Time spent on provision of Antenatal Care and associated factors among public and private health facilities in Axum town, North Ethiopia: Comparative cross sectional study

In most developing countries the contact time among antenatal care attendees and care providers have effects on quality of antenatal services and health outcomes. Effectiveness of focused antenatal care relies on standard time spent provisions. Hence this study evaluated the time spent and associated factors on provision of antenatal care in public and private health facilities in Axum Town, Northern Ethiopia. Institutional based comparative cross-sectional mixed quantitative and qualitative methods were used. Data were collected through exit interviews from 456 antenatal care attendees. Qualitative data were also collected using an in-depth interview with providers. The collected data were entered using EPI info version 3.5.1 software then exported to SPSS version 21 software for analysis. Multivariate logistic regression model was used to identify determinant factors of time spent on antenatal care provision at p-value < 0.05.


Abstract Background
In most developing countries the contact time among antenatal care attendees and care providers have effects on quality of antenatal services and health outcomes. Effectiveness of focused antenatal care relies on standard time spent provisions. Hence this study evaluated the time spent and associated factors on provision of antenatal care in public and private health facilities in Axum Town, Northern Ethiopia.

Methods
Institutional based comparative cross-sectional mixed quantitative and qualitative methods were used.
Data were collected through exit interviews from 456 antenatal care attendees. Qualitative data were also collected using an in-depth interview with providers. The collected data were entered using EPI info version 3.5.1 software then exported to SPSS version 21 software for analysis. Multivariate logistic regression model was used to identify determinant factors of time spent on antenatal care provision at pvalue < 0.05.

Results
Majority, 378 (84.8%) of pregnant woman were served below the mean standard time in both public and private health facilities. The mean (± SD) time spent for rst antenatal care provision in private was 19.7 (± 8.5) minutes, which is higher than public health facilities with mean time spent (± SD) of 13.2 (± 3.8) minutes. The mean time spent on antenatal care was signi cantly different in public and private health facilities. Factors that signi cantly affect time spent on provision of antenatal care were: type of health facilities [AOR = 2.60; 95% CI, 1.07-6.33], frequency of antenatal care visit [AOR = 3.50; 95% CI, 1.92- 6.36] and language similarity with provider [AOR = 2.74; 95% CI, 1.23-6.12].

Conclusions
The mean time spent for rst and revisit of ANC at both health facilities were lower than the WHO standards. Type of health facilities, frequency of antenatal care visit and language similarity with provider were predictors for time spent on ANC provision. Efforts should be targeted on standard provision of antenatal care.

Background
Among the various big pillars of safe motherhood initiatives, antenatal care (ANC) remains one of the essential interventions that have the potential to reduce maternal morbidity and mortality [1]. Despite the international emphasis in the last few years on the need to address the unmet health care needs of pregnant women and children progress in reducing maternal and child mortality, it is still a challenging agenda [2]. According to the Ethiopian Demographic and Health Survey (EDHS) 2011 report, the maternal mortality rate was 676 deaths per 100,000 live births [3].
World Health Organization (WHO) recommended strategies for safer motherhood health, one of this was the new four-visit focused antenatal care (FANC) model with standard time spent which would allow 30 to 40 minutes for a rst visit and 20 minutes for a revisit. It has been highlighted that since the number of visits is reduced to four in the basic component a "standard contact time" (SCT), Standard contact time is the length of time that health providers will need if they follow protocol and carry out appropriate steps with clients) [4].
While many factors affect the quality of ANC services, an emerging body of literature suggest that the amount of provider's time spent with clients known as patient contact time (PCT) was a good proxy for quality and the basis for patients' positive outcomes and it was one of the determinants for uptake, satisfaction and continued utilization of ANC service [5]. A study conducted at public health clinics in Bangladesh on the factors affecting PCT showed that when one percent of patient service increase, the patient contact time reduced by 0.34%. [6]. The study done in the Gambia on factors affecting ANC service offered at the public and private clinics showed that women at both health facilities (HF) did not receive su cient information, education and communication with their healthcare providers about the services provided during ANC [7].
Despite the fact that time spent on ANC service was essential for the quality of service and improvement of maternal and child health, the knowledge about client-provider time spent on ANC is not well studied in Ethiopia in general and in Tigray Region in particular. Therefore, the aim of this study was to evaluate the time spent on the provision of ANC and to identify factors associated with time spent during the provision of ANC at public and private HF in Axum Town, Northern Ethiopia.

