Introduction
Antenatal care (ANC), is given different meanings by different scholars, among others the meaning that says, “Antenatal Care means care before birth and includes education, counselling, screening and treatment to monitor and to promote the well-being of the mother and foetus”. In short it is the care that a woman receives during pregnancy that helps to ensure healthy outcomes for women and newborn (Adewoye, Musa, Atoyebi and Babatunde, 2013). Kalayou (2014) highlighted that antenatal care is a key entry point for pregnant women to receive a multiple range of health services such as nutritional support and prevention or treatment of anaemia; prevention, detection and treatment of malaria, tuberculosis and sexually transmitted infections.
Antenatal care was also recognised by Yang and Yoshitoku (2010) as an opportunity to promote the benefits of skilled attendance at birth and to encourage women to seek postpartum care for themselves and their newborn. It is also an ideal time to counsel women about the benefits of child spacing.
In spite of the fact that antenatal care have such attractive benefits and strategies, it is very worrisome that half a million women and girls still die as a result of complications during pregnancy, childbirth or the six weeks following delivery. Almost all (99%) of these deaths occur in developing countries which shows that the antenatal care activity is still very weak in developing country. Majority of these deaths are caused by haemorrhage, followed by eclampsia, infections, abortion complications and obstructed labour. Other issues are lack of knowledge and preparedness about reproductive health in the family, community and health provider (Ojo, 2015).
Igbokwe (2012) stated that antenatal care utilization and hospital delivery rate is still low in Nigeria, especially in rural areas due to many factors that need to be examined such as socio demographic factors, illiteracy level, unavailability of health care facilities, apathy of women towards antenatal care, lack of knowledge of social support, etc. Also, Akpan (2011) highlighted that many women from different studies have mentioned that women’s are embarrassed when assessing antenatal hence so many of the women are reluctant to visit the hospital for antenatal care during pregnancy.
Conceptual framework
According to Rosalia and Muhammed (2011), Antenatal care is a specialised care 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. This care is given by skilled health providers to promote awareness, the sociology of care in the aspect of childbearing, and the influence that these may have on the children.
Stanhope (2012) also noted that antenatal care also help to recognize deviation from the normal and provide management or treatment as required to support and encourage adjustment to childbearing, to prepare the women for labour lactation, and the subsequent care of her child. This gives an opportunity to inform and educate pregnant women about pregnancy, childbirth and care of the new born.
Cowan (2015) noted that the aim of antenatal care is to enable expectant mothers make appropriate decisions about health will lead to optimum outcome of pregnancy and the newborn care. Antenatal care (ANC) services indirectly saves the lives of mothers and babies by promoting and establishing good health before child birth and the early post natal period. It often presents 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 complications to a referral system, thus impacting positively on maternal and foetal health.
Phases of antenatal care
Olise (2007) classified antenatal care into two phases which are:
- Initial visit to the health facility.
- Subsequent visit to the health facility.
Initial visit
According to Olise (2007), the initial visit is also referred to as the booking visit. Ideally, booking should occur not later than 18 weeks of gestation so that appropriate interventions can be affected where indicated. Activities during the booking visit include obtaining a history, physical examination and carrying out further investigations (Cowan 2015).
According to Rifkin (2010), during the initial visit, 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.
According to Abraham (2012) previous obstetric history is also noted, especially
- Number of previous pregnancies and deliveries with dates.
- History of stillbirths
- 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 4.5 kg)
- History of toxaemia of pregnancy
- Post surgical history
Ailender (2011) also stated that physical examination is carried out. 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 manpower is available.
Munodawafa (2007) also noted that certain laboratory and other investigation are carried out, which include:
- Blood group
- Genotype
- Urine sugar
- Urine protein
- HIV screening etc.
The subsequent visit
This is the second type of antenatal care. According to Chege (2015) 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, after 28 weeks, every two weeks until 36 weeks and after 36 weeks, every week until the commencement of labour. At each visit, the weight, blood pressure and urine test are carried out. For most women, about 10 kg 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 (Chege, 2015)
Objectives of antenatal care and hospital delivery
According to Abraham (2012), the following are the objective of antenatal care:
- To promote, and maintain the health of pregnant women so that they may deliver safely.
