Magnitude of late initiation of antenatal care and its associated factors among pregnant women attending antenatal care in Woldia Public Health

Background: The World Health Organization states that every pregnant woman is at risk of complications. Antenatal care is vital to reduce complications and more likely to be effective if women begin receiving care in the �rst trimester of pregnancy and continue to receive care throughout pregnancy. The maternal mortality ratio in Ethiopia was estimated at 412 deaths per 100,000 live births in 2016. Methods: Institutional based cross-sectional study design was used. Data collection was collected using an interviewer-administered questionnaire. A systematic sampling technique with proportional allocation was used to get the �nal 390 study participants. Data was entered, cleared, and analyzed with Statistical Package for Social Sciences Version (SPSS) 20. Descriptive measures were presented with frequencies, tables, and diagrams. A binary logistic regression model was used to identify predictors of late antenatal care initiation. Results: The prevalence of late antenatal care initiation was 59.5% with 95% CI [54.6–64.1


Background
The antenatal care (ANC) provision or regular check-ups during pregnancy through the public health services in modern obstetrics was started during the late 1930s in the United Kingdom and Northern Ireland [1]. ANC is important for the survival and wellbeing of both the mother and the infant. Skilled care during pregnancy is an important intervention in reducing maternal and neonatal morbidity and mortality [2].
World Health Organization (WHO) recommends a minimum of eight contacts: ve contacts in the third trimester, one contact in the rst trimester, and two contacts in the second trimester, While many African countries are still struggling to achieve high coverage of four antenatal visits [3].
Antenatal care is more likely to be effective if women begin receiving care in the rst trimester of pregnancy and continue to receive care throughout pregnancy, according to accepted standards of periodicity [4]. The universal recommendation for the rst ANC initiation is in the rst trimester. According to WHO the rst trimester is the best time for a mother to book her pregnancy [5].
WHO ANC model states that every pregnant woman is at risk of complications and recommends early ANC visits. The visit is used to segregate pregnant women into two groups based on the previous history of pregnancy, current pregnancy state, and general medical conditions. Those eligible to receive routine ANC (basic component) and those who need special care based on their speci c health conditions or risk factors on average account for 25% of all pregnant women initiating ANC [6].
Worldwide there's an enormous discrepancy within the prevalence lately ANC follow up among pregnant mothers, starting from 27.5 to 88% in developed and developing countries respectively [7]. In Latin America, the Caribbean, the Middle East, and North Africa, two-thirds of women present for antenatal care visit in the rst trimester, while in sub-Saharan Africa, where women presenting for antenatal care are most likely to wait until the second trimester and a relatively substantial proportion present only in the third trimester. Although women in sub-Saharan Africa make their rst antenatal visit rather late in pregnancy, they nonetheless tend to report more than one visit [8].
The South African National Department of Health recommended that women should visit the ANC clinic as soon as they realize that they are pregnant and de nitely before 20 weeks of gestation. The ANC services should start with women's rst visit irrespective of gestational age. Antenatal Care guidelines recommend that pregnant women should start their ANC visit at 12 weeks of gestation. Despite the provision of free ANC services, South Africa is still performing poorly compared to other middle-income countries [9].
In Ethiopia, only 20% of women had their rst ANC during the rst trimester, 26% during their fourth to the fth month of pregnancy, and 14% during their sixth to the seventh month of pregnancy. Two percent of women did not receive any ANC until the eight months of pregnancy or later [2].
Poor and inadequate quality of care was a strong predictor for late ANC initiation, community-based information, health education and communication on ANC services, socio-economic and individual perception and knowledge of ANC services are major contributors to start ANC visit late in time [10].
Maternal knowledge on early ANC visit, planned pregnancy and parity were factors associated with early ANC visit, mothers of age, media access, advise to initiate ANC during the recommended time after amenorrhea, residence, husband's occupation, [11][12][13][14].
The maternal mortality ratio in Ethiopia was estimated at 412 deaths per 100,000 live births in 2016 (17). These maternal deaths could have been prevented if the pregnant women or adolescent girls had been able to access quality antenatal care (ANC) (it includes early initiation of antenatal care). Sixty percent of the stillbirths (1.46 million) occurred during the antepartum period and mainly due to untreated maternal infection, hypertension, and poor fetal growth [6].
Pregnant women should be offered infection early in ANC since appropriate ANC interventions can reduce mother-to-child transmission of HIV infection due to offered screening for HIV at ANC. Screening for syphilis should be offered to all pregnant women at an early stage. In pregnant women with untreated syphilis, 70-100% of infants will be infected and one third will be stillborn [6]. Pregnant women also offered iron and folic acid supplementation in early pregnancy for those who are at risk of nutritional de ciency until 12 weeks of gestation reduces the risk of a baby born with neural tube defects such as anencephaly and spinal bi da [15].
Despite ANC is provided free of charge and there is increased accessibility; low utilization and late booking is still a major problem [16,17]. According to the Ethiopian Demographic Health Survey 2016 (EDHS), only 20% of mothers start ANC early as per the recommendation [18].
Even though there is good health service coverage in Ethiopia, women come late for ANC follow up. Besides, there is a scarce study on magnitude and associated factors for late ANC among women attending ANC at Woldia town public health institutions, Northern Ethiopia. Therefore, this study aimed to assess the magnitude and factors associated with late initiation of ANC visit at Woldia public health institutions.

