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Table of Contents
ORIGINAL ARTICLES
Year : 2020  |  Volume : 25  |  Issue : 1  |  Page : 43-47

Association between multiple antenatal registration and pregnancy outcome in Enugu, South Eastern Nigeria


Department of Obstetrics and Gynaecology, College of Medicine, University of Nigeria, Enugu, Nigeria

Date of Submission25-Oct-2019
Date of Decision15-Nov-2019
Date of Acceptance12-Jan-2020
Date of Web Publication03-Apr-2020

Correspondence Address:
Dr. Emeka I Iloghalu
Department of Obstetrics and Gynaecology, College of Medicine, University of Nigeria, Ituku/Ozalla Campus, Enugu.
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijmh.IJMH_33_19

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  Abstract 

Background: The benefit of multiple antenatal registration for a current pregnancy is not proven with respect to pregnancy outcome. Aim: The aim of this study was to determine the association between multiple antenatal registration for a current pregnancy and maternal and neonatal complications. Materials and Methods: This was a cross-sectional study of 420 eligible women who delivered at the University of Nigeria Teaching Hospital, Ituku-Ozalla, Enugu, Nigeria, from July 2017 to September 2017. Structured pretested questionnaires were administered to consecutive 420 consenting women who delivered at the study center. Data analysis was both descriptive and inferential at 95% confidence interval (CI). A value of P < 0.05 was considered statistically significant. Results: The incidence of multiple booking was 52.1%, whereas the commonest reason was for a second opinion, 121 of 219 (55.3%). Maternal complications occurred in 12 of 121 (9.9%) of the participants who had multiple antenatal booking and in 10 of 201 (5.0%) of those who had a single-facility registration. This difference was however not statistically significant (P = 0.111, odds ratio [OR] 2.10 95%, CI 0.88, 5.03). Neonatal complications occurred in 17 of 121 (14.0%) of participants who had multiple antenatal booking and in 16 of 201 (8.0%) of participants who had a single-facility registration group. This difference was also not statistically significant (P = 0.090, OR 1.89 95%, CI 0.92, 3.90). Conclusion: There was no association between multiple antenatal registration and pregnancy outcome in terms of maternal and neonatal complication compared with single-facility antenatal registration. There is a dire need for health education to encourage single registration with a skilled birth attendant.

Keywords: Antenatal, complication, maternal, multiple booking, neonatal


How to cite this article:
Iloghalu EI, Ugwu EO, Udealor PC, Obi SN. Association between multiple antenatal registration and pregnancy outcome in Enugu, South Eastern Nigeria. Int J Med Health Dev 2020;25:43-7

How to cite this URL:
Iloghalu EI, Ugwu EO, Udealor PC, Obi SN. Association between multiple antenatal registration and pregnancy outcome in Enugu, South Eastern Nigeria. Int J Med Health Dev [serial online] 2020 [cited 2020 May 28];25:43-7. Available from: http://www.ijmhdev.com/text.asp?2020/25/1/43/281888




  Introduction Top


Antenatal care (ANC) is an essential component of maternal health care with the aim of ensuring a healthy mother and newborn at the end of the pregnancy. It provides an important opportunity for health promotion, screening, diagnosis, and also disease prevention.[1] Despite a worldwide effort to improve maternal health, perinatal and maternal morbidity and mortality is still a significant problem especially in low-income countries. In the developing countries, up to 80% of maternal deaths are caused by complications during pregnancy, delivery, and puerperium,[2] whereas these deaths are about 20% in high-income countries.[3] Pregnancy outcome has been shown to improve by adequate utilization of antenatal services.[4] The United Kingdom (UK), National Institute for Clinical Excellence (NICE) guideline recommends that the first antenatal visit should be before the end of first trimester.[5] Surveys in England[6] and the United States (US)[7] found 86% and 70.2% of pregnancies to have been booked in the first trimester, respectively. However, in the developing countries, including Nigeria, there are no existing national guidelines on ANC registration. Only 18% of pregnant women registered in the first trimester as reported in the 2013 Nigerian Demographic Health Survey (NDHS).[8] Several studies in Nigeria reported that women registered for ANC, in the second and third trimester,[9],[10],[11] hence termed late as defined after 14 weeks.[11],[12],[13] Several studies in the developed and developing countries have also shown that regular antenatal visit was associated with health facility-based delivery and improved pregnancy outcome.[14],[15],[16]

Multiple antenatal registration for a current pregnancy is a common occurrence in Nigeria especially in the urban areas.[17],[18],[19] Reported reasons for this multiple booking include fear of industrial action at government-owned hospitals, selection of a center with affordable services, residence far from desired center, and to select facility promising of vaginal delivery.[17],[18] The benefit of multiple antenatal registration for a current pregnancy is not proven with respect to maternal and neonatal outcome. However, there is also a risk of registering at a facility of lower status and level of care, hence compromising pregnancy outcome.

