Reasons behind not Attending Antenatal Care among Unbooked Patients Presenting at Abbasi Shaheed Hospital, Karachi
Rahila Imtiaz, , Zubaida Masood,Shabnam Nadeem,Ome Kulsoom, Rubina Izhar, Syed Hassan Ahmed Rizvi and Syed Hussain Ahmed Rizvi
Dr Rahila Imtiaz Assistant professor Gynae and Obstetrics Karachi Medical and dental College [email protected]
Dr Zubaida Masood Professor and incharge Gynaecology and obstetrics unit4 sobhraj hospital Karachi Medical and Dental College [email protected] Dr Shabnam Nadeem Associate Professor Gynaecology and Obstetrics Karachi Medical
and Dental College [email protected]
Dr Ome Kulsoom Senior Registrar Ziauddin Hospital [email protected] Dr Rubina Izhar Professor and Head of the department Gynaecology and Obstetrics Karachi
Medical and Dental College [email protected]
Syed Hassan Ahmed Rizvi 3rd year MBBS student DUHS [email protected] Syed Hussain Ahmed Rizvi 2ndyear MBBS student Shaheed Mohtarma Benazir Bhutto
Medical College Lyari [email protected]
Abstract
In our hospital we noted that a large number of unbooked patients came for antenatal ckeckup for first time in later gestations and majority of them came in an emergency with life threating and preventable complications. This made us to look into this matter and find out the reasons. For this purpose we developed a proforma and interviewed all those unbooked patients coming in OPD and emergency in out patient to find out the cause of no utilization of antenatal care. A total of 415 patients were interviewed. We found that lack of literacy, lack of formal education and a lack of awareness about the importance of antenatal care prevailed among all such patients. Fear of high cost of treatment, lack of transport facility to and from the antenatal clinics or hospitals, pressure from the in laws were the main reasons for not getting antenatal care. We concluded that the improvement of infrastructure is needed to take care of the pregnant patients in these underprivileged areas. More antenatal clinics should be set up, lady health visitors should be increased in numbers and should also be trained to provide proper antenatal care, identify the risk factors and refer them early to tertiary care hospital. The transport facilities should be provided to all pregnant ladies for antenatal care and in emergency situations.
Introduction
Poor antenatal Care is an important determinant of high maternal mortality rate and one of the basic components of maternal care on which life of mothers and babies depends.1 The WHO (World Health Organization)2 defines antenatal care as a dichotomous variable, having had one or more visits to a trained medical person during pregnancy. It includes routine follow up provided to all pregnant women at primary care level from screening to intensive life support during pregnancy and up to delivery1. Several studies conducted in developing countries on demographic and socio-cultural factors influencing the use of maternal health care services, have shown that factors like maternal age, number of living children, education, place of residence, occupation, religion and ethnicity are significantly associated with the utilization of antenatal care3,4. The other factors like poor state of health services, widespread ignorance, pervading superstition, traditional beliefs and customs and high cost of delivery and treatment tend to make traditional medicines and faith based practices more preferable than obstetric care in our communities. Evidence based treatment indicates that most pregnancy related maternal deaths could be averted with access to professional care during pregnancy, delivery and puerperium, as well as access to emergency obstetric care in the event of complications5. Conversely, a study done in Nigeria8 has concluded that no antenatal care, parity, level of education, and mode of delivery were significantly associated with maternal mortality. However, early antenatal care has many benefits, and accurate dating, early detection of medical disorders that could threaten pregnancy and its outcome, objective assessment of maternal baselines weight, blood pressure and urinalysis may provide a picture of pre pregnancy condition of women9. Other services include provision of tetanus toxoid vaccine, iron, folic acid supplementation and control of nutritional deficiencies10. Studies from developing countries11 have reported the influence of demographic and socio- economic factors on the utilization of maternal and child health care services. Women with higher economic strata12, higher educational levels11,12, and those living in urban areas12 with adequate health care services12,13 are more likely to utilize health care services.
Rationale:
This study was planned to identify the causes of non-utilization of antenatal care in urban population attending Abbasi Shaheed Hospital, Karachi. Factors have been identified and proposition made to design intervention to improve utilization of antenatal care.
