Abstract

Background: Maternal and neonatal mortality remains a major global public health burden. A well utilized antenatal care (ANC) is however among the identified interventions to reduce this burden of maternal and neonatal mortality rates.

Objectives: This study set out to assess the level of ANC utilization and identify the factors associated with ANC utilization amongst pregnant women in Santa Health District

Methods: It was a community based cross-sectional study involving 378 pregnant women (mean age 28 ± 6.4 years). Data for this study was collected using a pretested self-administered questionnaire. Results were presented using frequency distribution tables and continuous variables calculated using independent student t-test and One Way ANOVA as appropriate. Association between Categorical variables were assessed using cross tabulation. Odds ratios with their corresponding 95% confidence intervals were estimated for the factors associated with ANC utilization using binary logistic regression analysis. Further, a multivariate binary logistic regression analysis was performed to determine the independent predictors of ANC utilization using all the variables that were significant in the bivariate analysis. Statistical significant was set at p <0.05.

Results: Majority (71.4%) of pregnant women in Santa Health District attended ANC at least once during their last pregnancy of which 28.5% had four or more visits and 35.4% initiated their ANC attendance within their first trimester. Also 55.3% of the pregnant women had good knowledge of ANC. Being greater than 30years (OR=7.1, 95% CI: 2.5-20.0), being a Muslim (OR=4.2, 95% CI; 1.9-18.0), being single (OR=6.6, 95% CI; 3.5-12.4), and having a primary level of education (OR=4.4, 95% CI; 1.8-10.5) were significantly associated with ANC utilization (p<0.001). On multivariate analysis being older than 30 years was an independent predictor for ANC Utilization (OR=5.9; 95% CI: 1.7-20.3, p =0.005)

Conclusion: Being older than 30 years predisposes most pregnant women to under-utilize ANC services. Hence, health education activities about ANC services and its importance should be channeled more to this age group.

Keywords: Determinants, ANC, Pregnant Woman, Utilization, Santa Health District.

CHAPTER ONE

1 Background

Antenatal Care (ANC) is an important component of maternal and perinatal health and covers a wide range of activities leading to positive pregnancy outcomes [1].  However, large proportions of women do initiate ANC early resulting in adverse consequences.  Also, all regions of the world have experienced a decline in maternal deaths globally but still not achieving SDG 3 targets of 70 deaths per 100 000 for maternal and infant mortality (https://Cameroon.un.org >sdgs). Moreover, the utilization of recommended antenatal care (ANC) throughout pregnancy has been found to reduce maternal mortalities and morbidities with improved maternal health outcomes [1].

Maternal mortality and morbidity continue to be a significant problem in low-income countries, despite a worldwide focus on the need to improve maternal health. An estimated 99% of all maternal deaths occur in developing countries and more than half occur in sub-Saharan Africa (SSA) [2]. Developing countries continue to grapple with a huge burden of maternal and child mortalities where approximately 800 girls and women died as a result of pregnancy and childbirth-related complications in 2015 in SSA [3]. Globally, the maternal mortality rate (MMR) fell by nearly 44% over the past 25 years, to an estimated 216 maternal deaths per 100,000 live births in 2015. Developing regions accounted for approximately 99% (302,000) of these estimated global maternal deaths in 2015, with sub-Saharan Africa alone accounting for roughly 66% (201,000). WHO reports (WHO 2021) estimates MMR in Cameroon at 406 maternal deaths per 100,000 live births.

The situation calls for the adoption of drastic measures to stem the tide. Among the various strategies adopted to curb this menace are improvement in access and utilization of antenatal care services, increase in number of women who are attended to by skilled healthcare personnel during child birth, and provision of relevant postpartum or postnatal health services to both mothers and babies with. [3, 5]. Antenatal care (ANC), the first on the list of interventions, is broadly defined as encompassing pregnancy-related services provided between conception and the onset of labor with the aim of improving pregnancy outcomes and/or the health of the mother and/or child [6]. This care involves a series of assessments and appropriate treatments covering three components: monitoring of the health status of the woman and the fetus; provision of medical and psychosocial interventions; and support and health promotion [6].

ANC has over the years proven to be a good panacea to the problem of maternal and child mortalities. It is a key indicator of the Sustainable Development Goal (SDG) 3, target 3.1, reducing the global maternal mortality ratio to less than 70 per 100,000. Among others, ANC is commonly understood to have beneficial impact on pregnancy and birth outcomes through early diagnosis and treatment of complications as well as promoting the health of the pregnant woman through nutrition [7]. ANC services create the opportunity for service providers to establish contact with the woman to identify and manage current and potential risks and problems during pregnancy [8]. It also creates the opportunity for the woman and her care providers to establish a delivery plan based on her needs, resources, and circumstances [9]. Again it creates opportunity for screening for such conditions as HIV and Sexually Transmitted Infections among others. The main impact of ANC is that it can lead to a reduction in severe anemia and cases of obstructed labor, and it improves the treatment of medical conditions [10]. Although ANC alone cannot prevent all obstetric emergencies, the information provided during ANC services can go a long way to ensure the successful management of pregnancies and the subsequent wellbeing of the child [11].

