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Evidence-Based Antenatal Care

• First Online: 06 August 2021

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• Olufemi A. Olatunbosun 5 &
• Lindsay Edouard 5  

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Antenatal care is a major component of integrated maternal health the goal of which is to identify and treat potential pregnancy-related health problems throughout pregnancy while promoting healthy lifestyles that benefit both mother and child. Improved access to family planning and contraceptive services, and availability of routine antenatal care have played a large part in reducing maternal and perinatal morbidity and mortality, low birth weight infants and other preventable health problems in both developed and developing countries. This chapter describes features of community-based healthcare that incorporates research evidence from both developed and developing countries for the provision of cost-effective and efficient antenatal care. The chapter recommends elements that are imperative to the design of the structure of effective antenatal care. It specifically describes the need for practitioners to (1) promote access to care; (2) enhance patient education and involvement in their care; (3) provide a team approach to ongoing maternal and foetal surveillance and (4) establish uniform protocols for screening for high-risk conditions along with organised plans to address complications that may arise in pregnancy. It concludes by discussing innovative, concise, evidenced-based standards of antenatal care for improving maternal, newborn and infant outcomes in developing countries.

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Olatunbosun, O.A., Edouard, L. (2021). Evidence-Based Antenatal Care. In: Okonofua, F., Balogun, J.A., Odunsi, K., Chilaka, V.N. (eds) Contemporary Obstetrics and Gynecology for Developing Countries . Springer, Cham. https://doi.org/10.1007/978-3-030-75385-6_10

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A study on knowledge and practices of antenatal care among pregnant women attending antenatal clinic at a Tertiary Care Hospital of Pune, Maharashtra

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Expectations and satisfaction with antenatal care among pregnant women with a focus on vulnerable groups: a descriptive study in Ghent

• Anna Galle 1 ,
• An-Sofie Van Parys 1 ,
• Kristien Roelens 1 &
• Ines Keygnaert 1  

BMC Women's Health volume  15 , Article number:  112 ( 2015 ) Cite this article

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Previous studies demonstrate that people’s satisfaction with healthcare influences their further use of that healthcare system. Satisfied patients are more likely to take part in the decision making process and to complete treatment. One of the important determinants of satisfaction is the fulfillment of expectations. This study aims to analyse both expectations and satisfaction with antenatal care among pregnant women, with a particular focus on vulnerable groups.

A quantitative descriptive study was conducted in 155 women seeking antenatal care at the University Hospital of Ghent (Belgium), of whom 139 completed the questionnaire. The statistical program SPSS-21 was used for data analysis.

Women had high expectations relating to continuity of care and women-centered care, while expectations regarding availability of other services and complete care were low. We observed significantly lower expectations among women without higher education, with low income, younger than 26 years and women who reported intimate partner violence. General satisfaction with antenatal care was high. Women were satisfied with their relationship with the healthcare worker, however ; they evaluated the information received during the consultation and the organizational aspects of antenatal care as less satisfactory.

Conclusions

In order to improve satisfaction with antenatal care, organizational aspects of antenatal care (e.g. reducing waiting times and increasing accessibility) need to be improved. In addition, women would appreciate a better provision of information during consultation. More research is needed for an in-depth understanding of the determinants of satisfaction and the relationship with low socio economic status (SES).

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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 [ 1 , 2 ]. Patient satisfaction is a reflection of the patient’s judgment of different domains of health care, including technical, interpersonal, and organizational aspects [ 3 ]. 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 [ 3 , 4 ]. 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 [ 1 ].

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 aspects: the resource structure of the care organization and patients’ preferences. Patient satisfaction has increasingly come to be used as an indicator of quality of care [ 5 ]. Patient satisfaction is a subjective and dynamic perception of the extent to which the patient’s expected health care needs are met [ 4 ]. The definition and conceptualization of satisfaction with health care is complex and multidimensional [ 2 , 5 ]. To our knowledge there is no conceptual basis nor 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 physical environment all impact on women’s satisfaction with antenatal care [ 4 , 6 ]. More recently there is agreement that women’s satisfaction with antenatal care is determined by the interaction between their expectations and the characteristics of the healthcare they receive [ 3 , 7 ]. In practice, expectations can refer to ideal health care, anticipated health care, or desired health care, and sometimes people do not have explicit expectations [ 8 ]. 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 [ 7 ]. Christaens & Bracke [ 4 ] demonstrated the positive correlation 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 [ 9 – 12 ]. 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 [ 10 , 13 – 15 ]. Poor attendance at antenatal care is a well-known problem in vulnerable subgroups [ 15 , 16 ]. 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) [ 17 , 18 ].

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 [ 19 , 20 ]. Adequate antenatal care by professional health care providers has been proven not only to reduce maternal, foetal and infant morbidity and mortality but also to result in improved maternal health status and parenting behaviours after the child is born [ 13 ]. Considering that dissatisfaction can be a major demotivating 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 [ 21 ]. 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 [ 17 ].

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 [ 22 ].

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.

A cross-sectional study was conducted at the antenatal clinic of Ghent University Hospital, Belgium. This antenatal clinic offers care for low- and high-risk pregnancies, the latter often referred from other hospitals. The standard antenatal visiting schedule at the clinic for a normal pregnancy consists of ten visits, which includes two consultations by a midwife and eight by a gynaecologist. In Belgium women are free to choose their own health care provider during pregnancy. Gynaecologists are principle health care providers for the vast majority of childbearing women in Belgium, while in many other parts of the world (e.g. Australia, the United Kingdom, Sweden and the Netherlands) midwives are the main providers [ 22 – 25 ]. In 2009 about 94.5 % of the pregnancies in Belgium were followed by an obstetrician/gynaecologist (OB/GYN) while 4.5 % were seen by a combination of a general practitioner and OB/GYN [ 10 , 16 ].

Recruitment

The study was approved by the Ethical Committee of the Ghent University Hospital (B670201419522) and all participants completed and signed an informed consent form. Between March and April 2014, pregnant women seeking antenatal care at the Ghent University Hospital were invited to participate in the study. Women were invited during the waiting time before the antenatal care consultation. Inclusion criteria were: being 18 years or older, having had at least one antenatal consultation in the current pregnancy, speaking Dutch or English, and being able to fill out an assisted questionnaire in Dutch or English. Women that did not meet the inclusion criteria or were not able to complete the questionnaire in private were excluded from the study. The study was limited to one questionnaire per woman and we did not impose limits on gestational age.

The researcher (a qualified midwife and Masters student in Health Promotion) invited the pregnant women to participate in the study while they were waiting for their antenatal consultation. The estimated number of women to be recruited was 100. This estimation was based on the number of women expected to attend the clinic and availability of the researcher (taken into consideration that only one woman at a time could fill in the questionnaire). In order to include women with low and high SES in the study, women were recruited during consultation hours of Kind & Gezin (Child & Family: A Flemish governmental institution offering psychosocial support during the perinatal period, with special attention to vulnerable groups) and during consultation hours of different OB/GYN with a substantial proportion of vulnerable pregnant women among their patient population.

The researcher introduced the study as a survey on satisfaction with antenatal care and briefly explained the procedure. Consenting women were handed an informed consent form, a participant information sheet and a questionnaire which was completed in a separate room. If the woman was unable to fill out the questionnaire in private (e.g. presence of family), she was excluded from the study. This was in order to avoid any influence by family/companions/spouse, etc. and to guarantee that all women followed the same procedure. To ensure that women with less developed literacy skills could also participate, the researcher was always present to clarify items or to answer questions, however keeping an appropriate distance (working on a computer). Only a small proportion of the women (ten women) needed assistance. Completing the questionnaire took an average of ten minutes. The questionnaire was anonymous, but the respondents had the option of providing their personal details if they were willing to be included in potential follow-up research. After completing the questionnaire the woman went directly to the health care provider or went back to the waiting room if the provider was not yet available.

Questionnaires/measures

This cross-sectional study explored the expectations and satisfaction of pregnant women with antenatal care. Information on socio-demographic factors obtained from the questionnaire included: age, parity, number of living children, educational level completed, country of origin, income level, gestational age at the time of completing the questionnaire, number of antenatal visits, timing of first antenatal visit in the current pregnancy. A participant was classified as being of foreign descent if she or at least one of her parents was born outside the country of research. If both parents and the participant were born in Belgium, the participant was classified as having Belgian nationality. Two indicators, namely attained educational status and income level, were used to asses SES. Women with an academic degree (at college or university) were recoded as “higher education”, women without further education (no education, only primary or secondary school) were recoded as “without higher education”. Current household income of less than € 2000 per month was categorized as low income. Potential financial problems and financial dependency were further investigated by asking, “If you received an unexpected bill of 2824 euro how easy would it be for you to pay it within a week?”. Women indicating having no difficulties were recoded as “No” before the statistical analysis, while those indicating it would be “a little bit difficult” or “really difficult” were regarded as respectively experiencing moderate or serious financial distress. The questions regarding financial distress were based on the research of Wangel & Bidens Study Group [ 26 ] and the threshold of €2824 for financial distress in Belgium was based on the income distribution statistics of the European Commission [ 27 ]. Measurement of financial distress gives valuable information on a person’s financial situation and financial dependency. In addition, lifestyle factors were assessed including use of alcohol, drugs and medication. IPV prior to and during the current pregnancy was assessed using questions based on “The Abuse Assessment Screen” (AAS) [ 28 ]. The AAS is a questionnaire that asks about past and current emotional, sexual, and physical abuse, both prior to and during pregnancy. The AAS represents an important screening tool for obstetric populations and has mainly been tested with young and poor women [ 29 ]. We applied the short version of the AAS, which was previously used in a similar study conducted by one of the co-authors [ 30 ]. Assessment of vulnerability was done by identifying and analyzing a broad range of characteristics, according to our definition of vulnerability which takes into account all factors that can pose special challenges to health care delivery.

Satisfaction and expectations were measured by the PESPC (Patient Expectations and Satisfaction with Prenatal Care Instrument)-questionnaire, which was originally developed in the USA by Omar et al. [ 7 ]. The questionnaire was tested and validated by Omar et al. in a sample of women with low to middle socioeconomic status [ 7 ]. In 2013 test-retest analysis of the instrument was conducted by Prudencio et al. [ 31 ], with a positive correlation and strong magnitude ( r  = 0.82; p  < 0.001) on the expectations domain and a positive correlation of moderate magnitude ( r  = 0.66; p  < 0.001) for the satisfaction domain.

The original instrument was translated into Dutch and one of the 41 items was deleted. We decided to not include the item “I am satisfied with the services of a public health nurse as part of antenatal care” because these services do not exist in the Belgian health care context. Back translation methodology was followed with three independent translators, along with a test of the target language version with monolingual subjects [ 32 ]. In addition two experts established content validity.

The final instrument consisted of 40 items, divided into two domains: expectations and satisfaction. Each domain contained four subscales. The subscales in the expectations domain were: complete care, provider continuity, personalized care and availability of other services. The subscales in the satisfaction domain were: information, provider care, staff interest, and system characteristics. The questions to assess these subscales are listed in Additional files 1 and 2 .

A Likert scale ranging from 1 (totally disagree) to 6 (totally agree) was used for evaluating the items, no neutral response option. The Likert scale was previously developed in that way by Omar et al. [ 7 ]. No items were reversed, high ratings on the scale corresponds with high expectations and high satisfaction. Construct validity of the PESPC’s final instrument was verified through exploratory factor analysis with Varimax rotation for the two domains, expectations and satisfaction. In both domains, all the factor loads were grouped and were above 0.30. The highest communality value in the expectations domain was identified for item 9 (0.77) and the lowest for item 1 (0.35), in the satisfaction domain the highest communality value was identified for item item 8 (0.79) and the lowest for item 19 (0.34). The final instrument had a good internal consistency, with a Cronbach’s α value of 0.70 for expectations and 0.82 for satisfaction. The complete questionnaire can be found in Additional file 3 .

