1 1 SUBMITTED 14 FEB 23 1 REVISION REQ. 21 MAR 23; REVISION RECD. 5 APR 23 2 ACCEPTED 3 MAY 23 3 ONLINE-FIRST: MAY 2023 4 DOI: https://doi.org/10.18295/squmj.5.2023.032 5 6 7 Challenges and Strategies for Providing Effective Antenatal Education 8 Services in Oman’s Public Healthcare System 9 Perspectives of service providers and pregnant women 10 Maha Y.K. AlDughaishi,1 *Vidya Seshan,2 Gerald A. Matua3 11 12 1Labor Ward, Sultan Qaboos University Hospital, Muscat, Oman; Departments of 2Maternal & 13 Child Health and 3Fundamentals & Administration, College of Nursing, Sultan Qaboos 14 University, Muscat, Oman. 15 *Corresponding Author’s e-mail: vidya69@squ.edu.om 16 17 Abstract 18 Objectives: Globally, maternal mortality is considered a critical healthcare issue because 19 statistics consistently show that many avoidable deaths and injuries occur during pregnancy and 20 childbirth. The aim of this research was to explore the challenges to quality antenatal education 21 from the perspective of both the service providers and the pregnant women. Methods: This 22 qualitative study was carried out on 30 participants who were selected using purposive sampling 23 technique. Data was collected through in-depth interviews and field notes and analyzed manually 24 using thematic analysis. Results: The service providers identified their challenges as lack of 25 consultation room and designated space for health education, work overload, time constraints, 26 under-staffing, lack of educational materials, language barriers, lack of authority and negative 27 attitude. The pregnant women identified lack of focus on women’s needs, superficial antenatal 28 education, overcrowding, lack of educational facilities, use of medical jargon and unprofessional 29 staff attitude towards women as key barriers to quality service. The remedies included improved 30 staffing levels, designated space for antenatal education, expanded educational activities, 31 2 2 continuing education for caregivers, establishing midwife-led units, focused antenatal education 32 and improved communication between providers and the users. Conclusion: Based on the 33 results, both health care service providers and pregnant women experienced significant barriers 34 that hindered them from providing and accessing quality antenatal education services 35 respectively. Therefore, policymakers, health planners and hospital administrators should remove 36 these barriers and integrate some of the recommendations to promote better health outcomes. 37 Keywords: Antenatal Education; Challenges; Strategies; Health Care Providers; Pregnant 38 Women; Oman. 39 40 Advances in knowledge 41 • This study helped to explore the challenges faced by health care providers and pregnant 42 women while providing and receiving antenatal education. Identifying this will help to 43 design cost effective corrective strategies to lower maternal and fetal healthcare costs. 44 • The study revealed the existence of disparity in adherence to MOH National Guidelines 45 regarding antenatal education. This finding implies the need for wider dissemination of the 46 guidelines to streamline the provision of recommended antenatal education services across 47 all the healthcare setting in Oman. 48 Application to patient care 49 • Pregnant women trust and value the information provided by healthcare providers. 50 Healthcare providers should provide adequate, consistent, and comprehensive antenatal 51 education for pregnant women in every antenatal visit. This ensures better understanding 52 of vital information by pregnant women, resulting in positive maternal and fetal outcomes. 53 54 Introduction 55 Globally, maternal mortality has been considered a critical healthcare issue because statistics 56 consistently show that avoidable deaths and injury occur during pregnancy and childbirth.1 As 57 further evidence of the extent of this problem, (World Health Organization) WHO, (United Nations 58 International Children’s Emergency Fund) UNICEF, (United Nations Population Fund) UNFPA, 59 World Bank Group and the United Nations Population Division reported in their study that in 2017 60 alone, up to 295,000 women died during pregnancy until delivery across the world.2 These deaths 61 have been attributed to preventable complications, and would be stopped if women have access to 62 3 3 relatively basic maternal health education services to recognize the danger signs and act 63 accordingly.3,4 64 65 Several studies suggest that low levels of awareness of danger signs of pregnancy and delivery 66 contribute to high maternal mortality ratios globally.5 To address these challenges, the United 67 Nation through the Sustainable Development Goal (SDG 3) directed member countries to improve 68 maternal health through working to reduce Maternal Mortality Rate (MMR) to less than 70 per 69 100,000 live births by 2030.6,7,8 70 71 In Oman, like other developing countries, there have been both positive and negative changes in 72 significant health indicators like the Infant Mortality Rate (IMR), Low Birth weight (LBW), and 73 poor breastfeeding practices. For instance, in 2016, the Infant mortality rate was 5.3 per 1,000 live 74 births; in 2020, it increased to 7.6, and in 2021 further increased to 8.1 (MOH, 2021).9 There was 75 an increase in the number of Low birth weight (LBW) babies, from 11.3% in 2019 to 12% in 2021 76 (MOH, 2021).9 Similarly, in 2019, Maternal Mortality Rate (MMR) was 14.1 (per 100.000 live 77 births), and the unwelcoming increase in 2020 to 29.4 and 42.5 in 2021.9 Such gaps indicate the 78 existence of challenges in the system. 79 80 Another significant maternal health indicator is that in the last five years, the number of pregnant 81 women attending the antenatal clinic in the first trimester reduced nearly by 10,000 from 2016 to 82 2019.10 These statistics indicate the existence of significant problems occurring during the 83 antenatal period and emphasize the need to understand the contributing factors to devise corrective 84 strategies to reduce maternal and infant mortality and morbidity rate especially in developing 85 countries.11 An important ingredient in addressing the gaps in antenatal care is the central role 86 played by healthcare workers, who provide the necessary information to make pregnancy and 87 childbirth a positive experience for the fetus, the pregnant women and her family. 