According to the current study, economic constraints, place of residence, mothers’ lack of awareness, healthcare provider’s gender preference, husband’s disapproval, community perceptions, lack of acceptance by the community members, shortage of necessary equipments and supplies, lack of full ANC service packages in the majority of the health facilities, and shortage of healthcare workers were the main barriers of ANC service utilization. However, mothers’ better awareness, husbands’ support of ANC visit, presence of defaulter tracing mechanisms and horizontal referral system were identified as ANC service utilization enablers in the region.
Several studies have shown that socio-demographic factors affects the utilization of maternal healthcare services(2,5,7,10,12–14). They stated that the place where women live is associated with the utilization of ANC services. This finding revealed that place of residence has been significantly influence the use of maternal health care services in the Ethiopian Somali region. The people who live in the rural areas were not utilizing the ANC because of low access, long distance to travel between the resident’s home and the health facilities, and the pastoralist nature of the community. This is further debilitated by that the community perceived that the pregnant mothers should not travel long distances, even by using a car. The far distance where the care seekers live the more they might not go to the health facilities.
Poor economic status of the family was barriers for ANC utilization in this study. Studies conducted in South West Shoa Zone, the Tigray region in Ethiopia, Cameroon and Nigeria showed similar finding (6,10–18). It is know that the ANC services provided free of charge at the public health facilities in Ethiopian, but indirect costs related to the service like transportation and other accommodation costs was the barrier for ANC service utilization.
In this study, lack of knowledge and awareness, negative perceptions and acceptance of the ANC services were affecting its utilization. Similarly studies done in West Shoa, South-West Ethiopia, and Nigeria revealed that lack of knowledge and awareness, negative attitude and low acceptance of the services by the clients have a negative effect on ANC service utilization (6,8, 13, 15, 16, 19). This showed that if the individuals have no knowledge or information about the services, they are not expected to have awareness, positive attitude or a higher level of acceptance to the services.
At the community level, this study revealed that community’s poor perception of the benefits and lower acceptance of ANC visit in association with poor quality of ANC service in the health facilities were affecting ANC service utilization. In line with this, other studies revealed that socio cultural norms, beliefs about the causes of diseases, women needing spousal consent before receiving care, women receiving care from a male obstetrician as unacceptable were negatively affecting ANC services utilization (1,4,15).
At the organizational level, shortages of supplies and equipment, providing incomplete ANC packages almost at all health facilities, poor health care system due to shortage of health professionals, nonfunctional health facility, the HEWs leaving their health posts, unavailability of ANC Services in some of the health facilities, and dissatisfaction with health facility services appear as a reason of low ANC utilization. These organizational level factors were affecting the quality of the ANC services. Besides this, they have great influence on accessibility, acceptability, and sustainability of ANC service utilization to the community. On the other hand, hospitals which are located in the urban areas have better services for ANC.
Husbands’ acceptance of ANC services and support of their wives appears as enabling factors for ANC service utilization. This study documented that women whose husbands supported their health facility visit had higher level of motivation and utilization of ANC services. This result was similar with the study findings in Holeta town Ethiopia and Myanmar which indicated as spouses of husbands who support and accompanied them or approves antenatal visits was increased utilization ANC services (16, 20). On the other hand, Husbands disproval or objection, seeking permission to start and use ANC service by the pregnant women were decreased utilizing ANC services (11,18). This is because women are economically dependent on their husbands and husband’s/males decision is highly accepted in the family, so they decided that without their husbands it is difficult to achieve their goals.
Antenatal care service defaulter tracing mechanism which implemented on some districts in the region may give an opportunity to get pregnant mothers again and provide ANC services till they give birth.