Utilization and quality of antenatal care in Mathonkara area, rural Sierra Leone: A cross- sectional study

Utilization and quality of antenatal care in Mathonkara area, rural Sierra Leone: A cross- sectional study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (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],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Utilization and quality of antenatal care in Mathonkara area, rural Sierra Leone: A cross- sectional study Sebastian Starling, Rosa Roemers, Jenny Wussow, Tatyana D Fedorova, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7139990/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 6 You are reading this latest preprint version Abstract Introduction: Maternal and neonatal mortality remain major public health challenges in sub-Saharan Africa, with Sierra Leone among the affected countries. Antenatal care (ANC) is crucial for improving maternal and fetal health, yet disparities remain in both coverage and quality. This study examines ANC utilization and quality in rural Sierra Leone including factors influencing service uptake. Methods from February 25th to May 12th, 2023, we interviewed 513 women who had given birth within the past year in the Mathonkara catchment area, Tonkolili district, Sierra Leone. Structured questionnaires were used to collect data on demographics and ANC history. High quality ANC was defined as receipt of WHO-recommended ANC services including uptake of ANC visits, pregnancy drugs (e.g. iron and folic acid), injections (e.g. tetanus vaccination) and ultrasound scanning. ANC visits and uptake of ANC components were assessed using descriptive analysis. Associations between ANC uptake and socio-economic factors were explored with bivariate and multivariate analyses. Results While 86.6% of women attended ≥ 4 ANC visits, only 3.1% received all the ANC services assessed in this study. High ANC quality was received by 31.8% of the women. Only 4.9% of participants received ≥ 8 ANC visits, 20.5% received three doses of malaria prophylaxis, 42.1% received an early ultrasound, and 42.7% received two tetanus vaccinations. Women with ≥ 4 ANC visits were nearly three times more likely to receive iron and folic acid supplements, two doses of malaria prophylaxis, and ≥ 2 tetanus vaccinations. High-quality ANC was less likely among women living ≥ 9 km from a health facility (AOR = 0.52, 95% CI: 0.28–0.96) and among illiterate women (AOR = 0.70, 95% CI: 0.48–1.02), while employed women were more likely to receive high-quality ANC (AOR = 2.1, 95% CI: 0.98–4.56) Conclusion Our study highlights severe deficiencies in ANC quality in the Tonkolili district of rural Sierra Leone, with nearly no women receiving the full range of recommended services. While more ANC visits were associated with higher uptake of key interventions, overall quality remained low. Targeted interventions, such as improved infrastructure, community education, and supply-chain strengthening, are needed to ensure that ANC visits translate into comprehensive care. Antenatal care Maternal Health Antenatal care utilization Sierra Leone Tonkolili Figures Figure 1 1 Introduction Despite improvements, the maternal mortality ratio (MMR) in Sierra Leone remains alarmingly high at 354 per 100,000( 1 ). A review of 28 SSA countries found that women receiving higher quality ANC were more likely to access skilled delivery care and had a lower MMR( 2 ), and evidence from LMICs suggests ANC can reduce neonatal deaths by up to 34%( 3 ). ANC provide an opportunity to deliver preventive interventions, detect complications early, promote healthy pregnancy practices and counsel on pregnancy danger signs and family planning( 4 ). The World Health Organization (WHO) recommends at least eight ANC contacts during pregnancy, beginning in the first trimester, with provision of a defined set of evidence-based services( 5 ). These include daily iron–folic acid supplementation, a minimum of three preventive treatments of malaria with sulfadoxine-pyrimethamine (IPTp-SP), administration of at least two doses of tetanus toxoid (TT) vaccine and ultrasound scan before week 24( 5 ). TT vaccination prevent neonatal tetanus, particularly in home births conducted under unhygienic conditions( 6 ). Iron and folic acid( 7 ) supplements and malaria prophylaxis decrease risk of maternal anaemia and associated complications( 8 ). Studies from rural health facilities in the Tonkolili district have reported anaemia in over 65% of pregnant women and malaria in more than one-third( 9 ). Postpartum haemorrhage remains the leading cause of maternal mortality in Sierra Leone( 10 ) thus anaemia prevention is crucial. Attending ANC may not ensure improved outcomes unless all essential ANC components are provided according to recommended standards( 11 ). Despite the recognized importance of ANC, as well as attempts to improve adherence, significant gaps remain in the quality and completeness of care provided in many low-resource settings, including Sierra Leone( 4 , 12 , 13 ). Reducing maternal and neonatal mortality is a key objective of the United Nations' Sustainable Development Goals (SDGs), particularly SDG 3, which aims to lower maternal mortality to fewer than 70 deaths per 100,000 live births and neonatal mortality to below 12 per 1,000 live births by 2030( 14 ). Achieving these targets requires access to high-quality ANC( 15 , 16 ). In this study, we aim to assess ANC utilization, the completeness of care, and factors associated with low-quality ANC. Identifying and understanding these barriers is crucial for developing targeted strategies to improve maternal healthcare and reduce maternal and neonatal mortality in Sierra Leone. 2 Method 2.1 Research site and study population The study included all women of reproductive age who lived in one out of 23 selected villages surrounding the Mathonkara Community Health Centre (CHC) in the Tonkolili district, rural Sierra Leone for at least six months during pregnancy and who had a live birth between February 1, 2022, and January 31, 2023. The Mathonkara catchment area was specifically selected due to its poor health indicators and remote location ( 9 ). The geography of the area presents several logistical challenges, including long travel distances, limited access to nearby health facilities, impassable rivers, rugged mountainous terrain, and poorly maintained roads. For many of the women, reaching the closest ANC clinic, require travelling several hours by motorbike or on foot, navigating narrow dirt paths. 2.2 Study design and data collection This study is a baseline study prior to an ANC intervention aimed at increasing facility-based births, conducted in collaboration with the Maternal Outreach Team of Masanga Hospital and the Wouter Nolet Foundation. Data were collected using a structured questionnaire, which included a combination of single-choice, multiple-choice, open- and close-ended questions (Supplementary 1). The data were collected from February 25th to May 12th, 2023. Questionnaires were administered through individual, structured interviews, and responses were directly entered into KoboToolbox (Kobo Organization, USA). Six local research assistants, 3 women and 3 men, were recruited for data collection and received a one-week training program led by SS and JW. Prior to initiating data collection, meetings were held with village leaders to explain the study objectives and obtain their support. Women were identified using a door-to-door approach in each village. Eligible participants were invited to take part in the interview, which was conducted at their home or another private location. Interviews were conducted in Krio or Temne, by the local research assistants. To maximize participation, three revisits were made to each village to reach women who were not available during the initial visits. Quality control measures included on-site supervision during field activities. Every interview was supervised by SS, JW or both. Quality control further included systematic cross-checking of each entry for missing data, outliers, and inconsistencies within 48 hours of data entry, and two refresher training sessions for the research assistants to ensure data accuracy and reliability. 2.3 Definition of variables We assessed ANC components recommended by the WHO for optimal ANC: ≥ 8 ANC visits, iron, folic acid and albendazole supplementation, two TT vaccines, three prophylactic malaria treatments and an ultrasound scan before 24 weeks of gestation. We grouped quality of ANC into low-, medium- and high-quality ANC based on receipt of individual ANC components as described in Fig. 1 . Studies demonstrate increased effectiveness of ≥ 3 doses of IPTp-SP and ≥ 2 TT injections, however, the low number of women receiving the full coverage, did not allow for further analysis. High quality ANC therefore include one dose of IPTp-SP and one dose of TT injections. This division is seen in similar studies( 12 , 17 ). Socio-demographic characteristics include age, relationship status, literacy, educational level, occupation and distance to health facilities. Maternal health indicators include parity and age at first pregnancy. Distance to health facilities was measured based on the facility that each woman reported using, rather than the nearest one geographically. For villages with mapped roads, routes were calculated using Google Maps. In cases where roads were unmapped, distances were manually measured using satellite imagery on Google Maps. 2.4 Data analysis The statistical analysis was done using SPSS (SPSS Statistics 30.0.0). Demographic characteristics and ANC components were analysed using descriptive statistics. The associations between the number of ANC visits and the receipt of individual ANC components, as well as between high-quality ANC and socio-demographic factors, were analysed using bivariate and multivariate logistic regression. Variables with a p-value ≤ 0.1 in the bivariate analysis were included in the multivariate model to adjust for potential confounding factors. Adjusted Odds Ratios (AOR) with corresponding 95% confidence intervals (CI) were calculated for each variable in the multivariate analysis. Statistical significance was defined as a p-value < 0.05. 3 Results 3.1 Descriptive statistics A total of 513 women were included in the study. Most of the women were aged 20–40 years (75.0%, 385/513), while 19.3% (99/513) were ≤ 19 years at the time of the interview. Majority of the women were ≤ 19 years of age at the time of their first pregnancy (73.1%, 115/513). Of the women, 58.1% (298/513) were illiterate, and 53.6% (275/513) had no formal education. Around a third (27.7%, 142/513) lived in a village with a health facility while 17.0% (87/513) lived more than 9 km from the nearest health facility. Regarding parity, 23.4% (120/513) were first-time mothers, and 25.3% (130/513) had five or more children. [See Table 1 ] Table 1 Background characteristics of the study population Characteristics Number (n = 513) Percentages (%) Age groups ≤ 19 99 19.3 20–40 385 75.0 ≥ 41 9 1.8 Unknown 20 3.9 Literacy Literate 215 41.9 Illiterate 298 58.1 Relationship status Single/Widowed 29 5.7 Married/In a relationship 484 94.3 Highest level of education None 275 53.6 Primary 69 13.5 Junior secondary 94 18.3 Senior secondary 73 14.2 Higher 2 0.4 Occupation* Employed 468 91.2 Unemployed 45 8.8 Distance to closest health facility In the village (0 km) 142 27.7 1–4 km 161 31.4 5–8 km 123 24.0 ≥ 9 km 87 17.0 Parity 1 120 23.4 2–4 263 51.3 ≥ 5 130 25.3 Age at time of first pregnancy ≤ 19 115 73.1 ≥ 20 375 22.4 Unknown 23 4.5 * Multiple answers/occupations were possible. Occupations included: student, miner, farmer, trader, teacher, self-employment, driver, government employee, other (free text) Most women (81.1%, 416/513) attended four to seven ANC visits, but only few (4.9%, 25/513) completed the recommended ≥ 8 visits. The quality of ANC was classified as high in 31.8% (163/513), medium in 60.2% (309/513), and low in 8.0% (31/513). Only 3.1% (16/513) of the women received all recommended ANC services with ≥ 4 ANC visits, and just one woman (0.2%, 1/513) received all recommended services with ≥ 8 ANC visits. Malaria prophylaxis was the most commonly received ANC component (86.2%, 442/513), while timely ultrasound was the least (42.1, 216/513%). Majority of women received one dose of malaria prophylaxis (40.4%, 207/513), while 20.5% (105/513) received the recommended three doses. Most women received a TT injection (80.5%, 413/513), while only 42.7% (219/513) received the recommended two doses. There was only a slight difference in TT injections comparing nulliparous and multiparous women. See Table 2 for further details on the individual ANC components. Table 2: Components of antenatal care received by women in the Mathonkara catchment area Characteristics Number (n = 513) Percentages (%) Antenatal care visits ≤ 3 68 13.3 4-7 416 81.1 ≥ 8 25 4.9 Unknown 4 0.8 Received iron supplementation No 51 9.9 Some days/ran out 142 27.7 Through whole pregnancy 294 57.3 I don’t know 26 5.1 Folic acid supplementation No 54 10.5 Took folic acid 456 88.9 I don’t know 3 0.6 Received Malaria prophylaxis No 59 11.5 1 dose 207 40.4 2 doses 130 25.3 3 doses 105 20.5 I don’t know 12 2.3 Albendazole supplementation No 139 27.1 Took Albendazole 357 69.6 I don’t know 17 3.3 Tetanus toxoid (TT) injections No 56 10.9 1 dose 194 37.8 ≥ 2 doses 219 42.7 I don’t know 44 8.6 TT in primiparous women (n = 120) No 14 11.7 1 dose 51 42.5 ≥ 2 doses 47 38.8 I don’t know 8 6.7 TT in multiparous women (n = 393) No 42 10.7 1 dose 143 36.4 ≥ 2 doses 172 43.8 I don’t know 36 9.2 Received an ultrasound scan Yes 318 62.0 No 195 38.0 Received an ultrasound scan before 24 weeks of GA Yes 216 42.1 No 297 57.9 Received all recommended antenatal care services 1 with 8 ANC visits Yes 1 0.2 No 512 99.8 Received all recommended antenatal care services with 4 ANC visits Yes 16 3.1 No 497 96.9 Quality of Antenatal care 2 Low 41 8.0 Medium 309 60.2 High 163 31.8 1 As defined by the WHO: folic acid supplementation, albendazole supplementation, iron supplementation, two TT vaccines, three prophylactic malaria treatments and an ultrasound scan before 24 weeks of GA. 2 ANC quality defined as: High 7 points, medium 4-6 points and low 0-3 points. One point is given for each of the following components: ≥ 4 ANC visits, folic acid supplementation, albendazole supplementation, iron supplementation, ≥ 1 prophylactic malaria treatment, ≥ 1 TT vaccines and an ultrasound during pregnancy. 