FACTORS PREDICTING TIMELY INITIATION OF ANTENATAL CARE ...

FACTORS PREDICTING TIMELY INITIATION OF ANTENATAL CARE AMONG

PREGNANT WOMEN IN BINH DINH PROVINCE, VIETNAM

NGUYEN THI LE THUONG

A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS

FOR THE MASTER DEGREE OF NURSING SCIENCE

(INTERNATIONAL PROGRAM)

FACULTY OF NURSING

BURAPHA UNIVERSITY

AUGUST 2015

COPYRIGHT OF BURAPHA UNIVERSITY

ACKNOWLEDGEMENT

The success of this thesis was a result of the collaborative and supportive

effort from many people. First and foremost, special thanks and sincere gratitude goes

to my major advisor, Associate Professor Dr.Wannee Deoisres for giving me

guidance, support and valuable suggestion throughout my study. In addition, my

heartfelt thanks to the contribution of Assistant Professor Dr.Usa Chuahorm, my

co-advisor.

I wish to extend my sincere thanks to Dean of Faculty of Nursing, Burapha

University, Thailand, Associate Professor Dr.Nujjaree Chaimongkol and to the

Principal of Binh Dinh Medical College, Vietnam, Dr Tran Dinh Dat for giving me

a chance to study Master of Nursing Science Program in Thailand. My deep gratitude

goes to Dr.Nguyen Doan Tu, Director of Health Care in South Central Coast Region

Project, Vietnam Ministry of Health and MPU scholarship for financial support for the

Master study in Thailand.

Sincere thanks are given to the Director, the head midwife, and the midwives

at the Antenatal Clinic of Quy Nhon General Hospital, Binh Dinh Province, Vietnam

by allowing data collection at the Hospital and their help during this time. Thanks also

to the pregnant women who voluntarily participated in the study. Certainly, special

thanks to the officers of Graduate Office of Faculty of Nursing, Burapha University,

Thailand and also thanks to the staffs of the Health Care in South Central Coast

Region Project, Vietnam Ministry for support, concern, and care during my study time

in Thailand.

Exceptional cordial thanks to all my classmates, Vietnamese and Thai

students in the Nursing Dormitory, all my friends and colleagues in Vietnam, who

have been walking beside me throughout my study time.

Finally, the greatest love and thanks to my husband, my son, and my

daughter for their understanding, sympathies, encouragement, and support which help

me pursue and complete my study successfully. Gratitude goes to my parents, sibling

and relatives, who support me during the study time in Thailand.

Nguyen Thi Le Thuong

iv

56910108: MAJOR: NURSING SCIENCE: M.N.S.

KEY WORDS: PREGNANT WOMEN/ ANTENATAL CARE/ TIMELY

INITIATION OF ANTENATAL CARE

NGUYEN THI LE THUONG: FACTORS PREDICTING TIMELY

INITIATION OF ANTENATAL CARE AMONG PREGNANT WOMEN IN BINH

DINH PROVINCE, VIETNAM. ADVISORY COMMITTEE: WANNEE

DEOISRES, Ph.D., USA CHUAHORM, Ph.D. 91 P. 2015.

The objectives of this predictive correlation study were to determine the

timely initiation of antenatal care (ANC) and to examine the influence of maternal

age, maternal education, parity, knowledge about ANC, and family support for

pregnancy on timely initiation of ANC among Vietnamese pregnant women.

A random sample of 109 pregnant women visiting Antenatal Clinic from February to

March, 2015 at Quy Nhon General Hospital in Binh Dinh Province, Vietnam were

recruited in the study. The self-report questionnaires were used for data collection.

The data were analyzed by using descriptive statistics, Pearson Chi-Square, Point

Biserial, and multiple logistic regression.

The study results showed that the average gestational age for the first ANC

of the respondents were 11.85 weeks (SD = 5.34) and more than two thirds of the

respondents started ANC within 12 weeks (72.5%). Pregnant women with 18-35 years

old were 47.95 times more likely to initiate ANC after 12 weeks compared to women

older than 35 years old (AOR = 47.95, 95% CI = 3.80-605.74, p = .003). Women’s

knowledge about ANC (AOR = .24, 95% CI = .10-.57, p = .001) and family support

for pregnancy (AOR = .73, 95% CI = .57-.95, p = .020) were found to be predictors of

early initiation of ANC. These findings suggest that we should pay more attention to

pregnant women 18-35 years old and to increase knowledge about ANC for them.

Antenatal care needs to enlarge and encourage the attention of all members in family,

should not only focus on pregnant women.

v

CONTENTS

Page

ABSTRACT ............................................................................................................ iv

CONTENTS ............................................................................................................ v

LIST OF TABLES .................................................................................................. vii

LIST OF FIGURES ................................................................................................ viii

CHAPTER

1 INTRODUCTION ......................................................................................... 1

Background and significance ................................................................ 1

Research objectives ............................................................................... 6

Research hypothesis .............................................................................. 6

Scope of the study ................................................................................. 6

Conceptual framework .......................................................................... 7

Definition of terms ................................................................................ 9

2 LITERATURE REVIEWS ............................................................................ 11

Concept of ANC and timely initiation of ANC .................................... 11

Factors related to timely initiation of ANC ......................................... 17

Conclusion ............................................................................................ 25

3 RESEARCH METHODOLOGY .................................................................. 27

Study design ......................................................................................... 27

Setting of the study ............................................................................... 27

Population and sample .......................................................................... 28

Research instruments ............................................................................ 29

Translation process ............................................................................... 31

Validity and reliability of the instruments ............................................ 32

Protection of human subjects ................................................................ 33

Data collection procedures .................................................................... 33

Data analysis ......................................................................................... 34

4 RESULTS ...................................................................................................... 35

Part 1 Sample characteristics and description of independent variables 35

vi

CONTENTS (CONT.)

CHAPTER Page

Part 2 Timely initiation of ANC .......................................................... 39

Part 3 The relationship between predisposing characteristics, enabling

resource with timely initiation of ANC ............................................... 40

Part 4 Factors predicting timely initiation of ANC .............................. 41

5 CONCLUSION AND DISCUSSION ........................................................... 43

Summary of the study findings ............................................................ 43

Discussion ............................................................................................ 44

Implications of the study ....................................................................... 50

Limitations of the study ....................................................................... 50

Recommendations for future research ................................................. 51

REFERENCES ....................................................................................................... 52

APPENDICES ........................................................................................................ 61

APPENDIX 1 ................................................................................................. 62

APPENDIX 2 ................................................................................................. 65

APPENDIX 3 ................................................................................................. 72

APPENDIX 4 ................................................................................................. 78

APPENDIX 5 ................................................................................................. 87

APPENDIX 6 ................................................................................................. 89

BIOGRAPHY ......................................................................................................... 91

LIST OF TABLES

Tables Page

1 Frequency and percentage of personal information and predisposing

characteristics of the respondents ............................................................... 36

2 Range, mean, and standard deviation of knowledge about ANC of the

respondents ................................................................................................. 37

3 Frequency and percentage of each item of knowledge about ANC

of the respondents ....................................................................................... 38

4 Range, mean, and standard deviation of family support for pregnancy

of the respondents ....................................................................................... 39

5 Mean, standard deviation, frequency, and percentage of timely initiation

of ANC ........................................................................................................ 39

6 Pearson Chi-Square and Point-Biserial correlation coefficient between

factors and timely initiation of ANC .......................................................... 41

7 The association between significant factors and timely initiation of ANC

of the respondents ....................................................................................... 42

LIST OF FIGURES

Figures Page

1 The research framework of the study .......................................................... 8

2 Andersen’s Behavioral Model of Health Services Use ............................... 18

3 Translation process .................................................................................... 32

CHAPTER 1

INTRODUCTION

Background and significance

According to the World Health Organization [WHO] (2014 a), maternal and

neonatal mortality rates during pregnancy and childbirth significantly reduced in the

recent years; maternal deaths worldwide had dropped by 45 %, from 523,000 in 1990

to 289,000 in 2013 and nearly 99 % of these deaths occurred in the developing

countries. Complications during pregnancy and childbirth were the leading cause of

death and disability among women of reproductive age in developing countries

(WHO, 2005 b). The statistics in 2013 showed that maternal mortality ratio in the

developing countries was 230 versus 16 per 100,000 live births in the developed

countries. Maternal mortality ratio differed from one country to another, between

women having high and low income, and between women living in rural and urban

areas (WHO, 2014 a).

Vietnam is a developing country, located in Southeast Asia with population

about 90,796,000 people and the number of births each year is about 1,642,000

(WHO, 2014 b). The maternal and infant mortality rates have decreased in the recent

years. Maternal mortality has reduced by approximately two thirds, from 233 per

100,000 live births in 1990 to 69 per 100,000 in 2009, and 64 per 100,000 live births

in 2012 (United Nations Development Programme [UNDP], 2013). Seventy six

percent of maternal mortality was the direct causes and 23.7 % was the indirect

causes, most of the direct causes were related to pregnancy and childbirth (WHO,

2005 a).

The Millennium Development Goal 5 by WHO aims at reducing the

maternal mortality ratio by three quarters, between 1990 (523,000) and 2015.

The Government of Vietnam and Vietnam Ministry of Health had set up the target of

the Millennium Development Goals [MDGs] in order to reach the MDGs of WHO;

the aim is to reduce the number of maternal mortality to 58.3 deaths per 100,000 live

births by 2015 (UNDP, 2012).

Pregnancy is one of the most important periods in the life of a woman,

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a family and society. Extraordinary attention is therefore given to antenatal care by

the health care systems of most countries (WHO, 2003 b). If a mother dies while

giving birth or during pregnancy, this will let her family and community suffer, and

children often face higher risks of poverty, neglect, and mortality (WHO, 2005 b).

To prevent poor outcomes of pregnancy, as well as reduce the maternal mortality,

antenatal care includes some of the most important chain of actions to detect problems

in early pregnancy. In addition, in order to minimize the risk factors contributing to

the deaths of mothers, every country needs to have a strategy for continuum of

mother's health care and assure the quality of care, especially managing complications

during pregnancy and childbirth (WHO, 2005 b). One of the strategies for reducing

maternal mortality in Vietnam is provision of antenatal care (ANC) (Vietnam

Ministry of Health [VMOH], 2003).

Numerous studies showed that the timely initiation of ANC is related to

early detection of high risk pregnancy. Moreover, it also prevents poor outcomes of

pregnancy including premature birth, low birth weight, congenital malformations,

congenital infections, neonatal tetanus, preeclampsia, and anemia (Hollowell et al.,

2012). The women who initiated their ANC in the first trimester of pregnancy

maximize the benefits of screening for complications and monitoring fetal and

maternal health. Pregnant women who initiated their ANC later than the first trimester

showed poorer outcomes such as low birth weight and preterm birth (Low et al.,

2005). Early booking and adequate ANC were acknowledged to be an effective

method of preventing adverse outcomes in pregnant women and their babies.

Therefore, initiation of ANC is becoming one of the most important components of

the ANC and this should happen early.

According to American College of Obstetricians and Gynecologists [ACOG],

the women with uncomplicated pregnancies should book the initial visit at 8-10 weeks

of pregnancy, then every 4 weeks until the 28th week of pregnancy, continuing every

2-3 weeks until 36 weeks gestation, and then once a week until delivery (ACOG,

2012). The new ANC model recommended from the WHO includes five ANC visits

with four visits during pregnancy and one visit in postpartum period. The first visit

should occur in the first trimester, followed by the second visit occurring at 26 weeks

of gestational age, the third visit at week 32, and the final visit in pregnancy is the

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fourth visit occurring between 36-38 weeks. The fifth visit is the postpartum visit

within the first week after delivered (WHO, 2002). The ANC can vary in number of

visits, timing of visit, and the service contents in the visits based on their own national

ANC recommendations. In Vietnam, the Ministry of Health recommended at least

three ANC visits for uncomplicated pregnancies, one in each trimester with the first

visit occurring in the first trimester (VMOH, 2003).

According to the WHO statistics on ANC from 2006-2013, the percentage of

women attending four or more visits was much lower for the low income countries;

the global rate was 56 % but only 38 % of pregnant women in the low income

countries attended four or more ANC visits (WHO, 2014 c). The figures from the

Vietnamese Committee for Population, Family and Children [VCPEC] (2002) showed

that a significant number of Vietnamese women did not utilize ANC adequately.

Eighty seven percent of Vietnamese pregnant women attended at least one visit during

the pregnancy, of which 74 % of women made their first visits when they were almost

6 months pregnant. Only 29 % of the pregnant women in Vietnam had four or more

ANC visits. In addition, a study concluded that ANC utilization was low in Vietnam,

with 71 % of women having at least one ANC, 29 % of women not having any ANC.

Fifty one percent of women attended ANC within 4 months of pregnancy, and 41 % of

women entered ANC within 3 months (Trinh, Dibley, & Byles, 2006). More recently,

in the compendium of research on reproductive health in Viet Nam from United

Nations Fund for Population Activities [UNFPA] (2012) concluded that most of

pregnant women in Vietnam had only one visit; the report also showed that the first

ANC visit in their first trimester ranged widely among studies, from 50 to 80 %.

