Journal of Pregnancy and Child Health
Open Access

Antenatal care; Pregnant women; Maternal and child birth; Epidemiology

Pregnancy and childbirth are critical periods for women and their families because of the high risk for maternal and child morbidity and mortality [1-5]. In 2020, about 287,000 women died during and following pregnancy and childbirth, of which 95% of these deaths occurred in low and middle-income countries. However, most of these maternal deaths could have been prevented [6]. While the maternal mortality rate decreased from 339 in 2000 to 223 per 100,000 live births in 2020 [7], it remains unacceptably high for the targeted rate of 70 maternal deaths by 2030 according to the sustainable development goals [8]. In addition, perinatal mortality remains high, at 47 deaths per 1000 births in 2020 [9], highlighting the need for skilled care during delivery and newborns’ first days of life.

Inadequate and insufficient use of antenatal care (ANC) with qualified healthcare professionals contributes to the occurrence of these preventable maternal and perinatal deaths [10-12]. Indeed, ANC visits are key opportunities for women to receive care from qualified healthcare staff, enabling the prevention, identification, and treatment of illnesses during pregnancy [13]. Since 2016, the World Health Organization (WHO) has recommended that every woman should have a minimum of eight contacts with a skilled health worker during her pregnancy, with the first contact occurring in the first trimester of the pregnancy [13]. These recommendations replaced the previous guidelines of four focused ANC visits during pregnancy. The term “visit” was replaced by “contact” to take into account the active link between pregnant women and healthcare providers. In addition to the number of contacts, their timeline has been reorganized. Finally, these recommendations also include health system interventions to improve the use and quality of ANC to make pregnancy “a positive experience” for women and adolescents [13]. Sub-Saharan countries are not equal when it comes to implementing these recommendations. While adopted in Mali since 2019, they have not yet been adopted in Burkina Faso.

In 2022, UNICEF reported that only 66% of pregnant women had at least four ANC visits worldwide [14]. In sub-Saharan Africa, less than 60% of pregnant women attended at least four ANC visits [14]. This figure is even lower for Mali (24.4% in 2020) and Burkina Faso (38% in 2020) [15,16]. In addition, only 36% and 39% of pregnant women attended ANC visits during the first trimester of pregnancy in Mali in 2018 [17] and in Burkina Faso in 2020 [16], respectively. Many studies have documented the barriers preventing women from using ANC including economic, sociodemographic, geographic, and contextual barriers [18-23]. However, few studies have been conducted in Mali and Burkina Faso, and in the context of the 2016 WHO recommendations for ANC. In Mali, in 2018, based on Demographic and Health Survey (DHS) data, only 3.5% of women reported having eight contacts during their last pregnancy; these women were more likely to be affiliated with health insurance, to live close to a health center, to have a higher wealth index, and to have husbands whose education level is higher than primary school [24]. In Burkina Faso, studies assessing the determinants of ANC attendance used at least four ANC visits as the primary endpoint [25,26]. Identifying the ANC attendance barriers could help in designing appropriate interventions to improve access to and timeliness of prenatal care.

This study aimed to identify the determinants of women’s access to at least four ANC visits (ANC 4+) in two health districts in Mali and Burkina Faso in the context of the new 2016 WHO recommendations.

Methods

Data source

For this analysis, we used data collected during the baseline household surveys conducted June–July 2022 in the framework of the INTEGRATION (INcreasing the upTakE of IPTp-SP throuGh Seasonal MalaRiA Chemo-prevenTION channel delivery) project. This cluster randomized implementation trial (RIA2020S-3302), carried out in Mali and Burkina Faso, aims to increase the coverage of three doses of intermittent preventive treatment during pregnancy with sulfadoxine-pyrimethamine (IPTp-SP) by delivering IPTp in the community using the seasonal malaria chemoprevention (SMC) channel in addition to ANC delivery. SMC consists of the monthly administration of amodiaquine/sulfadoxine-pyrimethamine to children aged 3–59 months during the rainy season. In Mali and Burkina Faso, it is delivered door-to-door over four months by community health workers. During SMC visits, pregnant women are also encouraged to attend the maternity clinic for ANC, during and beyond the SMC period. The baseline household surveys served as a basis for assessing the coverage of both IPTp and ANC uptake before the trial implementation.

