Analysis of antenatal care service delivery in low health coverage areas in Benin

¹Senghor University, International Public Health, Alexandria, Egypt

^&Corresponding author
Nehemie Phycien, Senghor University, International Public Health, Alexandria, Egypt

Introduction    

Pregnancy is a natural process that proceeds without complications for many women. Typically lasting around nine months, it spans the period from conception to the birth of the newborn. As the fetus develops, various physiological symptoms progressively emerge in the pregnant woman [1]. Although advances in modern medicine have significantly reduced the risks associated with pregnancy [2], complications such as molar pregnancies, spontaneous miscarriages, ectopic pregnancies, and preeclampsia still occur [3,4]. When not properly managed, these complications can lead to the death of the mother and/or the newborn [1].

Globally, one woman dies every two minutes due to complications related to pregnancy and childbirth [5]. Despite being a natural and hopeful life event, pregnancy still endangers millions of women worldwide because of inadequate access to respectful and quality maternal healthcare [6,7]. The United Nations report "Trends in Maternal Mortality" underscores a concerning lack of progress, noting that maternal deaths have increased or remained stagnant across multiple global regions [5,8]. Effective antenatal care (ANC) contributes substantially to the prevention of maternal deaths through timely screening, diagnosis, and intervention [9]. According to global estimates, only 64% of pregnant women receive the minimum of four antenatal care visits, as recommended by international guidelines [8].

In Benin, the maternal mortality ratio stands at 391 deaths per 100,000 live births over the past seven years [10], still far from achieving Sustainable Development Goal 3 (SDG 3), which aims to reduce global maternal mortality to fewer than 70 deaths per 100,000 live births by 2030 [6]. According to the Demographic and Health Survey V (DHS-V), only 52% of pregnant women in Benin attended four ANC visits [11]. Moreover, attending ANC visits alone is not sufficient; these visits must also meet quality standards.

The objective of this study was to analyze the antenatal care (ANC) service delivery in the Ouidah-Kpomassè-Tori Bossito (OKT) health district in 2023, a region characterized by low health coverage.

Methods     

Study design: this was a qualitative study in which health facilities (HF) were selected based on purposive sampling. The study was conducted from May to September 2023.

Settings: the study was conducted in southern Benin, specifically in the Atlantique Department, which is organized into health districts [12]. Six HF were selected from the OKT health district, with two centers chosen from each commune; one located in an urban area and the other in a rural setting.

Participants: the study population consisted of two distinct groups: pregnant/breastfeeding women and antenatal care service providers. All pregnant and breastfeeding women who had received antenatal care at the selected HF within the twelve previous months, who were present on the day of the visit, and who provided informed consent to participate were included in the study. Health care providers (HCP) involved in antenatal care who were available at the data collection's time and consented to participate were also included. Women who were present during data collection but had medical conditions or physical disabilities (such as mutism or deafness) were excluded from the study.

Sampling method: a non-probability convenience sampling method was used, based on predefined inclusion criteria, and guided by the principle of theoretical saturation. Focus group discussions were conducted with pregnant and breastfeeding women; semi-structured interviews were held with antenatal care providers. Following authorization from the Training and Health Research authorities, local administrative authorities, including the Departmental Head and District Health Officers, were contacted and granted access to the selected HF. Focus group discussions were conducted within the HF, in different spaces from HCP and other influential individuals, in order to minimize information bias. After gathering women who had come for vaccinations or routine consultations, the study objectives were clearly explained to them. Each group consisted of approximately 10 women. The discussions were guided by a set of open-ended questions, allowing each participant the freedom to speak about her personal experiences. Efforts were made to balance speaking time across participants. Each session lasted approximately 90 minutes on average. With the support of a local, independent translator, women felt comfortable sharing their experiences related to antenatal care. Discussions were concluded once the key questions had been addressed.

