Improving maternal health: Women’s attitude to antenatal care utilization is crucial

The World Health Organisation in her 2018 release recommends that all women must have access to high quality care before, during and after childbirth to optimize maternal health. Women’s attitude towards antenatal care is crucial to her ability to access the requisite care. Findings reveal that women who do not receive care during pregnancy have worse pregnancy outcomes and risk maternal death. We advocate for more sensitization to change the attitude of pregnant women towards antenatal and intrapartum care. Correspondence to: Rosemary Ogu, Department of Obstetrics and Gynecology, Faculty of Clinical Sciences, College of Health Sciences, University of Port Harcourt, East West Road, Port Harcourt, Rivers State, Nigeria, Tel: +2348033129937; E-mail: rosemary.ogu@uniport.edu.ng


Introduction
Maternal health is the health of a woman during pregnancy, childbirth and in the six weeks after delivery while Antenatal care (ANC) is the specialized care a pregnant woman receives during her pregnancy through a series of consultations with trained health care professionals in order to help her attain and maintain a state of good health all through her pregnancy [1,2].
The 2016 World Health Statistics showed that ANC coverage was indirectly related to the maternal mortality ratio (MMR) worldwide, showing that countries with low ANC coverage are the Countries most likely to have a high MMR [3]. The global coverage of skilled attendance at birth was estimated to have reached 73% in 2013 [3]. However, despite steady improvement globally and within regions, millions of births were not assisted by a midwife, a doctor or a trained nurse. More than 40% of births in the WHO African Region and WHO South-East Asia Region were not attended by skilled health Personnel. The ANC coverage and skilled birth attendance in Kuwait, Finland and Canada were 100% with MMR of 4/100,000, 3/100,000 and 7/100,000 respectively. This is in contrast with what obtains in sub-Saharan Africa; Chad with 55% ANC coverage and a MMR of 856/100,000, and Nigeria with ANC coverage of 61% and MMR of 814/100,000. These MMRs are unacceptable, higher than the region's average -sub-Saharan Africa with the highest average MMR in the world (546/100,000), accounting for two-third (66%) of maternal deaths worldwide. It is also higher than the global average MMR of 216/100,000 [4].

Antenatal care utilization
Available evidence reveal that Nigeria has not attained the expected success in antenatal coverage and reduction in maternal mortality ratio [5,6]. The poor maternal health outcome in Nigeria could be a result of poor ANC coverage and utilization [7,8]. The importance of ANC services in enhancing maternal health during pregnancy and influencing the outcomes of pregnancy have been shown in previous studies [6,[9][10][11]. ANC allows for prevention, early identification and management of conditions that could be aggravated by pregnancy or threatening to the mother and/or her baby. ANC by trained skilled care providers also screens for anaemia, hypertension, gestational diabetes mellitus, infections, treats malaria, reduces the incidence of perinatal illness and death, provides birth preparedness, identifies danger signs in pregnancy and complication readiness through timely treatment and appropriate referrals [4,10,[12][13][14]. It also prevents the occurrence of eclampsia, obstetric haemorrhages, obstructed labour and other complications associated with labour and delivery.
Maternal mortality is undoubtedly a major public health problem in many developing countries, Nigeria inclusive, requiring urgent, concerted and effective intervention at the various levels of the society. It is possible to identify the precursors, early signs or risk factors for at least some of the major pathogenic causes of maternal death, such as pre-eclampsia, that may proceed to eclampsia. Antenatal care may reduce or eliminate maternal morbidity and mortality directly through the detection and treatment of pregnancy-related or intercurrent illnesses, or indirectly through the detection of women at increased risk of complications of delivery and ensuring that they deliver in suitably equipped health facilities.

Women's attitude to antenatal care and resultant maternal morbidity/mortality
The University of Port Harcourt Teaching Hospital (UPTH) is a tertiary hospital with an average of 3000 deliveries conducted annually. The hospital has approximately 900 bed spaces with the obstetric unit having a total of 135 beds. There are 30 beds in the antenatal ward, 40 beds in the postnatal ward, 40 beds in the unbooked lying in ward, 17 beds in the labour ward and 8 beds in private/semi-private rooms. There are five units; each unit has four consultant obstetricians, four specialist senior registrars and three registrars with many experienced nurses and midwives. The obstetric unit caters for both booked and unbooked clients. Booked clients are those pregnant women who come to the hospital and register to receive antenatal care. Unbooked clients are pregnant women who did not go to any hospital and who therefore had received no form of antenatal care during the index pregnancy.
A review of the annual report of 2017 showed that of the total deliveries; (20%) were unbooked clients. These unbooked clients had a higher prevalence of ante partum hemorrhage, obstructed labour and preclampsia/eclampsia compared to booked clients. In terms of mode of delivery, unbooked mothers had a higher caesarean section rate and also a higher rate of emergency caesarean section, with cephalopelvic disproportion, obstructed labour and hypertensive disorders of pregnancy (Pre-eclampsia and eclampsia) being the most common indications. There were 30 maternal death during the period and 28 of these occurred in unbooked mothers. This further clearly showed the critical connection between antenatal care and pregnancy outcomes.
Poor economic status may make it difficult for women to make informed decisions about using health preventive and promotive services, such as antenatal care, particularly in our environment. Women may also choose, under those unfavourable economic conditions, to seek for care in substandard facilities because of the perceived cost of treatment in centers with higher standards of care. Unbooked clients thus present late with complications making surgical interventions inevitable because of foetal distress and prolonged obstructed labour with attendant high perinatal mortality. Some of the unbooked patients may have been admitted in labour in substandard facilities within the community only to be referred to the university hospital after onset of complications. Some studies had highlighted various factors, such as aversion for caesarean sections, high hospital bills, religious beliefs, cultural beliefs, illiteracy, poverty, ignorance, availability and accessibility of antenatal services, husband's education and acceptance of the services as barriers hindering women from utilising antenatal care and hospital delivery [15][16][17].
The causes of maternal mortality such as severe preeclampsia/ eclampsia, obstetric haemorrhage, sepsis and obstructed labour are highly preventable, if the patients were booked for antenatal care. Affordability, availability and accessibility of ANC providers are the hurdles to ANC utilization in Nigeria. Addressing financial and other barriers to ANC use will go a long way in increasing ANC coverage/ utilization and improve maternal health in Nigeria.

Conclusion
Pregnancy and childbirth are holistic experience that is profoundly affected by the woman's attitude and the care received. The new WHO guideline [18] highlights the importance of woman-centred care to optimize the experience of labour and childbirth for women and their babies through a holistic, human rights-based approach. It introduces a global model of intrapartum care, which takes into account the complexity and diverse nature of prevailing models of care and contemporary practice. National and local public health policy-makers, implementers and managers of maternal and child health programmes, health care facility managers, nongovernmental organizations (NGOs), professional societies involved in the planning and management of maternal and child health services, health care professionals (including nurses, midwives, general medical practitioners and obstetricians) and academic staff involved in training health care professionals all have a role to play in the care and respect given to pregnant women. This new guideline released by WHO is a welcome development as more advocacy and sensitization are needed to transform women's attitude towards maternal health. We must continue to advocate for women and their well-being to ensure improved maternal health.

Authorship and contributorship
RNO and JOA made substantial contributions to conception and design, acquisition, analysis and interpretation of data; drafting and revising the article. They both gave final approval of the version to be published and agreed to act as guarantors of the work.