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Quality of antenatal care in Colombia: Evalua5on of clinical records in 20 provinces and three districts,
2009-‐2011
Pablo Montoya1*, Carolina Chavarro1, Eliane Barreto1, Ana J Blanco1, Rosalina Sánchez1, Sidia Caicedo2, Luz A Artunduaga3
1 2 3
Few facts about Colombia
• ~49.5 million inhabitants • Upper-‐middle income country
• According to 2010 DHS: • > 98% prenatal care aTendance
• > 94% insUtuUonal deliveries
Human Development Report, UNDP, 2014
Target x 1.5
Target x 2
Target x 5
Methods
• DescripUve, retrospecUve study • Between 03/2011-‐02/2012 • Review of 2651 obstetric clinical records (CR) from:
• 139 municipaliUes and 3 districts • 20 out of 32 Colombian departments • MunicipaliUes, health care faciliUes and CR randomly selected
• Assessment of compliance to ANC guidelines: • Evidence-‐based medical intervenUons • Included in naUonal norms since 2000
Methods
• 7 regional clusters: • Region 1: Amazonas, Arauca, Putumayo, Vaupés and Caquetá
• Region 2: Quindío, Risaralda and Caldas • Region 3: Cauca, Nariño and Chocó • Region 4: Bolívar, AtlánUco, Magdalena, Córdoba and La Guajira
• Region 5: Santander and Norte de Santander
• Region 6: Valle del Cauca • Region 7: AnUoquia
ANC ac5vi5es and compound indicators Variable Descrip8on (CR registry:)
Anamnesis • Vaginal fluids • Urinary symptoms
• Vascular spasm symptoms (>26 weeks) • Fetal movements (>26 weeks)
Physical examina8on
• Weight and height • Uterine height • Blood pressure
• Number of fetuses (>26 weeks) • Fetocardia (>26 weeks) • Fetal presentaUon (>34 weeks)
Rou8ne antenatal tests
• Hemoglobin • HemoclassificaUon • Glycemia • Urinalysis
• Obstetric ultrasound • PAP smear • HIV, syphilis and hepaUUs B screening
Health promo8on ac8vi8es
Counseling on: • Breaspeeding • Newborn care • Family planning • Alarm signs
• Psychosocial and violence screening • Pre and posTest counseling, informed
consent for HIV • AdministraUon of iron sulfate, calcium, folic
acid and anUtetanus vaccinaUon
Basic antenatal care
Includes what is most recommended by evidence (evidence A and B) and considered the minimum • Vaginal fluids, urinary and
vascular spasm symptoms • Weight, uterine height and
blood pressure
• Hemoglobin, hemoclassificaUon, urinalysis
• Syphilis, HIV and hepaUUs B screening • Counselling on alarm signs
Complete prenatal care (na8onal norm)
• All of the above menUoned acUviUes (ResoluUon 412/2000): anamnesis, physical examinaUon, rouUne antenatal tests, and health promoUon acUviUes
26 24
23 21
20 19
18 18
16 14
14 11 10
8 6
6 6
3 1 1 Mean 14.5% (n=384/2651)
0 30 35 40 45 50 5 10 15 20 25 Percentage of pregnant women without health insurance
Caqueta Narino
Santander Cauca
Norte de Santander Amazonas Magdalena
Valle Antioquia
Choco Putumayo Guaviare
Bolivar Quindio Caldas
Cordoba Risaralda Atlantico Vaupes
La Guajira
Proportion of women without health insurance per department ANC quality in Colombia 2009-2011
Type of insurance: Subsidized: 1683 (64%) Contribu8ve: 534 (20%) Especial: 43 (2%)
0
10
20
30
40
5
15
25
35
Ges
tatio
nal a
ge (w
eeks
)
Ris
aral
da
Ant
ioqu
ia
Cal
das
Caq
ueta
Atla
ntic
o
Nar
ino
Nor
te d
e S
anta
nder
Qui
ndio
San
tand
er
Bol
ivar
Cor
doba
Valle
Mag
dale
na
Gua
viar
e
Cau
ca
Put
umay
o
Am
azon
as
Cho
co
La G
uajir
a
Vaup
es
Gestational age at first ANC visit per department
Trim 3
Trim 2
ANC quality in Colombia 2009-2011
