Table of Contents
Antenatal care in Low-middle income country.
The importance of antenatal care.
Maternal mortality across the globe.
Appropriate Antenatal care.
World health organization models Antenatal care.
Significance of the Study.
Literature review aims.
Results and Discussion.
Health care factor.
Despite all the efforts made during the Millennium Development Goals (MDGs) era worldwide, the proportion of maternal and perinatal morbidity and mortality remain inadmissibly high (Blencowe et al., 2016). The maternal mortality rate in low-income countries is about 462 per 100000 live births versus 11 per 100000 live births in high-income countries. Women in less developed countries on average have more pregnancies than women in a developed country that increase their risk fo death with complications associated pregnancy (World Health Organization, 2019). Above 94% of these maternal deaths occur in Low-Middle-Income Countries (LMICs) and are avoidable as they are directly related to the surrounding resources. The increased rate of the maternal mortality rate is due to the uneven resources, decrease chances affordability, disturbed health care service system (UNICEF, 2019). The deaths occurring in Lower and middle-class countries is about 196 000 (68%) of the women died in sub-Saharan Africa (SSA) region and 58 000 (19%) in South Asia. Additionally, the lifetime risk of maternal deaths in high-income countries is 1 in 5,400, compared to 1 in 45 in low-income countries that directly demonstrate a great disparity in the health system across all regions (UN IGME, 2017).
One of the methods that can be utilized to reduce the maternal mortality rate includes Antenatal care that helps to deliver the important services that are required pregnancy to reduce complication. The services related to the Antenatal care are important for the female during and after the pregnancy the services provided in the low-income countries is about 24% on the other hand 81% in the high-income country (Jiwani et al., 2020). The low Antenatal care in the lower and middle-class income countries is due to lack of proper health care services that are provided to the mother and the child. The different quality of services that are required to provide the best Antenatal care includes different services. The first resource includes a structure that includes infrastructure, management and staffing. The second resource that is utilized includes the technical facility, functional facility and patient experience. The third aspect includes patient follow-ups; health outcome and patient return visits. The lower-income country lacks the Antenatal care facility due to decrease number of resources that enables them to provide accurate maternal care (Amo-Adjei et al., 2018).
There is a huge difference between the integrated care system in the lower and high-income countries and they directly affect the health sector service pattern. Some enablers that are associated with the high-income country include better governance arrangements, proper funding arrangement and integrated budget concerning health care facility, inter-organizational and interpersonal relationship. These factors improve the health care services of the high-income country that enables them to provide accurate Antenatal care. Some of the barriers that are faced by the lower and middle-income country include decreased funding, limited capacity, poor and fragmented health management, poorly coordinated system and under-resourced (Mounier-Jack et al., 2017). In lower and middle-income countries only 59% of pregnant women receive skilled birth attendants between 2012-2017 compared to more than 90% in High-Income Countries (World Health Organization, 2019). As maternal and neonatal healths are closely linked, pregnancy and childbirth complications are more likely to also affect the pregnancy outcome. Hence, worldwide, thousands of stillbirths and millions of neonatal deaths occur every day with some of the neonates developing lifetime complications (Lassi et al., 2019).
Antenatal care (ANC) also known as prenatal care or pregnancy care is the healthcare service provided to pregnant women and adolescents from conception to childbirth. The ANC is considered to be appropriate that are provided to the mother and child to prevent, detect and treat the risk factor that can lead to a complication during pregnancy (Kuhnt & Vollmer, 2017). The purpose of ANC is to ensure pregnant women receive sufficient services that contribute to positive pregnancy experience. There is a need to improve the understanding of the health care professional regarding the care process of pregnant women as it needs to be multifactorial to address her both medical and non-medical issue. The health care professionals are expected not only to help the mother on medical bases but also provide the social and mental help to the mother to reduce chances of complication (EBCOG Scientific Committee, 2015). These services include screening and identification of risk factors, early diagnosis and provision of timely and appropriate intervention, as well as prevention of potential health problems the woman may experience during pregnancy.
Ten principles are associated with the focused ANC which should be followed during the care process. The principle includes friendliness environment for women, person-centred care, proper assessment and management, family equal participation, culturally competent care, health promotion, community commitment, integration of accurate care, referrals and appropriate tests (Oshinyemi et al., 2018). The ANC is important as to help detect some disorder that can previously present but inappropriate care can lead to increase complication during pregnancy like hypertensive disorders, diabetes, cardiac conditions, non-pregnancy infections in particular HIV and AIDS, sexually transmitted infection (STIs) especially syphilis, tuberculosis (TB), malaria, tetanus and malnutrition. The lower and middle-income country lack proper facility thus the rate of infection during pregnancy is high that increase the need for the ANC program that can help to reduce maternally and child morbidity and mortality rate (Kuhnt & Vollmer, 2017).
