|Ahead of print publication
Impact of antenatal care on pregnancy outcomes: A cross-sectional study in a rural community in Malaysia
Tahmina Afrose Keya1, Kevin Fernandez1, Kailash C Kharkwal2, Nasrin Habib3
1 Department of Community Medicine, Faculty of Medicine, AIMST University, Semeling, 08100, Bedong, Kedah, Malaysia
2 Department of Obstetric and Gynaecology, Faculty of Medicine, AIMST University, Semeling, 08100, Bedong, Kedah, Malaysia
3 Department of Physiology, Faculty of Medicine, Quest International University Perak (QIUP) City Campus, No.227, Plaza Teh Teng Seng (Level 2), Jalan Raja Permaisuri Bainun, 30250 Ipoh, Perak Darul Ridzuan, Malaysia
|Date of Submission||14-Jan-2020|
|Date of Decision||03-Apr-2020|
|Date of Acceptance||25-Jun-2020|
Tahmina Afrose Keya,
Department of Community Medicine, Faculty of Medicine, AIMST University, 08100, Semeling, Bedong, Kedah
Source of Support: None, Conflict of Interest: None
Background: Malaysia has a high standard of health-care system, including antenatal care (ANC) services. Objective: This cross-sectional study was carried out to assess the impact of regular ANC visits on outcome in a rural community in Malaysia from September to November, 2019, in village Kampung Merbok in Kedah, Malaysia. Method and Materials: A pretested semi-structured questionnaire was used as a tool for data collection among the women who gave birth in public or private health-care centers. Association between the various components of ANC and pregnancy outcome was examined using multivariate logistic regression analysis, and Chi-square test/Fisher's exact test was used to interpret the association between the ANC visits and the outcome variables. Result: Among the respondents, 39 (78%) had more than four ANC visits. Fourteen (28%) respondents had adverse pregnancy outcome. All nonattendees had adverse outcome. Only 6 (12%) women (95% confidence interval: 3.22, 20.78) had a history of cesarean section. This study found statistically significant association between maternal ANC visits and maternal and neonatal outcome variables (P < 0.05). Pearson's correlation test also revealed the strong relationship between ANC and the outcome variables (P < 0.0001). Conclusion: In this study, mothers having regular ANC visits experienced better pregnancy outcome compared to those nonattendees. Nevertheless, it is necessary to adhere to a minimum level of four ANC visits for all pregnant women. More health promotion programs are required focusing on improving women's awareness of the necessity of ANC throughout their pregnancy.
Keywords: Antenatal care visit, maternal complications, pregnancy outcome, risk assessment, risk reduction
|How to cite this URL:|
Keya TA, Fernandez K, Kharkwal KC, Habib N. Impact of antenatal care on pregnancy outcomes: A cross-sectional study in a rural community in Malaysia. Med J DY Patil Vidyapeeth [Epub ahead of print] [cited 2021 Feb 26]. Available from: https://www.mjdrdypv.org/preprintarticle.asp?id=308219
| Introduction|| |
Antenatal care (ANC) is a type of preventive health care, provided by skilled health-care professionals to pregnant women to ensure the best health outcome for both mother and the baby by preventing potential health risk during pregnancy., This study was carried out to study the association between the regular ANC and pregnancy outcome of the mother.
The major components of ANC include promoting healthy lifestyle through proper counseling, medical information over physiological and biological changes during pregnancy, prenatal nutrition, prenatal screening through regular monitoring, and lab investigation for risk identification that may lead to hazardous intrapartum and postpartum outcomes and appropriate management of high-risk pregnancies. All these components emphasize the importance of ANC during antepartum period.
Maternal mortality ratio (MMR) has dropped by 38% worldwide in between 2000 and 2017. Most of the pregnancy-related complications are preventable. According to WHO guidelines, a minimum of eight ANC visits have been recommended to decrease adverse pregnancy outcome. The interventions are aimed at regular monitoring of all mothers and babies, additional care for at-risk pregnancies, and specialized obstetric and neonatal care for high-risk complicated pregnancies.,
One of the targets of the Sustainable Development Goals-3is to bring down the MMR worldwide <70/100,000 live births by 2030. The Malaysian health-care system achieved impressive improvement, which includes satisfactory maternal and child health (MCH) care services. All states/federal territories of Malaysia are providing similar health-care protocol including ANC services. Following British guidelines, the Ministry of Health (MOH) of Malaysia recommends ten and seven visits for normal uncomplicated primigravida and multigravida, respectively., According to Malaysian protocol, they maintain four color coding systems for the risk assessment, which include white color code for the pregnancy without any risk factor, where the pregnant women can be followed up by a nursing staff at the health clinic; the green color code for low-risk pregnancies which should be referred to the medical officer at the health clinic followed by regular monitoring by either the medical officer or the nursing staff at the health clinic; the yellow color code for high-risk pregnancies in which case the pregnant woman should be referred to the specialist in the hospital within 48 h; and the red color code for extreme high-risk pregnancy that requires urgent referral to the hospital.
