Number of antenatal care utilization and associated factors among pregnant women in Ethiopia: zero-inflated Poisson regression of 2019 intermediate Ethiopian Demography Health Survey

Multilevel negative binomial analysis of factors associated with numbers of antenatal care contacts in low and middle income countries: Findings from 59 nationally representative datasets

BACKGROUND

Antenatal care (ANC) is one of the recommended interventions to reduce stillbirth, maternal, neonatal, and child mortality through early identification and management of pregnancy complications or pre-existing conditions. Although increasing number of ANC is a key priority of the 2016 WHO recommendations, ANC uptake in Low and Middle Income Countries (LMICs) is insufficient. Therefore, this study aimed to investigate factors associated with the number of ANC contacts in LMICs.

METHODS

Data for the study were drawn from 59 recent Demographic and Health Surveys (DHS) conducted in LMICS. We included a total sample of 520,377 mothers who gave birth in the five years preceding the survey. A multilevel negative binomial regression model was applied to identify factors that may affect number of ANC. Adjusted incidence rate ratios (AIRR) with 95% Confidence Interval (CI) were reported to show association.

RESULTS

This study found that mothers and their partner with higher educational attainment, mothers aged >35 years, mothers who had decision making autonomy, mothers from female headed household, mothers from richer and richest household, mothers exposed to media, and residing in urban areas had significantly more ANC contacts. However, number of ANC contacts were significantly lower among mothers who initiated ANC after 12 weeks of gestation and perceived healthcare access to be a big problem.

CONCLUSION

Our results suggest that individual, household, and community-level factors were associated with number of ANC contacts among pregnant mothers in LMICs. Hence, local and international policymakers, and programmers should focus on improving community awareness about maternal health care services through mass media and outreach programs with especial emphasis on women's and their partners educational attainment, rural mothers, women's empowerment, and household socioeconomic status.

Utilization of Antenatal Care and Skilled Birth Delivery Services in Sub-Saharan Africa: A Systematic Scoping Review

Daily, the number of women who die around the world reaches an average of 800; these deaths are a result of obstetric complications in pregnancy and childbirth, and 99% of these deaths occur in low- and middle-income countries. This review probes the use of antenatal care (ANC) and skilled birth delivery (SBD) services in sub-Saharan Africa (SSA) and highlights research gaps using Arksey and O'Malley's methodological approach. The screening of abstracts and full text was carried out by two independent authors who ensured the eligibility of data extraction from the included articles. An exploration of the data was undertaken with descriptive analyses. In total, 350 potentially eligible articles were screened, and 137 studies were included for data extraction and analysis. From the 137 included studies, the majority were from Ethiopia (n = 40, 29.2%), followed by Nigeria (n = 30, 21.9%). Most of the studies were published between 2019 and 2023 (n = 84, 61%). Significant trends and challenges with ANC and SBD services emerged from the studies. It is revealed that there are wide gaps in the utilization of ANC and SBD services. Policy attention, intervention strategies to improve access, resources, rural-urban disparity, and women's literacy are recommended to improve the utilization of ANC and SBD services in SSA countries.

Antenatal care service utilization disparities between urban and rural communities in Ethiopia: A negative binomial Poisson regression of 2019 Ethiopian Demography Health Survey

BACKGROUND

Although there have been consistent improvements in maternal mortality, it remains high in developing countries due to unequal access to healthcare services during pregnancy and childbirth. Thus, this study aimed to further analyze the variations in the number of antenatal care utilizations and associated factors among pregnant women in urban and rural Ethiopia.

METHODS

A total of 3962 pregnant women were included in the analysis of 2019 Ethiopian Demographic and Health Survey data. A negative binomial Poisson regression statistical model was used to analyze the data using STATA version 14.0. An incident rate ratio with a 95% confidence interval was used to show the significantly associated variables.

