FACTORS ASSOCIATED WITH FOCUSED ANTENATAL CARE UTILIZATION

AMONG PRIMIGRAVIDA MOTHERS ATTENDING ANTENATAL CLINIC AT

NYERI COUNTY REFERRAL HOSPITAL

BY

CORNELIUS KROP KAPEL

H151-01-1416/2016

A RESEARCH PROJECT SUBMITTED IN PARTIAL FULFILMENT OF THE

REQUIREMENT FOR BACHELOR OF SCIENCE DEGREE IN NURSING IN THE
SCHOOL OF HEALTH SCIENCES AT DEDAN KIMATHI UNIVERSITY OF
TECHNOLOGY

2021
DECLARATION
This research project is my original work and has never been presented in any institution of
learning for academic purposes.

Signature . Date

Name: CORNELIUS KROP KAPEL

REG NO: H151-01-1416/2016

This research project has been submitted for examination with my approval as the student ’s
appointed supervisor.

Signature . Date ..

Moses Gitonga
Epidemiologist & Lecturer
School of Health Sciences
Dedan Kimathi University of Technology

i
DEDICATION
I dedicate this work to almighty God, my loving parent Mr. Muthike and the entire loving family
for their financial and emotional support they gave me to the completion of this research project.

ii
ACKNOWLEDGEMENT
I acknowledge God wholeheartedly for guidance, support and for enabling me to come up with
and development of this project. I appreciate my supervisor Mr. Gitonga for his tireless effort in
monitoring, correcting and supporting me through the entire project. Thank you for your
motivation and immense knowledge that enabled me to complete this study. I appreciate the
contribution of my Research methods and Biostatistics lecturers Mr. Mutua and Mr. Gitonga for
arming me with adequate knowledge that abetted me write the proposal, collect and analyze data
and report writing skills. I show my gratitude to the medical superintendent of Nyeri county
referral Hospital for accepting and allowing me to conduct research in his area of jurisdiction. I
also appreciate the support of research assistants for the great work they did in data collection.
Lastly, I acknowledge all those who directly or indirectly helped me in one way or another into
the completion of my research project.

iii
Table of Contents
DECLARATION..........................................................................................................................................i
DEDICATION............................................................................................................................................ii
ACKNOWLEDGEMENT..........................................................................................................................iii
List of tables...............................................................................................................................................vi
List of Acronyms and Abbreviations.........................................................................................................vii
OPERATIONAL DEFINITIONS.............................................................................................................viii
ABSTRACT...............................................................................................................................................ix
CHAPTER ONE: INTRODUCTION..........................................................................................................1
1.1BACKGROUND....................................................................................................................................1
1.2 PROBLEM STATEMENT......................................................................................................................3
1.3 RESEARCH OBJECTIVES......................................................................................................................4
1.4 RESEARCH QUESTIONS......................................................................................................................4
1.5 JUSTIFICATION...................................................................................................................................5
1.6 CONCEPTUAL FRAMEWORK..............................................................................................................5
2.1 INTRODUCTION.................................................................................................................................7
2.2 SOCIO-DEMOGRAPHIC FACTORS.......................................................................................................7
2.2.1 LEVEL OF EDUCATION.................................................................................................................8
2.2.2 RESIDENCE..................................................................................................................................8
2.2.3 MARITAL AND WORKING STATUS...............................................................................................8
2.3 KNOWLEDGE ON ANC SERVICES........................................................................................................9
2.4 FACILITY DETERMINANTS................................................................................................................10
CHAPTER THREE: METHODOLOGY..................................................................................................11
3.0 INTRODUCTION...............................................................................................................................11
3.1 RESEARCH DESIGN...........................................................................................................................11
3.2 STUDY AREA.....................................................................................................................................11
3.3 STUDY POPULATION........................................................................................................................11
3.4 INCLUSION AND EXCLUSION CRITERIA............................................................................................11
3.4.1 Inclusion Criteria.......................................................................................................................11
3.4.2 Exclusion Criteria......................................................................................................................12

iv
 3.5 SAMPLE SIZE DETERMINATION........................................................................................................12
3.6 SAMPLING TECHNIQUE....................................................................................................................13
3.8 DATA COLLECTION INSTRUMENT AND PROCEDURES......................................................................13
3.9 DATA CLEANING, VALIDITY AND RELIABILITY...................................................................................13
3.10 DATA ANALYSIS AND PRESENTATION............................................................................................13
3.11 ETHICAL CONSIDERATIONS............................................................................................................13
CHAPTER FOUR: RESULTS..................................................................................................................15
4.1 Social-demographic characteristics of the respondents..................................................................15
4.2 Knowledge of respondents on utilization of focused ANC...............................................................16
4.3 Facility factors that determine effective focused ANC utilization....................................................17
4.4 Relationship between social-demographic factors and utilization of focused ANC.........................19
4.5 Relationship between knowledge of ANC and utilization of focused ANC.......................................20
4.6 Relationship between facility factors and utilization of focused ANC..............................................21
5.1 DISCUSSION.....................................................................................................................................23
5.1.1 Social-demographic factors that influence the utilization of ANC services...............................23
5.1.2 The influence of knowledge on ANC to effective utilization of ANC services............................23
5.1.3 Facility factors that determine the effective utilization of ANC services...................................24
5.2 CONCLUSION...................................................................................................................................24
5.3 RECOMMENDATIONS......................................................................................................................25
References.................................................................................................................................................26
APPENDIX 1: QUESTIONNAIRE...............................................................................................................28
INTRODUCTION.................................................................................................................................28
Section A: PERSONAL FACTORS.........................................................................................................28
Section B: KNOWLEDGE ON ANC.......................................................................................................28
Section C: FACILITY RELATED DETERMINANTS..................................................................................29
APPENDIX 2: CONSENT FORM...............................................................................................................30
Appendix 3: letter of introduction to the hospital and the letter of permission to collect data...........31

v
List of tables
Table 1: Illustrations of social-demographic characteristics of the respondents..................15
Table 2: Illustration of the knowledge of respondents on utilization of focused ANC..........16
Table 3: Illustration of facility factors that determine effective focused ANC utilization....17
Table 4: Illustration of the relationship between social-demographic factors and utilization
of focused ANC............................................................................................................................18
Table 5: Illustration of relationship between knowledge of ANC and utilization of focused
ANC...............................................................................................................................................20
Table 6: Illustration of relationship between facility factors and utilization of focused ANC......21

vi
List of Acronyms and Abbreviations
WHO: World Health Organization

ANC: Antenatal Care

FANC: Focused Antenatal Care

vii
OPERATIONAL DEFINITIONS
Effective: includes care that is of benefit to both the mother and the child to ensure a better
outcome of the pregnancy during the attendance of ANC.