The purpose of this study was to assess the impact of regular ANC checkup on pregnancy outcome and identify the adverse effects that are associated with inadequate follow-up throughout pregnancy. Besides, this study aimed to add some information about how to improve the well-being of the mother as well as the fetus and the necessity of the screening procedure during the antenatal period to promote a healthy pregnancy outcome.
| Materials and Methods|| |
Study area and period
The study was conducted in a village, “Kampung Merbok,” Kedah, Malaysia. Kampung Merbok is located in the northern part of Malaysia around 390 km from the capital Kuala Lumpur. The village has one public health center, “Klinic Kesihatan Merbok;” one public hospital, which is around 5 km away; and two private hospitals around 5–8 km away from this village. The study was conducted from September to November, 2019.
This was a descriptive cross-sectional study.
All women of village Kampung Merbok, who gave birth in either public or private health-care center, have been included in this study. Women who were suffering from infertility and serious medical illness were excluded from this study.
Sample size determination and sampling technique
The sample size was calculated using OpenEpi (Version 3.01n updated on 2013/04/06, USA); considering hypothesized percentage frequency of outcome factor in the population (p): 20% ±5 and 5% alpha error, the minimum sample size was calculated to be 49. Fifty women were randomly selected from the study population (keeping nonresponse rate as 10%) using this line list through simple random sampling.
In this study, maternal outcome (antepartum/intrapartum/postpartum) and neonatal outcome (birth weight/neonatal mortality) with regular antenatal visit have been assessed. Informed verbal consent was ensured from each woman recruited into the study. A semi-structured questionnaire was used for this interview, which was prepared from the WHO recommendations for pregnancy. The questionnaire was pretested before carrying out the survey.
To assess ANC, we considered the number of visits who attended the outpatient clinic or any other settings. Three groups of women were considered which included: didn't attend ANC visit, attended 1–3 visits, and attended >4 visits. We compared these three groups for maternal outcomes.
In the survey questionnaire, the impact of ANC visit and its association with maternal outcome was assessed. The validated questionnaire was made up of the following five parts: the first part contained the details of ANC such as number of pregnancies, age of first pregnancy, regular ANC, number of ANC visits, place of ANC visit, tetanus toxoid (TT) immunization, iron/folic acid supplementation, history of miscarriage/abortion, antepartum complications, and routine antenatal investigations.
In the second part, intrapartum and postpartum outcomes of the respondents were assessed by using a 7-item questionnaire. The variables include place of delivery (public hospital/clinic private hospital/clinic), mode of delivery (vaginal delivery/instrument vaginal delivery/cesarean section), stillbirth (yes/no), intrapartum complications (yes/no), type of intrapartum complications (intrapartum hemorrhage/obstructed labor), postpartum complications (yes/no), and types of postpartum complications (postpartum hemorrhage [PPH]/postpartum depression [PPD]/puerperal sepsis).
The third part assessed the association of various ANC components with antepartum complications.
The fourth and fifth parts interpreted the association between maternal ANC visit with the outcome variables (antepartum/intrapartum/postpartum complications/neonatal outcome).
The sixth part assessed the relationship between the outcome variables among the study participants.
After collection of data, they were checked for completeness and were entered into Epidata 3.1 version and exported to SPSS 23.0 version for further analysis. Continuous variables were summarized as mean (standard deviation) with their 95% confidence intervals. Categorical variables were summarized as frequency (percentage).
Association of various ANC components with the outcome variable was analyzed by multivariate logistic regression analyses. Chi-square test/Fisher's exact test was used to find the association between maternal ANC visit with the outcome variables, which was summarized as odds ratio (OR). P < 0.05 was considered statistically significant. The Pearson's correlation test was conducted to establish the relationship between the outcome variables. Correlation was significant at 0.01 level (two tailed).
The main outcome variables were antepartum, intrapartum, and postpartum complications and the neonatal outcome among the study participants.
The ANC components and the pregnancy outcome variables have been described as individual levels.
