Determinants of Utilization and Quality of Antenatal Care Services in Lubumbashi, in the Democratic Republic of the Congo

INTRODUCTION

Pregnancy is a particularly natural and physiological event that does not always occur normally and is responsible for preventable morbidity and mortality.^[1] In 2017, the World Health Organization estimated that about 295,000 women died worldwide, and every day 810 women died for preventable reasons related to pregnancy and childbirth.^[2] The majority of these deaths (94%) occurred in low-resource countries, and most of them could have been avoided. In the same year, sub-Saharan Africa alone accounted for about two-thirds (196,000) of maternal deaths, while South Asia accounted for nearly one-fifth (58,000).^[2] In the Democratic Republic of the Congo (DRC), according to 2014 Demographic and Health Survey (2014 DHS-DRC), the maternal mortality ratio was estimated at 846 deaths per 100,000 live births and the neonatal mortality rate was 28‰.^[3]

Antenatal care (ANC) coverage is an indicator of access to and use of health-care services during pregnancy. ANC is one of the four pillars of safe motherhood aimed to reduce maternal and perinatal mortality.^[4] The antenatal period offers pregnant women opportunities for intervention that may also be necessary for the well-being of their babies.^[5,6] the timing of the first ANC visit has the utmost importance to ensure optimal health effects for both women and children.

As the recommended ANC services differ in terms and number of ANC visits and the type and frequency of health service content offered to women during their ANC visits, it is, therefore, difficult to provide a universal definition of pregnancy follow-up, whether adequate or insufficient. The number of ANC visits differs from country to country depending on the national recommendations of each country. For illustration, in developed countries, this number varies from 8 (in Italy) to 11 (in the United States).^[7] The previous studies have shown that essential interventions would be provided on four ANC visits at specified intervals, a minimum for healthy women without underlying medical problems.^[8,9] These studies prompted the WHO to define the new approach with four ANC visits focused on the objectives of ANC services. The recommended number of ANC visits in resource-limited settings depends not only on effectiveness but also on costs and barriers to accessing ANC services.^[8,9] High-quality ANC services can also influence women’s behavior to choose skilled health care services at birth.^[10,11] Positive experience during pregnancy and childbirth is essential for person-centered care and for the rights of every woman who gives birth, as highlighted in recent recommendations of the WHO.^[12-15]

However, it should be noted that there is a significant gap between developed countries (98%) and developing countries (68%) in the ANC coverage. Although this coverage is increasing in many African countries, it alone does not provide sufficient information on the ANC services.^[5] In addition, although the coverage of at least one ANC visit is relatively high, many women attending ANC services do not receive all evidence-based components during pregnancy. This gap in quality demonstrates the main missed opportunities in health systems.^[5,16]

The role of ANC visits is to ensure that pregnancy is carried out effectively while at the same time ensuring the safety of the mother and her child, in the sense that most of the risk factors related to pregnancy can be detected during it. The DRC’s health programs include health education actions to improve mothers’ knowledge and attitudes about preventive care.^[3] In other words, these information and education activities address the value and need for ANC visits, assisted delivery, postnatal visits, family planning, breastfeeding, nutrition, vaccination, and child growth monitoring. These educational activities are offered to women during any contact with public health facilities (health center, maternity, etc.) during pregnancy, at the time of delivery, and during post-natal visits.

One of the targets of Sustainable Development Goal 3 is to reduce the global maternal mortality rate to below 70 per 100,000 live births and the neonatal mortality rate to no more than 12 per 1000 live births.^[17] And improving maternal and child health remains a priority worldwide, particularly in the DRC, where perinatal programs have been implemented to reduce maternal and infant morbidity and mortality. Given that in resource-constrained settings like the DRC, where maternal and perinatal deaths remain among the highest in the world, high-quality care, acting upstream of delivery and postpartum, could help reduce the high death rate.

This concept of utilization and quality of ANC services is always faced with several factors, including the personal characteristics of patients, the availability and accessibility of ANC services, etc. In this regard, the main question that could be asked is: Are pregnant women adequately using ANC services and receiving high-quality ANCs in our settings?

This study aims to determine the utilization and high-quality rates of ANC services and to identify their determinants in Lubumbashi city, in the DRC.

MATERIAL AND METHODS

RESULTS

DISCUSSION

The present study showed that 10.5% of the women surveyed did not attend ANC services; this rate is slightly higher than the 6% recorded nationally in urban areas.^[3] The rate of women not attending ANCs varies widely, depending on period, country, or region. A recent study conducted in Lubumbashi (DRC) by Maleya et al.^[1] reported a rate of 21.23%. Brown et al.^[18] found a rate of 33% in Kwale (Kenya). El Hamdani et al.^[19] found 10% of women who did not attend ANC services and pointed out that many women belong to the group of poor and socially disadvantaged women (less educated women and migrant women). These are the most vulnerable women who need ANC the most. This increases the need to seek to better understand barriers that prevent these women from using ANC services and from receiving free healthcare in public health centers. In developing countries, women are often unaware of the health benefits of ANC or do not believe that ANCs are important to them or their babies.^[19] To be effective, ANC must start at an early stage of pregnancy and, above all, it must continue with some regularity until delivery. The WHO recommends at least four ANC visits, at regular intervals throughout pregnancy.^[14]

One of the main findings of this study is that the delay in initiation of ANC affects more than 44.1% of women. The main reasons for delayed ANC were the absence of pregnancy complications (75.0%) and the lack of financial means (16.7%). This proportion was 57.7% in the Mafuta and Kayembe study.^[20] These authors explained that delayed ANC is justified for the majority of respondents by financial difficulties, or by the absence of obstetric complications, although paradoxically, costs associated with ANC are bearable and the prices are cheaper.^[20]

