EVALUATION OF ANTENATAL CARE SERVICES AND WOMEN’S PERCEPTION IN ASSIUTUNIVERSITYHOSPITAL

Howieda Ahmed Abd Elmohimen^* ,  Ragaa Ali Abd-Rabou^**,
Hany Abdel-Aleem Ali^*** and Madiha Mohammed Tosson^****

*B.Sc., Nursing Clinical demonstrator, Faculty of Nursing, Assiut, **Assist. professor of Maternity and Newborn Health Faculty of NursingCairoUniversity, ***Professor of Obstetric
and Gynecology Faculty of Medicine, Assiut University, ****Lecturer of Maternity
and Gynecology Nursing Faculty of NursingAssiutUniversity

INTRODUCTION:

Antenatal care, the care a woman receives throughout her pregnancy is important in helping women and newborns survive pregnancy and childbirth. The traditional approach to antenatal care, which is based on European models developed in the early 1900s, assumes that more care is better in care for pregnant women. Frequent routine visits are norm, and women are classified into risk category to determine their chances of complications and the level of care they need. Many developing countries have adopted this approach without adjusting to meet the needs of this particular populations, taking into account their available resources or evaluating the scientific basis for specific practices^[12].

Antenatal care is a combination of monitoring for problems in mother and fetus, treatments and preventive care, health education, support and advice for pregnant women. Until recently, antenatal care has been largely un evaluated. There is limited evidence on speciefic component of antenatal care, but there was, at the time of planning the study, little evidence of overall effects of antenatal and delivery care on mothers and their babies, either in developed or developing countries^[16].

The consequences of failing to provide good maternal and perinatal care can be seen in the disturbing statistics of maternal and neonatal morbidity and mortality for developing countries. Traditionally antenatal care programmes have been recommended for developed countries with only minor adjustments for local conditions^{[ 22]}.

A recent Cochrane review examined the effect of a reduction in the number of antenatal visits. These studies concluded that reduction of the number of visits did not confer any adverse risk to either mother or fetus. However mothers in some studies in developed countries reported decreased satisfaction with the reduced schedule. Questions were also raised regarding the significance in the reduction of visits. However the two studies from developing countries showed a truly significant reduction in the number of visits had given important implications to their lack of resources^[23].

 At each antenatal visit midwives and doctors should offer information consistent advice, clear explanations, and provide women an opportunity to ask questions^[8]. Women are more likely to be satisfied with antenatal care when they perceive midwives and doctors are kind, supportive, counteous, respectful and recognize their individual needs. Women should not be kept waiting for long periods or feel rushed through visits and investigations^[11].

Aim of the Work:

The aim of the work is to evaluate antenatal care services in Assiut University Hospital. mother's perception about antenatal care and role of midwife as a health care provider in the out patient clinic at Assiut University Hospital.

SUBJECTS AND METHODS:

Design: It was a prospective design study.

Setting: The study was conducted at antenatal care clinic in Assiut University Hospital during the period from first September 2002 to the end of September 2003.

Sample:

A total of 1755 of pregnant women were recruited from those attending antenatal care clinic before 20 weeks of gestational age, low risk women, both primipara and multipara until the second trimester. They were divided into two groups regular attendants and irregular attendants according to number of visits. Mothers who came four visitsor more considered regular and those came less than four visits were considered irregular. Two hundred and eight of cases recruited (12%), were approached through home visit during the first four weeks after delivery.

Tools:

Interviewing sheet, which was designed by the investigator to collect data related to demographic characteristics, the mother obstetric profile, antenatal follow-up record.

Methods of data collection:

 The interviewing data collected by the investigator during the first contact with mother included: Personal history: Name, age, address and telephone number, date of interview and Educational level, medical history: Asked about Specific historical diseases and conditions as Hypertension, diabetes mellitus, heart diseases, chronic renal disease, epilepsy. Information about tetanus vaccination, number of previous pregnancies, number of living children, still birth, abortion, ectopic pregnancy and hydatiform mole. Current pregnancy: Last menstrual period and expected date of delivery.

Infant outcome: include examination of newborn for detecting any congenital anomalies, anthropometrics measurements done and include newborn weight, length, cephalic circumference and chest circumference. Evaluation of women's perception (opinion) toward antenatal care: include effect of care on the mothers and their infants, services during antenatal visits, women’s opinion toward frequency of antenatal visits, toward care providers (physician and nurse) and mother’s intention about antenatal follow-up at subsequent pregnancies.

RESULTS:

The study was conducted in antenatal care clinic evaluate antenatal care services in Assiut University Hospital. mother's perception about antenatal care at Assiut University Hospital.

