Factors Associated with Late Antenatal Care Initiation in an Ethiopian Clinic

Factors associated with late antenatal care initiation in an Ethiopian clinic

Wegene Ewnetu1, Sahilu Assegid2, Beyene Wondafrash3, Haimanot Ewnetu2 (hewnetu at yahoo dot com)#

1School of Medicine, College of Public Health and Medical Sciences, Jimma University, Jimma, Ethiopia. 2Department of Epidemiology, College of Public Health and Medical Sciences, Jimma University, Jimma, Ethiopia. 3Department of Population and Family health, College of Public Health and Medical Sciences, Jimma University, Jimma, Ethiopia

# : corresponding author

DOI

Date

2015-01-09

Cite as

Research 2015;2:1292

License

CC-BY

Abstract

Background: The goal of antenatal care is to prevent health problems in both infant and mother and to see that each newborn child has a good start. Late booking to antenatal care (ANC) is associated with poor outcomes for both mothers and babies. In Ethiopia, only 11% of women made their first ANC visit before the fourth month of pregnancy. Objective: To assess the prevalence of late ANC initiation and associated factors. Methodology: An institution-based cross-sectional study was conducted among pregnant mothers attending ANC clinic of Jimma University Specialized Hospital from June to July 2014. All pregnant women visited the clinic during the study period were included. The data was analyzed using SPSS version 16. Frequencies and summary statistics were used to describe the study population. The degree of association between dependent and independent variables was assessed using a chi square test. Result: Among a total 178 pregnant women, the prevalence of late ANC initiation is 60.1%. Level of education (X2=15.85, P=0.003), place of residence (X2= 4.51, P=0.034), history of premature birth (X2=5.57, P=0.018), time of pregnancy recognition (X2=12.25, P<0.01) and unplanned pregnancy (X2 =10.34, P<0.01) are among the factors that are associated with late ANC booking. Conclusion: The prevalence of late Antenatal care presentation is high. Education level of the mother, place of residence, history of premature birth, unplanned pregnancy and time of pregnancy recognition are associated with late ANC initiation. Provision of continuous health education with a focus on increasing mothers’ knowledge and awareness on ANC and complications related to pregnancy and delivery should be the core of intervention.

Background

Pregnancy is one of the most important periods in the life of a woman, a family and a society at large. Extraordinary attention is given to antenatal care by the health care systems of most countries. The goal of antenatal care is to prevent health problems in both newborn and mother. Maternal and neonatal morbidity and mortality have continued to be a major problem in developing countries despite a lot of efforts. Globally, more than 500,000 mothers die each year from pregnancy-related situations, and neonatal mortality accounts for 40% of the estimated 9.7 million under-five children deaths. In addition, ninety nine percent (99%) of maternal and newborn mortality occur in developing countries [1].

Worldwide, a woman dies every minute as a result of pregnancy or childbirth. Loss per annum of 500,000 women is overwhelming [2]. Thus, maternal mortality continues to be a major public health problem. The focus on maternal mortality was honed when reduction in maternal mortality became one of the eight goals for development in the Millennium Declaration Millennium Development Goal 5. The target for MDG 5 is to reduce the maternal mortality ratio (MMR) by three quarters from 1990 to 2015 [3]. The current Ethiopian maternal mortality ratio is 676 maternal deaths per 100,000 live births [4].

Studies demonstrating the high levels of maternal mortality and morbidity in developing countries and research identifying causes of maternal deaths have repeatedly emphasized the need for antenatal care and availability of trained personnel to attend women during labor and delivery [5][6]. Early commencement of antenatal care by pregnant women as well as regular visits have positive effect on maternal and fetal outcome [7][8]. WHO recommends four visits for women whose pregnancies are progressing normally with the first visit in the first trimester (ideally before 12 weeks but no later than 16 weeks) [9]. Beginning of antenatal care within the first 14 weeks of gestation is widely accepted as early and many previous workers have defined booking after the 14th week of pregnancy as late [10][11].

In Ethiopia, only eleven percent (11%) of women made their first ANC visit before the fourth month of pregnancy, though it is a two-fold increase from 6 percent in the 2005 EDHS. The median duration of pregnancy at the first visit is 5.2 months, while urban women made the first ANC visit earlier (4.4 months) than rural women (5.5 months) [4].

