A multi-center, institution-based cross-sectional study was conducted among clients attending antenatal care at selected public hospitals in the south Gondar zone, Ethiopia, from March 1 to May 30, 2024. The south Gondar zone is one of the ten administrative zones in the Amhara region, Ethiopia. Debre Tabor town is the capital city of south Gondar zone. The town is located approximately 669 km northwest of Addis Ababa, the capital city of Ethiopia, and 97 km southwest of Bahir Dar, the capital city of the Amhara region. It has an elevation of 2,706 m above sea level. According to the 2022 population projection, Debre Tabor town has a total population of 125,312, with 64,322 males and 60,990 females. Addis Zemen Hospital, Debre Tabor Comprehensive Specialized Hospital, Mekaneyesus Hospital, and Tesfaye Getachew Memorial Hospital were randomly selected among the ten public hospitals in the south Gondar zone.

Source and study population: All pregnant women who were attended antenatal care at south Gondar zone public hospitals were the source population for this study. Whereas, selected pregnant women who were attended antenatal care at the selected public hospitals during data collection periods were the study population.

Inclusion and Exclusion criteria: The inclusion criteria were pregnant mothers who were attended antenatal care at selected public hospitals during the study period. Women who were seriously ill, unable to hear and/or speak during data collection period were excluded from the study.

The sample size was determined using a single population proportion formula using a 50% proportion because no previous research had been done in Ethiopia. P = 50%, 10% non-response rate, 5% margin of error, and 95% confidence interval. After adding 10% non-response rate, 423 study participants were finally taken into account. Simple random sampling was used to choose the study hospitals. To choose the study subjects, systematic random selection was used. First, we determine the approximate number of women who have used antenatal care within the last three months for the selected facilities. The number of antenatal attendees in each selected hospitals were 567 in Debre Tabor comprehensive specialized hospital, 393 in Addis Zemen hospital, 386 in Mekaneyesus hospital and 346 in Tesfaye Getachew memorial hospital with a total of 1,692. The Kth intervals were calculated by dividing total number of attendees for the total sample size (1,692/423 = 4). The first study participant was selected via lottery method from 1 up to 4 which was 3. Finally, every 3rd pregnant women were interviewed until total sample size was reached (Figure 1).

Age, religion, educational level of women, educational level husband/partner/, marital status, residency, family size, head of house hold, decision on health care, income generator (the one who earns income in the family).

Gravidity, parity, pregnancy planned or not, hours to reach health institution, means of transportation, gestational age when antenatal care started.

Good knowledge and poor knowledge.

Favorable attitude and unfavorable attitude.

Prenatal vitamin utilization: it was measured by asking women whether they have used prenatal vitamins before conception or during pregnancy. Then it was considered as users of prenatal vitamin if the response was yes for one of two questions, otherwise non-users.

Knowledge on prenatal vitamins: women who scored above the median score (≥3) were classified as having good knowledge otherwise they were considered as poor knowledge (<3).

Attitude towards prenatal vitamins: women who scored above the median score (≥2) were classified as having favorable attitude otherwise they were considered as unfavorable attitude (<2).

Validated semi-structured questionnaires from prior studies were used (24–27). The tool was initially prepared in English. To ensure uniformity, this questionnaire was translated into Amharic and then back into English by a different translator. The data were collected by five diploma midwives at the exit of antenatal care service. Two bachelor degree midwives supervised the data collection process, which involved conducting in-person interviews with participants using a semi-structured questionnaire that the interviewer administered. Two days training was given for data collectors and supervisors. Pretest was done on 5% of sample size.

To make sure the data was of high quality, a half-day tool discussion with the authors was conducted. To ensure data quality, the supervisors and data collectors underwent comprehensive training on how and what information to collect from the specific data sources. The questionnaires were checked for accuracy and missing information before the data was collected. The principal investigator and supervisors swiftly offered input and checked the completeness of the data each day as it was being collected. The primary investigator cleaned the data before beginning the analysis. A pre-test was conducted 1 week prior to the start of the actual data collection at Megbaru Kebede memorial hospital. Subsequently, the questionnaire was assessed for its length, lucidity, and comprehensiveness, and any requisite modifications were implemented based on the findings.