The mean age of studied sample was 24.7 +5.6 years. Regarding residents, 88% of the women were from rural areas, while only 11.9% lived in urban areas. Regarding mother's education, 42.5% were illiterate, compared to 1.6% was highly educated
(Table 1).

Table (2): In relation to attendance of women to antenatal clinic. This table show that one hundred percent attendant at initial visit, and more than half (52.5%) attended at second visit and attendance at the forth visit was 37.6%.

Table (3): showed the sample’s sociodemo-graphic characteristics in relation to their attendance for ANC visits. According to women’s age. The mean age of regular group was 24.7+5.6 and the mean age of irregular was 26.8+7.3 (T=16.5) and that revealed highly significant difference at P=0.00. According to residence eighty percent was regular from rural area, while the majority (92.8%) was irregular, and nearly twenty percent (19.9%) was regular women from urban area, while 7.2% was irregular attendant. Chi-square (x²=62.4, P=0.00), and that revealed statistical significant difference according to educational level. Regular and irregular groups were comparable in non education percent about 40.9% and 43.4% women respectively, and more than half (58.2%) of educated women (primary to high education level) were regular, and 55.9% were irregular. Chi-square (x²=16.2, P=0.00) and that revealed statistical significant difference.

Table (4): Blood pressure assessment and albumin test during antenatal visits. The majority (99.4%) of women’s were within normal B.P. at first visit, and one hundred percent at the fourth visit. Only 0.6% were hypertensive at first visit and 0.3% at third visit. Regarding Albumin test, the majority (98.9%) were negative albumen at first visit, and also the majority (99.5%) at fourth visit, while 1.1% were negative at first visit, and 0.5% at fourth visit.

Table (5): Showed the distribution of the study by delivery process in relation to their attendance. Regarding the delivery sitting 85% of regular attendant mothers delivered in hospital, and 60.6% were irregular attendant mothers, 21.3% of regular attendant delivered at home, and 28.8% were irregular, (Z= 9.6, P=0.00) that showed statistical significant difference was found between two groups in relation to regularity of visits and choice of delivery sitting. Regarding the delivery supervisor the majority (90.3%) of regular attendant done by doctor, while more than two third (78.8%) were irregular attendant and 9.7% done, by Daya and nurse, were from regular attendant while (21.2%) were irregular. (Z= 11.5, P=0.00) that showed statistical significant difference. Regarding to mode of delivery the majority (92.9%) of regular attendants had spontaneous delivery, and two third (76.7%) were irregular. On the other hand 7.1% of regular attendant mothers had caesarean section, while 23.3% were irregular, (Z=14.5, P=0.00) and that revealed statistical significant difference.

Table (6): Distribution of the sample by their neonate measurements in relation to their attendance. Regarding birth weight, the mean weight was 3484.0+604.1gm, for regular attendants women, while the mean weight of irregular was 3467.3+448.9gm.with no statistical significant difference.

 Table (7): The distribution of the studied sample by the cause of irregular attendance, 14.2% were from far distance, 8.1% said their husband refused to follow-up, 11.1% prefer private clinic. 16.1% said they follow-up in MCH center and 10.1% didn’t have transport costs.

 Table (8): Examine the relation ship between attendance and ANC outcome. Regarding ANC services, 67.3% of attendant mothers was satisfied, while 34.5% were from irregular attendant, and 65.5% of irregular attendant mothers were not satisfied versus 2.7% were from regular group. Chi-square (x2=37.4, P=0.00) that revealed statistical significant difference.

Table (1): Distribution of the sample by sociodemographic characteristics among whole sample

Table (2):Distribution of the whole sample by regular attendance of antenatal visits during pregnancy period

Table (3):Distribution of the sample by sociodemographic characteristics in relation to their
attendance to ANC visits

Table (4): Distribution of the whole sample by blood pressure measurements and albumin tests at  antenatal visits

Notice: Hypertension: on border line: 140/90

Table (5): Distribution of the study by delivery process in relation to their attendance

Table (6): Neonate Birth weight and their anthropometrics measurements

Note: There was 2 cases of this sample had twins their weights ranged: 2000- 2250

Length ranged: 45- 48

Table (7): Distribution of the study by their cause of irregular attendance during antenatal care visits Characteristics

Notice: 70% of not satisfied cases asking for increase free medical supplementations.

Table (8): Distribution of studied sample according to attendance in relation to ANC services and frequency of visits

Notice: 70% of not satisfied cases asking for increase free medical supplementations.

DISCUSSION:

The present study was conducted to evaluate antenatal care services mother’s perception about ANC .

It was observed that, certain factors affect women’s attendance to antenatal care which were maternal sociodemographic character-istics. The results of our study revealed that the young women with their ages ranged between 15-35 and mean age was 24.7+5.6 had more regular attendance to ANC than the older women which their ages reach to 42 years. The same characteristics were reported^[1,2]. It has been suggested that young women tend to book earlier than older females 40.