Individual interviews were conducted with HCP. After receiving the necessary permissions and identifying eligible providers, they were approached to confirm their willingness to participate. Semi-structured interviews took place within the HF premises, in private settings, with those who consented and were available. Each interview lasted approximately 30 to 45 minutes. Structured interview guides ensured consistency across sessions. Recordings were transcribed verbatim and coded for analytical processing.

Study themes: the main themes of the study focused on accessibility, analyzed through three dimensions: geographic, financial, sociocultural, and service adequacy. To assess accessibility, participants were asked about modes of transportation, travel time to HF, waiting time at the facility, the language used during consultations, and the availability of services. Service adequacy was evaluated based on the World Health Organization (WHO) recommendations for antenatal care [13,14]. All WHO-recommended interventions listed in the ANC guideline checklist were reviewed with HCP and, for selected aspects, with pregnant women as well. These included, among others: the prescription of iron-folic acid supplements, tetanus vaccination, HIV and syphilis screening, screening for gestational diabetes, as well as counseling on healthy and balanced nutrition.

Women were also asked about their pregnancy, the perceived importance of antenatal care, the availability of services, and their level of satisfaction with the care provided. Each of the above sections consisted of four to five questions. A section was scored as "good" if at least two responses were provided and "poor" if fewer than two responses were given.

Data analysis: a thematic analysis was conducted following the focus group discussions and semi-structured interviews. The first phase of the analysis involved data preparation. At this stage, all audio recordings, anonymized and identified only by sequential numbers according to the chronological order of the interviews, were systematically translated and transcribed verbatim to ensure maximum fidelity to participants' statements.

An initial exploratory reading of the data corpus was conducted to gain a general understanding of the content [15]. This pre-analysis phase was followed by the identification and notation of the emerging themes. These themes were then grouped by similarity, prioritized based on their frequency and analytical relevance, and organized hierarchically. A preliminary coding process was applied using the central themes identified from the interviews, forming the foundation for subsequent thematic categorization. The second one focused on identifying similarities across different interviews to allow themes to emerge inductively. A coding grid developed in Microsoft Excel, along with NVivo 14 software, was used to empirically analyze the data.

Ethical considerations: health researchers authorization for this study was granted by the Ministry of Health of the Republic of Benin through the direction of research. The reference number is: 3115/MD/DC/SGM/DFRS/SRS/SA issued on July 25^th, 2023. Prior to data collection, all participants provided both oral and written informed consent in accordance with ethical research standards. To ensure confidentiality, respondents were assigned identification codes and remained anonymous throughout the study.

Results     

A total of eighty (80) individuals participated in the study, including 10 antenatal care providers and 70 women. The focus groups were diverse, comprising women from various backgrounds and age groups, including both adolescents and adults.

Description of HCP: the average age of the providers was 46 years, and all were adult women. Regarding professional roles, 99% were midwives and 1% were nurses. In terms of ethnicity, 40% identified as Fon. As for religious affiliation, 70% of providers were Catholic. Marital status revealed that 70% were married and 30% were in common-law relationships. All providers had attained the Brevet d'études du Premier Cycle (equivalent to lower secondary school diploma). On average, providers had 22 years of professional experience at the national level. All participants reported having received updated training in maternal health during the study's year (2023).

Accessibility of antenatal care services: women living near the HF reported that they walk a maximum of 15 minutes to reach the facility. In contrast, others reported having to walk between 1.5 and 2 hours. One participant explained: "the center is accessible, but not for everyone. For example, if I decide to walk, it takes me 1.5 to 2 hours to get there. So, I must take a motorcycle taxi (Zem) which costs between 600 and 800 CFA francs (approximately €1 to €1.50)".

Health care providers (HCP) also confirmed that "there are villages so far from the HF, even just transportation is too expensive for the women". According to participants, the HF distance from the villages was not the only issue, but essential services such as laboratory testing and ultrasound were not available in some facilities. In these cases, women had to travel to urban areas, which increased transportation costs. One woman shared: "there's ultrasound at the facility, but sometimes we are referred to private HF for certain tests or medications".