Binh Dinh Province is located in South Central Coast of Vietnam, and is the

key economic development region of Central Vietnam with the area of 6,050 km2.

According to the General Statistics Office of Vietnam [GSVN] (2011), Binh Dinh had

a total population of 1,497,300 people, equal to 247 people per km2 and the birth rate

in 2011 was 16.7 and death rate was 8.0 per 1000 population. A survey conducted by

the United Nations in 2007 in Binh Dinh found that the rate of antenatal checkups in

the highland was still low, only approximately 40 % (UNFPA, 2008). Binh Dinh had

made significant efforts in the past decade in the field of health care for mothers and

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children, gained encouraging results including infant mortality rate decreasing from 40

% in 2003 to 14 % in 2010 (GSVN, 2011).

Enhancing health care during pregnancy was one of the effective methods to

reduce poor outcomes for mothers and fetus. Andersen (1995) explained that people

used health service depending on three factors. The first was predisposing

characteristics including demographic factors, social structure, and health beliefs.

The second was enabling resources including personal/ family and community

resources. The last was need factors including perceived individuals and evaluated

need by medical care providers. The literature review showed that multiple factors

related to starting antenatal visit of a woman. However, this study focused on factors

significantly involving timely initiation of ANC with uncomplicated pregnancy.

Maternal age, maternal education, parity, and knowledge about ANC of mother were

classified as the predisposing factors; support from family for pregnancy was the

enabling factor in this study.

Based on literature review, maternal age and education was associated with

the starting of antenatal visit. Pregnant women in childbearing age tended to have

early seeking of ANC (Belayneh, Adefris, & Andargie, 2014). Teenage women were

starting antenatal visit later than other groups, as did by women who were more than

30 years old (Trinh & Rubin, 2006). Early starting ANC was most common in women

who were between 20-24 years old (Onoh et al., 2012). A study by Tayie and Lartey

(2008) showed that women who graduated high school or higher were booking ANC

earlier than women who had lower education. Another study also indicated that

mothers with formal education started antenatal visits earlier than mothers with no

formal education (Belayneh et al., 2014).

The relationships of the parity and knowledge of pregnant women about

ANC on timing of booking ANC showed in numerous studies. Parity significantly

influenced on the timely initiation of antenatal visits. A study by Nwagha and

Anyaehie (2008) indicated that primigravida women initiated booking later than

multigravida. Another study showed that second time mothers were more earlier

booking than other groups and the latest booking were women with 4 children (Onoh

et al., 2012). Moreover, knowledge of pregnant women about ANC plays an important

role in the early initiation of ANC. A previous study reported that more than one third

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of women in the study believed that the second trimester was the ideal gestational age

for booking. Therefore, 83.1 % of pregnant women in this study booked after the first

trimester and the mean gestational age for the first visit was 24.33 weeks (SD = 5.52)

(Onoh et al., 2012).

Most women who had the family support for pregnancy sought antenatal

visit earlier than those who lacked of family support (Secka, Helleve, Storeng, &

Toure’, 2010; Gross, Alba, Glass, Schellenberg, & Obrist, 2012). Support from

husbands/ partners positively influenced on booking visit, women who lacked support

from husband were later in booking ANC than those who were received these support

(Gross et al., 2012). Another study showed that pregnant women who received

support from mothers and sisters also started ANC visits early (Phafoli, Aswegen, &

Alberts, 2007).

The early antenatal visit was acknowledged to be an effective method of

preventing adverse outcomes in pregnant women and their infants. However, there

were a lot of pregnant women attending ANC late, including Vietnamese women

(UNFPA, 2012). The reason might be as following, traditionally, the typical family

structure in Vietnam is extended family with male-dominated. Confucian norms have

restricted the autonomy of women and reduce their ability to make independent

decisions about their pregnancy care. Therefore, other members of the family, as

mothers can make decisions for women on maternity care based on their experience.

It could be a barrier to women's access to care services ANC in recommended time.

There were many studies and research evidence around the world on initiation of

ANC; several studies in this field from the developing countries including Nigeria,

Uganda, and Ethiopia and the developed countries including New Zealand and Wales.

However, in Vietnam, little has been known about the ANC, especially studies

focusing on factors related to timely initiation of ANC. There were some previous

studies on ANC done in Southern (Trinh, Dibley, & Byles, 2007; Nguyen, Deoisres,

& Sangin, 2013) and Northern Vietnam (Tran, Gottvall, Nguyen, Ascher, & Petzold,

2012). In central of Vietnam there were few studies about ANC. In addition, the

results of this study indicated factors affecting the timing of first antenatal visit in

Vietnamese women; and based on these results the nurses/ midwives and health care

providers have appropriate interventions in order to improve the timing of the first

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ANC of pregnant women. This in turn prevents adverse outcomes for mothers and

fetus due to delayed ANC. Research in this field not only help the nurses improve

ANC for pregnant women in Vietnam but also contribute to the existing body of

knowledge nurses and midwives across the world.

This study was conducted in Binh Dinh Province, Vietnam. The results of

this study are beneficial to the nurses/ midwives, obstetricians, and other health care

providers. This help them identify factors that influence pregnant women in starting

antenatal care early or late, which help them develop interventions in improvement the

timely utilization of ANC more effectively. In addition, the results from this study

contribute to improve maternal and fetal health. In addition, the findings of the study

can support for the future studies and serve as a baseline data for ANC, especially,

studies in Vietnam.

Research objectives

1. To determine the timely initiation of ANC of pregnant women in Binh

Dinh Province, Vietnam.

2. To examine the influence of predisposing factors (maternal age, maternal

education, parity, knowledge about ANC) and enabling resource (family support for

pregnancy) on timely initiation of ANC among pregnant women in Binh Dinh

Province, Vietnam.

Research hypothesis

The selected factors including maternal age, maternal education, parity,

knowledge about ANC, and family support for pregnancy can predict the timely

initiation of ANC among pregnant women in Binh Dinh Province, Vietnam.

Scope of the study

This study was conducted with 109 pregnant women, who came to antenatal

visit in Binh Dinh Province, Vietnam from February to March, 2015. In the present

study, the dependent variable was timely initiation of ANC which was categorized

into two groups: ≤ 12 weeks and > 12 weeks. The independent variables were

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predisposing factors (maternal age, maternal education, parity, knowledge about

ANC) and enabling resource (family support for pregnancy).

Conceptual framework

The conceptual framework of this study is based on the Andersen’s

Behavioral Model of Health Services Use. This framework was first developed in

1968 and has since then gone through six phases of major revisions in the model

(Andersen, Rice, & Kominski, 2007). Andersen developed the Behavioral Model of

Health Services Use in an attempt to explain why individuals use health services.

More recently, the researchers have relied heavily on this model for guidance when

investigating the use of social services. It suggested that people's use of health service

was a function of their predisposition to use services, factors which enable or impede

use, and their need for care (Andersen, 1995). There were numerous studies using this

model as the guideline to examine factors affecting to early or late initiation of ANC

of women (Trinh & Rubin, 2006; Beeckman, Louckx, & Putman, 2011; Belayneh

et al., 2014) in the world.

Firstly, in this model, predisposing characteristics were the social-cultural

characteristics of individuals that exist prior to their illness. It included the

demographic characteristics, social structure, and health beliefs. The demographic

characteristics were age and gender. They presented biological imperatives suggesting

likelihood that people will need health services. Social structure characteristics were

marital status, education, occupation, ethnicity, and social relationships (e.g., family

status). Social structure was measured by a broad array of factors that determine the

status of a person in community, ability to cope with presenting problems and

commanding resources to deal with these problems. Mental factors in terms of health

beliefs were attitudes, values, and knowledge related to health and health services

(Andersen, 1995). Secondly, enabling resources were the logistical aspects of

obtaining care. It facilitates the use of services including personal and family

characteristics, income level, insurance coverage, access to transportation, and

awareness of service. At the community level, enabling characteristics included the

availability of the service and the distance to the service (Change, Karen, & Linda,

1998). Finally, service needs were the immediate cause of health service use from

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functional and health problems that generate the need for health care service. It can be

either an individual’s subjective assessment of need or an evaluated need provided by

a professional.

In this study, the researcher used Andersen’s Behavioral Model of Health

Services Uses to guide the study. Based on the model, predisposing characteristics

include demographic, social structure, and health beliefs. In the present study, the

demographic factors are maternal age and parity; social structure is maternal

education; and belief is knowledge about ANC. The enabling resource is the cause of

health service use, which is represented in this study by family support for pregnancy.

However, the service need factor was not included in this study because

pregnant women in this sample were low risk group, who might not differ in term of

their need to visit ANC. Moreover, the ANC service provided in Vietnam usually is

same for low risk group of pregnant women, with no special need for services.

Another reason is this study was conducted in one hospital, where the service for low

risk pregnant women is similar. Thus, no difference in service need factor among this

sample of pregnant women; hence the need factor was not studied in the current study.

Independent variables Dependent variable

Figure 1 The research framework of the study

Timely initiation of ANC

≤ 12 weeks

> 12 weeks

Predisposing characteristics:

Maternal age

Maternal education

Parity

Knowledge about ANC

Enabling resource:

Family support for pregnancy

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Definition of terms

Timely initiation of antenatal care refers to timing of the first antenatal

visit of participant in the present pregnancy. If a woman visits ANC only for

confirmation her pregnancy such for pregnancy test or ultrasound and she does not

using any contents of ANC service, she will not be counted as utilizing ANC. In this

study, the timely initiation of ANC is classified into two groups: early initiation of

ANC (initiation of ANC within 12 weeks of gestational age) and late initiation of

ANC (initiation of ANC later than 12 weeks of gestational age). The gestational age is

defined as the age of embryo/ fetus calculated by the last menstrual period or

ultrasound. It was measured by the Information about Timely Initiation of ANC

Questionnaire developed by the researcher.

Maternal age refers to the number of years the participant had lived from

the date of birth to the date of data collection. It is categorized into three groups: < 18

years old (younger high risk), 18-35 years old (proper child bearing age), and > 35

years old (elder high risk).

Maternal education refers to the highest level of education of participant

who has completed at the date of survey and is classified in to three groups: lower

than high school level, high school level, and higher than high school level.

Parity refers to the number of deliveries of participant. It is classified into

two groups: no parity that refers to a woman who has never delivered before. Parity

one and above are referring to women who had at least one delivery.

Knowledge about ANC refers to participant’s understanding about the

importance of receiving ANC for her health and her baby, especially, initiation of

ANC. It is measured by the Knowledge about ANC Questionnaire modified by the

researcher.

Family support for pregnancy refers to support from family members for

taking care pregnant women. It was measured by the Family Support for Pregnancy

Questionnaire developed by the researcher.

In the present study, family support consists of three dimensions: emotional

support, instrumental support, and informational support (House, 1981). Each

dimension is defined as below:

Emotional support refers to support in the form of empathy, love, caring.

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Instrumental support refers support in the form of tangible aid, including

physical care and financial resources.

Informational support refers to support in the form of advice, suggestions,

problem solving or any others form of information regarding pregnancy care.

CHAPTER 2

LITERATURE REVIEWS

In this chapter, the researcher reviewed concepts related to ANC, timely

initiation of ANC, and factors related to timely initiation of ANC. The information

will be presented follows:

1. Concepts of ANC and timely initiation of ANC

1.1 Definition of ANC and timely initiation of ANC

1.2 Significance of ANC and timely initiation of ANC

1.3 Guideline for ANC

1.4 Timely initiation of ANC in globally

1.5 Timely initiation of ANC in Vietnam

2. Factors related to timely initiation of ANC

2.1 Andersen’s behavioral model of health services use

2.2 Predisposing factors and timely initiation of ANC

2.3 Enabling factors and timely initiation of ANC

Concept of ANC and timely initiation of ANC

Definition of ANC and timely initiation of ANC

Definition of ANC

Antenatal care has been established in the developed countries for a long

time as a process of screening pregnant women with the aim of detecting and thereby

preventing adverse events for maternal and neonatal (Dodd, Robinson, & Crowther,

2002).

Antenatal care (also called prenatal care), the care that women received

during pregnancy, helped to ensure good outcomes for both mothers and fetus (WHO,

2003 b). The WHO (2006) defined ANC as services given to pregnant women by

health professionals. ANC monitors the progress of fetal growth and ascertains the

well-being of the mother and the fetus, ANC provides necessary care to the mother

and identifies complications of pregnancy such as: anemia, preeclampsia and

hypertension etc. in the mother and abnormal growth of the fetus. ANC is the timely

12

management of complications and referral to an appropriate facility if necessary for

further treatment. It also provides opportunity to prepare a birth plan and appropriate

health facilities for delivery (WHO, 2006). The contents of the antenatal visits for a

normal pregnancy were described in three main categories: assessment (history,

physical examination and laboratory tests), health promotion, and care provision

(WHO, 2007). Therefore, ANC as suggested by the WHO consists of services and

education for pregnant women.

