We investigated the prevalence and determinants of optimal ANC visits among reproductive-age women using data from the DHS of 54 LMICs and multilevel binary logistic regression analysis. The prevalence of optimal ANC visits was 60.1% overall. The result was significantly higher than in East Africa [37], Ethiopia [38, 39], Sub-Saharan Africa [36], and Jordan [40]. This result is also lower than those obtained in a systematic review and meta-analysis in Ethiopia [41], Ghana [42], Liberia [43], and Angola [44]. The systematic review and meta-analysis studies could explain this disparity; there is a sample size issue as well as a quality issue for articles that include the meta-analysis. Other studies are limited to a single country and are not representative of other regions. In terms of coverage of basic maternal health interventions such as antenatal care, the African Region has significant intraregional disparities [36]. According to the multilevel logistic regression analysis, maternal age, maternal education level, family size, number of children, sex of household head, wealth index, marital status, husband/partner education level, husband/partner occupation, maternal occupation, media exposure, place of delivery, and region were significant determinants of optimal ANC visits in LMICs.
Women and their partners with higher levels of education have a higher likelihood of receiving optimal ANC visits. This finding is consistent with previous research [3, 36, 45-49]. This is because education improves health-care utilization and increases knowledge about specific issues. Women's empowerment through education, household wealth, and decision-making increases their use of maternal health care services [50].
According to our findings, household wealth status is a significant predictor of optimal ANC visits. Women from the wealthiest families had significantly more ANC visits than women from the poorest families. In line with this finding, studies from Pakistan [51], Sub-Saharan Africa [52], Bangladesh [28, 30, 47], Indonesia [53], and India [54] discovered that women from the wealthiest families were more likely than women from poorer families to receive optimal ANC services. This could be because economic growth encourages health-care utilization and the ability to afford medical and non-medical costs associated with ANC services during pregnancy [55-58]. As a result of the findings, wealth status appears to be an important factor in determining optimal ANC visits. Because of their low socioeconomic status, they have less money to pay for transportation to a health facility to receive ANC services. Another possibility is that women from wealthy families have better education and access to the media than women from poor families.
We discovered that pregnant women with more children and a larger family size had a higher likelihood of receiving optimal ANC visits than pregnant women with fewer children and a smaller family size. It is comparable to previous research from Ethiopia [38, 59], Ghana [60], and Rwanda [61]. A larger family's lack of time and resources, as well as their self-confidence developed from previous pregnancy and childbirth, could be reasons for not using recommended ANC services [62-64].
In this study, married women and women who live with their partners were more likely to have optimal ANC visits than separated women. This research is related to studies [65, 66]. Separated women face a lack of or a reduced level of psychosocial support and relationship stability, according to theories that link marital status, pregnancy, and birth readiness. Unmarried pregnant women may be unplanned and/or unwanted. On the contrary, because illegitimate births are still stigmatized in many countries, social acceptance of separated status is low. As a result, separated women may differ fundamentally from married women in terms of empowerment, self-isolation, and motivation to seek health care [67-69].
According to our findings, working women and women whose husband or partner works had a higher likelihood of using optimal ANC visits than nonworking women and husbands or partners who do not work. This is supported by research from Nigeria [48], and Sub-Saharan Africa [70]. Nonworking women are unable to attend proper ANC visits and do not use health facility delivery due to financial constraints. Furthermore, women aged 20-34 and over 34 years were more likely than those aged under 20 to use optimal ANC visits. This finding corroborated previous research from Uganda [71], Ethiopia [72], and Sub-Saharan Africa [46].
In this study, access to media was also an important factor in health facility utilization. Individuals who had access to the media (reading newspapers or magazines, listening to the radio, and watching television) had a higher chance of using ANC than those who did not. This finding is in agreement with studies [49, 61, 70, 73]. Individuals with access to local media were also more likely to seek medical attention [74]. This simple fact may explain how individuals can quickly obtain various health messages, information about maternal health risk factors, and institutional delivery promotion via multiple radio or television programs [75]. According to the findings of this study, broadcasting the importance of health facility delivery on television, radio, and newspapers may help LMICs achieve maternal and child health-related goals [76]. According to the findings of this study, women who use health facility delivery have significantly higher optimal ANC visits than women who use home delivery. This finding was supported by the study from Sub-Saharan Africa [36]. One possible explanation is that women in health-care settings learned the value of ANC follow-up education. As a result, during ANC follow-up, women will exhibit behavioral changes toward health-care delivery.
Women with a female household head had a higher tendency to initiate optimal ANC visits than those with a male household head. This finding is consistent with the study's findings [70]. Seeking permission from others, especially those of the opposite gender, is a disincentive to early ANC initiation [77]. As a result, independent decision-making may be required for women to access and obtain optimal health care at ANC. Finally, these findings will help the government and stakeholders plan, design, and implement appropriate interventions, as well as address barriers to improving utilization of health facilities, thereby contributing to the reduction of maternal mortality in LMICs.
Strength and limitation of the study
The study's findings are supported by large datasets from 54 LMICs. The information was gathered using a standard, internationally accepted methodological procedure. The findings are representative of all included countries and generalizable to women in LMICs due to the survey's representative nature. The DHS survey year variation may have an impact on this result. The data was gathered using self-reports from mothers within the five years preceding the survey, which could be a source of recall and misclassification bias.