Antenatal care services utilization and their associated factors among postnatal women in Dodoma city: a cross-sectional study

Abstract

Background

In 2016, the World Health Organization (WHO) updated its antenatal care (ANC) guidelines to improve the quality and effectiveness of ANC services. Whether in Tanzania the services are utilized according to the WHO’s guidelines remains a subject for investigation. Thus, the aim of this study was to assess the utilization of ANC services in line with the antenatal care guidelines among postnatal women in Dodoma City, Tanzania.

Methods

We employed an analytical cross-sectional study design. A questionnaire was developed based on information from literature and the Tanzania ANC guideline of 2018 to obtain data about social demographic characteristics and ANC services utilization. A total of 426 postnatal women were sampled using a proportionate systematic random sampling procedure. Data were collected using a face-to-face interview and abstraction from the ANC card. Using SPSS software version 26, We performed descriptive and regression analyses using SPSS software version 26 to determine the utilization of services and the associated factors. Data were considered significant at a p-value < 0.05 and reported along with 96% confidence intervals.

Results

The majority of the postnatal women (63.2%) initiated ANC visits during their first trimester. The availability of ANC support person was the key factor associated with the early initiation of ANC services. The median number of antenatal contacts was 4, with only 6.8% of postnatal women being able to meet the minimum of eight contacts as recommended by WHO. The top ANC services provided to the majority of women include education about the use of bed nets to prevent malaria during pregnancy (92.9%), Tetanus Toxoid (TT) vaccination (86.8%), Intermittent Preventive Therapy for malaria (IPTp-SP) medication (90.8%) and mebendazole medication to treat or prevent parasitic infections (90.1%).

Conclusion

Overall, the majority of women in Dodoma initiate ANC contacts within the first trimester, but only a small proportion complete eight contacts as recommended by WHO. The health care system should prioritize addressing the factors identified in this study, particularly by encouraging ANC support persons to increase the frequency of ANC contacts.

Background

Antenatal care is an essential component of maternal and child health services, aimed at ensuring safe pregnancy and childbirth [1]. In 2016, the World Health Organization (WHO) updated its antenatal care guidelines to improve the quality and effectiveness of antenatal care services. Despite this, the implementation of these guidelines remains a challenge, particularly in low-resource settings [2]. There is a growing concern globally, especially within developing countries, to improve maternal and child health, whereby antenatal care provides an avenue for pregnant women with a wide range of interventions, including education, counselling, screening, treatment, monitoring, and promoting the well-being of the mother and fetus [3].

Maternal and child health are two main challenges globally that disproportionately strike Sub Saharan Africa. In 2017, about 810 women globally died each day from pregnancy and childbirth complications, such as severe bleeding and hypertensive disorders, while nearly two million stillbirths occurred in 2019 [4]. Globally, 86% of pregnant women access antenatal care with a skilled professional at least once, while 65% receive at least 4 visits [5]. Access to quality antenatal care before, during, and after childbirth has been classified as one of the most effective ways of reducing maternal mortality, whereby maternal deaths and stillbirths can be prevented through high-quality antenatal care in pregnancy and during and after childbirth [6].

Despite a 38% global reduction in maternal mortality from 2000 to 2017, sub-Saharan Africa accounted for two-thirds of global maternal deaths in 2017 [5]. Adequate antenatal services can minimize the maternal complications that are reported by WHO to be as high as 85% globally, acknowledging the role of ANC services for pregnant women [5]. This can occur directly by detecting and treating pregnancy-related complications or indirectly by identifying women and girls at increased risk of developing complications during labor and delivery, thus ensuring referral to an appropriate level of care [7]. However, antenatal care utilization among women in sub-Saharan Africa has been below the global rate; only 52% of pregnant women in sub-Saharan Africa receive at least 4 visits [6]. Pregnant women exhibit the greatest rates of maternal mortality and stillbirths. Disparities in the availability and quality of antenatal care services account for a significant proportion of maternal fatalities (66%) and stillbirths (40%) [5, 6].

