Pregnancy Outcome of Mothers with Effective Antenatal Care Versus Mothers of No Antenatal care in Wadmadani Hospital

Background: Antenatal care (ANC) is a preventive public health intervention to ensure healthy pregnancy outcomes and improve the survival and health of new-borns.

Purpose: To compare the pregnancy outcomes (maternal and fetal) of mothers with effective ANC and mothers with no effective ANC.

Method: It was a cross-sectional, comparative, and hospital-based study carried out at Wad Madani Teaching Hospital from January 2021 to January 2022 223 mothers with effective ANC and 223 mothers without effective ANC were enrolled in the study.

Results: The mean age was 26.21±1.16 among the study group (≤ 3 ANC visits women) and it was 27.03±3.83 among the comparative group > 3 ANC visits with significant differences. The majority of them had primary education, about 93.7% of them were housewives, 63.6% of them were multipara and 90.3% were healthy. The most common complications were APH, PPH, and eclampsia among the study group. The results reported that maternal complications occurred more commonly in women without effective ANC. Maternal death is more in non-effective ANC 21(9.6%) compared with 4(1.8%) maternal death in women with effective.

Conclusions: Pregnancy outcomes of women who had ≤ 3 ANC visits were associated with adverse maternal morbidity, perinatal morbidity, and mortality (ie, stillbirths plus early neonatal deaths).  Strategies to encourage to raise awareness about the importance of ANC services are essential.

Introduction Antenatal care (ANC) is the care given during pregnancy to promote the health of both the mother and the baby. Its interventions, including diagnostic tests, advice and counseling, iron folic acid (IFA) supplementation, and tetanus toxoid (TT) injections have been recommended for a long time and have been accepted worldwide [1-2]. Poor quality of care is a major impediment to efforts aimed at improving the health of populations in developing countries, particularly concerning Maternal, Neonatal, and Child Health (MNCH) [3-5]. The Sustainable Development Goal (SDG) has set ambitious health-related targets for mothers, newborns, and children under the umbrella of Universal Health Coverage (UHC) by 2030. Addressing quality of care will be fundamental in reducing maternal and newborn mortality and achieving the health-related SDG targets [6-8]. The three main strategies to reduce maternal and early neonatal deaths include reproductive health care. However, these conditions have been rarely studied together in the context of low- and middle-income countries [9-11]. Quality ANC connects women and their families with the healthcare system, increasing the likelihood of using skilled birth attendants and receiving postpartum family planning and essential newborn care. Inadequate care during this time breaks a critical link in the continuum of care and affects both women and babies [12-13]. In developing countries like Sudan, there is an observable number of un-booked patients, as a result of this unbooking this group of patients is more likely to be anemic, and they are at increased risk of having growth-restricted infants, preterm labor, and higher infant mortality, toxemia of pregnancy, eclampsia, Abnormal presentations, fetal anemia, IUFD. and high Rate of cesarean sections. In our country, especially in rural areas, there is low attendance to antenatal care due to a lack of access to care centers. Therefore, this study aims to increase knowledge and improve pregnancy outcomes. This study attempts to compare between pregnancy outcomes (maternal and fetal) of mothers with effective ANC and mothers with no ANC.

It was cross cross-sectional, comparative, and hospital-based study carried out at Wad Madani Obstetrics and Gynecology Teaching Hospital Sudan from January 2021 to January 2022. The inclusion criteria of this study were all women who attended and delivered at the labor room of Wad Madani Teaching Hospital either had effective ANC or no ANC and who agreed to participate in the study. Mother considered as having no ANC if she had not seen any medical personnel throughout her pregnancy, or had 3 or fewer visits to the antenatal clinic. A woman is considered to have effective ANC if she attends antenatal clinics at least 4 times also the patient is defined as a primigravida if she is pregnant for the first time, and multipara is a woman who has had two, three, or four births (live or stillborn) at 24 weeks or more of gestation, and if she had five or more births (life or stillborn) at 24 weeks gestation or more she is known as grand multipara. The study excluded patients who refused to participate in the study and health/mental conditions rendering it impossible. Data was collected by the researcher, registrars, and well-trained house officers through interviewing consented ladies who were included in the study in a comfortable closed office provided by the hospital by use of a questionnaire that fulfilled the objective of the study.

Independent variables were booking status (ANC attendance and non-attendance), dependent variables, and maternal and fetal complications (perinatal mortality, toxemia of pregnancy, eclampsia, APH, PPH. Abnormal fetal presentations, birth asphyxia, increased rate of CS mode of delivery (NVD, instrumental, (CS). Sample technique by simple random sampling methods, collecting the number of women who attended and delivered at the labor room of the hospital. A total of 223 mothers with non-effective ANC were enrolled in the study, representing the main study group, while 223 mothers with effective ANC were selected as the comparative group. Participants completed a questionnaire on personal data and clinical history. Questions regarding socio-demographics data include age, education, occupation, parity, residence, medical disorders, obstetric history, maternal complications (APH, PPH, eclampsia, others), and outcomes, neonatal complications, and outcomes (abnormal presentation, asphyxia, others), mothers with effective ANC and mothers with no ANC, mode of delivery (SVD, C/S), neonatal outcome (live Birth, fresh stillbirth, macerated stillbirth), and neonatal death. Statistical analysis was performed via SPSS 23 software (SPSS, Chicago, IL, USA).

