Patterns and Determinants of Utilization of Antenatal Care Services in Tanta, Egypt

Abstract

Background: Antenatal care (ANC) is the health care given to pregnant women, to monitor the pregnancy and reduce the risks for the mother and baby during pregnancy and at delivery. To be most effective, it is recommended that all pregnant women should have at least four antenatal checkups during pregnancy, started as early as possible in the first trimester. Aim: The study aimed to determine the utilization pattern of antenatal care facilities and to identify the determinants of utilization of the antenatal care services in family health centers in Tanta District. Methods: This cross-sectional study was conducted on 400 women attending four family health care facilities in Tanta city. The tools of the study were a predesigned, pretested structured questionnaire that inquire about socio-demographic data, obstetric history, medical history, the content of antenatal care program and utilization pattern, the attitude of the studied pregnant women towards ANC. Informed consent was obtained from each participant and data confidentiality was guaranteed. The data were collected through interviewing the selected women. Results: More than half of participants (51.3%) started the first visit of ANC in their first trimester. Most of them (62.3%) received adequate ANC. Mothers in rural areas utilized ANC more than urban ones. The age of pregnant women was significantly lower among those who received adequate ANC than those with inadequate ANC. A higher percentage of adequate ANC recipients were more educated however the difference was not statistically significant. There was a statistically significant difference between adequacy of ANC and family income. Gravidity, parity, and children’s numbers did not significantly differ according to the adequacy of ANC. Conclusion: Age of the women, residence, obstetric complication, the way to the health facility transportation cost, transportation comfortability, the number of work hours of health care providers were the significant predictors for the determination of utilization pattern of ANC services by the studied pregnant women.

Full text

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*Corresponding author
Journal of Advances in Medicine and Medical Research
34(15): 75-85, 2022; Article no.JAMMR.83174
ISSN: 2456-8899
(Past name: British Journal of Medicine and Medical Research, Past ISSN: 2231-0614,
NLM ID: 101570965)
Patterns and Determinants of Utilization of Antenatal
Care Services in Tanta, Egypt
Eman Abdulhamid Hamza a*, Shimaa M. Saied b, Asmaa Abd Elrheem Ataallah b
and Samir Abdelmageed Atlam b
a Primary Health Care Center at Konayeset Damsheet, Tanta, El Gharbia, Egypt.
b Public Health and Community Medicine, Faculty of Medicine, Tanta University, Tanta, Egypt.
Authors’ contributions
This work was carried out in collaboration among all authors. All authors read and approved the final
manuscript.
Article Information
DOI: 10.9734/JAMMR/2022/v34i1531405
Open Peer Review History:
This journal follows the Advanced Open Peer Review policy. Identity of the Reviewers, Editor(s) and additional Reviewers, peer
review comments, different versions of the manuscript, comments of the editors, etc are available here:
https://www.sdiarticle5.com/review-history/83174
Received 20 December 2021
Accepted 25 February 2022
Published 17 May 2022
ABSTRACT
Background: Antenatal care (ANC) is the health care given to pregnant women, to monitor the
pregnancy and reduce the risks for the mother and baby during pregnancy and at delivery. To be
most effective, it is recommended that all pregnant women should have at least four antenatal
checkups during pregnancy, started as early as possible in the first trimester.
Aim: The study aimed to determine the utilization pattern of antenatal care facilities and to identify
the determinants of utilization of the antenatal care services in family health centers in Tanta
District.
Methods: This cross-sectional study was conducted on 400 women attending four family health
care facilities in Tanta city. The tools of the study were a predesigned, pretested structured
questionnaire that inquire about socio-demographic data, obstetric history, medical history, the
content of antenatal care program and utilization pattern, the attitude of the studied pregnant
women towards ANC. Informed consent was obtained from each participant and data
confidentiality was guaranteed. The data were collected through interviewing the selected women.
Results: More than half of participants (51.3%) started the first visit of ANC in their first trimester.
Most of them (62.3%) received adequate ANC. Mothers in rural areas utilized ANC more than
urban ones. The age of pregnant women was significantly lower among those who received
adequate ANC than those with inadequate ANC. A higher percentage of adequate ANC recipients
Original Research Article

Hamza et al.; JAMMR, 34(15): 75-85, 2022; Article no.JAMMR.83174
76
were more educated however the difference was not statistically significant. There was a
statistically significant difference between adequacy of ANC and family income. Gravidity, parity,
and children’s numbers did not significantly differ according to the adequacy of ANC.
