Study design, setting and period
An institution-based cross sectional study was conducted from September 1st to October 30th, 2021. The study was conducted in the Northwest of Amhara regional state referral hospitals. The Amhara region is located at the Northwest Ethiopia. Northwestern part the region consists of six zones that contains a total population of 13,049,742. From those females account about 6,501,156 (51). In the Northwest part of the Amhara region, there are 5 referral hospitals such as: the University of Gondar comprehensive and specialized Hospital, Felegehiwot comprehensive and specialized hospital, Tibebe Gion comprehensive and specialized Hospital, Debretabor comprehensive and specialized Hospital and Debremarkos comprehensive and specialized Hospital. Each referral hospital’s catchment population is estimated to be 5–7 million people (52). According to recent report, the average monthly flow of women for first antenatal care service is around 200- 250 for each referral hospital as evidenced from hospitals monthly report (53).
Source and Study population
Source population
All pregnant women who came for antenatal care contact in Northwest of Amhara regional state referral hospitals.
Study population
All pregnant women who came for antenatal care contact in selected referral hospitals of Northwest Amhara regional state during the study period.
Inclusion criteria
All pregnant women who came for antenatal care contact before 16 week of gestation in selected hospitals of Northwest Amhara regional state had included.
Sample size determination
The sample size was determined by using the single population proportion formula by considering the following assumptions: proportion of intention to use ANC8+ 50% (since there was no previous study), 95% confidence level, and 5% margin of error. (n) = (
Where; n = the desirable sample size, Z = standard normal distribution curve value for 95% confidence level= 1.96, α = level of significance, P = proportion of intention to use ANC8+, and d= 5% margin of error. By considering a 10% none response rate and a design effect of 2 (since two stage sampling), the minimum adequate sample size was 847.
Sampling procedure and technique
There are five referral hospitals in Northwest of Amhara regional state. A multi-stage sampling technique was employed to select hospitals for a total of 847 eligible women. In the first stage, 60% (3) hospitals were selected randomly by lottery method including, the Felegehiwot comprehensive specialized hospital, Debretabor comprehensive specialized hospital, and Debremarkos comprehensive specialized hospital. The monthly first ANC contact flow was obtained from the respective hospitals and the skipping interval was computed. Thus, the total average client flow from the three selected hospitals was 2,022 by three month divided by the calculated sample size (847) resulted in 2.3 (approximated to 2). The study participants then selected every 2nd interval. The first case was selected randomly. Thereafter, the calculated sample size was proportionally allocated to each hospital. Then, systematic random sampling technique was used to select the study participants from the respective hospitals.
Study variables
Outcome variable
Intention to use eight antenatal care model (intended or not intended)
Independent variables
Socio demographic factors: Age, residence, average household monthly income, occupation, educational status, media exposure and marital status. Husband/male partner related factors: Husband /male partner involvement, husband occupation, husband educational status and household decision-making power Reproductive history and maternal health Service related factors: Distance to health institution, gravidity, parity, knowledge of pregnancy danger sign, previous experience to ANC, previous pregnancy outcome, pregnancy planeness and perceived interaction Behavioral and social factors: Attitude, subjective norm, and perceived behavioral control.
Operational definition
Intention to use ANC8+ model
An indication of pregnant women readiness/willingness to use ANC8+ and how much an effort they were planning to exert, and to use ANC8+. It was measured by using four questions. Each question contains of five points Likert scale. Finally, the outcome variable was dichotomized and women who scored ≥ 60% ( point score ≥ 12) considered as intended while those who scored < 60% (Point score <12 ) considered as not intended to use ANC8+ (54) (17).
Exposure to media
Respondents were asked if they listen radio, watch television, or read magazine. Those who respond at least once a week were considered to be regularly exposed to that form of media (7).
Husband /male partner involvement
Measured using five variables with a yes / no response. A score of 1 was given for ‘’Yes’’ and 0 for ‘’No’’. The involvement score for each respondent was ranged from 0 = no involvement to 5 = involved in all 5 activities. From total, women who scored of 3-5 was considered as a '’High'’ male involvement while those who scored 0-2 was considered as '’Low'’ relative to this particular population (55).
