Abstract

Background and aim: The timing of first antenatal booking is still a problem in Sub-Saharan Africa making the accomplishment of WHO recommendation of eight contacts before delivery a big problem. The factors associated with late antenatal booking are multifactorial and have not been studied in our environment. This study aimed to determine the prevalence of late first antenatal visits, and the associated factors in a tertiary health institution, South-East Nigeria.

Materials and methods: It was an analytical cross-sectional study of consecutively recruited consenting one hundred and twenty pregnant women who came for booking. A self-administered, semi-structured questionnaire was used to obtain information from the study participants. Data were analysed using Stata version 16.1 statistical software. A two-sided statistical analysis was used with a p-value of <0.05 set as significant.

Results: The prevalence of the late first antenatal visits was 65.00%, the mean gestational age at booking was 17.58 ± 7.91 weeks. The main reason identified as to why the study participants booked at the time, booked was that the pregnancy has been normal (64.17%), followed by complications (17.50%). Grand multipara [aOR=1.472;95% CI (0.503, 4.309)] and those with interpregnancy interval ≥5 years [aOR=3.519;95% CI (0.378, 32.724)] had a higher likelihood of late booking.

Conclusion: The prevalence of late first antenatal visits among pregnant women is high. Grand multiparity and interpregnancy interval >5 years were identified as having higher odds for late booking. We, therefore, recommend that the public should be educated on the importance of early booking into antenatal care.

Keywords: timing; antenatal booking; associated factors.

Citation: Nnamani CP, Onwusulu DN, Offor CC, Ekwebene OC. Timing and associated factors of antenatal booking among pregnant women at a tertiary health institution in Nigeria: A cross-sectional study. J Clin Images Med Case Rep. 2022; 3(2): 1646.

Introduction

The World Health Organization (WHO) visualizes a world where “every pregnant woman and new-born receive quality care throughout pregnancy, childbirth and postnatal period” [1]. Antenatal Care (ANC) reduces maternal and perinatal morbidity and mortality both directly and indirectly [2]. About 99% of maternal death and 98% of child death which occur in middle and low income countries can be prevented if pregnant women are able to access quality ANC [2]. Since the introduction of WHO ANC model known as focused ANC in 2002, the low and middle income countries increased ANC utilization [1]. In 2016, WHO developed a new ANC model to replace the previous four visits focused ANC model with a new recommendation of a minimum of eight ANC contacts [1]. This is in order to provide the pregnant women with respectful, individualized, person-centred care at every contact, with the implementation of effective clinical practices, provision of relevant timely information, also provide psychosocial and emotional support by the practitioners with good clinical and interpersonal skills within a well-functioning health system [1].

Booking visit serves as the entry point for ANC for an index pregnancy [3]. According to WHO, early ANC refers to initiation of ANC as soon as possible after confirmation of pregnancy or within 12 weeks of gestation while late ANC is starting ANC after 12 weeks of gestation [1,4]. Early booking helps pregnant women especially those unsure of their last menstrual period to have fairly accurate dating [5]. In addition, the women benefit from certain baseline measurements and investigations such as blood pressure, body mass index, urinalysis, retroviral screening, hepatitis screening, blood group and genotype etc, these give the clinician a fair idea of the pre-pregnancy state of the client [5]. It also plays a role in detecting and treating some complications of pregnancy [4,6].

Despite the aforementioned benefits of early antenatal booking, late antenatal booking is still a problem in Sub-Saharan Africa making the accomplishment of WHO recommendation of eight contacts before delivery a big problem. The prevalence of late antenatal booking beyond Africa are variable with 41% in Australia [7], 37.5% in United Kingdom [8], 56.2% in Myanmar [9] and 28.2% in Malaysia [6]. In the African sub-region the prevalence of late ANC booking is 44.0% in Cameroon [4], 52.5% in Ethiopia [10], 62.9% in Burkina Faso [11], 70.4% in Tanzania [12], 72.0% in Zambia [13] and 88.5% in Uganda [14]. Nigeria which is one of the developing countries in West African sub-region has a high prevalence rate of late ANC booking. This ranges from 77.3%-82.6% in South-West Nigeria, [3,5] 53.3% in North-Central Nigeria [15], 73.5%-80% in South-South Nigeria [16,17] and 83.1% in South-East Nigeria [18].