Conclusion: Age of the women, residence, obstetric complication, the way to the health facility
transportation cost, transportation comfortability, the number of work hours of health care providers
were the significant predictors for the determination of utilization pattern of ANC services by the
studied pregnant women.
Keywords: Utilization; antenatal care; determinants; pattern.
1. INTRODUCTION
Antenatal care (ANC) is the health care given to
pregnant women so that they have a safe
pregnancy and healthy babies. It includes routine
follow-up provided to all pregnant women at the
primary care level from screening to intensive life
support during pregnancy and up to delivery [1].
The common barriers for ANC include the
distance between homesteads and health
facilities, cost of services, availability of services,
knowledge on the availability of services,
husband’s approval and negative staff attitude
was found to correlate with the pattern of ANC
utilization [2].
Antenatal care from a skilled health professional
is essential to monitor the pregnancy and reduce
the risks for the mother and child during
pregnancy and at delivery. To be most effective,
it is recommended that all pregnant women
should have at least four antenatal checkups
during pregnancy, commencing as early as
possible in the first trimester [3].
In a systematic review in Egypt 2014 in the
samples from four studies, the proportion of
women receiving ANC ranged from 33.8% to
71.4% for any ANC and 42.5% to 73.2% for ANC
with a medical professional [4]. In Egypt, the
Demographic and Health Survey (DHS) 2014
demonstrated that about 83% of pregnant
women had at least four ANC visits [5]. The
maternal mortality ratio has been diminished in
Egypt from 120 in 1990 to 45 in 2013, a 62.5%
reduction. Though, national data hide large
discrepancies among rich and poor and urban
and rural residents [6].
Although the ANC follow-up visits have become
more frequent in Egypt than ever before.
Identifying the pattern of ANC utilization is not
well determined. Its identification can help
policymakers for the improvement of ANC health
services which in turn will improve the pregnancy
outcome, the mother, and the baby [7]. This was
the motive behind thinking of conducting this
study.
The study aimed to determine the utilization
pattern of antenatal care facilities and to identify
the determinants of utilization of the antenatal
care services in family health centers in Tanta
District.
2. PATIENTS AND METHODS
This cross-sectional study was carried out on
400 women who gave birth to a live baby in the
last 4-6 months attending the selected facilities
which were Saied Family Health Center,
Damsheet family health unit, Sibribai family
health unit, and Kafr Masoud family health unit,
with permanent residence in the study area when
they come for vaccination of their babies. The
study was carried out within six months via two
visits /week last 4-6 months.
2.1 Data Collection
The data were collected through interviewing the
selected women and filling up a specially
designed and pre-tested structured
questionnaire.
The questionnaire inquired about socio-
demographic data, medical history, past obstetric
history, the attitude of the studied woman for
ANC utilization, and determinants of ANC
utilization.
The study tools were tested for content and face
validity by a jury of four experts. The
questionnaire content validity index was 92%.
2.2 Sample Size Calculation
The sample size was calculated by using Epi-Info
software created by the Center for Disease
Prevention and Control (CDC), Atlanta, USA,
version 7.2., with confidence level =95% with
expected ANC utilization as 50% the least

Hamza et al.; JAMMR, 34(15): 75-85, 2022; Article no.JAMMR.83174
77
required sample size was 384 woman and
increased to 400 for more accuracy of the study.
A Pilot study was conducted on 40 pregnant
women who were not included in the statistical
analysis.
2.3 Statistical Analysis
The collected data were tabulated and analyzed
using SPSS software (Statistical Package for the
social sciences, version 24 SPSS Inc, Chicago
ILL, USA) Categorical data were presented as
numbers and percentages. The Chi-square test
(X2) was used to analyze categorical variables.
Quantitative data were expressed as mean ±
standard deviation, median, and range. Student
"t" test was used to analyze normally distributed
variables among 2 independent groups.
Regression analyses were used for the
prediction of variables. The accepted level of
significance in this work was stated at 0.05 (P
<0.05 was considered significant).
