TITTLE

HOW CAN ANTENATAL CARE SERVICES BE MADE

SATISFACTORY?

i
ii
 LIST OF ABBREVIATIONS

 HIV –Human immunodeficiency virus

 CDC (Centers for Disease Control and Prevention
 ANC Antenatal care
 FANC Focused antenatal care
 HMIS Health management information system
 IEC Information, education and communication
 MDG Millennium Development Goals
 MMR Maternal mortality ratio
 MDHS Malawi Demographic and Health Survey
 TTV Tetanus toxoid vaccine
 WHO World Health Organization
 UNICEF United Nations Children’s Fund
 MNH Maternal and Neonatal Health

iii
 TABLE OF CONTENTS

TITTLE......................................................................................................................................................... i

HOW CAN ANTENATAL CARE SERVICES BE MADE SATISFACTORY ..................................... i

DEDICATION.............................................................................................................................................. i

THIS PIECE OF WORK IS DEDICATED TO MY WONDERFUL HUSBAND AND

CHILDREN ................................................................................................... Error! Bookmark not defined.

ACKNOWLEDGEMENT ............................................................................ Error! Bookmark not defined.

LIST OF ABBREVIATIONS ................................................................................................................... iii

ABSTRACT ................................................................................................................................................. v

Introduction ................................................................................................................................................. 1

PART ONE .................................................................................................................................................. 4

1.0. ANTENATAL CARE SERVICES ..................................................................................................... 4

1.1. Health Promotion and Disease Prevention ........................................................................................ 5

1.2. Detection and Treatment of Existing Diseases and Conditions ....................................................... 7

1.3. Early Detection and Management of Complications ........................................................................ 7

1.4. Birth Preparedness and Complication Readiness ............................................................................. 7

1.5. Focused Antenatal Care in the Maternal and Neonatal Health (MNH) Program ......................... 8

PART TWO ............................................................................................................................................... 10

ANC SERVICES OFTEN FOUND TO BE SATISFACTORY ............................................................ 10

PART THREE........................................................................................................................................... 14

ANC SERVICES OFTEN FOUND TO BE LESS SATISFACTORY ................................................. 14

PART FOUR ............................................................................................................................................. 17

REASONS FOR NON SATISFACTION AS REPORTED IN OTHER WORKS ............................. 17

FACTOR AFFECTING THE IMPLEMENTATION OF EARLY ANTENATAL CARE

(ANC1) ....................................................................................................................................................... 20

CONCLUSION ......................................................................................................................................... 21

RECOMMENDATIONS .......................................................................................................................... 21

REFERENCES .......................................................................................................................................... 23

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 ABSTRACT

Quality of antenatal care is seen as a factor closely related to

effectiveness, utilization, compliance and continuity of care. Women's
satisfaction has been linked to the quality of services given and the extent to
which specific needs are met. This study aims to expose satisfaction with
antenatal care services by pregnant women ,outline services often found to be
satisfy, outline services often found to be less satisfactory; and to outline the
reason for non-satisfaction as reported in other works. Data was collected
through journals articles and internet. This study will thus help unravel the
benefits of early ANC attendance in identifying and mitigating the potential
complications during pregnancy. The findings of this study will help reduce
maternal and child morbidity and mortality rate. This work will help reveal the
perceptions of pregnant women regarding the quality of ANC they receive at

v
health areas and hospitals. It will help reveal their level of satisfaction with the
care they receive during ANC visit.

