ABSTRACT
Background and Aims
In Ethiopia, below one third of pregnant mothers initiate antenatal care before 3 months, which partially attributed to maternal and neonatal mortality. However, there is limited evidence on predictors of time to first Antenatal care booking among pregnant women using survival analysis. Thus, this study aimed to determine the time to first Antenatal care booking and its predictors among pregnant women in Pawe General Hospital.
Methods
An institutional‐based retrospective follow‐up study was conducted from June 05 to July 05, 2024. Total of 502 eligible women were enrolled consecutively until the sample size was reached. Data was collected using a structured interviewer‐administered questionnaire and a data extraction tool. STATA 14.0 was used for data analysis. Median, percentage, frequency, and Kaplan–Meier Curve were reported. A log‐normal parametric survival regression model was computed. A statistically significant association was declared at 95% confidence interval. Cox Snell Residuals were used to check overall model fitness.
Results
The incidence of early ANC in Pawe General Hospital was 15.94%. The median time to first ANC was 17 weeks (95% CI: 17, 18). Urban resident (φ = 0.47, 95% CI: 0.27, 0.83), Protestant or Catholic (φ = 0.46, 95% CI: 0.25, 0.84) and Planned pregnancy (φ = 0.45, 95% CI: 0.25, 0.81) were predictors that shorten time to first Antenatal care booking. Government or private employees (φ = 1.60, 95% CI: 1.01, 2.55) book their first ANC later than housewives.
Conclusion
Half of the women initiate their antenatal care after 17 weeks of their pregnancy. Urban residence, being Protestant or Catholic and planned pregnancy were factors associated with earlier ANC booking, while being a government or private employee was associated with late ANC booking. Therefore, we recommend targeted community outreach programs focusing on rural areas and government or private employees, as well as providing family planning to prevent unplanned pregnancies.
Keywords: ANC, antenatal care, Pawe, survival, time to first ANC
1. Background
Antenatal care (ANC) is routine care given by a trained health care provider for a woman during pregnancy, starting from the time of conception up to the delivery of the baby [1]. The components of ANC include: risk identification, prevention and management of pregnancy‐related or concurrent diseases, health education, and health promotion [1, 2]. Antenatal care from a trained health care provider is important to monitor pregnancy and to reduce complications and risks for the mother and child during pregnancy, delivery, and after giving birth. With access to antenatal care, especially in early pregnancy, many complications can be prevented or anticipated [3].
World Health Organization (WHO) and the Ethiopian Federal Ministry of Health recommended that pregnant women should seek ANC within the first 3 months of pregnancy [1, 2]. The Sustainable Development Goals (SDGs) set ambitious health‐related targets for mothers, newborns, and children by 2030. Timeliness, one of the seven criteria of quality of care, is critical to the operationalization of these global agendas and the achievement of the health‐related SDGs and targets [4].
ANC utilization was low in Sub‐Saharan African countries, which varies from 78.8% in the southern region of Africa to 53.4% in the Eastern region [5, 6]. ANC within the first trimester of pregnancy was 84.8% and 24.9% in developed regions and in Sub‐Saharan Africa, respectively [7]. The magnitude of early antenatal care initiation in developing African countries was very low, varying from 24% to 37.4% [8, 9]. The Ethiopian Mini Demographic and Health Survey (EMDHS) showed that only one third (28%) of women had ANC contact in the first trimester [10].
When a pregnant woman initiates and/or attends ANC follow‐up late, very little can be done to prevent, early detect, appropriately manage, and timely refer women with complications. This leads to a higher risk of complications, which could lead to morbidity, disability, and mortality [1, 11, 12]. Globally, about 260,000 women died during and following pregnancy and childbirth in 2023. About 700 women approximately die every day from preventable causes related to pregnancy and childbirth. This translates to maternal death occurring approximately every 2 min in 2023 [13, 14]. Sub‐Saharan Africa alone accounted for approximately 70% of global maternal deaths in 2023, with an estimated 182,000 maternal deaths [13]. Ethiopia is one of the countries with a moderate maternal mortality ratio (195 per 100,000 live births) in 2023, which is still far more than the global target by 2030 [14]. Also, globally, around 1.9 million stillbirths [15] in the year 2023 and 2.3 million neonatal deaths [16] in the year 2022 were reported. Of which the highest numbers were contributed by sub‐Saharan Africa, including Ethiopia and Southern Asia [16, 17]. Benishangul Gumuz region had the highest neonatal mortality [18] as reported in 2019, and one of the emerging regions with the highest maternal mortality rate [19].
To achieve the Sustainable Development Goals (SDGs) by 2030, the global maternal mortality ratio (MMR) should be reduced to less than 70 per 100,000 live births. This ambitious target aims to prevent maternal deaths and improve maternal health worldwide. One of the interventions is providing timely Antenatal care for pregnant mothers [1, 2, 20]. In Ethiopia, different studies have been done to determine the predictors of pregnant mothers' early initiation of ANC. The studies showed that individual socioeconomic factors such as income [9, 21, 22, 23, 24], age [9, 23], residence [9, 19, 21, 24], religion [9], educational status of women and their husband [9, 21, 22, 23], occupation [22], access to media [21, 22] and, and health system factors such as distance to the health facility [25] are predictors of time to first ANC contact.
Even though different researches were done about timely initiation of antenatal care, many of them were addressed with recall bias due to using self‐reported data and less accurate measurement by using either the last normal menstrual period or physical examination to determine the time to first ANC booking. However, it should be measured using ultrasound examination, which is the gold standard measurement to estimate gestational age [1], and extracting the exact date from the patient chart reduces recall bias. The last one is that many studies use binary logistic regression to determine predictors associated with the timing of ANC initiation, which ignores the time variable. The current study will use time to event analysis to determine predictors that shorten the time to first ANC booking, which integrates survival status (early and late) and the continuous time variable.
Thus, this research aims to determine the cumulative incidence of early ANC initiation, time to first ANC booking, and its predictors among pregnant mothers who attend ANC follow‐up at Pawe General Hospital, Northwest Ethiopia. This study serves as an input for governmental and non‐governmental organizations in order to intervene on problems related to antenatal care utilization, which results in reducing maternal and neonatal mortality.
2. Methods
2.1. Study Design, Study Area, and Study Period
An institution‐based retrospective follow‐up study was conducted from June 05 to July 05, 2024, at Pawe General Hospital, Pawe district. Pawe district is located in the Metekel zone, Benishangul Gumuz Region, Northwest Ethiopia. There are 23 kebeles in the District with a total population of 73,755, 3 health centers, 19 health posts, 1 general hospital, 164 health professionals, and 47 health extension workers. Pawe General Hospital is the largest health facility in the district which provides maternal health services like antenatal care, delivery and post‐natal care for pregnant mothers in the area. It is the only public health facility that provides ultrasound examination in Pawe district.
