FACTORS INFLUENCING LATE ANTENATAL CARE SEEKING BEHAVIOR AMONG PREGNANT WOMEN AT , DISTRICT, .

JOHA RASHID (2012/DCM/FT/004)

A RESEARCH REPORT SUBMITTED TO INSTITUTE OF ALLEID HEALTH SCIENCES IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE AWARD OF DIPLOMA IN CLINICAL MEDICINE AND COMMUNITY HEALTH OF INTERNATIONAL HEALTH SCIENCES UNIVERSITY

NOVEMBER, 2015

DECLARATION

I, Joha Rashid hereby declare that, to the best of my knowledge, this is my original work and has never been submitted to this University or any other institution of higher learning for an academic award/ publication.

Signiture: ...... ………………......

Date: ......

i

APPROVAL

This work has been submitted for examination with approval of my supervisor

Name:………………………………………………

Signature…………………………….……………..

Date…………………………………………………

ii

DEDICATION

This book is dedicated to my dearest mother Fatima Bazigaga, my beloved husband Kata Kasim and precious son Bashar Kata.

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ACKOWLEDGEMENT

I would like to extend my sincere gratitude to my supervisor Mr. Waako Christopher who rendered to me excellent mentorship and supervision.

I acknowledge Kawolo General Hospital for accepting me to carry out my study and greatly appreciate midwife Kaluya Ruth for her support during the development of this work.

I’m so grateful to my dear husband for the financial support, being very understanding the times

I got so busy with the course, encouraging, supporting and always believing in me that I could make it even when things got harder during the development of this work and throughout this course

I appreciate my family, sisters Jamilah Rashid, Zura Rashid, brother Nassor Rashid, my brother in-law Ali Gubujja and sister in-law Pia Rehema for the love and care, moral support given to me during the development of this work and throughout this course.

I wish to thank my friend Abdi Isadat for the moral support he gave me throughout the beginning till the end of this course.

I wish to extend my gratitude to my course mates Mercy Asianut, Koriang Hilder, Naigah

Rehema, Nsubuga Hamdan and Nsamba Abdi Razak, for the support and good company you gave me through this struggle especially the times when I was expecting my little one.

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ABSTRACT

Background; Pregnant mothers who initiate antenatal care late miss out on the chance of early diagnosis, treatment, prophylaxis and prevention of complications, health education on nutrition and danger signs to watch out during pregnancy. Many pregnant women initiate antennal care late above 20 weeks of gestation however; the health facility and individual factors influencing late antenatal care late were not documented. Therefore, this study was intended to find out the socio economic, individual and health facility factors influencing late antenatal care seeking behavior at Kawolo General Hospital.

Method; Descriptive cross sectional study was done on all pregnant women attending antenatal care during the study irrespective of their gestational age and whether it is their first visit or not using questionnaires. Data collected was analyzed using SPSS and results presented in tables.

Results; The study included 100 participants who were interviewed in August 2015 at Kawolo

General Hospital. Of these 98% had mean age of 27 years, 80% were married and 50% had attained secondary education. The pregnant mothers were mostly jobless (52%) and of their spouses were mostly business men (34%). Among them, 45% of these mothers made their first visit at < 20 weeks gestational age and 45% had knowledge on the recommended number of

ANC visits, (62%) said that < 20 weeks of gestational age was the appropriate time to initiate

ANC visit. Mothers mostly accessed the hospital using a taxi (40%), (46%) agreed that the transport fee was affordable, (87%) agreed that they do not pay for antenatal care services and

(9%) said the payment for the services was not affordable. (68% agreed that they were satisfied with antenatal care services provided at the hospital

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Conclusion and recommendations; This study showed that most pregnant women still did not know the benefits of early initiation and frequent visits during antenatal care therefore there is still more need to educate all women about the importance early initiation and frequent visits for antenatal care services. This can be achieved through going to communities, schools, churches and mosques and use of Village Health Teams (VHT’s). Reinforcement of male partner involvement during ANC visits. Positive working environment should be create for the health, recruiting more health staff to reduce turnaround time and long waiting hours by pregnant mothers and creating more incentives like providing a drink to the mothers, putting television with interesting programs at the waiting area, giving maternity dresses to those who initiate early and creating resting areas where by they can lie down to rest while waiting and freely interacting with one another.

Key words; Late seeking, Antenatal care, parity and Kawolo General Hospital

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TABLE OF CONTENTS

DECLARATION ...... i

APPROVAL ...... ii

DEDICATION ...... iii

ACKOWLEDGEMENT ...... iv

ABSTRACT ...... v

TABLE OF CONTENTS ...... vii

LIST OF TABLES ...... xi

LIST OF FIGURES ...... xii

ABBREVIATIONS ...... xiii

OPERATIONAL DEFINITIONS ...... xiv

CHAPTER ONE : BACKGROUND INFORMATION...... 1

1.0 Introduction ...... 1

1.1 Background of the study ...... 1

1.2 Background of study area ...... 4

1.3 Problem statement ...... 4

1.4 Purpose of the study ...... 5

1.5 Objectives ...... 5

1.5.1 General objective ...... 5

1.5.2 Specific objectives ...... 5

1.6 Research questions ...... 6

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1.7 Significance of the study ...... 6

1.8 Conceptual framework ...... 7

CHAPTER TWO: LITERATURE REVIEW ...... 8

2.0 Introduction ...... 8

2.1 ANC Performance indicators ...... 8

2.2 Socioeconomic factors influencing antenatal seeking behavior ...... 9

2.3 Individual factors influencing antenatal seeking behavior ...... 12

2.4 Health facility factor influencing antenatal seeking behavior ...... 13

CHAPTER THREE: METHODOLOGY ...... 15

3.0 Introduction ...... 15

3.1 Study design ...... 15

3.2 Study population ...... 15

3.3 Study area...... 15

3.4 Sample size determination ...... 16

3.5 Sampling procedure ...... 16

3.6 Data collection tools and technique ...... 17

3.7 Data presentation and analysis ...... 17

3.8.1 Inclusion criteria ...... 17

3.8.2 Exclusion criteria ...... 17

3.9 Data quality assurance and quality control ...... 17

3.10 Ethical consideration ...... 17

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3.11 Source of funding ...... 18

3.12 Dissemination of results ...... 18

3.13 Study limitation ...... 18

CHAPTER FOUR: RESULTS ...... 19

4.0 Introduction ...... 19

4.1 Characteristics of study participants ...... 19

4.2 Socio economic factors influencing late antenatal care seeking behavior ...... 20

4.4 Health facility factors influencing late ANC seeking behavior...... 25

CHAPTER FIVE: DISCUSSION ...... 27

5.0 Introduction ...... 27

5.1 Discussion of results ...... 27

5.1.1 Socio economic factors that influenced late ANC seeking behavior...... 28

5.1.2 Individual factors that influenced late ANC seeking behavior ...... 29

5.2.2 Health facility factors that influenced late ANC seeking behavior ...... 31

CHAPTER SIX: CONCLUSION AND RECOMENDATION ...... 33

6.0 Introduction ...... 33

6.1 Conclusion ...... 33

6.2 Recommendation ...... 33

REFERENCES ...... 35

APPENDICES ...... 37

APPENDIX I; CONSENT FORM...... 37

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APPENDIX II; QUESTIONNAIRE ...... 39

