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

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.

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:

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

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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.

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).

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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)

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)

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)

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)

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)

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).

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).

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)

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)

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).

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.

Recommendation for Future Research