Pregnancy is a normal process that results in a series of both physiological and psychological changes in expectant mothers. It is a unique and powerful feminine experience. However, normal pregnancy may be accompanied by some problems and complications that are potentially life threatening to the mother and/or the fetus 1.
Globally, every year, more than 200 million women become pregnant. Some of them (15%) are likely to develop complications that will require skilled obstetric care to prevent death or serious ill health. Between 25 and 33% of all deaths of women at reproductive age in many developing countries are the results of complications of pregnancy or childbirth. The majority (almost 90%) of these deaths occur in Asia and Sub-Sahara Africa, ∼10% in other developing regions, and less than 1% in the developed world 2,3.
Women and children in developing countries are dying from simple preventable conditions. The WHO estimated that more than 500 000 mothers die each year because of pregnancy and related complications. Approximately 20% of pregnancy-related deaths in developing countries are indirect deaths due to pre-existing maternal conditions such as anemia and malaria that are aggravated by pregnancy 4.
All women, whether their pregnancies are complicated or not, need good-quality maternal services during pregnancy, delivery, and the postpartum period to ensure their health and that of their infants’. High-quality maternal health services must be accessible, affordable, effective, appropriate for and acceptable to the women who need them 5. Millions of women in developing countries lack access to adequate care during pregnancy: about 63% in Africa, 65% in Asia, and 73% in Latin America. In contrast, maternal healthcare is nearly universal in developed countries 6. Many barriers limit a woman’s access to care for herself during pregnancy including distance, cost, multiple demands on women’s time, poverty, fear regarding pregnancy, knowledge, beliefs, behavior toward antenatal care (ANC), and a lack of decision-making power. Ensuring that women have access to maternal healthcare is essential to saving their lives 7,8.
It was found that about 88–98% of all maternal deaths could be avoided by proper handling during pregnancy and labor. The antenatal period (ANP) represents the most important time for pregnant women. Many of the practices carried out during the ANP improve the wellbeing of the mother and/or the baby and decrease the burden of adverse perinatal outcomes. The WHO has developed specific guidelines regarding the timing and the content of ANP visits 4.
Health knowledge is a vital element to enable women to be aware of their health status during their pregnancies. Data on the maternal health status in Libya is scarcely available. This study was conducted to determine the level of knowledge, the attitude, and practices related to ANC among pregnant women in primary healthcare centers in Benghazi, Libya.
Participants and methods
A cross-sectional study was carried out during the period of September to December 2012 at three primary healthcare centers in Benghazi, Libya.
The target population of this study included pregnant women attending the out-patient clinic of primary healthcare centers (PHCs). According to the estimated good knowledge of women regarding ANC, which was 75%, to achieve 95% confidence interval around the expected prevalence and an error of ±5% around this estimate 9, the required sample was 300 pregnant women. Participants were chosen by a systemic random sample from the three PHCs with the highest attendance rates present in difference zones with different socioeconomic levels of pregnant women (out of 20 PHCs in Benghazi, Libya). A specially designed interview questionnaire was used to collect the necessary data. It included data on sociodemographic characteristics (age, residence, education, and the work of the pregnant women, education of the husband, the family size, and the income) and obstetrical history (data pertaining to the month of pregnancy and the number of previous pregnancies, abortions, and full-term deliveries).
Data regarding the knowledge about early booking, follow-up, nutrition in pregnancy, the effect of smoking during pregnancy, vaccination, medication, and dental care during the ANP were collected. Three response scales were used, in which the pregnant women were requested to give ‘correct’, ‘incorrect’, or ‘don’t know’ responses to all questions. The level of knowledge was assessed on the basis of the correct response to all questions. The answer of each knowledge question was scored as follows: score 2 for correct answers and score 0 for incorrect or don’t know answers. The total score of each participant was converted into a percentage. Those who scored more than 75% were treated as ‘knowledgeable’ (a high level of knowledge), those with 50–75% were treated as having an average level of knowledge, whereas those with less than 50% were treated as ‘not knowledgeable’ (a low level of knowledge). Also, the questionnaire included data about woman’s sources of knowledge regarding ANC.
