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Determinants of Frequency and Content of Antenatal Care in Postnatal Mothers in Arba Minch Zuria District, SNNPR, Ethiopia, 2019

Background Antenatal care is one of the strategies for reducing maternal morbidity and mortality directly by affording increased chances of early detection of high-risk pregnancies. WHO recommends a minimum of four ANC visits. In order to make it effective, monitoring of the content and quality of the ANC is needed. However, a number of studies focus on the frequency of ANC, and evidence on core contents of the ANC was limited in this study area. The aim of this study was to determine factors associated with content of the ANC. Methods and Materials A cross-sectional study design was employed to collect data from a total of 432 respondents by using a semi-structured questionnaire. Data were entered in EpiData version 3.1 and exported to SPSS version 20 for analysis. Both binary logistic regression and generalized linear regression with Poisson type were applied to determine factors associated with frequency of the ANC and core contents of ANC, respectively. Results The majority of the mothers (78.7%) visited first ANC lately, and 25.2% of mothers attended ≥4 ANC visits. Only 17.1% of mothers received all the eight selected elements of ANC services. Predictors of the core contents of the ANC were the frequencies of ANC (AOR: 0.84 (95%CI: 0.76–0.93), pre-pregnancy utilization of contraception (0.63 (95%CI: 0.55–0.72)), pregnancy desire (AOR: 0.82 (95%CI: 0.71–0.94), and birth preparedness and complication readiness (AOR: 0.90 (95%CI: 0.82–0.98). Conclusion This study found that low level of WHO minimum recommended ANC and core contents of the ANC. This study suggests that identifying pregnant mothers early increases frequency of the ANC, which improves core content of care.


Background
Despite progress and efforts made to tackle maternal and neonatal mortality and morbidity they remain an urgent concern and become a major public health problem in low income countries. 1,2 Globally, near to 100% of maternal deaths occurred in developing countries and out of this, around two third deaths occurred in sub-Saharan Africa. 1,3 However, the majority of these deaths can be prevented with cost effective interventions. 4 Evidence has shown that antenatal care (ANC) can improve pregnancy outcomes through implementation of the WHO recommended strategies like early recognition and detection of pregnancy danger signs, birth preparedness and complication readiness, offering of preventive measures like TT vaccination, iron provision, and so on. 5,6 Although ANC in developing countries has been applied for a long time and has made observable achievements, most ANC programs established in low and middle income countries are largely underachieved. According to the WHO 2015 report, in high-income countries, almost all women have at least four ANC visits, while only 40% of all pregnant women in low-income countries had the recommended ANC visits. 7 As per a 2016 EDHS report, only 32% of pregnant women utilized the recommended ANC visits in Ethiopia. 3 Recently, a number of studies reported that attending ANC before 16 weeks as a predictor for adequate ANC utilization even if it is a challenging issue. 8,9 The WHO recommends a minimum of four visits of ANC to improve maternal and newborn health. 10 Despite that previous studies have revealed that, in addition to the number of ANC visits, the essential services covered by ANC visits greatly affect the effectiveness of the ANC. 11,12 In order to make it effective, monitoring of the content and quality of ANC is needed, which include blood pressure measurement, tetanus toxoid vaccination, urine testing, iron tablet supplementation, body weight measurement, HIV testing and counseling about danger signs. 13,14 However, a number of studies from around the globe reported very low level of content of ANC [15][16][17][18] even if it increases utilization of subsequent services such as maternal, newborn, and the child health continuum of care like skilled birth attendants and postnatal care. [19][20][21] Ethiopian guidelines on prenatal care recommends a minimum of four ANC visit and quality service for women who experience positive pregnancy. It also recommends weight measurement, blood pressure measurement, blood, and urine sample examination, minimum of two doses of tetanus toxoid vaccination, HIV test, counseling on danger signs and nutrition, iron (90+) provision to all pregnant women through respectful maternity care. However, according to the Ethiopia Demographic Health Survey (2016) report, it is underutilized. For instance, 49% of women's last births were protected against neonatal tetanus, 75% blood pressure measured, 73% blood sample taken, 66% Urine sample taken, and 66% were counseled about nutrition. 3 However, there were no data on percentages of mothers who received all the essential elements of ANC care. Furthermore, the majority of studies in subnational level, mainly focused on timing and frequency of ANC visits rather than the content of ANC care. 8,9,[22][23][24] In addition, in this study area, there was limited evidence regarding the level and factors of content of ANC. Thus, the aim of this study was to assess the magnitude and factors associated with frequency of the ANC, and to identify factors that facilitate or hinder the provision of the full contents of ANC.

Methods and Materials Study Area
The study was conducted at Arba Minch Zuria Woreda, Gamo Zone, Southern Ethiopia, 454 km south of Addis Ababa, the capital city of Ethiopia. The study area has a total of 29 kebeles, of which, two are semi-urban and the remaining 27 are rural.

