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1 These authors contributed equally to this study.
Affiliations
Department of Biochemistry and Food Analysis, Faculty of Nutrition and Food Science, Patuakhali Science and Technology University, Dumki, 8602, Patuakhali, Bangladesh
Department of Biochemistry and Food Analysis, Faculty of Nutrition and Food Science, Patuakhali Science and Technology University, Dumki, 8602, Patuakhali, Bangladesh
Department of Biochemistry and Food Analysis, Faculty of Nutrition and Food Science, Patuakhali Science and Technology University, Dumki, 8602, Patuakhali, Bangladesh
Department of Biochemistry and Food Analysis, Faculty of Nutrition and Food Science, Patuakhali Science and Technology University, Dumki, 8602, Patuakhali, Bangladesh
Department of Biochemistry and Food Analysis, Faculty of Nutrition and Food Science, Patuakhali Science and Technology University, Dumki, 8602, Patuakhali, Bangladesh
71% of pregnant women in rural northern Bangladesh had at least four ANC visits.
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Despite high rates of four ANC visits, initial ANC is mostly delayed.
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Only 58.2% of the total ANC visits are assisted by skilled personnel.
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Mother's education and employment status determine 4/4+ANC visits.
Abstract
Background
Despite the Government of Bangladesh's considerable efforts, utilization of antenatal care (ANC) services remains low among Bangladeshi women, notably those from rural areas. Therefore, this study aimed to assess the utilization and underlying factors affecting the utilization of ANC among women of reproductive age in rural Bangladesh.
Methods
We conducted a community-based cross-sectional study in three sub-districts of the Rangpur division, Bangladesh, from May 31, 2021, to June 9, 2021. A total of 1195 women with a live birth preceding the survey participated in the study. We used a multivariate logistic regression model to examine the association between all potential factors and the utilization of ANC4/4+ services. Multicollinearity and Hosmer-Lemeshow test was conducted to check the regression model's goodness fit test.
Results
The rate of utilization of ANC4/4+ services by women in the three sub-districts of the Rangpur division was 71.7%. Women with more age, education, having more than five members in a family, and being involved in any income-generating activities were more likely to utilize ANC4/4+ in this study.
Conclusion
The study found an insufficiency in ANC4/4+ usage, which might lead to missed opportunities for women in rural Bangladesh to have improved maternal outcomes. Particular focus should be given to women's higher education and prioritizing women's autonomy in health seeking issues in the rural women to increase the utilization of ANC4/4+.
The yearly death of women from pregnancy or childbirth-related complications worldwide is approximately 300,000, and most of these cases occur in poor-resource settings and are oftentimes preventable.
Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the un Maternal Mortality Estimation Inter-Agency Group.
Appropriate frequencies and qualities of Antenatal Care (ANC) can play an essential role in preventing and lowering maternal and child mortality rates, which will be crucial to achieving this worldwide and individual nation's targets.
Improvement of quality of antenatal care (ANC) service provision at the public health facilities in Lao PDR: perspective and experiences of supply and demand sides.
Besides, ANC has been considered a vital determinant for the maternal continuum of care. However, Bangladesh experiences the most drop out at this stage, followed by skilled birth attendants and postnatal care.
Rahman MH, Akter E, Jabeen S, Ahmed A, Rahman AE, Hossain AT. Level and wealth inequity in continuum of maternal healthcare services among Bangladeshi women of reproductive age : evidence from Bangladesh Multiple Indicator Cluster Survey 2012-13 and 2019. Published online 2022. doi:https://doi.org/10.21203/rs.3.rs-1676865/v1.
It has been demonstrated that ANC provided by professionally trained health personnel reduces pregnancy-related health complications. Stillbirths, intrauterine growth retardation, preterm births, low birth weight, fetal abnormalities, and other fetal complications may be mitigated through health promotion, disease prevention, screening, and treatment that improves maternal and newborn health survival.
The effectiveness of antenatal care programmes to reduce infant mortality and preterm birth in socially disadvantaged and vulnerable women in high-income countries: a systematic review.
