Utilization of Antenatal Care Services Within the Context of COVID-19, Security Challenges, and an Unstable Healthcare System at Primary Health Care Centers

Introduction

Improving maternal health is one of the World Health Organization’s (WHO) Millennium Development Goals (MDGs) and assessing progress toward these goals.¹ The WHO recommends four antenatal visits for uncomplicated pregnancies beginning within 12 weeks of gestational age.² These services enhance the health and overall well-being of pregnant women while also increasing the likelihood of receiving care from qualified birth attendants and facilitating effective communication with healthcare providers.³

Access to adequate and timely antenatal care services is the cornerstone of maternal and child health and is pivotal in reducing maternal and infant mortality rates.⁴ However, the utilization of such services can be significantly influenced by various contextual factors, including external challenges, such as health emergencies, security issues, and healthcare system instability. The outbreak of the COVID-19 pandemic, coupled with pre-existing security challenges and an unstable healthcare system, has posed unprecedented hurdles to maternal health services worldwide.⁵

In Sudan, antenatal care services provided by primary, secondary, and tertiary health care are the classical standard arrangements. Primary healthcare (PHC) is a basic health unit for ANC services.⁶

Sudan has a history of political, economic, and healthcare system challenges and faces unique obstacles in providing adequate maternal health care. The nation’s healthcare infrastructure has been further strained by the COVID-19 pandemic, which has disrupted healthcare delivery and created additional barriers to accessing antenatal care services.⁷ Concurrently, security challenges in some areas of Sudan have exacerbated the difficulties faced by pregnant women seeking essential healthcare.⁸

The emergence of the COVID-19 pandemic has significantly altered healthcare systems worldwide.⁹ The need for infection control measures, social distancing, and lockdowns has reduced access to healthcare facilities and changed health-seeking behaviors.¹⁰ Pregnant women, who constitute a vulnerable population, may be particularly affected by concerns regarding exposure to the virus. The pandemic’s impact on healthcare services and patient behavior has implications for antenatal care utilization, leading to potential delays in seeking care and compromising maternal and fetal health outcomes.¹¹

The instability of Sudan’s healthcare system, driven by various factors, including economic constraints and inadequate infrastructure, poses additional barriers to accessing antenatal care services. Limited resources, health workforce shortages, and inadequate facilities can result in suboptimal healthcare service delivery, further discouraging pregnant women from seeking care.¹²

The utilization of ANC at primary healthcare centers was hindered in numerous regions globally. The prevalence of maternal health service usage was observed to be low in various places, such as Ethiopia¹³ and several developed countries,¹⁴ as well as in many African countries like Congo, Sierra Leone, and Uganda.¹⁵ The extent of disruption varied across these diverse settings, and it appeared to be qualitatively associated with the stringency of lockdown measures and the perceived attitudes towards the risks posed by COVID-19.

The utilization of ANC was significantly impacted and decreased in the face of security challenges at primary healthcare centers. This was assessed by evaluating the accessibility of antenatal care (ANC) services in primary healthcare facilities in Pakistan,¹⁶ revealing a substantial decline in ANC utilization. In India,¹⁷ this challenge further complicated efforts to ensure patient safety and equity in ANC services in many low-and middle-income countries.¹⁸ Security instability similarly affected ANC utilization in various regions of Sudan.

The utilization of ANC in the unstable health care system at primary health care centers can vary depending on various factors. One study conducted in rural Zambia¹⁹ found that the utilization of ANC services was affected by the availability and accessibility of healthcare facilities. In areas with unstable healthcare systems, there may be a lack of well-equipped primary healthcare centers, leading to reduced utilization of ANC services.²⁰

Despite the acknowledged importance of antenatal care, limited research has explored the utilization of such services within the confluence of COVID-19, security challenges, and an unstable healthcare system, particularly in contexts like Sudan.²¹ We want by this study to address this gap by exploring the intersection of these complex challenges and their impact on the utilization of antenatal care services within primary health care centers in Sudan.

