimed at informing the development of a complex intervention study that would test the feasibility of ANC strengthening in Ethiopia. We applied the WHO guidelines for FANC as the best practice for efficient care, and the present paper provides an in-depth understanding that can guide adaption of FANC to the Jimma context. Using the terminology from the British Medical Research Council (MRC) guidance on complex interventions, this needs assessment is contributing to the initial phases of trial development, where the program theory is developed and modelled [
The study was conducted in Jimma city, which has a population of 121,000, and in the surrounding urban communities of Serbo and Agaro. The ANC program of all public health facilities in the area was studied, four health centres (Jimma Town, Higher 2, Serbo, and Agaro) and one hospital (Jimma University Specialized Hospital). The hospital serves as a referral site and provides specialized care for southwestern Ethiopia, with a catchment population of about 15 million, and ANC service is provided for women with complicated as well as uncomplicated pregnancies. At the health centres, pregnant women from the nearby urban and rural communities are seen, and primary health care services (including ANC, delivery services, postpartum care, and family planning) to all population groups are provided. The registration system is poor, but an estimated 6,500 pregnant women are seen at the facilities per year. All facilities are training sites for all types of health care professionals.
Field work was conducted in the study area from August 2008 to August 2009 by SFV, with linguistic, cultural, and logistical support from AT.
The quantitative component was a questionnaire survey at the household level. All women residing in the study area who gave birth in the year preceding the interview (date of birth from April 28, 2008, to June 20, 2009) were invited to participate. We collected information about the use of and experience with health facilities during the last pregnancy, and women were asked to recall the content of care received during ANC. The questions were based on the components of care recommended in the WHO FANC model and were inspired by the Ethiopian Demographic Health Survey [
The qualitative component included observations at ANC facilities, in-depth interviews with recent mothers and health system leaders, focus group discussions (male spouses and TBAs (Traditional Birth Attendants)), and workshops with health professionals. Observations took place regularly at all ANC facilities, adding up to 20–40 hours per site, and were focused on the infrastructure, availability of technology, types of health staff, and interaction between user and provider. Extensive field notes were taken based on these observations.
In-depth interviews were conducted with 13 recent mothers (20 days to 5 months after delivery) to understand their perceptions and experiences regarding pregnancy and utilization of ANC. We used purposeful sampling to capture the variation in ANC service delivered at different levels of care, women who followed ANC at hospital (3) or health centre level (6) or did not have any ANC at all (4). The ANC attendants were selected from the ANC archive and nonattendants from the archive of childhood immunizations. The tracing of women was difficult and time consuming due to incomplete registration at facility level and an informal address structure in the community. Apart from level of care, the sampling was therefore based on convenience. The women were interviewed in their own households by SFV and AT. Interview guidelines were developed in the local setting together with health professionals, pilot tested, and translated into the local language. The interviews were semistructured and took 25 to 45 minutes.
A focus group discussion with eight male spouses visiting Jimma Town Health Centre was conducted to gain information about their perceptions of pregnancy and to understand decision-making processes at the family level. These men attended the facility for different purposes on the day of the focus group. Further, a focus group discussion with 12 TBAs, who were recruited through a local nongovernmental organization (Family Guidance Association), was conducted to explore their roles regarding pregnancy and delivery at the community level. The discussions were conducted in the local language and facilitated by AGM. All interviews and discussions were recorded and later transcribed and translated into English.
Workshops with clinical staff members were conducted at Serbo, Jimma Town, and Higher 2 Health Centre and at the hospital (no physicians participated). The workshops consisted of two hours of group-based discussions on strengths, weaknesses, and solutions in ANC provision. The groups subsequently presented posters with their main perspectives for the rest of the group. Key informant interviews were performed with health authorities from the Town Health Bureau and managers from the obstetric department at the hospital in order to understand their perceptions of the organisation of the service as well as the regional and national priorities.
The survey data were analysed using mixed effect logistic regression to identify predictors of being dissatisfied with the service. Health facility was analysed as the random effect parameter to adjust for the potential clustering of women using each health facility. Further adjustment was made for maternal age, socioeconomic status, and number of ANC visits. All analyses were performed in STATA 11.0 (StatCorp, Texas, USA).
The initial analysis of the qualitative interview data and focus group discussions was based on domain analysis [
The quantitative and qualitative analyses were carried out with a parallel approach [
Ethical permission was obtained from the Jimma University Ethical Review Committee of the College of Public Health and Medical Sciences, and permission to observe the practice at health facilities was obtained from the relevant town and zonal health bureaus as well as the hospital administration. All informants were ensured anonymity and confidentiality, and they gave their informed consent after appropriate explanation of the study objectives and content.
