STRENGTHS AND LIMITATIONS OF THIS STUDY
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The study had a high response rate, which increases the reliability of the findings.
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Appropriate and validated data collection tools were used, ensuring the quality and accuracy of the information gathered.
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The cross-sectional study design limits the ability to establish a clear cause-and-effect relationship between the variables. It can only show associations, not direct causality.
Introduction
Antenatal care (ANC) is defined as the care provided by skilled healthcare professionals to pregnant women and adolescent girls in order to ensure the best health conditions for both mother and baby during pregnancy.1 It’s a critical component for improving maternal and newborn health and provides a platform for important healthcare functions, as well as birth preparedness and preparation for the postnatal period.1 2 It can reduce morbidity and mortality and optimise the overall health and well-being of the mother and her fetus.2
The 2016 WHO prenatal care guidelines for a healthy pregnancy experience reflect a change from the centred ANC model with a prescribed minimum of four ANC visits to a more expanded model that emphasises contact number, timing and services.1 3 4 Recent evidence suggests that the focused antenatal care (FANC) model, which was developed in the 1990s, is associated with more perinatal deaths than ANC models that comprise at least eight contacts. This brief highlights the WHO’s 2016 ANC recommendations and offers countries policy and programme considerations for adopting and implementing the recommendations.1 5
Adequate ANC utilisation is an essential matter of public health for protecting or preventing pregnancy-related complications and death.1 Studies showed that the timing and number of ANC contacts in low- and middle-income countries using the Demographic Health Surveys (DHS) revealed that only 11.3% of pregnant women achieved ANC 8+, with Latin America and the Caribbean having the highest proportion at 34.3%.3 4 Furthermore, the study suggested that Jordan had the leading eight or more prevalence of ANC contacts (74.0%). In addition, the percentage of women who had eight or more contacts ranged from 1% in Senegal, Uganda and Zambia to Ghana (43.0%) and Albania (30.0%).6
Based on evidence from 36 sub-Saharan African countries and the WHO report of 2017, approximately 810 women die daily from preventable causes related to pregnancy and childbirth. The vast majority of these deaths (94%) occurred in low-resource settings and Sub-Saharan Africa alone accounted for two-thirds (196 000) of those deaths.4 5
Several factors like maternal age, marital status, maternal and husband education, area of residence, religion, employment status, gestational ages, parity, previous experiences of pregnancy-related complications and time of ANC initiation have been identified as having an effect on ANC utilisation.1 6 7
Efforts have been made globally by preparing the FANC guidelines and shifting strategy to ANC 8+ contacts with the help of the WHO. Similarly, in Ethiopia, significant work has been done in regard to ANC by launching exempted services, though people are still suffering from pregnancy-related complications. This is mainly attributed to inadequate ANC utilisation.5 8 Although many studies have been conducted to assess the utilisation of ANC services and associated factors, relatively few studies have been done on ANC with eight or above contacts in low- and middle-income countries like Ethiopia, particularly among pregnant women in Yayo district. There is also limited local information that helps us understand what encourages or prevents women from completing eight or more ANC contacts, especially within the unique cultural and healthcare setting of Yayo District. Therefore, the present study aimed to assess the utilisation of ANC 8+ contacts and associated factors among pregnant women in Yayo District.
The results of the study provide relevant information for improving the level of ANC service utilisation and, therefore, contributing to the reduction of pregnancy-related complications. It will also help the Yayo District Health Office to plan appropriate interventions towards improving ANC utilisation and take corrective measures in the district. In addition, it may also help health facilities to correct their gaps and ensure adequate and quality ANC service for pregnant mothers. Finally, the community will get adequate ANC service, and pregnancy and birth-related complications will be reduced.
Methods and materials
Study area and period
The study was conducted in public health centres located in the Yayo District. Yayo is one of the 14 districts in the Ilu Aba Boor (I/A/Boor) zone, situated approximately 570 km southwest of Addis Ababa. According to 2015 EC data from the Yayo District Health Office, the district has a total population of 74 108, with 36 313 males and 37 795 females. Coffee is one of the district’s well-known cash crops and a major source of income. Additionally, Yayo is recognised for its UNESCO-registered forest, which serves as an ecological lung for the Ilu Aba Boor zone and its surrounding environment. The district has three public health centres. Based on data from these health centres, there are currently 1135 pregnant women in the Yayo District. The study was conducted from 1 June 2023 to 30 June 2023.
