RESEARCH ARTICLE |
https://doi.org/10.5005/jp-journals-10016-1295 |
Gestational Age at Booking for Antenatal Care in a Tertiary Healthcare Facility: A Glance
1,2Department of Obstetrics and Gynaecology, Saveetha Medical College and Hospital, Chennai, Tamil Nadu, India
Corresponding Author: Shanthi Ethirajan, Department of Obstetrics and Gynaecology, Saveetha Medical College and Hospital, Chennai, Tamil Nadu, India, Phone: +91 9790963795, e-mail: dreshanthi@gmail.com
Received on: 27 August 2020; Accepted on: 29 January 2021; Published on: 28 December 2022
ABSTRACT
Background: Perinatal care is important to improve the outcome of the pregnancy and reduce associated morbidity and/or mortality to the pregnant mother and the developing fetus. Ideally, preconception counseling and preparedness for conception are necessary for an optimal pregnancy outcome. But this is not practiced by everyone due to various reasons. In such a scenario, an early antenatal visit will provide an opportunity for early screening and prepare a plan of care that will result in a better outcome of the pregnancy. In many countries, pregnant women still start their first antenatal visit late. Hence this study aims to determine the mean gestational age at booking, the magnitude and the factors associated with late booking for antenatal care in a tertiary care referral hospital.
Objectives: (1) To assess the gestational age of booking for antenatal care in a tertiary referral healthcare facility. (2) To assess the prevalence of late booking and factors contributing to it.
Materials and methods: This is a prospective study conducted on pregnant women visiting the outpatient Obstetrics and Gynaecology Department at Saveetha Medical College and Hospital from February 2020 to July 2020. A total of 203 pregnant mothers, who consented to the study, were interviewed at the antenatal clinic by using a structured questionnaire. The data was compiled and assessed using Microsoft Excel. The mean gestational age at booking and prevalence of late booking visit and their causes are assessed. Bivariate and multivariate data analysis was performed using Statistical Software for the Social Sciences (SPSS) for Windows version 16.0.
Result: This study showed that 203 pregnant women who participated in the study were between 19 and 40 years of age. A total of 121 patients were nulliparous, and 82 were multiparous. The mean gestational age at booking was found to be approximately 11 weeks of gestation in the study group. Around 83 were late for their booking visit (40.89%). Lack of knowledge of early booking and its benefits was the most common cause of increased gestational age at the first antenatal visit (28.92%). The recent COVID-19 outbreak this year has caused a delay in the booking of 12 patients (14.46%).
How to cite this article: Aishwarya R, Ethirajan S. Gestational Age at Booking for Antenatal Care in a Tertiary Healthcare Facility: A Glance. Int J Infertil Fetal Med 2022;13(3):91-95.
Source of support: Nil
Conflict of interest: None
Keywords: Antenatal visit, Care, Early booking, Late booking, Pregnancy outcome.
INTRODUCTION
Pregnancy is a physiological process. Antenatal care is the care given to pregnant women to ensure that they have a safe pregnancy by screening, detecting complications, and intervening at the right time to have a healthy mother and baby.1 Because most fetal and maternal complications become apparent late in pregnancy; it has been thought previously that the later weeks of pregnancy is when the most intensive surveillance should be implemented. Traditionally, the frequency of antenatal visits progressively increases with advancing gestation and is recommended to be on a weekly basis from 36 completed weeks of gestation onwards.2
Recent decades have seen a paradigm shift of fetal and maternal investigations to the first trimester of pregnancy. Many studies have shown the benefits of early pregnancy evaluation and that some important complications that occur later in pregnancy can be predicted in the first trimester; therefore, it is worthwhile to increase the focus of clinical evaluations in early pregnancy, thus, inverting the pyramid of prenatal care.3
World Health Organization (WHO) absolute neutrophil count (ANC) model recommends a minimum of eight ANC visits, with the first visit scheduled to take place within the first trimester.4 It is recommended that the first antenatal visit, also known as the booking visit, should be initiated at ≤12 weeks.5 This early visit for antenatal care helps to diagnose the pregnancy early and estimate the expected date of delivery accurately, noting previous and current obstetric problems as well as medical, social, familial, and surgical problems related to the pregnancy.6 In addition, it has become apparent that an integrated first hospital visit at 11–13 weeks combining data from maternal characteristics and history with findings of biophysical and biochemical tests can define the patient-specific risk for various pregnancy complications, including fetal abnormalities, miscarriage and stillbirth, preeclampsia, preterm delivery, gestational diabetes, fetal growth restriction, and macrosomia.7
When antenatal care is initiated late, this crucial window period to screen for pregnancy complications and the opportunity to prevent and or treat is lost, leading to a suboptimal pregnancy outcome.8
Hence this study aimed to find the prevalence of late booking and to assess the causative factors of it, results of which in turn will help in formulating ways to improve early booking.
