factors predicting timely initiation of antenatal care
TRANSCRIPT
FACTORS PREDICTING TIMELY INITIATION OF ANTENATAL CARE AMONG
PREGNANT WOMEN IN BINH DINH PROVINCE, VIETNAM
NGUYEN THI LE THUONG
A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS
FOR THE MASTER DEGREE OF NURSING SCIENCE
(INTERNATIONAL PROGRAM)
FACULTY OF NURSING
BURAPHA UNIVERSITY
AUGUST 2015
COPYRIGHT OF BURAPHA UNIVERSITY
ACKNOWLEDGEMENT
The success of this thesis was a result of the collaborative and supportive
effort from many people. First and foremost, special thanks and sincere gratitude goes
to my major advisor, Associate Professor Dr.Wannee Deoisres for giving me
guidance, support and valuable suggestion throughout my study. In addition, my
heartfelt thanks to the contribution of Assistant Professor Dr.Usa Chuahorm, my
co-advisor.
I wish to extend my sincere thanks to Dean of Faculty of Nursing, Burapha
University, Thailand, Associate Professor Dr.Nujjaree Chaimongkol and to the
Principal of Binh Dinh Medical College, Vietnam, Dr Tran Dinh Dat for giving me
a chance to study Master of Nursing Science Program in Thailand. My deep gratitude
goes to Dr.Nguyen Doan Tu, Director of Health Care in South Central Coast Region
Project, Vietnam Ministry of Health and MPU scholarship for financial support for the
Master study in Thailand.
Sincere thanks are given to the Director, the head midwife, and the midwives
at the Antenatal Clinic of Quy Nhon General Hospital, Binh Dinh Province, Vietnam
by allowing data collection at the Hospital and their help during this time. Thanks also
to the pregnant women who voluntarily participated in the study. Certainly, special
thanks to the officers of Graduate Office of Faculty of Nursing, Burapha University,
Thailand and also thanks to the staffs of the Health Care in South Central Coast
Region Project, Vietnam Ministry for support, concern, and care during my study time
in Thailand.
Exceptional cordial thanks to all my classmates, Vietnamese and Thai
students in the Nursing Dormitory, all my friends and colleagues in Vietnam, who
have been walking beside me throughout my study time.
Finally, the greatest love and thanks to my husband, my son, and my
daughter for their understanding, sympathies, encouragement, and support which help
me pursue and complete my study successfully. Gratitude goes to my parents, sibling
and relatives, who support me during the study time in Thailand.
Nguyen Thi Le Thuong
iv
56910108: MAJOR: NURSING SCIENCE: M.N.S.
KEY WORDS: PREGNANT WOMEN/ ANTENATAL CARE/ TIMELY
INITIATION OF ANTENATAL CARE
NGUYEN THI LE THUONG: FACTORS PREDICTING TIMELY
INITIATION OF ANTENATAL CARE AMONG PREGNANT WOMEN IN BINH
DINH PROVINCE, VIETNAM. ADVISORY COMMITTEE: WANNEE
DEOISRES, Ph.D., USA CHUAHORM, Ph.D. 91 P. 2015.
The objectives of this predictive correlation study were to determine the
timely initiation of antenatal care (ANC) and to examine the influence of maternal
age, maternal education, parity, knowledge about ANC, and family support for
pregnancy on timely initiation of ANC among Vietnamese pregnant women.
A random sample of 109 pregnant women visiting Antenatal Clinic from February to
March, 2015 at Quy Nhon General Hospital in Binh Dinh Province, Vietnam were
recruited in the study. The self-report questionnaires were used for data collection.
The data were analyzed by using descriptive statistics, Pearson Chi-Square, Point
Biserial, and multiple logistic regression.
The study results showed that the average gestational age for the first ANC
of the respondents were 11.85 weeks (SD = 5.34) and more than two thirds of the
respondents started ANC within 12 weeks (72.5%). Pregnant women with 18-35 years
old were 47.95 times more likely to initiate ANC after 12 weeks compared to women
older than 35 years old (AOR = 47.95, 95% CI = 3.80-605.74, p = .003). Women’s
knowledge about ANC (AOR = .24, 95% CI = .10-.57, p = .001) and family support
for pregnancy (AOR = .73, 95% CI = .57-.95, p = .020) were found to be predictors of
early initiation of ANC. These findings suggest that we should pay more attention to
pregnant women 18-35 years old and to increase knowledge about ANC for them.
Antenatal care needs to enlarge and encourage the attention of all members in family,
should not only focus on pregnant women.
v
CONTENTS
Page
ABSTRACT ............................................................................................................ iv
CONTENTS ............................................................................................................ v
LIST OF TABLES .................................................................................................. vii
LIST OF FIGURES ................................................................................................ viii
CHAPTER
1 INTRODUCTION ......................................................................................... 1
Background and significance ................................................................ 1
Research objectives ............................................................................... 6
Research hypothesis .............................................................................. 6
Scope of the study ................................................................................. 6
Conceptual framework .......................................................................... 7
Definition of terms ................................................................................ 9
2 LITERATURE REVIEWS ............................................................................ 11
Concept of ANC and timely initiation of ANC .................................... 11
Factors related to timely initiation of ANC ......................................... 17
Conclusion ............................................................................................ 25
3 RESEARCH METHODOLOGY .................................................................. 27
Study design ......................................................................................... 27
Setting of the study ............................................................................... 27
Population and sample .......................................................................... 28
Research instruments ............................................................................ 29
Translation process ............................................................................... 31
Validity and reliability of the instruments ............................................ 32
Protection of human subjects ................................................................ 33
Data collection procedures .................................................................... 33
Data analysis ......................................................................................... 34
4 RESULTS ...................................................................................................... 35
Part 1 Sample characteristics and description of independent variables 35
vi
CONTENTS (CONT.)
CHAPTER Page
Part 2 Timely initiation of ANC .......................................................... 39
Part 3 The relationship between predisposing characteristics, enabling
resource with timely initiation of ANC ............................................... 40
Part 4 Factors predicting timely initiation of ANC .............................. 41
5 CONCLUSION AND DISCUSSION ........................................................... 43
Summary of the study findings ............................................................ 43
Discussion ............................................................................................ 44
Implications of the study ....................................................................... 50
Limitations of the study ....................................................................... 50
Recommendations for future research ................................................. 51
REFERENCES ....................................................................................................... 52
APPENDICES ........................................................................................................ 61
APPENDIX 1 ................................................................................................. 62
APPENDIX 2 ................................................................................................. 65
APPENDIX 3 ................................................................................................. 72
APPENDIX 4 ................................................................................................. 78
APPENDIX 5 ................................................................................................. 87
APPENDIX 6 ................................................................................................. 89
BIOGRAPHY ......................................................................................................... 91
LIST OF TABLES
Tables Page
1 Frequency and percentage of personal information and predisposing
characteristics of the respondents ............................................................... 36
2 Range, mean, and standard deviation of knowledge about ANC of the
respondents ................................................................................................. 37
3 Frequency and percentage of each item of knowledge about ANC
of the respondents ....................................................................................... 38
4 Range, mean, and standard deviation of family support for pregnancy
of the respondents ....................................................................................... 39
5 Mean, standard deviation, frequency, and percentage of timely initiation
of ANC ........................................................................................................ 39
6 Pearson Chi-Square and Point-Biserial correlation coefficient between
factors and timely initiation of ANC .......................................................... 41
7 The association between significant factors and timely initiation of ANC
of the respondents ....................................................................................... 42
LIST OF FIGURES
Figures Page
1 The research framework of the study .......................................................... 8
2 Andersen’s Behavioral Model of Health Services Use ............................... 18
3 Translation process .................................................................................... 32
CHAPTER 1
INTRODUCTION
Background and significance
According to the World Health Organization [WHO] (2014 a), maternal and
neonatal mortality rates during pregnancy and childbirth significantly reduced in the
recent years; maternal deaths worldwide had dropped by 45 %, from 523,000 in 1990
to 289,000 in 2013 and nearly 99 % of these deaths occurred in the developing
countries. Complications during pregnancy and childbirth were the leading cause of
death and disability among women of reproductive age in developing countries
(WHO, 2005 b). The statistics in 2013 showed that maternal mortality ratio in the
developing countries was 230 versus 16 per 100,000 live births in the developed
countries. Maternal mortality ratio differed from one country to another, between
women having high and low income, and between women living in rural and urban
areas (WHO, 2014 a).
Vietnam is a developing country, located in Southeast Asia with population
about 90,796,000 people and the number of births each year is about 1,642,000
(WHO, 2014 b). The maternal and infant mortality rates have decreased in the recent
years. Maternal mortality has reduced by approximately two thirds, from 233 per
100,000 live births in 1990 to 69 per 100,000 in 2009, and 64 per 100,000 live births
in 2012 (United Nations Development Programme [UNDP], 2013). Seventy six
percent of maternal mortality was the direct causes and 23.7 % was the indirect
causes, most of the direct causes were related to pregnancy and childbirth (WHO,
2005 a).
The Millennium Development Goal 5 by WHO aims at reducing the
maternal mortality ratio by three quarters, between 1990 (523,000) and 2015.
The Government of Vietnam and Vietnam Ministry of Health had set up the target of
the Millennium Development Goals [MDGs] in order to reach the MDGs of WHO;
the aim is to reduce the number of maternal mortality to 58.3 deaths per 100,000 live
births by 2015 (UNDP, 2012).
Pregnancy is one of the most important periods in the life of a woman,
2
a family and society. Extraordinary attention is therefore given to antenatal care by
the health care systems of most countries (WHO, 2003 b). If a mother dies while
giving birth or during pregnancy, this will let her family and community suffer, and
children often face higher risks of poverty, neglect, and mortality (WHO, 2005 b).
To prevent poor outcomes of pregnancy, as well as reduce the maternal mortality,
antenatal care includes some of the most important chain of actions to detect problems
in early pregnancy. In addition, in order to minimize the risk factors contributing to
the deaths of mothers, every country needs to have a strategy for continuum of
mother's health care and assure the quality of care, especially managing complications
during pregnancy and childbirth (WHO, 2005 b). One of the strategies for reducing
maternal mortality in Vietnam is provision of antenatal care (ANC) (Vietnam
Ministry of Health [VMOH], 2003).
Numerous studies showed that the timely initiation of ANC is related to
early detection of high risk pregnancy. Moreover, it also prevents poor outcomes of
pregnancy including premature birth, low birth weight, congenital malformations,
congenital infections, neonatal tetanus, preeclampsia, and anemia (Hollowell et al.,
2012). The women who initiated their ANC in the first trimester of pregnancy
maximize the benefits of screening for complications and monitoring fetal and
maternal health. Pregnant women who initiated their ANC later than the first trimester
showed poorer outcomes such as low birth weight and preterm birth (Low et al.,
2005). Early booking and adequate ANC were acknowledged to be an effective
method of preventing adverse outcomes in pregnant women and their babies.
Therefore, initiation of ANC is becoming one of the most important components of
the ANC and this should happen early.
According to American College of Obstetricians and Gynecologists [ACOG],
the women with uncomplicated pregnancies should book the initial visit at 8-10 weeks
of pregnancy, then every 4 weeks until the 28th week of pregnancy, continuing every
2-3 weeks until 36 weeks gestation, and then once a week until delivery (ACOG,
2012). The new ANC model recommended from the WHO includes five ANC visits
with four visits during pregnancy and one visit in postpartum period. The first visit
should occur in the first trimester, followed by the second visit occurring at 26 weeks
of gestational age, the third visit at week 32, and the final visit in pregnancy is the
3
fourth visit occurring between 36-38 weeks. The fifth visit is the postpartum visit
within the first week after delivered (WHO, 2002). The ANC can vary in number of
visits, timing of visit, and the service contents in the visits based on their own national
ANC recommendations. In Vietnam, the Ministry of Health recommended at least
three ANC visits for uncomplicated pregnancies, one in each trimester with the first
visit occurring in the first trimester (VMOH, 2003).
According to the WHO statistics on ANC from 2006-2013, the percentage of
women attending four or more visits was much lower for the low income countries;
the global rate was 56 % but only 38 % of pregnant women in the low income
countries attended four or more ANC visits (WHO, 2014 c). The figures from the
Vietnamese Committee for Population, Family and Children [VCPEC] (2002) showed
that a significant number of Vietnamese women did not utilize ANC adequately.
Eighty seven percent of Vietnamese pregnant women attended at least one visit during
the pregnancy, of which 74 % of women made their first visits when they were almost
6 months pregnant. Only 29 % of the pregnant women in Vietnam had four or more
ANC visits. In addition, a study concluded that ANC utilization was low in Vietnam,
with 71 % of women having at least one ANC, 29 % of women not having any ANC.
Fifty one percent of women attended ANC within 4 months of pregnancy, and 41 % of
women entered ANC within 3 months (Trinh, Dibley, & Byles, 2006). More recently,
in the compendium of research on reproductive health in Viet Nam from United
Nations Fund for Population Activities [UNFPA] (2012) concluded that most of
pregnant women in Vietnam had only one visit; the report also showed that the first
ANC visit in their first trimester ranged widely among studies, from 50 to 80 %.
Binh Dinh Province is located in South Central Coast of Vietnam, and is the
key economic development region of Central Vietnam with the area of 6,050 km2.
According to the General Statistics Office of Vietnam [GSVN] (2011), Binh Dinh had
a total population of 1,497,300 people, equal to 247 people per km2 and the birth rate
in 2011 was 16.7 and death rate was 8.0 per 1000 population. A survey conducted by
the United Nations in 2007 in Binh Dinh found that the rate of antenatal checkups in
the highland was still low, only approximately 40 % (UNFPA, 2008). Binh Dinh had
made significant efforts in the past decade in the field of health care for mothers and
4
children, gained encouraging results including infant mortality rate decreasing from 40
% in 2003 to 14 % in 2010 (GSVN, 2011).
Enhancing health care during pregnancy was one of the effective methods to
reduce poor outcomes for mothers and fetus. Andersen (1995) explained that people
used health service depending on three factors. The first was predisposing
characteristics including demographic factors, social structure, and health beliefs.
The second was enabling resources including personal/ family and community
resources. The last was need factors including perceived individuals and evaluated
need by medical care providers. The literature review showed that multiple factors
related to starting antenatal visit of a woman. However, this study focused on factors
significantly involving timely initiation of ANC with uncomplicated pregnancy.
Maternal age, maternal education, parity, and knowledge about ANC of mother were
classified as the predisposing factors; support from family for pregnancy was the
enabling factor in this study.
Based on literature review, maternal age and education was associated with
the starting of antenatal visit. Pregnant women in childbearing age tended to have
early seeking of ANC (Belayneh, Adefris, & Andargie, 2014). Teenage women were
starting antenatal visit later than other groups, as did by women who were more than
30 years old (Trinh & Rubin, 2006). Early starting ANC was most common in women
who were between 20-24 years old (Onoh et al., 2012). A study by Tayie and Lartey
(2008) showed that women who graduated high school or higher were booking ANC
earlier than women who had lower education. Another study also indicated that
mothers with formal education started antenatal visits earlier than mothers with no
formal education (Belayneh et al., 2014).