Study design: a facility-based cross-sectional study was employed.
Population
Source population: all pregnant women were found in the Yayo District.
Study population: randomly selected pregnant women having ANC follow-up in selected health facilities.
Inclusion and exclusion criteria
Inclusion criteria: pregnant women from selected health facilities who were on ANC follow-up during data collection.
Exclusion criteria: pregnant women who are unable to communicate (hearing loss), severely ill and improperly recorded pregnant women were excluded.
Sample size determination and sampling procedure
Sample size determination
The sample size was determined using a single population proportion formula with assumptions: 
where: Z=1.96, the confidence limits of the survey result (value of Z at α/2 or critical value for normal distribution at 95% CI).
P=0.5 (50%), the proportion of ANC 8+ contacts utilisation.
d=0.05, the desired precision of the estimate.
q=1 − P
n is the total sample size. Then, 
Then, by using the correction formula, 384
Next, by adding 5% of the non-response rate, the sample size was 301.
Sampling procedure and technique
The list of existing health centres and the number of pregnant women currently attending ANC were obtained from health centres found in the Yayo district. Next, study participants were proportionately allocated to each selected health facility based on the number of pregnant women. Then, the sampling frame was prepared for each health facility using the updated list of pregnant women on ANC. Finally, study participants were selected using a systematic random sampling method from each health facility, in which the k=4.
Variables
Dependent variable: ANC 8+ service utilisation.
Independent variables: maternal age, educational status, residence, occupation, contraception use, birth order, desired pregnancy, time of ANC initiation, parity, previous experience of pregnancy-related complications, access to healthcare and media exposure.
Operational definition and measurements
Adequate ANC 8+ service utilisation: percentage of mothers with gestational age ≥40 weeks and who have attended ANC service ≥8 contacts.
Inadequate ANC 8+ service utilisation: percentage of mothers with gestational age ≥40 weeks and who have attended ANC service <8 contacts (figure 1).
Percentage of ANC 8+ contacts service utilisation. ANC, antenatal care.
Data collection tools
The questionnaire was prepared originally in English, then translated to Afan Oromo and back to English by a language expert to check the consistency. Data were collected by using a pretested, structured Afan Oromo version of the interviewer-administered questionnaire adapted from related studies.9 10 The questionnaire has three parts: sociodemographic parts with eight questions, individual-level obstetric-related 10 questions and community or access-related six questions. A pretest was conducted in Mattu town health centre on 5% of the sample size, then the questionnaire was assessed, and the necessary corrections were made accordingly (online supplemental file 1).
Supplemental material
Data collection procedures
Data collection was conducted by three trained health workers (clinical nurses) who are not working at that specific health facility to reduce interviewer bias, and one BSc midwife supervisor to supervise the overall data collection process. A 2-day training regarding objectives, the relevance of the study and data collection techniques, such as interview techniques, the confidentiality of the information, participants’ rights, informed consent and a practical demonstration of the interview was given to the data collectors and supervisor by the principal investigator.
Data quality assurance
The supervisor and the principal investigator reviewed the filled-out questionnaires on a daily basis. The procedure manual for the data collection method was prepared and distributed to data collectors and supervisors. The supervisor and principal investigators closely followed the data collection process. Before data entry, each questionnaire was given a unique code by the principal investigator.
Data analysis procedure
The collected data were checked for completeness and clarity, edited, coded and tabulated according to study objectives in order to facilitate analysis. The coded responses were entered into Epi Data V.4.6 and exported to SPSS V.25.0 for analysis. Frequencies and cross tabulations were used to check for missed values of variables and to describe the study population in relation to relevant variables. Descriptive analysis was used to describe the percentages and number of distributions of the respondents by sociodemographic characteristics and other relevant variables in the study. Errors identified were corrected after revising the original questionnaires. Binary logistic regression analysis was performed on the independent variables, and their proportions and crude ORs were computed against the dependent variable. Finally, independent variables with a p value less than 0.25 were entered into the final multivariate logistic regression model to control for potential confounders and identify significant factors associated with the dependent variable. The adequacy of the model to fit the outcome variable with the predictors was checked using the Hosmer and Lemeshow tests for goodness of fit. Finally, the adjusted OR (AOR) along with the 95% CI was estimated to assess the strength of the association, and a p value <0.05 was considered to declare the statistical significance in the multivariate analysis in this study.