Looking at the residence condition in this study the majority (80%) of studied sample residing in rural areas was regular attendance more than urban areas. This can be explained by availability of maternal services in Assiut university hospital or in Assiut city and this agree^[2] who go in line with findings of this study. Contrary^[4,5] in their study which women living in urban areas are generally twice as likely as those living in rural areas to report four or more antenatal care visits. Overall, some 86% of women in urban areas report at least one antenatal visit and 61% report four or more visits.

                Concerning the level of education this study revealed that a highly significant difference between level of education and attending of mothers. This agree with data from a Survey and demographic analysis was done^[15], it was observed that the percentage of non educated pregnant women that received ANC was 17.2% while in educated pregnant women was 45.2%. And also agree^[2]. This could be explained by the fact that the more educated women have a more health awareness and this was supported^[10], and the same reported^[6], these results agree^[24], who reported that the higher the maternal education the higher the seek for ANC and meet agreement^[13]. The same agreement was reported^[5], the data confirm that in developing countries as a whole, educated women are more likely to receive antenatal care and the likelihood of their using antenatal care is associated with their level of education. Educated women are also more likely to report four or more visits. The regular attendance to ANC in the present study was significantly influenced by obstetric history as parity, the majority of regular attended women (80.0%) was primigravida and primiparas, while the lowest percentage (4.5%) of women was multiparas. These results agree^[2] who reported that the use of prenatal care was higher for primiparas and grand multi paras and so^[1], who reported that pregnant of high gravidity had the least frequencies for late booking (73.7%) compared to those with
low gravidity (84.5%). The same line of agreement^[5], also reported that Higher-parity women have lower levels of antenatal care in all regions of developing countries except sub-Saharan Africa, where differences are small. In the vast majority of countries, women expecting their first child are the most likely to present for antenatal care.

The findings of present study declared that 47.0% of women had attended less than 4 visits and 37.6% had attend 4 visits or more. That agreed^[13], who reported that 43.1% of women attended less than 5 visits and 36.6% attended  5 visits or more and also agree^[20]. On the other hand the findings of Vanden et al. study in zimbabawe who reported that 97% of pregnant women attend antenatal clinic once and these findings meet agreement with this study which reported that 100% of women attend one visit. Other relevant studies^[17]. stated that while the content of prenatal care recommended 10 visits for nulliparas and 8 visits for multiparas with a preconception visit within one year before conception, the average antenatal care attendance was 5 or less in most developed countries.

Also^[17,18] in a study that was conducted in Harare, Zimbabwe, achieved a reduction in the number of visits from six in control group to four in the intervention group. In multicentric studies done in Cuba, Argentina, Saudi Arabia and Thailand about the compliance of the pregnant women with the traditional model of antenatal care,^[19] found that a total of 15 or 16 visits was seen only in Cuba.

In Upper Egypt, the percentage of pregnant women that had a regular antenatal care visits was 27.2%, and those who had any antenatal care during pregnancy was 44.3%^[3] reported that in all developing regions, most women using antenatal care report four or more visits. Surprising finding is the frequency of four or more antenatal visits in Sub-Saharan Africa, with at least 70% of women reporting four or more visits in Ghana, Nigeria, Tanzania and Zambia In Rwanda and Senegal, on the other hand, 75% and 72% of women report only two or three visits^[5].

In the present study, in the majority of regular group and more than two thirds of irregular group, respectively had normal vaginal deliveries, on the other hand caesarean sections were 7.1% and 23.3%, these results agree^[99] whereas reported that one in ten deliveries in five-year period before the survey was by caeserean section. This proportion is somewhat higher than that in the 1995 EDHS when 7% of deliveries were by caesarean section^[25].

In this study, in both regular and irregular groups, infant measurements did not show significant difference; only was significant in the infant length. Other studies^[7], who reported that the number and adequacy of antenatal care affect, expected that patients with preterm birth have shorter gestations and therefore are expected to have fewer prenatal visits, and this result contrary to our study findings, which the infant measurements were within normal full term infant measurements except 0.9% of cases have twins was preterm infants but they were regular attendants to ANC visits.

RECOMMENDATIONS:

1-Promotion of the outreach home visiting programs for detecting and /or promoting the pregnant women awareness about maternal services and refer them to antenatal care clinics.

2-Adoptions of the new WHO antenatal care model in our maternal care services to eradicate of women’s barrier to attending regularly for antenatal care visits, and that revealed early detection of pregnant complication and that promote maternal health care in our society.

3-Applied training programmes of skilled attendants for nurses to improve their quality of care as a health care provider at antenatal clinic.

