Complete adherence to antenatal care guideline during the rst visit and antepartum complications in public health facilities: a prospective cohort study in Northwest Ethiopia

Adherence to a minimum level of recommended content during the rst Antenatal care (ANC) is low in Ethiopia but less is known about if there is an association between the level of adherence to focused ANC guideline and pregnancy outcomes. Therefore, the goal of this study was to examine the relationship between the level of adherence to Ethiopian ANC guidelines during the rst visit and maternal complications that occur during the antepartum period. cohort study in A total of 832 pregnant women with < who for their rst ANC visit were and followed until their last visit or before the commencement of labor. An 18-point checklist was used to record the level of providers’ adherence. Clients who received all the components in the ANC guideline during the rst visit adhered to by the provider were considered as an exposed group. A Log-binomial model was used to examine the relationship between the level of adherence to the guideline and the risk of antenatal complications. The adjusted Relative Risk (ARR) with a 95% Condence Interval (CI) was reported in the nal model. ascertained antenatal Both medical ANC charts of antenatal to abstract antenatal complications and recorded in the checklist prepared for this purpose. During recruitment, participants’ telephone numbers were registered. For those clients who didn’t avail themselves in the scheduled ANC visit, they were notied via a phone call. Those who could not be reached by any of these means were considered as lost to follow-up. Both the data collectors and supervisors were midwives and they were not employed in the health facilities under the study. Three days training was given on the data collection instrument, how to approach and observe the service provision to ensure the feasibility of replication of the measurements by comparable workers. For example, gestational age can be estimated from clinical information when ultrasound is not available. guideline adapted from recommendations. in in 11


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tobacco and alcohol during pregnancy. The trained providers, such as midwives and gynecologists who are working in the ANC rooms were ascertained antenatal complications. Both maternal medical records and integrated ANC charts of subsequent antenatal visits were reviewed to abstract antenatal complications and recorded in the checklist prepared for this purpose. During recruitment, participants' telephone numbers were registered. For those clients who didn't avail themselves in the scheduled ANC visit, they were noti ed via a phone call. Those who could not be reached by any of these means were considered as lost to follow-up. Both the data collectors and supervisors were midwives and they were not employed in the health facilities under the study. Three days training was given on the data collection instrument, how to approach and observe the service provision to ensure the feasibility of replication of the measurements by comparable workers. For example, gestational age can be estimated from clinical information when ultrasound is not available.

Variables
The outcome variables of the study were selected antenatal complications. These include anemia, pregnancy induced-hypertension (including pre-eclampsia and eclampsia), antepartum hemorrhage, urinary tract infection, gestational Diabetic Mellitus and premature rupture of membrane. The composite antenatal complication was de ned as the presence of at least one of the above complications.
The level of providers' adherence to the Ethiopian focused ANC guideline during the rst visit was the primary exposure variable. The other covariate variables include the type of facility, the client's socio-demographics, and obstetric factors.

Measurement of variables
Measuring adherence Provider adherence levels on the rst ANC guideline were de ned as complete or incomplete. The detailed measurement of the primary exposure variable, the adherence checklist, and the scoring criteria are described elsewhere [16].

Antenatal counseling
The extent of the counseling service during pregnancy was measured by monitoring nine composite variables. When one component of counseling service was given at all visits, it was coded as 1 otherwise 0. Composite counseling service was de ned as the service given to pregnant women who got counseling speci ed by at least one or more variables out of the nine counseling variables [27].

Anemia
Anemia was de ned as the occurrence of a hemoglobin level of less than 11 g/dL as identi ed after the rst visit [1].

Pregnancy-Induced Hypertension(PIH)
PIH was determined by measuring systolic blood pressure ≥ 140 mmHg and/or diastolic blood pressure ≥ 90 mmHg after 20 weeks of pregnancy with or without proteinuria or with tonic-colonic convulsion [30].
Antepartum Hemorrhage (APH) APH was de ned as bleeding from or into the genital tract, occurring during the third trimester of pregnancy and before the birth of the baby [30].
Gestational Diabetic Mellitus (GDM): The diagnosis of GDM was made when one or more of the following values of plasma glucose level was met (fasting: ≥ 92 mg/dL, 1 h: ≥180 mg/dL; 2 h: ≥ 153 mg/dL) after 24 weeks of pregnancy [31].
Urinary Tract Infection (UTI) UTC was identi ed by the presence of microorganisms (predominantly bacteria) in urine along with urinary symptoms of dysuria, frequency, urgency, and occasionally supra-pubic tenderness during pregnancy [30].

Spontaneous abortion
Spontaneous abortion was recognized by identi cation of vaginal bleeding through the genital tract before 28 weeks of gestation [23].
Premature Rupture of the Membrane (PROM) PROM was identi ed by recognition of rupture of membranes before the onset of labor [23].

Composite antepartum complication
The composite antepartum complication was de ned as the presence of at least one of the above complications.

