Abstract
Quality and timely antenatal care is a vital component of pregnancy care for the well-being of mothers and babies. The aim of this study of to assess self-reported obstetricians’ adherence to national and international antenatal care guidelines in Lebanon. This cross-sectional study approached all obstetricians registered with the Lebanese Society of Obstetrics and Gynecology and the Lebanese Order of Physicians to participate in an online and telephone-based survey. The study tool included all of the items from the World Health Organization and national guidelines for antenatal care. Obstetricians’ self-reported adherence was assessed across five modules including dietary interventions, dietary supplements, antenatal care assessment, fetal growth assessment, and antenatal care preventive measures. A total of 134 obstetricians completed the survey. Overall, adherence was high for most antenatal care guidelines except for providing nutrition services to undernourished pregnant women, screening for intimate partner violence, and providing tetanus vaccines. The number of recommended antenatal care visits (≥8 vs. <8 visits) was higher among obstetricians in Mount Lebanon or Beirut compared to other areas in Lebanon (72.7%vs.48.6%; p-value <0.01). Provision of tetanus or diphtheria, tetanus, and pertussis (DTP) vaccination was lower for obstetricians who provide care for women who pay out-of-pocket compared to obstetricians who provide care to women who use other payment methods (25.3%vs.45.7%; p-value = 0.024). Group B streptococcus screening test and the provision of at least five ultrasounds were higher among obstetricians who provide care in private clinics or clinics in private hospitals compared to clinics in public hospitals or primary healthcare centers (88.8%vs.66.7%; p-value = 0.023) and (83.6%vs.55.6%; p-value = 0.011), respectively. Reinforcing the adherence to all antenatal care guidelines by continuous monitoring of health facilities is crucial for best practice. Subsidies for essential services may be required for those who are unable to afford components of antenatal care.
Introduction
Both maternal and perinatal morbidity and mortality are major public health concerns as they remain the leading causes of premature morbidity and mortality. In 2020, an estimated 287 000 women globally died from a maternal cause [1]. In 2015, there were 2.6 million neonatal deaths and 2.1 million stillbirths worldwide [2–5]. According to the World Health Organization (WHO), 94% of maternal deaths occur in low-and middle-income countries (LMICs), and most are preventable [6]. Therefore, it is critical to reduce maternal and perinatal mortality specifically in LMICs, by ensuring a safe childbirth for mother and child, which can be accomplished through access to high-quality antenatal care [7,8].
Antenatal care (ANC) is the health care that pregnant women receive from skilled healthcare professionals to ensure safe childbirth and promote the health of the mother and newborn throughout the pregnancy [9]. During ANC visits, women are provided with tests and examinations, health education and promotion to enable a healthy pregnancy [9]. ANC is an instrument that aims to detect and treat pregnancy complications and identify women at high risk of complications during childbirth [9]. The WHO initiated evidence-based guidelines for ANC to reduce perinatal morbidity and mortality through improving the quality of care received. Although global coverage of early initiation of ANC and attendance of at least four ANC visits has increased, inequalities in coverage persist [10,11], as well as large variation in the content and quality of care provided [12].
The WHO released comprehensive ANC recommendations in various areas for pregnant women and adolescent girls [9]. These evidence-based guidelines aim to provide good quality and appropriate ANC with a minimum of eight visits between conception and birth [9]. However, these are general, non-setting specific guidelines that need to be adapted and contextualized. In 2016, the United Nations Population Fund (UNFPA)-Lebanon office in collaboration with the Ministry of Public Health (MOPH) released ANC guidelines as part of the service delivery guidelines to be implemented and utilized at primary health care level; yet, it remains unclear to what extent these guidelines are adopted by obstetricians in Lebanon [13].
Studies have shown that high ANC coverage does not necessarily translate into adequate content and high quality of care, particularly in LMICs [12,14]. Hence, adherence of health providers to ANC guidelines is a vehicle for uniformity of clinical care and a component of quality of care [15]. In Lebanon, studies on ANC are limited. A previous study in 2010 showed that infrastructure and human resources are key components for high coverage of ANC in Lebanon [16]. Other recent studies have focused on Syrian refugees, which showed limited uptake of ANC [17–19]. As for studies conducted on the Lebanese population regarding ANC guidelines adherence, the most recent was conducted in 2004 [20], and currently requires updating according to new practices and recommendations [16]. Therefore, a more comprehensive picture of ANC provision in Lebanon is still needed.
There is paucity of data about the quality and content of ANC provided in Lebanon. One component of quality of care is obstetricians’ adherence to ANC guidelines, which reflects the content of care provided during each visit. Measuring obstetricians’ adherence to the updated WHO and MOPH ANC guidelines can provide an understanding of existing gaps in care. This study aims to describe the provision of ANC in Lebanon using existing national and international guidelines, and whether adherence differs by type of healthcare facility, area, and primary payment method.
