Early Initiation of Antenatal Care and Factors Associated with Early Antenatal Care Initiation at Health Facilities in Southern Ethiopia

. Antenatal care (ANC) is care given to pregnant mothers to timely identify and mitigate pregnancy related problems that can harm mother or fetus. Most of Ethiopian mothers present late for ANC. The aim of this paper was to assess determinants of early antenatal care initiation among pregnant women. Mothers attending Shebedino District Health Centers for ANC between January 12 and February18,2015,wereinvitedtothestudy.Multistagesamplingtechniqueandstructuredquestionnairewereusedtocollectdataby traineddatacollectors.Univariateandbivariateanalysiswereconductedtostudytheassociationbetweenexplanatoryandoutcome variable.Outof608women,132[21.71%]hadtheirfirstANCwithintherecommendedtime[beforeorat3months].Mediaaccess [AOR=2.1195%CI1.00,3.22],knowledgeaboutthecorrecttimeofANCbooking[AOR=4.4995%CI2.47,6.16],andhavingbeen advisedtobookwithin12weeks[AOR=4.1495%CI3.80,5.21]weredeterminantsoffirst-trimesterbooking.Healthprofessionals andcareprovidersshouldprovidefullinformation,advice,andappropriatecareaboutearlyANCforeveryeligiblemother.


Introduction
The care that was given to the mother during pregnancy, during delivery, and after delivery is important for the wellbeing of the mother and the child.All pregnant ladies are recommended to go for their first antenatal check-up in the first trimester to identify and manage any medical complication as well as to screen them for any risk factors that may affect the progress and outcome of their pregnancy [1].The first visit which is expected to screen and treat anemia and syphilis, screen for risk factors and medical conditions that can be best dealt with in early pregnancy, and initiate prophylaxis if required (e.g., for anemia and malaria) is recommended to be held by the end of fourth month [2].ANC helps to ensure the well-being of the mother and fetus through early detection of risks in pregnancy, prevention of pregnancy, and labor complications and ensures the safe delivery of mother and child [3].In Ethiopia, 34% of pregnant women attend antenatal care at least once and 19% of them attend four times and only 11.2% attend early [4].In Ethiopia, antennal care services increased in the past 15 years from 27 percent in 2000 to 62 percent in 2015.However, it needs further improvement to achieve [5][6][7].
Globally, approximately 515,000 women die from pregnancy related complications each year [8].In developing world over 30 million women suffer each year from serious obstetric complications [9].Inadequate access and underutilization of modern healthcare services are major reasons for poor health in the developing countries.This inequality in the health and well-being of women in the developing world is a growing concern [10].Although services are given freely, a number of factors have been found to contribute to late initiation of ANC among pregnant women and these may vary between rural and urban areas [11].
Pregnant women should be offered screening for HIV infection early in ANC [12].Low ANC coverage, few visits, and late attendance at first antenatal visit are common 2 Advances in Public Health problems throughout Sub-Saharan Africa posing difficulty in accomplishing the WHO recommended ANC schedule [13].
Late ANC initiation may increase the total cost of caring for a pregnant woman [14].A study conducted in Hadiya zone Southern Ethiopia revealed that, concerning time of initiating care, only 8.7% of the ANC attendants initiated care during the first trimester of pregnancy while 68.1% had the first visit during the third trimester [15].Another study in Ethiopia showed that proper advice and information on timely booking from service providers and community level are very important for the effective utilization of the service [16].
Women in developing countries, particularly in Sub-Saharan Africa, tend to wait to start antenatal care until the second or third trimester [17].The standard of care when evaluating a woman with a potentially complicated firsttrimester pregnancy is to take a detailed history of the risk factors and ascertain the clinical course [18].Educational status of the women and family income were independent factors for late initiation of ANC [19].Pregnant mothers at younger age [20] register early for ANC compared to older age and younger women are more likely to accept modern health care as they are likely to have greater experience to modern medicine [21].
Women who have lower educational status, have good perception, and are urban residents are more likely to attend early for ANC compared to their counterparts [10,22].Parity [22] and late ANC initiation are also a factor for ANC utilization [23].The aim of this study is to assess the magnitude and factors associated with early antenatal care initiation of mothers in health facilities.

