Original article 119
Knowledge, attitude, and practices of pregnant women towards antenatal care in primary healthcare centers in Benghazi, Libya Hala K. Ibrahima, Mohamed D. El Borgyb and Huda O. Mohammedc Departments of aFamily Health, bHealth Administration and Behavioural Sciences, High Institute of Public Health, Alexandria University, Alexandria, Egypt and c Department of Public Health, Medical Arab University, Benghazi, Libya Correspondence to Hala K. Ibrahim, PhD, Department of Family Health, High Institute of Public Health, Alexandria University, 165 El-Horrya Ave, El-Hadara, 21311 Alexandria, Egypt Tel/fax: + 002 03 4260929; e-mail: [email protected]
Received 14 July 2014 Accepted 22 September 2014 Journal of the Egyptian Public Health Association 2014, 89:119–126
Background and aim Many underlying factors influence the capacity of women to survive from complications emerging during pregnancy and childbirth, including women’s health and nutritional status starting from childhood and during pregnancy. Also, women’s access to and the use of appropriate health services according to their knowledge, attitude, and behavior during pregnancy. This study was designed to assess the knowledge, the attitude, and practices of pregnant women toward antenatal care in primary healthcare centers in Benghazi, Libya. Study design and participants A cross-sectional study was conducted on a sample of 300 pregnant women, who were chosen from three primary healthcare centers with the highest attendance rate of pregnant women in Benghazi, Libya, using a structured interview questionnaire. Results The highest percentage (85.3%) of pregnant women had a high knowledge score regarding antenatal care, and most of them (96.0%) showed a positive attitude; the highest percentage (76.4%) of pregnant women also had good practice scores. The level of overall knowledge had a significant direct correlation with the practices towards antenatal care (r = 0.228, Pr0.001), whereas it had an insignificant correlation with the attitude (r = 0.029, P = 0.619). Conclusion and recommendations The majority of the participants of the study tended to have a high level of knowledge and practices. Also, most of them had a positive attitude towards antenatal care. These findings can be used to plan a customized health intervention program aiming to improve maternal health practices regarding antenatal care and eventually improve the health status of Libyan women. Keywords: antenatal care, attitude, knowledge, Libyan women, practices, primary healthcare centers J Egypt Public Health Assoc 89:119–126 & 2014 Egyptian Public Health Association 0013-2446
Introduction 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, B10% 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 0013-2446 & 2014 Egyptian Public Health Association
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 DOI: 10.1097/01.EPX.0000455673.91730.50
Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
120 Journal of the Egyptian Public Health Association
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).
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. Statistical analysis
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%
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 consideration
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.
Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
KAP of antenatal care, Lybia Ibrahim et al. 121
Researchers explained the purpose of the study and obtained informed consent before it was conducted.
Results 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 (o20 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.
Table 1. Distribution of the pregnant women by obstetrical data Obstetrical data Number of pregnancies (gravidity) 1 (primigravida) 2–4 5–7 8 or more Minimum–maximum Mean ± SD Parity (n = 245)a 1 2–4 5–7 8 or more Minimum–maximum Mean ± SD Number of live births (n = 245)a 1 2–4 5 or more Minimum–maximum Mean ± SD History of abortions 0 1 2–4 Number of stillbirths (n = 245)a 0 1 History of previous pregnancy (n = 245)a Normal pregnancy Concomitant diseases Threatened abortion Nature of previous deliveries (n = 245)a Normal vaginal delivery Cesarean sections Place of previous deliveries (n = 245)a Hospital Private clinic Home Attendant of previous deliveries (n = 245)a Male doctor Female doctor Nurse Daya
N (%) (n = 300) 55 (18.3) 133 (44.3) 88 (29.4) 24 (8.0) 1.0–13.0 3.94 ± 2.45 57 (23.3) 124 (50.6) 54 (22.0) 10 (4.1) 1.0–10.0 3.24 ± 2.0 60 (24.5) 123 (50.2) 62 (25.3) 1.0–10.0 3.19 ± 2.01 222 (74.0) 52 (17.3) 26 (8.7) 230 (93.9) 15 (6.1) 230 (93.8) 8 (3.3) 7 (2.9) 175 (71.4) 70 (28.6) 186 (75.9) 56 (22.9) 3 (1.2) 51 120 21 54
(20.8) (48.6) (8.6) (22.0)
a
Multiparous women.
