Socioeconomic and demographic characteristics of respondents
This study included 4685 mothers who have births, within the past 5 years preceding the survey. The background characteristics of mothers with timing of ANC visits are given in Table 2. Most mothers (70.3%) were from rural areas while only 29.7% of the mothers were from urban areas. Concerning regional administration, a slightly higher percentage of mothers were from Tigray (14.6%), SNNPR (13.3%), Oromia (11.2%), and Amhara (10.7%) while the smallest percent of mothers were from Afar (6.1%), Gambela (6.8%) and Harari (6.8%) regions. The higher percent of mothers were between 20 and 34 years with the median age of 27 years. Around 32 % of mothers were from the richest household, whereas about 23% of mothers were from the poorest household. A majority (49.5%) of mothers had no education at all, 32.8% had primary education and only 6.6% of mothers had a higher education level. Regarding the media exposure of mothers only 2.8%, 16.3%, and 21.2% of mothers have read a newspaper or magazine, listen to the radio, and watch television at least once a week during their recent pregnancy respectively. Whereas, the vast majority 88%, 67.6%, and 68.3% of mothers didn’t read the newspaper or magazine at all, didn’t listen to the radio at all, and didn’t watch television at all during their recent pregnancy. On the other hand, concerning decisions on respondent’s health care, about two-thirds (65%) of mothers reported both respondent and husband/partner usually decide on respondent's health care.
Further, about 26%, of the mothers reported they have a big problem of getting permission to go in seeking medical care for herself, whereas 50.1% of mothers have a big problem in getting money for treatment in seeking medical care for herself. Similarly, 44.2% of mothers reported they had a big distance to a health facility in seeking medical care for herself and 33.7% of mothers reported a big problem in not wanting to go alone in seeking medical care for herself. The majority (80%) of mothers was reported the last child was wanted at the time of pregnancy, whereas 14.7% of mothers reported the pregnancy was wanted later and 5.3% wanted no more.
Timing of first ANC visit by some characteristics of mothers
Only 20.1% of mothers initiated their first ANC visits within 12 months of the onset of pregnancy with a median month for first ANC visits of four months. The percentage of early initiating the first ANC visits was low in the SNNPR (22.2%), Benishangul-gumuz (23.1%), and Somali regions (32.1%) whereas mothers from Dire Dawa (68.6%) and Addis Ababa (62.5%) cities have a higher percentage of early initiating their first ANC. More than half (56.2%) of the mothers from rural areas initiated their first ANC visits within the first trimester. About 54% of mothers from the richest households initiate their first ANC visits within the first trimester compared to 30% of poor or poorer household mothers. Similarly, the percentage of early initiating of first ANC visits was highest among mothers who have higher levels of education (63.6%) compared to uneducated mothers (31%) and those who have only primary education (40%). Further, mothers whose husbands/partners have higher education level have the highest (57%) of early initiating their first ANC visit.
The percentage of early initiating first ANC visit was almost uniform among mothers’ age at pregnancy and their occupation. The majority 52% of mothers who reading newspaper or magazine at least once a week, 46% of mothers who listen to the radio at least once a week, and 58% of mothers who watch television at least once a week during their recent pregnancy started their ANC visits within the first trimester. On the other hand, mothers’ autonomy concerning decisions on their own health care increased the percentage of early initiating first ANC visits. The majority of mothers whose pregnancy was wanted (40%) early initiated first ANC visits compared to those mothers wanted no more child (25%). Moreover, mothers reported not a big problem in getting money for treatment in seeking medical care for herself (43%), not a big distance to a health facility in seeking medical care for herself (42.3%), and not a big problem in not wanting to go alone in seeking medical care for herself (41%) have a percentage of early initiating first ANC visits.