The section regarding the attitude of the pregnant women toward ANC comprised 10 statements with the three-point Likert scale, with ‘agree’, ‘neutral’, or ‘disagree’ responses for each statement. These statements focused on the importance of early antenatal booking, regular follow-up, screening tests, nutrition and supplements, dental and breast care, smoking, complications of pregnancy, and preparation for delivery. The response for each statement was scored from 1 to 3, with a higher score for a more positive attitude toward ANC.
Accordingly, the maximum possible score was 30 and the minimum possible score was 10. The percentage of attitude was calculated as follows: those who scored more than 70% were denoted as having a ‘positive attitude’, those who scored 50–70% were denoted as having a ‘neutral attitude’, whereas those with a score less than 50% were denoted as having a ‘negative attitude’.
In addition, components of antenatal practices measured in this study included whether they went for antenatal visits, the timing of their first antenatal check-up, regular attendance to the antenatal clinic, hygienic care (breast and dental care), consumption of iron, folic acid, and vitamin supplements, medication during pregnancy, screening tests, and ultrasonography.
A scoring system was applied to assess the practices of the pregnant women during pregnancy as follows: score 2 for yes responses and score 0 for no and other responses. The total practice score ranged from 0 to 16 points. The percentage of practice was then calculated as follows: those who scored more than 75% were denoted as having ‘good level of practices’, those who scored 50–75% were denoted as having ‘fair level of practices’, whereas those with less than 50% were scored as having ‘poor level of practices’.
Pretesting of the questionnaire was conducted on 15 pregnant women attending one of the three chosen PHCs. These women were not included in the sample.
SPSS (IBM SPSS statistics for Windows, version 20.0; IBM Corp., Armonk, New York, USA) was used for data analysis. Descriptive analysis was performed using frequencies, percentages, means, and SDs, and the Pearson coefficient (r) test.
Ethical approval to conduct the study was obtained from the Scientific Research Ethics Committee of the High Institute of Public Health, Alexandria University. In addition, approval was obtained from the Ministry of Health and the Local Health Authority in Benghazi, Libya.
Researchers explained the purpose of the study and obtained informed consent before it was conducted.
A total of 300 pregnant women agreed to participate in this study. Nearly two-third (63.4%) of them were between 20 and less than 35 years of age. Meanwhile, 4.0% of the sample were young mothers (<20 years), with a mean age of 30.68±6.60 years. The residence of 88% of the sample was in urban areas. Regarding the month of pregnancy, about 41.7% of pregnant women were in the second trimester, 39.3% of them were in the third trimester, whereas 19% were in the first trimester. The results show that most of the pregnant women (97%) had a normal pregnancy and only 3% had a high-risk pregnancy.
A nearly equal percent of the pregnant women had university or higher education and secondary education (33.0 and 31.0%, respectively). About 69% of them were housewives. The highest percentage (30%) of their husbands had secondary education, followed by those with university or higher graduation (27%), and then those who had preparatory education (26%). Regarding the family size, it ranged from 2 to 12 persons, with a mean number of 4.60±2.18 persons. Regarding the income, 53.7% of the studied sample stated that their income was sufficient, but not enough to save, whereas only 4.3% had insufficient income and always owed.
Table 1 shows the distribution of the pregnant women by obstetrical data. The table shows that regarding the number of pregnancies (gravidity), 44.3% of the sample had experienced 2–4 pregnancies, whereas only 8.0% of the sample was gravida 8 or more pregnancies, with a mean number of 3.94±2.45 for the total sample. Regarding the parity, the index delivery was the first one for 23.3% of the mothers. However, it was the second to the fourth delivery for 50.6% of the sample, with a mean parity of 3.24±2.0.