The relationships of the parity and knowledge of pregnant women about
ANC on timing of booking ANC showed in numerous studies. Parity significantly
influenced on the timely initiation of antenatal visits. A study by Nwagha and
Anyaehie (2008) indicated that primigravida women initiated booking later than
multigravida. Another study showed that second time mothers were more earlier
booking than other groups and the latest booking were women with 4 children (Onoh
et al., 2012). Moreover, knowledge of pregnant women about ANC plays an important
role in the early initiation of ANC. A previous study reported that more than one third
5
of women in the study believed that the second trimester was the ideal gestational age
for booking. Therefore, 83.1 % of pregnant women in this study booked after the first
trimester and the mean gestational age for the first visit was 24.33 weeks (SD = 5.52)
(Onoh et al., 2012).
Most women who had the family support for pregnancy sought antenatal
visit earlier than those who lacked of family support (Secka, Helleve, Storeng, &
Toure’, 2010; Gross, Alba, Glass, Schellenberg, & Obrist, 2012). Support from
husbands/ partners positively influenced on booking visit, women who lacked support
from husband were later in booking ANC than those who were received these support
(Gross et al., 2012). Another study showed that pregnant women who received
support from mothers and sisters also started ANC visits early (Phafoli, Aswegen, &
Alberts, 2007).
The early antenatal visit was acknowledged to be an effective method of
preventing adverse outcomes in pregnant women and their infants. However, there
were a lot of pregnant women attending ANC late, including Vietnamese women
(UNFPA, 2012). The reason might be as following, traditionally, the typical family
structure in Vietnam is extended family with male-dominated. Confucian norms have
restricted the autonomy of women and reduce their ability to make independent
decisions about their pregnancy care. Therefore, other members of the family, as
mothers can make decisions for women on maternity care based on their experience.
It could be a barrier to women's access to care services ANC in recommended time.
There were many studies and research evidence around the world on initiation of
ANC; several studies in this field from the developing countries including Nigeria,
Uganda, and Ethiopia and the developed countries including New Zealand and Wales.
However, in Vietnam, little has been known about the ANC, especially studies
focusing on factors related to timely initiation of ANC. There were some previous
studies on ANC done in Southern (Trinh, Dibley, & Byles, 2007; Nguyen, Deoisres,
& Sangin, 2013) and Northern Vietnam (Tran, Gottvall, Nguyen, Ascher, & Petzold,
2012). In central of Vietnam there were few studies about ANC. In addition, the
results of this study indicated factors affecting the timing of first antenatal visit in
Vietnamese women; and based on these results the nurses/ midwives and health care
providers have appropriate interventions in order to improve the timing of the first
6
ANC of pregnant women. This in turn prevents adverse outcomes for mothers and
fetus due to delayed ANC. Research in this field not only help the nurses improve
ANC for pregnant women in Vietnam but also contribute to the existing body of
knowledge nurses and midwives across the world.
This study was conducted in Binh Dinh Province, Vietnam. The results of
this study are beneficial to the nurses/ midwives, obstetricians, and other health care
providers. This help them identify factors that influence pregnant women in starting
antenatal care early or late, which help them develop interventions in improvement the
timely utilization of ANC more effectively. In addition, the results from this study
contribute to improve maternal and fetal health. In addition, the findings of the study
can support for the future studies and serve as a baseline data for ANC, especially,
studies in Vietnam.
Research objectives
1. To determine the timely initiation of ANC of pregnant women in Binh
Dinh Province, Vietnam.
2. To examine the influence of predisposing factors (maternal age, maternal
education, parity, knowledge about ANC) and enabling resource (family support for
pregnancy) on timely initiation of ANC among pregnant women in Binh Dinh
Province, Vietnam.
Research hypothesis
The selected factors including maternal age, maternal education, parity,
knowledge about ANC, and family support for pregnancy can predict the timely
initiation of ANC among pregnant women in Binh Dinh Province, Vietnam.
Scope of the study
This study was conducted with 109 pregnant women, who came to antenatal
visit in Binh Dinh Province, Vietnam from February to March, 2015. In the present
study, the dependent variable was timely initiation of ANC which was categorized
into two groups: ≤ 12 weeks and > 12 weeks. The independent variables were
7
predisposing factors (maternal age, maternal education, parity, knowledge about
ANC) and enabling resource (family support for pregnancy).
Conceptual framework
The conceptual framework of this study is based on the Andersen’s
Behavioral Model of Health Services Use. This framework was first developed in
1968 and has since then gone through six phases of major revisions in the model
(Andersen, Rice, & Kominski, 2007). Andersen developed the Behavioral Model of
Health Services Use in an attempt to explain why individuals use health services.
More recently, the researchers have relied heavily on this model for guidance when
investigating the use of social services. It suggested that people's use of health service
was a function of their predisposition to use services, factors which enable or impede
use, and their need for care (Andersen, 1995). There were numerous studies using this
model as the guideline to examine factors affecting to early or late initiation of ANC
of women (Trinh & Rubin, 2006; Beeckman, Louckx, & Putman, 2011; Belayneh
et al., 2014) in the world.
Firstly, in this model, predisposing characteristics were the social-cultural
characteristics of individuals that exist prior to their illness. It included the
demographic characteristics, social structure, and health beliefs. The demographic
characteristics were age and gender. They presented biological imperatives suggesting
likelihood that people will need health services. Social structure characteristics were
marital status, education, occupation, ethnicity, and social relationships (e.g., family
status). Social structure was measured by a broad array of factors that determine the
status of a person in community, ability to cope with presenting problems and
commanding resources to deal with these problems. Mental factors in terms of health
beliefs were attitudes, values, and knowledge related to health and health services
(Andersen, 1995). Secondly, enabling resources were the logistical aspects of
obtaining care. It facilitates the use of services including personal and family
characteristics, income level, insurance coverage, access to transportation, and
awareness of service. At the community level, enabling characteristics included the
availability of the service and the distance to the service (Change, Karen, & Linda,
1998). Finally, service needs were the immediate cause of health service use from
8
functional and health problems that generate the need for health care service. It can be
either an individual’s subjective assessment of need or an evaluated need provided by
a professional.
In this study, the researcher used Andersen’s Behavioral Model of Health
Services Uses to guide the study. Based on the model, predisposing characteristics
include demographic, social structure, and health beliefs. In the present study, the
demographic factors are maternal age and parity; social structure is maternal
education; and belief is knowledge about ANC. The enabling resource is the cause of
health service use, which is represented in this study by family support for pregnancy.
However, the service need factor was not included in this study because
pregnant women in this sample were low risk group, who might not differ in term of
their need to visit ANC. Moreover, the ANC service provided in Vietnam usually is
same for low risk group of pregnant women, with no special need for services.
Another reason is this study was conducted in one hospital, where the service for low
risk pregnant women is similar. Thus, no difference in service need factor among this
sample of pregnant women; hence the need factor was not studied in the current study.
Independent variables Dependent variable
Figure 1 The research framework of the study
Timely initiation of ANC
≤ 12 weeks
> 12 weeks
Predisposing characteristics:
Maternal age
Maternal education
Parity
Knowledge about ANC
Enabling resource:
Family support for pregnancy
9
Definition of terms
Timely initiation of antenatal care refers to timing of the first antenatal
visit of participant in the present pregnancy. If a woman visits ANC only for
confirmation her pregnancy such for pregnancy test or ultrasound and she does not
using any contents of ANC service, she will not be counted as utilizing ANC. In this
study, the timely initiation of ANC is classified into two groups: early initiation of
ANC (initiation of ANC within 12 weeks of gestational age) and late initiation of
ANC (initiation of ANC later than 12 weeks of gestational age). The gestational age is
defined as the age of embryo/ fetus calculated by the last menstrual period or
ultrasound. It was measured by the Information about Timely Initiation of ANC
Questionnaire developed by the researcher.
Maternal age refers to the number of years the participant had lived from
the date of birth to the date of data collection. It is categorized into three groups: < 18
years old (younger high risk), 18-35 years old (proper child bearing age), and > 35
years old (elder high risk).
Maternal education refers to the highest level of education of participant
who has completed at the date of survey and is classified in to three groups: lower
than high school level, high school level, and higher than high school level.
Parity refers to the number of deliveries of participant. It is classified into
two groups: no parity that refers to a woman who has never delivered before. Parity
one and above are referring to women who had at least one delivery.
Knowledge about ANC refers to participant’s understanding about the
importance of receiving ANC for her health and her baby, especially, initiation of
ANC. It is measured by the Knowledge about ANC Questionnaire modified by the
researcher.
Family support for pregnancy refers to support from family members for
taking care pregnant women. It was measured by the Family Support for Pregnancy
Questionnaire developed by the researcher.
In the present study, family support consists of three dimensions: emotional
support, instrumental support, and informational support (House, 1981). Each
dimension is defined as below:
Emotional support refers to support in the form of empathy, love, caring.
10
Instrumental support refers support in the form of tangible aid, including
physical care and financial resources.
Informational support refers to support in the form of advice, suggestions,
problem solving or any others form of information regarding pregnancy care.
CHAPTER 2
LITERATURE REVIEWS
In this chapter, the researcher reviewed concepts related to ANC, timely
initiation of ANC, and factors related to timely initiation of ANC. The information
will be presented follows:
1. Concepts of ANC and timely initiation of ANC
1.1 Definition of ANC and timely initiation of ANC
1.2 Significance of ANC and timely initiation of ANC
1.3 Guideline for ANC
1.4 Timely initiation of ANC in globally
1.5 Timely initiation of ANC in Vietnam
2. Factors related to timely initiation of ANC
2.1 Andersen’s behavioral model of health services use
2.2 Predisposing factors and timely initiation of ANC
2.3 Enabling factors and timely initiation of ANC
Concept of ANC and timely initiation of ANC
Definition of ANC and timely initiation of ANC
Definition of ANC
Antenatal care has been established in the developed countries for a long
time as a process of screening pregnant women with the aim of detecting and thereby
preventing adverse events for maternal and neonatal (Dodd, Robinson, & Crowther,
2002).
Antenatal care (also called prenatal care), the care that women received
during pregnancy, helped to ensure good outcomes for both mothers and fetus (WHO,
2003 b). The WHO (2006) defined ANC as services given to pregnant women by
health professionals. ANC monitors the progress of fetal growth and ascertains the
well-being of the mother and the fetus, ANC provides necessary care to the mother
and identifies complications of pregnancy such as: anemia, preeclampsia and
hypertension etc. in the mother and abnormal growth of the fetus. ANC is the timely
12
management of complications and referral to an appropriate facility if necessary for
further treatment. It also provides opportunity to prepare a birth plan and appropriate
health facilities for delivery (WHO, 2006). The contents of the antenatal visits for a
normal pregnancy were described in three main categories: assessment (history,
physical examination and laboratory tests), health promotion, and care provision
(WHO, 2007). Therefore, ANC as suggested by the WHO consists of services and
education for pregnant women.
Definition of timely initiation of ANC:
The first antenatal visit is the first time pregnant women come to antenatal
clinic to receive caring from health care professionals. The first ANC is defined as the
care to determine the health status of mothers and fetus, estimate the gestational age,
and initiate plans for continuing obstetrical care (Cunningham et al., 2014).
Antenatal care should be initiated as soon as possible. Delayed initiation or
inadequate care may result in women being delayed or ignored for the important
interventions, monitoring, and screening which may benefit mothers' health and that
of their infants (National Institute for Health and Clinical Excellence [NICE], 2008).
The first visit of ANC before 12 weeks gestation is recommended to ensure that
women do not miss benefits of health care for pregnant women and their babies
(Hollowell et al., 2012). In addition, having initial visits early as recommendations
will lead to earlier identification of multiple gestations, potentially improving
pregnancy outcomes (NICE, 2008).
In conclusion, ANC is the regular monitoring of the mother and fetus by a
health care professional during pregnancy through providing information and services
in order to promote maternal and their infants’ health. ANC is also an opportunity to
inform to women about the danger signs and symptoms of pregnancy, which need an
immediate assistance from health care providers. This will in turn achieve healthy
outcomes of pregnancy.
Significance of ANC and timely initiation of ANC
Significance of ANC
ANC is to promote and maintain the health of pregnant women and their
fetus, it aims to establish contact with pregnant women in order to detect and manage
current health problems. It is combination of the information imparting, facilitation of
13
education, screening of abnormalities and complications, ongoing assessment and
care, and preparation for delivery and motherhood. ANC if is used appropriately
would significantly help in identifying and mitigating the risk factors in pregnancy.
Berg and associates identified a fivefold increase in risk of maternal death in
women who received no ANC compared with group who received enough ANC
(Berg, Callagham, Syverson, & Henderson., 2010). Another study also found that lack
of prenatal care was related to more than a twofold increased risk of preterm labor
(Herbst, Mercer, Beazley, Meyer, & Carr., 2003). The data from National Center for
Health Statistics of United States in a study indicated that mothers with prenatal care
has reduced rate of stillbirth of 2.0 per 1,000 against the 14.1 per 1,000 for mothers
with no prenatal care (Vintzileos, Ananth, Smulian, Scorza, & Knuppel, 2002).
Moreover, prenatal care was associated with lower rate of preterm birth, fetal-growth
restriction, post term pregnancy, as well as neonatal death and placenta praevia
(Vintzileos et al., 2002)
Significance of timely initiation of ANC
The WHO recommended that women should initiate their ANC within the
first trimester of pregnancy (WHO, 2002). The first antenatal visit was a very
important visit as it offered the opportunities to collect basic information that will help
form the basis for care during pregnancy. The main purpose of this visit was to obtain
a comprehensive history of pregnancy and confirming the pregnancy, as well as the
identification of risk factors for mother and fetus. Early initiation of ANC was also
early detection and modification of pre-existing medical conditions that may influence
the course and outcome of pregnancy such as cervical incompetence, chronic
hypertension, diabetes mellitus, or severe anemia (WHO, 2002).
Pregnant women who initiate ANC after first trimester may miss the
opportunity to receive lifesaving care because there is the possibility that the signs of
life-threatening complications of pregnancy and childbirth will go unrecognized.
The delay subsequently can lead to delay in reaching treatment and in receiving
adequate treatment (Cresswell et al., 2013). Delayed antenatal clinic attendance
provides little or no time for screening tests of women in early pregnancy,
management of risk factors detected, or timely referral to higher treatment, which may
have a negative impact on both the mother and her fetus (Rowe et al., 2008).
14
Early ANC is one of strategies that will help reducing maternal and neonatal
morbidity and mortality directly through detection and treatment of pregnancy related
diseases, and indirectly through detecting the pregnant women at risk of complications
in order to guide them to the ANC and delivery under appropriate conditions (Banda,
Michelo, & Hazemba., 2012).
Guideline for ANC
The guideline from ACOG (2012) recommended that pregnant woman
should have the first ANC visit at 8-10 weeks of pregnancy (pregnant women who are
at risk for ectopic pregnancies need to visit earlier), next ANC visit at every 4 weeks
for first 28 weeks, then every 2-3 weeks until 36 weeks gestation, and every week
after 36 weeks of gestational age. The goals of visits are detection of risk factors and
pregnancy care (ACOG, 2012). The recommendations from NICE clinical guideline
(2010) were 10 appointments for nulliparous women and 7 for multiparous women,
and ideally, the first appointment at 10 weeks gestation (NICE, 2010).