WHO revised the ANC guidelines in 2016 and proposed a minimum of eight contacts with a specialized package of activities that should be provided in every contact [1]. Tanzania adapted this guideline in 2018 [2]. The updated Tanzania ANC guidelines of 2018 also recommend a minimum of eight ANC visits during pregnancy, with the first visit occurring in the first trimester [2]. The guidelines also recommended a comprehensive package of interventions, including screening and management of pregnancy-related complications, on nutrition and lifestyle counselling, and health promotion activities [8].

Despite all these efforts, structural, cultural, and literacy factors such as distance from health facilities, transport systems, knowledge of ANC schedules, poor staffing of health facilities, and insufficient resources may impede utilization of ANC services as recommended by the ANC guidelines. Therefore, it is crucial to conduct studies on the utilization of ANC services and the associated factors across different regions of Tanzania. Therefore, the aim of this study was to examine the utilization of antenatal care services in line with the Tanzania ANC guidelines of 2018 among postnatal women in Dodoma city, Tanzania. Specifically, the study examined the timing of ANC initiation, the frequency of ANC contacts, the extent of antenatal care services offered during trimesters 1, 2, and 3 in reference to the recommendations of antenatal care guidelines, and the factors associated with early initiation of ANC clinic attendance among postnatal women in Dodoma city, Tanzania.

Methods

This study adopted an analytical cross-sectional study design that recruited postnatal women who accessed antenatal care services at the health facilities in Dodoma municipality. This was a hospital-based study conducted in four health facilities: two hospitals (Dodoma Regional Referral Hospital (DRRH) and St. Gemma Designated District Hospital) and two health centres (Makole and Mkonze Health Centres) in Dodoma City selected for their largest number of women attending for obstetric services, Tanzania. Dodoma is the capital city of Tanzania, located in the central part of the country. The city currently has a population of 765,179 people, with 51.2% being females, out of whom 62.2% are women of reproductive age [9]. The healthcare system in the Dodoma region consists of public and private-owned hospitals, health centres, and dispensaries. All public health facilities in the region provide antenatal care (ANC) services, as do some private ones. Nevertheless, the majority of pregnant women receive ANC services at the health centres, and it is anticipated that the antenatal care guidelines of 2018 that recommended 8 contacts for every pregnant woman with the prescribed services for every contact are followed. The possible variations in the frequency and service package per woman in each visit may vary. That marks what this study is intended to find.

The population for this study was postnatal women who accessed antenatal care services at the health facilities. Women who have just completed the antenatal period, i.e., those who have immediately given birth and are receiving care at the postnatal wards, were recruited. To be included in this study, a woman needed to have given birth at either of the health facilities involved in the study, have used antenatal care services in Dodoma city for the current pregnancy, and be receiving immediate postnatal care after giving birth. The study excluded postnatal women who met the inclusion criteria but had physical illness with complications that could impair their participation in the study or could not speak the Swahili language.

The study sample size was calculated by using the standard formula for cross-sectional study designs given by Cochran (1975). n = Z² P(100-P)/e² whereby, n = minimum sample size, Z = (1.96) it is a value of standard normal deviation at the 5% level of significance, and p = expected proportion of women initiating ANC services within 12 weeks. Given the available study to evaluate ANC initiation in Tanzania [3] is too old and was conducted in rural settings, as opposed to the urban settings of this study, we cautiously used the proportion (P) of 0.5 to generate the most conservative maximum sample size [10]. Thus, the sample of 426 was obtained after accounting for a 10% non-response rate.

The study participants were recruited from the four health facilities in Dodoma that offer ANC services, including one regional hospital, one district hospital, and two health centres. We selected these health facilities because they admit the highest number of women seeking obstetric services in the city. Participants were sampled from each health facility by using a proportionate systematic random sampling procedure. We allocated a stratum sample size (a sample for each hospital) proportionate to the population size within each stratum. Thus, 150 women were recruited from the regional hospital, 64 from the district hospital, 150 from one health centre, and another 62 from the second health centre to obtain a total sample of 426 postnatal women. Two women at the regional hospital were too sick to participate due to birth complications and one at the district hospital declined for personal reasons. All three women were excluded and others on the list were selected to reach the desired sample size. Figure 1 summarizes the recruiting process for the participants. The response rate among those who agreed to join the study was 100%.