- To detect or predict complications of pregnancy as early as possible so as to institute a preventive measure including referral
- To give health education to pregnant mothers which will prepare them for labour and successful lactation.
- To encourage pregnant women to eat well through adequate nutrition and also through their effort in cooking balanced diet.
- To decrease and or remove anxiety and fears usually associated with pregnancy and in particular the first pregnancy.
- To teach mothers personal hygiene and environmental sanitation.
- To detect high risk pregnancy and take appropriate measures.
- To reduce infant and maternal mortality and morbidity.
- To promote appropriate utilization of health activities in the health centre for mothers and child care.
Knowledge and attitude of women toward antenatal care and hospital delivery
Study conducted in different part of the world has shown that the level of knowledge of mothers toward antenatal care and hospital delivery is important for their attitude toward utilizing antenatal service and hospital delivery. The level of knowledge of pregnant mother was found to vary in deferent part of the world. An institutional based cross sectional study conducted in north central Nigeria to investigate knowledge and utilization of antenatal service and hospital delivery has revealed that 87.7% of women in childbearing age were aware of the benefits of antenatal care and hospital delivery out of which 25.9% had fair knowledge about the activities carried out during the antenatal care services and hospital delivery, 69.9% had good knowledge while only 4.2% had poor knowledge (Igbokwe, 2012).
Similarly a study that was conducted in Tunisia to investigate mothers’ knowledge about preventive care indicated that 95% of women knew the importance of antenatal examination (Ojo, 2015). Different to these findings a cross-sectional study conducted using two-stage cluster sampling at 24 selected villages in the Kham District, Nagoya, Japan found that most of the respondents 73.9%, lacked sufficient knowledge towards antenatal care and hospital delivery (Maputle, Lebese, Khoza, Shilubane & Neshikweta, 2012). In another cross-sectional study conducted in Metekel zone, North West Ethiopia, 65.6% of women interviewed knew at least half of the knowledge questions on antenatal care and hospital delivery (Gurmesa, 2009).
In assessing the attitude women towards antenatal care and hospital delivery, Banda, Michelo and Hazemba (2012) described attitude as a state of readiness or tendency to respond in a certain manner when confronted with certain stimuli. The authors further stated that attitude is mostly dormant and is expressed in speech or behaviour only when the object or situation is encountered. It is person’s affective feelings of like and dislike. So in this study, attitude refers to expectant mothers affective feelings of like and dislike to antenatal services. Thus, the pregnant women’s personal experience to antenatal services can be positive or negative.
Studies in the developing world have shown an association of specific attitudes with utilization of and access to health services. The attitude towards antenatal care and health care delivery at government health facilities was significantly negatively and shows low utilization. Studies have reported negative attitudes as a major barrier to antenatal care utilization and hospital delivery (Rosalia & Muhammed, 2011). Level of education has a significant influence on the attitude of pregnant women to antenatal services. Pregnant women with basic education usually manifest positive attitude. Pregnant mothers with secondary and tertiary education qualification had positive attitude to antenatal services while the attitude to antenatal services by pregnant women with no formal education and primary education showed negative (Ali, Akhtar, Malik & Hasan, 2015).
According to the study conducted in Nigeria attitude of pregnant women towards antenatal services was positive. It reveals attitude of pregnant women with secondary school and tertiary education was positive while pregnant women with no formal education and primary educations were negative respectively. Generally different studies in different countries showed that there was similarity and differences on knowledge and attitude of pregnant women on the benefits of antenatal care and hospital delivery (Igbokwe, 2012).
