RESEARCH ARTICLE
Client Factors Affect Provider Adherence to
Clinical Guidelines during First Antenatal
Care
Mary Amoakoh-Coleman1,2*, Irene Akua Agyepong2, Nicolaas P. A. Zuithoff1, Gbenga
A Kayode1, Diederick E Grobbee1, Kerstin Klipstein-Grobusch1,3, Evelyn K Ansah4
1 Julius Global Health, Julius Center for Health Sciences and Primary Care, University Medical Centre
Utrecht, The Netherlands, 2 School of Public Health, University of Ghana, Legon, Ghana, 3 Division of
Epidemiology and Biostatistics, School of Public Health, Faculty of Health Sciences, University of the
a11111 Witwatersrand, Johannesburg, South Africa, 4 Research and Development Division, Ghana Health Service,
Accra, Ghana
*menba19@yahoo.com
Abstract
OPEN ACCESS
Citation: Amoakoh-Coleman M, Agyepong IA, Background
Zuithoff NPA, Kayode GA, Grobbee DE, Klipstein-
Grobusch K, et al. (2016) Client Factors Affect The first antenatal clinic (ANC) visit helps to distinguish pregnant women who require stan-
Provider Adherence to Clinical Guidelines during First dard care, from those with specific problems and so require special attention. There are pro-
Antenatal Care. PLoS ONE 11(6): e0157542. tocols to guide care providers to provide optimal care to women during ANC. Our objectives
doi:10.1371/journal.pone.0157542
were to determine the level of provider adherence to first antenatal visit guidelines in the
Editor: Julie Gutman, Centers for Disease Control Safe Motherhood Protocol (SMP), and assess patient factors that determine complete pro-
and Prevention, UNITED STATES
vider adherence.
Received: January 18, 2016
Accepted: June 1, 2016 Methods
Published: June 20, 2016 This cross-sectional study is part of a cohort study that recruited women who delivered in
eleven health facilities and who had utilized antenatal care services during their pregnancy
Copyright: © 2016 Amoakoh-Coleman et al. This is
an open access article distributed under the terms of in the Greater Accra region of Ghana. A record review of the first antenatal visit of partici-
the Creative Commons Attribution License, which pants was carried out to assess the level of adherence to the SMP, using a thirteen-point
permits unrestricted use, distribution, and checklist. Information on their socio-demographic characteristics and previous pregnancy
reproduction in any medium, provided the original
author and source are credited. history was collected using a questionnaire. Percentages of adherence levels and baseline
characteristics were estimated and cluster-adjusted odds ratios (OR) calculated to identify
Data Availability Statement: This paper is part of a
larger study for which ethical clearance from the determinants.
Ghana Health Service Ethical Review Committee to
collect and use the data for specific purposes was Results
obtained. As soon as complementary papers
currently in process have been accepted for A total of 948 women who had delivered in eleven public facilities were recruited with a
publication, the authors will be able deposit the data mean age (SD) of 28.2 (5.4) years. Overall, complete adherence to guidelines pertained to
set in their institutional database. The data will then only 48.1% of pregnant women. Providers were significantly more likely to completely
be available to any reader or researcher who meets adhere to guidelines when caring for multiparous women [OR = 5.43 (1.69–17.44), p<0.01]
the criteria for access to confidential data, upon
approval by the Ghana Health Service Ethical Review but less likely to do so when attending to women with history of previous pregnancy compli-
Committee. All requests for the use of the data shall cations [OR = 0.50 (0.33–0.75), p<0.01].
PLOS ONE | DOI:10.1371/journal.pone.0157542 June 20, 2016 1 / 13
Client Factors and Provider Adherence to Guidelines
be made to the corresponding author of this paper or Conclusion
the principal investigator of the larger study. The
name(s) of the individual(s) that readers may contact Complete provider adherence to first antenatal visit guidelines is low across different facility
to request the data; 1. Mary Amaokoh-Coleman, MD, types in the Greater Accra region of Ghana and is determined by parity and history of previ-
MPH (Principal investigator and corresponding author ous pregnancy complication. Providers should be trained and supported to adhere to the
of this paper); 2. Evelyn K. Ansah, MD, MPH, PhD
guidelines during provision of care to all pregnant women.
(Co- investigator of study and co-author of this
paper).