The new ANC model from WHO recommended four visits during pregnancy
and one visit in postpartum period. The first visit should occur in the first trimester
(within 12 weeks), the second visit should be scheduled close to week 26, the third
visit should take place in or around week 32, the fourth should happen between weeks
36 and 38, and the fifth visit was postpartum visit within the first week after delivery.
The fifth visit is a seldom done in most developing countries (WHO, 2002).
The content of first ANC visit should include physical examination as recording
weight, height, and calculate body mass index and measure blood pressure; perform
urine and blood test; iron and folic acid supplement to all women; and first injection
of tetanus toxoid (WHO, 2007).
The National Guidelines for reproductive health care from Vietnam Ministry
of Health recommended that pregnant women should start ANC visit within 12 weeks
of gestation. They recommended at least three ANC visits during pregnancy, one visit
in each trimester. The contents of first ANC visit included bio-medical assessments:
body height and weight, urine and blood testing; care provision: tetanus toxoid and
folate supplement; and health consultation (VMOH, 2003).
15
Timely initiation of ANC in globally
Measuring the antenatal care adequacy was based on timing of the first
antenatal visit and number of visits (Cunningham et al., 2014). The guidelines for
ANC initiation vary from one nation to another. The United Kingdom and United
States of America followed the schedule of WHO (2002) with the first ANC being
within 12 weeks of gestational age (Adekanle & Isawumi, 2008; Ndidi, & Oseremen,
2010). Meanwhile, there was no guideline in New Zealand for recommended number
and timing of ANC (Low et al, 2005) and many developing countries also did not
have national guidelines. In Nigeria, the recommended commencement of first ANC
visit for uncomplicated pregnancies was within 16 weeks gestation, after 16 week was
referred as late booking (Ifenne & Utoo, 2012; Kisuule et al., 2013), and the
Tanzanian guideline was also the same Nigeria (Gross et al., 2012). The Uganda
clinical guidelines of 2010 gave recommendation for the first visit ranging from 10 to
20 weeks of pregnancy (Kisuule et al., 2013). Whether they had their national
guidelines for the ANC or not, in general, the developed countries had same trend to
provide their first visit in the first trimester only; while, the developing countries’
recommendations varied and the first attendance was much later or between 16-20
weeks of gestation.
A recent research in the United Kingdom by Cresswell et al. (2013) showed
that 62.5 % of participants booked prior to the first trimester, 25.4 % booked between
13 to 20 weeks, and 2.1 % of women booked later than 20 weeks of gestation. In New
Zealand, more than a quarter (26.6 %) initiated ANC later than 15 weeks gestation in
their pregnancy, although almost all of them attended ANC at least once (Low et al.,
2005). An analysis of Demographic and Health Survey from 45 developing countries
in 1999 showed that women in developing countries began ANC later than developed
countries (WHO, 2003 a).
Many studies in developing countries in recent years indicated that starting
ANC in those countries is still delayed. In Uganda, the average gestationla age at first
antenatal care visit was 27.9 weeks (Kisuule et al., 2013). Similarly, a research by
Onoh et al. (2012) had results showing only 16.95 % of women initiate ANC in the
first trimester, with 83.15 % initiating in the second and the third trimesters; the mean
gestational age of booking was 24.33 weeks in that study (Onoh et al., 2012).
16
This index was more alarming in a study in 6 provinces of Rwanda in 2014, where
only 5 % of mothers initiated their ANC in the first trimester (Hagey, Rulisa, &
Pe´rez-Escamilla, 2014); and average gestational age for initiation was 27.9 weeks in
Uganda (Kisuule et al., 2013). According to the Ethiopian Demographic and Health
Survey 2011 report (Central Statistical Agency & Inner City Fund [ICF] International,
2012), only 11.2 % of pregnant women started ANC visit before four months of
pregnancy. In the urban areas, 31.0 % of women sought ANC visit before four months
of gestation and 23.1 % did not have any ANC. The figure for rural women was much
worse, with only 7.7 % starting ANC before 16 weeks and 63.1 % did not attend any
ANC during pregnancy (Belayneh et al., 2014). The Zambia Demographic and Health
survey showed a same trend with Ethiopia; nearly 19 % of mothers initiated their
ANC visit late as fourth month of pregnancy; also, 21 % of mothers in urban and 18 %
in rural districts had their first ANC within four months (Banda et al., 2012).
Overall, pregnant women in the developing countries started antenatal visits
later than in developed countries and also later than their national guidelines.
Especially, in the rural areas of African nations, only a small number of pregnant
women sought antenatal visit as schedule and most of them had the first ANC visit
late or even had no visit during pregnancy.
Timely initiation of ANC in Vietnam
According to Vietnamese National Target Program of 2012 for the
2012-2015 periods, one of the goals of reproductive health was to achieve 80 % of
pregnant women attending ANC at least 3 times, once in each trimester by the year
2015 (UNDP., 2012). The data from VCPFC (2002) showed that 74 % of women had
the first visit within 6 months gestation. A study in three provinces of Vietnam: Long
An, Ben Tre and Quang Ngai concluded that 29 % of women in these provinces had
not attended any ANC, 25 % of them had at least one ANC after 4 months, and the
average duration of pregnancy at the first visit among women who didn’t have any
ANC was 3.7 months (Trinh et al., 2007). The prevalence of first ANC visit in the
rural areas was not the same as in the urban areas. A recent research by Tran et al.
(2011) showed that 69.1 % of rural pregnant women and nearly 97.2 % in urban
attended the first ANC within 12 weeks. A collection and review research from
UNFPA for the whole country during the period of 2006-2010, which indicated that
17
50-80 % of pregnant women had the first ANC visit in the first trimester (UNFPA,
2012).
To reach the target of reproductive health care of pregnant women, the
research about factors influencing timely initiation of ANC is really essential. There
were many related factors which were reported in numerous studies. These factors will
be reviewed in the following sections.
Factors related to timely initiation of ANC
Andersen’s Behavioral Model of Health Services Use
Many theoretical frameworks have been utilized to examine health behaviors
in health service research. Andersen’s Behavioral Model of Health Services Use was
the most well-known and widely used theory of access to care (Radina & Barber,
2004; Sarmiento et al., 2004). The initial model was created in 1968 and has undergone
six revisions. With each revision, there was the addition of new components which led
to a more complex model. These models included new components that reflected the
changing dynamics of accessing health care (Andersen et al., 2007). They helped
researchers to examine their data in appropriate contexts.
The model assumes that seeking health behavior was the result of interaction
between characteristics of population and surrounding environment. It included three
components. The first component was predisposing characteristics: refer to the
predisposition of an individual to use services. This component included demographic
characteristics as age and gender; the social structure as education, occupation,
ethnicity, social networks, social interaction, and culture; and the health beliefs as
attitudes, values, and knowledge that people had concerning and toward to health care
system (Andersen, 1995). The second component was enabling resources, these
factors that allowed an individual to meet their care service needs (Andersen &
Newman, 1973). This component included family or personal resources. For example,
how to access health services, individual or family income, health insurance, a regular
source of care, extent and quality of social relationships; community as available
health personal and facilities, and waiting time; and possible additions as genetic and
psychological characteristics. The last component was need factors, including
perceived and evaluated. Perceived need will better help to understand care-seeking
18
and adherence to a medical regimen, and evaluated need related to women’s health
status of pregnant women and their need for medical care (Andersen, 1995).
Previous studies have used the Andersen’s behavioral model of health
services use to identify factors affecting timely initiation of ANC. A study used this
model as a conceptual framework to examine the timely booking of ANC service in
Addis Ababa, Ethiopia (Tariku, Melkamu, & Kebede., 2010). The results showed that
predisposing factors, enabling factors, and need factors were significantly associated
with timely booking of ANC. A study conducted in Northwest Ethiopia also used this
model as a conceptual framework and indicated that some factors of predisposing and
need factors were significantly related to timely initiation of ANC visit such as
mothers' age, education and perception (Belayneh et al., 2014). Another study
conducted in New South Wales, Australia based on Andersen’s behavioral model
concluded that predisposing, enabling, and need factors were associated with late
entry to ANC care. Predisposing characteristics and enabling resources considerably
affected to the duration of entry to ANC than need factors (Trinh & Rubin, 2006).
The findings from these studies contributed to explanation of the relationships of
predisposing, enabling, and need factors on timely initiation of ANC.
PREDISPOSING ENABLING NEED USE OF
CHARACTERISTICS RESOURCES HEALTH
SERVICES
Figure 2 Andersen’s Behavioral Model of Health Services Use (1995)
Beliefs
Social
Structure
Demographic
Community
Resources
Family/ Personal
Resources
Evaluated
Perceived
19
The present study uses Andersen’s Behavioral Model of Health Services Use
as a conceptual framework. Predisposing characteristics are the social-cultural
characteristics of individuals that exist prior to their illness, including demographic
factors, social structure, and health beliefs. In this study, demographic factors are
maternal age and parity; social structure is maternal education; health belief is
mother’s knowledge about ANC. Enabling resources are the logistical aspects of
obtaining care, including personal/ family resources and community level (Andersen,
1995). In this study, personal/ family resource is family support for pregnancy. The
use of Andersen’s behavioral model of health services use as a theoretical framework
to view the factors related to timely initiation of ANC. It will be described in the
following parts.
Predisposing factors and timely initiation of ANC
In the model, the predisposing factors are included demographic, social
structure, and belief of individual. In the present study, demographic factors are
maternal age and parity, social structure is maternal education, and belief is
knowledge of women about ANC. The review literature showed that age, education,
parity, and knowledge of women about ANC have related to timely initial ANC
(Nwagha & Anyaehie, 2008; Onoh et al., 2012; Trinh & Toney, 2012; Belayneh et al.,
2014)
Demographic factors
Maternal age
A review of studies from 1998-2011, using Andersen’s Behavioral Model of
Health Services Use as a conceptual framework indicated that there was a significant
association between age and utilization of healthcare services (Babitsch, Gohl, &
Lengerke, 2012). People in different age groups had different patterns of using
medical care (Andersen & Newman, 1973).
Maternal age is a significant factor associated with timely initiation of ANC.
A study in Nigeria in 2012 determined the antenatal booking pattern of mothers
concluded that 92.9 % among 365 teenage pregnant women in that study had late
antenatal visits (Onoh et al., 2012). It was consistent with a previous study by Trinh
and Rubin (2006), where in 56 % of teenagers started ANC visits late. Meanwhile,
early booking was most common in the group 20-24 years old (only 25 % in this
20
group booked late) (Onoh et al., 2012). If two groups of pregnant women including
younger age (who were less than 30 years old) and older age group (who were 31-45
years old), the younger age group was 3.83 times more likely to enter earlier than the
group of older women (AOR = 3.89, 95 % Cl = 1.89-10.53) (Belayneh et al., 2014).
In contrast, a study in Nigeria by Adekanle and Isawumi (2008) indicated that 91.1 %
participants who were less than 25 were significantly likely to book later than those
were older (78.9 %) (p < 0.01).
In summary, timely initiation of ANC varied significantly among age
groups, young and elder mothers have later booking trend than mothers in proper
childbearing age. Possible reasons for the adolescent pregnant women attending later
include lack of power to take decisions, lack of money, or lack of knowledge to
recognize pregnancy (Gross et al., 2012). Possible reasons for the elderly women
delayed ANC are that they assumed they gained experience with pregnancy and they
were not aware of any problems. Therefore, they think that they don’t need to come
for the early visit (Kisuule et al., 2013). Women in childbearing age are more early/
earlier to do the booking because they are more likely to be educated and have access
to information compared to the older women (Beeckman et al., 2011). Compared to
younger mothers, they are more confident and independent in making their own
decisions including the decision to initiate their ANC.
Maternal education
The Behavioral Model of Health Services Use indicated that education was a
social structure variable; it reflected the location of the individual in the society.
It may suggest the life style of the individual, the physical, social environment, and
associated behavior patterns of the individual which may be related to the use of
health services (Andersen & Newman, 1973).
Maternal level of education also associated with the early ANC. A study by
Tayie and Lartey in 2008 examined the associations between maternal educational
level, early antenatal care attendance, and pregnancy outcome in Ghana. The study
results concluded that there was a significantly positive association between maternal
education and time of antenatal booking (p < 0.01). The women, who had high school
or higher education booked ANC earlier compared to those who had secondary school
or less. A recent study by Belayneh et al. (2014) in Ethiopia assessed timing of ANC
21
booking and associated factors among 369 pregnant mothers. The results indicated
that the mothers who had formal education started ANC visit earlier, those with
formal education were 1.06 times more likely to initiate ANC earlier than those who
had no formal education (AOR = 1.06, 95 % Cl = 1.03-7.61) (Belayneh et al., 2014).
It was in line with previous studies by Adekanle and Isawumi (2008) and Onoh et al.
(2012). However, a study in Tanzania in 2012 of 440 adolescent and adult mothers
was not consistent with other studies. These results showed that maternal education
was not associated with an early or later timing of ANC visit (p = 0.987) (Gross et al.,
2012).
In conclusion, most of the studies indicated that maternal level of education
was positively associated with timely initiation of ANC, higher the maternal
education, earlier the initiation of ANC. A study by Ndidi and Oseremen (2010)
concluded that educational level of the woman was a major determinant of health
seeking behavior. But there was a slightly different with previous studies; a study
concluded that maternal education was not the reason for the early or late antenatal
visit. Hopefully, the results of the present study will make clearly the relationship
between maternal education level and timely initiation of ANC.
Parity
The Andersen’s behavioral model of health services use was used in a study
to assess the late initiation of antenatal care among pregnant women and indentify
related factors. The results of this study indicated that the number of deliveries of
women associated with entered ANC early or late in New South Wales meant that
higher parity was better initiation of ANC (Trinh & Rubin, 2006).
A prospective multicenter survey conducted in Nigeria in 2008 with a
sample size of 928 pregnant women to determine the influence of parity and other
socio demographic factors on gestational age at booking indicated that parity
significantly influenced the gestational age of the first antenatal visit (p < 0.05).
Generally, gestational age for booking was later than the first trimester, average 24.00
± 7.9 weeks for primigravidae and 27.16 ± 7.5 weeks for multigravidae (Nwagha &
Anyaehie, 2008). Another study in Nigeria in 2012 with 344 pregnant women was
conducted to determine the antenatal booking pattern of women and its determinants,
which results that the women with their first pregnancy were the most common parity
22
that booked ANC (32.3 %) compared with others. However, women who were
pregnant for second time had the highest percentage (24.1 %) of coming early for
ANC whereas women with 4 children had the highest percentage (90.9 %) of coming
late for ANC (Onoh et al., 2012). This study was consistent with a study in United
Kingdom by Baker and Rajasingam (2012). Similarly, a study was conducted in rural
and urban Zambia in 2012, aimed examining factors associated with late ANC
attendance showed that nulliparous women in the rural were 59 % less likely to
initiate ANC late compared to multiparous women (AOR = 0.411, 95 % CI = 0.238-
0.758), while the proportion in the urban district was 48 % (AOR = 0.518, 95 % CI =
0.316-0.848) (Banda et al., 2012).
