Exploring factors associated with first antenatal care booking among pregnant women in Northwestern Tanzania

INTRODUCTION

Antenatal care (ANC) is the term for the care given to pregnant women by qualified medical personnel. It comprises risk assessment and management, treatment of illnesses brought on by or connected to pregnancy, health promotion, and education.^[1] According to the World Health Organization, ANC should begin during the first trimester of pregnancy and should involve at least four and, ideally, eight visits.^[1] In 2002, Tanzania’s Ministry of Adopted Focused Antenatal Care (FANC) required pregnant women to attend at least four ANC visits during the course of pregnancy – the first visit before 12 weeks, the second at 26 weeks, the third at 32 weeks, and the fourth between 36 and 38 weeks.^[2] The FANC model integrates care through health promotion, prevention, detection and treatment of existing diseases, and birth preparation with four visits throughout pregnancy. The model also consolidates ANC with care and counseling for several other conditions, even though providing high-quality ANC is its top priority. For many women, the antenatal period is a crucial point of entry into the health system.^[2]

ANC is crucial in the examination of socioeconomic, medical, and obstetrical aspects to identify high-risk pregnancies. In addition, ANC programs are used to offer treatment and information that are not specifically related to pregnancy but can lower the risk factors for maternal mortality, such as promoting healthy lifestyles, addressing malnutrition, or educating about gender-based violence.^[3,4] Nevertheless, late initial ANC presentation is common in sub-Saharan Africa, with geographical disparities in the time of ANC presentation between urban and rural settings noted within nations.^[5,6] The result of arriving late for ANC is a missed opportunity to prevent negative pregnancy outcomes for the mother and the unborn child.^[7,8] Thus, all expectant mothers must undergo their initial antenatal examination during the first trimester to detect and treat any medical complications as well as to screen them for any risk factors that might affect the course and outcome of their pregnancy.^[9] The pregnant women are advised to schedule the initial appointment early, which will be used to diagnose, treat, and check for risk factors and illnesses that are best treated early in pregnancy and start prophylaxis if necessary.^[10] The latter will contribute to the early detection of pregnancy risks, prevention of pregnancy and labor difficulties, and safe delivery of mother and child and, therefore, improve the well-being of the mother and fetus.^[11]

Despite all the benefits, recommendations, and efforts to stimulate attendance, the majority of pregnant women do not book their first ANC timely.^[6,7,12] The prevalence of scheduling prenatal care appointments early was 43%, according to the available evidence globally.^[13] However, there is a significant disparity between the regions, with the sub-Saharan region having <25%, developing countries below 45%, and developed countries at 85%.^[13] Studies done in South Africa and Tanzania found a seemingly lower prevalence, ranging from 25% to 30%.^[5,7] In addition, in Tanzania, over 98% of pregnant women attend at least one antenatal clinic visit, few attend early (before 12 weeks), and the number of those who complete at least four visits remains very low.^[14] Other data from a review of the district annual health profile in Chato district in Tanzania revealed that nearly half of pregnant booked ANC attendance above the recommended period.^[12]

Several studies conducted in the past have found that lack of education, attitudes and knowledge about pregnancy, being unmarried, parity, a history of obstetric complications, healthcare service availability, distance to the healthcare facility, and cultural beliefs are all risk factors for late first ANC presentation.^[8,15,16] For instance, a recent study in Tanzania found that gender norms discourage men from participating in pregnancy and childbirth. Men as decision-makers and controllers of economic resources in households impact the timing of ANC attendance and influence women’s decisions and access to maternal and child health services.^[17] The same study reported that the implementation of the prevention of mother-to-child transmission policy discourages men from attending ANC, primarily due to their fear of HIV screening. As a result, women postponed or skipped ANC altogether due to a lack of support from their partners.^[17] Available data have revealed that mothers who did not receive information about when to begin ANC were nearly twice as likely not to book than those who did.^[18] Likewise, nulliparous mothers were twice as likely as primiparous and multiparous women to begin ANC early. In addition, mothers who could reach an ANC facility within 30 min were more likely to attend ANC early than those who had to travel for more than an hour.^[19] These studies have resulted in several interventions, including but not limited to sensitization through community healthcare workers, mass media campaigns, outreach services, and creating registers by village leaders to follow-up on ANC attendance and visits.^[12,20] Despite the implementation of these interventions, the number of pregnant women commencing their first ANC booking within 12 weeks of gestation has remained low.^[5-7] This current study aimed to determine the timing of the first ANC booking and identify factors influencing the first ANC booking among pregnant women.