In study conducted in Hadiya zone of Ethiopia, concerning time of initiating antenatal care, only 8.7% of the ANC attendants initiated care during the first trimester of pregnancy while 68.1% had the first visit during the third trimester [12]. To our knowledge there is no similar studies conducted in our study area and because of difference in setting and characteristics of study population, there may be additional factors that need to be explored. Therefore, the aim of this study is to determine the magnitude of late ANC and to identify factors that are associated with late initiation of ante natal care in JUSH and to forward possible interventions accordingly.

Methods

Study setting and participants

An institution based cross sectional study was conducted at Jimma University Specialized Hospital (JUSH) located in Jimma town, which is found 352 km southwest of Addis Ababa, the capital city.

The source and study populations were all pregnant women attending ANC clinic of JUSH during study period and those who fulfill the inclusion criteria.

Sample size and Sampling techniques

All pregnant women who visited the clinic during study period were consecutively included in the study based on the inclusion and exclusion criteria. Non respondents were replaced by the next respondents.

Data collection techniques and instruments

Before the actual data collection days, the questionnaire was pre-tested and correction on the questionnaires was made accordingly. Training was given for data collectors by the principal investigator.

Record (client’s chart) review was done to identify (to screen) eligible and non eligible participants. After screening of eligible participants, the respondent was asked for consent to participate on the study and interviewed using interviewer administered structured questionnaire by trained data collectors.

Data analysis

The data was Edited, cleaned and before entry to the computer and entered and analyzed using SPSS version 16 for windows. The data was cleaned for inconsistencies and missing values after revision of the original data. Frequencies and summary statistics were used to describe the study population in relation to socio-demographic and other relevant variables. The degree of association between dependent and independent variables was assessed using chi square test.

Ethical consideration

Ethical Clearance was obtained from Ethical Review Committee of Jimma University and verbal consent was taken from all the study participants.

Results

Socio-demographic characteristics

A total number of 178 pregnant women attending JUSH antenatal clinic during the study period were included in the study. The majority of the participants were in the age range of 20-29 years, representing 74.7% (n=133). Most of the women were married [ 93.8% (n=167)] . The predominant religion was Muslim making [ 48.9% (n=87)] of study population followed by orthodox which is [ 32% (n=57)] . Regarding place of residence, [ 62.4% (n=111)] were from urban while the rest [ 37.6% (n=67)] were from rural area. Concerning monthly income 48.9% fall in the category of 500-999ETB.

Categories / Early No (%) / Late No (%) / X2 / p-value
Gravidity
1 / 21(35.5) / 38(64.4) / 1.328 / 0.515
2-3 / 34(44.7%) / 42(55.3%)
4 and above / 16(37.2%) / 27(62.8%)
Parity
0 / 26(41.3%) / 37(58.7%) / 0.111 / 0.946
1 / 21(39.6%) / 32(60.4%)
2 and above / 24(38.7%) / 38(61.2%)
Gestational age of current pregnancy
<16 weeks / 21(95.5%) / 1(4.5%) / 33.688 / 0.000*
16-28weeks / 17(26.6%) / 47(73.4%)
29-42weeks / 33(35.9%) / 59(64.1%)
History of premature birth
Yes / 4(17.4%) / 19(82.6%) / 5.575 / 0.018*
No / 67(43.2%) / 88(56.8%)
History of still birth or abortion
Yes / 12(54.5%) / 10(45.5%) / 2.249 / 0.134
No / 59(37.8%) / 97(62.2%)
History of hypertensive disorder
Yes / 3(75.0%) / 1(25.0%) / 2.104 / 0.147
No / 68(39.1%) / 106(60.9%)
High risk mother
Yes / 8(36.4%) / 14(63.6%) / 0.13 / 0.718
No / 63(40.4%) / 93(59.6%)
Time of pregnancy recognition
<4month / 70(44.6%) / 87(55.4%) / 12.251 / .000*
4-7month / 1(4.8%) / 20(95.2%)
Is the pregnancy planned
Yes / 57(48.3%) / 61(51.7%) / 10.344 / 0.001*
No / 14(23.3%) / 46(76.7%)
Is the pregnancy wanted
Yes / 64(39.3%) / 99(60.7%) / 0.314 / 0.575
No / 7(46.7%) / 8(53.3%)
Risk category
High / 13(34.2%) / 25(65.8%) / 2.844 / 0.241
Low / 58(42.3%) / 79(57.7%)
unknown / 0 / 3(100%)

Table 1. Association between late ANC initiation and clinical factors (n=178), JUSH, 2014.

