Birth outcomes was expected to remain the big challenge for low- and middle-income countries. This study was aimed to examine the effect of time and times of antenatal contacts on birth outcomes and the overall unfavorable birth outcomes is 7.2% (CI, 5.7%, 8.8%). This finding was by far lower than the findings reported in different part of the country. A systematic review and meta-analysis in Ethiopia reported that the pooled prevalence of adverse fetal outcomes was 26.88%(2), the study in Gondar University Hospital, reported 23% (22), the study in North Wollo zone; reported 31. 8% (21) ,study at Hawassa town governmental health institutions, reported 18.3%(23) and the study in Bale zone hospitals reported 21%(31)
This discrepancy may be attributed to variation in the study settings, study period and current ministry of health direction. For instance, most of the studies cited above were conducted at health facility level where most of the time the mothers use health facilities when they experienced complications that could be the reason for the increment for the proportions unfavorable birth outcomes and Amhara region, the region which hosts the largest share of child-brides that contribute for the birth outcomes (32, 33) and working definition of the studies, some of these studies were used stillbirth, preterm birth, low birth weight, small for gestational age, neonatal death, and congenital anomalies whereas only preterm, stillbirth, low birth weight and neonatal death within the first 42 days used in this study.
ANC provide chances for monitoring the feto-maternal wellbeing and allow timely intervention for feto-maternal protection(34) and time of booking and times of contact for ANC are among the basic components of ANC services; that help mothers to receive full packages of ANC services, early detection, management, and prevention of pregnancy associated complications(16)
However, this study revealed the time and times of antenatal contacts has no effect on birth outcomes. This implies that what matter is not only the time and times of ANC contact but, the quality of the service that used for identification and management of obstetric complications that could contribute for the birth outcomes as early detection and prevention of complications is at the heart of ANC’s (31, 35)
We cannot conclude that birth outcome would be prevented only by an adequate ANC, as birth outcome is associated with collective interventions and complex and multifactorial etiology like societal factors, some cultures promote some food types and some promotes nutritional taboos that may deprive them of essential nutrients, adding to nutritional deficiencies that leads to less maternal weight gain during pregnancy (Less 10 kg) that reflects poor fetal growth, parity, maternal age, a gestational ages and in cultures rest for pregnant women is not to be acknowledged were risk factors for birth outcomes(36–38)
Also, systematic review about the interventions to reduce preterm birth, stillbirth, LBW and improve outcomes in MLICs reported as there was no significant difference effect on birth outcomes among the ANC users and non-users (10) and the evidence from 18 LMICs DHS reported as what matters is the quality of ANC services given during ANC visits than the frequency of ANC for preventing LBW (13)
Even though, timing of the first ANC check-up has an independent effect on the content of the care to be provided for pregnant women but ,the skill and motivation of care providers is critical to provide the WHO recommended standards of care(39)
However, this is contrast to the prospective follow-up study among pre-eclamptic patients conducted in Egypt that reported women who attended an inadequate number of visits had a 53-fold risk of a poor fetal outcome and a significantly higher risk of neonatal mortality in comparison to women who attended an adequate number of antenatal visits(40)
This study also observed other possible factors associated with on birth outcomes and educational status of the husband, family size, parity, mode of delivery, services given during ANC contact and social support were found to be the other possible predictors of birth outcomes.
This is agrees with a systematic review and meta-analysis that reported residency, lack of antenatal care follow up, previous history of adverse pregnancy outcome advanced maternal age, having current complication of pregnancy, presence of cat in the house, having chronic disease/s and knowledge of preconception care were significant predictor of adverse birth outcomes (2, 21–23)
Educated husbands have opportunity to have better income, and access to health facilities. Education helps them to know about pregnancy and problems of a pregnant woman and used to acquire their emotional support toward their pregnant wives and promote pregnant women's quality of life that contributed to birth outcomes.
Family size of the women is among the predictors of birth outcomes. Women who had less family are more likely to be care of themselves, educated and stay aware of the latest pregnancy related information, access to health facilities and regular visits that help for early detection, management, and prevention of pregnancy associated complications
Also, in this study service given during the ANC contact is among the predictors of birth outcomes. Quality of the service leads for early identification and management of obstetric complications that could contribute for the birth outcomes and continuation of maternal health care (35). To maintain the quality of ANC services that improves pregnancy outcomes WHO adopt a new ANC model that recommends to increase the numbers of contact from four visits to eight contacts (24)
Generally, the finding of this study should be interpreted with the following limitations. Due to insufficient count of cases, it was not possible to examine specific adverse birth outcomes separately with time and times of ANC contacts. In addition, this study does not include adverse birth outcomes small for gestational age and congenital anomalies.