Effect of Enhanced Nutrition and Infection Management Intervention Packages on Antenatal Quality of Care Indicators in Rural Amhara, Ethiopia.

Technical Summary: Effect of Enhanced Nutrition and Infection Management Intervention Packages on Antenatal Quality of Care Indicators in Rural Amhara, Ethiopia

Problem Statement
High-quality antenatal care (ANC) is critical for detecting and managing pregnancy-related complications, yet gaps in adherence to quality services persist in low-income settings like Ethiopia. While the World Health Organization (WHO) and the Ethiopian Ministry of Health recommend at least eight ANC contacts, evidence suggests that increasing contact frequency alone does not guarantee improved quality of care. Previous studies have shown marginal improvements in ANC coverage with single-package interventions but limited evidence regarding the impact of combined interventions on the quality of ANC services. The study addresses the need to assess whether integrating enhanced nutrition and infection management packages into the existing health system can improve both the frequency of ANC contacts and the composite quality of care score.

Methodology
The study was a secondary analysis of the Enhancing Nutrition and Antenatal Infection Treatment (ENAT) study, a pragmatic, open-label, 2x2 factorial randomized clinical effectiveness trial conducted in 12 rural health centers in West Gojam and South Gondar, Amhara, Ethiopia, between August 2020 and June 2022.

• Participants: 2,392 pregnant women presenting at <24 weeks of gestation were enrolled.
• Design: A cluster-randomized design was used for the nutrition component, while individual randomization was used for the infection component.
  • Cluster Level: Health facilities were allocated to either an Enhanced Nutrition Package (ENP) or routine nutrition care (non-ENP).
  • Individual Level: Participants were randomized to an Enhanced Infection Management Package (EIMP) or routine infection care (non-EIMP).
  • Arms: This resulted in four study arms: ENP+EIMP, ENP only, EIMP only, and routine care (neither package).
• Interventions:
  • ENP: Included nutritional counseling, monthly supply of iodized salt, iron-folic acid counseling/supply, and daily Balanced Energy Protein (BEP) supplements for undernourished women (MUAC <23 cm).
  • EIMP: Included screening and treatment for chlamydia, gonorrhea, bacterial vaginosis, and Trichomonas, plus deworming with mebendazole in the second and third trimesters. Both packages included reminders for scheduled visits and home visits for missed appointments.
• Outcome Measures: The primary outcomes were the number of ANC contacts and a composite Antenatal Quality of Care (ANC QoC) score. The QoC score (range 0–10) summed ten binary components: number of contacts, blood pressure measurement (≥2 times), infection screening, urine collection, tetanus toxoid vaccination (≥2 shots), deworming, iron/folic acid receipt, nutritional counseling, hemoglobin measurement, and counseling on danger signs.
• Statistical Analysis: Analyses utilized cluster-level t-tests for ENP marginal effects, multivariate linear regression for EIMP marginal effects, and generalized estimating equations (GEE) for combined effects. Models were adjusted for maternal age, education, occupation, parity, pregnancy intention, and land ownership.

Key Results
From August 2020 to December 2021, 2,392 women were randomized and followed until June 2022.

1. Enhanced Nutrition Package (ENP) Effects:

   • ANC Contacts: The ENP group had a significantly higher number of contacts compared to non-ENP (Adjusted Mean Difference [aMD] = 1.63; 95% CI: 1.13 to 2.13).
   • QoC Score: The ENP group showed a significantly higher ANC QoC score (aMD = 2.13; 95% CI: 0.54 to 3.72).
   • Specific Indicators: Significant improvements were observed in blood pressure measurement frequency.

2. Enhanced Infection Management Package (EIMP) Effects:

   • ANC Contacts: The EIMP group had a modest but significant increase in contacts compared to non-EIMP (aMD = 0.38; 95% CI: 0.14 to 0.62).
   • QoC Score: The EIMP group had a significantly higher QoC score (aMD = 0.89; 95% CI: 0.44 to 1.34).
   • Specific Indicators: Significant increases were noted in urine sample collection (aRR = 1.10) and deworming uptake (aRR = 2.61).

3. Combined Intervention (ENP+EIMP) Effects:

   • ANC Contacts: The combined arm demonstrated the largest effect, with an average of 4.6 contacts compared to 2.7 in the routine care arm (aMD = 1.92; 95% CI: 1.48 to 2.36).
   • QoC Score: The combined intervention resulted in the highest QoC score improvement (aMD = 2.77; 95% CI: 1.28 to 4.27).
   • Specific Indicators: Deworming uptake was significantly higher in the combined group (aRR = 2.29).

Significance and Claims
The paper claims that the combination of enhanced nutrition and infection management interventions had the largest positive effect on both the number of ANC contacts and the overall quality of care score. The authors posit that bolstering these specific services during pregnancy encourages additional ANC contacts, thereby creating more opportunities to provide targeted, high-quality care.

The study highlights that integrating these packages into the existing health system is a viable strategy to improve service coverage and quality, even during challenging periods such as the COVID-19 pandemic and regional conflicts. The authors conclude that these findings emphasize the need to adapt these quality-of-care components for the monitoring and evaluation of antenatal care programs in similar settings.

Limitations Noted by Authors
The authors acknowledge that the pandemic and civil conflict limited service delivery and follow-up, potentially compromising the measurement of ANC uptake throughout the entire pregnancy. Additionally, the study could not capture waiting times, a key component of service quality. The reliability of the ANC QoC scale (Cronbach's alpha = 0.576) was deemed sufficient but noted as requiring further enrichment for robust measurement.