IntegrationofcommunityserviceswithhospitaltoadherepregnanttofourANCvisitsinQuetta

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รุ่นปัจจุบันของ 06:56, 3 มกราคม 2556

Integration of Community Services with Hospital to Adhere Pregnant Women to Four ANC Visits in Quetta

Sheh Mureed College of Public Health Sciences Chulalongkorn University, Thailand E-mail: shehdr@gmail.com Tel: +92-336-7434351

Ratana Somrongthong College of Public Health Sciences Chulalongkorn University, Thailand E-mail: ratana.so@chula.ac.th Tel: +66-2218-8048

Abdul Ghaffar Health Department, Government of Balochistan, Pakistan E-mail: abdulghaffarlashari@gmail.com Tel: +92-333-7864526

Shahnaz Baloch Bolan Medical College Quetta, Pakistan E-mail: shahnzbaloch56@gmail.com Tel: +92-323-8102003

Najma Ghaffar Bolan Medical Complex Hospital Quetta, Pakistan E-mail: najmaghaffar@gmail.com Tel: +92-333-7929269

Abstract

This paper presents the finding of an experimental study conducted in tertiary care hospitals in Quetta Balochistan. The main objective of this study was to adhere pregnant women to attend 4 ANC visits during current pregnancy, through testing an intervention called Adherence to Antenatal Care (AAC). The study found that 38 (76%) women in intervention group attended ANC 4 times compared to 12 (24%) women in the control group. There was a significant change (p=<0.001) in the knowledge of subject regarding ANC in the intervention group. Also significant change (p=<0.001) in satisfaction of subject with ANC services was observed. To maximize opportunities for pregnant women to attend ANC, hospital services should work with existing community programs with outreach activities as demonstrated in this study. Efforts to strengthen ANC should focus on high coverage by addressing barriers to reaching vulnerable groups, quality improvement to increase women's satisfaction out, and integration of programs to maximize the contact between the woman and the health services.

Keywords: Focused Antenatal Care, Adherence, Integration, Pregnancy, Community, and Hospital

