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\title{Magnitude of Late ANC Booking and its Determinant Factors among Pregnant Women Attended Public Health Centers and Private Clinic in Artumafursi District, Amhara Regional State, Special Zone of Oromia, Ethiopia 2017}
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             \author[1]{Ayana Chimdessa  Fite}

             \author[2]{Nathan  Estifanos}

             \author[3]{Jote  Markos}

             \affil[1]{  Addis Ababa, Ethiopia}

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\date{\small \em Received: 8 December 2018 Accepted: 3 January 2019 Published: 15 January 2019}

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\begin{abstract}
        


Background: Pregnancy period is the most crucial time to determine the healthy life of a woman and whole families. It is a vital period to promote healthy behaviors and parenting skills.In Ethiopia only 34 % of women received antenatal care service at least once for their last birth. Only 11% of women had taken their first antenatal care (ANC) visit before the second trimester.Methods: Institutional based cross sectional survey was conducted from May 1-30, 2017. All pregnant women who had attended to two public health centers and one private clinic for ANC follow up were recruited by simple random sampling method. Particularly, lottery method was used to recruit participants in to the study. Data were collected using pre-tested interviewer administered questionnaire. Logistic regression was used to analyze the data by using IBM SPSS statics version 20.0.

\end{abstract}


\keywords{magnitude, antenatal care, determinant factors, pregnant women, ethiopia.}

