ADEQUACY OF ANTENATAL CARE: ASSOCIATED FACTORS AND PREGNANCY OUTCOMES AMONG WOMEN ATTENDING PUBLIC HEALTH CLINICS IN SELANGOR, MALAYSIA YEOH PING LING Malaya of FACULTY OF MEDICINE UNIVERSITY OF MALAYA KUALA LUMPUR University 2016 ADEQUACY OF ANTENATAL CARE: ASSOCIATED FACTORS AND PREGNANCY OUTCOMES AMONG WOMEN ATTENDING PUBLIC HEALTH CLINICS IN SELANGOR, MALAYSIA YEOH PING LING Malaya THESIS SUBMITTED IN FULFILMENT OF THE REQUIREMENTS FOR THE DEGREEof OF DOCTOR OF PHILOSOPHY FACULTY OF MEDICINE SOCIAL AND PREVENTIVE HEALTH DEPARTMENT UNIVERSITY OF MALAYA KUALA LUMPUR University 2016 UNIVERSITY OF MALAYA ORIGINAL LITERARY WORK DECLARATION Name of Candidate: Yeoh Ping Ling (I.C. No: ) Registration/Matric No: MHA110007 Name of Degree: Doctor of Philosophy (PhD) Title of Thesis (“this Work”): Adequacy of Antenatal Care: Associated Factors and Pregnancy Outcomes among Women Attending Public Health Clinics in Selangor, Malaysia Field of Study: I do solemnly and sincerely declare that: (1) I am the sole author/writer of this Work; (2) This Work is original; (3) Any use of any work in which copyright exists was done by way of fair dealing and for permitted purposes and any excerpt or extract from, or reference to or reproduction of any copyright work has been disclosed expressly and sufficiently and the title ofMalaya the Work and its authorship have been acknowledged in this Work; (4) I do not have any actual knowledge nor do I ought reasonably to know that the making of this work constitutesof an infringement of any copyright work; (5) I hereby assign all and every rights in the copyright to this Work to the University of Malaya (“UM”), who henceforth shall be owner of the copyright in this Work and that any reproduction or use in any form or by any means whatsoever is prohibited without the written consent of UM having been first had and obtained; (6) I am fully aware that if in the course of making this Work I have infringed any copyright whether intentionally or otherwise, I may be subject to legal action or any other action as may be determined by UM. Candidate’s Signature Date: University Subscribed and solemnly declared before, Witness’s Signature Date: Name: Prof Dr Maznah Dahlui Designation: Head of Department, Department of Social and Preventive Medicine ii ABSTRACT Malaysia has remarkable achievement in maternal-child–health over past decades. Relevant tracers continue to be excellent, and there has been increasing number of antenatal visits. Recent progress in pregnancy outcomes however does not improve with equal pace: maternal mortality has been stagnant since over a decade, birth weight <2,500g was higher than neighbouring countries, and stillbirth doubling that of developed nations. These pose the questions related to limitation of coverage indicators and need for assessing adequacy of antenatal care. The purpose of this study was to determine adequacy of antenatal care, its associated factors and pregnancy outcomes. Adequacy of antenatal care included adequacy of utilisation and adequacy of content that were analysed separately. Wherein, adequacy ofMalaya utilisation referred to the concept of Adequacy of Prenatal Care Utilisation Index which is defined by adequacy in initiation of care and observed-to-expectedof visits ratio adjusted for gestational age of delivery. Adequacy of content is defined as adequacy in compliance to recommended routine care. The study was conducted using retrospective cohort study design where data was extracted from individual records of public health clinics. The findings pointed to high proportion (63%) of intensive utilisation, with intensive utilisation noted among nearly 60% of low-risk women, while 26% of high-risk women did not have the expected intensive utilisation. The findings also highlighted inadequacy of routine care providedUniversity with 52% of women receiving <80% of recommended content; delivery of antenatal advice scored the lowest. High-risk had lower content score than low-risk (76% versus 78%, p=0.001). Women attended the smallest clinics had higher content score (80% versus 75-77%, p<0.001). Examining association between utilisation and pregnancy outcomes revealed that adequate utilisation appeared to lower the odds of preterm birth and maternal complications, compared to inadequate and intensive iii utilisation. Intensive utilisation however did not seem to lower the odds of preterm birth, low birth weight and maternal complications. Adequate content was significantly associated with lower odds (OR=1.00) of preterm birth than inadequate content (OR=3.72, 95%CI=1.58-8.72); but appeared to result in higher odds of stillbirth and maternal complications, indicating the influence of other aspect of care. The study presented several contributions to research