Study Design and Period
A community based cross-sectional study was conducted from 15 February to 15 March 2019.

Population
The source populations for this study were all postnatal (1-42 days postpartum) women in Arba Minch Zuria Woreda. The study populations were all postnatal (1-42 days postpartum) women who had at least one ANC visit in nine randomly selected kebeles of the Arba Minch Zuria district. Those women reside for <6 months and are critically ill will be excluded from this study.

Sample Size Determination
The single population proportion formula was used to determine sample size for this study. Twenty-two percent proportion of the overall contents of the ANC were obtained from a study in Bangladesh, and assuming 95% confidence level, 5% margin of error, design effect of 1.5, and 10% of nonresponse rate. The final sample size for this study was 436. 15

Sampling Technique
To obtain the sampling frame, we used secondary data from health facilities. A total of 1316 postnatal women registered at different health facilities were used as sampling frame. A simple random sampling technique using a computer generated number was used to select a total of 436 eligible women in this study.

Data Collection Techniques, Tools and Personnel's
Data were collected by nine diploma nurses and supervised by three public health officers. Both data collectors and supervisors were given a one-day intensive training on submit your manuscript | www.dovepress.com

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International Journal of Women's Health 2020:12 the data collection methods and instruments. All data were collected from women using an interviewer-administered questionnaire. The questionnaire was adapted from an EDHS tool, other related published literature and after considering constructing from Anderson's model for health care seeking. 3,25 The household wealth index tool was adapted from EDHS. 3 The houses of women were assessed by a local guide. Before data collection, pretesting was conducted on 5% of the sample (41 women) outside the study area. After conducting pretest, some modifications were made to alter unclear and confusing questions.

Data Quality Management
Training was given to the data collection team by the team of investigators with particular focus on the content of the questionnaire. A practical role-play on interviewing skills was exchanged between the data collection team. The questionnaire was initially prepared in English and translated to the local language by an expert in the language and finally back-translated by another expert to English to check its consistency with the original meanings. The final questionnaire in the local language was used for data collection. To minimize social desirability bias, women were interviewed in a separate private place in their own household compound.

Data Analysis
The data were analyzed using univariate (frequency distribution), bivariate and multivariate statistical methods. In univariate analysis, percentages were calculated for categorical variables. Chi-squared test was used for checking statistical significance for categorical variables in bivariate analyses.
For the content of ANC received which was the primary outcome variable in this study, ANOVA was used to check statistical significance. Multivariate statistical analyses using generalized linear models (GLM) approach were carried out to identify the determinants of content of ANC. 26 Since the contents of the ANC were count variable, Poisson regression was used. When checking assumption for Poisson regression model, it fulfills assumption of equal dispersion. Because of that Poisson regression was used in this study. Finally, the odd ratios and its 95%CI were used to report the statistical significance of the independent variables. The statistical software packages SPSS 20 is used for all statistical analysis.
For frequency of ANC, bivariate binary logistic regression analysis was done, and variables with p-value <0.25 was considered as a candidate for a multivariate logistic regression model. In multivariate logistic regression, variables with p-value <0.05 were reported as statistically significant. The association between frequency of ANC and explanatory variables was reported with AOR and its 95%CI.

Measurements of Variables Dependent Variable
Primary response variable: content of care received during ANC visit content of care received during ANC: eight essential elements of ANC services were included in this study; blood pressure measurement, blood sample collection, urine sample collection, weight measurement, tetanus toxoid (TT2+) vaccination, iron folate (90+) supplementation, HIV testing, health education on danger signs and nutrition. The variable was measured as composite variable and had 0 and eight minimum and maximum scores, respectively. If the mother scored zero, she did not use any services and if she scored eight, she had used all services during ANC. 15,16,27,28 Contents of antenatal care received during pregnancy were assessed as questions like "Was your weight measured? Was your blood pressure measured?". The answers were recorded as Yes or No.
Secondary response variable: frequency of antenatal care is a dichotomous variable which was measured as whether mothers had four or more ANC visit or not. 28,29

Independent Variables
Household wealth index: a composite indicator of socioeconomic status of women derived using principal component analysis based on information from housing characteristics and ownership of household durable goods. In this study, the factor scores of the first component were divided into quintiles.
Autonomy in household decision making: a woman was said to have autonomous decision-making power on seeking MNH service if she alone or jointly (with her husband) decides on seeking MNH services; otherwise (husband alone or a third person decides on seeking MNH services) she was categorized as nonautonomous. 30 Knowledge on key pregnancy danger signs: women were classified as knowledgeable if they spontaneously mentioned at least two of the four key danger signs of pregnancy (vaginal bleeding, severe headache, blurring of vision and feet or face swelling) if not they were classified as not knowledgeable. 31 International Journal of Women's Health 2020:12 submit your manuscript | www.dovepress.com

