Counselling on and women's awareness of pregnancy danger signs in selected rural health facilities in Burkina Faso, Ghana and Tanzania
The aims of this study were to (i) assess healthcare workers' counselling practices concerning danger signs during antenatal consultations in rural primary healthcare (PHC) facilities in Burkina Faso, Ghana and Tanzania; to (ii) assess pregnant women's awareness of these danger signs; and (iii) to identify factors affecting counselling practices and women's awareness.
Cross-sectional study in rural PHC facilities in Burkina Faso, Ghana and Tanzania. In each country, 12 facilities were randomly selected. WHO guidelines were used as standard for good counselling. We assessed providers' counselling practice on seven danger signs through direct observation study (35 observations/facility). Exit interviews (63 interviews/facility) were used to assess women's awareness of the same seven danger signs. We used negative binomial regression to assess associations with health services' and socio-demographic characteristics and to estimate per study site the average number of danger signs on which counselling was provided and the average number of danger signs mentioned by women.
About one in three women was not informed of any danger sign. For most danger signs, fewer than half of the women were counselled. Vaginal bleeding and severe abdominal pain were the signs most counselled on (between 52% and 66%). At study facilities in Burkina Faso, 58% of the pregnant women were not able to mention a danger sign, in Ghana this was 22% and in Tanzania 30%. Fever, vaginal bleeding and severe abdominal pain were the danger signs most frequently mentioned. The type of health worker (depending on the training they received) was significantly associated with counselling practices. Depending on the study site, characteristics significantly associated with awareness of signs were women's age, gestational age, gravidity and educational level.
Counselling practice is poor and not very efficient. A new approach of informing pregnant women on danger signs is needed. However, as effects of antenatal care education remain largely unknown, it is very well possible that improved counselling will not affect maternal and newborn mortality and morbidity.
(i) Evaluer les pratiques de conseil des travailleurs de santé concernant les signes de danger pendant les consultations prénatales dans les établissements de soins de santé primaires en milieu rural au Burkina-Faso, au Ghana et en Tanzanie, (ii) évaluer la connaissance de ces signes de danger par les femmes enceintes, et (iii) identifier les facteurs affectant les pratiques de conseil et de sensibilisation des femmes.
Etude transversale dans les établissements de soins de santé primaires en milieu rural au Burkina-Faso, au Ghana et en Tanzanie. Dans chaque pays, 12 établissements ont été choisis au hasard. Les directives de l’OMS ont été utilisées comme référence pour le bon conseil. Nous avons évalué la pratique de conseil donné par les prestataires sur sept signes de danger à travers l’étude d'observation directe (35 observations/établissement). Les entretiens à la sortie (63 entretiens/établissement) ont été utilisés pour évaluer la connaissance des femmes sur ces sept mêmes signes de danger. Nous avons utilisé la régression binomiale négative pour évaluer les associations avec les caractéristiques des services de santé et sociodémographiques et pour estimer par site d’étude, le nombre moyen de signes de danger pour lesquels le conseil était procuré et le nombre moyen de signes de danger mentionnés par les femmes.
Environ une femme sur trois n'a pas été informée de tout signe de danger. Pour la plupart des signes de danger, moins de la moitié des femmes ont été conseillées. Les saignements vaginaux et les douleurs abdominales sévères étaient les signes les plus conseillés (entre 52% et 66%). Dans les établissements d’études au Burkina Faso, 58% des femmes enceintes n'ont pas pu mentionner un signe de danger, au Ghana 22% et en Tanzanie 30%. La fièvre, les saignements vaginaux et les douleurs abdominales sévères étaient les signes de danger les plus fréquemment cités. Le type d'agent de la santé (selon la formation reçue) était significativement associé aux pratiques de conseil. Selon le site de l’étude, les caractéristiques associées de façon significative à la connaissance des signes étaient l’âge des femmes, l’âge gestationnel, la gravidité et le niveau d’éducation.
La pratique du conseil est faible et pas très efficace. Une nouvelle approche pour informer les femmes enceintes sur les signes de danger est nécessaire. Toutefois, comme les effets de l’éducation dans les cliniques prénatales demeurent largement inconnus, il est tout à fait possible que l'amélioration du conseil n'affectera pas la mortalité et la morbidité maternelle et néonatale.