The factors associated with late ANC booking are multifactorial and include pregnancy being too early, avoidance of frequent visit, poor knowledge about the right time to commence ANC, financial constraint, educational level, parity, age of the pregnant women, marital status, unplanned pregnancy, history of obstetrics complications [5,11,12,17-19].

Very few studies have been carried out in the South Eastern part of Nigeria and none in our institution hence necessitating the need for this study. The results from this study will provide information on the factors responsible for late ANC booking in this environment and the factors identified will help policy makers update existing policies. The findings will also help in public health education so as to promote a better pregnancy outcome. The aim of this study is therefore, to determine the prevalence of late first ANC visit, and the associated factors in a tertiary health institution, South- East Nigeria.

Materials and methods

Study design: It was an analytical cross-sectional study.

Study site: Nnamdi Azikiwe University Teaching Hospital, Nnewi was used.

Study population and sampling: This consisted of all consecutive, consenting pregnant women at their first antenatal visit in the institution till the calculated sample size is achieved. Convenience sampling method was adopted.

Sample size: For sample size calculation, the following assumptions was made based on previous studies: prevalence of late booking of 50%, 5% margin of error, and 95% confidence level, non-response rate of about 20%. Using Fisher’s formula, N = 𝑍2 𝑝𝑞 𝑑2 where N equals to sample size, Z is the standard normal deviate and for 95% confidence level and the value is 1.96, p is the proportion booking late, q is equal to 1-p which is 50%, d is the degree of precision or margin of error, =N = 1.962 . 5 × .5 .052 approximately 96, assuming 20% non-respondent, the final sample size = 96 1 − .20 = 120.

Inclusion and exclusion criteria: All pregnant women who came for antenatal booking at the study site and gave consent were recruited while those who refused to give consent were excluded from the study.

Study instrument and data collection: A self-administered semi structured questionnaire was developed and used to extract information from all consecutive consenting pregnant women coming for the first booking visit. A sample of about 15 questionnaires was pre-tested for the validity and reliability amongst the participants, also the people who understood the study topic read through the questionnaire to evaluate whether the questions effectively captured the study topic. Internal consistency of the questionnaire was assessed using Cronbach’s alpha; values between 0.8 to 0.9 was accepted as normal. The questionnaire included data on demography: age, gestational age, parity, level of education and occupation; the occupation and the level of education of the spouse will be included where possible. Other information included was reason for booking at the particular gestation, history of present and past pregnancies, medical and drug history. The questionnaire was self-administered for the literate client. The non-literate client was assisted by the research assistants assigned to the booking clinic to translate the questions in the questionnaire in the local language (Igbo) which was predominantly in the study location.

Ethical consideration: Approval was sought and obtained from the research and ethics committee of the Nnamdi Azikiwe University Teaching Hospital before commencement of the study. Informed consent was also be sought and obtained from all participants. Confidentiality was maintained throughout and beyond the study.

Statistical analysis

Stataversion 16.1 statistical softwarewas used for data entry and analysis. The data analysis was both descriptive and inferential. For normally distributed, categorical variables were presented as frequencies, percentages with confidence intervals. Continuous variables as mean and standard deviations. Inferential statistics using Chi-square, Fisher’s exact test was used where applicable for relating gestational age at booking to some demographic and obstetric variables. The associations were further explored using multivariate logistic regression to obtain adjusted odds ratio. A two-sided statistical analysis was used with p-value of <0.05 set as significant.

Results

Table 1 shows the socio-demographic distribution among the study participants. The mean age among the pregnant women was 29.06 ± 5.15 years with 25-29 years having the highest category (40.83%). Majority (98.33%) of the women were married and were mostly from the Catholic, Pentecostal and Anglican church denominations (50.00%, 25.83% and 23.33%) respectively, a higher proportion (42.50%) of the participants had to cover <5 km distance from their homes to the hospital facility.

