LITERATURE REVIEW Introduction: Antenatal Care

Running head: LITERATURE REVIEW
LITERATURE REVIEW
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Introduction:
Antenatal care can be defined as the care that is offered by the care professionals to
pregnant women. It includes the process of offering assistance to the expecting mothers
during the period of pregnancy prior to the delivery of the baby (Azzeh 2013). Antenatal care
is also referred to as maternity care and is administered by the multidisciplinary team of care
professionals that comprises of the GP, Obstetrician and Midwives. The primary role of the
care providers engaged in providing antenatal care characteristically involves regular health
check-up, disseminating essential information to the expecting mothers about their physical
health condition, discussing choices and options related to pregnancy and delivery and
resolving other queries that patients might raise. The World Health Organization (WHO) in
the year 2016 had recommended a revised set of guidelines that had essentially emphasised
on improving the quality of maternity care across maternity ward within healthcare
organizations globally so as to promote positive patient outcome and ensure pregnancy a
positive experience (WHO 2019). It should further be noted in this regard, that the guideline
not only focused on improving the quality of maternity care but also focused on improving
the quality of nutrition offered in healthcare settings and treating the symptoms of
psychological distress in expecting mothers. It should be critically noted here that the global
statistics indicate a high prevalence of pregnancy related deaths and still births which can
supposedly be controlled by improving the quality of antenatal care within healthcare
settings. This paper aims to investigate scholarly research papers in order to evaluate the fact
that whether or not an increase in attendance within the antenatal care unit could help in
promoting positive health outcome in pregnant women.
Research Question:

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On the basis of the background information, the research question that can be
articulated includes the following:
RQ1: Does an increase in attendance within the antenatal care unit improve maternal health
outcome?
RQ2: Does an increase in attendance within the antenatal care unit help in preventing adverse
foetal health outcome?
Research Aim:
The research aim is to scan the evidence base in order to evaluate that whether or not
increase in attendance at the antenatal care unit helps in improving maternal health outcome.
In addition to this, the research also intends to develop an understanding about the adverse
foetal health outcome associated with poor attendance within the antenatal care unit.
Research objectives:
Therefore, on the basis of the research question and the research aim, the research
objectives can be enlisted as follows:
 To evaluate the quality of maternal health outcome on increasing attendance within
the antenatal care unit
 To determine the impact of poor attendance within the antenatal care unit on the foetal
health outcome
Search Strategy:
In order to address the research question, an extensive search was conducted on the
popular electronic databases that included, Google Scholar, PubMed and MedLine.
Electronic databases store a gamut of information in the form of scholarly evidences that help
in formulating an idea about the latest research conducted in the area of interest. The

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electronic databases can be accessed online and can be customized by applying filters such as
publication date and author names. Upon specifying the filters, a wide number of research
papers can be accessed that help in conducting a review of the research papers published in
the topic of interest.
Exclusion Criteria:
According to Walliman (2017), exclusion criteria can be defined as a set of
characteristics that help in excluding a number of research papers that are not relevant to the
research question. Eliminating research papers based on specific exclusion criteria helps in
narrowing down the search into relevant research papers.
In this case, the exclusion criteria comprised of the following:
 Research papers published prior to 2013
 Research papers published in Foreign languages other than English
 Research papers that were not fully accessible
Inclusion Criteria:
As stated by Walliman (2017), inclusion criteria forms the set of characteristics that
help in including relevant research studies that align with the research paper. Papers that
qualify the inclusion criteria are included in the research study.
In this case, the inclusion criteria comprised of the following:
 Research papers published in between 2013 to 2017
 Research papers published in English
 Research papers that were fully accessible and aligned to the key words

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Key Words:
According to Flick (2015), keywords form the short phrases and words that strongly
align with the concept of research topic. Key words typically help in retrieving relevant
research studies. In this case, the key words that were used for the literature search included
the following:
Attendance, Antenatal Care Unit, Positive maternal health outcome, improved foetal
health outcome, Saudi Arabia, Care outcome, quality of health, Saudi Arabia
Boolean Operators:
Boolean operator typically comprise of the connectors AND/OR which are used to
connect the key words so as to retrieve relevant papers on the electronic databases. The
Boolean operators were used in combination of the key words in order to conduct the search
across the electronic database. For example, Attendance AND Antenatal Care Unit,
Positive maternal health outcome