Fig. 1

The sampling process for the participants

The formula n = N/k determined the daily sample per facility to ensure a proportionate sample of participants for the entire data collection period. Participants who declined to join the study were dropped, and others were sampled using the same procedure to maintain the calculated sample size for each facility.

After the ethics approval was granted by the University of Dodoma Research Ethics Committee, data were collected in face-to-face interviews using interviewer-administered questionnaires and abstraction of data from the ANC card. The first author trained the research assistants on data collection tools and procedures and supervised them during data collection in the four health facilities. The researcher developed a questionnaire based on information from literature, and the Tanzania ANC guideline of 2018 was used to collect data. The questionnaire comprised four sections, including socio-economic and demographic maternal characteristic variables and initiation and frequency of ANC services (17 mixed-type questions), items identifying health promotion actions and intervention services covered during the first contact in the first trimester (11 items), any of the second and third contact during the second trimester (11 items), and any of the fourth to eighth contact of the third trimester (14 items), as informed by the Tanzania ANC guidelines of 2018. The items in sections two to four needed the responses of “Yes” for a service that a woman received or “No” if a woman did not receive the mentioned service. Questionnaires were firstly developed in English then translated into Kiswahili to facilitate understandability by the postnatal women in the Dodoma region. Despite the critical review of the items of the questionnaire by the team of researchers to enhance content validity, the tool was also pilot tested on a small sample of 20 women who did not take part in the main study at one of the health centres to ensure face validity of the instrument. After the data were collected, the Cronbach’s alpha was calculated for each subscale measuring services offered in each trimester, and the results were as follows: We obtained a Cronbach’s alpha of 0.815 for the first trimester’s scale measuring services after deleting one item that failed to meet the criterion level of corelated-item total correlation of > 0.3, a Cronbach’s alpha of 0.761 for the second trimester’s scale measuring services after deleting one item that failed to meet the criterion level of corelated-item total correlation of > 0.3, and a Cronbach’s alpha of 0.877 for the third trimester’s scale measuring services after deleting two items that achieved the corelated-item total correlation below the criterion level of > 0.3.

The ANC cards typically contain information on the woman’s medical history, physical examination, laboratory tests, ultrasound scans, and other relevant data. The card also includes information about the date of the first ANC contact, the frequency of ANC contacts, and any deviation from the antenatal care guidelines. The antenatal care card was used as a source of data to triangulate and complement the data from a woman’s interview. Information abstracted from the antenatal card was compared with that reported by a woman, filling the gaps of information not shared or forgotten by a woman.

The independent variables comprised socio-economic, demographic, and maternal characteristic variables. They comprised items on socio-economic, demographic, and maternal characteristics that may have an association with or predict a woman’s timely initiation of ANC and frequency of ANC attendance. The dependent variable comprised ANC utilization by women defined by three sub-variables as (i) timely initiation of ANC services, defined as the gestational age at which a pregnant woman attends her first ANC contact at the health facility, (ii) frequency of ANC attendance, defined as the number of times a pregnant woman has attended ANC clinic from her first trimester contact to the time she came for giving birth, and (iii) ANC services received per contact, being a set of health promotion and intervention actions provided to a pregnant woman to ensure the best possible health outcomes for both the mother and the baby as defined in the Tanzania ANC guidelines.

Statistical analyses

Data were analyzed using Statistical Package for the Social Sciences (SPSS) software version 26. Descriptive statistics were used to describe socio-economic, demographic, and maternal characteristics of the sample. Descriptive statistics were also used to describe the mean time of initiation of ANC services, frequency of ANC attendance, and the proportion of the content of ANC services received per contact. Linear regression analysis was performed to examine the association between socio-economic, demographic, and maternal characteristic variables and the mean time of initiation of ANC services and frequency of ANC attendance. Results were considered statistically significant at p < 0.05 using 2-tailed tests, and the estimates are presented with their 95% confidence intervals.

Results

Recruitment and sociodemographic characteristic of the sample

A population of 3,180 women was available to sample from in all four health facilities over one month of data collection. The study enrolled a total of 426 postnatal women.

