Hrev_master Healthcare in Low-resource Settings 2025; volume 13:13084 Factors associated with obstetric ultrasound screening behavior during antenatal care at public health centers in Palu City Ketut Suarayasa,1 Miranti Miranti,1 Sumarni Sumarni,1 Elli Yane Bangkele,1 Andi Nuraspianti2 1Department of Public Health Community Medicine, Faculty of Medicine, Tadulako University, Palu City; 2Health Office of Palu, Palu City, Indonesia Abstract Antenatal screening by general practitioners in primary care using basic obstetric ultrasound aims to identify suspected patho- logical cases early. Early detection allows for timely intervention, potentially preventing complications. This study analyzed factors related to the knowledge, attitudes, and practices of pregnant women utilizing ultrasound for antenatal care in Palu City. A mixed-methods study with a quantitative approach was conducted on 380 pregnant women from 14 public health centers in Palu City using proportional random sampling with pregnant women and Maternal and Child Health (MCH) program officers at the Palu Health Office. Quantitative data were collected using a structured questionnaire that was adapted and modified from existing litera- ture. Researchers visited mothers’ homes to obtain information on socio-demographic factors, obstetric history, and knowledge and attitudes towards obstetric ultrasound scans. For the qualitative study, researchers conducted observations and in-depth interviews to explore sources of information about ultrasound, as well as knowledge, attitudes, practices, and barriers related to obstetric ultrasound during antenatal care. Bivariate and multivariate logis- tic regression were used to identify associated factors. The study found that 70.8% of pregnant women had good knowledge about obstetric ultrasound, and 77% had positive attitudes. Ultrasound was accessed by 55.4% of women on their first visit (K1) and 57.0% on their fifth visit (K5). Significant factors associated with knowledge included having a bachelor’s degree or higher (AOR 2.70; 95% CI 0.21-35.23), being a government employee (AOR 3.901; 95% CI 1.92-7.90), and previous exposure to ultrasound (AOR 1.966; 95% CI 1.24-3.12). Factors significantly associated with the practice of ultrasound screening were higher education (AOR 3.17; 95% CI 0.54-21.20), government employment (AOR 4.53; 95% CI 1.17-15.18), good knowledge (AOR 3.71; 95% CI 1.71-11.23), and positive attitudes (AOR 11.07; 95% CI 2.09- 17.20). Educational level, occupation, and previous exposure to ultrasound significantly influenced knowledge about obstetric ultrasound. The practice of ultrasound screening was significantly associated with education level, occupation, knowledge, and atti- tudes. Introduction Ultrasound is one of the medical imaging technologies used to monitor fetal development in the womb, alongside its various other applications. The primary objective of ultrasound is to aid in diagnosing fetal development in each trimester.1 In many coun- tries, ultrasound scanning is considered a standard practice for prenatal diagnosis and has been integrated into antenatal care due to its potential to enhance the quality of antenatal care.2,3 Obstetric ultrasound screening has become an integral compo- nent of antenatal care worldwide, offering valuable insights into fetal development and potential complications. However, the uti- lization of this technology varies significantly across different regions and healthcare settings. In low- and middle-income coun- tries, access to and uptake of obstetric ultrasound screening may be limited due to various factors, including resource constraints, Correspondence: Ketut Suarayasa, Department of Public Health Community Medicine, Faculty of Medicine, Tadulako University, Palu City, Indonesia. E-mail: suarayasa@yahoo.com Key words: antenatal care, attitude, knowledge, obstetric ultrasound, practice. Contributions: all authors have participated to drafting the manuscript, author KS revised it critically. All authors read and approved the final version of the manuscript. Funding: this research was funded by a grant from Tadulako University Conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. Ethics approval: all stages of this study were conducted following ethical recommendations from the Health Research Ethics Commission (KEPK) of the Faculty of Medicine, Tadulako University (1277/UN 28.1.30/ KL/2024). Informed consent: all patients participating in this study signed a written informed consent form for participating in this study. Patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient infor- mation to be published in this article. Availability of data and materials: all data generated or analyzed during this study are included in this published article. Acknowledgements: we would like to acknowledge the research partici- pants for their cooperation and the diligent data collectors for