|Year : 2016 | Volume
| Issue : 3 | Page : 317-321
The effect of frequency of antenatal visits on pregnancy outcome in Kaduna, Northern Nigeria
Polite I Onwuhafua, Ijeoma C Ozed.Williams, Abimbola O Kolawole, Joel A Adze
Department of Obstetrics and Gynecology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
|Date of Web Publication||8-Feb-2017|
Polite I Onwuhafua
Ahmadu Bello University Teaching Hospital, Zaria
Source of Support: None, Conflict of Interest: None
Context: The benefit of antenatal care is no longer in doubt, but the ideal number of encounters to achieve those benefits has been the subject of discussion among maternity care stakeholders.
Objective: To study the effect of frequency of antenatal visits on pregnancy outcome.
Materials and Methods: This is a prospective study of 228 pregnant women attending the antenatal clinic of the Ahmadu Bello University Teaching Hospital, Zaria, Nigeria, over a 3-month period. Maternal and fetal outcome were compared against the frequency of antenatal visits.
Results: The mean frequency of visits was 6.77. Majority of the women 124 (54.4%) attended less than seven times. Compliance with antenatal drugs and mean hemoglobin level at delivery increased with increasing frequency of visits reaching 93.7% and 11.44 g/dl, respectively, in the moderate attendees (4–6 visits). Prevalence of anemia was high (56.7%) among the unbooked but lowest (9.5%) with moderate attendees. Thereafter, there was no significant improvement. Delivery mode, malaria parasitemia, and gestational age at delivery were fairly uniform in all the groups. The prevalence of low birth weight was 20% in the unregistered and decreased from 22% in the low frequency (1–3 visits) group, to 4.8% in the moderate attendees, and to 0% in the very high-frequency (ten and above visits) group. Mean Apgar scores at 1 and 5 min were also best (7.1/8.1) in the moderate attendees and worst in the unregistered.
Conclusion: More than six visits conferred no significant advantage on fetomaternal outcome. Therefore, the new WHO recommendation on reduced antenatal visits can be satisfactorily implemented in Kaduna.
Keywords: Antenatal care; Northern Nigeria; pregnancy outcome.
|How to cite this article:|
Onwuhafua PI, Ozed.Williams IC, Kolawole AO, Adze JA. The effect of frequency of antenatal visits on pregnancy outcome in Kaduna, Northern Nigeria. Trop J Obstet Gynaecol 2016;33:317-21
|How to cite this URL:|
Onwuhafua PI, Ozed.Williams IC, Kolawole AO, Adze JA. The effect of frequency of antenatal visits on pregnancy outcome in Kaduna, Northern Nigeria. Trop J Obstet Gynaecol [serial online] 2016 [cited 2020 Sep 25];33:317-21. Available from: http://www.tjogonline.com/text.asp?2016/33/3/317/199813
| Introduction|| |
The benefits of antenatal care have been exhaustively discussed by several authors.,,,
It is gratifying that significant improvement in clinic attendance has been recorded over the years,, but even at that, our women do not keep to the traditional visit schedules for varying reasons.
WHO's recommendation of focused antenatal care  may be a welcome idea; nevertheless, since our women are just beginning to appreciate the value of antenatal care, it is only prudent to evaluate the current trend and its effectiveness before implementing a new recommendation.
This study was, therefore, undertaken to find out the average number of antenatal visits made by clients and any differences in outcomes with respect to the frequency of visits.
| Materials and Methods|| |
Ahmadu Bello University Teaching Hospital, Kaduna, received patients from all cadre of society because of government subsidies and did not render tertiary health services only. The study sample consisted of all consecutive pregnant women delivered between April 1 and June 30, 2002. Exclusion criteria were based on prior registration in another hospital since the antenatal records were not available, and any medical or obstetric problems necessitating more frequent antenatal visits.
Data were collected using a pro forma. On admission for delivery, sociodemographic information was obtained, and the woman was asked to rate her compliance to antenatal medications on a scale of regular/irregular. Information related to the frequency of antenatal visits, duration of pregnancy, and the gestational age (GA) at booking was extracted from the antenatal registration cards. Then, blood samples were taken for hemoglobin (Hb) and malaria parasites check and after delivery, the pro forma was completed with information on the sex, weight, and Apgar scores of the infant at 1 and 5 min.
