Sociodemographic characteristics
A total number of 424 Afghan women aged 18-45 years old enrolled in this study. The majority of them (44.3%) were in 25-34 age group and had no education (37.7%). Almost half of them had a job. More than half of them (56.6%) had 2-4 pregnancy experiences. In term of the husband education and employment, 27.8% of them had high school or higher education and almost all of them (98.1%) were employed. The family income was more than 4 million Toman (11500 Iranian Toman=1 USD) in about half of the households. More than 60% of participants were legal immigrants. Only 120 participants (45.5%) of legal immigrants had health insurance (Table 1).
Table 1. The distribution of sociodemographic characteristics of participants
|
|
n (%)
|
Age group (year)
|
|
18-24
|
131 (30.9)
|
25-34
|
188 (44.3)
|
35-44
|
105 (24.8)
|
Education
|
|
No education
|
160 (37.7)
|
Primary/secondary
|
136 (32.1)
|
High school or higher
|
128 (30.2)
|
Employment
|
|
Employed
|
216 (50.9)
|
Unemployed
|
208 (49.1)
|
Parity
|
|
1
|
80 (18.9)
|
2-4
|
240 (56.6)
|
≥ 5
|
104 (24.5)
|
Husband education
|
|
No education
|
159 (37.5)
|
Primary/secondary
|
147 (34.7)
|
High school or higher
|
118 (27.8)
|
Husband employment
|
|
Employed
|
416 (98.1)
|
Unemployed
|
8 (1.9)
|
Family income (Iranian Toman)
|
|
< 4 million
|
224 (52.8)
|
≥ 4 million
|
200 (47.2)
|
Length of stay in Iran
|
|
< 5 years
|
192 (45.3)
|
≥ 5 year
|
232 (54.7)
|
Legal status
|
|
Illegal
|
160 (37.7)
|
Legal
|
264 (62.3)
|
Insurance *
|
|
No insurance
|
144 (54.5)
|
Had insurance
|
120 (45.5)
|
The number of ANC
|
|
< 4
|
64 (15.1)
|
4-8
|
208 (49.1)
|
≥ 8
|
152 (35.8)
|
Total
|
424 (100)
|
* Only included the legal immigrant (n = 264)
|
Access to the ANC
According to the new WHO recommendation (2016) for adequate ANC, almost 36% of Afghan women received adequate ANC (≥ 8) during their pregnancy. However, based on previous WHO recommendation (2002) for adequate ANC (4 or more visits), about 85% of participants had adequate ANC.
The sociodemographic determinants of adequate ANC
Tables 2 and 5 illustrate the results of bivariate and multivariate analyses for the association of sociodemographic factors with adequate ANC. The results were as follows:
Age
In bivariate analysis, it appeared that the oldest age group (35-45 years) are less likely to have adequate
Table 2. The association between the sociodemographic factors and adequate ANC (≥ 8 visits) in Afghan women
|
|
Number of ANC
|
|
< 8 visits (%)
|
≥ 8 visits (%)
|
Crude OR (95% CI) 1
|
p-value
|
Age group (year)
|
18-24
|
70 (25.7)
|
61 (40.1)
|
Ref
|
|
25-34
|
137 (50.4)
|
51 (33.6)
|
0.43 (0.27-0.68)
|
|
35-45
|
65 (23.9)
|
40 (26.3)
|
0.71 (0.42-1.19)
|
0.002
|
Education
|
No education
|
120 (44.1)
|
40 (26.3)
|
Ref
|
|
|
Primary/secondary
|
96 (35.3)
|
40 (26.3)
|
1.25 (0.75-2.10)
|
|
|
High school or higher
|
56 (20.6)
|
72 (47.4)
|
3.86 (2.34-6.36)
|
0.001
|
Employment
|
Unemployed
|
128 (47.1)
|
88 (57.9)
|
Ref
|
|
|
Employed
|
144 (52.9)
|
64 (42.1)
|
0.65 (0.43-0.96)
|
0.032
|
Parity
|
1
|
48 (17.6)
|
32 (21.1)
|
Ref
|
|
|
2-4
|
152 (55.9)
|
88 (57.9)
|
0.87 (0.52-1.46)
|
|
|
≥ 5
|
72 (26.5)
|
32(21.1)
|
0.67 (0.36-1.23)
|
0.399
|
Husband education
|
No education
|
128 (47.1)
|
31 (20.4)
|
Ref
|
|
|
Primary/secondary
|
92 (33.8)
|
55 (36.2)
|
2.47 (1.47-4.13)
|
|
|