RESULTS

Of the 3962 (weighted 3916.67) pregnant women, about 155 (15.21%) lived in urban and 848 (29.29%) rural residences and did not use antenatal care services in 2019. Women age group 20-24 (IRR = 1.30, 95%CI:1.05-1.61), 25-29 (IRR = 1.56, 95%CI:1.27-1.92), 30-34 (IRR = 1.65, 95%CI:1.33-2.05), and 35-39 years old (IRR = 1.55, 95%CI:1.18-2.03), attending primary, secondary, and higher education (IRR = 1.18, 95%CI:1.07-1.30), (IRR = 1.26, 95%CI:1.13-1.42) and (IRR = 1.25, 95%CI:1.11-1.41) respectively, reside in middle household wealth (IRR = 1.31, 95%CI:1.13-1.52), richer (IRR = 1.45, 95%CI:1.26-1.66) and richest (IRR = 1.68, 95%CI:1.46-1.93) increases the number of antenatal care utilization among urban residences. While attending primary (IRR = 1.34, 95%CI:1.24-1.45), secondary (IRR = 1.54, 95%CI:1.34-1.76) and higher education (IRR = 1.58, 95%CI:1.28-1.95), following Protestant (IRR = 0.76, 95%CI:0.69-0.83), Muslim (IRR = 0.79, 95%CI:0.73-0.85) and Others (IRR = 0.56, 95%CI:0.43-0.71) religions, reside in poorer, middle, richer, and richest household wealth (IRR = 1.51, 95%CI:1.37-1.67), (IRR = 1.66, 95%CI:1.50-1.83), (IRR = 1.71, 95%CI:1.55-1.91) and (IRR = 1.89, 95%CI:1.72-2.09) respectively, being married and widowed/separated (IRR = 1.85, 95%CI:1.19-2.86), and (IRR = 1.95, 95%CI:1.24-3.07) respectively were significantly associated with the number of antenatal care utilization among rural residences.

CONCLUSION

The utilization of antenatal care is low among rural residents than among urban residents. To increase the frequency of antenatal care utilization, health extension workers and supporting actors should give special attention to pregnant women with low socioeconomic and educational levels through a safety-net lens.

Regional disparities in antenatal care utilization among pregnant women and its determinants in Ethiopia

Background

Antenatal care primarily focuses on health care checkups, the provision of advice on healthy behaviors, and the delivery of psychological, social, and emotional support for women with pregnancy. The national target set by the Ethiopian government is to achieve 95% of at least four ANC visits. Nevertheless, 43.11% of women had four or more checkups, according to the 2019 Ethiopian Demographic and Health Survey. Despite this achievement, antenatal care visits differ significantly between Ethiopian regions. Consequently, the purpose of this study was to assess regional disparities in pregnant women's utilization of antenatal care and its determinants in Ethiopia.

Methods

We have used 2019 intermediate Ethiopian Demographic and Health Survey data for analysis. The analysis comprised a total of 3,917 weighted women age 15-49 who had a live birth in the 5 years preceding the survey. Poisson regression analysis was done using SAS software version 9.4. To show the strength and direction of the association, an incidence rate ratio with a 95% confidence interval was used. Variables with a p-value <0.05 were declared as significant factors associated with the number of ANC visits.

Results

In Ethiopia, the number of ANC visits differs between regions. With a mean of 4.74 (95% CI: 4.49, 4.99), Addis Ababa reported the highest percentage of ANC visits (82.7%), while the Somali Region reported the lowest percentage (11.3%) with a mean of 0.73 (95% CI: 0.57, 0.88). Maternal age, educational level, religion, household wealth index, place of delivery, and household size show significant associations with the number of antenatal care visits.

Conclusions

In Ethiopia, there is the highest regional disparity in the number of ANC visits. The number of ANC visits was influenced by the mother's age, education, religion, household wealth index, place of delivery, and household size. Regarding the ANC visits, there should be initiatives that address the demands of pastoralist and agro-pastoralist communities to increase ANC utilization. As with many other health outcomes, education and low socio-economic status were associated with low ANC visit but these are tied to the overall social development of a country and are not immediately amenable to public health interventions.

