Authors: Jok Peter Mayom Jil, Peter Mawiir Piol Deng, and Ayak Mading Ador Deng (Research submitted in partial fulfillment of the requirements for the Award of BSc. in Public and Environmental Health at Upper Nile University)
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Chapter One: Introduction
1.1 Background to the Study
Factors affecting attendance of FANC among Pregnant Women in Munuki Payam (Juba, South Sudan)
Maternal and neonatal morbidity and mortality have continued to be a major problem in developing countries of which South Sudan is part despite efforts to reverse the trend.
Globally, more than 500,000 mothers die each year from pregnancy-related conditions, and neonatal mortality accounts for almost 40% of the estimated 9.7 million children under-five deaths (UNICEF, 2009).
In addition, 99% of maternal and newborn mortality occur in developing countries. The greatest risk of maternal deaths, which is now compounded by the HIV/AIDS pandemic, is faced by women in Sub-Saharan Africa (O’Callaghan, 1999).
Research has shown that most of the maternal and neonatal deaths are avoidable (Stevens-Simon, 2002). Antenatal care is one of the key strategies for reducing maternal and neonatal morbidity and mortality directly through detection and treatment of pregnancy related illnesses, or indirectly through detection of women at risk of complications of delivery and ensuring that they deliver in a suitably equipped facility (Anh, 2002).
A number of studies have demonstrated the association between antenatal care attendance and reduction of premature birth, low birth weight, congenital malformations, congenital infections, neonatal tetanus, pre-eclampsia and anaemia (Orvos, 2001).
In 2001 the World Health Organization (WHO) issued guideline on a new model of antenatal care (ANC) called goal-oriented or focused antenatal care (FANC), for implementation in developing countries (Villar, 2001).
In the new strategy of focused antenatal care, WHO recommends four antenatal care visits in low risk pregnancies and prescribes the evidence-based content for each visit (Villar, 2001).
The purpose of ANC is to care for pregnant mothers and to have all births attended by trained personnel, and to identify pregnancies where risk is high and provide special care for the mother and the infant.
Antenatal care constitutes screening for health and socioeconomic conditions likely to increase the possibility of specific adverse pregnancy outcomes, providing therapeutic interventions known to be effective, educating pregnant women about planning for safe birth, emergencies during pregnancy and how to deal with them (WHO, 2009).
There is a large body of evidence from routine statistics and special studies to suggest that women who have received prenatal care experience lower rates of maternal mortality.
Interventions that have proved to be of great benefit to the mother and the child include iron and folate supplementation in areas with high prevalence of anemia, serological screening for and treatment of syphilis, routine obstetric examination, intermittent presumptive therapy (IPT) for malaria, and tetanus immunization (Eijk, 2006).
Other interventions that can be linked to ANC include providing information on good nutrition, family planning, breastfeeding, and health benefits of delivery with the assistance of skilled health provider (WHO, 1999). Prevention of mother to child transmission (PMTCT) of HIV has recently been incorporated in the antenatal care service program. The above interventions will be of full benefit if women start attending antenatal clinic early in pregnancy.
Globally, progress has been made in terms of increasing access and use of one antenatal visit, although the proportion of women who are obtaining the recommended minimum of four visits is too low (Carroli, 2001).
Carroli (2001) says the first consultation is often made late in pregnancy, whereas maximum benefit requires early initiation of antenatal care.
Van Eijk et al observed that there was a tendency towards late attendance for the first ANC visit in Kenya. The whole of Sub-Saharan Africa lags behind other developing regions (WHO, 2006).
Various studies have reported factors associated with late entry to ANC. These include place of residence, ethnicity, age, education, employment status, parity, intention to get pregnant, use of contraceptive methods, economic status, health insurance, and travel time (Trinh, 2006)).
Men play a vital role in determining the health needs of a woman. In developing countries, men are the decision makers and in control of all the resources, they decide when and where woman should seek healthcare. It has been demonstrated that lack of male involvement in pregnancy and antenatal care and in prevention of mother-to child transmission (PMTCT) of HIV programmes have been identified as major bottlenecks to effective programme implementation (Horizons Programme Report, 2002).
Major activities during ANC visit include hemoglobin measurement to correct anemia, blood pressure measurement to detect hypertensive disorders in pregnancy, and treatment of sexually transmitted diseases and urinary tract infections, malaria and other infectious or parasitic diseases and immunization against tetanus.
Antenatal care can also play a role in identifying danger signs or predicting complications around delivery by screening for risk factors and arranging for appropriate delivery care when indicated.
According to the South Sudan National Baseline Household Survey 2009, the population of South Sudan was 8.26 million in the 2008 Census, with the total of 3.97 million fertile female capable of giving birth. This population needs sensitization on the importance of ANC services to allow them give birth adequately.
Proper assessment and follow up at the antenatal care clinics by pregnant women will contribute to reduction of the risk the young nation is facing in toping maternal mortality rate.
Analysis suggests that many of the women are not sensitized on the importance of ANC which this research views as of paramount importance as its objectives entail.
1.2 Problem Statement
In South Sudan, 90 per cent of women give birth at home, according to 2014 data taken from the South Sudan Ministry of Health District Health Information System (DHIS).
South Sudan has a maternal mortality rate of 2,054 deaths per every 100,000 live births, according to the 2006 Southern Sudan Household Health Survey, the most recent available data on this topic. This study will investigate why women do not meet their ANC services as a factor contributing to maternal death.
Pregnant women giving birth at home who do not visit the Primary Health Care Centers (PHCCs) or Primary Health Care Units (PHCUs) suffer from life-threatening complications such as excessive bleeding after birth, stillbirth or neonatal death due to the improper follow up of the fetus development, one of the ANC services. Similarly, pathogens are introduced into uterine cavity in a situation of no proper ANC services.
Based on an estimate prepared by World Health Organization (WHO) on the Global Burden of Disease, hemorrhage is reported to cause just over a quarter of direct obstetric deaths, induced abortion standing at 13 per cent, sepsis at 15 per cent, hypertensive disorders such as eclampsia about 12 per cent, and obstructed labor and other causes each about 8 per cent.
1.3 Study Justification
Literature has generally indicated the importance and benefits of ANC, hence need for research to understand the reasons for late antenatal attendance. This study takes a unique approach to understanding factors affecting antenatal attendance as it looks not only at individualized factors, but an ecological perspective. The study focuses on barriers to the utilization of the FANC. The results of this study may also be of use to health policy makers and other stakeholders for developing public health policies as regards reproductive health. Consequently, the findings might help to educate pregnant women in communities.
Almost 50% of women in low- and middle-income countries (LMICs) do not receive adequate antenatal care. Women’s views can offer important insights into this problem. Qualitative studies exploring inadequate use of antenatal services have been undertaken in a range of countries, but the findings are not easily transferable.
According to WHO Global Health Observatory (GHO) data many health problems in pregnant women can be prevented, detected and treated during antenatal care visits with trained health workers.
WHO recommends a minimum of four antenatal visits, comprising interventions such as tetanus toxoid vaccination, screening and treatment for infections, and identification of warning signs during pregnancy. WHO figures between 2005 and 2010 only 53% of pregnant women worldwide attended the recommended four antenatal visits in low-income countries where South Sudan falls despite huge international efforts to promote and provide antenatal care.
Globally, the proportion of women receiving antenatal care at least once during pregnancy was 83% for the period 2007–2014. However, only 64% of pregnant women received the recommended minimum of four antenatal care visits or more, suggesting that large expansions in antenatal care coverage are still needed.
1.4 Theoretical Framework
Healthcare in general is grounded in a biomedical paradigm that focuses on individual level determinants of health rather than in a socio-ecological paradigm that acknowledges the influence of the environment (Sword, 1999).
However, this study was guided by the socio-ecological model because it emphasizes the interaction between, and interdependence of, factors within and across all levels of a health problem (Barbara, 2005).
There are two key concepts of the ecological model that help to identify intervention points for promoting health: behavior both affects, and is affected by, multiple levels of influence; second, individual behavior both shapes, and is shaped by, the social environment. In order to explain the concepts, McLeroy and others (1988) identified five levels of influence for health-related behaviors and conditions.
1.5 Research Thesis or Dissertation Hypothesis
Few of the research questions have been selected in this chapter as much will be elaborated later in the preceding chapter.
1.5.1: What do pregnant women know about the ANC?
1.5.2: Do pregnant women visit and attend ANC facilities?
1.5.3: What demographic, socio-cultural factors hinder utilization of ANC?
1.5.4: What could be the perception of the health practitioners in service provision?
1.6 Definition of Key Concepts
1.6.1 Antenatal Care (ANC): is an umbrella term used to describe health care rendered during pregnancy (McDonagh, 1996).
1.6.2 Focused Antenatal care (FANC): is a new World Health Organization (WHO) model of antenatal care (ANC) sometimes called goal-oriented ANC for implementation in developing countries (Villar, 2001). The new model reduces the number of required antenatal visits to four, and provides focused services shown to improve maternal outcomes.
1.6.3 Intermittent presumptive therapy (IPT): involves the administration of full, curative-treatment doses of an effective antimalarial drug at predefined intervals during pregnancy (WHO, 2004). In Zambia sulfadoxine/pyrimethamine (Fansidar) is used for IPT in pregnancy.
1.6.4 Maternal Mortality Rate: refers to the number of registered deaths among women from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy, childbirth or within 42 days of termination of pregnancy, irrespective of the duration or site of the pregnancy, for every 100,000 live births in a given year
1.6.5 Neonatal mortality rate: refers to the number of registered deaths in the neonatal period per 1000 live births in a given year or period of time
1.6.6 Prevention of mother-to-child transmission of HIV (PMTCT): refers to the prevention of transmission of HIV from an HIV-positive woman during pregnancy, delivery or breastfeeding to her child. The term is used because the immediate source of the infection is the mother, and does not imply blame on the mother.
1.7 Limitations of the Study
Limitations are factors, usually beyond the researcher’s control, that may affect the results of the study or how the results are interpreted. They are simply factors or conditions that help the reader get a true sense of what the study results mean and how widely they can be generalized. Below are some of the limitations that should address the significant effect of this study.
- Due to the small (50 for pregnant women and 20 for health workers) sample collected in one Payam of Juba County, results may not be generalizable beyond the specific population from which the sample was drawn.
- Due to the failure of sample respondents to answer with candor or frankness, results might not accurately reflect the opinions of all members of the included population.
1.8 Objectives
1.8.1 General Objective: To assess the factors that prevent pregnant mothers from attending antenatal care services at Munuki Payam (Juba, South Sudan) in 2015.
1.8.2 Specific Objectives
- To assess the knowledge of pregnant women on the usage of ANC services.
- To find out if pregnant women visit and attend ANC facilities as recommended.
- To know if there are barriers that obstruct pregnant mothers from attending ANC facilities.
- To assess the practices and perceptions of the health care providers in service delivery.
