Development of Nursing Care Standards for

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Tanta University Faculty of Nursing Community Heath Nursing Department

Development of Nursing Care Standards for Antenatal Care at Rural Health Units THESIS Submitted to Faculty of Nursing Tanta University In Partial Fulfillment of the Requirements For the Doctoral Degree in Nursing Science (Community Health Nursing) By

Fatma El- Sayed Soliman SUPERVISORS Professor Dr. Bassima Ezzat Gowayed Professor of Community Health Nursing Faculty of Nursing Tanta University

Professor Dr. Ikbal Fathalla El-Shafie Professor of Community Health Nursing Faculty of Nursing Tanta University

Professor Dr. Manal Abd- El Fattah Oueda Professor of Community Health Nursing Faculty of Nursing Alexandria University 2011

II

Development of Nursing Care Standards for Antenatal Care at Rural Health Units Abstract: High quality antenatal care is a fundamental right for each woman. It is a good tool to reduce maternal morbidity and mortality in developing countries, reduce preterm birth and low birth weight infants. Nursing care standards for antenatal care are necessary to be available and applicable in all primary health care centers and units to demonstrate high quality, effective and efficient interventions for the pregnant women. Rural health units are still areas in need of standardization. Aim: is to develop standard for antenatal care at rural health units at Tanta city. Study design: Exploratory study. Materials and Method: This study was conducted in 14 rural health units affiliated to the Ministry of Health (MOH) at Tanta city selected randomly from 28 units. The subjects included: jury committee consisted of 25 members, 52 nurses were assessed for antenatal care knowledge, 37 nurses was observed for practice, and 140 pregnant women were assessed for satisfaction. Five tools were developed and used in data collection: 1) structured interview for basic competencies required for nurses providing antenatal care 2) resources checklist, 3) knowledge assessment sheet, 4) antenatal nursing activities observational checklist sheet, and 5) interview sheet for pregnant women satisfaction& needs assessment. Results: Acceptance of the jury committee by > 80% of them on 90.2% of nursing activities presented in the initial standards as basic nursing responsibility, except some sub-activities. Most resources needed for antenatal care were available. Others were not available or available but not used as: seats in waiting area, health education room, ultrasound apparatus, health education apparatus and equipments, laboratory equipments, pregnant women health card, and standards of antenatal care. Nurses had high knowledge about antenatal care. Meanwhile, they did not perform antenatal care activities at most of the units and had poor performance related to other activities. More than one half of the pregnant women had moderate satisfaction with antenatal care services provided at rural health units. The majority of them did not attend health education session. Conclusion and recommendation: Antenatal nursing care standards are important for improving nursing activities, so, it should be available and applicable in all antenatal care clinics at rural health units.

III

Faithfully Dedicated To My Mother My Father My Husband And to My Doughters

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Acknowledgement I wish to express my greatest sincerity, my deepest gratitude and appreciation to Prof. Dr. Bassima Ezzat Gowayed, Professor of Community Health Nursing, Faculty of Nursing, Tanta University, for the great help, moral support, valuable advice and continuous encouragement throughout the course of this study.

Words can not convey my profound, warm thanks, and cordial feelings to Prof. Dr. Ikbal Fathalla El-Shafie Professor of Community Health Nursing, Faculty of Nursing, Tanta University, for her unlimited patience and great help, continuous guidance, inspiring suggestions, effort and time she expanded which have enlightened the way to accomplish this work. I can not forget to express my sincere thanks and deepest gratitude to Prof. Dr. Manal Abd-El Fattah Oueda, Professor of Community Health Nursing, Faculty of Nursing, Alexandria University, for her patience, prompt assistance, and continuous encouragement to complete this search.

Finally, I would to express my thanks to all who cooperated and assisted in fulfilment of this work.

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CONTENTS Page

Chapter INTRODUCTION…………………………………………..

1

LITERATURE REVIEW…………………………………… Standard as a quality measurement tool………………….. Definition of the standard and standards of care……….... Dimensions of quality………………………………….... Steps of standard development…………………………… Standards of primary health care in Egypt………………. Rural health units in Egypt……………………………….. Quality of care in rural Egypt……………………………..

6 6 7 8 11 12 14 16

Antenatal care: - …………………………………………. - Importance of antenatal care…………………

17 17

- Objectives of antenatal care……………… - Components of antenatal care……………… High risk pregnancy……………………………………….

18 19 28

Role of the nurse in promoting the quality of antenatal care

30

II-

AIM OF THE STUDY……………………..............................

37

III-

MATERIAL AND METHODS ………....................................

38

IV-

RESULTS……………………………………….......................

53

V-

DISCUSSION………………………………………………….

138

VI-

CONCLUSION & RECOMMENDATIONS ………………….

160

VII-

SUMMARY ………………………………………………..

162

VIII-

REFERENCES ……………………………………………..

167

I-

APPENDICES …………… ARABIC SUMMARY…………

VI LIST OF TABLES

Table (1-4)

(2-4)

Page Percent distribution of the total nursing activities of the antenatal care according to the initial standards………. Percentage and rank order of the accepted elements of the initial antenatal nursing care standards……………..

(3-4)

55

57

Distribution of the accepted items of nursing care competencies for the initial standards of antenatal care among the jury committee……………………………..

(4-4)

59

Percent distribution of the accepted items by less than 80% of the total jury committee regarding basic nursing

(5-4)

(6-4)

(7-4)

(8-4)

(9-4)

competencies needed for antenatal care services………

62

Distribution of the rural health units according to its physical design needed for providing antenatal care…..

64

Distribution of the rural health units according to its material resources (apparatus) needed for antenatal care services…………………………………………………

66

Distribution of the rural health units according to its material resources (equipment and supplies) needed for antenatal care services.....................................................

68

Distribution of the rural health units according to its human resources (staff) in the antenatal care services….

70

Distribution of the rural health units according to the Availability of iron tablets, folic acid and the tetanus toxiod needed for antenatal care services ……………..

72

VII Page

Table (10-4)

(11-4)

(12-4)

Distribution of the rural health units according to the availability of recording system needed for antenatal care services……………............................... Distribution of the rural health units according to the availability of information documents of antenatal care …………………………………………

(15-4)

(16-4)

(17-4)

(18-4)

(19-4)

76

Distribution of nurses according to their knowledge about the elements of antenatal nursing care…………...

(14-4)

74

Distribution of nurses according to their educational and working characteristics……………………………

(13-4)

73

Distribution of nurses according to their knowledge about the items of health education during pregnancy………………………………………………

78

81

Distribution of nurses according to their knowledge about the elements of high risk pregnancy, its management and role of the nurse during antenatal car………………………………………………………

84

Relationship between nurses' 50 th percentile score of knowledge and their education, years of experience, training courses, and satisfaction with antenatal care services……………………………………………….

87

Distribution of rural health units according to the performed antenatal nursing tasks…………………

89

Distribution of the pregnant women according to their socio- demographic characteristics……………………..

93

Distribution of the pregnant women according to their obstetrical history……………………………………….

95

VIII Page

Table (20-4)

(21-4)

(22-4)

(23-4)

(24-4)

(25-4)

(26-4)

(27-4)

(28-4)

(29-4)

(30-4)

Distribution of the pregnant women according to their present history………………………………………….. Distribution of the pregnant women according to services provided to them during each visit in the present pregnancy……………………………………… Distribution of the pregnant women according to their satisfaction with antenatal care services provided at the rural health unit...............…………..…. Distribution of the pregnant women according to their satisfaction with health education provided during antenatal care at the rural health units ………………… Distribution of the pregnant women according to their score of satisfaction with antenatal care services provided at the rural health units ……………………… Distribution of the pregnant women according to their suggestions for improving the antenatal care services at the rural health units ………………………………… Distribution of nurses according to their satisfaction with antenatal care services in the rural health units……………………………………………... Distribution of nurses according to their opinions regarding the strengths of antenatal care services…………………..…………………………… Distribution of nurses according to their opinions regarding the weak points of antenatal care services……………………………………………… Distribution of the nurses according to their opinions regarding possible solutions of the problems of antenatal care services……………………………… The Final Nursing Care Standards for Antenatal Care....

97

99

101

102

103

104

105

106

107

108 110

CHAPTER: I

1 Introduction ---------------------------------------------------------------------------Introduction

Antenatal care is the care a woman receives throughout her pregnancy, it is important in helping to ensure that women and newborns survive pregnancy and childbirth.(1) Antenatal care is a preventive obstetric health care program aimed at optimizing maternal-fetal outcome through regular monitoring of pregnancy.(2) High quality antenatal care is a fundamental right for women to safeguard their health. (3) Antenatal period offers many opportunities to provide targeted health services. It is a process of empowerment i.e. giving sufficient help and information to the pregnant woman to enable her to make an informed decision about her care. It is also, a process of communication which has become a key factor, not only between health professionals and the woman, but also among the different health professionals providing the service. (4) The detection of high-risk pregnancies through antenatal care has been advocated as a good tool to reduce maternal mortality in developing countries. (5, 6) In addition, it was reported that poor and inadequate antenatal care is a major and the most important factor of increase the incidence of preterm birth and low birth weight infants. (7, 8, 9) So, prenatal care has intended to reduce the determinants and incidence of low birth weight, preterm babies, and other adverse pregnancy conditions and outcomes. (10, 11) It was reported according to Egypt Demographic and Health Survey (EDHS) 2008, that 26.4 % of the pregnant women had no antenatal care, and the rural health units were the source of antenatal care for 7.4 % of those pregnant women who received it. Rural health units were also the source for tetanus toxoid (TT) injection for 38.9 % of the pregnant women who had received TT from public sector. Urban mothers tended to see medical providers for antenatal care during

2 Introduction ---------------------------------------------------------------------------pregnancy more often than rural mothers, as mothers received regular antenatal care constituted 81 percent of urban births compared to 57 percent of rural births. (12)

Furthermore, the quality of the medical care that a woman received was better

for mothers who saw a medical provider for regular antenatal care than for other mothers. The content of the care women received varies, in general, the care was more likely to have been performed for urban than for rural births, with particularly low levels found for births in rural Upper Egypt.

(12)

Indicators on use of antenatal care services provide no information on the content or quality of the services. Despite the broad consensus on what the content and quality should be, it is generally recognized that the antenatal care services currently provided in many parts of the world fail to meet the standards recommended by WHO and results reflect the poor antenatal and delivery care services.

(13)

However, the available data do not report on specific interventions or

the quality of care.

(14)

The World Health Organization reported that health care is

still characterized by the following defects: uneven coverage and quality of services; inaccessibility of services, particularly for the under-privileged and rural communities in many countries in the Eastern Mediterranean Region. (15) Current antenatal care (ANC) programmes originate from patterns that were developed and practiced in the early twentieth century. Since then, their core content has remained unchanged except for the introduction of certain new technologies due to advances in medical knowledge in industrialized countries. Unfortunately, the bulk of the content of ANC programmes is based on tradition rather than on solid evidence of effectiveness linking them to better pregnancy and baby outcomes. Only lately have ANC programmes been subjected to rigorous criticism and review to try to design new programmes that are cost-effective in terms of quality of care, client satisfaction and health care service competencies and that improve obstetric and neonatal outcomes. (16)

3 Introduction ---------------------------------------------------------------------------In developing countries, assessing and improving the quality of health care was a low priority, both for policy makers and for technical agencies. The reasons for this long neglect of quality of care, include (i) a perceived priority of extending coverage at the expense of quality; (ii) the view that quality is difficult to assess in the absence of reliable documentation and health information system; and (iii) the perception that improving quality is tantamount to increasing input, thus costly and not affordable for many countries. (17) Antenatal care programs were poorly implemented and do little to promote the health of mothers and newborns. Until recently, many of the components of antenatal care had not been rigorously evaluated. The new approach to antenatal (18)

care emphasizes the quality of care rather than the quantity.

High quality

antenatal care is a fundamental right for women and one of the important factors to safeguard their health help women maintain normal pregnancies and reduce the rate of maternal morbidity and mortality. (18-22) It was reported that lack and poor quality of antenatal care contribute to maternal deaths. (2, 23) The World Health Organization (WHO), the United Nations Children's Fund (UNICEF), and the United Nations Population Fund (UNFPA) estimated total of 536 000 maternal deaths worldwide in 2005, developing countries accounted for 99% (533 000) of these deaths.

(24)

In the Eastern

Mediterranean Region alone, around 53 000 women of childbearing age die every year as a result of pregnancy-related complications. (25) As regard Egypt, more than 2500 women die every year from problems related to pregnancy and childbirth, leaving behind about 2000 motherless newborns. Many of these deaths follow high-risk pregnancies.

(26)

The maternal mortality rate in Egypt was reduced from

174 per 100 000 live births in 1992 /1993 to 84 in 2001. 000 live births) in 2002 then became 62.7 in 2006.

(27, 28)

(28, 29)

It was 69 (per 100

Perinatal mortality rate

per 1000 total births was 19.2 in 2008, while maternal mortality ratio (per 10000

4 Introduction ---------------------------------------------------------------------------live births) was 59 in the year 2006.

(30)

Maternal deaths are clustered around labour, delivery, the immediate postpartum period, with obstetric haemorrhage being the main medical cause of death. Inequalities in the risk of maternal death exist everywhere. Targeting of interventions to the most vulnerable-rural populations and poor people is essential to meet the fifth Millennium Development to reduce maternal mortality by 75% between 1990 and 2015.

(31, 32)

This need for both improved action for maternal

mortality reduction and increased efforts for the generation of robust data to provide better estimates in the future. (24) The changing nature of today's health care organizations, including pressure to reduce costs, improve the quality of care and meet stringent guidelines, has forced health care professionals to re-examine how they evaluate their performance. While many health care organizations have long recognized the need to look beyond financial measures when evaluating their performance, many still struggle with what measures to select and how to use the results of those measures. As a growing number of health care professionals have readily adopted quality concepts, so health care organizations should be able to quickly improve their performance measurement systems by following a few simple rules. (33-35) The way in which maternity care is provided is influenced by policies, availability and quality of services, and most importantly, the health-care-seeking behaviours of the women. (36) So, more attention is needed for the pregnant women during antenatal care period especially in the rural health units. Where the rural health units are one of the main sources of primary health care and antenatal care in the rural areas. According to the Egyptian Ministry of Health and Population quality regulations in health care, one of the accreditation requirements for the primary

5 Introduction ---------------------------------------------------------------------------health care institutions is the availability of medical protocol for follow up of the pregnant women during pregnancy, before and after delivery which should be included in the institution system. (37) On the other hand, nursing care standards for antenatal care are also necessary to be available and applicable in all primary health care centers and units to demonstrate high quality, effective and efficient interventions for the pregnant women.

(38)

Standards are also used to plan and evaluate nursing care.

ensuring the continuing of nursing professional development.

(39)

This for

(40)

In order to ensure quality of care, the nursing care needs some standards. Standards are degree of excellence. It reflects the values and priorities of the profession and provides direction for professional nursing practice and a framework for the evaluation of this practice.

(41)

The aim of standard nursing care

is to support and contribute to excellent practices. The role of nurse is constantly changing to meet the growing needs of health services. The importance of standards is to promote guides and aids in development of their competencies. It also aids in developing a better understanding & respect for the various & complimentary roles that nurses have. Professional standards ensure that the highest level of quality nursing care is promoted. Excellent nursing practice is a reflection of sound ethical standards. (42)

6 Literature Review ---------------------------------------------------------------------

Literature Review

Assuring and promoting quality in health care services continues to be a priority for any health care system.(5) The World Health Organization has emphasized the importance of quality in the delivery of health care, defined by the criteria of effectiveness, cost and social acceptability.(6) Providing good quality health care is of critical importance for the future economic and social well-being of our country. An increase in the quality of health care can result in increased patient satisfaction. This will in turn promote the appropriate use of the health services, which will be catering to the precise needs and aspirations of the community. (5, 43) It is believed that quality management is important in accountability. Many researchers are seeking evidence that outcomes of nursing care are of good quality and represent a cost-effective use of resources. (39, 44) This can be achieved through applying specific standards, which will result in improvement in the health status of clients, reduce unnecessary utilization of health care services, and meet specifications of clients. (39) Standard as a quality measurement tool: Standards can be used as the yardsticks for gauging the quality and quantity of care. Standard is a prim element of the management of the nursing services. It is used for measuring quality of care and to plan and evaluate nursing care through defining nursing care outcomes, nursing activities, and the structural resources needed.