2.2. Populations
The source populations were all pregnant women aged 15–49 who were on ANC follow‐up at Pawe General Hospital ANC clinic, whereas the study populations were all pregnant women aged 15–49 who followed antenatal care at Pawe General Hospital ANC clinic during the data collection period. All pregnant women with the age group of 15–49 attending ANC follow‐up were enrolled in the study, and pregnant women who did not have at least one ultrasound examination recorded on their ANC follow‐up card were excluded.
2.3. Sample Size Determination and Sampling Technique
The sample size for the survival study is estimated by STATA 14.0, taking into account a 95% confidence interval, a two‐sided level of significance at 0.05, an 80% power and an adjusted hazard ratio of 1.8, 1.9, and 1.5, which were taken from a study done using 2016 EDHS [26]. After adding 5% non‐response and incomplete records, the largest minimal sample size was 520.
Pregnant women aged 15–49 years who attended ANC follow‐up at Pawe General Hospital were included. The total sample size of 520 was selected from the sampling frame based on the performance of the previous month. Pawe General Hospital provided ANC follow‐up service for about 580 women in the preceding month. Consecutive sampling was the sampling technique until the final sample size was satisfied. Finally, 502 eligible pregnant women were included in the study, excluding 18 non‐respondents due to consent. The total response rate was 96.5%.
2.4. Study Variables
2.4.1. Dependent Variable
Time to first antenatal care booking (in weeks).
2.4.2. Independent Variables
Socio‐demographic variables: maternal age, marital status, maternal educational status, occupation of mother, husband's educational status, age difference between husband and wife, religion, residence, distance from health facility, family size, and media access.
Obstetric variables: gravidity, parity, history of abortion, history of still births, planned pregnancy, preceding birth interval, had ANC for previous pregnancy, and place of delivery for previous pregnancy.
2.4.3. Operational Definitions
Early ANC contact: Is defined as a pregnant woman contacting the ANC clinic within 12 weeks of gestational age [1].
Event: Pregnant women who booked their first ANC contact within 12 weeks of gestation.
Censored: Pregnant women who booked their first ANC contact after 12 weeks of gestation.
Follow‐up time: From the time of conception to either an event or censorship.
Time to first ANC: The time it takes to have the first ANC booking in weeks from the date of pregnancy to the first ANC booking (gestational age at first ANC booking).
Media Access: A pregnant woman who has functional television, radio, smartphone, or newspaper in her home, and at least she is exposed to it once a week.
Preceding Birth interval: The length of time or interval between the previous stillbirth or live birth and the current pregnancy.
2.5. Data Collection Method and Procedure
Data related to socio‐demographic and socio‐economic factors was collected using a structured, interviewer administered questionnaire. A structured interviewer‐administered questionnaire was prepared after reviewing different literature to collect relevant data [21, 24, 26, 27, 28, 29]. The questionnaire was developed in English and translated into Amharic. The interview was conducted in Amharic by two diploma midwives with eligible women at the antenatal care clinic. An English data extraction checklist was used for extracting information related to the Obstetric and other characteristics on the patient record. Incomplete data from the patient record was attempted to complete it again at the end of the data collection period. An electronic data collection tool (Kobo toolbox) was used to create a questionnaire and collect the data. The principal investigator and one BSc Midwife supervised the data collection process. The questionnaire was pre‐tested 5% of the sample size to make adjustments to the appropriateness of the data collection instrument. Training was provided for the supervisor and data collectors for 1 day by the principal investigator on the details of the questionnaire.
2.6. Data Processing and Analysis
The collected data was cleaned, edited, and recoded after being exported to SPSS version 25.0 for data cleaning. STATA version 14 was used for data analysis. After categorizing and defining variables, a descriptive analysis was employed for each of the independent variables, which is reported using frequency, percentages, and tables. Descriptive statistics like median time with interquartile range and incidence of early ANC‐initiated pregnant women were computed for the dependent variable. Log‐rank test was computed for comparison of categorical variables. Multicollinearity was checked before running selected survival model. The variance inflation factor result showed that the maximum VIF was 4.15 for parity and the mean VIF was 1.92. Based on the VIF result, there is no multicollinearity between covariates. Proportional hazard assumption test was checked graphically by using a log (–log) plot and statistically by the Schoenfeld residuals (Global test). The dataset did not fulfill the proportional hazard assumption as p value for Global test was less than 0.05. Thus, it was important to use parametric survival models. Akaike information criteria (AIC) and Bayesian information criteria (BIC) were computed to select an appropriate parametric survival model for the data. Log‐normal parametric survival model had a lower AIC and BIC value than other parametric survival models, which verified it was the best fitted model for this dataset. A two‐sided statistical test was performed. Variables having a p‐value of ≤ 0.25 in the bivariable analysis were included in the multivariable Log‐normal parametric survival model. Additionally, using domain knowledge, important variables such as parity, gravidity, and media access were also included in the multivariable model. In multivariable analysis, those variables having a p‐value of ≤ 0.05 were considered statistically significant determinants of time to first ANC booking. Cox Snell Residuals plot was used to check overall model fitness.
2.7. Ethics Approval and Consent to Participate
Ethical approval to initiate this research was granted by the Institutional Research Review Board at the Bahir Dar University, College of Medicine and Health Sciences, School of Public Health (protocol number of CMHS/IRB 929/2024). The letter was handed to Pawe General Hospital. Data was collected after explaining the rights and responsibilities of giving information and the purpose of the study to respondents and ascertaining their confidentiality by explaining that no data will be disclosed as an individual, but rather disseminated at the community and health institution level in general. Finally, both verbal and written informed consent were obtained from the participants after telling them that they have the right not to respond and withdraw at any time. Privacy and confidentiality of study participants was maintained by making the data abstraction form anonymous, protecting our personal computers with strong password, and giving training to data collectors on how to keep the data confidential.
3. Result
3.1. Socio‐Demographic Characteristics
Out of 520 pregnant women who were sampled to participate, 502 (96.53%) of the respondents were interviewed and included in the analysis. The median age of the mother was 26 years (IQR 23, 29). Among study participants, 340 (67.73%) and 134 (26.7%) of them were Orthodox Christian and Muslim, respectively. Around 424 (84.46%) of the respondents were urban dwellers. Regarding marital status, 492 (98.01%) of respondents were married, and 10 (1.99%) respondents were either single or divorced. One hundred fifty‐five (30.87%) of the study participants had occupation, while the rest of the participants were housewives (Table 1).
Table 1.
