Abstract
Introduction
To ensure positive pregnancy and birth outcomes, healthcare providers working in antenatal clinics are expected to provide regular antenatal education to enable early detection and timely treatment of pregnancy-related morbidities to prevent complications during labor, birth, and postnatal period. Although antenatal education and services are provided through standard programs in developed countries, presently there are no well-structured programs in many developing countries. The study compares the current service with the national and international guidelines.
Objective
To identify the current practices of healthcare providers in antenatal education service in Oman with the aim of identifying any major implementation gaps.
Methods
A qualitative inquiry was implemented through semi-structured in-depth interviews guided by open-ended questions. The study population were healthcare providers who routinely provide antenatal services at healthcare facilities. A purposive non-probability sampling technique was used to select the key informants. Data was analyzed manually using the thematic analysis framework.
Results
The antenatal education services provided fall under four themes: In relation to “Education for safe pregnancy,” the findings revealed that healthcare providers did not adequately address the needs. In relation to “Education for Safe labor and Birth,” the pregnant women are briefed with inadequate information about labor and birth during the antenatal period. In relation to “Education related to Postpartum,” healthcare providers generally do not provide information regarding pregnant women's psychological wellbeing, breastfeeding, family planning, hygiene, and nutrition during antenatal visits. In relation to “Education related to Newborn Care,” the study findings indicate that contrary to what was stipulated by the WHO (2016) to establish antenatal educational programs to help pregnant women gain the skills and knowledge regarding proper newborn care, our findings demonstrated a lack of education about newborn care by providers.
Conclusion
The findings have the capacity to contribute towards the development of remedial strategies to improve maternal and neonatal outcomes in Oman. This can be achieved by addressing the practice gaps identified when comparing the current practices with international standards.
Introduction
Antenatal care (ANC) provides the opportunity for a careful, systematic assessment and follow-up of pregnant women, which includes education, counselling, screening, and treatment to ensure the best possible health outcome for both the mother and her fetus (Al Ateeq & Al Rusaiess, 2015; Aji et al., 2019). To ensure positive pregnancy and birth outcomes, healthcare providers working in antenatal clinics are expected to provide regular antenatal education to enable early detection and timely treatment of pregnancy-related morbidities and to prevent complications during labor, birth, and postnatal period (Herval et al., 2019; Levett et al., 2020).
The knowledge pregnant women receive during antenatal classes enables them to make informed decisions about their pregnancy and advocate for themselves and their unborn babies (Grussua & Quatraro, 2020; Lothian, 2016). This knowledge also allows for proper preparation for childbirth. This knowledge also helps to build the woman's confidence by enabling her to understand the process and management of labor and birth. Overall, these measures reduce perinatal morbidity and mortality (Levett et al., 2020). Although antenatal education and services are provided through standard programs in developed countries, presently there are no well-structured programs in many developing countries (Heen et al., 2022; Isbir et al., 2016). According to the recommendations by Ministry of Health (MOH) Oman, World Health Organization (WHO), and National Institute for Health and Care Excellence (NICE) and Royal College of Obstetrics and Gynaecology (RCOG), effective antenatal education goes beyond measuring physiological changes in pregnancy. It includes preparing pregnant women for safe and positive pregnancy experience, safe labor and birth, transition to postnatal period. These are aimed at identifying and preventing complications to both the pregnant woman and her fetus (Janicka-Kubiak et al., 2022; Setyaningsih & Zakiyah, 2019).
In an attempt to ensure quality maternal and child healthcare services delivery, MOH, Oman provides in every healthcare facility, a standardized maternal health record and healthcare facility antenatal register. This standardized documentation provides key information on every pregnant woman including her medical problems and needs, risk factors as well as plan for antenatal, intra-natal, and postnatal care and outcomes.
In addition, every antenatal healthcare facility in Oman is provided with the latest practice guidelines. The guidelines are based on best practices and recommendations from the WHO and other international agencies for planning and managing pregnancy and childbirth (MOH, 2016). These guidelines are part of Oman's effort to adopt UNs’ sustainable development goals that aim to reduce U5MR to < 25 per 1000 and MMR to 70 per 100 000 live births by 2030 (Iqbal et al., 2022).