Definition of timely initiation of ANC:

The first antenatal visit is the first time pregnant women come to antenatal

clinic to receive caring from health care professionals. The first ANC is defined as the

care to determine the health status of mothers and fetus, estimate the gestational age,

and initiate plans for continuing obstetrical care (Cunningham et al., 2014).

Antenatal care should be initiated as soon as possible. Delayed initiation or

inadequate care may result in women being delayed or ignored for the important

interventions, monitoring, and screening which may benefit mothers' health and that

of their infants (National Institute for Health and Clinical Excellence [NICE], 2008).

The first visit of ANC before 12 weeks gestation is recommended to ensure that

women do not miss benefits of health care for pregnant women and their babies

(Hollowell et al., 2012). In addition, having initial visits early as recommendations

will lead to earlier identification of multiple gestations, potentially improving

pregnancy outcomes (NICE, 2008).

In conclusion, ANC is the regular monitoring of the mother and fetus by a

health care professional during pregnancy through providing information and services

in order to promote maternal and their infants’ health. ANC is also an opportunity to

inform to women about the danger signs and symptoms of pregnancy, which need an

immediate assistance from health care providers. This will in turn achieve healthy

outcomes of pregnancy.

Significance of ANC and timely initiation of ANC

Significance of ANC

ANC is to promote and maintain the health of pregnant women and their

fetus, it aims to establish contact with pregnant women in order to detect and manage

current health problems. It is combination of the information imparting, facilitation of

13

education, screening of abnormalities and complications, ongoing assessment and

care, and preparation for delivery and motherhood. ANC if is used appropriately

would significantly help in identifying and mitigating the risk factors in pregnancy.

Berg and associates identified a fivefold increase in risk of maternal death in

women who received no ANC compared with group who received enough ANC

(Berg, Callagham, Syverson, & Henderson., 2010). Another study also found that lack

of prenatal care was related to more than a twofold increased risk of preterm labor

(Herbst, Mercer, Beazley, Meyer, & Carr., 2003). The data from National Center for

Health Statistics of United States in a study indicated that mothers with prenatal care

has reduced rate of stillbirth of 2.0 per 1,000 against the 14.1 per 1,000 for mothers

with no prenatal care (Vintzileos, Ananth, Smulian, Scorza, & Knuppel, 2002).

Moreover, prenatal care was associated with lower rate of preterm birth, fetal-growth

restriction, post term pregnancy, as well as neonatal death and placenta praevia

(Vintzileos et al., 2002)

Significance of timely initiation of ANC

The WHO recommended that women should initiate their ANC within the

first trimester of pregnancy (WHO, 2002). The first antenatal visit was a very

important visit as it offered the opportunities to collect basic information that will help

form the basis for care during pregnancy. The main purpose of this visit was to obtain

a comprehensive history of pregnancy and confirming the pregnancy, as well as the

identification of risk factors for mother and fetus. Early initiation of ANC was also

early detection and modification of pre-existing medical conditions that may influence

the course and outcome of pregnancy such as cervical incompetence, chronic

hypertension, diabetes mellitus, or severe anemia (WHO, 2002).

Pregnant women who initiate ANC after first trimester may miss the

opportunity to receive lifesaving care because there is the possibility that the signs of

life-threatening complications of pregnancy and childbirth will go unrecognized.

The delay subsequently can lead to delay in reaching treatment and in receiving

adequate treatment (Cresswell et al., 2013). Delayed antenatal clinic attendance

provides little or no time for screening tests of women in early pregnancy,

management of risk factors detected, or timely referral to higher treatment, which may

have a negative impact on both the mother and her fetus (Rowe et al., 2008).

14

Early ANC is one of strategies that will help reducing maternal and neonatal

morbidity and mortality directly through detection and treatment of pregnancy related

diseases, and indirectly through detecting the pregnant women at risk of complications

in order to guide them to the ANC and delivery under appropriate conditions (Banda,

Michelo, & Hazemba., 2012).

Guideline for ANC

The guideline from ACOG (2012) recommended that pregnant woman

should have the first ANC visit at 8-10 weeks of pregnancy (pregnant women who are

at risk for ectopic pregnancies need to visit earlier), next ANC visit at every 4 weeks

for first 28 weeks, then every 2-3 weeks until 36 weeks gestation, and every week

after 36 weeks of gestational age. The goals of visits are detection of risk factors and

pregnancy care (ACOG, 2012). The recommendations from NICE clinical guideline

(2010) were 10 appointments for nulliparous women and 7 for multiparous women,

and ideally, the first appointment at 10 weeks gestation (NICE, 2010).

The new ANC model from WHO recommended four visits during pregnancy

and one visit in postpartum period. The first visit should occur in the first trimester

(within 12 weeks), the second visit should be scheduled close to week 26, the third

visit should take place in or around week 32, the fourth should happen between weeks

36 and 38, and the fifth visit was postpartum visit within the first week after delivery.

The fifth visit is a seldom done in most developing countries (WHO, 2002).

The content of first ANC visit should include physical examination as recording

weight, height, and calculate body mass index and measure blood pressure; perform

urine and blood test; iron and folic acid supplement to all women; and first injection

of tetanus toxoid (WHO, 2007).

The National Guidelines for reproductive health care from Vietnam Ministry

of Health recommended that pregnant women should start ANC visit within 12 weeks

of gestation. They recommended at least three ANC visits during pregnancy, one visit

in each trimester. The contents of first ANC visit included bio-medical assessments:

body height and weight, urine and blood testing; care provision: tetanus toxoid and

folate supplement; and health consultation (VMOH, 2003).

15

Timely initiation of ANC in globally

Measuring the antenatal care adequacy was based on timing of the first

antenatal visit and number of visits (Cunningham et al., 2014). The guidelines for

ANC initiation vary from one nation to another. The United Kingdom and United

States of America followed the schedule of WHO (2002) with the first ANC being

within 12 weeks of gestational age (Adekanle & Isawumi, 2008; Ndidi, & Oseremen,

2010). Meanwhile, there was no guideline in New Zealand for recommended number

and timing of ANC (Low et al, 2005) and many developing countries also did not

have national guidelines. In Nigeria, the recommended commencement of first ANC

visit for uncomplicated pregnancies was within 16 weeks gestation, after 16 week was

referred as late booking (Ifenne & Utoo, 2012; Kisuule et al., 2013), and the

Tanzanian guideline was also the same Nigeria (Gross et al., 2012). The Uganda

clinical guidelines of 2010 gave recommendation for the first visit ranging from 10 to

20 weeks of pregnancy (Kisuule et al., 2013). Whether they had their national

guidelines for the ANC or not, in general, the developed countries had same trend to

provide their first visit in the first trimester only; while, the developing countries’

recommendations varied and the first attendance was much later or between 16-20

weeks of gestation.

A recent research in the United Kingdom by Cresswell et al. (2013) showed

that 62.5 % of participants booked prior to the first trimester, 25.4 % booked between

13 to 20 weeks, and 2.1 % of women booked later than 20 weeks of gestation. In New

Zealand, more than a quarter (26.6 %) initiated ANC later than 15 weeks gestation in

their pregnancy, although almost all of them attended ANC at least once (Low et al.,

2005). An analysis of Demographic and Health Survey from 45 developing countries

in 1999 showed that women in developing countries began ANC later than developed

countries (WHO, 2003 a).

Many studies in developing countries in recent years indicated that starting

ANC in those countries is still delayed. In Uganda, the average gestationla age at first

antenatal care visit was 27.9 weeks (Kisuule et al., 2013). Similarly, a research by

Onoh et al. (2012) had results showing only 16.95 % of women initiate ANC in the

first trimester, with 83.15 % initiating in the second and the third trimesters; the mean

gestational age of booking was 24.33 weeks in that study (Onoh et al., 2012).

16

This index was more alarming in a study in 6 provinces of Rwanda in 2014, where

only 5 % of mothers initiated their ANC in the first trimester (Hagey, Rulisa, &

Pe´rez-Escamilla, 2014); and average gestational age for initiation was 27.9 weeks in

Uganda (Kisuule et al., 2013). According to the Ethiopian Demographic and Health

Survey 2011 report (Central Statistical Agency & Inner City Fund [ICF] International,

2012), only 11.2 % of pregnant women started ANC visit before four months of

pregnancy. In the urban areas, 31.0 % of women sought ANC visit before four months

of gestation and 23.1 % did not have any ANC. The figure for rural women was much

worse, with only 7.7 % starting ANC before 16 weeks and 63.1 % did not attend any

ANC during pregnancy (Belayneh et al., 2014). The Zambia Demographic and Health

survey showed a same trend with Ethiopia; nearly 19 % of mothers initiated their

ANC visit late as fourth month of pregnancy; also, 21 % of mothers in urban and 18 %

in rural districts had their first ANC within four months (Banda et al., 2012).

Overall, pregnant women in the developing countries started antenatal visits

later than in developed countries and also later than their national guidelines.

Especially, in the rural areas of African nations, only a small number of pregnant

women sought antenatal visit as schedule and most of them had the first ANC visit

late or even had no visit during pregnancy.

Timely initiation of ANC in Vietnam

According to Vietnamese National Target Program of 2012 for the

2012-2015 periods, one of the goals of reproductive health was to achieve 80 % of

pregnant women attending ANC at least 3 times, once in each trimester by the year

2015 (UNDP., 2012). The data from VCPFC (2002) showed that 74 % of women had

the first visit within 6 months gestation. A study in three provinces of Vietnam: Long

An, Ben Tre and Quang Ngai concluded that 29 % of women in these provinces had

not attended any ANC, 25 % of them had at least one ANC after 4 months, and the

average duration of pregnancy at the first visit among women who didn’t have any

ANC was 3.7 months (Trinh et al., 2007). The prevalence of first ANC visit in the

rural areas was not the same as in the urban areas. A recent research by Tran et al.

(2011) showed that 69.1 % of rural pregnant women and nearly 97.2 % in urban

attended the first ANC within 12 weeks. A collection and review research from

UNFPA for the whole country during the period of 2006-2010, which indicated that

17

50-80 % of pregnant women had the first ANC visit in the first trimester (UNFPA,

2012).

To reach the target of reproductive health care of pregnant women, the

research about factors influencing timely initiation of ANC is really essential. There

were many related factors which were reported in numerous studies. These factors will

be reviewed in the following sections.

Factors related to timely initiation of ANC

Andersen’s Behavioral Model of Health Services Use

Many theoretical frameworks have been utilized to examine health behaviors

in health service research. Andersen’s Behavioral Model of Health Services Use was

the most well-known and widely used theory of access to care (Radina & Barber,

2004; Sarmiento et al., 2004). The initial model was created in 1968 and has undergone

six revisions. With each revision, there was the addition of new components which led

to a more complex model. These models included new components that reflected the

changing dynamics of accessing health care (Andersen et al., 2007). They helped

researchers to examine their data in appropriate contexts.

The model assumes that seeking health behavior was the result of interaction

between characteristics of population and surrounding environment. It included three

components. The first component was predisposing characteristics: refer to the

predisposition of an individual to use services. This component included demographic

characteristics as age and gender; the social structure as education, occupation,

ethnicity, social networks, social interaction, and culture; and the health beliefs as

attitudes, values, and knowledge that people had concerning and toward to health care

system (Andersen, 1995). The second component was enabling resources, these

factors that allowed an individual to meet their care service needs (Andersen &

Newman, 1973). This component included family or personal resources. For example,

how to access health services, individual or family income, health insurance, a regular

source of care, extent and quality of social relationships; community as available

health personal and facilities, and waiting time; and possible additions as genetic and

psychological characteristics. The last component was need factors, including

perceived and evaluated. Perceived need will better help to understand care-seeking

18

and adherence to a medical regimen, and evaluated need related to women’s health

status of pregnant women and their need for medical care (Andersen, 1995).

Previous studies have used the Andersen’s behavioral model of health

services use to identify factors affecting timely initiation of ANC. A study used this

model as a conceptual framework to examine the timely booking of ANC service in

Addis Ababa, Ethiopia (Tariku, Melkamu, & Kebede., 2010). The results showed that

predisposing factors, enabling factors, and need factors were significantly associated

with timely booking of ANC. A study conducted in Northwest Ethiopia also used this

model as a conceptual framework and indicated that some factors of predisposing and

need factors were significantly related to timely initiation of ANC visit such as

mothers' age, education and perception (Belayneh et al., 2014). Another study

conducted in New South Wales, Australia based on Andersen’s behavioral model

concluded that predisposing, enabling, and need factors were associated with late

entry to ANC care. Predisposing characteristics and enabling resources considerably

affected to the duration of entry to ANC than need factors (Trinh & Rubin, 2006).

The findings from these studies contributed to explanation of the relationships of

predisposing, enabling, and need factors on timely initiation of ANC.