According to the World Health Organization's (WHO) recommended Focused Antenatal Care (FANC) Model, a woman should go for at least four ANC visits during pregnancy.
However, in recent times, WHO has issued the “2016 WHO ANC model” with a new series of recommendations to improve the quality of ANC, which in turn helps reduce the risk of stillbirths, and complications and ensures a positive pregnancy experience. As per this WHO 2016 model, a minimum of eight visits is recommended. The Sustainable Development Goal-3 and the WHO 2016 Antenatal Care (ANC) model both states that pregnant women must go through 4+ ANC visit to reduce maternal and child mortality.
The WHO 2016 ANC model provides appropriate knowledge, ready for delivery or any obstacles, and a lifesaving strategy for mother and child as it prevents the latency to care-seeking practices during obstetric emergencies that are the significant contributors to maternal mortality in a poor-resource setting.
Despite recommending eight visits by the recent WHO 2016 model, Bangladesh still promotes four ANC contacts due to slight time differences from the former WHO-recommended FANC model and inadequate resources.
In Bangladesh, according to the recent Bangladesh Demographic and Health Surveys (BDHS), the willingness to take services from medically trained providers (MTP) has increased.
However, geographical and regional differences exhibit in Bangladesh. The BDHS 2017-18 data shows a minimum of one ANC by an MTP is the lowest in the Sylhet division (71%) and the highest in the Khulna division (91%). The northern region (Rajshahi-85% and Rangpur-75%) and the southeast region (Chattogram-83%) also showed a higher prevalence of at least one ANC uptake. However, this regional difference has often fluctuated over the last decade.
Alongside the national survey, some other studies have been conducted in different locations in Bangladesh that determine the total number of ANC visits.
A previous study conducted in rural Bangladesh found that women's age, number of children, husband's education and wealth index were the determinants of first timely antenatal visit.
However, there is a lack of evidence of the determinants of the four or more ANC visits in Northern rural areas, particularly the rural settings of the Rangpur and Nilphamari districts. Therefore, this study aimed to explore the ANC utilization and factors associated with four or more ANC visits among pregnant women from the northern rural region of Bangladesh.
2. Methods and materials
2.1 Study design, and sample size
A community-based cross-sectional study was conducted among women with at least one live birth in three years. Data were collected from three sub-districts. The sub-districts were Gangachara from the Rangpur district and Jaldhaka and Dimla from the Nilphamari district. A Non-random sampling method was used to select the participants. The sample size was calculated using the formula: n = Z2pq/d.
Here, n is the sample size. The calculated sample size was 1067, considering the confidence interval at 95% (Z = 1.96), population proportion at 50% (p = 0.5), and margin of error at 3% (d = 0.03%); The sample size was calculated with OpenEpi.
Finally, a total of 1195 women responded to our study, of which 643 were from, Nilphamari and 552 were from the Rangpur district.
2.2 Data collection tool
The co-authors conducted an extensive and rigorous literature review to develop the questionnaire. The criteria for the literature review were the published papers addressing rural women's determinants of utilizing ANC visits in terms of the Bangladeshi context. Initially, a pilot test was done among 40 mothers to check the feasibility of the questionnaire, and modifications were made accordingly. The index of Item Objective Congruence (IOC) was conducted to validate the questionnaire. All of the items in the questionnaire had an index of IOC value of more than 0.75 which is considered a minimum value of item acceptance.
The data collection tool was divided into three parts as follows: (1) consent of the participants; (2) sociodemographic data including age, educational qualification, religion, monthly income of the family, mother's involvement in any income-generating activity, occupation of husband, family size, no of under-five children living in the family, number of under-five children of the respondent; (3) antenatal care practices (3 questions) – time of first ANC checkup, place of first ANC checkup, and type of healthcare provider from whom they received ANC. Doctors, nurses, midwives, paramedics, family welfare visitors, and community-based skilled birth attendants were considered skilled providers in this study.
