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

Globally, pregnancy disclosure is sensitive issue for women who have experienced unexplained pregnancy interruption (Pell, 2013). Most adolescent women, who have previously experienced several unexplained pregnancy interruptions, have not informed their closest friends and neighbours. Afrah (2013), limited pregnancy disclosure is generally reported as a means to avoid gossip and potential embarrassment if a woman did not bring her pregnancy to term. Women delaying pregnancy disclosure is a strong predictor of delayed ANC attendance (Mayumana, 2011).

Maternal death has declined substantially worldwide except in Sub-Saharan Africa. Of the 21 countries with the highest maternal mortality rate, 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.

The role of antenatal care cannot be underestimated. Adolescent women who disclose their pregnancy early and start antenatal care (ANC) attendance early, 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. 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. 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, 2012). Majority of women in sub-Saharan Africa start antenatal care considerably later than women from other regions enrolment after more than five months of gestation in sub-Saharan African countries.

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. 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. 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. Less is known about the influence of social and cultural determinants on prenatal care use among adult and adolescent pregnant women (Jamila, 2015).

Kisule (2014) states that in Uganda, adolescents are more likely to experience violence from parents, to be rejected by their partner, expelled from school, and to be stigmatized, and therefore this leads to hiding of their pregnancy, 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.

In Kisozi Sub County, data collected between 2009 and 2010 within the study area indicated that the proportion of pregnant women who initiated ANC attendance after the fifth month of gestation rose from 53% to 56% between 2009 and 2010. Over this period, 18% of all ANC attendees were 19 years old or less. In an in-depth study with a small sample of recent adult and adolescent mothers (Jona 2010), adolescent women were found to 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. There is a dearth of knowledge on what factors determine adolescent’s disclosure of pregnancy. Therefore, this study will look forward at assessing the personal, socio-economic and health facility related determinants that influence timing of antenatal care among adolescent women. The results from this study will help adolescents acquire information on timing of antenatal care which help them to have knowledge of the importance of antenatal care services.

1.2 Statement of the problem

Antenatal care continues to be a question of rituals than of effective interventions among adolescents where teenage pregnancy is at 25%, out of every six children born one dies. The report reveals that the proportion of women delivering in health units remains low at 41%, although the percentage that attends antenatal care is about twice as high (UBOS, 2011).

Irrespective of efforts by the Uganda government, late ANC attendance has continued to prevail exposing mothers and infants to the highest risk of deaths. In a survey carried out in Africa, Uganda received a rating of 49 for health service access, with an average of 46 for rural and 68 for urban. Rural access scores ranged from 38 to 72 suggesting an urgent need to utilize early alternatives to promote early and frequent appropriate ANC alternatives in Health Units/Hospitals (Mahal, 2014).

Despite the above efforts, maternal mortality has remained high in Uganda. The Uganda Demographic Health Survey of 2006 found that the maternal mortality rate declined by just 14% in the past 10 years, from 506/100,000 to 435/100,000, compared to a 28% decline in the previous 7 years (UBOS, 2011). The total fertility rate (TFR) in rural (7.1 children per woman) higher than the urban TFR (4.4children per woman) and the contraceptive prevalence rate (CPR) is 23%. Therefore, the study will be carried out to evaluate pregnancy disclosure and timing of antenatal care services paying close attention to alternatives to ANC being undertaken in early phases of pregnancy in Kisoro district.

1.3 Purpose of the Study

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;

1. To assess the relationship between household characteristics and timing of antenatal care among adolescent mothers in Kisozi Sub County.
2. To assess the socio-economic factors that influence timing of antenatal care among adolescent mothers in Kisozi Sub County.

• To investigate the health facility related characteristics that influence timing of antenatal care among adolescent mothers in Kisozi Sub County.

1.5 Research Questions

The research questions will include;

1. What is the relationship between household characteristics and timing of antenatal care among adolescent mothers in Kisozi Sub County?
2. What socio-economic factors influence timing of antenatal care among adolescent mothers in Kisozi Sub County?

• What health facility related characteristics influence timing of antenatal care among adolescent mothers 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 mothers who had a line birth during their pregnancy one year prior, health workers and their parents.

1.6.2 Geographical scope

The study will be conducted in Kisozi Sub County located in Wakiso District, Uganda. This is because it is one of the areas where adolescent mothers have low access to ANC services.

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

The study will 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. The findings will form a basis upon which appropriate interventions can be devised to improve access to antenatal care services to adolescents through facilitating timely disclosure of pregnancy and subsequent processes. The study will enable them realize the health related determinants that influence pregnant adolescents’ timing of disclosure and access to antenatal care. It’s hoped that the study will add on the existing knowledge about determinants of pregnancy disclosure and timing of antenatal care and challenges therein.

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

Independent variable                                                                        Dependent variable     

Extraneous variables

Source: Adopted from Koontz and Weihrich (1988:12).

Figure 1 above shows the linkage between pregnancy disclosure and timing of antenatal care services. It shows that timing of antenatal care services as a dependent variable is directly influenced by the independent variable, (pregnancy disclosure). According to Figure 1, pregnancy disclosure denoted household characteristics (age, education level, marital status, attitude towards her situation knowledge of ANC services), socio-economic factors (low status of the female in society, limited decision making powers, social immaturity and financial limitations) and health facility related characteristics (distance and location, availability of skilled health workers, availability of medical equipments and expertise of the health workers) contribute to timing of antenatal care services. If such mechanisms are employed effectively, then the timing of antenatal care services is likely to be high and if the mechanisms are employed poorly, then timing of antenatal care services may be low.

The researcher also identified some extraneous variables, which may affect timing of antenatal care services. These include, government policies, support, availability of the services among many. These variables are part of the input and process explained in the Ludwig’s Input-Output model. They play a role in bringing out the output, which is timing of antenatal care services. If these variables are not controlled, they may interfere with the results of the study. The researcher will control the effect of the extraneous variables by randomly selecting participants because randomization according to Amin (2005) is one of the ways to attempt to control many extraneous variables at the same time.

CHAPTER TWO

LITERATURE REVIEW

2.1 Introduction

This chapter presents literature related to determinants that other researchers have reviewed which was in line with study objectives.

2.2 Timing of antenatal care among adolescent

Pregnancy is a crucial time to promote health behaviors, prevent still births and avoid some of the major causes of illness among new borns. Essential interventions during the pregnancy period are provided through the ANC package, including, TT immunization, identification and management of STIs, including HIV and syphilis, malaria prevention through IPTp,ITN and treatment, identification and management of pregnancy complications such as anemia, nutrition, counseling, preparedness and counseling on maternal and new born danger signs (Hllen, 2013).

The usual recommendation nowadays is for booking (first antenatal visit) to take place in early pregnancy, prior to14 weeks. The World Health Organization (WHO) recommends that pregnant women in developing countries should seek ANC within the first 4 months of pregnancy. A WHO Technical working Group recommended a minimum of four antenatal visits for a woman with a normal pregnancy (lancet, 2001). Minimum of 4 visits should be made as follows; First visit- early (0-16 weeks) in first trimester after missed two periods; Second visit-16 >28 weeks; Third visit- between 28>36 weeks; Fourth visit- after 36 weeks.

