40An antenatal care indicator based on contact with services and content developed for 63 countries

Background Most antenatal care (ANC) indicators in use are criticized for considering only contact with services and not taking into account content of care. We aimed to create and validate a new indicator measured as a score, considering both contact and content, that can be used for monitoring. Methods We used data from national surveys conducted in low and middle-income countries (LMICs). Information on ANC was used to build an adequacy score (ANCq) that would be applicable to all women in need of ANC. We used a convergent validation approach, exploring the association of our proposed indicator with neonatal mortality. Results The ANCq score was derived from seven variables related to contact with services and content of care ranging from zero to ten. Surveys from 63 countries with all variables were used. The overall mean of ANCq was 6.7, ranging from 3.5 in Afghanistan to 9.3 in Cuba and the Dominican Republic. In most countries, the ANCq was inversely associated with neonatal mortality and the pooled for all surveys Odds Ratio was 0.90 (95% CI = 0.88-0.92). Conclusions The ANCq presented good validity properties, being a useful tool for assessing ANC coverage and adequacy of care in monitoring and accountability exercises. Key messages ANCq provides a standardized and comparable measure of ANC adequacy, allowing for comparisons between country population subgroups and between countries.

Five Months Later: The Psychodynamic Psychiatrist and Psychiatric Care in the Era of COVID-19

Five months following an earlier report on the initial impact of COVID-19, the same 24 contributing psychodynamic psychiatrists reported on how matters have shifted in their experience. Spread of the virus, lockdowns, politicization of all aspects of the pandemic, massive unemployment, and social justice frustrations have characterized the interim. The initial burst of acute uncertainty and worry has shifted into a more adaptive but still destabilizing long-term apprehension: distance treatment and its ramifications have become somewhat normalized, training now incorporates virtual treatment approaches, psychodynamically informed counseling has taken a larger role in the content of care. New theories of clinical practice are emerging that address these changes. As before, contributors’ narratives are considered from the perspective of administration and training, structure and content of treatment, and the impact of the pandemic both on patients and psychiatrists.

Content of Home-Based Dementia Care: Adverse Consequences of Unmet Toileting Needs

Despite high-intensity caregiving support, those with dementia may experience adverse consequences because the care they receive does not match their care needs. This study evaluates the relationship between content of care (i.e., specific assistance with toileting) and adverse consequences (i.e., toileting accidents because no one was there to help) in a population of community-dwelling Medicare beneficiaries with dementia and impairment in toileting enrolled in the National Health and Aging Trends Study (NHATS). Only two thirds of individuals received specific assistance with toileting, which was associated with a reduced risk of adverse consequences related to toileting in a multivariable model adjusted for key variables including high-intensity caregiving (odds ratio [OR] = 0.36, 95% confidence interval [CI] = [0.23, 0.58]). To ensure care meets the needs of those with dementia living in the community, it is important to consider not only the quantity but also the content of care received.

A new content-qualified antenatal care coverage indicator: development and validation of a score using national health surveys

IntroductionGood quality antenatal care (ANC) helps reduce maternal and newborn mortality and morbidity, especially in low and middle-income countries (LMICs). Most studies that attempted to measure ANC quality proposed categorical indicators considering either contact with services or based on content, sometimes both. We aimed to create and validate a new indicator measured as a score, considering both contact and content.MethodsWe used Demographic and Health Surveys and Multiple Indicator Cluster Surveys. Information on ANC contact and content was used to build an adequacy score that would be applicable to all women in need of ANC. Cronbach’s alpha and factor analysis were used to assess the proposed indicator. We also used a convergent validation approach, exploring the association with neonatal mortality.ResultsThe proposed indicator (ANCq) is derived from the number of visits, timing of the first visit, skill level of the attendant, blood pressure measurement, tetanus toxoid vaccination and collection of blood and urine samples. The validity assessment showed satisfactory results with Cronbach’s alpha coefficient equal to 0.82. ANCq score ranges from 0 to 10. The overall mean of ANCq in 63 LMICs with data was 6.7, ranging from 3.5 in Afghanistan to 9.3 in Cuba and the Dominican Republic. In most countries, higher scores of ANCq were associated with lower neonatal mortality, with pooled odds ratio of 0.90 (95% CI: 0.88-0.92).ConclusionANCq allows the assessment of ANC in LMICs considering contact with services and content of care. ANCq presented good validity properties, being a useful tool for assessing ANC coverage and adequacy of care in monitoring and accountability exercises.Key questionsWhat is already known?Antenatal care (ANC) is an important part of primary healthcare, being associated with reductions in maternal and new-born morbidity and mortality, mainly in low and middle-income countries (LMICs).Several indicators have been proposed to measured ANC quality either through contacts with services or based on content of care, or sometimes both. Several of the proposed indicators are applicable only to women who had at least one ANC visit, and measured quality as a categorical indicator.Consensus on the need for a more comprehensive ANC indicator that is suitable for monitoring progress, including aspects of quality of care.What are the new findings?We proposed a content-qualified ANC indicator in the form of a score, called ANCq. It includes seven different variables related to contact with services and content of care received during pregnancy. The indicator is applicable to all pregnant women.The indicator has good validity properties and was inversely associated with neonatal mortality.There is wide variation across countries regarding the average ANCq score, and large within-country variation at individual level. Latin America and the Caribbean and East Asia and the Pacific are the best performing regions.What do the new findings imply?The proposed indicator provides a standardized and comparable measure of ANC adequacy, allowing for comparisons between and within countries.The indicator can help monitoring ANC progress to all women in need of ANC, with several advantages over currently existing indicators: it is applicable to all pregnant women independent of having accessed ANC services, it includes serval aspects of ANC content and, being a score, provides a gradation of how suitable ANC was.

