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Purpose: This study aimed to identify the extent of antenatal care content received and associated factors among Ethiopian women. Methods: A nationally representative Performance Monitoring for Action 2020 Ethiopian data were used. A multistage cluster sampling design was used to select 2855 pregnant or recently postpartum women nested within 217 enumeration areas. Female resident enumera-tors collected the data using a semi-structured questionnaire. Researchers dichotomized the number of ANC content received greater than or equal to 75 percentiles as adequate. Otherwise, it was considered inadequate. A multilevel Poisson regression was fitted. The result was reported using an incidence rate ratio with a 95% confidence interval and a p-value less than 0.05 was considered for statistical significance. Results: The study revealed more than a quarter of pregnant women received adequate ANC content (27.8%; 95% CI: 23.8%, 32.2%). Multivariable analysis revealed urban residence (IRR = 1.09, 95% CI: 1.01, 1.21), attending secondary and above formal education (IRR = 1.08, 95% CI: 1.01, 1.16), maternal age 20–24 years (IRR = 1.10, 95% CI: 1.02, 1.19), and partner’s encouragement to attend clinic for antenatal care (IRR = 1.14, 95% CI: 1.05, 1.24) was significantly associated with receiving higher numbers of antenatal care content. Conclusion: The proportion of women who received adequate antenatal care content in Ethiopia was low. Despite Ethiopia’s effort to improve maternal health services utilization, disparities among regions and between rural and urban exist. This study highlights the importance of ensuring high received antenatal care content, which is crucial for reducing pregnancy-related morbidity and mortality. This implies prompt intersectoral collaboration to promote female education, target older aged women, and rural resident women, encourage partner involvements during the antenatal care process, minimize regional variation, and strengthen the implementation of received ANC content policies and programs with the active participation of the stakeholders are priority issues.
The panel study design was employed in five regions and one city administration (Tigray, Afar, Amhara, Oromia, South Nation, Nationalities and People (SNNP), and Addis Ababa) in Ethiopia. The data were collected from October 2019 to September 2020. Addis Ababa University (AAU) and Johns Hopkins Bloomberg School of Public Health (JHBSPH) were launched a large-scale collaborative Performance Monitoring for Action (PMA Ethiopia) project in Ethiopia to generate timely data on reproductive, maternal, and newborn health (RMNH). Therefore, PMA Ethiopia was developed to provide national estimates of key RMNH indicators to identify gaps in RMNH care services through the panel study design.36 The study used weighted panel data from the PMA Ethiopia, which is a nationally representative sample. The survey covered 13,192 study respondents of which, 2855 women of reproductive age (15–49 years) were randomly selected for the panel study. In addition, women (household members or women who stay during their pregnancy or postpartum period at their parents’ home) who were pregnant or postpartum (less than eight weeks) and living in the panel’s region were also eligible for enrollment. Exclusion criteria included visitors to the household. Therefore, of those, 2855 women who were enrolled in the panel study, 1855 study participants who had at least one ANC visit were considered to analyze the received ANC content. The questionnaire was adopted from the Demographic Health Survey (DHS) tool and previous PMA Ethiopia tool and reviewed literature.36 The data were collected using an Open Data Kit (ODK) installed on a smartphone by experienced (those who were participated in the DHS data collection or the PMA Ethiopia surveys since 2014 or the SNNP panel survey in 2016), and trained female resident enumerators (REs). PMA Ethiopia collected information on individual and community-level factors and contents of ANC services received. The data was collected during this study period twice. First, the REs interviewed eligible women who were enrolled during a baseline assessment. Second, these individuals/women were followed and interviewed between five and eight weeks postpartum. The sample size was retrospectively computed, assuming a 17.1% proportion of received ANC content,24 5% alpha, 27.8% alternative proportion, with 1855 final sample size to ensure the inclusion of adequate subjects in the analysis; hence, the power of the sample was greater than 99%. First, a census of all households in the selected EAs with a complete listing was compiled. Second, the supervisors randomly selected women aged 15–49 years who were pregnant or recently postpartum. Finally, eligible candidates who were randomly selected were enrolled in the study from the census. In this analysis, researchers chose 1855 women with at least one ANC visit from a total of 2855 participants enrolled in the panel study at baseline. The outcome variable was the number of components of ANC utilized. In the PMA Ethiopia, data were available for the recommended parts of ANC services. The standard ANC guidelines in Ethiopia state that every pregnant woman should get ANC from a skilled provider, including blood pressure screening, weight measure, blood testing, stool exam, urine samples test, HIV testing, syphilis testing, tetanus vaccine, iron supplementation, deworming, nutrition counseling, and discussion about birth preparedness and complication readiness. To obtain information on these twelve items of ANC content, each participant was asked “As part of ANC during this