Timely utilization of antenatal care services of women in reproductive age group.

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Introduction
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Antenatal care or ANC, is the health care given to a pregnant woman by health professionals

during her pregnancy (Jinga et.al., 2019). Pregnancy is a very crucial period of life for both the

mother and the infant in her womb. This is the period that causes the mother to experience

various changes in her body and needs to have frequent check-ups as she progresses with her

pregnancy. During the ANC period, a pregnant woman is offered a number of appointments with

the midwife so as to receive some of the services (Wynter et.al., 2021). ANC aims at ensuring

that pregnant mothers have the best nutrition, acquire appropriate screening and testing, and also

the infants are given appropriate immunization as well. In addition to this, ANC ensures that

pregnant women are educated on the importance of proper breastfeeding, visiting clinics

frequently, offering proper care to the newborn as well, and the importance of safeguarding their

health during pregnancy. ANC brings about various benefits since it can help women avoid or

deal with problems during pregnancy, and it can also help make sure their bodies are healthy

(Heinonen, 2021).

According to WHO (2016), a pregnant woman should receive health care and access antenatal

services at least four times during her pregnancy. The prenatal period offers various

opportunities for reaching pregnant women who need intervention due to the health and well-

being of their infants. Therefore, WHO argues that if a pregnant woman gets prenatal care at

least four times, she is more likely to get maternal health services. In addition to this, WHO

proves that ANC not only focuses on positive pregnancy experiences but also on the effective

transition to successful childbirth and motherhood (Tessema and Minyihun, 2021). With this,

WHO presents comprehensive guidelines in ensuring that prenatal care services are offered

without failure in all areas of the world.

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According to Nasira Boi, Izudi and Atim (2022), timely utilization of prenatal care is the ANC

visit made by a pregnant woman during her pregnancy period of less than four months. Although

this practice is highly associated with a positive effect to the life of pregnant mothers and their

children, there also exist some of the factors that limit various individuals and in various regions

to accessing the services perfectly. According to a study conducted by Nasira Boi, Izudi and

Atim (2022), in South Sudan on the various factors affecting timely ANC attendance, it was

observed that most of the pregnant women receive their first antenatal services after 12 weeks of

their pregnancy. In addition to this, the study specified that the main factors contributing to this

challenge are level of education, low monthly income level, antenatal history, available ANC

services, husband’s level of education, maternal age, exposure to the media, obstetric history,

and employment. In addition to this, the various factors were observed to be varying with the

developing countries and the developed countries as well.

Another study performed in the rural areas of Ethiopia by Suleman, Mulatu and Abate, (2021),

showed that regardless of the appealing benefits offered by antenatal care, In the past few years,

303000 women have died because of problems related to pregnancy or childbirth. Most of these

deaths happen in countries that are still developing, and Ethiopia is one of them. The study

showed that there is very low utilization of prenatal care in comparison to the WHO

recommendations in Ethiopia (Suleman, Mulatu, and Abate, 2021). It was found that 36.6% of

pregnant women in the whole country had made at least four antenatal visits in the whole

country. The low percentage was because of the mother’s education, household wealth index,

desire to have children, how often they read newspapers, where they lived, how often they

listened to the radio, and how often they watched TV. All these factors were observed to be

highly contributing to the low percentage of attendance for ANC.

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On the other hand, South Africa which is still a developing country has progressed in the

reduction of maternal deaths. Coleman et al. (2020) argues that a population-based survey

showed that about 87% of women in South Africa went to all four prenatal care visits. Lattof et

al. (2020) say that the South African Health Ministry has recently changed the four-visit

antenatal care model so that it meets the 2016 recommendations of the World Health

Organization about how many visits a pregnant woman should have before giving birth. In April

2017, South Africa Health Ministry began the implementation of the 8-contact antenatal care

after ensuring nationwide training programs were delivered successfully. In addition to this, the

South African Health Ministry ensured that women who are in need of prenatal care receive

respectful care and clinical inquiry is made or intimate partner violence. All these updates on

Antenatal care were made to improve the quality of Antenatal care so as to achieve good

pregnancy care, outcomes, and women’s experience as well.

Although the South African Health Ministry has been observed to improve the health measures

and facilities for the citizens and more so expectant women, there have been underlying

challenges and struggles faced by these women that make them not enjoy the services. Human

rights-based research found that there were barriers to antenatal care in South Africa. These

included a lack of patient privacy and consent at health facilities, a lack of information and

knowledge about sexual and reproductive health, and problems with the availability and cost of

transportation. However, the need for understanding the exact socio-demographic factors and

family characteristics that affect the utilization of antenatal care is of great importance in the

planning. Therefore, this report focuses on finding out the main factors that contribute to women

not receiving antenatal care as recommended by the health ministry in South Africa.