vi
Introduction
Over the last two decades, increasing importance has been given to the
opinions, expectations and experiences of women using health services,
especially in the USA and Europe. Consumer satisfaction is playing an
important role in quality of care reforms and health-care delivery [24, 25].
Patient satisfaction is a reflection of the patient’s judgment of different domains
of health care, including technical, interpersonal, and organizational aspects
[26]. International literature suggests that satisfaction with different aspects of
received antenatal care improves health outcomes, continuity of care, and
adherence to treatment, and the relationship with the provider [26, 27]. The
World Health Organization (WHO) recommends monitoring and evaluation of
maternal satisfaction with public health care services, in order to improve the
quality and efficiency of health care during pregnancy [24]. In developing
countries where each pregnancy represents a journey into the unknown from
which all too many woman never return, due to lack of care provision.(2)
According to the World Health Organization (WHO), the worldwide estimated
maternal mortality ratio (MMR) in year 2010 was 210 deaths/100.000 live
births among women aged 15-49 years, showing a decline of 43% from the
level in 2015. In Egypt, maternal mortality ratio has declined dramatically from
174/100000 live births in 1992-1993 to 67.6 / 100000 live births in 2005 to
44.6 / 100000 live births in 2009 to 33/100.000 live births in 2015. (3) Such
decrease in MMR reflects the country's effort in achievement of the millennium
developmental goals. The target of those goals was to reduce MMR by three
quarters by 2030. One of the corner stones for achievement of these goals is the
provision of quality antenatal care (4).

Antenatal care has been designated as one of the four Pillars of Safe
Motherhood, along with clean and safe delivery, essential obstetric care and
family planning. These four pillars are thought to contribute to reduction of

1
maternal mortality. The quality of ANC is an effective route to emergency
obstetric care and skilled delivery. Consequently it is an important determinant
of pregnancy outcome. Moreover, the provision of high quality ANC is
congruent with client's satisfaction toward this care (5). Satisfaction with quality
of care is the degree to which the client's desired expectations, goals and or
preferences are met by the healthcare provider and / or service (6). Client's
satisfaction has traditionally been linked to the quality of services given and the
extent to which specific needs are met. Satisfied clients are likely to come back
for the services and recommended service to others. Various factors including
attitude of staff, cost of care, time spent at the hospital and doctor
communication have been found to influence client's satisfaction. In general
satisfaction and dissatisfaction indicate client's judgment about the strengths and
weaknesses, respectively, of the service (6).

In Cameroon, [16] find that the proportion of the pregnant women who
consult a doctor at least once increases with the level of education. Less
educated women less often demand treatment because they lack financial means
or are less familiarized with the health system. As the level of pregnant women
increases, the more they enter the medical coverage and the more their demand
for healthcare is directed towards the medical units. Beninguisse [10] shows that
the use of obstetric services by pregnant young women is considered as a
function of their perceptions, beliefs and knowledge in the field of obstetrics,
their financial resources and the accessibility of the medical units. Also, [11]
find that the use of health services depends on social institutions such as habits,
solidarity networks, perceptions or symbolic image of pregnancy and childbirth,
degree of openness to modernity, and the economic conditions in which the
women live. Existing studies on the determinants of the use of maternal health
services in Cameroon are limited by the fact that they consider all modern
health services as homogenous. However, the perception that a pregnant woman

2
has of a district public hospital is not necessarily the same as that she has of the
denominational or private district hospital while in both cases, the hospitals are
modern health services. For example, an anxious mother will be able to travel a
long distance to treat her child in a private health establishment or traditional
midwife in which she has confidence but will not go the few kilometres
separating her from the nearest public hospital because she believes that the
latter will not be able to serve her properly [12]. This study aims at investigating
the level at which pregnant women are satisfied with the care they receive
during ANC. This study will serve as a way forward for nurses to best
understand how pregnant women feel about what they do in the clinic and
equally explore the goals of anc which will help improve the knowledge of
women who take steps backward in regard of ANC attendace, as well as the role
of nurses during ANC. It will thus be the objectives of this seminar;

 To expose all ANC services

 To outline services often found to be satisfactory
 To outline services often found to be less satisfactory
 To outline reasons for non-satisfaction as reported in other works

3
 PART ONE

1.0. ANTENATAL CARE SERVICES

Antenatal care, the care that women receive during pregnancy, helps to
ensure healthy outcomes for women and newborns [13]

The Maternal and Neonatal Health (MNH) Program’s approach to focused

antenatal care promotes interventions that address the most prevalent health
issues that affect mothers and newborns. The major goal of focused antenatal
care is to help women maintain normal pregnancies through [14].

