Timing and adequate attendance of antenatal care visits among women in Ethiopia

PLoS ONE, Volume 12, No. 9, Year 2017

Interpretation

Introduction: Although ANC services are increasingly available to women in low and middle-income countries, their inadequate use persists. This suggests a misalignment between aims of the services and maternal beliefs and circumstances. Owing to the dearth of studies examining the timing and adequacy of content of care, this current study aims to investigate the timing and frequency of ANC visits in Ethiopia. Methods: Data was obtained from the nationally representative 2011 Ethiopian Demographic and Health Survey (EDHS) which used a two-stage cluster sampling design to provide estimates for the health and demographic variables of interest for the country. Our study focused on a sample of 10,896 women with history of at least one childbirth event. Percentages of timing and adequacy of ANC visits were conducted across the levels of selected factors. Variables which were associated at 5% significance level were examined in the multivariable logistic regression model for association between timing and frequency of ANC visits and the explanatory variables while controlling for covariates. Furthermore, we presented the approach to estimate marginal effects involving covariate-adjusted logistic regression with corresponding 95%CI of delayed initiation of ANC visits and inadequate ANC attendance. The method used involved predicted probabilities added up to a weighted average showing the covariate distribution in the population. Results: Results indicate that 66.3% of women did not use ANC at first trimester and 22.3% had ANC less than 4 visits. The results of this study were unique in that the association between delayed ANC visits and adequacy of ANC visits were examined using multivariable logistic model and the marginal effects using predicted probabilities. Results revealed that older age interval has higher odds of inadequate ANC visits. More so, type of place of residence was associated with delayed initiation of ANC visits, with rural women having the higher odds of delayed initiation of ANC visits (OR = 1.65; 95%CI: 1.26–2.18). However, rural women had 44% reduction in the odds of having inadequate ANC visits. In addition, multi-parity showed higher odds of delayed initiation of ANC visit when compared to the primigravida (OR = 2.20; 95%CI: 1.07–2.69). On the contrary, there was 36% reduction in the odds of multigravida having inadequate ANC visits when compared to the women who were primigravida. There were higher odds of inadequacy in ANC visits among women who engaged in sales/business, agriculture, skilled manual and other jobs when compared to women who currently do not work, after adjusting for covariates. From the predictive margins, assuming the distribution of all covariates remained the same among respondents, but everyone was aged 15–19 years, we would expect 71.8% delayed initiation of ANC visit. If everyone was aged 20-24years, 73.4%; 25-29years, 66.5%; 30-34years, 64.8%; 35-39years, 65.6%; 40-44years, 59.6% and 45-49years, we would expect 70.1% delayed initiation of ANC visit. If instead the distribution of age was as observed and for other covariates remained the same among respondents, but no respondent lived in the rural, we would expect about 61.4% delayed initiation of ANC visit; if however, everyone lived in the rural, and we would expect 71.6% delayed initiation in ANC visit. Model III revealed the predictive margins of all factors examined for delayed initiation for ANC visits, while Model IV presented the predictive marginal effects of the determinants of adequacy of ANC visits. Conclusion: The precise mechanism by which these factors affect ANC visits remain blurred at best. There may be factors on the demand side like the women’s empowerment, financial support of the husband, knowledge of ANC visits in the context of timing, frequency and the expectations of ANC visits might be mediating the effects through the factors found associated in this study. Supply side factors like the quality of ANC services, skilled staff, and geographic location of the health centers also mediate their effects through the highlighted factors. Irrespective of the knowledge about the precise mechanism of action, policy makers could focus on improving women’s empowerment, improving women’s education, reducing wealth inequity and facilitating improved utilization of ANC through modifications on the supply side factors such as geographic location and focus on hard to reach women. This study used secondary data from the 2011 Ethiopian Demographic and Health Survey (EDHS). We accessed the data from MEASURE DHS database at http://dhsprogram.com/data/available-datasets.cfm. The Ethiopia survey was conducted by the Ethiopian Central Statistical Agency as part of the International Demographic and Health Survey program known as MEASURE DHS, which is currently active in 90 countries and conducted under the auspices of the United States Agency for International Development (USAID) with the technical assistance of ICF International, based in the USA. The Demographic and Health Surveys (DHSs) are free, public datasets, though researchers must register with MEASURE DHS and submit a request before access to DHS data is granted. This data request system ensures that all users understand and agree to basic data usage ethics standards. Sampling procedures were published in the final report [26]. The 2011 EDHS samples were selected using a stratified, two-stage cluster sampling design to provide estimates for the health and demographic variables of interest for the country. The sampling frame consists of a total of 85,057 Enumeration Areas (EAs). A nationally representative sample of 17,817 households was included in data collection. The outcome variables of this study were- 1) Timing of first ANC attendance, and 2) Total number of ANC attendance. ANC visits are of critical important to avert pregnancy related complications, counselling for maternal and foetal health, preparedness for health-facility delivery [27]. WHO recommends the first ANC visit should take place within the first trimester of gestation, and at least four visits during the course of the pregnancy. According to these guidelines, the outcome variables are categorized as: 1) Timing of first ANC attendance (Within 3 months of gestation = early, and beyond 3 month = delayed), and 2) Total number of ANC attendance (<4 visits and 4 or more visits). Besides these, several individual and community level factors were considered as explanatory variables for their relevance in the uptake of ANC care. These were: Age (15–19, 20–24, 25–29, 30–34, 35–39, 40–44, 45–49), Type of place of residence (Urban, Rural), Highest educational level (Nil, Primary, Secondary, Higher), Wealth index (Poorest, Poorer, Middle, Richer, Richest), Occupation (Not working, Sales, Agricultural, Other Skilled manual), Frequency of reading newspaper or magazine (Not at all, Less than once a week, At least once a week), Frequency of listening to radio (Not at all, Less than once a week, At least once a week), Frequency of watching television (Not at all, Less than once a week, At least once a week), Sex of household head (Male, Female), Decision maker of respondent's health care (Respondent alone, Respondent and husband/partner together, Husband/partner alone). Data analyses were carried out using STATA 14. The dataset was checked for cases which fulfilled all the inclusion criteria: age being 15 years and above, having experienced at least one childbirth, availability of information on ANC visits. Basic characteristics of the participants were tabled using frequencies and percentages. Chi-square test was performed to examine the association between timing and frequency of ANC visits and the explanatory variables. Furthermore, multivariable logistic regression analysis was used to determine the odds ratios (with corresponding 95%CI) of delayed initiation of ANC visits and less than four ANC visits. Examining marginal effects, we explored the disparities in predicted probabilities across the factors, in which estimated effects were proportionately adjusted according to a weight for each level of the covariates. Based on the estimation of marginal effects, we predicted the probability of delayed initiation and inadequacy of ANC visits [28]. Thus; Where Set[E = e] reflects putting all observations to a single exposure level e, and Z = z refers to a given set of observed values for the covariate vector Z. Furthermore, p^ez is the predicted probabilities of delayed initiation of ANC visits and adequacy of ANC visits respectively for any E = e and Z = z. The marginal effects indicate a weighted average over the distribution of the covariates or confounders and are equal to estimates got by standardizing to the entire population. As a post logistic regression test, the exposure E is set to the level e for all respondents in the dataset, and the logistic regression coefficients are used to compute predicted probabilities for every respondent at their observed covariate pattern and newly exposure value. Since predicted probabilities are computed under the same distribution of Z, there is no covariate of the corresponding effect measure estimates. After obtaining results of the logistic regression model; the margins command was then used to compute the marginal effects of the factors in STATA [28]. Before each interview, all participants gave informed consent to take part in the survey. The DHS Program maintains strict standards for ensuring data anonymity and protecting the privacy of all participants. ICF International ensures that the survey complies with the U.S. Department of Health and Human Services regulations for the protection of human subjects, whilst the host country ensures that the survey complies with local laws and norms. Further approval for this study was not required since the data is secondary and is available in the public domain. More details regarding DHS data and ethical standards are available at: http://goo.gl/ny8T6X.

