Introduction

Adequacy of antenatal care (ANC) is an important indicator for the Reproductive and Maternal Health Dimension of Sustainable Development Goals (SDGs), and specifically to reach the target 3.8, to achieve universal health coverage by 2030 [1]. ANC is defined as routine care provided to a pregnant woman between conception and the onset of labor. ANC is an essential component of basic primary healthcare and offers a platform for delivery of services that are vital to prevent, detect and treat materno-fetal morbidity, and preserve health throughout pregnancy [2–4]. An adequate number of ANC contacts with a skilled provider, initiated early in pregnancy, is crucial for screening modifiable risk-factors, preventing complications and managing pre-existing conditions [5]. Tests that can be performed during ANC contacts, especially an early contact, include screening for genetic and congenital disorders, periconceptional folic acid supplementation to reduce the risk of neural tube defects, preventing or treating iron deficiency anemia and multiple micronutrient deficiencies through multiple micronutrient supplementation, measuring blood pressure for chronic hypertension, and screening for sexually transmitted infections [5]. An adequate number of ANC contacts throughout pregnancy may also provide an opportunity to detect non-communicable diseases such as diabetes or gestational hypertension and to educate mothers-to-be on reducing modifiable lifestyle risk factors such as smoking, alcohol consumption, drug abuse, healthy eating, and occupational and environmental exposures.

In 2016, WHO released a revised ANC guideline, recommending eight ANC contacts throughout pregnancy, with the first contact occurring in the first trimester (up to 12 weeks of gestation) followed by two and five contacts in the second and third trimesters, respectively [6]. A timely first ANC contact has been shown to be associated with an increased total number of ANC contacts and the content of care received [7]. The recommended shift from four to eight ANC contacts highlights the importance of continuous care, starting early in pregnancy, to ensure early screening. During the years preceding its issuance, ANC coverage, defined as the percentage of women aged 15–49 years provided any antenatal care by a skilled provider, was estimated to be 85% globally and 77% in the low-income countries [4]. Previous studies have reported several factors associated with adequate antenatal care: initiation of care in the first trimester of pregnancy, residence in an urban area, especially close to an ANC facility, secondary or higher education, small household size (fewer than five members), higher socioeconomic status, lower parity (fewer than four live births), having health insurance, and being married vs single [3, 7–10]. Furthermore, early pregnancy registration, clinical competence of the healthcare provider, and attentive interactions are also thought to be significant predictors of achieving the WHO recommended number of eight ANC contacts in pregnancy [7, 10]. Globally, the percentage of women who initiate ANC in the first trimester has increased from 41% in 1999 to 59% in 2013. However, there is still a significant disparity in the receipt of any ANC coverage between low-income countries (24%) and high-income countries (82%) [5].

Palestine includes Northern, Central and South areas of the West Bank and the Gaza Strip. In the Gaza Strip, approximately 2.1 million people are housed in a 365 km² area of land, with an average population density of 5479 persons per square kilometer, making the area one of the most densely populated urban areas in the world [11]. In the West Bank, 2.9 million Palestinian population resides in approximately 5,655 km² including East Jerusalem [12]. The two million Palestine refugees comprise 44% of the total population in Palestine (~5 million); 63% of these refugees are in the Gaza Strip and 37% are in the West Bank and East Jerusalem [13].

