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BACKGROUND: Early initiation of antenatal care visits is an essential component of services to improving maternal and new born health. The Ethiopian Demographic and Health Survey conducted in 2011 indicated that only 11% of pregnant women start antenatal care in the first trimester. However, detailed study to identify factors associated with late initiation of care has not been conducted in Addis Ababa where access to health services is almost universal. The aim of this study was to assess the level of late first antenatal care visit and the associated factors.
Study area: The study was conducted in Addis Ababa, the capital city of Ethiopia, with an estimated total population of 3.2 million. The city is divided into ten administrative units referred to as “sub-cities”. There were 91 government health centers in the city that were more or less evenly distributed in the ten sub cities. In addition, there were 11 public hospitals, 33 private hospitals, 520 private clinics, 257 specialized clinics and 06 NGO clinics and health centers. Most health facilities in the city provide ANC services, but the standards vary remarkably. The public health facilities use the national guidelines for providing ANC services. The private facilities may not always follow the national guidelines (24).We conducted the study on public health centers that are supposed to be the first entry points for ANC according to the national guidelines. Study design: Facility based cross sectional study design with internal comparison was conducted in health facilities in Addis Ababa in the year 2013. Study participants: The study subjects were pregnant women who came for their first ANC visits in the selected health facilities during the study period, December 2013. Women who were seriously ill at the time of data collection and unable to give consent were excluded from the study. Sample size: Sample size was determined using the formula for single population proportion: prevalence of first ANC initiation before 16th weeks of gestation which is 40.2% was used to calculate the total sample size of 864. Adding 10% allowance for nonresponse and refusal to participate, a total sample of 960 was required to determine the proportion of women who come late for their first ANC visits and to identify factors associated with late first visits. The total sample was divided into the selected ten health centers proportional to their monthly client loads. Sampling procedure: A two-stage sampling procedure was used to select study subjects. First, one health center from each of the 10 sub-cities of Addis Ababa was selected using a simple random sampling procedure. Second, eligible pregnant women who came for their first ANC visits in the selected health centers were enrolled continuously until the required sample size was achieved. Participants were allocated proportionate to the monthly ANC client load of eachselected health facility. Data collection tools and procedures: Data were collected using structured questionnaire, which was developed based on the Ethiopian Demographic and Health Survey (DHS) data collection tool and other relevant literature. The questionnaire was first developed in English and later translated into Amharic. The information collected includes socio-demographic background of the mothers, obstetric history, past maternal service initialization and perception of ANC services. Data collectors were nurses who received training on the objective of the study, interview technique and details of the questionnaire. Pretest was done in a public health center that was not selected for the study. Recruitment of the study participants was facilitated by ANC service providers in each study health center. The interview was conducted in Amharic. Eligible mothers were interviewed face-to-face at exist of ANC clinic. In this study, late ANC initiation was defined as the first ANC visit made by pregnant women after 16 complete gestational weeks. Perceived time for initiating ANC was defined as what the women thought is the correct gestational age to initiate the first ANC visit. Data quality assurance: To maintain the quality of data, the questionnaire was pretested in a similar level health facility which was not part of the study. After the pretest, some modifications were made on the questionnaire to improve the clarity of meanings. Data collectors were given orientation on the changes before the main study was conducted. Moreover, regular follow up was made by the principal investigator to monitor the data collection process. Furthermore, the collected data were checked regularly for their completeness and clarity, and feedbackwas given to the data collectors. Data processing and analysis: double data entry procedure and data cleaning were done using EPI INFO version 3.5.1. Further data analysis was done using SPSS windows version 15.0 statistical software. The proportion and 95% confidence interval of the main outcome variable was calculated to show the extent of late initiation of ANC visit at the cutoff point of 16 weeks. The association of independent variables with late ANC initiation was examined by calculating the crude and adjusted odds ratios. Twelve variables were examined independently using a bivariate analysis, and those variables with a p-value of less than 0.20 were included into a logistic regression model to calculate the adjusted odds ratios and 95% confidence intervals. Ethical consideration: Ethical approval was obtained from Haramaya University and Addis Continental Institute of Public Health. Permission to carry out the study was granted from Addis Ababa Health Bureau. Individual informed verbal consent was obtained from each respondent after explaining the purpose of the study. Interviews were conducted in private space at the facility of the health center during exist from ANC services. Confidentiality was maintained by not recording identifying information and restricting access to data only to the research team.
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