Antenatal care (ANC) can be defined as “the care provided by skilled health care professionals to pregnant women and adolescent girls in order to ensure the best health conditions for both mother and baby during pregnancy” (1). Globally, only 50% of pregnant women attended the World Health Organization (WHO) recommended minimum of four ANC visits to improve fetal and maternal health (2, 3).

Low and middle-income countries (LMIC) account for the majority (99%) of global maternal deaths. In particular, sub-Saharan Africa and Southern Asia regions bear a significant portion, contributing to over 80% of global maternal mortality (4). However, the prevalence of recommended antenatal care (ANC) utilization in these regions is low, ranging from 53.39% to 78.86% in East Africa and Southern region of Africa respectively (5).

In sub-Saharan African countries, utilizing at least one ANC visit reduces the risk of neonatal mortality by 39% (6), and a systematic review and meta-analysis found a significant effect of ANC on maternal near-miss events in Ethiopia; at least one ANC visit will avoid approximately 75% of maternal near-miss events (7).

According to a Sub-Saharan Africa study conducted from 2006 to 2018, Ethiopia had the lowest prevalence of recommended ANC utilization, at 31.88% (5). However, trends in antenatal care use (4+ ANC visits) in Ethiopia in the past 14 years showed an increment from 12% to 43%. The coverage (four or more ANC visits) has increased more than two-fold (19% to 43%) (8), since community based health insurance (CBHI) started in Ethiopia (9).

Factors affecting ANC utilizations are distance to services (10), media exposure, wealth index and availability of maternal health services (11), maternal education, women's employment, marital status, household income, cost, and pregnant women's history of obstetric complications (12, 13).

Membership to health insurance scheme also increases the odds of antenatal care utilizations (14, 15). The community-based health insurance program is widely accepted in resource limited settings as a strategy for improving healthcare utilization and health seeking behaviors and reducing out-of-pocket catastrophic payments (16) and a promising means to attain universal health coverage (17–19). In the Sustainable Development Goals (SDGs), progress on Universal Health Coverage (UHC) is tracked using two indicators: coverage of essential health services (SDG 3.8.1); and catastrophic health spending (and related indicators) (SDG 3.8.2) (20).

Universal health coverage (UHC) is a situation where every individual and all communities have unparalleled access to quality health services without suffering any form of financial hardship (21). The UHC is effective in reducing barriers to accessing essential primary care services, including antenatal care through removing financial constraints and ensuring availability, UHC enables women to seek early and regular antenatal care, leading to improved maternal and child health outcomes (10).

Several studies have identified potential factors associated with maternal health seeking behavior. However, the association between community-based health insurance coverage and antenatal care utilization was not well investigated in Ethiopia. Therefore, this study was aimed at assessing the effect of community-based health insurance coverage on antenatal care use in Ethiopia.

In this study, we examined the relationship between community-based health insurance coverage and ANC utilization in Ethiopia using 2019 Ethiopia mini-DHS data. One in five of women with female household heads and 31.5% of women with male household heads were enrolled in the CBHI. Only 26.8% of women from the poorest wealth index were enrolled in the CBHI, compared to 40.3% of those from the median wealth index. According to our findings, antenatal care coverage in Ethiopia is less than fifty percent. Women are 33% more likely to use ANC if they have CBHI membership. In addition to CBHI membership, the authorities should think about access to the media, education, and wealth status to improve antenatal services for Ethiopian women.

Ethiopia has been implementing CBHI since 2011 (23). The CBHI in Ethiopia targeted the rural areas and citizens mainly recruited in informal sectors such as agriculture. Its expansion in the recent time has brought a significant improvement in healthcare utilizations and financial risk protection (23).

According to EDHS 2019, 43 percent of pregnant women received prenatal care (ANC 4+) (95% CI: 41.5%–44.3%). Despite of the fact that the prevalence of ANC 4 + coverage has risen over time (12% in 2005, 19% in 2011, and 32% in 2016), more than half of pregnant women did not use it during their pregnancy. Ethiopia is ranked 35th among sub-Saharan African nations in terms of coverage of ANC, according to Ataguba JE and colleagues (24). Multi-sectorial, personal factors and community perceptions are contributing to low coverage of maternal health services in Sub-Saharan Africa. One reason for persistent low coverage of antenatal care could be related to delayed initiation of antenatal care, which hinders the completion of ANC follow-up, as the median survival time was reported was between 5 and 7 months (25, 26). Indication, community attitudes regarding cultural beliefs, the ability of decisions, and interactions with healthcare providers are potential barriers to the utilization of healthcare services during pregnancy (26–28). The uptake of antenatal care (ANC) is critical for universal reproductive coverage. ANC represents women's entrance into health services and the potential to raise safe mother and newborn targets, even though it is not expected to directly impact mortality.

The current study depicted the positive association between health insurance enrollment and ANC 4 + utilizations. Different local studies also reported a significant association (29, 30). This finding is comparable to that of previous studies conducted across Sub Saharan Africa on the association of insurance with ANC use (10, 31). The positive association might be due to insurance providing sufficient protection against catastrophic expenditure and because insurance can be linked to other socioeconomic indicators (32). Although the government provided a complete exemption for the cost of healthcare services for pregnant women, health insurance coverage is essential to eliminate out-of-pocket payments and significantly eliminate the financial barriers that often limit women's ability to attend ANC. In addition, CBHI could have other positive impacts, such as community development and local accountability of health care providers (33–37). Hence, by emphasizing the importance of CBHI and focusing on increasing enrollment, societies can remove financial barriers to healthcare access, leading to improved health-seeking behavior and better health outcomes for their populations.

Being in the highest wealth quintile increased the likelihood of ANC 4 + utilization. The finding is comparable with studies conducted in Bangladesh (38), Mozambique (39) and systematic review across SSA (40). There is strong evidence that women's economic status was a strong predictor of compliance with the nationally recommended first contact with ANC and facility delivery, with the richest women more likely to seek early health care (40–42). This positive impact of economic status could decrease the dropout rate and enable women to attend optimal ANC.

Education emerged as a significant factor in our analyses. Pregnant women with lower formal education were less likely to have ANC attendance as compared to those who had higher education level. Our study also shows that among pregnant women with formal education, those who had secondary or higher education tend to have a higher likelihood of reporting attendance at the ANC compared to their counterparts who did not have formal education. This finding is consistent as previous EDHS data report similar finding (43). Similarly, those who do not have access to the media appear to be excluded from antenatal care programs. Although health planners cannot change education levels, they should be considered in health promotion activities, using methods that are appropriate for this more susceptible demographic. In Ethiopia, health extension workers are a vital resource at the community level, and they would be used to reach women with lower levels of education. Health promotion initiatives should incorporate methods that are appropriate for this group, such as non-written tools for information, education, and communication.

The study included data from a countrywide survey, which might be viewed as strength and could improve representativeness. The limitation is that a temporal relationship between the outcome and response variables cannot be established with the cross-sectional study design.

According to our findings, less than half of Ethiopian women had four and more antenatal care visits. We conclude that being covered by health insurance is associated with a higher likelihood of seeking timely ANC attendance. For this reason, we recommend that government and national health insurance authorities in Ethiopia to actively implement health insurance policies as well as roll out health educational programs that will facilitate and ensure high coverage of health insurance. Respondent age, Media access, marital status, education status, wealth index, and economic regions were also factors associated with antenatal care utilizations. Empowering the economic status of women and enhancing education coverage and media access are essential determinant to increase antenatal care utilization.