This study examines the utilization of antenatal care services within the challenging context of Sudan, where the COVID-19 pandemic, security challenges, and an unstable healthcare system at primary healthcare centers have posed significant barriers to the provision and utilization of essential maternal healthcare. By understanding the factors affecting antenatal care utilization in this context, we can identify strategies to improve access to and quality of care, ensuring the well-being of pregnant women and their infants. This study aims to shed light on the challenges faced by pregnant women in Sudan while offering insights and recommendations for policymakers and healthcare providers to address these issues effectively. The primary objective of this study was to assess the utilization of antenatal care services in the context of COVID-19, security challenges, and an unstable healthcare system at primary health care centers in Sudan.

Methodology

Study Design

This PHC-based cross-sectional study was conducted from June 2021 to June 2023. This study employed a mixed-methods research design to comprehensively investigate the utilization of antenatal care services within COVID-19, security challenges, and an unstable healthcare system in primary health care centers in Sudan. Integrating qualitative and quantitative approaches allows for a holistic understanding of the complex factors that influence antenatal care utilization.

Study Setting

The study was conducted across selected primary healthcare centers in the Sharge Elneil locality, Khartoum State, Sudan, including areas affected by security challenges. The centers were chosen to represent diverse socioeconomic backgrounds and varying degrees of healthcare system stability.

Theoretical Framework

Integrating a conceptual or theoretical model into research related to the utilization of antenatal care services within the context of COVID-19, security challenges, and an unstable healthcare system at primary health care centers are provide a structured framework for understanding the relationships and factors involved (Figure 1).

Figure 1 Integrating conceptual theoretical model.

Sampling Strategy

A stratified purposive sampling strategy was employed to ensure representation across geographical regions and security contexts. Fifteen primary health care centers were selected, and within each center, a convenience sample of pregnant women accessing antenatal care services was recruited.

Sampling

Simple random sampling was used to enroll participants. This study randomly investigated pregnant women regarding their utilization of antenatal care services. The sample size determines by: n =Zα/22×p (1–p)/d2 = 384 (minimum sample size). Accordingly, 536 women were enrolled in this study.

Data Collection

Quantitative Data Collection

A structured questionnaire was administered to pregnant women visiting the selected health care centers. To ensure the validity and reliability of the structured questionnaire it share the questionnaire with subject experts. The we collected feedback on the questionnaire’s clarity, relevance, and the appropriateness of the items. We make necessary revisions based on their suggestions.

The questionnaire included sections assessing sociodemographic characteristics, antenatal care utilization patterns, perceived barriers, experiences related to COVID-19, and security challenges. The questionnaire was developed based on validated scales and was adapted to the local context.

Qualitative Data Collection

Focus group discussions (FGD) were conducted with the 23 pregnant women to encourage open discussions and facilitate the exploration of shared experiences and perspectives. The FGD explores the aspects of antenatal care utilization, the impact of COVID-19 and security challenges, and perspectives on the stability of the healthcare system. We choose a skilled facilitator to guide the discussion, ensure all participants have an opportunity to speak, and maintain a constructive and respectful atmosphere.

Data Analysis

Quantitative Data Analysis

Descriptive statistical analysis was performed to summarize the demographic characteristics and antenatal care utilization patterns. A logistic regression analysis was executed to explore the relationship between various factors, encompassing sociodemographic elements, perceptions linked to COVID-19, concerns about security, and the extent of antenatal care utilization. The study data were subjected to various statistical procedures before analysis using STATA BE 17.

Qualitative Data Analysis

Thematic analysis was employed to analyze qualitative data from interviews and focus group discussions. Transcribed data were coded and categorized into themes and sub-themes to capture participants’ experiences, perceptions, and challenges related to antenatal care utilization.

Ethical Considerations

Ethical approval was obtained from the Gezira Institute of Safe Motherhood and Childhood. Informed consent was secured from all participants, underscoring their entitlement to privacy and voluntary engagement. Efforts were made to maintain confidentiality and anonymity of the participants.