their dedi- cation and patience. We also extend our gratitude to the Palu City Health Office and the Faculty of Medicine, Tadulako University. Received: 11 September 2024. Accepted: 14 January 2025. Early access: 2 April 2025. This work is licensed under a Creative Commons Attribution 4.0 License (by-nc 4.0). ©Copyright: the Author(s), 2025 Licensee PAGEPress, Italy Healthcare in Low-resource Settings 2025; 13:13084 doi:10.4081/hls.2025.1384 Publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organi- zations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [Healthcare in Low-resource Settings 2025;13:13084] [page 171] cultural beliefs, and lack of awareness among pregnant women.4 The International Federation of Gynecology and Obstetrics (FIGO) also recommends that all pregnant women undergo ultra- sound scanning twice during their pregnancies to mitigate the risk of adverse perinatal outcomes. Nevertheless, this practice carries potential risks to pregnant mothers, including diagnostic errors and potential biological effects.5 Several studies have shown that moth- ers’ knowledge and attitudes towards obstetric ultrasonography are crucial, as these influence their decisions to undergo pregnancy investigation.6,7 In Palu, the implementation of basic obstetric ultrasound examinations in primary care, particularly at public health centers, has been initiated since 2022. Since the introduction of ultrasound services at public health centers, there has been a notable increase in the enthusiasm of pregnant women for prenatal check-ups. This study aimed to analyze the factors associated with ultrasound screening behavior during antenatal care in primary care settings, including the knowledge, attitudes, and practices of pregnant women regarding the use of ultrasound for pregnancy examinations. Materials and Methods This study employed a mixed-methods approach, combining quantitative and qualitative methods. The quantitative method, with a cross-sectional design, was conducted over a four-month (February–May 2024) period at 14 public health centers in Palu City. The study population included all pregnant women who received antenatal care at these health centers in 2023, totaling 7.833 subjects. The sample size was determined using the Slovin formula with a 95% confidence level, resulting in a sample size of 380 pregnant mothers. A proportional random sampling technique was employed, with the sample size for each health center adjusted based on the number of antenatal visits, as detailed in Table 1. In the quantitative study, the research variables included: i) independent variables: socio-demographic factors (age, respon- dent’s education status, marital status, monthly income, husband’s education status, respondent’s occupation) and obstetric factors (parity, gestational age, previous obstetric complications, number of antenatal visits); ii) dependent variables: knowledge and atti- tudes towards obstetric ultrasonography examinations. Knowledge was assessed by measuring the accuracy of respondents’ answers to questions regarding ultrasound indications, procedures, and potential benefits. Attitudes were measured by assessing their level of agreement with statements related to their perceptions, feelings, and beliefs about ultrasound examinations. Quantitative data were collected using a structured question- naire that was adapted and modified from existing literature. Researchers visited mothers’ homes to obtain information on socio-demographic factors, obstetric history, and knowledge and attitudes towards obstetric ultrasound scans. For the qualitative study, researchers conducted observations and in-depth interviews to explore sources of information about ultrasound, as well as knowledge, attitudes, practices, and barriers related to obstetric ultrasound during antenatal care. Interviews were held with 14 pregnant women, each representing one of the 14 public health centers in Palu City, and included one key informant responsible for the Maternal and Child Health (MCH) program at the Palu Health Office. In the quantitative study, researchers used a struc- tured questionnaire adapted and developed from prior literature to collect data. This questionnaire gathered information on socio- demographic factors, obstetric history, and knowledge, attitudes, and practices regarding obstetric ultrasonography. Upon data col- lection, researchers reviewed the data for completeness and consis- tency before inputting it into the Statistical Package for the Social Sciences (SPSS) version 26.0. Binary logistic regression was uti- lized to examine the relationships between dependent and indepen- dent variables. Factors with a p-value of less than 0.25 in the bivariate analysis were incorporated into the multivariate logistic regression analysis to identify variables associated with the depen- dent variable. Significance in the multivariable logistic regression