Spatial distribution of antenatal care utilization and associated factors in Ethiopia: evidence from Ethiopian demographic health surveys

Antenatal care refers to the regular medical and nursing care recommended for women during pregnancy to prevent, detect and treat complications [1]. Timely initiation of antenatal care is an opportunity to prevent the direct causes of maternal deaths and reduce fetal and neonatal deaths related to obstetric complications [2].

Globally, about 300,000 women die each year as a result of pregnancy related complications [3], 2.6 million babies are estimated to be stillborn [4], and 4 million newborns die in the neonatal period. In sub-Saharan Africa and other resource-poor settings, maternal mortality remains a major public health problem [3, 5]. Such deaths could be prevented if pregnancy and birth-related complications are managed properly through the expansion and uptake improvement of basic antenatal care service [6].

In Ethiopia, the levels of maternal and infant morbidity and mortality are among the highest in the world [7]. These major problems could be addressed by proper utilization of ANC, skilled delivery and postnatal care services [8]. Geographic accessibility of the services is one of the most important factors associated with utilization of maternity care [9]. Rural populations are particularly disadvantaged as they often lack reliable means of transport [10]. Women who have a higher density of clinics nearby have a lower risk of starting antenatal care late [11].

Understanding the levels and geographical variations of ANC utilization would help policymakers, planners, programmers and partners in the health sector to formulate appropriate strategies and interventions and provide quality reproductive health services. The aim of this study was to assess the spatial distribution and identify factors associated with ANC utilization using evidence from the Ethiopian Health and Demographic Surveys between 2000 and 2011.

There are 14,642 households and 15,716 eligible women in 2000, 14,645 households and 14,717 eligible women in 2005, and 18,720 households and 17,385 eligible women in 2011. From this, a response rates for the first, second, and third surveys were 97.8% (n = 15,370), 95.6% (n = 14,069), and 95% (n = 16,515), respectively. The actual women included in this study were 7967 in 2000, 7304 in 2005, and 7909 in 2011.

SaTScan and GIS-based spatial statistical techniques provide an opportunity to clarify and identify antenatal care utilization within a country and help future investigations into factors responsible for increased antenatal care utilization. Geographic visualization of ANC utilization using these tools was instrumental to understand highest and modest utilization level and target interventions in high-risk areas. This study has provided a visually powerful analysis of spatial variation in antenatal care utilization among women in Ethiopia.

ANC utilization rate has substantially increased from 26.7% in 2000 to 27.6% in 2005 and 42.5% in 2011 in Ethiopia. High variations, however, are observed between rural and urban areas. This variation may be because of proximity of the health facility in the village and the geographical distribution of ANC clinics. These reasons are consistent with findings of another study in Brooklyn, US [11]. In all surveys, women from urban areas had less numbers than women from rural areas (11.4% versus 88.6%, in 2000, 8.7% versus 91.3% in 2005, and 15% versus 85% in 2011, respectively. There is also variation in antenatal care utilization across the country’s regions. Highest antenatal care utilization rates were reported in Addis Ababa, Dire Dawa, Harari, whereas comparatively modest utilization was reported in Somali regions and Affar. These regions are relatively urban in which health facilities are more accessible and women are more aware of maternal health services. The multivariable model also revealed consistent finding in which Tigray and Addis Ababa were the places where the highest ANC utilization is recorded and Somali is found to be the place where small number of mothers got ANC as compared to the biggest region (Oromia). These reasons are consistent with the findings of another study in Ethiopia [14].

Another factor that affected ANC utilization was the income of the mother, the odds of ANC utilization being higher among women in the richest wealth quintile. Even though, ANC is currently under exempted service in health facilities in Ethiopia, it was not like this before and women should pay to get the service. In addition, income would also affect health seeking behavior of the mother in which poor mothers had low health seeking behavior [15, 16].

Age of the mother and birth order are the other predictor variables reported to have an association with ANC utilization. Relatively younger women and whose pregnancy is for their first time were more likely to attend ANC service as compared to older and multiparous women. Similar studies have also reported an indirect relationship between parity and maternal services; women’s of high parity tend to use ANC less [17, 18]. This could be explained by low to no experience about the current pregnancy will make the new mother to have some sort of fear of risks associated with her pregnancy that make her more curios to have frequent ANC visits. The perception that they had better knowledge about pregnancy complications would be another factor that explains low ANC uptake by mothers who had more number of children as compared to new mothers [19].

Like previous studies [17‐19], in the current analysis, educated women were more likely to utilize ANC as compared to those relatively educated. It is true that education enhances the health seeking behavior of the mother, it also make the mother to actively involved in different knowledge enhancement activities like reading materials, service promotions, and peer discussions. It is also believed that more educated mothers would tend to give better care and concern for their health and their fetus and they are also more likely to strive to know benefits of the service and associated pregnancy complications.

This study identified spatial clusters of ANC utilization in Somalia Region with low utilization rates and Addis Ababa with the highest utilization rate. Richest wealth quintiles, lowest number of birth order, educated, living in urban areas and being younger increased the likelihood of utilizing ANC. These results provide further insights into identifying the true picture of ANC utilization clusters in the country and enable efficient and timely spatial targeting factors triggering low utilization of antenatal care.