In conclusion, the parity factor influenced the timely initiation of ANC in
pregnant women. Women with low parity often come earlier for ANC than high
parity. The possible reason is that the higher parity women feel confident with their
previous experience of childbearing; thus, feel no need for early initiation of ANC
(Oladokun, Oladokun, Morhason-Bello, Bello, & Adedokun, 2010).
Knowledge about ANC
Previous study applying Andersen’s Behavior Model of Health Services Use
by Nguyen et al., (2013) indicated that, the knowledge about ANC was strongly
associated with use of health services among pregnant women in Vietnam.
A cross sectional study in Ethiopia in 2008 to assess timing and factors
influencing the fist ANC booking showed that most of mothers (94.6 %) recognized
the significant importance of ANC for the health of mothers and fetus. However, only
75 % of them had knowledge about the right time for the first ANC visit was within
12 weeks of gestational age, 18.8 % though that it should occur after 12 weeks, 2 %
did not know the right time for the first ANC (Trinh & Toney, 2012). Similarly, a
study by Onoh et al. (2012) showed that more than one third (37.2 %) of women
understood that ideal gestational age for the first visit was the second trimester, while
34.9 % of women identified the correct time was the first trimester, and 18.3 % had no
idea of the gestational age of booking. The mean of gestational age at booking for the
study was 24.33 (5.52) weeks and more than 83 % (286/ 344) of them booked after the
first trimester, and only 16.9 % (56/ 344) of women booked early.
23
There were many reasons found for late booking ANC in previous studies.
The commonest reason (53.3 %) was the participants did not have any problems with
their pregnancy and so they thought there was no reason to come early for ANC
(Kisuule et al., 2013). A study in Nigeria in 2010 among 348 pregnant women
concluded that 21 % of respondents in this study also had the same reasons for
booking late (Ndidi & Oseremen, 2010) such as not having any serious problems and
did not understand benefits from early of ANC.
A cross sectional study from 440 pregnant women who came to ANC in
Southeastern Tanzania concluded that more than one fourth of mothers (27 %) awaked
that correct time for starting ANC should be after these mothers feel the fetus move
and 30 % said that they had not recognize pregnancy early. It was a strong predictor of
delay for antenatal visit in this study (p = 0.002) (Gross et al., 2012). A study in
Zambia in 2012 to examine factors associated with late ANC attendance among 613
pregnant women attending antenatal clinic indicated that, the women had lack
knowledge about ANC was 4 times likelihood of late attendance than those good
knowledge. Another study also concluded that women who had inadequate knowledge
about ANC to start ANC late was 2.2 times (AOR = 2.205, 95% CI = 1.021-4.759)
compared with women with adequate knowledge (Banda et al., 2012).
In summary, the findings from review showed that many pregnant women
did not recognize the importance of early first antenatal visit. Most women booked
late because in their knowledge there was no benefit of booking antenatal care in the
first three months of pregnancy. Some of them believed that the first ANC should
occur early only if their pregnancies had problems. Other mothers showed lack of
knowledge to recognize their pregnancy early. Therefore, most of them led to the late
initiation of ANC visit.
Enabling factors and timely initiation of ANC
Enabling factors in this model included family/ personal resources and
community resources. In this study, family resource is supports from family to
pregnant women. Numerous previous studies concluded that family support for
pregnancy played an important role in starting the antenatal visit early or late (Gross
et al., 2012; Secka et al., 2010).
24
Family support for pregnancy
A study that was conducted in the United State using Andersen's behavioral
model of health services use concluded that there was an association between family
support and use of health services. Women who received good family support were
more likely to use health care services than those who lacked of family support or
never received this support (Dhingra, Zack, Strine, Pearson, & Balluz, 2010).
Family support for pregnancy was significantly associated with timely
initiation of ANC. A study in Tanzania in 2012 was conducted among 440 women
who attended ANC; the study concluded that lack of support from husband/ partner
negatively influenced starting ANC visits. Women who did not receive husbands/
partners support were independently associated with a later ANC enrollment in the
multivariate analysis for all women (p = 0.035). Women who received support from
their husband attended nearly 3 weeks earlier than women who did not receive.
Moreover, that study also indicated that, in contrast to adult women, adolescent
pregnant women usually received advice about ANC from mothers or other people
(Gross et al., 2012). A qualitative research method was conducted in Gambia in 2010
with objective to explore socio-cultural factors associated with men’s involvement in
care and support of women during pregnancy and childbirth. The findings of this
study showed that most women who initiated antenatal care had their partners or men
in the family making decisions; eventually women had to seek approval of proposed
visits from men in the family. Some of men felt their responsibility to accompany
women to facilities and offer physical support when needed. Therefore, when her
husband travels or is not available at home for other reasons, the woman’s initiation of
ANC was delayed or she did not go (Secka et al., 2010).
A study was conducted in Nigeria in 2014 with sample size of 200 women of
childbearing age (18-35 years old). The results from this study indicated that most of
women agreed that husband support during pregnancy, labor and delivery were
necessary. Ninety six point five percent of women were encouraged by their husband’s
support, 86.5 % of women felt less stressful if they received their husband’s support,
and most of them received emotional security from their husband. Besides, 83.5 % of
women believed that lack of husband’s support during pregnancy, labor and delivery
would be dangerous. It was however discovered that even though men are generally
25
supportive of their pregnant wives, only 42 % of the husbands escorted their wives to
clinics for ANC (Mosunmola, Adekunbi, & Foluso, 2014).
In contrast, a qualitative study aimed to assess factors influencing pregnant
women’s decision to seek or avoid antenatal care, conducted from 24 women utilizing
ANC. Ten women avoiding ANC in Peru reported that their husbands/ partners and
mothers encouraged them to seek ANC but some women decided on their own as to
when ANC should be initiated, also, their relatives’ influence were limited (Ayala,
Blumenthal, & Sarnquist, 2013). A study in Lesotho had interesting results about
support from memberships in a family of the pregnant women, according to the
culture in this country, pregnancy and childbearing were considered a women’
concern, not concern of men, including father of the baby. They believed that their
husband and father mainly provided material needs in the form of money and food
while mothers and sisters provided psychological support. Moreover, these women
had a simple thinking; they only believed that they needed support in the forms of
supporting their children and themselves for nutrition, clothes, and blanket.
Surprisingly, they did not believe that they needed care for their pregnancy though
ANC. Therefore, women started their ANC only in the second and third trimester of
pregnancy; the reported rates were 71.43 % and 28.57 % in the second and third
trimester, respectively (Phafoli et al., 2007).
In conclusion, the support from family encourages women in seeking ANC
as the family support may help women feel confident to seek ANC early. Some of
women, their husbands escorting them to clinics seem a factor influencing their
decision for early or delay initiation of ANC. However, some women go to ANC
clinics by personal decision, not influenced by others. The present study will make
more clearly about the effect of family support on timely initiation of antenatal visit of
Vietnamese women.
Conclusion
Timely initiation of ANC is very important for the early detection of
complication in pregnancy and prevents adverse outcomes to mothers and fetus.
Understanding of factors related to timely initiation of ANC is very necessary.
The literature review and theoretical framework indicated that age, parity, education,
26
knowledge about ANC of women, and family support for pregnancy related to timely
initiation of ANC. However, there were limited studies in Vietnam about ANC and
minimal focusing on timely initiation of ANC. Hopefully, the results of this study
would be beneficial to nurses/ midwives and obstetricians in improving women' health
care, the health care services, changing perception of women as well as their family
about pregnancy care.
CHAPTER 3
RESEARCH METHODOLOGY
This chapter presents the study design, setting of study, population and
sample, instruments, protection of human subject, data collection procedures, and data
analysis procedures.
Study design
Predictive correlational design was used in this study to address the research
questions
Setting of the study
This study was conducted at Quy Nhon General Hospital. It located at
Quy Nhon City, Binh Dinh Province, Vietnam. Quy Nhon City is the capital of
Binh Đinh Province. It is also the major industrial and service central of Binh Đinh
Province, with a total area of 284 km² and population was 280,900 people (UNFPA,
2010). Quy Nhon General Hospital is a public hospital. This hospital provides health
care services for all people with many kinds of health problems including outpatient
and inpatient services for the acute and chronic diseases or injury. The hospital
provides health services for people not only in Binh Dinh Province but also
surrounding areas. The Antenatal Clinic is in the Obstetrics and Gynecology
Department of the Hospital.
The Antenatal Clinic is a place where women can receive health service
during pregnancy. The number of pregnant women who came for antenatal visits at
Quy Nhon General Hospital was around 15 per day and 300 per month (Quy Nhon
General Hospital, 2013). In this hospital, the ANC service is provided by obstetricians
and midwives and involved regular examination for pregnant women and specific tests
related to the health of fetus and women. Ultrasound, blood and urine tests are
provided in the Subclinical Department, not included in the Obstetrics and Gynecology
Department. The health services starts from 7:00 am to 11:30 am and from 1:30 pm to
5:00 pm, during Monday to Friday.
28
Population and sample
Target population
The target population in this study consisted of pregnant women who came
for antenatal visits at the Antenatal Clinic, Quy Nhon General Hospital in Binh Dinh
Province, Vietnam. Sample was pregnant women who met the following inclusion
criteria:
1. Women without severe complications during pregnancy.
2. If the pregnant women were younger than 18 years old, they had to be
accompanied by their parents or guardians.
3. These women were Vietnamese and able to communicate, read and write
Vietnamese language.
Sample size
Sample size was estimated by using formula of Tabachnick and Fidell
(2007). It was stated the simple rule of thumb: n ≥ 104 + m for testing predictors.
n = estimated sample size
m = the number of independent variables. In this study, it was 5.
The calculation of sample size in this study was as follows:
n ≥ 104 + m
n ≥ 104 + 5
n ≥ 109
Therefore, the sample size in this study was at least 109.
Sampling technique
Simple random sampling method was used in this study. Pregnant women
who met eligibility criteria were randomly selected from the list of registered pregnant
women names. Methods of sample selection were presented as follows:
1. There were around 15 pregnant women, who came to ANC in Quy Nhon
General Hospital per day and the time for data collection from February to March,
2015.
2. In the data collection days, the list of pregnant women who came for
antenatal visits at Antenatal Clinic was obtained.
29
3. Pregnant women registering during 6:30-7:30 am and 1:00-2:00 pm were
screened for eligibility criteria. Names of pregnant women who met the eligibility
criteria were written in the slips of paper, put in a box, and then mixed well.
4. The researcher randomly picked up pregnant women names from the box
twice per day; at 7:30 am and 2:00 pm, 7 or 8 pregnant women were chosen per day.
Research instruments
The data for present study were collected by using a self-report questionnaire
including 37 questions was developed by the researcher based on literature review and
modify from previous study. The instruments included Personal Background
Questionnaire, Information about Timely Initiation of Antenatal Care Questionnaire,
Knowledge about ANC Questionnaire, and Family Support for Pregnancy
Questionnaire.
1. The Personal Background Questionnaire
This questionnaire was developed by the researcher. It consisted of 9
questions, involved personal background of the participants including respondents’
age, educational level, parity and other characteristics.
Maternal age: one question with the blank to fill. The answers were divided
into two groups: ≤ 35 years old and > 35 years old. Then, it was coded as follows:
0 = more than 35 years old.
1 = ≤ 35 years old
Maternal education: one multiple choice question. Women marked in the
box that they choose and the answers were coded as follows:
0 = higher than high school level
1 = high school level
2 = less than high school level
Parity: one question with the blank to fill. The answers were divided into
two groups: never delivery and delivery at least once. Therefore, they were coded as
follows:
0 = no parity
1 = parity one and above.
30
2. The Information about Timely Initiation of Antenatal Care
Questionnaire
This questionnaire included two questions asking about the gestational age of
first ANC visit and contents of first ANC visit that pregnant women were received.
This questionnaire was developed by the researcher based on literature (WHO, 2007).
The answers were divided into two groups: gestational age of first ANC
within 12 weeks and gestational age of first ANC after 12 weeks. Then, they were
coded as follows:
0 = gestational age of first ANC within 12 weeks.
1 = gestational age of first ANC after 12 weeks.
3. The Knowledge about ANC Questionnaire
This questionnaire included 12 questions asking about understanding of the
participants regarding the appropriate time for ANC visit, the benefits and receiving
services in ANC, emphasizing on the first ANC. This questionnaire was modified by
the researcher based on “Knowledge toward ANC” questionnaire, which were
developed by Nguyen et al. (2013) for accessing postpartum women’ knowledge
about ANC, and based on literature (WHO, 2007; Kipronoh & Agina, 2009).
The content validity index for the questionnaire by Nguyen et al. (2013) was
.92 and the reliability accessed by Kuder-Richardson 20 was .75.
The questions with 3 options included true, false, and don’t know.
Correct answer got 1 score.
Incorrect answer or did not know got 0 score.
Therefore, the total scores were yielded a minimum of 0 and maximum of 12
scores. Higher scores were considered that the participants had high knowledge about
ANC and lower scores were considered that the participants had low knowledge about
ANC.
The Family Support for Pregnancy Questionnaire
This questionnaire consisted of 14 questions about support from family for
pregnant women. It was developed by the researcher based on conceptualization of
Social Support by House (1981) and literature (Sarason, Levine, Basham, & Sarason,
1983; Kipronoh & Agina, 2009; Secka et al., 2010; Mosunmola et al., 2014).
This questionnaire included 3 types of support: emotional support, instrumental
31
support, and informational support. The statements of this questionnaire were
recorded to 7-Likert scales. Level of agreement for each item was scored as follows:
Strongly disagree 1 score
Disagree 2 scores
Somewhat disagree 3 scores
Neutral 4 scores
Somewhat agree 5 scores
Agree 6 scores
Strongly agree 7 scores
Therefore, 14 questions were yielded a minimum of 14 and maximum of 98
scores. Higher scores indicated that the participants had high family support and lower
scores indicated that the participants had low family support for pregnancy.
Translation process
The original questionnaires were in English and translated into Vietnamese
language by Back-Translation technique (Cha, Kim, & Erlen, 2007). The backward
translation procedure was performed by three experts who were bilingual fluent
translators, in English and Vietnamese as well as familiar with the domain of maternal
and childbirth. This translational model had a cycle of steps as follows:
1. Two translators translated the original questionnaire independently from
English into Vietnamese.
2. The researcher and two translators discussed and combined the
Vietnamese version to be the one upon agreement.
3. Another translator translated the final Vietnamese version converse to
English.
4. Finally, the researcher and the researcher’s major advisor checked the
back-translated English version for language accuracy and comparability of the
contents, culture, and meanings between the English back-translated and the English
original version.
32
Figure 3 Translation process
Validity and reliability of the instruments
Validity
In this study, the content validity of the questionnaires was tested in the
Content Validity Index (CVI). Five experts in maternal-newborn nursing examined the
content validity, language suitability and criteria for scoring of the entire questionnaire.
The CVI score for “Timely Initiation of Antenatal Care Questionnaire” was 1.0,
“Knowledge about Antenatal Care Questionnaire” was 1.0, and “Family Support for
Pregnancy Questionnaire” was .95. Besides, some questions were revised based on the
comments and suggestions of those experts.
