Clinic facilities and staff communication skills influence antenatal care attendance in Saudi Arabia

Background The World Health Organisation recommends women have at least 4 antenatal care visits (ANC) during a low risk pregnancy. However, in Saudi Arabia, many mothers miss these appointments placing their health and that of their baby at risk. Limited research exploring why this is happening usually focuses on low maternal education or personal barriers such as lack of transport. The aim of the current research was therefore to understand what factors at the individual and healthcare systems level were associated with missing antenatal care in Saudi Arabia. Methods Pregnant women in their third trimester completed a questionnaire examining their care attendance alongside barriers to attending care. These included maternal demographic background, health literacy, personal barriers, health care system factors and staff communication). Results Over half of women had missed at least one appointment and a third had delayed their care. Mothers who had missed appointments blamed health care system factors such as poor clinic facilities and waiting times. Attending care was not associated with maternal education or literacy. However perceptions of staff communication, consistency and care were lower amongst those who had missed at least one appointment. Conclusions Although in previous research health professionals believe it is maternal education that leads to poor attendance, in our sample at least, is in fact perceptions staff communication that affect attendance. Making changes level e.g. through adapting clinic and investing


Abstract
Background The World Health Organisation recommends women have at least 4 antenatal care visits (ANC) during a low risk pregnancy. However, in Saudi Arabia, many mothers miss these appointments placing their health and that of their baby at risk. Limited research exploring why this is happening usually focuses on low maternal education or personal barriers such as lack of transport. The aim of the current research was therefore to understand what factors at the individual and healthcare systems level were associated with missing antenatal care in Saudi Arabia.
Methods Pregnant women in their third trimester completed a questionnaire examining their care attendance alongside barriers to attending care. These included maternal demographic background, health literacy, personal barriers, health care system factors and staff communication).
Results Over half of women had missed at least one appointment and a third had delayed their care.
Mothers who had missed appointments blamed health care system factors such as poor clinic facilities and waiting times. Attending care was not associated with maternal education or literacy.
However perceptions of staff communication, consistency and care were lower amongst those who had missed at least one appointment.
Conclusions Although in previous research health professionals believe it is maternal education that leads to poor attendance, in our sample at least, it is in fact perceptions of staff communication that affect attendance. Making changes at the health care level e.g. through adapting clinic times and investing in staff training may increase antenatal care attendance in Saudi Arabia.

Background
Antenatal care (ANC) is a vital component of reducing maternal and infant morbidity and mortality during pregnancy and birth, by treating and monitoring complications 1 . Globally, 500,000 women die as a result of pregnancy and birth complications 2 . The World Health Organisation recommends that women have at least four ANC appointments, with additional appointments if they are experiencing any complications. The first appointment should occur within the first four months of pregnancy 3 .
Globally however, many women are not offered, or do not attend this level of care 4 with less than two thirds having at least four appointments 5 .These figures are much lower in developing regions, with only 68% ever attending care, and just 39% meeting the target of four or more appointments 6 Antenatal care is available in Saudi Arabia, but low attendance is a significant issue. Although almost all women attend one appointment 7 , there is a particular issue with women not booking follow up appointments or missing booked appointments. One study estimated there to be an average nonattendance rate of 30% in public hospitals 8 . This is not because women in Saudi Arabia are having uncomplicated pregnancies and births; Saudi Arabia has a maternal death rate of 24 in 100,000 and a still birth rate of 12.9%, highest in rural and poorer regions 9 . Understanding why women are not attending ANC in Saudi Arabia is a government priority but research exploring this issue is sparse. For example, one interview based study identified a perceived lack of respectful communication from staff and clinics that were not well equipped 10 Conversely, other research in the area has simply focussed on exploring whether mothers value care rather than barriers to attendance. Notably, each study examining this issue concluded that mothers did value care, suggesting further barriers are likely to be preventing attendance [11][12][13] In a previous study we conducted qualitative interviews with pregnant and mothers who had missed at least one ANC appointment and health professionals working in ANC to understand perceptions on why appointments were missed 14 . Although both groups identified personal barriers such as a lack of transport, attitudes to importance of care, and antenatal care facilities such as poor accessibility, mothers and professionals differed in their perceptions of other factors. Whilst health professionals believed maternal low literacy and education affected their attendance, mothers described negative staff attitudes and disrespectful communication as a reason for non-attendance.
The aim of this study was to examine, in a quantitative study, whether each of these factors is associated with maternal non or delayed ANC attendance in Saudi Arabia. Specifically we were particularly interested in understanding whether health professionals views of maternal education and literacy affected attendance or whether staff attitudes and communication may instead be affecting uptake of this important care.