(39, 45)

Standards help to define the safe parameters by which individual

practitioners are able to offer care, and play a major role in maintaining the safety of clients who receive this care. Clinical knowledge is vital for one to practice safely. (46, 47)

7 Literature Review ---------------------------------------------------------------------

The quality of care that is expected from a health care facility is made explicit by written standards that direct the way the services is to be provided and the results that should be achieved from that services. (48) Quality means developing expectations or standards of quality as well as designing systems for quality. Measuring quality consists of quantifying the current level of performance or compliance with expected standards, including patient satisfaction. (49, 50) Definition of the standard and standards of care: A standard can be defined as the acceptable level of performance of an organization or individual. It relates to structures in place, conduct of a process, and measurable outcome achieved. Or it is an expected level of performance that, if attained, would lead to the highest levels of quality in a system. A standard is also a desired and achievable level of performance against which actual performance is measured. (51) It is also a predetermined level of excellence that serves as a guide for practice. It is established by an experienced authority, and communicated to and accepted by the people who are affected by the standards.

(52, 53)

Standards

statements are professionally agreed level of performance appropriate to the population addressed. This means that a group of professionals or members of the health care team get together and agreed upon the standards, taking into account research findings and changes in practice. (54, 55) Standards of care guide nursing practice. Standards of care are documents developed by professional groups to establish a level of practice agreed upon by members of the profession. In many instances, these standards reflect the minimum expectations required of professionals for a safe practice. Because standards are based on current knowledge, they are dynamic and may be subjected to change as new information becomes available. Standards of care are sometimes used in legal

8 Literature Review --------------------------------------------------------------------situations as a yardstick for determining if negligence occurred. Nurses should be knowledgeable about professional standards of practice in their specialty and practice within those guidelines. (56) Dimensions of quality: It is important to assess certain dimensions of quality specifically through determining the type of standard. It is relates to structure, process, and outcome. (39, 57-60)

Structure refers to both the quantity and the quality of the available or necessary resources used by health care providers in the delivery of health care. This includes facilities: (as drugs, investigation, and ultrasound), equipments (as stethoscope, sphygmomanometers, tongue depressors, laboratory equipments, chairs, and desks.), staffing patterns as health man power of all categories (doctors, nurses, assistants, and laboratory technicians, and their personal qualifications, knowledge, and experience).

(57, 58, 61)

Structure audits focuses on the setting in

which care takes place. They include physical facilities as organizational structure (buildings), care givers, polices procedures, and medical records. (39, 62) In the assessment of structure, there is a need to identify which parts of the structure of the health care delivery system contribute to the quality of care. Questions that should be addressed are: How is the service delivery system structured? Are the health care professionals well educated, well trained, and board- certified? Are primary care and specialty care clinics and hospitals accessible? Are medical records well maintained? (57, 63) Process is a series of actions or inters related activities and communications that transform the inputs (resources) into outputs (accomplishes services). For example, a rural health education program will require that staff develop an education strategy, develop educational materials, and deliver the education sessions. (51)

9 Literature Review --------------------------------------------------------------------Process of health care are those huge and complex activities and reactions between care providers and clients or what is done to and for the clients, including how the staff uses resources and knowledge for client care. It includes communication pattern between the staff and the clients, health promotion activities, prevention of health problems and complications, diagnosis and treatment of diseases, collaboration with the health- related sectors, and follow-up and referral. (39, 58) Process can be described as: what is actually done in giving and receiving care. It includes the patient's activities in seeking care and carrying it out, as well as the practitioner's activities in making a diagnosis and recommending or implementing treatment. (62, 64) Documentation of a process involves developing polices, procedures, and forms. Polices, procedures, and forms are developed to limit liability exposure while maintaining the quality of care. Polices can be written in the following areas: technical and professional skill, documentation of care, safety practices, and monitoring assessment tools.

(57)

Procedures are written sets of instructions

conveying the approved and recommended steps for a particular act of series of acts to meet a series of tasks.

(51)

Procedures are psychomotor tasks. They are the

step- by- step analysis of a specific task. In procedures, one step is dependent upon another, and the steps are best performed sequentially for optimum results. The practitioner is required only to follow the steps to achieve the outcome. (48) Outcomes are the effect(s) that an intervention has on a specific health problem. It reflects the purpose of the intervention. given and the cost of that care.

(57)

(65)

It reflects the result of care

Outcomes are the results obtained through

enactment and completion of a process. They can be divided into expected (desired) outcomes and unexpected (undesired) outcomes. Expected outcomes are usually achieved when a process is carried out as specified. Unexpected outcomes usually result from nonconformance with specifications or when an uncontrollable force affects the process.

(48)

Outcome audits can be concurrent or retrospective.

10 Literature Review --------------------------------------------------------------------They evaluate nursing performance in terms of establishing client outcome criteria. (39)

Health outcomes can be grouped into four categories: health status, healthrelated knowledge, health-related behavior, and satisfaction with the care. Health status describes whether consumers are improving, maintaining, or worsening their health. Health status helps us to compare population served across agencies, plans, or socioeconomic status. (57) Health-related knowledge describes how knowledgeable the consumer is about health prevention or treatment. When a consumer having knowledge about symptoms, prevention, and treatment of certain disease or health problem, this knowledge may motivate the consumer to seek health care earlier. (57, 66, 67) Healthrelated behavior describes the activities that the consumer initiates related to improving or maintaining their health. (57, 68) Satisfaction with care describes how satisfied consumers are with their overall experience with care provided by the agency or plan. For example, if the consumer feels that time spent waiting to see a clinician is too long, he or she may become dissatisfied with their care. This type of information is usually obtained using consumer surveys.

(57, 69)

Patient satisfaction is considered an important

indicator of the efficient utilization of health services, as it assesses an individual’s attitude to health services received and the extent to which these services meet the person’s requirements and needs. (70- 72) In recent decades, determining the level of patient satisfaction has been found to be the most useful tool for getting patients’ views on how to provide care. This is based on two major principles: patients are the best source of information on quality and quantity of medical services provided and patients’ views are determining factors in planning and evaluating satisfaction. (73- 76)

11 Literature Review --------------------------------------------------------------------Steps of standards development: There is no single best method for developing standards. The process for setting standards will be very different depending on the level and scope of the work, resources available, and complexity of the topic. According to previous researches in standards development

(77-79)

and according to the Quality Assurance

for Accreditation Project (QAAP) 2003 and the National Academic Reference Standards (NARS) 2007, a menu of six steps called the standards development cycle, provide a flexible process for setting standards that can be adapted to each specific situation. (80, 81) Step1. Definition and degree: Define the area or the topic which standards are being developed, state the scope of care and the level of the health care system for which the standards are being developed, clarify the consensus process and the approval process. Step2.

Select who should be involved: the stakeholders' expectations

should be incorporated in the consensus and approval process of standards development. Experts in the field may be invited to participate as well as consumers of the services. The last part of this step is to organize the work group that will develop the standards and to develop a management plan of action that provide the parameters for successful completion of the task and the process by which it is achieved. Step3. Gather information: the researcher or the working group gather information about the topic under review and other resources that can help define the key elements that should be included in the standards. Step4. Draft Standards: There are several components that need drafting standards such as decision of the structure and the format of the standards depending on their purpose. After the format is decided, the working group drafts the standards, develop indicators and criteria to measure performance according to

12 Literature Review --------------------------------------------------------------------the standards. Prior to field testing, the draft standards should be evaluated internally for validity. Step5. Test the standards: The working group must decide whether a field test is needed. Testing informs the wording and presentation of the standards, improves their quality, increases credibility, and continues the consensus- building process. Following an evaluation of the field test, revisions should be made to the standards and the revised standards field- tested again. The interactive process of the field-testing, revision, and field- testing continues until revisions are no longer needed and standards are submitted for approval. Step6. Communicate standards: although the standards setting process might be completed with the approval of the standards, the impact of welldeveloped standards depend on health care providers using the standards. Standards communication and implementation strategies are critical to achieve health care provider

performance

according

to

the

standards.

A

well-thought-out

communication plan is needed to identify how the correct people will receive the correct information so they will perform the correct tasks related to the standards. The communication process should allow opportunities for feedback, both on the standards and communication process itself. Standards of primary health care in Egypt: Primary health care is "front-line" or "first-contact" care. The unique characteristics of primary care are the role it plays as a regular or usual source of care for patients and their families. Formally, primary care has been defined as "the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community". (82, 83) Primary health care (PHC) is defined also by the World Health

13 Literature Review --------------------------------------------------------------------Organization (WHO) as essential health care made universally accessible to individuals and families in the community by means acceptable to them through their full participation and at a cost the community and the country can afford. (84) Eighty percent of medical care is primary care. Primary care includes routine medical care to treat common illnesses or to detect health problems in their early stages. Primary care usually is provided in practitioners' offices, clinics, and other outpatient facilities by physicians, nurse practitioners, physician assistants, and an array of other individuals on the primary care team. (82) In 2007, the Egyptian accreditation standards for Hospital, Ambulatory Clinics and Primary Health Care were accredited by the International Society for Quality in Health Care (ISQua). Egypt is the first Middle Eastern country to achieve ISQua Accreditation of its standards. These standards provide both a significant challenge and a clear road map for every one to work collaboratively to improve the quality of performance in health care facilities (51). In Egypt, the Ministry of Health and Population (MOHP) (2005), has formulated the Basic Benefits package. The maternal and child health (MCH) / reproductive health (RH) package of essential services is describing the activities and services that are to be implemented and delivered by clients, communities and health providers, to improve and assure the health of the Egyptian population. (2) Within the health system, services are delivered at two levels which are primary health care and secondary health care. Primary health care includes: rural health units, MCH centers, mobile clinics, rural health compound units, family health unit/centers, (integrated) rural hospitals, and urban health centers. Secondary health care includes: district hospitals and general hospitals. Each level is expected to provide good quality services for the population they serve.

(2)

Maternal and

child health (MCH) activities are integrated with other primary health care (PHC) components. (85) Therefore, antenatal care is a part of PHC services.

14 Literature Review --------------------------------------------------------------------MOHP includes the administrative structure and the service delivery structure. Today, most Egyptians have reasonable access to free primary health care provided by a government team of health personnel. The system operates through a vast network of more than 2209 rural and 238 urban health units, 161 integrated hospitals, 337 women health centres, 164 maternal and child health centres, and 354 health offices. These are evenly distributed thoughout the country. However, the government's success in bringing modern primary health care within reach of most communities has not been matched by a similar success in increasing cultural acceptability. (27) Rural health units in Egypt: Egypt started building health facilities in urban and rural areas to deliver primary health care (PHC) services in the early 1920s. In urban areas it took the form of maternal and child health (MCH) centers and in rural areas it took the form of rural health facilities. Nearly 60% of the Egyptian population lives in rural areas. The programme for rural health services started in 1942 by establishing rural health centers designed to serve about 30 000 inhabitants in one or more villages. Each centre was staffed by a physician and supporting staff. (29) The number of rural health units in Egypt was increased from 1880 unit in the year 1981/82 to 4500 unit in the year 2006/07. (86) The construction of the rural health units was revealed to 1960s, where it provided the medical service to the poor areas as in the villages and the rural areas. Most of the attendants of the rural health units are complaining of poor service provided to them. This mainly related to lack of available resources.

(28, 87)

In the public sector, people frequently face

unmotivated and inadequately trained staff, with long waiting times, inadequate supplies and drugs, and lack of confidentiality or privacy. (88, 89) Through the development plan and the application of the quality standards, the service will be provided through 24 hours and one doctor will be specialized

15 Literature Review --------------------------------------------------------------------with 600 families. This plan was initially started in the governorate of Sohag, Alexandria, and Al- Menofyia and will extend to compromise the rest of the republic governorates. The plan is also including reconstruction and reform of the rural units, where some of these units were constructed in 1950s and others on 1960s. (87, 88) Generally, in rural areas, there are shortage in physicians and nurses, as well as family practice physicians, nurse practitioners, and specialists, especially obstetricians, pediatricians, psychiatrists, and social service professionals.

(90)

The

health unit comprise of a health group including at least one or more doctors, a number of nurses and assistants as: clerks, health visitor, and lab technician, summated at least 19 members. (28, 87) In most countries in the Eastern Mediterranean Region, there continue to be significant imbalances in the distribution of the different types of health workers. The rates of physicians and nurses who work in primary health care are less encouraging. Other types of imbalance include inappropriate ratios between physicians and nursing/midwifery personnel.

(90, 92)

In Egypt, the number of

doctors (in thousand) was increased from 52.3 in 1981/82 to 164 in 2006/07 and the number of nursing categories (in thousand) was also increased from 60.3 in 1981/82 to 206 in 2006/07. (28) Generally in Egypt also, the human and physical resources indicator rates per 10 000 population in 2007 was as follows: physicians were 26.3, dentists were 3.9, Pharmacists were 15.1, and nursing and midwifery were 29.1. Primary health care units and centers were 0.7. (30) Rural areas are a conservative community. Men prefer their wives to go to a female doctor. So, Ministry of Health should look to redistribute recently graduated doctors, looking to assign more females to rural health posts to work for OB/GYN. The Ministry of Health in Egypt assigns recently graduated doctors to health posts for two years. If they make assignments on the basis of gender, they could ensure

16 Literature Review --------------------------------------------------------------------that more rural communities had at least one female doctor for pregnant women to see. (92, 93) Quality of care in rural Egypt: In Egypt, differences exist in the quality of care given by different health units, e.g. rural versus urban settings. The problem is in the striking variations in effectiveness rather than availability of health facilities.

(94)

Generally, in the past,

rural illness care was modeled after urban areas. Urban areas emphasize specialist providers and in-hospital acute care with many high-tech and expensive procedures. Many rural hospitals can no longer compete with the larger facilities. (95)

According to the World Health Organization, the antenatal care coverage in Egypt was 60 % in 2008.

(30)

The Ministry of Health and Population (2005) stated

antenatal care standards of practice as a responsibilities of primary health care which include the following items, diagnosing and managing mild complications of pregnancies, screening for high risk pregnancy, stabilize and refer high risk pregnancies to district hospital. It should also provide tetanus toxiod immunization, iron and folic acid supplementation, nutritional education, blood pressure monitoring, urine (for glucose, protein) and blood analysis (Hb%, Rh factor), breast feeding and family planning counseling, and promote delivery in a health facility. (2, 4)

Efforts are being made to strengthen aspects of antenatal care most likely to have an effect on the outcome of pregnancy. It is important for the pregnant woman to be cared for by a physician who can correctly take a full history and conduct a complete physical examination, then diagnose any problems and manage the pregnancy. Women, families, and traditional birth attendants (dayas) need to have enough information to recognize the danger signs of pregnancy and the puerperium so they can seek care promptly in an appropriate facility. (2, 96)

17 Literature Review ---------------------------------------------------------------------

Antenatal care:Antenatal care is the care a woman receives throughout her pregnancy, it is important in helping to ensure that women and newborns survive pregnancy and childbirth. (1) Antenatal care is a preventive obstetric health care program aimed at optimizing maternal-fetal outcome through regular monitoring of pregnancy.(2) It monitors the health during pregnancy, as well as the health and development of the baby. It can help predict possible problems with the pregnancy or the birth, so action can be taken to avoid or treat them. (97, 98)

Importance of antenatal care: Provision of antenatal care is regarded as a cornerstone of maternal and perinatal health care and is expected to have a considerable impact on achieving the Millennium Development Goals which aims to improve the health of mothers and reducing child mortality. (99) The fifth Millennium Development Goal (MDG) aims to improve maternal health. The two targets set for this goal are to “reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio” and “achieve, by 2015, universal access to reproductive health”.