Antenatal care utilization and its determinants in fragile and conflict-affected situations in Sekota Zuria District, Northern Ethiopia, 2022: A community-based cross-sectional study

BACKGROUND

Access to maternal and reproductive health services has been one of the most affected components by armed conflict. Understanding how fragility and conflict may restrict access to maternal health services and promoting situation-specific policy options are crucial for reducing the effects. As a result, this study intends to assess the antenatal care service usage and associated factors in vulnerable and conflict-affected situations in Sekota zuria district, Northern Ethiopia.

METHODS

A community-based cross-sectional study design was employed on 593 mothers who had given birth in the past two years preceding the survey in the Sekota zuria district from October 15 to 30, 2022. The data were collected by using an interviewer-administered structured and pretested questionnaire. To pinpoint the determining factors, a bivariable and multivariable logistic regression model was applied. For both steps, variables were deemed significant if they had a P-value of lower than 0.05. We use adjusted odds ratios to measure how strongly the dependent and outcome variables are related.

RESULTS

The prevalence of antenatal care service utilization in the study area was 54.5%, 95% CI: 50.0-58.0%. Considering prenatal visits as routine prenatal checkups (AOR = 2.54, 95% CI: 1.74-3.69), using healthcare providers as a source of information (AOR = 2.30, 95% CI: 1.38-3.81), planned pregnancies (AOR = 1.74, 95% CI: 1.07-2.82), were positively associated with utilization of antenatal care. Whereas, respondents' restricted movement because of insecurity negatively affected the service utilization (AOR = 0.30, 95% CI: 0.18-0.49) CONCLUSIONS: The antenatal care utilization in the study area was 54.5%. Respondents' restricted movement because of insecurity negatively affected the service utilization during the fragile and conflict-affected situation. So it demands designing context and vulnerable group-specific healthcare policies and strategies in fragile and conflict-affected situations. It is also very important to strengthen the availability and accessibility of maternal healthcare services in conflict-affected areas through outreach initiatives and mobile clinics.

Muslim and Christian Women's Perceptions of the Influence of Spirituality and Religious Beliefs on Motherhood and Child-Rearing: A Phenomenological Study

(1) Background: Spirituality is a factor that plays a role in decisions related to health and illness. When a woman becomes a mother, she undergoes physical, psychological, and social changes for which healthcare professionals must provide the necessary care. However, women may feel misunderstood and stigmatized when they carry out their religious practices and express their spirituality related to motherhood. The aim of this study was to describe the experiences of women with Muslim and Christian religious ideologies on the influence of spirituality and religious beliefs in motherhood and child-rearing. (2) Methods: A descriptive phenomenological qualitative study with two groups of women of Islamic and Christian ideology, respectively. Three focus groups and in-depth interviews were conducted, recorded, transcribed, and analyzed with ATLAS.ti 7.0. An inductive analysis was carried out according to the Moustakas model. (3) Results: Three themes were identified: religious and cultural aspects that determine child-rearing, the influence of spirituality and family on the mother's role, and the support received from healthcare personnel. (4) Conclusions: Spirituality and religious beliefs are manifested during motherhood and child-rearing in the form of infant feeding, the need for their protection, or the need for support from mothers. Healthcare personnel must be able to offer culturally competent and spiritually respectful care. Patients should not be judged based on their spirituality.

Factors determining antenatal care utilization among mothers of deceased perinates in Ethiopia

Introduction

Receiving adequate antenatal care (ANC) had an integral role in improving maternal and child health outcomes. However, several factors influence the utilization of ANC from the individual level up to the community level factors. Thus, this study aims to investigate factors that determine ANC service utilization among mothers of deceased perinate using the proper count regression model.

Method

Secondary data analysis was performed on perinatal death surveillance data. A total of 3,814 mothers of deceased perinates were included in this study. Hurdle Poisson regression with a random intercept at both count-and zero-part (MHPR.ERE) model was selected as a best-fitted model. The result of the model was presented in two ways, the first part of the count segment of the model was presented using the incidence rate ratio (IRR), while the zero parts of the model utilized the adjusted odds ratio (AOR).