I compared continuous variables using the student’s t-test (for paired data) or the Mann–Whitney U test for non-parametric data. For categorical data, we did a comparison using the Chi-square test (X2) or Fisher’s Exact test when appropriate. A P value of less than 0.05 was considered statistically significant. Ethical clearance and approval for conducting this research were obtained from the Sudan Medical Specialization Board and Education and Developmental Center, the general manager of Wad Madni Hospital, and informed written consent was obtained from every respondent who agreed to participate in the study. The respondents informed that the study is not associated with experimental or therapeutic intervention while information was collected from them.

The mean age was 26.21 ±1.16 among the study group (≤ 3 ANC visits women), and it was 27.03 ±3.83 among the comparative group > 3 ANC visits with significant differences. The majority of them had primary education, about 415 (93%) of them were housewives, 282(63.2%) of them were multipara, and 407(90.3%) were healthy. We found that women living in rural areas were less likely to use ANC services 181(81.2%), compared to their counterparts in urban areas 42 (18.8%) Table 1.

Table 1: Demographic and clinical characteristics of study participants (n=446).

Statistically significant at P-value .05 level

In regards to maternal outcome, about 346(76.9%) of participants were without any maternal complication. The complication was APH 17 (7.6%), PPH 22 (9.9%), and eclampsia 21(9.4%) in women without effective ANC compared with women with effective Antenatal care visit APH 4 (1.8%), PPH 9 (4%) and eclampsia 3 (1.4%). The study reported higher cesarean section (C/S) 97 (4.53%) in women who had non-effective ANC. Maternal death more in non-effective ANC 21 (9.6%) compared with maternal death in women with effective ANC 4 (1.8%). Concerning the fetal outcome, the study reported that fetal complications among mothers with effective ANC, Abnormal presentation 1(0, 44%), Asphyxia19(8.5%), Other17(7.7%) less than fetal complications among women with no effective ANC, Abnormal presentation 5 (2.3%), Asphyxia 34 (15.5%), Other 22 (10%). Neonatal deaths were higher in women with non-effective ANC 22 (9.9%) than in mothers with effective ANC 10 (4.7%) Table 2.

Table 2: Maternal and fetal outcome study participants (n=446).

Statistically significant at P-value .05 level.

The current study revealed that there was a highly significant association between ineffective ANC in developing countries like Sudan, there is an observable number of un-booked patients as a result of this unbooking this group of patients is more likely to be anemic, and they are at increased risk of having growth-restricted infants, preterm labor, and higher infant mortality, toxemia of pregnancy, eclampsia, Abnormal presentations, fetal anemia, IUFD. and high rate of cesarean sections. Our country especially the outskirts of the city they have poor attendance to antenatal care may be due to unavailability or inaccessibility to care centers, so the need for a current study emerged, to increase the knowledge, and improve pregnancy outcomes, Antenatal care visits and medical disorders complicated pregnancy, maternal complication (P. value =0.02), maternal death (P. value =0.002), neonate outcomes (P. value =0.04), and fetal complication. (P. value =0.00) Table 2.

Antenatal care is an important part of maternal and child health services. It offers various services to pregnant mothers. This was a comparison study conducted among two groups of women as effective antenatal care visits (more than 3 times) and non-effective antenatal care visits (3 ANC visits or less) at Wad Madani Teaching Hospital. The mean age was 26.21 ±1.16 among the study group (≤ 3 ANC visits women), and it was 27.03 ±3.83 among the comparative group > 3 ANC visits.  The association between age and non-effective antenatal care was statistically significant. Similarly, studies by Yanagisawa S OS et al. and Ram F SA et al. showed a significant association between age and ineffective antenatal [14-15].

The current study revealed that there was a highly significant association between non-effective antenatal care visits and maternal complications (P. value=0.000), maternal death (P. value=0.002), neonate death (P. value=0.000), and fetal complication. (P. value =0.001)., which was comparable to different studies [16-17]. In our study, women living in rural areas were less likely to use effective antenatal care services, compared to their counterparts in urban areas. Similar observations were shown in previous studies which have reported that non-use of antenatal services was significantly higher among rural women compared to their urban counterparts [18-19]. Our finding was supported by other studies, which reported that women living in rural areas were less likely to use ANC services, compared to their counterparts in urban areas [22-26]. Higher quality of care, shorter distances to health facilities, and women's education were also important factors in the routine use of ANC [18]. 

