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Abstract Antenatal care is the main point of contact for pregnant women to receive a wide range of services to promote the health of both mother and baby. Antenatal care is most effective when it starts early and continues throughout pregnancy. Pregnant women who dropout from ANC visits is considered at risk of potential complications during their pregnancy, and these complications can include maternal health, fetal health, or both. WHO recommends that pregnant women receive at least four antenatal care visits, and that ANC be provided by health care providers from the time of conception to the onset of delivery. However, pregnant women dropout of the ANC follow-up schedule, which is a noticeable problem in PHC facilities in Beheira Governorate. Hence, the present study aims to assess factors associated with pregnant women’s dropout from antenatal care visits in primary health care facilities. A descriptive, retrospective research design was used to carry out this study. It had been carried out in eight governmental primary health care facilities (4 urban health centers and 4 rural health units) in 4 health directorates in El Beheira Governorate namely: Kafer El-Dawar, Abo Homs, Damanhour and Kom Hamada by using an equal allocation technique based on the highest number of pregnant women’s dropout from antenatal care visits to be included in the study. The present study sample included a total of 354 women who were selected randomly from each of the previously selected primary health care settings. Tools of the Study Two tools were used to collect data in this study; Tool (I): Antenatal Care Dropout Related Factors Structured Interview Schedule, it was modified by the researcher after reviewing the recent literature and translated into Arabic language. It is composed of 3 parts: 1st part: women’s factors, 2nd part health care provider factors and 3rd part community factors. Tool (II): Women’s Satisfaction by Antenatal Care Services Structured Interview Schedule, RATER model was adopted and translated into the Arabic language. It is divided into: Reliability, Assurance, Tangibles, Empathy and Responsiveness. Study tools were tested for validity and reliability. Approvals were obtained for conducting the study at the specified settings. A pilot study was carried on 35 women to test the developed tool. The study was conducted over a period of 5 months (from the beginning of January 2021 to the end of May 2021). Data was collected by the researcher then appropriate descriptive and analytical statistics were carried out. The main results obtained from the study were as follows: - • Part I: Descriptive data of pregnant women’s dropout from antenatal care visits in their previous pregnancy Women’s factors (socio-demographic & obstetric characteristics): - Age of the studied women ranged from 18 to 45 years with a mean of (27.71 ± 7.66) years, the vast majority (98.0%) of the studied women were married, and more than half (53.4%) of the studied women were living in rural areas. - More than two fifths (44.3%) of the studied women had basic education, the majority (91.0%) of the studied women were housewives, nearly two fifths (39.3%) of the women’s husbands had secondary education, the majority (95.5%) of the women’s husbands were working and more than half (57.6%) of the participants stated that they had enough income to meet the demands of their lives. Summary 96 - The highest percent (51.1%) of the studied women had gravidity three or more and more than one third (36.7%) of the studied women had pregnancy complications. - Nearly three quarters (73.7%) of the participants reported that their mode of delivery was Caesarean Section (CS), most of the studied women (80.5%) preferred to receive their ANC visits from private clinics in their previous pregnancy, more than half (53.1%) of them initiated their ANC visits in the 2nd trimester in their previous pregnancy, and most of the studied women (81.9%) received inadequate ANC (less than 4) visits in their previous pregnancy. Health care provider factors: - Concerning registration, the highest percent (70.1%) of the studied women reported that waiting time wasn’t appropriate and less than two thirds (61%) of the studied women said that the health care provider’s communication was inappropriate during their last pregnancy. - Concerning history taking, the highest percent (40.4%) of the studied women reported that the health care provider didn’t ask them about their family history and nearly one third (31.1%) of them weren’t asked about their gynecological history during their last pregnancy. - Concerning physical examination, the highest percent (79.1%) of the