The determinant of Antenatal Care Visits among Pregnant Women in Ethiopia

Background Health care services during a pregnancy and after delivery are important for the survival and well being of both the mother and the infant. The World Health Organization recommends a minimum of four antenatal care visits during a pregnancy. In Ethiopia, only 38% of women aged 15-49 with a live birth received at least one-time antenatal care visits from a skilled provider. This value is much more below the average rates of least developed countries and Sub-Saharan Africa. This study aimed to identify the determinant factor of antenatal care service visits among pregnant women in Ethiopia Method The national-level cross-sectional Ethiopian Demographic and Health 2016 survey data were accessed and used for the analysis. A total of 7913 pregnant women were included in the study. Zero-inflated Poisson regression models were employed to identify the determinant of antenatal care visits. Results Only 35.5% of the pregnant mothers have visited at least four times and 64.5% of the pregnant mothers have visited less than four times during their periods of pregnancy. The study revealed that rich women (IRR 1.077, 95% CI: 1.029,1.127), having access to mass media (IRR=1.086, 95% CI: 1.045, 1.128), having pregnancy complications (IRR=1.203, 95% CI: 1.165, 1.242), secondary or above-educated women (IRR=1.112, 95% CI:1.052, 1.176), husband's having secondary or above level of education (IRR=1.085, 95% CI: 1.031, 1.142), being married (IRR = 1.187; 95% CI: 1.087,1.296) and women age >30 years (IRR=1.067, 95% CI: 1.024, 1.111) were strongly positively associated with the antenatal care visit. Rural pregnant women less antenatal visits (IRR=0.884, 95% CI: 0.846, 0.924) had also a statistically significant association with antenatal care visits. Conclusion This study was revealed rural women, poor women, uneducated mothers, uneducated husbands, not having access to


Introduction
Every day, approximately 830 women die of preventable causes related to pregnancy and childbirth.
Almost all maternal deaths (99%) occur in developing countries. More than half of these deaths occur in sub-Saharan Africa and almost one third occur in South Asia. The maternal mortality ratio in developing countries in 2015 is 239 per 100,000 live births versus 12 per 100 000 live births in developed countries [1,2]. In Ethiopia, the pregnancy-related mortality ratio of are 412 deaths per 100,000 live births. This means a woman's lifetime risk of maternal death is 1 in 243 Ethiopia [2,3] Antenatal care (ANC) can be defined as the care provided by skilled health-care professionals to pregnant women and adolescent girls to ensure the best health conditions for both mother and baby during the pregnancy [4]. The goal of ANC is to have a healthy mother and healthy baby by monitoring the well-being of both the woman and the fetus during pregnancy and helping them make a smooth transition to labor and delivery [4,5]. ANC will also help to achieve the Sustainable Development Goals (SDG) of drop child mortality as low as 25 per 1000 live births and maternal mortality to as low as 70 per 100,000 live births by the year 2030 [1].
In recent times, the World Health Organization (WHO) changed the antenatal care (ANC) model increasing the number of ANC contacts with a health provider from four to eight contacts [5]. Globally, 38% of pregnant women do not attend at least four ANC contacts. In Sub-Saharan Africa, approximately half of all mothers and newborns receive no skilled care during the pregnancy and immediately after birth [2,6]. In Ethiopia, 62% of women do not attend at least four ANC visits during their last pregnancy [3]. Health Sector Transformation Plan (HSTP) of the Ethiopian Federal Ministry of Health addresses issues related to have focused antenatal care with at least four visits per pregnancy as mainstream at all service delivery levels with a target to increase the proportion from 68-95%at the end of 2020 [7]. However, according to the EDHS (2016), the ANC coverage with at least four visits are only 32%, not 68% [3]. This indicated that ANC visit in Ethiopia is immobile under any acceptable standard. Consequently, ANC visits still the current problem in Ethiopia. Previous studies in Ethiopia were covered in small geographical areas like the regional level as well as the district area [8][9][10][11][12][13].
Therefore, this study tried to identify socioeconomic and demographic factors affecting ANC visits on the national level.

Data source
The data used for this study were taken from the 2016 Ethiopian Demographic and Health Survey (EDHS). This survey is the fourth compressive survey designed to provide estimates for the health and demographic variables of interest in the whole urban and rural areas of Ethiopia as a domain.
Women who had 9 months of pregnancy during the survey interview were included in the analysis.
The study includes 7193 of the fertile age group in the country of women who had at least 9 months of pregnancy period during the survey in 2016 EDHS.