This study was carried out by the MBBS Year-3 batch-23 students of AIMST University under their community medicine posting, which is part of the community diagnosis module. This is part of the AIMST University curriculum and annually, each batch carries out a survey at a different village in the region. The village is selected after the village head agrees to the students carrying out a survey in their locality. Ethical clearance was obtained from AIMST University's ethical review board and from District Health Office (DHO) Sungai Petani, Malaysia. Permission letter (AIMST/FOM/JKN/05/18) was also sought from DHO, and the copy of the letter was distributed to the selected sites. Verbal consent was secured from each participant after clear explanation of the purpose of the study. Confidentiality and anonymity was insured.
| Results|| |
[Table 1] depicts details of the ANC visits of the respondents. Among them, majority (39 [78%]) of them had a history of one to five numbers of pregnancies. Forty-two (80%) of them got married at 19–34 years of age. Only eight (16%) respondents did not attend any ANC checkup. Most (37 [88.10%]) of them attended public hospital/clinic for their regular ANC checkup. All (100%) respondents were fully immunized by TT, whereas 14 (72.0%) respondents did not take any iron/folic acid supplementation during their antepartum periods. Eleven (22%) of them reported for a previous history of miscarriage. Only 14 (28%) reported for antepartum complications and among them, 6 (42.9%), 4 (28.6%), 3 (21.4%), and 1 (7.1%) had the experience of pregnancy-induced hypertension, anemia, gestational diabetes mellitus, and preterm labor accordingly. Those eight nonattendees also did not undergo any routine antenatal investigations.
[Table 2] shows the intrapartum and postpartum outcomes of the respondents. More than half (33 [65.30%]) of the respondents have delivered their baby at public hospital/clinics. Forty-four (88%) reported for vaginal delivery. Only four (8%) of them had given birth of stillborn baby. Majority of the respondents (49 [98.0%]) have delivered normal birth weight baby and no respondents had the experience of neonatal death. Among the respondents, only eight had a history of intrapartum complications, out of which three and five respondents reported for intrapartum hemorrhage and obstructed labor, respectively. Only eight respondents were suffering from postpartum complications such as PPH, PPD, and puerperal sepsis.
[Table 3] represents the association of various ANC components (independent variables) with antepartum complications (dependent variable), which were analyzed by multivariate logistic regression. It explained the moderate relationship of the predictors (Xi-independent variables) to the variance of outcome variable (Y-dependent variable), which was not significantly associated (P > 0.05).
|Table 3: Association of various antenatal care components with antepartum complications as analyzed by multivariate logistic regression analyses|
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[Table 4] depicts the association between maternal ANC visits and the outcome variables. Chi-square test/Fisher's exact test was used to find the association between maternal ANC visits and the outcome variables of the respondents, which was statistically significant (P < 0.05). A total of 14 respondents were suffering from antepartum complications (OR = 13.5), and all nonattendees were suffering from antepartum complications. Overall, eight respondents had a history of intrapartum complications (OR = 27.56) and eight respondents were suffering from postpartum complications (OR = 27.56). Out of them, seven respondents did not take any ANC visit at all.
|Table 4: Association between maternal antenatal care visit and the outcome variables|
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[Table 5] represents the association between maternal ANC visits and the neonatal outcomes (stillborn and birth weight) among the study participants, which was also statistically significant (P < 0.05). Overall, four women had a history of still birth (OR = 0.087), whereas only one of them reported for giving birth of low birth weight baby (OR = 0.143).
|Table 5: Association between maternal ANC visits and the neonatal outcomes (stillborn and birth weight) among the study participants|
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The Pearson's correlation test was conducted to establish the relationship between the outcome variables; the findings are presented in [Table 6]. The results were statistically significant (P < 0.01).
|Table 6: Correlation between antepartum, intrapartum, and postpartum complications among the study participants (n=50)|
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| Discussion|| |
Overall, the ANC attendance was quite satisfactory in this study, and majority (39 [78%]) of them had a history of more than four ANC visits. The respondents were fully immunized by TT during their antenatal periods, and all the regular attendees had delivered through vaginal delivery without any pregnancy-related complications. A number of studies revealed the positive impact of regular ANC visits on pregnancy outcomes, which showed that appropriate checkup during the antenatal period can prevent most of the perinatal and postnatal life-threatening hazards.,, According to the WHO, more contact between pregnant women and a quality, cordial health-care services can trigger a positive pregnancy outcome.,
This study also showed similar results where most of the women experienced a safe delivery after getting regular and quality ANC follow-up. Besides, majority of the multipara with more than five children had taken less adequate visit compared to others. One study supports the same findings where they reported an inverse relationship between the ANC attendance and the number of parity. Another study showed the socioeconomic factor as a major cause for refusal of ANC follow-up in the high-parity women. However, our study does not support socioeconomic factor as a reason for that because of the easy accessibility and adequacy of the maternal and child care services (MCH) in that area. The complacent attitude could be the cause of lower attendance in this study.
