Do Early Antenatal Booking Predicts Maternal Services Utilization? An Analysis of Data from the 2015-16 Tanzania HIV and Malaria Indicators Survey

Optimizing maternal and neonatal health requires adequate use of antenatal services which have both curative and preventive services. Little is known on the inuence of early antenatal booking on maternal services utilization in Tanzania. Method: The study used data from the 2015-16 Tanzania HIV Demographic and Health Survey and Malaria Indicators Survey (2015-16 TDHS-MIS). A total of 6924 women of active reproductive age from 15 to 49 were included in the analysis. Both univariate and multiple regression analyses were used to determine the association between early antenatal booking and maternal services utilization. Separate regression analysis was done for each antenatal service to establish the inuence of early antenatal booking on antenatal services.


Abstract Background
Optimizing maternal and neonatal health requires adequate use of antenatal services which have both curative and preventive services. Little is known on the in uence of early antenatal booking on maternal services utilization in Tanzania.

Method:
The study used data from the 2015-16 Tanzania HIV Demographic and Health Survey and Malaria Indicators Survey (2015-16 TDHS-MIS). A total of 6924 women of active reproductive age from 15 to 49 were included in the analysis. Both univariate and multiple regression analyses were used to determine the association between early antenatal booking and maternal services utilization. Separate regression analysis was done for each antenatal service to establish the in uence of early antenatal booking on antenatal services.

Conclusion
The majority of pregnant women in Tanzania initiate antenatal clinics late in their pregnancy. Early antenatal booking showed a signi cant association with the utilization of maternal services during pregnancy. Innovative interventional studies are highly recommended to come up with cost-effective strategies which will improve timing for antenatal booking and hence use of the available maternal services in Tanzania Background Sustainable Development Goal (SDG) 3.1 has set a target to reduce maternal mortality to less than 70 deaths per 100,000 live births in 2030 [1]. Similarly, to reduce global newborns death to 5 deaths per 1000 live births in 2030 [1]. Despite the well-set target, the number of maternal and neonatal mortalities remains unacceptably high. In 2017, about 295 000 maternal death occurred globally, the countries in the sub-Saharan region contributed to about 94% of all deaths [2]. The number of neonatal mortalities is also high globally (18 deaths per 1000 live births) [3] with the largest burden in developing countries including Tanzania (21 deaths per 1000 live births) [4]. The current trend of maternal and neonatal mortalities provides little promise on achieving the target.
Antenatal services utilization, institutional delivery, and postnatal checkups have the potential to reduce both maternal and neonatal mortalities [5]. Services such as iron and folic acid supplementation are important in addressing the challenge of pregnancy-induced anemia. In low resources countries, women become pregnant while anemic. The state of their anemia become worsens with pregnancy and childbirth [6]. The process of providing iron and folic acid supplementation improves their health status.
Likewise, the process of iron and folic acid supplementation improves the health status of their developing child. Folic acid is responsible for the prevention of abnormalities in both mothers (anemia, peripheral neuropathy) and fetuses (congenital abnormalities) [7]. To address that health problem, a pregnant woman has to take folic acid supplementation to ensure to have birth to a healthy baby.
Also, in antenatal attendance, a pregnant woman is covered with de-worming drugs. In regions with worm infestation, the use of the de-worming drug is crucial to protect pregnant women from anemia. Tanzania is among the countries which provide de-worming services to all pregnant women. The nutritional intake of a pregnant woman is required by her developing child too [8]. This means the nutritional demand increase during pregnancy. Worm infestation may worsen the nutritional status of these mothers.
Tanzania is among the malaria-endemic regions. Malaria during pregnancy is among major public health problems that cause maternal, fetal, and infant morbidity and mortality. Intermittent treatment of malaria is among the antenatal services provided during pregnancy in malaria-endemic areas. Treatment of malaria is recommended for all pregnant women attending antenatal visits. The region for intermittent treatment for malaria is, the rst dose when pregnancy is in the gestation age of 24 weeks and the second dose when the pregnancy is of the gestations age of 28 weeks [8] All pregnant women are supposed to be protected against tetanus through vaccination. Tetanus is an acute infectious disease which is caused by toxigenic strains of the bacterium called Clostridium tetani.
The spores of these bacteria are found in the environment regardless of a geographical location [9].
According to WHO recommendations, if a pregnant woman has not previously been vaccinated, or if her immunization status is unknown, she should receive two doses of tetanus vaccination, one month apart with the second dose given at least two weeks before delivery to protect both pregnant women and her child against tetanus [8]. The two doses can protect both of them 1-3years [8]. The third dose is given six months later after the second dose and extends the protection to 6 years [8].
In the antenatal attendance, pregnant women are also checked for their blood pressure in each visit. The baseline recorded blood pressure is used to diagnose pregnancy-induced blood pressure. Early detection of pregnancy-induced hypertension facilitates timely management and hence saves the lives of both mothers and neonates. Blood induced hypertension is among the direct causes of maternal mortalities. A previous study done in Tanzania on causes of maternal death reported that high blood pressure (eclampsia) contributed up to 34% of all maternal deaths [10]. It is a routine that pregnant women must have a urine test to screen for gestational diabetes during 24 to 28 weeks of pregnancy and preeclampsia.
Although all these services are offered for free in Tanzania, some pregnant women fail to receive them. Despite the bene t and free access, some pregnant women fail to receive these important services in Tanzania.
Previous studies have worked out different factors that are associated with poor utilization of antenatal services. Exposure to media, wealth index of pregnant women's family is a few factors which the literature has mentioned to in uence maternal services utilization during pregnancy [11].
Antenatal visit connects pregnant women and their families to the health care system [12]. The majority of pregnant women in Tanzania attend antenatal clinics at least ones [4]. Late antenatal booking may largely contribute to inadequate antenatal visits. Inadequate attendances limit the likelihood of receiving antenatal services. Little is known on whether early initiation of antenatal visits increases the likelihood of antenatal services utilization.

