Factors associated with timely antenatal care booking among pregnant women in remote area of bule hora district, Southern Ethiopia

Background: Antenatal care (ANC) is one of the most cost-effective and crucial compo-nents of maternal health care services. In developing countries where access to care, empowerment, and decision making power of women is low, ANC service is vital. The time at which first ANC visit was done has the utmost importance to ensure optimal health effects for both women and children. This study aimed to assess the proportion and factors associated with early antenatal care booking among pregnant women who were attending public health institutions in a remote area of Bule Hora district, Southern Ethiopia, from May to July, 2019. Methods: Institutional-based cross-sectional study design was conducted at Bule Hora district public health facilities. Data were collected on systematically selected 377 pregnant women from 1st May to 30th July 2019. The sample size was determined by single population proportion formula and data were collected by using a standardized and pretested questionnaire and entered into Epidata 3.1 version, and then exported to Statistical Package for Social Science (SPSS) version 25 for analysis. The strength of association was measured by odds ratios with 95% confidence interval (CI) at a p-value of <0.05 and finally obtained results were presented by using simple frequency tables, bar graph, and texts. Results: The proportion of early antenatal care booking among pregnant women attending antenatal care in the study area was 57.8%. Factors contributing to early antenatal care booking were husband’s education (Adjusted odds ratio (AOR), 2.5; 95% CI: 1.2, 4.9), knowledge on antenatal care service (AOR,1.99; 95% CI:1.2,3.3), means of approving current pregnancy (AOR,1.8; 95% CI:1.1,2.8), and being advised before starting antenatal care visit (AOR,2.1; 95% CI:1.2,3.6). Conclusion: Generally, the timely initiation of ANC among pregnant mothers is not ideal. Modifiable factors like husband’s education, knowledge on antenatal care service, means of recognizing current pregnancy, and access to pre-ANC advice were found determinants for the timely initiation of ANC. Thus, it is advisable to provide proper information about antenatal care services by health care providers and enhancement of health extension program to increase community awareness before and during pregnancy at all levels of health care provision is very important. The study was conducted in Bule Hora district, West Guji Zone, Oromia regional state, Southern Ethiopia. The district is one of the remotest areas located at a distance of 467 Km away from the country’s capital, Addis Ababa. According to the 2018 report of zonal statistics office, the district has a total population of 263, 780 among which 49% (130 703) males, 51% (133 077) females. Bule Hora district has one general hospital and 6 health centers with 183 and 286 health care workers respectively. Institution-based cross-sectional study design was employed to assess the proportion of early antenatal care booking and associated factors among pregnant women. The study was conducted from May to July 2019. The source population was all pregnant women who were attending ANC clinic in public health institutions of Bule Hora district while the study populations were randomly selected pregnant women who were following ANC service at public health institutions of Bule Hora district during the data collection period and fulfills inclusion criteria. Pregnant women who were attending antenatal care clinics for ANC services were included whereas pregnant women who came after attending ANC service at another health facility were excluded. These women were excluded because; their gestational age at their first visit might not be known. The sample size was calculated for each specific objective and the optimal sample size was selected. For the proportion of early ANC booking, the sample size was determined using a single population proportion formula n= (Zα/2)2 p (1-p)/d2 with the following assumptions: the proportion of early ANC booking was taken from the previous study done in Dilla town which was 35.4%.15 The significant level at α= 0.05, with 95% CI, a maximum acceptable marginal error of 5%, and a non-response rate of 10% was used to obtain a final sample size of 386. All public health facilities found in Bule Hora districts that were providing ANC services during the study period namely, Bule Hora general hospital, Bule Hora Health Center, Kilenso Mokonisa Health Center, and Garba Health Center were included based on their client flow. The total sample size was proportionally allocated to these health facilities based on the previous average two-month flow of pregnant women for ANC in each health facility. The study respondents were recruited by using a systematic random sampling technique of every 2nd client after identification of the first study subject by lottery method. Early ANC booking. Maternal age, educational status, Ethnicity, religion, monthly income, marital status, residence, husband