Study settings

The INTEGRATION project was carried out in the catchment areas of Kangaba and Boussé health districts in Mali and Burkina Faso, respectively. Mali and Burkina Faso are two sub-Saharan countries with a catchment size of 1,241,238 km² and 274,220 km² and an estimated population of 20,732,476 and 20,487,979 inhabitants, respectively. The percentage of women who had completed at least one (1+) and four or more (4+) ANC visits in 2020 in the region covering Kangaba district were 82.4% and 32.3%, respectively, and 49.7% of them had received at least three doses (3+) of IPTp-SP [15]. In the health district of Boussé, 51.4% of pregnant women had attended at least one ANC visit in 2020, of whom 38.3% were in their first trimester of pregnancy. The proportion of pregnant women with four ANC visits was 48.6%; and 72.3% had received three doses of IPTp-SP in the district [16]. Studies are underway in each country to define the model for implementing the new WHO recommendations on ANC, but these are being carried out in districts other than Kangaba and Boussé, where the old WHO recommendations still apply.

Household survey sampling methods and data collection

In each country, a multi-stage cluster sampling method was followed to select the participants. A cluster was defined as the smallest geographic area comprising several adjacent households, which was considered as the unit of randomization. The sampling was carried out in three stages: (1) a random selection of clusters using probability proportional to size; (2) a random selection of households in each cluster; and (3) in each household, the selection of the woman with the most recent pregnancy among all women meeting the inclusion criteria (having given birth in the last 12 months (whether livebirth or stillborn), being a resident of the study area, and agreeing to sign an informed consent form).

A standardized questionnaire was used for data collection in both countries. It included the women’s sociodemographic characteristics and obstetrical history, the number of ANC visits women attended during their last pregnancy, and the reasons preventing them from seeking ANC more frequently. At the household level, the assets owned by the household and the characteristics of the house were collected to calculate the household wealth index. We also collected women’s reported costs for attending the last ANC visit.

Trained interviewers conducted the survey in the woman’s chosen language and entered their responses into a tablet using REDCap. Interviewers were neither residents of the villages they were surveying nor members of the intervention healthcare delivery staff. All interviewers were females, as the survey tool contained potentially sensitive questions. The number of ANC visits and IPTp-SP doses received during the last pregnancy was also collected from maternal health cards for concordance with women’s self-reported responses. Interviewers were supervised by the study team during data collection.

Variables of interest

For this specific analysis, the main outcome variable was the attendance of ANC 4+, which was categorized as 0: < 4 ANC visits or 1: ≥ 4 ANC visits. Because more than half of the women in Mali did not have a maternal health card, the main variable outcome (ANC attendance) was defined based on the women’s self-reporting only.

The potential factors associated with ANC attendance were selected based on the literature [19–21] [27]. They included sociodemographic and economic factors defined at individual and household level, such as the women’s age (categorized into < 21, 21–25, 26–30, or > 30 years old based on the age quartiles), her marital status (single; including no married, widows and divorced or married), and her ethnicity and religion. Additional factors were the education level of both the woman and the household head (categorized into no schooling, primary, or secondary/university), number of household members (categorized into <5, 6–7, 7–8, or > 8, based on the quartiles), and sex (categorized as male or female) and occupation of the household head (categorized into farmer/breeder, employee, worker, or unemployed). The household wealth quintiles (categorized into poorest, poorer, middle, richer, and richest) were calculated using principal component analysis [28] of household assets as follows: households were given scores based on the number and kinds of consumer goods they owned, ranging from a television to a bicycle or car, and housing characteristics such as the drinking water source, toilet facilities, and flooring materials. District wealth quintiles (from lowest to highest) were obtained by assigning a household score to each household member and ranking each person in the household population by her or his score [29]. The most recent DHS weights for each household asset were used to calculate a wealth index for each household within our sample in each country. Then the quintile ranges from the DHS at the national level for each country were applied to the wealth index of our sample. Regarding contextual factors, we considered the means of transportation to attend the maternity clinic (categorized into walking, bicycle, motorbike, car, or taxi), and the travel time to reach the maternity clinic (< 1 hour, or ≥ 1 hour). Finally, factors related to the woman’s obstetrical history and to ANC itself were considered as potential determinants of ANC uptake: gravidity (categorized into primiparous, two or three pregnancies, and large multiparous), history of stillbirth (yes or no), and gestational age at the first ANC visit (first, second, or third trimester). The reasons given by women for not attending ANC more often were investigated through the following questions: high cost of the ANC visit (yes or no), presence of female health providers at the facility (yes or no), closest facility open (yes or no), authorization from the husband/family required (yes or no), distance to the health facility perceived by the woman as too far or absence of transportation (yes or no), perceived necessity to seek ANC more frequently (yes or no), poor quality of the ANC services (yes or no), and the fact that the woman was unaccustomed to seeking ANC more frequently (yes or no). Women’s ANC expenses (categorized into up to US$ 2, 2.1–4, 4.1­–6, or greater than US$ 6), and the time spent waiting for and receiving ANC services (categorized into less than 1 hour or 1 hour and more) were also considered.

