Trends and factors associated with the utilisation of antenatal care services during the Millennium Development Goals era in Tanzania

Only 9% of mothers have eight and more ANC visit in 14 sub-saharan African countries; evidence from the most recent DHS 2018-2023: a multilevel analysis

BACKGROUND

The world health organization's global health observatory defines maternal mortality as annual number of female deaths, regardless of the period or location of the pregnancy, from any cause related to or caused by pregnancy or its management (aside from accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy and an estimated 287 000 women worldwide passed away from maternal causes between 2016 and 2020, that works out to be about 800 deaths per day or about one every two minutes.

METHOD

The most recent 2018-2023 DHS data set of 14 SSA countries was used a total of 89,489 weighted mothers who gave at list one live birth 3 years preceding the survey were included, a multilevel analysis was conducted. In the bi-variable analysis variables with p-value ≤ 0.20 were included in the multivariable analysis, and in the multivariable analysis, variables with p-value less than ≤ 0.05 were considered to be significant factors associated with having eight and more ANC visits.

RESULT

The magnitude of having eight and more ANC visits in 14 sub-Saharan African countries was 8.9% (95% CI: 8.76-9.13) ranging from 3.66% (95% CI: 3.54-3.79) in Gabon to 18.92% (95% CI: 18.67-19.17) in Nigeria. The multilevel analysis shows that maternal age (40-44, AOR;2.09, 95%CI: 1.75-2.53), maternal occupational status (AOR;1.14, 95%CI; 1.07-1.22), maternal educational level (secondary and above, AOR;1.26, 95%CI; 1.16-1.38), wealth status(AOR;1.65, 95%CI; 1.50-1.82), media exposure (AOR;1.20, 95%CI; 1.11-1.31), pregnancy intention (AOR;1.12, 95%CI; 1.05-1.20), ever had terminated pregnancy (AOR;1.16 95%CI; 1.07-1.25), timely initiation of first ANC visit (AOR;4.79, 95%CI; 4.49-5.10), empowerment on respondents health care (AOR;1.43, 95%CI; 1.30-1.56), urban place of residence (AOR;1.33, 95%CI; 1.22-1.44) were factors highly influencing the utilization of AN. On the other hand higher birth order (AOR;0.54, 95%CI; 0.53-0.66), not using contraceptive (AOR;0.80, 95%CI; 0.75-0.86) and survey year (AOR;0.47, 95%CI; 0.34-0.65) were factors negatively associated with having eight and more ANC visits.

CONCLUSION

In the 14 SSA included in this study, there is low adherence to WHO guidelines of eight and more ANC visits. Being educated, having jobs, getting access to media being from rural residence and rich wealth group contribute to having eight and more ANC visits, so we highly recommend policy implementers to advocate this practices.

Determinants of early antenatal care booking among pregnant mothers attending antenatal care at public health facilities in the Nole Kaba district, western Ethiopia: unmatched case-control study

BACKGROUND

Early initiation of antenatal care (ANC) is vital for the early detection and treatment of adverse pregnancy outcomes. Despite the widespread convenience of free ANC services, most women in Ethiopia attend their initial antenatal clinic late and fail to come back for follow-up care, which results in both maternal and fetal complications. Despite the fact that assessing the determinants of early ANC booking based on the local context is advised, it is not well studied in the study area.

OBJECTIVE

This study aimed to assess determinants of early ANC booking among pregnant women attending ANC at public health facilities in the Nole Kaba district, western Ethiopia.

METHODS

Facility-based unmatched case-control study design was conducted from April to June 2020. Systematic random sampling was used to select a total of 297 participants. A validated, pretested and structured instrument was used to interview the participants. The data were cleaned and coded before being entered into Epi-Info V.7.2.2.6 and exported to SPSS V.25 for analysis. The logistic regression analyses were done to assess the determinants of early ANC booking. Adjusted odds ratio (AOR) with 95% CI was estimated to measure the strength of the association. The level of statistical significance was set at a p value <0.05.

RESULT

A total of 297 pregnant women participated in the study (99 cases and 198 controls), with a 100% response rate. Place of residence (AOR=2.21, 95% CI 1.11, 2.72), level of education (AOR=3.42, 95% CI 1.01, 6.04), planned pregnancy (AOR=8.01, 95% CI 2.79, 23.03), history of abortion (AOR=5.96, 95% CI 2.07, 17.13), places of previous delivery (AOR=4.57, 95% CI 1.09, 19.12), presence of accompanied by husband during ANC visit (AOR=2.48, 95% CI 2.77, 7.98) and media exposure (AOR=6.95, 95 CI 2.68, 18.02) were found statistically significant.