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
Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
122 Journal of the Egyptian Public Health Association
Table 2. Distribution of the pregnant women by their knowledge regarding antenatal care N (%) (n = 300) Knowledge on about antenatal care
Correct
Should the first antenatal check-up be performed in the first 3 months? Does a pregnant woman need to come for at least five antenatal follow-ups throughout her pregnancy? Do pregnant women need to be regular in their follow-up? What is the importance of regular follow-up? Should you take healthy food during pregnancy? What is the importance of eating healthy food during pregnancy? Is maternal smoking harmful to the fetus? Does a pregnant woman need any vaccination during the pregnancy period? What is the importance of vaccination? Is medication intake without physician prescription safe for the fetus? Is dental care essential during pregnancy?
Figure 1.
240 270 292 292 286 288 292 003 208 255 257
Incorrect
(80.0) (90.0) (97.3) (97.3) (95.3) (96.0) (97.3) (1.0) (69.3) (85.0) (85.7)
55 10 7 0 7 1 7 150 44 29 40
(18.3) (3.3) (2.3) (0.0) (2.3) (0.3) (2.3) (50.0) (14.7) (9.7) (13.3)
Don’t know 5 20 1 8 7 11 1 147 48 16 3
(1.7) (6.7) (0.3) (2.7) (2.3) (3.7) (0.3) (49.0) (16.0) (5.3) (1.0)
Figure 2.
High 85.3%
70 60% 60
Percentage
50
40
25%
30
20
Fair 14.0% Low 0.7% Distribution of pregnant women by their total knowledge score.
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
10
0
6%
Doctor
Relative and friends
Books
5.3%
Media (Radio and TV.)
1%
2.7%
Nurse
Others (Internet)
Distribution of pregnant women according to their sources of knowledge about antenatal care.
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). Antenatal practices
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
Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
KAP of antenatal care, Lybia Ibrahim et al. 123
Table 3. Distribution of the pregnant women by their attitude regarding antenatal care N (%) (n = 300) Attitudes
Agree
I feel that smoking is harmful to the fetus Early antenatal booking is good for my pregnancy Routine screening test is important for my pregnant women I am willing to undergo an ultrasound scan during my pregnancy I believe that proteins, iron, and vitamins should be increased during pregnancy period I think that breast care during pregnancy prevents breast complications during puerperium Follow-up during pregnancy may decrease antenatal and postnatal complications Drug intake during pregnancy is harmful to the fetus Dental care decreases pregnancy and puerperium complications Regular follow-up makes the delivery easier.
Figure 3.
289 287 290 200 267 237 269 234 211 263
(96.3) (95.7) (96.7) (66.7) (89.0) (79.0) (89.7) (78.0) (70.3) (87.7)
Neutral 8 11 10 61 21 56 29 36 28 31
(2.7) (3.7) (3.3) (20.3) (7.0) (18.7) (9.7) (12.0) (9.3) (10.3)
Disagree 3 2 0 39 12 7 2 30 61 6
(1.0) (0.7) (0.0) (13.0) (4.0) (2.3) (0.7) (10.0) (20.3) (2.0)
Figure 4. High 76.3%
Positive attitude 96.0%
Average 20.3%
Neutral 4.0% Poor 3.3%
Negative attitude 0.0%
Distribution of pregnant women by their total practices score. Distribution of pregnant women by their total attitude score.
Discussion
Table 5 shows the correlation between the pregnant women’s knowledge, attitude, and practice scores.
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 table shows that the level of overall knowledge had a significant direct correlation with the practice towards ANC (r = 0.228, Po0.001), whereas it has an insignificant correlation with the attitude of the respondents (r = 0.029, P = 0.619).
