Correspondence to Mr Firaol Regea Gelassa; [email protected]
STRENGTHS AND LIMITATIONS OF THIS STUDY
The study was unique, as it comprehensively examined the determinants of antenatal care booking by examining many variables from different dimensions.
The results are generalisable to the reproductive age women living in the study area.
Data on dependent and independent variables were collected at the same time which is difficult to assess the causal relationships between variables.
The data were based on self-reports from women, which may be subject to recall biases.
Some variables (availability of the healthcare facility and distance from the facility) have not been reported for fear of bias during data collection.
Introduction
Despite the fact that maternal and neonatal health gained global priority, the United Nations target of reducing maternal mortality by 75% by the year 2015 was not met, and it shows lagging progress compared with other millennium development goals (except in the south-east Asian region, which shows a significant decline in the maternal mortality rate (MMR)).1 The mortality rate for children under the age of 5 in the world in 2020 was 38 deaths per 1000 live births and nearly half of those deaths were newborns, which are linked to inadequate antenatal care (ANC).2
According to 2015 report, about 303 000 of global women and adolescent girls died from pregnancy-related problems and about 2.6 million babies were stillborn.1 More than 80% of these mortality can be prevented, if the pregnant women or adolescent girls had been able to get high-quality ANC.3 The majority (99%) and 98% of maternal and child deaths, respectively, occurred in low-income and middle-income countries.3 Ethiopia is one of the sub-Saharan Africa (SSA) countries with a high number of maternal mortalities (412 deaths per 100 000 live birth) which puts the country among the top 10 (fourth in rank) countries with high MMR. Ethiopia shares 4% of global maternal deaths annually.3 4
ANC is one of the vital maternal care approaches to minimise maternal and neonatal death and disability. ANC is an essential activity to enhance maternal and newborn health. It (ANC) provides opportunities for medical services such as health promotion, screening and diagnosis, injury and disease prevention, birth preparation and postpartum care.5 ANC can minimise morbidity and mortality while improving general health and well-being by implementing timely and appropriate evidence-based practices.5
ANC includes respectfully communicating with pregnant women on physiological, biological, behavioural and sociocultural challenges as well as providing emotional and psychological support.4 6
The time of first ANC services initiation has the paramount importance to realise optimum pregnancy related maternal and neonatal complications.7 Early antenatal booking is one of the ANC pillars which help to increase the early detection, prevention and treatment of pregnancy related problems to achieve a maximum reduction of MMR and morbidity with intervention and information that promotes the well-being and survival of mothers and their babies.5
According to the WHO ANC guideline; every mother should begin ANC visit within the first 12 weeks of gestation in each WHO countries.2 Delay in ANC initiation and failure to attend ANC results pregnancy related complications and poor pregnancy outcomes, such as perinatal death, stillbirth, early neonatal death, lose the advantage of early diagnosis and intervention of existing illnesses such as HIV and sexually transmitted disease, anaemia and medical conditions.1 8–11
The WHO advises a minimum of eight contacts: five in the third trimester, one in the first trimester and two in the second trimester.7 This recommendation is predicated on the idea that each country will adapt the new model to its context based on the country’s defined core package of ANC services. Ethiopia just adopted the ANC8+suggestion recently, despite the fact that it was introduced in 2016 and launched the new WHO ANC guideline1 12
The report revealed that the ANC service is not widely used and the global ANC coverage for pregnant women and adolescent girls was only 71%.5 Furthermore, in SSA, only 44% of pregnant women attend their last ANC visit.3 In Ethiopia, only 62% of pregnant women received ANC at least once from the recommended WHO ANC visit and only three out of ten women received all ANC visit round.13 14
A thorough review of the literature shows low coverage of ANC in SSA including Ethiopia. A study done in Nigeria reveals the magnitude of ANC service usage differently, which ranges from the lowest 1.85% (north-west of Nigeria) to the highest 40.74% (nation-wide magnitude).15 The study done in Kenya, and Zambia showed that few women started their first ANC within 16 weeks of gestation which was 9% and 19%, respectively.16 17 According to EDHS 2016,18 only 20% of women had their first ANC during the first trimester, 26% during their fourth to the fifth month of pregnancy and 14% during their sixth to the seventh month of pregnancy. Two per cent of women did not get ANC until the eighth month of pregnancy or later.18
A goal of ending preventable maternal mortality is to reduce MMRs worldwide to less than 70 per 100 000 live births by 2030.19 According to this strategy, countries should reduce the MMR by at least two-thirds from the baseline level of 2010. By 2030, no nation shall have an MMR of more than 140 maternal deaths per 100 000 live births.19
Ethiopia’s MMR (412 per 100 000 live births) and child mortality rate (67 per 1000) are still unacceptably high, despite the country offering free ANC service package for maternal healthcare services. Even though there is a progression in institutional delivery, timely introduction of maternal health services is still difficult.20 In spite of the strong recommendation from the WHO toward the assessment of the determinants of early ANC booking, most of the recent studies emphasise the magnitude of delay in the first ANC visit, the number of ANC visits throughout pregnancy and gestational age at booking for ANC.12 21–24 Therefore, the purpose of this study was to assess determinants of early ANC booking among pregnant women attending ANC at public health facilities in the Nole Kaba district, western Ethiopia.
