A Qualitative Inquiry of Women's Perspective of Antenatal Education Services in Oman

Abstract

Introduction

Antenatal care (ANC) provides an opportunity for systematic assessment and follow-up of pregnant women to ensure positive outcomes for mother and foetus. Pregnant women should be offered evidence-based information with support to enable them to make informed decisions.

Objective

To identify the gap between the current practices and the recommended guidelines for antenatal education services in Oman.

Methods

A qualitative inquiry was implemented through semistructured in-depth interviews guided by open-ended questions and probes. A purposive non-probability sampling technique was used to select 13 pregnant women who had completed 30 weeks of gestation. The women were selected from 9 antenatal healthcare facilities among them: 7 primary health centers, one polyclinic and one, tertiary hospital.

Results

Antenatal education focused on four thematic areas of safe pregnancy; safe labor and birth; postpartum care; and new-born care. Regarding antenatal education for safe pregnancy, the findings indicate that most healthcare workers provided pregnant women adequate information to promote healthy dietary habits; cope with pregnancy symptoms; recognize and manage medical conditions, and to adhere to dietary supplements and medication. In addition, the findings revealed that the healthcare team did not provide the required antenatal education to meet the pregnant women's needs to ensure they had safe labor and birth, postpartum care, and new-born care.

Conclusion

This study is the first of its kind in Oman to provide baseline data regarding the current antenatal education services from the perspective of pregnant women. These findings will help in developing strategies to improve maternal and neonatal outcomes in the country.

Introduction

Antenatal Education Services (AES) is a vital pillar of antenatal care (ANC) that improves the health of pregnant women and unborn babies (Chikalipo et al., 2018; Gholipour et al., 2018). ANC provides opportunity for systematic assessment and follow-up of pregnant women to ensure positive outcomes for mother and foetus (Aji et al., 2019; Grussua & Quatraro, 2020).

Satisfying the healthcare needs of pregnant women is an important healthcare quality indicator (Al-Ateeq & Al-Rusaiess, 2015). This is done by healthcare workers sharing up-to-date knowledge about pregnancy, childbirth and postpartum, and offering a combination of preventive care, early detection and timely treatment or referral (Renfrew et al., 2014). Pregnant women should be offered evidence-based information with support to enable them to make informed decisions (NICE, 2019). In fact, WHO (2014) recommends that pregnant women should have a written plan for dealing with birth and unexpected complications that may occur during pregnancy, childbirth, or immediate after birth to ensure better outcomes for mother and foetus.

In Oman, antenatal care is provided through primary healthcare institutions of health centers and polyclinics, whereas childbirth and immediate postnatal care occurs in hospitals (Al Maqbali, 2018). In 2008, the country's ministry of health introduced a model of antenatal care consisting of at least six visits for low-risk pregnancies (Al Maqbali, 2018; MOH, 2010). This model required implementation of standardized protocols to manage pregnancy and childbirth in all healthcare institutions. The protocol requires that all employees ensure that each woman registers at the nearest health institution and receives care from the same healthcare providers to enhance continuity of care. In order to facilitate continuity and quality of care, each pregnant woman receives a copy of “Maternal Health Record” during the first visit (MOH, 2016; WHO, 2018).

As a result of these and other improvements, over the year's tremendous progress has been achieved in controlling maternal mortality rate (MMR), which showed a dramatic decline from 37.5 deaths in 2002 to 13.4 deaths in 2014. However, despite these efforts, the MMR increased steadily from 17 in 2015 to 19 per 100,000 live births in 2019, indicating the need for in depth assessment of maternal care in Oman's main hospitals (MOH, 2015, 2019; WHO, 2015).

