Determinants of adequate antenatal care visits among pregnant women in low-resource setting: evidence from Tanzania national survey (2024)

Background

Antenatal care (ANC) plays a crucial role in reducing maternal fatalities and morbidities through early detection and management of pregnancy-related complications and ensures the proper referral in the level of care. Various variables facilitate a pregnant woman’s ability to schedule enough ANC visits. This research sought to identify factors contributing to Tanzanian pregnant women receiving adequate antenatal care.

Methods

The study used data from the 2015-16 TDHS-MIS. We analysed a total of 6924 included in the analysis. The outcome variable was adequate ANC, and we assessed different predictors on how they influence good antenatal care attendance. Bivariate (chi-square) and multivariate logistic regression were conducted at the statistical significance of p < 0.05.

Results

3438 (49.7%) had inadequate ANC visits. Determinants for antenatal attendance included giving birth outside health facility (aOR = 0.77, 95%CI = 0.62–0.95, p-value = 0.02) are less likely to complete all the ANC, mothers who book early for ANC (aOR = 5.79, 95%CI = 4.56–7.35, p-value < 0.001) were more likely to achieve the recommended visits, parity of 2 to 4 (aOR = 0.63, 95%CI = 0.48–0.81, p-value < 0.001), and five and above (aOR = 0.48, 95%CI = 0.35–0.68, p-value < 0.001) showed a decreased odd to complete adequate ANC, the use of the Internet (aOR = 1.62, 95%CI = 1.08–2.42, p-value = 0.02) were two times more likely to attend the required visits, pregnant mothers who experienced sexual violence from partners (aOR = 0.70, 95%CI = 0.52–0.94, p-value = 0.02) were less likely to complete the adequate visit, and the use of the mobile telephone for health-related issues (aOR = 1.476, 95%CI = 1.02–2.14, p-value = 0.04) slightly increase the chance of attending adequate visits.

Conclusion

This study identified determinants influencing ANC visits. ANC booking, using the Internet, and mobile phones enhance the likelihood of completing recommended ANC visits while higher parity and experiencing partner-related sexual violence decrease these chances. These findings show a need for addressing wealth inequality, geographical barriers, the impact of intimate partner violence, encouraging internet access for health information, and health promotion for early ANC booking to improve the uptake of ANC services.

High maternal mortality rates in low-resource environments remain a critical public health concern [1]. These countries have disproportionately high maternal mortality rates due to the wide disparity in healthcare access and resources. Maternal mortality rates in low-income countries are frequently much higher than those in higher-income equivalents due to a lack of access to high-quality healthcare, inadequate prenatal and obstetric services, socioeconomic inequality, and inadequate education [2]. Collectively, Sub-Saharan countries face an incredible burden, representing a significant 70% of maternal fatalities worldwide in 2020 [3]. The maternal mortality rate in Tanzania increased slightly in 2020, from 151 to 152 deaths per 100,000 live births, which is a worrying trend. This trend is associated with 51,000 newborn deaths and 43,000 stillbirths, which occur yearly in the country, underscoring the urgent need for better maternal and neonatal healthcare procedures and resources to address these alarming consequences [4].

These statistics show how urgently low-income countries need to address the root causes of the problem and reduce maternal mortality. They also underscore the need for improved healthcare facilities, targeted interventions, and expanded international initiatives. Antenatal clinic (ANC) services are among the best remedies for minimising these pregnancy problems [5] and improving delivery outcomes and neonatal health [6]. ANC services are critical in lowering pregnancy-related issues despite differences in accessibility and availability in low- and middle-income countries. Improving ANC services aims to identify pregnancy-related problems early and avoid potential complications [7]. According to research, expecting mothers who attend enough antenatal clinics improve their odds of giving birth healthily [8].

The Tanzania Ministry of Health’s ANC Guideline recommended that pregnant women attend at least four appointments until WHO recently revised it to eight [6, 9]. About 90% of pregnant women in Tanzania make at least one visit [10]. Governmental and non-governmental organisations in Tanzania have worked to promote ANC services and uptake and prevent a later decline in the number of visits following the initial visit [11]. These initiatives include women-held case notes, job shifting, community-based intervention, and accessible ANC services [12]. Despite the increased efforts, some locations have poor uptake of these antenatal services due to inadequacy and costs [13]. In Tanzania, while nearly all women (98%) engage in at least one ANC visit, only half (51%) can access the recommended four or more visits, highlighting a gap in comprehensive care.