There are few studies that reported reasons for multiple antenatal registration and it is generally not known if this multiple antenatal registration has an effect on maternal or neonatal outcome. The aim of this study was to identify if there is any difference in maternal and neonatal outcome in relation to multiple versus single antenatal registrations for a current pregnancy, and to make recommendations that will be beneficial during health education.


  Materials and Methods Top


This was a cross-sectional study of eligible parturients who delivered at University of Nigeria Teaching Hospital (UNTH), Ituku-Ozalla, Enugu from July 2017 to September 2017. The study was conducted at the labor ward and postnatal ward of the hospital. The hospital is a government-owned tertiary health institution situated at the outskirt of Enugu, the capital of Enugu state, Nigeria. Unbooked women who delivered at the study center were excluded from the study.

Assuming multiple registration prevalence of 46.8% from a previous study[17] at a confidence level of 95% and attrition rate of 10%, 420 study participants were eligible for the study. Ethical approval was obtained from the Ethics Committee of UNTH, Enugu, prior to commencement of the study. Informed written consent was also obtained from each participant before enrollment. Structured pretested interviewer-administered questionnaires were administered to consecutive 420 consenting parturients as soon as they are stable and fit to answer questions after delivery. Data sought for included the following: information on maternal age, parity, level of education, gestational age, other booking facilities (where applicable), and reasons for the multiple booking. The reasons for multiple booking or registration were obtained from the participants’ hospital records where recall was not feasible. Information on maternal complications such as blood transfusion, additional use of uterotonics and antibiotics, and delayed discharge from hospital were obtained from the participants’ hospital records. Information on neonatal outcome such as Apgar score, intrauterine fetal death, and newborn admissions was also obtained from the participants’ hospital records. For the purpose of this study, a pregnancy was regarded as “booked” when the participant made at least one antenatal visit at the study center before delivery, whereas it was regarded as “unbooked” if no visit was made at the study center before delivery. Multiple antenatal registration for the study was referred to as when a pregnant woman voluntarily registered for ANC in more than one facility including health institutions and unorthodox places.

Data collected were keyed into the Statistical Package for the Social Sciences (SPSS) software, version 20 for Windows (IBM SPSS, Chicago, Illinois, USA). Continuous variables were analyzed using the mean + standard deviation (SD) and compared between the two groups using the Student’s t test. Proportions were compared using the Pearson’s chi-square test. Relationships were expressed using odds ratio (OR) at 95% confidence interval (CI). A value of P < 0.05 was considered statistically significant.


  Results Top


Four hundred and twenty participants were recruited from the study center. The 420 interviewer-administered questionnaires were filled correctly and returned, given a response rate of 100%.

[Table 1] shows the basic characteristics of the participants. The mean age of the participants was 32.12 + 5.04 (range: 20–42) years. Most participants in the study center were multiparous, 262 of 420 (62.4%). The modal parity was Para 2. The mean gestational age at booking among the participants was 14.41 + 6.17 (range: 4–37) weeks. The mean number of antenatal visits made by the participants in the study was 8.33 + 4.05 (range: 1–16) visits.
Table 1: Distribution of participants’ basic characteristics

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The incidence of multiple antenatal registration among the study population was 52.1% (219 of 420). Majority, 86.3% (189 of 219), of the participants in study center, who had multiple antenatal registration, registered in a health facility with a skilled birth attendant, whereas 13.7% (30 of 219) registered in an unorthodox place such as churches, healing home, and with traditional birth attendants. The commonest reason for multiple antenatal booking was for a second opinion (55.3%, 121 of 219). Other reasons were proximity to residence (25.6%, 56 of 219), affordability (14.2%, 31 of 219), and avoidance of caesarean section (5.0%, 11 of 219).

