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Background Early and frequent antenatal care (ANC) has been linked to better pregnancy outcomes. This study assessed whether having at least four ANC contacts was associated with increased prenatal care content if the first visit was started in the first trimester in Ethiopia. Methods Data from the 2019 Ethiopia Mini Demographic and Health Survey on 2894 women aged 15–49 who received ANC during their last pregnancy were analyzed. The sum of women’s responses to six questions about ANC components (blood pressure taken, urine sample taken, blood sample taken, provided or bought iron tablet, counselling by a health worker on nutrition, and told about pregnancy complications) was used to construct a composite score of routine ANC components. The main predictor was a combination of the timing of the first contact and the number of ANC contacts before birth. Results We found that 28.7% of women who began ANC early made at least four ANC contacts. More than one-third (36%) received all six components, with blood pressure monitoring being the most common (90.4%). After adjusting for potential confounding factors, women who had at least four contacts and booked early were substantially more likely than their counterparts to get a factor-of-one increase in the number of components received (IRR = 1.08; 95% CI: 1.03, 1.10). Conclusion We found a strong association between increased prenatal care content and early ANC with at least four contacts. However, less than a third of women in the study setting had at least four contacts, with the first occurring in the first trimester. In addition, less than half of women received essential prenatal care interventions before delivery. The findings suggest that the WHO’s new guidelines for ANC frequency and timing may be challenging to implement in some countries, such as Ethiopia, that already have low coverage of four or more contacts. If the recommendations are adopted, effective strategies for increasing early starts and increasing contacts are required.
The analysis in this study is based on data collected from the 2019 EMDHS, a nationally representative cross-sectional household survey. The sampling frame used for the 2019 EMDHS is a frame of all census enumeration areas (EAs) created by the Central Statistical Agency (CSA). The 2019 EMDHS sample was stratified and selected in two stages. Each region was stratified into urban and rural areas, yielding 21 sampling strata. In the first stage, 305 EAs were selected with a probability proportional to EA size and with independent selection in each sampling stratum. In the second stage of selection, a fixed number of 30 households per EA were selected with an equal probability of systematic selection from the newly created household listing. The sampling details for the 2019 EMDHS, data collection methods and tools, as well as quality control measures, have been documented in the full report [12]. This study utilised the individual recode (women’s file) dataset for analysis. A total of 2894 women aged 15–49 years who had received ANC services during their most recent pregnancy were analyzed. This sample was weighted to account for the complex study design used by the DHS program in its surveys. The outcome variable in this study is the number of components of prenatal care received by women of reproductive age during their most recent pregnancy. We developed composite scores of routine components of ANC based on the sum of women’s responses to a set of six questions regarding the component of prenatal care they received, including: 1) blood pressure taken; 2) urine sample taken; 3) blood sample taken; 4) given or bought iron tablet; 5) counselling by a health worker about nutrition; and 6) told about the signs of pregnancy complications. For each of these questions, the response options were yes (score = 1) or no (score = 0). The total scores ranged from 0 to 6, with “0” implying that none of the components was received and “6” implying that all six investigated components were received. We would like to point out that the six components studied in this study are not all-inclusive. Weight measurement, deworming, and birth preparation discussions are also recommended as part of the standard ANC guidelines for all pregnant women in Ethiopia [19]. However, these data were not available in the dataset that we used for the current study. The exposure variable investigated in this study is a combination of the timing of the first ANC contact and the total number of contacts made before delivery, labelled “early ANC with at least four ANC contacts”. The exposure variable was dichotomized into “No” and Yes” for analysis purposes. Women who started ANC early and had at least four contacts before delivery were classified as “Yes” (for early ANC with at least four ANC contacts). Those who started early but had fewer than four contacts were classified as “No”. Those who started late and made fewer than or more than four contacts were likewise classified as “No”. In the current study, a pregnant woman is defined as having an early ANC start when she reports that her first ANC contact was initiated during the first three months of her most recent pregnancy. We included the following demographic, obstetric, and socioeconomic characteristics as covariates: maternal age, educational level, current marital status, number of children ever born, region, type of place of residence, and wealth index based on previous studies conducted [19,20]. Most of these variables were used as they existed in the dataset. Using the existing DHS variables, however, new variables such as respondent age group, number of children ever born, and educational level were created. It is worth noting that the covariates included in the current study are not the only known factors that can influence women’s use of health services, as reported in the literature; cultural beliefs and perceptions about pregnancy, ease of access to health facilities, cost of services, and ANC quality have all been identified as factors influencing women’s use of health services, particularly ANC services in low-resource settings [21–23]. However, due to a lack of availability of these factors in the dataset, we were unable to include them in our analysis. Descriptive statistics were computed for the background characteristics and both for each question on the routine components of ANC received and the distribution of the components. We performed unadjusted and adjusted multivariable Poisson regressions to examine the association between the exposure variable and the outcome variable. Multicollinearity between variables was checked using the Variance Inflation Factor (VIF) method before building the adjusted model. The mean VIF was 1.49 (range: 1.01–1.94). To adjust for the complex survey design used in the DHS, sampling weight was applied in all the analyses [24]. All of the statistical analyses were conducted using Stata version 13.0 (StataCorp. LP, College Station, USA). The statistical significance was set at a p<0.05. This study focused on the analysis of secondary data from the Ethiopian Mini Demographic and Health Survey 2019. MEASURE DHS/Inner City Fund (ICF) International gave the authors permission to use the dataset. The DHS Program adheres to industry guidelines for protecting the privacy of respondents. ICF International guarantees that the survey complies with the Human Subjects Protection Act of the United States Department of Health and Human Services. Before the survey, the DHS project sought and received the required ethical approval. Informed consent was obtained from participants. Parents or guardians of respondents younger than 18 years old provided written informed consent. More information on data and ethical principles can be found online at the DHS program website (https://dhsprogram.com/methodology/Protecting-the-Privacy-of-DHS-Survey-Respondents.cfm). This study, therefore, did not require any additional approvals.
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