In terms of other factors associated with quality of maternity care, over the years Oman has experienced significant but rather negative changes in other health indicators like the neonatal mortality rate (NMR), low birth weight (LBW), infant deaths, and breastfeeding practices. For instance, in 2016, the NMR was 5.3 per 1,000 live births, while the early neonatal deaths rate was 82%. Similarly, in the same year the infant mortality rate was 18%. In addition, the number of LBW babies increased from 8.3% in 2015 to 11% in 2016, and 89% of infants ≤6 months old were not exclusively breastfed (MOH, 2016).
Another significant maternal health indicator is that in the last 5 years, the number of pregnant women attending the antenatal clinic in the first trimester reduced nearly by 10,000 from 2016 to 2019 (MOH, 2019). These statistics indicate the existence of significant problems occurring during the antenatal period in Oman's healthcare facilities. Yet, Tekelab and colleagues (2019) affirm that proper ANC has the potential to reduce neonatal mortality by 10%–20% besides improving other maternal and infant health indicators. These negative changes in the maternal health-related indicators reflect the need for more action by stakeholders.
Therefore, to reverse these negative trends in maternal and infant health indices, healthcare providers need to intensify their focus on health promotion and risk reduction. In fact, it is recommended that at each antenatal appointment, healthcare professionals should offer clear and consistent information about maternal care. In addition, healthcare providers should provide the opportunity to discuss issues of concern to pregnant women to ensure they have a positive pregnancy experience (Al Maqbali, 2018; NICE, 2008).
The significance of this study is that it is among the first in Oman to evaluate the perspectives of healthcare providers regarding the antenatal education services provided in healthcare settings in line with the Ministry of Health guidelines. The study compares the current service with the national and international guidelines with the aim of identifying any major implementation gaps.
Review of Literature
Healthcare providers occupy a central role in providing the necessary information to make pregnancy and childbirth a positive experience for both the pregnant woman and her family. Through proper health education, HCPs prepare parents to reflect on their lives and to make changes to be the best parents they can be for their new baby (Nolan, 2017). Furthermore, obstetricians, midwives, obstetric nurses, and antenatal educators through planned educational sessions play a vital role in helping pregnant women and their families to recognize abnormal signs and symptoms of pregnancy and to seek medical assistance (Amasha & Heeba, 2013).
In order to meet this expectation, healthcare professionals should therefore be well qualified to impart proper antenatal education and be well trained to understand the changes experienced during pregnancy and current practices (Silva et al., 2016). The providers of the antenatal education services must build professional relationships with the women, exchange information with them, and involve them in decision making. Such actions by healthcare providers are important in helping to shape the pregnant women's perceptions of and satisfaction with care (Al Maqbali, 2018). To make the pregnancy experience positive, women prefer to receive antenatal education from healthcare professionals who demonstrate competence, respect them and are attentive to their individual needs, thereby underscoring the important role of HCPs in ANE.
To meet these expectations, the International Confederation of Midwifery (ICM) recommends that midwives and other healthcare providers should provide high-quality ANC including health education to ensure positive pregnancy experience (ICM, 2018). Through effective health education, healthcare providers strengthen women's capabilities to undergo the normal processes of pregnancy, birth, postpartum, and breastfeeding. In this regard, they are expected to share up-to-date knowledge about pregnancy, childbirth, and postpartum, offering a combination of preventive care, early detection, and timely treatment or referral (Renfrew et al., 2014).
Methods
Study Design
The study utilized a generic qualitative descriptive design because it allows different salient features gathered from other qualitative approaches like grounded theory, phenomenology, or ethnography to be used without needing to stick to one research tradition (Bradshaw et al., 2017; Polit & Beck, 2017). This inquiry was implemented through semi-structured in-depth interviews, carefully guided by open-ended questions. We evaluated the current antenatal education services provided in selected healthcare facilities in Oman.
The study was conducted between December 2020 and January 2021 using four key questions (Table 1).
What specific education do you give to prepare the women for a safe pregnancy? What specific education do you provide to women to prepare them for labor and birth? What specific education do you provide to women about postpartum care? What specific education do you provide to women to prepare her for care of newborn?
Summary of Categories, Themes, and Subthemes.