Methods
Ethics statement
This study was approved by Social and Behavioral Sciences Institutional Review Board (IRB) of the institution (SBS-2021-0037). Consent to participate was obtained verbally from all participants for this telephone survey. The consent process and obstetricians’ responses were documented on Limesurvey platform. The IRB approved the use of verbal consent for this study.
Study design and setting
This was a cross-sectional study conducted in collaboration with the Lebanese Society of Obstetrics and Gynecology (LSOG) to assess adherence to ANC guidelines amongst obstetricians registered with the Lebanese Order of Physicians and LSOG in Lebanon. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines [21].
Study population
Obstetricians are the main source of ANC provision in Lebanon; therefore, nurses, midwives, and other healthcare professionals were not interviewed. Only obstetricians who worked in a healthcare facility for at least six months were eligible for the study. Those who retired, left the country, did not work in obstetrics, were not available, unreachable, or refused to participate were excluded from the study.
Sample selection
Between November 2021 and March 2022, obstetricians who were registered with the LSOG and Lebanese Order of Physicians were approached to participate in this study by email and through telephone invitation. An initial email invitation that included a link to the survey was sent to the registered obstetricians, while giving them the choice to complete the questionnaire electronically (self-administered) or via phone call interview. If after a month there was no response, obstetricians were contacted via telephone using phone numbers provided by the LSOG and Lebanese Order of Physicians. A clinically trained member of the team (MCR) undertook computer-assisted telephone interviews using the Limesurvey platform.
Data collection tool
A comprehensive list of components of care was mapped and drafted into a questionnaire using the existing WHO guidelines and the MOPH service delivery guidelines for ANC [9,13]. The WHO and MOPH guidelines were compiled together. If MOPH included a guideline that was not included in the WHO compilation, it was added. The survey included closed questions to determine the content of care for each item in the guidelines. The tool was based on five key modules: maternal and fetal growth assessment, antenatal care assessment, dietary interventions, dietary supplements, and ANC preventive measures. The dietary interventions module was divided into two sections: the first was addressed to obstetricians who provide care to pregnant women, and the second was related to those who provide care to undernourished pregnant women. Within each module, a question was asked per guideline item to determine whether the component of care was provided. In addition, the questionnaire also gathered general information about the type of healthcare facility, location, and primary method of payment used by women seeking ANC (social security, MOPH, out-of-pocket or private insurance, UNHCR or UNRWA). Given that some obstetricians practiced in more than one location (for example, private clinic vs. primary healthcare center), they were asked to complete the questionnaire based on the healthcare facility where they spent most of their time. The tool was reviewed by academics and two obstetricians before translating it into Arabic. Prior to onset of data collection, the English and Arabic versions of the questionnaires were piloted internally.
Outcome measures
Obstetricians’ adherence to ANC guidelines was determined based on the responses documented by the data collector, who was a clinically trained physician, on whether each of the recommended services, tests or advice were implemented during ANC visits (Yes/No). The interviewer asked the obstetricians whether they performed each item related to the ANC visit as proposed by the international and national guidelines. Therefore, a score of 1 was given for the obstetricians’ responses that aligned with the ANC guidelines of the WHO and the MOPH, and a score of 0 was given if they did not. The items were grouped into five modules that included fetal growth assessment (8 items), dietary interventions (8 items: 5 items for the first section, and 3 items for the second section), dietary supplements (8 items), ANC assessment (15 items), and ANC preventive measures (9 items). For every respondent, an overall score and 5 sub-scores for each module were generated by summing up the item scores. Since the dietary intervention module was divided into two sections, an additional sub-score was generated for obstetricians who provide care to undernourished pregnant women. More details about the items of each module can be found in S1 Table. A standard linear transformation was performed to convert the obtained scores within the range of 0 to 100. Based on clinical consensus, we created a sub-set of selected ANC guideline items from every module that were considered to be assessed against facility types, areas, and payment methods.
Statistical analysis
Frequencies and percentages were reported for categorical variables. Continuous variables were assessed for normality using histograms and the Shapiro-Wilk test. Normally distributed variables were represented as a mean with standard deviation (SD), while non-normally distributed variables were represented as median with interquartile ranges (IQR). Chi-square tests and Fischer’s exact tests were used to assess the difference of adherence to ANC across healthcare facility types, areas, and primary payment methods. Man-Whitney U tests were used to assess for the difference in scores across healthcare facility types. Partially completed questionnaires were excluded from data analysis. All analyses were conducted using Stata/SE 17.