A study from Ghana found that about a third of the rural population travel long distances (more than 5 km) to reach ANC services [20]. Thus, distance to maternal health services and transportation problems may greatly reduce access to ANC services in rural areas around Wad Madani capital town of Al Gazira state. The current study revealed that more than three-quarters of participants using effective antenatal care were without any maternal complication except 5.4% of them had eclampsia; this was similar to the study which shows that women with eclampsia have unfavourable risk profiles in pregnancy [21-26].  Maternal complications such as APH, eclampsia, caesarean section, and PPH were significantly higher in women with non-effective antenatal care as compared to women with effective antenatal care. Various studies reported that maternal complications like pregnancy-induced hypertension occurred more commonly in women without ANC [27-32].

The rate of CS is high among women who non-effectively use antenatal care (43.5%) compared with women who effectively use antenatal (23.5%) which is comparable to Raatikainen K, who revealed that the rate of CS is probably two to three times higher among women without antenatal care when compared to women who effectively use antenatal [33]and [34-36]. On the same point of view, our finding was supported by a study that reported that cesarean delivery was high among women who non-effectively use antenatal care [29-32]. Maternal deaths were higher among ≤ 3 ANC visits women versus those with> 3 ANC visits. In the current study ≤ 3 ANC visits women showed higher fetal and neonatal death versus > 3 ANC visits women (16.1% stillbirth against 3.2% with P value 0.01). Most large studies worldwide have reported similar findings and concluded that ≤ 3 ANC visits women are at significantly increased risk of stillbirth compared with > 3 ANC visits women, with relative risks of 1.2 to 4.5[37-41].

The strength of the study is that study women were compared in all maternal and fetal outcomes which increased the significance of the study. Also, maternal and neonatal information was collected by the registrar who offered the follow-up. Our hospital is a major referral hospital which enables the inclusion of this number of women and their characteristics can be generalized. The limitation of the study is that neonatal intensive care unit admission is not evaluated and indications of cesarean section delivery are not included. 

Pregnancy outcomes of women who had ≤ 3 ANC visits were associated with adverse maternal morbidity, perinatal morbidity, and mortality (i.e., stillbirths plus early neonatal deaths). Maternal and neonatal morbidity is related, in part, to complications from APH, preterm delivery, pre-eclampsia, PPH, and cesarean section. Maternal death is higher in non-effective ANC compared with women with effective ANC.

Mothers should be provided with a sequence of comprehensive information on the advantages of early attendance of antenatal care. Implementing strategies that would reduce the financial burden associated with using maternal health services, such as medical and transportation costs, would enable women from poor households to use maternal health services. There is a need to conduct another research with more different variables to find further factors that should be associated with the standard ANC visits.

ANC              Antenatal care

APH              Antepartum hemorrhage

CS                Cesarean section

DM               Diabetes mellitus

FANC           Focused Antenatal Care

HIN             Hypertension

IFA              Iron–folic Acid

MNCH         Maternal, Neonatal, and Child Health 

PPH             Postpartum hemorrhage

PG              Primigravida

SDG            Sustainable Development Goal 

SPSS           Statistical package for social sciences

SMSB          Sudan Medical Specialization Board 

SVD            Spontaneous vaginal delivery

TT               Tetanus Toxoid

WHO          World Health Organization

X2              Chi-square test

This article is our original work. The Submitted manuscripts contain original and authentic results, data, and ideas, which were not published elsewhere. No material from other publications is reproduced in our article. All co-authors should not submit the same manuscript, in the same language simultaneously to more than one journal. The author of this paper has read and approved the final version submitted.

Ethical clearance 

Ethics approval was obtained from the Research and Ethics Committee of the hospital (Wad Madani Obstetrics and Gynecology Teaching Hospital). Ethical clearance and approval for conducting this research were obtained from the general manager of the Ministry of Health (Gazira State). Ethical principles of autonomy, beneficence, non-maleficence, and justice, as stipulated in the ethical guidelines of the Sudan Medical Specialization Board (SMSB), and Medical Research Council, were upheld throughout the study. Informed written consent was obtained from every respondent who agreed to participate in the study. The respondents informed that the study is not associated with experimental or therapeutic intervention while information was collected from them. 

Availability of data and materials 

All data and materials are available when request.

Competing interest 

The authors declare that they have no financial or personal relationships which may have inappropriately influenced them in writing this paper. No direct or indirect financial interests or conflicts exist and all authors agree with the content of the manuscript and there are no conflicts of interests between or among them.

Funding

My research project was self-sponsored by me and with the help of my colleagues and co-authors. There was no funding from any institute or organization for this paper.

Authors contribution

All my authors play major roles and real contributions to achieve this project. Ahmed, Awadalla, Ayat, and Hajar participated in data collection and analysis, and Siddig, Nuha Isra, and Abdelsalam participated in the manuscript plan, editing, and writing of the article.

Acknowledgment

I acknowledge the cooperation of Wad Madani Obstetrics and Gynecology Teaching Hospitalresidents who participated in appointing the patients and following up. We also appreciate the commitment and compliance of the patients who reported the required data and attended the regular follow-up.

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