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EDITED BY
Sarosh Iqbal,
University of Management and Technology,
Pakistan
REVIEWED BY
Sali Suleman Hassen,
Mizan Tepi University, Ethiopia
Triphonie Nkurunziza,
World Health Organization—Regional Office for
Africa, Republic of Congo
Alan Kimber,
University of Southampton, United Kingdom
*CORRESPONDENCE
Melaku Hunie Asratie
melakhunie27@gmail.com
RECEIVED 11 April 2022
ACCEPTED 20 September 2023
PUBLISHED 03 October 2023
CITATION
Belay DG, Alemu MB, Aragaw FM and
Asratie MH (2023) Time to initiation of antenatal
care visit and its predictors among reproductive
age women in Ethiopia: Gompertz inverse
Gaussian shared frailty model.
Front. Glob. Womens Health 4:917895.
doi: 10.3389/fgwh.2023.917895
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© 2023 Belay, Alemu, Aragaw and Asratie. This
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No use, distribution or reproduction is
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terms.
Time to initiation of antenatal care
visit and its predictors among
reproductive age women in
Ethiopia: Gompertz inverse
Gaussian shared frailty model
Daniel Gashaneh Belay1,2,3, Melaku Birhanu Alemu1,4,
Fantu Mamo Aragaw2and Melaku Hunie Asratie5*
1
Curtin School of Population Health, Curtin University, Perth, WA, Australia,
2
Department of Epidemiology
and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of
Gondar, Gondar, Ethiopia,
3
Department of Human Anatomy, College of Medicine and Health Sciences,
University of Gondar, Gondar, Ethiopia,
4
Department of Health Systems and Policy, Institute of Public
Health, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia,
5
Department of
Women’s and Family Health, School of Midwifery, College of Medicine and Health Sciences, University of
Gondar, Gondar, Ethiopia
Background: Early initiation of antenatal care (ANC) is essential for the early
detection of pregnancy-related problems and unfavorable pregnancy outcomes.
However, a significant number of mothers do not initiate ANC at the
recommended time. Therefore, this study aimed to determine the median time
of ANC initiation and its predictors among reproductive-age women in Ethiopia.
Methods: We used the Ethiopian Demographic and Health Survey (EDHS) 2016
data set. The proportional hazard assumption was assessed using Schoenfeld
residual test and log–log plot. A life table was used to determine the median
survival time (time of ANC initiation). The Gompertz inverse Gaussian shared
frailty model was the best-fitting model for identifying the predictors for the
early initiation of ANC booking. Finally, the adjusted hazard ratio (AHR) with a
95% confidence interval (CI) was used to determine the significance of predictors.
Results: A total of 7,501 reproductive-aged women gave recent birth in the last
5 years preceding the survey. Nearly three in five women [61.95% (95% CI:
60.85–63.04%)] booked their first ANC visit with a median time of 4.4 months.
Women who attended primary education (AHR = 1.10, 95% CI: 1.01–1.20),
secondary and above (AHR = 1.26, 95% CI: 1.11–1.44), media exposure (AHR =
1.07, 95% CI: 1.00–1.16), rich wealthy (AHR = 1.17, 95% CI: 1.06–1.30), grand
multiparous (AHR = 0.82, 95% CI: 0.72–0.93), unwanted pregnancy (AHR = 0.88,
95% CI: 0.81–0.96), small periphery region (AHR = 0.58, 95% CI: 0.51–0.67), and
rural residence (AHR = 0.86, 95% CI: 0.75–0.99) were significantly associated
with first ANC visit.
Abbreviations
AHR, adjusted hazard ratio; AIC, Akaike information criteria; ANC, antenatal care; BIC, Bayesian information
criteria; CI, confidence interval; CSA, Central Statistical Agency; DHS, Demographic and Health Survey;
EDHS, Ethiopian Demographic and Health Survey; MOH, Ministry of Health; PNC, postnatal care; SDG,
Sustainable Development Goal; WHO, World Health Organization.