Data-analysis

The statistical program SPSS-21 was used for data analysis. Descriptive analysis was performed for all the variables. We analysed nominal and categorical variables using Pearson’s chi-squared and Fisher’s exact test for differences between two groups. Groups were created based on the absence or presence of specific characteristics (of vulnerability). For tables with expected count less than five the Fisher Exact test was used. Each variable was analysed separate without controlling for confounding factors.

To analyse differences between groups regarding satisfaction and expectations (continuous variables) the Independent Sample T-test was performed and the p -value was computed. The level of significance was fixed at 0.05. Normality was determined graphically by using a Q-Q plot. The assumption of homogeneity of variance was tested by using the Levene's Test of Equality of Variances. This research adhered to the STROBE guidelines for cross-sectional studies [ 33 ].

Figure  1 shows that of the 155 women who were eligible from the sample, 141 were recruited (participation rate of 90.67 %) and 139 women completed the full questionnaire (response rate of 89.68 %) [ 34 ]. The main reason for exclusion was insufficient language skills, only three women declined participation. Most women chose to fill out the questionnaire in Dutch (95 %) and 5 % in English.

Flow diagram recruitment

The average age of the respondents was 30.5 ± 4.6 years, range 18–40 years, and the vast majority (94 %) were cohabiting or married. As for educational status: 69.1 % had a higher education qualification (university or college), 20.1 % had a secondary education and 10.8 % did not complete secondary school. About three quarters (72.7 % or n  = 101) of the women were of Belgian nationality. With regard to income we found that 10 % of the women had an income lower than the national minimum wage (less than €800 or €1000, depending on marital status). More than a quarter of the women reported serious financial distress. A third (30.2 % or n  = 42) of the women were primigravida and 15.1 % ( n  = 21) of the pregnancies were unplanned. The first antenatal care visit was later than 12 weeks of gestation for 5 % ( n  = 7) of the women. The average timing of the first appointment was at seven weeks, ranging between the second week (medically assisted conception) and the 25th week. The main healthcare provider in the antenatal period was the OB/GYN, with the number of consultations varying between 2 and 20 at the time of completing the questionnaire. The average number of consultations with the OB/GYN was seven and the average number of consultations with the midwife was two. Gestational age at the time of completing the questionnaire varied between 7 and 40 weeks with an average of 29 weeks. More details are presented in Table  1 .

One third (33.8 %) of the women used substances during pregnancy: 1.4 % used medication (for example tranquilizers, sleeping pills, anti-anxiety drugs or anti-depressants), 1.4 % used illicit drugs (for example cannabis, amphetamines, ecstasy or cocaine), 20.8 % used alcohol and 13 % smoked cigarettes, more details are presented in Table  2 .

With regard to IPV, 5.8 % ( n  = 8) of the women reported to have been physically abused in the 12 months prior to or during pregnancy, 1.4 % ( n  = 2) reported sexual abuse and 4.2 % ( n  = 6) emotional abuse. The detailed IPV prevalence rates of our study population are presented in Table  3 .

Expectations and satisfaction related to different aspects of antenatal care

The average score among all women in our study was calculated for expectations and satisfaction and possible intervals and averages were calculated for each subscale (see Table  4 ). Calculations were made according to the scoring procedure used by Prudencio et al. [ 31 ].

Expectations about different aspects of antenatal care were assessed by the subscales (complete care, provider continuity, personalized care, other services). Percentages of less than 50 % demonstrate that women slightly disagree with the statements and indicate low expectations. The highest average score was obtained for personalized care with 67.4 % and the lowest average score was obtained for other services with 37.7 %. The subscales complete care and personalized care showed an average score of 45.4 and 67.4 % respectively (more details are represented in Table  4 ).

In the satisfaction scale the highest scores were obtained for the subscales ‘provider care’ and ‘staff interest’, 86.3 and 84.8 % respectively. The lowest scores were observed for the subscales ‘information’ and ‘system characteristics’, 78.7 and 78.0 % respectively. More details are available in Table  4 & Additional file 2 .

Risk factors for low expectations and/or satisfaction with antenatal care

Comparing average expectations sum scores by means of an independent T-test, we found the following variables to be significant: educational level, income, age, marital status and reporting IPV. We observed significantly lower expectations among women without higher education, with low income, younger than 26 years, single or divorced women and women who reported IPV. Origin showed a trend towards significance ( P  < 0.1), women with a foreign descent seem to have lower expectations. In the satisfaction domain, no variables were statistically significant. We present more details in Table  5 .

Risk factors (financial distress & IPV & unplanned pregnancy) for inadequate antenatal care

Table  6 illustrates the relationship between financial distress, unplanned pregnancy, IPV and several socio-demographic factors. Women without higher education ( P  < 0.001), younger than 26 years old ( P  < 0.001), with low income, divorced or single women ( P  = 0.004) and women who smoked ( P  = 0.020) reported significantly higher levels of financial distress during pregnancy. A significant association ( P  < 0.001) was also found between financial stress and being of foreign descent. In our study only 16.8 % of women with Belgian nationality reported financial distress compared to 50 % of women of foreign descent.

Furthermore, a significant association was found between IPV and other risk factors for inadequate antenatal care (see Table  6 ). Women without higher education ( P  < 0.001), younger than 26 years old, with low income ( P  < 0.001) and divorced or single women ( P  < 0.001) reported significantly more IPV in the 12 months prior to or during pregnancy. Only 4 % of women with an income of more than 2000 euro reported IPV compared to15.4 % of women with an income of less than 2000 euro.

We found significantly higher percentages of unplanned pregnancy in women of foreign descent ( P  < 0.001), without higher education ( P  < 0.001), younger than 26 years ( P  = 0.001), with low income ( P  < 0.001), divorced or single women ( P  = 0.018) and women who smoked during pregnancy ( P  = 0.032).

We know that increasing the satisfaction of pregnant women with antenatal services can result in better health outcomes for mother and child. This study analysed both expectations and satisfaction with antenatal care.

Satisfaction with antenatal care

In our study satisfaction scores where higher than those previously reported (with the same scale) in the United States, which may indicate that in Belgium women are very satisfied with antenatal care [ 7 ]. In the literature we found similar results indicating that overall satisfaction with the health care system in Belgium is very high [ 1 , 22 ]. Bleich, Özaltin & Murray examined satisfaction with health systems in 21 European Union countries and Belgium was ranked second after Austria [ 1 ]. Also Christiaens & Bracke found high satisfaction rates among women attending the Flemish perinatal healthcare system compared to women in the Netherlands [ 22 ].

Different aspects of antenatal care

For the subscales regarding the relationship with the healthcare provider (‘staff interest’ and ‘provider care’) we observed high satisfaction levels. The subscale ‘information’ had lower scores. Research suggests that more efforts should be made to improve the transfer of essential information during antenatal consultations: women seem to be satisfied with technical aspects of antenatal care but also report a lack of communication by health care professionals [ 3 , 6 , 35 – 37 ]. The OB/GYN is mainly addresses medical issues and time is limited. A recent study [ 38 ] has shown that women who have a midwife as their antenatal health care provider report fewer communication problems than women who receive care from other types of clinicians. This suggests that the assignment of a midwifery led care option for low-risk pregnancies may result in better communication with the health care provider during pregnancy, as may the introduction of more consultations with a midwife in the normal antenatal care trajectory in Belgium. In many other countries midwives are the main health care providers during pregnancy. Midwifery led care is a model which has demonstrated effectiveness, satisfaction, and lower costs in several studies; the benefits of introducing this model in Belgium should be further explored [ 38 , 39 ].

The subscale ‘system characteristics’ had the lowest scores and in particular the item ‘waiting times’ (see Additional file 2 ). This is in line with previous research addressing barriers to antenatal care [ 3 , 40 , 41 ]. Sunil et al. [ 41 ] reported service related barriers to be the most significant factor influencing the decision when to start antenatal care. Service barriers included: not having child care or transportation, having to wait too long to get an appointment, and having to wait too long in the waiting room to see the doctor or nurse. In order to improve antenatal care policy makers and providers should focus more on features of the antenatal care setting (such as accessibly, waiting times and availability of ancillary services) instead of further medicalization of pregnancy and concentrating mainly on technical proficiency [ 40 ].

Factors significantly associated with low expectations

Many studies attempt to identify how various factors directly influence patient perceptions (or more typically patient satisfaction) and patient expectations have rarely been explicitly studied. This makes it difficult, if not impossible, to determine whether differences in satisfaction reflect expectations, perceptions, definitions or criteria, or experiences [ 42 ]. Our results revealed different risk factors for low expectations of antenatal care. Women with low income, without higher education, <26 years old, of foreign descent (significant trend), single or divorced women and women who reported IPV had significantly lower expectations of antenatal care. This can be explained by various factors that influence patients’ expectations: the patient’s previous experiences, social and cultural norms (e.g. those with greater education or authority are more critically), patient demographics (e.g. age, gender), and last, but certainly not least, the extent to which the patient has knowledge of what s/he should expect [ 42 ]. Our findings were in line with previous research, which has found that women with low SES or women who are less familiar with the health care system (such as women with foreign descent) have lower expectations regarding antenatal care [ 31 , 42 ].

Factors significantly associated with low satisfaction

No significant relationship was found between satisfaction and SES in our study and other risk factors for low satisfaction with antenatal care could not be identified. Income and education were used as indicators for SES, while ethnicity was not included as a socio-economic indicator in our study. Consensus about the influence of SES on satisfaction is lacking in the literature. It remains unclear if women with low SES are less or more satisfied with antenatal care. Prudencio et al. [ 31 ] used the same instrument to measure satisfaction and only found a significant relationship between marital status and satisfaction, while income and education were not found to be related to satisfaction. Some studies have suggested that antenatal care can be particularly frustrating for women with low SES, due to experiences such as discrimination or stereotyping [ 36 , 41 , 43 ]. Language barriers and medical jargon may impede communication for women with lower literacy levels and migrants [ 36 , 44 ]. On the other hand many studies indicate positive experiences of women with low SES [ 1 , 31 ]. Bleich et al. observed a weak but statistically significant association between education and satisfaction with health care; people with some college education were less likely to be satisfied with the health system compared to people without a high school qualification [ 1 ].

The theory of Fishbein & Ajzen [ 45 ] can partially explain the higher satisfaction of women with low SES. Women with low SES have lower expectations about the care they will receive. These lower expectations are easier to fulfill and as a consequence women are more satisfied with the care they receive. With increasing levels of education, women′s expectations increases, which may explain why high educated women tend to be less satisfied. Our results also seem to support this hypothesis since women with low SES had significantly lower expectations than women with high SES. Women without higher education and low income women had higher average satisfaction scores, but these differences were not significant. Vulnerable women do not seem less satisfied but many other factors may impede their access to antenatal care. In our study several associations between factors of vulnerability were demonstrated. We found an association between financial stress and being of foreign descent. Literature has shown that migrants pay fewer and later antenatal visits, have poorer pregnancy outcomes and are more at risk of unintended pregnancies [ 46 , 47 ]. Financial barriers are still a main cause of not seeking antenatal care for undocumented migrants in Belgium. Antenatal care is considered as urgent medical care which means that the social welfare system (OCMW) should reimburse these medical costs for those who are undocumented. However, the implementation and interpretation of this regulation varies from doctor to doctor and from OCMW to OCMW, creating ambiguity and discrimination [ 48 ]. If policymakers want to guarantee universal access to antenatal care, removing organizational barriers should be a higher priority as well as removing financial barriers.

