Effectiveness of checklist-based box system intervention (CBBSI) versus routine care on improving utilization of antenatal care visits in Northwest Ethiopia: a cluster randomized controlled trial

Abstract

Background In Ethiopia, the proportion of mothers who attend the fourth antenatal care visit is lower than the proportion who attend the first visit. Although the reasons for these dropouts were investigated, few studies introduced interventions to promote the fourth antenatal care visit. Hence, the aim of this study was to assess the effectiveness of checklist-based box system intervention on improving fourth antenatal care visit. Method This study employed a double-blind, parallel-group, two-arm cluster randomized controlled trial to compare the effectiveness of checklist-based box system intervention with the usual standard of care as a control arm. Study clusters are assigned to intervention and control arm in 1:1 allocation ratio using simple randomization technique. Pregnant mothers below 16 weeks of gestation were enrolled. Open data kit was used to collect data from the baseline and end-line surveys, and STATA version 15.0 was used to analyse the data. A difference-in-difference estimator was used to compare fourth antenatal care visit between the intervention and control groups across time. Mixed effect multi-level logistic regression was used to examine the relationship between the dependent and independent variables. Result Data were collected from 2224 mothers who belong to 15 intervention and 15 control clusters. The difference in difference estimation resulted in a significant difference (26.1, 95%CI: 18–34%, p < 0.0001) between the intervention and control groups. Similarly, as compared to controls, the fourth antenatal care visit was found significantly higher in the intervention clusters (432 (85.2%) Vs. 297 (53.7%), p < 0.0001)/(AOR:5.69, 95% CI:4.14–7.82). Mothers who were knowledgeable about the services given during antenatal care visits (AOR: 2.31, 95% CI:1.65–3.24) and mothers who had a high level of social support (AOR:1.47, 95% CI: 1.06–2.04) were more likely to attend the fourth antenatal care visit. Conclusion Implementation of checklist-based box system intervention resulted in a statistically significant effect in attendance of fourth antenatal care visit. Community-level variables were found to be more important in explaining variability in the fourth antenatal care visit. It is recommended that the intervention be implemented on a larger scale. Trial registration ClinicalTrials.gov, Retrospectively registered on 26/03/2019, with trial registration number-NCT03891030.

Interventions That Improve the Uptake of Antenatal Care Services in Sub-saharan Africa: a Systematic Review and Meta-analysis

“…Among the 17 studies included in the review(18, 19,[21][22][23][31][32][33][34][35][36][37][38][39][40][41][42][43], four speci cally focused on HIVpositive pregnant women attending ANC. Out of these 17 studies, two employed text messaging interventions, four utilized enhanced health education, and two used conditional cash transfers as interventions.…”

“…All the included studies either had RCTs or cluster randomized controlled trial design methods. The studies were carried out in the Democratic Republic of Congo (DRC) (21,38), Ethiopia (19,34), Zimbabwe (33), Uganda (22,39,41), Ghana (41), Tanzania (18, 42), Nigeria (35), and Kenya (23,31,43).…”

“…The difference in target population did not have a signi cant impact on the effect size of intervention between 1.34(0.67 to 2.02) and 1.21(1.07 to 1.35) for HIV-positive pregnant women and those with undeclared HIV status, respectively. Country DRC (21,38) Ethiopia (19,34) Ghana (41) Kenya (23,31,32,38,43) Kenya & Nigeria (35) Sub-Saharan Africa (36) Tanzania (15,37,42) Uganda (22,39,41) Zimbabwe (33) 1.237 We performed meta-regression to delineate the impact of time of publication on study effect size. We found a rising trend with a regression coe cient of 0.13 (p-value 0.285) ( gure 3)…”

“…Overall, all the interventions analyzed in this review; including health education (19,34,39,42), conditional cash transfer (21,23), group ANC, home visit (35)(37), ANC integrated with HIV care (18, 43), telecommunication augmented ANC (18, 31), and increased frequency of ANC, led to increased ANC attendance. Amongst these interventions, group ANC, health education, and ANC with incentives were most effective in enhancing ANC uptake in SSA.…”

Assessing the association between an early and recommended number of focused antenatal care visits and the number of prenatal care content received before delivery in Ethiopia

“…If the recommendations are adopted, effective strategies for increasing early starts and increasing contacts will be required. In northwest Ethiopia, community-level demand creation and dropout tracing mechanisms were implemented, significantly increasing the frequency of ANC contacts among pregnant women [38]. These strategies can be scaled up across the country.…”