The ANC is considered to play a central role in the continuum care as it utilizes the set framework to understand the different factors that are associated with maternal, new-born and child health. The health care professionals are expected to utilize their skills to educate and engage with women to provide current health status associated care. ANC should be provided by a skilled ANC provider to ensure a positive pregnancy experience to the pregnant woman and support the neonate health status. Additionally, ANC provides an opportunity for the skilled ANC provider to offer women-centred health education that promotes modification of lifestyle to the pregnant woman, her partner and where possible the family (McNellan et al., 2019).
The ANC is considered to be support services for the women during the pregnancy and it is based on three par that includes screening for an adverse event, therapeutic intervention concerning the health and educational program for women. Further, the health education session with the pregnant woman focuses on promoting healthy pregnancy, clean and safe childbirth, safe transition to postnatal care such as immediate care and exclusive breastfeeding of the neonate, and helping the woman to make an optimal decision on the spacing of their subsequent pregnancies as well as counselling and/or provision of family planning (Al-Ateeq & Al-Rusaiess, 2015). Through the education component, ANC connects the pregnant women and her family with an appropriate health facility and is associated with a high probability of improved maternal and fetal health during pregnancy, access to a skilled birth attendant, the provision of essential care for the neonate and postnatal care (van den Broek, 2019).
Worldwide, close to 75% of all maternal deaths are due to direct causes such as ante and postpartum haemorrhage (27% of deaths), infections (11%), hypertensive disorders of pregnancy such as pre-eclampsia and eclampsia (14%), complications from birth (10%) and unsafe abortion (8%) (UNICEF, 2019). On closer inspection, the comparisons between LMICs and HICs and maternal mortality are notable. The mortality rate in the LMICs is considered due to the lack of resources and skills that can be improved which directly help to decrease the mortality rate. The major cause of maternal death is haemorrhage accounting for 659 000 (27.1%) of maternal mortality in LMICs compared to 2 400 (16.3%) in HICs. In the highly affected regions SSA and South Asia, haemorrhage accounts for 321 000 (24.5%) and 238 000 (30.3%), respectively. These can directly be reduced or managed if resources are properly utilized to provide accurate antenatal care to the mother (Say et al., 2014)
The fewer resources and decrease skill directly reduce the chances of the LMICs to provide accurate antenatal care to the women that help to support the pregnancy. The good quality of antenatal care is required to prevent and detect the potential issue before the time that can increase the complication of the mother as well as the baby. There is great health care inequality in the Antenatal care section in the LMICs and the care procedure also differ concerning the GDP of the country. There is a need to improve the antenatal care procedure to fill the gap between the actual antenatal care and care present in the LMICs.
The actual antenatal includes four visits of the women to the nearby antenatal care service that can be utilized to continuously monitor the women and baby health status. The first visit helps to evaluate the maternal health status for the base of the whole antenatal care procedure and visit schedule (World Health Organization, 2019).
During the first ANC visit, pregnant women are enrolled in care and given an ANC card or file to carry during pregnancy. The health care providers screen, treat and provide the preventative measure to the women followed by developing birth and emergency plan. During this visit, the skilled ANC provider obtains comprehensive medical history from the pregnant women such as obstetric and gynaecological history (including current pregnancy), medical, surgical, family, social and substance use history, allergies. Also, a systematic examination of the woman from head to toe including lung and heart functions as well as abdominal examination (inspection, palpation and auscultation) is carried out. Later, in the process several investigations mainly blood tests including blood group and rhesus factor, full blood count, hepatitis B, rubella, syphilis, HIV, TB and genetic testing are conducted according to standards guidelines (Hodgins & D’Agostino, 2014). The further visit for the mother will be planed according to the current health status and individual preference.
One of the models that are utilized for the care procedure for pregnant women is Focused Antenatal care model that aims to improve the health of pregnant women. The FANC model uses a goal-oriented approach and requires women to attend at least four ANC visits with the first visit scheduled within the first trimester and not later than 16 weeks of gestation. These visits should be between 8th week and 12th week, a second visit between the 24th week and 26th week, a third visit on the 32nd week and the final visit between the 36th week and 38th week. The program helps to provide the quality of care by a package of services that promote the health wellbeing of the women during pregnancy. This model is utilized by the low and middle-income country to improve the health care system for pregnant women (Mchenga et al., 2019). However, with the growing concern regarding maternal and perinatal deaths, researchers conducted investigations before the wrapping up of MDGs to inform the WHO on the best approach to be implemented post MDG era. Findings from different researchers associated increased perinatal and maternal mortality with reduced ANC visits (FANC) (Downe et al., 2018).