PREDISPOSING ENABLING NEED USE OF

CHARACTERISTICS RESOURCES HEALTH

SERVICES

Figure 2 Andersen’s Behavioral Model of Health Services Use (1995)

Beliefs

Social

Structure

Demographic

Community

Resources

Family/ Personal

Resources

Evaluated

Perceived

19

The present study uses Andersen’s Behavioral Model of Health Services Use

as a conceptual framework. Predisposing characteristics are the social-cultural

characteristics of individuals that exist prior to their illness, including demographic

factors, social structure, and health beliefs. In this study, demographic factors are

maternal age and parity; social structure is maternal education; health belief is

mother’s knowledge about ANC. Enabling resources are the logistical aspects of

obtaining care, including personal/ family resources and community level (Andersen,

1995). In this study, personal/ family resource is family support for pregnancy. The

use of Andersen’s behavioral model of health services use as a theoretical framework

to view the factors related to timely initiation of ANC. It will be described in the

following parts.

Predisposing factors and timely initiation of ANC

In the model, the predisposing factors are included demographic, social

structure, and belief of individual. In the present study, demographic factors are

maternal age and parity, social structure is maternal education, and belief is

knowledge of women about ANC. The review literature showed that age, education,

parity, and knowledge of women about ANC have related to timely initial ANC

(Nwagha & Anyaehie, 2008; Onoh et al., 2012; Trinh & Toney, 2012; Belayneh et al.,

2014)

Demographic factors

Maternal age

A review of studies from 1998-2011, using Andersen’s Behavioral Model of

Health Services Use as a conceptual framework indicated that there was a significant

association between age and utilization of healthcare services (Babitsch, Gohl, &

Lengerke, 2012). People in different age groups had different patterns of using

medical care (Andersen & Newman, 1973).

Maternal age is a significant factor associated with timely initiation of ANC.

A study in Nigeria in 2012 determined the antenatal booking pattern of mothers

concluded that 92.9 % among 365 teenage pregnant women in that study had late

antenatal visits (Onoh et al., 2012). It was consistent with a previous study by Trinh

and Rubin (2006), where in 56 % of teenagers started ANC visits late. Meanwhile,

early booking was most common in the group 20-24 years old (only 25 % in this

20

group booked late) (Onoh et al., 2012). If two groups of pregnant women including

younger age (who were less than 30 years old) and older age group (who were 31-45

years old), the younger age group was 3.83 times more likely to enter earlier than the

group of older women (AOR = 3.89, 95 % Cl = 1.89-10.53) (Belayneh et al., 2014).

In contrast, a study in Nigeria by Adekanle and Isawumi (2008) indicated that 91.1 %

participants who were less than 25 were significantly likely to book later than those

were older (78.9 %) (p < 0.01).

In summary, timely initiation of ANC varied significantly among age

groups, young and elder mothers have later booking trend than mothers in proper

childbearing age. Possible reasons for the adolescent pregnant women attending later

include lack of power to take decisions, lack of money, or lack of knowledge to

recognize pregnancy (Gross et al., 2012). Possible reasons for the elderly women

delayed ANC are that they assumed they gained experience with pregnancy and they

were not aware of any problems. Therefore, they think that they don’t need to come

for the early visit (Kisuule et al., 2013). Women in childbearing age are more early/

earlier to do the booking because they are more likely to be educated and have access

to information compared to the older women (Beeckman et al., 2011). Compared to

younger mothers, they are more confident and independent in making their own

decisions including the decision to initiate their ANC.

Maternal education

The Behavioral Model of Health Services Use indicated that education was a

social structure variable; it reflected the location of the individual in the society.

It may suggest the life style of the individual, the physical, social environment, and

associated behavior patterns of the individual which may be related to the use of

health services (Andersen & Newman, 1973).

Maternal level of education also associated with the early ANC. A study by

Tayie and Lartey in 2008 examined the associations between maternal educational

level, early antenatal care attendance, and pregnancy outcome in Ghana. The study

results concluded that there was a significantly positive association between maternal

education and time of antenatal booking (p < 0.01). The women, who had high school

or higher education booked ANC earlier compared to those who had secondary school

or less. A recent study by Belayneh et al. (2014) in Ethiopia assessed timing of ANC

21

booking and associated factors among 369 pregnant mothers. The results indicated

that the mothers who had formal education started ANC visit earlier, those with

formal education were 1.06 times more likely to initiate ANC earlier than those who

had no formal education (AOR = 1.06, 95 % Cl = 1.03-7.61) (Belayneh et al., 2014).

It was in line with previous studies by Adekanle and Isawumi (2008) and Onoh et al.

(2012). However, a study in Tanzania in 2012 of 440 adolescent and adult mothers

was not consistent with other studies. These results showed that maternal education

was not associated with an early or later timing of ANC visit (p = 0.987) (Gross et al.,

2012).

In conclusion, most of the studies indicated that maternal level of education

was positively associated with timely initiation of ANC, higher the maternal

education, earlier the initiation of ANC. A study by Ndidi and Oseremen (2010)

concluded that educational level of the woman was a major determinant of health

seeking behavior. But there was a slightly different with previous studies; a study

concluded that maternal education was not the reason for the early or late antenatal

visit. Hopefully, the results of the present study will make clearly the relationship

between maternal education level and timely initiation of ANC.

Parity

The Andersen’s behavioral model of health services use was used in a study

to assess the late initiation of antenatal care among pregnant women and indentify

related factors. The results of this study indicated that the number of deliveries of

women associated with entered ANC early or late in New South Wales meant that

higher parity was better initiation of ANC (Trinh & Rubin, 2006).

A prospective multicenter survey conducted in Nigeria in 2008 with a

sample size of 928 pregnant women to determine the influence of parity and other

socio demographic factors on gestational age at booking indicated that parity

significantly influenced the gestational age of the first antenatal visit (p < 0.05).

Generally, gestational age for booking was later than the first trimester, average 24.00

± 7.9 weeks for primigravidae and 27.16 ± 7.5 weeks for multigravidae (Nwagha &

Anyaehie, 2008). Another study in Nigeria in 2012 with 344 pregnant women was

conducted to determine the antenatal booking pattern of women and its determinants,

which results that the women with their first pregnancy were the most common parity

22

that booked ANC (32.3 %) compared with others. However, women who were

pregnant for second time had the highest percentage (24.1 %) of coming early for

ANC whereas women with 4 children had the highest percentage (90.9 %) of coming

late for ANC (Onoh et al., 2012). This study was consistent with a study in United

Kingdom by Baker and Rajasingam (2012). Similarly, a study was conducted in rural

and urban Zambia in 2012, aimed examining factors associated with late ANC

attendance showed that nulliparous women in the rural were 59 % less likely to

initiate ANC late compared to multiparous women (AOR = 0.411, 95 % CI = 0.238-

0.758), while the proportion in the urban district was 48 % (AOR = 0.518, 95 % CI =

0.316-0.848) (Banda et al., 2012).

In conclusion, the parity factor influenced the timely initiation of ANC in

pregnant women. Women with low parity often come earlier for ANC than high

parity. The possible reason is that the higher parity women feel confident with their

previous experience of childbearing; thus, feel no need for early initiation of ANC

(Oladokun, Oladokun, Morhason-Bello, Bello, & Adedokun, 2010).

Knowledge about ANC

Previous study applying Andersen’s Behavior Model of Health Services Use

by Nguyen et al., (2013) indicated that, the knowledge about ANC was strongly

associated with use of health services among pregnant women in Vietnam.

A cross sectional study in Ethiopia in 2008 to assess timing and factors

influencing the fist ANC booking showed that most of mothers (94.6 %) recognized

the significant importance of ANC for the health of mothers and fetus. However, only

75 % of them had knowledge about the right time for the first ANC visit was within

12 weeks of gestational age, 18.8 % though that it should occur after 12 weeks, 2 %

did not know the right time for the first ANC (Trinh & Toney, 2012). Similarly, a

study by Onoh et al. (2012) showed that more than one third (37.2 %) of women

understood that ideal gestational age for the first visit was the second trimester, while

34.9 % of women identified the correct time was the first trimester, and 18.3 % had no

idea of the gestational age of booking. The mean of gestational age at booking for the

study was 24.33 (5.52) weeks and more than 83 % (286/ 344) of them booked after the

first trimester, and only 16.9 % (56/ 344) of women booked early.

23

There were many reasons found for late booking ANC in previous studies.

The commonest reason (53.3 %) was the participants did not have any problems with

their pregnancy and so they thought there was no reason to come early for ANC

(Kisuule et al., 2013). A study in Nigeria in 2010 among 348 pregnant women

concluded that 21 % of respondents in this study also had the same reasons for

booking late (Ndidi & Oseremen, 2010) such as not having any serious problems and

did not understand benefits from early of ANC.

A cross sectional study from 440 pregnant women who came to ANC in

Southeastern Tanzania concluded that more than one fourth of mothers (27 %) awaked

that correct time for starting ANC should be after these mothers feel the fetus move

and 30 % said that they had not recognize pregnancy early. It was a strong predictor of

delay for antenatal visit in this study (p = 0.002) (Gross et al., 2012). A study in

Zambia in 2012 to examine factors associated with late ANC attendance among 613

pregnant women attending antenatal clinic indicated that, the women had lack

knowledge about ANC was 4 times likelihood of late attendance than those good

knowledge. Another study also concluded that women who had inadequate knowledge

about ANC to start ANC late was 2.2 times (AOR = 2.205, 95% CI = 1.021-4.759)

compared with women with adequate knowledge (Banda et al., 2012).

In summary, the findings from review showed that many pregnant women

did not recognize the importance of early first antenatal visit. Most women booked

late because in their knowledge there was no benefit of booking antenatal care in the

first three months of pregnancy. Some of them believed that the first ANC should

occur early only if their pregnancies had problems. Other mothers showed lack of

knowledge to recognize their pregnancy early. Therefore, most of them led to the late

initiation of ANC visit.

Enabling factors and timely initiation of ANC

Enabling factors in this model included family/ personal resources and

community resources. In this study, family resource is supports from family to

pregnant women. Numerous previous studies concluded that family support for

pregnancy played an important role in starting the antenatal visit early or late (Gross

et al., 2012; Secka et al., 2010).

24

Family support for pregnancy

A study that was conducted in the United State using Andersen's behavioral

model of health services use concluded that there was an association between family

support and use of health services. Women who received good family support were

more likely to use health care services than those who lacked of family support or

never received this support (Dhingra, Zack, Strine, Pearson, & Balluz, 2010).

Family support for pregnancy was significantly associated with timely

initiation of ANC. A study in Tanzania in 2012 was conducted among 440 women

who attended ANC; the study concluded that lack of support from husband/ partner

negatively influenced starting ANC visits. Women who did not receive husbands/

partners support were independently associated with a later ANC enrollment in the

multivariate analysis for all women (p = 0.035). Women who received support from

their husband attended nearly 3 weeks earlier than women who did not receive.

Moreover, that study also indicated that, in contrast to adult women, adolescent

pregnant women usually received advice about ANC from mothers or other people

(Gross et al., 2012). A qualitative research method was conducted in Gambia in 2010

with objective to explore socio-cultural factors associated with men’s involvement in

care and support of women during pregnancy and childbirth. The findings of this

study showed that most women who initiated antenatal care had their partners or men

in the family making decisions; eventually women had to seek approval of proposed

visits from men in the family. Some of men felt their responsibility to accompany

women to facilities and offer physical support when needed. Therefore, when her

husband travels or is not available at home for other reasons, the woman’s initiation of

ANC was delayed or she did not go (Secka et al., 2010).

A study was conducted in Nigeria in 2014 with sample size of 200 women of

childbearing age (18-35 years old). The results from this study indicated that most of

women agreed that husband support during pregnancy, labor and delivery were

necessary. Ninety six point five percent of women were encouraged by their husband’s

support, 86.5 % of women felt less stressful if they received their husband’s support,

and most of them received emotional security from their husband. Besides, 83.5 % of

women believed that lack of husband’s support during pregnancy, labor and delivery

would be dangerous. It was however discovered that even though men are generally

25

supportive of their pregnant wives, only 42 % of the husbands escorted their wives to

clinics for ANC (Mosunmola, Adekunbi, & Foluso, 2014).

In contrast, a qualitative study aimed to assess factors influencing pregnant

women’s decision to seek or avoid antenatal care, conducted from 24 women utilizing

ANC. Ten women avoiding ANC in Peru reported that their husbands/ partners and

mothers encouraged them to seek ANC but some women decided on their own as to

when ANC should be initiated, also, their relatives’ influence were limited (Ayala,

Blumenthal, & Sarnquist, 2013). A study in Lesotho had interesting results about

support from memberships in a family of the pregnant women, according to the

culture in this country, pregnancy and childbearing were considered a women’

concern, not concern of men, including father of the baby. They believed that their

husband and father mainly provided material needs in the form of money and food

while mothers and sisters provided psychological support. Moreover, these women

had a simple thinking; they only believed that they needed support in the forms of

supporting their children and themselves for nutrition, clothes, and blanket.

Surprisingly, they did not believe that they needed care for their pregnancy though

ANC. Therefore, women started their ANC only in the second and third trimester of

pregnancy; the reported rates were 71.43 % and 28.57 % in the second and third

trimester, respectively (Phafoli et al., 2007).