The lifetime risk of maternal mortality due to pregnancy complications, such as obstructed labor, excessive bleedings or eclampsia, is higher in Sub-Saharan Africa than in other parts of the world in part due to higher fertility rates, poorer nutritional status of women, inaccessibility to ANC clinics and higher prevalence of vulnerable life circumstances such as poverty and a higher prevalence of HIV infection [12, 13]. Also, higher ANC attendance among pregnant adolescents is particularly important as complications during pregnancy and childbirth have been shown to be a major cause of death among girls aged 15–19 in low- and middle-income countries [12]. Cameroon is a small country in the center of the African continent with approximately 20 million inhabitants. Sixty-two percent of women and 65% of men in Cameroon have completed some level of secondary education [14]. The majority of the low educated or illiterate women live in rural areas where more than 71.6% of the women are involved in small-scale agricultural activities. As in other low and middle-income countries, about 60% of maternal deaths in Cameroon is related to conditions that can be detected and addressed during the antenatal period. Such conditions include hypertension, HIV/AIDS infection, pre-existing medical conditions and sexually transmitted infections. Emergency situations may arise during childbirth, such as obstructed labor, severe bleeding and other problems that require emergency care [15, 16]. Deaths could be avoided if pregnant women have proper access to ANC services during pregnancy and support by a trained midwife during childbirth. Previous studies have suggested that demographic, socio-economic and behavioral factors such as age, time and cost of travel to the health facility, big family size and poor access to social support are associated with poor antenatal care attendance [12, 18]. Furthermore, a study on maternal health care across sub-Saharan Africa found that low level of education, rural residence, and low household income were all associated with poor ANC attendance [19]. Although Cameroon has adopted the previous WHO model of antenatal care, which recommends one visit during each trimester of gestation and a final visit immediately preceding delivery for women without pregnancy-related complications or risk factors, still only a proportion of pregnant women make all four recommended visits during pregnancy. This raises concerns regarding the adoption and implementation of the WHO new guidelines, which recommend that the number of contacts a pregnant woman has with a health provider throughout her pregnancy should increase from four to eight [20].

1.1 Problem Statement

Pregnancy related deaths and disorders remains inadmissibly high at the global front claiming millions of women and infants’ life [20]. It is a recommendation by the world health organization that, all pregnant women should have at least four antenatal visits throughout their pregnancy period [20]. Globally, while 86 percent of pregnant women access antenatal care with skilled health personnel at least once, only three in five (62 percent) receives at least four antenatal visits which is even worse in countries with high maternal mortality rates such as sub-Saharan Africa (51.9%) and least developed countries including Cameroon (45.8%) [21].

 In 2020, the global maternal mortality ratio was 152 deaths per live births. In sub-Saharan Africa the ratio is 533 deaths per live births while in Cameroon, maternal mortality ratio is 529 deaths per live birth. In 2017 maternal deaths for Cameroon was 4700 [21]. In Cameroon 970 306 pregnant women are expected to attend ANC every year. The national average is estimated at one single ANC visit per pregnancy for 83.3 to 85% of parturient women, among who only 60% have attended at least four visits [22]. In 2009 and 2010, only 35% of pregnant women attended the first quarter ANC visit. Missing this first visit increases maternal morbidity and mortality and mortgages a whole ANC process [23].

In Cameroon, the government has subscribed to many pledges and initiatives in order to reach the Millennium Development Goals 4 and 5, among which the increase and improvement of geographical coverage of ANC services and the launching in 2010 of the Campaign for Accelerated Reduction of Maternal Mortality in Africa (CARMMA) within the framework of the reproductive health program of the 2001-2015 health sector strategy [23]. Despite this effort by the government of Cameroon, ANC utilization still continues to be low, hence increasing maternal and neonatal mortality. It is therefore important to investigate into the factors associated with ANC utilization to help with the implementation of necessary policies which can help deal with maternal deaths and help produce healthy babies.

1.3 Research questions     

1. What is the proportion of pregnant women in Santa Health district attending ANC?
2. What is the knowledge level of pregnant women about antenatal care services in Santa Health district?
3. To what extent do availability, affordability and quality influence the uptake of ANC services amongst pregnant women in Santa Health district?
4. What are the factors associated with antenatal care service utilization by pregnant women in Santa Health district?

1.4 Hypothesis

There is no significant relationship between level of knowledge on ANC and utilization of ANC among pregnant women in Santa Health district

There is no significant association between the ANC utilization and some selected factors

 1.5 Main objective  

To assess the determinants of ANC utilization by pregnant women in Santa health district

1.6 Specific Objectives

1. To determine the level of antenatal care service utilization by pregnant women in Santa Health district.
2. To assess the knowledge level of pregnant women about antenatal care services in Santa Health district.
3. To investigate the perception of pregnant women with regards to the availability and affordability of ANC services amongst pregnant women in Santa Health district.
4. To identify the factors associated with antenatal care service utilization by pregnant women in Santa Health district