1. Introduction Pakistan’s maternal and child health profile is portrayed by high maternal mortality ratio (MMR) of 240 per 100,000 live births, high infant mortality rate (IMR) 74.6, low antenatal care (ANC) utilization, 61 percent women attend ANC one time, and only 39 percent births are attended by skilled birth attendants [1]. In Pakistan basic health units (BHUs) and rural health centers (RHCs) are delivering primary health care services, district head quarter hospitals (DHQs) are the second referral facilities providing acute, ambulatory and inpatient care and are being supported by tertiary care teaching Hospitals [2]. Balochistan is the largest province of Pakistan in terms of land area. It’s in contrast, the smallest by far in terms of population and economy. Only about 5 percent of the country’s population lives here. The Health status indicators of Balochistan are poorer then other provinces. The MMR is highest in Balochistan 785 per 100,000 live births [3]. Utilization of ANC is lowest only 39 percent pregnant women attend ANC only one time and 11 percent women attend ANC 4 times, 29 percent women are delivered by skilled attendants during birth. [4]. Causes of maternal mortality in Balochistan are multiple, interrelated, complex, and almost always preventable. Common direct causes of maternal death in Balochistan are postpartum hemorrhage (27%), puerperal sepsis (14%), and eclamptia/toxemia of pregnancy (10 %) [2]. Quetta is the provisional capital of Balochistan it’s also the study area for the research project. The projected population of Quetta in 2010 was 1,235,066. In the public sector there are 6 Hospitals (4 tertiary care), 3 RHCs, 34 BHUs, 13 Maternal and Child Health (MCH) centers [5]. There are also many private hospitals functioning in Quetta, there are no official documents stating their numbers. According to a survey in Quetta 43 percent women attended ANC one time and 17 percent women attended ANC 4 times or more, percentage of women who attended ANC had higher education attainment and were from the richer wealth qualities group [4]. To avert problems for mother and child depends on an operational continuum of care with accessible, high quality of care before and during pregnancy, childbirth, and the postnatal phase. It also depends on the support available to help pregnant women reach services, particularly when complications occur [6]. The purpose of the Focused ANC package is to prevent, detect, alleviate, or manage health problems during pregnancy as well as prepare for birth and parenthood. An effective ANC package depends on competent health care providers in a functioning health system with referral services and adequate supplies and laboratory support. A multi-country randomized control trial led by the WHO and a systematic review showed that essential intervention can be provided over four visits at specified intervals, at least for healthy women with no underlying medical problems. The first assessment in ANC is to classify women in to two groups, women who require special attention and more visits, and women who require standard care 4 visits [7] [8]. An analysis done using previously published methodology suggests that if 90 percent of women received ANC, up to 14 percent or 160,000 more newborn lives could be saved in Africa [9]. Women are more likely to give birth with a skilled attendant if they have at least on ANC visit [10]. Failure to attend antenatal care early results in the increased potential for complications during pregnancy, delivery and puerperium [11]. Family and community involvement is also crucial for healthy home behaviors during pregnancy and has shown to be a major determinant of use of ANC utilization. Establishing links between community and the facility can increase utilization of services, including ANC, and impact maternal and neonatal morality as well as stillbirths [12]. Important barrier for under-utilization of ANC in developing countries is the inability to pay for treatment prescribed in ANC [13]. As pregnancy is perceived as a natural process of life, women, families and communities may underestimate the importance of ANC [14]. In addition, women may lack knowledge about danger signs in pregnancy and will not know how to seek care when a complication occurs during pregnancy [15] [16]. The attitudes and behaviors of health care providers in ANC clinics compound this problem by failing to respect the privacy, confidentiality, and traditional beliefs of the women [17]. Conflict or poor communication and lack of competency among formal health care providers, traditional birth attendants (TBA) and other CHWs can also be the cause of low utilization of ANC services in certain communities. This paper presents the finding of an experimental study conducted in tertiary care hospitals in Quetta. The main objective of this study was to adhere pregnant women to attend 4 ANC visits during current pregnancy, through testing an intervention called Adherence to Antenatal Care (AAC) model. The other objective was to assess the change in knowledge of pregnant women regarding ANC and pregnancy, and to assess the change in subject’s satisfaction with ANC services before and after the intervention.

2. AAC Model Intervention The model has four components that were:

2.1. Focused ANC

The goal of focused ANC is to provide specific, evidence-based intervention for all women, carried out at certain critical times (4 times) in the pregnancy. The essential elements of this package are:

Table 1: Goals of Focused ANC for pregnant women with no underlying health conditions

Focused ANC First ANC Visit 8-12 weeks Second ANC Visit 24-26 weeks Third ANC Visit 32 weeks Fourth ANC Visit 36-38 weeks Confirm pregnancy and EDD, Classify women for Focused ANC, or more specialized care. Screen, treat and give preventive measures. Develop a birth and emergency plan. Advise and counsel. Assess maternal and fetal well-being. Exclude PIH and anemia. Give preventive measures. Review and modify birth and emergency plan. Advise and counsel Assess maternal and fetal well-being. Exclude PIH, anemia, multiple pregnancies. Give preventive measures. Review and modify birth and emergency plan. Advise and counsel. Assess maternal and fetal well-being. Exclude PIH, anemia, multiple pregnancies. Mal-presentation. Give preventive measures. Review and modify birth and emergency plan. Advise and counsel. Acronyms: (EDD= Estimated data of delivery; PIH=Pregnancy Induced hypertension)

2.2. Counseling By GATHER technique

The GATHER approach to counseling--Greet, Ask, Tell, Help, Explain, and Return has documented effectiveness in Family Planning programs. For the purpose of this intervention, the GATHER counseling technique has been adopted from the Ethiopia Antenatal Care HEAT Module [18]. The guide was used to counsel pregnant women regarding importance of ANC, complication during pregnancy, and to help subject return for their scheduled visit.

