Findings involving 320 participants from Kiganamo Health Centre and Kasulu Hospital were presented. A total of 192 accounts to 60% (60%) of participants attended at Kiganamo Health Centre, and remain 128 were from Kasulu Hospital. The demographic, socio-economic, and maternal characteristics of women with children aged 0–6 months were reported.
Demographic characteristics
Table 2 illustrates demographic characteristics such as mother’s age, education, marital status, husband’s age, and education. Regarding age, 44% of the women participants were 15–24 years. This proportion was high considering the sensitivity of the adolescent group, reported to face more barriers to initiating ANC visits than mature women. Over 50% (172) of the respondents had completed primary education, which is still low with implications in decision-making on their health. In contrast, 142 (45%) of the respondents aged between 25 and 34 years and 172 (53.8%) had completed secondary education and above respectively. However, age and education may imply differences in decision-making regarding health service-related matters. In addition, married women account for 285 (89.1%) of the respondents.
Socio-economic characteristics
The occupation of mothers and their partners has significant implications for the first ANC visits. About 232 (72.5%) of women were not employed in the formal system, and 88(27.5%) were employed in the private sector through self-employment either small farming activities or informal sectors. Contrary, about 140 husbands or partners equal to 43.8% were not employed. Regarding health-seeking behaviour, faith in various religions was an important factor to consider among participants. The findings unveiled that protestants and followers of other religions were 167 (52%), followed by Roman Catholics with 90 participants (28%) and 63 (20%) were Muslims as illustrated in Table 3.
Regarding the number of meals consumed in a day about 174 (54.4%) households took their meals twice or less as an indication of the nutrition status in this community. In this community, most households were regarded as poor and cannot afford to cover the costs of basic needs based on the household income history. According to Table 3 above, about 237 (74.1%) had income below TZS, which was 210,000 (USD 84) monthly. On the other hand, ownership of communication devices like television (TV) has implications for education and behaviour change, however, 98 equal to 30.6% alone, owned TVs. Therefore, the majority of the community members would have limited information when disseminated through television.
Timing of ANC visits and characteristics of participants
The timing of ANC visits was considered perfect if a woman attended the first ANC visit within the first trimester considering the quality of services provided. Women’s knowledge on the services received during pregnancy including counseling, nutritional advice, anaemia prevention, time spent to the facilities, availability of ANC components like iron-folic acid supplementation, anti-worms, HIV testing and Hb level, were captured using women’s satisfaction, and perception and their lived experience. Findings were used to recommend on the improvement of timely ANC attendance and maternal and child health outcomes. In the future, standalone study to assess quality of services and how is aligned with WHO recommendations. Gestational age was used to establish timing of ANC visits which was calculated from the Last Normal Menstrual Period (LNMP) and verified using registry book. A woman WHO attends ANC before 12 weeks (3 months) was considered to have initiated ANC in the first trimester. On the other hand, ultrasound (6–12 weeks) and Fundal Height Measurement when turn to second trimester to confirm gestational age especially LNMP is uncertain.
In this study, more than 60% of the participants initiated the first ANC visit in the second and third trimesters. Only 32% appeared for the first time in the first trimester. This is low proportional compared to the current national average of 34% in 2022, but high compared to 22% in 2016. Demographic attributes like social, economic, and maternal characteristics were associated with the timing of ANC visits. In addition, socio-belief, lack of knowledge about ANC visits, number of children, and lack of partner’s support were associated with late ANC visits. Figure 2 depicts the timing of ANC visits. The FGDs with pregnant women were conducted to capture their first-hand experiences, beliefs and barriers to timely ANC initiation. To complement FGDs, HCPs were interviewed because were interacting with diverse range of pregnant women in routine services and have a broader understanding of systemic challenges, health-seeking behaviour and patterns influencing early ANC visits which might not be fully captured through FGDs alone. This mixed perspective strengthen findings and improved the contextual understanding of ANC initiation drivers in KTC.
With regard to IDIs with HCPs, women appeared for ANC in the second and third trimesters. During key informant interview, HCP revealed that:
“…In our community pregnant women attend ANC late, more women appear for ANC in the first time when the pregnancy is over five months” (IDI: HCP, C-1).
Further, HCP disclosed that women who initiated ANC visits very late remain a challenge in the area; however, they provide them with education and explain the importance of early ANC visits using various methods, including a male involvement program. To emphasise this, one HCP said:
“…most women start ANC visits within 5–6 months; others appear for the first time with 8 months of pregnancy, just to get a delivery slot” (IDI: HCP, C-2).