Participants
Pregnant women aged 18+ in their third trimester of pregnancy (28+ weeks) participated in the study. This allowed sufficient time for missed or delayed care to have occurred. Exclusion criteria were major health complications (e.g. diabetic, hypertension, thyroid dysfunction, previous caesarean section, and any other chronic disease) as this would affect both the number of specialist appointments a woman would be required to have and a lack of ability to consent to take part. Ethical permission for the study was gained from a University Research Ethics Committee alongside the Research Ethics Committee in the Saudi Ministry of Health. All aspects of the Declaration of Helsinki 1964 were adhered to.

Setting
The study was conducted at three medical facilities in Saudi Arabia; two based in a city and one in a rural location. These three facilities encompassed the largest medical organisation in Saudi Arabia alongside smaller hospitals to ensure wider participation by women from different demographic backgrounds.

Procedure
The questionnaire was first piloted with six pregnant women to check its accuracy and any difficulties in completion. One participant experienced literacy difficulties completing the questionnaire, which reinforced the need for the researcher to be present to support mothers to complete the tool if necessary.
Data collection for the full study took place from July -September 2017. Permission to collect data was first taken from the head nurses in the clinic and from hospital administration in each hospital.
Data collection then focussed on the 28-week clinic appointment where women are offered a detailed ultrasound scan. Hospital records in Saudi Arabia has shown that this appointment is the best attended, even amongst women who have missed previous appointments. Many women who miss appointments attend this appointment but then attend no more until the birth 23 .
The nurses at each clinic provided a list of potential participants who met the inclusion criteria and the researcher approached each with a study information sheet, giving them time either to read the information or to have it verbally explained. Women who were interested could ask the researcher further questions and if she wished to complete the study, signed the consent form. She was then given a copy of the questionnaire to complete. If the woman needed support in completing the questionnaire, the researcher would verbally ask each question in private room. The researcher was available throughout each clinic time for any questions the participants or the nurses might have.

Data analysis
Data was analysed using SPSS version 22. Each of the pre-existing tools embedded in the questionnaire were scored as per instructions. Although the maternal barriers to attending care was based on tools used in previous research, as further items had been added and the reliability of the initial questions not clear, a factor analysis was conducted on these items. Factor analysis statistically groups items with similar response patterns together, allowing factors (themes) to be constructed.
To do this, a principal component analysis was conducted that was subject to varimax rotation. The regression scores were saved to use in any parametric tests. However, for ease of understanding, the raw scores were also added up for each of the items that grouped on each factor and used to illustrate the range and mean scores for each factor. An overall barriers score was also computed for each woman by adding up her score on each item. A higher score indicated greater barriers.
For attendance, participants were split into yes/no for previous attendance and yes versus no / unsure for planned future attendance. For timing of first appointment, in Saudi Arabia women are advised to have their first care appointment within the first 8 weeks 25 . Therefore women were split into 'on time' / 'late' for attendance.
The association between attendance / non-attendance for previous and future appointments, and timing of first appointment were explored separately for each of the scales used in the questionnaire.
Depending on the data type, either chi square tests of association were used to explore association between attendance and influences, or t tests to explore differences in influences for attendance / non-attendance. The association between maternal demographic background and attendance was also explored to ensure that where relevant the effect of demographic background could be controlled for.

Results
Two hundred forty-two pregnant women completed the questionnaire.

Maternal demographic background and ANC attendance
A series of chi square calculations were performed to explore the association between maternal demographic background and attendance. No significant association between age group, education group, marital status location, parity, or income and attending / not attending all appointments was found. For future intention to attend women were grouped into planning to attend all appointments and unsure/no. Again, no significant associations were found between demographic background and planned attendance. No significant association was found between demographic background and timing of first antenatal care attendance.

Personal barriers to attending appointments
The mean score and range of responses was calculated for overall barriers score and sub theme scores (table 3). Personal barriers received the highest score, and a perception of antenatal care not being important the lowest. The percentage of women agreeing with each individual item is also shown in table one. This shows that although a sub group of women identified with each personal barriers, the highest agreement was for mothers choosing to attend private care instead, followed by a working commitments, a lack of transport, a perception care was not important and poor clinic waiting times.
A series of t tests were performed to explore any differences in barriers based on attendance. For future appointments, a significant difference was found for 'lack of time' [ t (111) = -3.085 p =.003].
Women who were unsure whether they would attend all future appointments scored significantly more highly. No, further significant differences were seen for any other sub theme. A further series of t tests examined the difference in barriers between those who started ANC on time or late. No significant differences were found.

