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Predictors of Antenatal Care Service Utilization Among Women of Reproductive Age in Ethiopia: A Systematic Review and Meta-Analysis

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02 January 2025

Posted:

02 January 2025

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Abstract

Background: Previous primary studies reported controversial findings on the association between predictors and antenatal care (ANC) service use. Therefore, we aimed to provide pooled predictors of ANC service use among women of reproductive age in Ethiopia.Methods: All observational studies done in Ethiopia between 2002 and 2022 were included in this review. Studies were systematically searched from PubMed, Medline, CINAHL, EMBASE, Google Scholar, and Google. We conducted a database search from June 1-31, 2023. The Newcastle-Ottawa scale (NOS) tool was utilized for quality assessment (risk of bias). The review was registered in the PROSPERO register with the registration number CRD42022322940. All data analyses were conducted by utilizing Stata version 17. A random-effects model was used to get the pooled predictors of ANC use. The publication bias was checked using a funnel plot and Egger's regression test. Results: A total of twenty-two studies with a total sample size of 25,671 were comprised for this review. Based on the NOS checklist assessment, we classified eight studies as low quality. The identified predictors of ANC use were highest wealth rank (AOR 1.92 [95% CI: 1.53 - 2.31]), formal women education (AOR 2.40 [95% CI: 1.75 - 3.06]), formal husband education (AOR 1.49 [95% CI: 1.36 - 1.66]), women age > 20 (AOR 1.75 [95% CI: 1.47 - 2.17]), mass media exposure (AOR 1.44 [95% CI: 1.21 - 1.66]), good maternal knowledge about the pregnancy complication (AOR 1.49 [95% CI: 1.11 - 1.88]), planned pregnancy (AOR 1.59 [95% CI: 1.28 - 1.91]), women autonomy (AOR 1.42 [95% CI: 1.23 - 1.62]), and positive husband attitude about the ANC service use (AOR 2.63 [95% CI: 1.47 - 3.79]). Conclusions: Several predictors have increased the ANC utilization, like wealth status, women's and their husbands' education, older/increasing women's age, media exposure, maternal knowledge about the pregnancy complications, planned pregnancy, women's autonomy to decide on household health care, and positive husband attitude about the ANC service utilization. Thus, the government and stakeholders should create women-focused economic reforms such as encouraging women's involvement in rural saving and credit cooperative organizations and productive safety net programs to increase their income, advocate ANC in mass media, and increase the mechanism of ANC service messages to reach the largest women of reproductive age groups.

Keywords: 
Antenatal care
;  
utilization
;  
predictors
;  
socio-economic status
;  
women
;  
reproductive age groups
;  
planned pregnancy
;  
obstetrics danger signs
;  
education status
;  
mass media exposure
;  
and Ethiopia
Subject: 
Public Health and Healthcare  -   Public Health and Health Services