Primigravida mother: a woman pregnant for the first time

Holistic: includes all care provided to the primigravida mother all as a whole in an antenatal care
clinic rather than as parts from the different departments in a hospital setting

Utilization- this means the act of using and seeking the ANC services by primigravida women

viii
ABSTRACT
Focused antenatal care is a goal oriented approach in delivering antenatal care. The WHO
recommends that a pregnant woman should attend at least 8 visits. The FANC is an effective tool
aimed at reducing both infant and maternal mortality. This study was aimed at establishing the
various factors associated with utilization of the FANC services among the primigravida mothers
seeking care in Nyeri county referral hospital. A descriptive cross-sectional study was employed
among 50 mothers who were selected via convenience sampling. A self-administered
questionnaire was used to collect data which was coded, entered and analyzed via STATA
version 9.1. The study results revealed that majority of the primigravida mothers in the study
were youths aged 25-35 years, 56%(n=28), married, 62%(n=31) educated to secondary school
level, 52%(n=26) and of Christian denomination70%(n=35). Further, social-demographic factors
such as maternal age (p=0.002), maternal education (p=0.001) maternal occupation (p=0.008)
and residence (0.023) were found to be statistically associated with utilization of ANC services.
Moreover, various aspects of knowledge such as awareness (p=0.005), knowledge on
recommended number of ANC visits (p=0.031) and knowledge on the benefits of ANC was also
found to influence utilization of ANC services. Finally, health related factors such duration of
waiting at facility (p=0.000), relationship with the provider (p=0.004), number of ANC providers
(p=0.002) and degree of mothers satisfaction with the services provided (p=0.015) was found to
influence utilization of ANC services. It can therefore, be concluded that both social-
demographic, health related factors influence the utilization of ANC. The awareness on ANC
services should be heightened to all mothers as well as mothers should be educated on various
aspects of ANC care.

ix
CHAPTER ONE: INTRODUCTION
1.1BACKGROUND

Antenatal care (ANC) is care that is provided by skilled health care providers to pregnant women
to ensure good health of the mother and the child and good outcomes of the pregnancy. It is one
of the four pillars of safe motherhood which is an initiative to promote good health during
pregnancy and puperium. Focused antenatal care (FANC) is a goal oriented approach in
providing the care which is evidence based with the aim of promoting good and healthy outcome
of the pregnancy (World Health Organization, 2002). The FANC was adopted by the World
Health Organization (WHO) in 2002.

FANC aims at promoting health of the mothers and their babies via targeted assessment of the
pregnant mothers so as to: detect complications and other potential problems early and correct
them, provide prophylaxis for anemia, sexually transmitted diseases, malaria, urinary tract
infection and tetanus so as to protect the unborn baby and also deals with identification and
treatment of established disease (world health organization, 2016).

FANC also has it aim in providing holistic individualized care to the mother by providing
advises on: birth preparedness, nutrition and immunization, maintenance of personal hygiene,
counseling on danger signs and action to be taken. This holistic individualized care is guided by
the situation of each individual woman. FANC has its advantages in effectively reducing
perinatal mortality and morbidity rates hence improving the quality of life which is related to
good birth outcomes. In reference to the KDHS 2014, the estimated maternal mortality ratio
(MMR) was at 362 deaths per 100000 live births. This was estimated to be a 26% drop from
previous estimation results in 2008-2009KHDS (Gacheri, 2016). Among the leading causes of
the deaths in Kenya were hypertensive disorders, hemorrhage and sepsis which accounted for
more than half the deaths. Others such as complications of unsafe abortion accounted for 13%
and obstructed labor which accounted for 8% of the deaths (Gacheri, 2016). This rate can be
attributed to poor utilization of FANC visits.

1
In the health sector it has its advantage in that it can be easily applied and beneficial where there
are few skilled staff and where health infrastructure is limited (world health organization, 2016).

Previously, the WHO recommended a minimum of four visits which were to start within twelve
weeks of gestation. Recently in 2016, WHO recommended a minimum of eight ANC visits so as
to provide more woman-centered experience and to improve neonatal outcome. This followed
Cochrane review which implied that reduced antenatal visits was harmful to health. These visits
are supposed to be one visit in the first trimester, two in the second trimester and 5 in the third
trimester. In most of the developing countries, a large portion of women do not achieve a
minimum of the 8 visits (world health organization, 2016).

Utilization of the ANC services differs among the different countries. In developed countries,
women make their first visit is usually as early as up to the 13 th week as evidenced by many
studies. In sub Saharan Africa, utilization of ANC services is low compared with the developed
countries. In Tanzania, about half of the women make their first visit before or even on the fourth
month of gestation. In Uganda, a study by Kiwuwa and Mufubenga revealed that 57.7% of all
women who attended the ANC made their first visit in the second trimester of their pregnancy
while 33.5% made their first visit in third trimester (Kiwuwa M. S., 2012). In Kenya, 58% of
pregnant women made at least 4 or more ANC visits (KDHS, 2014).

A primigravida is a woman who has become pregnant for the first time (Collins, 2019). They can
be classified in two major groups which elderly primigravida which is a mother are getting
pregnant for the first time at the age of or above the age of 35years of age. The other major
category is the other women who get pregnant for the first time below the age of 35 years of age.
In reference to Kenya Demographic Health Survey (KDHS) 2014, the primigravida who
received antenatal care from a skilled health provider accounted for 97.3 % of the sampled
population (KDHS, 2014).

FANC is supposed to ensure early ANC attendance and adherence to the schedule which should
be sustained so as to optimize good outcomes. In the schedule laid by WHO for ANC is that,
ANC attendance should start before 12weeks of gestation then every month up to 28 th week of
gestation after which they attend the clinics every 2weeks till term so as to enhance achievement

2
of FANC objectives. In most situations, most women and especially primigravida fail to attend
their antenatal clinics before 12weeks of gestation.