Result

This study included 536 pregnant women attending antenatal care, regardless of their age and marital status, after matching the inclusion criteria. Table 1 provides an overview of antenatal care (ANC) service utilization according to various sociodemographic characteristics among the 536 participants. The table presents the distribution of participants who regularly attended ANC services and those who did not, categorized by different variables, including age, educational level, parity, occupation, marital status, and various interruptions related to COVID-19. University graduates (p = 0.00), multiparas (p = 0.01), and unemployed (p = 0.01) attended antenatal care. Several factors significantly hinder regular antenatal care attendance. Significantly, these disruptions resulted from the COVID-19 pandemic, affecting 163 participants (30.4%) (with a p-value = 0.03).

Table 1 Utilization of Antenatal Care Services According to the Characteristics and Issues Leaded to ANC Services Interruption (n=536)

Additionally, concerns regarding infection during the pandemic disrupted the care of 146 participants (27.2%) (p = 0.01). Public transportation instability also played a role, affecting 262 individuals (p = 0.01). Moreover, services were further interrupted owing to security challenges arising from unstable situations and conflicts. Beyond the influence of the COVID-19 pandemic, the significant reduction in the utilization of ANC services was attributed to challenging security instability, affecting 258 individuals (p = 0.00). The findings are presented in (Table 1).

Logistic regression analysis aimed to explore the relationships between sociodemographic factors, perceptions of COVID-19, security concerns, and the utilization of antenatal care services. Women aged 40–49 years had significantly lower odds of antenatal care utilization compared to women of other age groups (OR=0.56, CI 0.37–0.85, p = 0.007). Women with primary (OR 0.89), secondary (OR 1.12), university (OR 1.28), and post-graduate education (OR 1.45) had odds of antenatal care utilization that were not significantly different from those of illiterate women (p > 0.05). Women who were grand multipara had slightly lower odds of antenatal care utilization than multiparous women (OR=0.76, CI 0.53–1.10, p = 0.141). The odds of antenatal care utilization were not significantly different between the employed and unemployed women (odds ratio [OR] =0.91, CI 0.65–1.29, p = 0.614).

Women who had a perception of COVID-19 had lower odds of antenatal care utilization compared to those without the perception (OR=0.72, CI 0.53–0.98, p = 0.037). This suggests that COVID-19 perceptions may be associated with decreased ANC utilization. Women who expressed security concerns had slightly lower odds of antenatal care utilization than those without security concerns (OR=0.82, CI 0.58–1.16, p = 0.266). (Table 2).

Table 2 Logistic Regression Analysis to Examine the Factor Influence Antenatal Care Utilization (n=536)

Qualitative Findings

Qualitative interviews were undertaken to delve into the firsthand experiences and perspectives of participants concerning the utilization of ANC services in this particular context. In-depth interviews were conducted to explore pregnant women’s experiences and perceptions of attending ANC services in the context of COVID-19, security challenges, and an unstable healthcare system at primary health care centers in Sudan. The thematic analysis revealed insights into the motivations, challenges, and strategies for ANC attendance (Table 3).

Table 3 Summary of Qualitative Result

Many pregnant women reported significant fear and anxiety associated with attending antenatal care services because of prevailing security challenges. Some participants noted instances of violence and threats near healthcare centers, which deterred them from seeking care in areas with security challenges, access to reliable transportation to healthcare centers is a common barrier. Women expressed concerns about the safety of traveling to and from these centers, which often led to delayed or missed appointments.

Healthcare providers have described disruptions in antenatal care services caused by COVID-19, including the reallocation of resources and staff to respond to the pandemic. These disruptions result in a reduced frequency of antenatal check-ups.

Pregnant women conveyed concerns about the risk of contracting COVID-19 while attending healthcare centers, particularly given crowded waiting areas and shared facilities. These fears sometimes lead to reluctance to seek care.

In areas with unstable healthcare systems, some communities have established local, informal networks to provide basic antenatal care information and support, helping women manage their pregnancies in the absence of reliable healthcare services.

In response to the challenges posed by COVID-19 and security issues, healthcare providers have begun to implement telehealth and virtual consultation services. This allowed pregnant women to receive guidance and support regarding the safety of their homes.

Both pregnant women and healthcare providers emphasized the need for enhanced security measures around healthcare centers, such as increased policing and the establishment of safe zones to ensure the safety of pregnant women seeking care.