Chapter Two: Literature Review
2.0 Introduction to Previous Reviews
This chapter covers the research related to the topic of this study that has been underscored by other researchers and academics. It offers meaningful insights not only for policy-makers but also for scholars and practitioners in the area of antenatal care.
A review of literature will therefore provide a roadmap for the development and implementation of the research.
2.1 Maternal Health
According to the US National Library of Medicine, National Institutes of Health International Journal of Integrated Care, childbirth constitutes a major event in women’s lives during the prenatal period. Prenatal period is generally defined as the interval between the decision to have a child and one year after the birth. The mother, her partner and her family face important physical, psychological and social upheavals (Charo Rodríguez and Catherine des Rivières-Pigeon, 2007).
Large evidence of research suggests that attendance at ANC clinics and receipt of professional delivery care have been associated with reduction in maternal deaths (Magadi, 2001) (UNICEF, 2003).
The full benefits of interventions provided during ANC are unattainable because of late entry to ANC. In developed and developing countries, ANC attendance boosts the good outcome of pregnancy. A study in Kenya was able to show the causal relationship between ANC and good perinatal outcomes (Brown, 2008).
2.1.1 Maternal Health Overview in Developed and Developing Countries
In medical terminology the term maternal health is simply understood as pregnancy related health. Three different types of indicators have mostly been used to describe maternal health – maternal mortality, morbidity for selected illnesses, and nutrition related problems during pregnancy (Goodburn, 2001).
Maternal mortality still remains a burden to healthcare systems especially in the developing world. MMR is expressed as number of maternal deaths per 100,000 live births whereas maternal death is defined as the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental causes (WHO, 2005).
The trend of maternal mortality in developing countries has been increasing and various international organizations have reported that an important factor related to maternal and infant mortality has been linked to lack of antenatal care (Villar, 2001).
Despite the global efforts initiated to improve maternal health, more than half a million women worldwide die each year as a result of complications arising from pregnancy and childbirth (Ronsmans, 2006).
Almost all of these deaths occur in developing countries with Sub-Saharan Africa accounting for almost 47% of the toll (WHO, 2004). The lifetime risk of maternal death in Sub-Saharan Africa is 1 in 22 mothers compared to 1 in 210 for Northern Africa, 1 in 62 for Oceania, 1 in 120 for Asia, and 1 in 290 for Latin America and the Caribbean (WHO, 2007).
Table 1: Maternal Mortality Rate (MMR) for selected developed and developing countries, 1980-2008, deaths per 100,000 live births
| Country | 1980 | 1990 | 2000 | 2008 |
| Australia | 9 | 6 | 5 | 5 |
| Canada | 7 | 6 | 6 | 7 |
| Finland | 7 | 7 | 7 | 7 |
| Japan | 20 | 12 | 8 | 7 |
| United Kingdom | 10 | 8 | 8 | 8 |
| Nepal | 865 | 471 | 343 | 240 |
| Swaziland | 559 | 359 | 609 | 736 |
| Sierra Leone | 1240 | 1044 | 1200 | 1003 |
| Malawi | 632 | 743 | 1662 | 1140 |
| Central African Republic | 990 | 1757 | 1988 | 1570 |
Source: Hogan et al. 2010
In developing countries, in which South Sudan is part, complications of pregnancy and childbirth are the leading causes of deaths among women of reproductive age (WHO, 2012) (Rosato, 2006). Most of these maternal deaths and injuries are caused by biological processes, not from diseases which can be prevented and have been largely eradicated in the developed world. Hemorrhage is one of those biological processes, and accounts for 25% of maternal deaths globally (Figure 1), 34% in developing countries and 13% in developed countries. Sepsis, indirect causes (malaria, anemia), unsafe abortion, obstructed labor, eclampsia and other direct causes accounts for over a half of all maternal mortality (see figure 1).
Insufficient obstetric care in poor resource settings, low utilization of both antenatal and postnatal care as well as low coverage of births attended by skilled labor further exacerbate the MMR (Hogan, 2010)
In Malawi, the most common causes of maternal deaths are similar to those identified globally; for instance, studies have shown that hemorrhage accounts for 33%, ruptured uterus and obstructed labour 30%, eclampsia 7%, abortion 7% and indirect causes such as anemia 13%. Furthermore, infections such as meningitis (7%) and AIDS (7%) also contribute to maternal mortality (Geubbels, 2006).
2.1.2 Maternal Health in South Sudan
According to the South Sudan Health Sector Development Plan (HSDP) 2012-2016, the country has one of the highest MMR in the world, with less than 50% attending to the prenatal care services.
HSDP indicates close to 46.7% of pregnant women attend at least one ANC visit, only 14.7% of deliveries are attended by skilled health professionals, institutional deliveries account for just 12.3% of births, while the contraceptive prevalence rate is 4.7%.
The caesarean section rate, a good indicator of access to Comprehensive Emergency Obstetric & Neonatal Care (CEmONC), is only 0.5% of the population served in the three teaching hospitals in Juba, Malakal and Wau (Health Sector Development Plan, 2012).
Almost 50% of women in low- and middle-income countries (LMICs) of which South Sudan is part do not receive adequate antenatal care. This has made the country rank first in the World Maternal Death.
The Maternal Mortality Rate (MMR) is estimated at 2,054 deaths per 100,000 live births, while the Infant Mortality Rate (IMR) is estimated at 102 deaths per 1,000 live births (South Sudan Health Sector Development Plan , 2012).
HSDP highlights that stunting in children less than five is estimated at 25%. Neglected tropical diseases that have been virtually eliminated in most parts of the world are still endemic in South Sudan.
2.1.3 Safe Motherhood
In an effort to improve maternal health, the fifth United Nations MDG aims to reduce maternal deaths. WHO has been advocating for improvements of maternal health through safe motherhood initiative.
Safe motherhood initiative was developed in 1987 in Nairobi, Kenya at an international consortium of United Nation agencies, governments, nongovernmental organizations as well as donors in response to the escalating levels of maternal and infant morbidity and mortality in most developing countries.
Its main aim was to ensure that most pregnancies and deliveries are handled safely both at the community and health facility level in an act to reduce maternal deaths by 70% from 1990 to 2015 (WHO, 2012).
Although most maternal and infant deaths can be prevented through safe motherhood practices, millions of women worldwide are still being affected by maternal mortality and morbidity from preventable causes.
Safe motherhood encompasses a series of initiatives, practices, protocols and service delivery guidelines designed to ensure that women receive high-quality gynecological care, family planning, prenatal, delivery and postpartum care (Figure 2).
The pillars of safe motherhood are family planning, ANC, clean/safe delivery and essential obstetric care.
2.2 Antenatal Care
2.2.1 Description of Antenatal Care
Antenatal care refers to the regular medical and nursing care recommended for women during pregnancy. Furthermore, it is a type of preventive care with the goal of providing regular checkups that allow doctors or midwives to prevent, detect and as well treat potential health problems that may arise in a pregnant woman (WHO, 2005).
ANC offers a woman advice and information about appropriate place of delivery, depending on the woman’s condition and status.
In addition, ANC may assist in abating the severity of pregnancy related complications through monitoring and prompt treatment of conditions aggravated during pregnancy, such as pregnancy induced hypertension, malaria, and anemia which put at risk both the life of the mother and unborn baby (Bloom et al, 1999) (Bhatia and Cleland, 1995).
ANC has long been considered a basic component of any reproductive health programme. Different models of antenatal care have been put into practice all over the world. These models are the result of factors such as socio-cultural, historical, traditional nature as well as economy of the particular country. Moreover, human and financial resources of the specific health system substantially play a part in building the model (Shah and Say, 2007).
Most developed countries use traditional model of prenatal care which is based on larger number of visits, approximately 7-10 visits. They include starting antenatal as early as possible, monthly visits up to 28 weeks, followed by weekly up to 36 weeks until delivery (Say and Raine, 2007).
Pregnant women in these high income countries receive adequate prenatal care which includes frequent tests and ultrasound evaluation. They also give birth under supervision of medically trained personnel and have prompt access to emergency treatment if complications arise.
The traditional ANC had not done well in most developing countries as indicated in Table 2. Many of those who attend antenatal care clinics come only once or twice and sometimes late in pregnancy (Shah and Say, 2007).
Table 2: Percentage of women who had at least four antenatal visits with trained health personnel during the most recent pregnancy, 2000-2005: (Source: Shah and Say 2007)
| Country | Year | Percentage (%) |
| Asia | ||
| Cambodia | 2000 | 8 |
| Nepal | 2001 | 12 |
| Bangladesh | 2004 | 14 |
| Philippines | 2003 | 66 |
| Africa | ||
| Mauritania | 2001 | 8 |
| Rwanda | 2000 | 10 |
| Chad | 2004 | 16 |
| Malawi | 2000 | 53 |
| Ghana | 2003 | 68 |
| Latin America | ||
| Nicaragua | 2001 | 55 |
| Bolivia | 2003 | 55 |
| Colombia | 2005 | 83 |
2.2.2 Benefits of antenatal care
Antenatal care contributes to good pregnancy outcomes and oftentimes benefits of antenatal care are dependent on the timing and quality of the care provided (WHO and UNICEF, 2003).
It has been shown that regular antenatal care is necessary to establish confidence between the woman and her healthcare provider, to individualize health promotion messages, and to identify and manage any maternal complications or risk factors (Hollander, 1997).
During antenatal care visits, essential services such as tetanus toxoid immunization, iron and folic acid tablets, and nutrition education are also provided (Magadi et al, 1999).
Lack of antenatal care has been identified as one of the risk factors for maternal mortality and other adverse pregnancy outcomes in developing countries (Anandalakshmy et al, 1993) (Fawcus et al, 1996).
Moreover, many studies have demonstrated the association between lack of antenatal care and perinatal mortality, low birth weight, premature delivery, pre-eclampsia, and anaemia (Ahmed and Das, 1992) (Coria-Soto et al, 1996).
In a study conducted in Mexico by Coria-Soto et al. (1996), inadequate number of visits was associated with 63 per cent higher risk of intrauterine growth retardation. Similar results were reported in a Bangladeshi study where birth weight was positively correlated with the frequency of visits at antenatal clinics (Ahmed and Das, 1992).
All these results point to the important role of antenatal care in identifying and mitigating the potential complications during pregnancy. Moreover, a study conducted in Canada (Heaman et al, 2008) on inadequate prenatal care and association with adverse pregnancy outcome indicated that preterm birth, low birth weight, small-for-age gestational and increased mortality rate were associated with inadequate prenatal care. Raatikainen et al. (2007) showed similar findings in a study conducted in Finland, where an increase in low birth weight infants, more fetal deaths, and more neonatal deaths were common among those under attending ANC (Raatikainen et al, 2007).
2.3 Focused Antenatal Care (FANC)
2.3.1 Background of FANC
FANC is a personalized care provided to a pregnant woman with emphasis on the woman’s overall health, preparation for childbirth and readiness for complications. It is said to be timely, friendly, simple and safe service to a pregnant woman. Furthermore, it contributes to maternal and neonatal outcomes similar to those of traditional ANC (WHO and UNICEF, 2003).