was indicated by a p<0.05, and results were reported using Adjusted Odds Ratios (AOR). A 95% confidence level and a p<0.05 were considered statistically significant. For the qualita- tive study, researchers conducted in-depth interviews with several informants using structured interview guidelines. The audio recordings of these interviews were transcribed for thematic anal- ysis. Data reliability was ensured throughout the procedure using four key methods: credibility, dependability, confidentiality, and transferability. Article Table 1. Sample size based on the public health centers in Palu City. Public health center Number of antenatal care visits Sample size Singgani 508 25 Talise 894 43 Birobuli 799 39 Kawatuna 726 35 Mabelopura 585 28 Nosarara 485 24 Bulili 501 24 Kamonji 528 26 Sangurara 1067 50 Tipo 229 12 Mamboro 360 17 Tawaeli 321 16 Pantoloan 311 15 Lere 519 26 Total 7.833 380 [page 172] [Healthcare in Low-resource Settings 2025;13:13084] Ethical approval All stages of this study were conducted following ethical rec- ommendations from the Health Research Ethics Commission (KEPK) of the Faculty of Medicine, Tadulako University (1277/UN 28.1.30/KL/2024). Results Socio-demographic of study participants A total of 380 pregnant mothers participated in this study. The socio-demographic characteristics of respondents are shown in Table 2, which reveals that the majority of the study participants were aged 20–29 years (48.2%). Most (94.7%) were still with their partners (married) and had at least a high school education (39.7%). The most common occupations were housewives (50.3%), with the majority of households having a monthly income of <1,000,000 IDR (64.2%). This income level affects pregnant mothers’ purchasing power for adequate and nutritious food intake. Obstetric history of respondents The obstetric history of respondents indicates that a significant majority (72.6%) were multigravida, with more than half (52.4%) having attended three antenatal care visits. Additionally, 73.9% of the study participants initiated antenatal care services at 16 weeks or later. Notably, over half (50.5%) of them had been exposed to information about ultrasound during antenatal care (Table 3). Knowledge of pregnant women about obstetric ultrasound examinations Mothers’ were asked about their knowledge on the merits of obstetric ultrasound (Table 4). The findings reveal that 70.8% of the women demonstrated good knowledge about the merits of obstetric ultrasonography, while the remaining 29.2% had limited knowledge. The most commonly known benefits of ultrasound among mothers were its ability to confirm pregnancy (96.6%), determine fetal sex (89.7%), and determine gestational age (89.2%). These advantages (confirming pregnancy, determining fetal sex, and gestational age) were the main reasons for the increased visits of pregnant women to health centers in Palu City, as revealed in interviews with several respondents: “During my first and second pregnancies, I only attended check-ups at the integrated service posts known as Posyandu. Now, I wish to visit the health center for an ultrasound (US). I want to know my baby’s gender, hoping for a boy since my two older children are girls (laughing) …” (Mrs. BA, 32 years). “I plan to visit the health center for an ultrasound check-up. I want to monitor my baby’s condition. I often experience vomiting and worry that my baby might not be receiving adequate nutrition (laughing) …” (Mrs. TA, 25 years old). Attitudes towards obstetric ultrasound examinations Pregnant women exhibited several compelling attitudes towards undergoing ultrasound scans at health centers. A signifi- cant majority believed in the safety of ultrasound during pregnancy (87%), perceived ultrasound as an essential examination during pregnancy (86.7%), and trusted that ultrasound findings were more accurate (79.9%). Furthermore, the most prevalent belief was that ultrasound scans are legally permitted (94.8%). Although the respondents were not familiar with specific regulations, they were confident that ultrasound check-ups were legally compliant (Table 5). The majority of pregnant mothers considered knowing the gen- der of their baby to be very important (87.7%), yet none supported Article Table 2. Socio-demographic characteristics of pregnant women at the Public Health Centers in Palu City. Variable Category n % Maternal age (years) <20 59 15.5 20-29 183 48.2 30-35 122 32.1 >35 16 4.2 Marital status Married 360 94.7 Divorced 8 2.1 Widowed 12 2.2 Maternal education Illiterate 21 5.5 Primary 22 5.8 High school 151 39.7 Diploma 89 23.4 Bachelor or higher 97 25.6 Husband’s education Illiterate 9 2.4 Primary 113 29.7 Secondary 169 44.5 Diploma 10 2.6 Bachelor or higher 79 20.8 Maternal occupation Housewife 191 50.3 Government employee 64 16.8 Private employee 115 30.3 Entrepreneure 10 2.6 Household monthly income (IDR, Indonesian Rupiah) <1,000,000 