Participants suggested the need for more resilient healthcare systems that can adapt to unforeseen challenges, with better contingency planning and resource allocation to ensure continuous antenatal care services during crises, such as pandemics and security issues.

The qualitative findings underscore the resilience of pregnant women in attending ANC services amid the complexities of the COVID-19 pandemic, security challenges, and an unstable healthcare system.

Discussion

This study has uncovered critical insights into the complex landscape of antenatal care in challenging environments. In this discussion, we highlight the key findings and their implications.

The results of this study shed light on the complex interplay between sociodemographic factors, disruptions caused by the COVID-19 pandemic, and security challenges that influence ANC utilization. The outcomes of this study are in line with established literature, underscoring the diverse factors that impact ANC utilization.^22–24 These parallels underscore the global nature of these challenges and the need for context-specific intervention. We must address the complexity of the factors influencing ANC utilization, encompassing sociodemographic and external challenges.

Studies have demonstrated the detrimental impact of the pandemic on various healthcare services, in this study the significant reduction in the utilization of ANC services was attributed to challenging security instability. The study revealed that security challenges significantly impede the utilization of antenatal care services. Pregnant women faced fear, anxiety, and even violence when trying to access healthcare facilities. This aligns with research indicating that conflict and insecurity disrupt essential health services, particularly in low-resource settings.^25,26 This has profound implications for maternal and child health, as it discourages timely and regular antenatal check-ups. The presence of security concerns necessitates immediate attention from local authorities, possibly through increased policing and the establishment of safe zones around healthcare centers.

The community-based health initiatives, including telehealth and virtual consultations, emerged as innovative solutions to address the challenges presented by COVID-19 and security issues. These adaptations allowed pregnant women to receive the necessary guidance and support without risking exposure. These strategies should be further developed and integrated into healthcare systems as they have proven effective in ensuring care continuity. These adaptations align with global efforts to leverage technology and community engagement to ensure the continuity of essential healthcare services during crises.^25,26 Such strategies can potentially improve access to healthcare beyond the pandemic and promote equity and reach. The outcomes of this study are in line with established literature, underscoring the diverse factors that impact ANC utilization.^27,28 Health interventions involving communities can have lasting positive effects on healthcare-seeking behaviors and health outcomes.

The study participants strongly advocated for enhanced security measures and resilient healthcare systems. Increased policing and the establishment of safe zones were seen as necessary steps to ensure the safety of pregnant women seeking care. Additionally, participants stressed the importance of healthcare systems being flexible and adaptive to unforeseen challenges, with better contingency planning and resource allocation. These recommendations could serve as a blueprint for healthcare policy and planning in similar regions.^29–35 Comprehensive policy and programmatic interventions are essential to address the multifaceted challenges identified in this study.

This study provides essential insights into the utilization of antenatal care services in contexts of COVID-19, security challenges, and unstable healthcare systems. Addressing these challenges necessitates a multifaceted approach involving local authorities, healthcare providers, and communities. It is imperative to prioritize the safety and well-being of pregnant women, promote innovative solutions, and build healthcare systems that are resilient and adaptable in the face of crises.

Limitations

The study’s constraints encompass its cross-sectional design, which hampers the establishment of causal connections, and the potential for bias in participants’ self-reporting. Further research could explore the long-term impact of decreased ANC utilization on maternal and child health outcomes as well as the sustainability of adaptive strategies.

Conclusion

The proposed mixed-methods research design aimed to provide a comprehensive understanding of the utilization of antenatal care services in Sudan within the complex context of COVID-19, security challenges, and an unstable healthcare system. By integrating quantitative and qualitative approaches, this study attempts to capture the multifaceted factors shaping antenatal care utilization and inform policy recommendations that address the unique challenges faced by pregnant women in this context. In Sudan, the situation is more complicated than elsewhere because, in addition to the COVID −19 pandemic, there has been economic, social, and security instability since the Sudanese revolution. Ultimately, this study contributes to a broader understanding of healthcare access within complex contexts, advocating resilient and adaptable healthcare systems that prioritize maternal and neonatal health.