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Factors Determining Early Antenatal Care Utilization in Uganda

Keywords

antenatal care, likelihood, timely accessibility, education completion.

Research Identity (RIN)

XAMB1USQHF

Journal

LJMHR Volume 21, Issue 1, Compilation 1.0

License

Attribution 2.0 Generic (CC BY 2.0)

English

Abstract

Antenatal care utilization is a success story in Uganda (at least 90% of expectant mother received ANC), however, accessing first antenatal within the first three months of pregnancy is vital, a period for essential interventions like identification and management of obstetric complications. This study aimed at establishing factors contributing to early antenatal care service utilization in Uganda. The 2016 Uganda Demographic and Health Survey data was used. Andersenƒ??s Behavior model was used in determining the predictors while the binary logistic model was used to analyze the relationship between early antenatal care on age, highest maternal education level, marital status, wealth quintile, distance to health facility, cost of service, availability of health worker in community, exposure to media, nature of pregnancy and parity. Mothers who are age 19-35, completed primary seven, where distance is not a problem, with readily available community health workers and having no complicated pregnancy had relatively increased odds of early antenatal care utilization. Furthermore, mother aged 15-18, did not complete secondary level, not married, travel long distance to health facility, with cost of service being problematic, and parity were associated with reduced odds of early antenatal care utilization. The study recommends that policy makers should promote female education to primary seven completion hence delaying child marriages, reduction on costs of utilizing antenatal care by passing the insurance bill and encouraging pregnancy centering and sensitizing the public on benefits of early antenatal care utilization leading to improved maternal and newborn outcome during pregnancy.

Factors Determining Early Antenatal Care Utilization in Uganda

Ruth Atuhaireα, Will Kaberukaσ, Leonard. K. Atuhaireρ & R. WamalaѠ 

________________________________________

ABSTRACT

Antenatal care utilization is a success story in Uganda (at least 90% of expectant mothers received ANC); however, accessing the first antenatal within the first three months of pregnancy is vital, a period for essential interventions like identification and management of obstetric complications. This study aimed at establishing factors contributing to early antenatal care service utilization in Uganda.

We used a sample of 10,152 women of reproductive ages (15-49), who had given birth in the five years preceding the Uganda Demographic and Health Survey. Andersen’s Behavioral Model of Health Services Utilization guided the selection of covariates in the model. In contrast, binary logistic model was used to analyze the relationship between early antenatal care on age, highest maternal education level, marital status, wealth quintile, distance to a health facility, cost of service, availability of health worker in the community, exposure to media, nature of pregnancy and parity.

Predictors that had relatively increased odds of early antenatal care utilization include mothers who are age 19-35, completed primary seven, distance is not a problem, readily available community health workers, and no complicated pregnancy. Furthermore, mothers aged 15-18, did not complete secondary level, not married, traveled a long distance to a health facility, with the cost of service being problematic and parity were associated with reduced odds of early antenatal care utilization.

The study recommends that government should promote female education to primary seven completion hence delaying child marriages, reduce on costs of utilizing antenatal care by enacting the insurance bill and encouraging pregnancy centering and sensitizing the public on benefits of early utilization leading to improved maternal and newborn outcome during pregnancy.

Keywords: antenatal care, likelihood, timely accessibility, education completion.

  1. INTRODUCTION

Maternal health care comprises dimensions of antenatal/prenatal, childbirth delivery/intranasal, postnatal and neonatal care to reduce maternal morbidity and mortality (Rice, 2019; UBOS, 2017; UNICEF, 2019). Utilization includes ensuring comprehensive antenatal care (ANC) coverage for all pregnant women, the first ANC within the first three months of pregnancy (Rutaremwa, Wandera, Jhamba, Akiror, & Kiconco, 2015; Srivastava, Mahmood, Mishra, & Shrotriya, 2014; Wang & Hong, 2015). WHO (2015) defines antenatal care (ANC) as monthly visits during the first two trimesters (from week 1–28), fortnight visits from 28th week to 36th week of pregnancy and weekly visits after 36th week until delivery (delivery at week 38–42) at a health facility. Early ANC implies the utilization of antenatal care and services within the first trimester (Mamba, Muula, & Stones, 2017; Say et al., 2014; Tunçalp, Souza, & Gülmezoglu, 2013).

Even though the government has prioritized measures for improvement of maternal health services, most women access antenatal services late (Finlayson & Downe, 2013; Kawungezi et al., 2015; Kisuule et al., 2013; Mamba et al., 2017). According to UDHS 2016 survey, the median gestational age when women make their first antenatal visit is approximately 4.7 months. Though studies have focused on the utilization of antenatal care leading to a success story in Uganda (Kawungezi et al., 2015; Mugarura, Kaberuka, Atuhaire, Atuhaire, & Abaho, 2017; Wiluna et al., 2015), hardly any information is available on the causes of early antenatal care utilization.