Statistical analysis
Data analysis was carried out by STATA version 14 for analysis. Descriptive statistics were used to present the data in terms such as frequencies and percentages. A Log-binomial model was used to examine the possible relationship between complete provider adherence to the Ethiopian ANC guidelines during the rst visit and the risk of antenatal complications. Both the covariates and the main exposure variable were tted into the multivariable log-binomial model. Multicollinearity between variables was assessed using variance in ation factors (VIF), which was < 10 for all variables. The risk of each antenatal complication was described using the Crude Relative Risks (CRRs) and ARRs with the corresponding 95% CIs. Finally, a p-value < 0.05 was considered to identify statistically signi cant variables for each antenatal complication.

Result
Background characteristics of study participants Among the total of 832 eligible women, 808 (97.1%) of them completed their follow-up. The reasons for loss to follow-up were self-referral to other health facilities and permanent change in the workplace. There were no statistically signi cant differences at baseline among women who completed the process and those who were lost to follow-up.
Among women, who completed the follow-up, 112(13.9%) and 29(3.6%) were in the age group of 18-19 years (teenage pregnancy) and with age > 35 years (elderly pregnancy) respectively with a mean (± SD) age of 25.92 ± 1.93 years. Seven hundred ninety-two pregnant women (98%) came from the urban area. Five-hundred seventy (70.5%) women were booked for their rst visit after 16 weeks of gestation and 234 (28.9%) had 2-4 visits. One-fth (21.8) of study participants had a history of previous pregnancy complications. Details of the socio-demographic and obstetric characteristics of the participants in the exposed and non-exposed groups are given in Tables 1 and 2.   Table 1 Socio-demographic characteristics of study participants among exposed and unexposed groups in Gondar town public health facilities, 2020(n = 808).  Table 2 Obstetric characteristics of study participants among exposed and unexposed groups in Gondar town public health facilities, 2020 (n = 808)

Incidence of antepartum complications
Overall, two hundred forty-ve (30.2%) of the participants developed antepartum complications. Of these, the incidence of antepartum complications among mothers who received complete providers' to ANC guideline during the rst visit was 28.6%. The incidence of anemia among mothers who received either complete or incomplete adherence providers' was 6.1% and 10.8% respectively. The incidence of GDM among the exposed (1.2%) and unexposed group (1.3%) is almost the same (Fig. 1).
The relationship between complete providers' adherence to Ethiopian ANC guideline during the rst visit and antepartum complications  (Table 5). A more details of Bi-variable analysis for each antepartum complication with all variables is shown in additional le 1 (Table 4). Table 4: Bivariable association between independent variables and selected antepartum complications among study participants in Gondar town public health facilities, Northwest Ethiopia, 2020 (n = 808) *stands for Crude P-value<0.25 hemorrhage is the leading cause of maternal deaths [19], 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][33][34] and much lower compared to the incidence in a study done in Ghana [17]. It is reasonable to believe that universal free prenatal iron supplementation could result in a decrease in the incidence of anemia [35].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 [16]. This was because of most women reported late for the rst ANC. This surprised us because we had assumed that urban residents would nd 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 [1].
Secondly, we found that pregnant women whose providers adhered completely to the Ethiopian ANC guidelines during their rst 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 [36]. 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 rst ANC visit until their last visit. Our current study nding is consistent with ndings in other studies done in Ghana [17]. The incidence of anemia after rst visit among women who received either complete or incomplete provider's adherence to ANC guideline during the rst visit was 14.9% and 16.1% respectively. The agreement between our study ndings 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 [37], it is preventable through effective ANC screening to identify the onset of PIH before it can become severe [38]. Yet paradoxically, the ndings from the present study revealed that women whose providers adhered completely to the ANC guidelines during the rst visit were found to have a higher risk of PIH. This nding is consistent with other research nding conducted in Saudi Arabia [39].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 [40].
Therefore, focusing on screening clients who were at risk of developing PIH could lead to detection during the rst visit. The screening activities done included blood pressure measurement, urine analysis for protein, and for multigravida women asked about history of PIH [41]. According to Page 10/12 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 nding 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 speci c complications rather than combined outcomes. Finally, we are not sure that the level of provider adherence to the ANC guidelines during the rst visit has a causal effect on antepartum complications with cohort study.

Conclusion
The study showed that complete provider adherence to the rst-visit ANC guideline reduces at least one maternal complication during the antepartum period. A program to increase the level of provider's adherence to Ethiopian ANC guideline document should be developed. Complete adherence to the guidelines should become an essential component of antenatal care. We also believe that early antenatal care should also be encouraged amongst the population. The protocol has been reviewed by the Institutional ethical review board of University of the Gondar for its ethical soundness, ID: O/V/P/RCS/05/498/2018. Written informed consent was sought and obtained from each participant after the purpose and objectives of the study were explained to them before they were recruited into the study. Con dentiality was also maintained.

Consent for publication: Not applicable
Availability of data and materials The dataset analyzed during the current study available from the corresponding author on reasonable request.
Competing interest: None declared.

Funding
The author(s) received no speci c funding for this work Author contributions TS conceived and designed the study, analyzed the data and prepared the manuscript. MA, KC, and HL assisted in the development of the research idea, analysis, interpretation and preparation of the manuscript. All authors read and approved the nal manuscript.