AI Digest

Study Justification:

– The study aims to investigate the timing and frequency of antenatal care (ANC) visits in Ethiopia.
– ANC services are increasingly available, but their inadequate use persists, suggesting a misalignment between the services and maternal beliefs and circumstances.
– There is a dearth of studies examining the timing and adequacy of ANC visits in Ethiopia.

Study Highlights:

– Data was obtained from the nationally representative 2011 Ethiopian Demographic and Health Survey (EDHS).
– The study focused on a sample of 10,896 women with a history of at least one childbirth event.
– Results indicate that 66.3% of women did not use ANC in the first trimester and 22.3% had less than 4 ANC visits.
– Factors associated with delayed initiation of ANC visits included older age, rural residence, and multi-parity.
– Factors associated with inadequate ANC visits included engagement in sales/business, agriculture, skilled manual, and other jobs.
– Marginal effects analysis showed the predicted probabilities of delayed initiation and inadequacy of ANC visits across different age groups and residence types.

Study Recommendations:

– Policy makers could focus on improving women’s empowerment, education, and reducing wealth inequity to improve ANC utilization.
– Supply-side factors such as the quality of ANC services, skilled staff, and geographic location of health centers should be addressed to facilitate improved utilization of ANC.

Key Role Players:

– Policy makers
– Ministry of Health
– Health professionals
– Community health workers
– Non-governmental organizations (NGOs)
– Women’s empowerment organizations

Cost Items for Planning Recommendations:

– Training and capacity building for health professionals and community health workers
– Infrastructure improvement and equipment for health centers
– Awareness campaigns and education materials
– Monitoring and evaluation systems
– Research and data collection
– Program management and coordination
Please note that the cost items provided are general suggestions and may vary depending on the specific context and needs of the implementation.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study used a nationally representative dataset and employed multivariable logistic regression analysis to examine the association between timing and frequency of ANC visits and various explanatory variables. The study also presented the estimated marginal effects using predicted probabilities. However, the abstract does not provide information on the limitations of the study or potential biases in the data. To improve the strength of the evidence, the authors could include a discussion on the limitations and potential sources of bias in the study, such as the reliance on self-reported data and the potential for recall bias. Additionally, providing information on the representativeness of the sample and the generalizability of the findings would further enhance the evidence.

Abstract

This study used secondary data from the 2011 Ethiopian Demographic and Health Survey (EDHS). We accessed the data from MEASURE DHS database at http://dhsprogram.com/data/available-datasets.cfm. The Ethiopia survey was conducted by the Ethiopian Central Statistical Agency as part of the International Demographic and Health Survey program known as MEASURE DHS, which is currently active in 90 countries and conducted under the auspices of the United States Agency for International Development (USAID) with the technical assistance of ICF International, based in the USA. The Demographic and Health Surveys (DHSs) are free, public datasets, though researchers must register with MEASURE DHS and submit a request before access to DHS data is granted. This data request system ensures that all users understand and agree to basic data usage ethics standards. Sampling procedures were published in the final report [26]. The 2011 EDHS samples were selected using a stratified, two-stage cluster sampling design to provide estimates for the health and demographic variables of interest for the country. The sampling frame consists of a total of 85,057 Enumeration Areas (EAs). A nationally representative sample of 17,817 households was included in data collection. The outcome variables of this study were- 1) Timing of first ANC attendance, and 2) Total number of ANC attendance. ANC visits are of critical important to avert pregnancy related complications, counselling for maternal and foetal health, preparedness for health-facility delivery [27]. WHO recommends the first ANC visit should take place within the first trimester of gestation, and at least four visits during the course of the pregnancy. According to these guidelines, the outcome variables are categorized as: 1) Timing of first ANC attendance (Within 3 months of gestation = early, and beyond 3 month = delayed), and 2) Total number of ANC attendance (<4 visits and 4 or more visits). Besides these, several individual and community level factors were considered as explanatory variables for their relevance in the uptake of ANC care. These were: Age (15–19, 20–24, 25–29, 30–34, 35–39, 40–44, 45–49), Type of place of residence (Urban, Rural), Highest educational level (Nil, Primary, Secondary, Higher), Wealth index (Poorest, Poorer, Middle, Richer, Richest), Occupation (Not working, Sales, Agricultural, Other Skilled manual), Frequency of reading newspaper or magazine (Not at all, Less than once a week, At least once a week), Frequency of listening to radio (Not at all, Less than once a week, At least once a week), Frequency of watching television (Not at all, Less than once a week, At least once a week), Sex of household head (Male, Female), Decision maker of respondent's health care (Respondent alone, Respondent and husband/partner together, Husband/partner alone). Data analyses were carried out using STATA 14. The dataset was checked for cases which fulfilled all the inclusion criteria: age being 15 years and above, having experienced at least one childbirth, availability of information on ANC visits. Basic characteristics of the participants were tabled using frequencies and percentages. Chi-square test was performed to examine the association between timing and frequency of ANC visits and the explanatory variables. Furthermore, multivariable logistic regression analysis was used to determine the odds ratios (with corresponding 95%CI) of delayed initiation of ANC visits and less than four ANC visits. Examining marginal effects, we explored the disparities in predicted probabilities across the factors, in which estimated effects were proportionately adjusted according to a weight for each level of the covariates. Based on the estimation of marginal effects, we predicted the probability of delayed initiation and inadequacy of ANC visits [28]. Thus; Where Set[E = e] reflects putting all observations to a single exposure level e, and Z = z refers to a given set of observed values for the covariate vector Z. Furthermore, p^ez is the predicted probabilities of delayed initiation of ANC visits and adequacy of ANC visits respectively for any E = e and Z = z. The marginal effects indicate a weighted average over the distribution of the covariates or confounders and are equal to estimates got by standardizing to the entire population. As a post logistic regression test, the exposure E is set to the level e for all respondents in the dataset, and the logistic regression coefficients are used to compute predicted probabilities for every respondent at their observed covariate pattern and newly exposure value. Since predicted probabilities are computed under the same distribution of Z, there is no covariate of the corresponding effect measure estimates. After obtaining results of the logistic regression model; the margins command was then used to compute the marginal effects of the factors in STATA [28]. Before each interview, all participants gave informed consent to take part in the survey. The DHS Program maintains strict standards for ensuring data anonymity and protecting the privacy of all participants. ICF International ensures that the survey complies with the U.S. Department of Health and Human Services regulations for the protection of human subjects, whilst the host country ensures that the survey complies with local laws and norms. Further approval for this study was not required since the data is secondary and is available in the public domain. More details regarding DHS data and ethical standards are available at: http://goo.gl/ny8T6X.