(100)

In addition, it was reported

that poor and inadequate antenatal care is a major and the most important factor of increase the incidence of preterm birth and low birth weight infants.

(7- 9)

It has

been calculated that for every dollar spent on antenatal care for high-risk women, more than three dollars are saved (compared to managing complications arising from pregnancy). (97)

Antenatal care (ANC), first promoted in the early twentieth century, has prompted constant debate as regards its frequency, content, continuity, quality and

18 Literature Review --------------------------------------------------------------------effectiveness in reducing maternal and neonatal mortality and morbidity. This debate has intensified over the last two decades, coinciding with the advent of primary health care (PHC) and global concern over safe motherhood. (101, 102) The debate has focused on: firstly, reducing the number of ANC visits to an effective and efficient minimum; secondly, ensuring improved continuity of care by the same provider or a smaller group of providers throughout pregnancy and the postpartum period; thirdly, ensuring satisfaction of providers and receivers of the new style of ANC provision; fourthly, clarifying the appropriate policy, decisionmaking and programmatic implications of adopting and implementing the new ANC protocol (103). Objectives of antenatal care: The objectives of antenatal care according to Egyptian Ministry of Health and family planning and reproductive health training website include: (2, 104) •

Promote and maintain the physical, mental and social well-being of both the mother and baby by providing education on danger signals, nutrition, rest, sleep and personal hygiene



Detect and manage complications, whether medical, surgical or obstetrical



Develop birth preparedness plan: who attends, where, communication/ transportation, birth attendant, and who accompanies.



Develop complication readiness plan: where, who accompanies, who stays with children, who makes decisions if primary decision-maker not available,

potential

blood

donor,

finances,

transportation,

and

communication •

Help prepare the mother to breastfeed successfully, experience normal puerperium, and take good care of the child physically, psychologically and socially

19 Literature Review --------------------------------------------------------------------Components of antenatal care: According to the Standards of Practice for Integrated MCH/RH Services of Ministry of Health and Population, Arab Republic of Egypt, antenatal care mainly consists of initial visit, periodic visits, and health education for pregnant women. (2, 4, 105, 106)

Currently in the United States, American College of Obstetricians and Gynecologists (ACOG) recommends 13 prenatal visits during pregnancy for a normal low-risk woman: the initial visit in the first 6 weeks, one visit per month until the 28th week, one visit every 2 weeks until the 36th week, and one visit per week thereafter. This standardized universal visit schedule was developed in the early part of the century in order to improve maternal health and to prevent maternal mortality

(107)

. In United Kingdom (UK) the first antenatal appointment

will probably be booking-in appointment and usually happens at about eight to 12 weeks. The woman have appointments every four weeks after week 12, every two weeks from week 32, and every week during the last three or four weeks (98, 108) . In Egypt, (according to MOHP, 2005) the first antenatal visit should take place as early as possible during the first trimester as following: to 28th weeks gestation _ every 4 weeks, 28th - 36th weeks _ every 2 weeks, and thereafter _ every week. In a normal pregnancy, with no complications, a minimum of three antenatal visits is acceptable in the first 20 weeks. The minimum antenatal visits for a pregnant woman according to MOHP are five visits.

(2)

The emphasis in the

developing world continues to focus on early and regular attendance at antenatal clinics.

(109)

The first antenatal clinic visit should include both booking procedures

(registration) and a physical examination. The information should be recorded on the Antenatal Care Card. (2)

20 Literature Review --------------------------------------------------------------------The initial visit: Booking Procedures and/or Registration: which include (2, 110, 111) - Personal history: (name, age, address, occupation (both partners), duration of marriage, consanguinity, and potentially harmful habits (i.e., smoking). - Complaints: in detail and duration - Menstrual history: including first day of the last normal menstrual period (LNMP) and calculation of gestational age, and expected date of delivery (EDD). - Obstetric history: containing number of pregnancies, deliveries, abortions, and still births, antepartum care; and puerperium of previous pregnancies, mode of delivery, number and sex of living children, birth weights, and date of last labor and last abortion. - Present obstetric history: including symptoms of pregnancy, symptoms of preeclampsia, symptoms of disease in other organ systems and fetal movements. - Family history: as history of diabetes mellitus, hypertension, multiple pregnancies, and congenital anomalies in any family member. - Medical history: containing diseases as (diabetes mellitus, hypertension, urinary tract infections, heart diseases, viral infection, and drugs/allergies) and other: as (blood transfusion, Rh incompatibility, and X-ray exposure). (2, 111) - Surgical history: including: dilatation and curettage, vaginal repair, cesarean section, and non-gynecologic operations. - Family planning history: including previous use of family planning methods, type, duration, and associated problems or complications. - Immunization history: types of immunizations the woman received especially tetanus toxoid (TT), number of doses, time of the last dose, and side effects if experienced.

21 Literature Review --------------------------------------------------------------------- Breastfeeding history: previous breast feeding, duration, and associated problems. Examination: Minimal Physical Parameters to be Evaluated - General: including physical signs (vital signs, weight, height, pallor, and jaundice), and skeletal or neurological abnormalities. (112-114) - Chest and heart examination. - Abdominal (obstetric) examinaion:

(2, 115)

through inspection, palpation, and

auscultation. Inspection: of contour and size of abdomen, scars of previous operations, signs of pregnancy, fetal movements, varicose veins, hernial orifices and back, and edema. Palpation: to fundal level (FL), fundal grip, umbilical grip, and pelvic grip. Auscultation - Fetal Heart Sounds (FHS): at 10 weeks by Sonicaid, and at 20 weeks by Pinard's fetal stethoscope. - Breast examination: for its shape, size, and detection of any abnormalities as flat or inverted nipple. - Laboratory investigations in Egypt according to the Ministry of Health the following tests should be done, urine analysis for sugar and albumin, stool analysis for ova and parasites, and blood analysis which compromise the following tests: complete blood count, grouping and Rh typing, hepatitis B antigen, wasserman reaction, rubella antibody, and hemoglobin level to assess anemia. (2, 4) For patients with risk factors for diabetes, a random one-hour 50 gm oral glucose challenge test is performed according to MOHP. If levels are < 140 mg/dl, the test should repeat at 24-28 week of gestation. If test shows levels > 140mg/dl, refer the patient to the higher level of health care facility. (2, 116) In Australia, urine testing for chronic renal disease (CRD) and urine testing for symptomatic bacteriuria are performed for the pregnant women at booking,

22 Literature Review --------------------------------------------------------------------while, women are routinely screened for urine testing for proteinuria and urine testing for glycosuria at each antenatal visit. (117) Woman’s Health Card: The health care provider should check the Woman’s Health Card and fill in the data at each antenatal care visit. The health care provider should encourage the woman to bring this card to each visit and to her delivery, whether at home or at health facility. (2) Health Education for Pregnant Women Health education is the provision of health information about the impact of pregnancy on women's health and physical changes, advice on behaviors to promote a healthy pregnancy and healthy infant.

(107)

The Health education has an

effect in enhancing the self-care agency of pregnant women and in defining the role of their background characteristics in the success of this education. (2, 118-120) Adequate Nutrition (2) Calories: The recommended daily allowance of calories for the pregnant woman is 2500/day. Excess calories lead to fat deposition and obesity. The caloric requirement is the same as in the non-pregnant state. During pregnancy increased metabolism is compensated for by decreased activity. (2) Protein: The recommended daily allowance of protein for the pregnant woman is 85 gm/day. Animal sources are: meat, fish, cheese, milk, and eggs. Plant sources are peas, beans, and lentils. Insufficient protein in diet leads to fetal prematurity, intrauterine growth retardation, maternal anemia and edema. (2) Calcium:

23 Literature Review --------------------------------------------------------------------The recommended daily allowance of calcium for the pregnant woman is 1,500 mg/day. Sources are: milk, cheese, yogurt, calcium carbonate. Insufficient calcium in the diet may lead to rickets in infants and osteomalacia in mothers. (2) Iron: The recommended daily allowance of iron for the pregnant woman is 30 mg/day. Animal sources are liver and red meat. Plant source are green vegetables. Drug sources are ferrous gluconate, ferrous fumarate, and ferrous sulphate. Insufficient iron in the diet leads to maternal iron deficiency anemia. (2) In South Africa, each mother attending a public healthcare facility receives stocks of ferrous sulphate (200 mg daily) and folic acid (5 mg daily) for supplementation, until the next appointment.

(32)

In Egypt, according to MOHP 2005, actions which

should be done in the case of anemic pregnant woman (hemoglobin level < 11gm) are to: investigate for parasitic infestation, prophylactic dose of iron/folic acid started early where anemia is prevalent, estimate hemoglobin and hematocrit value, prescribe iron/folic acid, and if severe anemia, refer to hospital. (2) Fats: If 2/3 of protein is delivered from animal sources, fat intake should be adequate. (2) Carbohydrates: Carbohydrates can be slightly reduced to compensate for the increased calorie value of the proteins and more severely restricted if weight reduction is necessary. (2) Folic acid: Megaloblastic anemia from deficiency of folic acid may occur during pregnancy. To prevent megaloblastic anemia, it is recommended that women take 0.4 mg of folic acid a day. (2)

24 Literature Review --------------------------------------------------------------------Clothing: Clothes of the pregnant woman should be loose, light, and hanging from shoulders. High heels, shoes with thin soles, belts, and corsets should be avoided. Dental Care: The teeth of the pregnant woman would be examined twice during pregnancy. Tooth extraction is allowed even for pregnant women with rheumatic heart disease if prophylactic antibiotics are given. (2, 115) Breast Care: Daily washes with water (avoid soap) to reduce cracking . If there is dry secretion, treat with a mixture of glycerin and alcohol. If nipples are retracted, treat by pulling out. Brassiere should be light and not tight to support heavy breasts. (2,121)

Sexual Activity: Sexual Activity should be avoided in pregnant women with threatened abortion, preterm labor, or antepartum hemorrhage (APH). Traveling: Traveling is allowed when comfortable. In women with a history of APH or preterm labor it is better to be avoided. (2, 115) Weight Gain: The normal weight gain during the whole period of pregnancy is 10-12 kg. The pregnant woman increase in the first trimester 1-2 kg. The average weight gain from 20 weeks onward is 0.4 kg/week (range 0.2 - 0.6 kg/week). (2) Baths: Showers are preferable over tub baths. No vaginal douches are allowed.(2, 115)

25 Literature Review --------------------------------------------------------------------Exercise: Exercise should be mild, preferably walking. Housework, if not overtiring, is allowed for the pregnant woman. (2) Rest and Sleep: The pregnant woman should rest eight hours at night and two hours in the afternoon. Increase rest and sleep towards term. (2) Drugs: The pregnant woman should not receive any drugs without doctor order. All unnecessary drugs should be avoided during pregnancy. Minor complaints should be managed without the use of drugs whenever possible, by reassuring the woman. (2) Smoking: Smoking leads to spasm of placental blood vessels which can lead to fetal anoxia, low birth weight neonates (LBW), IUGR, prematurity, premature rupture of membranes (PROM), and placental abruption. (2) Immunization: In most developing countries maternal TT vaccination is implemented as part of the routine vaccination programme or implemented as a supplemental activity. (32, 122) Tetanus toxoid is an active immunization includes toxic product of micro organism which is detoxicated by chemical like formalin and alum rendering. It is harmless. Primary immunization of tetanus toxiod takes time to give acquired immunity, but booster dose gives rapid immune response. It has no adverse effect, so, it requires no sensitive test. It persists for long time generally for year or long life. The dose given to the pregnant woman is 0.5 ml IM in the deltoid muscle

26 Literature Review --------------------------------------------------------------------mostly at the left arm.Tetanus toxoid should be administered to prevent tetanus if the mother has not already been immunized, according to the following:- (2)

1) TT1--- At first contact, or as soon as possible during pregnancy (better after the first trimester). 2) TT2--- At least four weeks after TT1. 3) TT3--- At least 6 months after TT2 or during subsequent pregnancy. 4) TT4--- At least 6 months after TT3 or during subsequent pregnancy. 5) TT5--- Minimum 1 year after TT4 or during subsequent pregnancy.

In Egypt, according to the World Health Organization, the percentage of pregnant women immunized with two or more doses of tetanus toxoid was 48 % in 2008. (30) In South Africa, tetanus toxoid immunization (a total of 3 doses) is given to prevent neonatal tetanus: 0.5 ml intra-muscular (IM) at the first visit and is followed by a second dose 4 weeks later, and the third dose is given 6 months after the second dose. (32) Irradiation: The pregnant woman should avoid exposure to irradiation for its teratogenic effect on fetus. (2)

Common Complaints of Pregnancy: (2, 111)

27 Literature Review --------------------------------------------------------------------The most common complaints of pregnancy are: nausea and vomiting, heartburn and hyperacidity, ptyalism (excessive salivations), constipation, hemorrhoids and varicose veins, edema, leg cramps, leukorrhea (excessive odorless, colorless vaginal discharge not associated with burning sensation or pruritis vulvae), and backache. So, the pregnant woman should be assessed for any of this complains and related interventions would be applied. Alarming Signs and Symptoms: Pregnant women should be advised to seek immediate medical care if they experience any of the following symptoms or signs: vaginal bleeding, severe edema, escape of fluid from vagina, abnormal gain or loss of weight, decrease or cessation of fetal movements, severe headache, epigastric pain, blurred vision, fever, persistent vomiting, and dysuria. During antenatal care the occurrence of any of these signs or symptoms necessitates further evaluation. (2,115) Periodic Visits Record the information obtained at these visits on the Antenatal Care Card. Examination of the Pregnant Woman At each visit the following examinations should be done. - General examination: including blood pressure and body weight. (112,113) - Abdominal examination: of fundal level, fetal lie, fetal presentation, and fetal heart sounds (FHS). - Record any new complaints. - Urine examination: by dipstick for protein, glucose and ketones. - Blood examination: to assess hemoglobin level for iron deficiency anemia. - Assessment of fetal well-being: through identifying the following: fetal size through assessment of fundal level (FL), fetal kick count: at least 10 movements

28 Literature Review --------------------------------------------------------------------every12 hours, fetal movements: absence precedes intrauterine fetal death (IUFD) by 48 hours, and fetal heart sounds. Health Education for Pregnant Women: In addition to the health education provided as in the initial visit, it continues in the periodic visits according to the need of the woman and the trimester. In addition to: Counsel for the Place of Delivery: The health care provider should encourage the woman to deliver at a health facility (maternal and child health center, primary health care unit, district or general hospital). If the woman and/or her family decides to deliver at home, counsel her for home birth. (2) High risk pregnancy. High risk pregnancy is pregnancy which has one or more of risk factors which are conditions associated with child bearing that may jeopardize maternal or fetal welfare. (2, 123) An estimated 15% of pregnant women in developing countries experience pregnancy-related complications.