The various factors that influence attendance of ANC at early weeks of gestation vary between
countries. In Kenya, from the KDHS report, variation has been detected between women living
in rural areas and those living in urban areas. It was observed that women from the urban areas
are more likely to start ANC at an early gestation as compared to their counterparts living in the
rural areas. Other factors in KDHS include the level of education where the attendance and
utilization of antenatal services increases with increase in the level of education. Among other
factors included low social economic status, exclusive use of private ANC, parity and other
social demographic data (KDHS, 2014).

Campaigns on safe motherhood via FANC have been ongoing and this has led to an
improvement in the coverage which is at 96% from 92%KDHS in 2008-2009 and 88% in
2003KDHS.

1.2 PROBLEM STATEMENT

Most of the pregnancy related complications are preventable during ANC visits with early
detection via routine screening of pregnant mothers in FANC which has specific objectives for
each visit which are evidence based. Among the objectives of FANC is to facilitate early
detection of complications and other potential problems that may affect the outcome of a
pregnancy. In every visit, WHO recommends that each woman should have their blood pressure
taken, urine sample screened and also regular ultrasounds for monitoring fetal status in uterus
(world health organization, 2016). These can only be effective if there is early booking of
antenatal clinics and sustained attendance.

However, the attendance and sustenance in the visits are influenced by various factors. In the
KHDS 2014, only 58% of women attending ANC were able to achieve four or more of the
recommended visits by WHO in Kenya. Although estimated to be an increase of 11% from
2008-2009, there is still a gap in ensuring a much more rise in the FANC visit coverage in
reference to WHO recommended number of visits. Nyeri County was among the sampled areas
from which participants were sampled out for the survey. Hence it is not an exception of the
factors influencing utilization of the ANC services as despite the high percentage in coverage of

3
96.7% it has not achieved 100% in coverage (KDHS, 2014). Despite the fact that there is high
percentage in coverage of ANC, data shows that the majority of the mothers are multiparous at
88% and primigravida at 30 %(KDHS, 2014). Therefore there was a need to research on the
factors that hinders primigravida women from seeking ANC services.

Among the women receiving FANC services in Nyeri county referral hospital, are primigravida
mothers. Hence the study is aimed at assessing the various factors associated with their FANC
utilization behavior. Various studies have shown that there is correlation between utilization of
FANC with socio-demographic factors, knowledge and facility accessibility but fails to indicate
if they are associated with the level of utilization of the FANC services among the primigravida
mothers in Nyeri County. Therefore this study aims at assessing the factors associated with
focused antenatal care utilization among primigravida mothers in Nyeri county referral hospital.

1.3 RESEARCH OBJECTIVES

1.3.1 BROAD OBJECTIVE

1. To determine factors associated with focused antenatal care utilization among primigravida
mothers in Nyeri county referral hospital.

1.3.2 SPECIFIC OBJECTIVES

1. To establish the socio demographic factors influencing focused antenatal care utilization
2. To determine the influence of knowledge on ANC to focused utilization of ANC services.
3. To determine the facility factors associated with focused antenatal care utilization

1.4 RESEARCH QUESTIONS

1. What are the socio demographic factors that influence antenatal care utilization among
primigravida mothers?
2. What is the impact of knowledge on utilization of ANC services?
3. What are the facility factors associated with antenatal care utilization by primigravida
mothers?

4
1.5 JUSTIFICATION

FANC is an essential requirement for every pregnant mother who aims at having a better
outcome of her pregnancy. Early diagnosis and management of pregnancy related complications
leads to better outcomes of a pregnancy and therefore promoting quality of life for both the
mother and the fetus. The early diagnosis and management depends on the level of adherence
and sustenance in attending ANC (Donah Chorongo, 2016).

Among the many studies done on the factors associated with antenatal care utilization, no study
has shown the factors associated with focused antenatal care among primigravida mothers as a
distinct group in Kenya, and more so in Nyeri county.

This study aimed at showing how; the socio-demographic, facility related factors and knowledge
as a factor influence the level of utilization of ANC services among the primigravida mothers.

With assessment of the factors associated with FANC service utilization by primigravida mother,
will provide information that can be used by the government in the ministry of health to reinforce
those that contribute to positive influence as well as amend policies and practices that would
discourage women from utilizing the services.

1.6 CONCEPTUAL FRAMEWORK

Conceptual frame work below is a figure that demonstrates the relationship between variables,
that is the independent and the dependent variables. It is an overview of the ideas that form the
study and how it will be carried out.

This framework is made up of four independent variables: socio-demographic determinants,

knowledge on ANC services and facility determinants. These variables will be inter-related to
determine whether the woman would utilize the antenatal care services.

5
Independent variable Dependent variable
Socio-demographic
determinants

 Age
 Level of education
 Religion
 Residence
 Working status UTILIZATION

Knowledge on antenatal care Of ANC services

 Awareness on benefits
of ANC
 Timeliness of first visit
 Knowledge on the
number of visits

Facility determinants

 Distance to the facility

 Relation with health
care provider

6
CHAPTER TWO: LITERATURE REVIEW

2.1 INTRODUCTION

Antenatal care, by WHO, is described as the care provided by a skilled health provider to
pregnant women so as to enhance a good outcome of the pregnancy for both the mother and the
child (world health organization, 2016). Following introduction of the FANC model by the
WHO in 2002, which is a goal oriented approach, utilization of the ANC services has increased.
ANC services utilization has been found to be differing between countries.

In Kenya, utilization of the ANC services has also greatly improved from 88% in 2003 to 92% in
2008-2009 and now at 96% in 2014 (KDHS, 2014). This is due to much effort aimed at lowering
the high mortality rates. Several studies have been done in relation to the ANC utilization rates
and have revealed different results that are crucial in policy making.

The behavioral model proposed that, the level of utilization of any kind of a health service is as a
result of a set of three individual characteristics (Andersen R, 1973). They include the
predisposing characteristics under which age and education fall. The other set is the enabling
characteristics where income, characteristics of the health care system and availability of health
facilities are included the third set include the need characteristics which include the perceived
health status and the expected services to be provided. This behavioral model is essential in
explaining the outcome of the pregnancy during the seeking of ANC services as the set of
predisposing factors influencing seeking of care are similar in the FANC services seeking
behavior.

This chapter aims at reviewing various studies that have been done to assess the utilization and
their recommendations towards the same. This chapter will focus on studies done in Kenya and
in other countries in Africa and worldwide.