2.3 Study participants selection and data collection process
The location of the lactation women was collected from a reputed national non-government organization working in the study area. A total of 6651 lactating women were found in the study area. Among them, data collectors went to 2320 lactating women's homes to collect data. 337 lactating women declined to take part in the study, 479 lactating women were preoccupied with housework while the data was being collected, and 309 lactating women were relocated permanently. Finally, a total of 1195 women responded to our study, of which 643 were from, Nilphamari and 552 were from the Rangpur district [Fig. 1]. Data were collected from May 31, 2021 and June 9, 2021 through the home visit of each lactating woman by trained data collectors (research members) via face-to-face interviews with the lactating women by convenient sampling technique and monitored by two supervisors (senior research team members) daily for the consistency of the quality of data. The inclusion criteria were (a) lactating women who had at least one live birth in the previous three years, (b) lactating women who were physically fit to participate in the interview, and (c) lactating women who provided consent. Lactating women with dietary restrictions were excluded, as were lactating women who refused to provide consent.
STATA version 12.0 was used to analyze the data. Descriptive analysis was carried out to determine the frequency and percentage of the variables. A Chi-Square test was conducted to find the association between the outcome and explanatory variables. The cut-off of the p-value was set at p < 0.25 in the Chi-square test to select independent variables for logistic regression. Bivariate and multivariate logistic regression analyses were carried out to explore the association between outcome and explanatory variables. The Hosmer-Lemeshow test was conducted to test the goodness of fit of the final model. The test result was insignificant (p = 0.54), which indicates the final model is a good fit.
The correlation matrix assessed the multicollinearity of the predictors. It showed that the correlation coefficient among the predictors was less than 0.90, indicating no multicollinearity among the predictors.
The statistical significance level was set at 5% with a 95% confidence interval for binary logistic regression.
2.5 Ethical approval and consent to participate
This study was conducted according to the guidelines laid down in the Declaration of Helsinki, and all procedures involving research study participants were approved by the Institutional Review Board (IRB)/Ethical Review Committee (ERC) of North South University. Ethical approval reference number: 2021/OR-NSU/IRB-No.0701. All the respondents who participated in this study agreed to the aforementioned informed consent statement.
3. Results
3.1 Sociodemographic results
Table 1 represents the sociodemographic status of the participants. Nearly half of the participants were aged between 25 and 34 years. More than two-thirds of the mothers had primary or higher education. Similarly, around two-thirds of the participant's husbands had primary or higher education. More than half of the family's (55.4%) monthly income ranged between 5000 and 10000 Bangladeshi Taka (BDT). Half (50.3%) of the respondent's husbands were daily workers, and one-fifth (19.3%) were farmers. Only 20.7% of mothers were involved in any income-generating activities. The majority (94.4%) of mother's religious belief was Islam. Besides, only 10% of the mothers had two or more children.
Table 1Socio-demographic characteristics of the respondents (n = 1195).
Table 2 represents the ANC practice and utilization among the surveyed women. We found that nearly all the mothers took at least one ANC checkup, and about 71.7% of the mothers took four or more ANC checkups. However, only 13.8% of the mothers received the first ANC in one to three months of the pregnancy. More than half of the participants reported receiving their first ANC from a skilled provider, and almost all women received their first ANC visit from government facilities.
Table 2Antenatal Care Practices of respondents during the last pregnancy (n = 1195).
Table 3 represents the factors related to the utilization of 4+ ANC by the participants. The odds were 2.6, 2.8 and 1.8 times higher among who aged between 20 and 24 years [adjusted odds ratio (AOR) = 2.6, 95% CI: 1.6–4.4], 25–34 years [AOR = 2.8, 95% CI: 1.7–4.7], and above 35 years [AOR = 1.8, 95% CI: 1.0–3.4] respectively compared to women aged below 20 years. Moreover, the odds were consistently higher among who have higher secondary education or more [AOR = 7.2, 95% CI: 2.9–17.7], secondary education [AOR = 4.0, 95% CI: 2.4–6.6] and primary education [AOR = 1.5, 95% CI: 1.1–2.2] than mothers with no education. Furthermore, the odds were 1.4 times higher among women who belong to a family with five or more members [AOR = 1.4, 95% CI: 1.0–1.9] than women with less than five members. However, the odds were 0.5 times lower among women who were not involved in income-generating activities [AOR = 0.5, 95% CI: 0.3–0.7] than their counterparts.
