Antenatal counseling and booking linked to higher postnatal attendance in Bahrain

A package combining antenatal health education with an advance postnatal appointment was associated with substantially higher postnatal clinic attendance among women in four Bahraini primary health care centers, according to a non-randomized quasi-experimental study. Attendance was 72.7% among 77 women with available records in intervention centers, compared with 41.3% among 92 women in control centers. The unadjusted odds ratio was 3.79, with a 95% confidence interval of 1.98–7.27, while adjustment for age, family income, baseline knowledge and attitude produced an odds ratio of 5.55 (95% CI 2.04–15.08). The results are promising, but substantial differences between individual centers and the absence of random allocation mean that the intervention cannot yet be separated from the effects of the settings in which it was delivered.

The researchers enrolled pregnant women at 36 weeks of gestation or later between March 21 and June 20, 2024. Two centers in Bahrain’s Southern Governorate delivered the intervention, while two in the Northern Governorate provided standard care. Of 193 women approached, 175 enrolled, comprising 81 in the intervention arm and 94 in controls. Each intervention package had three inseparable elements: a standardized session delivered by a trained mother-and-child health midwife during a routine antenatal visit, an early booking for a postnatal consultation between six weeks and six months after delivery, and QR-coded educational material. Control centers offered the national program’s usual verbal notification, with women expected to arrange their own postnatal visit after childbirth.

Within the intervention group, immediate changes were striking. Mean knowledge scores on a nine-item scale rose from 2.16 before the session to 8.48 afterward, a mean increase of 6.32 points (95% CI 5.62–7.03; p<0.001). Attitudes measured on an eight-item, 40-point scale increased from 25.79 to 35.89, a mean gain of 10.10 points (95% CI 8.77–11.43; p<0.001). The standardized effect sizes were large, with Cohen’s dz values of 1.98 for knowledge and 1.65 for attitude. Forty-eight percent of intervention participants scored at least 38 out of 40 after the session, and 31 reached the maximum. These measurements were taken minutes apart, however, and the control group was assessed only once. Without a concurrent second measurement, the increases could reflect immediate recall, repeated questionnaire exposure, social-desirability effects or the antenatal visit itself rather than the session alone.

Postnatal attendance was the outcome assessed identically in both arms, using electronic mother-and-child health records at each woman’s own center. A documented consultation with either a physician or a staff nurse counted as attendance. Six of the 175 participants could not be matched to a delivery record, leaving 169 outcomes; the result remained statistically significant under all four extreme assumptions about those missing observations. The observed difference was 31.4 percentage points (95% CI 17.3–45.6), corresponding to a risk ratio of 1.76 and a number needed to treat of about three women for one additional postnatal consultation. Both groups exceeded the 29% national attendance rate recorded in 2019, before face-to-face postnatal services were disrupted by the COVID-19 pandemic. The control proportion also exceeded the 27% found in a 2023 national survey, making it an imperfect estimate of attendance under untreated routine care.

Center-level results expose the study’s central weakness. Attendance was 69.7% and 75.0% in the two intervention centers, but 26.5% and 58.1% in the control centers. The 31.6-percentage-point gap between control centers was as large as the overall difference between study arms, and one control center performed almost as well as the intervention centers. The centers were selected by convenience, their division into study arms was not random, and the arms were geographically separated, making study group completely confounded with governorate. Historical service data were unavailable to establish baseline equivalence. An intraclass correlation coefficient of 0.091 for attendance produced a design effect of 4.73 and an effective sample of approximately 36 women rather than 169. When this clustering adjustment was applied, the confidence interval for the unadjusted odds ratio included the null value.

The adjusted logistic regression strengthened the reported association, with intervention-group status remaining the only significant predictor of attendance. Baseline knowledge and attitude did not independently predict attendance in the model or in exploratory comparisons. That absence of evidence does not establish that understanding and attitudes are unimportant, particularly because the study was not designed to prove an absence of effect. It instead suggests that the structural elements of care may have been more closely connected with attendance than individual scores measured after the session. The intervention cannot identify which component mattered because education, QR-coded material and advance booking were always delivered together. The design also did not measure session duration, training duration, delivery fidelity, staff workload or implementation cost.

The study population offers additional context. Participants were Bahraini women or non-Bahraini women married to Bahrainis, were at least 18 years old, attended antenatal care at 36 weeks or later, spoke Arabic or English, used smartphones and did not have diabetes, hypertension, sickle cell disease or difficulty understanding the educational material. Excluding women without smartphones improved comparability between arms but limited generalizability, since those women may face some of the greatest barriers to postnatal care. The intervention group was older and had a more favorable family-income distribution, while baseline knowledge was also higher and attitudes were less favorable. The study did not establish baseline equivalence between the four centers, and the sample fell short of its target of 100 women per group. Among exploratory medical comparisons, daily medication use was associated with lower attendance, 34.2% compared with 61.8% among women not taking medication, but the finding came from multiple uncorrected subgroup tests and requires dedicated study.

Awareness of the postnatal clinic largely depended on informal networks. Among respondents who knew the clinic existed, 20% cited friends and 18% cited family, making social connections the leading reported sources of information. Doctors during antenatal visits accounted for 17%, doctors after delivery for 16%, and formal health-education sessions for only 3%. These findings connect the intervention to a practical problem: accurate information was often available through relatives and peers, while structured channels were rarely used. The intervention also tested more than information alone. By securing an appointment before delivery, it attempted to remove an organizational step that women in the control arm had to complete independently after childbirth, a task that a prior national survey found many women did not know how to perform.

For practice, the findings support further testing of routine early booking and provider-led counseling as an integrated antenatal service, rather than treating education and appointment logistics as separate issues. Bahrain’s postnatal clinics provide a free consultation for a general maternal assessment, depression screening and counseling on breastfeeding and family planning. The package tested in this study was delivered within an existing antenatal appointment, but the research did not demonstrate its cost, sustainability or acceptability. Confirmation now requires a larger cluster-randomized trial or a stronger quasi-experimental design involving more centers, preferably one capable of separating midwife counseling from advance booking and QR-coded information. Until then, the scientifically supported conclusion is that the combined approach was associated with higher documented postnatal attendance in the participating centers, while knowledge and attitudes improved immediately within the intervention arm. The striking between-arm result warrants attention, but the equally striking center-to-center variation prevents a definitive claim that the package itself caused the increase.

Subject of Research: Antenatal counseling and early postnatal booking in Bahraini primary health care centers

Article Title: Antenatal health education with early postnatal booking and postnatal clinic attendance in primary health care centers in Bahrain: a quasi-experimental study

Article References: Alhaddad, M. E. E., Hubail, M. A. H., Rashed, M. M. A., Alnajjar, I. B. S., Husain, T. K. S., AlAali, F. A., Asoomi, H. A., Makarem, B., Chlif, S., Habbash, F., Almarabheh, A., Salah, A. B., & Shehata, M. H. (2026). Antenatal health education with early postnatal booking and postnatal clinic attendance in primary health care centers in Bahrain: a quasi-experimental study. Frontiers in Public Health, 14, Article 1938634. https://doi.org/10.3389/fpubh.2026.1938634

Image Credits: AI Generated

DOI: 10.3389/fpubh.2026.1938634

Keywords: Bahrain, postnatal care, antenatal education, early booking, maternal health, primary health care, clinic attendance, quasi-experimental study, health services, Antenatal, health, education