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Research Article
Rec. Date: Mar 09, 2020
Acc. Date: Aug 16, 2020
Pub. Date: Aug 23, 2020

Patient and Obstetric Factors Influencing First Antenatal Care Visit Among Pregnant Women in Embakasi North Sub-County Health Centres, Kenya
Moses Wamwea Muraguri 1, Esther Ndonga1, Joseph Nyamai Juma1 and Oliver Waithaka Mbuthia2*
1P. O. Box 342 � 001000, Department of Epidemiology and Biostatistics, School of Public Health, Mount Kenya University
2Kenya AIDs Vaccines Initiative- Institute of Clinical Research, College of Health Sciences, University of Nairobi, Kenya*Corresponding author: Moses Wamwea Muraguri, Department of Epidemiology and Biostatistics, Mount Kenya University, Kenya, Tel: 254725815120; E-mail: moseswm2001@yahoo.com
Abstract
Background: Globally, maternal mortality ratio has reduced by 45% but the mortality rate in Sub-Saharan Africa remains elusive. Antenatal care (ANC) is one of the most effective interventions in reducing maternal mortalities. In Nairobi County, ANC coverage stands at 33% with low ANC visits contrary to the WHO recommendation of four ANC visits. The study aimed to determine factors influencing first ANC visit among pregnant women. Specifically, patient-related factors and obstetric related factors on access to first ANC visit among pregnant women in Embakasi North Sub-County were evaluated.
 Methods: In the year 2018, 368 pregnant women attending ANC in Kariobangi North health centre, Dandora 1 and Dandora 2 health centres were randomly selected. Factors influencing first ANC visit among pregnant women were determined. The study used a cross-sectional study design. A standardized questionnaire was used to collect information from the study participants and Focus Group Discussion (FGDs) formed. Statistical analyses were performed using SPSS and NVIVO software.
Result: The 368 participants responded 100% to the structured questionnaires. Majority of the study participants were aged between 35-39 years, followed by 34-34 years, then 25-25 years while the least was aged 40-44 years. Patient and obstetric factors were statistically significant in explaining the change in the first ANC visit (p � 0.05). A significant positive influence on the first ANC visit was found on patient (�1) and obstetric (�3) related factors with regression coefficient values of; �0=3.312, �1=0.752, �2=0.545, and �3=0.487. Among patient-related factors, Social Media Avenue contributed the most in providing ANC information (68%) while print media was the least at 42%. When asked reasons why pregnant women fail to seek ANC, financial constraints (78%); fear of disclosing pregnancy (56%); culture (40%); religion (38%); unplanned pregnancy (36%); fear of testing for HIV status (34%); limited Knowledge about ANC (33%); poor family and social support (44%); peer Influence (40%) and low decision-making authority (36%) were all statistically significant in accessing ANC services (p < 0.05). Slightly over half of the mothers (52%) interviewed indicated that they had never had complications with their previous pregnancy and equally 52% had given birth 2-4 times, 34% had been pregnant once while 19% had been pregnant for > 5 times. Conclusion: Patient and obstetric related factors influenced first ANC seeking behaviour among pregnant women in Embakasi North health centres. Patient-related attributes contributed more than the obstetric factors in access to the first ANC visit.
Conclusion and recommendation: This study showed that less than half of the participants had achieved continuum of care and education level, both respondents and husband occupation, parity, autonomy to health care decision, exposure to the mass media, and wontedness of pregnancy were associated with completion of maternity continuum of care, therefore working on enhancing of the capacity of women autonomy in health care decision making and preventing unintended pregnancy helps to improve completion of maternity continuum of care.Keywords: Antenatal clinic, patient related factors, obstetric related factors, healthcare, pregnant women, first ANC-visit.1. Introduction
Maternal health is the care provided to the pregnant woman and the baby by a skilled healthcare professional while adhering to the best health conditions ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"abstract":"Standards INTEGRATED MANAGEMENT OF PREGNANCY AND CHILDBIRTH (IMPAC) Requirements A national policy and locally adapted guidelines on iron and folate supplementation are in place and are correctly implemented. Health care providers of maternal and neonatal care are competent in: the importance of iron supplementation during pregnancy and the postpartum period; the correct dosage and duration of supplementation for the prevention and treatment of anaemia; anaemia detection in pregnant women; and when to refer women for further diagnosis and treatment. Iron and folate supplements are available at all levels of care. There is a functioning referral system that ensures timely referral of pregnant women for monitoring and treatment, especially in the case of severe anaemia. A mechanism is in place for recording cases and care of anaemia. Health education activities are carried out to increase awareness among women and in the community of the importance of iron and folate supplementation in pregnancy. Iron and folate supplementation All pregnant women in areas of high prevalence of malnutrition should routinely receive iron and folate supplements, together with appropriate dietary advice, to prevent anaemia. Where the prevalence of anaemia in pregnant women is high (40% or more), supplementation should continue for three months in the postpartum period. The standard �1�������1���1�����1����1��������1�������1��1 ����1������1���������1���1 in the postpartum period in order to improve maternal and perinatal health. Aim Applying the standard �����1����������1��1����������1�������1�4��������1�4������1 ����1������1���������1���1 postpartum visits must: Give all pregnant women a standard dose of 60 mg iron + 400 �g folic acid daily for 6 months or, if 6 months of treatment cannot be achieved during the pregnancy, either continue supplementation during the postpartum period or increase the dosage to 120 mg iron during pregnancy. Where the prevalence of anaemia in pregnancy is over 40%, advise the woman to continue the prophylaxis for three months in the postpartum period.","author":[{"dropping-particle":"","family":"World Health Organization","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"WHO","id":"ITEM-1","issued":{"date-parts":[["2016"]]},"title":"WHO | Integrated Management of Pregnancy and Childbirth (IMPAC)","type":"webpage"},"uris":["http://www.mendeley.com/documents/?uuid=0bc02f27-2c3b-40bd-a4f0-dd053de2ae35"]}],"mendeley":{"formattedCitation":"[1]","plainTextFormattedCitation":"[1]","previouslyFormattedCitation":"(World Health Organization, 2016)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[1]. These care involves antenatal care (ANC) as a comprehensive package tool for preventive, diagnostic and health-care functions to maternal health aimed to minimize maternal deaths both directly and indirectly ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"ISSN":"0269-5022","PMID":"11243499","abstract":"This is an overview of evidence of the effectiveness of antenatal care in relation to maternal mortality and serious morbidity, focused in particular on developing countries. It concentrates on the major causes of maternal mortality, and traces their antecedent morbidities and risk factors in pregnancy. It also includes interventions aimed at preventing, detecting or treating any stage along this pathway during pregnancy. This is an updated and expanded version of a review first published by the World Health Organization (WHO) in 1992. The scientific evidence from randomised controlled trials and other types of intervention or observational study on the effectiveness of these interventions is reviewed critically. The sources and quality of available data, and possible biases in their collection or interpretation are considered. As in other areas of maternal health, good-quality evidence is scarce and, just as in many aspects of health care generally, there are interventions in current practice that have not been subjected to rigorous evaluation. A table of antenatal interventions of proven effectiveness in conditions that can lead to maternal mortality or serious morbidity is presented. Interventions for which there is some promising evidence, short of proof, of effectiveness are explored, and the outstanding questions formulated. These are presented in a series of tables with suggestions about the types of study needed to answer them.","author":[{"dropping-particle":"","family":"Carroli","given":"G","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rooney","given":"C","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Villar","given":"J","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Paediatric and perinatal epidemiology","id":"ITEM-1","issued":{"date-parts":[["2001"]]},"title":"How effective is antenatal care in preventing maternal mortality and serious morbidity? An overview of the evidence.","type":"article-journal"},"uris":["http://www.mendeley.com/documents/?uuid=9d11ecd4-3310-4b9a-a485-2af92ef53813","http://www.mendeley.com/documents/?uuid=18c49964-eed4-4bcb-b5cb-4b7c348cabef"]}],"mendeley":{"formattedCitation":"[2]","plainTextFormattedCitation":"[2]","previouslyFormattedCitation":"(Carroli, Rooney, & Villar, 2001)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[2]. Goal 3 of the Sustainable Development Goals (SDGs) aims to reduce maternal health deaths by 70 per 100,000 birth lives by the year 2030 and this can only be realized through global, national and community-level initiative promoting ANC health delivery through universal healthcare. Death during pregnancy and maternal related complications are common with high staggering statistics of over 300,000 maternal deaths with nearly 100% of these deaths occurring in low-income settings ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/S0140-6736(15)00838-7","ISSN":"1474547X","abstract":"Background Millennium Development Goal 5 calls for a 75% reduction in the maternal mortality ratio (MMR) between 1990 and 2015. We estimated levels and trends in maternal mortality for 183 countries to assess progress made. Based on MMR estimates for 2015, we constructed projections to show the requirements for the Sustainable Development Goal (SDG) of less than 70 maternal deaths per 100 000 livebirths globally by 2030. Methods We updated the UN Maternal Mortality Estimation Inter-Agency Group (MMEIG) database with more than 200 additional records (vital statistics from civil registration systems, surveys, studies, or reports). We generated estimates of maternal mortality and related indicators with 80% uncertainty intervals (UIs) using a Bayesian model. The model combines the rate of change implied by a multilevel regression model with a time-series model to capture data-driven changes in country-specific MMRs, and includes a data model to adjust for systematic and random errors associated with different data sources. Results We had data for 171 of 183 countries. The global MMR fell from 385 deaths per 100 000 livebirths (80% UI 359-427) in 1990, to 216 (207-249) in 2015, corresponding to a relative decline of 43�9% (34�0-48�7), with 303 000 (291 000-349 000) maternal deaths worldwide in 2015. Regional progress in reducing the MMR since 1990 ranged from an annual rate of reduction of 1�8% (0�0-3�1) in the Caribbean to 5�0% (4�0-6�0) in eastern Asia. Regional MMRs for 2015 ranged from 12 deaths per 100 000 livebirths (11-14) for high-income regions to 546 (511-652) for sub-Saharan Africa. Accelerated progress will be needed to achieve the SDG goal; countries will need to reduce their MMRs at an annual rate of reduction of at least 7�5%. Interpretation Despite global progress in reducing maternal mortality, immediate action is needed to meet the ambitious SDG 2030 target, and ultimately eliminate preventable maternal mortality. Although the rates of reduction that are needed to achieve country-specific SDG targets are ambitious for most high mortality countries, countries that made a concerted effort to reduce maternal mortality between 2000 and 2010 provide inspiration and guidance on how to accomplish the acceleration necessary to substantially reduce preventable maternal deaths. Funding National University of Singapore, National Institute of Child Health and Human Development, USAID, and the UNDP/UNFPA/UNICEF/WHO/World Bank Special Programme of Resea�","author":[{"dropping-particle":"","family":"Alkema","given":"Leontine","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chou","given":"Doris","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hogan","given":"Daniel","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Zhang","given":"Sanqian","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Moller","given":"Ann Beth","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gemmill","given":"Alison","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Fat","given":"Doris Ma","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Boerma","given":"Ties","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Temmerman","given":"Marleen","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mathers","given":"Colin","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Say","given":"Lale","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"The Lancet","id":"ITEM-1","issued":{"date-parts":[["2016"]]},"title":"Global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: A systematic analysis by the un Maternal Mortality Estimation Inter-Agency Group","type":"article-journal"},"uris":["http://www.mendeley.com/documents/?uuid=20eee741-f5d0-435c-8eea-af4ab3c6f949","http://www.mendeley.com/documents/?uuid=0295c9fc-f22b-445d-8123-ebcc5bdcb6a6"]}],"mendeley":{"formattedCitation":"[4]","plainTextFormattedCitation":"[4]","previouslyFormattedCitation":"(Alkema et al., 2016)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[3, 4]. It is estimated that 830 pregnant women died daily in 2015 due to pregnancy complications and childbirth and among them, over 99% lived in low-resourced setting ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"URL":"https://www.who.int/gho/maternal_health/mortality/maternal_mortality_text/en/","author":[{"dropping-particle":"","family":"WHO","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2017"]]},"title":"WHO | Global Health Observatory (GHO) data: Maternal mortality","type":"webpage"},"uris":["http://www.mendeley.com/documents/?uuid=13c723fb-35fb-41ba-ba0d-83a561e02ba8"]}],"mendeley":{"formattedCitation":"[5]","plainTextFormattedCitation":"[5]","previouslyFormattedCitation":"(WHO, 2017a)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[5]. In Kenya it is estimated that 8000 maternal deaths occur annually, much higher than maternal death reports in Uganda (5700), Rwanda (1100), Zimbabwe (2400) and South Africa (1500) ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"URL":"https://www.who.int/gho/maternal_health/mortality/maternal_mortality_text/en/","author":[{"dropping-particle":"","family":"WHO","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2017"]]},"title":"WHO | Global Health Observatory (GHO) data: Maternal mortality","type":"webpage"},"uris":["http://www.mendeley.com/documents/?uuid=13c723fb-35fb-41ba-ba0d-83a561e02ba8"]}],"mendeley":{"formattedCitation":"[5]","plainTextFormattedCitation":"[5]","previouslyFormattedCitation":"(WHO, 2017a)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[5]. Women living in low-resourced areas have more than 33 folds higher at risk of dying from a maternal-related cause during her lifetime unlike women living in high-resourced areas ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"URL":"https://www.who.int/gho/maternal_health/mortality/maternal_mortality_text/en/","author":[{"dropping-particle":"","family":"WHO","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2017"]]},"title":"WHO | Global Health Observatory (GHO) data: Maternal mortality","type":"webpage"},"uris":["http://www.mendeley.com/documents/?uuid=13c723fb-35fb-41ba-ba0d-83a561e02ba8"]}],"mendeley":{"formattedCitation":"[5]","plainTextFormattedCitation":"[5]","previouslyFormattedCitation":"(WHO, 2017a)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[5]. Risks, complications and deaths are higher among adolescent girls in third world countries  whereby it is estimated that 1 in 180 pregnant adolescents aged 15 years will die in such countries compared to 1 in 4900 in developed countries ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"URL":"https://www.who.int/news-room/fact-sheets/detail/maternal-mortality","author":[{"dropping-particle":"","family":"WHO","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Facts sheet","id":"ITEM-1","issued":{"date-parts":[["2018"]]},"title":"Maternal mortality","type":"webpage"},"uris":["http://www.mendeley.com/documents/?uuid=9caebc6a-92e6-4f3f-9645-91f6d59c72a0"]}],"mendeley":{"formattedCitation":"[7]","plainTextFormattedCitation":"[7]","previouslyFormattedCitation":"(WHO, 2018)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/S0140-6736(09)60741-8","ISSN":"01406736","abstract":"Background: Pronounced changes in patterns of health take place in adolescence and young adulthood, but the effects on mortality patterns worldwide have not been reported. We analysed worldwide rates and patterns of mortality between early adolescence and young adulthood. Methods: We obtained data from the 2004 Global Burden of Disease Study, and used all-cause mortality estimates developed for the 2006 World Health Report, with adjustments for revisions in death from HIV/AIDS and from war and natural disasters. Data for cause of death were derived from national vital registration when available; for other countries we used sample registration data, verbal autopsy, and disease surveillance data to model causes of death. Worldwide rates and patterns of mortality were investigated by WHO region, income status, and cause in age-groups of 10-14 years, 15-19 years, and 20-24 years. Findings: 2�6 million deaths occurred in people aged 10-24 years in 2004. 