TOPIC: PREVALENCE AND FACTORS ASSOCIATED WITH LATE ANTENATAL CARE BOOKING AMONG PREGNANT WOMEN AT MAGOYE RURAL HEALTH CENTER IN MAZABUKA DISTRICT, SOUTHERN ZAMBIA

TOPIC: PREVALENCE AND FACTORS ASSOCIATED WITH LATE ANTENATAL CARE BOOKING AMONG PREGNANT WOMEN AT MAGOYE RURAL HEALTH CENTER IN MAZABUKA DISTRICT, SOUTHERN ZAMBIA | medRxiv /* */ /* */ <!-- <!-- /*! * yepnope1.5.4 * (c) WTFPL, GPLv2 */ (function(a,b,c){function d(a){return"[object Function]"==o.call(a)}function e(a){return"string"==typeof a}function f(){}function g(a){return!a||"loaded"==a||"complete"==a||"uninitialized"==a}function h(){var a=p.shift();q=1,a?a.t?m(function(){("c"==a.t?B.injectCss:B.injectJs)(a.s,0,a.a,a.x,a.e,1)},0):(a(),h()):q=0}function i(a,c,d,e,f,i,j){function k(b){if(!o&&g(l.readyState)&&(u.r=o=1,!q&&h(),l.onload=l.onreadystatechange=null,b)){"img"!=a&&m(function(){t.removeChild(l)},50);for(var d in y[c])y[c].hasOwnProperty(d)&&y[c][d].onload()}}var j=j||B.errorTimeout,l=b.createElement(a),o=0,r=0,u={t:d,s:c,e:f,a:i,x:j};1===y[c]&&(r=1,y[c]=[]),"object"==a?l.data=c:(l.src=c,l.type=a),l.width=l.height="0",l.onerror=l.onload=l.onreadystatechange=function(){k.call(this,r)},p.splice(e,0,u),"img"!=a&&(r||2===y[c]?(t.insertBefore(l,s?null:n),m(k,j)):y[c].push(l))}function j(a,b,c,d,f){return q=0,b=b||"j",e(a)?i("c"==b?v:u,a,b,this.i++,c,d,f):(p.splice(this.i++,0,a),1==p.length&&h()),this}function k(){var a=B;return a.loader={load:j,i:0},a}var l=b.documentElement,m=a.setTimeout,n=b.getElementsByTagName("script")[0],o={}.toString,p=[],q=0,r="MozAppearance"in l.style,s=r&&!!b.createRange().compareNode,t=s?l:n.parentNode,l=a.opera&&"[object Opera]"==o.call(a.opera),l=!!b.attachEvent&&!l,u=r?"object":l?"script":"img",v=l?"script":u,w=Array.isArray||function(a){return"[object Array]"==o.call(a)},x=[],y={},z={timeout:function(a,b){return b.length&&(a.timeout=b[0]),a}},A,B;B=function(a){function b(a){var a=a.split("!"),b=x.length,c=a.pop(),d=a.length,c={url:c,origUrl:c,prefixes:a},e,f,g;for(f=0;f<d;f++)g=a[f].split("="),(e=z[g.shift()])&&(c=e(c,g));for(f=0;f<b;f++)c=x[f](c);return c}function g(a,e,f,g,h){var i=b(a),j=i.autoCallback;i.url.split(".").pop().split("?").shift(),i.bypass||(e&&(e=d(e)?e:e[a]||e[g]||e[a.split("/").pop().split("?")[0]]),i.instead?i.instead(a,e,f,g,h):(y[i.url]?i.noexec=!0:y[i.url]=1,f.load(i.url,i.forceCSS||!i.forceJS&&"css"==i.url.split(".").pop().split("?").shift()?"c":c,i.noexec,i.attrs,i.timeout),(d(e)||d(j))&&f.load(function(){k(),e&&e(i.origUrl,h,g),j&&j(i.origUrl,h,g),y[i.url]=2})))}function h(a,b){function c(a,c){if(a){if(e(a))c||(j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}),g(a,j,b,0,h);else if(Object(a)===a)for(n in m=function(){var b=0,c;for(c in a)a.hasOwnProperty(c)&&b++;return b}(),a)a.hasOwnProperty(n)&&(!c&&!--m&&(d(j)?j=function(){var a=[].slice.call(arguments);k.apply(this,a),l()}:j[n]=function(a){return function(){var b=[].slice.call(arguments);a&&a.apply(this,b),l()}}(k[n])),g(a[n],j,b,n,h))}else!c&&l()}var h=!!a.test,i=a.load||a.both,j=a.callback||f,k=j,l=a.complete||f,m,n;c(h?a.yep:a.nope,!!i),i&&c(i)}var i,j,l=this.yepnope.loader;if(e(a))g(a,0,l,0);else if(w(a))for(i=0;i (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0];var j=d.createElement(s);var dl=l!='dataLayer'?'&l='+l:'';j.src='//www.googletagmanager.com/gtm.js?id='+i+dl;j.type='text/javascript';j.async=true;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-P4HH5NV'); Skip to main content Home About Submit ALERTS / RSS Search for this keyword Advanced Search TOPIC: PREVALENCE AND FACTORS ASSOCIATED WITH LATE ANTENATAL CARE BOOKING AMONG PREGNANT WOMEN AT MAGOYE RURAL HEALTH CENTER IN MAZABUKA DISTRICT, SOUTHERN ZAMBIA View ORCID Profile Mervis Nakacha Mweene Chilanga doi: https://doi.org/10.1101/2025.08.08.25333288 Mervis Nakacha Mweene Chilanga 1 University of Zambia, School of Public Health , Lusaka, Zambia Find this author on Google Scholar Find this author on PubMed Search for this author on this site ORCID record for Mervis Nakacha Mweene Chilanga For correspondence: mervischilanga{at}gmail.com Abstract Full Text Info/History Metrics Data/Code Preview PDF ABSTRACT Background Late antenatal care (ANC) booking has been a public health issue for women of childbearing age, 15 to 49 years. In low and middle-income countries, the prevalence of late antenatal care booking is 88 %, while in high-income countries, the prevalence of late antenatal care is 27% (WHO, 2012). In Zambia, the prevalence of late ANC booking is about 63% (ZDHS 2018). The high burden of maternal and neonatal mortality and morbidities is likely to be an attribute of