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
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%).
Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
124 Journal of the Egyptian Public Health Association
Table 4. Distribution of the pregnant women by their practices regarding antenatal care N (%) (n = 300) Women practices Are you visiting the clinic after you know that you are pregnant? Are you regular in visiting the primary healthcare? Do you care about your breast during pregnancy? Have you visited the dentist regularly? Have you taken supplements (iron and folic acid)? Have you taken medication without consultation? Have you undergone the routine investigations? Have you undergone ultrasound during pregnancy?
Yes
No
240 (80.0)
60 (20.0)
263 (87.7)
37 (12.3)
229 (76.3)
71 (23.7)
48 (16.0) 252 (84.0) 280 (93.3) 20 (6.7) 252 (84.0)
48 (16.0)
276 (92.0)
24 (8.0)
252 (84.0)
48 (16.0)
Table 5. Correlation between pregnant women’s knowledge, attitude, and practice scores Variables Knowledge vs. attitude Knowledge vs. practices Attitude vs. practices
r
P
0.029 0.228* – 0.041
0.619 o0.001 0.474
r, Pearson’s coefficient. *Statistically significant at Pr0.05.
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-thecounter 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
Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
KAP of antenatal care, Lybia Ibrahim et al. 125
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, lowbirth-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.
Acknowledgements The authors thank and acknowledge all the respondents for their useful information and cooperation.
Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
126 Journal of the Egyptian Public Health Association
Conflicts of interest
18 Lowdermilk DL, Perry SE. Maternity nursing. 7th ed. St. Louis: Mosby.
There are no conflicts of interest.
19 Pagnini DL, Reichman NE. Psychosocial factors and the timing of prenatal care among women in New Jersey’s HealthStart program. Fam Plann Perspect 2000; 32:56–64.
References 1 World Health Organization (WHO), Department of Reproductive Health and Research. Advancing safe motherhood through human rights. Geneva: WHO. 2 Graham W. A review of safe motherhood. Ministry of Health, Kenya. London: Options Consultancy Services Limited; 1997. pp. 1–3. 3 World Health Organization (WHO). World health day, safe mother hood, maternal mortality. Alexandria, Egypt: WHO; 1998. pp. 1–3. 4 World Health Organization (WHO). A listing of available information: coverage of maternal care. Geneva: WHO; 1997. pp. 10–20. 5 US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Maternal mortality. Child Health USA 2008–2009. Rockville (MD, USA): US Department of Health and Human Services. 6 Ziyo FY, Matly FA, Mehemd GM, Dofany EM. Relation between prenatal care and pregnancy outcome at Benghazi. Sudan J Public Health 2009; 4:1–8. 7 Pillitteri A. Maternal and child health nursing: assessing fetal and maternal health. 4th ed. New York: Wolters Kluwer Co..
20 El-Sherbini AF, El-Torky MA, Ashmawy AA, Abdel-Hamid HS. Assessment of knowledge, attitudes and practices of expectant mothers in relation to antenatal care in Assiut governorate. J Egypt Public Health Assoc 1993; 68 (5–6): 539–565. 21 Backe B. Overutilization of antenatal care in Norway. Scand J Public Health 2001; 29:129–132. 22 El Zanaty F, Way A. Egypt demographic and health survey. Calverton (MD, USA): Ministry of Health and Population (Egypt), National Population Council and ORC Marco; 2003. p. 50. 23 World Health Organization (WHO). Antenatal Care. Report of technical working group. Geneva: WHO. 24 Van Eijk AM, Bles HM, Odhiambo F, Ayisi JG, Blokland IE, Rosen DH, et al. Use of antenatal services and delivery care among women in rural western Kenya: A community based survey. Reprod Health 2006; 3:2. 25 Alcalay R, Ghee A, Scrimshaw S. Designing prenatal care messages for low-income Mexican women. Public Health Rep 1993; 108:354–362. 26 Lam CM, Wong SF. Risk factors for preterm delivery in women with placenta praevia and antepartum haemorrhage: retrospective study.. Hong Kong Med J 2002; 8:163–166.
