https://doi.org/10.15218/ejnm.2023.10 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article Prevalence and Associated Factors with Attending Antenatal Care in Akre City, Iraq ABSTRACT Background and Objectives: Antenatal care is essential for protecting the health of women and their unborn children. Antenatal care utilization is a key intervention in problem detection and treatment, promoting health-seeking behavior, and preparing pregnant women for birth. The present study aimed to investigate the prevalence and associated factors that affect attending and utilizing antenatal care in primary health care centers among pregnant women in Akre city. Methods: A cross-sectional study was conducted in the Maternity Hospital of Akre City from November 21 to February 21, 2022. Data were collected through interviews with 400 women who attended the hospital for delivery and via a questionnaire constructed for the study. The questionnaire included women's socio-demographic characteristics, socio-economic status, obstetrical and reproductive history, and factors affecting ante- natal care. Frequency, percentage, and chi-square tests were used to analyze the data. Result: The rate of attending antennal care was 20%. The study findings showed a statis- tically significant association between attending antenatal care in the last pregnancy with residency, type of family, parity, and previous mode of delivery. Conclusion: The prevalence of women who attend antenatal care is few. Effective media and providing special health care in primary health care centers and services are re- quired to improve the level of awareness of pregnant women for utilizing antenatal care. Keywords: Antenatal care; Prevalence; Factors; Iraq. Bnar Mustafa Ahmed; Department of Nursing, College of Nursing, University of Duhok , Duhok, Kurdistan Region, Iraq (Correspondence:bnar27akre@gmail.com) Hamdia Mirkhan Ahmed; Department of Nursing, College of Nursing , Hawler Medical University, Erbil, Kurdistan Region, Iraq. 84 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Received: 14/07/2022 Accepted: 12/09/2022 Published: 30/5/2023 mailto:bnar27akre@gmail.com mailto:@gmail .com mailto:bnar27akre@gmail.com https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.10 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article Pregnancy is necessary to promote good health psychologically and emotionally and prepare women and their families for parenthood. Antenatal care (ANC) is given to pregnant women and adolescent girls by skilled healthcare providers to ensure the best health conditions for both mother and baby during pregnancy [1]. Antenatal care is one of the "four pillars" of safe mother- hood initiatives to promote and establish good health during pregnancy and early postpartum [2]. Antenatal care also allows women to communicate with their healthcare providers and increases the like- lihood of using a skilled birth attendant [3]. Approximately 303,000 women and adoles- cent girls died from pregnancy and child- birth-related complications in 2015; 2.6 million babies were stillborn [4]. Maternal mortality is much too high. In 2017, ap- proximately 295,000 women died during and after pregnancy and childbirth. The vast majority of these deaths (94%) oc- curred in low-resource settings, which could have been avoided [5].The World Health Organization (WHO) envisions a world where every pregnant woman and newborn is provided with high-quality care throughout their pregnancy, delivery, and postpartum. Antenatal care (ANC) is an es- sential component of the reproductive healthcare continuum because it serves as a platform for crucial healthcare tasks such as disease prevention, screening and diag- nosis, and health promotion. It has been demonstrated that ANC can save lives by implementing timely and appropriate evi- dence-based practices. Notably, developing these ANC recommendations has empha- sized the importance of providing pregnant women with respectful communication about physiological, biomedical, behavior- al, and sociocultural issues and practical support, including social, cultural, emotion- al, and psychological support [6]. The WHO’s new recommendation declares that pregnant women should have at least eight visits to healthcare professionals [7]. The first visit between these should occur within the first 12 weeks of gestation, and the following visits occur repeatedly