Dependent variables
The dependant variable considered in this study was count variable: the number of ANC visits during the pregnancy.
The variable women education level, husband's occupation, wealth index, marital status, women's occupation mother's age, husband's education level, planned pregnancy, access to mass media, pregnancy complications, desire for the pregnancy and residence, were considered to be a possible independent variable in the study

Data analysis
The data were analyzed by using R software version 3.5.3. Descriptive statistics including percents and frequencies were used to describe the study respondents. The zero-inflated Poisson regression model was employed to explore the association between the response variable and the predictor variables. Point estimates of the Incidence Rate Ratio (IRR) and Adjusted Odds Ratio (AOR) with 95% confidence interval (CI) were computed to estimate the strength of association between the independent and dependent variables, number of antenatal care visit. P-values of less than 0.05 were considered to be statistically significant.

Results
From a total of 7913 pregnant women; 2545(35.4%) of the pregnant women have not visited ANC and only 2.9% visited eight and more than eight times. Besides, the variance of the number ANC visit (5.614) is larger than its mean (2.53) representing over-dispersion. Moreover, the data has excess zeros (35.4%) and the Zero Inflated Poisson model would be appropriate to predict the number of ANC visits (Table 1).

Socio-Demographic Characteristics
The majority of the study respondents were from rural residences (79%) and 21% of the respondents in urban residences. Most of the respondents were a housewife (70%) and 30% of the respondents were employed. About 60.6% of mothers no attended primary school and only 12.4% of mothers attended secondary and above education. The greater part, (69.4%) of the respondents had no pregnancy complications and 64.4% had not got access to mass media. About 91.5 percent of women were married, 3.2 percent of women were never married, while t 5.3% were divorced and widowed.
The majority, 79.8% of pregnancy was planned and 91.1% pregnancy was not terminated. The greater part, (69.4%) of the respondents had no pregnancy complications and 64.4% had not got access to mass media. Regarding husbands' education, 31.7% of husbands' had no formal education while 30% of husbands attend primary education. The more (50.70%) of women from low economic status, only 14.3% were from the medium. Regarding the mother's age, the majorities of mothers were under the age group of 30 years plus, then followed 25-29 years ( Table 2). Factors associated with ANC visit in Ethiopia Similarly, the incidence rate of non-zero ANC visit for husbands with secondary and above education was 1.09 (IRR =1.09; 95%CI: 1.03, 1.14) times higher compared to their uneducated counterparts.
The incidence rate of non-zero ANC visits of the rural woman was decreased by 12% (IRR =0.88; 95%CI: 1.85, 1.92) compared to their woman who was living in urban area.
The study also indicated that the husband's wealth index and marital status were a significant factor in the number of ANC visits. The incidence rate of non-zero ANC visits for rich wealth index would be 95% CI: 1.02, 1.10) times higher compared to whose age is 15-24. The incidence rate of non-zero-ANC visits for mothers age 30 and above was 1.07 (IRR =1.07; 95% CI: 1.02, 1.11) times higher compared to whose age is 15-24 (Table 3).  [11,14,19] which revealed that non-educated women were less ANC attendants than those who have educated women. This study also showed that marital status was found to be significantly affecting ANC visits. The number of ANC visits to married women was higher compared to never-married women. This is consistent with the study done in Tigray, Ethiopia [11] Wealth index and husbands´ occupation was positively associated with ANC visit. The study showed that poor women were less ANC attendants than those of middle and rich women. Studies elsewhere have also documented a positive relationship between economic status and the number of ANC visits [13,15,16,19]. The number of ANC visit with husbands who have worked was lower than as compared to fathers without work. These findings are in agreement with [11].
The result of this study indicated that residence and access to mass media significantly associated with the number of ANC visits. The ANC visit of rural women was lower than the urban woman. This is consistent with the study done in Amhara and South West Shoa, Ethiopia [12,13]. The number of ANC visits for women being the use of mass media higher than not the use of mass media. It is also supported by [13,17]. Besides, women who had seen signs of pregnancy complications were a higher number of ANC visits than women who had no signs of pregnancy complications. This finding is consistent with [12,18].
Moreover, the desire for the pregnancy and age of women were also significantly associated with the number of ANC visit. Women who had planned pregnancy were a higher number of ANC visits than an unplanned pregnancy. This finding is supported by [16][17][18]. Similarly, women in the age group 30 and above are more likely to use ANC service than women in the age group of [15][16][17][18][19]. Several studies found out that women's age plays a significant role in the utilization of maternal health care [8,14].

Limitations of the study
Some variables are not included because of many missing values like parity and health insurance.

Conclusion
Only 45% percent of women in with a live birth received at least four ANC visits during the length of their pregnancy. ANC visit in Ethiopia is very low and below average as compared to the minimum requirement of ANC visit recommended by WHO. The study rural women, poor wealth index, uneducated mother, uneducated husband, not having access to mass media, unmarried women, have not pregnancy complication was significantly associated with less number of antenatal care visit.
Therefore, efforts are needed to advance the socioeconomic status of women, increasing the educational level of women and their husbands. The concerned body also should be made maternal health-care programs should be stretched and intensified in rural areas.

Consent for publication
Not applicable.
I would like to thank the Ministry of Health and Central Statistical Agency, Government of Ethiopia, for making the data freely available for research purposes.