However, some women require more than four visits especially those who develop complications (Lancet, 2001). Although progress has been made globally in terms of increasing access and use of one antenatal visit, the proportion of women who are obtaining the recommended minimum of four visits is too low.

Countries implementing ANC will need to cost and assess the effect of the ANC service package in terms of its content, coverage, affordability, and sustainability of services over time. The challenge to most sub-Saharan African countries is to formulate application of the WHO ANC model within country needs and resources and identify the best approaches to deliver effective and sustainable ANC. This requires countries to respond to certain key questions: How to re-organize services to ensure delivery of a comprehensive, integrated package and assessing the contribution of the package to improve quality of care and components required in strengthening over time.

The person best able to offer ANC services is the person with midwifery skills who is part of and lives in the community she or he serves. However, in developing countries like Uganda which have a shortage of well-trained health care personnel, ANC care is often provided by less qualified staff such as auxiliary nurse/midwives, village midwives, health visitors and Traditional birth attendants (TBAs) whose background may be conditioned by strong cultural and traditional norms which may impede the effectiveness of their services. These persons have at least frequently provided the backbone of maternity services at the periphery. For the fulfillment of complete set of tasks required to manage normal pregnancies and births, their skills need to be improved through education, training and supervision by well-trained midwives.

In industrialized countries and in many urban areas in the developing world, skilled care at delivery is usually provided in a health facility. In most developing countries and particularly in rural areas, many women prefer to deliver in the familiar home environment or in the home of the parents, parents-in-law or in the setting provided by the TBA (WHO, 2007). Home delivery may be appropriate for normal deliveries, provided the person attending the delivery is suitably trained and equipped and referral to a higher level of care is an option.

According to Uganda‘s ministry of health sector strategic plan phase 1, the near universal first attendance at antenatal clinic has continued, but this was not matched by improvement in cases of emergency Obstetric Care (HSSP vol 1, 2009/2010). These achievements were made in spite of severe constraints of under-funding, continued inadequacies in the production, recruitment and deployment of trained personnel, frequent outs of essential medicines, and lack of equipment for operationalising the new health centers. The mismatch between the construction of HC IIs country wide and the speed at which resources are made available for their operationalization severely limits the planned inequity reduction targets.

Over the past decade considerable effort has been made to restore the functional capacity of the health sector, reactive disease control programmes and re-orient services to Primary Health Care. However, patterns in Uganda show that, poor access and poor quality of health care still persist with only 49% of population living within five kilometers or walking distance of a health care facility, and only 42.7% of parishes have some form of health facility (Annual Health Sector Performance report, 2006/2007). The challenges to implementation of minimum health services and the Minimum Health Care Package programme include inequality due to inefficient allocation of available resources within the sector, with more than 63% of the recurrent budget and 54% of the trained staff concentrated in hospitals. Poor distributions of human resources, low staff morale resulting from poor remuneration and over dependence on untrained personnel in primary health facilities, where only 34% of established positions are filled by qualified staff pose major structural problems to the effective implementation of health programmes.

Generally, many factors contribute to less utilization and access to antenatal care services in Uganda (Road map for accelerating Maternal mortality in Uganda, 2007-2015): high rates of teenage pregnancy, low perception of pregnancy related risks, low level of female involvement in reproductive health and rights, harmful and negative culture on reproduction, gender relations, and health seeking behavior as well as poor infrastructure.

2.3 Factors influencing timing of antenatal care services

2.3.1 Household characteristics that influence timing of antenatal care among adolescent women

Lack of knowledge

Adolescent pregnant women have been reported to most likely either not attend ANC or to attend late and infrequently (WHO, 2006; Bearinger et al., 2007) due to lack of knowledge, lack of power to take decisions. An early study from the US that reported lower prenatal care utilization among adolescents in their second pregnancy (Blankson et al., 2005) multiparous adolescents were found to start ANC attendance considerably later.

A study from Uganda comparing ANC attendance in adolescent and adult first time mothers found no difference in the timing of the first visit but a lower number of subsequent ANC visits in adolescents (Atuyambe et al., 2008). Similarly, Magadi et al. (2006), found more variation by age with regard to frequency of ANC attendance than with timing.

Late recognition of pregnancy

It was found to be a strong predictor of delayed ANC attendance. Similarly, late recognition of pregnancy and subsequent delay of ANC attendance has also been reported among South African women who received long acting hormonal contraceptives in the form of injections (Jewkes, 1998). Although pregnancy tests seem to be available at drug shops in the study area at a price of between (~0.30-0.60 USD) they are not widely used (Mayumana, 2011). More than a quarter of participating women said they waited for the quickening before initiating ANC attendance. Studies from Tanzania and other sub-Saharan countries have shown that late disclosure of the pregnancy due to local practices or beliefs such as witchcraft is common and has a negative influence on the timing of ANC attendance.

A study by Gross et al (2012), found out that almost a third of the women interviewed (30%) said that they had not recognized early that they were pregnant, some of them because of continued bleeding or previous use of contraception. Women’s late perception of pregnancy was independently associated with a later ANC start of 2 weeks. About a quarter of all women (27%) reported that they had waited for the foetus to move (quickening) before initiating ANC attendance. Although waiting for the quickening was not associated with a later ANC attendance in the first regression model, it became marginally associated with a later ANC start of one week, also included women attending the clinic for the first time in their life.

Furthermore, neither women who said that ANC attendance should be initiated within the first three months of pregnancy (67%) nor those who had a good knowledge about ANC services (22%) were found to start ANC attendance earlier than the others. Although only few women criticized the quality of ANC services (9%), multivariate analysis showed that those who did so initiated ANC attendance an average of three weeks later compared to those who were satisfied by the quality (p = 0.009). Criticism was related to lack of services; being sent back home without receiving services due to the lack of sufficient staff; and having to purchase drugs, cards or diagnostic tests despite the national exemption policy that guarantees free health services for pregnant women. Surprisingly, perceived poor attitudes of health workers were associated with two weeks earlier attendance, although the effect was only marginally significant. Few women sought treatment from sources other than ANC (9%) which was not associated with a late ANC initiation. Also, women who reported that they had visited a traditional healer were more likely to have had a history of a reproductive loss.

A study by Mbonye (2006), found out that being in the first pregnancy was strongly associated with an earlier ANC attendance. On average, primiparous women first visited ANC 0.87 month or three weeks earlier than multiparous women. After adjusting for other factors, women who had a previous miscarriage or stillbirth attended 2 weeks earlier compared to women who had not experienced such an incident. There was no evidence that education or marital status were associated with an earlier or later timing of ANC attendance.