Objective:
To determine the reasons behind not attending antenatal care among un-booked patients presenting at Abbasi Shaheed Hospital, a public sector hospital, Karachi.
Operational definition:
1. Antenatal care: WHO defines antenatal care as the care provided by skilled health- care professionals to pregnant women and adolescent girls in order to ensure the best
health conditions for both mother and baby during pregnancy. The components of antenatal care include: risk identification; prevention and management of pregnancy- related or concurrent diseases; and health education and health promotion.
2. Unbooked patients: An “unbooked patient” refers to a woman who did not have any antenatal visit till 36 weeks of gestation.
Materials and methods
Study design: Cross sectional study
Study setting: Department of Obstetrics and Gynecology Unit 2, Abbasi Shaheed Hospital, Karachi
Duration of study: Six months Research Instrument: Proforma
Sampling Technique: Non-Probability Consecutive Sampling
Sample size:
Sample size: Sample size calculated by using RaoSoff calculator (online) by fixing Confidence level=95%
Margin of error= 5%
Population: 6,000 (pregnant women attending OPD during 6 months on average) Sample size (n) = 415 un-registered patients
Formula n= z2p (1-P) /d2 Sample selection:
All un-booked patients attending gynae OPD (for first time at or after 36 weeks of gestation) and emergency labor ward (at or after 25 weeks of gestation) in Abbasi Shaheed hospital, Karachi during the study period.
Inclusion Criteria
All pregnant women who have never visited any doctor before visiting Abbasi Shaheed Hospital either in emergency or outpatient department with any complaint at or after 36 weeks of pregnancy and all those un-booked patients who came in emergency labor wards with any obstetric complications after 25 weeks of gestation.
Exclusion criteria
▪ Not given informed consent.
▪ First visit at antenatal clinic before 36 weeks of pregnancy for antenatal care.
▪ Patient who came first time at Abbasi Shaheed Hospital, but they were in follow up with any other doctor or general physician.
▪ Teenage or illegal pregnancy which revealed late on caretaker.
Data collection procedure:
Women attending Abbasi Shaheed Hospital, Karachi who have never attended any doctor before or till 36 weeks of gestation and visited for the first time either in the OPD or emergency with any complain have been included in this study after informed consent. A predesigned proforma was filled out at the time of arrival by attending doctor (post graduates, resident doctor, house officer and consultants). Questionnaire consists of demographic variables, obstetric history, maternal outcome and neonatal outcome. All demographic, clinical history were recorded by the principal investigator. Exclusion criteria have been followed strictly to avoid confounding variables.
Data analysis procedure
GRAPH 1
Graphical representation of gestational age of patients.
GRAPH 2
Graphical representation of the parity of the patient.
TABLE 1: PAST OBSTETRIC HISTORY OF COMPLICATIONS Frequency Percent Valid Percent
Cumulative Percent Valid INTRAUTERINE
DEATH
10 2.4 2.4 2.4
GDM 12 2.9 2.9 5.3
HEP E IN PREVIOUS PREGNACY
13 3.1 3.1 8.4
ANTEPARTUM
HAEMORRHAGE IN PREVIOUS
PREGNANCY
18 4.3 4.3 12.8
PPH IN LAST PREGNANCY
32 7.7 7.7 20.5
PERINIAL TEAR 11 2.7 2.7 23.1
PRETERM LABOR 6 1.4 1.4 24.6
NO COMPLICATIONS 313 75.4 75.4 100.0
Total 415 100.0 100.0
TABLE 2: RISK FACTORS IN CURRENT PREGNANCY
Frequen cy
Percen t
Valid Percent
Cumulati ve Percent Valid ANOMALOUS BABY 14 3.4 3.4 3.4
ANEMIA IN PREGNANCY 79 19.0 19.0 22.4 ANTIPARTUM HEMORHAGE 18 4.3 4.3 26.7
PRE TERM LABOR 6 1.4 1.4 28.2
INTRAUTERINE DEATH 11 2.7 2.7 30.8 BREECH PRESENTATION 6 1.4 1.4 32.3 PRE-TERM PRE-LABOR RUPTURE
OF MEMBRANE
12 2.9 2.9 35.2
INTRAUTERINE GROWTH RETARDATION
8 1.9 1.9 37.1
PERENEAL REPAIR IN PREVIOUS DELIVERY