CONCLUSION AND RECOMMENDATIONS

Places of residence, educational level, pregnancy, having a history of abortion, accompanied by the husband during ANC visit, place of previous delivery and media exposure were significantly associated with early initiation of ANC. Therefore, health extension programmes on early ANC initiation should be strengthened by giving priority to less educated women and living in rural areas.

Socioeconomic inequalities in maternal healthcare utilization: An analysis of the interaction between wealth status and education, a population-based surveys in Tanzania

Limited scientific, evidence has so far described the interactions between socioeconomic factors and the gap of inequalities in maternal healthcare utilization. This study assessed the interaction between wealth status and education to identify women with greater disadvantage. This analysis used secondary data from the three most recent rounds (2004, 2010, and 2016) of the Tanzania Demographic Health Survey (TDHS). Maternal healthcare utilization was assessed based on six services (outcomes) which are i) booking during the first trimester (bANC), ii) at least four antenatal visits (ANC4+), iii) adequate antenatal care (aANC), iv) facility-based delivery (FBD), v) skilled birth attendance (SBA), vi) cesarean section delivery (CSD). The concentration curve and the concentration index were used to measure socioeconomic inequality in maternal healthcare utilization outcomes. The interaction coefficients suggest that each unit increase in the wealth status is significantly associated with higher odds of utilizing all maternal healthcare services for women with primary and secondary or higher education compared to those with no education (booking during the first trimester [AOR = 1.30; 95% CI: 1.08-1.57], at least four antenatal visits [AOR = 1.16; 95% CI: 1.01-1.33], facility-based delivery [AOR = 1.29; 95% CI: 1.12-1.48], skilled birth attendance [AOR = 1.31; 95% CI: 1.15-1.49]). The highest wealth-related inequality in bANC (EI: 0.166), at least four antenatal visits (EI: 0.259), FBD (EI: 0.323) and skilled birth attendance (EI: 0.328) (P < 0.05) was observed among women with primary and secondary or higher education. These findings provide strong evidence that there is an interaction effect between education attainment and wealth status in socioeconomic inequalities of maternal health services utilization. Therefore, any approach which will address both women's education and wealth status might be the first step to reducing socioeconomic inequalities in maternal health services utilization in Tanzania.

The effects of community-based interventions on the uptake of selected maternal and child health services: experiences of the IMCHA project in Iringa Tanzania, 2015-2020

BACKGROUND

Maternal and child health (MCH) improvement has been prioritised in resource-constrained countries. This is due to the desire to meet the global sustainable development goals of achieving a maternal mortality rate of 70 per 100000 live births by 2030. The uptake of key maternal and child health services is crucial for reducing maternal and child health mortalities. Community-Based Interventions (CBIs) have been regarded as among the important strategies to improve maternal and child health service uptake. However, a paucity of studies examines the impacts of CBIs and related strategies on maternal and child health. This paper unveils the contribution of CBIs toward improving MCH in Tanzania.

METHODS

Convergent mixed method design was employed in this study. Questionnaires were used to examine the trajectory and trend of the selected MCH indicators using the baseline and end-line data for the implemented CBI interventions. Data was also collected through in-depth interviews and focus group discussions, mainly with implementers of the interventions from the community and the implementation research team. The collected quantitative data was analysed using IBM SPSS, while qualitative data was analysed thematically.

RESULTS

Antenatal care visits increased by 24% in Kilolo and 18% in Mufindi districts, and postnatal care increased by 14% in Kilolo and 31% in Mufindi districts. Male involvement increased by 5% in Kilolo and 13% in Mufindi districts. The uptake of modern family planning methods increased by 31% and 24% in Kilolo and Mufindi districts, respectively. Furthermore, the study demonstrated improved awareness and knowledge on matters pertaining to MCH services, attitude change amongst healthcare providers, and increased empowerment of women group members.

CONCLUSION

Community-Based Interventions through participatory women groups are vital for increasing the uptake of MCH services. However, the success of CBIs depends on the wide array of contextual settings, including the commitment of implementers of the interventions. Thus, CBIs should be strategically designed to enlist the support of the communities and implementers of the interventions.

Effect of cost-reduction interventions on facility-based deliveries in Burkina Faso: a controlled interrupted time-series study with multiple non-equivalent dependent variables

BACKGROUND

Evaluating health intervention effectiveness in low-income countries involves many methodological challenges to be addressed. The objective of this study was to estimate the sustained effects of two interventions to improve financial access to facility-based deliveries.

METHODS

In an innovative controlled interrupted time-series study with primary data, we used four non-equivalent dependent variables (antenatal care) as control outcomes to estimate the effects of a national subsidy for deliveries (January 2007-December 2013) and a local 'free delivery' intervention (June 2007-December 2010) on facility-based deliveries. The statistical analysis used spline linear regressions with random intercepts and slopes.

