AbstractZero-utilization of antenatal care (ZUANC) is a significant public health problem that increases the risks of maternal morbidity and mortality. However, the association of individual and community-level factors and the spatial clustering effects of ZUANC are often overlooked in Ethiopia. This study aimed to assess the spatial clustering and determinants of zero utilization of ANC services in Ethiopia. This study used a nationally representative sample of 3,926 women from the 2019 Ethiopian Mini Demographic and Health Survey. Multilevel binary logistic regression models were fitted. The Adjusted Odds Ratio (AOR) along with 95% Confidence Intervals (CI) was calculated, with p-values less than 0.05 considered statistically significant. The prevalence of ZUANC in Ethiopia was 25.56% (95% CI: 24.87, 27.63). It was significantly clustered across the country, with notable hotspot areas detected in Ethiopia. Besides, women with no education (AOR = 6.42; 95% CI: 3.77, 10.91) and those with primary education (AOR = 3.53, (95% CI: 2.09, 5.95) had higher odds of ZUANC. Women from poor (AOR = 2.41; 95% CI: 1.77, 3.29) and middle-income households (AOR = 1.64; 95% CI: 1.16, 2.33), those not using any contraceptive method (AOR = 1.78; 95% CI: 1.41, 2.24), women from rural areas (AOR = 2.03; 95% CI: 1.28, 3.21), and residing in the Somali regions (AOR = 5.08; 95% CI: 3.18, 7.92) also had higher odds of ZUANC. On the other hand, marriage reduced the likelihood of ZUANC (AOR = 0.26; 95% CI: 0.09, 0.73). In this study, one-fourth of pregnant women in Ethiopia had ZUANC. Therefore, targeted public health interventions to address these factors, particularly in the identified hotspot areas of ZUANC, are strongly recommended to increase ANC utilization.
IntroductionAntenatal care (ANC) is an essential component of maternal and child healthcare, providing essential services to monitor the health of pregnant women and their developing fetuses1. It plays a vital role in ensuring the well-being of both the mother and the child by identifying and managing potential complications during pregnancy2. The World Health Organization (WHO) recommends that pregnant women have at least eight ANC contacts with healthcare providers throughout their pregnancy3.Globally, in 2020 around 800 women lost their lives each day due to preventable causes associated with pregnancy and childbirth4. Nearly 95% of these maternal deaths occurred across low and middle-income countries, and 70% of maternal deaths throughout the world occurred in sub-Saharan African countries5. The majority of maternal deaths occur due to problems during pregnancy and childbirth; failing to receive the recommended ANC care has tremendous consequences for the woman and her fetus6. Globally, the WHO estimates that only 59.2% of pregnant women receive one or more antenatal care services7. Sub-Saharan Africa suffers the majority of the problem, with an estimated 32% and 37.2% of women in Nigeria8, and Ethiopia9, respectively, not utilizing antenatal care services.“Zero utilization of antenatal care” (ZUANC) refers to a woman not receiving any professional healthcare services, including medical examinations, screenings, or educational services that are normally provided during pregnancy3,10. It increases the risk of adverse health for both the mother and the unborn child3. The lack of ANC utilization is a complex issue, driven by a range of individual, household, community, and health system-level factors11. Understanding the determinants and spatial patterns of ZUANC is crucial for developing targeted interventions to improve maternal and child health outcomes.Several previous studies have explored the determinants of ZUANC, identifying factors such as maternal age, maternal educational status, marital status, wealth index, contraceptive utilization, women’s residence region, distance to health facilities, and low media exposures as being associated with zero utilization of antenatal care services12,13,14,15,16. Even though there was some prior research on the utilization of ANC services, almost all of them consisted of individual-level factor analysis. They failed to take into account the clustering effect of community-level variables as well as the spatial clustering effects of ANC service utilization. Despite WHO recommendations for pregnant women, the utilization of ANC services remains a significant public health challenge, particularly in developing countries17,18.Studying the spatial distribution of ZUANC is essential to reveal geographical hotspots and cold spots, helping to identify areas with particularly high or low levels of ANC utilization19. This spatial analysis can provide valuable insights into the underlying factors driving the unequal distribution of ANC services, such as access to healthcare facilities, socioeconomic status, and cultural norms. By understanding the