High school or higher
|
52 (19.1)
|
66 (43.4)
|
5.24 (3.07-8.95)
|
0.001
|
Husband employment
|
Employed
|
266 (97.8)
|
150 (98.7)
|
Ref
|
|
|
Unemployed
|
6 (2.2)
|
2 (1.3)
|
0.59 (0.12-2.97)
|
0.518
|
Family income
(Iranian Toman)
|
< 4 million
|
184 (67.6)
|
40 (26.3)
|
Ref
|
|
≥ 4 million
|
88 (32.4)
|
112 (73.7)
|
5.85 (3.77-9.10)
|
0.001
|
Length of stay in Iran
|
£ 5 years
|
152 (55.9)
|
40 (26.3)
|
Ref
|
|
|
> 5 year
|
120 (44.1)
|
112 (73.7)
|
3.55 (2.30-5.47)
|
0.001
|
Legal status
|
Illegal
|
136 (50.0)
|
24 (15.8)
|
Ref
|
|
|
Legal
|
136 (50.0)
|
128 (84.2)
|
5.33 (3.25-8.76)
|
0.001
|
Insurance *
|
No insurance
|
112 (82.4)
|
32 (25.0)
|
Ref
|
|
|
Has insurance
|
24 (17.6)
|
96 (75.0)
|
14.00 (7.71-25.39)
|
0.001*
|
* Only included the legal immigrant (n = 264)
1 The odds ratio (OR) and 95% confidence interval (95%CI) for adequate access to ANC (≥ 8 visits)
|
|
ANC (at least 8 visits) (26.3%) compared to the younger age groups; however, in multivariate analysis, after adjusting for other sociodemographic variables and component factors, the odds of having adequate ANC in this group became almost 11 times the youngest age group (18-24 years).
Education
Higher education level was significantly associated with adequate ANC in bivariate analysis. Likewise, in multivariate analysis, the literate women were more likely to have adequate ANC (AOR = 8.65; 95% CI [2.48-30.11]).
Employment
It appeared that having a job reduce the likelihood of having adequate ANC in Afghan women (COR = 0.65; 95% CI [0.43-0.96]). However, it became insignificant after adjusting for other variables in regression analysis (AOR = 0.54; 95% CI [0.18-1.59]).
Parity
There was no significant association between the number of pregnancies and having adequate ANC in bivariate analysis (p = 0.399). Therefore, we did not include it in final regression equation.
Husband education
Similar to bivariate analysis, the higher education of husband was significantly associated with adequate ANC in multivariate analysis, even adjusting for other variables (AOR = 4.67; 95% CI [1.91-11.40]).
Husband employment
There was no significant association between the husband employment and having adequate ANC in bivariate analysis (p = 0.518).
Family income
Having more than 4 million Toman family income was significantly associated with adequate ANC (AOR = 5.85; 95% CI [3.77-9.10]), even after adjustment for other variables in multivariate analysis, the odds of having more than 8 ANC visits was almost 8.59 times higher in women of 4 million or higher family income.
Length of stay in Iran
It appeared that the access to adequate ANC in settled Afghan refugees and immigrants (with more than 5 years in Iran) is significantly higher than that of the recent ones (5 years or less in Iran) in both bivariate (COR = 3.55; 95% CI [2.30-5.47]) and multivariate analysis (AOR = 3.29; 95% CI [1.43-7.61]).
Legal status
In both bivariate and multivariate analysis, the legal immigrants were more likely to have adequate ANC (AOR = 7.07; 95% CI [2.28-21.96]).
Health insurance
In Iran, only legal immigrants are eligible for having health insurance; thus, this variable was only examined among legal immigrants (Table 1, 2). The results showed that the odds of having adequate ANC is 14 times higher in insured Afghan women (COR = 14.00; 95% CI [7.71-25.39]).