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The objective of the Report

The general objective of this report is to investigate the timely utilization of antenatal care

services of women in the reproductive age group by socio-demographic variables and by their

husbands/partner characteristics. The report uses the survey data for women collected during the

2016 survey and the analysis is performed using the SPSS statistical software.

Methods Used

In this part of the report, we define the various statistical techniques that we will be used to meet

the main objective of the report. At first, a descriptive analysis will be performed so as to have a

good description of the data set. Descriptive analysis refers to the process of analyzing and

describing a dataset using various statistical techniques to summarize and visualize the main

features and patterns in the data. The goal of descriptive analysis is to gain an understanding of

the distribution, central tendency, variability, and other key characteristics of the data.

Descriptive analysis is often the first step in data analysis and can provide valuable insights into

the data and help to identify potential patterns or trends that may warrant further investigation. It

can also be used to summarize and communicate findings to others in a clear and concise

manner. Also, in this case, we shall be focused on understanding the nature of the various

variables that we have and specifying the variables of interest.

All of the variables in the set of data will be put into two groups: those that depend on other

variables and those that don't. A variable that is being studied and is affected by other variables,

which are called "independent variables," is called a "dependent variable." The value of the

dependent variable changes when the independent variable(s) change. An independent variable is

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a variable that is changed or controlled to see how it affects the dependent variable. The

independent variable is thought to be the cause or predictor of the dependent variable. The

researcher often changes the independent variable to see what effect it has on the dependent

variable.

Chi-Square test of association

The chi-square test of association is a statistical test used to determine whether there is a

significant association between two categorical variables. It is used to analyze the relationship

between two variables in a contingency table, which is a table that displays the frequency

distribution of two categorical variables. The null hypothesis of the chi-square test of association

is that there is no association between the two variables, and the alternative hypothesis is that

there is a significant association. In this report, this test will be useful in determining whether

there is an existing association between two categorical variables such as “husband/partner level

of education and timing of 1st antenatal check.

Testing for correlation

Correlation refers to the degree to which two variables are related to each other. It is a statistical

measure that indicates the strength and direction of the relationship between two variables. When

testing for correlation, we are trying to determine whether there is a relationship between two

variables. There are several statistical tests that can be used to test for correlation, but the most

commonly used are the Pearson correlation coefficient and spearman correlation coefficient.

These two coefficients test the correlation between different types of variables, the Pearson test

for the relationship between two continuous variables, and the Spearman correlation test for

categorical variables. In this report, we shall be investigating whether there exists a relationship

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between the husband’s age and the number of times a woman attends Antenatal care, and the

timing of the first antenatal check.

Multinomial Logistic Regression Modeling

Due to the nature of the dependent variables, a Multinomial Logistic regression model will be

appropriate for the regression analysis. Multinomial logistic regression is a statistical method

used to model and study the relationship between a categorical dependent variable with more

than two categories and one or more independent variables. It is a variation of logistic regression

that is used when the dependent variable has three or more unordered categories. The model

estimates separate sets of coefficients for each independent variable and for each pair of

categories of the dependent variable, resulting in a set of equations that describe the relationship

between the independent variables and the probabilities of each category of the dependent

variable. The coefficients are estimated using maximum likelihood estimation. However, in this

case, there will be the need for creating new variables for the outcome variable so as to have a

good model and perform the relationship test perfectly. The variable “M13$1” which indicates

the timing of the first antenatal check in months, will be recoded into a categorical variable of <

3, 3 – 6, and 6+ months. Also, the variable “M14$1” which indicates the number of antenatal

visits during pregnancy will be recoded into similar categories as the other variable. Therefore,

having the two variables transformed into new categorical variables would be appropriate to use

the multinomial logistic model. The method to be used for the above process of transforming

these two variables into new variables is the recoding into different variables method. The

Recode into Different Variables method in SPSS allows you to create a new variable based on

the values of an existing variable. This is very useful when you want to group or transform the

values of a variable into a new variable.

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Results

In this part of the report, all the outputs obtained from the analysis are presented and briefly

interpreted as to what they mean. This follows the procedure that was presented in the methods

used part. First, we take a look at the data description of the data set being dealt with, using the

descriptive statistics option.

From the above output, it can be observed that the total number of respondents in the survey was

about 14144 individuals between the age of 15 and 49. However, some of the other variables had

some missing values due to the cases where the respondent did not answer some of the questions

or had given “don’t know” answers.

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The above bar graph clearly shows the distribution of the timing of the first antenatal check for

the 2884 respondents who gave the feedback. Also, the distribution appears to be an asymmetric

normal distribution.

