Background

The sustainable development goal three (SDG 3), target one was set to reduce the global maternal mortality ratio to less than 70 per 100,000 livebirths by the end of 2030 [1]. To achieve this, a strong political commitment from countries especially those with poor maternal health outcomes, to control their preventable maternal morbidities and mortality are required [2–4]. As a result, the World Health Organisation (WHO) recommends that every woman should seek antenatal care (ANC) from a skilled provider. Following this recommendation, women should have their first ANC visit immediately after conception to twelve weeks of gestation–early ANC and extra seven visits be made after twelve weeks of gestation through to delivery [4]. Early ANC provided by skilled personnel is essential as it enables pregnant women to receive varied and comprehensive reproductive health services. These services include accurate assessment of gestational age to allow for precise treatment of preterm labour, screening for disorders, provision of folic acid supplements, and screening as well as treatment for iron deficiency anaemia and sexually transmitted infections [4–7]. Early ANC could offer health staff the opportunity to meet pregnant mothers and provide them guidance targeted at modifying risky behaviours such as smoking, alcohol consumption, drug abuse, obesity, malnutrition, and occupational exposures [4, 7].

Global report on early ANC indicates an increase in early ANC coverage from 40.9% in 1990 to 58.6% in 2013 [4]. However, disparities in the uptake of early ANC exist based on geographical locations. Whereas high-income countries recorded 84.8% of early ANC coverage in 2013, low-income countries’ early ANC coverage stalled at 48.1% [4]. Sub-Saharan Africa (24.9%) is among the notable regions which recorded the lowest early ANC visit coverage, globally [4]. Cameroon has seen a marginal rise in early ANC attendance from 33% to 35% between 1991 and 2014 [8]. However, the 2018 Cameroon Demographic and Health Survey (CDHS) reported that only forty-one in every hundred women (41%) in Cameroon sought early ANC services [8]. This implies that most women in Cameroon might not fully benefit from treatment and preventive measures covered under early ANC services such as the provision of iron and folate supplements for the treatment of anaemia, administering Intermittent Preventive Treatment (IPTp) to curb malaria in pregnancy, immunization against tetanus, tuberculosis, nutrition, and detection and management of HIV/AIDS and other sexually transmitted infections (STIs) [4–7].

Apart from the low uptake of early ANC in Cameroon, several studies have been done on predictors of ANC attendance in Cameroon [9–12]. However, none of them have considered individual and community-level factors that influence early ANC uptake. For instance, Halle-Ekane et al. [9] assessed the content and utilization of ANC services in a rural community in Cameroon whereas Halle-Ekane et al. [10] focused on the quality of antenatal care and outcome of pregnancy in a semi-urban area in Fako Division. The study of Tolefac et al. [11] also investigated why pregnant women present late for their first antenatal care consultation in Cameroon. Also, Venyuy et al. [12] looked at factors associated with the late start of late ANC among pregnant women in the Saint Elizabeth General Hospital Shisong (SEGHS), Cameroon, and found the cost of service, having a source of income, distance to a health facility, parity and level of education as determinants of late ANC in Cameroon [12]. The aforementioned studies were restricted to specific health facilities which present a challenge to understand determinants of early ANC attendance from a national scale. Therefore, there is a dearth of information on predictors that combined both the individual and community-level factors and the uptake of early ANC in Cameroon. Hence, the present study aimed at investigating the association between individual and community-level factors and early ANC uptake in Cameroon using nationally representative data. Findings of this study would be useful to the Ministry of Public Health and other agencies in Cameroon in programme designs targeted at early ANC uptake among women in their reproductive age group and also help in the attainment of SDG 3.1.

Methods

Results

Descriptive results for the study

The analysis indicated that, 46% (n = 1,931) [CI = 45.0–48.0] of the women aged 15–49 attended ANC earlier, with 54% (n = 2,252) [CI = 52.0–55.0] seeking ANC late (data not shown). Table 1 depicts the descriptive results of the study. The median age at which women started utilising early ANC was 28 (15 to 48) years. Generally, most of them were Christians (67%), married (75%), do not make health decisions alone (92%), belongs to the working class (75%), and do not read newspaper/magazine (83%) or listen to radio (63%) at all. Also, the majority of them declared that getting permission to seek medical help (68%), money needed for treatment (69%), and distance to health facility (61%) was not a problem when seeking medical help. A little over half of them (51%) resided in rural areas whereas 53% of them belong to a community of low socioeconomic status (Table 1).

