Factors Associated with the Continuum of Prenatal Care in the Post-Ebola Context in Guinea

Background: The 2018 demographic and health survey reports low coverage in the continuum of antenatal care over the period 2013 to 2018. However, little remains known about this indicator since the Ebola epidemic crisis was over. This epidemic has been reported to decrease utilization of maternal health services. This study aims to determine the coverage and factors associated with four or more antenatal care visits in Guinea in the post-Ebola context. Methods: This was a cross-sectional study using secondary data from the most recent (2018) Guinea Demographic and Health Survey. Women aged 15 to 49 years constituted our study population. Our sample included women who had their most recent birth over the last 24 months preceding data collection and whether or not they had performed 4 antenatal care (ANC) visits. Factors associated with performing four or more antenatal visits were assessed through a multivariate logistic regression analysis using Stata software version 15.1. The final model was constructed using the bottom-up stepwise method. Hosmer and Leeshawn’s goodness-of-fit test was used for model specification. Results: Among the 2634 women in the sample, 41% had four or more ANC visits. Factors associated with attending four or more ANC visits included education level, poverty quintile and region. Women with a secondary or higher education were 44% more likely to attend four or more ANC visits (OR = 1.44, 95% CI = [1.07 1.92]. Those whose spouses had secondary or education level were 1.66 times more likely to attend four or more ANC visits. Women from moderately wealthy households were 76% more likely to attend four or more ANC visits (OR = 1.76, 95% CI = [1.30 How to cite this paper: Soumah, A.M., Balde, M.D., Camara, B.S., Kourouma, K., Diallo, A., Sall, A.O., Toure, A.O., Diallo, R., Camara, S. and Cherif, I.S. (2022) Factors Associated with the Continuum of Prenatal Care in the Post-Ebola Context in Guinea. Open Journal of Epidemiology, 12, 207-220. https://doi.org/10.4236/ojepi.2022.122017 Received: April 8, 2022 Accepted: May 27, 2022 Published: May 30, 2022 Copyright © 2022 by author(s) and Scientific Research Publishing Inc. This work is licensed under the Creative Commons Attribution International License (CC BY 4.0). http://creativecommons.org/licenses/by/4.0/ Open Access


Plain English Summary
Many efforts have been made in Guinea to promote free use of maternal health services such as obstetric and neonatal care. However, according to the 2018 Demographic and Health Survey (DHS), there is a shortfall in use of antenatal care services from 81% for women attending one ANC visit to 35% for those attending the World Health Organization (WHO) recommended four or more ANC visits. In Guinea, the Ebola epidemic has contributed to the decline in attendance to four or more ANC visits. In fact, this indicator dropped from 57% in 2012 (before the Ebola epidemic) to 35% just after the epidemic. The data used in this study are from the 2018 DHS and are nationally representative. The results from this research show that educated women and those living in wealthy households were more likely to attend four or more ANC visits. Improving the use of ANC services requires raising community awareness about the benefits of these services for pregnant women and their babies. In addition, there is a need for greater engagement of health professionals to promote women's attendance to at least four ANC visits for good pregnancy outcomes.

Background
Every day, more than 800 women die worldwide during pregnancy or as a result of childbirth [1]. Sub-Saharan Africa and South Asia bear the greatest burden of these maternal and neonatal deaths. Yet, scientific evidence shows that most maternal deaths, as well as pregnancy-related complications, can be prevented if pregnant women have access to quality maternal health services during pregnancy, delivery, and the first hours following delivery [2] [3]. A key indicator of the quality of maternal health services is the completion of antenatal care (ANC) visits. Indeed, ANC plays an essential role in reducing maternal and perinatal morbidity and mortality through the detection and treatment of pregnancy-related complications. It also allows the identification of women at increased risk of developing complications during labor and delivery, and their timely referral to  [13]. The objective of this study is to determine coverage and factors associated with attending four or more ANC visits in Guinea in the post-Ebola context.

Study setting
The Republic of Guinea is located in the western part of the African continent and covers an area of 245,857 km 2 with a population of nearly 13 million people, the majority of whom live in rural areas (63%). The country has 33 prefectures.
The health system is based on a three-tier pyramid. The primary level includes health posts and centers; the secondary level includes regional and prefectural hospitals and communal medical centers; as for the tertiary level, it includes three national hospitals. ANC is provided at the primary and secondary levels. In 2014, the country had a ratio of about two physicians and one nurse per 10,000 inhabitants with a disparity between rural and urban areas. The study population consisted of women aged 15 -49 who gave birth over the last 24 months preceding data collection, attended at least one ANC visits.
Overall 2634 women were included in this study.

Inclusion criteria
All women who had given birth in the 2 years before the collection of data, who had made at least one ANC visits and who were present in households during data collection were included in this study.

Exclusion criteria
All women who had their last birth 2 years before data collection and who had not performed ANC, those who were absent, and women who refused to complete the questionnaire when the interviewers visited were excluded from this study.