FANC is goal-oriented, has no adverse effects on the pregnant mother and unborn baby even though the number of antenatal visits have been reduced to at least four, where each visit is focused rather than routine (Villar, 2001).
Most low income countries have incorporated FANC in their health systems. The model has fundamental public health implications especially in developing countries where healthcare resources are inadequate. It curtails the costs of the woman in terms of time traveling to and from the clinic, waiting time, transport costs where clinics are located far, loss of working hours, and care of other children at home. Consequently, time and energy would be saved by the health care personnel as well (Birungi et al , 2008).
Studies have been conducted both in Africa and other regions of the world to assess the feasibility, acceptability and effects of implementing FANC. It was eminent in studies conducted in Ghana, Kenya and South Africa that FANC is acceptable to clients and providers in Africa and can improve quality of care [ (Nyarko et al, 2006), (Birungi and Onyango-Ouma, 2006), (Chege et al, 2005)], which explains why most developing countries have welcomed FANC (Birungi et al. 2008).
The WHO recommends that pregnant women make a first visit between 8-12 weeks after conception and make further three visits between 24 and 38 weeks of gestation (WHO, 2002).
Table 3: Focused antenatal care (FANC) model outlined in WHO clinical guidelines
| First Visit
(8-12 weeks) |
Second Visit
(24-26 weeks) |
Third Visit
(32 weeks) |
Fourth Visit
(36-38 weeks) |
| – Confirm pregnancy
and expected date of delivery, classify women for basic ANC (four visits) or more specialized care.
– Screen, treat and give preventive measures such as iron and folate supplements, tetanus toxoid vaccine (TTV) and sulfadoxine pyrimethamine.
– Develop a birth and emergency plan.
– Advice and counsel on reproductive health, breastfeeding, tobacco and alcohol use. |
– Assess maternal and fetal well-being.
– Exclude pregnancy induced hypertension and anemia.
– Give preventive measures such iron supplements.
– Review and modify birth and emergency plan.
– Continue advising and counseling. |
– Assess maternal and fetal well-being.
– Exclude pregnancy induced hypertension, Anemia and multiple pregnancies.
– Give preventive measures such iron and second TTV administration.
– Review and modify birth and emergency plan.
– Continue advising and counseling |
– Assess maternal and
fetal well-being.
– Exclude pregnancy induced hypertension, anemia, multiple pregnancy and malpresentation
– Give preventive measures such as iron Supplements.
– Review and modify birth and emergency plan.
– Repeat advice given from previous visits. |
(Source: WHO 2002)
2.3.2 Aim and objectives of FANC
The main aim of FANC is to achieve a good outcome for the mother and the baby, and prevent any complications that may occur in pregnancy, labour, delivery and postpartum. This could be achieved through the following objectives.
Early detection and treatment of complications: It mainly focuses on assessment and examination of a pregnant woman for chronic conditions and infectious diseases. Conditions that may threaten the life of the mother and baby when not treated are HIV/AIDS, syphilis, other sexually transmitted diseases, malnutrition, tuberculosis and malaria. Furthermore, conditions such as severe anemia (Hb <7g/dl), vaginal bleeding, eclampsia, fetal distress, fetal mal-presentation after 36 weeks, and chronic conditions such as kidney failure, diabetes and heart problems should also be taken into consideration if we are to save the life of the mother and unborn (JHPIEGO, 2007).
Prevention of complications: It entails that a health service provider should ensure prevention of complications by providing TTV to prevent maternal and neonatal tetanus, iron and folic acid to prevent anemia. Moreover, the provider should ensure use of intermittent preventive treatment and insecticide treated nets to prevent malaria, and environmental hygiene to prevent diarrhea and intestinal worms (JHPIEGO, 2007).
Birth preparedness and complication readiness: It provides a woman with a plan about place of delivery, transportation, companionship, blood donor, items for clean and safe delivery. In addition, the woman is imparted with knowledge about danger signs, and actions to take if they arise. Data indicates that 15% of women develop pregnancy related complications, and that these women could die if nobody was there to make timely decision at home and health facility, and also if no plans for transportation and finances are made (JHPIEGO, 2007).
Health promotion and counseling: Encourage dialogue between the woman and service provider. Issues affecting a woman’s health and that of the newborn are discussed at length. It includes dietary and nutrition education; for example, how to get essential nutrients. Furthermore, the woman is given information about risk of smoking, use of herbs, rest, hygiene, safer sex, and medication. Information regarding family planning, exclusive breast feeding as well as immunization and care of the newborn is included in counseling (JHIEGO, 2007).
2.4 Factors that hinder utilization of ANC services
2.4.1 Demographic and Socio-Cultural factors
There are a number of studies done to establish factors relating to late antenatal attendance in the world. The related factors include place of residence, ethnicity, age, education, employment status, and parity, intention to get pregnant, use of contraceptive method, economic status, health insurance and travel time [ (McDonald, 1988), (Perloff, 1999), (Trinh, 2005), (Magadi, 2001), (LaVeist, 1995)].
Gestational Age and Timing of ANC
Maternal age has been shown to both negatively and positively influence utilization of FANC and ANC in general. A study conducted in Turkey demonstrated that teenage mothers were statistically less likely to use FANC services (Ciceklioglu et al, 2005).
Younger women, especially teenagers, are more likely to have unplanned pregnancies and lack information and resources to access ANC services (Trinh, 2006).
However, in other studies teenage mothers were more likely to start utilizing ANC services earlier than their older counter parts. Women below 18 years started antenatal early (Bhatia and Cleland, 1995).
Marital Status
As regards marital status, single women with unplanned pregnancies, like most pregnant teenagers, may have a negative attitude towards their pregnancy and, due to this, may be less aware of the signs of pregnancy and as a result seek care much later than would older women.
Location and place of residence
In most rural areas of sub-Saharan Africa, poor maternal health remains a major issue since health facilities do not provide a full range of primary healthcare services, undermining access to reproductive health services, including basic and Comprehensive Emergency Obstetric Care (EmOC) services [ (Tawiah, 2011), (Magadi et al, 2003), (Monir et al., 2009), (Pearson et al., 2005), (Lester et al., 2010)].
Place of residence has also been shown to influence FANC utilization. Women in urban areas were more likely to use FANC more than rural women in Ecuador (Paredes et al, 2005) and Nepal (Sharma, 2004).
On the other hand, a study in India found that women in urban areas of Karnataka were less likely to receive ANC than those living in rural areas (Navaneetham and Dharmalingam, 2002).
Collated research on urbanization in developing countries [ (Adomako-Ampofo et al, 2004), (Benefo, 2006), (Coast, 2006), (Dodoo, 1995), (Dodoo et al, 2003)] suggest that when women living in urban areas gain in reproductive self-determination and also in financial autonomy over their reproductive and family health decisions, it improves women’s healthcare seeking behaviour and wellbeing.
Distance to the health facility is inversely associated with ANC utilization (Glei et al, 2003). A study conducted by Magadi et al. (2000) in Kenya demonstrated that an increase in distance to the nearest healthcare facilities was associated with fewer antenatal visits.
Moreover, uncomfortable transport, poor road conditions and difficulties in crossing big rivers have also been shown to be barriers to utilization of FANC in studies conducted in Zimbabwe (Mathole et al, 2004) and in Pakistan (Mumtaz and Salway, 2005).
Unplanned Pregnancy
Studies on social factors influencing utilization of FANC demonstrate that desirability of pregnancy is a statistically significant determinant of FANC use. Pregnant women with unplanned pregnancies were found to make less FANC visits [ (Magadi et al, 2000), (Erci, 2003), (Paredes et al, 2005)].
Sometimes it is difficult to tell that you are pregnant. Some people have irregular periods; they miss periods for months only to find they are not pregnant, so it is better to wait, to see if you are really pregnant. [Pregnant woman, rural South Africa].
2.4.2 General knowledge on FANC/ANC services
Compared to women of low literacy level, educated women bear fewer children and achieve better child survival, because they avoid early marriages, teenage pregnancy, and high parity because they attend antenatal and postnatal more frequently.
Lack of awareness campaign
Knowledge on FANC and ANC is critical in determining pregnant women’s use of antenatal services (Simkhada et al, 2007). Studies have shown that exposure to mass media, particularly television and radio, significantly predicts utilization of FANC.
Pallikadavath et al. (2004) and Sharma (2004) in studies done in India and Nepal, respectively, found that pregnant women who were watching television every week were more likely to use FANC.
Lack of adequate knowledge
Moreover, studies have shown that adequate knowledge of ANC has a positive and statistically significant effect on FANC use (Paredes et al. 2005, Nisar and White 2003).
A study conducted by Ndyomugyenyi et al (1998) in rural areas of Uganda indicated that pregnant women with inadequate knowledge of maternal and child health were likely not to utilize ANC (Ndyomugyenyi, 1998).
A similar study was conducted in Nigeria by Amosu et al. (2011). The findings indicated that healthcare provider and pregnant women ignorance about FANC was one of the factors affecting utilization of FANC.
Low Level of Education
A study done in Kwale district, Kenya revealed that women with secondary education or above were more likely to attend for ANC (Brown et al. 2008).
Maternal education has also been shown to influence utilization of FANC. Matsumura and Gubhaju (2001) in study conducted in Nepal demonstrated that women with higher education were more likely to utilize FANC than those with lower education. Pallikadavath et al. (2004) found in similar results. In their study they had demonstrated that both maternal and paternal education positively influences utilization of FANC.
2.4.3. Socio-economic cost of ANC services
Limited resources directed to family control
Yakong’s (2008) study of rural Ghanaian women posited that economic ability to access health is a major factor affecting healthcare seeking behaviours in general and reproductive health of women in particular. For example, in Ghana, the majority of women have limited control over family property and household financial resources and limited access to credit from financial institutions.
Increase household expenditure
Income at household level has a bearing on antenatal attendance. This was established in studies from Jamaica that found out that an increased probability of early antenatal care attendance was associated with increased household expenditure (Gertler et al. 1993).
Women financial dependence on husbands
It is noted that women’s financial dependence on their husbands affects their decision making because healthcare options must be supported by husbands. (Tawiah, 2011; Atuyambe et al., 2005; Kasolo et al., 2000; Obemeryer, 1993; Birungi et al., 2006; Pearson et al., 2005).
Women lack the power to spend money on healthcare without their husbands’ permission. Collated findings exist elsewhere in Nigeria, Burkina Faso, Kenya, Ethiopia, Philippines, India, and Pakistan (Abdool-Karim et al., 1994; Mekonnen, 2003; Wong et al., 1987; Bhatia, 1995; Awusi et al., 2009; Negi et al., 2010; Babar et al., 2004).