Facility delivery and postnatal care services use among mothers who attended four or more antenatal care visits in Ethiopia: further analysis of the 2016 Demographic and Health Survey

IntroductionIn Ethiopia, many mothers who attend the recommended number of antenatal care visits fail to use facility delivery and postnatal care services. This study identifies factors associated with facility delivery and use of postnatal care among mothers who had four or more antenatal care visits, using data from the 2016 Ethiopian Demographic and Health Survey (EDHS).MethodsTo identify factors associated with facility delivery, we studied background and service-related characteristics among 2,415 mothers who attended four or more antenatal care visits for the most recent birth. In analyzing factors associated with postnatal care within 42 days after delivery, the study included 1,055 mothers who attended four or more antenatal care visits and delivered at home. We focused on women who delivered at home because women who deliver at a health facility are more likely also to receive postnatal care as well. A multivariable logistic regression model was fitted for each outcome to find significant associations between facility delivery and use of postnatal care.ResultsFifty-six percent of women who had four or more antenatal care visits delivered at a health facility, while 44% delivered at home. Mothers with secondary or above level of education, urban residents, women in the richest wealth quintile, and women who were working at the time of interview had higher odds of delivering in a health facility. High birth order was associated with a lower likelihood of health facility delivery. Among women who delivered at home, only 8% received postnatal care within 42 days after delivery. Quality of antenatal care as measured by the content of care received during antenatal care visits stood out as an important factor that influences both facility delivery and postnatal care. Among mothers who attended four or more antenatal care visits and delivered at home, the content of care received during ANC visits was the only factor that showed a statistically significant association with receiving postnatal care.ConclusionsThe more antenatal care components a mother receives, the higher her probability of delivering at a health facility and of receiving postnatal care. The health care system needs to increase the quality of antenatal care provided to mothers because receiving more components of antenatal care is associated with increased health facility delivery and postnatal care. Further research is recommended to identify other reasons why many women do not use facility delivery and postnatal care services even after attending four or more antenatal care visits.

Not just a number: examining coverage and content of antenatal care in low-income and middle-income countries

IntroductionAntenatal care (ANC) provides a critical opportunity for women and babies to benefit from good-quality maternal care. Using 10 countries as an illustrative analysis, we described ANC coverage (number of visits and timing of first visit) and operationalised indicators for content of care as available in population surveys, and examined how these two approaches are related.MethodsWe used the most recent Demographic and Health Survey to analyse ANC related to women’s most recent live birth up to 3 years preceding the survey. Content of care was assessed using six components routinely measured across all countries, and a further one to eight additional country-specific components. We estimated the percentage of women in need of ANC, and using ANC, who received each component, the six routine components and all components.ResultsIn all 10 countries, the majority of women in need of ANC reported 1+ ANC visits and over two-fifths reported 4+ visits. Receipt of the six routine components varied widely; blood pressure measurement was the most commonly reported component, and urine test and information on complications the least. Among the subset of women starting ANC in the first trimester and receiving 4+ visits, the percentage receiving all six routinely measured ANC components was low, ranging from 10% (Jordan) to around 50% in Nigeria, Nepal, Colombia and Haiti.ConclusionOur findings suggest that even among women with patterns of care that complied with global recommendations, the content of care was poor. Efficient and effective action to improve care quality relies on development of suitable content of care indicators.