3. RESULTS
The present study found that 6.7% of the studied
urban pregnant women used PHC only for ANC
compared to (14.4%) of the rural participants.
While higher percentage (93.3%) of urban
pregnant women used both private & PHC
sectors compared to (84.8%) of rural ones with a
statically significant difference in between
(p=0.033). First trimester ANC visit was found
among (44.0%) of the urban women while
(56.0%) of them started at 2nd trimester
compared to (55.6%) and (44.4%) among rural
pregnant women respectively with statistically
significant difference (p=0.025). About two-thirds
of rural pregnant women had regular ANC
(66.4%,) compared to (51.3%) of urban ones with
statistically significant difference (p=0.003). More
than half of rural pregnant women (53.6%) had
five and more ANC visits compared to (31.3%) of
urban ones with statistically significant
differences (p=0.000). The majority of urban
pregnant women (98.0%) received vaccination at
the health facility compared to (90.8%) of urban
ones with statistically significant differences
(p=0.004) Table 1.
Regarding do you think that ANC is important, in
urban centers the percentage of women that
answered "every pregnancy" was higher than
those in rural centers (93.3% vs 84.4%,
respectively) while (13.6%) who answered
complicated pregnancy was present in rural
centers than urban ones (5.3%) and the
difference was statistically significant (p=0.027).
As regards acceptance that the best facility for
ANC, in rural centers the percentage of women
that answered both (PHC facility and private
clinic) was higher than those in urban centers
(72.4% vs 56.7%, respectively) and the
difference was statistically significant (p=0.000)
Table 2.
Table 1. Pattern of ANC utilization among urban and ruler studied pregnant women
Pattern of ANC utilization
The urban health
center
(n=150)
The rural
health center
(n=250)
Total
X2 test
P-value
NO
%
NO
%
Age among
the studied
pregnant
women
age < 20
4
2.7
28
11.2
32 (8%)
10.7512
0.004*
>20 - < 35
134
89.3
195
78
329 (82.2%)
age > 35
12
8.0
27
10.8
39 (9.7%)
Health
facility type
PHC only
10
6.7
36
14.4
46 (11.5%)
6.851
0.033*
Private clinic
0
0.0
2
0.8
2 (0.5%)
Both private &
PHC
140
93.3
212
84.8
352 (88%)
Time of
starting of
ANC
1st trimester
66
44.0
139
55.6
205 (51%)
5.049
0.025*
2nd trimester
84
56.0
111
44.4
195 (48.7%)
Regularity of
attendance
Regular
77
51.3
166
66.4
243 (60.7%)
8.925
0.030*
Irregular
73
48.7
84
33.6
157 (39.2%)
Frequency of
ANC visits
Less than four
68
45.3
83
33.2
151 (37.7%)
19.591
0.000*
Four
35
23.3
33
13.2
68 (17%)
Five and more
47
31.3
134
53.6
181 (45.2%)
Vaccination
No
3
2.0
23
9.2
26 (6.5%)
7.997
0.050*
Yes
147
98.0
227
90.8
374 (93.5%)

Hamza et al.; JAMMR, 34(15): 75-85, 2022; Article no.JAMMR.83174
78
Pattern of ANC utilization
The urban health
center
(n=150)
The rural
health center
(n=250)
Total
X2 test
P-value
NO
%
NO
%
Treatment
No
56
37.3
71
28.4
127 (31.7%)
3.453
0.630
Yes
94
62.7
179
71.6
273 (68.2%)
Sonar
No
64
42.7
95
38.0
159 (39.7%)
0.852
3560
Yes
86
57.3
155
62.0
241 (60.2%)
Data are presented as number (%)
Table 2. The relationship between adequacy of ANC visit and Socio-demographic characters of
studied woman
Scio-demographic data
Inadequate ANC
(n=151)
Adequate ANC
(n=249)
X2 test
P value
NO
%
NO
%
Residence
Urban
68
45.0
82
32.9
5.873
0.015*
Rural
83