Number of ANC visits by some characteristics of mothers
Table 3 depicts descriptive statistics the mean number of ANC visits, the mean number of ANC contents or items received, and the frequency of ANC visits by the mother’s characteristics. The analysis showed that 62% of mothers have received at least one ANC visit from skilled providers and 36.3% received at least four visits from skilled providers. The proportion of mothers who received the recently WHO recommended at least eight ANC visits, was only 3.6%. The result reveals that mothers from Addis Ababa were more likely to have eight or more ANC visits and the higher mean of the number of ANC visits, while mothers from Benishangul-gumuz, Gambela, Somali and Oromia regions were less likely to have eight or more ANC visits and the lower mean number of ANC visits. The proportion of mothers having eight or more ANC visits was higher among urban mothers and has a higher mean number of ANC visits than their rural counterparts. Similarly, household wealth showed a significant inverse association with both the mean of ANC visits and the proportion of at least eight ANC visits. The proportion of mothers who have eight or more ANC visits was found to be 12.3% among the richest households, compared to 0.5% among the poorest households.
Educated mothers were more likely to have eight or more ANC visits and a higher mean number of ANC visits than uneducated mothers. The coverage of eight or more ANC visits was found to be 20.3% among mothers with higher education, compared to 1.2% among mothers with no education at all. Likewise, husbands/partner’s education level showed a significant positive association with the mean of ANC visits and the percentage of mothers who had eight or more ANC visits. On the other hand, the distribution of the mean of ANC visits and the coverage of eight or more ANC visits was uniform among different mother’s age groups. Mothers' autonomy of decision making about their own health care and exposure to media such as reading a newspaper/magazine at least once a week, listening to the radio at least once a week, and watching television at least once a week showed a significant positive association with the mean of ANC visits and mothers coverage of eight or more ANC visits. Mothers reported not a big problem in getting money for treatment in seeking medical care for herself, not a big distance to the health facility in seeking medical care for herself and not a big problem in not wanting to go alone in seeking medical care for herself showed a significant positive association with mean of ANC visits and the proportion of mother who had eight or more ANC visits.
Number of items of ANC service contents received by some characteristics of mothers
Of all mothers who received ANC at least once, 79.9% had their blood pressure measured, 73.8% had a urine sample taken, 79.5% had a blood sample taken, 46.3% had told about pregnancy complications, 45.4% received iron supplementations for at least 180 days, 5.8% received treatment for an intestinal parasite, 69.1% received counseling after tested AIDS, 53.7% informed about birth preparedness, 67% received nutritional counseling and 42.5% received two or more doses of tetanus toxoid vaccine from a skilled provider during their ANC visits (Figure 2).
Figure 3 presents the distribution of the number of ANC visits and the number of items of the ANC services received by mothers during ANC visits. The mean number of ANC visits was 2.63 visits and standard deviation 2.08, while the mean number of items received by the mothers was 3.5 items and standard deviation, indicating that the distribution is overdispersed. About 62% of mothers received ANC from skilled providers and 75% of mothers received at least one of the items of the ANC service contents and whereas, the rest 38% of mothers received no ANC services during their last pregnancy. Nearly 7% of mothers received only one item of ANC services and about 9% received eight items. The percentage of mothers’ decreases with the increase in the number of ANC visits and the number of items of ANC services received. For example, 53% of mothers received at least four items of the ANC, while only 14% received at least eight from ten items.
Further, the results of the mean of the number of contents/items of ANC services received in Table 3 across characteristics of mothers indicate the timing of the first ANC visit, and the numbers of ANC visits have a significant association with the number of items of ANC services received. The mean of items of ANC services received by the mothers during their ANC visits differ significantly across administrative regions, place of residence, household wealth, birth order, mother and partner’s education, media exposure, wanted pregnancy, mother’s decision on own health care, the problem in getting money for treatment in seeking medical care for herself, distance to the health facility in seeking medical care for herself and problem in not wanting to go alone in seeking medical care for own health. The frequency of ANC visits and early initiation of the first ANC visit showed a significant positive association with the mean number of items of ANC services received. For instance, mothers initiated first ANC within the first trimester had received on average 6.2 items of ANC service, while mothers with only one ANC visits had received on an average 3.8 items of ANC services, compared to virtually 6 items on average among the mothers with four or more ANC visits.
Figure 4 presents a further detailed examination of the relationship between the frequency of ANC visits and each number of items of ANC contents received. It revealed that the likelihood of receiving the greatest number of items of ANC content increase with the increase of frequency of ANC visits. The proportion of mothers received six items of ANC content has monotonically increased from 4.2% to 37.3% with the increase of ANC visits from only one visit to at least five ANC visits. Conversely, the pattern showed a declining trend of the likelihood of receiving only one item or two items, or three items with an increase in the number of ANC visits.