Of 1392 eligible women, 1364 (98%) consented to participate. The mean (range) age was 24.5 (15–46) years (Table
Background characteristics of 1364 women who had given birth within the previous 12 months in the Jimma area1.
Age, years, mean ± SD ( |
24.5 ± 4.7 (1357) |
Place of residence | |
Jimma | 71.6 (974) |
Serbo | 6.3 (86) |
Agaro | 22.1 (301) |
Maternal education | |
No school | 19.9 (271) |
Primary school | 46.1 (628) |
Secondary or higher school | 34.0 (464) |
Marital status | |
Single | 2.8 (38) |
Widow/divorced | 5.1 (69) |
Cohabitating | 92.1 (1254) |
Parity | |
Para I | 42.0 (566) |
Para II | 26.4 (355) |
Para III | 14.9 (201) |
Para IV+ | 16.7 (225) |
Outcome of last pregnancy | |
Singletons | 98.0 (1336) |
Twins and triplets | 2.1 (28) |
ANC attendance during last pregnancy | |
Yes | 83.1 (1132) |
No | 17.0 (231) |
Place of delivery | |
Health facility | 67.4 (904) |
Home | 32.6 (437) |
Almost 60% attended their 1st visit in the 2nd trimester (Table
ANC utilization patterns for 1132 women who had given birth within the previous 12 months in the Jimma area1.
ANC facility | |
Jimma Hospital | 31.9 (359) |
Higher 2 Health Centre | 13.0 (146) |
Jimma Town Health Centre | 19.1 (215) |
Serbo Health Centre | 4.9 (55) |
Agaro Health Centre | 22.2 (250) |
Others | 8.9 (100) |
Gestational age at 1st visit | |
1st trimester | 31.3 (336) |
2nd trimester | 57.8 (621) |
3rd trimester | 10.9 (117) |
Number of visits | |
1 | 3.1 (32) |
2 | 7.6 (80) |
3 | 19.7 (207) |
4 | 25.2 (265) |
5+ | 44.4 (466) |
Reported content of care, health staff practices, and ANC surroundings (%) by facility according to 1132 ANC attendants who had given birth within the previous 12 months in the Jimma area1.
Jimma Hospital |
Higher 2 HC |
Jimma T HC |
Serbo HC |
Agaro HC |
Other |
Total |
|
---|---|---|---|---|---|---|---|
Content of care | |||||||
Physical examination | |||||||
Blood pressure | 98.0 | 97.2 | 97.2 | 94.6 | 96.0 | 92.0 | 96.6 |
Weight measurement | 98.3 | 99.3 | 98.1 | 94.6 | 96.0 | 96.0 | 97.5 |
Abdominal examination | 95.8 | 86.3 | 86.5 | 96.4 | 66.8 | 83.0 | 85.2 |
Laboratory tests | |||||||
HIV test | 96.9 | 95.2 | 95.8 | 76.4 | 92.8 | 82.0 | 93.2 |
Blood analyses2 | 80.6 | 69.7 | 79.3 | 7.4 | 41.5 | 65.7 | 65.3 |
Urine analysis | 93.6 | 71.9 | 81.9 | 34.6 | 42.8 | 69.7 | 72.2 |
TT immunization | 85.7 | 95.2 | 97.2 | 76.4 | 95.2 | 91.0 | 91.3 |
Health education topics | |||||||
Danger signs during pregnancy | 44.1 | 29.9 | 38.9 | 18.5 | 30.8 | 46.5 | 37.2 |
Need for health facility delivery | 62.1 | 65.1 | 54.0 | 30.9 | 38.4 | 58.0 | 53.8 |
HIV and PMTCT | 61.1 | 50.7 | 54.0 | 35.3 | 64.0 | 51.1 | 57.2 |
Nutritional needs during pregnancy | 64.1 | 71.2 | 59.4 | 47.3 | 39.8 | 66.0 | 58.1 |
Breastfeeding | 59.6 | 58.2 | 58.2 | 47.3 | 46.8 | 59.0 | 55.7 |
ANC surroundings | |||||||
Waiting more than 1 hour preservice | 43.9 | 27.4 | 16.7 | 1.8 | 16.7 | 11.0 | 25.5 |
Poor cleanliness of institute | 5.0 | 0.7 | 0.0 | 3.6 | 13.3 | 1.0 | 4.9 |
Practice of health professionals | |||||||
Discomfort due to students | 36.8 | 15.2 | 23.0 | 25.5 | 26.0 | 13.3 | 26.3 |
Poor conduct of health professionals | 6.7 | 0.0 | 3.7 | 18.2 | 5.3 | 4.0 | 5.3 |
Nutritional practice of women | |||||||
Reduced food intake | 37.1 | 30.8 | 28.5 | 43.6 | 44.8 | 46.9 | 37.5 |
Iron supplementation | 6.8 | 5.6 | 4.2 | 1.9 | 0.8 | 9.1 | 4.8 |
Overall | |||||||
Not satisfied with service | 9.9 | 2.2 | 6.1 | 25.9 | 17.2 | 6.1 | 10.3 |
Lack of blood pressure testing, abdominal examination, HIV-testing, and TT immunization was not associated with satisfaction (Table
Predictors of being
Crude OR (CI) | Adjusted OR (CI)2 | |
---|---|---|
Physical examination | ||
No blood pressure measurement |
1.6 (0.7; 4.1) | 1.5 (0.5; 4.6) |
No weight measurement |