at weeks 20, 26, 30, 34, 36, 38, and 40 [4]. Maternal mortality rates in Maternity Teaching Hospital in Erbil city were found to be 44/per 100,000 live births. Because not all childbirths occur in hospitals, death in the hospital is a good predictor of death in the community [8]. The advantages of prenatal care were more readily available, particularly regarding gestational diabetes, hemoglobinopathy, and ultrasonography, and the update was started. This update has also given us a chance to look at a number of antenatal care-related issues, such as the creation of a tool to identify women who need additional care (the "antenatal assessment tool"), the distribu- tion of information to women, lifestyle (vitamin D supplementation, alcohol con- sumption), and fetal screening (using ultra- sound for assessing gestational age and screening for fetal abnormalities, methods for determining normal fetal growth, and plausibility tests) (hemoglobinopathy screening, gestational diabetes, pre- eclampsia and preterm labor) [9].The re- searcher was interested in the use of ante- natal care centers among pregnant wom- en. This study aimed to assess the preva- lence of antenatal care attendance and its associated characteristics among women in Akre City. A cross-sectional study was conducted among 400 women in the Maternity Hospi- tal in Akre city in the Kurdistan region of Iraq. This hospital is a public site. Akre is a small city with many villages comprising four primary healthcare centers. Four hun- dred women attending the mentioned 85 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. INTRODUCTION METHODS https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.10 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article 15-43 years old. The highest percentage (36.75%) of women aged 30 years or more, and the majority (97.25%) of them were housewives. Regarding residency, most of the study sample (69.50%) were living out- side Akre (rural). More than half of the study sample were passive smokers (50.63) and lived in an extended family (52.00%). hospital were interviewed by reviewing their records.Inclusions criteria included women who were attending the maternity hHospital for delivery at the time of col- lecting data, willingness to participate in the study, ability to speak clear Kurdish or Arabic. Exclusion criteria included women who disagreed to participate in the study. A questionnaire was developed for data collection and included (socio- demographic, socio-economic status, and obstetrical history of women and ques- tions regarding the rate of attending ante- natal care). All the women in the sample completed the questionnaire using face-to -face interview techniques. The question- naire form filled out the questionnaire took approximately 10 to 15 minutes. Be- fore data collection, permission to con- duct the study was obtained from the Sci- entific and Ethics Committee of the Uni- versity of Dohok /College of Nursing, the code of Ethical Approval 42001. Each question in the questionnaire was coded, and the data were entered and analyzed by JMP Pro 14.3.0. The patients' general information was presented in mean, standard deviation (SD), or number (No.). The prevalence utilization of ANC services and satisfaction with the ANC services were determined in number and percent- age. The level of ANC quality was deter- mined by mean and standard deviation (SD). A point was given for each item done by the medical staff during each ANC ses- sion. The total items were added together to obtain the total quality of ANC services. Before data collection, informed consent was taken from the study sample, and they had the right to withdraw from the study at any time. Table 1 shows the socio-demographic characteristics of the study sample. Re- garding age groups, they ranged between 86 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. RESULTS Table 1: Socio-demographic characteris- tics of the study sample Variable No. (%) Age (years) 15-43 27.16 (5.66) < 20 30 (7.5) 20-24 110 (27.5) 25-29 113 (28.25) 30 and older 147 (36.75) Occupation Contract temporary employee 5 (1.25) Governmental employee 5 (1.25) House wife 389 (97.25) Self-employed 1 (0.25) Residency Akre 122 (30.5) Outside 278 (69.5) Smoking Active 1 (0.25) Passive 202 (50.63) Non 196 (49.12) Type of family Extended 208 (52.00) Nuclear 192 (48.00) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.10 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article Table 2 shows the socio-economic status of the study sample, which was calculated according to women and husbands' educa- tion , crowding index , possession of care, type of housing, and cost of electrical machines. Overall socio-economic status divided into three groups, in which 67.5% of the study sample had medium status. 