International Journal of Advanced Medical and Health Research

: 2019  |  Volume : 6  |  Issue : 2  |  Page : 56--61

Utilization of focused antenatal care service and associated factors among women in Southern Ethiopia

Amare Abera1, Netsanet Abera Asseffa2, Mohammed Suleiman Obssa3, Elazar Tadese Balla4, Mengistu Meskele Koyira5,  
1 USAID-Transform Primary Health Care, South Region, Addis Ababa, Ethiopia
2 Department of Reproductive Health, School of Public Health, Hawassa University, Hawassa, Ethiopia
3 Department of Anesthesia, School of Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia
4 College of Health Sciences, Kotebe Metropolitan University, Addis Ababa, Ethiopia
5 Department of Reproductive Health, School of Public Health, Wolaita Sodo University, Wolaita Sodo, Ethiopia

Correspondence Address:
Mr. Netsanet Abera Asseffa
P.O. Box 138, Hawassa


Introduction: Antenatal care is a medical service provided to women during pregnancy with the aim of improving the pregnancy outcome. The approach considers that every pregnancy has the potential to be complicated. Objective: This study aimed to assess the utilization and factors associated with attending focused antenatal care (FANC) service in Wolaita Zone, Southern Ethiopia. Materials and Methods: A community-based cross-sectional study was conducted among 551 women who gave birth in the last 2 years. In this study, multistage cluster sampling technique was employed to select primary and secondary sampling units. Univariate and multivariable logistic regressions were done to determine associated factors. P < 0.05 and 95% confidence interval were considered to declare statistical significance. Results: The mean age of the respondents was 26.4 ± 4.9 years. The overall utilization of FANC was 85%. Among 540 interviewed mothers, 243 (45%) followed four and above times antenatal care visits during their last pregnancy, whereas 297 (55%) mothers followed <4 times. Mother's educational status, travel time, knowledge of danger signs, plan for last pregnancy, and knowledge on starting FANC were associated with FANC utilization. Conclusion: The findings of this study showed low utilization of recommended FANC. Efforts to improve utilization of FANC must strengthen initiatives that promote pregnant mothers' awareness on benefits of antenatal care, promote pregnancy planning, and reduction of travel time to health facility.

How to cite this article:
Abera A, Asseffa NA, Obssa MS, Balla ET, Koyira MM. Utilization of focused antenatal care service and associated factors among women in Southern Ethiopia.Int J Adv Med Health Res 2019;6:56-61

How to cite this URL:
Abera A, Asseffa NA, Obssa MS, Balla ET, Koyira MM. Utilization of focused antenatal care service and associated factors among women in Southern Ethiopia. Int J Adv Med Health Res [serial online] 2019 [cited 2022 Sep 25 ];6:56-61
Available from:

Full Text


Antenatal care is a service provided to women during her pregnancy with the aim of improving the pregnancy outcome and preserves their health.[1] Focused antenatal care (FANC) is helpful to early identify preventable complications and danger signs, and it is one of the big pillars of maternal health service.[2] The World Health Organization (WHO) recommends a minimum of four antenatal care visits by pregnant mothers. Each visit includes care that is appropriate to the woman's overall condition and stage of pregnancy and facilitates preparation for birth and care of the newborn.[3]

According to a systematic review, the minimum antenatal care visits recommended by WHO was attained in less than one-third of the pregnant women in some Sub-Saharan countries like Niger (15%), Ethiopia (19%), Chad (23%), Burundi (33%), and Mali and Rwanda (35% each).[4] Low antenatal care (ANC) coverage, few visits, and late attendance at first antenatal visit are common problems throughout sub-Saharan Africa posing difficulty in accomplishing the recommended ANC.[5]

Despite progress in antenatal care coverage, many countries, particularly sub-Saharan Africa and Southeast Asia are still in unsatisfactory levels. In addition, women in the region tend to wait to start antenatal care until the second or third trimester showing increase in later ANC visits.[6] Late ANC initiation may incur additional cost of caring for a pregnant woman that arises from missed opportunities to prevent or treat problems early in pregnancy.[7]

