Holistic antenatal care during pregnancy: A systematic review
Faculty of Health Sciences, Department of Advance Nursing Sciences, University of Venda, Thohoyandou, South Africa
College of Human Sciences, Department of Health Studies, University of South Africa, Pretoria, South Africa
#Violet.Chewe@univen.ac.zaAbstract
Background
Pregnancy outcomes are determined by the type of antenatal care a woman receives. The purpose of this review was to conduct a critical analysis of the literature on the provision of holistic antenatal care to pregnant women.
Design
A systematic research review was employed for the study.
Data Sources
A search of EBSCO Host, Google Scholar, Sabinet, and Science Direct databases was performed. After reviewing 150 paper titles and abstracts, 14 studies were found to meet the final criteria for quality assessment. Included were only English-language papers published from 2020 to 2023.
Eligibility Criteria for Selecting Studies
Quantitative, Qualitative, Review studies, Quasi-experimental, and cohort studies. Papers had to include adults (>18 years old), and pregnant women attending antenatal care at different health facilities worldwide and published in peer-reviewed journals from 2020 onwards.
Results
Four of the fourteen analysed articles focused on socioeconomic status, three on staff attitudes, age, parity, and religion, and one on infrastructure. Six studies focused on midwives ’role in providing holistic antenatal care. These factors impacted pregnant women’s ability to receive comprehensive antenatal care. Three studies on woman-centered care and three on focused antenatal care have also come to light to enhance midwives’ capacity to deliver comprehensive prenatal care.
Conclusion
Healthcare facilities should offer an environment where communities may learn about the importance of antenatal care visits and how to ensure pregnant women obtain acceptable treatments.
Implications
This study demonstrates the necessity for healthcare providers to be resourceful about offering holistic antenatal care to pregnant women to enhance outcomes for both mothers and newborns.
Article notes
Competing Interest Statement
The authors have declared no competing interest.
Funding Statement
The study received no funding.
Introduction
Holistic antenatal care is the level of excellence in providing antenatal care to pregnant women to lower maternal mortality [1]. Antenatal care (ANC) is the care given to pregnant women by qualified healthcare professionals to provide the best possible health outcomes for both mother and child throughout pregnancy [2].
Other countries like the Netherlands have holistic midwives who offer integrated ANC to pregnant women [3]. A holistic midwife is a single midwife who interacts with a woman’s physical, psychological, and emotional factors during her pregnancy and birthing [4]. Moreover, [3] proposes that holistic midwives be utilized for high-quality ANC due to their inclusive services. The services include good relationships with women, mutual respect, and trust.
According to the findings from the study conducted in Bandung, Indonesia, by [5], holistic antenatal care lowers maternal anxiety levels in pregnant women. [5] further asserts that holistic ANC provides pregnant women with comprehensive psychological, emotional, social, and spiritual care. According to [6], pregnant women use antenatal care services for quality, which can be attained when provided holistically. On the other hand, [7] states that providing holistic ANC in particular situations can be challenging as some women attend ANC appointments solely to reserve a birthing location. Therefore, in such cases, women do not understand why it is crucial to attend ANC; hence, they end up skipping their scheduled follow-up appointments.
In a remote Tanzanian district, the quality of antenatal care was evaluated from a holistic angle [8]. The results showed that regular ANC services function inconsistently, partially accounted for by insufficient resources. Taking an acceptable history, paying attention to the client’s well-being, doing a basic physical examination, and providing proper counseling and education all displayed poor performance. Embracing holistic antenatal care services may benefit pregnant women and their unborn children.
As of the 2021 report, the Maternal Mortality Ratio (MMR) stood at 148.1 maternal deaths per 100,000 live births [9]. This is a 47% increase in maternal mortalities from 2019 and a further increase from the MMR of 126.1 in 2020. This demonstrates that in 2021 and 2020, the sharp fall between 2010 and 2019 has reversed. There was an increase in MMR from 2019 in every province in South Africa.
The purpose of this review was to identify patterns and conduct a critical analysis of the literature about the provision of holistic antenatal care. While there are many studies regarding antenatal care, this study focuses mainly on holistic antenatal care. Pregnant women should receive holistic ANC, which includes care for their physical, emotional, and spiritual needs [9].
Research question: What factors impact the provision of holistic antenatal care?
