Prevalence and correlates of pregnancy self-testing among pregnant women attending antenatal care in western Kenya

In sub-Saharan Africa little is known about how often women use pregnancy self-tests or characteristics of these women despite evidence that pregnancy self-testing is associated with early antenatal care (ANC) initiation. Understanding the characteristics of women who use pregnancy self-tests can facilitate more targeted efforts to improve pregnancy testing experiences and entry into the ANC pathway. We conducted a cross-sectional survey among pregnant women enrolling in a pre-exposure prophylaxis (PrEP) implementation study to determine the prevalence and factors associated with pregnancy self-testing among women in western Kenya. Overall, in our study population, 17% of women obtained a pregnancy self-test from a pharmacy. Pregnancy test use was higher among employed women, women with secondary and college-level educated partners, and women who spent 30 minutes or less traveling to the maternal and child health (MCH) clinic. The most reported reasons for non-use of pregnancy self-tests included not thinking it was necessary, lack of knowledge, and money to pay for the test. Future research should focus on understanding the knowledge and attitudes of women toward pregnancy self-testing as well as developing community-based models to improve access to pregnancy testing and ANC.


Introduction
The World Health Organization (WHO) recommends that pregnant women should initiate the rst antenatal care (ANC) visit in the rst trimester of pregnancy because early ANC access is central to identifying pregnancy complications and managing pre-existing conditions.(1) However, in western Kenya, less than 20% of pregnant women are estimated to present for ANC in the rst trimester. (2) Barriers to early initiation of ANC due to uncertainty of pregnancy status during the rst trimester can potentially be addressed by improving access to pregnancy testing. (3,4) However, little is known about how often women use pregnancy self-tests or the characteristics of these women. Understanding the characteristics of women who use pregnancy self-tests is important to facilitate early access to ANC and to preventive interventions in pregnancy. In this study, our primary objective was to determine the prevalence of pregnancy self-testing and associated factors among pregnant women attending maternal and child health (MCH) clinics in western Kenya. In a secondary objective, we evaluated the factors associated with early ANC initiation among pregnant women.

Study design
From November 2018 to July 2019, we conducted a cross-sectional survey among pregnant women enrolling in the PrEP Implementation for Mothers in Antenatal Care (PrIMA) study. PrIMA is a cluster randomized trial (NCT03070600) that aims to compare approaches for delivering oral pre-exposure prophylaxis (PrEP) in pregnancy. The study protocol is described elsewhere.(5) Brie y, study participants were recruited from women presenting for ANC in 20 public health facilities in Homabay and Siaya counties in western Kenya. Participants answered questions on socio-demographics, medical and pregnancy history, and partner characteristics.

Study variables
We analyzed two dependent variables: pregnancy self-test use and early ANC. Pregnancy self-test users were de ned as those who reported using a pregnancy self-test when asked "Once you suspected that you were pregnant, how did you con rm that you were pregnant?" Early ANC was de ned as initiation of the rst ANC visit during the rst trimester of pregnancy. We analyzed variables that we hypothesized would be associated with pregnancy self-test use and early ANC including maternal age, education level, employment status, marital status, partners' education level, gravidity, prior pregnancy complications, travel time to health facility, and location of health facility. We analyzed pregnancy self-test use as an independent variable when evaluating factors associated with early ANC.

Statistical analysis
We examined the prevalence and correlates of pregnancy self-test use and early ANC among pregnant women. We estimated the odds of pregnancy self-test use and early ANC using univariate and multivariable logistic regression models. In the multivariable analyses, we adjusted for all the abovementioned independent variables. Statistical analyses were performed using R software (R-Studio Version 1.1.456) and STATA 15.1 (College Station, TX).

Ethics
The study was approved by the Kenyatta National Hospital and the University of Washington institutional review boards. All participants provided informed consent to participate in the study.