Background

Though pregnancy has been taken as an achievable natural experience that is emotional or sensitive to the women, many women pass through several problems where they suffer and even die [1,2,3,4]. Due to this, there is a demand to invest or advance in the health care of mothers. The investment could be accomplished in different techniques; one is promoting the ANC service use [4,5,6,7].
ANC remains an essential intervention for enhancing maternal and neonatal health outcomes [5,8]. It gives a chance for the pregnant mothers and healthcare providers to discuss adequate nutrition, identifying obstetrics danger signs (ODS), and a childbirth plan [9,10,11], and protective care, such as the supply of ferrous sulfate or folic acid pills and tetanus toxoid immunization [4,10]. Due to the above benefits, at least 8 ANC visits for mothers with a normal pregnancy have been recommended by the World Health Organization (WHO) to offer users a more women-centered and positive experience [12].
Globally, ANC service utilization was 72.9%, ranging from 53.3% in developing countries to 93.3% in the developed country [11]. Likewise, only 43% of women benefited from 4 or more ANC visits during pregnancy in Ethiopia [13]. Moreover, the coverage of ANC utilization varies by region, sub-region, and district in Ethiopia based on findings of studies and reports. The findings from these studies showed that the utilization of the ANC ranged from 12 to 94.8% [14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33]. The above variation in the coverage of ANC services is a significant barrier that influences Ethiopia’s progress toward achieving maternal and neonatal mortality statistics in line with Sustainable Development Goal (SDG) 3 [6,8].
Based on the 2019 Mini Ethiopian Demographic and Health Survey (EDHS) report, the ANC service utilization increased from 28% in 2005 to 74% in 2019 [13]. However, there is little progress in closing the gap between regional states, and Ethiopia’s urban and rural differences persist [13,14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33]. Besides, approximately a third of mothers who accessed ANC services do not receive the whole package of services during their follow-up [13,34].
The several interconnected predictors have contributed to low ANC utilization. They can be categorized as socioeconomic and demographic, obstetric characteristics, health facility or organizational, service quality-linked predictors, proper infrastructure and health system, socio-cultural, and the lack of transport in rural settings [14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33].
However, previous studies reported controversial findings on the relationship between different predictors and ANC service utilization in different settings of Ethiopia [14,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33]. For instance, some studies showed a positive association between the women’s and husband’s education and ANC utilization [23,25,27,29,32], while others showed no association [20,21,26]. Similarly, some studies reported the highest wealth rank and increased ANC utilization [25,29,32], whereas others showed no association [31]. Moreover, the prevailing evidence is conflicting between place of residence [14,16,19,25,26,32,33], women’s age [14,17,22,27,28,35], family income [14,15,16,17,18,20,21], women’s occupation [14,15,16,17,20,21,22,30,33], husband’s occupation [24,28,30], marital status [16,18,28,33], and women’s mass media exposure [15,16,19,22,25,36]. Keeping these controversies unanswered at the primary study level can directly lead to missing the target point of intervention strategies. Several small pocket studies conducted on the predictors of ANC utilization in Ethiopia have been published, although the results are varies from place to place. This review and meta-analysis is thus required to acquire a comprehensive picture of which determinants are essential and how much influence on the ANC utilization. This data is required for policymakers, implementers and program administrators to detect gaps in the utilization of ANC and design comprehensive strategies and initiatives to boost service utilization. Furthermore, there is limited evidence on the predictors of ANC utilization in Ethiopia. Therefore, we aimed to provide comprehensive evidence on pooled predictors of ANC service utilization among women of reproductive age in Ethiopia.

Research Question

What are the pooled predictors of antenatal care service utilization among women of reproductive age in Ethiopia?

Methods

Study Design

A systematic review and Meta-analysis were conducted to estimate the pooled predictors of ANC service use.

Eligibility Criteria to Include Studies

The following inclusion criteria were utilized to comprise studies in this review and meta-analysis. Study design: all observational studies reported predictors of ANC service utilization after multivariable analysis in Ethiopia; study period: studies conducted from 2002 to 2022 were included. The starting period was considered 2002 because the Ethiopian government implemented focused ANC during this period; study setting: both community- and institution-based studies were considered; study subjects: women of reproductive age groups who were pregnant or gave birth at least once preceding the survey. Exposure: determinants or predictors or associated factors of ANC service. The predictors are exposure or characteristics that influence the probability of ANC service utilization. These can be classified as socioeconomic and demographic, obstetric characteristics, health facility or organizational, service quality-linked predictors, proper infrastructure, health system, and socio-cultural. Outcome: a woman who has at least one ANC visit; language: A study containing full text only in English was included; publication status: unpublished and published studies.