The bar chart above visualizes the number of respondents who made a specific number of

antenatal visits during their pregnancy. The majority of the individuals are observed to have

made around 3 to 8 antenatal visits.

Association between Timing of 1st antenatal check(months) and the Husbands level of

education

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The above figure is a crosstabulation for the frequencies of the specific partner’s education level

and the timing of 1st antenatal visit. From just a simple observation, it can be noted that the

highest number of women who made their first antenatal visit below 3 months had their partner’s

level of education at the Secondary level.

From the output above, we observe the p-value of the likelihood ratio which (0.000) is less than

0.05 specified level of significance, hence we reject the null hypothesis and conclude that there is

a strong association between the partner’s level of education and the timing of 1st antenatal

check.

Relationship between Timing of 1st antenatal check(months) and the Husband/partner age

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The above output displays the Pearson correlation between the partner’s age and the timing of 1 st

antenatal check. It can be observed that there is a Pearson correlation of 0.054 which suggests

that there is a slight tendency for the two variables to increase or decrease together, but the

relationship is weak. This means that a change in one variable is not necessarily associated with

a significant change in the other variable.

Association between the number of antenatal visits during pregnancy and partner’s level of

education

From a simple observation of the above crosstab, it can be observed that most women who

received the recommended number of prenatal visits (at least 4), had partners/husbands with a

secondary education level.

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From the chi-square test output, it can be concluded that, since the p-value of Pearson Chi-square

is less than 0.05, we conclude that there is an association between the partner’s education level

and the number of prenatal visits the women makes during their pregnancy.

Relationship between the number of antenatal visits during pregnancy and

husband/partner’s age

In this case, a Spearman correlation of -0.07 suggests that the two variables have a weak negative

correlation, meaning that as one variable increases, the other tends to decrease, but the

relationship is not very strong. Therefore, we can conclude that the relationship between the

number of antenatal visits during pregnancy and the partner’s age is not significant.

Logistic Multinomial modeling

In this case, we shall investigate the significance of the other socio-demographic factors to the

outcome variables, which are the number of antenatal visits during pregnancy and the timing of

1st antenatal check. We shall treat these two outcome variables differently, with an aim of

understanding the general objective of timely utilization of prenatal services.

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The model above checks for the effect of all the other variables with respect to the outcome

variable which in this case is the number of prenatal visits made during pregnancy. It can be

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observed that only a few variables are significant to the model, comparing their p-value with the

level of significance of 0.05. The significant variables have a p-value less than 0.05 and they

include; Type of place of residence, Region, frequency of watching television, and has an

account in a bank or any financial institution. All these variables appear to have an effect on the

number of prenatal visits a pregnant woman makes during her pregnancy.

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The above figure displays the logistic multinomial model for the timing of 1st prenatal visit

variable and all the other socio-demographic variables. It can be observed that the few variables

that are significant to the model include, type of residence, source of drinking water, use of the

internet, and whether ever had a terminated pregnancy. These factors appeared to be contributing

some significant effect on the outcome variable.

Discussion and Conclusion of the results

From the results obtained above, we are now in a position to give an accurate answer to the

general question under investigation. The general question was about whether the indicated

socio-demographic factors and the husband’s characteristics cause some effect on the timely

utilization of prenatal services. Firstly, it was observed that there is a very strong association

between the timing of the first prenatal visit of a respondent and the partner’s level of education

as well as their age. This would mean that education is among the very important aspect of the

life of the people in South Africa. It is very essential to ensure that, the citizens in the country

receive a quality education so as to also achieve improved health measures for the families. In

addition to that, the results also showed that at some degree of significance, the age of the partner

causes some effect on the timely utilization of antenatal services. Therefore, in general, it can be

noted that the various characteristics of the husband affect the pattern of how a pregnant woman

receives prenatal services.

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On the other hand, it was observed that most of the socio-demographic factors included in the

survey were not very much significant to the pattern of how pregnant women received antenatal

services in South Africa. Firstly, the main factors contributing to some effect on the timely

utilization of antenatal services were; type of residence, source of drinking water, use of the

internet, ever had a terminated pregnancy, Region, frequency of watching television, and an

account in a bank or any financial institution. These variables have been observed to be having

some degree of significance to the outcome variable which is the timely utilization of the

antenatal services. These results are observed to be supported also by the various study

performed as indicated in the introduction. For instance, the study performed in Ethiopia showed

that some of the factors that contributed to various patterns of prenatal attendance included to be,

partner’s level of education, exposure to the media, and cost of living. Overall, the study findings

reveal that some of the socio-demographic factors and the characteristics of the partners have a

significant impact on the timely utilization of antenatal services for pregnant mothers. However,

interventions could be made to improve the timely utilization of antenatal care by offering

education and creating awareness for both women and their partners.

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