Table 3Characteristics, Unadjusted and Adjusted Odds Ratios (ORs) for factors associated with getting 4/4+ ANC checkup (n = 1195).
This study explored the ANC utilization and factors associated with four or more ANC visits among pregnant women from a rural region of Bangladesh. Overall, almost all the women received at least one ANC from, and about 71% of the women received at least four ANC from any provider, which was slightly higher than that of the national rate (at least one ANC = 83% and four or more ANC = 41%).
National Institute of Population Research and Training (NIPORT) International Centre for Diarrhoeal Disease Research Bangladesh (icddr b), MEASURE evaluation. Bangladesh: maternal mortality and health care survey 2016: final report.
However, another study conducted in the country's Northern region also found almost all the women receiving at least one ANC and 78% receiving four or more ANC.
Nevertheless, this high uptake rate of first ANC is delayed among women. Three additional studies conducted in Bangladesh that support our findings also suggest that the uptake of the first ANC is significantly delayed
National Institute of Population Research and Training (NIPORT) International Centre for Diarrhoeal Disease Research Bangladesh (icddr b), MEASURE evaluation. Bangladesh: maternal mortality and health care survey 2016: final report.
However, a lack of understanding of the importance of early ANC visits, previous births with a positive outcome, traditional gender roles, fear of shame and stigma, cultural beliefs about pregnancy, spouse accompany policy, the rude language used by health care providers, a shortage of health care providers and facilities, and the distance between health centers prevents early ANC visits.
Timing of first antenatal care attendance and associated factors among pregnant women in public health institutions of Axum town, Tigray, Ethiopia, 2017: a mixed design study.
Another study found that possible causes include maternal age, women's education, place of residence, wealth index, pregnancy intention status, child's birth order, and a desire for more children.
Further studies are recommended to explore the contributing factors that lead to delayed first ANC visits among these rural Northern regions of Bangladesh.
More than half of the respondents (58.2%) antenatal care checkups were assisted by skilled personnel, which was lower compared to the rural estimate (72%) from BDHS 2016.
National Institute of Population Research and Training (NIPORT) International Centre for Diarrhoeal Disease Research Bangladesh (icddr b), MEASURE evaluation. Bangladesh: maternal mortality and health care survey 2016: final report.
Bangladesh made significant progress in improving access to healthcare by deploying community healthcare workers and establishing primary healthcare settings.
However, according to another study, one of the major barriers to accessing maternal care from a skilled provider in distant rural locations is a lack of human resources and the unequal distribution of geographical distribution of healthcare workers in Bangladesh. Receiving maternal health care from skilled providers or a healthcare facility is made difficult by inadequate road and transit systems in Bangladeshi rural subdistrict areas.
Effect of an integrated maternal health intervention on skilled provider's care for maternal health in remote rural areas of Bangladesh: a pre and post study.
In the current study, we discovered a substantial relationship between age and the use of ANC services, with older mothers using ANC services more frequently, which agrees with earlier research conducted in Indonesia and India.
There's a chance that older women are more knowledgeable and aware of ANC services. On the other hand, our findings oppose those of several previous research, which found a negative relationship between age and the use of ANC services.
The results of our study indicate that as maternal education increased, so did the use of ANC services. This outcome is conceivable because women who receive greater education will know more about and be more aware of ANC services. This result is in line with earlier research conducted in other low-income countries
Educated mothers are more likely to have adequate knowledge about safe pregnancy and are keen to receive modern healthcare facilities. Different studies have shown that mothers with lower education are less interested in ANC services and face more difficulties receiving ANC services than mothers with higher education.
Factors influencing utilization of antenatal care services among pregnant women in ife central lga , osun state Nigeria national hospital abuja , Nigeria.
We found that husband's education is also a crucial determinant for the utilization of ANC among women in unadjusted model analysis, which is in line with earlier studies.
Prevalence and factors associated with underutilization of antenatal care services in Nigeria: a comparative study of rural and urban residences based on the 2013 Nigeria demographic and health survey.
the current study also showed that working women are more likely to use ANC services. Women who are employed have better financial means to use healthcare services during pregnancy.