Study Area and period
The study was conducted in the United Republic of Tanzania  Study population all women of reproductive age (aged 15-49 years) were the study population. The study used Individual le recode (TZIR7BFL) with a total of 13266 women who responded to the survey (97% response rate). The study included only women who remembered the timing for antenatal booking of their youngest child. Those who were not able to recall the timing and those who did not respond to the question were removed from the analysis. A total of 6924 women who had birth within ve years presiding the survey were included in the study.

Sampling Technique
Two stages of sampling were used to obtain a sample for urban and rural areas in Tanzania Mainland and Zanzibar. In the rst stage, a total of 608 clusters were selected and in the second stage, a systematic selection of households was involved. A total of 22 households were then systematically selected from each cluster, yielding a representative probability sample of 13,376 households for the 2015-16 TDHS-MIS. To enhance representativeness Tanzania was divided into nine geographic zones.
Grouping the regions into zones was done to reduce sampling error by increasing the number of people in the denominator. The zone was western (Tabora and Kigoma

Data Collection tool
The 2015-16 TDHS-MIS used household questionnaires and individual questionnaires. These questionnaires based on the Measure DHS standard AIDS Indicator Survey and Malaria Indicator Survey questionnaires standards. They were adapted and modi ed to re ect the Tanzanian population. They were translated into Kiswahili, Tanzania's national language. The data presented in this study are from the individual questionnaire.

Study variables
Through a literature review, the conceptual framework was developed to guide the conceptualization ( gure 1). The conceptual framework had an independent variable which is the timing for the initiation of antenatal visits. The confounding variables which were controlled were the primary independent factors (socio-demographic and obstetric characteristics of a woman). The dependent variables in this study were the utilization of maternal services during pregnancy. The study aimed to ascertain the association between early initiation of antenatal services and the use of maternal services. The primary independent variables have also direct relationship with the use of maternal services utilization that is why they are controlled to establish the relationship between timing for booking and use of services. The outcome variables were independently dummy coded as 1 if women use a service and 0 otherwise. The Independent variable included only timing for antenatal booking.

