The Sinfra department is a locality situated in the Central-West of Côte d’Ivoire. It is part of the administrative region of Marahoué and includes four (4) sub-prefectures: Sinfra, Bazré, Kouétinfla, and Kononfla. The Sinfra department covers an area of 1600 km² and is bordered to the north by the Bouaflé department, to the south by the Oumé and Gagnoa departments, to the east by the Yamoussoukro department, and to the west by the Daloa and Issia departments. The Sinfra department is located between longitudes 5˚38' and 6˚15' West and latitudes 6˚48' and 6˚82' North. It lies at the intersection of the degree squares of Gagnoa and Daloa (Figure 1).

This quantitative research was conducted using a sample of mothers with infants in the Sinfra district of Côte d’Ivoire. As we did not have a sampling frame for mothers with infants in the Sinfra district, we opted for a non-standardized approach.

Probabilistic, in particular snowball sampling. This allowed us to constitute a sample of 150 mothers with infants who were surveyed in the different villages and neighborhoods of Sinfra.

The choice of the snowball technique is explained by the fact that it allows the selection of mothers with infants meeting important criteria for achieving the objectives of this study. These criteria are: Being a pregnant woman residing in the Sinfra health district; Being a mother of an infant (0 to 12 months); Reside in the Sinfra health district; Being available to participate in the survey, and giving consent; Knowing how to express oneself well.

The collected data were analyzed using descriptive statistics tools: diagrams, histograms and statistical tables.

Although the WHO recommends eight antenatal care visits for a normal pregnancy, this study uses four visits as the benchmark for “complete coverage” of ANC [10]. This choice is based on the historical standard adopted by the Ivorian national health system prior to the adoption of the new WHO guidelines, as well as the fact that national statistics and monitoring indicators still frequently use four ANC visits as a threshold for minimum adequate care.

Source: S. Ouattara et al. [9].

Figure 1. The town of Sinfra in the Ivorian region.

Our study focused on a sample of 150 mothers with infants. The majority of these mothers live in rural areas, at a rate of 98.7%, and are more than 5 km from the nearest maternity ward. In fact, nearly 38.46% live more than 10 km away, and nearly 38.46% live between 5 and 10 km. Only 23.08% live less than 5 km from the nearest maternity ward.

This population is primarily made up of uneducated people. Indeed, the majority is uneducated, representing a rate of 57.7%. Nearly 23.1% have a primary education, 15.4% have a secondary education, and 3.8% have attended a Koranic school.

Figure 2. Distribution of mothers of infants by age.

The mothers of infants studied are mostly between 21 and 41 years old, with an average age of 31 years. The ages most represented are 36 and 38. The age distribution, as demonstrated in Figure 2, shows that the [21 - 26] age group is the most represented.

3.2.1. Knowledge of the Number of ANCs Recommended during a Normal Pregnancy

Table 1. Knowledge of the number of ANCs recommended for a normal pregnancy.

As illustrated in Table 1, the majority of women studied estimate that three (03) prenatal consultations are essential for a normal pregnancy, i.e. a rate of 54%. Nearly 38% estimate that four (04) the number of prenatal consultations is essential for a normal pregnancy, nearly 4% estimate at five (05) the number of prenatal consultations essential for a normal pregnancy and nearly 4% estimate at six (06) the number of prenatal consultations essential for a normal pregnancy.

3.2.2. Knowledge on the Importance of ANC

Table 2. Knowledge about the importance of ANCs.

The mothers surveyed have diverse perceptions of the importance of ANC as demonstrated in Table 2. The majority emphasized its role in monitoring the health of the mother and baby (95%), in reducing maternal and infant mortality (88%), in health education and preparation for childbirth (79%), in identifying and managing high-risk pregnancies (69%), in preventing complications (60%), and in strengthening the link between the patient and the health system (51%).

3.2.3. Knowledge of the Performance of ANC Free of Charge before the Last Pregnancy

Figure 3. Knowledge of the performance of ANC free of charge before the last pregnancy.

Figure 3 demonstrates that nearly 12% of the mothers surveyed were not informed about the free provision of ANC before the last pregnancy.

3.3.1. The Number of ANCs Performed

Table 3 shows that the majority of women studied had two antenatal care visits during pregnancy, a rate of 38%. Nearly 31% had three antenatal care visits, nearly 23% had one antenatal care visit, and nearly 8% had four antenatal care visits.

Table 3. Number of prenatal consultations carried out during pregnancy.

3.3.2. Free Access to Care for ANCs

Since 2012, maternity care has been free. This free service is the result of the targeted free care policy implemented by the Ivorian government and covers prenatal (ANC) and postnatal (CPoN) consultations, additional examinations (ultrasounds, laboratory analyses), normal delivery and its complications, caesarean sections, etc. However, patients must cover other indirect costs such as transport costs, booklet fees as well as the cost of medications not available at the health facility.