Results
Socio-demographic and pregnancy-related characteristics Overall, this analysis included 1085 pregnant women between the ages of 15-43 years, median age 24 (IQR 21-28). At the time of the survey, the majority of the respondents were married (87%), not employed (89%), 25 years or older (49%), not in school (91%) and had previously been pregnant (78%) ( Table 1).
Approximately 65% of women con rmed their pregnancy in the rst trimester. However, only 35% of the women presented for ANC early -in the rst 12 weeks of pregnancy. Fifty-eight percent of the women presented for ANC during the second trimester, and 8% during the third trimester.
Twenty-two percent of women reported using a pregnancy self-test to con rm their pregnancy (Table 1).
Of the 830 respondents who did not use a self-test: 85% con rmed their pregnancies at a public health facility, 9% at a private health facility, and 6% did not con rm their pregnancy. Users of pregnancy selftests obtained their kits from a community pharmacy (77%), a public health facility (14%), a private health facility (7%), and stores (2%). The most frequent reasons for non-use of pregnancy self-tests included: not thinking it was necessary (57%), lack of knowledge on self-tests (26%), and lack of money to pay for a self-test (11%). Prevalence and correlates of pregnancy self-testing In multivariate analyses, self-test use was more likely among women who were employed (aOR=2.43, 95% CI 1.53, 3.85), currently in school (aOR= 2.14, 95% CI 1.19, 3.85), had previous pregnancy complications (aOR=1.34, 95% CI 1.24, 2.53), and received services from urban health facilities (aOR=1.77, 95% CI 1.24, 2.53). Compared to women whose partners had a primary school education or less, self-test use was 2 times more likely among women whose partners had some high school education (aOR= 2.10, 95% CI 1.32, 3.34) and 6 times more likely among women whose partners had attended college (aOR=5.93, 95% CI 3.60, 9.76). Pregnancy self-testing was not associated with age, marital status, having had a prior pregnancy, and travel time to health facility.
Prevalence and correlates of early antenatal care attendance Early ANC initiation was not associated with pregnancy self-test use, age, marital status, employment status, education status, and travel time to health facility.