Socio-demographic Characteristics
The study included 6924 women of reproductive age who had given birth within ve years preceding the survey. Majority of study respondents 5113(73.8%) resided in the rural setting of Tanzania, aged 20 to 34 years 4557(65.8%), had primary education 4209(60.8) and were married 5650(86.1%) Table 1 Maternal Services Utilization during pregnancy When the use of maternal services utilization were assessed, majority of women 3480(50.3%) did not receive adequate vaccination; 2560(37%) did not take deworming drugs; 1276(18.4%) did not take an iron supplement; 2160(31.2%) did not take anti-malaria drugs for intermittent treatment of malaria; 1927(31.2%) their blood pressure were not checked throughout the pregnancy; 2631(38%) never donated urine sample for screening and 870(12.6%) never donated blood sample for screening ( gure 2) The relationship between antenatal services utilization and early antenatal booking When the relationship between maternal services utilization was assessed, the antenatal booking had a signi cant relationship with all variables of maternal services utilization, Table 3 The association between early antenatal booking and ever took an iron supplement during pregnancy After adjusting for confounders, there was a signi cant association between early antenatal booking and ever took iron supplement during pregnancy; AOR= 1.603 at 95% CI= 1.362 -1.887, p<0.001, Table 3 The association between early antenatal booking and ever took anti-malaria during pregnancy After adjusting for confounders, there was a signi cant relationship between early antenatal booking and ever taken anti-malaria drug for intermittent treatment for malaria, AOR=1.495 at 95% CL=1.306-1.712, p<0.001, Table 4.
The association between early antenatal booking and ever took de-worming drugs during pregnancy After adjusting for confounders there was a signi cant association between early antenatal booking and ever taken de-worming drugs during pregnancy; AOR=1.404 at 95% CI=1.24-1.59, p<0.001, Table 5.
The association between early antenatal booking and adequate tetanus vaccination After adjusting for confounders there was a signi cant association between early antenatal booking and adequate tetanus vaccination during pregnancy, AOR= 1.393 at 95% CI=1.234-1.571, p<0.001, Table 6 The association between early antenatal booking and ever checked for blood pressure After adjusting for confounders, there was a signi cant relationship between early antenatal booking and ever checked for blood pressure during pregnancy, AOR=1.496 at 95% CI=1.297-1.726, p<0.001, Table 7.
The association between early antenatal booking and ever donated urine for screening during pregnancy After adjusting for confounders there was a signi cant association between early antenatal booking and ever donated urine sample for screening during pregnancy, AOR= 1.728 at 95% CI=1.513-1.975, p<0.001, Table 8 The association between early antenatal booking and ever donated a blood sample After adjusting for confounders there was a signi cant association between early antenatal booking and ever donated blood sample for screening during pregnancy, AOR= 1.596 at 95% CI=1.312-1.942, p<0.001, Table 9 Discussion There are maternal and neonatal bene ts in maternal services utilization. The services have both preventive and curative abilities to both mothers and their growing fetus. These are given for free in Tanzania. The government plays her role by providing these services to protect both pregnant women and their growing fetus. It is surprising to nd some women fail to get these services in Tanzania.
This analysis found that of all maternal services tetanus vaccination was mostly not used service. It was found that 49.7% of women had an adequate tetanus vaccination. A similar study done in Ethiopia reported a higher proportion of women (56.2%) had adequate vaccination [13]. The possible difference could be due to differences in the sampling area. This study involved all women of reproductive age in Tanzania while the study done in Ethiopia included only postnatal mothers in Northern Ethiopia.
The study went further and works out the in uence of timing to initiate antenatal visits on adequate tetanus immunization during pregnancy. The study found that there was a signi cant association between early antenatal booking and adequate tetanus vaccination. Pregnant women who had early antenatal bookings were 1.4 times more likely to have adequate vaccination compared to those with late bookings. A similar nding was reported by a similar study done in Ethiopia [13]. The study recommends an innovative intervention study to nd up an effective strategy to improve early antenatal initiation.
The study also found that the majority of women (81.6%) ever received iron supplements during antenatal visits. Despite the high proportion, adherence to daily intake is questionable. A previous study done among pregnant women found a small proportion of only 12% of pregnant women adhere to a daily intake of supplements [14]. An iron supplement is recommended to all pregnant women for the prevention of pregnancy-induced anemia and neonatal underweight [15]. These supplements are offered for free in all antenatal clinics in the country. Wondering enough some women never received the supplement.
The study found there was a signi cant association between early initiations of antenatal visits and ever took the iron supplement. Women who had early antenatal bookings were 1.4 more likely to ever take an iron supplement compared to those who had a late antenatal booking. A similar nding was reported by a previous study done in Uganda [16].
Although antenatal clinics all over the country offer de-worming drugs to protect pregnant women against worms' infestation, 37% of respondents did not take de-worming drugs during pregnancy. Studies have reported that de-worming plus iron supplementations have a potential stabilizes hemoglobin level [17,18].
The study also found that there was a signi cant association between early antenatal bookings and ever took de-worming drugs. Women who had early bookings were 1.4 times more likely to take de-worming drugs if compared to those who had late bookings.
Tanzania is a malaria-endemic country. Intermittent preventive treatment of malaria is the routine treatment of pregnant women to protect them against malaria during pregnancy. The study found that 68.8% of pregnant women ever took ant malaria for intermittent treatment of malaria. Like other maternal services, anti-malaria treatment is given for free during antenatal visits. The study found up to 31.2% of interviewed women did not take anti-malaria for intermittent treatment of malaria. A different nding has been reported by a previous study done in Ghana that the majority of pregnant women (98.5%) received at least one dose of anti-malaria for intermittent treatment of malaria [19]. The difference could be due to differences in the study area. The study in Ghana included only urban women while this study included both urban and rural communities.
The study also found that there was a signi cant association between early antenatal initiations and ever took anti-malaria preventive treatment for malaria. Women who had early antenatal booking were 1.5 more likely to ever receive anti-malarial drugs if compared to those who had a late booking. Similar ndings have been reported by a previous study [20].
The study also found that there was a signi cant relationship between early antenatal bookings and ever checked for blood pressure during pregnancy. Women who had early antenatal booking were 1.5 more likely to ever checked for blood pressure during pregnancy if compared with pregnant women who initiated antenatal visits late. Checking for blood pressure is crucial during pregnancy for early detection of pregnancy-induced hypertension.

Conclusion
The majority of pregnant women in Tanzania initiate antenatal clinics late in their pregnancy. Early antenatal booking showed a signi cant association with the utilization of maternal services during pregnancy. Innovative interventional studies are highly recommended to come up with cost-effective strategies which will improve timing for antenatal booking and hence use of the available maternal services in Tanzania          Figure 1 The association between antenatal booking and maternal services utilization