Table 1: Socio-demographic distribution among the study participants.

Table 2 shows the history of present pregnancy, the mean gestational age at booking was 17.58 ± 7.91 weeks. Majority (64.17%) of the participants booked at the gestational age they booked because their pregnancy had been normal, 17.50% has had a problem since they were pregnant, 47.62% had cramps.

Table 3 shows that a higher proportion (37.80%) had 2 years as the pregnancy interval from their last delivery, 89.02% did not have any complication in their last pregnancy, 81.48% had normal baby as their previous delivery outcomes, 4.17% of the participants has history of infertility, 20.83% had miscarriage and 96.00% had the miscarriage at first three months of their pregnancy.

Table 2: History of present pregnancy.

Booking time of the study participants

The proportion of the study participants who booked late was 65.00% as shown in Table 4.

Table 3: Previous Obstetrics and Gynaecological history.

Table 4: Booking time of the study participants.

Relationship between obstetric history and booking time

There is a statistical difference in the relationship between medical history in present pregnancy and booking time. P- value; 0.055 as shown in Table 6.

Table 5: Cross-tabulation analysis showing relationship between Socio-demographic characteristics and booking time.

Table 6: Cross-tabulation analysis showing relationship between obstetric history and booking time.

Multivariate logistic regression showing the effect of sociodemographic factors and obstetric history on late booking

The logistic regression model was not significant for the covariates. However, using the adjusted odds ratio, the odds of late booking is very low for age groups >40 year (aOR=.298) compared with the younger group of <24 years; those with tertiary education had lowest odds (aOR=0.634) of late booking compared with other lower levels of education. Also, the odds are lower for the nullipara (aOR=0.846), those with problem in the index pregnancy (aOR=0.991), existing medical challenges (aOR=0.260) and distance more than 10 km from the hospital. (aOR=0.884) Grand multipara (aOR=1.72) and those with interpregnancy interval ≥5 years (aOR=3.519) have higher likelihood of late booking as shown in Table 7.

Table 7: Multivariate logistic regression showing the effect of sociodemographic factors and obstetric history on late booking.

Discussion

World Health Organization recommends that pregnant women should start ANC within 12 weeks Gestational Age (GA) [1]. In the present study, 65% of the participants booked late (ie. after 12 weeks GA while 35% booked before 12 weeks GA. This finding is similar to studies carried out in Burkina-Faso and Rwanda which reported the prevalence rates of late first booking visit to be 62.93% and 61.1% respectively [11,20]. The prevalence found in this study was higher than studies conducted in Malaysia (28.2%) [6], Wales (41%) [7], Cameroon (44%) [4], Ethiopia (52.5%), [10] and Myanmar (56.2%) [9]. The reasons for the difference could be attributed to better awareness by the study participants in these studies and also some of the studies classified late booking after 16 weeks GA unlike in the present study where 12 weeks GA was used as the cut off point for late booking [9]. However, the finding from this study was lower than rates obtained from other studies [14,19,21]. This difference could be attributed to the sociocultural factors of the study population. Also the time difference between the studies because presently there is an improvement of the awareness of antenatal care [10].

The mean gestational age at booking in the present study was 17.58 ± 7.91. Studies conducted in Ethiopia (17.7 weeks) [22] and Myanmar (18.23 weeks) [9] reported a similar result. However, a lower mean GA at booking was noted in a study conducted by Kyaw et al [23] while other studies [3,15,18,14] found a higher mean GA at booking. These variations maybe due to the differences the socioeconomic status of the study population and timing of these studies [9].

The main reason identified as to why the study participants booked at the time, they booked in the present study was that the pregnancy has been normal (64.17%), followed by complications (17.50%). This finding could be explained by the fact that most pregnant women especially those who had been pregnant in the past may not be enthusiastic to visit the hospital early to book, probably because of past experience as long as there was nothing unusual with their current pregnancy. In resource poor settings like Nigeria, one would expect that financial constraint would be the major reason why the women booked late but the findings from this study has shown the women’s understanding of the purpose of antenatal care play a major role. This finding is similar to a study conducted by Ndidi et al who in their study observed that majority (73%) of the women booked late because they did not have any serious problem [17]. Antenatal care seems viewed by most women as curative rather than preventive which is in contrast with the purpose of antenatal care which is mainly preventive [17]. Similarly, Kisuule et al in their study reported that 53.3% of the participants did not have any problem with their current pregnancy and so saw no reason to come early for antenatal care [24]. However, other studies [4,18,19] observed varied reasons such as financial constraints, long distance to the hospital, busy schedule, unaware they were pregnant, personal wishes as the reasons for late booking.