We carried out the study to establish factors contributing to early antenatal care service in Uganda. Andersen’s Behavioral Model of Health Services Utilization guided the selection of covariates in the model. The exogenous variables selected as determinants of early antenatal care services that are predisposing and enabling factors included mother’s wealth quintile, marital status, parity, maternal age at last birth, maternal highest education level, exposure to mass media, distance to a health facility, cost of service, if either the pregnancy was wanted or not, and if the pregnancy was complicated or not.

The study utilized data obtained from the 2016 Uganda Demographic Household and Health Survey (UDHS). The survey was a follow up to the previous UDHS carried out in 1988/89, 1995, 2000/2001, 2006, and 2011 and is implemented by the Uganda Bureau of Statistics. For all the years, the woman’s questionnaire collected information from all eligible women aged 15-49 years (those aged 15-49 minus those who had no live birth in the five years preceding the survey). Respondents were asked questions about their demographic and household characteristics, maternal and child health indicators. Table 1 shows the measurements of the variables adopted for the study.

Table 1: Measurement of variables used in the study

Code

Variable

Description

Coding if any

Data type

Y1

 Early

Antenatal

Timing of the first antenatal visit

1. Accessed antenatal care within first trimester.

2. Accessed after first trimester

Binary

X1

Age of the women

Age of the woman at the time of the survey

1. 15-18

2. 19-35

3. 36-49

ordinal

X2

Parity

Children ever born by the woman

Count

X3

Highest maternal education level

Mother’s highest level of education

1. some primary

2. completed primary seven

3. some secondary

4. completed secondary six

ordinal

X4

Income

Wealth quintile of the household

1. Poor

2. middle

3. Rich

ordinal

X5

Marital status

Marital status of the woman

1. Unmarried

2. Married

nominal

X6

Pregnancy wanted

If the mother wanted the last pregnancy

1. Yes

2. No

nominal

X7

Exposure to mass media

Women who listen to radio, read newspapers or watch television

1. Exposure

2. Non exposure

nominal

X8

Pregnancy complications

If the pregnancy was complicated or not

1. Yes

2. No

nominal

X9

Community factors

Availability of community health worker

1. Yes

2. No

nominal

X10

Distance to the health facility

If the distance from home to the health facility is a problem or not.

1. Big problem

2. not big problem

nominal

X11

Direct costs/fees

If cost paid while accessing a service is a problem or not

1. big problem

2. not

nominal

Data were analyzed using STATA 13.0. We performed a descriptive summary of the variables in the study in the form of frequency tables (see table2). At the bivariate level, we ran differentials in antenatal care with each predictor using a binary logistic regression model to estimate the odd ratios unadjusted (see table 3). This stage helped us determine the significant variables which we used in the final analysis. Variables that had a relatively small probability value of 0.05 or less were considered for inclusion in the final analysis to ascertain the predictors of early antenatal care utilization. At multivariate level, significant exogenous factors were included in the logit model, which allows each category of an unordered response variable compared to an arbitrary reference category.

The following equation expresses the relationship between early antenatal care and its predictors.  

Where; Y1  represent the early ANC,  represent the intercept of the model,  is the matrix of the slope coefficients and  is the matrix of independent variables (maternal education, marital status, age at last birth, parity, complications or not, whether the pregnancy was wanted or not, exposure to mass media, readily available community health workers, cost of services offered, and distance to a health facility), and,  is the error term.

The outcome variable considered in this study was early antenatal care and the predictors were; maternal age at birth, maternal education, parity, wealth quintile, marital status, costs incurred at health facility and distance to health facility. Community factors were availability of a worker and health facility in an area, while predisposing and need factors were exposure to media, pregnancy complications and if pregnancy wanted or not. Table 2 presents the frequencies of these study variables.

Table 2:        Frequency distribution table of the study variables

Variable

Frequency

Percent (%)

 Early Antenatal care

 Went within the first trimester

 Went after the first trimester

2897

7255

28.5

71.5

  Age

  15-18

  19-34

  35-49

2347

5154

2651

 

23.1

50.8

26.1

Highest Maternal education level

 Some Primary

 Completed primary seven

 Some secondary

 Completed secondary six

4406

1827

3198

721

43.4

18.0

31.5

  7.1

 Marital status 

 Married

 Unmarried

3189

6963

31.4

68.6

 Wealth quintile

  Poor

                Middle

                Rich

4128

1912

4112

40.7

18.8

40.5

Distance to health facility

                Big problem

                Not big problem

3957

6195

38.9

61.1

Cost of service

              Big problem

              Not big problem

4763

5389

46.9

53.1

Availability of a health worker in community

               Readily available

               Not readily available

7258

2894

71.5

28.5

Exposure to media

            Exposed to media

               Not exposed to media

8110

2042

79.9

20.1

Pregnancy wanted

   Yes

   No

6185

3967

60.9

39.1

Complications

 Yes

  No

660

9492

  6.5

93.5

Results show that less than 3 out of 10 women accessed their first ANC within 3 months of pregnancy. Significant delays for first ANC visit have been observed in other countries including Rwanda where only 38% of women have an ANC visit in their first three months of pregnancy (Manzi et al., 2014) and Ethiopia where more than half of women had a delayed ANC (Wiluna et al., 2015; Yesuf & Calderon-Margalit, 2013).

