Background
Methods
Study setting
Study design
Quantitative data collection process
Qualitative data collection process
Data management and analysis
Results
Household survey participant characteristics
Characteristic | Overall | Women attended ANC at least once (N = 1491) | Women not attended ANC (N = 228) | |||
---|---|---|---|---|---|---|
Mean(SD) | n (%) | n (%) | Mean (SD) | n (%) | Mean (SD) | |
Maternal age (in years) | 25.73 (6.60) | 25.51 (6.52) | 27.28 (6.96) | |||
Maternal height (in cm) | 155.66 (6.90) | 155.77 (6.73) | 154.89 (7.92) | |||
Maternal weight (in Kg) | 59.49 (8.39) | 59.71 (8.38) | 57.97 (8.31) | |||
Marital status | ||||||
Currently single | 91 (5.29) | 83 (5.57) | 8 (3.51) | |||
Currently married | 1628 (94.71) | 1408 (96.43) | 220 (96.49) | |||
Education level | ||||||
No formal education | 406 (23.61) | 347 (23.27) | 59 (25.88) | |||
Primary | 1179 (68.59) | 1024 (68.68) | 155 (67.98) | |||
Secondary & above | 134 (7.80) | 120 (8.05) | 14 (6.14) |
Household survey
Antenatal services utilization and availability
Characteristic | Services received at clinics | Prevalence | 95% CI |
---|---|---|---|
n (%) | n (%) | ||
HIV Status | |||
-Total Screened | 1237 (82.96) | ||
-Tested Positive | 48 (3.88) | 2.80–4.95 | |
-Tested Negative | 1189 (96.12) | ||
Hemoglobin level | |||
-Total screened | 721 (48.36) | ||
-Hb level < 10.9 g/dL | 390 (54.09) | 50.45–57.74 | |
-Hb level > =10.9 g/dL | 331 (45.91) | ||
Syphilis status | |||
-Total Screened | 97 (6.51) | ||
- Tested Positive | 18 (18.57) | 10.68–26.43 | |
- Tested Negative | 79 (81.43) | ||
Iron supplements | 1135 (76.12) | ||
Antihelminthic drugs | |||
- None | 520 (34.87) | ||
- One Dose | 475 (31.86) | ||
- Two Doses | 496 (33.27) | ||
Intermittent preventive treatment | |||
- None | 353 (23.68) | ||
- One Dose | 518 (34.74) | ||
-Two Doses | 620 (41.58) | ||
Tetanus toxoid vaccine | |||
- None | 134 (8.99) | ||
- One Dose | 229 (15.36) | ||
-Two or more doses | 1128 (75.65) |
Characteristic | Overall | Women who attended ANC at least once N = 1491 | Women who had not attended ANC N = 228 | Difference in proportions P value (chi2 test) | |
---|---|---|---|---|---|
n (%) | n (%) | n (%) | |||
Health facility delivery | Yes | 785 (45.67) | 730 (48.96) | 52 (24.12) | < 0.05 |
Transport preparation | Yes | 490 (28.50) | 448 (30.05) | 42 (18.42) | < 0.05 |
Saving money | Yes | 855 (49.74) | 783 (52.52) | 72 (31.58) | < 0.05 |
Purchase baby items | Yes | 574 (33.39) | 531 (35.61) | 43 (18.86) | < 0.05 |
Social support | Yes | 1438 (83.65) | 1254 (84.10) | 184 (80.70) | 0.20 |
General characteristics of participants in FGDs
Perceived barriers for antenatal care services
Participants also identified men’s lack of interest and their unwillingness to participate during pregnancy, which resulted in some women not attending ANC clinics. For HIV prevention of mother-to-child transmission, couples are required to go together to the first antenatal visit. This practice aims at providing counselling and HIV testing to both partners. However, some health providers deny ANC services to pregnant women who attended without their male partners. Fear of HIV testing by both female and male partners was also perceived to be a barrier to ANC for couples that were unwilling to participate in HIV testing together.Having no income in the family, and [the] health facility being far may lead to women not attending ANC services at all considering the family does not have even a bicycle. Female participant 1It could be poverty, since nurses here emphasize clean clothes and proper dress such as a maternity dress when a woman wants to attend clinic. If you don’t have a maternity dress you may not go. Female participant 5
In the rural settings, parents or in-laws make decisions for couples who live with them. Decisions related to health care seeking may depend upon the attitudes of parents/in-laws towards ANC services and their experiences with the health care system. Men who escort their wives are considered weak in this male dominant society. Participants indicated that parents/in-laws might hinder pregnant women from attending ANC clinics and it becomes a barrier when the couple depends on their parents/in-laws financially.Some women stay at home throughout their pregnancy period because men are not ready to accompany them to the clinic. It is a “must to go” with your husband on the first visit. Female participant 1Yes, men not escorting their women is a main problem I can say. When a pregnant woman attends clinic for the first time, the health provider must asks where is your husband, and if you don’t have your male partner the possibility of being seen in the clinic is very small and you may end up being scolded. To avoid being harassed, pregnant women may not attend the ANC clinic. Male CHW 1