This study was therefore undertaken to evaluate the perspectives of pregnant women regarding the antenatal education services being provided in the selected health care settings in Oman. The study compared the existing antenatal education services with the national and international guidelines for antenatal education services. International and MoH Oman guidelines require, pregnant women to be provided adequate information to ensure safe pregnancy, delivery, postpartum care and new born care. However, there have been incidences (both personal communication and experience) as well as literature (Al-Abri et al., 2019) gaps between recommended antenatal education practices and actual education received by the pregnant women.

Literature Review

HealthCare professionals should provide holistic antenatal health care that goes beyond the provision of basic physical antenatal care but that which includes education about emotional wellbeing (NICE, 2019). a descriptive study by Al Malik and Mosleh (2017) in Jordan identified the learning needs for women during pregnancy as managing the danger signs of pregnancy, understanding about nutrition, understanding routine screening and laboratory investigations, understanding the importance of dietary supplementation and scheduling follow-up visits during pregnancy. These findings are comparable with Kovala et al.'s study (2016) in London, which found that sharing information about new-born safety; breastfeeding, pregnancy complications, new-born care, and emotional status were highly preferred by participants. The researchers also highlighted that pregnant women wanted information about decision-making, and the physical and psychological changes during pregnancy as well as information about nutrition for pregnant women and her foetus.

A study conducted by Heitmann et al. in 2016 among Norwegian pregnant women showed that women highly valued timely attention to their minor disorders in pregnancy. These findings implied that HCPs should emphasize the management of minor disorders in pregnancy during antenatal education sessions to empower pregnant women to seek timely attention.

An observational study conducted by Izudi et al. in Sudan during 2019 to assess the effect of health education on birth preparedness and complication readiness (BPCR) on the use of antenatal education services found that mothers who received health education on BPCR were more likely to deliver in a healthcare setting by a skilled birth attendant. In addition, the study found that antenatal education significantly increased the number of women who return for postnatal care visits (P < .004). Furthermore, the education significantly improved participants’ knowledge and their ability to recognize postpartum complications compared to those who did not receive antenatal education (P < .001). These findings confirmed that receiving appropriate health education positively enhances the use of available healthcare services and enhances positive outcomes for mother and new born.

A systematic analysis of the Global Burden of Disease Study by Kassebaum et al. (2014), reported that more than one-half of pregnancy-related deaths occur during the immediate postpartum period. Therefore, it is essential that ANC healthcare providers educate pregnant women during antenatal education sessions about postnatal care including identifying any abnormalities for themselves and their newborn. According to the WHO (2018), encouraging pregnant women to space their pregnancies will likely decrease MMR by 30% and the infant mortality rate by 10%. In support, Sempeera et al. (2016) recommended pregnant women should receive information during antenatal education sessions about family planning methods, possible side effects and resumption of contraception after birth. Education about newborn care is vital to be included during antenatal education sessions because while many babies are born healthy, unfortunately, several health issues shortly put the neonate at risk within the first few hours of life (Al-ageswari et al., 2019). In fact, the World Health Organization (WHO)/United Nation (2015) estimated that neonatal deaths account for 45% of under-5 years’ deaths, out of which one-third of these deaths occur in the first 24 hours of life, whereas three-quarter of the neonatal deaths takes place in the first seven days of birth. In order to minimize associated complications, the WHO (2014), insists that newborn care education should include different components such as breastfeeding, cord care, eye care, thermoregulation, immunization, and recognition of danger signs. Furthermore, a study by Nautiyal et al. (2021) reported that childbirth education programs have a significant positive effect on neonatal outcomes such as rate of prematurity, birth weight, Apgar score, and early initiation of breastfeeding. As evidence to show the importance of antenatal education in promoting positive newborn outcomes and preventing illness, a study conducted by Darmstadt et al. (2013) reported that providing antenatal counseling related to newborn care decreases newborn illness and death through breastfeeding, skin to skin, improving umbilical cord hygiene, and providing appropriate thermal care.

Purpose of the Study

The purpose of the study was to evaluate antenatal education service provision in Oman.