Result

This study revealed that 33.0% of mothers of deceased perinates had four ANC visits. Being in advanced maternal age [IRR = 1.03; 95CI: (1.01-1.09)], attending primary level education [IRR = 1.08; 95 CI: (1.02-1.15)], having an advanced education (secondary and above) [IRR = 1.14; 95 CI: (1.07-1.21)] and being resident of a city administration [IRR = 1.17; 95 CI: (1.05-1.31)] were associated with a significantly higher frequency of ANC visits. On the other hand, women with secondary and above education [AOR = 0.37; 95CI: (0.26-0.53)] and women who live in urban areas [AOR = 0.42; 95 CI: (0.33-0.54)] were less likely to have unbooked ANC visit, while women who resided in pastoralist regions [AOR = 2.63; 95 CI: (1.02-6.81)] were more likely to have no ANC visit.

Conclusion

The uptake of ANC service among mothers having a deceased perinate was determined by both individual (maternal age and educational status) and community (residence and type of region) level factors. Thus, a concerted effort is needed to improve community awareness through various means of communication by targeting younger women. Furthermore, efforts should be intensified to narrow down inequalities observed in ANC service provision due to the residence of the mothers by availing necessary personnel and improving the accessibility of service in rural areas.

Missed Opportunity of Antenatal Care Services Utilization and Associated Factors among Reproductive Age Women in Eastern Hararghe Zone, Eastern Ethiopia: Mixed Methods Study

Background

Despite the enormous advantages of early pregnancy-related problem diagnosis and therapy during prenatal care visits, not all pregnant women begin antenatal care at the proper time. Thus, this study aims to identify factors associated with missed opportunities for antenatal care service utilization among reproductive-age women in Eastern Ethiopia.

Methods

A mixed methods study design (quantitative and qualitative) was conducted in Grawa, Meta, and Haramaya woredas from September 5 to December 5, 2019. The quantitative data were analyzed using SPSS version 25. A multivariable logistic regression analysis model was used to identify the predictors. Statistical software programs based on ATLAS.ti version 8.2 was were used to conduct the thematic analysis of the qualitative data.

Results

Overall, missed opportunities for antenatal care were 15.4% of 95% (12.1, 19.1%). Factors such as maternal age being 15-24 (AOR = 6.9, 95% CI: 2.89-8.81); having a college education (AOR = 0.02, 95% CI: 0.001, 0.42), elementary (AOR = 0.05, 95% CI: 0.002, 0.98), and secondary education (AOR = 0.04, 95% CI: 0.001, 0.88); having five and more parity (AOR = 0.08, 95% CI: 0.01, 0.75); three visits (AOR = 0.10, 95% CI: 0.02, 0.71); those in the first trimester (AOR = 0.02, 95% CI: 0.001, 0.35) and the second trimester (AOR = 0.01, 95% CI: 0.001, 0.26); and get information from a health facility (AOR =0.09, 95% CI: 0.01, 0.67) and traditional birth attendance (AOR = 0.02, 95% CI: 0.001, 0.74) were factors statistically associated with outcome variables.

Conclusions

According to this report, relatively high proportions of pregnant women experienced missed opportunities in antenatal care follow-up. Factors such as maternal age, education, parity, frequency, timing, and media access were statistically significantly correlated with missed antenatal care follow-up. Therefore, all stakeholders should emphasize advocating for and enhancing the benefits of antenatal care; this in turn plays a crucial role in increasing the follow-up of clients for these crucial services. Moreover, health policy implementers need to coordinate their tracking of pregnant women who missed their antenatal care session.

Disparities in Antenatal Care Visits between Urban and Rural Ethiopian Women

Background

Utilizing antenatal care is one of the best ways to identify issues that are already present or could arise throughout pregnancy. Despite increased efforts to expand health services and antenatal care utilization, less is known regarding antenatal care disparities across different population segments. Therefore, the purpose of this study was to assess the degree of discrepancies between urban and rural Ethiopian pregnant women's use of antenatal care.

