Early antenatal care (ANC) booking and associated factors among pregnant women attending ANC services at public health facilities in Bahir Dar City Administration, Northwestern Ethiopia, 2023: a cross-sectional study

Abstract

Antenatal care (ANC) is vital for improving maternal and fetal health by enabling the early detection and management of pregnancy-related complications. The World Health Organization recommends a minimum of eight ANC contacts to optimize maternal and neonatal outcomes and reduce perinatal mortality. Increased ANC contacts enhance the opportunity to identify and address potential complications, and studies show that eight or more ANC visits can reduce perinatal deaths by up to 8 per 1,000 births compared to fewer visits. Therefore, the main objective of this study is to assess early ANC booking and its associated factors among pregnant women attending antenatal care at public health facilities in Bahir Dar City Administration, Northwestern Ethiopia.

Methods An institution-based cross-sectional study was conducted from October 1st to November 1st, 2023, involving 392 randomly selected pregnant women. Data were collected through interviewer-administered, pre-tested structured questionnaires. Binary and multivariable logistic regression analyses were used to identify factors associated with early ANC booking. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) were reported, and statistical significance was set at p < 0.05.

Results About one-third of participants (32.7%) initiated ANC early (95% CI: 28.3%–37.2%). The majority (92.3%) had at least a primary level of education, and 71.4% were aware of the importance of early ANC. Factors significantly associated with early ANC booking included maternal education (AOR = 1.62), receiving counseling on early ANC booking (AOR = 4.00), and obstetric history, specifically higher gravidity and parity (AOR = 1.55).

Conclusion Early antenatal care (ANC) booking among pregnant women was found to be suboptimal. The key determinants of early antenatal care (ANC) booking included maternal educational status, receipt of counseling, and obstetric history, specifically gravidity and parity. These findings underscore the need for targeted health education interventions and individualized counseling approaches to promote early ANC engagement and enhance maternal health outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-025-08450-x.

Background

Antenatal care (ANC) refers to the healthcare services and support provided to pregnant women by skilled healthcare professionals throughout pregnancy. Its primary goal is to ensure the health and well-being of both the mother and the unborn child by monitoring the progress of the pregnancy, detecting potential complications, providing education and counseling, and preparing for childbirth and postnatal care [1, 2]. Key components of ANC include risk identification, prevention and management of pregnancy-related or concurrent conditions, and health promotion [3, 4].

Importantly, early antenatal care (ANC) booking preferably within the first trimester is critical for improving maternal and fetal health outcomes. Early ANC booking allows for timely identification of risks, implementation of preventive measures, and delivery of essential health education and services at a stage when interventions can have the greatest impact [5, 6].

The newly proposed model of ANC recognizes that every pregnant woman is at risk for complications and emphasizes more frequent visits to ensure better maternal and fetal health outcomes [7, 8]. The World Health Organization (WHO) has revised its recommendations to suggest at least 8 ANC visits for all pregnant women throughout their pregnancy [9]. This shift from the previous 4-visit model is based on evidence indicating that increased contact with healthcare providers leads to better detection and management of potential complications, ultimately improving maternal and newborn health outcomes [10, 11].

Early antenatal care (ANC) booking is a fundamental aspect of maternal and fetal health, aiming to reduce complications and improve outcomes [12]. Early antenatal care (ANC) booking is a fundamental aspect of maternal and fetal health, aiming to reduce complications and improve outcomes [13]. Maternal death, is a death of a woman during pregnancy, childbirth, or within 42 days of the end of pregnancy due to pregnancy-related causes, remains a significant global health concern [14]. Despite advances in maternal healthcare, maternal mortality rates are still high in many parts of the world, especially in low- and middle-income countries [15]. The World Health Organization (WHO) and other global health entities closely monitor maternal mortality to assess progress and identify areas for improvement [16].

Globally more than 830 women dying each day and over 303,000 deaths per year due to pregnancy and childbirth-related complications, maternal mortality remains a pressing global issue [16]. Almost 99% of these deaths occur in developing countries, with sub-Saharan Africa accounting for 66% and Southern Asia for 22% [17, 18].