244 64.2 1,000,000-5,000,000 88 23.1 >5,000,000 48 12.7 [Healthcare in Low-resource Settings 2025;13:13084] [page 173] the idea of terminating the pregnancy if the baby’s sex differed from their preference. Mrs. RB articulated the significance of knowing the baby’s gender: “… I think it is important so that a name can be prepared, whether it is a boy or a girl. Clothes can also be prepared…” When questioned about her reaction if the sex of her baby dif- fered from expectations based on an ultrasonography scan, and whether she would consider terminating the pregnancy, Mrs. RB firmly replied: “Of course not… The baby must be cared for. Accept whatever the gender is. It is a gift from God…” Pregnant women’s practice of obstetric ultrasound Among the 380 pregnant women, 210 (55.4%) accessed ante- natal care with ultrasound at their first visit, while 217 (57.0%) did so by their fifth visit. The highest coverage for both the first (K1 US=93.7%) and fifth (K5 US=88.6%) ultrasound visits was recorded at Mabelopura Health Center. Conversely, Tawaeli Health Center reported the lowest coverage, with 11.2% for the first ultra- sonography visit and 11.8% for the fifth ultrasound (Table 6). Interviews with the person in charge of the Maternal and Child Health program at the Palu City Health Office highlighted several factors influencing the variability in ANC coverage for ultrasonog- raphy. These factors include inadequate socialization and informa- tion dissemination about ultrasound during pregnancy, the absence Article [page 174] [Healthcare in Low-resource Settings 2025;13:13084] Table 3. Obstetric history of pregnant women at the Public Health Centers in Palu City. Variable n % Gravidity Multigravida 276 72.6 Primigravida 104 27.4 Number of antenatal care visits 1 56 14.7 2 95 25.0 3 199 52.4 ≥ 4 30 7.9 First antenatal care visits timing < 16 weeks 99 26.1 ≥ 16 weeks 281 73.9 History of abnormal or congenital anomalies Yes 17 4.5 No 363 95.5 History of abortion Yes 73 19.2 No 307 80.8 Exposure to information on ultrasound Yes 192 50.5 No 188 49.5 Table 4. Knowledge about obstetric ultrasound among pregnant women in Palu City. Knowledge about Ultrasound benefits Yes % Confirm pregnancy 367 96.6 Confirm the presence of multiple pregnancies 322 84.7 Confirm the presence of abnormal pregnancies (ectopic, molar) 241 63.4 Confirm fetal well-being 283 74.5 Detect defects or congenital anomalies during pregnancy 223 58.7 Monitoring of pregnancy complications 200 52.6 Determine the fetal position, cord, and placenta 241 63.4 Detect amniotic fluid volume 215 56.6 Determine fetal sex 341 89.7 Determine gestational age 339 89.2 Provide information about fetal weight 181 47.6 Estimate delivery time 144 37.9 Estimate delivery method (normal/cesarean) 86 22.6 Good knowledge 269 70.8 Poor knowledge 111 29.2 of innovative health centers program targeting pregnant women, and the level of attention health center management gives to mater- nal health. Mrs. AY (46 years old) explained: “Some health centers have reached their targets, but others have not. The main reasons include the role of health center leaders in prioritizing programs and the lack of socialization to pregnant mothers and the community. Nowadays, there are many media that can be utilized for information dissemination.” She further noted: “In successful health centers, they implement innovative pro- grams such as home visits, which increase coverage rates.” Factors associated with knowledge of obstetric ultrasound In the bivariate logistic regression analysis, seven variables were found to be associated with knowledge about obstetric ultra- sonography: age, education level of respondents, education level of parents or partners, occupation, number of antenatal visits, con- genital anomaly history, exposure to ultrasound for reasons other than pregnancy, experience of pregnancy, and prenatal ultrasound knowledge. However, the multivariate logistic regression analysis revealed that only a few variables remained significantly associat- ed with knowledge of obstetric ultrasonography. Specifically, pregnant women with a bachelor’s degree or higher (p=0.009, OR=2.70), women employed as government employees (p=0.000, OR 3.90), and those with a history of previous ultrasound exposure (p=0.004, OR=1.96) (Table 7). Article Table 5. Attitudes towards obstetric ultrasound examinations among pregnant women at the Public Health Centers in Palu City. Variable Response Strongly disagree Disagree Not sure Agree Strongly (%) (%) (%) (%) agree (%) Ultrasound is safe during pregnancy 0.2 0.7 12.1 59.3 27.7 Ultrasound can cause congenital anomalies in the fetus 0.7 49.5 34.4 12.8 2.6 Ultrasonography is an important screening during pregnancy 0.2 13.0 0.0 52.6 34.1 Feel comfortable during the ultrasonography examination 0.7 21.1 2.4 75.8 0.0 Ultrasound can cause cancer 7.8 31.3 53.1 7.8 0.0 Ultrasound examination causes