Generally, the majority of women initiate ANC visits late in the second and third trimesters, with nonconstructive implications for maternal and child health. These include pregnancy complications during pregnancy, delivery, and post-delivery period. Intensive strategies are required to improve early ANC visits during pregnancy.
Awareness of the number of recommended ANC visits
The ANC visit has the potential to improve maternal and newborn health; however, most respondents were unaware of the importance of an adequate number of ANC visits to ensure safe delivery. Of 320 respondents, 272 (85%) were unaware of the recommended number of ANC visits during pregnancy. In regard to ANC visits, 62.2% of the respondents attended at least four visits. Respondents do not have a clear understanding of the eight recommended ANC visits. For example, some said it four times, and others said it five and six times. During FGDs, one said:
“……I think any number of ANC visits is acceptable, whatever the pregnant woman can afford because of barriers differences” (FGD: women who had children B-2).
According to WHO, the number of ANC visits a woman is encouraged to make eight visits to which women thought this number of visits was limiting for early ANC visits, as stated below.
“Women complain about the number of ANC visits; they feel like the number of visits is a barrier to early ANC, as women in our area are disappointed with the number of ANC visits. They go to ANC so often but they can try to avoid it many times. Alternatively, women will return for an ANC visit late or visits early just and disappear for a duration of three complete months earlier than the subsequent visit” (IDI: HCP, C-3).
Women expressed discomfort in attending ANC visits earlier and tended to avoid the frequency of eight ANC visits. They also cited that they were not aware of the recommended number of ANC visits and the problem of spending too much time simply going for ANC visits.
Parity
This corresponds to parity and determinants related to ANC visits. In this study, women with para 1–3 were 221 (69%) while those with para four (4) and above were 99 (31%). Parity affects decision-making with regard to the initiation of ANC visits. The majority of primigravida women tend to initiate ANC visits early when their partners or family members accompany them. Further details are explained in Table 4.
Parity is defined as the number of times a woman has given birth with a gestational age of 24 weeks or more including live births and stillbirths.
Accompanying partners
Partners’ support has implications for early or late initiation of ANC visits. The study found that of 320 women, those accompanied by their partners for the first ANC were 186 (58%). The same was revealed in the qualitative findings that the rate of male accompanying their partners was low. The issue of prevention of HIV transmission from mothers to children (PMCTC) was raised during FGDs. In Tanzania, it is mandatory for both partners to test for HIV/AIDS during the first ANC visits men who are not ready to know their HIV status tend to deny accompanying their partners. This guideline made pregnant women initiate ANC visits outside of the prescribed first trimester.
“In my opinion, involving male partners when their wives visit for their first ANC is great. Nevertheless, the way it is implemented has far-reaching implications on when ANC visits should ideally begin. Let me give an example from my own experience and to be honest, I cannot find a reason why these processes should hurt me after all, I am married. After all, barriers related to HIV testing during pregnancy. I waited till my husband came back and initiated first ANC visits during my eighth months of this pregnancy, just imagine’’ (FGD: Women with children, B-3).
In addition, married women were not ready to face embarrassment for going for the first ANC visit without their male partners. The majority of women were ready to wait no matter how long it would take until their partners were ready to accompany them at ANC visits, especially in the first trimester. Cementing on such views, a woman during FGDs attested that:
“One of the challenges we have in our society is that men do not accompany their partners to ANC. While partners are often uncomfortable to accompany their wives for the first ANC visit, women delay initiating ANC earlier” (FGD: Women with children, B-4).
If a man is not ready to accompany his partner to the first ANC visit, women tend to wait but not ready to face discomfort from interrogation by HCPs. They are normally directed to seek approval from the village office, which warrants them with ANC services in the absence of their partners, which is also not comfortable. All these inconveniences make pregnant women delay their first ANC visits until they fulfill this conditions. This is an experience of a woman with her partner during FGD:
“Men have negative views about ANC visits, but allow me to tell you the truth. For this pregnancy, I asked my husband to accompany me for the ANC visits and he said he would not follow me because it is not him who carrying a pregnancy. I was so depressed indeed. Even if you convince them, I really don’t know how they can be persuaded to come to ANC willingly” (FGD: Pregnant Women-A3).
In this regard, males perceive that ANC visits are designed for women alone, and this perception continues to hinder the government’s efforts to recommend early ANC visits. Their resistance increases chances for maternal and child deaths that would otherwise be avoided. Pregnant adolescents are the most affected group, as they become pregnant out of socially unacceptable ways and the father is normally not exposed. This makes difficult for them to even go to the village chair and get a warrant to access ANC services. Thus, it becomes more difficult for them and therefore exacerbates more delays.