(i) Evaluar la prácticas de asesoramiento de los trabajadores sanitarios con respecto a los signos de peligro durante las consultas prenatales en centros sanitarios rurales de atención primaria en Burkina Faso, Ghana y Tanzania; y (ii) evaluar los conocimientos de las mujeres embarazadas sobre estos signos de peligro, e (iii) identificar los factores que afectan las prácticas de asesoramiento y los conocimientos de las mujeres.
Estudio croseccional en centros rurales de atención primaria en Burkina Faso, Ghana y Tanzania. En cada país se seleccionaron al azar 12 emplazamientos. Se utilizaron las guías de la OMS como estándar de buenas prácticas de asesoramiento. Evaluamos las prácticas de asesoramiento de los proveedores sobre siete signos de peligro, mediante un estudio de observación directa (35 observaciones/emplazamiento). Se utilizaron encuestas de salida (63 entrevistas/emplazamiento) para evaluar los conocimientos de las mujeres sobre los mismos siete signos de peligro. Utilizamos una regresión binomial negativa para evaluar las asociaciones entre los servicios sanitarios y las características socio-demográficas y para calcular por emplazamiento de estudio el número promedio de signos de peligro sobre los que se habían dado recomendaciones y el número promedio de signos de peligro mencionados por las mujeres.
Aproximadamente una de cada tres mujeres no había sido informada sobre ningún signo de peligro. Sobre la mayoría de los signos de peligro, menos de la mitad de mujeres habían recibido asesoramiento. El sangrado vaginal y el dolor abdominal severo fueron los signos sobre las que la mayoría recibieron consejo (entre un 52% y 66%). En los emplazamientos del estudio en Burkina Faso, un 58% de las mujeres embarazadas no eran capaces de mencionar ninguna señal de peligro; en Ghana un 22% y en Tanzania un 30%. Los signos de peligro más frecuentemente mencionados fueron la fiebre, el sangrado vaginal y el dolor abdominal severo. El tipo de trabajador sanitario (dependiendo del entrenamiento que habían recibido) estaba significativamente asociado con las prácticas de asesoramiento. Dependiendo del emplazamiento del estudio, las características significativamente asociadas con el conocimiento de los signos eran la edad de la mujer, la edad gestacional, gravidez y nivel de educación.
Las prácticas de asesoramiento son precarias y poco eficientes. Se requiere de un nuevo enfoque a la hora de informar a las mujeres embarazadas sobre los signos de peligro. Sin embargo, como los efectos de la educación prenatal son en gran parte desconocidos, es muy posible que el mejorar el asesoramiento no tenga efecto sobre la mortalidad y la morbilidad materno-infantil.
Despite a significant global drop in maternal mortality from 543 000 deaths in 1990 to 287 000 deaths in 2010 (WHO, UNICEF, UNFPA & World Bank 2012), and a decrease of under-5 mortality from 11.6 million deaths in 1990 to 7.2 million deaths in 2011 (Lozano et al. 2011), maternal and newborn mortality remain unacceptably high in sub-Saharan Africa. About 56% of maternal deaths (WHO, UNICEF, UNFPA & World Bank 2012) and 49% of under-5 deaths (Lozano et al. 2011) occur in sub-Saharan Africa, although this region is home to only about 13% of the world population (Population Reference Bureau (PRB) 2011) and 19% of the global under-5 population (UNICEF 2012). Most sub-Saharan African countries will need many years past 2015 to achieve the Millennium Development Goals 4 and 5 (MDGs 4 & 5), which aim to reduce the under-5 mortality rate by two-thirds and the maternal mortality ratio by three-quarters between 1990 and 2015 (Lozano et al. 2011; WHO, UNICEF, UNFPA & World Bank 2012).
Burkina Faso, Ghana and Tanzania are sub-Saharan African countries with high maternal and neonatal mortality. Lozano et al. (2011) report maternal mortality ratios of 354, 328 and 418 per 100 000 live births, and neonatal mortality rates of 39, 25 and 24 per 1000 live births, respectively, for these countries. Mortality data of the respective countries' demographic and health surveys are in line with these data, with reported maternal mortality ratios of 341 and 454 per 100 000 live births for Burkina Faso and Tanzania, respectively (data for Ghana are not available), and neonatal mortality rates of 28, 30 and 26 per 1000 live births for Burkina Faso, Ghana and Tanzania, respectively (Ghana Statistical Service (GSS), Ghana Health Service (GHS), & ICF Macro 2009b; Institut National de la Statistique et de la Démographie (INSD) et ICF International 2012; National Bureau of Statistics (NBS) [Tanzania] & ICF Macro [Tanzania] & ICF Macro [Tanzania] and ICF Macro 2011). At present, none of the three countries show enough progress in reducing maternal and child mortality to achieve the targets of MDGs 4 and 5 by 2015 (Lozano et al. 2011).