2.3. One-stop ANC Services

The purpose of One-stop ANC was to create a place where women were receiving components of Focused ANC.

2.4. Integration of Hospital and Community

One of the main components of this intervention was to integrate community and hospital services by using CHWs working in community. The purpose was to influence pregnant women, through the CHWs visiting homes to remind and encourage women and their families to attend scheduled ANC visits at the hospital. A linkage between hospital and community was created. A framework of CHW praxis and patient health behavior also suggested that CHWs influence patient behavior by enhancing patients’ confidence and their attitudes and values toward behavioral change [19].

Figure 1: Adherence to Antenatal Care (AAC) model intervention conceptual illustration

Acronyms: (BMCH= Bolan Medical Complex Hospital; SPH=Sandeman Provisional Hospital; CHWs=Community Health Workers)

3. Methodology

3.1. Study Design

The study design was a quasi-experimental study. It was conducted from May 2011 to March 2012. Two groups designee control and intervention, with before and after data collection. Two tertiary care hospitals in Quetta were selected. The Bolan Medical Complex Hospital (BMCH) was randomly selected as the hospital for implementation of AAC model intervention. The Sandmen Provisional Hospital (SPH) was the control hospital. Both the hospitals had similar organizational set up and other features and were comparable.

3.2. Sample size and sampling technique

The study subjects were the pregnant women who visited Out Patient Department (OPD) of gynecology and obstetrics department. Inclusion criteria for subjects were first trimester or within 12 weeks of pregnancy, given live birth once before, and no more then 5 children’s excluding the current pregnancy, and also qualifying for focused ANC. World Health Organization (WHO) checklist was used to identify subject qualifying for Focused ANC [20]. Sample size was calculated by using method effect size of therapies, proportional outcome [21], assuming that 30 percent of the subjects in control group would have 4 visits and so it will be of clinical relevance to observed 40 percent effect size absolute improvement for those in the intervention group, i.e. 60 percent of the subjects will have complete 4 ANC visits. After calculating the formula, a sample size of 40 subjects were required in each group, with an addition 20 percent to cover dropout, 100 subjects were enrolled for the study. By using systematic sampling technique subjects were enrolled in the study. According to the hospitals data, normally 27 pregnant women in their first trimester visited these OPDs on a working day. To select 4 subjects in a day, we tested 27/4= 6, after selecting the first subject randomly by drawing a number; every sixth subject attending ANC on that day was selected. The enrolment of the subjects was done in one month.

3.3. Ethical Consideration

Before enrolling the subject in to the study informed consent was shared. The informed consent contained information regarding the AAC model interventions benefits and harms. They were informed that they were free to choose if they wanted to or not to participate in this study. If they were willing to participate they had to sign on the consent form. For illiterate the consent was shared verbally, still thumbs impressions were taken. Pakistan Bioethical Committee (PBC) approved the ethical protocols of this study reference number: 4-87/11/NBC-71/RDC/ 904.

3.4. Data collection

Data collection was done two times, before and after the intervention, by using a structured questionnaire. The interval time between data collection was first ANC visit and the fourth ANC visit. The data collection was done simultaneously at both hospitals in the month of June 2011.