Regarding the ANC cost, some women considered it reasonable, while others found it unaffordable. The ANC fees ranged from 500 to 2,500 CFA francs (€1-€3), with initial visits being more expensive due to required tests, prescriptions, and consultation cost. As expressed by some participants: "the consultation cost is affordable, but the screening and medications are not".

Another woman noted: "healthcare is expensive here. Services we used to pay 200 francs now cost 500 francs. This really needs to be reviewed". Noted that the mentioned medications here included pregnancy-related supplements and antibiotics when needed.

According to one provider, the ANC cost remains a major barrier for women with limited access financially: "when we ask them why they don't attend ANC, they admit it's due to lack of money. A woman might come with only 1,000 francs. If she has to pay 500-700 francs for the consultation, the remaining 300 francs are insufficient to get medications". It was also noticed that the ANC cost and lab tests were higher in urban facilities compared to rural facilities, leading to more complaints among urban women than their rural homologous.

In general, ANC was conducted in the local dialect, and there were no significant language barriers. Women did not receive home visits, but according to some providers, community health relays maintained contact with outlying pregnant women through phone calls to follow up. As one provider explained: "we are in a village setting, a man cannot just go visiting a pregnant woman at home, her husband might attribute to him the pregnancy". Somewhere else, women admitted not reaching out to ANC during early pregnancy, though they did not elaborate. One said: "at the beginning, I didn't come for the ANC, but after the first three months I came regularly". Another noticed: "we don't usually come for a check-up in early pregnancy unless something is wrong".

According to a HCP, cultural beliefs prevent some women from attending ANC during the first trimester: "in some cultures (ethnic group), women are not allowed to see a HCP before the first three months, claiming that the pregnancy must remain hidden. Sometimes it's also religious. Certain spiritual leaders even keep women in cloisters after the first visit".

Adequacy of ANC: some HCP reported having the necessary equipment to deliver care to pregnant women. One explained: "we provide the necessary care. We are in a remote area here, and we are doing our best to give access to the ANC". Meanwhile in other facilities, providers noticed that the infrastructure was inadequate for the minimum service delivery.

Routine laboratory screenings were prescribed for all pregnant women. Facilities without laboratory services referred women to the nearest HF for testing. HIV and syphilis screening were conducted systematically. Iron-folic acid supplements were prescribed on the first visit. Blood glucose monitoring was performed in the third trimester. Counseling on a healthy and balanced nutrition was provided during the first visit in some facilities. Tetanus vaccination was administered to all women, although many could not name the vaccines they received. As one participant said: "they gave us several shots in the arm, but I don't know exactly what they were for". Antibiotic treatment for asymptomatic bacteriuria depended on the woman's ability to afford and complete the prescribed treatment. The most common health promotion activity across all facilities was information, education, and communication (IEC), though it was implemented irregularly.

Some facilities had insecticide-treated bed nets (ITNs), which were distributed during antenatal visits. Although HCP across all HF expressed the intention to implement outreach (advanced strategy) activities, but limited by a lack of funding. One HCP shared: "unless a technical partner requests to set up an advanced strategy activity, we can't do it; there's no way to do that". Overall, ANC responsibilities were primarily assigned to midwives or nurses, depending on the facility type and location, particularly in the urban HF. The number of HCP decreased progressively as the distance from urban areas increased.

Women's knowledge of pregnancy: women generally demonstrated a generally good understanding of pregnancy. They mentioned that once they noticed the absence of menstruation (amenorrhea), they would visit an HF for consultation. When asked about the essential medications or supplements required during pregnancy, the majority correctly identified iron-folic acid as necessary. They also acknowledged the importance of sleeping under an insecticide-treated bed net and adhering to preventive treatment to reduce the risk of malaria and related complications. However, most women were unfamiliar with the concept of warning signs during pregnancy and were unable to differentiate clinical signs of pregnancy and actual warning signs that required medical attention. Regarding routine examinations, they frequently mentioned blood tests and ultrasound scans.