Study Setting, Population, and Sampling
The study was conducted in nine Healthcare facilities located in Muscat Governorate, Oman. These facilities included one polyclinic, one tertiary hospital outpatient clinic, and seven primary health centers. The study population were healthcare providers who routinely provide antenatal services at healthcare facilities. The eligibility criteria to participate was limited to Doctors, Midwives, and Nurses who had worked in the ANC clinics for a minimum of 12 months. A purposive non-probability sampling method was used to enable careful selection of key informants who could provide rich information about education services being provided in these facilities.
Ethical Consideration
Data collection began after obtaining ethical clearance and study approval from the Colleges of Nursing and Medicine and Health Sciences, Sultan Qaboos University Hospital and the Ministry of Health. Each potential participant was explained the study purpose and process of data collection. They were given time to ask any questions and to address any of their concerns. They were informed that they have the right to withdraw at any stage either from individual questions or from the entire study without any consequences. Each participant signed an informed consent form once he/she understood the nature and purpose of the study and agreed to participate. Each interview was conducted individually in a private and quiet room in respective clinics and digitally recorded. The anonymity of each participant and the confidentiality of their data were upheld and preserved using a unique code number throughout the data analysis and reporting phases.
Data Collection
Data was generated using a semi-structured in-depth interview guide from 17 healthcare providers, which was reviewed by the specialty experts. The interview guide was first developed in English and translated into Arabic to minimize the confusion that might happen due to the meaning of the terms in the questions. Data collection ended once the data saturation was achieved (Etikan et al., 2016). The semi-structured interview is the most appropriate method for in-depth exploration of participants’ experiences as it allows for additional inquiry when new insight arises during interviews. Data was collected by using a semi-structured in-depth interview using a newly developed interview guide. As a quality control mechanism, the researcher enhanced the study's rigor by meeting the five critical elements of credibility, dependability, transferability, trustworthiness, and confirmability (Lincoln & Guba, 1985). The interviews were digitally audio-recorded and transcribed verbatim to preserve data integrity.
All the key informants were approached personally by both the researcher and the RA and participants were introduced to the study. Prior to the face-to-face semi-structured in-depth interviews, a written informed consent was obtained from each key informant who agreed to participate in the study before we began to collect the data. The participants were informed that the interview sessions will last between 45 and 60 min or until such time that the participants will have answered all the questions. Additionally, it was communicated to the participant at the beginning that the interview will be digitally audio-recorded in addition to interview field notes, which will help to secure and avoid losing accurate data (Charmaz, 2006). Importantly, all participants were assured that all the information they will share with the researcher would be kept confidential, and their privacy will be protected as well. All participants were informed that their participation is voluntary, and they have the right to withdraw from the study at any time without any consequences. All participants signed written informed consent demonstrating their acceptance to participate in the study following thorough explanation of the terms of participation.
To ensure that the key informants feel comfortable and relaxed, the researcher started the interview with casual conversation to set the stage for the participants to be ready for the interview. The open-ended questions were aimed at their personal experiences, including their thoughts, feelings, views, and perspectives regarding antenatal education service provision. To get more detailed information, follow-up questions were asked to encourage the participants to explain more by using probes and moderated silence.
Data Analysis
The data set analyzed was a combination of interview transcript and field notes. Data was analyzed manually using the thematic analysis framework through the process of reflexive “immersion and crystallization” (Borkan, 2021). Thematic analysis was chosen because it creates rich, trustworthy, sensitive, and insightful research findings, which is useful in identifying, describing, organizing, analyzing, and reporting themes (Nowell et al., 2017). This approach helped to improve data collection as it generated new insights which informed subsequent interviews. This was possible because data collection and analysis occurred concurrently and allowed probing for new insights resulting in much richer data (Charmaz, 2016).
Results
A total of 17 health care providers were interviewed including five doctors, five nurses, five midwives, and two health educators. On average, the participants have between 5 and 20 years of clinical experience of working in antenatal clinics. The antenatal education services provided fall under four thematic areas: (a) pregnancy, (b) labor and birth, (c) postpartum care, and (d) newborn care.
Theme 1—Education for Safe Pregnancy
The antenatal educational services provided during pregnancy can be organized under seven categories of Diet; Safe and tolerable exercises; Coping with pregnancy symptoms; Recognizing abnormalities and seeking medical advice; Medication and dietary supplements; and Appointment and procedures, and vaccination and Myths and misconceptions about pregnancy.
Diet
Under this category, two sub-themes emerged: “Promoting healthy dietary habits” and “Health condition based dietary advice.”