Search Strategy

All studies were systematically searched from international databases utilizing keywords such as antenatal care, maternal health care, prenatal care, utilization, utilisation, predictors, determinants, associated factors, women of reproductive age, and Ethiopia as search terms. PubMed, Medline, CINAHL, EMBASE, HINARI, the Cochrane Library, Google Scholar, and Google were searched to obtain studies done in Ethiopia between 2002 and 2022. This is the search strategy used for PubMed: ((((((Antenatal care) OR (Maternal health care)) OR (Prenatal care)) AND (Utilization)) OR (Utilisation)) AND (Predictors)) OR (Determinants)) OR (Associated factors)) AND (Women of reproductive age)) AND (Ethiopia). The details of the searching strategy for PubMed, Medline, CINAHL, and EMBASE are provided as supporting information (Additional File 1). The retrieved studies’ reference lists were reviewed to prevent the miss of other relevant articles during the search process. We registered the systematic review in the system of PROSPERO prospective register with the registration number CRD42022322940. The review protocol was prepared and can be accessed from the PROSPERO register. The review protocol amendment was not made.

Method of Study Selection

We utilized the PRISMA flow chart to describe the flow of information via different stages of a systematic review [37]. We used four steps to assess the applicability of studies in our review based on the eligibility criteria. First, the duplicated studies were rejected from different sources. Second, the titles and abstracts were critically assessed based on the eligibility criteria. Articles that fulfilled the eligibility criteria in the second screening procedure were considered candidates for the third screening procedure. Third, each article’s full-text review was conducted based on eligibility criteria before being included. We contacted the corresponding author of studies when studies have not contained adequate data. We obtained clarification on the concerns and solved all doubts encountered. Finally, this review included twenty-two studies that fulfilled pre-determined inclusion criteria (Figure 1). The checklists of PRISMA are provided as supporting information (Additional file 2).
Figure 1. Flow diagram presentation of the technique for selecting studies, including studying the utilization and predictors of antenatal care service in Ethiopia.

Quality Assessment (Risk of Bias)

The review authors (AY and FGG) rigorously assessed all studies chosen to include in the review. The NOS tool was utilized to assess the methodological quality of observational studies in systematic reviews and meta-analyses and evaluate the risk of bias within involved studies [38]. The included studies were given a maximum of four stars in the subject selection, two stars in group comparability, and three stars in the outcome measurement procedure based on NOS. For observational studies, the methodological quality was categorized as low, moderate, or high when the NOS score fell between 0 and 4, 5–6, and > 7 stars, respectively (see Additional file 3).

Data Abstraction or Extraction

Data abstraction format was used to extract data from included studies. It was constructed by both authors with explicit exclusion and inclusion criteria. Both authors were involved in data abstraction format development to ensure that the tool accurately captures all needed data to respond to the review queries. Both authors conducted data abstraction from the included studies. From each included study, the authors collected the name of the first author(s), the proportion of ANC service use, predictors, response rate, study areas, participants, design, data collection period, years of publication, sample size, and AOR with 95% CI (Table 1). The abstracted data from included studies are now provided as supporting information (Additional file 4).

Definition of Variables

ANC service utilization: women who have at least one ANC follow-up were considered as utilizing the services.
Residence was divided into urban and rural. The rural residence was used as a reference category group.
Age of the women: Women were allocated to age groups ≤ 19 and > 19 years. The second group was utilized as the reference group.
Women/husband’s education status: (no formal education and have formal education). The first group was utilized as the reference.
Marital status was categorized as married and other groups (comprising single, widowed, and divorced). The other group was utilized as the reference group in our analysis.
Parity was grouped into women having 1-4 and more than four living children. The last one was utilized as a reference.
Category of pregnancy: it was assigned as planned vs. unplanned. The latter one was used as the reference point.