87 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 2: Distribution of socio-economic status of the study sample n=400 Socio-economic Criteria Category No. (%) Women Education Illiterate 144 (36) Read and Write 73 (18.25) Primary 106 (29.5) Intermediate and Secondary 30 (7.5) Diploma, University and High Education 47 (11.75) Husband Education Illiterate 85 (21.25) Read and Write 94 (23.5) Primary 100 (25) Intermediate and Secondary 39 (9.75) Diploma, University and High Education 82 (20.5) Crowding Index <1.2 201 (50.25) 1.5-2.9 196 (49) ≥3 3 (0.75) Possession of Car Yes 191 (47.75) No 209 (52.25) Type of Housing Owned 163 (40-5) Partially Owned 195 (48.75) Rented 43 (10.75) Cost of Electrical Machines < 1500$ 222 (55.5) 1500 – 3000 $ 175 (43.75) > 3000 $ 3 (0.75) Overall socio-economic status Low SES Medium SES High SES 67 270 63 (16.75) (67.5) (15.75) https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.10 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article 88 had no abortion (76.50), and stillbirth (52%). Most of the study sample (74.50%) did not attend antenatal care in the previ- ous pregnancy. The majority (80%) of women did not attend antenatal care. The rate of attend- ing to antenatal care was 20%. Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 3 shows the obstetrical and repro- ductive history of the study sample. The highest percentage of them were multipa- ra (47.25%), Figure 1 shows the prevalence and rate of attending and utilizing antenatal care in the last pregnancy. Table 3:Disrtibution of the study according obstetrical and reproductive history Variable No. (%) Gravida Category Prime gravida 131 (32.75) Multi-gravida 169 (42.25) Grand multigravida 100 (25) Parity Null Parity 1 (0.25) Prime para 150 (37.5) Multi para 189 (47,25) Grant multi para 60 (15) Abortion 0 306 (76.5) 1 50 (12.5) 2-4 44 (11) Still birth 0 352 (88) 1 35 (8.75) 2-4 13 (3.25) Delivery Mode C/S 192 (48) Normal Delivery 208 (52) Attending ANC During Previous Pregnancies No 298 (74.5) Yes 102 (25.5) Figure 1: Prevalence and rate of attending and utilizing antenatal cate in last pregnancy https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.10 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article 89 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table 4 shows the association between attending ANC in the last pregnancy with women's socio-demographic characteris- tics and socio-economic status. There was no significant association between attend- ing antenatal care in the last pregnancy, women's age (P=0.0805) , occupation (P=0.0893), and smoking (P=0.3295). In contrast, there was a significant associa- tion between attending antenatal care in the last pregnancy with residency (P=0.0020), and type of family (P=0.0043). Table 4: : Association between attending ANC in last pregnancy with socio-demographic characteristic and socio-economic status of women Characteristics (n=400) No (n=320) No. (%) Yes (n=80) No. (%) P-value Age < 20 20-24 25-29 22 (73.33) 82 (74.55) 89 (78.76) 8 (26.67) 28 (25.45) 24 (21.24) 0.0805 Occupation contract/temporary employee Governmental employee House wife Self-employed 2 (40) 5 (100) 312 (80.21) 1 (100) 3 (60) 0 (0) 77 (19.79) 0 (0) 0.0893 Residency Akre Outside 109 (89.34) 13 (10.66) 0.0020 Type of family Extended Nuclear 155 (74.52) 165 (85.94) 53 (25.48) 27 (14.06) 0.0043 Smoking Active Passive None Socio economic status Low SES Medium SES High SES 1 (100) 167(82.67) 151 (77.04) 57(85.07) 213(78.89) 50(79.37) 0 (0) 35 (17.33) 45 (22.96) 10(14.93) 57(21.11) 13(20.63) 0.3295 0.5214 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.10 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article (P=0.0356) have a significant association with attending antenatal care, while gravi- da (P=0.0928) and having stillbirth (P=0.4655) do not. Table 5 describes the association between attending antenatal care in the last preg- nancy and women's obstetrical and repro- ductive history. In this