Results
Characteristics of the population
Out of 1,090 obstetricians registered with the LSOG and Lebanese Order of Physicians, 80 were retired, left the country, did not work in obstetrics, or were not available, 373 refused to participate, 402 were unreachable, and 101 partially completed the questionnaire (S1 Fig). A total of 134 obstetricians completed the ANC questionnaire and were included in this study. More than half of the obstetricians (64.9%) spent most of their time providing ANC in a private clinic. Most of the obstetricians reported that their primarily place of work was in healthcare facilities located in Beirut (38.1%) and Mount Lebanon (35.8%). The most common payment method for ANC services in healthcare facilities was out-of-pocket (53.7%), and the majority of patients in most clinics were Lebanese (83.6%) (Table 1).
Table 1. Background characteristics of obstetricians (n = 134).
| n | (%) | |
|---|---|---|
| Type of healthcare facility where most of the time was spent | ||
| Primary healthcare center | 17 | (12.7) |
| Private doctor’s clinic | 87 | (64.9) |
| Clinic in public hospital | 1 | (0.7) |
| Clinic in private hospital | 29 | (21.6) |
| Antenatal care type of payment | ||
| Ministry of Public Health | 3 | (2.2) |
| Military schemes | 2 | (1.5) |
| Non-Governmental Organizations (local or international) | 8 | (6.0) |
| National Social Security Fund (NSSF) | 25 | (18.7) |
| Out-of-Pocket | 72 | (53.7) |
| Private insurance | 17 | (12.7) |
| UN agencies–UNHCR | 7 | (5.2) |
| Most common nationality for women seeking antenatal care | ||
| Lebanese | 112 | (83.6) |
| Syrian | 21 | (15.7) |
| Palestinian | 1 | (0.7) |
| Governorate of practice | ||
| Baalbak-Hermel | 3 | (2.2) |
| Beirut | 51 | (38.1) |
| Beqaa | 11 | (8.2) |
| Mount Lebanon | 48 | (35.8) |
| Nabatieh | 6 | (4.5) |
| North | 2 | (1.5) |
| South | 13 | (9.7) |
Adherence to ANC guidelines
Table 2 represents adherence to ANC standards according to the national and international guidelines. Five modules were used to assess overall adherence among obstetricians. For the dietary intervention module, adherence to providing nutrition education and protein dietary supplements was 88.6% and 86.4% respectively; however, adherence to providing balanced energy and protein dietary supplements was relatively low, with only 27.3% adherence. Most obstetricians counselled about having a healthy diet (90.3%), physical activity (72.4%), excess weight during pregnancy (93.3%), and reducing caffeine intake (94%). For the dietary supplement’s module, most obstetricians recommended the intake of vitamins and minerals such as iron (89.5%), folic acid during pre-conception and the first trimester (91.8%), and calcium (63.4%). For the ANC assessment module, almost all obstetricians screened for anemia (99.3%), bacteriuria (99.3%), hyperglycemia (94.8%), gestational diabetes (92.1%), smoking (92.5%), hypertension (94.8%), requested full blood count (97.8%), midstream urine flow test (90.3%), group B streptococcus (85.8%), Toxoplasmosis, Rubella, and Hepatitis B surface antigen immunity status (95.5%), and measured blood pressure (97.8%). A smaller proportion of obstetricians screened for intimate partner violence (29.9%), substance misuse (42.5%), HIV and syphilis (51.5%), and other sexually transmitted infections (41.8%). For the fetal growth assessment module, 39.6% of obstetricians assessed fetal growth and well-being using ANC cardiotocography (non-stress test) and 48.5% by routine Doppler ultrasound. Almost all obstetricians assessed fetal growth using ultrasound scans throughout pregnancy (98.5%) (median: 7 ultrasounds [IQR: 5–9]), with the first ultrasound scan performed before 14 weeks of gestation (96.3%) and the last one at 37 weeks or after (62.7%). For the ANC preventive measures module, 91% prescribed antibiotics for bacteriuria when indicated. More than two thirds provided the flu vaccine (71.6%) and COVID-19 vaccine (84.3%). Most obstetricians gave anti-D immunoglobulin between 28 and 34 weeks of gestation (76.9%). Nearly a third of obstetricians provided the tetanus or diphtheria, tetanus, pertussis (DTP) vaccine during ANC (30.6%).
