This study has revealed that the 22% utilisation of 8 or more ANC contacts in Sierra Leone is higher compared to a similar study done in Benin . Although less than half of the women initiated ANC in the first trimester, it is higher compared to a study conducted in Northern Bangladesh (14%) , Kenya 10.9%  and in Ethiopia (20.1%, exploring DHS data of 2016)  but lower than that in Doula, Cameroon (56%) . The differences in the time, study settings can partially explain the differences in the observed prevalence. The studies that have reported lower prevalence were done earlier than our study while maternal health indicators have been shown to improve with time. The study in Cameroon that showed a higher proportion of women initiating women in the first trimester was conducted in a referral hospital in the economic capital of Cameroon while our study was national combining both rural and urban areas. To the best of our knowledge, this study is the foremost to explore the status and extent of in-country utilisation of ANC as per the new WHO guidelines of 2016.
Results further reveal that women in the Southern region, who were working, less parous, accessed and used internet and had no big problem seeking permission to access healthcare had higher odds of utilising at least 8 ANC contacts compared to those in the Western region who were not working, had higher parity, had no access to internet and had big problems seeking permission to access healthcare respectively. Moreover, women who were younger and those who initiated ANC after the first trimester had lower odds of utilising at least 8 ANC contacts compared to their counterparts who were older and those initiated ANC contacts in the first trimester. The same guideline further recommendation that initiation of the first ANC contact should occur in the first trimester, but results show that less than a half (44.8%) initiated ANC in the first trimester.
Higher wealth index was associated with higher odds of utilising 8 or more ANC contacts. This is similar to other studies conducted using DHS data in Ethiopia, Nepal and Benin [20, 26, 29, 30] and in a general hospital in Cameroon . Financial constraints, limited access to health facilities, limited decision-making power in regard to reproductive health matters have been linked to poor utilisation of ANC services. . Wealth index, a proxy of financial status means that wealthier women have enough funds which enable them afford direct and indirect costs involved in accessing quality and timely healthcare services [26, 30]. Furthermore, women from wealthier households are more enlightened and empowered hence have more decision making powers which enables them access healthcare more frequently and timely . Given that Sierra Leone has free maternal healthcare services , our results suggest that, apart from the cost of health services, other economic and social factors play a key role in influencing ANC utilisation. This is consistent with findings from other studies that reported economic factors such as transportation costs and miscellaneous fees paid for healthcare to influence the women’s utilisation of maternal healthcare [32, 33].
Region has been shown to influence the frequency of ANC utilisation. Unexpectedly, women in the Southern, Northern and Eastern regions were associated with more odds of timely initiation of ANC while Southern region was associated with more odds of utilising eight or more ANC contacts compared to women in the Western region. In Sierra Leone, the Western region has the largest concentration of health workers, it is the most developed and houses the capital and economic city of the country and hence has higher quality social amenities compared to other regions [31, 34]. However, the increasing numbers of urban poor in the developed Western region coupled with high standards of living and inequitable distribution of social amenities including public and private health facilities, make it hard for low income women to access the services. Furthermore, the documented staff challenges such as poor delegation, favoritism and a lack of autonomy could partly affect quality of services in public health facilities which further limits access to these facilities by pregnant women [31, 34]. The efforts of the government to ensure better service delivery in other regions that are far away from the capital could also have contributed to this observation . However, more studies are needed to explore these regional differences in the utilisation of ANC. The role of regional disparities in explaining ANC utilisation has also been documented in previous studies in Uganda and Nigeria [19, 35].
Younger age was associated with lower odds of utilising 8 or more ANC contacts. Mixed results have been documented in previous studies on the association between the pregnant woman’s age and utilisation of ANC contacts. Gudayu et al. in Northwestern Ethiopia showed younger age to be associated with better ANC utilisation compared to older age  which was a similar finding by Yaya et al. who analysed 2011 Ethiopia DHS data and showed older women to be more likely to have less ANC utilisation . Similar to our findings, Konlan et al. in Ghana, Gross et al. in Tanzania and Sinyange et al. in Zambia showed younger age to be associated with lower odds of increased ANC utilisation [37–39]. Younger age has been associated with limited knowledge on the importance of ANC, they have higher odds of unplanned and unwanted pregnancies which limits access to maternal care even to the extent of not utilising ANC contacts at all [20, 37]. Younger age is also associated with limited decision making power and financial constraints which further limit access to maternal care . Given the high prevalence of teenage pregnancy in Sierra Leone , this finding reinforces the need to intensify advocacy messages aimed at promoting increased ANC utilisation among younger women. However, beyond the scope of our study, it would be interesting to further explore the underlying factors mediating the effect of age of mother on utilisation of ANC.