 Targeted assessment to ensure normal progress of the childbearing cycle and

newborn period, and to facilitate the early detection of complications,
chronic conditions, and other problems/potential problems that will affect the
pregnancy; and
 Individualized care to help maintain normal progress, including preventive
measures, supportive care, health messages and counseling (including
empowering women and families for effective self-care), and birth
preparedness and complication readiness planning.

Following the lead of the World Health Organization, the MNH Program
promotes a minimum of four antenatal care visits—ideally, at 16 weeks, 24–28
weeks, 32 weeks, and 36 weeks—for women whose pregnancies are
progressing normally (15). Each visit includes care that is appropriate to the
woman’s overall condition and stage of pregnancy, and facilitates preparation
for birth and care of the newborn. Focused antenatal care visits generally
include the goal-directed interventions described below:

4
1.1. Health Promotion and Disease Prevention
Individual interaction is an essential component of focused antenatal care
visits. This is a time for providers and women to talk about important issues
affecting the woman’s health, her pregnancy, and her plans for childbirth and
the newborn period. Discussions should include the following [15,14,16] „

 How to recognize danger signs, what to do, and where to get help „
 Good nutrition and its importance to the health of the mother and baby; how
to get enough calories and essential macronutrients and micronutrients „
 Good hygiene and infection prevention practices „
 Risks of using tobacco, alcohol, medications, local drugs, and traditional
remedies „
 Rest and avoidance of heavy physical work „
 Benefits of child spacing to mother and child; options for family planning
services following the baby’s birth „
 Benefits (to mother and baby) of breastfeeding; importance of early and
exclusive breastfeeding „
 Protection against HIV and other sexually transmitted diseases through
individualized
 risk reduction;
 availability and benefits of HIV testing;
 and specific issues related to mother-to-child transmission and living with
AIDS (after a positive test result)

In many parts of the world, the majority (about two-thirds) of pregnant

women attend an antenatal clinic at least once during pregnancy. The MNH
Program sees antenatal care as a key platform for promoting safer health
practices, preventing and treating malaria, preventing mother-to-child

5
transmission of HIV, and preventing and treating other diseases such as syphilis,
as well as building a trusting relationship with a skilled provider.

The MNH Program advocates the following preventive interventions for all
pregnant women:

Immunization against tetanus with tetanus toxoid, a stable,

inexpensive vaccine that helps to prevent neonatal and maternal tetanus.
Tetanus causes about 500,000 neonatal deaths and 30,000 maternal deaths each
year (17). „

Reduction of iron deficiency anemia— the single most prevalent

nutritional deficiency affecting pregnant women— through iron and folate
supplementation (18). The prevention and treatment of hookworm infection and
the prevention and treatment of malaria are also important interventions to
reduce anemia.

In areas of high prevalence of disease, the Program also promotes the following:
Presumptive treatment for hookworm infection. Hookworm is a major cause
of iron-deficiency anemia. „

 Prevention of mother-to-child transmission of HIV—through counseling,

voluntary testing, antiretroviral therapy, and infant feeding support. Mother-
to-child transmission is the most significant source of HIV in children
below the age of 15 years. „
 Protection against malaria—through the use of insecticide-treated
nets,intermittent preventive treatment and effective case management of
malaria illness (19)„
 Protection against vitamin A and/or iodine deficiency—through
supplementation in areas of significant deficiency (20).

6
1.2. Detection and Treatment of Existing Diseases and Conditions
As part of the targeted assessment, the skilled provider talks with the
woman and examines her for signs and symptoms of chronic or infectious
diseases and conditions that are endemic among the population being served,
congenital problems, and other problems that may harm the health of the
pregnant woman or the newborn. Conditions that can severely affect mothers
and babies if they are left untreated include HIV, malaria, syphilis and other
sexually transmitted infections, anemia, heart disease, diabetes, malnutrition,
and tuberculosis (especially in populations where HIV is common) (21).