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Table 1. Individual and community-level factors and uptake of early ANC (Weighted N = 4,183).

https://doi.org/10.1371/journal.pone.0266594.t001

The analysis revealed that 49% of women aged 35–39 sought early ANC. Early ANC utilisation was phenomenal among the richest (70%), affiliates of other religions (65%), women with secondary or higher education (59%), and those cohabiting (52%). Early ANC utilisation peaked among those at parity two (55%). Those whose partners had secondary or higher education (57%) were the highest to utilise early ANC, just as among those that read newspaper/magazine at least once a week (71%) (Table 1).

Early ANC was high among women who listened to radio at least once a week (58%) and those who watched television at least once a week (60%). Similarly, early ANC was phenomenal among women who indicated that it was not a big problem (47%) to seek permission for healthcare and for those women who indicated that obtaining money for treatment is not a problem (54%). Furthermore, 50% of women who declared that distance to health facility was unproblematic as well as and 54% of women who made health decisions alone sought early ANC. A significant proportion of urban residents (55%), communities with high literacy (60%) and socioeconomic status (62%) had early ANC (Table 1).

Fixed effect results.

The third model (Model III) in Table 2 shows the fixed effect results of individual and community-level factors on early ANC. Compared with women aged 15–19, the odds to seek early ANC increased as one advance in age, especially among those aged 35–39 [aOR = 1.78, CI = 1.24–2.57]. The richest were about two-fold probable to have early ANC compared with the poorest [aOR = 2.43, CI = 1.63–3.64]. Muslims had lesser odds to seek early ANC compared with Christians [aOR = 0.73, CI = 0.60–0.88]. Those with secondary/higher education had higher odds to seek early ANC compared with those without formal education [aOR = 1.38, CI = 1.05–1.82].

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Table 2. A mixed effect of individual and community-level factors on early initiation of antenatal care.

https://doi.org/10.1371/journal.pone.0266594.t002

Relative to women at parity one, women at parity four or more had lesser odds to have early ANC [aOR = 0.63, CI = 0.49–0.82]. The findings showed that women whose partners had secondary or higher education had a higher likelihood to utilise early ANC compared with those whose partners had no education [aOR = 1.52, CI = 1.17–1.98]. The odds to seek early ANC increased among women who read newspaper/magazine less than once a week compared with their counterparts who were not reading newspaper/magazine at all [aOR = 1.28, CI = 1.03–1.59].

Discussion

This study investigated the effects of individual and community-level factors on early ANC in Cameroon. The present study recorded an early ANC prevalence of 46% among women aged 15–49 in Cameroon. This is below the WHO recommendation [27] and what was reported in Ghana [20]. The probable reason could be due to differences in the population characteristics surveyed among the two countries. This calls for strong political will from the Government of Cameroon, utilising the Ministry of Public Health and other agencies, to institute measures that could minimise the challenges obstructing women’s access to early ANC uptake.

The odds to utilise early ANC services increased across ages, especially among those aged 35–39 relative to those aged 15–19. This is in line with the theoretical proposition that demographic characteristics influence maternal healthcare utilisation [15, 16, 18]. A recent study from Ghana also found that there were increasing odds for mothers aged 20 and above for first-time mothers to initiate ANC visits in the first trimester of pregnancy compared to mothers below age 20 [20]. A plausible reason accounting for this observation is that most societies discourage pregnancy at teenage and in extreme instances, teenagers who get pregnant are dismissed from school and stigmatised. Hence some teenagers tend to be reluctant to disclose their pregnancy status and fail to utilise ANC services to avoid social pressures and unfair treatment.

The richest had over two-fold likelihood to seek early ANC service which affirms the theoretical stands that maternal wealth predicts their healthcare utilisation [15, 16, 18]. This is consistent with findings by Gebremeskel et al. [27] which indicated that monthly low-income level was significantly associated with late starting of first ANC in Ethiopia. Manyeh et al. [20] also found that there was an increased odds of women who belong to the richest socioeconomic status to initiate ANC visits in the first trimester compared with the poorest in Ghana. Similarly, Tolefac et al. [11] also observed that the odds of starting first ANC late were 3 times higher if the woman had a monthly income of less than 200 US dollars in Cameroon. The results are not surprising since financial constraints have been observed as a key challenge obstructing women’s access to early ANC services in sub-Sahara Africa [9, 28, 29] and the same reason could account for the observed phenomenon in this study. This connotes that families in Cameroon should financially assist women especially the poor so that they can afford user-fees associated with the utilisation of early ANC.