MATERIALS AND METHODS
A cross-sectional questionnaire-based observational study was done among pregnant mothers attending the outpatient Department of Obstetrics and Gynaecology at Saveetha Medical College and Hospital. Ethical clearance was obtained from the Institutional Review Board of Saveetha University for the study. The inclusion criteria included all pregnant women willing to take part in the study and who knew their date of last menstrual period with regular menstrual cycles and who knew the date of first antenatal visit. The exclusion criteria included all pregnant women not willing to take part in the study, who were unsure of the date of the last menstrual period, women with irregular menstrual cycles, and who were unsure of the date of their first antenatal visit. Patient selection was done by a convenient sampling method. Informed oral and written consent was obtained from the participants. The data was collected from the participants by the investigator through a direct interview with a structured questionnaire. The data thus obtained were demographic details, last menstrual period date, menstrual history, current and past obstetric history, personal history, family, and social history of the participant. The gestational age of booking was calculated from the last menstrual period. When the gestational age at booking was ≤12 weeks, it was considered as early booking, and when it was, >12 weeks; it was considered a late booking. The mothers with late booking were enquired about the reasons for the same.
Data analysis was done using Microsoft Excel. The results were presented in the form of tables, figures, and summary statistics such as mean and percentage to describe the study population in relation to relevant variables. The mean gestational age at booking and prevalence of late booking visit and their causes are assessed. Bivariate and multivariate data analysis was performed using SPSS for Windows version 16.0.
RESULTS
Demographic Details of the Study Group
A total of 203 volunteering pregnant mothers were included in the study after obtaining written informed consent. The age of participants were between 19 and 40 years of age. The mean age of the women in the study was 24.41 years. The maximum number of patients were observed to be in the age group of 21–25 years of age (38.92%). Except for 2.46% of women, all had received at least a primary school level of education. It was observed that 74.38%, 8.86%, and 16.74 % were Hindus, Christians, and Muslims, respectively. A total of 121 (59.61%) were primigravida/nulliparous (Table 1).
| Gestational age of booking (weeks) | Number of patients | Percentage |
|---|---|---|
| <6 | 66 | 32.51no |
| 6–12 | 54 | 26.60 |
| 12–15 | 35 | 42.17 |
| 16–20 | 25 | 30.12 |
| 21–25 | 15 | 18.07 |
| 26–30 | 8 | 9.63 |
Timing of Booking Visit (Gestational Age)
The mean gestational age at the first antenatal visit was found to be 11 weeks in the study population. The timing of the first ANC booking ranged from 4 to 29 weeks of pregnancy (Fig. 1). It was identified in this study that 83 (40.89%) women had their booking visit after 12 completed weeks of gestation (late booking) (Fig. 2).
Fig. 1: Pie chart on percentage of early vs late booking in study population
Fig. 2: Gestational age at the time of booking in the study population in a pie chart
Determinants of Late Booking
Women in the age group of 21–25 years contributed to the majority of the late booking group (40.96%) in this study as they were the majority in the study population (Fig. 3). When analyzed within the age-group categories, as the age increased, the proportion of women within that group who booked early increased. Muslim women were observed to have late bookings within that group (50%) in comparison with other religions.
Fig. 3: Comparison of women—early vs late booking with different dynamics (x-axis showing variables and y-axis being number of women)
The maximum number of patients with a late gestational age of booking for the first antenatal visit was observed to have received up to middle school level of education (42.17%). Parity was found to play an important role in early booking. It was evidenced that nulliparous and primigravida booked early compared to their counterparts (Table 2).
