A key component to reduce neonatal morbidity and mortality is having a high-quality ANC with a skilled provider [1, 2,3]. However, the neonatal mortality rate in Sao Tome and Principe remains high and it is necessary to unveil the proportion of women in STP obtaining complete ANC attendance with the essential interventions preconized. Therefore, with this study we aimed to know current ANC practices in the country, screenings performed, and antenatal problems commonly detected among pregnant women.
Regarding timing of first ANC visit and rate of attendance, we found that a high percentage (71.4%) of pregnant women attended before the 16th week. This finding is much higher compared to other studies in sub-Saharan Africa, per example, Tanzania 12.4%, Nigeria with 15.4%, Zambia with 17%, and Ethiopia with 27.5% [7, 39, 40]. Practically all women had at least one visit, what is in accordance with the rate published by the UNICEF’s 2019 Multiple Indicator Cluster Survey for Sao Tome and Principe (MICS6-STP) . Complete ANC attendance (8 or above visits) was achieved by 38.7% of pregnant women and a total of 84% had the minimum of 4 visits. The uptake was found to be higher than reported for the country regarding a minimum of four visits (12.8%) and eight attendances (4.3%) . It was also observed to be higher compared to the rates published for sub-Saharan countries with 13% of women not attending antenatal care at all and 53% having a minimum of 4 visits .
Detecting high-risk pregnancies is key in most prenatal programs in all developing countries and is also challenging . Age and parity are the most frequently used risk factors to define high risk. Most evidence for using age and parity as risk criteria comes from studies of perinatal mortality but increased risk has also been demonstrated for women at the extremes of the fertile age range nulliparae or grand multiparae . Women with risk factors for high-risk pregnancies have a one in four chance of developing complications than those with a low risk of high-risk pregnancies who have nearly one in ten [15, 42]. In this study, one third was registered as having a high-risk pregnancy in their antenatal cards, mainly due to advanced maternal age (16.8%) and teenage pregnancy (5.4%) as defined ≤16 years old in national guidelines. This is in accordance with the 10% to 30% rate reported worldwide of pregnancies estimated to be “at-risk” .
Regarding risky behaviours as alcohol consumption and the presence of domestic violence during pregnancy the percentage of notifications registered by the nurses in the antenatal cards was very low taking into consideration country MICS6-STP data . One can speculate that healthcare providers are not motivated enough to ask and report these risks.
Height, weight, and body mass index are not registered during antenatal care visits in STP as it’s not mandatory according to the WHO 2016 recommendations . Details of previous pregnancies, contraception, planned pregnancy, present medical problems and signalling of high-risk pregnancies were often missing. The antenatal card should be designed to make documentation easier, but it was found that important information was not always adequately recorded. This may impact on both maternal and foetal outcomes .
Routine nutritional interventions and blood pressure measurement were met in a high proportion (80-85%) as recommended during antenatal period to prevent maternal anaemia, puerperal sepsis, low birth weight, and preterm birth .
Intermittent preventive treatment for malaria during pregnancy was provided to half of the women and a high proportion received an insecticide treated net, similar to other nearby countries as Gabon . However, only 4.2% of pregnant women received a full IPTp-SP dose (at least two curative doses), a proportion much inferior compared to Gabon, that reaches 55% . By contrast, bed net coverage was higher for STP (85.3%) than the estimated for Gabon (60%) .
Antenatal screening of HIV, hepatitis B virus and syphilis are free of charge and approximately all pregnant women (89 to 94%) had one test for HIV and syphilis done. Nevertheless, only half had two HIV tests and 1.2% tested twice for syphilis. When compared to other evidence-based screenings that have costs for women, this rate drops substantially. For instances, having two haemoglobin and urine tests is only accomplished by ten percent of those with adequate ANC (4-7 visits) and by thirty percent of those with complete ANC (8 or more contacts).
Regarding evidence-based interventions completion according to number of attendances, pregnant women with complete ANC had more two testes done for each screening in comparison to the pregnant women with adequate and inadequate ANC.
Around sixty percent of the pregnant women performed one obstetric ultrasound. Still, only half of them did it before the 20th-24th week. Missing an early ultrasound represents a lost opportunity for detection of multiple gestation, congenital anomalies, estimate gestational age, foetal malpresentation and placenta praevia and needs to be urgently addressed . This reinforces that pregnancy costs are a blockage for reaching the optimal antenatal care.
Poverty may constitute a great barrier to accessing antenatal health services and can explain the incomplete use observed . Pregnant women may not have the financial resources needed to pay for the services rendered, especially if they cost 17 USD when living on a budget of 1.40 USD per day. This may explain why a complete ANC utilization is reached only by 38.7% of pregnant women.
Then again, poverty alone doesn´t explain why only half pregnant women are tested twice for HIV and only less than 2% for syphilis when these screenings are free. These findings also elucidate the existence of health system failures on the quality of ANC provision. As reported in other studies, offering total free ANC may be insufficient in improving ANC utilization because there are other significant barriers . Understanding all the demographic, societal, and cultural factors such as economic status, residence, decision making, educational opportunities, and transportation could help improving women’s health and accessibility to maternal health services .
Nonetheless, health system improvements that enhance the efficiency and broaden the benefits of free package for women reproductive health care services can go a long way to improve long term health gains for maternal and newborn health outcomes in Sao Tome and Principe.