Socio‐demographic characteristics of pregnant women who are at ANC follow‐up at Pawe General Hospital, Pawe District, North‐west Ethiopia, 2024 (N = 502).
| Variable | Categories | Survival status of time to first ANC booking | ||
|---|---|---|---|---|
| Event (%) | Censored (%) | Total frequency (%) | ||
| Age | 15–24 | 30 (18.8) | 135 (81.2) | 165 (32.9) |
| 25–34 | 46 (15.4) | 253 (84.6) | 299 (59.6) | |
| 35–49 | 4 (10.53) | 34 (89.47) | 38 (7.5) | |
| Marital Status | Married | 79 (16.1) | 413 (83.9) | 492 (98.0) |
| Single | 1 (12.5) | 7 (87.5) | 8 (1.6) | |
| Divorced | 0 (0) | 2 (100.0) | 2 (0.4) | |
| Age difference(n = 492) | 1–5 years | 39 (15.5) | 212 (84.4) | 251 (51.01) |
| Above 5 years | 40 (16.6) | 201 (83.4) | 241 (48.99) | |
| Husband's educational status(n = 492) | No education | 8 (10.8) | 66 (89.2) | 74 (15.0) |
| Primary and secondary education | 42 (16.7) | 209 (83.3) | 251 (51.0) | |
| College and above | 29 (17.4) | 138 (82.6) | 167 (28.0) | |
| Place of residence | Rural | 5 (6.4) | 73 (93.6) | 78 (15.5) |
| Urban | 75 (17.7) | 349 (82.3) | 424 (84.5) | |
| Religion | Orthodox | 49 (14.4) | 292 (85.6) | 341 (67.9) |
| Muslim | 23 (17.3) | 110 (82.7) | 133 (26.5) | |
| Other a | 8 (28.6) | 20 (71.4) | 28 (5.6) | |
| Mother's occupation | Housewife | 60 (17.3) | 287 (82.7) | 347 (69.1) |
| Government/private employee | 13 (14.3) | 78 (85.7) | 91 (18.1) | |
| Private businesswoman | 6 (10.5) | 51 (89.5) | 57 (11.4) | |
| Other b | 1 (14.3) | 6 (85.7) | 7 (1.4) | |
| Mother's educational status | No education | 7 (11.5) | 54 (88.5) | 61 (12.2) |
| Primary education | 18 (15.8) | 96 (84.2) | 114 (22.7) | |
| Secondary education | 21 (12.5) | 147 (87.5) | 168 (33.8) | |
| College and above | 34 (21.4) | 125 (78.6) | 159 (31.7) | |
| Distance from health facility | < 30 min | 64 (18.4) | 283 (81.6) | 347 (69.2) |
| 30–60 | 9 (11.8) | 67 (88.2) | 76 (15.1) | |
| > 60 min | 7 (8.86) | 72 (91.14) | 79 (15.7) | |
| Family size | ≤ 2 | 33 (18.2) | 148 (81.8) | 181 (36.1) |
| 3–4 | 42 (15.6) | 227 (84.4) | 269 (53.6) | |
| ≥ 5 | 5 (9.6) | 47 (90.4) | 52 (10.4) | |
| Family's average income | ≤ 5000 birr | 15 (13.9) | 155 (83.8) | 185 (36.8) |
| 5001–10000 birr | 35 (18.3) | 156 (81.7) | 191 (38.1) | |
| > 10000 birr | 15 (11.9) | 111 (88.1) | 126 (25.1) | |
| Media access | Yes | 54 (15.9) | 285 (84.1) | 339 (67.5) |
| No | 26 (15.9) | 137 (84.1) | 163 (32.5) | |
Protestant, Catholic.
Farmer, Student.
3.2. Obstetric and Other Related Factors
Among the pregnant women, 350 (69.72%) of pregnant women were multigravida. From 350 pregnant women, 33 (9.4%) women did not have antenatal care for the previous pregnancy. Around 84 (16.73%) and 20 (3.98%) pregnant women had one abortion and recurrent abortion history, respectively. 435 (86.65%) of pregnant women who visited the ANC clinic had planned the current pregnancy (Table 2).
Table 2.
Obstetric and other related factors of pregnant women who are at ANC Follow‐up at Pawe General Hospital, Pawe District, North‐west Ethiopia, 2024 (N = 502).
| Variable | Categories | Survival status of time to first ANC booking | ||
|---|---|---|---|---|
| Event (%) | Censored (%) | Total frequency (%) | ||
| Gravidity | Primigravida | 24 (15.8) | 128 (84.2) | 152 (30.3) |
| Multigravida | 56 (16.0) | 294 (84.0) | 350 (69.7) | |
| Parity | Nulliparity | 28 (15.6) | 152 (84.4) | 180 (35.9) |
| Primiparity | 33 (19.2) | 139 (80.8) | 172 (34.3) | |
| Multiparity | 19 (12.7) | 131 (87.3) | 150 (29.9) | |
| ANC for previous pregnancy (n = 350) | Yes | 53 (16.7) | 264 (83.3) | 317 (90.6) |
| No | 3 (9.1) | 30 (90.9) | 33 (9.4) | |
| Outcome of previous pregnancy (n = 350) | Live birth | 45 (15.5) | 246 (84.5) | 291 (58.0) |
| Still birth | 4 (44.4) | 5 (55.6) | 9 (1.8) | |
| Abortion | 7 (14.0) | 43 (86.0) | 50 (10.0) | |
| Place of delivery for previous pregnancy (n = 300) | At the health facility | 47 (16.8) | 232 (83.2) | 279 (93.0) |
| At home | 2 (9.5) | 19 (90.5) | 21 (7.0) | |
| Birth interval (n = 300) | < 24 month | 7 (58.3) | 5 (41.7) | 12 (4.0) |
| 24–36 month | 17 (14.4) | 97 (85.1) | 114 (38.0) | |
| ≥ 37 month | 25 (14.4) | 149 (85.6) | 174 (58.0) | |
| History of abortion | None | 61 (15.3) | 337 (84.7) | 398 (79.3) |
| One | 18 (21.4) | 66 (78.6) | 84 (16.7) | |
| Recurrent | 1 (5.0) | 19 (95.0) | 20 (4.0) | |
| History of still birth | Yes | 11 (32.3) | 23 (67.7) | 34 (6.8) |
| No | 69 (14.7) | 399 (85.3) | 468 (93.2) | |
| Planed pregnancy | Yes | 77 (17.7) | 358 (82.3) | 435 (86.7) |
| No | 3 (4.48) | 64 (95.52) | 67 (13.3) | |
3.3. Time to First Antenatal Care Booking
Among 502 pregnant women who were at ANC follow‐up, only 15.94% (95% CI: 13.01%, 19.44%) of them initiated their first ANC timely. The cumulative probability of the first ANC initiation was 51.79% at 17 weeks, 88.84% at 24 weeks, 95.62% at 30 weeks, and 99.2% at 38 weeks (Table 3). The survival function was computed with Kaplan–Meir survival estimate. The overall median survival time to first ANC booking was 17 weeks (95% CI: 17, 18) and the interquartile range was 14–21 weeks.