According to the Ethiopian Demographic and Health Survey (EDHS) 2014 report, 41% of women who gave birth received antenatal care from a trained health professional at least once for their last birth, and only 18% of mothers made their first ANC visit within the first 4 months of gestation.[8] In Ethiopia, FANC services are free of charge in most public health institutions and require a little cost in private facilities. Despite this, the EDHS 2014 report indicated that about four in every ten women (41%) did not receive any antenatal care for their last birth in the 5 years preceding the survey. When women initiate ANC late, they have an increased risk of poor pregnancy outcomes, maternal and neonatal mortality.[9] Regarding its utilization determinants, factors such as maternal age, maternal education, occupation, family income, accessibility of service, parity and past experience of service, perceived quality of service, cost of the service, awareness of care, and pregnancy-related complications were found to be predictors of FANC utilization.[7],[10],[11]

The utilization of FANC service has great importance in detection and treatment of existing diseases and conditions including early screening for HIV infection and syphilis to reduce mother-to-child transmission, ultrasound screening to identify congenital abnormalities and prevention of malaria, hookworm, tetanus, anemia, and other conditions. In addition to these, pregnant women receive other interventions that can be linked to FANC components such as provision of information about birth preparedness and complication readiness, nutrition, family planning, breastfeeding, and health benefits of delivery with the assistance of skilled health providers. Although FANC is essential for the improvement of maternal and child health, little is known about the utilization pattern and factors associated, particularly in the region. Therefore, this study aimed at determining extent of FANC service utilization and factors associated with ANC use, in Duguna Fango Woreda, Wolaita Zone, Southern Ethiopia.

 Materials and Methods

Study area

This study was conducted in Duguna Fango District, Wolayita Zone, Southern Ethiopia. The district is located 400 Km from Addis Ababa, the capital city and 64 Km from Hawassa, the regional capital. There were five health centers, 31 health posts, 8 private clinics, and 1 district hospital. The population was estimated to be 119,348, out of which 60,867 were female. The estimated reproductive age group women were 27,829 (23.3%) of total population. The total numbers of kebeles (the smallest administrative unit in Ethiopia) in the district were 32.

Study design

A community-based cross-sectional study was conducted from August to November 2017. All selected voluntary women of reproductive age who gave birth in the last 24 months were included. Women who were mentally and physically incapable of being interviewed were excluded.

Sample size determination

The sampling size was determined by using a single population proportion formula for cross-sectional study using the assumptions of Z, standardized normal distribution value for the 95% confidence interval (CI), which is 1.96, p, an estimate of the level for the population (32% =0.32)[8] and taking d, the margin of error to be 5.0% which gave 334. Adding design effect of 1.5 and 10% nonresponse rate 551 was the final sample size.

Sampling technique

Multistage cluster sampling technique was used to select primary and secondary sampling units. Out of 32 kebeles of the study area, nine kebeles were selected by simple random sampling as primary sampling unit. Then from secondary sampling units nine clusters/sub-kebeles were selected by simple random sampling from the list of cluster from each kebele, and the sample size was allocated to each clusters using probability proportion to population size. Then women of reproductive age who gave birth in the last 24 months in cluster were identified using the health postregistration book and then mothers were randomly selected until desired sample size was obtained.

Data collection and quality assurance

Training was given to data collectors and supervisors. Before conducting the main study, pretest carried out on 5% of mothers in the last 24 months who were not included in the study. Based on the findings of the pretest, data collectors reoriented and the questionnaire was modified as necessary. Feedback from the interviewers was incorporated to enrich the questionnaire and make it more applicable to the local situations. Anything which was unclear, missing and ambiguous were corrected on the next day and 10% of the sample was rechecked by supervisors whether the interviewers have done their job correctly or not.

Data were collected through structured questionnaire, which was prepared in English and translated to Amharic and back to English to check consistency. It was adapted from previously conducted studies and WHO standards with some modifications to address local context.[12] The 5% of the questionnaire was pretested and checked for its consistency in the same district but outside of study kebeles (the lowest administrative unit in Ethiopia). Nine nurses who were outside the study catchment area were identified for data collection and three health officers for supervision. The data collection was conducted by face-to-face interview. The structured questionnaire had sociodemographic variables, reproductive characteristics, and proportion of focused ANC use.

Operational definitions

FANC: It is a goal-oriented ANC approach that was adopted by the WHO with a minimum of four and more ANC visits. Antenatal care coverage is defined as the percentage of women who utilized antenatal care provided by formal health services at least once during pregnancy among all women who gave birth to a live child in a given time period. Antenatal services are services given by formal health facilities to pregnant women so that they have a safe pregnancy and healthy baby that include: risk screening, detection and management of associated diseases, efficient maintenance of maternal nutrition and health, and Information Education Communication related to safe delivery and early recognition and management of complications including abortion. Utilization is the action of receiving or using ANC service from formal health providers.