2.4.4. Traditions, Cultural Beliefs and Prejudice
Socio-cultural beliefs
Socio-cultural belief systems, values, and practices also shape an individual’s knowledge and perception of health and illness/disease, and healthcare seeking practices and behaviours (de- Graft Aikins, 2005; Caldwell and Caldwell, 1987; MoH, 2004; UNICEF, 2005).
These shared norms guide self-care practices, and the use of traditional healers, both of which may support some healthy behaviours and contribute to unmet health needs (Adongo et al., 1998; GMOH, 1999).
A study conducted in Malawi by Chiwaula (2011) also demonstrated that cultural beliefs negatively influence utilization on FANC.
Norms
Socio-cultural belief systems, values, and practices also shape an individual’s knowledge and perception of health and illness/disease, and health care seeking practices and behaviours (de- Graft Aikins, 2005; Caldwell and Caldwell, 1987; MoH, 2004; UNICEF, 2005).
These shared norms guide self-care practices, and the use of traditional healers, both of which may support some healthy behaviours and contribute to unmet health needs (Adongo et al., 1998; GMOH, 1999).
Role of men or husbands
In dominant patriarchal cultures such as those found in Uganda and other parts of Sub-Saharan Africa, men play an important role in determining what counts as a healthcare need for women; men are in control of almost all the resources in the family (Kasolo et al., 2000; Yakong, 2008; Bawah et al., 1995; Assfaw, 2010).
Men and women, young and old, who are often inclined to customary beliefs object to their wives going for antenatal care especially under skilled health providers. In Kasolo et al, (2000), perception of men and women depicts their agitation to deny their wives or for that matter daughters-in-law from seeking antenatal care.
2.4.5. TBA verses doctors/nurses
Most women prefer Traditional Birth Attendants (TBAs) to doctors/nurses since TBAs do not see private parts during attendance, except they just feel by a touch which is more common in the rural parts of the country.
In a study that examined women’s health behaviour in Ghana with respect to hygiene, malaria prevention and responsible sexual conduct, observed that factors that affect health behavior include the roles of education, rural-urban residence, self-determination, gender role norms with respect to women’s rejection of domestic violence, and social support networks.
2.4.6. Accessibility, coverage and quality of antenatal care services
In developing countries, including South Sudan, several factors impede accessibility, including cost of services, distance to health services, amongst others, as seen remains a significant challenge to health care service delivery.
Accessibility of antenatal care services
Myriad studies in Uganda and elsewhere in Sub-Saharan Africa (SSA) have identified physical or geographical access to healthcare as a major barrier affecting healthcare seeking behaviors of patients generally, and women’s reproductive healthcare seeking specifically (Kasolo et al., 2000; MoH, 2004; GMOH, 1999).
Distance to health facility
Distance to the health facility is inversely associated with ANC utilization (Glei et al.
2003). A study conducted by Magadi et al. (2000) in Kenya demonstrated that an increase in distance to the nearest healthcare facilities was associated with fewer antenatal visits.
Poor and uncomfortable transport
Moreover, uncomfortable transport, poor road conditions and difficulties in crossing big rivers have also been shown to be barriers to utilization of FANC in studies conducted in Zimbabwe (Mathole et al. 2004) and in Pakistan (Mumtaz and Salway 2005).
Quality of Health Service
Poor utilization of quality reproductive health services continues to contribute to maternal morbidity and mortality in developing countries. Understanding the different forms of social representations from which individuals or group members of a society draw meanings from the different social milieu and other external factors that may influence their preferences will help to identify policy gaps and develop strategies that will improve utilization of skilled obstetric services and thereby reduce unnecessary loss of lives (Abdool-Karim et al., 1994; Lockwood, 1995; Cook et al., 2009; Milliez, 2009).
Despite the progress in some countries, the global number of maternal deaths per year estimated at 529,000 or one every minute during the year 2000 has not changed significantly since the 1994 International Conference on Population and Development (ICPD), and also according to recent estimates by World Health Organization (WHO), United Nations Children’s Fund (UNICEF) and United Nations Population Fund (UNFPA). Most women survive but later suffer from illness and disability related to pregnancy and childbirth (WHO, 2003; Zeine et al., 2009).
2.4.7: Healthcare Workers’ Perspective
One of the most common reasons given for delaying or restricting antenatal visits was the poor attitude of staff at health care facilities www.ncbi.nlm.nih.gov/pmc. Findings from countries in Africa, Asia, and South America highlight insensitivity, rudeness, humiliation, neglect, abuse, and even physical violence by health centre staff as key factors in limiting women’s accessing of antenatal care.
“Healthcare workers at an antenatal clinic don’t care for patients; for example, when you go in the morning they will ask you: ‘At your home don’t you sleep?’ When you go at lunch time they will ask you whether at your place you don’t take lunch. And when you go in the evening they will tell you they have closed up.” – Atuyambe (Uganda, 2011).
Authors also reported that women felt intimidated because of the potential for abuse.
“When you see the health agent yelling at women who are not feeling well, you are afraid of telling them what is wrong with you too” – [Pregnant woman, Benin].
In other contexts, women recounted being punished or humiliated because of some perceived minor misdemeanor.
“If you arrive late at the clinic, the staff rebukes and punishes you with a fine or they order you to clean the floor or sweep the surroundings.” – Mubyazi [Limited user of antenatal care services, rural Tanzania].
In all of these examples, women reported feeling reluctant to return for another appointment, and some reverted to more traditional forms of antenatal care as a consequence.
Negative attitude of health providers
Healthcare providers’ compliance, perception and attitude play a crucial role as regards to utilization of FANC. Mathole et al. (2004) explains that poor attitude of health care providers towards pregnant women contributes to low utilization of FANC services in Zimbabwe. He further contends that many of these mothers prefer to deliver with unskilled birth attendants in the villages. Conrad et al. (2011) substantiate this finding in a multicentre study conducted in Tanzania, Uganda and Burkina Faso where it was noted that healthcare workers did not comply with the procedures stipulated in FANC guidelines and this had a tremendous effect on the utilization of FANC. Conversely, Yengo (2007) refuted the claim that health workers (nurses) perception affects implementation and utilization of FANC in Tanzania. She argued that health care workers perceive FANC as beneficial both to the pregnant mother and the unborn, but rather shortage of human and material resources impede successful implementation of FANC.
Those without cards rejected
Research suggested that a number of cases, particularly in sub-Saharan Africa, the practice of giving antenatal cards to women attending the clinic is being poorly managed and is having a detrimental effect on continued access. Some healthcare providers use the clinic card as “a passport” and refuse to admit laboring women to a clinic or hospital if they do not have one. This kind of negative reinforcement has created a situation in which pregnant women visit an antenatal facility only once to get a “clinic card”.
“I am just afraid of being denied services when I need them, so one must just go [to antenatal care] to get the [clinic] card. If you do not have a card, they will not accept you when there is a problem…otherwise we could just rest at home.” – Woman in ninth month of pregnancy, rural Tanzania.
2.4.8. Costs of health services
Asiimwe, (2010), found out that in western Uganda, the ability of a woman to afford antenatal care services has a significant association to the number of ANC visits she is likely to make. This resonates with studies elsewhere that women having to take transport to ANC facility, high fees for necessary but costly laboratory investigations, drugs and consultation fees in case of private centers not serviced by government hospitals are deterrence to the utilization of maternal services as highlighted by Atuyambe et al., (2005). Although in their study, there was no significant relationship between affordability and utilization of antenatal care, these associations indicate the unwillingness by mothers to pay for ANC services.
For example, in Ghana, the majority of women have limited control over family property and household financial resources and limited access to credit from financial institutions. In (Tawiah, 2011; Atuyambe et al., 2005; Kasolo et al., 2000; Obemeryer, 1993; Birungi et al., 2006; Pearson et al., 2005), it is noted that women’s financial dependence on their husbands affect their decision making because health care options must be supported by husbands.
Women lack the power to spend money on healthcare without their husbands’ permission.
Collated findings exist elsewhere in Nigeria, Burkina Faso, Kenya, Ethiopia, Philippines, India, and Pakistan (Abdool-Karim et al., 1994; Mekonnen, 2003; Wong et al., 1987; Bhatia, 1995; Awusi et al., 2009; Negi et al., 2010; Babar et al., 2004).
It is against this background that the study sets out to explore the inequalities and identify the socio-economic and demographic factors associated with inadequate and poor quality utilization of antenatal care (ANC) services. A framework adapted from Kroeger’s, (1983) healthcare utilization model, has three sets of explanatory variables that guide the use of healthcare services, predisposing factors (characteristics of subject), enabling factors (disorder/illness and peoples’ perception as well as the characteristics of health service system such as accessibility, acceptability, affordability and availability) that make a logic sequence to predict healthcare service use. The need factors represent the most immediate cause of safe motherhood service utilization. Given the presence of predisposing and enabling factors, a woman must perceive illness (pregnancy adjoined to the fear of pregnancy related complications or adverse outcome) or its possibility to invoke the use of safe motherhood services (Fiedler, 1981). Even though pregnancy is not an illness, its possibility of adverse outcome is treated as a symptom for higher need for health services.
2.4.9. Other factors
Influence by in-laws
Some cultural beliefs have also been found to influence utilization of FANC. In Nepal, mothers-in-law negatively influenced utilization of FANC by their daughters-in-law. Mothers-in-law tend to persuade their daughters-in-law to fulfill household duties instead of visiting ANC (Simkhada et al. 2010).
Similarly, a study conducted in Taiwan, also found that mothers-in-law and spouse heavily influence decision about where and whether to go for antenatal care. (Lee et al. 2009)
Early period of Pregnancy
Furthermore, in Zimbabwe, Mathole et al. (2004) found that the early period of pregnancy was the most vulnerable to witchcraft-associated fears, which was the reason for pregnant women not attending FANC in first trimester.
Women’s perceptions of ANC and Reasons for Attending
Studies on social factors influencing utilization of FANC demonstrate that desirability of pregnancy is a statistically significant determinant of FANC use. Pregnant women with unplanned pregnancies were found to make less FANC visits (Magadi et al. 2000, Erci 2003, Paredes et al. 2005).
2.5 Conceptual Framework: Health Belief Model
Conceptual framework refers to a set of concepts that are linked and described by broad generalizations which are formulated by an individual for a purpose (Rosenstock, 1974).
The purpose of this study is that women’s views can offer important insights into this problem. Qualitative studies exploring inadequate use of antenatal care services by the pregnant women will be undertaken in the next Chapter Three (Research Methodology).
This study was based on Health Belief Model (Figure 3), a modification of Becker and Maiman (1974) and Rosenstock (1974). Health Belief Model was adopted in this study to explain the concepts pinned in the study, because quantitative studies need to be based on existing body of knowledge or theory.
The Health Belief Model emanated from a foundation of cognitive theories of behavior that behavior is contingent upon the value that an individual places on a desired outcome, and the belief that a behavior, if performed well, will result in the desired outcome (Bandura, 1977).