Study setting
Institution-based comparative cross-sectional mixed quantitative-qualitative study design was conducted to evaluate the magnitude and associated factors of time spent on the provision of ANC among public and private health institutions in Axum Town, Northern Ethiopia.
Axum town is one of the zones found in the region located about 235 kilometers from Mekelle, the capital of Tigray and 1011km away from Addis Ababa, capital of Ethiopia. According to the Ethiopian National census report in 2007, the total population of Axum town was 56,576 [8]. The study was conducted in three public health facilities (HF) namely: Axum hospital, Axum health center and Millennium health center; and four private HF namely: Kaleb, Bazen, Tsion, and Senay higher clinics. Out of the total population of Axum town, 30,293 are females with a pregnancy rate of 3.4% and the annual ANC service coverage in the study area was 95% [9]. The study was conducted from January 27 to April 1, 2015. All pregnant women attending in public and private HF for ANC service during data collection were included. Pregnant women who were critically ill were excluded from the study.

Sample size and sampling technique
The required sample size was calculated using a double-population proportion formula with the assumptions of 36% of pregnant women in public HF time spent were more than 30 minutes [10]. The proportion of time spent among pregnant women > 30 minutes for provision of ANC were taken 50% in private HF due to lack of previous similar study and 14% signi cance difference was detected between public and private HF with a 95% con dence level, power of 80%, and 1:1 ratio. The total sample size after adding a 10% non-response rate was 456.
The study participants were selected based on proportional allocation based on the preliminary survey average number of ANC users in the most recent one month report from each health facility. Study subjects at each health facility were selected using systematic random sampling until the required sample size was achieved. The sampling interval (k = 3) was calculated by dividing the average number of ANC users in the most recent one month report from each Health facilities to the total sample size.
Qualitative part: from the owner and managers of the health facilities 10 interviewees were selected.
Hence there were no emerging new idea (information saturated) was reached further exploring idea is not needed. The key informants were purposively selected because of either they are the owner of private health facility or the manager of the facility to get adequate and correct information.

Data tools
The quantitative questionnaire was adopted and structured from different literatures [6,11,12]. The questionnaire was initially prepared in English and then translated into local the language (Tigrigna) and back to English to check its consistency. Pretest was done in shire health facilities which are 60 kilometers away from the study area. Any question which was ambiguous and/or unclear was modi ed or removed based on the pretest results. The questionnaire included socio-demographic characteristics, staff commitment, health care related factors, client-provider communication, and knowledge on ANC service.
Time spent between provider & clients was measured using stop watch monitoring, and open-ended interview guide using tape recorder (for provider's in-depth interview) and checklists for observational data (number of ANC attendants per day) were also used to collect the qualitative data (look at additional le). To observe the availability of standard services at both health facilities item sentences was developed. The items response was categorized on basis of their level of agreement on ve-point scale ranging from "strongly disagree" to "strongly agree". The reliability of the items was checked by item correlation analysis. The results were reported using cronbach's alpha (α). The result for internal consistency of items was reported as cronbach alpha 0.67

