Factors associated with comprehensive knowledge of antenatal care and attitude towards its uptake among women delivered at home in rural Sehala Seyemit district, northern Ethiopia: A community-based cross-sectional study

Background Despite the current sustainable development goal period (i.e. SDG 3), the prevention of maternal and neonatal mortality is not satisfactory in Ethiopia. Keeping women knowledgeable about antenatal care and maintaining a positive attitude towards its uptake, particularly in the marginalized rural community is crucial. However, evidence regarding the knowledge and attitude of women towards antenatal care uptake is scarce. Therefore, this study aimed to assess factors affecting comprehensive knowledge of antenatal care and attitude towards its uptake among women delivered at home in rural Sehala Seyemit district, northern Ethiopia. Methods A community-based cross-sectional study was conducted from September 1st to October 15th, 2020. A multi-stage sampling technique was used to select 653 women. The data were collected using a semi-structured interview guide. Data were entered into EPI INFO 7.1.2 and analyzed by SPSS version 25. Both bivariable and multivariable logistic regression analyses were undertaken to identify factors associated with women’s knowledge of antenatal care and attitude towards its uptake. The level of significant association in the multivariable analysis was determined based on a p-value of < 0.05. Results Women’s knowledge of antenatal care and positive attitude towards its uptake was 56.5% and 75.2%, respectively. Older age (AOR = 7.2; 95% CI: 3.43, 15.1), media exposure (AOR = 3.69; 95% CI: 2.41, 5.65), history of abortion (AOR = 11.6; 95% CI: 3.3, 14.6), time to reach health facility (AOR = 4.58; 95% CI: 3.05, 6.88), and history of obstetric danger signs (AOR = 7.3; 95% CI: 3.92, 13.64) were factors significantly associated with knowledge of antenatal care. Furthermore, higher decision-making power (AOR = 8.3; 95% CI: 4.8, 13.83), adequate knowledge of antenatal care (AOR = 2.2; 95% CI: 1.26, 3.71), delivery attended by health extension workers (AOR = 2.3; 95% CI: 1.1, 5.1), and media exposure (AOR = 2.27; 95% CI: 1.30, 3.97) were predictors of a favorable attitude towards antenatal care utilization. Conclusion Although the majority of women in the present study had a favorable attitude towards antenatal care uptake, their knowledge level was inadequate. Strengthening access to transportation, mass media, involvement in household decision-making, and encouraging women to deliver at a health facility by a skilled provider may increase women’s knowledge and attitude towards antenatal care uptake, thereby improving maternal healthcare service uptake.