In addition, when asked about their self-perceived timing of the first ANC visit, 56% of the participants said that they had made their first ANC visit late. Women who judged their first visit to be late attended ANC significantly later than women who perceived their first visit to be early (mean 5.5 gestational months vs. 4.7 months, t = 6.92, p < 0.001). Reasons given for late attendance were: not recognizing the pregnancy early (29%); poor accessibility due to distance, difficulties to cross rivers or poor road conditions (17%); not being able to come due to illness or other obligations such as travelling, caring for a sick person or agricultural work (14%); or negligence or apathy (13%). Women who said that they enrolled early in ANC did so in order to follow nurses’ advise and because one is supposed to do so (37%); to know health status and prevent health problems (31%); out of fear that the consequences of non-compliance would lead to not being treated or being scolded by the health facility staff (16%); or to treat a health problem (15%).

pregnancy disclosure influenced timing of ANC. Adolescents and unmarried younger women hide their pregnancies and delay ANC to avoid the potential social implications of pregnancy: exclusion from school, expulsion from their natal home, partner abandonment, stigmatization and gossip. In contrast, older women did not make active efforts to hide their pregnancies. However, they would only directly disclose their pregnancy to close relatives and their husband. Although ambivalent towards others discovering their pregnancy, which they considered inevitable as the pregnancy progressed, women were wary to be accused of boastfulness by spreading the news openly (Were, 2013).

Limited pregnancy disclosure was generally reported as a means to avoid gossip and potential embarrassment if a woman did not bring her pregnancy to term. In Malawi, however, there were reports of women delaying pregnancy disclosure and ANC (till the fourth month) to avoid suffering witchcraft that could harm a pregnancy. In Kenya and in Ghana, pregnant women (and other community members) described how they were at greater risk of witchcraft and sometimes attributed pregnancy interruptions to witchcraft. However, this was not viewed as a reason to delay ANC. Furthermore, in Ghana, although women acknowledged the dangers of witchcraft and personalistic threats to a pregnancy (threats posed by human or non-human sentient beings), they were reticent to talk about them (Afrah, 2013).

One study observed that disclosure was a particularly sensitive issue for women who had experienced unexplained pregnancy interruption. For example, although one Kenyan woman, who had previously experienced several unexplained pregnancy interruptions, was willing to be interviewed in early pregnancy, she had not informed her closest friends and neighbours. Later, she reported having lost the pregnancy, and although she did not refuse outright to be interviewed, henceforth, whenever approached, she did not have time to talk (Pell, 2013).

In spite of the concerns about gossip, embarrassment and witchcraft, it was possible to identify and interview women during early pregnancy. Contact was made at health facilities, or with the assistance of community leaders or other pregnant women. Although the numbers varied across the sites – from five in Kenya to twelve in Malawi – in total, over 30 women were interviewed during the first trimester of pregnancy (Taylor, 2013).

Marital Status

Mayumana (2011) observed that adolescent pregnant women were less likely to be married or to live with their partner than adult pregnant women. They were more likely to receive advice to attend the ANC and to have received this advice from their mother, or a close person they called ‘mother’, rather than from their partner compared to adult women.

Restrictions

Restrictions can prevent women from seeking health care outside the home for themselves and their children. This barrier is often raised still further when men provide services, and has been offered as one reason why Asian women living in Western countries often make little use of health services (Leonard, 2002).

Community characteristics

The individual‘s use of the health facility is also influenced by the characteristics of the community in which the person lives, indicating a need to look beyond the individual factors when examining health seeking behaviors (Stephenson R,2002) First, community’s lack of the human capital-education to promote their own and their families‘ health (Tim Ensor, 2004). Education may provide communities with a basis for evaluating whether they or a dependent require treatment inside or outside the home. Thus, rural areas like Kisoro with high rates of illiteracy have been characterized by less antenatal care visits by pregnant women and mothers.

Education level

Education provides the community with the basis for evaluating whether they require treatment. While it is sometimes suggested that individuals are unable to assimilate information on treatment options, this assumption is challenged by Leonard‘s recent work in Tanzania (Leonard K.L, 2002). These studies suggest that, far from being passive consumers, patients actively seek out not only the best-known provider but the best facility for a particular illness. Thus, Perceptions of quality do, in fact, accord quite well with technical evaluations.

In communities where women are not expected to mix freely, particularly with men, utilization of health services from static facilities may be impeded. Cultural conventions about proper treatment of health issues may also inhibit access. Ndyomugyenyi reports that, the women of the Alur tribe of Uganda may be thought weak if they receive help during delivery. A similar finding is reported for the Bariba tribe in Benin. There is also evidence that women often accept illness with genito-urinary symptoms as part of life and may be embarrassed to seek medical care. A a A study, in Bolivia, found that women were put off by well-ventilated delivery rooms when their own understanding required warm conditions for the delivery to progress.

In Malawi and Kenya, health staff promoted the involvement of husbands in ANC through, for example, giving preferential treatment and a free shawl for their child if the husband attended ANC with his wife. For a minority of Kenyan women, however, the participation of husbands in ANC decision-making, combined with HIV-related stigma, had negative implications for their ANC attendance: women were wary of attending ANC because they would be informed of their HIV status and a positive result had ramifications if their husbands discovered their status. Husbands often refused to be tested and rather, in the most extreme instances, accused their wives of adultery and abandoned them. In light of this, one of the Kenyan case studies reported delaying ANC to delay discovering her HIV status. This was possible, because although HIV/AIDS was not mentioned on the ANC card, people knew how to interpret the information available on the card to determine HIV status and one Kenyan woman had attempted to damage her ANC card to hide her status. Furthermore, Kenyan women were reticent to talk about HIV testing: unless specifically asked, they would not mention it as part of ANC. Although there were also reports of HIV-related stigma in Malawi, in general, Malawian women described the importance of knowing their status and HIV testing was not given as a reason to delay ANC. In Ghana, the HIV prevalence in the research sites was much lower and HIV/AIDS was not raised as an issue affecting ANC attendance (Pell, 2013).

Age of the mother

Both health staff and other community members confirmed that for women at all sites, gestational age was a meaningful concept and influenced ANC attendance. Although their estimations were not always accurate, women talked about the gestational age of their pregnancies – often measuring the progression in months – and reported that this affected when they initiated ANC. Although primagravidae, particularly young women and adolescents, were less certain (as is elaborated below), generally, women became aware of their pregnancy as a result of one or two months of amenorrhea. However, gestational age had a varied impact on ANC initiation across the sites: respondents from the different categories tended to characterize women in Ghana as generally starting ANC around the third or fourth month of pregnancy, whereas women in Kenya and Malawi were often reported to make their first visit at around the sixth or seventh month (Jewkes, 2003).

With regard to older multiparous women, health workers could confirm that particularly in Kenya and Malawi, and to a lesser extent in Ghana, they visited the clinic in later pregnancy: in some instances, waiting till the ninth month. Being more accustomed to the pregnancy experience, their priority was obtaining the antenatal card and they were less concerned about monitoring the progress of the pregnancy (Taylor, 2013).