The mothers interviewed confirmed that ANC is free in the Sinfra district.

3.3.3. Influence of Free Care on Early Completion of ANC

Figure 4. Influence of free care on early completion of ANC.

The majority of mothers initiated prenatal consultations early because they were free, at a rate of 61% as demonstrated in Figure 4.

3.3.4. Period of Implementation of ANC1

Table 4. Period of carrying out the first prenatal care.

It appears that the majority of women studied had their first prenatal consultation before the third month of pregnancy, a rate of 61.5%, as shown in Table 4. Nearly 30.8% had it in the third month and nearly 7.7% had it after the third month of pregnancy.

3.3.5. Factors Associated with Non-Completion of All ANC

Table 5. Factors associated with absence from prenatal care.

The table shows that several factors prevented the women studied from attending all prenatal consultations. While the majority of women mentioned a lack of financial means (34.62%) or a lack of time (26.92%), others mentioned treatments traditional, waiting times for consultations, difficulties in getting to the centers. For certain questions, particularly those related to the barriers to ANC completion (Table 5), respondents were allowed to provide multiple answers. As a result, the cumulative percentages in the corresponding tables may exceed 100%.

3.4.1. Implications of Free Healthcare

Table 6. Implication of free healthcare.

Table 6 shows that free maternity care led nearly 8% of mothers to complete all prenatal care visits. Nearly 13% mentioned its importance in providing easy access to health services. However, the majority emphasized the importance of free care in reducing pregnancy-related expenses, at a rate of 79%.

3.4.2. Influence of Free Care on the Quality of ANC Services

Figure 5. Influence of free care on the quality of ANC services.

The majority of mothers reveal the deterioration in the quality of prenatal consultation services and associate it with the result of free care, as shown in Figure 5.

3.4.3. Other Services to Be Included in the Free Delivery Kit

Table 7. Other services to be included in the free delivery kit.

Various other services were offered to improve the free delivery kit in the city of Sinfra, shown inTable 7. These services included: additional medical examinations; transportation to health centers; and the purchase of records and medications. However, the majority of mothers focused on additional medical examinations and medications.

The free prenatal care policy aims to reduce financial barriers such as consultation fees, basic medications, and certain tests. This leads to a reduction in expenses related to pregnancy and childbirth. Our study revealed that free prenatal care has helped reduce pregnancy-related expenses and facilitated access to health services.

However, the experience of the mothers surveyed in this study shows that financial determinants are not sufficient to improve attendance at all prenatal appointments. Indeed, other factors intervene in the attendance of ANC. These factors have also been highlighted by other researchers and concern: travel, loss of income related to the choice to attend antenatal care, particularly in the context of vulnerable families, distance from health facilities, low knowledge of the benefits of ANC, cultural constraints, lack of awareness, social norms, concerns related to the quality of services, etc.

Indeed, even if our results reveal that free prenatal care led to the early completion of ANC, the rate of completion of at least four (04) ANC is very low. Only 8% of mothers managed to participate in four (04) ANC. These women reveal several factors: lack of money, professional responsibilities, poor road conditions during the rainy season, recourse to traditional remedies, child care. K. Kouassi et al. [11] confirm the weight of traditional medicine in the abandonment of ANC. Salifou et al. [12] also support the weight of difficulties in geographical accessibility of health facilities, which leads to discouragement in the completion of ANC.

As in any industry, service quality is a key determinant of customer satisfaction and loyalty. In the context of prenatal care services, it plays an important role in ensuring continued ANC attendance.

Free care is generally associated with increased demand, which increases the burden on workers. The consequences for clients are: long queues, poor quality of care received, etc. In some settings, the overflow of health facilities, particularly in a vulnerable context where it is the pregnant woman who must go to the market after the consultation or go to the fields to look for food for the family and herself, can constitute an obstacle to regular attendance at prenatal appointments.

Free prenatal care also requires careful planning to ensure a sufficient supply of medical equipment, medications, and qualified personnel, which is not always guaranteed, particularly in developing countries, which are often characterized by insufficient resources. This can lead to stockouts, affecting the quality of care and leading to mistrust of prenatal care services among pregnant women.

In the context of our study, 100% of the mothers interviewed deplored the quality of prenatal care in local health establishments, which also explains this high abandonment rate of 92%. Cheickna [2] also confirms the importance of the quality of care in the continuity of ANC. Kochou HA Salomonet al. [13] integrates the reception of pregnant women in prenatal consultation into the quality of prenatal care.

However, the use of snowball sampling as a non-probabilistic method introduces potential selection biases. Mothers more integrated into social networks may have been overrepresented, while more isolated individuals might have been missed. As such, while the findings provide valuable insights, they cannot be generalized to the entire population of mothers in the Sinfra district.