FACTORS THAT DETERMINE ANTENATAL CARE ATTENDANCE

AMONG YOUNG MOTHERS IN GENERAL HOSPITAL

BY

OTHO DEVIA

16/U/11133/PS

216014107

SUPERVISED BY

SERUNJOGI AMBROSE

A REPORT SUBMITTED TO THE SCHOOL OF STATISTICS AND PLANNING IN

PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE AWARD OF THE

DEGREE OF BACHELOR OF SCIENCE IN QUANTITATIVE ECONOMICS

OF MAKERERE UNIVERSITY

AUGUST, 2019 DECLARATION

i APPROVAL

ii

DEDICATION

I dedicate this work to my family. May this work be an inspiration to you all. To my parents, brothers and sisters, thank you for standing with me through thick and thin.

iii ACKNOWLEDGEMENTS

First and foremost, I would like to thank The Almighty God for seeing me through the entire course and more so this research project. Special gratitude goes to my supervisor, Mr.

Serunjogi Ambrose for his tireless support in guiding me throughout this exercise. My genuine thanks go to my parents for their support and prayers throughout the entire course.

My heartfelt gratitude goes to the management and lecturers of the School of Statistics and

Planning for their patience in supporting and guiding me through the course. I also acknowledge the support of my fellow students of bachelor of science in Quantitative

Economics of the academic year 2016/17 for the moral support we accorded each other during the course.

May the good Lord bless you abundantly!

iv TABLE OF CONTENTS

DECLARATION ...... i

APPROVAL ...... ii

DEDICATION ...... iii

ACKNOWLEDGEMENTS ...... iv

TABLE OF CONTENTS ...... v

LIST OF TABLES ...... viii

LIST OF FIGURES ...... ix

ABSTRACT ...... x

CHAPTER ONE ...... 1

INTRODUCTION ...... 1

1.1 Background to the study ...... 1

1.2 Statement of the Problem...... 2

1.3 General Objective...... 3

1.4 Specific Objectives ...... 3

1.4 Research Hypotheses ...... 4

1.5 Scope of the study ...... 5

1.6 Significance of the Study ...... 5

1.7 Conceptual Framework ...... 6

1.8 Definition of Key Terms ...... 7

v CHAPTER TWO ...... 8

LITERATURE REVIEW ...... 8

2.1 Antenatal Care in ...... 8

2.2 Theories Pertaining utilization of antenatal care services ...... 9

2.2.1 Motivation–Ease as a Middle-Range Theory ...... 9

2.2.2 Exemplars Theory ...... 10

2.3 Factors associated with Utilization of Antenatal Care Services ...... 11

2.4 Antenatal care and health facility delivery ...... 13

2.5 Knowledge Gap ...... 14

CHAPTER THREE ...... 15

METHODOLOGY ...... 15

3.1 Introduction ...... 15

3.2 Research Design ...... 15

3.3 Study Population ...... 15

3.4 Sample size determination and selection ...... 16

3.5 Data Source...... 16

3.6 Data Collection Methods ...... 16

3.7 Data analysis techniques ...... 16

CHAPTER FOUR ...... 18

RESULTS AND DISCUSSION OF FINDINGS ...... 18

4.1 Introduction ...... 18

vi 4.2.1 Type of place of residence...... 19

4.2.2 Mother Education level ...... 19

4.2.4 Decision about attendances ...... 19

4.2.5 Occupation of the young mothers in the reproductive age ...... 20

4.3 Continuous factors of young mothers attending Nebbi hospital ...... 21

4.4 Association of mother’s education with antenatal attendance ...... 21

4.5 Factors Determining Antenatal Attendance in Nebbi Hospital ...... 23

4.6 Discussion of findings ...... 25

CHAPTER FIVE ...... 27

CONCLUSION AND RECOMMENDATIONS ...... 27

5.2 Conclusions ...... 27

5.3 Recommendations ...... 28

5.4 Areas for future research ...... 28

REFERENCES ...... 29

Research Questionnaire on factors affecting antenatal care attendance among young women in ...... 32

vii LIST OF TABLES

Table 4. 1: Frequency table for factors considered to affect antenatal attendance ...... 18

Table 4. 2: Summary of Descriptive Statistics ...... 21

Table 4. 3: ANOVA table for number of attendances by education level ...... 22

Table 4. 4: Multiple Regression for factors determining antenatal attendances in Nebbi ...... 24

viii LIST OF FIGURES

Figure 1. 1: Conceptual framework on Utilization of Antenatal Care Services (ANC) ...... 6

Figure 4. 1: A Pie Chart showing Respondents Occupation ...... 20

ix ABSTRACT

The study was an investigation of the factors influencing utilization of Antenatal Care Services among teenage Mothers attending at Nebbi General Hospital. Specifically, to establish the effect of mother’s age at first birth, mother’s education and distance to the health facility on utilization of antenatal care services among young mothers attending at Nebbi General Hospital.

