The Magnitude of Optimal Antenatal Care Utilization and Its Associated Factors among Pregnant Women in South Gondar Zone, Northwest Ethiopia: A Cross-Sectional Study

Background Adequate antenatal care is essential for the health of the mother and the development of the fetus. The World Health Organization recommends at least four antenatal care (ANC) visits during pregnancy. In Ethiopia, only 32% of women of childbearing age attend four or more ANC visits. This figure is significantly lower than the average for least developed countries. This study is aimed at calculating the magnitude and identifying the factors associated with optimal antenatal care utilization in the South Gondar Zone, Northwest Ethiopia. Methods A community-based cross-sectional study was conducted in the South Gondar Zone of Northwest Ethiopia from September 2020 to May 2021. A total of 434 participants were selected using multistage cluster sampling. Data were gathered through face-to-face interviews using a structured questionnaire. A multivariate binary logistic regression model was used to determine the factors associated with the optimal use of antenatal care. Result The magnitude of optimal antenatal care utilization was 59% (95% CI; 54.20, 63.65). The study showed that mothers who completed their secondary school (AOR = 8.205; 95% CI: 3.406, 19.767), women who completed their tertiary school (AOR = 6.406; 95% CI: 2.229, 18.416), women whose husbands' level of education is secondary school (AOR = 5.967; 95% CI: 2.753, 12.936), those with a planned pregnancy (AOR = 1.912; 95% CI: 1.117, 3.271), those with a wanted pregnancy (AOR = 2.341; 95% CI: 1.366, 4.009), women whose husbands work in the government or nongovernment sector (AOR = 3.736; 95% CI: 2.093, 6.669), those not being exposed to the media (AOR = 0.520; 95% CI: 0.345, 0.783), and rural women (AOR = 0.267; 95% CI: 0.164, 0.435) were significantly associated with optimal ANC utilization. Conclusion The findings suggest that more emphasis should be placed on education-based programs for women and their husbands that highlight the benefits of a planned pregnancy, desired pregnancy, and maternal health care. Meanwhile, the government and other concerned bodies should focus on expanding road accessibility, health institutions, and ambulance distribution to improve optimal ANC utilization in the area.


Introduction
The antenatal care (ANC) services provide an opportunity to prevent and manage existing and potential causes of maternal and newborn mortality and morbidity [1]. Antenatal care is supplied with the aid of talented healthcare providers to pregnant women and juvenile women to ensure the maximum extremely good well-being situations for each mother and baby throughout pregnancy [1]. In the past, the World Health Organization (WHO) has promoted 4 antenatal visits for single pregnancies. The first occurred in the 12 weeks following the age of gestation [2]. Antenatal care remains a major public health concern for the prevention of maternal and neonatal mortality worldwide by increasing the chances of access to vital obstetrics [3].
The high maternal mortality rate in certain parts of the world reflects unequal access to health services. Almost all causes of maternal mortality (99%) take place in the developing world. Over half of these deaths occur in sub-Saharan Africa and nearly one-third in South Asia [4][5][6].
The global reports in 2017 showed that only three in five women attended at least four antenatal visits. In regions with the highest rates of maternal mortality, such as sub-Saharan Africa, only 52% of women received at least four ANC visits [7]. The proportion of women with four or more ANC visits is considerably lower than the global average of 61.8% [2]. The prevalence of attending at least four or more ANC visits in 12 East African countries was 52.44% with the highest attending at least four or more ANC visits in Zimbabwe (75.72%) and the lowest attending at least four or more ANC visits in Ethiopia (31.82%) in 2012-2019 [2]. In the Ethiopian Demographic and Health Survey of women, 31.8% in 2016 [3,8] and 43.11% in 2019 [4] received four or more checkups.
The well-timed ANC usage can possibly save women from the direct causes of maternal and neonatal deaths associated with obstetric difficulty and might alleviate the consequences of pregnancy complications [13]. The enforcing and assuring usage of powerful maternity care of women in the growing international community is not a simple task [14][15][16][17]. In Ethiopia, the developments in maternal health care provide users with antenatal care, of which most of the women did not attend the minimal number of visits recommended by the World Health Organization [9,[18][19][20]. Most of the preceding research performed in Ethiopia meditated the low use of antenatal care in towns and cities [16,19,20]. Hence, this study is aimed at evaluating the coverage and risk factors of optimal antenatal care usage in the South Gondar Zone in Northwest Ethiopia.

Methodology
2.1. Study Setting, Data Source, and Study Design. This community-based cross-sectional study was conducted in the South Gondar Zone from September 2020 to May 2021. South Gondar is one of the zones found in the Amhara region and its capital city is Debre Tabor, which is located 666 km from Addis Ababa, the capital city of Ethiopia. According to the 2007 Ethiopian Central Statistical Agency Census, this area has a total population of 2,051,738, including 1,041,061 men and 1,010,677 women. Within this area, 468,238 households were enumerated, giving an average of 4.38 persons per household.

