Background
Sub-Saharan Africa (SSA) is one of the World Health Organization (WHO) regions with the highest maternal mortality ratio (MMR) worldwide [
1]. Antenatal care (ANC) has been recognised as a promising strategy for averting threats that compromise the health of pregnant women and subsides MMR prospects [
2,
3]. ANC is “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” [
4]. The WHO conceives early ANC as the initial visit occurring within the first 12 weeks of pregnancy [
4]. Early ANC is recommended for all pregnant women irrespective of occupation, socio-economic status, geographical location, parity inter alia. Prevention and management of pregnancy-related diseases, risk identification, health education and health promotion are some of the core components of ANC [
4,
5]. ANC reduces the likelihood of maternal and perinatal morbidity and mortality in two principal ways-by identifying and treating pregnancy-related complications and through identification of women who are at higher risk of labour and delivery complications [
6‐
8].
Early ANC is observed to be low in SSA [
9]. Globally, SSA is the penultimate region with lowest early ANC visit coverage (24·9% [22·6–27·2]) after Oceania [
10]. Reports of recent Demographic and Health Surveys have revealed same. For instance, 18%, 20% and 37% of women are reported to have obtained early ANC in Nigeria [
11], Ethiopia [
12] and Zambia [
13] respectively. A considerable section of women in SSA tend to delay and commence ANC in the second or third trimester [
14]. It is known that education [
15], younger age [
16,
17], family income [
18] and residential status [
19,
20] dictate the timing of ANC.
Occupational type has also been linked with early ANC initiation whereby women who work in particular professions seem to have early ANC visits [
14,
21]. This is believed to be enhanced by the relative economic advantage associated with particular occupations over others [
9,
21]. Maternal health care is cost-free in a number of sub-Saharan African countries [
22,
23]. Depending on a woman’s occupation type, some women seem to have relative economic advantage to pay the additional expenses such as those originating from transportation [
22,
24] laboratory tests and screening [
23] and unauthorised charges levied by some healthcare providers [
25]. The aforementioned studies have principally investigated occupational status (working or not working) without exploring early ANC initiation across the type of occupation (such as services, agriculture and clergy).
Due to that, whether the driving and inhibition factors of early ANC visits vary across women’s occupations seem unexplored in SSA. Meanwhile, different occupations have different commitment levels, time requirements, remuneration, and energy requirements [
26,
27]. This study, therefore, proposes that the type of occupation women engage in may have varying implications on their prospects of attaining early ANC visits. Investigating early ANC visits by type of occupation, as this study seeks to achieve, is of utmost priority for maternal health in order to develop pertinent demand-driven, well-tailored and fit for purpose interventions that can support all category of career women to achieve timely ANC visits in SSA and other developing WHO regions.
Discussion
Despite the scale-up of ANC services in SSA, a growing body of knowledge shows different level of adoption [
4,
10]. Hence, the focus of this study was to investigate maternal occupational type and early ANC initiation in SSA. Our findings show that Liberia had the highest early ANC visit while DR Congo had the least. This finding is in line with a prior study in Ethiopia, where a prevalence of was recorded [
35], Nigeria [
19], and Ethiopia [
17]. However, prevalence of our study was lower compared to Gulema et al. [
36] study in Ethiopia, Paudel, Jha, and Mehata [
34] study in Nepal and Moller et al. [
10] study among women in developed countries. The inconsistency in the findings could be due to the scope, time gap and other methodological variations between our study and the other studies compared. We also observed regional variations in early ANC visits, which could be due to difference in women socioeconomic status, government health policies, and different cultural orientations within SSA.
We observed a trend of increasing early ANC attendance in recent times. The rise in early ANC visits within SSA may be due to some initiatives by governments of SSA countries. For instance, WHO [
1] reports that tremendous investment has been made in the Liberian healthcare sector by stakeholder organisations and the government after the civil war. These investments might have helped improved maternal healthcare services leading to high ANC initiation as observed in this study [
37]. Similarly, the Government of Ghana in 2005 initiated a maternal health policy with free maternal health services at ANC [
24] meant to remove economic inequalities especially for rural women. Where such similar healthcare policies exist such as Nigeria [
38], Tanzania [
39] and Kenya [
40] increased early ANC more probable. It is therefore our advocacy that governments and policy makers within the sub region consider eliminating all forms of economic, sociocultural, political and structural barriers that might impede women’s access and utilisation of early ANC services.
Also, women from Liberia and Comoros had higher tendency to commence early ANC visits compared with those from Angola. The reasons for such disparities cannot possibly be fathomed without further investigation. Yet it is sound to reason that Liberia and Comoros could have enhanced facilitators to maternal ANC utilisation incentives coupled with limited barriers to maternal ANC services utilisation. For instance, a report by Agence Francaise De Development [AFD] [
41] show the Government of Comoros and its development partner France has consistently over the period invested heavily in the healthcare sector to increase access to health facilities, reduce financial barriers by providing financial incentives for obstetric care and many maternal health services. This according to the same report has led to the decrease in infant and maternal mortalities in Comoros and increase ANC utilisation among others. Such opportunity may be absent in other sub regional countries, and could be the driving force for early ANC visit in Comoros. We suggest to other SSA governments and policy analysts to under study these two countries for best practices that are influencing early maternal ANC visits.
