title: Patterns and determinants of antenatal care utilization: analysis of national survey data in seven countdown countries.
abstract: BACKGROUND
  Antenatal care (ANC) is critical for improving maternal and newborn health. WHO recommends that pregnant women complete at least four ANC visits. Countdown and other global monitoring efforts track the proportions of women who receive one or more visits by a skilled provider (ANC1+) and four or more visits by any provider (ANC4+). This study investigates patterns of drop-off in use between ANC1+ and ANC4+, and explores inequalities in women's use of ANC services. It also identifies determinants of utilization and describes countries' ANC-related policies, and programs.
  
  
  METHODS
  We performed secondary analyses using Demographic Health Survey (DHS) data from seven Countdown countries: Bangladesh, Cambodia, Cameroon, Nepal, Peru, Senegal and Uganda. The descriptive analysis illustrates country variations in the frequency of visits by provider type, content, and by household wealth, women's education and type of residence. We conducted a multivariable analysis using a conceptual framework to identify determinants of ANC utilization. We collected contextual information from countries through a standard questionnaire completed by country-based informants.
  
  
  RESULTS
  Each country had a unique pattern of ANC utilization in terms of coverage, inequality and the extent to which predictors affected the frequency of visits. Nevertheless, common patterns arise. Women having four or more visits usually saw a skilled provider at least once, and received more evidence-based content interventions than women reporting fewer than four visits. A considerable proportion of women reporting four or more visits did not report receiving the essential interventions. Large disparities exist in ANC use by household wealth, women's education and residence area; and are wider for a larger number of visits. The multivariable analyses of two models in each country showed that determinants had different effects on the dependent variable in each model. Overall, strong predictors of ANC initiation and having a higher frequency (4+) of visits were woman's education and household wealth. Gestational age at first visit, birth rank and preceding birth interval were generally negatively associated with initiating visits and with having four or more visits. Information on country policies and programs were somewhat informative in understanding the utilization patterns across the countries, although timing of adoption and actual implementation make direct linkages impossible to verify.
  
  
  CONCLUSIONS
  Secondary analyses provided a more detailed picture of ANC utilization patterns in the seven countries. While coverage levels differ by country and sub-groups, all countries can benefit from specific in-country assessments to properly identify the underserved women and the reasons behind low coverage and missed interventions. Overall, emphasis needs to be put on assessing the quality of care offered and identifying women's perception to the care as well as the barriers hindering utilization. Country policies and programs need to be reviewed, evaluated and/or implemented properly to ensure that women receive the recommended number of ANC visits with appropriate content, especially, poor and less educated women residing in rural areas.
authors.affiliation: Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.
authors.forename: Ghada
authors.initials: G
authors.lastname: Saad-Haddad
authors.affiliation: Faculty of Health Sciences, American University of Beirut, Beirut, Lebanon.
authors.forename: Jocelyn
authors.initials: J
authors.lastname: DeJong
authors.affiliation: Independent consultant.
authors.forename: Nancy
authors.initials: N
authors.lastname: Terreri
authors.affiliation: Federal University of Pelotas, Pelotas, Brazil.
authors.forename: María Clara
authors.initials: MC
authors.lastname: Restrepo-Méndez
authors.affiliation: Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Jamie
authors.initials: J
authors.lastname: Perin
authors.affiliation: Save the Children, Washington D.C., USA.
authors.forename: Lara
authors.initials: L
authors.lastname: Vaz
authors.affiliation: Division of Data, Research and Policy, United Nations Children's Fund, New York City, NY, USA.
authors.forename: Holly
authors.initials: H
authors.lastname: Newby
authors.affiliation: Division of Data, Research and Policy, United Nations Children's Fund, New York City, NY, USA.
authors.forename: Agbessi
authors.initials: A
authors.lastname: Amouzou
authors.affiliation: Federal University of Pelotas, Pelotas, Brazil.
authors.forename: Aluísio Jd
authors.initials: AJ
authors.lastname: Barros
authors.affiliation: Institute for International Programs, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
authors.forename: Jennifer
authors.initials: J
authors.lastname: Bryce
mesh_terms: D000328:Adult; D001459:Bangladesh; D002160:Cambodia; D002163:Cameroon; D005260:Female; D006306:Health Surveys; D006801:Humans; D009390:Nepal; D010568:Peru; D011247:Pregnancy; D011295:Prenatal Care / Q000706:statistics & numerical data*; D012675:Senegal; D012959:Socioeconomic Factors; D014454:Uganda