Population and Eligibility
Criteria of the Study. All women aged 15 to 49 years who had at least one birth in the South Gondar Zone were considered source populations. All women in the reproductive age group who had at least one birth in the previous 1-2 years before this study were randomly selected, except the women who were not permanent residents in the study region.
2.3. Sample Size and Sampling. The two-stage random cluster sampling technique was used to select the sample. In the first step, a sample of three (3) districts, namely, Laygayint, Farta, and Fogera, was selected independently within the zone. In the second phase, a sample of four kebeles (enumeration areas) was selected independently in each selected district. Finally, the calculated sample size was proportionally allocated to the kebele group based on the identified number of eligible mothers. Mothers in each of the kebeles were randomly selected using a simple random sampling technique.
The sample size was calculated using single population proportion formula with the assumption: 95% confidence interval, 4.2% margin of error, 10% estimated nonresponse rate, and taking 23.13% proportion of optimal ANC utilization in Southern Ethiopia [21] then, the required sample size was 434.

Data Collection Procedures and Quality Control
Measures. Data were collected using an intervieweradministered structured and pretested Amharic version of the questionnaire. The questionnaire was first developed in English and then translated to the Amharic language for appropriateness in approaching the study participants and then translated back to English by language experts to check its consistency. The questionnaire comprised sociodemographic, accessibility, behavioral, and obstetric variables. The training was given to data collectors and supervisors on the objective of the study, data collection procedures, data collecting tools, respondent's approach, data confidentiality, and respondents' right before the data collection date. The completeness of the questionnaire was checked every other day by the supervisors and investigators.

Prevalence of Maternal Health Care in South Gondar
Zone. The prevalence of mothers' health care use is presented in Table 1. A total of 434 women participated in the study. The magnitude of ANC service utilization was 59% (95% CI; 54.20, 63.65) ( Table 3).

Factors Associated with Four or More ANC Service Visits.
The results of bivariate and multivariable binary logistic regression analyses were summarized in Table 4. The model revealed that maternal education, maternal occupation, husband's education, husband's occupation, media exposure, time taken to get the nearest health facility, planned pregnancy, wanted pregnancy, health profession preferred by women, source of information about maternal care, media exposure, place of residence, residence, duty service of maternal health care, number of living children, and road accessibility to the nearest health facility, health provider behavior, presence of health facility in kebele, transportation, and family size were significantly associated with four or more antenatal care visits.
The results of this study showed that education had a positive association with 4 and more ANC service uptake, meaning that the amount of ANC service uptake increased as the woman's and husband's education levels increased. Women who had primary educational status were 12 Women who had planned and wanted pregnancies were more likely to use four or more ANC services than women who had unplanned or unwanted pregnancies. When compared to women who had an unplanned pregnancy, women who had a planned pregnancy were 1.912 (AOR = 1:912; 95% CI: 1.117, 3.271) times more likely to use four or more prenatal visits. Additionally, When compared to pregnant women who had an unwanted pregnancy, those who had a wanted pregnancy were 2.341 (AOR = 2:341; 95% CI: 1.366, 4.009) times more likely to use four or more prenatal care visits.
Four or more ANC service uptakes for husbands with primary education were 2.309 (AOR = 2:309; 95% CI: 1.272, 4.193) times higher compared with illiterate husbands. Similarly, four and above ANC service uptakes for husbands with secondary education were 5.967 (AOR = 5:967; 95% CI: 2.753, 12.936) times higher compared with illiterate husbands. Women who lived in urban areas were more likely to use four or more ANC services than women who lived in rural areas. Four and above ANC service uptakes of the rural women were 0.267 (AOR = 0:267; 95% CI: 0.164, 0.435) times lower compared with urban women.
Women whose husbands worked for the government or nongovernment sector were 3.736 (AOR = 3:736; 95% CI: 2.093, 6.669) times more likely to receive four or more ANC service uptakes than women whose husbands worked as farmers. Media exposure was linked to the use of four or more ANC services. Women who were exposed to the media were more likely to use four and more ANC services than women who were not exposed to the media. Women   who did not have access to the media were 0.520 (AOR = 0:520; 95% CI: 0.345, 0.783) times less likely to attend four ANCs than those who did. Finally, women who had to travel more than two hours to reach the nearest health facility were 0.332 (AOR = 0:332; 95 percent CI: 0.146, 0.757) less likely to receive four or more ANC services than their counterparts (Table 3).