3.2 Characteristics associated ANC visits and components of ANC The bivariate analysis demonstrated that receiving ≥ 4 ANC visits was significantly associated with iron supplementation, ≥ 1 doses of malaria prophylaxis, albendazole supplementation, ≥ 1 doses of tetanus vaccination and folic acid supplementation. In the multivariate analysis, consistent iron supplementation (AOR = 3.24 [1.15–9.12]), two doses of malaria prophylaxis (AOR = 3.13 [1.01–9.65]), folic acid supplementation (AOR = 2.71 [1.07–6.87]) and receiving two or more doses of tetanus toxoid injections (AOR = 3.15 [1.37–7.28]) remained associated with ≥ 4 ANC visits. Albendazole supplementation did not retain significance after adjustment. [See Table 3 ] Table 3 Association between ≥ 4 antenatal care (ANC) visits and components of ANC Demographics Bivariate analysis Multivariate analysis Characteristics ≥ 4 ANC visits (%) 441 (86.6) ≤ 3 ANC visits (%) 68 (13.4) Unadjusted OR (95% CI) P-value Adjusted OR (95% CI) P-value Components of antenatal care Received iron supplementation No 31 (7.0) 19 (27.9) Ref. Ref. Some days/ran out 119 (27.0) 22 (32.4) 3.32 (1.60–6.88) < 0.01 1.74 (0.64–4.74) 0.28 Consistently 269 (61.0) 23 (33.8) 7.17 (3.52–14.61) < 0.01 3.24 (1.15–9.12) 0.03 I don’t know 22 (5.0) 4 (5.9) 3.37 (1.01–11.29) 0.05 2.35 (0.54–10.24) 0.26 Received Malaria prophylaxis No 38 (8.6) 20 (29.4) Ref. Ref. 1 dose 181 (41.5) 22 (32.4) 4.38 (2.18–8.81) < 0.01 1.54 (0.57–4.18) 0.40 2 doses 121 (27.4) 8 (11.8) 7.96 (3.25–19.53) < 0.01 3.13 (1.01–9.65) 0.05 3 doses 91 (20.6) 14 (20.6) 3.42 (1.57–7.47) < 0.01 1.39 (0.47–4.12) 0.55 I don’t know 8 (1.8) 4 (5.9) 1.05 (0.28–3.93) 0.94 0.36 (0.06–2.21) 0.27 Albendazole supplementation No 107 (24.3) 31 (45.6) Ref. Ref. Yes 321 (72.8) 33 (48.5) 2.82 (1.65–4.82) < 0.01 1.22 (0.61–2.45) 0.57 I don’t know 13 (2.9) 4 (5.9) 0.94 (0.29–3.10) 0.92 0.97 (0.19–5.03) 0.98 Tetanus toxoid injections No 41 (9.3) 15 (22.1) Ref. Ref. 1 dose 171 (38.8) 23 (33.8) 2.72 (1.31–5.67) 0.01 2.04 (0.91–4.59) 0.08 ≥ 2 doses 200 (45.4) 17 (25.0) 4.30 (1.99–9.31) < 0.01 3.15 (1.37–7.28) 0.01 I don’t know 29 (6.6) 13 (19.1) 0.82 (0.34–1.97) 0.65 3.46 (0.98–12.17) 0.05 Folic acid supplementation No 33 (7.5) 20 (29.4) Ref. Ref. Yes 406 (92.1) 47 (69.1) 5.24 (2.78–9.85) < 0.01 2.71 (1.07–6.87) < 0.01 I don’t know 2 (0.5) 1 (1.5) 1.15 (0.10-14.24) 0.88 0.69 (0.04–12.78) 0.80 Received ultrasound scan in last pregnancy No 161 (36.5) 32 (47.1) Ref. Ref. Yes 280 (63.5) 36 (52.9) 1.55 (0.92–2.59) 0.09 1.64 (0.93–2.91) 0.09 Received ultrasound scan before 24 weeks GA No 250 (56.7) 44 (35.3) Ref. Yes 191 (43.3) 24 (64.7) 1.40 (0.82–2.38) 0.21 N = Number of individuals, OR = Odds ratio, AOR = Adjusted odds ratio, CI = Confidence Interval, Ref. = Reference, km = kilometre, ANC = Antenatal Care, GA = Gestational age After adjusting for potential confounders (occupation, literacy, and distance to ANC clinics), we found that women living more than 9 km away were less likely to receive high quality ANC (AOR = 0.50 [0.26–0.95]). Though not significant, women who had an occupation besides their housework were twice as likely to receive high quality ANC (AOR = 2.12 [0.98–4.56]), and illiterate women were less likely to receive high ANC quality (AOR = 0.70 [0.48–1.02]). [See Table 4 ] Table 4 Association between quality of antenatal care (ANC) and socio-demographic characteristics Quality of ANC Bivariate analysis Multivariate analysis Characteristics High ANC quality 1 (%) 163 (31.8) Low-medium ANC quality (%) 350 (68.2) Unadjusted OR (95% CI) P-value AOR (95% CI) P-value Demographic characteristics Age groups ≤ 19 29 (17.8) 70 (20.0) 0.83 (0.51–1.35) 0.45 20–40 128 (78.5) 257 (73.4) Ref. ≥ 41 3 (1.8) 6 (1.7) 1.00 (0.25–4.08) 0.99 Unknown 3 (1.8) 17 (4.9) 0.35 (0.10–1.23) 0.10 Relationship status Single/Widowed 10 (6.1) 19 (5.4) Ref. Married/Relationship 153 (93.9) 331 (94.6) 0.88 (0.40–1.93) 0.75 Literacy Literate 78 (47.9) 137 (39.1) Ref. Ref. Illiterate 85 (52.1) 213 (60.9) 0.70 (0.48–1.02) 0.06 0.70 (0.48–1.02) 0.06 Highest level of education None 81 (50.3) 194 (55.4) Ref. Primary 24 (14.9) 45 (12.9) 1.28 (0.73–2.23) 0.39 Junior secondary 28 (17.4) 66 (18.8) 1.02 (0.61–1.70) 0.95 Senior secondary/high 28 (17.4) 45 (12.9) 1.49 (0.87–2.55) 0.15 Occupation Unemployed 9 (5.5) 36 (10.3) Ref. Ref. Employed 154 (94.5) 314 (89.7) 1.96 (0.92–4.18) 0.08 2.12 (0.98–4.56) 0.05 Distance to closest health facility In the village (0 km) 47 (28.8) 95 (27.1) Ref. Ref. 1–4 km 53 (31.8) 108 (30.9) 0.99 (0.61–1.60) 0.97 1.02 (0.63–1.66) 0.93 5–8 km 46 (28.8) 77 (22.0) 1.21 (0.73-2.00) 0.47 1.34 (0.80–2.24) 0.27 ≥ 9 km 17 (10.4) 70 (20.0) 0.50 (0.26–0.93) 0.03 0.52 (0.27–0.98) 0.04 Parity 1 38 (23.3) 82 (23.4) Ref. 2–4 90 (55.2) 173 (49.4) 1.12 (0.71–1.78) 0.62 ≥ 5 35 (21.5) 95 (27.1) 0.80 (0.46–1.37) 0.41 Age first pregnancy ≤ 19 122 (74.8) 253 (72.3) 0.98 (0.63–1.52) 0.92 ≥ 20 38 (23.3) 77 (22.0) Ref. Unknown 3 (1.8) 20 (5.7) 0.30 (0.09–1.09) 0.07 Remarks: OR = Odds ratio, AOR = Adjusted odds ratio, CI = Confidence interval, Ref = Reference, km = Kilometre, ANC = Antenatal care 1 ANC quality defined as: High 7 points, medium 4–6 points and low 0–3 points. One point is given for each of the following components: ≥ 4 ANC visits, folic acid supplementation, albendazole supplementation, iron supplementation, ≥ 1 prophylactic malaria treatment, ≥ 1 TT vaccines and an ultrasound during pregnancy. 4 Discussion This study reveals gaps and socio-economic disparities in ANC uptake in the Tonkolili district of rural Sierra Leone. Despite most women receiving four or more ANC visits, few women received high quality ANC. In fact, only 3.1% received all seven key components recommended by the WHO. Women receiving four or more ANC visits had a three-fold chance of receiving consistent iron supplementation, two doses of malaria prophylaxis, folic acid supplementation and two or more TT doses. This emphasises the central role of ANC in women’s reproductive health. Our findings call for improvements in comprehensive ANC services, particularly targeting remoteness, illiteracy, and unemployment. 4.1 Findings in context of earlier research Most studies on ANC in SSA and Sierra Leone, focus on visit quantity, with few studies exploring ANC comprehensiveness( 18 , 19 ). As in this study, Yaya S. et al. found that women in Sierra Leone attending at least four ANC visits had significantly higher odds of receiving two doses of TT vaccine( 18 ). Likewise, Abdissa Z. et al. found that women in Ethiopia who attended four or more ANC visits were significantly more likely to receive essential services such as iron supplementation and TT vaccination( 19 ). Yet, even among frequent attenders, quality of care in our population remained low, raising the question of why key ANC components are still missed despite regular contact with the health system. Studies have found that barriers to utilization of IPTp-SP and TT injections, include stock-outs, inadequate training of healthcare providers, limited knowledge about the importance of the medicine among pregnant women and socioeconomic factors such as wealth and educational levels( 20 , 21 ). Kanyangarara, M. et al. investigated quality of ANC in 28 SSA countries, including Sierra Leone, and found that only one in five women with a recent live birth received care at a facility with trained staff, appropriate clinical guidelines, and necessary supplies such as iron, IPTp, or tetanus vaccine( 17 ). Even where supplies were available, provision of appropriate care was often hindered by underutilization of ANC services, lack of protocols, and a shortage of trained personnel to deliver interventions( 17 ). To improve ANC in our study area, further exploration of supply chain and availability, costs, and staff knowledge are needed to ensure women are offered all recommended services. This also raises questions about the feasibility of recommending eight contacts in low-resource settings, where additional visits could overburden limited staff. We recommend prioritizing comprehensive care within four visits before expanding to eight. Our study population is characterized by an alarmingly high proportion of women who entered motherhood before the age of 18, have little or no formal education, are illiterate and face significant challenges in accessing care due to the poor infrastructure and long distances to ANC clinics. These co-existing vulnerabilities may be an underlying driver of the low quality of ANC observed in the cohort. That we found no significant association between ANC and educational level and literacy in our data is likely because of a homogenic population (e.g. only 0.4% of women had attained education beyond the senior secondary level). Nonetheless, the current literature points towards maternal education as a crucial determinant of ANC quality( 22 – 25 ). Education is also tightly linked to wealth and residential status( 26 ), two other major social determinants of inequalities in ANC service utilization( 27 ). Data from the 2019 Sierra Leone Demographic and Health Survey show that working women and wealthier women are more likely to have more ANC visits( 28 ). In addition, previous studies from Sierra Leone and other low-income settings consistently show that geographic distance to health facilities reduces ANC utilization and quality( 12 , 13 , 17 , 29 , 30 ). Earlier studies, including our own work on home births in the same population have found, that increased ANC attendance is associated with higher rates of institutional deliveries and skilled birth attendance( 31 – 35 ). This suggest that ANC, even when imperfect, plays a role in informing and encouraging women to seek skilled delivery care. The extreme rate of adolescent pregnancy in our population may further contribute to poor ANC quality, as early motherhood has been linked to school dropout, long-term poverty, and reduced health literacy( 36 ). Studies show that adolescent mothers are less likely to receive ANC( 37 ) and more likely to give birth at home( 38 ). While improving education and reducing adolescent pregnancies are important long-term goals, our findings highlight the urgent need for targeted interventions for low-educated and remote women, with outreach and health education as key strategies. To our knowledge, this is the first study to explore the correlation between ANC visits and service uptake among women in SSA. The study benefits from a large sample, which provides robust estimates on some of the most disadvantages women in Sierra Leone. The cross-sectional design restricts our ability to infer causality. The reliance on self-reported data introduces potential recall bias and social desirability bias, although measures were taken to mitigate these through training and confidentiality assurances. Where available, data were supplemented by written sources such as ANC cards and clinic books, but these were not always accessible. Additionally, because only a small proportion of women received the full recommended doses of IPTp-SP and TT, we could not include these in our definition of high-quality ANC. This may have resulted in an overestimation of overall ANC quality and an underestimation of the true gap in achieving WHO standards. Finally, the quantitative design limits the depth of insight into cultural and contextual factors influencing ANC utilization. Future research could benefit from integrating qualitative methods to explore these aspects more deeply. 