Survival analysis and prognostic factors of the timing of first antenatal care visit in Nigeria

Time to initiation of antenatal care and its predictors among pregnant women who delivered in Arba Minch town public health facilities, Gamo Zone, southern Ethiopia, 2023: a retrospective follow-up study

BACKGROUND

Early antenatal care visit is important for optimal care and health outcomes for women and children. In the study area, there is a lack of information about the time to initiation of antenatal care. So, this study aimed to determine the time to initiation of antenatal care visits and its predictors among pregnant women who delivered in Arba Minch town public health facilities.

METHODS

An institution-based retrospective follow-up study was performed among 432 women. A systematic random sampling technique was employed to select the study participants. The Kaplan-Meier survival curve was used to estimate the survival time. A Multivariable Cox proportional hazard regression model was fitted to identify predictors of the time to initiation of antenatal care. An adjusted hazard ratio with a 95% confidence interval was used to assess statistical significance.

RESULTS

The median survival time to antenatal care initiation was 18 weeks (95% CI = (17, 19)). Urban residence (AHR = 2.67; 95% CI = 1.52, 4.71), Tertiary and above level of education of the women (AHR = 1.90; 95% CI = 1.28, 2.81), having pregnancy-related complications in a previous pregnancy (AHR = 1.53; 95% CI = 1.08, 2.16), not having antenatal care for previous pregnancy (AHR = 0.39; 95% CI = 0.21, 0.71) and unplanned pregnancy (AHR = 0.66; 95% CI = 0.48, 0.91) were statistically significant predictors.

CONCLUSION

Half of the women initiate their antenatal care visit after 18 weeks of their pregnancy which is not in line with the recommendation of the World Health Organization. Urban residence, tertiary and above level of education of the women, having pregnancy-related complications in a previous pregnancy, not having previous antenatal care visits and unplanned pregnancy were predictors of the time to initiation of antenatal care. Therefore, targeted community outreach programs including educational campaigns regarding antenatal care for women who live in rural areas, who are less educated, and who have no previous antenatal care experience should be provided, and comprehensive family planning services to prevent unplanned pregnancy are needed.

Time to initiation of antenatal care and its predictors among pregnant women in Ethiopia: a multilevel mixed-effects acceleration failure time model

OBJECTIVE

To assess the time to initiation of antenatal care (ANC) and its predictors among pregnant women in Ethiopia.

DESIGN

Retrospective follow-up study using secondary data from the 2019 Ethiopian Mini-Demographic and Health Survey.

SETTING AND PARTICIPANTS

2933 women aged 15-49 years who had ANC visits during their current or most recent pregnancy within the 5 years prior to the survey were included in this study. Women who attended prenatal appointments but whose gestational age was unknown at the first prenatal visit were excluded from the study.

OUTCOME MEASURES

Participants were interviewed about the gestational age in months at which they made the first ANC visit. Multivariable mixed-effects survival regression was fitted to identify factors associated with the time to initiation of ANC.

RESULTS

In this study, the estimated mean survival time of pregnant women to initiate the first ANC visit in Ethiopia was found to be 6.8 months (95% CI: 6.68, 6.95). Women whose last birth was a caesarean section (adjusted acceleration factor (AAF)=0.75; 95% CI: 0.61, 0.93) and women with higher education (AAF)=0.69; 95% CI: 0.50, 0.95) had a shorter time to initiate ANC early in the first trimester of pregnancy. However, being grand multiparous (AAF=1.31; 95% CI: 1.05, 1.63), being previously in a union (AAF=1.47; 95% CI: 1.07, 2.00), having a home birth (AAF=1.35; 95% CI: 1.13, 1.61) and living in a rural area (AAF=1.25; 95% CI: 1.03, 1.52) were the impediments to early ANC initiation.

CONCLUSION

Women in this study area sought their initial ANC far later than what the WHO recommended. Therefore, healthcare providers should collaborate with community health workers to provide home-based care in order to encourage prompt ANC among hard-to-reach populations, such as rural residents and those giving birth at home.