The study findings revealed that Out of 110 respondents interviewed, 76% (n = 84) were from within Nebbi town, the majority (59%; n = 65) had attained primary education level, the highest percentage (39%) of the young mothers were into subsistence agriculture implying that mothers were ideally unemployed. Also, the largest proportion (48%; n = 53) received that decisions about the antenatal attendances was collectively made by them and their partners. Furthermore, the study results revealed that averagely the mother conceived at the age of 27 years, youngest at the age of 14 years and the oldest at the age of 43 years. Surprisingly, results indicated that the less educated mothers attended antenatal care more often than the more educated mothers.

Mother’s age at first birth, Mother’s education and distance to the health facility were found to highly predict antenatal attendance among young mothers attending at Nebbi general hospital.

Antenatal care has the potential to reduce maternal morbidity and improve newborns' survival but this benefit may not be realized in areas such as Nebbi where there is limited sensitization and dominated by remote areas away from the town and health facilities. However, government needs to devise an approach to make services accessible in rural communities especially in the Northern

Uganda and to make regular sensitizations about the benefits of antenatal care.

x CHAPTER ONE

INTRODUCTION

1.1 Background to the study

Antenatal care attendance is measured by the number of antenatal attendances to the hospital.

Effective antenatal care services (ANC) present an opportunity to minimize the high risk for poor perinatal outcomes and other birth complications associated with teenage pregnancy.

With the failure by Uganda and majority of the Sub – Saharan Countries to achieve the

Sustainable Development Goals (SDG 4 & 5), there is need to understand factors influencing utilization of maternal health services among special groups within the reproductive age.

Therefore, this study identified factors that influence utilization of ANC services among women aged 13-19 years.

Teenage pregnancy and its associated complications pose a major challenge in efforts to address maternal, infant mortality and related morbidities in Sub-Saharan African countries.

Majority of Sub-Saharan African countries including Uganda have fallen short of attaining

Sustainable Development Goals (SDG) and particularly SDGs 4 and 5 targets. The slow progress in reduction of maternal and infant mortalities can be partially attributed to inequitable access to continuum care before, during, and after pregnancy. According to WHO a maternal mortality ratio in 2013 was estimated to be 230 per100,000 live births in developing countries compared to 16 per 100,000 live births in developed countries (WHO,

2015). Maternal deaths in Uganda were estimated to be 336 per 100,000 live birth down from

438 per live birth recorded in 2011 according to Uganda Demographic Health Survey (UDHS,

2017).

1 The problem of high child and maternal mortality is exacerbated by the relatively high prevalence of childhood marriages and teenage pregnancies in SSA and the high risks associated with adolescence childbirth. World Health Organization (WHO) estimates that about 16 million adolescent women give birth each year across the globe with about 95% of these births in the developing countries. WHO further estimates that adolescents (10-19 years), account for about 11 per cent of all global births and as such contribute to about 23% of pregnancy and childbirth related disease burden worldwide? Teenage pregnancy is associated with an increased risk for stillbirths and neonatal deaths with an estimated 50% higher risk among women under the age of 20 years compared to older women (WHO, 2015).

Antenatal care (ANC), a pillar in safe motherhood is recommended as one of the strategies to reduce maternal deaths given that it provides an opportunity for the pregnant woman to interface with the health care system to identify pre-existing conditions that may complicate pregnancy and lead to morbidity and or mortality. However, the coverage of ANC is low with about 78% and 49% of women in SSA attending at least one ANC and four or more attendances respectively during the course of their pregnancy (UNICEF, 2016). This implies that fewer women in SSA receive the benefits of comprehensive ANC.

1.2 Statement of the Problem

Majority of the women under the reproductive age 15-49 years face difficulties in delivery and eventually succumb to death due to failure to attend the antenatal care intended to identify and treat problems such as anaemia and infection (UDHS, 2017).

Out of the ninety-five percent of mothers who receive antenatal care from skilled providers, only forty-eight percent of them make four or more antenatal care attendances during their

2 pregnancy, and this percentage has remained almost the same since 2011. The median duration of pregnancy for the first antenatal visit is 5.1 months (UDHS, 2017).

Antenatal care (ANC) attendances from a skilled provider is important to monitor pregnancy and reduce morbidity and mortality risks for the mother and child during pregnancy, delivery, and the postnatal period (within 42 days after delivery).

This study shall assess the factors influencing utilization of antenatal care services among women in reproductive age 15-49 years using UDHS 2016 data. After finding out factors, the study shall suggest strategies to minimize the risks of both maternal and infant mortality with reference to antenatal care (ANC) services endorsed by WHO that recommends a minimum of four focused antenatal check-ups.

