Antenatal care visits of child-bearing mothers having a child five years preceding in the survey and associated factors in Benchi-Sheko Zone, Southwestern Ethiopia:Cross-sectional study

Background : Antenatal care (ANC) is the service given by the caregiver for pregnant women to make safe the health of both pregnant women and babies during the pregnancy period Objectives: The objective of the current study was to persuade high-quality public health service and plan the mothers and their households expressively and mentally for being motherhood by ever-increasing antenatal care visits from health institutions. Methods: Community-based cross-sectional study design was applied. Cross-sectional survey design mainly used for the collection of information on the Utilization of Antenatal Care Visit of Women During Pregnancy and its Related Factors in Bench-Sheko Zone, South Nation Nationalities Peoples of Region, Southwestern Ethiopia: Cross-sectional study. The study populations are all populations who are living in the study area, South Nation Nationalities peoples of Region, Southwestern Ethiopia. Results : Evidence tells us, one hundred twenty-nine (16.9%) of pregnant women were not visited by the caregiver during pregnancy. Around eighty-three percent of pregnant women were visited in health institutions at least once prior in the five years in the survey. The Poisson regression model was preferred to fit the data. As the output indicated in analysis, the odds ratio of women whose husband education status is illiterate is equal to exp(-0.272)=0.76(95% CI:-0.507,-0.038) (other variables are adjusted), it indicates that the women whose husband education status is 0.76 less likely to ANC visit than women whose husband education status is higher and above. Conclusions: The remark conclusion that the source of information, religion, educational status, birth order, knowledge of danger signs for pregnancy, and service satisfaction were significant at the alpha level of significance on the ANC visit of Women during pregnancy.


Introduction
Antenatal care (ANC) is the service given by the caregiver for pregnant women to make safe the health of both pregnant women and babies during the pregnancy period [1]. A significant antenatal care visit of pregnant women is a significant incident to persuade high-quality health outcomes and plan women on their households meaningfully and mentally for being motherhood by ever-increasing antennal care visits from either any clinics or hospitals [2]. Ninety-eight percent of pregnant mothers had received antenatal care visits at least one in developed countries, and sixty-eight percent of women had attended ANC visits in developing countries. [3]. A deficiency in pertinent ANC visits is the main issue in sub-Saharan Africa [4].
In Sub-Saharan Africa including Ethiopia, most pregnant mothers did not start to attend ANC visits in the first trimester even if most pregnancy history screen out in this stage, however, they took antenatal care visit at the last two trimesters( two and second trimesters ) [5]. Some factors may be hinder not taking ANC visits in the first trimesters like the education status of women and family [6], and the most important demographic factor and age are very critical for any issue regarding pregnancy complication [7].
In many work of literature, and according to the World Health Organization (WHO) recommendation, pregnant women should attend ANC visit in a minimum of four times during pregnancy until giving for a healthy pregnancy [8]. The number of ANC visits may decrease or increase depending upon the health status of women as well as the prevalence of risks. Hence, healthy pregnant women will attend ANC visits three times, two times and one time. In this regard, the dependent variable (count) measured in count form, and the model ( Poisson regression model ) should be mandatory to make sound or a representative decision to avoid misleading conclusions and recommendations [9].
The previous study was done in Sheka, Bench-Maji, and Kaffa zones showed that the prevalence of childbearing mothers attend ANC visit service utilization is very high compare to women those never ANC visit utilized in their last pregnancy period [9]. An antenatal care visit is the most anticipation strategy that makes it possible to reduce women and baby mortality.
Communicable and no communicable diseases expected to be managed and identified during ANC visit utilization [10]. Thus, the study was aimed to determine the number of ANC visit utilization women during pregnacey period in Bench-Sheko zone, Southwestern Ethiopia.