In a retrospective audit of perinatal deaths in South Africa reported a peak in stillbirths occurring between 35 and 38 weeks of gestation and where there was a spacing of 6 weeks between ANC visits in the site which are providing the FANC model compared to when ANC continued to be offered fortnightly (Lavin & Pattinson, 2017). Furthermore, a Cochrane review study conducted by Dowswell et al. (2015) concluded that two or three ANC visits during the third trimester are not sufficient to detect and manage women at risk as well as providing preventive measures for stillbirths and preterm births thus increasing the risk of perinatal deaths. Therefore, based on research evidence the WHO reviewed the FANC model and endorsed a new evidenced-based ANC model aiming at improving materno-foetal and neonatal health.
On 07th November 2016, the WHO released a new ANC model which embraces a human right-based approach centred around the pregnant woman and her family and aim at prevention of mortality and morbidity (Tunçalp et al., 2017). The World Health Organization (2016) recommends all pregnant women receive qualityare throughout the continuum of reproductive health care. Additionally, the model increases the number of contacts to at least eight, with the first contact scheduled within the first trimester and subsequent contacts scheduled at 20, 26, 30, 34, 36, 38 and 40 weeks of gestation (World Health Organization, 2016). As the third trimester is associated with a high risk of developing conditions such as hypertensive disorders of pregnancy, fetal growth restriction (FGR), unexplained intrauterine deaths, increasing the number of contacts during this time can facilitate detection and timely interventions for these conditions (World Health Organization, 2016a). For instance, measuring blood pressure will detect a woman with high blood pressure that warrants a referral to an appropriate health professional and health facility. The provision of this model is closely linked with improved maternal and neonatal health outcomes (Vogel, J; Mbuagbaw et al., 2015).
In 2017, global statistics suggest that approximately 86% of all pregnant women received at least one ANC contact with skilled health personnel, and 65% received at least four antenatal contacts. The data related to the LMICs indicate that only 46% of the women have attended one or more ANC services that directly indicate the health care service disparity (Tikmani et al., 2019; UNICEF, 2019a). Although the evidence suggests improvements in access and utilization of ANC services, the majority of pregnant women in LMICs do not receive the minimum recommended ANC contacts of at least eight per pregnancy (World Health Organization, 2016b). Research suggests there is a link between maternal and perinatal mortality and morbidity and a lack of, or inadequate ANC services (Rurangirwa et al., 2017), therefore, early access, adequate and appropriate ANC with a skilled healthcare provider is required in LMICs to improve maternal health and reduce maternal and perinatal mortality.
Notably, skilled birth attendants and adherence to clinical guidelines is also associated with positive pregnancy outcome (Sharma et al., 2018). As a result, obstetric complications during labour and birth such as haemorrhage (antepartum and postpartum) and obstructed labour as well as the proportion of women who give birth at home in the absence of skilled healthcare provider will be reduced. The reduced facility at home can lead to increase complication for the women with increased risk for the baby and 29% of the women encounter pre- or post-delivery complication in LMICs (Islam & Sultana, 2019). The systemic review aims to understand the level of the Antenatal care in Low and middle-income country that can be utilized to improve the care procedure.
Recently, global priorities focus on reducing global maternal mortality up to 75 % by improving the antenatal facilities. There are the different factors that contribute the to increase maternal mortality and neonatal death this there is need to identify the gap in the service process to improve the lifestyle of both mother and baby. The better understanding level to improve quality of care by increasing the understanding of the attendants to ensure a positive pregnancy experience for the pregnant women, her baby and the family (Alkema et al., 2016). The evidence from this review will furnish healthcare professionals, policymakers and stakeholders with evidenced-based information that support the development of contextualized and appropriate strategies to promote early seeking of maternity care behaviour among pregnant women in LMICs. Moreover, the review will also help in developing strategies to promote early initiation of not only ANC but maternal care services in LMICs. The review will help to understand the gap in the health care system concerning a different country that can be addressed by policies, health care setting or health care providers to improve the quality of antenatal care.
The study is going to utilize the interpretivism approach as the research paradigm in the study to improve the structure of the research. The interpretivism approach relies on the social construction of the realities and it utilizes the qualitative to understand the social phenomena concerning a different individual (Rehman, & Alharthi, 2016). The research design for the study will be exploratory as it is going to analyse the qualitative data. The exploratory research design is utilized in the field was low research has been initiated and it helps to provide the theoretical idea concerning the topic (Wright et al., 2016). The inductive approach will be preferred for the study as it helps to accurately analyse the qualitative data concerning the topic. The inductive approach helps to elaborate on the issue and theory can be framed after evaluating different observation concerning different researcher (Rahi, 2017).
The sample size for the research includes seven articles that are extracted after searching over many databases. The non-probability sampling technique is preferred during the study to retrieve more relevant data concerning the study that can increase help to evaluate accurate data. The purposive sampling technique out of others as it helps to provide the preferred information by deliberately preferring the particular sample to improve the regarding the particular sample (Taherdoost, 2016). The data collection tool that was utilized in the study is peer-reviewed journal articles as they are considered to be a reliable source for the study. The peer-reviewed journal article provides accurate information concerning the topic that helps to improve the quality of the study (Kabir, 2016).
