The study used the best practice recommendations jointly released by the Philippine Obstetrical and Gynecological Society and the Philippine Society of Maternal-Fetal Medicine [3]. Standard timing of outpatient department visits was suggested to be at 11–13 weeks, 20 weeks, 28 weeks, 32 weeks, 36 weeks, and 37 weeks of gestation. Interim visits at 16, 24, and 34 weeks were encouraged to be scheduled via telemedicine at the provider’s discretion. No interim guidelines were released by the Philippine Department of Health pertaining to the number of antenatal care visits during the COVID-19 pandemic. Published pre-pandemic data on antenatal care coverage by the Philippine Statistics Authority (PSA) [7] included having at least four visits. This was in line with the 2016 World Health Organization recommendation of having a minimum of four antenatal visits. This recommendation, however, has already been revised to a minimum of eight contacts including one contact in the first trimester, two contacts in the second trimester, and five contacts in the third trimester. The revision was due to the evidence that perinatal deaths increase with only four antenatal visits [8].
Initiation of antenatal care during the first trimester allows timely detection and prevention of complications. Patients receive earlier guidance on nutrition, immunization, and monitoring for danger signs. Despite previous findings by Landrian et al. that women were more likely to delay initiation of antenatal care during the pandemic, our results showed that majority of the respondents (71.38%) had their first antenatal care during the first trimester as recommended. This was similar to reported pre-pandemic data by the PSA that 71% initiated antenatal visits in the first trimester. Meanwhile, it was higher than pre-pandemic reported data by Hiroguchi and Nakazawa [9] of only 63.4% of Filipino women beginning antenatal care within the first trimester. It is possible that concerns regarding the potential risk of COVID-19 infection during their pregnancy served as motivation to seek earlier care.
Despite the physical and financial barriers to seeking antenatal care, most Filipino women were still able to seek consults for their pregnancies. Majority were seen primarily via face-to-face consults. However, less than half of the respondents were able to have at least six in-person antenatal visits. Of the 318 respondents, 46.37% had six or more face-to-face antenatal visits. This is higher compared to the utilization in Ethiopia of 29.3% [5] and lower compared to India of 75% [10]. The differences may be attributed to cultural differences, variations in sociodemographic profiles, and the national health structures. In the 2017 National Demographic and Health Survey (NDHS) published by the PSA, the percentage of women with at least four antenatal care visits was 87% in 2017. In our study, the proportion of women with at least four antenatal care visits was 64.78%. This was lower than the pre-pandemic coverage. Low utilization of services may be due to movement restrictions, fear of infection, economic pressure, and disruptions to healthcare systems.
Hospital outpatient services were closed in the early phases of the pandemic due to the lockdown restrictions. A strategy employed by most countries during the pandemic was remote care via telemedicine. However, telemedicine seems underutilized for antenatal visits in the Philippines. Half of the respondents did not have any consults by this method, which may be attributed to lack of knowledge of available services, lack of internet access, and limited availability of mobile electronic devices. These services should be promoted to improve antenatal care attendance for women with low-risk pregnancies. Expanding public health initiatives to ensure access to telemedicine should be prioritized, particularly for women of lower socioeconomic status.
The respondents utilized different facilities, with most having consultations in at least two types of facilities. Community or barangay health centers provided care to 48.86% of the women. Midwives at these centers provided most of their antenatal care. Our results showed that women attended to by midwives and nurses were more likely to have more visits than those seen by doctors. Barangay health centers and midwives were more accessible to most patients. It is plausible that some women deferred having consultations at hospitals for safety concerns.
The Maternal, Newborn, Child Health and Nutrition (MNCHN) strategy was implemented to reduce maternal and neonatal deaths aimed at the community level. This entails population-wide provision of MNCHN services to any locality in the Philippines. The strategy seeks to ensure that all pregnancies are adequately managed, and all deliveries are facility-based and managed by skilled birth attendants or health professionals. Key strategies include providing universal access and utilization of services, establishing a service delivery network, organized use of instruments for health systems development, and rapid build-up of institutional capacities. The service delivery teams in the MNCHN strategy include one women’s health team per barangay and one midwife per barangay health station. Barangay-based women’s health teams should be competent in pregnancy tracking, assisting pregnant women in birth planning, reporting maternal deaths, and organizing outreach activities as necessary [11].
The proportion of pregnant women receiving antenatal care from skilled providers increased from 85% to 1993 to 94% in 2017. The various geographic regions had antenatal care coverage by a skilled provider in 91.7–98.8%, except for the Autonomous Region in Muslim Mindanao with only 68.6%. The lack of adequate representation from the different regions in our study precludes comparison. In the 2017 NDHS, midwives were the primary providers for up to 50% of women, followed by doctors (39%) and nurses (4%). This was similar to the findings in the study, where midwives attended to 50.31% of the respondents during the pandemic. This underscores the indispensable role of primary-level health care through midwives in the country’s provision of maternal care services. Midwives should be given continuous training to strengthen their capacity as community workers.
