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Background: There are recent efforts made to eliminate inequalities in the utilisation of basic health care services. More emphasis is given for improvement of health in developing countries including maternal and child health. However, disparities for the fast-growing population of urban poor are masked by the urban averages. The aim of this paper is to report on the findings of antenatal care adequacy among slum residents in Addis Ababa, Ethiopia. Methods: This was a quantitative and cross-sectional community based study design which employed a stratified two-stage cluster sampling technique to determine the sample. Data was collected using structured questionnaire administered to 870 women aged 15-49 years. Weighted ‘backward selection’ logistic regression models were employed to identify predictors of adequacy of antenatal care. Results: Majority of slum residents did not have adequate antenatal care services with only 50.3, 20.2 and 11.0 % of the slum resident women initiated antenatal care early, received adequate antenatal care service contents and had overall adequate antenatal care services respectively. Educational status and place of ANC visits were important determinant factors for adequacy of ANC in the study area. Women with secondary and above educational status were 2.7 times more likely to receive overall adequate care compared to those with no formal education. Similarly, clients of private healthcare facilities were 2.2 times respectively more likely to receive overall adequate antenatal care compared to those clients of public healthcare facilities. Conclusion: In order to improve ANC adequacy in the study area, the policy-making, planning, and implementation processes should address the poor adequacy of ANC among the disadvantaged groups in particular and the slum residents in general.
The target population for this study was all women aged 15–49 years living in Addis Ababa, the capital city of Ethiopia. To be included in the study, women should have experienced at least one birth in the last 1–3 years before the date of data collection. The study employed a stratified, two-stage cluster design. In the urban Addis Ababa, stratification was achieved by using the sub-Cities (10 strata). In the first stage the sampling frame was the lists of clusters (enumeration areas) per stratum. Then using the 2007 Population and Housing Census data, 30 sample points known as enumeration areas (EAs) were selected independently from all the strata with Probability Proportional to Size (PPS) of households in each stratum. PPS is a special and efficient method in multistage cluster sampling [23]. Random sample selection was done using the number of households identified per EA during the 2011 EDHS [9]. The sampling frame in the second stage was the lists of households in each EA. Households (HHs) were the sampling units from which 906 households were selected using systematic random sampling technique i.e., approximately equal numbers of households (30 HHs) in each EA. The final valid sample size was 903 because of non-response. A 10 % adjustment was made during sample size calculation for potential non-response and reporting errors. Data was collected from December 2013 to January 2014. A questionnaire was developed by the researchers to assess adequacy of antenatal care among slum residents in Addis Ababa, Ethiopia. The questionnaire asked women about their most recent births and a list of questions were also asked to elicit the adequacy of antenatal care among study participants. Demographic and socioeconomic information was also included in the questionnaire. Prior to administration of the questionnaire, it was pilot tested with 15 women that have similar characteristics with the study population but among those outside the selected enumeration areas who were not included in the final sample. The questionnaire was also translated into Amharic the local language mainly used in Addis Ababa. This study was grounded on the basis of Andersen’s Health care Utilisation Model also known as the Behavioural Model of Health Services [24]. The Andersen Health care Utilisation Model has been used extensively in analysing factors that influence utilisation of health care services and to understand disparities in utilisation of medical services [25]. The model was initially developed to assist in understanding why families use health services, to define and measure equitable access to health care, and to assist in developing policies to promote equitable access [24, 26]. In the analysis of social and individual determinants of health services use among families, the model presupposes that health care utilisation is a function of multilevel factors called predisposing, enabling or need factors i.e. individual’s predisposition and the ability or need to use services. The latest framework shows the link between societal determinants, health care system and individual determinants and their impact on health care utilisation [26]. The independent variables for this study were selected based on the modified version of the Behavioural Model of Health Services [26]. The predisposing factors including age, number of living children, current marital status and pregnancy intention related to last childbirth, social structure variables such as education, occupation and ethnicity were considered at individual and household levels. As regards to pregnancy intention, women were asked about their recent birth whether they wanted it then, wanted later, or did not want to have any more children at all. In the analyses, pregnancy intention for the last birth was further defined as a dichotomy variable: intended for births wanted by then versus unintended for either mistimed or unwanted by then. Women’s education was defined here as the highest level of schooling attended regardless of whether the woman completed the level. Educational status was categorized as no education, primary education and secondary or higher education. Mother’s occupational status was categorized as employed and unemployed. In 2005, the government of Ethiopia stipulated a package of free maternity and selected child health services [27]. However; women continue to be charged for card fees, medical consultations, specific procedures, and supplies or medications. According to the Safe Motherhood Community-Based Survey, service fees are known to be major obstacles for women and their families when they need medical attention [28]. It is not also uncommon for women to be referred