Does antenatal care facilitate utilization of emergency obstetric care? A case-referent study of near-miss morbidity in Bolivia.

Objective: To determine whether lack of routine antenatal care (ANC) is associated with near-miss morbidity upon arrival at hospital.

Design: Case-referent study.

Setting: Four maternity hospitals in La Paz and El Alto, Bolivia, where free maternal health care is provided through a government subsidized program.

Sample: Women with severe maternal morbidity upon arrival at hospital (n = 297). Facility-matched referents with an uncomplicated childbirth at hospital (n = 297).

Methods: Prospective inclusion of participants over a period of six months, using clinical and management-based criteria for near-miss. Multivariate logistic regression.

Main Outcome Measures: Odds ratios (ORs) with 95% confidence intervals (CIs). Individual and joint effects of interacting variables.

Results: Lack of ANC, lower education levels, and rural residence were interactively associated with near-miss upon arrival. Lack of ANC among women with limited education resulted in a four-fold greater risk for this condition. Such risk was considerably increased for women who lived in rural areas (OR 12.6; 95% CI 2.8-56.6). In addition, high maternal age and first time pregnancy were associated with near-miss upon arrival.

Conclusions: This study identified subpopulations most likely to benefit from interventions designed to enable timely care-seeking for obstetric complications. ANC appears to facilitate utilization of emergency obstetric care, especially for women with socio-demographic disadvantages. Targeted initiatives to increase routine ANC may reduce severe maternal morbidity and mortality, both in urban and rural areas.