Moreover, the country faces a concerning stillbirth rate of 22.4 per 1,000 births, underscoring the urgent requirement for enhanced maternal and neonatal healthcare services to improve outcomes. Only 24% of expectant mothers started their first appointment at the recommended gestation age, but 51% finished all the necessary visits [14]. Despite these interventions, Tanzania still needs to catch up to the targeted, sustainable development objective for maternal and child health [15].

Several small population studies in Tanzania have documented the variables affecting sufficient ANC visits. Various variables influence whether pregnant women are motivated or discouraged to schedule enough antenatal appointments [16]. Men’s participation, maternal wealth, and awareness of antenatal care services all contributed to the uptake of ANC services [17]. The pregnant mother’s socioeconomic position, youth, and family’s financial stability also contributed to the uptake [13, 18]. However, despite using extensive data from a large population study in the country, more is needed about what constitutes sufficient ANC visits. Due to this, we decided to identify the factors that led pregnant women in Tanzania to schedule recommended ANC visits. We analysed the 2015–16 Tanzania HIV and Malaria Indicators Survey data to identify the factors. The information gained from this research will make it possible to create focused interventions to boost the uptake of ANC services in Tanzania as it uses data from the entire population. These findings will be useful as a historical comparison, longitudinal studies, contextual insight, and policy and program evaluation based on representative of a sizable population.

Data source

This research examined the Tanzania Demographic Health Survey-HIV and Malaria Indicator Survey (TDHS-HMIS) datasets for 2015–16. The data collection was conducted by Tanzania’s National Bureau of Statistics (NBS) in collaboration with the Office of the Chief Government Statistician (OCGS) in Zanzibar, the Tanzania Mainland Ministry of Health (MoH), and the Zanzibar MoH. ICF International’s DHS program supplied the technical assistance for the survey. TDHS surveyed a nationally representative group of women between the ages of 15 and 49 who lived in the chosen households for information. Data was weighted to ensure the representativeness of the study population.

The TDHS contains several datasets, but we used Individual file recode (TZIR7BFL) for the current study, including data from reproductive-age women.

Sample size and sampling technique

Two-stage cluster sampling methods created the 2015–16 TDHS–MIS sample. In the initial step, 608 clusters, or primary sampling units (PSUs), were chosen from a sampling frame of enumeration areas identified by the 2012 Tanzania Population and Housing Census [19]. To establish a sampling frame for the second step of household selection, the program completed an exhaustive list of all the households in each cluster (PSUs). Twenty-two households from each cluster were systematically chosen for the second step. TDHS included men and women between the ages of 15 and 49 who were regular residents or guests in the home the night before the data collection.

This current research used the results of the women’s questionnaire on behaviour related to maternal and child health and their responses. A total of 13,266 women with at least one live birth in the five years before the survey (97% answer rate) provided information for the study. However, this research analysed data from 6924 women who provided information about ANC services.

Outcome variable

Adequate ANC visits were the primary outcome variable. According to the WHO and Tanzania Ministry of Health ANC Guidelines, four appointments are considered acceptable antenatal visits. Because we conceptualise the research was performed before the WHO updated the antenatal visits, we considered all women of reproductive age who made at least four visits as having adequate visits in the 2015–16 TDHS–MIS datasets.

Independent variables

The following were independent variables: the place of residence, place of childbirth, age, educational level, parity, wealth index, marital status, respondent currently working, timing for ANC booking, perception of early booking, occupation, health insurance coverage, use of the Internet, frequency of watching television, listening to the radio, reading newspaper or magazine, experienced emotional violence, sexual violence (from partner) and use the mobile telephone for health-related issues.

We created a conceptual framework during the literature review to direct the data review in this analysis. The main independent variables were the women’s socio-demographic characteristics (age, education level, marital status, place of residence, and zones of residence), obstetric characteristics like parity, socioeconomic characteristics like wealth status, and current employment status. The timing of the start of antenatal booking and the attitude toward early antenatal booking are the intermediary factors. The main independent traits have an impact on these intermediate variables. The dependent is directly impacted by both the main independent factors and the intermediate factors. (Fig.1). The dependent variable is the number of ANC Visits, expressed as 1 for at least four visits and 0 for fewer than four. The conclusion of all four visits was deemed sufficient for ANC visits.

