Maternal mortality remains high in developing countries and data to monitor indicators of progress in maternal care is needed. We examined the status of maternal care before and after health care worker (HCW) training in WHO recommended Focused Antenatal Care.
An initial cross-sectional survey was conducted in 2002 in Asembo and Gem in western Kenya among a representative sample of women with a recent birth. HCW training was performed in 2003 in Asembo, and a repeat survey was conducted in 2005 in both areas.
Antenatal clinic (ANC) attendance was similar in both areas (86%) in 2005 and not significantly different from 2002 (90%). There was no difference in place of delivery between the areas or over time. However, in 2005, more women in Asembo were delivered by a skilled assistant compared to Gem (30% vs.23%, P = 0.04), and this proportion increased compared to 2002 (17.6% and 16.1%, respectively). Provision of iron (82.4%), folic acid (72.0%), sulfadoxine-pyrimethamine (61.7%), and anthelminths (12.7%) had increased in Asembo compared to 2002 (2002: 53.3%, 52.8%, 20.3%, and 4.6%, respectively), and was significantly higher than in Gem in 2005 (Gem 2005: 69.7%, 47.8%, 19.8%, and 4.1%, respectively) (P < 0.05 for all). Offering of tests for sexually transmitted diseases and providing information related to maternal health was overall low (<20%) and did not differ by area. In 2005, more women rated the quality of the antenatal service in Asembo as very satisfactory compared to Gem (17% vs. 6.5%, P < 0.05).
We observed improvements in some ANC services in the area where HCWs were trained. However, since our evaluation was carried out 2 years after three-day training, we consider any significant, sustained improvement to be remarkable.
Maternal mortality, the death of a woman while pregnant or within 42 days of termination of pregnancy, remains disturbingly high in sub-Saharan Africa. It is estimated that 270 000 maternal deaths occurred in the region in 2005 . The UN millennium Development goal (MDG) on maternal health aims to reduce the number of women who die in pregnancy and childbirth by three-quarters between 1990 and 2015 . To achieve this goal, it is estimated that an annual decline in maternal mortality of 5.5% is needed; however between 1990 and 2005 the annual decline was only 0.5% in the sub-Saharan region, compared to 4.2% for the middle income countries of Asia [1,3].
Maternal mortality occurs from risks attributable to pregnancy and child birth as well as from poor availability and quality of health services . The most common causes of maternal mortality in sub-Saharan Africa include haemorrhage (34%), sepsis/infections (10%), hypertensive disorders (9%), HIV/AIDS (6%), and other direct causes (5%); other indirect causes contributed approximately 17% .
Experiences from different countries have shown that reducing maternal mortality may depend in part on the availability and use of a professional attendant at labour and delivery and a referral mechanism for obstetric care for managing complications, or the use of basic essential obstetric care facilities for all deliveries . In many developing countries however, the majority of births occur at home, frequently without the help of a skilled assistant (midwife, nurse trained as midwife or a doctor) .
The effect of antenatal care on maternal mortality is unclear [8-10]. However, there is broad agreement that antenatal care interventions can lead to improved maternal and newborn health, which can also impact on the survival and health of the infant . Additionally, the ANC visit, which many women in sub-Saharan Africa attend, is an opportunity to reach pregnant women with messages and interventions. A global evaluation of antenatal care has resulted in the recommendation to deliver antenatal services in 4 focused visits (Focussed antenatal care; FANC), one within the first trimester and 3 after quickening, and this schedule is now endorsed by WHO [12,13]. Proven effective antenatal interventions include serologic screening for syphilis, provision of malaria prevention, anti-tetanus immunization, and prevention of mother-to-child transmission of HIV [14,15]. To fully benefit from these interventions, it is important that women start visiting the antenatal clinic (ANC) early in pregnancy.
We evaluated maternal care in western Kenya in 2002 and showed that preventive interventions received at the ANC were inadequate in spite of high (90%) ANC attendance . After this evaluation, the Kenyan Ministry of Health in conjunction with the Johns Hopkins Organization for International Education in Training and Reproductive Health (JHPIEGO) trained healthcare workers in FANC and malaria in pregnancy in part of the study area (Asembo). FANC emphasizes goal-oriented and women-centred care by skilled providers, whereby the quality instead of the quantity of visits is important . The FANC training in 2003 emphasized identification of pre-existing health problems, early detection of danger signs arising from pregnancy, health promotion, provision of intermittent preventive treatment for malaria in pregnancy (IPTp) with sulfadoxine-pyrimethamine (SP), provision of iron and folate, birth preparedness, blood pressure measurement, growth monitoring, urine albuminuria and preparation for post-partum family planning. The training was short (3 days) and focused on need-to-know information. An interactive training approach with user-friendly materials was used. These materials enabled the providers to cascade the training to their colleagues in the place of work. Supportive supervision to reinforce skills was undertaken following the training in May-June 2003 in a random sample comprising of 25% of the health facilities in which health care workers had been trained (because of resource constraints not all health facilities received supportive supervision). The focus of the supportive supervision was to identify any gaps and to reinforce knowledge on focused antenatal care and malaria in pregnancy.