In conclusion, the support from family encourages women in seeking ANC

as the family support may help women feel confident to seek ANC early. Some of

women, their husbands escorting them to clinics seem a factor influencing their

decision for early or delay initiation of ANC. However, some women go to ANC

clinics by personal decision, not influenced by others. The present study will make

more clearly about the effect of family support on timely initiation of antenatal visit of

Vietnamese women.

Conclusion

Timely initiation of ANC is very important for the early detection of

complication in pregnancy and prevents adverse outcomes to mothers and fetus.

Understanding of factors related to timely initiation of ANC is very necessary.

The literature review and theoretical framework indicated that age, parity, education,

26

knowledge about ANC of women, and family support for pregnancy related to timely

initiation of ANC. However, there were limited studies in Vietnam about ANC and

minimal focusing on timely initiation of ANC. Hopefully, the results of this study

would be beneficial to nurses/ midwives and obstetricians in improving women' health

care, the health care services, changing perception of women as well as their family

about pregnancy care.

CHAPTER 3

RESEARCH METHODOLOGY

This chapter presents the study design, setting of study, population and

sample, instruments, protection of human subject, data collection procedures, and data

analysis procedures.

Study design

Predictive correlational design was used in this study to address the research

questions

Setting of the study

This study was conducted at Quy Nhon General Hospital. It located at

Quy Nhon City, Binh Dinh Province, Vietnam. Quy Nhon City is the capital of

Binh Đinh Province. It is also the major industrial and service central of Binh Đinh

Province, with a total area of 284 km² and population was 280,900 people (UNFPA,

2010). Quy Nhon General Hospital is a public hospital. This hospital provides health

care services for all people with many kinds of health problems including outpatient

and inpatient services for the acute and chronic diseases or injury. The hospital

provides health services for people not only in Binh Dinh Province but also

surrounding areas. The Antenatal Clinic is in the Obstetrics and Gynecology

Department of the Hospital.

The Antenatal Clinic is a place where women can receive health service

during pregnancy. The number of pregnant women who came for antenatal visits at

Quy Nhon General Hospital was around 15 per day and 300 per month (Quy Nhon

General Hospital, 2013). In this hospital, the ANC service is provided by obstetricians

and midwives and involved regular examination for pregnant women and specific tests

related to the health of fetus and women. Ultrasound, blood and urine tests are

provided in the Subclinical Department, not included in the Obstetrics and Gynecology

Department. The health services starts from 7:00 am to 11:30 am and from 1:30 pm to

5:00 pm, during Monday to Friday.

28

Population and sample

Target population

The target population in this study consisted of pregnant women who came

for antenatal visits at the Antenatal Clinic, Quy Nhon General Hospital in Binh Dinh

Province, Vietnam. Sample was pregnant women who met the following inclusion

criteria:

1. Women without severe complications during pregnancy.

2. If the pregnant women were younger than 18 years old, they had to be

accompanied by their parents or guardians.

3. These women were Vietnamese and able to communicate, read and write

Vietnamese language.

Sample size

Sample size was estimated by using formula of Tabachnick and Fidell

(2007). It was stated the simple rule of thumb: n ≥ 104 + m for testing predictors.

n = estimated sample size

m = the number of independent variables. In this study, it was 5.

The calculation of sample size in this study was as follows:

n ≥ 104 + m

n ≥ 104 + 5

n ≥ 109

Therefore, the sample size in this study was at least 109.

Sampling technique

Simple random sampling method was used in this study. Pregnant women

who met eligibility criteria were randomly selected from the list of registered pregnant

women names. Methods of sample selection were presented as follows:

1. There were around 15 pregnant women, who came to ANC in Quy Nhon

General Hospital per day and the time for data collection from February to March,

2015.

2. In the data collection days, the list of pregnant women who came for

antenatal visits at Antenatal Clinic was obtained.

29

3. Pregnant women registering during 6:30-7:30 am and 1:00-2:00 pm were

screened for eligibility criteria. Names of pregnant women who met the eligibility

criteria were written in the slips of paper, put in a box, and then mixed well.

4. The researcher randomly picked up pregnant women names from the box

twice per day; at 7:30 am and 2:00 pm, 7 or 8 pregnant women were chosen per day.

Research instruments

The data for present study were collected by using a self-report questionnaire

including 37 questions was developed by the researcher based on literature review and

modify from previous study. The instruments included Personal Background

Questionnaire, Information about Timely Initiation of Antenatal Care Questionnaire,

Knowledge about ANC Questionnaire, and Family Support for Pregnancy

Questionnaire.

1. The Personal Background Questionnaire

This questionnaire was developed by the researcher. It consisted of 9

questions, involved personal background of the participants including respondents’

age, educational level, parity and other characteristics.

Maternal age: one question with the blank to fill. The answers were divided

into two groups: ≤ 35 years old and > 35 years old. Then, it was coded as follows:

0 = more than 35 years old.

1 = ≤ 35 years old

Maternal education: one multiple choice question. Women marked in the

box that they choose and the answers were coded as follows:

0 = higher than high school level

1 = high school level

2 = less than high school level

Parity: one question with the blank to fill. The answers were divided into

two groups: never delivery and delivery at least once. Therefore, they were coded as

follows:

0 = no parity

1 = parity one and above.

30

2. The Information about Timely Initiation of Antenatal Care

Questionnaire

This questionnaire included two questions asking about the gestational age of

first ANC visit and contents of first ANC visit that pregnant women were received.

This questionnaire was developed by the researcher based on literature (WHO, 2007).

The answers were divided into two groups: gestational age of first ANC

within 12 weeks and gestational age of first ANC after 12 weeks. Then, they were

coded as follows:

0 = gestational age of first ANC within 12 weeks.

1 = gestational age of first ANC after 12 weeks.

3. The Knowledge about ANC Questionnaire

This questionnaire included 12 questions asking about understanding of the

participants regarding the appropriate time for ANC visit, the benefits and receiving

services in ANC, emphasizing on the first ANC. This questionnaire was modified by

the researcher based on “Knowledge toward ANC” questionnaire, which were

developed by Nguyen et al. (2013) for accessing postpartum women’ knowledge

about ANC, and based on literature (WHO, 2007; Kipronoh & Agina, 2009).

The content validity index for the questionnaire by Nguyen et al. (2013) was

.92 and the reliability accessed by Kuder-Richardson 20 was .75.

The questions with 3 options included true, false, and don’t know.

Correct answer got 1 score.

Incorrect answer or did not know got 0 score.

Therefore, the total scores were yielded a minimum of 0 and maximum of 12

scores. Higher scores were considered that the participants had high knowledge about

ANC and lower scores were considered that the participants had low knowledge about

ANC.

The Family Support for Pregnancy Questionnaire

This questionnaire consisted of 14 questions about support from family for

pregnant women. It was developed by the researcher based on conceptualization of

Social Support by House (1981) and literature (Sarason, Levine, Basham, & Sarason,

1983; Kipronoh & Agina, 2009; Secka et al., 2010; Mosunmola et al., 2014).

This questionnaire included 3 types of support: emotional support, instrumental

31

support, and informational support. The statements of this questionnaire were

recorded to 7-Likert scales. Level of agreement for each item was scored as follows:

Strongly disagree 1 score

Disagree 2 scores

Somewhat disagree 3 scores

Neutral 4 scores

Somewhat agree 5 scores

Agree 6 scores

Strongly agree 7 scores

Therefore, 14 questions were yielded a minimum of 14 and maximum of 98

scores. Higher scores indicated that the participants had high family support and lower

scores indicated that the participants had low family support for pregnancy.

Translation process

The original questionnaires were in English and translated into Vietnamese

language by Back-Translation technique (Cha, Kim, & Erlen, 2007). The backward

translation procedure was performed by three experts who were bilingual fluent

translators, in English and Vietnamese as well as familiar with the domain of maternal

and childbirth. This translational model had a cycle of steps as follows:

1. Two translators translated the original questionnaire independently from

English into Vietnamese.

2. The researcher and two translators discussed and combined the

Vietnamese version to be the one upon agreement.

3. Another translator translated the final Vietnamese version converse to

English.

4. Finally, the researcher and the researcher’s major advisor checked the

back-translated English version for language accuracy and comparability of the

contents, culture, and meanings between the English back-translated and the English

original version.

32

Figure 3 Translation process

Validity and reliability of the instruments

Validity

In this study, the content validity of the questionnaires was tested in the

Content Validity Index (CVI). Five experts in maternal-newborn nursing examined the

content validity, language suitability and criteria for scoring of the entire questionnaire.

The CVI score for “Timely Initiation of Antenatal Care Questionnaire” was 1.0,

“Knowledge about Antenatal Care Questionnaire” was 1.0, and “Family Support for

Pregnancy Questionnaire” was .95. Besides, some questions were revised based on the

comments and suggestions of those experts.

Reliability

The Knowledge about ANC Questionnaire and the Family Support for

pregnancy Questionnaire in Vietnamese version were tested for the reliability with 30

pregnant women who had similar characteristics with the sample of this study. In this

study, the Kuder-Richardson 20 [KR-20] coefficient of Knowledge about ANC

Questionnaire was .74, and the Cronbach’s alpha coefficient of Family Support for

Original

English

version

English back

translated

version

Vietnamese

version 1

Compare

Combined

Vietnamese

version 2

Vietnamese

version

Translator

1

The researcher

The researcher

& major advisor

Translator

2

Translator

3

33

Pregnancy Questionnaire was .81.

Protection of human subjects

The researcher was aware of research ethics of human subjects. This

proposal was submitted to the Institution Review Broad, Faculty of Nursing, Burapha

University in Thailand. Then, the asking permission letter for data collection from

Burapha University was sent to the Director of Quy Nhon General Hospital.

The participants were informed clearly about the aims of the study, benefits, safety,

and data collection procedure. The pregnant women were randomly selected and willing

to participate in the study and could withdraw from the study at any time. Consent

forms were given to these participants for signing before the beginning of the data

collection. The consent forms were also delivered to their parents or guardians for the

participants under 18 years old. By using this procedure, the parents or guardians were

informed about the study and asked permission for their children to participate in this

study. All the forms were anonymous. All data were stored in a secure place and only

utilized for the purpose of this research, and the results were reported as a group of

data.

Data collection procedures

Data in this study were collected by the researcher.

1. After the proposal was approved by the Institutional Review Board, the

letter from the Dean of Faculty of Nursing, Burapha University was submitted to the

Director of Quy Nhon General Hospital for seeking the permission of data collection.

2. After getting the permission from the Director of Quy Nhon General

Hospital, the researcher met the head midwife of the Antenatal Clinic; presented

purposes of study and the method of data collection.

3. The researcher viewed the list of pregnant women registering at Antenatal

Clinic to identify the women who met eligibility criteria and recruited the participants

by using simple random technique. Seven or eight women were picked up per day.

4. The researcher was self introduction, the purposes of the study and the

data collection procedures were also presented to pregnant women. Then, the researcher

34

asked them about agreement to become participants for this study. The human

protection was explained and intended time for self-completion the questionnaire was

also informed. The consent forms were signed by the participants. The researcher

explained to the participants their benefits or the right to withdraw from the research

at any time.

5. The researcher guided the participants to fill in the questionnaire. The

questionnaire was hand-delivered to the participants for self-completion. After

collecting data, the questionnaires were immediately checked for the form’s

completeness and accuracy.

6. After finishing data collection, the researcher said thanks to the

participants.

7. Finally, the researcher entered data into software files for further analysis.

Data analysis

The questionnaires were coded and analyzed by using statistical software

program. The significant level of statistical test was set up at p < .05.

1. Descriptive statistics: All values regarding range, mean, standard

deviation, frequency, and percentage were used to describe personal information of

the respondents, knowledge about ANC of women, and family support for pregnancy.

2. Inferential statistics:

Pearson Chi-Square was used to examine the association of age, education,

parity, and timely initiation of ANC. Point-Biserial was used to examine the

association of knowledge about ANC, family support for pregnancy, and timely

initiation of ANC. Multiple logistic regression was used to determine the predictors of

timely initiation of ANC.

CHAPTER 4

RESULTS

A predictive-correlational study was conducted to determine the timely

initiation of ANC and predictors of timely initiation of ANC among pregnant women in

Binh Dinh Province, Vietnam. The results of data analysis are presented in four main

parts as follows:

Part 1 Sample characteristics and description of independent variables

1.1 Personal information and predisposing characteristics

1.2 Enabling resource

Part 2 Timely initiation of ANC

Part 3 The relationship between predisposing characteristics and enabling

resource with timely initiation of ANC

Part 4 Factors predicting timely initiation of ANC

Part 1 Sample characteristics and description of independent variables

1. Personal information and predisposing characteristics

There were 109 pregnant women participating in this study. Their age ranged

from 19 to 41 years old and the average age was 28.35 years (SD = 5.13), and most of the

respondents were married (89.9 %). Nearly half of the respondents’ education level was

above high school (42.2 %) with 51.3 % of them working for the government and private

companies. About half of them lived in urban area (49.5 %), and 44 % of them belonged

to extended families. Regarding to the parity, 40.4 % of women were with no previous

liable birth, in which 33 % of them were their first pregnancy. Although most women

realized their pregnancies in the first trimester, 9.2 % of them knew their pregnancies only

in the second trimester. The details of personal information of the respondents are

presented in the Table 1.