APPENDIX III; MAP OF UGANDA SHOWING DISTRICT OF THE STUDY AREA...... 43

APPENDIX IV; MAP OF SHOWING THE STUDY AREA...... 44

APPENDIX V; INTRODUCTION LETTER ...... 45

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LIST OF TABLES

Table 1: Characteristics of the study participants ...... 20

Table 2: Socio economic factors influencing late antenatal care seeking behavior ...... 21

Table 3: Individual factors influencing antenatal care seeking behavior ...... 23

Table 4: Health facility factors influencing late ANC seeking behavior...... 25

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LIST OF FIGURES

Figure 1: Conceptual framework ...... 7

Figure 2; Pregnant mother’s occupation and disclosure of early pregnancy ...... 22

Figure 3: Education level and first ANC visit ...... 22

Figure 4; First ANC visit and knowledge about the recommended number of visits ...... 24

Figure 5; ANC service got elsewhere versus appropriate time for the first visit ...... 24

Figure 6; ANC services satisfaction and access to hospital ...... 26

Figure 7; First ANC visit and transport affordability ...... 26

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ABBREVIATIONS

AIDS: Acquired Immune Deficiency Syndrome

ANC: Antenatal care eMTCT: Elimination of Mother to Child Transmission of HIV

HIV: Human immunodeficiency Virus

LNMP : Last Normal Menstruation Period

MDG: Millennium Development Goal

MMR: Maternal Mortality Rate

MOH: Ministry of Health

TBA: Traditional Birth Attendant

UBHS : Uganda Bureau of Health statistics

UDHS: Uganda Demographic Health Survey

UNICEF: United Nations International Children’s Emergency Fund

WHO: World Health Organization

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OPERATIONAL DEFINITIONS

Antenatal care This is a planed program for supervision, education and management of

(ANC); pregnant women with the aim of making pregnancy and delivery safe and

satisfying for the baby, mother and whole family.

Birth order; The ordinal position by birth of a child in relation to one or more other

siblings

Late ANC seeking; This is initiating of antenatal care by pregnant women at above twenty

weeks gestational age.

Parity; This is the number of times a woman has been pregnant and carries the

pregnancy to a viable gestational age

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CHAPTER ONE

BACKGROUND INFORMATION

1.0 Introduction

This study was intended to assess factors influencing late antenatal care seeking behavior among pregnant women at Kawolo General Hospital. In this chapter the following were presented: background information of the study, background information to the study area, problem statement, objectives both general and specific objectives, significance of the study and conceptual frame work.

1.1 Background of the study

Provision, timely use and continuous antenatal care visits is one of the significant interventions that can enhance the achievement of Millennium Development Goal 5 (MDG 5), the target for which is a 75% reduction in the maternal mortality ratio (MMR) from 1990 to 2015 (Hogan et al., 2010). Antenatal care is the care woman receive during pregnancy that helps ensure health outcomes for the woman and the new born (WHO/UNICEF 2003). During antenatal care visits, pregnant women receive range of health promoting and preventive services such as, tetanus immunization, prevention and treatment of anemia, malaria, sexually transmitted infections

(STI’s) / HIV/AIDs particularly through elimination of mother child transmission (eMTCT), nutritional support and health education. During antenatal care sessions mothers are educated about danger signs during pregnancy, appropriate nutrition, breastfeeding, contraceptive use for family planning and are given preventive and curative treatment. It also helps to create rapport between the soon-to-be mother and the health care provider which is significant prerequisite for a

1 safe childbirth. However the role played by early initiation and continuous visits for antenatal care services to ensure safe motherhood and childhood cannot be underestimated because it enables early screening of pregnant related illness, referral and early treatment to prevent complications. On the other hand, the optimal number of visits helps to ensure constant physician follow-up of fetal growth as well as the pregnant mother’s health.

The new World Health Organization (WHO) model of antenatal care separates pregnant women into two groups: those likely to need only routine antenatal care (75% of the total population of pregnant women) and those with specific health conditions or risk factors that necessitates special care (25% of pregnant women) For the first group, a standard program of four antenatal visits is recommended (with additional visits should conditions emerge which require special care). It is also recommended that the first visit should be initiated in the first trimester (first twelve weeks of pregnancy)such early visits help identify complications and risk factors for complications so that there is early establishment of interventions to mitigate the effects of such complications on the pregnant mothers and the fetus. Despite these guidelines, 41% of women initiated antenatal care visit after twelve gestation weeks, according to study of late entry to antenatal care in new south Wales, Australia (Trinh, 2006). The proportion of pregnant women in developing countries who attended at least four antenatal care visits increased from approximately 37% in 1990 to about 52% in 2012. In low-income countries only 38% of pregnant women attended four times or more antenatal care during 2006-2013 (WHO Global

Health Observatory 2015).

In a study of reasons given by pregnant women for late initiation of antenatal care in the Niger

Delta, Nigeria, 73.6% pregnant women initiated in second trimester, 26.4% of the women who

2 had given birth before attended in the third trimester, 80% had initiated late in atleast one of the previous pregnancy (Ndidi, 2010).

Similarly in a study of use of antenatal and post natal care from perspectives and experiences of women and health care providers in rural South Tanzania, pregnant women initiated antenatal care at 17th week, some at 18th or 19th week of pregnancy (Mrisho, 2009).

According to Uganda Clinical Guidelines of 2012, for normal or uncomplicated pregnancies, four routine antenatal care visits are recommended as follows: the first visit between 10–

20 weeks of pregnancy; the second visit between 20–28 weeks of pregnancy; the third antenatal care visit between 28–36 weeks and fourth antenatal care visit after 36 weeks. The guidelines also recommend more frequent visits and early antenatal care visits for mothers with pregnancy complications or those with identifiable risk factors for complications such as complications in a prior pregnancy (MOH, 2012). Despite these guidelines, The Uganda Demographic and Health

Survey (UDHS) 2011 showed that though over 90% of pregnant women attend antenatal care at least once, during the entire pregnancy only 48% made four or more antenatal care visits, 21% of women made their first antenatal care visit before the fourth month of pregnancy. This means that 79% of pregnant women initiated there first antenatal care visit late when the chance to diagnose problems early, provide treatment, and prevent further complications may have passed

(Kisuule et al., 2013).