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\let\tabcellsep& 	 	 		 \par
time to determine the healthy life of a woman and whole families. It is a vital period to promote healthy behaviors and parenting skills.\par
In Ethiopia only 34 \% of women received antenatal care service at least once for their last birth. Only 11\% of women had taken their first antenatal care (ANC) visit before the second trimester.\par
Methods: Institutional based cross sectional survey was conducted from May 1-30, 2017. All pregnant women who had attended to two public health centers and one private clinic for ANC follow up were recruited by simple random sampling method. Particularly, lottery method was used to recruit participants in to the study. Data were collected using pretested interviewer administered questionnaire. Logistic regression was used to analyze the data by using IBM SPSS statics version 20.0.\par
Results: The study has explored the magnitude and determinant factors of late ANC booking of participants in the district. Magnitude of late ANC booking among the study participants' was massive. The overall prevalence of late ANC booking time was 252 (60.9\%). Having diploma and above educational status (AOR 1.50, (95 \% CI, 2.10, 1.51)), being employed (AOR 2.20, (95\% CI, 2.73-1.01)) previous history of abortion (AOR 1.56 (95\% CI, 2.09-1.73) and urban resident (AOR 2.10 (95\% CI, 3.25-1.87)) were identified as major contributing factors for early initiation of ANC booking. Whereas, unintended pregnancy (AOR 0.45 (95\% CI, 0.34, 0.21)) and having poor knowledge of ANC services (AOR 0.51 (95\% CI, 0.71-0.21)) were contribute for late ANC booking.\par
Conclusions: The overall prevalence of late ANC booking time was 252 (60.9\%). Higher educational background, being employed, previous history of abortion and urban residents were identified as major contributing factors for seeking behavior of early ANC booking. Unintended pregnancy andI.\par
Back Ground regnancy period is the most crucial time to determine the healthy life of a woman and whole families. It is a vital period to promote healthy behaviors and parenting skills \hyperref[b0]{[1]}. Utilization of health services are complex behavioral phenomenon. Empirical studies of preventive and curative services found that the use of antenatal care (ANC) services are directly related to availability, accessibility, quality, cost of services, social structure, health beliefs and personal characteristics of clients \hyperref[b0]{[1,}\hyperref[b2]{3]}. Antenatal care refers to education, counseling, screening and treatment throughout pregnancy period. Promoting the well-being and monitoring the health status of families is another activities need attention during the period of pregnancy \hyperref[b0]{[1,}\hyperref[b1]{2]}.\par
Attaining to world health organization (WHO) recommendations on the new model of ANC goal-oriented implementation in developing countries is mandatory. Within this new strategy, WHO recommends four antenatal care visits for low risk pregnancies and prescribes evidence-based practices for every visit and classify them in to basic components and special care of ANC depending on their previous obstetric history. World health organization recommends that all pregnant women should receive prenatal care at early stage of their pregnancy to prevent any pregnancy related complications \hyperref[b0]{[1,}\hyperref[b2]{3]}. In addition to this, pregnant women should be screened for HIV and syphilis infections for the sake of reducing mother-to-child transmission \hyperref[b1]{[2,}\hyperref[b2]{3]}.\par
Different studies pointed that a timely initiation of ANC has Varity of benefits creating strong relationship among families, provision of individualized health promotion information, early problem identification, examination and management of maternal conditions that may later become life-threatening conditions. This time is also ideal to prepare mothers to plan for birth and care of a newborn. Those women who failed to initiate ANC at early stage may encounter negative impact of pregnancy related health conditions and may face long life health problems \hyperref[b0]{[1,}\hyperref[b1]{2,}\hyperref[b3]{4]} .\par
Even though pregnancy related mortality is almost always preventable, yet worldwide, more than half a million women die annually. Studies shows that about 1,600 women die every day due to pregnancy related complications. Out of these about 90-95\% is accounted by sub-Saharan countries \hyperref[b4]{[5]}.\par
Maternal mortality is one of the major challenges that developing countries are facing today. Even though indisputable actions have been taken to reduce maternal mortality, it is still significantly high in developing world. Recent studies showed that in average 1:16 life risk mothers die of pregnancy and childbirth related problems in developing countries compared with that of developed countries which is 1:2800. Out of 520,000 estimated deaths each year, about 99\% of these occur in developing world. About 300 million women in developing countries suffer from long term complications related to pregnancy and childbirth \hyperref[b0]{[1,}\hyperref[b4]{5]} Despite of charge free ANC services in public health institutions of Ethiopia, there is a very low magnitude of on time ANC visit and service provision as well. The 2014 Ethiopian demographic health survey (EDHS) report indicated that about four out of every ten Ethiopian women (43\%) had not received any antenatal care service for their last birth within the last five years prior to the survey \hyperref[b3]{[4]}. In Ethiopia the prevalence of maternal and infant mortality and morbidity are amongst the highest in the world. Thus, there are 676 maternal deaths for every 100,000 live births and infant mortality rate is 59 per 1,000 live births \hyperref[b3]{[4]}. Different studies reported that women who had never received ANC service may face lifelong health problems and even death. Despite the progress in antenatal care coverage, many countries of sub-Saharan Africa and South/ Southeast Asia have unsatisfactory results of registries for WHO recommended Focused Ante-Natal Care (FANC) visits. Additionally, in sub-Saharan Africa women tends to start their first antenatal care visit either in the second or third trimester \hyperref[b0]{[1,}\hyperref[b2]{3]}.\par
According to EDHS 2014, only 34\% of women received antenatal care service at least once for their last birth. Only 11\% of women had taken their first ANC visit before the second trimester of their last pregnancy \hyperref[b3]{[4]}. Therefore, it was the purpose of this study to investigate the magnitude of ANC service coverage and factors associated with late attendance to ANC services in ArtumaFursi district, Ethiopia. The results of this study provide direction for designing targeted ANC service intervention and timely initiation of reproductive age women for ANC follow up. 