8 Fatmi Z, Avan BI. Demographic, socio-economic and environmental determinants of utilisation of antenatal care in a rural setting of Sindh, Pakistan. J Pak Med Assoc 2002; 52:138–142. 9 Kishk NA. Knowledge, attitudes and practices of women towards antenatal care: rural-urban comparison. J Egypt Public Health Assoc 2002; 77 (5–6): 479–498.
27 Rotimi OO, Oluwafemi OO. Knowledge and attitudes of students in a Caribbean Medical School towards HIV/AIDS. Afr J Biomed Res 2008; 11:137–143.
10 BUPA. Antenatal care. Available at: http://hcd2.bupa.Co.UK/fact_sheets/ html/antenatal_care.html. [Accessed 7 February 2012].
29 Rashad W. Study for developing and testing nutritional educational booklet for low literate pregnant women [PhD thesis]. Alexandria: Faculty of Nursing, Alexandria University; 2001. pp. 100–169.
11 Kaddour A, Hafez R, Zurayk H. Women’s perceptions of reproductive health in three communities around Beirut, Lebanon. Reprod Health Matters 2005; 13:34–42. 12 Zhao Q, Kulane A, Gao Y, Xu B. Knowledge and attitude on maternal health care among rural-to-urban migrant women in Shanghai, China. BMC Womens Health 2009; 9:5–5. 13 Low P, Paterson J, Wouldes T, Carter S, Williams M, Percival T. Factors affecting antenatal care attendance by mothers of Pacific infants living in New Zealand. N Z Med J 2005; 118:U1489. 14 Hesham A. Women’s perception and practices towards working signs during pregnancy [Thesis]. Cairo: Ain Shams University, Faculty of Nursing; 2004. 15 Mohammed A. Factors affect the mothers’ utilization of antenatal care [Master thesis]. Cairo: Ain Shams University, Faculty of Nursing; 2005. 16 National Center for Immunization and Respiratory Diseases. Guidelines for vaccinating pregnant women; 2008. Available at: http://www.cdc.gov/vaccines/pubs/preg-guide.htm. [Accessed 16 January 2013]. 17 Macones G. Staying healthy during pregnancy; 2005. Available at: http:// www.kidshealth.Org/parent/pregnancy-newborn//pregnancy/preghealth.html. [Accessed 12 April 2012].
28 Mitchell MK. Nutrition across the life span. New York: W.B. Saunders Co.; 2004.
30 El Shazali H. Dietary practices during pregnancy among Sudanese women. J Clin Nutr 2000; 31:116–119. 31 Jimenez G. Nutritional habits during pregnancy and lactation. Agriculture and Food Institute and Corporation; 2004. Available at: http//:www.benson. byu.edu/puplication/BI/Lesson/volume21/Nutritionalhabits.asp. [Accessed 23 December 2012]. 32 March of Dimes Foundation. Prematurity: the answer can’t soon enough; 2004. Available at: http://www.marchofdimes.com/prematurity. [Accessed 10 August 2012]. 33 Lacey J. Healthy smile, healthy baby. In: National Healthy Mother, Healthy Babies Coalition in Alexandria 2001, editors. Dental care during pregnancy. Alexandria: National Healthy Mother, Healthy Babies Coalition 2007. Available at: http://att.iparenting.Com/pregnancy/healthy smile.htm. [Accessed 21 September 2012]. 34 Awan M, Akbar M, Khan M. A study of anemia in pregnant women of railway colony, Multan. Pak J Med Res 2004; 43:11–14. 35 Nisar N, White F. Factors affecting utilization of antenatal care among reproductive age group women (15–49 years) in an urban squatter settlement of Karachi. J Pak Med Assoc 2003; 53:47–53.
Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
Knowledge, attitude, and practices of pregnant women towards antenatal care in primary healthcare centers in Benghazi, Libya Hala K. Ibrahima, Mohamed D. El Borgyb and Huda O. Mohammedc Departments of aFamily Health, bHealth Administration and Behavioural Sciences, High Institute of Public Health, Alexandria University, Alexandria, Egypt and c Department of Public Health, Medical Arab University, Benghazi, Libya Correspondence to Hala K. Ibrahim, PhD, Department of Family Health, High Institute of Public Health, Alexandria University, 165 El-Horrya Ave, El-Hadara, 21311 Alexandria, Egypt Tel/fax: + 002 03 4260929; e-mail: [email protected]
Received 14 July 2014 Accepted 22 September 2014 Journal of the Egyptian Public Health Association 2014, 89:119–126
Background and aim Many underlying factors influence the capacity of women to survive from complications emerging during pregnancy and childbirth, including women’s health and nutritional status starting from childhood and during pregnancy. Also, women’s access to and the use of appropriate health services according to their knowledge, attitude, and behavior during pregnancy. This study was designed to assess the knowledge, the attitude, and practices of pregnant women toward antenatal care in primary healthcare centers in Benghazi, Libya. Study design and participants A cross-sectional study was conducted on a sample of 300 pregnant women, who were chosen from three primary healthcare centers with the highest attendance rate of pregnant women in Benghazi, Libya, using a structured interview questionnaire. Results The highest percentage (85.3%) of pregnant women had a high knowledge score regarding antenatal care, and most of them (96.0%) showed a positive attitude; the highest percentage (76.4%) of pregnant women also had good practice scores. The level of overall knowledge had a significant direct correlation with the practices towards antenatal care (r = 0.228, Pr0.001), whereas it had an insignificant correlation with the attitude (r = 0.029, P = 0.619). Conclusion and recommendations The majority of the participants of the study tended to have a high level of knowledge and practices. Also, most of them had a positive attitude towards antenatal care. These findings can be used to plan a customized health intervention program aiming to improve maternal health practices regarding antenatal care and eventually improve the health status of Libyan women. Keywords: antenatal care, attitude, knowledge, Libyan women, practices, primary healthcare centers J Egypt Public Health Assoc 89:119–126 & 2014 Egyptian Public Health Association 0013-2446
Introduction 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, B10% 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 0013-2446 & 2014 Egyptian Public Health Association
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 DOI: 10.1097/01.EPX.0000455673.91730.50
Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
120 Journal of the Egyptian Public Health Association
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).
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. Statistical analysis
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%
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 consideration
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.
Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
KAP of antenatal care, Lybia Ibrahim et al. 121
Researchers explained the purpose of the study and obtained informed consent before it was conducted.
Results 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 (o20 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.
Table 1. Distribution of the pregnant women by obstetrical data Obstetrical data Number of pregnancies (gravidity) 1 (primigravida) 2–4 5–7 8 or more Minimum–maximum Mean ± SD Parity (n = 245)a 1 2–4 5–7 8 or more Minimum–maximum Mean ± SD Number of live births (n = 245)a 1 2–4 5 or more Minimum–maximum Mean ± SD History of abortions 0 1 2–4 Number of stillbirths (n = 245)a 0 1 History of previous pregnancy (n = 245)a Normal pregnancy Concomitant diseases Threatened abortion Nature of previous deliveries (n = 245)a Normal vaginal delivery Cesarean sections Place of previous deliveries (n = 245)a Hospital Private clinic Home Attendant of previous deliveries (n = 245)a Male doctor Female doctor Nurse Daya
N (%) (n = 300) 55 (18.3) 133 (44.3) 88 (29.4) 24 (8.0) 1.0–13.0 3.94 ± 2.45 57 (23.3) 124 (50.6) 54 (22.0) 10 (4.1) 1.0–10.0 3.24 ± 2.0 60 (24.5) 123 (50.2) 62 (25.3) 1.0–10.0 3.19 ± 2.01 222 (74.0) 52 (17.3) 26 (8.7) 230 (93.9) 15 (6.1) 230 (93.8) 8 (3.3) 7 (2.9) 175 (71.4) 70 (28.6) 186 (75.9) 56 (22.9) 3 (1.2) 51 120 21 54
(20.8) (48.6) (8.6) (22.0)
a
Multiparous women.