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PRISMA:
Fig: PRISMA CHART
Literature Review:
According to the statistical report published by the World Health Organization (2019),
it had been estimated that a total number of 303,000 maternal deaths occur every year
globally due to pregnancy complications and ineffective care (WHO 2019). Further, the
report also indicated that on an average 2.7 million babies died within the first 28 days after
delivery. In addition to this, stillbirth accounts for 2.6 million of the infant mortality rates.
According to World Data Atlas (2015), infant mortality rate was estimated to be 11.94 per
1000 live births (Knoema 2019). A number of factors have been associated with the poor

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maternity and neonatal health outcome in Saudi Arabia. Factors such as lack of education and
awareness about ante-natal screening and pregnancy counselling in women residing within
the rural and remote locations of the Saudi Arabia accounts for the primary reason of high
infant mortality rate and poor maternal health outcome (Saied et al. 2013; Karout et al.2013).
A study conducted by Vogel et al. (2013) evaluated the effectiveness of an antenatal package
comprising of evidence-based screening, therapeutic intervention and education against the
effectiveness of the standard antenatal care package. The Antenatal Care Trial recommended
by the World Health Organization in the year 2001, suggested that an ordinary antenatal
package comprising of screening procedures, intervention and education within the low-risk
pregnant women could help in reducing medical expense. However, the researchers
conducted a review to evaluate the efficacy of the normal recommended antenatal care
package. The researchers conducted three-randomized control trials and the statistical
findings indicated a significant risk with the normal antenatal care package resulting in
perinatal morbidity.
The researchers thus concluded that increased visits, specific-goal oriented antenatal
care package could effectively help in reducing perinatal mortality. Precisely, the results of
the research study indicated that a high risk of foetal death normally occurs in between the
32nd to 34th week of pregnancy. Increased antenatal attendance and closely monitoring the
maternal and neonatal health outcome could significantly help in acquiring positive health
outcome. Another research study by Srivastava et al. (2015), conducted a systematic review
in order to evaluate the factors that could lead to increased level of maternal satisfaction and
positive maternal and foetal health outcome within developing Nations. The researchers
typically considered the parameters of maternal satisfaction and cultural competency of the
care professionals to render effective care to the pregnant women within the healthcare
setting. The results of the research study revealed that the determinants of maternal

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satisfaction included the consideration of factors such as quality of care delivery, process as
well as outcome (Srivastava et al. 2015). The findings revealed that the structural elements
that directly impacted the maternal satisfaction included cleanliness and hygienic
environment of the healthcare setting, spontaneous availability of care professionals to attend
concerns and proper medication supplies (Srivastava et al. 2015).
In addition to this, factors such as effective interpersonal behaviour, quality of
therapeutic relationship and courteous behaviour by care professionals directly affected that
satisfaction level of the expecting mothers (Oteng-Ntim et al. 2015). Courteous and culturally
safe care delivery by care professionals was tightly linked to an increased satisfaction level in
women opting for a normal delivery (Otaiby et al. 2013). The study typically highlighted the
fact that apart from focusing on the aspect of improving the infrastructure and process of
antenatal care in the developing nations. Regulatory authorities must as well consider the
aspect of improving the quality of care process so as to generate positive patient outcomes.
Al-Ateeq and Al-Rusaiess (2015) in their study investigated the need to incorporate health
literacy within antenatal care unit. A number of studies have mentioned that educated women
experienced better health outcome in comparison to women who were not educated about
pregnancy. In addition to this, studies have also mentioned that health literacy could ideally
help in preventing adverse complications and ensure a safe pregnancy. This could be
explained by the fact that educated patients were aware about the physiological changes that
occurs within the body during pregnancy and could proactively voice their concern to the
care professionals on sensing an adverse side-effect or a physiological complication (Al-
Ateeq and Al-Rusaiess 2015). On the contrary, uneducated patients possessed no knowledge
about the physiological complication or side-effects of medications and as a result, poor
maternal and foetal health outcome were invariably higher in uneducated women compared
to educated women (Al-Ateeq and Al-Rusaiess 2015).

