Introduction: Antenatal care (ANC) is strongly associated to better maternal and neonatal outcome. We wanted to determine the prevalence of ANC at Goma, Democratic Republic of Congo (DRC).

Method: A cross-sectional survey was conducted at the five main hospitals of Goma (DRC) during the period 01/02/2010 to 30/07/2010. Variables included ANC, classic socio demographic and selected health-related factors. Descriptive statistics, bivariate analysis and logistic regression were performed. A p-value of <0.05 was considered significant.

Results: 1,156 women were included. The mean age was 26.5years (95%CI: 26.2-26.9). Women who attended at least one ANC Clinic were 95.8% (95%CI: 94.7-97.0). Primary school level (OR= 1.912; 95%CI: 1.031- 3.535; p=0.039; reference=University) and attending Bethesda private hospital (OR=0.206; 95%CI: 0.049-0.857; p= 0.030; reference=HPNK public hospital) were significantly associated to ANC Clinic attendance.

Conclusion: ANC at Goma (DRC) is objectively high. Lower educated women paradoxically seem to have a better health behavior than university graduated.

Keywords: antenatal care uptake, correlates, goma, democratic republic of congo

ANC, antenatal care; DRC, democratic republic of congo; WHO, world health organization

Antenatal care (ANC) Clinics attendance by pregnant women has been proven to be strongly associated to better maternal and neonatal outcomes.¹ ANC which is given to pregnant women is widely used for prevention, early diagnosis and treatment of general perinatal and pregnancy-related issues. It helps to guarantee the well-being of Mother, fetus and neonate. ANC contributes to maternal and neonatal morbidity and mortality reduction.^2,3 Women on their part are expected to book as early as possible and attend adequate number of ANC prior to delivery. The World Health Organization (WHO) recommended that pregnant women should attend at least 4times starting from the first trimester of pregnancy.⁴ Despite this recommendation from WHO, a non-negligible number of women in Sub Sahara Africa do not attend ANC services.⁵

ANC Clinics attendance is associated to several factors. In Sub Sahara Africa, those already well documented include:
i. Maternal education ⁶⁻⁸

1. Household or individual income ^9,10

iii. Geographic setting ⁹

1. Cost of service ¹¹
2. Enrollment in insurance schemes ¹²
3. Parity ¹³

vii. Community active involvement ¹⁴

viii. Distance to health facilities ¹³

This study aims at investigating the prevalence of ANC uptake among women delivering at the main hospitals of Goma, Democratic Republic of Congo (DRC) and associated correlates, socio demographic and clinical.

Design

A period cross-sectional and hospital-based survey was adopted and conducted.

Setting

The five main hospitals of Goma (DRC), a nearly 600,000 inhabitant’s city at the period the study was conducted is located in the East part of DRC. The region has, for a long time, been theater of several humanitarian complex disasters.

Populatio

The study population was made of women of different age, who delivered their babies at the five main hospitals of Goma (DRC) during the period 01/02/2010 to 30/07/2014.

Sampling and Sample Size

A prospective systematic and random sampling stratified by healthcare institution was performed among the study population. Delivering women were included in the study on a chronological basis with intervals of 1 delivery.

The calculation of samples size was based on the following assumptions or hypotheses:

i. ANC Clinics attendance has an average rate in Sub-Saharan Africa of approximately 95.0%: 97.0% in a study by Emelumadu et al.,⁵ 84.6% in a study by Iyaniwura and Yussuf ⁷, 97.5% in a study by Mwaniki et al.,¹³ and 96.0% to 98.0% in a study by Rossier et al.,¹⁵

ii. The rate in Goma is expected to be slightly inferior, let us say around 90.0%, due to the fact that the surrounding area has been, theater of vary kind of wars and consequently humanitarian disasters, for many years.

The required minimum sample size, by healthcare institution, was estimated to be n=264 (p=90%, two-sided alpha=0.05). At the study completion, 1,156 women were included and distributed as following: HPNK public hospital n=242 (“response rate”: 91.7%) and private hospitals CBCAV n=274 (“response rate”: 103.8%), CMATERN n=243 (“response rate”: 92.0%), HAFRICA n=218 (“response rate”: 82.6%) and Bethesda n=179 (“response rate”: 67.8%).

Data Management and Statistical Analysis

Variables consisted of classic socio demographics (age, sex, residence, marital status, education attainment, occupation status) and selected health-related factors (parity, antenatal care uptake, delivery’s healthcare institution, abortions, past stillbirths, past cesarean section, women’s height and weight). It was not possible to collect reliable information about the following important factors: individual and household revenue, nutritional status, HIV serology status and malaria test result.