Major gaps in the diagnosis, treatment and follow-up of pregnant women were identified through this study. For instance, anaemia during pregnancy is a public health problem that leads to different life-threatening complications and poor pregnancy outcomes . In this study, 36.4% of pregnant women were anaemic and this finding is lower than official data from a previous study in the country that revealed an anaemia prevalence of 61% in pregnant women . Illustrating a high rate of anaemia among pregnant women in STP when the overall prevalence for Africa is 41.82%, with differences between countries which ranged from 23.36% in Rwanda to 57.10% in Tanzania . Thus, maternal anaemia in STP should be urgently treated by national policy in order to enhance newborn health and survival .
Other maternal issue related to adverse neonatal outcomes identified in this study is the high prevalence of asymptomatic urinary tract infections in pregnancy. We identified a rate of 43.2% of asymptomatic bacteriuria (ASB), which is more than double of the range usually reported for pregnant women in LMIC (2% to 16.43%) . Besides the high prevalence of ASB, we also identified that almost half of those in this situation go through all pregnancy without either receiving antibiotic treatment, neither repeating the urine tests. Furthermore, and unlike culture, strip urinalysis fails to identify the etiologic agents and the antibiotic sensitivity pattern. This practice will not allow proper management of urinary tract infection in pregnant women attending antenatal care in Sao Tome and Principe thus increasing their risk for complications. Additionally, the country doesn’t have the resources to perform urine cultures. Due to the above reasons, the burden of urinary tract infections in pregnant women and its associated complications in this country is highly underestimated.
Intestinal infections by parasites are highly frequent in STP and in this study almost 55.5% of pregnant women had at least one parasite . Anthelmintic treatment was administered in twenty percent of cases. Taking into account the country prevalence of anaemia, the implementation of preventive anthelminthic treatment for pregnant women, after the first trimester, as part of worm infection reduction programmes should be discussed .
HIV was detected in four (0.8%) pregnant women, what is in accordance with published data (0.2% in 2015) for the country . Syphilis was diagnosed in five (1%) women and although the vast majority had done only one test, this percentage is much lower than the estimated pooled prevalence of syphilis (2.87%) in sub-Saharan Africa . The STP´s HIV and sexually transmitted infections programs led to a decrease in the incidence of syphilis in pregnant women and congenital syphilis. Syphilis in pregnant women significantly decreased from about 1.8% in 2008 to 0.8% in 2017 in the country . There were no cases of congenital syphilis during that period. The percentage of women that required syphilis treatment in this study is identical to that published in other resourced-constrained countries as South Africa and Angola [34, 49]. This is a noteworthy point in the context of the triple elimination of HIV, syphilis and hepatitis B in Sao Tome and Principe. Regarding hepatitis B, expansion to universal newborn hepatitis B birth-dose vaccination (HepB-BD) without maternal screening started at the end of this study (third trimester of 2018) what is an excellent achievement for newborn health. Before that, the country had a selective hepatitis B birth-dose vaccination (HepB-BD) strategy targeting infants born to mothers who test positive for hepatitis B virus (HBV) surface antigen missing out many newborns as maternal screening for hepatitis B was low .
Typhoid fever is endemic in STP as common in low-resource environments that lack access to clean water and adequate sanitation . Typhoid fever was registered for 14.8% pregnant women. However, the mean sensitivity, specificity, negative and positive predictive value of Widal test remains below 80% . Therefore, the low specificity of this test and can lead to an over diagnosis of typhoid fever that may result in the overuse of antibiotics and delay the proper treatment for underlying conditions . The efficiency of Widal test in diagnosing typhoid fever without other confirmatory tests is not of diagnostic value, thus, it should not be recommended as a routine antenatal care practice in Sao Tome and Principe .
Gestational diabetes mellitus low rates in this study can also be underestimating the reality, taking into consideration, that half of the pregnant women only tested once and less than twenty percent tested twice throughout all pregnancy. Preeclampsia cases detected during ANC visits was of 7% what is in accordance to the range of 3% to 10% published for LMIC .
Another concern identified in this study is the risk for RhD alloimmunization as Rhesus factor was negative in 5.8% pregnant women. Similar frequency of RhD-negative phenotype was published in Nigeria 4.44%, 3.9% in Kenya, 4.06% in Guinea and 2.4% in Cameroon . Although, it is a much lower than the ≥14% prevalence of Rh-negative phenotype among Caucasians . This risk of alloimmunization to RhD can cause perinatal adverse outcomes and compromise women’s obstetric care in Sao Tome and Principe due to the unaffordability of anti-D immunoglobulin.
Sickle cell anaemia or the sickle cell trait was suspected in 13% pregnant women highlighting a crucial need to understand the burden of SCD in the country. Novel, rapid, inexpensive, and sensitive immunoassay-based point-of-care tests kits, found to have high sensitivity and specificity in sub-Saharan African settings should be available in STP for neonate screening programmes [24, 45, 46].
Sao Tome and Principe have made remarkable progress towards reaching a good coverage of ANC services and early attendance rates. Nevertheless, attending many antenatal care visits during pregnancy does not guarantee receiving the receipt of interventions that are effective in improving newborn health as highlighted in this study.