2.3.2 Socio-economic factors that influence timing of antenatal care among adolescent women

Lack of resources

Socio-economic factors such as the low status of the female in society, limited decision making powers, social immaturity and financial limitations might contribute to poor utilization of ANC services, resulting in an increased incidence of pregnancy and obstetric complications. Bouwer et al added that religious beliefs in certain societies may pose barriers to the utilization of ANC services. Bouwer et al recommended that health workers should understand variations in family composition, social class, health beliefs and behaviors and be able to bridge the gaps between the beliefs and behaviors. In a number of South Asian societies the mother-in-law dominates decisions on childbirth and care related to pregnancy, particularly in the early stages of marriage. In these circumstances, whether a woman is delivered at home by a family member, by a traditional birth attendant (TBA), or at a health facility, much depends on the beliefs of the mother-in-law. At the community level the TBA is also vital in influencing demand. One study in Rajasthan found that more than 90 percent of women that did not obtain referral care were advised against it by the TBAs (Hitesh J, 1996).

In Uganda lack of resources to improve quality and delivery of maternity services, despite good policies and concerted efforts, have hindered the increase in the utilization of those services by women or a reduction in the high ratio of maternal deaths (Bantebya, 2003). Yet there has not been an increase in the utilization by women of emergency obstetric services at health facilities nor a corresponding significant reduction in maternal deaths. The proportion of women delivering in health units remains low and there is a gap between the numbers attending antenatal services and those delivering in health services (EQUINET, 2007).

A study by Gross et al., (2012) observed that in particular not possessing money in cash when attending the ANC clinic and not receiving support from the husband/partner are independently associated with a later ANC enrolment for all women. Women who had no money in hand attended on average about 1 week later and women who felt not supported by their husband attended almost 3 weeks later than women who did receive such support. Including women who attended the ANC clinic for the first time in their life – not possessing money in cash when attending the ANC clinic became significantly associated with a later start of one week whereas there was not effect anymore for not receiving support from the husband/partner.

Mushi (2010) provides evidence for the negative influence of lacking social and financial support on women’s timing of their first ANC visit and the key role of the husband or partner. The results legitimize the attempts of the Tanzanian Ministry of Health and Social Welfare to encourage greater male involvement in maternal health issues.

In Kenya, it was apparent that charges for ANC varied across health facilities and amongst respondents: small charges were levied for the ANC card and also, where available, laboratory tests. Similarly, and in spite of the free health insurance for pregnant women, in the Ashanti Region, incidences of charging for some ANC services were reported: although, not encountered in all facilities, the pricing system was unclear and consequently the subject of women’s complaints. Furthermore, health staff described the efforts of local health administrations to tackle corruption and prosecute those responsible. In contrast, in Upper East Region, ANC was largely free. However, in some instances, as a result of shortages, women were required to bring with them medical supplies, such as bottles for sampling urine. In Ghana, ITNs were offered at a subsidized charge of 2$ for pregnant women and there were regular shortages. Although charges were not levied for ANC visits in Malawi, women were instructed to buy replacement generic health passports due to a shortage of ANC cards (Pell, 2013).

Attending ANC also entailed indirect costs. Travel costs varied amongst the sites and the respondents at each site: for example, in northern Ghana, where vehicles providing public transport were scarce, women mainly walked to the clinic and travel costs were minimal. In Kenya and Malawi, bicycle taxis were available, and in light of their pregnancy-related tiredness, women who could afford to pay, did so. Other women travelled on their husband’s bicycle and, in Kenya, a minority of women used motorbike taxis because of their greater comfort. Other indirect costs include the food that women purchased whilst waiting to be attended, either for themselves or their accompanying children. Given the particularly social nature of ANC visits, women with the available resources spent money on clothes and a visit to the hairdresser prior to attending (all women however made efforts to look smart). Many of the women cultivated land along with their husbands and other family members and were often responsible for cooking meals for family members; taking time out from these activities therefore represented an opportunity cost. There are also non-monetary costs: pregnancy, combined with women’s continued labour demands (that continue up to delivery and recommenced shortly after), was often an exhausting experience for women and the journey to health facilities represented a physical burden (Afrah, 2013).

Pell, 2013), delays in ANC initiation were not however solely due to the associated indirect and direct costs. The nature of ANC appointment scheduling by health staff, and women’s understanding of appointments as compulsory also contributed to delayed initiation, particularly in Kenya. In Kenya and Ghana, both women and health staff described how follow-up appointments were generally scheduled for one month after each appointment, except in the weeks prior to their due date, when women were scheduled for weekly or fortnightly visits. In Malawi, appointments were every two months except during the ninth month. Women, particularly in Kenya and Malawi, reported that they would not attend ANC until the sixth or seventh month to minimize the number of journeys and therefore the total cost of ANC. As women viewed the scheduled appointments as compulsory, attending in the third month of pregnancy could potentially result in eight journeys to the health facility (assuming that in the final month a fortnightly appointment is set and excluding delivery at a health facility).

Taylor (2013), a range of factors also mediated women’s access to the means necessary to meet the direct and indirect costs of ANC. At all the sites, women were primarily involved in subsistence farming, but, through their involvement in small businesses, some were able to gain access to cash. Women without direct access to cash often relied on their husbands or relatives to meet costs, which further complicates decision-making about ANC initiation. In some instances, however, it was not only a question of access to cash, but also access to the means of transport, such as a husband’s bicycle, to reach the health facility. Reports of women delaying ANC initiation because of an objection from their husbands or a relative responsible for household expenditure were however rare. The difficulties that some women face to access cash were highlighted by the experience of one Kenyan woman who worked as a live-in carer: she reported waiting for her employer, who knew of her pregnancy, to pay her salary before initiating ANC.

The UDHS 2007 findings indicate disparities in utilization of health services, with rich, urban and more educated people more likely to use health services than the poor less educated rural residents. This trend was attributed to better economic and physical access to services among the former but also to attitudes influenced by religion, culture and limited understanding of disease causation among the latter. The reason why the poor do not make more use of public services is driven by both supply and demand factors (Ensor T, 2004).

A review by WHO found that the direct costs of maternal health care range between one and five percent of total annual household expenditures, rising to between five and 34% if the woman suffers a maternal complication(WHO, 2006). At the national level, the WHO estimates totals of $95 million and$85 million are lost each year by Ethiopia and Uganda respectively due to poor maternal health. Globally, $15 billion is estimated to be lost every year due to reduced productivity related to the death of mothers and neonates. Country estimates range from $1.50 per person per year in Ethiopia to almost $5 in Senegal.

2.4 Health facility related determinants that influence timing of antenatal care among adolescent women

Availability of skilled health workers

ANC is an opportunity to promote the use of skilled attendance at delivery and healthy behaviors such as breastfeeding, early postnatal care, and postpartum family planning for limiting or spacing births. However, studies have shown that there are many missed opportunities for care, both because of client- and health system-related factors. Mothers and children may face risks because of limited or late-term ANC visits, low-quality care during visits due to poor provider training, infrastructure and administrative weakness at facilities (Armar-K, 2006). Thus, the introduction of ANC in sub-Saharan Africa and Uganda in particular makes demands on health systems that are already stressed.