2�56 million (97%) of these deaths were in low-income and middle-income countries, and almost two thirds (1�67 million) were in sub-Saharan Africa and southeast Asia. Pronounced rises in mortality rates were recorded from early adolescence (10-14 years) to young adulthood (20-24 years), but reasons varied by region and sex. Maternal conditions were a leading cause of female deaths at 15%. HIV/AIDS and tuberculosis contributed to 11% of deaths. Traffic accidents were the largest cause and accounted for 14% of male and 5% of female deaths. Other prominent causes included violence (12% of male deaths) and suicide (6% of all deaths). Interpretation: Present global priorities for adolescent health policy, which focus on HIV/AIDS and maternal mortality, are an important but insufficient response to prevent mortality in an age-group in which more than two in five deaths are due to intentional and unintentional injuries. Funding: WHO and National Health and Medical Research Council. � 2009 Elsevier Ltd. All rights reserved.","author":[{"dropping-particle":"","family":"Patton","given":"George C.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Coffey","given":"Carolyn","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Sawyer","given":"Susan M.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Viner","given":"Russell M.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Haller","given":"Dagmar M.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bose","given":"Krishna","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Vos","given":"Theo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ferguson","given":"Jane","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mathers","given":"Colin D.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"The Lancet","id":"ITEM-1","issued":{"date-parts":[["2009"]]},"title":"Global patterns of mortality in young people: a systematic analysis of population health data","type":"article-journal"},"uris":["http://www.mendeley.com/documents/?uuid=568438c3-4a9e-49ab-a28c-f7d855e0be60","http://www.mendeley.com/documents/?uuid=12563664-7054-4421-8aff-ac061496bee9"]}],"mendeley":{"formattedCitation":"[6]","plainTextFormattedCitation":"[6]","previouslyFormattedCitation":"(Patton et al., 2009)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}6,7]. Antenatal care contact is vital but the low intake among women of reproductive age in Africa is worrying. Statistics show that at least 69% of pregnant women achieve only one ANC visit against the WHO recommended four while globally only 64% of the women had attended all the four visits between the year 2007-2014 ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"abstract":"Standards INTEGRATED MANAGEMENT OF PREGNANCY AND CHILDBIRTH (IMPAC) Requirements A national policy and locally adapted guidelines on iron and folate supplementation are in place and are correctly implemented. Health care providers of maternal and neonatal care are competent in: the importance of iron supplementation during pregnancy and the postpartum period; the correct dosage and duration of supplementation for the prevention and treatment of anaemia; anaemia detection in pregnant women; and when to refer women for further diagnosis and treatment. Iron and folate supplements are available at all levels of care. There is a functioning referral system that ensures timely referral of pregnant women for monitoring and treatment, especially in the case of severe anaemia. A mechanism is in place for recording cases and care of anaemia. Health education activities are carried out to increase awareness among women and in the community of the importance of iron and folate supplementation in pregnancy. Iron and folate supplementation All pregnant women in areas of high prevalence of malnutrition should routinely receive iron and folate supplements, together with appropriate dietary advice, to prevent anaemia. Where the prevalence of anaemia in pregnant women is high (40% or more), supplementation should continue for three months in the postpartum period. The standard �1�������1���1�����1����1��������1�������1��1 ����1������1���������1���1 in the postpartum period in order to improve maternal and perinatal health. Aim Applying the standard �����1����������1��1����������1�������1�4��������1�4������1 ����1������1���������1���1 postpartum visits must: Give all pregnant women a standard dose of 60 mg iron + 400 �g folic acid daily for 6 months or, if 6 months of treatment cannot be achieved during the pregnancy, either continue supplementation during the postpartum period or increase the dosage to 120 mg iron during pregnancy. Where the prevalence of anaemia in pregnancy is over 40%, advise the woman to continue the prophylaxis for three months in the postpartum period.","author":[{"dropping-particle":"","family":"World Health Organization","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"WHO","id":"ITEM-1","issued":{"date-parts":[["2016"]]},"title":"WHO | Integrated Management of Pregnancy and Childbirth (IMPAC)","type":"webpage"},"uris":["http://www.mendeley.com/documents/?uuid=0bc02f27-2c3b-40bd-a4f0-dd053de2ae35"]}],"mendeley":{"formattedCitation":"[1]","plainTextFormattedCitation":"[1]","previouslyFormattedCitation":"(World Health Organization, 2016)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[1]. Up to 8 visits or more may be recommended during high-risk pregnancies and other pregnancy complications but empirical evidence shows that four visits are enough for uncomplicated pregnancies. Screening for maternal related diseases during ANC visits is paramount while malaria and HIV are associated with over 25% maternal deaths and near-misses ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/S0140-6736(13)60686-8","ISSN":"1474547X","abstract":"Background: We report the main findings of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), which aimed to assess the burden of complications related to pregnancy, the coverage of key maternal health interventions, and use of the maternal severity index (MSI) in a global network of health facilities. Methods: In our cross-sectional study, we included women attending health facilities in Africa, Asia, Latin America, and the Middle East that dealt with at least 1000 childbirths per year and had the capacity to provide caesarean section. We obtained data from analysis of hospital records for all women giving birth and all women who had a severe maternal outcome (SMO; ie, maternal death or maternal near miss). We regarded coverage of key maternal health interventions as the proportion of the target population who received an indicated intervention (eg, the proportion of women with eclampsia who received magnesium sulphate). We used areas under the receiver operator characteristic curves (AUROC) with 95% CI to externally validate a previously reported MSI as an indicator of severity. We assessed the overall performance of care (ie, the ability to produce a positive effect on health outcomes) through standardised mortality ratios. Results: From May 1, 2010, to Dec 31, 2011, we included 314 623 women attending 357 health facilities in 29 countries (2538 had a maternal near miss and 486 maternal deaths occurred). The mean period of data collection in each health facility was 89 days (SD 21). 23 015 (7�3%) women had potentially life-threatening disorders and 3024 (1�0%) developed an SMO. 808 (26�7%) women with an SMO had post-partum haemorrhage and 784 (25�9%) had pre-eclampsia or eclampsia. Cardiovascular, respiratory, and coagulation dysfunctions were the most frequent organ dysfunctions in women who had an SMO. Reported mortality in countries with a high or very high maternal mortality ratio was two-to-three-times higher than that expected for the assessed severity despite a high coverage of essential interventions. The MSI had good accuracy for maternal death prediction in women with markers of organ dysfunction (AUROC 0�826 [95% CI 0�802-0�851]). Interpretation: High coverage of essential interventions did not imply reduced maternal mortality in the health-care facilities we studied. If substantial reductions in maternal mortality are to be achieved, universal coverage of life-saving interventions need to be matched with comprehensive em�","author":[{"dropping-particle":"","family":"Souza","given":"Jo�o Paulo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"G�lmezoglu","given":"Ahmet Metin","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Vogel","given":"Joshua","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Carroli","given":"Guillermo","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lumbiganon","given":"Pisake","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Qureshi","given":"Zahida","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Costa","given":"Maria 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Lancet","id":"ITEM-1","issued":{"date-parts":[["2013"]]},"title":"Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): A cross-sectional study","type":"article-journal"},"uris":["http://www.mendeley.com/documents/?uuid=a9a15aff-2f69-4dd7-b8f1-d7b2f97f9c0c","http://www.mendeley.com/documents/?uuid=af8a92ac-24e9-4465-af86-947e8fc668d4"]}],"mendeley":{"formattedCitation":"[9]","plainTextFormattedCitation":"[9]","previouslyFormattedCitation":"(Souza et al., 2013)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[1, 8, 9]. Direct obstetric causes have been reported to be a leading cause of maternal deaths accounting for 73% mortalities while indirect causes account for 27% ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/S2214-109X(14)70227-X","ISSN":"2214-109X","PMID":"25103301","abstract":"Background: Data for the causes of maternal deaths are needed to inform policies to improve maternal health. We developed and analysed global, regional, and subregional estimates of the causes of maternal death during 2003-09, with a novel method, updating the previous WHO systematic review. Methods: We searched specialised and general bibliographic databases for articles published between between Jan 1, 2003, and Dec 31, 2012, for research data, with no language restrictions, and the WHO mortality database for vital registration data. On the basis of prespecified inclusion criteria, we analysed causes of maternal death from datasets. We aggregated country level estimates to report estimates of causes of death by Millennium Development Goal regions and worldwide, for main and subcauses of death categories with a Bayesian hierarchical model. Findings: We identified 23 eligible studies (published 2003-12). We included 417 datasets from 115 countries comprising 60 799 deaths in the analysis. About 73% (1 771 000 of 2 443 000) of all maternal deaths between 2003 and 2009 were due to direct obstetric causes and deaths due to indirect causes accounted for 27�5% (672 000, 95% UI 19�7-37�5) of all deaths. Haemorrhage accounted for 27�1% (661 000, 19�9-36�2), hypertensive disorders 14�0% (343 000, 11�1-17�4), and sepsis 10�7% (261 000, 5�9-18�6) of maternal deaths. The rest of deaths were due to abortion (7�9% [193 000], 4�7-13�2), embolism (3�2% [78 000], 1�8-5�5), and all other direct causes of death (9�6% [235 000], 6�5-14�3). Regional estimates varied substantially. Interpretation: Between 2003 and 2009, haemorrhage, hypertensive disorders, and sepsis were responsible for more than half of maternal deaths worldwide. More than a quarter of deaths were attributable to indirect causes. These analyses should inform the prioritisation of health policies, programmes, and funding to reduce maternal deaths at regional and global levels. Further efforts are needed to improve the availability and quality of data related to maternal mortality. Funding: USAID, the US Fund for UNICEF through a grant from the Bill & Melinda Gates Foundation to CHERG, and The UNDP/UNFPA/UNICEF/WHO/The World Bank Special Programme of Research, Development, and Research Training in Human Reproduction (HRP), Department of Reproductive Health and Research. � 2014 World Health Organization.","author":[{"dropping-particle":"","family":"Say","given":"Lale","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Chou","given":"Doris","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Gemmill","given":"Alison","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tun�alp","given":"�zge","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Moller","given":"Ann-Beth","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Daniels","given":"Jane","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"G�lmezoglu","given":"A Metin","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Temmerman","given":"Marleen","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Alkema","given":"Leontine","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"The Lancet. Global health","id":"ITEM-1","issued":{"date-parts":[["2014"]]},"title":"Global causes of maternal death: a WHO systematic analysis.","type":"article-journal"},"uris":["http://www.mendeley.com/documents/?uuid=2a7d6680-a5c1-4199-8fc7-cdc578414d30","http://www.mendeley.com/documents/?uuid=c43a8d51-36a6-4690-a9fd-7fb916bbf9a1"]}],"mendeley":{"formattedCitation":"[10]","plainTextFormattedCitation":"[10]","previouslyFormattedCitation":"(Say et al., 2014)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[10]. Other related complications such as nutrition problems and a myriad of many other complications  may go unnoticed if all ANC visits are not adhered. Practical models and policies that may be incorporated to region-specific may be a remedy to increase ANC up take among diverse communities in Sub-Saharan Africa where culture, religion, beliefs and communication barriers are key components to ANC underutilization ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"(WHO/MCA/17.10)","author":[{"dropping-particle":"","family":"WHO","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2017"]]},"publisher-place":"Geneva","title":"WHO recommendations on maternal health. Guidelines approved by the WHO Guidelines Review Committee.","type":"report"},"uris":["http://www.mendeley.com/documents/?uuid=749b97a2-68ac-4af4-80b3-66df49e00046"]}],"mendeley":{"formattedCitation":"[11]","plainTextFormattedCitation":"[11]","previouslyFormattedCitation":"(WHO, 2017b)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[11].
2. Methods 
2.1 Study site
The study was carried out in Embakasi North Sub-County in Nairobi County, Kenya, Three health centres within Embakasi North Sub-County were selected (Kariobangi North health centre, Dandora 1 and Dandora 2 health centres). The health centres were selected because Embakasi North Sub-County had the lowest ANC visits of pregnant women when compared amongst the other five Sub-Countries making Nairobi County, Kenya. 

