Background: Antenatal care refers to care provided by skilled healthcare professionals to pregnant mothers to ensure optimal health for both the mother and baby throughout the pregnancy period. It promotes health promotion, risk identification, prevention, and management of pregnancy-related illnesses to avoid health problems in both the fetus and mother. Quality antenatal care consists of delivering essential services to every pregnant woman and her fetus, while also providing more specialized care for those who need it.

Methods: A facility-based cross-sectional study was conducted from November 1 to November 30, 2024, involving 406 pregnant women attending antenatal care at a public health facility located in Dilla Town. Data were collected using a structured questionnaire and observational checklist. Study participants were selected using a systematic random sampling method. Trained data collectors conducted the exit interviews. The collected data were entered into EPI Data version 3.1 and subsequently analyzed using SPSS version 26. Bivariable and multivariable logistic regression analyses were performed. The results were presented as adjusted odds ratios with 95% confidence intervals. A p-value of less than 0.05 was used to declare statistical significance in all inferential analyses conducted in this study.

Result: This study indicated that about 52% (95% CI: (51.5%–52.5%)) of pregnant mothers had received quality ANC services. The frequency of ANC visits and satisfaction with ANC services were significantly associated with the quality of ANC services provided. Pregnant women who attended a second visit or more had 2.2 times greater odds of receiving good-quality ANC compared to those who only attended their first ANC visit (AOR = 2.24, 95% CI: 1.43– 3.51). Furthermore, participants who were satisfied with the ANC service had approximately 6.2 times higher odds of receiving quality ANC in comparison to those who were dissatisfied (AOR = 6.21, 95% CI: 3.48–11.08).

• Quality of ANC

• Pregnant women

• Factors associated

Doelaso ST, Samuel A (2025) Antenatal care Quality and Associated Factors among Pregnant Women Attending Public Health Facilities in Dilla Town, Southern Ethiopia, 2024. Ann Pregnancy Care 7(1): 1019.

ANC: Antenatal Care, AOR: Adjusted Odd Ratio, COR: Crude Odd Ratio, MMR: Maternal Mortality Rate, STI: Sexually Transmitted Infection, WHO: World Health Organization.

Antenatal Care (ANC) refers to the care provided by skilled healthcare professionals to pregnant mothers, aimed at ensuring optimal health for both the mother and baby throughout the pregnancy period. It promotes health promotion, risk identification, prevention and management of pregnancy-related diseases to avoid health problems in both the fetus and mother [1]. Quality ANC consists of delivering essential services to every pregnant woman and her fetus; while also providing more specialized care for those who require it. It is the most important issue to achieve the Sustainable Development Goals (SDGs) related to maternal health [2]. The World Health Organization (WHO) introduced a standard guideline for ANC that recommends a minimum of eight ANC contact sessions [1]. It involves documenting the medical history, providing pregnancy advice, evaluating personal needs, conducting various laboratory tests (HIV testing, urine analysis, blood type and Rh factor, and stool tests), conducting physical examinations, self-care education, and recognizing health conditions that may be harmful during pregnancy, along with initial treatment and referral services when necessary. Additionally, it advises that individuals should receive at least two tetanus toxoid vaccinations, and consume iron and folic acid supplements for at least 90 days [1-4]. The worldwide maternal mortality rate continues to be unreasonably high. About 95% of maternal deaths took place in low and middle-income nations, and the majority of these deaths were avoidable [2-5]. Ethiopian Demographic and Health Survey 2016 report estimated that there were 412 maternal deaths per every 100,000 live births; 62% of women received ANC from a skilled provider and 19% made four or more ANC visits [6]. This highlights the critical need for targeted interventions to address this serious problem [5]. Preventing maternal mortality and improving maternal health depend on the provision of quality ANC [7,8]. Approximately 25% of maternal deaths worldwide occur during pregnancy [9]. It is possible to prevent 28% of maternal deaths by improving the quality of ANC provided to pregnant mothers who seek care in health facilities [10]. It seems that much more work needs to be done to address maternal healthcare services [6-11]. The quality of services plays a crucial role in ANC outcomes [3]. Low quality care is affected by various factors [12]. The SDGs aim to ensure universal access to high-quality sexual and reproductive health care services and to reduce the maternal mortality ratio to below 70 per 100,000 live births by 2030 [2]. The provision of quality ANC services necessitates the availability of appropriate infrastructure, well-trained healthcare professionals, infection prevention measures, diagnostic tools, necessary supplies, and essential drugs. In addition, the quality of ANC services can be significantly affected by the length of waiting times, provider interactions, and approach styles [9]. Therefore, the objective of this study was to assess the quality of ANC and its associated factors among pregnant women visiting a public health facility in Dilla town, Southern Ethiopia, 2024.

