Poor attitude of pregnant women towards antenatal care: Rationale for health education/promotion

Introduction

Antenatal care refers to the care that is given to an expectant mother from the time of conception till labour begins (Myles, 2003). The rapid development in the health system and the growing use of technology makes it impossible for any system in any country to reject the use of western health care in all aspect of health delivery such as maternal care. In today’s word, very pregnant woman is encouraged to have some technological intervention during pregnancy.

Antenatal care is the aspect of technology which is broadly accepted as a way to improve women’s health even though some studies have disputed the advantage of some of the component of antenatal care. Care during pregnancy, child birth and post natal period is often provided by multi care givers, many of who work only on in the antenatal unit. Effective antenatal care is expected to improve the health of woman and infants, though some safe motherhood advocates questions on the effectiveness of antenatal mortality (McDanagh, 1996).

There is a little doubt that maternal health education and instructions about the recognition of symptoms leading to obstetric emergencies, usually given at antenatal sessions, can be lifesaving and reduce delay in seeding help (Bhatia, 1995).In highly fertile societies such as developing countries, the antenatal period offer opportunity to address other health related issues in women reproductive age (Arroli, 2001).

Counselling and voluntary screening for HIV, prevention of maternal to child transmission of HIV and the introduction of parturient to the use of insecticide treated bed nets has been successfully integrated into antenatal care. Furthermore antenatal care provides an opportunity to obstetricians and mid-wives for prevention and early detection early detection of maternal conditions as anaemia, malaria, hypertension and other medical conditions attending material health.

Antenatal care (ANC) services directly saves the life of mother and babies by promoting and establishing good health before child birth and the early post natal period. It often present the first contact opportunities for pregnant women to connect with health services, thus offering an entry point for integrated care, promoting healthy home practices, influencing care-seeking behaviours and linking women with pregnancy complication to a referral system, thus impacting positively on maternal and foetal health. The very low maternal infants morbidity and mortality rates reported for developed countries compared with the extremely high figures in developing countries have been attributed to the higher utilization of modern obstetric services by the former currently of women worldwide utilizes antenatal care (ANC) services and in industrialized countries south Asia and sub-Saharan African.

Conceptual framework

Antenatal care is largely established and gives an opportunity to inform and educate pregnant women about pregnancy, child birth, care of the new-born. Cowan (1995) noted that the aim of antenatal care is to enable expectant mothers makes appropriate decisions about health which will lead to optimum outcome of pregnancy and the new born care.

According to Ejebe (2007), poor quality health care in Africa account for 95% of neonatal death. The developing world sum up the 99% of maternal death and half of this mortality occur in sub- Saharan Africa. A child born in some of these developed countries are more likely to die in neonatal period than children born in industrialized world (Allender, 2001).The Ministry of Health in 2002 stated that Nigeria has the second highest maternal mortality rate in the world. 8 out of 1,000 women died due to maternal health complications. This is due to factors that include the lack of skilled birth attendants (only 35% of Nigerian women have a skilled attendant at delivery).

Davis (2005) reported from his study that financial difficulties are one of the most important reasons for not seeking health care for those within low income. In china, calls for the adoption of the antenatal care model termed focused antenatal care (FANC) have emanated from the desire to correct the poor implementation of traditional antenatal care (ANC) in developing countries. The FANC model is intended to reduce waiting time during antenatal visits and increase the time spent in educating women on pregnancy related issues (WHO 2001).

The traditional ANC involves a pre-clinic session in which nurses socialize with parturient through songs and prayers followed by health talk and an interactive session of question and answer. Clinical consultations then follow in open spaces, partitioned clinic spaces or consulting rooms depending on the faculty available in the centre (Corea, 1985).Antenatal clinic appointments are given monthly until 28 weeks, fortnight until 36 weeks and then weekly until delivery, counselling and screening for human immune deficiency virus (HIV), syphilis and hepatitis are integrated into traditional ANC. Treatment of HIV and the prevention of maternal to child transmission of HIV are provided in specialized clinics (William, 2001).

Effective antenatal care is expected to improve the health of women and infants, though some safe motherhood advocates questioning the effectiveness of antenatal care in the control of maternal mortality (Deal, 1995). There is little doubt that maternal health education and instructions about the recognition of symptoms leading to obstetrics emergencies, usually given at antenatal sessions, can be lifesaving and reduce delay in seeking help (Munodawara, 1997). In highly fertile societies such as developing countries, the antenatal period offers an opportunity to address other related issues in women of reproductive age (Carroli, 2001).

