Determinants And Implications For Focused Antenatal Care Interventions

Determinants And Implications For Focused Antenatal Care Interventions The coverage of antenatal care (ANC) in many areas is known and there are a number of interventions to encourage use of ANC services by pregnant women. However, for women who attend ANC, it is important that they register at the appropriate time and pay a given number of visits over the pregnancy period to ensure that they receive the interventions recommended for the antenatal period at the right time. When a pregnant woman makes regular contact which her skilled antenatal care provider, she is in a position to receive various services such as those meant for prevention of eclampsia, intermittent preventive treatment for malaria, early detection of HIV/AIDS infection and prevention of mother-to-child transmission, micronutrient supplementation, birth preparedness and provision of information on danger signs occurring while she is pregnant or during delivery.1 Presently, Nigeria is transiting to the Focused Antenatal Care (FANC) approach promoted by the World Health Organization (WHO ) which is aimed at ensuring that each antenatal visit counts and that antenatal care interventions are delivered at the appropriate time.2 FANC is one of the pillars of safe motherhood. The goal of FANC is to ensure that pregnancy is normal through for major actions: identification of pre-existing health conditions, early detection of complications arising during the pregnancy, health promotion and disease prevention and birth preparedness and complication readiness planning.3The interventions are deployed in such a way that they are appropriate for the womans stage of pregnancy.4 Unlike the previously used routine care which was ritualistic and frequent visits, the FANC approach emphasizes evidence-based goal-directed actions, family-centred care, quality, rather than quantity of visits as well as care by skilled providers.3 4 Thus, numerous routine visits are no longer recommended and are considered a burden to women and the health care system. The FANC approach also deemphasizes the routine risk assessment approach for classifying women into high and low risks groups.2 With the risk assessment approach, women attending antenatal care were offered services which include blood pressure check, urinalysis to detect protein or bacteria, and blood test to rule out syphilis or anaemia.5 However many women classified as low risk end up having a false sense of security, are unable to recognize and respond to problems and end up developing complications. In addition, most high risk women give birth without complications and the excess care provided constitutes an inefficient use of scarce resources. The FANC approach in Nigeria requires that pregnant women would have paid the first visit for ANC by the 16 week of pregnancy or earlier when the women first thinks she is pregnant, the second between the 24th to 28th week, the third at the 32nd week and the 4th at the 36th week of pregnancy.2 Some authors have considered early booking to mean that a woman pays her first visit before the 14th week to achieve the aim of improved outcome of pregnancy both for a mother and her unborn child.6 Thus, by 36 weeks, a pregnant woman should have made the required minimum of four visits while those with risk of complications of conditions that can impact on pregnancy would require additional visits. The time of booking and ANC attendance can affect the effectiveness of interventions recommended for pregnant women and thus the goals of FANC. Early booking helps ensure that problems are detected and managed early.2 The first visit gives the opportunity to record information on family, maternal and medical history, carry out a physical examination, request laboratory tests, provide care including intermittent preventive treatment (IPT) for malaria in pregnancy (if beyond first trimester), provide counselling including birth plan, use of insecticide treated bed nets (ITN), HIV counselling and testing and to discuss the schedule for care. The subsequent visits are necessary for noting complaints, targeted physical examination, reviewing test results, providing care including IPT for malaria, obtaining information on use of ITN, birth plans and carrying out HIV counselling. Justification for the study Interventions for pregnant women aim protect the woman and her unborn baby for the remaining period of the pregnancy and their provision should be timely. The later the timing of first visit the shorter the period of cover and the higher the risk of development of problems and complications for the woman and her baby. Thus it is not just important to know the proportion of pregnant women attending ANC, it is also important to know when attendees commence such visits and whether they pay