Data analysis

All the collected data were coded, checked for completeness and consistency. Data were entered into EPI Info version 3.5.4 (CDC, Atlanta, Georgia, USA) and transferred to SPSS version 20 (Armonk, New York city, USA) for analysis; descriptive statistics was done. Regarding the knowledge questions, those scoring below the mean score for knowledge questions were considered as poorly knowledgeable, whereas the rest were considered knowledgeable. Univariate and multiple logistic regressions were done to determine associated factors. Independent variables having P < 0.05 on univariate analysis were the candidates for multivariable analysis for further confounding effect control. Hosmer and Lemeshow goodness-of-fit test was done to assess the fitness of the model during multivariable analysis. With P = 0.25, the model was ensured being fit well for the multivariable analysis and accepted.

Both crude and adjusted odds ratios (AOR) with 95% CI were reported to measure the strength of association between exposure and outcome variable. The results of multiple logistic regression were considered statistically significant at P < 0.05.

Ethical consideration

Ethical clearance was obtained from the Ethical Review Committee of Wolaita Sodo University and permission to conduct the study was obtained from all relevant quarters. All selected participants were informed about the objectives and contribution of the study and their verbal consent was obtained before administering the questionnaires. Participants were informed that they have the right to discontinue or refuse to participate in the study and confidentiality was assured.


Sociodemographic characteristics

Of a total of 551 women who gave birth in the last 24 months prior to the study period, 540 (98%) participated in the study. Eleven mothers refused to participate in the study. Out of 540 mothers, majority 410 (75.9%) were between 20 and 34 age with the mean age of 26.4 and standard deviation of 4.9 years. Large majority study participants; 521 (96.5%), 466 (86.3%), and 512 (94.8%) were married, were protestant religion followers, and homemakers, respectively, and similarly 533 (98.7%) were Wolaita ethnic group. Regarding mothers' occupation, about 512 (94.8%) of mothers were homemakers and 28 (5.2%) were employed at work. Concerning mothers' educational status, half of the 312 (57.6%) had not attended formal education, 173 (32%) attended primary and 45 (8.3%) attended secondary, and 10 (1.9%) had received diploma and above education. Majority of respondents, 419 (71.2%), travel <2 h to reach the nearest health center (with minimum 0:10 min and maximum 4:30 h). Regarding means of transportation, almost all respondents, 461 (85.4%), travel on foot [Table 1].{Table 1}

Reproductive characteristics of mothers

Regarding reproductive characteristics of participants, 114 (21%), 181 (33.5%), 137 (25.4), and 108 (20%) were para one, 2–3, 4–5, and > 5, respectively. Similarly, 112 (20.7%) were gravida one, 155 (28.7%) were 2–3, 124 (23.0%) were 4–5, and 149 (27.6%) had >5 times gravidity. More than half (360 [66.7%]) of mothers planned their last child pregnancy, the rest 180 (33.3%) did not plan.

Knowledge on obstetric danger signs, number and starting month of focused antenatal care visits

Concerning knowledge on danger signs of pregnancy, more than half, 333 (61.7%), of the mothers were not knowledgeable and 207 (38.3%) were knowledgeable. Regarding when to start FANC, 275 (50.9%) of mother were knowledgeable and half of 265 (49.1%) were not knowledgeable on time at initiation FANC.

Proportion of focused antenatal care

Among 540 interviewed mothers' majority 459 (85.0%) attended focused antenatal visits at least once, out of these 30 (5.6%) and 243 (45%) attended once and four and more times during their last pregnancy, respectively. In addition, 258 (47.8%), 147 (27.2%), and 53 (9.8%) attended FANC at the first, second, and third trimester, respectively. Among those who attended FANC at least once, 200 (37.2%) of women attended late and 259 (47.8%) were early to FANC at health facilities.