Table 1 summarizes the social demographic characteristics of the sample. The median age of postnatal women at the time of interview was 26 years, with the youngest being 14 and the oldest being 51 years. Of the 426 postnatal women, 79.8% were in the reproductive age (20–39 years) and one participant (0.2%) had an age of 51 years. The postnatal women were engaged in various occupations; however, the majority were housewives (28.8%); some others were farmers (18.2%), and others were government employees (10.8%). As for level of education, the majority of the women had primary (30.4%) and secondary education (38.7%). A small proportion of the women (1.2%) were smoking, whereas a sizable proportion (16.7%) were using alcohol.

Table 1 Social-demographic and maternal characteristics of postnatal women (N = 426)

Antenatal care service utilization

The median gestational age at which the study participants initiated ANC visits was 3 months, with 16.4% starting as early as within the first month and 1.6% starting as late as 8th month of pregnancy. The majority of the postnatal women (63.2%) initiated ANC visits during their first trimester of gestation (less than 12 weeks) as recommended by WHO, while only a few (3.6%) initiated their first ANC service in their third trimester. Table 2. summarizes the information about timing and the profile of first ANC contact.

Table 2 Timing and profile of the first ANC contact (N = 426)

As for the frequency of ANC contacts, the median number of antenatal contacts was 4, with a minimum of zero and a maximum of eight contacts. Only 6.8% of postnatal women were able to meet the minimum of eight contacts, as recommended by WHO. At least 33.5% of women could not reach 4 contacts. The majority (50.8%) had a moderate frequency of 4 to 6 contacts, and only 15.7% could attain seven to eight contacts.

Intervention services designed for the 1st trimester were received by the great proportion of women. Most women (92.9%) received education about the use of bed nets to prevent malaria during pregnancy and received Tetanus Toxoid (TT) vaccination (86.8%) during the first trimester. Prescription and information on the importance of taking iron and folic acid during pregnancy (78.9%) was the service received by the lowest proportion of women during the first trimester. As administration and information on the importance of taking iron and folic acid during pregnancy is a recurring service, most of the women received it during the second trimester.

Nevertheless, in the second trimester, SP medication (90.8%) and mebendazole medication to treat or prevent parasitic infections (90.1%) were the most prominent services given to women. As for the third trimester, most of the women (> 85%) received the recommended intervention services for the third trimester. Table 3 below summarizes the extent of antenatal care services received by postnatal women during trimesters 1, 2, and 3 in comparison to the services outlined in the antenatal care guidelines for postnatal women.

Table 3 ANC services received by postnatal women during trimesters 1, 2, and 3

Factors associated with ANC utilization

63% (63.2%) of postnatal women had early initiation of their first ANC visit (visited ANC in the first trimester). The Chi-square analysis to examine the bivariate association between categorical social demographic and maternal variables and the timing of the first ANC visit showed that only the availability of ANC support person predicted early initiation of ANC visits (X² = 3.897, p = 0.048). The remaining factors, including age, marital status, occupation, level of education, smoking status, drinking status, comorbidities, use of herbal medicine during pregnancy, attending to TBA during pregnancy, and distance from home to health care facility, showed no statistical significance for their association with early initiation of ANC services. Table 4 shows the Chi-square analysis of factors associated with early initiation of ANC services.

Table 4 Chi square analysis of factors associated with early initiation of ANC services

Logistic regression of the availability of ANC support personnel that was significant in Chi-square analysis was performed by adjusting for potential confounders that are known from literature, including Age, level of education, and distance (from home to HCF). Results showed that the availability of ANC support person could predict early initiation of ANC services such that the presence of ANC support person was associated with 72.6% higher odds of early initiation of ANC contacts (AOR = 1.726, 95%CI = 1.055–2.822, p = 0.030). Other factors included in the multivariate regression model, including age, level of education, and distance from home to HCF, showed no statistical significance for their association with early initiation of ANC services. Table 5 summarizes the multivariate logistic regression analysis of factors associated with early initiation of ANC contacts.