2.2 SOCIO-DEMOGRAPHIC FACTORS

Personal determinants are factors of self that will lead a mother in this case to effectively utilize
or not utilize ANC services. These factors include the maternal age, level of education, religion
and residence. These factors have been found by other research studies to have greatly
influenced ANC utilization.

7
2.2.1 LEVEL OF EDUCATION
In a cross-sectional study in Jordan on the determinants of antenatal care utilization among
women residing in the highly disadvantaged communities in northern Jordan, revealed that with
high level of education there was increased tendency to seek and effectively utilize the antenatal
services by a factor of 1.5 (Heba H. Hijaz, 2018).

In another study conducted in Wakiso district, central Uganda, states that adolescent mothers
were likely to have low level of education and this in return affected their level of understanding
and implementation of health messages given in their antenatal visits (LYNN ATUYAMBE,
2008). In this case the study then reveals that there was significant association between the level
of education and effective utilization of antenatal services.

A study to assess effects of irregular antenatal care attendance among in primiparas on the
perinatal outcomes, suggested that those with irregular attendance patterns tend to be less
educated. (Ahmed M. Abbas, 2017).

2.2.2 RESIDENCE
Various studies have been done to find out the relationship between the residence and the
utilization of ANC services. Most of them found out the women living in the urban areas are
more likely to utilize ANC services more than those in the rural areas.

A study conducted to assess effects of irregular antenatal attendances had in it that most women
in the rural area failed to effectively utilize antenatal service (Ahmed M. Abbas, 2017). The
significance difference between the antenatal attendance between those living in urban and rural
areas was estimated to be a p-value of 0.023.

In a study conducted in Zambia to assess the probability of mothers utilizing a health facility for
maternal services revealed that there was a difference of utilization of the health facilities in rural
and urban areas (Hazemba AN, 2010)

2.2.3 MARITAL AND WORKING STATUS

A few studies have revealed that there is a significant difference in working status and marital
status with how effective the women utilize the FANC services.

8
In Myanmar, data shows that 96% of married female youths receive ANC at least once and 79%
make at least 4 visits (K.K, 2011). A study done in Ethiopia found that family income and low
social economic status affects the utilization of antenatal services. The studies found out that
those with higher income tend to attend ANC services more frequently than those with lower
income (Kidist Birmeta, 2013). This could be linked to their higher purchasing value as well as
high willingness to pay for any ANC services not available within facilities and are therefore
required to source them elsewhere.

In KDHS 2008-2009 indicated that wealthier women attend ANC than women of lower social
economic status. This is consistent with Kambaramiet. Al findings which found out that income,
a determinant to pay for ANC services including transport services to be a significant factor. This
in turn affected the level of effective ANC services utilization (Kambarami R. A., 2010)

2.3 KNOWLEDGE ON ANC SERVICES.

Knowledge on ANC service is a key variable that can influence the utilization of the services.
All women are required to know about pregnancy and ANC during the pre-conception period.
Inadequate knowledge about ANC services to both the mother and the child may influence the
ANC service utilization.

In study conducted in Malindi and Magarini sub-counties, it was found out that, 68% of the
respondents made their first ANC visit at the second trimester of their pregnancy. This was
attributed low level of awareness by the mothers (Donah Chorongo, 2016). The study also found
that the was an association between starting the ANC visits early and completing and that the
age at which the mother made the first visit gave ample time for increased awareness to enhance
a better outcome of the pregnancy (Donah Chorongo, 2016).

Attendance of antenatal clinic at an early gestation and sustenance in attendance as scheduled is

believed to improve both maternal and fetus outcome (Ziyo F, 2012).In study conducted in
Holeta town in Ethiopia to assess the determinant of maternal child health care utilization, had it
from reasons given, that reasons for not utilizing the ANC services included the mothers being in
a good state of health, being too busy which was an evidence there was minimal knowledge on
the benefits of ANC services (Kidist Birmeta, 2013).

9
2.4 FACILITY DETERMINANTS

The health facility condition and its staff are a major factor contributing to the level of utilization
of antenatal care services. On the facility condition, availability of trained and well equipped
staff together with the availability of essential gadgets and services greatly influences the
utilization.

In a study in India on the correlates of maternal health utilization, the distance to the health
facility greatly influenced their level of effective utilization of maternal health services. In this
study among the women sampled some of them lived in areas that were not easily accessible
which was due to poor infrastructure (Gunjan Kumar, 2018)

. A study done in Sudan, where mothers used vehicles to go hospital for ANC services, revealed
that majority never attended due to lack of transport (Ziyo F, 2012).

10
CHAPTER THREE: METHODOLOGY
3.0 INTRODUCTION

This chapter includes the means through which data was collected so as to attain the goal of the
study of assessing the determinants of the effective utilization of the FANC services. This
chapter includes the research study design, study area, study population, inclusion and exclusion
criteria used, sample size, sampling technique, study variables and how they were measured, data
collection.

3.1 RESEARCH DESIGN

The study employed a descriptive cross-sectional survey design. Welman and Kruger (2011)
define survey as an attempt to collect data from an identified population in order to establish the
current status of the population in respect to one or more variables. The descriptive cross-
sectional survey design is preferred because it allows the researcher to work with many
variables. Quantitative methods were employed

3.2 STUDY AREA

The study was carried out at Nyeri County Referral Hospital in Nyeri County- Kenya, at
the maternal child health (MCH). NCRH is purposely selected as a study area because it
is the largest hospital in Nyeri County that serves as a referral facility in Central region
and has large area of coverage.

3.3 STUDY POPULATION

The study population comprised of pregnant primigravida mothers attending MCH in Nyeri
County Referral Hospital. Most studies have been focusing on general utilization of ANC
services, being a distinct group there was a need to study on the primigravida pregnant women.

3.4 INCLUSION AND EXCLUSION CRITERIA

3.4.1 Inclusion Criteria

All primigravida mothers attending MCH in Nyeri County Referral Hospital and were willing to
consent to participate in the study.

11
3.4.2 Exclusion Criteria
Primigravida mothers who are of unsound mind and those who have a mental disability affecting
their judgment making them not able to consent for the data collection

3.5 SAMPLE SIZE DETERMINATION

Sample size was calculated using the formula below (Fishers, et al., 1998)

n = Z2p(q)

d2

Where:

n = the desired sample size.

Z = the standard normal deviate that provides 95% confidence interval (1.96)

p = is the estimated value for the proportion of a sample that have the state of interest and in this
case

p=96.7% which was the coverage of primigravida mothers in ANC services utilization according
to KDHS 2014.

q = 1-p.

d = absolute precision (error bound) (0.05).