Counselling and voluntary screening for HIV, prevention of maternal to child transmission of HIV and the introduction of parturient to the use of insecticide treated bed nest have been successfully integrated into antenatal care. Further, antenatal care provides an opportunity to obstetrician’s and midwives for prevention and early detection of maternal conditions such as anaemia, malaria, hypertension and other medical conditions affecting maternal health. No matter how well intended health programme may appear, clients, attitude remains vital for their successful inception and sustenance (Department of Health, 1993; Abrahams, 2001).

Lack of confidence in the changes and social issues have impeded the general acceptance and implementation of FANC in many developing countries including Nigeria. Even health care providers initially questioned aspects of FANC and its place in sub-Saharan Africa (Ekele, 2003).The reception of FANC by several sub-Saharan Africa countries, although the implementation of FANC in sub-Saharan Africa remains sub optimal, donor agency driven, not widespread and associated with poor compliance to guidelines (Nyako, 2006).Sustainable funding, socio-cultural barriers and social mobilization seem to affect the full implementation of FANC in sub-Saharan Africa.

In a study, 70% of the parturient did not desire a reduction in the number of their antenatal visits to four despite being assured of the safety to such a reduction. This is about three times the number in a previous study comparing FANC and traditional ANC in the United Kingdom, in which 26% of apparently eligible women refused to participate because they did not want to have antenatal visits (Brown 1970). Dissatisfaction with fewer is shared by some women in both developed and developing countries (Baldo, 2001).Most parturient who desired a reduction in the number of antenatal visits to four in study did so because they felt it would be more convenient and cheaper. Convenient and cheaper antenatal care is part of the long term goals of the new antenatal care model.

According to WHO (2001) the new model at its inception may entail the reconstruction of clinic space to ensure individualized consultation, privacy and confidentiality and to permit care providers to see each parturient in a defined location at each visit. Personnel training, the construction of side laboratories in the clinic area or relocating existing laboratories close to the clinics may similarly be required the initial costs of policy and programme development, provision of logistics and the cost of human resource development have so far impeded the realization of the full objectives of FANC in sub-Saharan Africa (Corea, 1995).

Women who preferred traditional ANC in this study did not accept the view that four visit were adequate to achieve their in antenatal care. They did not believe that in four visits they can learn enough about pregnancy, know their service providers enough and that disease would be detected early enough some (67%) simply enjoyed antenatal sessions. There is little doubt that the motivation for some women to attend antenatal clinics is socialization (Baldo, 2005).The psychosocial aspect of antenatal care is important as if influences parturient evaluation of care, the effectiveness of antenatal visits and their seeking practices (Abraham, 2001).

It may however, be difficult to justify the use of health provider’s time and resources merely for the provision of avenues for socialization (Meleis, 1997). Individualized consultation, privacy, confidentiality and being consistently seen by the same care provider in a definite location is design in FANC to improve parturient ease, their ability to obtain the information they require and their familiarization with their care providers. Myles (2003) observed that women in Ghana and Kenya were particularly impressed with FANC because the same care provider attended consistently to them at each visit.

Accordingly to Rifkin (2000) the effectiveness of FANC in the early detection and prevention of common disease and causes of complication in pregnancy was an initial hurdle to the reduction in the number of antenatal visits at the time of it conceptualization. This has been extensively studies and it was concluded that traditional ANC and FANC are of equivalent effectiveness in the detection and prevention of disease in women of low risk.

According to WHO (2001) apprehension by parturient about the anticipated inadequacy of FANC in the area of learning is addressed by emphasizing on health education, counselling and personalized consultation in the new model. Personalization and compartmentalization of care in FANC, however, increase the burden for human resources development and logistics in sub-Saharan African countries with already grossly under funded health services even in South Africa with one of the best resourced health programme. In sub-Saharan Africa, FANC has been severely limited and full expansion prevented by financial constraints (Akinsola, 2000).The study also shows that, almost 60% of those who took part in the study state that, financial difficulty is the main reason for not attending antenatal clinic. Other studies show that, oral knowledge on maternal health care result to lack of utilization of health care facilities (Fatusi, 200).

Antenatal care helps to promote and maintain health of women during pregnancy, also to educate mothers in various aspects of need such as nutrition, personal hygiene, family planning and environmental hygiene. These allow for recognition of “high risk cause and special attention given, which in turn reduce infant mortality” (Stanhope 2002). Antenatal care focused on evidence based as it goal directed action: it is cantered on family care; it is focused on quality care. Its care is given by skilled health providers.

• To promote awareness, the sociology of care in the aspect of a child bearing and the influences that theses may have on the children.
• To recognize deviation from the normal and provide management or treatment as required.
• To support and encourage a family healthy psychological adjustment to child bearing.
• To prepare the women for labour lactation, and the subsequent care of her child.

