Determinants of Antenatal Care Service Utilization during the First Trimester among Pregnant Women
in Boke Woreda, Ethiopia: A Facility Based
Unmutched Case Control Study
Teklemariam Ergat Yarinbab1* and Melese Wegayehu Gedle2
1Department of Public Health, College of Health Sciences, Mizan-Tepi University, Ethiopia
2Department of Reproductive Health, College of Health Sciences, Mekelle University, Ethiopia
Submission: May 02, 2018; Published: May 30, 2018
*Corresponding author: Teklemariam Ergat Yarinbab, Department of Public Health, College of Health Sciences, Mizan-Tepi University, Mizan-Aman, Ethiopia, Email: email@example.com
How to cite this article: Teklemariam E Y, Melese W G. Determinants of Antenatal Care Service Utilization during the First Trimester among Pregnant
Women in Boke Woreda, Ethiopia: A Facility Based Unmutched Case Control Study. Curr Trends Biomedical Eng & Biosci. 2018; 15(1): 555904.
Background:Antenatal Care (ANC) services utilization during the first trimester is very important for risk identification, and prevention and management of pregnancy-related diseases. However, the ANC services utilization during the first trimester in Ethiopia is very poor. Likewise, there has been no research conducted in Boke Woreda on determinants of ANC services utilization. Therefore, the aim of this study was to identify determinants of ANC services utilization during the first trimester in Boke Woreda, Ethiopia.
Methods: A health facility based unmatched case-control study design was conducted in Boke Woreda, Ethiopia. The data was collected using pre-tested and structured questionnaires through interviews. Data analysis was done by SPSS for Windows Version 20.0. Bivariate and multivariate logistic regressions were conducted. P-value <0.05 was used to declare statistically significant variables.
Result: All selected pregnant women (339 participants) were interviewed with 100% response rate. ANC services utilization was associated with maternal age at less than 26 years (AOR=3.87,95% CI:1.57,9.51), women travelling at lower than 30 minutes to the health facility (AOR=3.26,95% CI:1.46,7.26), Women who experienced one to two number of pregnancy (AOR=5.01,95% CI:1.74,14.41), Pregnant women who had zero to two birth before (AOR=3.93,95% CI:1.35,11.41), and previous ANC service utilization history (AOR=2.52,95% CI:1.03,6.20). Besides, ANC service utilization was also positively associated with pregnant women who were supported by their family (AOR=3.28, 95%CI: 1.18, 9.06), service waiting time at less than 45 minutes (AOR=6.17, 95% CI: 1.83, 20.73), and pregnant women who were welcomed by health workers (AOR=7.81, 95% CI: 3.19, 19.09).
Conclusion:Maternal age, travelling time to the health facilities, client welcomed appreciation, maternal knowledge on ANC services, previous service utilization, parity, gravidity, and service waiting time were found to be the determinants of antenatal care services at first trimester. Therefore; Policy makers and stakeholders in the area have to focus their intervention on the identified factors in order to improve the ANC service utilization in the first trimester.
Keywords:Determinants; Antenatal care; First trimester; Boke oreda
Antenatal Care (ANC) can be defined as the care provided by skilled health-care professionals to pregnant women and adolescent girls in order to ensure the best health conditions for both mother and baby during pregnancy and it is one of the pillars of maternal health services . The components of ANC include; risk identification, prevention and management of pregnancy-related or concurrent diseases and health education and promotion. The goal of ANC is to prevent health problems of pregnant women and to ensure that each newborn child has a good start [2,3].