Statistical Data Analysis Methods

The data extraction was conducted in Microsoft Excel format and exported to Stata version 17 software for analysis. We utilized figures and tables to summarize the descriptive results of included studies. The I2 statistic was calculated to decide heterogeneity between studies, and a p-value < 0.05 was utilized to identify it. If an I2 statistic value is less than or equal to 50%, we declare studies were homogeneous, and greater than 50% denotes high heterogeneity among studies, and the random effect model is recommended for meta-analysis [39,40]. The random effect model was used due to heterogeneity in our review based on recommendation. We implemented subgroup analysis based on the quality of studies, sample size, study design, year of data collection, and region due to heterogeneity between studies. Also, a meta-regression model was utilized to detect the sources of variations based on the year of data collection, sample size, region, and design. We utilized a forest plot of AOR with the 95% Confidence Interval (CI) to measure pooled effect size estimates for the predictors of ANC service use. The sensitivity analysis was done to evaluate the robustness or stability of the pooled estimates to the impact of individual studies and outliers. We utilized the funnel and counter-enhanced plot asymmetry and Egger’s test to check the presence of publication bias [41].

Results

Database Search Findings

A database search was carried out from June 1-31, 2023, and 711 studies were collected. Only 231 studies persisted following the rejection of duplicated records. We critically evaluated the titles and abstracts of the studies and rejected 169 studies based on the criteria. Only twenty-two studies remained following the application of the exclusion and inclusion criteria. We excluded forty studies after critically evaluating their full text from the review for several reasons (see Additional file 5).

Description of Included Study Features

We described the features of the included studies in a review (Table 1). The majority, 20 (90.9%) of included studies, were cross-sectional, and only two studies employed a cohort design. The total sample size from twenty-two studies was 25,671 and ranged between 307 and 7908 women of reproductive age. The majority, 10 (45.46%) of studies, were from Oromia (5) and South Nations Nationalities and Peoples Regional State (SNNPRS). Also, two regional and national-based studies were included. Most study subjects were women of reproductive age who gave birth in the five years preceding the survey. The utilization of ANC service was wide-ranging, between 28.5% and 90.6%, in this review. Among twenty-two studies, eight studies were categorized as low-quality based on the NOS checklist evaluation (Additional file 3). The primary limitation of these low-quality primary studies was that they used inappropriate sampling techniques [14,18,20,30,36], the sample size calculation was not straightforward and acceptable [18], and the statistical data analyses procedure was not explained clearly [15,18,22,23,36].

Predictors of ANC Service Utilization

Of twelve studies that assessed the place of residence as a predictor for ANC service utilization, eight studies reported that urban residence increased the odds of ANC service utilization among Ethiopian women. However, the four studies revealed that urban residence had no significant association with ANC service utilization. The pooled data from this analysis reported that urban residence had no significant association with women’s ANC service utilization (AOR = 1.02; 95% CI: 0.82 - 1.21). The six studies evaluated the effect of wealth status on ANC service use. Five studies reported a significant positive association between the highest wealth rank and ANC service use among women. However, one study reported that wealth status did not affect ANC service utilization. The results from this analysis reported that the highest wealth rank increased the odds of ANC service utilization two times among women in Ethiopia (AOR = 1.92; 95% CI: 1.53 - 2.31). Women’s education status was evaluated in seven studies, and six studies reported that the odds of ANC service utilization increased as the level of women’s education increased. The pooled estimates reported that the formal women’s education increased 2.40 times the odds of ANC service utilization (AOR = 2.40; 95% CI: 1.75 - 3.06) compared to women who had no formal education (Table 2).

Publication Bias

We checked the publication bias using a graphical diagnostic method (standard and contour-enhanced funnel plot), which demonstrated a symmetric shape (Figures S1 and S2). Thus, we further explored using the regression-based Egger test for the small study effect method, and publication bias was not detected due to a p-value > 0.05 (p = 0.88).

