The antenatal period offers many opportunities to provide targeted health services. Antenatal care became associated with general health evaluation

as a result of the increasing recognition of these factors as nutrition, social conditions and birth spacing influence pregnancy outcomes.(1) It is

now accepted that maternity services should be centered on the woman and her needs. Each

woman should be given sufficient help and information to enable her to make an informed decision about her care. In addition, the processes of empowerment and communication have become a key factor; not only between health professionals and women but also among the different health professionals providing the service. This is essential factor for effective team working to provide continuity of care.(2)

In recognition of the potential of care during the antenatal period to improve a range of health outcomes for women and children, the World Summit for Children in 1990 adopted antenatal care as a specific goal, namely “Access by all pregnant women to prenatal care, trained attendants during childbirth and referral facilities for high-risk pregnancies and obstetric emergencies”. Similar aims have been voiced in other major international conferences, including the International Conference on Population and Development in 1994, the Fourth World Conference on Women in 1995, their five-year follow-up evaluations of progress, and the United Nations General Assembly Special Session on Children in 2002.(3)

ISSN 1110-0834The antenatal period clearly presents opportunities for reaching pregnant women with a number of interventions that may be vital to their health and well-being and that of their infants. The aim of Antenatal Care (ANC) is to detect, prevent or manage abnormalities in early pregnancy and prepare mothers for safe deliveries.(4-6) ANC should also provide support and guidance to the woman and her partner or family, to help them in their transition to parenthood. This implies that both health care and health education are required from health services. This broad definition of ANC is endorsed by national labor laws(7) and by evidence-based clinical guideline.(8) Moreover, it introduces the needed holistic approach (biological care and concern with intellectual, emotional, social and cultural needs of women, babies and families) during pregnancy.(5) Care during pregnancy should enable a woman to make informed decisions, based on her needs, after discussing matters fully with the professionals involved. Any interventions offered in the antenatal period should be of proven effectiveness and be acceptable to the recipients. Both the individual components and the full package of ANC should conform to these criteria. Complex examinations

and a variety of combination of interventions

are part of modern ANC. Nevertheless, there is a huge variety of tests and medical procedures included in routine ANC worldwide.(9) Some of these interventions are based on evidence, but many of them are only based on long-held traditions. The state of the scientific evidence of risks and benefits of ANC interventions is a concern of health policy-makers. Another important concern is the level of care sufficient to delivering high-quality care for pregnant women.

Most antenatal care protocols in developing countries were established along the lines of

those used in developed countries, with little adjustment for local conditions.(10,11) The content of ANC for a normal pregnancy is described in three main categories: assessment (history, examination and laboratory tests), health promotion and

care provision. There is inevitably some degree of repetition but it has been retained for the sake of completeness and ease of reference. World Health Organization (WHO) recommends that antenatal care for the majority of normal pregnancies should consist of four visits during pregnancy, and has outlined the key elements of the visits and their timing.(12)

Use of antenatal care in developing countries rose steadily during the 1990s. Information on trends in antenatal care use over the past decade is limited to countries where more than one household survey has been carried out. At the end of 2001, a total of 49 countries had trend data.(12)

Most of the antenatal care models currently in

use around the world have not been subjected

to rigorous scientific evaluation to determine

their effectiveness. Despite a widespread desire to improve maternal care services, this lack of “hard” evidence has impeded the identification of effective interventions and thus the optimal allocation

of resources. In developing countries, routinely recommended antenatal care protocols are often poorly implemented, clinical visits are irregular, and waiting time is prolonged with poor maternal satisfaction.(13)

Due to global concern over safe motherhood, evaluation of ANC in PHCC in Medina; one of the holy cities in Saudi Arabia, this study was carried out.

Aim

The aim was to evaluate the antenatal care services given for pregnant women attending the Primary Health Care Centers, Medina city, Saudi Arabia 2009.

METHODS

The study was conducted during March through July 2009. The study population included pregnant women attending primary health care centers in Medina, Saudi Arabia for antenatal care.