Factors associated with focused antenatal care visits of mothers

Bivariate and multivariable logistic regression analyses were done to analyze factors associated with FANC utilization. P ≤ 0.2 was used as cutoff point and selected for the final model. On the bivariate analysis, variables such as age, education, parity, means of transportation to facility, family size, knowledge of danger signs during pregnancy, knowledge of starting month for FANC visits, and intend the pregnancy were significant and selected for multivariable analysis [Table 2].{Table 2}

Mothers who planned their last pregnancy were two times more likely to follow FANC than those who did not (AOR = 2.07 [1.2–3.5]. Mothers who knew the appropriate number for FANC visits were 8.3 times more likely to follow FANC than mothers who did not (AOR = 8.3 [5.13–13.6]). Knowledge of danger signs during pregnancy was found to be statistically significant; mothers who had knowledge about danger signs during pregnancy were 0.5 times more likely follow FANC than mothers' poor knowledge about danger signs during pregnancy (AOR = 0.4 [0.2–0.7]). Mothers who had access of transportation were two times more likely to follow FANC than mothers who had no transportation access (AOR = 2.1 [1.0–4.3]) [Table 2].


This study assessed FANC utilization and associated factors among childbearing mothers. Among 540 interviewed mothers, 243 (45%) followed FANC visit four and above times during their last pregnancy and 207 (40%) mothers did not utilize the service. This result was higher than the EDHS survey conducted in 2014 where 32% of mothers who have had a live birth in the 5 years received four and more prenatal care; this discrepancy might be related to time difference and EDHS survey encompasses remote areas of the country.[8],[13] Likewise, the finding is higher than a 15 years review done on disparities in ANC in Ethiopia, where only 10.4% attended four or more times.[14] This might be related to the fact that the Ethiopian Government and donors have implemented high impact interventions in maternal health including ANC.[15] However, the finding is lower than a study conducted in 2014 in Mekelle City, Northern Ethiopia, where 84.8% had four and above FANC contacts[2] and 60%, 95%, and 99% in Zambia, Ghana, and Ukraine, respectively;[16] this discrepancy might be due to the fact that this study was conducted in rural area, but those two were done in urban settings and had more educated participants. Moreover, access and means of transportation might vary.

In the multivariable analysis, like in many other studies,[4],[17],[18] educated mothers were more likely to use FANC as compared to their counterparts. This might be related to the fact that an educated mother tends to be aware of the benefits of using FANC and/or they had better access in terms of economy.

The access to transportation to health facilities significantly determined FANC utilization--mothers who had transportation to travel from their home to health center were 2.1 times more likely to follow FANC than their counterparts. Lack of transportation access to reach the nearest health facility discourages mothers to follow FANC because when they reach the third trimester they are weak to travel long distance in the case of rural areas without transport access. In contrary to that physical proximity of health institution was found to be a determinant of FANC utilization that 85.4% of the study participants traveled on foot. Mothers living in closer proximity to modern health services and having access to transportation were more likely to receive services from health personnel for the treatment of life-threatening and high-risk conditions and frequent FANC visits during the pregnancy period.

In this study, mothers who planned their last pregnancy were two times more likely to follow FANC than those who did not plan their last pregnancy. This finding is consistent with the study conducted in Yem special Woreda, Southwestern Ethiopia,[12] and Debre Birhan in 2012.[19] The possible explanation could be that mothers who had planned pregnancy might be more educated, and it is believed that wanted pregnancies are more likely to be cared that leads mothers to follow recommended FANC visit.

Mothers who knew the appropriate time for initiating FANC visits were 3.2 times more likely to follow FANC than mothers who did not know. This finding was in line with the study conducted in Debre Berhan in 2012.[19] This might be due to the fact that mothers starting FANC visit very soon have the probability of reaching four and above FANC, but if started late, they will deliver before reaching fourth visit and if they start first FANC early and providers inform and advise on pregnancy danger signs and services that enhance mothers to get FANC service.

Knowledge of danger signs during pregnancy was found to be significantly associated with FANC. This finding was consistent with a study conducted in Yem Special Woreda, Southwestern Ethiopia,[12] and Dere Teyare District, Eastern Ethiopia, 2015.[20] This may be due to the fact that mothers who had knowledge on danger signs are more likely to be aware of the possible adverse events that happen during pregnancy than their counterparts. The recall bias of women who gave birth in the last 24 months may cause error during data collection. In the cross-sectional study design, it is difficult to know which occured first, the exposure or the outcome.


The findings of this study showed that FANC utilization was low in the study area; 297 (55%) mothers did not follow FANC and more than half of the participants attended <4 visits. Hence, the regional health office has to strengthen activities to increase pregnant mothers' awareness on danger signs of pregnancy, benefits of antenatal care use, and work on improving access to health infrastructure to the community. Moreover, local health offices have to advise mothers to have planned pregnancy and work on early identification and service provision to pregnant mothers. Further studies should also be done on the quality of FANC service provided by health professionals in the setting.