88 89 Whereas the Ministry of Health in Oman, has made impressive steps to build a robust health 90 infrastructure across the country, promoting greater access in health care delivery to ensure that 91 all pregnant women receive quality healthcare services during antenatal visits, however some 92 challenges continue to hamper this success.12. In order to succeed in their mission of addressing 93 4 4 the healthcare needs of pregnant women, providers of antenatal education services must build 94 professional relationships, exchange information and involve the women in decision-making.13.14 95 96 This research reports the challenges experienced by healthcare providers and pregnant women 97 while delivering and receiving antenatal education services including some remedial strategies. 98 99 Methodology 100 Research Design 101 The study utilized a generic qualitative research approach using semi-structured in-depth 102 interviews guided by open-ended questions. Generic qualitative research approach is guided by 103 the naturalistic paradigm and utilizes different principles and practices from various qualitative 104 traditions and theories. The naturalistic framework was chosen because it allows the researcher to 105 explore poorly understood phenomena by generating rich data directly from concerned individuals 106 to make logical conclusions.16 This research approach resulted in a deeper understanding of the 107 challenges experienced by healthcare providers that negatively impacted their service provision. 108 Study Setting 109 This study was conducted in 9 outpatient antenatal clinics located in the public Health centers of 110 Muscat Governorate, Oman. These outpatient antenatal clinics provide health care services to both 111 low and high-risk pregnant women. 112 113 Study Sample and Sampling Method 114 A purposive non-probability sampling technique was used to identify participants who had 115 experience working in these units. These were health care providers who educated pregnant 116 women and pregnant women who received the antenatal education. 117 118 The healthcare providers included Doctors, Midwives, Nurses, and Health Educators (Both Omani 119 and Non-Omani) who had worked in the antenatal clinics for a minimum of 12 months. The 120 pregnant women had to be attending antenatal care services in one of the institutions, had to be 121 over 30 weeks of gestation, aged above 18 years, Omani and willing to participate in one- on-one 122 in depth interview with the research team. 123 124 5 5 The number of participants, both providers and users of the antenatal education services was 125 determined by the stage at which data saturation was reached.15 In this study, data saturation 126 occurred after a total of 17 healthcare providers and 13 pregnant women were interviewed.16,17. 127 128 Ethical Considerations 129 The researchers obtained ethical clearance and study approval from the relevant institutions and 130 the Ministry of Health. Each participant was asked to sign an informed consent form after 131 determining that they had understood the nature and purpose of the study. Prior to the data 132 collection, all the participants were informed that they had the right to withdraw from the study at 133 any stage either from individual questions or from the entire study without any consequences. The 134 anonymity of participants and confidentiality of their data were upheld and preserved. Each 135 interview was conducted individually in a private and quiet room in the respective clinics. To 136 ensure anonymity, codes were used instead of names and digital copies of the interview data were 137 kept under password protection, with access only to the research team. In addition, the physical 138 copies of the interview data are carefully stored in an office and will be destroyed after 3 years. 139 140 Data Collection 141 The research data was generated using a semi-structured in-depth interview guide up to the point 142 of data saturation, resulting in a total of 30 participants.15 The participants were informed that the 143 interview sessions would last between 45 to 60 minutes or until such time that the participants 144 answered all the questions. The researcher started the interview with casual conversation to set the 145 stage for the participants to be ready for the interview. The questions were developed by the 146 research team and validated by both subject and research experts. The open-ended questions were 147 aimed at their personal experiences, including their thoughts, feelings, views, and perspectives 148 regarding antenatal service, both as a provider and user. To get more detailed information, follow-149 up questions were asked to encourage the participants to explain more by using probes and silence. 150 151 13 pregnant women participated in the study aged between 23 to 39 years. All of them were 152 educated. The interview guide for the key informants consists of 7major questions with some 153 probing questions. The researcher used communication skills that enabled her to interact 154 sensitively with each participant during the interview by asking, maintaining proper eye contact, 155 6 6 listening attentively, observing, showing respect and interest in what they were saying, and asking 156 prop questions when needed. These strategies encouraged and motivated the participants to express 157 themselves more and control the flow of the interview. The researcher found no difficulty 158 communicating with all participants. 159 160 Sample Questions: 161 For Service providers 162 • What specific education do you give to prepare the women for a safe pregnancy? 163 • What challenges do you experience in providing antenatal education? 164 Probe question: 165 166 • What barriers hinder you from being an effective antenatal educator? 167 • How do these barriers affect your role as an antenatal educator? 168 • Which strategies would be useful in mitigating these barriers? 169 170 For Pregnant Women 171 • What challenges did you face during antenatal education sessions? 172 • What specific actions would help to resolve each challenge? 173 174 Probe question: 175 • Tell me if you had all your questions answered, if not? What went wrong? 