Distance and location of the health facility

Studies in many countries have also shown that barriers such as distance may be surmountable, as evidenced in cases where individuals bypass local services to reach ones of higher quality or when Distance is given as a reason for non-use, despite health facilities being available. There is much evidence to suggest that distance to facilities imposes a considerable cost on individuals and that this may reduce demand. In studies reviewed for this study, transport as a proportion of total patient costs, a study carried out in Bangladesh suggested that, transport to health facilities was the second most expensive item for patients after medicines (CIET Canada, 2000).

Location and distance costs are often seen to negatively impact ANC service utilization. A study in Vietnam found that distance is a principle determinant of how long patients delay before seeking care (Ensor T, 1996) Another, in Zimbabwe, suggested that up to 50% of maternal deaths from hemorrhage could be attributed to the absence of emergency transport. At the same time, distance is also cited as a reason why women choose to deliver at home rather than at a health facility in many rural areas in central and western Uganda (Nuwaha F, 2000).

In relation to the above, location of health centres and facilities is another important dimension of the cost of care. A study in Burkina Faso, for example, suggested that transport costs accounted for 28% of the total costs of using hospital services (Sauerborn R.1994). A recent delivery survey in Bangladesh found travel costs were the second most expensive item (after medicines) in outpatient treatment. According to one review of postnatal deaths in North-East Brazil, in an estimated 25% of cases, mothers reported that delays in transportation may have contributed to the death (Souza A.C.T, 2000). Distance as a barrier is not confined to low- and middle-income countries. A study of patients in Great Britain presenting for colorectal screening found that more than 27% of the total cost of the procedure was accounted for in travel cost. The same study suggested that this cost fell disproportionately on poorer households.

According to the study carried out by Ministry of Health in Uganda, about 49% of the population in rural areas resides within 5Km from a health facility (UMOH, 1996). Many families rely on self-treatment or seek services of traditional healers and traditional midwives. Whereas nearly 90% of pregnant women make an antenatal care visit, over 64% do not benefit from a trained assistant during childbirth (UDHS 1995). As a result, the Health Sector Strategic Plan has encouraged the training of the community level providers like the traditional birth attendants and contraceptive distribution agents to improve on the services provided at the community level.

The impact of location is not confined to low-income countries. One US study found that patients living more than 20 miles away from a hospital are much less likely to visit ambulatory services for after-care following myocardial infarction. In Japan, one study found that access to follow-up treatment after treatment for cerebrovascular disease was considerably influenced by access to suitable transportation (Tamiya K, 1996). Distance may also have a differential impact across income groups. A study in Australia found that the impact of costs fell most heavily on the poor. Qualitative evidence in Vietnam suggests that poorer households usually have access to inferior transport in the event of illness. Such restrictions may also interact with other barriers. One study in India found that distance was a much greater barrier to women than to men with similar incomes. This may be because it is culturally unacceptable for women to leave their homes for long periods, or it could reflect less access to household resources to pay for transport.

Two types of barrier are critical: physical and financial. In poor countries, the density of health infrastructures equipped and staffed with competent, available and committed personnel is low (Koblinsky M, et al, 2006). For women this often means they are too far to walk‘ and they prefer to deliver at home rather than embarking on a long and difficult journey to under-equipped health centres or poorly staffed district hospitals. When women or the family decision-makers decide to attend an appropriate health service, the next obstacle is money. In many settings, patients have to pay out-of-pocket for everything, including a tip for the personnel, and this may result in delay, which can sometimes be fatal, and in catastrophic expenditure for the household (Borghi J,2008).

Expertise of the health workers

Poor quality of health services is a major problem in many, but not all, developing countries (World Bank Report, 2004). However, facilities open and close irregularly; absenteeism rates of doctors and nurses can be very high; staff can be hostile, even violent to patients; misdiagnosis is not uncommon, medicines are all too often unavailable, sometimes due to staff pilfering for use in private practice; and there is inappropriate prescribing and treatment. Deficiencies in quality have direct implications for access to effective health care. Further, one expects that demand will diminish in response to the poor quality of the care offered. This confirmed by the example of Ghana where a decline in quality of public health care was associated with 40% fall in utilization within only five years (1979-1983).

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, study area, study population, sample size determination, sampling procedure, research instruments, data collection procedure, data management, data analysis, ethical consideration and anticipated limitation of the study.

3.2 Study Design

The study will use a descriptive cross sectional research design, employing quantitative data collection method. According to Baron (2011), qualitative research design helps to capture qualitative data, based on qualitative aspects that may not be quantified. It aids in discovering the motives and desires or what people think and how they feel about a given subject or situation. This method involves an unstructured approach to inquiry and allows flexibility in all aspects of the research process. It is more appropriate to explore the nature of a problem, issue or phenomenon without quantifying it.

3.3 Study Population

Study population is a complete set of individuals, cases or objects with some common observable characteristics. The study will target mothers and women who had a line birth during their pregnancy one year prior, health workers and parents.

3.4 Sample Size Determination

A sample of 60 respondents will be obtained including 40 mothers, 10 health workers and 10 parents. This was to be determined with the use of Modified Kish and Leslie formula Luven as n = [(Z a/₂)²pq]/£²

where: Z -the standard Z statistic of the normal distribution,

a= the level of significance,

p = proportion of the members with the required characteristics,

n= sample size selected,

q( I-p)= the proportion of members without the required characteristics,

e=the maximum probable error which was considered as 10 percent.

As there is no predetermined value for p,a default value of p=0.84 and thus q= 0.16 was taken. Z=l.96 (as it is in the normal distribution tables) calculating yields n=60 as the sample required.

Table 1: Sample size

3.5 Sampling procedure

According to Baron (2011), this is a definite plan determined before data collection for obtaining a sample from a given population. It involves three decisions: who to be sampled, how many people to sample, and how to obtain the sample.

Simple stratified random sampling will be then used to select samples from the population strata. It’s a method in which the population is divided into a number of divisions and a sample is drawn from division and such sample makes us the final sample. This technique will be employed since it eases the making of proportionate samples, and therefore meaningful, comparisons between homogeneous sub-groups (Zikmund, 2003).

The study also will employ purposive sampling technique. Silverrman (2001), purposive sampling involves deliberate selection of particular units of the population for constituting a representative sample. It involves convenience and judgemental sampling. Under judgemental sampling, the researcher will choose the sample based on who she thinks will be appropriate for the study while convenience sampling rose where the population elements will be selected for inclusion in the sample based on the ease of access. The researcher will use purposive sampling because it saves time, money and effort. It is flexible and meets multiple needs and interests. It enables researchers to select a sample based on the purpose of the study and knowledge of a population.

3.6 Research Instruments

Interviews

The main method in data collection will be interview.

Cohon and Manioh (1989) qualify interview to be a conservation initiated by the interviewer for specific purpose of obtaining research relevant information and focuses on content specified by research objectives of specific description. Semi-structured interviews will be used to generate additional information from the respondents. This method will be chosen because it helps in the collection of more data as it allows the interaction of both the researcher and the respondents. It is cheap and does not will bete much time.