Materials and Methods
Study was conducted in Shebedino district, which is one of 19 rural woredas of Sidama zone in Southern regions of Ethiopia, which is located 28 KM from capital city of southern regions, Hawassa, and organised by 32 rural and 3 urban kebeles for the purpose of administration.Source population was all mothers attending Shebedino district health facilities in Sidama zone.The study population was pregnant mothers attending Shebedino district health facilities for ANC services during study period with inclusion criteria of pregnant mothers attending those health facilities during study period for ANC services and exclusion criteria of pregnant mothers with some serious illness and labor.Five health centers were randomly selected by lottery method among 9 health centers in the woreda and 1 primary hospital.Multistage sampling technique was applied till the sample size was enough.Sample proportion or number of eligible pregnant mothers was calculated based on catchment population proportion using exit interview at every third mother.
The sample size was calculated using single population proportion based on the study conducted on timing of first ANC visit at Gondar Hospital, and a prevalence of 47.2% was taken to estimate the sample size [20].Six hundred thirty mothers were included in the study with an assumption of 95% confidence interval, 5% margin of error, 10% nonresponse rate, and a design effect of 1.5.
A pretested questionnaire which consists of a sociodemographic characteristic, obstetric information, and decisionmaking status of women was used.The data collection was exit interview with pregnant mothers after service of ANC Department of Health Facilities.The data was collected by trained clinical nurses or midwifes who were selected from other catchments which are not selected for data collection.Data collectors were supervised by trained supervisors daily during data collection.Before data collection, ethical approval was taken from IRB of Addis Continental Institute of Public Health and informed consent and confidentiality were assured by data collectors to the participants.
Questionnaire was checked daily by the principal investigator for consistency.The selecting criteria of data collectors were ability to speak local language, interest to participate, and being well mannered and disciplined.Data was entered into EPI info version 3.5.1 and transferred to Statistical Package for Social Science (SPSS) version 20.0 software for analysis.Descriptive and summary statistics was carried out. value 0.05 was considered statistical significance.Bivariate and multivariate logistic regression analyses were used to identify variables associated with early antenatal initiation.

Result
Out of 631 pregnant women who initiated to be included in this study, 608 [96.3%] have responded to the interview.The remaining 17 [2.7%]did not respond to the interview while 6 [1%] of them were unable to respond or they did not specify the gestational age when they started the ANC.The median age of respondents was 25 years ranging from 15 to 40 years (Table 1).

Obstetric History and Timing of First ANC Visits.
Majority, 409 [67.3%], of respondents had parity one and above, while 184 [30.3%] have no parity and the remaining 15 [2.4%] of the respondents had history of parity greater than five (Table 2).

Knowledge and Perception of ANC Service Utilization and
First Timing of ANC Visit.Majority, 596 [98.2%], of respondents perceived and rated that the importance of ANC for the health of the mother and fetus was highly important to the health of mother and fetus.Two-thirds, 410 [67.4%], of the respondents perceived that the correct time of ANC starting was after 12 weeks of gestation followed by 169 [27.8%] who perceived that the correct time of ANC starting was before 12 weeks of gestation.26 [4.3%] respondents perceived that only one visit of ANC was enough, 76 [12.5%] perceived that two to three visits of ANC were necessary, 430 [70.8%] perceived that four to six visits of ANC were necessary, and 75 [12.4%]perceived that more than six ANC visits are necessary (Table 3).