Funding: The Netherlands Organization for Scientific
Research (NWO) Global Health Policy and 396
Health Systems Research Program, Netherlands,
provided funds for the conduct of the study (Grant Introduction
number: 07.45.102.00). The funders had no role in
Efforts by the World Health Organization (WHO) to facilitate attainment of the Millennium
study design, data collection and analysis, decision to
publish, or preparation of the manuscript. Development Goals (MDGs) 4 & 5, to reduce child and maternal mortality, have included pro-
vision of evidence-based guidelines to ultimately improve quality of care [1–3] and these have
Competing Interests: The authors have declared
been adopted by member countries for implementation.
that no competing interests exist.
Antenatal Care
Antenatal care is a preventive and promotive health service provided to pregnant women, with
the goal of preventing, detecting and alleviating the health problems that affect mothers and
babies during pregnancy[4]. The full life-saving potential that antenatal care promises for
women and babies is realized with a minimum of four visits during the pregnancy, within the
context of focused antenatal care [4;5]. Some of the services to be provided include but are not
limited to taking the history of the woman; examination of the woman’s general and obstetric
wellbeing; screening for specific diseases and other conditions; preventive measures and thera-
pies, treatment for existing conditions, as well as health education and counseling. These mea-
sures are applicable even at the lowest level of care [4]. For the antenatal care interventions to
work effectively, it is important that the first antenatal clinic (ANC) visit takes place as early as
possible in pregnancy, preferably in the first trimester. Although most maternal deaths occur
during labour, delivery, or during the first 24 hours after delivery [6], those that are likely to
have problems at birth can be identified during the antenatal period[7]. The first ANC visit is
to identify and distinguish pregnant women who require standard care, from those with spe-
cific risk factors and so require special attention [4]. In Ghana, the guidelines for the first ante-
natal visit as per the Safe Motherhood Protocol (SMP) include history taking that covers age,
parity, gestational age at booking, and history of last pregnancy where applicable. Examination,
comprised of measuring of the weight and blood pressure of the pregnant woman as well as
abdominal examination are also required. Urine and hemoglobin tests are to be carried out and
finally, administration of iron supplements, tetanus injections and sulfadoxine pyrimethamine
for intermittent preventive therapy for malaria (IPTp) [8]. These requirements are in agree-
ment with what is prescribed in the national Standard Treatment Guidelines (STG). The
maternal health record book [9] which bears the records of the woman’s ANC visits is also
designed to capture all the requirements in the guidelines.
Adherence to Clinical Guidelines
The quality of clinical decision making by frontline providers of maternal and new-born care is
among the factors retarding Ghana’s progress towards the attainment of the Millennium
Development Goals 4&5 [10;11]. The health professionals’ attitudes towards risk can lead to
significant variations in the way that decisions regarding patient care are made [12]. Clinical
guidelines are set to ensure and assure uniformity as well as the quality of provision of care
PLOSONE | DOI:10.1371/journal.pone.0157542 June 20, 2016 2 / 13
Client Factors and Provider Adherence to Guidelines
[13]. Utilization of guidelines is admittedly complex, and influenced by many factors [14].
Adherence has been defined as “conformity to, fulfilling or following official, recognized or
institutional requirements, guidelines, recommendations, protocols, pathways or standards”
[15]. In clinical practice this translates into the extent to which care-giving practice conforms
to recognized and evidence-based standards [16–19]. Adherence studies have shown varying
levels of adherence to clinical practice guidelines, with data pointing to relatively lower levels of
adherence [20;21]. Many reasons have been assigned for non-adherence to guidelines [22;23].
Some of these reasons include but are not limited to, physicians’ unawareness of recommenda-
tions, their disagreement with the guidelines and their perceptions that the guidelines are not
easily applicable in daily practice, amongst others [1;24;25]. There is currently no information
in Ghana on how adherent providers are to available antenatal care guidelines like the SMP.
Direct patient factors influencing provider adherence have also not been extensively studied. In
this paper, our aim is to document the level of provider adherence, as well as assess patient fac-
tors that determine the level of provider adherence during the first ANC visit at different levels
of care [1].