Objective of the Study

The study aimed to identify the gap between the current practices and the recommended guidelines to design responsive and cost-effective corrective strategies to improve the quality and quantity of antenatal education services in Oman. This study is different because it is the first study to systematically document the different “antenatal educational bundles” targeting the different stages of pregnancy, labor and birth, postpartum, and new born care. Most previous studies focus on “small segments” within the pregnancy/newborn continuum.

Methodology

Design

A qualitative inquiry was implemented through semi-structured in-depth interviews guided by open-ended questions (Table 1). The study was conducted between December 2020 and January 2021 using 4 key questions:

1. What specific education did you receive to prepare you for a safe pregnancy?

2. What specific education did you receive to prepare you for labor and birth?

3. What specific education did you receive about postpartum care?

4. What specific education did you receive to prepare for your newborn baby?

The study utilized a generic qualitative descriptive approach to evaluate the antenatal education services currently being provided at facilities in Oman. According to Neergaard et al. (2009), unlike other types of qualitative research approaches that study the phenomena of interest through the lens of only one single methodology, generic qualitative research combines several approaches and claims no particular methodological view point in understanding the phenomena of interest from the “who,” “what,” “where,” and “why” perspective. Generic qualitative research is one of the naturalistic research approaches that generate a deeper understanding of a phenomenon guided by four philosophical viewpoints: ontological, epistemological, axiological, and methodological perspectives (Sandelowski, 2010).

Table 1.

Key Questions for the Semistructured Interviews With Pregnant Women.

Question	Key questions	Suggested points for probes
1	What specific education did you receive to prepare you for a safe pregnancy?	Date and time of appointments The importance of folic acid Purpose of various screening tests such as CBC, US scan etc., Effects of smoking and alcohol, nutrition, exercise, travel, medication, etc. Minor discomforts during pregnancy such as nausea, vomiting, etc. Danger signs in pregnancy, like severe vomiting, headache, blurred vision, etc
2	What specific education did you receive to prepare you for labor and birth?	Expectation about labor Recognition signs of true labor Stages of labor Recommended pushing techniques during second stage of labor Pharmacological and non-pharmacological pain relive, Importance of 30 min of skin-to-skin contact, etc
3	What specific education did you receive about postpartum care?	Proper latching Minor breastfeeding problems, Psychological problems such as anxiety and postpartum blue, Postnatal complications such as excessive bleeding, etc Postnatal hygiene, exercise Family planning options
4	What specific education did you receive to prepare for your newborn baby?	Routine newborn care vaccination and screening Newborn complications such as newborn such as convulsions, etc
5	What specific methods are used to provide antenatal education?	Lecture, Demonstration, Re-demonstration, Group discussion, Social media/ apps, etc
6	What teaching aids are used to give you antenatal education?	Audio-visual, Printed materials (leaflets), Flashcards etc
7	What challenges did you face during antenatal education sessions?	Were all your questions answered, if not What went wrong? barriers or challenges that you encountered.

Study Settings

This study was conducted in 9 health facilities consisting of 7 primary health centers; 1 polyclinic and Outpatients ANC clinics of a tertiary hospital all located in Muscat Governorate. Participants were selected based on parity, age, level of education, job status, and their perceived ability to understand and share their experiences and opinions with the interviewer.

Sampling and Sample Size

A purposive nonprobability sampling technique was used and this technique enabled the researcher to carefully select the key informants who could provide rich information and insight about antenatal education services they received from the selected healthcare facilities in Oman.

A total of 13 women participated in the study, determined by the stage at which data saturation was reached (Etikan et al., 2016); which is the point when no new information was elicited from the women with additional interviews (Bradshaw et al., 2017).

Inclusion and Exclusion Criteria

Participants were women attending ANC at healthcare facilities; who completed 30 weeks of gestation and were willing to share their perspectives with the research team. The researchers excluded women who were mentally challenged, deaf, or dumb as documented in the maternal health card. These groups were excluded because of their inability to communicate effectively.

