International Journal of MCH and AIDS (2016),Volume 5, Issue 2, 134-145

INTERNATIONAL JOURNAL
of MCH and AIDS
ISSN 2161-864X (Online)
ISSN 2161-8674 (Print)
Available online at www.mchandaids.org DOI: 10.21106/ijma.157
ORIGINAL ARTICLE
Factors that Influence Teenage Antenatal Care Utilization in John Taolo
Gaetsewe (JTG) District of Northern Cape Province, South Africa:
Underscoring the Need for Tackling Social Determinants of Health
Eshetu Bekele Worku, PhD;1 Selamawit Alemu Woldesenbet, PhD2
1
Northern Cape Department of Health, Kimberley 8301, South Africa, 2U.S. Centers for Disease Control and Prevention, Pretoria 0001,
South Africa

Corresponding author email: [email protected]

ABSTRACT
Background and Objectives: In resource-limited settings, the uptake of antenatal care visits among
women, especially teenage pregnant women, is disturbingly low. Factors that influence the uptake of ANC
services among teenage women is largely understudied and poorly understood in John Taolo Gaetsewe
(JTG), a predominantly rural and poor district of South Africa. The aim of this study was to determine the
factors that influence uptake of ANC services among teenage mothers in JTG district.
Methods: A cross-sectional health facility-based study utilising mixed method was conducted in all public
health facilities (n=44) at JTG district. Mother-infant pairs (n=383) who brought their infants for six-week
first DPT immunisation during the study period were enrolled in the study. Structured questionnaires were
used to collect data on demographic, socio-economic and uptake of ANC indicators.
Results: Out of 272 respondent mothers, 18.68% were adolescent mothers (13-19 years). The logistic
regression analysis shows that mother’s age (OR=2.11; 95%CI = 1.04 - 4.27); distance to the nearest health
facility (OR=3.38; 95%CI = 1.45-7.87); and client service satisfaction (OR=8.58; 95%CI =2.10-34.95 are
significantly associated with poor uptake of ANC services.
Conclusion and Global Health Implications: There is a need to improve the quality of adolescent
reproductive health services tailored to their health and developmental needs. Moreover, addressing the
social determinants of health that affect individual’s healthy life style and health seeking behavior is critical.
Key words: Antenatal Care Visits • Teenage Pregnancy • Social Determinants of Health • John Taolo
Gaetsewe

Copyright © 2016 Worku and Woldesenbet.This is an open-access article distributed under the terms of the Creative
Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided
the original work is properly cited.

©
2016 Global Health and Education Projects, Inc.
 Teenage Antenatal Care Utilization in South Africa

1. Introduction South Africa, the National Department of Health

has adopted a minimum of four ANC follow-up
Maternal and child health issues take a central stage
visits as recommended by the WHO for women
in global health agenda with the concerted efforts
without any risk factors. This is guided by following
of many players and a number of initiatives. This
the early booking visit (preferably <12 weeks) to
has been followed by a corresponding commitment
improve maternal and child health outcomes.[11]
on targets, interventions, and guidelines to avert
Furthermore, maternal and child health program
health risks and life threating dangers to women
has been considered as a priority program for
in pregnancy and childbirth. Despite the efforts
Government. Free primary healthcare (PHC)
of many global health players, data from the
services are provided for pregnant women and
World Health Organization (WHO), the Global
children in all public health facilities throughout
Health Observatory (GHO) 2015 data, and the
the country to provide quality health service that
United Nations Millennium Development Goals 2015
is equitable and more accessible to everyone.[12-16]
report show that pregnancy-related complications
Despite increased health facility coverage, many of
are still the leading causes of death amongst women
the ANC opportunities were missed, particularly
in the reproductive age in developing countries.[1,2]
by teenage pregnant women.[17] Late ANC booking
The risk of a woman in developing countries dying
is common and there is a concern on how to
from a maternal-related cause during a lifetime is
strengthen the ANC uptake as recommended in
about 33 times higher compared to a woman living
the national guidelines. To our knowledge, there are
in a developed country even though most of these
no studies that focused to identify the challenges
complications are preventable with improved access
and overcome the low uptake of ANC utilization
to quality health care service.[1]
in the district. Previous studies elsewhere indicated
Globally, 11% of all births occur to adolescents that late booking and inadequate number of ANC
aged 15 to 19 years, and 95% of these births occur visits were caused by multiple factors and expose
in developing countries.[3] International studies have pregnant women to higher pregnancy-related risks
shown that early child bearing is the biggest challenge and complications.[1,6,18] This study aimed to assess
to young people, as it is associated with increased whether teenage pregnancy was one of the risk
vulnerability to poor health as well as a long lasting factor for late attendance of ANC visit among other
impact on social, livelihood, education, physical, factors that influence teenage ANC utilization in JTG
mental health, including risks of maternal death.[4,5] district, in Northern Cape Province, South Africa.
Adolescent pregnancy is often not the result of a
The district has a 23,162 km2 and three local
deliberate choice, but rather the absence of choices
municipalities (Gamagara, GaSegonyana and Joe
which include little or no access to schooling, lack
Morolong) of which the majority (80%) are villages,
of information that positively influence behavior or
thus making the district mostly rural. The estimated
quality health services, and lack of empowerment,
population in the district in 2014, was 230 938 with
among others.[6,7] Studies indicate in some parts
the majority (> 75 %) being blacks. The district has
of the world, notably in sub-Saharan Africa, 35% of
the most challenging road infrastructure for the
pregnancies among adolescents are unplanned or
effective delivery of health services compared to the
unwanted during pregnancy that resulted due to
other four districts in the Province. The JTG district
unsafe sexual practices and lack of awareness.[8,9]
economy is based on mining (11 manganese and
To prevent, minimize or treat unfavourable 3 Iron Ore mines) and mixed farming, but there is a
outcomes of pregnancy, WHO recommends that high level (37.7% youth (25-34) official unemployment
all pregnant women should attend at least four rate and low level of income opportunities. Close
ANC visits as a minimum with skilled attendant to forty five percent (43.1%) of the households
throughout pregnancy, commencing as early as are female-headed. There are 44 health facilities of
possible in the first trimester.[10] Linked to this, in which five are Community Health Center, 37 clinics