176 • Tell me more about the other barriers or challenges that you encountered? 177 • From your point of view, what strategies would be useful in mitigating these barriers? 178 179 The researchers ensured that the study had rigor by meeting the gold standard articulated by 180 Lincoln and Guba (1985) consisting of five critical elements of credibility, dependability, 181 transferability, trustworthiness, and confirmability.18 To ensure data quality, all the 30 in depth 182 interviews were digitally audio-recorded and transcribed verbatim to preserve the data integrity. 183 184 Data Analysis 185 7 7 Data analysis occurred concurrently with data collection. The researchers analyzed the data set 186 manually using the thematic analysis framework through the process of reflexive ‘immersion and 187 crystallization’.19. The “immersion” phase started off with each researcher by reading and 188 rereading and examining portions of the data in detail, followed by suspending the process of 189 examining or reading the research data to reflect on the analysis experience. This phase then led 190 to the second, “crystallization phase”, which is characterized by the researchers identifying and 191 refining the themes. This two-step sequential data analysis process creates rich, trustworthy, 192 sensitive, and insightful research findings, hence its popularity among qualitative researchers.20 193 194 Results 195 Demographic characteristics 196 A total of 30 participants voluntarily participated in the study, 17 healthcare providers (Doctors 5, 197 Midwives 5, Nurses 5, and Health Educators 2) and 13 pregnant women. The healthcare providers 198 had between 5 and 20 years of clinical experience in antenatal clinics. The pregnant women 199 were aged between 23-39 years; were 30 to 37 weeks of gestation and had between 1 to 6 children. 200 All the pregnant women had either primary, secondary or college level education, with 9 formally 201 employed while 4 were housewives. 202 203 Part 1 A- Challenges Experienced by Service Providers 204 Lack of Consultation Room 205 The first challenge reported is the lack of a separate room for performing individual assessments 206 of pregnant women. Several healthcare workers reported the shared examination rooms as a major 207 challenge noting that it negatively affected the pregnant women’s ability to discuss sensitive issues 208 of concern with their healthcare providers, fearing they might be overheard by others: 209 “The patient doesn't feel comfortable…she might have a lot to discuss with her care 210 providers. But privacy issues are compromised here…” (HCP-DR#1). 211 “There is no privacy… we are seeing and talking with the women in the same room where 212 another doctor is seeing another woman” (HCP-MW#1). 213 214 Lack of Designated Space for Health Education 215 8 8 A second challenge that hindered provision of quality antenatal education services is the lack of 216 designated and private space for providing education: 217 “We do not have room to separate pregnant women and provide education session for 218 them” (HCP-MW#4) 219 “We need a proper place …. unfortunately, we have one office, and 2 colleagues share the 220 same office…Women don’t feel comfortable ….” (HCP-EDU#1) 221 “The room is really not suitable… sometimes because of disturbance I will forget to 222 provide education to the women. I cannot close the door, when I close it, the other patient 223 keeps knocking the door, so I decided to leave the door open” (HCP-SN#3) 224 225 Work Overload 226 Another significant challenge is increased work overload due to high patient numbers and multiple 227 responsibilities: 228 “We have a lot of patients… this is an issue that prevents us from providing the optimal 229 type of care in general…” (HCP-DR#1) 230 “Also, the patient list is long causing you to rush” (HCP-SN#4) 231 “.... the clinic is very busy and there's more workload…we are seeing overbooked cases. 232 …with this, of course is difficult to provide elaborative education to the women” (HCP-233 DR#5) 234 235 In relation to multiple assignments, the providers reported being assigned multiple tasks, which 236 hindered them from providing effective education: 237 “Usually,as a doctor we are doing multiple tasks, we are the one collecting blood for 238 investigation, doing ultrasound scan, and talking to the patient and giving advice…a lot of 239 things we are doing… we are in a rush” (HCP-DR#1) 240 “A lot of documentation, which consumes the time we register in the system, in the book 241 and the green card, etc. I feel if there was less registration [documentation] I might get 242 time so I can provide education…” (HCP-SN#5) 243 “My role here is to give education to all patients in the health centre including school 244 students, and those with chronic diseases, not just pregnant women” (HCP-EDU#2) 245 246 9 9 Lack of Time 247 The lack of time was another obstacle faced in providing antenatal education to pregnant women: 248 “No time for education, we really need time and honestly I feel that the women need a lot 249 of education as part of their care, lack of time is the biggest challenge….” (HCP-SN#5) 250 “...for proper counseling she [patient] needs at least 30 minutes along with examining her 251 and documenting the care, we are seeing lots of patients per day, so we don’t have much 252 time for education and counseling” (HCP-DR#4) 253 “No time to talk to them or to educate them but we give tips and if she has any question, 254 we’ll try to answer them but as a routine to teach them, no time to stay with the patient 255 explaining to her about her condition” (HCP-MW#4) 256 257 Under-Staffing 258 Another major challenge experienced by healthcare providers is the shortage of staff in the 259 antenatal clinics: 260 “We are only 2 staff in the clinic, we have a lot of things to do, but we try our best... we see 261 what they [ pregnant women] know and what they don’t know and based on that we give 262 the [missing] education…” (HCP-SN#1) 263 “The problem is we have one doctor, and she has to finish 14 patients …, that is why there’s 264 no time to sit and give time for patient education.” (HCP-SN#3) 265 266 Another aspect of the staff shortage reported was the non-availability of a midwife in these 267 antenatal clinics. 