Common causes of maternal death in these three countries are haemorrhage, infection/sepsis, hypertensive disorders, obstructed labour and abortion complications, accounting together for 77% of direct maternal deaths in Burkina Faso, 70% in Ghana and 86% in Tanzania (Ghana Statistical Service (GSS), Ghana Health Service (GHS), & Macro International 2009a; MoH 2006; MoHSW 2008). These complications are treatable; hence, most of these deaths are avoidable if women receive appropriate care timely. A condition of accessing appropriate care on time is that women are aware of and able to recognise the signs of these pregnancy complications, the so-called danger signs, and that they know what to do when these occur. In this respect, counselling during pregnancy is important and one of the strategies to reduce maternal and newborn mortality (WHO, UNFPA, UNICEF & World bank 2006; WHO 2010; Nyamtema et al. 2011). Counselling on danger signs is included in the WHO guidelines on pregnancy and childbirth as one of the key recommendations during antenatal care (ANC) (WHO, UNFPA, UNICEF & World bank 2006) and is adopted in the three study countries' national maternal health guidelines (Baker et al. 2012).
This study is part of the QUALMAT project, an intervention research project aiming to improve maternal and newborn health by improving the quality of care provided at primary healthcare (PHC) facilities. The project is conducted in selected PHC facilities in Burkina Faso, Ghana and Tanzania (QUALMAT 2013; Duysburgh et al. 2013). This study is part of the QUALMAT baseline assessment and aims to assess healthcare workers' counselling practices on danger signs during antenatal consultations and pregnant women's knowledge of these danger signs. We also aimed to identify characteristics affecting counselling practices and women's knowledge of danger signs.
This study was conducted in PHC facilities in Burkina Faso, Ghana and Tanzania. In each country, 12 facilities, located in two neighbouring rural districts, were randomly selected. Only PHC facilities providing ANC and childbirth services were eligible for selection. Selection of districts was based on being typical for the country in terms of medical infrastructure, equipment and staffing, corresponding to national norms. The names of these districts and some general demographic and maternal health-related indicators at district level are provided in Table 1.
Table 1. District demographic and maternal health-related indicators
|Burkina Faso||Nouna||305 351||6.8||93.6|
|Tanzania||Lindi Rural||244 256||4.4||99.6|
|Mtwara Rural||227 134||99.0|
Study design and sample size
A cross-sectional study was performed in all selected PHC facilities. As standard for good counselling, we used the WHO guideline on antenatal and childbirth care (WHO, UNFPA, UNICEF & World bank 2006). We assessed providers' counselling practice through a direct observation study. Exit interviews conducted immediately after the pregnant woman left the ANC consultation were used to assess women's knowledge on danger signs. For the observation study, we developed and used a structured checklist, and for the exit interview, a structured questionnaire.
During the observation study, we checked whether healthcare workers correctly advised pregnant women on how to recognise and what to do in case of (i) vaginal bleeding, (ii) convulsions, (iii) severe headache with blurred vision, (iv) fever and being too weak to get out of bed, (v) severe abdominal pain, (vi) fast and difficult breathing, and (vii) swelling of fingers, face and legs. Women's knowledge on these seven danger signs was assessed by an exit interview. During the exit interview, women were asked to mention all the danger signs they knew that can occur during pregnancy. The observation study and the exit interviews were conducted in all selected health facilities in the three study countries. Women participating in the exit interviews were not the same as those included in the observation study; however, they all received ANC in the same selected health facilities during the same time period of maximum 1 month.
We collected information on a number of characteristics to assess their possible association with the outcomes, that is, the number of danger signs on which counselling was provided and the number of danger signs mentioned by the women. These characteristics included (i) woman's age, (ii) gestational age, (iii) gravidity, (iv) number of ANC visits, (v) educational level and (vi) type of healthcare worker.
