Utilization and associated factors of antenatal care among women who gave birth within the last two years, in Teda Kebele,Gondar town, northwest Ethiopia


 Objective

The purpose of this study was to assess utilization and associated factors of antenatal care among women who gave birth within the last two years. Three hundred fifty two participants were selected by simple random sampling technique from April 1-May -27, 2015. Bivariate and multivariate data analysis was performed using SPSS for Windows version 23.

Result

The study identified that 84.4% of respondents were utilized antenatal care.


Introduction
Pregnancy is a normal physiological process associated with a certain risks to the health of women and the infant she bears. It is an important event from both social and medical point of view. Therefore, pregnant women should receive special care and attention from the family, community and the health care system (1).
Antenatal care (ANC) service utilization refers to skilled antenatal care rendered by the health workers in the health institution. This care is given to pregnant women and their baby from the time of conception to the delivery of the baby (2) Worldwide hundred thousands of women die from complications duringpregnancy and child birth each year; that is one women dying every 90 seconds and millions more are left with life altering disabilities (3).An estimated 287,000 women died during pregnancy and child birth in 2010. Every day, nearly 800 women across the global die due to complications during pregnancy and child birth, 99% of these occur in developing country including Ethiopia. In Ethiopia, the levels of maternal and infant morbidity and mortality are among the highest in the world. This attributed to, among other factors, non use of modern health care services by women in Ethiopia (4,5).
In Ethiopia, the levels of maternal and infant morbidity and mortality are the highest in the world. This is due to mainly non use of modern health care services by women in Ethiopia. According to the 2011EDHS, more than six in ten mothers did not receive ANC at all.The utilization of maternal health service remains low in the low resource countries like Ethiopia. The major direct cause of maternal morbidity and mortality are unsafe abortion, obstructed labour, haemorrhage, infection and hypertension (6, 7).
According to recent (2011) Ethiopian Demographic and Health Survey report, only 34%, 10%, and 6% women have ANC, delivery, and post natal care by skilled provider, respectively. This can be due to lack of knowledge about importance of health services, lack of transportation, distance from health facilities, small number of health facilities, lack of money and lack of family support (1,7). Therefore this study aims to determine the prevalence of ANC utilization and explore its determinants.

Study area
The study was carried out in Teda Kebele; which is one of the largest Kebele in Gondar town. It is located 710 km away from Addis Ababa, the capital city of Ethiopia, 145 km to the capital city of Amhara regional state, Bihar Dar and 35 km from Gondar town. It has a total population of 12518. From these populations 5917 are males and 6601are females. Of these 2546 women are in the age group of .Teda kebeles has one governmental and three healths post and three private pharmacies institutions.

Study design and period
A community based cross sectional study was conducted from January to April 13 among women who gave birth within the last two years in Teda Kebele, Gondar town, Northwest Ethiopia, 2015.

Sample size and sampling techniques
The sample size required for assessment of the utilization of antenatal care and associated factors among women who gave birth within the last two years in Teda kebeles, Gondar town was calculated using single population proportion formula by considering the following assumption: proportion (p) = 32.3% (8), w = tolerable (margin) of error = 5 % and Z = Z score for 95 % con dence interval = 1.96and considering 5% none response ratethen the nal calculated sample size was 352.Simple random sampling technique was used to select the study subjects after getting lists of the study population from health extension workers which is 823 women who gave birth within the last two years and 352 women included in the study by lottery method.

Measurement
Data collection tools and procedures Structured interviewer administered questionnaire was used to collect the data which was adapted from relevant literatures and modi ed to local context. Questionnaires was rst prepared in English language then it was translated rst in to Amharic and then to English to check consistency. The questionnaire was consisting of Socio demographic characteristics, Reproductive and obstetrics characteristics, and knowledge related questionnaires. Pre-tested structured interviewer administered questionnaire was used for data collection purposes. The data was collected by four diploma midwives and supervised by two BSc midwives by those who can speaks and write the local language.

Data quality assurance
The collected data were checked for the completeness, accuracy, clarity and consistency after conducting pre-test. A pre-test was conducted on 5% or 18 child bearing women and the instrument was amended accordingly. Any error, ambiguity or incompleteness identi ed was corrected immediately. The data collectors were trained for one day about the contents of the questionnaire, methods of data collection and aim of the study. The data collection process was supervised by the supervisor and the investigator throughout the data collection period.

Data processing, Analysis and Interpretation
Data was coded, cleaned and entered by Epi.info version 3.5.3 and analyzed using computer database software and transported to the SPSS version 20 statistical software. Descriptive statistics like frequencies and percentages were used to present the categorical independent variables, and mean/standard deviation was used to describe a continuous variable. Frequency tables and graphs were used to present descriptive results.
For this study, bivariate logistic regression model was tted as a primary method of analysis. Odds ratios (OR) was computed with the 95% con dence interval (CI) to see the awareness of OBF in relation to the considered associated factors in this research. Independent factors, with a P-value <0.2 obtained in the Bivariate logistic regression were entered into the multiple logistic regression models. Consequently, the most important associated factors were identi ed using the multivariate logistic regression analysis. Then an adjusted odds ratio (AOR) with 95% con dence interval was calculated for the signi cant predictive variables, and statistical signi cance was accepted at (P< 0.05).