Data management and analysis
Quantitative part: The collected data were entered, cleaned and analyzed using SPSS version 21 statistical software. Descriptive statistics such as mean ± standard deviation, frequency and percentages were used to summarize the ndings. Bivariable logistic regression model analysis was done to identify eligible variables at p-value < 0.05. To control confounding effect those signi cant variables were included in multivariable logistic analysis to identify predictors of time spent among ANC mothers at pvalue less than 0.05 with 95% CI. Finally t-test for signi cance difference in the mean time spent on ANC was assessed among public and private HF.
Qualitative data: The verbatim recorded information was analyzed; the Tigregna audio-recorded interviews were listened carefully and transcribed into texts. The transcribed data then translated into English language and back to Tigrigna to ensure consistency and accuracy of wording and authentic representation of the participant's information. Sorting of the emerging themes after we read and become familiar with the texts. Then, we developed themes and coded. Finally we read all transcripts, the codes of transcripts, if there is irrelevant information reduced unnecessary data. Lastly the themes were shared into meaningful data that was the interpretation.

Data quality control
For quantitative data For qualitative data the interviewer prepared secure and silent environment for interviewing before interview has started and made ready logistic requirements to assure quality of data. Before they were standby for interview, the interviewer greets politely to set the environment friendly. Guiding questions were avoided.

Socio-demographic characteristics
A total of 446 subjects were participated in this study with of 98% response rate. More than half 228 (51.12%) of the participants were from public HF. The mean (± SD) age of respondents in both HF was 27.8 (± 5.2) years. Of those who served in public HF 38.6% was not attended formal education. The majority (92.2%) of the respondents who visited private HF were from urban residents [ Table 1].

Variables Signi cantly Associated With Time Spent On Anc Provision
On bivariate binary logestics regression analysis, variables found to be signi cantly associated with ime spent on provision of ANC were: residence, education level, occupation, type of HF (public versus private), maternal frequency of visit, provider sex, payment for ANC services and language similarity with health care providers.
After multivariable binary logistic regression was applied, variables signi cantly associated with time spent on ANC provision were: type of HF (public versus private), maternal frequency of visit and pregnant women speaks similar language with health care providers [ Table 2]. Pregnant mothers who attended their ANC in private health facilities were 2.6 times more likely to spend expanded time with care provider than who attended in public HF [AOR = 2.61; (95% CI, 1.07-6.33)].
Participants who has rst visit for ANC were 3.5 times more likely to spent standard time with healthcare provider as compared to those pregnant mothers in subsequent ANC visit [AOR = 3.50; (95% CI, 1.93-6.37)].
Pregnant mothers who speak similar language with health care providers were 2.7 times more likely to spent longer time compared to who speaks different language [AOR = 2.74; (95% CI, 1.23-6.12)].

Qualitative ndings
In-depth interview with health care provider A total of ten health professionals (key-informants), one care provider from each service delivery points (six from public and four from private) and three the facility managers were included on the in-depth interview.
The three identi ed central themes that could be the reason for short time spent on care included: Health care provider's commitment, medical supplies related and social & cultural belief of the mothers on antenatal care.
Health care provider's commitment Health care provider expressed the reasons for short time spend with mothers during care were lack of inservice training, low staff motivation, low payments, shortages of workers, and large number of ANC 20-26 years from public health facility expressed his idea "…the time spent with clients was short, this could be due to lack of refresher training about focused ANC components, e.g. still I have not taken any in-service training either from the government or nongovernmental organizations as a result of this, I am unable even to counsel or deliver the whole ANC component to the clients in other words omission of some services resulted in short client contact time." Another 30-38 years from private health facility "…for standard time spent, smart facial expression or good client provider relationship during history taking and physical examination is mandatory for pregnant women to initiating for asking and discussing their issue. He also reported low level quali cation, lack of con dentiality and privacy are the main cause for short time spent. Knowledge and skill during history taking and physical examination is mandatory to deliver standard care on standard time. if pregnant mothers secured adequate con dential and privacy, they will more initiate for discussion their issue as a result spends enough time with us." A 20-25 years from public hospital also expressed that "…the time we spent for care to pregnant women was not enough because of poor administration and payment that causes de-motivation of staff. This de-motivation makes us to be negligence in providing the service based on focused ANC standards. Additionally, we forced to provide ANC service with limited man power to numerous attendants in limited time. So, to address all within the short working hours, we obligate to shorten each mothers contact time" Medical supplies or facilities Some health care providers also expressed their reasons on shorter time spent with provision of ANC.
20-27 years from public health center explained is idea as "… There is shortage and un-functional medical equipments like sphygmomanometer. And I was wondering here and there to nd the functional equipment; as a result, I waste my working hours in nding rather than providing care with clients. As a result large number of pregnant mothers forced to wait me to get the service and I am hurrying in each client contact time to address all the clients which may the reason of short time spent on care." Social and cultural belief of the mothers Religious, area of residence and family care has own affect on the time spent during care.
30-40 years old care providers reasoned their experiences as: "Pregnant mothers living in rural areas were less likely to be cooperative to discuss detail with health care provider about their health issue. This may be due to family poor communication and relation. Additionally, muslin-religious follower mothers are not cooperative to make physical examination due to their religious/cultural in uence. As a result we prefer to omit some care and this may make short time spent with the mothers".