The findings in a study on factors influencing timing and frequency of antenatal care in Uganda using UDHS on average, only 17% and 47% of mothers initiate their first antenatal care visit in the first trimester and attained at least four antenatal visits respectively. Pregnant mothers’ and partner’s education level, economic status, regional disparities, religious differences, access to social media, maternal autonomy in taking a health decision, occupations of the mother and her

3 partner, timing of pregnancy, birth histories, and birth order were significantly associated with the timing and frequency of antenatal care visits (Bbaale, 2011). However, the health facility factor and knowledge and attitude of pregnant women about the recommended four antenatal visits were not documented. Therefore, this study was intended to find out the factors influencing late antenatal care seeking behaviors among pregnant women at Kawolo General Hospital.

1.2 Background of study area

Kawolo General Hospital is a public hospital found in Buikwe District formally part of the greater Mukono. It is located in Town Council on the -Jinja-Mombasa highway,

45 kms East of Kampala City and was constructed in 1968 with the aim of providing specialized medical services to the population of and other people that use the Kampala-

Jinja and Mombasa highway. It is a 109 bed hospital almost halfway between Kampala City and

Jinja town. Because of its strategic location it is the only hospital managing road traffic accident cases that occur on this highway. Guided by the Ministry of Health policies, the hospital offers both outpatient and inpatient medical services’ for example antenatal care service, maternity and many others including outreach services to the lower surrounding communities. The study was aimed at investigating the factors influencing late antenatal care seeking behaviors among pregnant women at Kawolo General Hospital (MOH, 1968).

1.3 Problem statement

Early and frequent antenatal care attendance during pregnancy is important to identify and mitigate risk factors in pregnancy and to encourage women to have a skilled attendant at childbirth. The new WHO model of antenatal care recommends a standard program of four antenatal visits; the first visit should be initiated in the first trimester. Despite these guidelines,

4 many pregnant women in Sub-Saharan Africa start antenatal care attendance late.

In Uganda, less than half of women 47% attained at least four antenatal visits, the median gestational age was when women made their first antenatal care visit was 5.5 months when the opportunity may to diagnose problems early, provide treatment, and prevent further complications may have passed hence they do not fully benefit from its preventive and curative services (Bbaale, 2011)

Therefore this study was intended to evaluate the factors influencing late antenatal care seeking behavior at Kawolo General Hospital.

1.4 Purpose of the study

Purpose of the study was to determine the factors influencing late antenatal care seeking behavior among pregnant women at Kawolo General Hospital in order to empower them with knowledge about right gestational age at which they should initiate ANC, the recommended number of visits and benefits of early initiation.

1.5 Objectives

1.5.1 General objective

To determine the factors influencing late antenatal care seeking behavior among pregnant women at Kawolo General Hospital

1.5.2 Specific objectives

1. To evaluate socio economic factors influencing late antenatal care seeking behaviors

among pregnant women at Kawolo General Hospital.

2. To assess the individual factors influencing late antenatal care seeking behaviors among

pregnant women at Kawolo General Hospital.

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3. To determine the health facility factors influencing late antenatal care seeking behaviors

among pregnant women attending antenatal care services offered at Kawolo General

Hospital.

1.6 Research questions

1. What are the socio economic factors influencing late antenatal care seeking behavior

among pregnant women at Kawolo General Hospital?

2. What are the individual factors influencing late antenatal care seeking behavior among

pregnant women visits at Kawolo General Hospital?

3. What are the health-facility factors influencing late antenatal care seeking behavior

among pregnant women attending antenatal care services offered at Kawolo General

Hospital?

1.7 Significance of the study

This study was aimed at identifying the factors influencing late antenatal care seeking behaviors among pregnant women at Kawolo General Hospital to help empower pregnant women especially with knowledge about the timing, frequency and benefits of early initiation of antenatal care visits which would enable early screening of pregnancy related illness, early treatment and referral. The optimal number of visits would ensure constant follow-up of fetal growth as well as the health of the mother during pregnancy hence attaining the Millennium

Development Goal 5 (MDG 5), the target for which is a 75% reduction in the maternal mortality ratio (MMR) from 1990 to 2015 (Hogan et al., 2010). This study was also aimed at meeting my academic criteria in partial fulfillment of the requirements for the award of a Diploma in Clinical

Medicine and Community Health

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1.8 Conceptual framework

Socioeconomic factors Education level Occupation Parity Cultural beliefs Birth orders Economic status

Individual ANC seeking factors Knowledge behavior Attitude

Health facility factor Distance Services provided Customer care Cost of service

Figure 1: Conceptual framework showing the factors influencing late antenatal care seeking behavior.

The conceptual framework in Fig. 1 described the relationship between dependant and independent variables of the study, the dependant variable included ANC seeking behavior, the independent variable included socio economic factors which were assessed using education level, occupation, parity, cultural beliefs, birth orders and economic status, the individual factors were assessed using knowledge and attitude while health facility factors were assessed using distance, services provided, customer care and cost of service.

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CHAPTER TWO

LITERATURE REVIEW

2.0 Introduction

Early initiation of antenatal care by pregnant women and continued visits has the potential to affect maternal and fetal outcome positively. This chapter contains already existing information captured for the study of factors influencing late antenatal care seeking behaviors among pregnant women at Kawolo hospital based on the objectives; socioeconomic factors, individual factors and health facility factors.

2.1 ANC Performance indicators

The current World Health Organization (Villar, Ba'aqeel et al. 2001) model of antenatal care separates pregnant women into two groups: those likely to need only routine antenatal care (75% of the total population of pregnant women) and those with specific health conditions or risk factors that necessitates special care (25% of pregnant women). For the first group, a standard program of four antenatal visits is recommended (with additional visits should conditions emerge which require special care). It is also recommended that the first visit be initiated in the first trimester (first twelve weeks of pregnancy). Despite these guidelines, 41% of women commenced antenatal care after twelve weeks of gestation according to study of late entry to antenatal care in new south Wales, Australia (Trinh, 2006). Nationally according to Uganda

Clinical Guidelines of 2012, for normal or uncomplicated pregnancies, four routine antenatal care visits are recommended as follows: the first visit between 10–20 weeks of pregnancy; the second visit between 20–28 weeks of pregnancy; the third antenatal care visit between 28–

36 weeks and fourth antenatal care visit after 36 weeks. The guidelines also recommend more 8 frequent visits and early antenatal care visits for mothers with pregnancy complications or those with identifiable risk factors for complications such as complications in a prior pregnancy

(MOH, 2012). Despite these guidelines, over 90% of pregnant women attend antenatal care at least once, only 48% make four or more antenatal care visits during their entire pregnancy, only

21% of women made their first antenatal care visit before the fourth month of pregnancy. This means that 79% of pregnant women come late for their first antenatal care visit when the chance to diagnose problems, provide treatment, and prevent further complications earlier may have passed (Kisuule et al., 2013). All in all the performance rate of ANC is poor both nationally and globally.

2.2 Socioeconomic factors influencing antenatal seeking behavior

The variables under socioeconomic factors included; education level, occupation, parity, cultural beliefs, birth order and economic status.