an adequate number of visits. Although a number of studies have documented the timing of first visit and number of visits to ANC in the south-west region of Nigeria, little is known about the pattern in the south eastern region of the country. Additionally, most of the studies are limited in scope as they are facility based (usually tertiary hospital based) and thus reflect experience amongst pregnant women who are able to access such facilities even though primary health centres are the closest to people and usually the only available point of care in rural areas. Aim: This study is aimed at documenting the socio-demographic predictors of timing of ANC booking and subsequent attendance amongst pregnant women in order to understand the impact these can have on deployment of focused antenatal care interventions for pregnant women. Objectives: To determine the timing of booking and pattern of subsequent ANC attendance among pregnant women attending primary level facilities To examine whether the timing of ANC booking and clinic attendance is affected by individual level socio-demographic factors To assess the appropriateness of timing of booking and attendance for effective delivery of focused antenatal care interventions To examine how the findings of the study can impact on the deployment of antenatal care interventions for pregnant women. CHAPTER TWO LITERATURE REVIEW The concept of focused antenatal care is based on the assumption that since every pregnancy faces the risk of development of complications, every pregnant woman should be monitored to avoid development of such complications.2 Lack of antenatal care is known to be a major risk factor for development of negative pregnancy outcomes. However, when antenatal care is appropriately delivered, it has the potential to positively impact on maternal mortality and morbidity.7 Studies have shown that many women obtain care quite late during the pregnancy period and the care obtained is usually inadequate.2 8 9 The first visit for antenatal care in Africa usually takes place around the fourth to fifth month of pregnancy.5 In the African region, 73% of pregnant women aged 15 49 years pay at least one visit to a health care provider for antenatal care while only 44% pay at least four visits.10 A study by Al-Nasser in Saudi Arabia showed that majority (60.8%) of pregnant women attending antenatal clinic in primary health care centres were first seen before the 20th week of gestation.11 Fekede, et al noted that 42.8% of 360 pregnant women in an Ethiopian town attending antenatal clinic did so for the first time within the 3rd trimester while only 6.5% had the recommended minimum of four visits.12 In Nigeria, the figures assessing antenatal care utilization are below the African regional values as 58% of women aged 15-49 years receive ANC from a skilled health provider at least once during pregnancy while 45% of women make four or more visits for ANC.2 10 Based on the 2008 NDHS the median gestational age at booking is 5 months.2 Among 395 women attending antenatal clinic in public and private facilities covering the primary, secondary and tertiary levels of care in Ibadan, southwest Nigeria, 25.8% paid the first visit for antenatal care within the first trimester. Mean gestational age at booking was found to be 18.5 (Â ±6.3) weeks while the mean number of antenatal visits was 4.0 (Â ±2.4).13 A study carried out among 378 pregnant women attending a tertiary hospital in Edo state Nigeria noted that the 6th month of pregnancy as the peak period of first visit for antenatal care among the women.14 Okunlola et al found a mean gestational age at booking of 21.82 (Â ±7.0) weeks wi th only 14.1% of the women paying attending for the first time within the first trimester.6 In a tertiary facility in Osogbo Nigeria, the mean gestational age was found to be 20.3 (Â ±6.2) weeks and 82.6% of those studied booked late.15 Amongst 400 women attending antenatal clinic at a tertiary facility in Ile Ife, Nigeria, 71% had registered by the 20th week of gestation.16 Aluko and Oluwatosin found low rates of first trimester booking and irregular visits for antenatal care among women attending clinics in a mission hospital in Ibadan south west Nigeria.17 Socio-demographic factors and parity have been found to directly influence the timing of first visit for antenatal care though the results are sometimes dissimilar. Most women (79.9%) attending antenatal clinic in a tertiary hospital in Edo state Nigeria were found to have booked late.18 However, there was no significant difference in age, parity, level of education and social class between women booking early and late. In a study carried out among pregnant women attending a the Lagos University Teaching Hospital, Adegbola found a mean gestational age at first booking of 18.5 (Â ±8.3), 18.4 (Â ±7.4) weeks