3.5. Research Instruments

The questionnaire consisted of 4 parts including; socio demographic characteristics, ANC history of previous pregnancy, knowledge of subjects regarding ANC and satisfaction with ANC services. Knowledge part of the questionnaire consisted of 12 close-ended statements with a dichotomies response. The statements measured women’s knowledge towards importance of antenatal care during pregnancy, knowledge of complication’s during pregnancy, how many times to attend ANC, and components of ANC given during pregnancy. For each correct response a score of 1 was given and for a wrong response the value was zero. Knowledge of subject was divided into three groups; low (60%) or less, moderate (61% to 80%) and, high (81% or more). Satisfaction towards ANC services was measured by using patient’s satisfaction survey questionnaire (PSQ 18). Satisfaction was measured across 7 dimensions, which were general satisfaction, technical quality, communication, interpersonal aspect, financial aspect, time spent with doctor, availability, accessibility and convenience of ANC services. Each item was accompanied by 5 responses categories strongly agree, agree, uncertain, disagree, and strongly disagree. Satisfaction was categorized into two levels high satisfaction and low satisfaction by calculating the mean score for each group. The number and percent of ANC visits completed by each subject during the current pregnancy in both the hospitals measured adherence to ANC services. Expert opinion on the content of the instrument was taken from professors of gynecology and obstetrics department BMCH and professors of College of Public Health Sciences Chulalongkorn University Thailand.

3.6. Data Analysis

Statistical Package for Social Sciences (SPSS) version 16 was used for data analysis. Numbers, percentage, mean and standard deviation is used to describe the descriptive characteristic of the data. Chi square test was used to assess the difference between socio demographic characteristic of intervention and control group at the baseline. Wilxon signed ranked test was used to assess the difference in knowledge regarding ANC before and after the intervention. Paired sampled t-test was used to test the difference in satisfaction with ANC service before and after the intervention.

4. Study process A research team was recruited; it consisted of 4 interviewers, two lady medical officers (LMO), two-nurse counselors and a lab assistant. Training was conducted for two weeks. First week the interviewers were trained in the methods of data collection. Second week refreshment courses were conducted for the antenatal staff and selected nurses were trained in “Greet, Ask, Tell, Help, Explain, and Return” (GATHER) counseling technique guide. The training was conducted in Serena hotel Quetta; the training was done by the researcher, medical doctors and hired trainers. A separate space was assigned to the intervention team by the BMCH administration. The purposefulness of this space was to establish a one stop ANC. The subjects were interviewed individually, doctors provided component of Focused ANC and the trained nurse counseled subjects in this space. Medications were also kept in the same space and given to the subjects. The lab assistant would take the test and bring the results in lesser period of time. This was done for each visit. At the end of the day lady medical officer with the researcher regularly check the registers for details of services provided through ANC card, expenditures log, medicine log. The questionnaires filled from the subjects were also checked daily for any problems by the researcher and LMOs. After the subject went home their ANC cards were given to the CHWs. From the information on antenatal card, CHWs traced the subjects at their homes. The CHWs would visit the subject home before their scheduled visit, remind and encouraged the pregnant women to attend antenatal care at the intervention hospital. They also facilitated subjects during any pregnancy emergency. The CHWs did this while performing their regular duties. The lady health supervisors and the researcher did the monitoring of the CHWs. The CHWs were being paid for their services. The hospital also called the subjects home if they missed their any visit. In the control group hospital that is SPH the subject received care as usual. The subjects were only followed and the interviewers collected data two times at the 1st ANC and 4th ANC. If the subject didn't attended ANC they were traced at their homes for the after intervention data collection.

5. Results A total of 45 (90%) of the subjects in the intervention group and 43 (86%) subjects in the control group completed Questionnaires. Eight of the subjects dropped out of the study because of complications and 4 subjects couldn't be followed-up.

5.1. Socio Demographic Characteristics and Past ANC history

Regarding socio demographic characteristics according to the table 2 all the subjects were within the age range of 19 to 40 years. The mean age of pregnant women was 29 years. The Mean number of children was 3 children’s. Regarding education attainment 36 (72%) subjects in the intervention group and 33 (66%) in the control group had no formal education. For husband education attainment 23 (46%) subjects in the intervention group and 26 (52%) didn't have any formal education. There was significant difference (p=0.037) for the husband education attainment at the baseline between intervention and control group. Most subject in the intervention group 42 (84%) and in the control group 48 (96.0%) were housewives. Most husbands in both groups were working in private sector. Monthly family income for 29 (58%) subjects in the intervention group and 35 (70%) subjects in the intervention group was less then 10,000 Pakistani Rupees (PRK) that is 100 United States Dollar (USD). Most of the subjects were living in a joint family system. Except husbands education there were no significant difference in socio demographic characteristics of groups at the baseline.