Materials and Methods
Study design and setting
A cross-sectional analysis of the baseline data of a prospective cohort study on adherence to
protocol and how it affects pregnancy outcomes, was conducted in eleven health facilities in
the Greater Accra Region (GAR) of Ghana.
The Greater Accra Region (GAR) has a total of twenty health administrative districts and
sub-metropolises and is served by both public and private facilities. The public sector com-
prises of one teaching hospital, a regional hospital and nine district and sub-metropolitan hos-
pitals. There are ten polyclinics, thirty-one health centers, some community clinics and three
Community Health Planning and Services (CHPS) compounds. The polyclinics are primary
health care facilities like the health centers, usually sited in urban and populous areas and pro-
vide services for different conditions under different units. They are run by non-specialist med-
ical officers and medical or physician assistants, together with midwives, nurses and other
paramedical staffs. Cases are referred from here to the district hospitals. The CHPS compounds
operate at the community level, with midwives or community health nurses, either through
home visits or clients going to the compounds. They provide basic close-to-client primary care
services like health education, treatment of minor ailments and injuries, antenatal services, nor-
mal deliveries, and postnatal services. There are many private hospitals operating in the region
and some of these serve as district hospitals in the districts without a public hospital. All these
health facilities offer antenatal and delivery services, though the smaller facilities refer compli-
cations during pregnancy and delivery to the bigger health facilities. The National Health
Insurance Scheme (NHIS) is operational in all the public as well as in most of the private
facilities.
Sample size
The sample size for the cohort study which was computed using Open Epi calculator [26],
based on a prevalence of pregnancy complications of 6% [27]. We assumed that the complica-
tion rate will be twice as high amongst the exposed group (incomplete adherence). To detect a
two-sided significance difference at 95% confidence interval, at a power of 80%, and a one-to-
one ratio of exposure to non-exposure, a sample of 372 women was required per exposure
group. The total sample size therefore required for both arms was 744.
PLOSONE | DOI:10.1371/journal.pone.0157542 June 20, 2016 3 / 13
Client Factors and Provider Adherence to Guidelines
Selection of districts and facilities
We desired to have participants randomly selected from the different levels of care (variable
“type of facility”) across the Greater Accra region. In addition to the regional hospital, ten
health facilities (hospitals, polyclinics and a health center) were randomly selected for the
study. Initially, five out of the eight districts or sub-metropolises with hospitals were selected
by balloting with replacement for inclusion of their district or sub-metropolitan hospitals.
Another five of the remaining twelve districts (which have no public hospitals) were selected
by the same procedure for inclusion of a primary level facility offering both antenatal and deliv-
ery services. Thus in all 11 facilities (clusters) were used.
Variables
The outcome variable studied was provider adherence, defined as complete or incomplete
(moderate or poor).
The determinants were type of facility, client’s socio-demographics (age, educational level,
marital status and employment status), and client’s prenatal factors (parity, trimester at first
ANC visit, previous pregnancy history and number of times ANC was attended during
pregnancy).
Measuring adherence. Several studies have measured adherence using a scoring system,
based on available guidelines or protocol requirements [22;28–30]. A thirteen-point checklist
was used to score provider adherence to first antenatal visit guidelines. The questions on the
checklist were based on the requirements for first ANC visit as per the SMP for Ghana, which
is also consistent with the national treatment guidelines for first ANC visit. Two of the variables
on the checklist, herein referred to as “optional” variables, may not be due at the first ANC
visit, depending on the woman’s gestational age and therefore do not influence the adherence
categorization. These are the “last pregnancy history if applicable” and “Intermittent Presump-
tive Treatment in pregnancy (IPTp) given if woman is due”. IPTp is indicated for women in
the second and third trimesters only. The optional variables were included to help us assess
their influence on quality of antenatal care. The remaining eleven variables are required for all
clients irrespective of the gestational age (“age”, “parity”, “gestational age at booking”, “medi-
cal, surgical or family history”, “weight”, “blood pressure”, “abdomen examination”, “hemoglo-
bin test”, “urine test”, “iron supplement”, “tetanus injection”, and are herein referred to as
“mandatory” variables). Every record reviewed was assessed to see how many of the thirteen
variables were actually adhered to by the provider at the first ANC visit. Each variable adhered
to, scored a point of 1 while non-adherence scored 0. Scoring for adherence was based on only
the mandatory variables. A total score of 11 to all mandatory variables was classified as com-
plete adherence to guidelines. Non adherence to any of the mandatory variables was classified
as incomplete adherence. Incomplete adherence was re-categorized intomoderate (score of
9–10) and poor (score less than 9) adherence during data analysis. S1 Table describes the vari-
ables on the checklist and the scoring criteria.