Finally, our study equally also confirmed the association of IPV with other risk factors for inadequate antenatal care (low SES, unplanned pregnancy, financial distress, and <26 years old). Over the past decades, research has generated growing evidence that IPV is a prevalent problem that is linked to a broad range of adverse health outcomes and risk behaviour [ 14 , 49 ]. Antenatal home visiting programs and some multifaceted counselling interventions produced promising results to tackle IPV and other risk factors simultaneously in vulnerable pregnant women [ 49 , 50 ]. Currently, psychosocial services for vulnerable women in Belgium, provided by Kind & Gezin (K&G), are mainly directed towards the postnatal period. K&G offers free home visits by a district nurse for every mother in the first few months after birth. K&G could play an important role in testing out and introducing specific antenatal care programs for vulnerable women in Belgium.

We can conclude that vulnerable women are not less satisfied about the care they receive and many other factors besides their experience as a patient, such as social network, insurance, and health literacy, play a role in antenatal care attendance. Therefore improving satisfaction among vulnerable women may be of limited use for increasing antenatal care attendance, instead a wide array of determinants should be tackled simultaneously to increase access for vulnerable groups.

Limitations

The study has some limitations. Using a face to face recruitment and data collection procedure, we were able to obtain high response rate of 89.7 %. On the other hand personal and direct contact is a well-known risk for response bias, although no health care workers of the antenatal consultation were involved in the recruitment procedure [ 34 ]. Despite the high response rate, some selection bias could not be avoided as obviously women without any access to antenatal care were not reached. Also women younger than 18 years old were excluded from the study for ethical reasons, they only can be interviewed with parental permission. Qualitative research using snowball sampling could be a better approach for reaching these groups.

The issue of acquiescence response bias needs consideration for the questions concerning satisfaction: this section was the last part of the questionnaire and mainly high scores and little variation were obtained. Another limitation that should be taken into consideration is the wide range of gestational age, women at 7 weeks gestational age (with at least one previous antenatal care consultation) may have little experience with antenatal care compared to women at the end of their pregnancy.

Although previous research supported the validity and reliability of the questionnaire, it should be tested in more demographically and culturally diverse samples. Satisfaction with health care is a multidimensional construct and hard to measure [ 25 ]. We cannot be sure that the attributes chosen in the scales are those most important to quality of care. It is common that general questions are given high rates [ 51 ]. In order to have a more complete understanding of women’s expectations and satisfaction with antenatal care, specific questions about the importance of certain aspects of care could be added to the questionnaire [ 52 ]. Further research with a greater sample size is recommended to broaden the in-depth understanding of the determinants of satisfaction with the healthcare system and the relationship with SES. Future research can also address more diverse health care settings.

Conclusion & implications for practice

We do believe that this study provides useful insights for enhancing care for pregnant women in the antenatal period. The association between several risk factors (including smoking & unplanned pregnancy, foreign descent & financial distress, IPV & low SES) of vulnerability was demonstrated in our study. Furthermore we were able to demonstrate the link between some socio-demographic characteristics and low expectations about antenatal care. Antenatal care can be a window of opportunity to address these risk factors simultaneously, as they are closely linked to each other, and affect the health of both child and mother .

Our study highlighted the importance of the organizational aspects of care and the need for more information during consultations in order to achieve greater maternal satisfaction with antenatal health care. Institutions offering antenatal care should consider practical arrangements to remove some of the organizational barriers that affect the satisfaction of women including reduction of waiting times, improvement of transportation facilities and provision of walk-in consultations. A relatively small investment could have a great impact on the satisfaction of women, which can improve maternal and newborn health. Midwives can play an important role in improving the provision of adequate information and health promotion during pregnancy.

Abbreviations

Antenatal Care

International Centre for Reproductive Health

Intimate Partner Violence

Kind & Gezin

Obstetrician/ Gynaecologist

Openbaar Centrum voor Maatschappelijk Welzijn

Patient Expectations and Satisfaction with Prenatal Care Instrument

Socio Economic Status

Statistical Package for Social Sciences

United States of America

World Health Organization

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Acknowledgements

This study was not funded by any external organization. All authors are associated with the International Centre for Reproductive Health (ICRH) and Ghent University. We would like to thank all the women for their willingness to participate in our study. We would also like to thank the staff of the Ghent University antenatal clinic for their collaboration, especially Ms Regine Goemaes (Lead Midwife). Furthermore we like to thank Dr Samuel Galle, Ms Sally Griffin and Prof Olivier Degomme for their useful comments in drafting the paper.

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The authors declare that they have no competing interests.

Authors’ contributions

AG conceived the study, acquired the data, did the analysis and drafted the manuscript. ASVP and KR participated in the design of the study, were involved in drafting the article and gave critical input. IK contributed to the interpretation of results and writing of the manuscript from draft to submission. All authors read and approved the final manuscript.

Additional files

Additional file 1:.

Scale Expectations. An overview of the items used to assess the subscales in the expectations domain. (PDF 143 kb)

Additional file 2:

Scale Satisfaction. An overview of the items used to assess the subscales in the satisfaction domain. (PDF 148 kb)

Additional file 3:

Questionnaire. The complete questionnaire used in this study, a version in English and Dutch respectively. (PDF 426 kb)

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Galle, A., Van Parys, AS., Roelens, K. et al. Expectations and satisfaction with antenatal care among pregnant women with a focus on vulnerable groups: a descriptive study in Ghent. BMC Women's Health 15 , 112 (2015). https://doi.org/10.1186/s12905-015-0266-2

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DOI : https://doi.org/10.1186/s12905-015-0266-2

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• Antenatal care
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Positive experiences, key to antenatal care uptake and quality

Results from a Cochrane qualitative evidence synthesis suggests that women use antenatal care if they see it as a positive experience that fits with their beliefs and values, is easily accessible and affordable and treats them as an individual.

The review , covering 85 studies and published in the Cochrane Library, shows that women want care that makes them feel that they and their baby are safe, and is provided by kind, caring, culturally sensitive, flexible, and respectful staff that give support and reassurance about their health and of their babies. Women also value tests and treatments that are offered when needed, as well as being provided relevant information and advice.

Of the 85 studies in the synthesis, 46 explored the views and experiences of healthy pregnant or postnatal women, 17 studies explored the views and experiences of healthcare providers and 22 studies incorporated the views of both women and healthcare providers. Confidence in each finding was assessed using GRADE-CERQual.

The studies took place in 41 countries, including eight high-income countries, 18 middle-income countries and 15 low-income countries, in rural, urban and semi-urban locations. Fifty-two findings were developed in total and these were organized into three thematic domains: socio-cultural context (11 findings, five moderate- or high-confidence); service design and provision (24 findings, 15 moderate- or high-confidence); and what matters to women and staff (17 findings, 11 moderate- or high-confidence). The third domain was sub-divided into two conceptual areas: personalised supportive care, and information and safety. Two lines of argument, using high- or moderate-confidence findings were also developed.

• More about GRADE-CERQual

The authors conclude that the review complements existing effectiveness reviews of antenatal care provision and adds essential insights as to why a particular type of antenatal care provided in specific local contexts may or may not be acceptable, accessible, or valued by some pregnant women and their families or communities.

Those providing, and funding services should consider the three thematic domains identified by the review as basis for service development and improvement. Such developments should include pregnant and postnatal women, community members and other relevant stakeholders.

Pregnant women needlessly dying

Maternal deaths are unacceptably high, with about 830 women dying from pregnancy or childbirth-related complications around the world every day. Most of these complications develop during pregnancy and most are preventable or treatable. Other complications may exist before pregnancy but are worsened during pregnancy, especially if not managed as part of the woman’s care.

In 2015, it’s estimated that more than 300 000 women died during and following pregnancy and childbirth. Nearly all these deaths occurred in low-resource settings.

Quality health care during pregnancy and childbirth can prevent many of these deaths, yet globally, only 64% of women receive antenatal care four or more times throughout their pregnancy.

Antenatal care: essential for pregnant women

When women receive antenatal care, they are provided with support, reassurance, and information about pregnancy and birth, and tests and examinations to see if they and their baby are healthy. Problems or issues are then managed during the contact and, if needed, women are referred to other care providers.

Antenatal care is a vital opportunity for health providers to deliver care, support and information to pregnant women. This includes promoting a healthy lifestyle, including good nutrition, detecting and preventing diseases, providing family planning counselling, and supporting women who may be experiencing intimate partner violence.

While the World Health Organization (WHO) recommends that all pregnant women receive antenatal care, women do not always avail of this care, either because they do not think it is important, or because they cannot access this service. The quality of antenatal care and how women are treated plays a role as well.

The perspective of healthcare workers

The findings also suggest that healthcare staff want to be able to provide the same kinds of care that women want. They want to work in properly funded antenatal services that give them proper support, pay, training and education. They believe this helps them to have enough time to treat each pregnant woman as an individual, and to have the knowledge, skills, resources and equipment to do their job well.

WHO recommendations on antenatal care

The preliminary findings of this review contributed to the series of recommendations released by WHO in 2016 to improve the quality of antenatal care; reduce the risk of stillbirths and pregnancy complications; and give women a positive pregnancy experience. The results of this review, which include studies published up to February 2019, reinforce this guideline. Endorsed by the UN Secretary-General, it complements existing WHO recommendations on managing specific pregnancy-related complications.

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• Jana Kuhnt 1 ,
• Sebastian Vollmer 1 , 2
• 1 Department of Economics & Centre for Modern Indian Studies , University of Goettingen , Göttingen , Germany
• 2 Department of Global Health and Population , Harvard T.H. Chan School of Public Health , Boston , MA , USA
• Correspondence to Professor Sebastian Vollmer; svollmer{at}uni-goettingen.de

Objectives Antenatal care (ANC) is an essential part of primary healthcare and its provision has expanded worldwide. There is limited evidence of large-scale cross-country studies on the impact of ANC offered to pregnant women on child health outcomes. We investigate the association of ANC in low-income and middle-income countries with short- and long-term mortality and nutritional child outcomes.

Setting We used nationally representative health and welfare data from 193 Demographic and Health Surveys conducted between 1990 and 2013 from 69 low-income and middle-income countries for women of reproductive age (15–49 years), their children and their respective household.

Participants The analytical sample consisted of 752 635 observations for neonatal mortality, 574 675 observations for infant mortality, 400 426 observations for low birth weight, 501 484 observations for stunting and 512 424 observations for underweight.

Main outcomes and measures Outcome variables are neonatal and infant mortality, low birth weight, stunting and underweight.

Results At least one ANC visit was associated with a 1.04% points reduced probability of neonatal mortality and a 1.07% points lower probability of infant mortality. Having at least four ANC visits and having at least once seen a skilled provider reduced the probability by an additional 0.56% and 0.42% points, respectively. At least one ANC visit is associated with a 3.82% points reduced probability of giving birth to a low birth weight baby and a 4.11 and 3.26% points reduced stunting and underweight probability. Having at least four ANC visits and at least once seen a skilled provider reduced the probability by an additional 2.83%, 1.41% and 1.90% points, respectively.

Conclusions The currently existing and accessed ANC services in low-income and middle-income countries are directly associated with improved birth outcomes and longer-term reductions of child mortality and malnourishment.

• epidemiology
• perinatology

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

https://doi.org/10.1136/bmjopen-2017-017122

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Strengths and limitations of this study

This is the first study on the association of antenatal care (ANC) with child health and vital outcomes for all low-income and middle-income countries for which high-quality and comparable data are available.

This is the first study investigating the possible long-term effects of the utilisation of ANC on children’s nutritional and vital status.

The study focuses on the association between the ANC services effectively available and accessible to women in low-income and middle-income countries and hence, generates knowledge on the current status quo and effect of the ANC services on child health.