Types of antenatal care

Olise (2007) saw antenatal care in two phase, these are:

• The first is the initial visit to the health facility.
• The second is the subsequent visit to the health facility.

Initial visit

According to Olise (2007), the initial visit is also called the booking visit. Ideally, booking should occur not later than 18 weeks of gestation so that appropriate interventions can be effected where indicated. In Africa, however, pregnancy is largely a family secret till it can no longer be concealed. This, it is often claimed is to avoid giving evildoers the opportunity to harm the pregnancy. Activities during the booking visit include obtaining a history, physical examinations and carrying out further investigations. (Cowan, 1995). Just as Cowan, Rifkin (2000) gave the same factors of History, physical Examination and investigation.

History

According to Rifkin (2000) the health worker is expected to document essential information on the client by writing the name age, address, next of kin, marital status and occupation, social history like the partner’s occupation, her   own smoking or drinking habits should be noted.  Consumption of alcohol and smoking are detrimental to the foetus and the pregnant woman should be advised to stop or at the least drastically reduce the intake of both substances. The date of commencement of the last menstrual period is take so, too, is the regularity of the periods especially intrauterine device. According to Abraham (1992) previous obstetric history is also noted, especially:

• Number of previous pregnancies and deliveries with dates.
• History of still births
• History of mid trimester abortion
• History of postpartum haemorrhage
• Birth weight of other children especially if they are of low birth weight or too large (over 4.5kg)
• History of toxaemia of pregnancy

Physical examination

According to Allender (2001), the pregnant woman is weighed and the height measured, any deformity including unsteady joint should also be noted the breast is examined for any abnormal mass and inverted nipples. The booking blood pressure is recorded to act as a benchmark for subsequent readings where qualified man power is available, pelvic examination is recommended. After the first trimester, the uterus can be palpated on abdominal examination. As the pregnancy advances, the uterine fundus increases in height. Depending on the age of the pregnancy, the person and presentation may be determined.

Investigation

According to Munodawafa (1997), it is routine to perform certain laboratory and other investigation. They include:

• Blood group
• Genotype
• Urine sugar
• Urine protein
• HIV screening etc.

Not all these test may be available in primary health care facilities and so may have to be carried out elsewhere with advance technology; facilities for ultrasound scanning are increasingly available in urban settlement. Scanning is not yet a primary health care requirement in developing countries.

The subsequent visit

This is the second type of antenatal care. According to Chege (2005) after the initial visit, which is also known as booking visit, the frequency of subsequent visits depends on the history of the pregnancy. In the absence of specific risk factors, the expectant mothers are recommended to come for prenatal visit:

• Every four weeks till 28 weeks.
• Every two weeks until 36 weeks.

Every week until the commencement of labour. At each visit, the weight, blood pressure and urine test are, measured/done. For most women, about, 10kg is gained during pregnancy, mothers should be asked of foetal movement. The haemoglobin is repeated at 30 and 36 weeks and thereafter, the engagement of the head should be checked. As mentioned earlier, antenatal care provides the opportunity for helping the pregnant women with the problem of pregnancy and to prepare her for safe child birth. Health education both in group and one to one basis is vital (Change, 2005).

Objectives of antenatal care

According to Abraham (1992), the following are the objectives of antenatal care these are:

• To promote, and maintain the health of pregnant women so that they may deliver safely (Rifkin, 2000).
• To detect or predict complications of pregnancy as early as possible so as to institute a preventive measure including referral (Davis, 1983).
• To give health education to pregnant mothers which will prepare them for labour and successful lactation (Ejebe,2007).
• To encourage pregnant women to eat well through adequate nutrition and also through their effort in cooking balanced diet (Allender, 2001).
• To decrease and or remove anxiety and fears usually associated with pregnancy and in particular the first pregnancy (Cowan, 1995).
• To attend to under 5 children who accompany their mothers to the clinic (Myles, 2003).
• To teach mothers personal hygiene and environmental sanitation. (Olojoba, 2009).
• To detect high risk pregnancy and take appropriate measures (Enkin, 1995).
• To reduce infant and maternal mortality and morbidity (Akinsola, 2000).
• To promote appropriate utilization of health activities in the health centre for mothers and child care. (WHO, 1975).