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Women were classified under "well prepared" for birth and its complications when they reported that they have implemented five or more components of birth preparedness and complication readiness (BPCR) otherwise she was classified under "not well prepared". The components of BPCR considered in this study were identified place for birth, identified birth attendants, saved money, identified emergency transportation, identified labor and birth companion, identified blood donors if needed, and identified caregiver to children at home when the mother was away. 32,33 Ethics Approval and Consent to Participate Before the study was conducted ethical clearance was obtained from Arba Minch University, College of Medicine and Health Sciences institutional review board (IRB). Written informed consent was obtained from study participants for those aged 18 and above. For those participants, less than 18 years of age written informed consent was obtained from a parent or guardian using standard disclosure procedures. The confidentiality and privacy of participants were actively protected. All participants were assigned a unique identification number. Every effort was made to emphasize the voluntariness of this study and decisions to stop or discontinue in the study was respected. We confirmed that the study was conducted in accordance with the Declaration of Helsinki. Table 1. Shows the sociodemographic characteristics of the respondents, the majority of mothers aged under 35 (87.2%), married (96.3%), protestants (68.6%), more than 33% of mothers were unable to read and write, and only 16.2% were educated secondary grade. Regarding the accessibility of health services, most of the mothers walked as a means of transport (83.1%), around half (51.4%) were insured under community based health insurance system, 79.6% were made decision by both themselves and their husbands. Table 2 shows obstetric characteristics of the study participants. The majority of the mothers (78.7%) visited the first ANC late, more than three quarters attended ANC 1-3 times (75.8%), and had attended ANC at the health center (58.5%). Most of the mothers had parity 1 or 2 (70%), had planned the pregnancy (78%), had not well prepared the pregnancy and its complication (69.8%), currently using family planning method (68.1%).

Determinants of Frequency of Antenatal Care
In multivariable logistic regression analysis time of first antenatal visit, ANC provider, family planning utilization before recent birth, planned for pregnancy, and perceived required time to reach health facilities were identified as significant predictors of frequency of the ANC (Table 4). Mothers who started first ANC visit early (before three months were 3.8 times more likely to attended ≥4 ANC than their counterparts (AOR: 3.8, 95%CI: 2.2-6.7). The odds of receiving adequate ANC (four or more) among mothers with planned for pregnancy were 2.6 times higher compared to those had an unplanned pregnancy (AOR: 2.6, 95%CI: 1.1-6.9). Mothers who had obtained ANC services from a skilled provider had 1.8 times higher odds of receiving four or more ANC visits than the mothers who had obtained ANC services from unskilled health personnel (AOR: 1.8, 95%CI: 1.1-3.2). The likelihood of attending four or more ANC visits were 3.3 times higher for mothers who reported the perceived required time to reach health facilities was less than 30 minutes compared to the mothers who reported the required time was greater than 30 minutes (AOR: 3.3, 95%CI: 1.8-6.1). Mothers who used prepregnancy contraceptive were four times more likely attended ANC visits ≥4 compared to mothers who had not used contraception before recent birth (AOR: 4.0, 95%CI: 1.7-9.2) ( Table 3).

Contents of Antenatal Care
In the current study, only 17.1% of mothers received all the eight selected elements of ANC services. Among the elements of ANC, blood pressure measurement was the most frequently used item by 78.5% mothers, closely followed by education on danger signs and nutrition by 78% mothers, weight measurement by 77.8% mothers. More than two thirds (67.4%) of mothers were reported to have blood tests. More than half (56.3%) of mothers were reported to have an HIV test, 53.2% had been vaccinated for tetanus, 54.4% had urine test, and 50% mothers reported that they were taking iron (90+) during the ANC visit.

Determinants of Contents of Antenatal Care
The analysis of this study found that four variables that determine the content of antenatal care. Frequency of antenatal care, birth preparedness and its complication readiness, prepregnancy contraceptive utilization, and pregnancy desire as significant predictors of receiving the items of ANC services.
Mothers who had less than four ANC visit were 16% less likely to receive items of ANC content (AOR: 0.84, 95%CI: 0.76-0.93). Pregnancy desire of mother's also revealed significant association with the use of ANC service. Mothers were found to have at least 18% lower odds of receiving items of ANC services if the pregnancy was unplanned at the time (AOR: 0.82, 95%CI: 0.71-0.94). Mothers with no history of utilization of contraception before recent birth had a lower chance of using the elements of ANC services than the mothers with a history of contraceptive utilization before recent birth (AOR: 0.63, 95%CI: 0.55-0.72). Mothers who were not well prepared for