Table 2. Self-reported obstetricians’ adherence to items from antenatal care guidelines.
| Intervention | Recommendation according to international1 and national guideline2 | Obstetricians’ adherence to items | |||
|---|---|---|---|---|---|
| No | Yes | ||||
| n | (%) | n | (%) | ||
| Module 1 (a): Dietary interventions (n = 134) | |||||
| Do you provide counselling about? | |||||
| Healthy diet | Recommended | 13 | (9.7) | 121 | (90.3) |
| Increased physical activity | Recommended | 37 | (27.6) | 97 | (72.4) |
| Excess weight gain during pregnancy | Recommended | 9 | (6.7) | 125 | (93.3) |
| At least one of the above | Recommended | 1 | (0.7) | 133 | (99.3) |
| Do you provide advice about daily caffeine intake? | Recommended3 | 8 | (6.0) | 126 | (94.0) |
| Module 1 (b): Dietary interventions (Among those who provide care to undernourished pregnant women) (n = 44) | |||||
| Do you provide antenatal care about? | |||||
| Nutrition education | Recommended | 5 | (11.4) | 39 | (88.6) |
| Balanced energy and protein dietary supplements | Recommended | 32 | (72.7) | 12 | (27.3) |
| High protein supplements | Not recommended | 38 | (86.4) | 6 | (13.6) |
| Module 2: Dietary supplements (n = 134) | |||||
| Do you recommend dietary supplementation such as vitamins and minerals? | Recommended | 7 | (5.2) | 127 | (94.8) |
| Type of supplementation recommended | |||||
| Iron | Recommended | 14 | (10.5) | 120 | (89.5) |
| Folic acid | Recommended during pre-conception and first trimester | 11 | (8.2) | 123 | (91.8) |
| Calcium | Recommended if woman has low dietary calcium intake | 49 | (36.6) | 85 | (63.4) |
| Multiple micronutrients | Not recommended | 58 | (43.3) | 76 | (56.7) |
| Vitamin B6 | Not recommended | 32 | (23.9) | 102 | (76.1) |
| Vitamin E and C | Not recommended | 16 | (11.9) | 118 | (88.1) |
| Vitamin D | Not recommended | 36 | (26.9) | 98 | (73.1) |
| Module 3: Antenatal care assessment (n = 134) | |||||
| Do you screen for any of the following risk factors or conditions? | |||||
| Anemia | Recommended | 1 | (0.7) | 133 | (99.3) |
| Bacteriuria | Recommended | 1 | (0.7) | 133 | (99.3) |
| Intimate partner violence | Recommended | 94 | (70.1) | 40 | (29.9) |
| Hyperglycemia | Recommended | 7 | (5.2) | 127 | (94.8) |
| Smoking during pregnancy | Recommended | 10 | (7.5) | 124 | (92.5) |
| Substance misuse | Recommended | 77 | (57.5) | 57 | (42.5) |
| HIV and Syphilis | Recommended | 65 | (48.5) | 69 | (51.5) |
| Hypertension | Recommended | 7 | (5.2) | 127 | (94.8) |
| Other sexually transmitted infections | Recommended | 78 | (58.2) | 56 | (41.8) |
| Do you provide any of the following tests during the ANC period? | |||||
| Full blood count | Recommended | 3 | (2.2) | 131 | (97.8) |
| If no to full blood count, other haemoglobin testing | Recommended if no full blood count | 0 | 3 | (100.0) | |
| Midstream urine flow | Recommended | 13 | (9.7) | 121 | (90.3) |
| If no to midstream urine flow, dipstick testing | Recommended if no to midstream urine flow | 5 | (38.5) | 8 | (61.5) |
| Group B streptococcus screening testing | Recommended | 19 | (14.2) | 115 | (85.8) |
| Immunity status check for Toxoplasmosis, Rubella and Hepatitis B surface antigen | Recommended | 6 | (4.5) | 128 | (95.5) |
| Blood pressure measurements | Recommended | 3 | (2.2) | 131 | (97.8) |
| None of the above recommended tests | Not recommended | 0 | 134 | (100.0) | |
| Do you screen your patients for gestational diabetes by ordering the 1-hour glucose challenge test? | Recommended | 24 | (17.9) | 110 | (92.1) |
| Module 4: Fetal growth assessment (n = 134) | |||||
| Do you assess fetal growth and well-being with any of the following measures? | |||||
| Recommend fetal movement chart | Recommended based on the context | 72 | (53.7) | 62 | (46.3) |
| Measure symphysis-fundal height | Not recommended | 38 | (28.4) | 96 | (71.6) |
| Assess fetal growth via abdominal palpation | Not recommended | 34 | (25.4) | 100 | (74.6) |
| Perform antenatal cardiotocography | Recommended | 81 | (60.4) | 53 | (39.6) |