It is a habit based on parents’ experiences. Men do think if my mother did not attend clinic at all or attended only once and gave birth without any problem why bother now. It is common with couples that stay with their parents. If your wife mentions about escorting her to the clinic, your father may say in our times, we did not go with women to their services, why do you want to do it now. This is being weak, your mother did not go and all went well. Then you think no need for my wife to attend clinic. Male CHW 5Sometimes, a few men may prevent women from attending ANC arguing, do women who miss out ANC face any problems during delivery? But there are those who attended and still experienced complications. So you will stay at home, all will be well. With this response, some women decide not to attend at all. Female participant 6For those families that stay with their in-laws, since the mother-in-law did not attend clinic, a pregnant woman will find it difficult to attend ANC clinic. Since her mother-in-law will discourage her saying, “We did not go to ANC clinic in those years why do you want to go there?” It becomes more difficult if a man depends on his parent financially. Female CHW 6
Challenges faced by women in visiting ANC clinics
Women appeared to have some knowledge of the benefits of initiating early ANC services; however, perceived poor quality of ANC services in this community discouraged timely initiation of care. Pregnant women are supposed to receive comprehensive ANC when attending clinics, but in these communities, the absence of health care providers and shortages of supplies and drugs were identified as common challenges.Due to distance and other issues, instead of visiting to the clinic every month a woman opts to attend only once to avoid the frequency of going to the clinic every month by attending in the last months of the pregnancy from seventh month. Female CHW 1Sometimes you may feel weak and lazy to walk every month, remember we cannot afford paying for boda boda because we don’t have money. Then you decide to wait till you approach the 8th or 9th month so that you have one visit to get an ANC card. Female participant 3Long distance for some of the villages discourages most of the pregnant women to attend ANC clinics early. Some villages are far away from dispensaries, approximately more than 7 kilometers, making it difficult for pregnant women to walk that long distance. This is worse when the household does not have a bicycle or a motorcycle or money for fare. Even if they know the importance of ANC services, still they may not attend early. Male CHW 1
Lack of male involvement and participation during pregnancy was also a challenge for women who attended ANC clinics in the rural communities. Participants noted that the lack of men’s involvement or interest was associated with cultural beliefs, the influence of in-laws, and the environment at the health facilities, which was not male friendly. HIV testing is crucial for both partners; however, and both partners need to agree to HIV testing after proper counselling and health education. In this community, HIV testing was associated with fear by the women as the laboratory test was done in the presence of the male partner. Furthermore, the existing health facilities provided no privacy for the couple during the counselling or the conduct of HIV testing.Most of the services such as antimalarial drugs, iron tablets, mosquito nets are not always available, and laboratory supplies are on and off because our clinics serve a large population, which is not proportional to the available supplies and drugs. Female CHW 1When you go for ANC they send you back several times because health providers are not there or have gone for seminars. You may go to clinic several times with no luck of receiving any ANC services till you get tired and give up. You may miss the services for several visits because the health providers have gone for seminars or training. Female participant 5This practice of sending back pregnant women without services has been common in our dispensary and it discourages pregnant women. For example, recently there were no ANC services for the entire week because of the shortage of health providers. There was only one health provider attending only out patients and other emergency care services. Male CHW 6
Some cultural beliefs in relation to pregnancy were perceived as causing delays in visiting ANC clinics. For example, in the first trimester, women do not disclose their “invisible” pregnancy to people including health providers for the fear of being witched. In addition, there were misconceptions about use of hematinics as many women thought that iron supplements prolonged the period of pregnancy, tended to exaggerate morning sickness symptoms, and sometimes even cause adverse outcomes. To avoid prolonged use of hematinics, they delay the initiation of ANC care.Actually, most women in this community go late for antenatal services because of the fear of HIV testing while some men refuse to escort their women for fear of HIV testing. Female participant 4It is really challenging in this community because of the high rates of HIV infection. The habit of HIV testing among men is not there. Escorting women to the clinic requires men to be ready for HIV testing and results. They think how I can go there when I am not ready to take an HIV test. It is better I just send my wife and I will know if I am safe or not through my wife’s HIV result. They believe if a woman is HIV negative they are also negative so there is no need of going there. Male CHW 4We do not have a friendly environment. For example, with our health facility there is no infrastructure for a reproductive and child health unit. Currently, all patients who come for TB and HIV drugs, out patients, and pregnant women and under-five children are gathered in one place. There is no privacy and friendly environment for the couple. Male CHW 3