These figures underscore the disparities in healthcare access and quality. Though early antenatal care booking allows for early detection and management of complications during pregnancy, reducing the risk of adverse outcomes [19, 20]. Despite its benefits, many women start ANC late, often after 16 weeks of gestational age and its delay increases the risk of complications going undetected [21, 22].

Factors like residence, age, educational status, employment, economic status, travel time to healthcare facilities, lack of health insurance, cultural attitudes towards pregnancy and access to education can impact the timing of ANC initiation [23].

While there are studies on early antenatal care booking in Ethiopia, there is limited data for specific regions like our study area. This gap in knowledge necessitates further research to understand local factors affecting early ANC booking, identify unique factors influencing ANC booking and suggest targeted interventions.

Addressing maternal mortality and promoting early ANC booking require a multi-faceted approach. Efforts should focus on improving healthcare access, addressing socioeconomic barriers, and increasing education and awareness about the importance of early ANC. Research studies in specific regions like Axum can provide insights into local factors affecting ANC initiation, allowing for tailored strategies to improve maternal health outcomes.

Methods and materials

Study area and paired

The study was conducted from October 1 st to November 1 st, 2023, at selected public health facilities in Bahir Dar City Administration, Northwestern Ethiopia. The study was focus on all pregnant women attending ANC in Bahir Dar city which is one of the leading tourist destinations in Ethiopia. Bahir Dar, the capital of the Amhara National Regional State, is situated 563 km northwest of Addis Ababa, the capital of Ethiopia. The city is notable for its proximity to Lake Tana, the largest lake in Ethiopia and the source of the Blue Nile River, which flows through the city, bordering its eastern side.

As per the Central Statistical Authority (CSA-2021), Bahir Dar city is situated at coordinates 11°37′ N and 37°25′ E. The total population of Bahir Dar is approximately 332,865, with 166,992 (50.2%) being women. The city has three public hospitals, ten health centers, and numerous private health institutions, according to the Bahir Dar City Administration Office.

Study design and populations

An institution based cross-sectional study design was employed among all pregnant women who attended antenatal care (ANC) services at selected public health facilities in Bahir Dar city administration during the data collection period.

Eligibility criteria

Pregnant women who attending ANC at these selected public health facilities in Bahir Dar city administration during the data collections and volunteer to participate in the study were included in the study as a sample. But pregnant women who were mentally and critical ill at the time of data collection were excluded.

Sample size determination and sampling procedure

The sample size (n) required for this study was determined using a single population proportion formula (n=(Zα/2)² p(1-p)/d²)); Here’s the breakdown: n- represents the required sample size, Zα/2²: is the z-score for a 95% confidence interval, which is 1.96 at α = 0.05, p: is the estimated proportion of timely antenatal care (ANC) visits, assumed to be 40.6% [24], and d: is the margin of error, set at 5%. Adding a 10% non-response rate. Substituting these values into the formula, we calculated the sample size. Considering a potential 10% non-response rate, the final required sample size came to 406.

Pregnant mothers were allocated to each hospital and health center using proportionate allocation based on the number of antenatal care attendees at each facility. A sampling frame was prepared for each of the four selected facilities (Felege Hiwot Comprehensive Specialized Hospital, Tibebe Ghion Specialized Teaching Hospital, Han Health center, and Bahir Dar health center). After determining the proportionate sample size for each facility, systematic sampling was employed to select participants.

From each facility’s sampling frame, every kth pregnant mother was selected, where the k interval was calculated based on the total number of ANC attendees and the required sample size for that facility. The starting point for the selection was determined randomly using a lottery method. This process was repeated until the required sample size was achieved at each facility. The value of k varied across facilities depending on the size of the sampling frame and the allocated sample. 7th, 8th, 6th, and 5th pregnant women were selected at each step in the respective facilities.

Data collection tools and procedures

Data were collected using a structured, interviewer-administered questionnaire, which was developed based on a review of relevant literature and adapted from validated tools used in similar studies [25, 26]. The questionnaire was initially prepared in English, and translated into Amharic (the local language), and then back-translated to English to ensure consistency and accuracy. The data collection tool was pre-tested on 5% (21 participants) of the sample size at Dangila General Hospital, a facility outside the study area and not included in the main study.