2.2 Research Design
A cross sectional study design approach was used. The study design enabled the researchers to be more informed on a situation at a given period of time.
2.3 Target Population
The target population included all the pregnant women visiting health centres in Embakasi North Sub County for the first time before they saw a clinician. Written informed consent was obtained from all the study participants.

2.4 Inclusion Criteria
The study included all pregnant mothers attending FIRST antenatal clinic in Kariobangi North health centre, Dandora 1 and Dandora 2 health centres in Embakasi North Sub County.

2.5 Sampling Design
Probability sampling technique was used where everyone in the target population had equal chance of participating. The target population was spread in three administrative wards and sampling frame was used to determine the sample size in each of the wards based on target population. Three facilities were used, one in each ward and in each facility a systematic random sampling was used where sample size was worked out and sampling interval determined. The nth number provided the number that was subjected to the interviews. Stratified random sampling was also used whereby stratification of the population was considered since pregnant women could be stratified into young and those who were attending the ANC visits for the 1st time without previous pregnancy while the other strata consisted of those women who had another pregnancy before coming for the 1st time during the current pregnancy. From each strata, systematic random sampling was used to achieve the desired sample size.

2.6 Target Populationc
The target population included all the pregnant women visiting health centres in Embakasi North Sub County for the first time before they saw a clinician. Written informed consent was obtained from all the study participants.

2.7 Inclusion Criteria
The study included all pregnant mothers attending FIRST antenatal clinic in Kariobangi North health centre, Dandora 1 and Dandora 2 health centres in Embakasi North Sub County.
2.8 Sampling Design 
Probability sampling technique was used where everyone in the target population had equal chance of participating. The target population was spread in three administrative wards and sampling frame was used to determine the sample size in each of the wards based on target population. Three facilities were used, one in each ward and in each facility a systematic random sampling was used where sample size was worked out and sampling interval determined. The nth number provided the number that was subjected to the interviews. Stratified random sampling was also used whereby stratification of the population was considered since pregnant women could be stratified into young and those who were attending the ANC visits for the 1st time without previous pregnancy while the other strata consisted of those women who had another pregnancy before coming for the 1st time during the current pregnancy. From each strata, systematic random sampling was used to achieve the desired sample size.