Data entry and coding were done using EpiData version 3.1 software. The entered data were exported into the Statistical Package for Social Science (SPSS) version 26 software for further analysis. The analysis process includes several steps. First, basic descriptive statistics such a frequency distribution and percentages were used to describe the respondents' demographic, socioeconomic, and obstetric aspects. Second, a bivariate logistic regression was performed, pairing each independent variable with the outcome variable. If the bivariate test of a variable yielded a p-value of less than 0.2, it was considered a possible candidate for the multivariable model. Following the determination of the variables, multivariable analysis was performed. To determine whether the data was appropriate for multiple logistic regression analysis, the Hosmer and Lemeshow goodness-of-fit test was used (p = 0.27). Multicolliniarity was checked and there was no Multicolliniarity between independent variables. A multivariable logistic regression model was ultimately developed in order to determine distinct factors of prenatal vitamin utilization. The crude and adjusted odds ratios, as well as the corresponding 95% confidence intervals, were computed to assess the strength of the association. For all two-sided tests, a statistical significance level of P < 0.05 was employed.

In this study, 416 pregnant women participated with response rate of 98.34%. The mean age of the women were 25.8(SD ± 4.62). Among 416 pregnant women, 382 (91.83) of them were orthodox Christians. More than half (53.13%) of principal income generator of the household were husbands (Table 1).

More than half (55.04%) of pregnant women were multigravida. Two hundred fifty five (61.25%) of participants reaches to health institution with in 1 h of travel. From the total of study participant, 59.13% of them started antenatal care at second trimester (Table 2).

Among the total respondents, 242 (58.17%) of had no ever heard about prenatal vitamins. Nearly one quarter (25.25%) and 23.56% of study participants had good knowledge and favorable attitude respectively (Table 3).

In this study, we found that 87.5% (95% CI: 84.31, 90.34) of pregnant women didn't use prenatal vitamins (Figure 2).

From the total study participants, 178(48.9%) of them listed absence of information on prenatal vitamins as the reason for not using it (Figure 3).

Age of women, educational status, residency, gravidity, pregnancy planned, decision on health care, knowledge and attitude on prenatal vitamins were candidate variables for multivariable logistic regression analysis.

Women not having formal education were 2.72 times higher to be non-users of prenatal vitamin compared with women whose educational level were college and above (AOR = 2.72, 95%CI: 1.44–5.15). Non-users of prenatal vitamins were 2.58 times higher among unplanned pregnancy compared with planned pregnancy (AOR = 2.58, 95%CI: 1.76–3.78). The odds of being non-users of prenatal vitamins were 1.71 times higher among women whose husband were decision maker in health care compared with women who decide alone (AOR = 1.71, 95%CI:1.09–2.68). Women who had poor knowledge (AOR = 3.27, 95%CI: 1.44–7.42) and unfavorable attitude (AOR = 3.63, 95%CI: 1.61–8.18) on prenatal vitamins were less likely to take it compared with their counter parts (Table 4).

The results of this study highlight the need for laws governing public health to encourage pregnant women to take prenatal multivitamins, especially in groups where nutrient deficiencies are more likely to occur. Policy makers ought to think about launching educational initiatives that increase the knowledge of prenatal multivitamins. Incorporating prenatal multivitamin supplements in to current maternal health initiatives can also help guarantee that all women have access to vital nutrients, which will lower the prevalence of unfavorable pregnancy outcomes linked to deficiencies. Healthcare professionals should give special attention to talking about the usage of prenatal multivitamins. This entails clearing up any misunderstandings regarding the advantages of vitamins and minerals and offering precise instructions on the kinds required for optimum pregnancy wellness. Additionally, by collaborating with pharmacies and community health organizations, healthcare systems can make it easier for people to obtain reasonably priced prenatal multivitamins. We can improve maternal care and promote healthier pregnancies by implementing these measures, which will eventually benefit women and their offspring.

Being multi-center is one of the strength of the study since it increases the representativeness of the population. At the start of the interview, participants were assured that their responses would be kept entirely anonymous, which helped to minimize the desirability bias. However, absence of adequate literatures on the area makes it difficult to compare and discuss.