2.0 (0.8; 5.2) | 3.1 (1.0; 9.1) |
No abdominal examination |
1.0 (0.6; 1.7) | 1.0 (0.6; 1.9) |
Laboratory tests | ||
No HIV test |
0.6 (0.2; 1.5) | 0.7 (0.3; 1.9) |
No blood analysis, other |
2.2 (1.4; 3.4) | 2.3 (1.4; 3.8) |
No urine analysis |
2.0 (1.2; 3.1) | 1.8 (1.1; 3.0) |
No TT immunization |
1.0 (0.5; 1.7) | 1.2 (0.6; 2.5) |
No health education on need of health institution delivery |
2.8 (1.8; 4.3) | 2.7 (1.7; 4.3) |
Waiting more than 1 hour |
4.4 (2.7; 6.9) | 3.9 (2.4; 6.4) |
Poor cleanliness of health institution |
14.1 (7.6; 26.1) | 14.1 (7.3; 27.3) |
Discomfort due to students |
7.9 (5.1; 12.4) | 7.4 (4.6; 11.8) |
Poor conduct of health staff |
59.1 (28.9; 120.7) | 66.0 (29.7; 146.7) |
2Adjusted for maternal age, maternal education, and number of ANC visits.
Participants in in-depth interviews were women aged 18 to 32 years, most of whom were primiparous, but also women with three and four children were interviewed. They were housewives, students, employees, and day labourers. Nine attended ANC service; two did not attend at all; and another two had contact with the service but did not classify themselves as attendants: one because she never reached the awareness that ANC is a special program for follow-up care for pregnant women.
A central aspect shared by both women and men was that women were considered vulnerable while pregnant and hence needed to be taken care of by their husbands and relatives. For some women, pregnancy added to the worry associated with poor living conditions and concerns about how to take care of their family. In general, women and men made joint decisions about health practices during pregnancy. Relatives, especially the mothers of the pregnant women, also played a significant supervising role during pregnancy. Seeking health care was seen as a way to cope with the increased vulnerability of being pregnant. Overall, the women described ANC in positive terms.
According to our enquiries and observations, there were no ANC guidelines in Ethiopia. The only references to guidelines were a Ministry of Health poster and a training manual for health professionals found at health centres, both based on the FANC guidelines (with four visits per pregnancy). The booking of ANC visits followed the FANC guidelines at health centres, where, in contrast, the hospital recommended monthly appointments until 28 weeks, biweekly appointments until 36 weeks, and then weekly appointments until the birth.
At all facilities, health professionals and consultation rooms were dedicated to ANC provision. At some facilities, the ANC duty would shift among all staff; at others, one person was responsible. At the health centres, the permanent staff members providing ANC were all at the nurse or midwife level; however, occasionally, the service would be provided by students, alone or under supervision. At the hospital, the ANC facility was staffed by nurses who did the measurement of blood pressure and body weight, whereas all other physical examinations and consultations were provided by medical students, who cycled through the department every 14 days, which resulted in a lack of continuity of care. The students were providing service with reference to obstetricians, but the level of supervision was low, as the obstetricians were busy attending a high number of complicated deliveries and other teaching assignments. Further, at the hospital, collaboration problems between nurses and medical students were frequent. The nurses and midwives indicated that the medical students received more attention and feedback from the senior medical staff than they did, and this made them feel less appreciated. The nurses would not have authority over medical students, so nurses refrained from taking responsibility in the presence of medical students.
