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Association Between Compliance With the New WHO-Recommended Frequency and Timing of Antenatal Care Contacts and Receiving Quality Antenatal Care in Cameroon

Association Between Compliance With the New WHO-Recommended Frequency and Timing of Antenatal... The objective of this study was to determine whether adherence to the new WHO recommendations for the frequency and timing of antenatal care (ANC) contacts was associated with receiving quality prenatal care in Cameroon. The 2018 Cameroon Demographic and Health Survey yielded a weighted sample of 5,694 women aged 15 to 49 years for analysis. We found that 8.9% of women had at least eight ANC contacts, with 47.3% of those occurring during the first trimester. Overall, 28.3% (95% CI [26.4, 30.3]) of the women received all eight ANC interventions studied. Women who made at least eight ANC contacts prior to delivery had a higher chance of receiving the full set of interventions (AOR = 1.41; 95% CI [1.00, 1.99]). Even among women who started ANC in the second trimester, those who made at least eight contacts were more likely than those who made fewer contacts to receive the full set of interventions. Furthermore, women who had their first contact later in the second (AOR = 0.85; 95% CI [0.72, 0.99]) or third trimester (AOR = 0.33; 95% CI [0.19, 0.57]) were less likely to receive the full set of interventions. According to our findings, Cameroonian women who followed the new global recommendations for prenatal care were more likely to receive quality prenatal care before giving birth. To have a positive pregnancy experience, however, more women must begin ANC in the first trimester and have at least eight contacts with health care providers before delivery. Keywords antenatal care, maternal health, quality care, Cameroon Antenatal care (ANC) during pregnancy provides a vari- Introduction ety of services that can help with the early prevention, detec- Globally, the number of women who die from pregnancy and tion, and treatment of risk factors. It is also frequently used childbirth-related causes or complications has decreased, but to promote the use of skilled birth attendants as well as remains high, especially in low- and middle-income countries healthy behaviors such as breastfeeding, early postnatal care, (LMICs). An estimated 295,000 women died from pregnancy- and pregnancy spacing planning (Lincetto et al., 2013). related causes in 2017, and 2.4 million newborns die before Malaria, syphilis, tetanus, HIV/AIDS, and other undiag- their first 28 days of life each year, the majority of whom are nosed infections during pregnancy, as well as high blood born prematurely (United Nations Inter-agency Group for pressure, diabetes, and other pre-existing health conditions, Child Mortality Estimation, 2017; World Health Organization frequently complicate pregnancy and endanger both mother [WHO], 2019a). At least 94% of the global maternal deaths and child. However, the majority of adverse maternal and occur in LMICs, with sub-Saharan Africa (SSA) and Southern perinatal outcomes can be avoided with high-quality ANC Asia accounting for approximately 86% of the global number of maternal deaths; the burden is highest in SSA, with 196,000 School of Public Health, University for Development Studies, Tamale, Ghana deaths (WHO, 2021). The United Nations’ Global Strategy for University of Ngaoundere, Cameroon Women’s, Children’s, and Adolescent’s Health (2016–2030) Corresponding Author: prioritizes maternal health, with an ambitious mortality reduc- Michael Boah, Department of Epidemiology, Biostatistics, and Disease tion target of fewer than 70 deaths per 100,000 live births Control, School of Public Health, University for Development Studies, included in the Sustainable Development Goals (SDGs; Every P.O Box TL 1883, Tamale 00233, Ghana. Woman Every Child, 2015; WHO, 2019b). Emails: boahmichael@gmail.com; mboah@uds.edu.gh Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (https://creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 SAGE Open (Afulani, 2016; Arunda et al., 2017; Kuhnt & Vollmer, 2017; by Ameyaw et al. (2021). They reported that women’s Tuladhar & Dhakal, 2011). The widely used global bench- empowerment indicators such as knowledge and attitude mark for ANC coverage was reporting at least four ANC vis- toward domestic violence were associated with receiving its. But studies have shown that pregnant women need more quality care during pregnancy in Cameroon. However, than four ANC visits to get all the care they need and lower because the focus of their study was on how women’s their risk of dying during pregnancy (Benova et al., 2018; empowerment affects their ability to get good care during Carvajal-Aguirre et al., 2017; Kyei et al., 2012). pregnancy, more research is needed to better understand the The WHO issued new comprehensive recommendations relationship between the frequency and timing of ANC con- on routine ANC for positive pregnancy outcomes in tact under the revised WHO guidelines and the likelihood of November 2016, taking a human rights-based approach to getting basic ANC interventions during pregnancy. addressing the complex nature of ANC practice, organization, This study examined the relationship between adhering and delivery within diverse health systems (WHO, 2016). to the new WHO antenatal care contact frequency and tim- The new guidelines recommend a minimum of eight ANC ing recommendations and receiving high-quality prenatal contacts, with the first occurring in the first trimester (up to care during pregnancy using data from Cameroon’s 2018 3 months of gestation). According to data from Africa, the Demographic and Health Survey (DHS). The results will prevalence of a minimum of eight contacts is generally low in help policymakers and health care providers figure out what most countries, ranging from 1% in Senegal, Zambia, and they can do and how well they follow the standard ANC Uganda to 43% in Ghana (Ekholuenetale, 2021). The report- model recommended by the WHO. ing of eight or more ANC contacts during pregnancy has been linked to factors such as the timing of the first ANC contact, Methods maternal education, and wealth (Ahinkorah et al., 2021; Ekholuenetale, 2021; Ekholuenetale, Benebo, et al., 2020). Data Source Cameroon is one of 16 SSA countries with a high maternal In most countries, including Cameroon, the DHSs are the mortality rate. In 2017, the country had 529 maternal deaths per most comprehensive sources of population-level data on 100,000 live births (WHO, 2019a). A review of the literature maternal and child health outcomes. However, these surveys identified no or inadequate ANC, hypertensive disorders of have a significant shortcoming in that they cannot provide pregnancy, severe malaria, HIV/AIDS, pre-existing co-morbid- information on the type of prenatal care provided. Nonetheless, ities, ectopic pregnancy, placenta previa, anemia, pneumonia, basic services such as weighing, urine analyses, blood pres- heart disease, and delays in arrival at health facilities as drivers sure measurement, tetanus vaccination, and so on are fre- of maternal mortality in Cameroon, the majority of which can quently recorded during ANC. This data does not cover the be detected and managed early in pregnancy (Wirsiy et al., entire range of services provided, but it can be used to deter- 2019). However, with the previous benchmark of at least four mine whether women receive the bare minimum of services. ANC contacts, there was underutilization of ANC. Although As a result, information obtained through the DHS can pro- pregnant women in Cameroon have nearly universal access to vide, at a minimum, a basic indicator of care quality. one skilled ANC contact, a significantly lower percentage have For this study, data were obtained from the 2018 Cameroon their first contact in the first trimester, and only about two-thirds Demographic and Health Survey (CDHS), which was imple- have four or more contacts before delivery (National Institute of mented by the National Institute of Statistics (NIS), in collabo- Statistics (Cameroon) & ICF, 2020). According to a recent ration with the Ministry of Public Health. The 2018 CDHS is study, 6.3% of married women in the country had eight or more the fifth DHS in Cameroon since 1991. A nationally represen- ANC contacts, with 35.6% of contacts occurring during the first tative sample of 13,527 women aged 15 to 49 from all selected trimester (Ahinkorah et al., 2021). households and 6,978 men aged 15 to 64 from half of the Measuring health-care contacts with the health system selected households were interviewed, which represented a without data on the care received is insufficient to reduce response rate of 98% for women and 98% for men. The sample preventable deaths among women and newborns and achieve design for the 2018 CDHS provides estimates at the national