For ease of analysis, the women were categorized into five groups: Not registered, low-frequency attendees, (1–3 visits), moderate attendees (4–6 visits), high attendees (7–9 visits), and very high attendees, (ten visits and above). Relevant frequency tables were drawn, and measures of average used to summarize data. Comparative tables were also drawn and Chi-squared tests of significance and analysis of variance were applied.
| Results|| |
Frequency of antenatal visits
The 194 women accounted for a total of 1313 visits within the study period, 31 (13.6%) low-frequency attendees, 63 (27.6%) moderate attendees, 72 (31.6%) high-frequency attendees, and 32 (14.0%) very high-frequency attendees. The thirty unregistered women made up 13.2% of the study population.
The mean number of visits was 6.77 with a standard deviation of 3.5. The t-statistic was 24.7 and P < 0.05.
The largest number 72 (31.6%) was in the high-frequency attendance group. This number was significantly higher than the 63 (27.6%) in the moderate frequency group. The number of the low-frequency, very high-frequency, and the unregistered groups was almost the same at 31 (13.6%), 32 (14%), and 30 (13.2%), respectively.
The mean age for the sample was 28.9 years, mean parity was 1.85, mean last childbirth (LCB) was 2.25 years, mean booking GA was 22.5 weeks, and mean GA at delivery was 277.9 days. The variances were homogeneous in all the groups with respect to age, LCB, GA at registration, and at delivery, justifying grounds for comparison even though the mean parity of the unregistered women (2.63) was significantly higher than the rest [Table 1].
The mean Hb for the sample was 10.95 g/dl, whereas the prevalence of anemia was 25% using a cutoff point of 10.0 g/dl. The lowest mean Hb was in the unregistered group (9.68 g/dl), followed by the low-frequency attendance group. There was no significant difference in the mean Hb between the moderate, high, and very high groups [Table 2].
The largest proportion of anemic women at delivery were in the unregistered group (56.7%), followed by the low attendance group (37.8%). These figures were significantly higher than in the other groups. The moderate attendees had the least prevalence (9.5%). [Figure 1] illustrates that the widest gap between the anemic and nonanemic patients occurred in the moderate group.
There was no significant difference between the groups in malaria parasitemia and mode of delivery.
All (100%) of the unregistered women either did not take any drugs at all or were irregular at antenatal drugs. The drug compliance improved with increasing frequency of visits. There was a very significant jump in compliance from 67.7% at the low group to 93.7% at the moderate group [Table 2].
The mean birth weight was significantly lower in the unregistered group (2.87 kg) and the low-frequency (2.81 kg) groups than the moderate group (3.14 kg). There was only a very slight increase in the high- and very high-frequency groups to 3.22 kg and 3.30 kg, respectively. The overall mean birth weight was 3.11 kg. Similarly, there was a higher proportion of low birth weight infants among the unregistered group, i.e., six (20.0%) and the low-frequency visits, i.e., seven (22.6%) than in the other groups. The least proportion of low birth weight infants was in the moderate group, i.e., three (4.8%) [Table 3].
The mean Apgar scores at 1 and 5 min improved significantly from the unregistered (4.9/5.6), through the low-frequency group (5.6/6.6) to the moderate group (7.1/8.1). There was no significant difference between the moderate, high, and very high groups.
| Discussion|| |
The mean number of antenatal visits by the women in this study is 6.77 visits, with most women attending less than seven times. This is less than the 8–9 visits advocated by some authors,, but higher than the four visits suggested as adequate by the WHO expert committee.
Apparently, there is no strict adherence to the traditional scheduled appointments which would have produced a greater frequency of visits. Thirty (13.2%) women were not registered, and of those that registered, their mean GA at booking was over 22 weeks, as was also found in this environment: this makes one to ask, why not first focus on educating our women to book early?
The maternal outcome parameters that showed any variation between the groups were Hb level and drug compliance. Drug compliance probably increased steadily with increasing frequency of visits since an important part of the antenatal clinic routine focuses on health talks and encouraging compliance. This is indeed one of the shortcomings of the WHO focused antenatal care model.
The overall mean Hb level of 10.95 g/dl is consistent with that reported in the environment,, but this increased significantly with increasing number of visits until the moderate group (4–6 visits). Thereafter, there was no more significant increase suggesting that 4–6 visits were adequate to correct any preexisting low Hb and lending support to the current WHO recommendations.