late ANC booking. The World Health Organization recommends the first ANC appointment before 12 weeks of gestation (WHO, 2016). In Zambia, the Ministry of Health and its cooperating partners have interventions in place to scale up the provision of standard ANC services, ranging from policies to ANC and other maternal programs. However, no significant successes have been made so far. This study sought to find out the prevalence of late ANC booking at Magoye Rural Health Center and the factors associated with it. Methodology A cross-sectional study was used for data collection and analysis. Convenience sampling was used to select the study site, while a facility-based purposive sampling was used to recruit study participants. The participants were between 15 and 49 years old, accessed ANC services at the facility during the study period, and willingly participated. Data analysis was done using SPSS version 29 software. Descriptive statistics, frequencies, and percentages were used to determine the prevalence of late ANC booking. In contrast, bivariate and multivariate logistic regression analyses were used to determine factors associated with late ANC booking. Results Prevalence of late ANC booking was 80.6%. The significant variables from the regression model were being married (p-value <0.047, C.I 1.014-5.791, AOR 2.423), multigravida (p-value 0.016, C.I 1.246-8.904, AOR 3.330) and multiparous (p-value <0.001, C.I 1.930-8.820, AOR 4.126) all with higher odds of booking for ANC late. Conclusion The prevalence of late ANC booking was found to be high. The associated factors were being married, multigravida, and multiparous. There is a need to intensify sensitization on the dangers of late ANC booking. This can be done, among others, by coming up with results-oriented policies and strategies around late ANC booking. INTRODUCTION Background Antenatal care is defined as a systematic assessment and anticipatory guidance of a pregnant woman (MoH Annual Report, 2022). Pregnancy is one of the most important periods in the life of a woman, a family, and society (WHO, 2018). During pregnancy, women undergo many physiological changes that can lead to life-threatening problems for both the expectant mother and the baby, leading to a compromise in maternal health. Antenatal care is one of the key indicators of maternal health, as most maternal and neonatal mortalities and morbidities can be prevented through ANC. Antenatal care is essentially one of the four pillars of safe motherhood: family planning, clean and safe delivery, ANC, and essential obstetric care ( Aduloju et al., 2016 ). Other key indicators include maternal mortality ratio (MMR) per 100,000 births in a given period, maternal mortality rate (MMR), proportion of births attended by skilled health personnel, institutional delivery rate, antenatal care coverage, and number of ANC contacts, contraceptive prevalence rate of modern methods, unmet need for family planning, adolescents birth rates, stillbirth rate per 1000 live births, neonatal mortality rate (NMR) per 1000 live births and total fertility rate (TFR) (NHSP, 2022-2026). Antenatal care allows for improvement in maternal health and the survival of the baby, as well as providing information on warning signs, nutrition, contraception, HIV/AIDS, and infant feeding (The Basic Antenatal Care Plus Handbook, 2017). During ANC, screening of common pregnancy-related ailments like preeclampsia, fetal abnormalities, hypertension, and other pregnancy-related conditions is usually done. At the global level, the prevalence of late ANC booking among pregnant women of childbearing age of 15 to 49 years in low and middle-income countries is 88%, while in high-income countries, only 27% book late (WHO, 2012). The World Health Organization recommends that pregnant women have their first ANC contact in the first 12 weeks of gestation (WHO, 2016). Based on the district health survey and other nationally representative household survey data, the lowest levels of antenatal care are observed in sub-Saharan Africa and South Asia (UNICEF, 2024). In Zambia, the prevalence of late ANC booking is about 63% (ZDHS, 2018). Antenatal seeking behaviors among pregnant women have remained poor as it is usually start late or never, despite it being free. Antenatal care (ANC) booking later than 14 weeks of gestation is what is termed late booking (MoH, 2012). In Zambia, a mother dies every 12 hours, a newborn dies every 30 minutes, and a stillbirth occurs every hour. In 2023 alone, 782 mothers and 16,000 newborns died, while 5,000 stillbirths were registered (UNICEF, 2024). The high burden of maternal and neonatal mortalities and morbidities is likely to be a contribution to late ANC booking. Most of the maternal and neonatal mortalities and morbidities are avoidable ( Stevens et al., 2002 ). Zambia has aligned itself with the WHO 2030 target on maternal health of reducing the maternal mortality ratio to less than 70 deaths per 100,000. In the quest to resolve the issues surrounding maternal health concerning antenatal care services, the Ministry of Health has put in place policies among which are the following; eight (8) ANC contacts during pregnancy, early ANC initiation; 14 weeks or earlier, provision of ANC services by skilled health personnel and free ANC services (UNICEF, 2024). It is recommended that pregnant women have 8 ANC contacts with their first contact in the first 12 weeks of gestation with subsequent contacts taking place at 20, 26, 30, 34, 36, 38, and 40 weeks of gestation according to the ANC model by the health mother body, WHO (2016). During the subsequent contacts, pregnant women should have an ultrasound done by the 24 th week of gestation to ascertain the true age of the pregnancy (WHO, 2024). The WHO ANC model shows a shift from the old focused ANC model (FANC model), which only recommended 4 visits during one’s gestation period. Other initiatives for scaling up ANC services include the following: health education, nutrition counseling, HIV testing and counseling, malaria prevention, blood pressure testing, and urine testing all to be done during ANC visits. Some programs have also been put in place to improve ANC services in rural areas like the community-based health planning and services program (CHPSP) through community-based workers, MomConnect Zambia (mHealth) initiative program which utilizes mobile phones to send health education messages and ANC visits reminders to pregnant women, and the Saving Mothers Giving Life (SMGL) initiative (ANC Guidelines, 2018). Zambia’s success in improving antenatal care services is evident in the upward progression of the overall coverage of first antenatal care visits to consistently above 90% from 2018 to 2022, rural and urban ANC access equity, enhanced quality of care, improved maternal and newborn health outcomes, and innovative solutions and partnerships. These successes have demonstrated Zambia’s commitment to improving antenatal care service outcomes and provide a foundation for continued progress and innovation (MoH Annual Progress Report, 2022). Despite the successes outlined above, a higher percentage of pregnant women still book for ANC late. The proportion of pregnant women attending antenatal care in the 1st trimester of pregnancy remains between 30% and 37% in Zambia (Annual Progress Report, 2022) The prevalence of late ANC booking varies across provinces in Zambia. Based on the 2007 Zambian demographic health survey, urban areas of Eastern, Luapula, Northern, and North Western provinces recorded the highest proportions of late ANC booking. In rural areas, there was a high late ANC booking in Central, Copperbelt, and Lusaka provinces. These disparities highlight the need for targeted interventions to improve access to ANC services, particularly in rural and hard-to-reach areas. The percentage of women who had at least four ANC visits has fluctuated over the years. The percentage increased from 69% in 1992 to 71% in 1996 and 72% in 2001-02 and then decreased markedly to 60% in 2007. The percentage decreased again to 56% in 2013-14 before increasing to 64% in 2018. Altogether, it can be said that the percentage of women who had ANC in the first trimester increased from 10% in 1992 to 37% in 2018. RESEARCH METHODOLOGY Research Design A cross-sectional study design was used to collect and analyze primary data. This is because it’s appropriate for describing relationships amongst phenomena at a fixed point in time and is economical ( Polite and Beck, 2012 ). Study setting The study was conducted at Magoye Rural Health Center in the Mazabuka district with a catchment population of 8,740. Mazabuka District has 61 health facilities; 44 are owned by the Ministry of Health, 1 is owned by the Zambia Correctional Service, and 16 are owned by the private sector. Geographically, Magoye Rural Health Center lies at latitude 16.0017 and longitude 27.6042 (HPCZ, 2024). Target Population All pregnant women aged 15 to 49 years who accessed ANC services from Magoye Rural Health Center during the study period. Study Population All pregnant women who met the inclusion criterion Inclusion Criterion All consenting pregnant women