on antenatal care adequacy. One, intensive utilisation does not seem to improve pregnancy outcomes. While it is justified for high- risk to have more frequent visits for additional care, there is no reason for low-risk to have higher number of visits than standard schedule. Two, over half of women had <80% of routine content indicates need to improve technical performance of care. All women should be given complete routine care. Three, the findings have resulted in an accompanying insight on the need to review the Malayacurrent guidelines, spinning from reviewing guidelines from countries with better pregnancy outcomes. Lastly, the methods used could be reviewed as to oftheir utility in expanding monitoring and evaluation framework for improving quality and informing policy formulation. Further researches are required to assess how technical performance of routine antenatal care can be improved, in particular, delivery of antenatal advice. Future studies may consider qualitative study involving stakeholders responsible for guidelines and policy formulation, examining rationale of excluding and including certain practices. Keywords: antenatal care; ANC; utilisation; content; guidelines; adherence; adequacy; quality of care; pregnancyUniversity outcomes; preterm birth; low birth weight; stillbirth; maternal complications. iv ABSTRAK Malaysia telah menikmati pencapaian yang mengagumkan di bidang kesihatan ibu dan anak semenjak beberapa dekad kebelakangan ini. Prestasi petunjuk yang berkaitan masih kekal cemerlang manakala bilangan lawatan penjagaan antenatal semakin meningkat. Walaubagaimanapun, prestasi pencapaian penjagaan kehamilan tidak meningkat pada kadar yang sama, di mana: kadar kematian ibu tidak berganjak dalam lebih sedekad, berat kelahiran <2,500g masih lebih tinggi daripada negara-negara jiran, dan kadar kelahiran mati adalah dua kali ganda kadar negara maju. Ini menimbulkan persoalan berkenaan ketepatan petunjuk liputan dan keperluan untuk menilai tahap penjagaan antenatal. Tujuan kajian ini adalah untuk menentukan tahap adekuasi penjagaan antenatal, faktor-faktor yang berkaitan dan pencapaian prestasi penjagaan kehamilan. Adekuasi penjagaan antenatal termasukMalaya adekuasi utilisasi dan adekuasi kandungan penjagaan antenatal yang dianalisa secara berasingan, di mana, adekuasi utilisasi antenatal merujuk kepada konsepof “Adequacy of Prenatal Care Utilisation Index” yang ditakrifkan sebagai adekuasi permulaan penjagaan, dan nisbah lawatan sebenar dengan lawatan jangkaan yang diselaraskan untuk usia kandungan; manakala adekuasi kandungan penjagaan antenatal ditakrifkan sebagai kecukupan penjagaan rutin yang disyorkan. Kajian ini menggunakan kaedah kohot secara retrospektif di mana data diambil daripada rekod individu di klinik kesihatan awam. Hasil kajian menunjukkan tahap penggunaan intensif pada kadar yang tinggi (63%), di mana pemerhatian menunjukkanUniversity penggunaan intensif berlaku di kalangan hampir 60% wanita berisiko rendah, sedangkan penggunaan intensif yang dijangka, tidak berlaku ke atas 26% wanita berisiko tinggi. Penekanan keatas penjagaan rutin yang diberikan didapati kurang di mana 52% wanita menerima <80% kandungan asas antenatal yang dicadangkan, seperti penyampaian nasihat antenatal yang mendapat skor terendah. Wanita berisiko tinggi mendapat skor kandungan lebih rendah daripada wanita berisiko rendah (76% vs 78%, v p=0.001). Wanita yang menghadiri klinik-klinik kecil mendapat skor kandungan yang lebih tinggi (80% vs 75-77%, p<0.001). Utilisasi antenatal tahap mencukupi dikaitkan dengan kemungkinan kelahiran pramatang dan komplikasi ibu yang lebih rendah, berbanding dengan tahap penggunaan antenatal yang tidak mencukupi mahupun intensif. Penggunaan tahap intensif bagaimanapun tidak mengurangkan kemungkinan untuk kelahiran pramatang, berat lahir rendah, dan komplikasi ibu. Kandungan penjagaan antenatal yang mencukupi didapati berkaitan dengan kemungkinan kelahiran pramatang yang lebih rendah (OR=1.00) berbanding dengan kandungan penjagaan antenatal yang tidak mencukupi (OR=3.72, 95%CI=1.58-8.72); tetapi kemungkinan yang lebih tinggi untuk kelahiran mati dan komplikasi ibu. Ini menunjukkan terdapat kepentingan bagi aspek penjagaan yang lain. Kajian ini memberi sumbangan kepada penyelidikan mengenai adequasi tahap penjagaanMalaya antenatal. Pertama, penggunaan intensif nampaknya tidak meningkatkan hasil pencapaian kehamilan. Wanita berisiko tinggi wajar mempunyai lawatan yang lebihof kerap untuk penjagaan tambahan, namun wanita berisiko rendah tidak ada sebab untuk membuat lawatan antenatal lebih daripada jadual standard. Kedua, lebih daripada separuh wanita mempunyai <80% kandungan penjagaan rutin dan ini menunjukkan terdapat keperluan untuk meningkatkan prestasi penjagaan antenatal