| Perform routine Doppler ultrasound | Recommended | 69 | (51.5) | 65 | (48.5) |
| Perform ultrasound | Recommended | 2 | (1.5) | 132 | (98.5) |
| None of the above recommended measures | Not recommended | 0 | 134 | (100.0) | |
|
Number of ultrasounds performed [n = 132; Median (IQR)] |
At least one scan before 24 weeks of gestation, then at least 1 scan every month | 7 | (5–9) | ||
| Performance of at least 5 ultrasounds during pregnancy | 27 | (20.1) | 107 | (79.9) | |
| Performance of the first ultrasound during the first trimester | Recommended during the first trimester | 5 | (3.7) | 129 | (96.3) |
| Performance of the last ultrasound after 37 weeks of gestation | Recommended until delivery | 50 | (37.3) | 84 | (62.7) |
| Module 5: Antenatal care preventive measures (n = 134) | |||||
| Do you provide any of the following medications/treatments during antenatal care? | |||||
| Antibiotics when indicated | Recommended when indicated | 3 | (2.2) | 131 | (97.8) |
| Antibiotics for group B streptococcus infection | Recommended when indicated | 44 | (32.8) | 90 | (67.2) |
| Antibiotics for bacteriuria | Recommended when indicated | 12 | (9.0) | 122 | (91.0) |
| Antibiotics to prevent recurrent urinary tract infection | Not recommended | 67 | (50.0) | 67 | (50.0) |
| Tetanus vaccine or DTP4 | Recommended | 93 | (69.4) | 41 | (30.6) |
| Flu vaccine | Recommended | 38 | (28.4) | 96 | (71.6) |
| For women at risk, pre-exposure prophylaxis to prevent HIV | Recommended based on the context | 117 | (87.3) | 17 | (12.7) |
| COVID-19 vaccine | Recommended | 21 | (15.7) | 113 | (84.3) |
| None of the above recommended medications/treatments5 | Not recommended | 3 | (2.2) | 131 | (97.8) |
| Do you give anti-D immunoglobulin between 28 and 34 weeks of gestation? | Recommended | 31 | (23.1) | 103 | (76.9) |
1: World Health Organization.
2: Lebanese Ministry of Public Health.
3: Adapted, since obstetricians who gave advice regarding caffeine intake, regardless of the amount, are considered to have adhered to the recommendations.
4: DTP: Diphtheria, tetanus, and pertussis vaccination.
5: Including antibiotics in general when indicated, tetanus vaccine or DTP, flu vaccine and pre-exposure prophylaxis to prevent HIV.
Adherence to ANC guidelines by healthcare facility type, area, and payment method
Table 3 shows the distribution of selected ANC services according to the area where the healthcare facility is located (Mount Lebanon or Beirut vs. Other). The provision of flu vaccine, COVID-19 vaccine, full blood count, group B streptococcus screening test, blood pressure measurements, midstream urine flow test, five or more ultrasound scans, iron and folic acid supplements, and gestational diabetes screening was high across all areas with no statistical difference. The number of ANC visits (≥8 vs. <8 visits) recommended to pregnant women was significantly higher among providers located in Mount Lebanon or Beirut compared to those located in other areas of the country (72.7% vs. 48.6%; p-value <0.01). The provision of group B streptococcus screening test (88.8% vs. 66.7%; p-value = 0.023) and performing at least 5 ultrasounds during pregnancy (83.6% vs. 55.6%; p-value = 0.011) were significantly higher among obstetricians practicing in private clinics or clinics in private hospitals compared to those practicing in clinics in public hospitals or primary healthcare centers. The provision of other ANC items was similar with no significant difference across different facility types (Table 4). Adherence to the selected ANC items was high with no significant difference across different payment methods (out-of-pocket vs. other payment methods), except for the provision of the tetanus or diphtheria, tetanus, and pertussis (DTP) vaccine; the latter was significantly lower among obstetricians taking care of women who pay out-of-pocket compared to those who use other payment methods (25.3% vs. 45.7%; p-value = 0.024) (S2 Table).
Table 3. Adherence to selected antenatal care services by area in Lebanon.