Furthermore, the model explains that a range of health behaviors can be predicted based on information from determinants such as perceived susceptibility, perceived severity, perceived benefits/barriers and modifying factors associated with engaging in a behavior. The application of the model in this study has been outlined in subsequent paragraphs below.
Figure 3: The Health Belief Model
(Modified from Rosenstock 1974; Maiman and Backer 1974)
Perceived susceptibility: Perceived susceptibility refers to an individual’s judgment of their risk of contracting a health problem. The likelihood of seeking health interventions increases as the level of perceived susceptibility increases (Rosenstock, 1974). For instance, pregnant women would be more likely to seek medical attention – in this case antenatal services – if they believe that they are susceptible of developing pregnancy complications.
Perceived severity: Perceived severity refers to the subjective evaluation of the likelihood that a problem/illness or disability, if contracted or left untreated, will have severe consequences such as pain, death, handicap, or reduced quality of life in general (Backer and Maiman, 1977). In the context of this study, willingness of pregnant mother to utilize FANC would depend also on personal evaluation of the seriousness of the consequences associated with pregnancy complications, for example, death of the fetus.
Perceived benefits/barriers: Individual’s choice of behavioral options depends on their perception of benefits and barriers. Therefore, a cost benefit analysis allows an individual to evaluate the outcome expectations and assess whether the expected benefit of a behavior outweighs the perceived expenditure incurred by engaging in the behavior, (Rosenstock 1974).
Compliance with recommended health seeking behavior is impeded to the extent that perceived barriers outweigh perceived benefits that would result from engaging in the health behavior (Rosenstock, 1974). For example, inconveniences such as long waiting time at antenatal clinic and distance to the health facility would act as barriers to utilization of FANC. A pregnant woman would opt not to go to the clinic if she sees no benefit in doing so. Furthermore, health care workers’ negative attitude towards focused antenatal care, inadequate resources both material and human, inadequate equipment and supplies, and lack of knowledge regarding benefits of FANC would also impede utilization of FANC (Simkhada et al.2008).
Modifying factors: These may include socio-cultural factors as well as demographic aspects such as age, parity, religion, educational status, social values, beliefs and practices of pregnant woman in relation to utilization of FANC (Chivonivoni et al. 2008).
2.6 Summary of Literature Review
The body of evidence on global trend of maternal mortality reviewed has shown persistent high MMR in developing countries. The problem of increased maternal mortality is largely compounded by poor socio-economic status in most developing countries.
It has also been shown that there is low utilization of FANC, and absence of quality emergency obstetric care exacerbates the situation. Furthermore, the literature highlighted some factors associated with low utilization of FANC. These include inadequate knowledge of both pregnant mothers and healthcare providers on FANC, some socio-cultural factors as well as perception of providers’ towards FANC.
The literature also unveils the benefits of early FANC attendance in identifying and mitigating the potential complications during pregnancy and birth that may cause both maternal and infant morbidity and mortality. The Health Belief Model was adopted in this study to illustrate the concepts related to the utilization of FANC in developing countries.
Fewer amongst the research questions are highlighted here. First, why are pregnant women not visiting ANC centers? In other words, what modalities does this ANC adopt and what is its impact on patients, professionals and the health system as a whole? Second, how can this knowledge be useful to policy/decision-makers interested in perinatal care in an effort to reduce the peak of MMR?
In order to address these questions, we selected a reproducible sample of scientific studies later seen in Chapter Three and decided, in order to appraise the studies retrieved, to focus on the current status of the topic under study, rather than looking at the methodological quality of the studies being reviewed.
We have chosen to create an original conceptual framework to guide our analysis by blending a schema for health services and policy analysis with varying definitions of integrated care. It allows us to draw a clear portrait of the type of knowledge that is covered (and not covered) in the scientific literature, and reveals the strategies that need intervention.
We consider that this paper makes two clear and intertwined contributions. First, in terms of theory, this kind of literature review on antenatal care is innovative because we assume it has never been done before. Second, in terms of practice, it provides direct research support to policy/decision-makers interested in this modality of health care organizing.
Amongst sections covered include traditions, cultural beliefs and prejudice, illiteracy and ignorance, distance and locations of health facilities, disrespect and abuse of health workers.
Chapter Three: Research Methodology
3.1 Introduction Research Methodology
This chapter presents all the processes and description of methods for this research paper. It explains the components involved in this chapter; study area, target population, variables, study design, inclusion and exclusion criteria, sample size determination and data collection, analysis, management and ethical considerations.
3.2 Area of Study
This study was done in Munuki Payam, Juba County of Central Equatoria State, Juba South Sudan.
Based on Sudan Census 2008, Juba County holds a population of 362,423 in an area of 18,396.15 Km² of the State (1,103,952 population) with Juba County having the largest population, followed by Yei County and Lanya County the least.
The population density of Central Equatoria State was reported as 26 persons/km2, with sex distribution of 52% and 48% of females and males, respectively.
As of 2011, the County’s Payams alongside Munuki, include Bungu, Dollo (or Dolo), Ganji, Gondokoro, Lirya, Lobonok, Lokiliri, Mangalla, Northern Bari, Rajaf, Rokon, Tijor, and Wonduruba, the latter of which is administrated by Central Equatoria State. In March 2011, Juba, Kator, and Muniki Payams were consolidated into Juba proper under the administration of the Juba City Council.
Central Equatoria State is the smallest state in the Republic of South Sudan, covering an area of 22,956 Km², with a population of 1.1 million people and borders Eastern Equatoria State to the east, Jonglei State to the northeast, Western Equatoria State to the west, Lakes State to the northwest, the Democratic Republic of Congo to the southwest and Uganda to the south.
The state is in the tropical climatic zone, where annual temperature ranges from 24.7 degree Celsius to 34.5 degree Celsius, with a long rainy season from April to November. It is inhabited by fourteen tribes in which about 81 % lives in rural areas and 19 % in urban areas.
Bari, Mundari, Kakwa, Pojulu, Makaraka, Kuku, Lugbara, and Lokoya are the main ethnic groups speaking different languages but under the umbrella of Bari Speakers with local Arabic (Juba Arabic) and English as official languages widely spoken (CES Profile, 2010). The predominant religion is Christianity, with Bari speakers as the main ethnic group.
The Republic of South Sudan was formerly Southern Sudan, an autonomous region of Sudan during the period 2005-2011, formed as a result of the Comprehensive Peace Agreement (CPA) in 2005. It became independent on July 9, 2011.
It is a landlocked country located in the Sahel region of the northeast Africa bordering Ethiopia to the East, Kenya to South East, Uganda to South, Democratic Republic of Congo to South West, Central African Republic to West and Sudan to North. It lies at latitude between 30 and 130 N and a longitude 240 and 360 E.
The 2008 Population and Housing Census indicates that South Sudan has a population of 8.26 million people, with 52% female and 48% male. It is one of the poorest country with 50.9% people living below USD$1 per day in Africa despite its late emerge.
According to its educational achievements, at national level 88% of females and 63% of males have never attended any school holding the country with the high illiteracy rate.
3.3 Study Design
The research study is a cross sectional descriptive study in which quantitative data were collected based on deductive approach using questionnaires.
The purpose for employing the deductive approach was to obtain data on different variables at a given point of time so that the variables are measured and compared and eventually assist in drawing inferences on the research findings.
There were two kinds of questionnaires, one for the pregnant women of age ranging from 20 to 41 years and the other for the health practitioners (See Appendices 1 and 2). The former questionnaire was administered to the pregnant women by the researchers in an interview format because the majority of them were illiterate while the latter questionnaire was self-administered.
3.4 Study Variables
The general description of categories of variables used in the present study was selected to answer specified objectives on the two questionnaires as described below.
3.4.1 Obstacle to utilization of FANC
Utilization in the present study refers to the number of visits pregnant women made as well as gestation age at which initial FANC visit was made by pregnant women.
Pregnant women were asked to mention the number of FANC visits they had made. The number of visits was categorized as low or adequate based on recommended WHO FANC visits. Therefore, low utilization, which is the outcome variable in the study, referred to less than 4 FANC visits during the entire pregnancy.
3.4.2 Knowledge of pregnant women on importance of FANC
Participating mothers were asked questions on whether they have ever heard about FANC as well as the sources of the information regarding FANC. A list of potential sources of information on FANC such as radio, relatives, health workers and traditional birth attendants, was read to the participating mothers and participating mothers were asked to rate their agreements with the statement on the benefits of FANC, the detailed questions are in Part C of the pregnant women questionnaire as shown in Appendix 1.
3.4.3 Demographic, social and cultural factors that hinder utilization of FANC
Demographic variables for participating mothers used include age, parity, occupation, education, and marital status. Age was categorized into 6 categories; namely, 16-20, 21-25, 26-30, 31-35, 36-40, and 41 and above years.
Education was categorized into lower and upper primary, secondary and tertiary level. Part A of the women questionnaire contains details of the remaining demographic variables as shown in Table 1.
Some of the socio-cultural variables included distance to the nearest health facility, transportation, seeking permission to use FANC and male involvement. To find out social and cultural beliefs that obstruct them from utilization of FANC, the responses were categorized and coded based on similarity for analysis.
3.4.4 Practices and perceptions of healthcare providers towards FANC
In order to assess health workers’ current practices, questions were designed among others to capture their professional level, training on reproductive health and FANC in general and duration of their involvement in reproductive health.
Health workers were asked to indicate the level of agreement or disagreement, on a scale ranging from strongly agree to disagree. They were also assessed on their perception on FANC utilization in Munuki in line with obstacles associated with low utilization.
3.5 Study or Targeted Population; Inclusion and Exclusion.
The study population was pregnant women of child-bearing age from 16-41 years selected from their households by simple random sampling technique.
The research included all pregnant mothers who had chance to interview regardless of socio-economic status, educational background and professions, provided they were willing to answer research questions. In other words, it was a voluntary exercise with exception of the nonresident.
In addition, health workers in various health facilities of the study area who are the key informants on the research were included in the study and analyzed on their ANC services delivery to the recipients of antenatal care at the health facilities.
3.6 Sample size Determination
A sample size calculation was done using Epi InfoTM 3.5.1 (Centers for Disease Control or CDC and Prevention, Atlanta, GA, USA).
3.7 Data collection
Two separate questionnaire were administered to pregnant women and the other to health practitioners.
Probability sampling methods by means of clusters was used to reach the pregnant women. 50 participants were selected from four zones in Munuki Payam (Munuki, Nyakuron, Gudele and Rock City) and further divided in residential areas and households (HH).
Pregnant women who participated in the study were then selected from their households by simple random sampling. Also, health workers in mentioned zones’ health facilities were reached using the same procedures above.
3.8 Data analysis
Data were entered and analyzed using tallied and tabulated descriptive statistics including frequencies and cross tabulations run to generate outputs on all variables.
The number of FANC visits was categorized into two variables: FANC visits < 4 indicates low utilization and FANC visits 4 denoting adequate utilization.
Identification of demographic and socio-cultural variables associated with low utilization was carried out using cross tabulations. Statistical significance, evaluated at 0.05 levels, was assessed with Pearson Chi-Square Tests.