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The researchers typically evaluated the impact of education on maternal and foetal
health outcome in participants from four developing nations which included, Argentina,
Cuba, Saudi Arabia and Thailand (Al-Ateeq and Al-Rusaiess 2015). The findings of the
research study indicated that expecting mothers placed within their third trimester of
pregnancy were majorly influenced by their socio-cultural and religious beliefs. In addition to
this, it was also found that women belonging to Saudi-Arabia were influenced by a cultural
belief that recommended them to consume more calories that the recommended level of
calorie intake during the period of pregnancy by the SMA Nutrition Guidelines (Al-Ateeq
and Al-Rusaiess 2015). In addition to this, women in Thailand, Argentina and Cuba were also
influenced by cultural beliefs that associated superstitions with pregnancy and lactation. Also,
women in Saudi Arabia and other Islam dominated developing nations were deeply
influenced by their religious beliefs that forbade them to raise their concern against sexual
health during pregnancy (Al-Ateeq and Al-Rusaiess 2015). Also, in some communities,
women did not avail care facilities during pregnancy because of cultural incompetence
exhibited by the care professionals. It can hence be stated that the researchers in the study
clearly identified the superstitions and socio-cultural beliefs that influence health behaviour
during pregnancy.
Therefore, health literacy should be mandatorily imparted to expecting mothers within
the antenatal care unit by care professionals in a culturally safe manner so as to ensure that
the expecting mothers are completely aware about the physiological process and can
experience a safe pregnancy. Another study conducted by Dowswell et al. (2015), focused on
assessing the optimum number of antenatal care visits that could help in ensuring a safe
pregnancy in expecting mothers. The researchers selected the participants for the research
study on the basis of randomised control study and critically compared the effectiveness of
antenatal goal oriented care against standard care. In order to avoid biases the study was

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reviewed by two authors independently. The researchers conducted a total of seven trials and
the sample size included a population of 60,000 pregnant women (Dowswell et al. 2015). The
randomised clusters were segregated into three in low and middle income nations and four in
developed nations. The Nations that were considered by the researchers included Argentina,
Cuba, Saudi Arabia, Thailand and Zimbabwe (Dowswell et al. 2015). The findings of the
research study indicated that the number of antenatal visits prior to the delivery varied
between the developed and the developing nations.
While in the developed nations, the optimal number of visits comprised a total of 8 to
12 visits, the number of visits within developing nations was less than 5 times (Dowswell et
al. 2015). In addition to this, the study also revealed that the cases of perinatal mortality was
more in case women where the visit was lesser than 5 times. Whereas the cases of perinatal
mortality was significantly less in high income countries (Dowswell et al. 2015). Also, the
researchers recommended that the lower antenatal visit in low-income countries was widely
because of limited resources. The lower antenatal attendance was linked with poor maternal
and foetal health outcome and therefore, the researchers suggested that the close monitoring
of the maternal health during the period of pregnancy could help in improving health
outcome despite lower number of antenatal visits. Another study conducted by Bener et al.
(2013), investigated the complications that occur in pregnant mothers during the third
trimester and evaluated the associated neonatal and maternal health outcome. The researchers
performed a prospective healthcare-setting based study that included a sample size of 432
pregnant women. The sample participants considered for the research interview belonged to
the age group between 30 years to 35 years (Bener et al. 2013). The findings of the study
revealed that the pregnant mothers experienced physiological health complications such as
gestational diabetes, gestational hypertension, ante-partum haemorrhage and maternal
anaemia (Bener et al. 2013).