Women have shown not to access early ANC checkup, an essential time recommended for receiving medical information over maternal physiological and biological changes in pregnancy and prenatal nutrition, health personnel checking the mother’s medical history, for example if a mother had a history of an ectopic pregnancy to avoid reoccurrence, test for HIV status, birth defects and blood pressure (Carroli, Rooney, & Villar, 2005; Chama-Chiliba & Koch, 2013; Chukwuma, Wosu, Mbachu, & Weze, 2017; Ebonwu, Mumbauer, Uys, Wainberg, & Medina- Marino, 2018; Mamba et al., 2017).  

Half of the sampled women were of age 19-35, the most fertile period (Elster, 1984). More than 5 out of 10 women had completed primary seven (56.6%) though very few women had completed secondary six (7.1%). A good proportion of women were unmarried (68.59%). Women from a poor background were almost equal to those from the rich background (40.66% and 40.51% respec- tively), and women from an average background were the fewest (18.83%). Six in every ten women (61.02%) didn’t point out distance to health facilities as a big problem. There was a slight difference between women who thought cost of service was a big problem compared to those who thought it was not (46.92% and 53.08% respectively). Most health workers were readily available in the community (71.5%), and most women were exposed to at least one form of media (79.89%). Results in Table 2 further indicated that at least 6 in every 10 women wanted the pregnancy and a small proportion of women had complicated pregnancy (6.5%). On average, women had 3 children ever born with a standard deviation of 3 children.

Table 3: Differentials in Early ANC utilization

Factor

 Unadjusted OR(95% CI)

Adjusted OR(95% CI)

Age

                                 15-18

    19-34

     35-49                              

                                 

1.890(1.756-1.99)*

0.980(0.881-1.023)

1.200(0.990-1.245)*

1.0

0.92(0.82-1.00)

1.18(1.08-1.26)*

Highest Maternal education level

       Some primary

       Completed primary seven

       Some secondary

       Completed secondary six

                                                                               

1.321(1.001-1.456)

1.687(1.482-1.812)*

0.790(0.633-0.985)*

1.126(0.833-1.511)

                                                                               

1.0

1.68(1.58-1.81)*

0.9(0.63-0.98)

1.12(0.83-1.51)

Marital status

Unmarried

   Married

                                                                                           

0.845(0.750-0.987)*

0.990(0.856-1.099)*

                                                                                           

1.0

0.93(0.89-1.20)*

Wealth quintile 

  Poor

     Middle

  Rich

0.932(0.876-1.007)                                        0.857(0.716-1.027)

0.863(0.734-1.011)

-

-

-

Distance to health facility

         Not Big problem    

  Big problem

                                                                             

1.512(1.234-1.650)*

0.974(0.859-1.103)*

                                                                           

1.0

0.97(0.85-1.10)*

Cost of service

         Not big problem

   Big problem

                                                                               

1.031(0.987-1.143)*

0.605(0.472-0.822)*

                                                                               

1.0

0.50(0.37-0.82)*

Availability of a health worker in community

          Not readily available

     Readily available

                                                                                       

1.021(0.954-1.170)*

1.061(0.970-1.182)*

                                                                                       

1.0

1.06(0.97-1.18)*

Exposure to media

           Exposure

           Non-exposure

                                                                                    0.923(0.876-1.100)

1.077(0.927-1.251)

-

-

Pregnancy wanted

   No

      Yes

                                                                               

0.823(0.765-0.987)*

1.170(1.033-1.367)*

                                                                               

1.0

1.15(1.03-1.36)*

Complications

No

  Yes

                                                                                           0.621(0.543-0.876)*

1.942(1.733-2.367)*

                                                                                           1.0

2.04(1.89-2.26)*

Parity

0.942(0.918-0.967)*

0.89(0.81-0.92)*

Note 1: (OR): Exponential coefficients; CI: confidence intervals; * indicates variables with p<0.05 Note 2: estimates based on weighted data

Table 3 indicates that the factors associated with relatively increased odds of early ANC were women with age of 19-34 years, completing primary seven, distance to health not being a big problem, cost of service not being a big problem, a readily available health worker in a community compared to when a health worker is not readily available, women’s desire for pregnancy and complications (p<0.05).