TYPE Original Research
PUBLISHED 03 October 2023
|
DOI 10.3389/fgwh.2023.917895
Frontiers in Global Women’s Health 01 frontiersin.org
Conclusion: According to this study, a significant number of women missed their first ANC
visit. The education status of women, place of residence, region, wealth index, media
exposure, unintended pregnancy, and multi-parity were significantly associated with the
time of initiation of the first ANC visit. Therefore, policymakers should focus on
improving the socioeconomic status (education, media coverage, and wealth) of
reproductive-aged women by prioritizing women who live in small periphery regions and
rural residences to improve the early initiation of ANC.
KEYWORDS
antenatal care visit, maternal health, survival analysis, shared frailty, Ethiopia
Background
Maternal and child health issues are major public health concerns
globally. Maternal and neonatal mortality is unacceptably high with
more than one woman dying every 2 min in 2017.
Disproportionately, more than 95% of maternal and neonatal
deaths occur in low and lower-middle-income countries (1–3). Sub-
Saharan Africa takes the lion’s share of mortality accounting for
more than half of the global burdens, where the maternity
continuum of care was scarcely used (1,4). Ethiopian women have
a 21 per 1,000 women lifetime risk for death related to pregnancy
with a maternal mortality ratio of 412 per 100,000 live births (5).
The United Nations (UN) Sustainable Development Goal
(SDG) sets an objective to reduce maternal mortality to 70 per
100,000 by the year, 2030 with no country falling short more
than double this target (1). Providing sustainable and quality
maternal care services during pregnancy, childbirth, and the
postnatal period can reduce more than two-thirds of maternal
and newborn deaths (6,7). Women who received professional
care had a 16% and 24% lower likelihood of losing their baby
and experiencing preterm birth, respectively (8). Globally,
providing maternity and neonatal continuum of care could
prevent approximately half a million neonatal and 3–4 million
maternal mortalities (2,9). The Ministry of Health-Ethiopia
(MoH-E) is developing a strategy envisioned to end preventable
maternal deaths by 2035 (10) although it looks impossible as
evidence points out that maternal mortality is high in the 2016
Ethiopian Demographic and Health Survey (EDHS) (5,11).
Antenatal care (ANC) services were started across the globe to
reduce maternal and neonatal mortality by increasing skilled birth
attendance and institutional delivery rate (12–15). Early ANC is
defined as the booking of all WHO-recommended services before
16 weeks of gestation, which is vital for the health of both the
mother and the neonate (16). The timing of the first ANC visit
is very important for subsequent maternal and neonatal care
service utilization, which reduces maternal and neonatal
mortalities significantly (17–20).
Sociodemographic factors such as parity, education, and wealth
status are significantly associated with the time of ANC booking in
Pakistan (16). Being a rural residence, married, employed
occupation, unplanned pregnancy, and first pregnancy all had a
significant impact on the late first ANC initiation (18). However,
there is no evidence of the median time of ANC booking among
pregnant women in Ethiopia. Therefore, this study aimed to assess
the survival time to book the first ANC visit and to identify its
possible predictors among pregnant women in Ethiopia. Based on
the findings reported from the study, policymakers and
stakeholders may be able to develop policies and strategies and
design intervention programs to improve maternal care.
Methodology
Study design and data source and
populations
The study used population-based cross-sectional survey data
from EDHS 2016. Ethiopia is an East African country with the
second largest population in Africa. Administratively, Ethiopia is
federally decentralized into nine regions [Afar, Amhara,
Benishangul-Gumuz, Gambela, Harari, Oromia, Somali, Southern
Nations, Nationalities, and People’s Region (SNNPR), and
Tigray] and two administrative cities (Addis Ababa and Dire-
Dawa). The EDHS employed a stratified two-stage cluster
sampling technique selected in two stages using the 2007
Population and Housing Census (PHC) as a sampling frame.
Stratification was achieved by separating each region into urban
and rural areas. In the first stage, enumeration areas (EAs) were
selected with probability selection proportional to the EA size,
and in the second stage, households were systematically selected.
The study design and setting are described in detail elsewhere (21).
The study population consisted of women who gave recent
birth in the last 5 years preceding the survey. A total of 46
women who responded that they did not know the timing and
number of their first ANC visit were excluded from the analysis.
Finally, a total weighted sample of 7,501 reproductive-age women
was included in the analysis.
