Patterns and determinants of antenatal care utilization: analysis of national survey data in seven countdown countries

Abstract

Background: Antenatal care (ANC) is critical for improving maternal and newborn health. WHO recommends that pregnant women complete at least four ANC visits. Countdown and other global monitoring efforts track the proportions of women who receive one or more visits by a skilled provider (ANC1+) and four or more visits by any provider (ANC4+). This study investigates patterns of drop-off in use between ANC1+ and ANC4+, and explores inequalities in women's use of ANC services. It also identifies determinants of utilization and describes countries' ANC-related policies, and programs.

Methods: We performed secondary analyses using Demographic Health Survey (DHS) data from seven Countdown countries: Bangladesh, Cambodia, Cameroon, Nepal, Peru, Senegal and Uganda. The descriptive analysis illustrates country variations in the frequency of visits by provider type, content, and by household wealth, women's education and type of residence. We conducted a multivariable analysis using a conceptual framework to identify determinants of ANC utilization. We collected contextual information from countries through a standard questionnaire completed by country-based informants.

Results: Each country had a unique pattern of ANC utilization in terms of coverage, inequality and the extent to which predictors affected the frequency of visits. Nevertheless, common patterns arise. Women having four or more visits usually saw a skilled provider at least once, and received more evidence-based content interventions than women reporting fewer than four visits. A considerable proportion of women reporting four or more visits did not report receiving the essential interventions. Large disparities exist in ANC use by household wealth, women's education and residence area; and are wider for a larger number of visits. The multivariable analyses of two models in each country showed that determinants had different effects on the dependent variable in each model. Overall, strong predictors of ANC initiation and having a higher frequency (4+) of visits were woman's education and household wealth. Gestational age at first visit, birth rank and preceding birth interval were generally negatively associated with initiating visits and with having four or more visits. Information on country policies and programs were somewhat informative in understanding the utilization patterns across the countries, although timing of adoption and actual implementation make direct linkages impossible to verify.

Conclusion: Secondary analyses provided a more detailed picture of ANC utilization patterns in the seven countries. While coverage levels differ by country and sub-groups, all countries can benefit from specific in-country assessments to properly identify the underserved women and the reasons behind low coverage and missed interventions. Overall, emphasis needs to be put on assessing the quality of care offered and identifying women's perception to the care as well as the barriers hindering utilization. Country policies and programs need to be reviewed, evaluated and/or implemented properly to ensure that women receive the recommended number of ANC visits with appropriate content, especially, poor and less educated women residing in rural areas.

Figure 1

The conceptual framework based on Anderson’s Behavioral Model of Healthcare Use and the corresponding determinants used in our secondary analysis [31]. Source: Anderson 1995 [31]. ⁱ Age at woman’s most recent birth was calculated by subtracting the last child’s date of birth from the woman’s date of birth divided by 12. ⁱⁱReligion was categorized as dominant religion and other religions. ⁱⁱⁱHousehold wealth quintile is made up of five wealth quintiles from poorest to richest as constructed by DHS where each quintile represents 20% of the households in the study sample. ^ivThe variable ‘who decides about woman’s health care’ is categorized as: woman alone, woman & partner, partner alone, someone else. ^vGestational age at first ANC visit was grouped into trimesters. ^viBirth rank was categorized as: 1^st – 2^nd birth, 3^rd – 4^th birth, 5^th birth or more. ^viiPreceding birth interval was grouped into: first birth (no interval), less than 2 years interval, 2–3 years interval, more than 3 years interval.

Figure 2

Percentage of women who had a live birth in the five years preceding the DHS surveys reporting zero to more than nine ANC visits for their most recent live birth, and mean of ANC visits among all these women (95% confidence intervals), in seven Countdown countries.

Figure 3

Cumulative percentage of women who had a birth in the five years preceding the DHS surveys by number of ANC visits and type of provider for their most recent live birth, in seven Countdown countries.

Figure 4

Percentage of women receiving content interventions during any ANC visit among women reporting one to three ANC visits or four or more ANC visits for their last live birth in the five years preceding the DHS survey, in seven Countdown countries.

Figure 5

Percentage of women who had a live birth in the five years preceding the DHS surveys by number of ANC visits and household wealth quintiles, in seven Countdown countries.