Table 5 Multivariate logistic regression of factors associated with early initiation of ANC services

Discussion

The present study investigated the utilization of antenatal care services among postnatal women in Dodoma city, Tanzania, with a specific focus on the timing of ANC initiation, the frequency of contacts, and the services provided across the pregnancy trimesters in accordance with the 2018 Tanzania ANC guidelines. The study also aimed to identify factors associated with early initiation of ANC clinic attendance. The results demonstrated substantial ANC service coverage, with more than 80% of women obtaining recommended interventions; however, only 78.9% consistently received critical iron and folic acid supplements. A majority of women (63.2%) commenced antenatal care visits during the first trimester, fulfilling the early initiation objective; nevertheless, hardly 6.8% attained the advised eight contacts. The presence of support persons was a crucial predictor for the prompt commencement of antenatal care, underscoring the significance of community and familial engagement in promoting consistent ANC utilization.

The results revealed that, the majority of the services were provided to higher extent, with the majority showing services provided to a proportion exceeding 80%, with the minimum being prescription and information on the importance of taking iron and folic acid during pregnancy scoring 78.9%. Similar findings were observed in a study conducted in the Geita district, northwest Tanzania, which also revealed that the majority of ANC services were provided to a higher extent, and that included checking for HIV status (82.96%), receiving tetanus toxoid (91.01%), and receiving iron supplements at least once (76.12%) [11]. The majority of previous studies do not provide details of services provided as documented in the WHO’s ANC guidelines [2] but report about selected intervention services such as folate supplementation, iron supplementation, or taking tetanus toxoid [12, 13]. Thus, it is difficult to benchmark the findings of this study with those of the previous studies. Nevertheless, the findings of this study reflect the fact that ANC coverage in Tanzania is high [6], and the intervention services provided at the ANC for women who get access are high.

This study acknowledged that prescription and information on the importance of taking iron and folic acid during the first trimester of pregnancy was 78.9%. This proportion is low and shows the discrepancy against the recommendation of the WHO ANC guidelines of 2016 [14] and Tanzania ANC guidelines of 2018 [6], which require that all women during all trimesters receive iron and folic acid supplements. Whether iron and folic acid were not available at the ANC clinic, or it was the health care providers not giving the supplements to the women, or it was the women rejecting the supplements, is beyond the scope of this study, and we cannot fully conclude about why this service was poorly provided to women. Future studies therefore, should examine the services available and the women’s acceptance of each service, as suggested by the National ANC guidelines. Further, this suggests a need for improved alignment between health care provider practices and established protocols to ensure that women receive the full spectrum of care necessary for their well-being and that of their unborn child.

The importance of early and adequate ANC for the health and well-being of mothers and children remains undisputed. Early initiation of ANC has been recognized as a pivotal factor in safeguarding maternal and foetal health [7]. This study found that a significant percentage of postnatal women in the Dodoma region initiated ANC services within the time as recommended by the guidelines [15]. A great majority (63.2%) of women initiated the first ANC within the first trimester (in less than 12 weeks), while 33.3% received it during the second trimester, and a few (3.6%), received during the third trimester. This may have been contributed to by the fact that the study was conducted in urban settings where health promotion interventions are done frequently and adequately in both hospital and community settings [16]. Similar to this study, a study conducted in Nepal found that a great majority (70%) initiated their first ANC four months or earlier [17]. The mean gestational age (GA) at first ANC booking of this study was 3.2 months, which was lower compared to the one found in the studies conducted in Ethiopia, which was 18.49 weeks [18], and Nigeria, 20.86 weeks [19], which might be due to differences in infrastructures, living standards, and accessibility of health facilities.

This study uncovered variations in the frequency of ANC contacts among postnatal women. Regular and consistent ANC visits are essential for effective monitoring and early detection of potential complications. This study found that although ANC initiation timing was positive among the majority of women, almost all (93.2%) of postnatal women received less than 8 contacts of ANC, which is contrary to the recommendations of WHO. The disparity between initiation and consistent contact frequency may result from logistical or socio-economic problems, including considerable distances to ANC clinics, long waiting times at the ANC, or cultural and gender norms that have ever been found by the previous studies [20, 21] but were beyond the scope of this study. The inadequate rate of recommended contacts underscores a significant deficiency in complete ANC coverage, as regular monitoring and engagement with healthcare practitioners are vital for the early identification and intervention of complications. Mitigating these obstacles could provide more consistent participation throughout the entirety of pregnancy. These findings are similar to those of the study conducted in Bangladesh, which also found that only 6% received the recommended eight or more ANC contacts [14]. Again, findings from multi-country nationally representative data also showed a low prevalence (13%) of eight or more contacts [22]. Nevertheless, our study findings are contrary to the ones found in Jordan that found 74% of pregnant women attending 8 or more ANC contacts, Ghana (43.0%) and Albania (30.0%) [14]. The key reasons for the high prevalence of completers of 8 ANC visits in these countries compared to ours could be high ANC coverage, adequate infrastructure, good levels of education, good or high enlightenment, and wealth index [14].

