PREGNANCY DISCLOSURE AND TIMING OF ANTENATAL CARE AMONG ADOLESCENT WOMEN IN KISOZI SUB COUNTY
CHAPTER ONE
1.0 Introduction
This chapter contains the Background of the study, Statement of the problem, Purpose of the study, Research objectives, Research questions, Scope of the study, and Significance of the study, as shown in the subsequent sections below.
1.1 Background to the study
Maternal death has declined substantially worldwide except in Sub-Saharan Africa. Of the 21 countries with the highest maternal mortality 15 are in sub-Saharan Africa (Hogan et al., 2010). In 2010, pregnancy and childbirth-related complications led to an estimated 454 maternal deaths per 100’000 live births in Tanzania (NBS, 2010). Most of these complications occur unpredictably during labour, delivery and the immediate postpartum period (Ronsmans, 2006). Deaths could be averted with prompt and adequate diagnosis and care (Campbell, 2006). However, 49% of all women in developing countries still deliver at home without any skilled attendant.
Moreover, according to the definition of the World Health Organisation (WHO) (WHO, 2006), a quarter of all women in developing countries begin childbearing as adolescents before reaching the age of 20 years. An estimated 70’000 adolescent mothers die each year worldwide because their bodies are not yet physically ready for motherhood and due to social disadvantages (Bearinger et al., 2007). Pregnancy and childbirth thus constitutes the number one killer among 15-19 year old girls worldwide (WHO, 2006).
Women who start antenatal care (ANC) attendance early and attend frequently are more likely to be assisted during delivery by a skilled attendant compared to those who initiate ANC late and attended only few visits (Mpembeni et al, 2007). Although ANC might not have the potential to predict and avert obstetric emergencies during pregnancy and childbirth, it exposes women to health education on risk factors and encourages them to deliver with a skilled attendant or in a health facility. Women who knew about risk factors were more likely to utilize health facilities for delivery than those without knowledge (Stekelenburg et al., 2004). Moreover, ANC provides the opportunity to detect and treat anomalies of pregnancy and to deliver preventive health services such as immunization against tetanus, prophylactic treatment of malaria and worms, and HIV testing and counselling (leading to Preventing Mother to Child Transmission of HIV, PMTCT) (Villar, 2002). Women in sub-Saharan Africa start antenatal care considerably later than women from other regions and late ANC enrolment after more than five months of gestation in sub-Saharan African countries (Abou-Zahr, 2001).
In Mozambique and southern Tanzania, women at an early stage of pregnancy delay ANC initiation purposely in order to protect the unborn from witchcraft and sorcery attacks of jealous neighbours and kin (Chapman, 2003). Women’s ANC attendance is mediated by their experiences and the quality of care at earlier ANC visits. Beyond demographic and socio-economic factors, social and cultural factors as well as individual perception of pregnancy and care impact women’s timing of ANC enrolment (Bearinger et al., 2007).
In most East African countries, late booking of antenatal care has repeatedly been associated with young age, premarital status, unwanted pregnancies, high parity, lack of formal education, low socio-economic status (SES) and ethnicity (McCray, 2005). Less is known about the influence of social and cultural determinants on prenatal care use among adult and adolescent pregnant women.
Adolescents in Uganda are more likely to experience violence from parents, to be rejected by their partner, expelled from school, and to be stigmatized, and therefore this lead to hiding of their pregnancy (Jewkes, 1998). Late recognition of and uncertainty about the pregnancy, as well as cultural beliefs and practices around pregnancy, have been reported to influence women’s timing of ANC attendance (Launiala, 2005).
In Kisozi sub county, adolescent women visit the ANC clinic later and less frequently than adult women. Moreover, adolescent mothers differ from adult mothers in several ways: most of them are in their first pregnancy which is unplanned and prior to marriage, they still live at their parents’ home and they do not get any social or economic support from their partner or the child’s father. Based on the insights from the background, the study will assess the relationship between pregnancy disclosure and timing of antenatal care among adolescent women in Kisozi Sub County.
1.2 Statement of the problem
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. However, many pregnant women in sub-Saharan Africa start antenatal care attendance late, particularly adolescent pregnant women. Therefore they do not fully benefit from its preventive and curative services. This study assesses the timing of adolescent pregnant women’s first antenatal care visit and identifies factors influencing early and late attendance in Kisozi Sub County.