In terms of promoting healthy dietary habits, many healthcare providers mentioned they provide general education about eating healthy foods during pregnancy, as these participants noted:
I am giving education about healthy food… which is very important… (HCP-MW#1)
We give information in general like diet advice, healthy diet, types of diet (HCP-DR#3)
In addition to general health education, the findings show that healthcare workers often provided health education to pregnant women based on the underlying disease condition as these noted:
We give the advice that is related to her disease… for example like for diabetic patient; we advised them to be strict on a diabetic diet (HCP-DR#3)
For those who have some medical problem like gestational diabetes,…we tend to focus on nutrition and diet to manage such problem (HCP-EDU#1)
Exercises
In addition to diet and education, most caregivers reported encouraging pregnant women to engage in safe and tolerable exercises like walking in early and late pregnancy as noted below:
Usually I advise her about exercise especially at last month like walking if she can tolerate she can do walking (HCP-SN#2)
During the third trimester of pregnancy, we recommend that she starts walking, especially if she does not suffer from specific problems (HCP-EDU#2)
Coping
Another significant antenatal education service provided to pregnant women relates to helping them deal with the pregnancy-related challenges as evidenced in these verbatim descriptions:
During history taking we normally teach them what are the risk factors and …make sure they understand what happens in each trimester (HCP-DR#5)
If the women are having hyperemesis or acidity,… I advised her to take antacid, …and I reassured her that this is normal during pregnancy … (HCP-MW#2)
Recognition of Abnormalities
General antenatal education was provided about complications such as bleeding, reduced fetal movement as danger signs that pregnant women needed to look out for and seek medical help:
If there are some red flags, we provide general health education. We will explain to the patient if there are some complications like PV [per vagina] bleeding or reduced foetal movement to report (HCP-DR#1)
Also we tell them the red flag and the danger signs such as rupture of membrane, bleeding, reduced foetal movement, she has to go to the hospital immediately without waiting for the contraction to occur (HCP-MW#2)
Medication and Supplements
Some healthcare providers, especially doctors emphasized the importance of iron and folic acid and other prescribed medications during pregnancy as evidenced in the narrative below:
…we instruct pregnant women to take supplements and vitamins, we encourage her to avoid taking any other medication unless… (HCP-DR#2)
We inform her of the necessity of commitment during the first term of pregnancy to take folic acid until she reaches her 12th week of pregnancy (HCP-EDU#2)
Appointments and Procedures
Another focal point of health education services emphasized by most participants relates to their explaining to pregnant women reasons for antenatal follow-up, procedures, and vaccination:
used to explain to them about the investigation needed, some of them they need an ultrasound, or medication, some patient they have a frequent appointment in the clinic so I make sure she understands the indication of that appointments and what will be done for her (HCP-MW#3)
I make sure in every visit to explain the indication of every visit especially for primi as there are routine visit and it can go up if she develops any risk factor with that she will understand the importance of each visit and ensure the compliance (HCP-DR#5)
Myths and Misconceptions
The health education targeting myths and misconceptions was reported by general health educators and not by doctors, midwives, or nurses. They maintained that discussing such issues with pregnant women is an important aspect of ANC services as evident below:
…some pregnant women hear from their mothers and grandmothers that they shouldn’t do any exercise durig early pregancy as it can lead to abortion… so we teach her the importance of light physical activity in pregnancy and how it will help her to avoid many other health problems in future (HCP-EDU#1)
Theme 2—Education for Safe Labor and Birth
The antenatal educational services provided during pregnancy targeting safe labor and birth can be organized under three categories of “Preparedness for labor and birth”; “Pain management in labor,” and “Myths and misconception related to labor” as highlighted in the section below.
Preparedness for Labor and Birth
Under this category, the sub-themes were: “Preparation for onset of labor” and “Preparation for childbirth.”
