Antenatal care (ANC) is defined as the care provided by skilled health care professionals to pregnant women and adolescent girls in order to ensure the best health conditions for both mother and baby during pregnancy [1]. The components of ANC are risk identification, prevention and management of pregnancy-related or concurrent diseases, health education, and health promotion [1]. The World Health Organization (WHO) recommends that pregnant women in developing countries initiate early prenatal care before the end of the fourth month of pregnancy [2].  ANC in the first trimester is fundamental and decisive in identifying and evaluating the risk factors usually present before pregnancy [2]. However, in developing countries, the coverage and early initiation of ANC are lower than in developed countries. A significant number of pregnant women started their first ANC visit during the second and third trimesters because of different factors in different developing countries [3].

Worldwide, 85 percent of pregnant women received antenatal care with skilled health care providers at least once, and only 49 percent received at least four antenatal visits in sub-Saharan Africa [4]. Globally, more than half a million women are still dying annually as a result of complications of pregnancy and childbirth, and ninety-nine percent of these occur in developing countries [5]. Of these deaths, 50 percent occurred in sub-Saharan Africa [5, 6]. According to the 2016 Ethiopian demographic and health survey report (EDHS), 62 percent of women who gave birth in the five years preceding the survey received antenatal care from a skilled health care provider at least once for their last birth, and only 32 percent had four or more ANC visits for their most recent live birth [7]. The lifetime death risk of a woman from pregnancy-related causes in sub-Saharan Africa is 1 in 16, which is 500 times higher than for a woman in Northern Europe [8].

Age, a woman’s place of residence, level of education, employment status, intention to get pregnant, economic status, health insurance, parity, and traveling time are among the most cited factors related to late ANC visits [1-4].

Proper care during pregnancy and delivery is important for the health of both the mother and the baby. Antenatal care from a skilled provider is important to monitor pregnancy and reduce morbidity and mortality risks for the mother and child during pregnancy, delivery, and the postnatal period [6, 7]. In developing countries, however, only 50 percent of pregnant mothers receive the recommended number of antenatal care visits and start late in their pregnancy. To our knowledge, there are limited studies conducted on ANC and its associated factors in the study area. Thus, the aim of this study was to assess the magnitude and factors associated with the timing of antenatal care attendance in Hawassa City, Sidama, Ethiopia.

Study Setting and Design       

A facility-based cross-sectional study was conducted at Hawassa City, the capital of the Sidama Region, which is located 275 kilometers South of Addis Ababa [9]. The total population of the city is 394,057 [9]. There are 4 public hospitals (Hawassa University Comprehensive Specialized Hospital, Adare General Hospital, Motite Primary Hospital, and Tula Primary Hospitals), 4 non-governmental hospitals, 11 governmental and 1 non-government health centers, and 7 diagnostic laboratories in the city [9]. Of these, three randomly selected health centers were included in the study.

Study Population and Sample Size

Mothers who were following ANC at the health centers of Hawassa City Administration were included in the study. Women who were mentally and physically incapable of being interviewed, including those who were ill, were excluded from the study. Three health centers (Tula, Alamura, and Millennium) were randomly selected among the eleven health centers found in the city. A systematic random sampling technique was used to select study participants. A single population proportion formula was used to calculate the sample size. Using the assumptions, the level of significance is 5%, the margin of error is 5%, and the prevalence of late initiation of ANC is 82.6% [10]. A contingency of 10% was considered for non-respondents. Finally, a total of 235 pregnant mothers participated in the study.

Data Collection Tools and Procedures

The questionnaire was developed after reviewing literature that has similar study objectives and the EDHS tools. The questionnaire was developed in English first and then translated into Amharic by a translator to ensure its consistency. Finally, it was translated back into English. A structured questionnaire, which contains questions on the socio-demographic characteristics of the mothers, their knowledge of ANC, their past history of ANC service utilization, their current pregnancy, their current utilization of antenatal care, and the timing of their first ANC-related measures, was used to collect the data. The timing of the ANC visit was explained as a categorical variable with two possible values: early beginning of the ANC ("yes") or late initiation ("no") of the ANC visit. Information regarding the study was explained to study participants before the interview. Data was collected from mothers through direct interviews conducted in Amharic face-to-face at the exit of the ANC clinic. Data collection was conducted by four trained BSc midwives on day and night rotations to address the assigned sample size. To minimize bias and ensure the high quality of the information, training was given to data collectors and supervisors. Before data collection, 5% of the sample was pretested, and corrections were made outside of the study area. Throughout the data collection process, monitoring of the data collection, timely feedback, and checking for questionnaire completeness and consistency were done.