Study variables
The outcome variable of the study is the time between the date
of pregnancy of the women and their first ANC visit, which is
measured in months. A woman is considered as an event (had
her first ANC visit) if she booked WHO-recommended services
during her gestational time; otherwise, she is censored. The
WHO-recommended services during pregnancies are (1) blood
pressure measurements for detecting pre-eclampsia, (2) blood
Belay et al. 10.3389/fgwh.2023.917895
Frontiers in Global Women’s Health 02 frontiersin.org
tests for infection and anemia, (3) urine tests for detecting
bacteriuria and proteinuria, (4) counseling about the danger
signs of pregnancy, (5) provision of iron supplements, and (6)
provision of nutritional counseling (22,23).
Time is defined as the time in months from conception of
pregnancy up to the first ANC visit.
Survival time is defined as the time duration of the mother
surpassing without the first ANC contact in months.
Failure time is defined as the time in months when the mother
gets her first ANC care.
The independent variables considered for this study were
categorized as sociodemographic variables such as the age of the
mother, marital status, maternal education, education status of the
husband, place of residence, household head wealth index, media
exposure, pregnancy-related factors such as parity, pregnancy desire,
terminated pregnancy, and health facility–related factors such as
distance from the health facility, and health insurance coverage.
Data processing and analysis
The data were accessed in Stata format after registering as an
authorized user. We weighed the data as per the
recommendation of the major Demographic and Health Survey
(DHS). Stata 14 was used for data clearance and analysis. The
data were weighted using sampling weight before any statistical
analysis to restore the representativeness of the survey. The data
clearance and descriptive and summary statistics were conducted
using Stata version 14 software. Since the EDHS data have a
hierarchical structure where pregnant women are nested within a
cluster/EA, the assumption of independent observations and
equal variance across the clusters is violated. The random effect
of the survival model was checked to assess the clustering effect,
and the theta parameter (variance) was used to assess whether
there was any significant clustering (24). It showed whether or
not there was unobserved heterogeneity or shared frailty that
needed to be considered to get a reliable estimate.
Schoenfeld residual test, log–log plot, and Kaplan–Meier and
predicted survival plots were applied to check the proportional
hazard (PH) assumptions. The log-likelihood ratio test, deviance
(−2LL), and Akaike information and criteria (AIC) were applied
for model selection. A model with the highest values of log-
likelihood and the lowest value of AIC was the best-fitting
model. Deviance, AIC, and Cox–Snell residual graph showed that
the Gompertz inverse Gaussian shared frailty model had the
lowest value and the closest graph to the bisector, which was the
best-fitting model for the data (25).
A variable with a p-value less than 0.20 in the univariable
Gompertz inverse Gaussian shared frailty analysis was included
in the multivariable analysis. In the multivariable analysis, the
adjusted hazard ratio (AHR) with 95% confidence interval (CI)
was used to declare significant predictors for time to first ANC
booking. The AHR is the simultaneous inclusion of multiple
variables while adjusting for their potential confounding effects.
It represents the hazard ratio for the exposure of interest,
adjusted for the effects of other variables in the model.
Result
Characteristics of the study population
A total of 7,501 reproductive-age women were included in this
study, of whom more than half of the mothers were in the age
group 25–34 years (55.70%). Most of the study participants
[6,934 (92.45%)] were married, and nearly two-third [4,721
(62.94%)] had no formal education (Table 1).
The median time for initiation of the first
ANC visit
Of the total studied women, 4,701 (61.95%) initiated ANC
visits from skilled health personnel, whereas the remaining 2,800
(38.05%) had no ANC visits (they were censored) during the
follow-up time. Of those who had ANC, only 62.67% (95% CI:
60.95%–64.35%) of the pregnant women initiated their first ANC
visits timely (within 16 weeks of gestational age). Of the total
TABLE 1 Characteristics of the study population in Ethiopia, 2016 EDHS.