In terms of preparations for labor, we found that many healthcare providers regularly explained to pregnant women about the nature of labor pain, the types and signs and symptoms associated with onset of labor. This was to prepare them for onset of labor so they can seek medical help:
We explain to them about labour pain, some of them don’t understand much about uterine contractions, especially the first time mothers,. [so] we explain about onset of labour pain and we say if its regular, we advise her to come immediately (HCP-SN#2)
We tell them about the signs of true labour, labour pain, and tell them, if the birth water breaks or they pass mucus with blood, we advise her to go the hospital (HCP-DR#4)
Besides understanding teaching them the signs of onset of labor, some healthcare givers underscored the importance of preparing women psychologically for labor and birth as well:
As you know the emotional preparation is essential, especially if it is the first experience, they will be very scared and will ask what will happen, so I explain to them about signs of labour and symptoms (HCP-DR#2)
… we talk to them about childbirth and things that might help them to ease labour pain and how she can prepare herself emotionally… (HCP-EDU#1)
In terms of preparations for childbirth, only midwives consistently provided antenatal education about the stages of labor and birth process to the pregnant women as subsequently described:
I explain to them about the stages of labour and her role in each stage and what is the role of her attendant, and what is expected from the staff in the labour room to do (HCP-MW#4)
I am always telling them you’ll have a midwife and she’ll assess you and guide you when you need to start pushing, I will give them a brief about labour pain… (HCP-MW#2)
The results indicated that doctors, nurses, and educators were not consistently providing information about the stages of labor to pregnant women and how to prepare for them:
Unfortunately we don’t discuss with them about stages of labour and labour process. I wish we could, but the clinics are busy and we cannot explain in depth… (HCP-DR#5)
…we don’t give much education here about stages of labour and pain relief in labour, …not at all, may be the doctors will do that but I am not sure honestly (HCP-SN#1)
Pain Management in Labor
Under this second category, two sub-themes of “Pharmacological” and “Non-pharmacological” forms of pain management during labor emerged as highlighted in the following section.
In terms of the pharmacological forms of pain management, only few healthcare providers educated pregnant women about the available painkillers to help them cope with labor pain:
We have some women who are concerned about pain management and they will ask about epidural injection and its effectiveness… so we answer them (HCP-DR#1).
I provide them with different options…especially about epidural injection … so that when she will come into labour she has already set her mind and decided what she wants for pain management… (HCP-DR#3)
However, majority of the providers observed that they either do not provide this education to the pregnant women or they tend to provide such education only if the women asked them as highlighted below:
To be honest I do not discuss with her about pain management for labour (HCP-SN#5)
If the women are well educated and she asked about what type of analgesia available for labour …that time only we start counselling her (HCP-DR#4)
Myths and Misconceptions Related to Labor and Birth
Under this third category, only few providers focused on women who had some negative beliefs and misconceptions related to labor and birth, with the vast majority not paying much attention:
Also I discuss with them about the wrong beliefs very common in our society… which is the usage of herbal medication to fasten their labour. I discourage them …as [such medication] can cause side effect to her and her baby (HCP-EDU#1)
Themes 3—Education Related to Postpartum
The educational services provided for the postpartum period fall under four areas of “Routine postnatal care”; “postpartum psychological education”; “Breastfeeding;” and “Family planning.”
Routine Postnatal Care
The study found that only a handful of healthcare providers provide general information about routine postnatal care, which included maintaining personal hygiene and episiotomy care:
We talk to her about personal hygiene, such as sitting in a basin of water and salt and always trying to keep the sensitive area dry and clean… (HCP-EDU#2)
Mostly we talk about episiotomy care, sitz bath and to report to health centre [if any concerns arise ]…. (HCP-SN#4)
The vast majority of the care providers did not provide health education related to the postpartum period, with some justifying that such information shouldn’t be given during antenatal period:
Education related to postnatal care is usually not provided… We prepare them for the third trimester and delivery.…it is too early to talk about postpartum… (HCP-MW#5)
Postpartum Psychological Education
The study found that only three of the 17 healthcare providers talked about the psychological status of women during the postpartum period as stated in the description below:
Also I tell her about the importance of psychological support from her relatives and family (HCP-MW#1)
Sometimes we educate them about postpartum depression…and not with every woman… Only with women who give clues that she needs psychological support… (HCP-SN#5)
Breastfeeding
Breastfeeding education was emphasized by most healthcare providers as highlighted below:
In the last trimester we explain to the women that you will deliver soon. We educate her about breastfeeding… because if we don’t educate now, the baby might face problems with sucking… (HCP-SN#2)
I will advise her about breastfeeding in the 3rd trimester … I always emphasise on this topic and that is because a lot of women use artificial milk (HCP-DR#1)
Family Planning
The study found that whilst healthcare providers gave antenatal health education about family planning, they tended to provide such information very briefly and only to pregnant women, whom they felt needed to have advice about family planning as evident in these descriptions:
I discuss with some women about contraceptive antenatally but in brief only (HCP-DR#5)
… when they come for booking, and say I conceived by mistake or accidentally, so then I understand they need education about birth spacing… (HCP-MW#1)
Furthermore, the study also found that many healthcare providers had misconceptions about the right timing to give education about family planning, with most preferring the postnatal period:
we do not give much education about family planning [antenatally] (HCP-MW#3)
No, we don’t talk about postnatal procedures during pregnancy… (HCP-DR#3)
Theme 4—Education Related to Newborn Care
The educational services provided for the newborn care fall under two areas of “Routine Newborn care” and “Recognition of danger signs in the newborn.”