Study area and period

The study was conducted in Dilla town, Southern Ethiopia, approximately 359 km from the capital Addis Ababa, along the route to Moyale. The estimated total population of the town is 125,067. The town was equipped with one referral hospital, two public health centers, ten private clinics, one government pharmacy, and twelve private pharmacies. The three public health facilities offer regular ANC services to pregnant mothers along with other maternity services. Data were collected from November 1 to November 30, 2024, across the three public health facilities.

Study Design

• Facility based cross sectional study

Source and study Population Source Population

• All pregnant women who visit public health facilities for ANC services.

Study Population

• Randomly selected pregnant women who visit public health facilities for ANC services.

Eligibility Criteria Inclusion Criteria

• All pregnant women visited public health facilities for ANC services in Dilla town during the study period.

Exclusion Criteria

• Pregnant women who could not provide informed consent (mentally impaired or critically ill) were excluded from the study.

Sample Size Calculation

The sample size was calculated by using a single population proportion formula by considering the following assumptions: 41.2% of pregnant women had received good quality ANC services in public hospitals in Sidama Region [13], 5% margin of error, 95% confidence level (1.96) and 10% for possible non-response rate.

Finally, 10% was added to compensate possible non response rate. The total sample size was estimated as 406.

Sampling Methods

The study included three public health facilities offering ANC services in Dilla town. By using the previous months ANC flow of pregnant women as a baseline, a total of 958 pregnant women visited the public health facilities (481 Dilla University Referral Hospital, 247 Haroresa Health Center, and 230 Oddaya Health Center) who fulfilled the eligibility criteria of the study. The number of pregnant women interviewed at each health facility was determined based on proportionate allocation to size. The interval (K) was calculated by dividing 958 by a sample size of 406, resulting in two intervals. The lottery method was used to select the first participant for the study at each health facility. Subsequently, every other pregnant woman was interviewed, and a file checkup was conducted.

Data collection and quality control

Data were collected using structured questionnaires, which were prepared by reviewing the relevant literature to address the study objectives. Relevant experts reviewed the data collection tool to ensure alignment with the study objective. Data were collected through exit interviews, document review and an observational checklist. The data collection tool was pre-tested on 5% of the sample at the Wonago health center one week prior to the data collection. Three nurses were appointed as data collectors and one health officer served as the supervisor. One-day training was provided on study purpose, data collection tool, and data handling and maintaining respondents’ confidentiality.

Data Analysis and Processing

The collected data were coded, cleaned, and entered in to a computer using EPI-DATA 3.1 and exported to the SPSS version 26 Windows program for further analysis. Bivariable logistic regression was employed to identify candidate variables for multivariable logistic regression with a significance level of ≤ 0.25. Variables showing a p-value of < 0.05 in the final model were considered statistically significant. Both the Crude Odds Ratio (COR) and Adjusted Odds Ratios (AOR), along with their respective 95% Confidence Intervals (CI) were used to assess the strength of the association. The assumptions of the logistic regression were checked before the final multivariable analysis.