Besides, our findings showed that women in all other work categories had lower odds of early ANC initiation and this was phenomenal among agricultural workers. A possible inference is that women in managerial positions have much more enablers to early ANC visit. This is possible because managerial mothers may have acquired the necessary educational and economic empowerments which is observed in previous studies to be associated with early ANC [
24]. This finding is consistent with the National Survey analysis by Saad-Haddad et al. [
42] that mothers’ occupational status significantly affects maternal early ANC visits. Implications of this finding is that, despite the introduction of the free maternal health policy in some SSA countries to enable mothers meet the recommended WHO early ANC visit, there are s still challenges partly influenced by monetary capabilities where highly placed occupational mothers can access maternal health services compared to other occupational types [
22,
24]. This has been observed in our finding where mothers who revealed that getting money needed for treatment was not a big problem and richest mothers were most likely to have early ANC visit. This corroborates Akowuah et al. [
23] and Arthur’s [
24] findings that wealth significantly influences early ANC visit among mothers. It is thus imperative for SSA countries without social interventions that can enhance early ANC visit to introduce social interventions and provide sustainable jobs to women so as to remove financial barriers to maternal health service utilisation.
Again, our findings show that women aged 40–44 were inclined to early ANC visits compared to aged 15–19. Inferring from Grossman model of prediction, which states that age increases the rate of depreciation of one’s health [
43], that is, older mothers may be prone to certain health conditions including pregnancy complications, and may therefore be motivated to initiate early ANC. Similarly, evidence from a qualitative study by Pell et al. [
25], in Ghana, Kenya and Malawi support our finding that younger adolescents do not initiate early ANC as recommended by WHO compared to older adults. Additionally, other quantitative studies in Ethiopia [
3], Finland [
44] and India [
45] add credence to our finding that older women initiate early ANC compared to younger mothers. We reasoned with Pell et al. [
25] that, due to social stigma and repercussions of teen pregnancy (i.e., drop out from school), adolescents are hesitant in disclosing pregnancy and may hinder early ANC initiation. This calls for segregated adolescent friendly ANC clinics to improve early maternal ANC among adolescents, which consequently may help reduce morbidities and mortalities among adolescent mothers and their new-borns. On the contrary, some scholars indicate that younger mothers reported early ANC utilisation in discordance with our findings [
3,
24,
46]. The difference in the findings could be due to some methodological variations such as sample size differentials. We suggest that SSA governments and policy makers be critical on age demography, especially in maternal ANC services provision in order to meet sustainable development goal 3 and 5 [
47].
Women who considered their pregnancies as unwanted were least likely to early initiate ANC compared with those that judged theirs as planned. This finding resonates previous studies [
19,
48,
49]. In a similar finding, Alemu and Aragaw [
19] adduced that a woman who is yearning for a child would likely initiate early ANC once diagnosed of being pregnant. However, a woman carrying an unwanted pregnancy might already be contemplating on terminating the pregnancy and so would not see the need to engage in early ANC to protect the gestation of something she does not want [
50].
The propensity to initiate early ANC was higher among women whose household head was a female compared with those having a male as household head. Essentially, for a pregnant woman to seek permission from someone else especially the opposite sex, is a disincentive to early ANC initiation [
51]. So, for women to access and obtain optimum health at ANC, their independent decision-making may be essential.
Our findings revealed that mothers with higher education, those who resides in rural areas, those who were exposed to mass media (i.e., radio, reading newspaper/magazine and watching television daily) were likely to initiate early ANC. Arthur [
24] similarly found that women who had higher education, and women who listen to radio and watches television daily had early ANC visit. It is possible that most non-educated mothers may reside in rural areas which are mostly deprived of health facilities and the right tailored media information [
52]. Although women in urban locations may have better geographical access to health facilities compared with rural residents, hectic traffic and heavy workloads could compromise the ability of urban women from having early ANC. Notwithstanding, a systematic review on rural residence and early ANC initiation concluded inconsistent with our finding [
53] which could be due to contextual factors.
Another significant finding of our study was the propensity of married women to initiate early ANC compared to the never married. This could be reasoned that the married women may have their partners support (i.e. financial and psychosocial) which may not be available for the never married. Community action is needed to encourage men participation in ANC. Moreover, the probability of early ANC visit declined among women at various parities especially among those at parity four or more compared with those at parity one. This finding was probably expected as previous studies in SSA [
3] and elsewhere [
54], showed that high parity mothers exhibited late ANC visit. This finding could be influenced by maternal experience, complacency, and pregnancy risk assessment which could have far reaching consequences for both mother and fetus. Women with four or higher parity have increased risk of haemorrhage, however, most of these women are not educated on the need to prioritise ANC and subsequent health facility delivery, where blood transfusion can transpire [
55,
56]. Because of this, most of these women, would erroneously perceive that they are not at risk since they had no problems in earlier pregnancies. Healthcare providers must therefore consistently educate and remind women of higher parity on the need to prioritise ANC and health facility delivery, due to their higher risk of experiencing haemorrhage and other childbirth complications.
Strengths and limitations of the study
Findings from this study were generated from high quality data gathered through the DHS Program. The sampling procedure and representativeness of the datasets strengthen the generalisability of the findings. Conversely, the cross-sectional design of the DHS limits the ability to make causal inferences between the outcome variables, however, associations can be drawn between occupation type and early ANC visit. The study presented evidence at the sub-regional level, thereby making recommendations not directly applicable at the national level. Due to this, we mentioned the specific countries in instances of extreme cases and we have also indicated in the conclusion section that implementation of our recommendations should be guided by contextual circumstances per country. Some of the variables were also self-reported, hence, there is a high tendency for social desirability and recall biases. We recommend that further studies should employ qualitative study designs and theoretical models for a better understanding of nuances surrounding type of occupation and early ANC attendance.
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