Removing user fees and providing knowledge can improve utilization of FANC services, findings from a cross-sectional study in rural Kenya

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It requires that a woman seeks medical care at least four times in the course of her pregnancy if there are no complications. However, in the low income settings, women are not able to attend ANC early and for all the schedules because of the costs involved including medical fees. In 2017, Kenya included antenatal care in the package of free maternal services provided by the government. We aimed to examine the uptake of free antenatal care (FANC) services by women in a rural community. Methods A cross-sectional design employing mixed methods was conducted among 400 pregnant women who attended antenatal services in eight health facilities in Siaya sub-county following the introduction of FANC in these facilities. The women were interviewed on services received the timing of these antenatal visits, the number of visits in the course of the pregnancy and the challenges to attending antenatal services. Participants’ characteristics were described using means and proportions. Uptake of FANC defined by the number of women who sought FANC, the timing of the visits and how frequently they attended was described using percentages/frequencies. Log-binomial regression model was used to identify socio-demographic factors associated with uptake of FANC among the women. In this analysis, attendance to ANC four times or more was the outcome variable. Results Our findings showed an increase in the uptake of FANC compared to published rates of uptake. Overall, 76.4% (n=400) of the women reported attending ANC four times or more. Over half (61.7%), of the women had their first ANC visit in the second and third trimester. Women who were not married were 1.5 times (PR=1.50; CI=1.16-1.93) more likely to complete 4+ FANC visits when compared to women who were married. Women who attended ANC for the first time in their second and third trimester were 41% (PR=0.59; CI=0.49-0.72) and 90% (PR=0.10; CI=0.03-0.37) respectively, less likely to complete the 4+ FANC visits, when compared to those who started ANC in the first trimester. Conclusion The findings indicate that when women do not have to pay for antenatal services, their attendance and compliance to the scheduled visits improves. Therefore, strategies aimed at optimizing maternal pregnancy outcomes should also invest in providing free maternal services. Other implications of the study are discussed. antenatal care free maternity services maternal services utilization ANC attendance Figures Figure 1 Figure 2 Background Sub-Saharan Africa (SSA) accounts for the largest global maternal deaths at 66%[ 1 ]. Maternal deaths result from obstetric haemorrhage, non-obstetric complications, hypertensive disorders of pregnancy and pregnancy-related infections[ 2 ]. The World Health Organization (WHO) has developed strategies to fight preventable maternal deaths that include addressing the access and quality of sexual, reproductive, maternal and new-born health care services[ 3 ]. In its guidelines for maternal health, the WHO recommends the promotion, prevention and protection of maternal and perinatal health through antenatal care, particularly, focused antenatal care (FANC)[ 4 ]. This provision enables health systems to constantly monitor a pregnant woman in a deliberate effort to address health challenges associated with pregnancy. Antenatal care (ANC) provides an opportunity to incorporate interventions that may strengthen maternal, neonatal and child health through delivery of essential interventions in the course of antenatal visits. Research has shown that ANC has the potential to promote skilled birth attendance, postnatal attendance and have a positive effect on neonatal mortality and neonatal health outcomes [ 5 ], [ 6 ]. ANC coverage has increased by 43.3% globally between 1990–2013[ 7 ] but marked disparity exists between the global north and south. Estimated coverage of ANC and early ANC care visits both stood at 81% in developed countries compared to 48% ANC coverage and 24% early ANC care visits in SSA. Moreover, majority of women in developed countries have their first ANC visit in their first trimester of pregnancy whilst most of their SSA counterparts start antenatal care in the second and third trimesters[ 7 ]. There is potential to improve the coverage and utilization of ANC services in the SSA region by giving special focus to rural, poor and uneducated women so as to reduce physical barriers, creating demand for services through public information system improving the quality of services in order to meet the potential demand, according to research from Ethiopia, Nigeria and Seirra Leone[ 8 ]–[ 11 ]. Utilization of antenatal services in SSA has been linked to various factors affecting the demand and supply sides. Studies in Ethiopia [ 12 ] and Nigeria[ 13 ] have reported financial constraints in paying for transport costs to the health facility, and paying for services at the facility as key barriers to utilisation of ANC services. Particular to Kenya, direct and indirect costs to accessing healthcare have been reported as the main barriers to the access and utilization of ANC[ 14 ]. Pell et al.[ 14 ] found different charges across health facilities required from pregnant women in order to access ANC care. Charges were levied for the ANC card and laboratory tests. Transport costs to health facilities is a barrier especially to women of low income status[ 15 ]. Equally important are other individual factors such as age, the level of education, marital status, household income, higher parity, having a history of obstetric complications, religion, ethnicity and cultural beliefs that limit women from attendance to antenatal services[ 16 ]–[ 18 ]. In Kenya, achievements have been noted towards ensuring better access to maternal services by women. First, a presidential directive on June 1, 2013 saw the abolishment of delivery costs in public health facilities with the aim of promoting utilization of maternal services in the health facilities and reducing maternal mortalities[ 19 ]. Later in October 2016, the government launched the Linda Mama Program which expanded the free maternal services for women to include antenatal and postnatal care. Evidence generated immediately following the introduction of free maternal services for the period ending in 2014 showed improvements in skilled birth attendance from 44% in the previous period to 62% and in one time antenatal visits from 92–96%. When assessed for their attendance to focused antenatal care after the introduction of free maternal services, this was minimal with 58% of women being found to be adherent up from 47%, contrywide [ 20 ]. The improvements to one-time attendance of ANC [ 21 ], [ 22 ] show the potential to achieve the recommended 4 + FANC visits if the barriers and limitations in the access and utilization of the services are addressed. Evidence available after the introduction of free maternal services in Kenya shows that the implementation of the policy leaned more towards free skilled deliveries more than all other maternal services[ 23 ]. There was inadequate preparedness on the part of health facilities to manage the growing demands for services resulting in challenges with optimal service provision on the part of health facilities[ 24 ]. In order to have a positive impact on the maternal and neonatal mortality as defined by the Sustainable Development Goal 3, it is imperative to establish the levels of uptake of FANC and factors prohibiting use of these antenatal services following the removal of the user fees. Additionally, little is known about the constraints/challenges by health facilities in delivering free antenatal services. This study assessed the uptake of antenatal care services and the factors affecting the use and provision of these services since the provision of the FMP, in a rural setting. Methods Study design and setting This was a mixed methods cross sectional study that was nested in a larger study that examined the