55.0
167
67.1
Marital status
Married
150
99.3
249
100.0
1.633
0.199
Divorced
1
0.7
0
0.0
Education
Illiterate
5
3.3
5
2.0
4.836
0.305
Read &write
5
3.3
6
2.4
Primary-preparatory
4
2.6
13
5.2
Secondary
43
28.5
89
35.7
University & high
94
62.3
136
54.6
Occupation
Not working
87
57.6
167
67.1
6.773
0.148
manual work
2
1.3
1
0.4
Clerk
19
12.6
19
7.6
Professional
42
27.8
62
24.9
Others
1
0.7
0
0.0
Family
income
Not enough
2
1.3
0
0.0
8.081
0.018*
Enough & not saving
83
55.0
166
66.7
Enough & saving
66
43.7
83
33.3
Type of
family
Nuclear
127
84.1
197
79.1
1.521
0.218
Extended
24
15.9
52
20.9
Pregnant Women Age
28.35 ± 4.895
26.47 ± 4.977
0.000*
Children no
2.10 ± 1.005
2.00 ± 0.935
0.298
Family size
4.10 ± 0.998
4.03 ± 0.985
0.486
Husband Age
32.41 ± 5.453
31.41 ± 5.526
0.077
Data are presented as mean ± SD or number (%)
Pregnant women who received inadequate ANC
utilized private hospitals higher than those who
received adequate ANC (98.0% vs 82.3%,
respectively), and the difference was statistically
significant (p=0.000). Pregnant women who
received adequate ANC had obstetric
complications higher than those with inadequate
ANC (27.3% vs 18.5%, respectively), and the
difference was statistically significant (p=0.047)
Table 3.
Pregnant women who utilized both private and
PHC was higher among not adequate ANC
group than those who received adequate ANC
(98.0% vs 81.9%, respectively) while a higher
percentage (18.1%) who utilized PHC only was
present among recipients of adequate ANC than
not adequate ANC group (0.7%) and the
difference was statistically significant (p=0.000).
Among adequate ANC recipients, the percentage
of women whose ANC started in the 1st trimester
was higher than those who received inadequate
ANC (70.7% vs 19.2%, respectively) the
difference was statistically significant (p=0.000).
Concerning regularity of attendance, inadequate
ANC the percentage of women who had regular
visits was higher than those in the inadequate
ANC group (91.2% vs 10.6%, respectively) the
difference was statistically significant (p=0.000).

Hamza et al.; JAMMR, 34(15): 75-85, 2022; Article no.JAMMR.83174
79
Table 3. Relationship between adequacy of ANC visit and past obstetric history of studied
pregnant women
*Data are presented as number (%)
Among the "inadequate ANC" group, the
percentage of women who had less than four
visits was much higher than those in the
“adequate ANC” group (100.0% vs 0.4%,
respectively) while the majority (72.3%) of
adequate ANC and none of the “inadequate
ANC” group had five and more visits, and the
difference was statistically significant (p=0.000).
Among participants who received adequate ANC;
the percentage of women who received
treatment was much higher than those who
received treatment in the "not adequate ANC"
group (92.0% vs 29.1%, respectively), and the
difference was statistically significant (p=0.000)
Table 4.
The residence, obstetric complications, the way
to go to the health facility, transportation cost,
transportation comfortability, age and the number
of work hours of health care providers were the
significant predictors for the determination of
adequate utilization of antenatal care services
(p=0.015, 0.047,0.000,0.032,0.000,0.000,0.029),
respectively Table 5.
Past obstetric history
Not adequate ANC
(n= 151)
Adequate ANC
(n=249)
X2 test
P value
No.
%
No.