| Mount Lebanon or Beirut (n = 99 (73.9%)) | All other areas in Lebanon* (n = 35 (26.1%)) | P-value | |||
|---|---|---|---|---|---|
| n | (%) | n | (%) | ||
| Do you provide tetanus vaccine or DTP? | |||||
| No | 68 | (68.7) | 25 | (71.4) | 0.762 |
| Yes | 31 | (31.3) | 10 | (28.6) | |
| Do you provide flu vaccine? | |||||
| No | 27 | (27.3) | 11 | (31.4) | 0.639 |
| Yes | 72 | (72.7) | 24 | (68.6) | |
| Do you provide COVID-19 vaccine? | |||||
| No | 18 | (18.2) | 3 | (8.6) | 0.179 |
| Yes | 81 | (81.8) | 32 | (91.4) | |
| Do you provide full blood count? | |||||
| No | 2 | (2.0) | 1 | (2.9) | 1.000f |
| Yes | 97 | (98.0) | 34 | (97.1) | |
| Do you provide group B streptococcus screening test? | |||||
| No | 11 | (11.1) | 8 | (22.9) | 0.087 |
| Yes | 88 | (88.9) | 27 | (77.1) | |
| Do you provide blood pressure measurements? | |||||
| No | 3 | (3.0) | 0 | (0.0) | 0.567f |
| Yes | 96 | (97.0) | 35 | (100.0) | |
| Do you provide midstream urine flow test? | |||||
| No | 11 | (11.1) | 2 | (5.7) | 0.513f |
| Yes | 88 | (88.9) | 33 | (94.3) | |
| Do you perform at least 5 ultrasounds during pregnancy? | |||||
| No | 22 | (22.2) | 5 | (14.3) | 0.314 |
| Yes | 77 | (77.8) | 30 | (85.7) | |
| Do you recommend iron? | |||||
| No | 10 | (10.1) | 4 | (11.4) | 0.759f |
| Yes | 89 | (89.9) | 31 | (88.6) | |
| Do you recommend folic acid during pre-conception and the first trimester? | |||||
| No | 8 | (8.1) | 3 | (8.6) | 1.000f |
| Yes | 91 | (91.9) | 32 | (91.4) | |
| Do you screen your patients for gestational diabetes by ordering the 1-hour glucose challenge test? | |||||
| No | 18 | (18.2) | 6 | (17.1) | 0.890 |
| Yes | 81 | (81.8) | 29 | (82.9) | |
| Number of visits recommended | |||||
| Less than 8 visits | 27 | (27.3) | 18 | (51.4) | 0.009 |
| 8 or more visits | 72 | (72.7) | 17 | (48.6) | |
| Adherence to guidelines | |||||
| Adherence to all | 15 | (14.1) | 1 | (2.9) | 0.115f |
| Adherence to some | 85 | (85.9) | 34 | (97.1) | |
*Other areas include: Baalbak-Hermel, Beqaa, Nabatieh, North and South.
f Fisher’s exact test was used.
Table 4. Adherence to selected antenatal care services by healthcare facility type in Lebanon.
| Clinic in private hospital or private doctor clinic (n = 116 (86.6%)) | Clinic in public hospital or primary healthcare center (n = 18 (13.4%)) | P-value | |||
|---|---|---|---|---|---|
| n | (%) | n | (%) | ||
| Do you provide tetanus vaccine or DTP? | |||||
| No | 82 | (70.7) | 11 | (61.1) | 0.412 |
| Yes | 34 | (29.3) | 7 | (38.9) | |
| Do you provide flu vaccine? | |||||
| No | 32 | (27.6) | 6 | (33.3) | 0.615 |
| Yes | 84 | (72.4) | 12 | (66.7) | |
| Do you provide COVID-19 vaccine? | |||||
| No | 19 | (16.4) | 2 | (11.1) | 0.738f |
| Yes | 97 | (83.6) | 16 | (88.9) | |
| Do you provide full blood count? | |||||
| No | 2 | (1.7) | 1 | (5.6) | 0.354f |
| Yes | 114 | (98.3) | 17 | (94.4) | |
| Do you provide group B streptococcus s test? | |||||
| No | 13 | (11.2) | 6 | (33.3) | 0.023f |
| Yes | 103 | (88.8) | 12 | (66.7) | |
| Do you provide blood pressure measurements? | |||||
| No | 3 | (2.6) | 0 | (0.0) | 1.000f |
| Yes | 113 | (97.4) | 18 | (100.0) | |
| Do you provide midstream urine flow test? | |||||
| No | 11 | (9.5) | 2 | (11.1) | 0.687f |
| Yes | 105 | (90.5) | 16 | (88.9) | |
| Do you perform at least 5 ultrasounds during pregnancy? | |||||
| No | 19 | (16.4) | 8 | (44.4) | 0.011f |
| Yes | 97 | (83.6) | 10 | (55.6) | |
| Do you recommend iron? | |||||
| No | 12 | (10.3) | 2 | (11.1) | 1.000f |
| Yes | 104 | (89.7) | 16 | (88.9) | |
| Do you recommend folic acid during pre-conception and the first trimester? | |||||
| No | 8 | (6.9) | 3 | (16.7) | 0.168f |
| Yes | 108 | (93.1) | 15 | (83.3) | |
| Do you screen your patients for gestational diabetes by ordering the 1-hour glucose challenge test? | |||||
| No | 21 | (18.1) | 3 | (16.7) | 1.000f |
| Yes | 95 | (81.9) | 15 | (83.3) | |
| Number of visits recommended | |||||
| Less than 8 visits | 37 | (31.9) | 8 | (44.4) | 0.294 |
| 8 or more visits | 79 | (68.1) | 10 | (55.6) | |
| Adherence to guidelines | |||||
| Adherence to all | 14 | (12.1) | 1 | (5.6) | 0.692f |
| Adherence to some | 102 | (87.9) | 17 | (94.4) | |
f Fisher’s exact test was used.