studied women complained that the uterine fundus examination wasn’t entirely performed, nearly three quarters (74.9%, 72.3%) of the studied women reported that the position of fetus examination wasn’t perfectly carried out and the ultrasound examination wasn’t done during their last pregnancy respectively. - The same percent 71.8% of the studied women mentioned that the fetal heart sound examination and dental examination service weren’t entirely conducted, and more than half (58.2%) of the studied women reported that the consultation time was rather inappropriate during their last pregnancy. • Concerning laboratory investigations, more than one third (34.5%) equal percent of the studied women said that the albuminuria test, and glucosuria test weren’t done, and more than one fifth (20.9%) of the studied women complained that the Rhesus factor (Rh) test wasn’t implemented during their last pregnancy. • Concerning health education, the majority (93.5%, 92.9%, 86.7%) of the studied women reported that the health care provider didn’t give them any information about the importance of ANC follow-up visits, a balanced diet, or the ANC visits schedule respectively. And more than two thirds (67.8%) of the studied women reported that the health care provider didn’t give them any instructions about danger signs. • Nearly two thirds (65.5%) of the studied women said that the health care provider’s information was unclear, and less than two thirds (63.6%) of the studied women claimed that they didn’t get any information about ANC services. • The majority (92.9%) of the studied women reported that their follow-up visits were irregular, more than three quarters (82.2%) of the studied women reported that they weren’t informed about the follow-up results, and more than two thirds (69.5%) of the studied women complained that the health care provider didn’t conduct any home visits in their previous pregnancy. • The highest precent (59.0%) of the studied women had an average ANC visit dropout related to health care provider factors. Summary 97 Community factors: ▪ The highest precent (57.9%) of the studied women indicated that they didn’t get any support from their husbands and family, more than half (51.1%) of the studied women reported that they had a problem with the accessibility to (Primary Health Care) PHC facilities, more than one third (37.6%) of the studied women reported that the cost of transportation wasn’t affordable, and only 15.0% of the studied women reported that the cost of ANC service wasn’t affordable. ▪ The highest precent (52.6%) of the studied women had a low ANC visit dropout rate related to community factors. Women’s Satisfaction with the Quality of Antenatal Care Service: • More than two thirds (68.9%) of studied women had a low level of satisfaction, and only (1.2%) of them had a high level of satisfaction. Part II: Relationship between Studied Variables: • A statistically significant relation was existed between dropout from ANC visits and women’s age ( 2 =18.637, p<0.001*), place of residence (2 =31.180, p<0.001*), women’s education ( 2 =109.665, p< 0.001*), husband’s education ( 2 =15.336, p= 0.002*), women’s occupation ( 2 =5.312, p= 0.021*), husband’s occupation ( 2 =7.882, MCp = 0.011*), socio-economic level ( 2 =12.348, p= 0.002*), gravidity ( 2 = 11.528, p= 0.003*), parity (2 = 9.341, p= 0.006*), living child (2 = 5.954, p=0.015*), mode of delivery (2 = 5.086, p=0.024*), place of antenatal care visits (2 = 19.069, p <0.001*) and time of initial antenatal care visits (2 = 46.685, p <0.001*). • Furthermore, communication of health care provider (2 = 26.724, p <0.001*), treat in a respectable manner (2 = 68.055, p <0.001*), waiting time (2 = 68.055, p <0.001*), medical procedures explanation (2 = 10.016, p=0.002*), ultrasound examination (2 = 35.424, p<0.001*), level of uterine fundus examination (2 = 8.045, p=0.005*), dental examination (2 = 8.045, p=0.005*), consultation time (2 = 4.113, p=0.043*), health education about the importance of ANC (2 = 15.718, p<0.001*). clear information (2 = 5.329, p=0.021*), danger signs (2 = 13.411, p<0.001*), balanced diet (2 = 5.833, FEp=0.027*), taking prescribed medicines (2 = 11.845, p=0.001*), follow-up appointments (2 = 6.385, p=0.012*), ANC follow-up results (2 = 66.651, p<0.001*), home visits (2 = 9.871, p=0.002*), accessibility to primary health care facilities (2 = 54.511, p<0.001*), affordability of transportation (2 = 13.839, p<0.001*), husbands and family support (2 = 20.188, p<0.001*) and overall studied women’s satisfaction (2 = 27.710, MCp<0.001*) Part III: Most different risk factors associated with pregnant women’s dropout from antenatal care visits: • Finally, the most independent