A community-based cross-sectional study was conducted from September 1st to October 15th, 2020. This study was conducted in rural Sehala Seyemit district, Waghimra zone, Amhara regional state, Northern Ethiopia. Sehala Seyemit district is located 285 km northeast of Bahir Dar (the capital city of Amhara regional state) and about 799 km north of Addis Ababa (the capital city of Ethiopia). Accessing health services in the district is difficult because of the lack of transportation to each “kebeles” (which is the smallest administrative unit in Ethiopia). Maternal health services such as ANC, childbirth, and postnatal care are given for free in Ethiopia, including the study area. The district has 13 “kebeles”; 12 rural and 1 urban “kebeles”. Currently, the district has a population of 39,435. Over 90% of the population are farmers. Moreover, there are 3 health centers and 13 health posts serving the community. Furthermore, there were a total of 923 women who gave birth at home in the last 2 years (Sehala Seyemit Woreda report, unpublished data). All women who gave birth in the last two years in the selected “kebeles” during the data collection period were selected to be part of the study. All critically ill women throughout the data collection period were excluded. The sample size for this study was determined by using a single population proportion formula by considering the following assumptions: women’s attitude towards ANC in Mizan, Ethiopia-70.6% [4], 95% level of confidence, and 5% margin of error. Thus, n=(Zα/2)2p(1−p)d2=n=(1.96)2*0.706(1−0.706)(0.05)2 = 319. Where, n = required sample size, α = level of significant, z = standard normal distribution curve value for 95% confidence level = 1.96, p = women’s attitude towards ANC, and d = margin of error. By considering a design effect of 2 (since multistage sampling) and a 5% non-response rate, the minimum adequate sample size was 670. A multistage sampling technique was employed to select the study participants. In the first stage, eight kebeles were selected randomly among the 12 rural “kebeles”. In addition, the lists of home-delivered women from the selected kebeles were obtained from health extension workers (HEWs) and local administrators. Thereafter, the sampling frame was designed by numbering the list of women. Then, the total sample size was distributed to each selected “kebeles” proportionally. In the second stage, the women were selected by a simple random sampling technique using a table of random generation. Women’s knowledge of ANC (adequate/inadequate) and women’s attitude towards ANC uptake (favorable/unfavorable) were the outcome variables. Whereas age of the women, marital status, women’s educational status, women’s occupation, husband educational status, husband occupation, family size, exposure to mass media, time to reach the nearby health facility, parity, history of ANC, number of ANC, birth assistant, husband involvement in maternal and children’s health, household decision-making power, history of abortion, history of neonatal death, history of obstetric danger signs during pregnancy, and status of the pregnancy were the explanatory variables. Home delivery: Is defined as a birth that has taken place at the laboring woman’s own home, or her relative, or her neighbor rather than a birthing center without a skilled birth attendant [39]. Traditional birth attendant: Is a person who is traditionally experienced in attending labor to assist women in childbirth and give care during pregnancy and childbirth [38]. Comprehensive knowledge of ANC: Includes knowledge of ANC and pregnancy, knowledge of obstetric danger signs, knowledge of birth preparedness and complication readiness, knowledge of malaria prevention, knowledge of anemia prevention, knowledge of helminthic infection prevention, and knowledge of tetanus prevention during pregnancy. A total of 20 open and close-ended questions were designed to assess the comprehensive knowledge of ANC. Correct and/or “Yes” answers were coded as 1, whereas incorrect and/or “No”/don’t know answers were coded as 0. The minimum and maximum scores were 0 and 20, respectively. Thus, based on the summative score of variables designed to assess knowledge, a score above the mean was considered knowledgeable [4,5,40] (S1 File). Women’s attitude: Women’s attitude towards ANC was measured using 9 questions: 1) Want to have ANC follow up for next time 2) Intention to deliver in a health facility for the next pregnancy 3) Health care professionals providing antenatal care is good 4) All pregnant women should have ANC follow up 5) Timely ANC follow up will be safer for both mother and baby 6) Want to pay for ANC if it is with fee 7) Husbands should be present during ANC follow-up 8) Advice regarding proper health during pregnancy can be gotten outside the hospital 9) Follow up during pregnancy may decrease antenatal and postnatal complications. Each question has a five-point Likert scale (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree). The total score was 9–45 and women who scored above the mean value were considered as having a favorable attitude [33,41,42]. Husband involvement: Husband involvement in maternal and child health-related activities was measured using 9 questions: 1) did your husband go with you for ANC follow-up at least once in your most recent pregnancy? 2) Did your husband provide transport/gave money for transport during your recent pregnancy or delivery? 3) Did your husband accompany you to the hospital during labor for your recent delivery? 4) Did your husband discuss with health care providers during your recent pregnancy or delivery? 5) Did your husband look after the child at home/stay with the babies while you are outside the home? 6) Did your husband bathe a newborn/infant while you are busy? 7) Did your husband buy clothes/other things for infants/neonates? 8) Did your husband go with you for immunization services? 9) Did your husband assist you while you breastfeed the newborn/infant? Each question was coded as 0 for “no” and 1 for “yes”. The total score ranged from 0–9 and a score of above the mean was considered as husband involved Based on the summative score of variables designed to assess husband involvement a score above the mean was considered as involved [43,44]. Household decision-making power: Women’s decision-making power was assessed using 9 questions: 1) who decides about health care for you? 2) Who decides on the large household purchase or sell? 3) Who decides on intra-household resource allocation/ daily household purchases? 4) Who decides on where and when to seek medical care for sick newborns/children? 5) Who decides on visits of family, friends, or relatives? 6) Who decides when to have an additional child? 7) Who usually decides how your partner’s/husband earnings will be used? 8) Who decides to go for an ANC visit, postnatal (PNC) visit, where to deliver, and infant immunization? 9) Who usually decides what foods to be cooked each day? The possible answers were me alone which was coded as 2, both of us which was coded as 1, and the husband alone or others which was coded as 0. The score ranged from 0 to 18 and a woman who scored above the mean was considered as having higher household decision-making power [45]. Media exposure: Those women who responded at least once a week to one of the media are considered to be regularly exposed to that form of media (i.e. TV, radio, or magazine) [19]. Experienced danger signs: Women who have experienced one or more of the danger signs during their last pregnancy or childbirth were considered as experienced danger signs. History of neonatal death: Women who have experienced the death of a neonate within the first 28 completed days of life [46]. History of abortion: Women who have experienced termination of pregnancy before 28 weeks gestation in the Ethiopian context [47]. The data collection tool was developed by reviewing the literature [4,5,28,33,41,42]. The data were collected using a semi-structured interviewer-administered questionnaire through face-to-face interviews. Initially, the questionnaire was prepared in English and translated to the Amharic language, and back to English to ensure consistency. The questionnaire contains socio-demographic characteristics, reproductive and maternity healthcare characteristics, husband involvement in maternal and child health-related activities, household decision-making power, and questions assessing women’s comprehensive knowledge of ANC, and attitude towards its uptake. The questionnaire was assessed by a group of researchers (three in the field of maternal and child health, one in the field of public health, and two midwives in the hospital) to evaluate and enhance the items in the question. Before the actual data collection, we did a pretest on 34 women at Ziquala Woreda which has similar socio-cultural and living standards as the study population. Eight female HEWs and four male Diploma in midwifery holders were recruited for data collection and supervision, respectively. Two days of training were given regarding the overall data collection process. During the data collection, the questionnaire was checked for completeness daily by the supervisors. Data were checked, coded, and entered into EPI INFO version 7.1.2, and were exported to SPSS version 25 for further cleaning and analysis. Before analysis, re-coding, transforming, computing, and categorizing of variables were done. Descriptive statistics were used to show participants’ characteristics, comprehensive knowledge of ANC, and attitude towards its uptake. Binary logistic regression analysis was fitted to identify statistically significant independent variables, and variables having a p-value of < 0.25 were included in the multivariable logistic regression for controlling confounders. The multicollinearity assumption was checked using the variance inflation factor (VIF), where VIF <10 was acceptable. In the multivariable logistic regression (Backward Likelihood Ratio approach), a p-value of < 0.05 with a 95% CI for the adjusted odds ratio was employed to ascertain the significant association. We conducted the study under the declaration of Helsinki. Ethical approval was obtained from the Institutional Ethical Review Board of Debre Berhan University (protocol number; P005/20). A formal letter of administrative support was gained from the Sehala Seyemit Woreda health office. Both oral and written informed consent was collected from each of the study members after a clear explanation of the aim of the study and their right to withdraw from the study at any time. For those women who cannot read and write, a thumbprint was taken (i.e. it is a common practice in Ethiopia including banking services and other large issues that need a signature). The study participants were assured that the collected information is anonymous and kept confidential for the study purpose only.

• kebede, azmeraw ambachew
• taye, birhan tsegaw
• wondie, kindu yinges