Prevalence and correlates of pregnancy self-testing among pregnant women attending antenatal care in western Kenya

In sub-Saharan Africa little is known about how often women use pregnancy self-tests or characteristics of these women despite evidence that pregnancy self-testing is associated with early antenatal care (ANC) initiation. Understanding the characteristics of women who use pregnancy self-tests can facilitate more targeted efforts to improve pregnancy testing experiences and entry into the ANC pathway. We conducted a cross-sectional survey among pregnant women enrolling in a pre-exposure prophylaxis (PrEP) implementation study to determine the prevalence and factors associated with pregnancy self-testing among women in western Kenya. Overall, in our study population, 17% of women obtained a pregnancy self-test from a pharmacy. Pregnancy test use was higher among employed women, women with secondary and college-level educated partners, and women who spent 30 minutes or less traveling to the maternal and child health (MCH) clinic. The most reported reasons for non-use of pregnancy self-tests included not thinking it was necessary, lack of knowledge, and money to pay for the test. Future research should focus on understanding the knowledge and attitudes of women toward pregnancy self-testing as well as developing community-based models to improve access to pregnancy testing and ANC. From December 2018 to July 2019, we collected data as part of a baseline survey among pregnant women enrolling in the PrEP Implementation for Mothers in Antenatal Care (PrIMA) study. PrIMA is a cluster randomized trial ({“type”:”clinical-trial”,”attrs”:{“text”:”NCT03070600″,”term_id”:”NCT03070600″}}NCT03070600) that compares facility-based approaches for delivering oral pre-exposure prophylaxis (PrEP) in pregnancy. Briefly, between January 2018 and July 2019, study participants were recruited from women presenting for ANC in 20 public health facilities in Homabay and Siaya counties in western Kenya. In this region, approximately more than 95% of pregnant women receive antenatal care from a skilled provider [2]. Health facilities eligible for inclusion in the PrIMA study were located in counties with an HIV prevalence of at least 20%, had more than 350 HIV-negative clients receiving ANC annually, and provided postnatal care services, including infant immunizations. Women were eligible for enrollment if they were: (1) pregnant, (2) HIV negative (based on test results abstracted from the MCH card), (3) not currently using PrEP, (4) ≥ 15 years of age, (5) TB negative and (6) planned to receive postnatal and infant care at the enrollment facility. Participants were recruited for the study while waiting to access ANC services at any ANC visit and at any gestational age. The study team administered the enrollment questionnaire in English, Kiswahili, or the local language, Dholuo (see S1 Appendix). Participants answered questions on socio-demographics, medical and pregnancy history, and partner characteristics. Additional details on the PrIMA study protocol are described elsewhere [5]. We analyzed two dependent variables: “obtained pregnancy self-test from pharmacy” and “early ANC initiation.” If a woman reported using a pregnancy test on her own to confirm her pregnancy and obtained the pregnancy test from the pharmacy, we categorized her as having obtained a pregnancy self-test from the pharmacy. We defined “early ANC initiation” as starting ANC during the first trimester of pregnancy (gestational age less than 13 weeks). We analyzed variables that we hypothesized from the literature would be associated with pregnancy self-test use and early ANC: socio-demographics (age, partner status, number of years in school, partner’s education level, and history of prior pregnancy), accessibility (travel time to the health facility), affordability (women’s employment status) and women’s knowledge or attitudes (history of pregnancy or delivery complications) [3, 4, 6–9]. We analyzed “obtained pregnancy self-test from pharmacy” as an independent variable when evaluating factors associated with early ANC initiation [3, 4]. We categorized age into three groups: 15–19 years, 20–24 years, and > 25 years. We included three different age groups because adolescents and young women face unique challenges in pregnancy and are likely to have different health-seeking behaviors [10]. We defined and categorized partner status into two groups: having a partner (including a married partner) or not having a partner in the last three months at the time of the survey. The number of years in school was categorized into three groups (8 years, 9–12 years, and >12 years), reflecting the number of years that individuals have typically spent in school at primary, secondary, and college levels in the region. We categorized the partner’s education level into four groups: primary school and below (no formal schooling or having attended or completed primary school), secondary school (having attended or completed secondary school), and college (having attended or completed college). We defined history of prior pregnancy as a woman reporting that she had previously been pregnant. Women reported estimated travel time to the health facility in minutes which we categorized into two groups (≤ 30 minutes versus > 30 minutes) based on the median travel time. Women were categorized as employed if they reported currently having regular employment. Women had a history of prior pregnancy or delivery complications if they indicated that they had the following problems during her last pregnancy: late pregnancy bleeding, miscarriage, fetal miscarriage, high blood pressure, laceration, hemorrhage, obstructed labor, premature birth (<37 weeks), spontaneous fetal death (< 20 weeks) or stillbirth. All variables were self-reported. We conducted a descriptive analysis of the independent (age, partner status, history of prior pregnancy, employment status, and the number of years in school) and dependent variables (obtained pregnancy self-test from pharmacy and early ANC initiation). We examined the sources of pregnancy self-tests and the reasons for non-use of pregnancy self-tests among pregnant women. We conducted bivariate logistic regression analyses to examine the associations between the independent variables and each of the two dependent variables. In the multivariable logistic regression analysis, we excluded age and number of years in school because they were strongly correlated with a history of prior pregnancy and partner’s education level, respectively (Cramer’s V > 0.30, p <0.05) [11]. To maintain the sample size, we excluded history of pregnancy or delivery complications because we could only determine this variable among women who had previously been pregnant. We included women who reported not having a partner as a separate category under the partner’s education level. We used the Mantel-Haenszel test of homogeneity to identify potential modifiers of the relationship between obtaining a pregnancy self-test from a pharmacy and early ANC initiation. The relationship differed significantly by partner’s education level; therefore, we stratified the analysis by this variable. Given that we conducted a secondary analysis of data from an existing cluster randomized trial, we adjusted for the 20 facility clusters using a robust method of standard errors. Overall, 93% of records had complete data. Missingness ranged from 0.6% to 4.6% across all variables. Statistical analyses were performed using R software (R-Studio Version 1.1.456) and STATA 16.1 (College Station, TX). The Kenyatta National Hospital (P73/02/2017) and the University of Washington (STUDY00000438) institutional review boards approved this study. All participants provided written informed consent to participate in the study.