1.3 General Objective

The main objective of this study was to assess the factors influencing utilization of Antenatal

Care Services among teenage Mothers attending at Nebbi General Hospital.

1.4 Specific Objectives

Specifically, the study sought to: -

i) To establish the effect of mother’s age at first birth on utilization of antenatal care

services among young mothers attending at Nebbi General Hospital;

ii) To establish the effect of mother’s education on utilization of antenatal care services

among mothers attending at Nebbi General Hospital;

iii) To find out the effect of distance to the health facility on utilization of antenatal care

services among young mothers attending at Nebbi general hospital.

3 1.4 Research Hypotheses

The following hypotheses were tested: -

i) Mother’s age at first birth does not have any significant effect on the utilization of

antenatal care services among young mothers attending at Nebbi General Hospital.

ii) Mother’s education does not have any significant effect on the utilization of antenatal

care services among young mothers attending at Nebbi General Hospital.

iii) Distance to the health facility does not have any effect on the utilization of antenatal

care services among young mothers attending at Nebbi general hospital.

4 1.5 Scope of the study

This study focused on the factors determining antenatal care attendance among young mothers attending Nebbi general hospital. The study has based its findings on mother’s age at first birth, mother’s education and distance to the health facility.

1.6 Significance of the Study

The primary beneficiaries of the findings of this study will be thousands of adolescent mothers not utilizing antenatal care services in Urban-informal settlements. This will lead to improved pregnancies, delivery and postpartum outcomes. It will also provide a systematic body of knowledge that can be explored for appropriate policy formulation, act as a reminder to both the state and civil society to always incorporate reproductive health needs of adolescents. Effective level of utilization of ANC services, through early ANC attendance, receiving health promotion information and health care is crucial to improving maternal and foetal health during pregnancy and reducing morbidity and mortality rates.

5 1.7 Conceptual Framework

Background Characteristics Age of mother at birth Level of Education Wealth Quintile Religion

Utilization of antenatal services Measured by the number of Visits Other factors Accessibility Availability Costs of tests, screening, drugs Distance to facility Mode of Transport

Source: Author (2019)

Figure 1. 1: Conceptual framework on Utilization of Antenatal Care Services (ANC)

The conceptual framework in figure 1 shows the relationship between the dependent and the independent variables. It provides abstract basis for thinking about what the researcher should do and about what it means, it is influenced by the ideas and research of others. In this regard, it forms an overview of ideas and practices that shape the way this study shall be done. In this framework, three major factors were presented as the main factors that contribute to utilization and satisfaction with Antenatal Care Services (ANC). These were: Socio-economic and demographic factors, Knowledge on Antenatal Care Services and Accessibility of the

6 ANC. These three factors were interrelated in a way and determined whether a woman could utilize and be satisfied with Antenatal Care Services.

1.8 Definition of Key Terms

Prenatal Care: Prenatal care comes in many forms and formats. The content of care may vary from simple health measurement to intensive health teaching and ancillary services

(Villar, Carroli, Khan-Neelofur, Piaggio, & Gülmezoglu, 2007). We will use the WHO statement of prenatal, also known as antenatal care, that is inclusive of all these formats. The

WHO states, “The aim of antenatal care is to assist women to remain healthy, to find and correct adverse conditions when present and thus to aid the health of the unborn (Simona,

Vittorio, & Spettoli, 2005).”

Access to Prenatal Care: Access to prenatal care is the self-reported ability of a woman to obtain care for herself and fetus during pregnancy. Access has societal, maternal, structural, and medical components, as consistent with a critical realist paradigm. Maternal motivation is a precursor to access and utilization is the consequence of motivation and access. The changing frequency and nature of prenatal care encounters across gestation may also affect a woman’s ability and willingness to obtain prenatal care (WHO, 2009).

Utilization of Prenatal Care: Utilization of prenatal care is defined as a woman receiving prenatal care. Khan and Bhardwaj define utilization as “realized access.” Access represents a woman’s potential to enter care and utilization is the quantifiable “proof” of access.

Utilization is frequently used as a marker for access in research studies, although a lack of utilization could signal lack of access or a lack of maternal motivation for care (Julia, 2011).

7 CHAPTER TWO

LITERATURE REVIEW

2.1 Antenatal Care in Uganda

Antenatal care (ANC) from a skilled provider is important to monitor pregnancy and reduce morbidity and mortality risks for the mother and child during pregnancy, delivery, and the postnatal period (within 42 days after delivery). The 2016 UDHS results show that 97 percent of women who gave birth in the 5 years preceding the survey received ANC from a skilled provider at least once for their last birth. Six of every ten women had four or more ANC attendances (60 percent) (UDHS, 2017). While there is no difference between the proportion of women that received ANC from a skilled provider by residence (98 percent of women in urban areas and 97 percent of women in rural areas), women in urban areas are more likely to have had four or more ANC attendances than rural women (65 percent and 58 percent, respectively).