Explanatory variables were dichotomized prior to running cross tabulations. ‘Yes’ or ‘No’ responses were assigned to some socio-cultural variables.
Demographic variables such as marital status (married and unmarried), parity (nulliparous and multiparous), gravidity (primigravidae and muiltigravidae) and occupation (farming and others) were also dichotomized.
Participating mothers’ responses to open ended questions on obstacle associated with low utilization were put into themes, and thereafter responses were coded and dichotomized (Yes or No).
Frequencies and percentages were generated from participating mothers’ responses regarding sources of information and FANC knowledge.
Base responses on FANC knowledge were categorized and then dichotomized (agree and not agree, not sure).
Percentages were used to describe FANC knowledge among participating mothers. Responses of health workers on current practices were mainly Yes or No based, the data were analyzed using frequencies and percentages to describe information and services they render to their clients.
On perception tabulation was used to capture responses from the health workers, the responses were categorized and dichotomized (agree or disagree).
Percentages were generated from the dichotomized categories, and the mean percentage of those who agreed was calculated to provide a general perception whether positive or negative, using the cut-off point of 50%, so that above 50% will indicate positive and negative perception respectively.
3.9 Data management
Data were checked for completeness and validity of information by the researchers after questionnaires were back from the field. This was done to check for missing data, correct mistakes, in order to avoid differences and errors in the data collected.
The corrected data sheets were serially numbered and tallied by the researchers and checked questionnaires were kept for data processing and analysis.
3.10 Ethical Consideration
Ethical approval to conduct the study was assayed and obtained from the University Research Council, and the Faculty administration.
Permission to conduct the study was looked for from Juba City Council, Munuki Town Block. Verbal consent was obtained from participating mothers and written consent was obtained from the healthcare workers as shown in appendixes attached.
However, to maintain confidentiality for participating mothers and health workers, numbers instead of names were used on the questionnaires for anonymity while those who allowed their names to be used where availed.
Chapter Four: Results, Display and Analysis
4.1 Study results
The results of this study were collected in Munuki Payam, Central Equatoria State from the period of November 2015 to January 2016 using the collection approached explained in the previous chapter.
4.1.1 Demographic characteristics
Table 1 shows the socio-demographic characteristics of mothers of reproductive age who were asses in the study to look at their utilization of the ANC services who participated in the study.
The highest number 36% fall within the age range of 26-30 years, followed by 26% of age range 21-25, 16-20 (16%), 31-35 (12%), 36-40 (5%) and only one in the range of 41 above with 2%. No women in the age range of 11-15.
Majority of the women were married 82% of studied pregnant women; 6% separate 6%, widow 4% single, and 2 % divorce.
A greater number (74%) attended formal education up to tertiary level. Only 26% did not attend either of the level of education. Same number 26% attended up to upper primary and secondary school, 8% attended lower primary and only 14% attained tertiary education.
Considerably, 54% of 27 out of 50 women are jobless, 10% do business to earn a living while 14% and 12% do piece of work and office work respectively for sustainability. On their male counterparts (husband), 48% do office work, 26% business, 10% piece of work, 14% do piece of work, while only 2% who do not do anything to earn a living.
A total of 66% women have given birth at health facility with only 26% at home from one child to more than four children. Only 8% never gave birth.
Majority of the women 32% had two children and 8% with more than 4 children.
Table 4: Shows the Demographic characteristics of women in the study.
| Characteristics | N=50 | Percentage (100%) |
| Age | ||
| 16 – 20 | 8 | 8 |
| 21 – 25 | 13 | 13 |
| 26 – 30 | 17 | 17 |
| 31 – 35 | 6 | 6 |
| 36 – 40 | 5 | 5 |
| 41 – above | 1 | 1 |
| Marital Status | ||
| Married | 41 | 82 |
| Single | 2 | 4 |
| Divorced | 1 | 2 |
| Widowed | 3 | 6 |
| Separate | 3 | 6 |
| Level of Education | ||
| Lower Primary | 4 | 8 |
| Upper Primary | 13 | 26 |
| Secondary School | 13 | 26 |
| Tertiary | 7 | 14 |
| Zero Level | 13 | 26 |
| Occupation of Women | ||
| Business | 10 | 20 |
| Piece of Work | 7 | 14 |
| Office Work | 6 | 12 |
| Farming | 0 | 0 |
| No Work | 27 | 54 |
| Occupation of husbands | ||
| Business | 13 | 26 |
| Piece of Work | 5 | 10 |
| Office Work | 24 | 48 |
| Farming | 1 | 2 |
| No Work | 7 | 14 |
| Number of deliveries (Parity) | ||
| None | 5 | 10 |
| One | 10 | 20 |
| Two | 14 | 28 |
| Three | 8 | 16 |
| Four | 4 | 8 |
| More than Four | 9 | 18 |
| Place of delivery | ||
| Health Facility | 33 | 66 |
| At Home | 13 | 26 |
| Don’t Know | 4 | 8 |
4.1.2 Knowledge of ANC
The study explored the knowledge of the ANC users. In this study almost all (48 out of 50) participating mothers 96% had knowledge of FANC (Table 2).
The major sources of information on knowledge of FANC got were the radio 20%, healthcare providers 18%, relatives 46%, TBA 6%, and others 10%.
Utilization of the ANC services was seen clearly during the pregnancy (72%); otherwise without the pregnancy no need to visit the health facility. 16% visit the facility when they are told by others, 10% visit when they are sick, and only 2% when there is complication.
The mothers said they take permission when they want to go for the ANC; those who took from husband 72%, uncle 4%, mother 20%, mother in-law 4%, others 8%.
Only 34% of the women said they are accompanied by their husband or spouse while greater number (66%) were not accompanied by others.
The responses on the recommended number of visits to the FANC clinic when there is no problem were varied with 34% of the respondents indicating 4 times.
Variability on the number of visits when the pregnant woman is experiencing problems was quite big in this study population; however, similar 34% indicated that the pregnant woman is supposed to visit the FANC more than 4 times with less than 34%.
Regarding the perceived benefits of FANC, about 56% of the respondents agreed that FANC would be useful in establishing a rapport between the pregnant mother and the nurse.
Nearly all (92%) participants agreed with the notion that antenatal care would help in early detection of risk conditions associated with pregnancy. 62% of the women agreed that they were given chance of health education on the importance of ANC and other services, while 38% disagreed.
About 46% of the respondents also agreed to the fact that the FANC would enable the pregnant woman to receive tetanus toxoid vaccine (TTV), Vitamin A and iron supplementation, insecticide treated nets, intermittent preventive treatment and hookworm treatment.
Table 5: shows sources of information and knowledge of participating mothers
| Characteristics | N=50 | Percentage (%) |
| Source of information | ||
| Husband | 32 | 64 |
| Uncle | 2 | 4 |
| Mother | 10 | 20 |
| Mother-in-law | 2 | 4 |
| Other | 4 | 8 |
| Total | 50 | 100 |
| Number of visits when there is no problem | ||
| 1-3 visits | 17 | 34 |
| 4-6 visits | 17 | 34 |
| 7 above visits | 15 | 30 |
| Don’t know | 1 | 2 |
| Total | 50 | 100 |
| Reason for attendance to ANC | ||
| Pregnancy | 36 | 72 |
| Sickness | 5 | 10 |
| Told by others | 8 | 16 |
| Previous pregnancy complication | 1 | 2 |
| Previous fetal loss | 0 | 0 |
| Total | 50 | 100 |
| Benefit of the ANC | ||
| Establishing report between pregnant mothers and Antenatal Care provider | 28 | 56 |
| Early detection of risk conditions associated with pregnancy | 46 | 92 |
| Give chance of health education on the importance of ANC and other services | 31 | 62 |
| Additional supplement to ANC services offered. | 46 | 92 |
4.1.3 ANC Utilization
This section focuses on utilization of the FANC in general and especially decisions related to whether the participants had free will to start FANC as well as their satisfaction with the services delivered to them.
Almost all the participants *48 out of 50 studied, 96%) attended FANC during their prenatal and postnatal period. Nevertheless 4% did not attend as shown in the Table 6 below. Regarding the visits, 34% completed their required 4 visits, and same number visited below the required number while 15 (30%) visited more than 4 times, and only 2% having not visited a facility. 94% of the women are satisfied with the services delivered while 6% did not agree with the satisfaction.
On start of the FANC, 56% visited in the first 3 months (0-3), 20 women 40% in the fourth to sixth months, and only 4% did not know the gestation visits.
Table 6: Shows the attendance, gestational age at initiation and number of visits
| Attended Focused Antenatal Care | N=50 | 100 % |
| Total attendance | 48 | 96 |
| No attendance | 2 | 4 |
| Number of visits | ||
| 4 visits | 17 | 34 |
| <4 visits | 17 | 34 |
| >4 visits | 15 | 30 |
| No Visit | 1 | 2 |
| Gestational age (months) of initiation | ||
| 0-3 months | 28 | 56 |
| 4-6 months | 20 | 40 |
| 7-9months | 0 | 0 |
| Don’t know | 2 | 4 |
| Influencing factors | ||
| Good health worker attitudes | 29 | 58 |
| Short waiting hours | 8 | 16 |
| Availability of staff | 13 | 26 |
| Flexibility of clinic schedule | 0 | 0 |
| Male involvement initiative | 0 | 0 |
| Satisfaction of the ANC services | ||
| Satisfied | 47 | 94 |
| Not satisfied | 3 | 6 |
4.1.4 Demographic and socio-cultural factors that obstruct utilization of ANC
Demographic factors.
Table 4 shows demographic factors that obstruct utilization of FANC service. Results show that, age was related to the number of visits, with those between 21-25 (26%) and 26-30 (34%) having more visits than those at 31-35 years (12%) and 41 years (2%).
Parity was significantly associated with the number of visits to the FANC, those with first and second pregnancy were more like likely to have visited FANC for more than 4 times compared to those who had never had any pregnancy.
Educational level in general did not appear to influence the number of visits to the FANC clinic. It shows that those with upper primary (26%), secondary (26%) and tertiary (4%) education were likely to visit though majority dropped out at primary and secondary with few attending to tertiary.