REFERENCES:

1-Abbass S, Kharboush I.F and Mohmed A. (1994): Late booking for antenatal care in El-Zagazing. The new Egyptian Med. J.11 (3): 1213-1221.

2-Abdel-Aleem H, Aboloyoun E.M, Moftah F.M, Ismail S.A, Abdullah S.A (1993): Utilization of maternal care in upper Egypt (User factors). Assiut Med. J.17 (5): 87-95.

3-Abdel-Elraheem M.I (2001): Doctoral thesis for Evaluation of new Antenatal care program (comparative study).

4-Abouzahar C., Hill K, and T. Ward law, (2001): Estimates of Maternal Mortality for 1995. Bulletin of the WHO 79 (3):182-93.

5-AbouZahr and Wardlaw, (2002): Demographic Health surveys in 45 developing countries.

6-Amin M.F, Abdel-Moneim M.N, Hafez A.S, Hammoda K. (1998): Evaluation of Knowledge, Attitudes and practices of pregnant women towards ANC in Qalubya Governorate. The New Egyptian Med. J. 18 (3): 191-196.

7-Baston H. (2002): Medwifery basics. Antenatal care: the options avialable. Pract Midwife 2002, 5: 10-13. (PubMed Abstract).

8-Baston H. (2002): Medwifery basics. Antenatal care: the options avialable. Pract Midwife 2002, 5: 10-13. (PubMed Abstract).

9-Brown S, Dawson W, Gunn J, Mc Nair R. (2002): Review of share Obstetric care: Summary Report Center for the Study of Mother’s and Children’s Health library, No. 5.Geneva, World Health Organization.

10-Bulatao R.A, and J.A.Ross (2000): Rating Maternal and Neonate Health Programs in developing countries.

11-Ferrinho P.D, Gear J.S. and Reinach G.J, (1991): “Reproductive Health Care in the Gelukspan Health ward”. South Africa Med. J. Dec.7; 80(11-12): 584-587.

12-Garcia J, Red show M, Fit Simons B, Kneene J, (1998): First class delivery: Antenatal Survey of women’s views of Maternity care. Audit commission, London.

13-JHPIEGO Trainer News, (2003): Focused ANC: Planning and providing care during pregnancy. December.www.jhpiego.org

14-Mansour A.M (2000): Assessment of antenatal care in antenatal urban area. International Islamic Center for Population Studies and Research, Al-Azhar University. The New Egyptian Journal of Medicine. 23 (6): 281-287.

15-Maynard C, Every N.R et al. (2000): Outcome of coronary angio plastic procedures performed in rural hospitals. American J Med. 108 (9): 710- 13.

16-Ministery of Health. Egypt (2000): Survey and Demographic analysis of Egypt 2000.

17-Mugford M, Hutton G, Fox-Rushby J.A. (2000): Methods for economic evaluation alongside a multicentre trial in developing countries: a case study from the WHO Antenatal care trial. Paediatrics and perinatal Epidemiology; 12 (suppl. 2): 75-97.

18-Munjanja S.P, Lindmark G, Nystromal. (1996): Randomized controlled trial of reduced- visits programme of ANC in Harare, Zimbabowe lancet 1996. 348: 364-9.

19-Neelofur D, Gulmezoglu M, Villar J, (1998): Who should provide routine ANC for women, and how often? A systematic review randomized controlled trials. WHO Antenatal Research Group. Paediatr Perinat Epidemoil. Oct. 12. supple 2: 7.

20-Piaggio G et al. (1998): The Practice of antenatal care: comparing four study sites in different parts of the world in the WHO Antenatal Care Randomized Controlled Trial. Pediatric and Perinatal Epidimiology, 12 (Suppl.2): 116-141.

21-Vanden Heuvel O.A, de May WG, Bueldingh H, Bots M.L (1999): Use of maternal care in a rueal area of Zimbabwe: Apopulation-based study. Act Obstet. Gynec. Scand. 19999. Nov. 78 (10): 838-46.

22-Villar J et al. (2001): For the WHO Antenatal Care Trial Research Group. WHO antenatal care randomized trial for the evaluation of a new model of antenatal care. The lancet, 357: 1551-1564.

23-Villar J et al. (2002): Pattern of routine antenatal care for-low risk pregnancy. The Cochran Library, issue No.2. Oxford, Update soft ware.

24-Villar J, Khan-Neelofur D., (2000): Patterns of routine ANC for low-risk pregnancy (Cochran Review). In: The Cochran library, issue 4. Oxford update soft ware.

25-Wildschut H.I, Bender P, Polet M, Trass H, Vanagt N.L, Vander Mass P.J (1999): Practice variation of test procedures reportedly used in routine antenatal care in Nether Lands. Acta Obstet. Gynecol Scand, J. 78 (10): 27-32.