Materials and Methods
A systematic review evaluated the factors that impact providing holistic antenatal care to pregnant women. There is no registration for the systematic review protocol.
Eligibility Criteria
Inclusion
Studies were selected for the systematic review if they included adults (>18 years old) who attended antenatal care at public health facilities worldwide. Quantitative, Qualitative, Review, Quasi-experimental, and cohort studies were included. Studies had to have been published in peer-reviewed journals from 2020 onwards. Only articles published in English were considered for inclusion in the review due to the need for more resources available for translation services.
Exclusion
Grey literature, including conference abstracts, posters, and case reports, were excluded to ensure that only high-quality, peer-reviewed data was used in this systematic review. Published protocols with results were considered.
Information sources
A subject librarian from the University of South Africa (UNISA) assisted with this process. The researcher used the following search engines to locate appropriate information for the study: EBSCO Host, Google Scholar, Sabinet, and Science Direct on 29 October 2023. The reference lists of non-experimental studies discovered through the electronic search and considered relevant to the review topic were also examined to identify relevant articles for inclusion in the next abstract review phase. There was no need for ethics approval because this was a review study.
The following attributes of each study in this review were extracted from the abstracts of the publications: author and year of publication, objective/aim, country, study design, population and sample size, outcomes, and limitations. Refer to Table 2 for the characteristics of the included studies.
Search Strategy
The researchers collaborated with the subject librarian to conduct a thorough literature search on all major electronic databases, including EBSCO Host, Google Scholar, Sabinet, and Science Direct. The studies extracted were those published between 2020 and 2024. The search parameters were antenatal care, holistic, care, and pregnancy to include all possibly relevant papers. The electronic databases used are listed in Table 1. The references of any non-experimental papers included in the search result were screened for relevant experimental studies.
Selection process
Both authors VM and JM independently read the title and abstract of each paper to identify studies selected for full-text review based on the criteria mentioned above. Experimental studies whose interventions, patient populations, or outcomes could have been clearer based on the abstract, or papers that did not have an abstract available, were also moved on to full- text review for further assessment. Full texts of papers were also screened for mentions of the “Holistic/ quality antenatal care, midwives, pregnant women, quality antenatal care” population for the study. Papers with no references to these words were considered not to include populations of interest and were excluded from the full-text stage of the review. Finally, eligible papers deemed to meet inclusion and exclusion criteria following the full-text review underwent quality appraisal and final inclusion in the systematic review. Any discrepancies were resolved by both the author and the co-author.
The researcher outlined the study flow in the search results using the PRISMA flow chart suggested by [10] (see Figure 1). The search yielded a total of 150 articles. In these papers, the researchers conducted full-text, topic, and abstract screenings; as a result, duplicates were eliminated, and studies that didn’t meet the inclusion criteria were disqualified. Ultimately, it was concluded that 14 papers were appropriate for inclusion in the analysis since they addressed the study’s purpose, focus, and review question.
Data collection process
The author and the co-author independently extracted relevant information from each paper. Where information still needed to be included after reviewing those sources, the papers were excluded from the review.
Data Items
Specific study-related outcomes were extracted from each paper by applying the data from the original publication. Data on the study demographic, participant number, holistic/high- quality prenatal care, and outcomes reported in the original study were collected from each publication to create Table 2.
Study risk of bias assessment
The Revised Cochrane risk-of-bias tool for randomized trials (RoB 2) was used for randomized, controlled trials in the final publication batch [11]. VM and JM evaluated the tool’s signaling questions individually to evaluate each paper’s quality and bias risk. After the meeting, VM and JM agreed on any differences in their assessments of the quality of the work. Similarly, the overall risk of bias in the quasi-experimental study was calculated using Tables 1 and 2 of the ROBINS-I tool [12]. VM and JM carried out the quality assessment in the process stated above.
Results
The analysis approach of choice was thematic, employing Caulfield’s method [13]. It aided the researchers’ familiarisation with the data as they read the articles and abstracts. After that, during the coding process, the researchers highlighted terms, phrases, and conclusions that often emerged in the data. The researchers established themes from these, as shown in Table 3, which led to the findings and discussions.