This literature review will investigate why limited access to antenatal care in LMICs is a concern for women and their neonates, and how well the WHO antenatal care guidelines (year) have been implemented into LMICs. The purpose of this literature review is to inform the systematic review for this thesis where the factors that contribute to late initiation of antenatal care will be thoroughly explored. This review will analyse existing evidence on the antenatal care, access for pregnant women and implementation of WHO ANC guidelines in LMICS and provide a full report of the findings. The aim of the literature review is in two-folds:
Against the above background, this literature review sought to find out limited access to antenatal care in low-middle income countries an issue for women and their neonates. Another aspect that is going to address by the literature includes how the World Health Organization antenatal care guidelines implemented in low middle-income countries.
A systematic search was undertaken on 01st April 2020 by utilizing the Monash University library databases, OVID Medline, Embase, EBSOHOST CINHL, ProQuest, Scopus, Web of Science and Google scholar. The WHO library was also searched to identify literature on the current status on the implementation of the ANC guidelines in LMICs. The MeSH terms and text words used were, “antenatal care” OR “prenatal care” OR “antepartum care” OR “pregnancy care”, AND “World Health Organization guidelines”, OR “guidelines” OR “antenatal care model” OR “ANC guidelines” AND “low-middle-income countries” OR “developing countries” OR “third world countries” OR “resource-limited” LMICs”. Search for this literature review was limited to studies published in the last 5 years (2015 to 2020), in the English language only and focussed on LMICs. All quantitative and qualitative studies were included. A systematic approach to screening title and abstract followed by the screening of full-text articles resulted in 13 full-text articles included in the findings of this review shown in a PRISMA flowchart (Appendix 1). The included studies are then summarised in a Matrix Table (Appendix 2).
The study has analysed 15 different articles to understand the gap in the health care system of the Low-middle income countries that is increasing disparity. After the data analysis, it was revealed that not one or two many factors have directly deteriorated the health care facility related to the Antenatal care which has directly impacted over the mortality rate of the mother and the newborn. Many complications are associated with the limited access postpartum bleeding, unexplained abortion, uterine rupture, HIV, Hepatitis, anemia, haemorrhage and bleeding.
The findings reveal that both individual and health care factors have differently influenced the accessibility toward the antenatal car and these factors directly increase the complication of the women and newborn.
The individual factor that has directly decreased the chances of the mothers to avail the antenatal services includes different aspect. The education is considered to be on the important factor that has directly decreased the chances to avail the health care facility. Decrease education directly reduces the chances of the mother to understand and avail antenatal services that can help to improve the quality of life. Age is also one of the factors that have a direct influence over getting the appropriate antenatal services. Increasing age directly increases the carelessness and new mothers are more aware of avail antenatal services. Ethnicity was also one of the factors discussed in the article that can influence the rate of ANC visits. Some different beliefs have a different tradition and practise that directly resists the individual to avail such services. Reduced health literacy directly resists the individual as they are unable to understand the different health associated aspect. Mother autonomy is also one of the factors that can directly influence the rate of getting appropriate care.
Reduced resources are one of the major issues faced by the low-middle income country and it directly resists the health care setting to provide accurate antenatal care services to the mother. The culturally competent skill of the staff also influences the rate of the ANC care services as they are in direct contact with the patient which directly influences the patient experience. The reduced number of health care service point directly decreases the chances of rural women to avail ANC services. The reduced skills of the health care providers are also one of the issues that directly restrict the proper utilization of the ANC services by pregnant women. The decrease awareness of the population regarding antenatal care and its importance due to decreased promotion from the health care setting directly reduce the chances that pregnant women avail antenatal services.
The study directly reveals that there is a great disparity in the health care setting concerning the antenatal care service. The limited accessibility toward the antenatal care directly increases the complication of mother by increasing risk for multiple disorder. The decreased availability of the antenatal care service directly increased the chances of the mortality and morbidity in the mother and newborn also. This there is needed to reduce the disparity in the health care system to improve the antenatal care services. The strength associated with the study includes the use of peer-reviewed journals, utilizing updated data and the use of different databases all these factors have helped to improve the quality of the study. The certain limitation associated with study includes small sample size and non-probability sampling can hamper the resulting quality. The study can be utilized in future to improve the health care system concerning improve the antenatal care procedure.
The study indicates there is a need to improve the health care facility to provide accurate care to the pregnant women in low-middle income country. Further research can explore the different strategies that can be applied to improve the care and help to improve the rate of ANC visit which will directly reduce the mortality rate of pregnant women and newborn. The study can be utilized as a base to further research over the topic and improve the antenatal utilization in a health care setting.
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