Study variables
The dependent variable for this study was attendance to four or more ANC visits. It is was dichotomous variable, constructed as follows: all women who attended one to three ANC visits were grouped and coded as 0 and those who attended four or more ANC visits were coded as 1.  *Women with at least one birth in the last 24 months preceding data collection.  (Table 2).   Note: * p < 0.05; ** p < 0.01; *** p < 0.001.

Discussion
This study is one of the first to analyze indicators of the continuum of ANC in the specific post-Ebola context in Guinea. It reports that over the two years (2017-2018) following the end of the Ebola epidemic in Guinea, 41% of women attended the WHO-recommended four or more ANC visits. Factors predicting attendance to four or more ANC visits included education level, household poverty quintile, and administrative region.
The results show lower coverage in four or more ANC visits in the post-Ebola context compared to the pre-Ebola coverage, which was 57% as reported by the 2012 DHS [13]. Decline in ANC coverage the post-Ebola context could be explained by persistent underutilization of health facilities in general and maternal Open Journal of Epidemiology health services in particular, due to fear of infectious risk. Other studies in Guinea have also reported underutilization of maternal health services following the Ebola epidemic [15] [16] [17]. A study in Liberia in 2017 also reported a 9% decrease in the achievement of four or more ANC visits in 2014 during the Ebola epidemic. This decline was attributed to low utilization of services due to poor care-seeking behavior, as well as the closure of most health facilities during Ebola epidemic [18]. However, other African countries that have not experienced epidemics, particularly Ebola, have prevalence rates of ANC those reported in Guinea in the post-Ebola period such Nigeria (54% -57%), Benin (52%) and Mali (43%) than Guinea [19] [20] [21] [22].
Furthermore, the multivariate analysis in our study reveals that women living in the administrative regions of Boké and Nzérékoré are 44% -47% less likely to have 4 or more ANC visits compared to women living in the city of Conakry. This finding could be explained by the fact that the Ebola epidemic affected different regions. The results of another study conducted in Guinea also show a disparity between the region in the use of ANC services with the performance of ANC4 at 9% in the region of Labé compared to 28% in the region of Kindia and 44% in Conakry [23]. To improve overall utilization of ANC services, the authors recommended collaboration with community actors, availability of health workers, performance of health facilities, levels of trust in the health system, or cost and payment of user fees may vary from region to region [23].
The study found that women from poorest households were less likely to attend four or more ANC visits than those from middle-wealth wealthier and wealthiest households. Thus, women from wealthier households are almost three times more likely to perform 4 or more ANC than women from poorer households. Indeed, the Ebola epidemic has a prolonged negative effect on access to health services that is linked to economic accessibility (household income). Our results are similar with those of a multi-country study covering 7 countries from Africa, Asia, and Latin America; this study found that women from poorer households were less likely to attend four or more ANC visits compared with wealthier women. To this end, the authors suggest that despite free care, unexpected charges for prescribed drugs or tests, and indirect costs associated with transportation to the facility could influence the continuum of ANC [10].

Strengths and Limitations
This research is the first to explore factors associated with the continuum of ANC in the post-Ebola epidemic context in Guinea. This, it strongly contributes to understanding use of ANC services in this specific post-epidemic context. However, as this study based on a secondary analysis of the DHS data, it could not assess properly potential factors related to the quality and accessibility of health services. As the study included women who gave birth two years then, it may have led to some recall bias. However, despite these limitations, the findings of this study can contribute to a better understanding of the factors influencing achievement of the continuum of maternal care during pregnancy in Guinea. It

Implications for Practices and Research
This research has shown a low coverage in four or more ANC visits in the post-Ebola period in Guinea and identified the determinants of this low coverage. This study's findings will help guide decision makers in planning and implementing promising strategies. One of these strategies would be community awareness raising campaigns, training of community health workers on the importance of ANC visit, and involvement of the media in awareness raising around ANC services.
However, there is need for future research using mixed-methods (qualitative and quantitative data) to better explore the determinants of low coverage in the continuum of ANC, from the perspectives of users and providers of ANC services.

Conclusions
The Ebola epidemic in Guinea has had an impact on maternal and neonatal health indicators. Analysis of data limited to the post-Ebola period, showed lower coverage in four or more ANC visits, compared to the pre-Ebola period. Factors associated with this coverage included education level, poverty quintile, and region. Women from poor and poorer households were much less likely to attend four or more ANC visits. Also, the lack of formal education negatively influences achievement of four or more ANC visits. The strategies to be adopted should account for these factors.
Improving coverage in four or more ANC visits in the post-Ebola epidemic context in Guinea requires efforts to rebuild community trust in healthcare providers through awareness-raising. Reorganizing provision of care across regions would be appropriate. Future research is needed to better understand the persisting low coverage in the continuum of ANC despite efforts to strengthen the health system.