Table 7 shows the Demographic and socio-cultural factors that obstruct utilization of ANC
| Characteristics | N=50 | Percentage (%) |
| Age | ||
| 16 – 20 | 8 | 16 |
| 21 – 25 | 13 | 26 |
| 26 – 30 | 17 | 34 |
| 31 – 35 | 6 | 12 |
| 36 – 40 | 5 | 10 |
| 41 – above | 1 | 2 |
| Marital Status | ||
| Married | 41 | 82 |
| Single | 2 | 4 |
| Divorced | 1 | 2 |
| Widowed | 3 | 6 |
| Separate | 3 | 6 |
| Level of Education | ||
| Lower Primary | 4 | 8 |
| Upper Primary | 13 | 26 |
| Secondary School | 13 | 26 |
| Tertiary | 7 | 14 |
| Zero Level | 13 | 26 |
| Total | 50 | 100 |
| Occupation of Women | ||
| Business | 10 | 20 |
| Piece of Work | 7 | 14 |
| Office Work | 6 | 12 |
| Farming | 0 | 0 |
| No Work | 27 | 54 |
| Occupation of husbands | ||
| Business | 13 | 26 |
| Piece of Work | 5 | 10 |
| Office Work | 24 | 48 |
| Farming | 1 | 2 |
| No Work | 7 | 14 |
| Number of deliveries (Parity) | ||
| None | 5 | 10 |
| One | 10 | 20 |
| Two | 14 | 28 |
| Three | 8 | 16 |
| Four | 4 | 8 |
| More than Four | 9 | 18 |
| Place of delivery | ||
| Health Facility | 33 | 66 |
| At Home | 13 | 26 |
Occupations of respondent were seen to be the challenge in utilizing the services due to cost overcoming, 54% without job, business 20%, 14% for piece of work. On their spouse counterpart, 48% have office work while 26% do business, 14% with no work.
Socio-cultural factors: Participating women who reported that they seek permission before visiting FANC were very likely to make less than required 4 visits to the FANC. Waiting to obtain permission was not a factor which significantly resulted in less number of visits to FANC.
Long distance also significantly influences the number of visits to perception of showing off the pregnancy was also a highly significant factor (22%) associated with low utilization of FANC, which is reflected in the high proportions of women starting antenatal visits in second trimester (4-6months).
Only 24% said they did not have any problem hindering them in utilizing the services. Transport money was the major problem since many of them are not employed (40%), long distance (22%), desirability (8%) while factors such as low risk, waiting for permission and concern on the availability of health workers were not noticed.
Almost all of the women studied denied effect of traditional beliefs (86%) while only 14% agreed few norms affecting the utilization.
Table 8: Showing factors that hinder the utilization of the ANC services
| Characteristics | N=50 | Percentage (%) |
| Transport money | 20 | 40 |
| Long Distance | 11 | 22 |
| Desirability | 4 | 8 |
| Being a low risk | 0 | 0 |
| Waiting for permission from someone | 0 | 0 |
| Concern that there will be no health worker | 0 | 0 |
| Limited Transport Option | 3 | 6 |
| Non was a problem | 12 | 24 |
| Payment of money for ANC | 39 | 78 |
| Traditional beliefs | 7 | 14% |
4.2 Health practitioners’ or providers’ demographic factors
Of the 20 health practitioners; 45% were registered nurses while midwives were 55%) were nurse mid-wife technicians, out of that 10% were male and 90% were female.
Majority of practitioners lie in the range of 31-40 (40%), 41-50 (30%), 51 and above (20%) and 20-30 (10%)
Table 9: Shows the demographic characteristics of health workers
| Characteristics | N=50 | 100% |
| Age | ||
| 20-30 | 2 | 10 |
| 31-40 | 8 | 40 |
| 41-50 | 6 | 30 |
| 51-above | 4 | 20 |
| Sex | ||
| Male | 2 | 10% |
| Female | 18 | 90% |
| Professional | ||
| Registered nurses | 9 | 45 |
| Midwives | 11 | 55 |
4.2.2 Trainings and knowledge of the ANC by practitioners.
All the health care workers who participated in the study (100%) had undergone formal training in Reproductive health. 65% were trained in the duration of more than 4 years while 35% were trained for 3 years. (Table 10).
However, 3% and 5% were not trained in safe motherhood and FANC, respectively. All the nurses who were trained in FANC said that they remembered what they have been taught during the training. Table 7 presents the number of nurses who had different aspects of any knowledge gained from FANC training and summarizes the nurses’ current practices regarding FANC.
Almost all the health workers said the facility they worked in provide all the services that the pregnant mothers are satisfied with majority attending more than 4 visits.
However, on the other side, other services were not adequately met due to shortages and they could not be given on daily basis.
Table 10 showing training, knowledge gained from FANC and current practices of healthcare workers with regard to Reproductive Health and FANC
| Characteristics | N=20 | 100 (%) |
| Trainings | ||
| Training on reproductive and child health | 20 | 100 |
| Duration of training on reproductive health intervention | 4 years above | 65 |
| FANC | 20 | 100 |
| Knowledge gained | ||
| FANC guidelines | 20 | 100 |
| Early detection and treatment of complication | 20 | 100 |
| Principal underlying FANC | 20 | 100 |
| Individual birth preparedness and complications readiness | 20 | 100 |
| Intermittent prevention and malaria treatment | 20 | 100 |
| Health promotion and disease prevention | 20 | 100 |
| Roles played | ||
| Health education role | 7 | 35 |
| Health assessment and provision of services e.g. malaria prevention, taking blood pressure, gestation age etc | 11 | 55 |
| Supervision | 2 | 10 |
Table 11 showing services delivered and the services not met on time.
| Services offered at the health facility by the health practitioners | N=20 | |
| Strongly agree | Agree | |
| HIV testing and counseling | 75% | 25% |
| Administration of TTV | 70% | 30% |
| Iron supplementation | 70% | 30% |
| Individualized health education | 75% | 25% |
| Deworming of hook worms | 35% | 65% |
| Vitamin A supplementation | 40% | 60% |
| Early detection and treatment of complications | 70% | 30% |
| Presumptive malaria treatment in special care | 75% | 25% |
4.2.3 Health workers’ views and perception of women late ANC
Of all the studied health workers (n=20), (100%) attested that ignorance, long distance, decision by pregnant mother’s spouse, transport to facility by women, insecurity, lack of accompany were some of the issues outlined as they obstruct the pregnant mothers from attending to ANC services.
Table 12 showing the obstacles that prevent mothers from going to health care as thought by practitioners
| Categories | N=20, % |
| Ignorance of pregnant mothers | 20, 100 |
| Long distance walked by mothers | 20, 100 |
| Decision from husband | 20, 100 |
| Transport payment and delay | 20,100 |
| Insecurity, mothers’ fear of attack on the roads to facility. | 20, 100 |
| Lack of mothers accompany by husbands for ANC | 20,100 |
4.3 Analysis and discussion of the results for pregnant mothers and health care providers
The results from this study suggest that human behavior, in this case late initiation of antenatal care, is affected by a multilayered set of systems, including family, peer group, and neighborhood, as well as effects of healthcare, social service systems, and cultural belief and value system of the society in which individuals live (Pilot et al., 2008).
4.3.1 Demographic characteristics
Teenagers ranging from 16-20 compared to 21-30 have low attendance to ANC facilities like in the age from 31-40 who do not attend. This is in line with the study done in Turkey that teenage mothers were statistically less likely to use FANC services (Ciceklioglu et al. (2005). A review by Simkhada et al. (2008) on use of antenatal care in developing countries had shown conflicting findings on the influence of age of the pregnant woman on use of antenatal services. However, it was pointed out that the effect of confounders may have resulted in suppressing the influence of age on antenatal use. This finding reinforces the need to intensify advocacy messages aimed at promoting FANC utilization among women of reproductive age group.
Many of the women 41 out of 50 studied were married and attend the ANC services unlike the divorced, separated and single mothers. This research is similar to what has been studied that single women with unplanned pregnancies, like most pregnant teenagers, may have a negative attitude towards their pregnancy and, due to this, may be less aware of the signs of pregnancy and as a result seek care much later than would older women (Kogan, et al. 1998). The study has established that marital status had no influence of service utilization in antenatal services. This finding differs with Tann et al. (2007) that unmarried status influenced less uptake of antenatal care services.
In this study education level did not affect utilization of FANC because majority (37 out 50) attended school up to tertiary, which is not in line with most published results. Matsumula and Gubhaju (2001) demonstrated that low utilization of FANC is associated with low education. The effect of education on utilization of FANC in our study may be due to dropout among the participating women during their school time making it hard to show a difference. Moreover, Pallikadavath et al. (2004) argues that education assists in adequate utilization of FANC services. Similarly, a study done in Kwale district, Kenya revealed that women with secondary education or above were more likely to attend ANC (Brown et al. 2008). Pallikadavath et al. (2004) found similar results; in their study they had demonstrated that both maternal and paternal education positively influences utilization of FANC.
Many of the pregnant women occupations are not working as it is evidenced by 27 out of 50 studied found but the majority of their husband 24 out of 50 working, thus making them have less contribution in catering for the ANC services. For example, in Ghana the majority of women have limited control over resources
Parous women have high attendance of the ANC services unlike multiparous. This research has demonstrated an inverse relationship between parity and utilization of FANC, with multiparous women making significantly fewer visits to FANC than nulliparous women. This could be due to the fact that nulliparous women perceive themselves as being at high risk of developing pregnancy related complications, where as their multiparous counterparts perceive themselves as being at low risk owing to experience from previous pregnancies and births. This is similar with the studies in Kenya Magadi et al. (2000) that higher parity was associated with low utilization of FANC services. However, Ethiopian multiparous mothers were more likely to use FANC services than nulliparous counterparts (Mekonnen and Mekonnen 2003). These findings allude to the fact that there is still more need to continue with community sensitization on the need to maximize FANC regardless of parity.
This research found that most women (33 out of 50) deliver at the health facility and attended by trained nurses, midwives and doctors. This is not the same with the study that women prefer Traditional Birth Attendants (TBAs) to doctors/nurses in Ghana complaining of their private parts being seen and fear of palpation.
4.3.2 Knowledge of ANC
Source of information: This study shows that studied women had varied sources of information on FANC almost all (48 out of 50) participating mothers (96%) had knowledge of FANC. Relatives (23, 46%) were the major source of information, followed by radio (n=10, 20%). Apparently the National Ministry of Health policy discourages women from accessing antenatal services, including delivery by traditional birth attendants. Furthermore, other studies have also demonstrated that the radio is a significant source of FANC knowledge and that those who were watching television and listening to the radio were more likely to use FANC (Pallikadavath et al. 2004; Sharma 2004).
The present study has demonstrated that majority of the participating women have knowledge on the importance of FANC services, and almost all respondents indicate they know the existence and importance of FANC. It would be expected that knowledge of the role played by FANC would have brought positive results in terms of utilization of the FANC services (Nisar and White 2003). However, there has been a downward trend in terms of proportion of women utilizing FANC services. In the present study a very small proportion of respondents had indicated that they use FANC services as recommended by national and WHO protocols. At district level, there has been a negative trend in the proportion of women utilizing FANC services; the district level utilization rate is at below 30% which has not been improving over the years.
Results of the study have also demonstrated that respondents have adequate knowledge on the benefits of utilizing FANC services. One of the most prominent benefits cited by participating mothers was that FANC assists in creating good rapport between health workers and the service users. This finding is in agreement with Hollander (1997) who found rapport building amongst women using antenatal care services as a pre-requisite for continuation of service utilization. Other benefits mentioned are shown in Table 5.