Education level of mother and partner is one of the factors outlined to affect antenatal care both mother’s and partners education is level significantly influences early initiation and utilization of antenatal care. Women who are educated are more likely to initiate antenatal care visits early than those who are less educated (Simkhada, 2008).

According to Phafoli; (2007), women who are educated compared to illiterate ones, they bear fewer children and achieve better child survival, because they avoid early marriage, teenage pregnancy, high parity and they attend antenatal and postnatal services more frequently. These are all important aspects in the prevention of maternal deaths. In a study on factors influencing timing and frequency of antenatal care in Uganda by UDHS, 6-11% of mothers who attained secondary education were more likely to initiate early and make the four recommended visits and

5% mothers who attained primary education level were less likely to initiate their first in the first

9 trimester compared to those without education whereas 10-23% mothers whose partners attained secondary education were more likely to attain the four recommended visits compared to their counterparts without education (Bbaale, 2006).

In the same study economic status both wealth and poverty can significantly influence antenatal seeking behaviors. 9-15% mothers who are rich were more likely to make the four visits compared to the poor ones.

Bbaale (2006) also compared mothers in agriculture to those with white collar jobs were 10% less likely to attain the four recommended visits while there partners in agriculture and blue collar jobs were 6% less likely to make the four visits. Both the pregnant mother and partners occupation influences early initiation of antenatal care.

High parity is also a hindrance to utilization and adequate use of antenatal care services (Magadi et al. 2000). According to the cross sectional study of the reasons given by pregnant women for late initiation of antenatal care in Niger delta Nigeria, of the 256 multiparous women 80% had booked atleast one pregnancy late ( Ndidi, 2010). Multiparous women that had normal pregnancy viewed pregnancy as normal life event rather than medical condition that required professional monitoring and supervision (Matsuoka, 2009 cited in Finlayson, 2013). On the other hand the first antenatal care visit was initiated earlier in higher parity women in India

(Simkhada, 2008). In a qualitative study of Factors Affecting Antenatal Care Attendance in

Ghana, Kenya and Malawi, older multiparous women were at particular risk of delaying ANC; they only visit early to meet their needs. Care preferences and the messages about the dangers of complication due to pregnancy may promote early initiation of ANC among this group

(Christopher, 2013). In the same study, Parity had a complex impact on ANC initiation women not used to the experience of pregnancy and its associated signs and symptoms. Prime gravida’s

10 were more likely to seek assistance and advice from older women to initiate ANC earlier.

However, they were more prone to unintentionally delay ANC because they were not familiar with the signs of pregnancy also prompted uncertainty hence less likely to recognize a pregnancy.

Mothers with high birth order compared to the first are less likely to attain the four recommended antenatal care visit and to make their first visit in the first trimester. 6-7% of mothers with third birth order were less likely to attain the four recommended visits compared to those with first,

4-5% mothers in third birth order compared to the first are less likely to initiate first visit for antenatal care in the first trimester (Bbaale, 2006). Similarly in study of frequency and timing of antenatal care in Kenya, high birth order is associated with late start or inadequate use of antenatal care (Magadi et al.2000).

Another socioeconomic factor which was consistently found to affect the ANC seeking behavior was cultural beliefs. There are many cultural beliefs attached to pregnancy therefore many pregnant women choose not to disclose because of the fear of the possible consequences for making the pregnancy public. Findings in a cross sectional study of the reasons given by pregnant women for late initiation of antenatal care in Niger delta Nigeria revealed that 6.3% of the pregnant women did not make their pregnancy public, 2.9% did not want those who didn’t wish them well to know that there pregnant ( Ndidi, 2010). Similarly many women were dictated by a cultural belief that they shouldn’t confirm a pregnancy unless they have missed their periods for several months (Abraham, 2011 cited in Finlayson, 2013). Cultural beliefs also leads to failure to initiate antenatal care early since pregnant women lacked the motivation to visit the health facility because they were superseded superstitious beliefs about pregnancy disclosure

(Grossman, 2011 cited in Finlayson, 2013).

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2.3 Individual factors influencing antenatal seeking behavior

The individual factors that can influence antenatal seeking behavior included knowledge and attitude. Knowledge is one of important individual factor that influences antenatal seeking both positively and negatively. In a study conducted at Mulago hospital Kampala about timing and reasons for coming late for the first antenatal visit, results showed that 72.7% didn’t know the right gestational age to initiate antenatal care and 53.3% reported to have no problem with current pregnancy therefore they did not have any reason to start antenatal care early (Kisuule et al., 2013). Similarly in a study of why do women seek antenatal care late from Perspective from rural South Africa conducted in the rural district of Habisa, Kwazulu natal, several women (n=8) said they had no reason to book for antenatal care early and they saw no benefit of early initiation (Myer, 2010). Another cross sectional study of reasons given by pregnant women for late initiation of antenatal care in Nigeria, 8.1% pregnant women did not see any benefit in booking in the first trimester (Ndidi, 2010). Kisuule ;( 2013) also reported the commonest reasons for late antenatal care attendance was that they didn’t know the right gestational age at which to they should make their first antenatal care visit. According to qualitative study of factors Affecting Antenatal Care Attendance in Ghana, Kenya and Malawi, pregnant women reported that they only attended ANC to check on the progress of their pregnancy or to see the position of the unborn child. In Upper East Region, they attended ANC because they wanted to identify problems during their pregnancy, whereas, in the Ashanti Region, pregnant women reported that medicines are provided during ANC and they are important to ensure that the pregnant woman is healthy and there was normal fetal development. They also viewed ANC visiting as a normal activity done during pregnancy and they reported that it was simply attending the clinic. In Upper East Region in Kenya, they reported that they were motivated to

12 attend ANC just to obtain the ANC or birth card, ANC visits were considered compulsory because it was linked to authority of health staff (Christopher, 2013).

Pregnant women attitude was also found to greatly influence antenatal seeking behavior.

According to study of why do women seek antenatal care late from Perspective from rural South

Africa conducted in the rural district of Habisa, Kwazulu natal, 0.6% of women got tired of antenatal care during their past pregnancy (Myer, 2010). The commonest reasons for late antenatal care attendance due to poor attitude of the health worker at health care (Abrahams,

2011 cited in Finlayson, 2013). Finlayson ;( 2013) reported that young woman in Uganda recounted poor attitude of health care provider and she attributed it to failure by health workers to their job.

2.4 Health facility factor influencing antenatal seeking behavior

The variables under these included distance, customer care, cost for the service and services provided at health facility. According to Myer (2010), 22 women who booked for the first time, only the 49% lived close enough to walk to the health facility the remaining 13 had to use tax services to access the health facility which was a bit costly. Similarly, 27.7% did not have money for transport to take them to the health facility (Kisuule et al, 2013). And also pregnant women who lived in areas lacking community health care facilities had travel to distant locations to receive antenatal care which was a difficulty they couldn’t overcome (Abraham, 2001 cited in

Finlayson 2013).

