Antenatal care registration and predicting factors of late registration among pregnant women

Abstract

Summary

The objective of antenatal care (ANC) is prevention, early recognition and treatment of pregnancy related ailments as well as general medical problems. It also provides an opportunity for reproductive health counselling. Early registration at an antenatal clinic is recommended. However, the majority of pregnant women are entered late into an antenatal care programme, especially in developing countries such as India. We explored the factors associated with late antenatal registration in a rural area of Gujarat State.

Introduction

Early registration to antenatal care (ANC) is imperative for the timely diagnosis and treatment of pregnancy related morbidities. ANC has progressed over a period of time, with the trend shifting gradually from indoor care to the out-patient care that we have at present.^1,2 Good ANC for pregnant women has become a vital component in the safe motherhood programme whose aim is to improve the outcome of pregnancy for both the mother and the fetus.^2,3 The usual recommendation nowadays is for registration (first antenatal visit) to take place in early pregnancy – prior to 14 weeks. The World Health Organization (WHO) recommends that pregnant women in developing countries should seek ANC within the first 4 months of pregnancy.⁴ In developed countries such as the UK and the USA, the first ANC visit is recommended within the first 12 weeks of pregnancy.^5,6

Early registration makes it possible to have a good idea of the pre-pregnancy state of the women by noting certain baseline measurements, such as body mass index, blood pressure and urine testing.^7,8 In addition, early ANC visits also enable fairly accurate calculation of the expected date of delivery, especially in women who are unsure of their last menstrual period.^7,8

Worldwide, studies have reported the following factors associated with late ANC registration: place of residence;^9–11 age;¹⁰ ethnicity;¹² use of contraceptive methods;¹² education;^11,13,14 economic status;^9,12,13 employment status;^12,15 parity;^{10– 12,14} intention to become pregnant;^9,12 health insurance;^9–11,13,16 and distance from the ANC centre.⁹

However, in spite of advantages of early registration, late registration is common in the developing world. Studies from developing areas of Benin and Sokoto showed that the mean gestational ages at registration among the pregnant women were 23.7 and 23.55 weeks, respectively.^17,18 The aim of this study was to assess the proportion of pregnant women who registered late for ANC in Chandkheda, Western India, during 2008 and to identify factors related to late registration.

Subjects and methods

After obtaining consent, structured questionnaires were completed via personal interviews of pregnant women attending antenatal clinic at Chandkheda Health Centre (CHC) which is located in a rural area of Gujarat State, India. ANC women presenting to the health centre before completion of 12 weeks of gestation were considered as ‘early registrations’ and those presenting after that were ‘late registrations’. CHC is the rural health training centre of NHL Medical College, Ahmedabad. Antenatal women registered during the year 2008 were included in the study. Ethical approval was obtained from the ethical committee of NHL Medical College and verbal consent was obtained from all participants. We used a descriptive statistics system, mean and standard deviation for continuous variables and frequency for categorical variables. The test of association was carried out using chi-square. Multivariate stepwise logistic regression was performed in order to identify significant predictors – all at 5% level of significance. Data analysis was performed using SPSS version 16 (registered to VNSGU, Surat).

Results

Among the 418 ANC who visited the centre, 393 (94.0%) agreed to participate in the study. The mean age of the respondents was 28 years with standard deviation of 4.6 years (17–41). Among the participants, 77 (19.6%) registered within 12 weeks of gestation, while the majority, 316 (80.4%), registered after that time. The mean gestational age at the time of registration was 20.3 ± 6.2 weeks. Of the 393 participants, 325 (82.7%) were expecting single pregnancies, 18 (4.6%) twin pregnancies and 50 (12.7%) were uncertain.

One hundred and eighty-two (46.3%) had received secondary education while 175 (44.5%) were housewife/ unemployed. Most, 277 (70.5%), were parous and the other 116 (29.5%) were nulliparous (Table 1). Women with a lower family incomes were more likely to register late compared to those with higher incomes (P < 0.01). Similarly, 86 (21.9%) women aged less than 25 years registered late compared to 307 (78.1%) over 25 years and this difference was statistically significant (P < 0.01).

Table 1

Distribution of selected socio-demographic variables among study population

Variables	Frequency (n = 393) (%)
Age of antenatal women (years)
≤19	11 (2.8)
20–24	75 (19.1)
25–29	157 (39.9)
30–34	116 (29.5)
≥35	34 (8.7)
Religion
Hindu	339 (86.3)
Islam	18 (4.6)
Others	36 (9.2)
Educational status
No formal education	42 (10.7)
Primary school level	117 (29.8)
Secondary school level	182 (46.3)
Tertiary school level	52 (13.2)
Employment status
Government service	73 (18.6)
Private employed	40 (10.2)
Self-employed	53 (13.5)
Unemployed/housewife	175 (44.5)
Student	52 (13.2)
Husband's educational status
No formal education	16 (4.1)
Primary school level	19 (4.8)
Secondary school level	124 (31.6)
Tertiary school level	234 (59.5)
Parity of antenatal women
Nullipara	116 (29.5)
Para (>1)	277 (70.5)

Factors such as previous caesarean delivery, complications during the index pregnancy, problems in the past pregnancy and parity were not significantly associated with the time of antenatal registration. Neither the educational status of the women or their husbands was significantly associated with the time of antenatal registration (Table 2).