Variables Categories Weighted
frequency
Percentage
(%)
Maternal age (years) 15–24 1,780 23.73
25–34 4,178 55.70
35–49 1,544 20.57
Maternal education No education 4,721 62.94
Primary education 2,136 28.00
Secondary and above 645 8.59
Husband education No education 3,321 47.29
Primary education 2,719 39.00
Secondary and above 983 14.00
Head of household Male 6,405 85.39
Female 1,096 14.61
Media exposure No 4,914 65.52
Yes 2,586 34.48
Marital status Not married 566 7.55
Married 6,934 92.45
Wealth index Poor 3,271 43.61
Middle 1,563 20.84
Rich 2,666 35.55
Insurance covered No 7,189 95.85
Yes 312 4.15
Parity Primiparous 1,408 18.77
Multiparous 3,161 42.14
Grand multiparous 2,932 39.09
Terminated pregnancy No 6,834 91.11
Yes 667 8.89
Child wantedness Wanted 6,639 93.57
Unwanted 456 93.57
Residence Urban 1,779 23.73
Rural 4,178 55.70
Distance from HF Big problem 1,543 20.57
Not a big problem 3,135 41.79
Region Metropolis 245 3.27
Large central 6,821 90.94
Small periphery 434.7 5.80
HF; Health facility.
Belay et al. 10.3389/fgwh.2023.917895
Frontiers in Global Women’s Health 03 frontiersin.org
pregnant women, only 35.12% (95% CI: 34.06%–36.20%) initiated
their first ANC visits timely. The total follow-up time contributed
by all study participants was 19,189 person-years. The overall
median survival time (the time when half of the pregnant
women were found without booking their first ANC) was 4.4
months. The median survival time varies according to the
characteristics of the respondents. The median survival time, for
example, in urban areas was 4.0 months, whereas in rural areas
(Figure 1).
Predictors of first ANC visit among women
in Ethiopia
Comparisons of the survival functions of the first
ANC visit for different categorical variables
The log-rank test and the Kaplan–Meier survival function were
used to determine the differences in key variables at the baseline
among different categories. The Kaplan–Meier survival function
was constructed for different categorical variables. In general, the
pattern of the survivorship function lying above another
indicated that the group defined by the upper curve (red color)
had a longer survival (short time failure) than that of the group
defined by the lower curve (blue color). Based on this, in our
study, rural residents have longer survival than urban residents at
a log-rank p-value of <0.001. The significance of the graphically
observed difference was assessed by log-rank test, and it is
indicated in the p-value of the respective figures (Figure 2).
Model diagnostics and comparison
The Schoenfeld residuals test was used to assess the PH
assumption, with results showing that a p-value of <0.001 with a
chi-square value of 76.06 is significant. This smallest p-value is
evidence to contradict the PH assumption.Therefore, a
parametric type of model should be fitted. Based on deviance,
AIC, and Cox–Snell residual test, the shared frailty model with
Gompertz distribution and inverse Gaussian frailty was most
efficient, because it had the lowest deviance and AIC value
(Table 2).
In the Gompertz inverse Gaussian shared frailty model, the
variables with a p-value of <0.2 in the bi-variable analysis were
considered for multivariable analysis. Based on these, the
variables such as place of residence, maternal education, partner
education, wealth index, parity, wanted last pregnancy, and
media exposure and residence were significant predictors of the
initiation of the first ANC visit in the multivariable analysis.
Women living in rural residences have a 14% lower hazard of
initiating their first ANC visits than those living in urban
residences (AHR = 0.86, 95% CI: 0.75–0.99). The hazard of
initiating the first ANC visit among women who have primary and
secondary and higher education is 1.10 and 1.26 times higher than
no formal education (AHR = 1.10, 95% CI: 1.01–1.20) and (AHR
= 1.26, 95% CI: 1.11–1.44), respectively. The hazard of initiating
the first ANC visit among women whose husbands have primary
and secondary and higher education is 1.17 and 1.32 times higher
than those who had no education (AHR = 1.17, 95% CI: 1.04–
1.22) and (AHR = 1.32, 95% CI: 1.12–1.39), respectively. Women
who have media exposure have a 1.07 times higher hazard of
having their first ANC visits than that in women who have no
media exposure (AHR = 1.07, 95% CI: 1.00–1.16). The hazard of
initiating the first ANC visit among women who have a rich
wealth index is 1.17 times higher than that in those having a poor
wealth index (AHR = 1.17, 95% CI: 1.06–1.30). Women who are
grand multiparous have an 18% lower hazard of initiating their
first ANC visit than that in those primiparous (AHR = 0.82, 95%
CI: 0.72–0.93). The hazard of having the first ANC visit among
FIGURE 1
The overall Kaplan–Meier failure curve of initiation of first antenatal care visits in Ethiopia in 2016.