Staff attitudes and communication
The questionnaire was scored to give three scales: Information (perception of quality of information given), Continuity (how consistent staff were in messaging), and Care (how caring staff were perceived to be). The mean score for Information was 21.77 (SD: 4.64) with a range from 8-30. The mean score for Continuity was 3.65 (SD:.902) with a range from 1-5. The mean score for Care was 7.20 (SD: 1.67) with a range from 2-10. A higher score implied a more positive perception.
T tests were used to explore differences in the three factors based on attendance. For missing appointments, significant differences were found for

Discussion
This study explored the association between potential factors that have previously been identified by mothers and health professionals as being associated with missing or delaying antenatal care appointments in Saudi Arabia. These factors included a broad range of influences including maternal health care literacy, personal barriers and healthcare system factors including staff communication, reflecting findings in other regions 26,27 . Potentially, improving these factors could increase maternal antenatal care attendance and the findings will be useful for those working in maternal health care and policy.
Overall, the findings showed that around half of Saudi mothers had already missed one or more antenatal care appointments by the time they were 28 weeks pregnant, with only two thirds having started their care on time. A further 15% stated they weren't sure if they would attend all appointments in future, which is likely to be an underestimation. Given over half had already missed appointments, it is likely that the proportion of women who will go on to miss appointments is much higher. It is also likely that some women will have stated they will attend future appointments due to wishing to give the 'correct' answer, or may not have envisaged barriers, which will reduce their attendance.
In terms of what factors were identified as affecting care attendance, unlike health professional perceptions in previous research 14 , the maternal demographic and literacy background was not strongly associated with attendance. No significant association was found between attendance and education, location or income at all. This is in contrast to previous research which has identified lower education and income as a barrier to attendance 28,29 , although not every study has been conclusive 30 .
Likewise, no significant association was found in this study between health literacy and missing appointments. This is in contrast to much of the literature that identified that low health literacy during pregnancy as a reason for missing appointments 26,31 . However, delaying care was associated with a lower literacy level, which has been extensively identified in review papers as a barrier to timely care attendance 32 . Potentially it is not that mothers do not perceive care as important, but do not recognise they are pregnant, or do not know when care should begin. Once they attend, in this sample at least, they are not more likely to miss or plan to miss appointments.
In terms of health literacy, it is possible that mothers may not wish to admit that they do not have health literacy skills. The measurement tool is not a test of whether they can demonstrate health literacy, but a measure of whether they believe they have good health literacy. Mothers may feel embarrassed or apprehensive admitting that they lack the skills 33 . However, a wide range of scores was seen across the participants. Potential scores on the tool range from 13-65, and mothers presented with scores ranging from 13-65. Three illiterate women were supported to fill the questionnaire.
Importantly for professionals and policy makers, maternal attendance was associated with a number of factors that could be adapted to potentially increase attendance levels. Firstly, to some extent, maternal beliefs around the importance of care affected attendance. In the health beliefs questionnaire, mothers who had missed appointments had lower scores for attitudes to general health and towards perceived benefits of antenatal care. This supports previous studies which also found that women who missed appointments identified their pregnancy as a normal and going well, rather than something where health care appointments were important 34 . However, amongst women who had already missed appointments, there was no association between timing or care or planned attendance and their beliefs around whether care was important.
A key question for professional and policy makers is how some women's perceptions of the importance of their health and care during pregnancy can be increased. Any intervention must be culturally relevant. Saudi Arabia has a collectivist community, where women learn from and are influenced by those around them, particularly women in their families. Decision making, including in healthcare is not the sole decision of the individual, but part of a wider shared decision amongst the family 35. If those around her tell a woman that pregnancy is 'normal', she may be less likely to seek care.
Notably, perceived susceptibility / severity of potential pregnancy complications was not associated with attendance. In one study in Ethiopia, women who did perceive potential complications to be more severe were more likely to attend 36 . However, a number of studies has shown that fear does not necessarily lead to positive health behaviours 37 . Fear can lead to individuals avoiding thinking about their health issue rather than tackling it, which is one reason why fear based health promotion campaigns often do not work 38 . It is possible that women are worried about their health in pregnancy but this does not affect attendance; some attend as they are highly concerned, but others will avoid appointments.
In terms of specific reasons why women who had missed appointments did not attend, each of the themes identified in our previous qualitative research 14 were identified as barriers to attending care within the sample. Women stated they didn't attend due to personal barriers such as transport, a lack of time, clinic-based factors and a belief that care was not important (as pregnancy was just a normal occurrence). In terms of relation with other attendance factors, only a perceived lack of time was associated with not being sure whether they would attend all future appointments.