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In addition this, neonatal complications were also common in the new born babies. It
can be mentioned in this context that frequent antenatal visits could significantly help in
addressing the risk factors that includes the maternal and neonatal complications and could
positively help in promoting effective recovery. Another study conducted by Wahabi et al.
(2014) indicated that the prevalence of gestational Diabetes in Arab women had significantly
increased over the decade. The researchers in the study, tried to evaluate that whether or not
an increase in antenatal attendance could help in early detection of Gestational Diabetes in
Saudi Arabian women and promote positive maternal and foetal health outcome (Eman et al.
2015). The researchers conducted a prospective descriptive study of women who presented to
the Maternity and Children Hospital in Medina, Saudi Arabia. The findings of the study
indicated early detection and OGTT could help in detecting the presence of Gestational
Diabetes in 51% women and could prevent the possibility of delivering a child with a
congenital disorder (Eman et al. 2015).
Also, Mushi et al. (2013) conducted a study to identify the reason that accounted for
lower body weight and increased morbidity and foetal mortality rate in women based at the
Jeddah city, Saudi Arabia. The findings of the study indicated that lower foetal weight could
be correlated to a number of factors that included maternal medical complications or social
and demographical attributes (Mushi et al. 2013). However, the researchers were of the
opinion that improved screening procedures and increased antenatal visits could help in
assessing the risks at an initial stage and prevent the progression of complications by devising
appropriate interventions. Another study conducted by Rowaily et al. (2014), conducted a
research study to assess the factors that could prevent risks related to caesarean delivery and
identify adverse complications so as to promote positive maternal and foetal health outcome
within healthcare setting. The researchers conducted a retrospective cohort study and
considered a sample size of 4305 women who were residents of Riyadh, Saudi Arabia

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(Rowaily et al. 2014). The findings of the research study indicated that difficult labour and
medical history of C-section were considered as the parameters for opting C-section in the
subsequent pregnancy (Rowaily et al. 2014). In addition to this, the findings also revealed
that C-section was involved with a number of complications and imparting education and
awareness about a safer pregnancy and a safer delivery route in combination with effective
counselling during antenatal attendance by care professionals could help in promoting
positive outcome.
Conclusion:
Therefore, to conclude, it can be mentioned that the evidence base reveals that an
increase in the number of antenatal visits or attendance by care professionals within Saudi
Arabia could help in the promotion of positive maternal and foetal health outcome. A number
of maternal health complications and foetal health outcomes could be significantly improved
by increasing the number of antenatal visits. It should also be noted in this regard that women
within the rural and remote areas of Saudi Arabia are greatly influenced by socio cultural as
well as religious beliefs that serves as a barrier and limits their accessibility to care services.
This invariably leads to foetal morbidity and mortality along with poor maternal health
outcome. It should also be noted that compulsory screening and imparting health education
could also help in the promotion of positive maternal health outcome. Compulsory and
frequent physiological health screening methods have been identified to successfully detect
complications at an early stage in expecting mothers. Also, neonatal screening and health
literacy could help in creating awareness in expecting mothers about pregnancy and discuss
options about a safer delivery method. As has already been discussed in the paper, a major
percentage of women in Saudi Arabia do not access maternal care facilities on account of
dissatisfaction based upon religious and cultural beliefs, thus, there is a need to reform the

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quality of service delivery so as to make pregnancy a safe experience for women. Further, it
should also be noted that according to the recommendation published by the World Health
Organization, a minimum of four visits is essential to improve the quality of antenatal care. It
has further been mentioned in this regard that poor attendance of the antenatal care clinic
invariably leads to lower body weight of the babies at birth. Also, it leads to a number of
neonatal deaths. The vital components that must be included within a antenatal care clinic
must comprise of imparting patient education about nutrition, child care, adapting safe
measures during pregnancy and screening procedures so as to avoid complications related to
child birth and maternal health. Also, antenatal care visits help in the detection of infectious
diseases such as malaria or STIs such as Syphilis or HIV. Typically antenatal care could be
made available to the pregnant mothers through community services or home visits. While
dealing with pregnant mothers belonging to the rural and remote areas which makes access to
healthcare extremely difficult for them, home care visits could be the most feasible option
and would promote positive outcome.