RESULTS

The analysis involved 20 877 observations for the national subsidy and 8842 for the 'free delivery' intervention. The two interventions did not have immediate effects. However, both were associated with positive trend changes varying from 0.21 to 0.52 deliveries per month during the first 12 months and from 0.78 to 2.39 deliveries per month during the first 6 months. The absolute effects, evaluated 84 and 42 months after introduction, ranged from 2.64 (95% CI 0.51 to 4.77) to 10.78 (95% CI 8.52 to 13.03) and from 9.57 (95% CI 5.97 to 13.18) to 14.47 (95% CI 10.47 to 18.47) deliveries per month for the national subsidy and the 'free delivery' intervention, respectively, depending on the type of antenatal care used as a control outcome.

CONCLUSION

The results suggest that both interventions were associated with sustained non-linear increases in facility-based deliveries. The use of multiple control groups strengthens the credibility of the results, making them useful for policy makers seeking solutions for universal health coverage.

Dependency Theory: An Evaluation of the Period-Based Changes in the Utilization of Maternal Health Care and Neonatal Mortality in Tanzania Between 1991 and 2016

While efforts have been made to increase maternal health care (MHC) utilization and decrease neonatal mortality in Tanzania, much remains to be known about the effect of dependency (particularly on reproductive policy changes) on the use of MHC and neonatal health over time among varying socioeconomic groups. This study applied dependency theory to cross-sectional secondary data (collected by the Tanzania Demographic Health Surveys between 1991 and 2016) to investigate period-based changes in MHC and neonatal mortalities in Tanzania. Results from the data analysis found that while neonatal mortalities were decreasing in Tanzania (from 1991 to 2016), the odds of neonatal mortality were still greater in 2016. Also, a decline in the recommended skilled delivery assistance and 4 + antenatal care visits occurred in the data period. A significant increase in socioeconomic inequality around MHC use and neonatal mortality occurred during the study period as well. Policy recommendations to reduce these inequalities and move toward meeting Sustainability Development Goals for maternal and neonatal health in Tanzania are discussed.

Determinants of Focused Antenatal Care Utilization Among Women in Simiyu Region Tanzania

Antenatal care (ANC) is a critical period for promoting the health of both mothers and babies. ANC visit is a key entry point for a pregnant woman to the health care system to receive health intervention. The new World Health Organization (WHO) guideline recommends eight ANC contacts. However, the coverage of at least four ANC visits is still low in the Simiyu region.

Objective

To assess determinants of focused ANC visits utilization among women in the Simiyu Region Tanzania.

Methodology

The study employed a cross-sectional study among women of reproductive age. Data was collected through an interviewer-administered questionnaire and analyzed using Stata version 15. Data were summarized using mean and standard deviation for continuous variables while frequency and percentage were used for categorical variables. A generalized linear model, Poisson family, with a log link was used to identify determinants of focused ANC utilization.

Results

All 785 women analyzed reported having at least one ANC visit, with 259 (34%) having four or more visits and only 40 (5.1%) having eight or more visits. Women who made a self-decision were 30% less likely to complete four and more ANC visits than their counterparts (APR = 0.70; 95%CI = 0.501-0.978). Women who visited the dispensary were 27% less likely to complete four ANC visits than those who visited health centers (APR = 0.73; 95%CI = 0.540-0.982). However, education level and planned pregnancy were both marginally significantly associated with focused ANC utilisation.

Conclusion

Generally, the majority of pregnant women in the Simiyu region do not adequately utilize four and more ANC visits. There is a need to enhance health education to women and their spouses on the importance of attending four or more visits and improving the quality of maternal health services to facilitate the utilization of ANC among women in the study area.

Spatial variation and inequities in antenatal care coverage in Kenya, Uganda and mainland Tanzania using model-based geostatistics: a socioeconomic and geographical accessibility lens

BACKGROUND

Pregnant women in sub-Saharan Africa (SSA) experience the highest levels of maternal mortality and stillbirths due to predominantly avoidable causes. Antenatal care (ANC) can prevent, detect, alleviate, or manage these causes. While eight ANC contacts are now recommended, coverage of the previous minimum of four visits (ANC4+) remains low and inequitable in SSA.

METHODS

We modelled ANC4+ coverage and likelihood of attaining district-level target coverage of 70% across three equity stratifiers (household wealth, maternal education, and travel time to the nearest health facility) based on data from malaria indicator surveys in Kenya (2020), Uganda (2018/19) and Tanzania (2017). Geostatistical models were fitted to predict ANC4+ coverage and compute exceedance probability for target coverage. The number of pregnant women without ANC4+ were computed. Prediction was at 3 km spatial resolution and aggregated at national and district -level for sub-national planning.