%
Gravidity
1
90
59.6
166
66.7
8.492
0.131
2 - < 5
57
37.7
72
28.9
>5
4
2.7
11
4.4
Parity
1
98
64.9
180
72.3
4.027
0.402
2 - < 5
51
33.8
67
26.9
>5
2
1.3
2
0.8
Place of the last
delivery
At home or on the
way to a health
facility
0
0.0
1
0.4
3.026
0.388
Health center or
dispensary
1
0.7
3
1.2
Hospital
146
96.7
243
97.6
Private clinic
4
2.6
2
0.8
Hospital type
Private
148
98.0
205
82.3
22.298
0.000*
Governmental
3
2.0
44
17.7
Type of delivery in
the last delivery
Normal vaginal
Delivery
29
19.2
41
24.5
1.510
0.219
Cesarean section
122
80.8
188
75.5
Obstetric
complications
Yes
28
18.5
68
27.3
3.960
0.047*
Abortion
NO
137
90.7
214
85.9
2.002
0.157
YES
14
9.3
35
14.1
Low Birth weight
NO
148
98.0
243
97.6
0.076
0.782
YES
3
2.0
6
2.4
Hyper Emesis
gravidarum
NO
139
92.1
222
89.2
0.896
0.344
YES
12
7.9
27
10.8
Eclampsia
NO
147
97.4
240
96.4
0.279
0.598
YES
4
2.6
9
3.6
Gestational
Diabetes
NO
151
100.0
246
98.8
1.833
0.176
YES
0
0.0
3
1.2
Anemia
NO
141
93.4
224
90.0
1.375
0.241
YES
10
6.6
52
10.0
Other complication
NO
150
99.3
249
100.0
1.653
0.199
YES
1
0.7
0
0.0

Hamza et al.; JAMMR, 34(15): 75-85, 2022; Article no.JAMMR.83174
80
Table 4. Relationship between adequacy of ANC visits and Pattern of ANC utilization in the last
pregnancy
Pattern of ANC utilization
Not adequate ANC
(n= 151)
Adequate ANC
(n=249)
X2 test
P value
NO
%
NO
%
Health facilities
utilized for
ANC
PHC only
1
0.7
45
18.1
30.837
0.000*
Private clinic
2
1.3
0
0.0
Both private & PHC
148
98.0
204
81.9
Time of
starting of
ANC
1st trimester
29
19.2
176
70.7
99.697
0.000*
2nd trimester
122
80.8
73
29.3
Regularity of
attendance
Regular
16
10.6
227
91.2
255.895
0.000*
Irregular
135
89.4
22
8.8
Frequency of
ANC visits
Less than four
151
100.0
1
0.4
395.773
0.000*
Four
0
0.0
68
27.3
Five and more
0
0.0
180
72.3
Vaccination
No
11
7.3
15
6.0
0.246
0.620
Yes
140
92.7
234
94.0
Treatment
No
107
70.9
20
8.0
171.233
0.000*
Yes
44
29.1
229
92.0
Sonar
No
107
70.9
52
20.9
98.032
0.000*
Yes
44
29.1
197
79.1
*Data are presented as number (%)
Table 5. Logistic regression analysis of the determinants of utilization of antenatal care among
participants
Variables
Categories
Not
adequate
ANC
Adequate
ANC
AOR
P-
value
95.% C.I. for
AOR
Independent
Variables
Lower
Upper
Residence
Urban
68
82
1.67
0.015
1.1
2.53
Rural
83
167
Educational level
Illiterate
5
5
1.66
0.632
0.48
5.87
Educated
146
244
Occupation
Not working
87
167
0.67
0.072
0.44
1.01
Working
64
82
Family income
Not enough
2
0
Enough
149
249
Type of family
Nuclear
127
197
1.4
0.218
0.82
2.38
Extended
24
52
Gravidity
Gravidity < 2
90
166
0.74
0.187
0.49
1.12
Gravity >5
61
83
Parity
Parity <2
98
180
0.71
0.148
0.46
1.09
Parity >5
53
69
Obstetric
complications
Yes
28
68
0.61
0.047
0.37
1
No
123
181
Presence of health
care facility in the
place of living
Yes
149
248
0.30
0.66
0.02
3.3
No
2
1
The way to go to
the health facility
Walking
13
162
0.05
0.000
0.03
0.1
Transportation
137
88
Transportation
Availability
Available
151
246
Not available
0
3
Transportation cost
Expensive
15
2
5.29
0.032
1.18
23.72

Hamza et al.; JAMMR, 34(15): 75-85, 2022; Article no.JAMMR.83174
81
Variables
Categories
Not
adequate
ANC
Adequate
ANC
AOR
P-
value
95.% C.I. for
AOR
Independent
Variables
Lower
Upper
Not expensive
122
86
Transportation
Comfort ability
Comfortable
50
11
3.93
0.000
1.91
8.08
Not
comfortable
89
77
Service provider
dealing
Friendly
147
246
0.8
0.768
0.18
3.61
Not friendly at
all
3
4
Privacy
There is
privacy during
the medical
examination
148
249
There is no
privacy
3
0
Age
0.905
0.000
0.859
0.954
No. of children
0.701
0.437
0.287
1.715
Time walking to ANC clinic
0.870
0.514
0.573
1.321
Waiting time
1.164
0.339
0.852
1.590
Number of work hours of health care
provider
1.319
0.029
1.029
1.690
*Statistically significant
4. DISCUSSION
According to Egypt Demographic Health Survey
(EDHS 2014), the rate of utilization of ANC has
increased from 57% in 1988 to >90% in 2014 to
meet the Millennium Development Goals (MDG)
in the area of maternal health [8].