Importance of antenatal care: the women did not have a good understanding of ANC, nor were they fully aware of the reasons behind certain interventions during pregnancy. However, they recognized importance of attending ANC for their own well-being and for their baby. When asked whether ANC was important for a pregnant woman, they responded "it's mandatory," reflecting their perception that seeking care during pregnancy is an obligation. One woman shared: "as soon as we feel unwell or notice that our menstruation has stopped, we go to the HF to find out whether we are pregnant". Another added: "once you notice that your menstruation has stopped, you should know that you're pregnant and go to the HF to check if the baby and the mother are doing well".

Regarding the number of recommended antenatal visits, some women said they should attend once a month until delivery. Others believed the number of visits should depend on the mother's health status: "the number of visits depends on the woman's health. If she's not feeling well even if it's not yet her scheduled appointment, she must come anyway".

Women's satisfaction with quality of care: women's overall satisfaction with ANC was moderate, with specific concerns centered on reception, waiting time, and the nature of interactions with HCP. As one woman shared: "the way that we are welcomed varies depending on the HCP. Sometimes the midwives insult us, but it's still not too bad". Another participant noticed: "when I came for my last pregnancy, the reception was good. But on the delivery day it was different. They forgot I was in labor, and the communication was terrible".

One woman commented: "among 100 HCP, maybe 10 give us good treatment. Some others even hit us during labor, and nobody likes that". Others mentioned issues when missing appointments and being penalized once coming back: "sometimes we miss appointments for health or personal reasons, and when we come back, we must either wait a long time, or the HCP tells us to come back another day. That increases our expenses".

Long waiting times were a recurrent complaint: "the waiting is too long. Even if you arrive at 8 a.m., expect to spend the whole day. Before they even start consultations, they waste time chatting. Today, I must go to the market, and even though I came early, I'm still there".

Some participants recognized the issue of staff being overwhelmed: "we understand that sometimes the long waiting time is due to insufficient staff. It would be ideal to increase the number of HCP".

Finally, concerns increased about hygiene standards in HF: "the hygiene in the HF needs to be improved. It's unacceptable to catch infections at the hospital while they're telling us how to prevent it".

Discussion     

This study explored the provision of ANC in both rural and urban settings within areas classified as having low health coverage. It was intended neither to evaluate the quality of antenatal care, nor to compare service delivery across different HF. The two main themes examined were accessibility and adequacy of care, as perceived by pregnant and breastfeeding women and HCP.

On the accessibility of ANC: the concept of healthcare accessibility means an individual's capacity to utilize required services, inherently shaped by the presence of economic, geographic, and sociocultural constraints. According to HCP, geographic and sociocultural accessibility represented the main obstacles preventing women from attending ANC. On the women's side, however, women less frequently expressed these issues; their concerns focused more on financial access, the quality of reception, waiting times, and the availability of services.

These findings are consistent with those of Sohag et al. [16], who conducted a study in 2010 across three sub-Saharan African countries of Kenya, Ghana, and Malawi. Their observations and interviews revealed that the cost of antenatal consultations varied from one facility to another and from respondent to respondent. Fee structures were often unclear, which led to frequent complaints from women. In northern Ghana, where public transportation was poorly regulated, women often walked to clinics to reduce travel costs [16].

Community participation, an essential element of effective ANC, was not fully used. The roles of community health agents or community relays were not clearly defined in the delivery of services. Similarly, local and religious leaders were rarely involved, further burdening women with the responsibility of navigating ANC independently. A systematic review by Hajizadeh et al. [17] highlighted that various access-related factors such as distance to HF, travel ways, walking time, appointment systems, and both direct and indirect discrimination by providers had a strong influence on ANC utilization.

Our study also underscored sociocultural dimensions of access, aligning with findings from other African countries. In certain communities, cultural beliefs often reinforced by family or community members discouraged women from seeking antenatal care, especially in the early stages of pregnancy [17,18]. Numerous strategies have been proposed to improve accessibility to quality care in rural areas of developing countries [2,19]. In Madagascar, for instance, a mobile health system was established in rural zones to improve the quality of ANC [20]. Similarly, in Ivory Coast, a study on the reorganization of ANC demonstrated improved outcomes in focused ANC indicators. These improvements were achieved through specific strategies such as personnel training and redeployment, facility rehabilitation, and provision of medical equipment [21].

