1.0 INTRODUCTION
Antenatal care services are defined as an umbrella term used to describe the medical procedures
and care carried out during pregnancy. Antenatal care, a pregnancy related services provided to
pregnant women by health professionals, is among the Millennium Development Goal (MDGs)
four and five, the major interventions which is aimed at preventing Neonatal death and maintaining
the health of the women during pregnancy (Nove et al,.2021)
ANC has many components such as laboratory investigation, referral, health education etc.
Antenatal care is very important to pregnant women as it helps prevent mother and child mortality,
prevent complications help foster a good relationship between the husband and wife, mother and
child and father and child (Luseno et al,. 2019)
ANC can help women prepared for delivery and understand warning signs during pregnancy and
childbirth. It can be a source for micronutrient supplementation, treatment for pregnancy induced
hypertension provition of immunization against tetanus, HIV testing and medication. Although
this ANC is important for these pregnant women, they are some factors that hinder these women
from using ANC such as poverty and lack of health facilities (McCauley, 2022).
Improving maternal health is of the developments of the MDGs. The aim of this is to Strengthening
health systems, Monitoring and evaluating the burden of maternal and newborn ill-health, building
effective partnership in order to make best use of scarce resources. Although maternal death
worldwide has almost halved since 1990 according to WHO latest figure, every roughly 800
women and adolescence girls die from complications of pregnancy or childbirth. In 2010, 287,000
women died during childbirth with almost all of this death (99%) occurring in low-resources
setting but a decline of 47% were recorded from all levels 1990. Most of them died because they
had no access to skilled routine and emergency care. Since 1990, some countries in Asia andNorthern Africa have more than halved maternal mortality (Kurjak, Stanojevic, Sen, &
Chervenak, 2020).The frequent visit aid is used to classifying pregnant women into low and high
risk by predicting the complication ahead of time. The traditional approach was replaced by
Focused Antenatal Care (FANC) a goal-oriented approach which was recommended by researcher
in 2001 and adopted by WHO in 2002. During ANC visit, pregnant women are educated on the
following important topics: nutrition, medication, lifestyle, exercise, personal and environmental
hygiene, safety in the environment, etc. (Santos-Rocha et al, 2022). The extend to ANC service
underutilization by pregnant women is based at the individual and family level, the crucial factors
are; employment of the women, education of the women and spouse, marital status, house hold
income, exposure to media, obstetrical complications, parity, age, religious belief, culture, and preconception of pregnancy. Among the social – demographic factors, the odds for underutilizing
ANC services increased significantly for mothers with low educational attainment and from
households with a low wealth index.
1.1 BACKGROUND
Background of Antenatal Care Historical Background of Antenatal Care, Antenatal care (ANC)
developed gradually as part of efforts to reduce maternal and infant mortality, which were very
high in the past. ( Cunningham, 2018 ) .,Before the 20th century, pregnancy and childbirth were
largely managed at home by traditional birth attendants, and complications were often detected too
late. The formal concept of antenatal care emerged in the late 19th and early 20th centuries, when
medical professionals began to recognize that many maternal and foetal deaths could be prevented
through care during pregnancy, not only at delivery. One of the earliest goals of ANC was the early
detection of conditions such as pre-eclampsia, anemia, infections, and obstructed labour, which
were major causes of maternal death. There is no single individual who “discovered” ANC, but it was systematically introduced and developed by obstetricians and public health practitioners.