The desired accuracy of results is at 95% confidence.

Sample Size

n= (1.96)20.967(1-0.967)

(0.05)2

n =49.0357 which is approximately 50.

12
3.6 SAMPLING TECHNIQUE

Convenience sampling, a non-probability sampling method was used. The

Primigravida mothers who were making their visits during the time of data collection were used
in the study.

3.8 DATA COLLECTION INSTRUMENT AND PROCEDURES

The researcher administered structured questionnaires to collect data from primigravida mothers.
The questionnaires captured data based on the study objectives and were coded to facilitate data
entry and analysis. The respondent was issued with questionnaires to read and fill in the answers
by herself in the presence of the interviewer who provided necessary assistance when needed.

3.9 DATA CLEANING, VALIDITY AND RELIABILITY

Questionnaires were checked for completeness, validity and clarity. Each questionnaire was
entered against its unique identifier number. The research instrument was reviewed before the
study to ensure validity.

3.10 DATA ANALYSIS AND PRESENTATION

Data analysis was done using the stata 9 software. CHI square test was applied to explore the
association between different independent variables and the dependent variable which in this
case is focused antenatal care utilization by primigravida mothers. The study findings are
presented inform of tables.

3.11 ETHICAL CONSIDERATIONS

Permission was also sought from the Nyeri county referral hospital administration and from the
MCH department. Participants signed voluntary informed consent prior to participation in the
study. Identification of participation was ensured by serializing the structured questionnaires.
Participants were informed of their rights, assured of confidentiality, benefits and risks of the
study.

13
14
CHAPTER FOUR: RESULTS
4.1 Social-demographic characteristics of the respondents

The study findings revealed that majority of the mothers, 56% (n=28) were aged between 26-35
years. Christianity was the most dominant religion accounting for 70% (n=35). Further, majority
of the mothers, 52% (n=26) had attained secondary education as their highest level of education
as shown in the table 1 below.

Table 1: social-demographic characteristics of the respondents

Characteristic Category Frequency Percentage

(N) (%)
Age of mothers in years 15-25 13 26.00
26-35 28 56.00
Above 35 12 18.00
Religion Christianity 35 70.00
Muslim 11 22.00
Others 4 8.00
Level of education Informal 6 24.00
Primary 10 20.00
Secondary 26 52.00
Tertiary 8 16.00
Residence Rural 13 26.00
Urban 37 74.00
Marital status Single 11 22.00
Married 31 62.00
Divorced 5 20.00
Separated/widowed 3 6.00
Occupation Housewife 4 8.00
Small business 28 56.00
Former 10 20.00
Formally employed 8 16.00

15
4.2 Knowledge of respondents on utilization of focused ANC

Study results revealed that majority of the primigravida mothers, 88% (n=44) had high
awareness on focused antenatal care clinic services and almost half of them, 44% (n=22) had
obtained the information from more than one source to include social media, friends and parents.
Further, majority of the respondents, 64 %( n=32) had correct knowledge that pregnant women
should start attending their ANC care as from the first trimester of their pregnancy. Moreover,
almost two-thirds of the respondents, 60% (n=30) had correct knowledge on the recommended
number of FANC visits as four. Finally, most of the respondents, 66% (n=33) had knowledge on
the benefits of FANC services to the mother and developing fetus as illustrated in table 2.0
below.

Table 2: knowledge of respondents on utilization of focused ANC

Characteristics Category Frequency Percentage

(N) (%)
Aware of focused ANC services Yes 44 88.00
No 6 12.00
Sources of information Friends 8 16.00
Parents 9 18.00
Social media 11 22.00
More than 1 22 44.00
Knowledge on the time of pregnancy First trimester 32 64.00
when ANC is initiated Second trimester 7 14.00
Third trimester 5 10.00
Never 6 12.00
Knowledge on the recommended number Less than 4 12 24.00
of FANC visits 4 30 60.00
More than 4 8 16.00
Knowledge on benefits of FANC Yes 33 66.00

16
services 17
No 34.00

4.3 Facility factors that determine effective focused ANC utilization

The results revealed that majority of the respondents, 70% (n=35) had ever attended ANC clinic
and most, 72% (n=32) of these reported to have attended between 2-4 FANC visits. Further,
more than half of the respondents, 52% (n=26) reported to have use Matatu as a mode of
transport to health facility when seeking ANC services. In addition, half of those who had used
Matatu transport to the health facility, 50% (n=40) reported to have paid Ksh. 40-60 as a fare.
Most respondents, 70% (n=35) claimed to have been attended by less than three antenatal care
providers during their ANC care visits. Moreover, almost half of the respondents, 44% (n=22)
rated their relationship with antenatal care provider as good as well as 48% (n=24) reported to
have been satisfied with the kind of antenatal care services they received during FANC visits.
Finally, majority of the mothers, 70% (n=35) reported to have waited for duration of less than 20
minutes before they were provided with antenatal care services as shown in table 3 below.

17
Table 3: Illustration of facility factors that determine effective focused ANC utilization

Characteristic Category Frequency Percentage

(N) (%)
Ever attended ANC clinic Yes 35 70.00
No 15 30.00
Number of visits attended in FANC <2 6 12.00
clinic 2-4 36 72.00
>4 8 16.00
Mode of transport to clinic Walk 14 28.00
Matatu 26 52.00
Motorbike 10 20.00
Pay for transport services Yes 40 80.00
No 10 20.00
If yes for payment, amount in Ksh <40 5 12.50
40-60 20 50.00
>60 15 37.50
Number of ANC providers that attended <3 35 70.00
you 3-4 10 20.00
>4 5 10.00
Kind of relationship between mother and Poor 5 10.00
ANC service provider Very poor 3 6.00
Average 15 30.00
Good 22 44.00
Very good 5 10.00
Duration it took before accessing ANC <20 minutes 35 70.00
services 20-60 minutes 11 22.00
More than 60 minutes 4 8.00
Mother satisfaction with ANC services Poor 5 10.00
received Very poor 4 8.00
Average 24 48.00
Good 12 24.00

18
 Very good 5 10.00

4.4 Relationship between social-demographic factors and utilization of focused ANC

There was a statistically significant association between respondents age (χ2=26.0466 df = 2 p =

0.000*); respondent’s marital status (χ2=14.7088 df = 1p = 0.002*); respondent’s level of
education (χ2=17.7204 df = 3p = 0.001*); respondent’s occupation (χ 2=11.8707 df = 1p =
0.008*) ; respondent’s residence (χ2=15.4231 df = 1p = 0.023*); maternal occupation(χ 2=11.8707
df = 1 p = 0.008*) and ever utilized focused ANC services while maternal religion was not
statistically significant with the ever utilized focused ANC services as illustrated in table 4.0
below.