1.3 Purpose of the Study
The purpose of the study will assess the relationship between pregnancy disclosure and timing of antenatal care among adolescent women in Kisozi Sub County.
1.4 Research objectives
The objectives of the study will include;
- To assess the personal determinants that influence timing of antenatal care among adolescent women in Kisozi Sub County.
- To identify the socio-economic determinants that influence timing of antenatal care among adolescent women in Kisozi Sub County.
- To assess the health facility related determinants that influence timing of antenatal care among adolescent women in Kisozi Sub County.
1.5 Research Questions
The research questions will include;
- What personal determinants influence timing of antenatal care among adolescent women in Kisozi Sub County?
- What socio-economic determinants influence timing of antenatal care among adolescent women in Kisozi Sub County?
- What health facility related determinants influence timing of antenatal care among adolescent women in Kisozi Sub County?
1.6 Scope of the study
1.6.1 Content scope
The research study will focus on pregnancy disclosure and timing of antenatal care services. The study will target pregnant adolescent women, adolescent mothers, health workers and their parents.
1.6.2 Geographical scope
The study will be conducted in Kisozi Sub County located in Wakiso District. This is because it is one of the areas with the highest child abuse cases.
1.6.3 Time scope
The study was carried out for a period from June to October, 2017 and considering 2007-2016 as the period of body of knowledge to review literature.
1.7 Significance of the study
To the community of kisozi, the study would help them acquire information on timing of antenatal care among adolescent women which help them to have knowledge of the importance of antenatal care services. This would be ensured by holding a session with them which will take 30 minutes to discuss the results and recommendations of the study.
To local leaders, the findings would form a basis upon which appropriate interventions can be devised to improve access to antenatal care services for their community members.
To health workers, the study would enable them realise the health related determinants that influence people’s timing of antenatal care among adolescent women and hence improve areas which need to be improved.
To other researchers, the research report would act as a source of literature to other future researchers. This would be ensured by putting a copy of the report in the school library.
1.8 Conceptual framework
This section proposes a conceptual framework within which the concept, Timing of antenatal care services is treated in this work. It is arrived at basing on the System’s theory Input-Output model advanced by Ludwig Von Bertalanffy in 1956. The selection of the model is based on the belief that, the quality of input invariably affects quality of output. (Acato 2006)
Figure 1. Showing the conceptual framework for this study
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Independent variable Dependent variable
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Extraneous variables
Source: Adopted from Koontz and Weihrich (1988:12).
This chapter presents literature related to determinants that other researchers have reviewed which was in line with study objectives.
2.2 Personal determinants that influence timing of antenatal care among adolescent women
According to Winklebly, (2014), education shapes future occupational opportunities and earning potential in developed countries like US. It also provides knowledge and life skills that allow better-educated persons to gain more ready access to information and resources to promote health services such as medical examination.
According to a study by Hannah, (2012) on the factors affecting access to healthcare services by intermarried Filipino women in rural Tasmania, it was found out that cultural beliefs and practices hindered participants’ access to antenatal care servicess, particularly those from rural areas. They find it hard to adopt the new health practices. For instance, it was mentioned that ‘their practices have been part of their lives since birth’. Thus, accepting and adopting new health practices affects their accustomed ways of maintaining health and wellbeing, as well as accessing the new health services.
According to a study by Magoma et al., (2010), on the high antenatal care coverage and low skilled attendance in a rural Tanzanian district, it was established that increasing knowledge and awareness of the determinants influencing access to antenatal care services and how they interact can inform effective policy development and improve the availability and accessibility of health care services that fit the needs of different communities in Tanzania. Therefore, increased awareness and knowledge about health issues influences the access to antenatal care services.
According to Mare, (2012), in his study Socio-Economic Careers and Measurement and Analysis of Mortality, he stated that the work status of women has also been linked to knowledge and use of medical examinations. Women who work outside the home have higher rate of accessing antenatal care services than women who do not work outside home (housewives). Working women, particularly, those who earn cash incomes are assumed to have greater control over household decisions and increased awareness of the world outside home.