RESULTS

About six in ten women reported ANC4+ visits, meaning that approximately 3 million women in the three countries had  20,000 women having

CONCLUSIONS

These findings will be invaluable to policymakers for annual appropriations of resources as part of efforts to reduce maternal deaths and stillbirths.

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Key Words

• Antenatal care
• District
• Household wealth
• Inequities
• Kenya
• Maternal education
• Model-based geostatistics
• Subnational
• Tanzania
• Travel time to healthcare
• Uganda

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MESH Headings

• Pregnancy
• Female
• Humans
• Prenatal Care
• Kenya/epidemiology
• Geography
• Maternal Death
• Uganda/epidemiology

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Grants

• EP/T003677/1 Engineering and Physical Sciences Research Council
• NIF/R1/201418 Royal Society
• Wellcome Trust
• 203077 Wellcome Trust
• 1234820N Fonds Wetenschappelijk Onderzoek

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Affiliation(s)

Peter M. Macharia Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya Centre for Health Informatics, Computing, and Statistics, Lancaster Medical School, Lancaster University, Lancaster, UK
Noel K. Joseph Population Health Unit, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya Centre for Health Informatics, Computing, and Statistics, Lancaster Medical School, Lancaster University, Lancaster, UK
Gorrette Kayondo Nalwadda College of Health Sciences, Makerere University, Kampala, Uganda
Beatrice Mwilike Community Health Nursing Department, School of Nursing, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
Aduragbemi Banke-Thomas School of Human Sciences, University of Greenwich, London, UK
Lenka Benova Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
Olatunji Johnson Department of Mathematics, The University of Manchester, Manchester, UK

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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.

Multilevel analysis of quality of antenatal care and associated factors among pregnant women in Ethiopia: a community based cross-sectional study

OBJECTIVE

To determine the magnitude of quality of antenatal care and associated factors among pregnant women in Ethiopia.

DESIGN

A community-based cross-sectional study.

SETTING

Ethiopia.

PARTICIPANTS

A total of 4757 weighted sample of pregnant women from 18 January 2016 to 27 June 2016, were included for this analysis.

OUTCOME

Quality of antenatal care (ANC).

METHODS

Our analysis was based on secondary data using the 2016 Ethiopian Demographic and Health Survey. The quality of ANC was measured when all six essential components, such as blood pressure measurements, blood tests, urine tests, nutrition counselling, birth preparation advice during pregnancy and information on potential complications, were provided. Stata V.14 software was used for analysis. A multilevel mixed-effect logistic regression analysis was fitted. Adjusted OR (AOR) with 95% CIs was used to show the strength and direction of the association. Statistical significance was declared at a p value less than 0.05.

RESULTS

The magnitude of quality of ANC in Ethiopia was 22.48% (95% CI: 21.31% to 23.69%). Educational status; primary (AOR=1.34; 95% CI: 1.06 to 1.68) and secondary (AOR=2.46; 95% CI: 1.76 to 3.45), middle (AOR=1.31; 95% CI: 1.01 to 1.72) and rich (AOR=2.08; 95% CI: 1.59 to 2.72) wealth status, being married (AOR=2.34; 95% CI: 1.08 to 5.10) and four or more ANC (AOR=2.01; 95% CI: 1.67 to 2.40) were statistically significant associated factors of quality ANC in Ethiopia.

CONCLUSIONS

This study found that nearly only one in five pregnant women received quality ANC during pregnancy. To improve the quality of ANC in Ethiopia, Ministry of Health and health facilities are needed to increase financial support strategies that enable pregnant women from poor households to use health services and enhance pregnant women's understanding of the significance of quality of ANC through health education. Additionally, Community health workers should also be placed on supporting unmarried pregnant women to have quality ANC.

Trend change in delayed first antenatal care visit among reproductive-aged women in Ethiopia: multivariate decomposition analysis

Background

Early first antenatal care visit is a critical health care service for the well-being of women and newborn babies. However, many women in Ethiopia still start their first antenatal care visit late. We aimed to examine the trend in delayed first antenatal care visit and identify the contributing factors for the trend change in delayed first antenatal care visits in Ethiopia over the study period 2000–2016.

Method

We analyzed the data on reproductive-aged women from the four consecutive Ethiopian Demographic and Health Surveys to determine the magnitude and trend of delayed first antenatal care visit. A weighted sample of 2146 in 2000, 2051 in 2005, 3368 in 2011, and 4740 women in 2016 EDHS were involved in this study. All statistical analysis was undertaken using STATA 14. Multivariate logistic decomposition analysis was used to analyze the trends of delayed first antenatal care visit over time and the contributing factors to the change in delayed first antenatal care visit.