Discussion
Socioeconomic disparities in terms of ANC services impact certain localities. For example, financial and geographical barriers make it difficult for American doctors to provide women with the antenatal care they require [14]. The study by [15] claims wealthier women are advantaged as they can pay and access healthcare services. This demonstrates how income, education, and residence location can contribute to disparities in access to ANC services. According to [16], women living in rural Sub-Saharan nations are more likely to receive substandard ANC due to low incomes and a location of residence. The study by [17] found additional socioeconomic determinants, such as a husband’s acceptance. Despite the obstacles mentioned, Muslim pregnant women in Nigeria receive early ANC timing [17].
Maternal age, parity, and marital status appear to impact the use of ANC services in certain cases. [18] claims that young, single women are hesitant to seek antenatal care when pregnant. Additional research reveals that women with high parity are reluctant to use antenatal services due to a history of healthy pregnancies, lack of need, and other factors [19]. Quality ANC is additionally related to other factors, such as the woman’s behavioral and psychological well-being and the number of antenatal visits she had [1].
In most African countries, including South Africa, women hold a range of religious beliefs, which could influence how they use ANC services. According to [20, 17], pregnant women who experience stigma associated with their pregnancy, fear of witchcraft, cultural beliefs, and problems with family support are less likely to use antenatal services.
Healthcare personnel should always have a welcoming approach, according to one of the ministerial goals of South Africa [21]. According to [20], concerns were made about the staff members’ lack of courtesy. A further obstacle that has been identified as discouraging pregnant women from accessing ANC is the staff members’ disrespect towards them [22]. As such, midwives should welcome pregnant women positively and use the appointment system to commence making amends.
The results additionally indicated that pregnant women are more reluctant to be treated at healthcare facilities with inadequate, clean, or well-kept amenities. To provide pregnant women in SA with holistic ANC and lower the rate of maternal and newborn mortality, commitment and resource allocation are required [23]. Health facilities should regularly maintain their infrastructure, as it is mentioned as another factor that contributes to pregnant women’s poor attendance and inadequate ANC.
Woman-centered care prioritizes each woman’s needs, goals, and aspirations ahead of those of the institution or the midwifery profession. According to [24], women reported feeling disrespected and leaving ANC confused or with questions. Enhancing ANC was considered a means of improving the standard of ANC. According to a study conducted in 2021 by [25], women who received better ANC were more inclined than those who received traditional care. Furthermore, woman-centered approaches enable healthcare systems to identify and address the needs and preferences of women, encouraging the provision of high-quality ANC [26]. Given this, delivery anxiety was much reduced by improved ANC as compared to standard treatment.
The World Health Organization created focused antenatal care (FANC), a novel type of ANC, in 2001 with the goal of using it in underdeveloped countries [19]. While a pregnant woman participates in FANC, she attends at least four scheduled ANC visits. She receives all comprehensive packages from registered healthcare practitioners recommended by the World Health Organization [2]. The quality of services rather than their quantity matters under this strategy.
Although the overall ANC use might have seemed adequate, the strategy needed to be more comprehensive, targeted, and consistent with current norms. For example, [27] demonstrates how inadequately pregnant women use FANC. Furthermore, according to [28], there is little knowledge about the method in pregnant women. Thus, the emphasis of antenatal treatment continues to be on clinical evaluation and regular clinic visits, despite recognizing the importance of FANC.
Strength and limitations
The authors VM and JM are experts in midwifery care who are currently practicing in academia, with antenatal care as their niche area of research. The analysis considered papers from international, Sub-Saharan African, African, and South African publications. The study was limited by current articles that matched the inclusion criteria.
Conclusion
The systematic review identified issues affecting pregnant women’s access to holistic ANC. These include facility infrastructure, staff attitudes, age, parity, religion, and socioeconomic status. Nevertheless, other research acknowledged FANC and woman-centered care as ways to improve midwives’ ability to provide holistic ANC. It might make sense for healthcare institutions to provide a setting where residents are informed about the crucial nature of ANC consultations and how they can ensure that pregnant women obtain safe services.
Data Availability
The author can give the data supporting the study's findings upon request.
Acknowledgment
The researchers’ independent research from antenatal and maternal health research studies is presented in this article. Therefore, only writers’ opinions and points of view are expressed.
Supporting information
S1 File. (ZIP)
Funding
There was no funding for the study.