The analysis does not allow a causal interpretation of the results.

Data availability limits the investigation of the association of more disaggregated quality indicators of ANC with the outcome variables.

Introduction

Despite strong international efforts to expand the worldwide coverage of basic primary health services for women, pregnancy and childbirth still represent a high-risk period for mother and child; especially in low-income and middle-income countries. Reductions in maternal and early child mortality remain high on the global development policy agenda, which can be seen in its inclusion in the Sustainabile Development Goal 3. 1 However, nearly 3 million babies die every year during their first month of life, and in low-income and middle-income countries, many of those deaths and morbidities are due to easily preventable causes. 2 3 Undetected infections during pregnancy, such as malaria, syphilis, tuberculosis, tetanus or HIV/AIDS, as well as high blood pressure, diabetes and other pre-existing health conditions often complicate or aggravate pregnancy and pose significant risk for mother and child. Antenatal care (ANC)—the services offered to mother and unborn child during pregnancy—is an essential part of basic primary healthcare during pregnancy, and offers a mosaic of services that can prevent, detect and treat risk factors early on in the pregnancy. The detection of high-risk pregnancies through the analysis of socioeconomic, medical and obstetrical factors represents a key element of ANC. It is also often used as a platform for additional interventions that have been shown to positively influence the maternal and child health status, such as immunisation and nutrition programmes and breastfeeding counselling, or to educate women about the possibilities of family planning and birth spacing. 4–13 In addition, ANC programmes are used to provide care and information that is not directly related to pregnancy but can reduce the possible maternal risk factors, such as promoting healthy lifestyles, tackle malnutrition or inform about gender-based violence. Hence, ANC is a potentially important determinant in reducing maternal and child morbidity and mortality. 14–22

Within the last decades, the provision of ANC services has increased worldwide. During 2010–2015, the ANC coverage, defined as the percentage of women aged 15–49 years who attended at least one ANC visit with a skilled provider, was around 85% globally and approximately 77% in the least developed countries. 23 24 To our knowledge, there exists no global study for all low-income and middle-income countries, which analyses the association of existing ANC services that are offered to pregnant women in low-income and middle-income countries on child health outcomes.

Numerous studies have helped to develop an internationally accepted set of so-called essential ANC services by evaluating the effects of single interventions, such as tetanus and malaria prevention programmes, on maternal and neonatal health 25–30 or by studying the optimal number and content of ANC visits. 31–34 However, the de facto offered and used set of ANC services can deviate greatly from the recommended ANC interventions. A couple of studies evaluate the relationship between the utilisation of ANC services and perinatal outcomes in individual low-income and middle-income countries. The majority have shown the positive effects of ANC on newborn mortality, the occurrence of stillbirth and preterm labour and low birth weight. 35–43 However, they exclusively focus on single countries, are often conducted at the clinic level and have small sample sizes. This limits their external validity. We identified only one study that focuses on a larger regional sample. Conde-Agudelo et al studied 837 232 births in Latin America between 1985 and 1997. 44 One major risk factor associated with fetal death was the lack of ANC. We could not find a study that took into account the possible long-term effects of the utilisation of ANC services on children’s nutritional and vital status.

With up to 193 Demographic and Health Surveys (DHS) from 69 low-income and middle-income countries, we use the most comprehensive data for low-income and middle-income countries that currently exist. Specifically, we investigate whether the attendance of mothers at ANC services was associated with improved short-term and long-term survival rates or reductions in the prevalence of low birth weight, stunting and underweight in their children.

We used data from the DHS, which are publicly available online ( http://dhsprogram.com ). The DHS are cross-sectional household surveys that use a harmonised questionnaire to facilitate between-country comparisons. The DHS collect nationally representative health and welfare data for women of reproductive age (15–49 years), their children and their respective household.

They have been conducted at different time intervals in 90 low-income and middle-income countries since 1985. We included all surveys, which have information for the relevant outcome and explanatory variables. The final sample consists of pooled data from up to 193 surveys in 69 low-income and middle-income countries worldwide, conducted between 1 January 1990 and 31 December 2013. The DHS used a multistage stratified sampling. Countries were divided into regions, within which populations were stratified by area of residence and from which a random sample was taken according to the most recent population census. Those are the primary sampling units (clusters with an average of 250 households), which are equally likely to be selected to the proportion of the specific cluster’s population that contributed to the total population. At the second stage, after a complete listing of all households within the cluster, an average of 20–30 households were randomly selected by equal probability. Sampling weights in order to calculate nationally representative statistics are provided by the DHS.

Women were, among other things, asked for each live birth within 5 (or in some cases 3) years prior to the survey about date of birth, birth weight, vital status at the time of the interview and either current age or age at death of the child. Furthermore, the DHS collected information on the height and weight of the children born during the last 3 or 5 years.

For each last-born live birth of the previous 3 or 5 years, there is information on the attendance rates and quality of ANC visits during the last pregnancy that led to a live birth. Considering the ongoing debates on the importance of the quality and number of ANC visits, 31 45–48 we specified two different main explanatory variables. First, the mere attendance of ANC (a dummy variable indicating whether the woman attended at least one ANC visit during her last pregnancy leading to a live birth) irrespective of the total number of visits and the type of provider. To proxy WHOrecommendations regarding prenatal care (at least four visits at a skilled provider 1 ), we specified a variable indicating whether the woman saw at least once a skilled provider during her at least four ANC visits. Unfortunately, we were unable to identify whether all ANC visits were provided by a skilled professional. ANC visits to a doctor, midwife, nurse, auxiliary midwife, obstetrician, health professional or trained (traditional) birth attendant were considered as skilled ANC services, whereas ANC with a traditional birth attendant, relatives, any other person or none of the mentioned was classified as unskilled ANC.

We analysed the data for short-term and long-term vital outcomes and low birth weight of all last-born live births as well as stunting and underweight for the last-born children aged 0–59 months (in some surveys 0–36 months) at the time of the interview. Hence, each woman is represented only once in the dataset with the information of her last-born child (in case of a live birth). Mortality outcomes were neonatal death, defined as death of a live birth within the first month of life, and infant death, defined as death after the first month but within the first year of life. The latter excludes neonatal deaths and is restricted to children aged at least 1 year. Nutritional outcomes were low birth weight, stunting and underweight. We used WHO classification that defines low birth weight as a birth weight below 2500 g at birth. Following WHO and Unicef suggestions, we only included biologically plausible birth weights from 500 to 5999 g. To calculate stunting and underweight, we used anthropometric data defined by WHO standards and classifications (using the Stata package ‘igrowup_stata’). Comparing the child’s height and weight to those of a well-nourished reference population of the same age and sex allows us to calculate the z-scores of height-for-age and weight-for-age. Stunting is defined by a height-for-age z-score of less than −2, and underweight is defined by a weight-for-age z-score of less than −2. Biologically implausible values of the z-scores were excluded following WHO guidelines.

Statistical analysis

We used linear probability regression models to investigate the association between ANC services and short-term and long-term vital and health outcomes of children. We adjusted the regressions for confounding factors and controlled for primary sampling unit (PSU) fixed effects. The PSU fixed effects are survey specific and herewith, we control for common factors faced by households in the same PSU at one point in time, such as the local availability and quality of health providers and other local factors. SEs were clustered at the PSU level as respondents in the same PSU might experience common shocks. They capture characteristics of local enumeration areas that are common to all respondents from that area. We used sex, birth order (five categories: ranging from ‘first born’ to ‘fifth or later born’ child), birth spacing (five categories: ranging from ‘no preceding birth’ to ‘equal or more than 36 months’), birth month and whether the child was a multiple birth, the mother’s age at birth (five categories: ranging from ‘below 17’ to ‘equal or above 30’ years), education (five categories: ranging from ‘no education’ to ‘higher education’), work status, relation to the household head (dummy indicating whether the mother is the household head) and her marital status and household wealth quintile as covariates. The wealth quintile variable is constructed by using a principal component analysis, is based on the ownership of household assets (eg, electricity, television and quality of dwelling) and indicates the household’s wealth relative to other households within the respective country in that survey. Additionally, by including variables indicating the place of delivery, mode of delivery (vaginal or caesarean), status of tetanus injection of mother before birth and if the mother breastfed at least 1 month after birth (several only applicable for long-term outcomes), we inspected the possible mediator variables, meaning that the uptake of ANC services might starkly influence those variables, which themselves might affect the outcome variables.

Using Stata (V.14.0) for all statistical analyses, we also took into account the stratified survey design by using the Stata svy command. We used sampling weights provided by the DHS in all our regressions.

Our initial samples consisted of surveys for which the respective outcome variable and the information on ANC visits were collected and composed children between 0 and 59 months at the time of the interview and who were permanent members of the respective household. The total sample for neonatal and infant mortality included observations for 1 019 463 children. In some survey rounds, data on birth weight and in others on anthropometric measures were not systematically collected. This left us with data of 947 365 children, where information on their birth weight could have potentially been recorded. For stunting, this amounted up to 865 959 children and for underweight to 857 908 children.

Observations were lost due to missing data on outcome variables, missing data on the ANC variables (including the dummies indicating the mere attendance of ANC visits and the attendance of at least four ANC visits while the woman at least once saw a skilled provider) or missing data on covariates. The final analytical sample was 752 635 for neonatal mortality, 400 426 for low birth weight, 574 675 for infant mortality, 501 484 for stunting and 512 424 for underweight (see figure 1 and online supplementary table A1 ).

Supplementary file 1

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Sample deduction. ANC, antenatal care; LMIC, low-income and middle-income countries.

The prevalence of newborn death was higher among women who did not receive any ANC check-up (3.12%) compared with those attending at least one check-up (1.67%). For infant mortality, the respective numbers are 4.23% and 2.21%. Prevalence of all outcome variables was higher among women not attending any ANC visit than those attending at least one ANC check-up and to  those who received at least four ANC visits while at least once having seen a skilled provider ( table 1 ). Pregnant women who did not attend ANC visits were on average less educated and poorer than those women who attended at least one ANC check-up (see online supplementary table A2 appendix ).

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Descriptive statistics

In table 2 , we report the association between ANC take-up and short-term and long-term mortality outcomes. For each outcome, we show the results from three different specifications where PSU fixed effects are included in all three. The first column shows the mere association between the attendance of at least one ANC visit without controlling for any covariates. The second column shows the association adjusted for control variables, and the third column reports the coefficients while adding whether the mother has received at least four ANC visits during pregnancy while at least having once seen a skilled provider. The interpretation of this additional term follows the logic of an interaction term as it overlaps in its definition with the variable indicating the mere attendance of ANC. Hence, it shows the additional effect if the mother followed more closely WHO recommendations. In supplementary table A2 and A4 appendix ), we report the regression results where in addition to control variables, we also adjusted for potential transmission channels of ANC (place of delivery, mode of delivery, status of tetanus toxoid injection of mother before birth and whether the mother breastfed at least for 1 month after birth). We will focus on the second and third specifications adjusted for control variables and only refer to the other specifications for comparison purposes.

Associations between antenatal care visits and mortality outcomes

Women attending at least one ANC visit have a 1.04% points reduced probability of their newborn dying within the first month after birth and a 1.07% points lower probability of experiencing death of their child within the first year of life. Following the WHO recommendations on ANC visits is significantly related to lower mortality outcomes. Compared with the mere attendance of less than four ANC visits (irrespective of the quality of the provider), having at least four ANC visits and having at least once seen a skilled provider reduce the probability of neonatal deaths by an additional 0.56% points and are associated with an additional 0.42% points reduction in the probability of infant deaths.