36

Table 1 Frequency and percentage of personal information and predisposing

characteristics of the respondents (n = 109)

Personal information and predisposing

characteristics

Frequency Percentage

Age

≤ 35 years old 93 85.3

> 35 years old 16 14.7

Mean = 28.35, SD = 5.13, Minimum = 19, Maximum = 41

Education

Less than high school level 28 25.7

High school level 35 32.1

Higher than high school level 46 42.2

Accommodation

Urban 54 49.5

Suburban 27 24.8

Rural 28 25.7

Occupation

Housewife 21 19.3

Government employee 17 15.6

Private company employee 39 35.7

Own business 21 19.3

Others 11 10.1

Marital status

Married 98 89.9

Single 5 4.6

Widowed/ Divorced/ Separated 6 5.5

Number of Pregnancy

The first pregnancy 36 33.0

The second and above 73 67.0

37

Table 1 (Cont.)

Personal information and predisposing

characteristics

Frequency Percentage

Parity

No parity 44 40.4

Parity one and above 65 59.6

First know pregnancy

The first trimester 99 90.8

The second trimester 10 9.2

Family structure

Nuclear family 61 56.0

Extended family 48 44.0

Knowledge about ANC

The results of knowledge about ANC of the respondents are summarized in the

Table 2. The mean score of knowledge about ANC was 9.01 (SD = 1.93), it ranged from

4-12 scores. The results in the Table 3 showed that most of the respondents knew that

they should be received iron and folic acid during their pregnancies (93.6 %). The

knowledge about tetanus vaccine injection for prevention of their babies from tetanus was

90.8 %. However, only 45.9 % of them knew the schedule of ANC visit. The number of

women who had knowledge about the timing for the first ANC was 60.6 % and blood test

for HIV infection was 61.5 %. The details of data are showed in the tables below.

Table 2 Range, mean, and standard deviation of knowledge about ANC of the

respondents (n = 109)

Knowledge about ANC Range

M SD Possible Actual

Total score of knowledge about ANC 0-12 4-12 9.01 1.93

38

Table 3 Frequency and percentage of each item of knowledge about ANC of the

respondents (n = 109)

No. Statements Correct answer

Frequency Percentage

1 Pregnant women should have the first antenatal care

visit within 12 weeks of gestation.

66 60.6

2 Pregnant women should attend antenatal care visit at

least once every three months.

50 45.9

3 Early antenatal visit is very important for early detection

of risk conditions associated with pregnancy

90 82.6

4 Antenatal care is very important to check the fetal

health.

91 83.5

5 Pregnant women need to have blood tested for HIV

infection in the first antenatal care.

67 61.5

6 Health care providers calculate the expected date of

delivery for pregnant women in the first visit.

88 80.7

7 Pregnant women are consulted to supply iron and folic

acid during their pregnancy.

102 93.6

8 Pregnant women are consulted to take extra food as

compared with non pregnant state.

85 78.0

9 Pregnant women need to have their blood pressure

checked in every antenatal visit.

78 71.6

10 Pregnant women need to be injected tetanus vaccine to

prevent her baby from tetanus.

99 90.8

11 At the antenatal care unit, the pregnant women are

informed about the dangerous signs and symptoms

during their pregnancy.

82 75.2

12 At the first antenatal visit, the pregnant women will be

informed about health care practice during their

pregnancy

84 77.1

39

2. Enabling resource: Family support for pregnancy

The results of family support for pregnancy are summarized in the Table 4.

The mean score of family support for pregnancy was 86.60 (SD = 6.89), which ranged

from 58-98 scores. High mean score meant more positive family support for pregnant

women.

Table 4 Range, mean, and standard deviation of family support for pregnancy of the

respondents (n = 109)

Family support for pregnancy Range

M SD Possible Actual

Total score of family support for

pregnancy 14-98 58-98 86.60 6.89

Part 2 Timely initiation of ANC

As it is shown in the Table 4 below, the mean score of the timely initiation

of ANC of the pregnant women in Binh Dinh Province, Vietnam was 11.85 weeks

(SD = 5.34), it ranged from 5-30 weeks. These results also indicated that most of the

respondents started antenatal visit early (72.5 %), and 27.5 % started ANC late.

Table 5 Mean, standard deviation, frequency, and percentage of timely initiation of

ANC (n = 109)

Timely initiation of ANC Frequency Percentage

Mean = 11.85, SD = 5.34, Min = 5, Max = 30

≤ 12 weeks 79 72.5

> 12 weeks 30 27.5

40

Part 3 The relationship between predisposing characteristics,

enabling resource with timely initiation of ANC

Pearson Chi-Square was used to test the correlation between the age,

educational level, parity of the respondents and timely initiation of ANC.

Maternal age: The results indicated that there was a significant association

between age of the respondents and timely initiation of ANC ( = 27.14, p < .001)

Maternal education: The results found that there was significant

association between education of the respondents and timely initiation of ANC ( =

27.07, p < .001). The results also showed that almost all of the respondents who had

higher high school level started ANC early (97.8 %), and who had lower than high

school level started ANC later than other groups (53.6 %).

Parity: There was strong association between parity of the pregnant women

and timely initiation of ANC ( = 4.99, p = .026). The results showed that 15.9 % of

the respondents with no parity started ANC late compared to 35.4 % of the

respondents with parity one and above.

Point-Biserial was used to test the correlation between knowledge about

ANC, family support for pregnancy and timely initiation of ANC of the pregnant

women.

Knowledge about ANC: The result indicated that there was significant

positive association between knowledge about ANC and timely initiation of ANC

(rpb = .61, p < .001). Thus, pregnant women with higher score of knowledge about

ANC came to antenatal visit early.

Family support for pregnancy: The results showed that family support for

pregnancy was positively associated with timely initiation of ANC (rpb = .56, p <

.001). High score meant more positive support from family for pregnant women and

the pregnant women came to ANC early.

41

Table 6 Pearson Chi-Square and Point-Biserial correlation coefficient between factors

and timely initiation of ANC (n = 109)

Factors

Timely initiation of ANC

p-value ≤ 12 weeks

(n = 79)

> 12 weeks

(n = 30)

n % n %

Age

≤ 35 years old 76 81.7 17 18.3 < .001a

> 35 years old 3 18.8 13 81.2

Education

Less than high school 13 46.4 15 53.6 < .001a

High school 21 60.0 14 40.0

Higher than high school 45 97.8 1 2.2

Parity

No parity 37 84.1 7 15.9 .026a

Parity one and above 42 64.6 23 35.4

Knowledge about ANC < .001b

Family support for pregnancy < .001b

a Pearson Chi-Square test

b Point-Biserial test

Part 4 Factors predicting timely initiation of ANC

The multiple logistic regression was performed to examine predictors of

timely initiation of ANC among pregnant women using significant factors from the

univariate analysis including maternal age, educational level, parity, knowledge about

ANC, and family support for pregnancy. The Omnibus tests of model coefficients

indicated that p -value of this model was less than .001. Therefore, the model was

statistically significant ( = 91.158, df = 6).

The results in the Table 6 show that age of the respondents had statistically

significant association with timely initiation of ANC. The odds ratio showed that

42

women who were ≤ 35 years old were 47.95 times more likely to have obtained the

first ANC visit after 12 weeks compared to the group of older than 35 years (AOR =

47.95, 95 % CI = 3.80-605.74, p = .003).

Knowledge about ANC of the respondents showed statistically significant

association with timely initiation of ANC among pregnant women (AOR = .24, 95 %

CI = .10-.57, p = .001). The odds ratio was .24, indicating that for each one score

increase of the knowledge about ANC, there was .24 times less likely to get ANC after

12 weeks of the respondents.

Similarly, the results indicated that family support for the respondents during

pregnancy had statistically significant association with timely initiation of ANC

(AOR = .73, 95 % CI = .57-.95, p = .020). The odds ratio showed that with each one

score increase in the family support for pregnancy, there were .73 times less likely that

the respondents will get ANC later than 12 weeks.

Table 7 The association between significant factors and timely initiation of ANC of

the respondents (n = 109)

Variables B Adjusted OR 95 % CI p-value

Age

≤ 35 years old 3.87 47.95 3.80 - 605.74 .003

> 35 years old 1.00

Education

Less than high school 2.62 13.68 .86 - 216.60 .063

High school 2.79 16.29 .94 - 282.95 .055

Higher than high school 1.00

Parity

No parity 1.00

Parity one and above -1.20 .30 .04 - 2.22 .238

Knowledge about ANC -1.42 .24 .10 - .57 .001

Family support for pregnancy -.31 .73 .57 - .95 .020

CHAPTER 5

CONCLUSION AND DISCUSSION

This chapter summarizes and discusses the study results in order to provide

the implication of the findings for nursing practice and education. In addition,

recommendations for the future research as well as the limitation of the study are also

presented in this chapter.

Summary of the study findings

The aims of this study were to determine the timely initiation of ANC and to

examine the influence of predisposing factors (maternal age, maternal education,

parity, knowledge about ANC), and enabling factor (family support for pregnancy)

on timely initiation of ANC among pregnant women in Binh Dinh Province, Vietnam.

The sample was 109 pregnant women who were randomly selected from Quy Nhon

General Hospital in Binh Dinh Province, Vietnam. The data were collected by using

self-report questionnaires.

The instruments for this study were developed and modified by the

researcher. The KR-20 coefficient of the Knowledge about ANC Questionnaire was

.74 and the Cronbach’s alpha coefficient of Family Support for Pregnancy

Questionnaire was .81.

The data analysis used descriptive statistics to describe the study sample and

variables. The Pearson Chi-Square and Point-Biserial were used to determine the

relationship between predisposing characteristics, enabling resources on timely

initiation of ANC. To examine factors predicting timely initiation of ANC, the multiple

logistic regression was used.

The results of this study are presented as follow:

1. The results indicated that the age of the respondents ranged from 19 to 41

years old and their average age was 28.35 years (SD = 5.13), and almost all the

respondents were married (89.9 %). Nearly half of the respondents had higher than high

school level (42.2 %), and 51.3 % of them worked for the government and private

companies. About half of them lived in urban area (49.5 %) and 44 % were living with

44

extended families. About 40 % of women were no parity, in which 33 % were in their first

pregnancy. Although most women realized their pregnancies in the first trimester, 9.2 %

of them knew their pregnancies only in the second trimester.

The mean score of knowledge about ANC was 9.01 (SD = 1.93), which ranged

from 4-12 scores. High mean score meant high knowledge about ANC of the respondents.

Likewise, the mean score of family support for pregnancy was 86.60 (SD = 6.89), which

ranged from 58-98 scores. High mean score meant more positive family support for

pregnant women.

2. The results found that the average gestational age for the first ANC was

11.85 weeks (SD = 5.34). This result also presented that more than two thirds of the

respondents had their first ANC visit within 12 weeks (72.5 %), and 27.5 % delayed

ANC, which was a deviation from recommended ANC visit time.

3. There was significant association between factors including maternal age,

education, parity, knowledge about ANC, and family support for pregnancy with timely

initiation of ANC with p-value of each factor as follow: maternal age ( = 27.14, p <

.001), educational level ( = 27.07, p < .001), parity of the respondents

( = 4.99, p = .026), knowledge about ANC (rpb = .61, p < .001), and family support

for pregnancy (rpb = .56, p < .001).

4. The results of multiple logistic regression revealed that the age of the

respondents was significantly associated with timely initiation of ANC. The odds ratio

indicated that the respondents who were ≤ 35 years old were 47.95 times more likely

to start ANC after 12 weeks compared to women older than 35 years (AOR = 47 .95,

95 % CI = 3.80-605.74, p = .003). The results also showed that for each one score

increase in knowledge about ANC and family support for pregnancy, there were .24

times (AOR = .24, 95 % CI = .10-.57, p = .001) and .73 times (95 % CI = .57-.95, p =

.020) less likely to get ANC after 12 weeks of pregnant women, respectively.

Discussion

This part was focused on discussing the research objectives. Firstly, the

timely initiation of ANC among pregnant women in Quy Nhon General Hospital was

discussed. Secondly, the relationships between predisposing factors, enabling resource

45

on timely initiation of ANC, followed by the discussion on factors predicting the

timely initiation of ANC are discussed.

1. The timely initiation of ANC among pregnant women in Quy Nhon

General Hospital, Binh Dinh Province, Vietnam.

This study found that the average gestational age of the respondents at first

antenatal visit was 11.85 weeks. This result indicated that pregnant women visiting

ANC within 12 weeks had lesser average gestational age compared to many previous

studies. The average duration for first ANC visit reported by a previous study in

Vietnam was 3.7 months (Trinh et al., 2007), which was relatively higher than current

findings. In addition, other studies showed the average age of the first ANC as 24.33

weeks (Onoh et al., 2012) and 27.9 weeks (Kisuule et al., 2013).