spatial patterns of ZUANC, policymakers and public health authorities can better target interventions and allocate resources to address the issue effectively, ultimately improving maternal and child health outcomes. Therefore, this study aimed to assess the spatial clustering and determinants of zero utilization of antenatal care in Ethiopia through spatial and multilevel analysis. As a result, this study will support public health evidence-based decision-making by providing valuable information for policymakers and stakeholders to improve maternal and child health outcomes.MethodsStudy design, setting, and periodWe used the most recent national representative data from the Ethiopian Mini Demographic and Health Survey (EMDHS). The EMDHS was a cross-sectional survey conducted between March 21 and June 28, 2019, in two city administrations and nine regions. Ethiopia is located in the Horn of Africa. At the time of the survey, the country was divided into nine administrative regions: Tigray, Afar, Amhara, Oromia, Somali, Benishangul-Gumuz, Southern Nations, Nationalities, and Peoples’ Region (SNNPR), Gambella, and Harari, as well as two self-governing city administrations, Addis Ababa and Dire Dawa.Inclusion and exclusion criteriaIn this study, women aged 15–49 who had given birth in the three years preceding the surveys and resided in Ethiopia were included. However, women with mental health disorders, as well as those who refused to participate or those unable to provide informed consent, were excluded from the 2019 EMDHS survey.Data source and extractionPermission was secured after the online request from Measure Demographic and Health Surveys (DHS) (http://www.dhsprogram.com/). Then, survey and geographic location data, such as longitude and latitude coordinates were obtained. After that, the outcome variable Zero utilization of antenatal care and its individual and community-level variables were carefully extracted from the 2019 EMDHS women’s data set (IR) file.Variables of studyDependent variableIn this study, the outcome variable was categorized as zero and not zero utilization of antenatal care. Women who had not had antenatal care follow-up were considered to have zero utilization of antenatal care services; this refers to pregnant women who do not attend antenatal care visits throughout their pregnancy. Those who had had one or more antenatal care follow-ups were defined as not-zero utilization of antenatal care, which means they utilized the maternal continuum of care during their pregnancy.Independent variablesThe study’s independent variables were grouped into two categories: factors at the individual and community levels. The individual-level variables included maternal age, educational status of women, marital status, religion, household wealth index, the contraceptive method used, preceding birth interval, family size, and sex of the household head. The place of residence and region of the study participants were considered community-level variables.Data collection tools and proceduresIn the study, a stratified, two-stage cluster sampling method was used to select the sample. A total of 305 enumeration areas (93 in urban areas and 212 in rural areas) were chosen with a probability proportional to the size of the enumeration area. In the second stage of selection, 30 households per cluster were selected using an equal probability systematic selection method from a newly created household listing. Information from all eligible women aged 15–49 was collected using the Woman’s Questionnaire, and the 2019 EMDHS utilized an electronic data collection system20.Data processingAfter extracting the data from the women’s dataset of the EMDHS 2019, we performed data cleaning, recoding, generation, labeling, and analysis using STATA version 17, following the Guide to DHS Statistics. We weighted the data for probability sampling and non-response using sample weight to ensure the survey’s representativeness and obtain reliable statistical estimates. We then conducted descriptive, spatial, and multilevel analyses.Data analysisSpatial distribution and autocorrelation of zero utilization of ANCThe spatial autocorrelation (Global Moran’s I) statistic measure was utilized to determine if zero utilization of antenatal care was dispersed, clustered, or randomly distributed in Ethiopia. The value of Moran’s I close to −1indicates dispersed zero utilization of ANC, close to + 1 indicates clustered ZUANC visit and a Moran’s I value of zero indicates a random distribution21.Hotspot analysisThe Getis-Ord Gi* statistic (Hotspot Analysis) uses z-scores and significant p-values to identify areas where high or low values cluster in space22. Hotspot areas indicate a high proportion of ZUANC, while cold spot areas indicate a low proportion of ZUANC.Spatial interpolationThe spatial interpolation technique is utilized to predict the ZUANC