aged 15 to 49 who were from the facility’s catchment area and accessed ANC services from the Magoye Rural Health Center. Exclusion Criterion All pregnant women so ill to participate in the study, and those who did not have enough time to adequately answer the questionnaire Sample Size The sample size was determined by Cochran’s single-proportion formula for an infinite population since the study was dealing with a single population. An assumption of a 95% confidence interval, 5% margin of error, and 70% of the expected proportion of late ANC booking ( Battu et al., 2021 ). To compensate for the non-response, 10% of the determined sample size was added to cater for non-response. The calculated sample size was n =Z 2 p (1-p) / d 2 ; = 355 participants, large enough to ensure the external validity of the research study. Sampling Techniques Magoye Rural Health Center was conveniently selected for its proximity to Mazabuka General Hospital and acts as a feeder rural health center. Furthermore, Magoye Rural Health Center has a high catchment population, making it ideal for a cross-sectional study. Purposive sampling was used to recruit study participants as it seeks out-group characteristics where the processes being studied are most likely to occur (Denzin and Lincoln, 2000). Therefore, every pregnant woman who met the inclusion criteria was recruited for the study. Ethical Considerations An ethical clearance letter was sought from the University of Zambia Biomedical Research Ethics Committee (UNZABREC) REF. No. 5212-2024 and the National Health Research Authority (NHRA) in Lusaka. The health center from which data was collected was asked for permission from the Ministry of Health (MoH) offices in Mazabuka. Informed written consent was obtained from the study participants and parents or guardians of minor participants. Minor participants signed assent forms after getting consent for participation from their parents or guardians. Dissemination of the Research Findings Reports of the research findings were shared with the PHO, DHO, NHRA, and the School of Public Health at the University of Zambia. A manuscript titled “Prevalence and Factors Associated with Late Antenatal Care Booking at Magoye Rural Health Center in Mazabuka, Southern Zambia” was sent for publication in peer-reviewed journals. Data Collection Instruments Researcher-administered structured questionnaires were used to collect data from pregnant women Data Analysis The prevalence of late ANC booking among pregnant women was determined by descriptive statistics; frequencies, and percentages, to determine the association between ANC utilization and each independent variable, Chi-squared Test and Fisher’s exact test were used dependent on the chi-square assumptions being met. The associated factors were determined by binary logistic regression, using bivariate and multivariate logistic regressions at p-values < 0.25 and 0.05, respectively, at 95% confidence intervals. The significant variables in the multivariate logistic regression analysis model were used to determine the presence and strength of association between dependent and independent variables. RESULTS Two hundred and eighty-six (80.6%) pregnant women were booked for ANC late, while sixty-nine (19.4%) pregnant women were booked for ANC early out of the three hundred and fifty-five (355) pregnant women that entered the study. Figure 1 below shows the Prevalence Of Late Antenatal Care Booking among Pregnant Women at Magoye Rural Health Center. ( Figure 1 ) Download figure Open in new tab Figure 1: The Prevalence Of Late Antenatal Care Booking among Pregnant Women at Magoye Rural Health Center. Three hundred and fifty-five (355) pregnant women were enrolled in the study, out of this number 294(82.8%) were above 19 years of which 243(85%) booked late, 183(51.5%) were married of which 165(57.7%) booked for ANC late, 193(54.4%) had primary education of which 162(56.6%) booked for ANC late and out of the 148(41.7%) who were self-employed 120(42%) booked late for ANC. The 175(49.3) women who were earning less than ZMK500 income, 137(48%) booked foe ANC late, 221(62.3%) who had unplanned pregnancies 190(66.4%) of them booked for ANC late and out of the 205(57.7%) pregnant women who footed to access antenatal care, 167(58.4%) booked for ANC late. ( Table 1 ) View this table: View inline View popup Download powerpoint Table 1: Social Demographic Characteristics of Pregnant Women and ANC Booking Two hundred and ninety-seven (83.7%) multigravida pregnant women entered the study out of which 250(87.4%) booked for late, of the 297 (61.4%) multiparous pregnant women in the study, 192(54.1%) booked for ANC late and of the 192(54.1%) women with history of miscarriage who entered the study, 156(54.4%) booked for antenatal care late while of the 205(57.7%) pregnant women who had history of stillbirth, 161(56.3%) of them booked for ANC late. Two hundred and forty-five (69.0%) pregnant women without history of caesarian section birth entered the study and 202(70.6%) of them booked for ANC services late whereas, of the 195(54.9%) pregnant women who had no other obstetric complications who entered the study, 160(55.9%) booked for antenatal care service late. ( Table 2 ) View this table: View inline View popup Download powerpoint Table 2: Obstetric Characteristics of pregnant women and ANC Booking Factors Associated With Late ANC Booking Bivariate and multivariate logistic regression analyses were used to determine factors associated with late ANC booking. Factors with p-values higher than 0.25 (obstetric complication history, caesarian section birth, stillbirth, mode of transport and miscarriage history) were adjusted for while those with p-values less than 0.25 (marital status, education level, occupation, income, planned pregnancy, gravida and parity) were entered into the multivariate logistic regression analysis. After multivariate logistic regression analysis was carried out at 0.05 level of significance, the odds of booking late among married women were 2.423 times higher than those who were single (AOR=2.423, 95%CI=1.014-5.791), the odds of multigravida women booking for ANC late were 3.330 times higher than primagravida women (AOR=3.330, 95%CI=1.246-8.904)) and the odds of multiparous women booking for ANC late were 4.126 times higher than primiparous women (AOR=4.126, 95% CI =1.930-8.820). ( Table 3 ) View this table: View inline View popup Download powerpoint Table 3: Bivariate and Multivariate Logistic Regression Analysis of Factors Associated With Late ANC Booking DISCUSSION OF THE STUDY FINDINGS In the study, the prevalence of late ANC booking was 80.6%, lower than 85.3% by Chewe (2015) in Zambia and 86.56% by Ndomba et al. (2023) in Tanzania. This could mean that, slowly, the initiatives to combat late ANC booking that are in place are beginning to gain recognition in some areas. However, the study findings are higher than 73.6% by Ndidi and Osman (2010) in Nigeria, 72% by Hazemba et al. (2012) in Zambia, and others. Possible reasons for the findings could be that rural areas are not well covered with the programs and initiatives in place to improve maternal health through ANC. Another possible reason could be the low level of education among the study participants, as most of the study participants only had primary education, which could suggest lack of proper understanding of the effects that late ANC booking poses on the baby and expectant mothers; hence, ANC booking was taken as business as usual by pregnant women. The study findings indicate that most married women booked for ANC late. The findings were similar to a study by Chewe et al. (2016) . Reasons for these findings could not be captured as the study was quantitative. However, in South West Nigeria, some earlier studies highlighted that husbands of pregnant women influence ANC booking as they decide when their wives should book for ANC Olayinka et al. (2022) . Furthermore, some studies indicated that married women book for ANC late, this could be due to the feeling that having a spouse who can stand by their side if complications arose along the gestation period is enough. Additionally, some married women may book for ANC late due to refusal by their spouses to provide money for transport to the health facility to access ANC services ( Denis &Asha, 2020 ). Multigravida was another significant variable in the study, as most multigravida women booked for ANC late. This could be most multigravida pregnant women felt experienced enough to handle pregnancy related complications. This eventually leads to delayed ANC booking, especially when pregnant women have had no history of caesarian section birth, stillbirths, miscarriage, and a history of obstetric complications, as was the case in the study. Logically, when pregnant women have had multiple and challenging pregnancies, they may consider booking for ANC early. These findings were similar to those of Jinga et al. (2019) in South Africa, Dorji (2019 ) in Bhutan, and many others. Multiparous was equally a significant variable in the study. Reasonably, when pregnant women have given birth before, especially if they had no complications and the