Many women link the need for ANC to the occurrence of pregnancy complications. Moreover, they are not sufficiently motivated by the desire to attend ANC, insofar as they do not recognize the need for ANCs and consider them an unnecessary step. It should be noted that the use of ANC services is primarily determined by women’s belief that pregnancy monitoring is necessary for the well-being of their fetus. The previous studies reported that this lack of motivation among some women is a barrier to ANC.^[19,20]

The proportion of women who initiated the first ANC visit late, reported in this study, is less than 77.8% found in urban areas by 2014 DHS-DRC.^[3] This difference could be due to the greater accuracy of the estimate of the 2014 DHS-DRC, linked to the larger sample size, but also the reference period. The proportion reported in the present study better reflects the current state of this phenomenon, as the 2014 DHS-DRC estimate covered 5 years representing a cumulative annual proportion. In this case, there is not only a significant risk of recall bias for respondents but also the influence of extreme values.^[3] This proportion is also greater than 33.4% found by Ewunetie et al.,^[21] <66.3% reported by Yaya et al.^[22] in Ethiopia and 57.7% recorded by Kotoh and Boah in northern Ghana.^[23] These differences may be due to differences in study location, selection procedures, and methodologies. Some of these authors have studied the phenomenon in health units with a high risk of concentration of cases, unlike the current community survey which is likely to lead to dilution of the phenomenon. Our results reflect a shift towards improving maternal health as a result of the efforts of several global initiatives.

Many studies suggest that the quality of ANCs is more important than the number of ANC visits and the timing of the first ANC.^[19] In developing countries, and particularly in the African context, ANC offers the unique opportunity for many women to interact with health services and this opportunity must be used to implement proven-effective actions to reduce maternal morbidity and mortality.^[24] In the present survey, we found that more than 80% of women had received tetanus vaccination, intestinal antiparasitic treatment, iron supplementation, and antimalarial treatment. Nearly 60% had been tested for HIV, and over 60% had urine and blood samples tested.

This study found that teenage mothers, single mothers, and mothers with low educational levels (illiterate or primary) were less likely to use ANC services compared to other groups. This finding is also found in African literature.^[25-27] Kakudji et al.,^[28] in a study conducted in Lubumbashi (DRC), found a very highly significant association between adolescence and lack of ANC services utilization. After multivariate analyses, this study shows that mothers educational level had a significant contribution to the utilization and the quality of ANC services. It showed that mothers with no or primary educational level were less likely to utilize and to have good quality ANC services than those with secondary and higher educational levels. This fact clearly shows that mothers with low educational levels (illiterate or primary) were not able to seek ANC services due to a lack of maternal health care knowledge and ignorance. On the other hand, mothers who were educated were able to fully attend ANC services since they had knowledge and practices of better health attainment. They made good use of the services available since they were empowered and therefore were good in decision-making.^[29] Educated women are better able to absorb maternal health messages and therefore more likely to attend ANC services during their pregnancy.^[30] In addition, illiteracy associated with spouse refusal, risk ignorance, and unwanted pregnancies were additional factors described by Ndiaye et al.^[25] Four et al.^[31] added that, in certain specific situations, pregnant women were held at home for household activities. Gandzien et al.^[27] emphasized that the financial dependence of pregnant women on their spouse or family was considered a major obstacle to attending ANC services during their pregnancies. Finally, other sociocultural aspects identified as factors influencing the use of ANC services are the beliefs that pregnancy is known early by the entourage it may suffer bad spells or fail.^[10] Single women have most often concealed their pregnancy from their parents to avoid family conflicts.^[27] In developing countries, reasons cited for this apathy toward ANC services among young pregnant single women are lack of family or social support, unpleasant remarks from health workers, and attempts to avoid public scrutiny.^[32] A study in Bulawayo showed that fear of HIV testing is a major factor in the lack of follow-up of teenage pregnancy.^[33] Unmarried young women often have poor access to reproductive health services, which explains their low use of contraception, including modern methods, and their frequent use of abortion.

Our study found a significant relationship between primiparity and utilization of ANC services. Other studies have found that the rate of ANC utilization decreases as the parity increases significantly.^[19,34] Multiparous are convinced that the current pregnancy is progressing well despite the absence of ANCs, because of the better course of previous pregnancies. These women eventually become convinced that ANCs are useless or have less value in encouraging them to limit the use of ANC services.

However, there are limitations in interpreting the results of this study. The first limitation is the cross-sectional nature of the study, which does not allow a dynamic view of the evolution of pregnancy, nor does it establish a causal relationship with the factors identified. However, this study has the merit of being, to the best of our knowledge, one of the first to address questions on the use, adequacy, and quality of ANC services in the community in our settings, and to have identified factors that, taken into account, could influence national guidelines in this area. Second, it is important to keep in mind that the data analyzed include information reported by mothers only during the most recent pregnancies or deliveries. Therefore, concerning the specific service content received by respondents during their last ANC visits, women may not be specifically aware of the laboratory investigations that were performed on them during ANC visits. The study was also limited to Lubumbashi city and the results may not reflect the situation in the rest of the country.

CONCLUSION

The use and quality of ANC services remain a problem in urban areas across our country. This situation hampers the achievement of maternal and child health goals. Identifying key determinants encourages the promotion of targeted strategies to influence the behaviors and attitudes of the most vulnerable women. To improve the adequacy of ANC services in the study area, policy development, planning, and implementation processes should focus on women with lower educational levels and unmarried women.

Specific efforts on basic ANC are needed to target and raise awareness among women of low socioeconomic status, including those with lower educational levels. Qualitative research is recommended for a thorough understanding of the problem. This study should be replicated in other parts of the country, including rural areas, using indicator combinations to see levels, and trends in the use and quality of ANC services. It could also involve male partners or husbands rather than just women as subjects for further study.