Considering the history of live births, the table also reveals that 50.2% of the multiparous women had a history of 2–4 live births, with a mean of 3.19±2.01.
Regarding the history of abortion, about three-quarter (74.0%) of the pregnant women did not have any history of abortion, whereas 17.3% of them had a history of one abortion, and only 8.7% had a history of 2–4 abortions.
Regarding the history of stillbirths, the table reveals that only 6.1% of the sample had a history of one stillbirth. With regard to the history of the previous pregnancy, 93.8% of the pregnant women had a normal pregnancy. Regarding the nature of previous deliveries, 71.4% of the multiparous women mentioned that they had previous normal vaginal deliveries, whereas, 28.6% of the sample had previous cesarean sections. About three-quarter (75.9%) of the multiparous women gave birth in hospitals, whereas 22.9% of the multiparous women had previous deliveries at private clinics, and only 1.2% of them delivered at home. Nearly half (48.6%) of the multiparous women mentioned that they had at least one previous delivery attended by a female doctor, 22.0% of the sample had the delivery attended by a daya, and nearly one-fifth (20.8%) of them mentioned that they had at least one previous delivery attended by a male doctor. Meanwhile, nurses attended the deliveries of only 8.6% the multiparous women.
Knowledge of the pregnant women regarding antenatal care
Table 2 and Fig. 1 show that the highest percentage of the pregnant women (85.3%) had a high knowledge score, with a mean percent of 83.42 (SD=13.08). Further analysis of the questions on knowledge revealed that most of the respondents (97.3%) knew that pregnant women need to go for antenatal check-up and the harmful effect of maternal smoking on their fetus. However, only 1% knew that vaccination is important during the pregnancy period.
Figure 2 shows the distribution of the pregnant women according to their source of knowledge about ANC.
The figure illustrates that 60.0% of the pregnant women stated that their source of knowledge about ANC was from doctors, followed by 25.0% of them from relatives and friends, whereas only 6.0% the sources of their knowledge were from books.
Attitude of the pregnant women toward antenatal care
Table 3 and Fig. 3 show the distribution of the pregnant women by their attitude towards ANC.
With regard to the overall attitude towards ANC, results show that most of the pregnant women (96.0%) showed a positive attitude with a mean score percent of 89.75 (SD=8.93). For individual questions, it was noted that there was a good response to statements on the importance of routine screening tests, wherein 96.7% of the respondents agreed to it, followed by the harmful effect of smoking on their fetus (96.3%), and then the importance of early antenatal booking (95.7%). Also, the majority of the women agreed on the following statements: follow-up during pregnancy may decrease antenatal and postnatal complications, the amount of proteins, iron, and vitamins, and regular follow-up makes the delivery easier (89.7, 89.0, and 87.7%, respectively).
Table 4 and Fig. 4 show the distribution of the pregnant women regarding their ANC practices.
Results show that the highest rates of the respondents (above 75%) had a good practices score, with a mean score percent of 76.67 (SD=15.24). Also, when the women were asked about selected antenatal practices, the results revealed that the majority of them had correct practices regarding all ANC practices, except regular visits to the dentist during pregnancy (16.0%).
Table 5 shows the correlation between the pregnant women’s knowledge, attitude, and practice scores.
The table shows that the level of overall knowledge had a significant direct correlation with the practice towards ANC (r=0.228, P<0.001), whereas it has an insignificant correlation with the attitude of the respondents (r=0.029, P=0.619).
Pregnancy is a special event, and the family and the community should treat a pregnant woman with particular care 10. The importance of knowledge and awareness among pregnant women as factors affecting the acceptance and utilization of health services has been shown in other studies 11,12. Similarly, appropriate knowledge and attitude is vital in ensuring sustainable acceptance of antenatal services among the Libyan women.