Prevalence and factors associated with underutilization of antenatal care services in Nigeria: a comparative study of rural and urban residences based on the 2013 Nigeria demographic and health survey.
contradict our finding, which showed that pregnant from nuclear families had better use of antenatal services. About half of our study population belonged to a larger family, and the family size was positively related to more ANC visits. The joint family offers women a better relationship with other family members, such as mothers-in-law other than their husbands, and results in higher ANC visits.
We have surveyed a more extensive population via face-to-face interviews, which is the major strength of this study. However, this particular study still has several limitations. As a cross-sectional study, we cannot conclude causality between any variables studied. Recall biases may be another notable limitation, as our study population was those with at least one live birth in the last three years. Moreover, our data were collected from rural Nilphamari and Rangpur districts; the results might not necessarily reflect service practices and costs in other districts or urban settings. Measuring family income was also a big challenge, as participants hardly wanted to express real income. Despite these drawbacks, this study gives some valuable insight into ANC practices and associated factors, which will play vital roles in designing and sustaining ANC-related interventions. Moreover, the public health researcher should focus on qualitative research to determine the stigma and cultural beliefs that prevent ANC visits. Our study showed that women's higher education increases the chances of ANC4/4+. Hence, policymakers and civil society organizations should emphasize female higher education to increase ANC4/4+ visits that these educational interventions was found effective to increase ANC visits [7]. The health care providers can also increase the numbers and quality of the ANC contents to increase the 4/4+ ANC visits [8].
5. Conclusions
The majority of the mothers got ANC from government facilities. However, almost three-quarters of mothers completed the highest number of ANC visits. Initiation of ANC was delayed among the majority of the population, and still, around half of the respondents took services from non-skilled personnel. Furthermore, the mother's higher age and higher educational qualifications have a significantly positive relationship in taking four or more ANC visits, whereas having five or more family members was the opposite.
Source of funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Data availability
Data will be available upon request from the corresponding author.
Declaration of interest
None
Author's contributions
M. W. R. N, M. M. A. S, and M. D. H. H conceived the idea of the study, developed the tool, and managed data collection, analyses, interpretation, and report writing. M. W. R. N, M. M. A. S, M. O. F, M. F. A and M. A. S assisted with tool development, data analysis, and interpretation and critically reviewed the manuscript. M. W. R. N, M. M. A. S, F. F, and S. K. M conceptualized and assisted with the study's design, tool development, data interpretation, and manuscript drafting. M. H. R assisted with critically reviewing and manuscript writing. All authors read and approved the final manuscript.
Acknowledgment
We thank the participants, data collectors, and supervisors for their valuable time.
References
Alkema L.
Chou D.
Hogan D.
et al.
Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the un Maternal Mortality Estimation Inter-Agency Group.
Improvement of quality of antenatal care (ANC) service provision at the public health facilities in Lao PDR: perspective and experiences of supply and demand sides.
Rahman MH, Akter E, Jabeen S, Ahmed A, Rahman AE, Hossain AT. Level and wealth inequity in continuum of maternal healthcare services among Bangladeshi women of reproductive age : evidence from Bangladesh Multiple Indicator Cluster Survey 2012-13 and 2019. Published online 2022. doi:https://doi.org/10.21203/rs.3.rs-1676865/v1.
The effectiveness of antenatal care programmes to reduce infant mortality and preterm birth in socially disadvantaged and vulnerable women in high-income countries: a systematic review.
Timing of first antenatal care attendance and associated factors among pregnant women in public health institutions of Axum town, Tigray, Ethiopia, 2017: a mixed design study.
Effect of an integrated maternal health intervention on skilled provider's care for maternal health in remote rural areas of Bangladesh: a pre and post study.
Factors influencing utilization of antenatal care services among pregnant women in ife central lga , osun state Nigeria national hospital abuja , Nigeria.
Prevalence and factors associated with underutilization of antenatal care services in Nigeria: a comparative study of rural and urban residences based on the 2013 Nigeria demographic and health survey.
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