Ethical Consideration

As an ethical requirement, data generation began after obtaining permission and ethical approval. The researcher obtained written informed consent after explaining the study purpose and process to each participant prior to their participation in the study. To enhance the confidentiality and anonymity of the data, each participant was provided with a unique code number which was used throughout the data analysis and reporting phases. Each interview was conducted individually in a private room in the health facilities. To enhance data validity and triangulation, the interview guide was reviewed by experts in the field.

Data Collection Procedure

After the consent process, data was collected by using a semi-structured in-depth interview guided by an interview guide, which was hitherto reviewed by specialty experts. The interviews were conducted by the principal investigator (the MSN student) Ms. Maha AlDughaishi, under close supervision of instructors. The interview guide was developed in English and then translated into Arabic to improve participants’ understanding. The semistructured interview is the most appropriate method for in-depth exploration of participants ‘experiences as it allows the researcher to ask additional questions if new or interesting inquiry or insight developed during the interview (Young et al., 2018). All the interviews were digitally audio-recorded and transcribed verbatim to preserve the meaning units. All interviews conducted in Arabic were transcribed verbatim and then translated into English.

Statistical Analysis

The final data set comprised the verbatim transcription and field notes. The data was subjected to manual thematic analysis operationalized through the process of reflexive “immersion and crystallisation” (Borkan, 2021). Thematic analysis creates rich, trustworthy, sensitive, and insightful research findings and is useful for identifying, describing, organizing, analyzing, and reporting themes (Nowell et al., 2017). As Charmaz (2016) recommends, data collection and analysis occurred concurrently. This enabled the researcher to identify gaps and probe further resulting in deeper understanding, in addition to allowing more time for themes to emerge. Initial data analysis was conducted by Maha AlDughaishi. The initial findings were then subjected to a thorough review and validation process by the other two co-authors Vidya Seshan and Gerald Amandu Matua. These validation exercises resulted in the refinement of the study findings and recommendations.

Results

Sample Characteristics

A total of 13 women participated in the study. The pregnant women were aged between 23 and 39 years, with gestation periods ranging from 30 to 37 weeks and they had 1 to 6 children. In terms of education, all of them had either primary-, secondary-, or college-level education. In terms of employment, 9 of them were employed while 4 were housewives with no formal employment.

The antenatal education services reported fall under four thematic areas of pregnancy, labor and birth, postpartum care and newborn care, and summarize the key services pregnant women expected to receive from service providers to ensure positive outcomes for them and their babies (Table 2).

Table 2.

Summary of Themes, Categories, and Subthemes.

Themes	Theme description	Categories and ubthemes
1	Antenatal Education for Safe pregnancy	(1) Diet (2) Safe and tolerable exercises. (3) Coping with pregnancy symptoms. (4) Recognizing abnormalities and seeking medical advice. (5) Medication and dietary supplements. (6) Appointment, procedures, routine investigation, and vaccination.
2	Antenatal Education for Safe Labor and Birth	(1) Preparedness for labor and birth (2) Pain management in labor
3	Antenatal Education for Postpartum Care	(1) Routine postnatal care (2) Postpartum psychological education (3) Breastfeeding (4) Family planning
4	Antenatal Education related to New-born Care	(1) Routine New-born care (2) Recognition of danger signs in the new-born

Theme 1- Antenatal Education for Safe Pregnancy

The educational services related to pregnancy fall under six categories of Diet; Safe and tolerable exercises; Coping with pregnancy symptoms; Recognizing abnormalities and seeking medical advice; Medication and dietary supplements; and Appointment, procedures, routine investigation, and vaccination.

Diet

Under this category, two sub-themes emerged which are “Promoting healthy dietary habits” and “Health condition based dietary advice.”