An interview guide will be used for the in-depth interviews with health workers and parents. The interview guide will be developed based on the objectives. They will be designed in English language. It will be used because it promotes greater depth of response which is not possible through other means and it allows the researcher to get information concerning feelings, attitudes in relation to research questions. It is also cheap and easy to administer.

Questionnaires

The questionnaire will be used because large amounts of information can be collected from a large number of people in a short period of time and in a relatively cost effective way, can be carried out by the researcher or by any number of people with limited affect to its validity and reliability, the results of the questionnaires can usually be quickly and easily quantified by either a researcher or through the use of a software package, can be analysed more ‘scientifically’ and objectively, when data has been quantified, it can be used to compare and contrast other research and may be used to measure change.

Informal observation

Informal observation is usually done when the researcher has little knowledge of a population and its behaviour. The main purpose of informal observation is to create hypotheses to be tested later, in a survey or using for a survey. This method involves watching and listening to people.

Focus group discussions

Focus group discussions will be used due to the capacity of the short period of time. Focus group discussions will be used on mothers and pregnant women.  This will enable the participants to debate and discuss on the study directed by the few questions set and followed. The instrument used will be the focus group discussion guide where questions were set and followed. The study involved 5 focus group discussions (in groups of 5) and will take about 30 minutes each.

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 24 respondents per day for a period of 5 days to make a total of 60 respondents.

3.8 Data presentation and analysis

The data will be presented using percentages and tables according to objectives of the study to come up with the conclusions and recommendations basing on the findings. Data will be qualitatively analyzed using quick impression which will be done by summarizing the key findings, content analysis will include recording and reviewing of the recorded information in order to understand data better and on a broader context, thematic analysis will also be used. Here the researcher will identify relevant information and classify it into relevant topics.  These techniques will be exploratory in nature since they will be highlighted, sorted, scrutinized and reviewed better to ensure accuracy in the data collected.

3.9 Ethical Consideration

The researcher will obtain all the necessary permission from the university and the authorities where the research will be carried out. But most importantly, the values and norms of the local people will be studied well and respected to avoid any misconception. In addition participants will be asked for their consent to participate in focus group discussion (FGD) and fill in structured questionnaire.

3.10 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.

CHAPTER FOUR

ANALYSIS, INTERPRETATION AND DISCUSSION

4.1 Introduction

This chapter provides the results that were obtained from data analysis and are presented in figures and tables in form of frequencies and percentages. Data was collected from a sample of 30 respondents by means of an interview guide. The results presentation was based on the study objectives

4.2 Socio-demographic characteristics of respondents

Table 1: Socio-demographic characteristics of respondents

According to age, majority of respondents (40%) were aged 36-45 years and the minority of the respondents were (13.3%) 18-25years.

Regarding sex, majority of respondents (76.7%) were female and the minority (23.3%) of the respondents were male.

Religion, Highest number of respondents (30%) were Anglicans and the lowest number (10%) of the respondents were Catholics.

Table 2: Level of Education

Regarding education, most of the respondents 35% had reached secondary level, 25% of the respondents had never gone to school, 26.7% of the respondents had reached tertiary/university and only 13.3% of them were of primary level.

4.2 Household characteristics and timing of antenatal care services

The first objective of the study sought to assess the relationship between household characteristics and timing of antenatal care services among adolescent mothers. Several questions were posed to respondents and the following responses were obtained;

Table 3: Showing how old respondents were when they first got pregnant

From the table above 57.5% of the respondents mentioned that they were 18-19years and the remaining 42.5% of the respondents said 15-17years. This implies that most adolescent gave birth when they were 18-19years.

Table 4: showing responses on whether respondents were married by their first pregnancy

From findings, majority of the respondents (90%) were not married when they first had their pregnancy and only 10% of the adolescent mothers were married. This implies most adolescent mothers get their first pregnancy when they are not married. One key informant was quoted;

“My daughter got pregnant while she was in secondary level while staying with me at home”

Respondents were also asked to mention when they realized they were pregnant and the following results were obtained;

Although their estimations were not always accurate, women talked about the gestational age of their pregnancies – often measuring the progression in months – and reported that this affected when they initiated ANC.

Particularly adolescents were less certain, generally, women became aware of their pregnancy as a result of one or two months of amenorrhea. This had a varied impact on ANC initiation.

Respondents were asked about their reaction when they realized they were pregnant. Varied responses were obtained as presented below;

Table 3: Showing how response on reaction about the pregnancy

Results in the table above indicate that majority of the respondents (77.5%) indicated that they felt bad when they realized they were pregnant while only 22.5% of the respondents had a positive attitude. One respondent indicated that they felt good because their stayed with their partners who approved their pregnancy at the time.

Generally started ANC around the third or fourth month of pregnancy while others often reported to make their first visit at around the sixth or seventh month.

Respondents further were required to indicate who they disclosed their pregnancy to and the following results were obtained;

Table 4: showing results of who they disclosed pregnancy to

From the results above, majority of the respondents (42.5%) mentioned partner, 22.5% of them indicated sister, 17.5% of the respondents mentioned close friend, 10% of the study respondents indicated parents, 5% said brother and only 2.5% of the respondents mentioned close relative. This implies that most adolescent mothers always close to their partners about their pregnancies first. This is because of them do not have what to do, so they decide to contact their partners so that they get a solution while other adolescent mothers contacted their close friends and sisters so that they give them some advice to the pregnancy.

Respondents asked to indicate how their parents reaction to the pregnancy and the following responses were obtained;

Table 5: Parent’s reaction to the pregnancy

Results as shown in table above indicates that majority of the respondents (77.5%) said that their parents were negative about their pregnancy and only 22.5% of the interviewed mothers indicated positive.

Those respondents who indicated that their parents reacted positively were staying with their partners. One respondent was quoted;

“My parent was not happy about my pregnancy; he even denied to pay my school fees after afterwards. I was forced to go and stay with my aunt. Because life had become hard and my partner was unable to take care of me”.

From findings only 47.5% of the study respondents mentioned that they received support from the parents while 52.5% of the respondents did not receive any support from their parents.

Respondents, who received support from their parents, received it in form of finances, food, and pregnancy support. Generally, parents had a negative attitude towards pregnancy.

4.3 Socio-economic factors and timing of antenatal care services among adolescent mothers

The second objective of the study sought to assess the socio-economic factors that influence timing of antenatal care services among adolescent mothers. Varied responses were obtained and are presented below;

Table 6: Community perception towards the pregnancy

From the table above, majority of the respondents (100%) indicated that the community had a poor attitude towards the pregnancy. One respondent was quoted;

“Community perceives pregnancy at an early age as a disgrace. When girls get pregnant they are few chances that they pay their dowry. Girls who get pregnancy at early age mostly do not complete their education therefore this community does not encourage girls to get pregnant at adolescent stage”.