children are all alive a feeling of being experienced is built. This breeds a feeling in them to say everything is okay and will be since it was earlier, hence, they may see no need to book for ANC early. These research findings were similar to those by Hazemba et al. (2012) in Zambia, Towongo et al. (2022) in Uganda, and others. CONCLUSION Research findings indicated that the prevalence of late ANC booking is still high, and the associated factors are being married, multigravida, and multiparous. This makes early diagnosis of pregnancy-related complications a challenge, eventually leading to maternal, neonatal, and child mortalities and morbidities. The study findings supported earlier scholars and hence added to the existing literature. Limitations of the study Gestation age uncertainty at the time of booking for ANC services leaves room for imprecise findings. The research also lacked information about pregnant women who may have opted to use private health facilities for their ANC services. This could mean that the research findings may not have been representative enough. The study design was cross-sectional, hence, cause-and-effect relationships could not be established. Recommendations Scaling up sensitization about the dangers of late ANC booking among pregnant women by the Ministry of Health and its cooperating partners to lower the prevalence of late ANC booking Adoption of new strategies around the public health issue, along with continued engagement of community workers and gatekeepers to ensure that pregnant women get information on the dangers of late ANC booking, even without accessing health facilities. Continued involvement of men in ANC services to reduce their impact on ANC booking of their partners. Health education to be given to pregnant women about the dangers of being multigravida and multiparous Public health facilities to meet the WHO recommendations for the accessibility of health services for pregnant women, to reduce gestational age uncertainty at booking among pregnant women. Research implications of the findings The prevalence of late ANC booking is still high (80.6%), and associated factors are similar to those of earlier studies. This indicates that late ANC booking has been a public health issue. Policy implications of the findings There is a need to develop improved awareness policies on the effects of late ANC booking. This can be done by developing policies that include men in the ANC services to rule out the impact they pose on ANC booking of their spouses. Furthermore, there is a need to develop policies that will ensure continued sensitization of pregnant women on the dangers of multigravida and multiparous, as most pregnant women usually undermine their impact, as evident from the study findings. Data Availability The data set analyzed during the study is available from the author on reasonable request and can be accessed from the University of Zambia's main Library. DECLARATIONS Ethical approval The study approval was done by the University of Zambia Biomedical Research Ethics Committee, REF. No. 5212-2024. The health center from which data was collected was asked for permission from the Ministry of Health (MoH) District Offices in Mazabuka. Informed written and verbal consents were obtained from the study participants and parents or guardians of minor participants. Minor participants signed assent forms after getting consent for participation from their parents or guardians. Consent for publication Not applicable Availability of data and material The data set analyzed during the study is available from the author on reasonable request and can be accessed from the University of Zambia’s main Library. Competing interest The author has no competing interests Funding statement The study was not funded Author’s contribution The author was responsible for the Conceptualization, Methodology, analyzing the data, interpreting of the findings, and drafting the manuscript Author’s information The research was part of a thesis for MCNM who was perusing a Master’s of Science in Public health at the University of Zambia, School of public Health. Acknowledgement The author wishes to send sincere appreciation and acknowledgments to the lecturers at the University of Zambia, school of public health in particular Dr. Alice Ngoma Hazemba and Dr. Isaac Fwemba for the mentorship, Mazabuka District Medical Office and Magoye Rural Health Center for the permission to collect data, NHIRA for researcher certification and UNZABREC for ethical approval granted. 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