In terms of promoting healthy dietary habits, the pregnant women reported receiving information about diet and nutrition during their pregnancy as expressed by these responses below:

…my weight was increasing rapidly and the doctor transferred me to a nutritionist. The nutritionist talked to me about nutrition and commitment to healthy eating (P.W#11)

In the early stages of pregnancy, they tell us some information, such as advice about food we need to eat[healthy] food, we need to avoid[food] which may harm the baby … (P.W#12)

In relation to the health condition-based dietary advice, the commonest topic healthcare providers focused on was advising about diabetes and anemia as shown in the narratives below:

During this pregnancy, I was diagnosed with it [diabetes]. The doctor was very cooperative and gave me brochures with foods that I could eat to help me reduce my blood sugar level (P.W #2)

During pregnancy, they give me a paper with instructions about diabetes, and another with meals and types of food that I can eat for breakfast, lunch, dinner and snacks (P.W#13)

Safe and Tolerable Exercises

Two of the 13 pregnant women reported receiving educational advice about physical activity:

They also give us a schedule of walking and when it is safe [to do] (P.W#8)

She explained to me about exercising at the beginning of my pregnancy. She advised me to walk for a quarter of an hour and not exhaust myself … (P.W#10)

However, 11 of the 13 participants denied receiving education regarding physical activity:

No one told me when I am supposed to start doing exercise and what kind of exercises are best for my condition? (PW#12)

This is my fourth pregnancy, but I don't remember that they talked to me about exercise … They only do routine tests … (PW#13)

Coping with Pregnancy Symptoms

Most participants reported receiving regular information about managing pregnancy symptoms:

They gave us education about morning sickness and methods that help to relieve morning sickness (P.W#8)

I remember they told me about acidity because I complained about it. So, they told me if I have acidity, I need to drink milk and have frequent meals (P.W#9)

Recognizing Abnormalities and Seeking Medical Advice

The pregnant women were provided general health education about complications such as bleeding and reduced foetal movement and encouraged to seek medical help as highlighted:

When I come to every appointment, they always ask me if there is bleeding, how does the baby move? The ask me and I answer them [healthcare providers] (P.W#10)

They told me from the seventh month if have symptoms like swelling in the foot, blurry eyes, severe headache, or anything else to go to the health centre directly (P.W#11)

Medication and Dietary Supplements

One of the key messages focused on educating pregnant women on the importance of taking folic acid and other prescribed medication such as iron supplements as reported below:

I remember they told me about folic-acid and that it must be taken daily (P.W#7)

The doctor told us about iron tablets. They asked us not to stop taking the medicine (P.W#9)

Appointments, Procedure, Investigation, and Vaccination

In terms of receiving detailed explanation about the indication for antenatal follow-up, procedures, and vaccination, 11 of the 13 participants denied receiving any such information:

… frankly i did not get all information, we just come for the visit, do the routine check-up and urine test, wait to be seen by doctors … or I come next visit to see results (PW#3).

Honestly, I did not get any information from the medical staff. When I came for the first time, … they informed me of my next visit to see the doctor without further explanation. On the next visit, the doctor did sonar for me and told me that everything was good … (PW#5)

Theme 2—Antenatal Education for Safe Labor and Birth

The antenatal education services related to labor and birth fall under two categories: “Preparedness for labour and birth” and “Pain management in labour.”

In terms of preparedness for labor, most participants stated that they did not receive any educational information from healthcare providers about preparing for labor or birth. They explained that whatever they knew was largely what they knew from their own personal research or previous experience or from networking with their relatives as highlighted below:

Nobody talked to me about labour … I’m now at 9 months and this is my first experience, all information I know from personal search and reading (PW #1).

Although I am in my ninth month of pregnancy and a first-time mother, they did not educate me in preparing for the childbirth. They have not even told me about the hospital where I may give birth! No one told me about any of this information (PW#5)

With regard to pain management in labor, none of the participants received education about how to cope with labor pain either with medication or by using natural remedies as described:

No one discussed this issue with me about how to decrease the pain in labour (PW#6)

In the [ANC] clinic, no one gave me the option of painkillers available …. (PW#7)

I came to know about injection for pain only in the labour room… (PW#3).