268 “I don’t have a midwife here... she could help somehow if we work together, and I guess 269 she can help a lot in this part as well” (HCP-DR#5) 270 “We do not have a midwife in our institution and me as a nurse I did not have any 271 [midwifery]course …except[from] my experience working in an ANC clinic. I learn things 272 from daily work and self-learning…” (HCP-SN#4) 273 274 Lack of Educational Materials 275 The non-availability of teaching resources and materials was also cited as these participants noted: 276 10 10 “We are not provided with the educational resources and materials such as recorded 277 videos to provide the education, only we are depending on the leaflets and we try to give 278 education when they ask us…” (HCP-MW#5) 279 “We do not have leaflets for all educational topics, that is why we sometimes ask them to 280 read more on the internet…” (HCP-SN#3) 281 282 Lack of Authority and Recognition 283 In addition to other barriers, several midwives particularly emphasized the persistent challenge of 284 disempowerment by the healthcare system in relation to their limited prescribed scope of practice 285 in the antenatal clinics: 286 “I feel the midwife has the capability to provide antenatal education 287 comprehensively if she was given the support [read permission] to do that by the 288 necessary authorities” (HCP-MW#1) 289 “I am here as a general nurse not as a midwife, although my certificate is in 290 midwifery... in the clinic my responsibility is just to inform the doctors. ...We are 291 not authorized to give education regarding complications of pregnancy. (HCP-292 MW#4) 293 294 Identifying valuable educational sessions 295 An important challenge experienced by health workers is reluctance of some women to 296 focus on the available health education opportunities. This challenge was reported mainly 297 as reluctance of some pregnant women to planned educational sessions as herein reported: 298 “…[some pregnant women]…are not interested, and they don’t ask… even if we tell 299 something they will not show the interest to learn or to know” (HCP-DR#4) 300 “Also some women who have previous experience, for example with diabetes, will 301 tell that I already know what to eat and what to do from my previous experience... 302 she will not come even if the services are available. I wish the women take it 303 seriously...” (HCP-EDU#1) 304 305 11 11 This meant that the health care professional had to shoulder the additional burden of 306 constantly finding out the desired educational needs of the women. This resulted in an 307 additional workload for HCP’s. 308 309 Part 1B- Challenges Experienced by Pregnant Women 310 Lack of Focus on Women’ Actual Needs and superficial Education 311 A major challenge experienced by pregnant women in this study was that lack of focus of antenatal 312 education on the actual needs of pregnant women: 313 “Every pregnant woman should receive education …even me when I will come for 314 my second pregnancy, I believe I might need education in many things, each 315 pregnancy is unique, it should not be treated as she knows from her previous 316 experience” (P.W#1) 317 “Unfortunately, she explained without details… the patient comes out of the 318 [antenatal] clinic with questions in her mind. As that was my first childbirth, that 319 situation caused me fear and phobia…” (P.W#4) 320 321 In addition, some women felt that the healthcare providers gave them answers that did not 322 address their needs. They perceived this as providing them with superficial education: 323 “We see that the pregnant woman is not aware of the problem and the doctor gives 324 her superficial information about treatment and the risks and consequences. The 325 medical staff must ask and discuss the problems and symptoms with the pregnant 326 woman in [more] detail” (P.W#7) 327 “We also need those [HCPs] to focus more on educating us about childbirth, the 328 postpartum stage and how to deal with a nursing baby” (P.W#9) 329 “We wish the medical staff would pay more attention to education… they only pay 330 attention to routine examinations of pregnant women…” (P.W#12) 331 “They are not focusing on educating the pregnant women. If the pregnant woman 332 is educated and aware of these topics, she would be able to deal with every symptom 333 and problem that happens with her” (P.W#13) 334 335 Overcrowding in the Antenatal Clinic 336 12 12 Another hindrance is the large number of patients resulting in overcrowding in the clinics: 337 “Another big problem is the overcrowded clinic and the large number of pregnant women 338 who visit the clinic. Sometimes I find six patients with me in the same room to do blood 339 pressure examinations. So, you find the nurse is trying to finish off the patients and just 340 leave”. (P.W#4) 341 342 In further agreement, another participant reiterated that: 343 “The problem in the institution is the limited number of employees. Every day, they receive 344 from 20-30 pregnant women. This is difficult … [and] over the health workers’ capacity. 345 They cannot make lectures or provide [quality] antenatal educational services for all the 346 women here” (P.W#5) 347 348 Lack of Educational Resources 349 Another persistent challenge mentioned by most pregnant women is the lack of resources required 350 for effective teaching sessions: 351 “We need more educational services… The medical staff is only depending on leaflets...they are 352 not using a variety of methods... How can they guarantee pregnant women will read these leaflets 353 to get the information? (P.W#11) 354 355 Use of Medical Jargons 356 This use of unfamiliar language during sessions limited women's understanding of the content: 357 “Among the challenges I face as a pregnant woman is the medical staff's use of terms that 358 I do not understand. Although I’m a nurse, there are some terms I do not understand 359 especially that I do not work in maternity department” (P.W#7) 360 361 Part 2 A- Strategies to Improve Antenatal Education Services 362 The providers suggested the following strategies to improve antenatal education services: 363 Staffing the Antenatal Clinic with Midwives 364 Some providers recommended staffing antenatal clinics with midwives as a strategy to help 365 improve the provision of antenatal educational services: 366 13 13 “...we should also have