Antenatal care dropout from the WHO 8 + antenatal care contacts model and associated factors among women who delivered at public health facilities in the Harari region, Eastern Ethiopia: a mixed-methods study

Abstract Background Antenatal care (ANC) is essential for improving maternal and newborn health and reducing maternal and child mortality. However, implementation evidence regarding ANC dropout and associated factors under the World Health Organization (WHO)-recommended eight-contact ANC model remains scarce in the study area. Therefore, this study aimed to evaluate implementation performance by determining the proportion of dropout from the WHO-recommended eight-contact ANC model and identifying factors associated with dropout among women who delivered at public health facilities in the Harari Region, Eastern Ethiopia. Methods A facility-based explanatory sequential mixed-methods design incorporating a quantitative cross-sectional survey and qualitative interviews was conducted from August 1 to October 26, 2024. A sample of 416 participants was included in the study using systematic sampling for the quantitative phase. A validated and pre-tested tool was employed for data collection through the Kobo Toolbox version 2024.2.4, and the data collected were analyzed using the Statistical Package for the Social Sciences (SPSS) Version 27. Bivariable and multivariable logistic regression were applied to identify factors associated with the dropout of antenatal care. A p-value < 0.05 was used to declare statistical significance, and an adjusted odds ratio (AOR) along with a 95% confidence interval (CI) was used to indicate association. Subsequently, participants were selected purposively for the qualitative phase until data saturation was reached. Key informant interviews with healthcare providers and heads of ANC units, and in-depth interviews with postpartum women were conducted. The findings were analyzed via manual thematic analysis using an inductive-deductive framework, ensuring trustworthiness through triangulation and consensus-based peer debriefing. Results The proportion of antenatal care dropouts was 78.4% [95% CI: 74.1–82.2]. Protective factors included maternal awareness of antenatal care (AOR = 0.36, 95% CI: 0.20–0.66) and maternal satisfaction with antenatal care (AOR = 0.28, 95% CI: 0.14–0.56). Risk factors included no previous bad obstetric history (BOH) (AOR = 3.6, 95% CI: 1.71–7.74), the absence of pregnancy danger signs (AOR = 2.8, 95% CI: 1.13–6.86), and a travel distance to the health facility of more than 2 h (AOR = 3.0, 95% CI: 1.05–9.09). These quantitative findings were supported by the qualitative findings, which identified infrastructure deficits, barriers to accessing quality ANC services, poor maternal health-seeking behavior, and cultural and personal barriers as key themes. Conclusion The proportion of antenatal care (ANC) dropout in the study area was high and was associated with geographic barriers, low maternal risk perception, and gaps in service quality. These multi-level barriers require comprehensive programmatic interventions, including decentralized ANC service delivery, improvements in the quality of care to enhance client satisfaction, the implementation of woman-held case notes to strengthen continuity of care, and risk-awareness counseling during routine ANC visits.