{
  "abstract": "Background A significant number of women die from pregnancy and childbirth complications globally, particularly in low and middle-income countries. Receiving at least four antenatal care (ANC) visits is important in reducing maternal and perinatal deaths. However, few studies have investigated the factors linked to the completion of ≥4 ANC visits in Nepal.Objective To investigate factors associated with attending ≥4 ANC visits in Sarlahi district of southern Nepal.Design, setting and participants A secondary analysis was conducted on data from the Nepal Oil Massage Study (NOMS), a cluster-randomised, community-based longitudinal pregnancy trial including 34 village development committees. We investigated the associations between attendance of ≥4 ANC visits and socioeconomic, demographic, morbidity and pregnancy history factors using logistic regression; generalised estimating equations were used to account for multiple pregnancies per woman. All pregnancies resulting in a live birth (LB) (n=31 867) were included.Primary and secondary outcome measures Attendance of ≥4 ANC visits.Results 31.4% of those pregnancies received 4+ ANC visits. Significant positive associations included socioeconomic factors such as participation in non-farming occupations for women (OR=1.52, 95% CI 1.19 to 1.93), higher education (OR=1.79, 95% CI 1.66 to 1.93) and wealth quintile (OR=1.44, 95% CI 1.31 to 1.59), nutritional status such as non-short stature (OR=1.17, 95% CI 1.07 to 1.27), obstetric history such as adequate interpregnancy interval (OR=1.31, 95% CI 1.19 to 1.45) and prior pregnancy but no LB (OR=2.14, 95% CI 1.57 to 2.92), symptoms such as vaginal bleeding (OR=1.35, 95% CI 1.11 to 1.65) and awareness of the government’s conditional cash transfer ANC programme (OR=2.26, 95% CI 2.01 to 2.54). Conversely, identifying as the Shudra caste (OR=0.56, 95% CI 0.47 to 0.67), maternal age below 18 or above 35 (OR=0.81, 95% CI 0.74 to 0.88; OR=0.77, 95% CI 0.62 to 0.96), preterm birth (OR=0.41, 95% CI 0.35 to 0.49), parity ≥1 (OR=0.66, 95% CI 0.61 to 0.72) and the presence of hypertension during pregnancy (OR=0.79, 95% CI 0.69 to 0.90) were associated with decreased likelihood of attending ≥4 ANC visits.Conclusions These findings demonstrate the importance of socioeconomic factors, including education, caste, wealth and occupation in completion of ≥4 ANC visits. In addition, biological factors including birth spacing, pregnancy complications and nutrition are important. The association with awareness of the government’s conditional cash transfer programme is a motivation for a full evaluation of whether expanding that programme might improve prenatal care.Trial registration number The clinicaltrial.gov trial registration number for NOMS was NCT01177111.",
  "authors": [
    {
      "affiliations": [
        "Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA",
        "Department of Mental Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA"
      ],
      "name": "Yiwei Yue"
    },
    {
      "affiliations": [
        "Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA"
      ],
      "name": "Elizabeth A Hazel"
    },
    {
      "affiliations": [
        "Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA"
      ],
      "name": "Seema Subedi"
    },
    {
      "affiliations": [
        "Department of Biostatistics, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA"
      ],
      "name": "Scott Zeger"
    },
    {
      "affiliations": [
        "Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA"
      ],
      "name": "Diwakar Mohan"
    },
    {
      "affiliations": [
        "Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA"
      ],
      "name": "Luke C Mullany"
    },
    {
      "affiliations": [
        "Department of Global Health, Milken Institute School of Public Health, George Washington University, Washington, DC, USA"
      ],
      "name": "James M Tielsch"
    },
    {
      "affiliations": [
        "Nepal Nutrition Intervention Project, Lalitpur, Nepal"
      ],
      "name": "Subarna Khatry"
    },
    {
      "affiliations": [
        "Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA",
        "Nepal Nutrition Intervention Project, Lalitpur, Nepal"
      ],
      "name": "Steven C LeClerq"
    },
    {
      "affiliations": [
        "Department of International Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA"
      ],
      "name": "Joanne Katz"
    }
  ],
  "title": "Observational analysis of factors associated with completion of four or more antenatal care visits in Sarlahi district, Nepal",
  "uid": "ee4999e0-960b-517d-b185-bc0d79150ede"
}