specialized staff mainly midwives so that they can give more, since 367 they are more familiar with these topics that need to be discussed with pregnant women, 368 and they can give better services” (HCP-SN#1) 369 370 “[It is] very important to have a midwife...she will help to make my life easy. She knows 371 what to do without coming back to me. A midwife is very important to be available in each 372 health center…” (HCP-DR#1) 373 “If we have a midwife, she can help a lot… she can do abdominal palpation, checking the 374 foetal heart rate, providing health education, if she is available, I feel the burden will be 375 divided and the workload will be divided between us…” (HCP-DR#2) 376 “The midwife will help a lot…and she will be more interested to prepare the women for 377 delivery and even she can explain to the doctors here about the management of different 378 stages of labour” (HCP-DR#3) 379 380 Designated Space for Antenatal Education 381 Another recommendation is having a designated room provided to the clients: 382 “We need a proper place to educate mothers because education is an essential part of 383 antenatal care” (HCP-MW#3) 384 “One of the solutions is to provide room for counseling” (HCP-EDU#2) 385 386 Improving Staffing Levels 387 Some healthcare providers further recommended increasing the number of clinical staff: 388 “If we increase the number of staff will help to improve the quality of our service” (HCP- 389 DR#5) 390 “If they can give enough staff that will help a lot in this area” (HCP-NS#1) 391 “They need to provide more educators to the [antenatal] clinics” (HCP-EDU#1) 392 393 Expansion of Educational Activities and Methods 394 Expanding and ensuring diversity in the educational activities and methods is another strategy 395 to improve provision of educational service to the users: 396 14 14 “We [currently use] leaflets and posters. …[but] we need various educational materials, 397 such as figurine and manikins…to explain and deliver the information clearly…, the 398 illustrations attract more attention” (HCP-EDU#2) 399 “Maybe we can make audio-visual aids will really help to attract especially the new 400 generation of the young and even the multigravida mothers” (HCP-DR#5) 401 “Put a schedule for nurses to prepare a topic for the pregnant women, and we can 402 cooperate with other healthcare providers like physiotherapist, dietitian to provide 403 teaching session for the pregnant women, it will be fair enough for the pregnant women to 404 provide them with schedule with different educational classes” (HCP-MW#4) 405 406 In terms of the scheduled teaching sessions, a midwife recommended that: 407 “I think we should schedule teaching session for pregnant women at least weekly” (HCP-408 MW#1) 409 410 Continuing Professional Development programs 411 Participants also suggested continuing professional development through courses and workshops: 412 “[we] need courses related to antenatal education because there are many methods, we 413 can learn to provide better services… and if the educator is trained then more topics can 414 be included in education… it will be perfect” (HCP-MW#2) 415 “...workshops are needed and training for the staff to improve because not all are familiar 416 with the educational topics… sometime new staff need somebody to follow with…., the idea 417 of training will be good for us to learn, refresh and update our knowledge…” (HCP-SN#4) 418 “Providing training courses for the physician, nurses and educators especially about the 419 topics related labour and birth, exercises contraceptive…etc , will be very helpful to 420 improve” (HCP-DR#5) 421 422 Dedicated staff for Antenatal Education 423 An important strategy suggested by a midwife to improve the provision of ANE services involves 424 hiring a dedicated staff for provision of education. 425 “I will suggest assigning a staff, whose role is to educate the women only, that really will 426 help a lot …even a simple advice you will give it might stick with her [PW] mind and it will 427 15 15 help to change a lot of behaviours. As a midwife we try our best to benefit the women with 428 the information we gained from midwifery program… education should be something 429 regularly provided to the women in all aspect of care for the pregnant women and s… not 430 wait for the complication to occur to provide the education”. (HCP-MW#5) 431 432 Provision of Hotline for Urgent Clarification 433 An innovative strategy suggested is providing a hotline for pregnant women to enable them call 434 and inquire about key questions that need to be answered instantly by healthcare providers: 435 “...they need a hotline to answer inquiries… I believe some of the questions might not come 436 during the visit; when she will go home some questions might arise and then she wonders 437 what to do…” (HCP-MW#2) 438 439 Establishment of Midwife-led Care units 440 Another recommendation is the establishment of midwifery-led care units across the country: 441 “In the midwife-led clinic we have sufficient time to discuss and provide individualized 442 care… the women will be seen by the same midwife, so it helps in strengthening the trust 443 relationship… Also, she will feel more comfortable to discuss and express [herself] rather 444 than be seen by different providers during each visit…” (HCP-MW#2) 445 446 Mass Education through social media 447 The use of social media to pass educational messages was also recommended to be used since 448 social media is widely accepted by many people as this participant affirms: 449 “Like in TV, structured education can be displayed in TV so people can see and follow 450 because I feel through social media the idea of [antenatal] education will be more accepted 451 by people” (HCP-SN#4) 452 453 Part 2 B- Recommendations from Pregnant Women 454 The pregnant women suggested the following ways to improve antenatal education services: 455 Focused Antenatal Education 456 The women suggest the need for focused and regular antenatal education throughout pregnancy: 457 16 16 “The pregnant woman should get education before going through the experience of 458 childbirth… she might go too late…, also they should focus more on the proper method of 459 pushing while giving birth….” (P.W#10) 460 “They need to give us information about childbirth and the child. In the first trimester, they 461 are supposed to give us information about the correct meals, medicine, exercises, and 462 positions of sleeping and the movement of the pregnant woman for safe pregnancy”. 