According to Kinney et al., (2010), the observed variation in medical examination use by place of residence may be attributed to differences in the availability of such social services as education, information about medical examination, access to medical examination and health care services.
Fiscella, Franks & Clancy (2008), religion may affect compliance or access to health services. It is recognised also that in most African countries like Uganda, health professionals put into account these types of religious beliefs and values when communicating with patients or users; this may affect ones access to antenatal care services.
A longitudinal study carried out by Green & Pope (2009) on social factors and the use of medical services, the study found out that more than ninety percent of women attending antennal clinic but less than half of them frequently did antenatal care services in health facility. The study also found out that a higher number of respondents had a positive attitude towards medical examination implying that majority of them went for antenatal care services.
In a study done by Adler & Newman, (2012), in Uganda on Low use of rural maternity services in Uganda, the study revealed that quality of care, which only partly overlaps with medical quality of care, is thought to be an important influence on health care-seeking and antenatal care services. Assessment of quality of services largely depends on personal experience with health system.
2.3 Socio-economic determinants that influence timing of antenatal care among adolescent women
UDHS, (2011), showed that Ugandan women in the lowest wealth quintile have no access to antenatal care services as those in the highest wealth quintile. Percentage of women in the lowest quintile has no education compared with 38 percent in the highest quintile” shows the obvious fact that wealth and education go hand-in-hand and, together, make the biggest fertility impact. The lower the income levels the higher the access to antenatal care services.
According to Fiscella, Franks & Clancy (2008), argues that the location of health services in developing countries may result in poor access for antenatal care services. Also household financial capacity is one of the major factors in the determinants of antenatal care services, and this depends on occupation of family members.
According to Ross, (2011), household financial capacity is one of the major factors in the determination of antenatal care services in most African Countries. A limited ability to pay and high hospital costs have been identified as the major barriers for the rural poor wishing to access health care, due to economic difficulties in rural areas women are not able to afford costs related to antenatal care services.
According to Link and Phelan, (2010), the inequalities in the apparent circumstances of individual’s lives, like individuals’ access to health care, schools, their conditions of work and leisure, households, communities, towns, or cities, affect people’s ability to lead a flourishing life and maintain health, thus access to antenatal care services.
Women who are working and earning money may be able to save and decide to spend it on a health issues. Several studies find that farming women are less likely to have routine examination than women in other occupations (PHAC, 2011). This may be due to limited financial resources and health services in such areas.
2.4 Health facility related determinants that influence timing of antenatal care among adolescent women
According to a research carried out by Agency for Healthcare Research and Quality (AHRQ) in the US, 2008, lack of access, or limited access, to health services greatly impacts an individual’s health status. For example, when individuals do not have health insurance, they are less likely to participate in preventive care and are more likely to delay medical treatment.
Unreliable transport is also a barrier to access health services, failure to plan in advance for transport cause higher number of people to forego antenatal care services (Mrisho et al., 2007).
In most developing countries, inadequate knowledge and skills for health workers on management of obstetrics cases can be the barrier for antenatal care services in health facilities, several study found that health workers tend to unnecessary refer pregnant mother to higher level because they don’t know to use partogram which monitor the progress of labour and the woman end up delivering normally. This woman will never come back to that facility due to unnecessary referral to other health facility (Shankwaya, 2008)
Health provider behavior and attitudes are also determinant factor, some of the health workers are very rude, using abusive language and refusing to assist the patients, and these attitudes limit access to antenatal care services however positives attitudes of health workers attract people in health facilities (Mrisho et al, 2008).
Distance is one of the determinants for routine examination especially in rural areas where by health facilities are scarcely distributed. It is relevant to have health facility which is well equipped and properly staffed but not accessed by anyone due to walking distance. Shankwaya, (2008), noted that the use of health services decline with distance. According to Fiscella, Franks & Clancy (2008), argues that the location of health services in developing countries may result in poor access for antenatal care services.
CHAPTER THREE
METHODOLOGY
3.1 Introduction
The chapter focuses on the methods and procedures that will be used in conducting the study which includes; the study design and rationale, study setting and rationale, study population, sample size determination, sampling procedure, inclusion criteria, exclusion criteria, definition of variables, research instruments, data collection procedure, data management, data analysis, ethical consideration and anticipated limitation of the study.