Applicable methods of antenatal care

According to Fatusi (2000), the following are the applicable methods of antenatal care, these are;

• Health education
• Immunization against tetanus
• Other preventive measures

1. Health education

According to WHO (1975) this is as important as the examination to the mother. As well as guidance on her own diet, the mother should be given instruction in baby and child care the importance and the length of breast feeding necessary for the child should be stressed. Other useful topics to discuss are the importance of child spacing, the dangers of unsafe abortions, and methods of family planning. In all these discussions it may prove helpful to include fathers, elders in the family and the community. Opportunities for health education can be created through home visits, community or club meetings, or has one to one talks in clinics. Discussions in small groups are always more effective than lectures. With time and experience of working in an area one can develop insight into people’s  knowledge, beliefs and attitudes, the type of health message that is received best, the most effective methods of health education and so on.

2. Immunization against tetanus

According to Bhatia(1995), neonatal tetanus is a common cause of death in many rural areas. In spite of the growing popularity of the western type of medicine, a large proportion of babies under such circumstances, antenatal measures for protecting the babies against tetanus in the new-born period are essential (Peter, 2007).

Immunization of the mother during the antenatal period with tetanus toxoid produces a high level of antibodies in her blood, which is sufficient to protect the baby from tetanus at birth. Hence in areas with area a high incidence of neonatal tetanus the mother should be immunized with tetanus toxiod by the means of three injections of 1ml each, given at monthly intervals during the latter half of pregnancy. If previously immunized, one booster injection in the last trimester will provide adequate protection

3. Other preventive measures

According to Myles (2003), anaemia is widespread in pregnant women in developing countries. Most of it is due to iron deficiency even though deficiency of folic acid also plays a significant role. In malarious areas there is an added of anaemia caused by the  malaria parasite regular administration of iron (ferrous sulphate , 200mg) and folic acid (10mg), especially in the last trimester will ensure against deficiency. Regular anti-malarias, such as chloroquinne150mg once a week, will not only protect the mother against anaemia of material origin but will also ensure adequate foetal growth.

Poor utilization of antenatal services by pregnant woman

According to Sikorski (1996), poor utilization of health care services is a major barrier to health which leads to high maternal mortality. It is estimated that, 60% to 80% of women deliver outside modern health facilities.

Okojie (2005) noted in a study that, in the eastern part of Nigeria, it was found that all 93% of rural mothers who had child birth or spontaneous abortion registered for prenatal care, 49% delivered at home under the care of TBAs. Similarly in the study of 377 women who delivered before arrival at the hospital, 65% of the women have been delivered by aTBAs, while 7.3.7% had sought help form TBAs as well.

WHO, UNICEF, and UNFPA promote the training of TBA as in order to bridge the gap until all women and children have access to acceptable professional modern health care services (WHO, 1978).

Management of poor antenatal care

According to Stanhope (2002) the following are ways to manage poor antenatal care, these are:

• There should be public enlightenment on the important of antenatal care. It helps to reduce maternal mortality, prolong labour and also treat pregnant mothers against diseases.
• Health education on factors associated with at risk pregnancy. These factors include severe malaria, swelling legs, bleeding. These are condition that needs special attention (WHO, 1978).
• There should be trained personnel at health centre and hospitals such as the nurse and other health personnel.

References

Abraham, G. J. & Ranken, J. P. (2001).Primary health care reorienting organisional support. London: Macmillan Press.

Akinsola, H. A. (2000). Effects of epidemic and the community home-based care programmed on the health of older Botswana Southern African Journal of Gerontology 9,(1), 4-9.

Allender, J.A. (2001): Reading in community health nursing (5^thed), Lippincott, Philadelphia pp121.

Brown & Dixon (1970).Antenatal care. Great Britain: Longman Group Ltd.

Cowan, M. (1995): Children’s Health Chapter 27 In Stanhope M & Lancaster, J. Community Health Nursing (4^thed) Mosby

Deal,L.W. (1995): The effectiveness of community health nursing interventions.

Davis, A.J. & Anoskar, M. A.  (1983).Ethical dilemmas and nursing practice (2^nded) Norway. Connection: Appleton century

Ejebe, A. (2007). Maternal and child health care setting. Warri: Eregha Publishers,

Munodawafa, D. & Cube, E. (1997).HIV/AIDS home-based care guide a booklet for health professionals. Ministry of Health, AIDS STD Unit, Garbone, Botswana.

Ministry of health (2002) HIV and AIDS best practices. The experience from          Botswana. Gaborone: Government of Botswana, AIDS / STD Unity UNDP & USAID.

Meleis, A.I (1997). Primary health care: a confusion of philosophies.

Rifkin, S.B (2000). Lessons from community participation in health programmers health policy plan I. pp240-249.

Stanhope, M. (2002): Community health nurse in home health and hospital care. Chapter 41 in: Stanhope, M. & LanChaster J. (eds). Community Health Nursing, (4^thed) Mosby St. Louis, Pp806.