Routine Newborn Care
In terms of routine newborn care, only 3 of the 17 caregivers reported regularly giving antenatal education about newborn care. However, they noted that this education was limited to general information such as baby massage, vaccinations for newborn, and care of umbilical cord site:
I focus my education on how to take care of the baby, baby bath, and washing the clothes of the baby…also tell them about vaccine (HCP-MW#1)
We educate her about the care of umbilical site if there are any signs of infection (HCP-MW#2)
The vast majority 14 healthcare providers reported that they do not give newborn education during pregnancy and if they give, it will be only in the postpartum period as highlighted below:
Antenatally, I never discuss, usually we do this postnatally… (HCP-DR#2)
We don’t talk much about the new born baby, unfortunately… (HCP-MW#5)
…newborn education, unfortunately, we are not giving… (HCP-MW#4)
Recognition of Danger Signs in Newborn
In terms of health education geared towards empowering pregnant women to identify, danger signs in their newborn, all the healthcare providers reported that this was not an area they focused on during routine antenatal education as confirmed in the description below:
We do not touch this part during antenatal care… (HCP-DR#4)
We don’t talk much about the new born baby unfortunately (HCP-MW#5)
Discussion
The study evaluated the antenatal education service provision in Oman and sought to deeply understand the challenges associated with antenatal education. This was done by exploring the perspective of healthcare providers working in selected antenatal healthcare facilities in Muscat. The antenatal education services discussed in this section include health education provided to ensure safe pregnancy; labor and birth; postpartum and newborn care as highlighted below.
Education About Safe Pregnancy
The findings revealed that the health education provided focused on three areas: “early recognition of danger signs and seeking advice”; “management of medical conditions;” and “adherence to dietary supplements and medication.” These results conform to Oman's antenatal practice guidelines for delivery of quality ANC, which is aimed at promoting positive pregnancy outcomes (Al Malik & Mosleh, 2017; Çankaya, & Şimşek, 2021; MOH, 2016; Seshan et al., 2018).
While three areas met the required standards, the findings revealed that healthcare providers did not adequately address the needs for the following four areas: “education on healthy diet,” “physical activity in pregnancy,” “minor disorders during pregnancy,” and “antenatal appointments, routine investigations and screening services.” These findings compare negatively with investigations in the neighboring region of India by Dhiman et al. (2017) which showed that most pregnant women receive counsel about healthy diet in pregnancy. Our findings indicate that antenatal services are not being provided according to the recommendations that encourage healthy eating and physical activity during pregnancy (MOH, 2016; WHO, 2016). This is a significant negative finding since deficiencies in maternal nutrition result in adverse maternal and birth outcomes such as LBW, preterm labor, gestational anemia (Hambidge & Krebs, 2018; Nankumbi et al., 2018). This is of concern because as Seshan and colleagues (2018) observed, the prevalence of anemia is high among Omani pregnant women and intervention with nutrition education and regular follow-up reminders effectively reduced anemia in pregnancy. This means nutrition education should be a priority for all pregnant women in Oman.
With regard to physical activity, while some healthcare providers educated women on walking as the safest exercise during pregnancy, many of them did not recommend the women to continue with the exercise even during late pregnancy. The recommendations to integrate physical exercise are consistent with the study conducted in Brazil, which found walking was recommended by the healthcare providers (Heim et al., 2019). This finding is significant because obesity has been found to have serious implications on maternal, fetal, and neonatal health, as reported by Zutshi and colleagues (2018) in a study conducted in Royal Hospital, a tertiary health facility in Oman. This study found that one-third of obese participants had a significantly increased incidence of developing gestational hypertensive disorders, gestational diabetes, and a higher rate of Caesarean section, fetal macrosomia, and excessive bleeding postnatally. As a remedy, healthcare providers should pay greater attention to educating pregnant women about the importance of physical activity as a strategy to mitigate complications of obesity in pregnancy.