In the current study a multivariate logistic regression was performed to ascertain the effects of the various sociodemographic, obstetrics/gynaecological, and medical factors on the likelihood that participants booked late. The logistic regression model was not significant for the covariates a. However, it is noteworthy that using the adjusted odds ratio, that the odds of late booking was very low for age groups >40 year (aOR=.298) compared with the younger group of <24 years; those with tertiary education had lowest odds (aOR=0.634) of late booking compared with other lower levels of education. In the same vein, the odds were lower for the nullipara (aOR=0.846), those with problem in the index pregnancy (aOR=0.991), existing medical challenges (aOR=0.260) and distance more than 10 km from the hospital (aOR=0.884). Grand multipara (aOR=1.472) and those with interpregnancy interval ≥5 years (aOR=3.519) had higher likelihood of late booking. Similarly, Jice et al in their study reported that pregnant mothers with no past medical history of medical illness (95% CI=1.26, 6.59) were 2.88 times more likely to book their pregnancy late than those with a history of medical illness. Pregnant mothers without a history of pregnancy complications (95% CI = 1.09, 4.99) were 2.34 times more likely to delay their antenatal booking, compared to those with a history of complications during pregnancy [6]. However, Tolefac et al in their study observed that the odds of starting ANC late were about 2 times higher if the participant live greater than 10 km from the hospital [4]. This variation may probably be attributed to the fact that the study was conducted in a rural community where assess to the hospital may be cumbersome due to bad road and poor transportation system, in the rural community. Limitation of the study is that the study is a hospital-based cross-sectional study whose findings are not generalized to the general population.

Conclusion

From the present study, the prevalence of late antenatal booking among pregnant women is high. Grand multiparity and interpregnancy interval >5 years were identified as having higher odds for late booking. We therefore recommend that the public should be educated on the importance of early booking into antenatal care. Also, women should be counselled during their routine postnatal visit on the need to book early in their subsequent pregnancy, if they wish to conceive again.