5 Conclusion This study provides an update on ANC utilization in rural Sierra Leone, highlighting persistent challenges despite ongoing efforts to improve maternal health services. ANC visits appear to be a facilitator of uptake of ANC components. While progress has been made in increasing ANC attendance, substantial gaps remain in ensuring that visits translate into comprehensive care. We call for research investigating underlying factors for individual ANC components in Sierra Leone and interventions targeting particularly illiterate and low educated families. Without targeted action, ANC quality will remain suboptimal, hindering progress toward achieving the United Nation’s SDG 3 on reducing maternal mortality and achieving universal health coverage including access to essential maternal healthcare services. Abbreviations Abbreviation Full Term ANC Antenatal Care AOR Adjusted Odds Ratio CHC Community Health Centre CI Confidence Interval IPTp-SP Intermittent Preventive Treatment in Pregnancy with Sulfadoxine-Pyrimethamine LMICs Low- and Middle-Income Countries MMR Maternal Mortality Rate NTNU Norwegian University of Science and Technology OR Odds Ratio PCMH Princess Christian Maternity Hospital SDG Sustainable Development Goal SSA Sub-Saharan Africa SLESRC Sierra Leone Ethics and Scientific Review Committee SPSS Statistical Package for the Social Sciences TT Tetanus Toxoid UNESCO United Nations Educational, Scientific and Cultural Organization WHO World Health Organization Declarations Ethical considerations Ethical approval for the study was obtained from the Sierra Leone Ethics and Scientific Review Committee (SLESRC No: 018/02/2023). Written informed consent was collected from all participants; those unable to write provided consent using a thumbprint. To ensure confidentiality, all data were anonymized and securely stored in a locked room. Consent for publication Not applicable. The study does not include any individual person’s data in any form (such as images, videos, or personal details). Availability of data materials: The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that there are no financial interests or personal relationships that could have affected the work presented in this paper. Funding: The Wouter Nolet Foundation funded this research project. The foundations involvement did not include designing the study, collecting the data, analysing the results, or interpreting the findings. Author contributions: S.S : Writing – Original draft, Writing – Review and Editing, Data curation, Formal Analysis, Visualisation, Investigation, Project administration. R.R : Writing – Review and Editing, Methodology, Supervision. J.Wu : Writing – Review and Editing, Investigation, Project administration, Data curation. T.D.F : Writing – Review and Editing, Methodology, Conceptualisation, Supervision. M.I.C : Investigation, Writing – Review & Editing. I.A.K : Investigation, Writing – Review and Editing. H.S.S : Investigation, Writing – Review and Editing. A.D : Investigation, Writing – Review and Editing. Z.M.S : Investigation, Writing – Review and Editing. H.A.B : Writing – Review and Editing, Methodology, Conceptualisation. J.We .: Writing – Review and Editing, Methodology, Conceptualisation. M.L.K : Writing – Review and Editing, Methodology, Conceptualisation, Supervision, Funding Acquisition. Acknowledgement: We would like to thank and acknowledge that we are grateful to all the women who took part in this study and generously shared their time and experiences. We also appreciate the dedication and effort of our research assistants, as well as the invaluable support from the staff at Masanga Hospital. Lastly, we extend our thanks to the Wouter Nolet Foundation for their financial backing and commitment to improving maternal health in Sierra Leone. References Organization WH. Trends in maternal mortality estimates 2000 to 2023: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: World Health Organization; 2025. Chukwuma A, Wosu AC, Mbachu C, Weze K. Quality of antenatal care predicts retention in skilled birth attendance: a multilevel analysis of 28 African countries. BMC Pregnancy Childbirth. 2017;17(1):152. Wondemagegn AT, Alebel A, Tesema C, Abie W. The effect of antenatal care follow-up on neonatal health outcomes: a systematic review and meta-analysis. Public Health Rev. 2018;39:33. Statistics Sierra Leone I. Demographic and Health Survey. Freetown, Sierra Leone and Rockville, USA; 2019. Organization WH. WHO recommendations on antenatal care for a positive pregnancy experience. World Health Organization; 2016. Tesfay N, Tariku R, Zenebe A, Dejene Z, Woldeyohannes F. Cause and risk factors of early neonatal death in Ethiopia. PLoS One. 2022;17(9):e0275475. WHO. Daily iron and folic acid supplementation in pregnant women.: Guideline: Geneva, World Health Organization; 2012. Balarajan Y, Ramakrishnan U, Ozaltin E, Shankar AH, Subramanian SV. Anaemia in low-income and middle-income countries. Lancet. 2011;378(9809):2123-35. Bussink-Voorend D, Bussink AP, Falama AM, Stekelenburg J. Health Indicators of Pregnant Women in Tonkolili District, Rural Sierra Leone. Int J Environ Res Public Health. 2020;17(11). Shafiq Y, Caviglia M, Juheh Bah Z, Tognon F, Orsi M, A KK, et al. Causes of maternal deaths in Sierra Leone from 2016 to 2019: analysis of districts' maternal death surveillance and response data. BMJ Open. 2024;14(1):e076256. Benova L, Tunçalp Ö, Moran AC, Campbell OMR. Not just a number: examining coverage and content of antenatal care in low-income and middle-income countries. BMJ Glob Health. 2018;3(2):e000779. Dickson KS, Kwabena Ameyaw E, Akpeke M, Mottey BE, Adde KS, Esia-Donkoh K. Socio-economic disadvantage and quality Antenatal Care (ANC) in Sierra Leone: Evidence from Demographic and Health Survey. PLoS One. 2023;18(1):e0280061. Kangbai DM, Bandoh DA, Manu A, Kangbai JY, Kenu E, Addo-Lartey A. Socio-economic determinants of maternal health care utilization in Kailahun District, Sierra Leone, 2020. BMC Pregnancy Childbirth. 2022;22(1):276. Nations U. The 17 goals: Department of Economic and Social Affairs Sustainable Development; 2025 [Available from: https://sdgs.un.org/goals. Kebede TT, Godana W, Utaile MM, Sebsibe YB. Effects of antenatal care service utilization on maternal near miss in Gamo Gofa zone, southern Ethiopia: retrospective cohort study. BMC Pregnancy Childbirth. 2021;21(1):209. Wolde HF, Tsegaye AT, Sisay MM. Late initiation of antenatal care and associated factors among pregnant women in Addis Zemen primary hospital, South Gondar, Ethiopia. Reprod Health. 2019;16(1):73. Kanyangarara M, Munos MK, Walker N. Quality of antenatal care service provision in health facilities across sub-Saharan Africa: Evidence from nationally representative health facility assessments. J Glob Health. 2017;7(2):021101. Yaya S, Kota K, Buh A, Bishwajit G. Prevalence and predictors of taking tetanus toxoid vaccine in pregnancy: a cross-sectional study of 8,722 women in Sierra Leone. BMC Public Health. 2020;20(1):855. Abdissa Z, Alemu K, Lemma S, Berhanu D, Defar A, Getachew T, et al. Effective coverage of antenatal care services in Ethiopia: a population-based cross-sectional study. BMC Pregnancy Childbirth. 2024;24(1):330. Hurley EA, Harvey SA, Rao N, Diarra NH, Klein MC, Diop SI, et al. Underreporting and Missed Opportunities for Uptake of Intermittent Preventative Treatment of Malaria in Pregnancy (IPTp) in Mali. PLoS One. 2016;11(8):e0160008. Berchie GO, Doe PF, Azu TD, Agyeiwaa J, Owusu G, Boso CM, et al. Uptake and Effectiveness of Intermittent Preventive Treatment with Sulfadoxine-Pyrimethamine during Pregnancy in Africa: A Scoping Review. Diseases. 2024;12(9). Afulani PA. Rural/urban and socioeconomic differentials in quality of antenatal care in Ghana. PLoS One. 2015;10(2):e0117996. Tsawe M, Susuman AS. Inequalities in maternal healthcare use in Sierra Leone: Evidence from the 2008-2019 Demographic and Health Surveys. PLoS One. 2022;17(10):e0276102. Wang H, Frasco E, Takesue R, Tang K. Maternal education level and maternal healthcare utilization in the Democratic Republic of the Congo: an analysis of the multiple indicator cluster survey 2017/18. BMC Health Serv Res. 2021;21(1):850. Okedo-Alex IN, Akamike IC, Ezeanosike OB, Uneke CJ. Determinants of antenatal care utilisation in sub-Saharan Africa: a systematic review. BMJ Open. 2019;9(10):e031890. Patrinos HA PG. Returns to education in developing countries. . London: Elsevier. 2020(Bradley S, Green C (eds). The Economics of Education):54-64. Ameyaw EK, Baatiema L, Naawa A, Odame F, Koramah D, Arthur-Holmes F, et al. Quality of antenatal care in 13 sub-Saharan African countries in the SDG era: evidence from Demographic and Health Surveys. BMC Pregnancy Childbirth. 2024;24(1):303. Sserwanja Q, Musaba MW, Kamara K, Mutisya LM, Mukunya D. Status of the latest 2016 World Health Organization recommended frequency of antenatal care contacts in Sierra Leone: a nationally representative survey. BMC Health Serv Res. 2022;22(1):1208. Koroma MM, Kamara SS, Bangura EA, Kamara MA, Lokossou V, Keita N. The quality of free antenatal and delivery services in Northern Sierra Leone. Health Res Policy Syst. 2017;15(Suppl 1):49. Obse AG, Ataguba JE. Explaining socioeconomic disparities and gaps in the use of antenatal care services in 36 countries in sub-Saharan Africa. Health Policy Plan. 2021;36(5):651-61. Mohammed S, Worku A, Girma E. Receiving quality antenatal care service increases the chance of maternal use of skilled birth attendants in Ethiopia: Using a longitudinal panel survey. PLoS One. 2022;17(12):e0279495. Dahiru T, Oche OM. Determinants of antenatal care, institutional delivery and postnatal care services utilization in Nigeria. Pan Afr Med J. 2015;21:321. Adjiwanou V, Legrand T. Does antenatal care matter in the use of skilled birth attendance in rural Africa: a multi-country analysis. Soc Sci Med. 2013;86:26-34. Tekelab T, Yadecha B, Melka AS. Antenatal care and women's decision making power as determinants of institutional delivery in rural area of Western Ethiopia. BMC Res Notes. 2015;8:769. Bayo P, Belaid L, Tahir EO, Ochola E, Dimiti A, Greco D, et al. "Midwives do not appreciate pregnant women who come to the maternity with torn and dirty clothing": institutional delivery and postnatal care in Torit County, South Sudan: a mixed method study. BMC Pregnancy Childbirth. 2020;20(1):250. Wodon Q, Yedan A, Edmeades J. Economic Impacts of Child Marriage: Educational Attainment2017. Tolossa T, Gold L, Dheresa M, Turi E, Yeshitila YG, Abimanyi-Ochom J. Adolescent maternal health services utilization and associated barriers in Sub-Saharan Africa: A comprehensive systematic review and meta-analysis before and during the sustainable development goals. Heliyon. 2024;10(15):e35629. Budu E, Chattu VK, Ahinkorah BO, Seidu A-A, Mohammed A, Tetteh JK, et al. Early age at first childbirth and skilled birth attendance during delivery among young women in sub-Saharan Africa. BMC Pregnancy and Childbirth. 2021;21(1):834. Additional Declarations No competing interests reported. Supplementary Files Supplementarymaterial.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 26 Aug, 2025 Reviewers invited by journal 20 Aug, 2025 Editor invited by journal 23 Jul, 2025 Editor assigned by journal 22 Jul, 2025 Submission checks completed at journal 22 Jul, 2025 First submitted to journal 16 Jul, 2025 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-7139990","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":506206148,"identity":"d5b596d4-f8be-4438-98b5-1cd65163c655","order_by":0,"name":"Sebastian Starling","email":"","orcid":"","institution":"Aarhus University","correspondingAuthor":false,"prefix":"","firstName":"Sebastian","middleName":"","lastName":"Starling","suffix":""},{"id":506206149,"identity":"f6ef26b5-da75-4900-95b4-cc065ed3ed20","order_by":1,"name":"Rosa Roemers","email":"","orcid":"","institution":"Masanga 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(NTNU)","correspondingAuthor":false,"prefix":"","firstName":"Josien","middleName":"","lastName":"Westendorp","suffix":""},{"id":506206162,"identity":"79d546f5-aa1b-4fca-b8c5-2cd60c2b118c","order_by":11,"name":"Rugiatu Jalloh","email":"","orcid":"","institution":"Princess Christina Maternity Hospital (PCMH)","correspondingAuthor":false,"prefix":"","firstName":"Rugiatu","middleName":"","lastName":"Jalloh","suffix":""},{"id":506206163,"identity":"f66283c3-fe05-492d-b016-750476fd49b1","order_by":12,"name":"Monica Lauridsen Kujabi","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA/ElEQVRIiWNgGAWjYJCCA0BsAKTYGBIqQPwEZiDBbECkljNEamGAaGFgY2BsI0KLbnvvwQM/ahiMDQ4efvbg4by6xO3sCczGPAzWxri0mJ05l3Cw5xiDmcGBY+YGidsOJ+7secCczMOQboZTy40cg8NAJ9kYHDhgJpG47UDihhsJzId5GA7b4NfyD6Tl+DeJxDl1RGoB+hrosDNAWxqYwVqADjuM22Fnzhgc7O2TMJY8cKbcIOHYYeMNZx42G84xSMft/eM9xh9+fLMx7LtxfNvDHzV1shuOJx+WeFNhbdiASw8ESADRARiHsQESTwQBPwFTR8EoGAWjYOQCAIBqX4LlZxIcAAAAAElFTkSuQmCC","orcid":"","institution":"University of Copenhagen","correspondingAuthor":true,"prefix":"","firstName":"Monica","middleName":"Lauridsen","lastName":"Kujabi","suffix":""}],"badges":[],"createdAt":"2025-07-16 12:23:23","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7139990/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7139990/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":90307323,"identity":"e20db758-9a9c-4cbf-a68f-e56c1795e4dc","added_by":"auto","created_at":"2025-09-01 09:31:06","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":77773,"visible":true,"origin":"","legend":"\u003cp\u003eDefinition of low-, medium- and high-quality of antenatal care (ANC)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eScoring system for antenatal care (ANC) quality\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEach of the seven key ANC components contributes one point toward an overall ANC quality score: at least four ANC visits, iron supplementation, folic acid supplementation, tetanus vaccination (≥1 dose), malaria prophylaxis (≥1 dose), albendazole supplementation, and ultrasound scan. Based on total scores, ANC quality was categorized as follows: 0–3 points = low quality, 4–6 = medium quality, and 7 = high quality.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7139990/v1/074ae50e25c6e4ff4e88dadb.png"},{"id":90310920,"identity":"3bfa1810-d7b8-4a34-92a3-f002d7e99a45","added_by":"auto","created_at":"2025-09-01 09:47:07","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1761439,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7139990/v1/02a07d89-9137-40f0-9b10-a417fd365284.pdf"},{"id":90307320,"identity":"7c33744f-cf12-41ce-b7d9-986a3d5fde70","added_by":"auto","created_at":"2025-09-01 09:31:06","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":33171,"visible":true,"origin":"","legend":"","description":"","filename":"Supplementarymaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-7139990/v1/50cae8d5a89d2c0e8abf4dbe.