Table 4: relationship between social-demographic factors and utilization of focused ANC

Characteristic Category Frequency Percentage Ever Chi-

(N) (%) utilized square(χ2)
FANC
services
Yes No
Age of mothers 15-25 13 26.00 12 1 χ2=26.0466
in years 26-35 28 56.00 23 5
Above 35 12 18.00 0 9 df = 2
p = 0.000*
Religion Christianity 35 70.00 21 14 χ2=15.6710
Muslim 11 22.00 10 1
Others 4 8.00 4 0 df = 1
p = 0.059
Level of Informal 6 24.00 4 2 χ2=17.7204
education Primary 10 20.00 6 4
Secondary 26 52.00 19 7 df = 3
Tertiary 8 16.00 6 2 p = 0.001*
Residence Rural 13 26.00 8 8 χ2=15.4231
Urban 37 74.00 27 10
df = 1
p = 0.023*
Marital status Single 11 22.00 6 5 χ2=14.7088
Married 31 62.00 27 4
Divorced 5 20.00 2 3 df = 1
Separated/widowed 3 6.00 0 3 p = 0.002*

Occupation Housewife 4 8.00 0 4 χ2=11.8707

Small business 28 56.00 25 3
19
 Former 10 20.00 8 2 df = 1
Formally employed 8 16.00 5 3
p = 0.008*

4.5 Relationship between knowledge of ANC and utilization of focused ANC

There was a statistically significant association between respondents awareness of FANC

services (χ2=22.8707 df = 1p = 0.005*); Knowledge on the time of pregnancy when ANC is
initiated (χ2=13.5823df = 3p = 0.021*); Knowledge on the recommended number of FANC visits
(χ2=17.4356 df = 1p = 0.031*; Knowledge on benefits of FANC services (χ 2=21.2234 df = 1p =
0.004*) ; and ever utilized focused ANC services while knowledge on source of information
was not statistically significant with the ever utilized focused ANC services as illustrated in table
5.0 below.

Table 5: relationship between knowledge of ANC and utilization of focused ANC

Characteristics Category Frequency Percentage Ever Chi-

(N) (%) utilized square(χ2)
FANC
services
Yes No
Aware of focused Yes 44 88.00 40 4 χ2=22.8707
ANC services No 6 12.00 0 6
df = 1
p = 0.005*
Sources of Friends 8 16.00 4 4 χ2=16.9072
information Parents 9 18.00 4 5
Social media 11 22.00 5 6 df = 3
More than 1 22 44.00 22 0 p = 0.123
Knowledge on First trimester 32 64.00 24 8 χ2=13.5823
the time of Second trimester 7 14.00 3 4
pregnancy when Third trimester 5 10.00 3 2 df = 3
ANC is initiated Never 6 12.00 5 1 p = 0.021*
Knowledge on Less than 4 12 24.00 10 2 χ2=17.4356
the recommended 4 30 60.00 19 11
number of FANC More than 4 8 16.00 6 2 df = 1
visits p = 0.031*
Knowledge on Yes 33 66.00 24 9 χ2=21.2234
benefits of FANC No 17 34.00 11 6
services df = 1
p = 0.004*

20
4.6 Relationship between facility factors and utilization of focused ANC

There was a statistically significant association between mother satisfaction with ANC services
received (χ2=22.8707 df = 1p = 0.005*); mode of transport to clinic (χ 2=15.7352 df = 2p =
0.023*); Paid for transport services (χ2=11.2843 df = 3p = 0.034*); Kind of relationship between
mother(χ2=13.6508 df = 1p = 0.004*) ; number of ANC service provider(χ 2=24.2134 df = 1p =
0.002*); Duration it took before accessing ANC services(χ 2=21.3241 df = 1p = 0.000*) ;Number
of ANC providers that attended you (χ2=24.2134 df = 1p = 0.002*) ; and ever utilized focused
ANC services while the number of visits attended in FANC clinic was not statistically significant
with the ever utilized focused ANC services as illustrated in table 6.0 below.

21
Table 6: relationship between facility factors and utilization of focused ANC

Characteristic Category Frequency Percentage Ever Chi-

(N) (%) utilized square(χ2)
FANC
services
Yes No
Number of visits <2 6 12.00 6 0 χ2=20.4321
attended in FANC 2-4 36 72.00 25 11
clinic >4 8 16.00 4 4 df = 1
p = 0.129
Mode of transport to Walk 14 28.00 10 4 χ2=15.7352
clinic Matatu 26 52.00 21 5
Motorbike 10 20.00 4 6 df = 2
p = 0.023*
Pay for transport Yes 40 80.00 25 11 χ2=11.2843
services No 10 20.00 10 4
df = 3
p = 0.034*
If yes for payment, <40 5 12.50 5 2 χ2=12.5678
amount in Ksh 40-60 20 50.00 12 11
>60 15 37.50 18 2 df = 2
p = 0.214
Number of ANC <3 35 70.00 25 10 χ2=24.2134
providers that 3-4 10 20.00 6 4
attended you >4 5 10.00 4 1 df = 1
p = 0.002*
Kind of relationship Poor 5 10.00 5 0 χ2=13.6508
between mother and Very poor 3 6.00 3 0
ANC service Average 15 30.00 14 1 df = 1
provider Good 22 44.00 11 11 p = 0.004*
Very good 5 10.00 2 3
Duration it took <20 minutes 35 70.00 35 0 χ2=21.3241
before accessing 20-60 minutes 11 22.00 0 11
ANC services More than 60 4 8.00 0 4 df = 1
minutes p = 0.000*
Mother satisfaction Poor 5 10.00 3 2 χ2=18.9683
with ANC services Very poor 4 8.00 4 0
received Average 24 48.00 18 6 df = 1
Good 12 24.00 5 7 p = 0.015*
Very good 5 10.00 5 0