For provision of antenatal care services like tetanus toxoid immunization, intermittent preventive treatment of malaria, de-worming, iron and folic acid is very important before four months of pregnancies. In addition to this, pregnant women should be offered screening for HIV infection and syphilis to reduce mother-to-child transmission. Other intervention that can be linked to early ANC include ultrasound screening to identify congenital abnormalities, provision of information about birth preparedness and complication readiness plan, nutrition, family planning, breastfeeding, and health benefits of delivery with the assistance of skilled health provider. Hence, early antenatal care
booking is a strong predictor of positive pregnancy outcomes,
and has a substantial impact on maternal and child mortality [1-
Globally, annual maternal mortality was reported to be
303,000 in 2015. Developing regions account for approximately
99% of the global maternal deaths in 2015, with sub-Saharan
Africa alone accounting for roughly 66% (201,000), followed
by Southern Asia 21% (66,000) . It has been estimated that
25 percent of maternal deaths occur during pregnancy, with
variability between countries depending on the prevalence of
unsafe abortion, violence, and disease in the area. Between a
third and a half of maternal deaths are due to causes such as
hypertension (pre-eclampsia and eclampsia) and ante partum
hemorrhage, which are directly related to inadequate care
during pregnancy [4,5].
Some studies reported that maternal education, younger age,
marital status, first pregnancy, lower parity, planned pregnancy,
history of still birth, previous early antenatal care visit, advice
on early antenatal care visit were associated with early antenatal
care booking [8-11]. In contrary, there are studies which
stated that maternal age, previous utilization of the services
and travel time to the health facilities has no association with
early antenatal care utilization [6,12-14]. So it needs further
investigation in identifying the independent determinants of
utilization of antenatal care services during the first trimester.
There is also a gap in information among pregnant mothers
in utilization of ANC at first trimester and there is no study
conducted in the study area. Therefore, the purpose of this study
was to identify determinants of ANC services utilization during
the first trimesters in Boke Woreda, Oromia Region, Ethiopia.
The study was conducted in Boke Woreda from February
15 -April 10/2017. Boke Woreda is found in Western Hararghe,
Oromia Regional State, Ethiopia. It is located 375 kilometers
to the East of Addis Ababa, the capital city of the country. The
Woreda had an estimated total population of 141,829 of whom
69,496 are male and 72,333 are females. There were five public
Health Centers (HC), 23 health posts and four private clinics.
The participants were recruited from all the five Public Health
Centers namely Ido-Aroji HC, Boke Tiko HC, Hatura HC, Boke
Gudo HC and Arba HC.
The sample size was calculated by taking educational level
of pregnant women as the major determinant of ANC services
utilization which gives large sample size; 32.9% proportion of
exposure among cases and 31.2% proportion of exposure among
controls [8,11]. 2 odds ratio to detect case (OR), 80% power and
95% confidence level and ratio of cases to controls was 1:2 and
10% non-response rate. The calculated sample size was 339
(113 cases and 226 controls).
Those women fulfilling the inclusion criteria were recruited
until the required sample size was achieved. For each case two
consecutive controls were selected among the pregnant women
who were attending the ANC services during the first trimester
of the last four months.
The questionnaires were translated from English into
the local language (Afan-Oromo) & vice versa. A pre-test was
conducted on 5% of the sample. Data collectors were trained on
how to conduct the data. Daily supervision was held at all health
centers by field supervisors and the investigator. Data collectors
were enabled to rectify incomplete and inconsistent data by
supervisors at the time of data collection. Supervisors used to
check all procedures and completeness of formats randomly. The
collected data were rechecked before data entry.
The data was collected using pre-tested structured
questionnaire. The study subjects were selected in case to
control (1:2) ratio. Five BSc degree holder nurses, who were not
working in the department of maternity, were participated in the data collection. Two supervisors were participated from the
adjacent woreda health office. Half a day orientation was given
to the data collectors and supervisors on the data collection
tools and procedures by the principal investigator.
Data were edited, coded and entered in to Epi info version
3.5.1 and then exported to and analyzed by SPSS windows version
20. Frequencies and percentages of different variables were
computed to summarize the data. Bivariate logistic regression
model was fitted as a primary method of analysis. Based on
the findings of bivariate analysis, variables having p<0.2 were
entered into multivariate logistic regression analysis using the
forward LR method. Finally, P<0.05 in multivariate analysis
was used to identify confounding factors and determinants of
early ANC utilization. The fitness of logistic regression models
was assessed using the Hosmer-Leme show statistic and
multicollinearity problem was also checked and the variables
which had high multicollinearity problems were eliminated
from the model.