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Utilization and quality of antenatal care in Mathonkara area, rural Sierra Leone: A cross- sectional study","fulltext":[{"header":"1 Introduction","content":"\u003cp\u003eDespite improvements, the maternal mortality ratio (MMR) in Sierra Leone remains alarmingly high at 354 per 100,000(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e). A review of 28 SSA countries found that women receiving higher quality ANC were more likely to access skilled delivery care and had a lower MMR(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e), and evidence from LMICs suggests ANC can reduce neonatal deaths by up to 34%(\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eANC provide an opportunity to deliver preventive interventions, detect complications early, promote healthy pregnancy practices and counsel on pregnancy danger signs and family planning(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). The World Health Organization (WHO) recommends at least eight ANC contacts during pregnancy, beginning in the first trimester, with provision of a defined set of evidence-based services(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). These include daily iron\u0026ndash;folic acid supplementation, a minimum of three preventive treatments of malaria with sulfadoxine-pyrimethamine (IPTp-SP), administration of at least two doses of tetanus toxoid (TT) vaccine and ultrasound scan before week 24(\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). TT vaccination prevent neonatal tetanus, particularly in home births conducted under unhygienic conditions(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). Iron and folic acid(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) supplements and malaria prophylaxis decrease risk of maternal anaemia and associated complications(\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). Studies from rural health facilities in the Tonkolili district have reported anaemia in over 65% of pregnant women and malaria in more than one-third(\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Postpartum haemorrhage remains the leading cause of maternal mortality in Sierra Leone(\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e) thus anaemia prevention is crucial. Attending ANC may not ensure improved outcomes unless all essential ANC components are provided according to recommended standards(\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Despite the recognized importance of ANC, as well as attempts to improve adherence, significant gaps remain in the quality and completeness of care provided in many low-resource settings, including Sierra Leone(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Reducing maternal and neonatal mortality is a key objective of the United Nations' Sustainable Development Goals (SDGs), particularly SDG 3, which aims to lower maternal mortality to fewer than 70 deaths per 100,000 live births and neonatal mortality to below 12 per 1,000 live births by 2030(\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e). Achieving these targets requires access to high-quality ANC(\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn this study, we aim to assess ANC utilization, the completeness of care, and factors associated with low-quality ANC. Identifying and understanding these barriers is crucial for developing targeted strategies to improve maternal healthcare and reduce maternal and neonatal mortality in Sierra Leone.\u003c/p\u003e"},{"header":"2 Method","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003e2.1 Research site and study population\u003c/h2\u003e\u003cp\u003eThe study included all women of reproductive age who lived in one out of 23 selected villages surrounding the Mathonkara Community Health Centre (CHC) in the Tonkolili district, rural Sierra Leone for at least six months during pregnancy and who had a live birth between February 1, 2022, and January 31, 2023. The Mathonkara catchment area was specifically selected due to its poor health indicators and remote location (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe geography of the area presents several logistical challenges, including long travel distances, limited access to nearby health facilities, impassable rivers, rugged mountainous terrain, and poorly maintained roads. For many of the women, reaching the closest ANC clinic, require travelling several hours by motorbike or on foot, navigating narrow dirt paths.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e\u003ch2\u003e2.2 Study design and data collection\u003c/h2\u003e\u003cp\u003eThis study is a baseline study prior to an ANC intervention aimed at increasing facility-based births, conducted in collaboration with the Maternal Outreach Team of Masanga Hospital and the Wouter Nolet Foundation. Data were collected using a structured questionnaire, which included a combination of single-choice, multiple-choice, open- and close-ended questions (Supplementary 1). The data were collected from February 25th to May 12th, 2023. Questionnaires were administered through individual, structured interviews, and responses were directly entered into KoboToolbox (Kobo Organization, USA).\u003c/p\u003e\u003cp\u003eSix local research assistants, 3 women and 3 men, were recruited for data collection and received a one-week training program led by SS and JW. Prior to initiating data collection, meetings were held with village leaders to explain the study objectives and obtain their support.\u003c/p\u003e\u003cp\u003eWomen were identified using a door-to-door approach in each village. Eligible participants were invited to take part in the interview, which was conducted at their home or another private location. Interviews were conducted in Krio or Temne, by the local research assistants. To maximize participation, three revisits were made to each village to reach women who were not available during the initial visits.\u003c/p\u003e\u003cp\u003eQuality control measures included on-site supervision during field activities. Every interview was supervised by SS, JW or both. Quality control further included systematic cross-checking of each entry for missing data, outliers, and inconsistencies within 48 hours of data entry, and two refresher training sessions for the research assistants to ensure data accuracy and reliability.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e\u003ch2\u003e2.3 Definition of variables\u003c/h2\u003e\u003cp\u003eWe assessed ANC components recommended by the WHO for optimal ANC: \u0026ge; 8 ANC visits, iron, folic acid and albendazole supplementation, two TT vaccines, three prophylactic malaria treatments and an ultrasound scan before 24 weeks of gestation. We grouped quality of ANC into low-, medium- and high-quality ANC based on receipt of individual ANC components as described in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Studies demonstrate increased effectiveness of \u0026ge;\u0026thinsp;3 doses of IPTp-SP and \u0026ge;\u0026thinsp;2 TT injections, however, the low number of women receiving the full coverage, did not allow for further analysis. High quality ANC therefore include one dose of IPTp-SP and one dose of TT injections. This division is seen in similar studies(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSocio-demographic characteristics include age, relationship status, literacy, educational level, occupation and distance to health facilities. Maternal health indicators include parity and age at first pregnancy.\u003c/p\u003e\u003cp\u003eDistance to health facilities was measured based on the facility that each woman reported using, rather than the nearest one geographically. For villages with mapped roads, routes were calculated using Google Maps. In cases where roads were unmapped, distances were manually measured using satellite imagery on Google Maps.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003e2.4 Data analysis\u003c/h2\u003e\u003cp\u003eThe statistical analysis was done using SPSS (SPSS Statistics 30.0.0). Demographic characteristics and ANC components were analysed using descriptive statistics. The associations between the number of ANC visits and the receipt of individual ANC components, as well as between high-quality ANC and socio-demographic factors, were analysed using bivariate and multivariate logistic regression. Variables with a p-value\u0026thinsp;\u0026le;\u0026thinsp;0.1 in the bivariate analysis were included in the multivariate model to adjust for potential confounding factors. Adjusted Odds Ratios (AOR) with corresponding 95% confidence intervals (CI) were calculated for each variable in the multivariate analysis. Statistical significance was defined as a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05.\u003c/p\u003e\u003c/div\u003e"},{"header":"3 Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003e3.1 Descriptive statistics\u003c/h2\u003e\u003cp\u003eA total of 513 women were included in the study. Most of the women were aged 20\u0026ndash;40 years (75.0%, 385/513), while 19.3% (99/513) were \u0026le;\u0026thinsp;19 years at the time of the interview. Majority of the women were \u0026le;\u0026thinsp;19 years of age at the time of their first pregnancy (73.1%, 115/513). Of the women, 58.1% (298/513) were illiterate, and 53.6% (275/513) had no formal education. Around a third (27.7%, 142/513) lived in a village with a health facility while 17.0% (87/513) lived more than 9 km from the nearest health facility. Regarding parity, 23.4% (120/513) were first-time mothers, and 25.3% (130/513) had five or more children. [See 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\u003eBackground characteristics of the study population\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\u003eCharacteristics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eNumber (n\u0026thinsp;=\u0026thinsp;513)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePercentages (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge groups\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20\u0026ndash;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e385\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e75.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnknown\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLiteracy\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiterate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e215\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e41.9\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIlliterate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e298\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e58.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRelationship status\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSingle/Widowed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried/In a relationship\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e484\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e94.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHighest level of education\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\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e275\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e53.6\u003c/p\u003e\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\u003e69\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJunior secondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e18.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSenior secondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e73\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14.2\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHigher\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOccupation*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e468\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e91.2\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\u003e45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.8\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDistance to closest health facility\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIn the village (0 km)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e142\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e27.7\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u0026ndash;4 km\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e161\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u0026ndash;8 km\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e123\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;9 km\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e87\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17.0\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eParity\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e120\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026ndash;4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e263\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e51.