Table 2: Socio Demographic characteristics of 100 subjects participating in the study

Socio Demographic Characteristics Intervention BMCH Control SPH Total P-Value n=50 (%) n=50 (%) Age in Years 0.407 ≤ 20 - 2 (4.0) 2 21-15 16 (32.0) 19 (38.0) 35 26-30 19 (38.0) 18 (36.0) 37 ≥ 31 15 (30.0) 11 (22.0) 26 Mean ± SD = 29.85, Mini-Max (19-40) Number of Children 0.396 1 8 (16.0) 4 (8.0) 12 2 9 (18.0) 15 (30.0) 24 3 11 (22.0) 10 (20.0) 21 4 10 (20.0) 13 (26.0) 23 5 12 (24.0) 8 (16.0) 20 Mean ± SD = 3.15 ± 1.32, Mini-Max (1-5) Women Education 0.625 No Formal Education 36 (72.0) 33 (66.0) 69 Primary to secondary school 10 (20.0) 14 (28.0) 24 High School and Above 4 (8.0) 3 (6.0) 7 Husbands Education - No Formal Education 23 (46.0) 26 (52.0) 49 Primary to secondary school 15 (30.0) 21 (22.0) 36 High School and Above 12 (24.0) 3 (6.0) 15 Women Occupation 0.092 House wife 42 (84.0) 48 (96.0) 90 Working women 8 (16.0) 2 (4.0) 10 Husbands Occupation 0.238 Unemployed 9 (18.0) 4 (8.0) 13 Government services 13 (26.0) 11(22.0) 24 Private services 28 (56.0) 35 (50.0) 63 Family Income (1 USD= 96 PKR) 0.388 ≤ 10,000 PKR 29 (58.0) 35 (70.0) 64 11,000 to 20,0000 PKR 15 (30.0) 12 (24.)) 27 ≥ 21,000 PKR 6 (12.0) 3 (6.0) 9 Family Type 0.635 Joint Family 37 (74.0) 40 (80.0) 77 Nuclear Family 13 (26.0) 10 (20.0) 23

• Significant Level at p-value = < .05, ** Fisher Exact Test was applied, Acronyms: (BMCH= Bolan Medical Complex Hospital; SPH=Sandeman Provisional Hospital; USD=United States Dollar; PKR=Pakistani Rupees; SD=Stander Deviation)

According to table 3, 39 (78%) subjects in the intervention group and 35 (70%) in the control group attended ANC during their last pregnancies. From subject who attended ANC most of them attended ANC 2 times and only one subject in the intervention group attended ANC 4 times. The main place for attending ANC was government hospitals. The main reason subject gave for not attending ANC was that they didn't know about ANC.   Table 3: ANC history of the 100 subjects participating in the study Past ANC History Intervention BMCH Control SPH Total P-Value n=50 (%) n=50 (%) ANC during previous pregnancy 0.495 No 11 (22.0) 15 (30.0) 26 Yes 39 (78.0) 35 (70.0) 74

1. Of visits during previous pregnancy (n=39) (n=35) 0.560

1 visit 13 (33.0) 10 (28.0) 23 2 visits 19 (50.0) 17 (49.0) 36 3 visits 5 (13.0) 8 (23.0) 12 4 visits 1 (2.0) - 1 ≥ 5 visits 1 (2.0) - 1 Place of ANC during previous pregnancy 0.631 Government 35 (90.0) 32 (91.0) 37 Hospital 3 (8.0) 3 (9.0) 6 Other 1(2.0) - 1 Reasons for not attending ANC during previous pregnancy (n=11) (n=15) 0.237 Costly 2 (18.0) - 2 Distance 1 (9.0) 3 (20.0) 4 Don't know about ANC 7 (64.0) 10 (67.0) 17 Waiting time 1 (9.0) 2 (13.0) 3 Significant Level at p – value = < .05, ** Fisher Exact test was applied, Acronyms: (BMCH= Bolan Medical Complex Hospital; SPH=Sandeman Provisional Hospital)

