Factors Associated With Changes in Adequate Antenatal Care Visits Among Pregnant Women Aged 15-49 Years in Tanzania From 2004 to 2016

Abstract

Background:

Antenatal care (ANC) is crucial for the health of the mother and the unborn child as it delivers highly–effective health interventions that can prevent maternal and newborn deaths and morbidity. In 2002, the World Health Organization (WHO) recommended a minimum of four ANC visits for a pregnant woman with a positive pregnancy during the entire gestational period. Tanzania has sub-optimal adequate (four or more) ANC visits and the trend has been fluctuating over time. An understanding of the factors associated with changes in adequate ANC visits over years is crucial in improving the proportions of pregnant women attaining adequate ANC visits in Tanzania.

Methods

The study used secondary data from Tanzania Demographic Health Survey (TDHS) from 2004 to 2016. The study included 17976 women aged 15–49 years. Data were analyzed using stata version 13. Categorical and continuous variables were summarized using descriptive statistics and using the weighted proportions. A Poisson regression analysis was done to determine factors associated with adequate antenatal. A multivariable Poisson decomposition analysis was done to determine factors associated with changes in adequate ANC visits among pregnant women in Tanzania from 2004 to 2016.

Results

The overall proportion of women who had adequate ANC visits in 2004/05, 2010 and 2015/16 was 62%, 43% and 51% respectively. The identified determinants of adequate ANC visits were: early ANC initiation, zones, having more than one child, being aged 20 years and above, wanting pregnancy later, belonging to a richer and richest wealth quintile, having secondary and higher education, reporting distance to health facility not a big problem and watching TV at least once per week. Comparing 2004/05 and 2010 surveys, changes in the population structure contributed 4.2% of changes in adequate antenatal care visits while changes in coefficients contributed 95.8% of the changes. Also, comparing 2015/16 to 2010 surveys, changes in population structure and coefficients contributed 66.2% and 33.8% respectively.

Conclusion

Early ANC initiation has greatly contributed to increased proportion of pregnant women who attain four or more ANC visits overtime. More effort should focus on pregnant women to initiate ANC in the first trimester in order to increase proportion of women with adequate ANC visit.

Background

Adequate and quality antenatal care (ANC) is effective at promoting better health outcomes for both the mother and child during pregnancy(1, 2). Strong evidence exists to support the link between ANC during pregnancy, skilled birth attendant during delivery and quality postnatal and reduced maternal and infant morbidity and mortality(3–8). Globally, almost 60% of stillbirths are due to poor fetal growth, untreated and unattended maternal infection and conditions, which could have been prevented or treated by expert attention available during ANC visits(7). A wide range of services can be offered during ANC including screening, detection, prevention to treatment of any pregnancy related complication, infection or morbidity(9).

WHO 2002 Focus Antenatal care (FANC) model recommends a minimum of four ANC visits for a woman with uncomplicated pregnancy with the first visit during the first trimester, although currently there is a 8 contacts model in place (9, 10). In 2002 Tanzania adopted FANC with the exception that the first ANC was initiated within 16th gestational weeks(11). Globally, ANC coverage (one ANC visit) is 86%, however only 62% meet the recommended four ANC visits. In Africa ANC coverage is 69% with only 54% attending the minimum of four ANC visits, in Tanzania ANC coverage is higher (98%) but only 51% of pregnant women attend the minimum of four ANC visits(12). Despite a high ANC coverage, adequate ANC visits (defined as 4 or more visits) is still suboptimal and could in part explain the unacceptably high neonatal mortality and still birth rates in Tanzania, 25 deaths/1000 live births and 39 deaths/1000 pregnancies respectively(13).