education, husband occupation. Parity, number of alive children, planned pregnancy/wanted pregnancy, medical complication in a previous pregnancy, previous birth outcome, previous use of ANC service, women decision on ANC, husband involvement on ANC, pregnancy approval by a spouse. Perceived starting time, number of ANC visits, source of information. Distance, cost of service, waiting time. Booking for first ANC before 16 weeks of gestational age after pregnancy is confirmed either by missed period or urine test for the current pregnancy.16 Each knowledge question answered correctly was scored one mark while the question answered incorrectly was scored zero marks. The total score ranging from 0–7 obtained by each respondent was added up and was computed to categorize knowledge into: Those pregnant women who answered knowledge-related questions of above 60%.17 Those pregnant women who answered knowledge-related questions of below 60%.17 Data were collected using standardized and pretested questionnaires by interviewing pregnant mothers. The tool was adapted from Safe motherhood and modified from different literatures.15,18 The questionnaire had six parts which consist of socio-demographic characteristics, knowledge of ANC, current pregnancy and experience of health services utilization, obstetric history of the mother, health service-related, and women decision making and husband involvement. The data collection tool was first prepared in English and then translated to regional working language, Afaan Oromo, by language experts. The tool was retranslated back into English by other language experts to check for consistency. The edited final version of Afaan Oromo questionnaire was used for data collection. Four degree holder professional nurses were recruited based on their experience of data collection and communication skills with pregnant mothers and two lecturers were assigned for supervision from Bule Hora University based on their language skills and experience. Pregnant women were interviewed on exit after they completed their daily visits. Client card was also reviewed to extract important variables, like the gestational age of the mother for those women who were not sure of their gestational age. To control the quality of data, the questionnaire was pre-tested on 5% of the study population at Finchawa health center which was different from the selected health institutions. Data collectors along with the supervisors were trained for two days on the purpose of the study, study tools, data collection procedures, and data handling. Supervisors carried out their regular supervision, spot-checking, and reviewing the completed questionnaire daily to maintain data quality. The overall activity was coordinated by the principal investigator. Data were entered into Epidata 3.1 version and exported to SPSS version 25 statistical software for analysis. Cross tabulation was done among dependent and independent variables for data exploration and to compute descriptive summary statistics. The descriptive statistics result of numerical variables expressed by mean with standard deviation while categorical variables were presented using frequency with percentage, and displayed by tables, bar graph, line graph, and pie chart, whereas the normality of continuous variables was checked by histogram and Shapiro-Wilk test. Bivariable logistic regression analysis was used to assess the association between the dependent and all the independent variables and to identify candidate variables for multivariable analysis with p-value <0.25 in order to control potential confounders and to predict the association of explanatory variables and outcome.19 The multivariable logistic regression model was applied by the backward elimination stepwise method. The crude and Adjusted OR results together with their corresponding 95% CI with computed a p-value less than 0.05 were considered to declare predictive candidate variables. The Hosmer and Lemeshow model goodness of fit test was checked for the fitness of the variables fulfilled at p-value >0.05 and the value was 0.908.19 The variance inflation factors (VIF) was used to test multicollinearity among predictor variables. Ethical clearance was obtained from the Institutional Ethical approval Committee of Wollega University. A formal letter from the Institute of health sciences of Wollega University was written to the Bule Hora district, and then the permission and support letter was written to each health facility. Written consent was obtained from each study participants after explaining the purpose of the data collection and before the interview. Respondents’ names were not written on the questionnaire for anonymity and confidentiality of their information. Assent was obtained from participants under the age of 18 years, and was approved by Institutional Ethical approval Committee of Wollega University to provide informed consent on their own behalf. They were also informed that they were free to withdraw from the interview and study at any time. This study was conducted in accordance with the Declaration of Helsinki.