Reliability
The Knowledge about ANC Questionnaire and the Family Support for
pregnancy Questionnaire in Vietnamese version were tested for the reliability with 30
pregnant women who had similar characteristics with the sample of this study. In this
study, the Kuder-Richardson 20 [KR-20] coefficient of Knowledge about ANC
Questionnaire was .74, and the Cronbach’s alpha coefficient of Family Support for
Original
English
version
English back
translated
version
Vietnamese
version 1
Compare
Combined
Vietnamese
version 2
Vietnamese
version
Translator
1
The researcher
The researcher
& major advisor
Translator
2
Translator
3
33
Pregnancy Questionnaire was .81.
Protection of human subjects
The researcher was aware of research ethics of human subjects. This
proposal was submitted to the Institution Review Broad, Faculty of Nursing, Burapha
University in Thailand. Then, the asking permission letter for data collection from
Burapha University was sent to the Director of Quy Nhon General Hospital.
The participants were informed clearly about the aims of the study, benefits, safety,
and data collection procedure. The pregnant women were randomly selected and willing
to participate in the study and could withdraw from the study at any time. Consent
forms were given to these participants for signing before the beginning of the data
collection. The consent forms were also delivered to their parents or guardians for the
participants under 18 years old. By using this procedure, the parents or guardians were
informed about the study and asked permission for their children to participate in this
study. All the forms were anonymous. All data were stored in a secure place and only
utilized for the purpose of this research, and the results were reported as a group of
data.
Data collection procedures
Data in this study were collected by the researcher.
1. After the proposal was approved by the Institutional Review Board, the
letter from the Dean of Faculty of Nursing, Burapha University was submitted to the
Director of Quy Nhon General Hospital for seeking the permission of data collection.
2. After getting the permission from the Director of Quy Nhon General
Hospital, the researcher met the head midwife of the Antenatal Clinic; presented
purposes of study and the method of data collection.
3. The researcher viewed the list of pregnant women registering at Antenatal
Clinic to identify the women who met eligibility criteria and recruited the participants
by using simple random technique. Seven or eight women were picked up per day.
4. The researcher was self introduction, the purposes of the study and the
data collection procedures were also presented to pregnant women. Then, the researcher
34
asked them about agreement to become participants for this study. The human
protection was explained and intended time for self-completion the questionnaire was
also informed. The consent forms were signed by the participants. The researcher
explained to the participants their benefits or the right to withdraw from the research
at any time.
5. The researcher guided the participants to fill in the questionnaire. The
questionnaire was hand-delivered to the participants for self-completion. After
collecting data, the questionnaires were immediately checked for the form’s
completeness and accuracy.
6. After finishing data collection, the researcher said thanks to the
participants.
7. Finally, the researcher entered data into software files for further analysis.
Data analysis
The questionnaires were coded and analyzed by using statistical software
program. The significant level of statistical test was set up at p < .05.
1. Descriptive statistics: All values regarding range, mean, standard
deviation, frequency, and percentage were used to describe personal information of
the respondents, knowledge about ANC of women, and family support for pregnancy.
2. Inferential statistics:
Pearson Chi-Square was used to examine the association of age, education,
parity, and timely initiation of ANC. Point-Biserial was used to examine the
association of knowledge about ANC, family support for pregnancy, and timely
initiation of ANC. Multiple logistic regression was used to determine the predictors of
timely initiation of ANC.
CHAPTER 4
RESULTS
A predictive-correlational study was conducted to determine the timely
initiation of ANC and predictors of timely initiation of ANC among pregnant women in
Binh Dinh Province, Vietnam. The results of data analysis are presented in four main
parts as follows:
Part 1 Sample characteristics and description of independent variables
1.1 Personal information and predisposing characteristics
1.2 Enabling resource
Part 2 Timely initiation of ANC
Part 3 The relationship between predisposing characteristics and enabling
resource with timely initiation of ANC
Part 4 Factors predicting timely initiation of ANC
Part 1 Sample characteristics and description of independent variables
1. Personal information and predisposing characteristics
There were 109 pregnant women participating in this study. Their age ranged
from 19 to 41 years old and the average age was 28.35 years (SD = 5.13), and most of the
respondents were married (89.9 %). Nearly half of the respondents’ education level was
above high school (42.2 %) with 51.3 % of them working for the government and private
companies. About half of them lived in urban area (49.5 %), and 44 % of them belonged
to extended families. Regarding to the parity, 40.4 % of women were with no previous
liable birth, in which 33 % of them were their first pregnancy. Although most women
realized their pregnancies in the first trimester, 9.2 % of them knew their pregnancies only
in the second trimester. The details of personal information of the respondents are
presented in the Table 1.
36
Table 1 Frequency and percentage of personal information and predisposing
characteristics of the respondents (n = 109)
Personal information and predisposing
characteristics
Frequency Percentage
Age
≤ 35 years old 93 85.3
> 35 years old 16 14.7
Mean = 28.35, SD = 5.13, Minimum = 19, Maximum = 41
Education
Less than high school level 28 25.7
High school level 35 32.1
Higher than high school level 46 42.2
Accommodation
Urban 54 49.5
Suburban 27 24.8
Rural 28 25.7
Occupation
Housewife 21 19.3
Government employee 17 15.6
Private company employee 39 35.7
Own business 21 19.3
Others 11 10.1
Marital status
Married 98 89.9
Single 5 4.6
Widowed/ Divorced/ Separated 6 5.5
Number of Pregnancy
The first pregnancy 36 33.0
The second and above 73 67.0
37
Table 1 (Cont.)
Personal information and predisposing
characteristics
Frequency Percentage
Parity
No parity 44 40.4
Parity one and above 65 59.6
First know pregnancy
The first trimester 99 90.8
The second trimester 10 9.2
Family structure
Nuclear family 61 56.0
Extended family 48 44.0
Knowledge about ANC
The results of knowledge about ANC of the respondents are summarized in the
Table 2. The mean score of knowledge about ANC was 9.01 (SD = 1.93), it ranged from
4-12 scores. The results in the Table 3 showed that most of the respondents knew that
they should be received iron and folic acid during their pregnancies (93.6 %). The
knowledge about tetanus vaccine injection for prevention of their babies from tetanus was
90.8 %. However, only 45.9 % of them knew the schedule of ANC visit. The number of
women who had knowledge about the timing for the first ANC was 60.6 % and blood test
for HIV infection was 61.5 %. The details of data are showed in the tables below.
Table 2 Range, mean, and standard deviation of knowledge about ANC of the
respondents (n = 109)
Knowledge about ANC Range
M SD Possible Actual
Total score of knowledge about ANC 0-12 4-12 9.01 1.93
38
Table 3 Frequency and percentage of each item of knowledge about ANC of the
respondents (n = 109)
No. Statements Correct answer
Frequency Percentage
1 Pregnant women should have the first antenatal care
visit within 12 weeks of gestation.
66 60.6
2 Pregnant women should attend antenatal care visit at
least once every three months.
50 45.9
3 Early antenatal visit is very important for early detection
of risk conditions associated with pregnancy
90 82.6
4 Antenatal care is very important to check the fetal
health.
91 83.5
5 Pregnant women need to have blood tested for HIV
infection in the first antenatal care.
67 61.5
6 Health care providers calculate the expected date of
delivery for pregnant women in the first visit.
88 80.7
7 Pregnant women are consulted to supply iron and folic
acid during their pregnancy.
102 93.6
8 Pregnant women are consulted to take extra food as
compared with non pregnant state.
85 78.0
9 Pregnant women need to have their blood pressure
checked in every antenatal visit.
78 71.6
10 Pregnant women need to be injected tetanus vaccine to
prevent her baby from tetanus.
99 90.8
11 At the antenatal care unit, the pregnant women are
informed about the dangerous signs and symptoms
during their pregnancy.
82 75.2
12 At the first antenatal visit, the pregnant women will be
informed about health care practice during their
pregnancy
84 77.1
39
2. Enabling resource: Family support for pregnancy
The results of family support for pregnancy are summarized in the Table 4.
The mean score of family support for pregnancy was 86.60 (SD = 6.89), which ranged
from 58-98 scores. High mean score meant more positive family support for pregnant
women.
Table 4 Range, mean, and standard deviation of family support for pregnancy of the
respondents (n = 109)
Family support for pregnancy Range
M SD Possible Actual
Total score of family support for
pregnancy 14-98 58-98 86.60 6.89
Part 2 Timely initiation of ANC
As it is shown in the Table 4 below, the mean score of the timely initiation
of ANC of the pregnant women in Binh Dinh Province, Vietnam was 11.85 weeks
(SD = 5.34), it ranged from 5-30 weeks. These results also indicated that most of the
respondents started antenatal visit early (72.5 %), and 27.5 % started ANC late.
Table 5 Mean, standard deviation, frequency, and percentage of timely initiation of
ANC (n = 109)
Timely initiation of ANC Frequency Percentage
Mean = 11.85, SD = 5.34, Min = 5, Max = 30
≤ 12 weeks 79 72.5
> 12 weeks 30 27.5
40
Part 3 The relationship between predisposing characteristics,
enabling resource with timely initiation of ANC
Pearson Chi-Square was used to test the correlation between the age,
educational level, parity of the respondents and timely initiation of ANC.
Maternal age: The results indicated that there was a significant association
between age of the respondents and timely initiation of ANC ( = 27.14, p < .001)
Maternal education: The results found that there was significant
association between education of the respondents and timely initiation of ANC ( =
27.07, p < .001). The results also showed that almost all of the respondents who had
higher high school level started ANC early (97.8 %), and who had lower than high
school level started ANC later than other groups (53.6 %).
Parity: There was strong association between parity of the pregnant women
and timely initiation of ANC ( = 4.99, p = .026). The results showed that 15.9 % of
the respondents with no parity started ANC late compared to 35.4 % of the
respondents with parity one and above.
Point-Biserial was used to test the correlation between knowledge about
ANC, family support for pregnancy and timely initiation of ANC of the pregnant
women.
Knowledge about ANC: The result indicated that there was significant
positive association between knowledge about ANC and timely initiation of ANC
(rpb = .61, p < .001). Thus, pregnant women with higher score of knowledge about
ANC came to antenatal visit early.
Family support for pregnancy: The results showed that family support for
pregnancy was positively associated with timely initiation of ANC (rpb = .56, p <
.001). High score meant more positive support from family for pregnant women and
the pregnant women came to ANC early.
41
Table 6 Pearson Chi-Square and Point-Biserial correlation coefficient between factors
and timely initiation of ANC (n = 109)
Factors
Timely initiation of ANC
p-value ≤ 12 weeks
(n = 79)
> 12 weeks
(n = 30)
n % n %
Age
≤ 35 years old 76 81.7 17 18.3 < .001a
> 35 years old 3 18.8 13 81.2
Education
Less than high school 13 46.4 15 53.6 < .001a
High school 21 60.0 14 40.0
Higher than high school 45 97.8 1 2.2
Parity
No parity 37 84.1 7 15.9 .026a
Parity one and above 42 64.6 23 35.4
Knowledge about ANC < .001b
Family support for pregnancy < .001b
a Pearson Chi-Square test
b Point-Biserial test
Part 4 Factors predicting timely initiation of ANC
The multiple logistic regression was performed to examine predictors of
timely initiation of ANC among pregnant women using significant factors from the
univariate analysis including maternal age, educational level, parity, knowledge about
ANC, and family support for pregnancy. The Omnibus tests of model coefficients
indicated that p -value of this model was less than .001. Therefore, the model was
statistically significant ( = 91.158, df = 6).
The results in the Table 6 show that age of the respondents had statistically
significant association with timely initiation of ANC. The odds ratio showed that
42
women who were ≤ 35 years old were 47.95 times more likely to have obtained the
first ANC visit after 12 weeks compared to the group of older than 35 years (AOR =
47.95, 95 % CI = 3.80-605.74, p = .003).
Knowledge about ANC of the respondents showed statistically significant
association with timely initiation of ANC among pregnant women (AOR = .24, 95 %
CI = .10-.57, p = .001). The odds ratio was .24, indicating that for each one score
increase of the knowledge about ANC, there was .24 times less likely to get ANC after
12 weeks of the respondents.
Similarly, the results indicated that family support for the respondents during
pregnancy had statistically significant association with timely initiation of ANC
(AOR = .73, 95 % CI = .57-.95, p = .020). The odds ratio showed that with each one
score increase in the family support for pregnancy, there were .73 times less likely that
the respondents will get ANC later than 12 weeks.
Table 7 The association between significant factors and timely initiation of ANC of
the respondents (n = 109)
Variables B Adjusted OR 95 % CI p-value
Age
≤ 35 years old 3.87 47.95 3.80 - 605.74 .003
> 35 years old 1.00
Education
Less than high school 2.62 13.68 .86 - 216.60 .063
High school 2.79 16.29 .94 - 282.95 .055
Higher than high school 1.00
Parity
No parity 1.00
Parity one and above -1.20 .30 .04 - 2.22 .238
Knowledge about ANC -1.42 .24 .10 - .57 .001
Family support for pregnancy -.31 .73 .57 - .95 .020
CHAPTER 5
CONCLUSION AND DISCUSSION
This chapter summarizes and discusses the study results in order to provide
the implication of the findings for nursing practice and education. In addition,
recommendations for the future research as well as the limitation of the study are also
presented in this chapter.
Summary of the study findings
The aims of this study were to determine the timely initiation of ANC and to
examine the influence of predisposing factors (maternal age, maternal education,
parity, knowledge about ANC), and enabling factor (family support for pregnancy)
on timely initiation of ANC among pregnant women in Binh Dinh Province, Vietnam.
The sample was 109 pregnant women who were randomly selected from Quy Nhon
General Hospital in Binh Dinh Province, Vietnam. The data were collected by using
self-report questionnaires.
The instruments for this study were developed and modified by the
researcher. The KR-20 coefficient of the Knowledge about ANC Questionnaire was
.74 and the Cronbach’s alpha coefficient of Family Support for Pregnancy
Questionnaire was .81.
The data analysis used descriptive statistics to describe the study sample and
variables. The Pearson Chi-Square and Point-Biserial were used to determine the
relationship between predisposing characteristics, enabling resources on timely
initiation of ANC. To examine factors predicting timely initiation of ANC, the multiple
logistic regression was used.
The results of this study are presented as follow:
1. The results indicated that the age of the respondents ranged from 19 to 41
years old and their average age was 28.35 years (SD = 5.13), and almost all the
respondents were married (89.9 %). Nearly half of the respondents had higher than high
school level (42.2 %), and 51.3 % of them worked for the government and private
companies. About half of them lived in urban area (49.5 %) and 44 % were living with
44
extended families. About 40 % of women were no parity, in which 33 % were in their first
pregnancy. Although most women realized their pregnancies in the first trimester, 9.2 %
of them knew their pregnancies only in the second trimester.
The mean score of knowledge about ANC was 9.01 (SD = 1.93), which ranged
from 4-12 scores. High mean score meant high knowledge about ANC of the respondents.
Likewise, the mean score of family support for pregnancy was 86.60 (SD = 6.89), which
ranged from 58-98 scores. High mean score meant more positive family support for
pregnant women.
2. The results found that the average gestational age for the first ANC was
11.85 weeks (SD = 5.34). This result also presented that more than two thirds of the
respondents had their first ANC visit within 12 weeks (72.5 %), and 27.5 % delayed
ANC, which was a deviation from recommended ANC visit time.