Simple random selection of seven major primary health care centers in Medina was done. The total number of the pregnant women included in the study was calculated using the following equation: n= (Z2 X p X q) / D2. A total of 394 pregnant women were included and were proportionally allocated based on attendants of each health center.

A specially designed format was designed and filled by the researcher herself. Collection of data from the selected centers was done after official permission. Ethics Review Committee reviewed and approved the proposal. The survey tool was pre-tested on a random sample of 35 participants obtained from 2 centers to ensure practicability, validity and interpretation of responses. The reliability of the questionnaire was assessed using Cronbach’s alpha (0.812). The format including information on: assessment of the service (at the initial visit and return visit), health promotion and care provision. The time spent for each visit was included as well as education, work status of pregnant women, and some socio-demographic data of the physician were included (nationality, mother language , qualification and age).

The centers were ordered according to the order of their visit.

Each of the items of antenatal tasks was scored as following: (0) for non performed task and (1) for performed one; giving a performance score ranging as follow:

1- Assessment: a. Initial visit: i. history taking: 0-21, ii. examination: 0-12, iii. laboratory investigations: 0-11

b. Return visit: i. history taking: 0-3, ii. examination: 0-9

2- Health promotion: 0-10

3- Care provision: 0-6.

The total performance score was calculated for each task at each center. Then the mean percent score was calculated.

Statistical Analysis

Statistical Package for Social Sciences SPSS version 10 was used. Frequencies, percentages and arithmetic mean were calculated. Chi-square test, and F- test were used. P value <0.05 was considered significant.

RESULTS

Description of the studied centers

A total of seven centers were recruited, from them 394 pregnant women were included in the study. The most populous center was center number 4 where it was serving 35000 inhabitants (fig. 1) followed by centers 3 and 7 which were serving 28000, with significant difference between centers (p=0.000).

There was only one physician per center who was carrying out antenatal care (in some centers, this physician had another tasks as examination of children in well baby clinic, etc.). Non-Saudi formed the majority of physicians where more than half (57.1%) were Egyptian, 28.7% were Pakistani and 14.2% Bangladeshi, with a mean age of 45.7±4.7 years.

General characteristics of the included pregnant

The minority of the included pregnant women

was illiterate (0.8%) (Table I), while 41.4% got secondary education and 33.2% got university one. Only 14.0% were working.

Regarding duration of pregnancy, 34.4% were in the first trimester, 36.3% in second and 29.4% in

the third trimester, and 51.5% were visiting the center for the first time. The mean duration of the initial visit was 10.3±2.3 minutes (Fig. 2), while

that of return visit 9.1±1.1 minutes; and there was a significant statistical difference between centers (p=0.000).

Poorly covered antenatal tasks

Social history and support, history of FGM, examination of general appearance, breast examination, examination for signs of physical abuse, planning for delivery and development of individualized delivery plan, smoking history and psychosocial support had lowest coverage percent (Table II).

Performance scores

In initial visit, history taking and investigations (Table III) had higher mean percent score (93.4 ±1.5 and 95.0±1.4 respectively) than return visit’ history taking (83.0±5.4). Meanwhile clinical examination in return visit was better performed than that of initial visit (86.1±7.7 and 75.6±11.7 respectively). All the centers had the same score for care provision (83.0±3.6). Nevertheless, health promotion had the worst score (64.9±12.7). The overall total mean percent score for antenatal care services in general was 77.1±1.1, with statistical significant difference between the studied centers (p=0.000).

DISCUSSION

Screening and monitoring in pregnancy are strategies used by health care providers to identify high risk pregnancies so that they can provide more targeted and appropriate treatment and follow up care and to monitor fetal well-being in both low and high risk pregnancies.(2,3)

This study aimed at evaluation of the antenatal care services given to pregnant women attending PHCC in Medina City, Saudi Arabia. The study

was conducted using specially designed format including 394 pregnant women attended seven PHCC in Medina City for antenatal care. Effective and appropriate ANC should be offered to all pregnant women. However, different countries offer different sets of routine ANC, which are hardly based on explicit effectiveness criteria, being mainly linked with long term tradition or other inexplicit criteria.(14)