Methods and materials
Study area and period
The study was conducted in the Nole Kaba district, which is found in the west Wollega zone, Oromia region, Ethiopia. It is located 494 km to the west of Addis Ababa, the capital city of Ethiopia and 50 km from the zonal town Gimbi. The woreda has an estimated total population of 96 946 of whom 49% are male and 51% are females, 21 619 are female reproductive age group (15–49 years), and pregnant women are 2772. There are 4 health centres (HCs), 27 health posts, 1 primary hospital and 14 private clinics. The study was conducted from April to June 2020.
Patient and public involvement
The research questions and study design were designed by the investigators, who subsequently had them approved by the Ambo University’s institutional review board. None of the participants in this study were involved in its conception, execution or dissemination strategies.
Study design
Facility based unmatched case–control study was conducted.
Populations
The source populations for this study were all pregnant women in the Nole Kaba district, those who visited the public health facilities during the study period, and the study populations were those systematically selected pregnant women who visited the public health facilities in the Nole Kaba district during the study period.
The study population was divided into cases and controls.
Case
Pregnant women visited the ANC unit before 16 weeks of pregnancy (ie, early initiators of ANC).
Controls
Pregnant women who visited the ANC unit after or at 16 weeks of pregnancy (ie, late initiators of ANC).
Eligibility criteria
Pregnant women who start ANC visits before 16 weeks and after or at 16 weeks were included as cases and controls, respectively. For both case and control—women with unknown gestational ages at their initial visit were excluded.
Sample size determination and sampling techniques
Sample size determination
Sample size was determined by considering factors that are significantly associated with the outcome variable. We considered educational level of pregnant women as the major determinant of early ANC booking which gave a large sample size; 31.3% proportion of exposure among cases and 35.7% proportion of exposure among controls, 2.15 OR to detect case,22 80% power and two-sided confidence level 95% and the ratio of cases to controls was 1:2 (table 1). Then, the largest sample size (270) was considered for this study. Adding 10% non-response rate, the final sample size became 297 (cases=99 and controls=198).
Table 1Sample size determination for factors associated with early antenatal care booking among pregnant mothers attending public health facilities in Nole Kaba district
| Main variables | CL (confidence level) % | Power (%) | Unexposed (%) | Exposed (%) | OR | Ratio of controls to case | Sample size |
| Means of recognition of pregnancy | 95 | 80 | 75.4 | 92.7 | 7.21 | 2.01 | 111 |
| Women’s occupation | 95 | 80 | 56 | 44 | 0.43 | 2.01 | 204 |
| Educational status | 95 | 80 | 31.3 | 35.7 | 2.15 | 2.01 | 270 |
| Parity | 95 | 80 | 38.5 | 90.3 | 3.93 | 2.01 | 191 |
Sampling procedure and technique
In this study, all health facilities that were providing ANC service in Nole Kaba district (Bubbe primary hospital, Nole Kaba HC, Ula Babu HC, Siba Koche HC and Haro Gondiyo HC) were included. The total sample size was proportionally allocated to each selected health facility based on the number of last month ANC flow (ie, here the quarter flow was estimated from the last quarter flow) by referring the registration books of each ANC unit before data collection started. Thus, average number of pregnant women who attended ANC in each health facilities per month (estimated from quarter flow) multiplied by the total sample size (N=297), divided by the total number of pregnant women attending ANC visit in each health facilities (462). Cases were consecutively enrolled as they were identified. For each case, two controls were selected by using a systematic random sampling technique (ie, Kth=N/sample size≥396/198=2), thus every second from the same health facility until the required sample size was obtained (see figure 1).