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
Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
122 Journal of the Egyptian Public Health Association
Table 2. Distribution of the pregnant women by their knowledge regarding antenatal care N (%) (n = 300) Knowledge on about antenatal care
Correct
Should the first antenatal check-up be performed in the first 3 months? Does a pregnant woman need to come for at least five antenatal follow-ups throughout her pregnancy? Do pregnant women need to be regular in their follow-up? What is the importance of regular follow-up? Should you take healthy food during pregnancy? What is the importance of eating healthy food during pregnancy? Is maternal smoking harmful to the fetus? Does a pregnant woman need any vaccination during the pregnancy period? What is the importance of vaccination? Is medication intake without physician prescription safe for the fetus? Is dental care essential during pregnancy?
Figure 1.
240 270 292 292 286 288 292 003 208 255 257
Incorrect
(80.0) (90.0) (97.3) (97.3) (95.3) (96.0) (97.3) (1.0) (69.3) (85.0) (85.7)
55 10 7 0 7 1 7 150 44 29 40
(18.3) (3.3) (2.3) (0.0) (2.3) (0.3) (2.3) (50.0) (14.7) (9.7) (13.3)
Don’t know 5 20 1 8 7 11 1 147 48 16 3
(1.7) (6.7) (0.3) (2.7) (2.3) (3.7) (0.3) (49.0) (16.0) (5.3) (1.0)
Figure 2.
High 85.3%
70 60% 60
Percentage
50
40
25%
30
20
Fair 14.0% Low 0.7% Distribution of pregnant women by their total knowledge score.
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
10
0
6%
Doctor
Relative and friends
Books
5.3%
Media (Radio and TV.)
1%
2.7%
Nurse
Others (Internet)
Distribution of pregnant women according to their sources of knowledge about antenatal care.
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). Antenatal practices
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
Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
KAP of antenatal care, Lybia Ibrahim et al. 123
Table 3. Distribution of the pregnant women by their attitude regarding antenatal care N (%) (n = 300) Attitudes
Agree
I feel that smoking is harmful to the fetus Early antenatal booking is good for my pregnancy Routine screening test is important for my pregnant women I am willing to undergo an ultrasound scan during my pregnancy I believe that proteins, iron, and vitamins should be increased during pregnancy period I think that breast care during pregnancy prevents breast complications during puerperium Follow-up during pregnancy may decrease antenatal and postnatal complications Drug intake during pregnancy is harmful to the fetus Dental care decreases pregnancy and puerperium complications Regular follow-up makes the delivery easier.
Figure 3.
289 287 290 200 267 237 269 234 211 263
(96.3) (95.7) (96.7) (66.7) (89.0) (79.0) (89.7) (78.0) (70.3) (87.7)
Neutral 8 11 10 61 21 56 29 36 28 31
(2.7) (3.7) (3.3) (20.3) (7.0) (18.7) (9.7) (12.0) (9.3) (10.3)
Disagree 3 2 0 39 12 7 2 30 61 6
(1.0) (0.7) (0.0) (13.0) (4.0) (2.3) (0.7) (10.0) (20.3) (2.0)
Figure 4. High 76.3%
Positive attitude 96.0%
Average 20.3%
Neutral 4.0% Poor 3.3%
Negative attitude 0.0%
Distribution of pregnant women by their total practices score. Distribution of pregnant women by their total attitude score.
Discussion
Table 5 shows the correlation between the pregnant women’s knowledge, attitude, and practice scores.
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 table shows that the level of overall knowledge had a significant direct correlation with the practice towards ANC (r = 0.228, Po0.001), whereas it has an insignificant correlation with the attitude of the respondents (r = 0.029, P = 0.619).
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
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%).
Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
124 Journal of the Egyptian Public Health Association
Table 4. Distribution of the pregnant women by their practices regarding antenatal care N (%) (n = 300) Women practices Are you visiting the clinic after you know that you are pregnant? Are you regular in visiting the primary healthcare? Do you care about your breast during pregnancy? Have you visited the dentist regularly? Have you taken supplements (iron and folic acid)? Have you taken medication without consultation? Have you undergone the routine investigations? Have you undergone ultrasound during pregnancy?
Yes
No
240 (80.0)
60 (20.0)
263 (87.7)
37 (12.3)
229 (76.3)
71 (23.7)
48 (16.0) 252 (84.0) 280 (93.3) 20 (6.7) 252 (84.0)
48 (16.0)
276 (92.0)
24 (8.0)
252 (84.0)
48 (16.0)
Table 5. Correlation between pregnant women’s knowledge, attitude, and practice scores Variables Knowledge vs. attitude Knowledge vs. practices Attitude vs. practices
r
P
0.029 0.228* – 0.041
0.619 o0.001 0.474
r, Pearson’s coefficient. *Statistically significant at Pr0.05.
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-thecounter 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
Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
KAP of antenatal care, Lybia Ibrahim et al. 125
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, lowbirth-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.
Acknowledgements The authors thank and acknowledge all the respondents for their useful information and cooperation.
Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
126 Journal of the Egyptian Public Health Association
Conflicts of interest
18 Lowdermilk DL, Perry SE. Maternity nursing. 7th ed. St. Louis: Mosby.
There are no conflicts of interest.
19 Pagnini DL, Reichman NE. Psychosocial factors and the timing of prenatal care among women in New Jersey’s HealthStart program. Fam Plann Perspect 2000; 32:56–64.
References 1 World Health Organization (WHO), Department of Reproductive Health and Research. Advancing safe motherhood through human rights. Geneva: WHO. 2 Graham W. A review of safe motherhood. Ministry of Health, Kenya. London: Options Consultancy Services Limited; 1997. pp. 1–3. 3 World Health Organization (WHO). World health day, safe mother hood, maternal mortality. Alexandria, Egypt: WHO; 1998. pp. 1–3. 4 World Health Organization (WHO). A listing of available information: coverage of maternal care. Geneva: WHO; 1997. pp. 10–20. 5 US Department of Health and Human Services, Health Resources and Services Administration, Maternal and Child Health Bureau. Maternal mortality. Child Health USA 2008–2009. Rockville (MD, USA): US Department of Health and Human Services. 6 Ziyo FY, Matly FA, Mehemd GM, Dofany EM. Relation between prenatal care and pregnancy outcome at Benghazi. Sudan J Public Health 2009; 4:1–8. 7 Pillitteri A. Maternal and child health nursing: assessing fetal and maternal health. 4th ed. New York: Wolters Kluwer Co..
20 El-Sherbini AF, El-Torky MA, Ashmawy AA, Abdel-Hamid HS. Assessment of knowledge, attitudes and practices of expectant mothers in relation to antenatal care in Assiut governorate. J Egypt Public Health Assoc 1993; 68 (5–6): 539–565. 21 Backe B. Overutilization of antenatal care in Norway. Scand J Public Health 2001; 29:129–132. 22 El Zanaty F, Way A. Egypt demographic and health survey. Calverton (MD, USA): Ministry of Health and Population (Egypt), National Population Council and ORC Marco; 2003. p. 50. 23 World Health Organization (WHO). Antenatal Care. Report of technical working group. Geneva: WHO. 24 Van Eijk AM, Bles HM, Odhiambo F, Ayisi JG, Blokland IE, Rosen DH, et al. Use of antenatal services and delivery care among women in rural western Kenya: A community based survey. Reprod Health 2006; 3:2. 25 Alcalay R, Ghee A, Scrimshaw S. Designing prenatal care messages for low-income Mexican women. Public Health Rep 1993; 108:354–362. 26 Lam CM, Wong SF. Risk factors for preterm delivery in women with placenta praevia and antepartum haemorrhage: retrospective study.. Hong Kong Med J 2002; 8:163–166.