The prevalence of anemia at the time of delivery of 25% in this study was worse than the 17.2% recently recorded among an ethnic group in Nigeria, but better than the 41.6% and 48% recorded by Taner et al. and by Dop et al. using a cutoff point of 11.0 g/dl. Again, the lowest prevalence (9.5%) was found in the moderate group.
As for the homogeneous results got in the other maternal outcome parameters, it would seem that our present mode of antenatal care has no effect on malaria parasitemia, according to reasons suggested by Shulman and Dorman , collaborated by Agan et al., Uneke et al., and Bodeau-Livinec et al. and on the eventual mode of delivery.
The mean fetal weight of 3.11 kg also compares with the 3.20 kg and 3.29 kg found elsewhere in Nigeria ,, and was improved by increasing antenatal visits, but there was no statistically significant difference found beyond 4th–6th visit. The overall incidence of low birth weight of 9.6% compares favorably with findings in similar institutions in Nigeria and countries with similar socioeconomic disposition and even in developed countries., 9, ,,,
The sharp reduction in low birth weight from 22.6% in low-frequency group, to 4.8% in the moderate group, to 0% in the very high-frequency group might suggest that greater frequency of visits favors good birth weights. This finding, among many more again, brings into question the WHO recommended focused antenatal care with reduced number of visits. Focused antenatal care was formulated without putting into consideration the absence of preconception care in most of the so-called resource-poor countries!
That Apgar scores also significantly improved with increased frequency of visits are consistent with what has been reported by Munjanja et al.
Whereas some authors found both women and caregivers more satisfied with the reduced frequency of visits,,, some others found the contrary., This was not evaluated in this study. Other indices of maternal and perinatal outcomes such as preeclampsia/eclampsia, admissions into Special Care Baby Unit, neonatal sepsis, and neonatal jaundice were also not subjects of this study.
| Conclusion|| |
There is no doubt that a lot of benefits is derived from antenatal care in terms of eventual outcome of pregnancy. However, with paucities of resources and personnel in developing countries, it would seem prudent to reduce the number of visits required of a client, and instead make these visits more focused and goal-oriented. A moderate number of 4–6 visits would seem adequate for both mother and infant and is acceptable to the women. A drive to make our women book early in pregnancy one believes should be given more priority though.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Malloy MH, Kao TC, Lee YJ. Analysing the effect of prenatal care on pregnancy outcome: A conditional approach. Am J Public Health 1992;84:1450-7.
Douglas JB, Rodney ET, Leindecker K, Marques D, Marques L, Quattrocchi M. Clinical obstetric outcomes related to continuity in prenatal care. J Am Board Fam Pract 2001;14:418-23.
van Eijk AM, Bles HM, Odhiambo F, Ayisi JG, Blokland IE, Rosen DH, et al.
Use of antenatal services and delivery care among women in rural Western Kenya: A community based survey. Reprod Health 2006;3:2.
Hollowell J, Oakley L, Kurinczuk JJ, Brocklehurst P, Gray R. The effectiveness of antenatal care programmes to reduce infant mortality and preterm birth in socially disadvantaged and vulnerable women in high-income countries: A systematic review. BMC Pregnancy Childbirth 2011;11:13.
National Population Commission (Nigeria) and ICF International. Nigeria Demographic and Health Survey 2013. Abuja, Nigeria; 2014.
Akanbiemu FA, Manuwa-Olumide A, Fagbamigbe AF, Adebowale AS, et al
. Effect of perception and free maternal health services on antenatal care facilities utilization in selected rural and semi-urban communities of Ondo State, Nigeria. British Journal of Medicine and Medical Research 2013;3:681-97.
Young A, Chad T. The effectiveness of current antenatal care. In: Studd J, editor. Progress in Obstetrics and Gynaecology. Vol. 12. New York: Churchill Livingstone; 1996. p. 3-18.
Binstock MA, Wolde-Tsadik G. Alternative prenatal care. Impact of reduced visit frequency, focused visits and continuity of care. J Reprod Med 1995;40:507-12.
McDuffie RS Jr., Beck A, Bischoff K, Cross J, Orleans M. Effect of frequency of prenatal care visits on perinatal outcome among low-risk women. A randomized controlled trial. JAMA 1996;275:847-51.