Discussion

Wealth status, women’s and their husbands’ education, older/increasing women’s age, media exposure, maternal knowledge about the pregnancy complications, planned pregnancy, women’s autonomy to decide on household health care, and positive husband attitude about the ANC service use were found to be predictors of ANC service use.
This meta-analysis found that women and their husbands’ formal education increased the odds of the ANC visits. The possible rationale could be described as educated families were tending to possess good health-seeking behavior, being more autonomous and economically independent, being more confident and positive thinkers, having better job opportunities, and having information on the benefits of ANC to the baby and mother [29,42]. Similar results were reported from reviews in developed countries [43], developing countries [44,45], SSA [46], Iran [47], and Ethiopia [48]. The study conducted in Nigeria identified education status as a major predictor of health inequality of ANC utilization [49].
The current meta-analysis also reported that older/increasing women’s age was significantly associated with ANC utilization. Similar results were reported from the reviews conducted in sub-Saharan Africa (SSA) [46], developing countries [44], and Iran [47]. The association of age with ANC utilization might be explained since younger women have less experience in childbearing, as they may be adolescents or newlyweds and thus more likely ignorant of ANC utilization or have limited awareness of pregnancy complications [46]. Also, the confounding effect of parity might be another explanation because low parity was significantly associated with the ANC utilization in the reviewed studies [14,22,24,25,28,35].
The household’s highest wealth rank was significantly associated with ANC utilization. reviews conducted in developing countries [44], SSA [46,50], West African countries [51], South Asia [52], and Iran [47] documented similar significant positive associations. The likely justification might be indirect and direct non-medical and medical costs related to ANC service influencing ANC utilization in SSA [53,54]. Though ANC services are free in Ethiopia, women still pay out of pocket for indirect costs such as transportation, some laboratory tests and drugs, and food during stays in towns. Researchers argued that women from scarce resource communities had been challenged to pay for the healthcare, and these costs present economic barriers to utilizing ANC by pregnant women [55,56]. Therefore, due to lack of economic access, the mothers may not visit ANC at all, decrease the number of recommended ANC follow-ups, or even start ANC in late pregnancy.
In this meta-analysis, women’s autonomy in decision-making on household health care was significantly associated with ANC utilization. Similar results were reported from reviews in Bangladesh [57], Ethiopia [58], and SSA [46]. The researchers argued that women who are denied autonomy could not decide to visit ANC service without authorization from their spouses, due to cultural norms and economic dependence [59]. Another possible justification might be that autonomous women, more likely educated, increased their knowledge about the benefits of ANC utilization.
This meta-analysis also showed that women whose pregnancies were planned were associated with ANC use. This result agreed with reviews done in developing countries [44], Ethiopia [58], SSA [46], Iran [47], and developing and developed countries [60]. Women who plan to have children may better know their health and baby [46]. Consequently, they may be organized in all the required prearrangements to utilize ANC services efficiently and effectively. Also, women whose pregnancy was unplanned might panic about unintended pregnancy’s social ramifications or implications and thus can avoid ANC services use.
Women’s exposure to mass media was significantly associated with ANC service use. Reviews conducted in developing countries [44] and SSA [46] reported similar significant positive associations. The WHO report argued that women who had a high living standard and income could have better exposure to mass media that increased awareness and knowledge of ANC services [61]. This argument is supported by results from studies employed in low-income countries [62,63].
Moreover, this meta-analysis showed that good maternal knowledge about pregnancy complications was significantly associated with ANC service use. Reviews conducted in developing countries [44], SSA [46], and Ethiopia [58] reported similar significant positive associations. The reasons might be that women who have good knowledge about ODS may better perceive the severity of problems and get prepared to utilize ANC services. Also, many researchers argued that women who have poor knowledge of ODS are less prepared for birth and complications; as a result, they frequently delay seeking proper MHS [64,65].