1.3. Early Detection and Management of Complications

The skilled provider talks with and examines the woman to detect
problems that might need additional care. Conditions such as severe anemia,
infection, vaginal bleeding, pre- eclampsia/eclampsia, abnormal fetal growth,
and abnormal fetal position after 36 weeks may cause or be indicative of a life-
threatening complication. Early treatment of these conditions, using evidence-
based practices, can mean the difference between death and survival for the
woman and her newborn.

1.4. Birth Preparedness and Complication Readiness

Focused antenatal care includes attention to a woman’s preparations for
childbirth, such as getting the support she will need from her healthcare
provider, family, and community, and making arrangements for her newborn
(22). This is an important time to encourage women to select a skilled
providerfor birth and to establish an emergency plan (23). Because 15 percent of
all pregnant women develop a life-threatening complication and most of these
complications cannot be predicted, every woman and her family must be ready
to respond in case a problem occurs. Women and their families should plan for
the following: „

7
 A skilled provider to be at the birth „
 The place of birth and how to get there, as well as emergency transportation if
needed „ Items needed for the birth, whether it will be at home or in a
healthcare facility „
 Money to pay for the skilled provider and any needed medications, as well as
unexpected costs of an emergency „
 A person designated to make decisions on the woman’s behalf, in case she is
ill and unable to make decisions herself „
 A way to communicate with a source of help (skilled provider, facility,
transportation) „ Support during and after the birth, including someone to
accompany the woman and someone to take care of her family while she is
away „
 Blood donors in case of emergency

1.5. Focused Antenatal Care in the Maternal and Neonatal Health (MNH)
Program
The MNH Program emphasizes several general principles as integral to
the provision of quality focused antenatal care for pregnant women. The
Program promotes care that is „

Woman-friendly: The woman’s health and survival, basic human rights,

and comfort are given clear priority. The woman’s personal desires and
preferences are also respected. „

Inclusive of a woman’s partner:[13] Communication, participation, and

partnership in seeking and making decisions about care help to ensure a fuller
and safer reproductive health experience for the woman, her newborn, and her
family. „

8
 Culturally appropriate: Every culture has its own rituals, taboos, and
proscriptions surrounding pregnancy and childbirth. These beliefs and practices
are deeply heldand define what a culture regards as acceptable or unacceptable
conduct on the part of the pregnant woman, her partner and family, and others
who are caring for her. Cultural awareness, competency, and openness are
essential in a care relationship with a woman during this important time in her
life. „ Individualized: By taking into consideration all of the information
known about a woman

 Current health
 Medical history
 Daily habits and lifestyle
 Cultural beliefs and customs

And other unique circumstances the skilled provider can individualize

components of the care plan for each woman.

The MNH Program promotes focused antenatal care as one of several

essential maternal and neonatal care interventions that are evidence-based and
that build on global lessons learned about what works to save the lives of
mothers and newborns. While effective antenatal care alone will not prevent
global maternal and newborn mortality, the care a woman receives during
pregnancy plays a vital role in ensuring the healthiest possible outcome for
mother and baby.

9
 PART TWO

ANC SERVICES OFTEN FOUND TO BE SATISFACTORY

Antenatal care (ANC) is an important part of preventive medicine and
professionals providing this service can reduce the risk of complications
through education, counseling and various interventions. The proportion of
Nigerian women that receive antenatal care and those that are delivered by
skilled birth attendants has however remained far from acceptable1.

For many years, high standards of care were considered a luxury

particularly in developing countries where service coverage was largely
inadequate [28, 29]. Quality of health care is seen as a factor closely related to
effectiveness, compliance and continuity of care particularly for ethical reasons
[30]. Women’s perceptions

of antenatal visits significantly influence their assessment of quality of

services that are provided[31]. As a result of this new focus, measurement of
customer satisfaction has become equally important in assessing system
performance.