Data processing and statistical analysis

This research used data from the 2015–16 Tanzania HIV Demographic and Health Survey and the Malaria Indicators Survey. The study covered 6924 women in the reproductive age range of 15 to 49 years. Categorical factors were compiled using proportions and then displayed in tables for descriptive analyses. Bivariate analysis was performed to assess the association between independent variables and outcome variable, and we applied a chi-square test. Unadjusted logistic regression models were used to isolate the variables linked with sufficient antenatal care visits. The multivariable logistics regression analysis model included all independent factors with a p-value of 0.2 in unadjusted models. We employed a stepwise (backward) elimination technique to fit the adjusted model, and we considered a p-value < 0.05 as having a statistical significance. To assess the relationship between each variable and the result variable, odds ratios (OR) were computed along with their 95% confidence intervals. All analyses were weighted, considering that the initial 2015–16 TDHS–MIS used a complex survey design multistage cluster sampling technique.

Socio-demographic characteristics

We conducted this analysis to determine what factors influence the adequacy of ANC attendance among pregnant women in limited settings, as evidenced by Tanzania’s national survey. This study included 6924 women of reproductive age who had given birth within the previous five years. The majority of study participants lived in a rural area of Tanzania (73.8%), fell within the 20 to 30 age range (65.8%), were married (86.1%), and had completed only primary education (60.8%). The majority were parity 2 to 4 (45.6%), had a high wealth index (40.8%), and most of them were working (78.4%). The analysis showed that most participants were from mainland rural (62.9%), and almost all had a positive perception of early ANC booking (99.3%). Table1 summarises the socio-demographic results.

Antenatal visits

The results indicated that more than half of the study participants had adequate antenatal visits during their pregnancies (50.3%), while the remaining percentage presents those women with inadequate ANC visits (49.7%).

Bivariate analysis of determinants of ANC visits

Table2 presents the bivariate analysis of ANC visits among the respondent’s characteristics. Early ANC booking was significantly associated with the likelihood of completing all required ANC visits (p < 0.001). Urban residents with ages below 20 years, high wealth index, high education and lower parity (those who are para one) were also correlated with a higher proportion of participants who completed adequate ANC visits (p < 0.05). Contrarily, late ANC booking, rural residence, older age of more than 34 years, lower wealth index, lower level of education and higher parity were linked with fewer adequate ANC visits (p < 0.05). The working status of study participants did not show a statistically significant association with ANC visits.

Multivariate analysis

Table3 presents a multivariate analysis for determinants of at least 4 ANC. We included factors in the multivariate analysis based on the bivariate analysis and potential factors from the literature review. Among the factors influencing ANC attendance was the planned place of delivery outside the health facility (aOR = 0.77 at 95% CI = 0.62–0.95, p-value = 0.02), which was noted to decrease the likelihood of completing all the required ANC visits. Findings showed that early booking of ANC services (aOR = 5.79 at 95% CI = 4.56–7.35, p-value < 0.001) increased the chances of completing all the recommended visits by five times compared to late booking. Another factor found to influence ANC attendance was parity of 2 to 4 (aOR = 0.63 at 95% CI = 0.48–0.81, p-value < 0.001) and parity of five and above (aOR = 0.48, 95% CI = 0.35–0.68, p-value < 0.001). As parity increases, the likelihood of consuming adequate ANC decreases. The use of the Internet for the last twelve months (aOR = 1.62 at 95% CI = 1.08–2.42, p-value = 0.02) showed to slightly influence the adequate consumption of ANC visits. The highest wealth index (aOR = 1.31 at 95% CI = 0.99–1.73, p-value = 0.05) was also associated with a slightly increased likelihood of attending all the ANC visits in a modest effect. Pregnant mothers who experienced sexual violence from partners (aOR = 0.70 at 95% CI = 0.52–0.94, p-value = 0.02) decreased the likelihood of consuming the recommended ANC visits. The other factor was the use of mobile telephones for health-related issues (aOR = 1.476 at 95% CI = 1.02–2.14, p-value = 0.04), which demonstrates a slight influence on the complete consumption of all the required ANC visits.