UDHS (2016) further indicated that Bunyooro and Bugisu sub regions have the lowest percentage of women who have had four or more ANC visits (45 percent and 47 percent, respectively). The percentage of women who had four or more ANC visits for their most recent birth in the 5 years preceding the survey increased greatly with women’s education.

Among women with no education, 53 percent went on four or more ANC visits compared with 72 percent of women with more than a secondary education. The survey revealed that the proportion of women with four or more ANC visits also increases with household wealth

(UDHS, 2017).

8 2.2 Theories Pertaining utilization of antenatal care services

Several theoretical models have been used to conceptualize and frame health services research regarding access and particularly prenatal care access. In this brief critical review of pertinent literature on access to care, we focus on those conceptual models that have been tested in the study of prenatal care access, particularly their clinical usefulness. Most of these models did not arise from the discipline of nursing. Nevertheless, their concepts fall within the domain of nursing, including person, health, and environment, and have been used by nurse researchers.

2.2.1 Motivation–Ease as a Middle-Range Theory

The Motivation-Ease Middle-Range Theory states that maternal motivation interfaces with the ease of clinic access to affect access and utilization of prenatal care. The concepts of this middle-range theory are derived from Lewin’s grand theory of human behavior. His “field theory of human behavior” arose in the 1930s as an antireductionist approach yet compatible with empirical study. Lewin stated that all behavior is a function of the person and the environment as it exists for that person. If internal drive or motivation is high enough, a woman might access care even when it may be quite difficult. If motivation is low, the degree of ease must be greater to achieve the desired behavior: the utilization of care. The choice of the word complementary is not intended to imply a magic sum of the two parts or a linear process, but rather a combination, which is sufficient to initiate a reaction for an individual. A particular clinic may need a variety of interventions to resonate with the needs of different women. One woman may struggle with transportation while another may need clinical accommodations that are safe for her bring her to toddler (Julia, 2011).

9 2.2.2 Exemplars Theory

Point-of-contact clinicians are often on the leading edge of designing practical interventions, but direct care providers seldom write about their innovations, although nursing and other organizations often reward innovative practices. With minimal theoretical attribution, practitioners located in small rural clinics to large medical centers have already begun to ease women into prenatal care with multiple open pathways to access. These attempts are congruent with the M-E middle range theory, whether or not they were even considered as theoretically based. We include two excellent exemplars of practical application on small and large scales. Outcome data from the following examples are included if it was available (Julia,

2011).

Realist theories are designed to facilitate empirical testing of potential explanations. Women’s opinions regarding what components of the clinic facilitate, or ease, their access into prenatal care are foundational to explicating our theory. The extant literature on women’s perceptions of prenatal care access does not include clear information on what facilitates women in obtaining care. Future research needs to query women on what components of the clinic assist(ed) them in obtaining care. Conversely, those who do not interface prenatal care but first access care in an emergency room or already in labor also have valuable information on why prenatal care was not utilized. Survey responses as well as interview and focus groups data from women could be triangulated with extant data on barriers to inform providers on mechanisms of ease as perceived by users and non-users (Julia, 2011).

10 2.3 Factors associated with Utilization of Antenatal Care Services

In a study to identify the factors affecting utilization of antenatal care services for women in reproductive age in Yemen. This cross-sectional community-based study was conducted in six districts of Sana’a City where 460 mothers who gave birth in the past six months were face- to-face interviewed at home found out that only 54% of mothers made four or more antenatal care visits. Reasons for not receiving antenatal care services due to absence of health problems, high cost of antenatal care services, long waiting time, and poor staff attitude. Sixty percent of participants were unaware of the danger symptoms of common health problems in pregnancy. The significant factors affecting utilization of antenatal services were mother education, residence place, age at first pregnancy, gravida, parity, occurrence of pregnancy without planning, and number of live children (Othman, Almahbashi, Alabed, & Alserouri,

2017).

In the study that aimed at investigating the accessibility factors that influence the use of ANC services in Mangwe district employed a qualitative approach using explorative design to target women who had babies under 1 year of age. The study was conducted in Mangwe district, Matabeleland South province, Zimbabwe. Data were collected through semi- structured interviews and observations. Data saturation was reached after 15 women who were conveniently sampled were interviewed. Field notes were analyzed thematically using

Tech’s steps. Five themes emerged during data analysis, namely lack of transport, high transport costs for ANC visits, long distance to the health facility, health care workers’ attitudes towards ANC women, type and quality of care rendered and delays in receiving care influence women’s utilization of ANC services in Mangwe district, Zimbabwe (Leoba,

Augustine, Takalani, & Molyn, 2017).