World Health Organization. W.H.O. Antenatal Care Randomized Trial: Manual for the Implementation of the New Model. W.H.O. Reproductive Health Library Number 5. Geneva: World Health Organization; 2002.
Ekele BA, Audu LR. Gestational age at first antenatal attendance in Sokoto, Northern Nigeria. Trop J Obstet Gynaecol 1998;15:39-40.
Adinma JI, Adinma A, Ikechebelu JI, Adinma E. Influence of antenatal care on the haematocrit value of pregnant Nigerian Igbo women. Trop J Obstet Gynaecol 2002;19:68-70.
Dop MC, Blot I, Dyck JL, Assimadi K, Hodonou AK, Doh A. Anemia at delivery in Lome (Togo): Prevalence, risk factors and consequences in newborn infants. Rev Epidemiol Sante Publique 1992;40:259-67.
Taner CE, Ekin A, Solmaz U, Gezer C, Çetin B, Kelesoglu M, et al.
Prevalence and risk factors of anemia among pregnant women attending a high-volume tertiary care center for delivery. J Turk Ger Gynecol Assoc 2015;16:231-6.
Shulman CE, Dorman EK. Importance and prevention of malaria in pregnancy. Trans R Soc Trop Med Hyg 2003;97:30-5.
Nwali MI, Ejikeme BN, Agboeze JJ, Onyebuchi AK, Anozie BO. Plasmodium falciparum
parasitaemia among booked parturients who received two doses of sulfadoxine-pyrimethamine (SP) for intermittent preventive treatment in pregnancy (IPTp) in a tertiary health facility Southeast Nigeria. Niger Med J 2015;56:218-24.
Agan T, Ekabua J, Udoh A, Ekanem E, Efiok E, Mgbekem M. Prevalence of anemia in women with asymptomatic malaria parasitemia at first antenatal care visit at the University of Calabar Teaching Hospital, Calabar, Nigeria. Int J Womens Health 2010;2:229-33.
Uneke CJ, Sunday-Adeoye I, Iyare FE, Ugwuja EI, Duhlinska DD. Impact of maternal Plasmodium falciparum
malaria and haematological parameters on pregnancy and its outcome in Southeastern Nigeria. J Vector Borne Dis 2007;44:285-90.
Bodeau-Livinec F, Briand V, Berger J, Xiong X, Massougbodji A, Day KP, et al.
Maternal anemia in Benin: Prevalence, risk factors, and association with low birth weight. Am J Trop Med Hyg 2011;85:414-20.
Nnatu S. Epidemiology of foetal birth weight in Nigeria. Trop J Obstet Gynaecol 1990;8:31-4.
Gini PC. Gestational duration in Igbo women and its relationship with birth weight and parity. Trop J Obstet Gynaecol 1991;9:57-64.
Osungbade KO, Ayinde OO. Birth outcomes among booked and unbooked women at a secondary health facility in Southwest Nigeria: Implications for strengthening perinatal health services. J Child Health Care 2011;15:320-8.
Yilgwan CS, Abok II, Yinnang WD, Vagime BA. Prevalence and risk factors of low birth weight in Jos. Jos J Med 2009;4:12-5.
Takai IU, Bukar M, Audu BM. A prospective study of maternal risk factors for low birth weight babies in Maiduguri, North-Eastern Nigeria. Niger J Basic Clin Sci 2014;11:89-98.
Saaka M, Rauf AA. Relationship between uptake of antenatal care services and low birth weight in the Gushegu district of Northern Ghana. Int J Child Health Nutr 2016;5:3.
OECD. Infant Health: Low Birth Weight, in Health at a Glance: Europe 2012. Berlin: OECD Publishing; 2012.
Munjanja SP, Lindmark G, Nyström L. Randomised controlled trial of a reduced-visits programme of antenatal care in Harare, Zimbabwe. Lancet 1996;348:364-9.
Sikorski J, Wilson J, Clement S, Das S, Smeeton N. A randomised controlled trial comparing two schedules of antenatal visits: The antenatal care project. BMJ 1996;312:546-53.
Carroli G, Villar J, Piaggio G, Khan-Neelofur D, Gülmezoglu M, Mugford M, et al.
WHO systematic review of randomised controlled trials of routine antenatal care. Lancet 2001;357:1565-70.
[Table 1], [Table 2], [Table 3]