Assessing the Extent of Adherence to the Recommended Antenatal Care Content in Malaysia: Room for Improvement

Background
Recent papers on monitoring of health services affirmed that while antenatal care (ANC) is an effective measure, quality is still a problem. Quality in maternal services “…involves providing a minimum level of care to all pregnant women…” Yet adherence to a minimum level of recommended ANC content appears to be unmet. Comprehensive review of ANC content rendered in environments with rapid changes in demographic, socio-economic, lifestyle and morbidity was sparse. Malaysia is such a country that has undergone these transitions with tremendous progress in health. However, recent progress in pregnancy outcomes is stagnating. This study aims to analyse adherence to recommended ANC; specifically, to examine the extent of adherence to recommended ANC content and to determine the factors influencing ANC content score.
Methods
A retrospective cohort study of 522 randomly selected women who used ANC was conducted. Data were extracted from individual records. The study examined adherence to essential ANC guidelines using weighted scoring for physical examination, health screening, case management, and health education. GLM Univariate analysis procedure was used to determine the factors associated with ANC content score. Binary logistic regression was used to assess ANC content level and pregnancy outcomes, controlled for ANC utilisation.
Results
Around half of the women had <80% of recommended ANC content documented. Health education had the lowest mean score, at around 35%. The low-risk pregnancies had a higher ANC content score than the high-risk pregnancies (78% vs. 75%; P = 0.002). The smallest clinics had a higher ANC content score than the bigger clinics (78% vs. 74–76%; P<0.001). ANC content score among the women with “adequate” ANC utilisation, as defined by the modified Adequacy of Prenatal Care Utilisation Index, was lower than the women with “adequate-plus” ANC utilisation (75% vs. 78%, P<0.001). Assessment of symphysis-fundal height, foetal presentation and foetal heart auscultation were initiated earlier than recommended. Inadequate ANC content was associated with higher prevalence of preterm birth.
Conclusions
Our findings indicate the presence of issues related to delivery of recommended ANC content. We advocate for all pregnant women to be ensured of adherence to the recommended ANC content. We also recommend monitoring the delivery of health advice. Conforming to recommended timing of initiation for ANC practices is essential due to resource implication and possible implication on maternal wellbeing. The association of inadequate ANC content and preterm birth may be due to lesser opportunities to receive some of the care because of lower number of ANC visits among preterm birth; this may also indicate the importance of having adequate ANC content.

背景
近期有关卫生服务监测的研究指出，尽管产前保健（antenatal care, ANC）是一项有效的干预措施，但其质量仍存在诸多问题。产科服务质量"指为所有孕妇提供最低标准的照护"，但目前对推荐的ANC核心内容的最低标准依从性仍未达标。在人口结构、社会经济状况、生活方式及疾病谱快速变迁的环境中，针对ANC服务内容的全面综述仍较为匮乏。马来西亚正是经历了这类变迁且卫生事业取得长足发展的国家之一，但近年来其妊娠结局的改善已陷入停滞。本研究旨在分析推荐ANC服务的依从性情况：具体而言，即评估研究对象对推荐ANC核心内容的依从程度，并明确影响ANC内容评分的相关因素。
方法
本研究采用回顾性队列研究设计，纳入522名随机选取的接受ANC服务的孕妇，研究数据从个体病历中提取。研究通过对体格检查、健康筛查、病例管理及健康教育四个维度设置加权评分，评估研究对象对核心ANC指南的依从性。本研究采用广义线性模型（Generalized Linear Model, GLM）单变量分析程序，明确与ANC内容评分相关的影响因素；采用二元logistic回归分析，在控制ANC服务利用情况的前提下，评估ANC内容水平与妊娠结局之间的关联。
结果
约半数孕妇的病历中记录的ANC服务内容未达到推荐标准的80%。健康教育维度的平均得分最低，仅约35%。低危妊娠孕妇的ANC内容评分高于高危妊娠孕妇（78% vs. 75%；P=0.002）。小型诊所的ANC内容评分高于大型诊所（78% vs. 74%~76%；P<0.001）。根据改良产前保健利用充足性指数（modified Adequacy of Prenatal Care Utilisation Index）定义，"充分利用"ANC服务的孕妇其ANC内容评分低于"超充分利用"组（75% vs. 78%，P<0.001）。耻骨联合-宫底高度测量、胎儿胎位评估及胎儿胎心听诊的实施时间早于推荐方案。ANC内容不达标与早产患病率升高存在关联。
结论
本研究结果显示，当前ANC服务的推荐内容落实仍存在诸多问题。我们呼吁应确保所有孕妇均能获得符合推荐标准的ANC服务。同时建议加强健康指导服务落实情况的监测。由于涉及医疗资源配置及可能对孕妇健康产生影响，严格遵循ANC服务启动的推荐时间至关重要。ANC内容不达标与早产的关联，可能是由于早产孕妇的ANC随访次数较少，从而获得部分照护的机会不足；这也侧面体现了落实达标ANC服务内容的重要性。