The Tanzania demographic and Health survey (TDHS) reported a fluctuating trend in adequate ANC visits; a fall from 62–43% and a rise to 51% for the 2004/05, 2010 and 2015/16 survey respectively(13). This underutilization of ANC has been associated with a number of factors as documented in various studies. The factors include: Long distance to health facility, geographical zone, 1st ANC initiation, woman’s desire to avoid pregnancy, marital status, wealth quintiles, parity, living in urban, and higher education level(14–19). With the current trend, it is still unclear what had contributed to the changes in adequate ANC visits among pregnant women over time. Therefore, this rises a need to determine factors associated with changes in adequate ANC visits among pregnant women aged 15–49 years in Tanzania from 2004 to 2016.

Methods

Study Population

The population was all women of reproductive age (15–49 years) who had given birth to at least one child within the five years prior the survey and had information on ANC visits. For a woman with more than one child birth during the five-year period, the most recent birth was considered for this analysis. A total of 33,734 women age 15–49 years in Tanzania participated in the three TDHS surveys. Within 2004/5 there were 10,329, 10,139 in 2010, and 13,266 in 2015/16. Of these, 15,668 (46.4%) did not give birth within the preceding five years period and they were excluded from the analysis leaving 18,066 (53.6%) who reported a birth in the previous 5 years. Women who reported a birth in the past 5 years was 5658 in 2004/05, 5358 in 2010 and 7050 in 2015/16. Of the remaining a total of 90(0.5%) were also excluded due to missing information on the outcome and finally a total of 17,976(53.3%) were included for the final analysis. Of the17,976 women enrolled in the study; 4541(77.9%), 4201(76.9%) and 5193(70.1%) for 2004/05, 2010 and 2015/16 surveys respectively (Fig. 1).

Study Variables

The dependent variable was adequate ANC visits, which was categorized as four or more ANC visits and coded 1. Less than four ANC visits as inadequate and coded 0. The independent variables included respondent’s age at last birth (15–19 years, 20–24 years, 25–29 years, 30–34 years, 35 + years), education level (no formal education, primary education, secondary and higher education), employment status (unemployed, employed), marital status (married/cohabiting, single, divorced/widowed/separated), residence (urban, rural), wealth index (poorest, poorer, middle, richer, richest), zones (western zone, northern zone, central zone, southern highlands, southern zone, south west highlands zone, lake zone, eastern zone, Zanzibar), first ANC initiated (later than 1st trimester, within 1st trimester), decision maker of respondent’s health care (respondent alone, respondent and partner, partner alone, someone else), parity (1 child, 2–3 children, 4–5 children, 6 or more children), frequency of listening to radio (not at all, Less than once a week, at least once a week), frequency of watching TV (not at all, less than once a week, at least once a week), desire of last pregnancy (wanted then, wanted later, wanted no more), history of terminated pregnancy (never had, ever had) and distance from health facility (big problem, not a big problem).

Results

Discussion

This study has shown that the prevalence of adequate ANC visits has fluctuated in 10-year period between 2004/05 and 2015/16; starting at 62% in 2004/05, dropping to 43% in 2010 and then rising again to 51% in 2015/16. The fluctuating trend of adequate ANC visit could be partially explained by changes in the timing of ANC initiation. This findings were similar to TDHS but contrast to Bangladesh and Ethiopia the proportion of women achieving an adequate ANC visits (13, 20, 21). Between 2004 and 2016 both the proportion of women achieving adequate ANC visits and those who initiated within the first trimester increased. Suggesting that women who initiate first ANC visit within the first trimester are more likely to attain four recommended ANC visits. The initial timing of the first ANC visit may, in some way, explain the decline in the proportion of women achieving adequate ANC visits that was observed between 2004 and 2010. At this time the national guidance in Tanzania stated that women should attend by her 16th gestational week and not, within 12 weeks, like in other countries(11). This of course, delays the first visit and could then subsequently lead to a lower adequate attendance. Also, Tanzania Service Provision Assessment Survey reports although 82% of all facilities offer ANC there have been differentials on services offered across region (22). Efforts to ensure Tanzania reached the MDG 4 and 5 and “Wazazi nipendeni” campaign in 2012 could explain the increase in adequate attendance between 2010 and 2016 (15, 16). Whilst it is not possible to directly attribute impact to these campaigns it is likely that these played a part in increases early attendance, which is a contributing factor to adequate attendance. Strengthened and focused efforts are needed where early ANC attendance and subsequent adequate attendance remains sub-optimal.

