We conducted an analytical cross-sectional study at Laquintinie hospital; site chosen for its strong patient base and cosmopolitan character.

Our study took place from January 15 to April 15, 2020, a duration of 3 months.

Our target population was any woman who gave birth at LDH during our study period.

Inclusion criteria

Any childbirth who met all of the following criteria was included in our study;

-Having given birth and postpartum in the gyneco-obstetrics department of the LDH.

-Hospitalized postpartum.

-Having followed their ANC at the LDH or not.

-At least 15 years old.

Exclusion and non-inclusion criteria

-Those who do not have a complete pregnancy monitoring record.

-Deliveries resulting from a multiple pregnancy.

-Having refused to participate in the study.

We carried out exhaustive probabilistic sampling; all those who gave birth had the same chance of participating in the study.

Administrative procedures and ethical modalities

A research protocol was submitted to the ethics committee of the University of Douala with ethical clearance obtained from the institutional and ethical council of the University of Douala under number 2111 CEI-Udo/02/2020/T; we also requested and obtained research authorization from the Director of the LDH. These prerequisites obtained; we proceeded to test the questionnaire on 3 women who gave birth at the LDH maternity ward then followed the recruitment.

Strict confidentiality of all information was ensured. The data collected was only used for the purpose of the study and in strict compliance with medical confidentiality.

Data collection procedure

The data was collected and recorded using a questionnaire on a pre-established and pre-tested technical sheet.

After revealing the identity of the investigator, a preliminary interview with the woman giving birth was established to explain the objective of the study and the different stages in order to obtain the signature of the informed consent form. Informed consent was obtained for each enrolled delivery.

We recruited our hospitalized births, more specifically in the postpartum room. They answered the questions on the pre-established and pre-tested survey sheet, and we supplemented the information with data contained in medical files and pregnancy follow-up booklets.

To carry out our study we used for our collection:

-Academic equipment: pens, erasers, pencils, pencil sharpeners, highlighting, reams of format, books, articles, dissertations and theses;

-Computer equipment: computer, mobile phone, USB keys and modem;

-Medical equipment: white coat, treatment gloves, sterile gloves, pinard fetoscope, blood pressure monitor, tape measure;

-Collection material: survey sheets, intra-hospital documentation (pregnancy monitoring logs, results of laboratory and imaging assessments).

Sociodemographic and reproductive characteristics of women giving birth

a) Socio-demographic characteristics concerned:

-Age, occupation, level of study, nationality, marital status, religion, region of origin.

b) Reproductive characteristics of those who have given birth

-Gestational age, gestation, parity, location of prenatal consultations, qualification of the consultant, number of prenatal consultations.

Assessment of the quality of prenatal consultations

a) Promotional component

-Education on health and diet measures, rest and activity;

-The use of potentially harmful products;

-Advice on early and exclusive breastfeeding;

-Promotion of the benefits of the presence of a competent provider during childbirth;

-Encourage women to receive postpartum care for themselves and their newborns.

b) Screening and treatment of risky pathologies;

Blood group (ABO, Rhesus), Glycosuria and albuminuria, Hbs antigen, VDRL/TPHA, Thick blood film, Hookworm KOAP, HIV serology, Hemoglobin electrophoresis, Anti-HCV Ab, Blood counts, Stool examination, Toxoplasmosis, Cervico-vaginal sampling, Rubella, Chlamydia, Fasting blood sugar, Ultrasound examination of the 1st, 2nd and 3rd trimester, Hypertension and obesity.

c) Preventive aspect

-Against malaria: administration of intermittent preventive treatment, distribution of mosquito nets;

-Tetanus vaccine (VAT);

-Iron and folic acid supplementation;

-Prevention of mother-to-child transmission if pregnant carrier of the Human Immunodeficiency Virus;

-National/regional interventions as appropriate:

d) Preparation for childbirth

-The choice of service provider;

-The choice of health facility;

-Danger and warning signs;

-Identification of blood donors, companions, support people during childbirth and items necessary for childbirth (mother and newborn);

-Education of women on the signs of labor and danger signs;

-Clarify transport conditions even in an emergency;

-The financial resources necessary for childbirth and the management of emergency situations;

-Taking leave of the pregnant woman;

-Driving the pregnant woman to the door and thanking you at the end of the visit;

-Prenatal follow-up consultation: scheduling appointments for follow-up.