The present study also indicated that most of pregnant women started ANC

within 12 weeks (72.5 %). The result showed that the percentage of pregnant women

with initiation of ANC in the first trimester was higher than the results from a

previous study by Cresswell et al. (2013) in the United Kingdom, which reported 62.5

% booking in the first trimester. Also, current results are much higher than some

studies in other developing countries such as from Rwanda (5 %) (Hagey et al., 2014),

and Nigeria (16.95 %) (Onoh et al., 2012). It also was higher compared to 69.1% in a

previous study in Vietnam (Tran et al., 2011). The results of this study were consistent

with a collection and review research in period of 2006-2010 in Vietnam, which had

50-80 % of pregnant women starting their ANC in the first three months (UNFPA,

2012).

The findings indicated that the average gestational age of the respondents for

the first ANC in this study was in line with the recommended time. Moreover, the

percentage of women who initiated ANC within 12 weeks had increased compared to

the reported from some of previous studies in Vietnam and other countries.

The reasons for this increase and improvement in timely initiation of ANC might

because of betterment of the policy on health care for mothers and children in

Vietnam. The communication and health education to people about the benefits of

early prenatal care is increasingly popular and effective. In addition, Vietnam's health

insurance is covered for the entire population and the ANC is provided for free if

women had health insurance cards. Besides, according to the Population Policy in

46

Vietnam, each family only had from 1 child to 2 children. Thus, pregnancy and

prenatal care are also more interesting and more care is taken in many Vietnamese

families. Finally, the results showed that the economic life and social health care in

Vietnam were growing with better direction.

2. Factors association and predicting timely initiation of ANC

Maternal age

The average age of the respondents in this study was 28.35 years old with

85.3 % of them in the age group of ≤ 35 years old. The Pearson Chi-Square test

indicated that age had strong significant association with timely initiation of ANC

( = 27.14, p < .001). The multiple logistic regression revealed that there was a

significant association between the age of the respondents and timely initiation of

ANC. Pregnant women who were ≤ 35 years old were 47.95 times more likely to start

ANC visit late compared with older women. These findings were consistent with other

research in Australia, in which women in the age of forties and fifties were .91 times

less likely to book ANC late compared to women in the age of thirties (OR = .91, p =

.022) (Trinh & Rubin, 2006). Also, nearly the same with a study by Baker and

Rajasingam (2012), in which women aged more than 35 years were less likely to book

late compared to women in age group of 25-29 (group of 35-39: OR= .791, p = .009,

group of 40-49: OR = .701, p = .012). The present study was slightly different from a

previous study, which reported that age was not associated with initiation of ANC by

the respondents ( = 5.88, p = .317) (Onoh et al., 2012). These findings might be

explained that women, who are older than 35 years old, usually have had stable

education, lesser unemployed, and more income than younger women. Therefore, they

could spent more money to go to ANC than their younger counterparts. Moreover,

they had more experience to recognize their pregnancies earlier than the younger

women, and the most important, they also have more knowledge to realize that they

are in the group of high risk pregnancy. Thus, they go to ANC earlier than other

groups.

This study did not have any respondents who are younger than 18 years.

The reason may be the adolescent pregnancy had decreased because of the

effectiveness of propagation preventing teenage pregnancy in schools. Another likely

reason is the population policy in Vietnam, which doesn’t allow a person less than 18

47

years to get married. Thus, their pregnancies are out of wedlock. A lot of them do not

want to keep the fetus and done abortion (about 20 % in 300,000 abortion cases each

year in Vietnam were adolescents (Hai, 2014)). In addition, following the tradition,

these women often have psychological fears, want to hide their pregnancies.

Therefore, they do not want to check their pregnancies in the public hospital, where

they can meet acquaintances, they have trend to choose the private clinics. That might

be the reason that the researcher could not capture this section of age group in this

study.

Maternal education

Educational level of the respondents in this study was significantly

association with timely initiation of ANC ( = 27.07, p < .001). However, this factor

did not predict the timely initiation of ANC (p > .05). This finding was consistent with

previous studies which were conducted by Onoh et al. (2012) and Gross et al. (2012).

The results of this study were contrasted with a study by Belayneh et al. (2014), which

reported that pregnant women with formal education were more likely to start ANC

earlier than their counterparts (AOR = 1.06, 95 % CI = 1.03-7.6). It was also contrast

to a study by Ifenne and Utoo (2012) which reported that late booking was

significantly influenced by maternal education ( = 10.19, p = .017). A study by

Adekanle and Isawumi (2008) also concluded that better educated women were 2.63

times more likely book earlier than less educated ones (AOR = 2.63, 95 % CI =

1.287-5.378). The reasons for the results of this study might be the education about

antenatal care is not different in educational levels as it may not have been much

mentioned in the schools. Actually, the reproductive health education in Vietnamese

schools almost focuses on prevention of adolescent pregnancies and does not pay

much attention on pregnancy care.

Parity

There was significant association between parity of the respondents and

timely initiation of ANC ( = 4.99, p = .026). However, the results of multiple

logistic regressions indicated that parity did not predict for timely initiation of ANC in

this study (p = .238). This result was similar to a study by Onoh et al. (2012) ( =

6.179, p = .289) and another study by Ifenne and Utoo (2012) ( = 4.29, p = .61).

48

In contrast, some previous studies indicated that parity highly predicted the initiation

of ANC, a study found that women with lower parity were significant predictors of

early booking (OR = 1.76, p = .016) (Oladokun et al., 2010). Similarly, a research was

reported that multiparous women were more likely to book ANC late than nulliparous

women (AOR = .99 and 95 % CI = .92-1.07) (Cresswell et al., 2013). Another study

also showed that nulliparous women less likely to initiate ANC late compared to

multiparous women in both rural (AOR = .411, p = .001) and urban districts (AOR =

.518, p = .009) (Banda et al., 2012). In this study, nearly half of the respondents lived

in the extended families. So, they usually had the trend to receive advices for

pregnancy care from their mothers, mothers-in-law, or older sisters. Besides,

traditionally, Vietnamese women in the first child birth often seek advices for

pregnancy care from other women who are considered to have the experience of

childbirth. Eventually, in most instances, the initiation time of ANC is not much

depending on the parity as can be seen in this study.

Knowledge about ANC

The finding from this study showed that knowledge about ANC of the

respondents was significantly associated with timely initiation of ANC (rpb = .61, p <

.001) and it strongly predicted the timing initiation of ANC (AOR = .24, 95 % CI =

.10-.57, p = .001). The results indicated that for each one score increase on knowledge

about ANC, there was .24 times less likely that pregnant women would start ANC >

12 weeks. This finding was consistent with a study by Banda et al. (2012), which

reported that pregnant women having adequate knowledge were 2.2 times more likely

to initiate ANC within recommended time compared to those without adequate

knowledge about ANC (AOR = 2.205, 95% CI = 1.021-4.759). Another study also

indicated that women having knowledge about the time of booking were 1.5 times

more likely to book earlier than lack of knowledge (AOR = 1.50, 95 % CI = .72-3.11)

(Tariku et al., 2010). One of the reasons for the late prenatal care among women is

that they might lack knowledge of pregnancy care to realize they are pregnant early

compared to those with good knowledge. Another reason could be that pregnant

women who have the perception of the benefits of antenatal visit tend to attend ANC

early to receive pregnancy care soon. Therefore, health education could be important

in the improvement of timing of ANC attendance. Improving knowledge about

49

prenatal care for women is an important factor to reduce the incidence of late antenatal

women and the consequences of late booking. Moreover, enhanced knowledge will

make health care better for women.

Family support for pregnancy

Concerning the family support for pregnancy, there was statistically

significant strong association between family support for pregnancy and timely

initiation of ANC with the odds ratio of .73 (p = .020). This finding was explained that

for each one score increase in family support for pregnant women, it was .73 times

were less likely for women to initiate ANC late. This was consistent with a study of

Gross et al. (2012), which presented that women who lacked support from husbands

or partners were booking ANC almost 3 weeks later than women who did receive such

support (p = .035). The current findings were also in line with another study by Rowe

et al. (2008), which reported that women who did not receive support from family

were 2.74 times more likely to start ANC late. The results of this study showed the

important role of the family members in prenatal care and the contribution of family

members to improvement of the timely initiation of ANC by pregnant women.

Therefore, one of the strategies to increase the percentage of mothers attending

antenatal clinics early is educating family members regarding the importance of timely

initiation of ANC. Help them recognize their roles and responsibilities in pregnancy

care, encourage them to accompany women to antenatal clinics, and discuss the result

of the ANC and planning for pregnancy care from health care providers. Thus, they

can share about pregnancy care and give more support for women during pregnancy.

Therefore, proper education campaigns and the dissemination of information for all

people about antenatal care can prove to be investment for long term activities.

Lastly, the findings of this study could be an evidence to support validity of

Andersen’s Behavioral Model of Health Services Use such as antenatal care.

Antenatal care is an important component of women's health care; it is more effective

if initiated early. This study demonstrated that pregnant women who are in the group

of older than 35 years old, with high knowledge about ANC, and more support from

family were more likely to start ANC early. These factors of Andersen’s Behavioral

Model were demonstrated as predictors for timely initiation of ANC in previous

50

studies (Trinh & Rubin, 2006; Tariku et al., 2010; Belayneh et al., 2014), which

results were consistent with the present study.

Implications of the study

The findings of the study showed that women with higher knowledge about

ANC would attend ANC less lately than other group. Besides, woman’s decision

about pregnancy care is not only influenced by herself alone but also by her family's

advices and support. Therefore, in the preconception care classes or counseling about

pregnancy care, the nurses and midwives should not only focus on women but need to

enlarge and encourage other members in her family to attend the classes. They would

play an important role in contributing to improve the health care for women during

pregnancy.

The results of this study showed that participants in this study had relatively

good knowledge of antenatal care. Thus, reinforcement and maintenance of health

education for communities should be continued and developed. Moreover, health care

providers and health care system should pay more attention to pregnant women ≤ 35,

who having less experience about pregnancy.

Limitations of the study

In this study, the pregnant women with either first time visit or subsequent

visit for ANC were included. The different number of visits could possibly confound

the knowledge about ANC of the pregnant women. Therefore, study in the future,

the researcher should collect the data only from the mothers coming for the first ANC

visit.

The researcher could not collect the data with pregnant women younger than

18 years old because they did not come for ANC at that time. If the actual rate of teen

pregnancy has declined significantly, it is a good sign. However, the lack of an age

group is also a limitation of this study because this result cannot be generalized to all

age group of pregnant women.

51

Recommendations for future research

1. This study focused on some factors predicting timely initiation of ANC

(maternal age, maternal education, parity, knowledge about ANC, and family support

for pregnancy). The studies in the future should be considered to other factors that

influencing to the time of first ANC visit such as maternal occupation, family income,

distance from health service, waiting time for ANC, health insurance, and so on.

2. This study was conducted in the central of Vietnam. Studies in the future

should be conducted to compare the ANC utilization with other areas in Vietnam.

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61

APPENDICES

62

APPENDIX 1

Permission letter to use the instruments

63

LETTER ASKING PERMISSION TO USE THE

QUESTIONNAIRE

Dear Ms Nguyen Thi Nhan,

My name is Nguyen Thi Le Thuong, a Master Degree Student in Faculty of Nursing,

Burapha University, Thailand. My major is Midwifery.

I will conduct a thesis with the topic "Factors Predicting Timely Initiation of

Antenatal Care among Pregnant Women in Binh Dinh Province, Vietnam".

After I read your article: "Factor Predicting Antenatal Care Utilization among

Postpartum Women in Tu Du Hospital, Ho Chi Minh City, Vietnam" I feel interesting

with the questionnaire "Knowledge toward Antenatal Care". I think it could be

suitable for me develop the questionnaire "Knowledge about Antenatal Care of

Pregnant Women".

So, I would like to ask you please give me your questionnaire.

Thank you so much. I am waiting for your answer.

Best Regards,

Mrs Thuong

Nguyen Thi Le Thuong

Dear Ms. Thuong,

Thank you for your interest in my questionnaire. Of course, you can use the

questionnaire to develop your research. It is my pleasure.

By the way, my name is Nhan. I hope next time you can call my name correctly.

Good luck in your studying.

Best regards,

Nhan

Dear Ms Nhan,

Thank you so much for the questionnaire you sent to me.

Now, I would like to ask you that: Would you permit me translate your questionnaire

from English to Vietnamese and contrary? I am looking forward your answer.

64

Thank you very much

Mrs Thuong

Dear Ms. Thuong,

You can use the translation process to translate the questionnaire.

Best Regards,

Nguyen Thi Nhan

Dear Ms Nhan,

I already received your answer that you permit me translate your questionnaire from

English to Vietnamese and contrary.