| Characteristics | Total | % | Early booking (number) | Early booking (%) | Late booking (number) | Late booking (%) |
|---|---|---|---|---|---|---|
| Age | ||||||
| 19–20 21–25 26–30 31–35 >35 |
19 79 60 30 15 |
9.36 38.92 29.56 14.78 7.39 |
7 45 40 20 8 |
5.83 37.5 33.33 16.67 6.67 |
12 34 20 10 7 |
14.46 40.96 24.09 12.05 8.4 |
| Education | ||||||
| Illiterate Primary school Middle school Higher secondary Graduate |
5 53 70 47 28 |
2.46 26.11 34.49 23.15 13.79 |
2 28 35 32 23 |
1.67 44.17 29.17 26.67 19.17 |
3 25 35 15 5 |
3.62 30.12 42.17 18.07 6.02 |
| Religion | ||||||
| Hindu Christian Muslim |
151 18 34 |
74.38 8.86 16.74 |
92 11 17 |
76.67 9.17 14.17 |
59 7 17 |
71.08 8.43 20.48 |
| Parity | ||||||
| Nullipara/ Primigravida Multiparous |
121 82 |
59.61 40.39 |
91 29 |
75.83 24.17 |
30 53 |
36.14 63.86 |
The reasons for late booking were observed to be lack of knowledge of current pregnancy (13.25%), lack of knowledge and the benefits of early booking (28.92%), financial constraints (18.07%), uncooperative husband (2.41%), COVID-19 situation (14.46%), and others (3.61%) (Table 3 and Fig. 4).
| Reason for late booking | Number | Percentage |
|---|---|---|
| Lack of knowledge of current pregnancy | 11 | 13.25 |
| Lack of knowledge and benefits of early booking | 24 | 28.92 |
| Financial constraints | 15 | 18.07 |
| Distance and travel issues | 16 | 19.28 |
| Family/ husband is not cooperative | 2 | 2.41 |
| Corona (lockdown, etc) | 12 | 14.46 |
| Others (out of town, work, etc) | 3 | 3.61 |
Fig. 4: Reasons for late booking in study population (in numbers)
DISCUSSION
Early booking is important to ensure proper nutrition, vaccination, screening for any abnormalities, prediction of certain pregnancy complications, and time management. It ensures safe pregnancy and good maternal and fetal outcomes. The WHO ANC model recommends that pregnant women should attend their first clinical visit within the first trimester.8 However, late booking in this study is found to be 40.89% which is less compared to 83.1% in a study conducted by Onoh et al.9 The mean age of gestation at the first antenatal visit is found to be 11 weeks. This is early compared to a study conducted at Lagos University Teaching Hospital, a tertiary health care center in Lagos, where the gestational age at booking visit was 19.1 ± 7.8.10
Mothers in the age group of 21–25 years were found to have more defaulters of early booking (40.96%). This might be because elder expectant mothers are more eager, and their pregnancy may have been a result of assistance or careful planning. It was also observed in research conducted by Zhao et al.11 This observation differs from what had been observed by studies done in Addis Ababa and Nigeria, where pregnant women below 25 years of age were found to attend their first antenatal visit earlier compared to mothers aged above 25 years of age.12
The education level of mothers was observed to have a positive result for mothers. Mothers educated in high school and above, especially graduates, showed to be the least defaulters in an early booking (6.2%). This was also supported in the study conducted by Ifenne et al., where it was found that mothers with tertiary level of education booked early.13 Hence education is vital.
Parity is found to be a key factor in determining the gestational age at booking.9
Primigravid and nulliparous women were observed to have their first antenatal visit earlier when compared to the parous antenatal mothers in this study. A similar pattern had been observed in a study conducted by Adegbola et al.,14 but another study by Ifenne et al. found that there is no link between parity with the gestational age at the booking visit.13
A significant percentage of women did not have knowledge of early booking and its benefits (28.92%). A study conducted by Onoh et al. also produced similar results (18.1%).9
Most studies show a positive association between socioeconomic status and gestational age at booking visit.15 In this study, financial constraints have been found to cause a delay in booking in 18.07% of the women. Distance also plays a role. It was observed that 19.28 % had a delay in booking due to distance from their residence and the health care center, similar to the observations in a study conducted by Ali et al.16
Due to the recent COVID-19 world pandemic, it has been found that 14.46% of women had undergone late booking. This might have been due to the lockdown in their residential region and fear of acquiring COVID infection and its effect on their life and pregnancy outcome.
CONCLUSION
It is evident that still many pregnant women have their first booking visit beyond the first trimester. Having poor knowledge of early booking and its benefits is found to be the leading cause. Creating awareness about the importance of early booking in pregnancy for an optimal maternal and fetal outcome in the community through various health education and awareness programs and health schemes can help to overcome this problem of late booking.
ACKNOWLEDGMENTS
I would like to thank the Obstetrics and Gynaecology Department in Saveetha Medical College and Hospital and the volunteered patients for helping in completing the study. I thank my guide Dr Shanthi, Professor in the Department of Obstetrics and Gynaecology, for guiding and supervising the research.
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