3. There was significant association between factors including maternal age,
education, parity, knowledge about ANC, and family support for pregnancy with timely
initiation of ANC with p-value of each factor as follow: maternal age ( = 27.14, p <
.001), educational level ( = 27.07, p < .001), parity of the respondents
( = 4.99, p = .026), knowledge about ANC (rpb = .61, p < .001), and family support
for pregnancy (rpb = .56, p < .001).
4. The results of multiple logistic regression revealed that the age of the
respondents was significantly associated with timely initiation of ANC. The odds ratio
indicated that the respondents who were ≤ 35 years old were 47.95 times more likely
to start ANC after 12 weeks compared to women older than 35 years (AOR = 47 .95,
95 % CI = 3.80-605.74, p = .003). The results also showed that for each one score
increase in knowledge about ANC and family support for pregnancy, there were .24
times (AOR = .24, 95 % CI = .10-.57, p = .001) and .73 times (95 % CI = .57-.95, p =
.020) less likely to get ANC after 12 weeks of pregnant women, respectively.
Discussion
This part was focused on discussing the research objectives. Firstly, the
timely initiation of ANC among pregnant women in Quy Nhon General Hospital was
discussed. Secondly, the relationships between predisposing factors, enabling resource
45
on timely initiation of ANC, followed by the discussion on factors predicting the
timely initiation of ANC are discussed.
1. The timely initiation of ANC among pregnant women in Quy Nhon
General Hospital, Binh Dinh Province, Vietnam.
This study found that the average gestational age of the respondents at first
antenatal visit was 11.85 weeks. This result indicated that pregnant women visiting
ANC within 12 weeks had lesser average gestational age compared to many previous
studies. The average duration for first ANC visit reported by a previous study in
Vietnam was 3.7 months (Trinh et al., 2007), which was relatively higher than current
findings. In addition, other studies showed the average age of the first ANC as 24.33
weeks (Onoh et al., 2012) and 27.9 weeks (Kisuule et al., 2013).
The present study also indicated that most of pregnant women started ANC
within 12 weeks (72.5 %). The result showed that the percentage of pregnant women
with initiation of ANC in the first trimester was higher than the results from a
previous study by Cresswell et al. (2013) in the United Kingdom, which reported 62.5
% booking in the first trimester. Also, current results are much higher than some
studies in other developing countries such as from Rwanda (5 %) (Hagey et al., 2014),
and Nigeria (16.95 %) (Onoh et al., 2012). It also was higher compared to 69.1% in a
previous study in Vietnam (Tran et al., 2011). The results of this study were consistent
with a collection and review research in period of 2006-2010 in Vietnam, which had
50-80 % of pregnant women starting their ANC in the first three months (UNFPA,
2012).
The findings indicated that the average gestational age of the respondents for
the first ANC in this study was in line with the recommended time. Moreover, the
percentage of women who initiated ANC within 12 weeks had increased compared to
the reported from some of previous studies in Vietnam and other countries.
The reasons for this increase and improvement in timely initiation of ANC might
because of betterment of the policy on health care for mothers and children in
Vietnam. The communication and health education to people about the benefits of
early prenatal care is increasingly popular and effective. In addition, Vietnam's health
insurance is covered for the entire population and the ANC is provided for free if
women had health insurance cards. Besides, according to the Population Policy in
46
Vietnam, each family only had from 1 child to 2 children. Thus, pregnancy and
prenatal care are also more interesting and more care is taken in many Vietnamese
families. Finally, the results showed that the economic life and social health care in
Vietnam were growing with better direction.
2. Factors association and predicting timely initiation of ANC
Maternal age
The average age of the respondents in this study was 28.35 years old with
85.3 % of them in the age group of ≤ 35 years old. The Pearson Chi-Square test
indicated that age had strong significant association with timely initiation of ANC
( = 27.14, p < .001). The multiple logistic regression revealed that there was a
significant association between the age of the respondents and timely initiation of
ANC. Pregnant women who were ≤ 35 years old were 47.95 times more likely to start
ANC visit late compared with older women. These findings were consistent with other
research in Australia, in which women in the age of forties and fifties were .91 times
less likely to book ANC late compared to women in the age of thirties (OR = .91, p =
.022) (Trinh & Rubin, 2006). Also, nearly the same with a study by Baker and
Rajasingam (2012), in which women aged more than 35 years were less likely to book
late compared to women in age group of 25-29 (group of 35-39: OR= .791, p = .009,
group of 40-49: OR = .701, p = .012). The present study was slightly different from a
previous study, which reported that age was not associated with initiation of ANC by
the respondents ( = 5.88, p = .317) (Onoh et al., 2012). These findings might be
explained that women, who are older than 35 years old, usually have had stable
education, lesser unemployed, and more income than younger women. Therefore, they
could spent more money to go to ANC than their younger counterparts. Moreover,
they had more experience to recognize their pregnancies earlier than the younger
women, and the most important, they also have more knowledge to realize that they
are in the group of high risk pregnancy. Thus, they go to ANC earlier than other
groups.
This study did not have any respondents who are younger than 18 years.
The reason may be the adolescent pregnancy had decreased because of the
effectiveness of propagation preventing teenage pregnancy in schools. Another likely
reason is the population policy in Vietnam, which doesn’t allow a person less than 18
47
years to get married. Thus, their pregnancies are out of wedlock. A lot of them do not
want to keep the fetus and done abortion (about 20 % in 300,000 abortion cases each
year in Vietnam were adolescents (Hai, 2014)). In addition, following the tradition,
these women often have psychological fears, want to hide their pregnancies.
Therefore, they do not want to check their pregnancies in the public hospital, where
they can meet acquaintances, they have trend to choose the private clinics. That might
be the reason that the researcher could not capture this section of age group in this
study.
Maternal education
Educational level of the respondents in this study was significantly
association with timely initiation of ANC ( = 27.07, p < .001). However, this factor
did not predict the timely initiation of ANC (p > .05). This finding was consistent with
previous studies which were conducted by Onoh et al. (2012) and Gross et al. (2012).
The results of this study were contrasted with a study by Belayneh et al. (2014), which
reported that pregnant women with formal education were more likely to start ANC
earlier than their counterparts (AOR = 1.06, 95 % CI = 1.03-7.6). It was also contrast
to a study by Ifenne and Utoo (2012) which reported that late booking was
significantly influenced by maternal education ( = 10.19, p = .017). A study by
Adekanle and Isawumi (2008) also concluded that better educated women were 2.63
times more likely book earlier than less educated ones (AOR = 2.63, 95 % CI =
1.287-5.378). The reasons for the results of this study might be the education about
antenatal care is not different in educational levels as it may not have been much
mentioned in the schools. Actually, the reproductive health education in Vietnamese
schools almost focuses on prevention of adolescent pregnancies and does not pay
much attention on pregnancy care.
Parity
There was significant association between parity of the respondents and
timely initiation of ANC ( = 4.99, p = .026). However, the results of multiple
logistic regressions indicated that parity did not predict for timely initiation of ANC in
this study (p = .238). This result was similar to a study by Onoh et al. (2012) ( =
6.179, p = .289) and another study by Ifenne and Utoo (2012) ( = 4.29, p = .61).
48
In contrast, some previous studies indicated that parity highly predicted the initiation
of ANC, a study found that women with lower parity were significant predictors of
early booking (OR = 1.76, p = .016) (Oladokun et al., 2010). Similarly, a research was
reported that multiparous women were more likely to book ANC late than nulliparous
women (AOR = .99 and 95 % CI = .92-1.07) (Cresswell et al., 2013). Another study
also showed that nulliparous women less likely to initiate ANC late compared to
multiparous women in both rural (AOR = .411, p = .001) and urban districts (AOR =
.518, p = .009) (Banda et al., 2012). In this study, nearly half of the respondents lived
in the extended families. So, they usually had the trend to receive advices for
pregnancy care from their mothers, mothers-in-law, or older sisters. Besides,
traditionally, Vietnamese women in the first child birth often seek advices for
pregnancy care from other women who are considered to have the experience of
childbirth. Eventually, in most instances, the initiation time of ANC is not much
depending on the parity as can be seen in this study.
Knowledge about ANC
The finding from this study showed that knowledge about ANC of the
respondents was significantly associated with timely initiation of ANC (rpb = .61, p <
.001) and it strongly predicted the timing initiation of ANC (AOR = .24, 95 % CI =
.10-.57, p = .001). The results indicated that for each one score increase on knowledge
about ANC, there was .24 times less likely that pregnant women would start ANC >
12 weeks. This finding was consistent with a study by Banda et al. (2012), which
reported that pregnant women having adequate knowledge were 2.2 times more likely
to initiate ANC within recommended time compared to those without adequate
knowledge about ANC (AOR = 2.205, 95% CI = 1.021-4.759). Another study also
indicated that women having knowledge about the time of booking were 1.5 times
more likely to book earlier than lack of knowledge (AOR = 1.50, 95 % CI = .72-3.11)
(Tariku et al., 2010). One of the reasons for the late prenatal care among women is
that they might lack knowledge of pregnancy care to realize they are pregnant early
compared to those with good knowledge. Another reason could be that pregnant
women who have the perception of the benefits of antenatal visit tend to attend ANC
early to receive pregnancy care soon. Therefore, health education could be important
in the improvement of timing of ANC attendance. Improving knowledge about
49
prenatal care for women is an important factor to reduce the incidence of late antenatal
women and the consequences of late booking. Moreover, enhanced knowledge will
make health care better for women.
Family support for pregnancy
Concerning the family support for pregnancy, there was statistically
significant strong association between family support for pregnancy and timely
initiation of ANC with the odds ratio of .73 (p = .020). This finding was explained that
for each one score increase in family support for pregnant women, it was .73 times
were less likely for women to initiate ANC late. This was consistent with a study of
Gross et al. (2012), which presented that women who lacked support from husbands
or partners were booking ANC almost 3 weeks later than women who did receive such
support (p = .035). The current findings were also in line with another study by Rowe
et al. (2008), which reported that women who did not receive support from family
were 2.74 times more likely to start ANC late. The results of this study showed the
important role of the family members in prenatal care and the contribution of family
members to improvement of the timely initiation of ANC by pregnant women.
Therefore, one of the strategies to increase the percentage of mothers attending
antenatal clinics early is educating family members regarding the importance of timely
initiation of ANC. Help them recognize their roles and responsibilities in pregnancy
care, encourage them to accompany women to antenatal clinics, and discuss the result
of the ANC and planning for pregnancy care from health care providers. Thus, they
can share about pregnancy care and give more support for women during pregnancy.
Therefore, proper education campaigns and the dissemination of information for all
people about antenatal care can prove to be investment for long term activities.
Lastly, the findings of this study could be an evidence to support validity of
Andersen’s Behavioral Model of Health Services Use such as antenatal care.
Antenatal care is an important component of women's health care; it is more effective
if initiated early. This study demonstrated that pregnant women who are in the group
of older than 35 years old, with high knowledge about ANC, and more support from
family were more likely to start ANC early. These factors of Andersen’s Behavioral
Model were demonstrated as predictors for timely initiation of ANC in previous
50
studies (Trinh & Rubin, 2006; Tariku et al., 2010; Belayneh et al., 2014), which
results were consistent with the present study.
Implications of the study
The findings of the study showed that women with higher knowledge about
ANC would attend ANC less lately than other group. Besides, woman’s decision
about pregnancy care is not only influenced by herself alone but also by her family's
advices and support. Therefore, in the preconception care classes or counseling about
pregnancy care, the nurses and midwives should not only focus on women but need to
enlarge and encourage other members in her family to attend the classes. They would
play an important role in contributing to improve the health care for women during
pregnancy.
The results of this study showed that participants in this study had relatively
good knowledge of antenatal care. Thus, reinforcement and maintenance of health
education for communities should be continued and developed. Moreover, health care
providers and health care system should pay more attention to pregnant women ≤ 35,
who having less experience about pregnancy.
Limitations of the study
In this study, the pregnant women with either first time visit or subsequent
visit for ANC were included. The different number of visits could possibly confound
the knowledge about ANC of the pregnant women. Therefore, study in the future,
the researcher should collect the data only from the mothers coming for the first ANC
visit.
The researcher could not collect the data with pregnant women younger than
18 years old because they did not come for ANC at that time. If the actual rate of teen
pregnancy has declined significantly, it is a good sign. However, the lack of an age
group is also a limitation of this study because this result cannot be generalized to all
age group of pregnant women.
51
Recommendations for future research
1. This study focused on some factors predicting timely initiation of ANC
(maternal age, maternal education, parity, knowledge about ANC, and family support
for pregnancy). The studies in the future should be considered to other factors that
influencing to the time of first ANC visit such as maternal occupation, family income,
distance from health service, waiting time for ANC, health insurance, and so on.
2. This study was conducted in the central of Vietnam. Studies in the future
should be conducted to compare the ANC utilization with other areas in Vietnam.
REFERENCES
Adekanle, D. A., & Isawumi, A. I. (2008). Late antenatal care booking and its
predictors among pregnant women in South Western Nigeria. The Online
Journal of Health and Allied Science, 7(1), 4-7.
American College of Obstetricians and Gynecologists [ACOG]. (2012). Guidelines
for perinatal care. Summary of ACOG Guidelines for perinatal care.
Retrieved from http://www.uhccommunityplan.com/content/dam/
communityplan/healthcareprofessionals/clinicalguidelines/ACOG_Perinatal_
Care_Guideline_Summary_7th_Edition.pdf
Andersen, R. M. (1995). Revisiting the behavioral model and access to medical care:
Does it matter? The Journal of Health and Social Behavior, 36(1), 1-10.
Andersen, R. M., & Newman, J. (1973). Societal and individual determinants of
medical care utilization in the United States. Journal of Health and Society,
51(1), 95-124.
Andersen, R.M., Rice., T. H., & Kominski., G. F. (2007). Improving access to care in
America: Individual and contextual indicators. In R. M. Andersen, T. H.
Rice, & G. F. Kominski (Eds.), Changing the U.S. health care system: Key
issues in health services, policy and management (3rd
ed., pp. 3-30). San
Francisco: Jossey-Bass.
Ayala, L. S. H, Blumenthal, P. D., & Sarnquist, C. C. (2013). Factors influencing
women’s decision to seek antenatal care in the ANDES of Peru.
The Journal of Maternal Children Health, 17(6), 112-1118.
doi:10.1007/s10995-012-1113-9
Babitsch, B., Gohl, D., & Lengerke, T. (2012). Re-revisiting Andersen’s behavioral
model of health services use: a systematic review of studies from 1998-2011.
GMS Psycho-Social-Medicine, 9(11), 1-15. doi:10.3205/psm000089
Baker, E. C., & Rajasingam, D. (2012). Using trust databases to identify predictors of
late booking for antenatal care within the UK. The Journal of Public Health,
126(2), 112-116. doi:10.1016/j.puhe.2011.10.007
53
Banda, I., Michelo, C., & Hazemba, A. (2012). Factors associated with late antenatal
care attendance in selected rural and urban communities of the Copperbelt
Province of Zambia. Medical Journal of Zambia, 39(3), 29-36.