Thank you so much

Best Regards,

Mrs Thuong

Nguyen Thi Le Thuong

Master Student (International Program)

Falcuty of Nursing, Burapha University, Thailand

Email: [email protected]

65

APPENDIX 2

Questionnaires in English

66

Date of interview…………………..……

No…...………………

QUESTIONNAIRE

“FACTORS PREDICTING TIMELY INITIATION OF

ANTENATAL CARE AMONG PREGNANT WOMEN IN BINH

DINH PROVINCE, VIETNAM”

Part 1: Personal Background

Please answer the following questions. Fill in the blank or mark “X” sign into the box

“ ” that you choose

1. Age …………………….. years old

2. What is the highest level of your education?

1. Primary school 2. Secondary school 3. High school

4. College 5. Bachelor’s degree and higher

3. Where do you live?

1. Urban 2. Suburban 3. Rural

4. What is your occupation?

1. Housewife

2. Government employee

3. Private company employee

4. Own business

5. Other (specific):………………….

5. What is your marital status?

1. Single 2. Married 3. Widowed

4. Divorced 5. Separated

6. How many times have you got pregnant (Including this pregnancy)?

1. One 2. Two or more

7. How many times have you delivered babies? (Not including abortion and this

child).....................time(s)

67

8. When did you firstly know that you were pregnant in this pregnancy?

At …………………weeks gestation.

9. What is your family structure?

1. Nuclear family 2. Extended family

68

Part 2: Information about Timely Initiation of ANC

1. What was the gestational age at your first antenatal visit?

………………………weeks (Do not count the visit that was only for confirmation of

your pregnancy such as pregnancy test or ultrasound)

2. What health care service did you receive in the first antenatal care visit?

No Contents Self-report

Yes No

2.1 Pregnancy test.

2.2 ……………………….

2.3 ……………………….

2.4 Physical assessments (height/ weight/ blood

pressure).

2.5 ……………………….

2.6 ……………………….

2.7 Others (specific):…………………………

69

Part 3: Knowledge about ANC (12 items)

Please mark a check (√) in only ONE appropriate column according to your

understanding

No Statement True False No

idea

1 Pregnant women should have the first antenatal care visit

within 12 weeks of gestation.

2 ………………………

3 ………………………

4 Antenatal care is very important to check the fetal health.

5 ………………………

6 ………………………

7 Pregnant women are consulted to supply iron and folic

acid during their pregnancy.

8 ………………………

9 Pregnant women need to have their blood pressure

checked in every antenatal visit.

10 ………………………

11 ………………………

12 At the first antenatal visit, the pregnant women will be

informed about health care practice during their pregnancy.

70

Part 4: Family Support for Pregnancy (14 items)

Please mark a check (√) in only ONE appropriate column according to your feeling

Mark in the column (1) if you strongly disagree

Mark in the column (1) if you strongly disagree

Mark in the column (2) if you disagree

Mark in the column (3) if somewhat disagree

Mark in the column (4) if you neutral

Mark in the column (5) if somewhat agree

Mark in the column (6) if you agree

Mark in the column (7) if you strongly agree

No Statement 1 2 3 4 5 6 7

1

I get the emotional support

from my family during

pregnancy.

2 ………………………

3 ………………………

4 ………………………

5

I am not lonely in pregnancy

because my family is always

beside me.

6 ………………………

7 My family shares experience

about pregnancy care with me.

8 ………………………

9 ………………………

10 ………………………

11 ………………………

71

No Statement 1 2 3 4 5 6 7

12

I can talk about my pregnant

problems that I have with my

family.

13 ………………………

14 My family encourages me come

to antenatal clinic on schedule.

72

APPENDIX 3

Questionnaires in Vietnamese

73

Ngày phỏng vấn:………………………..

Số:……………………….

BỘ CÂU HỎI VỀ

CÁC YẾU TỐ TÁC ĐỘNG ĐẾN THỜI GIAN ĐI KHÁM THAI

LẦN ĐẦU Ở THAI PHỤ TẠI TỈNH BÌNH ĐỊNH, VIỆT NAM

Phần 1: Thông tin cá nhân

Xin vui lòng trả lời những câu hỏi sau bằng cách điền vào chỗ trống hoặc đánh dấu

“X” vào ô “ ”mà bạn chọn.

1. Tuổi………………….

2. Trình độ học vấn cao nhất của bạn?

1. Cấp 1 2. Cấp 2 3. Cấp 3

4. Cao đẳng 5. Đại học và trên đại học

3. Bạn sống ở đâu?

1. Thành phố 2. Ngoại ô 3. Nông thôn

4. Nghề nghiệp của bạn là gì?

1. Nội trợ 2. Công chức nhà nước

3. Làm việc cho tư nhân 4. Tự kinh doanh riêng

5. Nghề nghiệp khác (cụ thể)…………………

5. Tình trạng hôn nhân của bạn hiện nay?

1. Độc thân 2. Kết hôn 3. Góa phụ

4. Ly hôn 5. Ly thân

6. Bạn đã mang thai bao nhiêu lần? (Kể cả lần mang thai này)

1. Một lần 2. Hai lần hay nhiều hơn.

7. Bạn đã sinh bao nhiêu lần? (Không kể nạo phá thai và lần mang thai này)

……………….lần.

8. Trong lần mang thai này, bạn biết mình có thai khi nào? Lúc………………..tuần.

9. Cấu trúc gia đình bạn đang sống là gì?

1. Gia đình 2 thế hệ 2. Gia đình nhiều thế hệ

74

Phần 2: Thông tin về lần khám thai đầu

1. Bạn đi khám lần đầu lúc thai bao nhiêu tuần?...............tuần.

(Không tính lần khám thai chỉ để xác định có thai như thử test thai hoặc siêu âm)

2. Bạn đã nhận được những chăm sóc gì trong lần khám thai đầu?

STT Nội dung Tự báo cáo

Có Không

2.1 Xét nghiệm có thai.

2.2 ………………………

2.3 Xét nghiệm HIV.

2.4 ………………………

2.5 ………………………

2.6 ………………………

2.7 Dịch vụ khác (cụ thể):…………………………

75

Phần 3: Kiến thức về chăm sóc tiền sản

Xin vui lòng đánh dấu (√) vào MỘT cột thích hợp theo sự hiểu biết của bạn

TT Câu hỏi Đúng Sai Không

biết

1 Phụ nữ mang thai nên đi khám thai lần đầu trong vòng

12 tuần tuổi thai.

2 ………………………

3 ………………………

4 Chăm sóc tiền sản rất quan trọng để kiểm tra sự khỏe

mạnh của thai nhi.

5 ………………………

6 ………………………

7 Phụ nữ mang thai được tư vấn bổ sung viên sắt và acid

folic trong thai kỳ.

8 ………………………

9 ………………………

10 ………………………

11 Khi khám thai, người phụ nữ được thông báo về những

dấu hiệu và triệu chứng nguy hiểm trong thai kỳ.

12

Trong lần khám thai đầu tiên, người phụ nữ sẽ được

cung cấp thông tin về thực hành chăm sóc sức khỏe

trong suốt thai kỳ.

76

Phần 4: Hỗ trợ của gia đình cho phụ nữ mang thai

Xin vui lòng đánh dấu (√) trong MỘT cột thích hợp theo sự cảm nhận của bạn

Đánh dấu vào côt (1) nếu bạn rất không đồng ý

Đánh dấu vào côt (2) nếu bạn không đồng ý

Đánh dấu vào côt (3) nếu bạn không đồng ý một phần

Đánh dấu vào côt (4) nếu bạn không rõ ràng đồng ý hay không đồng ý

Đánh dấu vào côt (5) nếu bạn đồng ý một phần

Đánh dấu vào côt (6) nếu bạn đồng ý

Đánh dấu vào côt (7) nếu bạn hoàn toàn đồng ý

TT Câu hỏi 1 2 3 4 5 6 7

1

Tôi nhận được sự hỗ trợ tinh

thần từ gia đình tôi trong suốt

thai kỳ.

2 ………………………

3 ………………………

4

Tôi cảm thấy tự tin hơn khi

chăm sóc thai kỳ cùng với gia

đình.

5 ………………………

6 ……………………….

7

Gia đình của tôi đã chia sẻ

những kinh nghiệm về chăm sóc

thai nghén với tôi.

8 ……………………….

9 Gia đình tôi đã đi cùng tôi đến

phòng khám thai, nếu tôi cần.

10 ……………………….

11 ……………………….

77

TT Câu hỏi 1 2 3 4 5 6 7

12

Tôi có thể nói về những vấn đề

thai nghén mà tôi gặp phải với

gia đình tôi.

13 ……………………….

14 Gia đình tôi khuyến khích tôi

đi khám thai đúng lịch.

78

APPENDIX 4

IRB approval, Hospital permission, and Formed consents form

79

80

81

82

83

84

PARTICIPANT’S INFORMATION SHEET

Dear Participant,

My name is Nguyen Thi Le Thuong, a student studying Master of Nursing

Science at the Faculty of Nursing in Burapha University, Thailand. I am conducting a

study entitled: “Factors predicting timely initiation of antenatal care (ANC) among

pregnant women in Binh Dinh province, Vietnam”. The purposes of study are to

determine timely the initiation of ANC of pregnant women and to examine the

influence of maternal age, maternal education, parity, knowledge of pregnant women

about ANC, and family support for pregnancy on timely initiation of ANC among

pregnant women. The number of samples will be 109 pregnant women in Binh Dinh

Province, Vietnam.

This study is a survey study. If you agree participate the study, you will sign

in this form and self complete the questionnaire for participant. It will take you about

20- 25 minutes. The benefits of participant that you may help health care providers to

identify factors that influence pregnant women in starting ANC early or late, which

will help them develop intervention in order to improve the timely utilization of ANC

more effectively and results from this study will contribute to improve maternal and

fetal health.

The participation is voluntary, you have the right to refuse or withdraw the

participant at any time, and not necessary to inform to the researcher. You may refuse

to answer any specific question, remain silent, or leave this study at any time. Any

information received from this study, including your identity and your name, will be

kept confidential. A coding number will be assigned to you and your name will not

used. The results of this study will be showed as a group of data. All data will be

destroyed completely within one year after publishing or presenting the findings. You

will receive a complete explanation of the nature of the study upon its completion, if

you wish.

85

The study will be conducted by Nguyen Thi Le Thuong under supervision of

my major-advisor, Assoc. Prof. Dr.Wannee Deoisres. If you have any questions,

please contact with me at telephone number: +84906675103 or email address:

[email protected] and/or my advisor’s email address: [email protected].

Your cooperation is greatly appreciated. You will be given a copy of this

consent form to keep.

Researcher

Nguyen Thi Le Thuong

86

CONSENT/ASSENT TO PARTICIPATE IN THE RESEARCH

STUDY

Title: “ Factors predicting timely initiation of antenatal care among

pregnant women in Binh Dinh Province, Vietnam”

IRB approval number:

Date …………… Month …………. Years………………

Before giving my signature below, I have been clearly explained from

the researcher, Mrs. Nguyen Thi Le Thuong about purposes, method, procedures,

benefits and possible risk associated with participation in this study, and I understood

all of that explanation. I agree to participate in this research project and I have

received a copy of this form.

I am Mrs. Nguyen Thi Le Thuong as a researcher had explained to the above

named individual the nature and purpose, benefit and possible risk associated with

participation in this research with honestly. All data and information of the

participants will only be used for the purpose of this research study.

____________________ ____________________

Name and Signature of the Participant Date

____________________ ____________________

Name and Signature of witness Name and Signature of the researcher

Nguyen Thi Le Thuong

87

APPENDIX 5

List of experts for content validity of the instruments

88

LIST OF EXPERTS FOR CONTENT VALIDITY

OF THE INSTRUMENTS

1. Chintana Wacharasin, Ph.D. Associate Professor

Pediatrics Nursing, Faculty of Nursing,

Burapha University

2. Siriwan Sangin, Ph.D. Assistant Professor

Maternal-Newborn Nursing and Midwifery

Faculty of Nursing, Burapha University

3. Supit Siriarunrat, Ph.D. Maternal-Newborn Nursing and Midwifery

Faculty of Nursing, Burapha University

4. Tatirat Suwansujarid, Ph.D. Midwifery, Maternal-Newborn Nursing and

Midwifery

Faculty of Nursing, Burapha University

5. Wantana Suppaseemanont, Ph.D. Maternal-Newborn Nursing and Midwifery

Faculty of Nursing, Burapha University

89

APPENDIX 6

List of bilingual translators of the instruments

90

LIST OF BILINGUAL TRANSLATORS OF THE INSTRUMENTS

1. Le Nguyen Huong Giang, Master of English Lecturer

Department of Foreign Language

Binh Dinh Medical College,

Vietnam.

2. Nguyen Thi Nhan, Master of Midwifery Vice Head of Training Department

Faculty of Nursing and Medical

Technology, University of

Medicine and Pharmacy at

Ho Chi Minh City, Vietnam

3. Nguyen Thao Quyen, Master of Midwifery Lecturer

Department of Midwifery,

Faculty of Nursing and Medical

Technology University of

Medicine and Pharmacy at

Ho Chi Minh City, Vietnam