However, Dr. John William Ballantyne (1861–1923), a Scottish obstetrician, is widely
recognized as a pioneer of antenatal care. He strongly advocated that care of the mother before
birth is essential for the health of the baby. He introduced the idea of regular supervision of
pregnant women. He emphasized prevention rather than treatment of complications. Antenatal care was first formally developed in Europe, particularly in the United Kingdom. The first antenatal
clinic is believed to have been established in Edinburgh, Scotland, in the early 1900s.By 1910,
organized antenatal clinics began spreading across England and other parts of Europe, and later to
North America. Antenatal care was introduced for several important reasons: High maternal
mortality rates, Many women died from preventable pregnancy complications such as eclampsia,
hemorrhage, and infections, High infant and perinatal mortality, Stillbirths and neonatal deaths
were common due to poor maternal health and lack of monitoring, Late detection of pregnancy
complications, Problems were often identified only during labour, when it was too late to intervene
effectively, Need for prevention rather than cure. Health professionals realized that early
supervision during pregnancy could prevent complications.( Lawn , J . E ., et al .2021)
Governments and health systems began promoting maternal and child health as a public health
priority. Early ANC focused mainly on detecting pre-eclampsia and providing advice on hygiene
and nutrition. Over time, ANC expanded to include: Laboratory screening, Immunization (tetanus
toxoid),Malaria prevention, HIV and STI screening, Health education and birth preparedness.(
Souza, J.p., et al ., 2023
In 2001, WHO introduced Focused Antenatal Care (FANC). In 2016, WHO updated guidelines to
recommend a minimum of 8 ANC contacts to improve pregnancy outcomes.( Cunningham FG,
Leveno KJ at al (2018) ) . The theoretical background of Antenatal Care (ANC) is based on public
health, nursing, midwifery, and medical theories that emphasize prevention, early detection of
risks, health promotion, and continuity of care for pregnant women and their unborn babies.
Antenatal care is grounded in the preventive health care model, which focuses on preventing
disease rather than treating it. Levels of Prevention Applied in ANC ; Primary prevention: Health
education, nutrition counselling, tetanus toxoid immunization, malaria prevention, iron and folic
acid supplementation. Secondary prevention: Early detection of complications through screening(anemia, hypertension, diabetes, infections) ( Kuhnt ,J. , and Vollmer, S . , 2020 ) .
Tertiary prevention: Management of complications and prevention of further deterioration through
treatment and referral. Regular ANC visits help prevent maternal and fetal complications before
they become severe. The risk approach is a major theoretical foundation of ANC. It involvesidentifying high-risk pregnancies early. Women are classified as low-risk or high-risk based on
medical, obstetric, and social factors. High-risk women receive specialized care or referral. This
approach allows limited health resources to be used efficiently while improving maternal and fetal
outcomes. ANC is also based on health promotion theory, which empowers individuals to take
control of their health. Focuses on behavior change, such as improved nutrition, hygiene, and
health-seeking behavior. Encourages informed decision-making and self-care during pregnancy.
Through education and counselling, women adopt healthy lifestyles that benefit pregnancy
outcomes. The continuum of care model links cares across: Time: pre-pregnancy → pregnancy
→ childbirth → postnatal period, Place: home → community → health facility. ANC is the entry
point into the maternal and newborn health continuum, ensuring continuity and referral across
levels of care. This theory recognizes the interdependence between maternal and fetal health. The
fetus depends entirely on the mother’s physical, emotional, and nutritional status. Any maternal
illness directly affects fetal well-being. Monitoring maternal health ensures optimal fetal growth
and development. Nursing and Midwifery Care Theories ;Holistic Care ,ANC addresses physical,
psychological, social, and cultural needs of the pregnant woman ,Client-Centered Care
Emphasizes respect, dignity, informed choice, and shared decision-making. These theories guide
midwives to provide compassionate, respectful, and individualized care. UNICEF. ( 2023) .Public
Health Systems : ANC operates within the health systems framework, involving: Policy
development ,Service delivery, Community participation, Monitoring and evaluation, Strong
health systems ensure accessibility, equity, and quality of antenatal services. The implementation
of antenatal care (ANC) has had a significant positive impact on communities, improving maternal
and child health, strengthening health systems, and promoting social and economic development ;
Reduction in Maternal Mortality and Morbidity, Early detection and management of pregnancyrelated complications such as anemia, hypertension, hemorrhage, infections, and pre-eclampsia ,
Timely referral of high-risk pregnancies to appropriate health facilities, Overall reduction in
preventable maternal deaths within the community, Improved Newborn and Child Survival,Reduced rates of stillbirths, preterm births, and low birth weight, Early detection and treatment of