References

1. World Health Organization (WHO). WHO recommedation on antenatal care for a positive pregancy experience. WHO. 2016; 172.
2. World Health Organization (WHO). WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience : Summary Highlights and Key Messages from the World Health Organization ’ s 2016 Global Recommendations for Routine Antenatal Care. Geneva, Switzerland, 2018.
3. Aduloju OP, Akintayo AA, Ade-ojo IP, Awoleke JO, Aduloju T, Ogundare OR. Gestational age at initiation of antenatal care in a tertiary hospital, Southwestern Nigeria. Niger J Clin Pr. 2016; 19: 772–777.
4. Tolefac PN, Halle-ekane GE, Agbor VN, Sama CB, Ngwasiri C, Tebeu PM. Why do pregnant women present late for their first antenatal care consultation in Cameroon ? Materal Heal Neonatol Perinatol. 2017; 3: 1–6.
5. Adekanle D, Isawumi A. Late Antenatal Care Booking And Its Predictors Among Pregnant Women In South Western Nigeria. Online J Heal Allied Scs. 2008; 7: 4.
6. Jice SF, Safii R, Hazmi H. Late Antenatal Booking and its Predictors in Lundu District of Sarawak. Malaysia. Int J Public Heal Res. 2018; 8: 956–964.
7. Thuy L, Trinh T, Rubin G. Late entry to antenatal care in New South Wales. Australia. Reprod Health. 2006; 3: 1–8.
8. Cresswell JA, Yu G, Hatherall B, Morris J, Jamal F, Harden A et al. Predictors of the timing of initiation of antenatal care in an ethnically diverse urban cohort in the UK. BMC Pregnancy Childbirth. 2013; 13: 103.
9. Aung TZ, Oo WM, Khaing W, Lwin N, Dar HT. Late initiation of antenatal care and its determinants : A hospital based crosssectional study. Int J Community Med Public Heal. 2016; 3: 900– 905.
10. Wolde HF, Tsegaye AT, Sisay MM. Late initiation of antenatal care and associated factors among pregnant women in Addis Zemen primary hospital, South Gondar, Ethiopia. Reprod Health. 2019; 16: 1–8.
11. Some A, Baguiya A, Coulibaly A, Bagnoa V. Prevalence and Factors Associated with Late First Antenatal Care Visit in Kaya Health District, Burkina Faso. Afr J Reprod Health. 2020; 24: 19–26.
12. Njiku F, Wella HL, Sariah A, Protas J. Prevalence and factors associated with late antenatal care visit among pregnant women in Lushoto, Tanzania. Tanzan J Health Res. 2017; 19: 1–6.
13. Banda I, Michelo C, Hazemba A. Factors Associated with late Antenatal Care Attendance in Selected Rural and Urban Communities of the Copperbelt Province of Zambia. Med J Zambia. 2012; 39: 29–36.
14. Turyasiima M, Tugume R, Openy A, Ahairwomugisha E, Opio R, Ntunguka M et al. Determinants of first antenatal care visit by pregnant women at community based education, research and service sites in Northern Uganda. East Afr Med J. 2015; 91: 317–322.
15. Ifenne DI, Utoo BT. Gestational age at booking for antenatal care in a tertiary health facility in north ‑ central , Nigeria. Niger J Paediatr. 2012; 53: 236–239.
16. Awoyesuku PA, Macpepple DA, Kwosah NJ. Pattern and Sociodemographic Determinants of Gestational Age at Antenatal Booking at the Rivers State University Teaching Hospital , Nigeria : A Two- Year Review. Asian J Pregnancy Childbirth. 2019; 2: 1–8.
17. Ndidi EP, Oseremen IG. Reasons given by pregnant women for late initiation of antenatal care in the Niger Delta, Nigeria. Ghana Med J. 2010; 44: 47–51.
18. Onoh R, Umeora O, Agwu U, Ezegwui H, Ezeonu P, Onyebuchi A, et al. Pattern and Determinants of Antenatal Booking at Abakaliki Southeast Nigeria. Ann Med Health Sci Res. 2012; 2: 169–175.
19. Chewe MM, Muleya MC, Maimoboiwa M. Factors associated with late antenatal care booking among pregnant women in Ndola District , Zambia. Afr J Midwifery Womens Health. 2016; 10: 169–178.
20. Manzi A, Munyaneza F, Mujawase F, Banamwana L, Sayinzoga F, Thomson DR, et al. Assessing predictors of delayed antenatal care visits in Rwanda: A secondary analysis of Rwanda demographic and health survey 2010. BMC Pregnancy Childbirth. 2014; 14: 1–8.
21. Ejeta E, Dabsu R, Zewdie O, Merdassa E. Factors determining late antenatal care booking and the content of care among pregnant mother attending antenatal care services in East Wollega administrative zone, West Ethiopia. Pan Afr Med J. 2017; 27: 184.
22. Gudayu TW, Woldeyohannes SM, Abdo AA. Timing and factors associated with first antenatal care booking among pregnant mothers in Gondar Town; North West Ethiopia. BMC Pregnancy Childbirth. 2014; 14: 1–7.
23. Kyaw O, Saw S, Mon M, Yin Thet Nu O, Maung T, Myint S, et al. Challenges faced by skilled birth attendants in providing antenatal and intrapartum care in selected rural areas of Myanmar. apps.who.int. 2012; 1: 467–476.
24. Kisuule I, Kaye DK, Najjuka F, Ssematimba SK, Arinda A, Nakitende G, et al. Timing and reasons for coming late for the first antenatal care visit by pregnant women at Mulago hospital, Kampala Uganda. BMC Pregnancy Childbirth. 2013; 13: 121.