Spatial distribution of delayed initiation of antenatal care visits and associated factors among reproductive age women in Ethiopia: spatial and multilevel analysis of 2019 mini-demographic and health survey

OBJECTIVES

This study aimed to assess the spatial distribution, wealth-related inequality and determinants for delayed initiation of antenatal care (ANC) visits among reproductive-age women in Ethiopia.

DESIGN

Cross-sectional study design.

SETTING

Ethiopia.

PARTICIPANTS

A total of 2924 reproductive-age women who had given birth in the 5 years preceding the survey.

OUTCOME MEASURE

Delayed initiation of ANC visits.

RESULTS

The magnitude of delayed initiation of ANC visits among reproductive-age women in Ethiopia was 62.63% (95% CI 60.86%, 64.37%). Women aged 35-49 (AOR=1.42; 95% CI 1.04, 1.94), being protestant religion followers (AOR=1.43; 95% CI 1.06, 1.94), being in higher wealth index (AOR=0.53; 95% CI 0.41, 0.69), living in rural residence (AOR=1.50; 95% CI 1.02, 2.19) and living in the metropolitan region (AOR=0.45; 95% CI 0.26, 0.77) were significantly associated with delayed initiation of ANC visit. Southern Nations Nationalities and Peoples Region (SNNPR), Somalia, Benishangul Gumuz, Southern Addis Ababa and Gambella regions were hot spot regions for delayed initiation of ANC visits. The SaTScan analysis result identified 107 primary clusters of delayed initiation of ANC visits located in regions of SNNPR, Gambella, Southern Addis Ababa, Eastern Oromia and Benishangul Gumuz.

CONCLUSIONS

Significant spatial clustering of delayed initiation of ANC visits was observed in Ethiopia. More than half of women had delayed initiation of ANC visits in Ethiopia. Women's age, religion, wealth index, residence and region were significant predictors of delayed initiation of ANC visits. There is a disproportional pro-poor distribution of delayed initiation of ANC visits in Ethiopia. Therefore, interventions should be designed in the hot spot areas where delayed initiation of ANC visits was high to enhance the timely initiation of ANC visits.

Multilevel Modelling of the Individual and Regional Level Variability in Predictors of Incomplete Antenatal Care Visit among Women of Reproductive Age in Ethiopia: Classical and Bayesian Approaches

Background: Antenatal care is an operational public health intervention to minimize maternal and child morbidity and mortality. However, for varied reasons, many women fail to complete the recommended number of visits. The objective of this study was to assess antenatal care utilization and identify the factors associated with the incomplete antenatal care visit among reproductive age women in Ethiopia. Methods: The 2019 Ethiopian Mini Demographic and Health Survey data were used for this study. Multilevel logistic regression analysis and two level binary logistic regression models were utilized. Results: Around 56.8% of women in Ethiopia did not complete the recommended number of antenatal care visits. Women from rural areas were about 1.622 times more likely to have incomplete antenatal care compared to women from urban areas. Women who had no pregnancy complication signs were about 2.967 times more likely to have incomplete antenatal care compared to women who had pregnancy complication signs. Women who had a slight problem and a big problem with the distance from a health center were about 1.776 and 2.973 times more likely, respectively, to have incomplete antenatal care compared to women whose distance from a health center was not a problem. Furthermore, women who had ever terminated pregnancy were about 10.6% less likely to have incomplete antenatal care compared to women who had never terminated pregnancy. Conclusions: The design and strengthening of existing interventions (e.g., small clinics) should consider identified factors aimed at facilitating antenatal care visits to promote maternal and child health related outcomes. Issues related to urban–rural disparities and noted hotspot areas for incomplete antenatal care visits should be given special attention.