pain 7.6 82.2 0.0 10.2 0.0 Ultrasound examinations are permitted by law 1.2 1.4 2.6 51.9 42.9 Terminate pregnancy if the child’s sex is different from the desired 71.8 28.2 0.0 0.0 0.0 Routine ultrasound can be performed 63.7 0.0 0.0 28.2 8.1 Ultrasound findings are more accurate 0.0 17.8 2.4 58.1 21.8 Knowing the child’s sex is essential 0.0 12.3 0.0 74.2 13.5 Table 6. Number of first and fifth ultrasound visits (K1 US and K5 US) among pregnant women at the Public Health Centers in Palu City. Health Center Number of pregnant mothers *K1 US **K5 US Number (n) Percentage (%) Number (n) Percentage (%) Singgani 25 9 37.8 10 39.0 Talise 43 33 75.7 33 76.0 Birobuli 39 11 27.7 11 28.7 Kawatuna 35 25 71.1 26 73.1 Mabelopura 28 26 93.7 25 88.6 Nosarara 24 14 60.2 11 47.4 Bulili 24 13 53.7 10 40.7 Kamonji 26 23 87.5 22 84.1 Sangurara 50 25 49.9 30 60.0 Tipo 12 8 65.1 10 84.7 Mamboro 17 3 18.3 4 23.3 Tawaeli 16 2 11.2 2 11.8 Pantoloan 15 11 71.1 12 79.7 Lere 26 8 31.0 12 44.7 Total 380 210 55.4 217 57.0 *K1 US, mothers’ first visit in the first trimester + ultrasound scan. **K6 US, mothers’ fifth visit in the third trimester + ultrasound scan [Healthcare in Low-resource Settings 2025;13:13084] [page 175] Factors associated with attitudes towards obstetric ultrasound scan The bivariate logistic regression analysis identified several variables associated with attitudes towards obstetric ultrasound, including occupation, monthly household income, timing of the first antenatal care visit, abortion history, congenital anomaly his- tory, and ultrasound exposure for reasons other than pregnancy. However, the multivariate logistic regression analysis found that only a few variables were significantly associated with pregnant women’s attitudes towards obstetric ultrasonography. These vari- ables were employment as government employees/civil servants (p=0.000, OR=6.83), household income between IDR 1,000,000 and 5,000,000 (p=0.001, OR=5.31), and a history of congenital anomalies (p=0.010, OR=21.07) (Table 8). Factors associated with the practice of obstetric ultrasound examination The bivariate logistic regression analysis identified several variables associated with pregnant mothers’ practice of antenatal ultrasound check-ups, including age, maternal occupation, knowl- edge, and attitude. However, in the multivariate logistic regression analysis, only a few variables remained significantly associated with the practice of accessing obstetric ultrasonography. These variables included having a higher degree (p=0.019; OR=2.70), being a housewife (p=0.007; OR 6.83), mothers’ knowledge (p=0.009; OR=5.31), and having positive attitudes towards ultra- sound (p=0.010; OR=11.07) (Table 9). Discussion Knowledge of obstetric ultrasound In this study, 70.8% of participants demonstrated good knowl- edge regarding the use of ultrasound scanning during pregnancy. A significant majority recognized the importance of scans in antenatal care for confirming pregnancy. Modern obstetrics acknowledges that pregnancy and childbirth inherently carry the risks of complica- tions. These complications can be mild or severe, and may lead to maternal and/or infant mortality, morbidity, and disability. Therefore, proactive preventive measures during pregnancy, such as early detection of risks through ultrasound investigation, are essen- tial. Ultrasound technology enables imaging inside the body, allow- ing for the timely and effective management of identified complica- tions.8 In research by Molla et al. (2022), it shows that pregnant Article Table 7. Factors associated with knowledge of obstetric ultrasonography among pregnant women at the Public Health Centers in Palu City. Variable Knowledge COR (95%CI) AOR (95%CI) Sig. Poor Good Age < 20 28 31 1 1 20-29 99 84 0.75 (0.43-1.30) 0.68 (0.35-1.31) 0.248 30-35 53 69 1.14 (0.63-2.06) 0.95 (0.47-1.92) 0.893 > 35 4 12 2.30 (0.73-7.19)* 2.45 (0.68-8.76) 0.169 Maternal education Illiterate 2 19 1 1 Primary 11 11 0.10 (0.02-0.47)* 0.094 (0.016-0.555) 0.448 High school 82 69 0.07 (0.017-0.32)* 0.76 (0.09-6.21) 0.803 Diploma 47 42 0.079 (0.018-0.35)* 0.35 (0.04-2.81) 0.322 Bachelor or higher 44 53 0.087 (0.016-0.46)* 2.70 (0.21-35.23) 0.009* Husband’s education level Illiterate 4 5 1 1 Primary 42 71 1.145 (0.30-4.27) 1.46 (0.26-8.03) 0.661 High school 96 73 0.49 (0.14-1.81) 0.99 (0.17-5.49) 0.989 Diploma 8 2 0.148 (0.02-1.08)* 0.155 (0.007-3.39) 0.236 Bachelor or higher 34 45 0.087 (0.23-3.33) 2.13 (0.28-16.03) 0.463 Maternal occupation Housewife 61 130 1.145 (0.30-4.27) 1.46 (0.26-8.03) 0.751 Government employee 20 44 3.25 (1.86-5.67)* 3.90 (1.92-7.90) 0.000* Private employee 78 37 0.72 (0.39-1.32) 0.68 (0.32-1.41) 0.306 Entrepreneure 6 4 0.87 (0.23-3.27) 0.63 (0.15-2.66) 0.537 Number of antenatal care visits 1 18 38 1 1 2 49 46 0.84 (0.33-2.14) 1.26 (0.44-3.61) 0.656 3 109 90 0.36 (0.15-0.85)* 0.58 (0.22-1.58) 0.296 ≥ 4 8 22 0.32 (0.14-0.73)* 0.47 (0.18-1.19) 0.111 History of congenital anomalies Yes 13 4 1 1 No 170 193 4.2 (1.37-12.88)* 2.68 (0.70-10.25) 0.149 Ultrasound exposure for reasons other than pregnancy Yes 103 89 1 1 No 80 108 0.64 (0.44-0.94)* 1.96 (1.24-3.12) 0.004* 1, reference group; COR, crude odd ratio; CI, confidence interval; *p<0.05. [page 176] [Healthcare in Low-resource Settings 2025;13:13084] women’s knowledge about obstetric ultrasound examinations is (35.3%).9 Knowledge about obstetric ultrasound was significantly related to pregnant women’s educational status, parity, and place of residence. The high level of knowledge observed in this study can be attributed to several factors. Firstly, the widespread availability of information through healthcare providers and educational programs likely plays a role. Secondly, the national health insurance program, BPJS, which covers the costs of ultrasound scans, might encourage more women to seek information and understand the benefits of the procedure. Moreover, the importance of ultrasound in detecting and managing potential pregnancy complications is well-publicized, contributing to the overall awareness among pregnant women. Article Table 8. Factors associated with attitudes towards obstetric ultrasonography among pregnant mothers at the Public Health Center in Palu City. Variable Attitude COR (95% CI) AOR (95% CI) p Negative Positive Occupation Housewife 61 130 1 1 Government employee 9 55 2.90 (1.54-5.45)* 6.83 (2.43-19.18) 0.000* Private employee 55 60 0.45 (0.24-0.82)* 0.091 (0.03-0.25) 0.070 Entrepreneure 6 4 0.27 (0.07-1.03)* 0.10 (0.016-0.63) 0.051 Household monthly income (IDR) <1.000.000 66 178 1 1 1.000.000-5.000.000 19 69 1.25 (0.72-2.16) 5.31 (2.01-14.03) 0.001* >5.000.000 28 20 0.25 (0.13-0.45)* 1.47 (0.56-3.86) 0.426 First antenatal visits timing <16 weeks 68 31 1 1 ≥16 weeks 45 236 11.71 (7.06-19.4)* 33.89 (13.8-83.27) 0.060 Exposure of ultrasound Yes 46 146 1 1 No 68 120 1.77 (1.16-2.71)* 1.55 (0.86-2.80) 0.140 History of abortion Yes 15 58 1 1 No 113 194 0.56 (0.13-1.01)* 0.92 (0.40-2.12) 0.858 History of congenital anomaly Yes 2 15 1 1 No 112 251 0.12 (0.016-0.93)* 21.07 (2.09-21.21) 0.010* 1, reference group; CO, crude odd ratio; AOR, adjusted odd ratio; CI, confidence interval; *IDR-Indonesian Rupiah; *p<0.05 Table 9. Factors associated with the obstetric ultrasound practice among pregnant mothers at the Public Health Centers in Palu City. Variable Practices COR (95% CI) AOR (95% CI) p Poor Well Age < 20 28 31 1 1 20-29 99 84 0.75 (0.43-1.30) 1.1 (0.81-1.63) 0.448 30-35 53 69 1.14 (0.63-2.06) 0.95 (0.77-2.92) 0.993 > 35 4 12 2.30 (0.73-7.19)* 2.55 (0.68-8.76) 0.269 Maternal education Illiterate 2 19 1 1 Primary 11 11 0.10 (0.02-0.47) 0.074 (0.02-0.56) 0,330 High school 82 69 0.07 (0.017-0.32)* 0.76 (0.09-6.21) 0,558 Diploma 47 42 0.07 (0.018-0.35) 0.35 (0.04-2.81) 0.322 Bachelor or higher 44 53 0.08 (0.016-0.46)* 3.17 (0.54-21.20) 0.019* Maternal occupation Housewife 61 130 1 1 Government employee 20 44 2.90 (1.54-5.45)* 4.53 (1.17-15.18) 0.007* Private employee 78 37 0.45 (0.24-0.82)* 0.091 (0.03-0.25) 0,118 Entrepreneure 6 4 0.27 (0.07-1.03) 0.10 (0.016-0.63) 0.061 Knowledge Well 67 202 1.25 (0.72-2.16)* 3.71 (1.71-11.23) 0.009* Poor 71 40 0.25 (0.13-0.45) 1.47 (0.56-3.86) 0.426 Attitude Positive 32 301 0.12 (0.016-0.93)* 11.07 (2.09-17.21) 0.010* Negative 26 21 0.56 (0.13-1.01) 0.92 (0.40-2.12) 0.858 COR, crude odd ratio; AOR,adjusted odd ratio; CI, confidence interval; *IDR-Indonesian Rupiah. *p<0.05. [Healthcare in Low-resource Settings 2025;13:13084] [page 177] Attitudes towards obstetric ultrasound examinations The majority of respondents (77.0%) believed that ultrasound check-ups were safe for pregnant mothers, aligning with findings from studies in Jeddah (78.9%), Tanzania, and India. This percep- tion likely stems from the belief that the examination is safe for both the fetus and the mother. Additionally, 89.8% of participants disagreed that ultrasound causes pain during the scan, reinforcing the positive outlook towards the procedure. A study by Maryam in Tulungagung found that 56% of women had a positive attitude towards ultrasonography.10 Overall, our findings indicate a general trend of positive attitudes towards obstetric ultrasound examina- tions. Several factors contribute to this positive attitude. The com- fort experienced during the scanning process and the coverage of its costs by the national health insurance program, BPJS, play sig- nificant roles. Maniragena et al. (2021). reported that study partic- ipants were motivated to undergo more screenings due to friendly health worker responses, satisfaction with the examinations, and relatively low costs.11 Additionally, the desire to know the baby’s gender, estimated delivery date, and the baby’s well-being further influenced their attitudes towards obstetric ultrasonography. These positive attitudes are also evident as some pregnant