MATERIAL AND METHODS

RESULTS

DISCUSSION

There is still an alarming trend of delayed first ANC visits among pregnant women, highlighting a crucial gap in maternal health care. This delay, which is influenced by factors such as occupation, marital status, pregnancy planning, family/partner support, and complications during pregnancy, reveals systemic hurdles that limit timely access to essential prenatal services.

Our study has revealed that nearly three-quarters of pregnant women do not book their first ANC visit within the recommended time. These findings are higher compared to the data obtained in the same district 2 years ago.^[12] Likewise, the proportion obtained in our study is higher compared to several previous studies done in Ethiopia,^[18,21,22] Nigeria,^[23] and the United Arab Emirates.^[24] However, the proportion obtained in this study is comparatively lower when compared to other previous studies done in Nigeria^[25] and Zambia.^[6]

Several factors could have contributed to the differences in the proportion of first ANC booking observed; these include but are not limited to disparities in healthcare access, socioeconomic factors, cultural and religious beliefs, health policies and programs, information and awareness, quality of care, and financial barriers.^[1] The differences could also be attributed to variability in ANC policies or practices across countries. For instance, in Tanzania, these practices include male engagement in ANC, which warrants male partners to escort their pregnant couples to clinics during their first ANC visit. Despite the benefits, this policy and/or practice could impact women’s first visit.^[26]

This current study has found that pregnant women who were married, had a salaried job, planned pregnancy, and had familial or partner support had an increased likelihood of booking their first ANC appointment within the recommended time. These findings are somewhat similar to a previous study done in Zambia.^[6] On the other hand, the first ANC booking was not associated with the education level of the pregnant woman or spouse, distance to the health-care clinics, money spent to get to clinics, gravidity, gender-based violence (GBV), etc. The findings contradict similar studies conducted in the past across different countries and regions, which found significant associations.^[19,22,25] The observed disparities between these studies could be attributable to the time difference between this current study and the previous studies. Again, changes in policies/practices throughout time and socioeconomic developments could have contributed to the observed disparities.

Although, we found no significant relationships between GBV and the first ANC appointment, pregnant women do encounter violence. More than a decade ago, a survey in Tanzania revealed that almost one-third and nearly a quarter of women had experienced physical and sexual violence, respectively. Furthermore, more than one-third of these women did not inform anyone or seek help.^[27] GBV can have a major impact on maternal health, especially during the first prenatal visit. In addition, survivors may find challenges in obtaining ANC care because of fear, stigma, or a lack of support. Healthcare providers should be trained to recognize indicators of violence, create a safe environment for disclosure during an ANC, and provide necessary support services. Addressing GBV is critical for improving a mother’s health and providing comprehensive prenatal care.

CONCLUSION

This study explored the factors that influence pregnant women’s first ANC visits in Northwestern Tanzania. Despite the benefits of scheduling an antenatal appointment early, a significant proportion of pregnant women do not schedule their first visit within the suggested time frame. This underscores the need for targeted policies to address socioeconomic barriers and enhance healthcare accessibility, thereby promoting earlier ANC bookings and improving maternal health outcomes. In addition, our study is limited to two institutions, which could have affected the generalizability of the findings. However, the choice of these sites was deliberate and intended to capture the diversity of ANC booking behaviors across different socioeconomic groups within Chato District. Nonetheless, we recommend studies involving more health-care facilities across the Chato district to be conducted to enhance generalizability.