for unsampled areas based on sampled clusters23. We employed a geostatistical ordinary Kriging spatial interpolation technique using ArcGIS Version 10.8 software for unsampled cluster prediction.Spatial scan statisticsThe spatial scanning statistics in the Bernoulli model are utilized to identify statistically significant clusters’ geographical locations for ZUANC through the use of Kuldorff’s SaTScan V.9.6 software24. A scanning window moves across the study area, considering women ZUANC as cases and those women with non-zero ANC utilization as controls to fit the Bernoulli model. The most probable cluster was determined using likelihood ratio and p-value tests.Multilevel analysisThe DHS data was analyzed using multilevel logistic regression to determine the factors influencing ZUANC. The analysis involved computing the Intraclass Correlation Coefficient (ICC) and Median Odds Ratio (MOR) to measure cluster variation and community-level variability. Additionally, the Proportional Change in Variance (PCV) was calculated to determine how much of the variation in zero utilization of ANC was explained by the final model.Model buildingFour models were created for the multilevel logistic regression analysis. The first model, known as the null model, aimed to measure the impact of cluster variations on zero utilization of ANC. Model II included individual-level variables, while Model III involved community-level variables. Finally, model IV incorporated both individual and community-level variables simultaneously. After comparing the models, it was determined that model IV, with the highest likelihood and lowest deviation values, was the best-fitted model. In the multivariable multilevel logistic regression analysis, variables with a p-value < 0.05 were considered statistically significant. Adjusted Odds Ratios (AOR) and their corresponding 95% confidence intervals (CI) were calculated to identify factors associated with ZUANC.Ethical considerationThe permission for access to the data was obtained from ICF International by registering and stating the purposes of the study. The data used in this study are freely available, aggregated secondary data that didn’t contain any personal identifiers that can be linked to the study participants (http://www.dhsprogram.com). The data were used exclusively for the registered research topic and were not shared with other parties. Complete information about the ethical issue can be found in the EMDHS-2019 report.ResultsZero-utilization of ANC by socio-demographic, and reproductive characteristics of womenThis study included 3,926 women aged 15–49 in the weighted sample. Approximately 92.64% of the participants were married. Around 51.90% of the women had no formal education, and 64.11% of the women did not intend to use any contraceptive methods. The overall weighted prevalence of zero utilization of antenatal care in Ethiopia was 25.56% (95% CI: 24.87, 27.63). Additionally, rural residents and the Somali regions had the highest proportion of zero utilization of antenatal care. See (Table 1).Table 1 Zero-utilization of antenatal care by socio-demographic and other characteristics in Ethiopia, 2019 EMDHS.Full size tableSpatial analysisSpatial autocorrelation of zero-utilization of antenatal careWe used 305 clusters to analyze the spatial autocorrelation of zero antenatal care utilization in Ethiopia. The Moran’s I statistics indicated that the distribution of ZUANC in Ethiopia was not random; it clustered across the area (the global Moran’s I value = 1.42, p < 0.001), suggesting that further spatial analysis assumptions have been made. The z-score of 31.09 indicates that there is less than a 1% probability that this clustered pattern of zero antenatal care utilization could be the result of random chance (Fig. 1).Fig. 1The global spatial autocorrelation analysis of zero-utilization of antenatal care in Ethiopia, EMDHS 2019.Full size imageHotspot analysis of zero-utilization of ANC in EthiopiaGlobal autocorrelations indicate a clustering effect (spatial autocorrelation) of zero-utilization of ANC care in Ethiopia, requiring further investigation using figures and maps. Consequently, we performed hotspot analysis (Gettis-Ord Gi*) to pinpoint spatial distribution patterns. As the Getis-Ord statistic showed, the significant hotspot areas of zero utilization of antenatal care in Ethiopia were in Somali, SNNPR, Afar, and some parts of Oromia regions indicated in red on the map. As indicated in blue, Ethiopia’s central and northern parts were significant cold spots (Fig. 2).Fig. 2Hotspot and Cold spot analysis of zero-utilization antenatal care in Ethiopia, EMDHS 2019.Full size imageSpatial interpolation of zero-utilization of ANCThe Kriging interpolation identified the Somali and Southern Afar regions as having the predicted high prevalence of zero ANC utilization in Ethiopia. In contrast, Addis