Deteriorating socioeconomic condition in the Gaza Strip reflects the challenges imposed by the blockade and repeated conflicts. For example, since the 7^th of October 2023, humanitarian catastrophe has been unfolding in Palestine, with mass destruction of civil infrastructure and health systems, displacement, blockade of food, water and fuel in the Gaza Strip, while in the West Bank, a complete curfew, an increase in violence, and demolition of Palestinian structures have been implemented. Approximately 1.2 million, which is 24.7% of the total population in Palestine, are estimated to be women of reproductive age (15–49 years) with the fertility rate of 3.8 in Palestine; 3.9 in the Gaza Strip and 3.8 in the West Bank [14]. In 2020, ANC services were provided by 475 Ministry of Health clinics, 65 clinics operated by the United Nations Relief and Works Agency for Palestine Refugees in the Near East (UNRWA), 17 private clinics and 192 clinics run by non-governmental organizations (NGOs) [15–17]. Health services were financed through a mixture of taxes, health insurance premiums and co-payments, out-of-pocket payments, local community financial and in-kind donations, and loans and grants from the international community (e.g. UNRWA). Based on the monetary poverty concept, 29.3% of Palestinian households lived below the poverty level in 2017 with the poverty rates of 13.9% in the West Bank and 53% in the Gaza Strip [18]. Palestine continues to experience military occupation, restrictions of the movement imposed by multiple checkpoints, blockade and siege on the Gaza Strip, geographic divisions, and isolation by construction of the Separation Wall, which limits access to healthcare services [19–21].

It is widely reported that prenatal stress due to conflict, malnutrition and poverty has an impact on fetal development, pregnancy complications and pregnancy outcomes [22]. In addition, deteriorated living conditions in Palestine due to repeated exposures to political violence, ongoing siege on the Gaza Strip since 2017, coupled with the high poverty and unemployment rates affect access to ANC [21]. Given the vulnerability of the population in Palestine, ANC faces a major challenge to provide timely, adequate and appropriate care to pregnant women. However, there is little reported national data on the frequency, timing and contents of services received by the women attending ANC, which are provided by multiple agencies, in Palestine. Some studies of health care access conducted in Palestine rely on sub-national data which are not representative of the overall population, and frequently exclude the Gaza Strip, likely reflecting the challenges of collecting data for the entire Palestine due to the geographical separation between the West Bank and the Gaza Strip [21]. The lack of information needed for management of ANC is one of the major difficulties, restricting the capacity to plan and assess performance [20]. Thus, the objectives of this study are, for the four areas of Palestine (Gaza Strip and Northern, Central and South areas of the West Bank), to: 1) summarize sociodemographic characteristics of pregnant women; 2) estimate the proportion of pregnant women, based on data, whose number of ANC contracts were below WHO recommendation (0–7 contacts; ANC0-7) versus those who were compliant with WHO recommendation (8 or more contacts; ANC8+); 3) identify maternal characteristics associated with ANC0-7, which could further inform targeting antenatal services, and completing WHO recommended number of ANC contacts among women in Palestine.

Methods

Results

Sample characteristics

Table 1 summarizes the characteristics of 2,028 women aged between 15 to 49 whom data were available on reported ANC services received during the most recent pregnancy within the last two years in the Palestinian MICS 2019–2020. The mean age of the participants was 28 years, with the majority between 20 to 29 years (59%). Approximately half of women obtained secondary education or higher (47.3%). Most of the women were married (99.3%), and average number of parities was three. Thirty-seven percent of respondents self-reported to be a refugee, which could include both the registered refugees who hold a refugee registration card issued by UNRWA and non-registered refugees who do not hold such a card. Majority of women lived in urban areas (76.6%), while 16.1% lived in rural areas and 7.4% in the camps. About 40% of women held governmental health insurance, while 36.4% received free health services from UNRWA as a registered Palestine refugee.

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Table 1. Characteristics of women who participated in the 2019–2020 Palestinian Multiple Indicator Cluster Survey (n = 2,028).

https://doi.org/10.1371/journal.pone.0297956.t001

Factors associated with number of antenatal contacts

Table 2 presents the percentage of women with ANC0-7 vs ANC8+ by their characteristics. Women with ANC0-7 were slightly older (28.8 vs 27.7), less likely to be educated, have greater number of parity (3.7 vs 2.9), and lower distribution of wealth index. Among the four areas of Palestine, prevalence of ANC0-7 was the highest in South West Bank (33.3%), followed by Gaza Strip (29.1%), North West Bank (27%) and Central West Bank (18.1%). In addition, women living in rural areas had the highest proportion of ANC0-7 (29.2%), followed by those living in urban areas (28.3%) and in camps (25.6%). Compared to women with ANC8+, those with ANC0-7 were less likely to receive ANC from doctors only (30.2% vs 69.8%), nurse/midwife only (42.3% vs 57.7%) or both doctor and nurse/midwife (22.1% vs 77.9%) compared to those with ANC8+. Importantly, greater proportion of women who initiated antenatal care contact in the second or third trimesters (6.6% and 52.4%, respectively) reported to be ANC0-7 than ANC8+.