Materials

N/A

Innovations

Based on the information provided, here are some potential innovations that could improve access to maternal health in Ethiopia:

1. Mobile Health (mHealth) Solutions: Develop mobile applications or SMS-based systems to provide pregnant women with timely reminders and information about antenatal care visits. This could help address the issue of delayed initiation of ANC visits by ensuring that women are aware of the importance of early attendance.

2. Community Health Workers: Train and deploy community health workers to reach remote and rural areas where access to healthcare facilities is limited. These workers can provide education and counseling on the importance of ANC visits, as well as facilitate referrals and transportation for pregnant women.

3. Telemedicine: Establish telemedicine networks to connect healthcare providers in urban areas with pregnant women in rural areas. This would enable remote consultations and monitoring, reducing the need for women to travel long distances for ANC visits.

4. Financial Incentives: Introduce financial incentives, such as conditional cash transfers or vouchers, to encourage pregnant women to attend ANC visits. This could help address barriers related to cost and affordability of healthcare services.

5. Quality Improvement Initiatives: Implement quality improvement initiatives in healthcare facilities to ensure that ANC services are comprehensive and meet the needs of pregnant women. This could include training healthcare providers, improving infrastructure, and enhancing the availability of essential supplies and equipment.

6. Health Education Campaigns: Launch targeted health education campaigns to raise awareness about the benefits of ANC visits and address misconceptions or cultural beliefs that may discourage women from seeking care. These campaigns could utilize various media channels, including radio, television, and community outreach programs.

7. Public-Private Partnerships: Foster collaborations between the government, private sector, and non-profit organizations to improve access to maternal health services. This could involve leveraging private sector resources and expertise to expand healthcare infrastructure and service delivery in underserved areas.

8. Integration of Services: Integrate ANC services with other healthcare interventions, such as family planning, immunization, and HIV testing, to maximize the impact and reach of maternal health programs. This would ensure that women receive comprehensive care during their pregnancy and beyond.

It is important to note that the implementation of these innovations should be context-specific and tailored to the local needs and resources available in Ethiopia.

AI Innovations Description

The study titled “Timing and adequate attendance of antenatal care visits among women in Ethiopia” aimed to investigate the timing and frequency of antenatal care (ANC) visits in Ethiopia. The study used data from the nationally representative 2011 Ethiopian Demographic and Health Survey (EDHS). The study focused on a sample of 10,896 women with a history of at least one childbirth event.