SDG-3 by 2030. Furthermore, emerging data show that even level, for urban and rural areas, and 12 study domains. The in LMICs with high levels of ANC coverage, quality is sig- final report contains additional information about the study nificantly lower and inequitable (Arsenault et al., 2018; design, sampling strategy, and data collected in the 2018 CDHS Carvajal–Aguirre et al., 2017). Nevertheless, there is a dearth (National Institute of Statistics (Cameroon) & ICF, 2020). of literature on how compliance with the revised guidelines on ANC coverage relates to receiving quality care in Cameroon, a country with a high burden of maternal mortal- Sample ity where most of the existing studies have focused on the utilization of ANC, including the determinants of the timing For this analysis, the children’s recode file was used. We and frequency of ANC contacts (Ahinkorah et al., 2021; identified a total of 9,733 women aged 15 to 49 years with Tolefac et al., 2017; Venyuy et al., 2020). We found a recent information covering a wide range of topics. In the dataset, publication on the quality of care received during pregnancy 6,463 women had information on ANC, of which 822 (12.7%) Boah et al. 3 did not use ANC during their most recent pregnancy, and 68 receiving quality maternal health care. Existing literature did not know the number of ANC contacts they made during linking these characteristics to the content of care received their most recent pregnancy. The women who did not use influenced their inclusion (Ameyaw et al., 2021; Jiwani ANC during their most recent pregnancy and those who did et al., 2020). not know the number of contacts they made before delivery were excluded in the analysis. Furthermore, women who did Statistical Analysis not know the gestational age of their pregnancy at their initial ANC contact (n = 6) were also excluded. A total of 5,567 Descriptive statistics were used to describe the distribution of women (weighted N = 5,694) who gave birth within the previ- respondents by demographic and economic characteristics, ous 5 years and had information on ANC use were studied. the number of ANC contacts, the timing of the first ANC con- tact, and the coverage of interventions received by mothers. The association between each of the independent variables Measures and the outcome variable was investigated using a design- based Chi-square test. To investigate the relationship between Dependent Variable Measurement the number of ANC contacts, as well as the timing of the first Based on their availability in the dataset and in line with contact, and the receipt of quality prenatal care, a series of global recommendations, the study included eight ANC inter- binary logistic regression models were used. In model 1, we ventions as a proxy for ANC quality. We evaluated the fol- conducted a univariate analysis to determine the relationship lowing ANC services: blood pressure measurement, blood between having at least eight contacts and the outcome. The sample collection for analysis, tetanus toxoid vaccination, analysis in model 2 was restricted to the timing of the first urine testing, intestinal parasite treatment, HIV counseling ANC contact. The final model (model 3) took into account and testing, iron–folate supplementation, and sulfadoxine/ the impact of other maternal, obstetric, demographic, and pyrimethamine for malaria prevention. The survey asked economic factors on the outcome. The “svy” commands were women if they had received any of these services at ANC dur- used to account for the cluster sampling design and sampling ing their most recent pregnancy. If a woman reported receiv- weights. The statistical significance level was set at p0.05. ing the service, she received a “1 point,” otherwise she The findings are presented in the form of adjusted odds ratios received a “0 point.” A composite quality of maternal health (AOR) with confidence intervals. Stata/SE 13.0 was used for care indicator (denoted total number of interventions received) all analyses (StataCorp LP, College Station, TX, USA). was developed by counting the number of interventions mothers received from the set of interventions evaluated. For Ethical Considerations regression analysis, a dummy variable with a binary outcome was created, with “0” representing women who received The dataset used in this paper is publicly available on the fewer than eight interventions (i.e., 0–7) and “1” representing DHS program website in de-identified form. As a result, no women who received the full set of interventions. additional ethical approval from an Institutional Review Board (IRB) was required for the current study (IRB). The Primary Independent Variables Results The number of ANC contacts made prior to delivery and the timing of the first contact are the main independent variables. Characteristics of Study Respondents The information was gathered from women’s self-reports of More than half of all study participants (66.4%; 95% CI [64.2, the number of ANC contacts they made prior to delivery dur- 68.5]) had four to seven ANC contacts, while only 8.9% (95% ing their most recent pregnancy, as well as the age of the CI [7.8, 10.1]) had at least eight contacts before delivery. The pregnancy when the first ANC contact occurred. The number majority of women (59.3%) were married, and 51.8% lived in of contacts was classified as 1 to 3, 4 to 7, and 8 or more urban areas. Approximately 47.0%, 49.0%, and 3.0% of the contacts based on the previous ANC model and the 2016 women made their first ANC contact in the first, second, and WHO recommendation. The timing of the first ANC contact third trimesters, respectively. Table 1 shows the distribution was classified as first trimester: 0 to 3 months; second trimes- of participants based on the other characteristics. ter: 4 to 6 months; and third trimester: >6 months. Coverage of Antenatal Care Covariates Interventions Among the Study Women’s demographic, obstetric, and economic character- Participants istics such as age, highest level of education, parity, marital status, place of residence, region, and wealth quintile were The majority of ANC interventions had a high level of cover- included as confounding factors to examine the indepen- age. For example, more than 9 in 10 women reported that dent relationship between the number of ANC contacts and they had been weighed (97.8%) and that their blood pressure 4 SAGE Open (97.7%), urine (92.4%), and blood (97.1%) samples had Table 1. Descriptive Statistics of the Study Participants (Weighted N = 5,694). been taken during ANC for the most recent pregnancy. However, of all the interventions offered to women during Variables Frequency Percentage (%) ANC, giving drugs to treat intestinal parasites had the lowest Number of ANC contacts coverage (36.0%; Figure 1a). In addition, 0.2% received 1–3 1,409 24.7 none of the interventions and one intervention during ANC, 4–7 3,780 66.4 while 42.3% received seven interventions. Overall, 28.3% ≥8 505 8.9 (95% CI [26.4, 30.3]) of the women received the full set of Timing of the first ANC contact interventions investigated (Figure 1b). First trimester 2,692 47.3 Second trimester 2,810 49.4 Third trimester 192 3.4 Receipt of the Full Set of Antenatal Number of children ever born Care Interventions by Antenatal 1–2 2,389 41.9 Care Coverage Indicators and Key 3–4 1,655 29.1 Demographic and Economic Factors ≥5 1,650 29.0 Age group The distribution of antenatal care interventions by predictor 15–24 1,797 31.5 variables is shown in Table 2. The study found significant dif- 25–34 2,736 48.1 ferences in the receipt of all eight interventions depending on 35–49 1,161 20.4 the number of ANC contacts made during pregnancy and the Education timing of the first contact. In comparison to their counter- No formal education 1,161 20.4 parts, a significant percentage of women who had at least Primary 1,739 30.5 eight ANC contacts during their pregnancy received all eight At least secondary 2,794 49.1 interventions, according to the data. Similarly, more women Marital status who had their first contact during the first trimester received Never in a union 753 13.2 the full set of ANC interventions than those who had their Married 3,377 59.3 first ANC contact in the second or third trimester. Among the Living with partner 1,147 20.1 subsample of women who made at least eight contacts during Widowed 88 1.5 the first trimester, a slightly higher percentage of those who Divorced 61 1.0 made one to three and four to seven contacts received all Separated 268 4.7 interventions (p = .387). On the other hand, among women Region Adamawa 217 3.8 who made their first visit in the second trimester, a greater Center (without Yaoundé) 633 11.1 proportion of those who made at least eight contacts received Douala 612 10.7 all the interventions than the other groups. There were signifi- East 376 6.6 cant differences in the receipt of the full set of ANC