for nulliparous and primiparous women respectively.19 The overall mean gestational age at booking was 19.1(Â ±7.2) weeks. Women with parity 5 booked at significantly higher mean gestational age of 25.9 (Â ±) weeks and women of lower social class tend to book earlier for antenatal care. Similarly Adeyemi, et al found that late booking was thrice as common in multiparous women com pared with the nulliparous group and the difference was significant.20 Other authors have found an association between parity and timing of first visit, and number of antenatal visits.11 21 A number of studies have documented the factors that affect use of ANC amongst women in the developing countries;9 these determinants are also likely to affect the timeliness of attendance for ANC. Chandrashekar, et al found that women who are poor, illiterate, multiparous, unskilled and over 30 years of age were less likely to receive antenatal care in India.22 Age was found to be a significant predictor of ANC attendance in a community based study in Ethiopia where women aged 15-24 years were found 2.75 times more likely to attend than those aged 25-34 years.12 Geographic place of residence can also have an impact as women living in urban areas are more likely to receive antenatal care during pregnancy. Women have also been found to concurrently use multiple antenatal care providers and this can affect the timing of booking in a facility. Adeoye, et al found that 25% and 30.5% of women attending two antenatal care clinics in a tertiary facility in Ebonyi state were concurrently using both formal and informal providers of antenatal care.23 Of 535 women attending a tertiary facility in Enugu Nigeria, 69.5% were booked in more than one facility.24 The time of commencement of ANC visits has implications for the period of protection that pregnant women have from interventions. For example where women attend antenatal care late in pregnancy, they may not receive the recommended 2-3 doses of Intermittent Preventive Treatment (IPT) for malaria in pregnancy using sulphadoxine-pyrimethamine combinations.25 Data from the 2008 National Demographic and Health Survey (NDHS) shows that among 11,027 women aged 15 49 years with a live birth within a period of 2 years preceding the survey, only 8.0% received at least one dose of IPT while 4.9% received 2 or more doses.2 The proportion was 9.9% and 5.4% respectively for the south east region of Nigeria. It is important that pregnant women are available at the appropriate time for delivery of IPT which is best given when the growth of the foetus is occurring at its highest velocity (16th 24th week) as this helps to reduce placental parasitaemia, foetal growth reduction and the resultant low birth weight.26 It is also known that the negative impact of malaria is worse among women with their first and second pregnancies compared to those that have had more than two pregnancies.27-29 Thus primi and secundi-gravidae need to pay their first visit early enough to ensure adequate protection through the pregnancy period. The same consideration holds sway for interventions such as insecticide treated nets for which the potential protective time period depends on how early in pregnancy a woman starts sleeping under the net. All it all, timely attendance to ANC is important to enhance the potential for positive pregnancy outcomes since it provides pregnant women with the opportunity to receive recommended interventions and the protection from problems and complications. Socio-demographic and maternal factors such as parity can affect the timeliness of ANC visits by pregnant women. CHAPTER THREE METHODOLOGY Study area: This study will be carried out in Enugu State, South-East Nigeria. Enugu state comprises of 17 Local Government Areas (LGAs), has a total population of 3,257,298 people and an annual growth rate of 3.0.30 Three of the 17 LGAs (Enugu North, Enugu South and Nsukka) are urban, one (Enugu East) has a mix of urban and rural areas while the remaining 13 LGAs are rural. The people of Enugu are of Igbo ethnicity and are predominantly Christians. A substantial proportion of the working population in the state is engaged in farming, trading, and public service employment. Study site: Two areas will be purposively selected for the study to enable collection of data across for those in both urban and rural areas of the state. These are Udi LGA comprising Udi North and South Development Councils will be used to represent the rural areas while Enugu North and South LGAs will represent the urban areas. Udi has a population of 234,002 while Enugu North and South have a population of 244,852 and 198,723 respectively.30 Udi LGA has 14 primary health facilities that offer ANC services while Enugu North and South (referred to as Enugu) together have 12 primary facilities that offer ANC (appendix 1). Study