11 A study that identified factors that influenced utilization of ANC services among women aged

13-19 years. A facility-based cross-sectional study was conducted among 385 teenage mothers using semi-structured questionnaires and key informants’ interviews in Malindi Sub-

County. Quantitative data were analyzed using descriptive statistics, chi square test and logistic regression at the 5% level of significance while qualitative data were analyzed thematically. It revealed that Mean age of the participants to be 18.10 % and about 69% were married. In total, 91.2% of the participants reported poor utilization of ANC services with less than 4 ANC visits. About 54.7% reported late/inappropriate booking time. Knowledge of the recommended ANC visits, marital status, occupation, and the person making the decision to attend ANC were strong determinants of ANC utilization. Participants with good knowledge of the recommended ANC visits and made the decision to start ANC clinics were about 3 times more likely to have good utilization of ANC services than their counterparts

(Ndambuki, Oyindamola, & Chris, 2017).

In a study to assess the factors influencing timing and frequency of antenatal care in Uganda, the authors used data from the Uganda Demographic and Health Survey (UDHS) 2006 and employed both descriptive and quantitative approaches (probit estimation) to generate marginal effects in order to interpret the results as probabilities of utilization of antenatal care given particular background characteristics. Results revealed that on average, only 17% and

47% of mothers initiated the first antenatal visit in the first trimester and attained at least four antenatal visits, respectively. They further found out that timing and frequency of antenatal visits were significantly associated with education of the mother and her partner, wealth status, regional disparities, religious differences, access to media, maternal autonomy in

12 taking a health decision, occupations of the mother and her partner, timing of pregnancy, birth histories, and birth order (Bbaale, 2011).

2.4 Antenatal care and health facility delivery

Several studies on the benefits of antenatal attendance and the pregnancy outcomes have reported positive associations especially when the pregnant woman attends more sessions. A multi-country study conducted in 28 African countries to explore the association between antenatal care attendance and skilled birth attendance found that 66% of women who attended antenatal care had a skilled birth attendance; and among women who received ANC components such as blood pressure check, blood tests and danger signs information the odds were higher (Chukwuma, Wosu, Mbachu, & Weze, 2017).

Similar studies done using demographic health survey (DHS) data in Uganda and Pakistan demonstrated that the more components of ANC package a pregnant woman received the more likely she was to have a health facility delivery (Agha, et al., 2016). The studies further demonstrated that with more antenatal care visits, a pregnant woman’s chances of receiving more components of ANC package increase in order to increase the number of women delivering at health facilities under support of a skilled birth attendant to reduce the risk of maternal mortality.

Although health facility delivery is predictive of maternal mortality, the quality of ANC is also linked with health facility delivery. A study comparing implementation of the two models of ANC reported significant foetal mortality between weeks 32-36 of gestation for women attending FANC compared to standard ANC care and suggested quality of ANC may have a lot to do with the outcomes (von Both, et al., 2016). Therefore, given that these studies

13 define quality based on the number of components of ANC package provided, it is important to note that the outcomes of pregnancy hinge on the quality of services provided to identify risk factors and mitigate them.

2.5 Knowledge Gap

A study by Othman, Almahbashi, Alabed, & Alserouri (2017), aimed at identifying factors affecting utilization of antenatal care services for women in reproductive age in Yemen, this study found out that the significant factors affecting utilization of antenatal services were mother education, residence place, age at first pregnancy, gravida, parity, occurrence of pregnancy without planning, and number of live children. Similarly, a study that aimed at investigating the accessibility factors that influence the use of ANC services in Mangwe district employed a qualitative approach using explorative design to target women who had babies under 1 year of age found out that lack of transport, high transport costs for ANC visits, long distance to the health facility, health care workers’ attitudes towards ANC women, type and quality of care rendered and delays in receiving care influence women’s utilization of ANC services in Mangwe district, Zimbabwe (Leoba, Augustine, Takalani, & Molyn,

2017). After reading the numerous literatures above, one, you realize that most of the authors applied exploratory research approach in trying to investigate factors affecting utilization of antenatal services, this study seeks to close this gap by employing both descriptive and inferential approaches aimed at studying the effects, their direction and magnitude through

Multiple Linear Regression analysis. Secondly, this study shall not only look at utilization of the antenatal services, but also shall focus on women who had four or more ANC visits for their most recent birth in the 5 years.

14 CHAPTER THREE

METHODOLOGY

3.1 Introduction

This chapter provides the research design to be adopted in the study, the description of the study population, sample size determination and sampling procedure, data collection methods, data analysis techniques to be employed during the research process.

3.2 Research Design

This research used analytical cross section study to collect information that aimed at addressing the objective of the survey.