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Table 2. Characteristics of women compared by completion of recommended antenatal care contacts, reported in the 2019–2020 Palestinian MICS (n = 2,028)^a.

https://doi.org/10.1371/journal.pone.0297956.t002

Table 3 shows the crude prevalence ratios (cPrR) and adjusted prevalence ratios (aPrR) for ANC0-7 and respective 95% CIs. In crude model, ANC0-7 was associated with age, none or basic level of education, number of parities, wealth index, area of residence, type of ANC provider (either seeing a doctor only or nurse/midwife only) and timing of first contact for ANC (P < 0.05 for all). The prevalence of ANC0-7 increased as a number of parities increased and was higher among women in poorer or poorest wealth index quantile (aPrR 1.92; 95% CI 1.36, 2.72 for poorer and aPrR 1.75; 95% CI 1.10, 2.78 for poorest) compared to the richest women while controlling for age, education level, area of residence, type of ANC provider, and timing of first antenatal contact. The prevalence of ANC0-7, not meeting the WHO recommended number of antenatal contacts, was 48% and 72% higher among women living in North West Bank and South West Bank, respectively, compared to Central West Bank, while controlling for age, education level, parity, wealth index, and timing of initial antenatal contact. The women who delayed the first antenatal contact to the 2^nd and 3^rd trimesters had 2.80 times (95% CI 2.31, 3.39) and 2.72 times (95% CI 1.84, 4.03) the prevalence of those who completed the 1^st antenatal contact in the 1st trimester. In adjusted model, age and education were not statistically significantly associated with ANC0-7.

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Table 3. Crude and adjusted prevalence ratios (PrR) for ANC0-7 contacts among women who reported giving live birth within the last two years, 2019–2020 Palestinian Multiple Indicator Cluster Survey.

https://doi.org/10.1371/journal.pone.0297956.t003

Discussion

Access to antenatal services enable women to receive appropriate and timely care to preserve health throughout gestation, which is expected to be coupled to adequate obstetric and postnatal care. Using the most recent 2019–2020 MICS data, our study analyzed responses of 2028 women on questions about ANC contacts during their most recent pregnancy within the previous two years. While ~95% of respondents reported receiving appropriate clinical assessments, including blood pressure measurement and collection of urine and blood tests, a quarter of women reported not meeting the WHO recommended number of ANC contacts, and 12% failed to initiate ANC contact in the first trimester. Those who did not meet the WHO recommendation of eight antenatal contacts (i.e., ANC0-7) were slightly older (28.7 vs 27.8 years), poorer, reported to be of higher parity, and less likely to see both doctor and nurse/midwife, and initiate an antenatal visit in the first trimester. Although the health systems in Palestine are challenged by recurrent conflicts, movement restrictions, insufficient resources and funding, shortage of health care providers, and complex politics, ANC coverage in 2019–2020 in Palestine was comparable to that in neighboring countries in the Middle Eastern Region [17, 21]. Based on the recent national household surveys in both Jordan and Egypt, 67.8% and 60.6% of women, respectively, initiated ANC contact in the first trimester and completed at least eight ANC visits [28].