We wait for a visible pregnancy for us to start clinic. You cannot start attending clinic with an invisible pregnancy; our fellow women may scold you when we go to fetch water. We do not mention to everyone that you are pregnant. We do this because we fear being witched since you cannot know who your enemy is. Female participant 6You may visit the household with the aim of identifying a pregnant woman. Nobody in the family would dare to disclose that. To your surprise a few months late, you may meet the same woman with a newborn baby. Misconceptions on haematinics are also a challenge because pregnant women think when you use iron or folate you may experience abortion, fetus progress delay, and annoying side effects. Male CHW 5Misconception regarding use of iron tablet/syrup exists among women thinking that when you use these drugs you delay the growth of the pregnancy while others complain about the side effects of the drugs such as nausea. So they prefer to visit clinic late to avoid continued use of these drugs. Female CHW 4
How women cope with existing ANC requirements
Husband for hire do exist in our villages. These are boda boda men. When a woman gets a boda boda to take her to the health facility, she also requests if the man is willing to escort her for HIV testing just to pretend being a husband. Female CHW 6Since men will not accept escorting their wives to the antenatal clinic for fear of HIV testing, women decide to go to the village leaders for the letter explaining that the husband for this woman is not present in the village and may be working outside the district. They get a letter because health providers insist if you come without your husband you will not get any service. Female CHW 5Your husband must be there when you go to the clinic for the first visit. This is a big challenge for women. Therefore, for those who cannot get their husband to escort them [they] may go to a clinic far from this ward because nobody knows their husband there. The boda boda driver usually can pretend to be your husband and you pay him something small. Female participant 1
Key issues | Themes | Sub themes |
---|---|---|
Perceived barriers to utilization of ANC services | Poverty | • Health facility was far from home and pregnant women feeling tied to walking long distances |
• Women or family not having income to afford transport | ||
• Having no fare for hiring a bicycle or paying for a boda boda | ||
• Not having a maternity dress | ||
Fear of HIV testing | • Pregnant women’s fear of HIV testing | |
• Male partner fear of HIV testing results | ||
• Misconception regarding HIV testing | ||
• Self stigmization arising from HIV results | ||
• Infidelity among men/risk behaviors in fishing community and mining community | ||
Socio-cultural beliefs | • Men’s refusal to escort women/men feel no need to be involved | |
• Normal practices or habits because no history of pregnancy related complications | ||
• Parental influence especially among those couples who live with their parents | ||
Challenges faced by women when utilizing the ANC services | Lack of male involvement | • Unfriendly male environment |
• Men not willing to escort women | ||
• Attended ANC clinic but not provided services as male partner did not attend | ||
Perceived poor quality of care | • Services not available because supplies and/or drugs are out of stock | |
• No services available most of the times | ||
• Long waiting times for services | ||
• Frequent shortages of health providers | ||
Informal regulation | • HIV testing is no longer voluntarily | |
• Male partner must be there during the first ANC visit | ||
• Not receiving HIV testing since a man is not with you | ||
Coping strategies for existing ANC requirements | Men for hire | • Husband for hire do exist in our villages |
• Men will not accept escorting their wives | ||
• Boda boda men are willing to accompany women if they are provided with a little money for escorting you | ||
Letter from village leaders | • To avoid being scolded and to obtain services you get a letter from village leader to present to the CHWs | |
• If your partner refuses to escort you state that he is away | ||
Health facility | • Attend a health facility that is far away from your home | |
• Where health providers do not know you or your husband |