The study found that 66.3% of women did not use ANC services during the first trimester of pregnancy, and 22.3% had less than four ANC visits. The study identified several factors associated with delayed initiation and inadequate attendance of ANC visits. These factors included older age, rural residence, multi-parity, and certain occupations.

The study recommended several strategies to improve access to maternal health services, specifically ANC. These recommendations include:

1. Improving women’s empowerment: Policy makers should focus on improving women’s empowerment, which can include initiatives to enhance education and reduce gender inequities. Empowered women are more likely to seek and utilize ANC services.

2. Enhancing women’s education: Increasing access to education for women can improve their knowledge and understanding of the importance of ANC visits. Education can also empower women to make informed decisions about their health and seek appropriate care.

3. Reducing wealth inequity: Efforts should be made to reduce wealth inequities, as women from poorer households may face barriers to accessing ANC services. Providing financial support or subsidies for ANC visits can help overcome these barriers.

4. Improving geographic accessibility: Policy makers should focus on improving the geographic accessibility of ANC services, particularly in rural areas. This can include establishing more health centers or mobile clinics in remote areas to ensure that women have access to timely and adequate ANC services.

By implementing these recommendations, it is expected that access to maternal health services, specifically ANC, will be improved, leading to better maternal and child health outcomes in Ethiopia.

AI Innovations Methodology

Based on the information provided, here are some potential recommendations for improving access to maternal health in Ethiopia:

1. Increase awareness and education: Implement targeted campaigns to raise awareness about the importance of antenatal care (ANC) visits and the recommended timing and frequency. This can be done through community outreach programs, mass media campaigns, and educational materials.

2. Improve accessibility of ANC services: Increase the number of health facilities that provide ANC services, particularly in rural areas where access is limited. This can involve building new health centers or expanding existing ones to ensure that pregnant women have access to quality care.

3. Address financial barriers: Develop strategies to reduce financial barriers that prevent women from seeking ANC services. This can include providing subsidies or financial incentives for ANC visits, implementing health insurance schemes, or integrating ANC services into existing healthcare programs.

4. Enhance quality of ANC services: Improve the quality of ANC services by ensuring that healthcare providers are adequately trained and equipped to provide comprehensive care. This can involve providing training programs for healthcare providers, improving infrastructure and equipment in health facilities, and implementing quality assurance mechanisms.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could be developed using the following steps:

1. Define the indicators: Identify the key indicators that will be used to measure the impact of the recommendations. This could include indicators such as the percentage of women attending ANC visits in the first trimester, the percentage of women attending at least four ANC visits, and the overall coverage of ANC services.

2. Collect baseline data: Gather baseline data on the current status of access to maternal health services in Ethiopia, including information on ANC attendance rates, timing of ANC visits, and other relevant factors.

3. Develop a simulation model: Create a simulation model that incorporates the recommendations and their potential impact on access to maternal health. This model should take into account factors such as population demographics, healthcare infrastructure, and the effectiveness of the recommendations.

4. Run the simulation: Use the simulation model to project the potential impact of the recommendations on access to maternal health. This can involve running different scenarios based on varying levels of implementation and assessing the outcomes.

5. Analyze the results: Analyze the results of the simulation to determine the potential impact of the recommendations on improving access to maternal health. This can involve comparing the projected outcomes with the baseline data to assess the effectiveness of the recommendations.

6. Refine and adjust the model: Based on the analysis of the simulation results, refine and adjust the simulation model as needed. This may involve incorporating additional factors or adjusting the parameters of the model to better reflect the real-world context.

7. Monitor and evaluate: Continuously monitor and evaluate the implementation of the recommendations and their impact on access to maternal health. This can involve collecting data on ANC attendance rates, conducting surveys or interviews with pregnant women to assess their experiences, and tracking progress towards the desired outcomes.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of different recommendations on improving access to maternal health and make informed decisions on how to allocate resources and implement interventions.

Author

Dima Health

Statistics:

Citations: 74

Identifiers:

DOI: 10.1371/journal.pone.0184934

Research Areas:

Community Interventions, Disparities, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Ethiopia

Study Design:

Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Male & Female