The main objective of laboratory investigation during antenatal period is to identify any preexisting risk factor that could complicate the pregnancy during antepartum, intrapartum, or postpartum periods. This study showed that all ANC attendees also performed the laboratory investigations as indicated. Several studies have given the importance of laboratory tests, which include Modified Glucose Tolerance Test, urine full/microscopic examination, blood sugar profile, glycated hemoglobin (Hb) test, full blood picture, iron studies, and Hb analysis (Hb electrophoresis). They recommended laboratory test to rule out the high-risk pregnancy before the delivery.,, This study also showed better pregnancy outcome among the regular ANC attendees compared to those nonattendees. Some other studies also showed a significant relationship between regular careful pregnancy monitoring and positive pregnancy outcomes.,
Women in developing countries suffer from several pregnancy-related complications. A number of studies have been undertaken to go through some interventions such as designed antenatal cards to improvisation of the adverse pregnancy outcome. One of those study proved that appropriate follow-up by using designed ANC cards can result in positive pregnancy outcomes with risk reduction.,, The MOH Malaysia recommends color coding system in antennal follow-up that is being used to identify the level of care needed based on the condition of the pregnant women in order to boost up the perinatal and postnatal outcome.
Iron and folic acid supplementation are being taken throughout pregnancy to overcome physiological anemia. One study in Malaysia identified mild anemia in majority of the pregnant women during their ANC checkup. It supports the profound beneficial effects and the necessity of iron/folic acid supplementations during pregnancy. Similarly, another study proves anemia reduction as the most important function of ANC services. This study showed that 14 respondents did not take any sort of iron and folic acid supplementations. Among them, six respondents have been found anemic during their antenatal period. Despite not taking iron and folic acid supplements, seven respondents were nonanemic. Appropriate dietary intake might be protecting them from being anemic.
Among those 14 respondents, who were suffering from antepartum complications, eight respondents did not attend the ANC checkup at all. Regardless, taking regular antenatal follow up six respondents were also suffering from antepartum complications. Several studies also support this evidence, which revealed the adverse pregnancy outcomes in low-risk pregnancy.,, Moreover, in this study, the four stillborn babies and one low birth weight newborn were belonged to those mothers who did not receive regular ANC checkup at all. There was also no neonatal death among the respondents. The regular antenatal follow-up may be the reason behind this better outcome. Similar findings have been found in another study, which showed the potential significance of regular ANC follow-up for improving the child health outcomes.
Besides, the nonattendees were also found to have both the intrapartum and postpartum complications. This study also showed the statistically significant association (P < 0.0001) between the number of antenatal visits and pregnancy outcome and antepartum, intrapartum, and postpartum complications. This explains the adverse pregnancy outcome of the nonattendees during and after their delivery.
Consistent with many studies which have been carried out in both developed and developing countries, regular ANC visit was a strong predictor in this study. As a whole, this study showed a positive pregnancy outcome because of the regular ANC attendance of the most of the women in this community. Maternal counseling, careful monitoring, and screening for high-risk factors throughout pregnancy might be the key factors behind this satisfactory pregnancy outcome.
Because of small sample size, the findings of this study may not reflect the whole population. Nevertheless, the strength of the present study is that we had the opportunity to assess the effects of regular ANC visit on pregnancy outcomes, which reflect the significance of antenatal follow-up throughout the pregnancy. The outcome was quite satisfactory among the regular ANC attendees. Furthermore, this study also revealed that the intrapartum and postpartum hazards that were experienced by the nonattendees were preventable if they would have had regular follow-up during their antepartum period.
In summary, this study provides the evidence of potential importance of regular ANC services for improving both MCH outcomes, which might be an important tool to achieve the SGD-3 by 2030.
| Conclusion|| |
ANC is one of the major components of primary health-care services that ensure the well-being of pregnant mother as well as the newborn by reducing the pregnancy-related hazards. Adequate level of ANC services by early detection of high-risk pregnancy and timely management of preexisting risk factors can prevent and control a number of pregnancy-related hazards. Individual's awareness plays a crucial role here. Health education during the antepartum period influences the pregnant mother toward a healthy behavior, which is a strong predictor for a healthy pregnancy outcome. High-risk pregnancies do require additional medical attention by a quality level of ANC with specialized health-care professionals.
Proper ANC service reduces maternal and perinatal morbidity and mortality as well as reduces the probability of adverse neonatal outcome. Future research is required to strengthen the components, especially the screening methods of ANC follow-up.
We thank all the participants who took part in this study, the MBBS Year-3 group-E students of AIMST University, who were actively engaged in data collection and statistical data analysis.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]