Data were collected through face-to-face interviews with eligible pregnant women attending antenatal care (ANC) at selected public health facilities in Bahir Dar city administration. Interviews were conducted in a private setting to maintain confidentiality and encourage honest responses. Completed questionnaires were checked daily by supervisors for completeness and consistency. The pre-test was conducted to assess the clarity, consistency, and reliability of the questionnaire. Based on the findings, necessary modifications were made to improve the tool. Seven BSc-qualified midwives data collector, and two master’s degrees in clinical midwifery supervisors were recruited from deferent health facilities outside the study area to minimize bias.

Prior to data collection, a two-day training was provided to both data collectors and supervisors, covering the questionnaire content, ethical considerations, and proper interviewing techniques to ensure data quality and consistency. By considering early antenatal care (ANC) booking defined as the initiation of the first ANC visit at or before 12 weeks of gestation, in accordance with World Health Organization and Ethiopian national guidelines several variables were grouped into three main categories: socio-demographic characteristics (age, marital status, educational level, occupation, household income, and place of residence [urban or rural]); knowledge and awareness variables (awareness of the recommended time to initiate ANC, sources of information about ANC, knowledge of the benefits of early ANC booking, and whether the woman received counseling about early ANC during the current pregnancy); and obstetric and reproductive history (gravidity and parity, history of previous ANC attendance, history of abortion or stillbirth, pregnancy planning status, and gestational age at the first ANC visit).

Data quality control

To ensure the quality of data, the questionnaire was first prepared in English and translated into Amharic (the local language) then back into English to ensure its consistency.

Two days of Training were given to all data collectors and supervisors about the purpose of the study, methods of data collection, ethical issues, and sampling procedure. Before actual data collection, the questionnaire was pretested on 5% of the participants. Findings from the pretesting were utilized to check the clarity, sensitiveness, ambiguity, arrangement order, options, and skipping pattern of the questionnaire accordingly. Each questionnaire was checked during the data collection period by the principal investigators and supervisors daily to see its completeness, clarity, and consistency. Before analysis, the data was cleaned thoroughly to check for completeness and errors during collection.

Data processing and analysis

Following data collection, each questionnaire was meticulously reviewed by the data collectors, supervisors, and investigators to ensure consistency and completeness. The data were then entered into Epi Info version 7 and exported to SPSS Windows software version 25 for analysis. Descriptive statistics, including frequencies, means, standard deviations, percentages, and cross-tabulations, were calculated to summarize the data.

To assess the relationship between each independent variable and the dependent variable, bi-variate logistic regression was used. Independent variables with a p-value less than 0.2 in the bi-variate logistic regression were included in a multivariate logistic regression analysis to adjust for potential confounding factors and perform a deeper analysis.

In the multivariate analysis, variables with a p-value less than 0.05 were considered significantly associated with the outcome. The results presented using tables, charts, and descriptive result statements.

Operational definitions

Antenatal care (ANC)

Refer to a healthcare service provided to pregnant individuals throughout their pregnancy to ensure the health and well-being of both the mother and the developing baby.

Knowledge about ANC

Those participants who scored greater or equal to the mean score from the knowledge measuring questions were considered as having good knowledge about ANC and those participants who scored below the mean score from the knowledge measuring questions were considered as having poor knowledge about ANC.

Late antenatal care (ANC) booking

Refers to a situation where a pregnant mother begins receiving antenatal care later than recommended. Typically, late ANC booking implies that the first antenatal care booking occurs after 12 weeks’ gestation [8].

Early antenatal care(ANC) booking

Refers to pregnant mothers beginning their first ANC contact in the first 12 weeks’ gestation, typically within the first trimester [8].

Results

Socio-demographic characteristics of the study participants

A total of 392 study participants were interviewed, yielding a response rate of 97%. The majority of the pregnant women age was in the range of 26–34 years with the average age of 28.46 years. Of the pregnant women, 179 (45.7%) were Orthodox Christians, and nearly two-thirds of the pregnant women were housewives. A significant majority (92.3%) had educational backgrounds of primary level or higher, while 93.9% of respondents were married. Additionally, 300 pregnant women (76.53%) had family sizes of four or more members (Table 1).

Table 1.