\section[{II.}]{II.} 
\section[{Methods and Materials}]{Methods and Materials}\par
Institutional based cross sectional survey was conducted from May 1-30, 2017. All pregnant women who had attended to two public health centers and one private clinic for ANC follow up were recruited by simple random sampling method. Particularly, lottery method was used to recruit participants in to the study. All Pregnant women who had attended ANC service were included. Pregnant women who were critical ill during data collection period were excluded from the study. Sample size was calculated by using p=50\% to obtain maximum sample size, CI 95\%, margin of error d=0.05 and summation of 10\% considerable non-response rate. Totally, 424 participants had taken part in the study. Late booked mothers for ANC services were considered as an outcome variable for this study. Initial time of visit for ANC service was tested with independent variables. Late ANC booked mothers referred to those who had booked for the service after 12 weeks of their gestational age.\par
Partially adopted structured interview-based questionnaire was used for data collection. The questionnaire was prepared in English and then translated to local language (Afan Oromo) by formal translator and re-translated to English in order to check for its consistency. Finally, the local language version was used for data collection. Before actual data collection, the questionnaire was pre-tested on 5\% of the sample size at Kombolcha health center. Based on the pre-test results, some amendments were done. Data was collected by 6 B.Sc. Nurses, Midwifes and two trained supervisors. All data collectors and supervisors had given two days of intensive training on the objectives, procedures and content of the study.\par
The collected data was entered in to Epi Info 7 and exported to IBM SPSS statics version 20.0 to clean and analyze data. Frequencies, proportions, mean and summary statics were used to describe parameters under investigations. Association between outcome variable and independent variables were assessed and presented using odd ratio and confidence intervals. Multivariate logistic regression is done to control for possible confounders.\par
Ethical clearance was obtained from Wollo University Institutional Review Board (IRB) and given to all responsible bodies abiding with a formal letter. Written informed consent was obtained from each study participants. Participation in the study was voluntary and collected information has been kept confidential. 
\section[{III.}]{III.} 
\section[{Results}]{Results}\par
A total of 424 participants were involved in the study. Data from414 (97.7\%) were included in the analysis. Information from ten respondents was excluded from analysis for their incompleteness. 
\section[{a) Socio-demographic characteristics}]{a) Socio-demographic characteristics}\par
As indicated in Table \hyperref[tab_0]{1}, the mean age of respondents was 23.43 ranging from 18 49 years old.\par
Of the total, 403 (97.3\%) of participants were from Oromo ethnic group. Majority 248 (59.9\%) and 160 (38.6\%) of respondents were Muslim and Christian followers respectively. About 264 (63.8\%) of respondents were married. More than half 254 (61.4\%) of participants were housewives. About 149 (36\%) had never been to school and 265 (64 \%) of participants were living in the rural parts of the district.   
\section[{Discussion}]{Discussion}\par
This study provides prevalence and identify determinant factors for late ANC booking of pregnant mothers in ArtumaFursi district, Ethiopia.\par
The findings revealed that late ANC booking among the study units was massive. Out of the total, majority 252 (60.9\%) booked late for antenatal care. However, previous studies conducted in Addis Ababa and Zambia showed that about 59.8\% and 72\% mothers booked early for ANC services respectively \hyperref[b5]{[6,}\hyperref[b6]{7]}. This variation might be due to the residence of study participants since; most of the mothers in this study were rural residents. The other possible explanation for this huge difference might be the deployment of health care professionals because; most of health cadres prefer to work in urban areas.\par
In this study, educational and occupational status of the participants was the most determinant factors influencing ANC booking time. Both employed and highly educated women had booked earlier than their counter parts. Whereas, those who had never been to school and housewives had booked late for ANC accounting 92\% and 94.9\% respectively. This finding is similar with studies conducted in East Wollega, Bangladesh Nigeria and Tanzania \hyperref[b4]{[5,}\hyperref[b7]{8,}\hyperref[b8]{9,}\hyperref[b9]{10,}\hyperref[b10]{11]}.\par
About 73.9\% of uniparous mothers booked lately for antennal care compared to multiparous ones. This finding is similar with studies conducted in other parts of Ethiopia, Tanzania and India \hyperref[b6]{[7,}\hyperref[b8]{9,}\hyperref[b11]{12,}\hyperref[b12]{13,}\hyperref[b13]{14]}.\par
Previous obstetrichi story of mothers also determine the time of ANC service seeking. Among women who had history of abortion, majority 73.9\% of them visited health institutions for ANC service earlier compared to their counter parts. The finding is concurrent with studies conducted in Ethiopia and Zimbabwe \hyperref[b11]{[12,}\hyperref[b14]{15,}\hyperref[b15]{16 ]}.\par
Unintended pregnancy and lack of good knowledge about antenatal care were other factors to determine the time of ANC service seeking behavior. Those mothers who had had unintended pregnancy (88.7\%) and had poor knowledge (80.4\%) were too late for initiation of ANC service booking. These findings are parallel with similar studies conducted in Uganda, Malawi Zambia and other parts of Ethiopia \hyperref[b5]{[6,}\hyperref[b8]{9,}\hyperref[b16]{17,}\hyperref[b17]{18}  
\section[{Conclusion}]{Conclusion}\par
The magnitude of late booking for ANC service was huge among study participants. Of the total, majority 252 (60.9\%) of women were lately booked for ANC services. Additionally, low educational status, being a house wife, rural residency, having poor knowledge of ANC services and unintended pregnancy were pertinent factors for late antenatal care booking. Generally, early ANC service seeking behavior of study participants is very low hence, it needs attention.\begin{figure}[htbp]
\noindent\textbf{1} \par 
\begin{longtable}{P{0.85\textwidth}}
Ethiopia, 2017 (n=414)\end{longtable} \par
 