Factors affecting antenatal care and hospital delivery
Several researches have shown that the utilization of antenatal care and hospital delivery are affected by several factors which include:
- Gestational age
- Reproductive concerns and uncertainties
- Parity and age
- Interactions with healthcare workers
- The direct and indirect costs of antenatal care and hospital delivery
- Husbands and HIV-related stigma
Gestational age
Gestational age influence antenatal initiation, attendance and hospital delivery. Very young girls especially victims of unwanted pregnancy usually try to hide their pregnancy until when it becomes too obvious to be hidden thereby affecting the utilization of antenatal care. Also women who have had one or two children before their current pregnancy usually shy away from antenatal care especially in their first trimester claiming to have been too familiar with the antenatal care routine (Akpan-Nnah, 2011).
Reproductive concerns and uncertainties
Previous or ongoing health problems usually pregnancy-related or otherwise prompted women to seek care at a health facility in early pregnancy (the first or early second trimester). In generally, women initiated antenatal care in early pregnancy and, from the first visit, antenatal care is conducted in a problem-focused manner: health workers reportedly paid attention to women’s complaints and possible remedies. This is characterized by women complaining of ill health during early pregnancy would however generally not attend antenatal care but rather seek care at a health facility, without disclosing their pregnancy to staff (Rosalia & Muhammed, 2011).
Parity and age
Parity has a complex impact upon antenatal care initiation and hospital delivery. For example, unaccustomed to the experience of pregnancy, the associated signs and symptoms, some primagravidae were more likely to seek advice and assistance and initiate antenatal care earlier. However, this lack of familiarity with the signs of pregnancy also prompted uncertainty to recognize a pregnancy, they were more prone to unintentionally delay antenatal care. However, adolescents and unmarried younger women hid their pregnancies and delayed antenatal care to avoid the potential social implications of pregnancy such as exclusion from school, expulsion from their natal home, partner abandonment, stigmatization and gossip. In contrast, older women did not make active efforts to hide their pregnancies. However, they would only directly disclose their pregnancy to close relatives and their husband (Adewoye et l., 2013).
Interactions with healthcare workers
Pregnant women’s interactions with healthcare staff at antenatal care have varying implications for antenatal care attendance and hospital delivery. There have been several reports that delaying antenatal care until the third trimester, usually lead to chastisements from health workers. This is also the case if a woman arrived at a health facility to deliver without having previously attended antenatal care, hence women’s fear of chastisement from health workers sometimes prompted antenatal care attendance (Kalayou, 2014)
The direct and indirect costs of antenatal care and hospital delivery
Charges for antenatal care and hospital varied across health facilities; small charges are usually levied for the card and also, where available, laboratory tests. Attending antenatal also entailed indirect costs such as travel costs and food that women purchase whilst waiting to be attended, either for themselves or their accompanying children (Yang & Yoshitoku, 2010).
Husbands and HIV-related stigma
In some areas healthcare staff promotes the involvement of husbands in antenatal care. HIV-related stigma, has negative implications for their antenatal care attendance since some women will be wary of attending antenatal care because they would be informed of their HIV status and a positive result had ramifications if their husbands discovered their status. Husbands often refused to be tested and rather, in the most extreme instances, accused their wives of adultery and abandoned them (Maputle et al., 2012).
Measures to promote antenatal care and hospital delivery
According to Stanhope (2012) the following are ways to promote antenatal care and hospital delivery:
- There should be public enlightenment on the important of antenatal care. It helps to reduce maternal mortality, prolong labour and also to 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.
- There should be adequately trained personnel at the health centre and hospitals such as the nurses and other health personnel.
- Ensure that all branches of government are involved in the response to maternal mortality, HIV and gender-based discrimination, and develop programmes to promote safe pregnancies and deliveries, including by addressing the social and economic challenges women and girls face accessing early antenatal care.
- Ensure that all health system procedures uphold patient confidentiality and enhance non-discrimination, avoiding for instance the use of specific files for HIV treatment, separate queues and designated waiting areas for people living with HIV.
- Take steps to increase awareness about patients’ rights, particularly the right to informed consent.
- Improve knowledge about sexual and reproductive health and rights, including through comprehensive sexuality education that involves men and boys.
- Urgently address the persistent lack of safe, convenient and adequate transport, and the poor condition of roads, particularly in rural settings, including through subsidized or free transport, grants to pregnant women and girls to cover transport costs, improving road infrastructure, and improved transport options.