Socio-demographic characteristics of pregnant mothers attending first antenatal care booking in Bahir Dar City administration, October to November 2023

Variables		Frequency	Percent (%)
Age (in years)	17–25 Years	96	24.5
	26–34 years	249	63.5
	> 35 years	47	12.0
Marital status	married	368	93.9
	single	11	2.8
	Others	13	3.3
Religion	Orthodox	179	45.7
	Muslim	152	38.8
	Protestant	61	15.6
Maternal occupations	House wife	243	62.0
	Private work	73	18.6
	Government	76	19.4
Maternal education	No formal school	30	7.7
	Primary	117	29.8
	Secondary	131	33.4
	Preparatory & above	114	29.1
Husband education	No formal schooling	12	3.1
	Primary	116	29.6
	Secondary	116	29.6
	Preparatory & above	148	37.8
Husband occupation	Private work	130	33.2
	Government	115	29.3
	Merchant	100	25.5
	Daily worker	23	5.9
	Others	24	6.1
Family Size	< 4 members	300	76.53
	>=4 members	92	23.47
Monthly income	< 3000ETB	103	26.3
	300–6000 ETB	183	46.7
	> 6000 ETB	106	27.0

Knowledge on the timing of first ANC attendance

Of the total respondents, 280 (71.4%) reported that antenatal care (ANC) services were important for maternal health. Additionally, 73% believed that timely initiation of ANC visits could reduce maternal mortality rates. Similarly, 67% had a positive perception of ANC services, stating that the first ANC visit should occur before or at 12 weeks of gestation. The majority, 79.1%, and two-thirds of the respondents reported that early antenatal care (ANC) visits improve the pregnancy outcome for the fetus and for the mothers, respectively.

However, most respondents stated that not all pregnant mothers are at risk for pregnancy complications. Lastly, three-fourths of participants were knowledgeable about the importance of timely initiation for the first antenatal care booking for pregnant mothers, and it was presented in (Table 2 & Fig. 1).

Table 2.

Knowledge of pregnant mothers attending first antenatal care booking in Bahir Dar City administration, October to November 2023

Variables character		Frequency	Percent (%)
ANC service important for a mother’s health	Yes	280	71.4
	No	112	28.6
ANC visits decrease maternal mortality rates	Yes	286	73
	No	106	27
Perception of timing of first ANC before and at 12 weeks of gestation	Yes	264	67.3
	No	128	32.7
Early ANC visits improve the pregnancy outcome of the fetus	Yes	310	79.1
	No	82	20.9
Early ANC visits improve the pregnancy outcome of the mother	Yes	262	66.8
	No	130	33.2
Pregnant woman sees the doctor for ANC if she has pregnancy complication	Yes	273	69.6
	No	119	30.4
All pregnant women are at risk of pregnancy complication	Yes	55	14
	No	337	86
Knowledge of ANC follow-up	Poor knowledge	91	23.2
	Good knowledge	301	76.8

Fig. 1.

Level of knowledge of first ANC booking among pregnant mothers attending first antenatal care booking in Bahir Dar city administration, October to November 2023

Obstetric history of pregnant mothers

In the obstetric history, three-fourths of the respondents 293 (74.7%) had a history of two or more pregnancies, and similarly, three-fourths of the respondents had a history of one or more childbirths (parity). Additionally, over 85% of the birth outcomes were live births, and more than 86% of the respondents had attended at least one antenatal care (ANC) visit during their last pregnancy. The majority, over 91%, of the respondents gave birth via spontaneous vaginal delivery (SVD), while over 11% of the respondents had a history of abortions. According to the table, only 21.16% of the respondents had a history of complications in a previous delivery.

According to this table, about three-quarters of the respondents reported that their pregnancies were planned, indicating a strong focus on family planning. A significant majority, 279 respondents (95.22%), gave birth in a health institution.

Additionally, nearly all respondents recognized the benefits of early antenatal care (ANC) booking, indicating a high level of awareness about the importance of early prenatal care. This awareness can lead to better health outcomes for both mothers and babies, as early ANC helps identify and manage potential complications during pregnancy (Table 3).

Table 3.

