This study contributes to the body of knowledge on the relationship between the level of provider adherence to the Ethiopian ANC guidelines and the incidence of antepartum maternal complications. Our findings demonstrated that complete provider adherence to the ANC guidelines during the first visit was associated with a lower risk of anemia in the mothers, but a higher risk for PIH.
During the antepartum period, over 26% of the study participants in the current study had at least one type of complication. Among these complications, the incidence of anemia was the highest (9.1%), and the incidence increased as the gestational age increased. In a country where hemorrhage is the leading cause of maternal deaths , this is troubling since anemia will affect the capacity of the woman to adequately compensate physiologically in case of bleeding during childbirth. The incidence of anemia among the subjects in the present study was, however, much lower than the incidence reported in other studies conducted in Ethiopia [32–34] and much lower compared to the incidence in a study done in Ghana . It is reasonable to believe that universal free prenatal iron supplementation could result in a decrease in the incidence of anemia.In addition, the women in the present study, unlike those in many other studies, were all urban residents. Urban women tend to have better access to information about basic pregnancy care.
Although 93% of the participants in our baseline study were prescribed iron tablets when they entered the study, only one of three began to take these at gestational week 16 or before . This was because of most women reported late for the first ANC. This surprised us because we had assumed that urban residents would find it perhaps easier to attend on time than would women living in other settings. We did not attempt to ascertain the reasons for not attending at the assigned time. Late arrival led to late prescription and taking of iron and folic acid tablets. It is clear that in accordance with WHO recommendations, programs must be strengthen to insure that iron tablets and folic acid are prescribed and provided for pregnant women and taken as early as possible during pregnancy .
Secondly, we found that pregnant women whose providers adhered completely to the Ethiopian ANC guidelines during their first visit were at a lower risk of anemia by 46%. The plausible explanation for the reduction of anemia among these women is that the provider made clear to them that they were to take the prescribed iron tablets and folic acid. Another contributing factor was that the counselors explained how to take the iron tablets and how to minimize any possible side effects of these medications so that the women would take them on schedule until they gave birth. Orally administered iron can cause nausea and dyspepsia, and the level of these side-effects seems to be linked to the amount of iron absorbed . Therefore, the counselor must explain to each woman how to minimize side effects. In the current study, 69.1% of pregnant women received counseling service on iron supplementation continuously from the first ANC visit until their last visit. Our current study finding is consistent with findings in other studies done in Ghana . The incidence of anemia after first visit among women who received either complete or incomplete provider’s adherence to ANC guideline during the first visit was 14.9% and 16.1% respectively. The agreement between our study findings and those in the study done in Ghana could be due to similarities in the study setting, nature of study design and use of the same ANC guideline adapted from WHO recommendations. The study done in Ghana was a cohort study conducted in 11 health facilities in the Greater Accra region.
Though PIH is one of the unpredictable maternal complication , it is preventable through effective ANC screening to identify the onset of PIH before it can become severe . Yet paradoxically, the findings from the present study revealed that women whose providers adhered completely to the ANC guidelines during the first visit were found to have a higher risk of PIH. This finding is consistent with other research finding conducted in Saudi Arabia.In Both studies, it is possible to explain the positive association between exposure and the risk of antepartum PIH in more than one way. This is probably because it is uncertain whether early detection of pre-eclampsia will reduce the incidence of eclampsia, and preventive interventions like calcium supplementation are not completely effective in reducing the risk of pre-eclampsia . Therefore, focusing on screening clients who were at risk of developing PIH could lead to detection during the first visit. The screening activities done included blood pressure measurement, urine analysis for protein, and for multigravida women asked about history of PIH . According to the finding from our baseline cross-sectional study, Women with previous complications received complete adherence to a higher extent . This might lead health care providers to follow clients more strictly during the antepartum period than they normally would. Finally, clients who had received complete provider adherence to the first visit ANC guideline might be well counseled about the danger signs. This would probably make clients more aware of their risks and make them more conscious of the need to come to the health facility when they saw the severity signs .
However, the finding of this study was incongruent with the findings of a previous study done in Ghana which reported no significant association between received complete provider adherence to ANC guideline during the first visit and PIH identified during antepartum period. These differences may be attributable to different clinical reasons. In the Ghana study, PIH was ascertained from the data collected from medical records retrospectively from the facility. Complications detected during pregnancy might be underreported by the health care providers. Therefore, a strong prediction tool should be developed to screen pregnant women who are at high risk of developing pre-eclampsia.
Health promotion through tailored counseling during the antepartum period was not consistently addressed in the current study. Health promotion is one of the core components of routine ANC visits that ideally would be addressed across during every ANC visit . Advice on HIV testing and counseling, birth preparedness, complication readiness and advice on nutrition and risk of alcohol and smoking were the least addressed health promotion services across all visits during pregnancy. High client load and scarcity of staff were the major reasons for not adhering to health promotion services in the study public health facilities . In a situation when more clients seek care per day, providers would choose which guideline items they will deal with by exempting other cervices.
The results of our study have this implication for the clinical practice. Full adherence to ANC guidelines is essential. The provider who does not adhere may fail to inform the pregnant woman about something that could result in dire consequences. Perhaps providers need to use ANC guideline to ensure that every item is dealt with during the first visit.
The prospective cohort design is the major strength of our study. The cohort design enabled us to assess the effect of single exposure on multiple antenatal complications simultaneously. In addition, we have done everything possible to minimize the magnitude of loss to follow-up during the enrollment and follow-up period. The study does, however, have limitations, which should be noted. The principal limitation of the study is that the finding of the study is not generalizable to all outcome variables. For example, only 10 and 17 participants had GDM and spontaneous abortion among all participants respectively. It would have been better to calculate the sample size for specific complications rather than combined outcomes. Finally, we are not sure that the level of provider adherence to the ANC guidelines during the first visit has a causal effect on antepartum complications with cohort study.