Statistical analysis methods

Statistical analyses were performed using Stata version 15.0. The analyses were conducted for each country separately. All analyses accounted for clustering.

First, we described the characteristics of both women and their households. The number of ANC visits, the proportion of women with four ANC visits (ANC4+), and the distribution of gestational age at the first ANC visit were computed using both maternal health cards and the women’s self-reported responses. The concordance between ANC uptake from data collected in the ANC card vs. self-reported was assessed. Moreover, women’s characteristics according to whether they had an ANC card or not were compared using Chi-square test and Student T-test.

Secondly, we conducted unadjusted analyses to determine which factors were associated with at least four ANC visits using logistic regression models with generalized estimating equations. All the variables that were significantly associated with ANC4+ (p-value < 0.2) in the unadjusted analyses were selected for the adjusted analysis, for which we used a logistic regression model using generalized estimating equations. A p-value less than 0.05 was considered statistically significant.

Results

Characteristics of the study population

Overall, 1590 women (780 in Mali and 810 in Burkina Faso) gave birth in the last 12 months before the surveys and were included in the study. For the outcome data collection, ANC cards were available for 335/780 women in Mali and 792/810 in Burkina Faso (Figure 1).

Women’s characteristics are summarized in (Table 1). In Mali, about 60% of the women surveyed were under the age of 25 years, most of them were of the Malinké ethnic group (67.7%), the majority were not educated (56%), they were married (98%), and they were predominantly Muslim (more than 97%). Half of the women (50%) had at least three pregnancies, and 12% had a history of stillbirth. The majority of the household heads were men (98.9%). In Burkina Faso, over 55% of the women surveyed were over the age of 25 years, most of them were of the Mossi ethnic group (95%), the majority were not educated (70%), they were married (99%), and they were predominantly Christian (over 60%). More than half of the women (53%) had at least three pregnancies, and 17% had a history of stillbirth. The majority of household heads were men (96.5%).

Number and timing of ANC visits

(Figure 2) shows the distribution of the number of ANC visits attended by pregnant women during their last pregnancy. About 53.5% (CI95 % [49.9 – 57.3]) and 79.9% (CI 95% [76.2 – 83.1]) of women attended four ANC visits in Mali and Burkina Faso, respectively.

(Figure 3) presents the distribution of gestational age at the first ANC visit: 38.7% (CI95 % [34.5 – 40.0]) and 43.8% (CI 95 % [39.3 – 48.5]) of women had their first visit in the first trimester in Mali and Burkina Faso, respectively.

Reasons preventing women from seeking antenatal care more frequently

(Table 2) presents the reasons preventing women from seeking ANC more frequently in Mali and Burkina Faso.

Out of the 780 women surveyed in Mali, 26% reported that ANC visits were too expensive, and 16% did not see the need to have several ANC visits. Also in Mali, 71% of women went to ANC visits by foot, walking less than an hour (82.7%); 50% of them spent more than US$ 6 for an ANC visit, and most of them (63%) spent more than 1 hour in the facility for ANC, including waiting time and time receiving ANC services.