Clinical factors

Among the total sample size, 59 (33.15%) of them are primigravida while the rest, 119 (66.85%) have at least one previous pregnancy. Regarding history of premature birth, 24 (13.5%) has history of premature birth and 12.4% have history of abortion or still birth. Concerning the time of ANC initiation, 71 (39.9%) presented to ANC visit before 16 weeks of gestation. 92 (51.7%) and 15 (8.4%) presented in second and third trimester respectively. Gestational age of their current pregnancy is also found to be strongly associated with early initiation of antenatal care as 95.5% of those in first trimester initiated ANC before 16 weeks (p=0.000). Having history of premature birth is also associated with late ANC attendance (p=0.018) (table 1).

Categories / Early No (%) / Late No (%) / X2 / P-value
Place of last child delivery if any
Home / 11(32.4%) / 23(67.6%) / 0.998 / 0.607
Health institution / 35(41.2%) / 50(58.8%)
Planned place of delivery
home / 0 / 1 / 0.667 / 0.414
Health institution / 71(40.1%) / 106(59.9%)
Time it takes to reach health center
<1hour / 21(52.5%) / 19(47.5%) / 3.489 / 0.175
1-2hours / 3(35.5%) / 60(64.5%)
>2hours / 17(37.8%) / 28(62.2%)
Time of waiting to get ANC service
<30 minutes / 16(50%) / 16(50%) / 2.556 / 0.465
30 min -1hour / 28(34.6%) / 53(65.4%)
>1hour / 27(41.5%) / 38(58.5%)

Table 2. Association between late ANC initiation and service related factor (n=178), JUSH, 2014.

Service or provider related factors

The study also revealed that, among the respondents who have history of delivery, 34(19.1%) of study subjects gave birth to their last child at home and the rest (47.8%) gave birth in health institution. Almost all of the participants planned to give birth at health institution. There were no provider related factors that is associated with late antenatal care attendance (table 2).

Category / Early (%) / Late (%) / X2 / P value
Age
15-24 / 33(40.2%) / 49(59.8%) / 0.012 / 0.994
25-29 / 24(39.3%) / 37(60.7%)
30-39 / 14(40.0%) / 21(60.0%)
Religion
Orthodox / 27(47.4%) / 30(52.6%) / 6.001 / 0.112
Muslim / 32(36.4%) / 56(63.6%)
Protestant / 12(44.4%) / 15(55.6%)
Catholic / 6(100.0%)
Educational status of mother
Illiterate / 16(22.5%) / 55(77.5%) / 15.855 / 0.003*
Read and write / 27(51.9%) / 25(48.1%)
Primary (1-8) / 18(48.6%) / 19(51.4%)
Secondary and above / 10(55.5%) / 8(44.5%)
Educational status of husband
Illiterate / 12(30.0%) / 28(70.0%) / 4.248 / 0.236
Read and write / 16(34.8%) / 30(65.2%)
Primary(1-8) / 27(49.1%) / 28(50.9%)
Secondary and above / 16(43.2%) / 21(56.8%)
Occupation of mother
House wife / 40(36.7%) / 69(63.3%) / 1.405 / 0.704
Govt employee / 13(41.9%) / 18(58.1%)
merchant / 10(47.6%) / 11(52.4%)
Others / 8(47.1%) / 9(52.9%)
Occupation of husband
Gov employee / 28(47.5%) / 31(52.5%) / 5.75 / 0.218
merchant / 19(40.4%) / 28(59.6%)
farmer / 14(29.8%) / 33(70.2%)
others / 10(40.0%) / 15(60.0%)
Income
≤499 / 13(31.0%) / 29(69.0%) / 2.419 / 0.298
500-999 / 35(40.2%) / 52(59.8%)
≥1000 / 23(46.9%) / 26(53.1%)
Place of residence
Urban / 51(45.9%) / 60(54.1%) / 4.514 / 0.034**
Rural / 20(29.9%) / 47(70.1%)

Table 3. Association between socio demographic factors and late ANC initiation (n=178),JUSH, 2014.