maternal infections that affect newborns. Increased survival of newborns through better pregnancymonitoring and skilled delivery, Increased Health Awareness and Health-Seeking Behavior,
Women and families become more knowledgeable about: Pregnancy danger signs, Importance of
skilled birth attendance, Nutrition, hygiene, and newborn care, Communities develop a culture of
early care-seeking and prevention, Control and Prevention of Communicable Diseases, Reduction
of tetanus, malaria, HIV, and syphilis transmission through: Immunization, Screening and
treatment, Preventive therapies (e.g., IPTp for malaria),Protection extends beyond pregnant
women to the entire community, Strengthening of Health Systems ,Improved use of health
facilities and trust in healthcare services. Better data collection for maternal and child health
planning. ( Gadama, L.,et al ., 2020 ) ,Increased collaboration between community health
workers, midwives, and referral facilities., Improved Nutrition and Food Practices, Nutrition
counselling during ANC leads to: Improved maternal diet, Reduced anemia, Healthier infants,
Positive nutrition practices are shared within families and communities, Promotion of Women’s
Empowerment, ANC encourages women to: Participate in decisions about their health Plan for
safe delivery and emergencies, Access family planning services, Enhanced status of women within
families and communities, Economic and Social Benefits, Reduced healthcare costs due to
prevention rather than treatment of complications. Healthier mothers and babies contribute to
productive households and communities, Lower burden on families and health systems. (
Woldbank (2019),UNICEf (2019)) .
By investigating the perspectives of women using ANC, together with those of other stakeholders
(including health-care providers, men and traditional midwives), this study is grounded in
theoretical and methodological underpinnings as elucidated in the constructivist framework
(Berger and Luckmann, 1967; Guba and Lincoln, 1989; Nygren, 1999; Lincoln, 2001). A basic
tenet according to the constructivist frame of thought is that the world is constituted by multiple and competing versions of truth and realities and that ways of understanding are socially
constructed in interaction with the contexts within which they occur. The actors therein create their
orders as they move through a social landscape, continually interacting and engaging in dialogue
and at the same time altering the contexts. The concern, thus, is for strategies in knowledge creation
that acknowledge and engage stakeholders of different perspectives in ways that help them not only make sense of their experiences but also include their perspectives in planned actions. criticise
traditional means of evaluation for often allowing some perspectives to be viewed as more
legitimate than others and advocate for those that give voice to stakeholders of different
perspectives. They argue instead for a view that sees local knowledge as socially constructed and
the focus of critical analysis being the process that tends to legitimize certain hierarchies of
knowledge. The emphasis is thus investigation of the manner in which ways of understanding are
constructed in interaction with the contexts in which they develop.( Chappell, P., and Rule, P. ,
2021)
The timing of initiation of the first antenatal care visit is paramount for ensuring optimal care and
health outcomes for women and children. Globally, there has been a change in the pattern and type
of obstetric outcomes, as a greater proportion of deaths and morbidities are related to complications
of pre-existing medical conditions, namely indirect conditions, in a phenomenon described as the
obstetric transition.
An early antenatal care visit gives the opportunity to provide screening and tests that are most
effective early in the pregnancy (ie, correct assessment of gestational age to allow for accurate
treatment of preterm labour, screening for genetic and congenital disorders, provision of folic acid
supplementation to reduce the risk of neural tube defects, and screening and treatment for iron
deficiency anemia and sexually transmitted infections). Additionally, the visit can potentially
capture non-communicable diseases such as diabetes and provide guidance on modifiable lifestyle
risks such as smoking, alcohol by 2030 reduce the global maternal mortality ratio to less than
70 per 100 000 livebirths consumption, drug abuse, obesity, malnutrition, and occupational
exposures. All these conditions can be detected and treated if early, timely, and high-quality
antenatal care is provided, but beyond the content the antenatal care services need to be available, accessible, and acceptable.( UN Feb. 24 , 2017)
1.2 PROBLEM STATEMENT
Globally, antenatal care is a cornerstone of safe motherhood, serving as a platform for essential
health services during pregnancy. The World Health Organization (WHO) recommends a minimum of eight antenatal contacts to detect and manage complications, promote better birth
outcomes, and reduce maternal and perinatal mortality . Despite these recommendations and global
efforts to improve maternal health, many low- and middle-income countries, including Cameroon,
continue to struggle with inadequate utilization of these essential services.