Characteristics of the outcome of childbirth

a) Maternal outcomes

-Mode of delivery.

-Infection.

-Gestational diabetes.

-Anemia.

-Preeclampsia/eclampsia.

-Postpartum hemorrhage.

b) Neonatal outcomes

-Stillborn alive.

-Neonatal infections.

-Congenital anomalies.

-Prematurity.

-Low birth weight.

A rating (0; 1) was made for the criteria identified above. We assigned a score of 1 to any procedure followed and 0 to any procedure not followed. The sum of the scores applied to the evaluation scale made it possible to assess the level of quality of prenatal consultations. The evaluation scale is as follows:

Level IV: Greater than 95% corresponding to the good quality of prenatal consultations;

Level III: 75% to 95% corresponding to prenatal consultations of average quality.

Level II: Between 50% and 75% corresponding to prenatal consultations of insufficient quality.

Level I: less than 50% corresponding to poor quality prenatal consultations [18] .

The data collected were entered and analyzed using Epi-info version 3.5.4 software. A value of p < 0.05 was considered statistically significant for all analyses. Quantitative variables were grouped into mean, median and standard deviation; qualitative variables are expressed in the form of frequencies. Comparison of proportions was made with the Chi-square test and Fischer’s exact test. The association between the quality of prenatal consultations and pregnancy outcomes was measured using the Odds Ratio expressed with its 95% confidence interval.

Age

The average age of our study population was 29.2 ± 6.4 years and the modal class was 30 to 35 years ( Figure 2 ).

Gestation

In our study, 31.20% of births were in their first gestational experience ( Figure 3 ).

Parity

In our study, 65.10% of those who gave birth were at most in their second birth ( Figure 4 ).

Gestational age

The majority of those giving birth had a term between 37 and 41 weeks and almost 30% were premature babies ( Table 1 ).

Out of 109 births included, 28 (i.e. 25.70%) carried out their ANC in a public reference hospital ( Table 2 ).

*: CMA, Catholic Hospital.

ANC was done by an obstetrician-gynecologist in 39.40% of cases ( Figure 5 ).

Only 12.80% of those giving birth had completed at least 8 ANCs ( Table 3 ).

A little more than half of those giving birth, i.e. 51.40%, had started ANC in the 2nd trimester of pregnancy ( Figure 6 ).

Evaluation of the content and programming of prenatal consultations

In our study, 52% of those giving birth had benefited from poor quality ANC ( Figure 7 ).

In our study, out of 109 women who gave birth, none had benefited from good ANC ( Figure 8 ).

In our study, a little more than half of the births (51.40%) had benefited from poor quality ANC ( Figure 9 ).

Pre-eclampsia/eclampsia and infections were the main complications during pregnancies with poor ANC quality ( Figure 10 ).

Low birth weight represented 25.70% of births ( Figure 11 )

In our study, prematurity of newborns represented 27.50%; IUGR represented 24.80% of cases as well as neonatal resuscitation; and neonatal infection 10.10% ( Table 4 ).

In our study, age > 40 appeared to be a significant association factor with poor quality ANC ( Table 5 ).

In our study, a parity > 4 appeared significantly associated with poor quality ANC ( Table 6 ).

In our study, a number of ANCs ≥ 8 was a protective factor for poor quality ANCs ( Table 7 ).

In our study, prematurity appeared to be significantly associated with poor quality of ANC ( Table 8 ).

It appears in the light of this table that being consulted by an obstetrician-gynecologist was protective against poor quality ANC ( Table 9 ).

In our study, starting ANC in the 2nd trimester of pregnancy was significantly associated with poor ANC quality ( Table 10 ).

There was no statistically significant association between gestational morbidity and poor quality of ANC ( Table 11 ).