Study area and period
The study was conducted at Woldia public health institutions. Woldia town is the capital city of North Wollo Zone. It is located 520 Km away from the capital city Addis Ababa and 360 Km from the Regional capital

Study design
A facility-based cross-sectional study was conducted.

Source and study population
The source population was all pregnant women attending antenatal care visits at Woldia town public health institutions. Whereas the study population was sampled pregnant women attending ANC at Woldia town Public Health institutions.
Sample size and sampling procedure

Sample size
The nal sample of the study was determined with the assumptions of a 95% con dence level, 5% margin of error. The sample size was calculated for the prevalence and the factors and the sample size calculated for the prevalence yields the largest and selected.
Using the formula Where n = the desired sample size Z = level of signi cance at 95% con dence interval P = is the prevalence of late ANC visit (taken from a study conducted at public health centers of Debre Data collection tools and techniques Data were collected using an interviewer-administered questionnaire. The questionnaire was adopted by reviewing the literature. The questionnaire was rst prepared in English and then translated to the local language Amharic. The data collection was conducted by trained Midwives.

Data Quality control
A pretest was done by taking 5% of the sample from the Kobo Hospital, one week before data collection to check whether the questionnaire was correct and consistent. Data was cleared and checked for completeness and consistency by the principal investigators. The training was given for data collectors regarding the purpose of the research and issues associated with the questionnaire including the method and steps of data collection, the contents of the questionnaire, proper coding of the response variables.

Data Processing and analysis
Data was entered into EPI info version 3.5.1 for data exploration and cleaning. The cleaned data was exported to SPSS version 25 for statistical analysis. Descriptive statistics were used to summarize categorical variables. Both bivariate and multivariable analyses were performed using logistic regression and adjusted odds ratios (AOR) with 95% con dence intervals for factors associated with late initiation of antenatal care. P-value < 0.05 was considered statistically signi cant.

Sociodemographic characteristics of participants
The mean age of the mother was 28 years (SD ± 5.4). More than half of the respondents 213(54.6%) were residents of urban areas. Of the total mothers, 228(58.5%) were Orthodox Christians. The majority of the mothers were 357(91.5%) Amhara ethnic group. Of the total 390 mothers, 339 (86.9%) were married mothers (Table 1).  Partner related characteristics From the total respondents, nearly a quarter of 95(24.4) of their husbands had no plan for the current pregnancy. Around 226 (57.9%) of husbands of respondents did not know when to start ANC follow up by their wives. One hundred and fty-eight (40.5%) of the respondents had come for ANC with their husbands (Table 3).

Factors associated with the time of ANC initiation
Mothers who reside in urban areas were ve times more likely to initiate ANC early than rural residents.
Payment for health services, Plan for pregnancy, Counseled for ANC, and the number of lifetime pregnancies was factors signi cantly associated with late initiation of ANC (Table 4).

Discussion
The ndings of this study revealed that the prevalence of late antenatal care initiation among study subjects was 59.5%. This nding was greater than a study conducted in Colombia (29.7%) [14], which might be attributable to demographic and cultural differences. The nding was less than a study conducted at Debrebirhan health institutions (73.8%) [17], Gonder town (64.9%) [22], and study conducted at Southern Ethiopia (79.8%) [21]. this might be attributable to the difference in the time of the study.
In this study, mothers from the urban residence were nearly ve times more likely to initiate ANC at and before 12 weeks of gestation. This nding is in line with a study conducted in Zambia, EDHS 2016 [19,24], this is because of the differences in the awareness level and access to health services among rural and urban mothers.
Mothers who had a history of payment-related health services were nearly 14 times more likely to initiate ANC late than those who had not paid, attributable to those who had paid previously for health services might fear the fee and come late for antenatal care. This nding also revealed that those mothers who had planned for the current pregnancy were 13 times more likely to initiate ANC before /at 12 weeks of gestation than those mothers who had no plan. This nding was in line with the study conducted at Debrebirhan health institutions [17], Southern Ethiopia, Addis Abeba [21,23] It is because of mothers who did not have a plan for their pregnancies, might know their pregnancy status late, or do not want to disclose their pregnancy status.
According to this study mothers who had counseled and advised regarding ANC were 13.5 more likely to initiate ANC before/at 12 weeks of gestation than those mothers who did not. The nding is in line with a study conducted at Addis Abeba [23]. This is because of mothers who were advised on antenatal care follow-up understood the signi cance of initiating antenatal care follow up early.
The ndings of this study also show that primigravida mothers were 5.5 times more likely to initiate ANC before/at 12 weeks of gestation than multigravida mothers. The nding was similar to the study conducted at Tanzania [20] and Southern Ethiopia [21]. This might be due to mothers who did not have previous exposure for pregnancy fear the risks and seek immediate health care.

Conclusion
Our study showed that 59.5% of mothers attended antenatal care follow-up late from the recommended time of initiation. Residence, payment for pregnancy-related health services, plan for pregnancy, Counseled, and advised regarding antenatal care follow-up and gravidity were factors signi cantly associated with antenatal care initiation.