EVALUATION OF ANTENATAL CARE SERVICES AND WOMEN’S PERCEPTION IN ASSIUTUNIVERSITYHOSPITAL

Howieda Ahmed Abd Elmohimen^* ,  Ragaa Ali Abd-Rabou^**,
Hany Abdel-Aleem Ali^*** and Madiha Mohammed Tosson^****

*B.Sc., Nursing Clinical demonstrator, Faculty of Nursing, Assiut, **Assist. professor of Maternity and Newborn Health Faculty of NursingCairoUniversity, ***Professor of Obstetric
and Gynecology Faculty of Medicine, Assiut University, ****Lecturer of Maternity
and Gynecology Nursing Faculty of NursingAssiutUniversity

INTRODUCTION:

Antenatal care, the care a woman receives throughout her pregnancy is important in helping women and newborns survive pregnancy and childbirth. The traditional approach to antenatal care, which is based on European models developed in the early 1900s, assumes that more care is better in care for pregnant women. Frequent routine visits are norm, and women are classified into risk category to determine their chances of complications and the level of care they need. Many developing countries have adopted this approach without adjusting to meet the needs of this particular populations, taking into account their available resources or evaluating the scientific basis for specific practices^[12].

Antenatal care is a combination of monitoring for problems in mother and fetus, treatments and preventive care, health education, support and advice for pregnant women. Until recently, antenatal care has been largely un evaluated. There is limited evidence on speciefic component of antenatal care, but there was, at the time of planning the study, little evidence of overall effects of antenatal and delivery care on mothers and their babies, either in developed or developing countries^[16].

The consequences of failing to provide good maternal and perinatal care can be seen in the disturbing statistics of maternal and neonatal morbidity and mortality for developing countries. Traditionally antenatal care programmes have been recommended for developed countries with only minor adjustments for local conditions^{[ 22]}.

A recent Cochrane review examined the effect of a reduction in the number of antenatal visits. These studies concluded that reduction of the number of visits did not confer any adverse risk to either mother or fetus. However mothers in some studies in developed countries reported decreased satisfaction with the reduced schedule. Questions were also raised regarding the significance in the reduction of visits. However the two studies from developing countries showed a truly significant reduction in the number of visits had given important implications to their lack of resources^[23].

 At each antenatal visit midwives and doctors should offer information consistent advice, clear explanations, and provide women an opportunity to ask questions^[8]. Women are more likely to be satisfied with antenatal care when they perceive midwives and doctors are kind, supportive, counteous, respectful and recognize their individual needs. Women should not be kept waiting for long periods or feel rushed through visits and investigations^[11].

Aim of the Work:

The aim of the work is to evaluate antenatal care services in Assiut University Hospital. mother's perception about antenatal care and role of midwife as a health care provider in the out patient clinic at Assiut University Hospital.

SUBJECTS AND METHODS:

Design: It was a prospective design study.

Setting: The study was conducted at antenatal care clinic in Assiut University Hospital during the period from first September 2002 to the end of September 2003.

Sample:

A total of 1755 of pregnant women were recruited from those attending antenatal care clinic before 20 weeks of gestational age, low risk women, both primipara and multipara until the second trimester. They were divided into two groups regular attendants and irregular attendants according to number of visits. Mothers who came four visitsor more considered regular and those came less than four visits were considered irregular. Two hundred and eight of cases recruited (12%), were approached through home visit during the first four weeks after delivery.

Tools:

Interviewing sheet, which was designed by the investigator to collect data related to demographic characteristics, the mother obstetric profile, antenatal follow-up record.

Methods of data collection:

 The interviewing data collected by the investigator during the first contact with mother included: Personal history: Name, age, address and telephone number, date of interview and Educational level, medical history: Asked about Specific historical diseases and conditions as Hypertension, diabetes mellitus, heart diseases, chronic renal disease, epilepsy. Information about tetanus vaccination, number of previous pregnancies, number of living children, still birth, abortion, ectopic pregnancy and hydatiform mole. Current pregnancy: Last menstrual period and expected date of delivery.

Infant outcome: include examination of newborn for detecting any congenital anomalies, anthropometrics measurements done and include newborn weight, length, cephalic circumference and chest circumference. Evaluation of women's perception (opinion) toward antenatal care: include effect of care on the mothers and their infants, services during antenatal visits, women’s opinion toward frequency of antenatal visits, toward care providers (physician and nurse) and mother’s intention about antenatal follow-up at subsequent pregnancies.

RESULTS:

The study was conducted in antenatal care clinic evaluate antenatal care services in Assiut University Hospital. mother's perception about antenatal care at Assiut University Hospital.