Spatial Patterns and Multilevel Analysis of Factors Associated with Antenatal Care Visits in Nigeria: Insight from the 2018 Nigeria Demographic Health Survey

Despite global progress towards antenatal care (ANC) uptake, ANC utilization in a number of countries in sub-Saharan Africa, such as Nigeria, is low. Although several studies have identified the determinants and factors associated with ANC services utilization in Nigeria, there is a gap in knowledge about the spatial patterns in ANC use. Therefore, this study aims to map the spatial distribution and factors associated with ANC visits in Nigeria. A cross-sectional dataset was obtained from the 2018 Nigeria Demographic and Health Survey. A total of 20,003 women aged 15-49 were considered in this study. Both spatial and multilevel analyses were carried out. The results were presented in spatial maps and adjusted odds ratios (aOR) at a 95% confidence interval (CI). Hot spot areas (high proportion of an incomplete ANC visit) were located in Sokoto, Kebbi, Zamfara, Katsina, Kano, Jigawa, Bauchi, Niger, Borno, Gombe, and Bayelsa. Regional disparities in incomplete ANC visits were found in this study. Maternal age, maternal education, partner's level of education, working status, ethnicity, parity, religion, exposure to media, place of residence, wealth index, region, and community literacy level were factors associated with incomplete ANC. There is a need to consider these factors in the design and strengthening of existing interventions (e.g., mini-clinics) aimed at increasing ANC visits to help attain maternal health-related Sustainable Development Goals by 2030. The regional disparities in incomplete ANC visits also need to be considered by encouraging pregnant women in hotspot areas to attend ANC visits.

Timing of first antenatal care contact, its associated factors and state-level analysis in Nigeria: a cross-sectional assessment of compliance with the WHO guidelines

OBJECTIVES

To assess the compliance of WHO guidelines on the timeliness of antenatal care (ANC) initiation in Nigeria and its associated factors and to provide subcountry analysis of disparities in the timing of the first ANC in Nigeria.

DESIGN

Cross-sectional.

SETTING

Nationally representative data of most recent pregnancies between 2013 and 2018 in Nigeria.

PARTICIPANTS

Women with pregnancies within 5 years before the study.

PRIMARY AND SECONDARY OUTCOME MEASURES

The outcome variable was the trimesters of the first ANC contact. Data were analysed using descriptive statistics, bivariable and multivariable multinomial logistic regression at 5% significance level.

RESULTS

Of all the 21 785 respondents, 75% had at least one ANC contact during their most recent pregnancies within the five years preceding the data collection. Among which 24% and 63% started in the first and second trimester, respectively. The proportion who started ANC in the first trimester was highest in Benue (44.5%), Lagos (41.4%) and Nasarawa (39.3%) and lowest in Zamfara (7.6%), Kano (7.4%) and Sokoto (4.8%). Respondents aged 40-49 years were 65% (adjusted relative risk ratio (aRRR: 1.65, 95 % CI: 1.10 to 2.45) more likely to initiate ANC during the first trimester of pregnancy relative to those aged 15-19 years. Although insignificant, women who participate in their healthcare utilisation were 4% (aRRR: 1.04, 95 % CI: 0.90 to 1.20) times more likely to have early initiation of ANC. Other significant factors were respondents' and spousal educational attainment, household wealth quintiles, region of residence, ethnicity, religion and birth order.

CONCLUSIONS

Only a quarter of pregnant women, initiated ANC contact during the first trimester with wider disparities across the states in Nigeria and across the background characteristics of the pregnant women. There are needs to enhance women's autonomy in healthcare utilisation. Concerted efforts on awareness creation and empowerment for women by all stakeholders in maternal and child healthcare are antidotes for early ANC contact initiation.

Determinants of change in timely first antenatal booking among pregnant women in Ethiopia: A decomposition analysis

Background

Even though maternal health was highly targeted in different global strategies, maternal mortality could not be decreased as was expected. Besides this, prior decomposition analysis to the possible cause of changes to timely first antenatal booking has not been conducted. Therefore, this study aimed to assess determinants of change in timely first antenatal booking among pregnant women in Ethiopia.

Methods

The study utilized three consecutive Ethiopia Demographic and Health Survey (EDHS) datasets which were collected through cross-sectional study design. The number of pregnant women who gave birth in 2005, 2011 and 2016 survey included in the analysis was 7,307, 7,908 and 7,590 respectively. The data were analyzed by using Stata/SE version 14.0. Logit-based decomposition analysis was done to identify contributing factors for change in timely first antenatal booking and statistical significance was determined by using P-value.