The study findings for 2004/05 TDHS suggest that women who initiate first ANC within first trimester were more likely to accomplish adequate ANC visits. These findings are consistent with another study done in Tanzania, Peru, Cambodia, Cameroon, Senegal, Uganda and Nepal (23, 24). This similarity can be explained by NGOs support and various campaigns that have been conducted in the mentioned countries on ANC utilization as well as early initiation of ANC visits among pregnant women. This positive association between early ANC initiation and adequate ANC visits has also been reported in many other literatures as well. These findings were also observed in 2010 and 2015/16 surveys as well.

Also, for the same survey year, the study found that pregnant women belonging to richer or richest wealth status had higher prevalence of having adequate ANC visits. This findings are similar to a study done in Indonesia, Nepal, Senegal, Uganda and Ethiopia as well as Colombia (18, 19, 23, 25, 26). The findings complements the 2018 USAID Health Policy Plus report which also showed wealth status as a significant determinant of maternal healthcare utilization in Tanzania (17). This would reflect inequities across wealth quintiles which is a barrier in accessing ANC thus leads to not attaining adequate ANC attendance. This can also be explained by the indirect costs such as transportation, unexpected fees or costs for medication, tests or procedures which are not covered in waivers or exemptions policies for ANC services. Also, women from richer and richest household had most of women who had secondary and higher education 28.8% and 57.7% respectively. Education to a woman implies empowerment whereby she becomes more aware has autonomy in utilization health services which influences attaining adequate ANC visits during pregnancy. This highlights the need to address financial barriers and to accessing ANC service and advocating on educating girls and women which will help women from low income families to achieve adequate ANC visits.

The decomposition analysis in this study suggest that changes in both the population and the effects contributed to the changes seen in adequate ANC visits. The changes in adequate ANC in the South West Highlands contributed to 14.2% of this decline from 2004 to 2010, which was due to the decrease in effects of zone between the two time points. However, initiating ANC within first trimester contributed negatively (-8.9%) to a decline in adequate ANC visits. This means that initiating ANC within first trimester leads to the increase in adequate ANC visits, and if there had not been an increase in women initiating ANC within first trimester the decline in adequate ANC visits would have been 8.9% larger. This was influenced by an increase in proportion of women who had first ANC visit within first trimester from 14% (2004) to 16% (2010), so mainly due to the population dynamics. Also,

For 2010 and 2015-16 survey, first ANC within the first trimester had contributed 50.5% of the increase in proportion of women with adequate ANC visits on differences due to population structure. This might be explained by efforts of government and other stakeholders through safe motherhood campaign (Wazazi nipendeni campaign) which emphasized on initiating ANC within first trimester and sharpened one plan, Big Results which have been improving maternal, neonatal, and child health services (15, 16). Not only that, but also South West Highlands contributed 21.4% of the increase in proportion of pregnant women with adequate ANC visits. This is explained by the increase in proportion of pregnant women with adequate ANC visits compared to other zones of which it might be attributed by Wazazi na mwana campaign which was in Rukwa one of the regions included in the zone (27). So, a need to focus on other regions in Tanzania so as to promote early ANC initiation and subsequently lead to increase in number of women attaining adequate ANC.

5.2 Conclusion

The results of this study indicate that adequate ANC attendance has been declining from 2004 to 2010 but a gradual increase has been observed in 2016. This study has found association between early ANC initiation, zones, having more than one child, someone else decides on a woman’s health, being aged 20 years and above, wanting pregnancy later, belonging to a richer and richest wealth quintile, having secondary or tertiary education, reporting distance to health facility not a big problem and watching TV at least once per week as factors associated with adequate ANC attendance. Early ANC initiation has greatly contributed to increased proportion of pregnant women who attain four or more ANC visits overtime.