5.2. Knowledge Towards ANC

Table 4 shows us the percentage of subject who answered correctly to the knowledge items before and the after the intervention in both groups. In the intervention group we see higher percentage in correct answers in knowledge statements after the intervention.

Table 4: Correct answers of knowledge statements regarding ANC before and after the intervention

1. Knowledge Statements Intervention BMCH Control SPH

Before After Before After n=50 (%) n=45 (%) n= 50 (%) n=43 (%) 1 Important of ANC 46 (91.0) 43 (95.0) 37 (77.0) 36 (84.0) 2 Number of ANC Visits 37 (75.0) 41 (92.0) 31 (62.0) 30 (67.0) 3 Complications of pregnancy 32 (65.0) 42 (93.0) 35 (69.0) 32 (74.0) 4 Components of ANC 33 (67.0) 40 (91. 0) 24 (49.0) 31 (72.0) Acronyms: (BMCH= Bolan Medical Complex Hospital; SPH=Sandeman Provisional Hospital)

Knowledge was categorized in to three levels low, moderate, high by adding up the scores. According to the table 5 before in the intervention group 32 (64%) subjects had moderate knowledge level, after the intervention 71 percent subjects had high knowledge towards ANC.  

Table 5: knowledge levels of the subjects regarding ANC before and after the intervention Intervention BMCH Control SPH Knowledge Level Before After Before After n=50 (%) n=45 (%) n=50 (%) n=43 (%) Low 6 (12.0) 1 (2.0) 13 (26.0) 4 (9.0) Moderate 32 (64.0) 12 (27.0) 28 (56.0) 31 (72.0) High 12 (24.0) 32 (71.0) 9 (18.0) 8 (19.0) Acronyms: (BMCH= Bolan Medical Complex Hospital; SPH=Sandeman Provisional Hospital)

Table 6 shows the statistical change of knowledge score regarding ANC services before and after the intervention. Wilcoxon signed Rank test was used to see the mean difference between knowledge of the subjects before and after the intervention. There was significant difference (p=<0.001) in knowledge score of the subjects in the intervention group before and after the intervention. There was no significant difference in knowledge scores of subjects in the control group.

Table 6: mean differences of knowledge score regarding ANC before and after the intervention Intervention BMCH Control SPH Variable Before After P-value Before After P –value Mean (SD) Mean (SD) Mean (SD) Mean (SD) Knowledge 8.68 (2.03) 11.15 (1.16) <0.001 8.16 (2.45) 9.16 (1.54) 0.083 Significant Level at p – value = < .05, Acronyms: (BMCH= Bolan Medical Complex Hospital; SPH=Sandeman Provisional Hospital; SD=Stander Deviation)

5.3. Satisfaction Towards ANC

Satisfaction towards ANC service was measured across 7 dimensions. Table 7 shows us the result of subject who had high satisfaction regarding the 7 aspects of satisfaction in the intervention group and control group. Subjects were categorized in to high or low satisfaction by calculating the mean score for every aspect. There is change in percentage of subjects with high satisfaction before and after the intervention in both groups.

