Determinants of Numbers on Antenatal Care Visits in Rural Ethiopia: A Multilevel Negative Binomial Regression Analysis

doi:10.21203/rs.3.rs-283138/v1

Introduction: Antenatal care (ANC) is an umbrella term used to describe medical care and procedures that are carried out for pregnant women. Data on the number of antenatal care visits can help policymakers to show the gap in service provision. So, the paper determines associated factors of the number of antenatal care visits among women who gave birth in the last five years in rural Ethiopia.

Methods: Total weighted sample of 6611 women who gave birth in the 5 years preceding the survey were included from the nationally representative 2016 Ethiopian Demographic and Health Survey. We used multi-level negative binomial regression analysis to consider the hierarchal nature of the data. In the multivariable analysis, variables with a p-value < 0.05 were considered to be significantly associated with the number of antenatal care visits.

Results: Overall, 27.3% (95% CI: 14.63, 15.76) of women had at least four antenatal care visits during their pregnancy in rural Ethiopia. Age group 25-29 years (adjusted incidence rate ratio (AIRR)=1.13,95% CI:1.02,1.26), household rich wealth status (AIRR=1.17, 95% CI:1.04,1.31), women’s educational status (primary, AIRR=1.19,95% CI:1.08,1.32; Secondary, AIRR= 1.30,95% CI:1.08,1.55; above secondary, AIRR=1.35, 95%CI:1.07,1.71), partner educational status (primary, AIRR=1.16, 95%CI:1.05,1.28; secondary, AIRR=1.22,95% CI:1.08,1.38), and autonomy to decision to their care (AIRR=1.25,95%CI:1.10,1.42) were positively associated individual-level factors with number of antenatal care visits whereas having a birth order of five or more (AIRR=0.80,95% CI: 0.69,0.94) was a negatively associated factor with number of antenatal care visits. Among community-level variables; being in higher community level literacy (AIRR=1.35, 95% CI: 1.14, 1.59) and higher poverty level (AIRR=0.77, 95% CI: 0.64, 0.92) were significantly associated factors with the number of antenatal care visits.

Conclusions and recommendations: The level of antenatal care visits in rural areas was low. Age of women, wealth status, women's educational status, partner educational status, autonomy to decision making in health care, and birth order were the most important associated factors with the number of antenatal care visits. Furthermore, poverty and literacy are also important determinants at the community level. Addressing economic and educational interventions for rural women should be given the top priority.

Health Economics & Outcomes Research

Health Policy

Antenatal care

Women

Rural Ethiopia

Multilevel Negative Binomial count analysis

Table 1: Sociodemographic characteristics of women who gave birth within the last five years preceding the survey in rural Ethiopia, EDHS 2016, 2020(N=6611).

Variable	Category	Unweight n (%)	Weighted n (%)
Age in years	Mean ± SD	29.4 ± 7.1	29.7 ± 7.1
	15–24	1,498(26.4)	1,622(24.5)
	25-29	1,495(26.4)	1,770(26.8)
	30-49	2,674 (47.2)	3,219 (48.7)
Region	Tigray	630(11.1)	438(6.6)
	Afar	571(10.1)	57 (0.9)
	Amhara	688(12.1)	1,410(21.3)
	Oromia	968(17.1)	2,916(44.1)
	Somali	646(11.4)	226(3.4)
	Benishangul Gumz	536(9.5)	74(1.1)
	SNNPR	813(14.3)	1,452(22.0)
	Gambela	393(6.9)	12(0.2)
	Harari	246(4.3)	10(0.2)
	Dire Dawa	176(3.1)	16(0.2)
Religion	Orthodox Christian	1,650 (29.1)	2,332(35.3)
	Muslim	2,753(48.6)	2,596(39.3)
	Protestant	1,122(19.8)	1,463(22.1)
	Other	142(2.5)	221(3.3)
Educational status of women	No education	3,973(70.1)	4,555(68.9)
	Primary	1,423(25.1)	1,833(27.7)
	Secondary	222(3.9)	191(2.9)
	Above	49(0.9)	33(0.5)
Educational status of partner/husband	No education	2,909(54.8)	3,194(51.4)
	Primary	1,785(33.6)	2,479(39.9)
	Secondary	387(7.3)	382(6.1)
	Above	200(3.8)	129(2.1)
	Don't know	32(0.6)	33(0.5)
Current marital status	Single/separated	81(1.4)	114(1.7)
	Married/in union	5,313(93.8)	6,218(94.1)
	Divorced/Widowed	273(4.8)	279(4.2)
Occupation status of women	No work	3,315(58.5)	3,681(55.7)
	Agriculture employee	1,389(24.5)	1,706(25.8)
	Non agriculture workers	963(17.0)	1,225(18.5)
Sex of household head	Female	1,100(19.4)	871(13.2)
Sex of household head	Male	4,567(80.6)	5,741(86.8)
Household wealth status	Poor	3,506(61.9)	3,243(49.1)
	Middle	993(17.5)	1,565(23.7)
	Rich	1,168(20.6)	1,803(27.2)
Total		5,667(100)	6,611(100)

Table 2: Maternal, Obstetric, and health service-related characteristics of women who gave birth within the last five years preceding the survey in rural Ethiopia, EDHS 2016, 2020.