Initiating care in the first trimester portended a higher probability of completing the WHO recommended number of ANC contacts. Mothers who delayed their visit beyond the first trimester were nearly three-fold less likely to comply to the WHO guideline than those presenting to clinics in the first trimester, after adjusting for age, education, parity, wealth index, and area of residence. The percentage of studied women not meeting the recommended number of visits increased with parity, such that women were 1.39 times less likely to achieve this WHO contact goal with each previously reported live birth, as has been seen elsewhere. Based on a secondary data analysis of 54 Demographic and Health Surveys and MICS conducted since 2012, Jiwani et al (2020) concluded that women with low wealth status were less likely to begin antenatal care on a timely basis [7]. The same study reported that women residing in larger than smaller households, having shorter birth intervals and higher parity were also less likely to initiate early antenatal care and, thus, unlikely to achieve eight contacts [7]. Women with high parity may be less likely to seek ANC services because they may feel more confident with accumulated experience. Alternatively, it may be difficult for them to find time to seek antenatal services given their caretaker roles for children and other family members [29, 30]. In Palestine, there is considerable variation by location in the frequency with which pregnant women visit ANC clinics, with low contact likely a consequence of restricted movement imposed by blockades such as checkpoints, road gates, earthen walls, roadblocks, Separation Walls (barriers that cut through Palestinian towns in the West Bank) and bureaucratic or administrative restrictions on travel without permits [21, 31–33]. For example, women residing in the North and South regions of the West Bank are nearly twice as likely to not meet the WHO-recommended eight contacts than in the Central region. One study, using geographic spatial analysis, identified Palestinian communities in the West Bank as fragmented, like small “islands”, that are separated and divided from each other while surrounded by settlement communities [34, 35]. Fragmentation of Palestinian lands can pose barriers to receiving healthcare, but also foster economic stagnation, limit access to education, degrade quality of life and increase exposure to political violence by the military and settlers [34]. In contrast, the Gaza Strip is a small area without checkpoints, with shorter distances to ANC facilities than in the West Bank [21]. While the population in the Gaza Strip faces difficult living conditions due to recurrent hostilities and ongoing siege, access to routine ANC contacts might have been easier in the Gaza Strip in 2019–2020 compared to the West Bank. However, the conflict that began on the 7^th of October 2023 has severely destroyed health system infrastructure and impeded the movement of civilians, which have likely impeded access to and coverage of ANC in Palestine.

Political strife and conflict markedly disrupt provision and receipt of health care in many ways, such that supplies are reduced, retention of medical specialists is challenged, physical access to health care is interrupted by damage to infrastructure, and intensified fear for safety prevents people from seeking health care [21, 36]. The ongoing political instability, conflicts and violence, geographical separation, and deteriorating socioeconomic and living conditions continue to challenge Palestinian health systems [17, 21]. Practical approaches to continuously provide ANC services and strengthening its monitoring and evaluation mechanism in Palestine should be further considered.

A strength of this analysis is that it has drawn on representative data from the most recent 2019–2020 UNICEF Multiple Indicator Cluster Survey in Palestine, providing findings on antenatal care access that can be generalized to pregnant women living throughout Palestine. However, as a secondary analysis of a pre-existing survey, we had limited contextual influences to examine such as neighborhood characteristics and other local factors that could affect ANC coverage. Further, as with any survey collecting historical data, our results are prone to self-reporting recall bias, possibly leading to imprecise recall of number of ANC contacts and care received.

Conclusions

The study results suggest that there was variation in achieving the WHO-recommended number of ANC contacts across socioeconomic status and clinic catchment areas. In particular, women with lower socioeconomic status may encounter obstacles in accessing ANC services, worsened by the geographic and political fragmentation in Palestine and mobility restrictions. There may be an opportunity to reduce inequalities to ANC coverage in Palestine; however, further studies on this issue and periodic evaluation of ANC services are likely needed to better inform and guide implementation of policies to improve ANC coverage in Palestine.

Acknowledgments

The authors would like to acknowledge the George G. Graham Professorship Endowment in supporting the publication. The authors would like to thank Dr. Keith West, Jr. at Johns Hopkins Bloomberg School of Public Health by providing suggestions for the manuscript writing and organization. The first author greatly acknowledges the support from the United Nations Relief and Works Agency for Palestine Refugees in the Near East, the Ministry of Foreign Affairs of Japan, and from the Sight and Life Global Nutrition Research Institution, Baltimore, MD.