Methods
The data collected by the data collectors from Bench-Sheko Zone's kebeles. Bench-Maji Zone now it is called Bench-Sheko Zone. Bench-Sheko Zone is one of the zones in South, Nation, Nationality Peoples of Region. It has mount Guraferda and Omo National park. The main crops are Maize, Godere, Enset, Sorghum, spices; different fruits, coffee, and honey are common in the zone [11]. The sample size calculated using a single population proportion formula based on the following assumptions: Forty-four of the respondents started their ANC within the recommended time, ninety-five percent of the confidence interval, five percent of margin of error, and design effect considered, and seven hundred sixty-four participants have participated.

Study Variables
The dependent variable is antenatal care visits of child-bearing mothers having a child five years preceding in the survey. Independent variables are as follows: residents, mother's level of education, husband's level of education, Marital status, Religion, distance in a kilometer, service satisfactory, birth order, mother's occupation, husband's occupation, age of mothers, mother's Knowledge of danger sign of pregnancy complication, the problem of transportation, information source, and mother's age at first pregnancy. The dependent variable is antenatal care visits of child-bearing mothers having a child five years preceding in the survey.

Statistical Methods
Descriptive statistics were computed to the characteristics of the respondents using percentage, mean, and standard deviation.
Poisson Regression Model is the model that fits the count response that follows the Poisson distribution. The value of the dependent variable is counted as 0,1,2..........and the assumption of a model is equality of mean and variance(variance greater than mean). The negative binomial regression model allows overdispersion that accounts for unobserved heterogeneity that comes from observation i [12]. Thus, Poisson and Negative binomial regression modes can be Given (1) and (1.2) and the assumption that the observations ⁄ are independent, the most natural estimator is maximum likelihood (ML). The log-likelihood function is The Poisson MLE, denoted , is the solution to k nonlinear equations corresponding to the First-order condition for maximum likelihood, By the standard maximum likelihood theory of correctly specified models, the estimator ˆp  is consistent for  and asymptotically normal with the sample covariance matrix [9].

Negative Binomial Regression Model
The negative binomial regression model was of the form [13]; Where is the i t covariate and Is the regression coefficient of log it model.

Model Selection Criteria
Akaike Information Criterion (AIC) and the Basic information criterion (BIC) used to judge the performance of the model. Smaller the AIC and BIC value, the best model. [14].

Parametric Estimation
The parameter estimators were estimated by maximum likelihood function and obtained by partial derivatives equal to zero [15].

Model Comparison Criterion
The different models can be compared as they were estimated by likelihood fuanction. And its pereformace of different models can be compared by Akkakian and Bayesian information criteria. The smallest akkkaian and bayesisn information is the better one . It is given by = −2 + 2 , where ,l denotes the log likelihood evaluated for estimated parameters and p For this measure, the smaller the AIC, the better the model [16].

Results
Seven hundred sixty-four mothers had given birth within five years before the survey. Table 1 shows that the women residing in rural residents (50.8%) and urban area (49.2%); women with  Table 2 shows that women did not attend ANC visits during pregnancy. Evidence tells us, one hundred twenty-nine (16.9%) did not take ANC visits at the health institution. Thirty-six women attended bellow four ANC visits during pregnancy. It is below a minimum of world health organization recommendation.  Table 4). The odd ratio of women whose religion is Catholic is equal to exp(0.093)=1.46 (95% CI:0.067,0.691)(other variables are adjusted). It implies that the women whose religion is catholic are 1.46 times more likely to have more visits to the health center than women whose religion was traditional. To some extent, husband education status is a significant effect on the women to take ANC visit utilization. As the output indicated in table 4, the odds ratio of women whose husband education status is illiterate is equal to exp(-0.272)=0.76(95% CI:-0.507,-0.038) (other variables adjusted), it indicates that the women whose husband education status is 0.76 less likely to visit ANC visit than women whose husband education status is higher and above. Household decision making, knowledge of women on danger sign of pregnancy complication, gain information, service satisfaction, and age of women at early pregnancy are significantly influence the women on antenatal care visits while they are pregnant. From the output given in