Obstetric history of pregnant mothers attending first antenatal care booking in Bahir Dar City administration, October to November 2023

Variables character		Frequency	Percent (%)
Number of pregnancies	Only one	99	25.3
	Two and above	293	74.7
Parity	Parity zero	97	24.7
	Parity one and above	295	75.3
Birth outcome	Alive	251	85.66
	Stillbirth	42	14.34
ANC visit for last pregnancy	Yes	245	86.69
	No	48	13.31
Rout of delivery of previous birth	SVD	267	91.12
	C/S	26	8.88
History of abortion	Yes	46	11.74
	No	346	88.26
Complication in previous delivery	Yes	231	78.84
	No	62	21.16
Type of pregnancy	Planned	290	74
	Unplanned	102	26
Place of delivery	Home	14	4.78
	Health facility	279	95.22
Satisfaction on ANC service	Yes	306	78.1
	No	86	21.9
Goodness of early ANC booking	Yes	386	98.5
	No	6	4.5

The prevalence of early initiation of first ANC booking

The finding that nearly 32.7% of pregnant women in the study area received their first antenatal care (ANC) booking within the recommended time frame (in the first 12 weeks’ gestation, typically within the first trimester). According to the World Health Organization (WHO), the recommended time for the first ANC visit is during the first trimester, ideally before or at 12 weeks of gestation. This is a positive sign that most women are aware of the importance of early ANC and are accessing these services accordingly.

Although 67.3% is a positive figure, it also means that nearly one-third of pregnant women are not receiving their first ANC visit within the recommended time frame. This could point to barriers such as lack of awareness, limited access to healthcare services, obstetric factors, and cultural or social factors. Addressing these barriers could increase the rate of early ANC visits (Fig. 2).

Fig. 2.

Timing of first ANC booking among pregnant mothers attending first antenatal care booking in Bahir Dar city administration, October to November 2023

Factors associated with timing of first ANC booking among pregnant mothers

Table 4 outlines a bi-variable and multivariate analysis of factors linked to the early initiation of antenatal care (ANC) among pregnant women attending ANC in Bahir Dar city administration. In the bi-variable logistic regression analysis, showed a p-value of less than 0.2, indicating a potential association with early ANC initiation, but only four factors emerged as significantly associated with the early initiation of ANC in the multi-variable logistic regression analysis.

Table 4.

Factors associated with initiation of ANC among pregnant mothers attending first antenatal care booking in Bahir Dar City administration, October to November 2023

Variables	Characteristics	Initiation of ANC		COR at 95%CI	AOR at 95% CI
		Let	Early
Age of the women	17–25 Years	61	35	1.50(0.70, 3.22)	1.92 (0.83, 4.44)
	26–34 years	169	80	1.24(0.62, 2.47)	1.22 (0.56, 2.63)
	> 35 years	34	13	1	1
Maternal educational level	No formal school	69	20	0.42 (0.22, 0.81)	0.38 (0.17, 0.85) *
	Primary	63	33	0.76 (0.42, 1.38)	0.49 (0.22, 1.10)
	Secondary	78	38	0.71(0.40, 1.26)	0.57 (0.29, 1.14)
	Prep. and above	54	37	1	1
Husband education	No formal schooling	7	5	1.44 (0.44, 4.78)	0.52 (0.22, 1.20)
	Primary	82	34	0.84 (0.49, 1.42)	0.63 (0.27, 1.46)
	Secondary	76	40	1.06(0.64, 1.78)	0.51 (0.23, 1.12)
	Prep. and above	99	49	1
Maternal occupation status	House wife	164	79	0.98 (0.57, 1.70)	1.64 (0.79, 3.39)
	private work	49	24	1.00 (0.50, 1.98)	1.20 (0.55, 2.62)
	Govt Employee	51	25	1	1
Occupation status of the father	Private work	89	41	1.34 (0.63, 2.85)	1.15(0.48, 2.74)
	Govt Employee	74	41	1.62 (0.76, 3.45)	1.52(0.65, 3.54)
	Merchant	66	34	1.50 (0.69, 3.26)	1.37(0.57, 3.29)
	Daily worker	35	12	1	1
Counseling about ANC	Yes	228	121	2.73 (1.18, 6.32)	3.95(1.65, 9.45) *
	No	36	7	1	1
Family size	< 4 members	201	99	1.07 (0.65, 1.77)	1.07(0.63, 1.83)
	>=4 members	63	29	1	1
Number of Gravid	One	77	22	0.50 (0.30, 0.86)	0.51(0.26, 0.79) *
	Two and above	187	106	1	1
No of parity	No parity	75	22	0.52 (0.31, 0.89)	0.54(0.22, 0.76) *
	1–5 parity	189	106	1	1
Type of pregnancy	Planned	190	100	1.39(0.84, 2.29	1.18(0.66, 2.11)
	Unplanned	74	28	1
ANC visits for last pregnancy	Yes	161	84	0.62(0.33, 1.15)	0.59(0.34, 1.02)
	No	26	22	1

