Interventions to improve adherence to antenatal and postnatal care regimens among pregnant women in sub-Saharan Africa: A systematic review Kristina Esopo * , Lilly Derby † , Johannes Haushofer *‡ April 2018 Corresponding author: Johannes Haushofer, Ph.D. Assistant Professor Princeton University Department of Psychology 427 Peretsman Scully Hall Princeton, NJ 08544 Phone: 617-360-1605 [email protected]* Department of Psychology, Princeton University. † Center for Behavioral Cardiovascular Health, Columbia University Medical Center. ‡ Woodrow Wilson School for Public and International Affairs & Department of Economics, Princeton University. 1
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Interventions to improve adherence to antenatal and
postnatal care regimens among pregnant women in
sub-Saharan Africa: A systematic review
Kristina Esopo∗, Lilly Derby†, Johannes Haushofer∗‡
∗Department of Psychology, Princeton University.†Center for Behavioral Cardiovascular Health, Columbia University Medical Center.‡Woodrow Wilson School for Public and International Affairs & Department of Economics, Princeton University.
1
INTERVENTIONS TO IMPROVE ANC/PNC ADHERENCE IN SUB-SAHARAN AFRICA 2
Abstract
Pregnant women in sub-Saharan Africa tend to have low adherence to antenatal (ANC) and
postnatal care (PNC) regimens, contributing to high infant and child mortality rates. We con-
ducted a systematic review of the literature to determine the effectiveness of existing inter-
ventions to improve adherence to ANC and PNC regimens among pregnant women in sub-
Saharan Africa. Full text, peer-reviewed articles, published in English and listed in PubMed
or PsycINFO were included. Studies were restricted to randomized controlled trials (RCTs)
only and had to assess the intervention’s impact on ANC/PNC attendance specifically. Data on
the study population, methodology, recruitment, baseline characteristics, treatment arms, study
completion rates, primary and secondary outcomes measured, and treatment effects were ex-
tracted from 19 studies during full-text screening. Of the 19, five studies met our inclusion
criteria. Using the Cochrane risk of bias tool, the risk of systematic error in each included
study was also evaluated. Although the risk of bias was unclear or high in some cases, it re-
mained low in most categories across studies. None of the interventions were directly aimed
at improving adherence, but two of the five, both behavioral interventions, demonstrated effec-
tiveness in increasing ANC and PNC uptake, respectively. Three home visit interventions had
no effect on ANC adherence. Results point to a large gap in the literature on interventions to
Contributions: KE and JH determined the search strategy; KE conducted the search; KE and LD
independently screened abstracts with JH reconciling discrepancies; KE and LD independently
completed full-text review and data extraction with JH reconciling discrepancies; KE and LD
independently completed risk of bias assessment for each study with JH reconciling
discrepancies; KE and JH interpreted results; KE wrote the paper with comments from JH and
LD incorporated.
INTERVENTIONS TO IMPROVE ANC/PNC ADHERENCE IN SUB-SAHARAN AFRICA 16
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Figure 1: PRISMA Flow Diagram
INTERVENTIONS TO IMPROVE ANC/PNC ADHERENCE IN SUB-SAHARAN AFRICA 20
Table 1: Summary of Included Studies and Intervention Effects on ANC/PNC Adherence1stAuthor,publica-tiondate,country
Treatment (n=627): in addition to routine educationalmessages in ANC clinic, received village health teams (VHTs)making home visits to provide educational messages formaternal/newborn care & each VHT had mobile phone handsetcapable of making unlimited phone consultation w/ healthworkers; VHTs made 2 ANC & 1 PNC home visit.Control (n=758): received group education routinely offered inhealth centers, but did not receive VHT home visits or mobilephones.
ANC attendancewas measuredthrough self-reportwhere attendingthree or more ANCvisits wascategorized asadequate & the restwere grouped asinadequate
85% of theinterventiongroup made 3+antenatal visits,compared to71% of thecontrol,adjusted oddsratio 1.82 (95%CI 0.65-5.09,p=0.26)
Home visitintervention hasno effect onrecommendedANCattendance
Cherniak,2017,Uganda
Pregnant women(Kabale district)
ClusterRCT
Treatment (n=100): word of mouth ANC advertisement carriedout by local community leaders who announced free ANC atcommunity gatherings, plus advertisement for availability ofportable ultrasound (pOBU), further divided into word ofmouth of pOBU & ANC (n=16), radio advertisement of onlyANC & word of mouth of ANC & pOBU (n=7), or word ofmouth + radio of both ANC & pOBU (n=75).Control (n=59): word of mouth advertisment of ANC onlywith no mention of pOBU.
ANC uptake ratecalculated using #of womenattending ANC asthe numerator &number of womenattending firstANC in 2013-2014throughgovernment-runclinics as thedenominator
Rate of ANCattendance was65.1% per 1000pregnantwomen wherepOBUadvertised byradio & word ofmouth vs.11.1% incontrolcommunities(rate ratio 5.86,95% CI2.6-13.0,p<.0001)
AdvertisingpOBU by radiomessagingsignificantlyincreases ANCuptake ascompared toword of mouthadvertisementof ANC only
Kirkwood,2013,Ghana
Pregnant women(Brong Ahafo region)
ClusterRCT
Treatment (n=9174): integrated intervention trainingcommunity based surveillance volunteers (CBSVs) to identifypregnant women in their community, undertake 2 home visitsduring pregnancy & 3 visits after birth on days 1, 3, & 7 inaddition to standard care provided. CBSVs also wereresponsible to weigh the newborn & check them for dangersigns after birth.Control (n=9435): routine maternal/child health care available,which consisted of antenatal clinics, access to free facilitydelivery, post-partum checkups, infant welfare clinics, &routine CBSV activities for outreach.
Attendance to fouror more ANCvisits wasmeasured viaself-reportfollowing birth
76% treatment& 73.7%control attended4 or more ANCvisits (2.3%incr.), relativerisk 1.02 (95%CI 0.96-1.09,p=0.52)
Home visitintervention hasno effect onrecommendedANCattendance
Magoma,2013,Tanzania
Pregnant women(Ngorongoro district,
Arusha region)
ClusterRCT
Treatment (n=404): introduction & promotion of birth plans bycare providers during ANC to prepare women & families forbirth. Discussions on place of delivery, importance of skilleddelivery care, transport arrangements, funding, possible blooddonors, birth companions, & home support.Control (n=501): Standard care without birth plan
Treatment (n=894): 5 home visits by community healthworkers (CHWs), 2 during pregnancy & 3 in the 1st week afterbirth (day 1, 3, & 7) to offer preventative & promotivecare/counseling with extra visits for sick & small newborns toassess & refer plus improved facilitiesControl (n=893): standard care overseen by district health teamin addition to the improved facilities
Data on attendanceto one or moreANC visits and tofour or more ANCvisits werecollected viaself-report