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e130\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e25.3\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge at time of first pregnancy\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e115\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e73.1\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e375\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22.4\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnknown\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e* Multiple answers/occupations were possible. Occupations included: student, miner, farmer, trader, teacher, self-employment, driver, government employee, other (free text)\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMost women (81.1%, 416/513) attended four to seven ANC visits, but only few (4.9%, 25/513) completed the recommended\u0026thinsp;\u0026ge;\u0026thinsp;8 visits. The quality of ANC was classified as high in 31.8% (163/513), medium in 60.2% (309/513), and low in 8.0% (31/513). Only 3.1% (16/513) of the women received all recommended ANC services with \u0026ge;\u0026thinsp;4 ANC visits, and just one woman (0.2%, 1/513) received all recommended services with \u0026ge;\u0026thinsp;8 ANC visits.\u003c/p\u003e\u003cp\u003eMalaria prophylaxis was the most commonly received ANC component (86.2%, 442/513), while timely ultrasound was the least (42.1, 216/513%). Majority of women received one dose of malaria prophylaxis (40.4%, 207/513), while 20.5% (105/513) received the recommended three doses. Most women received a TT injection (80.5%, 413/513), while only 42.7% (219/513) received the recommended two doses. There was only a slight difference in TT injections comparing nulliparous and multiparous women. See Table\u0026nbsp;2 for further details on the individual ANC components.\u003c/p\u003e\u003c/div\u003e\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"593\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 67.4038%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTable 2:\u003c/strong\u003e Components of antenatal care received by women in the Mathonkara catchment area\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eCharacteristics\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003eNumber (n = 513)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003ePercentages (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 60.7183%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Antenatal care visits\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7517%;\"\u003e\n \u003cp\u003e\u0026le; 3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e68\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e13.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7517%;\"\u003e\n \u003cp\u003e\u0026nbsp; 4-7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e416\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e81.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7517%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026ge; 8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e4.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 15.7517%;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp;Unknown\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 67.4038%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReceived iron supplementation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e9.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eSome days/ran out\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e142\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e27.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eThrough whole pregnancy\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e294\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e57.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eI don\u0026rsquo;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e26\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e5.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 67.4038%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFolic acid supplementation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e54\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e10.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eTook folic acid\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e456\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e88.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eI don\u0026rsquo;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 67.4038%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReceived Malaria prophylaxis\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e59\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e11.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003e1 dose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e207\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e40.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003e2 doses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e130\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e25.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003e3 doses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e105\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e20.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eI don\u0026rsquo;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e12\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e2.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 67.4038%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAlbendazole supplementation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e139\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e27.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eTook Albendazole\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e357\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e69.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eI don\u0026rsquo;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e17\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e3.3\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 67.4038%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTetanus toxoid (TT) injections\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e10.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003e1 dose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e194\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e37.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003e\u0026ge; 2 doses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e219\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e42.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eI don\u0026rsquo;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e44\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e8.6\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 67.4038%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTT in primiparous women (n = 120)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e14\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e11.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003e1 dose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e51\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e42.5\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003e\u0026ge; 2 doses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e47\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e38.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eI don\u0026rsquo;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 67.4038%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTT in multiparous women (n = 393)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e42\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e10.7\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 213px;\"\u003e\n \u003cp\u003e\u0026nbsp; \u0026nbsp;1 dose\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e143\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e36.4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003e\u0026ge; 2 doses\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e172\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e43.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eI don\u0026rsquo;t know\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e36\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e9.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 67.4038%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReceived an ultrasound scan\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e318\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e62.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e195\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e38.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 67.4038%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReceived an ultrasound scan before 24 weeks of GA\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e216\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e42.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e297\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e57.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 67.4038%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReceived all recommended antenatal care services\u003csup\u003e1\u003c/sup\u003e with 8 ANC visits\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e0.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e512\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e99.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 67.4038%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eReceived all recommended antenatal care services with 4 ANC visits\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eYes\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e16\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e3.1\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eNo\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e497\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e96.9\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" valign=\"top\" style=\"width: 67.4038%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eQuality of Antenatal care\u003csup\u003e2\u003c/sup\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eLow\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e41\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e8.0\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eMedium\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e309\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e60.2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 23.1299%;\"\u003e\n \u003cp\u003eHigh\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 20.7936%;\"\u003e\n \u003cp\u003e163\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 23.3635%;\"\u003e\n \u003cp\u003e31.8\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e1 As defined by the WHO: folic acid supplementation, albendazole supplementation, iron supplementation, two TT vaccines, three prophylactic malaria treatments and an ultrasound scan before 24 weeks of GA.\u003c/p\u003e\n\u003cp\u003e2 ANC quality defined as: High 7 points, medium 4-6 points and low 0-3 points. One point is given for each of the following components: \u0026nbsp;\u0026ge; 4 ANC visits, folic acid supplementation, albendazole supplementation, iron supplementation, \u0026ge; 1 prophylactic malaria treatment, \u0026ge; 1 TT vaccines and an ultrasound during pregnancy.\u003c/p\u003e\u003cdiv id=\"Sec9\" class=\"Section2\"\u003e\u003ch2\u003e3.2 Characteristics associated ANC visits and components of ANC\u003c/h2\u003e\u003cp\u003eThe bivariate analysis demonstrated that receiving\u0026thinsp;\u0026ge;\u0026thinsp;4 ANC visits was significantly associated with iron supplementation, \u0026ge; 1 doses of malaria prophylaxis, albendazole supplementation, \u0026ge; 1 doses of tetanus vaccination and folic acid supplementation.\u003c/p\u003e\u003cp\u003eIn the multivariate analysis, consistent iron supplementation (AOR\u0026thinsp;=\u0026thinsp;3.24 [1.15\u0026ndash;9.12]), two doses of malaria prophylaxis (AOR\u0026thinsp;=\u0026thinsp;3.13 [1.01\u0026ndash;9.65]), folic acid supplementation (AOR\u0026thinsp;=\u0026thinsp;2.71 [1.07\u0026ndash;6.87]) and receiving two or more doses of tetanus toxoid injections (AOR\u0026thinsp;=\u0026thinsp;3.15 [1.37\u0026ndash;7.28]) remained associated with \u0026ge;\u0026thinsp;4 ANC visits. Albendazole supplementation did not retain significance after adjustment. [See Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\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 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAssociation between \u0026ge;\u0026thinsp;4 antenatal care (ANC) visits and components of ANC\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"9\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eDemographics\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u003cp\u003eBivariate analysis\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c9\" namest=\"c6\"\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\u003eCharacteristics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;4 ANC visits (%)\u003c/p\u003e \u003cp\u003e441 (86.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;3 ANC visits (%)\u003c/p\u003e\u003cp\u003e68 (13.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eUnadjusted OR (95% CI)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003eAdjusted OR (95% CI)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eComponents of antenatal care\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eReceived iron supplementation\u003c/b\u003e\u003c/p\u003e\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\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\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\u003e31 (7.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19 (27.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSome days/ran out\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e119 (27.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22 (32.