Before the establishment of the new ANC guideline, we intended to determine the factors influencing pregnant women to attend at least four antenatal appointments. 6924 women of reproductive age who had given birth within the previous five years were included in the research. Our study revealed a high prevalence of pregnant women who started their ANC visits later than necessary and did not finish all the required visits. In Tanzania, a sizable percentage of pregnant women continue to raise the risk of maternal and perinatal mortality. Targeted healthcare interventions must aim at these populations to reduce the late first antenatal appointment. Contrary to this study, the proportions observed in other studies were slightly higher, indicating potential inadequate antenatal visits [20,21,22].

Early booking in antenatal clinics was noted to facilitate pregnant mothers in completing four or more ANC. A systematic review supports this finding, where those who made their reservations early either completed all four visits or increased their chances of doing so [23]. Medical professionals create an extensive care plan specifically adapted to the needs of the pregnant woman and the developing foetus. Early prenatal consultations make it possible to quickly identify and address any potential health risks or problems, thereby supporting a safe pregnancy. The Ethiopian study found that most participants started their first antenatal visit within the suggested timeframe, boosting the likelihood of getting adequate visits [24, 25]. According to their research, these groups must be prioritised to ensure that the best-recommended practice is followed. Contrary to what we found, antenatal clinics in Cameroon did not benefit from early booking [26]. Early booking in the antenatal clinic was affected by additional variables, such as education and residence location, and is impossible in Nepal [27]. These outside factors might be to blame for the inadequate intake in Cameroon and Nepal, where early booking was not a concern.

Another factor that affected ANC visits was wealth inequality. Comparatively, to other groups, those with high incomes were motivated to finish sufficient ANC visits. Higher levels of wealth are linked with better access to and prioritisation of comprehensive ANC services. The availability of better transportation, healthcare-seeking behaviour, and general health knowledge may facilitate better access to ANC services. This result was consistent with New Guinean [28] and Nepal studies, which showed a lower uptake due to socioeconomic status [29].

Additionally, it was observed that the participants with a middle income completed all four visits, which was also supported by an additional study [30]. Low socioeconomic position significantly influences the quality of antenatal care, primarily due to financial limitations and inadequate educational opportunities. However, government programs, like M-MAMA and telehealth initiatives, can lessen the burden and improve attendance of ANC visits amid financial constraints. Safe motherhood initiatives, enhancing financing for maternal and child health programs and easy access to medical facilities can help lessen these obstacles and encourage underserved groups to use ANC more effectively [31]. Although the results are statistically significant, it is essential to use caution when interpreting them due to the relatively narrow confidence range and p-value that is approaching the threshold.

The observed impact of parity revealed an interesting pattern in our study. Parity played a role by showing reduced odds of having recommended ANC visits. Our results were consistent with research, which showed that most of the multiparous who did not develop complications in their first pregnancy had decreased attendance at ANC clinics [32]. The decline in the attendance of ANC clinics can be associated with factors such as perceived familiarity with the pregnancy processes based on previous pregnancies, economic consideration and lack of enough time. Another study also showed late initiation of ANC services from multiparous women [33]. Understanding these factors is crucial for guiding interventions to improve ANC attendance among multiparous women. Further qualitative studies must be conducted to understand specific barriers and formulate targeted strategies to improve their engagement. Previous study documented the use of health education among multiparous mothers during antenatal and postnatal clinics improved ANC uptake [34].

This research underscores the noteworthy association between the place for delivery choice and the adequacy of antenatal visits. Our study revealed that women who chose to give birth outside of a birth centre were less motivated to receive the recommended amount of ANC compared to women who intended to give birth in a medical facility. According to research, the geographic location of healthcare institutions also affected the choice of the birthplace, which in turn affected the appropriateness of ANC visits. Due to the distance between the client and the healthcare facility, many women chose to give birth at home or with traditional birth attendants, which decreased the number of adequate ANC visits [35]. Strategic initiatives to address geographical gaps and promote safer delivery practices in medical facilities could include establishing mobile health clinics to increase ANC utilisation among women who prefer non-medical birth settings, implementing community-based education programs to raise awareness about the advantages of facility-based deliveries, and providing incentives to encourage timely and comprehensive ANC attendance. Previous studies showed the use of mobile clinics and health outreach as modalities to overcome geographical gaps which leads to giving birth outside health facilities and decreasing the ANC uptake [36, 37].