Epidemiological studies have demonstrated the benefits of ANC in reducing maternal and perinatal complications, although the exact components

and timing of such ANC has been difficult to demonstrate. This uncertainty leads to the adoption of antenatal practices that are not comparable and are largely inconsistent between and within countries.(14-17)

Among safe motherhood advocates, antenatal care has been down played in recent years as an intervention for reducing maternal mortality. It is not surprising that little attention has been paid to patterns and trends in antenatal care use.(17)

Major barriers prevent the effectiveness of

ANC in low resource settings in Medina, Saudi Arabia. Poor knowledge of the general practioners about maternal and fetal risk factors and complications that are detected in pregnancy

which could prevent a large proportion of

maternal and fetal morbidity and mortality, together with the language barrier between pregnant

mother and health care provider, poor maternal education and nutrition and lack of strategies that improve the quality of care, all are factors behind poor performance of ANC.

Physician is the crucial person in the process of ANC. Availability of one physician only who

was carrying out ANC during the period of the study in the PHCC would never met the recommended time for ANC which supposed to be given for each woman to discuss her personal needs and for physician to respond appropriately especially for

the first visit, when full history has to be taken and an individualized birth plan should be started. It

was found that the mean duration of the initial

visit 10.3 ± 2.3 minutes compared to the desired

20 minutes. Furthermore, when the appropriate

number of physicians will be available, this duration will be feasible even in areas with high birth rate.(18,19) ANC performance of the studied centers correlated with age, language and qualification of the working physician. There was greater ability of younger, Arabic, qualified physicians to attain better performance scores especially for health care promotion.

More than three fourths of the included pregnant women had secondary (41.4%) or university (33.2%) education. It was noticed that in developing countries as a whole, women with secondary or higher education are more likely to have ANC than women with no education.(17) Not only that, but it was also found that the educational level and work status of the attending pregnant women have been positively correlated with the ANC performance of the studied center.

Nearly half (51.5%) of the studied pregnant women attended the PHCC for the first time during the first trimester. The early initiation of ANC is important to prevent and treat anemia and to identify and manage women with medical complications. Early care also allows for the development of interpersonal relationship between health care providers and pregnant women.(20,21)

Health promotion of pregnant women can improve their own health and that of her child and the

risks of maternal and perinatal complications can

be reduced; yet, in developing countries, ANC protocols are often poorly implemented.(22-29)

Although care provision should address psychosocial need of women and development of individualized delivery plan as well as their medical needs, (30-35) this study shows that aspects that were poorly implemented were psychosocial support (not done for 98.0%), planning for delivery (not done

for 94.2%) and development of individualized delivery plan (not done for 99.5%). This poor implementation could be attributed to the fact

that these items are not included in the maternal

card that is in use in the PHCC. Also the fact

that all pregnant women will be referred to

maternity hospital for delivery as no delivery is allowed outside hospitals cause reluctant and

neglect attitude in discussing the delivery plan. However, some items which are crucial and already present in the maternal card as general appearance (not done for 96.1%) and breast examination (not done for 91.1%) are just filled with symbols NAS which denoting no abnormal signs; even without examination.

Study limitation

This study carried out only for seven PHCC, and inclusion of all centers was needed which was not feasible to be performed by the researcher together with comparison of the urban and rural one. No detailed obestritic history was included. Also job satisfaction of health care providers was not fulfilled.

Conclusion and Recommendations

-This is the first study aimed at assessing the performance of the PHCC. We found variation between centers in their performance scores. Variation in performance scores of the studied PHCC denoting that improvement will be mandatory.

-A further study using specially designed interviewing format is needed to study in depth health care providers’ characteristics, and the obstacles they face in the work place to find out suggested solutions for improvement.

-Continuous medical education and training of all health care providers for ANC implemented protocol.

-Ensuring satisfaction of both health care providers and receivers of ANC.

-Clarifying the appropriate policy, decision-making and programmatic implications of adopting and implementing the new ANC protocols.

-Perinatal audit system which aims to improve quality of care by identifying deficiencies in care.

-Health promotion needs to be stressed upon especially nutritional care, rest and hygiene, and educational resources.