feasibility and effectiveness of a health facility-based combined with home-based early childhood development (ECD) intervention in Bondo sub-County, Siaya County, Kenya (ref for the protocol). Pregnant women participating in the main study were recruited in this sub-study that focused on the uptake of free ANC services in the government health facilities. Bondo is a rural community located in the Western part of Kenya, and is noted to have high high infant and maternal mortality rates at 60/1000 live births and 488/100000 respectively against national rates of 52 /1000 and 363/100000 respectively[25]–[27]. Bondo sub-County is in Siaya County on the Western part Kenya. Women of reproductive age is represent about 23% of the population and the fertility rate is at 4.2, slightly higher than the national rate of 3.9[25]. Bondo sub-County is served by 31 public health facilities and 189 health workers. The sub-County has 29 functional community health units, which serve as the basic health care unit through Community Health Volunteers (CHVs) at community level[28]. Bondo therefore represents a typical rural setting in Kenya. Sampling and sampling procedure The study was conducted among women who delivered in a public health facility within six months, as at the time of the interview. The women were selected from maternity wards and postnatal clinics. The sample size was determined using Fishers method[29] Where: z represents 1.96 value of confidence level at 95% p the know prevalence (attendance) of 4+ ANC of 58%[20] d is the absolute precision (margin of error) at 5% and Standard normal deviation set at 95% confidence level. Based on this, the required sample size was determined to be 400 women. Fifty women were recruited from eight health facilities on a first come basis until the numbers were sufficient. The eight facilities that were selected for this study were primary health care facilities of level 2, 3, and 4 thar reported more than 300 live births per year in Bondo sub-County. Data collection Data collection was done between September 2018 and February 2019. Interviewer-administered questionnaires were used to collect information on their experiences during their ANC attendance and services they received, timing and reasons for the timing of their first antenatal visit, as well as the challenges experienced with accessing and utilization of the ANC services. This information was collected from the women retrospectively from women who had just delivered a child and had confirmed use of antenatal services during pregnancy. Measurements The questionnaire was designed to collect information on attendance of antenatal care as the dependent (outcome) variable. Independent variables which were age, marital status, level of education, employment status, gestational age, services received during ANC and challenges involved in attendance to ANC. For the dependent variable, indicators of good FANC attendance were at least 4 visits and having the first visit during the first trimester. Data analysis Data was cleaned and analysis was done using STATA Version 15. Data were described using means, and percentages and frequencies for continuous and categorical variables respectively. We examined for factors associated with ANC attendance and gestation at first visit (primary outcomes) first using bivariate regressions, followed by multivariable regression analysis including maternal age, education level, marital status, employment status, travel time to health facility, and whether a caregiver encountered challenges during ANC visits. For all the analyses, a 95% confidence interval and p-value significance level of 0.005 were used. Results Participant characteristics The respondents age ranged between 16 to 43 years. Majority of the respondents were aged between 20–30 years (61.5%) while only 6% were above the age of 35 years. Majority of the women (85.4%) were married. Majority of the respondents, 65.8% had primary school education and only 12% had completed secondary level of education. Over half of the respondents (60.2%) were unemployed and almost half of the respondents, 43% lived on a household income of less than KES 10000 per month as indicated in Table 1 . Table 1 Participants’ characteristics (N = 400) Variable Category Frequency n (%) Age-group 35 years 25 (6.3) Highest education level attained No formal education 6 (1.5) Primary education 257 (64.3) Secondary education 116 (29) Above Secondary 17 (4.3) Not comfortable answering 4 (1.0) Marital status Currently married/living together 340 (85.0) Single (never married) 60 (15.1) Main occupation Unemployed 266 (66.5) Employed/self-employed/informally employed 134 (33.5) Religion Christian 395 (98.8) Non- Christian 5 (1.2) Household monthly income Less than Ksh.10,000 167 (41.8) More than Ksh.10,000 105 (26.4) Don't know/Not comfortable answering 128 (32.0) Number of ANC visits during last pregnancy Less than four times 95 (23.8) Four times and above 305 (76.2) Where ANC services were offered Health facility 397 (99.2) Traditional birth attendant 3 (0.8) Gestational age at first ANC visit Trimester I 154 (38.5) Trimester II 228 (57.0) Trimester III 18 (4.5) Mean SD Age (years) 26.4 5.7 Anc Attendance And Timing More than two thirds of the respondents (76.2%) had attended four or more antenatal care visits. Most women (61.5%) had their first ANC visit during or after the second trimester as shown in Table 2 . Table 2 Frequency of and gestational age at first ANC visit during last pregnancy (n = 400) Variable Category n (%) Number of times caregiver received ANC during last pregnancy Less than four times 95 (23.8) Four times and above 305 (76.2) Place caregiver sought ANC services Health facility 397 (99.2) Traditional birth attendant 3 (0.8) Gestational age at first ANC visit Trimester I 154 (38.5) Trimester II 228 (57.0) Trimester III 18 (4.5) Factors Associated With Anc Attendance The lack of information regarding benefits of ANC and where to get the service was reported by 54.1% of the participants as the main reason for delaying ANC attendance in the first trimester. Other important factors included the lack of time to seek health services and long distance to the health facility. Figure 1 summarises determinants for ANC attendance in the first trimester. Indicators for quality of service delivery at the health facility were biggest barriers to access and utilization of ANC services. Excessive waiting time (47.4%), long distance to the health facility (26.3%) and lack of prescribed tests and drugs (15.8) were the main facility dependent challenges associated with the ANC services. Other factors are shown in Fig. 2 . Factors Associated With Utilization Of Fanc Age, education level and employment status did not have an effect on the attendance to 4 + FANC services. Marital status, gestational age when first ANC was attended and presence of challenges during attendance were seen to have an effect. In the case of marital status, women who were not currently married were found to be 50% times more likely (1.16-1.9395% CI) to have 4 + FANC attendance compared to women who were married, adjusting all other variables in the model. Gestational timing of first ANC was significantly associated with frequency of attendance as in Table 2 . Women who attended ANC in their second trimester were 41% (0.49–0.72 CI) times less likely to achieve intended 4 + FANC while those beginning in the third trimester 90% (0.03-0.37CI) times less likely to complete FANC visits when compared to those who started ANC in the first trimester of their pregnancy. As presented in Table 3, there was a significant association between attendance in the first trimester of pregnancy and frequency of attendance. Those who had more than four visits to FANC were 7.78 (3.16–19.15 CI) times likely to begin attendance within the first trimester. Experience with challenges while attending ANC also had a predictive effect on attendance of FANC. Those who did not encounter challenges were 46% (0.41–0.71) more likely to have 4 + FANC attendance compared to those who did faced challenges when attending ANC. Table 3: Factors associated