Enlarge this image.Figure 1. Schematic representation of sampling techniques to assess the determinant factors of early antenatal care booking in the Nole Kaba District, west Wollega zone, Oromia, Ethiopia. HC, health centre; PH, primary hospital.
Operational definitions
ANC is defined as the care provided by skilled healthcare professionals to pregnant women and adolescent girls to ensure the best health conditions for both mother and baby during pregnancy.4
Early ANC booking is defined as those pregnant women entering ANC before or at 16 weeks of pregnancy3 4 whereas, late ANC booking was defined as those pregnant women starting ANC after 16 weeks of their pregnancy. This is taken from the last menstrual period of the woman.4 6
Cases were pregnant women visited the ANC unit before 16 weeks of gestational age (ie, early initiators of ANC) while, controls were pregnant women who visit the ANC unit at or after 16 weeks of their gestational age (ie, late initiators of ANC).
Data collection tools and techniques
The data were collected through face-to-face interviews, which were adopted from Ethiopian Demographic and Health Survey and different related literature.23 24 The questionnaire has: sociodemographic factors, knowledge-related factors, past and current obstetric history, history of service usage, health service-related factors and environmental-related characteristics. Five data collectors and two supervisors were recruited for data collection.
Data quality control and management
Questionnaires were translated from English to the local language (Afan-Oromo) and then translated back to English to check consistency by language experts. Questionnaires were pretested among 15 (5%) of the sample at neighbouring district before actual data collection. Data collectors and supervisors were trained in data collection and procedures. Daily strict supervision was provided. Data completeness and inconsistency were checked daily. All the data were cleaned and cross-checked for their completeness before data entry.
Methods of data analysis
Data was entered into epi-info V.7.2.2.6 software and then exported to SPSS V.25 for further analysis. The descriptive analysis like percentage, frequency and mean was computed to show the data characteristics. Binary and multivariable logistic regression analysis was used to identify associations between dependent and independent variables. In bivariable logistic regression analysis, variables with p≤0.25 were considered as candidate to be analysed in multi-variable logistic regression analysis. The variables that show p value <0.05 were declared as statistically significant variables in multivariable logistic regression analysis.
The degree of association between independent and dependent variables was assessed using crude OR and adjusted OR (AOR) with 95% CI. The Hosmer-Lemeshow test was used to check the model fitness, statistically, not significant was considered as model fitted (ie, Nagelkerke R2 value 0.689 and Homser and Lemeshow test sig p value was 0.8). Multicollinearity was checked (variance inflation factor <10), indicating that there was no multicollinearity among the variables in this study.
Results
Sociodemographic characteristics of the study participants
Two hundred ninety-seven pregnant women participated in the study (99 cases and 198 controls) with a 100% response rate. The mean age of the respondents was 27.42 years (±5.72 SD). Fifty-five (55.6%) of cases and 150 (75.8%) of controls were rural resident. Out of the total, 38 (38.4%) of the cases and 54 (27.3%) of controls attended secondary education (9–12 grade). Regarding the occupation of study participants, 63 (63.6%) of cases and 33 (16.7%) of the controls were housewives (see table 2).