Socio demographic factors associated with late ANC attendance

Level of education was found to be significantly associated with late antenatal care attendance (p= 0.003). Most of the women (55.5%) with secondary and above education initiated ANC early compared to those in lower levels of education. Place of residence is also associated with timing of initiation of ANC as those who are from urban areas (45.9%) initiate ANC early (p=0.034) (table 3).

Discussion

Prevalence of late ANC initiation: The study shows that the prevalence of late antenatal care attendance is high which was found to be 60.1%. This result is slightly lower than what was reported in Zambia where prevalence of late ANC attendance is 72% [13]. And it is also lower than the study reported in Hadiya zone where prevalence of late ANC attendance is 68.2% [12] but it is higher than the study conducted in UK which is 31 % [14]. The difference could be due to difference in study area and study population and design.

Socio demographic factors: The study revealed that maternal age was not associated with late antenatal care attendance which is in line with a study conducted in Zambia and Sudan [13][15] where it was observed that there was no effect of maternal age on ANC utilization. Regarding educational level, the study highlighted that educational status of the mother was associated with time of ANC initiation which is inconsistent with the study conducted in Zambia [13]. This might be due to understanding of the importance of ANC, pregnancy and delivery related aspects if the mother is educated.

Place of residence is also another important factor that exhibited association with late ANC initiation(P=0.034) as those from urban areas started ANC early which probably explained by lack of adequate information regarding ANC and long distance from Health Institutions and lack of adequate transportation in rural areas. This is supported by study conducted in Ethiopia, indicating increment of maternal health services in urban areas [16].

Clinical factors: From clinical factors, gestational age of current pregnancy were tend to be a significant factor for early initiation of ANC (P=0.000). This is probably because women who are in the first trimester of pregnancy for few months are likely to initiate ANC than those who are in their second or third trimester if at all indicating as the gestational age increases women’s interest in seeking health care get less and less.

Having history of premature birth is also associated with late ANC initiation (P=0.018). This might because, being the high risk mother discourage the women from seeking early ANC care. This is in line with study conducted in England and Wales [17]. This is in contrary with the study conducted in Nigeria indicating women who did not have medical problems in either previous or index pregnancy were more likely to book late for antenatal care [18].

Time of pregnancy recognition was associated with late ANC initiation (P=0.00) in this study indicating almost all who recognize the pregnancy after 4 months booked late to ANC. This indicates the fact that late recognition is a contributor for late enrollment. This finding is supported by systematic review done in high income countries [19].

In contrast to women who planned their pregnancy, women who get pregnant unintentionally were more likely to start ANC late (P=0.001). The finding is in line with study done in copper belt province where it was indicated that younger women with unplanned pregnancy booked for ANC late [13]. It is believed that wanted pregnancies are more cared for by pregnant women and their spouses; this enable women to book for ANC timely.

Service or provider related factors: According to this study there were no significant association between service related factors and timing of initiation of ANC even if long distance from health institution contributes to late initiation of ANC. A study conducted in Haiti revealed that longer traveling time and greater distances to health facilities in rural areas constituted the greatest barriers to antenatal care utilization [20]. Similarly the study assessed travelling time and distance to health facilities but does not exhibit significant association with late ANC booking.

Conclusion

Generally, the study identified late antenatal care attendance is high. Level education of the mother and place of residence are associated with late ANC initiation from socio demographic factors. Gestational age, history of premature birth, unplanned pregnancy and time of pregnancy recognition are also the factors that affect late ANC initiation. Provision of continuous health education with a focus on increasing mothers’ knowledge and awareness on ANC and complications related to pregnancy and delivery should be the core of intervention.

Declarations

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

WE conceived and designed the study and collected data in the field, performed analysis, interpretation of data, and draft the manuscript. SA assisted with the design, interpretation of data and the critical review of the manuscript. BW assisted with the design, interpretation of data and the critical review of the manuscript. HE assisted with the design, interpretation of data and the critical review of the manuscript All authors approved and read the final manuscript. All authors participated in critical appraisal and revision of the manuscript

Acknowledgements

We acknowledge Jimma University for financing the study. We thank all participants for devoting their time to take part in this study.

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ISSN : 2334-1009

Topics

• prenatal care