Customer care given to pregnant women during the antenatal care significantly influences their seeking behavior. According to the study of timing and reasons for coming late for the first antenatal visit at Mulago hospital Kampala, 0.6% mothers reported that doctors and nurses do not pay attention to them when antenatal care is initiated early (Kisuule et al, 2013).

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Cost for the service also influences antenatal care seeking especially in private health facilities where services are paid for unlike in government health facilities where antenatal care services are offered free of charge. In study of reasons given by pregnant women for late initiation of antenatal care in Nigeria, 10.1% did not book for antenatal care services because they didn’t have money to pay for the services (Ndidi, 2010). Christopher (2013) reported the delays in

ANC seeking were due to direct Charges for the services although not authorized in national

ANC policy they added other costs and an anticipated cost of paying for drugs, tests and medical cards even in countries which offer free antenatal care services strained them and their family’s finances. These led to delays in attendance and reduced compliance with the WHO recommended number of ANC visits (Finlayson, 2013).

The Services provided during ANC includes screening for STI’s like syphilis, UTI’S, HIV, blood grouping, malaria prophylaxis, iron supplementation and mama kits given can significantly influence antenatal seeking positively. Some women stated long waiting hours, in convenient service hours and poor treatment by the health service providers were the reasons that influenced their delays (Flynn, 1995 cited in Phafoli, 2007). Finlayson (2013) also reported that women were discouraged from attending antenatal care because they had to wait for long time to be seen by health worker after they had traveled from far distances from their homes to health facility

Despite all the contribution from various researchers pregnant women still did not know the right gestation age at which they should initiate their first antenatal care visit and the importance of early initiation therefore this study was aimed at assessing factors influencing late antenatal care seeking behavior among pregnant women at Kawolo General Hospital.

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CHAPTER THREE

METHODOLOGY

3.0 Introduction

This chapter consists of study design, study population, study unit, data collection tools and technique, selection criteria, sample, data analysis and presentation, ethical consideration, data quality assurance and quality control, source of funding, source of funding, budgeting and possible study limitations.

3.1 Study design

A descriptive cross sectional study was done at Kawolo General Hospital in June 2015 where all pregnant mothers attending the antenatal clinic during the study period were recruited. This helped describe the status of mothers attending antenatal care. Qualitative and Quantitave techniques of data collection and analysis were used.

3.2 Study population

The study population included all pregnant women attending antenatal care clinic at Kawolo

General Hospital.

3.3 Study area

The study was conducted at Kawolo General Hospital antenatal clinic. Kawolo General Hospital is located in Buikwe district 45 km from Kampala City on Kampala-Jinja highway. It is a 109 bed capacity district hospital for Buikwe District. It serves as a referral health facility for Buikwe and Mukono Districts. 15

3.4 Sample size determination

Sample size was determined using the formula of Kish and Leslie for the descriptive studies.

n = (Z2pq) (e) 2 Where: n = The desired sample size

Z = The standard normal deviation usually set at 1.96 which correspond to 95% confidence level p = The proportion in the target population estimated to have a particular characteristics and in this study p was 79% (Kisuule, 2013) q = 1-p e = the degree of accuracy desired, usually set at 0.1 level

2 n = (1.96) (0.79)(1-0.79)

(0.08)2 n = (3.8416)(0.79)(0.21)

0.0064

N= 99.5 which is approximately equal to 100

Therefore the sample size was 100.

3.5 Sampling procedure

Non probability or convenience sampling procedure was used which included all pregnant women who were available for ANC and easily accessible at Kawolo General Hospital were recruited into the study.

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3.6 Data collection tools and technique

Self administered and interviewer administered questionnaires were used to collect data from the respondents.

3.7 Data presentation and analysis

Data was analyzed using SPSS and Excel; it was presented using tables and bar graphs.

3.8.1 Inclusion criteria

Every pregnant woman came for ANC and had consented was consecutively included in to the study and each pregnant woman was recruited once.

3.8.2 Exclusion criteria

All pregnant women who came to the hospital to seek other services were excluded from the study.

3.9 Data quality assurance and quality control

The tools were pre–tested, research assistants were trained and there was clerical guidance by the supervisor to ensure both validity and reliability.

3.10 Ethical consideration

The study sought approval from the Research and ethics committee of International health

Sciences University and permission from the management of Kawolo General Hospital. The participants were given enough information about the study and then their informed consent was taken with their own free will. Participation in the study was voluntary and a participant would

17 choose to withdraw from the study at any time without any penalty. The information from this study was kept confidential by use of passwords (restricted access) and kept in the supervisors’ offices. Study numbers were assigned to participants not names to guarantee confidentiality.

3.11 Source of funding

The study was self funded. However any individual or organization interested in the study was welcomed to fund the study.

3.12 Dissemination of results

The results were disseminated to International Health Sciences University, Institute of Allied

Health Sciences to meet my academic criteria and to Kawolo General Hospital.

3.13 Study limitation

The limitation of this study was that it included all pregnant women who attended antenatal care irrespective of the gestation age this was challenge as some could not remember the gestation age at which they made their first visit and others couldn’t remember there last normal menstruation period (LNMP) and ultrasound scan was not used to confirm the gestation age but other methods like palpating the fundal height was used in such instances. However the results obtained are a fair representation of factors influencing late antenatal care seeking implying that there is need to further strengthen education of communities on benefits of early antenatal care initiation.

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CHAPTER FOUR

RESULTS

4.0 Introduction

This chapter contains characteristics of study participants, results of the analyses of socio- economic factors, individual factors and health facility factors influencing late antenatal care seeking behavior among pregnant women at Kawolo general hospital.

4.1 Characteristics of study participants

The study included 100 participants who were interviewed in August 2015 at Kawolo General

Hospital. Of these 98% had mean age of 27 years, 80% of them were married, 50% attained secondary education. The pregnant mothers were mostly jobless 52% and of their spouses were mostly business men 34%, the details are shown in table 1

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Table 1: Characteristics of the study participants

Category Frequency Percent Area assessed Age 15-24 58 58 25-34 98 98 35-44 5 5 Marital status Married 80 80.0 Single 14 14.0 Divorced 2 2.0 Cohabiting 3 3.0 Separated 1 1.0 Education level Primary level 45 45.0 Secondary level 50 50.0 Institution 2 2.0 University 1 1.0 Unknown 2 2.0 Pregnant mother's white collar job 6 6.0 occupation Agriculture 20 20.0 Business 22 22.0 Non 52 52.0 Spouse’s occupation white collar job 19 19.0 Agriculture 32 32.0 Business 34 34.0 Non 15 15.0

4.2 Socio economic factors influencing late antenatal care seeking behavior

The socio economic that were analyzed included education level of the pregnant mother, pregnant mother and spouse’s occupation, parity, birth order and cultural beliefs. Details of results analyzed are shown in table 2.