Ababa, Tigray, Amhara, and some parts of the Benishangul-Gumz and Gambella regions showed the predicted low prevalence of zero-utilization of ANC in Ethiopia (Fig. 3).Fig. 3Kriging interpolation analysis of zero-utilization to antenatal care in Ethiopia, EMDHS 2019.Full size imageSpatial scan statistical analysisWe conducted a spatial scan statistical analysis to identify the primary cluster and another secondary cluster. The spatial scan statistics of zero ANC utilization in Ethiopia have two significant scanning windows. The first scanning window is located at 6.639662 N, 44.465855 E, which covers most parts of Somali and some parts of Oromia regions, containing 22 clusters with a 381.83 km radius, LLR 195.21, p-value < 0.000. Women in this area have a 3.55-fold higher risk of not using ANC care compared to women outside these areas. The second scanning window for the secondary clusters was found in the Afar region, which contained 10 clusters located at 10.027735 N, 40.469799 E, with a 97.24 km radius, LLR 40.24, and a p-value < 0.000. Women inside this cluster have a 2.49 times higher risk of zero-utilization of ANC care compared to women outside the area, See (Fig. 4), (Table 2).Fig. 4Spatial scan statistics analysis of zero-utilization of antenatal care among pregnant women in Ethiopia, EMDHS, 2019.Full size imageTable 2 SaTScan analysis results for significant clustering of zero utilization of ANC care in Ethiopia, 2019 EMDHS.Full size tableMulti-level analysis of factors associated with zero-utilization of ANCRandom effect and model comparisonThe null model’s inter-cluster correlation (ICC) value showed that 48% of the differences in pregnant women who didn’t use ANC care were due to factors at the cluster level. The null model’s median odds ratio (MOR) value also showed that the number of women who did not use ANC care was 5.24 times higher or lower in the higher prevalence clusters compared to the lower prevalence clusters. Community and individual factors could explain about 75% of the variation in not using ANC care, according to the final model’s proportional change in variance (PCV) value. We fitted and compared the models using the deviance and likelihood tests, determining that Model 4 was the better-fitted model with the highest likelihood and lowest deviation values (Table 3).Table 3 Random effect analysis result and model fit statistics for multi-level models.Full size tableFixed effect analysis resultsThe final model (model 4) demonstrates the incorporation of individual and community-level predictors into the multi-level analysis. Maternal educational status, marital status, wealth index, family planning method, women’s residence, and region were identified as significant predictors of zero-utilization of ANC care in Ethiopia.Compared to secondary and above-educated women, women without formal education were 6.42 (AOR = 6.42; 95% CI: 3.77, 10.91) and 3.53 (AOR [95% CI: 2.09, 5.95]) times more likely to have never used ANC care.Married women had a 74% lower likelihood of having zero ANC care utilization compared to unmarried women (AOR = 0.26; 95% CI: 0.09, 0.73). Women from the poor and middle wealth index had 2.41 (AOR = 2.41; 95% CI: 1.77, 3.29) and 1.64 (AOR = 1.64; 95% CI: 1.16, 2.33) times higher odds of having zero-utilization of ANC care, respectively, than women from the rich wealth index.The odds of zero-utilization of ANC care among women who didn’t use any contraceptive method were 1.78 (AOR = 1.78; 95% CI: 1.41, 2.24) times higher than women who used modern contraceptive methods. Women from rural areas were 2.03 (AOR = 2.03; 95% CI: 1.28, 3.21) times higher in the odds of zero utilization of ANC care than their counterparts. Furthermore, women from Somali regions had 5.08 (AOR = 5.08; 95% CI: 3.18, 7.92) times higher odds of zero-utilization of ANC care as compared to women from Addis Ababa, See (Table 4).Table 4 Multilevel analysis for factors associated with zero-utilization of ANC care in Ethiopia, EMDHS 2019.Full size tableDiscussionsEven though the World Health Organization (WHO) recommends pregnant women to have at least eight ANC contacts with healthcare providers throughout pregnancy1, zero-utilization of ANC care is still a significant public health concern in developing countries like Ethiopia, and it has serious consequences for both mothers and their fetuses. This study investigated the prevalence and associated factors of zero-utilization of ANC among pregnant women in Ethiopia, based on evidence from EMDHS 2019.In this study, the overall weighted prevalence of Zero-utilization of ANC in Ethiopia was 25.56% (95% CI: 24.87, 27.63). This finding aligns with the Nigerian study where 26.1% of women did not utilize antenatal care during their pregnancy25. However, this study’s result of zero utilization of ANC is indeed higher compared to studies done in Brazil26, Belgium27, and