Early access to antenatal care can help stop mothers from dying during childbirth, writes Dr Anja Smith of the Department of Economics at Stellenbosch University in an opinion piece published on The Conversation website on Monday (2 May 2016).

• Read the complete article below or click here for the article as published.
  

Early pregnancy care crucial in preventing maternal deaths

Anja Smith

South Africa has extremely high maternal mortality levels compared to developed countries and even other developing countries. According to World Health Organization (WHO) estimates for 2015, 138 women per 100,000 live births in South Africa died due to pregnancy and childbirth related reasons. In Sweden, fewer than five women per 100,000 live births died from the same causes, while for Brazil, the estimate was 44 women per 100,000 live births.

Since many South African women die preventable deaths during and due to pregnancy and childbirth, and many children grow up without their mothers as a result, it is necessary to understand why this is happening.

Unlike many other developing countries, most South African women give birth in healthcare facilities and attend pregnancy care. On average, pregnant women visit antenatal clinics for almost the minimum number of four times as recommended by the WHO. However, many women who attend antenatal care for the first time in their pregnancies go to the clinic too late. And here lies part of our high maternal mortality problem.

So, why do pregnant women visit clinics too late? Is it due to their behaviour and choices, or is it due the way the public health system operates?

Research from different parts of South Africa shows that pregnant women may visit clinics late because only a limited number can be accommodated on any given day. They may go to antenatal care clinics early in their pregnancies, but are then told to return on another day. Or they go to clinics, but are not treated with dignity or provided appropriate services, making it difficult for them to see the value in pregnancy care.

Some research found that women in certain areas of the country may choose not to go early because they are afraid of jealous neighbours and friends knowing about and bewitching their pregnancy. They may also fear the results (and associated stigma) of the HIV test administered as part of the routine series of pregnancy care tests. This should come as no surprise as almost a third of pregnant women who visit antenatal clinics in South Africa are HIV-positive.

Since HIV has been identified as the biggest contributor to maternal deaths in the country, it is important that pregnant women attend antenatal care clinics as early as possible  ̶  preferably during the first three months of pregnancy  ̶   for the detection and treatment of the virus. Early attendance also allows for the management of other treatable health conditions such as high blood pressure and anaemia, which are also major risk factors for maternal deaths.

These are, however, not the only reasons why pregnant women may attend antenatal care late in their pregnancy.

To find out what other factors could keep pregnant women from visiting clinics early enough, my research team and I interviewed 221 women in the Cape Metropole shortly after they gave birth at four public healthcare facilities. We asked them when in their pregnancies they first went to the clinic and, if they went late, why. We used a definition of late attendance as going to the clinic for the first time at or after 20 weeks (five months) of pregnancy.  The National Department of Health uses the same definition to monitor early visits to antenatal clinics. More than a quarter of the women said they went to the clinic late in their pregnancies. If we apply a definition of late attendance at or after three months of pregnancy, almost four in five women said they went late.

The single biggest reason more than 50% of the women gave for not going to the clinic early enough is that they only realised quite late that they were pregnant. Some said they purposefully postponed the visit.

More than two thirds of the women said nothing about the clinic would have made them go earlier. A small number of women said that when they first went to the clinic, they were asked to return on another day.

The study revealed that lower education levels and poverty also contributed towards late attendance. Women who went late were more likely to not have completed high school and were also more likely to fall among the poorest 40% of those interviewed. Women who attended late were more also more likely to say they consumed alcohol (compared to early attenders) during pregnancy.  Women who attend antenatal care late are more likely to live in difficult and vulnerable circumstances.

​Another interesting finding was that almost four in five of all the women interviewed said they had an unplanned pregnancy. This is a high figure considering the free access to contraception at public healthcare facilities. Women who had unplanned pregnancies were not more likely to attend antenatal care late if we used the five month definition of lateness. However, when we looked at the information provided by those who attended at or after three months of pregnancy, we found that they were more likely to say they had an unplanned pregnancy. Although we did not ask women whether they were using contraception when they fell pregnant, the high level of unplanned pregnancies suggests limited effective access to contraception.

So, what does this mean for policy about pregnancy care in South Africa?

Firstly, if late pregnancy recognition is one of the major reasons for late attendance, we need to make it much easier for women to recognise pregnancy. Providing better access to urine pregnancy tests is one option. These tests could be made as widely available as condoms. Early pregnancy identification is likely to not only improve antenatal care attendance rates, but also enable women to make more informed choices, for example, give them time to consider abortion in the case of an unplanned pregnancy.

Secondly, we need to think long and hard about how contraception is provided at clinics because it seems the current system is not having the intended effect in preventing pregnancies and enabling women to make better choices for themselves and their children. If we could implement these measures, we could go a long way in improving maternal health and ensuring fewer children grow up without their mothers.

*Dr Anja Smith is a post-doctoral fellow in the Department of Economics at Stellenbosch University (SU). This article is based on her recent doctorate in Economics at SU as well as a research project with Prof Ronelle Burger from the same department and Dr Vivian Black from the Department of Clinical Microbiology and Infectious Diseases at the University of the Witwatersrand.

Sources:

Haddad D A N, Makin J D, Pattinson R C, Forsyth B W. 2016. Barriers to early prenatal care in South Africa. International Journal of Gynaecology & Obstetrics. 132: 64–67.

Moodley, J. (Ed.). 2014. Saving Mothers 2011-2013: Sixth report on confidential enquiries into maternal deaths in South Africa, Short report. Pretoria: National Department of Health.

The 2013 National Antenatal Sentinel HIV Prevalence Survey in South Africa. Published 2015. Pretoria: National Department of Health.