Patient and public involvement
Health workers and clients were not involved in the development of the research question, study design or outcome measures, nor the interpretation or writing up of the results for this study. Data from this study will be available on request. Investigators may disseminate the results of this study to local ministries of health, patients and relevant medical organisations in the communities where the study was conducted.
Results
Sociodemographic characteristics
In this study, a total of 298 pregnant women on ANC participated, with a response rate of 99%. The mean age of participants was 28.62 years (SD±5.029). The majority, 129 (43.3%) of them, attended college, while only 30 (10.1%) of them attended primary education. Most of the mothers, 248 (83.2%), were married, while 10 (3.4%) were divorced. Furthermore, about 139 (46.6%) of the respondents were housewives (table 1).
Sociodemographic characteristics of mothers on antenatal care in public health centres of Yayo District, Southwest Ethiopia, 2023 (n=298)
ANC 8+ service utilisation
Based on the findings of the study, ANC with eight or more contacts utilisation was 23 (7.7%). Among 298 total pregnant women on ANC, 268 (89.9%) of them had ever used family planning (FP). The majority, 158 (53%) of them have had less than two pregnancies. In addition, 258 (86.6%) of participants have a planned pregnancy. Furthermore, 170 (58%) of them have a history of previous pregnancies (table 2).
Antenatal care 8+ contacts utilisation of pregnant mothers in public health centres of Yayo District, Southwest Ethiopia, 2023 (n=298)
Factors associated with ANC 8+ contacts utilisation
In binary logistic regression, variables like time of ANC initiation, order of pregnancy, number of children alive, previous pregnancy-related complications and access to transportation were candidates for the final model with p value of <0.25.
Then, multivariate logistic regression analysis revealed that previous pregnancy-related complications (AOR 5.238 (95% CI 1.004 to 27.31)) and period of ANC initiation (AOR 29.09 (95% CI 8.87 to 59.3)) were found to be significantly associated with ANC 8+ contacts utilisation at p value <0.05.
The study showed that mothers with previous pregnancy-related complications are five times more likely to use ANC 8+ contacts than those with no previous pregnancy-related complications (AOR 5.238 (95% CI 1.004 to 27.31)).
In addition, the study revealed that ANC 8+ contacts utilisation was 29 times higher among mothers with early initiation of ANC <12 weeks of gestational age as compared with their counterparts (AOR 29.09 (95% CI 8.87, 59.3)) (table 3).
Bivariate and multivariate logistic regression analysis output of ANC 8+ contacts utilisation and associated factors in public health centres of Yayo District, Southwest Ethiopia, 2023 (n=298)
Discussion
Ensuring optimal utilisation of ANC 8+ contacts is still a major challenge across the world, and it is a more severe problem in developing countries like Ethiopia. This, in turn, resulted in a high prevalence of birth-related complications.7 Therefore, to reduce pregnancy and birth-related complications, it is necessary to understand mothers’ utilisation of ANC 8+ contacts and the factors associated with it.11 In this study, 7.7% (95% CI 4.9 to 10.4) of mothers used ANC 8+ contacts. This figure highlights a substantial gap in meeting the WHO’s 2016 recommendation for eight or more ANC contacts, which was introduced to improve maternal and perinatal outcomes.
This finding is higher than the findings of a study conducted in Senegal, Uganda and Zambia (1%).12 The variation might be due to differences in year of study, study settings and a mother’s sociodemographic profile.
But it was lower than studies conducted in Jordan (74.0%), Ghana (44.0%) and Albania (30.0%). Similarly, this finding was lower than studies conducted in Sierra Leone (22%), DHS and Multiple Indicator Cluster Surveys of 54 countries (11.3%) and systematic review, meta-analysis done (18.35%) and Nigeria (43.5%).11 13–16 The variation may be attributed to differences in the health policy and programme implementation, including the level of investment in maternal health, study period, sample size, sociocultural and educational factors influencing ANC uptake. However, the present finding was comparable with a study conducted in Benin, 8%.10 Suggesting that some countries may share common challenges, such as delayed implementation of WHO guidelines, lack of awareness about the shift from the previous 4-visit model to 8+ and barriers related to transportation, cost or cultural perceptions of pregnancy.