The mean age of studied sample was 24.7 +5.6 years. Regarding residents, 88% of the women were from rural areas, while only 11.9% lived in urban areas. Regarding mother's education, 42.5% were illiterate, compared to 1.6% was highly educated
(Table 1).

Table (2): In relation to attendance of women to antenatal clinic. This table show that one hundred percent attendant at initial visit, and more than half (52.5%) attended at second visit and attendance at the forth visit was 37.6%.

Table (3): showed the sample’s sociodemo-graphic characteristics in relation to their attendance for ANC visits. According to women’s age. The mean age of regular group was 24.7+5.6 and the mean age of irregular was 26.8+7.3 (T=16.5) and that revealed highly significant difference at P=0.00. According to residence eighty percent was regular from rural area, while the majority (92.8%) was irregular, and nearly twenty percent (19.9%) was regular women from urban area, while 7.2% was irregular attendant. Chi-square (x²=62.4, P=0.00), and that revealed statistical significant difference according to educational level. Regular and irregular groups were comparable in non education percent about 40.9% and 43.4% women respectively, and more than half (58.2%) of educated women (primary to high education level) were regular, and 55.9% were irregular. Chi-square (x²=16.2, P=0.00) and that revealed statistical significant difference.

Table (4): Blood pressure assessment and albumin test during antenatal visits. The majority (99.4%) of women’s were within normal B.P. at first visit, and one hundred percent at the fourth visit. Only 0.6% were hypertensive at first visit and 0.3% at third visit. Regarding Albumin test, the majority (98.9%) were negative albumen at first visit, and also the majority (99.5%) at fourth visit, while 1.1% were negative at first visit, and 0.5% at fourth visit.

Table (5): Showed the distribution of the study by delivery process in relation to their attendance. Regarding the delivery sitting 85% of regular attendant mothers delivered in hospital, and 60.6% were irregular attendant mothers, 21.3% of regular attendant delivered at home, and 28.8% were irregular, (Z= 9.6, P=0.00) that showed statistical significant difference was found between two groups in relation to regularity of visits and choice of delivery sitting. Regarding the delivery supervisor the majority (90.3%) of regular attendant done by doctor, while more than two third (78.8%) were irregular attendant and 9.7% done, by Daya and nurse, were from regular attendant while (21.2%) were irregular. (Z= 11.5, P=0.00) that showed statistical significant difference. Regarding to mode of delivery the majority (92.9%) of regular attendants had spontaneous delivery, and two third (76.7%) were irregular. On the other hand 7.1% of regular attendant mothers had caesarean section, while 23.3% were irregular, (Z=14.5, P=0.00) and that revealed statistical significant difference.

Table (6): Distribution of the sample by their neonate measurements in relation to their attendance. Regarding birth weight, the mean weight was 3484.0+604.1gm, for regular attendants women, while the mean weight of irregular was 3467.3+448.9gm.with no statistical significant difference.

 Table (7): The distribution of the studied sample by the cause of irregular attendance, 14.2% were from far distance, 8.1% said their husband refused to follow-up, 11.1% prefer private clinic. 16.1% said they follow-up in MCH center and 10.1% didn’t have transport costs.

 Table (8): Examine the relation ship between attendance and ANC outcome. Regarding ANC services, 67.3% of attendant mothers was satisfied, while 34.5% were from irregular attendant, and 65.5% of irregular attendant mothers were not satisfied versus 2.7% were from regular group. Chi-square (x2=37.4, P=0.00) that revealed statistical significant difference.

Table (1): Distribution of the sample by sociodemographic characteristics among whole sample

Table (2):Distribution of the whole sample by regular attendance of antenatal visits during pregnancy period

Table (3):Distribution of the sample by sociodemographic characteristics in relation to their
attendance to ANC visits

Table (4): Distribution of the whole sample by blood pressure measurements and albumin tests at  antenatal visits

Notice: Hypertension: on border line: 140/90

Table (5): Distribution of the study by delivery process in relation to their attendance

Table (6): Neonate Birth weight and their anthropometrics measurements

Note: There was 2 cases of this sample had twins their weights ranged: 2000- 2250

Length ranged: 45- 48

Table (7): Distribution of the study by their cause of irregular attendance during antenatal care visits Characteristics

Notice: 70% of not satisfied cases asking for increase free medical supplementations.

Table (8): Distribution of studied sample according to attendance in relation to ANC services and frequency of visits

Notice: 70% of not satisfied cases asking for increase free medical supplementations.

DISCUSSION:

The present study was conducted to evaluate antenatal care services mother’s perception about ANC .

It was observed that, certain factors affect women’s attendance to antenatal care which were maternal sociodemographic character-istics. The results of our study revealed that the young women with their ages ranged between 15-35 and mean age was 24.7+5.6 had more regular attendance to ANC than the older women which their ages reach to 42 years. The same characteristics were reported^[1,2]. It has been suggested that young women tend to book earlier than older females 40.