Recruitment of women
Participants were recruited at delivery and once they met the inclusion criteria, informed con-
sent was obtained. The inclusion criteria included the following: participant 18 years or older;
participant has had at least one ANC visit in a health facility during the current pregnancy; par-
ticipant had first ANC visit at gestational age less than or equal to 5 months and participant
had first ANC visit at the facility of delivery or in one of the sampled facilities for this study.
From each of the eleven [11] facilities sampled for the study, we recruited a minimum of 68
women, 34 exposed to non-adherence (incomplete adherence) and 34 unexposed (complete
PLOSONE | DOI:10.1371/journal.pone.0157542 June 20, 2016 4 / 13
Client Factors and Provider Adherence to Guidelines
adherence). We needed to ensure that the minimum number of clients with the required expo-
sure status was satisfied. The initial assumption was that the exposed (non-adherence) would
be less than the unexposed. That was the basis for the decision to recruit till a minimum of 34
exposed per facility were recruited. However, during the conduct of the study we noticed that
the exposed were rather more and so we had to recruit till a minimum of 34 unexposed were
recruited. The minimum of 34 participants per exposure status was therefore satisfied. This
also enabled the estimation of the prevalence of adherence to the guidelines at baseline among
the study participants.
Data collection processes and tools
Every woman delivering at the facility on any day and who met the inclusion criteria, and pro-
vided consent for participation, was enrolled into the study.
At recruitment, a record review of their first ANC visit from the maternal health record
book was carried out using a checklist. Data on their socio-demographic characteristics, poten-
tial confounders as well as the 13 variables on guideline requirements were collected. Records
of subsequent ANC visits were also reviewed for any complications developed and identified
during the pregnancy. Finally, data on the delivery outcomes was collected from both the
maternal health record book and delivery register and notes. Participants’ telephone numbers
were linked to their study identification numbers (IDs) for follow up.
The women and their neonates were followed up till 6 weeks postpartum to complete data
collection on outcomes. Follow-up was at the health facility during postnatal care and also by
phone. Those who could not be reached by any of these means were treated as lost to follow
up, but this loss to follow-up was expected to be minimal and was taken into consideration dur-
ing the sample size calculation. A facility audit was conducted to assess facility factors such as
the availability of personnel, services, infrastructure, logistics and supplies that are needed to
support adherence to the guidelines at facility level.
The assumption was made that any information on history, examination, laboratory exami-
nation and treatment available is what was recorded in the maternal health record book. Infor-
mation on any service not recorded, was deemed not to have been delivered. (WHO
recommends that at the first visit, all such information should be recorded in the client’s record
book)
Data Analysis
Descriptive analysis of participants’ socio-demographic information was carried out. Adher-
ence to guidelines was computed by calculating the proportion of women whose first ANC vis-
its met the criteria for complete adherence. Incomplete adherence (exposure) was re-
categorized into moderate and poor adherence status to assess whether different extents of
non-adherence affect the association with the determinants. The association between determi-
nants was analyzed with a generalized linear model for dichotomous outcomes. An exchange-
able residual (i.e. the generalized estimation equation type) covariance matrix was
incorporated to correct for a potential cluster effect, which may arise due to our sampling strat-
egy, which involved 11 facilities (clusters) [31]. Associations were estimated with odds ratios
with their 95% confidence intervals (CI), significance tests were based on Wald chi-square
tests. P-values< 0.05 were considered significant. We tested a model with all potential con-
founders, except “number of times ANC was attended” since this cannot be known at the time
of the first ANC visit and so cannot be a determinant of provider adherence at that time. Data
analysis was carried out using IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY:
IBM Corp.
PLOSONE | DOI:10.1371/journal.pone.0157542 June 20, 2016 5 / 13
Client Factors and Provider Adherence to Guidelines
Ethical considerations
The protocol, which included a written consent document, was submitted to the Ghana Health
Service (GHS) Ethical Review Committee (ERC) and approval obtained under study ID No.