with FANC utilization Outcome= (Attendance of at least 4 times (1) vs less than 4 times (0)) Bivariate Analysis Multivariate Analysis Predictors Attended ≥ 4 ANC visits (N = 305) n(%) Crude Prevalence Ratio (PR) 95% CI P-value Adjusted Prevalence Ratio (PR) 95% CI P-value Age of caregiver (years) 1.00 (0.99–1.01) 0.686 1.01 (1.00-1.03) 0.190 Education level of caregiver No formal Education 3 1.00 1.00 Primary 192 (62.9) 1.47 (0.61–3.55) 0.391 1.03 (0.42–2.53) 0.954 Secondary 97 (31.8) 1.67 (0.67–4.20) 0.273 1.05 (0.42–2.62) 0.914 Above Secondary 13 (4.3) 1.53 (0.56–4.15) 0.404 0.39 (0.03–4.57) 0.452 Marital status Currently married/cohabiting 257 (84.3) 1.00 1.00 Not currently married 48 (15.7) 1.06 (0.88–1.28) 0.557 1.50 (1.16–1.93) 0.002 Employment status Self-employed/informal 93 (30.5) 1.00 1.00 Employed-salaried/formal 11 (3.6) 1.20 (1.00-1.45) 0.053 4.69 (0.48–46.19) 0.186 Unemployed 201 (65.9) 0.99 (0.90–1.10) 0.863 1.13 (0.97–1.31) 0.106 Gestational age at first ANC visit Trimester I 148 (48.5) 1.00 1.00 Trimester II 155 (50.8) 0.71 (0.62–0.80) < 0.001 0.59 (0.49–0.72) < 0.001 Trimester III 2 (0.7) 0.12 (0.03–0.39) 0.001 0.10 (0.03–0.37) 0.001 Travel time to health facility 30 min 143 (46.9) 1.07 (0.94–1.22) 0.320 1.05 (0.96–1.15) 0.277 Encountered challenges during ANC visits Yes 16 (5.2) 1.00 1.00 No 289 (94.8) 0.90 (0.74–1.10) 0.310 0.54 (0.41–0.71) < 0.001 Discussion This study set out to establish the factors affecting attendance to FANC and the factors affecting optimal use of the service in a rural setting. Our findings show that there was increased uptake of antenatal services after the introduction of free maternal services in the country when compared to attendance indicators documented before this study. Our results further show that most women came for their first ANC visit during the second trimester of the pregnancy primarily due to lack of information as reported by the women. Through this study we realize that women are still under-informed or lack knowledge on their medical care requirements during pregnancy. We also found that when women faced challenges in attending care such as too much waiting time at the facility and the lack of prescribed tests and drugs, this dissuaded their attendance. Our multivariate analysis shows that single women are more likely to adhere to four antenatal visits. These women were found to engage with antenatal care at an early gestational age. Our findings resonate with previous studies that provide evidence to the fact that user fees is a main barrier for women in the access of maternal services, removing the cost to services enables the uptake and adherence to antenatal services as required. Our study is consistent with findings in Ethiopia[ 30 ], [ 31 ] and in rural Ghana[ 32 ] that observe health facility inadequacies with staffing, medicines, supplies and appropriate equipment discourages the utilization of antenatal care. Evidence from Zambia[ 33 ] shows that married women experience challenges in attending maternal services because of the demands of domestic work and childcare needs of their other children. Strengths And Limitation To the best of our knowledge, this is among the first studies that has delved into studying the utilization of FANC in a cost-free environment in Kenya. This study provides evidence as to the barriers that still need to be addressed so that women can benefit focused antenatal care as required. Our major limitation was the cross-sectional study design that limits our capacity to make definite attribution. This study was also done in a rural sub-county and therefore may be difficult to generalize for a different context. We also note that much of our data was self-reported retrospectively and could be limited by recall bias. Conclusion This study shows that the directive by government to remove user fees enabled more women to access antenatal care. In order to achieve timely and optimal utilization of services as prescribed by WHO, community members must be educated on the importance of seeking care early from the first trimester of pregnancy. Health facilities should be equipped with sufficient health workers and the required medicines and equipment in order to provide efficient and effective service that do not discourage the users of the services from engaging as required. Declarations Ethical considerations In line with Helsinki declarations, this study was reviewed and approved by the Kenya Medical Research Institution Scientific Ethics Review Unit (KEMRI-SERU) and was permitted to carry out the study. Approval reference KEMRI/SERU/CPHR/005/3698. Informed, voluntary written consent was obtained from each participants prior to collecting the data. For participants who could not read or write, consent was obtained using a thumb print in presence of a witness. The research team collecting this data was trained on protection of human research participants and we ensured compliance with ethical standards of research by counterchecking that the participants understood what the data was for and how it was going to be used and stored. Participant identity was anonymized to protect their confidentiality. Consent for publication The authors wish to declare their full approval of this material for publication by the journal. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests There are no competing interests to this manuscript. Funding This study was conducted as part of the MSc program for the lead author, who was privately sponsored. The larger study in which the project was nested was supported by PATH and the ELMA Foundation through funding awarded to APHRC. Author contribution: EW, designed the study, undertook data collection, analysis, drafted the manuscript, reviewed and approved the manuscript for submission. EE and AM guided the study design and data collection and analysis and reviewed the manuscript as academic supervisors to EW. FMW and NKL analyzed and gave guidance to the manuscript. Acknowledgements I thank the African Population and Health Research Center (APHRC) for their support through the study “ Evaluation of the feasibility and effectiveness of a health facility-based combined with home-based early childhood development (ECD) intervention in Siaya County, Kenya” . It is through this support that this study was able to collect data. I also acknowledge Jomo Kenyatta University of Agriculture and Technology (JKUAT) who are the university through which l undertake my studies in Masters of Public Health in conjunction with the Institute of Tropical Medicine and Infectious Diseases (ITROMID). 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Gebresilassie, “Timing of first antenatal care attendance and associated factors among pregnant women in public health institutions of Axum town, Tigray, Ethiopia, 2017: A mixed design study,” BMC Pregnancy Childbirth, vol. 19, no. 1, p. 340, Sep. 2019, doi: 10.1186/s12884-019-2490-5 . Y. Alemu and A. Aragaw, “Early initiations of first antenatal care visit and associated factor among mothers who gave birth in the last six months preceding birth in Bahir Dar Zuria Woreda North West Ethiopia,” Reprod. Health , vol. 15, no. 1, p. 203, Dec. 2018, doi: 10.1186/s12978-018-0646-9 . U. Haruna, G. Dandeebo, and S. Z. Galaa, “Improving Access and Utilization of Maternal Healthcare Services through Focused Antenatal Care in Rural Ghana: A Qualitative Study,” Adv. Public Heal. , vol. 2019, pp. 1–11, Jul. 2019, doi: 10.1155/2019/9181758 . C. M. Chama-Chiliba and S. F. Koch, “Utilization of focused antenatal care in Zambia: examining individual- and community-level factors using a multilevel analysis,” Health Policy Plan. , vol. 30, no. 1, pp. 78–87, Feb. 2015, doi: 10.1093/heapol/czt099 . Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-1148529","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":94680464,"identity":"29924484-1a6c-4a5a-8406-3bad1bfc154b","order_by":0,"name":"Elizabeth Wambui","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA0ElEQVRIiWNgGAWjYNACgwQefgYGNhK1SDaQpoUhgcHgALFa+MXOGH4uKEiTMT5+9tjjihoGOfP+Bfi1SM7OMZaeYZDDY3YmL93wzDEGY5kbD/BrMbidu0Gax6CCx+xAjplkYwND4gyJA/i12N/O3fwbpMW4/w2RWgykc7cBbcnhMZCA2cLfgF+LxO38b9Y8Bmk8EjfepUk2HJMwlpDAr4OBf3Za8m2eP8n2/P25xyQbamzkJPgJOAwJ8IBtBaIE0rSALCbellEwCkbBKBgZAADlazv5pvT2nwAAAABJRU5ErkJggg==","orcid":"","institution":"African Population and Health Research Centre (APHRC)","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Elizabeth","middleName":"","lastName":"Wambui","suffix":""},{"id":94680465,"identity":"99e2eb98-383d-420d-b0fb-735ed5d10339","order_by":1,"name":"Elizabeth Echoka","email":"","orcid":"","institution":"Kenya Medical Research Institute","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Elizabeth","middleName":"","lastName":"Echoka","suffix":""},{"id":94680466,"identity":"80913f0a-b11d-48b4-8d7f-22f41a4ba813","order_by":2,"name":"Frederick Murunga Wekesa","email":"","orcid":"","institution":"African Population and Health Research Centre (APHRC)","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Frederick","middleName":"Murunga","lastName":"Wekesa","suffix":""},{"id":94680467,"identity":"61bc94cb-df4b-451b-85d3-ddc53802b4fd","order_by":3,"name":"Nelson Langat","email":"","orcid":"","institution":"African Population and Health Research Centre (APHRC)","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Nelson","middleName":"","lastName":"Langat","suffix":""},{"id":94680468,"identity":"5eb9b896-33b2-4aaa-bfac-de6999040077","order_by":4,"name":"Anselimo Makokha","email":"","orcid":"","institution":"Jomo Kenyatta University of Agriculture and Technology","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Anselimo","middleName":"","lastName":"Makokha","suffix":""}],"badges":[],"createdAt":"2021-12-07 10:29:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-1148529/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-1148529/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":19835485,"identity":"7c651b86-9d2b-49b7-a6ec-90fa9606b7ef","added_by":"auto","created_at":"2022-03-31 18:51:52","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":124068,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eReasons for not attending ANC during the first three months of pregnancy\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-1148529/v1/1bbb74015a6a90d9120c2b43.png"},{"id":19835486,"identity":"756f9418-a8f2-45e7-a50c-a097cc2398e2","added_by":"auto","created_at":"2022-03-31 18:51:53","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":132467,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cem\u003eChallenges encountered when attending the ANC services at the facility\u003c/em\u003e\u003c/p\u003e","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-1148529/v1/d9a7491bc08cdec409d78c83.png"},{"id":24393743,"identity":"754ed0ba-d5ce-4509-8c52-e3350e63e39a","added_by":"auto","created_at":"2022-07-27 10:44:20","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":674605,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-1148529/v1/0d632ceb-4c9a-4c93-b99a-9f565f87fbec.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Removing user fees and providing knowledge can improve utilization of FANC services, findings from a cross-sectional study in rural Kenya","fulltext":[{"header":"Background","content":"\u003cp\u003eSub-Saharan Africa (SSA) accounts for the largest global maternal deaths at 66%[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Maternal deaths result from obstetric haemorrhage, non-obstetric complications, hypertensive disorders of pregnancy and pregnancy-related infections[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe World Health Organization (WHO) has developed strategies to fight preventable maternal deaths that include addressing the access and quality of sexual, reproductive, maternal and new-born health care services[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. In its guidelines for maternal health, the WHO recommends the promotion, prevention and protection of maternal and perinatal health through antenatal care, particularly, focused antenatal care (FANC)[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. This provision enables health systems to constantly monitor a pregnant woman in a deliberate effort to address health challenges associated with pregnancy. Antenatal care (ANC) provides an opportunity to incorporate interventions that may strengthen maternal, neonatal and child health through delivery of essential interventions in the course of antenatal visits. Research has shown that ANC has the potential to promote skilled birth attendance, postnatal attendance and have a positive effect on neonatal mortality and neonatal health outcomes [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e], [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eANC coverage has increased by 43.3% globally between 1990\u0026ndash;2013[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e] but marked disparity exists between the global north and south. Estimated coverage of ANC and early ANC care visits both stood at 81% in developed countries compared to 48% ANC coverage and 24% early ANC care visits in SSA. Moreover, majority of women in developed countries have their first ANC visit in their first trimester of pregnancy whilst most of their SSA counterparts start antenatal care in the second and third trimesters[\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThere is potential to improve the coverage and utilization of ANC services in the SSA region by giving special focus to rural, poor and uneducated women so as to reduce physical barriers, creating demand for services through public information system improving the quality of services in order to meet the potential demand, according to research from Ethiopia, Nigeria and Seirra Leone[\u003cspan additionalcitationids=\"CR9 CR10\" citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]\u0026ndash;[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eUtilization of antenatal services in SSA has been linked to various factors affecting the demand and supply sides. Studies in Ethiopia [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e] and Nigeria[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e] have reported financial constraints in paying for transport costs to the health facility, and paying for services at the facility as key barriers to utilisation of ANC services. Particular to Kenya, direct and indirect costs to accessing healthcare have been reported as the main barriers to the access and utilization of ANC[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Pell et al.[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e] found different charges across health facilities required from pregnant women in order to access ANC care. Charges were levied for the ANC card and laboratory tests. Transport costs to health facilities is a barrier especially to women of low income status[\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Equally important are other individual factors such as age, the level of education, marital status, household income, higher parity, having a history of obstetric complications, religion, ethnicity and cultural beliefs that limit women from attendance to antenatal services[\u003cspan additionalcitationids=\"CR17\" citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]\u0026ndash;[\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn Kenya, achievements have been noted towards ensuring better access to maternal services by women. First, a presidential directive on June 1, 2013 saw the abolishment of delivery costs in public health facilities with the aim of promoting utilization of maternal services in the health facilities and reducing maternal mortalities[\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Later in October 2016, the government launched the \u003cem\u003eLinda Mama Program\u003c/em\u003e which expanded the free maternal services for women to include antenatal and postnatal care. Evidence generated immediately following the introduction of free maternal services for the period ending in 2014 showed improvements in skilled birth attendance from 44% in the previous period to 62% and in one time antenatal visits from 92\u0026ndash;96%. When assessed for