Results

The prevalence of delayed first antenatal care visit in Ethiopia decreased significantly from 76.8% (95% CI 75.1−78.6) in 2000 to 67.3% (95% CI 65.9−68.6) in 2016. Decomposition analysis revealed that 39% of the overall change in delayed first antenatal care visit overtime was due to differences in women’s composition, whereas 61% was due to women’s behavioral changes. In this study, residence, husband's education, maternal occupation, ever told about pregnancy complications, cesarean delivery and family sizes were significantly contributing factors for the decline in delayed first antenatal care visit over the study periods.

Conclusion

The prevalence of delayed first antenatal care visit in Ethiopia among women decreased significantly over time. More than halves (61%) decline in delayed first antenatal care visits was due to women’s behavioral changes. Public health interventions targeting rural residents, poor household economic status and improving awareness about pregnancy-related complications would help to reduce the prevalence of delayed first antenatal care visit.

Antenatal care visits during the first trimester of the pregnancy stage provide opportunities for women to improve their health, prevent disease, and identify and manage pregnancy and childbirth complications. However, delayed first antenatal care visit is a major leading cause of pregnancy and childbirth complications, and many women in Ethiopia still start ANC visits late. Hence, we aimed to examine the trends in delayed first antenatal care visits and identify the contributing factors for the trend change in delayed first antenatal care visits in Ethiopia over the study period (2000–2016). We obtained data on women aged 15–49 years from four consecutive Ethiopian Demographic and Health Surveys (EDHSs) conducted in 2000, 2005, 2011, and 2016. We extracted both response and independent variables for this study from the Kids Record (KR file) data set. The prevalence of delayed first ANC visit has significantly decreased from 76.8% [95% CI 75.1, 78.6] in 2000 to 67.3% [95% CI 65.9, 68.6] in 2016 over the last sixteen years in Ethiopia. The overall trend change in delayed first antenatal care visits over the study periods was due to the difference in women's composition of selected characteristics and women's behavioral changes on ANC initiation. More than halves (61%) decline in delayed first ANC visits among reproductive-aged women was due to women's behavioral change, and 39% was due to change in women's composition over time. The significant contributing factors for the decline in delayed first antenatal care visits over the study period were residence, husband's educational level, mass media exposure, ever told about pregnancy complications, cesarean delivery and family sizes. Changes in the composition of women's characteristics according to residence areas, media exposure, ever told about pregnancy complications, cesarean delivery and family sizes were statistically significant variables for the decline in delayed first ANC visit over time. Only husbands who had secondary and above education were attributable to women’s behavioral change on ANC services.

Socio-demographic factors associated with early antenatal care visits among pregnant women in Malawi: 2004-2016

INTRODUCTION

In 2016, the WHO published recommendations increasing the number of recommended antenatal care (ANC) visits per pregnancy from four to eight. Prior to the implementation of this policy, coverage of four ANC visits has been suboptimal in many low-income settings. In this study we explore socio-demographic factors associated with early initiation of first ANC contact and attending at least four ANC visits ("ANC4+") in Malawi using the Malawi Demographic and Health Survey (MDHS) data collected between 2004 and 2016, prior to the implementation of new recommendations.

METHODS

We combined data from the 2004-5, 2010 and 2015-16 MDHS using Stata version 16. Participants included all women surveyed between the ages of 15-49 who had given birth in the five years preceding the survey. We conducted weighted univariate, bivariate and multivariable logistic regression analysis of the effects of each of the predictor variables on the binary endpoint of the woman attending at least four ANC visits and having the first ANC attendance within or before the four months of pregnancy (ANC4+). To determine whether a factor was included in the model, the likelihood ratio test was used with a statistical significance of P< 0.05 as the threshold.

RESULTS

We evaluated data collected in surveys in 2004/5, 2010 and 2015/6 from 26386 women who had given birth in the five years before being surveyed. The median gestational age, in months, at the time of presenting for the first ANC visit was 5 (inter quartile range: 4-6). The proportion of women initiating ANC4+ increased from 21.3% in 2004-5 to 38.8% in 2015-16. From multivariate analysis, there was increasing trend in ANC4+ from women aged 20-24 years (adjusted odds ratio (aOR) = 1.27, 95%CI:1.05-1.53, P = 0.01) to women aged 45-49 years (aOR = 1.91, 95%CI:1.18-3.09, P = 0.008) compared to those aged 15-19 years. Women from richest socio-economic position ((aOR = 1.32, 95%CI:1.12-1.58, P<0.001) were more likely to demonstrate ANC4+ than those from low socio-economic position. Additionally, women who had completed secondary (aOR = 1.24, 95%CI:1.02-1.51, P = 0.03) and tertiary (aOR = 2.64, 95%CI:1.65-4.22, P<0.001) education were more likely to report having ANC4+ than those with no formal education. Conversely increasing parity was associated with a reduction in likelihood of ANC4+ with women who had previously delivered 2-3 (aOR = 0.74, 95%CI:0.63-0.86, P<0.001), 4-5 (aOR = 0.65, 95%CI:0.53-0.80, P<0.001) or greater than 6 (aOR = 0.61, 95%CI: 0.47-0.79, <0.001) children being less likely to demonstrate ANC4+.