Factors associated with early initiation of the first ANC visits: multilevel mixed-effects logistic regression analysis
In the multivariable multilevel logistic regression, factors such as birth order of the child, place of residence, education level of the mother as well as husband/partner, household wealth, age of mother, frequency of listening to the radio and watching television, wanted last pregnancy and distance to health facility were found to be independently associated with the timing of first ANC visit (Table 4). The likelihood of early initiating first ANC visit was lower among six or more birth order of children (AOR = 0.74; 95%CI: 0.56-0.96) as compared to the first birth childbirth order. Moreover, rural mothers were less likely to be starting their first ANC visit within the first trimester (AOR = 0.41; 95%CI: 0.31-0.54) as compared to urban counterparts.
The log odds of early initiating first ANC visit was higher among mothers of richest (AOR = 2.17; 95%CI: 1.61-2.92), richer (AOR = 2.29; 95%CI: 1.87-2.81) and middle (AOR = 2.02; 95%CI: 1.68-2.42) household wealth status, respectively as compared to the poorest household wealth. The educated mothers were more likely to start first ANC visit early i.e., the odds of early initiating ANC visit was higher among mothers with higher education level (AOR = 5.20; 95%CI: 2.25-12.03), a secondary education level (AOR = 2.14; 95%CI: 1.50-3.06) and primary education level (AOR = 1.73; 95%CI: 148-2.02), compared to uneducated mothers after controlling for other variables in the model. Moreover, every one unit increase in a mother’s year of schooling increased the odds of early initiating first ANC by 9% (AOR = 1.091; 95%CI: 1.01-1.19). Similarly, the odds of early initiating first ANC visit were 45% (AOR = 1.45; 95%CI: 1.08-1.95) more likely among mothers whose husband has a higher education level than those whose husband is not educated. Similarly, mothers with secondary and higher education were 27% (AOR = 0.73; 95%CI: 0.57-0.95) times less likely to have initiate ANC visit compared to those with no education. Mothers aged 40-44 years old were 34% (AOR = 0.66; 95%CI: 0.44-0.99) less likely to start first ANC visit early compared to mothers 15-19 years old.
The odds of early initiation of first ANC were also higher among mothers listen to the radio less than once a week (AOR = 1.56; 95%CI: 1.25-1.93), listen to the radio at least once a week (AOR = 1.49; 95%CI: 1.20-1.85) and watching television at least once a week (AOR = 1.58; 95%CI: 1.11-2.23) compared to those who didn’t listen to the radio and watching television at all respectively. Pregnant mothers who want no more children were 39% (AOR = 0.61; 95%CI: 0.48-0.77), less likely to start the first ANC visit within the first trimester than an wanted child at the time of pregnancy. Furthermore, mothers reported no problem or not, a big problem in distance to a health facility in seeking medical care for herself was 55% (AOR = 1.55; 95%CI: 1.35-1.78) more likely to start first ANC visit within the first trimester. In contrast, variables such as sex of household head, mother’s occupation, frequency of reading newspaper/magazine, decision making power on health care, the problem of getting permission to go in seeking medical care for herself, the problem in getting money for treatment in seeking medical care, and problem in not wanting to go alone in seeking medical care for herself had no significant effect on the timing of first ANC (P > 0.05) after adjusting for other variables within the model (Table 4).
Factors associated with reduced numbers of ANC visits: multilevel mixed-effects Negative binomial analysis
The multivariable multilevel mixed effect negative binomial model with random effects presented in Table 4, indicated that birth order, place of residence, mother’s as well as husband’s education level, household wealth, women’s media exposure such as listening to the radio and watching television, wanted last pregnancy, mother’s decision making power on their own healthcare issues, mother’s problem of getting permission to go in seeking their own medical care, and distance to a health facility in seeking own medical care have highly significant effects on the frequency of antenatal care use. The result indicated that the number of ANC visits a mother had received, reduced by 12% (IRR = 0.88; 95%CI: 0.80-0.97) for six or more birth order as compared to the first birth. Likewise, mothers from rural were 19% (IRR = 0.81; 95%CI: 0.74-0.89) times less likely to have a higher number of ANC visits during their pregnancy as compared to urban mothers. As household wealth was concerned, compared to being from the poorest households wealth status mothers from the richest households were 1.59 (IRR =1.59; 95%CI: 1.48-1.72) and mothers from middle households wealth were 1.47 (IRR =1.47; 95%CI: 1.37-1.59) times more likely to receive higher numbers of ANC visits controlling for other variables.