In April 2005, we conducted a repeat cross-sectional survey among a random sample of women with a recent birth living in the same areas as the previous survey to assess whether there were improvements in antenatal and delivery care and if there were differences between the area where service providers were trained in FANC and the area where training did not occur.
The Centers for Disease Control and Prevention and the Kenya Medical Research Institute (CDC/KEMRI) conduct a demographic surveillance system (DSS) in western Kenya, since 2002. The DSS area is located in Asembo (Rarieda Division, Bondo district) and Gem (Yala and Wagai Divisions, Siaya District), of Nyanza province in western Kenya, and covers 217 villages (75 in Asembo and 142 in Gem) spread over approximately 500 km2 along the shores of Lake Victoria. The vast majority of the population are members of the Luo tribe who earn their living through subsistence farming and fishing . Residents of the DSS are visited in their homes every 4 months to record births, deaths, pregnancies, pregnancy outcomes, immigration and out-migration . Health indicators are poor in the area when compared to national figures, with infant mortality rate estimated at 125 per 1000 live births compared to the national figure of 77 per 1000 live births, under-five mortality rate of 227 per 1000 live births compared to 115 nationally, and overall life expectancy at birth at 38 years (36 for men and 39 for women) compared to 48 nationally . The maternal mortality ratio was estimated at 753 per 100,000 live births in 2003 compared to 414 per 100,000 live births nationally . This area traditionally experienced intense perennial malaria transmission with an estimated entomological inoculation rate of ≈ 60-300 infectious bites per person per year . However, the widespread provision of insecticide-treated nets (ITNs) during a bed net efficacy trial reduced transmission in the study area by about 90% and continuous provision of ITNs has maintained malaria transmission at a low level [22,23]. The prevalence of malaria parasitemia and anaemia was 36% and 53% respectively among pregnant women in a community survey in 2003 . In the 2003 Demographic and Health Survey, the seroprevalence of HIV/AIDS in Nyanza Province (15%) was about twice as high as the national average of 7% . The age-adjusted prevalence rates of HIV in men and women 13-34 years old in the DSS area were 11% and 21%, respectively (P. Amornkul, personal communication). A survey among 13 antenatal clinics in Asembo in 2005 revealed that 7 ANCs did not charge for ANC visits, and 9 provided treatments such as iron and folic acid without charge (P. Ouma, personal communication). We do not have this information for ANCs in Gem.
The sample size estimate for this study was based on a comparison of IPTp use in Asembo and Gem, and aimed to detect at least 50 percentage point difference in IPTp use in Asembo compared to Gem after FANC training, with 80% power and 95% confidence interval. Allowing for 15% failure to recruit, a random sample of 830 women was selected using a list of women who had delivered between 30th of September 2004 and 30th of March 2005 in the DSS . Interviews were conducted by experienced interviewers in the local language using a standardized questionnaire. Participants were asked questions on ANC clinic visits, services received at the clinic, where their last delivery occurred, who assisted with the delivery and satisfaction with antenatal and delivery services. Interviewers were instructed not to probe with options. Questions were similar to the 2002 survey, except for the quality assessment of the maternal services, which had not been included in the 2002 survey.
Data management and statistical methods
We first compared the two areas in the survey in 2005, and then compared the results of the survey in 2005 to the survey in 2002. We examined the use of antenatal and delivery care, and the type of ANC services received, and the satisfaction with the services (2005 only).
Differences in proportions were compared using the Chi-square or Fisher's exact tests as appropriate. For the comparisons of medians, we used the Wilcoxon two sample test (non-parametric). Education level was dichotomized as < 8 years or ≥ 8 years, the minimum number of years required to complete primary education in Kenya. We used Principal Components Analysis (PCA) method to generate weights for the following broad household characteristics: occupation of participant and spouse, source and quality of water, source of fuel for cooking, livestock and asset ownership, and dwelling/housing structure. The scores were used to rank the study participants in socio-economic status (SES) quintiles . A medium/low SES was defined as a rank in the bottom three quintiles of the wealth index. The statistical program SAS was used for all analyses (SAS for windows version 8; SAS Institute, Cary, North Carolina, USA).
Ethical approval for this study was obtained from the institutional review boards of the Kenya Medical Research Institute (Nairobi, Kenya) and the Centers for Disease Control and Prevention (Atlanta, Georgia, USA).