5.3 Study Limitation And Strength

The study has utilized national representative data which makes the findings generalizable. The study has enough sample size which gives it power to make a conclusion about factors associated with changes in adequate ANC visits. Also, to the best of our knowledge this is the first study in Tanzania to look at factors associated with the observed changes in adequate ANC visits across three time points. This study has been able to analyze the data using Poisson regression analysis, as an alternative to the classical logistic regression when the outcome is common. This study has used the decomposition analysis which made it possible to obtain the contribution for each factor that influenced the changes in adequate ANC visits.

The study has used secondary data of which some variables have been missing in some of the survey, variable such as covered by health insurance which is known to be positively associated with adequate ANC visits was only captured in 2015-16 TDHS. Also, the data was self-reported by a woman, this makes the data more prone to failure to recall which might have led to an over estimation or under estimation of the effect. Also, the study is prone to social desirability bias as the women are aware of the recommended minimum ANC visits, which could have overestimated the effects. This study is a Crossectional study, thus no temporal relationship can be established.

5.4 Recommendation

Basing on the findings obtained, we would recommend the following:

• The government and policy makers to put more effort on promoting first ANC visit to be initiated within the first trimester.
• The government to add more effort on various zones in Tanzania that have been shown to have lowest proportions in adequate ANC visits such as in the western zone which includes regions Tabora and Kigoma.
• Interventions emphasizing on pregnant women to attain adequate ANC visits should focus women who are more vulnerable, this includes women at younger age less than 30 years old, from poorer, poorest and middle wealth quintiles, women with more than one child, women with unwanted pregnancy and also among women without secondary or tertiary education.

• Further studies to asses why women are not able to attain adequate ANC despite a high ANC coverage (98%).

List Of Abbreviations

ANC Ante-natal care

APR Adjusted Prevalence Ratios

FANC Focused Antenatal Care

LBW Low Birth Weight

MDG Millennium Development Goals

MMR Maternal Mortality Ratio

SDG Sustainable Development Goals

TDHS Tanzania Demographic and Health Survey

WHO World Health Organization

Declarations

Ethics approval and consent to participate

Ethical approval to conduct the study was obtained from the Kilimanjaro Christian Medical

University college research ethical committee. The ethical approval number granted was 2389.

Demographic and Health Survey Program authorized data access and the data were used solely for

the purpose of the current study.

Consent for publication

Not applicable.

Availability of data and materials

Data and material will be available upon request from the corresponding author with authorization

form demographic and health survey program, measure DHS.

Competing Interests

The authors declare that they have no competing interests.

Funding

This work was supported through the DELTAS Africa Initiative Grant No.107754/Z/15/ZDELTASAfrica SSACAB. The DELTAS Africa Initiative is an independent funding scheme of the African Academy of Sciences (AAS) ‘s Alliance for Accelerating Excellence in Science in Africa (AESA) and supported by the New Partnership for Africa’s Development Planning and Coordinating Agency (NEPAD Agency) with funding from the Wellcome Trust (Grant No. 107754/Z/15/Z) and the UK government. The views expressed in this publication are those of the author(s) and not necessarily those of AAS, NEPAD Agency, Wellcome Trust or the UK government.

Authors' contributions

Concept development and study design: EK, JT, JR; Data acquisition: EK; Supervision of the study: JT, JR; Data analysis and statistical support: JT, JR; critically revised the manuscript: EK, JT, JR; All authors read and finally approved the manuscript draft for publication.

Acknowledgements

We would like to thank the Kilimanjaro Christian Medical University college and Sub-Saharan Africa Consortium for Advanced Biostatistics Training programme for making it possible to carry out this study. And also, the Demographic and Health Survey Program which granted access to use TDHS for this study. My sincere gratitude to the department of Epidemiology and Biostatistics at Kilimanjaro Christian Medical University College and Epidemiology and classmates for their continuous support.

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28. Titles for the figures:.