(32)

There are five major categories

according to MOHP 2005. These factors are: 1) personal factors, 2) obstetrical history, 3) past health history, 4) family health history, 5) ongoing maternal and/or fetal problems. (2, 4, 123) 1. Personal Factors: These factors including: the age of the pregnant woman is less than 18 years or more than 35 years, the woman who lives far from hospital or health facility, positive consanguinity, smoking, and long duration of marriage with infertility and use of ovulatory drugs. (2, 4)

29 Literature Review --------------------------------------------------------------------2. Obstetrical History: High risk pregnancy related to obstetrical factors include: parity ≥ 5, no spacing, previous intrauterine fetal death (IUFD) or neonatal death, previous small for gestational age, previous large for gestational age, previous fetal malformation, previous spontaneous second trimester abortion or preterm labor, recurrent first trimester abortion, previous hypertensive disorders during pregnancy, previous cesarean section delivery, previous retained placenta or postpartum hemorrhage, duration of labor < 4 hours, and previous instrumental delivery (vacuum extraction or forceps). (2, 4) 3. Past Health History: The past factors which make the pregnant woman at high risk are: if the woman had hypertension, heart disease or heart murmur, tuberculosis or intake of antituberculous drugs, epilepsy or intake of antiepileptic drugs, chronic illness, uterine anomalies including uterine fibroid or other pelvic masses, previous myomectomy, previous successful classical repair, previous successful repair of fistula, and previous blood transfusion. (2, 4) 4. Family History: The pregnant woman will be at high risk if any of her family members has fetal abnormality, twin or multiple pregnancy of mother and sister, hypertension, or diabetes. (2, 4) 5. Ongoing Maternal and/or Fetal Problems: There are many factors in the current or present pregnancy that make the pregnant woman at high risk. These including: unknown last menstrual period (LMP), gait: "limping", color of the woman is pallor or jaundice, maternal weight > 90 kg "excessive obesity" or < 45 kg, maternal length ≤ 150 cm, marked varicosities of lower limbs, hyperemesis gravidarum, non immune against tetanus

30 Literature Review --------------------------------------------------------------------neonatorum, absent fetal movements, marked changes in frequency and/or intensity of fetal movements, smaller or larger uterine size than gestational age, vaginal bleeding in early pregnancy, blood pressure ≥ 140/90 mmHg, excess or diminished amniotic fluid, preterm uterine contractions, third trimester vaginal bleeding, sudden gush of vaginal watery fluid, hemoglobin < 11 gm, proteinuria > +1, glucosuria, rubella exposure, herpes, nonengagement of fetal head at 40 weeks gestation in primigravida, malpresentation (breech or transverse lie), and bacteriuria (> 100,000 bacteria in urine culture). (2, 4) Action to be taken in the case of many of the previous high risk factors is to refer the high risk pregnant woman to a higher level of health care facility, in addition to laboratory evaluation and prenatal health education. Good assessment and monitoring of pregnancy through good quality antenatal care could make the high risk woman pass pregnancy safer and without complications. The nurse has a great role in this approach. (2) Role of the nurse in promoting the quality of antenatal care. Each nurse plays a daily role in ensuring quality of care while care is provided. The nurse also is responsible for participating in organizational quality improvement (QI) efforts. All health care organizations should have quality improvement programs, which can be found in hospitals, home care, and long-term care.(65, 124, 125) The National Health services (NHS) in United Kingdom (UK), has made a rapid changes in how health care is delivered, resulting in role changes and alternative professional competencies for nurses. There has been a realization that the major health improvements needed in the NHS cannot be made without advanced nursing skills and roles. (126, 127) Quality management activities are fundamental to nursing practice. The core competencies for basic nursing practice include participation in self-

31 Literature Review --------------------------------------------------------------------evaluation, peer review, continuing education, and other activities that ensure and validate quality practice as a professional responsibility of certified nurse.

(47, 128,

129)

Some roles may be used more often by some nurses depending on the setting in which they are employed. In the antenatal care, the nurse can play several roles in providing and promoting the service. The common roles which are practiced by the nurse are: advocator, consultant, coordinator, counselor, educator, evaluator, planner, provider, researcher, and specialist. (47, 126, 130) Advocator The nurse act on behalf of the women to improve the services and ensure their rights in high quality care. She also should support the woman when referral is needed to a higher heath care facility. Working with the community members is also needed by the nurse to determine solutions for identified problems related to the pregnancy which may affect the health of the pregnant woman as: illiteracy or low level of education and low socioeconomic conditions which may affect the nutrition of the pregnant woman. (47,130) Consultant The nurse may serve as a consultant to a number of different groups, either to other health care providers as social worker, health care agencies, or to a special community groups as pregnant women. The nurse should be expertise, have knowledge, and enough information related to pregnancy and antenatal care to perform this role. It is very helpful to the nurse to be aware of the impact of her words on others, to plan ahead, clarify her thinking on issues, and practice her ability to state her opinions in a clear and concise way in dealing with the pregnant women. (131, 132)

32 Literature Review --------------------------------------------------------------------Coordinator The nurse is often responsible for coordinating activities of antenatal care or at least for participation in the coordination. This role requires a familiarity with the antenatal care services and the roles of other providers as pharmacists, lab technicians, doctors' specialists, staff of other clinics, and other heath care facilities when referral is needed. (133-135)

Counselor The role of counselor is most commonly applied with pregnant women and their families. The nurse provides crisis intervention in case of high risk pregnancy or when occurrence of danger sings during pregnancy. She also provides supportive counseling and other types of counseling that commensurate with education and skills. (136) Counseling skill is also used with community groups. For instance, a nurse working in antenatal care services can provide several group sessions for pregnant women to discuss common and more concerns of them. Preparation for the role of counselor includes classes and practice in antenatal care, additional readings, and attendance at seminars related to advancing the counseling skills. (137) Educator The role of educator encompasses not only individual education of clients but also family education and education of specific groups as the pregnant women. Skills of teaching are incorporated with knowledge of the learning process in order to provide the best possible educational experience. The role of educator is incorporated on almost a daily basis in the nurse's activities as providing the antenatal care services.

(138)

Most nurses learn basic content in their nursing

program in preparation for teaching role. This may be supplemented and enhanced

33 Literature Review --------------------------------------------------------------------by observing teaching technique and other health care educators, by doing further reading on the subject of teaching techniques, and by obtaining feedback on teaching skills. (139, 140) The nurse is teaching the pregnant woman either individually or in groups about pregnancy, the importance of antenatal care and its schedule, the most common minor discomfort and its management, and danger signs during pregnancy. She also should teach them about: nutrition during pregnancy, tetanus immunization, dental care, and clothing of the pregnant woman. She also should allow the woman time to express her feelings and to declare her complaints.

(2,140,

141)

Evaluator The evaluator role of the nurse is implemented in many ways. A nurse may be involved in evaluating antenatal health care program. The nurse practices this role through inspection of the duties of other nurses working in antenatal care services and inspection of day care facilities.

(142)

Preparation for the

role of evaluator will include becoming familiar with the purpose of the evaluation, the person or content to be evaluated, and the communication skills needed to communicate effectively the finding of the evaluation.

(143)

The nurse will often

have to be oriented with the state of antenatal care or its standards. It is important to read and review these standards prior to implementing the evaluation process. It is also helpful to have a written guideline or checklist to use while conducting the evaluation (2, 4, 129, 144) Planner The nurse becomes involved with antenatal care planning for the pregnant woman or larger group of the pregnant women. This role could involve gathering data through assessment or participating in implementation. Following assessment of the woman and identification of actual and potential health

34 Literature Review --------------------------------------------------------------------problems, the nurse should advice plane of care in conjunction with other health care members. Short-term and long-term goals should be delineated and the plan reviewed and revised for the woman at each visit. If the management and care delivery for the woman exceeds the nurse' scope of practice, she must seek help and support from more experienced or senior colleagues. (124, 126, 145) Provider The role of provider is the most common role for the nurse, and it is usually the one at which the nurse spends the largest percent of time in providing nursing care. The type of nursing care provided may vary depending on the setting and the group which the care is provided to them. For instance, nursing care provided in antenatal care clinics for the pregnant women usually involves the care provided to the new attendants and the recurrent attendants of them. Generally this care includes: booking or registration procedure to the pregnant women's information either past or present histories, general and specific assessment of the women through the examination and investigations, and health education about all related issues of pregnancy

(142).

Every nurse can continue to enhance the role of

provider by reading professional journals, attending continuing education conferences, and consulting with colleagues on approaches to antenatal care

(146,

147)

. She also has a role in:

Case finding: Early detection of risk factors during pregnancy is important to prevent hazards for the mothers and / or the outcome of pregnancy. At-risk concept means "there is standard care for everyone, and more care for those in need according to the need". At-risk factors can be detected from the history taking and the first antenatal care examination, or may develop during the course of pregnancy. The at-risk approach is a method by which we ensure that everyone is receiving a standard level of care, and that more care is given to those at-risk

35 Literature Review --------------------------------------------------------------------according to the type of risk. The aim of at-risk approach is to provide quality, cost-effective, rationalized care for every mother according to her own needs. According to their condition, mothers are (a) observed more closely, (b) referred to specialist, or (c) directed to have mandatory hospital delivery (88). Following up: Following up of the pregnant women could be practiced through the periodic visits to the antenatal care clinics. Attendance to the unit can promote continuity of receiving the care. Many activities could be done for the women in the follow up visits such as: registration, examination, laboratory investigations, and health education. Detecting the high risk pregnant woman is a major concern of the nurse's role in the follow up visits to ensure the mother and fetal wellbeing. The skilled provider interviews and examines the woman to detect problems that might affect the woman's pregnancy and require additional care. (1, 2) Referral: Referral guidelines If at any time the nurse is about the pregnant woman unsure assessment, it is perfectly acceptable to ask another colleague to perform the assessment with a woman's permission. If the nurse unsure of a decisive finding, it will be necessary to ask for the on-call obstetric registrar or clinic consultant to review the assessment. Women with obstetric related complaints, which require immediate day medical attention, can be referred to the obstetric registrar or urgent emergency care; women with obstetric related complaints, which do not require same day medical attention, can be referred to the team obstetrician at his/her next clinic day; while women with minor non-obstetric medical complaints can be referred to their local general practitioner (117).

36 Literature Review --------------------------------------------------------------------Researcher Depending on educational preparation, the nurse may participate in research. She can identify potential research problems related to pregnancy, pregnant women, and antenatal care. Then read widely on the subject, and identify research that has already been done in the area. The nurse can then select recommendations for use in practice (144, 148, 149). Specialist Some nurses specialize in a particular aspect of nursing care. A clinical specialist may be employed in community health agency as MCH centers and rural health units. Example of specialists include nurse practitioners educated in areas such as family health or midwifery (134, 146, 150) . Preparation for the role of clinical specialist includes advanced education and advanced clinical practice. It is most helpful for the nurse who wishes to assume this role to practice in a clinical setting for several years first to develop practice skills and to identify areas of particular interest. Then, the nurse can look into advanced educational programs (40, 151- 153)

.

CHAPTER: II

37 Aim of the study-----------------------------------------------------------------------

Aim of the Study

The aim of this study is to:

Develop of nursing care standards for antenatal care at rural health units.

CHAPTER: III

38 Materials and Method ----------------------------------------------------------------

Materials and Method Materials Study design:Exploratory study.

Setting of the study: This study was conducted in rural health units affiliated to the Ministry of Health (MOH) at Tanta city. The total number of the rural health units in Tanta city are (28) units distributed on two sectors, (15) in the first sector and (13) in the second sector. Fifty percent of the units were selected randomly, (8) units from the first sector and (6) units from the second sector to be included in the study. The total number of units amounted to 14 units (Appendix I).

Subjects:Subjects of this study consisted of three groups:Group I: Jury committee The committee consisted of 25 experts who concerned with maternity health care services especially the antenatal health care provided in the rural health units. This group included the following specialists: -

6 academic nursing staff members in community health: (4 professors from community health nursing department in Alexandria Faculty of Nursing and 2 professors from public health and preventive medicine department in Tanta Faculty of Medicine).

-

19 medical and nursing staff who were working in the MOH and were responsible for the service of antenatal care in the rural health units

39 Materials and Method ---------------------------------------------------------------including the following :o

The director of primary care of the rural health in the directorate of health at Tanta City (one).

o

The director of maternal and child health (MCH) department in the directorate of health at Tanta City (one).

o The general director of nursing in El-Gharbia (one). o

Three nursing inspectors of primary health care in the directorate of health at Tanta City.

o Three nursing supervisors of rural health units in the two health administrations at Tanta City. o Five doctors who were providing antenatal care for at least two years was selected randomly from two MCH centers in Tanta City. o Five old experienced nurses who were providing the antenatal care in the rural health units (at least two years experience) were also selected randomly. Group II: All nurses providing antenatal care at the selected rural health units during the period of data collection. Their experience in antenatal care was not less than one year. They consisted of: A. Fifty two nurses who were assessed for their knowledge regarding antenatal nursing care. B. Thirty seven nurses who were observed for their activities of antenatal care. Group III: The pregnant women A random sample of (140) pregnant women who attended the previous health units were included in the study. Equal percent from each unit was selected from the pregnant women (ten women from each unit).

The criteria

40 Materials and Method ---------------------------------------------------------------of inclusion were those women who attended at least two visits for antenatal care (one initial and one recurrent).

Tools of the study:Five tools were developed and used by the researcher to obtain the necessary data:Tool I: Structured interview for basic competencies required for nurses providing antenatal care: (Appendix II) This tool was developed by the researcher in order to elicit the opinion of the jury committee members regarding the identification of basic competencies required for nurses providing antenatal care. Most of these competencies were developed according to Ministry of Health and Population, Arab Republic of Egypt, Basic Essential Obstetric Care: Protocols for Physicians. Standards of Practice for Integrated MCH/RH Services, 2005 (57). The tool covered the following competencies:I-

Communication with the pregnant woman: this competency was presented to the jury committee consisted of 11 activities.

II-

Woman's right: this competency consisted of 8 activities.

III-

Infection control: this competency consisted of 10 activities.