interven- Far-North 917 16.1 tions among women based on age, education, marital status, Littoral (without Douala) 214 3.8 region, place of residence, and wealth quintile (Table 2). North 700 12.3 Binary logistic regression analysis of the relationship North-West 403 7.1 between eight or more antenatal care contacts and the receipt West 662 11.6 of the full set of antenatal care interventions. South 295 5.2 Bivariate analysis in Model 1 revealed that having made at South-West 101 1.8 least eight contacts during pregnancy was associated with Yaoundé 564 9.9 increased odds of receiving all interventions investigated Place of residence (OR = 2.16; 95% CI [1.58, 2.97]). In Model 2, the analysis Urban 2,949 51.8 showed that women who made their first contact in the sec- Rural 2,745 48.2 ond or third trimesters had reduced odds of receiving all the Wealth quintile interventions (AOR = 0.65; 95% CI [0.56, 0.77] and Poorest 920 16.2 AOR = 0.26; 95% CI [0.12, 0.34], respectively). We also dis- Poorer 1,204 21.1 covered that women who had their first ANC contact in the Middle 1,201 21.1 second and third trimesters had a lower chance of receiving Richer 1,264 22.2 the full set of interventions. Women’s obstetric, demographic, Richest 1,105 19.4 and economic characteristics were included as confounding factors in the full model (Model 3). According to the findings, CI [1.00, 1.99]). The model fitness statistics showed that there having at least eight contacts increased the likelihood of was not enough statistical evidence (p = .317) to indicate a receiving all ANC interventions by 41% (AOR = 1.41; 95% Boah et al. 5 Figure 1. Coverage of antenatal care interventions among the study participants: (a) antenatal care interventions and (b) number of interventions received. lack of fit in our model. Other factors linked to receiving the of pregnant women making their first contact in the second full set of interventions included the timing of the first ANC trimester and more than half making four to seven contacts contact, marital status, region, the number of children born, before delivery. Similar patterns have been observed by other and wealth quintile (Table 3). researchers in less resourced settings around the world, including but not limited to Ghana, Nigeria, and Myanmar (Ahinkorah et al., 2021; Ekholuenetale, Benebo, et al., 2020; Discussion Ekholuenetale, Nzoputam, et al., 2020; Mugo et al., 2020). In Prior to 2016, the widely used global indicator for measuring LMICs, at least half of pregnant women contact the health ANC coverage was at least four ANC visits, which was later system on time, and one in every nine pregnant women con- found to be insufficient for pregnant women to receive all of tacts the health system at least eight times before giving birth the necessary ANC interventions and to reduce the risk of (Jiwani et al., 2020). Noncompliance with the minimum of maternal mortality, particularly when the first contact is delayed eight contacts is, indeed, a common occurrence in SSA and (Benova et al., 2018; Carvajal-Aguirre et al., 2017; Kyei et al., has been estimated to range from 99% in Zambia to 73% in 2012). The WHO issued new guidelines in 2016 regarding the Libya (Odusina et al., 2021). Although the profile of women number of ANC contacts required for a positive pregnancy in Cameroon who initiate ANC late and make fewer than experience, increasing the minimum of four visits to eight eight contacts was not explored in this study, an earlier study ANC contacts, with the first contact occurring in the first tri- reported that women in the study area who exhibited these mester and increased contacts occurring during the third tri- patterns were adolescents, had no formal education, had three mester (WHO, 2016). Increased coverage of recommended to four children, and were from the poorest socioeconomic contacts, however, should be accompanied by a greater empha- group (Ahinkorah et al., 2021). Other factors contributing to sis on the quality of care received. This study examined the the delay in ANC initiation in Cameroon include financial relationship between compliance with the new WHO guide- constraints and a long distance to health facilities (Tolefac lines on the frequency and timing of ANC contact and receiv- et al., 2017). In general, our findings suggest that compliance ing quality prenatal care, as defined by a set of eight essential with the new guidelines remains difficult in Cameroon, par- ANC interventions, using a nationally representative dataset. ticularly given that health care is largely paid for out of According to the study, only about 9% and 47% of women, pocket. According to a cost analysis carried out in one of respectively, complied with the new WHO guidelines for Cameroon’s districts, while pregnant women preferred the ANC contact frequency and timing, with at least half increase from four to eight contacts, they were unwilling to 6 SAGE Open Table 2. Chi-Square Test of the Receipt of the Full Set of Antenatal Care Interventions by Predictor Variables (Weighted N = 5,694 Unless Indicated). The total number of interventions received Variable <8 (% of women) All 8 (% of women) p-Value Antenatal care coverage indicators Number of ANC contacts <.001 1–3 79.6 20.4 4–7 69.7 30.3 ≥8 64.3 35.7 Timing of first ANC contact <.001 First trimester 66.6 33.4 Second trimester 75.3 24.7 Third trimester 90.8 9.2 Number of ANC contacts among first-trimester .387 registrants (N = 2,691) 1–3 70.5 29.5 4–7 66.7 33.3 ≥8 63.6 36.4 Number of ANC contacts among second-trimester .005 registrants (N = 2,810) 1–3 79.8 20.2 4–7 73.0 27.0 ≥8 65.8 34.2 Women’s characteristics Number of children ever born .958 1–2 71.8 28.2 3–4 71.8 28.2 ≥5 71.4 28.6 Age group .006 15–24 72.1 27.9 25–34 73.1 26.9 35–49 67.7 32.3 Education <.001 No formal education 84.8 15.2 Primary 71.0 29.0 At least secondary 66.7 33.3 Marital status .003 Never in a union 68.8 31.2 Married 73.7 26.3 Living with partner 70.3 29.7 Widowed 64.9 35.1 Divorced 73.3 26.7 Separated 61.3 38.7 Region <.001 Adamawa 77.9 22.1 Center (without Yaoundé) 68.7 31.3 Douala 67.8 32.2 East 61.1 38.9 Far-North 78.1 21.9 Littoral (without Douala) 78.9 21.1 North 93.2 6.8 North-West 64.0 36.0 West 66.5 33.5 South 51.0 49.0 (continued) Boah et al. 7 Table 2. (continued) The total number of interventions received Variable <8 (% of women) All 8 (% of women) p-Value South-West 61.6 38.4 Yaoundé 68.3 31.7 Place of residence .001 Urban 68.4 31.6 Rural 75.2 24.8 Wealth quintile <.001 Poorest 87.6 12.4 Poorer 72.0 28.0 Middle 70.1 29.9 Richer 68.8 31.2 Richest 63.2 36.8 pay for the contacts (Ngequih Tumasang et al., 2021). a higher number of preventive screening components as part Strategies such as user fee exemption and waivers for preg- of ANC during pregnancy, undermining the goal of ANC, nant women have increased women’s utilization of ANC ser- which is to detect and manage complications early during vices, including timely initiation and more contacts (Dennis pregnancy. Qualitative studies may help us better understand et al., 2020; Manthalu et al., 2016). These strategies could be the quality of care women receive as part of ANC, such as adapted in the study setting to increase ANC utilization. respectful, individualized, person-centered care. In terms of the quality of care received, we discovered According to our findings, the frequency and timing of that almost all of the interventions studied had high popula- the first ANC contact had an independent relationship with tion coverage, with the exception of deworming, which had the quality of care received. On the one hand, women who very low coverage. Routine ANC deworming reduces the made at least eight contacts during their prenatal period risk of adverse pregnancy outcomes such as neonatal mortal- had a higher chance of receiving the full set of interven- ity and low birth weight (Walia et al., 2021). However, only tions. Women whose first contact was initiated in the sec- about a third of women in our study received drugs to pre- ond or third trimester, on the other hand, had a lower vent intestinal worms. This finding is consistent with chance of receiving the full set of interventions, with a Zambian reports (Kyei et al., 2012). More broadly, deworm- much lower chance noted among those whose first contact ing coverage among pregnant women in soil-transmitted hel- was in the third trimester. Previous studies identified that late minthiasis endemic areas is reportedly low, at 23% (Bangert initiation of ANC was associated with fewer than eight con- et al., 2019). Low coverage has been attributed (in part) to a tacts, resulting in missed opportunities for ANC interven- lack of country-specific guidance on the safety and efficacy tions (Ekholuenetale, Benebo, et al., 2020; Ekholuenetale, of deworming, inadequate drug supply, and perceived fear of Nzoputam, et al., 2020). Our bivariate analyses revealed that side effects, particularly