GHS-ERC 12/07/2013 before the study was conducted. Approval from the district/ sub-metro-
politan heads as well as the regional health directorate was also obtained. Written informed
consent was obtained from each participant (pregnant women, heads of facilities and unit
heads)' using the approved consent document.
Results
Overall, nine hundred and forty-six women who had delivered in eleven public facilities were
recruited into the study from December 2013 to April 2014. Fifty-six percent (531) of them
were seen to at six district hospitals, while 36.0% (341) were from four polyclinics and 7.9%
(74) from a health center.
Participants’ characteristics: Demographic and socio-economic factors
The mean age (SD) of the women in the study was 28.2 (5.4) years. About eighty-five per-
cent of them were within the 20–35 years age group. Half of participants (430) had second-
ary education, with 11.6% (109) and 19.9% (187) having no education and primary
education respectively. Most of the women 644 (69.0%) first attended ANC during the sec-
ond trimester and 78.2% (741) attended at least four times during the pregnancy. Married
women comprised 74.2% (689) of all participants and most of the participants 797 (85.0%)
were employed. Only 7.6% (72) of the women had a previous pregnancy complication
(Table 1).
Adherence to first ANC guidelines
At their first ANC visit, all 946 participants had their ages checked, 99.3% (939) had a urine
test done, 99.0% (937) had their weight checked, 98.5% (932) had a hemoglobin test done, and
98.3% (930) had their blood pressure checked. A total of 916 (96.8%) participants had iron tab-
lets prescribed for them while 86.3% (816) had their parity checked. Only 72.4% (685) had
their abdomen examined while the dose of sulphadoxine pyrimethamine for prevention of
malaria in pregnancy was administered to 581 (61.4%) participants.
The mean total adherence score (95% CI) out of a maximum of 13 was 11.7 (11.7–11.8).
Mean percentage adherence per variable on the checklist was 90.3% (83.1–97.4%). Overall,
complete adherence to guidelines pertained to only 48.1% of participants during their first
ANC visit. Care for 38.2% (361) of women reflected moderate adherence to guidelines by pro-
viders while for 13.7% (130) of women there was poor adherence. Complete adherence to
guidelines was higher amongst women seen at the polyclinics (51.9%) than those seen in hospi-
tals (47.6%) and the health center (33.8%).
Adherence to the mandatory variable ‘abdominal examination’ was positively correlated
with ‘gestational trimester at the first visit’ (p<0.01), with 77.8% (501/644) whose first ANC
visit was during the second trimester being examined compared to 59.9% (173/289) of
women who first came during the first trimester. Adherence to the optional variable ‘IPTp
given if woman is due’ was positively correlated with ‘gestational trimester at the first visit’
(p<0.001), with 70.0% (451/644) of second trimester registrants given IPTp compared to
43.6% (126/289) first trimester registrants. Details of adherence scores are presented in
Table 2.
PLOSONE | DOI:10.1371/journal.pone.0157542 June 20, 2016 6 / 13
Client Factors and Provider Adherence to Guidelines
Table 1. Baseline characteristics of study participants and association of these characteristics with provider adherence levels to first ANC
guidelines.