IV-

Initial visit: this competency consisted of 68 activities. It comprised the

following sub competencies: A- Booking procedures and / or Registration: this competency consisted of 12 activities including registration in the woman health card. B- Taking the Woman's History: for personal history of the pregnant woman, menstrual history, obstetric history (past & present), family history, medical history (past & present), surgical history (past &

41 Materials and Method ---------------------------------------------------------------present), family planning history (past), immunization history (past & present), breast feeding history, and complaints. C- Examination of the pregnant woman which included: general (systemic) examination, chest and heart examination, abdominal examination through inspection; palpation; auscultation. This competency consisted of 24 activities. D- Laboratory investigation: of urine for sugar & albumin, and blood analysis. This competency consisted of 5 activities. E- Health education for pregnant women: about schedule of antenatal care visits, adequate nutrition, clothing, dental care, breast care, sexual activity, traveling, weight gain, baths, exercise, drugs, rest and sleep, smoking, immunization, and irradiation. This competency consisted of 24 activities. V- Periodic visits: the total activities included in the periodic visit as presented to the jury committee consisted of 25 activities. It comprised the following competencies: A. Examination of the Pregnant Woman: it included the following examinations: general, abdominal, urine & blood examination, and assessment of fetal well- being. B. Health education for pregnant women: it included counsel for the place of delivery. C. High risk pregnancy and actions to be taken: it included determination and differentiation of high risk pregnancy and referral technique. Tool II: Resources checklist: (Appendix III) This tool was developed by the researcher to assess the availability of the resources needed to provide the antenatal care in the previously mentioned rural

42 Materials and Method ---------------------------------------------------------------health units. It consisted of four parts as follow: Part 1: The physical design: it included 24 items related to the place of the rural health unit in relation to the village, the space of the antenatal clinic and its cleanliness, the presence of adequate light and ventilation, availability of waiting area for pregnant women, availability of health education room, the availability of lab, bath rooms, examination and emergency room, and dental room. Part 2: Human resources (manpower): this part comprised the availability of the following staff in the antenatal care services: Doctors (obstetrician), nurses, dentists, lab technician, social worker, auxiliary personnel, nutritionist, and pharmacist. This part demonstrated the total number of the previous staff in each unit, their sex, educational level, years of experience, and the training courses attended. Part 3: Material resources (equipment and supplies): This part included 29 types of equipment and supplies needed for antenatal care as ultrasound apparatus, weight measurement scale, sphygmomanometers, stethoscopes, thermometers, laboratory equipments, educational supplies and teaching aids, iron and folic acid tablets, tetanus toxiod, and supplies of recording system. Part 4: Information papers: availability of polices, protocols, and /or standards related to antenatal care, infection control policy, and quality care protocol. Tool III: Knowledge assessment sheet: (Appendix IV) Knowledge assessment sheet was developed by the researcher to assess the knowledge of the nurses working in the antenatal care clinic (group II A). It comprised 53 questions, 16 questions choose the correct answer and 37 questions true or false. This tool included the following items: o Socio-demographic data such as: name, qualification, years of experience, attendance of training courses in antenatal care and number of training

43 Materials and Method ---------------------------------------------------------------courses attended. o Nurses' knowledge about: objectives and importance of antenatal care, infection control, registration and history taking of the pregnant women, physical examination of pregnant women, laboratory investigation, health education during pregnancy, high risk pregnancy, management of high risk pregnancy, and role of the nurse during antenatal care. o Nurses' perception about: their satisfaction with the services, their opinions regarding the strength points and weak points of antenatal care services, and their opinions regarding possible solutions of the problems of antenatal care services. Tool IV: Antenatal nursing activities observational checklist sheet: (Appendix V) An observational checklist sheet for nurses (group II B) was developed by the researcher after the recommendations of the jury committee on the initial standards. This tool was derived from tool I (the initial standards). The activities were checked by the researcher whether done, not done, or not applicable. It covered the following items and activities of nurses' role in the antenatal care: I- Communication with the pregnant woman: it included 10 activities. II- Woman's right: it included 5 activities III- Infection control: it included 8 activities and 10 sub activity. IV- Initial visit: it included booking procedures and / or registration (12 activities), taking the woman's history (9 activities), examination of the pregnant woman (41 activities and 38 sub activity), laboratory investigations (4 activities), and health education for pregnant women (34 activities). V- Periodic visits: it included examination of the pregnant woman (13 activities), health education for pregnant women (5 activities in addition to the activities in the initial visit), and high risk pregnancy and actions to be taken (8 activities).

44 Materials and Method ---------------------------------------------------------------Tool V: Interview sheet for pregnant women satisfaction& needs assessment: (Appendix VI) This tool was developed by the researcher to assess the pregnant women's (group III) satisfaction and needs regarding the antenatal care activities provided in the rural health units. It included six parts as follows: Part 1: Socio demographic characteristics of the pregnant woman such as: woman's age, education, occupation, and number of family members. Part 2: Obstetrical and gynecological history: As number of pregnancies, number of deliveries, place of the last delivery, person who assisted the last delivery of the woman, number of abortions , number of still birth , number of premature infants , previous cesarean section , ante partum hemorrhage, and previous toxoplasmosis. Part 3: Present history: as duration of pregnancy by weeks, time of the first visit to the unit, number of follow up visits to the unit, number of received doses of tetanus immunization, place which the woman went to when she needed to go to a doctor, and if the woman follows up her pregnancy at a private doctor? Part 4: Services provided to the woman during present pregnancy: as measuring blood pressure, weighing, blood analysis for hemoglobin level, urine analysis for sugar and albumin, giving iron tablets from the unit, visiting the woman's home by a nurse, waiting time spent, time spent in the antenatal care room with the nurse, and if the pregnant woman examined by the doctor at each visit and received counseling. Part 5: Pregnant women's satisfaction regarding services provided during pregnancy at the rural health unit: as satisfaction with: the health services, nurses and doctors communication (dealing), keeping the woman's privacy, waiting and examination area, cleaning of clinics and bathrooms, infection control measures,

45 Materials and Method ---------------------------------------------------------------analysis and sample taking, equipments and apparatus used as ultrasound, working times in the unit, and follow up services. Part 6: Pregnant women's satisfaction regarding health education provided: as attending health education sessions, receiving health education individually from a nurse, the subjects of the education received, and the satisfaction regarding this education. The women were also asked about their suggestions for improving the services provided to the pregnant women at the rural health unit.

46 Materials and Method ----------------------------------------------------------------

Method Administrative process:1- An official letter was directed from Faculty of Nursing to the Undersecretary of Ministry of health to facilitate the process of data collection from jury members in the Directorate of Health, the nursing and medical administrators, and personnel in rural health units in Tanta city. 2- The objective of the study was explained to all participants in the study. The anonymity and confidentiality of responses, voluntary participation and right to refuse to participate in the study was a right to all subjects. 3- Meetings with supervisors of the first and second health administrations who were responsible for rural health units were done to attain the address of each unit and to define the working schedule for antenatal care services. 4- Several meetings were conducted with nurses working in antenatal care and head nurse in the rural health unit to collect initial information about the current situation of antenatal care in the rural heath units. Theses meetings resulted in that no standards of antenatal care were found for nurses in the rural heath units. 5- An interview with the manager and head nurse of each rural health unit was conducted to facilitate the work of the researcher and to determine the functioning of the present health care system regarding antenatal care in the unit. The objective of the study was explained to them.

47 Materials and Method ---------------------------------------------------------------Development of the initial standards:6- Developing standards for antenatal care at rural health unit: a. The basic competencies of antenatal care and the underlying activities of each competency were developed in the form of initial standards based on the recent literature review depending mainly on the resources from the Ministry of Health (MOH) (57). b. Arabic form of the standards was developed to suit all educational level of the jury committee especially the nurses. c. The initial standards were presented to the jury committee to obtain their opinion whether the activities under each competency is basic and should be performed by the nurse or not. Each expert took a period of 1day to 3 weeks to state his/her opinion. d. The comments of the jury members were analyzed and tested for validity. Testing the validity of the standards: i. The standards composed of main elements; each element included different tasks / activities. ii.

Each activity was answered by the jury with agree or disagree; scored as (1 or 0).

iii. Each element of the standards was given a total score according to the degree of acceptance by the jury then the mean acceptance (agreement) for each element was calculated. iv. The standards were accepted only if the average of acceptance was 80% and more for each element in the initial

48 Materials and Method ---------------------------------------------------------------standards. v. To estimate the mean score of the jury members' responses, the following estimation was used: Sum of total score in each item among all sheets N (Maximum score in each item for each sheet) ×Frequency (25 sheet) e. The recommendations of the jury were done. Items accepted by less than 80% were excluded from the standards as activities related to:, health education, and laboratory investigation. 7- In spite of the agreements of some nursing activities by less than 80% of the jury which should be discarded, some of these were decided to be included in the standards as important activities. Examples of these activities were: a. Permit only one woman at a time in the antenatal room to provide her privacy as an activity of the communication. b. Change the linen of the examination bed by another one between women as an activity of the infection control. c. Sign after any registration procedure as an activity of taking the woman's history. d. General examination as: check sings of anemia, varicose vein, and thyroid enlargement. e. Keep copies of the radiological reports and / or any other examination reports concerning the pregnant woman in the antenatal clinic as an activity of the management of high risk pregnancy. 8- Comments on the activity by two members or more were considered to be applied.

49 Materials and Method ---------------------------------------------------------------Development of the tools:9- Resources checklist: a. This tool was used initially in the first visit to each rural health unit to determine the resources available in the unit for providing antenatal care. The information of this tool was obtained by asking the workers of the unit and observing the resources. In some instances the information was obtained from more than one source. b. The results of this tool were presented as a simple frequency method. 10- Knowledge assessment sheet: a. This tool was developed by the researcher to assess the knowledge of the nurses working in the antenatal care clinic (group II A). b. A pilot study was conducted before starting data collection on 5 nurses selected from different units other than those involved in the study to test this tool for its clarity, organization, and to estimate the time needed for the sheet. Necessary modifications were done. Some questions were clarified and others were restated to reach the final form. c. The sheets were distributed to the nurses providing antenatal care in the rural health units and welling to fill the sheet individually. Sheets were gathered by the researcher at the next visit to the unit. 11- Antenatal nursing activities observational checklist sheet: a. This tool was developed and mainly derived from the initial standards to check the nursing activities related to antenatal care. b. Observation of the nurses (group II B) was conducted by using this

50 Materials and Method ---------------------------------------------------------------tool in the days which antenatal care services are provided in each unit. c. Each activity in the sheet was checked by the researcher whether done, not done, or not applicable. 12- Interview sheet for pregnant women satisfaction& needs assessment: a. This tool was developed to assess the pregnant women satisfaction and needs related to antenatal care. b. A pilot study was conducted on 5 pregnant women to test the tool for its clarity, organization. Accordingly modification was done. Some questions were restated, some questions were added and others were omitted. They were excluded from the original sample. c. The days of the tetanus immunization session in each health unit was selected to complete this tool to assure the availability of the pregnant women. d. Interview with each pregnant woman was conducted individually in a suitable place in each unit to fill the sheet after obtaining her oral consent and demonstrating the objective of the study. 13- Development of the final standards:a. Results of the observation checklist for nurses' performance which was derived mainly from the modified initial standards were used in together with the findings of nurses' knowledge and women's satisfaction to formulate the final standards. Some items were added to the standards as: i. Adding the tetanus immunization procedure. ii. Writing in details the categories of high risk pregnancy.

51 Materials and Method ---------------------------------------------------------------b. The final standards were developed after the agreement of the jury committee on the modified initial standards. c. A booklet of the final and acceptable standards (Arabic form) were distributed by the stakeholders who are responsible for antenatal care in the rural health units for applicability by nurses. (Appendix VII) 14- The period of data collection was extended from September 2009 to December 2010. Data analysis:15- The data collected were coded and tabulated using the statistical package for social science (SPSS) and used for data entry and analysis. Fisher exact test was used to do the test of significance. 16- Knowledge assessment: a. The educational and working characteristics of the nurses were presented as simple frequency, mean, and standard deviation. The questions related to the nurses' knowledge were amounted 53 questions distributed to 9 categories related to antenatal care. This part was presented as correct and incorrect answers according to knowledge response. b. The fifth (50th) percentiles of nurses' score of knowledge was used to make the relation between nurses' knowledge and their education, years of experience, training courses, and satisfaction with antenatal care services. 17- Observational checklist: a. The score of not applicable item take the same score of not done item, but the done item take another score. The items of antenatal

52 Materials and Method ---------------------------------------------------------------nursing tasks presented as: tasks not performed and performed tasks. Performed tasks were rated according to the score of each item as: poor performance, fair performance, and accepted performance as following: Rating scale

Score

poor performance

< 50 %

fair performance

50 % - < 70 %

accepted performance

> 70

Limitations of the study: The observation could not be performed for each nurse because of the following reasons:1- Some of the nurses were only working at child care activities in spite of their distribution by the administration of health as specialized in maternal & child health. 2- The routine work organization in the rural health units assign one nurse for each nursing activity (e.g. a nurse for registering the pregnant women at the initial visit, a nurse for registering the pregnant women at the recurrent visits, a nurse for weighing and measuring blood pressure, a nurse for tetanus immunization, and a nurse for deliveries and post- partum visits. This makes the number of nurses who were observed for the activities of antenatal 37 nurses distributed over the 14 units. The observation was then based on checking the nursing activity at each unit.

CHAPTER: IV

53 Results ------------------------------------------------------------------------------------------

Results The results of this study will be presented within seven parts:-

Part I. Development of initial nursing care standards for antenatal care.

Part II. Resources of antenatal care at the rural health units.

Part III. Knowledge of nurses about antenatal care .

Part IV. Practices of nurses working in the rural health units regarding antenatal care . Part V. Pregnant women satisfaction regarding antenatal care .

Part VI. Nurses' opinions regarding antenatal care services . Part VII. Final nursing care standards for antenatal care.

54 Results ------------------------------------------------------------------------------------------

Part I. Development of initial nursing care standards for antenatal care.

Table (1-4) presents the percent distribution of the total nursing activities of the antenatal care according to the initial standards presented to the jury committee.

It shows that the total nursing activities of the antenatal care of the initial standards were 122 activities. More than half (55.7%) of this activities were done in the initial visit. While, one fifth (20.5%) of them were done in the periodic visits. The rest of the activities are related to infection control, woman's right, and the communication skills (8.6%, 6.6%, 9% respectively).

55 Results ------------------------------------------------------------------------------------------

Table (1-4): Percent distribution of the total nursing activities of the antenatal care according to the initial standards presented to the jury committee.

Nursing activities items

No of activities

%

I- Communication

11

9.0

II- Woman's rights

8

6.6

III- Infection control

10

8.2

IV- Initial visit:

68

55.7

12

17.6

3

4.4

24

35.3

5

7.4

24

35.3

25

20.5

A- Examination

14

56.0

B- Health education

3

12.0

C- High risk pregnancy

8

32.0

122

100.0

A- Booking (registration) B- History taking C- Examination D- Laboratory investigation E- Health education V- Periodic visits:

Total

56 Results ------------------------------------------------------------------------------------------

Table (2-4) presents the percentage and the rank order of the accepted elements of the initial antenatal nursing care standards by the jury committee.

The table shows that among the highly accepted (90-100%) nursing activities, nursing competencies related to woman's rights and health education were the two elements of the antenatal nursing care standards that were highly accepted by the jury ( 96.5%, and 96.3% respectively), followed by booking or registration, and communication (95.7%, and 93.5% respectively).

Infection control and periodic visits activities were also highly accepted and have nearly the same level of acceptance (92.4% and 92.3%), followed by the laboratory investigation (90.4%). Examination and history taking activities were moderately accepted (87.8% and 85.3%) by the jury committee.

57 Results ------------------------------------------------------------------------------------------

Table (2-4): Percentage and rank order of the accepted elements of the initial antenatal nursing care standards by the jury committee.

Highly accepted (90-100%)

Moderately accepted (80- 89.9 %)

Low accepted (< 80 %)

Rank order

I- Communication

93.5 %

0.0

6.5%

4

II- Woman's rights

96.5 %

0.0

3.5%

1

III- Infection control

92.4 %

0.0

7.6%

5

IV- Initial visit: A- Booking (registration)

95.7 %

0.0

4.3%

3

Elements of the initial standards

B- History taking

0.0

85.3 %

14.6%

9

C- Examination

0.0

87.8 %

12.2%

8

D-Laboratory investigation

90.4 %

0.0

9.6%

7

E- Health education

96.3 %

0.0

3.7%

2

V- Periodic visits

92.3 %

0.0

7.7%

6

58 Results ------------------------------------------------------------------------------------------

Table (3-4) demonstrates the distribution of the accepted items of nursing care competencies for the initial standards of antenatal care among the total jury committee.

The table shows that the total number of academic staff (100%) accepted the items of nursing care competencies related to communication, woman's rights, infection control, laboratory investigation, health education, and periodic visits by equal or more than 80%. Two thirds of them (66.7%) accepted the items related to booking or registration, history taking, and the examination by also equal or more than 80%. As regard to the activities accepted by the nurses by equal or more than 80%, all the nurses (100%) accepted the items related to communication, woman's rights, booking or registration, health education, and periodic visits, while the majority of them (91.7%) accepted the items related to examination and laboratory investigation. History taking and infection control were accepted by 83.3% and 75% respectively. The responses of doctors show that the total number of doctors (100%) accepted only booking or registration by equal to or more than 80%. Followed by woman's right, infection control, and health education which were accepted by 71.4% of the doctors. More than one half (57.1%) of the doctors accepted the items related to communication, laboratory investigation, and periodic visits by equal or more than 80%. The least accepted activities by > 80% of the doctors were those related to history taking and examination. A significant difference was found between responses of jury committee (academic staff, nurses, and doctors) and items of nursing care competencies of antenatal care related to communication, booking (registration), history taking, examination, laboratory investigation, and periodic visits.