463 (P.W#9) 464 “The staff in antenatal clinic should give pregnant women at the beginning of their 465 pregnancy a lecture on how to deal with the symptoms of pregnancy and the 466 complications that they may be exposed to,…we need more focus from the medical staff 467 … educate them about pregnancy…as a very sensitive and important stage” (P.W#4) 468 “They [HCPs] are supposed to tell us that at the first stage of pregnancy, avoid this type 469 of food, and in the second stage, certain types that you avoid or take…also they should 470 educate us about the movement and physical activity in the pregnancy either as routine or 471 daily, especially if the pregnant women have problems during pregnancy” (P.W#8) 472 473 Innovative Educational Activities 474 Some pregnant women suggested introduction of various educational activities in the clinics: 475 “We do not need only routine visits and check-ups; we need education about all related 476 care. I suggest conducting educational lectures… and to discuss the experiences of other 477 mothers. Also the available posters and brochures should be reviewed and updated … 478 (P.W#2) 479 “Make a group and give education, and sometime in same group some women might have 480 the experience so other women will benefit from each other’s experience” (P.W#3) 481 “We also wish there to have an awareness video for the pregnant woman to benefit from 482 and to understand and comprehend the information more” (P.W#7) 483 484 Dedicated Staff for Antenatal Education 485 In addition, some pregnant women recommended hiring a dedicated staff: 486 “It would be beneficial if we have a specialist nurse in the health institution for the 487 antenatal educational services” (P.W#13) 488 17 17 “I feel the nurses are busy., so better employ somebody to provide the teaching and 489 education…, so this person will listen to the woman, answer all her questions, reassure her 490 and make her feel supported…” (P.W#1) 491 “I belief that a nurse or a specialist in antenatal educational services must provide the 492 pregnant women with all information needed” (P.W#2) 493 494 Provide a dedicated Space for Education 495 Similar to providers, the users also suggested a dedicated office for education and counseling: 496 “an education office can be set up for pregnant women. This will result in more caring, 497 … they will open their hearts to express their feelings, needs and inquiries. This will help 498 to answer questions in their mind …” (P.W#2) 499 500 Improved Communication 501 Another recommendation to improve antenatal services is minimizing the use of medical jargon: 502 “The first thing is to make sure that the pregnant woman understands all that the doctor 503 says to her, so they need to avoid using difficult terms” (P.W#7). 504 505 Discussion 506 The study identified many factors that negatively impacted the provision and receiving of antenatal 507 education services in the selected health facilities in Oman. These findings are comparable to those 508 of previous studies conducted in Oman by Al Maqbali (2018) who found that pregnant women 509 appeared disempowered and seemed to lack control over the care they received.14 As a result the 510 women felt that their needs were not satisfied since a significant discrepancy existed between what 511 they expected and needed and the actual care and information they received during antenatal visits. 512 513 Similarly, in Iran, Javanmardi, et al., (2019) in a study on the challenges women experience to 514 access health information during pregnancy, found that there was insufficient interaction between 515 women and healthcare providers. In addition, there was also failure to access various information 516 resources from the health facilities.21 The authors recommended that policymakers and health 517 planners should remove the barriers that interfere with delivery of quality health information 518 during pregnancy. A study conducted in Addis Ababa in Ethiopia on antenatal care and health 519 18 18 education also identified similar challenges. The challenges included but were not limited to the 520 shortage of staff, lack of time, lack of training, negative staff attitude, negative cultural beliefs and 521 practices, and lack of incentives for providers. As reported in the current study, these barriers 522 hindered effective antenatal education service provision in the selected health facilities.5 523 524 In terms of how these challenges might be mitigated, both healthcare providers and pregnant 525 women provided some suggestions about who, where, when and how to improve the current 526 antenatal education services. The rationale for these strategies is that when such gaps are 527 addressed, they result in improved antenatal education services, which in turn creates positive 528 impact on obstetrical outcomes, such as reducing low-birthweight, prematurity and promoting 529 exclusive breastfeeding among other positive outcomes for baby, mother and family.22,23 530 531 The most prominent suggestions from both groups included the need for proper designated space 532 for antenatal education, dedicated staff for antenatal education, innovative educational activities 533 and facilities and provision of tailor-made training for healthcare providers. These 534 recommendations are consistent with those documented in Woldeyohannes and Modiba’s (2020) 535 study in Ethiopia which advocated for ongoing education for healthcare givers, assignment of 536 dedicated staff to provide antenatal education services, and reducing the patient numbers per day.5 537 538 Another recommendation that has received attention in previous studies is the midwife-led 539 antenatal clinics. A classical Cochrane Collaborative study found that pregnant women who 540 received prenatal, intrapartum, and postnatal care primarily from a midwife were less likely to 541 deliver prematurely while requiring fewer medical interventions, compared with women cared for 542 by obstetricians or family physicians.24 The study found that midwife-led care resulted in fewer 543 epidurals, fewer episiotomies, lower