Variable Variable Frequency (%) % Poor adherence % Moderate % Complete Cluster-adjusted
category N = 946 N = 130 adherence N = 361 adherence N = 455 p-value
Facility type <0.01
Hospital 531 (56.1) 14.3 38.0 47.6
Polyclinic 341(36.0) 7.9 40.2 51.9
Health center 74 (7.9 36.5 29.7 33.8
Age category 0.11
< 20 years 54 (5.7) 20.4 53.7 25.9
20–35 years 805 (85.3) 13.9 36.9 49.2
>35 years 85 (9.0) 7.1 41.2 51.8
Parity 0.01
0 264 (27.9) 23.5 53.8 22.7
1–2 485 (51.3) 8.0 32.8 59.3
3–4 164 (17.3) 12.8 31.1 56.1
>4 33 (3.5) 24.2 27.3 48.5
Education 0.91
None 109 (11.6) 11.0 36.7 52.3
Primary 187 (19.9) 14.4 34.2 51.3
Secondary 430 (45.7) 14.4 37.4 49.1
Tertiary 166 (17.7) 12.7 45.2 42.2
Other 48 (5.1) 8.3 39.6 52.1
Trimester of 1st ANC 0.03
First 289 (31.0) 12.5 45.3 42.2
Second 644 (69.0) 13.8 34.8 51.4
No. of times ANC <0.01
attended
1 46 (4.9) 45.7 34.8 19.6
2–3 138 (14.6) 16.8 32.1 51.1
> = 4 741 (78.2) 11.2 39.3 49.5
Marital status 0.01
Single 102 (11.0) 13.7 51.0 35.3
Married 689 (74.2) 11.2 37.4 51.4
Formerly 12 (1.3) 41.7 16.7 41.7
married
Living together 125 (13.5) 22.4 34.4 43.2
Employment 0.02
No 141 (15.0) 12.8 53.2 34.0
Yes 797 (85.0) 13.7 35.8 50.6
Previous pregnancy 0.33
complication
No 872 (92.4) 14.2 37.4 48.4
complication
Complication 72 (7.6) 8.3 48.6 43.1
Mean age (SD) 28.2 (5.4) 26.7 (5.3) 27.4 (5.7) 29.1 (4.9) <0.01
doi:10.1371/journal.pone.0157542.t001
Baseline comparison of participants and adherence level groups
The mean age (SD) of the women whose care reflected complete adherence is 29.1 (4.9) years
compared to 27.4 (5.7) and 26.7 (5.3) years respectively for those whose care reflected moderate
PLOSONE | DOI:10.1371/journal.pone.0157542 June 20, 2016 7 / 13
Client Factors and Provider Adherence to Guidelines
Table 2. Summary of proportion of provider adherence to first ANC guidelines for 946 study
participants.
Variable Variable Category Frequency (%) Yes / Checked
Checklist variable Age 946 (100.0)
Parity 816 (86.3)
Gestational age at registration 862 (91.1)
Last pregnancy history taken if applicable 807 (85.3)
Medical history taken 930 (98.3)
Weight recorded 937 (99.0)
Blood pressure measured 930 (98.3)
Abdomen examined 685 (72.4)
Hemoglobin test done 932 (98.5)
Urine test done 939 (99.3)
Iron tablet given 916 (96.8)
Tetanus injection given or status recorded 822 (86.9)
IPTp given if due 581 (61.4)
Total adherence score
6 1 (0.1)
7 4 (0.4)
8 8 (0.8)
9 20 (2.1)
10 97 (10.3)
11 273 (28. 8)
12 212 (22.4)
13 331 (35.0)
Adherence status
Complete 455 (48.1)
Incomplete (moderate) 361 (38.2)
Incomplete (poor) 130 (13.7)
Mean total adherence score (95% CI) 11.73 (11.65–11.81)
Mean % adherence per variable on checklist (95% CI) 90.27 (83.07–97.47)
doi:10.1371/journal.pone.0157542.t002
and poor adherence levels respectively. Complete adherence levels for the different parity
groups were significantly different (p = 0.01). Differences in percentage complete adherence
amongst the different educational levels were not significant (p = 0.91). Care for 331 out of 644
(51.6%) women attending their first ANC during the second trimester of pregnancy, reflected
complete adherence compared to (122/289) 42.2% of those attending in first trimester. Com-
plete adherence was reflected in the care of 70/138 (50.7%) women who attended ANC 2–3
times during pregnancy which was higher compared to level of adherence of the other groups,
at p< 0.01. There was no significant difference between the levels of complete adherence
between the care for women with and without previous pregnancy complication, both of which
were below 50.0% (p = 0.33). Table 1 gives details of the comparability of the women in the
three adherence level groups.
Patient determinants of adequate provider adherence
In unadjusted univariate analysis, providers were more likely to completely adhere to first
ANC guidelines when caring for multiparous women [OR = 4.68 (1.42–15.43), p = 0.01],
employed women [OR = 2.1 (1.2–3.7) p = 0.02], married women [OR = 2.09 (1.18–3.71),
PLOSONE | DOI:10.1371/journal.pone.0157542 June 20, 2016 8 / 13
Client Factors and Provider Adherence to Guidelines
Table 3. Patient determinants of complete provider adherence to first ANC guidelines (Crude and adjusted odds ratios with p-values).