3.3 Study Population

The study population for this study was Nebbi general hospital. The hospital is located in the central business district of the town of Nebbi, in , in the West Nile sub- region, in Northern Uganda, about 78 kilometers (48 mi) southeast of Regional Referral

Hospital. This is approximately 173 kilometers (107 mi) southwest of Regional Referral

Hospital. The coordinates of the hospital are: 02°28'39.0"N, 31°05'08.0"E

(Latitude:2.477495; Longitude:31.085549). Nebbi Hospital was established in 1969 by the first government of Prime Minister Milton Obote. It has a bed capacity of 108. As with many government hospitals built at the same time, the hospital infrastructure was in dilapidated state, with antiquated equipment.

15 3.4 Sample size determination and selection

Out of the women population of 18506, only a reasonable portion was considered for this study. The sample size was computed using Yamane’s formula as shown below;

The sample of 18,506 women in the reproductive age 15-49 were purposively selected from

20,880 households according to UDHS 2016. However, for the purposes of this study, only

110 young women were interviewed and considered for analysis.

3.5 Data Source

This study used strictly primary data source. Primary data in this study was collected by the use of a structured questionnaire as in appendix A. The questionnaire drafted only contains one module that bears questions that address the study objectives.

3.6 Data Collection Methods

Similar to the women UDHS 2016 women data, this study contains questions on antenatal care visits based on the background characteristics of women such as their age, age at first marriage, children ever born, income and education level. This study was collected through a questionnaire administration in Nebbi general hospital.

3.7 Data analysis techniques

In this study, data analysis incorporated descriptive statistics, inferential statistics (cross tabulation, T-test, ANOVA and Pearson correlation) and Multiple Linear Regression analysis.

Descriptive statistical tools to be used in this study are: percentages, frequency distribution tables, histograms and charts.

16 Firstly, the analysis of variance (ANOVA) was performed to assess the effect of any of the categorical variables on number of antenatal visits (outcome variable). The model below used is as follows;

Where

=the observed number of visits; = effect due to the woman; = general mean;

= random error / error term. On addition to the P-values produced by the ANOVA table is the Bartley’s test for equality of variances.

17 CHAPTER FOUR

RESULTS AND DISCUSSION OF FINDINGS

4.1 Introduction

This chapter presents the analysis of the study based on the objectives, it entails univariate analysis

results on the location of residents, mother’s education level, decision maker on the attendances,

bivariate analysis on the relationship between education level and antenatal attendance and lastly the

multiple linear regression.

4.2 Factors considered to affect antenatal attendance

In Nebbi, factors such as distance from their location to the health facility, mother’s education

level, decision maker highly affect the number of times women attend antenatal as follows;

Table 4. 1: Frequency table for factors considered to affect antenatal attendance

Variables Frequency (n=110) Percent (%) Location of respondent Outside Nebbi 26 24% Within Nebbi 84 76% Mother Education level no education 12 11% Primary 65 59% Secondary 25 23% Higher 8 7% Decision about attendances respondent alone 27 24% Both respondent & partner 53 48% Husband/Partner Alone 30 27% Total 110 100% Source: Otho Devia’s Analysis

18 4.2.1 Type of place of residence

Out of 110 respondents interviewed, 76% (n = 84) were from within Nebbi town while 24%

(n = 26) were from far away areas of Nebbi. This is not so far from the fact that most of the

Ugandan population resides in the rural compared to the urban.

4.2.2 Mother Education level

With regards to the educational breakdown of the young mothers, the majority (59%; n = 65) were from primary education level; 23% (n = 25) were from secondary education level; 11%

(n = 12) had not acquired any level of education while only 7% (n = 8) had attained higher education. Results revealed that most of the young mothers interviewed were lowly educated.

4.2.4 Decision about attendances

The largest proportion (48%; n = 53) received that decisions about the antenatal attendances is made collectively by them and their partners; 27% (n = 30) revealed that decisions about antenatal attendances are made singly by their partners; 24% (n = 27) make antenatal decisions themselves while the rest had other people that make their antenatal decisions such as their young mothers-in-law, fathers-in-law, sisters, brothers and so on.

19 4.2.5 Occupation of the young mothers in the reproductive age

The highest percentage (39%) of the young mothers were into subsistence agriculture; 22% were not working; 12% were doing skilled manual jobs; 8% were into sales and marketing of products;5% were doing domestic household jobs; 4% were doing unskilled manual jobs with a few of them into professional jobs.

A Pie Chart showing Respondents Occupation

Variables Urban Higher Secondary 0% 12% 11% 4%

Primary 29% Rural 38%

no education Variables 6% Type of place of residence Urban Rural Mother Education level no education Primary Secondary Higher

Figure 4. 1: A Pie Chart showing Respondents Occupation

The results above show that most of the young mothers were ideally unemployed and thus diverted into farming for household consumption and for commercial purposes only on a small scale. This could have been the reasons why some do not go expensive packages during the antenatal attendances in the hospitals.