Beeckman, K., Louckx, F., & Putman, K. (2011). Predisposing, enabling and
pregnancy-related determinants of late initiation of prenatal care. Maternal
Child Health Journal, 15(7), 1067-1075. doi10.1007/s10995-010-0652-1
Belayneh, T., Adefris, M., & Andargie, G. (2014). Previous early antenatal service
utilization improves timely booking: Cross-sectional study at university of
Gondar hospital, Northwest Ethiopia. Journal of Pregnancy, 3, 1-7.
Berg, C. J., Callagham, W. M., Syverson, C., & Henderson, Z. (2010). Pregnancy-
related mortality in the United States, 1998 to 2005. The Journal of
Obstetrics and Gynecology, 116(6), 1302-1309. doi:10.1097/AOG.0b013
e3181fdfb11
Central Statistical Agency & Inner City Fund [ICF] International. (2012). Ethiopia
demographic and health survey 2011. Retrieved from http://dhsprogram.
com/pubs/pdf/FR255/FR255.pdf
Cha, E-S., Kim, K. H., & Erlen, J. A. (2007). Translation of scales in cross-cultural
research: Issues and techniques. Journal of Advanced Nursing, 58(4), 386-
395. doi:10.1111/j.1365-2648.2007.04242.x
Change, R. R., Karen, A. R., & Linda, E. P. (1998). Patterns of service use and
theories of help-seeking behavior. Retrieved from http://www.sagepub.com/
upm-data/19108_Chapter_3.pdf
Cresswell, J. A., Yu, G., Hatherall, B., Morris, J., Jamal, F., Harden, A., & Renton, A.
(2013). Predictors of the timing of initiation of antenatal care in an ethnically
diverse urban cohort in the UK. The Journal of BioMed Cental Pregnancy
and Childbirth, 13(103), 1-8. doi:10.1186/1471-2393-13-103
Cunningham, F. G., Leveno, K. J., Bloom, S. L., Spong, C. Y., Deshe, J. S., Hoffman,
B. L., Casey, B. M., & Sheffield, J. S. (2014). Prenatal care. In Williams
Obstetrics (24th
ed., pp. 167-192). New York: McGraw-Hill.
Dhingra, S. S., Zack, M., Strine, T., Pearson, W. S., & Balluz, L. (2010). Determining
prevalence and correlates of psychiatric treatment with Andersen's
behavioral model of health services use. Psychiatric Service. 61(5), 524-528.
54
Dodd, J. M., Robinson J. S., & Crowther C. A. (2002). Guiding antenatal care.
Medical Journal of Australia, 176(6), 253-256.
General Statistics Office of Viet Nam [GSVN]. (2011). Cuc Thong Ke. Retrieved
from http://www.gso.gov.vn/Default_en.aspx?tabid=491
Gross, K., Alba, S., Glass, T. R., Schellenberg, J. A., & Obrist, B. (2012). Timing of
antenatal care for adolescent and adult pregnant women in South-Eastern
Tanzania. Journal of BioMed Central Pregnancy and Childbirth, 12(16),
1-12. doi:10.1186/1471-2393-12-16
Hagey, J., Rulisa, S., & Pe´rez-Escamilla, R. (2014). Barriers and solutions for timely
initiation of antenatal care in Kigali, Rwanda: Health facility professionals’
perspective. The Journal of Midwifery, 30(2014), 96-102. doi.org/10.1016/
j.midw.2013.01.01
Hai, M. (2014). Alarm about adolescent abortion and childbirth. Retrieved from:
http://vnmedia.vn/VN/suc-khoe/tin-tuc/bao-dong-tre-vi-thanh-nien-pha-thai,-
sinh-con-73-2972454.html
Herbst, M. A., Mercer, B. M, Beazley, D., Meyer, N., & Carr, T. (2003). Relationship
of prenatal care and perinatal morbidity in low-birth-weight infants. The
Journal of Obstetrics and Gynecology, 189(4), 930-933. doi:10.1067/S0002-
9378(03)01055-X
Hollowell, L., Oakley, L., Vigurs, C., Barnett-Page, E., Kavanagh, J., & Oliver, S.
(2012). Increasing the early initiation of antenatal care by Black and
Minority Ethnic women in the United Kingdom: A systematic review and
mixed methods synthesis of women’s views and the literature on intervention
effectiveness. Oxford: npeu.
House, J. S. (1981). Work stress and social support. Reading, M A: Addition-Wesley.
Ifenne, D. I., & Utoo, B. T. (2012). Gestational age at booking for antenatal care in a
tertiary health facility in North‑Central, Nigeria. Nigerian Medical Journal,
53(4), 236-239. doi:10.4103/0300-1652.107602
Kipronoh, K. M., & Agina, B. M .O. (2009). Factors influencing the quality of
antenatal care in public maternal and child health facilities in Nairobi
province, Kenya. Master’s thesis, Faculty of Public Health, Kenyatta
University.
55
Kisuule, I., Kaye, D. K., Najjuka, F., Ssematimba, S. K., Arinda, A., Nakitende, G., &
Otim, L. (2013). Timing and reasons for coming late for the first antenatal
care visit by pregnant women at Mulago Hospital, Kampala Uganda. Journal
of BioMed Central Pregnancy and Childbirth, 13(121), 1-7. doi:10.1186/
1471-2393-13-121
Low, P., Paterson, J., Wouldes, T., Carter, S., Williams, M., & Percival, T. (2005).
Factors affecting antenatal care attendance by mothers of Pacific infants
living in New Zealand. The New Zealand Medical Journal, 118(1216), 1-10.
Mosunmola, S., Adekunbi, F., & Foluso, O. (2014). Women’s perception of husbands’
support during pregnancy, labour and delivery. Journal of Nursing and
Health Science, 3(3), 45-50.
National Institute for Health and Clinical Excellence [NICE]. (2008). Antenatal care:
Routine care for the healthy pregnant women. London: NICE.
National Institute for Health and Clinical Excellence [NICE]. (2010). Antenatal care.
Retrieved from http://guidance.nice.org.uk/cg62
Ndidi, E. P., & Oseremen, I. G. (2010). Reasons given by pregnant women for late
initiation of antenatal care in the Niger Delta, Nigeria. Ghana Medical
Journal, 44(2), 47-51.
Nguyen, N. T., Deoisres, W., & Sangin, S. (2013). Factors predicting antenatal care
utilization among postpartum women in Tu Du Hospital, Ho Chi Minh City,
Vietnam. The Journal of Science, Technology, and Humanities, 11(1), 49-54.
Nwagha, U. I., & Anyaehie, U. S. B. (2008). The influence of parity on the gestational
age at booking among pregnant women in Enugu, South East Nigeria.
Nigerian Journal of Physiological Sciences, 23(1), 67-70.
Oladokun, A., Oladokun, R. E., Morhason-Bello, I., Bello, A. F., & Adedokun, B.
(2010). Proximate predictors of early antenatal registration among Nigerian
pregnant women. The journal of Annals of African Medicine, 9(4), 222-225.
doi:10.4103/1596-3519.709
Onoh, R. C., Umeora, O. U. J., Agwu, U. M., Ezegwui, H. U., Ezeonu, P. O., &
Onyebuchi, A. K. (2012). Pattern and determinants of antenatal booking at
Abakaliki Southeast Nigeria. Annals of Medical and Health Sciences
Research, 2(2), 169-175. doi:10.4103/2141-9248.105666
56
Phafoli, S. H., Aswegen, V., & Alberts, U. U. (2007). Variables influencing delay in
antenatal clinic attendance among teenagers in Lesotho. Journal of South
African Family Practice, 49(9), 17-17h. doi:10.1080/ 20786204.2007.1087
3633
Quy Nhon General Hospital. (2013). Introduction about Quy Nhon General Hospital.
Retrieved from http://benhvienquynhon.gov.vn/home2/index.php/vi/
gioithieubenhvien/GIOI-THIEU-CHUNG/Gioi-thieu-ve-Benh-vien-da-khoa-
TP-Quy-Nhon-1/
Radina, M. E., & Barber, C. E. (2004). Utilization of formal support services among
Hispanic Americans caring for aging parents. Journal of Gerontological
Social Work, 43(2), 5-23.
Rowe, R. E., Magee, H., Quigley, M. A., Heron, P., Askham, J., & Brocklehurst, P.
(2008). Social and ethnic differences in attendance for antenatal care in
England. The Journal of Public Health 122, 1363-1372. doi:10.1016/j.puhe.
2008.05.011
Sarason, I. G., Levine, H. M., Basham, R. B., & Sarason, B. R. (1983). Assessing
social support: The social support questionnaire. Journal of Personality and
Social Psychology, 44(1), 127-139.
Sarmiento, O. L., Miller, W. C., Ford, C. A., Schoenbach, V. J., Viadro, C. I.,
Adimora, A. A., & Suchindran, C. M. (2004). Disparities in routine physical
examinations among in-school adolescents of differing Latino origins.
Journal of Adolescent Health, 35(4), 310-320. doi:10.1016/ j.jadohealth.
2003.09.020
Secka, E., Helleve, A., Storeng, K., & Toure’, S. O. (2010). Men’s involvement in care
and support during pregnancy and childbirth. A qualitative study conducted
in the Gambia. Master’s thesis. Faculty of General Practice and Community
Medicine, University of Oslo.
Tabachnick, B. G., & Fidell, L. S. (2007). Using multivariate statistics. (5th ed). Boston, MA:
Allyn and Bacon.
57
Tariku, A., Melkamu, Y., & Kebede, Z. (2010). Previous utilization of service does
not improve timely booking in antenatal care: Cross sectional study on
timing of antenatal care booking at public health facilities in Addis Ababa.
Ethiopian Journal of Health Development, 24(3), 226-233.
Tayie, F. A. K., & Lartey, A. (2008). Antenatal care and pregnancy outcome in
Ghana, the importance of women’s education. African Journal of Food
Agriculture Nutrition and Development, 8(3), 291-303.
Tran, T. K., Gottvall, K., Nguyen, H. D., Ascher, H., & Petzold, M. (2012). Factors
associated with antenatal care adequacy in rural and urban contexts-results
from two health and demographic surveillance sites in Vietnam. The Journal
of Health Service Research, 12(40), 1-10. doi:10.1186/1472-6963-12-40
Tran, T. K., Nguyen, C. T. K., Nguyen, H. D., Eriksson, B., Bondjers, G., Gottvall,
K., Ascher, H., & Petzold, M. (2011). Urban-rural disparities in antenatal
care utilization: A study of two cohorts of pregnant women in Vietnam. The
Journal of BMC Health Service Research, 15(29), 163-171. doi:10.1186/
1472-6963-11-120
Trinh, H., & Toney, M. B. (2012). Ethnic disparities in prenatal care utilization in
Vietnam. Master’s thesis, Faculty of Sociology, University of Utah.
Trinh, L. T. T., & Rubin, G. (2006). Late entry to antenatal care in New South Wales,
Australia. Reproductive Health Journal, 3(8), 1-8. doi:10.1186/1742-4755-3-
8
Trinh, L. T. T., Dibley, M. J., & Byles, J. (2006). Antenatal care adequacy in three
provinces of Vietnam: Long An, Ben Tre and Quang Ngai. The Journal of
Public Health Reports, 121(4), 468-475.
Trinh, L. T. T., Dibley, M. J., & Byles, J. (2007). Determinants of antenatal care
utilization in three rural areas of Vietnam. The Journal of Public Health
Nursing, 24(4), 300-310. doi:10.1111/j.1525-1446.2007.00638.x
58
United Nations Development Programme [UNDP]. (2012). Quyet dinh phe duyet
Chuong trinh muc tieu quoc gia Y te giai doan 2012-2015. Retrieved from
http://www.chinhphu.vn/portal/page/portal/chinhphu/noidungchuongtrinhmu
ctieuquocgia?_piref135_18249_135_18248_18248.strutsAction=ViewDetail
Action.do&_piref135_18249_135_18248_18248.docid=1359&_piref135
_18249_135_18248_18248.substract=
United Nations Development Programme [UNDP]. (2013). The 8 millennium
development goals: Improve maternal health. Retrieved from http://www.vn.
undp.org/content/vietnam/en/home/ mdgoverview/overview/mdg5/
United Nations Fund for Population Activities [UNFPA]. (2008). Childbirth in ethnic
minority communities: A qualitative study in Binh Dinh province. Retrieved
from http://vietnam.unfpa.org/webdav/site/vietnam/shared/Childbirth_EM_
Eng.pdf
United Nations Fund for Population Activities [UNFPA]. (2010). The 2009 Vietnam
population and housing census: Major findings. Retrieved from
http://unstats.un.org/unsd/demographic/sources/census/2010_phc/Viet%20N
am/Vietnam-Findings.pdf
United Nations Fund for Population Activities [UNFPA]. (2012). Compendium of
research on reproductive health in Viet Nam for the period 2006-2010.
Hanoi: Luck House Graphics.
Vietnam Committee for Population, Family and Children [VCPFC]. (2002). Vietnam
demographic and health survey 2002. Hanoi: Vietnam committee for
population, family and children general statistical office. Retrieved from
http://www.measuredhs.com/pubs/pub_details.cfm?ID=412&SrvyTp=&ctry
_id=56
Vietnam Ministry of Health [VMOH]. (2003). National Guideline on reproductive
health services. Retrieved from http://www.un.org/popin/unfpa/
taskforce/guide/iatfreph.gdl.html
Vietnam Ministry of Health [VMOH]. (2009). National Plan of Action for Child
Survival 2009-2015. Hanoi: Vietnam Ministry of Health.
59
Vintzileos, A. M., Ananth, C. V., Smulian, J. C., Scorza, W. E., & Knuppel, R. A.
(2002). Prenatal care and black-white fetal death disparity in the United
States: Heterogeneity by high-risk conditions. The Journal of Obstetrics and
Gynecology, 99(3), 483-489.
World Health Organization [WHO]. (2002). Who antenatal care randomized trial:
Manual for the implementation of the new model. Retrieved from
http://whqlibdoc.who.int/ hq/2001/WHO_RHR_01.30.pdf
World Health Organization [WHO]. (2003 a). Antenatal care in developing countries
promises, achievements and missed opportunities: An analysis of trends,
levels, and differentials. Geneva: World Health Organization.
World Health Organization [WHO]. (2003 b). What is the efficacy/ effectiveness of
antenatal care and the financial and organizational implications? Geneva:
World Health Organization.
World Health Organization [WHO]. (2005 a). Maternal mortality in Viet Nam 2000-
2001 - An indepth analysis of causes and determinants. Retrieved from
http://www.wpro.who.int/NR/ rdonlyres/ CF3FDC73-48DE-46AA-BC41-
2C93F73B438B/0/ Maternal_Mortality_in_ VietNam.pdf.
World Health Organization [WHO]. (2005 b). The world health report: Make every
mother and child count. Geneva: World Health Organization.
World Health Organization [WHO]. (2006). Neonatal and perinatal mortality:
Country, regional, and global estimates. Geneva: World Health
Organization.
World Health Organization [WHO]. (2007). Intergrated management of pregnancy
and childbirth: Standards for maternal and neonatal care. Geneva: World
Health Organization.
World Health Organization [WHO]. (2014 a). Trends in maternal mortality: 1990 to
2013. Estimates by WHO, UNICEF, UNFPA, The world bank and the united
nations population division. Geneva: World Health Organization.
