Spatiotemporal distribution and determinants of delayed first antenatal care visit among reproductive age women in Ethiopia: a spatial and multilevel analysis

One of World Healh Organization (WHO’s) top priorities is to promote maternal health, including antenatal care (ANC), which is one of the Healthy Motherhood Initiative’s four pillars [1]. Maternal health refers to the well-being of women before, during, and after pregnancy, as well as during childbirth and the postpartum period [2]. Antenatal care (ANC) can be defined as the care provided by skilled healthcare providers to pregnant women and adolescent girls to ensure the best maternal and child health during pregnancy [3]. Antenatal maternity care is a way for pregnant women to enter the health-care system and allows them to arrange the resources they need to have a stable pregnancy, a safe childbirth, and a healthy mother-baby pair [1, 4].

The ANC promotes the health of pregnant women and has been demonstrated to reduce the risk of unfavorable pregnancy effects, perinatal and fetal mortality, and morbidity [5, 6]. The ANC’s early visit allows health care workers to test and treat numerous maternal and fetal health issues as soon as possible, such as malnutrition, sexually transmitted diseases, congenital malformations, and other pregnancy complications [5]. The first stair flight to hit the maximum of success for healthy motherhood is antenatal care (ANC) [6]. For early detection of pregnancy-related problems and unfavorable pregnancy outcomes, like low birth weight, stillbirth, intrauterine fetal death and other complications, early initiation of ANC are essential, however, most of the mothers initiate ANC late [7, 8].

Prenatal care is more likely to be successful if women start receiving care in the first trimester of pregnancy and continue to receive care throught pregnancy, according to agreed guidelines [9]. The first antenatal check-up is defined as the first time a pregnant woman attends to a maternity health services to receive health care. It is used to consider the health status of mothers and the fetus, to predict the gestational age (GA) and expected delivery date (EDD), and to launch plans for future follow-ups [7].

The first trimester of pregnancy is the fetus’s most rapid developing stage, during which all of its organs are fully developed and require special care [10]. ANC follow-up during this period indirectly saves the lives of babies and mothers by promoting and establishing good health and proper nutrition of both the child [11]. Malnutrition of the child in the first 1000 days which results from poor adherence to ANC is associated with poorer cognitive development and lower educational outcomes [12].

Pregnant women in developing countries should have at least four ANC checks, with the first one occurring before the gestational age of 12 weeks, according to the World Health Organization (WHO) [13].

Daily, 830 women die in the world as a result of pregnancy and childbirth-related problems, and more than 303,000 women die annually [14]. Almost all, of those deaths, occur in developing countries, and from this, Sub-saharan Africa alone accounts for about 66%, followed by Southern Asia 22% [14]. Furthermore, it is reported that 2.6 million babies are stillborn, with another 4 million newborns dying during the neonatal period. Many of these deaths may have been prevented without delay during the first visit by measures offered as part of basic antenatal care services [14, 15].

While the worldwide coverage of early prenatal care visits rose by 43% between 1990 and 2013, only less than half of all women in less developed countries had early prenatal care visits [16]. Maternal mortality continues to vary between developing and developed countries. The overall lifetime risk of a woman’s death due to pregnancy and related causes is estimated at 1 in 180 in developing countries, while it is around 1 in 4900 in developed countries [17].

Ethiopia is one of the Subsaharan African countries which have a high magnitude maternal mortality rate which was 401 per 100,000 live births in 2017 and remains among the highest in the world [10, 18]. In developing countries like Ethiopia, obstetric complications during pregnancy and childbirth are the leading causes of death among reproductive-aged women [19, 20]. The lack of access and insufficient use of antenatal care (ANC) during pregnancy is widely recognized as leading to adverse maternal health outcomes. Antenatal care uptake is one of the key indicators for monitoring the progress of improving maternal outcomes [8, 19‐21].

A systematic study and meta-analysis conducted in Ethiopia found that the pooled magnitude of delayed ANC was 64% [17]. In another study in Ethiopia also showed 89% of women made their first antenatal care visit after the fourth month of pregnancy nationwide [10]. The study was conducted based on the 2011 Ethiopian demographic and health survey (EDHS) and, a study conducted in Addis Zemen primary hospital showed that 66.3 and 52.5% of women did not use ANC in the first trimester respectively [22, 23]. But in the study conducted in the Tigray region, Ethiopia it was 27.5% [24].

Different studies on determinants of antenatal care utilization of show that women living in urban residence [5], having old age [5], having low parity [5], being educated and having an educated partner [5, 24], being employed [5, 22], being exposed to mass media [5], being married [5, 25], and having an ANC follow up at a private hospital or clinic [25] had a positively associated with good ANC attendance and timeliness (Fig. 1).