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.32 (1.60\u0026ndash;6.88)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e1.74 (0.64\u0026ndash;4.74)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.28\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConsistently\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e269 (61.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23 (33.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.17 (3.52\u0026ndash;14.61)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e3.24 (1.15\u0026ndash;9.12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eI don\u0026rsquo;t know\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e22 (5.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (5.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.37 (1.01\u0026ndash;11.29)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e2.35 (0.54\u0026ndash;10.24)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.26\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eReceived Malaria prophylaxis\u003c/b\u003e\u003c/p\u003e\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\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\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\u003e38 (8.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (29.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1 dose\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e181 (41.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e22 (32.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.38 (2.18\u0026ndash;8.81)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e1.54 (0.57\u0026ndash;4.18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.40\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2 doses\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e121 (27.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8 (11.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.96 (3.25\u0026ndash;19.53)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e3.13 (1.01\u0026ndash;9.65)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e3 doses\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e91 (20.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e14 (20.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.42 (1.57\u0026ndash;7.47)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e1.39 (0.47\u0026ndash;4.12)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.55\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eI don\u0026rsquo;t know\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e8 (1.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (5.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.05 (0.28\u0026ndash;3.93)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.94\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e0.36 (0.06\u0026ndash;2.21)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAlbendazole supplementation\u003c/b\u003e\u003c/p\u003e\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\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\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\u003e107 (24.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e31 (45.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\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\u003e321 (72.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e33 (48.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.82 (1.65\u0026ndash;4.82)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e1.22 (0.61\u0026ndash;2.45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.57\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eI don\u0026rsquo;t know\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e13 (2.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4 (5.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.94 (0.29\u0026ndash;3.10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e0.97 (0.19\u0026ndash;5.03)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.98\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eTetanus toxoid injections\u003c/b\u003e\u003c/p\u003e\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\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\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\u003e41 (9.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e15 (22.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1 dose\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e171 (38.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e23 (33.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.72 (1.31\u0026ndash;5.67)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e2.04 (0.91\u0026ndash;4.59)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;2 doses\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e200 (45.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (25.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e4.30 (1.99\u0026ndash;9.31)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e3.15 (1.37\u0026ndash;7.28)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eI don\u0026rsquo;t know\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29 (6.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e13 (19.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.82 (0.34\u0026ndash;1.97)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.65\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e3.46 (0.98\u0026ndash;12.17)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eFolic acid supplementation\u003c/b\u003e\u003c/p\u003e\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\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\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\u003e33 (7.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (29.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\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\u003e406 (92.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e47 (69.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e5.24 (2.78\u0026ndash;9.85)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e2.71 (1.07\u0026ndash;6.87)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;0.01\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eI don\u0026rsquo;t know\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e2 (0.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1 (1.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.15 (0.10-14.24)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.88\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e0.69 (0.04\u0026ndash;12.78)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.80\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"4\" nameend=\"c4\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eReceived ultrasound scan in last pregnancy\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\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\u003e161 (36.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e32 (47.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\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\u003e280 (63.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36 (52.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.55 (0.92\u0026ndash;2.59)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u003cp\u003e1.64 (0.93\u0026ndash;2.91)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.09\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"6\" nameend=\"c6\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eReceived ultrasound scan before 24 weeks GA\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\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\u003e250 (56.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e44 (35.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\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\u003e191 (43.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e24 (64.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.40 (0.82\u0026ndash;2.38)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"5\" nameend=\"c5\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eN\u0026thinsp;=\u0026thinsp;Number of individuals, OR\u0026thinsp;=\u0026thinsp;Odds ratio, AOR\u0026thinsp;=\u0026thinsp;Adjusted odds ratio, CI\u0026thinsp;=\u0026thinsp;Confidence Interval, Ref. = Reference, km\u0026thinsp;=\u0026thinsp;kilometre, ANC\u0026thinsp;=\u0026thinsp;Antenatal Care, GA\u0026thinsp;=\u0026thinsp;Gestational age\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAfter adjusting for potential confounders (occupation, literacy, and distance to ANC clinics), we found that women living more than 9 km away were less likely to receive high quality ANC (AOR\u0026thinsp;=\u0026thinsp;0.50 [0.26\u0026ndash;0.95]). Though not significant, women who had an occupation besides their housework were twice as likely to receive high quality ANC (AOR\u0026thinsp;=\u0026thinsp;2.12 [0.98\u0026ndash;4.56]), and illiterate women were less likely to receive high ANC quality (AOR\u0026thinsp;=\u0026thinsp;0.70 [0.48\u0026ndash;1.02]). [See Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e4\u003c/span\u003e]\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAssociation between quality of antenatal care (ANC) and socio-demographic characteristics\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"8\"\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\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e\u003cp\u003eQuality of ANC\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u003cp\u003eBivariate analysis\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colspan=\"2\" nameend=\"c8\" namest=\"c7\"\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\u003eCharacteristics\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eHigh ANC quality\u003csup\u003e1\u003c/sup\u003e (%)\u003c/p\u003e\u003cp\u003e163 (31.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003eLow-medium ANC quality (%) 350 (68.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eUnadjusted OR (95% CI)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eAOR (95% CI)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003eP-value\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c8\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDemographic characteristics\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge groups\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\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e29 (17.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70 (20.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.83 (0.51\u0026ndash;1.35)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.45\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e20\u0026ndash;40\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e128 (78.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e257 (73.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (1.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e6 (1.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.00 (0.25\u0026ndash;4.08)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.99\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnknown\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (1.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e17 (4.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.35 (0.10\u0026ndash;1.23)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.10\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eRelationship status\u003c/b\u003e\u003c/p\u003e\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\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSingle/Widowed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e10 (6.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e19 (5.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMarried/Relationship\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e153 (93.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e331 (94.6)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.88 (0.40\u0026ndash;1.93)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.75\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eLiteracy\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\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLiterate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e78 (47.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e137 (39.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIlliterate\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e85 (52.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e213 (60.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.70 (0.48\u0026ndash;1.02)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e0.70 (0.48\u0026ndash;1.02)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.06\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eHighest level of education\u003c/b\u003e\u003c/p\u003e\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\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNone\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e81 (50.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e194 (55.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\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\u003e24 (14.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45 (12.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.28 (0.73\u0026ndash;2.23)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.39\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eJunior secondary\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28 (17.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e66 (18.