teratogenicity, among women and even among women who initiated ANC in the second trimes- health personnel (Insetta et al., 2014). Nonetheless, there is ter, those who made at least eight contacts were more likely substantial evidence that deworming is safe for pregnant to receive the full set of interventions. However, it is unclear women once they have passed the first trimester (Gyorkos at what contacts in these women’s schedules these interven- et al., 2006; Salam et al., 2021). tions were received, given that the DHS only records if the Overall, 28% of women received the full set of interven- service was received by the woman during ANC. The find- tions, which is slightly higher than the 14% reported by ings emphasize the importance of both timely ANC initiation Ameyaw et al. (2021) in the same setting when they exam- and frequent contact by pregnant women before delivery to ined the relationship between women’s empowerment indi- reap the majority of the benefits of ANC. Specifically, a min- cators and receiving quality care during pregnancy. The imum of eight ANC contacts appears to be the key driver of different interventions used to measure the quality of care, as receiving a greater number of ANC components during preg- well as a different study sample, could explain the observed nancy, lending support to the new guideline on the minimum differences. We recognize that assessing the quality of ANC contacts required by pregnant women for a positive preg- content from DHS data is difficult because the existing ques- nancy experience (WHO, 2016). tions in these datasets are limited and focus on the receipt of In line with previous research (Afulani, 2016; Agha & components reported by the mother rather than the overall Tappis, 2016; Ameyaw et al., 2021; Carvajal–Aguirre et al., quality of services received per se. Our results, therefore, 2017; Mugo et al., 2020), we discovered that the number of suggest that less than a third of women in Cameroon receive children ever born, marital status, region, and wealth quintile 8 SAGE Open Table 3. Analysis of the Relationship Between Eight or More Antenatal Contacts and the Receipt of the Full Set of Antenatal Care Interventions (N = 5,694). Model 1 Model 2 Model 3 Variables OR [95% CI] AOR [95% CI] AOR [95% CI] Number of ANC contacts 1–3 1.00 1.00 4–7 1.69 [1.34, 2.12]*** 1.27 [0.99, 1.64] ≥8 2.16 [1.58, 2.97]*** 1.41 [1.00,1.99]* Timing of first ANC contact First trimester 1.00 1.00 Second trimester 0.65 [0.56, 0.77]*** 0.85 [0.72,0.99]* Third trimester 0.20 [0.12, 0.34]*** 0.33 [0.19,0.57]*** Number of children ever born 1–2 1.00 3–4 1.12 [0.94,1.33] ≥5 1.38 [1.10, 1.73]** Age group 15–24 1.00 25–34 0.85 [0.72, 1.00] 35–49 0.97 [0.75, 1.26] Education No formal education 1.00 Primary 1.35 [0.95, 1.92] At least secondary 1.37 [0.98, 1.93] Marital status Never in a union 1.00 Married 1.07 [0.84, 1.36] Living with partner 1.00 [0.81, 1.25] Widowed 1.52 [0.89, 2.57] Divorced 1.23 [0.53, 2.83] Separated 1.60 [1.13, 2.28]** Region Adamawa 1.00 Center (without Yaoundé) 1.24 [0.78, 1.97] Douala 1.05 [0.65, 1.68] East 2.07 [1.29, 3.30]** Far-North 1.25 [0.75, 2.09] Littoral (without Douala) 0.71 [0.45, 1.13] North 0.31 [0.18, 0.53]*** North-West 1.66 [1.03, 2.69]* West 1.29 [0.82, 2.04] South 2.66 [1.71, 4.15]*** South-West 1.56 [0.92, 2.55] Yaoundé 1.08 [0.66, 1.75] Place of residence Urban 1.00 Rural 1.07 [0.80, 1.42] Wealth quintile Poorest 1.00 Poorer 1.76 [1.16, 2.65]** Middle 1.95 [1.27, 3.01]** Richer 2.08 [1.29, 3.35]** Richest 2.62 [1.57, 4.38]*** Model fitness statistics Number of observations 5,567 Weighted population 5,694 F-adjusted test statistic = F(9,400) 1.164 Prob > F .317 Note. AOR = adjusted odds ratio; OR = odds ratio. *p < .05. **p < .01. ***p < .001. Boah et al. 9 were all related to the quality of care received. Wealth has and components received at ANC, were based on mothers’ been linked to timely ANC contact and a greater number of recollections of events during the prenatal period and may be ANC contacts, both of which increase the likelihood of prone to recall bias. Another limitation is that the DHS used receiving a greater number of ANC components during preg- a cross-sectional study design, which makes it impossible to nancy (Ahinkorah et al., 2021; Jiwani et al., 2020; Mugo draw causal inferences from the results. Finally, we excluded et al., 2020). The association between higher parity and women who did not use ANC during their most recent preg- receiving the full set of interventions in this study may be nancy. As a result, the conclusions reached in this study are difficult to explain, because a large body of literature sug- limited to Cameroonian women of the reproductive age who gests that women of high parity initiate ANC late and make have used ANC at least once during pregnancy. fewer contacts, reducing their chances of receiving quality ANC (Ahinkorah et al., 2021; Bolarinwa et al., 2021; Conclusion Ekholuenetale, 2021; Jiwani et al., 2020; Mugo et al., 2020). Indeed, women who have had five or more successful preg- From this study, it has been shown that many Cameroonian nancies are reluctant to attend ANC, and when they do, it is women of reproductive age who attend at least one ANC visit usually after the second trimester, claiming that they have before giving birth do not begin ANC early enough and do not experience coping with the common minor disorders of attend it frequently enough to receive quality maternal health pregnancy (Mulondo, 2020). In contrast to our findings, care before delivery. According to the findings, compliance other scholars reported that primiparous women were more with the 2016 WHO ANC guidelines for a positive pregnancy likely than women with five or more children to receive a experience was significantly associated with receiving a higher number of ANC components (Carvajal–Aguirre et al., higher number of ANC interventions before delivery. We also 2017). Nonetheless, the findings of this study show that mak- discovered that the number of children ever born, marital sta- ing at least eight contacts increases the chances of receiving tus, region, and wealth quintile were all related to the quality the full set of interventions, even when the first contact is of care received during pregnancy. Strategies are needed in made in the second trimester. Because of their increased risk the study setting to promote timely initiation of ANC and a of obstetric complications, neonatal morbidity, and perinatal higher number of contacts (8+) among pregnant women for a mortality, it is reasonable to assume that women with high positive pregnancy experience. parity (≥5) were advised by healthcare professionals to make more frequent contact and were provided with preven- Author Contributions tive services (Asundep et al., 2014; Bai et al., 2002). MB, ANI, DY, MRK, and JS conceived and designed the study. MB and DY conducted the data analysis. ANI, MRK, and JS inter- preted the results for intellectual content. MB and JS wrote the draft Policy Implications of Our Findings manuscript. ANI, DY, and MRK revised the draft manuscript. All Our research has policy implications. While there are clear authors read and approved the final manuscript. benefits to increasing antenatal contacts, implementing the new guidelines in Cameroon will be much more difficult Data Availability Statement given the current findings of this study. There are, however, The dataset used for this analysis is publicly available on the DHS evidence-based strategies available, such as user fee exemp- website (https://dhsprogram.com/data/dataset_admin/index.cfm). tions and waivers, which can be used to increase women’s Interested researchers can download the dataset with permission chances of initiating ANC early in pregnancy and making from the DHS program. more contacts. Our findings show that, with the shift from a minimum of four to eight ANC contacts, there is a need to Declaration of Conflicting Interests identify women who initiate ANC late, as they are less likely The author(s) declared no potential conflicts of interest with respect to meet the new recommended threshold for a positive preg- to the research, authorship, and/or publication of this article. nancy experience. Funding Limitations The author(s) received no financial support for the research, author- ship, and/or publication of this article. A limitation of this study is that we were only able to analyze the content of ANC based on only eight interventions ORCID iD reported to have been received at least once during ANC. We Michael Boah https://orcid.org/0000-0002-5660-2292 recognize that these are not all of the components of ANC, nor are they the most important, but they are the ones most References frequently reported in DHS. 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Association Between Compliance With the New WHO-Recommended Frequency and Timing of Antenatal Care Contacts and Receiving Quality Antenatal Care in Cameroon