References
Abraham, N. (2012). Antenatal and postnatal care service utilization in southern Ethiopia a population-based study. African Health Sciences, 11(3), 390 – 397
Adewoye, K.R.,Musa, I. O., Atoyebi, O. A. & Babatunde, O. A. (2013). Knowledge and utilization of antenatal care services by women of child bearing age in Ilorin-East Local Government Area, North Central Nigeria. International Journal of Science and Technology, 3(3), 7-9
Ailender , M. (2011). Ethiopia demographic and Health survey Addis Ababa. Ethiopia and USA: CSA
Akpan, M. (2011). Acceptance and practice of focused antenatal care by health care providers in south west zone of Nigeria. Arch. Appl. Science Research, 3(10), 484 – 491.
Akpan-Nnah, E. M. (2011). Knowledge and attitude of pregnant women towards focused antenatal care in General Hospital, Ikot Ekpene, Akwa Ibom State, International Professional Nursing Journal, 9(1), 96 – 104
Ali, N., Akhtar, L., Malik, A. & Hasan, E. (2015). The Effectiveness of Community Health Nursing Interventions. New York: Sage
Banda, K. Michelo, L. & Hazemba, N. (2012). Antenatal care. Great Britain Longman Group Ltd.
Chege, H. (2015). Antenatal Care in Developing Countries: Promises, Achievements and Missed Opportunities: An Analysis of Trends, Levels, and Differentials: 1990–2001. WHO & UNICEF, Geneva, New York.
Cowan, E. (2015). Factors related to the utilization of antenatal care services among postpartum mothers in Pasar Rebo General Hospital, Jakarta, Indonesia. J Public Health Dev, 6, 113–122
Gurmesa, T. (2009). Antenatal Care Service Utilization and Associated Factors in Metekel Zone, Northwest Ethiopia. Ethiop J Health Sci. 19, 20-9
Igbokwe, C. C. (2012). Knowledge And Attitude Of Pregnant Women Towards Antenatal Services In Nsukka Local Government Area Of Enugu State, Nigeria. Journal of Research in Education and Society, 3, 1-5
Kalayou, K. B. (2014). Assessment of Antenatal Care Utilization and its Associated Factors Among 15 to 49 Years of Age Women in AyderKebelle, Mekelle City 2012/2013; A Cross sectional study. American Journal of Advanced Drug Delivery. 062-075,
Maputle, M. S., Lebese, R. T., Khoza, L. B., Shilubane, N. H. & Neshikweta, L. M. (2012). Knowledge and attitudes of pregnant women towards Antenatal care services at Tshino village, Vhembe district,south Africa .Africa Journal for Physical, Health Education ,Recreation and Dance.
Munodawafa, E. (2007). Factors related to regular utilization of antenatal care service among postpartum mothers in Pasara Rebogenerl Hospital Jacarta Indonesia. Journal of Public Health and Development 6(1),20-8.
Ojo, A. (2015). A textbook for midwives in the Tropics (5th ed), London: Holden and Stoughton.
Olise, R. (2007). Factors related to the utilization of antenatal care services among postpartum mothers in PasarRebo General Hospital, Jakarta, Indonesia. J Public Health Dev, 6, 113–122
Rifkin, C. (2010). How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of the evidence. Paediatric and Perinatal Epidemiology. 15 (supplement 1):1-42.
Rosalia, A. M. & Muhammed, J. J. (2011). Knowledge, attitude and practices on antenatal care among Orangasli women in Repel, Nigeria Sembelian. Malaysian. Journal of Public Health Medicine, 11(2), 13-21
Stanhope, S. (2012). Knowledge, attitude and belief of pregnant women towards safe motherhood in a rural Indian setting Manju Sharma. Vol. 1 No. 1, 13-18,
Yang, Y. & Yoshitoku, Y. (2010). Factors affecting the utilization of antenatal care services among women In Kham District, Xiengkhouang Province, LAO PDR. Nagoya J. Med. Sci., 72, 23-33.
