Do health care providers give sufficient information and good counseling during ante-natal care in Lao PDR?: an observational study

Effective pre-, intra-, and post-natal care interventions play an important role in reducing maternal and child mortality and morbidity [1‐5]. Antenatal care (ANC) is the care that a woman receives throughout her pregnancy and for some weeks during the post-partum period in addition to identification of problems occurring during pregnancy [1, 6], ANC provides an excellent opportunity to establish a birth plan and to promote a healthy lifestyle that improves health outcomes for the woman, her unborn child and possibly her family [7, 8]. Besides medical history-taking and physical examination, treatment and referral to a hospital, health education and counseling play an important role in ANC [9‐11].

Good health education and counseling in ANC means that a pregnant woman should be fully informed about the progress of her pregnancy and that she is provided with evidence-based information and support to make informed decisions, in a manner suitable to her culture and life experience [10, 12]. Pregnant women and their family members should have the opportunity to be informed about care, treatment, and possibility of unexpected matters, in partnership with their health care providers [12].

A previous study demonstrated that more women changed their behavior for reducing adverse pregnancy outcomes after having received nutrition counseling [13, 14]. In other studies, the positive effect of health education and counseling was significantly associated with improvement of maternal behaviors and health outcomes [13, 15, 16]. It has been shown that individual counseling with weekly reinforcement can bring about improvement in nutritional status during pregnancy [17].

However, in actual practice, the quality of ANC services is often poor in low-and middle-income countries and the information provided often does not match the social and cultural context of women to promote their healthy behavior at home [12, 18]. Improving this approach will strengthen the link between women and their family members and the health services during and after childbirth and may also help to promote delivery at health facilities, breastfeeding and a healthy lifestyle [12, 18].

Laos, where this study was done, is no exception. Although access to ANC has improved over the past decade [19, 20], the quality of ANC service remains inadequate [21], and there are indications that especially counseling is usually not practiced well at public health facilities [22]. The poor health education and counseling provided by health care workers has not yet been explicitly addressed in health interventions, just as poor public awareness and empowering women have not.

Very little is known about the current practice of Lao health care workers providing ANC services at the public health facilities. A recent study provided evidence of the perspectives and experiences of both supply and demand sides as to this issue, based on in-depth interviews (submitted for publication). However, the actual providers’ practice on health education and counseling was not described in that report. To address this knowledge gap, we conducted an observational study on the current practice of ANC health education and counseling to pregnant women by health providers at public health facilities in both urban and rural areas. The study aims to assess the ANC quality at the public health facilities in Laos; the results provide suggestions to improve health education and counseling in addition to other routine care in public ANC services.

A total of 77 ANC providers (20 from urban and 57 from rural areas) were enrolled in the study. During the study period, 421 observation sessions with 421 pregnant women (81 in urban and 340 in rural areas) were conducted.

The characteristics of health providers are shown in Table 2. Their overall mean age was 35 years, 98.7% were female and about 60% were nurses. Their median working experience was 11 years, ranging from 1 to 33 years, and was significantly higher in urban [17 (1–33)] than in rural [9 (1–29)] areas (P = 0.042).

The characteristics of pregnant women who visited ANC are presented in Table 3. These women were relatively young, with mean age of 25 years, which was not significantly different in urban and rural areas. At the time of observation, 55.6% of the pregnant women were visiting ANC in their third trimester; the overall median and range of gestational age was similar in urban and rural areas. Approximately one third of the women came for ANC alone, although this was significantly more common in urban than in rural areas (P = 0.003).

Overall, the medical history taking and physical examination performance by the health providers were relatively poor, as shown in Table 4. Six questions were related to ‘medical history taken’. Out of a maximum possible score of 6, the median was 3, and it was significantly higher in rural than in urban areas (P = 0.007). Half of the providers asked about the mothers’ last menstruation, prior pregnancies, current pregnancy problems and any medicines taken by the mothers during their pregnancies, while only one third of them asked about mother’s previous pregnancy problems. The percentage of the providers who asked about mothers’ age, last menstruation, and prior pregnancies was significantly lower in urban as compared to rural areas (P < 0.001, P = 0.01, and P = 0.002, respectively). The median score out of 6 was significantly lower in urban than in rural areas (P = 0.007). Observation of performance of the six items of physical examination resulted in higher scores, which were significantly lower in rural than in urban areas (P = 0.002) (Table 3). However, looking at the average scores, it appears that only examination of the abdomen was done in more than 70% of the cases, while in only 41.6% of the consultations did the health providers listen to the fetal heartbeat.

Although the health providers from urban areas provided more health promotion messages to the mothers as compared to those in the rural areas, their overall performance for this service remained unsatisfactory (Table 5). For example, each of eight items separately was performed in less than 50% of the observations. The overall median score out of a possible 8 on health promotion during pregnancy was only 2 and was significantly lower in rural than urban areas (P < 0.001).

Health promotion on childbirth and postpartum care to mothers by the providers both in urban and rural areas was also very poor, as illustrated by the data in Table 4. For example, just 47.3% of the providers gave advice on a safe place for childbirth, and only 15% advised mothers to bring their children for vaccination. None of them provided counseling on child vaccination, breastfeeding and nutrition. The overall median score for health promotion on childbirth and the postpartum period out of a possible 12 was only 2; although both were very low, the score was significantly higher in urban than in rural areas (P < 0.001).

The availability of health education materials for each ANC session observed and their use during health education by health providers at the public health facilities was highly inadequate as shown in Table 6. Health education materials were used to provide health information in fewer than 10% of the sessions, although more than 50% of required health education materials were available at each health facility at the time. The very low frequency of using materials to explain about diet during pregnancy (9.7%), after childbirth (2.6%), and for child vaccination (3.6%) was not significantly different between urban and rural areas.