Over a quarter of women stated that they did not attend appointments due to believing pregnancy was just a normal event so no additional care was needed. It is possible that those having an easier pregnancy do not attend. We know from previous research in Sudan that women who have previous pregnancies without complications can feel more confident during pregnancy and feel no need to attend regularly 39 . Limited research in other countries like in Ghana and Saudi Arabia has shown that education particularly in trying to change socio-cultural beliefs around the factors that affect pregnancy complications and the need for regular care can increase attendance 40 , For example, when mothers believe care improves the outcomes for their baby, they are more likely to attend 27,41 .
Accessibility to ANC was another factor discouraging women to attend. Around a quarter had missed appointments due to lack of transportation. In Saudi many women rely on a male guardian for any travel which will exacerbate this 42 . This is a common barrier to care attendance across the Middle East and Africa 43,44 . Notably, however, in contrast to our previous study 14 , family influences were not identified as a strong influence.
A lack of time was also identified as a barrier by a quarter of participants and predicted attendance at future appointments. Time has been identified as a critical factor in a systematic review of studies across Bangladesh, Benin and Cambodia 27 . Organisation of clinic times means that women can need a whole day for an appointment due to the long clinic wait-time. Women will need time away from their job or family, potentially losing wages or needing to find alternate care for their other children.
Indeed, over a quarter of women in this study stated that working commitments prevented them from attending.
Perhaps one of the most important findings in this study however was the strong association between perceived staff communication and care attendance. Mothers who had missed care appointments rated staff communication poorer across all three elements of information, consistency and care.
Perceptions of care was also associated with delaying the first appointment. This finding echoes our previous qualitative study 14 , alongside findings in South Africa 9 and across southern Tanzania, Cambodia, Uganda and India 27 .
For example, research has highlighted that perceived staff rudeness, neglect, disrespect and poor care prevented women from pursuing antenatal care 45 . In one study negative staff communication were even linked to poorer pregnancy outcomes, via women not attending appointments 46 .
Our findings here identify that attendance is linked to both practical information (Information and Consistency) and emotional support (Care) highlighting the value of both these elements for Saudi women. This reflects findings in Oman when pregnant women specifically criticised a focus on practical check ups rather than emotional care and communication of information, leaving women feeling ignored. Mothers wanted reassurance 41 . In other research in Iran, mothers reported feeling like they were not given enough information about what is happening to them, or enough to enable them to make informed decisions, feeling that they were ignored as an individual 47 . Conversely, we know where women feel practically and emotionally supported their attendance and birth outcomes are improved 46 .
It is likely that directly or not, health professional beliefs that maternal care attendance is affected primarily by their education and literacy 14 are affecting this. These findings identify that in this study at least, attendance is not driven by education or literacy (apart for timing of first appointment) yet if health professionals believe this, they may be directly or indirectly conveying this to mothers in their words or actions. Further emphasis is needed on providing women centred, supportive care to all women in Saudi Arabia.
Finally, it is significant that almost half stated they had missed an appointment because they chose to follow up with a private clinic instead. Private clinics have been shown to have shorter waiting times, and appointments available at a variety of times-of course appealing to those who are worried about fitting in appointments around their job, alongside an enhanced standard of care 48 . In Oman for instance, a recent study highlighted that Omani pregnant women often preferred to follow-up after their first initial booking visit with private antenatal care to prevent long waiting time in an unsuitable environment, and a perception that they would receive more in depth care and attention 41 .
The research does have its limitations. As with almost every research study reaching those in the most deprived circumstances is a challenge. Although mothers from a variety of different educational and income groups took part, the sample was weighted towards those with a higher education level.
Linked to this, exploring the experiences of mothers who miss antenatal care appointments is a challenge as by its nature they will be less likely to be attending any care appointments to participate in the research. This was reduced by using the most well visited appointment for recruitment, but we know that some women who avoid the care system altogether will not have been offered opportunity to participate 49 . However, even from this appointment alone, half of participants had already missed one appointment, with a third having delayed their care.
It is also possible that participants felt that they had to give the 'correct' answer as they were in a care facility and the researcher had a health professional background. However steps were taken to acknowledge and mitigate the bias this may have brought including participants who were able to complete the questionnaire alone doing so in private and anonymously, sealing their response in an envelope. In addition, a wide variety of responses was seen; a sub section of women at least was confident enough to criticise the care they received.

Discussion
Our findings provide an important insight into the factors, which affect ANC in Saudi Arabia. They predominantly focus on factors that could be modified by health professionals and policy makers e.g.
clinic times, facilities and staff communication skills and those with the power to make such changes must be aware of this. It is important that clinicians do not continue to believe that a lack of care attendance is driven by poor maternal education and literacy. Although this may be the case for the most deprived women (who likely did not take part in this study) for this group of Saudi women health care system factors are driving their attendance, potentially putting their health and that of their baby at risk.

Declarations abbreviations
writing support and critical revisions. All authors have read and approved the manuscript.