Score of ANC adherence for each domain
A score of adherence was generated for the five modules of the questionnaire. Overall (out of 45 items), the adherence score ranged between 42.2% and 95.6% with a median score of 77.8% [IQR: 68.9%; 80%]. Among all obstetricians who provide care for pregnant women, the highest level of adherence to ANC guidelines was observed for the dietary interventions (median: 100% [IQR: 80%; 100%]), followed by dietary supplements (median: 87.5% [IQR: 75%; 87.5%]). A slightly lower adherence was observed in the domains of antenatal care assessment (median: 80% [IQR: 73.3%; 86.7%]) and fetal growth assessment (median: 75% [IQR: 62.5%; 87.5%]). The lowest adherence score was observed for the antenatal care preventive measures (median: 66.7% [IQR: 55.6%; 77.8%]). In addition, among obstetricians who provided care for undernourished pregnant women, the adherence to items related to dietary interventions or counselling for these women was 66.7% (Table 5). The adherence scores did not differ significantly across healthcare facility types, areas, and payment methods (S3 Table).
Table 5. Overall and module-specific score of obstetricians’ adherence to antenatal care guidelines.
| Actual scores | Linear transformation (%) | |||||
|---|---|---|---|---|---|---|
| Range | Median | [IQR] | Range | Median | [IQR] | |
| Overall score (n = 134) | 19; 43 | 35 | [31; 36] | 42.2; 95.6 | 77.8 | [68.9; 80] |
| Sub score for all respondents (n = 134) | ||||||
| Dietary interventions | 1; 5 | 5 | [4; 5] | 20; 100 | 100 | [80; 100] |
| Dietary supplements | 0; 8 | 7 | [6; 7] | 0; 100 | 87.5 | [75; 87.5] |
| Antenatal care assessment | 7; 15 | 12 | [11; 13] | 46.7; 100 | 80.0 | [73.3; 86.7] |
| Fetal growth assessment | 0; 8 | 5 | [4; 6] | 0; 100 | 75.0 | [62.5; 87.5] |
| Antenatal care preventive measures | 0; 8 | 6 | [5; 7] | 0; 88.9 | 66.7 | [55.6; 77.8] |
| Sub score for respondents who provide care to undernourished pregnant women (n = 44) | ||||||
| Dietary interventions | 0; 3 | 2 | [2; 2] | 0; 100 | 66.7 | [66.7; 66.7] |
Discussion
This study on self-reported adherence showed that there was a moderate to high level of obstetricians’ adherence to ANC guidelines with no difference in scores across healthcare facility type, areas, and payment methods. Performing at least five ultrasounds during pregnancy and provision of group B streptococcus screening was higher among obstetricians who practice in private clinics or clinics in private hospitals compared to those who practice in clinics in public hospitals or primary health care settings. Nearly a third of the obstetricians adhered to the provision of tetanus or DTP vaccination, and this was lower among those who have more patients who paid out-of-pocket.
Results in context
Adherence to ANC preventive measures score was acceptable among obstetricians, where half of the participants had a score between 55.6% and 77.8%. However, adherence of obstetricians to the provision of tetanus or DTP vaccine, flu vaccine, and COVID-19 vaccine was low. Vaccines are an essential component of care that can prevent maternal and perinatal morbidity [22–24]. With regards to the tetanus or DTP vaccine, the observed percentages were lower than those reported in LMICs such as Ethiopia and Tanzania with rates of adherence above 85% [25,26]. Strengthening the adherence of obstetricians to providing tetanus vaccination through regular monitoring and training on the importance of vaccine provision is necessary to prevent adverse pregnancy outcomes and to reach optimal obstetric care.
The reported average number of ANC visits was significantly less than eight among obstetricians who practice in areas outside Beirut and Mount Lebanon compared to those who practice in Beirut and Mount Lebanon. According to the recent WHO and the UNFPA-Lebanon guidelines, a minimum of eight ANC visits should be provided to improve the quality and content of care. The results might be related to women’s circumstances rather than obstetricians, as many women struggle to access ANC in LMICs, particularly in rural areas [11,27]. Notably, pregnant women in rural areas in Lebanon may have low socioeconomic characteristics, which may limit the number of ANC visits due to financial reasons. Under-attendance (1–5 visits) is associated with adverse health outcomes [28]. Hence, it is advisable for municipalities in each governorate to collaborate with international organizations to provide educational and financial support to local community clinics, healthcare dispensaries and public health departments. This collaboration would ensure the availability of accessible and affordable ANC services.