2.9 Sample size determination
From the target population of 8,688 pregnant women seeking ANC services the sample size determination formula for estimating the population proportion with specified relative precision was applied while setting the � at 0.05, and a detection rate of 50% among pregnant women of reproductive age in Embakasi North Health Centres, a total of 368 pregnant women were recruited to achieve 0.95 power. From the sample size of 368 pregnant women, stratified random sampling technique was used to determine sample size from each of the three health centres proportionate to the target population ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Department","given":"Health Records","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2017"]]},"publisher-place":"Nairobi","title":"Embakasi North Sub County, ANC Statistics, 2017","type":"report"},"uris":["http://www.mendeley.com/documents/?uuid=9c4ec636-39fd-4287-9d8e-af100c904279"]}],"mendeley":{"formattedCitation":"[14]","plainTextFormattedCitation":"[14]","previouslyFormattedCitation":"(Department, 2017)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[12, 13, 14] (Table 1).

2.10 Data Collection Instruments
The procedure that was used in data collection included structured questionnaires to collect quantitative data. Quantitative data was collected by conducting focused group discussion (FGDs).  

2.11 Validity: 
Pre-testing was conducted in the three hospitals prior to validate the research methods and tools.

2.12 Data collection
Questionnaires were administered to the pregnant women upon consent at the ANC department before interacting with the clinicians. The questionnaires consisted of both open and closed-ended questions specific to the study objectives. With the help of research assistants, Focus Group Discussion forums were formed at a different section within the heath facility. Each FGD composed of 5-8 participants. A total of 10 FDGs were formed within the study period each lasting between 1 hour to 11/2 hours. A schedule designed to probe further and develop deeper insight on the study objectives was used during all FDG forums. Voice recording and note taking were the main methods used to collect the information from the study participants. 

2.13 Data Analysis and Presentation
The data collected was coded and entered in the computer for analysis using the Statistical Package for Social Science (SPSS). Data analysis procedures that was used included both qualitative and quantitative methods. Qualitative data was analyzed using content analysis by grouping the main themes of the respondents and use of N-vivo software. Quantitative data was analyzed using SPSS whereby descriptive statistics such as frequency, percentages, median and data presentation using, tables, pie charts and bar charts were used. Inferential statistics included regression analysis to perform the t, f-tests and assisted in establishing the effect of the factors on access to ANC visit among pregnant women.

2.14 Ethical consideration
Ethical approval was granted by Mount Kenya University Ethics and Research Review Committee (MKU-ERC) MKU/ERC/0913 Research permit was given by the National Commission for Science Technology and Innovation (NACOSTI) NACOSTI/P/18/03459/25530. Permission was also given by the Nairobi County Commissioner, Nairobi County director of Health and Nairobi County director of Education. Further permit to collect data was given by the medical superintendents of the respective health centres within Embakasi North Sub-County. The study was performed in accordance with the Helsinki Declaration ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1001/jama.2013.281053","ISSN":"1538-3598","PMID":"24141714","abstract":"TheWorld Medical Association(WMA)has developed the Dec- laration of Helsinki as a statementof ethical principles formedi- cal research involving human subjects, including research on identifiable human material and data. The Declaration is intended to be read as a whole and each of its constituent paragraphs should be applied with consider- ation of all other relevant paragraphs.","author":[{"dropping-particle":"","family":"World Medical Association","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Journal of American Medical Association","id":"ITEM-1","issue":"20","issued":{"date-parts":[["2013"]]},"page":"2191-2194","title":"World Medical Association Declaration of Helsinki. Ethical principles for medical research involving human subjects","type":"article-journal","volume":"310"},"uris":["http://www.mendeley.com/documents/?uuid=ba53a0f6-f533-4864-b9a3-9cff6dd4e029"]}],"mendeley":{"formattedCitation":"[15]","plainTextFormattedCitation":"[15]","previouslyFormattedCitation":"(World Medical Association, 2013)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[15].



3. Result

3.1 Demographic factors and access to first ANC services	
The age distribution of the pregnant mothers interviewed at the time of ANC visit. The study participants were aged 35-39 years (25%); 30-34 years (23%); 25-29 years (17%); 20-24 years (13%); 15-19 years (12%); and 40-44 years (10%) respectively. Majority of the study participants had graduated from O-levels (42%); (33%) tertiary education and (25%) had some form of A-level education. Married women (44%) were the dominant among the study participants followed by those who were cohabiting (24%), single women (15%); separated (12%), and lastly women who had divorced (5%). Casual laborers accounted for the majority economic income source (26%) followed closely by women who were self-employed (26%) while 12% of all study participants were unemployed. On overall, the study showed a significant relationship between socio-demographic attributes with first ANC service (p < 0.05) (Table 2).

3.2 Sources of information about Antenatal Care Services 

The sources of information through which mothers learnt about ANC services. The study participants had diverse communication channels that they used to learn about ANC services which included social media platforms (68%), mass media �TV and Radio (62%), friends & relatives (45%); and by reading on print media (42%) (Table 3).

3.3 Patient related factors influencing access to ANC services 

The main patient related factors identified by mothers which influenced them in accessing the first ANC services included; financial constraints (78%); fear of disclosing pregnancy (56%); culture (40%); religion (38%); unplanned pregnancy (36%); fear of testing for HIV status (34%); limited knowledge about ANC (33%); poor family and social support (44%); peer Influence (40%); and low decision-making authority (36%). The study further determined that there is a significant relationship between patient related factors and access to first ANC services in Embakasi North Sub County (�2 =14.294; df = 6; p < 0.032) (Table 4).

3.4 Obstetric related factors influencing access to ANC services

The study participants were asked on obstetric attributes that could have influenced access of ANC services. The three main obstetric related factors analyzed included gravidity, parity and complications during previous pregnancies. The number of times the mothers had been pregnant (gravidity). Most of the mothers (48%) had been pregnant for two to four times, 34% had been pregnant once while 19% had been pregnant for over five times.
Further on parity, 52% of the study participants had given birth 2-4 times, 32% had given birth once while 32% of the mothers interviewed indicated that they had given birth five times as shown in (Figure 1, 2). 

In addition, slightly over half of the study participants (52%) indicated that they had never had complications with their previous pregnancies. However, nearly half (48%) of the mothers in the study indicated that they had complications with their previous pregnancies (Figure 3).

3.5 Coefficient of Determination 

In general, at 5% level of significance, patient and obstetric attributes (independent variables) were statistically significant in explaining change in first ANC visit (P < 0.05). From the regression model and statistical analysis, a unit increase in the patient related factors led to 0.545 increases in first ANC visit among women of reproductive age and a unit increase in the obstetric related factors led to 0.487 increases in first ANC visit among pregnant women (Table 5). 