Regarding factors associated with ANC 8+ contacts utilisation, this study revealed that the presence of previous pregnancy-related complications was significantly associated with the utilisation of ANC 8+ contacts. The likelihood of using ANC 8+ contacts among mothers who have a history of pregnancy-related complications was five times higher than that of mothers who do not have a history of pregnancy-related complications. This finding was supported by studies conducted in Benin, Ghana and Arba Minch town, reinforcing that personal risk perception drives service utilisation.10 12 17 This might be due to the effect of events that happened in previous pregnancies on mothers being able to positively affect their utilisation of ANC as a standard. Whenever there is a history of previous complications, the mother’s behaviour will change due to fear of previous exposure. This implies health systems should leverage this awareness by actively identifying high-risk mothers and ensuring close follow-up, while also working to increase risk perception among low-risk mothers.
In addition, the time of ANC initiation was significantly associated with ANC 8+ contacts utilisation. Mothers with early initiation (<12 weeks of gestation) were 29 times more likely to use ANC 8+ contacts than their counterparts. This study is supported by studies conducted in Sierra Leone and Benin, which emphasise the crucial role of early engagement.10 11 18 This might be due to the fact that early initiation of ANC contact can give sufficient time to reach ANC 8+ contacts. The earlier the mothers begin ANC follow-up, the higher the probability of reaching ANC 8+ contacts they will have and healthcare providers also make efforts to counsel pregnant women and highlight the importance of completing all recommended ANC visits. This implies health promotion strategies must prioritise early identification and enrolment of pregnant women into ANC programmes, possibly through community health workers and incentive-based approaches.
Limitations of the study
The cross-sectional study design limits the ability to establish a clear cause-and-effect relationship between the variables. It can only show associations, not direct causality.
Generalisability of the study results
While the 7.7% rate of ANC 8+ contacts utilisation found in this study reflects the specific realities of the Ethiopian setting, it may not directly apply to countries with stronger and well-resourced maternal health systems. However, the key factors that influenced higher ANC use, such as experiencing complications in a previous pregnancy and starting ANC early, are likely relevant in many other low- and middle-income countries facing similar barriers.
What this study really shows is that some lessons go beyond borders. Encouraging early engagement in pregnancy care, focusing on women with higher risk and strengthening community support can be powerful tools not just in Ethiopia, but in many places where maternal health remains a challenge. These findings can help guide practical steps in similar settings to better align with the WHO’s recommendation for at least eight ANC visits.
Conclusions
The study contributes to the growing evidence that despite global recommendations, the utilisation of eight or more ANC contacts was found to be remarkably low in the study area. While slightly better than some neighbouring countries, it still lags far behind many others. Factors such as previous pregnancy-related complications and the timing of ANC initiation were significantly associated with whether women completed the recommended number of visits. Addressing these determinants through focused policy, service delivery and community engagement could significantly enhance ANC 8+ coverage and reduce maternal and neonatal risks. This highlights the need for greater investment in promoting the updated ANC model, which emphasises a minimum of eight contacts. Special attention should be given to encouraging and supporting mothers to begin ANC early, ideally before 12 weeks of gestation, to help reduce the risk of complications and improve the overall uptake of ANC 8+ contacts; using community-level interventions targeting early pregnancy detection and referral. The low utilisation of eight or more ANC contacts suggests that existing strategies may not be sufficient to promote the updated WHO recommendations. There is a clear need to strengthen community-based education and awareness campaigns to emphasise the benefits of early ANC initiation and consistent follow-up.
Factors like prior complications and early initiation were strongly associated with higher utilisation, aligning with trends observed elsewhere. Addressing these determinants through focused policy, service delivery and community engagement could significantly enhance ANC 8+ coverage and reduce maternal and neonatal risks.
Data availability statement
Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Ethics approval
This study involves human participants. The ethical clearance letter was obtained from the ethical committee of Mattu University, College of Health Sciences, Department of Public Health, which is CHS/7054/2015, before conducting the study. Then, a letter of permission was obtained from the Yayo District Health Office. Next, study units were given information on the objective of the study, and consent was sought. After the interviews, respondents were given feedback. Confidentiality of the data was maintained at all times by using codes instead of writing the names of respondents. Participants gave informed consent to participate in the study before taking part.
References
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Individual- level and community- level factors associated with eight or more antenatal care contacts in sub- Saharan Africa: evidence from 36 sub- Saharan African countries. 2022.
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Factors associated with the utilization of antenatal care services among pregnant women in Eswatini. 2022.
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This post was originally published on https://bmjopen.bmj.com