Belay et al. 10.3389/fgwh.2023.917895
Frontiers in Global Women’s Health 04 frontiersin.org
women who had an unwanted last pregnancy was decreased by 18%
as compared to that in those with wanted pregnancy (AHR = 0.88,
95% CI: 0.81–0.96).Women who are living in large central and
small periphery regions have a 42% decrease in the hazard of
initiating their first ANC visit as compared to that in those living
in metropolis cities (AHR = 0.58, 95% CI: 0.51–0.67) (Table 3).
FIGURE 2
Kaplan–Meier survival curves and log rank tests of initiation of first ANC visits by women education status (A), parity (B),residence (C)andregion(D)inEthiopia,2016.
TABLE 2 Model diagnostics and comparison for time to initiation of first antenatal care visit and predictors among reproductive-age women in Ethiopia.
Models Distribution Frailty Theta AIC BIC Deviance (−2LL) LR test of theta
Shared frailty Gompertz Gamma 0.33 9,452 9,608 9,776 120
Shared frailty Gompertz Inverse Gaussian 0.37 9,447 9,603 9,772 124
Shared frailty Exponential Gamma 0.30 9,997 10,140 9,952 106
Shared frailty Exponential Inverse Gaussian 0.34 9,992 10,140 9,948 110
Shared frailty Weibull Gamma 0.30 9,999 10,150 9,952 105
Shared frailty Weibull Inverse Gaussian 0.34 9,994 10,150 9,948 109
Shared frailty Log-normal Gamma 0.28 10,340 10,490 10,296 94
Shared frailty Log-normal Inverse Gaussian 0.30 10,330 10,490 10,292 98
Shared frailty Log–log Gamma 0.29 10,150 10,310 10,112 99
Shared frailty Log–log Inverse Gaussian 0.31 10,150 10,310 10,108 102
LR; Likelihood ratio.
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Discussion
This study was conducted to assess the predictors of initiating the
first ANC booking in Ethiopia based on the EDHS 2016 data.
According to this study, only 61.95% (95% CI: 60.85%–63.04%) of
women had their ANC visits. Of those who had ANC, only 62.67%
(95% CI: 60.95%–64.35%) of pregnant women initiated their first
ANC visits timely (within 16 weeks of gestational age). Of the total
pregnant women, only 35.12% (95% CI: 34.06%–36.20%) of women
initiated their first ANC visits timely. Moreover, the overall median
survival time (the time when half of the pregnant women were
found without booking their first ANC) was 4.4 months. This
finding was less than the finding from health centers of Addis
Ababa, where 65.6% of women started their ANC visit within
16 weeks of gestation. The discrepancy might be because Addis
Ababa is the capital of the country and the community there might
have better health awareness than other parts of the country. It
could also be due to EDHS covering more remote areas where
health institutions could be a major predictor of ANC utilization.
In the Gompertz inverse Gaussian shared frailty model
analysis, the education statuses of women and husbands, media
exposure, wealth index, wanted child, parity, and place of
residence were significantly associated with the time of the first
ANC visit.
Women who had formal education had a higher chance of
booking their first ANC visit as compared to that in women who
had no formal education. This is supported by the findings of
the studies conducted in Northern (26) and Northwest Ethiopia
(27) and Nigeria (28). Better education status of husbands
increases the risk of early ANC visits of women as compared to
that of their counterparts. This is supported by evidence from a
study conducted in Southern Ethiopia (29), where women with
educated husbands had more chance of early ANC visits. This is
due to being educated to understand the importance of ANC
visits, which encourages them to have early ANC bookings.
Women living in rural residences and small periphery regions
had less risk of having initiation of ANC visits compared to that of
their counterparts. This finding is supported by findings from
TABLE 3 Shard frailty survival regression analysis of initiation of first antenatal care visit among reproductive-age women in Ethiopia, EDHS 2016
perspective.