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.02 (0.61\u0026ndash;1.70)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.95\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSenior secondary/high\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e28 (17.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e45 (12.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.49 (0.87\u0026ndash;2.55)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.15\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eOccupation\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\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\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\u003e9 (5.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e36 (10.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmployed\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e154 (94.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e314 (89.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.96 (0.92\u0026ndash;4.18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.08\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e2.12 (0.98\u0026ndash;4.56)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.05\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eDistance to closest health facility\u003c/b\u003e\u003c/p\u003e\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\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eIn the village (0 km)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e47 (28.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95 (27.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u0026ndash;4 km\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e53 (31.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e108 (30.9)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.99 (0.61\u0026ndash;1.60)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.97\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e1.02 (0.63\u0026ndash;1.66)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.93\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e5\u0026ndash;8 km\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e46 (28.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e77 (22.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.21 (0.73-2.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.47\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e1.34 (0.80\u0026ndash;2.24)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.27\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;9 km\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e17 (10.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e70 (20.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.50 (0.26\u0026ndash;0.93)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.03\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u003cp\u003e0.52 (0.27\u0026ndash;0.98)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e0.04\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eParity\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\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38 (23.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e82 (23.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u0026ndash;4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e90 (55.2)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e173 (49.4)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.12 (0.71\u0026ndash;1.78)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.62\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;5\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e35 (21.5)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e95 (27.1)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.80 (0.46\u0026ndash;1.37)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.41\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eAge first pregnancy\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\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026le;\u0026thinsp;19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e122 (74.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e253 (72.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.98 (0.63\u0026ndash;1.52)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.92\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e38 (23.3)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e77 (22.0)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eRef.\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eUnknown\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e3 (1.8)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (5.7)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.30 (0.09\u0026ndash;1.09)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.07\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c7\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003eRemarks: OR\u0026thinsp;=\u0026thinsp;Odds ratio, AOR\u0026thinsp;=\u0026thinsp;Adjusted odds ratio, CI\u0026thinsp;=\u0026thinsp;Confidence interval, Ref\u0026thinsp;=\u0026thinsp;Reference, km\u0026thinsp;=\u0026thinsp;Kilometre, ANC\u0026thinsp;=\u0026thinsp;Antenatal care\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003e1 ANC quality defined as: High 7 points, medium 4\u0026ndash;6 points and low 0\u0026ndash;3 points. One point is given for each of the following components: \u0026ge; 4 ANC visits, folic acid supplementation, albendazole supplementation, iron supplementation, \u0026ge; 1 prophylactic malaria treatment, \u0026ge; 1 TT vaccines and an ultrasound during pregnancy.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"4 Discussion","content":"\u003cp\u003eThis study reveals gaps and socio-economic disparities in ANC uptake in the Tonkolili district of rural Sierra Leone. Despite most women receiving four or more ANC visits, few women received high quality ANC. In fact, only 3.1% received all seven key components recommended by the WHO. Women receiving four or more ANC visits had a three-fold chance of receiving consistent iron supplementation, two doses of malaria prophylaxis, folic acid supplementation and two or more TT doses. This emphasises the central role of ANC in women\u0026rsquo;s reproductive health. Our findings call for improvements in comprehensive ANC services, particularly targeting remoteness, illiteracy, and unemployment.\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003e4.1 Findings in context of earlier research\u003c/h2\u003e\u003cp\u003eMost studies on ANC in SSA and Sierra Leone, focus on visit quantity, with few studies exploring ANC comprehensiveness(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). As in this study, Yaya S. et al. found that women in Sierra Leone attending at least four ANC visits had significantly higher odds of receiving two doses of TT vaccine(\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Likewise, Abdissa Z. et al. found that women in Ethiopia who attended four or more ANC visits were significantly more likely to receive essential services such as iron supplementation and TT vaccination(\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Yet, even among frequent attenders, quality of care in our population remained low, raising the question of why key ANC components are still missed despite regular contact with the health system. Studies have found that barriers to utilization of IPTp-SP and TT injections, include stock-outs, inadequate training of healthcare providers, limited knowledge about the importance of the medicine among pregnant women and socioeconomic factors such as wealth and educational levels(\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e). Kanyangarara, M. et al. investigated quality of ANC in 28 SSA countries, including Sierra Leone, and found that only one in five women with a recent live birth received care at a facility with trained staff, appropriate clinical guidelines, and necessary supplies such as iron, IPTp, or tetanus vaccine(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Even where supplies were available, provision of appropriate care was often hindered by underutilization of ANC services, lack of protocols, and a shortage of trained personnel to deliver interventions(\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). To improve ANC in our study area, further exploration of supply chain and availability, costs, and staff knowledge are needed to ensure women are offered all recommended services. This also raises questions about the feasibility of recommending eight contacts in low-resource settings, where additional visits could overburden limited staff. We recommend prioritizing comprehensive care within four visits before expanding to eight.\u003c/p\u003e\u003cp\u003eOur study population is characterized by an alarmingly high proportion of women who entered motherhood before the age of 18, have little or no formal education, are illiterate and face significant challenges in accessing care due to the poor infrastructure and long distances to ANC clinics. These co-existing vulnerabilities may be an underlying driver of the low quality of ANC observed in the cohort. That we found no significant association between ANC and educational level and literacy in our data is likely because of a homogenic population (e.g. only 0.4% of women had attained education beyond the senior secondary level). Nonetheless, the current literature points towards maternal education as a crucial determinant of ANC quality(\u003cspan additionalcitationids=\"CR23 CR24\" citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). Education is also tightly linked to wealth and residential status(\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), two other major social determinants of inequalities in ANC service utilization(\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e). Data from the 2019 Sierra Leone Demographic and Health Survey show that working women and wealthier women are more likely to have more ANC visits(\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). In addition, previous studies from Sierra Leone and other low-income settings consistently show that geographic distance to health facilities reduces ANC utilization and quality(\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eEarlier studies, including our own work on home births in the same population have found, that increased ANC attendance is associated with higher rates of institutional deliveries and skilled birth attendance(\u003cspan additionalcitationids=\"CR32 CR33 CR34\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e). This suggest that ANC, even when imperfect, plays a role in informing and encouraging women to seek skilled delivery care.\u003c/p\u003e\u003cp\u003eThe extreme rate of adolescent pregnancy in our population may further contribute to poor ANC quality, as early motherhood has been linked to school dropout, long-term poverty, and reduced health literacy(\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). Studies show that adolescent mothers are less likely to receive ANC(\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) and more likely to give birth at home(\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eWhile improving education and reducing adolescent pregnancies are important long-term goals, our findings highlight the urgent need for targeted interventions for low-educated and remote women, with outreach and health education as key strategies.\u003c/p\u003e\u003cp\u003eTo our knowledge, this is the first study to explore the correlation between ANC visits and service uptake among women in SSA. The study benefits from a large sample, which provides robust estimates on some of the most disadvantages women in Sierra Leone.\u003c/p\u003e\u003cp\u003eThe cross-sectional design restricts our ability to infer causality. The reliance on self-reported data introduces potential recall bias and social desirability bias, although measures were taken to mitigate these through training and confidentiality assurances. Where available, data were supplemented by written sources such as ANC cards and clinic books, but these were not always accessible.\u003c/p\u003e\u003cp\u003eAdditionally, because only a small proportion of women received the full recommended doses of IPTp-SP and TT, we could not include these in our definition of high-quality ANC. This may have resulted in an overestimation of overall ANC quality and an underestimation of the true gap in achieving WHO standards.\u003c/p\u003e\u003cp\u003eFinally, the quantitative design limits the depth of insight into cultural and contextual factors influencing ANC utilization. Future research could benefit from integrating qualitative methods to explore these aspects more deeply.\u003c/p\u003e\u003c/div\u003e"},{"header":"5 Conclusion","content":"\u003cp\u003eThis study provides an update on ANC utilization in rural Sierra Leone, highlighting persistent challenges despite ongoing efforts to improve maternal health services. ANC visits appear to be a facilitator of uptake of ANC components. While progress has been made in increasing ANC attendance, substantial gaps remain in ensuring that visits translate into comprehensive care. We call for research investigating underlying factors for individual ANC components in Sierra Leone and interventions targeting particularly illiterate and low educated families. Without targeted action, ANC quality will remain suboptimal, hindering progress toward achieving the United Nation\u0026rsquo;s SDG 3 on reducing maternal mortality and achieving universal health coverage including access to essential maternal healthcare services.