Limitation of the Study

This review has several strengths. From these, we registered the systematic review in the system of PROSPERO prospective register with the registration number CRD42022322940 to avoid duplication. Second, our sample size was large as compared to previous review. Hence, the findings are generalizable to all women of reproductive age in Ethiopia and vital to developing appropriate intervention and policy strategies for efficient and effective promotion of ANC services use. Lastly, it comprehensively mapped out the several predictors of ANC service use among WRA in Ethiopia.
On the other hand, the current review has some limitations to consider while concluding our results. First, the probability of recall bias might be high in our review because most included primary studies collected data from the study subject who gave birth in the last five years of preceding surveys. Also, the findings may have been influenced by reporting bias because data were collected by using the respondents’ self-report in most primary studies. There is the risk of intentionally misreporting personally related predictors like age, income, occupation, and household materials (social desirability bias). The extent of these predictors might have been undervalued. The correlation of these predictors with ANC service use might have been underestimated. Second, our review included only two cohort studies; more than 90% is cross-sectional, which restricts us from establishing a causal association. Third, we failed to report the pooled effect size for all variables due to the lack of a standardized cut-off point, and categorization of data to carry out comprehensive Meta-Analyses. Fourth, the socio-demographic predictors were most examined and identified predictors of ANC service use in the primary studies. This limited or influenced us not comprehensively explore predictors such as health service availability and accessibility, health system and health care providers related, behavioral, and infrastructure-related which are an area of future research.

Practical Implications of This Study

This research will contribute to the field of public health, particularly in improving ANC utilization by providing valuable information for implementers, managers, policymakers, and researchers. Besides, this study is important because it comprehensively and adequately addressed most of the predictors of ANC utilization to design suitable strategies to promote antenatal care utilization. Furthermore, the potential bodies (target audience) that might be interested in this study are organizations/institutions/health facilities, government officials/managers/policy makers, implementers, researchers, and other stakeholders; partners and bilateral organizations will use findings to make decisions on ANC utilization. Finally, research findings have significant implications for the broader community or society by improving ANC utilization in Ethiopia.

Conclusion

Our review resolved controversies of primary studies and identified several pertinent predictors of ANC service use. Wealth status, women and their husband’s education, older/increasing women’s age, media exposure, maternal knowledge about the pregnancy complications, planned pregnancy, women’s autonomy to decide on household health care, and positive husband attitude about the ANC service use were found to be predictors of ANC service use. Based on the results of this review, the intervention strategies in Ethiopia should emphasize the following essential areas: Promoting women’s and husband’s education status through cooperation with education sector, designing young women’s health education programs to support and mobilize young women about ANC service, creating women-focused economic reforms, developing programs to alter favorable husband’s attitudes to participate in ANC, empowering women to decide on household issues, increasing women exposure to mass media (radio and television), advocating ANC in mass media, and developing programs to improve knowledge about pregnancy complication.

Supplementary Materials

The following supporting information can be downloaded at the website of this paper posted on Preprints.org.

Author Contributions

AY- Involved in initiation of the research question, prepared the research protocol, carried out the research, did the data abstraction and analysis, and wrote the manuscript. FGG- Involved in initiation of the research question, prepared the research protocol, did the data abstraction and analysis and revised the manuscript. Both authors read and approved the final manuscript.

Funding

The authors declare that they have not received financial support from any organization.

Ethics Approval and Consent to Participate

Not applicable.

Consent for Publication

Not applicable.

Availability of Data and Materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Acknowledgments

Not applicable.

Competing Interests

The authors declare that they have no competing interests.

List of Abbreviations

ANC: Antenatal care; AOR: Adjusted odds ratio; CI: Confidence Interval; C.S: Cross-sectional; EDHS: Ethiopian Demographic and Health Survey; HCPs: Health Care Providers; H.F: Health Facilities; KA-HDSS: Kilite-Awlaelo Health and Demographic Surveillance System; K.M: Kilometer; LMIC: Low and Middle-Income Countries; MHS: Maternal Health Service; MHSU: Maternal Health Service Utilization; NOS: Newcastle-Ottawa scale; ODS: Obstetric Danger Signs; PNC: Postnatal Care; PRISMA: Preferred Reporting Items for Systematic Review and Meta-Analyses; SBA: Skilled Birth Attendant; SDG: Sustainable Development Goal; SNNPRS: South Nations Nationalities and peoples Regional State; WHO: World Health Organization; WRA: Women of Reproductive Age.

