The results of this study show that although a large proportion of women attending antenatal clinics did so repeatedly, they were not benefiting from effective information, education and communication which together form one of the primary purposes of antenatal care. Ninety percent of those interviewed had attended the antenatal clinic more than once and 52% four or more times. However, most of them (70.5%) said they spent 3 minutes or less with the antenatal care provider and less than 40% could recall being informed or educated about important subjects such as diet and nutrition, care of the baby, family planning, place of birth. An even smaller proportion (19.3%) could recall being educated about what to do if there was a complication.
One of the lessons learned from the Safe Motherhood Initiative is that community involvement is a key requirement for sustainable reduction of maternal mortality [16
]. However, individual women, families and communities need information and education to be empowered to contribute positively to making pregnancy safer. Therefore, the large proportion of pregnant women in this study who reported that they were not informed or educated about important issues is of concern.
We observed that pregnant women were least likely to recall having received the IEC that related to the recognition of danger and response to pregnancy-related problems. In a study of women 6–12 months after giving birth in another health division, Walraven et al found even lower levels of antenatal education on danger signs and complication readiness [17
]. This low level of awareness of danger signs contributes to a failure to obtain adequate care in time and hence, maternal death in The Gambia [13
]. There was even less awareness about danger signs for the unborn child.
Information, education and communication require time. The new antenatal care model recommends 30–40 minutes for the first visit and 20 minutes for subsequent visits to carry out all activities including individual IEC [18
]. However, most women said they spent 3 minutes or less with their provider. Communicating effectively under this circumstance would be an enormous challenge and could explain the poor provider-client interaction. It was not surprising that in this "rushed" scenario very few women asked questions. On the other hand, it is encouraging that 95% of women understood the answers given to the questions they asked. Direct observation in Nepal revealed that an average of only one minute was spent on counseling [19
]. Little attention was also paid to danger signs and complication readiness with communication flowing mostly in one direction from health worker to pregnant woman. Although, the health system in Nepal is probably different from ours, it suggests that the challenge to provide adequate antenatal IEC is not unique to our setting. On the other hand, the new antenatal care model also recommends fewer routine antenatal visits with the expectation that this would give providers more time to spend communicating effectively with clients.
Staff shortages are a major constraint in the delivery of health services in The Gambia but midwives are particularly affected by excessive workloads [20
]. Since each midwife must attend to a relatively large number of women in a defined period, the provision of IEC may be given less priority. Even where there are adequate numbers, staff training, attitudes, supervision and incentives would be important determinants of the quality of the services that are delivered. We did not assess these issues but believe that they would be important for planning and organization of services.
There are efforts to improve the human resource situation but in the short term, an effective IEC strategy is needed. Traditionally, IEC has been provided at the antenatal clinic level. In view of the human resource constraints and the need to reach a wider audience, we propose a strategy that provides IEC through the mass media – addressing various issues and encouraging women to ask questions at the antenatal clinic. This has several advantages. A uniform message will be disseminated, it will reach non-pregnant women who will be better informed and able to make better choices early on when they become pregnant (such as early attendance which is particularly important for effective intermittent preventive treatment of malaria). These messages will also reach men (who are influential in maternal health) to encourage positive participation as partners in making pregnancy safer. Cultural perceptions at family and community levels influence how the woman, family and community respond to pregnancy-related complications [15
]. By using the mass media, family members and the community as a whole would also be reached with messages that encourage positive attitudes and participation. This is more consistent with intentions of the National Reproductive Health Policy [11
Ensuring messages reach the target audience is a concern. However, there is recent positive experience in the country with the use of radio for IEC for increasing awareness and knowledge of HIV/AIDS [21
]. In Guatemala, clinic and population-based surveys demonstrated that pregnancy-related radio messages increased awareness of danger signs in pregnancy and were an important complement to clinic-based education [22
The nationwide Maternal Mortality Survey showed that women in rural areas were at increased risk of maternal death [9
]. However, the reported provision of IEC was similar in both urban and rural antenatal clinics and where differences occurred, women attending rural antenatal clinics performed better. Thus, the higher risk of death among rural women was not because they were less likely to recognize danger compared to women in urban areas. A possible explanation is that delivery services are less readily available to rural women compared to urban women. In rural communities, access to antenatal services is enhanced through outreach ("trekking") clinics. Health workers from designated base clinics travel to the communities on specific days to provide antenatal services and return to their base. For delivery, women in these rural communities have to travel to the base clinic. Thus, the distance barrier has been overcome for antenatal services but not for delivery services. This is a critical issue since most complications that lead to maternal death occur around the time of delivery.