JIIMS final 33 ORIGINAL ARTICLE ABSTRACT Objective: To assess the quality of antenatal care provided to pregnant women in our set up at social security Hospital Rawalpindi. Study Design: Cross sectional Place and Duration of Study: Department of Obstetrics and Gynaecology, Social Security Hospital, Islamabad from October to December 2011. Materials and Methods: Women attending the antenatal OPD were interviewed using a pre tested semi structured questionnaire. A total of 285 women were included in the study. They were interviewed at their first antenatal visit. Results: Mean age of study population was 30 years and parity ranged from 0- 7.Majority were house wives and had their monthly family income less than 10,000 Rupees. Majority of the patients 'were multigravidas. All (100%) patients were looked after by doctors in Out- Patient Department (OPD). About 34.78% patients were educated about complications of Labour. Only 16.84% and 28.42% patients got advice about antenatal exercises and episiotomy care respectively. More than half (56.8%) patients were counseled for delivery in hospital, 26.31% patients were given contraception advice. About 57% received specific dietary advice for pregnant ladies and 45.26% were told about importance of breast feeding. Conclusion: Our study concluded that adequate antenatal care does not mean merely establishment or improvement of health centers or antenatal clinics, adequate supply of medicines and reducing waiting time, but it also involves education of pregnant women about good antenatal care and different health related issues. Key words: Antenatal, labour, family planning, immunization, lactation. affecting antenatal care: maternal education, husband' education, marital status, household income, women's employment 5and history of obstetric complications. Woman's parity is another factor which affects antenatal care; women with high parity tend to attend hospital less frequently, so parity has a significantly 6,7,8negative effect on antenatalattendance. The importance of quality antenatal care cannot be questioned. Good care can reduce the maternal morbidity and mortality and result in a healthy perinatal outcome. In the present study we want to emphasize the importance of good care for women during pregnancy that will enable them to go safely through pregnancy and child birth, producing a healthy baby. A cross sectional study was conducted in October- December 2011 in Social Security Materials and Methods Introduction Antenatal care is defined as the care of mother and fetus before birth. It is essential to reduce both the maternal and perinatal 1,2morbidity and mortality. Systematic antenatal care was introduced first in the early 20th century, in Europe and North America and is now almost universal in the 3d e v e l o p e d w o r l d . W o r l d h e a l t h organization (WHO) found that a new model with a reduced number of high quality antenatal visits did not result in worse maternal and perinatal outcomes than standard antenatal care that involved a 4greater number of visits. Studies Most commonly identified the following factors ------------------------------------------------- Quality of Antenatal Care Provided at Social Security Hospital, Islamabad Sughra Shehzad, Amina Aftab, LalaRukh, Asma Faisal Correspondence: Dr. Sughra Shahzad Assistant Prof. OBS/Gynae Social Security Hospital Islamabad Medical & Dental College Islamabad. e-mail: Sstts 80@gmail.com 33 34 Hospital, Islamabad. This hospital is providing health facilities to 318,000 registered patients (secured workers and their dependents). About 80 patients' daily visit the out- patient department in Gynaecology department. In obstetric set up of Social Security Hospital, antenatal care is provided by women medical officers' under the supervision of a gynecologist. Record of antenatal visits is kept on specially designed antenatal cards to select high risk patients. Antenatal record includes detailed history, findings of examination, details of investigations and ultrasonography. It also contains advice including hospital delivery especially in high risk patients, tetanus prophylaxis and warning signs of labour. The patients include wives of secured workers who are entitled in the hospital for free of cost treatment. So no patients are lost to follow up. Inclusion Criteria A total of 285 patients attending the antenatal OPD were included in the study. They were interviewed at their first antenatal visit. Data was collected through semi structured p r e t e s t e d q u e s t i o n n a i r e a n d b y interviewing the patients. The questionnaire was written in easy Urdu, so that most of the patients could read and understand it. Those not able to read Urdu were interviewed by the women medical officers (WMO) of Gynae department. T h e v a r i a b l e s i n c l u d e d w e r e s o c i o d e m o g r a p h i c f a c t o r s , h e a l t h information and satisfaction for resources. Questionnaire sought information about bio data, factors affecting antenatal attendance and knowledge about antenatal services. Data collected was entered on SPSS- 12 and was analyzed. The results were shown in