Theme 3—Antenatal Education for Postpartum Care

The education services related to postpartum care are classified under four categories: “Routine postnatal care”; “Postpartum psychological education”; “Breastfeeding” and “Family planning.”

In terms of Routine Postnatal Care, the findings show that healthcare providers did not generally provide postnatal health education during antenatal period as confirmed by the pregnant women:

No one has told me anything about the postpartum stage … (PW#2)

In my previous pregnancy, I gave birth by operation… they didn’t even tell me about the wound and how to care for it in the postpartum [period] (PW#11)

With regard to postpartum psychological education, the study participants complained of scanty information received from the attending healthcare providers during antenatal visits:

No one ever talked about the psychological status of the women, especially after delivery. Many pregnant women have symptoms of postpartum depression, and they do not know the cause of these symptoms. The main reason is the lack of the antenatal education regarding the psychological health of the mother after childbirth (PW#7)

With breastfeeding information, many participants reported not receiving sufficient education prior to delivery, however, they agreed some information was passed to them after childbirth:

Due to my lack of knowledge about breastfeeding, …my son did not breastfeed for two months. I was not very sure about the position of breastfeeding … Unfortunately, there is a great lack of education and awareness from the side of the medical staff …, (PW#7)

“They never gave us anything regarding the baby even about breastfeeding. They only asked me in my two weeks visit after the childbirth if I breastfeed my baby naturally or not” (PW#9)

Regarding family planning information, most participants reported not receiving such education during the antenatal period. However, some reported receiving leaflets with information about family planning after childbirth which they had to read by themselves without staff explanation:

As for birth spacing, they asked me to think of the proper way for me. ..[this] was during the two-week visit, [after birth] they did not give me much education (P.W#11)

They gave me leaflets to read and to choose one method during the visit after delivery… (PW#12)

Theme 4—Antenatal Education Related to New-Born Care

The health education provided to pregnant women relating to newborn care can be categorized as “Routine newborn care” and “Recognition of danger signs in the newborn” as explained further.

In terms of routine newborn Care, the pregnant women reported receiving no such information during their antenatal classes. To address this knowledge gap, the pregnant women resorted to learn about new-born care from previous experience, relatives or through self-directed learning:

“Unfortunately, they don't talk about babies during pregnancy … After delivery, they will write … the dates of the next vaccination, and we don't know what vaccine is given and for what?! No explanation at all, …” (PW#3).

No one has told me about baby care, neither during pregnancy nor after childbirth. Although, these topics are very important especially for [first time mothers]…  (PW#11).

.Like routine newborn care information, the study participants denied receiving any education about recognizing danger signs in new-born babies during their antenatal sessions as highlighted:

I can’t remember being told this information [recognition of danger signs] during pregnancy. …in the health centres, no one talks about this topic [ danger signs] (PW#8)

During this pregnancy, they never discuss topics related to [danger signs] in my child … (P.W#13).

Discussion

The discussions are presented under four thematic areas of pregnancy, labor and birth, postpartum care, and new-born care which the Ministry of Health, Oman recommends as best practice to ensure positive outcomes for both the expecting mother and her new-born baby.

Antenatal Education About Safe Pregnancy

The findings show while there is still room for further improvement, health care providers provided fairly adequate information on four areas of “promoting healthy dietary habits,’ “coping with pregnancy symptoms,” “recognition and management of medical conditions,” and “adherence to dietary supplements and medication.” These results conform to the Ministry of Health antenatal education standard guidelines for ensuring safe pregnancy (MOH, 2016). These findings are comparable to a Jordanian study which highlighted that key educational messages should address women's’ needs for nutrition, medication, supplementation, screening as well as identification and management of danger signs during pregnancy (Al Malik & Mosleh, 2017).