Operational Definition

• Quality of ANC: - This is a binary variable and set as 1 if the respondents had received all six essential ANC components and 0 otherwise. These components included checking blood pressure, blood and urine tests, being informed about potential complications, nutritional counseling, and advice on birth preparedness plans [1-14].
• Maternal Satisfaction: - Individual perception of service that might involve interpersonal relationships, short waiting time, information and education, privacy and confidentiality, cultural sensitivity, or emotional support.
• Ethical Consideration Ethical clearance was obtained from the Institutional Research Ethical Review Committee (IRERC) of Pharma College School of Graduate Studies. Permission letters were acquired from the Dilla town health department and formal letters were written to each healthcare facility. Informed verbal consent was obtained from each study participant to confirm their willingness to participate after explaining the objectives of the study. Participants were guaranteed that their responses would remain confidential from both the data collectors and supervisors. The collected data were used solely for study purposes.

Socio-demographic characteristics

A total of 406 expectant mothers were planned to be interviewed; however, 402 interviews were carried out, resulting in a response rate of 99%. The mean age of the participants was 26.36 (±4.8) years. The majority, 377 (93.8%), were in a married, and approximately two-thirds, 294 (73.1%) of them lived in a large family (> 4 members). Approximately a quarter 101 (25.1%) of the respondents were housewives. Around two-thirds, 270 (67.2%) of the pregnant women had a household income more than 3000 ETB (Table 1).

Table 1: Socio-demographic and economic characteristics of the respondents in Dilla town, Southern Ethiopia, 2024.

Obstetric history of respondents

The majority of 296 (73.6%) respondents had a previous history of pregnancy. Regarding birth interval, 188 (64.2 %) responded that they had more than two years since last birth. All respondents had information on the importance of ANC follow up, with health professionals being the primary source of information on ANC for 68.9% of them. About 236 (58.7%) of the respondents initiated their initial ANC visit in the first trimester of pregnancy. Nearly two-thirds 261 (64.9%) of the study participants had two or more ANC visits (Table 2).

Table 2: Obstetric characteristics of respondents, Dilla town, Southern Ethiopia, 2024.

Healthcare facility related factors

Nearly half, 193 (48%) of the participants had to wait more than an hour to obtain the service. The majority of respondents, 379 (94.3%) experienced respectful treatment from the provider during their most recent visit. About three-quarters, 301 (74.9%) of the respondents were satisfied with the service they received from the healthcare facility. All respondents were appointed to the subsequent visit. Among the study participants, 255 (63.4%) needed to improve the service delivery to obtain a better ANC service (Table 3).

Table 3: Healthcare facilities related characteristics, Dilla town, Southern Ethiopia, 2024.

Service provision related factors A comprehensive physical examination was a fundamental component of quality ANC services, with assessments of blood pressure (95.5%), weight measurement (96.8%), evaluation of pallor (96.3%), examination of edema (96.5%), and ultrasound performed (33.6%) as part of a comprehensive physical examination. In routine laboratory tests, the CBC test (particularly Hgb) was conducted (76.4%), VDRL test (71.1%), blood group/RH factor test (72.6%), urine analysis (68.7%), and HIV test (96.3%). About 343 (85.3%) and 382 (95%) of the study participants acknowledged receiving iron supplementation and tetanus immunization, respectively (Table 4).

Table 4: Service provision related characteristics, Dilla town, Southern Ethiopia, 2024.

Observational checklist

The observational checklist had 15 questions with four options (1 = very poor, 2 = poor, 3 = satisfactory, and 4 = excellent). The first two choices (very poor and poor) indicated that tasks were not performed correctly, while the latter two (satisfactory and excellent) indicated that tasks were carried out correctly. About 30 study participants’ service provision and care provider approaches were assessed by taking 10 study participants from each health facility. Most individuals were not greeted and called their names appropriately upon arrival. No washing facilities (water, soap, and towels) were available for pregnant women at the healthcare facility. Most healthcare providers accurately measured patients’ pulse rate, blood pressure, and temperature. Most respondents’ gestational age, expected date of delivery, and progress of pregnancy were correctly recorded. Reviewing clinical documents before starting the session and checking previous medical and obstetric history was properly done for all respondents. Nearly all participants were informed about the risks of consuming unauthorized medications during pregnancy, advised on danger signs and place of birth. 