This study showed that mothers in rural areas
utilized ANC more than urban residents. This
finding agreed with Tarekegn et al. [9] who
revealed that residing in the rural area made
attending at least four ANC visits more likely than
residing in the urban area. In contrast, utilizing
ANC had been wider among urban than rural
women in Egypt over the past years, and this
was evident in all surveys done in Egypt
throughout EDHS 2000, 2004, 2008, and 2014
[10]. Also, a recent study from Zagazig District,
Egypt, showed that ANC utilization was higher in
urban than rural populations and that large
difference was linked to financial accessibility
(i.e. Tickets fees, drug price, lab investigation
fees, etc.) [11].
The current study showed that the age of
pregnant women was significantly lower among
the adequate ANC group than inadequate ANC
group. This comes in agreement with Yeneneh et
al. [12] who found Nigerian women aged less
than 20 years were more likely to use ANC than
their older counterparts.
This was in similarity with Wassif et al. [13] who
illustrated that women aged from 19 to less than
39 years were more likely to utilize ANC if
compared to those aging ≥ 39 Ys. This was in
accordance with that reported by Hassan et al.
[14] who found that mothers with adequate ANC
were significantly different from those without
regarding their age. Older women, on the other
hand, tend to believe that maternal health care
services are not necessarily due to their
experiences from previous pregnancies. Also,
Pandey et al.[15] found that the lower age group
were more likely to have ANC services more
than four times than the women in the higher age
group and younger maternal age was a predictor
of early ANC initiation in the Kuuire et al. study
[16].
This study showed that a higher percentage of
adequate ANC was reported among highly
educated women than low educated ones
however the difference was not statistically
significant.
This agreed with Ali et al. [17] who found the
level of education of pregnant women was linked
to high ANC utilization. A high education level is
associated with high awareness about the
provided ANC services, resulting in adequate
utilization. This finding is consistent with a study
in Egypt which demonstrated that the probability

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82
of using ANC services was strongly influenced by
the education of pregnant women and their
ANC knowledge [18]. Further, El-Zanaty and
Way [19] showed that women’s education was a
predictor for utilizing ANC and its regularity. The
educational level within the household is one of
the most powerful predictors of ANC
utilization. Also, Dansou et al. [20] reported that
maternal education was a predictor of the
frequency of ANC. Higher attending at least four
ANC visits were more in women who had higher
educational levels. Banke-Thomas et al. [21]
and Mulinge et al. [22] reported that
women’s education is the most significant
predictor for the utilization of maternal health
services with women having a secondary and
above level of education more likely to seek
maternity care than those who had no
education.
This study showed that there was a statistically
significant difference between adequacy of ANC
and family income as it was enough with
adequate ANC. These results are supported by a
survey conducted in rural areas in Upper Egypt
(2010–11) which found that higher family income
level was associated with higher receiving ANC
[4]. Further, the results of the studies done in the
Philippines found that the higher family income
the higher the utilization of ANC services Wong
et al. [23] Nisar et al. [24] demonstrated that
income affects ANC services utilization; women
of higher income were two times more likely to
utilize ANC as compared to the lower-income
ones.
The current study found no statistically significant
association between adequacy of ANC and
occupation. This agreed with a study from
Nigeria that reported a insignificant association
between women’s occupation and ANC
utilization [25]. Also, Ali et al. [17] revealed no
association was observed between women's
occupation and the utilization of ANC services.
However, these results did not match results
reported in EDHS (2014) which showed higher
rates of ever utilization and regular utilization of
ANC among working mothers (94%) than non-
workers (89.5%) [26]. Some studies referred to
women’s occupation as an empowering factor
that raises her income and consequently
increases her ANC utilization [27,28]. The
difference between results may be explained by
the nature of the mother’s work. If the work is for
long times and with low wages, mothers will find
no time to go to ANC with their limited low
household income.
