Abdel-Hady El-Gilany⁽¹⁾,
Adel El-Wehady⁽²⁾

(1) Prof. of Public Health, College of Medicine in Al-Hassa, Saudi Arabia
(2) Technical Director of primary health care, Al-Hassa Directorate of Health, Saudi Arabia

Correspondence:
Abdel-Hady El-Gilany
Prof. of Public Health,
Family and Community Medicine Department,
College of Medicine in Al-Hassa
King Faisal University
-
Community Medicine Department,
College of Medicine,
Mansoura University,
Mansoura 35516 - Egypt
E-mail: ahgilany@gmail.com , ahgilany@hotmail.co.uk

ABSTRACT Objectives: To reveal causes of non-registration for antenatal care at local PHC centers; to reveal causes for not receiving antenatal care; and to assess coverage, sources and contents of antenatal care. Methods: The study involved 1996 mothers from urban, rural and hegar (deserts collection) areas. Trained nurses collected data from family files and maternity cards kept at primary health care centers (PHCC), as well as interview with mothers, within two weeks after delivery, during registration of new births. Results: About two-fifths of mothers failed to register for antenatal care at their local PHCC for a variety of reasons. Furthermore, 2.3% of them failed to seek antenatal care from any source mainly due to the idea that pregnancy is normal and there is no need for care. On average, each mother received 7.8 antenatal visits and about 72% of them initiated care at the first trimester of pregnancy. Different independent predictors were found to be associated with failure to register for antenatal care, failure to receive antenatal care, late initiation of prenatal care, seeking antenatal care at private clinics. Conclusion: Despite a high level of antenatal care coverage, there is room for improvement in coverage and registration at local PHCCs. The increasing role of private health services in providing maternity care necessitates a liaison between PHC and private clinics with adequate feedback for proper monitoring and evaluation of maternity care at the community level. Key words: Antenatal care - antenatal morbidity - antenatal visits - Saudi Arabia

The fifth Millennium Development Goal (MDG) is to improve maternal health through preventing unplanned and high-risk pregnancies and providing care in pregnancy, childbirth and the postpartum period to save womens' lives⁽¹⁾. Protecting the health of mothers during reproduction safeguards their future contributions to society and ensures the health and productivity of future generations⁽²⁾.

The problems affecting health of mothers are multi-factorial. Maternal morbidities are preventable through effective maternal care programs^(3,4). In Saudi Arabia, consanguineous marriage, marriage at early age, repeated un-spaced pregnancies resulting in high parity as well as pregnancy and delivery at early and late ages, are factors that lead to a higher rate of complications. Because of socio-economic, biological and health factors and despite availability of good health services, the quality of maternal care needs to be monitored and improved at all levels of health care, particularly at the primary health care (PHC) level⁽⁵⁾.

Supervision of maternal health is an essential component of primary health care. This involves regular antenatal check ups and referral to hospital if any complications are anticipated⁽⁶⁾. Antenatal services are useful to care for mother and fetus simultaneously. Effective antenatal services can be refined if one knows the existing maternal health problems. The complete and regular coverage of all expectant mothers at all levels of health care delivery is essential⁽⁴⁾. The primary aim of antenatal care is to achieve at the end of a pregnancy a healthy mother and a healthy baby. The current international accepted antenatal care schedule for a normal pregnancy consists of 13 visits (monthly first six months, twice monthly in the 7th and 8th months and weekly in the 9th month)^(3,5,6).

Antenatal care is a complex set of activities (basically a multi-phasic screening procedure) aimed at reducing maternal and fetal morbidities and mortality. Excessive concern about reaching a fixed number of antenatal visits has obscured the fact that content and quality of care was considered a luxury not available to developing countries. It was assumed that any form of care would be in some way good, useful, and accepted⁽⁷⁾.

Results from a nationally representative family health survey in Saudi Arabia, indicated that around 90% of mothers received antenatal care⁽⁸⁾. Another study in the Northern Region of Saudi Arabia indicated that only 8% of mothers never received antenatal care, however only 66.9% and 95.9% of mothers of urban and rural areas, respectively, were found to have registered at their local primary health centers (PHCC)⁽⁹⁾.

