Delay in timing of first antenatal care utilisation among women of reproductive age in sub-Saharan Africa: a multilevel mixed effect analysis

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BACKGROUND: Several studies in sub-Saharan Africa and elsewhere have affirmed the importance of community-level factors in influencing maternal health seeking behaviour. However, literature shows no uniform pattern in terms of how contextual-level factors influence delay in seeking antenatal care service in different parts of the region. The association of contextual factors and timing of antenatal care is not well documented at regional level. Thus, this study was conducted to examine how community-level characteristics influence decision not to initiate antenatal care in the first trimester. Regional-level analyses of antenatal care utilisation in sub-Saharan Africa are important because they help identify geographic disparities in access and utilisation of the service. Thus, allowing for targeted interventions to improve maternal health outcomes. METHODS: Data from the most recent Demographic and Health Surveys conducted between January 2010 and December 2021 were used in this study. A sample of 222,436 women aged 15-49 who gave birth in the last five years preceding each of the 33 country surveys in the region was used in the analysis. The association between individual and contextual-level factors and timing of antenatal care was assessed using multilevel binary logistic regression models. Stata software version 17 was used to perform statistical analysis taking into account the complex survey design. Multivariable results were presented using adjusted odds ratios at 95% confidence interval. RESULTS: The prevalence of delay in utilisation of first antenatal care service in sub-Saharan Africa was 61.1% [95% CI, 60.6, 61.5]. Mozambique had the highest prevalence of 85.5% [95% CI, [84.2, 86.7] while Liberia had the lowest prevalence at 27.8% [95% CI, [25.6, 30.1]. Women in the age groups 25-34 [aOR = 0.79, 95%CI = 0.76-0.82] or 35-49 [aOR = 0.66, 95%CI = 0.63-0.69], those with secondary or tertiary education [aOR = 0.97, 95%CI = 0.93-1.01] and [aOR = 0.71, 95%CI = 0.66-0.77], belonging to rich households [aOR = 0.91, 95%CI = 0.88-0.95], and those who experienced a pregnancy loss [aOR = 0.84, 95%CI = 0.81-0.87] were less likely to delay first ANC utilisation. Conversely, women living in rural areas [aOR = 1.18, 95%CI = 1.13-1.23], communities with a high proportion of women who experienced unwanted births [aOR = 1.08, 95%CI = 1.02-1.14] were more likely to delay first antenatal care visit. CONCLUSION: Both individual and community-level factors influenced women's delay in seeking antenatal care service in sub-Saharan Africa. Integrating community level factors when designing maternal health promotion interventions would be key to improve early utilisation of antenatal care services. There is need to strengthen maternal health promotion initiatives such as Community Health Worker Outreach, Mobile Messaging Campaigns, Male Involvement Initiatives and, School and Youth Friendly Health Programmes targeting women in marginalised communities such as rural settings.

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