4. Discussion
In our study, age was a significant factor among pregnant mothers seeking first ANC services in line with results reported by different researchers on similar studies elsewhere ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.11604/pamj.2016.25.91.9710","ISSN":"19378688","abstract":"INTRODUCTION Birth preparedness and complication readiness (BP/CR) promotes timely access to skilled maternal and neonatal services, active preparation and decision-making for seeking health care to prevent any adverse outcomes. The aim was to assess level of male partner (MP) involvement in the birth plan, the attitude of the women towards maternal care and factors associated with BP/CR among obstetric referrals in rural Rwanda. METHODS This was a cross-sectional study among 350 pregnant women who were admitted as referrals at Ruhengeri hospital, between July 2015 and November 2015. Data was collected on socio-demographics, level of MP's participation in maternal health care and domestic activities, women's attitude towards involvement of men in maternal care and BP/CR. Any woman who arranged to have a birth companion, made a plan of where to deliver from, received health education on pregnancy and childbirth complications, saved money in case of pregnancy complication and had attended antenatal care (ANC) at least 4 times, was deemed as having made a birth plan. RESULTS The mean age was 27.7 years, while mean age of the spouse was 31.3 years. Majority of the women (n=193; 55.1%) and their spouse (n=208; 59.4%) had completed primary education. Men's role was found to be mainly in the area of financial support. The level of men ANC attendance was low (n=103; 29.4%), while 78 (22.3%) women were accompanied to the labor ward. However, there was a strong opposition to the physical presence of MP in the labor room (n=178; 50.9%). The main reason cited by women opposing MP presence is that it is against their culture for a man to witness the delivery of a baby. On multivariable analysis, maternal education level of secondary or higher adjusted odds ratio [AOR] 1.4 95% CI (1.8-2.6), formal occupation of spouse, AOR 2.4 95% CI (1.4-4.2) and personnel checked during ANC being community health worker AOR 2.2, 95% CI; (1.3-3.7) were associated with being well prepared. CONCLUSION Male involvement in pregnancy and antenatal care is low. To increase men involvement in birth plan addressing cultural barriers and refraining care-givers and health facility policies towards family delivery is paramount.","author":[{"dropping-particle":"","family":"Kalisa","given":"Richard","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Malande","given":"Oliver Ombeva","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Pan African Medical Journal","id":"ITEM-1","issued":{"date-parts":[["2016"]]},"title":"Birth preparedness, complication readiness and male partner involvement for obstetric emergencies in rural Rwanda","type":"article-journal"},"uris":["http://www.mendeley.com/documents/?uuid=fc58302e-1fa4-4d0b-98bd-42bf4f33854b"]}],"mendeley":{"formattedCitation":"[16]","plainTextFormattedCitation":"[16]","previouslyFormattedCitation":"(Kalisa & Malande, 2016)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[16]. Majority of the women were beyond 30 years during their 1st ANC visit while the finding that only a few pregnant women (12%) aged below 19 years may be attributed due to the implementation of the National Adolescent Sexual and Reproductive Health Policy (2015),  legal implications pertaining sexual activities with pedophiles (< 18 years) as prescribed in the Sexual Offences Act (2014, Children Act (2012, and the Marriage Act (2014) ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"Kenya","given":"Republic of","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2014"]]},"publisher-place":"Nairobi","title":"Marriage Act","type":"report"},"uris":["http://www.mendeley.com/documents/?uuid=3f5f2868-ff59-47fe-805a-c849e0e26db0"]}],"mendeley":{"formattedCitation":"[17]","plainTextFormattedCitation":"[17]","previouslyFormattedCitation":"(R. of Kenya, 2014)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[17, 18, 19].  All pregnant women in this study had achieved some form of education and it can therefore be deduced that the study participants were informed on the importance of ANC. Studies have documented a correlation of health seeking behavior during pregnancy with education level ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1007/s10995-016-1976-2","ISSN":"1573-6628","PMID":"27194528","abstract":"Objectives Four antenatal visits, delivery in a health facility, and three postnatal visits are the World Health Organization recommendations for women to optimize maternal health outcomes. This study examines maternal compliance with the full recommended maternal health visits in rural Tanzania with the goal of illuminating interventions to reduce inequalities in maternal health. Methods Analysis included 907 women who had given birth within two�years preceding a survey of women of reproductive age. Multinomial logistic regression was used to assess the influence of maternal, household, and community-level characteristics on four alternative classes defining relative compliance with optimal configuration of maternal health care seeking behavior. Results Parity, wealth index, timeliness of ANC initiation, nearest health facility type, religion, and district of residence were significant predictors of maternal health care seeking when adjusted for other factors. Multiparous women compared to primiparous were less likely to seek care at the high level [RRR 0.16, 95�% confidence interval (CI) 0.06-0.46], at the mid-level (RRR 0.22, 95�% CI 0.09-0.58), and the mid-low level (RRR 0.27, 95�% CI 0.09-0.80). Women in the highest wealth index compared to those in the poorest group were almost three times more likely to seek the highest two levels of care versus the lowest level (high RRR 2.92, 95�% CI 1.27-6.71, mid-level RRR 2.71, 95�% 1.31-5.62). Conclusion Results suggest that efforts to improve the overall impact of services on the continuum of care in rural Tanzania would derive particular benefit from strategies that improve maternal health coverage among multiparous and low socioeconomic status women.","author":[{"dropping-particle":"","family":"Larsen","given":"Anna","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Exavery","given":"Amon","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Phillips","given":"James F","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tani","given":"Kassimu","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kant�","given":"Almamy M","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Maternal and child health journal","id":"ITEM-1","issued":{"date-parts":[["2016"]]},"title":"Predictors of Health Care Seeking Behavior During Pregnancy, Delivery, and the Postnatal Period in Rural Tanzania.","type":"article-journal"},"uris":["http://www.mendeley.com/documents/?uuid=b73fed07-2e53-4fbb-be8a-5c266afb2067"]}],"mendeley":{"formattedCitation":"[20]","plainTextFormattedCitation":"[20]","previouslyFormattedCitation":"(Larsen, Exavery, Phillips, Tani, & Kant�, 2016)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[20]. Marital status is a key indicator on ANC visits and our data showed that pregnant women who were married dominated and may be attributed to husband`s support and financial stability. Husband`s employment status influenced maternal healthcare among pregnant women in Bangladesh and a husband was also found mainly to provide financial support to their pregnant wives in Rwanda ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.11604/pamj.2016.25.91.9710","ISSN":"19378688","abstract":"INTRODUCTION Birth preparedness and complication readiness (BP/CR) promotes timely access to skilled maternal and neonatal services, active preparation and decision-making for seeking health care to prevent any adverse outcomes. The aim was to assess level of male partner (MP) involvement in the birth plan, the attitude of the women towards maternal care and factors associated with BP/CR among obstetric referrals in rural Rwanda. METHODS This was a cross-sectional study among 350 pregnant women who were admitted as referrals at Ruhengeri hospital, between July 2015 and November 2015. Data was collected on socio-demographics, level of MP's participation in maternal health care and domestic activities, women's attitude towards involvement of men in maternal care and BP/CR. Any woman who arranged to have a birth companion, made a plan of where to deliver from, received health education on pregnancy and childbirth complications, saved money in case of pregnancy complication and had attended antenatal care (ANC) at least 4 times, was deemed as having made a birth plan. RESULTS The mean age was 27.7 years, while mean age of the spouse was 31.3 years. Majority of the women (n=193; 55.1%) and their spouse (n=208; 59.4%) had completed primary education. Men's role was found to be mainly in the area of financial support. The level of men ANC attendance was low (n=103; 29.4%), while 78 (22.3%) women were accompanied to the labor ward. However, there was a strong opposition to the physical presence of MP in the labor room (n=178; 50.9%). The main reason cited by women opposing MP presence is that it is against their culture for a man to witness the delivery of a baby. On multivariable analysis, maternal education level of secondary or higher adjusted odds ratio [AOR] 1.4 95% CI (1.8-2.6), formal occupation of spouse, AOR 2.4 95% CI (1.4-4.2) and personnel checked during ANC being community health worker AOR 2.2, 95% CI; (1.3-3.7) were associated with being well prepared. CONCLUSION Male involvement in pregnancy and antenatal care is low. To increase men involvement in birth plan addressing cultural barriers and refraining care-givers and health facility policies towards family delivery is paramount.","author":[{"dropping-particle":"","family":"Kalisa","given":"Richard","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Malande","given":"Oliver Ombeva","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Pan African Medical Journal","id":"ITEM-1","issued":{"date-parts":[["2016"]]},"title":"Birth preparedness, complication readiness and male partner involvement for obstetric emergencies in rural Rwanda","type":"article-journal"},"uris":["http://www.mendeley.com/documents/?uuid=60e2efec-da41-412a-a150-2f309909e725","http://www.mendeley.com/documents/?uuid=fc58302e-1fa4-4d0b-98bd-42bf4f33854b"]}],"mendeley":{"formattedCitation":"[16]","plainTextFormattedCitation":"[16]","previouslyFormattedCitation":"(Kalisa & Malande, 2016)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[16,21]. Antenatal services in Kenya are free but majority of the study participants (78%) felt that financial constraints inhibited them from attending all ANC visits due to some indirect fee charges such as transport and laboratory tests.

While the minority were either single or divorced in the current study, a study was able to demonstrate that women's autonomy had a positive influence on maternal health and were able to make ANC decisions without external forces. The place of residence, whether urban or rural has been associated with ANC attendance and information access ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.3389/fpubh.2017.00011","abstract":"OBJECTIVE Optimal utilization of maternal health-care services is associated with reduction of mortality and morbidity for both mothers and their neonates. However, deficiencies and disparity in the use of key maternal health services within most developing countries still persist. We examined patterns and predictors associated with the utilization of specific indicators for maternal health services among mothers living in the poorest and remote district populations of Zambia. METHODS A cross-sectional baseline household survey was conducted in May 2012. A total of 551 mothers with children between the ages 0 and 5	 months were sampled from 29 catchment areas in four rural and remote districts of Zambia using the lot quality assurance sampling method. Using multilevel modeling, we accounted for individual- and community-level factors associated with utilization of maternal health-care services, with a focus on antenatal care (ANC), skilled birth attendance (SBA), and postnatal care (PNC). RESULTS Utilization rates of focused ANC, SBA, and PNC within 48	 h were 30, 37, and 28%, respectively. The mother's ability to take an HIV test and receiving test results and uptake of intermittent preventive treatment for malaria were positive predictors of focused ANC. Receiving ANC at least once from skilled personnel was a significant predictor of SBA and PNC within 48	 h after delivery. Women who live in centralized rural areas were more likely to use SBA than those living in remote rural areas. CONCLUSION Utilization of maternal health services by mothers living among the remote and poor marginalized populations of Zambia is much lower than the national averages. Finding that women that receive ANC once from a skilled attendant among the remote and poorest populations are more likely to have a SBA and PNC, suggests the importance of contact with a skilled health worker even if it is just once, in influencing use of services. Therefore, it appears that in order for women in these marginalized communities to benefit from SBA and PNC, it is important for them to have at least one ANC provided by a skilled personnel, rather than non-skilled health-care providers.","author":[{"dropping-particle":"","family":"Jacobs","given":"Choolwe","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Moshabela","given":"Mosa","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Maswenyeho","given":"Sitali","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lambo","given":"Nildah","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Michelo","given":"Charles","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Frontiers in Public Health","id":"ITEM-1","issued":{"date-parts":[["2017"]]},"title":"Predictors of Antenatal Care, Skilled Birth Attendance, and Postnatal Care Utilization among the Remote and Poorest Rural Communities of Zambia: A Multilevel Analysis","type":"article-journal"},"uris":["http://www.mendeley.com/documents/?uuid=ea4b2765-ac6b-45af-a632-cb81d8baacb0"]}],"mendeley":{"formattedCitation":"[23]","plainTextFormattedCitation":"[23]","previouslyFormattedCitation":"(Jacobs, Moshabela, Maswenyeho, Lambo, & Michelo, 2017)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[22, 23].  Increased access to technology infrastructure in urban and rural Kenya across all age groups has not only eased service delivery but speedy access of information through social and mass media which were the major avenues on ANC information access in our study. A study in Nepal found that mothers living in urban areas were more exposed to general media and were more likely to receive good quality ANC services ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1186/1471-2393-14-94","ISSN":"1471-2393","PMID":"24589139","abstract":"BACKGROUND Good quality antenatal care (ANC) reduces maternal and neonatal mortality and improves health outcomes, particularly in low-income countries. Quality of ANC is measured by three dimensions: number of visits, timing of initiation of care and inclusion of all recommended components of care. Although some studies report on predictors of the first two indicators, no studies on the third indicator, which measures quality of ANC received, have been conducted in Nepal. Nepal follows the World Health Organization's recommendations of initiation of ANC within the first four months of pregnancy and at least four ANC visits during the course of an uncomplicated pregnancy. This study aimed to identify factors associated with 1) attendance at four or more ANC visits and 2) receipt of good quality ANC. METHODS Data from Nepal Demographic and Health Survey 2011 were analysed for 4,079 mothers. Good quality ANC was defined as that which included all seven recommended components: blood pressure measurement; urine tests for detecting bacteriuria and proteinuria; blood tests for syphilis and anaemia; and provision of iron supplementation, intestinal parasite drugs, tetanus toxoid injections and health education. RESULTS Half the women had four or more ANC visits and 85% had at least one visit. Health education, iron supplementation, blood pressure measurement and tetanus toxoid were the more commonly received components of ANC. Older age, higher parity, and higher levels of education and household economic status of the women were predictors of both attendance at four or more visits and receipt of good quality ANC. Women who did not smoke, had a say in decision-making, whose husbands had higher levels of education and were involved in occupations other than agriculture were more likely to attend four or more visits. Other predictors of women's receipt of good quality ANC were receiving their ANC from a skilled provider, in a hospital, living in an urban area and being exposed to general media. CONCLUSIONS Continued efforts at improving access to quality ANC in Nepal are required. In the short term, less educated women from socioeconomically disadvantaged households require targeting. Long-term improvements require a focus on improving female education.","author":[{"dropping-particle":"","family":"Joshi","given":"Chandni","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Torvaldsen","given":"Siranda","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hodgson","given":"Ray","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Hayen","given":"Andrew","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"BMC pregnancy and childbirth","id":"ITEM-1","issued":{"date-parts":[["2014"]]},"title":"Factors associated with the use and quality of antenatal care in Nepal: a population-based study using the demographic and health survey data.","type":"article-journal"},"uris":["http://www.mendeley.com/documents/?uuid=9d14dd50-e936-43bb-a3a5-1d19863a861a","http://www.mendeley.com/documents/?uuid=a8777f9f-7523-4cb6-acd8-98005df583f6"]}],"mendeley":{"formattedCitation":"[24]","plainTextFormattedCitation":"[24]","previouslyFormattedCitation":"(Joshi, Torvaldsen, Hodgson, & Hayen, 2014)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[24]. The current study participants were delivered from urban or semi-urban areas who were likely having internet access, radios or televisions. 
Cultural related factors and societal values were key components significant to first ANC attendance among the study participants. Kenya has diverse communities with different deep-rooted cultural norms and values whereby unwanted and mistimed pregnancies are associated with poor ANC attendance ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"abstract":"Appropriate antenatal care is important in preventing adverse pregnancy outcomes for both the mother and the baby but many mothers in the developing world do not receive such care. This paper uses data from the 1993 Kenya Demographic and Health Survey to study the variations in the use of antenatal services in Kenya. The analysis is based on modelling the frequency and timing of antenatal visits using three-level linear regression models. The results show that the use of antenatal care in Kenya is determined by a range of socio-economic, cultural and reproductive factors, including the availability and accessibility of health services and the desirability of a pregnancy. Unwanted and mistimed pregnancies are associated with poor attendance at antenatal clinics but this effect varies significantly between women. The results also indicate that women are highly consistent in the use of antenatal care during pregnancies and the correlation is strongest in urban areas.","author":[{"dropping-particle":"","family":"Magadi","given":"Monica A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Madise","given":"Nyovani J.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rodrigues","given":"Roberto N.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Social Science & Medicine","id":"ITEM-1","issued":{"date-parts":[["2000"]]},"title":"Variations in antenatal care between women of different communities in Kenya","type":"article-journal"},"uris":["http://www.mendeley.com/documents/?uuid=90495cfd-c031-4166-88e2-e919accaf91b","http://www.mendeley.com/documents/?uuid=8b2f3b6b-3733-4361-ae1e-87124b38957a"]}],"mendeley":{"formattedCitation":"[25]","plainTextFormattedCitation":"[25]","previouslyFormattedCitation":"(Magadi, Madise, & Rodrigues, 2000)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[25]. Testing for Sexually Transmitted Diseases (STDs) such as Syphilis and HIV are key components of ANC and majority of the study participants stated that they were afraid of disclosing their HIV status or pregnancy. A study in Zambia found a positive predictor to focused ANC if mothers were to be done a HIV test and other preventive treatments ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.3389/fpubh.2017.00011","abstract":"OBJECTIVE Optimal utilization of maternal health-care services is associated with reduction of mortality and morbidity for both mothers and their neonates. However, deficiencies and disparity in the use of key maternal health services within most developing countries still persist. We examined patterns and predictors associated with the utilization of specific indicators for maternal health services among mothers living in the poorest and remote district populations of Zambia. METHODS A cross-sectional baseline household survey was conducted in May 2012. A total of 551 mothers with children between the ages 0 and 5	 months were sampled from 29 catchment areas in four rural and remote districts of Zambia using the lot quality assurance sampling method. Using multilevel modeling, we accounted for individual- and community-level factors associated with utilization of maternal health-care services, with a focus on antenatal care (ANC), skilled birth attendance (SBA), and postnatal care (PNC). RESULTS Utilization rates of focused ANC, SBA, and PNC within 48	 h were 30, 37, and 28%, respectively. The mother's ability to take an HIV test and receiving test results and uptake of intermittent preventive treatment for malaria were positive predictors of focused ANC. Receiving ANC at least once from skilled personnel was a significant predictor of SBA and PNC within 48	 h after delivery. Women who live in centralized rural areas were more likely to use SBA than those living in remote rural areas. CONCLUSION Utilization of maternal health services by mothers living among the remote and poor marginalized populations of Zambia is much lower than the national averages. Finding that women that receive ANC once from a skilled attendant among the remote and poorest populations are more likely to have a SBA and PNC, suggests the importance of contact with a skilled health worker even if it is just once, in influencing use of services. Therefore, it appears that in order for women in these marginalized communities to benefit from SBA and PNC, it is important for them to have at least one ANC provided by a skilled personnel, rather than non-skilled health-care providers.","author":[{"dropping-particle":"","family":"Jacobs","given":"Choolwe","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Moshabela","given":"Mosa","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Maswenyeho","given":"Sitali","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lambo","given":"Nildah","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Michelo","given":"Charles","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Frontiers in Public Health","id":"ITEM-1","issued":{"date-parts":[["2017"]]},"title":"Predictors of Antenatal Care, Skilled Birth Attendance, and Postnatal Care Utilization among the Remote and Poorest Rural Communities of Zambia: A Multilevel Analysis","type":"article-journal"},"uris":["http://www.mendeley.com/documents/?uuid=62d12ca3-c1d6-4130-b1ab-98ef659b211c","http://www.mendeley.com/documents/?uuid=ea4b2765-ac6b-45af-a632-cb81d8baacb0"]}],"mendeley":{"formattedCitation":"[23]","plainTextFormattedCitation":"[23]","previouslyFormattedCitation":"(Jacobs et al., 2017)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[23]. Community diversity has been associated with poor maternal health in Africa and among immigrant women who may be afraid to disclose certain information even to skilled health professionals for fear of discrimination and stigmatization ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1016/j.midw.2014.03.005","ISSN":"02666138","abstract":"Introduction: pregnancy, childbirth and motherhood are natural processes that bring joy to individual women and families. However, for many migrant women, becoming a mother while attempting to settle in a new country where the culture is different, can be a challenge for them. Aim: to identify and synthesise qualitative research studies that explore the perceptions of pregnancy, childbirth and motherhood, and lived experiences of migrant women in their new home country. Methods: the seven steps of Noblit and Hare[U+05F3]s meta-ethnography was used to conduct the meta-synthesis. Searches for literature of qualitative studies were conducted in May and June 2013 using PubMed, CINAHL, Google Scholar and La Trobe University databases. Studies published in English addressing pregnancy, childbirth and motherhood experiences of women from immigrant backgrounds met the inclusion criteria. Findings: 15 studies published between 2003 and 2013 related to the pregnancy, childbirth and motherhood experiences for women from migrant backgrounds were eligible for the meta-synthesis. Four major themes were identified as common in all the qualitative studies: expectations of pregnancy and childbirth; experiences of motherhood; encountering confusion and conflict with beliefs; and dealing with migration challenges. Conclusions: migrant women[U+05F3]s pregnancy, childbirth and motherhood experiences are influenced by societal and cultural values, and they vary depending on the adjustment process in the new home country. The provision of culturally sensitive maternal health services enhances positive outcomes of a healthy mother and healthy infant. Supportive structures that address the issue of language and cultural barriers seem to promote antenatal clinic attendance, prevent pregnancy and childbirth complications, and enhance their positive motherhood experiences. Implications: women from immigrant backgrounds have the right to receive adequate and sensitive health care during the childbearing and childrearing times regardless of their migrant status. � 2014 Elsevier Ltd.","author":[{"dropping-particle":"","family":"Benza","given":"Sandra","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Liamputtong","given":"Pranee","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Midwifery","id":"ITEM-1","issued":{"date-parts":[["2014"]]},"title":"Pregnancy, childbirth and motherhood: A meta-synthesis of the lived experiences of immigrant women","type":"article"},"uris":["http://www.mendeley.com/documents/?uuid=95b652ac-c705-4eac-80be-f73cecbd6c16","http://www.mendeley.com/documents/?uuid=18eb7cb7-2273-437f-9f76-621c03399c02"]}],"mendeley":{"formattedCitation":"[26]","plainTextFormattedCitation":"[26]","previouslyFormattedCitation":"(Benza & Liamputtong, 2014)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[16, 26].

Obstetric related factors were found significant to ANC access in the current study. Majority of the women studied stated that they had 2-4 births (parity) and previous studies have shown lower parity to been associated with frequent ANC visits and less adverse outcomes ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1007/s10995-013-1338-2","ISSN":"15736628","abstract":"Antenatal care (ANC) has been shown to influence infant and maternal outcomes. WHO recommends 4 ANC visits for uncomplicated pregnancies. However, pregnant women in Ghana are required to attend 8-13 antenatal visits. We investigated the association of ANC attendance with adverse pregnancy outcomes (defined as low infant birth weight, stillbirth, preterm delivery or small for gestational age). A quantitative crosssectional study was conducted on 629 women, age 19-48 years who presented for delivery at two selected public hospitals and 16 traditional birth attendants from July to November 2011. Socio-demographic and antenatal information were collected using a structured questionnaire. ANC attendance, medical and obstetric/gynecological history were abstracted from maternal antenatal records. Data were analyzed using Chi square and logistic regression. Twenty-two percent of the women experienced an adverse outcome. Eleven percent of the women attended  < 4 ANC visits. In an unadjusted model, these women had an increased likelihood of experiencing an adverse outcome (OR 2.27; 95 % CI 1.30-3.94; p = 0.0038). High parity ( > 5 children) was also associated with adverse birth outcomes. Women screened for syphilis or use of insecticide- treated bed nets had a 40 and 36 % (p = 0.0447 and p = 0.0293) reduced likelihood of experiencing an adverse pregnancy outcome respectively. After adjusting for confounders, attending < 4 antenatal visits was associated with adverse pregnancy outcome compared with e"4 ANC visits (Adjusted OR 2.55; 95 % CI 1.16-5.63; p = 0.0202). Attending  < 4 antenatal visits and high parity were associated with adverse pregnancy outcomes for uncomplicated pregnancies. � Springer Science+Business Media New York 2013.","author":[{"dropping-particle":"","family":"Asundep","given":"Ntui N.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Jolly","given":"Pauline E.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Carson","given":"April","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Turpin","given":"Cornelius A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Zhang","given":"Kui","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tameru","given":"Berhanu","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Maternal and Child Health Journal","id":"ITEM-1","issued":{"date-parts":[["2014"]]},"title":"Antenatal care attendance, a surrogate for pregnancy outcome the case of kumasi, Ghana","type":"article-journal"},"uris":["http://www.mendeley.com/documents/?uuid=5eef39e7-844a-43cb-bc7a-f3af04cfaaa2","http://www.mendeley.com/documents/?uuid=27f0683b-17c3-4311-81c5-8d114d019328"]}],"mendeley":{"formattedCitation":"[27]","plainTextFormattedCitation":"[27]","previouslyFormattedCitation":"(Asundep et al., 2014)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[21, 27]. Parity was also a predictor indicator for maternal health care seeking behavior in rural Tanzania ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1007/s10995-016-1976-2","ISSN":"1573-6628","PMID":"27194528","abstract":"Objectives Four antenatal visits, delivery in a health facility, and three postnatal visits are the World Health Organization recommendations for women to optimize maternal health outcomes. This study examines maternal compliance with the full recommended maternal health visits in rural Tanzania with the goal of illuminating interventions to reduce inequalities in maternal health. Methods Analysis included 907 women who had given birth within two�years preceding a survey of women of reproductive age. Multinomial logistic regression was used to assess the influence of maternal, household, and community-level characteristics on four alternative classes defining relative compliance with optimal configuration of maternal health care seeking behavior. Results Parity, wealth index, timeliness of ANC initiation, nearest health facility type, religion, and district of residence were significant predictors of maternal health care seeking when adjusted for other factors. Multiparous women compared to primiparous were less likely to seek care at the high level [RRR 0.16, 95�% confidence interval (CI) 0.06-0.46], at the mid-level (RRR 0.22, 95�% CI 0.09-0.58), and the mid-low level (RRR 0.27, 95�% CI 0.09-0.80). Women in the highest wealth index compared to those in the poorest group were almost three times more likely to seek the highest two levels of care versus the lowest level (high RRR 2.92, 95�% CI 1.27-6.71, mid-level RRR 2.71, 95�% 1.31-5.62). Conclusion Results suggest that efforts to improve the overall impact of services on the continuum of care in rural Tanzania would derive particular benefit from strategies that improve maternal health coverage among multiparous and low socioeconomic status women.","author":[{"dropping-particle":"","family":"Larsen","given":"Anna","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Exavery","given":"Amon","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Phillips","given":"James F","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Tani","given":"Kassimu","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kant�","given":"Almamy M","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Maternal and child health journal","id":"ITEM-1","issued":{"date-parts":[["2016"]]},"title":"Predictors of Health Care Seeking Behavior During Pregnancy, Delivery, and the Postnatal Period in Rural Tanzania.","type":"article-journal"},"uris":["http://www.mendeley.com/documents/?uuid=9766c754-cdd8-4ecf-aed0-55680dc2232f","http://www.mendeley.com/documents/?uuid=b73fed07-2e53-4fbb-be8a-5c266afb2067"]}],"mendeley":{"formattedCitation":"[20]","plainTextFormattedCitation":"[20]","previouslyFormattedCitation":"(Larsen et al., 2016)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[20] as well as women attendance to ANC in Ethiopia ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1186/1471-2393-14-161","ISSN":"14712393","abstract":"BACKGROUND: Antenatal Care (ANC), use of skilled delivery attendants and postnatal care (PNC) services are key maternal health services that can significantly reduce maternal mortality. Understanding the factors that affect service utilization helps to design appropriate strategies and policies towards improvement of service utilization and thereby reduce maternal mortality. The objective of this study was to identify factors that affect utilization of maternal health services in Ethiopia.\\n\\nMETHODS: Data were drawn from the 2011 Ethiopia Demographic and Health Survey. The dependent variables were use of ANC, skilled delivery attendants and PNC services. The independent variables were categorized as socio-cultural, perceived needs and accessibility related factors. Data analysis was done using SPSS for windows version 20.0. Bivariate and multivariate logistic regression models were used in the analysis.\\n\\nRESULTS: Thirty four percent of women had ANC visits, 11.7% used skilled delivery attendants and 9.7% of women had a postnatal health checkup. Education of women, place of residence, ethnicity, parity, women's autonomy and household wealth had a significant association with the use of maternal health services. Women who completed higher education were more likely to use ANC (AOR	 =	 3.8, 95% CI	 =	 1.8-7.8), skilled delivery attendants (AOR	 =	 3.4, 95% CI	 =	 1.9-6.2) and PNC (AOR	 =	 3.2, 95% CI	 =	 2.0-5.2). Women from urban areas use ANC (AOR	 =	 2.3, 95% CI	 =	 1.9-2.9), skilled delivery attendants (AOR	 =	 4.9, 95% CI	 =	 3.8-6.3) and PNC services (AOR	 =	 2.6, 95% CI	 =	 2.0-3.4) more than women from rural areas. Women who have had ANC visits during the index pregnancy were more likely to subsequently use skilled delivery attendants (AOR	 =	 1.3, 95% CI	 =	 1.1-1.7) and PNC (AOR	 =	 3.4, 95% CI	 =	 2.8-4.1). Utilization of ANC, delivery and PNC services is more among more autonomous women than those whose spending is controlled by other people.\\n\\nCONCLUSION: Maternal health service utilization in Ethiopia is very low. Socio-demographic and accessibility related factors are major determinants of service utilization. There is a high inequality in service utilization among women with differences in education, household wealth, autonomy and residence. ANC is an important entry point for subsequent use of delivery and PNC services. Strategies that aim improving maternal health service utilization should target improvement of education, economic status and empowerment of women.","author":[{"dropping-particle":"","family":"Tarekegn","given":"Shegaw M.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lieberman","given":"Leslie S.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Giedraitis","given":"Vincentas","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"BMC Pregnancy and Childbirth","id":"ITEM-1","issued":{"date-parts":[["2014"]]},"title":"Determinants of maternal health service utilization in Ethiopia: Analysis of the 2011 Ethiopian Demographic and Health Survey","type":"article-journal"},"uris":["http://www.mendeley.com/documents/?uuid=6955f6cb-8097-4bb2-9647-fe601b0bc803","http://www.mendeley.com/documents/?uuid=e5ec2f25-6d34-46ad-b4ac-7cf2f706d9bb"]}],"mendeley":{"formattedCitation":"[22]","plainTextFormattedCitation":"[22]","previouslyFormattedCitation":"(Tarekegn et al., 2014)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[22]. Complications may arise during pregnancy or delivery and nearly half of the study participants indicated that they previously had a pregnancy-related complication. Forty (40%) of pregnant women experience some form of complication 15% being life-threatening ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"author":[{"dropping-particle":"","family":"UNFPA","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2005"]]},"title":"UNFPA the state of the world population 2005: The Promise of Equality Gender Equity, Reproductive Health and the Millennium Development Goals","type":"report"},"uris":["http://www.mendeley.com/documents/?uuid=c5201d09-f2e6-41c3-9651-fc218100d1af"]}],"mendeley":{"formattedCitation":"[28]","plainTextFormattedCitation":"[28]","previouslyFormattedCitation":"(UNFPA, 2005)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[28]. Antenatal visits enhances health professionals determine the level of care and skills required by the health care-provider so that the best and safest options available are offered. Skilled birth attendants have been documented to greatly minimize maternal deaths ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1111/1471-0528.13451","abstract":"In 2015, as we review progress towards Millennium Devel-opment Goals (MDGs), despite significant progress in reduction of mortality, we still have unacceptably high numbers of maternal and newborn deaths globally. Efforts over the past decade to reduce adverse outcomes for preg-nant women and newborns have been directed at increas-ing skilled birth attendance. 1,2 This has resulted in higher rates of births in health facilities in all regions. 3 The pro-portion of deliveries reportedly attended by skilled health personnel in developing countries rose from 56% in 1990 to 68% in 2012. 4 With increasing utilisation of health ser-vices, a higher proportion of avoidable maternal and peri-natal mortality and morbidity have moved to health facilities. In this context, poor quality of care (QoC) in many facilities becomes a paramount roadblock in our quest to end preventable mortality and morbidity. QoC during childbirth in health facilities reflects the available physical infrastructure, supplies, management, and human resources with the knowledge, skills and capacity to deal with pregnancy and childbirth�normal physiological, social and cultural processes, but prone to complications that may require prompt life-saving interventions. Research shows that it is necessary to go beyond maximising cover-age of essential interventions to accelerate reductions in maternal and perinatal mortality and severe morbidity.","author":[{"dropping-particle":"","family":"Tunc","given":"�","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Were","given":"Wm","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Maclennan","given":"C","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Oladapo","given":"Ot","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bahl","given":"R","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Daelmans","given":"B","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mathai","given":"M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Say","given":"L","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Kristensen","given":"F","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Temmerman","given":"M","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bustreo","given":"F","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"BJOG","id":"ITEM-1","issued":{"date-parts":[["2015"]]},"title":"Quality of care for pregnant women and newborns�the WHO vision","type":"article-journal"},"uris":["http://www.mendeley.com/documents/?uuid=b4a66069-c848-448c-a619-32d15510e249"]}],"mendeley":{"formattedCitation":"[3]","plainTextFormattedCitation":"[3]","previouslyFormattedCitation":"(Tunc et al., 2015)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[3]. In Kenya, 53% of the births were attended by skilled health personnel (doctors, nurses or midwives) in the year 2015  but the situation may worsen due to acute shortage of skilled labour of health professionals in the country ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"URL":"https://www.who.int/gho/maternal_health/mortality/maternal_mortality_text/en/","author":[{"dropping-particle":"","family":"WHO","given":"","non-dropping-particle":"","parse-names":false,"suffix":""}],"id":"ITEM-1","issued":{"date-parts":[["2017"]]},"title":"WHO | Global Health Observatory (GHO) data: Maternal mortality","type":"webpage"},"uris":["http://www.mendeley.com/documents/?uuid=13c723fb-35fb-41ba-ba0d-83a561e02ba8"]}],"mendeley":{"formattedCitation":"[5]","plainTextFormattedCitation":"[5]","previouslyFormattedCitation":"(WHO, 2017a)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[5]. In the KDHS (2008/9) data, when other factors were adjusted, it was found that women whose husbands attended at least one ANC visit were more likely to have a skilled-birth attendance ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"ISSN":"0012835X","abstract":"OBJECTIVE To determine whether there is a relationship between male involvement in maternal health and utilisation of skilled birth attendants (SBAs) after controlling for socio-demographic and maternal characteristics. DESIGN Data from the Kenya Demographic and Health Survey (KDHS) conducted in 2008-09 were analysed. SETTING Nationally representative survey in Kenya. SUBJECTS The unit of analysis was couples who met the inclusion criteria of being married and having had a child in the three years before the survey. RESULTS The adjusted odds ratio after controlling for other factors indicates that women whose husbands attended at least one ANC visit were more likely to have skilled birth attendance than those whose husbands did not attend any ANC visits [AOR, 1.9; 95 percent CI, 1.09-3.32]. Maternal characteristics that had a statistically significant association with delivery by an SBA included educational level, employment, number of ANC visits, and parity. The province where the couple resided also was statistically significant. CONCLUSION In Kenya a male partner's participation, through attending ANC visits, is associated with a woman's use of an SBA during delivery.","author":[{"dropping-particle":"","family":"Mangeni","given":"J. N.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mwangi","given":"A.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mbugua","given":"S.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Mukthar","given":"V. K.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"East African Medical Journal","id":"ITEM-1","issued":{"date-parts":[["2012"]]},"title":"Male involvement in maternal healthcare as a determinant of utilisation of skilled birth attendants in kenya","type":"article-journal"},"uris":["http://www.mendeley.com/documents/?uuid=68ee7888-dd3e-4d6e-a089-04a49e99a7ce","http://www.mendeley.com/documents/?uuid=fe217da3-a7ca-4b0f-ba8b-168cb182b642"]}],"mendeley":{"formattedCitation":"[29]","plainTextFormattedCitation":"[29]","previouslyFormattedCitation":"(Mangeni, Mwangi, Mbugua, & Mukthar, 2012)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[29]. Skilled assistance in a health facility was viewed positively in Western Kenya, but a previous study within the same region had indicated that 80% of women had delivered away from health care facility with assistance of traditional birth attendants ADDIN CSL_CITATION {"citationItems":[{"id":"ITEM-1","itemData":{"DOI":"10.1186/1742-4755-3-2","ISSN":"17424755","abstract":"BACKGROUND: Improving maternal health is one of the UN Millennium Development Goals. We assessed provision and use of antenatal services and delivery care among women in rural Kenya to determine whether women were receiving appropriate care. METHODS: Population-based cross-sectional survey among women who had recently delivered. RESULTS: Of 635 participants, 90% visited the antenatal clinic (ANC) at least once during their last pregnancy (median number of visits 4). Most women (64%) first visited the ANC in the third	
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����է֧٧ڧܧ�������������z�zf�V=1jh�h�1GB*CJU\�aJmH	ph�sH	h�1Gh�1GCJ\�aJmH	sH	&jh�h�B*CJUaJph�%h�h�B*CJaJmH	ph�sH	.jh�h�B*CJUaJmH	ph�sH	h�CJaJmH	sH	h�1Gh�1GCJaJmH	sH	&jh�h�1GB*CJUaJph�.jh�h�1GB*CJUaJmH	ph�sH	%h�h�1GB*CJaJmH	ph�sH	��#�$�(�)�$�%����@ABFIJKNOPQ[\����뾮�����뾮�vj^j�U?+h�w|h�w|5�CJOJPJQJaJmH	sH	h�1G5�CJaJh�w|h�w|5�CJaJh$�h$�5�CJaJh�v�5�CJaJh�`5�CJaJh�1Gh�1GCJaJmH	sH	(h�h�B*CJ\�aJmH	ph�sH	Uh�1Gh�1GCJ\�aJmH	sH	&jh�h�1GB*CJUaJph�1jh�h�1GB*CJU\�aJmH	ph�sH	(h�h�1GB*CJ\�aJmH	ph�sH	 trimester; a perceived lack of quality in the ANC was associated with a late first ANC visit (Odds ratio [OR] 1.5, 95% confidence interval [CI] 1.0-2.4). Women who did not visit an ANC were more likely to have < 8 years of education (adjusted OR [AOR] 3.0, 95% CI 1.5-6.0), and a low socio-economic status (SES) (AOR 2.8, 95% CI 1.5-5.3). The ANC provision of abdominal palpation, tetanus vaccination and weight measurement were high (>90%), but provision of other services was low, e.g. malaria prevention (21%), iron (53%) and folate (44%) supplementation, syphilis testing (19.4%) and health talks (14.4%). Eighty percent of women delivered outside a health facility; among these, traditional birth attendants assisted 42%, laypersons assisted 36%, while 22% received no assistance. Factors significantly associated with giving birth outside a health facility included: age >or= 30 years, parity >or= 5, low SES, < 8 years of education, and > 1 hour walking distance from the health facility. Women who delivered unassisted were more likely to be of parity >or= 5 (AOR 5.7, 95% CI 2.8-11.6). CONCLUSION: In this rural area, usage of the ANC was high, but this opportunity to deliver important health services was not fully utilized. Use of professional delivery services was low, and almost 1 out of 5 women delivered unassisted. There is an urgent need to improve this dangerous situation.","author":[{"dropping-particle":"","family":"Eijk","given":"Anna M.","non-dropping-particle":"Van","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Bles","given":"Hanneke M.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Odhiambo","given":"Frank","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Ayisi","given":"John G.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Blokland","given":"Ilse E.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Rosen","given":"Daniel H.","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Adazu","given":"Kubaje","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Slutsker","given":"Laurence","non-dropping-particle":"","parse-names":false,"suffix":""},{"dropping-particle":"","family":"Lindblade","given":"Kim A.","non-dropping-particle":"","parse-names":false,"suffix":""}],"container-title":"Reproductive Health","id":"ITEM-1","issued":{"date-parts":[["2006"]]},"title":"Use of antenatal services and delivery care among women in rural western Kenya: A community based survey","type":"article"},"uris":["http://www.mendeley.com/documents/?uuid=2805b875-c1a3-40ea-90dd-b4a8a3215f13","http://www.mendeley.com/documents/?uuid=852149b6-2c5a-42be-89b5-6865a369c72e"]}],"mendeley":{"formattedCitation":"[31]","plainTextFormattedCitation":"[31]","previouslyFormattedCitation":"(Van Eijk et al., 2006)"},"properties":{"noteIndex":0},"schema":"https://github.com/citation-style-language/schema/raw/master/csl-citation.json"}[30, 31].
 