odds of premature delivery and greater odds of spontaneous 544 vaginal birth and overall better pregnancy experience. This finding is consistent with WHO (2016), 545 ICM (2018) and NICE (2019) recommendation, which state that midwife-led care is the safest 546 approach of care for healthy pregnant women, who have no immediate danger signs.25,26,27 547 548 In addition, several other studies argue that midwife-led-care is associated with increased 549 empowerment and confidence in the pregnant women's ability to give birth without the need for 550 19 19 medical and obstetric intervention. According to International Confederation of Midwives (ICM) 551 (2018), a midwife-led- care means that the midwife is the lead health-care professional who is 552 responsible for the planning, organizing and delivering of care to a woman from the initial booking 553 of antenatal care until the postpartum period.26 The women in these studies also reported 554 developing the ability to recognize the danger signs in pregnancy, which helped them to abstain 555 from risky behaviors and reduced complications associated with pregnancy and childbirth resulting 556 in positive outcomes.28,29 In recent times, this model has received further support in 2020 with the 557 World Health Organization advocating for investment in such midwifery models of care to provide 558 high-certainty and evidence-based care. This strategy would improve maternity care by integrating 559 such care into existing healthcare systems, thereby helping to transform maternal health globally.30 560 561 Moreover, these proposed strategies align with the antenatal care recommendations stated by 562 Queensland Health, Australia (2018), which requires antenatal education to equip pregnant women 563 with balanced information, including information about pregnancy, birth and possible 564 complexities and transition to the postnatal period. In addition, the strategy recommends a 565 dedicated health educator who should be adequately trained and prepared to provide antenatal 566 education based on the principle of adult learning (Queensland Health, 2018).31 Further, in Ireland, 567 the National Women, and Infant Health Program (2020) states that providers of antenatal education 568 should be supported with the most up to date educational materials. This support should include 569 innovative audio-visual aids to provide evidence-based information to the parents. Besides, these 570 providers should be granted protected time to engage in continuous professional development 571 programs to improve their skills and understanding of adult learning, group facilitation, and 572 evidence-based practice among others. The program further recommends conducting the antenatal 573 education in a safe, clean and well-equipped physical environment to enhance each pregnant 574 woman's active participation so as to adequately meet their learning needs. 575 576 Conclusion 577 The study identified that healthcare providers and pregnant women experienced many challenges 578 while providing and receiving antenatal education services. As a result of the barriers, significant 579 deficiencies exist in the quality and quantity of antenatal education services provided to pregnant 580 women related to pregnancy, labor and birth, postpartum and newborn care. The findings also 581 20 20 clearly indicate that these antenatal educational services are not provided uniformly and adequately 582 to all pregnant women. As a remedy, it is recommended that there should be designated spaces, 583 dedicated staff, innovative educational activities, and creation of awareness about the actual scope 584 of midwifery practice among healthcare providers and the public. Finally it is also recommended 585 that midwife-led antenatal clinics should be established to provide comprehensive maternity 586 services in line with the current recommendation of the World health organization. 587 588 Conflicts of Interest 589 The authors declare no conflict of interests. 590 591 Funding 592 No funding was received for this study. 593 594 Authors’ Contribution 595 MYKA conceptualized the idea, involved in data collection. VS and GAM contributed to the 596 design and analysis and drafting of the manuscript. VS and GAM supervised the study. All 597 authors approved the final version of the manuscript. 598 599 Acknowledgement 600 The authors are grateful to all the participants, the Health Care providers, and pregnant women 601 for their participation in the study. 602 603 References 604 1. World Health Organization (2021). New global targets to prevent maternal deaths. 605 https://www.who.int/news/item/05-10-2021-new-global-targets-to-prevent-maternal-deaths. 606 2. WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. 607 Maternal mortality: Levels and trends 2000 to 2017. Geneva: 2019. 608 (https://www.who.int/reproductivehealth/publications/maternalmortality-2000-2017/en/). 609 3. Ahmad D, Mohanty I, Hazra A, Niyonsenga T. (2021). The knowledge of danger signs of 610 obstetric complications among women in rural India: evaluating an integrated microfinance 611 21 21 and health literacy program. BMC Pregnancy Childbirth 2021; 21:79. 612 doi: https://10.1186/s12884-021-03563-5. 613 4. Feroz A, Perveen S, Aftab W. Role of mHealth applications for improving antenatal and 614 postnatal care in low and middle income countries: a systematic review. BMC health services 615 research 2017; 17:1- 704. https://doi.org/10.1186/s12913-017-2664-7. 616 5. Wulandaria RD, Laksonob AD. (2020). Education as predictor of the knowledge of pregnancy 617 danger signs in Rural Indonesia. International Journal of Innovation, Creativity and Change 618 2020; 13:1-10.1037- 1051. 619 6. Kruk ME, Chukwuma A, Mbaruku G, Leslie HH. (2017). Variation in quality of primary-care 620 services in Kenya, Malawi, Namibia, Rwanda, Senegal, Uganda and the United Republic of 621 Tanzania. Bulletin of the World Health Organization 2017; 95:6-408. 622 https://dx.doi.org/10.2471%2FBLT.16.175869. 623 7. Ononokpono DN, Baffour B, Richardson A. (2020) Mapping maternal healthcare access in 624 selected west african countries. Etude de la Population Africaine 2020; 34 :1-5082-5105. 625 https://dx.doi.org/10.11564/34-1-1495. 