Statistical Analysis      

The data cleaning and analyses was done using the Statistical Package for Social Science (SPSS) version 26. Descriptive statistics was used to summarize the data. Logistic regression model was used to analyze the data. Bivariable analysis was conducted to identify candidate variables for the final model, considering p-value < 0.25. An adjusted odds ratio (AOR) with a 95% confidence interval was used to determine factors associated with the outcome variable with a p-value < 0.05, to declare statistical significance.

Ethical Consideration

Ethical clearance was obtained from research review and ethics committee of Hawassa college of Health Sciences. Legal permission was obtained from the health centers. The respondents were informed about the purpose of the study and their right to withdraw at any time. Furthermore, written consent was obtained from each respondent. Informed assent was obtained from a parent or guardian for study participants younger than 18 years of age. Confidentiality was maintained throughout the study by excluding personal identifiers, such as names and addresses.

Socio Demographic Characteristics of the Study Participants

A total of 235 study subjects participated in this study, with a response rate of 100%. The mean age of the respondent was 27 years, and it ranges from 15 to 39 years. The majority of the respondents, 89 (37.9%), were in the age group of 25–29 years. Regarding their ethnicity, about 105 (44.7%) was Sidama, followed by Wolyta, which was 57 (24.7%). More than half of the respondents, 133 (56.6%)) were Protestant, 76 (32.3%) were Orthodox, 19 (8.1%) were Muslims, 3 (1.3%) were Catholic, and others were 4 (1.7%). Out of 235 respondents, 232 (98.7%) were married, 2 (0.9%) were unmarried, and the rest (1.4%) were widowed.

More than half of the respondent’s educational level was secondary school (9–12 grade) and college (university), which accounts for 87 (37.0%) and 75 (31.9%), respectively. The net incomes of 185 (78.7%) respondents were greater than 2000 ETB, and only 12 (5.1%) respondents’ incomes were found to be between 500 and 1000 ETB per month (Table 1).

Table 1: Socio - demographic characteristics of pregnant women who come for the first ANC visit in three selected health centers from September 1 to 30, 2022, n=235.

Economic and Pregnancy Related Factors of Pregnant Women Who Come for The First ANC Visit

Based on their income, more than three-fourths 185(78.7%) of the respondents were getting net income per month of >2000ETB, while only 12(5.1%) were getting 500-1000ETB net income per month.  About 173(75.9%) of the respondents had no payment for transportation and 154(65.54%) of the respondents were paying <20 ETB for transportation. Concerning their number of pregnancy, about 98(41.7%) of the respondents had once, while 32(13.6%) of the respondents had four and more times. About 204(86.8%) of the respondents had no history of abortion. Based on their number of parity, 106(45.1%) of the respondents had none, and 8(3.4%) of the respondent had 4 and more times. The majority, 23(98.3%) of the respondents had the history of stillbirth (Table 2).

Table 2: Economic and pregnancy related factors of pregnant women who come for the first ANC visit in three selected health centers from September 1 to 30, 2022.

By the respondents to initiate the first ANC after amenorrhea was different. About 4 (1.7%) responded that it is better if the first ANC is initiated in the first month, 28 (11.9%) responded that it should be initiated in the second month, 105 (44.7%) responded that it should be initiated in the third month, 91 (38.7%) responded that it should be initiated in the fourth month, and the rest (7.0%) responded that it should be initiated in the fifth and above month. Only 3 (1.3%) of respondents believe that the frequency of ANC is two times, 30(12.8%) believe it is three times, the majority of respondents (136, 57.9%) believe it is four times, and the rest (66, 28.1%) believe it is five or more times over the pregnancy. Regarding knowledge of danger signs, 121 (51.5%) respondents had no knowledge of danger signs that may occur during pregnancy, while the rest, 114 (48.5%) of the respondents, had knowledge. The majority of respondents mention vaginal bleeding and cessation of fetal movement as danger signs. From those who got ANC during a previous pregnancy, 30 (23.3%) respondents did not have knowledge of danger signs, while 99 (76.7%) had knowledge (Table 3).