COR crude odd ratio, AOR adjusted odd ratio

*Indicates significant association at P <0.05 in multivariate, 1=Reference category

Maternal Education: Higher maternal education levels were linked to earlier ANC initiation. Consoling about ANC: Pregnant mothers who received counseling about ANC were more likely to start ANC visits early. Number of Gravid: The total number of pregnancies a mother had influenced the timing of ANC initiation. Number of Parity: The number of given births also significantly affected early ANC initiation. These results highlight that education, counseling, and reproductive/obstetric history play key roles in promoting early ANC visits among pregnant mothers in Bahir Dar city administration.

When considering maternal education status, mothers who were unable to read and write were 62% less likely to practice early initiation of antenatal care (ANC) compared with those who had a preparatory-level education or higher [(AOR 0.38, 95% CI (0.17, 0.85).

This indicates that lower levels of education can be a significant barrier to the early/timely initiation of ANC among pregnant mothers.

On the other hand, counseling about the importance of antenatal care (ANC) was a significant variable in the outcome. Mothers who were counseled about the importance of ANC were nearly four times more likely to practice early initiation of ANC [(AOR 3.95, 95% CI (1.65, 9.45)] compared with those who did not receive counseling about the importance of ANC during their last pregnancy. This finding suggests that effective counseling can play a critical role in encouraging early ANC practices among pregnant mothers.

In this finding, the number of pregnancies (Gravid) is also a significant variable that affects the practice of early initiation of antenatal care (ANC). Mothers with Gravid two and above were 49% more likely to practice early initiation of ANC [(AOR 0.51, 95% CI (0.26, 0.79)] compared to those with gravid one.

Similarly, the number of parities is another factor that influences the early initiation of ANC visits for pregnant women. Mothers with one or more parity were also 46% more likely to practice early initiation of ANC [(AOR 0.54, 95% CI (0.22, 0.76)] compared to those with parity zero. These results suggest that the reproductive history of a mother, specifically the number of pregnancies and parities, has a significant impact on the likelihood of practicing early initiation of ANC. Mothers with fewer pregnancies and no previous births are less likely to initiate ANC early as WHO recommendation (Table 4).

Discussion

In our study out of a total sample 128 (32.7%); 95% CI 28.3%, 37.2%) of pregnant women initiated their first Antenatal Care (ANC) visit early at or before 12 weeks of pregnancy. By contrast, the remaining 264 (67.3%) of pregnant women had their first ANC appointment after 12 weeks of pregnancy, indicating that nearly two-third of the respondents booked their first ANC appointment later than WHO recommendation.

The prevalence of early antenatal care (ANC) booking in this study is lower than the study in Gedeo General Hospital, Oromia 41.5% [27], in Jimma Zone Public Hospitals, Southwest Ethiopia 52% [28], in Southwest Ethiopia, 41.9% [29], study in Gondar Hospital 47.4% [30], the study in Nepal 70% [31], study in Debre Birhan town, Ethiopia 40.6% [25]. The reason for this variation might be geographic variation: Differences in healthcare infrastructure, access to services, and cultural norms across regions can result in variations in ANC utilization rates, differing healthcare resources and practices, variances in study design, sampling methods, data collection techniques, and measurement tools can impact the reported prevalence rates of early ANC booking among pregnant women.