Table 7: percentage of subject with high satisfaction with ANC services before and after the intervention

1. Satisfaction Intervention BMCH Control SPH

Before After Before After n=50 (%) n=45 (%) n=50 (%) n=43 (%) 1 General Satisfaction 24 (48.0) 32 (71.0) 28 (56.0) 21 (50.0) 2 Technical Quality 23 (46.0) 24 (53.0) 16 (32.0) 18 (44.0) 3 Interpersonal skills 30 (60.0) 30 (67.0) 23 (46.0) 23 (53.0) 4 Communication 14 (28.0) 36 (80.0) 16 (32.0) 22 (51.0) 5 Financial Aspect 25 (50.0) 18 (40.0) 22 (44.0) 13 (30.0) 6 Time Spend with staff 24 (48.0) 30 (66.0) 22 (44.0) 25 (58.0) 7 Accessibility and convenience 22 (44.0) 30 (66.0) 30 (60.0) 26 (60.0) Acronyms: (BMCH= Bolan Medical Complex Hospital; SPH=Sandeman Provisional Hospital)

Over all satisfaction with ANC was divided into two levels high satisfaction and low satisfaction. Table 8 shows us that before the intervention 25 (48%) subjects in the intervention group had high satisfaction and after the intervention 29 (64%) subjects had high satisfaction. In the control group before the intervention 22 (44%) subjects had high satisfaction and after the intervention 22 (51%) subjects had high satisfaction.

Table 8: percentages of subjects with high over all satisfaction with ANC services before and after the intervention Satisfaction Level Intervention BMCH Control SPH Before After Before After n=50 (%) n=45 (%) n=50 (%) n=43 (%) Low satisfaction 26 (52.0) 16 (36.0) 28 (56.0) 21 (49.0) High satisfaction 25 (48.0) 29 (64.0) 22 (44.0) 22 (51.0) Acronyms: (BMCH= Bolan Medical Complex Hospital; SPH=Sandeman Provisional Hospital)

According to the table 9 we find that there was a significant difference (p=<0.001) and (p=0.038) in both the group for over all satisfaction with ANC services before and after the intervention. In the control group mean score for satisfaction had significantly decreased during the study period.

Table 9: mean differences in over all satisfaction score before and after the intervention Intervention BMCH Control SPH Variable Name Before After p-value Before After p –value Mean (SD) Mean (SD) Mean (SD) Mean (SD) Satisfaction 56.97 (4.13) 65.02 (3.28) <0.001 56.72 (2.45) 54.65 (4.42) 0.038 Significant Level at p – value = < 0.05, Acronyms: (BMCH= Bolan Medical Complex Hospital; SPH=Sandeman Provisional Hospital; SD=Stander Deviation)

5.4. Adherence to ANC

The main objective of the study was to adhere pregnant women to 4 times ANC visits. Table 10 shows that in the intervention group 38 (76%) subjects attended ANC 4 times, while only 12 (24%) subjects from control group attended ANC 4 times.

Table 10: pregnant women who attended number of ANC visits in control and intervention groups ANC Visits Intervention BMCH n=50 (%) Control SPH n=50 (%) One ANC Visit 6 (12.0) 24 (48.0) Two ANC Visits 3 (6.0) 12 (24.0) Three ANC Visits 3 (6.0) 2 (4.0) Four ANC Visits 38 (76.0) 12 (24.0) Acronyms: (BMCH= Bolan Medical Complex Hospital; SPH=Sandeman Provisional Hospital)

