Antenatal care is the care offered for pregnant women and is recognized as a input for maternal service in improving and keeping health outcomes for both lives of mothers and newborns. World health organization (WHO) ANC model recommends a minimum of four ANC contacts, and encourages that the first contact appointment will take place within the first trimester (1). Antenatal care is also referred as the care provided by skilled healthcare providers to pregnant mothers to make sure the health conditions for both mother and baby. ANC is one of the “four pillars” of safe motherhood initiatives, which is used to promote and establish good health during pregnancy and the early postpartum periods (2–4).

Globally, there is a huge difference in the prevalence of late ANC checkup among pregnant mothers that is the prevalence of late ANC in developed countries is 27.5%, and that of developing countries is 88 % (5–8). In spite of ANC service is given without fee and there is high accessibility; low ANC utilization and late registering or booking is still a main problem (9, 10).

Even though, most studies have revealed a lot of factors affecting the utilization of ANC in different contexts, these findings have not been prepared collectively for a factor that affects mothers for late ANC initiation (11). According to a study conducted in Mekelle city, Most of the attendees 109 (48%) made their first visit in their first trimesters and a study done in Jimma town about (51.8%) of the mothers started ANC at late (12–14).

Women who have an inadequate number of ANC visits or start ANC later than the first trimester seem to have higher rates of poor pregnancy outcomes, such as low birth weight and pre-term birth (15, 16). Maternal health complications and lack of prenatal outcomes are often associated with other factors like the non-utilization of antenatal and childbirth services and poor socioeconomic status. Unwanted outcomes are, seen in those mothers who have not done ANC registration due to their delay of antenatal care because of dissatisfaction toward the quality of service pregnant mothers are affected by complications like: preeclampsia, malaria, lack of birth readiness, post-partum hemorrhage due to lack of risk identification at ANC level (17–23).

According to a study done in Niger Delta, Nigeria 73.6% of mothers booked lately (24). According to research conducted in Douala general hospital (DGH), Cameroon From a total of participated women, about 44% of them registered the first ANC visit lately (25). A study done in public health institutions of Axum town, the prevalence of timely ANC initiation of was 27.5%. But, about three fourth of the mothers (72.5%) booked their ANC visit lately (26). A study conducted in Kembata Tembaro Zone in SNNPR also shows that the magnitude of participants who started ANC early was 31.4% while those who registered lately were 68.6%. The finding of the study conducted in northern Ethiopia shows that 59.4% of pregnant mothers began their first visit after the first trimester and in the central zone of the Tigray region the prevalence of late ANC booking at the first visit was 85% (1, 8, 19, 27–29).

According to a study done in Debre Markos town, the magnitude of participants who made their first antenatal care visit after 16 weeks of gestation was found to be 33% (30). A done in Debre Berhan town, the proportion of pregnant women who had ANC booking within the first trimester of pregnancy was 40.6% (31). According to a study done in Ilu Ababor Oromia regional state, the proportion of respondents who initiated ANC lately was 71.2% (32).

There is no study done on the time of ANC initiation amongst pregnant mothers in the selected study area to the best of our knowledge. It is essential to identify the status of ANC late initiation and associated factors to improve maternal and fetal outcomes via sufficient utilization of Antenatal care.

The results of this study showed that among 330 women, about 58.5 % of women came for their first ANC visit initiation lately or registered first ANC visit after 16 weeks of gestation. The finding of this study is almost higher than when compared to with a study done in Douala general hospital (DGH), Cameroon 44 % (25), Debre Markos, 33.4 % (30). This is might be due to socio-demographic differences and health care service awareness. But the prevalence of women who started for their first ANC visit lately is significantly lower than Nigeria 73.6% (24), Axum town (72.5%) (26), Kembata Tembaro Zone (68.6%) (27), Ilu Ababor (71.2%) (33), East Wollega 81.5% (23). This is because of the high distribution of health posts and the promotion of maternal health care utilization by health extension workers.

Furthermore, the magnitude of respondents who registered lately in this study is lower than the Ethiopian demographic health survey 2019 report of 72% or only 28% of women had their first ANC visit during the first trimester (34). This may be due to this study being at a specific hospital in which total populations are different when we compare with the national and gap in the year of study and a lot of strategies and work has been done since then to improve maternal health services.

In this study, teenagers mothers were utilized late ANC than older women. This finding is similar with the studies done in Zambia (35), Nigeria (36), and the United Kingdom (37). This might be young teenagers women may have lack of knowledge, single, unwanted pregnancy, did not experienced with pregnancy when compared with women aged >20 years (35–37). Women who were housewives in their occupation were came lately to ANC visit as compared to those mothers who were governmental employees. This finding was similar with other studies done in North West of Ethiopia (38). The probable justification might be that those women who were governmental employee might have better access of knowledge, peer pressure, awareness and understanding about early ANC services (39).

Mothers who were living with high family size were came lately ANC visit initiation as compared to those who were living with less and equal to three family size. This study is in line with the study done in Rwanda (40) and Illu Abbabora, Ethiopia (33). This might be due to lack of economy which increases as the number of family size increases in developing country. Another reason might be most women overtake their time on other workload activities to develop their family to fulfill their basic needs rather than considering about their pregnancy checkup early.

Regarding distance, Women who travel >1 h and above of walking time from their home to the health facility had 5.52 times higher odds of late first ANC visit initiation as compared to those who travel <1 h and above of walking time. This study is in line with a study done in Zambia, Bahirdar Zuria Wereda, Ethiopia (35, 41). The possible reason might be those women living in a low income country utilize their time in day to day activity for survival of them self's and their family rather than considering their health checkup until they feel some symptoms. The other reason might be due to lack of transport and uncomfortable road for vehicles due to most valley land or unsuitable geographical area.

In this study, the majority of women started their first antenatal care initiation lately. Women's age, being housewives, having a large family size, and long-distance from a health facility were factors identified for late first ANC initiation. Based on the findings of this study, Ambo Zonal Health Office and Cheliya Wereda Health Office should strengthen the provision of training for health extension workers to teach pregnant mothers about early ANC initiation by going home to home. Provision of education and communication for young mothers and their partners by health professionals at a hospital during morning health education and Provision of additional Hospital or ambulance for the community to reach easily and timely at health facility service.

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding authors.

An ethical clearance letter was obtained from the Ambo University Department of Midwifery Ethical Committee with the reference number UGC/83/2021. Written informed consent to participate in this study was provided by the participants' legal guardian/next of kin.

KD and BD conceptualized the idea, wrote the original draft, supervised the overall study, analyzed data, prepared the manuscript, drafted or revised the article, gave final approval of the version to be published, and agree to be accountable for all aspects of the work.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

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