Table 3.
Life table times of pregnant women who are at ANC Follow‐up at Pawe General Hospital, Pawe District, North‐west Ethiopia, 2024 (N = 502).
| Time (in weeks) | Begning total | Book first ANC up to a time | Failure function | 95% Confidence interval | |
|---|---|---|---|---|---|
| 12 | 435 | 80 | 0.1594 | 0.1301 | 0.1944 |
| 16 | 335 | 213 | 0.4243 | 0.3824 | 0.4688 |
| 17 | 289 | 260 | 0.5179 | 0.4750 | 0.5623 |
| 20 | 155 | 374 | 0.7450 | 0.7062 | 0.7823 |
| 24 | 65 | 446 | 0.8884 | 0.8591 | 0.9141 |
| 28 | 30 | 475 | 0.9462 | 0.9241 | 0.9636 |
| 32 | 19 | 485 | 0.9661 | 0.9476 | 0.9795 |
| 36 | 14 | 490 | 0.9761 | 0.9598 | 0.9869 |
| 38 | 7 | 498 | 0.9920 | 0.9807 | 0.9973 |
The median survival time varies according to the characteristics of the respondents. The median time to first ANC contact for rural resident pregnant women was 21 weeks (95% CI: 20, 23), which is higher than that of urban resident pregnant women with 17 weeks (95% CI: 16, 17). The median time to first ANC contact for pregnant women's who had a history of stillbirth was less than that of pregnant women who had no history of stillbirth, with 15 weeks (95% CI: 15, 18) and 17 weeks (95% CI: 17, 18), respectively. Women who had an unplanned pregnancy had a median time to first ANC of 20 weeks (95% CI: 18, 21), which was longer than pregnant women who planned their pregnancy (17 weeks [95% CI: 17, 17]).
3.4. Comparison of Failure Curves Between Categories
The log‐rank test was computed to test the difference in survival time between categories for categorical variables. The null hypothesis of interest is no difference between survival curves. Based on the result, there is a smaller p‐value as compared to 5% level of significance for the covariates Residence (p value = 0.02, Chi‐square = 5.61) and Planned pregnancy (p value = 0.01, Chi‐square = 6.00). Thus, there is a significant difference between the survival curves of two groups of Residence (urban and rural), and Planned pregnancy (planned and unplanned) (Figure 1).
Figure 1.
Kaplan–Meier estimate curve of time to first ANC booking among pregnant women who are at ANC follow‐up at Pawe General Hospital, Pawe District, North–west Ethiopia, 2024: classification based on residence and planned pregnancy.
3.5. Predictors of Time to First Antenatal Care Booking
The bivariable analysis was fitted for every determinant by Accelerated failure time models using different baseline distributions. Weibull, exponential, log‐logistic, and log‐normal distributions were computed. Based on bivariable analysis, independent variables with a p value ≤ 0.25 and important variables like parity, gravidity, and media access were candidates for further analysis. AIC and BIC were used to choose the best fitted model. Lognormal AFT model, which has the smallest AIC = 511.42 and BIC = 624.78, was selected for the time to first ANC booking data set (Table 4).
Table 4.
Comparisons of Akaike information criteria and Bayesian information criteria among different accelerated failure time models.
| Models | Log likelihood (null) | Log likelihood (model) | AIC | BIC |
|---|---|---|---|---|
| Exponential | −272.23 | −244.53 | 541.07 | 650.23 |
| Weibull | −267.48 | −235.38 | 524.76 | 638.12 |
| Log logistic | −265.1009 | −233.36 | 520.72 | 634.08 |
| Log normal | −258.37 | −228.71 | 511.42 | 624.78 |
In the multivariable lognormal AFT model, maternal occupation, residence, religion, and planned pregnancy were found to be significant determinants of time to first ANC booking. The acceleration factor for time to first ANC booking among women who were government or private employees was 1.60 (φ = 1.60, 95% CI: 1.01, 2.55) when compared to women who were housewives. This shows pregnant women who work as either a government or private employee booked their first ANC later as compared to those who were housewives. Pregnant women who reside in urban areas had 0.47 (φ = 0.47, 95% CI: 0.27, 0.83) times shorter survival times when compared to women who reside in rural areas. Similarly, Pregnant women who were either Protestant or Catholic had 0.46 (φ = 0.46, 95% CI: 0.25, 0.84) times shorter survival times when compared to women who were Muslims. The acceleration factor for time to first ANC booking among pregnant women who planned the pregnancy was 0.45 (φ = 0.45, 95% CI: 0.25, 0.81) when compared to women who unplanned the pregnancy. This result showed urban residents, Protestant or Catholic women, and women who planned the pregnancy booked their first ANC early when compared to rural residents, Muslim women, and women who unplanned pregnancy, respectively (Table 5).
Table 5.
Lognormal survival regression model for predictors of time to first ANC booking among pregnant women who are at ANC follow‐up at Pawe General Hospital, Pawe District, North‐west Ethiopia, 2024 (N = 502).