20 4.3 Continuous factors of young mothers attending Nebbi hospital

Factors such as number of attendances, mother’s age, age at first sex were also obtained from

the young mothers attending Nebbi hospital in quantitative form and described using

descriptive statistics as follows;

Table 4. 2: Summary of Descriptive Statistics

Variable Obs Mean Std. Dev. Skewness Min Max

Number of attendances 18,506 1.280179 .6351102 2.832181 1 5

Mother’s age in years 18,506 27.96606 9.374336 .4799672 15 49

Age at first sex 18,506 14.11217 6.28377 -1.369021 14 43

Source: Otho Devia’s Analysis

The minimum number of attendances were 1 while the maximum number of attendances by

the mother were 5. Averagely mothers had visited the hospitals about 2 attendances which is

way less than the recommended number of times. The number of times mothers visited the

hospital was found to be highly positively skewed (skewness =2.832181) caused due to the

non-uniformity of the attendances to the hospital which has escalated a number of issues for

the mothers. Furthermore, the study results revealed that averagely the mother conceived at

the age of 27 years, youngest at the age of 14 years and the oldest at the age of 43 years.

4.4 Association of mother’s education with antenatal attendance

With the aid of ANOVA table, the study sought to find out whether there is a significant

difference in the ANC attendance among various education levels of women. The following

table below shows that there is a significant mean difference in ANC by education levels of

young mothers;

21 Table 4. 3: ANOVA table for number of attendances by education level

Summary of number of

antenatal attendances Education level Mean Std. Dev. Freq.

No School 1.3655239 .76464712 18.82727

Primary 1.2933994 .65411319 99.02727

Secondary 1.22122 .53015052 38.3

Higher 1.2257336 .53088349 12.08182

Total 1.2801794 .63511025 110

Analysis of Variance

Source SS df MS F Prob > F

Between groups 16.8023344 3 11.8577133 29.53 0.0000

Within groups 60.6772574 102 .401507765

Total 7464.2698 18505 .403365026

Bartlett's test for equal variances: (3) = 501.6421 Prob>chi2 = 0.000

The ANOVA results (F-test =29.53; df= (3, 102); PValue = 0.0000) suggest that there is a

significant difference in the mean hospital attendance among those without education

(1.3655239); those that ended at primary level (1.2933994); those that ended at secondary

level (1.22122) and those that made it to higher education of learning (1.2257336). Results

reveal that number of attendances made to the hospital for antenatal care varies with the

mother’s level of education. Surprisingly, results show that the less educated mothers attend

antenatal care more often than the more educated mothers.

22 4.5 Factors Determining Antenatal Attendance in Nebbi Hospital

The multiple linear regression was used to determine the effect that mother’s age, distance to the hospital from home of mother and the mother’s education level have on antenatal attendance and the results are as follows;

23 Table 4. 4: Multiple Regression for factors determining antenatal attendances in Nebbi

Variable Coefficient Std. Error t-Statistic Prob.

_cons 1.003155 .0587763 17.07 0.000

Age in mother .0064384 .00095 6.78 0.000

Distance to health facility .0747461 .0210035 3.56 0.000

Mother’s education level -.0268905 .0124125 -2.17 0.030

Number of Obs = 6,144

F (7, 6136) = 19.20

Prob > F = 0.0000

R-squared = 0.7214

Adj R-squared = 0.0203

Root MSE = .60222

Source: Otho Devia’s Analysis

The p-value is lower than 0.05 to showing a statistically significant relationship between the independent variables and the number of antenatal attendances. Second, the R-squared value show that the variables such as age in mother; place of residence of mothers; mother’s occupation and region of origin of the mother explain 72% of the variations in the antenatal attendances by the mother.

The regression coefficients reveal that if mother’s age increases by one unit (one percentage point), their number of hospital attendance goes up by percentage units. This implied that the older the mothers, the higher the antenatal attendances and the younger the

24 mothers, the lower the antenatal attendances. If the distance from their residences to the health facilities is reduced by about one kilometer, their number of attendances is expected to raise by percentage points.

More educated young mothers appeared to have a few antenatal attendances as compared to the less educated young mother (coef. = -.0268905).

4.6 Discussion of findings

The study rejected the hypothesis that mother’s age at first birth did not have any significant effect on the utilization of antenatal care services among young mothers attending at Nebbi

General Hospital. Mother’s age was found to be highly important in determining antenatal attendance of young women in Nebbi where very young and slightly older mothers did not accurately make the four straight visits to the hospital, the young mother found to be cohabiting appeared not to be aware of the activity while the older mothers abandoned it.

Mother’s education does not have any significant effect on the utilization of antenatal care services among young mothers attending at Nebbi General Hospital was untrue both at the bivariate and in the regression. Education of these young mothers was found to play a key role in enabling them understand and appreciate the role of antenatal care in their well-being and of their new unborn babies.