However, having an unplanned pregnancy [5, 22, 24], having previous pregnancy complications [5], having more than six children [25], lack of husband’s support [5], increased distance to the health facility [5, 22, 25], and not having health insurance and high cost of services [5, 25], were found to be the cause for delayed antenatal visits (Fig. 1).

This study hypothesized that there is a variation in the distribution of delayed first ANC visits in time and region in Ethiopia and there are factors that contribute to these variations. Therefore this study aimed to investigate the spatiotemporal distribution of delayed first ANC visits and its predictors using multilevel binary logistic regression analysis which could certainly provide new evidence helpful for implementers for highly targeted and effective interventions.

The findings of this study are also essential in determining which factors are most important in postponing their first ANC visit, as well as answering the question of when and where delays in their first ANC visit are more common, and what are the causes for this spatiotemporal distribution.

This study shows that 67.6% (95%CI: 66.3 to 68.9%) of women had delayed to take their first ANC visit in recent 2016 EDHS. This finding was almost similar to a systematic review and meta-analysis study conducted in Ethiopia (64%) [17]. However, the research is done in Bangladesh revealed a small prevalence of delayed first ANC visit (13.5) [20]. This discrepancy is may be due to differences in health service coverge and health-seeking behavior of the societies in western countries.

According to our finding factors associated with delayed first ANC visit were women with no education, women with an unwanted pregnancy, and residence of women. In our study, as compared with educated women, uneducated women have more likely to have delayed first ANC visit. This finding was supported by a systematic review and meta-analysis study conducted in Ethiopia [17], research done in Debre Markos, Ethiopia [10], and research done on Tribal women of Bangladesh [20]. This shows that increasing women’s educational status has a positive impact on timely booking of their first ANC visit.

In this study women who had an unwanted pregnancy for their last child was associated with an increased occurrence of delayed first ANC visit. This is in line with a systematic review and meta-analysis study conducted in Ethiopia [17, 33], research done in Tanzania [34], a study in Rwanda [25]. This might due to lack of information, lack of decision-making authority, lack of resources, or cultural factors, women with unintended pregnancy may delay ANC initiation [33]. Unintended pregnancies are often linked to social and cultural determinants of health-seeking behaviors, such as sexual harassment, inadequate use of family planning, which are barriers to health care access, which leading to the late initiation of ANC [33].

Living in a rural area was found to be associated with an increased occurrence of delayed first ANC visit in women. This is in line with studies conducted in Ethiopia [17, 23]. This might due to that the the distance from the healthcare facility and the quality of ANC services provided may be mediating such outcomes. Other factors like knowledge about the importance of timing and frequency of ANC visits also have a contribution [23]. The spatial distribution of delayed first ANC visit was almost similar in the three survey years. In EDHS 2005 hot spot areas of delayed first ANC visit were detected in entire of Tigray, Northern west Amhara, and the southern part SNNRP regions, whereas in 2011, and 2016 EDHS high clustering of delayed first ANC visit was detected in most parts of Tigray, the western part of Benshangul Gumuz, southern Oromia and the northern part of SNNPR regions. It was supported by multivariate analysis in this study which shows that women who live in SNNRP, Benshangul Gumuz, and Oromia regions had higher odds of delayed first ANC visit as compared to Addis Ababa. The inclusion of nationally representative datasets gave this study its merits, allowing it to be generalised to all reproductive-age women in the study context. Secondly, the estimates of the study were done after the data were weighted to make it representative at the national and regional levels. This study included the spatiotemporal distribution of delayed first ANC visit which was spatially autocorrelated. However, this study is not free from limitations, Since 21 clusters did not have coordinated data we excluded it in the analysis which may affect the estimated result. The data used in this study are cross-sectional data, which limit the conclusions about the causality of factors in the dependent variable. Since it was secondary data some important variables like behavioral factors and service utilization-related parameters were missed.

According to this study, even if the proportion of pregnant women who had delayed the first ANC visit decreased in each consecutive survey, the magnitude of the problem is still high. Maternal education was positively associated with delayed first ANC visit, whereas having unwanted pregnancy for the last child and rural residence have negatively associated with delayed first ANC visit. In Ethiopia delayed first ANC visit varies in each EDHS period and across regions. In recent two EDHS, high clustering of delayed first ANC visit was detected in most parts of Tigray, the western part of Benshangul Gumuz, Southern Oromia, and the northern part of SNNPR regions.

Therefore, The governmental and non-governmental organizations should work by giving special attention to those groups of women who had a higher prevalence of delayed ANC visit such as unwanted pregnancy for the last child and living in rural residences is needed. Women’s education should be encouraged and better expand. A targeted intervention program is also required in highly affected regions of Ethiopia. A further case-control study will be needed to dig out the proximal factors contributing to the delayed first ANC visit.