Data of interest were manually extracted from questionnaires and obstetrics’ records. They then were transferred in a Microsoft Office Excel 2007 spreadsheet and finally in the statistical package Stata 10/SE. Data-quality assessment was performed by a systematic check of the following abnormalities: missing values, outliers, improbable and impossible values and inconsistencies. They were corrected when possible. Several variables including age, education attainment and delivery healthcare institution were transformed in binary’s ones. New and dummy variables were also created as needed.

Analysis began by descriptive statistics. Then followed Pearson chi-squared test for binay variables and Whitney-Mann test for quantitative continuous ones. We finally performed multiple logistic regressions. Models building was based on the “Backwise stepwise selection” technique while the post logistic Hosmer-Lemeshow test and ROC curve were used for models goodness-of-fit assessment. A p-value of <0.05 was considered significant.¹⁶ All the analyses were carried out by means of the statistical package STATA 12/SE.¹⁷

1,156 women were included (914 from the four private hospitals and 214 from the public general hospital). The distribution of the sample ‘age was not normal (Shapiro-Wilk p<0.000). The mean age was 26.5years (95%CI: 26.2%-26.9%) while the median was 26.0. There was no significant difference of age’s medians between women from the five hospitals (Bartlett’s test for equal variances: chi2 (4) = 4.5402 Prob>chi2=0.338; Kruskall-Wallis test: chi-squared with ties=4.658 with 4 d.f. p=0.324). Most of them were resident at Goma (95.3%; 95%CI: 94.1%-96.5%), married (92.8%; 95%CI: 91.3%-94.3%), high school graduated (59.1%; 95%CI: 56.3%-62.0%) and unemployed (56.8%; 95%CI: 54.0%-59.7%).

Women who attended at least one ANC were 95.31% (95%CI: 94.7%-97.0%). Being a primary school graduate was associated with higher probabilities of ANC attendance (OR= 1.912; 95%CI: 1.031- 3.535; p= 0.039; Logistic regression reference=University degree) while delivering at Bethesda private hospital was significantly associated with lower probabilities of ANC attendance (OR=0.206, 95%CI: 0.049-0.857, p=0.030; Logistic regression reference=HPNK public hospital). The results of the goodness-of-fit tests were as following: Hosmer-Lemeshow chi2 (2) =0.79 Prob > chi2 =0.6744; Area under ROC curve=0.6469. Detailed information is presented in Tables 1-3.

ANC attendance at the main hospitals of Goma (DRC) seems surprisingly high taking account of the fact that the city belongs to the Congolese area which the most recently suffered from civil wars and other kind of humanitarian complex disasters including a devastating volcano eruption. It would therefore have been expected that attendance of health services and particularly of antenatal care would have been low. In fact, as virtually all health services in DRC are for payers and many households of that part of DRC have probably lost a significant part of their revenue, the logical expected behavior should be a net reduction of services utilization and focus on curative rather than preventive care. As stated in an above paragraph, economic factors are strongly associated to ANC attendance.⁹⁻¹²

One possible explanation may be found in the dynamics of the real target population. In fact lots of people regularly leave the inlands areas, theater of endless conflicts, to the “safe” island represented by Goma city. This ongoing massive displacement of populations to Goma has surely provoked an overcrowding of the city with consequent increase in demands and reduction of the average distance to available healthcare services. Distance is an important obstacle of ANC attendance.¹³ An apparent “normal” utilization or “overutilization” of available ANC services can therefore be evidenced while it is in fact due to a significant increase in the de facto target population size (the denominator).

A limit to this explanation is the fact that only 4.7% of the interested delivering women declared having moved from rural zones. However the validity of this information is questionable. In fact once they have found a stable settlement in the host city of Goma, virtually all the families coming from the inlands areas usually consider themselves as host city residents. Therefore risk of information bias can’t be excluded.

Our study showed two singular facts: university educated women and those who delivered at a private setting (Bethesda hospital) were less likely to attend the ANC than their counterparts theoretically more socially disadvantaged (primary school graduated and delivering at a public hospital). This finding is in absolute odds with international literature including African’s.⁶⁻¹² We are unable to propose an acceptable explanation except the possibility of information’s bias. This is particularly true regarding education attainment which was not verified rather it was a self-declared information. As a locally well quoted private health institution, Bethesda hospital is expected to be largely attended by the wealthy and well educated women of the city and surrounding areas. In fact, it has been showed that the cited population subgroup usually has better health-related behaviors than the disadvantaged counterpart.¹⁸⁻²⁰

ANC attendance at the main hospitals of Goma (DRC) is rather high if one takes account of the context. It paradoxically seems that women theoretically most socially disadvantaged (primary school graduated and delivering at a public hospital) have better healthcare behavior. However caution is the rule as risk of information’s bias can’t be excluded and the study was based on institutions rather than on communities.

None.

Author declares there are no conflicts of interest.

None.

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