design: This will be a cross-sectional study involving eliciting of information from pregnant women attending primary health centres for antenatal care through exit interviews using a pre-tested questionnaire. Sampling and sample size: All the primary health care facilities providing ANC in the study LGAs will be used for the study. Since the level of attendance of ANC varies for different facilities, a proportionate method will be used for determining the sample size for each facility. The proportion will be determined by considering the average weekly number of antenatal clinic attendees to the facility relative to the total from all facilities as reported by the heads of the facilities and the relative proportion will be computed. The minimum sample size required for the study is 374. This was determined using the formula for determination of sample size for population proportion,31 an ANC coverage level of 58%,2 a confidence level of 95% and an error margin of 0.05. Z= 1.96 at 95% confidence level, (two-sided). p=ANC coverage = 58% d=margin of error tolerated = 0.05 Considering a potential refusal rate of 10%, 411 women will be sampled. Study tools: Data will be collected using a pre-tested interviewer administered questionnaire (appendix 2) which will be administered by trained field workers. The questionnaire will be pre-tested amongst pregnant women attending ANC at the Primary Health Centre Abakpa, Enugu East LGA which will not be used for the study. Data analysis: Epi Info statistical software will be used for data entry while SPSS and Stata Softwares will be used for data analysis. Data will initially aim to elicit the determinants of timing of booking of ANC. Subsequently, a continuous socio-economic status index will be generated using the principal component analysis technique in STATA software package 32 to enable disaggregation of data into socio-economic quintiles. Information that will be used include households asset holdings including television, radio, refrigerator, car, bicycle, rechargeable lamp, kerosene lamp, electric fan, air conditioner, motorcycle.33 The SES quintiles generated will be used in assessing differences in timing of booking for women of various SES groups. Logistic regression analysis will be employed for examination of the determinants of the timing of booking. Data analysis will also aim to estimate the proportion of women attending at the appropriate time for delivery of recommended interventions . Chi squared test will be used to test for significance of differences observed for categorical data while chi squared for trend test will be employed for ordered categorical data. All tests of significance will be done a p value of 0.05. Ethical considerations: Ethical clearance will be obtained from the Research Ethics Committee of the University of Nigeria Teaching Hospital Enugu, while permission to carry out the study will be obtained from the Primary Health Care Coordinator of the LGAs as well as from the heads of facilities to be used. Written consent will be obtained from patients who are interviewed after they have been informed of the objectives of the study and the voluntary nature of their participation.

Goblin Market by Christina Rosetti Essay

Goblin Market by Christina Rosetti I believe this poem tells a story, a story about temptation and lust, about the desire to obtain something the narrator clearly is not meant to take or have. It has similarities to the Story in the bible about the Garden of Eden. Adam and Eve have been told â€Å"You are free to eat from any tree in the garden; but you must not eat from the tree of the knowledge of good and evil, for if you eat you will surely die. † When I read the poem by Christina Rosetti it makes me think about that story because of the opening lines â€Å"I ate and ate my fill, Yet my mouth waters still;† The narrator, like Adam and Eve, felt discontented with what they were getting. They were always going to want more, never satisfied. There are subtle hints that the narrator should not be eating the fruit, but this makes the fruit taste better and more appealing. The words that have been used are double edged for example â€Å"Cherries worth getting† On it own this sounds innocent and appears to be about fruit! The double meaning here, I believe, suggests that something or someone is desired. Wanting to taste but not being quite sure; this also links with virginity, ‘untouched’ and this is where the lust comes in I think the words Christina Rosetti has chosen are extremely clever because you have to read the poem time and time again to get the true meaning; this keeps the reader interested for longer. Every time you look at this poem you find something else you didn’t notice before. I feel that to try and pull out the striking words would not be of benefit, as they are all seemingly