The uptake of adequate ANC was also influenced by using electronic devices to access the Internet and other health-related problems. Our research showed that people using the Internet for health-related problems were likelier to have sufficient ANC visits. Our finding was supported by research conducted in Qatar that demonstrated how internet access increased access to ANC [38]. Another research revealed that the majority wanted to seek out ANC services, which increased the sufficiency of these services due to the increased level of eagerness and worry caused by pregnancy-related information from online sources [39]. Another systematic review demonstrated the role of the Internet in influencing pregnant women to seek out antenatal care, most of whom do so after becoming aware of pregnancy-related material [40]. Increased internet service accessibility in environments with constrained resources will also help to boost the adoption of sufficient ANC visits.

One of the factors hindered ANC visits was also discovered to be sexual violence committed by male partners. Contrary to those who did not experience any form of sexual violence, expectant mothers who are experiencing intimate partner violence were less motivated to use appropriate ANC services. Our results were supported by data from research done in Rwanda. According to the study, increased intimate partner violence caused pregnant women to use fewer ANC services [41]. According to another research, ANC services were consistently used in Mozambique despite increased intimate partner violence. The study’s findings also indicated that intimate partner violence had little bearing on receiving adequate ANC [42]. Following these complexities, potential measures need to focus on offering comprehensive support to expectant mothers who are victims of intimate relationship violence. Initiatives could include setting up safe areas for open discussion inside healthcare institutions, combining ANC services with domestic violence therapy, and teaching medical staff how to recognise and gently handle abuse indicators. Despite the difficulties presented by intimate partner violence, health providers and community organisations can work together to create a supportive atmosphere for pregnant women and ensure that they receive appropriate ANC. Several studies have recommended community health education towards ending these violences to improve the ANC uptake.

The main strength of this study is that it used a country-wide representative sample, which ensured a high degree of accuracy in assessing adequate ANC visits among pregnant women in Tanzania. Nevertheless, the study’s cross-sectional nature is a limitation, and the study failed to determine the causality assumptions. Moreover, the outcome variable was based on four ANC visits (old WHO recommendations) to categorise whether women had adequate ANC visits or not. This is because the data were collected in 2015-16 before new WHO recommendations, which insist pregnant women attend at least eight ANC visits. Also, another potential limitation of this study is the poor response rate of about 50% to the question regarding information about ANC services. This low response rate could be caused by a variety of factors, including the questions’ ambiguity or complexity regarding ANC services, participants not having enough knowledge of the significance of ANC services, or problems with the data collection procedure, such interviewer bias or data entry errors. Although the specific cause of the low response rate remains uncertain, its implications for the study’s findings are significant. Therefore, our findings might be interpreted with caution. Further qualitative research needs to be conducted to understand the specific barriers. Additionally, further research can investigate interventions’ implementation and sustained effectiveness to address barriers.

ANC:

Antenatal Care

TDHS:

HMIS–Tanzania Demographic Health Survey–HIV and Malaria Indicator Survey

Authors and Affiliations

1. Clinical Nursing Teaching and Research Section, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan, China

   Elihuruma Eliufoo,Yusheng Tian&Yamin Li

2. Department of Clinical Nursing, School of Nursing and Public Health, The University of Dodoma, Dodoma, Tanzania

   Elihuruma Eliufoo&Fabiola Moshi

3. Directorate of Nursing Services, Dodoma Regional Referral Hospital, Dodoma, Tanzania

   Victoria Majengo

4. Department of Community Medicine, School of Medicine and Dentistry, The University of Dodoma, Dodoma, Tanzania

   Deogratius Bintabara

5. Department of Nursing Management and Education, School of Nursing and Public Health, The University of Dodoma, Dodoma, Tanzania

   Fabiola Moshi

Contributions

EE, VM, YT, DB, FM, and YL participated in the analysis plan, framework, data analysis, and final manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Yamin Li.

Ethics approval and consent to analyse

The existing public domain survey (2015–16 TDHS–HMIS) datasets that are openly accessible online and stripped of all identifying information served as the study’s foundation. The National Institute of Medical Research Ethics Committee in Tanzania and the ICF Macro Ethics Committee in Calverton, New York, approved the initial survey. Therefore, we obtained permission to use DHS data. Participants’ informed consent was requested and received before the interview. All methods were carried out following the relevant guidelines and regulations.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

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