Reducing the delay in eligible couple registration through networking with marriage registrars

1. Post Graduate Trainee, Post graduate Institute of Medicine, Colombo 2. Professor, Department of Clinical Medicine, Faculty of Medicine, University of Colombo 3. Regional Director of Health Services, Puttalam District Correspondence: pubududesilva@ymail.com Abstract Introduction: The newly married couples are rarely encountered by the Medical Officer of Health (MOH) and there is a delay in registering them in the Eligible Couple Register (ECR). A new service model was developed with marriage registrars for newly married.


Introduction
Sri Lanka lacks a formal institutional structure to counsel couples and newly married partners.On occasion Public Health Midwives (PHM) counsel during home visits.PHM seek and register newly married couples in the Eligible Couple Register (ECR) and provide necessary health advice (1,2), usually at the time of the registration of the first pregnancy.Newly married couples are rarely seen by the Medical Officer of Health (MOH).Thus an opportunity to identify modifiable risk factors of pregnancy before conception is often missed.
We initiated a service model with registrars of marriage to facilitate pre-pregnancy services for the newly married by the MOH in the Arachchikattuwa MOH area.
The model recruits newly married couples for MOH clinics providing for counseling and assessment of pre-pregnancy risk conditions and also facilitates for early registration in the ECR.

Objective:
To describe the delay in eligible couple registration before and after networking with marriage registrars and to describe the detected pre-pregnancy risk factors through this newly implemented model.

Setting
The study was carried out at Arachchikattuwa MOH area, which lies 12km North of Chilaw Town on the Colombo -Puttalam Road.The population is approximately 49,526 with 9,684 house holds.The MOH area of Arachchikattuwa has 13 PHM areas and 05 Public Health Inspector (PHI) areas.There are four marriage registrars (MR) serving the area.According to the records of Arachchikattuwa District Secretariat, on average 04 marriages per month are registered by each MR and none were seen by the PHM or MOH.For the study two marriage registrars were involved covering 7 PHM areas.

Method
One of the authors (APDS) developed a simple referral form to be sent by the MR to the MOH office.The couples who visit the MR to obtain an appointment date for their registration were given the referral form and requested to meet their respective PHM prior to the date of marriage.No incentives were offered except to state that the form should be handed over to the MR on the date of registration.The couples took the referral form and met the PHM who counseled and advised them to come to the MOH clinic for screening for pre-pregnancy risk conditions.The PHM handed over the back-referral form to be given to the MR on the date of marriage registration, so that MR would know the couple had met the PHM.Those who sought emergency registration were also given the referral form at the time of the marriage and advised to meet the relevant PHM.Apart from the above referral methods PHM directed the newly married couples to the MOH at the time of the registration in the ECR.
The Office of MOH also receives a weekly return of newly married couples from the MR, which gave information for PHM to conduct home visits for early registration in the ECR.The PHM issued a booklet to the couple, titled -Blessing for Mar-riage‖ (-Yuga Diviyata Asiri‖) published by the Population Division (available in Sinhalese and Tamil) of the Family Health Bureau to be read and returned.
The clinics for the newly married couples were conducted on the same day as the relevant polyclinic and they were given appointments usually after 11.30 am (after seeing the antenatal mothers and children).At the clinic the anthropometric measure-ments, clinical examination and investigations (haemoglobin, urine sugar and urine albumin) were done.A record sheet was developed to record the data (socio-demographic data of the newly married couple and detected pre pregnancy risk conditions).The MOH also counseled the couples on prepregnancy screening, sexual health and contraception.If the necessity arose these newly married couples were referred to the General Hospital Chilaw (GHC).
The records of ECR from 06 January 2004 to 12 January 2006 and the records of all couples presented for MOH clinics in Arachchikattuwa MOH area from 23 May 2005 to 12 January 2006 were collected and analysed.Those who were residing out side the Arachchikattuwa MOH area before marriage were excluded from the study.The study was a quasy-experimental in design and the intervention commenced from the second week of May 2005.The delay in eligible couple registration was calculated as subtracting the date of marriage from the date of registration of the eligible couple in the ECR.

Delay of ECR registration = Date of ECR registration -Date of marriage
We also calculated the percentage registered in ECR on the same day or after pregnancy registration (among primigravidae) as an indicator to further compliment the delay in eligible couple registration.

Date of pregnancy registration -Date of ECR registration ≤ 0
Those who were reregistered in ECR on the same day or after pregnancy registration would have a value of 0 or less (minus value).Only primigravidae were included for this analysis as the inclusion of multigravidae would create a bias.

Results
There were 235 couples registered in the ECR before the intervention period (approximately 16 months) from 06 January 2004 to 22 May 2005 while 52 were registered during the intervention period (approximately 7 months) from 23 May 2005 to 12 January 2006.During the intervention period 63 marriages registered by the MR were reported through the weekly return to the MOH Office.Although MR referred all of them, none of these couples had met their relevant PHM.From the weekly returns PHM recruited 24 newly married to the MOH clinic, while the rest has left the Arachchikat tuwa MOH area as their place of residence.Table 01 describes analysis of ECR before and after the intervention.Among those registered in the ECR before intervention, 219 were primigravidae while this was 32 in the after intervention group, at the time of data analysis.

Discussion
We described a service model initiated in Arachchikattuwa MOH area that reduces the delay in eligible couple registration and detection of pre pregnancy risk conditions.Prior to the intervention a substantial proportion of eligible couples were registered in the ECR only when the female partner presented for antenatal care.Even though following the intervention the majority (53.8%) of newly married couples was detected by PHM yet the overall reduction of the delay in registering the eligible couples was significant.Following the intervention the mean delay in registering the eligible couples among the PHM detected group is thrice higher compared to the mean delay among MR notified group yet it is significantly lesser (p<0.01)than the mean delay observed before the intervention.Possible reasons for this could be the motivation created due to the intervention among the PHM and the intervention creating community awareness through MR.Another possibility is that most in the PHM detected group got conceived and therefore they were registered in the ECR when they presented for pregnancy registration.This seems to be more likely since 81.2% were registered in the ECR after pregnancy registration when compared with 18.8% of the MR notified group.
Before the commencement of the intervention the teenage pregnancy rate was 12% in the Arachchikattuwa MOH area and after six months it came down to 8% (p<0.05).
The model helped to provide the following additional services:  Relevant information was given to those who wanted to delay the first pregnancy  The teenagers were counseled to delay their first pregnancy.
 Folic acid distributed to all those expecting a pregnancy.
 Health education (on one to one basis) by the MOH on following areas: 1. Importance of folic acid 2. Period of conception 3. Delaying teenage pregnancies 4. Natural family planning methods

Early registration of pregnancy
The main limitation of this model is that the women who marry men from other MOH areas moves out of Archchikattuwa MOH area and thus unable to provide the above services.
It is feasible to replicate this model in areas (and countries) with a reasonably well developed marriage registration service and family health worker network.
Presently pre-pregnancy counseling and detection of pre-pregnancy risk conditions are done in Kalutara (3) and Beruwala (4) MOH areas administered by the National Institute of Health Sciences.

Conclusion:
Linking up with marriage registrars reduces the delay in eligible couple registration significantly.
Through provision of services by MOH to newly married couples selected pre-pregnancy risk conditions can be identified and addressed.