The current study revealed that the majority (85.3%) of the pregnant women had a high level of knowledge regarding ANC. This finding is in contrast to a study in New Zealand 13. It is also relatively in disagreement with an Egyptian study, which reported that 58.2% of the pregnant women had unsatisfactory knowledge about ANC 14. In contrast, the current finding is in line with another study in Egypt 15, which revealed that 90.1 and 72.2% of their participants, respectively, had high knowledge regarding ANC. Obviously, the discrepancy among the different study results could be explained by the differences in the sampled populations and also the differences in the data collection tools.
Concerning vaccination, the tetanus toxoid vaccine is effective in preventing tetanus neonatorum, a potentially life-threatening condition. Tetanus infection can cause the production of a neurotoxin, leading to titanic muscle contractions. Tetanus immunization should be given twice in the first pregnancy, and once in each subsequent pregnancy 16.
Although the tetanus toxoid vaccine was canceled in Libya in 2009 by the Ministry of Health, in this respect, it was quite promising to find out that more than half (69.3%) of the pregnant women in the current study had correct knowledge about the importance of tetanus vaccine. This may be due to their experience during previous years before stopping the vaccine in 2009 and the role of television and mass media programs about vaccination during pregnancy.
The present study revealed that the majority (84.0%) of the women did not use any medications during pregnancy without physician prescription. They also mentioned that unprescribed medications without the doctor’s advice may have an adverse effect on women’s health and may cause congenital anomalies to the fetus. This finding was in line with a previous study, which emphasized that women should not use medications without prescription from their healthcare providers. Moreover, women who use drugs may be placing their unborn babies at risk for premature birth, poor growth, and birth defects. Babies born to such women may acquire addiction to those drugs themselves. Furthermore, even the common or over-the-counter medications that are generally safe may be considered off-limits during pregnancy because of their potential effects on the baby 17.
With regard to the previous delivery, nearly half of the study sample was examined and attended by a female doctor; this may be because many women prefer a female healthcare provider. It was reported that examination by a male doctor was a concern to their modesty, and hence a deterrent to many women seeking ANC. In Libya, for some women, exposing body parts, especially to a male doctor, is considered a major violation of their modesty.
For many cultural groups, a physician is deemed appropriate only in times of illness, and because pregnancy is considered as a normal process and the woman is in a state of health, the services of a physician are considered inappropriate 18.
Regarding the time of initial ANC visit, the majority (80%) of the study sample started receiving ANC during the first trimester. This result was not in line with Paganini and Reichmann 19, who found in their study in New Jersey, USA, that 63% of their participants had initiated ANC during the second and the third trimesters. Also, a study conducted by El-Sherbini et al. 20 revealed that 79% of the women began their ANC during the second and the third trimesters.
Furthermore, a study conducted in Norway on the overutilization of ANC stated that pregnant women must begin ANC as early as possible after the first missed period 21. In addition, a study conducted in Egypt recommended that a woman should have the first antenatal check-up early in the pregnancy to prevent problems 22.
Meanwhile, the WHO emphasized the importance of antenatal visits during pregnancy, and stated that women should visit the antenatal clinic at least four times during the whole course of pregnancy. These visits will help the healthcare provider to detect any problem such as anemia and chronic constipation as early as possible and help the mother to acquire the necessary information about pregnancy, labor, and puerperium 23.
The finding of the present study was consistent with the finding of a study in Cairo 15, which revealed that 86.4% of their participants had initiated ANC during the first trimester.
Regular antenatal check-up by trained medical providers is very important in assessing the physical status of women during pregnancy 22. The present study revealed that more than three-quarter (87.7%) of women visited antenatal clinics early and regularly; the nonattendance of pregnant women to antenatal clinics (12.3%) may be due to their unstable security situation in Libya during the revolution. These factors were proven to be associated with a lack of attendance or late initiation of ANC. This finding is in contrast to that of Van Eijk et al. 24, who reported in their study in rural western Kenya that women with either inadequate or no visits were more likely to be less educated and have a low socioeconomic status.
The results of the present study revealed that the main sources of knowledge about ANC were the doctors. The results of the current study are congruent with a study conducted in Mexico on designing prenatal care message for low-income Mexican women, where the main sources of knowledge are the doctors 25.