During observations we noted that there was a lack of alignment of procedures in the facilities where the staff rotated or students were in charge of the ANC service. This was visible in the registration procedure, which changed from provider to provider, as well as in the placement of the equipment. During visits to the clinics, it was difficult to find a person who took the lead of providing the ANC services. In contrast, at Serbo and Higher 2 Health Centres, one person was in charge of ANC, and this created continuity and a sense of leadership. At all facilities, a standard registration book had a fixed place. Though always present, the registration procedures were faulty with no basis for reflection or adjustment of procedures. It was observed that supervision of the ANC staff and practice was minimal, which seemed to lead to apathy in the service provision. The observed lack of continuity, thorough registration procedures, and supervision were not reported a concern by the health staff during the workshops. However, they did note that preventive services were not prioritized as much as curative services. The interviews with the senior health staff indicated that these issues were part of the clinical culture and that solving them was not a priority.
At the workshops, the health professionals themselves requested training on FANC, especially in-service training that could improve their skills during their normal working hours. They felt that it was challenging to provide good-quality service due to the lack of equipment and the low standards of the physical environment.
Serbo, Higher 2, and Agaro Health Centres only had laboratory facilities for HIV-testing and not for analysis of urine, haemoglobin, and syphilis and determination of blood group. Therefore, the staff referred ANC attendants to private clinics, where testing could be done based on user fees. At the hospital and Jimma Town Health Centre, the laboratory facilities were available, but, at the health centre, a minimum fee was charged: haemoglobin 3 ETB (0.17 USD), syphilis 3 ETB, blood group and Rh status 4 ETB (0.23 USD), and urine analysis 3 ETB. Iron and folic acid supplementation was not given for free at any site.
Women expected ANC service to be free, and therefore the costs of laboratory tests caused frustration. For some, tests were too expensive, and they gave up taking tests. This affected their satisfaction with the health centres: “
The women associated pregnancy and the need for health care with HIV, but with no other specific diseases. The health system in Jimma had previously received funding for HIV/AIDS activities, for example, training of staff. Our observations revealed that the staff members were more careful to provide good-quality service and to make thorough registrations for the PMTCT service than they were for the basic ANC service. The increased attention might be due to close follow-up and guidance by senior doctors, health authorities, and donor agencies.
Some women mentioned that HIV-counselling was provided, whereas the majority said that no health education was given. This inconsistency was supported by our observations, and the staff expressed a wish to improve the health education. The interactions between users and providers were dominated by the provider, and conversations were often formal and very limited. This seemed to be what both parts expected. Further, the women indicated that the service sometimes occurred without the expected content of ANC and that the staff sometimes delayed services, even though they were not busy. Poor conduct of health professionals was a recurring theme mentioned in the interviews. Both women and men reported that some health professionals had a reputation of purposely insulting the women.
A particularly important issue for the women and their partners was that ANC was not conducted in privacy, due to the presence of a high number of students. We observed that it was common to have five health providers in the room conducting ANC services for one woman. A woman put it this way: “
Some of the students were inexperienced and inadequately supervised. The women sometimes felt unsafe in their hands: “
In adjacent rooms, to which the doors could not close, other services were provided. A father recommended that if many health providers had to be present, the supervision and discipline should be improved: “
Poor conduct of staff was identified as a problem by the staff themselves, but they did not reflect on the issues of lack of privacy and the negative effect on the well-being of their clients.
The need for ANC strengthening was assessed using a mixed-method approach. There were no national guidelines for ANC in Ethiopia, and the providers in Jimma did not have support to give high priority to ANC. Within the health system, teaching of health professional students was given high priority, and that contributed to a lack of continuity and privacy for women. Poor user-provider interaction was a serious concern for the women, and contributed to a lack of trust in the providers. The interaction was deemed poor because of a combination of a poor privacy culture, a high number of students present, and a lack of dialogue and attention to the women’s individual needs. Therefore, we conclude that the women and the health system have different priorities, and, from the women’s point of view, the agenda of the health system compromises the care provided, and that hinders trust and mutual respect. Further, the care provision was compromised by inadequacies in leadership, supervision, skills of professionals, and routine registrations as well as a shortage of laboratory facilities. However, in the PMTCT services integrated in the ANC program, priority and funding made it possible to overcome these issues.