Distance to the health facility does not have any effect on the utilization of antenatal care services among young mothers attending at Nebbi general hospital as stated in chapter one was rejected. Mothers who came from within the district recorded a greater number of visits as compared to those that came from other districts to Nebbi for delivery and antenatal care.

25 Those that recorded a smaller number of visits lamented of the transport costs between their areas of origin to the health facility and called upon governments’ assistance in extending the health services to all areas in Nebbi district.

26 CHAPTER FIVE

CONCLUSION AND RECOMMENDATIONS

5.1 Introduction

This chapter concludes this study, it entails the conclusions based on the study, the recommendations and the other areas of research.

5.2 Conclusions

Mother’s age at first birth was revealed to have a significant effect on the utilization of antenatal care services among young mothers attending at Nebbi General Hospital. if mother’s age increases by one unit (one percentage point), their number of hospital attendance goes up by percentage units. This implied that the older the mothers, the higher the antenatal attendances and the younger the mothers, the lower the antenatal attendances.

Mother’s education was also found to have a highly significant effect on the utilization of antenatal care services among young mothers attending at Nebbi General Hospital. More educated young mothers appeared to have a few antenatal attendances as compared to the less educated young mother (coef. = -.0268905).

Distance to the health facility highly predicted antenatal attendance among young mothers attending at Nebbi general hospital. Results showed that If the distance from their residences to the health facilities is reduced by about one kilometer, their number of attendances is expected to raise by percentage points.

27 5.3 Recommendations

Antenatal care has the potential to reduce maternal morbidity and improve newborns' survival but this benefit may not be realized in areas such as Nebbi where there is limited sensitization and dominated by remote areas away from the town and health facilities. However, government needs to devise an approach to make services accessible in rural communities especially in the Northern Uganda and to make regular sensitizations about the benefits of antenatal care.

Young mothers should make an attempt to attain formal education as it shall enlighten them on health education as an effective transmission of accurate, useful, health-related information to community members; it enables individuals and groups to develop their knowledge of health issues, and increase their self-reliance and competence to solve their own health problems through their own initiatives.

5.4 Areas for future research

A similar study needs to be carried out to investigate factors that influence antenatal care among all mother nationally to attain a broader perspective of the issue at hand.

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31 Research Questionnaire on factors affecting antenatal care attendance among young women in Nebbi

general hospital

My name is Otho Devia, a final year student pursuing a Bachelor’s of Statistics at Makerere

University’s School of Statistics and Planning. As a partial fulfillment of this degree, I am conducting a research survey on the “Factors influencing utilization of Antenatal Care Services, Nebbi General

Hospital”. The objective of this work is purely academic and I hereby guarantee the confidentiality of the information given and its use for this purpose only.

Section A: Socio-demographic and Economic Attribute of Respondents

Qn. 1) Under which age bracket do you belong?

1) Below 19

2) 19-24

3) 25-29

4) 30-34

5) 35 and above

Qn. 2) Current Marital status:

1) Married 2) Divorced 3) Separated

4) Widowed 5) Never Married

Qn. 3) Number of children ever born: ______

Qn.4) Under which age bracket were you at first birth?

1) Below 19

2) 19-24

3) 25-29

4) 30-34

5) 35 and above

32 Qn. 4) How easily do you access Nebbi general hospital?

1) 100m-900m

2) 1km-5km

3) 6km-10km

Qn. 5) Education level of the respondent:

1) No school 2) Primary 3) Secondary

4) Diploma 5) University

Qn. 6) Employment status:

1) Public servant 2) Business person 3) Farming

4) Student 5) unemployed 6) others (specify): ______

Qn. 7) How many times have you ever been pregnant? ______

Qn. 8) What were the outcomes?

1) Normal delivery 2) Complications 3) Others (specify) ___

Qn. 9) Did you ever attend Antenatal Care during your pregnancy?

1) Yes 2) No

Qn. 10) If yes, how many times did you ever go for antenatal care? ______

Qn. 11) If no, what could have been the limitations to attending antenatal?

1) Availability 2) Distance/location

3) Cost associated with antenatal 4) Awareness/Ignorance

5) Lack of support 6) Others (specify) ______

33 Qn. 12) Who made the decision on whether or not to attend antenatal care services?

1) Yourself

2) Husband (Partner)

3) Cousin

4) In laws

5) Siblings/mother

Qn.13) Estimate the monthly income earned by your family on average? ______

Qn.14) In your own opinion, do you think that the hospital staffs were;

1) Excellent

2) Good

3) Fair

4) Bad

Qn. 15) What do you think can be done to improve the health antenatal care services in your locality?

______

______

______

______

______

Thank you for your insightful responses!!!

34