On the adequacy of ANC: ANC plays a vital role in safeguarding maternal and fetal health by ensuring timely surveillance and clinical intervention throughout pregnancy [20,22]. The very brief and general descriptions of ANC provided by the women in this study indicated a lack of information and understanding about the pregnancy process. Furthermore, the patient-provider relationship appeared underdeveloped. A 2014 study conducted in Burkina Faso by Niang et al. [23] showed that limited knowledge of the ANC schedule and its objectives was one of the key factors discouraging early attendance during the first trimester.

Similarly, a study in Mozambique found that a woman's level of education, marital status, and living environment influenced both the gestational age at first antenatal visit and the total number of visits throughout pregnancy [24]. The most frequently mentioned concern among women in our study was the perceived intolerance, impatience, and lack of understanding shown by HCP. The same study from Burkina Faso reported women's experiences of stigmatization, humiliation, and even abuse during ANC [23]. Such an environment fosters fear and mistrust toward HCP, which can discourage women from seeking care even when facing health risks.

These findings suggest that both the inaccessibility and inadequacy of ANC remain major barriers to effective pregnancy monitoring and postpartum follow-up, particularly for women living in rural areas. It is imperative that authorities at various levels strengthen maternal healthcare strategies to eliminate these avoidable obstacles and ensure better outcomes for women.

Limitations and strengths of study: the results of this study cannot be generalized to the overall situation in Benin due to the qualitative design and the limited sample size. Potential biases related to social desirability, particularly among HCP as well as group dynamics during focus group discussions and the setting of data collection (within HF), may have influenced participants' responses. Another source of bias may be the translation of women's statements from the local language (Fon) into French. Although careful measures were taken to mitigate this, including the recruitment of a competent and independent local translator, some nuances may have been lost or altered in translation.

However, the qualitative approach adopted in this study based on semi-structured interviews and focus group discussions represents one of its major strengths. To our knowledge, this is one of the first studies to incorporate the perspectives of women regarding ANC provision in rural Benin. The methodology employed allowed us to gain valuable insights into the structure and delivery of ANC, as well as the lived experiences of pregnant women in low-coverage areas. This work follows a 2010 study conducted at Suru Léré Hospital, where the researchers relied on procedural verification and direct observation of healthcare workers' actions in prenatal clinics [25]. Our study was based on the World Health Organization's recommendations on antenatal care, which emphasize making pregnancy a positive experience for all women. We also referred to the national guidelines issued by the Beninese Ministry of Health for analyzing service provision. The WHO recommendations include 49 measures, categorized into universally recommended interventions and context-specific ones [14]. These guidelines aim to place women at the center of care, enhance their pregnancy experience, and ensure that newborns have the best possible start in life.

Conclusion     

This study provided a more detailed perspective on the delivery of ANC in rural areas of Benin. Discussions with both women and healthcare providers highlighted challenges encountered on both sides. Antenatal care was found to be neither fully adequate nor universally accessible. Barriers in different aspects, such as financial, geographic, and sociocultural, were reported as significant factors that hindered women's ability to make informed decisions in favor of their health. In addition, a lack of HCP and overwhelming work in rural areas negatively impacted the utilization of antenatal care services. It would be beneficial to conduct more extensive and in-depth research at a national scale to obtain a more holistic understanding of the issue in the Beninese context.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

Study conception, design, data collection and analysis, manuscript drafting and revision: Nehemie Phycien; study design, manuscript drafting and revision: Rodrigue Zinsou Ahodègnon; study design and data collection: Pleck Boris Dansou. All the authors read and approved the final version of this manuscript.

Acknowledgments     

The authors thank the healthcare workers, municipal authorities, and community members of the Ouidah, Kpomassè and Tori-Bossito Municipalities for their valuable contributions to the completion of this study.

References