Variable Variable category OR (95%CI) p-value AOR* (95% CI) p-value
Facility type
Hospital 1.00 1.00
Polyclinic 1.16 (0.74–1.09) 0.52 1.18 (0.56–2.49) 0.67
Health center 0.55 (0.47–0.62) <0.01 0.54 (0.40–0.73) <0.01
Age
<20 years 1.00 1.00
20–35 years 2.90 (1.45–5.79) <0.01 1.31 (0.59–2.90) 0.55
>35 years 3.11 (1.11–8.71) 0.03 0.85 (0.43–1.70) 0.64
Trimester first ANC
First 1.00 1.00
Second 1.37 (0.99–1.90) 0.06 1.16 (0.72–1.87) 0.54
Education
None 1.00 1.00
Primary 0.99 (0.63–1.59) 0.99 0.92 (0.60–1.42) 0.70
Secondary 0.87 (0.68–1.11) 0.26 1.02 (0.72–1.44) 0.93
Tertiary 0.72 (0.50–1.04) 0.08 0.86 (0.56–1.33) 0.43
Other 1.04 (0.55–1.34) 0.91 0.24 (0.69–2.24) 0.47
Parity
0 1.00 1.00
1–2 5.25 (1.54–17.91) 0.01 5.23 (1.59–17.26) 0,01
3–4 4.68 (1.42–15.43) 0.01 5.43 (1.69–17.44) <0.01
>4 4.08 (1.28–12.97 0.02 4.77 (1.55–14.69) 0.01
Marital status
Single 1.00 1.00
Married 2.09 (1.18–3.71) 0.01 1.06 (0.59–1.88) 0.82
Formerly married 1.89 (0.74–4.79) 0.19 1.06 (0.59–1.88) 0.13
Living together 1.55 (0.74–3.21) 0.24 0.92 (0.52–1.61) 0.75
Employment
No 1.00 1.00
Yes 2.06 (1.15–3.68) 0.02 1.43 (0.92–2.24) 0.11
Previous history of pregnancy complication
No 1.00 1.00
Yes 0.83 (0.57–1.21) 0.33 0.50 (0.33–0.75) <0.01
doi:10.1371/journal.pone.0157542.t003
p = 0.01] and women attending first ANC during the second trimester [1.4 (1.0–1.9) p = 0.06]
(Table 3).
In a multivariable analysis that adjusted for client factors, providers were significantly more
likely to completely adhere to guidelines when caring for multiparous women [OR = 5.43
(1.69–17.44), p<0.01] but less likely to do so when attending to women with previous preg-
nancy complications [OR = 0.50 (0.33–0.75), p<0.01] (Table 3).
Discussion
Main findings
We found complete adherence to first ANC guidelines level of 48.1% amongst our study partic-
ipants. This is relatively low compared to complete adherence level of 54.5% found in a meta-
analysis of adherence to practice guidelines for various medical and surgical conditions, as well
PLOSONE | DOI:10.1371/journal.pone.0157542 June 20, 2016 9 / 13
Client Factors and Provider Adherence to Guidelines
as 55.9% at baseline of a cohort study in the USA [32;33]. It is however better than the estimate
found in another study which reported 30.5% full or complete adherence level [34]. Another
study found as high as 68% full adherence but this was in a prospective study and the authors
admit possibility of Hawthorne effect[35]. We believe this level of complete adherence needs to
be improved upon and education of providers about the guidelines and how they help improve
service delivery outcomes will be essential.
The mandatory variable that was least adhered to was abdominal examination and we
believe it is explained by its positive association with gestational trimester at the first visit. This
supports the thinking of some providers who work in the study setting that when the gesta-
tional age is small, there is nothing significant to be palpated on abdominal examination. How-
ever this could be a missed opportunity since abdominal examination can corroborate the
accuracy of the last menstrual period (LMP) data provided, and is also useful in assessing fetal
viability towards the end of the first trimester. This may indicate the need for better training of
or reminding providers in assessing gestational age by fundal height measurements and use of
fetoscope. It must be noted that all women in our study had their first antenatal visit either dur-
ing the first trimester or early second trimester as per the inclusion criteria.