Before the actual data collection; the proposal was presented
to Mekelle University, School of Public Health, and then ethical
clearance letter was obtained from Institutional Review Board
(IRB) of College of Health Sciences. The participants were well
informed about the purposes of the study, and oral consents
were obtained accordingly. The participants’ rights to refuse
or withdraw from participating in the study and confidentiality
issues were considered.
i. Good knowledge: Those who knew 60% or above from
six knowledge measuring questions.
Poor Knowledge: Those who knew less than 60% from six
knowledge measuring questions .
ii. Timely attending ANC: Attending ANC before 16 weeks
of gestational age for current pregnancies.
iii. Lately attending ANC: Pregnant women who never
came before 16 weeks of gestational age and Attending
ANC within four to nine months of pregnancy for current
iv. Client welcomed appreciation: positive relationship
between pregnant women and health care providers,
measured as they were hospitalized or not by the health
care provider for the provision of ANC services at the health
v. Family support: opinion, financial, and other physical
support from family members such as husband, mother,
sister etc. during ANC service follow up.
The total numbers of study participants was three hundred
thirty nine (113 cases and 226 controls) with 100% response
rate. The mean age for cases and controls were 22.4(+SD4.15)
and 28.04(+SD 5.08), respectively (Table 1).
Seventy four (65.5%) of cases and thirty nine (17.25%) of
controls had less than or equal to two pregnancies while thirty
nine (34.5%) of cases and 187(82.7%) of controls had three and
more number of pregnancies prior to current pregnancies. Large
proportion of cases and controls had no history of still births
which is one hundred ten (97.3%) of cases and 196(86.7%) of
controls respectively (Table 2).
From the total of antenatal care services attendants, fortytwo
(37.2%) of cases and fifty-three (23.45%) of controls were
responded as it is the right time to visit. On the other hand, thirtyone
(27.4%) of cases and sixty (26.5%) of controls responded
as they visited because of sickness whilst thirty-three (29.2%)
of cases and 51(22.57%) of controls said it was for pregnancy
checkup (Figure 1).
The odds of pregnant women at less than 26 years old were
about 4 times (AOR=3.86, 95% CI: 1.57,9.51) more likely to use
ANC services during the first trimester than pregnant women
who were at age greater than or equal to 26 years of age groups.
Similarly, the odds of pregnant women travelling at lower than
30 minutes were 3 times (AOR=3.26, 95% CI: 1.46, 7.26) more
likely to use ANC service during the first trimester than women
who travel at 30 minutes and above.
The odds of ANC services use in the first trimester for
pregnant women who recognized their current pregnancy within
1-3 months were 7 times (AOR=7.32, 95% CI: 2.65, 20.24) more
likely than their counterparts. Besides, the odds of pregnant
women who had good knowledge were 10 times (AOR=9.76,
95% CI: 3.80, 25.09) more likely to use ANC services during the
first trimester than those who had poor knowledge about the
importance of the services. The odds of pregnant women who
had experiences of ANC utilization, on the other hand, were 3
times (AOR=2.52, 95% CI: 1.03-6.20) more likely to use ANC
services than those who had no experiences.
The odds of pregnant women who supported by their families
were 3 times (AOR=3.27, 95% CI: 1.18, 9.06) more likely to use
ANC during first trimester than those who were not supported,
where as the odds of pregnant women who wait services at less
than 45 minutes were 6 times (AOR=6.17, 95% CI: 1.84, 20.73)
higher to use ANC services than those who wait services for 45
minutes and more (Table 3 & 4).