By reviewing the health statistics of maternity care in Al-Hassa PHCC, it was noticed that there is a discrepancy between numbers of registered births and numbers of mothers registered for antenatal care and delivered during the 1426 H. (15032 live births vs. 9729 delivered mothers and registered for antenatal care)

This study aims to assess coverage, sources, and contents of antenatal care; to reveal causes of non-registration for antenatal care at local PHC centers; and to reveal causes of not receiving antenatal care.

This study was carried out in Al-Hassa, Saudi Arabia, during a period of six months from January 1 to the end of July 2007 G.

Sample size was calculated using Epi Info 2004 software. From statistics of Al-Hassa Directorate of Health 15032 births were registered during 1426, Hegira and non-registered mothers were 35.3%. With confidence interval of 95% and power of 80%, the number of mothers required was 1908.

This sample size was recruited during a period of 4 months in both urban and rural area. In Hegar , study period was 6 month due to low workload.

Two-stage stratified sampling technique was used. First stage is stratification of Al-Hassa into urban, rural and Hegar (desert Bedouin collections) areas. At the second stage, five primary health care (PHC) centers were chosen from each stratum.

Data was collected by direct interview with mothers. In addition, maternity cards for mothers attended for antenatal care at the PHC center were reviewed. Mothers were assured that data collected will be dealt with confidentially and the impact of the study will be respected, maintained, and used only for research purposes and for improving services.

Field supervisor as well as nurse interviewers were oriented about the project and trained on data collection.

In each center, a list was prepared for all registered births during study period, on weekly basis. Mothers of these births were separated into registrants at their local PHC centers and non-registrants.

*Registered mothers: data were abstracted on standardized form from both family file and maternity cards kept in family file at PHC centers as well as direct interview with the mothers. Maternity card has been developed to include the appropriate data on prenatal, natal, and postnatal care, as well as, a list of factors of high-risk pregnancy for referral purposes. Ministry of Health has developed special guidelines for using the card, explaining its contents and how to use it, as well as defining the various measurements and investigation and their normal limits. It is shared by the health centers and hospital. There is continuous stress on completeness of this card⁽⁵⁾.

*Non-registered mothers: A questionnaire for non-registrants was prepared and pre-tested during the pilot study on 60 mothers in other health center not chosen in the full-scale study. This form revealed whether the mother received any antenatal care, its source and contents, and reasons for choosing other sources of care or not attending for care at all. These in addition to socio-demographics of the family and reproductive characteristic of the mother.

In each PHCC an Arabic speaking female nurse completed questionnaires during interview with mothers during birth registration (within two weeks of birth).

Data were analyzed using SPSS (Statistical Package for Social Sciences) version 11. Descriptive statistics were done. Unpaired student's t test and ANOVA (F) test with Bonferroni multiple comparisons were used for comparison of quantitative variables between different groups, as appropriate. For categorical the chi-square, or Fisher's exact test (FET) was used as a test of significance, as appropriate. Significant predictors of violence in bivariate analysis were entered into multivariate stepwise forward Wald logistic regression analysis. P=0.05 was considered statistically significant.

During the study period a total of 2130 births were registered in the chosen health centers. These belong to 2107 mothers. About ninety-five percent of target mothers (1996) were involved in the study. More registrants than non-registrants were studied (97.0% vs. 91.6% of target, respectively). Forty-six mothers (2.3 of studied mothers) never received antenatal care.

The commonest reasons of not seeking antenatal care were the idea that pregnancy is normal with no need for care (54.3%), busy husbands (37.0%), and PHC center is far from home (21.9%). Other reasons are lack of transportation, busy mothers, not present at the usual residence during pregnancy and unwanted pregnancy. In 8.4% of mothers no reason was cited. On the other hand, the commonest reasons of non-registration at local PHC centers were busy husband's (29.1%), no specialist or female doctor at local PHC center (28.1%), attending care at husband's or own health insurance (27.9%), long waiting/overcrowding of local PHC centers (11.8%), not present at the usual residence during pregnancy (11.1%) and others (data not shown in tables).