high-risk factors associated with pregnant women’s dropout from ANC visits in primary health care facilities, working women (OR = 21.101, p=0.009*), studied women who reported that PHC facilities inaccessible (OR = 16.023, p<0.001*), ANC follow-up unscheduled (OR = 11.491, p=0.002*), those who were unsupported from husband and family (OR = 8.117, p<0.001*), respondents who were living in rural residence (OR = 8.078, p=0.002*). Moreover, studied women who had a low class (OR = 6.535, p=0.006*), who reported that ultrasound examination not done (OR = 6.427, p=0.001*), who preferred ANC follow-up in private clinic (OR = 5.889, p=0.005*), women’s who had a Low level of education (OR = 5.411, p=0.001*), and who had a low level of women’s satisfaction (OR = 4.590, p=0.008*). Summary 98 Conclusion and Recommendations Based on the results of the present study, it could be concluded that: It’s worth noting the high dropout rate from antenatal care services in El-Beheira Governorate. The result of the present study shows that the majority of the mothers who attended ANC visits initiated them later than recommended by WHO, additionally, the majority of the participants received fewer than four ANC visits. Both women’s factors, health care provider factors and community factors are associated with dropout from ANC visits and most of these factors are preventable. There was a significant relationship between dropout from ANC visits and studied women who were working, who reported that PHC facilities were inaccessible, ANC follow-up was unscheduled, unsupported by husband and family, respondents who were living in rural residence, who had a low socio- economic class, had a low level of education., assumed that ultrasound examination wasn’t done, preferred ANC follow-up in a private clinic, and had a low level of women’s satisfaction Based on the current study findings the following recommendations are suggested: ➢ Recommendations directed to the Ministry of Health& Population (MOHP): 1. Support the implementation of the “Maternal and Fetal Health” presidential initiative in various PHC facilities all over the Egyptian country. 2. The existence of evidence-based practice guidelines that help health care providers who are working in antenatal clinics is beneficial for patients and healthcare systems. ➢ Recommendations for the Directorate of Health and Population 1. Continue its efforts to establish and improve health campaigns focusing on the health of pregnant women and their unborn children. 2. Implementation of health education programs in primary health care settings to improve their knowledge and skills to ensure their compliance with antenatal guidelines. 3. Reinforce the regular supervision of nurses in the antenatal clinics to ensure that they comply with antenatal guidelines. ➢ Recommendations for the health directorate 1. A monitoring system should be established to ensure the smooth functioning of the referral process for pregnant women and to detect any problems or rights violations. 2. The ANC clinics should be prepared with the required equipment and medical supplies to guarantee the provision of good ANC services. 3. Increase the number of ANC clinics and the number of health care providers in PHC facilities in order to decrease waiting times and increase provider contact times. 4. Minimizing waiting time and keeping the waiting area uncrowded is a good way for healthcare practices to better satisfy pregnant women. This also makes healthcare providers work without any inconvenience to women and their companions. ➢ Recommendations for healthcare providers 1. Health education programs should be initiated for those target men to create awareness about the importance of ANC services in PHC facilities and why they should involve themselves in ANC. 2. Health educators should include the minimum and maximum ANC contacts, pregnant women are supposed to have according to the WHO recommendations in their education and promotion sessions. Summary 99 3. More attention should be given to pregnant women, especially with their increasing age to conduct their ANC visits on time. 4. Encourage pregnant women who first time ANC visitors to increase the chance for a return ANC visit and recommended for other. ➢ Recommendations for mothers 1. ANC visit should be started as soon as a pregnancy is detected. 2. Pregnant women should be asked about their rights and asked for help if needed. ➢ Recommendations for further research 1. Further study is proposed to investigate the ANC nurse’s performance in primary health care facilities. 2. Further study is needed to design awareness program to improve pregnant women attendances ANC services in primary health care facilities. |