Looking at the residence condition in this study the majority (80%) of studied sample residing in rural areas was regular attendance more than urban areas. This can be explained by availability of maternal services in Assiut university hospital or in Assiut city and this agree^[2] who go in line with findings of this study. Contrary^[4,5] in their study which women living in urban areas are generally twice as likely as those living in rural areas to report four or more antenatal care visits. Overall, some 86% of women in urban areas report at least one antenatal visit and 61% report four or more visits.

                Concerning the level of education this study revealed that a highly significant difference between level of education and attending of mothers. This agree with data from a Survey and demographic analysis was done^[15], it was observed that the percentage of non educated pregnant women that received ANC was 17.2% while in educated pregnant women was 45.2%. And also agree^[2]. This could be explained by the fact that the more educated women have a more health awareness and this was supported^[10], and the same reported^[6], these results agree^[24], who reported that the higher the maternal education the higher the seek for ANC and meet agreement^[13]. The same agreement was reported^[5], the data confirm that in developing countries as a whole, educated women are more likely to receive antenatal care and the likelihood of their using antenatal care is associated with their level of education. Educated women are also more likely to report four or more visits. The regular attendance to ANC in the present study was significantly influenced by obstetric history as parity, the majority of regular attended women (80.0%) was primigravida and primiparas, while the lowest percentage (4.5%) of women was multiparas. These results agree^[2] who reported that the use of prenatal care was higher for primiparas and grand multi paras and so^[1], who reported that pregnant of high gravidity had the least frequencies for late booking (73.7%) compared to those with
low gravidity (84.5%). The same line of agreement^[5], also reported that Higher-parity women have lower levels of antenatal care in all regions of developing countries except sub-Saharan Africa, where differences are small. In the vast majority of countries, women expecting their first child are the most likely to present for antenatal care.

The findings of present study declared that 47.0% of women had attended less than 4 visits and 37.6% had attend 4 visits or more. That agreed^[13], who reported that 43.1% of women attended less than 5 visits and 36.6% attended  5 visits or more and also agree^[20]. On the other hand the findings of Vanden et al. study in zimbabawe who reported that 97% of pregnant women attend antenatal clinic once and these findings meet agreement with this study which reported that 100% of women attend one visit. Other relevant studies^[17]. stated that while the content of prenatal care recommended 10 visits for nulliparas and 8 visits for multiparas with a preconception visit within one year before conception, the average antenatal care attendance was 5 or less in most developed countries.

Also^[17,18] in a study that was conducted in Harare, Zimbabwe, achieved a reduction in the number of visits from six in control group to four in the intervention group. In multicentric studies done in Cuba, Argentina, Saudi Arabia and Thailand about the compliance of the pregnant women with the traditional model of antenatal care,^[19] found that a total of 15 or 16 visits was seen only in Cuba.

In Upper Egypt, the percentage of pregnant women that had a regular antenatal care visits was 27.2%, and those who had any antenatal care during pregnancy was 44.3%^[3] reported that in all developing regions, most women using antenatal care report four or more visits. Surprising finding is the frequency of four or more antenatal visits in Sub-Saharan Africa, with at least 70% of women reporting four or more visits in Ghana, Nigeria, Tanzania and Zambia In Rwanda and Senegal, on the other hand, 75% and 72% of women report only two or three visits^[5].

In the present study, in the majority of regular group and more than two thirds of irregular group, respectively had normal vaginal deliveries, on the other hand caesarean sections were 7.1% and 23.3%, these results agree^[99] whereas reported that one in ten deliveries in five-year period before the survey was by caeserean section. This proportion is somewhat higher than that in the 1995 EDHS when 7% of deliveries were by caesarean section^[25].

In this study, in both regular and irregular groups, infant measurements did not show significant difference; only was significant in the infant length. Other studies^[7], who reported that the number and adequacy of antenatal care affect, expected that patients with preterm birth have shorter gestations and therefore are expected to have fewer prenatal visits, and this result contrary to our study findings, which the infant measurements were within normal full term infant measurements except 0.9% of cases have twins was preterm infants but they were regular attendants to ANC visits.

RECOMMENDATIONS:

1-Promotion of the outreach home visiting programs for detecting and /or promoting the pregnant women awareness about maternal services and refer them to antenatal care clinics.

2-Adoptions of the new WHO antenatal care model in our maternal care services to eradicate of women’s barrier to attending regularly for antenatal care visits, and that revealed early detection of pregnant complication and that promote maternal health care in our society.

3-Applied training programmes of skilled attendants for nurses to improve their quality of care as a health care provider at antenatal clinic.

REFERENCES:

1-Abbass S, Kharboush I.F and Mohmed A. (1994): Late booking for antenatal care in El-Zagazing. The new Egyptian Med. J.11 (3): 1213-1221.

2-Abdel-Aleem H, Aboloyoun E.M, Moftah F.M, Ismail S.A, Abdullah S.A (1993): Utilization of maternal care in upper Egypt (User factors). Assiut Med. J.17 (5): 87-95.

3-Abdel-Elraheem M.I (2001): Doctoral thesis for Evaluation of new Antenatal care program (comparative study).

4-Abouzahar C., Hill K, and T. Ward law, (2001): Estimates of Maternal Mortality for 1995. Bulletin of the WHO 79 (3):182-93.

5-AbouZahr and Wardlaw, (2002): Demographic Health surveys in 45 developing countries.

6-Amin M.F, Abdel-Moneim M.N, Hafez A.S, Hammoda K. (1998): Evaluation of Knowledge, Attitudes and practices of pregnant women towards ANC in Qalubya Governorate. The New Egyptian Med. J. 18 (3): 191-196.

7-Baston H. (2002): Medwifery basics. Antenatal care: the options avialable. Pract Midwife 2002, 5: 10-13. (PubMed Abstract).

8-Baston H. (2002): Medwifery basics. Antenatal care: the options avialable. Pract Midwife 2002, 5: 10-13. (PubMed Abstract).

9-Brown S, Dawson W, Gunn J, Mc Nair R. (2002): Review of share Obstetric care: Summary Report Center for the Study of Mother’s and Children’s Health library, No. 5.Geneva, World Health Organization.

10-Bulatao R.A, and J.A.Ross (2000): Rating Maternal and Neonate Health Programs in developing countries.

11-Ferrinho P.D, Gear J.S. and Reinach G.J, (1991): “Reproductive Health Care in the Gelukspan Health ward”. South Africa Med. J. Dec.7; 80(11-12): 584-587.

12-Garcia J, Red show M, Fit Simons B, Kneene J, (1998): First class delivery: Antenatal Survey of women’s views of Maternity care. Audit commission, London.

13-JHPIEGO Trainer News, (2003): Focused ANC: Planning and providing care during pregnancy. December.www.jhpiego.org

14-Mansour A.M (2000): Assessment of antenatal care in antenatal urban area. International Islamic Center for Population Studies and Research, Al-Azhar University. The New Egyptian Journal of Medicine. 23 (6): 281-287.

15-Maynard C, Every N.R et al. (2000): Outcome of coronary angio plastic procedures performed in rural hospitals. American J Med. 108 (9): 710- 13.

16-Ministery of Health. Egypt (2000): Survey and Demographic analysis of Egypt 2000.

17-Mugford M, Hutton G, Fox-Rushby J.A. (2000): Methods for economic evaluation alongside a multicentre trial in developing countries: a case study from the WHO Antenatal care trial. Paediatrics and perinatal Epidemiology; 12 (suppl. 2): 75-97.

18-Munjanja S.P, Lindmark G, Nystromal. (1996): Randomized controlled trial of reduced- visits programme of ANC in Harare, Zimbabowe lancet 1996. 348: 364-9.

19-Neelofur D, Gulmezoglu M, Villar J, (1998): Who should provide routine ANC for women, and how often? A systematic review randomized controlled trials. WHO Antenatal Research Group. Paediatr Perinat Epidemoil. Oct. 12. supple 2: 7.

20-Piaggio G et al. (1998): The Practice of antenatal care: comparing four study sites in different parts of the world in the WHO Antenatal Care Randomized Controlled Trial. Pediatric and Perinatal Epidimiology, 12 (Suppl.2): 116-141.

21-Vanden Heuvel O.A, de May WG, Bueldingh H, Bots M.L (1999): Use of maternal care in a rueal area of Zimbabwe: Apopulation-based study. Act Obstet. Gynec. Scand. 19999. Nov. 78 (10): 838-46.

22-Villar J et al. (2001): For the WHO Antenatal Care Trial Research Group. WHO antenatal care randomized trial for the evaluation of a new model of antenatal care. The lancet, 357: 1551-1564.

23-Villar J et al. (2002): Pattern of routine antenatal care for-low risk pregnancy. The Cochran Library, issue No.2. Oxford, Update soft ware.

24-Villar J, Khan-Neelofur D., (2000): Patterns of routine ANC for low-risk pregnancy (Cochran Review). In: The Cochran library, issue 4. Oxford update soft ware.

25-Wildschut H.I, Bender P, Polet M, Trass H, Vanagt N.L, Vander Mass P.J (1999): Practice variation of test procedures reportedly used in routine antenatal care in Nether Lands. Acta Obstet. Gynecol Scand, J. 78 (10): 27-32.