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References:
Al Rowaily, M.A., Alsalem, F.A. and Abolfotouh, M.A., 2014. Cesarean section in a high-
parity community in Saudi Arabia: clinical indications and obstetric outcomes. BMC
pregnancy and childbirth, 14(1), p.92.
Al-Ateeq, M.A. and Al-Rusaiess, A.A., 2015. Health education during antenatal care: the
need for more. International journal of women's health, 7, p.239.
Alfadhli, E.M., Osman, E.N., Basri, T.H., Mansuri, N.S., Youssef, M.H., Assaaedi, S.A. and
Aljohani, B.A., 2015. Gestational diabetes among Saudi women: prevalence, risk factors and
pregnancy outcomes. Annals of Saudi medicine, 35(3), pp.222-230.
Azzeh, F.S., 2013. Pregnant Women: A Preliminary Study in Western Saudi Arabia. Journal
of Biological Sciences, 13(5), pp.417-421.
Bener, A., Al-Nufal, M., Vachhani, P.J., Ali, A.I., Samson, N. and Saleh, N.M., 2013.
Maternal complications and neonatal outcome in Arab women of a fast developing
country. Journal of family & community medicine, 20(1), p.27.
Dowswell, T., Carroli, G., Duley, L., Gates, S., Gülmezoglu, A.M., Khan‐Neelofur, D. and
Piaggio, G., 2015. Alternative versus standard packages of antenatal care for low‐risk
pregnancy. Cochrane Database of Systematic Reviews, (7).
Flick, U. 2015. Introducing research methodology: A beginner's guide to doing a research
project. Sage.
Karout, N., Abdelaziz, S.H., Goda, M., AlTuwaijri, S., Almostafa, N., Ashour, R. and Alradi,
H., 2013. Cultural diversity: a qualitative study on Saudi Arabian women’s experience and

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perception of maternal health services. Journal of Nursing Education and Practice, 3(11),
pp.172-182.
Knoema 2019. Saudi Arabia Infant mortality rate, 1950-2018 - knoema.com. [online]
Knoema. Available at:
https://knoema.com/atlas/Saudi-Arabia/topics/Demographics/Mortality/Infant-mortality-rate
[Accessed 23 Feb. 2019].
Munshi, A.Y., Balbaid, O. and Qureshi, N.A., 2014. Prevalence and risk factors of very low
birth weight in infants born at the maternity and children hospitals in Jeddah, Saudi Arabia
during 2012-2013. British Journal of Medicine and Medical Research, 4(27), p.4553.
Otaiby, T.A., Jradi, H. and Bawazir, A., 2013. Antenatal education: Assessment of pregnant
women knowledge and preferance in Saudi Arabia. J Women’s Health Care, 2(139),
pp.2167-0420.
Oteng-Ntim, E., Meeks, D., Seed, P.T., Webster, L., Howard, J., Doyle, P. and Chappell,
L.C., 2015. Adverse maternal and perinatal outcomes in pregnant women with sickle cell
disease: systematic review and meta-analysis. Blood, 125(21), pp.3316-3325.
Pacagnella, R.C., Cecatti, J.G., Parpinelli, M.A., Sousa, M.H., Haddad, S.M., Costa, M.L.,
Souza, J.P. and Pattinson, R.C., 2014. Delays in receiving obstetric care and poor maternal
outcomes: results from a national multicentre cross-sectional study. BMC pregnancy and
childbirth, 14(1), p.159.
Saied¹, H., Mohamed¹, A., Suliman, A. and Al Anazi, W., 2013. Breastfeeding knowledge,
attitude and barriers among Saudi women in Riyadh. Journal of Natural Sciences
Research, 3(12), pp.6-13.

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Srivastava, A., Avan, B. I., Rajbangshi, P., and Bhattacharyya, S. 2015. Determinants of
women’s satisfaction with maternal health care: a review of literature from developing
countries. BMC pregnancy and childbirth, 15(1), 97.
Vogel, J.P., Habib, N.A., Souza, J.P., Gülmezoglu, A.M., Dowswell, T., Carroli, G., Baaqeel,
H.S., Lumbiganon, P., Piaggio, G. and Oladapo, O.T., 2013. Antenatal care packages with
reduced visits and perinatal mortality: a secondary analysis of the WHO Antenatal Care
Trial. Reproductive health, 10(1), p.19.
Wahabi, H.A., Fayed, A. and Esmaeil, S.A., 2014. Maternal and Perinatal Outcomes of
Pregnancies Complicated with Pre-gestational and Gestational Diabetes Mellitus in Saudi
Arabia. J Diabetes Metab, 5(399), p.2.
Walliman, N., 2017. Research methods: The basics. Routledge.P.90-95
World Health Organization 2019. New guidelines on antenatal care for a positive pregnancy
experience. [online] World Health Organization. Available at:
https://www.who.int/reproductivehealth/news/antenatal-care/en/ [Accessed 23 Feb. 2019].

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Screenshot of search-results: