FACTORS ASSOCIATED WITH LATE ANTENATAL CARE ATTENDANCE IN

SELECTED RURAL AND URBAN COMMUNITIES OF THE COPPERBELT

PROVINCE, ZAMBIA

By
ISAAC BANDA

A dissertation submitted to the University of Zambia in partial fulfillment of the

requirement of the degree for Master of Public Health

The University of Zambia

Lusaka
2012
DECLARATION
I hereby declare that all the work in this dissertation is my own and has never been
submitted for another degree in this or any other university or institution of higher
learning.
Dr Isaac Banda
Signature Date
------------------------------------- ---------------------------------

This dissertation is submitted with the approval of the following supervisors

Dr Charles Michelo -MBChB, PhD
Department of Community Medicine
University of Zambia
School of Medicine
Lusaka
Signature Date
------------------------------------- -----------------------------------

Mrs Alice N. Hazemba- BSc Nursing, MPH

Department of Community Medicine
University of Zambia
School of Medicine
Lusaka
Signature Date
----------------------------------------------- -------------------------------------------

ii
Certificate of Approval
This dissertation by Isaac Banda is approved in partial fulfillment of the requirements for
the award of a Master of Public Health (MPH) by the University of Zambia

Examiner: 1. ______________________ Date: _____________________________

Examiner: 2. ______________________ Date: _____________________________

Examiner: 3. ______________________ Date: _____________________________

Examiner: 4. ______________________ Date: _____________________________

Head of Department
Signature: ________________________ Date: ____________________________
Department of Community Medicine, University of Zambia

iii
Abstract
Background: Despite antenatal care services being provided free of charge or sometimes
at a minimal cost in Zambia, only 19% of women attend antenatal care by their fourth
month of pregnancy, as recommended by World Health Organization (WHO). An
estimated 21% of pregnant women in urban and 18% in rural districts make their first
ANC visit by 4th months of pregnancy. A number of factors have been found to
contribute to late initiation of Antenatal care among pregnant women and these may vary
between rural and urban areas. Therefore, a study aimed at examining factors associated
with late ANC attendance amongst pregnant women in selected communities of the
Copperbelt Province was conducted.

Methodology: A cross- sectional study using a semi-structured questionnaire was

conducted in selected health facilities of Mpongwe and Ndola districts. A total number of
613 women attending antenatal clinic, distributed evenly between Mpongwe rural district
(51% (307/613) and Ndola urban district (49% (306/613) were included in the study.
Data from the completed questionnaires was entered using Epi InfoTM 3.5.1 and finally
analyzed with SPSS version 16.0.

Results: The prevalence of late ANC attendance was 72.0 % (n=221) and 68.6% (n=210)
in rural and urban districts respectively. However, the difference between two districts
was not statistically significant [OR 0.851 (95% CI=0.6, 1.2), p=0.363]. In the rural
district, nulliparous women were 59% (AOR 0.411, 95% CI 0.238, 0.758) less likely to
initiate ANC late compared to multiparous women, while the proportion the urban was
48% (AOR 0.518, 95% CI 0.316, 0.848). Inadequate knowledge about ANC resulted into
2.2 times high odds for late ANC attendance (AOR 2.205, 95% CI 1.021, and 4.759) than
women who had adequate knowledge in urban district. Women who fell pregnant
unintentionally had a higher odds of starting ANC late in both rural [4.2 times (AOR
4.258, 95% CI 1.631, 11.119)] and urban [3.1 times (AOR 3.103, 95% CI 1.261, 7.641)]
respectively. The perception of no benefits derived from commencement of ANC early
was associated with 4 times (AOR 3.983, 95% CI 1.365, 11.627) likelihood of late
attendance in the urban district. Compared to lack of privacy at health institutions,

iv
pregnant women in rural were 3.4 times (AOR 3.377, 95% CI 1.180, and 9.660) more
likely to initiate ANC late because of long distance to health facilities. Compared to
misconceptions on ANC, pregnant women in rural areas were 2.2 times (AOR 2.211 95%
CI 1.049, 4.660) more likely to start ANC late because of community norm(less value
attached to ANC); while in urban late ANC attendance was 2.9 times (AOR 2.899, 95%
CI 1.372, 6.083) higher due to cultural beliefs than misconceptions.

Conclusion: Late antenatal care attendance remains high in both rural and urban districts
indicating the need for intensified and more focused utilization of resources aimed at
increasing sensitization of the importance of early attendance for high risk groups, such
as women with unplanned pregnancies, inadequate knowledge about ANC, cultural
beliefs and multiparous.

v
Acknowledgement

I would like to thank my supervisors; Dr Charles Michelo and Mrs A. Hazemba for the
sound advice and support that led to the completion of this research.
I am also grateful to Ndola and Mpongwe District Medical Offices for allowing me
conduct this study from their facilities. My sincere gratitude also goes to the pregnant
women who provided valuable information that led to the realization of this dissertation.
The lecturers and other staff in the department of community medicine, I would like to
thank you for making my MPH course enjoyable.
Lastly, but not the least, I am grateful to my entire family for the selfless love and
support.

vi
Table of Contents
Page
Table of contents vii
List of figures x
List of tables xi
Acronyms xii
Chapter 1 1
1.0 Introduction 1
1.1 Background to the study 1
1.2 Problem statement 3
1.3 Study Justification 4
1.4 Theoretical framework 4
1.5 Research question 7
1.6 Definitions of key concepts 7

Chapter 2 9
2.0 Literature review 9
2.1 Introduction 9

Chapter 3 12
3.0 Study objectives 12
3.1 General objective 12
3.2 Specific objectives 12

Chapter 4 13
4.0 Research Methodology 13
4.1 Study sites 13
4.2 Study design 14
4.3 Study variables 14
4.4 Study population 14
4.5 Inclusion criteria 14
4.6 Exclusion criteria 15

vii
 4.7 Sample size determination 15
4.8 Sampling procedure 15
4.9 Data collection tools 16
4.10 Pre-test 16
4.11 Ethical considerations 16
4.12 Data management and analysis 16

Chapter 5 17
5.0 Results 17
5.1 Sample Description 17
5.2 Obstetric characteristics 17
5.3 Comparison of Prevalence of late ANC attendance between Mpongwe and
Ndola 21
5.4 Intrapersonal factors associated with late ANC attendance 22
5.5 Interpersonal factors associated with late ANC attendance 24
5.6 Institutional factors associated with late ANC attendance 24
5.7 Community factors associated with late ANC attendance 24
5.8 Public Policy factors associated with late ANC attendance 27
5.9 Logistic regression analysis 28

Chapter 6 31
6.0 Discussion 31
6.1 Prevalence of late ANC attendance 31
6.2 Factors associated with late ANC attendance 31
6.3 Limitation of the study 33
6.4 Conclusion 34
6.5 Recommendations 34

References 35
Appendices 40
Appendix (I) Questionnaire 40
Appendix (II) Information sheet 44

viii
Consent forms 46
Appendix (IV) Letters of permission 47

ix
List of Figures
Figure: 1 An Ecological Model of determinants of ANC attendance 6
Figure: 2 Gestation age distributions at ANC booking 20
Figure: 3 Prevalence of Late ANC attendance 21

x
LIST OF TABLES

Table: 1 Socio-demographic characteristics of participants 18

Table: 2 Obstetric characteristics of participants 19
Table: 3 Comparison of late ANC attendance between Mpongwe and Ndola 21
Table: 4 Intrapersonal factors associated with late ANC attendance 23
Table: 5 Interpersonal factors associated with late ANC attendance 25
Table: 6 Institutional factors associated with late ANC attendance 26
Table: 7 Community factors associated with late ANC attendance 26
Table: 8 Public policy factors associated with late ANC attendance 27
Table: 9 Predictors of late ANC attendance- logistic regression 29

xi
ACRONYMS
AIDS Acquired immune deficiency Syndrome.
ANC- Antenatal Care.
DHMT- District Health Management Team
FANC- Focused Antenatal Care
HIV Human Immunodeficiency Virus.
HMIS- Health Management Information Systems
IPT Intermittent Presumptive Therapy
MCH- Maternal and Child Health
PMTCT Prevention of Mother to Child Transmission.
UNICEF- United Nations Childrens Fund
WHO- World Health Organization
ZDHS- Zambia Demographic and Health Survey

xii
Chapter 1
1.0 Introduction
1.1 Background to the study
Maternal and neonatal morbidity and mortality have continued to be a major problem in
developing countries despite efforts to reverse the trend. Globally, more than 500,000
mothers die each year from pregnancy related conditions, and neonatal mortality accounts
for almost 40% of the estimated 9.7 million children under-five deaths (UNICEF, 2009).
Furthermore, ninety nine percent (99%), of maternal and newborn mortality occur in
developing countries. The greatest risk of maternal deaths, which is now compounded by
the HIV/AIDS pandemic, is faced by women in Sub-Saharan Africa (OCallaghan, 1999).
According to a survey conducted in Zambia, it was reported that maternal mortality ratio
stood at 591 per 100 000 live births while neonatal mortality was estimated at 34 per
1000 live births (ZDHS, 2007).

Research has shown that most of the maternal and neonatal deaths are avoidable
(Stevens-Simon, 2002). Antenatal care is one of the key strategies for reducing maternal
and neonatal morbidity and mortality directly through detection and treatment of
pregnancy related illness, or indirectly through detection of women at risk of
complications of delivery and ensuring that they deliver in a suitably equipped facility
(Anh, 2002). A number of studies have demonstrated the association between antenatal
care attendance and reduction of premature birth, low birth weight, congenital
malformations, congenital infections, neonatal tetanus, pre-eclampsia and anaemia
(Orvos et al. 2001).

In 2001 the World Health Organization (WHO) issued guidance on a new model of
antenatal care (ANC) called goal-oriented or focused antenatal care (FANC), for imple-
mentation in developing countries (Villar et al. 2001). In this new strategy of focused
antenatal care, WHO recommends four antenatal care visits in low risk pregnancies and
prescribes the evidence-based content for each visit (Villar et al. 2002) Antenatal care
constitutes screening for health and socioeconomic conditions likely to increase the
possibility of specific adverse pregnancy outcomes, providing therapeutic interventions

1
known to be effective; and educating pregnant women about planning for safe birth,
emergencies during pregnancy and how to deal with them (WHO, 2009). Interventions
that have proved to be of great benefit to the mother and the child include iron and folate
supplementation in areas with high prevalence of anemia, serological screening for and
treatment of syphilis, routine obstetric examination, intermittent presumptive therapy
(IPT) for malaria, and tetanus immunization (van Eijk , 2006). Other interventions that
can be linked to ANC include providing information on good nutrition, family planning,
breastfeeding, and health benefits of delivery with the assistance of skilled health
provider (WHO, 1999). Prevention of mother to child transmission (PMTCT) of HIV has
recently been incorporated in the antenatal care service program. The above interventions
will be of full benefit if women start attending antenatal early in pregnancy.

Globally, progress has been made in terms of increasing access and use of one antenatal
visit, although the proportion of women who are obtaining the recommended minimum
of four visits is too low (Carroli, 2001). In addition, the first consultation is often made
late in pregnancy, whereas maximum benefit requires early initiation of antenatal care.
Van Eijk et al. observed that there was a tendency towards late attendance for the first
ANC visit in Kenya. The whole of Sub-Saharan Africa lags behind other developing
regions (WHO, 2006). Various studies have reported factors associated with late entry to
ANC, these include place of residence, ethnicity, age, education, employment status,
parity, intention to get pregnant, use of contraceptive methods, economic status, health
insurance, and travel time (Trinh, 2006; Adekanle, 2008).

Men play a vital role in determining the health needs of a woman. In developing
countries, men are decision makers and in control of all the resources, they decide when
and where woman should seek health care. It has been demonstrated that lack of male
involvement in pregnancy and antenatal care and in prevention of mother-to child
transmission (PMTCT) of HIV programmes have been identified as major bottlenecks to
effective programme implementation (Horizons Programme Report, 2002).

2
1.2 Problem statement
In Zambia ANC services are provided free of charge in most government health
institutions and at a minimal cost in private clinics. As a result, the Zambia Demographic
and Health survey indicates that the vast majority (94%) of pregnant women receive some
antenatal care (ANC) from a skilled provider, most commonly from a nurse/midwife
(87%). However, only 19% of women attend antenatal care by their fourth month of
pregnancy, as recommended by World Health Organization (ZDHS, 2007). Furthermore,
in terms of urban and rural variation, 21% of pregnant women in urban and 18% in rural
districts had their first ANC visit by 4th months of pregnancy.

Mpongwe one of the rural districts in Zambia, showed the same trend. Out of 6,448 first
antenatal attendance in 2008, only 2,296 pregnant women attended antenatal by the 20 th
week of their pregnancy, representing 74% of late antenatal attendance (HMIS, 2008).
The average number of ANC visits per pregnancy was 2.6 (HMIS, 2008). Similarly, the
Ndola 2008 HMIS reported that only 30% of pregnant women attended ANC by 20th
week of pregnancy. Out of 19,964 first ANC attendance, only 5,992 attended by 20th
week of pregnancy making the proportion of late ANC attendance to be 70%.

Recently, the potential of the antenatal period as an entry point for HIV prevention and
care, in particular for the prevention of HIV transmission from mother to child, has led to
renewed interest in access to and use of ANC services (Campbell et al. 2006).
Additionally, World Health Organization (WHO) recommends that all pregnant women
in areas of stable malaria transmission should receive at least two doses of Intermittent
Presumptive Therapy for malaria at the beginning of second trimester or after quickening
(first noted movement of the foetus) during routinely scheduled antenatal clinic visits
(Kiwuwa, 2008). Thus, late antenatal attendance makes it difficult to implement
effectively the above and other routine ANC strategies that enhance maternal wellbeing
and good perinatal outcomes. In this regard, the identification of factors associated with
late ANC attendance is a major public health objective. It could help come up with
strategies that could improve the quality ANC service provision and timing of first ANC
attendance.

3
1.3 Study justification
Literature has generally indicated the importance and the benefits of ANC, therefore
research needs to be done to understand the reasons for late antenatal attendance. This
study takes a unique approach to understanding factors affecting antenatal attendance as
it looks not only at individualized factors, but an ecological perspective. Hence, the study
will focus on comprehending intrapersonal or individual factors, interpersonal factors,
institutional or organizational factors, community factors, and public policy factors
affecting antenatal attendance. It is hoped that information obtained from this study will
add to the existing body of knowledge in the area of maternal and child health. The
results of this study may also be of use to health policy makers and other stakeholders for
developing healthy public policies as regards reproductive health. Consequently, the
findings might help to enhance family and social support system for pregnant women in
communities.

1.4 Theoretical framework

Health care in general is grounded in a biomedical paradigm that focuses on individual
level determinants of health rather than in a socio-ecological paradigm that acknowledges
the influence of the environment (Sword, 1999). However, this study was guided by the
socio-ecological model because it emphasizes the interaction between, and
interdependence of, factors within and across all levels of a health problem (Barbara et al,
2005). In addition, there are two key concepts of the ecological model that help to
identify intervention points for promoting health. The first is that, behavior both affects,
and is affected by, multiple levels of influence; second, individual behavior both shapes,
and is shaped by, the social environment. In order to explain the concepts, McLeroy and
others (1988) identified five levels of influence for health-related behaviors and
conditions. These levels include; intrapersonal or individual factors, interpersonal factors,
institutional or organizational factors, community factors, and public policy factors.
The socio-ecological model will help to explain why some women attend ANC early
while others do not. As potential health care system users, pregnant women are located

4
within a socio-political environment that shapes their personal and situational
characteristics and, ultimately, has a determining role in attending ANC (Sword, 1999).

5
Figure 1.

An Ecological model of determinants of antenatal care attendance

Individual level Interpersonal Institutional level Community Public policy

Age level Distance to level Cost of
Marital Husband/part ANC Local ANC
status ners support Waiting time beliefs on services
Educational Peer Attitude of ANC Travel cost
level influence health Value to ANC
Intention of Family providers attached to Conditions
influence ANC
pregnancy Lack of of service
Adopted fro
Knowledge Media Community for ANC
privacy
norms
Attitude providers

Beliefs
Parity
Satisfaction
of service
ANC ATTENDANCE

Adapted from Theory at a Glance (Barbara et al, 2005)

6
1.5 Research question
1.5.1 Does area of residence, urban or rural, have any effect on the timing of entry to
antenatal care?

1.5.2 What intrapersonal, interpersonal, institutional, community and public policy

factors are associated with late antenatal attendance amongst pregnant women in selected
rural and urban communities of the Copperbelt province?

1.6 Definition of Key concepts

1.6.1 Antenatal Care (ANC): is an umbrella term used to describe health care rendered
during pregnancy (McDonagh, 1996).

1.6.2 Focused Antenatal care (FANC): This is a new World Health Organization
(WHO) model of antenatal care (ANC) sometimes called goal-oriented ANC for imple-
mentation in developing countries (Villar et al. 2001). The new model reduces the
number of required antenatal visits to four, and provides focused services shown to
improve maternal outcomes. FANC eliminates the traditional risk assessments and
instead emphasizes helping women to maintain normal pregnancies by identifying
existing health conditions, detecting emerging complications, promoting health,
preparing for a healthy birth, and educating clients on postpartum care including nutri-
tion, breastfeeding, and family planning.

1.6.3 Intermittent presumptive therapy (IPT): Intermittent therapy involves the

administration of full, curative-treatment doses of an effective antimalarial drug at
predefined intervals during pregnancy (WHO, 2004). In Zambia
sulfadoxine/pyrimethamine (Fansidar) is used for IPT in pregnancy.

1.6.4 Maternal mortality ratio: The number of registered deaths among women, from
any cause related to or aggravated by pregnancy or its management (excluding accidental
or incidental causes) during pregnancy, childbirth or within 42 days of termination of

7
pregnancy, irrespective of the duration or site of the pregnancy, for every 100 000 live
births in a given year or period of time.

1.6.5 Neonatal mortality rate: T he number of registered deaths in the neonatal period
per 1000 live births in a given year or period of time

1.6.6 Prevention of mother to child transmission of HIV (PMTCT): This refers to the
prevention of transmission of HIV from an HIV-positive woman during pregnancy,
delivery or breastfeeding to her child. The term is used because the immediate source of
the infection is the mother, and does not imply blame on the mother.

8
Chapter 2:
2.0 Literature review
2.1 Introduction
The purpose of literature review in this study is to identify factors influencing antenatal
attendance from the works done by other researchers. A review of literature will therefore
provide a road map for the development and implementation of the research (Burns et al.
2005).

Despite the global efforts initiated to improve maternal health, more than half a million
women worldwide die each year as a result of complications arising from pregnancy and
child birth (Ronsmans et al. 2006). Almost all of these deaths occur in developing
countries with sub-Saharan Africa accounting for almost 47% of the toll (WHO, 2004).
The lifetime risk of maternal death in sub-Saharan Africa is 1 in 22 mothers compared to
1 in 210 in Northern Africa, 1 in 62 for Oceania, 1 in 120 for Asia, and 1 in 290 for Latin
America and the Caribbean (WHO, 2007). In Zambia the maternal mortality ratio stands
at 449 per 100 000 live births and neonatal mortality is estimated at 34 per 1000 live
births (ZDHS, 2007). Attendances at ANC clinics and receipt of professional delivery
care have been associated with reduction in maternal deaths (Magadi et al. 2001;
UNICEF, 2003). The full benefits of interventions provided during ANC are unattainable
because of late entry to ANC. In developed and developing countries, ANC attendance
boosts the good outcome of pregnancy. A study in Kenya was able to show the causal
relationship between ANC and good perinatal outcomes (Brown et al. 2008).

2.2 Socio-demographic characteristics

There are a number of studies done to establish factors relating to late antenatal
attendance in the world. The related factors include place of residence, ethnicity, age,
education, employment status, parity, intention to get pregnant, use of contraceptive
method, economic status, health insurance and travel time (McDonald, 1988; Perloff,
1999; Trinh, 2005; Magadi, 2000; LaVeist, 1995).

9
Younger women, especially teenagers, are more likely to have unplanned pregnancies
and lack information and resources to access ANC services (Trinh, 2006). As regards
marital status, single women with unplanned pregnancies, like most pregnant teenagers,
may have a negative attitude towards their pregnancy and, due to this, may be less aware
of the signs of pregnancy and as a result seek care much later than would older women
(Kogan, et al. 1998).

2.3 Educational attainment

Compared to women of low literacy level, educated women bear fewer children and
achieve better child survival, because they avoid early marriages, teenage pregnancy, and
high parity because they attend antenatal and postnatal more frequently. A study done in
Kwale district, Kenya revealed that women with secondary education or above were
more likely to attend for ANC (Brown et al. 2008). The same study also highlighted the
relationship between ANC and good perinatal outcomes. Women should be educated on
sex, pregnancy and contraceptive use early in life as this would help them make informed
decision later on in life (Ehlers, 2000).

2.4 Socio-economic conditions

Income at household level has a bearing on antenatal attendance. This was established in
Studies from Jamaica that found that, an increased probability of early antenatal care
attendance was associated with increased household expenditure (Gertler et al. 1993).

2.5 Intention to get pregnant

The use of antenatal care services can also be delayed by womans attitude towards her
pregnancy. Teenagers with unplanned pregnancies may have a negative attitude towards
their pregnancy and, for this reason they may seek ANC much later than would older
married women (Kogan et al. 1998).

2.6 Negative attitude of health providers

In a study done by Dennis et al. 1995, some women stated that the reasons affecting their
delay in or lack of antenatal clinic attendance were the long waiting hours, inconvenient

10
service hours and that they were not treated well by the service providers. The
judgmental nature of some health workers towards pregnant adolescents may negatively
influence pregnant teenagers efforts to attend antenatal services (Nichols, 1997).

2.7 Knowledge
Inadequate knowledge about ANC and the benefits derived from it for the mothers and
newborns has negatively influence utilization. Sometimes pregnant women especially
adolescents, may not be aware of the problems that results from not attending ANC
(Dennill et al 1999). Lack of knowledge about dangers of not seeking health care in
pregnancy and delivery, including inability to make independent decisions were major
barriers to seeking health care among pregnant women in Uganda (Matua, 2004).

2.8 Accessibility of antenatal care services

Physical accessibility of health services has been an important determinant of utilization
of health services in developing countries. WHO reported that distance from MCH
services, and the time and the cost involved in traveling to services are significantly
associated not only with ANC use but also with the use of institutional delivery, postnatal
and infant care services (WHO, 2006). According to the WHO, a reasonable distance to
the health facility should be about five to ten kilometres (Dennill et al. 1999). Smart
(1996) states that the environment in which services are provided for young people
should be appealing to them, probably by avoiding the clinical atmosphere often
associated with hospitals or hospital-based care.

A study done in Kalabo district of Zambia on maternity services indicated that, distance
is a significant factor affecting delay to decide to seek care from health facilities. It also
influences the delay caused by the travel time from home to the clinic. The geographical
features of Kalabo district, the uneven distribution of facilities and the absence of any
roads or transport systems were also hindrance factors to maternity service utilization
(Stekelenburg et al. 2004).

11
Chapter 3
3.0 Study Objectives
3.1 General objective
To examine the factors associated with ANC attendance amongst pregnant women in
selected rural and urban communities of the Copperbelt Province.

3.2 Specific objectives

i. To find out the proportion of late antenatal attendance amongst pregnant women
in selected rural and urban communities of the Copperbelt province

ii. To identify intrapersonal, interpersonal, institutional, community and public

policy factors associated with late antenatal attendance amongst pregnant women
in selected rural and urban communities

iii. To compare and contrast intrapersonal, interpersonal, institutional, community

and public policy factors associated with late antenatal attendance amongst
pregnant women in selected rural and urban communities

12
Chapter 4
4.0 Research Methodology
4.1 Introduction
This chapter discuses research methodology under the following headings; study sites,
study population, study design, inclusion and exclusion criteria, sampling, data
management, pilot study and study limitation.

4.2 Study sites

This study was conducted in 2 districts, Mpongwe and Ndola which are rural and urban
respectively.
Mpongwe is one of the three rural districts found on the Copperbelt province of Zambia.
It lies about 99 Km to the southwest of Ndola. The area is found within the central
plateau of Zambia lying between 1200 metres and1500 metres above the sea level. It has
generally a flat and undulating relief with low-lying hills. The District shares boundaries
with Central Province to the south, Kasempa and Lufwanyama Districts to the west and
Masaiti District to the north-east.

Mpongwe had an estimated population of 96, 888 and the expected number of
pregnancies was 5,232 (CSO 2000 projections). The district had 2 first level hospitals, 11
rural health centers and 2 company clinics.

On the other hand, Ndola is a major urban centre in Zambia, and is the provincial capital
of the Copperbelt province. The District is located at an altitude of 1,270 meters above
sea level. It is on latitude 13 degrees south and longitude 28.39 degrees east. It is located
320 kilometers north of Lusaka, the capital of Zambia and covers an area of 1,103 square
kilometers.
The district health management team had 18 health centers and 2 hospitals. Its estimated
population was 487,881 and expected number of pregnancies was 26,346 (CSO, 2000).
Antenatal care services in Ndola were provided by both private and government
institutions.

13
4.3 Study design
This was a cross-sectional quantitative study aimed at examining factors that were
associated with late antenatal attendance in selected urban and rural districts of the
Copperbelt province. The rural district that was picked was Mpongwe and on the other
hand Ndola represented the urban community.

4.4 Study variables

Dependent variable
Antenatal attendance
Early attendance refers to initiating ANC before 20th week of gestation
Late attendance refers initiating ANC at 20th gestation or more

Independent variables
Distance to health facility
Waiting time
Attitude of health professionals
Intention to get pregnant
Contraceptive utilization
Traveling time
Cost of service
Parity
Lack of privacy
Knowledge of ANC services
Local Beliefs

4.5 Study population

The study population consisted of pregnant women attending antenatal care

4.6 Inclusion criteria

a) Pregnant women

14
 b) Residents of the study areas
c) Willing to participate in the study

4.7 Exclusion criteria

a) Non- pregnant women
b) Non residents
c) Not willing to participate

4.8 Sample size determination

A sample size calculation was done using Epi InfoTM 3.5.1 ( Centers for Disease Control
and Prevention, Atlanta, GA, USA).

4.8.1 Sample size determination for Ndola

Estimate number of pregnancies for Ndola (CSO 2000 projections): 26,346
Prevalence: 70% of late ANC attendance
Worst acceptable level: 65%
Sample size at 95% confidence interval: 319
Adjusted for non-response 10% = 319/0.9 = 354
Total sample size for Ndola was: 360

4.8.2 Sample size determination for Mpongwe

Estimate number of pregnancies for Ndola (CSO 2000 projections): 5,232
Prevalence: 74% of late ANC attendance
Worst acceptable level: 69%
Sample size at 95% confidence interval: 280
Adjusted for non-response 10% = 280/0.9 = 312
Total sample size for Mpongwe was: 312

4.9 Sampling procedure

Probability sampling methods by means of multistage sampling technique was used to
reach at the pregnant women attending ANC

15
 1. 9 from 18 facilities were selected to participate in Ndola while in Mpongwe 8 out of 15
Mpongwe were selected using systematic sampling
2. Pregnant women who participated in the study were then selected by simple random
sampling

4.10 Data collection tools

A semi-structured questionnaire was administered on pregnant women.

4.11 Pre-test
The semi-structured questionnaire was pre-tested in non-participating facilities.

4.12 Ethical considerations

The research proposal was submitted to UNZA Biomedical Research ethics committee
and clearance to conduct the study was given.
Permission was sought from Mpongwe and Ndola DHMTs to conduct the research from
their health facilities.
Informed consent was obtained from all participants before the interview. The
information that was collected was kept confidential. No names were used; however, the
questionnaires were serial numbered for the purpose of data entry.

4.13 Data Management and analysis

Data from the completed questionnaires was entered in a database using the double entry
system in Epi InfoTM 3.5.1 ( Centers for Disease Control and Prevention, Atlanta, GA,
USA), with in-built consistency and range checks. The database was converted to SPSS
version 16.0 for recoding, where necessary, and final analyses.

Tabulations of characteristics (factors) were produced to determine overall distributions.

Chi-square was used to test for association and logistic regression to identify significant
predictors of ANC attendance. A p value less or equal to 0.05 was considered indicative
of a significant factor effect.

16
Chapter 5

5.0 Results

5.1 Sample Descriptions

Table 1 shows the socio-demographic characteristics of pregnant women who
participated in the study. A total number of 613 women attending antenatal clinics were
included in the study with the distribution between 2 districts almost equal; 50.1%
(n=307) to Mpongwe and 49.9% (n=306) to Ndola. The majority of the participants were
in the age category of 20- 29 years, representing 46.6% in Mpongwe and 52.0% in Ndola
respectively. Most of the women in the two districts were married [86.6% (n=266) to
Mpongwe and 83.3% (n=255) to Ndola]. Unemployment level of participants was 95.8%
in Mpongwe compared to 75.8% in Ndola. Almost all participants were Christians
(99.7% to Mpongwe and 98.4% to Ndola). Primary school was the highest level of
education attained by participants in Mpongwe (56.7%) while the majority in Ndola
(54.6%) attained Secondary school.

5.2 Obstetric characteristics

Table 2 shows obstetric characteristics of women who participated in the study. Majority
of in had 1 or more children before [74.6% (n=229) in Mpongwe compared to 61.4%
(n=188) in Ndola]. In Mpongwe the majority of women (56.0%) had 3 or more previous
pregnancies while in Ndola the majority (42.2) had 2 previous pregnancies. Most of the
respondents had their last child in the age category of 2 to 5 years; the distribution was
52.1% to Mpongwe and 42.2% to Ndola respectively. Information on initiation of ANC
revealed that 72% of the participants in Mpongwe booked for ANC late while in Ndola
the proportion was 68.6%

17
 Table 1 : Socio-demographic characteristics of participants (n=613)
**
Characteristics *Rural Urban
n(%) n(%)
Area of residence
Participants 307(50.1) 306(49.9)

Age (Years)
Mean (SD) 25.2(6.6) 26.9(6.3)
<20 79(25.7) 41(13.4)
20 - 29 140(46.6) 159(52.0)
30 and above 88(28.7) 106(34.6)

Marital status
Married 266(86.6) 255(83.3)
Single 27(8.8) 44(14.4)
Divorced 9(2.9) 2(0.7)
Windowed 3(1.0) 4(1.3)

Occupation
Employed 13(4.2) 74(24.2)
Not employed 294(95.8) 232(75.8)

Religion
Christian 306(99.7) 301(98.4)
Muslim 1(0.3) 5(1.6)

Level of education
Never been to school 20(6.5) 6(2.0)
Primary 174(56.7) 73(23.9)
Secondary 106(34.5) 167(54.6)
College/University 7(2.3) 57(18.6)
*refers to Mpongwe
**refers to Ndola

18
Table 2 : Obstetric characteristics of participants
Characteristics *Rural **Urban
n(%) n(%)
Party (number of children)
Nulliparous 78(25.4) 116(37.9)
1 or more children 229(74.6) 188(61.4)

Gravidity (number of previous pregnancies)

1 77(25.1) 65(21.2)
2 57(18.6) 129(42.2)
3 or more 172(56.0) 45(14.7)

Age of last child (years)

<2 118(38.4) 65(21.2)
2 to 5 169(52.1) 129(42.2)
>5 26(8.5) 45(14.7)

Antenatal care entry

Early 86(28.0) 96(31.4)
Late 221(72.0) 210(68.6)
*refers to Mpongwe
**refers to Ndola

19
Figure 2: Gestation age distribution at ANC Booking (District 1 represents Mpongwe and 2
represents Ndola)

20
5.3 Comparison of the prevalence of late Antenatal care attendance between
Mpongwe and Ndola districts
The prevalence of late ANC attendance, as Table 3 indicates was 72.0 % (n=221) to
Mpongwe and 68.6% (n=210) to Ndola. However, the difference between two districts
was not statistically significant [OR 0.851 (95% CI=0.6, 1.2), p=0.363].

Table 3 : Comparison of the prevalence of Late ANC attendance between Mpongwe

and Ndola
Characteristics ANC Entry OR 95% CI p- value
*Early **Late
n(%) n(%) n(%)
Area of
residence
Mpongwe 86(28.0) 221(72.0) 0.851 (0, 1.2) 0.363
Ndola 96(31.4) 210(68.6) 1
th
*refers to ANC initiation before 20 Week of pregnancy

**refers to ANC initiation after 20th week of pregnancy

Figure 3: Prevalence of Late ANC Attendance in Mpongwe and Ndola

80
70
60
50
Percentage

40
Early ANC
30
Late ANC
20
10
0
Mpongwe Ndola
Area of residence

21
5.4 Intrapersonal/individual factors associated with late ANC attendance
In Ndola district, level of education was found to be associated with late antenatal care
attendance (p-value= 0.009). Most of the women (50.9%) with college or university
education initiated ANC early compared to those in lower levels of education. In contrast
to these findings, there was no association between late ANC attendance and level of
education in Mpongwe district. Among pregnant women who had 1 or more children
before, there was a significant association in both districts (p- value= 0.001and 0.008 to
Mpongwe and Ndola respectively). Similarly, the number of previous pregnancies was
associated with late ANC attendance. In both districts, the higher the number of previous
pregnancies a woman had, the more likely that she would initiate ANC late (p-value
0.009 for Mpongwe and 0.001 for Ndola. Other factors that were associated with late
ANC attendance in Ndola were; age of last child (p-value =0.015), inadequate knowledge
about ANC (p-value 0.04), unintended pregnancy (p-value = 0.01) and perception of no
benefits in starting early (p-value = 0.007). Regarding Mpongwe district, the other factor
that was found to be significant was unintended pregnancy (p-value = 0.002).

22
 Table 4 :Intrapersonal factors associated with Late ANC attendance
*Rural **Urban

Early Late P-value Early Late P-value

Factors n(%) n(%) n(%) n(%)
Age (years) 0.274 0.768
< 20 25(31.6) 54(68.4) 11(26.8) 30(73.9)
20 to 29 42(30.0) 98(70.0) 50(31.4) 109(68.6)
30 and above 19(21.6) 69(78.4) 35(33.0) 71(67.0)

Occupation 0.137
Employed 6(46.2) 7(53.8) 28(37.8) 46(62.2) 0.169
Unemployed 80(27.2) 214(72.8) 68(29.3) 164(70.7)

Level of Education 0.245 0.009

Never been to school 3(15.0) 17(85.0) 3(50.0) 3(50.0)
Primary 45(25.9) 129(74.1) 17(23.3) 56(76.7)
Secondary 35(33.0) 71(67.0) 47(28.1) 120(71.9)
College/University 3(42.9) 4(57.1) 29(50.9) 28(49.1)

Party (no.of children) 0.001 0.008

Nulliporous 33(42.3) 45(57.7) 47(40.5) 69(59.5)
1 or more children 53(23.1) 176(76.9) 49(26.1) 139(73.9)

Gravidity (no.of previous pregnancies) 0.009 0.001

1 32(41.6) 45(58.4) 46(41.4) 65(58.6)
2 15(26.3) 42(73.3) 9(14.3) 54(85.7)
3 or more 39(22.7) 133(77.3) 41(31.5) 89(68.5)

Age of last child (years) 0.183 0.015

<2 40(33.9) 78(66.1) 29(44.6) 36(55.4)
2 to 5 39(24.4) 121(75.6) 37(28.7) 92(71.3)
>5 6(23.4) 20(76.9) 9(20.0) 36(80.0)

Inadequate knowledge about ANC 0.695 0.04

Yes 2(22.2) 7(77.8) 9(18.8) 39(81.2)
No 84(28.2) 214(71.8) 87(33.7) 171(66.3)

Pregnancy was unintended 0.002 0.01

Yes 5(9.8) 46(90.2) 6(14.3) 36(85.7)
No 81(31.6) 175(68.4) 90(34.1) 174(65.9)

There are no benefits in starting ANC early 0.074 0.007

Yes 0(0.0) 8(100.0) 4(11.4) 31(88.6)
No 86(28.8) 213(71.2) 92(33.9) 179(66.1)
*refers to Mpongwe
**refers to Ndola

23
5.5 Interpersonal factors associated with late ANC attendance
There were no interpersonal factors that were significantly associated with motivating
pregnant women to book for ANC early apart from health providers being unlikely to do
so in Mpongwe district [(73%) p-value=0.025] as table 5 indicates.

5.6 Institutional factors associated with late ANC attendance

In Mpongwe, majority of respondents [(74.7%) p-value =0.046] initiated ANC late due to
long distance to service delivery points, while in Ndola most of the respondents [(75.0) p-
value =<0.001] initiated ANC late because of long waiting time.

5.7 Community factors associated with late ANC attendance

In Mpongwe district community norm was a factor that was significantly associated with
late ANC attendance [(82.7%) p- value =0.007)], whereas for Ndola cultural belief was a
major factor of influence [(82.9%) p- value =0.008] as table 7 indicates.

24
Table 5 : Interpersonal factors associated with Late ANC attendance at Interpersonal Level
*Rural **Urban

Early Late p-value Early Late p-value

Factors n(%) n(%) n(%) n(%)
Marital status 0.687 0.832
Married 76(28.6) 190(71.4) 81(31.8) 175(68.2)
Single 6(22.2) 21(77.8) 14(31.8) 30(68.2)
Divorced 3(33.3) 6(66.7) 0(0.0) 2(100.0)
Windowed 0(0.0) 3(100.0) 1(25.0) 3(75.0)

Who motivated you to attend ANC clinics

Husband 0.284 0.88
Yes 1(16.7) 5(83.3) 43(30.9) 96(69.1)
No 8(28.2) 216(71.8) 53(31.7) 114(68.3)

Friends 0.532 0.513

Yes 1(16.7) 5(83.3) 12(36.4) 21(63.6)
No 8(28.2) 216(71.8) 84(30.8) 189(69.2)

Media (Radio, TV, Newspaper

etc)
Yes 0(0.0) 1(100.0) 1(100.0) 0(0.0)
No 86(28.1) 220(71.9) 95(31.1) 210(68.9)

Health Provider 0.025 0.644

Yes 8(53.3) 7(46.7) 8(27.6) 21(72.4)
No 78(26.7) 214(73.3) 88(31.8) 189(68.2)
*refers to Mpongwe
**refers to Ndola

25
Table 6 : Institutional factors associated with late ANC attendance
*Rural **Urban

Early Late p-value Early Late p-value

Factors n(%) n(%) n(%) n(%)
Institutional hindrances 0.046 < 0.001
Distance 67(25.3) 198(74.7) 10(43.5) 13(56.6)
Long waiting time 6(42.9) 8(57.1) 57(25.0) 17(75.0)
Attitude of Health Workers 5(38.5) 8(61.5) 22(59.5) 15(40.5)
Privacy 8(53.3) 7(46.7) 7(38.9) 11(61.1)
*refers to Mpongwe
**refers to Ndola

Table 7 :Community factors associated with late ANC attendance

*Rural **Urban
Early Late p-value Early Late p-value
Factors n(%) n(%) n(%) n(%)
Community hindrances 0.007 0.008
Misconceptions 18(31.6) 39(68.4) 31(37.3) 52(62.7)
Community norm 19(17.3) 91(82.7) 52(35.4) 95(64.6)
Cultural beliefs 49(35.0) 91(65.0) 13(17.1) 63(82.9)
*refers to Mpongwe
**refers to Ndola

26
5.8 Public Policy factors associated with late ANC attendance
As shown in table 7 there were no public policy variable that were significantly
associated with late ANC attendance in Ndola. However, traveling time [(91.9%) p-value
=<0.001] and inadequate health facilities [(80.6%) p-value =0.021] were factors that
significantly associated with ANC attendance.

Table 8: Public Policy factors associated with late ANC attendance

*Rural **Urban
p-
Early late p-value Early late value
Factors n(%) n(%) n(%) n(%)

High cost 0.67 0.445

Yes 9(31.0) 20(69.0) 4(21.1) 15(78.9)
No 77(27.7) 201(72.3) 92(32.1) 195(67.9)

Traveling
time <0.001 0.891
Yes 14(8.1) 159(91.9) 6(30.0) 14(70.0)
No 72(5.7) 62(46.3) 90(31.3) 196(68.5)

Inadequate Health facilities 0.021 0.4

Yes 19(19.4) 79(80.6) 23(27.7) 60(72.3)
no 67(32.1) 142(67.9) 73(32.7) 150(76.3)
*refers to Mpongwe
**refers to Ndola

27
5.9 Logistic regression analysis
Results show that in Mpongwe nulliparous women were59% (AOR 0.411, 95% CI 0.238,
0.758) less likely to initiate ANC late compared to multiparous women while the
proportion in Ndola was 48% (AOR 0.518, 95% CI 0.316, 0.848). Women with 3 or
more previous pregnancies in Mpongwe were 2.4 times (AOR 2.425, 95% CI 1.362,
4.318) more likely to start ANC late compared to women falling pregnant for the first
time (primegravida); in the same way, women who had 2 previous pregnancies in Ndola
were 4 times (AOR 4.264, 95% CI 1.907, 9.453) more likely to start ANC late. In Ndola,
the likelihood of women with last child in the age group 2-5 years to start ANC late was 2
times (AOR 2.003, 95% CI 1.079, 3.724) higher than women with last child less than 2
years; also the likelihood of women with last child more than 5 years old was 3 times
(AOR 3.222, 95% CI 1.338, 7.761) higher. In Ndola likelihood of women who had
inadequate knowledge about ANC to start ANC late was 2.2 times (AOR 2.205, 95% CI
1.021, and 4.759) higher than women with adequate knowledge. Women who fell
pregnant unintentionally had a higher odds of staring ANC late in both Mpongwe[ 4.2
times (AOR 4.258, 95% CI 1.631, 11.119)] and Ndola [3.1 times (AOR 3.103, 95% CI
1.261, 7.641)] respectively. The perception of no benefits derived from commencement
of ANC early was associated with 4 times (AOR 3.983, 95% CI 1.365, 11.627) likelihood
of late attendance in Ndola.
Compared to lack of privacy at health institutions, pregnant women in Mpongwe were
3.4 times (AOR 3.377, 95% CI 1.180, and 9.660) more likely to initiate ANC late
because of long distance to health facilities. Compared to misconceptions on ANC,
pregnant women in Mpongwe were 2.2 times (AOR 2.211 95% CI 1.049, 4.660) more
likely to start ANC late because of community norm(less value attached to ANC); while
in Ndola late ANC attendance was 2.9 times (AOR 2.899, 95% CI 1.372, 6.083) higher
due to cultural beliefs than misconceptions. Women who spent longer time traveling to
ANC were 13.2 times(AOR 13.189 95% CI 6.931, 25.096) more likely to start ANC late
than those who spent less time in Mpongwe, while 96% (AOR 1.962, 95% CI 1.100,
3.500) of pregnant women were more likely to start ANC late because of inadequate
Health facilities.

28
Table 9: Predictors of Late ANC attendance in Mpongwe and Ndola-logistic regression
Predictors Rural Urban
p-
AOR 95% CI p-value AOR 95% CI value
Parity
Nulliparous 0.411 (0.238, 0.758) 0.001 0.518 (0.316, 0.848) 0.009
1 or more children 1 1

Gravidity
1 1 1
2 1.991 (0.947, 4.188) 0.69 4.246 (1.907, 9.453) <0.001
3 or more 2.425 (1.362, 4.318) 0.003 1.536 (0.905, 2.606) 0.111

Age of last child (years)

<2 1 1
2 to 5 1.591 (0.941, 2.689) 0.83 2.003 (1.077, 3.724) 0.028
>5 1.709 (0.636, 4.595) 0.288 3.222 (1.338, 7.761) 0.009

Inadequate Knowledge about ANC

Yes 1.374 (0.280, 6.748) 0.696 2.205 (1.021, 4.759) 0.044
No 1 1

Unintended Pregnancy
Yes 4.258 (1.631, 11.119) 0.003 3.103 (1.261, 7.641) 0.014
No 1 1

No perceived benefits of starting

early
Yes - - - 3.983 (1.365, 11.627) 0.011
No 1 1

29
Table: Predictor of Late ANC attendance in Mpongwe and Ndola logistic regression
Predictors *Rural **Urban
AOR 95% CI p-value AOR 95% CI p-value
Institutional hindrances
Distance 3.377 (1.180, 9.666) 0.023 0.827 (0.236, 2.905) 0.767
Long waiting time 1.524 (0.352, 6.601) 0.573 1.909 (0.707, 5.158) 0.202
Attitude of Health workers 1.829 (0.404, 8.270) 0.433 0.434 (0.137, 1.324) 0.156
Privacy 1 1

Community hindrances
Misconceptions 1 1
Community norm 2.211 (1.049, 4.660) 0.037 1.089 (0.623, 1.904) 0.765
Cultural beliefs 0.857 (0.444, 1.655) 0.646 2.889 (1.372, 6.083) 0.005

Traveling time
Yes 13.189 (6.931, 25.096) <0.001 1.071 (0.399, 2.879) 0.891
No 1 1

Inadequate Health facilities

Yes 1.962 (1.100, 3.500) 0.023 1.27 (0.728, 2.214) 0.4
No 1 1
*refers to Mpongwe
**refers to Ndola

30
Chapter 6
6.0 Discussion
6.1 Prevalence of Late ANC Attendance in Selected Rural and Urban Communities
of the Copperbelt Province
Information that was gathered from this study shows that the prevalence of late antenatal
care attendance is high in both rural and urban communities. The prevalence of late ANC
attendance was 72.0 % in rural and 68.6% in urban districts respectively. This result is
slightly lower than what was reported in the Nigerian study where the prevalence of late
ANC attendance was 81% (Adekanle, 2008) and higher than the 41% established in the
Australian study (Trinh et al., 2004). In this study it was found that the difference of late
ANC attendance between two districts was not statistically significant. This result is
different from what was reported in a study done in Vietnam where it was reported that
early ANC utilization was lower in the rural than the urban communities (Tran et al.,
2007). There was no significance difference in the proportion of late ANC attendance
between rural and urban areas probably because rural areas are more active in the
provision of outreach (mobile) maternity services than urban districts.

6.2 Factors Associated With Late ANC Attendance

The results from this study suggest that human behavior, in this case late initiation of
antenatal care, is affected by a multilayered set of systems; including family, peer group,
and neighborhood, as well as effects of health care, social services systems, cultural
belief and value system of the society in which individuals live (Pilot et al., 2008).

6.2.1 Intrapersonal factors associated with late ANC attendance

In this study maternal age was not associated with late antenatal care attendance. This is
in line with a study done in Sudan where it was observed that there was no effect of
maternal age on ANC utilization (Ali et al., 2010). This study established that there was a
tendency of initiating ANC late amongst women of high parity and gravidity in both rural
and urban communities. This could be as result of limited resources in the family and
negative perceptions resulting from previous pregnancy experiences. It is also possible

31
that multiparous women feel more confident after previous experience and feel that
starting ANC early is not necessary.
Regarding knowledge about ANC, the study revealed that women with adequate
knowledge were likely to initiate ANC early compared to those without. This finding is
similar to what Tariku and others found out in their study where women who were well
informed about ANC were more likely to book for ANC within the recommended time
(Tariku, 2010). Furthermore, this study was able to prove that pregnant women who had
the perception of no benefits are derived from staring early, tend to start ANC late.
Therefore, it could be concluded that health education could be important in the
improvement of timing of ANC attendance.
The intention to get pregnant was an important factor in this study. In contrast to women
who planned their pregnancy, women who fell pregnant unintentionally were more likely
to start ANC late. The finding is in line with study done in New South Wales, Australia
where it was indicated that younger women with unplanned pregnancy lacked
information about ANC resulting in late attendance (Trinh, 2004). It is believed that
wanted pregnancies are more cared for by pregnant women and their spouses; this enable
women to book for ANC timely.

6.2.2 Institutional and Public Policy Factors Associated with Late ANC Attendance
In the current study, pregnant women in rural areas reported that availability and
accessibility of health facilities could be the cause of late antenatal attendance. This claim
was not found to be significantly associated with late antenatal attendance in urban
communities. The effect of differences in attendance of antenatal care between the urban
and rural areas could be due to differences in distribution of health facilities. Usually,
these facilities are disproportionately distributed in favor of urban areas in most
developing countries making them more available and accessible to urban women
(Adamu, 2011). A study conducted in Haiti revealed that longer traveling time and
greater distances to health facilities in rural areas constituted the greatest barriers to
antenatal care utilization (Alexandre et al., 2005). Similarly this study established long
traveling time, long distance to health facilities and inadequate health facilities were
significantly affecting the timing of antenatal attendance. This is in agreement with a

32
study done in Kalabo district of Zambia on maternity services which indicated that
distance is a significant factor affecting delay to decide to seek care from health facilities.
It also influences the delay caused by the travel time from home to the clinic. The
geographical features of Kalabo district, the uneven distribution of facilities and the
absence of any roads or transport systems were also hindrance factors to maternity
service utilization (Stekelenburg et al. 2004).
Univariate analysis of this study revealed that long waiting time prior to being attended to
at ANC facilities was a barrier to initiating ANC in recommended period.

6.2.3 Community Factors Associated with Late ANC Attendance

The study was not able to establish the effect of misconceptions on the ANC attendance.
However, it was observed that it was a community norm to attend ANC late in rural
communities because of less value attached to it. Additionally, the study revealed that in
urban communities cultural (traditional) beliefs played a major role in deterring early
antenatal attendance. It is believed that in some cultures mobility of pregnant women is
restricted, thus creating a significant barrier to accessing antenatal services. According to
Mekonnen et al (2002), women who followed a traditional belief system are less likely to
use maternity services service than religious groups. Cultural beliefs and practices often
lead to self-care and consultation with tradition healers. In most communities women
seek advice on important health matters from older women first before turning to health
professionals.

6.3 Limitations of the Study

Considering that the study was conducted from health facilities, there is a possibility that
factors related to attitude of health workers could have been under reported.
The use of different research assistants could have created variances, although they were
oriented on questioning and recording of responses. The researcher also checked for
completeness of the questionnaire after the interview.

33
6.4 Conclusion
Late antenatal care attendance remains high in both rural and urban districts indicating
the need for intensified and more focused utilization of resources aimed at increasing
sensitization of importance of early attendance for high risk groups such as women with
unplanned pregnancies, inadequate knowledge about ANC, cultural beliefs and
multiparous .

6.5 Recommendations
The study has provided information on the various aspects of late antenatal attendance in
urban and rural communities. Therefore, the following recommendations if implemented
may improve timely accessing of health services and the quality of service provided;
District Medial Offices should increase accessibility of ANC services by proving
scheduled outreach programs in remote areas
Ministry of health and District Medical Offices need to provide continuous health
education on the importance of timely accessing of ANC services through the
media and community sensitization meetings
Campaign against harmful community norms and cultural beliefs that could
hinder mothers from accessing health services
Ministry of Health should improve on the staffing of health care workers at all
levels of service delivery
Government through Ministry of Health should construct more health facilities to
improve availability and accessibility especially in rural areas
Ministry of health and District Medical Offices should strengthen other aspects of
reproductive health such as family planning to reduce on the unintended
pregnancies.

34
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APPENDICES
APPENDIX (I)
QUESTIONNAIRE: Serial
no.
INTERVIEW FOR PREGNANT WOMEN ATTENDING ANC IN MPONGWE
AND NDOLA DISTRICTS

SECTION A
SOCIO-DEMOGRAPHIC DATA
1. Age (Last birthday)
2. Marital status
1. Married
2. Single
3. Divorced
4. Widowed

3. Occupation
1. Employed
2. Not employed

4. What type of employment (specify).

5. Religion
1. Christian
2. Muslim
3. Hindu
4. Others .

6. Level of education
1. Never been to school
2. Primary
3. Secondary
4. College/university
SECTION B:
OBSTETRIC INFORMATION

7. Parity

40
 8. Gravidity ..
9. Age of the last child ..

10. How old was your pregnancy when you made

your first ANC visit?.........
(Age of pregnancy in weeks)

11. What family planning method did you

use before you fell pregnant?
1. Pills
2. Injections
3. IUCD
4. Implants
5. Condoms
6. Breastfeeding
7. Nothing

12. What were the reasons for stopping using family planning
methods?

SECTION C
Individual level

13. List factors that influenced you to book for antenatal

.
14. What hindered you to book for ANC early?
(before 20th week of pregnancy)
1. Pregnancy was unintended
2. No knowledge about ANC
3. Not satisfied with service
4. No benefits of starting early
5. Others (specify.)

15. Would being tested for HIV prevent you from attending ANC
1. Yes
2. No

Interpersonal level

41
 16. Who motivated you to book for ANC?
1. Husband/spouse
2. Friend
3. Media
4. Health provider
5. TBA
6. Others (specify) ..

17. What was/is your husbands attitude towards ANC?

1. Supportive
2. Not supportive
3. Dont know

If supportive, how were you supported?

..
.

18. Do you think it would be a good idea for husbands to be accompanying pregnant
women to ANC?
1. Yes
2. No

Give reasons for your answer to question 17

Institutional level
19. Which of the following factors do you think could prevent you from attending ANC
early?
1. Distance to ANC services
2. Long waiting time
3. Negative attitude of health providers
4. Lack of privacy

Community level
20. What community influence could stop you attending ANC
1. Misconceptions on ANC
2. Value attached to ANC (Community
norm)
3. Cultural beliefs

42
Public policy
21. Could High cost of accessing ANC prevent you from booking early?
1. Yes
2. No
22. Could Traveling time hinder you from accessing ANC on time?
1. Yes
2. No
23. Could inadequate health facilities prevent you from accessing ANC on time?
1. Yes
2. No

Section D
24. What strategies could be put in place to enhance ANC attendance?
.
..
..

43
APPENDIX (II)
INFORMATION SHEET AND CONSENT FORM
TOPIC: A STUDY TO EXAMINE FACTORS ASSOCIATED WITH LATE
ANTENATAL CARE ATTENDANCE AMONGST PREGNANT WOMEN IN
SELECTED RURAL AND URBAN COMMUNITIES OF THE COPPERBELT
PROVINCE

INTRODUCTION
I am a Master of Public Health student at the University of Zambia, school of Medicine. I
would like to request for your participation in my research.

PURPOSE OF THE STUDY

The purpose of the study is to examine the factors associated with late ANC attendance
amongst pregnant women in Mpongwe and Ndola districts. This will help future policy
formulation to regarding provision of antenatal care services. This will ultimately
improve the utilization and quality of ANC.

VOLUNTARY PARTICIPATION
Your participation in this study is purely voluntary. You are free to decline to participate
in the study or withdraw if you so wish without consequences.

RISKS AND DISCOMFORTS

The study does not involve any obvious risks to you, except I will take a bit of your time
as you answer the questionnaire.

BENEFITS
There are no monetary benefits for participating in this study. However, by participating
in the study, you will contribute to information that will assist ministry of health and
policy makers to consider community opinions as they formulate policies. Therefore the
time you will spend in discussing the issue is highly appreciated.

44
CONFIDENTIALITY
I would like to reassure you that your personal information that you will entrust me with
will not be disclosed to any other third party unless legally required to do so and with
your consent. Your identity will be kept anonymous by using a number to identify you
instead of your name.

INFORMATION AND CLARIFICATION

Please be informed that if you at any time need clarifications over the research study,
direct your questions to:

DR ISAAC BANDA
UNIVERSITY OF ZAMBIA
SCHOOL OF MEDICINE
DEPARTMENT OF COMMUNITY MEDICINE
P.O. BOX 50110
LUSAKA
CELL # 0977348278
Email: matembobanda@yahoo.co.uk

OR
THE CHAIRPERSON
BIOMEDICAL RESEARCH ETHICS COMMITTEE OF UNZA
UNIVERSITY OF ZAMBIA
P.O. BOX 50110
LUSAKA. ZAMBIA
TEL # 01 256067

45
CONSENT FORM
The purpose of the study has been explained to me and I fully understand what is
involved. I have volunteered to participate in the study out of my own free will.

Signed:.
(May use participants right thumb print if unable to sign)
Date:.
Witness:

DR ISAAC BANDA
UNIVERSITY OF ZAMBIA
SCHOOL OF MEDICINE
DEPARTMENT OF COMMUNITY MEDICINE
P.O. BOX 50110
LUSAKA
CELL # 0977348278
Email: matembobanda@yahoo.co.uk

OR
THE CHAIRPERSON
BIOMEDICAL RESEARCH ETHICS COMMITTEE OF UNZA
UNIVERSITY OF ZAMBIA
P.O. BOX 50110
LUSAKA. ZAMBIA
TEL # 01 256067

46
APPENDIX (III)
Permission Request

The District Medical officer

Ministry of Health
P. O Box 55
Mpongwe.

Ufs: Head of Department

Community Medicine
UNZA

Dear Sir,
RE: PERMISSION TO CONDUCT A RESEARCH FROM YOUR HEALTH
FACILITIES
I am a Master of Public Health student at the University of Zambia, school of Medicine.
As partial fulfillment of the program, I am required to conduct a research study.

In this regard, I am requesting for permission to conduct my study from your health
facilities.
The proposed research will look at factors associated with antenatal attendance in
selected rural and urban communities of Zambia.

Your favorable response will be greatly appreciated.

Yours faithfully,

Dr Isaac Banda
MPH STUDENT

47
Appendix (IV)
Project management
Introduction
This chapter depicts graphically in form of a Gantt chart, the order in which various
activities will be completed and the duration for each. It also presents a budget for the
research study showing the resources required.

Work plan and Budget

Gantt chart for summarizing work plan for the research project (Figure 4).
Description Ja Fe Ma Ap Ma Ju Ju Au Se Oc No De
of Activity n b r r y n l g p t v c

Presentation
of proposal
presentation
ethics
committee
Mobilizatio
n of
resources
Data
Collection
Data
Analysis
Report
Writing
Submission
of research
project

48