At each selected PHC facility, we aimed at observing at least 35 ANC consultations and interviewing at least 63 women after receiving ANC consultation. This sample size was chosen within the framework of the QUALMAT research project to enable us to assess changes in quality of care as a result of the QUALMAT intervention study.
Data collection and analysis
Data collection took place between June and November 2010 by certified healthcare workers (nurses and midwifes without links to the assessed facilities) who had undergone 5 days of training. In each facility, data collection started on a randomly selected day and continued until the predefined sample size was achieved. To avoid a potential bias, women included in the observation study could not be included in the exit interviews. Interviews were conducted in the local language. Data collection took about 1 month per facility. To ensure objectivity, data collectors were rotated every 2 weeks. At some health facilities, data collection was stopped too early; thus, slightly fewer than of 35 ANC observations and 63 interviews were reached in these facilities.
Data were double-entered in Epi Info version 3.5.1 and analysed in Stata/IC 11.2. We used negative binomial regression to identify, by study country, the association between the above-mentioned characteristics and the number of danger signs on which counselling was provided and the number of danger signs mentioned by women. Associations were first assessed in univariate models. Characteristics significant at the 0.10 level were included in the final model. We then used a backward elimination procedure, and probability for removal was set at 0.05. All characteristics that were significantly associated in any of the study countries were retained in the final models for the three countries. We tested for plausible interactions between the characteristics retained in the final models.
Written informed consent was obtained from all women and healthcare workers before enrolment in the study. To guarantee confidentiality, study tools did not include patient identifiers. Ethical clearance was granted by the Ethics Committee of the Centre de Recherche en Santé de Nouna for Burkina Faso; the Institutional Review Board of the Navrongo Health Research Centre for Ghana; Muhimbili University of Health and the Allied Science Review Committee for Tanzania; the Ethics Committee of the Medical Faculty, University of Heidelberg, Germany; and the Ethics Committee of the University of Ghent.
General characteristics of women and primary healthcare facilities
The majority of the selected health facilities were public health facilities; others were faith-based private not-for-profit facilities (Table 2). As Table 2 shows, the characteristics of the PHC facilities were rather similar in the three countries, except for smaller catchment area populations and fewer ANC consultations in Tanzania.
Table 2. General characteristics of the research primary healthcare facilities
|12 facilities in Burkina Faso||All public||11 039 (3463–41 346)||5 (3–20)||1549 (455–3693)|
|12 facilities in Ghana||10 public, 2 private not-for-profit (faith based)||13 975 (2083–20 444)||8.5 (2–14)||1417 (269–5077)|
|12 facilities in Tanzania||11 public, 1 private not-for-profit (faith based)||7994 (3551–16 773)||6 (2–13)||508 (138–1325)|
Socio-demographic and pregnancy characteristics of women involved in the observation study and the exit interviews are presented in Table 3. By and large, they were very similar across the study sites. Only the educational level of pregnant women participating in the exit interviews in Burkina Faso was lower than in the other two sites.
Table 3. Characteristics of women included in the observation study and exit interviews
|Observation study||Number of women observed, n||411||420||418|
|Age, median (range), years||24 (14–55)||26 (15–50)||26 (15–49)|
|Gestation age at time of consultation, median (range), weeks||28 (6–45)||28 (4–41)||24 (8–40)|
|Number of ANC visit, median||2||3||2|
|Women with 2 or more ANC visits, %||61||76||62|
|Exit interview||Number of women interviewed, n||644||710||611|
|Age, median (range), years||24 (15–44)||25 (14–55)||26 (14–46)|
|Gestation age at the time of consultation, median (range), weeks||28 (5–42)||26 (5–39)||20 (3–40)|
|Number of ANC visit, median||2||3||2|
|Women with 2 or more ANC visits, %||73||80||66|
|Number of pregnancies (including present pregnancy), median (range)||3 (1–15)||3 (1–8)||3 (1–10)|
|Never attended school, %||81||48||46|
|Completed primary school, %||12||32||44|
Providers' counselling practice on and women's knowledge of pregnancy danger signs
The healthcare worker provided counselling by listing danger signs and telling the pregnant woman what she should do when these occurred. The observation study showed that, during the ANC consultations, about one in three women was not informed on any of the seven pregnancy danger signs in all three sites: 31.4% in Burkina Faso, 29.5% in Ghana and 39.5% in Tanzania. Only 5.4% of women in Burkina Faso, 30.0% in Ghana and 22.5% in Tanzania were counselled on all seven danger signs (Table 4). For most individual danger signs, fewer than half of the women were counselled (Table 4). The danger signs most consistently counselled on in all study sites were vaginal bleeding and severe abdominal pain. However, even for those signs, the proportion of women counselled only ranged from 51.6% to 66.4%. Counselling on what to do when convulsions or fast and difficult breathing occurs was weak at all study sites (13.4–39.8% of women were counselled on any of these signs per study site; Table 4). On average, women were counselled on 2.5 of seven danger signs at the study site in Burkina Faso, on 3.6 in Ghana and on 3.0 in Tanzania.