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Abstract

The objective of this study was to determine whether adherence to the new WHO recommendations for the frequency and timing of antenatal care (ANC) contacts was associated with receiving quality prenatal care in Cameroon. The 2018 Cameroon Demographic and Health Survey yielded a weighted sample of 5,694 women aged 15 to 49 years for analysis. We found that 8.9% of women had at least eight ANC contacts, with 47.3% of those occurring during the first trimester. Overall, 28.3% (95% CI [26.4, 30.3]) of the women received all eight ANC interventions studied. Women who made at least eight ANC contacts prior to delivery had a higher chance of receiving the full set of interventions (AOR = 1.41; 95% CI [1.00, 1.99]). Even among women who started ANC in the second trimester, those who made at least eight contacts were more likely than those who made fewer contacts to receive the full set of interventions. Furthermore, women who had their first contact later in the second (AOR = 0.85; 95% CI [0.72, 0.99]) or third trimester (AOR = 0.33; 95% CI [0.19, 0.57]) were less likely to receive the full set of interventions. According to our findings, Cameroonian women who followed the new global recommendations for prenatal care were more likely to receive quality prenatal care before giving birth. To have a positive pregnancy experience, however, more women must begin ANC in the first trimester and have at least eight contacts with health care providers before delivery. Keywords antenatal care, maternal health, quality care, Cameroon Antenatal care (ANC) during pregnancy provides a vari- Introduction ety of services that can help with the early prevention, detec- Globally, the number of women who die from pregnancy and tion, and treatment of risk factors. It is also frequently used childbirth-related causes or complications has decreased, but to promote the use of skilled birth attendants as well as remains high, especially in low- and middle-income countries healthy behaviors such as breastfeeding, early postnatal care, (LMICs). An estimated 295,000 women died from pregnancy- and pregnancy spacing planning (Lincetto et al., 2013). related causes in 2017, and 2.4 million newborns die before Malaria, syphilis, tetanus, HIV/AIDS, and other undiag- their first 28 days of life each year, the majority of whom are nosed infections during pregnancy, as well as high blood born prematurely (United Nations Inter-agency Group for pressure, diabetes, and other pre-existing health conditions, Child Mortality Estimation, 2017; World Health Organization frequently complicate pregnancy and endanger both mother [WHO], 2019a). At least 94% of the global maternal deaths and child. However, the majority of adverse maternal and occur in LMICs, with sub-Saharan Africa (SSA) and Southern perinatal outcomes can be avoided with high-quality ANC Asia accounting for approximately 86% of the global number of maternal deaths; the burden is highest in SSA, with 196,000 School of Public Health, University for Development Studies, Tamale, Ghana deaths (WHO, 2021). The United Nations’ Global Strategy for University of Ngaoundere, Cameroon Women’s, Children’s, and Adolescent’s Health (2016–2030) Corresponding Author: prioritizes maternal health, with an ambitious mortality reduc- Michael Boah, Department of Epidemiology, Biostatistics, and Disease tion target of fewer than 70 deaths per 100,000 live births Control, School of Public Health, University for Development Studies, included in the Sustainable Development Goals (SDGs; Every P.O Box TL 1883, Tamale 00233, Ghana. Woman Every Child, 2015; WHO, 2019b). Emails: boahmichael@gmail.com; mboah@uds.edu.gh Creative Commons CC BY: This article is distributed under the terms of the Creative Commons Attribution 4.0 License (https://creativecommons.org/licenses/by/4.0/) which permits any use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage). 2 SAGE Open (Afulani, 2016; Arunda et al., 2017; Kuhnt & Vollmer, 2017; by Ameyaw et al. (2021). They reported that women’s Tuladhar & Dhakal, 2011). The widely used global bench- empowerment indicators such as knowledge and attitude mark for ANC coverage was reporting at least four ANC vis- toward domestic violence were associated with receiving its. But studies have shown that pregnant women need more quality care during pregnancy in Cameroon. However, than four ANC visits to get all the care they need and lower because the focus of their study was on how women’s their risk of dying during pregnancy (Benova et al., 2018; empowerment affects their ability to get good care during Carvajal-Aguirre et al., 2017; Kyei et al., 2012). pregnancy, more research is needed to better understand the The WHO issued new comprehensive recommendations relationship between the frequency and timing of ANC con- on routine ANC for positive pregnancy outcomes in tact under the revised WHO guidelines and the likelihood of November 2016, taking a human rights-based approach to getting basic ANC interventions during pregnancy. addressing the complex nature of ANC practice, organization, This study examined the relationship between adhering and delivery within diverse health systems (WHO, 2016). to the new WHO antenatal care contact frequency and tim- The new guidelines recommend a minimum of eight ANC ing recommendations and receiving high-quality prenatal contacts, with the first occurring in the first trimester (up to care during pregnancy using data from Cameroon’s 2018 3 months of gestation). According to data from Africa, the Demographic and Health Survey (DHS). The results will prevalence of a minimum of eight contacts is generally low in help policymakers and health care providers figure out what most countries, ranging from 1% in Senegal, Zambia, and they can do and how well they follow the standard ANC Uganda to 43% in Ghana (Ekholuenetale, 2021). The report- model recommended by the WHO. ing of eight or more ANC contacts during pregnancy has been linked to factors such as the timing of the first ANC contact, Methods maternal education, and wealth (Ahinkorah et al., 2021; Ekholuenetale, 2021; Ekholuenetale, Benebo, et al., 2020). Data Source Cameroon is one of 16 SSA countries with a high maternal In most countries, including Cameroon, the DHSs are the mortality rate. In 2017, the country had 529 maternal deaths per most comprehensive sources of population-level data on 100,000 live births (WHO, 2019a). A review of the literature maternal and child health outcomes. However, these surveys identified no or inadequate ANC, hypertensive disorders of have a significant shortcoming in that they cannot provide pregnancy, severe malaria, HIV/AIDS, pre-existing co-morbid- information on the type of prenatal care provided. Nonetheless, ities, ectopic pregnancy, placenta previa, anemia, pneumonia, basic services such as weighing, urine analyses, blood pres- heart disease, and delays in arrival at health facilities as drivers sure measurement, tetanus vaccination, and so on are fre- of maternal mortality in Cameroon, the majority of which can quently recorded during ANC. This data does not cover the be detected and managed early in pregnancy (Wirsiy et al., entire range of services provided, but it can be used to deter- 2019). However, with the previous benchmark of at least four mine whether women receive the bare minimum of services. ANC contacts, there was underutilization of ANC. Although As a result, information obtained through the DHS can pro- pregnant women in Cameroon have nearly universal access to vide, at a minimum, a basic indicator of care quality. one skilled ANC contact, a significantly lower percentage have For this study, data were obtained from the 2018 Cameroon their first contact in the first trimester, and only about two-thirds Demographic and Health Survey (CDHS), which was imple- have four or more contacts before delivery (National Institute of mented by the National Institute of Statistics (NIS), in collabo- Statistics (Cameroon) & ICF, 2020). According to a recent ration with the Ministry of Public Health. The 2018 CDHS is study, 6.3% of married women in the country had eight or more the fifth DHS in Cameroon since 1991. A nationally represen- ANC contacts, with 35.6% of contacts occurring during the first tative sample of 13,527 women aged 15 to 49 from all selected trimester (Ahinkorah et al., 2021). households and 6,978 men aged 15 to 64 from half of the Measuring health-care contacts with the health system selected households were interviewed, which represented a without data on the care received is insufficient to reduce response rate of 98% for women and 98% for men. The sample preventable deaths among women and newborns and achieve design for the 2018 CDHS provides estimates at the national SDG-3 by 2030. Furthermore, emerging data show that even