The DHS dataset also provides information on several variables that are well-established in the literature to impact mortality and morbidity outcomes of children and that simultaneously are potentially influenced by ANC attendance. When controlling for these potential transmission channels of ANC services, it can be seen that the majority of the ANC coefficients are somewhat attenuated when controlling for these additional variables but not by much (online supplementary table A3 ). Results for all covariates are provided in online supplementary A5 appendix .

In table 3 , we report the association between ANC and short-term and long-term nutritional outcomes of the child. If the mother attends at least one ANC visit, this is associated with a 3.82% points reduced probability of giving birth to a low birth weight baby. Stunting and underweight outcomes are reduced by 4.11% and 3.26% points, respectively. Attendance at a skilled provider during at least one of at least four ANC visits further reduces the probability of having a low birth weight baby by 2.83% points, for stunting by 1.41% points and for underweight by 1.90% points.

Associations between antenatal care visits and nutritional outcomes

Adding potential transmission channels of ANC services to the regression slightly attenuates the ANC coefficients in case of low birth weight and underweight (online supplementary table A4 ). Results for all covariates are provided in online supplementary table A5 .

Most existing evidence on the effect of ANC on child health is based on data from high-income countries, and their conclusions are not easily transferable to low-income and middle-income settings. The existing studies for low-income and middle-income countries often focus on individual countries. Furthermore, the studied effects of ANC have been limited to direct short-term maternal and child delivery outcomes. This is the first large-scale cross-country study for all low-income and middle-income countries with available comparable data for ANC, which systematically investigates the association of ANC with short-term and long-term mortality and nutritional child outcomes.

Using child vital data and child anthropometry from up to 193 surveys in 69 low-income and middle-income countries, we have shown that ANC is associated with reductions in neonatal and infant mortality, low birth weight, stunting and underweight. While we measure the average effects across countries and years, we find that this association remains relatively stable across survey rounds (online supplementary table A6 ) and can be seen for all outcomes in almost all world regions (online supplementary figures A1 and A2 ); though it is especially strong in Latin America and Caribbean, Sub-Saharan Africa and South and Southeast Asia (which constitute about 90% of our sample). Receiving prenatal care by skilled providers and attending at least four ANC visits is significantly associated with additional prevalence reductions of all outcome variables and hence, plays an important role in the provision of ANC services. The magnitude of the association is quantitatively important, as it varies around −1.04% and −4.11% points.

Many pregnant women in low-income and middle-income countries have no access to or do not attend ANC services regularly enough (more than four visits) and many do not see a skilled provider. 23 49 50 According to our results, improving the coverage and uptake of ANC services could be an important tool to improve short-term and even long-term mortality and nutritional outcomes of children.

There are a couple of self-selection issues and limitations that we have attempted to address. Unfortunately, we do not have disaggregated information on the type of provider (skilled/unskilled) for each ANC visit. We try to proxy this by including whether the woman has at least once seen a skilled provider during her pregnancy. Furthermore, we controlled for mother’s education and household wealth, since more educated or more affluent mothers might be more likely to seek ANC and at the same time have a better overall health status. Similarly, we adjusted for PSU fixed effects to control for community characteristics, overall health status in the region and the local availability and quality of healthcare services as well as other characteristics that are common to the local area. However, there are a few maternal characteristics, which we did not observe and therefore were not able to control for. For instance, if pregnant women feel that there could be something wrong, they might be more likely to seek ANC. Similarly, if women had negative birth outcomes in the past, they might also be more likely to seek ANC to avoid the repetition of the negative birth outcome. Both cases would downward bias our estimates and the true association would be even stronger than the association, which we found in our analysis. It is important to point out again that we are only including the outcomes of live births. The attendance at ANC services might lead to better survival chances of those babies that would have otherwise died before birth. This might impose a downward bias on our estimates. However, there are also potential selection issues, which could bias the results in the other direction. For instance, it is unclear how women would behave in case of an unwanted pregnancy.  They might be less likely to seek ANC and have worse overall health behaviour compared with women in planned pregnancies. In a robustness check, we controlled for an indicator variable if the pregnancy was wanted, and this did not change the results. Additionally, we cannot further approximate the quality of care received by the women. As the quality of care will influence the effect of ANC, this limits our study. By including PSU level fixed effects, we absorb indicators that are similar across this geographical unit and survey. Assuming that the quality of ANC available to women within the same PSU is comparable, we successfully address this data limitation. We also assume that missing data in our sample was not systematically correlated with the true unobserved child health and vital outcomes and the availability and accessibility of ANC services.

In summary, our study provides evidence for the potential importance of ANC for improving child health and vital outcomes in low-income and middle-income countries and might be an important tool to reach the third Sustainable Development Goal by 2030.

Acknowledgments

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• 2. ↵ WHO . Global Health Observatory (GHO) data: Neonatal Mortality. World Health Organization . 2017 http://www.who.int/gho/child_health/mortality/neonatal_text/en/ ( accessed 12 Aug 2017 ).
• 3. ↵ UNICEF . Committing to child survival: a promise renewed. Progress report 2015. United Nations Children’s Fund . 2015 .
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↵ [1] In 2016, WHO updated their recommendations to at least eight prenatal care visits at skilled providers. 51

Contributors JK and SV conceptualised the study, developed the analytical strategy and interpreted the data. JK conducted the statistical analysis and wrote the first draft of the manuscript. SV critically revised the manuscript.

Competing interests None declared.

Patient consent Obtained.

Ethics approval Procedures and questionnaires for standard DHS surveys have been approved by the ICF Institutional Review Board (IRB) and by the relevant body in each country. ICF IRB ensures that the survey complies with the US Department of Health and Human Services regulations for the protection of human subjects (45 CFR 46), while the host country IRB ensures that the survey complies with laws and norms of the nation.

Provenance and peer review Not commissioned; externally peer reviewed.

Data sharing statement This study used data that was collected by the Demographic and Health Surveys Program (www.dhsprogram.com), under a contract from the US Agency for International Development.

Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice. 3rd edition.

C antenatal care.

• Always begin with Rapid assessment and management (RAM) B3-B7 . If the woman has no emergency or priority signs and has come for antenatal care, use this section for further care.
• Next use the Pregnancy status and birth plan chart C2 to ask the woman about her present pregnancy status, history of previous pregancies, and check her for general danger signs. Decide on an appropriate place of birth for the woman using this chart and prepare the birth and emergency plan. The birth plan should be reviewed during every follow-up visit.
• Check all women for pre-eclampsia, anaemia, syphilis and HIV status according to the charts C3 - C6 .
• In cases where an abnormal sign is identified (volunteered or observed), use the charts Respond to observed signs or volunteered problems C7 - C11 to classify the condition and identify appropriate treatment(s).
• Give preventive measures due C12 .
• Develop a birth and emergency plan C14-C15 .
• Advise and counsel on nutrition C13 , family planning C16 , labour signs, danger signs C15 , routine and follow-up visits C17 using Information and Counselling sheets M1 -M19 .
• Record all positive findings, birth plan, treatments given and the next scheduled visit in the home-based maternal card/clinic recording form.
• Assess eligibility of ART for HIV-infected woman C19 .
• If the woman is HIV infected, adolescent or has special needs, see G1 - G11 H1 - H4 .

C2. ASSESS THE PREGNANT WOMAN: PREGNANCY STATUS, BIRTH AND EMERGENCY PLAN

Use this chart to assess the pregnant woman at each of the four antenatal care visits. During first antenatal visit, prepare a birth and emergency plan using this chart and review them during following visits. Modify the birth plan if any complications arise.

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C3. CHECK FOR PRE-ECLAMPSIA

Screen all pregnant women at every visit.

C4. CHECK FOR ANAEMIA

C5. CHECK FOR SYPHILIS

Test all pregnant women at first visit. Check status at every visit.

C6. CHECK FOR HIV STATUS

Test and counsel all pregnant women for HIV at the first antenatal visit. Check status at every visit.

If no problem, go to page C12 .

C7-C11. RESPOND TO OBSERVED SIGNS OR VOLUNTEERED PROBLEMS

C12. GIVE PREVENTIVE MEASURES

Advise and counsel all pregnant women at every antenatal care visit.

C13. ADVISE AND COUNSEL ON NUTRITION AND SELF-CARE AND SUBSTANCE ABUSE

Use the information and counselling sheet to support your interaction with the woman, her partner and family.

Counsel on nutrition

• Advise the woman to eat a greater amount and variety of healthy foods, such as meat, fish, oils, nuts, seeds, cereals, beans, vegetables, cheese, milk, to help her feel well and strong (give examples of types of food and how much to eat).
• Spend more time on nutrition counselling with very thin, adolescent and HIV-infected woman.
• Determine if there are important taboos about foods which are nutritionally important for good health. Advise the woman against these taboos.
• Talk to family members such as the partner and mother-in-law, to encourage them to help ensure the woman eats enough and avoids hard physical work.

Advise on self-care during pregnancy

Advise the woman to:

• Take iron tablets F3 .
• Rest and avoid lifting heavy objects.
• Sleep under an insecticide impregnated bednet.
• Counsel on safer sex including use of condoms, if at risk for STI or HIV G2 .
• Avoid alcohol and smoking during pregnancy.
• NOT to take medication unless prescribed at the health centre/hospital.

Counsel on Substance Abuse:

• Avoid tobacco use during pregnancy.
• Avoid exposure to second-hand smoke.
• Do not take any drugs or Nicotine Replacement Therapy for tobacco cessation.

Counsel on alcohol use:

• Avoid alcohol during pregnancy.

Counsel on drug use:

• Avoid use of drugs during pregnancy.

C14-C15. DEVELOP A BIRTH AND EMERGENCY PLAN

Facility delivery.

Explain why birth in a facility is recommended

• Any complication can develop during delivery - they are not always predictable.
• A facility has staff, equipment, supplies and drugs available to provide best care if needed, and a referral system.
• If HIV-infected she will need appropriate ARV treatment for herself and her baby during childbirth.
• Complications are more common in HIV-infected women and their newborns. HIV-infected women should deliver in a facility.

Advise how to prepare

Review the arrangements for delivery:

• How will she get there? Will she have to pay for transport?
• How much will it cost to deliver at the facility? How will she pay?
• Can she start saving straight away?
• Who will go with her for support during labour and delivery?
• Who will help while she is away to care for her home and other children?

Advise when to go

• If the woman lives near the facility, she should go at the first signs of labour.
• If living far from the facility, she should go 2-3 weeks before baby due date and stay either at the maternity waiting home or with family or friends near the facility.
• Advise to ask for help from the community, if needed I2 .

Advise what to bring

• Home-based maternal record.
• Clean cloths for washing, drying and wrapping the baby.
• Additional clean cloths to use as sanitary pads after birth.
• Clothes for mother and baby.
• Food and water for woman and support person.

Home delivery with a skilled attendant

• Review the following with her:
• Who will be the companion during labour and delivery?
• Who will be close by for at least 24 hours after delivery?
• Who will help to care for her home and other children?
• Advise to call the skilled attendant at the first signs of labour.
• Advise to have her home-based maternal record ready.

Explain supplies needed for home delivery

• Warm spot for the birth with a clean surface or a clean cloth.
• Clean cloths of different sizes: for the bed, for drying and wrapping the baby, for cleaning the baby's eyes, for the birth attendant to wash and dry her hands, for use as sanitary pads.
• Buckets of clean water and some way to heat this water.
• Bowls: 2 for washing and 1 for the placenta.
• Plastic for wrapping the placenta.

Advise on labour signs

Advise to go to the facility or contact the skilled birth attendant if any of the following signs:

• a bloody sticky discharge.
• painful contractions every 20 minutes or less.
• waters have broken.