We would like to thank Wolaita Sodo University for administrative support. We are grateful to the data collectors and participants.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Darega B, Dida N. Unplanned pregnancy: Prevalence and associated factors among antenatal care attending women in bale zone, oromiya region, Southeast Ethiopia: A facility – Based cross sectional study. Glob J Med Res 2015;15:4.
2Fisseha G. Predictors of timing of first antenatal care booking at public health centers in Mekelle city, Northern Ethiopia. J Gynecol Obstet 2015;3:55.
3Ornella Lincetto SM, PG. Antenatal care. Opportunities for Africa's Newborns, 2015. Bulletin of the World Health Organization; 2013. Available from: [Last accessed on 2018 Jun 21].
4Berhan Y, Berhan A. Antenatal care as a means of increasing birth in the health facility and reducing maternal mortality: A systematic review. Ethiop J Health Sci 2014;24 Suppl: 93-104.
5World Health Organization. WHO Antenatal Care Randomized Control Trial: Manual for the Implientation of the New Model. Geneva, Switherland: World Health Organization; 2002. Available from: [Last accessed on 2018 Sep 12].
6World Health Organization, United Nations Children's Fund, United Nations Population Fund, Bank of Taiwan. WHO,Trends in Maternal Mortality: 1990 to 2010. World Health Organization, United Nations Children's Fund, United Nations Population Fund, Bank of Taiwan; 2012. p. 59.
7Tekelab T, Berhanu B. Factors associated with late initiation of antenatal care among pregnant women attending antenatal clinic at public health centers in Kembata Tembaro Zone, Southern Ethiopia. Sci Technol Arts Res J 2014;3:108.
8Central Statistical Agency. Ethiopia Mini Demographic and Health Survey. Central Statistical Agency; 2014.
9Tesfaye G, Loxton D, Chojenta C, Semahegn A, Smith R. Delayed initiation of antenatal care and associated factors in Ethiopia: A systematic review and meta-analysis. Reprod Health 2017;14:150.
10Tariku A, Melkamu Y, Kebede Z. Previous utilization of service does not improve timely booking in antenatal care: Cross sectional study on timing of antenatal care booking at public health facilities in Addis Ababa. Ethiop J Health Dev 2010;24:226-33.
11Getachew T, Abajobir AA, Aychiluhim M. Focused antenatal care service utilization and associated factors in Dejen and. Prim Health care open Access 2014;4:1-8.
12Bahilu T, Abebe G, Yohannes D. Factors affecting antenatal care utilization in yem special woreda, Southwestern Ethiopia. Ethiop J Heal Sci 2012;9:25-7.
13ICF Central Statistical Agency. Ethiopia Demographic and Health Survey 2016: Key Indicators Report. Addis Ababa, Ethiopia, and Rockville, Maryland, USA: ICF Central Statistical Agency; 2016.
14Yesuf EA, Calderon-Margalit R. Disparities in the use of antenatal care service in Ethiopia over a period of fifteen years. BMC Pregnancy Childbirth 2013;13:131.
15Ethiopia Ministry of Health. Health Sector Development Program: 2010/11-2014/15. Federal Democratic Republic of Ethiopia Ministry of Health 2010. p. 1-131.
16Chama-Chiliba CM, Koch SF. Utilization of focused antenatal care in Zambia: Examining individual – And community-level factors using a multilevel analysis. Health Policy Plan 2015;30:78-87.
17Simkhada B, Teijlingen ER, Porter M, Simkhada P. Factors affecting the utilization of antenatal care in developing countries: Systematic review of the literature. J Adv Nurs 2008;61:244-60.
18World Health Organization. WHO Recommendation on Antenatal Care for Positive Pregnancy Experience. Geneva, Switherland: World Health Organization; 2016. p. 152.
19Zegeye AM, Bitew BD, Koye DN. Prevalence and determinants of early antenatal care visit among pregnant women attending antenatal care in debre berhan health institutions, central Ethiopia. Afr J Reprod Health 2013;17:130-6.
20Tilahun T, Sinaga M. Knowledge of obstetric danger signs and birth preparedness practices among pregnant women in rural communities of Eastern Ethiopia. Int J Nurs Midwifery 2016;8:1-11.