Spatial Pattern and Associated Factors of ANC Visits in Ethiopia: Spatial and Multilevel Modeling of Ethiopian Demographic Health Survey Data

BACKGROUND: Although there is an increase in having antenatal care (ANC), still many women lack recommended ANC contacts in Ethiopia. Therefore, this study was aimed at determining spatial patterns and associated factors of not having ANC visits using the Ethiopian Demographic and Health Survey (EDHS) 2016 data. METHODS: A two-stage stratified cluster sampling technique was employed based on EDHS data from January 18 to June 27, 2016. A total of 7,462 women were included in the study. ArcGIS version 10.7 software was used to visualize the spatial distribution. The Bernoulli model was applied using Kilduff SaTScan version 9.6 software to identify significant purely spatial clusters for not having ANC visits in Ethiopia. A multivariable multilevel logistic regression model was used to identify individual- and community-level determinants of not having antenatal care. Model comparison was checked using the likelihood test and goodness of fit was assessed by the deviance test. RESULTS: The primary clusters' spatial window was located in Somalia, Oromia, Afar, Dire Dawa, and Harari regions with the log-likelihood ratio (LLR) of 133.02, at p < 0.001 level of significance. In this study, Islam religion (adjusted odds ratio (AOR) = 0.7 with 95% confidence interval (CI) (0.52,0.96)), mother education being primary (AOR = 0.59, 95% CI (0.49,0.71)), distance from health facility being a big problem (AOR = 0.76, CI (0.65,0.89)), second birth order (AOR = 1.35, CI (1.03, 1.76)), richer wealth index (AOR = 0.65, CI (0.51,0.82)), rural residence (AOR = 2.38, CI (1.54,3.66)), and high community media exposure (AOR = 0.68, CI (0.52,0.89)) were determinants of not having antenatal care in Ethiopia. CONCLUSION: The spatial distribution of ANC in Ethiopia is non-random. A higher proportion of not having ANC is found in northeast Amhara, west Benishangul Gumuz, Somali, Afar, north, and northeast SNNPR. On the other hand, a low proportion of not having ANC was found in Tigray, Addis Ababa, and Dire Dawa. In Ethiopia, not having antenatal care is affected by both individual- and community-level factors. Prompt attention by the Federal Ministry of Health is compulsory to improve ANC especially in rural residents, uneducated women, poor households, and regions like Oromia, Gambella, and Somalia.