*Significant in COR at p value<0.05
**Significant in AOR; 1-reference category
*Significant in COR at p value< 0.05;** Significant in AOR; 1-reference category
The study focused on the important determinants of ANC
utilization during the first trimester. It revealed that pregnant
women with the age of less than 26 years were more likely to use
ANC services at first trimester than those at age of greater than
or equal to 26 years old. This finding is in line with the study
findings in Ethiopia and Benin which revealed that ANC early
utilization is about 2-4 times more common among age of less
than 26 years than their counter parts [7,8,16,17]. The possible
reason may be existence of more fear in younger women for
fist pregnancy and their better health seeking behavior due
to their access to health information. However, this finding is
inconsistent with the findings of a study in Hadiya zone, Ethiopia,
and a finding from Meta-analysis in middle income countries
[18-20]. The possible reasons may be lack of experiences in the
use of ANC services among younger women and cultural factors.
Women who traveled less than 30 minutes to the health
facility were more likely to use ANC at first trimester than those
who travel at 30 minutes and above. This finding is consistent
with the findings from a cross sectional study in Assosa District,
Ethiopia  whilst it is in contrast with a study finding in
Kembata Tembaro Zone, Ethiopia [14,20].
Gravidity and Parity also showed a strong association with
antenatal care utilization. This finding is in line with the findings
from cross sectional studies in Holeta town, Ethiopia, and Benin
[9,16]. This may be due to the fact that women with more
pregnancy and parity prior to current pregnancies have already
developed confidences that modern health care is not necessary
at the first trimester.
Family support was found to be associated with ANC
utilization. Accordingly, pregnant women who supported by
their family were more likely to use ANC services during the
first trimester than those who were not supported. This result is
in line with the study findings in Holeta Town and Benishangul
Gumuz, Ethiopia [9,19].
Besides, waiting time and health care providers welcomed
appreciation showed a significant association with ANC
utilization. It revealed that pregnant women who spent less than
45 minutes to get a service were more likely to use ANC during
the first trimester than those spent more time. This indicates
that long waiting time for a service at the facilities is a barrier
to initiate ANC utilization in recommended period. This finding
is in line with a study conducted in Holeta town which revealed
that waiting for a long time of the services may hinder early ANC
service utilization . Pregnant women welcomed by health
care providers, on the other hand, showed more likelihood of
ANC utilization. This is in line with the study findings in Benin
. This indicates that the pregnant women who were more
welcomed and had positive relationship with the health care
providers were more likely to use ANC services earlier.
The study revealed that age at pregnancy, travel time to the
health facility, number of pregnancy, number of births, early
recognition of current pregnancy, services waiting time, presence
of family support, knowledge about the ANC services, previous
antenatal care service use, and client welcomed appreciation
were the most important determinants of antenatal care service
utilization during the first trimester.
FMOH and RHB should design and implement specific
behavioral change communication program to improve clienthealth
care provider’s relationship. Zonal and Woreda health
offices should focus on improving women’s knowledge on ANC
service utilization in the first trimester through adult learning
program. Health workers and Health extension workers should
take an opportunity to encourage mothers to start their first
antenatal care visit before four months of pregnancy. Health care
providers should also carry out community based intervention
to improve communication and support through facilitated
participatory learning and actions cycles with women groups. Families should be welcomed to attend an ANC session with
the pregnant woman. WDAs and community leaders should be
capacitated and strengthen in participating of early antenatal
care service utilization. Further study is needed to assess the
effect of quality of the services on ANC utilization during the first
Both TE and MW took the role from conception to design,
wrote down the proposal, supervised the data collection process,
conducted the final analysis and report writing, and drafted the
manuscript. Both authors critically reviewed and approved the
First of all, our deepest gratitude and appreciation goes
to School of Public Health, College of Health Sciences, Mekelle
University. We would also like to extend our gratitude to Boke
woreda health office staffs and the health center staffs for their
cooperation in the data collection. Finally, our great appreciation
goes to the data collectors and supervisors who participated in