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAbbreviation\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFull Term\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eANC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eAntenatal Care\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eAOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eAdjusted Odds Ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eCHC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eCommunity Health Centre\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eCI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eConfidence Interval\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eIPTp-SP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eIntermittent Preventive Treatment in Pregnancy with Sulfadoxine-Pyrimethamine\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eLMICs\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eLow- and Middle-Income Countries\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eMMR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eMaternal Mortality Rate\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eNTNU\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eNorwegian University of Science and Technology\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eOR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eOdds Ratio\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003ePCMH\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003ePrincess Christian Maternity Hospital\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eSDG\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eSustainable Development Goal\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eSSA\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eSub-Saharan Africa\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eSLESRC\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eSierra Leone Ethics and Scientific Review Committee\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eSPSS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eStatistical Package for the Social Sciences\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eTT\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eTetanus Toxoid\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eUNESCO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eUnited Nations Educational, Scientific and Cultural Organization\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eWHO\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 50%;\"\u003e\n \u003cp\u003eWorld Health Organization\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical considerations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval for the study was obtained from the Sierra Leone Ethics and Scientific Review Committee (SLESRC No: 018/02/2023). Written informed consent was collected from all participants; those unable to write provided consent using a thumbprint. To ensure confidentiality, all data were anonymized and securely stored in a locked room.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable. The study does not include any individual person’s data in any form (such as images, videos, or personal details).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data materials:\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\u003eThe authors declare that there are no financial interests or personal relationships that could have affected the work presented in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe Wouter Nolet Foundation funded this research project. The foundations involvement did not include designing the study, collecting the data, analysing the results, or interpreting the findings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor contributions:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eS.S\u003c/strong\u003e: Writing – Original draft, Writing – Review and Editing, Data curation, Formal Analysis, Visualisation, Investigation, Project administration. \u003cstrong\u003eR.R\u003c/strong\u003e: Writing – Review and Editing, Methodology, Supervision. \u003cstrong\u003eJ.Wu\u003c/strong\u003e: Writing – Review and Editing, Investigation, Project administration, Data curation. \u003cstrong\u003eT.D.F\u003c/strong\u003e: Writing – Review and Editing, Methodology, Conceptualisation, Supervision. \u003cstrong\u003eM.I.C\u003c/strong\u003e: Investigation, Writing – Review \u0026amp; Editing. \u003cstrong\u003eI.A.K\u003c/strong\u003e: Investigation, Writing – Review and Editing. \u003cstrong\u003eH.S.S\u003c/strong\u003e: Investigation, Writing – Review and Editing. \u003cstrong\u003eA.D\u003c/strong\u003e: Investigation, Writing – Review and Editing. \u003cstrong\u003eZ.M.S\u003c/strong\u003e: Investigation, Writing – Review and Editing. \u003cstrong\u003eH.A.B\u003c/strong\u003e: Writing – Review and Editing, Methodology, Conceptualisation. \u003cstrong\u003eJ.We\u003c/strong\u003e.: Writing – Review and Editing, Methodology, Conceptualisation. \u003cstrong\u003eM.L.K\u003c/strong\u003e: Writing – Review and Editing, Methodology, Conceptualisation, Supervision, Funding Acquisition.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe would like to thank and acknowledge that we are grateful to all the women who took part in this study and generously shared their time and experiences. We also appreciate the dedication and effort of our research assistants, as well as the invaluable support from the staff at Masanga Hospital. Lastly, we extend our thanks to the Wouter Nolet Foundation for their financial backing and commitment to improving maternal health in Sierra Leone.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eOrganization WH. Trends in maternal mortality estimates 2000 to 2023: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: World Health Organization; 2025.\u003c/li\u003e\n\u003cli\u003eChukwuma A, Wosu AC, Mbachu C, Weze K. Quality of antenatal care predicts retention in skilled birth attendance: a multilevel analysis of 28 African countries. BMC Pregnancy Childbirth. 2017;17(1):152.\u003c/li\u003e\n\u003cli\u003eWondemagegn AT, Alebel A, Tesema C, Abie W. The effect of antenatal care follow-up on neonatal health outcomes: a systematic review and meta-analysis. Public Health Rev. 2018;39:33.\u003c/li\u003e\n\u003cli\u003eStatistics Sierra Leone I. Demographic and Health Survey. Freetown, Sierra Leone and Rockville, USA; 2019.\u003c/li\u003e\n\u003cli\u003eOrganization WH. WHO recommendations on antenatal care for a positive pregnancy experience. World Health Organization; 2016.\u003c/li\u003e\n\u003cli\u003eTesfay N, Tariku R, Zenebe A, Dejene Z, Woldeyohannes F. Cause and risk factors of early neonatal death in Ethiopia. PLoS One. 2022;17(9):e0275475.\u003c/li\u003e\n\u003cli\u003eWHO. Daily iron and folic acid supplementation in pregnant women.: Guideline: Geneva, World Health Organization; 2012.\u003c/li\u003e\n\u003cli\u003eBalarajan Y, Ramakrishnan U, Ozaltin E, Shankar AH, Subramanian SV. Anaemia in low-income and middle-income countries. Lancet. 2011;378(9809):2123-35.\u003c/li\u003e\n\u003cli\u003eBussink-Voorend D, Bussink AP, Falama AM, Stekelenburg J. Health Indicators of Pregnant Women in Tonkolili District, Rural Sierra Leone. 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Socio-economic determinants of maternal health care utilization in Kailahun District, Sierra Leone, 2020. BMC Pregnancy Childbirth. 2022;22(1):276.\u003c/li\u003e\n\u003cli\u003eNations U. The 17 goals: Department of Economic and Social Affairs Sustainable Development; 2025 [Available from: https://sdgs.un.org/goals.\u003c/li\u003e\n\u003cli\u003eKebede TT, Godana W, Utaile MM, Sebsibe YB. Effects of antenatal care service utilization on maternal near miss in Gamo Gofa zone, southern Ethiopia: retrospective cohort study. BMC Pregnancy Childbirth. 2021;21(1):209.\u003c/li\u003e\n\u003cli\u003eWolde HF, Tsegaye AT, Sisay MM. Late initiation of antenatal care and associated factors among pregnant women in Addis Zemen primary hospital, South Gondar, Ethiopia. Reprod Health. 2019;16(1):73.\u003c/li\u003e\n\u003cli\u003eKanyangarara M, Munos MK, Walker N. 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The quality of free antenatal and delivery services in Northern Sierra Leone. Health Res Policy Syst. 2017;15(Suppl 1):49.\u003c/li\u003e\n\u003cli\u003eObse AG, Ataguba JE. Explaining socioeconomic disparities and gaps in the use of antenatal care services in 36 countries in sub-Saharan Africa. Health Policy Plan. 2021;36(5):651-61.\u003c/li\u003e\n\u003cli\u003eMohammed S, Worku A, Girma E. Receiving quality antenatal care service increases the chance of maternal use of skilled birth attendants in Ethiopia: Using a longitudinal panel survey. PLoS One. 2022;17(12):e0279495.\u003c/li\u003e\n\u003cli\u003eDahiru T, Oche OM. Determinants of antenatal care, institutional delivery and postnatal care services utilization in Nigeria. Pan Afr Med J. 2015;21:321.\u003c/li\u003e\n\u003cli\u003eAdjiwanou V, Legrand T. Does antenatal care matter in the use of skilled birth attendance in rural Africa: a multi-country analysis. 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BMC Pregnancy and Childbirth. 2021;21(1):834.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"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":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Antenatal care, Maternal Health, Antenatal care utilization, Sierra Leone, Tonkolili","lastPublishedDoi":"10.21203/rs.3.rs-7139990/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7139990/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eIntroduction:\u003c/h2\u003e\u003cp\u003eMaternal and neonatal mortality remain major public health challenges in sub-Saharan Africa, with Sierra Leone among the affected countries. Antenatal care (ANC) is crucial for improving maternal and fetal health, yet disparities remain in both coverage and quality. This study examines ANC utilization and quality in rural Sierra Leone including factors influencing service uptake.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003efrom February 25th to May 12th, 2023, we interviewed 513 women who had given birth within the past year in the Mathonkara catchment area, Tonkolili district, Sierra Leone. Structured questionnaires were used to collect data on demographics and ANC history. High quality ANC was defined as receipt of WHO-recommended ANC services including uptake of ANC visits, pregnancy drugs (e.g. iron and folic acid), injections (e.g. tetanus vaccination) and ultrasound scanning. ANC visits and uptake of ANC components were assessed using descriptive analysis. Associations between ANC uptake and socio-economic factors were explored with bivariate and multivariate analyses.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eWhile 86.6% of women attended\u0026thinsp;\u0026ge;\u0026thinsp;4 ANC visits, only 3.1% received all the ANC services assessed in this study. High ANC quality was received by 31.8% of the women. Only 4.9% of participants received\u0026thinsp;\u0026ge;\u0026thinsp;8 ANC visits, 20.5% received three doses of malaria prophylaxis, 42.1% received an early ultrasound, and 42.7% received two tetanus vaccinations. Women with \u0026ge;\u0026thinsp;4 ANC visits were nearly three times more likely to receive iron and folic acid supplements, two doses of malaria prophylaxis, and \u0026ge;\u0026thinsp;2 tetanus vaccinations. High-quality ANC was less likely among women living\u0026thinsp;\u0026ge;\u0026thinsp;9 km from a health facility (AOR\u0026thinsp;=\u0026thinsp;0.52, 95% CI: 0.28\u0026ndash;0.96) and among illiterate women (AOR\u0026thinsp;=\u0026thinsp;0.70, 95% CI: 0.48\u0026ndash;1.02), while employed women were more likely to receive high-quality ANC (AOR\u0026thinsp;=\u0026thinsp;2.1, 95% CI: 0.98\u0026ndash;4.56)\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eOur study highlights severe deficiencies in ANC quality in the Tonkolili district of rural Sierra Leone, with nearly no women receiving the full range of recommended services. While more ANC visits were associated with higher uptake of key interventions, overall quality remained low. Targeted interventions, such as improved infrastructure, community education, and supply-chain strengthening, are needed to ensure that ANC visits translate into comprehensive care.\u003c/p\u003e","manuscriptTitle":"Utilization and quality of antenatal care in Mathonkara area, rural Sierra Leone: A cross- sectional study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-01 09:31:02","doi":"10.21203/rs.3.rs-7139990/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"158015227499297786875797227571490948958","date":"2025-08-26T16:41:38+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-20T09:25:15+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-23T09:49:32+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-22T09:12:26+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-22T09:09:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-07-16T12:20:51+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"6f6e545a-29ec-49f9-bd8b-890233fa266d","owner":[],"postedDate":"September 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-09-01T09:31:02+00:00","versionOfRecord":[],"versionCreatedAt":"2025-09-01 09:31:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7139990","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7139990","identity":"rs-7139990","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}