A total of 11,056 women were included in the analysis, and Table 1 illustrates the characteristics of the study samples, which are organized by the number of ANC visits. 18.8% of women completed four times or greater ANC visits, whereas a majority of women (81.2%) completed less than four times visits. The women who completed ANC visits four times or greater were more likely to reside in urban areas and be wealthier and literate, and their husbands or partners tend to be better educated. The groups did not differ in terms of age or access to transportation. The total number of children was slightly fewer among the group that completed four or more ANC visits. A greater proportion of women reported barriers to medical care among women who completed less than four visits. A statistically significant difference was observed between different ethnic groups. Women that belong to Tajik and Hazara tend to have an increased number of ANC visits.
Table 1
Characteristics of study samples (women aged 15-49 in Afghanistan) by the number of antenatal care visits (weight adjusted) (n=11,056)
|
ANC visits <4
(n=9,041, 81.2%)
|
4 ANC visits
(n= 2,015, 18.8%)
|
|
|
n (weighted %)1
|
n (weighted %)
|
P-value2
|
Age (mean, SE)
|
29.0 (0.1)
|
29.1 (0.3)
|
0.8
|
Region
|
|
|
<0.001
|
Urban
|
1,936 (65.5)
|
827 (34.5)
|
|
Rural
|
7,105 (85.8)
|
1,188 (14.2)
|
|
Wealth Index
|
|
|
<0.001
|
Poorest
|
1,875 (89.5)
|
242 (10.5)
|
|
Poorer
|
2,144 (88.4)
|
274 (11.6)
|
|
Middle
|
2,052 (85.3)
|
396 (14.7)
|
|
Richer
|
1,878 (79.0)
|
498 (21.0)
|
|
Richest
|
1,092 (63.4)
|
605 (36.6)
|
|
Ethnicity
|
|
|
<0.001
|
Pashtun
|
3,822 (86.0)
|
553 (14.0)
|
|
Tajik
|
2,824 (74.6)
|
942 (25.4)
|
|
Hazara
|
854 (77.4)
|
234 (22.6)
|
|
Uzbek
|
535 (84.1)
|
172 (15.9)
|
|
Others
|
1,006 (88.1)
|
114 (11.9)
|
|
Husband/partner’s education level
|
|
|
<0.001
|
No education
|
5,358 (85.0)
|
864 (15.0)
|
|
Primary
|
1,296 (83.1)
|
314 (16.9)
|
|
Secondary
|
1,899 (77.7)
|
553 (22.3)
|
|
Higher
|
488 (56.0)
|
284 (44.1)
|
|
Access to transportation3
|
|
|
0.8
|
No access
|
3,997 (81.4)
|
861 (18.6)
|
|
Access
|
5,044 (81.1)
|
1,154 (18.9)
|
|
Barriers to medical care4
|
|
|
<0.001
|
No reported barriers
|
646 (68.0)
|
348 (32.0)
|
|
Any reported barriers
|
8,395 (82.8)
|
1,667 (17.2)
|
|
Total number of children5 (mean, SE)
|
4.4 (0.1)
|
4.0 (0.1)
|
<0.05
|
Abbreviation: ANC, antenatal care; SE, standard error
1Numbers and weighted row percentages
2Pearson’s chi-square test with correction for the complex design and survey weighted t-test (means) were used for comparison between the groups.
3The percentage/number of those who have any means of transportation (bicycle, motorcycle/scooter, or car/truck) in the household compared to those who do not have any means.
4Any perceived barriers to medical care (whether respondents reported any perceived barriers such as getting money for treatment to get medical help for themselves
5Total number of children ever born
In an unadjusted model, all the variables, except employment and domestic violence, were associated with higher odds of at least four ANC visits (Table 2). Among the variables, women’s education had the highest crude odds ratio. The crude odds ratios were 1.91 for primary education (95%CI 1.33, 2.73), 3.45 for secondary (95%CI 2.17, 5.49), and 5.77 (95%CI 2.36, 14.13) for higher education.
After adjusting for maternal age, partner/husband’s educational level, region, ethnicity, wealth index, access to transportation, and perceived barriers to medical care, access to information and decision-making were associated with four or more ANC visits with an adjusted odds ratio (AOR) of 1.38 (95%CI 1.24, 1.54) and 1.16 (95%CI 1.08, 1.24), respectively (Table 2 and Figure 2).