Variables Categories Event (%)
n= 4,700 (62%)
Failure (%)
n= 2,800 (38%)
Crude hazard ratio (95% CI) Adjusted hazard
ratio (95% CI)
Age of women 15–24 1,215 (68.25) 565 (31.75) 1.00 1.00
25–34 894 (21.38) 1,496 (35.82) 0.97 (0.91–1.05) 1.10 (0.99–1.20)
35–49 804 (52.14) 738 (47.86) 0.84 (0.76–0.93)* 1.07 (0.93–1.23)
Residence Urban 859 (90.16) 94 (9.84) 1.00 1.00
Rural 3,842 (58.67) 2,706 (4,133) 0.48 (0.40–0.59)*** 0.86 (0.75–0.99)***
Women education
status
No education 2,527 (53.54) 2,193 (46.46) 1.00 1.00
Primary 1,562 (73.19) 572 (26.81) 1.28 (1.19–1.38) *** 1.10 (1.01–1.20)*
Secondary and above 610 (94.66) 35 (5.36) 1.88 (1.69–2.06) *** 1.26 (1.11–1.44)**
Partner education
status
No education 1,767 (53.2) 1,554 (46.8) 1.00 1.00
Primary 18,03 (66.34) 915 (33.66) 1.25 (1.16–1.36)*** 1.17 (1.04–1.22)*
Secondary and above 843 (85.76) 140 (14.24) 1.78 (1.62–1.96)*** 1.32 (1.12–1.39)**
Marital status Not married 338 (59.75) 228 (40.25) 1.00 1.00
Married 4,362 (62.91) 2,572 (37.09) 0.96 (0.86–1.08) 1.19 (0.89–1.59)
Head of household Male 4,024 (62.84) 2,380 (37.16) 1.00 1.00
Female 676 (61.68) 420 (38.32) 1.12 (1.04–1.22)* 0.07 (0.98–1.17)
Media
exposure
No 2,705 (55.03) 2,210 (44.97) 1.00 1.00
Yes 1,996 (77.17) 590 (22.83) 1.40 (1.30–1.50)*** 1.07 (1.00–1.16)*
Wealth index Poor 1,706 (52.17) 1,564 (47.83) 1.00 1.00
Middle 975 (62.41) 588 (37.59) 1.10 (0.99–1.21) 1.06 (0.95–1.17)
Rich 2,018 (75.70) 648 (24.3) 1.58 (1.46–1.72)*** 1.17 (1.06–1.30)***
Insurance
covered
No 4,465 (62.11) 2,724 (37.89) 1.001.00 1.00
Yes 236 (75.59) 76 (24.41) 1.21 (1.03–1.43)* 1.19 (1.01–1.41)*
Parity Primiparous 10.98 (78.02) 309 (21.98) 1.00 1.00
Multiparous 2,067 (65.42) 10.93 (34.58) 0.91 (0.84–0.98)* 0.92 (0.85–1.02)
Grand multiparous 1,535 (52.34) 1,397 (47.66) 0.71 (0.65–0.78)*** 0.82 (0.72–0.93)**
Child wantedness Wanted 3,572 (64.79) 1,941 (35.21) 1.00 1.00
Unwanted 1,127 (56.77) 859 (43.23) 0.86 (0.79–0.93)** 0.88 (0.81–0.96)**
Distance from HF Big problem 2,372 (54.34) 1,993 (45.66) 1.00 1.00
Not a big problem 2,338 (74.27) 806 25.73 1.16 (1.08–1.24)* 1.00 (0.94–1.08)
Region Metropolis 230 (93.99) 15 (6.01) 1.00 1.00
Large central 4,248 (62.29) 2,572 (37.71) 0.43 (0.38–0.48)** 0.58 (0.50–0.66)***
Small periphery 221 (50.91) 213 (49.09) 0.43 (0.38–0.491)** 0.58 (0.51–0.67)***
HF; health facility.
Event = women who booked an ANC; failure = women who did not book an ANC.
*p-value < 0.05.
