Determinants of early first attendance at antenatal care clinics in the Amazon region of Peru: a case-control study

Nora Moore, MSc CandidateCPHA-Public Health 2014, May 27, 2014

Belén

Antenatal Care• Antenatal care (ANC) significantly reduces the risk of adverse

pregnancy outcomes through prevention, early detection and treatment.

• WHO recommends: – Initiating ANC in first trimester of pregnancy– Attending at least 4 ANC visits during pregnancy

• ANC interventions – • Iron and folic acid supplementation for anemia • Counselling on nutrition, breastfeeding, family planning• Detection and treatment of danger signs• Education about the need for skilled attendance at delivery • Deworming

Deworming• WHO recommends deworming during pregnancy

• 4 Countries adopt WHO recommendation – Nepal, Sri Lanka, Kenya and Madagascar

• Why not Peru?– Lack of uptake of scientific evidence and WHO

recommendation ?– Lack of guidelines from the Ministry of Health of Peru ?– Additional tasks for ANC personnel ?– Cost ?– Necessity to consider stage of pregnancy

Primary Study Objective

To identify socio-demographic determinants of early first attendance at ANC.

Retrospective matched nested case-control study

Populations• Study population:

– Cases: Women whose first ANC visit occurred in 1st trimester of pregnancy (<= 12 weeks)

– Controls: Women whose first ANC visit occurred in 2nd or 3rd trimester of pregnancy (>12 weeks)

• Source population: all pregnant women in Belén who had attended ANC at the two health centres, during the years 2010, 2011, and 2012

• Target population: all pregnant women in parasite-endemic areas of the world

Methods• Location:– Belén Health Centre– 6 de Octubre Health Centre

• Matching variables– Health Centre– Date of first ANC visit

• Data sources– 1) ANC registry– 2) antenatal cards– 3) medical charts

• Conditional logistic regression

• Ethics approval: Canada and Peru

Methods: Data collection

• 1st step: sampling frame• 2010, 2011, 2012

• 2nd step: study population• All cases/random selection

of matched controls

• 3rd step: Data extraction

Missing Data

Results

2,647 pregnant women 34 excluded

2,613 remaining

825 cases

1,788 controls

825 controls

Results: Demographic Characteristics

Characteristics Cases (n=825)

Controls (n=825)

No. % No. %Age (in years) 10-14 14 1.7 20 2.415-19 201 24.4 253 30.7≥ 20 609 73.9 552 66.9Marital Status

Not Married 69 8.4 110 13.3Married/Conviviente 685 83.0 659 79.9

EducationSome primary 108 13.1 121 14.7Some secondary 402 48.7 476 57.7Some university 259 31.4 192 23.3

Results: Multivariable analysis Adjusted Odds Ratio (95% Confidence Interval)

ParityNulliparous REFMultiparous 1.06 (0.84, 1.33)

Marital StatusNot married REFMarried/Conviviente 1.71 (1.20, 2.44)

Education Some primary REFSome secondary 0.92 (0.67, 1.25)Some university 1.47 (1.04, 2.08)

Geographic area of residenceUrban REFPeri-Rural 0.58 (0.34, 0.99)

Previous MiscarriagesNo previous miscarriage REFPrevious miscarriages 1.51 (1.10, 2.07)

Discussion1. Most women (74%) attend ≥ 4 ANC visits but only 33%

attend in first trimester.

2. Location of residence, marital status, education level and the number of previous miscarriages determine early first attendance at ANC.

3. Community health workers in the peri-rural areas should pay particular attention to supporting and encouraging at-risk pregnant women in their jurisdiction to attend ANC in their first trimester.

4. Encouraging women to come early to ANC will ensure that the timing of interventions, like deworming, in each woman is appropriate and effective.

Conclusion

• This study contributes first-time evidence on the determinants of early first attendance at antenatal care services offered by local health authorities in the Peruvian Amazon.

Acknowledgements

Financial Support:

• Dirección Regional de Salud de Loreto• Asociación Civil Selva Amazónica• All health centre personnel at Belén and 6 de Octubre• Research assistants: Sully Cruzalegui and Tatiana Tuesta• Research coordinators: Brittany Blouin, Lidsky Pezo, Hugo Razuri• Serene Joseph, Layla Mofid, François Thériault• Supervisor: Dr. Theresa Gyorkos• Committee members: Dr. Elham Rahme and Dr. Martin Casapia

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