Cameroon faces significant maternal health challenges, with maternal death rates among the
highest in the world . The country’s maternal mortality ratio is estimated at 438 per 100,000 live
births, ranking 16th globally for maternal deaths . While national policies and strategies, such as
the Health Sector Strategy (2016-2027), aim to improve maternal and child health, the utilization
of ANC services remains suboptimal . A recent study conducted in the Central Hospital of Yaoundé
found that a staggering 70.5% of women had inadequate antenatal contacts, falling short of the
recommended eight visits . This high prevalence of inadequate ANC is associated with various
maternal factors, including delivering before 40 weeks of gestation, being referred for care, and
being unmarried .
The situation in Cameroon’s urban centres, particularly Douala, is complex. The Littoral Region,
where Douala is located, hosts a significant number of internally displaced persons due to sociopolitical crises in other regions, placing additional strain on health facilities like the Deido District
Hospital . While the Deido District Hospital benefits from the support of international partners like
UNFPA, which has deployed midwives to provide reproductive health services, the specific
knowledge, practices, and barriers faced by the pregnant women who attend this facility remain
largely unexplored .
Existing research in Cameroon has highlighted numerous obstacles to optimal ANC use. These
include long distances to health facilities, high costs, long waiting times, and unfriendly health
worker attitudes . Furthermore, deeply rooted socio-cultural norms often position ANC as a
“female affair,” limiting the support women receive from their partners and families . A lack ofawareness about the importance of early and regular ANC visits, coupled with limited female
agency to make independent health decisions, further compounds the problem . However, these findings are often from different regions and may not fully capture the unique challenges and level
of understanding among women seeking care at Deido District Hospital.
Preliminary observations and the lack of facility-specific data suggest that there may be a
significant gap between what pregnant women at Deido District Hospital know about ANC, what
they actually do, and the barriers they encounter. Without a clear understanding of these three
interconnected elements—knowledge, practice, and barriers—it is impossible to design targeted
and effective interventions to improve ANC attendance and, consequently, maternal and neonatal
health outcomes in this specific catchment area.
Therefore, this study seeks to fill this critical information gap by assessing the level of knowledge,
current practices, and perceived barriers regarding the importance of ANC visits among pregnant
women attending the Deido District Hospital in Douala. The findings will provide essential
baseline data for hospital administrators, local health authorities, and partners like UNFPA to
develop context-specific strategies that address the unique needs of this population and contribute
to reducing preventable maternal and newborn deaths.
1.3 RESEARCH QUESTIONS
1.3.1 Main Research Questions
What are the levels of knowledge, practice and Barriers of pregnant women on the important of
ANC visit for pregnant women at Deido district hospital.
1.3.2 Specific Research Questions
1.Do pregnant women at Deido district hospital have adequate knowledge of attending ANC ?
2 . What is their understanding of the practices of ANC at Deido district hospital ?
3. What are the barriers to consistently attending ANC at Deido district hospital ?1.4 RESEARCH OBJECTIVES
1.4.1 Main Objective
To assess the knowledge, practices and Barriers of pregnant women age 17 to 45 regarding the
importance of Antenatal Care visits at the Deido District Hospital.
1.4.2 Specific objectives
1. To determine the level of knowledge of pregnant women concerning ANC schedule and its
components at Deïdo district hospital
2.To evaluate ANC practices among pregnant women in the study at Deïdo district hospital.
3.To identify the main perceived barriers that influene ANC attendance among this population at
Deïdo district hospita