CONCLUSION

The proportion of women reporting ANC4+ and of key ANC interventions in Malawi have increased significantly since 2004. However, we found that most women did not access the recommended number of ANC visits in Malawi, prior to the 2016 WHO policy change which may mean that women are less likely to undertake the 2016 WHO recommendation of 8 contacts per pregnancy. Additionally, our results highlighted significant variation in coverage according to key socio-demographic variables which should be considered when devising national strategies to ensure that all women access the appropriate frequency of ANC visits during their pregnancy.

Trends and determinants of late antenatal care initiation in three East African countries, 2007-2016: A population based cross-sectional analysis

Early antenatal care is critical for the mother and newborn's health. Antenatal care is often delayed in Sub-Saharan Africa. The study aims to examine the trends and determinants of late antenatal care initiation in the Democratic Republic of Congo, Kenya, and Tanzania from 2007-2016. The study employed Demographic Health Surveys data of reproductive-age women seeking antenatal care in the Democratic Republic of Congo (2007-2013/14), Kenya (2008-2014), and Tanzania (2010-2015/16). Bivariate and multivariate analysis was conducted per survey, taking sampling weights into account. The determinants of late antenatal care initiation were measured using multivariate logistic regression models and the trends were assessed using prediction scores. Late antenatal care initiation declined in Tanzania (60.9%-49.8%) and Kenya (67.8%-60.5%) but increased in the Democratic Republic of Congo (56.8%-61.0%) between surveys. In the Democratic Republic of Congo, higher birth order was associated with antenatal care initiation delays from 2007-2014, whilst rural residency (AOR:1.28;95%CI:1.09-1.52), lower maternal education (AOR:1.29;95%CI:1.13-1.47) and lower-income households (AOR:1.30;95%CI:1.08-1.55) were linked to antenatal care initiation delays in 2014. In Kenya, lower maternal education and lower-income households were associated with antenatal care initiation delays from 2008-2014, whilst rural residency (AOR:1.24;95%CI:1.11-1.38) and increased birth order (AOR:1.12; 95%CI:1.01-1.28) were linked to antenatal care initiation delays in 2014. In Tanzania, higher birth order and larger households were linked to antenatal care initiation delays from 2010-2016, whilst antenatal care initiation delays were associated with lower maternal education (OR:1.51;95%CI:1.16-1.97) in 2010 and lower-income households (OR:1.45;95%CI:1.20-1.72) in 2016. Except for the Democratic Republic of Congo, the sub-region is making progress in reducing antenatal care delays. Women from various geographic, educational, parity, and economic groups exhibited varying levels of delayed antenatal care uptake. Increasing women's access to information platforms and strengthening initiatives that enhance female education, household incomes, and localise services may enhance early antenatal care utilisation.

Quality of antenatal care and associated factors among pregnant women in East Africa using Demographic and Health Surveys: A multilevel analysis

INTRODUCTION

Antenatal care offers a forum for critical healthcare functions, including health education, screening, and disease prevention. Several pocket studies carried out in specific localities of East African countries were investigated. However, these were neither representative of the country nor specific to the recommended minimum of four antenatal care visits. Therefore, this study aimed to identify factors associated with quality of antenatal care among pregnant women in East Africa.

METHODS

A secondary data analysis was done using Demographic and Health Survey data of six East African Countries from 2008 to 2018. A total of 46,656 women who gave birth in the 5 years preceding the survey were included in this study. A multilevel mixed-effect logistic regression model was fitted. Variables with a p-value < 0.05 were declared as significant factors associated with the quality of antenatal care.

RESULTS

The magnitude of quality of antenatal care in East Africa was 11.16% (95% confidence interval: 10.87-11.45). Women of age 35-49 (adjusted odds ratio = 1.51; 95% confidence interval: 1.25-1.80), primary education (adjusted odds ratio = 1.35; 95% confidence interval: 1.18-1.55), richest wealth index (adjusted odds ratio = 2.35; 95% confidence interval: 2.02-2.74), and rural resident (adjusted odds ratio = 0.62; 95% confidence interval: 0.55-0.69) were among factors significantly associated with quality of antenatal care.