However, the study also revealed significant gaps by healthcare providers in providing adequate information to address the health education needs for two key areas of “physical activity in pregnancy” and “antenatal appointments, routine investigations and screening services.” These findings contradict WHO's recommendation, that “pregnant women should be counseled about healthy eating and keeping physically active during pregnancy to prevent excessive weight gain during pregnancy” (WHO, 2016). In terms of explaining various routine services, most pregnant women stated they did not receive an explanation for most tests and procedures. These findings indicate inconsistencies in providing antenatal education services related to routine procedures and their indications. These findings fall short of the National Institute for Health and Care Excellence (NICE) guidelines (2019) that require consistent information to be provided during each antenatal visit information about procedures and screening tests and to ensure the pregnant woman understands all the information to facilitate her decision-making. Similarly, this finding is inconsistent with the MOH, Oman (2016) guideline which requires appropriate information about the timing, and numbers of the antenatal visit should be discussed with all pregnant women including the type of care. These study findings thus indicate inadequate implementation and partial adherence to these important guidelines.

Antenatal Education About Labor and Birth

The findings demonstrate that pregnant women are briefed with inadequate information about labor and birth during the antenatal period. Yet, according to Nolan (2020), antenatal education provides an ideal opportunity to prepare pregnant women for labor and birth. Adequate education helps to increase the woman's self-confidence and helps her to learn the skills to reduce and respond to a stressful situation of childbirth. These findings are similar to a recent study that reported that care providers in an Ethiopian study were unable to provide pregnant women with adequate information to ready them for childbirth (Woldeselassie & Modiba, 2020). These findings further indicate inadequate or partial adherence to important MOH guidelines.

A second major area of concern was the fact that all participants, both first-time mothers and multiparous women reported that they did not receive any information about pain management in labor, whether by using pharmacological or non-pharmacological means. In addition, pregnant women were not properly educated about the stages of labor or how to prepare for childbirth. A similar failure by healthcare workers to provide important information about labor and birth was also observed in a study conducted in Nigeria. This study noted that 30% of women did not receive any information during antenatal consultation about techniques for pain control during labor (Agnes et al., 2015). Such process failures negatively affect the quality of maternity care because as demonstrated by researchers Heim et al. (2019) in Brazil, pregnant women are usually eager to receive information and guidance on pain relief in labor. Such pertinent information that is best given during antenatal care helps women to gain confidence in their ability to manage their pain during the labor process (MOH, 2016; NICE, 2019; WHO, 2016).

Antenatal Education About Postpartum Care

The findings indicate that most pregnant women did not receive adequate education about postpartum care during the antenatal period. These findings are consistent with the results of a study conducted by Dol et al. (2019) who showed that in many Low- and Middle-income countries such as Oman, the majority of postnatal and new-born education focus on breastfeeding. Similarly, a study conducted in India showed that more than half of the respondents did not receive any education about postpartum care and if they received it was about breastfeeding and it did not include other important aspects of care (Bhatia et al., 2019). This lack of focus on antenatal education has a significant impact because prenatal education program decreases negative conditions such as postpartum depression (PPD) and increase maternal confidence to successfully go through the process of labor, childbirth, and childcare (Shimpuku et al., 2021).

As a best practice, apart from breastfeeding information, education about the postnatal period should include information about the mother's psychological wellbeing, hygiene, nutrition among others. In the present study, scanty antenatal education was provided for the psychological, hygiene, and nutritional needs of pregnant women, yet psychological care is particularly vital for the study population. The lack of mental health care has serious health consequences because according to Ayoub et al. (2020), PPD is a major public health problem that is likely to affect at least 1 in 5 mothers among Arab women. 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). Early detection of postnatal depression improves mother–child interaction and relationship, helps the mother to adjust to motherhood and prevents the worsening of depressive symptoms (Al Hinai & Al Hinai, 2014). This finding calls for more attention to the psychological wellbeing of women during antenatal sessions.