22
CHAPTER FIVE: DISCUSSION, CONCLUSION AND RECOMMENDATIONS

5.1 DISCUSSION

5.1.1 Social-demographic factors that influence the utilization of ANC services

The results revealed that maternal age was a significant factor influencing utilization ANC as
majority of them were the youths. Can be linked to the increased risks that are associated with
youthful pregnancy. These findings were in agreement with the findings of a study India where
young mothers attended ANC services than other groups (Gunjan, 2018). Further, maternal age
was a critical factor and this can be alluded to the high awareness and information acquired
through education in regard with ANC. These findings were congruent with findings of a study
in Jordan Northern (Hebu & Hija, 2018) and Uganda (Ahmed, 2017) where high level of
education among mothers was associated with increased tendency to seek antenatal care services.
Marital status was another significant factor. This can be alluded to increased couple
responsibility in caring of the youthful pregnancy. This was a contrast to findings of a study in
Ethiopia where marital status was not found to be associated with utilization of ANC services
(Kidist, 2013). Further, residence was another significant factor as majority of the mothers were
residing in the urban areas. This can be linked to their accessibility to the facility. These findings
were in support of a similar study in Kenya which revealed that youthful women who resided in
rural areas visited FANC clinic two times more than women in the rural areas (Donah, 2016).

5.1.2 The influence of knowledge on ANC to effective utilization of ANC services

Various aspects of knowledge were found to influence the utilization of ANC services. For
example awareness of ANC was a significant factor as majority of the mothers were aware of
ANC services. This can be linked to their high education level and accessibility to various
information sources. This was in agreement with findings of a similar study in Kenya where low
level of awareness of ANC resulted to mothers not attending ANC clinics (Donah, 2016).
Further, having knowledge on the correct time of initiating ANC services can be linked to high
level of maternal education. This was in support of the findings of a study in Tanzania (Andes,
2008) and Sudan (Ziyo ,2012) where mother were found to be having correct knowledge that
ANC clinics should be initiated in the first trimester. Another significant factor was knowledge
on the recommended number of ANC clinic visits whereby majority of the mothers reported it to
be 4 visits and can be alluded to the wide sources of acquiring information regarding ANC. This

23
was concurrent with findings of a study in Ethiopia where mothers knew that four FANC visits
were the recommended ones (Kidist, 2013). Again, knowing the benefits of ANC services was a
significant factor as majority reported to know the benefits of ANC and this can be linked to high
maternal education and increased exposure to a variety of information sources. Findings were not
in agreement with findings of a study in Tanzania where having knowledge on benefits of ANC
service was not concurrent to its utilization.

5.1.3 Facility factors that determine the effective utilization of ANC services
Results revealed that the means of transport to the health facility was a significant factor as
majority of women used a Matatu. This can be linked to associated cost incurred in paying for
transport. The findings were in support of a study in Sudan where mothers used vehicles to go
hospital for ANC services, majority never attended because of lack of transport (Ziyo, 2012).
Further, the number of antenatal providers that attend the mothers was another significant factor
whereby majority of them reported to have been attended by more than one worker. This was in
an agreement with a study in Sudan where more mothers reported to attend more visits when
they were attended by more than one provider (Ziyo, 2012). Further, the relationship between the
mother and the antenatal provider was another critical factor. This can be linked to the attitude
the mother develops towards the providers. This was in support of a study results in Jordan
Northern where mothers had high tendency to return for ANC visits when they had good
relations with the providers (Hebu &Hijaz, 2012).Moreover, the duration of waiting at the
facility before receiving services was another significant factor as long waiting hours can
discourage women from attending the ANC clinics. This was congruent to findings of a study in
Zambia where long waiting hours at the facility was associated with few mothers attending ANC
clinics (Hazemba, 2010). Finally, mothers satisfaction with the ANC services provided was
another significant factor. This was related to the findings of a studies in Zimbabwe (Kambarani
et al., 2010) and Ethiopia (Kidist, 2013) where the mothers who felt that the services they
received was good had high chances of completing the recommend number of ANC visits.

5.2 CONCLUSION

The study results revealed that majority of the primigravida mothers in the study were youths,
married, educated to secondary school level and of Christian denomination. Further social-
demographic factors such as maternal age, maternal education maternal occupation and residence

24
were found to be statistically influencing the effective utilization of ANC services. Moreover,
various aspects of knowledge such as awareness, knowledge on recommended number of ANC
visits and knowledge on the benefits of ANC was also found to influence effective utilization of
ANC services. Finally, health related factors such duration of waiting at facility, relationship
with the provider, number of ANC providers and degree of mother ’s satisfaction with the
services provided was found to influence effective utilization of ANC services.

5.3 RECOMMENDATIONS

The researcher recommends that:

1. The awareness on ANC services should be heightened to all mothers as well as mothers
should be educated on various aspects of ANC care.

2. All primigravida mothers should be encouraged to attend ANC clinics by taking

services near to them as well as by reducing the waiting time at the facility.

3. ANC care providers should make the services provided more satisfactory so as to
encourage more primigravida mothers to seek for the health care.

25
References
Ahmed M. Abbas, M. R. (2017). Effects of irregular antenatal care attendance in primiparas on
theperinatal outcomes. proceedings in obstetrics and gynecology, 8.

Andersen R, N. J. (1973). societal and individual determinants of medical care utilization in

unted states. London: Milbank fund Q health soc.

Andes K Marchant T., C. P. (2008). iming of intermittent preventive treatment for malaria during
pregnancy and the implications of current policy on early uptake in north east Tanzania.
malaria, 79.

Donah Chorongo, F. M. (2016). Factors influencing the utilization of focussed antenatal care
services in malindi and magarini sub-counties of kilifi county in Kenya. The Pan-African
medical journal, 14.

ELT, C. (2019). Collins English Dictionary. London: HarperCollins Publishers.

Gacheri, A. (2016). Tacking High Maternal Deaths in Kenya. Nairobi: oxford publisher.

Gunjan Kumar, S. T. (2018). Utilisation, equity and determinants of full antenmatal care in India.
BMC pregnancy and child birth, 5.

Hazemba AN, S. S. (2010). Prevalence and correlates of utilization of health facilities in

chongwe district, Zambia. choice of place of birth, 53.

Heba H. Hijaz, M. S. (2018). Determinants of antenatal care attendance among women residing
in highly disadvantaged communities in northern Jordan. Jordan: cross mark.

K.K, S. (2011). Maternal Health care utilisation among ever married youths in Kyimyindaing
township, Myanmar. marternal child health journal, 37.