| Variables | Categories | Survival status | Crude φ (95% CI) | p value | Adjusted φ (95% CI) | p value | |
|---|---|---|---|---|---|---|---|
| Event (%) | Censored (%) | ||||||
| Age | 15–24 | 30 (18.8) | 135 (81.2) | 1 | 1 | ||
| 25–34 | 46 (15.4) | 253 (84.6) | 1.13 (0.82, 1.55) | 0.44 | 1.07 (0.74, 1.54) | 0.71 | |
| 35–49 | 4 (10.53) | 34 (89.47) | 1.58 (0.81, 3.08) | 0.17 | 1.07 (0.52, 2.20) | 0.84 | |
| Mother's educational status | No education | 7 (11.4) | 54 (88.5) | 1 | 1 | ||
| Primary education | 18 (15.7) | 96 (84.2) | 0.75 (0.43, 1.32) | 0.33 | 0.89 (0.51, 1.57) | 0.70 | |
| Secondary education | 21 (12.5) | 147 (87.5) | 0.86 (0.50, 1.48) | 0.60 | 1.13 (0.64, 2.03) | 0.65 | |
| College and above | 34 (21.3) | 125 (78.6) | 0.59 (0.35, 1.01) | 0.05 | 0.67 (0.37, 1.23) | 0.20 | |
| Mother's occupation | Housewife | 60 (17.3) | 287 (82.7) | 1 | 1 | ||
| Government/private employee | 13 (14.3) | 78 (85.7) | 1.13 (0.76, 1.70) | 0.53 | 1.60 (1.01, 2.55) | 0.04 | |
| Private business woman | 6 (10.5) | 51 (89.5) | 1.53 (0.90, 2.61) | 0.11 | 1.52 (0.92, 2.52) | 0.09 | |
| Othera | 1 (14.3) | 6 (85.7) | 1.43 (0.39, 5.25) | 0.58 | — | 0.98 | |
| Place of residence | Rural | 5 (6.4) | 73 (93.6) | 1 | |||
| Urban | 75 (17.7) | 349 (82.3) | 0.42 (0.26, 0.70) | 0.01 | 0.47 (0.27, 0.83) | 0.01 | |
| Religion | Muslim | 23 (17.3) | 110 (82.7) | 1 | 1 | ||
| Orthodox | 49 (14.4) | 292 (85.6) | 1.17 (0.84, 1.65) | 0.34 | 1.01 (0.71, 1.42) | 0.97 | |
| Otherb | 8 (28.6) | 20 (71.4) | 0.61 (0.33, 1.13) | 0.11 | 0.45 (0.25, 0.84) | 0.01 | |
| Family size | ≤ 2 | 33 (18.2) | 148 (81.8) | 1 | 1 | ||
| 3‐4 | 42 (15.6) | 227 (84.4) | 1.13 (0.82, 1.55) | 0.49 | 1.52 (0.75, 3.10) | 0.24 | |
| ≥ 5 | 5 (9.6) | 47 (90.4) | 1.69 (0.94, 3.03) | 0.17 | 2.08 (0.82, 5.33) | 0.12 | |
| Distance from health facility | < 30 min | 64 (18.4) | 283 (81.6) | 1 | 1 | ||
| 30–60 min | 9 (11.8) | 67 (88.2) | 1.34 (0.86, 2.01) | 0.18 | 1.07 (0.70, 1.64) | 0.75 | |
| > 60 min | 7 (8.86) | 72 (91.14) | 1.85 (1.16, 2.96) | 0.01 | 1.24 (0.75, 2.04) | 0.39 | |
| Husband's educational status (n = 492) | No education | 8 (10.8) | 66 (89.2) | 1 | 1 | ||
| Primary and secondary education | 42 (16.7) | 209 (83.3) | 0.71 (0.44, 1.15) | 0.16 | 0.90 (0.54, 1.50) | 0.68 | |
| College and above | 29 (17.4) | 138 (82.6) | 0.66 (0.40, 1.09) | 0.11 | 0.87 (0.47, 1.60) | 0.66 | |
| History of abortion | None | 61 (15.3) | 337 (84.7) | 1 | 1 | ||
| One | 18 (21.4) | 66 (78.6) | 0.76 (0.51, 1.11) | 0.15 | 0.82 (0.55, 1.22) | 0.33 | |
| Recurrent | 1 (5.0) | 19 (95.0) | 2.02 (0.68, 6.07) | 0.21 | 1.70 (0.61, 4.70) | 0.31 | |
| History of stillbirth | No | 69 (14.7) | 399 (85.3) | 1 | 1 | ||
| Yes | 11 (32.3) | 23 (67.7) | 0.57 (0.34, 0.95) | 0.03 | 0.73 (0.43, 1.23) | 0.23 | |
| Planed pregnancy | No | 3 (4.48) | 64 (95.52) | 1 | 1 | ||
| Yes | 77 (17.7) | 358 (82.3) | 0.38 (0.20, 0.70) | 0.01 | 0.45 (0.25, 0.81) | 0.008 | |
| Parity | Nulliparity | 28 (15.6) | 152 (84.4) | 1 | 1 | ||
| Primiparity | 33 (19.2) | 139 (80.8) | 0.88 (0.62, 1.25) | 0.48 | 0.49 (0.12, 1.220 | 0.13 | |
| Multiparity | 19 (12.7) | 131 (87.3) | 1.18 (0.80, 1.74) | 0.38 | 0.54 (0.20, 1.42) | 0.21 | |
| Gravidity | Primigravida | 24 (15.8) | 128 (84.2) | 1 | 1 | ||
| Multigravida | 56 (16.0) | 294 (84.0) | 1.01 (0.73, 1.41) | 0.93 | 1.47 (0.67, 3.21) | 0.33 | |
| Media access | No | 26 (15.9) | 137 (84.1) | 1 | 1 | ||
| Yes | 54 (15.9) | 285 (84.1) | 0.94 (0.68, 1.30) | 0.72 | 1.26 (0.89, 1.77) | 0.19 | |
Farmer, Student;
Protestant, Catholic
4. Discussion
The objective of the study was to determine cumulative incidence of early ANC initiation, the median time to first ANC booking and its predictors among pregnant women who are on ANC follow‐up at Pawe General Hospital, Ethiopia, 2024. The result showed 15.94% of pregnant women booked their first ANC before 12 weeks of gestation. The overall median time to ANC initiation was 17 weeks. Maternal occupation, religion, planned pregnancy, and residence were found to be predictors of the time to first ANC booking.
The incidence of early ANC among pregnant women in this study was low. It was in line with studies done in Bangladesh [30] and in Saudi Arabia [31]. The result was lower than studies done in lower and middle income countries [32], in the UAE [33], Bangladesh [34], in Africa [35], in sub‐Saharan Africa [36], in Rwanda [37], in Nigeria [38], and studies in Ethiopia [21, 27, 39, 40]. The variation might be due to the fact that the study setting is found in an emerging region in which the literacy rate is low and there is inadequate awareness of the timing of the first ANC. Furthermore, the cut point of gestational week difference for early ANC also has an effect on the difference between the studies, in which some studies use 16 weeks as a cut point for as early ANC initiation [27, 33].
The median time to ANC initiation in this study was 17 weeks, which showed that more than half of women are at risk of several obstetric complications, which may lead to maternal and neonatal morbidity and mortality. This result is later than the time the WHO recommended for every pregnant woman, which is before 12 weeks of gestation [1]. The finding is consistent with a study from India [41], East Africa [42], Kenya [43], Ethiopia in 2016 and 2019 demographic health survey [21, 24], and Arba Minch [39], which is 4 months. However, the median time to ANC initiation was earlier as compared to the study performed using 2016 EDHS [26] which is 7 months, which may be due to the variation attributed to the fact that recently, in Ethiopia, different interventions were done in line with the Ethiopian national reproductive health strategy with the outcome of interest to improve maternal and neonatal morbidity and mortality [2]. Result variation from the same demographic health surveys was due to the difference in study population, in which some of the literature use live births as the target population and others use all pregnant women with ANC follow up as the target population [21, 26]. The median time was also earlier when compared to study done using Nigeria DHS [38] which may be due to differences in the study setting: the participants from this study were mainly from an urban area where women had access to education, exposure to media and health facilities whereas the study in Nigeria was from the Nigerian demographic and health survey where the majority of the women were from rural areas.