Table 2

Factors influencing late registration into antenatal care

Variables	Gestational age ≤ 12 weeks Frequency (n = 77) (%)	Gestational age > 12 weeks Frequency (n = 316) (%)	χ²	df	P value
Problems in last delivery
Yes	14 (25.0)	42 (75.0)
No	63 (18.7)	274 (81.3)	1.21	1	0.272
Previous history of caesarean section
Yes	9 (24.3)	28 (75.7)
No	68 (19.1)	288 (80.9)	0.58	1	0.45
Problems in index pregnancy
Yes	8 (25.0)	24 (75.0)
No	69 (19.1)	292 (80.9)	0.65	1	0.42
Income per month (US dollars)
<40	13 (10.8)	107 (89.2)
40–80	19 (17.8)	88 (82.2)
80–120	21 (21.6)	76 (78.4)
>120	24 (34.8)	45 (65.2)	16.44	3	0.000
Parity
Para 0	24 (21.1)	90 (78.9)
Para ≥ 1	53 (19.0)	226 (81.0)	0.22	1	0.64
Educational status
Primary and below	25 (15.7)	134 (84.3)
Secondary and above	52 (22.2)	182 (77.8)	2.54	1	0.11
Husband's educational status
Primary and below	5 (14.3)	30 (85.7)
Secondary and above	72 (20.1)	286 (79.9)	0.69	1	0.41
Age (years)
<25	7 (8.1)	79 (91.9)
≥25	70 (22.8)	237 (77.2)	9.17	1	0.002

χ², Chi-square; df, degree of freedom

Multivariate analysis, by adjusting other factors, revealed that participants who had received secondary or higher education were more likely to register early compared to those who had only a primary school education or below [odds ratio (OR) = 2.63, 95% confidence interval (CI), 1.29–5.38]. Those who were aged less than 25 years were more likely to register late compared to older women (OR = 8.31, 95% CI, 3.75–18.49; Table 3).

Table 3

Multivariate analyses of factors associated with late registration

Variables	Crude OR (95% CI)	Adjusted OR (95% CI)
Problems in last delivery
Yes	1	1
No	1.45(0.75–2.82)	2.04(0.93–4.47)
Educational status
Secondary and above	1	1
Primary and below	1.53(0.90–2.59)	2.63(1.29–5.38)**
Maternal age (years)
<25	1	1
≥25	3.33(1.47–7.55)**	8.31(3.75–18.49)*

P < 0.05

P < 0.01

OR, odd ratio; CI, confidence interval

Discussion

The study attempted to assess the prevalence of pregnant women who registered late for antenatal care in Western India and to identify the associated factors. Only 20% entered ANC before 12 weeks of gestation. This was half the number reported in an Australian study in 2004 but similar to studies reported in parts of the developing world.^19,20 The mean gestational age at the time of antenatal registration was still very high but somewhat lower compared to some studies from developing countries.^17,19 These results indicate a poor appreciation of the importance of early registration as recommended by WHO.

Our results were similar to those of other studies on the importance of age of mother,¹⁰ and education of the mother.¹¹ Women younger than 25 years of age, who were less educated, earning less and less likely to be employed, were more likely to register late. However, after adjusting for other factors, earnings became statistically insignificant and this may be because of the customary practice of attending antenatal services late in this setting due to the belief that, since pregnancy is not an illness, there is no urgent need to register early. Studies in developed countries were in agreement with our observation that women with a higher education registered earlier than those who were illiterate or had received a lower education.^11,13,14 Educated mothers were better informed and more likely to understand the importance of early ANC than less educated mothers. This finding underlines the significance of education on ANC. Another study agreed that a past bad obstetric history, such as still birth, intrauterine fetal death, caesarean section and eclampsia, had no influence on the duration of pregnancy at registration.¹⁹

The lack of an association of nulliparity and complications in a previous pregnancy with early registration in current pregnancy in our study was in contrast to the findings of other reports where the association was consider to be significant. ^17,19 This finding indicates that, in the study area pregnant women had not received counselling or had been poorly counselled even after having complications in previous pregnancies. It also points to a lack of midwifery skill in grass root workers.

In our community, antenatal care behaviour of nulliparous women is largely influenced by their mother who would discourage early antenatal care seeking behaviour.

Conclusion

We found that a significant number of women registered late for ANC in our community which indicates that efforts are still needed to ensure that the community understand the importance of early registration. The level of education received by the mother, the age of the mother and a higher income were found to increase the number of antenatal registrations. It is important to raise public awareness of the benefits of early antenatal registration in routine health education programmes, especially among adolescents. Better education and better employment opportunities for women would contribute considerably to the need for early antenatal registration.

Early counselling for antenatal mothers (and perhaps their partners) about the option of a concurrent tubal ligation in cases where a caesarean section may be necessary, and also about tubal ligation soon after vagina delivery, would be an added benefit of early ante natal registration.

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