The measurement of satisfaction with care in the survey was relevant as an overall assessment of the women’s evaluations of the care received; however, satisfaction has previously been shown to be dependent on the expectations towards care [
In this study, 67% of the women gave birth in a health facility, which is higher than the national urban average (51%), but still lower than the ANC coverage (83%). Some studies show that the use of ANC predicts the use of health institution delivery [
This study revealed that both the health system and the women had high awareness of HIV, which may reflect how a vertical program can be well implemented in a less functional horizontal program. Both the high priority of HIV and the general health system falling behind have been described in other settings [
Although the importance of ANC for maternal health is under debate, the guidelines for FANC are based on best available evidence, ANC is implemented globally, and coverage is high. Therefore, it is surprising how poorly the FANC guidelines are implemented in low-income countries, including Ethiopia. Langley and Denis [
The survey is based on a relatively large study population, with a very high participation rate. We cannot preclude selection bias; socioeconomically disadvantaged women, women with stillbirths, and mothers who experienced infant deaths might be underrepresented. Nevertheless, we did everything feasible to ensure inclusion of all women: local female data collectors were trained and kebele guides assisted in identifying the women. The kebele guides facilitated the acceptance of the survey in the community.
The qualitative interviews with women were conducted in their own homes because it was assumed that they would be more comfortable there. This was an important step to reduce the effects it could have when relatively powerful people from the local community together with a foreigner ask questions about the health system. In general, the participants appeared happy to meet us and to reflect on the theme introduced. At the workshops with the health professionals, it was known by all that this study was part of a needs assessment for a future intervention. Therefore, the health staff had reasons to be strategic in their expressions. Further, the health centre leaders were present, and it might have been difficult to express critical perspectives on the local leadership, including perspectives on supervision, continuity, and job responsibilities, and this is one limitation that could possibly have influenced our data. However, the extensive field stay (SFV) and the participation of local researchers (DN, AGM, and AT) in this study alleviated this risk of bias and provided a strong background for developing interview guides and for the contextualisation and interpretation of the data [
The findings were relatively consistent, and this consistency enhanced the validity and relevance of our conclusions [
Data in this study stem from a single area in Ethiopia, and a discussion of transferability is relevant [
The focus of this study was the ANC system. However, the quality of this program depends on the health system it is nested in. On a large scale, funding and leadership are found to be cornerstones for health system strengthening in low-income countries [
It seems essential that ANC services should be given increased attention and that stronger leadership should be implemented with more supervision and monitoring of the service providers. Based on our findings, one suggestion for improved continuity of care could be to avoid job rotations. Further, if many health professional students have to be present during service provision, a different culture for how to approach the women could be encouraged. In other settings, it has been suggested that improved quality of care can be achieved by in-service training and improved supportive structures at managing levels [
Based on this needs assessment, an ANC strengthening intervention (the Maternity Study) is to be developed. According to the MRC guidelines for complex interventions, the intervention will be considered an exploratory trial, where the feasibility of implementing the intervention and its acceptability to providers and users will be tested [
The ANC program in the study area was not based on guidelines. The ANC coverage was high. Improvements are needed on guidelines development and implementation, upgrading of laboratory facilities, health education, and user-provider interaction as well as training of health professionals.
National and international decision makers need to be aware of the consequences of having one of the most utilized health care services running without guidelines and structured supervision, for example, inadequate quality of care and the loss of health professionals’ motivation and user’s trust in the health care system. More importance on the role of ANC in efforts to promote skilled birth attendance and maternal health is needed. However, it is clear that dedicated implementation of FANC takes strong leadership and we suggest supportive supervision of health care providers geared towards building trust and mutual respect to protect maternal and infant health.
The authors declare that they have no conflict of interests.
Sarah Fredsted Villadsen, Vibeke Rasch, and Henrik Friis conceived and designed this study. Sarah Fredsted Villadsen, Dereje Negussie, Abebe GebreMariam, and Abebech Tilahun conducted the study. Qualitative analysis and write-up of qualitative sections were done by Sarah Fredsted Villadsen and Britt Pinkowski Tersbøl. Sarah Fredsted Villadsen, Vibeke Rasch, and Henrik Friis did the quantitative analyses. All authors have contributed to the writing and approval of the final version of the paper.
This study is a part of the JUCAN Project (Jimma University/University of Copenhagen Alliance in Nutrition). The authors want to thank the JUCAN team for their support and logistical assistance. They thank all of the local stakeholders for their willingness to contribute. They thank the Jimma University Research and Publication Office for the permission to undertake the study. This study was supported by Danida, through the Consultative Research Committee for Development Research, and by the Danish Council for Independent Research, Medical Sciences, the Danish Society of Obstetrics and Gynaecology, and the Danish Research Network for International Health