This study also explored factors associated with the timing of antenatal care. The findings of our study indicate a significant predictor for early initiation of ANC services was the availability of ANC support person. The availability of ANC support persons can offer informational, emotional, and practical support to pregnant women, which plays a crucial role in encouraging women to seek ANC services at the recommended time [23, 24]. This finding suggests that the development of community and familial support systems may be an effective approach to increasing the rate of early ANC initiation. Previous studies conducted in different regions have also reported similar associations between the availability of support persons and early initiation of ANC services. For example, a study conducted in Geita, Northwest Tanzania, found that pregnant women who had a support person initiate early ANC services within the recommended timeframe compared to those without such support [11].

Two attributes are considered the strengths of this study. The first was the use of both face-to-face interviews and data abstraction from ANC cards. This was crucial for enhancing data accuracy by cross-verifying self-reported information with recorded health data and minimizing the recall bias and strengthening the study’s validity. The second strength was the assessment of ANC utilization in the context of WHO and Tanzania’s updated guidelines of 2018. This enabled us to address an important health priority through comparing the real-world ANC practices against global standards. This contributes to valuable insights into healthcare delivery in low-resource settings like Dodoma, Tanzania.

Notwithstanding the stated strengths of this study, two limitations should be considered for cautious interpretations of the findings. The first is on limited generalizability, as the study was conducted only in Dodoma city and within selected health facilities. Because the study was conducted in the urban areas, the findings cannot be generalized to rural facilities where ANC utilization may be different. Also, the fact that this study used only a quantitative approach. This may limit qualitative insights into the reasons behind low ANC contact frequency or late ANC initiation. In-depth exploration into these aspects could provide more actionable insights into improving ANC.

The findings of this study encourage the health care providers to adhere closely to antenatal care guidelines, ensuring broad care delivery and improving maternal and child health outcomes. Healthcare providers should enrich health education for pregnant women concerning the importance of attending early ANC services and all eight ANC contacts to help with early detection of complications and improving the quality of maternal health services. The health facilities should implement consistent training and monitoring to ensure consistent adherence to antenatal care guidelines, thereby optimizing the quality of care for pregnant women.

Also, based on the findings of this study, we recommend the Ministry of Health enhance public education campaigns to raise awareness about ANC services and their implications for the pregnant women. Communities can also engage in establishing community-based support groups to provide platforms for pregnant women to share their experiences, ask questions, and receive guidance from peers who have benefited from ANC services to promote timely initiation of ANC contacts, minimizing the frequency to eight contacts as recommended by WHO.

Future research could focus on categorizing specific interventions or strategies that could increase and improve the utilization of antenatal care services, employing a qualitative approach to sightsee the lived experiences of pregnant women concerning various factors to effective utilization of antenatal care services, exploration of barriers to guideline adherence, and the impact of socioeconomic factors on access to care.

Conclusions

This study highlights the high rate of utilization of ANC services among postnatal women in Dodoma, especially for the early initiation of the first ANC contact. The infrequent occurrence of the recommended eight ANC visits and the irregular delivery of essential therapies, including iron and folic acid supplementation, underscore areas requiring improvement. Enhancing community support, especially through support persons such as spouses or family members, mitigating obstacles to consistent attendance, and guaranteeing that all services adhere to ANC recommendations are essential for improving maternal and child health outcomes in Tanzania.

Therefore, policymakers and healthcare providers can work together to enhance and ultimately improve maternal and child health outcomes by ensuring the availability of required services at the health facilities while the community could enhance utilization of ANC services by pregnant women through information, logistical, and moral support.