Results
Socio-demographic and reproductive characteristics of the respondents A total of 352 women were interviewed with response rate of 100%.Two hundred forty four (69.3%) of the respondents were in the age group of 21-34 years. Three hundred thirty (93.8%) was followers of Orthodox. Three hundred fty one (71.3%) of the study participants were housewives. Three hundred fty (99.4%) were Amhara and one hundred eighty four (52.3%) were unable write and read. 331(94.0%) have knowledge of the presence of regular ANC visit. Of the total respondents 296(84.1%) revealed that ANC is important for child, mother and family. Three hundred six (86.9%) of respondents Saied that ANC is needed for all pregnant women. Among the total respondents 328(93.2%) were believed ANC reduces associated problems that occurs during pregnancy. Of the respondents180 (51.1%) revealed that both husband and wife decide ANC follow up. Of the total respodents333 (94.6%) were knowing all pregnant women have the right to get ANC follow up (table 1)..

Current situation of antenatal care utilization
Among the total participants 84.4 % of women were have ANC. The rest 15.6 % were not attended ANC among 84.4% respondents (those who had ANC) only 70.7 were attended ANC within the recommended time ( gure 1)..

Associated factors of ANC utilization
Bivariate analysis was done to asses any association between independent variables and dependant variable.
In bivariate analysis: Distance, women education, residence, age at rst pregnancy, occupation and state of pregnancy was considered statistically signi cant with utilization of ANC.
Multivariable logistic regression analysis showed that women in urban area uses ANC services three times more than women in rural area with AOR (95% CI) 3.18(1.28,7.92).. Likewise women with primary level of education and above were more likely to be utilized than those who had no education with AOR (95% CI) 1.95(1.075, 2.68) andrespondents who were their pregnancy planned were more likely to utilize ANC compared to respondents with unplanned pregnancy with AOR (95% CI) 1.21(1.001, 3.301) (Table2)..

Discussion
This study showed that the prevalence of antenatal care was 84.6%. Although this shows a high level of antenatal care utilization, more than 50% of them initiated their rst visit during the second and third trimester of pregnancy.
This nding is consistent with the result of the studies in Holeta town and Hadiaya zone which showed 87% and 86.6% (9&10) respectively. This might be due to the fact that closeness of the study time and have related socio demographic factors. The nding of this study was signi cantly higher than from North Gondar zone and Metekel zone which were (32.8% and 49.8 % (8, 11) respectively. This might be due to the previous study conducted in the zonal level and it covered more areas like remote areas and distance from health institution and those participants were less chance of getting / exposing to media,information and education but our studies conducted in the town Kebele label that covers small area so that more informative to service utilization. It is also important to note the time gap between the current studies to the previous study.
In this study, socio-demographic, obstetric and information factors related to the utilization of antenatal care. Residence is signi cantly associated with ANC utilization; That is women in urban area uses ANC services three times more than women in rural area with AOR (95% CI) 3.18(1.28, 7.92); This nding agrees with the studies done in (9, 10&12) respectively; This may be due to the fact that rural women are less likely to use different media, information, getting written papers and have less knowledge about their health than urban women. The other explanation could be busy to different activities, family and selfattitude, inadequate health service, etc.
Antenatal care utilization was signi cantly related to their level of education. Women with primary level of education and above were more likely to be utilized than those who had no education with AOR (95% CI) 1. 95(1.075, 2.68).This nding agrees with the studies done in (13, 14, 15, 16 and 17) respectively; this might be female education has a positive effect for maternal health service utilization. The possible explanation for why education is a key determinant could be that better educated women would likely appreciate the importance of service utilization more than uneducated ones. In other perspective the higher the educational status the better understanding and having good knowledge and easily access for media and information.
The analysis showed that respondents who were their pregnancy planned were more likely to utilize ANC compared to respondents with unplanned pregnancy with AOR (95% CI) 1.21(1.001,3.301);The association of women with unintended pregnancies and early initiation of rst antenatal care were they recognize the pregnancy late, might be not ready emotionally and nancially,busyness for the care of the family and to full feel the demands of the family more likely to less care of themselves and the developing fetus during pregnancy.

Conclusion
In this study the antenatal care service utilization is high, which is higher than the study done in North Gondar zone. However, the majority of women who attend ANC did not receive adequate number of visits. It is statistically signi cant with residence, educational level and state of pregnancy.

Limitation of the study
Since the data was collected from those gave birth within the last two years, it may be affected by recall bias.
Since the data collectors were health professionals, it may induce social desirability bias.
Abbreviations ANC: AnteNatal Care EDHS: Ethiopian Demography Health Survey Declarations Authors' Contribution FY inception designed the protocol, data analysis, interpretation, manuscript drafting, wrote the paper and revised the manuscript. AG data collection, data analysis and interpretation. Both authors read and approved the nal paper Acknowledgment We are highly thanks to Teda kebele administrative for permitting to conduct the study and providing the necessary preliminary information. We would also like to extend our appreciation to the study participants, supervisors and data collectors.
Con ict of Interests: The authors declare that they have no con ict of interests regarding the publication of this paper.  Figure 1 prevalence of rst registration of ANC among women who gave birth in the last two years in Teda Kebele, Gondar town, Northwest Ethiopia, 2014.