study, parity (P=0.0200) and previous mode of delivery 90 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. Table5: Association between attending antenatal care in last pregnancy with Obstetrical and reproductive history of pregnant women Variables=400 No (n=320) No. (%) Yes (n=80) N0. (%) P-value Gravida category Prime 2-4 ≥ 5 97 (74.05) 138 (81.66) 85 (85) 34 (25.95) 31 (18.34) 15 (15) 0.0928 Parity Null parity Prime Multipara Grant multipara 1 (100) 108 (72) 161 (85.19) 50 (83.33) 0 (0) 42 (28) 28 (14.81) 10 (16.67) 0.0200 Abortion 0 1 2-4 244 (79.74) 36 (72) 40 (90.91) 62 (20.26) 14 (28) 4 (9.09) 0.0712 Still birth 0 1 2-4 279 (79.26) 29 (82.86) 12 (92.31) 73 (20.74) 6 (17.14) 1 (7.69) 0.4655 Previous mode of delivery C/S Normal delivery 162 (84.38) 158 (75.96) 30 (15.63) 50 (24.04) 0.0356 https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.10 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article finding, a high percentage (89.5%) of wom- en were living in urban areas attending ANC; the result of this study is different result with the study done in Akre, that residency is significantly associated with antenatal care utilization [16,17]. Women in Nigeria [18] attended (82%) more ANC visits than rural women (45%); according to the report, a study conducted in Nigeria found that living in an urban setting in- creases the likelihood of using antenatal care services by more than twofold [19]. This contradicts research is done in eastern Sudan, which found no link between resi- dency and antenatal care utilization [20]. The discrepancy could be because women in urban areas have better access to health facilities and information and hence re- ceive services from nearby health facilities. There is no study that is similar to this study regarding residency. Regarding socio -economic status, the high percentage of socio-economic classes in this study was reported as a medium class (67.50%), which is similar to the results of a study done in Erbil city in which the rate of attending ANC (80.5%) [21]. Higher than this finding was reported by the study [22] in Ethiopia, they found (1.41%)low per- centage of women were in the middle class of SES. The current study revealed that the use of ANC was higher (92.2%) among women with a high SES. This finding was similar to previous studies done in Turkey [23]. These findings are similar to those of previous studies indicating that family income and the cost of accessing care played a very important role in the utilization of ANC services and in encourag- ing pregnant women to visit ANC [24,25]. In a recent review conducted in low and middle-income countries, the mother's and her partner's education were the most significant factors that influence the utiliza- tion of maternal healthcare services [26]. A study in sub-Saharan African countries The prevalence and rate of attending an- tenatal care in the last pregnancy in Akre city was low (20%). Compared to another study, a high proportion of women in the Syrian refugee camps in Erbil attended antenatal care services during the last pregnancy (99.6%), with different results [10]. According to this study, Egyptian women in 2000-2014 utilizing ANC was low; its similar result [11] about (28.5%) of women's attending ANC women's edu- cation and quality of health services play significant roles in increasing accessibility of antenatal health care services. On the other hand, women's empowerment has shown a positive effect; another study shows the utilization of ANC service is very low even for women who have ac- cess to the service in Ethiopia in general (49.8%) of the study sample attending ANC in the last delivery, in a study con- ducted in North Maharashtra Utilization of Antenatal care (ANC) services is poor in the tribal areas, causing increased mater- nal morbidity and mortality [12]. (64.2 %) its different result [13, 14]. The Study par- ticipants might be in similar socio- demographic status, understanding of an- tenatal care options, and common tradi- tional practices encouraging home treat- ment, which could explain the consisten- cy. However, this figure is higher than the (34%) attendance rate reported in the Ethiopia Demographic Health Survey 2011 its similar result [15]. The analysis was done on any women who received ante- natal care follow-up by any health profes- sional, more awareness, and better access to service, which could be the