59 Results -----------------------------------------------------------------------------------------Table (3-4): Distribution of the accepted items of nursing care competencies for the initial standards of antenatal care among the jury committee (n = 25) Academic staff

Nurses

Doctors

Total

n = (6)

n = (12)

n = (7)

n= (25)

90 kg "excessive obesity" or < 45 kg. Maternal length ≤ 150 cm. Marked varicosities of lower limbs. Hyperemesis gravidarum. Non immune against tetanus neonatorum. Absent fetal movements. Marked changes in frequency and/or intensity of fetal movements. Smaller or larger uterine size than gestational age. Vaginal bleeding in early pregnancy. Blood pressure ≥ 140/90 mmHg. Excess or diminished amniotic fluid. Preterm uterine contractions. Third trimester vaginal bleeding. Sudden gush of vaginal watery fluid. Hemoglobin < 11 gm. Proteinuria > +1. Glucosuria. Rubella exposure.

137 Results ------------------------------------------------------------------------------------------

Nonengagement of fetal head at 40 weeks gestation in primigravida. Malpresentation (breech or transverse lie). Bacteriuria (> 100,000 bacteria in urine culture).

3- Differentiate the maternal health record of the high risk woman from the normal one (different color of the card as red). 4- Keep copies of the radiological reports and / or any other examination reports concerning the pregnant woman in the antenatal clinic. Referral technique:1- Refer the high risk pregnant woman to higher health facility to receive a specific medical care if it is not available in the unit if required. 2- Explain the reason for the referral to the pregnant woman. 3- Document the reason for the referral in the woman's health record. 4- Transfer the complete and up to date examinations and investigation results with the woman to the referral health facility.

CHAPTER: V

138 Discussion ----------------------------------------------------------------------Discussion High quality antenatal care is a fundamental right for women to safeguard their health and to help women to maintain normal pregnancies and reduce the rate of maternal morbidity and mortality.

(18-22)

To ensure quality of care, the nursing

care needs some standards which provide direction for professional nursing practice and a framework for planning and evaluation of this practice. It is also important for ensuring the continuing of nursing professional development.

(40, 41)

Nursing care standards for antenatal care are necessary to be available and applicable in all primary health care centers and units to demonstrate high quality, effective and efficient interventions for the pregnant women. Antenatal care is important in helping to ensure that women and newborns survive pregnancy and childbirth. The traditional approach to antenatal care, which is based on European models developed in the early 1900s. (1) The development of systemized, screening programmes for antenatal care were first introduced in Western Europe at the beginning of the twentieth century.

(108)

Frequent routine

visits were the norm, and women are classified by risk category to determine their chances of complications and the level of care they need. Many developing countries have adopted this approach without adjusting the interventions to meet the needs of their particular populations, taking into account their available resources or evaluating the scientific basis for specific practices. (1) In Egypt, Ministry of Health (2005) developed standards of practice for integrated Maternal and Child Health and Reproductive Health (MCH/ RH) services for physicians and specified a chapter for antenatal care and high risk pregnancy.

(2)

No nursing standard for antenatal care is available, however the

present standard was developed and derived based on the identified services in the previous Ministry of health standard.

139 Discussion ----------------------------------------------------------------------Antenatal care is still an area in need of standardization. Lavender et. al., (2007), who studied the access to antenatal care, recommended that it is difficult to set measurable standards across the whole pregnant population; different standards may be needed for different populations. This means that standards which are suitable for the urban pregnant women, may not suit the rural ones. (108) The results of Abd Elgwad (2009), in a study about: monitoring the quality of antenatal nursing care at maternity and child health centers at Tanta and ElMahala in Egypt revealed that the studied MCH centers did not have standard for nurses' performance. This was also true for the rural health units.

(154)

Therefore,

the present study has been conducted in rural health units at Tanta city, aiming at developing standards for antenatal care. According to Egypt's National Human Development Report (2005), the concentrations of poor populations are mainly in rural areas. Because of the poor performance of rural areas, a good health policy should provide the poor with some form of health security, particularly to protect them from paying for catastrophic medical episodes. This can come about if the services themselves are upgraded and brought up to a standard of care. (155) Comprehensive development and modernization is one of the Egypt's priorities towards improving the quality of health care services available for all Egyptians. Ministry of Health has adopted, as a top priority, developing a current system to provide and finance the health services. It put a plan to institutionalize the Health Sector Reform Program on the national level. The plan is focusing on implementing the Family Health Model at all primary health care facilities in the 27 governorates.

(88)

Family medicine is the underpinning of the unified

comprehensive health insurance system in Egypt over the last years. It aims at providing health services and studying the society’s health problems so as to find the appropriate solutions for about 80 % to 90% of the cases. This system has been

140 Discussion ----------------------------------------------------------------------implemented in 18 governorates through a number of 845 health units, providing a physician for every 500 families and so each family gets about 70% of health services in the nearest health unit. These services are almost precautionary services that include children vaccinations, first-aid health services, pharmaceuticals, motherhood and childhood care as well as family planning and laboratory tests. In light of this medical system, each family has a medical record that contains the family’s medical and genetic history.

(28)

During the period of data collection for

this study, two units from the fourteen were found to have quality care protocol (table 11-4). This means that they were accredited as family medicine units and applied the quality care concerning this system. The other units were preparing for the accreditation. In the present study, the results of the jury assessment (face validity) of the initial standards showed that nursing activities related to examination had the least acceptance by >80% of the doctors (table 3-4). Their rational was that these activities are the doctors' role not the nurses' role. These doctors, of the jury committee, were working at the maternal and child health centers (MCH) at Tanta City where their number was sufficient and these activities were done routinely by them. This was not the situation at the rural health units where no obstetricians were available or if present, they were available for one or two days per week and may be rotated to other centers. So, these activities were insisted by the supervisors to be included in the final nursing standards. In Canada, complete physical examination is performed during first and subsequent pregnancy visits. Recording height and weight and calculating prepregnancy BMI are also performed.

(156)

In South Africa, the following physical

examinations are done for the pregnant woman: general appearance, woman's height and weight, breast examination, and abdominal examination. (157)

141 Discussion ----------------------------------------------------------------------Although the woman's rights are found to be the highly accepted elements of antenatal care by the jury committee in the present study (table 2-4), the nursing task of permitting one woman only at a time in the antenatal room was not accepted by the jury (table 4-4). They explained this by that it is difficult to be applied because of the large number of the pregnant women who are usually crowded in a same time and mostly in the days of tetanus immunization to receive the tetanus toxoid. WHO, (2006), in its publication related to Integrated Management of Pregnancy and Childbirth reported that privacy and confidentiality are considered from the principles of good care. A private place for the examination and counseling should be ensured in all contacts with the woman and her partner. The examination area should be organized so that, during examination, the woman is protected from the view of other people by curtain, screen, and wall. (158) Privacy is a fundamental right of the patient. It comprises privacy of medical assessment, privacy of medical records, and privacy of medical

examination. (159)

Infection control is a first priority in any health care setting. Changing linen between women is a measure for preventing transmitting infection at antenatal care clinic. The jury committee in this study did not accept the nursing activity related to infection control which concerned with changing the linen of the examination bed by another one between women (table 4-4). Their rational was the difficulty in applying this activity because of the shortage of the linens and their willingness to keep cleaned ones to be available in case of auditing or supervision from inspectors. The researcher and the supervisors insisted to include this nursing task in the final standards for its importance in limiting the infections between women, with a recommendation to supply rural health units with enough linen aiming to reduce infection across women. All medical records should be dated, the time entered, and signed.

(160)

The

jury members did not accept the nursing activity related to signature after any registration procedure. Their rational for this was that the work in the antenatal

142 Discussion ----------------------------------------------------------------------clinic was distributed on the nurses and each nurse was assigned to specific activity, so there was no need for signature. Both the researcher and the supervisors showed that it is important for the nurse to sign after any registration procedure to determine the responsibility. Health education was found to be one of the highly accepted antenatal care elements by the jury committee in the present study (table 2-4). Then majority of nurses gave correct answers related to the most items of health education during pregnancy (table 14-4). Inspite of this, nurses had poor performance related to health education of the initial visit in the majority of the units and did not perform tasks related to health education of the periodic visits in the majority of the units (table 17-4). This could be explained by the lack or unavailability of health education resources as: unavailability of health education room in most of the studied units (table 5-4), unavailability of educational apparatus as data show or over head projector (table 6-4), and educational supplies and teaching aids for antenatal care as posters, flip charts or handouts for health education (table 7-4). This could be reflected on the provision of educational activities by nurses. In London, National institute for Health and Clinical Excellence insisted that antenatal information should be given to pregnant women according to the schedule of their attendants. (161) It was also found in this study that at all units nurses did not conduct health education sessions for the pregnant women (table 17-4). This may be related to the lack of health education strategy at the units for the pregnant women and absence of the assertiveness, supervision, and evaluation for application of this strategy. This may be also related to the shortage of trained personnel on health education. Pasinlioqlu, (2004), who studied the health education for pregnant women in Turkey, reported that health education has an effect on enhancing the self-care agency of pregnant women. (118)

143 Discussion ----------------------------------------------------------------------The present study revealed that more than two thirds of the nurses did not attend any training courses in antenatal care. The number of training courses attended, was only one course for most of the nurses (table 12-4). Consequently, it was found that nurses who had equal to or more than the 50th percentile of knowledge score constituted slightly more than half the nurses. And more than one half of them had years of experience from 10 to less than 20 years. However, a significance positive relationship was found between nurses' score of knowledge and years of experience (table 16-4). In this context, Alwan et. al., (2002), stated that the efficient use of human resources and institutional capability must be seen as an essential part of any reform process and a basic challenge for all countries. This includes refocusing the education, training and practice of health professionals, and finding ways to retain and strengthen their capabilities over time. Too little attention is given to continuing education, which in many countries is not part of the health services. Training of health personnel is therefore inadequate and unfocused. (15) This study revealed that the majority of nurses answered correctly on the questions related to infection control (table 13-4), while their performance was poor in this area (table 17-4). On the other hand, it was observed that, infection control policy was available in all units (table 11-4), as well as disposable syringes, hand washing sink, and solutions for disinfection (table 7-4). This is because of the continuous supervision and evaluation from the directorate and administration of health on the availability of infection control supplies and equipment. Meanwhile, supervision on the performance was not continuous. So, nurses' performance may improve and infection control measures could be applied in the case of direct supervision of nurses. The results of the current study revealed that majority of the nurses answered correctly the questions related to registration and history taking of the pregnant women (table 13-4). Nurses as well had accepted performance related to

144 Discussion ----------------------------------------------------------------------booking (registration) at the majority of units either in the initial or recurrent visit (table 17-4). The reason for this is that there were blocks that could be easily filled in with the woman's information in the pregnant women's registers. This would be revised by the supervisors or the auditors. On the other hand, vital signs (except the blood pressure) had no place in the pregnant women register to be filled in, therefore, nurses did not perform activities related to taking vital signs at all the units as well as the details of woman's history. The availability of recording system for antenatal care services in the rural health units can help in performing the registration process. The current study revealed that the new pregnant women register was available in the majority of the units, and the recurrent women register was available in most of the units. This may be the cause which reflected on the nurses' performance. Meanwhile, the pregnant women's health card was not available in the majority of the units (table 10-4). Nurses overcome these problems by making a photocopy of the register in the case of its unavailability, and in case of the shortage of the pregnant women's health card, nurses asked every pregnant woman to buy a note and filed it with the same information present in the printed one. Wong et. al., (2009), studied the developing patient registration and medical records management system in Ethiopia, stated that in low-income countries, medical record management is often lacking. They commented that a well-organized medical record management system can be effective in improving patient information accessibility and completeness in hospitals in low-income countries despite the lack of resources. Longer follow-up is required to assess the sustainability of the hospital improvements accomplished. (110) The majority of nurses in the present study gave correct answers related to physical examination of pregnant women especially measuring weight and blood pressure (table 13-4). Nurses at one half of the units had poor performance related to measuring weight and height, while 42.9% of them had fair performance related

145 Discussion ----------------------------------------------------------------------to measuring blood pressure (table 17-4). Inspit of the availability of weight measurement scale and sphygmomanometers in the majority of the units. This could be due to negligence as these are simple nursing procedures that could be done by any nurse. Hoque et. al., (2008), studied auditing of antenatal care in a rural district of KZN, South Africa reported that 95% of the attendees for first antenatal care visit had recorded complete past pregnancy history, 96% of them had recorded present pregnancy history, 100% of them had recorded measurement of height and weight, and 97% of them had recorded blood pressure.

(32)

In Australia,

according to standard antenatal check, estimation of EDD, measuring blood pressure and fundal level, assessing fetal movements, auscultation of fetal heart, performing abdominal inspection and palpation, and referring the high risk woman are important. (117) The results of this study revealed that, at all the units, nurses did not perform abdominal examination task. Abdominal examination was not performed either by nurses or by doctors (table 17-4). This could be due to the believe that abdominal examination is not a nursing task and the unavailability of obstetrician. Pregnant women, who required medical advice, received it orally in most of the times. This resulted that many pregnant women follow their pregnancy at private doctors where they receive the needed care and came to the health unit for just receiving tetanus immunization, measuring weight and height, and registration the newborn to receive immunizations. As regard to the nurses performed tasks of the initial antenatal care visit, nurses' performance was poor related to communication in the present study (table 17-4). This may be related to the large number of the pregnant women at the same time in the antenatal care room and nurses did not find enough time to spend with each woman. In addition, the pregnant women themselves were hurried up in most of times to receive the care and go back home. It could be attributed to this recommendation, that availability of assertive and knowledgeable supervisors will

146 Discussion ----------------------------------------------------------------------improve the nurses' performance. Abou El Enein et. al., (2010), studied the health care providers' views on supervisory visits in family health centers and units in Alexandria, Egypt, and proposed that to improve the quality of health services including the supportive supervision approach that improves services by focusing on meeting staff needs for management support, logistics, training and continuing education. (162) Regarding the women's satisfaction with antenatal care, one of the indicators measuring quality of antenatal care is client satisfaction which includes: percent of clients satisfied with the services received, perception of clients satisfied with the waiting time, percent of clients who felt that privacy was adequate for counseling/clinical examination.

(21)

Quality is achieved when an organization's

processes and activities are designed and implemented in order to continuously meet the organization's pregnant women needs and expectations and defining their characteristics. (163) The present study revealed that the age of the majority of the pregnant women ranged from 20 years to less than 35 years old (table 18-4). Hoque et. al., (2008), who made an audit of antenatal care in a rural district of KZN, South Africa reported that the age of 66% of the pregnant women ranged from 20 to 34 years old. (32) The mean age of the pregnant women in this study was 23.96 + 3.98 years, while it was 29.08 + 3.95 years in another study in Sindh, Pakistan (2007). (3) This may be related to the early marriage and occurrence of pregnancy in young age in the rural areas where our study were conducted. It was found that there was significant relationship between clients' satisfaction and level of education.

(164)

Hildingsson et. al., (2005), in Sweden

reported that women with low levels of education were more likely to be dissatisfied with both medical and emotional aspects of antenatal care.

(72)

As

regard pregnant women's education, it was found in this study that more than half

147 Discussion ----------------------------------------------------------------------of them had secondary education and less than one fifth of them had university education. This high number of educated women reflects the increase in the awareness of the rural population about woman's rights as female education. In Sindh, Pakistan (2007), 43.5% of women were illiterates, 47.2% had primary education and 9.3% had secondary education and the majority of the pregnant women were housewives.

(3)

This is in accordance with the results of this study.