Patient satisfaction has traditionally been linked to the quality of services

given and the extent to which specific needs are met. Satisfied patients are
likely to come back for the services and recommend services to others [32].
Hospital and doctor communication have been found to influence patient
satisfaction in previous studies [33-35]. A cross sectional study carried out in
Nigeria noted that; the clinic usually commences with an interactive health talk
co-ordinated by a qualified community health nurse which usually lasts for at
least 45minutes.

10
 The health talk usually covers various topical issues including nutrition,
diet, personal hygiene, and danger signs in pregnancy, the labour experience,
care of the newborn, exclusive breast feeding and immunization.

Other health issues such as hypertension, diabetes mellitus, malaria,

anaemia, HIV/AIDS and family planning are also discussed. Routine services
following the health talk include weight and height measurement, blood
pressure estimation, urinalysis, haemoglobin estimation and multivitamin
supplementation. Thereafter, patients are called individually to see their doctors
for clinical examination and treatment. This study evaluated the perception of
patients and their level of satisfaction with antenatal care. Previous research has
revealed positive correlation between patients’ satisfaction and health care
utilization [36, 37]. Majority of the women were satisfied with the quality of
antenatal care they received and would recommend the facility to friends. The
participants were also willing to use the same facility in subsequent
pregnancies. It was however observed that the level of satisfaction was not
always in tandem with willingness to access the services. An earlier survey
suggested that women may generally express satisfaction with the quality of
antenatal services despite inconsistencies between received care and their
expectations of the facilities [36]. Other authors have stated that client
satisfaction may only indicate low expectations from health care services or a
desire to please the interviewer, avoid anxieties about provider bias or express
feelings driven by cultural perceptions [38, 39]. Oladapo and Osiberu found that
socio-demographic and obstetric characteristics were not associated with the
overall satisfaction with antenatal care quality [40]. There was a similar finding
in this study as they are seen to have limited impact on their perception of
antenatal care.

Specifically, a significant proportion of clients viewed waiting time as

long. This is similar to findings from Kano in Northern Nigeria [41]. Another

11
study demonstrated that customer satisfaction is affected not just by waiting
time but by customer expectations or attribution of causes for waiting [42].
Consequently, one

of the issues in queue management is not only the actual amount of time
the customer has to wait but also the customer’s perceptions of that wait [43].
The views of the clients’ about waiting time may be related to the hospital’s
location in the most populous part of the state with numerous referrals from
different levels of care.

The high level of satisfaction with the cost of antenatal care obtained in
this study may have resulted from the safety net provided to some respondents
by the National Health Insurance Scheme (NHIS), waivers for staff of the UCH
and for People Living with HIV/AIDS (PLWHA). In spite of this, a good
number of patients who paid for their antenatal care which they mostly
perceived as expensive still expressed satisfaction. Clients may be willing to
accept higher costs if they believe that services are of high quality. This has
been observed in Indonesia where clients were willing to pay reasonable fees
for quality antenatal and post-natal care; other research has found that ill and
poor people by passed free or subsidized services in facilities they perceived to
be offering low quality [44].

The attitude of health personnel was a significant determinant of patients’

perception and satisfaction with antenatal care in this study; this was a similar
pattern in some studies and a contrast with others [33, 45, 46]. Good provider-
patient relationships are therapeutic and have been described as the single most
important component of good medical practice, not only because it identifies
problems quickly and clearly, but it also defines expectation and helps establish
trust between the clinician and patient [47, 48].Supervision of antenatal care and
the contributions of ancillary bodies such as SERVICOM may have played a

12
role in the patient’s perception of the health personnel’s attitude. The
availability and level of utilization of such services was observed to be higher
than other similar studies in this environment [35, 49, 50]. This may be
attributable to a recent upgrade of facilities at the clinic by the hospital
management. The perception of patients to HIV screening might be associated
with understanding of the counseling process as HIV screening is established as
a mandatory test in the study centre. An unfortunate finding was the relatively
infrequent discussion of cervical cancer prevention during antenatal clinic
sessions; cervical cancer remains a significant cause of mortality among women
in developing countries and these needs to be urgently addressed by policy
makers. Our study included women irrespective of the number of antenatal
clinic visits; this may limit interpretation because some women may not have
had enough exposure to the clinic to enable them make concrete judgments on
perception and satisfaction. Other possible influences on our study outcomes
include selection of subjects without randomization and recall bias. Findings
from the logistic regression confirm that continued utilization of antenatal
services is directly linked to the satisfaction of the clients. This re- emphasizes
the need for continued audit and evaluation of services at the antenatal clinic by
health providers and policy makers.