Results

The trend of timely first antenatal booking was increased from 6% to 20% in the last ten years. The analysis revealed that 14% of the overall change was because of the change in women’s composition. Changes in the composition of women according to region, education and occupation status were the major sources of this change. The remaining, 86% of the change was due to differences in the coefficient. Mostly, the change in behaviors of the Oromia population, those who have lived in the rural areas and male household head were some of the contributing factors for the increase in timely first antenatal booking.

Conclusions

There was a significant increase in timely first antenatal booking among pregnant women in Ethiopia from 2005 to 2016 EDHS. The change in the women composition according to residency, education and occupation status of women and the difference in behaviors like: behavior of rural residents and male household head contributed to the majority of the change. Interventions targeting the male household head, rural residents and those women who lived in the Oromia region should be emphasized to increase further timely booking. In addition, promoting women in terms of education and creating job opportunities could be the other recalled intervention areas of the country.

Sub-national analysis and determinants of numbers of antenatal care contacts in Nigeria: assessing the compliance with the WHO recommended standard guidelines

Background

Nigeria has unimpressive maternal and child health indicators. Compliance with the WHO guidelines on the minimum number of antenatal care (ANC) contacts could improve these indicators. We assessed the compliance with WHO recommended standards on ANC contacts in Nigeria and identify the associated factors.

Methods

Nationally representative cross-sectional data during pregnancy of 21,785 most recent births within five years preceding the 2018 Nigeria Demographic Health Survey was used. The number of ANC contacts was categorised into “None”, “1–3”, “4–7” and “8 or more” contacts based on subsequent WHO guidelines. Descriptive statistics, bivariable and multivariable multinomial logistic regression was used at p = 0.05.

Results

About 25 % of the women had no ANC contact, 58 % had at least 4 contacts while only 20 % had 8 or more ANC contacts. The highest rate of 8 or more ANC contacts was in Osun (80.2 %), Lagos (76.8 %), and Imo (72.0 %) while the lowest rates were in Kebbi (0.2 %), Zamfara (1.1 %) and Yobe (1.3 %). Respondents with higher education were twelve times (adjusted relative risk (aRR): 12.46, 95 % CI: 7.33–21.2), having secondary education was thrice (aRR: 2.91, 95 % CI: 2.35–3.60), and having primary education was twice (aRR: 2.17, 95 % CI: 1.77–2.66) more likely to make at least 8 contacts than those with no education. Respondents from households in the richest and middle wealth categories were 129 and 67 % more likely to make 8 or more ANC contacts compared to those from households in the lowest wealth category respectively. The likelihood of making 8 ANC contacts was 89 and 47 % higher among respondents from communities in the least and middle disadvantaged groups, respectively,  compared to the most disadvantaged group. Other significant variables were spouse education, health care decision making, media access, ethnicity, religion, and other community factors.

Conclusions

Compliance with WHO guidelines on the minimum number of ANC contacts in Nigeria is poor. Thus, Nigeria has a long walk to attaining sustainable development goal’s targets on child and maternal health. We recommend that the maternal and child health programmers should review existing policies and develop new policies to adopt, implement and tackle the challenges of adherence to the WHO recommended minimum of 8 ANC contacts. Women's education, socioeconomic status and adequate mobilization of families should be prioritized. There is a need for urgent intervention to narrow the identified inequalities and substantial disparities in the characteristics of pregnant women across the regions and states.

Survival time to first antenatal care visit and its predictors among women in Ethiopia

BACKGROUND

First-trimester pregnancy stage is the fastest developmental period of the fetus, in which all organs become well developed and need special care. Yet, many women make their first antenatal visit with the pregnancy already compromised due to fetomaternal complications. This study aimed to fill this dearth using the 2016 national representative data set to augment early antenatal care visits in Ethiopia.

METHODS

A cross-sectional study design using the 2016 Ethiopia Demographic and Health Survey (EDHS) data set. Kaplan-Meir estimate was used to explain the median survival time of the timing of the first ANC visit. Multivariate Cox-proportional hazard regression analysis was performed to identify the factors related to the timing of the first ANC visit. Adjusted hazard ratios (AHR) with a 95% Confidence interval (CI) plus a p-value of < 0.05 were considered to declare a statistically significant association.