3.2 Study Design and rationale
The study will be cross sectional and descriptive in design, employing quantitative data collection method. It will be a cross sectional type of design because a number of variables like age, gender, religion, and education will be assessed. The study design will be chosen because it will help to study various factors i.e. personal, social and economic and health related.
3.3 Study area
The study will be conducted in Kisozi Sub County district. The main economic activities that people engage in include farming and businesses. The stable food is matooke and potatoes. This area is chosen because it is near for the researcher to access.
3.4 Study Population
The study will target female teenagers aged 13 to 19 years old, pregnant or non-pregnant, including those who have ever given birth, health workers and parents.
3.4.1 Sample Size Determination
The study will involve 60 respondents. The research will choose only 60 respondents because they are representative enough of the study population and because of the limited finances and time.
3.4.2 Sampling procedure
Purposive sampling will be employed where any female teenagers aged 13 to 19 pregnant or non-pregnant will be sampled from their homes until the required sample size is obtained. The researcher will access the home where females aged 13 to 19 will be identified.
3.4.3 Inclusion criteria
The study will include female teenagers aged 13 to 19 years pregnant or non-pregnant.
3.4.4 Exclusion Criteria
The study will exclude all adolescent boys.
3.5 Definition of variables
Variables are the characteristics of a respondent the researcher wishes to explore or study.
Independent variables
These are the demographic characteristics of the respondents such as age, marital status, education, occupation.
Dependent variable
The dependent variables of the study will be personal factors and socio-economic variable.
Personal factors: are the individual factors that strongly influence their behaviors.
Social Economic factors: this refers to how economic activity affects and is shaped by social processes. In general it analyzes how societies progress, stagnate, or regress because of their local or regional economy, or the global economy.
3.6 Research Instruments
A questionnaire will be used which will be first pretested on 5 people to assess its effectiveness and accuracy. The questionnaire will be written in English.
3.7 Data Collection Procedure
A letter of introduction will be obtained from Kyambogo University which will be given to the LC 1 chairperson who will be explained to the purpose and objective of the study. The LC 1 chairperson will introduce the researcher to the village health team (VHT) member who will help to introduce the researcher to the respondents. The researcher will explain the purpose and objective of the study to respondents and ask for their informed consent. Every respondent who will fit in the inclusion criteria and is willing to consent will be given a questionnaire to answer and for those who don’t understand English will be assisted by the research assistant. Every completed questionnaire will be collected per day until the desired number of respondents is reached. The researcher will sample 12 respondents per day for a period of 5 days to make a total of 60 respondents.
3.7.1 Data management
This will include all measures put in place to ensure that quality data is obtained. The management will include data editing before leaving the area of study to ensure that there are no mistakes or areas left blank and if any mistakes are found they will be corrected before leaving the field. The researcher will also code the questionnaire and store them in the file for safety and locked in a place which can only be accessed by the researcher.
3.7.2 Data analysis and presentation
The data will be analysed manually by use of pens and papers to tally thereafter quantitative data will be analyzed statistically and presented in tables, figure and narratives.
3.8 Ethical Consideration
A letter of introduction will be obtained from Kyambogo Univeersity seeking permission to carry out the study. The letter will be presented to the local council one chairperson who will introduce the researcher to the village health team (VHT) member who will help to introduce the researcher to the respondents. The study will only commence after the purpose and the objectives of the study have been clearly and well explained to participants. Only those who will be willing to participate in the study will be given questionnaire. Respondents will be assured of confidentiality and privacy.
3.9 Anticipated Limitations of the Study
The researcher might face a challenge of limited cooperation from the respondents. This may be due to their own reasons among themselves being that they have limited time and interest in providing the information required. However, the researcher will strive to explain to them the importance of the study as academic so as to get their cooperation.
Also the researcher may face a challenge of some respondents who are not literate. This will be overcome by translating to them the meaning of the questions in the language that they understand.
The research may face limited time to carry out research and other classroom work. However, the researcher will draw a work plan which will be strictly followed.
The Researcher may be limited by financial resources such as the transport costs and stationery to carry out her research effectively. In an effort to mitigate this shortcoming, the researcher will source for funds from a few relatives.