13
 PART THREE

ANC SERVICES OFTEN FOUND TO BE LESS SATISFACTORY

Over the last two decades, increasing importance has been given to the
opinions, expectations and experiences of women using health services,
especially in the USA and Europe. Consumer satisfaction is playing an
important role in quality of care reforms and healthcare delivery [51, 52].
Patient satisfaction is a reflection of the patient’s judgment of different domains
of health care, including technical, interpersonal, and organizational aspects
[53]. International literature suggests that satisfaction with different aspects of
received antenatal care improves health outcomes, continuity of care, adherence
to treatment, and the relationship with the provider [53, 54]. The World Health
Organization (WHO) recommends monitoring and evaluation of maternal satis-
faction with public health care services, in order to improve the quality and
efficiency of health care during pregnancy [51].

Measurement of satisfaction Quality of care is considered a

multidimensional concept that has been given different meanings in the
literature. Quality of care can be understood in light of two as- pects: the
resource structure of the care organization and patients’ preferences. Patient
satisfaction has in- creasingly come to be used as an indicator of quality of care
[55]. Patient satisfaction is a subjective and dynamic perception of the extent to
which the patient’s expected health care needs are met [54]. The definition and
conceptualization of satisfaction with health care is com- plex and
multidimensional [52, 55]. To our knowledge there is no conceptual basis nor
do consistent measurement tool for satisfaction with antenatal care and a wide
array of determinants seem to play a role. The existing studies demonstrate that
factors such as waiting time before consultation, continuity in seeing the same
health care worker, communication with the health care worker, setting and

14
physical environment all impact on women’s satisfaction with antenatal care
[54, 56]. More recently there is agreement that women’s satisfaction with ante-
natal care is determined by the interaction between their expectations and the
characteristics of the healthcare they receive [53, 57]. In practice, expectations
can refer to ideal health care, anticipated health care, or desired health care, and
sometimes people do not have explicit expectations [58]. We use the second
approach and define expectations as the pregnant women’s beliefs about the
content, type and quality of care she will receive [57]. Christaens & Bracke [54]
demonstrated the positive co- relation of expectations and satisfaction, with
fulfillment of expectations being one of the most consistent predictors of
satisfaction.

Vulnerable groups & health care satisfaction several observational studies

demonstrate the association of late initiation of antenatal care and fewer
antenatal visits (defined as ‘inadequate antenatal care’) with a number of socio-
demographic factors in the USA and Europe [59–62]. These include young
maternal age, migration background, low income, high parity, low level of
education, low socio- economic status (SES), exposure to intimate partner
violence (IPV), and not being in a steady relationship [60, 63–65]. Poor
attendance at antenatal care is a well- known problem in vulnerable subgroups
[65, 66]. Vulnerable populations can be defined as groups that face
discrimination because of underlying differences in social status, which can lead
to potential gaps in health or health care, considering race/ethnicity as well as
other characteristics, such as disability and living conditions that pose special
challenges to health care delivery (e.g., homeless, institutionalized, uninsured or
homebound patients) [67, 68]. Increasing access to antenatal care for all women
has become established as the key population-based public