RESULTS

Data for 4666 study participants who had ANC follow-up history during pregnancy were included in the study and analyzed. The overall median survival time in this study was seven months. The timing of the first ANC visit was shorter by 2.5 times (AHR: 2.5; 95% CI: 2.34-3.68), 4.3 times (AHR: 4.3; 95% CI: 2.2-7.66), 4.8 times (AHR: 4.8, 95% CI: 4.56-10.8) among women who attended primary, secondary, and higher education as compared with non-educated one. Similarly, women who were residing in urban areas had 3.6 times (AHR: 3.6; 95% CI: 2.7-4.32) shorter timing of first ANC visit than rural residents. Furthermore, the timing of the first visit among the richest women was 3.2 times (AHR: 3.2; 95% CI: 2.5-9.65) shorter than the poorest women.

CONCLUSION

The median survival time of the first ANC visit was seven months. The timing of the first ANC was longer among younger, poorer women, those who had no access to media, who considered distances as a big challenge to reach a health facility and, those with no education. Therefore, health care providers and community health workers should provide health education to create community awareness regarding the timing of the first ANC visit.

Does where mothers live matter? Regional variations in factors influencing place of child delivery in Nigeria

Utilization of health care facilities for child delivery is associated with improved maternal and neonatal outcomes, but less than half of mothers use these for child delivery in Nigeria. This study investigated the factors associated with facility delivery in Nigeria, and their variation between the Northern and Southern parts of the country - two regions with distinct socio-cultural make-ups. The study included 33,924 mothers aged 15-49 who had given birth in the last 5 years preceding the 2018 Nigeria Demographic and Health Survey. Overall, higher age, being educated, being a Christian, being an urban resident, being exposed to mass media, making joint decisions with partner on health care, beginning antenatal visits in the first trimester and attending antenatal clinics frequently were found to be associated with improved use of a health care facility for child delivery. An average mother in Northern Nigeria had a 38% chance of having a facility-based delivery, whereas the likelihood in the South was 76%. When other factors were adjusted for, age and listening to the radio were significant predictors of facility-based delivery in the South but not in the North. In the North, Christians were more likely than Muslims to have a facility-based delivery, but the reverse was true in the South. Rural women in the South had a 16% greater chance of having a facility-based delivery than urban women in the North. The study results suggest that there is inequality in access to health care facilities in Nigeria, and the differences in the socio-cultural make-up of the two regions suggest that uniform intervention programmes may not yield similar results across the regions. The findings give credence to, and expand on, the Cosmopolitan-Success and Conservative-Failure Hypothesis.

Antenatal care utilization in the fragile and conflict-affected context of the Democratic Republic of the Congo

Maternal mortality represents one of the widest gaps between developed and developing countries. Ninety-nine percent of maternal deaths occur in developing countries, with over half occurring in sub-Saharan Africa. This health indicator became a global priority when the United Nations' Sustainable Development Goal 3.1 set out to decrease the global maternal mortality rate to less than 70 per 100 000 births by 2030. In the Democratic Republic of the Congo (DRC), 473 of every 100 000 women who give birth die due to pregnancy-related complications. These deaths could be prevented through enhanced access and utilization of antenatal care services and skilled birth attendants. However, amid prolonged conflict, violence, and authoritarian governments, the Democratic Republic of the Congo has been classified as a fragile and conflict-affected situation and women are prone to face difficulties accessing maternal health services. This study examined the utilization of antenatal care and skilled birth attendants in the Democratic Republic of Congo using logistic regressions. Our findings show that women living in regions with extremely high levels of prolonged conflict were significantly less likely than those in regions with moderate levels of conflict to have their first antenatal care visit within the first trimester (OR = 0.29, p < 0.01), and to have four visits (OR = 0.46, p < 0.01). Overall, women in regions with extremely high levels of conflict (OR = 0.41, p < 0.01) were less likely to meet the World Health Organization's antenatal care recommendations compared to those in regions with moderate levels of conflict. The findings suggest that conflict-affected countries, such as the Democratic Republic of the Congo, require context-specific interventions if progress is to be made towards achieving Sustainable Development Goal 3.1.