626 8. United Nations Sustainable Development Goal 3: Ensure healthy lives and promote well-being 627 for all at all ages. NewYork: 2022. https://www.un.org/sustainabledevelopment/health/ 628 9. Ministry of Health (2021). Annual Health Report https://www.moh.gov.om/en/web/statistics/-629 /-2-10 630 10. Ministry of Health (2019). Annual Health Report. 631 https://www.moh.gov.om/en/web/statistics/annual-reports . 632 11. Karlsen S, Say L, Souza JP. et al. The relationship between maternal education and mortality 633 among women giving birth in health care institutions: Analysis of the cross sectional WHO 634 Global Survey on Maternal and Perinatal Health. BMC Public Health 2011; 11:606. 635 https://doi.org/10.1186/1471-2458-11-606. 636 12. Halim LB, Alajmi F, & Al Lamki S. (2018). Ensuring universal access to primary health care 637 in Oman 2018. Primary Health Care Performance 638 Initiative.https://improvingphc.org/ensuring-universal-access-primary-health-care-oman . 639 13. Dong K, Jameel B, Gagliardi AR. (2022). How is patient-centred care conceptualized in 640 obstetrical health? comparison of themes from concept analyses in obstetrical health- and 641 patient-centred care. Health Expect 2022; 25:3-823-839. doi: 10.1111/hex.13434. 642 https://doi.org/10.1186%2Fs12884-021-03563-5 https://doi.org/10.1186/s12913-017-2664-7 https://dx.doi.org/10.2471%2FBLT.16.175869 https://dx.doi.org/10.2471%2FBLT.16.175869 https://doi.org/10.11564/34-1-1495 https://www.un.org/sustainabledevelopment/health/ https://www.moh.gov.om/en/web/statistics/annual-reports https://www.moh.gov.om/en/web/statistics/annual-reports https://improvingphc.org/ensuring-universal-access-primary-health-care-oman 22 22 14. Al Maqbali F. (2018). Navigating Antenatal Care in Oman: A Grounded Theory of Women's 643 and Healthcare Professionals' Experiences. PhD Thesis, 2019, The University of Manchester, 644 UK. ProQuest Dissertations Publishing, 27775318. 645 15. Etikan I, Musa SA, Alkassim RS. Comparison of convenience sampling and purposive 646 sampling. American journal of theoretical and applied statistics 2016; 5:1-1-4. doi: 647 10.11648/j.ajtas.20160501.11 648 16. Bradshaw, C., Atkinson, S., & Doody, O. (2017). Employing a qualitative description approach 649 in health care research. Global qualitative nursing research, 4, 2333393617742282. 650 https://doi.org/10.1177%2F2333393617742282 651 17. Moser A & Korstjens I. 2018. Series: Practical guidance to qualitative research. Part 3: 652 Sampling, data collection and analysis. Eur J Gen Pract 2018; 24:1-9-18. doi: 653 10.1080/13814788.2017.1375091. 654 18. Lincoln Y. Guba EG. (1985). Naturalistic inquiry. Newbury Park, CA: Sage 655 19. Borkan JM. (2021). Immersion–Crystallization: a valuable analytic tool for healthcare 656 research. Family Practice 2021; 39: 785–789. https://doi.org/10.1093/fampra/cmab158. 657 20. Nowell, L. S., Norris, J. M., White, D. E., & Moules, N. J. (2017). Thematic analysis: 658 Striving to meet the trustworthiness criteria. International journal of qualitative methods, 659 16(1), 1609406917733847. 660 661 21. Javanmardi M, Noroozi M, Mostafavi F, Ashrafi-Rizi H (2019). Challenges to access health 662 information during pregnancy in Iran: a qualitative study from the perspective of pregnant 663 women, midwives and obstetricians. Reproductive health 2019;16:1-1-7. 664 https://doi.org/10.1186/s12978-019-0789-3. 665 22. Silva EPD, Lima RTD, Osorio MM. (2016). Impact of educational strategies in low-risk 666 prenatal care: systematic review of randomized clinical trials. Ciência & Saúde Coletiva 667 2016;21:2935-2948. https://doi.org/10.1590/1413-81232015219.01602015. 668 23. Maastrup R, Rom AL, Walloee S, Sandfeld HB, Kronborg H. Improved exclusive 669 breastfeeding rates in preterm infants after a neonatal nurse training program focusing on six 670 breastfeeding-supportive clinical practices. PLOS ONE 2021; 16:2- 671 e0245273. https://doi.org/10.1371/journal.pone.0245273. 672 about:blank https://doi.org/10.1093/fampra/cmab158 about:blank about:blank about:blank https://doi.org/10.1590/1413-81232015219.01602015 https://doi.org/10.1371/journal.pone.0245273 23 23 24. Potera C. Evidence supports midwife-led care models: fewer premature births, epidurals, and 673 episiotomies; greater patient satisfaction. Am J Nurs 2013;113:11-15. doi: 674 10.1097/01.NAJ.0000437097.53361.dd. PMID: 24149253. 675 25. World Health Organization. Standards for improving quality of maternal and new born care in 676 health facilities 2016. Retrieve from 677 https://apps.who.int/iris/bitstream/handle/10665/249155/9789241511216-per.pdf. 678 26. International Confederation of Midwives. Philosophy and Model of Midwifery Care 2018. 679 https://www.internationalmidwives.org/assets/files/definitionsfiles/eng-philosophy-and-680 model-of-midwifery- 681 27. National Institute for national and Care Excellent. Antenatal care for uncomplicated 682 pregnancies. Clinical guideline 2020. https://www.nice.org.uk/terms-and-conditions#notice- 683 of rights. 684 28. Voon, S. T., Lay, J. T. S., San, W. T. W., Shorey, S., & Lin, S. K. S. (2017). Comparison of 685 midwife-led care and obstetrician-led care on maternal and neonatal outcomes in Singapore: 686 A retrospective cohort study. Midwifery, 53, 71-687 79.https://doi.org/10.1016/j.midw.2017.07.010 688 689 29. Sandall, J., Soltani, H., Gates, S., Shennan, A., & Devane, D. (2016). Midwife‐led continuity 690 models versus other models of care for childbearing women. Cochrane database of 691 systematic reviews, (4).https://doi.org/10.1002/14651858.CD004667.pub5 692 30. Edmonds JK, Ivanof J, & Kafulafula U. Midwife Led Units: Transforming Maternity Care 693 Globally. Annals of global health 2020; 86:1. https://dx.doi.org/10.5334%2Faogh.2794 694 31. The Queensland Health. (2018). Recommendations for antenatal education Content, 695 development and delivery. https://clinicalexcellence.qld.gov.au/priority-areas/service-696 improvement/maternity-service-improvement. 697 https://apps.who.int/iris/bitstream/handle/10665/249155/9789241511216-per.pdf https://doi.org/10.1016/j.midw.2017.07.010 https://doi.org/10.1002/14651858.CD004667.pub5 https://dx.doi.org/10.5334%2Faogh.2794 https://clinicalexcellence.qld.gov.au/priority-areas/service-improvement/maternity-service-improvement https://clinicalexcellence.qld.gov.au/priority-areas/service-improvement/maternity-service-improvement