Poor quality of ANC exposed people to prematurity 2.93 times more; 4.7 times more in low birth weight and 11.3 times more in newborns with neonatal infections ( Table 12 ).

The average age of women who gave birth in the maternity ward of the Laquintinie hospital in Douala was 29.2 ± 6.4 with a majority of 30 to 35 years old, far from the group of adolescents who are often the breeding ground for abortions and obstructed births due to an immature pelvis; our finding is the opposite of that of Fomba so the modal range was 20 to 29 years old [19] . They were mainly pauci gesture and pauci pares in our series ( Figure 3 and Figure 4 ).

The quality of care depends on the material infrastructure, human resources, knowledge, skills and capacity to manage both normal pregnancies and complications that require rapid, life-saving interventions [14] .

Following the recommendations of the literature consulted for this purpose, prenatal monitoring must be provided by qualified personnel: general practitioner, obstetrician-gynecologist or a midwife [20] ;

In our series, our results showed a strong involvement of doctors, particularly gynecologists, in prenatal monitoring (39.40%) in contrast to Coulibaly who reported a high percentage of ANC performed by midwives (84.4%) [21] ; this high variance is explained, in our opinion, by the community health framework of his study.

The outcome of a pregnancy is significantly correlated with the number of prenatal visits carried out as well as the start of it.

According to the WHO, more frequent and better-quality consultations for all women during pregnancy will facilitate the application of preventive measures and early detection of risks, avoid complications as much as possible and help remedy health inequalities. Thus, a model of focused prenatal care that emphasizes quality has been recommended since 2016, according to which the number of prenatal consultations increases from four to eight [20] [22] .

In our study, 46.80% of births had benefited from at least 4 to 8 ANC and 40.40% had performed less than 4 ANC, Referring to the authors who have addressed this aspect, notably Kowe in the same geographical area, our findings are dichotomous due, in our opinion, to the rural setting of his study; a framework which is specified by various constraints, notably low health coverage, access to care, financial barriers but also the weight of traditional cultures [15] .

Unlike Brown (15 to 25%) in Kenya, 46.80% of our sample had initiated the first ANC in the 1st trimester [23] .

The ANC offers a package of services including tetanus vaccination, prevention of anemia, protection against malaria, prevention of Sexually Transmitted Infections and AIDS viruses (STI/HIV/AIDS) and mother-to-child transmission of HIV, prevention of malnutrition, the information necessary to prevent sometimes fatal complications that can occur during childbirth but also for planning future births. In developed countries, 99% of women receive quality antenatal care while in developing countries this proportion is 1% [20] [24] - [26] .

Overall, the procedures were of poor quality in both the 2nd and 3rd ANC with respective scores of 70.9% and 100%. The qualities observed in our study seem to be mediocre to those of Jacques Saizonou and colleagues in a district hospital in Benin in 2014 who found quality scores of 62.96% between the 2 - 4th ANC [1] .

According to the literature, 15% of pregnant women develop complications during pregnancy, during childbirth and post-partum [5] ; our findings confirm this in an order of superimposable percentage for preeclampsia/eclampsia and neonatal infections with 17.40% and 11% respectively. But unlike other authors, we did not find a statistically significant link between gestational morbidity and poor quality of ANC.

The numerical insufficiency of ANC < 4 as well as the delay in this obstetric offer were consistent with the data in the literature; i.e. source of poor-quality ANC with unfavorable outcome [15] ; our findings did not escape it.

The poor quality of ANC put people at risk of prematurity almost 3 times; almost 5 times in low birth weight and 11.3 times in newborns with neonatal infections.

In our series, parity > 4 as well as age > 40 appeared as exposures to poor quality ANC; thus, corroborating the findings of F.Z. El Hamdani et al. [27] . This trend towards a reduction in the number of ANC can be explained by the fact that pregnant women over 40 and multiparous often do not find it relevant and believe they have mastered its outlines.

Prematurity, low birth weight and neonatal infections were significantly correlated with poor quality prenatal consultations as known and reported in the literature on this aspect including some authors from the same geographical area such as Kowe [15] .