level, for urban and rural areas, and 12 study domains. The in LMICs with high levels of ANC coverage, quality is sig- final report contains additional information about the study nificantly lower and inequitable (Arsenault et al., 2018; design, sampling strategy, and data collected in the 2018 CDHS Carvajal–Aguirre et al., 2017). Nevertheless, there is a dearth (National Institute of Statistics (Cameroon) & ICF, 2020). of literature on how compliance with the revised guidelines on ANC coverage relates to receiving quality care in Cameroon, a country with a high burden of maternal mortal- Sample ity where most of the existing studies have focused on the utilization of ANC, including the determinants of the timing For this analysis, the children’s recode file was used. We and frequency of ANC contacts (Ahinkorah et al., 2021; identified a total of 9,733 women aged 15 to 49 years with Tolefac et al., 2017; Venyuy et al., 2020). We found a recent information covering a wide range of topics. In the dataset, publication on the quality of care received during pregnancy 6,463 women had information on ANC, of which 822 (12.7%) Boah et al. 3 did not use ANC during their most recent pregnancy, and 68 receiving quality maternal health care. Existing literature did not know the number of ANC contacts they made during linking these characteristics to the content of care received their most recent pregnancy. The women who did not use influenced their inclusion (Ameyaw et al., 2021; Jiwani ANC during their most recent pregnancy and those who did et al., 2020). not know the number of contacts they made before delivery were excluded in the analysis. Furthermore, women who did Statistical Analysis not know the gestational age of their pregnancy at their initial ANC contact (n = 6) were also excluded. A total of 5,567 Descriptive statistics were used to describe the distribution of women (weighted N = 5,694) who gave birth within the previ- respondents by demographic and economic characteristics, ous 5 years and had information on ANC use were studied. the number of ANC contacts, the timing of the first ANC con- tact, and the coverage of interventions received by mothers. The association between each of the independent variables Measures and the outcome variable was investigated using a design- based Chi-square test. To investigate the relationship between Dependent Variable Measurement the number of ANC contacts, as well as the timing of the first Based on their availability in the dataset and in line with contact, and the receipt of quality prenatal care, a series of global recommendations, the study included eight ANC inter- binary logistic regression models were used. In model 1, we ventions as a proxy for ANC quality. We evaluated the fol- conducted a univariate analysis to determine the relationship lowing ANC services: blood pressure measurement, blood between having at least eight contacts and the outcome. The sample collection for analysis, tetanus toxoid vaccination, analysis in model 2 was restricted to the timing of the first urine testing, intestinal parasite treatment, HIV counseling ANC contact. The final model (model 3) took into account and testing, iron–folate supplementation, and sulfadoxine/ the impact of other maternal, obstetric, demographic, and pyrimethamine for malaria prevention. The survey asked economic factors on the outcome. The “svy” commands were women if they had received any of these services at ANC dur- used to account for the cluster sampling design and sampling ing their most recent pregnancy. If a woman reported receiv- weights. The statistical significance level was set at p0.05. ing the service, she received a “1 point,” otherwise she The findings are presented in the form of adjusted odds ratios received a “0 point.” A composite quality of maternal health (AOR) with confidence intervals. Stata/SE 13.0 was used for care indicator (denoted total number of interventions received) all analyses (StataCorp LP, College Station, TX, USA). was developed by counting the number of interventions mothers received from the set of interventions evaluated. For Ethical Considerations regression analysis, a dummy variable with a binary outcome was created, with “0” representing women who received The dataset used in this paper is publicly available on the fewer than eight interventions (i.e., 0–7) and “1” representing DHS program website in de-identified form. As a result, no women who received the full set of interventions. additional ethical approval from an Institutional Review Board (IRB) was required for the current study (IRB). The Primary Independent Variables Results The number of ANC contacts made prior to delivery and the timing of the first contact are the main independent variables. Characteristics of Study Respondents The information was gathered from women’s self-reports of More than half of all study participants (66.4%; 95% CI [64.2, the number of ANC contacts they made prior to delivery dur- 68.5]) had four to seven ANC contacts, while only 8.9% (95% ing their most recent pregnancy, as well as the age of the CI [7.8, 10.1]) had at least eight contacts before delivery. The pregnancy when the first ANC contact occurred. The number majority of women (59.3%) were married, and 51.8% lived in of contacts was classified as 1 to 3, 4 to 7, and 8 or more urban areas. Approximately 47.0%, 49.0%, and 3.0% of the contacts based on the previous ANC model and the 2016 women made their first ANC contact in the first, second, and WHO recommendation. The timing of the first ANC contact third trimesters, respectively. Table 1 shows the distribution was classified as first trimester: 0 to 3 months; second trimes- of participants based on the other characteristics. ter: 4 to 6 months; and third trimester: >6 months. Coverage of Antenatal Care Covariates Interventions Among the Study Women’s demographic, obstetric, and economic character- Participants istics such as age, highest level of education, parity, marital status, place of residence, region, and wealth quintile were The majority of ANC interventions had a high level of cover- included as confounding factors to examine the indepen- age. For example, more than 9 in 10 women reported that dent relationship between the number of ANC contacts and they had been weighed (97.8%) and that their blood pressure 4 SAGE Open (97.7%), urine (92.4%), and blood (97.1%) samples had Table 1. Descriptive Statistics of the Study Participants (Weighted N = 5,694). been taken during ANC for the most recent pregnancy. However, of all the interventions offered to women during Variables Frequency Percentage (%) ANC, giving drugs to treat intestinal parasites had the lowest Number of ANC contacts coverage (36.0%; Figure 1a). In addition, 0.2% received 1–3 1,409 24.7 none of the interventions and one intervention during ANC, 4–7 3,780 66.4 while 42.3% received seven interventions. Overall, 28.3% ≥8 505 8.9 (95% CI [26.4, 30.3]) of the women received the full set of Timing of the first ANC contact interventions investigated (Figure 1b). First trimester 2,692 47.3 Second trimester 2,810 49.4 Third trimester 192 3.4 Receipt of the Full Set of Antenatal Number of children ever born Care Interventions by Antenatal 1–2 2,389 41.9 Care Coverage Indicators and Key 3–4 1,655 29.1 Demographic and Economic Factors ≥5 1,650 29.0 Age group The distribution of antenatal care interventions by predictor 15–24 1,797 31.5 variables is shown in Table 2. The study found significant dif- 25–34 2,736 48.1 ferences in the receipt of all eight interventions depending on 35–49 1,161 20.4 the number of ANC contacts made during pregnancy and the Education timing of the first contact. In comparison to their counter- No formal education 1,161 20.4 parts, a significant percentage of women who had at least Primary 1,739 30.5 eight ANC contacts during their pregnancy received all eight At least secondary 2,794 49.1 interventions, according to the data. Similarly, more women Marital status who had their first contact during the first trimester received Never in a union 753 13.2 the full set of ANC interventions than those who had their Married 3,377 59.3 first ANC contact in the second or third trimester. Among the Living with partner 1,147 20.1 subsample of women who made at least eight contacts during Widowed 88 1.5 the first trimester, a slightly higher percentage of those who Divorced 61 1.0 made one to three and four to seven contacts received all Separated 268 4.7 interventions (p = .387). On the other hand, among women Region Adamawa 217 3.8 who made their first visit in the second trimester, a greater Center (without Yaoundé) 633 11.1 proportion of those who made at least eight contacts received Douala 612 10.7 all the interventions than the other groups. There were signifi- East 376 6.6 cant differences in the receipt of the full set of ANC interven- Far-North 917 16.1 tions among women based on