The factors that were associated with relatively reduced odds of early ANC were women aged 15-18 years, not completing secondary, being married compared to unmarried, distance to a health facility as big problem, cost of service being a big problem, women who didn’t want the pregnancy, without complications, and parity (p<0.05).

Additionally, the factors that significantly contributed to early ANC were: maternal age, maternal education, marital status, distance to health facility, cost of attaining service, availability of a health worker in the community, desire for pregnancy, complications and parity (p<0.05).

Holding other factors constant,  adult mothers age 35-49 had an 18% increased odds of utilizing early ANC as compared to teenage mothers age 15-19 (OR=1.18). Women who completed primary seven had a 68% increased odds of utilizing ANC within the first trimester as compared to a woman who had incomplete primary education (OR=1.68). A married woman had a 7% reduced odds to utilize early ANC as compared to an unmarried woman (OR=0.93).

Women were distance to a health facility a big problem that had a 3% reduced odds to utilize early ANC as compared to women were distance to a health facility is not a big problem(OR=0.97). Women with the cost of service problems were half as likely to utilize ANC within the first trimester as compared to women with no problems (OR=0.5). Women in communities with readily available health workers had a 6% increased odds of utilizing early ANC as compared to women in communities with no readily available health workers (OR=1.06).

Women who wanted the pregnancy had a 15% increased odds of utilizing ANC services within the first trimester as compared to women who did not (OR=1.15). Women with complicated pregnancy were twice as likely to utilize early ANC compared to women with no complications (OR=2.04). One more live child ever born in a household lowered the odds on average by 11%, holding other factors constant (OR=0.89).

Results from this study are in agreement with most scholars who revealed that adult women and high education levels are associated with early utilization of antenatal care services (Ensor & Cooper, 2004; Mamba et al., 2017; Sacks et al., 2017; Wilunda et al., 2014), and in affirmation with studies in Kenya (Arunda, Emmelin, & Asamoah, 2017; Kitui, Lewis, & Davey, 2013; Magadi, Madise, & Rodrigues, 2000), Rwanda  (Golooba-Mutebi, 2011; Hagey, Rulisa, & Perez-Escamilla, 2014; Manzi et al., 2014), India (Pallikadavath, Foss, & Stones, 2004; Singh, Rai, Alagarajan, & Singh, 2012; Srivastava et al., 2014), Zambia (Sacks et al., 2017) and in the USA (Yaya, Bishwajit, & Shah, 2016). However, some studies reported a strong association between teenage mothers and early use of ANC (Mosiur Rahman, Haque, & Sarwar Zahan, 2011; Ochako, Fotso, Ikamari, & Khasakhala, 2011).

Additionally, women delayed to attain early ANC services because of direct costs involved, overcrowding in hospital, staff attitude, and long distances to a health facility in Ethiopia (Abosse, Woldie, & Ololo, 2010; Wudineh, Nigusie, Gesese, Tesu, & Beyene, 2018), Rwanda (Golooba-Mutebi, 2011; Hagey et al., 2014), Benin (Dansou, Adekunle, & Arowojolu, 2017), India (Pallika- davath et al., 2004; Singh et al., 2012; Srivastava et al., 2014) and Tanzania (Mrisho et al., 2009).

A study by Finlayson and Downe (2013) reveal that barriers to early ANC utilization are driven by views that pregnancy is a healthy state, women's limited financial resources, and not getting it right the first time due to inadequate services for mother with other children.

In essence: The right timing of ANC leads to avoiding most of the maternal health conditions during pregnancy.

Pregnancy should be an enjoyable stage in every woman’s life, and mothers should be mindful of the benefits of utilizing early antenatal healthcare service to reduce incidences of maternal and neonatal underlying conditions, especially abortions. Though maternal mortality was declining and increased proportionate of women attain antenatal care services, late timing will continue to pre-dispose women and newborns to the risk of morbidity and mortality.  

The majority of women have not completed primary and secondary levels of education. This is because childbirth in Uganda starts as early as 13 years (UBOS, 2017) when the girls are supposed to be at school. To improve the utilization of early ANC, there is a need to formulate policies and design maternal health service programs that sensitize women about the benefits of comprehensive ANC visits. Mothers should be encouraged to give “first visit within three months of pregnancy” priority and avoid delayed access for better maternal and neonatal outcomes.

The government of Uganda and other stakeholders should reduce the costs of attaining health services by enacting the bill on insurance, encourage pregnancy centering, and strengthen the position of community health workers.

There is need for female child education completion, scholarship programs and legislation against early marriages promotions for young women to remain in school longer. Educated women are better positioned to acquire, understand, and utilize knowledge when exposed to media on maternal health information.

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Will Kaberuka
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