Observational analysis of factors associated with completion of four or more antenatal care visits in Sarlahi district, Nepal.

backgroundA significant number of women die from pregnancy and childbirth complications globally, particularly in low and middle-income countries. Receiving at least four antenatal care (ANC) visits is important in reducing maternal and perinatal deaths. However, few studies have investigated the factors linked to the completion of ≥4 ANC visits in Nepal.

objectiveTo investigate factors associated with attending ≥4 ANC visits in Sarlahi district of southern Nepal. DESIGN, SETTING AND

participantsA secondary analysis was conducted on data from the Nepal Oil Massage Study (NOMS), a cluster-randomised, community-based longitudinal pregnancy trial including 34 village development committees. We investigated the associations between attendance of ≥4 ANC visits and socioeconomic, demographic, morbidity and pregnancy history factors using logistic regression; generalised estimating equations were used to account for multiple pregnancies per woman. All pregnancies resulting in a live birth (LB) (n=31 867) were included. PRIMARY AND SECONDARY OUTCOME MEASURES: Attendance of ≥4 ANC visits.

results31.4% of those pregnancies received 4+ ANC visits. Significant positive associations included socioeconomic factors such as participation in non-farming occupations for women (OR=1.52, 95% CI 1.19 to 1.93), higher education (OR=1.79, 95% CI 1.66 to 1.93) and wealth quintile (OR=1.44, 95% CI 1.31 to 1.59), nutritional status such as non-short stature (OR=1.17, 95% CI 1.07 to 1.27), obstetric history such as adequate interpregnancy interval (OR=1.31, 95% CI 1.19 to 1.45) and prior pregnancy but no LB (OR=2.14, 95% CI 1.57 to 2.92), symptoms such as vaginal bleeding (OR=1.35, 95% CI 1.11 to 1.65) and awareness of the government's conditional cash transfer ANC programme (OR=2.26, 95% CI 2.01 to 2.54). Conversely, identifying as the Shudra caste (OR=0.56, 95% CI 0.47 to 0.67), maternal age below 18 or above 35 (OR=0.81, 95% CI 0.74 to 0.88; OR=0.77, 95% CI 0.62 to 0.96), preterm birth (OR=0.41, 95% CI 0.35 to 0.49), parity ≥1 (OR=0.66, 95% CI 0.61 to 0.72) and the presence of hypertension during pregnancy (OR=0.79, 95% CI 0.69 to 0.90) were associated with decreased likelihood of attending ≥4 ANC visits.

conclusionsThese findings demonstrate the importance of socioeconomic factors, including education, caste, wealth and occupation in completion of ≥4 ANC visits. In addition, biological factors including birth spacing, pregnancy complications and nutrition are important. The association with awareness of the government's conditional cash transfer programme is a motivation for a full evaluation of whether expanding that programme might improve prenatal care. TRIAL REGISTRATION NUMBER: The clinicaltrial.gov trial registration number for NOMS was NCT01177111.