Variations in initiation of first antenatal care among women of reproductive age in sub-Saharan Africa: an event history analysis approach

Despite global commitment and investment in improving maternal and child health, inequities in antenatal care (ANC) persist, especially in sub-Saharan Africa (SSA), but evidence on variations in ANC initiation at the global SSA level is limited. This study analyzed variations in ANC initiation and examined the associated factors among women of reproductive age in SSA. The data were drawn from the most recent Demographic and Health Survey conducted between 2007 and 2019 in thirty-six (36) countries. The analytical sample consisted of 123,134 women who had births in the two years preceding the survey and made at least one ANC visit during the index pregnancy. The association between the timing of ANC initiation and each independent variable was examined using the Pearson chi-square test. Kaplan-Meier survivor curves were generated to examine the extent to which ANC initiation occurred over time. Event history analysis models were specified using the discrete-time logit function to examine the unadjusted and adjusted effects of each covariate on ANC initiation. The results indicate that only 36.9% of the women initiated ANC within the first trimester during the index pregnancy and a little less than 1 in 10 (8.2%) did not initiate ANC until the third trimester. The country-specific results show wide variations in the initiation of ANC. For example, ANC initiation in the first month of pregnancy was least common in Niger (0.2%) and most common in Liberia (16.6%). The time to initiation of ANC visits at any time interval was greater for women in rural areas, those with no education or primary education and women who had no exposure to mass media. Among several covariates, increased involvement of females in household decision-making and household wealth status were found to be associated with ANC initiation. Women who participated in making three and four household decisions were more likely to initiate ANC (aOR = 1.02, p < 0.05 and 1.03, p < 0.01 respectively) compared to women who did not participate in household decision-making. Women who belonged to higher wealth status categories showed higher odds of ANC initiation compared to those in the poorest category. The findings of the present study indicate that early initiation and universal coverage of ANC among women of reproductive age in SSA continues to be a challenge. Policies that target female education up to at least the secondary level and interventions that improve the socioeconomic status of women can empower women to make decisions for themselves, which could increase the chances of early and timely ANC initiation.