The reasons for inadequate ANC
Table 3. The distribution of potential reasons and their association with adequate ANC (≥ 8 visits) in Afghan women
|
|
Number of ANC
|
< 8 visits (%)
|
≥ 8 visits (%)
|
Crude OR (95% CI) 1
|
p-value
|
I was healthy
|
136 (50.0)
|
64 (42.1)
|
0.72 (0.48-1.09)
|
0.118
|
I think it is unnecessary
|
176 (64.7)
|
48 (31.6)
|
0.25 (0.16-0.38)
|
0.001
|
Expenses were unaffordable
|
192 (70.6)
|
72 (47.4)
|
0.38 (0.25-0.57)
|
0.001
|
Clinic was too far
|
184 (67.6)
|
48 (31.6)
|
0.22 (0.14-0.34)
|
0.001
|
Family members disapproved*
|
16 (5.9)
|
8 (5.3)
|
|
0.791
|
Poor transportation
|
216 (79.4)
|
72 (47.4)
|
0.23 (0.15-0.35)
|
0.001
|
Scare of / being discriminated or poorly treated
|
168 (61.8)
|
64 (42.1)
|
0.45 (0.30-0.67)
|
0.001
|
No one to accompany me
|
120 (44.1)
|
24 (15.8)
|
0.24 (0.14-0.39)
|
0.001
|
The services were not good
|
56 (20.6)
|
8 (5.3)
|
0.21 (0.10-0.46)
|
0.001
|
Long waiting time
|
96 (35.3)
|
24 (15.8)
|
0.34 (0.21-0.57)
|
0.001
|
Religious and cultural reasons
|
144 (52.9)
|
40 (26.3)
|
0.31 (0.21-0.49)
|
0.001
|
Better service at home*
|
8 (2.9)
|
0
|
|
0.055
|
Fear of arrest/deportation
|
120 (44.1)
|
24 (15.8)
|
0.24 (0.14-0.39)
|
0.001
|
Total
|
272
|
152
|
|
|
* These variables were not included in the factor analyses as well as regression analyses.
1 The odds ratio (OR) and 95% confidence interval (95%CI) for adequate access to ANC (≥ 8 visits)
|
|
Poor knowledge and attitude toward ANC
The component factor “poor personal knowledge and attitude toward ANC” was negatively associated with the adequate ANC among Afghan women (COR = 0.37; 95% CI [0.25-0.57]). Likewise, in multivariate analysis, after adjustment for other variables in equation, this relation remained significant (AOR = 0.06; 95% CI [0.03-0.15]).
Difficulties in access
The hardships in seeking ANC such as unaffordable expenses, far distance, and poor transportation were more prevalent among those with inadequate ANC (70.6%, 67.7%, and 79.4% respectively). Although in bivariate analysis; the component factor “difficulties in access” was associated with inadequate ANC (COR = 0.29; 95% CI [0.17-0.48]), adjustment for other variables in multivariate analysis, diluted this association (AOR = 0.33; 95% CI [0.11-1.00]).
Table 4. Factors emerged in factor analysis and their association with adequate ANC (≥ 8 visits) in Afghan women
|
|
Number of ANC
|
< 8 visits (%)
|
≥ 8 visits (%)
|
Crude OR (95% CI)
|
p-value
|
Poor knowledge/attitude toward ANC1
|
192 (70.6)
|
72 (47.4)
|
0.37 (0.25-0.57)
|
0.001
|
Difficulties in access2
|
240 (88.2)
|
104 (68.4)
|
0.29 (0.17-0.48)
|
0.001
|
Poor quality of services3
|
112 (41.2)
|
32 (21.1)
|
0.38 (0.24-0.60)
|
0.001
|
Sociocultural/legal issues4
|
200 (73.5)
|
88 (57.9)
|
0.50 (0.33-0.75)
|
0.001
|
Total
|
272
|
152
|
|
|
1 composed of: “I was healthy”, “I think it is unnecessary”.
2 composed of: “Expenses were unaffordable”, “Clinic was too far”, “Poor transportation”
3 composed of: “The services were not good”, “Long waiting time”
4 composed of: “Scare of / being discriminated or poorly treated”, “Religious and cultural reasons”, “Fear of arrest/deportation”, “No one to accompany me”
|
|
Poor quality of services
Poor quality of services appeared to be a significant obstacle in having adequate ANC in both bivariate (COR = 0.38; 95% CI [0.24-0.60]) and multivariate analyses (AOR = 0.17 95% CI [0.07-0.41]).
Sociocultural/legal issues
The sociocultural and legal issues such the fear of being discriminated or poorly treated, religious and cultural concerns, and fear of deportation or arrest were respectively reported among 61.8 %, 52.9%, and 44.1% of those with inadequate ANC. Accordingly, these issues were negatively associated with adequate ANC in bivariate analysis (COR = 0.50; 95% CI [0.33-0.75]). However, adjusting for other variables in multivariate analysis, reduced the cumulative impact of these issues on adequate ANC among Afghan women (AOR = 0.46; 95% CI [0.19-1.10]).