In terms of minor disorders, most pregnant women did not receive education about pregnancy symptoms and how to deal with the physiological changes associated with normal pregnancy due to reported lack of time and increased workload by healthcare providers. Yet research evidence shows that minor disorders in pregnancy impact the physical, emotional, and psychological health-related quality of life negatively and their overall wellbeing (Einarson et al., 2013). The neglect of minor disorder may be attributed to healthcare providers undermining complaints of minor disorders such as fatigue and morning sickness, perceiving them as part of early pregnancy (Bai et al., 2016; Heitmann et al., 2016). This tendency contravenes WHO (2016) and ACOG (2018) recommendations which require healthcare providers to advise pregnant women about interventions for physiological symptoms including recognition of abnormal symptoms.
Furthermore, in terms of informing and explaining to pregnant women the various routine services, not all healthcare providers regularly explained to pregnant women about indications for various screening tests and procedures. These findings indicate there is inconsistency in providing antenatal education services related to routine procedures and their indications. These findings are also inconsistent with NICE guidelines (2019) that require every healthcare provider to consistently inform pregnant women during each antenatal visit about procedures and screening tests, ensuring that she understands all the information to facilitate her decision-making process. This finding is also inconsistent with the MOH Oman (2016) guideline which requires that appropriate information about the timing, numbers of the antenatal visit should be discussed with all pregnant women including the type of care at every stage of her pregnancy. These study findings indicate inadequate implementation and partial adherence to these important guidelines.
Education About Labor and Birth
The findings demonstrate that pregnant women are briefed with inadequate information about labor and birth during the antenatal period. These findings are comparable to those of a recent study conducted in Ethiopia, which found that the healthcare providers did not provide pregnant women adequate information about childbirth preparedness (Woldeyohannes & Modiba, 2020). This is unwelcome reality because as Nolan (2017) noted, antenatal education provides an ideal opportunity to prepare pregnant women for labor and birth. The rationale for education during this period is hinged on the premise that antenatal counselling increases a woman's self-confidence by empowering her with the skills that help her deal with the stress of childbirth.
Another significant observation made by the researcher during the data collection period was that midwives were the only healthcare providers educating the women about the labor and birthing process. The researchers also discovered that many healthcare providers expressed that the role of educating pregnant women about labor and birth was not theirs, but that of delivery suite staff.
This failure by healthcare providers to provide important information about labor and birth was also observed in a study conducted in Nigeria. This study found that 30% of women did not receive any information during antenatal consultation about techniques for pain control during labor (Agnes et al., 2015). This inadequate provision of information leaves pregnant women without trusted information and guidance on pain relief and other important processes in labor (Heim et al., 2019). Moreover, studies show that such information when given during ANC helps the women to gain confidence in their ability to manage themselves during the labor process. The justification for this is the fact that the antenatal phase is the ideal time for pregnant women to comprehend information about the birthing process including strategies for pain management so they are physically and psychologically prepared for labor, birth, and childcare. Besides, knowledge reduces chances of fear-induced caesarean delivery as well as the possibility of antepartum depression and anxiety levels (Heim & Makuch, 2022; Olieman et al., 2017).
Education About Postpartum Care
The study revealed that healthcare providers generally do not provide information regarding pregnant women's psychological wellbeing, breastfeeding, family planning, hygiene, and nutrition during antenatal visits. This lack of education has serious implications since the psychological wellbeing of women is vital. In fact, Ayoub et al. (2020) notes that postpartum depression (PPD) is a major public health problem that affects at least 1 in 5 Arab mothers. In Oman, the prevalence of PPD is about 13.5% (EPDS scores of ≥13) indicating that Omani women are at higher risk of developing PPD (Al Hinai & Al Hinai, 2014). Since early detection improves mother–child interaction and relationship, and helps the mother to adjust to motherhood and prevents worsening of depressive symptoms (Al Hinai & Al Hinai, 2014), more attention should therefore be paid to the psychological wellbeing of pregnant women during the antenatal education sessions.