Discussion
The majority, 378 (84.8%) of pregnant mothers have below the standard time spent on the provision of antenatal care in both public and private health facilities. The mean (± SD) time spent in the rst ANC provision for each mother in the private was 19.7 (± 8.5) minutes, and 13.2 (± 3.8) minutes in public health facilities.
The study revealed that type of HF (public or private), frequency of ANC visit and pregnant women who speak a similar language with health care providers were found to be signi cant predictors for time spent on provision of ANC.
Pregnant women who attended their antenatal care at public health facility were spent shorter time than those who attended at private HF. This result in line with studies done in the Gambia [7] in Pakistan [13] and comparative study from Tanzania, Kenya and Ghana [14]. The possible explanation for the time difference during Antenatal care in the facility could be; public health providers are less likely to be motivated by incentives compared to the private facilities. Health care providers at private facility have incentives which initiate to provide compassionate maternal caring service provision, short waiting times and standard cares to women. Additionally, this was also supported from the interview expressed that lack of incentive at public health facility make them low motivation.
Maternal frequency of ANC visit was predictor of time spent for provision of ANC. Pregnant women who visited rst for antenatal care were more likely to spent longer time than revisited women. This nding was consistent with studies conducted in Burkina Faso, Uganda and Tanzania [5,10,15]. This can be explained that, health care providers failed to perform all standard procedures stipulated by WHO guideline. And some cares may be exempted in revisit and subsequent visit.
Respondents who speak similar language with the health care provider during care have also a predictor variable for time spent on provision ANC. This result was inline with study done in USA [12]. This can be explained by the fact that a language difference with care provider was a barrier for effective communication. In the absence of effective communication the provision of standard maternal care will be limited and have short time spent with client.

Limitation
The limitation of this study might be that study participants from private health facilities have provided maternal care at evening. As a result study participants and the key informants were in hurry to get deep information. So, there might be information bias.

Conclusion
This study revealed that majority of pregnant women utilized ANC services shorter time spent at both health facilities. The mean time spent on provision of ANC at the public health facility was signi cantly shorter than the private HF. Type of HF care provided, frequency of ANC visit and pregnant women who speak similar language with health care providers were predictors of time spent for ANC provision. To provide quality of maternal care, efforts should be targeted at standard provision of ANC with adequate time spent to clients. Mekelle University with reference number MU/CHS/RCS/215/2015. The letter of support was given from regional health bureau to respected health facilities. Respondents were given information about the objectives of the study and they have the right to participate or decline in the study and able to withdraw from the study at any time. Both written and verbal consent was obtained from the respondents before data collection. To keep con dentiality data was analysed anonymously.

Consent for publication
Not applicable Availability of data and materials Datasets obtained or analyzed during the current study are available from the corresponding author on reasonable request.