Health intervention to address racial-ethnic disparities in perinatal outcomes

[69, 70]. Adequate antenatal care by professional health care providers has been

15
proven not only to reduce maternal, foetal and infant morbidity and mortality
but also to result in improved maternal health status and parenting behaviour
after the child is born [63]. Considering that dissatisfaction can be a major de-
motivating factor in the use of antenatal care facilities, enhancing satisfaction
among vulnerable women can result in more regular consultations and a better
relationship with the provider, eventually improving the quality of antenatal
care [71]. At the same time we must recognize that many other factors such as
social insurance, family support and transport play a role in patient health care
use and outcomes in vulnerable groups, which will not be addressed by only
improving patient satisfaction [67]. Across the continuum of antenatal,
perinatal, and postnatal care, the assessment of maternal satisfaction with
antenatal care is not well documented in Belgium. Christiaens & Bracke
focused on the place of birth and maternal satisfaction, which gave valuable
insights in this area, but specific research related to the satisfaction with
antenatal care, is lacking [72]. Hence, the general objective of this study was to
assess expectations and satisfaction with antenatal care, with a focus on
vulnerable women. Specific aims were to identify risk factors for low
expectations and satisfaction and to explore which aspects of antenatal care
could be improved in a hospital setting.

16
 PART FOUR

REASONS FOR NON SATISFACTION AS REPORTED IN OTHER

WORKS
According to other works, adverse pregnancy outcomes are still a public
health challenge in African countries. The maternal and neonatal mortality
indicators have increased despite women’s motivation to attend prenatal care
[1]. Prenatal pregnancy monitoring does fit into the framework of a preventive
medicine intended to diagnose any inter-current pathology or pregnancy-caused
pathology. This prevention is based on a regular medical follow-up consisting
of clinical examination and additional, compulsory or directed tests [2]. To
ensure an efficient pregnancy follow-up, the WHO recommends four ANC
including one in the first quarter, one in the second quarter, two in the third
quarter, the last of which in the ninth month for a normal course of pregnancy.
Those prenatal care visits should start in the first quarter to confirm pregnancy,
specify its location, assess maternal status and draw up pregnancy prognosis [3].
The overall remark is that in our areas, pregnant women undertake just a little
first quarter care. For Bonono [4] in Cameroon, suboptimal use of ANC
strongly limits the impact of measures taken for the Campaign

For Accelerated Reduction of Maternal Mortality in Africa (CARMMA). In the

Tanguieta-Materi-Cobly Health Zone (North-Benin), in 2012 ANC coverage
rate was estimated at 93% but the coverage rate of first quarter antenatal care
(ANC1) which was 16% remained almost unchanged as regards 2011 (15.7%)
[5]. accordingly, this means a continuing ANC low coverage rate in the first
quarter.

A cross-sectional, descriptive and analytical study focused on pregnant

women who attended antenatal care in the maternities of the central borough of
Cobly (Atacora region) was conducted in the four (04) health centers. It was

17
carried out over a one-month period from August 5 to September 5, 2013. The
study population consisted of pregnant women living in the central borough of
Cobly for a minimum of six months before starting the survey. We carried out
an exhaustive census of pregnant women who attended antenatal care during the
study period. Based on the maternity’s monthly forecasts, 225 pregnant women
were expected for antenatal care during the survey period. Concealment of
pregnancy: 82 pregnant women out of the 215 respondents indicated that they
hid their pregnancy in the first quarter i.e. 38%, 48 (56%) of them because of
awaiting pregnancy announcement ceremonies, 62 (76%) for they felt ashamed
to carry a pregnancy and 54 (66%) were afraid of witch craft or evil spirits.
Women’s point of view about ANC: More than half of the respondents
(65.60%) indicated that ANC was compulsory, 31.60% argued that ANC was
optional and 2.80% considered that ANC was necessary only when the pregnant
woman got sick. Care for pregnant women during ANC sessions: Care in health
facilities during ANC sessions was perceived as very satisfactory, satisfactory
and not satisfactory respectively by 25%, 60% and 15% of the patients. Reasons
for delay in ANC1: Several reasons were suggested by the respondents to justify
delay in ANC1. At least, two reasons were mentioned for each respondent.
Table I presents the frequency distribution of the reasons forwarded by pregnant
women to justify delay in ANC1. Pregnant women’s knowledge of ANC:
Knowledge of the number of ANC sessions recommended during pregnancy.
According to respondents, that number varies from 2 to 9 and most pregnant
women (75%) knew that a minimum of 4 ANC is required during a pregnancy
monitoring. Knowledge about disease prevention during pregnancy: The
respondents considered that malaria (83.7%), anemia (41.9%) and neonatal
tetanus (28.8%) were the pathologies likely to be prevented through ANC
implementation. Knowledge of early ANC1 advantages: 60% of the respondents
indicated that early ANC1 helped prevent pathologies, 54.9% that it helped
facilitate delivery, 27% argued it allowed pregnancy develop normally, 25.1%