their attendance to focused antenatal care after the introduction of free maternal services, this was minimal with 58% of women being found to be adherent up from 47%, contrywide [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe improvements to one-time attendance of ANC [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e], [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e] show the potential to achieve the recommended 4\u0026thinsp;+\u0026thinsp;FANC visits if the barriers and limitations in the access and utilization of the services are addressed. Evidence available after the introduction of free maternal services in Kenya shows that the implementation of the policy leaned more towards free skilled deliveries more than all other maternal services[\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. There was inadequate preparedness on the part of health facilities to manage the growing demands for services resulting in challenges with optimal service provision on the part of health facilities[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn order to have a positive impact on the maternal and neonatal mortality as defined by the Sustainable Development Goal 3, it is imperative to establish the levels of uptake of FANC and factors prohibiting use of these antenatal services following the removal of the user fees. Additionally, little is known about the constraints/challenges by health facilities in delivering free antenatal services.\u003c/p\u003e \u003cp\u003eThis study assessed the uptake of antenatal care services and the factors affecting the use and provision of these services since the provision of the FMP, in a rural setting.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cstrong\u003eStudy design and setting\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis was a mixed methods cross sectional study that was nested in a larger study that examined the feasibility and effectiveness of a health facility-based combined with home-based early childhood development (ECD) intervention in Bondo sub-County, Siaya County, Kenya (ref for the protocol). Pregnant women participating in the main study were recruited in this sub-study that focused on the uptake of free ANC services in the government health facilities.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBondo is a rural community located in the Western part of Kenya, and is noted to have high high infant and maternal mortality rates at 60/1000 live births and 488/100000 respectively against national rates of 52 /1000 and 363/100000 respectively[25]\u0026ndash;[27]. Bondo sub-County is in Siaya County on the Western part Kenya. Women of reproductive age is represent about 23% of the population and the fertility rate is at 4.2, slightly higher than the national rate of 3.9[25]. Bondo sub-County is served by 31 public health facilities and 189 health workers. The sub-County has 29 functional community health units, which serve as the basic health care unit through Community Health Volunteers (CHVs) at community level[28]. \u0026nbsp;Bondo therefore represents a typical rural setting in Kenya.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSampling and sampling procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was conducted among women who delivered in a public health facility within six months, as at the time of the interview. The women were selected from maternity wards and postnatal clinics.\u003c/p\u003e\n\u003cp\u003eThe sample size was determined \u0026nbsp;using Fishers method[29]\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cimg 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represents 1.96 value of confidence level at 95%\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ep\u003c/em\u003e the know prevalence (attendance) of 4+ ANC of 58%[20] \u0026nbsp;\u003c/p\u003e\n\u003cp\u003ed\u0026nbsp;is the absolute precision (margin of error) at 5% and\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eStandard normal deviation set at 95% confidence level.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBased on this, the required sample size was determined to be\u0026nbsp;400 women. Fifty women were recruited from eight health facilities on a first come basis until the numbers were sufficient. The eight facilities that were selected for this study were primary health care facilities of level 2, 3, and 4 thar reported more than 300 live births per year in Bondo sub-County.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData collection\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData collection was done between September 2018 and February 2019. Interviewer-administered questionnaires were used to collect information\u0026nbsp;on their experiences during their ANC attendance and services they received, timing and reasons for the timing of their first antenatal visit, as well as the challenges experienced with accessing and utilization of the ANC services. This information was collected from the women retrospectively from women who had just delivered a child and had confirmed use of antenatal services during pregnancy.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMeasurements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe questionnaire was designed to collect information on attendance of antenatal care as the dependent (outcome) variable. Independent variables which were age, marital status, level of education, employment status, gestational age, services received during ANC and challenges involved in attendance to ANC. For the dependent variable, indicators of good FANC attendance were at least 4 visits and having the first visit during the first trimester.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData was cleaned and analysis was done using STATA Version 15. Data were described using means, and percentages and frequencies for continuous and categorical variables respectively. We examined for factors associated with ANC attendance and gestation at first visit (primary outcomes) first using bivariate regressions, followed by multivariable regression analysis including \u0026nbsp;maternal age, education level, marital status, employment status, travel time to health facility, and whether a caregiver encountered challenges during ANC visits. For all the analyses, a 95% confidence interval and p-value significance level of 0.005 were used.\u003c/p\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eParticipant characteristics\u003c/h2\u003e \u003cp\u003eThe respondents age ranged between 16 to 43 years. Majority of the respondents were aged between 20\u0026ndash;30 years (61.5%) while only 6% were above the age of 35 years. Majority of the women (85.4%) were married. Majority of the respondents, 65.8% had primary school education and only 12% had completed secondary level of education. Over half of the respondents (60.2%) were unemployed and almost half of the respondents, 43% lived on a household income of less than KES 10000 per month as indicated in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eParticipants\u0026rsquo; characteristics (N\u0026thinsp;=\u0026thinsp;400)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFrequency n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eAge-group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;20 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (12.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e20\u0026ndash;25 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e152 (38.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26\u0026ndash;30 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e94 (23.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e31\u0026ndash;35 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78 (19.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;35 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25 (6.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"3\" rowspan=\"4\"\u003e \u003cp\u003eHighest education level attained\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNo formal education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 (1.