Table 4. Women counselled on pregnancy danger signs and women knowing pregnancy danger signs by study site
|Severe headache with blurred vision||43.3||14.4||55.2||54.2||48.1||28.6|
|Fever and too weak to get out of bed||40.6||28.0||54.8||40.8||28.7||44.7|
|Severe abdominal pain||66.4||34.8||56.4||40.6||54.3||33.9|
|Fast and difficult breathing||18.7||1.9||39.8||4.2||25.6||2.5|
|Swelling of fingers, face, legs||11.4||5.0||56.0||32.1||47.8||26.2|
|All of the above signs||5.4||0.5||30.0||0.1||22.5||0.0|
|None of the above signs||31.4||58.2||29.5||21.7||39.5||30.0|
Exit interview results show that awareness of danger signs among the women is poor. In Burkina Faso, 58.2% were unable to mention any of the seven danger signs; in Ghana, 21.7%; and in Tanzania, 30.0%. Only three of 644 women interviewed in Burkina Faso were able to mention all seven danger signs, in Ghana one of 710 women, and in Tanzania none of the 611 women interviewed. Awareness of danger signs matches the danger signs counselled on: fever, vaginal bleeding and severe abdominal pain were most frequently mentioned (percentages of women mentioning one of these signs by study site range from 24.8% to 57.6%), and convulsions and fast and difficult breathing least frequently (between 0.5% and 10.0%; Table 4). On average, in Burkina Faso, women mentioned 1.1 danger signs, in Ghana 2.1 and in Tanzania 2.0.
Characteristics associated with counselling practice
In univariate analysis, type of healthcare worker was significantly associated with number of danger signs women were counselled on in Burkina Faso and in Tanzania. In Ghana, only midwives were involved (Table 5). Health staff with a higher educational level provided better counselling in Burkina Faso, but in Tanzania, some of the less educated health cadres offer better counselling than their higher-educated colleagues.
Table 5. Characteristics associated with counselling practice by study site, univariate analysis
|Accoucheuse Auxiliaire||307||2.6||Ref|| || || || || || |
|Agent Itinerant de Sante||100||1.9||0.013|| || || || || || |
|Midwife|| || || ||415||3.6||–|| || || |
|Clinical officer|| || || || || || ||87||2.6||Ref|
|Nurse midwife|| || || || || || ||76||3.7||0.020|
|Public health nurse|| || || || || || ||44||1.8||0.052|
|Enrolled nurse|| || || || || || ||29||6.8||<0.001|
|Maternal and child health aid|| || || || || || ||6||7.0||0.008|
|Nurse assistant/attendant|| || || || || || ||69||3.9||0.008|
|Number of ANC visits|
Women older than 30 years received significantly less counselling in Burkina than their younger peers; this was not seen in Ghana and Tanzania. Gestational age and the number of ANC visits were not associated with counselling provided in any of the countries.
Characteristics associated with awareness of danger signs
Overall awareness was poor, and in none of the subgroups, the predicted average number of danger signs mentioned was more than 2.5. On univariate analysis, ‘number of ANC visits’ was not associated in any of the countries, all other characteristics were retained in the final model (Table 6). Depending on the study site, characteristics significantly associated with knowing danger signs in our final model were age (Burkina Faso), gestational age (Burkina Faso and Tanzania), gravidity (Ghana) and educational level (Burkina Faso and Tanzania). Older women had better awareness in Burkina Faso, but in the other countries, there was no difference between the age groups. Gestational age of 28 weeks or above was associated with higher danger sign awareness in Tanzania, but lower awareness in Burkina Faso. Having completed primary education was associated with better awareness in all three countries, although this effect was not statistically significant in Ghana (Table 7).