Discussion
This study assessed the risk factors of coverage and associated risk factors of optimal antenatal care utilization in the South Gondar Zone. The study illustrated that the proportion of optimal antenatal care utilization was found to be 59.0%. This antenatal care utilization is lower than 60.2% in the Indonesia Demographic and Health Survey 2017 [22]. However, this antenatal care utilization is higher than 30% in the Bangladesh Demographic and Health Survey 2014 [23], 58.53% in Sub-Saharan Africa from 2006 to 2018 [24], 35.3% in Debre Tabor Town, Northwest Ethiopia, 2017 [25], 46% in Rwanda, 2014 [26], 58% in Nigeria using the 2018 Nigeria Demographic Health Survey [27], and 52% in Tharaka Nithi County, Kenya, 2016 [28].
The educational level of women was the factor to receive four and above antenatal care visits. This finding was consistent with the study conducted in Amhara regional states, Ethiopia [29], Ethiopia [30], and Vietnam [31]. It showed that the increased educational level increases women's received optimal ANC visits. Furthermore, the husband's education is also a factor of women who use ANC visits. Similar findings were reported in studies conducted in Ethiopia [32]. Most women in the South Gondar Zone are socioeconomically dependent on male partners who make household decisions, and this has an impact on maternal health care utilization [32]. It is because educated mothers are thought to be more aware of the importance and availability of ANC services and more likely to use them. Education provides women with the opportunity to be empowered for more confident and capable decisions to use modern health care services for themselves and their children. Furthermore, it increases women's knowledge on where and how the best health care can be accessed and enhances women's capability of making autonomous decisions [33].
Women who had planned and wanted pregnancies were more likely to use four or more ANC services compared to women who had unplanned or unintended pregnancies. This finding is consistent with studies done in East African Countries [34]. This may be because mothers who plan to have a child want to have a safe pregnancy and therefore pay special attention to their prenatal care. Additionally, the wanted pregnancy of women has increased the use of ANC visits. This finding is consistent with studies done in Ethiopia. This could be because mothers who want to have a child want a healthy pregnancy and hence pay special attention to their antenatal care.
Place of residence was a factor of women to use four or more ANC services. This result was consistent with those of studies in Ethiopia [25]. Women who live in an urban area may have easier access to material resources (such as money, automobiles, or motorcycles) that can make ANC services more accessible. This could be attributed to the fact that urban women are more inclined than rural women to use various media, information, and written papers, as well as have more understanding about their health. Another factor might be that you are too worried about other hobbies, your family, and your self-image or you do not have access to enough health care.
Women who were exposed to the media were more likely to use four and more ANC services than women who were not exposed to the media. This finding is similar to studies conducted in Ethiopia [30], Vietnam [31], and Tanzania [35]. Access to the media may have resulted in the more frequent use of ANC visits because the media may have offered relevant health promotion messages, such as the advantages of ANC and information on the danger signs of probable pregnancy problems [35]. Women who had to travel more than two hours to reach the nearest health facility were less likely to use the recommended four ANC visits. This finding is consistent with studies conducted in Ethiopia [32]. These findings revealed that enhancing access to and distribution of health care, especially in rural areas, should be a primary priority [32]. The proportion of women who had the recommended four ANC visits was lowest among women who had four or more births. This is in line with other studies conducted in Nigeria [27].   The occupation of husbands (work in the governmental or nongovernmental sector) had a significant impact on women to use four or more ANC services in the study area. It is known that most women are socioeconomically dependent on male partners who are decision-makers in households, and this influences maternal health care services utilization in Ethiopia [36]. This study contradicts the previous study in Ari Woreda, South Omo Zone, Ethiopia [37], which states that occupation had no significant effect with optimal ANC visit.
The time needed to get to the nearest HF was an important factor for women to use four or more ANC services in this study. This study was in line with the previous study [11,12], which shows that increased distance to a health facility decreased ANC services. This might be the distance to a health facility or time taken to get to the nearest HF that decreases the chance of getting health services due to less access to the transportation system and low economy for payment for transportation. In addition, the optimal use of antenatal care in this study had a significant impact on road access to HFs. In fact, the cost of transport and the type of transport depend on the availability of the road as it increases optimal use of antenatal care.
This study identified the behavior of health care providers as an important factor in optimal maternal use of antenatal care. This is because health care workers who had good behavior initiate mothers who use ANC visits and may give further explanation about the importance of optimal antenatal care utilization for mothers. The study showed that the number of live children from mothers was significantly related to optimal use of antenatal care. This might be because as the number of children increases, the mothers' want for pregnancy decreases-which leads to a decrease in the use of ANC visits. Similarly, family size in the household reduces the optimal use of the mother's antenatal care in this study. Because the large size of the family leads to a low economic level, an undesired pregnancy leads to low optimal use of maternal prenatal care.

Conclusion and Recommendations
The purpose of this study was to find out what factors influence optimal maternal antenatal care utilization in the South Gondar Zone, such as socioeconomic, demographic, health, and environmental factors. The result of this study showed that the magnitude of ANC services was 59%. When compared to the national average, this figure was extremely low. The study found that maternal education, maternal occupation, husband's education, husband's occupation, media exposure, time taken to get the nearest health facility,  International Journal of Reproductive Medicine planned pregnancy, wanted pregnancy, health profession preferred by women, source of information about maternal care, media exposure, residence, and road accessibility to the nearest health facility was significantly associated with optimal maternal antenatal care utilization. Ensuring the continuity of maternal optimal antenatal care utilization in the area, the government's efforts to establish a functional referral system through the distribution of ambulances to districts and the free maternal care policy should be maintained and strengthened as well as expanding educational programs aimed at educating mothers and their husbands on the benefits of a planned pregnancy, wanted pregnancy, and maternal health care and transportation problem and costs require long-term solutions for rural areas.