age, education, marital status, Littoral (without Douala) 214 3.8 region, place of residence, and wealth quintile (Table 2). North 700 12.3 Binary logistic regression analysis of the relationship North-West 403 7.1 between eight or more antenatal care contacts and the receipt West 662 11.6 of the full set of antenatal care interventions. South 295 5.2 Bivariate analysis in Model 1 revealed that having made at South-West 101 1.8 least eight contacts during pregnancy was associated with Yaoundé 564 9.9 increased odds of receiving all interventions investigated Place of residence (OR = 2.16; 95% CI [1.58, 2.97]). In Model 2, the analysis Urban 2,949 51.8 showed that women who made their first contact in the sec- Rural 2,745 48.2 ond or third trimesters had reduced odds of receiving all the Wealth quintile interventions (AOR = 0.65; 95% CI [0.56, 0.77] and Poorest 920 16.2 AOR = 0.26; 95% CI [0.12, 0.34], respectively). We also dis- Poorer 1,204 21.1 covered that women who had their first ANC contact in the Middle 1,201 21.1 second and third trimesters had a lower chance of receiving Richer 1,264 22.2 the full set of interventions. Women’s obstetric, demographic, Richest 1,105 19.4 and economic characteristics were included as confounding factors in the full model (Model 3). According to the findings, CI [1.00, 1.99]). The model fitness statistics showed that there having at least eight contacts increased the likelihood of was not enough statistical evidence (p = .317) to indicate a receiving all ANC interventions by 41% (AOR = 1.41; 95% Boah et al. 5 Figure 1. Coverage of antenatal care interventions among the study participants: (a) antenatal care interventions and (b) number of interventions received. lack of fit in our model. Other factors linked to receiving the of pregnant women making their first contact in the second full set of interventions included the timing of the first ANC trimester and more than half making four to seven contacts contact, marital status, region, the number of children born, before delivery. Similar patterns have been observed by other and wealth quintile (Table 3). researchers in less resourced settings around the world, including but not limited to Ghana, Nigeria, and Myanmar (Ahinkorah et al., 2021; Ekholuenetale, Benebo, et al., 2020; Discussion Ekholuenetale, Nzoputam, et al., 2020; Mugo et al., 2020). In Prior to 2016, the widely used global indicator for measuring LMICs, at least half of pregnant women contact the health ANC coverage was at least four ANC visits, which was later system on time, and one in every nine pregnant women con- found to be insufficient for pregnant women to receive all of tacts the health system at least eight times before giving birth the necessary ANC interventions and to reduce the risk of (Jiwani et al., 2020). Noncompliance with the minimum of maternal mortality, particularly when the first contact is delayed eight contacts is, indeed, a common occurrence in SSA and (Benova et al., 2018; Carvajal-Aguirre et al., 2017; Kyei et al., has been estimated to range from 99% in Zambia to 73% in 2012). The WHO issued new guidelines in 2016 regarding the Libya (Odusina et al., 2021). Although the profile of women number of ANC contacts required for a positive pregnancy in Cameroon who initiate ANC late and make fewer than experience, increasing the minimum of four visits to eight eight contacts was not explored in this study, an earlier study ANC contacts, with the first contact occurring in the first tri- reported that women in the study area who exhibited these mester and increased contacts occurring during the third tri- patterns were adolescents, had no formal education, had three mester (WHO, 2016). Increased coverage of recommended to four children, and were from the poorest socioeconomic contacts, however, should be accompanied by a greater empha- group (Ahinkorah et al., 2021). Other factors contributing to sis on the quality of care received. This study examined the the delay in ANC initiation in Cameroon include financial relationship between compliance with the new WHO guide- constraints and a long distance to health facilities (Tolefac lines on the frequency and timing of ANC contact and receiv- et al., 2017). In general, our findings suggest that compliance ing quality prenatal care, as defined by a set of eight essential with the new guidelines remains difficult in Cameroon, par- ANC interventions, using a nationally representative dataset. ticularly given that health care is largely paid for out of According to the study, only about 9% and 47% of women, pocket. According to a cost analysis carried out in one of respectively, complied with the new WHO guidelines for Cameroon’s districts, while pregnant women preferred the ANC contact frequency and timing, with at least half increase from four to eight contacts, they were unwilling to 6 SAGE Open Table 2. Chi-Square Test of the Receipt of the Full Set of Antenatal Care Interventions by Predictor Variables (Weighted N = 5,694 Unless Indicated). The total number of interventions received Variable <8 (% of women) All 8 (% of women) p-Value Antenatal care coverage indicators Number of ANC contacts <.001 1–3 79.6 20.4 4–7 69.7 30.3 ≥8 64.3 35.7 Timing of first ANC contact <.001 First trimester 66.6 33.4 Second trimester 75.3 24.7 Third trimester 90.8 9.2 Number of ANC contacts among first-trimester .387 registrants (N = 2,691) 1–3 70.5 29.5 4–7 66.7 33.3 ≥8 63.6 36.4 Number of ANC contacts among second-trimester .005 registrants (N = 2,810) 1–3 79.8 20.2 4–7 73.0 27.0 ≥8 65.8 34.2 Women’s characteristics Number of children ever born .958 1–2 71.8 28.2 3–4 71.8 28.2 ≥5 71.4 28.6 Age group .006 15–24 72.1 27.9 25–34 73.1 26.9 35–49 67.7 32.3 Education <.001 No formal education 84.8 15.2 Primary 71.0 29.0 At least secondary 66.7 33.3 Marital status .003 Never in a union 68.8 31.2 Married 73.7 26.3 Living with partner 70.3 29.7 Widowed 64.9 35.1 Divorced 73.3 26.7 Separated 61.3 38.7 Region <.001 Adamawa 77.9 22.1 Center (without Yaoundé) 68.7 31.3 Douala 67.8 32.2 East 61.1 38.9 Far-North 78.1 21.9 Littoral (without Douala) 78.9 21.1 North 93.2 6.8 North-West 64.0 36.0 West 66.5 33.5 South 51.0 49.0 (continued) Boah et al. 7 Table 2. (continued) The total number of interventions received Variable <8 (% of women) All 8 (% of women) p-Value South-West 61.6 38.4 Yaoundé 68.3 31.7 Place of residence .001 Urban 68.4 31.6 Rural 75.2 24.8 Wealth quintile <.001 Poorest 87.6 12.4 Poorer 72.0 28.0 Middle 70.1 29.9 Richer 68.8 31.2 Richest 63.2 36.8 pay for the contacts (Ngequih Tumasang et al., 2021). a higher number of preventive screening components as part Strategies such as user fee exemption and waivers for preg- of ANC during pregnancy, undermining the goal of ANC, nant women have increased women’s utilization of ANC ser- which is to detect and manage complications early during vices, including timely initiation and more contacts (Dennis pregnancy. Qualitative studies may help us better understand et al., 2020; Manthalu et al., 2016). These strategies could be the quality of care women receive as part of ANC, such as adapted in the study setting to increase ANC utilization. respectful, individualized, person-centered care. In terms of the quality of care received, we discovered According to our findings, the frequency and timing of that almost all of the interventions studied had high popula- the first ANC contact had an independent relationship with tion coverage, with the exception of deworming, which had the quality of care received. On the one hand, women who very low coverage. Routine ANC deworming reduces the made at least eight contacts during their prenatal period risk of adverse pregnancy outcomes such as neonatal mortal- had a higher chance of receiving the full set of interven- ity and low birth weight (Walia et al., 2021). However, only tions. Women whose first contact was initiated in the sec- about a third of women in our study received drugs to pre- ond or third trimester, on the other hand, had a lower vent intestinal worms. This finding is consistent with chance of receiving the full set of interventions, with a Zambian reports (Kyei et al., 2012). More broadly, deworm- much lower chance noted among those whose first contact ing coverage among pregnant women in soil-transmitted hel- was in the third trimester. Previous studies identified that late minthiasis endemic areas is reportedly low, at 23% (Bangert initiation of ANC was associated with fewer than eight con- et al., 2019). Low coverage has been attributed (in part) to a tacts, resulting in missed opportunities for ANC interven- lack of country-specific guidance on the safety and efficacy tions (Ekholuenetale, Benebo, et al., 2020; Ekholuenetale, of deworming, inadequate drug supply, and perceived fear of Nzoputam, et al., 2020). Our bivariate analyses revealed that side effects, particularly teratogenicity, among women and even among women