Table 2Sociodemographic characteristics of study participant attending health facilities in Nole Kaba district, west Oromia, Ethiopia, 2020 (n=297)
| Variables | Category | Cases (n=99) | Controls (n=198) | Total (n=297) |
| N (%) | N (%) | |||
| Age at current pregnancy | 15–24 | 37 (37.4) | 58 (29.3) | 95 (32) |
| 24–34 | 56 (56.6) | 103 (52.0) | 159 (53.5) | |
| 35–44 | 6 (6.1) | 37 (18.7) | 43 (14.5) | |
| Residence | Urban | 44 (44.4) | 48 (24.2) | 92 (31) |
| Rural | 55 (55.6) | 150 (75.8) | 205(69) | |
| Marital status | Married | 95 (96.0) | 186 (93.9) | 281 (94.6) |
| Others* | 4 (4.0) | 12 (6.1) | 16 (5.4) | |
| Ethnicity | Oromo | 90 (90.9) | 184 (92.9) | 274(92) |
| Others† | 9 (9.1) | 14 (7.1) | 23 (8) | |
| Religion | Protestant | 58 (58.6) | 114 (57.6) | 172(58) |
| Orthodox | 23 (23.2) | 62 (31.3) | 85 (28.6) | |
| Others‡ | 18 (18.2) | 22 (11.1) | 40 (13.4) | |
| Women’s educational level | Cannot read and write | 8 (8.1) | 44 (22.2) | 52 (17.5) |
| Primary (1–8) | 31 (31.3) | 92 (46.5) | 123 (41.4) | |
| Secondary (9–12 grade) | 38 (38.4) | 54 (27.3) | 92 (31) | |
| Diploma and above | 22 (22.2) | 8 (4.0) | 30 (10.1) | |
| Women’s main occupation | Government employed | 8 (8.1)) | 10 (5.1) | 18 (6) |
| Daily labourer | 63 (63.6) | 33 (16.7) | 96 (32.3) | |
| Housewife | 21 (21.2) | 133 (67.2) | 154 (51.9)) | |
| Others§ | 7 (7.1) | 22 (11.1) | 29 (9.8) | |
| Husbands’ educational level | Cannot and write | 1 (1.0) | 9 (4.5) | 10 (3.4) |
| Primary (1–8) | 21 (21.2) | 88 (44.4) | 109 (36.7) | |
| Secondary (9–12 grade) | 38 (38.4) | 84 (42.4) | 122(41) | |
| Diploma and above | 39 (39.4) | 17 (8.6) | 56 (18.9) | |
| Husbands main occupation | Government employed | 25 (25.2) | 14 (7.1) | 39 (13.1) |
| Daily labourer | 11 (11.1) | 38 (19.2) | 49 (16.5) | |
| Farmers | 45 (45.5) | 112 (56.6) | 157 (52.9) | |
| Others¶ | 18 (18.2) | 34 (17.2) | 52 (17.5) |
*Single, divorced, widowed.
†Gurage, Amhara.
‡Muslim and Catholic.
§Merchants, private employed.
¶Non-govermental organisation, Merchant and student.
Knowledge-related characteristics of the study participants
Out of the total women interviewed, 93 (93.9%) of cases and 169 (85.4%) of controls knew the importance of early ANC booking. Among the study participants, 12 (12.2%) of cases and 132 (66.7%) of controls perceived a number of ANC visits less than or equal to three visits. From the total respondents, 86 (86.9%) of the mothers among cases and 48 (24.2%) of mothers among controls perceived the right time of ANC initiation as less than 16 weeks of gestation (see table 3).
Table 3Knowledge related characteristics among study participant attending public health facilities in Nole Kaba district, west Oromia, Ethiopia, 2020 (n=297)
| Variables | Category | Cases (n=99) | Controls (n=198) | Total (n=297) |
| Early antenatal care (ANC) booking is important | N (%) | N (%) | N (%) | |
| Yes | 93 (93.9) | 169 (85.4) | 262 (88.2) | |
| No | 6 (6.1) | 29 (14.6) | 35 (11.8) | |
| Perceived number of ANC visit | ≥4 | 87 (87.9) | 66 (33.3) | 153 (51.5) |
| ≤3 | 12 (12.2) | 132 (66.7) | 144 (48.5) | |
| Know danger sign in pregnancy | Yes | 69 (69.69) | 97 (48.98) | 166 (55.9) |
| No | 30 (30.31) | 101 (50.02) | 131 (44.1) | |
| Perceived right time of ANC initiation | <16 weeks | 86 (86.9) | 48 (24.2) | 134 (45.1) |
| ≥16 weeks | 13 (13.1) | 150 (75.8) | 163 (54.9) |
Obstetric and health service-related characteristics of the study participants
Out of the total participants, 20 (20.2%) mothers with cases and 44 (22.2%) mothers with controls were primigravida and 36 (36.4%) of mothers with cases and 46 (23.2%) of mothers with controls had a history of abortion. More than two-thirds of case (78.8%) and controls 153 (77.3%), respectively were ever gave birth. Among them, 27 (27.3%) of the mother with cases and 91 (46%) of mothers with controls had a history of birth at home for the preceding birth. Of the total mothers, 63 (63.6%) of cases and 104 (52.5%) of controls had a history of using family planning before the current pregnancy (see online supplemental file 1).