The results of assessing the performance of health providers’ communication with the mothers are presented in Table 7. Generally, the communication between health providers and their clients had a lot of weaknesses. Except for sitting at the same level and using simple language with the mothers, other communication items expressed or performed by the health providers were inadequate. For example, the items helping brainstorming, agreeing on an appointment for the next visit, asking if there are more questions, and encouraging to ask questions were almost never performed. The overall median score out of 24 on communication was only 6; there was no significant difference between urban and rural areas.

The overall mean time spent for ANC per visitor was 16.21 min (SD 4.28), and it was significantly longer in rural [20.65 (4.92)] than in urban [15.15 (3.33)] areas (P < 0.001). Paradoxically, significant negative correlations were found between time spent and physical examination scores [r = − 1.117*, P = 0.016] and time spent and health promotion [r = − 1.200*, p = 0.013]. Time spent for medical history scores and counseling scores were not correlated. Total performance scores were also not significantly correlated, though a negative trend was observed.

Further analysis using Pearson or Spearman correlation tests revealed correlations between health providers’ working experience and age and their performance scores. There was a significantly positive correlation between working experience and age of health providers and their physical examination performance scores [r = 0.301** (n = 77), P = 0.008 and r = 0.285** (n = 77), P = 0.024, respectively]. In a multiple linear regression analysis, working experience of health providers was independently correlated with their physical performance scores (adjusted R square = 0.017).

To the best of our knowledge, this is the first study conducted in Laos to assess the working performance of the ANC health workers, with special emphasis on the provision of information and counseling to their clients by using structured observation at public health facilities. The findings demonstrate that the overall performance of ANC providers was very poor in both urban and rural areas.

Thus although women are accessing ANC, they are not benefiting optimally from ANC services. They are not sufficiently protected through direct screening; do not get enough information on safe pregnancy or on how to nurture the child in the first 1000 days. Medical history taking and physical examination in ANC service are crucial for initial assessment to detect danger signs that may need treatment or referral to a higher level health facility [6, 12]. We found that performance on history taking remained poor, while physical examination was adequate but needs improvement. It is especially worrisome that in fewer than half of the cases observed did providers listen to the fetal heartbeat. Similar findings were reported from Tanzania [25]. If ANC is not carefully conducted, preventable health issues can be missed, such as hypertension and edema (pre-eclampsia and eclampsia), of caus important maternal death during pregnancy [26].

We found that medical history taking by health providers was better in rural than in urban areas, but the opposite was true for physical examination and other procedures. There may be different reasons for this finding. For example, time constraints can be an important factor, contributing to inadequate performance by health providers where facilities are overcrowded (submitted for publication). In this study, however, there was a negative correlation between time spent per consultation and performance in physical examination and health promotion. The approximate number of clients per day was 40 in urban and 10 in rural areas. This finding therefore requires further research. On the other hand, ANC services in urban areas often focus on high-risk screening in addition to routine ANC, while the rural areas provide basic services.

The results of our study clearly demonstrate that the provision of health promotion messages by health workers to clients in both urban and rural areas remains inadequate. During ANC visits, all pregnant women should have the opportunity to be fully informed about their pregnancy and given evidence-based information to help them make decisions [2, 6, 12]. Unfortunately, the pregnant women in the locations we studied received very little information; less than one quarter of them was given health promotion messages. The situation was similar situation in rural Burkina Faso, Uganda and Tanzania, where less than 20% of health workers provided health education to pregnant women and only 2 to 7% of women received information on danger signs of pregnancies [27].

Strengthening the relationship between pregnant women, their family members and health providers would also help to promote childbirth at health facilities, as well as breastfeeding and a healthy lifestyle [12, 18]. Unfortunately, family members who accompanied pregnant women to visit ANC in our study did not have the opportunity to be informed about care, treatment, and or possibility of unexpected problems, because they were not invited to attend during ANC sessions together with pregnant women (submitted for publication).

Although effective counseling can help to improve women’s behavior and health outcomes [15, 16], none of the health providers in this study performed counseling on nutrition, child vaccination, and breastfeeding. This was probably due to lack of training, guidelines, and a specific private room for counseling in the public health facilities in Laos [28, 29].

Information materials seemed to be a neglected component for ANC provision at public health facilities in Laos. Our study demonstrated that ANC health care providers rarely apply IEC materials for their health promotion activities even when they were available – this may be due to insufficient materials and/or to lack of good training. This is supported by the findings from another recent study in which health workers reported that they lacked materials and guidelines to use at their health facilities, and a lack of training on how to use existing materials effectively (submitted for publication).

The health care providers’ communication skills influence women’s satisfaction with maternal health care services [30]. Improvement of those communication skills, for example by training, should enhance their information provision and increase women’s involvement in their own health care [31]. The results of this study also suggest that communication between health care providers and their clients is still very weak. Health care providers need to show more kindness and respect, and need more privacy for communication with their clients. A study in Ethiopia on clients’ satisfaction with health care providers’ communication also demonstrated that pregnant women were particularly dissatisfied about information provision and the time limitations of consultations [32].

The overall performance of ANC services by health care providers at the public health facilities in Lao PDR was observed to be inadequate in both urban and rural areas. Insufficient provision of health education and poor communication skills of health care providers were revealed. Existing IEC materials were scarcely used for health education by health care providers both in urban and rural areas even when they were available. Taking action to improve the quality of ANC services by training and providing specific guidelines, creating separate rooms, and providing sufficient and effective materials to be used for counseling is urgently required at the public health facilities in Laos.