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Table 2: Socio economic factors influencing late antenatal care seeking behavior

Factor Category Frequency Percent

Education level Primary level 45 45.0 Secondary level 50 50.0 Institution 2 2.0 University 1 1.0 Unknown 2 2.0 Pregnant mothers white collar job 6 6.0 occupation Agriculture 20 20.0 Business 22 22.0 Non 52 52.0 Spouses occupation white collar job 19 19.0 Agriculture 32 32.0 Business 34 34.0 Non 15 15.0 Parity High parity 19 19.0 low parity 54 54.0 null parious 27 27.0 Birth order High 19 19.0 Low 54 54.0 Disclose early Yes 63 63.0 pregnancy No 36 36.0

Most pregnant mother’s attained secondary education 50%, they were mostly jobless 50%, and

34% of their spouses were businessmen, with 54% low parity and low birth order, discloser of

63%.

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Figure 2; Relationship between Pregnant mother’s occupation and disclosure of early pregnancy

The highest percentage of pregnant mothers who would disclose early pregnancy was 55.5% and they the ones who were jobless mean while the pregnant mothers who had white collar jobs had the lowest 4.80%. Details are shown in figure 2.

Figure 3: Relationship between education level and first ANC visit

22

48.9% of the pregnant mothers initiated their first ANC visit at <20 weeks of pregnancy and they had attained primary level of education while those at institutions and university where 2.2%.

Details are shown in figure 3.

4.3 Individual factors influencing late antenatal care seeking behavior

The individual factors analyzed to be affecting ANC seeking behaviour in this study included knowledge and attitude of pregnant mothers towards ANC seeking behavior. Details of the results obtained are shown in table 3.

Table 3: Individual factors influencing antenatal care seeking behavior

Category Frequency Percent Factor

First ANC visit <20 weeks 45 45.0 20-24 weeks 26 26.0 28-32 weeks 29 29.0 Recommended 2 14 14.0 number of ANC visits 3 26 26.0 4 45 45.0 >4 15 15.0 Appropriate time for <20 weeks 62 62.0 ANC first visit 20-24 weeks 17 17.0 28-32 weeks 21 21.0 ANC got else where Yes 30 30.0 No 70 70.0 Benefits of early ANC Yes 100 100.0

45% of the pregnant mothers made their first visit at < 20 weeks gestational age and 45% of them have knowledge on the recommended number of ANC visits, 62% said that < 20 weeks of gestational age was the appropriate time to initiate ANC visit, 70% of them sought ANC services from hospital. All pregnant mothers agreed that there were benefits of early ANC initiation.

23

Figure 4; Relationship between first ANC visit and knowledge about the recommended number of visits

55.5% of the pregnant mothers who had their first ANC visit at <20 gestational weeks reported 4 as the recommended number of ANC visit and this was highest meanwhile the lowest percentage reported was 7.7% who made their first ANC visit at 20-24 weeks said 2 as the recommended number of ANC visits. Details are shown in figure 3.

Figure 5; ANC service got elsewhere versus appropriate time for the first visit

67% of pregnant women who did not get ANC services apart from hospital reported that <20 weeks was the appropriate time to initiate their first visit and this was highest while lowest was

10% who reported 20-24 weeks was the appropriate time for first visit. Details are shown in figure 4. 24

4.4 Health facility factors influencing late ANC seeking behavior.

The variables analyzed under health facility factors included distance to health facility, customer care services provided and cost of service. Details of the results are shown in the table 4.

Table 4: Health facility factors influencing late ANC seeking behavior.

Category Frequency Percent Factor

Access to hospital Walking 28 28.0 Taxi 40 40.0 Motorcycle 32 32.0 Transport Yes 46 46.0 affordability No 24 24.0 ANC service payment Yes 13 13.0 No 87 87.0 ANC service payment Yes 4 4.0 affordability No 9 9.0 ANC services Yes 68 68.0 satisfaction No 32 32.0 The mothers mostly accessed the hospital using a taxi 40%, 46% agreed that the transport fee was affordable, 87% agreed that they do not pay for antenatal care services and 9% said the payment for the services was not affordable. 68% agreed that they were satisfied with antenatal care services provided at the hospital,

25

Figure 6; Relationship between ANC services satisfaction and access to hospital

50% of the pregnant mothers who accessed the hospital using taxi were not satisfied with the ANC services provided at the health facility and this was the highest while the lowest dissatisfaction was 21.9% and these accessed the hospital through walking. Details are shown in figure 4.

Figure 7; Relationship between first ANC visit and transport affordability

Findings revealed that 43.5% of pregnant mothers who agreed to transport being affordable made their first ANC visits at 28-32 weeks of pregnancy meanwhile most of them who couldn’t afford transport initiated their first visit at <20 weeks. Details are shown in figure 5.

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CHAPTER FIVE

DISCUSSION

5.0 Introduction

This chapter contains discussion of the results of study aimed at determining the factors influencing late antenatal care seeking behavior among pregnant women at Kawolo general hospital.

5.1 Discussion of results

This study showed that many of the pregnant women initiated there first antenatal care visits late despite the fact that many knew the right gestation age that they should make their first visits.

The mothers who started attending ANC earlier had the knowledge about the recommended number of visits. The commonest reasons were because they didn’t want to disclose early pregnancy and that early initiation increases on the number of visiting times the health worker will assign to them. However most of them did not know the recommended number of visits they were supposed to make during pregnancy.

The average gestation age at first attendance of pregnant women who came late was for antenatal care visit was 27.5% (approximately 7 months) this was higher than the median gestational age of 5.5 months in a study carried of Factors influencing timing and frequency of antenatal care in

Uganda.(Bbaale,E.,2011)

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5.1.1 Socio economic factors that influenced late ANC seeking behavior.

Education level as one of variables analyzed under the socio economic factor in this study showed that 48.9% of the pregnant mothers initiated their first ANC visit at <20 weeks of pregnancy and they had attained primary level of education while those at institutions and university where 2.2%. This means that mothers who had attained primary level of education initiated their first antenatal care earlier compared to those who had attained secondary and tertiary level of education. This finding disagrees with those found in very many studies for example Bbaale, (2006) reported that 6-11% of mothers who attained secondary education were more likely to initiate ANC early and make the four recommended visits and 5% mothers who attained primary education level were less likely to initiate their first in the first trimester.

Simkhada, (2008) also reported that women who are educated are more likely to initiate antenatal care visits early than those who are less educated. Educated women were more likely to attend antenatal and postnatal services more frequently (Phafoli; 2007).

The pregnant women in the study were mostly married and appeared to be of low economic status, this is evidenced by the fact that most of them had attained secondary and primary level of education and were full time housewives. Some agreed that they would not afford to pay for antenatal care services if they were not free. This finding is in agreement with other another study where by economic status both wealth and poverty was found to significantly influence antenatal seeking behaviors. 9-15% mothers who are rich were more likely to make the four visits compared to the poor ones (Bbaale, 2006). .