Advise on danger signs

Advise to go to the hospital/health centre immediately, day or night, WITHOUT waiting if any of the following signs:

• vaginal bleeding.
• convulsions.
• severe headaches with blurred vision.
• fever and too weak to get out of bed.
• severe abdominal pain.
• fast or difficult breathing.
• She should go to the health centre as soon as possible if any of the following signs:
• abdominal pain.
• swelling of fingers, face, legs.

Discuss how to prepare for an emergency in pregnancy

where will she go?

how will they get there?

how much it will cost for services and transport?

can she start saving straight away?

who will go with her for support during labour and delivery?

who will care for her home and other children?

• Advise the woman to ask for help from the community, if needed I1 – I3 .
• Advise her to bring her home-based maternal record to the health centre, even for an emergency visit.

C16. ADVISE AND COUNSEL ON FAMILY PLANNING

Counsel on the importance of family planning.

• If appropriate, ask the woman if she would like her partner or another family member to be included in the counselling session.

Ask about plans for having more children. If she (and her partner) want more children, advise that waiting at least 2 years before trying to become pregnant again is good for the mother and for the baby's health.

Information on when to start a method after delivery will vary depending whether a woman is breastfeeding or not.

Make arrangements for the woman to see a family planning counsellor, or counsel her directly (see the Decision-making tool for family planning providers and clients for information on methods and on the counselling process).

• Counsel on safer sex including use of condoms for dual protection from sexually transmitted infections (STI) or HIV and pregnancy. Promote especially if at risk for STI or HIV G4 .
• For HIV-infected women, see G4 for family planning considerations
• Her partner can decide to have a vasectomy (male sterilization) at any time.

Method options for the non-breastfeeding woman

Special considerations for family planning counselling during pregnancy

Counselling should be given during the third trimester of pregnancy.

can be performed immediately postpartum if no sign of infection (ideally within 7 days, or delay for 6 weeks).

plan for delivery in hospital or health centre where they are trained to carry out the procedure.

ensure counselling and informed consent prior to labour and delivery.

can be inserted immediately postpartum if no sign of infection (up to 48 hours, or delay 4 weeks)

plan for delivery in hospital or health centre where they are trained to insert the IUD.

Method options for the breastfeeding woman

C17. ADVISE ON ROUTINE AND FOLLOW-UP VISITS

Encourage the woman to bring her partner or family member to at least 1 visit.

Routine antenatal care visits

• All pregnant women should have 4 routine antenatal visits.
• First antenatal contact should be as early in pregnancy as possible.
• During the last visit, inform the woman to return if she does not deliver within 2 weeks after the expected date of delivery.
• More frequent visits or different schedules may be required according to national malaria or HIV policies.
• If women is HIV-infected ensure a visit between 26-28 weeks.

Follow-up visits

C18. HOME DELIVERY WITHOUT A SKILLED ATTENDANT

Reinforce the importance of delivery with a skilled birth attendant

Instruct mother and family on clean and safer delivery at home

If the woman has chosen to deliver at home without a skilled attendant, review these simple instructions with the woman and family members.

• Give them a disposable delivery kit and explain how to use it.

Tell her/them:

• To ensure a clean delivery surface for the birth.
• To ensure that the attendant should wash her hands with clean water and soap before/after touching mother/baby. She should also keep her nails clean.
• To, after birth, dry and place the baby on the mother's chest with skin-to-skin contact and wipe the baby's eyes using a clean cloth for each eye.
• To cover the mother and the baby.
• To use the ties and razor blade from the disposable delivery kit to tie and cut the cord.The cord is cut when it stops pulsating.
• To wipe baby clean but not bathe the baby until after 6 hours.
• To wait for the placenta to deliver on its own.
• To start breastfeeding when the baby shows signs of readiness, within the first hour after birth.
• To NOT leave the mother alone for the first 24 hours.
• To keep the mother and baby warm.To dress or wrap the baby, including the baby's head.
• To dispose of the placenta in a correct, safe and culturally appropriate manner (burn or bury).
• Advise her/them on danger signs for the mother and the baby and where to go.

Advise to avoid harmful practices

For example:

not to use local medications to hasten labour.

not to wait for waters to stop before going to health facility.

NOT to insert any substances into the vagina during labour or after delivery.

NOT to push on the abdomen during labour or delivery.

NOT to pull on the cord to deliver the placenta.

NOT to put ashes, cow dung or other substance on umbilical cord/stump.

Encourage helpful traditional practices:

If the mother or baby has any of these signs, she/they must go to the health centre immediately, day or night, WITHOUT waiting

• Waters break and not in labour after 6 hours.
• Labour pains/contractions continue for more than 12 hours.
• Heavy bleeding after delivery (pad/cloth soaked in less than 5 minutes).
• Bleeding increases.
• Placenta not expelled 1 hour after birth of the baby.
• Very small.
• Difficulty in breathing.
• Feels cold.
• Not able to feed.

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• ASSESS THE PREGNANT WOMAN: PREGNANCY STATUS, BIRTH AND EMERGENCY PLAN
• RESPOND TO OBSERVED SIGNS OR VOLUNTEERED PROBLEMS
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• Published: 19 October 2023

What do mothers think about their antenatal classes? A mixed-method study in Switzerland

• Valérie Avignon 1 , 2 , 3 ,
• Laurent Gaucher 2 , 4 ,
• David Baud 1 ,
• Hélène Legardeur 1 ,
• Corinne Dupont 2 &
• Antje Horsch 1 , 3  

BMC Pregnancy and Childbirth volume  23 , Article number:  741 ( 2023 ) Cite this article

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Research so far has evaluated the effect of antenatal classes, but few studies have investigated its usefulness from the perspective of mothers after birth.

Antenatal classes evolved from pain management to a mother-centred approach, including birth plans and parenting education. Evaluating the perception of the usefulness of these classes is important to meet mother’s needs. However, so far, research on the mothers’ perception of the usefulness of these classes is sparse, particularly when measured after childbirth. Given that antenatal classes are considered as adult education, it is necessary to carry out this evaluation after mothers have had an opportunity to apply some of the competences they acquired during the antenatal classes during their childbirth.

This study investigated mothers’ satisfaction and perceived usefulness of antenatal classes provided within a university hospital in Switzerland, as assessed in the postpartum period.

Primiparous mothers who gave birth at a Swiss university hospital from January 2018 to September 2020 were contacted. Those who had attended the hospital’s antenatal classes were invited to complete a questionnaire consisting of a quantitative and qualitative part about usefulness and satisfaction about antenatal classes. Quantitative data were analysed using both descriptive and inferential statistics. Qualitative data were analysed using thematic analysis.

Among the 259 mothers who answered, 61% ( n  = 158) were globally satisfied with the antenatal classes and 56.2% ( n  = 145) found the sessions useful in general. However, looking at the utility score of each theme, none of them achieved a score of usefulness above 44%. The timing of some of these sessions was questioned. Some mothers regretted the lack of accurate information, especially on labour complications and postnatal care.

Antenatal classes were valued for their peer support. However, in their salutogenic vision of empowerment, they did not address the complications of childbirth, even though this was what some mothers needed. Furthermore, these classes could also be more oriented towards the postpartum period, as requested by some mothers.

Revising antenatal classes to fit mothers’ needs could lead to greater satisfaction and thus a better impact on the well-being of mothers and their families.

Peer Review reports

Antenatal classes (AC) were developed in the 1950s on the assumption that pain is not inherent to the birth process but that fear of childbirth generates tension, which in turn leads to pain [ 1 ]. The concepts of fearless childbirth (Dick-Read; 1890–1959) or painless childbirth strongly inspired by Pavlov’s theories (Lamaze; 1891–1957) stem from this principle [ 1 , 2 ]. Painless childbirth, or obstetrical psychoprophylaxis, spread rapidly in Europe [ 2 ] and became commonplace in the 1970s [ 1 ]. Profound changes in AC in the 1980s [ 3 ] due to the development of feminism and the reduction of postnatal hospitalisation, led to a greater involvement of partners to share tasks with the newborn and support the mother at home. On the other hand, medicalisation of childbirth, including the development of epidurals, changed the AC’s content [ 3 ]. Pain control was no longer the main objective and new mother-centred approaches were developed, such as Leboyer’s non-violent childbirth, sophrology, yoga, prenatal singing, haptonomy, and aquanatal sessions [ 1 ].

Since the beginning of the 2000s, the psychoprophylactic approach (mental and physical training) received increased interest [ 4 ]. Theoretical knowledge about pregnancy and childbirth, breathing techniques, postural work, and relaxation remain the base of AC [ 5 ]. However, new AC goals are to enable the woman to develop her own birth plan, considering her preferences, emotions, and perceptions, as well as her life context [ 6 ]. Antenatal classes are now widely implemented in the Western World [ 7 ]. With a wide range of goals and modalities, the theoretical bases are linked to Dick-Read’s and Lamaze’s approaches, enhanced by novel theories like “Active Birth” and “Hypnobirthing” [ 7 ].

The evaluation of antenatal classes is scarce [ 4 , 8 ] and mainly focuses on mothers’ knowledge, obstetrical, neonatal or psychological outcomes rather than on satisfaction [ 9 ]. However, exploring patient satisfaction, i.e., if the care approach fulfilled the patients’ expectations [ 10 ], is a key measure of healthcare quality [ 11 ]. However, evaluating it after the completion of the courses but before birth means only assessing what mothers think about the sessions and what they think they could do without taking into account what they were, really, able to do during birth and as new parents [ 12 ]. Several quantitative and qualitative studies explored the satisfaction with and perceived usefulness of AC after birth [ 13 , 14 , 15 , 16 ]. The poor quality of studies [ 8 ] and a lack of standardization and guidelines regarding the content and modalities of AC make it difficult to generalise the results [ 7 ]. However, antenatal classes seem to be necessary and should be proposed to all primiparous women [ 8 ]. Moreover, so far, no evaluation of mothers’ satisfaction and/or perceived usefulness of AC in Switzerland, after the birth, was available.

Therefore, we aimed to conduct a quantitative and qualitative evaluation of antenatal classes offered by our University Hospital from the mothers’ perspective, based on the Lamaze theoretical model.

A mixed-method study analysing quantitative and qualitative sections of a satisfaction questionnaire was conducted. Quantitative and qualitative approaches are complementary, collected at the same time, and analysed a ccording to a convergent parallel method [ 17 ]. The questionnaire was part of a larger cross-sectional study investigating relationships between AC attendance, birth satisfaction, and symptoms of post-traumatic stress disorder [ 18 ].

The Lausanne University Hospital (CHUV, Switzerland), realize approximately 3200 births per year. Pregnancies are monitored by a gynaecologist in the community or by a gynaecologist and/or midwife in the hospital During birth, one-to-one midwifery care is organised. After the birth, the hospital stay varies in general from 2 to 5 days. Following discharge, independent midwives follow up 93.8% of women at home, with an average of 7.6 home visits [ 19 ].

The CHUV proposes four different formats of AC: psychoprophylactic sessions, aqua natal sessions, antenatal exercise classes, and short antenatal sessions. Mothers also have the option of attending AC outside the hospital. AC are refunded by Swiss health insurances up to an amount of 150 Swiss francs per session. The session fees of the short antenatal sessions are based on this amount, enabling all pregnant women to sign up to AC.

The CHUV AC sessions, based on the Lamaze theoretical model, focus on coping strategies by emphasizing a pro-active problem-solving approach. They were designed to increase mothers’ self-confidence for childbirth and parenting by using case examples, allowing mothers and couples to project themselves into childbirth. Except for short AC sessions, programs comprise five two-hour sessions before birth (32 to 36 weeks of gestation), and one at 6 weeks after birth. Practical exercises are proposed in different formats (antenatal exercise classes, aqua natal sessions or psychoprophylactic sessions) including posture correction exercises, relaxation, and breathing techniques (see Supplementary materials Table S 1 ). The time dedicated to the practical part is greater in antenatal exercise classes and aquanatal sessions, which makes them particularly popular with multiparous mothers. The short antenatal sessions are limited to two-hour theoretical sessions on childbirth or breastfeeding, without practical exercises. A previous publication highlighted that the AC attendees are generally higher educated and from a more privileged socio-economic background [ 18 ].

