Chapter 2: Literature review
2.3 Socioeconomic factors
2.3.3 Maternal employment status
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A study on factors associated with the use of antenatal care in Sindh province, Pakistan, found that household wealth was strongly associated with ANC utilization revealed that women in the poorest quintile were six times less likely to make the recommended four ANC visits than women in the richest quintile (Noh, et al, 2019). Khatib et al (2020), also found that for wealth index quintiles comparison with the poorest quintile, the higher the wealth index quintile the lower the likelihood of less than four ANC visits in Nigeria. In Kenya as well, the odds of four or more ANC utilisation were two times higher in the least poor quintile (rich) than the poorest wealth quintile (Wairoto, et al, 2020).
The poor women category consisted of 17 percent of women who attended the minimum ANC visits, 32 percent from the middle-income household and 57 percent in the rich households attended four or more antenatal care visits, in a study on quality of antenatal care services and completion of four or more antenatal care visits in Ethiopia carried out by Muchie (2017). Women in the middle household were 78 percent more likely to complete for our more visits, while women in the rich index were 85% more likely, compared to their counterparts (Muchie, 2017).
The results obtained for ANC visits by household wealth index showed that a substantial gap exists between the well-off and the disadvantaged. Women from wealthy household quintiles were more likely to attend four or more ANC than women in the middle-income households, who more likely to complete the ANC coverage compared to their poor counterparts. Distance, costs, and transport were the main reasons for poor antenatal care utilization among the economically less fortunate.
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a link between partners occupation with the use of at least four or more ANC, finding that women whose husbands were involved in agriculture had lower odds of four or more ANC visits than those whose husbands were involved in other occupations, in Nepal. The authors linked farming with poverty and lack of disposable income. (Joshi, et al, 2014).
Contrary to this, in the review of studies Sub-Saharan Africa, 40 percent of the papers found no association between employment and receiving antenatal care services, while other studies found that women who were farmers were more likely to utilise four or more ANC services (Alex, et al, 2019).
Rwabilimbo (2020), found that in Tanzania, the highest prevalence of four or more ANC service use was among women who were formally employed, while informally employed women had the highest prevalence of attending between one and three ANC visits. A study conducted in Cambodia also found that women who were employed in white collar profession had significantly higher odds of timely and adequate use of ANC (Zhou, et al, 2020).
According to Muhwava (2016), employed women had more access to antenatal care than unemployed women. This may be attributed to the inability to meet the costs associated with the ANC visits, for instance, transport and food, despite the health service that is provided free of charge. In South Africa, transport has been identified as the biggest cost of ANC. Furthermore, employed women claimed to have received better quality due to seeking private health care and having access to health insurance, than unemployed women who rely on public health care facilities (Muhwava, 2016). In Nigeria as well, respondents that were not employed had 40 percent likelihood of not attending the required number of ANC visits. Unemployed women do not earn income and therefore have less probability of attending ANC and further undertaking frequent visits (Nghargbu and Olvania, 2019). Mekonnen et al (2019), found that in Ethiopia, mothers who were unemployed were four times less likely to utilise ANC coverage than their unemployed counterparts.
The odds of having at least four visits among women who had occupation increased by 24 percent compared with women who had no occupation in Africa. These findings were related to income and societal influence that come with employment outside the home (Tessama and Minyihun
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2021). In a systematic review by Alex et al (2019), the results showed that women who were employed were three times more likely to meet the recommended number of antenatal care services than unemployed women in Sub-Saharan Africa. Being employed also increased the odds of early initiation of ANC. Employment status is closely related to income and educational status as educated women tend to be employed and consequently earn income. Beyond being a source of funds for sponsoring ANC use, employment can also increase women’s exposure and access to information on ANC, thus further promoting utilisation (Alex, et al, 2019).
Contrary to this, data obtained from the Timor-Leste Demographic and Health Survey 2009-2010 found that employed women attended four or more antenatal care visits less than the unemployed, claiming that losing hours of work results in losing income which has a large impact on their livelihood (Khanal, et al, 2015).
Women who are employed seem to mostly have higher odds of attending the four or more recommended number of antenatal care visits in Angola (Shibre, 2020). The author attributes this to women’s involvement in employment not only increase their financial ability to use quality medical care, but also empower them to take part in the decision-making process regarding accessing healthcare, because it raises their awareness and provides new behaviours, opportunities, and ideas through the interaction with other people outside the community and home (Shibre, 2020).
The studies that have been previously examined have revealed the factors that determine antenatal care frequency, timing and complications of low use of antenatal care attendance.
These studies were inadequate in that they did not disclose factors and determinants associated with provincial difference in antenatal care visits. Also, these studies were limited in geographical scope and sample size as they only focused on a handful of communities with studies such as determinants of access to and use of maternal health care service by Tsawe and Susuman (2014), women’s knowledge and its associated factors regarding optimum utilisation of antenatal care in rural Ghana by Afaya et al, (2020), the use of antenatal care in two rural districts of Upper West region in Ghana by Sumankuuro and Wang (2017), determinants of utilization of antenatal care and skilled birth attendant at delivery in South West Shoa Zone by Wilunda et al (2015), utilising
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a minimum of four antenatal care visits and associated factors in Debre Berhan Town, North Shewa, Amhara, Ethiopia, 2020 by Tizazu et al (2020) and psychosocial factors associated with early initiation and frequency of antenatal care (ANC) visits in a rural and urban setting in South Africa by Muhwava (2016) among others. These issues therefore limit their applicability to a society like South Africa that is always socially changing. These limitations make it imperious for this study to be to analyse the levels of antenatal care visits and establish the factors of differentials in the patterns of antenatal care services visits within and between the nine provinces which could be beneficial for health decisions on the South African population