Table (1) shows that failure to register for antenatal care at their local PHCC was less likely in rural and hegar, family with unsatisfactory income and husbands other than professional and semiprofessional. However, it more likely among highly educated parents, older maternal age, and more pregnancy spacing. On the other hand, mother of hegar residence, with unsatisfactory family income, living away from PHCC, with large family size, more gravidity, low educational level are less likely to receive antenatal care whatever its source. However, logistic regression revealed that the independent predictors of failure to register for antenatal care at local PHCC are parental education, maternal age, and pregnancy spacing. Only residence and maternal education are the independent predictors of failure to seek antenatal care⁽²⁾.

Table (3) shows that mothers of rural and hegar residence, with unsatisfactory income, and married to non-professional husband are less likely to seek private clinics for antenatal care. On the other hand, highly educated mothers with highly educated husbands, older age mothers and those with more pregnancy spacing are more likely to seek antenatal care at private clinics. On the other hand, More than 28% of mothers initiated care after the first trimester of pregnancy. Later initiation of antenatal care is more likely to be reported by mother of rural and hegar residence, working mother and of older gravidity. On the other hand, mothers seeking care at private and facilities other than PHCC are less likely to delay initiation of care. However, logistic regression analysis revealed that the independent predictors of seeking antenatal care at private clinics are residence, family income, husband's education and work, maternal age and pregnancy spacing. The independent predictors of late initiation of antenatal care are maternal work and source of antenatal care (table 4).

On average, each mother received 7.8 visits during the index pregnancy. Mother of urban residence, with satisfactory income, with high education, housewives, married to highly educated husbands, of high gravidity and seeking antenatal care in facilities other than PHCC are more likely to attend more antenatal care visits, compared to the other groups.

Only 1.1 of them was not protected by tetanus toxoid and 6.3% of them never had ultrasound examination during their antenatal care. Other contents of antenatal visits were listed in table (6). Some antenatal procedures were likely to be done in PHCC e.g. height measurement, blood group/Rh testing, tetanus toxoid coverage, edema testing and sickle cell testing. However, most investigations are more likely to be repeated in private clinics e.g. ultrasound, urine analysis, hemoglobin testing and blood sugar estimation.

aThe first two categories were merged as a reference group.
* Primigravidae were excluded
OR= Odds ratio, CI= Confidence Interval, r= reference group

aThe first two categories were merged as a reference group.
*Primigravidae were excluded
OR= Odds ratio, CI= Confidence Interval, r= reference group

* Primigravidae were excluded, # Governmental hospitals, National Guard, shared care.
OR= Odds ratio, CI= Confidence Interval, r= reference group

*Primigravidae were excluded, # Governmental hospitals, National Guard, shared care.
OR= Odds ratio, CI= Confidence Interval, r= reference group

* Primigravidae were excluded, # Governmental hospitals, National Guard, shared care.
A, B and C significant difference between the corresponding groups by Bonferroni multiple comparisons

*Brucellosis, toxoplasmosis, Hepatitis Bs antigen, VDRL, stool analysis, pregnancy test, urine culture
FHS= fetal heart sound, IFA= iron & folic acid, FET = Fisher's exact test
A, B and C significant difference between the corresponding groups by Bonferroni multiple comparisons
#Private & others were merged for FET calculation.

Currently, the primary health care program of the Kingdom of Saudi Arabia has become well established, with the attainment of a very wide coverage. Special emphasis was placed on the quality issues of maternal health services. Certain aspects of maternal health care can be deducted from the results of statistical and/or survey data. Health care services provided by the governmental sector in Saudi Arabia accounts for over 80% of total services and almost provided free of charge. Health care is also provided by other agencies e.g. National Guard, ARAMCO and private sector⁽⁸⁾.