Determinants of early ANC booking in logistic regression analysis
In bivariable logistic regression analysis, age of women, place of residence, level of education, history of abortion, place of previous delivery, using family planning, planned pregnancy, means of pregnancy identification, availability of transportation, presence of advice to start ANC early, service fee, accompanied with husband, media exposure.
In multi-variable analysis, after adjusting for the possible effect of confounding variables, women’s educational level, planned pregnancy, women who had a history of abortion, previous place of delivery, place of residence, women accompanied with husband during ANC visit and media exposure became significantly associated with early ANC booking.
Our study showed that women who had a diploma and above the level of education were three times more likely to initiate ANC early than women who were unable to read and write (AOR=3.42, 95% CI 1.01, 6.04). The odds of early initiation of ANC visit among mothers with planned pregnancy (AOR=8.02, 95% CI 2.79, 13.03)) were eight times higher than women with an unplanned pregnancy. Women with a history of abortion (AOR=5.96, 95% CI 2.07, 9.13) had six times more likely to initiate ANC early when compared with women who had no history of abortion. Women who had a history of institutional delivery (AOR=4.57, 95% CI 1.1, 9.1) were five times more likely to initiate ANC early when compared with women who had a history of home delivery.
In this study, women from urban (AOR=2.21, 95% CI 1.11, 2.72) were two times more likely to start ANC early when compared with women from rural. Mothers who were accompanied by husbands during ANC visits (AOR=2.48, 95% CI 1.77, 7.98) were two times more likely to book ANC early as compared with those who did not accompany by husbands during ANC visits. The result of this study showed that women exposed to the media tended to book early as compared with those who did not (see table 4).
Table 4Multivariate analysis to assess variables associated with early ANC booking among women visiting public health facilities in Nole Kaba district, west Wollega, Oromia, Ethiopia
| Variables | Category | Booked at <16 weeks of gestation | Multivariate analysis | ||
| Yes (cases=99) | No (controls=198) | ||||
| Early booked (%) | Lately booked (%) | AOR (95% CI) | P value | ||
| Age at current pregnancy | 15–24 | 37 (37.4) | 58 (29.3) | 0.24 (0.05, 1.1) | 0.45 |
| 24–34 | 56 (56.6) | 103 (52.0) | 4.41 (0.67, 1.45) | 0.062 | |
| ≥35 | 6 (6.1) | 37 (18.7) | 1 | ||
| Residence | Urban | 44 (44.4) | 44 (24.2) | 2.21 (1.11, 2.72)* | 0.007 |
| Rural | 55 (55.6) | 156 (75.8) | 1 | ||
| Women’s educational level | Cannot and write | 8 (8.1) | 44 (22.2) | 1 | |
| Primary (1–8) | 31 (31.3) | 92 (46.5) | 0.39 (0.1, 1.59) | 0.067 | |
| Secondary (9–12 grade) | 38 (38.4) | 54 (27.3) | 0.24 (0.44, 1.32) | 0.099 | |
| Diploma and above | 22 (22.2) | 8 (4.0) | 3.42 (1.01, 6.04)* | 0.019 | |
| ≤3 | 12 (12.2) | 132 (66.7) | 1 | ||
| Place of delivery last pregnancy | At home | 16 (16.2) | 67 (33.8) | 1 | |
| At institution | 60 (60.6) | 83 (41.9) | 4.57 (1.09, 19.10)* | 0.011 | |
| History of abortion | Yes | 36 (24.14) | 178 (89.89) | 5.96 (2.07, 17.13)* | 0.001 |
| No | 75 (75.75) | 20 (10.10) | 1 | ||
| Means of approved pregnancy | Missed period | 33 (33.3) | 108 (54.5) | 1.89 (0.70, 5.089) | 0.76 |
| Urine test | 66 (66.7) | 90 (45.45) | 1 | ||
| Planned pregnancy | Yes | 87 (87.9%) | 100 (50.5) | 8.02 (2.79, 23.03)* | 0.001 |
| No | 12 (12.15) | 98 (49.5%) | 1 | ||
| Plan included spouse | Yes | 86 (86.9) | 97 (49.0) | 0.736 (0.073, 7.3) | 0.89 |
| No | 13 (13.1) | 101 (51.0) | 1 | ||
