Nora Moore, MSc Candidate CPHA-Public Health 2014, May 27, 2014

1. Determinants of early first attendance at antenatal care clinics in the Amazon region of Peru: a case-control study Nora Moore, MSc Candidate CPHA-Public Health 2014, May 27, 2014

3. Belén

4. Antenatal Care • Antenatal care (ANC) significantly reduces the risk of adverse pregnancy outcomes through prevention, early detection and treatment. • WHO recommends: • Initiating ANC in first trimester of pregnancy • Attending at least 4 ANC visits during pregnancy • ANC interventions – • Iron and folic acid supplementation for anemia • Counselling on nutrition, breastfeeding, family planning • Detection and treatment of danger signs • Education about the need for skilled attendance at delivery • Deworming

5. Deworming • WHO recommends deworming during pregnancy • 4 Countries adopt WHO recommendation • Nepal, Sri Lanka, Kenya and Madagascar • Why not Peru? • Lack of uptake of scientific evidence and WHO recommendation ? • Lack of guidelines from the Ministry of Health of Peru ? • Additional tasks for ANC personnel ? • Cost ? • Necessity to consider stage of pregnancy

6. Primary Study Objective To identify socio-demographic determinants of early first attendance at ANC. Retrospective matched nested case-control study

7. Populations • Study population: • Cases: Women whose first ANC visit occurred in 1st trimester of pregnancy (<= 12 weeks) • Controls: Women whose first ANC visit occurred in 2nd or 3rd trimester of pregnancy (>12 weeks) • Source population: all pregnant women in Belén who had attended ANC at the two health centres, during the years 2010, 2011, and 2012 • Target population: all pregnant women in parasite-endemic areas of the world

8. Methods • Location: • Belén Health Centre • 6 de Octubre Health Centre • Matching variables • Health Centre • Date of first ANC visit • Data sources • 1) ANC registry • 2) antenatal cards • 3) medical charts • Conditional logistic regression • Ethics approval: Canada and Peru

9. Methods: Data collection • 1st step: sampling frame • 2010, 2011, 2012 • 2nd step: study population • All cases/random selection of matched controls • 3rd step: Data extraction

10. Missing Data

11. Results 2,647 pregnant women • 34 excluded • 2,613 remaining • 1,788 controls • 825 cases • 825 controls

14. Discussion • Most women (74%) attend ≥ 4 ANC visits but only 33% attend in first trimester. • Location of residence, marital status, education level and the number of previous miscarriages determine early first attendance at ANC. • Community health workers in the peri-rural areas should pay particular attention to supporting and encouraging at-risk pregnant women in their jurisdiction to attend ANC in their first trimester. • Encouraging women to come early to ANC will ensure that the timing of interventions, like deworming, in each woman is appropriate and effective.

15. Conclusion • This study contributes first-time evidence on the determinants of early first attendance at antenatal care services offered by local health authorities in the Peruvian Amazon.

16. Acknowledgements • Dirección Regional de Salud de Loreto • Asociación Civil Selva Amazónica • All health centre personnel at Belén and 6 de Octubre • Research assistants: Sully Cruzalegui and Tatiana Tuesta • Research coordinators: Brittany Blouin, Lidsky Pezo, Hugo Razuri • Serene Joseph, Layla Mofid, François Thériault • Supervisor: Dr. Theresa Gyorkos • Committee members: Dr. Elham Rahme and Dr. Martin Casapia Financial Support: Axe en santé mondiale