striking and without the rest of the poem attached they would not appear as exceptional; I believe this would not be doing justice to the poem. For example the word â€Å"Pellucid† to me is very striking but alone, without the rest of the sentence, it makes no sense and the feeling is not the same. The line â€Å"Pellucid grapes without one seed† To me has much more of an effect and shows a lot more about the narrator’s emotions. I think the tone of this poem is unpredictable as there are different meanings. When you first read this poem and you see that it is about fruit, one may start to feel that the narrator is babbling, as it does not make a great deal of sense. For example â€Å"To-morrow night I will buy some more; and kissed her†. This, in the context of fruit, seems out of place and somewhat irrelevant. It is only when you read the poem again, this time realising that it is not quite as ‘innocent’ as it first seemed, that the tone changes; it becomes more exciting and profound. I would say that the mood of the poem changes when the realisation of the poem’s true meaning sinks in. While the poem just seems to be about fruit I found the persona offered no excitement or anticipation. This changes quite dramatically when you realise that the poem is actually quite unconventional as it is hinting at a sexual relationship between two women. For example â€Å"Cheek to cheek and breast to breast Locked together in one nest† At this point the voice then seems to become playfully mischievous. There are a lot of similes in this poem, for instance â€Å"Like two pigeons in one nest† I think Christina Rosetti wanted the reader to really visualise what was going on; also I feel that she used simile to create a feeling of anticipation, using a familiar image of closeness. â€Å"Like two flakes of newly fallen snow† Is very clearly talking about two people who are having a sexual relationship, but also telling us that it is the first time and in actual fact they are both virgins. Snow, when it has just fallen, is untouched and perfect in everyway thus symbolising purity. â€Å"Not a bat flapped to and fro Round their nest† Is an example of the use of metaphor in this poem. People do not sleep in a nest and yet these two people are being likened to animals. This I believe creates a feeling of peacefulness, nothing moving. This is representing that they have reached a climax and they are now enjoying the serenity of the moment. An illustration of the use of personification in this poem is â€Å"Wind sang to them a lullaby† The wind of course cannot sing but the image is used to create a peaceful atmosphere. I image it would be really calming and relaxing to have the wind singing a lullaby. Alliteration is not strongly used in this poem I could only find one example which is â€Å"And sugar sweet their sap† I feel this is to heighten the readers’ experience, making them almost taste the sugariness, thus allowing the reader to really get in touch with what is happening in the poem. This poem uses a lot of run on lines an there are only two full stops in the poem. I think this increases the anticipation as well as the feeling of expectation as you can never see how it is going to end. The metre is quite smooth and sinuous and it is used by the narrator to keep the sequence of events told in the poem flowing. The tempo and manner of the poem, as I said earlier, changes when you realise its true meaning. I feel that this happens to keep the suspense. This poem has a sporadic rhyming style because some lines rhyme and others don’t but I feel that this is in keeping with the rest of the poem’s style as it is all rather unconventional.

Jealousy By Ted Project Thesis Jealousy - 1232 Words

Self esteem has more to do with Jealousy than we thought. TED Project Thesis: Jealousy leads our minds to see things differently than they appear and create a story in our minds that isn t true. I want my audience to know how a person s self esteem affects a person and how that makes a person feel more jealous. I also want my audience to see how the mind trick us into seeing and thinking things that are not true so we can get even more jealous. I had a story that lead me to this idea of jealousy. One time I was at a party and looked over to the door and I saw my ex boyfriend walking in, and behind him I see his girlfriend. At that moment, I felt jealous. I wasn t sure why I was jealous because what happened between me and him was a long time ago. This moment had me thinking about if there are different types of jealousy there was and if there are people who got more jealous than others. As I was doing research, my mind shifted to a lot of different places which got me to this point of how jealousy leads our minds to see things differently and also a person s self esteem. Some of the research I have done is watch a TED talk