**p-value < 0.01.
***p-value < 0.001.
Belay et al. 10.3389/fgwh.2023.917895
Frontiers in Global Women’s Health 06 frontiersin.org
Zambia (30) and might be explained by urban women who may
have better access to health facilities to have an early booking. A
better wealth index increases the chance of first ANC visits as
compared to the poor. This is supported by evidence reported
from Nigeria (28) and Zambia (30), where better household
wealth improves the time for women to have their first ANC
visit. This might be explained by women with better wealth may
have better transport access and the ability to pay for transport
to visit health facilities.
Women with media exposure had an increased risk of initiation
of their first ANC visit. This is also in line with other findings from
Nigeria (28). This could be justified by those women with better
media exposure who had better knowledge about the importance
of ANC visits, which encourages them to have early ANC
bookings.
Being a grand multipara significantly decreases the risk of
initiation of the first ANC visit as compared to primiparous
women. This is supported by findings of studies conducted in
the United Kingdom (31) where having high parity increases the
risk of women having late ANC visits. This might be because
those women with primigravida are more sensitive to
complications and visit health facilities to have experiences with
delivery and other services, whereas the multiparous women
adapt the pregnancy and labor so they may not visit the health
institution early. Women with unwanted pregnancies had a lower
risk of initiation of the first ANC visit as compared to those with
unwanted pregnancies in Ethiopia. This is in agreement with the
reports of studies conducted in Northwest Ethiopia (32) and
Zambia (30), where women with wanted pregnancies had a
double risk of early initiation of ANC visits. This might be
explained by the women with wanted pregnancies who might
have a positive experience and more intention to have a healthy
neonate with additional support from husbands or families
which will encourage them to have an early ANC visit.
The main strength of this study was the use of weighted
nationally representative data with a large sample that makes it
representative at national and regional levels. Therefore, it can be
generalized to all pregnant women during the study period in
Ethiopia. Moreover, this study used a shared frailty model that
considered the nested nature of the EDHS data and the
variability within the community to get a reliable estimate and
standard errors. But it is not free of limitations mainly resulting
from the use of secondary data. Since the study includes women
who delivered in the last 5 years before the data collection and
asked about the essential service she provided, there might be a
recall bias for relatively older delivery. Moreover, some important
confounders like the health service quality and behavioral factors
are missed. In addition, the outcome variable is measured in an
integer even though the continuous time survival model is fitted.
Conclusion
According to this study, only three-fifth of pregnant women
booked their first ANC visit. The median survival time for
initiation of the first ANC visit is higher than what the WHO
recommends. The place of residence, education of women and
husbands, wealth index, media exposure, pregnancy wantedness,
and multi-parity were significantly associated with the time of
the first ANC visit.
Therefore, empowering women through improving education
level, access to media, and improvements in wealth status can
lead to the early booking of ANC by raising awareness and
promoting positive healthcare-seeking behaviors. A priority
should be given to women in the periphery regions and rural
residences, with targeted interventions designed to overcome
barriers and ensure equitable access to ANC services for all women.
Data availability statement
The original contributions presented in the study are included
in the article/Supplementary Material, further inquiries can be
directed to the corresponding author.
Ethics statement
Ethical approval was not required for the study involving
humans in accordance with the local legislation and institutional
requirements. Written informed consent to participate in this
study was not required from the participants or the legal
guardians/next of kin of the participants in accordance with the
national legislation and the institutional requirements.
Author contributions
The conception and design of the work, acquisition of data,
analysis, and interpretation of data were conducted by DB, MA,
and FA. Data curation, drafting of the article, critical revision for
intellectual content, validation, and final approval of the version
to be published were done by DB, FA, and MA. All authors
contributed to the article and approved the submitted version.
Acknowledgments
We would like to thank the measure DHS program for
providing the data set.
Conflict of interest
The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could
be construed as a potential conflict of interest.
Belay et al. 10.3389/fgwh.2023.917895
Frontiers in Global Women’s Health 07 frontiersin.org
Publisher’s note
All claims expressed in this article are solely those of the
authors and do not necessarily represent those of their affiliated
organizations, or those of the publisher, the editors and the
reviewers. Any product that may be evaluated in this article, or
claim that may be made by its manufacturer, is not guaranteed
or endorsed by the publisher.
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