This study explored the association between potential factors that have previously been identified by mothers and health professionals in a qualitative study 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 regions26,27. Potentially, improving 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 pregnancy 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, 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 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 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 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 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 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, as they may be receiving information directly from their health professionals about the importance of attendance.
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 skills33. 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, in this study, 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 people 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 people 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 work38. 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 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 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 Arabia 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 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 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. 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 study14, alongside findings in South Africa 9 and across southern Tanzania, Cambodia, Uganda and India27. For example, research has highlighted that perceived staff rudeness, neglect, disrespect and poor care prevented women from pursuing antenatal care45. 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 reassurance41. 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 mothers who are worried about fitting in appointments around their job, alongside an enhanced standard of care48. 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 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. A lack of time and shortage of staff has been shown to be a main barrier to shared clinical decision making in previous research in Saudi Arabia53. It 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 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 participate56. 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.
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 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.