©
2016 Global Health and Education Projects, Inc. | www.mchandaids.org 135
 Worku and Woldesenbet International Journal of MCH and AIDS (2016), Vol. 5, No. 2, 134-145

and 2 district hospitals - the two district hospitals attendants. The FGDs were captured using a digital
are both located in GaSegoyana local municipality. recorder. The information then was transcribed
The district has poor and substantial fluctuation for analysis where similar emergent teams were
in maternal and child health outcomes records differently categorised. Lay counsellors who were
between 2009 and 2013. According to the National trained for two days on data collection tools and
Committee on Confidential Enquires into Maternal research ethics collected the data. Lay counsellors
Deaths (NCCEMD) report, in 2009/10, the Maternal signed a confidentiality agreement prior to data
Mortality Rate (MMR) was 129.9 per 100,000 live collection. Observational data and field notes were
births. In 2010/11 and 2011/12 the MMR was collected during field visits. Use of ANC services was
435.3 and 191 per 100,000 live births respectively. determined by the participants self-report and was
The confidential enquiry report by the committee confirmed from clinical records.
for 2013/14 reported that the high MMR significantly
2.2. Sampling techniques and sample size for
slowed down to 93.2 per 100,000 live births in
facility based survey
2013/14. These substantial year-to-year fluctuations
in MMR outcomes records could partially linked Mothers attending six-week immunization for
to uptake of ANC services by pregnant mothers. their infants in all public health facilities in JTG
It was against this background that this study was district were the study population from which the
conducted to assess factors that influence the poor sample was drawn. By means of the 2011 census,
uptake of ANC in JTG district, South Africa. the study population was estimated to consist of
72,000 women. The six-week immunization and
2. Methods reproductive health services utilization rate data
2.1. Study design from the 2012/13 District Health Information System
(DHIS) was used to quantify the number of mothers
A cross-sectional study was conducted at all public
expected to attend six-week immunization visit for
health facilities in JTG district between September
their infants per facility over the study period. For the
and November 2014 using mixed method approach.
facility-based survey, a precision based sample size was
Both qualitative and quantitative data collection
calculated taking into account the expected annual
techniques were used for collecting primary data.
utilization of ANC services, a precision level of 2-3%;
Quantitative data was obtained using a standardized
and 95% confidence level.This provided a sample size
anonymous questionnaire adapted from validated
of 383 respondent mothers who will be attending
tools[19,20],which included information on maternal
six-week immunization services for their infants in
reproductive knowledge, attitude and practice, socio-
all public health facilities within the district. Sample
economic status, utilization of ANC services, delivery
size was allocated for each facility proportionate to
and postnatal visits (six-week), facility performances
their size as determined by the number of six-week
and supply side constraints in provision of maternal
immunizations coverage for 2013/14.
and child health services. Health facilities sampled
include 2 District Hospitals, 5 Community Health 2.3. Data analysis
Center (CHCs) and 37 Clinics. Questionnaires were
Data analysis was conducted using STATA version 13.
translated from English into two local languages
Univariate, and multivariate logistic regression
Afrikaans and Setswana languages and back translated
models were fitted to identify factors influencing the
into English to ensure accuracy
total number of ANC visits and late ANC booking.
Qualitative data was collected through semi- Results were expressed using descriptive statistics
structured interviews and Focus Group Discussion and where necessary, data was disaggregated by
(FGD) from purposely-selected participants that different sociodemographic and economic status of
included high reproductive health risk groups such respondents. We used a dichotomous dependent or
as teenage mothers, mother who do not utilise ANC outcome variable of the study on pregnant women’s
services at health services and traditional births use of ANC visit, categorized into: - those who

136 www.mchandaids.org | ©
2016 Global Health and Education Projects, Inc.
 Teenage Antenatal Care Utilization in South Africa

attend at least 4 ANC visits, and those who do not group), and age group older than or equal to 20 years
during the time of pregnancy. The literature shows of age (middle and older women).Women’s education
that the relationship between a binary outcome level was defined in terms of the formal education
variable of study such as attending at least 4 ANC system of South Africa: School not attended,
visits during the time of pregnancy or failure and elementary (grade 1-7), high school (8-12), college
predictor variables that affect the outcome variable or above. Marital status of mothers categorized as
can successfully be explained using the binary logistic married, living together, widowed/separated, and
regression model.[21,22] Binary logistic regression single. Place of residence was categorized as rural
analysis was performed to identify predictor versus urban. Distance to health facility for ANC
variables that influence the number of ANC service services categorized as more than or equal to one
utilization. The econometric measure of effect in hour or less. Other independent variables include
binary logistic regression analysis is the odds ratio. income, level of a mother, individual health seeking
Odds ratios arising from binary logistic regression behavior and service provider’s attitude. Household
analysis are estimated based on the maximum assets, including ownership of durable goods (such
likelihood estimation technique.[23,24] The logit model as car, fridge, televisions, stove and washing machine).
is used quite extensively for the estimation of odds Dwelling characteristics included were source of
ratios in economic studies involving a dichotomous drinking water, sanitation facilities, and construction
outcome.[25,26] materials and others used as predictor variables for
binary logistic regression analysis. The identification
Consider a dependent variable Y with 2 possible
of influential predictor variables was done based
outcomes (1, 0). The expression Y=1 represents the
on odds ratios. In binary logistic regression analysis,
event that a mother has failed to attend 4 ANC visits.
influential predictor variables are characterized
The expression Y=0 represents the event that a
by odds ratios that are significantly different
pregnant mother has attended at least 4 ANC visits
from 1, 95% confidence intervals of odds ratios that
successfully.
do not contain 1, and P-values that are smaller than
Previous studies revealed that utilization of 0.05, at the 5% level of significance.
ANC services is highly influenced by different
2.4. Ethical consideration
sociodemographic, economic factors as well as
specific individual-level characteristics both at The study was approved by the Northern Cape
the client and service providers’ side. Continuous Provincial Health Research and Ethics Committee
predictable variables had to be dichotomised in (PHREC), reference number NC-PHREC-2014/021.
order to perform Pearson’s Chi-square tests of
association. For instance, the Pearson Chi-square 3. Results
test of association is used to test the null hypothesis 3.1. Descriptive statistics
that two factors such the dependent variable and
Of 383 sample mothers approached for study
independent variable are independent of each other,
participation, 272 agreed to participate in the
against the alternative hypothesis that the two
study and completed the survey questionnaire
factors are significantly associated with each other.
which resulted in a 72% of response rate. Out of
The Pearson chi-square test of association is used
272 mother-infant pairs interviewed at 6 weeks
only for the screening of variables.
immunization visits, 69.37% had secondary
Accordingly, we included several theoretically education. Only 8.9% have completed college or
pertinent sociodemographic and economic above. The majority (84.79%) respondent mothers
independent variables (indicators) that influence were unemployed or housewives. Regarding the type
uptake of pregnant women’s ANC services. of employment sector, government and company
Respondent women’s age was classified into age employment jointly account for only 15.27%. Most
group of respondents less than 20 years (adolescent of the unemployed mothers depend for their source

©
2016 Global Health and Education Projects, Inc. | www.mchandaids.org 137
 Worku and Woldesenbet International Journal of MCH and AIDS (2016), Vol. 5, No. 2, 134-145

of income on child support grant, disability grant, felt about their pregnancy, 25.49% of respondent
and donations. However, for 54.76% respondent teenage mother responded that the pregnancy
mothers, the total monthly income was less than or was wanted, while the majority (74.51%) reported
equal to one thousand Rand (100 US Dollars). that their pregnancies were unwanted at that time.
About 2 percent (1.96%) of teenage pregnant
About one-fifth (18.68%) of the respondents were
mothers completed college or above whilst the
teenagers younger than 20 years of age, 71.96% were
majority (86.27%) were in secondary education.
single mothers, Close to half (44.69 %) of mothers
82.35% of them were single mothers, while 5.88%
reported they had their first baby before the age
were married, 9.80% were living together, and
of 20 years. Out of the 18.68% respondent mothers
1.96% were separated/divorced. The bulk of them
who were teens in this study, 94%, and 82.35% of them
(94%) were unemployed, and for the majority of
were unemployed and single mothers respectively.
(58.7 %) respondent teenage mothers their total
Regarding ages of the respondents, 15 years was
monthly income was less than or equal to one
the youngest age and 45 years was the oldest age.
thousand Rand (or about $100).
About 16.91% of the respondents were married;
9.56% were living together; 1.84% were separated/ 3.2. Logistic regression analysis
divorced; and 1.11% were widowed. About two-third
A number of predictor variables influencing the use
(71.96%) respondents were single mothers.
of ANC services were studied for two outcome
In this study, only 28.62% respondents own variables using the multiple binary logistic regression
houses, while 6.32% live in rented houses; 57.52% live models: (1) number of ANC visits (≥4 vs. < 4);
with their relatives, and 9.67% lived with a spouse/ and (2) time of attendance of ANC (early vs. late).
partner. With regards to the main source of water We estimated the odds ratios (ORs) to assess
used for drinking, 93.38 % respondents were using the strength of the associations for the 95% of
tap water either inside the house (16.54%); or yards confidence intervals (CIs). Regarding the number of
(15.44%) or (61.76%) public taps. Close to ninety ANC visits, in multivariable regression after adjusting
percent (88.97%) of the houses were connected for employment status, marital status, relationship
to electricity, and for more than 80.44% of the with the father of the child, waiting time, fear of HIV
respondents, electricity was the main type of fuel for test, partner support, and education level, we found
cooking in the house. 21.72% households were using that mother’s age (OR=2.11; 95%CI = 1.04 - 4.27);
flush toilets, 43.82% pit latrines private, and 31.46% distance to the nearest health facility (OR=3.38;
ventilated pit latrines. Table 1 presents a summary of 95%CI = 1.45-7.87); and client service satisfaction
the socioeconomic and demographic characteristics (OR=8.58; 95%CI =2.10-34.95) are significantly
of the study respondents (Table 1). associated with poor uptake of ANC services
(Table 2). This suggests that the probability greater
Close to half (49 %) of the teenage pregnant
number of ANC visits is 2.1 times more likely higher
women attended at least four ANC visit during their
with age group older than or equal to 20 years
pregnancy. However, the majority (64.71%) of teenage
compared to adolescents. Increased distance (more
mothers booked for the first ANC visit after 12 weeks
than or equal to one hour) to ANC services, is
into pregnancy. Only (35.29%) of teenage pregnant
3.3 times more likely to negatively impact uptake
women booked for an early ANC first visit before
of ANC visits. Satisfied mothers with ANC services
12 weeks of pregnancy as recommended by the South
were 8.58 time more likely to use ANC visits. None
African Department of Health and WHO guidelines.
of the predictor variable were strongly associated
More than ninety percent (92%) teenage pregnant with the outcome variable time of first ANC (early
mothers attended their first ANC visits at public or late) attendance (Table 3).A comparison of Table 2
health facilities, and a few mothers attended private with Table 3 shows that the independent variables
health facilities (6%) or both public and private did not affect both number of ANC visits and ANC
facilities (2%). Regarding how pregnant women booking the same way.

138 www.mchandaids.org | ©
2016 Global Health and Education Projects, Inc.
 Teenage Antenatal Care Utilization in South Africa

Table 1: Sociodemographic characteristics and descriptive analysis of the study respondents

Variable Variable categories Respondents < 19 years of >20 years of
age (%) age (%)
Age in years n 272 51 (18.68) 221 (81.32)
Marital status n 272 51 (18.68 ) 221 (81.32 )
Married 46 (16.91%) 3 (5.88 ) 43 (19.46 )
Living together 26 (9.56%) 5 (9.8 ) 21 (9.5 )
Divorced/widowed 5 (1.84%) 1 (1.96) 4 (1.82 )
Single 195 (71.69%) 42 (82.35 ) 153 (69.23 )
Highest education n 272 51 (18.68 ) 221 (81.32)
School not attended 6 (2.21%) None 6 (2.21)
Elementary 53 (19.56%) 6 (11.76 ) 47 (21.35 )
High school 188 (69.37%) 44 (86.27 ) 144 (65.45 )
College or above 24 (8.86%) 1 (1.96) 23 (10.45 )
Employment status n 263 50 (19.01) 213 (80.98)
Employed 40 (15.21%) 3 (6 ) 37 (17.37)
Unemployed 223 (84.79%) 47 (94 ) 176 (82.63 )
Total monthly income n 252 46 (18.25) 206 (81.74)
< RI000 138 (54.76%) 27 (58.7 ) 111 (53.88 )
≥ R1000 & < R3000 52 (20.63%) 9 (19.57) 43 (20.87 )
≥ R3000 & < R5000 35 (13.89%) 4 (8.7 ) 31 (15.05 )
≥ R5000 27 (10.71%) 6 (13.04) 21 (10.19 )
Housing n 269 51 (18.95) 218 (81.04)
Own house 77 (28.62%) 13 (25.49 ) 64 (29.36)
Rented 17 (6.32%) 4 (7.84 ) 13 (5.96)
Living with relative/spouse 175 (65.06%) 34 (66.66 ) 141 (64.68)
Main source of water n 272 51 (18.75) 221 (81.25)
Tap 254 (93.38%) 47 (92.16 ) 207 (93.67 )
Bore hole/well 6 (2.21%) 1 (1.96) 5 (2.26 )
River/other 12 (4.41%) 3 (5.88 ) 9 (4.07)
Connected to electricity n 272 51 (18.75) 221 (81.25)
Connected 242 (88.97%) 45 (88.24) 197 (89.14 )
Not connected 30 (11.03%) 6 (11.76) 24 (10.86 )
Type of toilet n 267 50 217
Flush toilet 58 (21.72%) 13 (26 ) 45 (20.74 )
Pit latrine 117 (43.82%) 24 (48 ) 93 (42.86 )
Ventilated pit latrine 84 (31.46%) 12 (24 ) 72 (33.18 )
Other 8 (2.99%) 1 (2 ) 7 (3.23 )
Service satisfaction n 272 51 (18.75) 221 (81.25)
Yes 255 (93.77%) 49 (96) 207 (93.24 )
No 17 (6.23%) 2 (3.92 ) 15( 6.76)
Was the pregnancy n 272 51 (18.75) 221 (81.25)
planned
Yes 93 (34.19%) 13 (25.49 ) 80 (36.2 )
(Contd...)
©
2016 Global Health and Education Projects, Inc. | www.mchandaids.org 139
 Worku and Woldesenbet International Journal of MCH and AIDS (2016), Vol. 5, No. 2, 134-145

Table 1: (Continued)
Variable Variable categories Respondents < 19 years of >20 years of
age (%) age (%)
No 179 (63.91%) 87 (74.51) 141 (63.8 )
Number of ANC visits n 272 51 (18.75) 221 (81.25)
>=4 ANC visits 80 (29.3%) 19 (37.25) 61 (27.52)
<=3 ANC visits 192 (70.7%) 32 (62.75 ) 16 (72.52)
Smoke cigarette n 264 51 (19.31) 213 (80.68)
Yes 74 (28.03%) 27 (53 ) 47 (22.07)
No 190 (71.97%) 24 (47 ) 166 (77.93 )
Alcohol consumption n 251 48 (19.12) 203 (80.87)
Yes 70 (27.89%) 11 (22.92 ) 59 (29.06 )
No 181 (72.11%) 37 (77.08 ) 143 (71.94 )

Table 2: Estimates obtained from binary logistic (i) women who fully or partially missed reproductive
regression analysis on number of ANC visits health services; (ii) high risk reproductive health groups
Dependent Variable : Number of ANC visits (1, 0) which include adolescents, mothers who plan to give
birth at home, late presenters to reproductive health,
Variables Odds P-value 95%
Ratio confidence
and those women who have unplanned pregnancies;
interval (iii) traditional birth attendants, and (iv) healthcare
Mother age 2.11 0.038 1.04-4.27
service providers.
Marital status 0.57 0.097 0.29-1.10 We found that teenage pregnancy was more
Distance to health facility 3.38 0.005 1.45-7.87 common in the JTG district and most of it was
Relationship 0.59 0.56 9 0.23-1.49 unplanned pregnancy. According to adolescents’
Waiting time 0.85 0.710 0.85-1.92 focus group informants, the main reason for
Service satisfaction 8.58 0.003 2.10-34.95 unwanted pregnancy among teens was peer pressure
Fear of HIV test 1.36 0.549 0.49-3.74 from friends and economic dependency. Some of the
Fist ANC booking time 0.95 0.876 0.52-1.72 teens had not completed school, were not married
Employment status 1.44 0.418 0.59-3.55 and the support they were getting from the child’s
Education level 0.81 0.693 0.28-2.28 father were not consistent. According to one of the
Partner support 0.76 0. 397 0.39-1.46
teenage pregnant women:
Number of observations 261
“At the earlier months of my pregnancy, he was
there. But recently, I have no communication with
Pseudo R-Square 0.0938
the father of my child. Most of the time his cell
Prob>chi2 0.0020
phone is off and he is not responding to my calls.
LR chi2 (11) 29.38
Because the child’s father is no longer able to sup-
port us, I will apply for the government child social
3.3. Focus group discussions grant. I will also request my parents to look after my
child so that I will be able to look for work.”
In addition to the surveys questionnaires,we conducted
Another teenage participant responded, “For me
a focus group discussion to reveal a wealth of detailed
everything is still fine with this child’s father and he
information and deep insights on the utilization
is still supporting me, although I had one more child
of ANC services and provide recommendations
from different father.”
on strategies to tackle the challenges and achieve
better health outcomes. For each group 10-15 key Regarding knowledge about benefits of early
participants were selected from the following groups. and adequate number of ANC visits, the majority

140 www.mchandaids.org | ©
2016 Global Health and Education Projects, Inc.
 Teenage Antenatal Care Utilization in South Africa

Table 3: Estimates obtained from binary logistic one nurse has to see 35 patients a day but they
regression analysis on time of first ANC visits often see more than that number daily”.
Dependent variable: Time of first ANC visits (1, 0) 4. Discussion
Variables Odds P-value 95%
ratio confidence
Findings from this study indicate that many of
interval the opportunities for ANC benefits continue to
Mother age 0.077 0.338 0.081-0.023
be missed in the JTG district, particularly among
Marital status 0.005 0. 946 0.151-0.141
teenagers. There is a need to design innovative
strategy and encourage a positive move towards using
Distance to health facility 0.095 0.323 0.297-0.098
ANC services among teenagers as recommended by
Relationship 0.008 0.926 0.169-0.186
the South Africa Department of Health and WHO
Waiting time 0.071 0.395 0.093-0.236
guidelines. Our study results showed that out of
Service satisfaction 0.068 0.654 0.217-0.205
the 18.68% respondent mothers who were teens in
Fear of HIV test 0.006 0.955 0.217-0.205
this study, less than half (49%) of them had attended
Total ANC visit 0.009 0.894 0.153-0.135
four or more ANC visits during their pregnancy.
Employment status 0.028 0.755 0.152-0.210 Only (35.29%) of teenage pregnant women booked
Education level 0.159 0.165 0.065-0.384 for an early ANC first visit before 12 weeks of
Partner support 0.095 0. 18 0.046-0.236 pregnancy. The study observed that 94%, and 82.35%
Number of observations 261 of them were unemployed and single mothers
Pseudo R-Square 0.035 respectively. Furthermore, results from multiple
Prob>chi2 0.598 logistic regression analysis elucidate that mother’s
LR chi2 (11) 49.8 age, distance to health facility and client’s service
satisfaction found to be highly influential over the use
of ANC services. Our results support findings from
of respondents were aware of the benefits. They
several other studies that show teenage pregnancy
mentioned the role played by community healthcare
(mother’s age) linked to increased risks of maternal,
workers. According to one of the respondents:
and infant mortality and morbidity partially due to
“The community healthcare workers are helping us
lower utilization of ANC services.[27,29-31]
to use health care services, remind patients about
the date to go to the clinic visits. Sometimes they According to WHO and National Department
assist patients to the clinic, they encourage patients of Health (NDoH) guidelines, all pregnant women
to take their pills as well as educate them on govern- should attend at least four ANC visits during
ment’s policy with regard to their health. I think they pregnancy and the first visit should happen before
are supporting the healthcare system in reaching 12 weeks of gestation for healthy pregnancy
the communities. However, some other partici- outcomes.[10,11] ANC provides the opportunity to
pants suggested, “There is a need to have ade- better clinical management of risk causes through
quate nurses, and adequate space at the facility as early detection, treatment of anomalies of pregnancy
well as priority should be given for pregnant women. as well as preventive health services.[11] However, to
The problem is that the clinics use a supermarket fully benefit from these interventions, it is vital that
approach in providing health services, which means pregnant women should start the visit as early in
first come first served. This leads to a long waiting their pregnancy and attend at least four ANC visits.
time for pregnant women and can be seen by other In this study, both the focus group discussions and
patients from the community which teen pregnant the logistic regression analysis results showed that
mother do not want.” In our district there are many the importance of the quality of services at health
facilities operating with only a nurse who has to per- facility for increased uptake of ANC services. During
form all the services which include antenatal, family the focus group discussion, research respondents
planning, chronic and also emergencies. On average indicated that teenagers do not want to be seen by

©
2016 Global Health and Education Projects, Inc. | www.mchandaids.org 141
 Worku and Woldesenbet International Journal of MCH and AIDS (2016), Vol. 5, No. 2, 134-145

other community members while attending ANC countries have been able to make significant
services. Generally, this is due to the expected fear progress in the reduction of maternal and child
of religious belief, low level of education, cultural mortalities.[2,41,42] Although undeniably, there have
factors, ethical and social norms of the society, been remarkable gains witnessed, still there is a long
which do not appreciate teenage pregnancy out of way to go with focused approach particularly in low-
marriage.[18,29,30] If such perceptions are informed resource geographic settings and socio-economically
by fear of being judged then this could be a strong disadvantaged population groups.[2] As many of
predictor for both late ANC attendance and lower the root causes of poor health and health seeking
utilization of ANC services by teenagers. A recent behaviors are linked to the social determinants of
publication from World Bank research output health,[39] and empirical evidence shows that there is
confirms that there is a widely accepted truth that a strong bi-causal links between poverty and poor
socio-cultural factors shape perceptions, cognition, health status[6,43] people at a lower socio-economic
and preferences in durable ways.[32] Previous studies conditions are often disproportionately vulnerable to
point to a strong causal links between client-friendly ill-health.[18,44] Effective implementation of Sustainable
quality of services and utilization of health care Development Goals (SDGs) agenda tailored to
services.[33-37] country’s holistic development need can address
many of the health related challenges. Bu this needs
Adolescent pregnancy is often not the result
everyone to contribute their part: governments, the
of a deliberate choice, but rather the absence
private sector, civil society and individuals.
of choices which include little or no access to
school, lack of information that positively influence 4.1. Limitation of the study
behavior or good quality health services and lack of
The study designed with a particular focus in JTG
empowerment among others.[6,7,27] Hence pregnancy
district. The findings of the study are limited to this
and ANC use in developing countries could be
district and cannot be generalized to the Northern
associated with various inter-related markers of Cape Province or the country. The study findings
the social determinants of health[27-29,38] Present may not be representative of all pregnant mothers
study showed that the fact that 74.52% of teenage who do not attend six-week immunization due to
pregnant mothers did not want to be pregnant child illness or death.
during that time, and 86.27 % teenage mothers
only had secondary education, and the bulk of them 5. Conclusion and Global Health
(94%) are unemployed, and for the majority (58.7%) Implications
respondent teenage mothers the total monthly
This study concludes that several factors influence
income is less than or equal to one thousand Rand
uptake of ANC services by pregnant women in John
(or about $100) shows the influences of the social
Taolo Gaetsewe district. Use of ANC was significantly
determinants of health. Teenagers engage in risky
influenced by mother’s age, longer distance to health
sexual behaviors, not only due to lack of knowledge
facility, and poor quality of ANC services provided
but also due to unfavorable decisions linked to their
at health facilities among others. We recommend
socio-demographic and economic conditions.[8,9,33,39]
government and nongovernment organizations to
Lower socio-economic status is a risk factor for
create client age friendly ANC services. Furthermore,
both unplanned and unwanted pregnancies and
tackling the social determinants of health are critical
healthy decisions.[4,35,38,40].
to empower women and avoid unwanted pregnancies
Thus, there is a need to address the social and the associated risks. Moreover, there is a need for
determinant of health factors along with improvement community awareness, particularly in rural areas on
in health systems to provide adolescent friendly the WHO’s and South African National Department
services. Following the Millennium Development of Health guidelines regarding the number of ANC
Goals (MDGs), which was adopted by the visits and booking time to improve maternal and
international community in 2000, many developing child health outcomes in JTG district.

142 www.mchandaids.org | ©
2016 Global Health and Education Projects, Inc.
 Teenage Antenatal Care Utilization in South Africa

Compliance with Ethical Standards September 2014; cited 2015 November 30].
Available from: http://www.who.int/mediacentre/
Competing Interests: The authors have declared factsheets/fs364/en
that no competing interests exist. Funding: This study
4. Brahmbhatt H, Kågesten A, Emerson M, Decker MR,
was supported through funding to undertake the
Olumide AO, Ojengbede O, et al. Prevalence and
research by the Provincial Department of Health and determinants of adolescent pregnancy in urban
the Premier Office of the Northern Cape Province. disadvantaged settings across five cities. Journal of
Acknowledgements: The data used here derive from Adolescent Health. 2014; 55 (6):S48–57.
the Maternal and Child Health Programme Effectiveness
5. Christofides J, Jewkes K, Dunkle L, et al. Early
Survey conducted in 2014 in John Taolo Gaetsewe adolescent pregnancy increases risk of incident
district, Northern Cape Province, South Africa. We like HIV infection in the Eastern Cape, South Africa: a
to acknowledge all participants who participated in longitudinal study. Journal of the International Aids
the study including provincial and district MCH units, Society. 2014; 17:18585
public health facility managers. We are also grateful to 6. World Health Organization. Pregnant adolescents:
the editors and referees for their valuable insight and delivering on global promises of hope. Geneva:
feedbacks. WHO; 2006.
7. UNFPA. News on Adolescent Pregnancy [home
page on the Internet]. [cited 2015 December 23].
Key Messages Available from: http://www.unfpa.org/adolescent-
pregnancy
• There is an urgent need to improve the quality
of adolescent reproductive health services tai- 8. Mchunu G, Peltzer K, Tutshana B, et al, Adolescent
lored to their health and developmental needs. pregnancy and associated factors in South African
• Collaborative efforts across countries, gov- youth. African Health Sciences. 2012; 12(4):426-434.
ernments, partners and the UN agencies, are 9. Bankole A, Malarcher S. Removing barriers to
required to tackle the social determinants of adolescents’ access to contraceptive information
health and advance an era of more equitable and services. Studies in Family Planning. 2010;
and healthier people, irrespective of where 41(2):117-124.
one lives as aspired by SDG. 10. Villar J, Bergsjo P: WHO antenatal care randomized
• Preventing early pregnancy, through creating trial: Manual for the implementation of the new
opportunities for empowerment, along with model. 2002; Geneva.
individual’s healthy life style and health seeking 11. National Department of Health. Guidelines for
behavior is critical. maternity care in South Africa. A manual for clinics,
community health centres and district hospitals.
National Department of Health. 2015; Pretoria,
References South Africa.

1. World Health Organization. Global health 12. Barron P, Shasha W, Schneider H, et al. Reengineering
observatory data on maternal and reproductive Primary Health Care in South Africa, discussion
health [home page on the Internet]. [cited Document. 2010.
2015 December 23]. Available from: http://www. 13. National Department of Health. Handbook for
who.int/gho/maternal_health/en. district clinical specialist teams, 2014. Pretoria, South
2. United Nations.The Millennium Development Goals Africa.
Report 2015 [home page on the Internet]. [cited 14. Department of Health. White paper for the
2015 December 12]. Available from: http://www. transformation of the health system in South Africa.
un.org/millenniumgoals/2015_MDG_Report/pdf/ Pretoria: Government Publishers; 1997. [cited
MDG%202015%20rev%20(July%201).pdf 2015 December 23]. Available from: http://www.info.
3. World Health Organization. Adolescent pregnancy gov.za/whitepapers/1997/health.Htm
fact sheet [home page on the Internet]. [updated 15. Department of Health. Human resources for health

©
2016 Global Health and Education Projects, Inc. | www.mchandaids.org 143
 Worku and Woldesenbet International Journal of MCH and AIDS (2016), Vol. 5, No. 2, 134-145

South Africa. HRH strategy for the health sector: Attendance and Utilization of Antenatal Care (ANC)
2012/13-2016/17, National Department of Health. Services: Multi-Center Study in Upcountry Areas of
2011. Pretoria, South Africa. Uganda. Open Journal of Preventive Medicine. 2015;
16. African National Congress. A National Health Plan 5(3): 132–142.
for South Africa. 30 May 1994. 29. Habiba K, Erin M, Francesca B. et al. Deprivation and
17. Worku EB, for MCHPE study group. Maternal and poor psychological support are key determinants of
child Health programme effectiveness evaluation late antenatal presentation and poor fetal outcomes – a
(MCHPE) John Taolo Gaetsewe District, assessment combined retrospective and perspective study. BMC
report, 2015. Northern Cape Department of Health. Pregnancy and Childbirth. 2015; 15:309.
Kimberley. 30. Mugo NS, Dibley MJ, Agho KE. Prevalence and risk
18. Kalule-Sabiti I, Amoateng A, Ngake M. The effect factors for non-use of antenatal care visits: analysis
of socio-demographic factors on the utilization of of the 2010 South Sudan household Survey. BMC
Maternal Health Care Services in Uganda. African Pregnancy Childbirth 2015; 15:68.
Population Studies. 2014; 28 (1). 31. Mondal MNI, Ullah MMMN, Islam MR, Rahman MS,
19. Mkrtchyan Z. Baseline assessment of reproductive, Khan MN, et al. Sociodemographic and Health
maternal and child health services in project Determinants of Inequalities in Life Expectancy in
nova supported networks. Maternal and child Least Developed Countries. International Journal of
health services in project NOVA; 2007. [cited MCH and AIDS, 2015; 3(2):96-105.
2015 January 13]. Available from: http://pdf.usaid. 32. Hoff K, Stiglitz JE. Exploring the Second Strand of
gov/pdf_docs/PNADR170.pdf Behavioral Economics. World Bank Policy Research
20. Woldesenbet S, Goga A, Jackson, D, for the Working Paper 7537. [cited 2015 January 13].
SAPMTCT group. The South African programme Available from: http://www.worldbank.org/en/
to prevent mother-to-child transmission of HIV events/2016/02/22/exploring-second-strand-
(PMTCT) evaluation of systems for early infant behavioral-economics
diagnosis in primary health care facilities in South 33. van Eijk AM, Bles HM, Odhiambo F,Ayisi JG, Blokland IE,
Africa: report on results of a situational assessment, Rosen DH, Adazu K, Slutsker L, Lindblade KA. Use of
2010 report. antenatal services and delivery care among women
21. Tsyliakus A. Survival of the Ukrainian SMEs: What in rural western Kenya: a community based survey.
Matters? EERC/EROC Annual Student Conference. Reproductive Health. 2006; 3:2.
Ukraine; 2007. 34. Gross K, Alba S, Glass T, Schellenberg J, Obrist B.
22. Hosmer D. Lemeshow S. 2nd edition. Applied Logistic Timing of antenatal care for adolescent and adult
Regression. New York: John Wiley and Sons; 1999. pregnant women in south-eastern Tanzania. BMC
Pregnancy Childbirth. 2012; 12: 16.
23. Green W. Econometrics Analysis. 3rd ed. Prentice
Hall. New York: University of Michigan; 1997. 35. Asiimwe K.J. Utilization of antenatal services
among adolescents in western Uganda, 2007. [cited
24. Lancaster T. An Introduction to Modern Bayesian 2016 April22]. Available from: http://uaps2007.
Econometrics. New York: Blackwell Publishing; 2004. princeton.edu/download.as
25. Glogova E, Halling M, Hyaden E, Hoger A. Using 36. UNFPA. Motherhood in Childhood-Facing the
Survival Time Analysis to Predict Bank Failure. Challenge of Adolescent Pregnancy. The State of
Austria: University of Vienna; 2005. World Population; 2013.
26. Cramer J. Logit Models from Economics and Other 37. Commission on Social Determinants of Health
Fields. London: Cambridge University Press; 2003. (CSDH). Closing the gap in a generation: health
27. Floridia M, Pinnetti C, Ravizza M. et al. Rate, equity through action on the social determinants
predictors, and consequences of late antenatal of health. Final report of the Commission on
booking in a national cohort study of pregnant Social Determinants of Health. 2008, World Health
women with HIV in Italy. HIV Clinical Trials. 2014; Organization: Geneva.
15(3):104. 38. Islam A, Mondal N, Khatun M, et al. Prevalence of
28. Kawungezi PC, AkiiBua D, Aleni C, Michael EW, et.al. determinants of contraceptive use among employed

144 www.mchandaids.org | ©
2016 Global Health and Education Projects, Inc.
 Teenage Antenatal Care Utilization in South Africa

and unemployed women in Bangladesh. International Sciences. 2010; No.277.

Journal of MCH and AIDS.2016; 5(2):92-102. 42. United Nations General Assembly. Resolutions
39. Ochako R, Fotso CJ, Ikamari L, Khasakhala A. adopted by the General Assembly, United Nations
Utilization of maternal health services among Millennium Declaration. Fifty fifth sessions,
young women in Kenya: Insights from the Kenya 18 September, 2000.
Demographic and Health Survey, 2003. BMC 43. World Health Organization. Improving equity in
Pregnancy and Childbirth. 2011;1(1). health by addressing social determinants/edited by
40. Worku EB, Woldesenbet SA. Poverty and the Commission on Social Determinants of Health
inequality – but of what - as social determinants of Knowledge Networks, Jennifer H. Lee and Ritu
health in Africa? African Health Sciences. 2015;15(4). Sadana. World Health Organization 2011.
41. Bonds M, Keenan D, Pejman R, Sachs J. Poverty 44. Worku EB and Woldesenbet SA.Are there particular
Traps Formed by the Ecology of Infectious Diseases. social determinants of health for the world’s poorest
Proceedings of the Royal Society of Biological countries? African Health Sciences. 2011;(1): 108-115

©
2016 Global Health and Education Projects, Inc. | www.mchandaids.org 145