Adequate knowledge on FANC services would contribute to reduction in maternal mortality rate, as suggested by the WHO (2010). The study further established that participating mothers were aware that individualized health education amongst the service users assists in transferring of knowledge from service providers to pregnant women but still needs more emphasis to boost the ANC service utilization.
Regarding specific knowledge on recommended number of visits a woman is supposed to make whether or not there is a problem, participating women also demonstrated higher knowledge of recommended visits. More than three quarters of the participating mothers had indicated that 4 visits should be made when there is a problem. However, over two thirds indicated that more than 4 visits should be made when there is a general health or pregnancy related problem. These results demonstrate that the general knowledge among participating mothers on FANC is quite high; nevertheless, knowledge is not translated into utilization as pointed out that only a small proportion of participating mothers indicated appropriately utilizes FANC.
The mothers said they take permission when they want to go for the ANC; those who took from husband (72%), uncle (4%), mother (20%), mother-in-law (4%), and others (8%). Though many take permission from husbands, only 34% of the women said they are accompanied by their husband or spouse while greater number (66%) are not accompanied by others.
The responses on the recommended number of visits to the FANC clinic when there is no problem were varied with 34% of the respondents indicating 4 times.
Variability on the number of visits when the pregnant woman is experiencing problems was quite big in this study population; however, similar 34% indicated that the pregnant woman is supposed to visit the FANC more than 4 times with less than 34%.
Regarding the perceived benefits of FANC, about 56% of the respondents agreed that FANC would be useful in establishing a rapport between the pregnant mother and the nurse.
4.3.3 ANC Utilization
The participating women during this study said they could only visit and utilize services when they are pregnant (72%); otherwise without the pregnancy there is no need to visit the health facility. On the other hand, the visits come when they are told by others (16%), sick (10%), and when there is complication (2%).
Nearly all (92%) participants agreed with the notion that antenatal care would help in early detection of risk conditions associated with pregnancy 62% of the women agreed that they were given chance of health education on the importance of ANC and other services on the contrary 38% disagreed.
About 46% of the respondents also agreed with the fact that the FANC would enable the pregnant woman to receive tetanus toxoid vaccine (TTV), Vitamin A, iron supplementation, insecticide treated nets, intermittent preventive treatment and hookworm treatment.
Women lack the power to spend money on health care without their husbands’ permission. Collated findings exist elsewhere in Nigeria, Burkina Faso, Kenya, Ethiopia, Philippines, India, and Pakistan (Abdool-Karim et al., 1994; Mekonnen, 2003; Wong et al., 1987; Bhatia, 1995; Awusi et al., 2009; Negi et al., 2010; Babar et al., 2004).
Knowledge on FANC and ANC is critical in determining pregnant women’s use of antenatal services (Simkhada et al. 2007). Studies have shown that exposure to mass media particularly television and radio significantly predicts utilization of FANC.
4.3.4 Demographic and socio-cultural factors that obstruct utilization of ANC
Majority of the participating healthcare workers (40%) were aged between 31-40 years.
This has some benefits in terms of delivery of FANC services in that younger workforce is still more productive than the ageing health workforce. Young et al. (2003) had indicated that there is an inverse association between quality performance and age of health workers. The association was observed health workers between 50 and 60 years.
All the healthcare workers who participated in the present study had undergone former training of reproductive health. However, at Munuki Payam there were 9 registered nurses and 11 midwives. This is encouraging in that healthcare workers in the area are qualified to perform their duties and by implication they are ready to offer FANC services as expected.
The study looked at training in reproductive health and FANC in general. Specifically looking at whether the healthcare workers were complying with WHO outlined FANC procedures, all health workers (100%) indicated being trained in reproductive health. Healthcare workers had specifically gained knowledge on FANC guidelines and principles. This is beneficial in that providers are kept up-to-date with relevant knowledge and skills for effective FANC implementation which would eventually contribute towards reduction in maternal and infant mortality. Although the country leads in the maternal death, this could be due to the other factors.
Regarding current practices on FANC, all healthcare workers (100%) in this study had indicated that they follow all recommended FANC procedures, like provision of tetanus toxoid vaccine, sufadoxine pyrimethamine, iron tablets, HIV testing and counseling and deworming of hookworms. These findings are also encouraging in that compliance with FANC guidelines is very likely to lead to good pregnancy outcomes, for instance HIV testing would help to inform appropriate measures aimed at prevention of vertical transition thus ensuring a healthy baby.
Also provision of malaria prophylaxis like Sufadoxine-Pyrimethamine helps to prevent maternal morbidity and mortality (WHO, 2002), the same with iron supplementation at recommended doses.
With respect to information provision to pregnant women, 100% of the health workers had indicated that they provide individualized health education to pregnant women. One of the reasons for failure to provide individualized health education could be related to shortage of health workers in the facilities (Yengo, 2009).
However, each and every pregnant woman is unique and individualized health education is vital to respond to specific individual pregnancy related problems or issues. High proportion (94%) of health workers indicated discussing nutrition and appropriate infant feeding practices with the pregnant women, which is critical for infant growth, development and survival (Bhutta et al. 2008).
All health workers (100%) had indicated that they provide information regarding danger signs in pregnancy to pregnant women. This is also a positive finding in that informing mothers about potential danger signs would help the pregnant women to promptly seek medical assistance if they experience some of the danger signs thereby minimizing the risk of morbidity and mortality.
Furthermore, all 100% of health care workers indicated that they inform pregnant mothers on the early detection of risks and treatment of complication as well as plans for delivery. Consequently, this adherence to FANC procedures by health workers is very likely to contribute towards meeting both national and international goals on maternal and child health. This is in line with Tita et al. (2005), who indicated that improvement in maternal and perinatal outcomes was due to effective dissemination of information on reproductive health to pregnant women.
The study explored perception of health workers on FANC in general. The study has shown high proportion (100%) of health workers in Munuki Payam with positive perception about FANC. This is in line with the report in some parts of sub-Saharan Africa. Yengo (2009) reported positive perception of nurses on FANC in Tanzania. It is well established that health workers’ perception and attitude play a significant role in FANC utilization by pregnant women (Conrad et al. 2011). Negative perception and attitude of healthcare providers towards FANC contributes to low FANC utilization and often leads to women preferring to deliver with unskilled birth attendants (Mathole et al. 2004).
All health care workers (100%) in the present study indicated that FANC training was helpful; this is an encouraging finding considering that a well trained workforce is required to implement FANC since it is a relatively new concept.
While health workers in this study had positive perception as well as training on FANC, almost 100% of them indicated that their facilities were ready to provide FANC from 8:30am to 4:30pm.
However, 95% of the health workers indicated that there are stills more obstacles and limitations which need to be addressed in order to fully implement FANC in health facilities. These findings illustrate that the workforce is ready to implement FANC, but more needs to be done to ensure facilities are equipped and ready, cultural factors like ignorance, support to women, spouse accompanying their wives should be addressed for effective FANC implementation.
Chapter Five: Conclusion and Recommendations
5.1 Conclusion
Late antenatal care attendance remains high in most areas prompting maternal death. This, therefore, indicates the need for intensified and more focused utilization of resources aimed at increasing awareness of the importance of early attendance and follow-up of ANC services for high risk groups such as women with unplanned pregnancies, inadequate knowledge about ANC, cultural beliefs and multiparity to reduce the looming country’s maternal mortality rate. Below are some hints:-
- The research approved problems such as transport money, distance from the health facilities, limited transport options, and lack of accompanying of pregnant mothers by their husbands.
- The study has shown that age group affects ANC services, as teenager and over 30 years have less ANC attendance, but it is not the case in middle-aged groups.
- Another factor that this research has found is high rate of unemployment among women compared to men. This affects ANC services because pregnant mothers do not have money to cater for ANC services.
- The findings also concluded that ignorance/inadequate awareness is a major issue as many pregnant mothers got informed by their relative to go antenatal care services. This is also evidenced by the number of visit pregnant women made during whole pregnancy period. Many of them had 1-3 visit which is below the recommended number visit (WHO). Also pregnant mothers start focused ANC before 12 weeks which indicates low knowledge of FANC.
- The research findings concluded pregnant mothers sought permissions from their spouse or any other relative before attending ANC and, as a result, obstruct regular visits due to delay or denial.
- The research findings concluded that pregnant mothers fear of attacks or robbery on their way to the health centers.
5.2 Recommendations
The study has provided information on the various aspects of late antenatal attendance in urban and rural communities. Therefore, the following recommendations, if implemented, may improve timely accessing of health services and the quality of service provided.
- Payam health administrators should increase accessibility of ANC services by proving scheduled outreach programs in remote areas.
- The Ministry of Health and Payam health practitioners need to provide continuous health education on the importance of timely accessing ANC services through the media and community sensitization meetings.
- Campaign against harmful community norms and cultural beliefs that could hinder mothers from accessing health services.
- The Ministry of Health should improve on the staffing of health care workers at all levels of service delivery.
- The Government, through Ministry of Health, should construct more health facilities to improve availability and accessibility especially in rural areas. Increase in the number of health facilities could avail more and accessibility to the pregnant mothers hence reducing the issue of distance covered in seeking antenatal care services.
- Education for girls: Government need to strengthen girl child education by formulating policy that encourage sending girls to school and focus on the areas of early drop from school. This will in fact reduce ignorance of mothers which affect the utilization of antenatal care services.
- In the study, it was found that good numbers of pregnant mothers were not working which affects ANC attendance in terms of transport money. As such provision of jobs to women by training them in skill for life like tailoring, green vegetable planting, so they can run small businesses and thus become self-reliant.
- Strengthening of family planning activities to reduce the risk to both mother and foetus. Any risk factor associated with number of deliveries can be reduced if family planning activities are improved. Study shown that 18% had more than four children who also had less ANC visit.
- Husbands need to accompany their wives for ANC services for the first visit. It important that husband should be sensitized to accompany their wives at ANC visit. This can make other follow-up visits easy for the mothers.
- Routine and reliable source of ANC information. Government and stakeholders in the health sector should establish routine and reliable sources of ANC information such radio, newspapers and integrated school curriculum. This will can increase awareness among girls in school.
- Security should be guaranteed to eliminate fear of robbery. There is need for the government to crackdown gangs and robbers who rob women’s belongings on their ways. Crackdown of such incidences can reduce fear among pregnant women.
REFERENCES
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- WHO, 2006. Provision of Focused Antenatal Care for Pregnant Women, Geneva.
- WHO, 2007. Maternal mortality in 2005: estimates developed by WHO, UNICEF, UNFPA, and the World Bank Geneva.
- The UK National Institute for Health and Clinical Excellence has evidence-based guidelines on antenatal care
- The White Ribbon Alliance for Safe Motherhood has a series of web pages and links relating to respectful maternity care in LMICs
- International Federation of Gynecology and Obstetricsis an international organization with connections to various maternity initiatives in LMICs
- International Confederation of Midwives has details of the Millennium Development Goals relating to maternity care.
The End
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