For the capability domain, compared to those without any education, women with primary education (AOR 1.67, 95%CI 1.02, 2.72), secondary education (AOR 2.43, 95%CI 1.25, 4.70), and higher education (AOR 3.03, 95%CI 1.30, 7.07) had greater odds of at least four ANC visits. One thing to note is literacy. The unadjusted odds ratio for literacy was 2.77 (95%CI 1.89, 4.08, yet after adjusting for covariables, the odds ratio was 0.66 (0.40, 1.09), although it was no longer statistically significant.
Under the adjusted model, none of the variables under the security domain were statistically significant. Other interesting results were employment and asset ownership in the domain of access to resources. Although access to information was still positively associated with greater odds of ANC visits (AOR 1.38, 95%CI 1.24, 1.54), employment and asset ownership were negatively associated with four or more ANC visits (AOR 0.76, 95%CI 0.57, 1.01 and AOR 0.72, 95%CI 0.56, 0.92, respectively) after adjusting. Decision-making was still positively associated with a greater odds of ANC visits (AOR 1.16, 95%CI 1.08, 1.24). Excluding influential observations, we performed a sensitivity analysis (n=10,397) and overall, the results were consistent with the primary analysis, suggesting that the results are robust.
Table 2
Logistic regression odds ratios and 95% confidence intervals for the relationship between women’s empowerment and antenatal care utilization1 (n=11,056)
|
4 ANC visits
(n= 2,015,18.8%)
|
Unadjusted OR
(95% CI)
|
p-value
|
Adjusted OR2 (95% CI)
|
p-value
|
Capability
|
|
|
|
|
|
Education
|
|
|
|
|
|
No Education
|
1,407 (15.5)
|
1 (Reference category)
|
|
1 (Reference category)
|
|
Primary
|
234 (26.0)
|
1.91 (1.33, 2.73)
|
<0.001
|
1.67 (1.02, 2.72)
|
0.04
|
Secondary
|
268 (38.8)
|
3.45 (2.17, 5.49)
|
<0.001
|
2.43 (1.25, 4.70)
|
0.01
|
Higher
|
106 (51.5)
|
5.77 (2.36, 14.13)
|
<0.001
|
3.03 (1.30, 7.07)
|
0.01
|
Literacy
|
550 (34.4)
|
2.77 (1.89, 4.08)
|
<0.001
|
0.66 (0.40, 1.09)
|
0.11
|
Access to resources
|
|
|
|
|
|
Employment
|
182 (16.8)
|
0.86 (0.64, 1.15)
|
0.30
|
0.76 (0.57, 1.01)
|
0.06
|
Access to information3
(mean, SE)
|
1.22 (0.03)
|
1.83 (1.60, 2.09)
|
<0.001
|
1.38 (1.24, 1.54)
|
<0.001
|
Asset ownership4
|
791 (15.9)
|
0.72 (0.58, 0.90)
|
0.003
|
0.72 (0.56, 0.92)
|
0.01
|
Security
|
|
|
|
|
|
Domestic violence5
|
824 (17.5)
|
0.83 (0.67, 1.03)
|
0.09
|
1.09 (0.87, 1.35)
|
0.45
|
Perception toward violence6 (mean, SE)
|
2.6 (0.1)
|
1.07 (1.02, 1.13)
|
0.01
|
1.00 (0.95, 1.06)
|
0.90
|
Decision-making and power
|
|
|
|
|
|
Decision-making7 (mean, SE)
|
2.1 (0.1)
|
1.19 (1.11, 1.28)
|
<0.001
|
1.16 (1.08, 1.24)
|
<0.001
|
1Antenatal care utilization is defined by antenatal care visits ≥ 4
2Adjusted for maternal age, partner/husband’s educational level, region, ethnicity, wealth index, access to transportation, and perceived barriers to medical care
3The percentage/number of those who read newspaper, listen to radio, and watch television compared to those who do not.
4Owns house or land alone or jointly
5Experienced any physical violence
6Scales ranging from 0-5 with greater numbers indicating more disagreement with itemized physical domestic violence
7Scales ranging from 0-4 with greater numbers indicating more decisions made alone or jointly