Out of the 810 women surveyed in Burkina Faso, about 11% and 21%, respectively, reported that they were unaccustomed to seeking ANC and did not see the need to have several visits. About 78% of the women went to ANC visits on a bicycle, for a travel time of less than an hour (71%), and 88% of them spent less than US$ 2 for an ANC visit. Most of them (77%) spent more than 1 hour waiting and receiving ANC services in the facility.

*Footnote:  perception of the women interviewed regarding the ANC costs.

Comparison between self-reported vs. recorded data on maternal health card

Supplementary Table 1 shows the concordance between the numbers of ANC visits during the last pregnancy using self-reported data vs. data extracted from maternal health cards. Overall, the agreement (percentage of the same responses for a given outcome between the two sources) was 21.8% in Mali and 81% in Burkina Faso. In Mali, while we found relatively similar proportions of women with one or two ANC visits whichever the data source, a higher proportion of women reported three or four ANC visits compared with what we found using maternal health cards (Supplementary Table 2). The same pattern was observed in Burkina Faso but to a lesser extent. Supplementary (Table 3) shows that in Mali, women with and without a maternal health card had similar baseline characteristics, except for the history of stillbirth. Women with a history of stillbirth were more likely to have a maternal health card (p = 0.04).

Factors associated with ANC 4+

Factors associated with ANC4+ in the unadjusted and adjusted analyses in Mali and Burkina Faso are presented in Table 3.

In Mali, in the adjusted analysis, determinants positively associated with ANC 4+ were: a history of stillbirth (OR = 1.3, CI 95% [1-6]) and time spent waiting and receiving ANC services ≥ 1 hour (OR = 1.1, CI 95% [1-3]). In contrast, factors negatively associated with ANC4+ were: the cost of the ANC visit perceived as high by the women (OR = 0.6, CI 95% [5-7]), the fact that women were unaccustomed to seeking ANC more frequently (OR = 0.7, CI 95% [5-9]), and travel time to attend the maternity clinic ≥ 1 hour (OR = 0.6, CI 95% [5-8]).

In Burkina Faso, in the adjusted analysis, no evidence was found of any factors positively associated with ANC4+. In contrast, factors negatively associated with ANC4+ were the cost of the ANC visit perceived as high by the women (OR = 0.5, CI 95% [4-7]), the distance to the facility perceived as too far or the lack of transportation means (OR = 0.7, CI 95% [5-9]), the fact that women were unaccustomed to seeking ANC more often (OR = 0.8, CI 95% [7-9]) or believed frequent visits were unnecessary (OR = 0.8, CI 95% [7-9]), and the travel time to attend the maternity clinic ≥ 1 hour (OR = 0.9, CI 95% [8-9]).

Discussion

The coverage of ANC4+ was higher in Burkina Faso than in Mali, with less than half of women attending their first ANC visit in the first trimester of pregnancy. In these settings, we confirmed known individual and contextual factors associated with ANC attendance such as the obstetrical history, the distance or time spent to reach the health facility, the ANC cost, and the women’s lack of recognition of the importance of prenatal care.

ANC4+ coverage was 53.6% and 79.9% in Mali and Burkina Faso, respectively. These coverage estimates are higher than those reported in 2020: in Mali, in the Koulikoro region, which includes the Kangaba health district, ANC4+ was 32.3% while in Burkina Faso, in the region covering the Boussé health district (Plateau Central), it was 39% [15,16]. The higher coverage rates in our study may reflect differences in ANC4+ within the Koulikoro and Plateau Central regions. This could also be explained by higher access to and use of care by women during the study period than in 2020, probably due to the COVID-19 pandemic. As the new WHO recommendations have not yet been implemented in Mali and Burkina Faso, they have had no impact on the use of antenatal care in the two study districts. The new recommendations stipulate that the first contact be made in the first trimester. This allows for determining the number of fetuses and checking their viability, as well as initiating certain preventive measures such as the distribution of mosquito nets [13]. Also, it has been shown that early attendance in pregnancy is associated with a higher number of ANC visits throughout the pregnancy [24].

