The purpose of the study was to identify determinants of late antennal care at first visit in health facilities of eastern zone of Tigray, Northern Ethiopia 2018. Women with unplanned pregnancy (AOR = 4.03, 95%, CI 1.56–5.67), Participants whose previous first antenatal care was after 16 weeks (AOR = 3.9, 95% CI 1.98–7.68), Participants did not accompanied by their partner for antenatal visit (AOR = 1.29, 95%, CI 1.05–4.67), women recognized their current pregnancy at 3 months or late (AOR = 4.7, 95%, CI 2.49–9.04) and participants provided adequate time for their previous antenatal care by health professionals (AOR = 0.461, 95% CI 0.342–0.875) were found the determinant factors of late antenatal care at first Visit. Hence family planning utilization, times of first visit antenatal, information flow and supporting by partners have a great role in improving antenatal care at first visit. There for responsible bodies should give focuses on utilization of family planning, increasing awareness of pregnancy symptoms and health provisional provide adequate time during visits.

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Determinants of late antenatal care follow up among pregnant women in Easter zone Tigray, Northern Ethiopia, 2018: unmatched case-control study

The third Sustainable Development Goal for 2030 development agenda aims to reduce maternal and newborn deaths. Pregnant women’s understanding of danger signs is an important factor in seeking timely care during emergencies. We assessed knowledge of obstetric danger signs using both recall and understanding of appropriate action required during obstetric emergencies. This was a cross-sectional study among pregnant women attending antenatal clinic at Bhutan’s largest hospital in Thimphu. Recall was assessed against seven obstetric danger signs outlined in the Mother and Child Health Handbook (7 points). Understanding of danger signs was tested using 13 multiple choice questions (13 points). Knowledge was scored out of 20 points and reported as ‘good’ (≥80%), ‘satisfactory’ (60–79%) and ‘poor’ (< 60%). Correlation between participant characteristics and knowledge score as well as number of danger signs recalled was tested using Pearson’s correlation coefficient. Association between knowledge score and participant characteristics was tested using t-tests (and Kruskal-Wallis test) for numeric variables. Socio-demographic and clinical characteristics associated with the level of knowledge ('good’ versus ‘satisfactory’ and ‘poor’ combined) were assessed with odds ratios using a log-binomial regression model. All results with p < 0.05 were considered significant. Four hundred and twenty-two women responded to the survey (response rate = 96.0%). Mean (±SD) knowledge score was 12 (±2.5). Twenty women (4.7%) had ‘good’ knowledge, 245 (58.1%) had ‘satisfactory’ knowledge and 157 (37.2%) had ‘poor’ knowledge. The median number of danger signs recalled was 2 (IQR 1, 3) while 68 women (20.3%) could not recall any danger signs. Most women were knowledgeable about pre-labour rupture of membranes (96.0%) while very few women were knowledgeable about spotting during pregnancy (19.9%). Both knowledge score and number of danger signs recalled had significant correlation with the period of gestation. Women with previous surgery on the reproductive tract had higher odds of having ‘good’ level of knowledge. Most pregnant women had ‘satisfactory’ knowledge score with poor explicit recall of danger signs. However, women recognized obstetric emergencies and identified the appropriate action warranted.

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Knowledge and understanding of obstetric danger signs among pregnant women attending the antenatal clinic at the National Referral Hospital in Thimphu, Bhutan: a cross-sectional study.

Maternal mortality refers to deaths due to complications from pregnancy or childbirth. Though, the number of women and girls who died each year from complications of pregnancy has declined from 451,000 in 2000 to 295,000 in 2017, yet over 810 women are still dying every day, while for every woman who dies, approximately 20 others suffer serious injuries, infections or disabilities. Further, 94% of all maternal deaths occur in low and lower middle-income countries. Two regions, sub-Saharan Africa and South Asia, account for 86 per cent of all maternal deaths worldwide. The high number of maternal deaths in some areas of the world reflects inequities in access to health services, and highlights the gap between rich andpoor.

Study of utilization of antenatal care services and its determinants among pregnant women admitted in a tertiary care hospital in Mangaluru, Karnataka, India

Background: Antenatal care (ANC) plays an important role in reducing maternal morbidity and mortality. The South Asian Association for Regional Cooperation (SAARC) is an economic and political organization of eight countries in South Asia. There is an unacceptably high burden of neonatal mortality and stillbirths in the SAARC region.
Purpose: The purpose of this study is to estimate the percentage of at least one ANC visit from 2015 to 2030 from previously available data and to compare the progress among SAARC nations.
Methodology: This is a secondary analysis study. Data indicating percentages of women attending at least one ANC by skilled health personnel in SAARC countries Maternal and newborn health coverage dataset-May 2021 by United Nations International Children’s Emergency Fund (UNICEF) was used. Regression Coefficient was used first to check the strength of the relationship for prediction at a 5 % significance level. Then, the percentages of ANC visits were predicted. To compare the percentages among countries, non-Parametric correlation Kendall’s tau was used.
Findings: Results indicate that SAARC countries are struggling to reach at least one ANC visit. Comparison among these countries has shown no significant trend and it is concluded that there is no significant difference among SAARC countries' women ANC visits from 2015 to 2030 at a 5% significance level for all years.
Practical Implications: The estimations of this research would help to develop innovative strategies for uplifting maternal health among SAARC countries to reach Sustainable development goals (SDGs).