percentage. The mean age of women was 30 years and parity ranged from zero to seven. Most of the patients (84.2%) were less than 30 years old and 15.78% were more than 30 years. Majority of them belonged to poor socioeconomic group as 89.47% had their monthly family income less than 10,000 Rupees. Only 5.26% patients had income between 10,000- 15,000 Rupees and a similar proportion more than 15,000 Rupees. Majority (91.57%) patients were house wives and 8.42% were self-employed in mills and schools. In our study, 135 (47.36%) women were educated to secondary level, 57 (20%) had got primary education, 33 (11.57%) were graduates and 12 (4.21%) had master degree; however 48 (16.84%) patients were illiterate. In the study population, 22.1% patients were primigravidas, 74.3% were multigravida and 3.6% were grand multipara. All (100%) were attended by doctors (medical officers, specialists/ consultants) in OPD. All women were aware of at least one or two methods of family planning. Table I shows distribution of different factors which affect attendance of Pregnant patients in antenatal care OPD. Table II shows the education of women during antenatal visit. Regarding different aspects of patient's education or instructions given to the patients by their attending doctors during their check- up, 99 patients ( 3 4 . 7 3 % ) w e r e c o u n s e l e d a b o u t complications or problems of labour, 201 ( 7 0 . 5 2 % ) w e r e c o u n s e l e d r e g a r d i n g immunization against tetanus, 129 (45.26%) were emphasized about benefits of breast feeding, its importance and standard Results 34 35 methods of lactation. More than half (57.89%) patients were educated about specific dietary needs of pregnant ladies, and possible psychological problems in pregnancy and puerperium were discussed with 33 (11.57%) patients. Only 48 (16.84%) ladies received information about antenatal exercises and 84 (28.42%) patients were counseled about the possibility and care of episiotomy. Need for hospital delivery was emphasized during counselling of 56.84% patient. About 60% patients were satisfied with the overall care provided to them; however 40%showed their concerns over quality of care. Most of them were unsatisfied about waiting time in outpatient department. Most of them said that they had to wait for more than two hours. Especially worth mentioning was their apprehension about delay in getting laboratory investigations. About 70% women were worried about g e t t i n g m e d i c i n e s a n d s h o r t a g e o f medicines. Table-I: Sociodemographic variables affecting antenatal attendance *Women having more than five viable pregnancies. Table-II: Education of women during antenatal visit Discussion High quality antenatal care is a fundamental right of women to safeguard their health and attain a desirably healthy outcome of pregnancy. It not only includes detailed h i s t o r y , e x a m i n a t i o n , a p p r o p r i a t e investigations and ultrasonography but also contains advice including specific dietary needs for pregnant women, preparation of patient for labour and possible problems, hospital delivery especially in high risk 8patients. tetanus prophylaxis and warning signs of labour. Counseling for breast feeding as well as contraceptive advice must also be included in the care of antenatal patients. In our study, mean age of the study population was 30 years, majority of them belonged to poor socioeconomic group, they 35 36 were unemployed and had got education up to secondary level. Majority of them were multigravidas and only a minority were grand multiparas (patients having more than five viable pregnancies). This fact has also been observed in other surveys that women with high parity tend to seek advice 7, 8and care less frequently. In Pakistan, only 30% patients utilize antenatal care services, while 70% do not. Only one third of deliveries take place in hospitals. Only 25% patients are counselled a b o u t w a r n i n g s i g n s o f p r e g n a n c y complications and less than half receive any 9post natal care. It has been emphasized in different studies that quality care has improved maternal and 10,11perinatal outcomes worldwide. About 88- 98% of all maternal deaths could be avoided by proper care and handling during 12,13pregnancy. Awareness should be created 14for proper utilization of services. In this study, all pregnant women were attended by doctors. This is contrary to findings in another study conducted at a public sector hospital of Hyderabad (Sindh), most of the women reported that they received care 14from lady health visitors (LHV). Although 100% patients were attended by doctors in our study, but their actual performance in taking care of women and their education regarding various health related issues was not up to the desired level. Less than one third patients received advice about antenatal exercises, care of episiotomy and problems/ warning signs of labour. Need for hospital delivery was discussed with half of the patients. The need for proper training of medical and paramedical staff for effective delivery of available services has 14,15also been emphasized in other studies. In