Measurement

Utilisation of ANC services was assessed in relation to four dimensions of antenatal care: initiation of antenatal care (i.e., time of the first ANC visit), frequency of ANC attendance, adequacy of ANC attendance and adherence to ANC schedules.

Initiation of ANC and frequency of ANC attendance were assessed by an item in a self-report questionnaire asking about the gestational age at which the women attended for each of their ANC visits. Any ANC initiated before or at the 16th week of gestation was labeled as “timely initiation” and visits after this time were labeled “late” based on WHO recommendations. Adherence to ANC attendance schedules was estimated in relation to WHO guidance, which proposes that the first ANC attendance should take place before the 16th week of gestation; second ANC attendance between weeks 24 and 28; third ANC between weeks 30 and 32; and fourth ANC visit between weeks 36 and 40. Any visits out of these proposed intervals were considered to be non-scheduled. Women who initiated ANC visits between 24 and 28 weeks of gestation and continued the remaining visits as recommended were considered to be non-adherent for the first ANC schedules but adherent for the remaining ANC schedules. Finally, the numbers of scheduled and non-scheduled ANC visits were counted for each respondent. Respondents were asked about the number of emergency contacts for pregnancy complications with a range of specified types of traditional healers or biomedical health service providers available in the area [49].

The frequency of antenatal care visits was expressed as the ratio of the number of actual ANC visits to the total number of ANC visits recommended by WHO at the given gestational age. WHO proposes one, two, three and four ANC contacts for women at the 16th, 28th, 32nd and 40th week of gestation, respectively. Finally a ratio of 125 % or more of the recommended number of ANC visits was categorized as “increased use of ANC” and otherwise as “expected use of ANC”. Adequacy of ANC use was also categorized based on Kotlchuk’s index [50]. Women with 50 % or more ANC attendance and timely initiation (during or before the 16th week of gestation), as defined by WHO, were described as receiving “adequate ANC” while those with either late initiation or less than a 50 % expected attendance of ANC were defined as receiving “inadequate ANC”.

Antenatal depressive symptoms were assessed with a locally validated Amharic version of the Patient Health Questionnaire (PHQ-9) [51]. A score of five or more was considered to be indicative of high antenatal depressive symptoms (the optimal score for increased probability of major depressive disorder in the criterion validation study). In Ethiopia, the PHQ-9 was found to have good internal consistency (Cronbach’s alpha = 0.81) and excellent intra-class correlation of 0.92 in a study of 926 outpatients in a major referral hospital in Addis Ababa [52]. Measures of depression specific to the perinatal period were considered; however, a validation study in rural Ethiopia concluded that Edinburgh Postnatal Depression Scale had low criterion validity and poor internal consistency [53]. Although previous Ethiopian studies had used the locally-validated Self-Reporting Questionnaire (SRQ-20) for measurement of common mental disorders [34], the PHQ-9 was preferred due to its focus on depressive symptoms [53].

Intimate partner violence (IPV) was assessed using a five item scale, the Women’s Abuse Screening Test (WAST) [54, 55]. The scale was chosen for its brevity and the acceptability of the wording. Social support was measured using the Oslo Social Support Scale (OSSS-3) [56], a three item scale which asks about concern from others, ease of getting help and the number of supporting persons that participants can count on. Stressful life events were measured with the list of threatening experiences (LTE), a 12-item self-report questionnaire. The LTE has good test-retest reliability and internal consistency [57]. Both the OSSS-3 and LTE have been used in a community based study in the same setting [47].

Respondents were asked about the number of previous stillbirths, miscarriages, neonatal and infant mortality. The items were adapted from the Ethiopian Demographic Health Survey of 2011 [5]. Women were also asked whether they had chronic medical conditions, including HIV, tuberculosis, renal or cardiac diseases, hypertension, anemia or gastritis. Items asking the number of emergency health care provider visits to biomedical and traditional health care providers were used to assess women’s emergency health care use for pregnancy-related complications.

An item from the Ethiopian Demographic Health Survey was used to ask whether the woman wanted the pregnancy (labeled as “wanted”) or would have preferred it to happen at a future date (labeled as “mistimed”) or if she had never wanted to be pregnant at all (labeled as “unwanted”). Accessibility of health care was measured by using seven items asking respondents about the level of difficulty and distance to reach the nearest health facility and travel time to their respective nearest health facility, as well as affordability and availability of health care facilities [58]. Finally, self-reported pregnancy complications included a list of key danger signs during pregnancy, including bleeding, swollen hands/face, blurred vision, convulsions, high fever, loss of consciousness, severe abdominal pain, premature rupture of membranes, and discharge with unusual odor, pain during urination, severe headache and severe weakness. Closed ended questions were used to assess socio-demographic and socio-economic variables, including residence, marital status, estimated monthly income and educational level of participants.