purpose of antenatal care?

The purpose of antenatal care is to ensure that a woman has a safe pregnancy and that does not mean absence of any disease during this period. Antenatal care allows screening of preeclampsia, fetal abnormalities and other prevention strategies to be incorporated. The purpose of this study was to assess the reason for attending antenatal care clinics and knowledge of antenatal care content package in women.
METHODS

A cross-sectional study was conducted on 395 pregnant women attending antenatal care clinic at the. Each eligible woman was asked about the reason for attendance and her knowledge about WHO standardized antenatal care pac

The commonest reason for utilizing antenatal care in booked attendees was place of birth concern (25.9%) and in not booked was referral from private centers (33.6%) which was statistically significant (p=0.006). Both booked and not booked women (67.9% vs 59.1%, p=0.409) stated avoidance of complication during pregnancy and labor as the commonest reason for attendance. Women with higher parity were more likely to identify weight measurement (p=0.001), iron and folic acid supplementation (p=0.001), and urine detailed report (p=0.002), as content of the standard package.
CONCLUSIONS

Our study shows that women did not utilize antenatal care clinics for improving their health or the health of their fetus. The knowledge of the antenatal care package was limited to weight measurement and supplements. Moreover, attendance and visits at an antenatal care facility do not equate to good service provision.
Keywords: reasons, antenatal care, World Health Organization (WHO) antenatal care package, low-middle income countries (LMIC)
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INTRODUCTION

Antenatal care is not just a regular health check for pregnant women but serves a unique purpose. The purpose of antenatal care is to ensure that a woman has a safe pregnancy and that does not mean absence of any disease during this period1. Antenatal care allows screening of preeclampsia, fetal abnormalities and other prevention strategies to be incorporated2. But the utilization of antenatal care by women in low- and middle-income countries is very different from that of high-income countries. Although the utilization has increased considerably in the past two decades, the reasons for utilization are not very convincing3.

A visit should ideally incorporate the pregnancy specific care but the common reasons for accessing an antenatal care facility by Pakistani women were surprisingly different4. In a multicenter study, the Pakistani women were more concerned with birth preparation, and were less inclined to utilize any other preventive or screening services offered at the facility5.

The antenatal services are not utilized to their full potential in the country. It has been reported that women seldom present for antenatal care or present really late6. The birth specific complaints or pregnancy related concerns form a minor fraction of presenting complaints7.

Presentation to the antenatal care clinic is often the only time a woman comes in contact with the health professional. But this increasing attendance at antenatal care in Pakistan can merely pass for better service provision and not actual service utilization. There is a need to motivate women not to just access this service but utilize it to its true potential. Antenatal care is the best platform for screening, educating and providing needed healthcare during pregnancy. We conducted this study to assess the reasons for utilizing antenatal care in women presenting to an outpatient department.
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METHODS

The study was conducted from, and was carried out in the outpatient clinic of obstetrics and gynecology of the Ruth K. M. Pfau Civil Hospital, Karachi. Karachi is the biggest city of Pakistan and has a population of about 20 million8. The specific civil hospital is the largest tertiary care public sector hospital that receives patients from all walks of life. The delivery rate at this civil hospital is 7500 deliveries per year, and around 200 women come for antenatal care each day. The antenatal clinic is held daily from Mondays through Saturdays, from 9 a.m. to 1 p.m. These clinics are run by consultant obstetricians with their teams of resident doctors and are assisted by nurses.
Inclusion and exclusion criteria

All pregnant women aged 20–40 years attending antenatal clinic were informed and invited. Brief history and informed consent were obtained from each patient. Women in active labor on history and examination, women who had active bleeding or needed emergency treatment were excluded. Women who refused to consent were also excluded. A woman was considered to have adequate ANC visits and inadequate visits according to old WHO criteria of 20149.

Women who met the inclusion criteria were asked about antenatal care and the reasons for which they presented to the antenatal clinic. The findings of variables were entered in pre-designed proforma attached as an annex.
Power of sample size

To calculate an adequate sample size we searched the literature for reasons for utilizing antenatal care. There is only one study which directly quoted reasons for antenatal care utilization10. Using that study as reference and assuming similar proportion for this population, the sample size for the study was determined as n=359. The sample size was calculated using the WHO software where, true utilization of antenatal care for pregnancy was 37%, margin of error=5% and 95% confidence level. We used the estimating population proportion with specified absolute precision test to calculate the sample size (Sample Size Determination in Health Studies, Version 2.00, Copyright (c) 1996–98, World Health Organization). To compensate for incomplete responses, the sample size was increased by 7% so that 384 women were included.
Statistical analysis

Data was analyzed using SPSS Version 16. Means and standard deviations were calculated for the quantitative variables, such as maternal age and gestational week at which a woman presented. Frequencies and percentages were calculated for the qualitative variables, such as monthly income in PKR (low: ≤10000, middle 10000– 40000, and high >40000), occupational status, educational level, and parity. The classification for monthly income was as previously used in local studies11. Effect modifiers were controlled through stratification of maternal age, monthly income, occupational status, educational level and parity, to see the effect of these on the outcome variable. Post-stratification chi-squared test was applied taking p≤0.05 as statistically significant.

A bivariate analysis was done to assess the association of reasons for antenatal care utilization with adequate antenatal visits. The Pearson chi-squared test was used to assess associations between variables for an alpha error of 5%.

A further analysis was conducted to assess the knowledge of these women with respect to WHO package for minimum criteria. Each woman was asked about the seven essential variables: weight measurement, blood pressure measurement, blood tests, tetanus toxoid, urine detailed report, iron/folic acid, and counselling for dangerous signs. Women were stratified according to their parity: primigravida, parity ≤3, and >3. The parity classification was used because the total fertility rate for Pakistani women is 3.212. As parity increases the exposure of women to antenatal service is expected to increase. This association of parity with knowledge of the care package was assessed by a separate analysis.
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RESULTS
Basic demographic and clinical characteristics of studied population

During the study period 384 women were approached. Of these, 16 women refused to consent and 9 were excluded due to incomplete responses. We therefore included 359 women. Mean age of the participants was 31.12 years. Of these women, 47.6% had 3 or less children and had 2–4 visits (42.6%). Only 31.2% had adequate antenatal care and the majority (87.5%) had presented for the first time after 14 weeks of gestation.

Among the attendees, 171 (41.6%) had primary education, 185 (51.5%) were of low socioeconomic status (51.5%), 80.5% resided in an urban area and 53.5% were unemployed.

Of those who presented at the clinic, 206 (57.4%) had previously delivered vaginally and only 13.9% were having their first baby. Most of these women (192; 53.5%) had delivered at other government hospitals, while only 16.7% of the women had previously delivered at the Civil Hospital, Karachi. The characteristics of the population studied are summarized in Table 1.