addition to history taking, examination and advice of appropriate investigations, improvement of women's perception and counseling about standard antenatal care is 15also desirable. This involves giving i n f o r m a t i o n / e d u c a t i o n a b o u t complications of pregnancy, antenatal exercises, immunization, lactation and advice about family planning. Information should also be given about care of e p i s i o t o m y . S p e c i f i c p s y c h o l o g i c a l problems in pregnancy and puerperium must also be addressed. Good antenatal care also means hospital delivery especially in high risk patients. Dietary advice for a pregnant and lactating mother must also be part and parcel of optimal care. Medical and paramedical staff needs to be trained about the various educational needs of the patients and factors influencing patient satisfaction in order to improve quality of health 10,16care. Most of our patients expressed their dissatisfaction about prolonged waiting time, inappropriate attitude of hospital staff and availability of medicines. Among pregnant women, long waiting time, spending time during visit, inadequate supply of medicine and attitude of medical and paramedical staff were seen to be main 17areas of dissatisfaction in another study. Need for up grading the existing facilities as well as adequate training of medical and para medical staff to improve delivery of the available facilities has also been emphasized 14, 18in different studies. Our study concluded that adequate antenatal care does not mean merely establishment or improvement of health centers or antenatal clinics, adequate supply of medicines and reducing waiting time, but it also involves education of pregnant Conclusion 36 37 women about good antenatal care and different health related issues. Medical and Para medical staff needs to be trained for improving counseling skills, so that patients receive the available services and education in a more effective manner. 1. World health organization. Antenatal Care: Report of a technical working group. Geneva: WHO, 1994. 2. World health organization. World Health Report 2005: Make every mother and child count. Geneva: WHO, 2005. 3. Rooney C. Antenatal care and maternal health, how effective is it? document WHO/ MSM 92.4 Geneva: WHO, 1992: 6-9 4. Molzan J, Bulut A. The quality of hospital based antenatal care in Istanbul. Studies in Family Planning 2006; 37: 49- 60. 5. Simkhada B, Teliligen ER. Factors affecting the utilization of antenatal care in developing countries: systematic review of the literature. J AdvNurs 2008; 61: 244-60. 6. Thonneau P, ToureB,Cantrelle P. Risk factors for maternal mortality; Results of a case control study conducted in Conakry (Guinae). Intl J Obstet Gynecol 1992; 39: 87-92. 7. World health organization. MotherBaby package: Implementing Safe Motherhood in Countries. WHO, 1994: 24-5. 8. Malone MI. The quality of care in an antenatal clinic in Kenya. East African medical journal 1980; 57: 86-96. References 9. Pakistan Demographic and Household Survey 2006-7, Islamabad: Government of Pakistan 2006-7. 10. Chowdhury RI, Islam MA, Gulshan J, Chakraborty N. Delivery complications and health care seeking behavior- The Bangladesh Demographic Health Survey 1999- 2000. Health and social care in community; 15: 254- 64. 11. Sultan A, Riaz R, Rehman A, Sabir SA. Patient satisfaction in two tertiary care hospitals of Rawalpindi. JRMC 2009; 13: 41- 43. 1 2 . T u r m e n T . S a f e m o t h e r h o o d . E a s t e r n mediteranean health journal 1998; 4: 15-17 13. Ghada H. Maternal mortality: A neglected and s o c i a l l y u n j u s t i f i a b l e t r a g e d y . E a s t e r n Mediteranean Health Journal 1998; 4: 7- 10. 14. Nisar N, Amjad R. Patterns of antenatal care provided at a public sector hospital, Hyderabad, Sindh. J ayub med coll 2007; 19: 11- 13. 15. Andaleeb SS, Siddiqui N, Khandakar S. Patient satisfaction with healthservices in Bangladesh. Health policy and planning; 22: 263- 73 16. Afzal M, Khan A, Rizvi F, Hussain A. Patient satisfaction level in outpatient department of a teaching hospital. JIMDC; 2011; 1: 26- 29. 17. Fawole AO, Okunlola MA, Adekunle AO. Client's perceptions of the quality of antenatal care. Journal of the National Medical Association 2008; 100: 1052- 8. 18. Ali M, Ayaz M, Rizwan H, Hashim S, Kuroiwa C. Emergency Obstetric Care, availability, accessibility and utilization in eight districts in Pakistan's North West Frontier Province. J Ayub Med Coll Abbottabad 2006; 18: 10-15. 37 38 INSTRUCTIONS FOR AUTHORS The 'JIIMC' agrees to accept manuscripts prepared in accordance with the “Uniform Requirements submitted to the Biomedical Journals” published in the British Medical Journal 1991; 302: 334-41. be of about 250 words. Editorials are written by invitation. Authors should keep one copy of their manuscript for reference, and send three copies (laser copies or inkjet, photocopies are not accepted) to the Managing Editor, Journal of Islamic International Medical College, Pakistan. The author should also submit an electronic copy of the manuscript typed in MS Word. 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