In addition, the findings that seem to indicate that poor quality antenatal education is being provided to pregnant women about postpartum care, there was also a belief among a wide section of participants that education related to postpartum care should be given postnatally. This may be an indication that there is a lack of staff awareness about the importance of antenatal education regarding postpartum care. According to Al Ageswari et al. (2019), postnatal care is an integral part of maternal healthcare because many physiological and psychological changes occur during this period. It is thus essential to provide every woman with antenatal education to help her identify high-risk health conditions in her and her newborn baby. If properly implemented, this strategy would enable postnatal mothers to seek healthcare early when complications arise.
Education About Newborn Care
The study findings indicate that contrary to what was stipulated by the WHO (2016) to establish antenatal educational programs to help pregnant women gain the skills and knowledge regarding proper newborn care, our findings demonstrated a lack of education about newborn care by providers. Similarly, these findings are consistent with the results of a study conducted by Ayiasi and others (2013), who observed that pregnant women in a Ugandan study were not adequately provided with recommended newborn care, thereby resulting in negative health outcomes for mothers or their babies. Lack of education about newborn care has critical consequences because in the absence of such information, pregnant women and her families often fail to recognize the danger signs of newborn illness and to seek immediate healthcare.
Moreover, according to Singh and Tripathi (2013), the better the quality of ANC provided to the women during pregnancy including enhanced antenatal education, the higher the potential to reduce neonatal mortality and morbidity. We found that because healthcare providers were not providing adequate information, most pregnant women used other resources such as the internet to obtain information to alleviate their anxiety and stress about their doubts.
While some pregnant women found the online resources useful, to the contrary most reported that such resources often caused confusion and increased their stress levels. This finding is consistent with that of a study conducted in Iran by Javanmardi et al. (2019), who reported that the use of the internet and different websites caused confusion among pregnant women and their families.
Strength and Limitation of the Study
The study's major strength is the first of its kind to evaluate antenatal education services from the perspective of healthcare providers. Limitation of this study was that data was collected from only one governorate of Oman, which might limit the generalizability of the study findings. Another challenge experienced by the researcher in the early part of the study was to separate her perceptions, feelings, and views from the perspective of being a researcher, a previous user of antenatal services and as midwife. This “mental dialogue” might have negatively impacted the research process in the early stages (Dwyer & Buckle, 2009). However, the researcher in a conscious effort to remain neutral began to maintain regular reflexive journaling. The purpose of this journaling was to acknowledge her own perceptions and preconceptions so they would be kept away as much as possible from the questioning and analysis process. This “bracketing” strategy proved very helpful to control and be aware of them and minimize their effect on the interpretation of the data (Corbin & Strauss, 2015).
Implications for Practice
The existing national guidelines by MOH should be clearly and widely communicated to all healthcare providers in all antenatal healthcare settings so the antenatal education provided to pregnant women is adequate and consistent. Based on the study findings, a clear policy should be adopted to place a midwife in every ANC clinic to deliver comprehensive antenatal education in the units. Midwives and nurses should appreciate their roles as educator, hence they should receive regular training program about antenatal education to update their knowledge and skills and competences in order to provide effective and evidence-based antenatal education to pregnant women.
Conclusion
The study is the first of its kind to provide baseline data regarding the current antenatal education service provision from the perspectives of healthcare providers. The findings have the capacity to contribute towards the development of remedial strategies to improve maternal and neonatal outcomes in Oman. This can be achieved by addressing the practice gaps identified when comparing the current practices with international standards established by the Ministry of Health, Oman in line with World Health Organization, National Institute for Health and Care Excellence and the International Federation of Gynecology and Obstetrics global recommendations.
In addition, the findings revealed a significant gap in providing antenatal education service to pregnant women when compared to the standards for safe pregnancy, labor and birth, postpartum and newborn care stipulated by Omani Ministry of Health national guidelines. While the national guidelines emphasize providing antenatal education to all pregnant women at every antenatal visit, our study found that antenatal education services provided did not address important educational needs to ensure safe pregnancy, labor and birth, postpartum and new born care. This inadequate education about labor and birth, postpartum and newborn care left most women ill prepared for childbirth and parenthood experience. There was also inconsistency in provision of antenatal education services, with nutrition education provided only to those identified with medical conditions such as diabetes, resulting in disparities in health outcomes.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