\caption{\label{tab_0}Table 1 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{P{0.85\textwidth}}
Ethiopia, 2017 (n = 414)\end{longtable} \par
  {\small\itshape [Note: ( )]} 
\caption{\label{tab_1}Table 2 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{2} \par 
\begin{longtable}{}
\end{longtable} \par
 
\caption{\label{tab_2}Table 2 :}\end{figure}
 \begin{figure}[htbp]
\noindent\textbf{} \par 
\begin{longtable}{P{0.2168016194331984\textwidth}P{0.1837651821862348\textwidth}P{0.1431578947368421\textwidth}P{0.1651821862348178\textwidth}P{0.1383400809716599\textwidth}P{0.0027530364372469634\textwidth}}
V.\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
Variables\tabcellsep \multicolumn{2}{l}{Late book for ANC services Yes: n (\%) No: n (\%)}\tabcellsep COR (95.5\% CI)\tabcellsep \multicolumn{2}{l}{P-value AOR (95\% CI) P-value}\\
Marital status\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
Divorced/window/separated\tabcellsep 19 (73.1\%)\tabcellsep 7 (26.9\%)\tabcellsep 4.67 (1.96-11.52)\tabcellsep 0.001\tabcellsep \\
Unmarried\tabcellsep 103 (83.1\%)\tabcellsep 21 (16.9\%)\tabcellsep 1.02 (.65-1.58)\tabcellsep \tabcellsep \\
Married\tabcellsep 130 (49.2\%)\tabcellsep 134 (50.8\%)\tabcellsep 1\tabcellsep \tabcellsep \\
Educational status\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
Diploma and above\tabcellsep 32 (32.7\%)\tabcellsep 66 (67.3\%)\tabcellsep 2.64 (3.33-2.22)\tabcellsep \multicolumn{2}{l}{0.002 1.50 (2.10-1.51) 0.001}\\
Secondary\tabcellsep 59 (73.8\%)\tabcellsep 21 (26.2\%)\tabcellsep .33 (.18-.611)\tabcellsep \tabcellsep \\
Primary\tabcellsep 66 (75.9\%)\tabcellsep 21 (24.1\%)\tabcellsep 1.11 (.59-2.08)\tabcellsep \tabcellsep \\
Never been to school\tabcellsep 137 (92\%)\tabcellsep 12 (8\%)\tabcellsep 2.41 (.20-.84)\tabcellsep \tabcellsep \\
Occupation\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
House wife\tabcellsep 241 (94.9 \%)\tabcellsep 13 (5.1\%)\tabcellsep 1\tabcellsep \tabcellsep \\
Employed\tabcellsep 11 (6.9 \%)\tabcellsep 149 (93.1\%)\tabcellsep 3.04 (4.58-2.02)\tabcellsep 0.0001 2.20 (2.73-1.01)\tabcellsep 0.02\\
Residency\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
Rural\tabcellsep 198\tabcellsep 67\tabcellsep \tabcellsep \tabcellsep \\
Urban\tabcellsep 54\tabcellsep 95\tabcellsep 6,51 (8.12-4.34)\tabcellsep \multicolumn{2}{l}{0.003 4.53 (7.31-2.57) 0.001}\\
Unintended pregnancy\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
Yes\tabcellsep 86 (88.7\%)\tabcellsep 11 (11.3\%)\tabcellsep 0.61 (5.10-2.95)\tabcellsep \multicolumn{2}{l}{0.002 0.45 (0.34-0.21) 0.001}\\
No\tabcellsep 151 (47.6\%)\tabcellsep 166 (52.4\%)\tabcellsep 1\tabcellsep \tabcellsep \\
Previous history of Abortion\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
Yes\tabcellsep 42 (26.1\%)\tabcellsep 119 (73.9\%)\tabcellsep 3.12 (4.71-3.01)\tabcellsep \multicolumn{2}{l}{0.002 1.56 (2.09-1.73) 0.013}\\
No\tabcellsep 210 (83 \%)\tabcellsep 43 (17\%)\tabcellsep 1\tabcellsep \tabcellsep \\
Number of ANC follow up\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
One\tabcellsep 101 (55.2\%)\tabcellsep 82 (44.8\%)\tabcellsep 4.17 (5.12-2.05)\tabcellsep 0.04\tabcellsep \\
Two\tabcellsep 83 (64.8\%)\tabcellsep 45 (35.2\%)\tabcellsep 2.89 (8.03-4.09)\tabcellsep \tabcellsep \\
Three\tabcellsep 49 (62\%)\tabcellsep 30 (38\%)\tabcellsep 5.43 (4.74-1.23)\tabcellsep \tabcellsep \\
More than three\tabcellsep 19 (79.2\%)\tabcellsep 5 (20.8\%)\tabcellsep 1\tabcellsep \tabcellsep \\
Knowledge of ANC\tabcellsep \tabcellsep \tabcellsep \tabcellsep \tabcellsep \\
Good\tabcellsep 18 (14.6\%)\tabcellsep 105 (85.4\%)\tabcellsep 1\tabcellsep \tabcellsep \\
Poor\tabcellsep 234 (80.4\%)\tabcellsep 57 (19.6\%)\tabcellsep 0.75 (0.91-0.23)\tabcellsep \multicolumn{2}{l}{0.003 0.51 (0.71-0.21) 0.002}\end{longtable} \par
 