Knowledge about the timing of early ANC visits
The timing of the initiation of an ANC visit is crucial for maternal and newborn health. In this study, the proportion of women with proper knowledge about the timing of ANC visits was low at 36% (115). In regard to the knowledge revealed during FGDs with pregnant women when responding to the question on the proper time for starting ANC visits. One pregnant woman asserted that.
“I am not sure when to begin antenatal care. However, the women around say it is after three to five months of pregnancy and others say the right time is just one to two weeks into the pregnancy. What I believe is that the first ANC visit should be done any time after realising that you an expecting mother’’ (FGD: Pregnant Women, A-1).
Similar respondents asked about the benefits of initiating ANC visits early. Most of them were unclear about the benefits of initiating ANC visits in the first trimester. One pregnant woman has something to say on the matter:
“…. I don’t know, this is my first pregnancy, I would like to hear more about any advantage that can be gained if a person makes an early ANC visit” (FGD: Pregnant Women A-2).
While the data collected across all sources depicted low knowledge among pregnant women on the benefit of initiating ANC within the first trimester, it is clear that limited intervention strategies at the community level and work overload among HCPs have attributed to low health-seeking behaviour among pregnant women.
Danger signs identification
A woman undergoes profound changes in their bodies after conception including experiencing diverse danger signs which if not managed early, may lead to maternal deaths. On this basis, a study sought to establish whether respondents could identify such signs. The study developed a list of danger signs for the respondents to identify them including severe virginal bleeding, convulsion, and severe headache with blurred vision, severe abdominal pain, and fatigue. On the other hand, listed danger signs were fast or difficulty breathing, reduced fetal movement, fever, and swelling of the fingers, face, and legs. Table 5 shows respondents’ capacity to identify danger signs women encounter during pregnancy.
Proper understanding of the danger signs during pregnancy is a good indicator of improving the health of the pregnant woman and their child. A woman who managed to identify at least five danger signs out of nine was considered to be informed by HCPs or other health promotion platforms, including radio, television, and family members. As shown in Table 5, only 212 (66%) of women managed to identify danger signs that women may encounter during pregnancy. A better understanding of danger signs is crucial during the planning of interventions to reduce maternal and child mortality. Despite the proportion of women informed about the danger signs, more efforts are needed to promote early utilisation of ANC services.
Perceived health services and timing of ANC
The majority of participants were positive about services provided during ANC visits and about 70% (234) were optimistic. This is notwithstanding the existing shortage of HCPs, which would have increased their burden. Similar findings echoed during FGDs, which hinted that the few available HCPs worked beyond their limit to ensure that ANC and additional health services were properly delivered. During FGD, study participants shared their experiences and perceptions of ANC services offered at the facilities.
“…. I know from my own experience that nurses help us whatever late we are. Actually, nurses rushed into my delivery bed to attend me on my first pregnancy. But they would provide me instructions that helped me survive”. (FGD: Women with Children (B-5).
A similar statement was provided by one HCP, who attested how they work hard to ensure that all those who appear for the ANC are attended, as quoted:
“This facility is placed in a busy area so we get many clients at the RCH department and because of this we have made everything possible to meet their needs. This is despite them not meeting the diverse ANC guidelines by coming late, we give them all services including regular check-ups while pregnant” (IDI: HCP, C-1).
Overall, women perceived the effectiveness of ANC services as an imperative tool in motivating them to seek ANC services. Pregnant women are assured that even when they delay seeking ANC services, they are still attended by HCPs from the facilities. Actually, services stipulated during ANC visits greatly benefit pregnant women and newborns if pregnant women adhere to ANC visits thoroughly.
Demographic, socio-economic, and maternal characteristics associated with timing of ANC visits
Table 6 illustrates the factors associated with the timing of ANC visits during the first trimester as a potential period to reduce the number of maternal deaths and other negative outcomes. Regarding, the proportion of women who attended ANC visit in the first trimester during pregnancy was low. Reasons for delays were less motivation from their husbands and partners, cultural beliefs, knowledge of early ANC visits, and maternal age. The model used to assess the characteristics associated with the timing of ANC visits during pregnancy was significant at P < 0.05 with an adjusted R of 0.199 from Nagelkerke R square. The model was the best fit to predict the associated characteristics by 99.7%. A binary logistic regression model was used to detect the associated characteristics with ANC attendance, including maternal age, accompany of the husband or partner, and parity.
Indeed, early initiation of ANC among pregnant women attended at public facilities in Kasulu TC was significantly associated with six variables. Therefore, factors with high AOR should be considered when designing interventions to improve the timing of the utilisation of ANC in the future.
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