Methods

A total sample of 3927 women who gave birth to living children between 2014 and 2019 was included in the study from the 2019 Ethiopia Mini Demographic and Health Survey. Negative binomial Poisson's regression was adopted to analyze the data.

Results

The majority of pregnant women (73.8%) attend at least one antenatal care. Pregnant women in rural areas visited fewer number of antenatal care (68.36%) than those in urban areas (90.1%). Women with age range of 30-40 (IRR: 4.56, 95% CI: 1.07-19.34), women with attending incomplete primary education (IRR: 0.05, 95% CI: 0.02-0.12), women with attending complete primary education (IRR: 0.17, 95% CI: 0.07-0.42), women from middle-income households (IRR: 0.12, 95% CI: 0.06-0.24), women from richer household (IRR: 0.26, 95% CI: 0.14,0.5), women from the richest household (IRR: 0.45, 95% CI: 0.24-0.86), and pregnant women from rural areas (IRR: 0.615, 95%: 0.56-0.67) were observed to be linked with the frequency of antenatal care visits.

Conclusion

In Ethiopia, three-fourths of pregnant women attend at least one antenatal care. Place of residence, educational attainment, age in five years' group, and wealth index for urban/rural were related to the frequency of antenatal care visits.

Multilevel Count Regression Analysis of Factors Associated with the Desired Number of Antenatal Care Service Visits in Ethiopia

BACKGROUND

Visiting the desired number of antenatal care services improve the success of maternal health programs in terms of mother and child health. The study aimed to identify the factors associated with differences in the number of antenatal care service visits across and within regions of Ethiopia by using the 2019 Ethiopian Mini Demographic Health Survey (EMDHS).

METHODS

A total of 3979 women who were pregnant or gave birth within 5 years preceding the survey from the 2019 Ethiopian Mini Demographic Health Survey were included in the analysis. A multi-level Hurdle negative binomial regression model was selected to consider the hierarchical nature of the data in determining the factors associated with the barriers to the desired number of antenatal care service visits.

RESULTS

About one-fourth (26.2%) of mothers did not visit any antenatal care, and only 137 (3.4%) women visited the service eight times and above. The random intercept with the fixed coefficient of multilevel Hurdle negative binomial model results has shown that women in the age group between 25 and 34 (AOR = 1.057), in the age group between 35 and 49 (AOR = 1.108), protestant religion follower women (AOR = 0.918), Muslim women (AOR = 0.945), other religion follower women (AOR = 0.768), mothers in primary educational level (AOR = 1.123), secondary and higher education level (AOR = 1.228), rich mothers (AOR = 1.134), and mothers living in rural (AOR = 0.789) were statistically associated with regional variation regarding the frequency of ANC service visits.

CONCLUSIONS

The majority of pregnant women did not visit antenatal care services according to the findings of this study. This study's results revealed that the predictor variables such as mother's age, education level, religion, place of residence, marital status, and wealth index were significant, and the findings revealed that there were regional differences in ANC visits in Ethiopia. Women's economic and educational interventions should be a top priority.

The Magnitude of Optimal Antenatal Care Utilization and Its Associated Factors among Pregnant Women in South Gondar Zone, Northwest Ethiopia: A Cross-Sectional Study