18
that it enabled detect high-risk pregnancies, 22.8% that it helped manage
pregnancy complications and 9.3% that it enabled to avoid maternal and
newborn deaths.

19
 FACTOR AFFECTING THE IMPLEMENTATION OF EARLY
ANTENATAL CARE (ANC1)
Husbands ‘educational attainment and ANC1: the study investigated
pregnant women according to husbands’ educational attainment. Distance
between woman’s home and health center and ANC1. ANC1 implementation by
the investigated pregnant women according to distance between their homes and
health center in some studies. According to other studies, the main factors
associated with delayed initial ANC in pregnant women in the central borough
of Cobly in 2013: Early ANC1 implementation had a statistically significant
relationship with husband’s educational attainment. These outcomes are similar
to the ones found at national level according to the Health Survey called EDS
IV [9] where antenatal care was strongly influenced by the educational
attainment of the pregnant woman or of her husbands. N’DIAYE [6] had found
a significant relationship between delayed ANC1 and illiterate social profile.
Most pregnant women claimed that they dedicated themselves to traditional
practices before ANC1. 54.4% particularly recognized that they informed the
woman of her pregnancy through her mother-in- law and of the announcement
ceremony through an aunt and religious leaders before anything else.
Respondents’ religion was statistically associated with ANC1 implementation.
The influence of (animistic) religion might be explained by the fact that
pregnant woman awaits the rites or the ceremony she must perform before
anything else. According to animists, «those ceremonies announce to the gods
that woman is pregnant to seek their protection against evil spirits». This case
study has suggested that the nature of pregnancy was statistically associated
with the implementation of initial prenatal care. Actually, unintended
pregnancies cause lack of motivation to start early ANC sessions. This result is
similar to the one of Ndiaye in Senegal 2005 [6] whose research work
demonstrated that the nature of pregnancy (intended or not) had a significant
relationship with ANC1 timely implementation.

20
 CONCLUSION
 Based on the findings of the seminar, it could be concluded that quality of
antenatal care provided at most hospitals in developing countries is poor, this
due to lack of proper infrastructure for providing antenatal care, shortage of
staff, lack of necessary medications , vaccination, equipment and supplies. The
pregnant women are equally unsatisfied with the antenatal care provided in
these centers. It indicates that a decrease in the quality of care level is
followed by a decrease in the clients' satisfaction level.
 From part two, it could be concluded that, among pregnant women receiving
prenatal care at the Antenatal Clinic, Ibadan, levels of satisfaction were high.
Most respondents were willing to recommend antenatal care at this facility to
relatives and friends.

Nurses have the biggest role to play in other to make ANC very
satisfactory and hence decrease maternal and child death in developing
countries. The goals of ANC are said to meet only if nurses and midwives who
take charge of maternity implement roles set by international bodies.

RECOMMENDATIONS
Based on the findings of the present seminar, the following recommendations
are suggested:

The Ministry of Health through the district health implementation plan

should consistently provide adequate number of staff, supplies, equipments and
drugs for providing antenatal care

Continuous training of the health care providers at maternal and child

health center is recommended as it may improve their performance and
consequently raise the quality level.

21
 Continuous monitoring of clients' satisfaction with all aspects of care
could aid in improvement of the quality of services.

Different health education methods should be available to increase

awareness of the pregnant women about the importance and components of
antenatal care.

Further researches:

Further studies to investigate the possible applicable strategies for

amelioration of antenatal quality of care.

Further study to identify the pregnant women expectations versus

received antenatal care.

22
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