8 Fatmi Z, Avan BI. Demographic, socio-economic and environmental determinants of utilisation of antenatal care in a rural setting of Sindh, Pakistan. J Pak Med Assoc 2002; 52:138–142. 9 Kishk NA. Knowledge, attitudes and practices of women towards antenatal care: rural-urban comparison. J Egypt Public Health Assoc 2002; 77 (5–6): 479–498.
27 Rotimi OO, Oluwafemi OO. Knowledge and attitudes of students in a Caribbean Medical School towards HIV/AIDS. Afr J Biomed Res 2008; 11:137–143.
10 BUPA. Antenatal care. Available at: http://hcd2.bupa.Co.UK/fact_sheets/ html/antenatal_care.html. [Accessed 7 February 2012].
29 Rashad W. Study for developing and testing nutritional educational booklet for low literate pregnant women [PhD thesis]. Alexandria: Faculty of Nursing, Alexandria University; 2001. pp. 100–169.
11 Kaddour A, Hafez R, Zurayk H. Women’s perceptions of reproductive health in three communities around Beirut, Lebanon. Reprod Health Matters 2005; 13:34–42. 12 Zhao Q, Kulane A, Gao Y, Xu B. Knowledge and attitude on maternal health care among rural-to-urban migrant women in Shanghai, China. BMC Womens Health 2009; 9:5–5. 13 Low P, Paterson J, Wouldes T, Carter S, Williams M, Percival T. Factors affecting antenatal care attendance by mothers of Pacific infants living in New Zealand. N Z Med J 2005; 118:U1489. 14 Hesham A. Women’s perception and practices towards working signs during pregnancy [Thesis]. Cairo: Ain Shams University, Faculty of Nursing; 2004. 15 Mohammed A. Factors affect the mothers’ utilization of antenatal care [Master thesis]. Cairo: Ain Shams University, Faculty of Nursing; 2005. 16 National Center for Immunization and Respiratory Diseases. Guidelines for vaccinating pregnant women; 2008. Available at: http://www.cdc.gov/vaccines/pubs/preg-guide.htm. [Accessed 16 January 2013]. 17 Macones G. Staying healthy during pregnancy; 2005. Available at: http:// www.kidshealth.Org/parent/pregnancy-newborn//pregnancy/preghealth.html. [Accessed 12 April 2012].
28 Mitchell MK. Nutrition across the life span. New York: W.B. Saunders Co.; 2004.
30 El Shazali H. Dietary practices during pregnancy among Sudanese women. J Clin Nutr 2000; 31:116–119. 31 Jimenez G. Nutritional habits during pregnancy and lactation. Agriculture and Food Institute and Corporation; 2004. Available at: http//:www.benson. byu.edu/puplication/BI/Lesson/volume21/Nutritionalhabits.asp. [Accessed 23 December 2012]. 32 March of Dimes Foundation. Prematurity: the answer can’t soon enough; 2004. Available at: http://www.marchofdimes.com/prematurity. [Accessed 10 August 2012]. 33 Lacey J. Healthy smile, healthy baby. In: National Healthy Mother, Healthy Babies Coalition in Alexandria 2001, editors. Dental care during pregnancy. Alexandria: National Healthy Mother, Healthy Babies Coalition 2007. Available at: http://att.iparenting.Com/pregnancy/healthy smile.htm. [Accessed 21 September 2012]. 34 Awan M, Akbar M, Khan M. A study of anemia in pregnant women of railway colony, Multan. Pak J Med Res 2004; 43:11–14. 35 Nisar N, White F. Factors affecting utilization of antenatal care among reproductive age group women (15–49 years) in an urban squatter settlement of Karachi. J Pak Med Assoc 2003; 53:47–53.
Copyright © Journal of the Egyptian Public Health Association. Unauthorized reproduction of this article is prohibited.