Kambarami R. A., C. M. (2010). Antenatal care patterns and factors associated with perinatal
outcome in two rural ares in Zimbabwe. Central Africa Journal of Medicine, 294.

KDHS. (2014). Kenya Demographic Health Survey. Nairobi: Kenya Bureau of Statistics.

26
Kidist Birmeta, Y. D. (2013). Determinants of maternal health care utilization in Holeta town,
Ethiopia. Addis Ababa: BMC Health Services Research.

Kiwuwa M. S., M. P. (2012). Use of antenatal care, maternity services, intermittent presumtive
treatment and insecticide treated bed nets by pregnant women. malaria, 44.

LYNN ATUYAMBE, F. M. (2008). Adolescent and adult first time mothers' health seeking
practices during pregnancy and early motherhoodin Wakiso district , Uganda. Kampala:
Bio med centre.

Mugenda, M. a. (2003). RESEARCH METHODS, QUALITATIVE AND QUATITATIVE

APPROACHES. NAIROBI: ACT PRESS.

World Health Organization, W. (2002). MATERNAL, NEWBORN, CHILD AND ADOLESCENT

HEALTH. WORLD HEALTH ORGANIZATION.

WORLD HEALTH ORGANIZATION, W. (2016). COMPONENTS OF FOCUSED

ANTENATAL CARE. WORLD HEALTH ORGAANIZATION.

Ziyo F, M. F. (2012). relation between prenatal care and pregnancy outcome at Beghazi.
Sudanese journal of public health, 403.

27
APPENDICES

APPENDIX 1: QUESTIONNAIRE

INTRODUCTION
This research aims at establishing the determinant factors that influence the effective utilization
of focused antenatal care among the primigravida mothers seeking care in the Nyeri County
Referral Hospital.

Section A: PERSONAL FACTORS

1. How old are you (tick against your age bracket)?
15-25 [ ] 26-35 [ ] 36-49 [ ]
2. What is your highest level of education?
Primary [ ] Secondary [ ] Tertiary (university, polytechnic, college) [ ]
3. What is your religion?
Islam [ ] Christian [ ] others (specify)
4. Where do you live?
Rural area [ ] Within Nyeri town [ ]
5. What is your marital status?
Single [ ] Married [ ] Divorced [ ] Widowed [ ] Separated [ ]
6. What is your occupation?
Housewife [ ] Runs small business [ ] Formal employment [ ]
Farmer [ ]

Section B: KNOWLEDGE ON ANC

1. How did you learn about ANC services?
From friends [ ] From my parent [ ] From the social media (whatsapp,
Facebook, radio, TV, etc.) [ ]
2. At what month of the pregnancy do you think a pregnant woman should start ANC?
First trimester (1-3months) [ ] Second trimester (4-6months) [ ]
Third trimester (7-9months) [ ] Never [ ]

28
 3. How many visits should a pregnant mother make to the antenatal care clinic during
the entire pregnancy period?
Once [ ] Twice [ ] Thrice [ ] Four times [ ] More than four [ ]
None [ ]
4. List two benefits of antenatal care
1) ..
2) ..

Section C: FACILITY RELATED DETERMINANTS

1. How many visits have you attended for the antenatal care?
One [ ] Two [ ] Three [ ] Four [ ] More than four [ ]
2. What means of transport do you use when accessing the antenatal care services?
Walk [ ] Matatu [ ] Motorbike [ ]
3. Do you pay for transport to and from services?
Yes [ ] No [ ]
If yes, how much?
20-40 [ ] 41-60 [ ] Above 60 [ ]
4. Do you pay for antenatal care services?
Yes [ ] No [ ]
If yes how much?
0-50 [ ] 51-100 [ ] 101-150[ ] Above 150 [ ]
5. How many people attend to you when you access antenatal care services at the clinic?
1-2 people [ ] 3-4 [ ] 5 and above [ ]
6. How do you rate the relationship with your antenatal care service provider?
Very poor [ ] Poor [ ] Average [ ] Good [ ] Very good [ ]
7. How long does it take to access antenatal care service?
1-20minutes [ ] 20-40minutes [ ] 40-60minute [ ] More than 60minutes [ ]
8. How can you rate your satisfaction with the antenatal care services?
Very poor [ ] Poor [ ] Average [ ] Good [ ] Very good [ ]

29
APPENDIX 2: CONSENT FORM

This informed consent is for respondents who will participate on a research study on
ASSESSING THE FACTORS ASSOCIATED WITH FOCUSED ANTENATAL CARE
UTILIZATION AMONG PRIMIGRAVIDA MOTHERS ATTENDING FOUTH ANC IN
NYERI COUNTY REFERRAL HOSPITAL

INTRODUCTION

I am HELLEN NYANDIA MUTHIKE a student at Dedan Kimathi University conducting

research on ASSESSING THE FACTORS ASSOCIATED WITH FOCUSED ANTENATAL
CARE UTILIZATION AMONG PRIMIGRAVIDA MOTHERS ATTENDING FOUTH ANC
IN NYERI COUNTY REFERRAL HOSPITAL. Am going to give you information and invite
you to be part of this research. Before you decide you can talk to anyone you feel comfortable
with about the research.

PURPOSE OF THE RESEARCH

The study is carried out for academic purposes and also for findings that will help in
improvement of maternal health care services delivery

VOLUNTARY PARTICIPATION

Your participation in this study is entirely voluntary. It is your right to participate or not. You
may decide to terminate your participation at any stage of the research process.

DESCRIPTION OF THE PROCESS

You will be given a questionnaire which you’ll be required to fill the questions honestly and
complete all the sections in it under the guidance of the researcher or research assistant. Then the
data collected from the respondents will be aggregated and analyzed.

RISKS

30
There are no expected risks in this study as it will not involve any manipulation of the sample
population in term of behavior or functioning.

BENEFITS

There will be no benefits directly to you but your responses will help us answer research
question which help will later on improvement of maternal health care services.

CONFIDENTIALITY

The questionnaire to be used in data collection will be coded and the respondent will not be
required to indicate his name or other identification credentials. The information collected will
only be subjected to the relevant research team.

I have read the foregoing information and had the opportunity to ask questions about it and any
questions that have asked have been answered to my satisfaction. I consent voluntarily to
participate as a participant in this research.

Signature of the participant .

Date

Appendix 3: letter of introduction to the hospital and the letter of permission to collect
data

31
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