This study found higher percentages of adequate
ANC among women with low gravidity, low parity
than high gravidity, parity but with no significant
difference. This agreed with Onasoga et al. [25]
who suggested that parity has no role in the
utilization of ANC. In contradiction with El-Zanaty
and Way [19] who showed that with increasing
birth order of the last pregnancy, women were
more likely to be reluctant to attend ANC service.
High parity was perceived as a barrier to ANC
utilization in some studies mothers with high
parity were more likely to use ANC than those
with low parity [27,28]. Women with high parity or
large household sizes had at least four ANC
contacts in the course of pregnancy [29].
Our study found that concerning obstetric
complications, among pregnant women who
received adequate ANC; the percentage of
women that had obstetric complications was
higher than those with inadequate ANC. This is
to some extent similar to the results of Mulinge et
al. [22] who found women who had obstetric
complications had higher adequate ANC
utilization.
This study showed that there was a statistically
significant association between adequacy of
ANC and utilized governmental hospitals as it
was higher in women with adequate ANC. The
finding is supported by findings in a study in
Tanzania Adjiwanou et al. [30] and points to a
statistically significant and positive effect of
women’s attendance at governmental healthcare
facilities on the adequacy of ANC. This disagreed
with Bayou et al. [31] they revealed that clients of
private healthcare facilities were more likely to
receive overall adequate antenatal care
compared to those clients of public healthcare
facilities.
This study shows that the most common
determinants of utilization of antenatal care
among participants were (Maternal age, obstetric
complication, the way to go to health facility,
transportation cost, transportation Comfortability,
rural residence, education, and working hours of
health care providers). Similarly, Ye et al. [32]
found that significant predictors of ANC
utilization) were: level of education (OR = 6.8,
95% CI = 2.7-16.8), income (OR = 2.6, 95% CI =
1.2-5.7), distance (OR = 2.9, 95% CI = 1.1-7.6),
availability of public transportation (OR = 4.5,
95% CI = 2.0-10.4), cost of transportation (OR =
2.5, 95% CI = 1.1-5.7), and cost of service (OR =
4.6, 95% CI = 2.2-9.6). Education has been
reported as one of the key social determinants of

Hamza et al.; JAMMR, 34(15): 75-85, 2022; Article no.JAMMR.83174
83
health and healthcare and women with low levels
of education usually have less knowledge about
ANC and poor access to the service [33].
A facility-based study in Addis Ababa has shown
that women with planned pregnancies were more
likely to book ANC early Tariku et al. [34] as
compared to those with unplanned pregnancies.
Other studies also show that unintended
pregnancies are associated with delayed
initiation of antenatal care [35,36]. An urban-
based study shows that women who had
unplanned pregnancies were less likely to attend
ANC services compared to those who had
planned their pregnancies by themselves or
jointly with their partners [37].
This study showed that almost all women had the
desire to use ANC services in future pregnancies
as the majority of them were aware of the
importance of ANC in urban and rural centers
(93.3- 84.4%) respectively. This agreed with
Wassif et al. [13] who found there was no
statistically significant difference between the
urban health center and the rural health center
regarding the proper frequency of ANC and use
of ANC again in future pregnancies.
5. CONCLUSION
The present study concluded that the age,
residence, obstetric complication, the way to the
health facility transportation cost, transportation
comfortability, the number of work hours of
health care providers were the significant
predictors for the determination of utilization
pattern of ANC services by the studied pregnant
women.
DISCLAIMER
The products used for this research are
commonly and predominantly used products in
our area of research and country. There is
absolutely no conflict of interest between the
authors and producers of the products because
we do not intend to use these products as an
avenue for any litigation but for the advancement
of knowledge. Also, the research was not funded
by the producing company rather it was funded
by the personal efforts of the authors.
ETHICAL APPROVAL
The study protocol was approved by the Ethical
Committee of the faculty of Medicine at Tanta
University in November 2018 (32705/11/18).
CONSENT
Informed consent was obtained from each
participant and data confidentiality was
guaranteed.
COMPETING INTERESTS
Authors have declared that no competing
interests exist.
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