6. Discussion An intervention called AAC model intervention was implemented to adhere pregnant women to 4 times ANC visit in a tertiary care hospital in Quetta provisional capital of Balochistan. The efficacy of this intervention was measured by 4 ANC visits completed by pregnant women during the current pregnancy. In this study we found that in the intervention group higher numbers of pregnant women completed their 4 ANC visits. Showing that the AAC model intervention was efficacious to adhere pregnant women to 4 ANC visits in a tertiary care hospital. An important component of this intervention was to create linkage between community and hospital through CHWs. This type of intervention had never been employed in a tertiary care hospital in Quetta, CHWs usually work in community-based health projects, but this was the first they were working in coordination with a tertiary care hospital in Quetta. Sustained access to a community-based, integrated, shared antenatal service has been found to improve perinatal outcomes among Indigenous women in Townsville Australia [22]. Bhutta et al. used CHW’s such as Lady Health Workers (LHWs) to deliver intervention package to promote ANC and maternal education by arranging group sessions in a community in Pakistan. The biggest changes occurred in behaviors related to seeking of antenatal care and in-facility births [23]. A paper reviewing interventions models involving CHWs at the household and community levels found that this strategy appears to be effective in increasing health facilitates utilization [24]. There was significant change in knowledge of pregnant women regarding ANC before and after the intervention. Counseling of subject during each visit by using GATHER technique increased knowledge regarding ANC of subjects. Studies from developing countries have found knowledge of pregnant women; to have positive association with ANC service utilization [25] [26]. There was significant change in satisfaction of pregnant women before and after the intervention. Satisfaction with ANC services significantly increased in the intervention group. Conversely there was a decrees observed in satisfaction of subject in control group. Subjects were satisfied with the services provided at the intervention hospital and its outreach by CHW’s. Satisfied patients have shown to be more inclined to comply with recommended treatment and keep appointments, and less inclined look for a doctor, than dissatisfied patients [27]. Patients are more likely to be very satisfied with the quality of care they receive when the doctor provides better care than he usually does. Patients do, in fact, recognize and value quality care [28]. Some limitation of this study should be noted. In view of the geographical boundaries, the issue of contamination and diffusion between intervention and control clusters should be considered. According to the data only five participants were living within same area of the city. However, even if the slightest still we cannot exclude the possibility of exchange or diffusion of information between intervention and control groups. In this kind of study design homogeneity of study groups is important. In this study there was a statistical significant difference in pregnant women husbands education attainment during the baseline. This is a potential confounder meaning it might have influenced the results positively. Yet there was no statistical significant difference in number of ANC visits completed by the subjects during their previous pregnancy. Less or more, the effect of this on study findings can’t be ruled out. Other contextual factors should be considered. The intervention was delivered through public sector LHWs and the government health system, and was thus subject to human resource constraints, the competing demands of other routine activities, and general weaknesses in health system functionality [29]. Despite these limitations the AAC mode intervention provides reassurance that a public sector hospital promoting preventive care through working with community health programs can lead to increase in knowledge, behavioral change and care seeking of pregnant women during pregnancy. This intervention can be implemented at secondary care hospitals LHWs could work effectively with hospitals, but items required to provide all components of focused ANC should be available at all time. However according to Balochistan health facilities assessment report regarding maternal health, major issues in health facilities were lack of staff like women medical officers at RHCs and specialist (including gynecologist, anesthetists and pediatrician) at SCH hospitals [30]. It is recommended that quality of ANC services at hospitals should be bettered by promoting evidence-based guidelines and standards for focused ANC. This intervention AAC model can be used as a quality improvement strategy to provide client-orientated, effective ANC and ensure that women return after their first ANC visit. Refreshment courses should be carried out from time to time to increase the capacity of the hospital staff and CHWs empowering them to work more efficiently. Maternal and child health facilities in Balochistan should be provided with complete range of assess items to perform signal functions. To maximize opportunities for pregnant women to attend ANC, hospital services should integrate with existing community programs with outreach activities as demonstrated in this study. Previous projections have suggested that community and outreach interventions, if implemented at large scale, have the potential increasing utilization of ANC services in developing states [31].

7. Conclusion ANC offers tremendous opportunities to reach a large number of women and communities with effective clinical and health promotion interventions during pregnancy. However rural, poor and less educated women of Balochistan and other developing places may not benefit from ANC services or may not complete recommended four visits due to assess barriers or low service quality. Efforts to strengthen ANC should focus on universal coverage by addressing barriers to reaching vulnerable groups, quality improvement to increase women's satisfaction, and integration of programs to maximize the contact between the woman and the health services.

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