In Mali, we found that women with a history of stillbirth were more likely to seek ANC4+. This is in agreement with a study in Nigeria where stillbirth was reported to be a key factor in starting ANC follow-up early [30]. Infections during pregnancy (urinary tract infection, sexually transmitted infection, malaria, etc.) cause half of all stillbirths in developing countries. These infections and other pathologies are detectable during ANC visits, hence the need for more frequent antenatal care [4]. Having a stillbirth in a previous pregnancy is a negative experience for women; to prevent the same situation from happening again, pregnant women could seek prenatal care more frequently.

Another finding in Mali was the positive association between the uptake of ANC4+ visits and the time spent waiting and receiving ANC services ≥ 1 hour. Although we were unable to distinguish between waiting time and time spent in consultation, time spent with a qualified healthcare staff could be a factor in encouraging pregnant women to attend several ANC visits as they have time to express their concerns related to their state of health and pregnancy. This fact was reported in Ghana where spending at least 20 minutes or more during the first ANC contact was associated with eight and more ANC contacts [31]. In contrast, pregnant women could perceive a relatively short consultation time as synonymous with poor quality of health services provided, as reported in Uganda, Burkina Faso, and Tanzania, where the duration of first visits was <15 minutes; and health workers spent even less time in subsequent visits because of non-compliance with all the procedures stipulated in the focused ANC guideline [32].

The cost of the ANC visit perceived as high by the women was significantly associated with a lower probability of attending ANC4+ visits. This association was found independently of the household wealth index. Attending ANC involves both direct and indirect costs, especially in Mali where ANC visits for pregnant women are not free of charge [33]. In Burkina Faso, where healthcare has been freed for pregnant and breastfeeding women since 2016, the indirect costs for pregnant women can also be perceived as very high. Drug stockouts or when certain tests are unavailable or not offered free of charge in the health center can result in additional ANC-related expenses beyond travel costs [34, 35]. In the event of a drug stockout at the health center, the pregnant woman receives a prescription to pay for the medicines in private pharmacies. Also, tests such as determination of rhesus blood group and obstetric ultrasound are not available in peripheral health centers, leading women to carry out these examinations at their own expense.

Pregnant women’s knowledge of ANC recommendations can have an influence on whether they seek ANC. In Burkina Faso, we found that women who did not think it was necessary to make frequent visits to the maternity clinic in the absence of pregnancy-related problems were less likely to have made four or more visits. Thus, ensuring women have better knowledge and understanding of what is expected from them in terms of ANC can have an impact on their attitude toward ANC. A recent systematic review has reported the role of community health workers in improving knowledge about ANC and pregnancy outcomes [36].

Another factor preventing pregnant women from attending ANC4+ visits was the travel time to attend the maternity clinic in both Mali and Burkina Faso. In sub-Saharan Africa, the distance to the health facility and the quality of the roads are a real problem for the population, and particularly for pregnant women, to access healthcare [18,37]. Pregnant women in Burkina Faso also reported distance, and not only travel time, as a limiting factor for attending ANC4+ visits in Burkina Faso [18]. In the Kangaba and Boussé areas, health centers are relatively far away, with bicycles, motorbikes, or walking as the means of transportation, and are therefore difficult to access due to poor road conditions [38,39]. This is even worse during the rainy season. This makes it particularly relevant to use community health workers to deliver counseling and to encourage women in the community to initiate early and attend more ANC at the health center.

Conclusion

This study revealed that in Mali, where the new WHO recommendations have not yet been implemented at scale, the rate of ANC4+ remains low, which calls into question the feasibility of the recommendation of eight contacts implementation. In Burkina Faso, where ANC4+ is higher, these recommendations have not yet been adopted. In both countries, factors identified as barriers to ANC uptake were mostly contextual or cultural, such as travel time to ANC, not recognizing the need for ANC, and the perceived high cost of ANC. Health policies aimed at achieving the new WHO recommendations may involve reducing the costs of health services or even making them free for pregnant women and strengthening their knowledge of the importance of contact with qualified health personnel. This would reduce the indirect costs of ANC and increase access to more frequent ANC for pregnant women. Finally, these countries could explore other strategies such as enlisting professionalized community health workers in raising women’s awareness and encouraging them to attend antenatal care.

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