The findings of the current study demonstrate that this was the best performed activity since averagely all nurses had good compliance. This was a great improvement compared to a previous finding by Pell, Menacaet al (2013)(26) in Kenya, Ghana and Malawi where inconsistency in provision of prophylaxis was reported due to unavailability of the necessary drugs or inability of the women to pay for the services. The improvement can be attributed to free antenatal and delivery services as well as donor support in some facilities.
Malaria prophylaxis in the current study was actually being given under direct observation treatment (DOTS) whereby the client swallows the drug in the health facility under the observation of the nurse to ensure it is actually taken in almost all the facilities. Compliance in malaria prophylaxis is in line with Abuja declaration 2000 which had set a target of above 60% coverage of pregnant women with IPT and ITNs by 2005 and beyond(27). Insecticide treated bed nets were given by a vast majority of the study participants and equally, iron and folic acid supplementation as well as deworming tablets were issued by majority of the study participants. Moreover antiretroviral drugs were available in all the clinics and all study participants were able to give those who were HIV positive. HIV care was observed to be well complied with courtesy of development partners.
An alarming finding of the current study is that health education was not given or partially given to clients by a vast majority of the study participants. Furthermore in some clinics student nurses gave group teaching to the clients without supervision before start of clinic while in others the nurses reported that health education is given to the clients by community health volunteers when they visit them in their homes.
Provision of information on danger signs should be mandatory at every antenatal clinic visit because complications like hemorrhage and puerperal sepsis cannot be predicted through antenatal screening. Women should be made aware of the symptoms and advised on what to do in case of such occurrences(28). However, the current study reveals that just above one tenth of the study participants had good compliance on education about danger signs in pregnancy.
Several previous studies have come up with similar findings that indicate that health teaching during antenatal clinics is not adequate. These include Kearns Annie et al (2014)(29). On the same line Conrad et al (2012)(21) observed that very few health workers talked to the clients about danger signs in pregnancy and likewise Sarker et al (2010)(22) concluded that linking danger signs to clinical examination and laboratory results with effective client follow-up is crucial for success of antenatal care services.
Birth preparedness was not covered by more than half of the study participants. The same findings have been documented in other researches where health education was noted as a major gap existing between actual performance and ideal performance in FANC by Von Both(2006)(30), Omari(2016)(31) and Mutiso (2008)(32).
Given that development of an individual birth plan and birth preparedness are major components of focused antenatal care, this gap is likely to be the explanation behind suboptimal achievement of aims of antenatal care as has been indicated in other researches in the past that health education is ignored in most antenatal care clinics. This observation was made in the same regard of inadequate health teaching given to clients by Nikiema et al 2009(35) to emphasize on unmet needs in provision of information in pregnancy in Sub Saharan Africa and she reported that pregnant women are not routinely given information especially on danger signs of pregnancy, likewise Harriet Birungi et al (2006)(13)shared the same sentiments.
Regarding health teaching on nutrition and infant feeding, the current study revealed that majority of the study participants did not give nutritional advice to the clients nor tell them about infant feeding, a finding supported by Mekonnenet al (2017)(20)who stated that nutritional advice was rarely given to women. Likewise, prevention of mother to child transmission of HIV was talked about by minority of the study participants despite the high prevalence of HIV in the county. Moreover, information on sexually transmitted infections as well as health teaching on family planning was given by a very small percentage of the study participants.
Current study findings reveal that nurses are not utilizing information, education and counseling (IEC) which is an important component of focused antenatal care(33). This coupled with the fact that feedback from the client at the end of the session to confirm understanding of the content was rarely elicited, raises the question as to whether health teaching during the antenatal clinics has been given the importance it deserves by the nurses.
Most of the health information required during antenatal clinic visits is outlined in the mother and baby booklet so some study participants were observed telling the clients that the book had so much information and they should read it at their own time. The finding is consistent with Schellenberg et al (2011)(16) who noted that the nurses relied much on what was indicated in the antenatal cards or books for service provision other than FANC guidelines. On the other hand Magoma et al (2010)(34) attributed low skilled birth attendance despite high antenatal clinic attendance to lack of health education especially on birth preparedness during antenatal clinic which includes information on hospital delivery. To stress on this as unmet educational need, Nikiema et al (2009)(35) reiterated that receiving information on birth preparedness and danger signs in pregnancy increases the chances of having skilled attendant at birth as well as chances of making the minimum four visits required by focused antenatal care. Moreover this represents a missed opportunity and is basically a result of little time spent with the clients during a session as the health care provider rush to clear the queue.
Determinants of nurses’ compliance with focused antenatal care