Maternal Occupation was a significant predictor of time to first ANC in the study setting; government and private employee pregnant women book their first ANC later than housewife women. The result was in line with studies done in Gondar [44] and in Ambo [40], which states that government employees book ANC later than housewives and merchants. This might be due to focus on work commitment and also a lack of awareness of the ideal time to first ANC initiation [45]. However, the result was different from studies done in Bangladesh [30], in Africa [35], in sub‐Saharan Africa [46], in the West Shoa zone, Ethiopia [47], which states that housewife pregnant women booked ANC later than employed mothers. Those results implied maternal occupation was a significant determinant, which needs consideration for policymakers and public health professionals.
Residence was a significant determinant for time to first ANC booking, as rural resident women book their first ANC later than urban residents. This result is consistent with studies done in Bangladesh [34], Africa [35], in Sub‐Saharan Africa [25], in Kenya [43], and in Ethiopia using nationally representative studies [21, 24, 26] as well as pocket studies around different parts of the country [27, 39, 48]. These might be due to Women from urban areas may be aware of the importance of early ANC initiation as they have better educational opportunities [49] and easy access to various media outlets [50].
The result showed that there is religion difference in initiating first ANC, as Protestant and Catholic women book earlier than Orthodox women. Studies done in sub‐Saharan Africa [46], in Kenya [43], in Nigeria [9], and Ethiopia [51] also revealed religion as a significant determinant of ANC initiation. The difference might be due to cultural differences as well as perceived attitude towards maternal health service utilization.
Planned pregnancy has been a significant factor in studies done across the world. This study showed that planned pregnancy is a significant predictor of shortening the time to first ANC booking for their pregnancy. It is in line with studies done in Bangladesh [34], Africa [35], sub‐Saharan Africa [46], East Africa [42], Rwanda [37], Ethiopia using EDHS 2016 [21], Ethiopia Nole Kaba district [48], and Arba Minch public health facilities [39]. The reason may be that women who want a pregnancy might have an intention to have a healthy neonate and prevent complications, which makes women have an early ANC contact. Women who find themselves with an unplanned pregnancy may experience sadness, regret, and denial. These emotions could affect their acceptance and attitude towards the pregnancy, which results in late initiation of ANC. Additionally, the unexpected nature of unplanned pregnancies can result in delayed recognition and awareness of the pregnancy status, which can lead to late ANC initiation [52].
An unexpected finding was that employed women initiated antenatal care later than housewives. This may be due to workplace‐related barriers such as inflexible working hours and limited time to attend health facilities during routine clinic hours. Similar constraints may also reduce opportunities for health information exposure, contributing to delayed ANC booking.
5. Conclusion and Reccomendation
World Health Organization recommended that every pregnant woman initiate ANC before 12 weeks of gestation. The median time to ANC initiation was seventeen weeks of gestation in the study area. The highest proportion of women in the study setting are still late for first ANC booking, which in turn implies that many women are at risk of several obstetric complications. To identify the determinants of time to first ANC contact, Log normal survival regression was applied. Planned pregnancy, being Protestant or Catholic and urban residents were found to be positive predictors for early antenatal care initiation, whereas being a private or government employee was found to be a negative predictor of time to first ANC when compared to being a housewife. Maternal health programs should consider strategies that make ANC services more accessible for working women. Health facilities could introduce flexible appointment schedules or extended clinic hours to accommodate employed mothers. We recommend regional health office provide health information, education, and communication to create community awareness regarding the starting time of first antenatal care visits with its advantages through health workers, health extension, and any other concerned bodies. Regional Health Bureau and Ministry of Health should continue creating awareness and providing family planning, which plays an important role in reducing unplanned pregnancies, which affects the time to initiation of early. For researchers, we recommend further qualitative research focusing on early initiation of antenatal care, including further reasons why private and government employees book ANC late.
6. Limitations of the Study
The limitation of the study was that important factors like knowledge and perception of early ANC initiation were not assessed in the study due to the retrospective nature of the study. Additionally, the study was conducted in a single hospital, which may limit generalizability to other settings in Ethiopia.
Author Contributions
Ammar Bishaw Ebrahim: writing – original draft, writing – review and editing, visualization, validation, software, project administration, methodology, investigation, formal analysis, data curation, conceptualization. Gebeyaw Wudie Tsegaye: writing – original draft, writing – review and editing, visualization, validation, project administration, software, methodology, investigation, formal analysis, conceptualization. Bezawit Getachew Nega: writing – review and editing, formal analysis, data curation. Ergoye Melese Sendek: writing – original draft, writing – review and editing, visualization, validation, software, methodology, project administration, investigation, formal analysis, data curation, conceptualization.
Funding
The authors have nothing to report.
Consent
The authors have nothing to report.
Conflicts of Interest
The authors declare no conflicts of interest.
Transparency Statement
The lead author, Ammar Bishaw Ebrahim, affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.
Acknowledgments
We would like to thank Bahir Dar University, Pawi Wereda Health Office, managers of health facilities, staff at Pawe General Hospital, staff who work in maternal and child health units, and the study participants for their great cooperation in this research. All authors have reviewed and approved the final version of the manuscript. The corresponding author had full access to all study data and assumes complete responsibility for the data's integrity and the accuracy of the data analysis.
Data Availability Statement
All data supporting the findings are included in the manuscript. The dataset for this article is openly available without restriction upon request from the corresponding author.
References
- 1. World Health Organization . WHO Recommendations on Antenatal Care For a Positive Pregnancy Experience: World Health Organization (2016). [PubMed] [Google Scholar]
- 2. Federal Ministry of Health (FMoH) . Ethiopian National Antenatal care Guideline 2022.
- 3. C. E. B. C. O. G. S ., “The Public Health Importance of Antenatal Care,” Facts, Views & Vision in ObGyn 7, no. 1 (2015): 5–6. [PMC free article] [PubMed] [Google Scholar]
- 4. World Health Organization . The Network For Improving Quality of Care For Maternal, Newborn and Child Health: Evolution, Implementation and Progress: 2017‐2020 report. 2021.
- 5. Antenatal care. UNICEF 2022, https://data.unicef.org/topic/maternal-health/antenatal-care/.