CONCLUSION

The magnitude of antenatal care quality was low in East Africa. Age, level of education, wealth index, birth order, husband/partners' level of education, residence, and living countries were among the factors associated with the quality of antenatal care. It would be useful to increase financial support strategies that enable mothers from poor households to use health services and enhance women's understanding of the significance of antenatal care utilization through health education targeting both women and partners with no education is very crucial.

Health care costs associated with clinic visits for prevention of mother-to-child transmission of HIV in Dar es Salaam, Tanzania

Early and appropriate antenatal care (ANC) is key for the effectiveness of prevention of mother-to-child transmission (PMTCT) of human immunodeficiency virus (HIV). We evaluated the importance of ANC visits and related service costs for women receiving option B+ to prevent mother-to-child transmission (MTCT) of HIV in Tanzania.A cost analysis from a health care sector perspective was conducted using routine data of 2224 pregnant women newly diagnosed with HIV who gave birth between August 2014 and May 2016 in Dar es Salaam, Tanzania. We evaluated risk of infant HIV infection at 12 weeks postnatally in relation to ANC visits (<4 vs ≥4 visits). Costs for service utilisation were estimated through empirical observations and the World Health Organisation Global Price Reporting Mechanism.Mean gestational age at first ANC visit was 22 (±7) weeks. The average number of ANC/prevention of MTCT visits among the 2224 pregnant women in our sample was 3.6 (95% confidence interval [CI] 3.6-3.7), and 57.3% made ≥4 visits. At 12 weeks postnatally, 2.7% (95% CI 2.2-3.6) of HIV exposed infants had been infected. The risk of MTCT decreased with the number of ANC visits: 4.8% (95% CI 3.6-6.4) if the mother had <4 visits, and 1.0% (95% CI 0.5-1.7) at ≥4. The adjusted MTCT rates decreased by 51% (odds ratio 0.49, 95% CI 0.31-0.77) for each additional ANC visit made. The potential cost-saving was 2.2 US$ per woman at ≥4 visits (84.8 US$) compared to <4 visits (87.0 US$), mainly due to less defaulter tracing.Most pregnant women living with HIV in Dar es Salaam initiated ANC late and >40% failed to adhere to the recommended minimum of 4 visits. Improved ANC attendance would likely lead to fewer HIV-infected infants and reduce both short and long-term health care costs due to less spending on defaulter tracing and future treatment costs for the children.

Timing of first antenatal care visits and number of items of antenatal care contents received and associated factors in Ethiopia: multilevel mixed effects analysis

Background

Receiving quality antenatal care (ANC) from skilled providers is essential to ensure the critical health circumstances of a pregnant woman and her child. Thus, this study attempted to assess which risk factors are significantly associated with the timing of antenatal care and the number of items of antenatal care content received from skilled providers in recent pregnancies among mothers in Ethiopia.

Methods

The data was extracted from the Ethiopian Demographic and Health Survey 2016. A total of 6645 mothers were included in the analysis. Multilevel mixed-effects logistic regression analysis and multilevel mixed Negative binomial models were fitted to find the factors associated with the timing and items of the content of ANC services. The 95% Confidence Interval of Odds Ratio/Incidence Rate Ratio, excluding one, was reported as significant.

Results

About 20% of the mothers initiated ANC within the first trimester, and only 53% received at least four items of antenatal care content. Being rural residents (IRR = 0.82; 95%CI: 0.75–0.90), wanting no more children (IRR = 0.87; 95%CI: 0.79–0.96), and the husband being the sole decision maker of health care (IRR = 0.88; 95%CI: 0.81–0.96), were associated with reduced items of ANC content received. Further, birth order of six or more (IRR = 0.74; 95%CI: 0.56–0.96), rural residence (IRR = 0.0.41; 95%CI: 0.34–0.51), and wanting no more children (IRR = 0.61; 95%CI: 0.48–0.77) were associated with delayed antenatal care utilization.

Conclusions

Rural residences, the poorest household wealth status, no education level of mothers or partners, unexposed to mass media, unwanted pregnancy, mothers without decision-making power, and considerable distance to the nearest health facility have a significant impact on delaying the timing of ANC visits and reducing the number of items of ANC received in Ethiopia. Mothers should start an antenatal care visit early to ensure that a mother receives all of the necessary components of ANC treatment during her pregnancy.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12978-021-01275-9.