women proac- tively request ultrasound scans on their own initiative. Attitude, defined as a person’s internal response to a specific stimulus or object involving opinions and emotions, plays a crucial role in health behaviors. The results of our study showed that the majority of women (86.7%) agreed that obstetric ultrasound is an important pregnancy screening, consistent with findings from Kano, Nigeria (93.8%), and Puducherry, India (88.0%).12 This per- centage was higher than that found in a study conducted in Kenya (71.8%), likely because most respondents understand the benefits of the examination for both the fetus and the mother during preg- nancy. Several studies have shown that patients’ attitudes towards health programs, including ultrasound scans, are influenced by the friendliness of health workers and the affordability of examination costs. Practice of obstetric ultrasound examinations The findings reveal that 210 respondents (55.4%) underwent an obstetric ultrasound scan during their first visit (K5) and 217 women (57.0%) did so by their fifth visit (K5). Health centers with high coverage rates often implemented innovative programs, such as home visits, and provided education on obstetric ultrasonogra- phy at the health center. Basic health research results indicated that some pregnant women still initiate antenatal care in the second trimester. This study highlights that barriers to utilizing antenatal services are multifactorial. These barriers include not only individ- ual obstacles but also issues related to maternal health service providers, support systems, cultural factors, and religious factors. Effective improvement of the timely and regular use of antenatal care services requires a multisectoral approach.13 By addressing these various factors collectively, interventions can be more com- prehensive and effective, ultimately improving maternal and fetal health outcomes. This study indicates that maternal education level, working status, and ultrasound exposure for non-pregnancy-related reasons were significantly associated with their knowledge about obstetric ultrasonography. Education is the most significant factor influenc- ing knowledge. Higher education enables individuals to respond more rationally to information and to evaluate its benefits for per- sonal development and goal achievement.14 Occupation is closely linked to education level; individuals with higher education are more likely to hold better positions, such as government or private sector jobs. Good knowledge can form motivation and positive attitudes in pregnant women, encouraging them to undergo routine ultrasound screening during pregnancy.9 Regarding attitudes, this study demonstrates that mothers with a history of congenital anomalies, as well as those with specific occupations and house- hold incomes, exhibit significant associations with their attitudes towards obstetric ultrasound. Income level is a factor that reflects a family’s economic con- dition and is closely linked to the ability to access education and health services.15 This correlation arises from the fact that most activities in life, such as schooling and healthcare access, entail financial costs. Pregnant women’s attitudes toward obstetric ultra- sound were significantly associated with women’s occupation, monthly household income, and history of births with congenital anomalies.16 Attitude plays an important role in influencing a per- son’s actions within their environment, although behavior is also affected by various factors, such as stimuli, individual background, motivation, and personality. Enhanced knowledge about the importance of a pregnancy exam and the merits of ultrasound cor- relates with a more positive attitude.17 Attitude has three main components: belief or confidence in an object, emotional evalua- tion of the object, and a tendency to act towards it.18 The health of individuals or communities is shaped by two primary factors: behavioral and non-behavioral causes.19 Behavioral factors are fur- ther influenced by three key elements: predisposing factors, enabling factors, and reinforcing factors. Predisposing factors, such as age, occupation, education, knowledge, and attitudes, play a crucial role in shaping pregnant women’s behavior in accessing obstetric ultrasound examinations during antenatal care. Conclusions The findings reveal that a majority of participants (70.8%) demonstrated good knowledge of obstetric ultrasound, with a sig- nificant proportion recognizing its importance in antenatal care. Positive attitudes towards ultrasound examinations were prevalent, with 77.0% of respondents believing in their safety and 86.7% acknowledging their importance as a pregnancy screening tool. The study identified several factors significantly associated with knowledge and attitudes towards obstetric ultrasound. Educational attainment, occupation, and prior exposure