- 6. Tessema Z. T., Teshale A. B., Tesema G. A., and Tamirat K. S., “Determinants of Completing Recommended Antenatal Care Utilization in Sub‐Saharan From 2006 to 2018: Evidence From 36 Countries Using Demographic and Health Surveys,” BMC Pregnancy and Childbirth 21, no. 1 (2021): 192, 10.1186/s12884-021-03669-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Moller A. B., Petzold M., Chou D., and Say L., “Early Antenatal Care Visit: A Systematic Analysis of Regional and Global Levels and Trends of Coverage From 1990 to 2013,” Lancet Global Health 5, no. 10 (2017): e977–e983, 10.1016/s2214-109x(17)30325-x. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Abebe G. F., Alie M. S., Girma D., Mankelkl G., Berchedi A. A., and Negesse Y., “Determinants of Early Initiation of First Antenatal Care Visit in Ethiopia Based on the 2019 Ethiopia Mini‐Demographic and Health Survey: A Multilevel Analysis,” PLoS One 18, no. 3 (2023): e0281038, 10.1371/journal.pone.0281038. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Fagbamigbe A. F., Olaseinde O., and Fagbamigbe O. S., “Timing of First Antenatal Care Contact, its Associated Factors and State‐Level Analysis in Nigeria: A Cross‐Sectional Assessment of Compliance With the WHO Guidelines,” BMJ Open 11, no. 9 (2021): e047835. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10. EPHI and ICF ., Ethiopian Mini Demographic and Health Survey, Key Indicators (EPHI and ICF, 2019). [Google Scholar]
- 11. World health Oranization . Strategies Toward Ending Preventable Maternal Mortality 2015.
- 12. World Health Organization . Trends in Maternal Mortality 2000 to 2020: Estimates by WHO, UNICEF, UNFPA (World Bank Group and UNDESA/Population Division: executive summary, 2023). [Google Scholar]
- 13. World Health Oranization. Maternal Mortality 2025 [cited 2025 Oct 21], https://www.who.int/news-room/fact-sheets/detail/maternal-mortality. [Google Scholar]
- 14. World Health Organization . Trends in maternal mortality 2000 to 2023: Estimates by WHO, UNICEF, UNFPA (World Bank Group and UNDESA/Population Division, 2025). [Google Scholar]
- 15. UNICEF . Standing Up for Stillbirth: Current Estimates and Key Interventions 2025 [cited 2025 Oct 21], https://data.unicef.org/resources/standing-up-for-stillbirth-report/.
- 16. UNICEF . Monitoring the Situation of Children and Women 2024, [https://data.unicef.org/topic/child-survival/neonatal-mortality/.
- 17. UNICEF . Monitoring the Situation of Women and Children 2023 [cited 2024 April 06], https://data.unicef.org/topic/child-survival/stillbirths/.
- 18. Gudayu T. W., “Epidemiology of Neonatal Mortality: A Spatial and Multilevel Analysis of the 2019 Mini‐Ethiopian Demographic and Health Survey Data,” BMC Pediatrics 23, no. 1 (2023): 26. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 19. Hussen A. M., Ibrahim I. M., Tilahun B., Tunçalp Ö., Grobbee D. E., and Browne J. L., “Completion of the Continuum of Maternity Care in the Emerging Regions of Ethiopia: Analysis of the 2019 Demographic and Health Survey,” International Journal of Environmental Research and Public Health 20, no. 13 (2023): 6320, https://www.mdpi.com/1660-4601/20/13/6320. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 20. World Health Organization . 2023. World Health Statistics Monitoring Health for SDGs, Sustainable Development Goals, 2023.
- 21. Belay D. G., Alemu M. B., Aragaw F. M., and Asratie M. H., “Time to Initiation of Antenatal Care Visit and Its Predictors Among Reproductive Age Women in Ethiopia: Gompertz Inverse Gaussian Shared Frailty Model,” Frontiers in Global Women's Health 4 (2023): 917895, 10.3389/fgwh.2023.917895. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 22. Fentaw K. D., Fenta S. M., Biresaw H. B., and Mulugeta S. S., “Time to First Antenatal Care Visit Among Pregnant Women in Ethiopia: Secondary Analysis of EDHS 2016; Application of AFT Shared Frailty Models,” Archives of Public Health 79, no. 1 (2021): 192, 10.1186/s13690-021-00720-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 23. Hussen N. M., Gebre K. K., Rorisa T. G., and Mohammed M. A., “Survival Analysis of Early Initiation of Antenatal Care Visits and Associated Factors Among Pregnant Women in Ethiopia,” PLoS One 19, no. 12 (2024): e0315724, 10.1371/journal.pone.0315724. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 24. Kitaw T. A. and Haile R. N., “Time to First Antenatal Care Booking and Its Determinants Among Pregnant Women in Ethiopia: Survival Analysis of Recent Evidence From EDHS 2019,” BMC Pregnancy and Childbirth 22, no. 1 (2022): 921, 10.1186/s12884-022-05270-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 25. Alem A. Z., Yeshaw Y., Liyew A. M., et al., “Timely Initiation of Antenatal Care and its Associated Factors Among Pregnant Women in Sub‐Saharan Africa: A Multicountry Analysis of Demographic and Health Surveys,” PLoS One 17, no. 1 (2022): e0262411, 10.1371/journal.pone.0262411. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 26. Seid A. and Ahmed M., “Survival Time to First Antenatal Care Visit and its Predictors Among Women in Ethiopia,” PLoS One 16, no. 5 (2021): e0251322, 10.1371/journal.pone.0251322. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27. Ambaye E., Regasa Z. W., and Hailiye G., “Early Initiation of Antenatal Care and Its Associated Factors Among Pregnant Women Attending Antenatal Care at Public Health Centres in Bahir Dar Zuria Zone, Northwest Ethiopia, 2021: A Cross‐Sectional Study,” BMJ Open 13, no. 1 (2023): e065169, 10.1136/bmjopen-2022-065169. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 28. Fetene W., Mekonnen A., Shiferaw Z., Genet A., and Haile S., “Timely Initiation of First Antenatal Care Visit and Associated Factors Among Pregnant Women in the Amhara Region, North‐West Ethiopia: A Comparative Cross‐Sectional Study,” Pan African Medical Journal 44 (2023): 51, 10.11604/pamj.2023.44.51.33997. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29. Tufa G., Tsegaye R., and Seyoum D., “Factors Associated With Timely Antenatal Care Booking Among Pregnant Women in Remote Area of Bule Hora District, Southern Ethiopia,” International Journal of Women's Health 12 (2020): 657–666, 10.2147/IJWH.S255009. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30. Sarker B. K., Rahman M., Rahman T., et al., “Status of the WHO Recommended Timing and Frequency of Antenatal Care Visits in Northern Bangladesh,” PLoS One 15, no. 11 (2020): e0241185. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 31. Alqifari S., “Antenatal Care Practices: A Population‐Based Multicenter Study From Saudi Arabia,” International Journal of Women's Health 16 (2024): 331–343. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 32. Jiwani S. S., Amouzou‐Aguirre A., Carvajal L., et al., “Timing and Number of Antenatal Care Contacts in Low and Middle‐Income Countries: Analysis in the Countdown to 2030 Priority Countries,” Journal of Global Health 10, no. 1 (2020): 010502. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 33. Ali N., Elbarazi I., Alabboud S., Al‐Maskari F., Loney T., and Ahmed L. A., “Antenatal Care Initiation Among Pregnant Women in the United Arab Emirates: The Mutaba'ah Study,” Frontiers in Public Health 8 (2020): 211, https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7300181/pdf/fpubh-08-00211.pdf. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34. Hossain M. I., Rahman T., Sadia T. S., et al., “Survival Analysis of Early Intention of Antenatal Care Among Women in Bangladesh,” Scientific Reports 14, no. 1 (2024): 4738, 10.1038/s41598-024-55443-5. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35. Abdo R., Demelash M., Seid A. M., and Mussema A., “First Trimester Antenatal Care Contact in Africa: A Systematic Review and Meta‐Analysis of Prevalence and Contributing Factors,” BMC Pregnancy and Childbirth 23, no. 1 (2023): 742. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 36. Habte A., Tamene A., and Melis T., “Compliance Towards WHO Recommendations on Antenatal Care for a Positive Pregnancy Experience: Timeliness and Adequacy of Antenatal Care Visit in Sub‐Saharan African Countries: Evidence From the Most Recent Standard Demographic Health Survey Data,” PLoS One 19, no. 1 (2024): e0294981. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 37. Mkandawire P., Atari O., Kangmennaang J., Arku G., Luginaah I., and Etowa J., “Pregnancy Intention and Gestational Age at First Antenatal Care (ANC) Visit in Rwanda,” Midwifery 68 (2019): 30–38. [DOI] [PubMed] [Google Scholar]
- 38. Fagbamigbe A. F., Abel C., Mashabe B., and Adebowale A. S., “Survival Analysis and Prognostic Factors of the Timing of First Antenatal Care Visit in Nigeria,” Advances in Integrative Medicine 6, no. 3 (2019): 110–119, 10.1016/j.aimed.2018.12.002. [DOI] [Google Scholar]
- 39. Belete A. G., Debere M. K., Gurara M. K., Sidamo N. B., Shimbre M. S., and Teshale M. Y., “Time to Initiation of Antenatal Care and Its Predictors Among Pregnant Women Who Delivered in Arba Minch Town Public Health Facilities, Gamo Zone, Southern Ethiopia, 2023: a Retrospective Follow‐up Study,” Reproductive health 21, no. 1 (2024): 73, 10.1186/s12978-024-01818-w. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40. Edessa A., Dida N., and Teferi E., “Early Initiation of Antenatal Care and Its Associated Factors Among Antenatal Care Followers at Public Health Facilities in Ambo Town Administration, Central Ethiopia,” Journal of Family Medicine and Primary Care 12, no. 1 (2023): 67–75, 10.4103/jfmpc.jfmpc_725_22. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 41. Tripathy A. and Mishra P. S., “Inequality in Time to First Antenatal Care Visits and Its Predictors Among Pregnant Women in India: An Evidence From National Family Health Survey,” Scientific Reports 13, no. 1 (2023): 4706. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 42. Endawkie A., Kebede S. D., Abera K. M., et al., “Time to Antenatal Care Booking and Its Predictors Among Pregnant Women in East Africa: A Weibull Gamma Shared Frailty Model Using a Recent Demographic and Health Survey,” Frontiers in Global Women's Health 5 (2024): 1457350. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 43. Kase B. F., Seifu B. L., Mare K. U., et al., “Time to First Antenatal Care Visit and Its Predictors Among Women in Kenya: Weibull Gamma Shared Frailty Model (Based on the Recent 2022 KDHS Data),” BMC Pregnancy and Childbirth 25, no. 1 (2025): 50. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 44. Wolde H. F., Tsegaye A. T., and Sisay M. M., “Late Initiation of Antenatal Care and Associated Factors Among Pregnant Women in Addis Zemen Primary Hospital, South Gondar, Ethiopia,” Reproductive Health 16, no. 1 (2019): 73, 10.1186/s12978-019-0745-2. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 45. El‐Gilany A. H., El‐Wehady A., and El‐Hawary A., “Maternal Employment and Maternity Care in Al‐Hassa, Saudi Arabia,” European Journal of Contraception & Reproductive Health Care: The Official Journal of the European Society of Contraception 13, no. 3 (2008): 304–312. [DOI] [PubMed] [Google Scholar]
- 46. Okedo‐Alex I. N., Akamike I. C., Ezeanosike O. B., and Uneke C. J., “Determinants of Antenatal Care Utilisation in Sub‐Saharan Africa: A Systematic Review,” BMJ Open 9, no. 10 (2019): e031890. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 47. Debelo B. T. and Danusa K. T., “Level of Late Initiation of Antenatal Care Visit and Associated Factors Amongst Antenatal Care Attendant Mothers in Gedo General Hospital, West Shoa Zone, Oromia Region, Ethiopia,” Frontiers in Public Health 10 (2022): 866030, 10.3389/fpubh.2022.866030. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 48. Gelassa F. R., Tafasa S. M., and Kumera D., “Determinants of Early Antenatal Care Booking Among Pregnant Mothers Attending Antenatal Care at Public Health Facilities in the Nole Kaba District, Western Ethiopia: Unmatched Case‐Control Study,” BMJ Open 13, no. 10 (2023): e073228, 10.1136/bmjopen-2023-073228. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 49. Sisaye S., “Education and Rural Development in Ethiopia,” Agricultural Administration 20, no. 4 (1985): 237–255. [Google Scholar]
- 50. Gilano G., Hailegebreal S., Sako S., and Seboka B. T., “Understanding the Association of Mass Media With the Timing of Antenatal Care in Ethiopia: An Impression From the 2016 Ethiopia Demographic and Health Survey,” Journal of Maternal‐Fetal & Neonatal Medicine: The Official Journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians 36, no. 1 (2023): 2183760. [DOI] [PubMed] [Google Scholar]
- 51. Teklu R., Aragaw F., Negash W., Fetene S., and Fentie E., “Survival Analysis and Factors of the Timing of Antenatal Care Visit in Ethiopia: Accelerated Failure Time Shared Frailty Mod‐els,” International Archives of Nursing and Health Care 9 (2023): 181. [Google Scholar]
- 52. Tolossa T., Turi E., Fetensa G., Fekadu G., and Kebede F., “Association Between Pregnancy Intention and Late Initiation of Antenatal Care Among Pregnant Women in Ethiopia: A Systematic Review and Meta‐Analysis,” Systematic Reviews 9 (2020): 191. [DOI] [PMC free article] [PubMed] [Google Scholar]
Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
All data supporting the findings are included in the manuscript. The dataset for this article is openly available without restriction upon request from the corresponding author.