Respondents further were asked to indicate whether the household had a source of income by the first pregnancy and various responses were obtained;

Table 7: Showing results on whether household had a source of income

From the results as indicated in table above, most respondents (67.5%) indicated that their household had a source of income by their first pregnancy and only 32.5% of them said no. respondents indicated that their parents were business persons, civil servants, farmers among others.

Table 8: Showing partners reaction towards the pregnancy

From the table, majority of the respondents (77.5%) indicated that their partners had a poor reaction towards their pregnancy while 22.5% of the respondents had a positive reaction toward their pregnancy.

Respondents indicated that their partners were ready to start a family because they had not source of income and others were still studying so they had no financial support to give to their partners.

When asked about their self-perceived timing of the first ANC visit, 56.5% of the participants said that they had made their first ANC visit late. Women who judged their first visit to be late attended ANC significantly later than women who perceived their first visit to be early. Women who said that they enrolled early in ANC did so in order to follow nurses’ advise and because one is supposed to do so (37.5%); to know health status and prevent health problems (31.5%); out of fear that the consequences of non-compliance would lead to not being treated or being scolded by the health facility staff (16%); or to treat a health problem (15%).

4.4 Health facility related factors and timing of antenatal care services

The third objectives sought to establish the relationship between health facility related factors and timing of antenatal care services. The following services were obtained;

Table 9: Shows whether medical workers are always available when one visits the hospital

From table 9 above, a greater number (90%) of respondents indicated that medical workers were always available when they visited the hospital and lower number (10%) of respondents said that indicated medical workers were not available when they visited the hospital.

Table 10: Shows response on what respondents did when they failed to see the medical workers when they visited the health facility

Results in table 10 above indicate that, most (75%) of the respondents said try another nearby health facility and the least (25%) said wait for the health worker.

Figure 1: Shows whether the health facility is equipped to carry out antenatal care services

From figure above, a greater number (90%) of respondents mentioned that the health facility is equipped to carry out antenatal care services and the least number (10%) said the health facility is not equipped to carry out antenatal care services.

Results indicate that, the highest number (66.7%) of respondents said that they went to another health facility and the lowest number (33.3) said that they went back home.

Figure 2: Shows distance of the health facility from the respondent’s home

Findings in figure above indicate that, majority (60%) of the respondents stayed below 1km from the health facility and none of the respondent stayed above 5km from the health facility.

Table 11: Shows response on whether the distance between the health facility and the community affect accessibility to antenatal care services

From table 11 above, most respondents 24/60 (80%) said that the distance between the health facility and the community does not affect their accessibility to antenatal care services and few respondents 6/60 (20%) indicated that the distance between the health facility and the community affects their accessibility.

Figure 3: Shows the attitude of health workers towards antenatal care services

From figure 3 above, majority (90%) of respondents said that health workers had a positive attitude towards antenatal care services and the minority (10%) of the respondents reported negative attitude.

Adolescent pregnant women have been reported to most likely either not attend ANC or to attend late and infrequently  due to lack of knowledge, lack of power to take decisions, lack of money, or cultural factors including local concepts of illness.

Due to the study design of using interviews, we could only obtain information on women’s timing of their first ANC visit and were unable to assess their overall utilization of ANC or even non-attendance.

Women were well aware about their timing of ANC attendance, suggesting that confusion about the recommended starting time was not a problem. Few women (22%) could name more than four ANC services, but contrary to expectations, neither knowledge about correct ANC timing nor good knowledge of ANC services were associated with early ANC attendance.

Knowledge about available services might thus not imply that women are aware of the services’ benefits. This matches with the surprisingly large number of women (53%) who indicated that they had attended ANC early because everyone does so, because of nurses’ advice or because they feared the consequences of non-compliance with nurses’ rules. In the exploratory study women indicated that their principal reason for attending the ANC clinic was to obtain an ANC card which was perceived as a necessary ‘entry ticket’ for services during delivery and illness rather than any conviction that ANC was good for their own or their child’s health.

Late recognition of pregnancy was found to be a strong predictor of delayed ANC attendance in this study. Similarly, late recognition of pregnancy and subsequent delay of ANC attendance has also been reported among South African women who received long acting hormonal contraceptives in the form of injections (Jewkes, 1998).

CHAPTER FIVE

CONCLUSION AND RECOMMENDATIONS

5.0 Introduction

This chapter presents the conclusion on the basis of the specific objectives set to achieve as analyzed in chapter four and recommendations.

5.1 Conclusion

Timely ANC attendance was influenced by: the design of ANC and its capacity to deal with uncertainty around pregnancy status and the degree to which care is orientated towards women’s health concerns; the provision of clear, unambiguous recommendations about the timing of ANC and messages that identify ANC as a service that deals with health concerns during early pregnancy; and the perceived normality of ANC initiation in early pregnancy. Furthermore, a perceived lack of flexibility regarding follow-up appointments increased the total cost of ANC, which can result in delayed ANC, particularly, amongst women with limited resources and who face high transport costs. Adolescents women were at particular risk of delaying ANC initiation and further research should focus on this group.

The majority of pregnant women delayed ANC attendance starting at an average of five months gestation. Adolescents had no greater delay in ANC initiation than adult pregnant women despite being more likely to be single. However, first ANC attendance at four months is recommended, so it is likely that some women missed important services offered during ANC such as preventive health measures, risk screening and health education.

5.2 Recommendations

These findings call for combined interventions at the community and health system level.

Promotion of early and frequent ANC utilization through community-based interventions – involving also male community volunteers – could potentially be scaled up at low cost and adapted to local needs.

Supporting income generating activities for women such as revolving funds might complement the approach in order to reduce delay due to lack of economic means needed for ANC or other maternal health services.

At the same time, the quality of antenatal care services needs to be improved to attract women to use medical care throughout pregnancy, birth and the postpartum period.

Outreach services should be offered on a regular basis in order to bring services closer to women living in very distant settlements

Informal rules created by health workers in order to force women to attend the ANC clinic should be replaced with informing women about the benefits of maternal health services, but also the use of pregnancy tests.

CONSENT FORM

Researcher: Namusu Carol

Topic: Pregnancy disclosure and timing of antenatal care among adolescent women in Kisozi Sub County

The purpose of this study is to assess the relationship between pregnancy disclosure and timing of antenatal care among adolescent women.

The information you give will be treated with maximum confidentiality and you are assured of privacy.

No names will be included in this research but only numbers. This research is for academic purposes only and no financial benefits will be given.

This research will take you 20 – 30 minutes to complete.

I have clearly explained the purpose and objectives of the study to the respondents and he/she has understood and consented to participate.

Signature: ……………………………… Date: …………………………………

(Researcher)

I have clearly understood the purpose and objectives of the study and voluntarily accept to participate in the study.