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePrimary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e257 (64.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSecondary education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e116 (29)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAbove Secondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (4.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot comfortable answering\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4 (1.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMarital status\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCurrently married/living together\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e340 (85.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSingle (never married)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e60 (15.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMain occupation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e266 (66.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eEmployed/self-employed/informally employed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e134 (33.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eReligion\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eChristian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e395 (98.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNon- Christian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (1.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eHousehold monthly income\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLess than Ksh.10,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e167 (41.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMore than Ksh.10,000\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e105 (26.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDon't know/Not comfortable answering\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e128 (32.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNumber of ANC visits during last pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLess than four times\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e95 (23.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFour times and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e305 (76.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhere ANC services were offered\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e397 (99.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTraditional birth attendant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3 (0.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGestational age at first ANC visit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrimester I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e154 (38.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrimester II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e228 (57.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrimester III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e18 (4.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMean\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSD\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e26.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e\n\u003ch2\u003eAnc Attendance And Timing\u003c/h2\u003e\n\u003cp\u003eMore than two thirds of the respondents (76.2%) had attended four or more antenatal care visits. Most women (61.5%) had their first ANC visit during or after the second trimester as shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFrequency of and gestational age at first ANC visit during last pregnancy (n\u0026thinsp;=\u0026thinsp;400)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003en (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eNumber of times caregiver received ANC during last pregnancy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLess than four times\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e95 (23.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFour times and above\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e305 (76.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003ePlace caregiver sought ANC services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHealth facility\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e397 (99.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTraditional birth attendant\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e3 (0.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"2\" rowspan=\"3\"\u003e \u003cp\u003eGestational age at first ANC visit\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrimester I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e154 (38.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrimester II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e228 (57.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrimester III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18 (4.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e\n\u003ch2\u003eFactors Associated With Anc Attendance\u003c/h2\u003e\n\u003cp\u003eThe lack of information regarding benefits of ANC and where to get the service was reported by 54.1% of the participants as the main reason for delaying ANC attendance in the first trimester. Other important factors included the lack of time to seek health services and long distance to the health facility. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarises determinants for ANC attendance in the first trimester.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIndicators for quality of service delivery at the health facility were biggest barriers to access and utilization of ANC services. Excessive waiting time (47.4%), long distance to the health facility (26.3%) and lack of prescribed tests and drugs (15.8) were the main facility dependent challenges associated with the ANC services. Other factors are shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e\n\u003ch2\u003eFactors Associated With Utilization Of Fanc\u003c/h2\u003e\n\u003cp\u003eAge, education level and employment status did not have an effect on the attendance to 4\u0026thinsp;+\u0026thinsp;FANC services. Marital status, gestational age when first ANC was attended and presence of challenges during attendance were seen to have an effect.\u003c/p\u003e \u003cp\u003eIn the case of marital status, women who were not currently married were found to be 50% times more likely (1.16-1.9395% CI) to have 4\u0026thinsp;+\u0026thinsp;FANC attendance compared to women who were married, adjusting all other variables in the model.\u003c/p\u003e \u003cp\u003eGestational timing of first ANC was significantly associated with frequency of attendance as in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Women who attended ANC in their second trimester were 41% (0.49\u0026ndash;0.72 CI) times less likely to achieve intended 4\u0026thinsp;+\u0026thinsp;FANC while those beginning in the third trimester 90% (0.03-0.37CI) times less likely to complete FANC visits when compared to those who started ANC in the first trimester of their pregnancy. As presented in Table\u0026nbsp;3, there was a significant association between attendance in the first trimester of pregnancy and frequency of attendance. Those who had more than four visits to FANC were 7.78 (3.16\u0026ndash;19.15 CI) times likely to begin attendance within the first trimester.\u003c/p\u003e \u003cp\u003eExperience with challenges while attending ANC also had a predictive effect on attendance of FANC. Those who did not encounter challenges were 46% (0.41\u0026ndash;0.71) more likely to have 4\u0026thinsp;+\u0026thinsp;FANC attendance compared to those who did faced challenges when attending ANC.