Antenatal Education About New-Born Care

The results of this study with respect to newborn education were contrary to what was stipulated by the WHO (2016), suggesting that there is a need to establish an educational program based on the best practices to help pregnant women gain the skills and knowledge regarding newborn care. Similarly, these findings are similar to the results of a study conducted by Ayiasi et al. (2013), who observed that antenatally, pregnant women in some areas in Uganda were not adequately prepared to provide recommended newborn care, thereby resulting in negative health outcomes for mother or the baby. The present findings demonstrated a lack of education about new-born care provided by healthcare providers as evidenced by the unanimous responses of all participants that they did not receive such education. This finding is critical because providing education for pregnant women and their family about newborn care helps them to recognize the danger signs of newborn illness and to seek immediate healthcare (Aguiar & Jennings, 2015). Moreover, a recent Turkish clinical trial revealed that antenatal education with breastfeeding information increases maternal breastfeeding self-efficacy and breastfeeding success in the postpartum period, hence positive outcomes for the baby (Öztürk et al., 2022).

This inadequate provision of antenatal education has serious implications because as demonstrated by Tripathi and Singh (2013), proper antenatal care provided to the women during pregnancy increases the potential to reduce neonatal mortality and morbidity. In the present study, because the pregnant women were not receiving adequate information, most of them resorted to resources such as the internet to obtain information about their doubts, which caused some of them stress and confusion. This may have negative consequences since not all information on the internet has been medically verified or is presented in an understandable way. 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 websites caused confusion among pregnant women and overall resulted in them feeling dissatisfied with the antenatal education services they received.

Strengths and Limitations

The study's major strength is the first of its kind to evaluate antenatal education services from the perspective of pregnant women in Oman. Moreover, the explicit and precise presentation of the study findings supported with direct quotes further enhanced the transferability and quality of the findings (Eldh, Årestedt & Berterö, 2019).

The researcher had challenges in the early part of the study 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 helped the researcher to control and be constantly aware of preconceptions and minimize their effect on the interpretation of the data (Corbin & Strauss, 2015). Furthermore, another limitation of this study is that data was collected from only one region of Oman, which might limit the generalizability of the study findings.

Implications for Practice

pregnant women trust and value the information provided by healthcare providers. Therefore, healthcare professionals should provide adequate, consistent, and comprehensive antenatal education for all pregnant women in every antenatal visit based on recommended guidelines to enable them to make an informed decision. The healthcare providers should be informed about their roles and responsibilities related to antenatal education services provided to pregnant women.

Recommendation for Future Research

1. A nationwide study to gain a deeper understanding of the provision of current antenatal education services in entire Oman.

2. Developing and validating a tool to assess the quality of antenatal education services provided in the Middle Eastern region.

3. Investigation on how innovative antenatal education tools such as audio-visual aids, booklets, and group discussions impact maternal and fetal outcomes.

Conclusion

The present study is the first of its kind to provide baseline data regarding the current antenatal education services in Oman from the perspective of pregnant women. The study findings will help to develop strategies to improve maternal and neonatal outcomes in the Sultanate of Oman. The findings of this study, especially the complaints of inadequate antenatal education further underscore the need to follow the international standards established by the WHO (Geneva), the NICE (UK), International Federation of Gynecology and Obstetrics (Canada) and the American College of Obstetrics and Gynecology (USA) and Omani Ministry of Health national guidelines which emphasize the provision of comprehensive antenatal education at every visit.

In essence, the researchers concluded that the antenatal education services provided to pregnant women were not comprehensive and consistent enough and were below national and international standards. This means the education services provided did not address all the educational needs to ensure safety and best outcomes for both the mother and her baby during pregnancy, labor, birth, as well as during the postpartum period for effective new-born care.