main com- ponent that boosted antenatal care ser- vice use in this study. Regarding residen- cy, the highest percentage (69.50 %) of women were living outside Akre (rural) and attending antenatal care, while in this 91 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. DISCUSSION https://creativecommons.org/licenses/by-nc-sa/4.0/ https://doi.org/10.15218/ejnm.2023.10 Erbil j. nurs. midwifery, Vol. 6, No. (1), May 2023 Original Article 018-2014-8 [Accessed: 20th Aug 2022]. [3] World Health Organization. WHO recom- mended interventions for improving mater- nal and newborn health: integrated manage- ment of pregnancy and childbirth. World Health Organization; 2007. [4] Tunçalp Ӧzge, Pena-Rosas JP, Lawrie T, Bucagu M, Oladapo OT, Portela A, et al. WHO recommendations on antenatal care for a positive pregnancy experience-going beyond survival. An international Journal of Obstetrics and Gynaecology. 2017;124 (6):860–862. [5] World Health Organization. Trends in mater- nal mortality 2000 to 2017: estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division; 2019; [6] World Health Organization. WHO recom- mendations on antenatal care for a positive pregnancy experience: summary: highlights and key messages from the World Health Organization’s 2016 global recommenda- tions for routine antenatal care. World Health Organization; 2018. [7] World Health Organization. WHO recom- mendations on antenatal care for a positive pregnancy experience; World Health Organi- zation. 2016b. [8] Ali MS, Jawad AK, Jawad RK. Maternal mor- tality at the Maternity Teaching Hospital in Erbil, Kurdistan: A hospital-based data 2011- 2013. Zanco Journal of Medical Sciences. 2015;19(3):1116–22. [9] Guıa NI. National Collaborating Centre for Women’s and Children’s Health (UK) and National Institute for Health and Care Excel- lence (UK). Bronchiolitis. Diagnosis and Man- agement of Bronchiolitis in Children. 2015. [10] Fareed SM, Ismail KH. Utilization of antena- tal care services in Syrian refugee camps in Erbil, Iraq. Zanco Journal of Medical Scienc- es. 2019;23(2):250–6. [11] Zaky HH, Armanious DM, Hussein MA. De- terminants of Antenatal Health Care Utiliza- tion in Egypt (2000-2014) Using Binary and Count Outcomes. Health (N Y). 2019;11 (01):25. [12] Tura G. Antenatal care service utilization and associated factors in Metekel Zone, North- west Ethiopia. Ethiopian Journal of Health Sciences. 2009;19(2). [13] Mumbare SS, Rege R. Ante natal care ser- vices utilization, delivery practices and fac- tors affecting them in tribal area of North revealed that use of antenatal care was associated with mother’s age, parity, in- teraction with healthcare provider and cost of antenatal care [27]. Another study in urban slum areas in Islamabad found that family income was not significantly associated with antenatal care utilization women's education and husband’s educa- tion were significantly associated with the utilization of antenatal care facilities in this study [28]. The results show the majority of women have not attended and utilized ANC dur- ing pregnancy. There were statistically significant associations between attend- ing antenatal care with residency, type of family, parity, and previous mode of de- livery. It is recommended that effective media and health education can be used to raise pregnant women's awareness and that professional staff in primary health care centers. Pregnant women should encourage to attend antenatal care to ensure the best health conditions for both mother and baby during preg- nancy. There is no conflict of interest. [1] Organization WH. WHO antenatal care recommendations for a positive preg- nancy experience: nutritional interven- tions update: vitamin D supplements during pregnancy. 2020. [2] Konje ET, Magoma MT, Hatfield J, Kuhn S, Sauve RS, Dewey DM. Missed oppor- tunities in antenatal care for improving the health of pregnant women and newborns in Geita district, Northwest Tanzania. BMC pregnancy and child- birth. 2018 Dec;18(1):1-13. Available from: https://doi.org/10.1186/s12884- 92 Copyright ©2022 The Author(s). This is an Open Access article which licensed under the terms and conditions of the Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. It permits no additional restrictions on use, distribution, and reproduction in any medium provided the original work is properly cited. 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