During prenatal period, medical history of a pregnant woman (the woman and her baby) is largely depend on antenatal care (ANC). Antenatal care refers to caring of women during pregnancy, which ideally should begin soon after conception and continue throughout pregnancy. The primary aim of antenatal care is to achieve at the end of the pregnancy, a healthy mother and a healthy baby. Despite the fact is that, once a complication develop, ANC per see cannot save the life of the pregnant woman or the newborn baby. Nevertheless, there is overwhelming evidence that lack of antenatal care increases the risk of maternal mortality and newborn death. Risks of as high as over ten times among none-antenatal care attendants have been documented (Yego,
D'Este, Byles, Williams & Nyongesa 2014:38; Ngoc, Merialdi, Abdel-Aleem, Carroli, Manorama, Campodonico, Ali, Hofmeyr, Mathai et al 2006:699-705; Mashini 1984:275-279).
Attempts were made to retrieve the antenatal care cards of the deceased women; and, collect meticulous information on the antenatal care of the deceased newborn babies' mothers. Respondents of 74 maternal cases (56 percent) and 129 mothers of deceased newborn cases were claimed to receive antenatal care. However, it was only possible to recover 63 (47 percent) antenatal care record cards of the deceased maternal cases, and antenatal care information of 113 (40 percent) deceased newborn babies' mothers.
Among those cards recovered (N=63), 55 were found in different health facilities (hospitals, health centres and health posts) and the other eight with the deceased families. Among those retrieved within the health facilities, 38 were found filed in the deceased women's case notes, the other 17 were extensively searched and later found in different pool of many antenatal cards abandoned in drawers at the maternity ward.
The multiple places where they were kept the cards in the health facilities should be a cause for concern. Antenatal care cards provide valuable information to the woman, her newborn baby, her relatives, to the health care providers and to the health system including health researchers. This shows the confusion among care providers on who should keep the card when the woman dies. More surprisingly, only 23 of the 63 maternal cases (37 percent) had their medical and obstetric history documented, leaving a substantial number of the cases had their history not taken during prenatal care registration. The inconsistency in the filling of the cards should also be a concern.
The possible reasons for the poor filling of cards may be the inadequate staffing situation, time constraint on the part of the available staff or their lack of concern for records or record-keeping.
The quality of antenatal care (ANC) can be measured by the qualifications of the provider and the number and frequency of ANC visits. Antenatal care quality can also be monitored through the content of services received and the kinds of information given to women during their visits. The Ethiopian government also practices in the sense that these services raise awareness of the danger signs during pregnancy, delivery, and the postnatal period (MoH 2015b:4-29; MoH 2014a:14-20). It was also acknowledged that ANC visits improve the health-seeking behaviour of the client, orient
the client to birth preparedness issues, and provide basic preventive and therapeutic care.
Table 4.7 shows depiction of core aspects of ANC services utilisation by the deceased mothers and mothers of the deceased newborn babies. Forty-seven percent of maternal cases and 40 percent of the deceased newborn mothers evidently claimed that they had received ANC services during their last pregnancy. As per WHO recommendation, a pregnant woman should have at least four ANC visits (WHO 2002c:24). The findings shown in Table 4.7 depicts that only 20 percent of maternal cases and 16 percent of the deceased newborn mothers made four or more antenatal care visits during their pregnancy, with 53 percent of maternal cases and 60 percent of the deceased newborn mothers making no ANC visits at all. More strikingly, it was just 34 of the 63 (54 percent) of deceased women (maternal cases) that reported receiving antenatal care from a skilled provider (a doctor, or a nurse/midwife) during their pregnancy. The remaining 46 percent of pregnant women received antenatal care from health extension workers or trained health workers such as a health assistant. This drops the rate of deceased maternal cases that receive antenatal care from a skilled provider to only 26 percent.
In general, health centres and health posts were the two major sources of ANC services for the deceased women. Correspondingly, the findings also show that among the deceased mothers and mothers of the deceased newborn babies who sought ANC services at least once, 73 and 77 percent had their weight taken, 86 and 81 percent had their blood pressure measured, 37 and 44 percent had their urine tested and 55 and 51 percent had their blood tested respectively. But when it comes to the deceased mothers and mothers of the deceased newborn babies who tested all the four test, the figures drop to only 25 and 20 percent respectively.