Household decision making power
Women were considered to participate in the house hold decisions, those who made decisions alone or jointly with their husband in all the seven selected areas (7).
Perceived interaction
The health care provider to client relationship was measured by 13 questions on a 5-point Likert scale; the total score was ranged from 13 to 65. To group participants by their level of the perceived health care provider to client relationship, participants was divided into three groups; a score of 13–51 was considered to be ‘low’, a score of 52–64 ‘medium’, and a score of 65 was considered to be an ‘optimal’ perceived relationship (56).
Knowledge of pregnancy danger signs
In this research, a woman was considered as knowledgeable, those mentioned at least three key danger signs of pregnancy (57).
Women’s attitude toward ANC8+
Attitude towards ANC8+ was measured using four questions. Each question contained five point Likert scales (1 = strongly disagree, 2 = disagree, 3 =neutral, 4 = agree, 5 = strongly agree). The total score was between 4–20 and women who scored ≥ 60% (point score ≥12) considered as having good attitudes (54).
Subjective norms (SN)
Subjective norm towards ANC8+ utilization, related to women perceptions of social pressure to utilize ANC8+ measured by using five questions. Each question had contained five points Likert scales (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree). The total score was 5–25 and women whose scored ≥ 60% (point score ≥15) considered as having favorable SNs (54)
Perceived behavioral control (PBC)
Perceived behavioral control towards ANC8+ is an indicator of the extent to which women feel confident to utilize ANC8+. PBC was measured by using three questions. Each question had contained five point Likert scales (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree). The total score was ranged from 3 to 15 and women who scored ≥ 60% (point score ≥ 9) considered as having positive PBC (54).
Data collection tools and procedures
The data collection tool was developed by reviewing literature and guidelines (7,54–57) and data were collected using a structured, interviewer administered questionnaire through face-to-face interviews. The content validity of the questionnaire was judged by a group of researchers who are experts on maternal and child health to evaluate and enhance the items in the question. Therefore, some corrections were done accordingly. The questionnaire contains socio-demographic, husband/ male partner related factors, reproductive history and maternity health service, and social and behavioral related characteristics. Three BSc and three MSc Midwives, were trained at common place, about the interview technique, and how to collect and supervise the data respectively. Data were collected from the women directly after she took the antenatal care service at the same day of interview, immediately after she leaved the service room. The data collectors used the ANC registration to identify interview candidate pregnant women. Gestational age estimation was done ether from the last normal menstrual period, early ultrasound, or pregnancy fundal height.
Data quality control
Initially, the questionnaire was prepared in English and translated to Amharic language and back to English by two different language experts with the help of health professionals to ensure its consistency and better understandability. Two days training was given on how to collect the data, the way of approach to the study participants, interview technique, and how to keep information. A week before the actual data collection, a pretest was done on pregnant women of Tibebe Gion specialized hospital on 5% (43) of the sample size to check response, language clarity, and appropriateness of the questionnaire. Thereafter, amendments done accordingly. Order rearrangements done and ambiguity words replaced. During the actual data collection, the questionnaire was checked for completeness daily by the supervisors.
Data processing and analysis
The collected data were checked for completeness manually and incomplete data were excluded from the analysis. Then, the data were checked, coded, and entered into EPI data version 4.6 statistical software and then exported to SPSS version 23 for analysis. Descriptive statistics like percentages, frequency, mean, standard deviation stated using tables and graphs to present the characteristics of study participants. Chi-squared test was performed to examine the association between individual-level factors and the outcome variable. The binary logistic regression model was fitted to identify risk factors for pregnant women intention to use the ANC8+ recommendation. Initially, bivariable analysis was done to identify the candidate explanatory variables for the multivariable analysis. Thereafter, all explanatory variables having a p-value of ≤ 0.25 in the bivariable analysis was included in the multivariable logistic regression analysis to handle the effect of possible confounders and to identify independent factors affecting pregnant women intention to use the ANC8+. Model fitness was checked using Hosmer and Lemeshow goodness of fit. Then, the level of significance was declared based on a 95% CI at a p-value of ≤ 0.05.