Determinants of numbers on Antenatal care visits in rural Ethiopia: A Multilevel negative 1 binomial regression analysis 2

Introduction : Antenatal care (ANC) is an umbrella term used to describe medical care and 4 procedures that are carried out for pregnant women. Data on the number of antenatal care visits 5 can help policymakers to show the gap in service provision. So, the paper determines associated 6 factors of the number of antenatal care visits among women who gave birth in the last five years 7 in rural Ethiopia. Methods: Total weighted sample of 6611 women who gave birth in the 5 years preceding the 9 survey were included from the nationally representative 2016 Ethiopian Demographic and Health 10 Survey. We used multi-level negative binomial regression analysis to consider the hierarchal 11 nature of the data. In the multivariable analysis, variables with a p-value < 0.05 were considered 12 to be significantly associated with the number of antenatal care visits. Results: Overall, 27.3% (95% CI: 14.63, 15.76) of women had at least four antenatal care visits 14 during their pregnancy in rural Ethiopia. Age group 25-29 years (adjusted incidence rate ratio 15 (AIRR)=1.13,95% CI:1.02,1.26), household rich wealth status (AIRR=1.17, 95% CI:1.04,1.31), 16 women’s educational status (primary, CI:1.08,1.32; Secondary, AIRR= 17 1.30,95% CI:1.08,1.55; above secondary, AIRR=1.35, 95%CI:1.07,1.71), partner educational 18 status (primary, AIRR=1.16, 95%CI:1.05,1.28; secondary, AIRR=1.22,95% CI:1.08,1.38), and 19 autonomy to decision to their care (AIRR=1.25,95%CI:1.10,1.42) were positively associated 20 individual-level factors with number of antenatal care visits whereas having a birth order of five 21 or more (AIRR=0.80,95% CI: 0.69,0.94) was a negatively associated factor with number of 22 antenatal care visits. Among community-level variables; being in higher community level literacy 23 (AIRR=1.35, 95% CI: 1.14, 1.59) and higher poverty level (AIRR=0.77, 95% CI: 0.64, 0.92) were 24 significantly associated factors with the number of antenatal care visits. 25 Conclusions and recommendations: The level of antenatal care visits in rural areas was low. Age 26 of women, wealth status, women's educational status, partner educational status, autonomy to 27 decision making in health care, and birth order were the most important associated factors with the 28 number of antenatal care visits. Furthermore, poverty and literacy are also important determinants 29 at the community level. Addressing economic and educational interventions for rural women 30 should be given the top priority. 31


Introduction
Antenatal care (ANC) is an umbrella term that describes medical care and procedures that are 35 carried out for pregnant women (1). It is the health care delivery that is given to pregnant women 36 throughout their pregnancy. Services during ANC visit aimed at detecting the already existing 37 problems and/or problems that might be developed during pregnancy, which may affect the 38 pregnant woman and/or her unborn child (2). Screening tests, diagnostic procedures, and 39 prophylactic treatments are the services provided to pregnant women based on identified problems  The number of antenatal care services is determined by socio-demographic characteristics and 55 contextual causes. Regarding individual factors, higher educational status, older age, and higher-56 income were positively associated with the number of antenatal care visits. Fewer antenatal care 57 visits were associated with parity, gestational age at delivery, time of initiation of ANC, and 58 medical risks during the pregnancy. Concerning contextual factors; distance from a health facility, 59 service waiting time, and client welcomed appreciation were associated with ANC services 60 utilization. Besides, women's knowledge regarding ANC, the presence of electricity in 61 households, and housing conditions were associated with ANC services utilization(8,9,18-62 27,10,28-32,11-17).

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Even though antenatal care is crucial, the information in rural areas of Ethiopia is still very limited 64 due to different factors. Little is known about factors affecting the number of antenatal care visits 65 in rural Ethiopia. Thus, a detailed investigation of the factors affecting the number of ANC service 66 utilization is crucial. That is why this study was conducted to analyze the number of ANC visits 67 and determinants among women who gave birth in the last five years preceding the survey in rural 68 Ethiopia. Besides, this study valuable information on count data models.

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Study area and data source 77 The study was conducted in Ethiopia, which is located in the horn of Africa, lies between 3 0 and 78 15 0 North latitudes and 33 0 and 48 0 East longitudes. We used the EDHS 2016 dataset which was  Population and sampling procedure 85 The study was conducted using nationally representative data from the 2016 Ethiopian   Individual (woman), household, community, and regional level variables have been considered as 96 explanatory variables. The individual-level explanatory variables included education status of the 97 women and their husbands, age of the women, the autonomy of the women to healthcare issues, 98 women's and husbands' occupational status, birth order of a child, and household wealth status 99 whereas community-level variables were regional settings, community-level poverty, and literacy.

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Data processing and analysis 101 The data were cleaned using STATA version 16.0 software. The analysis was conducted after 102 sample weights were applied for complex sampling procedures. The characteristics of the study 103 participants were described using frequencies and percentages.      (Table 1).      The current study showed that women who were in the age group of 25-29 years were 13 251 percentage points more likely to visit health institutions for ANC services compared with those 252 who were in the age group of 15-24 years. This finding supports previous studies done in different countries(6,39,40) that showed the positive association between ANC visits and increased age of 254 women. This might be due to health conditions and birth complications are higher in older women 255 who tend to demand more visits. But it is not in line with studies done in metropolitan 256 countries(10).

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The finding of the study also indicated that women who had primary, secondary, and above

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The current finding also showed that the birth order of the child influences the number of antenatal Ethiopia. Besides, birth order is inversely and significantly associated with the frequency of ANC Our deepest gratitude goes to the Central statistical Agency for providing the data.

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Competing interests 334 The authors declare that they have no competing interests.

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Availability of data and materials 336 The datasets used and/or analyzed during the current study available from the corresponding author 337 on reasonable request.

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Consent for publication 339 Not applicable as there are no image or other confidentiality-related issues.

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Ethics approval and consent to participate 341 It is not applicable, because the data was collected by the performance monitoring and 342 accountability 2020 (PMA2020)/Ethiopia survey project.

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Not applicable