who initiated ANC in the second trimes- health personnel (Insetta et al., 2014). Nonetheless, there is ter, those who made at least eight contacts were more likely substantial evidence that deworming is safe for pregnant to receive the full set of interventions. However, it is unclear women once they have passed the first trimester (Gyorkos at what contacts in these women’s schedules these interven- et al., 2006; Salam et al., 2021). tions were received, given that the DHS only records if the Overall, 28% of women received the full set of interven- service was received by the woman during ANC. The find- tions, which is slightly higher than the 14% reported by ings emphasize the importance of both timely ANC initiation Ameyaw et al. (2021) in the same setting when they exam- and frequent contact by pregnant women before delivery to ined the relationship between women’s empowerment indi- reap the majority of the benefits of ANC. Specifically, a min- cators and receiving quality care during pregnancy. The imum of eight ANC contacts appears to be the key driver of different interventions used to measure the quality of care, as receiving a greater number of ANC components during preg- well as a different study sample, could explain the observed nancy, lending support to the new guideline on the minimum differences. We recognize that assessing the quality of ANC contacts required by pregnant women for a positive preg- content from DHS data is difficult because the existing ques- nancy experience (WHO, 2016). tions in these datasets are limited and focus on the receipt of In line with previous research (Afulani, 2016; Agha & components reported by the mother rather than the overall Tappis, 2016; Ameyaw et al., 2021; Carvajal–Aguirre et al., quality of services received per se. Our results, therefore, 2017; Mugo et al., 2020), we discovered that the number of suggest that less than a third of women in Cameroon receive children ever born, marital status, region, and wealth quintile 8 SAGE Open Table 3. Analysis of the Relationship Between Eight or More Antenatal Contacts and the Receipt of the Full Set of Antenatal Care Interventions (N = 5,694). Model 1 Model 2 Model 3 Variables OR [95% CI] AOR [95% CI] AOR [95% CI] Number of ANC contacts 1–3 1.00 1.00 4–7 1.69 [1.34, 2.12]*** 1.27 [0.99, 1.64] ≥8 2.16 [1.58, 2.97]*** 1.41 [1.00,1.99]* Timing of first ANC contact First trimester 1.00 1.00 Second trimester 0.65 [0.56, 0.77]*** 0.85 [0.72,0.99]* Third trimester 0.20 [0.12, 0.34]*** 0.33 [0.19,0.57]*** Number of children ever born 1–2 1.00 3–4 1.12 [0.94,1.33] ≥5 1.38 [1.10, 1.73]** Age group 15–24 1.00 25–34 0.85 [0.72, 1.00] 35–49 0.97 [0.75, 1.26] Education No formal education 1.00 Primary 1.35 [0.95, 1.92] At least secondary 1.37 [0.98, 1.93] Marital status Never in a union 1.00 Married 1.07 [0.84, 1.36] Living with partner 1.00 [0.81, 1.25] Widowed 1.52 [0.89, 2.57] Divorced 1.23 [0.53, 2.83] Separated 1.60 [1.13, 2.28]** Region Adamawa 1.00 Center (without Yaoundé) 1.24 [0.78, 1.97] Douala 1.05 [0.65, 1.68] East 2.07 [1.29, 3.30]** Far-North 1.25 [0.75, 2.09] Littoral (without Douala) 0.71 [0.45, 1.13] North 0.31 [0.18, 0.53]*** North-West 1.66 [1.03, 2.69]* West 1.29 [0.82, 2.04] South 2.66 [1.71, 4.15]*** South-West 1.56 [0.92, 2.55] Yaoundé 1.08 [0.66, 1.75] Place of residence Urban 1.00 Rural 1.07 [0.80, 1.42] Wealth quintile Poorest 1.00 Poorer 1.76 [1.16, 2.65]** Middle 1.95 [1.27, 3.01]** Richer 2.08 [1.29, 3.35]** Richest 2.62 [1.57, 4.38]*** Model fitness statistics Number of observations 5,567 Weighted population 5,694 F-adjusted test statistic = F(9,400) 1.164 Prob > F .317 Note. AOR = adjusted odds ratio; OR = odds ratio. *p < .05. **p < .01. ***p < .001. Boah et al. 9 were all related to the quality of care received. Wealth has and components received at ANC, were based on mothers’ been linked to timely ANC contact and a greater number of recollections of events during the prenatal period and may be ANC contacts, both of which increase the likelihood of prone to recall bias. Another limitation is that the DHS used receiving a greater number of ANC components during preg- a cross-sectional study design, which makes it impossible to nancy (Ahinkorah et al., 2021; Jiwani et al., 2020; Mugo draw causal inferences from the results. Finally, we excluded et al., 2020). The association between higher parity and women who did not use ANC during their most recent preg- receiving the full set of interventions in this study may be nancy. As a result, the conclusions reached in this study are difficult to explain, because a large body of literature sug- limited to Cameroonian women of the reproductive age who gests that women of high parity initiate ANC late and make have used ANC at least once during pregnancy. fewer contacts, reducing their chances of receiving quality ANC (Ahinkorah et al., 2021; Bolarinwa et al., 2021; Conclusion Ekholuenetale, 2021; Jiwani et al., 2020; Mugo et al., 2020). Indeed, women who have had five or more successful preg- From this study, it has been shown that many Cameroonian nancies are reluctant to attend ANC, and when they do, it is women of reproductive age who attend at least one ANC visit usually after the second trimester, claiming that they have before giving birth do not begin ANC early enough and do not experience coping with the common minor disorders of attend it frequently enough to receive quality maternal health pregnancy (Mulondo, 2020). In contrast to our findings, care before delivery. According to the findings, compliance other scholars reported that primiparous women were more with the 2016 WHO ANC guidelines for a positive pregnancy likely than women with five or more children to receive a experience was significantly associated with receiving a higher number of ANC components (Carvajal–Aguirre et al., higher number of ANC interventions before delivery. We also 2017). Nonetheless, the findings of this study show that mak- discovered that the number of children ever born, marital sta- ing at least eight contacts increases the chances of receiving tus, region, and wealth quintile were all related to the quality the full set of interventions, even when the first contact is of care received during pregnancy. Strategies are needed in made in the second trimester. Because of their increased risk the study setting to promote timely initiation of ANC and a of obstetric complications, neonatal morbidity, and perinatal higher number of contacts (8+) among pregnant women for a mortality, it is reasonable to assume that women with high positive pregnancy experience. parity (≥5) were advised by healthcare professionals to make more frequent contact and were provided with preven- Author Contributions tive services (Asundep et al., 2014; Bai et al., 2002). MB, ANI, DY, MRK, and JS conceived and designed the study. MB and DY conducted the data analysis. ANI, MRK, and JS inter- preted the results for intellectual content. MB and JS wrote the draft Policy Implications of Our Findings manuscript. ANI, DY, and MRK revised the draft manuscript. All Our research has policy implications. While there are clear authors read and approved the final manuscript. benefits to increasing antenatal contacts, implementing the new guidelines in Cameroon will be much more difficult Data Availability Statement given the current findings of this study. There are, however, The dataset used for this analysis is publicly available on the DHS evidence-based strategies available, such as user fee exemp- website (https://dhsprogram.com/data/dataset_admin/index.cfm). tions and waivers, which can be used to increase women’s Interested researchers can download the dataset with permission chances of initiating ANC early in pregnancy and making from the DHS program. more contacts. Our findings show that, with the shift from a minimum of four to eight ANC contacts, there is a need to Declaration of Conflicting Interests identify women who initiate ANC late, as they are less likely The author(s) declared no potential conflicts of interest with respect to meet the new recommended threshold for a positive preg- to the research, authorship, and/or publication of this article. nancy experience. Funding Limitations The author(s) received no financial support for the research, author- ship, and/or publication of this article. A limitation of this study is that we were only able to analyze the content of ANC based on only eight interventions ORCID iD reported to have been received at least once during ANC. We Michael Boah https://orcid.org/0000-0002-5660-2292 recognize that these are not all of the components of ANC, nor are they the most important, but they are the ones most References frequently reported in DHS. 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SAGE OpenSAGE

Published: Aug 9, 2022

Keywords: antenatal care; maternal health; quality care; Cameroon

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