pregnancy, were any of the items performed or discussed at least once (ie, Yes, No). Was weight measured? Was blood pressure measured? Was a blood sample taken? Was a urine sample taken? Was a stool sample taken? Were you tested for syphilis? Were you tested for HIV? Were iron tablets provided? Was a tetanus vaccine provided? Was deworming medication provided? Was nutrition discussed? Were birth preparedness and complication readiness discussed?” For this study, for birth preparedness and pregnancy complication readiness, ‘Yes’ was recorded if the woman discussed three items (ie, place of delivery, delivery by a skilled attendant, arrangement for transport for delivery) with her skilled provider during any ANC visit(s). Otherwise, ‘No’ was recorded.37–40 Although the women may have utilized the ANC items several times during the pregnancy, the response of any action was registered as single action and each of the ANC components had equal weight. Based on the woman’s response, researchers created a composite index of ANC content received which included a simple count of the number of care components received by the women.20,23,41 A minimum value of zero indicates that the woman did not receive any items and a maximum value (12) shows she has utilized all items. Furthermore, we dichotomized the received ANC content as those who received greater than or equal to 75 percentiles as received adequate ANC content and less than as inadequate.42,43 The study also included individual-level factors like maternal age (15–19, 20–24, 25–29, 30–34, 35–39, 40–49), educational status (never attended, primary, secondary, technical or vocational, and higher), marital status (others or married), a partner has other wives or women (yes or no), ever been pregnant (yes or no), current pregnancy desired (then, later or not at all), birth events (primipara, multipara, grand-multipara), and partner encouraged you to attend ANC (yes or no). Additionally, community-level factors were included, such as place of residence (urban or rural), regions (Tigray, Afar, Amhara, Oromia, SNNP, Addis Ababa), wealth quartile (lowest, lower, middle, higher, highest), and structural quality of care for ANC (ie, availability of ANC guideline, ANC checklist, blood pressure apparatus, hemoglobin test, urine dipstick protein test, iron tablets, folic acid tablets, tetanus toxoid vaccine, and insecticide-treated bed net)44 as explanatory variables. This structural quality of ANC was determined based on counted items ranging from 0 to 10 as a continuous variable of interest.45 The downloaded data from the ODK aggregate server daily were cleaned using STATA version 16.1. Descriptive statistics such as frequency tables and percentages were used to tabulate the essential characteristics of the study participants using STATA version 16.1 software. Bivariate analysis was computed using explanatory and outcome variables; those variables with p-value < 0.20 were considered in the multivariable analysis. The EAs used by the Central Statistical Agency (CSA) were employed to construct sample weights. Two weights in the panel (household and female) were used throughout the analysis to adjust for the clustering effect of the study’s sampling design, non-response, and restore the representativeness. Multi-collinearity between explanatory variables was checked using variance inflation factors (VIF) before fitting the models and the mean VIF was less than 5% among independent variables. An intra-cluster correlation coefficient (ICC) was computed before considering the multilevel model since ICC of 5% with a cluster size of 20 per cluster can lead to underestimating the actual precision of estimates (type I error).46 Furthermore, a multilevel mixed-effects count model was used to account for the hierarchical nature of the PMA Ethiopia data and observe factors associated with the number of components of ANC received during pregnancy. The number of received ANC content is a count variable; therefore, the Poisson regression model with a log link function was employed as a point of reference.47 Since Poisson regression assumes an equal variance of the distribution to its mean, the investigators checked model fitness and run the inferential multivariable analysis of the predictors and outcome variable, ie, models one, two, and three for community-, individual- and both community- and individual-level factors, respectively. Finally, a model comparison of multilevel mixed-effects Poisson regression best fit (ie, model III) to the data was decided using Akaike’s Information Criterion (AIC) and Bayesian Information Criterion (BIC), and the lower value of AIC or BIC a better fit of the model.48 The incidence rate ratios (IRRs) with the corresponding 95% confidence interval were reported for each explanatory variable using a p-value less than 0.05 to declare the statistical significance. Ethical approval was received from Addis Ababa University, College of Health Sciences (AAU/CHS) (Ref: AAUMF 01–008) and the Johns Hopkins University Bloomberg School of Public Health (JHSPH) Institutional Review Board (FWA00000287) by PMA Ethiopia.36 The data use policy of PMA Ethiopia frankly stated datasets are anonymized (ie, no result is published in which communities or individuals can be identified) before it is made publicly available for download via the www.pmadata.org website. The PMA Ethiopia review submitted requests and granted access to indicated datasets. The data is treated as confidential and it is forbidden to make any effort to identify individual, household, or enumeration areas in the survey and use the data for marketing and commercial ventures.
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