78.9% of mothers with high parity initiated their first ANC visit late, this was almost equal to the findings in a study of reasons given by pregnant women for late initiation of antenatal care in

Niger delta Nigeria where of the 256 multiparous women 80% had booked atleast one pregnancy

28 late ( Ndidi, 2010). On the other hand this study disagrees with the findings in India were first antenatal care visit was initiated earlier in higher parity women (Matsuoka, 2009 cited in

Finlayson, 2013).

This study showed that 52,6% of pregnant mother’s spouse who had white collar jobs reported early for their first ANC visit compared to those in business, agriculture and those who were jobless. This finding agrees with those that Bbaale (2006) reported pregnant women with partners in agriculture and blue collar jobs were 6% less likely to initiate early and make the four visits.

Pregnant mother’s occupation was linked to pregnancy disclosure where almost half 55.5% of pregnant mothers would disclose early pregnancy were jobless mean while the pregnant mothers who had white collar jobs had the lowest 4.80%. this may due to the fact that pregnant women with white collar jobs are very busy to talk about their pregnancy compared to those who are jobless, the women who couldn’t disclose their early pregnancy reported that you may not be sure, pregnancy reveals its self may never know it’s outcome and who might wish you bad luck just like in study conducted in Nigeria (Ndidi, 2010) therefore socio economic status influences late antenatal care seeking.

5.1.2 Individual factors that influenced late ANC seeking behavior

The findings in this study showed 45% of the pregnant mothers made their first visit at < 20 weeks gestational age and 45% of them have knowledge on the recommended number of ANC visits, 62% said that < 20 weeks of gestational age was the appropriate time to initiate ANC visit this means that most women did not have the knowledge about the right gestational age to initiate ANC and the recommended number of visits and this was slightly lower than the findings

29 in study carried out by Kisuule (2013) where 72.7% didn’t know the right gestational age to initiate antenatal care.

This study also showed that 55.5% of the pregnant mothers who had their first ANC visit at <20 gestational weeks reported four as the recommended number of ANC visit and this was highest meanwhile the lowest percentage reported was 7.7% who made their first ANC visit at 20-24 weeks said two was the recommended number of ANC visits. Those who initiated early reported that it was because they were taught in their health facility during health education about the benefits of early initiation of antenatal care services during their previous antenatal care visits.

It’s important to note that 67% of pregnant women who did not get ANC services apart from hospital reported that <20 weeks was the appropriate time to initiate their first visit and this was highest while lowest was 10% who reported 20-24 weeks was the appropriate time for first visit.

This implies that those who seek ANC elsewhere miss out on health education about the right gestational age and recommended number of visits taught to those attending at health facility.

Those pregnant mothers who sought ANC services elsewhere gave reasons like they had gone to the TBA for herbs for drinking and bathing in order to get strength and ease delivery, mean while others said that it was because health workers were harsh, would bark at them and they had poor attitude towards the multi and grand parious women. This finding is in line with the findings by

Myer; (2010), and Finlayson; (2013)

All the pregnant women in the study agreed that early ANC seeking was beneficial and when asked why they gave reasons like it’s important for monitoring baby’s growth, pregnant mother gets treated when seek, helps in knowing baby’s sex and position and others said it was important for booking for delivery. This findings were contrary to those reported from South

Africa by Myer (2010) where pregnant women said they had no reason to book for antenatal care

30 early and they saw no benefit of early initiation and in Nigeria, where 8.1% pregnant women did not see any benefit in booking in the first trimester (Ndidi, 2010). All I all individual factors greatly influence ANC seeking.

5.2.2 Health facility factors that influenced late ANC seeking behavior

Health facility factors like transport affordability had significant impact on this study whereby

43.5% of pregnant mothers who agreed to transport being affordable made their first ANC visits at 28-32 weeks of pregnancy meanwhile most of them who couldn’t afford transport initiated their first visit at <20 weeks. This means that those who couldn’t afford transport to the health facility initiated ANC early while those who could afford initiated late. This disagrees with

27.7% who couldn’t afford transport to take them to the health facility (Kisuule et al, 2013).

This study showed 50% of the pregnant mothers who accessed the hospital using taxi were not satisfied with the ANC services provided at the health facility and this was the highest while the lowest dissatisfaction was 21.9% and these accessed the hospital through walking, this was because they came from distant places and they had to wait for long hours to be seen by the health worker. This finding is in agreement with those found by Phafoli; (2007) where some women stated long waiting hours, in convenient service hours and poor treatment by the health service providers were the reasons that influenced their delays and Finlayson; (2013) who also reported that women were discouraged from attending antenatal care because they had to wait for long time to be seen by health worker after they had traveled from far distances from their homes to health facility.

Findings in this study showed that 68% of the pregnant women were satisfied while 32% were not and this was because they had to wait for long hours to see the health worker, this finding is in agreement with Finlayson; (2013)

31

The study also showed that 87% agreed that the ANC services provided was free of charge since this being a government hospital however 13% disagreed because they incurred small costs like for buying drugs and which 4% agreed that it was affordable while 9% disagreed. This is in agreement with Christopher; (2013) reported the delays in ANC seeking were due to direct

Charges for the services although not authorized in national ANC policy they added other costs and an anticipated cost of paying for drugs, tests and medical cards even in countries which offer free antenatal care services strained them and their family’s finances.

To sum it all, socio economic, individual and health facility factors had significant impact on late

ANC seeking behavior among pregnant women at Kawolo general hospital.

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CHAPTER SIX

CONCLUSION AND RECOMENDATION

6.0 Introduction

This chapter contains conclusions, recommendations and limitations of the study aimed at determining factors influencing late antenatal care seeking behavior among pregnant women at Kawolo general hospital.

6.1 Conclusion

In conclusion this study shows most pregnant women knew the benefits of early initiation of

ANC and appropriate time to initiate to their first ANC visits however most did not know the recommended number of visits. and therefore it is less effective to only educate the mothers about the benefits early initiation of antenatal care without emphasizing on the recommended number of visits they are supposed to make since its during this continuous visits that the both the mother and the fetus’ health is monitored and she is prepared for delivery at health facility.

6.2 Recommendation

There is still more need to educate all women about the importance of early initiation and frequent visits for antenatal care services and this can be achieved through going to communities, schools, churches and mosques or use of village health teams (VHTs).

Male partner involvement during ANC should be reinforced since they are the head of households and decision makers.

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Positive working environment should create for the health workers in order for them to enjoy their work.

Turnaround time should be reduced in order to reduce on long waiting hours by pregnant mothers; this can be achieved by training, recruiting more health staff and the reception nurse positively communicating to the waiting mothers.

Creating more incentives like providing a drink to the mothers, putting television with interesting programs at the waiting area, giving maternity dresses to those who initiate early and creating resting areas where by they can lie down to rest while waiting and freely interacting with one another.