to ultrasound were found to be significantly related to knowledge levels. Attitudes were significantly influenced by maternal occupation, monthly household income, and history of congenital anomalies. Regarding practices, the study revealed that 55.4% of respondents underwent an obstetric ultrasound scan during their first antenatal visit, while 57.0% did so by their fifth visit. This highlights the need for con- tinued efforts to improve timely and regular utilization of antenatal care services, including ultrasound examinations. The findings underscore the importance of a multisectoral approach in addressing barriers to antenatal care utilization, con- sidering individual, provider-related, cultural, and religious fac- tors. Furthermore, the study emphasizes the role of education, income, and previous experiences in shaping knowledge, attitudes, and practices related to obstetric ultrasound. These results provide valuable information for healthcare providers and policymakers to develop targeted interventions aimed at improving knowledge, attitudes, and utilization of obstetric ultrasound examinations, ulti- mately contributing to better maternal and fetal health outcomes. Article [page 178] [Healthcare in Low-resource Settings 2025;13:13084] References 1. Whitworth M, Bricker L, Mullan C. Ultrasound for fetal assessment in early pregnancy. Cochrane Database Syst Rev 2015;2015:CD007058. 2. Tefera M, Mezmur H, Jemal M, Assefa N. Midwives’ expe- riences of performing obstetric ultrasounds in antenatal care in eastern Ethiopia: Qualitative exploratory study. Womens Health (Lond) 2024;20:17455057241228135. 3. Kim ET, Singh K, Moran A, et al. Obstetric ultrasound use in low and middle income countries: a narrative review. Reproductive Health 2018;15:129. 4. Moncrieff G, Finlayson K, Cordey S, et al. First and second trimester ultrasound in pregnancy: A systematic review and metasynthesis of the views and experiences of pregnant women, partners, and health workers. PLoS One 2021;16:e0261096. 5. Sun H, Wu A, Lu M, Cao S. Liability, risks, and recommen- dations for ultrasound use in the diagnosis of obstetrics dis- eases. Heliyon 2023;9:e21829. 6. Abduljabbar HS, Jabal NAB, Hussain FA, et al. Knowledge, attitudes and practice about obstetric ultrasonog- raphy among women attending a university hospital: a cross- sectional study. Open J Obstetrics Gynecol 2020;10:1763–75. 7. Edvardsson K, Ntaganira J, Åhman A, et al. Physicians’ experiences and views on the role of obstetric ultrasound in rural and urban Rwanda: a qualitative study. Tropical Med Int Health 2016;21:895–906. 8. Carovac A, Smajlovic F, Junuzovic D. Application of ultra- sound in medicine. Acta Inform Med 2011;19:168–71. 9. Molla W, Mengistu N, Wudneh A. Pregnant women’s knowledge, attitude, and associated factors toward obstetric ultrasound in public hospitals, Ethiopia, 2021: Multi-centered cross-sectional study. Womens Health (Lond) 2022;18:17455057221091357. 10. Maryam, Ervianti A. Pengetahuan dan sikap ibu hamil ter- hadap penggunaan alat USG (USG) dalam pemeriksaan ante- natal care (ANC) di Desa Waung Kecamatan Boyolangu Kabupaten Tulungagung. Jurnal Kebidanan 2023;12:82–6. 11. Maniragena J, Kasozi D, Mubuuke G, Murachi E. Knowledge, attitudes and practices of pregnant women towards obstetric ultrasound at mulago hospital: a cross-sectional survey. Int J Sci Basic Appl Res (IJSBAR) 2021;60:78–92. 12. Matiang’i M, Ngunju P, Nyagero J, Omogi J. Knowledge and skills gap of midwives to conduct obstetric ultrasonography screening in primary health care facilities in Kajiado and Kisii Counties, Kenya. Open J Clinical Diagnostics 2020;10:65–79. 13. Mutowo J, Yazbek M, van der Wath A, Maree C. Barriers to using antenatal care services in a rural district in Zimbabwe. Int J Africa Nursing Sci 2021;15:100319. 14. Kim HB, Choi S, Kim B, Pop-Eleches C. The role of education interventions in improving economic rationality. Science 2018;362:83–6. 15. McMaughan DJ, Oloruntoba O, Smith ML. Socioeconomic status and access to healthcare: interrelated drivers for healthy aging. Front Public Health 2020;8:231. 16. Haile ZW, Gurmu AG. Knowledge, attitude, barriers, and asso- ciated factors of obstetric ultrasound among pregnant women in public hospitals, Ethiopia, 2022: a cross-sectional study. J Ultrasound 2023;27:31–40. 17. Yousefzadeh S, Esmaeili Darmiyan M, Asadi Younesi M, Shakeri M. The effect of a training program during pregnancy on the attitude and intention of nulliparous women to choose the delivery mode. J Midwifery Reprod Health 2016;4:704–11. 18. Bakanauskas A, Kondrotienė E, Puksas A. The theoretical aspects of attitude formation factors and their impact on health behaviour. Management Organizations Systematic Res 2020;83:15–36. 19. Ryan P. Integrated theory of health behavior change. Clin Nurse Spec 2009;23:161–72. Article [Healthcare in Low-resource Settings 2025;13:13084] [page 179]