A Comparative Study on Percentage of Women (Age 15–49) Attending at Least One Antenatal Care by Skilled Health Personnel in SAARC Countries (2015-2030)

Background Bhutan has made much efforts to provide timely access to health services during pregnancy and increase institutional deliveries. However, as specialist obstetric services became available in seven hospitals in the country, there has been a steady increase in the rates of caesarean deliveries. This article describes the national rates and indications of caesarean section deliveries in Bhutan. Methods This is a review of hospital records and a qualitative analysis of peer-reviewed articles on caesarean deliveries in Bhutan. Data on the volume of all deliveries that happened in the country from 2015 to 2019 were retrieved from the Annual Health Bulletins published by the Ministry of Health. The volume of deliveries and caesarean deliveries were extracted from the Annual Report of the National Referral Hospital 2015-2019 and the data were collected from hospital records of six other obstetric centres. A national rate of caesarean section was calculated as a proportion out of the total institutional deliveries at all hospitals combined. At the hospital level, the proportion of caesarean deliveries are presented as a proportion out of total institutional deliveries conducted in that hospital. Results For the period 2015-2019, the average national rate of caesarean section was 20.1% with a statistically significant increase from 18.1 to 21.5%. The average rate at the six obstetric centres was 29.9% with Phuentsholing Hospital (37.2%), Eastern Regional Referral Hospital (34.2%) and Samtse General Hospital (32.0%) reporting rates higher than that of the National Referral Hospital (28.1%). Except for the Eastern Regional Referral and Trashigang Hospitals, the other three centres showed significant increase in the proportion of caesarean deliveries during the study period. The proportion of emergency caesarean section at National Referral Hospital, Central Regional Referral Hospital and the Phuentsholing General Hospital was 58.8%. The National Referral Hospital (71.6%) and Phuentsholing General Hospital reported higher proportions of emergency caesarean sections (64.4%) while the Central Regional Referral Hospital reported higher proportions of elective sections (59.5%). The common indications were 'past caesarean section' (27.5%), foetal distress and non-reassuring cardiotocograph (14.3%), failed progress of labour (13.2%), cephalo-pelvic disproportion or shoulder dystocia (12.0%), and malpresentation including breech (8.8%). Conclusion Bhutan's caesarean section rates are high and on the rise despite a shortage of obstetricians. This trend may be counterproductive to Bhutan's efforts towards 2030 Sustainable Development Goal agendas and calls for a review of obstetric standards and practices to reduce primary caesarean sections.

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Rates and indications of caesarean section deliveries in Bhutan 2015-2019: a national review.

To achieve the Sustainable Development Goal related to maternal and neonatal outcomes, the World Health Organization advocates for a first antenatal care (ANC) contact before 12 weeks of gestation. In order to guide interventions to achieve early ANC in the lower middle-income setting of Bhutan, we conducted an assessment of the magnitude and determinants of late ANC in this context. This was a mixed-methods study with quantitative (cross-sectional study) and qualitative (in-depth interviews with pregnant women and ANC providers) component in a concurrent triangulation design. The quantitative component retrospectively analysed the socio-demographic and clinical characteristics, and the gestational age at booking of women who were provided care for delivery or miscarriages at the three tertiary hospitals in Bhutan from May–August 2018. The qualitative component involved thematic analysis of in-depth interviews with ten women attending ANC visits and four healthcare workers involved in ANC provision. Among 868 women studied, 67% (n = 584) had a late booking (after 12 weeks), and 1% (n = 13) had no booking. Women with only primary education and those residing in rural areas were more likely to have a late first ANC booking. While many women achieved the recommended eight ANC visits, this did not necessarily reflect early booking. Late booking was common among multigravida women. The interviews illustrated a general understanding and recognition of the importance of early ANC. Support from peers, family and co-workers, and male participation in accessing ANC were seen as enablers. The outreach clinics (ORCs) at the primary healthcare level were an important means of reaching the ANC services to women in rural areas where geographical accessibility was a barrier. Specific barriers to early ANC were gender insensitivity in providing care through male health workers, cost/time in ANC visits, and the inability to produce the documents of the father for booking ANC. Late ANC booking was common in Bhutan, and appeared to be associated with educational, geographic, socio-cultural and administrative characteristics. A comprehensive information package on ANC needs to be developed for pregnant mothers, and the quality of ANC coverage needs to be measured in terms of early ANC booking.

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Tashi Tshomo

Papers

"If we miss this chance, it's futile later on" - late antenatal booking and its determinants in Bhutan: a mixed-methods study.