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REFERENCES

Bbaale, E., 2011. Factors influencing timing and frequency of antenatal care in Uganda. The Australasian medical journal 4, 431. Christopher Pell1,2*, Arantza Men˜ aca2, Florence Were3, Nana A. Afrah4, Samuel Chatio5, Lucinda MandaTaylor6, Mary J. Hamel8, Abraham Hodgson5, Harry Tagbor4,7, Linda

Kalilani6, Peter Ouma3,8,Robert Pool1, 2, 2013 Factors Affecting Antenatal Care Attendance:

Results from Qualitative Studies in Ghana, Kenya and Malawi Hogan, M.C., Foreman, K.J., Naghavi, M., Ahn, S.Y., Wang, M., Makela, S.M., Lopez, A.D., Lozano, R., Murray, C.J., 2010. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. The lancet 375, 1609-1623. J Adv Nurs, 619(3):244-260. J Midwifery Women’s Health, 48(4):268-272 Finlayson K., Downe S., 2013. Why Do Women Not Use Antenatal Services in Low- and Middle- Income Countries? A Meta-Synthesis of Qualitative Studies Kisuule, I., Kaye, D.K., Najjuka, F., Ssematimba, S.K., Arinda, A., Nakitende, G., Otim, L., 2013. Timing and reasons for coming late for the first antenatal care visit by pregnant women at Mulago hospital, Kampala Uganda. BMC pregnancy and childbirth 13, 121. Magadi MA, Madise NJ and Rodrigues RN, 2000. Frequency and timing of antenatal care in Kenya: explaining the variations between women of different communities. Ministry of Health; Uganda (2012) Clinical Guidelines: antenatal care. 348. Revised first edition; Myer L, Harrison A, 2003. Why do women seek antenatal care late? Perspectives from South rural Africa Phafoli SH, Van A swegen EJ, Alberts UU, 2007. Variables influencing delay in antenatal clinic attendance among teenagers in Lesotho. Published: January 22Reproductive Health, 3:8. Simkhada B, Teijlingen ER and Porter M, Simkhada P, 2008. Factors affecting the utilization of antenatal care in developing countries: systematic review of the literature. Soc Sci Med, 51(4):551-561. South African Family Practice, 49:9. Trinh LT, Rubin G, 2006. late entry to antenatal care in New South Wales, Australia.

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WHO Global Health Observatory (2015) Antenatal care-situations. Villar, J., H. Ba'aqeel, et al. (2001). "WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care." The Lancet 357(9268): 1551-1564.

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APPENDICES

APPENDIX I; CONSENT FORM

Title of the study:

Factors Influencing late Antenatal Care seeking behavior among pregnant women at

Kawolo General Hospital

I am Joha Rashid, a student offering Diploma in Clinical Medicine and Community Health at

International Health Sciences University Kampala. As a requirement for the course am to conduct a study that will add value to the health services in our local settings and am privileged to conduct study about ANC services at the ANC clinic in Kawolo General Hospital. The study is scheduled for one week in June 2015; the purpose of the study is to empower pregnant women with knowledge about right gestational age at which they should initiate ANC, the recommended four visits and benefits of early seeking thus healthy mothers and babies. A questionnaire will be administered to all pregnant women attending the ANC clinic who are willing to participate in the study. The study imposes no risks to the participants and the research investigator; questionnaires will be professionally administered, participation is voluntary and participants may consent with their own free will, participants also have a right to withdraw from the study at any time without any penalty and withdrawing from the study will not affect the services provided by the ANC clinic. There will be no direct benefits and compensation during/from the study to the participants. However the results will be used for decision making. Informed consent will be obtained from all the participants and all information will be kept confidential, study numbers will be used not names. Access will be restricted to only the authorized persons. Any questions about the study will be answered directly.

37

Statement of Consent

This consent form has been read and explained to me and I have understood, and my questions have been addressed. I therefore willingly agree to participate in the study entitled: Factors

Influencing late Antenatal Care seeking behavior among pregnant women at Kawolo General

Hospital

Name/Signature/Thumb print of the participant and date______,

______,______

Names of witness/Signature and date______, ______,

______

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APPENDIX II; QUESTIONNAIRE

This questionnaire is used to collect information for the research entitled ‘Factors influencing late antenatal care seeking behavior among pregnant women at Kawolo

General Hospital’

STUDY NUMBER ……………..

1. Demographic data

i. Age……

ii. Date of birth (DD/MM/YY)…………

iii. Address…………….village………………sub county…………..parish………….

iv. Marital status

Married Single Divorced Cohabiting Separated

v. Education level

Primary level Secondary level Institution University Unknown 5.

vi. Gravida…………………….. Para ………………… LNMP……………….. vii. Source of income.

Wife’s ……………………………… spouse ……………………………………

39

Assessing socioeconomic factors influencing ANC seeking behavior

2. Is this your first antenatal care for the current pregnancy?

Yes No

i. If no at how many weeks of your pregnancy did you make your first visit?

< 20 weeks 20-24 weeks 28-32 weeks. 37 weeks

ii. If not < 20 weeks why?

…………………………………………………………………………………………

3. Would you disclose your status during the early weeks of pregnancy?

Yes No

i. If no, why? ......

4. How many pregnancies have u carried up to 28 weeks irrespective of the outcome?

………………………………………………………………………….

i. Did u go for antenatal care visits?

Yes No

ii. If yes at how many months did you make your first visit?

......

5. How many times did you make antenatal visits?

1 2 3 4 >4

How many children do you have?

…………………………………………………………………………………………….. 40

Assessing the health facility factors influencing ANC seeking

6. How do you access the hospital?

Walking Taxi Motor cycle bicycle

i. If not walking how much is the transport fee?

…………………………………………………………………………

ii. Is it affordable to you? Yes No

7. Do you pay for antenatal services? Yes No

i. If yes, how much? ………………………………………………………………..

ii. If yes, is it affordable to you?

Yes No

8. Are you satisfied with the antenatal care services provided at this Hospital?

Yes No

If no, what is the reason for your dissatisfaction?

………………………………………………………………………………………………

9. Is there anywhere else you seek antenatal care apart from the hospital?

Yes No

i. If yes where?......

ii. Why would you choose the above place? ......

41

Assessing the individual factors influencing ANC seeking

10. When do you think is the appropriate time to initiate antenatal care?

< 20 weeks 20-24 weeks 28-32 weeks. 37 weeks

i. How many times is recommended for antenatal care visits? 1

2 3 4 >4

ii. Is there any benefit in seeking antenatal care in the early weeks of pregnancy?

Yes No iii. If yes what do you think is the benefit? …………………………………………

11. What would you recommend to improve on late antenatal care seeking behavior at this

Hospital? ……………………………………………………………………………………….

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APPENDIX III; MAP OF UGANDA SHOWING DISTRICT OF THE STUDY AREA.

KEY

Buikwe District

43

APPENDIX IV; MAP OF BUIKWE DISTRICT SHOWING THE STUDY AREA

Kawolo Hospital

44

APPENDIX V; INTRODUCTION LETTER

45