World Health Organization [WHO]. (2014 b). World blood donor day. Retrieved from
http://www.who.int/mediacentre/en/
60
World Health Organization [WHO]. (2014 c). World health statistic 2014: Part I
Health-related millennium development goals. Geneva: World Health
Organization.
61
APPENDICES
62
APPENDIX 1
Permission letter to use the instruments
63
LETTER ASKING PERMISSION TO USE THE
QUESTIONNAIRE
Dear Ms Nguyen Thi Nhan,
My name is Nguyen Thi Le Thuong, a Master Degree Student in Faculty of Nursing,
Burapha University, Thailand. My major is Midwifery.
I will conduct a thesis with the topic "Factors Predicting Timely Initiation of
Antenatal Care among Pregnant Women in Binh Dinh Province, Vietnam".
After I read your article: "Factor Predicting Antenatal Care Utilization among
Postpartum Women in Tu Du Hospital, Ho Chi Minh City, Vietnam" I feel interesting
with the questionnaire "Knowledge toward Antenatal Care". I think it could be
suitable for me develop the questionnaire "Knowledge about Antenatal Care of
Pregnant Women".
So, I would like to ask you please give me your questionnaire.
Thank you so much. I am waiting for your answer.
Best Regards,
Mrs Thuong
Nguyen Thi Le Thuong
Dear Ms. Thuong,
Thank you for your interest in my questionnaire. Of course, you can use the
questionnaire to develop your research. It is my pleasure.
By the way, my name is Nhan. I hope next time you can call my name correctly.
Good luck in your studying.
Best regards,
Nhan
Dear Ms Nhan,
Thank you so much for the questionnaire you sent to me.
Now, I would like to ask you that: Would you permit me translate your questionnaire
from English to Vietnamese and contrary? I am looking forward your answer.
64
Thank you very much
Mrs Thuong
Dear Ms. Thuong,
You can use the translation process to translate the questionnaire.
Best Regards,
Nguyen Thi Nhan
Dear Ms Nhan,
I already received your answer that you permit me translate your questionnaire from
English to Vietnamese and contrary.
Thank you so much
Best Regards,
Mrs Thuong
Nguyen Thi Le Thuong
Master Student (International Program)
Falcuty of Nursing, Burapha University, Thailand
Email: [email protected]
65
APPENDIX 2
Questionnaires in English
66
Date of interview…………………..……
No…...………………
QUESTIONNAIRE
“FACTORS PREDICTING TIMELY INITIATION OF
ANTENATAL CARE AMONG PREGNANT WOMEN IN BINH
DINH PROVINCE, VIETNAM”
Part 1: Personal Background
Please answer the following questions. Fill in the blank or mark “X” sign into the box
“ ” that you choose
1. Age …………………….. years old
2. What is the highest level of your education?
1. Primary school 2. Secondary school 3. High school
4. College 5. Bachelor’s degree and higher
3. Where do you live?
1. Urban 2. Suburban 3. Rural
4. What is your occupation?
1. Housewife
2. Government employee
3. Private company employee
4. Own business
5. Other (specific):………………….
5. What is your marital status?
1. Single 2. Married 3. Widowed
4. Divorced 5. Separated
6. How many times have you got pregnant (Including this pregnancy)?
1. One 2. Two or more
7. How many times have you delivered babies? (Not including abortion and this
child).....................time(s)
67
8. When did you firstly know that you were pregnant in this pregnancy?
At …………………weeks gestation.
9. What is your family structure?
1. Nuclear family 2. Extended family
68
Part 2: Information about Timely Initiation of ANC
1. What was the gestational age at your first antenatal visit?
………………………weeks (Do not count the visit that was only for confirmation of
your pregnancy such as pregnancy test or ultrasound)
2. What health care service did you receive in the first antenatal care visit?
No Contents Self-report
Yes No
2.1 Pregnancy test.
2.2 ……………………….
2.3 ……………………….
2.4 Physical assessments (height/ weight/ blood
pressure).
2.5 ……………………….
2.6 ……………………….
2.7 Others (specific):…………………………
69
Part 3: Knowledge about ANC (12 items)
Please mark a check (√) in only ONE appropriate column according to your
understanding
No Statement True False No
idea
1 Pregnant women should have the first antenatal care visit
within 12 weeks of gestation.
2 ………………………
3 ………………………
4 Antenatal care is very important to check the fetal health.
5 ………………………
6 ………………………
7 Pregnant women are consulted to supply iron and folic
acid during their pregnancy.
8 ………………………
9 Pregnant women need to have their blood pressure
checked in every antenatal visit.
10 ………………………
11 ………………………
12 At the first antenatal visit, the pregnant women will be
informed about health care practice during their pregnancy.
70
Part 4: Family Support for Pregnancy (14 items)
Please mark a check (√) in only ONE appropriate column according to your feeling
Mark in the column (1) if you strongly disagree
Mark in the column (1) if you strongly disagree
Mark in the column (2) if you disagree
Mark in the column (3) if somewhat disagree
Mark in the column (4) if you neutral
Mark in the column (5) if somewhat agree
Mark in the column (6) if you agree
Mark in the column (7) if you strongly agree
No Statement 1 2 3 4 5 6 7
1
I get the emotional support
from my family during
pregnancy.
2 ………………………
3 ………………………
4 ………………………
5
I am not lonely in pregnancy
because my family is always
beside me.
6 ………………………
7 My family shares experience
about pregnancy care with me.
8 ………………………
9 ………………………
10 ………………………
11 ………………………
71
No Statement 1 2 3 4 5 6 7
12
I can talk about my pregnant
problems that I have with my
family.
13 ………………………
14 My family encourages me come
to antenatal clinic on schedule.
72
APPENDIX 3
Questionnaires in Vietnamese
73
Ngày phỏng vấn:………………………..
Số:……………………….
BỘ CÂU HỎI VỀ
CÁC YẾU TỐ TÁC ĐỘNG ĐẾN THỜI GIAN ĐI KHÁM THAI
LẦN ĐẦU Ở THAI PHỤ TẠI TỈNH BÌNH ĐỊNH, VIỆT NAM
Phần 1: Thông tin cá nhân
Xin vui lòng trả lời những câu hỏi sau bằng cách điền vào chỗ trống hoặc đánh dấu
“X” vào ô “ ”mà bạn chọn.
1. Tuổi………………….
2. Trình độ học vấn cao nhất của bạn?
1. Cấp 1 2. Cấp 2 3. Cấp 3
4. Cao đẳng 5. Đại học và trên đại học
3. Bạn sống ở đâu?
1. Thành phố 2. Ngoại ô 3. Nông thôn
4. Nghề nghiệp của bạn là gì?
1. Nội trợ 2. Công chức nhà nước
3. Làm việc cho tư nhân 4. Tự kinh doanh riêng
5. Nghề nghiệp khác (cụ thể)…………………
5. Tình trạng hôn nhân của bạn hiện nay?
1. Độc thân 2. Kết hôn 3. Góa phụ
4. Ly hôn 5. Ly thân
6. Bạn đã mang thai bao nhiêu lần? (Kể cả lần mang thai này)
1. Một lần 2. Hai lần hay nhiều hơn.
7. Bạn đã sinh bao nhiêu lần? (Không kể nạo phá thai và lần mang thai này)
……………….lần.
8. Trong lần mang thai này, bạn biết mình có thai khi nào? Lúc………………..tuần.
9. Cấu trúc gia đình bạn đang sống là gì?
1. Gia đình 2 thế hệ 2. Gia đình nhiều thế hệ
74
Phần 2: Thông tin về lần khám thai đầu
1. Bạn đi khám lần đầu lúc thai bao nhiêu tuần?...............tuần.
(Không tính lần khám thai chỉ để xác định có thai như thử test thai hoặc siêu âm)
2. Bạn đã nhận được những chăm sóc gì trong lần khám thai đầu?
STT Nội dung Tự báo cáo
Có Không
2.1 Xét nghiệm có thai.
2.2 ………………………
2.3 Xét nghiệm HIV.
2.4 ………………………
2.5 ………………………
2.6 ………………………
2.7 Dịch vụ khác (cụ thể):…………………………
75
Phần 3: Kiến thức về chăm sóc tiền sản
Xin vui lòng đánh dấu (√) vào MỘT cột thích hợp theo sự hiểu biết của bạn
TT Câu hỏi Đúng Sai Không
biết
1 Phụ nữ mang thai nên đi khám thai lần đầu trong vòng
12 tuần tuổi thai.
2 ………………………
3 ………………………
4 Chăm sóc tiền sản rất quan trọng để kiểm tra sự khỏe
mạnh của thai nhi.
5 ………………………
6 ………………………
7 Phụ nữ mang thai được tư vấn bổ sung viên sắt và acid
folic trong thai kỳ.
8 ………………………
9 ………………………
10 ………………………
11 Khi khám thai, người phụ nữ được thông báo về những
dấu hiệu và triệu chứng nguy hiểm trong thai kỳ.
12
Trong lần khám thai đầu tiên, người phụ nữ sẽ được
cung cấp thông tin về thực hành chăm sóc sức khỏe
trong suốt thai kỳ.
76
Phần 4: Hỗ trợ của gia đình cho phụ nữ mang thai
Xin vui lòng đánh dấu (√) trong MỘT cột thích hợp theo sự cảm nhận của bạn
Đánh dấu vào côt (1) nếu bạn rất không đồng ý
Đánh dấu vào côt (2) nếu bạn không đồng ý
Đánh dấu vào côt (3) nếu bạn không đồng ý một phần
Đánh dấu vào côt (4) nếu bạn không rõ ràng đồng ý hay không đồng ý
Đánh dấu vào côt (5) nếu bạn đồng ý một phần
Đánh dấu vào côt (6) nếu bạn đồng ý
Đánh dấu vào côt (7) nếu bạn hoàn toàn đồng ý
TT Câu hỏi 1 2 3 4 5 6 7
1
Tôi nhận được sự hỗ trợ tinh
thần từ gia đình tôi trong suốt
thai kỳ.
2 ………………………
3 ………………………
4
Tôi cảm thấy tự tin hơn khi
chăm sóc thai kỳ cùng với gia
đình.
5 ………………………
6 ……………………….
7
Gia đình của tôi đã chia sẻ
những kinh nghiệm về chăm sóc
thai nghén với tôi.
8 ……………………….
9 Gia đình tôi đã đi cùng tôi đến
phòng khám thai, nếu tôi cần.
10 ……………………….
11 ……………………….
77
TT Câu hỏi 1 2 3 4 5 6 7
12
Tôi có thể nói về những vấn đề
thai nghén mà tôi gặp phải với
gia đình tôi.
13 ……………………….
14 Gia đình tôi khuyến khích tôi
đi khám thai đúng lịch.
78
APPENDIX 4
IRB approval, Hospital permission, and Formed consents form
79
80
81
82
83
84
PARTICIPANT’S INFORMATION SHEET
Dear Participant,
My name is Nguyen Thi Le Thuong, a student studying Master of Nursing
Science at the Faculty of Nursing in Burapha University, Thailand. I am conducting a
study entitled: “Factors predicting timely initiation of antenatal care (ANC) among
pregnant women in Binh Dinh province, Vietnam”. The purposes of study are to
determine timely the initiation of ANC of pregnant women and to examine the
influence of maternal age, maternal education, parity, knowledge of pregnant women
about ANC, and family support for pregnancy on timely initiation of ANC among
pregnant women. The number of samples will be 109 pregnant women in Binh Dinh
Province, Vietnam.
This study is a survey study. If you agree participate the study, you will sign
in this form and self complete the questionnaire for participant. It will take you about
20- 25 minutes. The benefits of participant that you may help health care providers to
identify factors that influence pregnant women in starting ANC early or late, which
will help them develop intervention in order to improve the timely utilization of ANC
more effectively and results from this study will contribute to improve maternal and
fetal health.
The participation is voluntary, you have the right to refuse or withdraw the
participant at any time, and not necessary to inform to the researcher. You may refuse
to answer any specific question, remain silent, or leave this study at any time. Any
information received from this study, including your identity and your name, will be
kept confidential. A coding number will be assigned to you and your name will not
used. The results of this study will be showed as a group of data. All data will be
destroyed completely within one year after publishing or presenting the findings. You
will receive a complete explanation of the nature of the study upon its completion, if
you wish.
85
The study will be conducted by Nguyen Thi Le Thuong under supervision of
my major-advisor, Assoc. Prof. Dr.Wannee Deoisres. If you have any questions,
please contact with me at telephone number: +84906675103 or email address:
[email protected] and/or my advisor’s email address: [email protected].
Your cooperation is greatly appreciated. You will be given a copy of this
consent form to keep.
Researcher
Nguyen Thi Le Thuong
86
CONSENT/ASSENT TO PARTICIPATE IN THE RESEARCH
STUDY
Title: “ Factors predicting timely initiation of antenatal care among
pregnant women in Binh Dinh Province, Vietnam”
IRB approval number:
Date …………… Month …………. Years………………
Before giving my signature below, I have been clearly explained from
the researcher, Mrs. Nguyen Thi Le Thuong about purposes, method, procedures,
benefits and possible risk associated with participation in this study, and I understood
all of that explanation. I agree to participate in this research project and I have
received a copy of this form.
I am Mrs. Nguyen Thi Le Thuong as a researcher had explained to the above
named individual the nature and purpose, benefit and possible risk associated with
participation in this research with honestly. All data and information of the
participants will only be used for the purpose of this research study.
____________________ ____________________
Name and Signature of the Participant Date
____________________ ____________________
Name and Signature of witness Name and Signature of the researcher
Nguyen Thi Le Thuong
87
APPENDIX 5
List of experts for content validity of the instruments
88
LIST OF EXPERTS FOR CONTENT VALIDITY
OF THE INSTRUMENTS
1. Chintana Wacharasin, Ph.D. Associate Professor
Pediatrics Nursing, Faculty of Nursing,
Burapha University
2. Siriwan Sangin, Ph.D. Assistant Professor
Maternal-Newborn Nursing and Midwifery
Faculty of Nursing, Burapha University
3. Supit Siriarunrat, Ph.D. Maternal-Newborn Nursing and Midwifery
Faculty of Nursing, Burapha University
4. Tatirat Suwansujarid, Ph.D. Midwifery, Maternal-Newborn Nursing and
Midwifery
Faculty of Nursing, Burapha University
5. Wantana Suppaseemanont, Ph.D. Maternal-Newborn Nursing and Midwifery
Faculty of Nursing, Burapha University
89
APPENDIX 6
List of bilingual translators of the instruments
90
LIST OF BILINGUAL TRANSLATORS OF THE INSTRUMENTS
1. Le Nguyen Huong Giang, Master of English Lecturer
Department of Foreign Language
Binh Dinh Medical College,
Vietnam.
2. Nguyen Thi Nhan, Master of Midwifery Vice Head of Training Department
Faculty of Nursing and Medical
Technology, University of
Medicine and Pharmacy at
Ho Chi Minh City, Vietnam
3. Nguyen Thao Quyen, Master of Midwifery Lecturer
Department of Midwifery,
Faculty of Nursing and Medical
Technology University of
Medicine and Pharmacy at
Ho Chi Minh City, Vietnam