Among the sociodemographic characteristics, marital status showed a significant difference in the adequacy of antenatal care of women. Married women and those with common-law partners were 1.75 and 1.89 times more likely to get adequate consults than single women. Spousal support was related to positive effects on mothers’ mental health and overall wellbeing. The woman’s financial capability to seek antenatal consult is augmented by having support from her husband or partner. The physical, emotional, psychological, and financial support given to women improves their health-seeking behavior during pregnancy [12].
The current study did not find a significant correlation between educational status and adequacy of antenatal care. This is contrary to previous studies that demonstrate the positive association between higher education attainment and utilization of antenatal care services [13, 14]. Education improves health literacy [13]. Thus, educated women have better understanding of the benefits of antenatal care and confidence in decision-making. Aside from education, the economic status was correlated to utilization of antenatal care in earlier studies [14, 15]. A higher economic status allows women to be able to afford healthcare costs, including travel and service expenses. Meanwhile, low-income women may allocate their limited resources to the basic needs of their family. Our study should no difference on utilization based on monthly household income. This may underscore the important role of local community health centers which are more accessible to patients. These centers provide free services and may alleviate the disparity of access to antenatal care services.
Employment was negatively correlated to the adequacy of antenatal care. Previous studies have indicated that employed mothers were more likely to have adequate antenatal care [16]. In our study, however, employed mothers were less likely to have adequate antenatal care because of their less flexible schedules and salary deductions from tardiness or absences. The development of labor laws supporting maternity leaves for antenatal care should be supported. Republic Act 11,210, an act increasing the maternity leave period to 105 days, should be strictly enforced and supported by stakeholders. Likewise, mothers should be made aware of the existence of such laws.
Among the obstetric and medical characteristics, predictors of adequate antenatal care utilization are previous pregnancies, previous live births, and having living children. Women who have had previous pregnancies may have better knowledge of pregnancy-related complications, having received previous antenatal care. Likewise, they may better understand the importance of antenatal care for improving neonatal outcomes. This may also reflect past positive experiences and outcomes with antenatal visits. History of miscarriage and existing medical illnesses are thought to improve the health-seeking behavior of women in subsequent pregnancies. These women are more likely to initiate antenatal consults for guidance and care in avoiding pregnancy complications. However, these were not found to affect the adequacy of antenatal care among the study participants, Women who had complications in their previous pregnancies were more likely to have adequate antenatal care. This demonstrates their understanding of the need for stricter follow-up and monitoring schemes for women with poor obstetric histories.
Most respondents travel less than 30 min to the nearest healthcare facility reflecting the number and distribution of available facilities. This may also reflect the active participation of primary-level care at barangay health stations in providing health care. The pandemic resulted in traveling restrictions and cancellations of public transportation modalities, which affected women’s access to facilities. Women with private vehicles were 2.65 times more likely to have adequate consults than those who utilize public modes of transportation. This further underscores the disparities experienced by women of lower economic status. The national government should address issues on transportation and improve access to continue the equitable provision of services.
Once at the facilities, more than half of the respondents waited for 15 to 30 min, while 32.71% waited more than 30 min. Women who were seen at hospitals were more likely to wait more than 30 min. This is similar to the findings of Rabbani et al. [10], where women seen at hospitals had longer waiting times compared to primary health care clinics (90 vs. 30 min). Organizing the flow of patients is vital to decrease the waiting time and thus exposure of patients to possibly infected individuals. Reducing the waiting time will also improve patient satisfaction and promote a positive antenatal care experience.
The facility in which study participants delivered did not have significant correlation with the adequacy of antenatal care. Majority of the study participants sought antenatal care in community centers and lying-in clinics but ultimately delivered in hospitals. Adequate antenatal care increases the probability of utilizing skilled attendants or community health workers in developing countries [2]. The choice of facility for antenatal care and delivery was certainly affected by the pandemic. Several facilities were understaffed and may have limited their number of obstetric admissions. Referral networks with obstetricians and pediatricians were authorized to ensure non-refusal of patients within the healthcare provider network.
The study showed a positive perception of antenatal care, with all respondents agreeing on its necessity. Despite this, nearly half of the women reported cancellation of scheduled antenatal visits. Reasons for cancellations included lockdown or quarantine restrictions, transportation problems, fear of going to the hospital or contracting coronavirus, financial and employment status problems, full schedules of hospitals or clinics, and lack of companion. These were similar to an online survey among pregnant Chinese women to investigate their attitudes toward antenatal care during the pandemic [17]. About 20% of the respondents were afraid to have any in-hospital visits. More than half postponed and canceled their appointments at any point during the pregnancy because of anxiety about going to a hospital.
Periconceptional counseling is essential to improve pregnancy outcomes. Most participants have participated in counseling and medical examination before pregnancy. However, those who have participated in a medical examination before pregnancy had 63% less odds of having adequate antenatal care. There may be a need to strengthen patient education during annual gynecologic and medical examinations of reproductive-aged women to emphasize the importance of antenatal care.
The study highlighted the determinants of health behaviors and utilization of pregnant women during the pandemic. Responsive healthcare systems should recognize these indicators, create policies to address identified problems, strengthen enabling factors, and perform continuous surveillance.