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Table 1. Description of essential features of studies included in the review, 2023.
Table 1. Description of essential features of studies included in the review, 2023.
Author and year Region Study design Data collection period Study subject Sample size Response rate (%) Predictors Outcome ANC use (%)
Kidist B et al, 2013 Oromia CS January to
February 2012		 Women who
gave birth
in the past three
years		 422 99.2 Maternal age and education status, income, media exposure, planned pregnancy, knowledge of ODS MHC (ANC and SBA)
Women who utilized at least one ANC service		 87.1
Tesfaye G et al, 2018 Oromia CS June to August 2017 WRA, who gave birth in
the three years before the survey		 1294 100 Women’s education status, previous utilization of ANC, residence, wealth index, husband’s attitude about ANC Women who utilized at least one ANC service 53.6
Jira C et al,
2005		 Oromia CS Feb 1 to 20,2004 Pregnant
women in their third trimester		 307 100 Women’s education and occupation status, perceived importance of ANC visit Women who utilized at least one ANC service 90.6
Desalew ZA et al, 2014 Oromia CS June 2012 Women who gave at least one live birth in the 5 years 495 100 Women’s age, education, family size, perceived importance of ANC of services, residence MHC (ANC and SBA) Women who utilized at least one ANC service 86.1
Bontu F, 2007 Oromia CS Jan-Feb,2006 Pregnant women in their third trimester 384 93.8 Women’s education and occupation status, income, and religion Women who utilized at least one ANC service 76.7
Abebaw GW
et al, 2013		 Amhara Cohort
study		 Jan-
Mar 2012		 Women who had birthed in the last year preceding the survey 1730 96.4 Women’s education, awareness on places to get skilled providers, previous pregnancy ANC use MHC (ANC, SBA and
PNC)
Women who utilized at least one ANC service		 32.3
Author and year Region Study design Data collection period Study subject Sample size Response rate (%) Predictors
 Outcome ANC use (%)
Gebeyeu TN et al, 2015 Amhara CS Feb-Mar, 2013 WRA who had a birth in the past one year 317 96.8 Women’s education and occupation status, income, plan of pregnancy, knowledge of ODS Women who utilized at least one ANC service 55.7
Yohannes AM et al, 2014 Tigray Longitudinal
cohort study		 Sept-August,2013 Pregnant and
women who
had given birth past 5 years		 2361 98.2 Women’s age, education, occupation, and residence
 ANC and SBA
Women who utilized at least one ANC service		 76.5
Yalem T et al,
2013		 Tigray CS Aug-
Sep 2009		 Women who
had given birth in
the five years		 1,115 99 Age, marital status, education, parity, husbands
Occupation		 ANC and SBA
Women who utilized at least one ANC service		 54
Zeine A et al,
2010		 SNNPR CS Janu-Feb,2009 Women who
gave birth in the last five years		 710 97.3 Women’s age and education status, parity, planned pregnancy, knowledge of ODS Women who utilized at least one ANC service 86.3
Abebaw AM et al, 2021 SNNPR CS Aug- Sept 30, 2018 WRA, who gave birth within six
months of the survey		 720 100 Education status of women and husbands, residence, wealth index Women who utilized at least one ANC service 72.6
Zeleke D
et al, 2015		 SNNPR CS Jan 2014 Women who
gave birth in the last year		 634 98.2 Planned pregnancy, knowledge of ODS, education status, occupation, women’s autonomy MHC (ANC and SBA)
Women who utilized at least one ANC service		 87.6
Melese G et al,2016 SNNPR CS Jan-Feb,2015 Women who gave birth in the one year preceding the study 778 96.1 Residence, women and husband education, media exposure Women who utilized at least one ANC service 71
Author and year Region Study design Data collection period Study subject Sample size Response rate (%) Predictors