78 66
49
93 88 67
88 75
52
88 77 70
86 80
32
92 79
54
93 85 88 88 78 59
20 40 60 80
100
20 40 60 80
100
20 40 60 80
100
Amazonia Eje Cafetero Pacífico
Caribe Santanderes Valle del Cauca
Antioquia Total
Syphilis HIV Hepatitis B
Syphilis, HIV and hepatitis B screening per region
ANC quality in Colombia 2009-2011
70 57 63
21
76
54 67
19
89 69 71
38
72
35
63
14
78 57
67
23
20 40 60 80
100
20 40 60 80
100
No insurance Subsidized Contributive
Especial Total
HIV screening Pretest counseling
Consent Post-test counseling
HIV screening, pre and post-test counseling, and informed consent per type of insurance
ANC quality in Colombia 2009-2011
90
84
83
80
79
30
10 20 30 40 50 60 70 80 90 100 Percentage of CR
Basic routine antenatal tests
PAP smear Ultrasound Glycemia Urinalysis Hemoclass Hemoglobin
ANC quality in Colombia 2009-2011
91
42
37
30
24
10 20 30 40 50 60 70 80 90 100 Percentage of CR
Counseling on basic health promotion activities
Newborn care FP Psychoprophylaxis Breastfeeding Alarm signs
ANC quality in Colombia 2009-2011
86 85 81
30
98 98 98 55
93 93 93 68
95 94 92 66
98 97 97 47
90 86 89 52
100 100 100 72 94 93 92
55
0 20 40 60 80
100
0 20 40 60 80
100
0 20 40 60 80
100
Amazonia Eje Cafetero Pacífico
Caribe Santanderes Valle del Cauca
Antioquia Total
Iron sulfate Folic acid Calcium Tetanus vaccine
Per
cent
age
of H
C
Micronutrients and tetanus vaccine per region
*p<0.001
ANC quality in Colombia 2009-2011
60
40
24
53
19 11
22
54
5
21
1 0
10 20 30 40 50 60 70 80 90
100
Per
cent
age
of C
R
Complete activities accomplished
Anamnesis Physical examination Basic lab tests HIV, syphilis, hep B
Routine ANC tests Basic H promotion HIV counseling Micronutrients and tetanus vaccine
Complete H promotion Basic ANC Complete ANC R-‐412/00
ANC quality in Colombia 2009-2011
3
2 1
No
Si
No
Si
11 8
13
1 4
17
9
2
6 7
3
10
5
16
12
14 Raizal
Indigenous
Afro None
Secondary None
Technical/ university
Primary
Contributive
Subsidized
Especial
No insurance Valle
Eje Cafe
Antioquia
Caribe Santanderes Amazonia
Pacífico
10 20 30 40 50 60 70 80 90
100
Per
cent
age
of C
R
20.6% (547/2651) CR with main evidence based activities p<0.001 for bivariate analysis for all variables in all included
Basic ANC (mean) ANC quality in Colombia 2009-2011
98
94
91
72
70
64
56 Mean 80% (n=994/1249)
10 20 30 40 50 60 70 80 90 100 Percentage of CR
Antioquia
Eje Cafetero
Santanderes
Valle del Cauca
Caribe
Amazonia
Pacífico
Newborn hepatitis B vaccination in first 12 hours per region
ANC quality in Colombia 2009-2011
• ~50% CR with informaUon about delivery
• ~26% C-‐secUons [10%-‐53%]
In short words…
Quite deficient ANC with great inequaliUes
From MDG to SDG
How to make it?
Recommenda5ons • CollaboraUon among health care system actors
• Joint health quality improvement acUons at territorial level • Avoid and sancUon service fragmentaUon
• Involve communiUes • Service quality supervision, claim of rights, contextual approaches
• Improve monitoring and evaluaUon for decision making and incenUves • ConUnuous technical support and supervision focusing on locally idenUfied problems: including integraUon, moUvaUon and humanizaUon
• ImplementaUon research to improve program delivery and results • Work with different sectors to tackle social determinants
www.sinergiasong.org [email protected]
¡Gracias!
PublicaUon URL: unfpa.org.co/wp-‐content/uploads/2014/08/DocumentoMATERNOINFANTIL_web.pdf