Bangladesh28, where 2%, 9.7%, and 18%, respectively, didn’t utilize antenatal care services. The possible reasons for the difference could be the country’s healthcare infrastructure, socioeconomic factors, and literacy rates, which may contribute to the lower utilization of ANC care in Ethiopia29. Furthermore, the higher zero utilization of ANC services is attributed to societal cultures, knowledge, and attitudes about the importance of prenatal care30. Therefore, addressing these issues requires comprehensive policy interventions, improved healthcare services, and community engagement to raise awareness about the importance of ANC.In this study, there is a spatial autocorrelation in zero utilization of ANC care, and its distribution varied greatly across regions in Ethiopia. Significant hotspots of zero utilization of ANC care were detected in the Somali, SNNPR, Afar, and some Oromia regions. Additionally, the SaTScan analysis results revealed primary and secondary clusters in Somali and the southern parts of the Afar region. This finding, supported by previous studies in Ethiopia31, Sudan32, and Nigeria33, indicated that there is a geographical difference in women’s use of maternal healthcare across the regions. Difficulty in accessing transportation and healthcare facilities may render those areas hotspots for zero ANC utilization34. These areas tend to be remote with scattered populations35, as a result, traveling to health facilities could be difficult and time-consuming, especially for routine antenatal care follow-ups.In Ethiopia, factors such as maternal educational status, marital status, wealth index, family planning methods, women’s residence, and region were identified as significantly associated with zero-utilization of ANC care. According to this study, uneducated women and those who had only attended primary school had 6.42 and 3.53 times higher odds of zero ANC care utilization than secondary and above-educated women, respectively. It’s supported by the study conducted in west Shoa Zone Ethiopia36, and Bangladesh37, revealed that women who completed higher education were more likely to have antenatal care follow-ups than those who were not educated. Women with lower levels of education generally have a lower awareness of the importance of maternal health services38. Women with lower levels of education may have limited access to information regarding the benefits and availability of maternal health services39, which could lead to a higher rate of zero utilization of ANC care.Compared to unmarried women, married women had a lower likelihood of having zero utilization of ANC care; this result is in line with a study conducted in Ethiopia40, and Ghana16, which revealed that married women were more likely to utilize antenatal care than unmarried women. This could be due to husbands encouraging their wives to attend ANC follow-ups and providing emotional and psychological support during their pregnancies41. These factors may contribute to better ANC utilization among married women.This study found that women from the poor and middle wealth index were more likely to have never used ANC care than those from the richest. This result aligns with a Cambodian study42, that revealed poorer women had less access to ongoing maternal care. Furthermore, studies from Tanzania43, and Pakistan44, showed that women from the wealthiest households had higher utilization of the maternal continuum of care compared to their counterparts. The reason behind this could be that women from the poorest wealth index might be unable to access ANC care, because of the high expense of transportation to healthcare facilities45. Additionally, ANC clinic hours may overlap with job schedules, which can be inconvenient for women and keep them from receiving antenatal care.Compared to women who used modern contraceptive methods, those who did not use any contraceptive method had a higher likelihood of having zero ANC care utilization. Studies conducted in Burkina Faso46, and Ghana47, found this result, revealing an increase in the use of ANC services among women who use modern contraceptives. Women who don’t use family planning methods may have limited contact with the healthcare profession. They may become less aware and less likely to use antenatal care services.Women from rural areas were more likely to have zero utilization of ANC services as compared to their counterparts; this result is supported by other studies in Asian countries48, which show that women who live in rural areas experience fewer ANC visits compared to their counterparts. Rural areas often have fewer healthcare facilities, and those might be far away49, making it difficult for ANC follow-ups. In addition, women from rural areas may have lower levels of education50, which may limit their understanding of the importance of the maternal continuum of care.Furthermore, in