Table 3: The knowledge status of the pregnant women towards the ANC service who come for the first ANC visit in three selected health centers from September 1 to 30, 2022.

Past History of ANC Service Utilization Among Pregnant Women

During the previous pregnancy, 8 (5.8%) respondents did not utilize ANC services, while the rest (129 (94.2%)) did. From those who had a history of ANC utilization, 53 (41.1%) respondents initiated their first ANC visit within 16 weeks of gestation, while 75 (58.9%) respondents initiated their first ANC visit after 16 weeks of gestation. Even though the service is given free of charge, some respondents paid money for some services. Three respondents were paid money for ultrasound, which ranges from 100-200 ETB (Table 4).

Table 4: Past history of ANC service utilization of pregnant women who come for the first ANC visit in three selected health centers from September 1 to 30, 2022.

History of Current Pregnancy

Among the total respondents, 131 (55.7%) knew their pregnancy by missed periods, 81 (34.5%) knew it by laboratory, 21 (8.9%) knew it by physiological and physical changes of the body, and the rest (2.9%) knew it by ultrasound. 62 (26.4%) respondents initiated their first ANC visit within 16 weeks of gestation, and the rest (173 (73.6%) respondents initiated their first ANC visit after 16 weeks of gestation during this pregnancy. From 235 respondents, 137 (58.3%) had information about antenatal care services, while 98 (41.7%) did not have any information.

Of the total respondents, 188 (80.0%) used family planning, and 47 (20.0%) did not use family planning before this pregnancy. Injectable and implants were the most commonly used family planning methods, with 100 (53.2%) and 66 (35.1%), respectively. Regarding the plan of pregnancy, 202 (85.5%) of the respondent’s pregnancy was planned, with all 202 (86.0%) of the husband's involvement in the pregnancy planning, and the rest, 33 (14.0%), was not planned, with only 28 (82.4%) of the husband's acceptance after the occurrence of an unplanned pregnancy. Regarding pregnancy plans, 202 (86%) respondents pregnancies were planned with their husband’s involvement, and the rest, 33 (14.0%), were not planned (Table 5).

Table 5: Current pregnancy history of pregnant women who attend ANC clinic for the first ANC visit in three selected health centers from September 1 to 30, 2022.

Current ANC service utilization of pregnant women

Among the study subjects, 198 (84.3%) of respondents came to the ANC clinic for a pregnancy checkup, and 37 (15.7%) of respondents came to take the TT vaccine. The majority, 218 (92.8%) of respondents, come to the clinic by themselves, while the rest (17.2%) are sent by another person (health extension workers). More than two-thirds (68.9%) of respondents came to the ANC clinic for their first ANC after 16 weeks of gestation. The reason for coming after 16 weeks of gestation for the first ANC visit was health professional’s advice not to come to ANC early before four months. 84 (51.5%), absence of problems during pregnancy for 30 (18.4%) of respondents, acceptance that it is the right time to start ANC for 41 (25.2%) of respondents, work load in the office and business area for 15 (11.8%) of respondents, and 8 (4.9%) of respondents. The place where they will give birth was assessed. Out of a total of 235 respondents, 216 (91.9%) prefer health institutions, and 4 (1.7%) prefer to deliver their child at home. But 15 (6.4%) of the respondents had not decided where to give birth (Table 6).

Table 6: Current ANC service utilization of pregnant women who come for the first ANC visit in three selected health centers September 1 to 30, 2022.

Figure 1: Gestational age at first antenatal care initiation of pregnant mother who attend antenatal clinic in public health centers from September 1 to 30, 2022.

Factors Associated with The Late Initiation of The First ANC Visit

Bivariate logistic regression was conducted to identify candidate variables for the final model, considering a p-value <0.25. In our study, previous late first ANC initiation, having no information about ANC service, and unplanned pregnancy were identified as factors that have an association with the timing of current late first ANC initiation (Table 7).

Table 7: Bi-variable analysis of factors associated with late initiation of first antenatal care among pregnant women who attend ANC clinic late for the first ANC visit in public health centers from September 1 to 30, 2022.

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