Discussion
The current study aimed to judge factors associated with the ANC visits of women in the Benchi-Sheko zone. Using the primary source of data which has been collected from different kebeles, seven hundred sixty-four childbearing mothers who had to give birth within five years priorly, 83.1 percent of women attended ANC visits in health institutions at least once [17]. The current study supported by the study done [18], how ever, the current study is some how small in percentage of number of visit. Around seventeen percent of women did not utilize ANC visit, forty-four percent of women attended 4 times and bellow a minimum of WHO recommendation.
Around thirty-six women have not utilized according to WHO guidelines.
The study showed that the age of women who had attended ANC visits varied from youngest to oldest. Women at the age of 15, the number of ANC visit is low. Whereas women at the age of 29 to 35 somewhat increase and women at the oldest age are extremely decreased. This might be the fertility rate may differ within age differences. The current study was consistent with the study done [4], [19].
The result showed that child-bearing mothers who had known danger signs of pregnancy complications greater than as compared to women who did not know it. This might be due to the traditional mechanism and maybe health service access to the Bench-Sheko zone. This study was consistent with other studies done [3]. The education of women in the study showed that the number of ANC visit varies. Few women recorded that the women were not educated. It is noted that the number of ANC visits increases as per upgraded their education status. This is suggested that awareness comes from education and it is important. This study much related to the study done somewhere [20], [10].
From Women, those who had lived in rural residents were less likely to have ANC visits.
According to the current study the women who had lived in urban had an odds ratio of  [23].
The study showed that the age of mother at early pregnancy was significantly influencing the utilization of antenatal care visits even if the attendance of antenatal care visits with age varies.
Because the ANC visits of child-bearing mothers in the oldest age is likely to have ANC visit than the youngest one. This study is supported by the study on the number of antenatal care done [9], [24], [6].
Based on the final model, birth order, decision making, residence, and education status are significant variables that influence the ANC visits of women. Thus, women whose husband education status is literate are more likely to utilize ANC visit as compared to mothers' husband education status is illiterate, women's birth order or birth interval between 2 and 3 are more likely to attend ANC visit than whose birth interval above 5, women who decided herself or jointly are more likely to have ANC visit as compared to those who are decided by others and the women who lived in rural residents were less likely to have ANC visit as compared to those who had lived in urban resident [25].

Strength and Limitation
This study is very important that used to assess the socio-demographic factors on ANC visit of childbearing mothers in the Benchi-Sheko Zone, SNNPR, Ethiopia using a representative model.
In many studies, the study was done using the binary logistic regression model to account for the data by deauthorizing the number of visits, however, it is confusing to say women utilize ANC visits during pregnancy. There fore, the stud tells us how many times the women attend ANC during pregnancy by counting principles. The only limitation of the study that there is no intervention and recalling bias during the survey of the data.

Conclusions
The current study revealed that residence of child-bearing mothers, source of information obtained, birth order, husband education status, knowledge of mothers about danger sign of pregnancy, age at first pregnancy, service satisfaction, religion and decision making are significantly influencing on the number of ANC visit on women during pregnancy. By educating the households, creating awareness about the danger sign of pregnancy, accessing the source of information, and increasing service satisfaction, it is possible to reduce the deaths of women and babies from pregnancy complications.

List abbreviations
AIC: Akkakian Information Criteria EDHS: Ethiopia Demographic and Health Survey OR: Odds ratio SNNPR: South Nation Nationalities Peoples of Region

Ethics approval and consent to participate
The study was approved by the research and community service standing committee of the Mizan-Tepi University, and the permission letter with reference number MTU/02/2017 was confirmed.

Consent for publication
Not applicable

Competing Interests
No potential conflicts of interest are declared

Availability of data and material
The data will be given by the corresponding author upon request.

Funding
The funding was sponsored by Mizan-Tepi University regardless of designing research methodology, analysis and manuscript preparation.

Authors' contributions
Assaye Belay Gelaw was responsible for designing the methodology of the research, analyzing, interpreting, and drafting the manuscript.
Abiyot Negash Terefe was responsible for validating the research question, designing, analyzing, and interpret the data.
Solomon Abebaw was responsible for analysis and writing the manuscript.