| Advised to initiate ANC early before | Yes | 79 (79.8) | 101 (51.0) | 2.51 (1.84, 7.53)* | 0.45 |
| No | 20 (20.2) | 97 (49.0) | 1 | ||
| Any payments asked for the service | Yes | 48 (48.5) | 71 (35.9) | 0.87 (1.05, 6.35)* | 0.065 |
| No | 51 (51.5) | 127 (64.14) | 1 | ||
| Ever attended ANC visit | Yes | 73 (73.7) | 120 (60.6) | 1.99 (1.74, 4.96) | 0.37 |
| No | 26 (26.3) | 78 (39.4) | 1 | ||
| Accompanied by person during ANC visit | Yes | 58 (58.6) | 66 (33.3) | 2.48 (1.77, 7.98)* | 0.042 |
| No | 41 (41.4) | 132 (66.7) | 1 | ||
| Use transportation during ANC visit | Yes | 63 (63.6) | 48 (24.2) | 3.06 (1.19, 7.85)* | 0.18 |
| No | 36 (36.4) | 150 (78.5) | 1 | ||
| Media exposure | Yes | 82 (82.8) | 70 (35.4) | 6.95 (2.68, 18.02)* | 0.001 |
| No | 17 (17.2) | 128 (64.6) | 1 | ||
1: reference category.
*Statistically significant at p value <0.05.
ANC, antenatal care; AOR, adjusted OR.
Discussion
This study investigated the determinants of early ANC booking among pregnant women attending public health facilities in the Nole Kaba district. Place of residence, women’s educational level, planned pregnancy, having a history of abortion, the place of previous delivery, women accompanied by their husbands during ANC visits and media exposure were found to be the determinants of early ANC booking among pregnant women.
This study revealed that women who are urban dwellers were more likely to initiate ANC care early when compared with women who live in rural areas. This is in line with a study conducted in the Accra metropolitan area, Ghana, Malawi and the Democratic Republic of the Congo.25–27 This might be because urban women have easier access to transportation and social media, which help them easily, obtain information about the significance, timeliness and services offered by healthcare facilities. Additionally, most of the healthcare facilities (both public and private) are more easily accessible to urban dwellers than rural ones.
Our study also revealed a strong relationship between women’s level of education and the timing of their first ANC visit. Women who had a diploma and a higher level of education were three times more likely to initiate ANC early than women who were unable to read and write. This is in line with the findings from studies conducted in Ghana, Tanzania, Nigeria, Nepal, Tigray, Hadiya zone, and Debre Markos town, north-west Ethiopia.25 28–31
This might be resulted from the association between education and women’s empowerment. Education is the basis for empowerment, and the initiation of an ANC visit is associated with women’s empowerment.30 Additionally, educated women understand the benefits of early initiation of ANC for themselves and their fetuses. In the present study, women with planned pregnancies were eight times more likely to initiate their first ANC visit early than those with unplanned pregnancies. This finding is consistent with a study done in Kenya, Addis Ababa, and Debre Markos town, north-west Ethiopia.20 32 33 This could be due to the fact that pregnant women with planned pregnancies might get support from a partner or family, so they might recognise their pregnancy follow-up early and give more care to their pregnancy. Women with a history of abortion had a sixfold higher chance of starting ANC early as compared with those who did not have a history of abortion. This is similar to the findings of studies from Ghana and South Africa.25 34 The reason might be that women with a history of abortion at a healthcare institution are likely to have early antenatal visits because they might have received ANC advice during abortion care. Additionally, they might seek healthcare early to prevent any similar problems with a previous pregnancy.