Discussion
In this study, only about 21.72% of respondents have started their ANC within the recommended time with 95% CI (18%, 25%) and the remaining 78.28% booked it lately with 95% CI (75%, 81%).The timing of first booking ranged from first month after last menstrual period to ninth month of gestation.The proportion of women who came for their first ANC within recommended time is lower than studies done in Gondar, Addis Ababa, and higher than studies conducted in Hadiya, Kembata zone, Yem special district, and EDHS 2011 [4, 13,[18][19][20][21].Possible explanation for this might be those who have more proportion of early ANC due to better access and awareness regarding services while the lower proportion may be due to time variation in this study and the access and awareness improvement.
According to the result, mothers of age ≤ 25 years were found to be more likely to have early initiation of ANC when compared with others (COR = 1.309 95% CI 0.92, 2.458), but not significant.This idea was slightly supported by study done in Addis Ababa, Yem, Gondar, and Debrebrhan; this idea contradicts the study done in Tanzania (18)(19)(20)(21)8).This might be because younger mothers were more informed and convincible to seek appropriate prenatal care.
Respondents who had media access TV/radio initiated ANC within recommended time twice more likely when compared to those who had not (AOR = 2.109 95% CI 1.001, 4.445).This might be due to exposure to source of information, as result of the study indicated that prim gravid mothers start ANC timely 1.4 times more likely when compared to multigravid mothers (AOR = 1.038 95% CI 1.02, 1.92).Another study conducted in Tanzania showed that higher gravidity is more likely to be predictor of late antenatal care initiation compared to early ANC initiation [8].This could be because prim gravid mothers may be younger and educated and easily understand an advice to commence ANC early and different information.
Parity of respondents was found to be more likely predictor of timely booking of ANC (COR = 1.429 95% CI 0.951, 2.145), but not significant, and this finding was similar to that of study done in Debrebrhan and lower than the studies done in Gondar and Kembata Tembaro zone as parity was found as the most predictor for late utilization of ANC.The same studies revealed that pervious ANC utilization was also found to be a positive predictor for timely ANC booking [21,22].Perception of respondents concerning correct time of early initiation of ANC was highly associated with early initiation of ANC at recommended time and mothers who perceived right time to be in the first 12 weeks of gestation were nearly 4.5 times more likely to commence ANC timely than those who perceived right time beyond 12 weeks of gestation (AOR = 4.499 95% CI 2.470, 6.160) ( value = 0.000).This finding was supported by and higher than other findings of many studies conducted in different parts of our country [4, 14,18,20].
The finding of this study revealed that the maternal perception concerning the correct time to ANC booking was similar to that of study done in Gondar town.This in fact may be determinant factor for early ANC initiation at recommended time [22].
The result of the study indicates that respondents who received correct advice to book ANC during recommended time after amenorrhea used early ANC 4 times more likely than those not advised about correct time (AOR = 4.146 95% CI 3.806, 21.398) ( value = 0.001).The study conducted at Addis Ababa also concluded that physical and financial accessibility alone cannot assure effective service utilization of ANC.The need for proper advice and information on timely booking from service providers and community level and/or health institution is very important for the effective utilization of the service [16].The current finding was also similar to that finding.As revealed on the result of the study, occupation of the respondents had no effect on the early ANC initiation; this finding contradicts the study done in Kembata Tembaro 6 Advances in Public Health [21].And others like educational level of mothers and their husbands, parity, and pregnancy plan by mothers and their husbands were not statistically significant findings.

Conclusion
Early time of initiation for ANC at recommended time is low.Perception of mothers on correct time of ANC initiation, advice on correct time of ANC initiation, past experience of early booking of ANC, and media access are the positive predictors or factors of early ANC initiation.Multigravid mothers start ANC more early than prim gravid mothers.Health professionals and care providers should provide full information and advice and appropriate care about early ANC for every eligible mother.Mass media worker should include early initiation of ANC.Care takers should consider the importance of past experience of early ANC and perceive appropriate time to start ANC.

Table 1 :
Timely ANC Initiation.Bivariate analysis showed that respondents who had media access (TV/radio) [OR = 1.485 95% CI 1.002, 2.202], who had perceived that the correct time of ANC booking is within 12 weeks of gestation [OR = 20.75595% CI 12.816, 33.613], Sociodemographic characteristics of respondents by time of ANC booking in Shebedino district in 2015.

Table 2 :
Number of respondents by obstetric history and time of first ANC, Shebedino district in 2015.

Table 3 :
Knowledge and perception of ANC service utilization and timing of first ANC, Shebedino in district SNNPR, Ethiopia, in 2015.
weeks [OR = 4.146 95% CI 5.806, 21.398] were also more likely to book ANC within the recommended time compared to corresponding counterparts and these factors were found positively associated (Table4).