\caption{\label{tab_3}}\end{figure}
 			\footnote{© 2019 Global Journals} 		 		\backmatter   			 
\subsection[{Acknowledgements}]{Acknowledgements}\par
The authors would like to heart fully thank the study participants who dedicated to participate in the study and contribute their valuable responses for this study. 			  			 \par
Information education and communication (IEC) about on time booking for ANC services targeting women and their partners in the district should be under taken through multi-cultural, religious leadersand community involvement perspectives. It's better to consider integrating health education of ANC with other health care services holistically. Integrating health education with other services, information dissemination about advantage of early ANC visit should be implemented. Simultaneously, establishing pregnant mothers' group discussion forum about ANC, creating and using Health Development Army (HAD) with high participation of reproductive age women "for the community by the community" must be considered by both governmental and non-governmental organizations co-operatively.  
\subsection[{Limitation of the study:}]{Limitation of the study:} 
\subsection[{Availability of data and materials}]{Availability of data and materials}\par
The materials and data shall be obtained upon request of corresponding author. 
\subsection[{Competing interest}]{Competing interest}\par
The authors declared that there is no any competing interest. 
\subsection[{Funding}]{Funding}\par
This research article has not been funded from any source of organization. 
\subsection[{Authors' contribution}]{Authors' contribution}\par
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