Signature: …………………………… Date: …………………………………

(Respondent)

INTERVIEW GUIDE

Pregnancy disclosure and timing of antenatal care among adolescent women

Section A: Background Characteristics of Respondents

1. What is your age?
2. Number of children
3. Marital status
4. History o abort/still birth
5. What is your education level

Section B: Household Characteristics and timing of antenatal care among adolescent mothers

1. Do you have any knowledge of antenatal care services?

Yes                              No

1. When did you notice that you were pregnant?

………………………………………………………………………………………………………………………………………………………………………………………………

1. Did you parents approve your decision?

………………………………………………………………………………………………………………………………………………………………………………………………

1. How many months were you when you first received ANC for this pregnancy?

………………………………………………………………………………………………………………………………………………………………………………………………

1. How much support, assistance were you provided?

………………………………………………………………………………………………………………………………………………………………………………………………

1. What were the parent’s reactions to your pregnancy?

………………………………………………………………………………………………………………………………………………………………………………………………

Section C: Social-economic factors and timing of antenatal care among adolescent mothers

12. Does your community encourage you to go for antenatal care services?
13. Yes
14. No

If yes how?

………………………………………………………………………………………

………………………………………………………………………………………

………………………………………………………………………………………

If no why?

………………………………………………………………………………………

………………………………………………………………………………………

………………………………………………………………………………………

13. Do you think your job affects your access to antenatal care services?
14. Yes
15. No

If yes how?

………………………………………………………………………………………

………………………………………………………………………………………

………………………………………………………………………………………

14. Do you think that one’s income affects ones access to antenatal care services?
15. Yes
16. No

15. If yes, how?

………………………………………………………………………………………

………………………………………………………………………………………

………………………………………………………………………………………

Section D: Health facility characteristics and timing of antenatal care among adolescent mothers

16. Are the medical workers always available when you visit the hospital for antenatal care services?
17. Yes
18. No

If no, what do you do?

………………………………………………………………………………………

17. Is the health facility equipped to carryout antenatal care services?
18. Yes
19. No

If no, how do you deal with it?

………………………………………………………………………………………

………………………………………………………………………………………

18. How far is your home to the health facility?
19. Below 1km
20. 2km
21. 3-5km
22. Above 5km
23. Does the distance to the health facility hinder you from accessing antenatal care services?
24. Yes
25. No
26. What is the attitude of health workers towards antenatal care services?
27. Positive
28. Negative

Thank you for your time

FOCUS GROUP DISCUSSION

Pregnancy disclosure and timing of antenatal care among adolescent women

1. Do you have any knowledge of antenatal care services
2. Perceived service quality
3. Traditional method used
4. Perceived health worker attitude
5. When did you notice that you were pregnant?
6. Did you want to get pregnant
7. Whom did you share your suspicion of a possible pregnancy?
8. What were their discussions?
9. Which difficult situations did you face either alone or with their partner?
10. How much support, assistance were you provided?
11. What were the parent’s reactions to your pregnancy?
12. Which kind of decisions did you make due to the pregnancy?
13. Did you parents approve your decision?
14. How did you announce to your parents?
15. How did they take the news
16. How did the family manage the consequences of pregnancy?
17. Did you see anyone for ANC for this pregnancy?
18. Whom did you see?
19. Where did you receive ANC of the pregnancy
20. How many months were you when you first received ANC for this pregnancy
21. How far is it from your home to this Health Facility?
22. What mode of transport have you used to this health facility?
23. State the number of times you visit a health facility for antenatal care services
24. Do you know why a pregnant woman should go for antenatal care early in pregnancy?
25. In your view, state the factors that influence women‘s access to antenatal care services in your area
26. In your view, state how women‘s access to antenatal care can be improved in your area

Thank you for your time

QUESTIONNAIRE GUIDE

Dear respondent,

I am Namusu Carol, a student of Kyambogo University undertaking a research on “pregnancy disclosure and timing of antenatal care among adolescent women in Kisozi Sub County.

The information you give will be treated with maximum confidentiality and you are assured of privacy. No names will be included in this research but only numbers. This research is for academic purposes only and no financial benefits will be given. This research will take you 20 – 30 minutes to complete.

Section A: Background information of respondents

1. Age
2. 18 – 25
3. 26 – 35
4. 36– 45
5. 46 and above
6. Sex
7. Male
8. Female
9. Religion
10. Catholic
11. Anglican
12. Muslim
13. Pentecostal
14. Seventh Day Adventist
15. Others (specify)………………………………………………….
16. Marital status?
17. Single
18. Married
19. Divorced
20. Widowed
21. Other (specify)…………………………………………………

5. Level of education?
6. Uneducated
7. Primary
8. Secondary
9. Tertiary/University

Section B: Household characteristics and timing of antenatal care among adolescent women

6. How old were you when you got first pregnant?

………………………………………………………………………………………

………………………………………………………………………………………

7. Were you married by your first pregnancy?

Yes                                          No

8. When did you realize that you were pregnant?

………………………………………………………………………………………

………………………………………………………………………………………

9. What was your reaction when you knew you were pregnant?

………………………………………………………………………………………

………………………………………………………………………………………

10. Did you disclose to anyone?

Yes                                          No

If yes, who?

………………………………………………………………………………………

………………………………………………………………………………………

If no, why?

………………………………………………………………………………………

………………………………………………………………………………………

11. When did your parents know that you were pregnant?

………………………………………………………………………………………

………………………………………………………………………………………

12. How did your parents know that you were pregnant?

………………………………………………………………………………………

………………………………………………………………………………………

13. How did they react to your pregnancy?

………………………………………………………………………………………

………………………………………………………………………………………

14. Did you receive any support from your parents?

Yes                              No

If yes, what support?

………………………………………………………………………………………

………………………………………………………………………………………

If no, why?

………………………………………………………………………………………

………………………………………………………………………………………

15. What was the attitude of your family members towards your pregnancy?

………………………………………………………………………………………

………………………………………………………………………………………

Section C: Socio-economic factors and timing of antenatal care services

16. What was the attitude of the community members towards your first pregnancy?

………………………………………………………………………………………

………………………………………………………………………………………

Give reasons for your answer

………………………………………………………………………………………

………………………………………………………………………………………

17. Did your household have any source of income by your first pregnancy?

Yes                              No

If yes, mention sources

………………………………………………………………………………………

18. What was the reaction of your partners when he knew about your pregnancy?

Positive                                   Negative

If positive, which support did he give to you?

………………………………………………………………………………………

………………………………………………………………………………………

19. Did you get advice to attend antenatal care?

Yes                              No

If yes, from who?

………………………………………………………………………………………

20. Were you accompanied to the clinic?

Yes                              No

If yes, by who?

………………………………………………………………………………………

………………………………………………………………………………………

Section D: Health facility related characteristics and timing of antenatal care

21. Are you aware of any antenatal care services provided in your area/

Yes                              No

If yes, mention them?

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22. Where are antenatal care services provided in this area?

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24. Where did you go for your first antenatal care services and why?

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25. Did you pay for antenatal care services?

Yes                              No

If yes, how much

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26. What service did you receive your first time?

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27. What is the distance between your home/place and the nearest health facility (kms0?

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28. Does the health facility have adolescent services?

Yes                              No

If yes, mention them

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29. What is the attitude of the health workers providing antenatal care services?

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Thank you for your time