The third Sustainable Development Goals prioritizes maternal mortality reduction, intending to lower the worldwide maternal mortality rate to 70 per 100,000 live births by 2030. Regular antenatal care from a skilled provider reduces maternal mortality by 20%. The overall quality of ANC service is determined collectively by the timing of ANC, and the contents of ANC received. Though there is an increase in ANC visits and the quality of services received, only 74% of women who gave birth in 2019 received antenatal care from a skilled provider, ranging from 85% in the urban to 70% in the rural. Thus, the quality and content of care might remain poor while the coverage of ANC visits is high. Therefore, it is necessary to analyze the levels and risk factors that affect the timing of ANC visits and contents to assess the quality of ANC services. This is the focus of the current study's research. In this study, nationally representative data from the 2016 Ethiopian Demographic and Health Survey was employed. Our study shows that rural residences, the poorest wealth quintile, no education level, unexposed to mass media, unwanted pregnancy, without decision-making power, and being far from the nearest health facility were found to be factors that hinder early initiation of ANC visits and reduce the number of items of ANC received. In conclusion, we ought to initiate an ANC visit early for a frequent antenatal care visit so that a mother will receive the necessary ANC components.

Twelve-year persistence of inequalities in antenatal care utilisation among women in Tanzania: a decomposition analysis of population-based cross-sectional surveys

OBJECTIVE

This study was undertaken to assess the trend and contributors of socioeconomic inequalities in antenatal care (ANC) utilisation among women of reproductive age in Tanzania from 2004 to 2016.

DESIGN

Population-based cross-sectional surveys.

SETTING

This study analysed nationally representative data for women of reproductive age obtained from the 2004-2016 Tanzania Demographic Health Surveys.

PRIMARY OUTCOME MEASURE

The outcome variables analysed in this study are: (1) attendance of ANC and (2) accessing adequate antenatal care.

ANALYTICAL METHODS

The concentration curve and the concentration index were used to measure socioeconomic inequality in attending and accessing adequate ANC. The concentration index was decomposed to identify the factors explaining the observed socioeconomic inequality of these two outcomes.

RESULTS

The concentration index for attending at least four ANC visits increased from 0.169 in 2004 to 0.243 in 2016 (p<0.01). Similarly, for accessing adequate care, the index increased from 0.147 in 2004 to 0.355 in 2016 (p<0.01). This indicates the significant increase in socioeconomic inequalities (favouring wealthier women) for these two outcomes over time. Furthermore, the results show that wealth status was the largest contributor to inequality in both attending at least four visits (71%, 50% and 70%) and accessing adequate ANC (50%, 42% and 51%) in 2004, 2010 and 2016, respectively, in favour of wealthier women (p<0.05). The other contributors to socioeconomic inequalities in ANC utilisation were maternal education and type of residence.

CONCLUSION

Over the 12 years of surveys, there was no reduction in socioeconomic inequalities in ANC utilisation in Tanzania. Therefore, the efforts of achieving universal health coverage should focus on reducing wealth-related inequality and improving women's education from poor households.

Magnitude of antenatal care service uptake and associated factors among pregnant women: analysis of the 2016 Ethiopia Demographic and Health Survey

Objective

Antenatal and postnatal cares are crucial for the survival and well-being of both the mother and the child. WHO recommends a minimum of four antenatal care (ANC) visits during a pregnancy. In Ethiopia, only 38% of women in the reproductive age make a minimum of first ANC visits. This value is far below the typical rates of least developed countries. This study aimed to calculate the magnitude and identify associated factors of ANC service utilisation among pregnant women in Ethiopia.

Design

Cross-sectional study design.

Setting

Ethiopia.

Participants

A total of 7913 pregnant women participated in the study.

Primary outcome measures

Antenatal care service uptake among pregnant women.

Result

Only 35.5% of the pregnant mothers have used ANC services at least four times and 64.5% of the pregnant mothers have used less than three times during their periods of pregnancy. The study showed that rich women (PR=1.077, 95% CI: 1.029 to 1.127), having access to mass media (PR=1.086, 95% CI: 1.045 to 1.128), having pregnancy complications (PR=1.203, 95% CI: 1.165 to 1.242), secondary education and above (PR=1.112, 95% CI:1.052 to 1.176), husbands’ having secondary education and above (PR=1.085, 95% CI: 1.031 to 1.142) and married (PR=1.187; 95% CI: 1.087 to 1.296), rural women (PR=0.884, 95% CI: 0.846 to 0.924) and women>30 years of age (PR=1.067, 95% CI: 1.024 to 1.111) significantly associated with the ANC service uptake.

Conclusion

The magnitude of ANC service uptake was low. This low magnitude of ANC service utilisation calls for a need to improve community awareness about maternal health. More importantly, intensive health education is required for pregnant women to have better ANC service uptake and follow-up adherence.