Table 4.7: Description of antenatal care services received importantly the National Health and Demographic survey consistently shown that antenatal care attendance is low indicating 27% (CSA 2001:111); 28% (CSA 2006:112) and 34% (CSA 2011:119). The reason for this low coverage may be as a result of geographical accessibility to health facilities; associated cost of getting the services and most importantly women’s knowledge, attitude and practice for prenatal care.
As a general rule, early prenatal care is important as it avails the opportunity for early identification of a preventable cause of death like anaemia; an important indirect cause of death in this study. Maternal mortality rates are associated with the period of registration at antenatal clinic and are lowest among those who register early in their
first trimester (Kisuule, Kaye, Najjuka, Ssematimba, Arinda, Nakitende & Otim 2013:121; Ngoc, Merialdi, Abdel-Aleem et al 2006:699-705; Rattanporn 1980:8-15).
This theory is supported by the present study as among the 63 maternal cases, whose time of antenatal care registration was known, 56 (89%) registered after the first trimester of pregnancy. The majority of which, 32 (58%) registered in the third trimester of pregnancy. Late antenatal care registration is common in Ethiopia despite efforts made by the Ministry of Health (MoH) to avert the situation. Cultural factors may explain some element of it. During the verbal autopsy, it was discovered that early going to antenatal care clinic is practically the same as to disclosing pregnancy to family members, which was witnessed as not welcomed in most families’ cultures in Ethiopia.
Family members are expected to discover the pregnancy themselves. Disclosing pregnancy or going to antenatal care clinic before family members discovers the pregnancy is believed to lead to poor pregnancy outcomes.
Early antenatal care and making several ANC visits are equally important and are mostly influenced by the same factors. The majority of ANC visits recorded in this study is not within the WHO model recommendation (WHO 2002c:24) as it is only 20% of the deceased maternal cases and 16% of the mothers of the deceased newborn babies made four or more visits. A significant proportion made less than four visits mostly among women in their first pregnancy or those who had more than four previous pregnancies. First time pregnant women generally feel shy to attend clinics for fear of the 'unknown'. And relatively high parity women often register late in pregnancy and make limited number of visits to prenatal clinics. This may be because their previous pregnancies were problem free so they don’t see the need for it. Other social factors may also contribute to the lesser number of visits by high parity women. Attending the same antenatal clinic together with other women who are far younger daunt other women from frequently attending clinic. The age of the care providers also matters to them. A young or what they called 'child health care providers' frequently witnessed not to be their preference.
Substandard antenatal care can also be a major factor contributing to both low utilisation of ANC services and/or none attendance of antenatal clinic. Antenatal care is effective if the services provided are of high quality – i.e. in conformity with standard guidelines or if perceived by the user as satisfactory. As presented on table 4.8. below, a detailed review of the ANC card of the deceased women (maternal cases) were made
and reveals that in a significant number of visits, various observations or investigations such as weight, height, blood pressure, and haemoglobin measurements were not performed. Lack of basic equipment such as weighing scales, sphygmomanometers, haemoglobin meters, and inadequate number of trained staff in health facilities are the main reasons for this.
The poor quality of prenatal care may be a product of the way and manner clinics are conducted. Tasks such as history taking and screening (blood pressure, weight measure) are mostly performed by untrained personnel who often perform them wrongly, and even if assessed accurately, they cannot interpret the findings. Low morale among staff and the virtually non-existent supervision of peripheral health staff in the study areas may also have played a role in the poor quality of antenatal care services.
Prenatal clinics are dreadfully not well organised as there are usually too many patients to be seen by very few staff. They do not have the time to extensively provide individualised care to the pregnant women. In a case of a woman that died of eclampsia, she had six regular prenatal care visits but had her blood pressure checked only twice.
Almost all of cases (94%) failed to be classified by risk status of their pregnancy at the antenatal clinic and a significant proportion of these (76%) were at-risk according to the maternal health guidelines. Furthermore, in 88% of the cases recommended place of delivery was not stated during antenatal care visit. All these may expose the degree of the poor quality of antenatal care being provided. Table 4.8 shows the investigations performed during routine prenatal care visits.
Table 4.8: ANC investigation record summary of the deceased women Number of visits for which weight was not taken:
Once 6 (35.29%)