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Background: Antenatal care (ANC) is crucial for the health of the mother and unborn child as it delivers highly effective health interventions that can prevent maternal and newborn morbidity and mortality. In 2002, the World Health Organization (WHO) recommended a minimum of four ANC visits for a pregnant woman with a positive pregnancy during the entire gestational period. Tanzania has sub-optimal adequate (four or more) ANC visits, and the trend has been fluctuating over time. An understanding of the factors that have been contributing to the fluctuating trend over years is pivotal in increasing the proportions of pregnant women attaining adequate ANC visits in Tanzania. Methods: The study used secondary data from Tanzania Demographic Health Survey (TDHS) from 2004 to 2016. The study included 17976 women aged 15-49 years. Data were analyzed using Stata version 14. Categorical and continuous variables were summarized using descriptive statistics and weighted proportions. A Poisson regression analysis was done to determine factors associated with adequate ANC visits. To determine factors associated with changes in adequate ANC visits among pregnant women in Tanzania from 2004 to 2016, multivariable Poisson decomposition analysis was done. Results: The overall proportion of women who had adequate ANC visits in 2004/05, 2010 and 2015/16 was 62, 43 and 51% respectively. The increase in the proportion of women attaining adequate ANC from 2010 to 2015/16 was mainly, 66.2% due to changes in population structure, thus an improvement in health behavior. While 33.8% was due to changes in the mother’s characteristics. Early initiation of first ANC visit had contributed 51% of the overall changes in adequate ANC attendance in TDHS 2015/16 survey. Conclusion: Early ANC initiation has greatly contributed to the increased proportion of pregnant women who attain four or more ANC visits overtime. Interventions on initiating the first ANC visit within the first twelve weeks of pregnancy should be a priority to increase proportion of women with adequate ANC visit.
The study was conducted in Tanzania, which includes the mainland and island. This was a Crossectional study that used data from the Tanzania Demographic Health Survey (TDHS), Further details of the survey are available elsewhere [13], but in brief this is a national representative survey done after five years with the objective to obtain the current and reliable information on demographic and health indicators about family planning, fertility levels and preferences, maternal mortality, infant and child mortality, nutritional status of mothers and children, ANC, delivery care, and childhood immunizations and diseases. Data were obtained from www.dhsprogram.com, after being granted permission to access and use TDHS data. Data from 2004/04, 2010 and 2015/16 surveys were used. The population was all women of reproductive age (15-49 years) who had given birth to at least one child within the five years before the survey and had information on ANC visits. For a woman with multiple births during the five-year period, we considered mother’s last birth within 5 years prior the survey for this analysis. A total of 33,734 women aged 15-49 years in Tanzania participated in the three TDHS surveys. After excluding those with missing information on ANC visits, we remained with a total of 17,976. Of 17,976 women enrolled in the study: 4541(77.9%), 4201(76.9%) and 5193(70.1%) for 2004/05, 2010 and 2015/16 surveys respectively (Fig. (Fig.11). Flow chart showing participants enrolled in the study per respective survey years Our dependent variable was adequate ANC visits, which was categorized as four or more ANC visits and coded 1, less than four ANC visits as inadequate were coded 0. Independent variables were respondent’s age at last birth (15-19 years, 20-24 years, 25-29 years, 30-34 years, 35+ years), education level (no formal education, primary education, secondary and higher education), employment status (unemployed, employed), marital status (married/cohabiting, single, divorced/widowed/separated), residence (urban, rural), wealth index (poorest, poorer, middle, richer, richest), zones; these are administrative regions grouped according to geographical location (western zone, northern zone, central zone, southern highlands, southern zone, south west highlands zone, lake zone, eastern zone, Zanzibar), first ANC initiated (women with first ANC visit later than 12 gestational weeks, women with first ANC visit by 12 gestational weeks), decision maker of respondent’s health care (respondent alone, respondent and partner, partner alone, someone else), parity (1 child, 2-3 children, 4-5 children, 6 or more children), frequency of listening to radio (not at all, Less than once a week, at least once a week), frequency of watching TV (not at all, less than once a week, at least once a week), desire of last pregnancy (wanted then, wanted later, wanted no more), history of terminated pregnancy (never had, ever had) and distance from health facility (big problem, not a big problem). The selection of variables was made using the Andersen’s Behavioural Model of Health Services Use [20]. All these variables were considered as mother’s characteristics and population characteristics in the analysis. Data were analyzed using STATA Corporation, College Station, TX, USA version 14 (Stata/SE 14.2). The analysis considered the complex survey features: primary sampling units, strata, and sampling weights. A Poisson regression analysis was done to determine factors associated with adequate ANC visits. Multivariable Poisson decomposition analysis was conducted to determine factors associated with changes in adequate ANC visits. Decomposition analysis was conducted to understand whether observed changes in adequate ANC visits could be explained by changes in factors over time or in the population structure (population dynamics). To explain the observed change in the percentage of pregnant women attaining adequate ANC visits, we used the Blinder-Oaxaca decomposition analysis [21–23]. The main goal decomposition analysis was to explain on the individual contributions of the factors on adequate ANC visits differences among pregnant women in Tanzania in different surveys. The differentials in adequate ANC visits between these groups was portioned into two components, one that can be attributable to differences in characteristics and the component that is attributable to the effect of those characteristics. The factors might have a different contribution on the change observed at different survey period. The decomposition analysis was done between two time points, at first, we decomposed survey year 2004/05 to 2010 and lastly survey year 2015/16 to 2010. The baseline survey year was the one with the lowest proportion of pregnant women with adequate ANC visits, thus survey year 2010 for both decomposition analysis. Contributions were considered statistically significant at a P-value of less than 0.05.
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