this study, women from Somali regions had higher odds of zero-utilization of ANC care as compared to women from Addis Ababa. Other studies in Ethiopia revealed that ANC utilization was lower in the Somali and Afar regions than in the capital city of Ethiopia51. This could be because access to healthcare services is difficult in Somali regions, which have a larger population of nomadic people and less established transportation infrastructure. Furthermore, Somali communities’ cultural norms and beliefs may favor traditional birth attendants over formal healthcare professionals during pregnancy and labor52.Strengths and limitations of the studyThis study utilized nationally representative data with a large sample size, ensuring the generalizability of the findings. It incorporated individual and community-level factors for a comprehensive analysis and employed spatial and multilevel analysis to identify hotspot areas and account for data hierarchy, thereby enhancing result robustness. However, the cross-sectional design limits causal inference. Additionally, key contextual factors, such as healthcare facility capacity and sociocultural influences affecting ANC utilization, were not included due to the absence of data in the 2019 EMDHS.Public health and clinical implicationsThe findings of this study on zero utilization of ANC care in Ethiopia have significant public health and clinical implications for improving maternal and child health outcomes. This study pinpoints areas with higher zero utilization of ANC care and identifies factors associated with zero utilization of ANC care in Ethiopia. It will help to develop targeted public health strategies to ensure all pregnant women have access to essential ANC services. Clinically, the findings highlight the need for healthcare providers to actively counsel non-contraceptive users and advocate for the importance and benefits of ANC. This can help to decrease zero ANC utilization. As a result, it will contribute to reducing maternal and child mortality, as targeted by the 2030 Sustainable Development Goals.ConclusionPregnant women in Ethiopia had a significant proportion of ZUANC, which showed spatial clustering. In addition to factors such as women with lower levels of education and those who did not use any contraceptive methods, the risk of ZUANC care was also increased by the poor and middle wealth index, rural residency, and Somali region. However, in Ethiopia, marriage significantly reduced the likelihood of ZUANC. Therefore, we recommended implementing targeted public health interventions that address the identified determinants, especially in these hotspot areas for ZUANC.
Data availability
The datasets we used for this study were publicly available at Measured DHS website http://www.dhsprogram.com.
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Download referencesAcknowledgementsAll authors express our gratitude to Measure DHS for permitting us to access the DHS datasets.FundingThe authors received no specific funding for this work.Author informationAuthors and AffiliationsDepartment of Epidemiology and Biostatistics, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Gondar, EthiopiaHabtamu Wagnew Abuhay, Tigabu Kidie Tesfie & Melaku Kindie YenitSchool of Health and Medical Sciences, Centre for Health Research, University of Southern Queensland, Queensland, QLD, AustraliaMelaku Kindie YenitAuthorsHabtamu Wagnew AbuhayView author publicationsYou can also search for this author in
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PubMed Google ScholarContributionsHWA conceived and designed the study. HWA, TKT, and MKY participated in data processing and data management, analyzed the data, and drafted the manuscript. HWA and MKY participated in data analysis and interpretation. HWA, TKT, and MKY reviewed the drafted manuscript. All authors read and approved the final manuscript.Corresponding authorCorrespondence to
Habtamu Wagnew Abuhay.Ethics declarations
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The authors declare no competing interests.
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Reprints and permissionsAbout this articleCite this articleAbuhay, H.W., Tesfie, T.K. & Yenit, M.K. Spatial clustering and determinants of zero-utilization of antenatal care among pregnant women in Ethiopia.
Sci Rep 15, 8791 (2025). https://doi.org/10.1038/s41598-025-93253-5Download citationReceived: 02 July 2024Accepted: 05 March 2025Published: 14 March 2025DOI: https://doi.org/10.1038/s41598-025-93253-5Share this articleAnyone you share the following link with will be able to read this content:Get shareable linkSorry, a shareable link is not currently available for this article.Copy to clipboard
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KeywordsAntenatal carePregnant womenMaternal health servicesSpatial analysisMultilevel analysisEthiopia