\u003c/p\u003e \u003cp\u003e \u003cb\u003eTable\u0026nbsp;3: Factors associated with FANC utilization\u003c/b\u003e \u003c/p\u003e \u003cp\u003eOutcome= (Attendance of at least 4 times (1) vs less than 4 times (0))\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"No\" id=\"Taba\" border=\"1\"\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003eBivariate Analysis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003eMultivariate Analysis\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePredictors\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eAttended\u0026thinsp;\u0026ge;\u0026thinsp;4 ANC visits (N\u0026thinsp;=\u0026thinsp;305)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003en(%)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eCrude Prevalence Ratio (PR)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003eP-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003eAdjusted Prevalence Ratio (PR)\u003c/b\u003e\u003c/p\u003e \u003cp\u003e\u003cb\u003e95% CI\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003eP-value\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge of caregiver (years)\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00 (0.99\u0026ndash;1.01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.686\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.01 (1.00-1.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.190\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation level of caregiver\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo formal Education\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e192 (62.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.47 (0.61\u0026ndash;3.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.391\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.03 (0.42\u0026ndash;2.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.954\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSecondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97 (31.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.67 (0.67\u0026ndash;4.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.273\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.05 (0.42\u0026ndash;2.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.914\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAbove Secondary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e13 (4.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.53 (0.56\u0026ndash;4.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.404\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.39 (0.03\u0026ndash;4.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.452\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCurrently married/cohabiting\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e257 (84.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot currently married\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e48 (15.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.06 (0.88\u0026ndash;1.28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.557\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.50 (1.16\u0026ndash;1.93)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.002\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEmployment status\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSelf-employed/informal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93 (30.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed-salaried/formal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11 (3.6)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.20 (1.00-1.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.053\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e4.69 (0.48\u0026ndash;46.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.186\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnemployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e201 (65.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.99 (0.90\u0026ndash;1.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.863\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.13 (0.97\u0026ndash;1.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.106\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGestational age at first ANC visit\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrimester I\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e148 (48.5)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrimester II\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e155 (50.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.71 (0.62\u0026ndash;0.80)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.59 (0.49\u0026ndash;0.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTrimester III\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (0.7)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.12 (0.03\u0026ndash;0.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.10 (0.03\u0026ndash;0.37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eTravel time to health facility\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026lt;=30 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e162 (53.1)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u0026gt;\u0026thinsp;30 min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e143 (46.9)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.07 (0.94\u0026ndash;1.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.320\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.05 (0.96\u0026ndash;1.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.277\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEncountered challenges during ANC visits\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16 (5.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e289 (94.8)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.90 (0.74\u0026ndash;1.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.310\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.54 (0.41\u0026ndash;0.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study set out to establish the factors affecting attendance to FANC and the factors affecting optimal use of the service in a rural setting.\u003c/p\u003e \u003cp\u003eOur findings show that there was increased uptake of antenatal services after the introduction of free maternal services in the country when compared to attendance indicators documented before this study. Our results further show that most women came for their first ANC visit during the second trimester of the pregnancy primarily due to lack of information as reported by the women. Through this study we realize that women are still under-informed or lack knowledge on their medical care requirements during pregnancy. We also found that when women faced challenges in attending care such as too much waiting time at the facility and the lack of prescribed tests and drugs, this dissuaded their attendance. Our multivariate analysis shows that single women are more likely to adhere to four antenatal visits. These women were found to engage with antenatal care at an early gestational age.\u003c/p\u003e \u003cp\u003eOur findings resonate with previous studies that provide evidence to the fact that user fees is a main barrier for women in the access of maternal services, removing the cost to services enables the uptake and adherence to antenatal services as required. Our study is consistent with findings in Ethiopia[\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e], [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e] and in rural Ghana[\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e] that observe health facility inadequacies with staffing, medicines, supplies and appropriate equipment discourages the utilization of antenatal care. Evidence from Zambia[\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e] shows that married women experience challenges in attending maternal services because of the demands of domestic work and childcare needs of their other children.\u003c/p\u003e"},{"header":"Strengths And Limitation","content":"\u003cp\u003eTo the best of our knowledge, this is among the first studies that has delved into studying the utilization of FANC in a cost-free environment in Kenya. This study provides evidence as to the barriers that still need to be addressed so that women can benefit focused antenatal care as required. Our major limitation was the cross-sectional study design that limits our capacity to make definite attribution. This study was also done in a rural sub-county and therefore may be difficult to generalize for a different context. We also note that much of our data was self-reported retrospectively and could be limited by recall bias.