Variable	Category	Unweight n (%)	Weighted n (%)
Family size	Less than five	2,571 (45.4)	2,962 (44.8)
	Five to ten	2,929 (51.6)	3,451 (52.2)
	Greater than ten	167 (3.0)	197 (3.0)
Autonomy to the decision of health care	No	1,524 (26.9)	1,721 (26.0)
Autonomy to the decision of health care	Yes	4,143 (73.1)	4,890 (74.0)
Distance to the health facility	Not big problem	2,189 (38.6)	2,371 (35.9)
Distance to the health facility	Big problem	3,478 (61.4)	4,240 (64.1)
Birth order	one	950 (16.8)	1,099(16.6)
	Two to five	2,994 (52.8)	3,475 (52.6)
	Greater than five	1,723 (30.4)	2,037 (30.8)
Community-level poverty	Low	2,821(48.5)	4,611(69.8)
Community-level poverty	High	2,991(51.5)	1,999(30.2)
Community-level literacy	Low	2,644(45.5)	2,452( 37.1)
Community-level literacy	High	3,168(54.5)	4,159(62.9)
Total		5,667(100)	6,611(100)

Table 3: Multi-level Negative binomial regression on the number of Antenatal care among women who gave birth within the last five years preceding the survey in rural Ethiopia, EDHS 2016, 2020.

Variables	Category		CIRR (95%CI)	Model I(Null)	Model II (AIRR (95% CI))	Mode III (AIRR (95%CI))	Full Model (AIRR (95%CI))
Age of women	15-24		1		1		1
	25-29		1.03(0.95,1.13)		1.14(1.03,1.27)		1.13 (1.02, 1.26) *
	30-49		0.85(0.77,0.92)		1.06(0.93,1.21)		1.04 (0.91, 1.19)
Educational status of women	No education		1		1		1
	Primary		1.29(1.19,1.40)		1.21(1.01,1.34)		1.19 (1.08, 1.32)***
	Secondary		1.48(1.30,1.69)		1.32(1.11,1.58)		1.30 (1.08, 1.55)*
	Above		1.84(1.62,2.09)		1.36(1.08,1.73)		1.35 (1.07, 1.71)*
Educational status of Husband	No education		1		1		1
	Primary		1.26(1.16,1.37)		1.17(1.07,1.29)		1.16 (1.05, 1.28)*
	Secondary		1.46(1.31,1.63)		1.24(1.09,1.39)		1.22 (1.08, 1.38) **
	Above		1.44(1.24,1.66)		1.05(0.84,1.33)		1.05 (0.83, 1.32)
Occupational status of women	No work		1		1		1
	Agriculture		1.02(0.92,1.14)		1.11(0.98,1.25)		1.10 (0.97, 1.25)
	Non-agriculture		1.13(1.01,1.26)		1.13(1.01,1.28)		1.13 (1.01, 1.27)
Wealth status	Poor		1		1		1
	Middle		1.11(1.01,1.23)		1.11(0.99,1.25)		1.08 (0.96, 1.21)
	Rich		1.27(1.15,1.41)		1.22(1.09,1.36)		1.17 (1.04, 1.31) *
Family size	<5		1		1		1
	5-10		0.89(0.82,0.96)		1.01(0.91,1.10)		1.01(0.91, 1.11)
	>10		0.93(0.70,1.25)		1.04(0.71,1.52)		1.05 (0.72, 1.54)
Autonomy to the decision of health care	No		1		1		1
Autonomy to the decision of health care	Yes		1.21(1.09,1.33)		1.26(1.11,1.43)		1.25 (1.10, 1.42)***
Distance to a health facility	Not a big problem		1		1		1
Distance to a health facility	Big problem		0.92(0.84,1.01)		0.93(0.85,1.02)		0.86 (0.96, 1.03)
Birth order	1		1		1		1
	2-5		0.87(0.79,0.96)		0.89(0.79,0.99)		0.88 (0.79,0.99)*
	>5		0.74(0.67,0.82)		0.80(0.68,0.93)		0.80 (0.69,0.94)*
Community-level literacy		Lower	1			1	1
Community-level literacy		Higher	1.87 (1.61,2.19)			1.53(1.29,1.81)	1.35 (1.14, 1.59)***
Community-level poverty		Lower	1			1	1
Community-level poverty		Higher	0.54(0.46,0.63)			0.68 (0.57,0.82)	0.77 (0.64,0.92)*
Random effects
ICC (%)				10.7
Log-likelihood (LL)				-12439.9	-11530.33	-12395.74	-11,508.22
PCV-Explained variation (%)							74.9

CIRR= Crude incidence rate ratio; AIRR: Adjusted incidence rate ratio; CI: confidence interval; * = significant at p-value 0.05-0.01, **=significant at p-value 0.01, ***= significant at p-value 0.001; 1: reference group; SNNP = Southern nation, nationalities and peoples; Others = Catholic and traditional religion followers; Model I=model without independent variables; Model II= model includes only individual level variables; Model III=model includes only community level &continuous variables; Full model=model includes all variables; ICC=intra cluster correlation; PCV =percent change of variance

Table 4 not available with this version

No competing interests reported.

Determinants of Numbers on Antenatal Care Visits in Rural Ethiopia: A Multilevel Negative Binomial Regression Analysis

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