The study’s findings was in line with those from prior research, including the 2019 Ethiopia Mini-Demographic and Health Survey 37.37% [24], a study in Ambo town administration 30.5% [26], the study in Mekelle City, Northern Ethiopia 32.7% [32], the rural Parts of Ethiopia 31% [33], EDHS, 2016 32.69% [3], Tanzania Demographic Health Survey 22.9 [34], and study in Lushoto, Tanzania 29.4% [35], and study in Dilla town, Gedeo Zone 35.4% [36].

The similarity in these research findings across multiple studies can indeed be attributed to several key factors. Firstly, the consistency in methodologies, sampling techniques, and data collection instruments utilized across these studies likely plays a significant role. When researchers employ similar rigorous methods, it enhances the comparability and reliability of their findings.

Moreover, the shared demographic, socioeconomic, and cultural characteristics among the populations studied also contribute to the congruence in results. These commonalities create a foundation for uniform patterns or trends, making it more likely for different studies to yield comparable outcomes. In addition, regional or contextual similarities between the study areas, such as healthcare access, infrastructure, or prevalent social norms, may influence the outcomes and contribute to consistency in findings.

Lastly the finding of this study was higher than the study in Tanzania 14.7% [37], Zambia 13.8% [38], in Debre Birhan, Ethiopia 26.2% [39], and in South Western Nigeria 14.7% [40]. The reason for this variation might be due to socio-demographic, economic, agricultural, and cultural factors.

This is evidenced by the fact that the majority of respondents in our study received counseling about the importance of timely initiation, most of them completed primary school, and almost all of them live in Bahir Dar City, which is more urbanized compared to the other study area.

In this research maternal education was one important significant factor, mothers’ educational status primary and above was 62% times more likely to practice early antenatal care booking as compared to those who had no formal education. This was supported with the study in Myanmar [41], in Nepal [31], In South Western Nigeria [40], in Dilla town, Gedeo Zone [36], Bahir Dar, Ethiopia [42], study in Axum Ethiopia [43], 2019 Ethiopia mini-demographic and health survey [44], systematic review and meta-analysis of Ethiopia [19], study on women in Rural Parts of Ethiopia [33], and in Bahir Dar Zuria zone, Northwest Ethiopia [13]. The reason for this similarity, as we all know, is that education is the most powerful instrument for increasing the awareness of mothers about the importance of early antenatal care (ANC) for both the fetus and the pregnant women. It also plays a crucial role in raising awareness about other critical aspects of maternal and child health, such as child feeding, family planning, institutional delivery, and recognizing neonatal danger signs. By providing mothers with educational opportunities, they are better equipped to make informed decisions regarding their health and the health of their children.

On the other hand, maternal counseling about the importance of ANC during the last pregnancy was one more significant variable to the outcome. Pregnant mothers who were counseled about the importance of early ANC booking were 4 times more likely to practice early ANC booking than those who didn’t counsel about the importance of early booking.

This is evidenced by the study in Arba Minch Town and Arba Minch District, Gamo-Goffa Zone [1], study in Axum town, Tigray, Ethiopia [43], study in Bahir Dar city [42], study in Ambo town administration, Central Ethiopia [26], and central Zone Tigray, Ethiopia [45].

The possible explanation for this relationship might be as we have seen from the above paragraph, counseling regarding to the importance of early ANC booking increase the level of awareness about the importance of the service to the fetus and the mothers. The strategies of the Federal Ministry of Ethiopia are mainly focused on the prevention of the disease or primary prevention than the curative intervention so, counseling of the pregnant mothers about early initiation of ANC booking means prevention of the complication of maternal, fetal and neonatal complication associated or related to pregnancy.

Lastly the findings of this study highlight that obstetric characteristic such as gravid and parity has significant contributing factors for the dalliance of early initiation of ANC booking. Pregnant mothers who had more than one gravid and Para were 55% more likely to practice early ANC booking as compared to gravid one and Para zero.

This is supported with the evidence of the study in Myanmar [41], the study in in Southwest Ethiopia [46], the study in Ambo town administration, Central Ethiopia [26], a systematic review and meta-analysis in Ethiopia [19], in Bahir Dar Zuria zone, Northwest Ethiopia [13], and study in central Zone, Tigray, Ethiopia [45].