 Outcome ANC use (%)
Bahilu T et al, 2009 SNNPR CS April 2008 Women who had given birth in the past 12 months 651 96.3 Women’s education, residence, planned pregnancy, knowledge of ODS Women who utilized at least one ANC service 28. 5
Shegaw M et al, 2014 National CS Decem-June,2011 Women who
gave at least one birth within the last 5 years		 7908 100 Residence, education status, H.H. wealth status, husband education, the autonomy of women, media exposure MHC (ANC
and SBA)
Women who utilized at least one ANC service 		33.9
Muluwas A et al, 2015 Benishangul
Gumuz		 CS May,2012 Women who
gave birth in past five
years		 536 97.9 Place of residence,
educational status,
awareness on ANC
service, distance		 Women who utilized at least one ANC service 81.9
Gurmesa T G,2009 Benishangul
Gumuz		 CS Janu-
Feb 2007		 Women gave birth at least one birth in the past 5 years 1060 97.9 Place of residence, women’s education and occupation status, media exposure, wealth status Women who utilized at least one ANC service 49.8
Kassahun T et al, 2019 Benishangul
Gumuz		 Regional CS From Decem 2010 to
June 2011		 Mothers who had at least one child in the 5 years before the survey 916 100 Women’s age and education, residence, religion, and ethnicity, wealth index Women who utilized at least one ANC service 37.7
Tsegay B et al, 2021 Sidama CS Janu, 2019 Women who gave at least one birth in the last year
preceding survey		 692 98.67 Wealth index, education, media access, and plan pregnancy, information, and counseling about ANC Skilled MHSU
Women who utilized at least one ANC service
69.1
N Regassa, 2011 Sidama CS 2011 Women who
had a child < 2 years		 1094 100 Women’s age, education and occupation status, media exposure, planned pregnancy ANC and PNC
Women who utilized at least one ANC service 		77.4
Author and year Region Study design Data collection period Study subject Sample size Response rate (%) Predictors
 Outcome ANC use (%)
Nejimu B et al, 2016 Afar CS Janu-Feb, 2015 Women who gave birth within 2 years prior
to survey		 788 100 Residence, occupation, income, source of information Women who utilized at least one ANC service 42.4
Wubareg S et al, 2017 Somali CS June,
2011		 Women who had childbirth in the past year 759 95.7 Maternal age, husband education, attitude, and parity MHSU Women who received ANC at least once 66.2
ANC: Antenatal care; CS: Cross-sectional; MHSU: Maternal health service utilization; ODS: Obstetric danger signs; PNC: Postnatal care; SBA: Skilled birth attendant; SNNPR: South Nations Nationalities and Peoples Regional State.
Table 2. Meta-Analyses of predictors of antenatal care utilization among women of reproductive age in Ethiopia, 2023.
Table 2. Meta-Analyses of predictors of antenatal care utilization among women of reproductive age in Ethiopia, 2023.
Predictors No of included in analysis categories Pooled AOR with 95% CI
Place of residence 12 urban 1.02 (0.82 - 1.21)
rural 1
Wealth rank 6 Highest 1.92 (1.53 - 2.31)
Lowest 1
Women’s education status 7 Have formal 2.40 (1.75 - 3.06)
No schooling 1
husband’s education status 8 Have formal 1.49 (1.31–1.66)
No schooling 1
Women age groups 7 ≥ 20 years 1.75 (1.47 - 2.17)
< 20 years 1
Marital status 5 Married 0.97 (0.69, 1.25)
Others 1
Parity 6 1-4 0.91 (0.76 - 1.06)
>4 1
Media exposure 7 Yes 1.44 (1.21 - 1.66)
No 1
Knowledge about pregnancy complication 6 Adequate 1.49 (1.11 - 1.88)
Inadequate 1
Planned pregnancy 10 Yes 1.59 (1.28 - 1.91)
No 1
women’s autonomy to decide 4 Yes 1.42 (1.23 - 1.62)
No 1
Perceived the importance of ANC follow-up 4 Yes 2.68 (0.27 - 5.09)
No 1
Husband’s attitude 5 Positive 1.42 (1.23 - 1.62)
Negative 1
1: Shows the reference categories.
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