Delayed initiation of antenatal care and its determinants in Ethiopia: A systematic review and meta-analysis

Timely initiation of antenatal care (ANC) is essential for improving maternal and newborn outcomes. However, in Ethiopia, a large proportion of women delay their first ANC visit beyond the recommended first trimester, despite free access to ANC services. Prior reviews have not clearly distinguished between early and late ANC initiation.

To systematically review and meta-analyze the prevalence and factors associated with delayed initiation of ANC among pregnant women in Ethiopia.

This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched multiple databases and grey literature for observational studies reporting on late ANC initiation and its determinants in Ethiopia. Random-effects meta-analysis was used to pool odds ratios (ORs) with 95% confidence intervals (CIs) for variables reported in three or more studies. A narrative synthesis was conducted for uniquely reported factors. Publication bias was assessed using funnel plots and Egger's test.

Twenty-five studies were included. The pooled prevalence of delayed ANC initiation was 61% (95% CI: 54-68%), with considerable heterogeneity (I² = 99.4%). Subgroup analysis revealed variations by region and by the definition of "late" (>12 weeks: 64.7%, 95% CI: 60.3-69.1%; >16 weeks: 57.1%, 95% CI: 44.4-69.8%). Significant determinants included rural residence (OR: 1.89, 95% CI: 1.52-2.34), unplanned pregnancy (OR: 2.51, 95% CI: 1.97-3.19), perceiving the correct time to start ANC as >12 weeks (OR: 5.17, 95% CI: 2.98-8.97), and travel time >1 h to a health facility (OR: 6.23, 95% CI: 3.44-11.30). Higher income was protective (OR: 0.58, 95% CI: 0.34-0.99).

Delayed ANC initiation in Ethiopia is driven by educational, informational, and access-related barriers. Targeted interventions are needed to promote timely ANC, especially among high-risk groups.