Hoque et. al., (2008), also reported in their study in rural district of KZN, South Africa that the majority of the pregnant mothers were unemployed.

(32)

Rajaeefard

et. al., (2007), who studied preterm delivery risk factors in Shiraz, Islamic Republic of Iran, reported also that the majority of pregnant women either with low or high risk were housewives. (102) The highly educated women may have knowledge about antenatal care which enable them seeking care at the proper time and to be oriented about the high risk factors and actions to be taken when necessary. Housewives may have the time and the opportunity to care for themselves and to reduce the work factors that may endanger their pregnancy. As regard the obstetrical history of the pregnant women, the present study revealed that more than two fifths of the women had three or less pregnancies (table 19-4). In another study in Shiraz, Islamic Republic of Iran by Rajaeefard et. al., (2007), found in their study that 55.4% of low risk pregnant women had number of pregnancy from 2-4 pregnancies. (102) In this study, more than one third of the women had a history of previous abortion. This is similar to the result of Nisar et. al., in Sindh, Pakistan (2007), which revealed that 32% of the pregnant women had history of abortions. (3) The results of a study in Damascus by Bashour et. al., (2008), revealed that 30.8% of the studied women had history of spontaneous abortion.

(36)

The present study

revealed that 5.9 % of the studied women had a history of still birth or neonatal death. Bashour et. al., (2008), in Damascus, stated that 6.6% of the studied women had a history of still birth, and 33.4% of them had history of non-normal delivery.

148 Discussion ----------------------------------------------------------------------(36)

Rajaeefard et. Al., (2007), in Shiraz, Islamic Republic of Iran found in their

study that 0.3% of high risk pregnant women had 2 stillbirths and 2 neonatal deaths as major risk factors. (102) The present study revealed that more than one quarter of the women had a history of cesarean section. This is in accordance with EDHS 2008, which revealed that more than one-quarter of deliveries in the five-year period before the 2008 EDHS survey were by caesarean section. (12) Aali et. al., (2005), in Kerman, Islamic Republic of Iran stated that 33.0% of the studied women had positive attitudes towards caesarean section. (165) The last delivery for the majority of women in the present study conducted by a doctor . This is similar to the results of 2008 EDHS which showed that about two thirds of the women who were assisted during delivery by a doctor were from rural residence.

(12)

This cofirms that government and MOH have invested heavily

to increase the availability and accessibility of maternal health services, improve the quality of obstetric care, and train traditional birth attendants (dayas) to refer women with obstetric complications. It is worth mention that Maternal Mortality Rates are decreasing as a consequence, and Egypt is well on track to reach the Millennium Development Goal of reducing the MMR to 21/100,000 live births in 2015 (a 3/4 reduction). (166) Hypertension is one of the major risk factors during pregnancy which needs special care and attention from the nurse to help the high risk woman to pass pregnancy safer and without complications.

(2, 4)

Almost one quarter of the

pregnant women in this study had a history of hypertension during pregnancy. It is a policy that the nurse put a red point beside the data of high risk factor in the pregnant women register. However, nurses do not have a definite role in referral or guidance. Abd Elgwad M E, (2009), in a research about: monitoring quality of antenatal nursing care at maternity and child health centers at Tanta and Ell-Mahala

149 Discussion ----------------------------------------------------------------------in Egypt found that nurses were lacking knowledge about standards to differentiate normal from high risk pregnancy.

(154)

Rajaeefard et. al., (2007), who investigated

preterm delivery risk factors: a prevention strategy in Shiraz, Islamic Republic of Iran found in their study that 2.7% of high risk pregnant women were found to have gestational hypertension as a major risk factor. (102) The first antenatal visit to the unit by pregnant women, in the present study was during the second trimester for almost three quarters of the women (table 204). This may be due to that the pregnant women attended the unit mainly for receiving tetanus toxoid immunization which is given mostly in the second trimester. Hoque et. al., (2008), reported in their study related to audit of antenatal care in rural district of KZN, South Africa that only 9% of the pregnant women booked a visit during their first trimester but most of them (two-thirds) booked a visit during the second trimester of pregnancy. (32) The time of first antenatal care visit according to 2008 EDHS was = ?4$‬ﻡ‪$‬ت ا‪$‬ی‪ #‬أ[!‪$‬ء ا  ا‪,‬ﺡة ا‪ #3V‬؟‬ ‫‬‫‬‫‬‫‬‫‪-‬‬

‫ی!‪)B‬‬

‫(‬

‫‪١‬‬ ‫‪Appendix VII‬‬ ‫ا  ا  ا أ ء ا‬ ‫ا ‪ /‬ا ط‬

‫اءة‬ ‫ا ‬

‫‪   -١‬ة   ا و  ‪.‬‬ ‫أو‪-:‬‬ ‫ا‪#‬ا"‬ ‫& ﻡ‪$‬‬ ‫ا( 'ة‬ ‫اﻡ‬

‫‪& -٢‬ف ‪  $‬ذاآة ا! وا‪.‬‬ ‫‪ + -٣‬ا* )( ‪ $‬و‪  ./‬ة ا‪.,-‬‬ ‫‪A‬ة اﻡ‪ ,v :‬ا! ‪،‬ا ‪ ،‬ا&‪$‬ان‪ ،‬درA‬ة‪.‬‬ ‫‪ .٢‬ار@ ا‪n‬ﻥ=&; ‪.‬‬ ‫‪ .٣‬ار@ ا>‪ .‬ا(&‪' ( 4‬ة‪.‬‬

‫‪١٩‬‬

‫‪ .٤‬ار@ ا>‪r .‬ة‪.‬‬ ‫‪ .٥‬اآ ا ا‪& 1‬م وا= ‪.7‬‬ ‫‪.١‬ا‪#‬اﻡ ا‪' ( >A‬ة وا اآ‪#5+ 2‬رة‪:‬‬ ‫ أن ی^ن  ا ة ا‪ ,-‬أ(‪ $ ١٨  ,‬أو أآ‪.$ ٣٥  v‬‬‫ أن ^ن ا ة &ة ا ‪ 8J‬أو ا ا‪.-2‬‬‫ ا‪+‬ا  ار-‬أ ء ا =ورى ' آ ﻡاآ‪ 9‬وو)ات ا  ا‪&0‬ا‪%‬و& ‪ &,-‬دة  & ذات‬ ‫آ‪ 3‬ءة و' ‪ ' &+‬ا‪ *-‬ﻡ ﻡ@ ا?&)ات ااﻡ‪ .‬وا)ات ا‪ &0‬ا‪ &3‬ﻡ زا‪ D‬ﺕ*‪ 5-‬ﻡ‪ C‬ا‪AB‬ت‬ ‫ا‪ &0‬ا‪ -‬ﺕ‪ -‬ج ا ﻡ* & ‪  +‬ا‪.&>-‬‬ ‫و‪ ' FG‬ن هف ه‪ HG‬ا)را  ه ٳ)اد ﻡ* & ‪  +‬ا‪ &>-‬أ ء ا ' ا)ات ا‪ &0‬ا‪&3‬‬ ‫ﺏ) ‪. 74‬‬ ‫ﻡ‪ *+‬ا)(‪-:‬‬ ‫و‪ )1‬أ‪ D‬ه‪ HG‬ا)را  ' ‪ ١٤‬و)ة ﺹ& ر‪ &3‬ﺏ) ‪ 74‬ﺕ ﺏ* زارة ا‪ .0‬ﺕ‪ N‬ا‪ &-M‬ره‪B C‬ا‪. &O‬‬ ‫'‪ %٥٠ C+P C$‬ﻡ‪ C‬ا  )د ا)ات ا‪ &0‬ا‪ ' &3‬ﻡ) ‪ 74‬وا(ﺕ )ده‪ (٢٨) C‬و)ة‬ ‫ﻡز ‪ (١٥) ،C& 71 +‬و)ة ﺏ ‪ 7,‬ع ا‪%‬ول و)‪ (١٣‬و)ة ﺏ ‪ 7,‬ع ا‪ P‬ﻥ‪ ),' .‬ﺕ‪ N‬ا‪ &-M‬ر )‪ (٨‬و)ات ﻡ‪C‬‬ ‫ا‪ 7,‬ع ا‪%‬ول و)‪ (٦‬و)ات ﻡ‪ C‬ا‪ 7,‬ع ا‪ P‬ﻥ‪.‬‬ ‫ﺕ‪ N‬ٳ)اد ا* & ا‪  + &O)5‬ا‪ &>-‬أ ء ا ﺏا ‪ 7‬ا‪ P 5‬ﺏ*) ﺏ\ د‪ &1‬وﻡا*‬ ‫‪ 0+‬دروﺏ*) ‪ ,‬ءات ))ة ﺏ‪ &0^B‬ت ﻡ?]و ‪ C‬ا  ا‪ &0‬أ ء ا ' ا)ات ا‪&0‬‬ ‫ا‪ .&3‬و‪ )1‬ﺕ‪ N‬ض ا* & ا‪ ` + &O)5‬ا‪ N&-‬اﻥ ﻡ‪ > ٢٥ C‬وه‪ ٦ :N‬أ ﺕ‪G‬ة ' ﺕ^‪b0‬‬ ‫ﺹ ا`‪ @-‬وا‪ 0‬ا* ﻡ ﺏ‪ &+‬ا‪  ،d-‬ﻡ* ا( )ر‪ ،‬وﺏ‪ &+‬ا‪ ،c7‬ﻡ* ‪ ٧ ، 74‬أ‪ 54‬ء‬ ‫) ﻡ‪ N$‬ﻡ) ا‪ 0‬ا‪ ،&3‬وﻡ) ﺹ ا‪%‬ﻡﻡ وا‪ ،37‬و‪ ٥‬أ‪ 54‬ء ﻡ‪ C‬ﻡ‪),‬ﻡ ‪)M‬ﻡ ت ا  أ ء‬ ‫ا ' ﻡ) ‪ ١٢ ،( 74‬ﻡ= ) ﻡ‪ N$‬ﻡ) ا‪ d-‬ﺏ ‪f‬ﺏ&‪ ٣ ،‬ﻡ‪ B-3‬ت ﺕ‪ ٣ ،d‬ﻡ‪ 'B‬ت‬ ‫ﺕ‪ ،d‬و ‪ ٥‬ﻡ= ت *‪ & ' C+‬دات ر  ااﻡ ﺏ )ات ا‪ &0‬ا‪ .(&3‬و‪ )1‬ﺕ‪ N‬ا‪' GM%‬‬ ‫ا(‪ 5-‬ر ﺏ‪-‬ﺹ& ت ` ا‪.N&-‬‬

‫‪٢‬‬ ‫ا  ا ‪-----------------------------------------------------------------------------------‬‬

‫و ‪ N-‬اﺹل ا ٳ)اد ا* & ا‪ &>-‬ا‪  + &O $‬أ ء ا‪ ),' ،‬ﺕ‪ N‬ﻡا* ﻡارد ا ‬ ‫أ ء ا‪ ،‬وٳ ‪ &5-‬ن ﻡ*‪+‬ﻡ ت ا= ت )‪ (٥٢‬ﻡ=‪ ،‬وﻡ‪ gh‬أداء ا= ت)‪ (٣٧‬ﻡ=‪،‬‬ ‫وٳ ‪ &5-‬ن ﻡ)ى ر= ء ا?&)ات ااﻡ ‪)M C‬ﻡ ت ا  أ ء ا)‪)& (١٤٠‬ة ﻡ?‪)^-‬ﻡ ا‪-‬دوات‬ ‫ا‪i‬ﺕ&‪:‬‬

‫ا‪-‬داة ا‪-‬و‪ :‬ﻡ‪  1‬ﻡة  ‪0‬ءات ا‪ //-‬ا ‪ # 5‬ﻡ‪ 4‬ا ﺽت ‪ 21‬ا أء ا ‪:‬‬ ‫أ)ت ه‪ HG‬ا‪%‬داة ﺏا ‪ 7‬ا‪ P 5‬ﺏ‪)$‬ف ا‪*-‬ف ‪ +‬رأى أ> ء ` ا‪ N&-‬ﺏ^‪0‬ص ا‪ 3‬ءات‬ ‫ا‪ & %‬ا‪+7‬ﺏ ﻡ‪ C‬ا= ت ‪ N),-‬ا  أ ء ا‪ .‬و‪ )1‬ﺵ‪ D+‬ه‪ HG‬ا‪ 3‬ءات‪ :‬ا‪-‬اﺹ ﻡ@ ا?&)ة‬ ‫ا ﻡ‪, ،‬ق ا?&)ات‪ ،‬ﻡ ' ا*)وى‪ ،‬ا‪ 9‬رة ا‪%‬و ‪  +‬أ ء ا‪ ،‬وا‪ 9‬رات ا‪-‬رة ‪ +‬‬ ‫أ ء ا‪.‬‬ ‫ا‪-‬داة ا‪7‬ﻥ‪  :; :‬ﻡا‪ 9‬ا ‪#‬ارد‪:‬‬ ‫أ)ت ه‪ HG‬ا‪%‬داة ﺏا ‪ 7‬ا‪ P 5‬آ ‪ N-‬ا‪*-‬ف ‪ +‬اارد ا‪  -‬ا‪+7‬ﺏ ‪ N),-‬ا  أ ء ا‬ ‫' ا)ات ا‪ &0‬ا‪ &3‬ا? ﺏ ذآه ‪ HG$' .‬ا‪%‬داة ﺕ‪-‬ن ﻡ‪ C‬أرﺏ* أ‪9‬اء آ ‪ : -‬ا`‪9‬ء ا‪-‬ول‪ :‬ﺕ‪N&0‬‬ ‫ا‪ ،5‬ا`‪9‬ء ا‪7‬ﻥ‪ :‬اارد ا‪ ،B5‬ا`‪9‬ء ا‪ :(7‬اارد ا د‪ ،‬ا`‪9‬ء اا=‪ :‬و ‪ O‬ا*‪+‬ﻡ ت‪.‬‬

‫ا‪-‬داة ا‪ :77‬ٳ‪ /‬رة ٳ‪)/‬ن ا  ‪#‬ﻡت‪:‬‬ ‫أ)ت ه‪ HG‬ا‪%‬داة ﺏا ‪ 7‬ا‪ P 5‬آ ‪ N-‬ا‪*-‬ف ‪ +‬ﻡ*‪+‬ﻡ ت ا= ت ا‪h+‬ﺕ *‪ C+‬ﺏ*& دة ا  أ ء‬ ‫ا‪ HG$' .‬ا‪%‬داة اﺵ‪] ٥٣ + D+-‬ال‪] ١٦ ،‬ال ٳ‪ &-M‬ر ﻡ‪ C‬ﻡ‪)*-‬د‪ ،‬و‪] ٣٧‬ال ﺹاب أم ‪ .n7M‬و‪)1‬‬ ‫ا‪-‬ت ه‪ HG‬ا‪%‬داة ‪ +‬ا* ﺹ ا‪i‬ﺕ&‪ :‬ا‪ &5‬ﻥ ت ا‪ =+ &0^B‬ت‪ ،‬ﻡ*‪+‬ﻡ ت ا= ت ‪ C‬ا ‬ ‫أ ء ا‪ ،‬وﻡ)ى ر= ء ا= ت وأرا‪ ' C$O‬ا  ا‪),‬ﻡ أ ء ا‪.‬‬