[Table 2] shows the basic characteristics of participants who had multiple registrations for a second opinion and that of the control who had antenatal registration in a single facility. The basic characteristics did not vary between the two groups. Majority of them in both groups registered for ANC at less than 14 weeks’ gestational age, 56.2% (68 of 121) in the multiple booking group, and 58.7% (118 of 201) in the single-facility registration (control) group with P = 0.727.
Table 2: Sociodemographic characteristics of participants who had second booking and control

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[Table 3] shows the association between multiple antenatal registration and pregnancy outcome. Maternal complications occurred in 12 of 121 (9.9%) of the participants who had multiple antenatal booking for second opinion and in 10 of 201 (5.0%) of the control who had a single-facility registration. This difference was however not statistically significant (P = 0.111, OR 2.10 95%, CI 0.88, 5.03). Neonatal complications occurred in 17 of 121 (14.0%) of the participants who had multiple antenatal booking for second opinion and in 16 of 201 (8.0%) of the control. This difference was also not statistically significant (P = 0.090, OR 1.89 95%, CI 0.92, 3.90).
Table 3: Association between multiple booking due to second opinion and pregnancy outcome

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Most of the participants in the study, 294 of 420 (70.0%), indicated that they will not have multiple antenatal booking in the next pregnancy, whereas 10 of 420 (2.4%) indicated that they were not sure of their decision in the next pregnancy.


  Discussion Top


ANC ensures a state of good health throughout pregnancy and greatly improves the chances of having a safe delivery and a healthy newborn. More so, the importance of ANC on pregnancy outcome has been well documented.[20] Early booking for ANC is necessary for early detection and treatment of adverse pregnancy outcome. The mean gestational age at booking in Enugu in the study was 14.41 weeks. This was earlier than the reported 26 weeks in a previous study in UNTH in 2008[10] and the 28 weeks and above reported in NDHS 2013.[8] The reason could be due to better enlightenment on maternal health among the study populace and the increased utilization of antenatal services, which was reported to be high in urban areas, 83% and 86% in the 2008[21] and 2013[8] NDHS, respectively. However, this gestational age at booking in the study was described as late booking by some authors because it was later than 14 weeks.[11],[12],[13] It was also later than that repeated in the US[7] and UK.[6]

Multiple booking for ANC is a common occurrence in Nigeria. Its incidence in this study was high (52.1%). This was similar to findings from studies in Port Harcourt[18] and Enugu,[17] which reported 44.6% and 46.8%, respectively, for booking at two centers. However, it was reported as low as 20% in Ebonyi,[19] a neighboring state. The commonest reason given by the participants for multiple booking in this study was the need to have a second opinion on management. In the study in Port Harcourt,[18] the commonest reason was due to incessant strike action by the government-owned facility hospital, whereas Ikojo et al.,[17] in Enugu in 2010, reported selection of hospital with cheaper and more affordable services as the commonest reason followed by selection of a facility promising vaginal delivery. Enugu is an urban area in Nigeria and has two government-owned teaching hospitals and several specialist hospitals, hence a high antenatal coverage, utilization, and health seeking behavior in the populace. The participants in this study also had higher level of education as most of them attained tertiary level of education. These could be the reason why they sort for second opinion. More so, teaching hospitals and specialist hospitals are at times perceived by pregnant women to have high caesarean section rate and so it could also be a reason why the participants needed a second opinion in case they are offered abdominal delivery or to justify need for abdominal delivery if offered. In this study, no significant difference was found in pregnancy outcome with regard to maternal and neonatal complication when those that had multiple antenatal registration were compared with the control of those who had single-facility registration. Thus, multiple antenatal registration for second opinion is not beneficial especially when the client has registered with a skilled birth attendant. This results to financial wastefulness and there is also a risk of registering in a facility of lower status. However, more studies are necessary to clarify this assertion. Majority of the participants in this study admitted they will not have multiple antenatal registrations in their next pregnancy. This could be as a result of realization of the financial and human resource wastefulness. However, a quarter of the participants insisted they will have multiple-facility registration in their next pregnancy, hence the need for emphasis on health education stating the demerits of the common practice during antenatal registration.

This study is limited by a single-center data. A multicenter study including data from rural hospitals would improve generalization of study findings to the study population.


  Conclusion and Recommendation Top


The rate of multiple antenatal registration for a current pregnancy in Enugu is high and the commonest reason is for a second opinion on management. There was no association between multiple antenatal registration for a second opinion and pregnancy outcome in terms of maternal and neonatal complication compared with single-facility antenatal registration. Efforts at health education are required in order to encourage single registration in a facility with skilled birth attendants.

Acknowledgement

We acknowledge the entire consultants and nursing staff of the Department of Obstetrics and Gynaecology, University of Nigeria Teaching Hospital, Ituku/Ozalla, Enugu, Nigeria.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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