More than two-fifths of mothers studied failed to register for antenatal care at their local PHCC. The main reasons cited for this failure were busy husbands or mother, absence of specialists and/or female doctors at PHCC as well as availability of family health insurance at private clinics and long distance from the local PHCC. Logistic regression revealed that mothers with unsatisfactory family income are less likely to fail to register for antenatal care at their local PHCC. On the other hand, highly educated mothers, with long pregnancy spacing and married to educated mothers are more likely to fail to register for antenatal care at their local PHCC. A study in the Northern Region of the Kingdom revealed that the rates of defaulting were 33.1% and 4.1% in urban and rural areas, respectively, with the same reasons of defaulting(9).

Antenatal coverage is one of the indicators of the maternal and reproductive health indicators. It is the percentage of women who have attended at least once during their pregnancy to be checked by skilled health care personnel for reasons related to pregnancy⁽¹⁰⁾. For most pregnant women, participation in antenatal care is not motivated by health problems. They attend in order to confirm pregnancy is proceeding normally⁽¹¹⁾. We found that 2.3% of mothers interviewed never received antenatal care during the index pregnancy. This is much lower than the findings from other regions of the Kingdom. The percentage of never receiving prenatal care ranged from 8% in Northern region⁽⁹⁾, to 30% in Riyadh and Al-Majma'ah^(12-14) and up to 80% to 90% in Tarut island, Al-Hassa and Al-Khobar^(15-17). The national figure of those not receiving antenatal care was estimated to be about 33% of mothers in 1989⁽¹⁸⁾. This figure declined to 14% in 1991⁽²⁰⁾ and in 1995 further declined to 6% was reported⁽²¹⁾. Results from a nationally representative Family Health survey indicated that around 10% of the mothers never received antenatal care⁽⁸⁾. This increase in antenatal coverage is attributed to the expansion of maternity health services in the Kingdom, especially after full implementation of PHC with continuous training of health team as well as more public awareness.

Social and cultural constraints may be an obstacle to attendance, lack of resources and quality are major constraints⁽²²⁾. The commonest reasons for not receiving antenatal care were the false belief that pregnancy is a normal state and that there is no need for care, followed by busy husbands to accompany mothers to PHCC, and PHCC is far away from home. The same reasons of defaulting were reported in different proportion by other studies^(9,15,16,18).

The logistic regression analysis revealed that the independent predictors of failure to receive prenatal care were residence and maternal education. Mothers living in hegar (desert collection) are more likely to default antenatal care. Most of these are mobile nomadic mothers. In addition, mothers that are more educated are less likely to default antenatal care. Previous studies revealed the same findings^(9,18). Literacy denotes a greater recognition of the need for the services, wider knowledge of the services available and greater ability to make full use of them(⁽¹⁸⁾.

The timing of antenatal care is crucial to its effectiveness. Women should report to health centers as soon as she feels that she is pregnant. This does not happen because the community is conservative, the husband may not be free to accompany his wife to the health center, and most women are busy caring for the child at home⁽²³⁾.

In this study 71.8%, 16.8%, and 11.3% of mothers registered for care during the first, second and third trimesters, respectively. This agrees with the finding of the Northern region study⁽²³⁾. Mothers with late initiation do not have either the recommended minimum number of visits during pregnancy or the minimum first trimester evaluation. In the Saudi Arabia child health survey, 85% and 7% of mothers have their first visit in the first and third trimester, respectively⁽¹⁸⁾. In the W.H.O. randomized clinical trial of antenatal care in Jeddah, 42% initiated care in the first trimester⁽²⁴⁾. In USA and Australia 84% and 60% of mothers initiated care in the first trimester^(25,26). A much lower rate of initiation of care in the first trimester were reported from developing countries^(27-31).

Logistic regression analysis revealed that working mothers are more likely to initiate care in the third trimester. On the other hand, mothers received antennal care at private clinics are less likely to delay initiation. This agrees with other studies^(23,32).