Study procedure and participants

All primiparous mothers over 18 years, who gave birth to a single, live, term baby (≥ 37 weeks of gestational age) at the hospital between January 2018 to September 2020, were contacted by Short Message Services (SMS) from June 2020 to December 2020, with three reminders. This SMS invited them to complete a questionnaire via an internet link (see [ 18 ] for more details). Mothers indicated in the questionnaire whether they had attended AC and if so, where. Only mothers who attended CHUV antenatal classes were included in the present study.

The quantitative part consisted of six items related to satisfaction (fulfilment of a need) and usefulness (relevance of the information to the context) of overall and different parts of the AC (pregnancy, childbirth, newborn’s and mother’s needs). The last author developed the questionnaire for another study [ 20 ] and adapted it to the childbirth context for this study. Each question used a five-point Likert scale ranging from “1 = Not at all satisfied” or “1 = Not at all helpful” to “5 = Extremely satisfied” or “5 = Extremely helpful”. A question about the timing of AC was answered with a three-point Likert scale: “too early”, “adequate” or “too late”. Mothers were also asked if they would recommend these AC to a friend.

The qualitative part consisted of a free text space available after each quantitative question, allowing mothers to explain their evaluation but also to express their feelings about each part of the AC. Moreover, three open-ended questions were asked: two about the three most helpful or difficult things regarding AC and another about the topics that mothers would have liked to have discussed and that were not addressed (See Supplementary material S 3 ).

Demographic information (citizenship, civil status, educational background) and was collected via self-report questionnaires. Medical data (maternal age at birth, induction of labour, oxytocin augmentation, analgesia, mode of birth, admission in NICU) were extracted from medical records.

Data analysis

This study consisted of two different but concurrent phases [ 17 ]. In this design, quantitative and qualitative data were collected together by questionnaire. The data were separately analysed and then merged, allowing qualitative data to support quantitative results [ 17 ].

Quantitative analyses were conducted with SPSS® (Statistical Package for Social Sciences, IBM®, version 27.0). Descriptive statistics for obstetric and neonatal outcomes, as well as for satisfaction and usefulness of the sessions were done. Bi-variate correlations were carried out to examine whether satisfaction and usefulness of the sessions were related to the number of sessions attended or the time between the childbirth and the completion of the questionnaire. Some demographic data and obstetrical data were missing (see Table 1 ). No missing data were replaced.

Qualitative analyses, conducted by the first author, used a hybrid approach of qualitative methods of thematic analysis [ 21 ]. It consisted firstly of a deductive approach using an a-priori template of codes based on the domains addressed in the questionnaire (Overall comment, Pregnancy, Childbirth, New-borns’ and Mothers’ needs) according to the approach of Crabtree and Miller [ 22 ]. Secondly, according to the methodology describe by Boyatzis [ 23 ], a data-driven inductive approach was implemented to isolate the themes within the pre-defined domains. This complementary approach allowed new themes and sub-themes to emerge within the domains induced by the structure of the questionnaire and thus provided additional data in the analysis of mothers’ satisfaction with their AC.

Ethical issues

This project was developed in accordance with the rules and regulations in relation to research on human beings in force in Switzerland (risk category A). Each woman had to electronically sign an informed e-consent before participating in the study. The Ethical Committee of the Canton de Vaud approved the study protocol (n°2019–02228).

Of the 2876 eligible mothers contacted in the main study, 289 mothers (10%) were involved in the AC at the CHUV (Fig.  1 ). Respondents had a mean age of 32.8 years, were mostly Swiss (58.5%; n  = 169), in a couple relationship (67.7%; n  = 195), and had a strong educational background (73.6%; n  = 212). Participants mainly had a vaginal birth (79.2%; n  = 229), with epidural analgesia (58.5%; n  = 169), and gave birth to a healthy newborn (91.7%; n  = 65; Table 1 ).

Study flow chart

Among the 289 study participants, 89% had followed the psychoprophylactic sessions, 6% the aqua natal classes, 4% the antenatal exercise classes, and 1% ( n  = 2) said “other methods”. The majority of mothers followed five sessions [min = 1-max = 10]. No significant associations between the number of attended sessions and the satisfaction with or perceived usefulness of those sessions were found, except for the usefulness of the session about pregnancy. Mothers who followed only one session found the information about pregnancy significantly less helpful (Table 2 ). Data collection occurred between 2 to 29 months after birth. There were no significant associations between satisfaction with perceived usefulness of the AC and the time between birth and data collection (Table 2 ).

Depending on the questions, between 91 and 138 mothers made comments used in the thematic analysis. Detailed information about characteristics of the mothers whose quotes are included in the text are available as supplementary material (Table S 2 ). From the five main domains, the data-driven inductive approach made it possible to highlight three main themes and nine sub-themes (Table 3 ). The three main themes were: “1. Satisfaction and usefulness of classes”, “2. Timing of classes”, and “3. Content of classes”.

Satisfaction and usefulness of classes

More than half of the mothers (61.0%; n  = 158) were very or extremely satisfied with AC and 56.2% ( n  = 145) found these sessions very or extremely helpful. The timing of the sessions appeared mostly appropriate (83.6%; n  = 209), although too late for 12.8% ( n  = 37) of mothers. Moreover, 85.9% ( n  = 221) of the mothers who attended AC would recommend these sessions to a friend.

One of the main sources of satisfaction was peer support. It is the first most useful point of AC cited by mothers (17.6%) not related to childbirth (see Fig.  3 ). The group allowed sharing “feelings and worries” (P84), experiences and concerns (P414) “ with other people who are in the same situation” (P661) , which was seen as “reassuring” (P661) and “very precious” (P1936).

Regarding usefulness of AC, the best-rated session was the childbirth session, found to be very or extremely helpful by 43.9% ( n  = 108) of mothers. Satisfied mothers stated that AC provided clear information, allowed feeling more secure, confident and well prepared for the childbirth, even in the case of difficulties and complication. The midwife helped them to “feel confident” (P320) and the fact that mothers can “ ask the midwife any questions about the birth and the pregnancy ” led to a feeling of being accompanied (P390). Breathing exercises were mentioned as “ a beneficial aid during the management of contraction-related pain ” (P94). However, some mothers also reported difficulties in moving from teaching to practice “Because when it comes to the real labour, the real pain, the adrenaline, the emotion, etc ., we forget everything we have learned during these courses!” (P481).

However, no session was overwhelmingly rated as very or extremely useful (Fig.  2 ).

Participants’ perceived usefulness ratings according to the different topics addressed during antenatal classes ( n  = 289)

Only nine mothers (3%), rated each session as very or extremely helpful. The least useful session was the one on the needs of postpartum mothers, which was considered very or extremely useful by only 22.7% of them (Fig.  2 ). Information about postnatal care for mothers and newborns was found to be globally of little use, with about 47% ( n  = 55) of the mothers saying that this subject was poorly discussed. Newborn’s needs were not specifically discussed, and this was felt by a participant as “a shame because [she] didn’t knows how to deal with a child.” (P185). Regarding mothers’ needs, the lack of information and dialogue on these issues gave participants the impression that “the postpartum period, which takes place at home in the following days, remains taboo” (P594). Moreover, the lack of solutions to prevent difficulties was also a source of dissatisfaction: “ We hear about potential postpartum depression, but how can we avoid it? What are the keys to a successful postpartum? What can we do before the baby arrives to make sure we feel good after giving birth?” (P224).

Timing of classes

Mothers found the timing of the sessions adequate (89%, n  = 199), but questioned the timing of some of them in the comments. For instance, the session about pregnancy “take place close to the end of the pregnancy” (P481) and “there was little connection with (…) (the) pregnancy” (P268). Mothers felt “ already familiar with the course of the pregnancy” (P481). The question of the timing of sessions also arose with regard to sessions dedicated to mothers’ and newborns’ needs. Some mothers felt that discussing postnatal care in AC “ was not the purpose.” (P145). It was “Too early to think about it almost” (P219) and it seems better to advance “step by step on these points” (P280). Perhaps, mothers would be “most receptive to this after the birth” (P29) as “as long as the baby is not here, it is difficult to retain all this information” (P266) . Finally, the AC may not be the best place to discuss this but “ rather with the midwife who visits at home” (P280) because “The change of life is so radical that the courses cannot prepare (them) for it” (P439). Finally, a woman raised the question of the place of post-natal support:

“I never imagined that the hormonal drop would be so difficult to live with, the feeling of emptiness left inside me, the fusion that I miss with my baby, the doubts, the fatigue, dealing with the people around me... (…) It would be very useful to be able to open a dialogue on this point and to warn future mothers of this important challenge...” (P30).

Content of classes

The conceptual content analysis revealed that the three most helpful topics were related to childbirth: stages of childbirth including duration of labour and birthing positions, the visits of the delivery rooms and the pain management including breathing, relaxation, and positioning during contraction to alleviate pain (Fig.  3 ).

Percentages of mothers perceiving topics discussed during the antenatal classes as helpful or missing

Explanations about the stages of childbirth were seen as helpful “to de-stress ” (P729) and “ knowing when to call the hospital (first contractions, frequency, pain, etc .) was reassuring (P396). Mothers particularly highlighted “ some useful exercises to relieve the contractions (…)” (P396) and the “ provision of useful ways to manage pain, concentration, and breathing ” (P820) to “feel empowered during the birth” (P390). Moreover, these sessions also provided the opportunity to explain the hospital procedure “ The arrival protocol, explanations of possible medical procedures, the reasons for them, and how they are carried out” (P4). Finally, the sessions provided a space to involve the partner in the process of pregnancy and childbirth and for the postnatal, thus relieving the woman of the teaching role towards her partner: Finally, “The sessions strengthened the ‘team’ spirit in the couple.” (P390). One woman summarised particularly well this topic saying: “I was afraid of childbirth, so having the right information helped me. To know when labour started when to go to the maternity ward, the different positions to reduce the pain of contractions and, above all, to involve my partner in this process ” (P201).

However, the majority of mothers were dissatisfied with the content of the different sessions that they found incomplete and/or inadequate. For example, among the mothers who responded that childbirth classes were moderately to not at all helpful, 19% ( n  = 13) had a caesarean section and received no information on this topic. Dissatisfaction of mothers came from a feeling that the midwife avoided talking about possible difficulties and complications. The content of the sessions seemed to be too centred on natural birth and mothers felt not prepared for other situations. A woman said, “We are not told everything to “protect” us and in the end, we feel a bit lost when the day comes.” (P 276), while another highlighted “ a tendency to want to show the hunky-dory side of things” , which leads to feeling “ so disappointed afterwards when there are complications” (P454).

Finally, one woman expressed the feeling of “ frustration” about the birth plan developed with the help of AC and thought that “ Preparing to ‘welcome’ the unexpected would have been more useful.” (P382). Mothers suggested that “ complications need to be addressed clearly and mothers need to be told what can happen in certain situations, so that they can react or interact in the best possible way during the birth .” (P454). Dissatisfied mothers found in the sessions “ A lot of banalities, lack of dialogue, little information on a less conventional delivery (e.g., caesarean section), very little information on postpartum in general, and very little information on breastfeeding” (P516), with also “ little information on pregnancy in general and on the stages of development of the baby in the womb” (P460). Moreover, “the sessions only repeat the content of the received documents” (P11) and as “the internet already provides a lot of information” (P198) it makes “the preparation sessions (…) boring…”( P297). Furthermore, some mothers questioned the correspondence of the content of the sessions with the reality of childbirth: “ The contractions didn’t go as I had imagined. We realised that it wouldn’t be like what we had prepared for .” (P126).