Discussion
In this study, we investigated the prevalence and correlates of pregnancy self-testing among pregnant women attending maternal and child health clinics in western Kenya. To our knowledge, this is the rst study that has examined the factors associated with pregnancy self-testing among pregnant women. Overall, the prevalence of pregnancy self-testing in the study population was low with 22% of women reporting having used a pregnancy self-test to con rm their pregnancy. These ndings are similar to a South African study in 2006 that reported use of pregnancy self-tests among 27% of ANC clients. (6) It is interesting to note that the majority of women who did not use a pregnancy self-test either did not think it was necessary or did not know that they could use one suggesting the need for further studies to understand women's knowledge and attitudes toward pregnancy self-testing. In the study population, maternal employment and education status, prior pregnancy complications, location of health facility, and partner's education level were the strongest correlates of pregnancy self-testing. These ndings might re ect awareness or perception of the need for pregnancy self-testing, or availability of nancial resources toward pregnancy self-tests. Employed women may have greater autonomy in their nances compared to women who are not employed.(7) Education may be directly related to awareness of pregnancy self-tests which can be attributed to formal education.(8) Partner's education is an important determinant of women's health seeking behavior. One study found that a partner's schooling has strong effects on their spouses' health care utilization especially when partners have at least a secondary school education.(7) Women residing in rural areas are less likely to use pregnancy self-tests due to the sparse distribution of health services.(9) Poor education levels in rural areas may impact awareness of pregnancy tests. For women with previous pregnancy complications, con rming a pregnancy early becomes increasingly important due to the stigma surrounding infertility. (10) In this study population, we found that 35% of women reported attending their rst ANC visit in the rst trimester of pregnancy. This proportion is similar to ndings reported for sub-Saharan Africa (24.9%) in a recent systematic review (12) and a 20% national average in the Kenya Demographic and Health Survey (KDHS).(2) We found that women who initiated ANC in the rst trimester were more likely to have been previously pregnant, have had previous pregnancy complications, have a partner who attended college, and received services from an urban health facility. Our ndings are consistent with other studies which have shown that multigravida women are less likely to present early for ANC than primigravida women. (10) One study from Zimbabwe found that women who had at least one previous pregnancy were more likely to delay ANC. (13) As the number of children increases, the utility of ANC decreases.(11) Women with prior pregnancy complications are more likely to present early for ANC. This nding is consistent with ndings from other studies and can be attributed to the fact that women who have not experienced adverse pregnancy complications do not perceive the necessity of ANC services. (4,10,(14)(15)(16) There are several mechanisms through which partner's education may affect ANC utilization. Having more education may encourage adoption of positive health seeking behaviors, including the appropriate and timely use of ANC services. (17) Education also in uences one's occupational trajectories and earning potential. (18) Women residing in rural locations are more likely to delay initiation of ANC compared with urban dwellers. This nding is consistent with other studies in sub-Saharan Africa. (8,13,(19)(20)(21) This may be due to better access and availability of health care services in urban areas. However, we did not nd any association between maternal education and early ANC attendance. This could be explained by the fact that maternal education was categorized as a binary variable and women were assigned to either being currently in school or not currently in school. We did not have access to the women's education levels, which is a limitation of this study.
To our knowledge this is one of the few studies to evaluate whether pregnancy testing is associated with early ANC attendance. Several studies have found that women who recognized their pregnancy using a urine test were less likely to delay ANC compared to women who used other means such as missed periods. (22,23) A prior study in South Africa reported an association between pregnancy self-testing and timing of ANC initiation. The study treated timing of ANC initiation as a continuous variable and found that obtaining a urine pregnancy test from a private pharmacy was associated with a 3.6 week decrease in the gestational age at presentation for ANC. (6) In this study, we treated early ANC initiation -ANC attendance during the rst 12 weeks of pregnancy -as a categorical variable. In the univariate analysis, we found that women who reported having used a pregnancy self-test were more likely to attend antenatal care in the rst 12 weeks of pregnancy. However, after adjusting for partner's education level, location of the health facility, gravidity, and previous pregnancy complications, this association was no longer signi cant. The study sample size may not have been su cient to observe a statistically signi cant association. Additionally, the characteristics of the pregnant women in our study population could have been different from the women in the South Africa study. As such the women in our study population could have different antenatal care seeking behaviors. Also, while previous studies focused on whether access to pregnancy testing reduced gestational age at presentation for ANC, our study evaluated whether pregnancy self-testing was associated with an increased likelihood of presenting for ANC during the rst trimester. Future research should investigate whether access to pregnancy self-tests by women who are less likely to use pregnancy self-tests would increase the likelihood of presenting early for ANC.
Our study has some limitations. Although we were able to recruit over 1000 study participants from 20 clinics in western Kenya, the majority of the participants came from rural areas therefore some aspects of our ndings may not generalize to other settings. Secondly, participants self-reported when they con rmed their pregnancy and when they rst presented for antenatal care, this could lead to differential misclassi cation due to recall bias. Finally, given that we conducted secondary analysis from an existing cluster randomized trial, we were unable to assess additional variables such as knowledge and attitudes toward pregnancy self-testing and ANC that may be associated with pregnancy testing and early ANC.
In conclusion, our study found a modest overall use of pregnancy self-tests. The majority of women either did not see the utility of pregnancy self-testing or did not know about pregnancy self-tests. Promoting awareness of pregnancy self-tests may be a useful driver of earlier ANC attendance and warrants further research. Qualitative research is needed to understand women's attitudes, knowledge and motivations toward pregnancy self-testing and how it informs decision-making around ANC attendance. The study was approved by the Kenyatta National Hospital and the University of Washington institutional review boards. All participants provided informed consent to participate in the study.

Consent for publication
Not applicable.
Availability of data and materials The datasets during and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests
The authors declare that they have no competing interests.

Funding
This work was supported by the National Institutes of Health (NIH) (grant number R01 AI125498). Additional support was provided by the University of Washington Center for AIDS Research (grant number P30 AI027757).
Authors' contributions NN designed the study, worked on the analysis and drafted the manuscript. MM designed the study, supervised and worked on the analysis and drafted the manuscript. KM supervised the data analysis, contributed to interpretation of the analysis and revised the manuscript. JD, JK, JB, GJS, LG, MM and BO revised the manuscript. All authors read and approved the nal manuscript.