for laboratory investigations to private facilities as the public health centres and hospitals do not have all the necessary services that are included in the free maternity services. Therefore, as enabling factors, individual and family resource indicator variables including health insurance and wealth quintile were included in this study. Those who visited health facility for ANC were asked whether there was an organization or agency that either partially or fully covered their expenses and responses were grouped as ‘yes’ or ‘no’. The relative economic status of the households was determined indirectly through the creation of a wealth index. The construction of wealth index was done using principal components analysis (PCA) via a collection of indicators representing durable goods owned by the household, materials used in construction of the home, water and sanitation facilities and size of the home. A community resource variable, type of resident was also used in the analysis. Type of resident was categorized based on the five indicators developed by the United Nation Human Settlements Programme (UN-Habitat) [29]. Access to improved water, access to improved sanitation, sufficient living area, durability of housing and secure tenure (housing tenure) were used in the construction of type of resident. According to UN-Habitat a household is categorized as non-slum if all of the above five indicators are fulfilled, otherwise slum. Of the 903 respondents, 870 were slum residents and the remaining 66 were either non-slum households or missing. Hence, this paper focuses on the slum residents only. A woman meeting at least one of the following criteria was classified as having history of high-risk pregnancy i.e., more than four previous births; history of spontaneous abortion, known high blood pressure, diabetes, or epilepsy was considered high-risk [30]. In this study, a single overall ANC adequacy indicator was constructed using the three ANC utilization indicators i.e., timing of first visit, number of visits, and adequacy of service content. Timing of visit was considered adequate if the first visit took place within the first 12 weeks; and the number of visits was considered adequate if the mother had at least four visits in the pregnancy period. To assess service content, participants were asked about the basic ANC components received as recommended by WHO for all women regardless of the gestational age at first visit to clinics [4]. Information on mother’s weight and height, blood pressure, fundal or uterine height and fetal heartbeat, urine and blood sample taken (blood type, haemoglobin (anaemia) and syphilis test), tetanus injection, iron supplementation, and information or counselling given about signs of pregnancy complications- abdominal pain, severe headache, vaginal bleeding was obtained from respondents. Service content was categorized as adequate if all the above services were provided to the mother according to the national recommendation, at least once during the last pregnancy, otherwise inadequate. However, it should be noted that women may not specifically know the procedures, examinations or laboratory investigations done for them during antenatal visit. Although the 1–3 years recall period for this study is shorter than that for Demographic and Health Surveys (up to five years), it still represents a lengthy recall period not far from the recall period of up to two years by the United Nations Children’s Fund supported Multiple Indicator Cluster Surveys (MICS) [9, 31]. Due to inadequate routine health information system usually, national and international monitoring systems have relied on community based survey data like DHS and MICS. Indicators recommended for the DHS and MICS surveys are those that showed accurate reporting at both the individual and population levels. The data collection instrument for this study was developed based on the DHS women’s questionnaire. Population survey validity studies on antenatal and delivery care from China (recall of five years) and Mozambique (recall of 8–10 months) showed accuracy measure ranging from 56 to 88 % [31, 32]. Then, ANC service content was combined with timing of initiation of first antenatal visit and number of antenatal visits in estimating the overall service adequacy. Finally, ANC was defined as overall adequate if the woman had her first antenatal visit within the first 12 weeks and had at least four antenatal visits and had received the above 12 basic ANC service contents at least once in the last pregnancy period; otherwise inadequate. In this study, data was entered using the Census and Survey Processing System (CSPro) software and was analysed for both descriptive and inferential statistics using the Statistical Package for Social Sciences (SPSS) version 16.0. Chi-square test was used for descriptive analyses. Logistic regression modelling was undertaken to examine the net effects of set of explanatory variables over the outcome variables and the odds ratios (OR) were adjusted for all other variables. As the data was collected using complex sampling design (two-stage cluster design), there is unequal probability in the selection of study participants. This may in turn lead to biased parameter estimates. To rectify such problems, in this study, sampling weights and clustering was employed for each outcome variable. As there were multiple potential predictor variables of interest for each of the variables of outcomes, backward selection logistic regression modeling was fitted with probability of removal of a variable set at 0.2. Multi-collinearity and interaction effect checks were also done by measuring Variance Inflation Factors (VIF), labelling of outliers and running cross products. Multicollinearity and interaction effects were not observed among the variables included in the models. The estimates of the crude and adjusted odds ratios were fairly similar and this shows that the variables used for adjustment are not confounding variables. The outcome variables, number and timing, adequacy of services content and overall adequacy of ANC services, were dichotomized with “1” being adequate and “0” being inadequate. Four different models were fitted to investigate the factors predicting the adequacy of ANC services i.e., for timing, number, service content and overall adequacy. For this study, p-value <0.05 was considered as statistically significant at 95 % confidence interval. In this study, data are weighted unless otherwise indicated.
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