When compared with their counterparts, pregnant women who were accompanied by husbands during the antenatal visit were more likely to initiate the ANC early. This is supported by findings from Hosanna town, Hadiya zone, Sidama zone, south Ethiopia.28 35 This might be due to the fact that the period of ANC beginning is significantly influenced by husband involvement and recognition. Husbands who accompany their wives during ANC visits might initiate them to have an early ANC visit, and this makes the follow-up activities easier during each ANN visit.
Mothers who had delivered at a health institution for the last pregnancy were five times more likely to start ANC early when compared with mothers who gave birth at home. This is in line with the study conducted in Halaba Kulito, Ethiopia.36 A possible explanation might be that mothers who gave birth at health institutions might receive advice and experience regarding the importance of early antenatal booking for themselves and their fetuses.
According to this study, the likelihood of early ANC booking is increased by sevenfold in women who have social media exposure when compared with their counterparts. This is in line with the findings of the study conducted in Nepal, Uganda and Hadiya zone, Ethiopia.25 37 38 This might be due to the fact that the majority of reproductive-related healthcare is promoted by different social media platforms, which might positively influence women’s attitudes towards early ANC visits and their adherence to subsequent follow-ups by providing them with relevant information regarding the risk of pregnancy and the benefits of services.
Conclusions
In this study, women’s place of residence, educational level, planned pregnancy, history of abortion, previous place of delivery, women accompanied by the husband during ANC visit, and media exposure were determinants of early ANC booking. Therefore, in order to improve the early initiation of ANC booking, health extension programmes on early ANC initiation should be strengthened by giving priority to less educated women, women who live in rural areas and women who are less active on social media. They should also promote husband involvement programmes.
Limitation of the study
Since data on dependent and independent variables were collected at the same point in time, no causal interpretation can be made of the relationships between variables. The data were based on self-reports from women, which may be subject to recall biases. This study was included only public health institutions; pregnant women who attend ANC at private health facilities were not included in the study. Additionally, some variables (availability of the healthcare facility and distance from the facility) have not been reported for fear of bias during data collection.
Our appreciation goes to the Nole Kaba district health office and selected public health facilities in the district for facilitating the process of data collection and providing valuable information. We are also thankful to the study participants, data collectors and supervisors for their contribution to this study.
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Not applicable.
Ethics approval
This study involves human participants. All methods of this study were carried out under the Declaration of Helsinki’s ethical principle for medical research involving human subjects. Ethical approval to conduct this study was obtained from the ethical review committee of Ambo University, College of Medicine and Health Science (Ref. No: PGC/33/2020). An official letter was sent to the Nole Kaba district health office. A permission letter was delivered to public health facilities in the district. The objective of the study, the advantages and disadvantages of being part of the study were explained to the participants and informed written consent was obtained from each respondent before the interview. Mothers were interviewed in a private place and all information that was obtained from the respondents was kept confidential. No names were included in the questionnaire. Participants were informed that they have the right to refuse and withdraw from the interview at any time they want. Confidentiality and privacy of the information were maintained. The participants were informed that participation is fully voluntary. Name of ethical review board: Jiregna Darega (Assistant Professor of Public Health), Tsegae Benti (Assistant Professor of Public Health), Mecha Aboma (Assistant Professor of Public Health), Negassa Dida (Associate Professor of Public Health).
Contributors DK designed and participated in data collection, and conducted the data analysis and interpretation. SMT and FRG wrote the original manuscript, and advised on the data analysis, interpretation and report writing. All authors critically reviewed and approved the final version of the manuscript. FRG is responsible for the overall content as the guarantor.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.
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; Segni Mulugeta Tafasa 2 ; Kumera, Diriba 3 1 Department of Nursing, Assosa University, Asossa, Ethiopia
2 Department of Public Health, Wollega University, Nekemte, Ethiopia
3 Department of Public Health, Ambo University, Ambo, Ethiopia