Exposure to TV, radio and newspapers were not associated with ANC utilisation while using internet was associated with higher odds of utilising eight or more ANC contacts. Exposure to media has been shown in previous studies to have a positive association with ANC utilisation [3, 40–42]. Absence of association between exposure to newspaper or magazines and ANC utilisation could partly be attributed to the low levels of education with over 52.7% having no education and the fact that most women reside in rural areas where access to Newspapers or magazines is hard and not sustainable due to the daily or weekly costs involved. Internet use was associated with higher odds of increased ANC utilisation. Different internet resources such as web pages, social media platforms, bulletin boards, and chatrooms may contain health information and provide access to information [43, 44]. Access to this information on the internet helps in reducing knowledge gaps by sensitising women on the benefits of ANC utilisation which leads to positive attitudes, challenges negative social norms and improves health seeking behavior [40, 45].
Our findings also reveal that working women had higher odds of utilising eight or more ANC contacts compared to those who were not working. Women who work are more likely have better financial status which enables them to afford the direct and indirect costs associated with access to maternal healthcare. The importance of working status in influencing ANC utilisation has been documented in the previous literature [19, 29]. Our study revealed a negative could it also be that those who start early have better health seeking behaviour and are more likely to attend more visits.
The association between parity and ANC utilisation, with those of low parity having more ANC contacts compared to the multiparous (5 and above) women. This has been observed in similar studies [19, 29, 37]. Multiparous women tend to have a false sense of perceived low risk due to prior experience of [29, 37]. Furthermore, limited time availability due to the high the responsibilities of other children might make it hard for these women to access 8 or more ANC contacts [46, 47]. In addition, women who initiated ANC contacts after the first trimester had lower odds of attending 8 or more ANC contacts. Similarly, the findings from previous studies showed that early booking for ANC would result in optimal number of ANC contacts during pregnancy [26, 48]. Timely initiation of ANC contacts ensures that the women get timely and adequate health education sessions regarding the benefits of maternal care during pregnancy and further creates rapport between the health workers and the pregnant women [49–51]. It’s also possible that those who initiate ANC in the first trimester have better health seeking behaviour and hence are more likely to utilise more ANC contacts.
Problems in seeking permission to access healthcare decision was another variable found to be associated with timing and frequency of ANC contacts. Women who had less problems in seeking permission were more likely to initiate ANC early and utilise 8 or more ANC contacts compared to those who had more problems. This may be a depiction of low women’s empowerment and cultural beliefs. Studies have emphasised the importance of improving women’s empowerment mainly in the aspect of healthcare seeking and decision-making [20, 52]. In addition, creation of awareness through mass media to provide information about the importance of empowering women so as to seek healthcare freely would be helpful in facilitating behavior change and ensuring increased ANC utilisation [19, 26]. Several studies have documented the effect of low decision-making powers of women in accessing and seeking ANC [20, 26, 36].
Strengths and limitation
This study used the most recent SLDHS data with a larger sample size and higher quality, which substantially reduces the risk of sampling bias and measurement bias. The findings of the study also provide a timely evidence for maternal healthcare stakeholders and policy-makers with respect to effective implementation of the 2016 WHO ANC model and ensuring reduction of maternal and infant mortality which highly depend on increased use of reproductive and maternal health services. This study used cross-sectional data which only enables associations to be established but not causal relationships. The other limitation was that the SLDHS did not include information on crucial factors such as male involvement in ANC, knowledge of ANC contacts in the context of timing and frequency, timing of the subsequent ANC contacts and the quality of healthcare which could have an effect on uptake of ANC services.