This study explored whether factors that were previously identified in a qualitative study by mothers and health professionals in Saudi Arabia as reasons for missing or delaying antenatal care, were associated with care attendance in a larger quantitative study. Similar to findings in the previous study, and reflecting findings in other regions26,27, care attendance was associated with maternal health care literacy, personal barriers, and healthcare system factors including staff communication. Potentially, making changes to improve these factors could increase maternal antenatal care attendance and the findings will be useful for individuals working in maternal health care and policy.
Overall, the findings showed that missing or delaying antenatal care is common amongst pregnant women in Saudi Arabia. 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. However, this 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 would be much higher than 15%. 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 the barriers which will reduce their attendance.
In terms of what factors were identified as affecting care attendance, unlike health professional perceptions in previous research14, maternal demographic background and health literacy was not strongly associated with attendance. No significant association was found between attendance and maternal age, marital status, education, location or income. This is in contrast to previous research which has identified lower education and income as barriers to attendance28,29, although not every study has been conclusive30.
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 has identified that low health literacy during pregnancy as a reason for missing appointments26,31. However, delaying care was associated with a lower literacy level, which has been identified previously in a systematic review as a barrier to timely care attendance32. Potentially it is not that mothers do not perceive care as important, but perhaps they do not immediately recognise that 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. Potentially this is because once connected with a health professional they receive information about the importance of attendance and how often they should attend.
It is also possible that health literacy tools do not accurately measure health literacy. Such tools do not demonstrate accurate health knowledge but rather are a measure of whether the individual believes that they have good health literacy. Mothers may feel embarrassed or apprehensive admitting that they lack the skills or do not realise what they do not know33. However, a wide range of scores was seen across participants. Potential scores on the tool range from 13 – 65, and mothers presented with scores ranging from 13 – 65. Moreover, three illiterate women were supported to fill the questionnaire demonstrating a variety of potential skill.
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’ event and going well, rather than something where health care appointments were important 34. However, for the items directly asking women who had missed appointments whether their perceptions of care affected attendance, there was no association between timing or care or planned attendance and their beliefs.
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 improved. Any intervention must be culturally relevant. Saudi Arabia has a collectivist community, where women learn from and are influenced by people around them, particularly women in their families. Decision making, including for healthcare matters, is not the sole decision of the individual, but part of a wider shared decision amongst the family35. If people around her tell a woman that pregnancy is ‘normal’, she may be less likely to seek care. Therefore, potentially interventions should focus on improving the attitudes of the wider public towards care, not the individual mother alone.
Notably, perceived susceptibility / severity of potential pregnancy complications was not associated with attendance. Although in one study in Ethiopia, women who did perceive potential complications to be more severe were more likely to attend36, a number of studies have shown that fear does not necessarily lead to positive health behaviours37. 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 work38. It is possible that women are worried about their health in pregnancy, but this does not affect attendance; some might 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 research14 were again 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). However, 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 mothers 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 regularly39. Limited research in other countries including Ghana and Saudi Arabia has shown that education, particularly that which tries to change inaccurate socio-cultural beliefs around the factors that affect pregnancy complications and the need for regular care can increase attendance40, For example, when mothers believe care improves the outcomes for their baby, they are more likely to attend27,41.
Accessibility to ANC was another factor discouraging women to attend. Around a quarter had missed appointments due to lack of transportation. In Saudi Arabia many women rely on a male guardian for any travel, which will exacerbate non-attendance as they are reliant on his beliefs and willingness to take her to the clinic42. This is a common barrier to care attendance across the Middle East and Africa43,44. Notably, however, in contrast to our previous study14 , 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 to care attendance in a systematic review of studies across Bangladesh, Benin and Cambodia27. Organisation of clinic times means that women can need a whole day for an appointment due to the long clinic wait-time and often distance needed to travel. 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 as poorer across all three elements of information, consistency and care. Perceptions of care were also associated with delaying the first appointment. This finding echoes our previous qualitative study14, alongside findings in South Africa9 and across southern Tanzania, Cambodia, Uganda and India27. For example, research has highlighted that perceived staff rudeness, neglect, disrespect and poor care prevent women from pursuing antenatal care45. In one study negative staff communication were even linked to poorer pregnancy outcomes, attributed to women not attending appointments and therefore complications not being identified at an early stage46.
Our findings here identify that attendance is linked to both perceptions of staff providing 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 an overemphasis on practical check-ups rather than emotional care and communication of information, leaving women feeling ignored. Mothers wanted reassurance and sensitivity not simply information about their baby41. 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 individual47. Conversely, we know where women feel practically and emotionally supported their attendance and birth outcomes are improved46.
It is likely that directly or not, health professional beliefs that maternal care attendance is affected primarily by their education and literacy14 may be affecting mothers perceptions of staff communication and attitudes. 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, respectful and 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 make appointments with a private clinic instead. Private clinics have been shown to have shorter waiting times, and appointments available at a variety of times, appealing to mothers who are worried about fitting in appointments around their job. They have also been shown to have an enhanced standard of care, meaning women who feel that their professionals do not respect them might be more likely to see private care instead48. 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 times in what they perceived to be an unsuitable environment. They also believed that they would receive more in depth care and attention at a private clinic 41.
The findings have clear application for individuals working in health care policy or supporting pregnant women in Saudi Arabia. As in other regions around the world, women in Saudi Arabia would likely benefit from a woman centred care approach, which has a focus on respect, dignity and shared decision making49. Continuity of care, where women have a named midwife who sees them through pregnancy and birth may also help build trust and reduce complications – a pattern that has been found in other regions50.
Ensuring women have this degree of respect, autonomy and quality care is especially important in a culture such as Saudi Arabia where many women are affected by the beliefs and wishes of their husband, mother or family51. Yet we know that when women feel in charge of their labour and birth, feeling they are in control of decisions being made, they are more satisfied with their experience and have better birth outcomes44. Consideration needs to be given to how women can be given more autonomy in birth in such a patriarchal culture.
Investment in staffing may be needed to implement this. Saudi Arabia is currently suffering from a shortage of nursing staff, like many areas around the world52. Previous research in Saudi Arabia has shown that a lack of time and shortage of staff have been shown to be major barriers to shared clinical decision making53. Understaffing has also been attributed to long working hours and overload with work, meaning that nurses and midwife time have little time to give quality care, especially in terms of emotional support54, leaving them feeling frustrated and guilty55.
The research does have its limitations. As with almost every research study reaching mothers 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 mothers with a higher education level. Linked to this, exploring the experiences of mothers who miss antenatal care appointments is a challenge as 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 participate56. However, even from this appointment alone, half of participants had already missed one appointment, with a third having delayed their care showing the severity of this issue in Saudi Arabia.
It is also possible that participants felt that they had to give the ‘correct’ answer as data was collected 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.
The findings raise a number of important questions for future researchers. Alongside tackling some of the limitations of the study, such as exploring these outcomes in a more diverse sample, research may wish to conduct interviews with health professionals about their perceptions of delivering care and the barriers that they face. It would also be of interest to examine whether mothers’ perceptions and experiences of antenatal care has any association with birth outcomes. If care is associated with an increased risk of complications this would further the case for greater investment. Research in other regions shows that although a continuity of care model focussing on woman centred midwifery support may initially be more expensive to deliver, it saves money in the long term due to improved birth outcomes56.