The observed correlation between gestational trimester at first ANC visit and whether the
woman received presumptive treatment for malaria may be due to the fact that sulphadoxine-
pyrimethamine is prescribed only after the woman feels quickening or after 16 weeks gestation
during the second trimester. It is thus surprising that about 40% of the women who first
attended ANC during the first trimester were prescribed the medication. This could have seri-
ous consequences for the survival of the fetus as a result of congenital malformations in early
life, due to the anti-folate nature of sulphadoxine pyrimethamine [36].
We did not evaluate the type of provider in relation to adherence levels. Whereas a previous
study [34], has shown that care given by specialists usually conforms to practice guidelines,
other studies have shown that providers at lower level facilities are more likely to follow guide-
lines[37]. In our study setting adherence levels were observed to be better in polyclinics com-
pared to health centers and hospitals, although generally polyclinics tend not to have specialists
present. This suggests that other factors, beyond the training of the provider, play a role in the
level of the provider adherence. These factors could be further explored.
Anemia in pregnancy is common in developing countries, making routine iron supplemen-
tation necessary for every pregnant woman in these areas [38] The current study demonstrates
excellent adherence to testing for hemoglobin at first visit (98.5%) and prescription of iron tab-
lets (98%).
Patient factors have been found to be associated with provider adherence to guidelines
[39;40]. We observed that provider complete adherence to the guidelines is determined by
some patient factors like parity of the pregnant woman and history of previous pregnancy com-
plication. Parity is known to be related to pregnancy outcomes, with multi-parity endangering
outcomes [41;42]. It is therefore perhaps useful that multi-parity increases the likelihood of pro-
vider complete adherence to guidelines. Compromising quality of care by provider non-adher-
ence to guidelines could result in dire consequences for both mother and neonate. It however
seems counter-intuitive that in caring for women with positive history of previous pregnancy
complication, providers tend to incompletely adhere to the first ANC guidelines. A similar find-
ing was observed when providers were reported to be non-adherent to guidelines in caring for
patients with severe form of disease [39]. Perhaps when there is such signal to danger, providers
rather pay attention to the guideline items that relate to the woman’s specific problem, although
it is unclear how this applies to the first antenatal visit. Guideline use seeks to ensure quality of
care patients receive, with implications on care outcomes. It is therefore important that all
women receive appropriate care as prescribed by the guidelines, irrespective of their status.
PLOSONE | DOI:10.1371/journal.pone.0157542 June 20, 2016 10 / 13
Client Factors and Provider Adherence to Guidelines
In general, complete adherence levels were observed to be low and it is therefore important
that providers are engaged in a process to ascertain possible reasons for this finding and how
best to improve it. Also, most women report late for first antenatal care and therefore public
education and community based activities should be implemented to encourage women to
seek ANC earlier.
Strengths and limitations
This study retrospectively analyzed baseline data of a cohort of women so it is not possible that
provider practice changed related to the study. The results reflect everyday provider practice
and we believe this is strength of the study. As only women attending ANC and delivering in
public facilities were included in the study, generalizability of the results to private practice is
limited. We were also not able to gather data that explain other factors, especially from the pro-
vider’s perspective that might have influenced adherence to guidelines. We therefore recom-
mend that these factors be explored in future qualitative studies.
Conclusion
Complete provider adherence to first antenatal visit guidelines is low across different facility
types in the Greater Accra region of Ghana and is determined by maternal parity and history
of previous pregnancy complication. Since adherence to the guidelines at first visit has major
implications for the quality of care of the pregnant woman providers should be trained to
adhere to the guidelines during provision of care to all pregnant women.
Supporting Information
S1 Table. Table showing variables on adherence checklist for first ANC guidelines and scor-
ing criteria.
(DOCX)
Acknowledgments
The authors gratefully acknowledge technical support from the Julius Center for Health Sci-
ences and Primary Care. We also thank the Netherlands Organization for Scientific Research
(NWO) Global Health Policy and 396 Health Systems Research Program, Netherlands, for pro-
viding funds for the conduct of the study (Grant number: 07.45.102.00).
Author Contributions
Conceived and designed the experiments: MAC EKA KKG. Performed the experiments: MAC
EKA. Analyzed the data: MAC NPAZ GAK. Contributed reagents/materials/analysis tools:
MAC NPAZ. Wrote the paper: IAA DEGMAC GAK NPAZ KKG EKA.
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