Table 6. Characteristics associated with women's awareness on danger signs by study site, univariate analysis
|Number of ANC visits|
|No formal education||510||1.0||Ref||330||2.1||Ref||262||1.8||Ref|
|Primary education started||43||1.2||0.439||136||2.1||0.704||54||2.0||0.379|
|Primary education finished and above||76||2.1||<0.001||221||2.1||0.630||252||2.3||0.001|
Table 7. Characteristics associated with women's awareness on danger signs by study site, multivariate analysis
|No formal education||1.0||Ref||2.0||Ref||1.9||Ref|
|Primary education started||1.1||0.688||2.1||0.439||2.0||0.593|
|Primary education finished and above||2.0||<0.001||2.2||0.081||2.5||0.001|
The group with the highest predicted mean, that is, the group in which on average women knew most danger signs, is the group of highest educated women in Tanzania. Even in this group, the predicted average number of danger signs mentioned is only 2.45 of the total 7 (Table 7).
Recognising danger signs during pregnancy and taking timely action are crucial to reduce maternal and newborn mortality and morbidity. Therefore, counselling on danger signs is an essential element of ANC (WHO, UNFPA, UNICEF & World bank 2006). Yet our study results show that in all three study sites, counselling practices are poor and inefficient. About one-third of the women attending ANC consultations were not counselled at all; when women were counselled, they did not seem to get the message as reflected by their limited knowledge of danger signs. These findings are consistent with previous studies in sub-Saharan Africa, suggesting that counselling practices and knowledge of danger signs are poor (Nikiema et al. 2009; Pembe et al. 2009, 2010; Jennings et al. 2010; Sarker et al. 2010; Kabakyenga et al. 2011). Poor counselling practice is also reported in the demographic and health surveys of the countries in which our study sites are located. In Burkina Faso, 52.6% of women who received ANC for their most recent birth in the last 5 years were informed on signs of pregnancy complications (Institut National de la Statistique et de la Démographie (INSD) et ICF International 2012), in Ghana 68.4% (Ghana Statistical Service (GSS), Ghana Health Service (GHS), & ICF Macro 2009b), and in Tanzania 52.9% (National Bureau of Statistics (NBS) [Tanzania] & ICF Macro [Tanzania] & ICF Macro [Tanzania] and ICF Macro 2011).
Although far from adequate, haemorrhage and severe abdominal pain are the danger signs most counselled on and among those best known. This is probably a reflection of the fact that both signs are immediately connected to pregnancy and that vaginal bleeding is still the most common cause of maternal mortality in the three study countries (Ghana Statistical Service (GSS), Ghana Health Service (GHS), & Macro International 2009a; MoH 2006; MoHSW 2008).
Receiving counselling on danger signs was associated with type of healthcare worker in Burkina Faso and Tanzania, consistent with previous reports (Jennings et al. 2010; Pembe et al. 2010). In Burkina Faso, better counselling was provided by healthcare workers with higher education. In Tanzania, best counselling was provided by two types of health cadres (‘enrolled nurse’ and ‘maternal and child health aid’) with just 2 years of pre-service training, while other cadres with 3 and 4 years of pre-service training counselled worse. The differences in counselling practice by health cadres might be explained by the different focus of their tasks at the health facility and of the training they received.
Depending on the study site, older age of the women, gestational age, being a multigravida and/or having a higher education level were correlated with a better awareness of danger signs. Better knowledge among older women and multigravida may be related to the women's own experiences of previous pregnancies or events in the community (Pembe et al. 2009). This may also explain why older women in Burkina Faso have a better knowledge on danger signs, even though they are less counselled. Higher-educated women might have less difficulties processing and understanding the information they received during the ANC consultation, but they might also have easier access to other sources of information regarding pregnancy, thus increasing their knowledge. It is expected that higher gestational age (≥28 weeks) would result in knowing more danger signs, as women who have been pregnant longer are expected to have had more ANC visits and more opportunities to be counselled. However, only in Tanzania such an association was found, and even there, the effect was rather weak (2.0 vs. 2.4 danger signs mentioned). Surprisingly, in Burkina Faso, women of higher gestational age were on average even less aware of danger signs. Number of previous ANC visits was not associated with increased awareness anywhere. Apparently, there is no added effect in the number of danger signs mentioned with increase in exposure to counselling, indicating that awareness on danger signs might primarily be acquired elsewhere.