Number of antenatal visits ranged from 1-18 with a mean and median of 7.8 and 8 visits, respectively. This is lower than the mean of 8.4 reported from the Northern region(23), but comparable to the findings from Riyadh and Al-Qassim regions of Saudi Arabia^(32,33). In the Saudi Arabia health survey, more than 90% had at least four check-ups and around three-fifths had seven or more check-ups⁽¹⁸⁾. Higher average number of visits up to 15 was reported from developed countries^(34,35). A lower number of visits were reported from developing countries^(28,31,36).

Mean number of visits are significantly more frequent among housewives urban mothers, with satisfactory family income, highly educated and married to educated husbands, primigravida, multigravida with long pregnancy spacing, and those seeking care at private clinics. This agrees with different studies^(8,36-38).

Most studies have focused on the quantity and timing of antenatal care visits, but few on the contents. The quality of services provided and the standard of care a woman receive will encourage the families to seek prenatal care. The Ministry of Health guidelines^(5,39) were utilized for the assessment of the quality of care provided to pregnant women in PHCC in Saudi Arabia, these guidelines were in accordance with the WHO standards and constitute part of the quality assurance program implemented in PHC in the Kingdom.

Among procedures that done once during pregnancy (height measurement, blood group and Rh testing) were done for more than 93% of mothers. Among the non-routine laboratory tests that were required on need, pregnancy test and sickle cell testing were the most frequently done. The procedures that should be repeated each visit i.e. weight, blood pressure, abdominal examination and fetal heart sound auscultation, urine analysis, blood sugar and hemoglobin estimation were done for nearly all mothers. The mean numbers of repetition of these procedures were highest for weight, blood pressure and urine analysis (7.6, 7.8 and 7, respectively). These findings are more or less similar to the findings of the Northern region⁽²³⁾, but the number of repetition is lower than our study.

The W.H.O. randomized controlled trial in Jeddah, revealed that the clinical activities repeatedly done included physical examination (100%), blood pressure measurement (99.6%), obstetric examination (100%), uterine height measurement (93%0, maternal weight gain monitoring (95.6%), Rh testing (98%), urinary tract infection screening (99.3%) and fasting blood glucose test (90%)⁽²⁴⁾.

According to the guidelines devised by Ministry of Health^(5,39), antenatal mothers should be routinely referred for ultrasonic examination at least twice, the first between 16 and 18 weeks and the later between 34 to 36 weeks to ensure their wellbeing. In our study about 94% of mothers received ultrasonic examination with a mean of 2.5. A previous studies reported that 57.6% and 52.6% of mothers received ultrasonic examination once, respectively^(23,24).

Tetanus toxoid immunization should be given as early as possible during pregnancy. Mothers who were not immunized previously should be given two doses of adsorbed tetanus toxoid, spaced at least four weeks apart. In each subsequent pregnancy, a booster dose is given and the fifth dose will protect her for life^(5,39). In our study, only 1.1% of mothers were not fully protected against tetanus. This is much lower than other studies^(8,21,23,24).

The role of private sector is expanding in Saudi Arabia in all health services including maternity care. In this study 31.9% of mothers received antenatal attended the private clinics. In Saudi Arabia Family Health survey, just 15% received antenatal care from private health clinics⁽⁸⁾. In agreement with the same authors, we found that educated parents, professional husbands are associated with increased likelihood of seeking antenatal and natal care at private clinics.

Despite the high coverage of antenatal, there is room for improvement in the quality of care, especially in PHCC. PHC staff should periodically trace defaulting mothers through telephone communication or home visits.

Good record keeping is essential for ongoing assessment of the quality of care for evaluation and making decision. A computerized data base system will be very useful in this aspect.

The expanding role of private clinics in maternity care necessitates a liaison between these clinics and PHCC with adequate feedback system during antenatal care.

Continuous re-training of PHCC staff is mandatory with recruitment of female doctors to implement the maternity care. The adoption of the policy of family doctor may contribute to more improvement of maternity care.

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