called, â€Å"An Ode to Envy†, by Parul Sehgal. Sehgal talks about when she was in elementary school she felt jealousy for a classmate of hers because her classmate had a cute pencil case and was a great speller. Sehgal also talks about how she went into the teacher s grade book and changed her c lassmate A’s into D’s and some of her D’s into A’s.Show MoreRelatedDeveloping Management Skills404131 Words   |  1617 PagesAcquisitions Editor: Kim Norbuta Editorial Project Manager: Claudia Fernandes Director of Marketing: Patrice Lumumba Jones Marketing Manager: Nikki Ayana Jones Senior Marketing Assistant: Ian Gold Senior Managing Editor: Judy Leale Senior Production Project Manager: Kelly Warsak Senior Operations Supervisor: Arnold Vila Operations Specialist: Ilene Kahn Senior Art Director: Janet Slowik Interior Design: Suzanne Duda and Michael Fruhbeis Permissions Project Manager: Shannon Barbe Manager, Cover VisualRead MoreMarketing Mistakes and Successes175322 Words   |  702 Pagescould use their laptops. Social events and entertainment were Friday afternoon and evening features. As a spur for creativity, a policy was set that software engineers spend at least 20 percent of their time, or one day a week, working on whatever projects interested them. Do you see any downside to these workplace amenities? Would these influence your choosing to work for Google despite less money? Would some of these be appropriate to other firms? If so, what kind of firms? 16 †¢ Chapter 2:Read MoreStephen P. Robbins Timothy A. Judge (2011) Organizational Behaviour 15th Edition New Jersey: Prentice Hall393164 Words   |  1573 PagesSingapore Taipei Tokyo Editorial Director: Sally Yagan Director of Editorial Services: Ashley Santora Acquisitions Editor: Brian Mickelson Editorial Project Manager: Sarah Holle Editorial Assistant: Ashlee Bradbury VP Director of Marketing: Patrice Lumumba Jones Senior Marketing Manager: Nikki Ayana Jones Senior Managing Editor: Judy Leale Production Project Manager: Becca Groves Senior Operations Supervisor: Arnold Vila Operations Specialist: Cathleen Petersen Senior Art Director: Janet Slowik Art

Franklin D. Roosevelts National Industrial Recovery Act...

President Franklin D. Roosevelt’s New Deal was a package of economic programs that were made and proposed from 1933 up to 1936. The goals of the package were to give relief to farmers, reform to business and finance, and recovery to the economy during the Great Depression. Among many other new acts to help give recovery to the economy, the NIRA was born. The National Industrial Recovery Act (NIRA) was created by Roosevelt to see to the needs of industry, trade unions, and even the consumer, promoting cooperation among corporations while also establishing codes for fair competition between industries. Most importantly, the purpose of the NIRA was the put people back to work and fight the Great Depression. As Roosevelt saw it, the NIRA†¦show more content†¦The previously mentioned codes dealing with minimum work hours, wages, and labor conditions were also not working out. Those codes would not become a part of work and labor laws until later in history. Another secti on of these codes dealt with fair competition. All sorts of codes were created just dealing with fair competition, but they would not apply to antitrust laws. Antitrust laws were laws made to reduce competition between companies and prevent monopolies from forming (National Industrial Recovery Act of 1933). Since these codes did not apply to antitrust laws it basically gave businesses the opportunity to create monopolies. After monopolies were created, it had raised the prices on goods and services. That is certainly not the best thing for an economy, and to add more fuel to the fire deflation was also a major problem during this time. Deflation is the lowering of the price of goods and services. These higher prices were made on purpose to allow people like farmers to prosper. Their theory of higher prices equals more prosperity failed miserably and made the economy just stop. The prices ended up being too high, and that did absolutely nothing for the economy or the people (National Industrial Recovery Act (1933)). Another reason the NIRA wasn’t all too successful in the thirties was the lack of support it had from businesses. Larger business had given their support to the NIRA, although smaller businesses didShow MoreRelatedThe Great Depression Essay747 Words   |  3 PagesThe Great Depression From black Thursday on October 24, 1929, to December 7, 1941, and the attack on Pearl Harbor, America endured many changes concerning The Great Depression. From the Hooveradministration to Franklin D. Roosevelt; the desperate economic condition threatening the United States in the late twenties and thirties only grew worse. 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