9 2.2 2.2 39.3
HYPERTENSIVE / CARDIAC DISEASE OF PREGNANCY
23 5.5 5.5 44.8
PREV CESEAREAN SECTION 12 2.9 2.9 47.7 POST DATE PREGNANCY 12 2.9 2.9 50.6
SEVERE JAUNDICE 15 3.6 3.6 54.2
PREGNANCY WITH DIABETES 7 1.7 1.7 55.9
CHORIOAMNIONITIS 11 2.7 2.7 58.6
MULTIPLE PREGNENCIES 3 .7 .7 59.3 NO RISK FACTORS 169 40.7 40.7 100.0
Total 415 100.0 100.0
TABLE 3: REASONS FOR NOT GETTING REGISTERED IN AN ANTENATAL CLINIC
Frequenc y
Percen t
Valid Percent
Cumulati ve Percent Valid CARELESSNESS OF HUSBAND 13 3.1 3.1 3.1
FAMILY COMMITMENT 30 7.2 7.2 10.4 TRADITIONAL BIRTH
ATTENDANT
83 20.0 20.0 30.4
LACK OF AWARENESS OF THE PATIENT AND HUSBAND
33 8.0 8.0 38.3
FEAR OF HIGH COST OF TREATMENT
79 19.0 19.0 57.3
IN LAWS PRESSURE 43 10.4 10.4 67.7 FEAR OF CESEAREAN SECTION 4 1.0 1.0 68.7 LOGISTIC/TRANSPORTATION
ISSUES
71 17.1 17.1 85.8
MORNING OPD TIMINGS 59 14.2 14.2 100.0
Total 415 100.0 100.0
▪ While considering the attendance or reporting of the patients in terms of age 22 years and 30 years were high 14% and 20% respectively. This gives an impression that during the first pregnancy and having several ones the patients are more likely to escape the hospital booking. This also gives an impression that during the first pregnancy and after having several ones without complications patients become more careless to consult a qualified medical care personnel. Maximum patient age was 35- 36 years having 8% frequency.
▪ In terms of parity (Graph 2), 54% were multigravida followed by primigravida 31%
and grand multigravida 25%. This once again indicates that women having a number of deliveries are more negligent to consult a medical personnel. In terms of gravidity we see that the first pregnancy and the fourth pregnancy had the maximum frequencies (31% and 25% respectively). In our cultural and socioeconomic strata primigravidas especially at younger age are not independent in dicission making regarding availing basic health care facilities and others are unaware about the possible complications during and after pregnancy and assuming it is a normal physiology need no medical screening for possible complications. In multigravidas after having a number of uneventful successful deliveries by traditional birth
attendants ’s (dais) they don’t realises the importance of professional medical care and then they reported with complications and life threating condition to hospital.
▪ In terms of estimated gestational age (Graph1), 25% of the patients reported at 33-34 weeks, 22% at 37-38 weeks, 20% at 35-36 weeks and 10% at 31-32 weeks. Rest of the reported frequencies were around 5% or less. This indicates that the patients didn’t realises to have antenatal care during their initial days of pregnancy and report to the hospital or caring obstetrician only when any complication noticed or when the time of delivery is close.
▪ Past obstetric history of complications indicate that as high as 75% cases there were no past history of complications (Table1). This indicates that the previous uncomplicated and uneventful pregnancies further reassures the the patients and their confidence and determination to deliver the child is a normal physiological process need no medical assistance and help. Only 8% patients reported post partum hemorrhage during third pregnancy.
▪ In 41% patients there were no risk factors (Table 4), 19% patients were anemic.
Frequency of other risk factors were less than 5%.
▪ While mentioning their reasons for non-registration with a qualified obstetrician or hospital (Table 4) 20% mentioned familial traditional birth attendant, 19% mentioned perceived high cost of treatment, 17% mentioned logistic/transportation issues, 14%
mentioned unsuitable hospital timings (morning hour OPD), 10% mentioned pressure from their in laws and 8% said their lack of awareness and 7% mentioned family commitment. All other reasons were having less than 5% citation.