Also, about one-quarter of the pregnant women mentioned that relatives and friends were the main sources of knowledge about ANC; however, relatives and friends may give incorrect and unreliable information, or information based on hearsay and their personal experience. This finding is relatively in accordance with the study conducted in Egypt 15.
The present study revealed that the great majority (96.0%) of the women had a positive attitude toward ANC. This is similar to results of a study conducted in Malaysia on the risk factors for preterm delivery 26, which showed that women have, in general, a positive attitude towards ANC. Conversely, an Egyptian study 14 reported that less than half (46%) of the study sample had a positive attitude towards ANC. Again, the differences might be attributed to methodological variations related to sampling and data collection.
Knowledge and attitude studies are generally used worldwide in designing health promotion and health education program interventions that would be used to impact knowledge and alter attitudes and behaviors that are risky to health 27.
Healthy eating is very important during pregnancy: maternal nutritional needs change to meet the demands of pregnancy. Healthy eating can help ensure that adequate nutrients are available for both the mother and the fetus 28.
The present study revealed that the majority of the pregnant women believed that healthy food containing proteins, iron, and calcium should be increased during pregnancy. This result is in line with a study about developing and testing a nutritional educational booklet for low literate pregnant women in Egypt 29. However, in Sudan, women eat less fish because they believe that it will harden the bones of the fetus and may lead to difficult labor and delivery 30.
Furthermore, a study conducted in Guatemala about nutritional habits during pregnancy and lactation concluded that eating vegetables, grains, and milk during pregnancy will promote the health of the baby 31. This may be due to the fact that food habits and practices vary among people and are influenced by sociocultural beliefs, which can be harmful to maternal health.
According to the US March of Dimes Foundation 32 and the National Healthy Mother, Healthy Babies Coalition in Alexandria 33, which stated that there is a strong link between oral hygiene and prenatal care, the evidence suggests implications for preterm delivery, low-birth-weight babies and even infant death. In the present study, however, oral hygiene seemed to be generally appreciated among the study sample, and yet, the majority of them did not actually practice dental care. This harmful practice may exist because the cost of dental care and treatments may be an obstacle for dental care practices.
Regarding the use of supplements (iron and folic acid) during pregnancy, the current study revealed that 93.3% of the pregnant women mentioned that they take supplements during pregnancy. This is expected because supplements are routinely given to women attending ANC facilities and health advice for appropriate dietary practices to reduce anemia. Similarly, a study conducted in Pakistan on pregnant women revealed that 96% of them took iron and folic acid supplements 34.
The current study revealed a statistically significant association between women’s knowledge and practices towards ANC. Thus, most of the women with satisfactory knowledge about ANC had a positive attitude and good practices. Similar conclusions were reported in a study conducted in Karachi, Pakistan, which stated that women who received ANC are usually better informed about its importance, compared with those who did not receive ANC 35.
Nevertheless, levels of satisfactory knowledge, a positive attitude, and good practices towards ANC were high. The improvement of women’s knowledge, attitude, and practices toward ANC could be attributed to the spread of information about this issue through mass media (television and radio), posters, and health education materials in primary healthcare centers.
Conclusion and recommendations
The findings indicate that the majority of the participants of the study had a high level of knowledge and also practices; most of them had a positive attitude toward ANC. The level of overall knowledge of the women about ANC was significantly correlated with their practices during pregnancy, whereas it was insignificantly correlated with their attitude.
On the basis of these findings, it is recommended that health education programs be undertaken to improve women’s awareness toward ANC and eventually improve the health status of Libyan women. Knowledge about healthy behavior during pregnancy should be diffused through mass media. This should reinforce the message given by health personnel about pregnancy and the importance of antenatal follow-up visits.
The authors thank and acknowledge all the respondents for their useful information and cooperation.
Conflicts of interest
There are no conflicts of interest.
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