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. 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 1 st trimester of pregnancy (<= 12 weeks) – Controls: Women whose first ANC visit occurred in 2 nd or 3 rd 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 1 st step: sampling frame 2010, 2011, 2012 2 nd step: study population All cases/random selection of matched controls 3 rd step: Data extraction

10. Missing Data

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

12. Results: Demographic Characteristics Characteristics Cases (n=825) Controls (n=825) No.% % Age (in years) 10-14141.7202.4 15-1920124.425330.7 ≥ 2060973.955266.9 Marital Status Not Married698.411013.3 Married/Conviviente68583.065979.9 Education Some primary10813.112114.7 Some secondary40248.747657.7 Some university25931.419223.3

13. Results: Multivariable analysis Adjusted Odds Ratio (95% Confidence Interval) Parity NulliparousREF Multiparous1.06 (0.84, 1.33) Marital Status Not marriedREF Married/Conviviente1.71 (1.20, 2.44) Education Some primaryREF Some secondary0.92 (0.67, 1.25) Some university1.47 (1.04, 2.08) Geographic area of residence UrbanREF Peri-Rural0.58 (0.34, 0.99) Previous Miscarriages No previous miscarriageREF Previous miscarriages1.51 (1.10, 2.07)

14. Discussion 1.Most women (74%) attend ≥ 4 ANC visits but only 33% attend in first trimester. 2.Location of residence, marital status, education level and the number of previous miscarriages determine early first attendance at ANC. 3.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. 4.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 Financial Support: 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 Axe en santé mondiale