The provision of five or more ultrasounds during pregnancy was higher among obstetricians practicing in private practice compared to those practicing in clinics in public hospitals. This difference could be attributed to the socioeconomic status of women seeking ANC. Additionally, the financial strain caused by the economic crisis in Lebanon may have further hindered the ability to afford regular check-ups and led to fewer ultrasounds in public hospitals settings.
The lowest score of adherence was observed for the dietary intervention domain related to undernourished pregnant women, particularly in providing balanced energy and protein dietary supplementation. Although studies targeting adherence among undernourished pregnant women are limited, our results are aligned with a recent study conducted among pregnant women in Bangladesh, where low adherence to nutrition services by healthcare providers was reported [29]. This could be explained by obstetricians prioritizing curative health services over preventive nutritional services due to high workload pressure [29]. Previous studies have shown that provision of nutritional education to undernourished pregnant women and enabling women to have a balanced diet reduced maternal complications, stillbirth, and infant low birth weight [30–32]. In Lebanon, a large proportion of the population has fallen below the poverty line [33], which has exacerbated pre-existing food insecurity rates [34], therefore, nutritional interventions and counselling remain an essential component of ANC in the Lebanese context.
Recommendations
By prioritizing and strengthening adherence to the essential components of ANC, we can reduce the risk of maternal and fetal complications and promote healthier outcomes for both mothers and infants. Hence, ongoing professional development and training programs tailored to the specific needs of obstetricians would enhance adherence and enable the delivery of comprehensive ANC. In addition, subsidies for crucial components of ANC should be provided to all women in Lebanon to tackle underlying inequalities. Future qualitative research would provide valuable insights into the perspectives and experiences of pregnant women, obstetricians, and other stakeholders involved in ANC provision. In addition, future studies should consider cross-referencing obstetricians’ responses with electronic health records or patients’ surveys.
Strength and limitations
This study addresses an important knowledge gap in obstetricians’ adherence to ANC services in Lebanon and presents a comprehensive score using the updated WHO and national guidelines. In addition, this study considered multi-level factors (healthcare facility type, area, and payment method) and applied a stratified descriptive analysis to target recommendations to improve service delivery.
This study is subject to several limitations. The outcomes were self-reported and were not cross-referenced with other sources such as electronic medical records, which may introduce information bias. The small sample size may not be representative of all the LSOG community so the findings cannot be generalized. In addition, there is a possibility that a proportion of obstetricians with busy practices were not available to participate in the study. Furthermore, factors that could influence the provision of ANC services were not explored in this study including resource availability in healthcare facilities and obstetricians’ workload. Additionally, we did not collect certain background characteristics of the obstetricians, such as years of experience, age, and other factors.
Conclusions
The present study underlined the importance of reinforcing the adherence to all ANC guidelines for the best possible practice. Overall, high adherence to multiple components of ANC was noted. However, there was low adherence in the provision of nutritional counselling and interventions to undernourished pregnant women, and also in the provision of tetanus or DTP vaccination. Furthermore, disparities in provision of ANC are required to be tackled in Lebanon. Future research is needed to identify factors influencing the provision of ANC from both the obstetricians’ and women’s perspectives for better intervention planning.
Supporting information
(TIFF)
(XLSX)
(DOCX)
(DOCX)
Data Availability
The data contains potentially identifying information about the clinicians who participated in the study. Participants did not give consent to share their data in an open format and the study did not receive ethical approval to share data. To share the data in an open database without consent of the participants and included in the original ethical approval would breach the AUB's Institutional Research Boards' rules. Anonymized data can be shared with researchers upon request to crph@aub.edu.lb.
Funding Statement
This study was funded by the University Research Board (Grant number: 103946) at the American University of Beirut (AUB). Funds were received by SJM, CA and FEK. The funder had no participation in the design, data collection and analysis, decision to publish, or preparation of the manuscript. TK received a salary as part of her Research Assistant duties.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
(TIFF)
(XLSX)
(DOCX)
(DOCX)
Data Availability Statement
The data contains potentially identifying information about the clinicians who participated in the study. Participants did not give consent to share their data in an open format and the study did not receive ethical approval to share data. To share the data in an open database without consent of the participants and included in the original ethical approval would breach the AUB's Institutional Research Boards' rules. Anonymized data can be shared with researchers upon request to crph@aub.edu.lb.