6. Conclusion
Patient related factors (demography, cultural, economic & information source) and Obstetric related factors (gravidity, parity & previous pregnancy complications) were statistically significant in explaining change in first ANC seeking behavior among women of reproductive age in Embakasi North in Nairobi County, Kenya. These factors are attributes that positively influence ANC access among pregnant women in Embakasi North Sub-County, Kenya. It is known that low ANC uptake among pregnant women is associated with adverse pregnancy related complications and high maternal mortality rates. The data derived from this study provide vital information on factors that influence the recommended 4 ANC visits among Embakasi women and therefore triggers public health action strategies to prevent severe adverse effects during pregnancy. Sensitization by healthcare workers on the importance of all ANC visits, ANC visit follow-ups, transport support by the County Government and other actors such as prompt and affordable provision of ambulance services are key factors that can improve ANC uptake among the pregnant women in Embakasi Sub County in Nairobi County, Kenya.

Competing interests: The author declares no competing interest
Authors� contributions: Moses Wamwea Muraguri was the principal investigator and was involved in all stages of the study which included conceptualization, proposal writing, methodology, data collection, and formal data analysis. Esther Ndonga and Joseph Juma Nyamai were involved in the entire supervision of the study. Oliver Waithaka Mbuthia participated in data analysis, developed the initial manuscript, reviewed and edited the manuscript for submission. All authors gave their expert reviews and gave approval for the manuscript publication. 
Acknowledgements: Much appreciation is expressed to all the study participants involved in this study. We thank Mount Kenya University Ethics Review Committee for giving approval to conduct this study. We recognize and appreciate all efforts by the research assistants as well as the supervisory roles from Dr E. Ndonga and Dr J Juma.
Authors� contributions 
Moses Wamwea Muraguri was the principal investigator and was involved in all stages of the study which included conceptualization, proposal writing, methodology, data collection, and formal data analysis. Esther Ndonga and Joseph Juma Nyamai were involved in the entire supervision of the study. Oliver Waithaka Mbuthia participated in data analysis, developed the initial manuscript, reviewed and edited the manuscript for submission. All authors gave their expert reviews and gave approval for the manuscript publication. 














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