‫ا‪-‬داة اا‪ :‬ٳ‪ /‬رة ﻡ‪C‬ﺡ‪ B‬أداء ا ﺽت ‪A‬ﻥ@‪ 5‬أء ا ‪:‬‬ ‫أ)ت ه‪ HG‬ا‪%‬داة ﺏا ‪ 7‬ا‪ P 5‬ﺏ*) ا* ﺏ‪-‬ﺹ& ت ` ا‪ + N&-‬ا* & ا‪ ),' .&O)5‬ٳﺵ‪ D,-‬ه‪HG‬‬ ‫ا‪%‬داة ﻡ‪ C‬ا‪%‬داة ا‪%‬و )ا* & ا‪ .(&O)5‬و‪ 1 ),‬ﻡ‪ D‬ا‪ P 5‬ﺏ‪ ))-‬ا‪%‬ﻥ‪ 7B‬ٳﻡ )ﺕ‪ ، $+*' N‬أو ‪ N‬ﺕ‪ ،*3‬أو(‬ ‫ﺕ‪ ),' .( 57‬اﺵ‪ D+-‬ه‪ HG‬ا‪%‬داة ‪ +‬ا* ﺹ وا‪%‬ﻥ‪ 7B‬ا^ ﺹ ﺏ)ور ا= ' ا  أ ء ا‬ ‫آ ‪ : -‬ا‪-‬اﺹ ﻡ@ ا ﻡ‪, ،‬ق ا?&)ات‪ ،‬ﻡ ' ا*)وى‪ ،‬ا‪ 9‬رة ا‪%‬و ‪  +‬أ ء ا‪،‬‬ ‫وا‪ 9‬رات ا‪-‬رة ‪  +‬أ ء ا‪.‬‬

‫‪٣‬‬ ‫ا  ا ‪-----------------------------------------------------------------------------------‬‬

‫ا‪-‬داة ا ﻡ‪ :DEEE‬ٳ‪ EEE/‬رة ﻡ‪ EEEE 1‬ﺵ ‪  EEE‬ﻡ‪ =EEEE‬ا‪DEEE‬ات ا‪#‬اﻡ‪)EEE/G EEEE‬ن رﺽ‪ 4EEE 4+:EEEE‬ا ﻡ‪:EEEE‬‬ ‫أ)ت ه‪ HG‬ا‪%‬داة ﺏا ‪ 7‬ا‪ '* P 5‬ﻡ)ى ر= ء ا?&)ات ااﻡ ‪ C‬أﻥ‪ 7B‬ا  أ ء ا‬ ‫ا‪),‬ﻡ ' ا)ات ا‪ &0‬ا‪ .&3‬و‪ )1‬ٳﺵ‪ - + D+-‬أ‪9‬اء آ ‪ : : -‬ا`‪9‬ء ا‪-‬ول‪ :‬ا‪ &5‬ﻥ ت ا‪&0^B‬‬ ‫‪ +‬ﻡ‪ ،‬ا`‪9‬ء ا‪E7‬ﻥ‪ :‬ا‪ -‬ر‪ q‬ا‪r‬ﻥ` ﺏ‪ ،‬ا`‪9‬ء ا‪ :(E7‬ا‪ -‬ر‪ q‬ا ‪ ،‬ا`‪9‬ء اا‪ :=E‬ا^)ﻡ ت ا‪ -‬ﺕ‪N‬‬ ‫ﺕ‪)&?+ $),‬ة أ ء ا ا ‪ ،‬ا`‪9‬ء ا ﻡ‪ :H‬ﻡ)ى ر= ء ا?&)ات ااﻡ ‪)M C‬ﻡ ت ا  ا‪),‬ﻡ‬ ‫أ ء ا ' ا)ة ا‪ &0‬ا‪ ،&3‬ا`‪9‬ء ا‪D‬دس‪ :‬ﻡ)ى ر= ء ا?&)ات ااﻡ ‪ C‬ا‪ s&,P-‬ا‪0‬‬ ‫ا‪),‬م ‪ .C$‬و‪ )1‬ﺕ‪ N‬ٳ)اد ا* & ا‪ &O $‬ﺏ*) ﻡا'‪ ` ,‬ا‪ + N&-‬ا* & ا‪ &O)5‬ا*) )ا‪ -‬ﺕ‪N‬‬ ‫ﺕ*)‪ $+‬ﺏ*) ﺕ`&@ ا‪ &5‬ﻥ ت(‪.‬‬ ‫وﻡ‪ 4‬أه‪ 2‬ﻥ‪ *:‬ه‪J‬ا ا)( ﻡ  ‪:‬‬ ‫‪-‬‬

‫ﻡا'‪ ` ,‬ا‪ + N&-‬ﻡ*‪ Ng‬ا‪%‬ﻥ‪ 7B‬ا‪ &>-‬ا‪ -‬ﺕ‪ ' $= N‬ا* & ا‪ &O)5‬آ‪ $‬م‬ ‫ﺕ>& أ &‪) &' ،‬ا ﺏ*‪ d‬ا‪ $‬م ا)ر ﺕ‪ D‬ا‪ $‬م ا‪ &?&O‬وﻡ‪ : $‬ا? ح ?&)ة وا)ة‬ ‫'‪ u,‬ﺏ ‪-‬ا) دا‪` M‬ة ا ‪ ،‬ﺕ‪ &&f‬ﻡ‪h‬ءة  ا‪ sB‬ﺏ&‪ C‬آ &)ة وأ‪M‬ى‪ ،‬ﺕ‪@&1‬‬ ‫ا= ﺏ*) آ ‪ &+‬ﺕ?`&‪ ،‬وﺏ*‪ d‬ا‪ $‬م ا^ ﺹ ﺏ‪ b3‬ا?&)ة ا ﻡ‪.‬‬

‫‪-‬‬

‫ﻡ*‪ Ng‬اارد ا‪+7‬ﺏ ‪ N),-‬ا  أ ء ا آ ﻥ‪ D‬ﻡ‪ ، -‬وﻡارد أ‪M‬ى آ ﻥ‪ &v D‬ﻡ‪  -‬أو‬ ‫ﻡ‪  -‬و‪ &v‬ﻡ?‪)^-‬ﻡ ﻡ‪ :P‬ا‪ ' ) ,‬ﻡ ن ا(ﻥ‪ g-‬ر‪` ،‬ة ‪ s&,P-+‬ا‪ $ ،0‬ز آ‪sB‬‬ ‫ا?ﻥ ر‪ ،‬أ‪9$‬ة وأدوات ا‪ s&,P-‬ا‪ ،0‬أدوات ا*‪،‬أ‪1‬اص ا)) و‪ d‬ا‪ ،F&3‬ا‪1 75‬‬ ‫ا‪)&?+ &0‬ات ااﻡ‪ ،‬أ‪ 54‬ء ' ﺕ^‪ b0‬ا? ء وا‪ ،)&-‬وﻡ* & ‪  +‬أ ء ا‪.‬‬

‫‪-‬‬

‫أآ‪ P‬ﻡ‪ ( % ٦٩x٢)P+ C‬ا= ت ‪> N‬ن دورات ﺕ)ر‪ M &5‬ﺹ ﺏ   أ ء ا‪.‬‬ ‫وآ ن )د ا)ورات ا‪)-‬ر‪ &5‬ا‪ -‬ﺕ‪> N‬ره دورة وا)ة  ‪ % ٦٢x٥‬ﻡ‪ C‬ا= ت ا(ﺕ‬ ‫>ن دورات ‪.‬‬

‫‪-‬‬

‫أ‪$y‬ت ﻡ*‪+‬ﻡ ت ا= ت ﺏ ?‪  + 5‬ا‪ &0‬أ ء ا ﻥ?‪n' .&  c‬آ‪ P‬ﻡ‪% ٩٠ C‬‬ ‫ﻡ‪ C‬ا= ت أ‪ C5‬إ ﺏ ﺹ& ‪ +‬ﻡ*‪ Ng‬ا‪ .+z %‬و‪ )1‬و)ت ‪ 1h‬ذات د( إ‪ &O 0‬ﺏ&‪C‬‬ ‫ﻡ*‪+‬ﻡ ت ا= ت ودر ﺕ*‪ ،C$&+‬وآ‪ FG‬ﺏ&‪ C‬ﻡ*‪+‬ﻡ ﺕ‪ C$‬و ات ا^‪5‬ة‪.‬‬

‫‪-‬‬

‫‪ N‬ﺕ‪ N,‬ا= ت ﺏ‪n‬داء ﺏ*‪ d‬ا‪%‬ﻥ‪ 7B‬أ ء ا ' آ ا)ات ﻡ‪ :P‬أ‪ GM‬ا*‪h‬ﻡ ت ا&‬ ‫‪)&?+‬ات ااﻡ‪ ،‬ا‪%‬ﻥ‪ 7B‬ا^ ﺹ ﺏ‪ b3‬ا‪ c+,‬وا‪)0‬ر و'‪ b‬ا‪ ،C75‬وآ‪ ?+ ), FG‬ت‬ ‫ا‪ s&,P-‬ا‪ .0‬وآ ن أداء ا= ت &‪ z‬ﺏ?‪ 5‬ﺕ‪ ' %٥٠ C ,‬ﻡ*‪ Ng‬ا)ات ﺏ ?‪5‬‬

‫‪٤‬‬ ‫ا  ا ‪-----------------------------------------------------------------------------------‬‬ ‫‪ d*5‬ا‪%‬ﻥ‪ 7B‬ﻡ‪ :P‬ا‪-‬اﺹ ﻡ@ ا?&)ة ا ﻡ‪ ،‬أﻥ‪ 7B‬ﻡ ' ا*)وى‪ ،‬و إﻡ)اد ا?&)ات ااﻡ‬ ‫ﺏ *‪+‬ﻡ ت‪.‬‬ ‫‪-‬‬

‫أآ‪ P‬ﻡ‪ C‬ﻥ‪ s0‬ا?&)ات ااﻡ )‪ (% ٥٣x٦‬آ ن ر= ؤه‪ C‬ﻡ‪ ( %٧٥ - % ٥٠) u -‬ﺏ ?‪5‬‬ ‫^)ﻡ ت ا  ا‪),‬ﻡ أ ء ا ' ا)ات ا‪ &0‬ا‪.&3‬‬

‫‪-‬‬

‫ﺕ‪ &+‬ا‪5‬ل ‪ ?+‬وا‪(9‬ل وأ‪ GM‬ا‪B‬رة ﺏا ‪ 7‬ا‪ N- N c&57‬ﺕ‪ Ng* $),‬ا?&)ات ااﻡ‪.‬‬

‫‪-‬‬

‫ﻡ*‪ Ng‬ا?&)ات ‪> N‬ن ‪ ?+‬ت ﺕ‪ s&,P‬ﺹ‪ .‬و ‪ % ٥٢x١‬ﻡ‪ C$‬ﺕ‪ C&,+‬ا‪ s&,P-‬ا‪' 0‬د ‬ ‫ﻡ‪ C‬ا=‪.‬‬

‫‪-‬‬

‫‪)1 ),‬ﻡ‪ D‬ا?&)ات ﺏ*‪ d‬ا‪ -,‬ت ‪)M C&?-‬ﻡ ت ا  أ ء ا ﻡ‪ :P‬إﺕ  ‪ $‬ز ا?ﻥ ر‪،‬‬ ‫إﺕ  )د آ ف ﻡ‪ C‬أ‪ 54‬ء ا? ء وا‪ ،)&-‬ﺕ‪ N),‬ا‪ )9‬ﻡ‪ C‬ا(ه‪ -‬م وا  ﺏ ?&)ة ا ﻡ‪ ،‬اﺕ ‬ ‫ا‪%‬دوات ا‪h‬زﻡ ‪ ،‬وﺕ‪ N),‬ا‪ s&,P-‬ا‪)&?+ 0‬ات ااﻡ‪.‬‬

‫وء   ﻥ‪ *:‬ه‪ OJ‬ارا‪ /‬ﻥ ‪# N‬ﺹت ا‪L‬ﺕ‪:‬‬ ‫‪ c` -١‬أن ‪ '-‬و‪ 57‬ا‪-‬ﺹ&‪ s‬ا‪  3&y‬ا= ت ا‪h‬ﺕ *‪ ' C+‬ﺕ‪ N),‬ا  أ ء‬ ‫ا ا‪ -‬دا ‪ +‬ا* & ا‪ -‬ﺕ‪. $= N‬‬ ‫‪ -٢‬ا(ه‪ -‬م ﺏ* ﺏﻥ ﻡ| ا‪)-‬ر‪ c‬ا?‪ -‬أ ء ا* ا^ ص ﺏ   أ ء ا‪ ،‬وأن ن ﻡ` ﻥ‬ ‫‪ =+‬ت ا‪h‬ﺕ *‪ & ' C+‬دات ا ‪.‬‬ ‫‪ -٣‬ﺕ'&اارد ا^ ﺹ ﺏ   أ ء ا ﺏا ‪ 7‬وزارة ا‪ 0‬و أن ﺕ‪ )9‬ازارة ﻡ‪ C‬اه‪ -‬ﻡ‪ $‬‬ ‫ﺏ )ات ا‪ &0‬ا‪.&3‬‬ ‫‪ c` -٤‬أن ‪ 57‬ﻥ‪ g‬م ا‪ -‬ﺏ* ا?‪-‬ة وا` دة ‪ +‬أداء ا= ت ' آ ا)ات ا‪&0‬‬ ‫ا‪ &3‬و‪ M‬ﺹ ' & دات ا  أ ء ا‪.‬‬ ‫‪ -٥‬ﺕ‪ ?+ &57‬ت ا‪ s&,P-‬ا‪)&?+ 0‬ات ااﻡ‪ ،‬وأن ‪ N-‬ا‪ $&+ @&`B-‬ﻡ‪ C‬ا?]و&‪ ' C‬ﻡ)‬ ‫ا‪ 0‬و' ا(دارة ا‪.&0‬‬ ‫‪ -٦‬ﻡا‪ 51‬وﻡ‪ -‬ﺏ*  دة ﺏا ‪ 7‬ا?‪ C C&z‬ا‪ 0‬ا‪ &3‬و‪ C‬ﺹ ا‪%‬ﻡﻡ وا‪ &57- 37‬‬ ‫ﻡ* & ا  ا‪ &>-‬أ ء ا ا‪ -‬ﺕ‪ N‬ﺕز*‪ + $‬ا)ات ا‪ &0‬ا‪ -‬ﺏ* ) ‪. 74‬‬ ‫‪ -٧‬ز دة )د ا‪ 5&57‬ت ' ا)ات ا‪ &0‬ا‪ &3‬ﺏا ‪ 7‬وزارة ا‪.0‬‬

‫  ‬ ‫آ ا ‬ ‫ ﺕ  ا  ‬

‫إاد     ا أ ء ا ‬ ‫اﺡات ا ا‬ ‫رﺱ‬ ‫   ا ‪  -‬‬ ‫إ ‪1‬ءا ‪ - ./‬وط ا*‪%‬ل (' در  اآ‪%‬را‪"# $‬‬ ‫م ا‬ ‫)ﺕ‪ 4*5‬ﺕ‬

‫ﺹ ا‪("#‬‬

‫‪6‬‬ ‫ & ا) ( ن ‬ ‫رس ( ‪  7‬ﺕ  ا  ‬ ‫آ ا ‬ ‫  ‬

‫ا*ن‬ ‫ا‪:‬ﺱذ اآ‪%‬ر‬ ‫إ‪ 23‬ل ‪ 0‬ا‪ /‬ا* ‪.‬‬ ‫) ا ‪ -‬ف ا ‪( '.‬‬ ‫أﺱذ ﺕ  ا  ‬ ‫آ ا ‬ ‫  ‬

‫ا‪:‬ﺱذ اآ‪%‬ر‬ ‫) ‪,‬ت ﺝ‬‫أﺱذ ﺕ  ا  ‬ ‫آ ا ‬ ‫  ‬

‫ا‪:‬ﺱذ اآ‪%‬ر‬ ‫ ل ‪ 2‬ا ح ‬ ‫أﺱذ ﺕ  ا  ‬ ‫آ ا ‬ ‫  ا>ﺱر ‬

‫‪٢٠١١‬‬