Factors associated factors with the Quality of ANC

In the bivariable logistic regression analysis variables, such as the current number of ANC visits, waiting time, satisfaction with ANC service, and respectful approach were variables associated with dependent variables at p-value ≤ 0.25. After controlling for the effect of confounding factors in the multivariable analysis, variables such as number of ANC visits and satisfaction with ANC service were found to be significantly associated with the quality of ANC service (p <0.05). The likelihood of obtaining quality ANC service was 2.2 times greater for pregnant mothers with a second visit or more (AOR = 2.24, 95% CI: 1.43–3.51). Those who were satisfied with the ANC service had about 6.2 times higher odds of receiving quality ANC services (AOR = 6.21, 95% CI: 3.48–11.08) (Table 5).

Table 5: Factors associated with ANC quality among pregnant women visiting public health facilities in Dilla town, Southern Ethiopia, 2024.

A facility-based cross-sectional study was carried out to assess the quality of ANC and its associated factors among pregnant women visiting public health facilities in Dilla town, Southern Ethiopia. This study revealed that 52% (95% CI: 51.5%–52.5%) of pregnant women had received good-quality ANC services, which was comparable with findings presented by studies conducted in Chencha district, Southern Ethiopia (52.4%) [15], and Bahir Dar, Ethiopia (52.3%) [16]. Several studies conducted in different parts of the world, Southern Ethiopia (41.2%) [13], Northern Ethiopia (41%) [17], Northwest Ethiopia 32.7% [18], Eastern Ethiopia (24.3%) [19], Nepal (42%) [20], and Zambia (29%) [21], reported a lower prevalence of quality ANC than the present findings. In contrast to this, studies carried out in different parts of the world, South Ethiopia (69.1%) [12], Southwest Ethiopia (60.4%) [22], Bishoftu Central Ethiopia (84.9%) [23], and Malaysia (63%) [24], reported a higher prevalence of quality ANC utilized by pregnant women. These discrepancies might be related to differences in sociodemographic characteristics, ANC quality measurement methods, availability of trained health professionals, approach of healthcare providers, and the study setting. The odds of obtaining quality ANC increased by 2.2 times among women who had two or more ANC visits as compared with their counterparts (AOR=2.24; 95% CI: 1.43-3.51). This finding is consistent with studies conducted in Ethiopia, Northwest Ethiopia [18], Southern Ethiopia [25], Southern Ethiopia [13], and Nigeria [26]. A possible reason might be that frequent exposure to ANC services might enhance the familiarity of women with the services and encourage them to share information freely with healthcare providers. This study showed that pregnant women who are satisfied by service provision had 6.21 times higher odds of quality ANC service compared with their counterparts (AOR=6.21; 95% CI: 3.48-11.08). This finding is consistent with studies conducted in Ethiopia, Addis Ababa, Ethiopia [27], Southern Ethiopia [13], Southwest Ethiopia [22], Northwest Ethiopia [16], and West Ethiopia [28]. A possible explanation might be that satisfaction with ANC services comes from healthcare providers’ approach, laboratory investigation, physical examination, and advice provided by the service provider.

Limitation

This study aimed to determine the quality of ANC and its associated factors in pregnant women attending public health facilities. However, this study had some limitations. This study was based on urban health facilities; therefore, it might not be possible to generalize the findings to all pregnant women in rural health facilities. The study used only quantitative methods; if it were triangulated with qualitative data, strong evidence could be generated.

This study showed that only half of the pregnant women received quality ANC services in public health facilities, which indicates that pregnant mothers who received quality ANC are low and more effort is required. Different factors contribute to the quality of ANC services, including the number of ANC visits and satisfaction with ANC. This study provides valuable indications regarding the areas that should be focused on to promote the quality of ANC services for pregnant mothers. In addition, the country is still far from achieving universal coverage of recommended ANC content.

Data sharing statement

Data used to support the findings of this study are available from the corresponding author upon request.

Acknowledgments

We would like to acknowledge all study participants for their voluntary participation. We would also like to extend our appreciation to the Pharma College for providing us with the opportunity to conduct this study.

Funding

Pharma College did not financially support this study. The college had no role in the design of the study, data collection, data analysis, and interpretation.

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