The results of the study shown in Table 4 also indicate that mothers attending primary education (IRR = 1.19; 95%CI: 1.12-1.25), secondary education (IRR = 1.20; 95%CI: 1.09-1.32) and higher education (IRR = 1.39; 95%CI: 1.04-2.45), as well as whose husband attending primary education (IRR = 1.21; 95%CI: 1.14-1.28), secondary education (IRR = 1.25; 95%CI: 1.15-1.37) and higher education (IRR = 1.29; 95%CI: 1.09-1.35), mothers frequently listen to radio at least once a week (IRR = 1.15; 95%CI: 1.07-1.23), frequently watch television at least once a week (IRR = 1.17; 95%CI: 1.06-1.28), mothers joint make decision with partners on their own health (IRR =1.21; 95%CI: 1.04-1.37), mothers with no problem of getting permission to go in seeking their own medical care (IRR = 1.07; 95%CI: 1.01-1.14) no big problem of distance to health facility in seeking own medical care (IRR = 1.12; 95%CI: 1.06-1.19) had a significantly higher frequency of ANC visits, while mothers whose husband/partner alone make decision on healthcare issues (IRR = 0.90; 95%CI: 0.83-0.98), and mothers wanted no more children (IRR = 0.83; 95%CI: 0.75-0.91) and whose pregnancy wanted later (IRR = 0.94; 95%CI: 0.88-0.99) had a significantly lower frequency of ANC visits.
Factors associated with contents ANC service visits: multilevel mixed-effects Negative binomial analysis
The multivariable multilevel negative binomial analysis of predicting the number of items of the content of ANC services received by a mother during her pregnancy showed factors such as place of residence, household wealth status, mothers as well as partners education status, mass media exposure such as frequency of listening to the radio and watching television, decision making power of mothers on their own health care, distance to the health facility, permission to go in seeking medical care for herself, wanted last pregnancy and frequency of ANC visits were independently associated with the incidence rate ratio (IRR) of numbers of items the contents of ANC services received from skilled providers.
The estimated IRR shown in Table 4 indicate that mothers from the rural (IRR = 0.82; 95%CI: 0.75–0.90), female household head (IRR = 0.91; 95%CI: 0.85–0.97), wanted no more children (IRR = 0.87; 95%CI: 0.79–0.96) and mothers without decision making power on own health care (husband/partner make decision alone) were significantly less likely to have higher numbers of items of contents of ANC services. In contrast, mothers from the richest (IRR = 1.51; 95%CI: 1.36–1.67), richer (IRR = 1.62; 95%CI: 1.49-1.75) and middle (IRR = 1.47; 95%CI: 1.37-1.59) households wealth status, mothers with primary (IRR = 1.24; 95%CI: 1.17-1.32), secondary (IRR: 1.22, CI: 1.10-1.34) and higher education (IRR = 1.21; 95%CI: 1.05-1.39) as well as mothers with partners who have primary (IRR = 1.17; 95%CI: 1.01-1.24), secondary (IRR = 1.21; 95%CI: 1.11-1.34) and higher education (IRR = 1.16; 95%CI: 1.04-1.30), have no problem of getting permission (IRR = 1.10; 95%CI: 1.03-1.17), have no problem of distance to health facilities (IRR = 1.19; 95%CI: 1.12-1.26), listen to radio less than once a week (IRR = 1.12; 95%CI: 1.04-1.19) and at least once a week (IRR = 1.15; 95%CI: 1.07-1.23), watch television less than once a week (IRR = 1.09; 95%CI: 1.01-1.19), received 1-3 ANC (IRR = 5.12; 95%CI: 4.68-5.59) and at least four ANC (IRR = 6.08; 95%CI: 5.56-6.65) from skilled provider were significantly more likely to have a higher number of items of contents of ANC services during their pregnancy.