The possible reason for this might be women who have experienced multiple pregnancies (gravidity) and childbirths (parity) may possess greater knowledge and awareness about the importance of ANC and the benefits of initiating care early in pregnancy.

Similarly, mothers with multiple pregnancies and childbirths may be more accustomed to engaging with healthcare services, including ANC, due to their previous experiences. Familiarity with the healthcare system and a positive history of ANC utilization may encourage them to initiate ANC early in subsequent pregnancies.

Conclusions

The prevalence of antenatal care booking observed in this study is characterized as moderate. The study investigated various factors associated with early initiation of ANC booking. Maternal education, counseling about the importance of early ANC booking, and obstetric characteristics such as gravidity (number of pregnancies) and parity (number of childbirths) were identified as scientifically significant factors influencing early ANC booking. Our study highlights the multifactorial influences on early antenatal care (ANC) booking among pregnant women. It underscores the need to address educational disparities, enhance health education and counseling, and incorporate obstetric history into maternal healthcare strategies. These efforts are essential to improving ANC utilization and advancing maternal health outcomes in the region.

Strength and limitation

A key strength of this study is its focused objective, specifically examining the timing of ANC initiation, a critical factor for maternal and fetal health outcomes. However, the study has several limitations. First, as an institution-based study, it included only pregnant women who attended health facilities for ANC, potentially excluding those who did not seek care. This may lead to selection bias and limit the generalizability of the findings, particularly to women with limited access to healthcare. Second, the cross-sectional design prevents the establishment of causal relationships; only associations can be drawn. Third, there is a risk of recall bias, especially concerning gestational age at the first ANC booking, as some information relied on self-reporting. Lastly, the study focused primarily on individual-level factors and may not have adequately captured health system related barriers such as service availability, provider behavior, and quality of care.

Recommendations

Based on our study’s findings, maternal education, counseling on early ANC booking, and obstetric history significantly influence early ANC booking. Based on our study findings, we recommend that the regional health bureau and healthcare providers strengthen educational programs targeting women of reproductive age particularly those with lower levels of education to increase awareness about the importance and timing of early antenatal care (ANC) booking. Counseling services within health facilities should be strengthened to ensure pregnant women receive comprehensive information during all healthcare contacts.

Additionally, targeted interventions are needed for multiparous women to address specific barriers they may face in initiating ANC early.

Collaboration with community health workers is also essential to improve the dissemination of information and counseling at the community level, thereby increasing accessibility and awareness of early ANC services.

Abbreviations

ANC

Antenatal Care

AIDS

Acquired Immune Deficiency Syndrome

EDHS

Ethiopian Demographic Health Survey

HEW

Health extension worker

HIV

Human Immune deficiency Virus

NGO

Nongovernmental Organization

SPSS

Statistical Package for Social Sciences

PX

Pregnancy

WHO

World Health Organization

Authors’ contributions

SM, YTT, STM, AGB, OA, and HBN were Conceived and designed the write-up and the analysis, MAM, GBM, GM, AEB, and WT: were prepare the manuscript, play a role in the methods, and contributed data collection tools. SM, AGB, HBN, and AEB: Conceived and designed the manuscript and wrote the paper.

Funding

This research received no any specific grant or funding agency in the public, commercial, or not-for-profit sectors.

Data availability

All data supporting the findings of this study are available within the hand of the corresponding authors and it will available at the reasonable request.

Declarations

Ethics approval and consent to participate

The formal letter was obtained from the Ethical committee of the College of Health Sciences, Bahir Dar University. Official letters at different levels including Bahir Dar city administrative office, selected Households and health center were communicated through formal letters. We apply written informed consent for the participants about the purpose and objective of the study.

Respondents were also being told the right not to respond to the questions if they don’t want to respond or to terminate the interview at any time and verbal consent was obtained from each study participant. Confidentiality of the information was assured and privacy was also maintained.

Consent for publication

We hereby grant permission for the publication of the article titled “Early Ante Natal Care (ANC) Booking and Associated Factors among Pregnant Women Attending Ante Natal Care at Bahir Dar City Administration, Northwestern Ethiopia.” We, the authors, confirm that we are the original authors of this work and hold the rights to grant this permission. We agree to any necessary editorial revisions required for the publication process.

Competing interests

The authors declare no competing interests.