Background. Adequate antenatal care is essential for the health of the mother and the development of the fetus. The World Health Organization recommends at least four antenatal care (ANC) visits during pregnancy. In Ethiopia, only 32% of women of childbearing age attend four or more ANC visits. This figure is significantly lower than the average for least developed countries. This study is aimed at calculating the magnitude and identifying the factors associated with optimal antenatal care utilization in the South Gondar Zone, Northwest Ethiopia. Methods. A community-based cross-sectional study was conducted in the South Gondar Zone of Northwest Ethiopia from September 2020 to May 2021. A total of 434 participants were selected using multistage cluster sampling. Data were gathered through face-to-face interviews using a structured questionnaire. A multivariate binary logistic regression model was used to determine the factors associated with the optimal use of antenatal care. Result. The magnitude of optimal antenatal care utilization was 59% (95% CI; 54.20, 63.65). The study showed that mothers who completed their secondary school ( $\text{AOR}=8.205$ ; 95% CI: 3.406, 19.767), women who completed their tertiary school ( $\text{AOR}=6.406$ ; 95% CI: 2.229, 18.416), women whose husbands’ level of education is secondary school ( $\text{AOR}=5.967$ ; 95% CI: 2.753, 12.936), those with a planned pregnancy ( $\text{AOR}=1.912$ ; 95% CI: 1.117, 3.271), those with a wanted pregnancy ( $\text{AOR}=2.341$ ; 95% CI: 1.366, 4.009), women whose husbands work in the government or nongovernment sector ( $\text{AOR}=3.736$ ; 95% CI: 2.093, 6.669), those not being exposed to the media ( $\text{AOR}=0.520$ ; 95% CI: 0.345, 0.783), and rural women ( $\text{AOR}=0.267$ ; 95% CI: 0.164, 0.435) were significantly associated with optimal ANC utilization. Conclusion. The findings suggest that more emphasis should be placed on education-based programs for women and their husbands that highlight the benefits of a planned pregnancy, desired pregnancy, and maternal health care. Meanwhile, the government and other concerned bodies should focus on expanding road accessibility, health institutions, and ambulance distribution to improve optimal ANC utilization in the area.

Factors Affecting Nonadherence to WHO’s Recommended Antenatal Care Visits among Women in Pastoral Community, Northeastern Ethiopia: A Community-Based Cross-Sectional Study

Introduction. More than half of the pregnant women in Ethiopia do not receive the recommended number of antenatal care visits. In the Afar region, where women have limited access to healthcare services due to pastoral livelihood, evidence on noncompliance to the adequate number of antenatal care visits is scarce. Therefore, this study was intended to examine the level of nonadherence to the recommended antenatal care visits and its associated factors in the pastoral community of Northeast Ethiopia. Methods. A community-based cross-sectional study was conducted from 04 February to 22 March 2020 among randomly selected 703 women who gave birth within 24 months preceding the survey in the Transform HDR districts of the Afar region. Data were collected using a pretested structured interviewer-administered questionnaire. Data were entered into Epi-data version 4.2 and finally exported to Stata version 16 for further analysis. Bivariable and multivariable binary logistic regression analyses were done to identify factors affecting the nonadherence to the recommended antenatal care visits. Odds ratio with the corresponding 95% confidence interval were computed and the statistical significance of the explanatory variables was declared at a $p$ -value <0.05. Results. Nonadherence to the recommended antenatal care visits was 57.0% (95% CI: 53.3%–60.7%). Attending primary (AOR (95% CI): 0.39 (0.22–0.72)) and secondary education and above (AOR (95% CI): 0.25 (0.08–0.77)), being married at the age of 18 years or older (AOR (95% CI): 0.48 (0.36–0.71)), and attending antenatal care at a health center (AOR (95% CI): 0.46 (0.26–0.81)) were associated decreased odds of nonadherence to the recommend visits. Moreover, a higher likelihood of nonadherence was found among women from households not possessing communication media (AOR (95% CI): 1.85 (1.18–2.88)) and those who initiated antenatal care attendance during the second (AOR (95% CI): 5.23 (3.54–7.72)) and third trimesters (AOR (95% CI): 8.81 (1.88–41.20)). Conclusions. Nearly six in ten women do not receive the recommended antenatal care visits, consistent with the national prevalence. Women’s education, age at marriage, type of health facility, possession of mass media, and timing of antenatal care attendance were associated with nonadherence to the recommended antenatal care visits. Thus, improving women’s literacy, dissemination of information regarding antenatal care through mass media, and strengthening interventions targeted to end child marriage are important in scaling up the level of adherence. Moreover, supporting community-based health education through health extension programs is crucial in reaching women with limited access to mass media.