The poor quality of counselling during ANC, reflected by counselling on only few danger signs by the healthcare workers and by the poor recall of danger signs by women during an exit interview, reveals the inefficiency of the counselling techniques currently used and the need for new approaches to better inform women on danger signs (Kabakyenga et al. 2011). The poor recall of danger signs by women can be partially explained by the short duration of the client–provider interaction time documented in several studies (von Both et al. 2006; Magoma et al. 2011), but also by the type of counselling that we observed: the healthcare worker only listed information and did not encourage clients to ask questions or check whether the clients understood the information. Efficiency of counselling could be improved by providing client-centred interactive counselling, where socio-cultural aspects and existing knowledge of the client are taken into consideration and the counselling is tailored to the individual (WHO 2001; Jennings et al. 2010; Pembe et al. 2010). This often results in providing less counselling and fewer health education messages as only relevant information is passed on. However, such a communication/counselling strategy requires specific communication skills from the healthcare worker, which are not always available.
One may also wonder whether all this detailed counselling during ANC is really needed or whether it is possible to transfer so much information in an efficient way. It can be expected that, given the wealth of information and impressions a woman receives during the ANC consultation, information not considered important by the pregnant woman at that moment gets lost. We might also expect that someone who develops severe signs and symptoms, such as convulsions, severe abdominal pain and/or difficult breathing, will consult a health facility anyhow, even if she was not strictly counselled on these signs and cannot mention these events as danger signs connected with pregnancy. As was observed in earlier studies, the effects of general ANC education remain largely unknown (Gagnon & Sandall 2007). This makes it difficult to continue supporting the present ANC counselling and health education policy and approach, which is moreover very time-consuming for the healthcare workers (von Both et al. 2006). This underlines the need for more research in this field, in particular more specific research on what made women decide to seek help at the health facility when confronted with danger signs.
The study has some limitations. Firstly, the non-participatory observations may have influenced the performance of healthcare workers in a positive direction, the so-called Hawthorne effect (Leonard & Masatu 2006). However, the effect of the presence of an observer is short-lived: 10–15 observations (Leonard & Masatu 2006). Secondly, the study was conducted in two rural districts in each country; quality of ANC counselling provided in the facilities in these districts might differ from other rural districts and from urban areas. Thirdly, due to the design of the QUALMAT project, the study was only conducted in PHC facilities, which hampers getting an overview of the overall quality of ANC counselling because the quality of counselling provided at referral facility/hospital level is not included in this study. Fourthly, because participation at exit interviews and observation studies was voluntary, it might have resulted in selection bias. Such bias would, however, be most likely to have resulted in an overestimation of the knowledge of the women.
Our observations indicate that counselling practice is poor and inefficient: women do not get the message. A new approach to informing pregnant women on danger signs is needed. Adopting a more client-centred approach might be an option. However, as the effects of ANC education remain largely unknown (Gagnon & Sandall 2007), improved counselling and health education during the ANC consultation may not have any effect on maternal and newborn mortality and morbidity. The little knowledge women have on danger signs may not have been acquired through ANC consultation, but through other channels (peers in the community, radio messages, etc.), and other factors may cause women to consult the health facility when they develop danger signs, which need to be investigated. Research to examine the impact of counselling or lack of it on women who developed a danger sign and did not consult a health facility is also needed. More insight into this can be obtained by performing systematic audits of maternal deaths and of maternal near-miss events.
The QUALMAT research project (Quality of Maternal and Prenatal Care: Bridging the Know-do Gap) funded as part of the 7th Framework Programme of the European Union is a collaboration between the Centre de Recherche en Santé de Nouna (Burkina Faso), Ghent University (Belgium), Heidelberg University (Germany), Karolinska Institute (Sweden), Muhimbili University of Health and Allied Sciences (Tanzania), and Navrongo Health Research Centre (Ghana). The overall objective of this research is to improve the motivation and performance of healthcare workers and ultimately the quality of prenatal and maternal care services. The intervention packages include the development and implementation of a system of performance-based incentives and a computer-assisted clinical decision support system based on WHO guidelines. The interventions are being evaluated in a pre–post-controlled study design in rural Burkina Faso, Ghana and Tanzania between 2009 and 2014.