Discussion
This study revealed low levels of WHO's recommended minimum ANC visits by mothers (25.2%). Receiving ANC from a skilled provider, perceived required time to reach health facilities, wanted pregnancy, modern contraceptive utilization, time for ANC visit were identified as predictors of frequency of ANC. However the recent report of the EDHS (2019) revealed four or more ANC of 43%. 34 This indicates unsatisfactory compliance with WHO's recommendations on optimal antenatal care visits in Ethiopia.
In this study, mothers who had received ANC care from health professionals were more likely to complete the recommended ANC visits compared to their counterparts. This is inconsistent with studies conducted elsewhere. 15,35,36 The result suggested that provision of ANC services by skilled professionals increased the chance of adequate ANC visit.
The current study found a significant association between time spent to reach health facilities and frequency of ANC visits. Mothers spending more than 30 min to reach health facilities were less likely to attend adequate ANC compared to their counterparts. Although there is a strong recommendation of universal access to health services and reducing financial hardship, still there is regional variation in easy access to health services. 37,38 This implies that outreach service should be strengthened to avail maternal services to mothers who reside some distance from the nearest health facilities.
According to this study, time for an ANC visit is identified as a factor of the frequency of the ANC. Those mothers who started ANC early or before 16 weeks were more likely to attend ≥4 ANC compared to late visitors. This is in line with a study elsewhere. 38 This is may be due  to early visitors having more time to attend. This is explained by community extension workers should screen and identify pregnancy early. Existing evidence indicates community engagement can be effective in increasing access to early ANC. The study finding indicates the overall utilization of the items of ANC was 17.1% (95%CI: 13.2-20.6) which is consistent with a study in Uganda, while lower when compared to studies in Nepal and Bangladesh. 15,28,39 This might be due to national variation on the minimum recommendation of ANC visits.
The number of antenatal visits is identified as a factor that affects the utilization of ANC content. This is explained as the higher number of ANC visits might maximize the likelihood of items of the ANC. This is supported by studies conducted elsewhere. 15,17,18,39 Moreover, the WHO came up with the new ANC model, which recommends eight contacts which might increase utilization of contents of antenatal care so that this finding implies the policy makers should strengthen the implementation of the new model of ANC. 40 In addition, awareness creation sessions should be there to help mothers understand the effect of frequent visits as recommended by a health professional.
This study shows that having of history of prepregnancy contraceptive utilization before recent birth positively predicts receiving of both adequate ANC and content of the ANC. This finding is supported by studies from Nepal, Bangladesh, and Uganda. 15,28,39 This might be due to family planning helping mothers to have children in the right spacing and hence allow them the resources and time to attend the next antenatal visits with ease. Researchers also reflect on the provision of education on family planning during antenatal visits.
In this study pregnancy desire is significantly associated with both the frequencies of the ANC and utilization of items of the ANC. The probability of receiving a higher number of items and attending more ANC visits was lower for mothers who had an unplanned pregnancy compared to planned pregnancy. This finding is in line with studies elsewhere. 15,22,41 The finding indicates that mothers are usually less careful about receiving ANC services in the case of an unwanted pregnancy. In addition, this might be due to women who had an unplanned pregnancy, attended ANC care late, and accessed fewer full items of ANC. 17,22,42 Thus, the policy makers should strengthen the implementation of strategies that decrease unplanned pregnancies. Moreover, early identification of women with unplanned pregnancy by health workers should be strengthened. This study indicate that mothers who were well prepared for birth and ready for its complications were more likely to receive items of ANC. This might be due to wellprepared mothers who were more aware about preventive measures of pregnancy-related complications, and who seek care for it from health professionals. [43][44][45] Moreover, the WHO recommends birth preparedness and complication readiness in order to increase skilled birth and to reduce postpartum related complications. 7 Researchers also believe that BPCR increases visits for subsequent maternal health care. 33

Limitation of the Study
This study had both strengths and limitations. There was limited evidence on the determinants of the contents of ANC in this study area. Thus, it adds inputs at local and policy level. It also improves ANC service implementation at health facilities. Since this study is cross sectional, no cause and effect relationship was reported. In addition, social desirability bias could be another limitation.

Conclusion
The findings of this study showed a low level of WHO minimum recommended ANC and core contents of the ANC. This finding implies that the government should focus on not only on the frequency of ANC visits, but also give attention to care contents. In this study preconception care like prepregnancy contraceptive utilization was identified as a determinant for both frequencies of the ANC and the contents of ANC care. This implies policy makers and concerned government bodies should give attention to strengthening the implementation of preconception care.
Since this study is cross sectional, it is difficult to conclude as frequency of ANC does indeed influence the content of the ANC. Therefore, further study with analytic and experimental design might support these findings.
In this study, time for the first ANC visit was significantly associated with ANC frequency while not with core contents of ANC even if a number of previous studies found its association. Consequently, further study focusing on time for ANC visits.

Data Sharing Statement
The data used to support the findings of this study are available from the corresponding author upon request via email address of derehaile2010@gmail.com