Regarding the postpartum, the great majority (76%) of the mothers found the content of the sessions useless. The conceptual content analysis showed that the most frequently mentioned missing topic was the postnatal including the return home and the impact on lifestyle (see Fig.  3 ) . For some mothers , “postpartum needs were extensively discussed. Lots of info were given about where we could find support/help in case of postpartum-related issues” (P84). Moreover, “hearing some advice allowed to talk about it as a couple and to prepare, to take some decisions” (P126). Finally, “the description of the possible postpartum states was reassuring afterwards when fatigue and panic overtook us. You don’t feel alone” (P820). Finally, the presence of the partner during this session was considered helpful in order to support the childbearing mother: “because otherwise I would have totally forgotten myself for the baby. My husband had learned from the course what my needs would be and he looked after me while I looked after the baby.” (P725). However, the majority considered that “this is a big gap in general” (P330), with “little mention of the baby blues. No mention at all about vaginal bleeding, soreness, breast tenderness” (P369). They also wanted “more info about postpartum depression risks and recovery from childbirth” (P464). Opinions about breastfeeding were more contrasted. Half of the mothers found this session “informative, warm, and professional” (P 714), “useful and necessary (P313 ) and especially useful “to understand that breastfeeding takes time… there, the numbers, days, averages…”(P 611) with solutions to deal with breastfeeding (P842). The other half were not satisfied with these sessions, as they found them “very quick and rather superficial” (P594) with a kind of “idealisation of breastfeeding” (P11). Moreover, some mothers were very dissatisfied to experience “a lot of pressure on breastfeeding” (P 483) and one of them felt the need to “prepare (herself) for the painful pro-breastfeeding propaganda that awaited (her)” (P 603). Moreover , “no info on bottles, although (they) would have deserved to have this info too.” (P 483) and “some information on infant colic would have been useful” (P712). Mothers also noted “few explanations on the first days of life (of the baby), i.e., the most destabilizing, sleep, breastfeeding” (P372).

This mixed-method study investigated satisfaction and usefulness of AC after the birth which is, to our knowledge, the first time this was done in Switzerland. The quantitative part of the study found that less than two-third of mothers after birth were satisfied with the AC. In the qualitative part, mothers questioned the usefulness of these sessions, their content, as well as the timing of some of these sessions. They wanted to be more informed, in a realistic way, and not to be overprotected regarding possible risks or complications of childbirth and postpartum.

One important point our participants raised was that AC were an important space for sharing and meeting other future parents. This is in line with previous research showing that AC improved peer support [ 24 ] and were a source of knowledge [ 25 ]. Moreover, sharing problems with other parents normalizes their concerns [ 25 ].

The lack of perceived usefulness of AC may partly be explained by the fact that data collection occurred after the birth. Another study showed that comments about the content of these sessions were less favourable when evaluated after the birth rather than after the completion of AC [ 26 ]. However, mothers in an Italian study described the AC as very useful when asked after the birth even if, as in our study, the ability to put into practice the knowledge of the sessions was the more difficult thing [ 14 ]. Yet, the number of sessions and the stakeholders were different. Moreover, the completion of the questionnaire occurred in the immediate postpartum period, which could explain some of the differences in the results, especially with regard to satisfaction with the postpartum period and care of the baby [ 14 ].

Regarding the timing of the sessions, others studies have already highlighted that the pregnancy session arrived often too late and recommended starting AC in the second trimester [ 27 ] or, according to parents’ opinions, before conception or at the beginning of pregnancy [ 28 ]. Breastfeeding and its potential problems seemed to be, for the parent, the most important point to be addressed during AC [ 29 ]. However, this theme, together with the topic of parenting, was addressed at the very end of pregnancy, after the childbirth session, while mothers seemed to be interested in motherhood, and particularly in breastfeeding, from the 24 th week of pregnancy [ 30 ]. Allowing parents to discuss this information earlier in the pregnancy, at a more privileged moment of attention, might be preferable. Finally, parents would also prefer sessions to continue up to one year after birth in order to discuss more about parenting [ 30 ].

Regarding the content, one of the top two reasons for AC attendance was to feel more secure when taking care of their newborn [ 31 ]. However, this theme seemed to be poorly discussed in our study, even if 40% of the antenatal sessions were devoted to the postnatal. This was also the case in other studies [ 27 , 32 ], with up to 67% of the content being relative to childbirth [ 27 ]. In a Swedish study, only 40% of mothers thought that AC helped them prepare for early parenthood [ 33 ]. This feeling of unpreparedness for parenthood was widely shared by parents in the literature, even though some mothers thought that they might have forgotten some AC information [ 32 ]. Regarding breastfeeding education, mothers felt largely unprepared for potential breastfeeding complications [ 16 , 26 , 27 ], as half the comments in our study showed. Midwives are particularly convinced of the value of breastfeeding and actively transmit this message [ 34 ]. The discourse is sometimes perceived to be more coercive than informative [ 34 ], something that some of our mothers also seem to have experienced.

Strengths and limitations

One of the main strengths of our study is that comments were collected after the birth. This enabled the mothers to better evaluate the usefulness of the information provided, to realise what information was missing, as well as the difficulties in putting them into practice. Providing questionnaires in French and English was also a positive point, as this covered the two main languages used in the hospital providing the AC.

However, this study has a number of limitations. First, some of the mothers may have forgotten some points explained in the sessions, as for some participants, up to 2 years had passed since birth. In addition, some women may have become pregnant again between the first birth and the time of data collection. Furthermore, mothers may have only retained the most salient points of their experience. Additionally, the low response rate of the main study (27.6%) means that the participants’ remarks can be seen as a non-exhaustive reflection of what mothers think about prenatal care, although the response rate is comparable to other questionnaire studies [ 35 , 36 , 37 ], particularly to online surveys [ 38 , 39 ]. Our sample only represents a relatively privileged population compared to the general population, even though it is typical for the population that attends AC in this hospital. Moreover, the low caesarean rate of the sample (21.9%) compared to the caesarean rate of the hospital at this time (25%) suggests that our sample is not fully representative of the population of women giving birth in a Swiss hospital. The sample over-represented women who had a partner or were married (69.1% in our study versus 49% in the canton of Vaud), as well as women with a high level of education (71% in our study versus 42% in the canton of Vaud). Finally, this study was only conducted in one Swiss university hospital, thus limiting generalization of the results.

Implications for research and practice

As the AC do not meet the needs of mothers, it seems necessary to investigate their needs and, broadly, the needs of couples in terms of preparation for childbirth and parenthood, and to see if common needs exist across countries. A prospective approach would allow to reach all the women who attended antenatal classes and to compare responders and non-responders, and is therefore recommended. Furthermore, future studies should consider the use of a validated tool in order to measure satisfaction. Based on these needs, a new model of AC will have to be developed, guided by adult learning principles [ 40 , 41 ]. Moreover, this new model should take into consideration mothers with a lower level of education and less financial means, who are often excluded from AC, even if the sessions are free of charge [ 18 , 42 ]. Finally, standardisation of the basic content and training of those involved will also be necessary to generalise this new AC approach [ 7 , 43 , 44 ]. In parallel, it seems necessary to systematically evaluate this.

Mothers were mostly satisfied with AC but asked for a realistic view of childbirth and a better preparation for the postpartum period. Therefore, this study showed that it is necessary to rethink and adapt AC based on service users’ needs.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

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Acknowledgements

The authors gratefully acknowledge the mothers who participated in this study.

Open access funding provided by University of Lausanne This study was part of the PhD work of the first author and was funded by the Department Woman-Mother–Child of Lausanne University Hospital (Switzerland). Antje Horsch is on the management board of COST CA18211.

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A.H., D.B. and V.A: conceived and designed the study. V.A conducted the data acquisition. A.H. and V.A contributed to the analysis and wrote the paper. A.H., D.B., L.G, H.L and C.D substantively revised it. All authors approved the final manuscript prior to submission.

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Supplementary Information

Additional file 1: supplementary materials 3., additional file 2: table s1..

Brief description of antenatal sessions (scenarios are available in French on request to the authors).

Additional file 3: Table S2.

Obstetrical and neonatal outcomes of mothers whose citation are include in the text.

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Avignon, V., Gaucher, L., Baud, D. et al. What do mothers think about their antenatal classes? A mixed-method study in Switzerland. BMC Pregnancy Childbirth 23 , 741 (2023). https://doi.org/10.1186/s12884-023-06049-8

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DOI : https://doi.org/10.1186/s12884-023-06049-8

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Kolkata doctor rape and murder: Mamata gives police 7 days to crack the case

Updated - August 12, 2024 11:35 pm IST

Published - August 12, 2024 01:45 pm IST - Kolkata

West Bengal Chief Minister Mamata Banerjee. File | Photo Credit: PTI

As protests continued to rage over the alleged rape and murder of a doctor at Kolkata R G Kar Medical College and Hospital, West Bengal Chief Minister Mamata Banerjee on Monday (August 12, 2024) gave the police a seven-day deadline to make progress in the case, failing which she would hand over the investigation to the Central Bureau of Investigation (CBI).

“I want the police to arrest the culprits as soon as possible. If by Sunday they are unable to crack the case, then I will hand over the investigation to the CBI... because insiders may be involved,” Ms. Banerjee said.

The Chief Minister made the announcement after meeting the family members of the victim who was found dead in a seminar room of the State-run health facility on Friday.

Ms. Banerjee said that even the family members alleged the possibility of an outsider being involved. “I am surprised as to how the incident occurred — nurses were there, the security personnel were there,” she added.

The Chief Minister said that all the people who were in positions of responsibility — like the principal and medical superintendent of the hospital and the police officer in charge of security — have been removed from their respective positions.

Also watch : Kolkata doctor rape and murder: Doctors across India continue strike

Earlier in the day, the Principal of the medical college and hospital, Sandip Ghosh resigned from his post. The State government had already removed Sanjay Vasistha, the Medical Superintendent of the hospital, from his post. The Kolkata Police on Saturday arrested a civic police volunteer in connection with the crime. The accused was allegedly seen in CCTV footage near the crime scene. Signs of sexual assault have emerged from the post-mortem exam.

Also read: Strike continues for 4th day, hospital services hit across Bengal

There were rumours about involvement of more people in the crime, which the Commissioner of Kolkata Police Vinnet Kumar Goyal rejected during discussions with the protesting students on Sunday.

The junior doctors protesting against the brutal crime rejected the Chief Minister’s offer and said that they would keep up the demonstrations. The Federation of Resident Doctors’ Association of India (FORDA) has endorsed the strike. A two-member team of the National Commission for Women (NCW) arrived in Kolkata and visited the State police headquarters to probe the incident.

The incident has sparked a political war of words, with Opposition parties targeting the Trinamool Congress government. On Monday, Congress leader Priyanka Gandhi Vadra described the incident as heartbreaking. “Safety of women at the workplace is a big issue in the country and concrete efforts are needed for this. I appeal to the State government to take immediate and strict action in this case and ensure justice to the victim’s family and fellow doctors,” she said.

Reacting to the deadline given by Chief Minister to Kolkata Police, BJP leader Amit Malviya alleged that the underlying implication of this deadline was that she required more time to obfuscate the situation, protect the influential individuals and their kin involved in the rape and murder, intimidate the victim’s family. “She will subsequently transfer a compromised case to the CBI, blame them and mask her own administrative failings,” he added.

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