Discussion
According to WHO16 810 women died daily in 2017 due to preventable causes of pregnancy and childbirth. For the year this figure becomes 295,000 worldwide. As high as 94% of these deaths occur in low and lower middle class population. South Asia accounts for almost one third of the above figure (almost 100,000). Young mothers (14 years or below) have a higher risk in maternal death. All these deaths are preventable if care can be provided before, during and after childbirth. The reason of death are complications during pregnancy and delivery17: infection and severe bleeding (mostly after childbirth), preeclampsia and eclampsia, abortion without the care of qualified obstetricians. There are indirect maternal death also which occur due to other associated diseases like cardiac diseases, diabetes etc18,19. These findings correlates with our findings. We have seen that a good number of poor young women do not get the consultation of qualified obstetricians. Most of the women were of multigravida and primigravida. Our findings include post partum hemorrhage (8%) as the most occurred complication which relates to the above referred finding as well. The women who do not get the professional care are mostly poor as per findings reported by WHO16. Our findings confirm the WHO findings. Our findings also include anemia, mainly due to poor family background of the patients which need to be considered as well.
Maternal health is also responsible for infant mortality. In 2018, infant mortality rate for Pakistan was 69 deaths per 1,000 live births20 as against 29 globally21. Child mortality rate of Pakistan fell gradually from 194.4 deaths per 1,000 live births in 1969 to 69 deaths per 1,000 live births in 2018. According to WHO16 poverty and late care seeking are two major reasons for infant mortality. Pakistan has a weak and fragile healthcare system and there is no organized system or infrastructure to take obstetrical care.
A lot of improvement in infrastructure is needed. There should be evening satellite clinics in all underprivileged areas. If this is not possible mobile clinics is another option.
Antenatal clinics should also be available in these areas. Local LHVs should be trained to take care of antenatal patients in the locality and identify the risk factors. Once these risk factors re identified such patients can be referred to nearby hospitals. High risk patients should be referred to even earlier. Conveyance to and from hospital or antenatal clinics for such patients should be provided. Free of cost antenatal care and delivery services should also be aimed for.
We have noted that majority of these patients and their husbands were illiterate and uneducated. While literacy and education are not the domain of healthcare, education about the risks of home delivery and benefits of antenatal care should developed. In this connection we propose that fourth year and final year students should be utilized to visit door to door in under privileged locality to create awareness and educate the couple.
Conclusions
Almost all of our patients belonged to the underprivileged areas of the city. We have found that in general there is a lack of awareness of the importance of antenatal care and delivery by a qualified obstetrician. It is also important to mention there is a shortage of qualified health care personnel in these areas mainly due to insufficient income against time and expertise. As a result most of these patients go to unqualified quacks and LHVs having inadequate training and exposure to handle the cases professionally.
Pakistan is one of those countries having high maternal mortality. The leading causes are post partum hemorrhage, eclampsia, infection and other complications. Most of these complications are preventable if appropriate and timely measures are taken.
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PROFORMA
Reasons behind not attending antenatal care among unbooked patients presenting at Abbasi Shaheed Hospital.
BIODATA:
▪ Date:
▪ Name: _________________wife of
▪ Age: _________years
▪ Parity: ______
▪ Gravida: ______
▪ LMP: ________
▪ Estimated EDD: __________
▪ Estimated gestational age: _______
▪ Weight: _________
Residence: Rural Urban
Occupation of patient: ___________
Occupation of husband: _______
Education level of patient:______
Education level of husband:________
Past obstetrics history/complications: _________
Risk factor in current pregnancy: _____________
Socioeconomic status: <10000 >10000 Reasons:
▪ In laws pressure: Poor state of health services:
▪ Morning hours OPD: transportation): Logistical issues (like
▪ Familial traditional birth attendant: Lack of awareness of patient:
▪ Fear of caesarian section: Lack of awareness of husband:
▪ Fear of high hospital bills: Carelessness of husband:
▪ Other reasons:
