PREVALENCE OF ATTAINING FOUR ANTENATAL VISITS AND ASSOCIATED

FACTORS AMONG PREGNANT YOUNG WOMEN IN BIDBIDI REFUGEE CAMP

YUMBE DISTRICT, UGANDA.
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.
 CHAPTER ONE

INTRODUCTION

Background of the Study

World Health Organization (WHO) defines antenatal care (ANC) as the care provided to

expectant women by skilled healthcare professionals during pregnancy. It is an essential service

for pregnant women and adolescent girls that aims to improve their health and well-being, as

well as that of their unborn fetuses and newborns. It includes risk identification and screening,

prevention and management of pregnancy-related or concurrent diseases, and health education

and promotion. The ministry of health (MOH) of Uganda in adherence of WHO recommends a

simplified antenatal care of four visits for normal gestations; Initial appointment to occur in the

1st trimester(10-20 weeks of gestation),2nd appointment to Occur in second trimester(20-28weeks

of gestation), 3rd appointment to be in the third trimester(28-36), finally 4 th appointment to be in

be at 36 and above weeks of gestation. (Mugisha et al., 2010). Receiving antenatal care at least

four times increases the likelihood of receiving interventions that can improve maternal and

neonatal outcomes. Antenatal care coverage is an indicator of access and use of health care in

perinatal period and was estimated to lower death of mothers by 20% (Islam & Masud, 2018).

Young women are at higher danger of morbidity and mortality from gestation and

delivery difficulties, compared to elder women. Grønvik & Sandøy (2018) reported that found

mothers died more than old women, in a systematic review and meta-analysis, which intended to

assess whether childbirth <18 years of age in Sub-Saharan Africa was associated with amplified

risk of maternal and infant difficulties. In agreement, Amoadu et al. (2022) reported that young

expectant mothers were linked with poor gestational consequences, due to ANC deprivation, in
a study that reviewed literature of PubMed Central, Science Direct and JSTOR, to assess adverse

pregnancy outcomes and risk factors associated with adolescent pregnancy in Africa. Similarly,

Mezmur& Alemaye (2021) reported that70,000 adolescent mothers die annually from gestational

related problems, in a cross-sectional study that related adverse fetal consequences amongst teen

and adult pregnant women in rural Eastern Ethiopia.

Receiving the recommended ANC visits provides an opportunity to reduce maternal

mortality and morbidity. However, previous studies indicate constant low ANC utilization across

the globe and regions. In 2019, UNICEF that 65% of pregnant women received at least four

antenatal visits globally. While, UNICEF (2021) reported 52 % of 4 ANC visit utilization in sub-

Saharan Africa. Moreover, Bain (2022) found that the prevalence of maternal healthcare

utilization among young women in SSA was 55.2%, in a cross-sectional study, which intended to

examine prevalence of maternal healthcare utilization among young women aged 15–24 years in

SSA.

Singh et al. (2021) showed that 46% of women between 15-24 years completed ANC

attendance, in National Family Health Surveys of India, which intended to assess the trends and

determinants of full antenatal care and skilled birth attendance utilization among young married

mothers in India. Correspondingly, Ronen et al. (2017) reported that 35.2% of the young

mothers accessed 4 ANC visits and beyond, in a nationwide cross-sectional survey, which

compared visit in the PMTCT cascade between mature and young women in Kenya. Moreover,

Worku& Woldesenbet, (2016) found that 49 % of adolescent mothers attended 4 ANC, in a

cross-sectional health facility-based study that aimed to determine the factors that influence

uptake of ANC services among teenage mothers in JTG district. However, Anaba et al. (2022)

found 84% attendance of 4 ANC visit and above among adolescent and young mothers, in a
Multiple Indicator Cluster Survey, which investigated the prevalence of obtaining 4 or more

ANC visits and associated factors among adolescent and young mothers where?

Uganda like other countries faces a challenge of poor ANC uptake among young mothers,

which can affect their health and that of their babies. Kayemba et al. (2023) reported that only

36% of quality ANC attendance among adolescent mothers, in a cross-sectional study, which

aimed to examine the determinants of timing and quality of ANC attendance among mothers

between 10-19 years of age in Luuka district, Eastern Uganda. Similarly, Babughirana et al

(2020) reported 55.1% proportion of ANC attendance for no less than four antenatal care visits,

in a cross-sectional study, which assessed the uptake of lifesaving in the gestation period and

delivery among…in Hoima District, Uganda. Moreover, Atuoye et al (2020) reported 24%

ANC uptake of the 4 recommended visits, in Ugandan Demographic and Health Survey of

2016,which examined utilization of antenatal and skilled delivery services among primigravids

in Uganda.. Aidah& Kizito (2022) carried to examine the level of access ANC 4th visit and

factors affecting the utilization in Rubirizi District, Uganda, by a cross-sectional study. Results

showed that 59% of the mothers utilized ANC 4th visit. Okumu& Bbaale(2016) showed that

42% of pregnant mothers accessed 4 ANC visits, in Uganda Demographic Household Survey

analysis of 2000/2001,which intended to investigated and understood access to antenatal care

uptake in Uganda.

Some studies have assessed ANC utilization among expectant women in refugee setting and

reported a low ANC utilization. Saunders et al. (2023) reported that ANC was delayed for

women who were classified as immigrants, refugees, and asylum seekers according to WHO

ANC recommendations, in systematic review of scholarly abstracts, which investigated

evidence of ANC uptake and factors associated with inadequate access to universal healthcare,
and to evaluate the link between ANC and the risk of pregnancy outcomes in the immigrant,

refugee and asylum seeker population. Similarly, Alibhai et al. (2022) showed that women in

fragile and conflict-affected situations never meet the WHO four ANC visits during pregnancy,

in a systematic review, which assessed factors that impact ANC usage in the 37 countries

classified as fragile and conflict-affected situations. Additionally, Ziegler (2020) found that

women with in high conflict location were significantly less likely to access the recommended

ANC, in a study that investigated influential determinants for ANC attendance and skilled birth

attendant, in study…….. in the Democratic Republic of the Congo and Burundi. Moreover,

Yumbe district one of the fragile and conflict-affected situations (FCAS) in Uganda, according to

the 2016 Uganda Demographic and Health Survey (UDHS), showed that 40% of women in

Yumbe district attended ANC4 and above (Okedo et al, 2019). Additionally, Aneta(2018)

reported that only 25.3% of mothers accessed 4 ANC visits, a cross sectional mixed study that

aimed to assess the factors influencing the utilization of Maternal Health Care Services among

women age 15-45 years in Bidi bidi refugee camp. Another intervention by the MOH of

Uganda is to adapt the WHO recommendations on ANC for a positive pregnancy

experience for the Ugandan context. Barreix et al. (2020) described the development of a

toolkit to support countries to systematically adapt the WHO ANC recommendations

based on their local needs and resources. The toolkit was user-tested by stakeholders from

Burkina Faso, India, Rwanda and Zambia, including four MOH policy-makers from

Uganda. The toolkit consists of a baseline assessment tool and a Slidedoc® that outlines the

qualitative data that shaped the women-centred perspective of the guidelines. The current

recommended policy on antenatal care (ANC) by MOH Uganda is the Goal Oriented

Antenatal Care Protocol, it recommends that pregnant women should attend at least four
antenatal care visits. World Health Organization, at least four ANC visits are

recommended for a healthy pregnancy. The guideline provides global, evidence-informed

recommendations on routine antenatal care. The guidance aims to capture the complex

nature of the issues surrounding ANC health care practices and delivery and to prioritize

person-centred health and well-being, not only the prevention of death and morbidity, in

accordance with the Sustainable Development Goals.

In the context of the Sustainable Development Goals (SDG), countries have united

behind the target to accelerate the decline of maternal mortality by 2030. SDG 3 includes

an ambitious target: “reducing the global MMR to less than 70 per 100 000 births, with no

country having a maternal mortality rate of more than twice the global average. WHO

works to contribute to the reduction of maternal mortality by increasing research evidence,

providing evidence-based clinical and programmatic guidance, setting global standards,

and providing technical support to Member States on developing and implementing

effective policy and programs. addressing inequalities in access to and quality of

reproductive, maternal and newborn health care services; ensuring universal health

coverage for comprehensive reproductive, maternal and newborn health care; addressing

all causes of maternal mortality, reproductive and maternal morbidities, and related

disabilities; strengthening health systems to collect high quality data in order to respond to

the needs and priorities of women and girls; and ensuring accountability in order to

improve quality of care and equity. (WHO Maternal mortality, 22 Feb 2023)

PROBLEM STATEMENT

The global target for ANC coverage (at least four visits) is 90% by 2030, as part of the

Global Strategy for Women’s, Children’s and Adolescents’ Health (2016-2030) and the universal
health coverage agenda (WHO, 2021b). Moreover, according to the Ministry of Health (MOH)

Uganda, the current target for antenatal care (ANC) coverage is to achieve at least four ANC

visits for 90% of pregnant women by 2025. This is part of the Reproductive, Maternal, Newborn,

Child and Adolescent Health (RMNCAH) Sharpened Plan, which aims to reduce maternal and

child mortality and morbidity in Uganda. One of the current interventions by WHO to increase

ANC uptake is to introduce a new model of routine antenatal care (ANC) that provides a positive

pregnancy experience for women and their families. This model is based on the latest WHO

recommendations on antenatal care for a positive pregnancy experience, which cover five

categories of interventions: nutritional, maternal and fetal assessment, preventive, symptomatic,

and health system-level. The new model aims to complement existing WHO guidelines on the

management of specific pregnancy-related complications and to prioritize person-centred health

and well-being, not only the prevention of death and morbidity, in accordance with a human

rights-based approach. The new model also proposes a minimum of eight ANC contacts for all

pregnant women, with the first contact occurring in the first trimester, as evidence suggests that

this can reduce perinatal mortality and improve women's experience of care. However, the latest

available data show that only 64% of pregnant women in worldwide received at least four

ANC visits, with significant regional and national variations (WHO, 2021a). While, Bain

(2022) reported 55.2% of ANC utilization among young women in Sub-Saharan Africa, in a

cross-sectional study, which intended to examine prevalence of maternal healthcare utilization

among young women aged 15–24 years. The MOH Uganda reports that as of 2019/2020, the

ANC coverage for at least four visits was 60%, indicating a gap of 30% to reach the target.

Yumbe district one of the fragile and conflict-affected situations (FCAS) in Uganda, according to

the 2016 Uganda Demographic and Health Survey (UDHS), showed that 40% of women in
Yumbe district attended ANC4 and above (Okedo et al, 2019). Additionally, Aneta (2018)

reported that only 25.3% of mothers accessed 4 ANC visits, in a cross sectional mixed study

that aimed to assess the factors influencing the utilization of Maternal Health Care Services

among women age 15-45 years in Bidi bidi refugee camp.

The ANC uptake of 25.3% reported among women of 15-49 years is lower than the

WHO target is three times lower than the target of 90% at both global and national, also lower

than that reported at the Yumbe District of 40%, where the study site is located. moreover, it is as

well to that reported at the national level of 60%. Additionally, the study done in Bidibidi Camp

revealed an ice burg of poor ANC utilization among general population of women in

reproductive age, it is silent about the ANC uptake among the most at risk for maternal and

mortality, the young women between 15-24 years of age. Therefore, the current study intends to

investigate the prevalence of 4 ANC attendance and associated factors among the young women

between 15-24 years in Bidibid Refugee Camp. Otherwise the complications related to poor

ANC utilization will continue to escalate and the expected achievement of Sustainable

Development Goal (SDG) target of reducing the MMR to less than 70 deaths by 2030, and a

global target of 90% by 2030 will not to realized.

General Objective

To investigate the determinant factors for 4 ANC visit uptake among expectant young women in

Bidibidi Refugee Camp.

Specific Objectives
To determine the prevalence of 4 ANC visit uptake among expectant young women, in Bidi bidi

Refugee Camp, Yumbe District, Uganda.

To assess the social geographic, pregnancy and facility related factors for 4 ANC visit uptake

among expectant young women, in Bidi bidi Refugee Camp, Yumbe, District, Uganda.

To establish the relationship between the social demographics, pregnancy, and facility factors

with the 4 ANC uptake among expectant young women in Bidibidi Refugee Camp, Yumbe,

District, Uganda.

Hypothesis of the Study

The null hypothesis states that, there is no significant association between social demographic,

pregnancy, health facility factors and the 4 ANC uptake among expectant young women in

Bidibidi Refugee Camp, Yumbe, District, Uganda.

Research questions

What is the prevalence of 4 ANC visit uptake of the 4 ANC visit uptake among expectant young

women, in Bidi bidi Refugee Camp, Yumbe, District, Uganda?

What are the social geographic, pregnancy and facility related factors for 4 ANC visit uptake

among expectant young women, in Bidi bidi Refugee Camp?

What relationship is there between the social demographics, pregnancy, and facility factors with

the 4 ANC uptake among expectant young women in Bidibidi Refugee Camp, Yumbe, District,

Uganda?,
 Significance of the study.

The findings of the study may help the government through the Ministry of health find

ways of improving the health care services during pregnancy, could be used for program

planning and policy development aimed at increasing health ANC utilization, and the

information will contribute to the already existing knowledge in the academic world.

Scope of the Study

The study area selection was based on the following previous studies; the study done in

sub-Saharan Africa by Bain (2022), reported 55.2% of maternal healthcare utilization among

young women 15–24 years. This study revealed a lower ANC uptake among the most at-risk

group compared to the WHO target of 90% by 2030. Similarly, The MOH Uganda reports that as

of 2019/2020, the ANC coverage for at least four visits was 60%, indicating a gap of 30% to

reach the target. Additionally, Yumbe district one of the fragile and conflict-affected situations

(FCAS) in Uganda reported 40% of 4 and above ANC visit utilization among women, according

to the 2016 Uganda Demographic and Health Survey Okedo et al. (2019), this showed a gap of

50% to attain the MOH of Uganda target of 90% by 2025. Additionally, in Bidi bidi refugee

camp study done by Aneta (2018), reported only 25.3% of 4 ANC visits utilization among

women between 15-45 years of age, this was almost 3times more less than the global and

national target of 90%, and the study was silent about the most at risk group of young women

between 15-24years for maternal and mortality rate. The above studies depict a general low ANC

uptake and most of them are silent about the young women. Hence, the current study found a

basis to investigate the prevalence of the 4ANC visit uptake and the associated factors among the

young women in Bidibid Refugee Camp, Yumbe District, Uganda.

The study will be conducted for a total of 8 weeks after the proposal defence. The study will

examine the social demographic and facility factors that influence ANC uptake among expectant

young women between 15-24 year in Bidibidi Refugee Camp.

Limitations of the Study

The current research will encounter some constraints during its operations. It will a be a cross-

sectional research design that will provide information about the level of outcome variable and

will be difficult to derive causal relationships between the independent and dependant variables.

Non-response bias may be realized when some respondents included in the sample fail to reply

to some fields in the questionnaire. Various ways will be considered to reduce non-response bias

like the internal and external validity, seeking consent prior data collection, ensuring

confidentiality and quality control level one etc.

Theoretical Framework

The current study will adapt the Health believe model and self determination theories to

understand the determinants of individual health related behaviours in ANC utilisation among

the expectant young women (Kahsay et al, 2019). For instance, specific perception and health

beliefs matter in taking necessary actions, are claimed in the health belief model, in this regard,

adequate antenatal care uptake is determined by individual insights of susceptibility, severity,

benefits, barriers and exposure towards cues-to-action (Rosenstock, 2005). While, self-

determination theory, self-determined people are more proficient in taking unrestrained self-

chioces on all realms of life (Ryan and Deci, 2017). This theory suggests that people can

become self-determined when their needs for competence, relatedness and autonomy are
satisfied (Cherry,2019). Adopting self-determination theory simplifies understanding of how

maternal self-determination leads to making choices related to a desirable behavior, like ANC

utilization. Earlier authors have reported that absence of self-determination and lacking the

ability to make self-decisions are some of the hinderances for ANC uptake in several African

countries (Umar,2017; Gudu,2018 and Jeong,2019).

Conceptual Framework

Previous studies have identified various factors that affect ANC utilization. For example;

Okedo-Alex et al. (2019), in a meta-analysis, which aimed to assess the ANC utilization

determinants in sub-Saharan Africa, found that maternal age, marital status, education level,

occupation, parity, household wealth index, residence, distance to health facility, husband's

education level, and media exposure were significantly associated with ANC utilization. In

agreement, Galadima et al. (2021), in a systematic review, that aimed to examine the influential

factors for childhood immunization uptake in Africa, which is closely related to ANC uptake,

found that the modifiable factors included obstetric factors, maternal knowledge, attitude, self-

efficacy and outcome expectation, whereas the non-modifiable factors were sociodemographic

factors of parent and child, logistic and administration factors. Similarly, another systematic

review by Alibhai et al. (2022) examined the factors impacting ANC utilization in 37 fragile and

conflict-affected situations (FCAS) in Africa. The review found that the most cited factors

impacting ANC were socioeconomic status, education, and poor quality of ANC.
 Figure 1: Conceptual Framework

Independent Variables Dependent Variable

Social demographic factors

maternalAge
Religion
Marital status
Maternal education
Paternal education
Economic status
4 ANC visit Uptake
Knowledge
Perception
Stigma
Decision making power
Social support
Media exposure
Pregnancy factors
Parity
Gravida
Pregnancy plan
Pregnancy complication
Institutional factors
Distance
Health providers’ attitude
community health workers
 Operational Definition of Terms:

The dependent variable is 4ANC visit uptake, will be based on threshold for the values of 4 visits

as recommended by WHO for healthy pregnancy of women. its will be measured on binary scale

where, 1=yes 4 ANC visit attendance, 2=No 4 ANC visit attendance.

Maternal age: this will mean the age of the respondent will be at the time of the study and will
be categorised as, 1=15-18years, 2=19-24years

Religion: This will mean any of the current different dominions, it will be measured on ordinal
scale where;1= Catholic,2=Muslim, 3=Protestant, 4=Seventh Day Adventist,5=other

Marital status: used will mean one with a sexual partner of legal or not, will be measured on
ordinal scale where, 1=Married, 2=Single, 3= Windowed

Maternal Education - will refer to the level of academic attained by the mother at the time of

study, and will be measured on ordinal scale where by 1=none, 2=primary level, 3=secondary,

4=tertiary and above

Paternal education: will refer to the level of academic attained by the partner to the study

participant at the time of study, and will be measured on ordinal scale where by 1=none,

2=primary level, 3=secondary, 4=tertiary and above

Economic status: this will mean the total income of the individual at a house hold level, will be
measures as; 1=<500000/=,2=500000-1000000,3=>1000000

Knowledge: This will mean the participant’s knowledge about ANC services . The variable

of knowledge will be measured by asking women about their awareness of the recommended

number and timing of ANC visits, the benefits, and the danger signs during pregnancy. The

responses will be scored and categorized into low, medium, and high levels of knowledge. will

include closed and open-ended questions that will allow the participants to express their opinions

and experiences in their own words.

Perception: This will mean is the insight of pregnant women about the quality, barrier, benefit

and satisfaction of ANC services, it will be measured by a structured questionnaire on a five-

point Likert scale. The mean scores will be calculated and standard deviations for each aspect of

ANC perception and performed a factor analysis to identify the underlying dimensions of ANC

perception.

Stigma, this will mean a negative attitude or belief that will be attached to a person, based on

some characteristic or attribute. This will be measured by one question to assess how they felt

when discovered that they were pregnant, on a 5likert scale, some other 2 questions will be

closed ended to ask them whom they shared with about their pregnancies and if they faced any

challenges in seeking ANC, then an open ended question let the participants provide their

challenges they faced in attending ANC.

Decision making power, this will mean the capacity of the participant to choose seeking ANC

services. The questionnaire will include closed ended questions to get information on the source

of choice for the participant to attend ANC visit.

Social support This will mean help got by the mother in relation to ANC attendance, closed and
open-ended questions will be used to get information if they get support, the source of support
and type of support whether financial or psychological support.

Media exposure, this will mean the accessibility of the participant to any form of public way of
accessing information about ANC services such as radio, television, Newspapers. Questionnaire
will contain closed and open-ended questions to assess information about their main source of
information about ANC services, the frequency use of the media and the importance of such
message in influencing them to attend ANC services.

Gravidity will mean the number of pregnancies women will have got including the current one at the

time of study and any abortions experience before. It will be measured in whole numbers.
Parity will mean the number of live births she will have at the time of study, and it will be measured in

whole numbers
 CHAPTER TWO

LITERATURE REVIEW

This chapter contains literature on factors influencing ANC utilisation among women.

The sources of Literature were published journals and articles. The purpose of literature review

in this section was to review other researchers with aim of identifying the gaps. The factors

influencing health care attendancy during pregnancy among women in reproductive period are

the collected works confined in this section. Hence, this chapter addresses the works of the

previous scholars regarding the current study.

The prevalence of ANC uptake

Previous studies have been done to estimate the prevalence of the 4 ANC visit utilization

in various countries. Similarly, Dusingizimana (2023) showed 54% prevalence of ANC uptake in

the study that explored determinants for attaining the endorsed 4 ANC visits by a geo-referenced

cross-sectional study in Rutsiro district, Western province of Rwanda. Similarly, Bocher et al.

(2021) showed 10% proportion of women who attended all the recommended 4 ANC visits, in a

Cross-sectional study that investigated the social and financial aspects that determine the uptake

of ANC in Somalia. Moreover, Okedo et al. (2019) reported 40% of the 4 ANC visit utilization.,

Yumbe district in relation to the Uganda Demographic and Health Survey (2016). Additionally,

Aneta (2018) reported that only 25.3% of mothers accessed 4 ANC visits, in a cross-sectional

mixed study that aimed to assess the factors influencing the utilization of Maternal Health Care

Services among women age 15-45 years in Bidi bidi refugee camp.

The prevalence of the 4 ANC visit utilization in the reviewed literature was generally

lower than the global target of 90% for 2030.Much as that in the country of 54% Rwanda was

better than the rest, Somalia showed 10% the poorest 4 ANC Visit uptake. However, the authors
provided data in the general population of women in the reproductive age, they are silent about

the young women, at more risk for maternal mortality and morbidity which calls for further

investigations.

Social demographic factors

Maternal Age

Previous studies were done and established a connection between maternal age and ANC

utilization. Okedo et al. (2019) reported that older age, was a predictor factor for timely ANC

attendance, in Systematic review, which assessed the influential factors for antenatal care

utilization in sub-Saharan Africa. Similarly, Ejeta et al., (2017) showed that women who were 25

years and above were 6.05 folds more chances to attend ANC services, in a cross-sectional study,

aimed to examine factors for late attendance of Health care services during pregnancy and

constitute of care among expectant women that attended antenatal care services in East Wollega

administrative zone, West Ethiopia. Moreover, Tessema et al (2023) found age group of 25-34

years to be a predictor for seeking ANC service on time, in a Cross-Sectional study, which

evaluated the prevalence of timely initiation of ANC and its associated factors among pregnant

women who attended antenatal clinics in Wachemo University Nigist Eleni Mohammed

Memorial comprehensive specialized hospital, Hossana, Ethiopia. In a similar way, Gebeyehu et

al (2022) showed that age between 36-49years was significantly associated with health care use

during pregnancy in the study analyzed DHS data of 2008–2019 in Sub-Saharan Africa, to

examine the number of pre-birth care visits and associated factors amongst women between 15-

49years.
 None of the studies reviewed were done in Bidibid Refugee Camp the study site. There is

however, a steady responsibility to seek ANC service the more women advance in age, this

might be due to the fact elder women could be more experienced in pregnancy related risks and

advantages of ANC attendance.

Religion

Prior studies have reported a relation between women’s religion and ANC uptake. Okedo

et al. (2019) reported that Christian women were significantly associated with ANC attendance

and timeliness, in a systematic review, which assessed the influential factors for antenatal care

utilization in sub-Saharan Africa. While, Rutaremwa et al. (2015) showed that moslem women

had lowered chances to attend ANC services, in UDHS data analysis of 2011, that in examined

influential factors for ANC in Uganda. Movere, Singh et al. (2021) showed that Muslim women,

women were less likely to utilize both the maternal health care services, in a National Family

Health Surveys of India, which intended to assess the trends and determinants of full antenatal

care and skilled birth attendance utilization among young married mothers in India.

Most of these studies were not done in the current study area, however, Christian

religion leaders might be having health educational programs that increase peoples knowledge

to enable them seek for ANC services as opposed to the moslem religion.

Marital status

There was a relationship between marital status and ANC utilization as per the previous

studies. Okedo et al. (2019) showed that women who were married were significantly associated

with ANC attendance, in a systematic review that assessed the influential factors for antenatal
care utilization in sub-Saharan Africa. In agreement, Owusu, (2021) indicated that marital status

was a predictor factor ANC uptake, in a cross-sectional study, which aimed to assess the factors

associated with the ANC uptake amongst women in perinatal period in the Sunyani

municipality. Similarly, Chilot et al. (2023) showed that married women were significantly

linked with ANC uptake, in a multi-country analysis that used DHS data, which aimed to

determine the Pooled prevalence and determinants of antenatal care visits in countries with high

maternal mortality and morbidity.

Contrary, Rutaremwa et al. (2015) reported that married women were less likely to seek

for ANC services, in a UDHS data analysis, which aimed to establish ANC uptake and its

influential factors in Uganda.

There exists a discrepancy in the information provided by the authors, this required more

investigations. However, Married women might receive more support in terms of finance to

cover ANC expenses and moral support from their partners, which could motivate them to seek

more ANC services in comparison to the un married ones. While, married women may be

limited in making decision to attend ANC services by their spouses, due to culture norms

surrounded. maternal education

Previous studies were done and established a connection between mother’s education and

ANC utilization. Tessema et al (2023) indicated that mother’s education at tertiary level

influenced them to seek ANC services, in a Cross-Sectional Study that evaluated the prevalence

of timely initiation of ANC and its associated factors among pregnant women who attended

antenatal clinics in Wachemo University Nigist Eleni Mohammed Memorial comprehensive

specialized hospital, Hossana, Ethiopia. Similarly, Ali et al. (2020) reported that learned women

were more likely to achieve appropriate ANC initiation, in a baseline cross-sectional that aimed
to describe the patterns of ANC utilization and factors associated with appropriate ANC

initiation in the United Arab Emirates. Furthermore, Dusingizimana et al. (2023) showed that

mothers who attained secondary school were 2times more likely to attend the four ANC visits, in

a cross-sectional study that intended to explore the determinants for attaining the endorsed 4

ANC visits in Rutsiro district, Western province of Rwanda. Consistently, Gebeyehu et al (2022)

indicated that women who attained secondary education &above were significantly associated

with attainment of the required the number of ANC visits, in the study that analyzed DHS data in

Sub-Saharan Africa, which ained to examine the sum of pre-birth care visits and linked

influences amongst women between 15-49years.

Education level might predispose women to attain better employment that enable them to

stand ANC expenses to be incurred, additionally, educated women may be empowered to make

self-decision in seeking health care services during pregnancy. However, none of the studies

were done in the study area.

Partner’s education

Previous studies were done and established association between expectant women’s ANC

seeking and their partners’ education. Islam et al. (2022) indicated that pregnant women whose

spouses had attained education were 2.27 folds of chances to utilize ANC services and it was a

predictor factor, in a study done in Bangladesh and 28 other low-and middle-income countries

which, measured influential factors for health care use during pregnancy among expectant

mothers to realize the Sustainable Development Goals for maternal mortality ratio by 2030.

Tumwizere et al. (2023) as well, reported that women whose partners were educated had

increased likelihoods of ANC attendance for their first visit after 12 weeks, in a study that

analyzed UDHS data of 2016, which aimed to examine factors related to delayed health care
seeking during pregnancy for the initial visit after 12 weeks of pregnancy among mothers with

high parity in Uganda. Equally, Okedo et al. (2019) assessed the influential factors for antenatal

care utilization in sub-Saharan Africa by Systematic review, and reported that mothers with

educated spouses, were significantly associated with timely ANC attendance.

However, Rurangirwa et al (2017) carried out a population-based, cross sectional study to

examine the determinants of poor utilization of antenatal care services among newly delivered

women in Rwanda, reported that educational level for women with spouses who attained higher

education, were more likely to attend ANC services, education was not a significant factor for

poor utilization of ANC services

There is discrepancy found in the authors indicating a knowledge gap. However,

educated men may be exposed to various health knowledge regarding maternal health, enabling

them to support their wives in ANC seeking.

Stigma

Some earlier studies have found that there is an association between women with stigma

and ANC utilization. Mweteni et al. (2021) reported that young mother from 10-19years, their

ANC seeking was limited by social stigma, in a qualitative study that assessed the experiences

of expectant women adolescents with health care utilization during pregnancy in Misungwi

district, Tanzania. Similarly, Erasmus et al. (2020) showed that stigma about teenage gestation in

the interest to preservation culture of non-disclosure, and shame prevented young pregnant

women from ANC attendance, in qualitative study that investigated the opinions of the expectant

young women to find hinderances to attend ANC within a certain community of South Africa.

Women with stigma might as well have low ANC knowledge more especially the that

could be aggravated with stigma to have poor ANC seeking behavior.

 Economic status

The association between a woman’s economic status and ANC utilization was established

by former researchers. Islam et al. (2022) indicated that wealth index was a significant factor for

health care during pregnancy, in the study carried out in Bangladesh and 28 other low-and

middle-income countries, which measured influential factors for health care use during

pregnancy among expectant mothers to realize the Sustainable Development Goals for maternal

mortality ratio by 2030. In agreement, Ejeta et al. (2017) reported that monthly income of 15000

and above Ethiopian birrs led to delayed ANC attendance among the pregnant mothers, in a

cross-sectional study that investigated factors for late attendance of Health care services during

pregnancy and constitute of care among expectant women that attended antenatal care services in

East Wollega administrative zone, West Ethiopia. Moreover, Dusingizimana et al.(2023) found

that women from poor households were twice less likely to attend the four ANC visits, in a

cross-sectional study, that aimed to explore determinants for attaining the endorsed 4 ANC visits

in Rutsiro district, Western province of Rwanda, furthermore, Ahinkorah et al.(2021) showed

that women with economic ability were I.38 more times likely to attend ANC in their first

trimester, in the study that analyzed demographic health survey data, mainly to assess factors

that hinder the attendance of health care services for pregnant women, in sub-Saharan Africa

countries specifically Nigeria, Mali, Guinea and Zambia.

Women with better economic status might be in position to meet ANC associated

expenses such as transportations to the health facilities, medical bills etc. However, the studies
were not done in the study area and most of them were done among the general setting women

other than the Refugee camp setting, which raises a knowledge gap, Hence a call for further

investigation

Knowledge

The association between a woman’s knowledge about ANC survives and its utilization

was established by earlier scholars. Tessema et al. (2023), in a Cross-Sectional Study that

evaluated the prevalence of timely initiation of ANC and its associated factors among pregnant

women who attended antenatal clinics in Wachemo University Nigist Eleni Mohammed

Memorial comprehensive specialized hospital, Hossana, Ethiopia, indicated that indicated

women who knew about ANC services and pregnancy related risks had a significant association

with ANC attendance. In agreement, Okedo et al. (2019) reported that awareness of danger

signs, timing and adequate number of antenatal visits made attendance and initiation of ANC in

first trimester more likely, in a systematic review, which intended to assess the influential factors

for antenatal care utilization in sub-Saharan Africa. Moreover, Bocher et al (2021) indicated that

70% of the respondents had no knowledge about the benefits for ANC uptake, in a Cross-

sectional study, which investigated the social and financial aspects that deter or enable the uptake

of ANC in Somalia.

None of these studies were not done in a camp setting and the study target population,

which creates room for more research, However, knowing the pregnant related dangers and ANC

services might make women get worried about the outcomes, hence prompting them to seek for

ANC services to minimize.

Perception
 The association between a woman’s Perception and ANC utilization was established by

former researchers. Bocher et al. (2021) reported that women who had perception that ANC was

not needed affected their attendance for pregnancy health care, in a Cross-sectional study, which

investigated the social and financial aspects that deter or enable the uptake of ANC in Somalia.

Similarly, Uldbjerg et al. (2020) reported that mothers who had perception about the attitude of

the health worker and poor quality of care were less likely to seek for ANC utilization, in a

qualitative study, which investigated factors that hinder ANC use in a rural post-conflict Awach

sub-county, Gulu District, northern Uganda. Moreover, Okedo et al. (2019) assessed the

influential factors for antenatal care utilization in sub-Saharan Africa by Systematic review. The

study reported that good attitude towards ANC utilization made attendance and initiation of

ANC in first trimester more likely.

There is great power in the way people set up their mind and behaviors in relation to

health care seeking

Decision power

Some of the previous studies found a relationship between women’s power for decision

and the pregnancy care seeking. African women have been often perceived to have little

participation in health care decisions, Alemayehu & Meskele (2017) reported that 40.9% of

women’s choices for health care seeking was determined by their partners, in a cross-sectional

study, which intended to assess the contributing influences of decision-making autonomy and

inequalities across diverse socio-cultural contexts, Wolaita and Dawro zones, Southern Ethiopia.

Similarly, Bocher et al (2021) found 44% of women’s decision to utilize pregnant care was

done by their spouses, in a Cross-sectional study, which examined the social and financial

aspects that deter or enable the uptake of ANC in Somalia. Also, Steele et al. (2021) showed that
women who had no autonomy to make choices regarding their health seeking were less likely to

attend ANC services, in a community-based mixed study, which aimed to categorize ANC

turnout patterns and determinants for attendance amongst Bakiga and Native Batwa women in

Kanungu District, Uganda.

The power for decision making regarding health care seeking for ANC might be

attributed to some cultures that believe that men are the family heads and should make all

decisions for their families.

Social Support

Social Support was found to be associated with ANC utilization regarding various

previous studies. Uldbjerg et al. (2020) indicated that lack of support from the husband was a

barrier to seek for health care services, in a qualitative study, which investigated factors that

hinder perceived barriers to ANC use in a rural post-conflict Awach sub-county, Gulu District,

northern Uganda. In agreement, Okedo et al. (2019) reported that women who had no partner’s

support impacted their overall uptake, timing and frequency of antenatal visits in a negative way,

in Systematic review which, assessed the influential factors for antenatal care utilization in sub-

Saharan Africa. similarly, Rurangirwa et al (2017) reported that mothers who had poor social

support were 1.71times more likely not use ANC services, in a cross-sectional design that

examined the determinants of poor utilization of antenatal care services among newly delivered

women in Rwanda.

Some of the studies used qualitative approach, which limit generalization of their

findings. However Social support might help women to have a positive view of health care

seeking during pregnancy, making them to attend ANC services.

 Media exposure

Exposure to mass media was found to be associated with ANC utilization according to

various prior studies. Islam et al (2022) indicated that women who had contact with media had

2.47folds more chances to attend ANC services than their counter parts, and media access was a

key significant factors, in the study done Bangladesh and 28 other low-and middle-income

countries, which assessed influential factors for health care use during pregnancy among

expectant mothers to realize the Sustainable Development Goals for maternal mortality ratio by

2030. Compatibly, Okedo et al. (2019) showed that mothers that got exposed to media had more

chances to seek for pregnancy care in their first trimester, in a Systematic review, which aimed to

assess the influential factors for antenatal care utilization in sub-Saharan Africa. Moreover,

Chilot et al (2023) showed that women who had access to media were significantly associated

with ANC uptake, in a multi-country analysis that used DHS data, to determine the Pooled

prevalence and determinants of antenatal care visits in countries with high maternal mortality

and morbidity.

Exposure to media might provide more chances for mothers to gain a lot of knowledge

and awareness regarding ANC services, through educational programs. This could increase

women’s access to the health care during pregnancy

Pregnancy related factors

Pregnancy plan

The association between a planned pregnancy ANC utilization was established by earlier

scholars. Basha (2019) reported that readiness for a new pregnancy was a significant factor
associated with the utilization of a minimum of four ANC services, in Ethiopia Demographic

and Health Survey (2016),which examined influential factors for ANC service utilization.

Correspondingly, Tumwizere et al (2023) showed that women who chosen to get extra children

were 0.8 times more likely to seek ANC care compared to their counterparts, in a study that used

data from Uganda demographic and health survey of 2016, which examined factors related to

delayed health care seeking during pregnancy for the initial visit after 12 weeks of pregnancy

among mothers with high parity in Uganda.

On other hand, Okedo et al. (2019) showed that unplanned pregnancy negatively

impacted the overall uptake, timing and frequency of antenatal visits, in a systematic review

study that assessed the influential factors for antenatal care utilization in sub-Saharan Africa. In

the same way, Chilot et al (2023) showed that women that never planned for their conception

were less likely to attend ANC services, in a multi-country analysis that used DHS data, to

determine the Pooled prevalence and determinants of antenatal care visits in countries with high

maternal mortality and morbidity.

Women who intend to conceive may have a positive mind to make decisions to seek for

the ANC care with the aim to get successful outcome of the pregnancy.

Gravida

The number of pregnancies were found to associate with ANC utilization according to

some previous scholars. Islam et al. (2022) indicated that birth order was a predictor for ANC

attendance, in a study carried out in Bangladesh and 28 other low-and middle-income countries

and measured influential factors for health care use during pregnancy among expectant mothers

to realize the Sustainable Development Goals (SDG) for maternal mortality ratio (MMR) by

2030. In the same way, Chilot et al. (2023) found that mothers who were between 2-5 order of
birth, and above 5 and were negatively associated with attend ANC service use, in a multi-

country analysis that used DHS data, which determined the Pooled prevalence and determinants

of antenatal care visits in countries with high maternal mortality and morbidity. Moreover,

Tessema et al. (2021) showed that birth order was a significant factor for endorsed ANC uptake,

in a meta-analysis of DHS data from 2006 to 2018, which aimed to establish the pooled

prevalence and determinants of recommended ANC utilization in Sub-Saharan Africa.

The birth order might expose mothers to various risks related to pregnancy or benefits on

previous pregnancies that could prompt them to attend ANC services.

Pregnancy Complications

Some of the previous studies found a relationship between Pregnancy Complications and

the pregnancy care seeking. Ali et al. (2020) showed that women experienced previous infertility

treatment or miscarriages were more likely to achieve appropriate ANC initiation compared to

their counterparts, in a baseline cross-sectional study, which intended to a baseline cross-

sectional to define the forms of ANC utilization and factors associated with appropriate ANC

initiation in the United Arab Emirates for the first time. Similarly, Chilot et al (2023) showed

that women that experience complications with their previous pregnancies, were positively

associated with ANC attendance, in a multi-country analysis that used DHS data, to determine

the Pooled prevalence and determinants of antenatal care visits in countries with high maternal

mortality and morbidity.

However, Okedo et al. (2019) found that women that had previous pregnancy

complications negatively impacted the overall uptake, timing and frequency of antenatal visits, in

a systematic review that assessed the influential factors for antenatal care utilization in sub-

Saharan Africa.
 The authors have contradicting information that require further examination. However,

women with previous pregnancy complications might yarn for ANC care for fear of getting the

same issues such that attain successful outcome. While some women that experience some

compilations might lose hope in the success of the pregnancy such as women who suffer

infertility for a number of years may stay in without seeking for ANC due to several failures to

conceive in many trials leaving them in lost hope.

The Health facility factors

Distance

Distance to health facility is one of the associated factors to health care attendance among

expectant women that was reported by earlier researchers. Aziz et al .(2020) indicated that

mothers that resided in a shorter distances less than 5 km were 1.21 times more likely to attend

ANC services than their counterparts, in a community-based case-control study, which aimed to

assess the relationship between road network distance from a ANC clinic and Health care

attendance during pregnancy amongst women between 15-49years old, in a community-based

case-control study, which assessed the relationship between road network distance from a ANC

clinic and Health care attendance in pregnancy amongst ladies of age group from 15-49years in

Thatta Pakistan. In agreement, Dusingizimana et al. (2023) showed that distance to the health

service facility was a predictor for attending the 4 recommended ANC visits, in a cross-sectional

study, which explored the determinants for attaining the endorsed 4 ANC visits among expectant

women in Rutsiro district, Western province of Rwanda. Consistently, Okedo et al. (2019)

indicated that ANC uptake reduced as there was increase in distance to heath facility, in a by

Systematic review, which assessed the influential factors for antenatal care utilization in sub-

Saharan Africa. Moreover, Bocher et al (2021) showed that distance to health centers as a key
issue for non-use of ANC, in a Cross-sectional study, which investigated the social and financial

aspects that deter or enable the uptake of ANC in Somalia.

Contrary, Ahinkorah et al. (2021) reported that distance to the health facility never

affected women in their ANC seeking, in a systematic review, which assessed hindering factors

to ANC attendance among pregnant women, in sub-Saharan African countries. Additionally,

Gebeyehu et al. (2022) showed that distance to the health facility was not a hinderance to access

the initial ANC, in a study that used DHS data of 2008–2019, which examined the sum of pre-

birth care visits and linked influences amongst women between 15-49years in Sub-Saharan

Africa.

There exists discrepancy information among the authors, so there is a need to carry out

more investigations. However, women that leave closer to health facilities may find it cheaper to

reach health facilities, in terms of easy transportation. On the other hand, if people realize the

value of ANC utilization may continue to seek for the services however much the distance to

health service center is far from their homes.

Health providers’ attitude

Health providers’ attitude has showed to affect women’s ANC utilization regarding

previous scholars. Steele et al(2021) showed that mothers who experienced poor

communications with medical workers were less likely to achieve the recommended ANC visits,

in a community-based mixed research, which aimed to categorize ANC turnout patterns and

determinants for attendance amongst Bakiga and Native Batwa women in Kanungu District,

Uganda. Similarly, Kilowua, & Otieno (2019) showed that poor medical workers attitude

reduced uptake of ANC, in a study that examined the factors affecting uptake of Antenatal Care

by a mixed method of data collection, among women of reproductive age in Kisumu County,
Kenya. While, Guma (2022) found that good attitude of medical workers contributed to uptake

of ANC service utilization, in a cross-sectional descriptive study, which assessed antenatal care

service utilization among pregnant mothers in Parabek refugee settlement in Parabek Ogiri sub-

county, Lamwo district.

The poor attitude of health workers might affect women’s sense of security and interfere

with their freedom to open up their health problems, this rendering it no value seeking ANC

services.

Community health workers

The presence of community workers was found to influence the health care attendance

for pregnant women. Wolderufael et al. (2018) showed that availability of health extension

workers as the main predictor factors for ANC attendance, in a cross-sectional mixed study, in

Menit-Shasha Woreda Bench Maji zone, southwest Ethiopia. Additionally, Chaurasiya et al.

(2019) found that women that were in contact with Female community Health Volunteers were

significantly associated with ANC attendance, in a cross-sectional study, which investigated the

rate and factors associated with the pregnant care service use among the utmost deprived cultural

group Dalit population, kin Mahottari district. In the same way, Chilot et al. (2023) found that

high community education was positively associated with optimal ANC visits, in a multi-country

analysis that used DHS data of 27 countries that experience the highest mortality rate.

The availability of community extension workers might provide more sensitization about

the value of ANC services to women at community level, which increase awareness and

encourage mothers to seek for ANC services, Additionally, community heath extension workers,

may help to build a good rapport with mothers that enable them to freely seek for ANC services.
 CHAPTER THREE

METHODOLOGY

Introduction

This chapter highlights the methodological features and procedure for conducting the

study. These include the research design, location of the study, population of the study, Data

source sampling techniques, data collection methods, Validity of the study tools, Ethical

considerations, reliability of the study data processing and analysis. The operational structures

are of high interest in this section.

Research Design

The research design will be a health facility-based cross-sectional study combining both

qualitative and quantitative methods. with structured observation will be conducted in selected

healthcare facilities Jowhar District, Somali. The investigator will not provide any intervention

but will measure the outcome and the exposures in the study participants at the same time and

study their association (Acharya et al., 2012). This study will adopt quantitative research

approached (Amin, 2005).

Locale of the Study

Bidi Bidi refugee camp is located in Yumbe District of north western Uganda and is one of the

largest camps of its kind in the world. It was built in 2016 to provide shelter for refugees fleeing

the civil conflict in South Sudan. The camp covers an area mass of 250 square kilometres and

houses over 270,000 refugees. The district is bordered by South Sudan to the north, Moyo
District to the east, Adjumani District to the southeast, Arua District to the south, Maracha

District to the southwest and Koboko District to the west.

The study area selection is based on the 2 studies, Okedo et al. (2019) showed 40% of women

in Yumbe district attended 4vists and above ANC, in Uganda Demographic and Health Survey

of 2016, this proportion of 40% is showed a gap of 50% to the global and national target for

2030 and 2025 respectively. Similarly, Neta (2018) indicated that only 25.3% of ANC utilization

of four visits, by cross sectional study, which assessed the factors influencing the utilization of

Maternal Health Care Services among mothers between 15-45 years in Bidi bidi refugee camp.

These studies showed a general low uptake of ANC services among women of reproductive age,

and they are silent about the most at-risk group for mortality and morbidity, age between 15-24

years. Moreover, Yumbe district recorded 343,655teenage pregnancies in 2020, which is a is a

major contributor to maternal mortality, the key indicator of the health and well-being of women

around the world. In 2020, almost 95% of all maternal deaths occurred in low and lower middle-

income countries, and the MMR in low-income countries was 430 per 100,000 live births.

Therefore, there the current study intends to investigate the prevalence of4 ANC visit utilization

among the young women between 15-24 years of age in Bibidi Refugee Camp, Yumbe District,

Uganda.

Population and Target Population of the Study

The study population will consist of All mothers attending ANC visits in the selected

health centers in Bidibidi Refugee Camp, aged between 15-24 years of age and who will have

consented to participate. Bain (2022) reported 55.2% of ANC utilization among young women in

Sub-Saharan Africa, in a cross-sectional study, which intended to examine prevalence of

maternal healthcare utilization among young women aged 15–24 years. Young women are more

vulnerable for maternal mortality, face higher risks of complications during pregnancy and

childbirth than older women (UNICEF, 2019). Maternal mortality is the death of a woman while

pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of

the pregnancy, from any cause related to or aggravated by the pregnancy or its management

(WHO). According to UNICEF, in 2019, adolescents aged 15–19 years in low- and middle-

income countries (LMICs) had an estimated 21 million pregnancies each year. Moreover,

Uganda Bureau of Statistics (UBOS) reported 17.2 % of maternal mortality of young mother

between 16-19years, in Uganda. The maternal mortality ratio (MMR) for Uganda was estimated

at 336 deaths per 100,000 live births in 2018. Yet the study done in Bidibidi Refugee camp

reported a very low ANC utilization of 25.3% in the general population of women in

reproductive age Neta (2018), but never examined the specific group of young women that are

more at risk for mortality and morbidity. Therefore, the current study intends to investigate the

prevalence and 4ANC visit attendance among the young women between 15-24 years of age, in

Bidibidi Refugee camp, Yume District, Uganda.

Sample Size

For sample size calculation of unknown population size by (Taro Yamane, 1967) will be

used, formula: n= z2. [p*q]/d2), which is used to calculate the sample size of a qualitative

variable in prevalence or cross-sectional studies.

In this formula, n = the sample size, P is the estimated proportion of the study variable or

construct based on previous studies or pilot studies (70%), q = 1-P (30%), and d is the margin of

error (5%).
z = the Z-score or a standard normal deviate corresponding to (100%, α/2%), where α refers to

the significance level or the probability of making a type I error. The Z score for different

significance levels is 1.96 for 5%, 1.28 for 10%, and 2.58 for 1%. After adding a hypothetical

value to cater none responses, the sample size will be 323. The number of expectant young

women to be selected from each healthcare facility by purposive and systematic rando sampling

will be used. At each study facility site, potential participants will be selected systematically. A

list of the ANC visit attendees on a clinic day will be prepared and a number assigned for each

attendee who will be young and in her 3rd trimester will be purposely and randomly picked.

Data Collection Methods and Instruments

The study will collect primary data from eligible participants by structured

questionnaires A questionnaire survey is a method of data collection containing a series of

questions and providing spaces as well as options to be attempted by the respondents themselves

(Yin and Robert, 2003). The questionnaire surveys will include close-ended and open-ended

questions as well as leading questions pertaining the research variables and objectives. The

questionnaire will include questions about social demographic, pregnancy related and health

facility factors.

Validity and Reliability

Prior to data collection, the validity and reliability of the questionnaire will be

ascertained. The validity of the questionnaire will be confirmed when the supervisors’ check the

relevance of each question in providing answers to the study objectives, and appropriate

modifications will be made. Then, a content validity index C.V.I will be computed using the

formula:

C.V.I = Number of relevant items in the instrument

 Total number of items in the questionnaire

The instrument will be considered valid when the CVI is 0.94, that will be greater than 0.6 as

recommended by (Amin, 2005).

The reliability of the questionnaire will be ensured after a pilot study that will be done on 20

respondents in one of the non-study areas, which will not be the study site, and the respondents

in the pretest of the questionnaire will not be part of the real data collection. This aims at

obtaining responses expected from the participants in the final study. Expectant young women

(20) will be identified and each will be asked to respond based on the content of the

questionnaire. While completing the questionnaire, participants will be asked to think aloud and

share what come to their mind on each question. They will be asked whether they will have

understood the questions and which questions attracted a sense of discomfort and what options

they could provide. Thereafter, changes in the question phrasing and structuring will made.

Data Collection Procedure

The investigator will ensure that all the required regulatory requirements prior data

collection. The letter from the Dean of school of Graduate Studies (Bugema University) will be

obtained and followed by IRB approval letter. This will be presented to the administrator at the

study sites in Bidibidi Refugee Camp, who will grant permission for the investigator to access

the research sites

The investigator of this study will follow all required integrity throughout the research

process. The researcher will ensure voluntary participation and confidentiality of the participants,

follow all the ethical guidelines that include getting informed consent from the respondents

before any study procedure, ensuring that respondents are aware of their voluntary participation

and freedom to withdraw from participation at any time. Moreover, anonymous questionnaire
forms will be used during the data collection and their custody will be safeguarded. The

researcher will maintain ethical considerations prior and after data collection.

Data Analysis

After data collection, the raw data collected will be systematically organized to facilitate

analysis. Completed questionnaires will be, coded, cross examined for completeness and

consistency, Descriptive statistics will be used in data analysis. Data to be obtained from open-

ended items in the questionnaires will be categorized according to themes relevant to the study

and will be presented in a narrative form using descriptions. Statistical Package for Social

Scientists (SPSS) will be used in data Analysis, descriptive statistics will be generated. In this

study, quantitative data from the questionnaires will be analyzed by use of frequency counts and

frequency tables derived from the responses to the research questions. multiple binary logistic

regression model and multivariate analysis will be used to determine the existing relationship

between social demographic, pregnancy and health facility factors with the utilization of 4 ANC

visits among young women in Bidibid Refugee Camp, Yumbe district. Results will be reported

as crude odds ratio (COR), adjusted odds ratio (AOR), 95% confidence interval(CI) and p-values

less than 0.05 will considered statistically significant.

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