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003e This study shows that the directive by government to remove user fees enabled more women to access antenatal care. In order to achieve timely and optimal utilization of services as prescribed by WHO, community members must be educated on the importance of seeking care early from the first trimester of pregnancy. Health facilities should be equipped with sufficient health workers and the required medicines and equipment in order to provide efficient and effective service that do not discourage the users of the services from engaging as required.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eIn line with Helsinki declarations, this study was reviewed and approved by the Kenya Medical Research Institution Scientific Ethics Review Unit (KEMRI-SERU) and was permitted to carry out the study. Approval reference KEMRI/SERU/CPHR/005/3698.\u0026nbsp;Informed, voluntary written consent was obtained from each participants prior to collecting the data. For participants who could not read or write, consent was obtained using a thumb print in presence of a witness. The research team collecting this data was trained on protection of human research participants and we ensured compliance with ethical standards of research by counterchecking that the participants understood what the data was for and how it was going to be used and stored. Participant identity was anonymized to protect their confidentiality.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors wish to declare their full approval of this material for publication by the journal.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are no competing interests to this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted as part of the MSc program for the lead author, who was privately sponsored. The larger study in which the project was nested was supported by PATH and the ELMA Foundation through funding awarded to APHRC.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contribution:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEW, designed the study, undertook data collection, analysis, drafted the manuscript, reviewed and approved the manuscript for submission. EE and AM guided the study design and data collection and analysis and reviewed the manuscript as academic supervisors to EW. FMW and NKL analyzed and gave guidance to the manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eI thank the African Population and Health Research Center (APHRC) for their support through the study \u0026ldquo;\u003cem\u003eEvaluation of the feasibility and effectiveness of a health facility-based combined with home-based early childhood development (ECD) intervention in Siaya County, Kenya\u0026rdquo;\u003c/em\u003e. It is through this support that this study was able to collect data. I also acknowledge\u0026nbsp;Jomo Kenyatta University of Agriculture and Technology (JKUAT) who are the university through which l undertake my studies in Masters of Public Health\u0026nbsp;in conjunction with the Institute of Tropical Medicine and Infectious Diseases (ITROMID).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor\u0026rsquo;s Information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEW is a student undertaking a Masters of Public Health at JKUAT/ITROMID. She is also a research officer at APHRC. She collected this data and analysed this work in fulfilment of the study program.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eWorld Health Organization, \u0026ldquo;Trends in Maternal Mortality: 1990 to 2015: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division,\u0026rdquo; 2015. [Online]. 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Koch, \u0026ldquo;Utilization of focused antenatal care in Zambia: examining individual- and community-level factors using a multilevel analysis,\u0026rdquo; \u003cem\u003eHealth Policy Plan.\u003c/em\u003e, vol.\u0026nbsp;30, no. 1, pp.\u0026nbsp;78\u0026ndash;87, Feb. 2015, doi: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1093/heapol/czt099\u003c/span\u003e\u003cspan address=\"10.1093/heapol/czt099\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"antenatal care, free maternity services, maternal services, utilization, ANC attendance","lastPublishedDoi":"10.21203/rs.3.rs-1148529/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-1148529/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eFocused antenatal care was recommended by the World Health Organization to mitigate negative pregnancy and birth outcomes. It requires that a woman seeks medical care at least four times in the course of her pregnancy if there are no complications. However, in the low income settings, women are not able to attend ANC early and for all the schedules because of the costs involved including medical fees. In 2017, Kenya included antenatal care in the package of free maternal services provided by the government. We aimed to examine the uptake of free antenatal care (FANC) services by women in a rural community.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eA cross-sectional design employing mixed methods was conducted among 400 pregnant women who attended antenatal services in eight health facilities in Siaya sub-county following the introduction of FANC in these facilities. The women were interviewed on services received the timing of these antenatal visits, the number of visits in the course of the pregnancy and the challenges to attending antenatal services. Participants’ characteristics were described using means and proportions. Uptake of FANC defined by the number of women who sought FANC, the timing of the visits and how frequently they attended was described using percentages/frequencies. \u0026nbsp;Log-binomial regression model was used to identify socio-demographic factors associated with uptake of FANC among the women. In this analysis, attendance to ANC four times or more was the outcome variable.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\u003cp\u003eOur findings showed an increase in the uptake of FANC compared to published rates of uptake. Overall, 76.4% (n=400) of the women reported attending ANC four times or more. Over half (61.7%), of the women had their first ANC visit in the second and third trimester. Women who were not married were 1.5 times (PR=1.50; CI=1.16-1.93) more likely to complete 4+ FANC visits when compared to women who were married. Women who attended ANC for the first time in their second and third trimester were 41% (PR=0.59; CI=0.49-0.72) and 90% (PR=0.10; CI=0.03-0.37) respectively, less likely to complete the 4+ FANC visits, when compared to those who started ANC in the first trimester.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConclusion \u003c/strong\u003e\u003c/p\u003e\u003cp\u003eThe findings indicate that when women do not have to pay for antenatal services, their attendance and compliance to the scheduled visits improves. Therefore, strategies aimed at optimizing maternal pregnancy outcomes should also invest in providing free maternal services. Other implications of the study are discussed.\u003c/p\u003e","manuscriptTitle":"Removing user fees and providing knowledge can improve utilization of FANC services, findings from a cross-sectional study in rural Kenya","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2022-03-31 18:51:50","doi":"10.21203/rs.3.rs-1148529/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"657f80d9-bd93-446d-8fe0-df3fc88bf968","owner":[],"postedDate":"March 31st, 2022","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2022-07-27T10:44:12+00:00","versionOfRecord":[],"versionCreatedAt":"2022-03-31 18:51:50","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-1148529","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-1148529","identity":"rs-1148529","version":["v1"]},"buildId":"WrCJVZZCHTDjtuVLN7oU0","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}