The present study noted that the probability to utilise early ANC declined among the Muslim compared with Christians. Kuuire et al. [30] also found that women who were Muslims and traditionalists were less likely to initiate ANC in the first trimester in Malawai and Nigeria. Apart from that, studies have reported mixed results concerning the influence of religion on ANC attendance. In Nigeria [31, 32] and Zimbabwe [33], it was known that Christians were more likely to use ANC service compared with traditional African religion and Muslims and a similar finding was reported in Benin [34]. Findings from Ghana [35] and Kenya [36] also established that women who had no religion were less likely to attend ANC. Perhaps, the variance in religious teachings could explain the observed difference in early ANC uptake among women in Cameroon. However, the substantive evidence on religion and ANC utilisation suggests religion influences ANC uptake; hence, a further study including a qualitative type, to explore the influence of religion on early uptake of ANC services is worthy to understand the phenomenon better.

Those with secondary/higher education had higher odds to seek early ANC compared with those without education just as among women whose partners had completed secondary or higher education compared with those whose partners had no education. Theoretically, education empowers women to be able to make informed decisions concerning their health and hence seek healthcare [15, 16, 18]. In Ethiopia, Gebresilassie et al. [37] also found that mothers who have completed secondary school and higher were two-fold probable to seek timely ANC services compared to the mothers who completed primary school or had no formal education. The authors explained that educated mothers might be knowledgeable about pregnancy issues, the benefits of ANC, and early booking and hence, tend to book ANC services on time. Another plausible reason in explaining the relationship between education and ANC service utilisation is that education influences the chances to better employment opportunities rendering the elites financially independent, and at the same time, education propels women to be better informed on the significance of using early ANC [38]. Based on these, it is possible women from Cameroon with higher education or those with elite partners shall be inclined to early ANC. The results are consistent with several studies that indicated that educated women and those whose partners possess higher education are more likely to use antenatal services and also initiate this within the first trimester of pregnancy [39–41].

Relative with those at parity one, women at parity four or more had lesser odds to seek early ANC service. This confirms the theoretical proposition that parity as a predisposing factor, plausibly influences maternal healthcare utilisation [15–17]. Parity has been observed in several studies as a determinant of ANC initiation with those at low or zero parity seeking early bookings whereas their counterparts with higher parity tend to initiate ANC late [30, 42–46]. Two arguments have been advanced in explaining the role of parity on ANC utilisation. Some scholars argue that women, especially those at higher parity who have had previous pregnancies, may consider themselves as experienced and are often accustomed to the routine care given to women during ANC, hence delay in seeking ANC earlier or reducing the number of ANC visits [47]. Others also hold that the decline in ANC utilisation among women of higher parity is as a result of inadequate resources in the family and previous exposure to poor treatment received from health personnel [39]. Any of these explanations could account for the reason why women of low parity had a higher likelihood to seek early ANC services relative to those of higher parity.

The likelihood to seek early ANC increased among those that read newspaper/magazine less than once a week compared with their counterparts that do not read newspaper/magazine. This finding is in line with a study by Geta and Yallew [21] which showed that Ethiopian mothers who had access to TV/radio were twice more likely to initiate early ANC than those who were not. In Nepal, Acharya et al. [48] also find out that mothers exposed to mass media were more likely to be attending ANC visits than mothers who were not exposed. Similarly, Edward [49] observed that women having access to media were more likely to use antenatal care services relative to those with no access in Uganda. Theoretically, it is possible for women in Cameroon who are exposed to newspaper/magazine to be inclined to early ANC since some of the newspapers/magazines convey health information and benefits of seeking ANC services which end up enlightening its readers [15–17].

Finally, the variance in the propensity to seek early ANC was due to variance in the primary sampling units (PSUs)/clusters. This is suggestive that in designing a health information and sensitisation programs targeted at early ANC uptake, attention should be paid to the cluster variations in Cameroon.

Conclusion

The present study noted that there was a low uptake of early ANC in Cameroon. The study further revealed that maternal age, wealth status, religion of affiliation, educational attainment, partners’ educational attainment, parity, and access to newspaper/magazine (all are individual-level factors) predicted early ANC uptake in Cameroon. The low uptake of early ANC in Cameroon suggests that the Government of Cameroon through its Ministry of Public Health should institute proactive interventions to address challenges that prevent women’s access to early ANC. The Departments of Health Promotion, Health Information Center and eHealth under the Ministry of Public Health, Cameroon, have to strengthen mass sensitisation programs on early ANC uptake and such programs should consider individual differences such as age, wealth status, education, and religious affiliation, in its program design. Such programs should also employ mass media, especially newspaper/magazine in reaching out to women in Cameroon.

Acknowledgments

I thank Measure DHS for making data available and accessible for the study.