Late antenatal care booking and associated factors among pregnant women in Mizan-Aman town, South West Ethiopia, 2021

**Background:** Antenatal care (ANC) is a critical intervention for reducing maternal and neonatal morbidity and mortality. Despite WHO recommendations that the first ANC contact should occur during the first trimester, many pregnant women in low-income countries initiate care late. Limited data existed on factors influencing ANC timing in Mizan-Aman town, Southwest Ethiopia.

**Methods:** An institutional-based cross-sectional study was conducted from February 15 to March 25, 2021, in Mizan-Aman town. A systematic random sampling method was used to recruit 425 pregnant women attending ANC services at two public health facilities (Mizan Tepi University Teaching Hospital and Mizan Teferi Health Center). Data were collected via face-to-face interviews using a structured questionnaire adapted from prior literature, translated into Amharic, and pretested. Gestational age was verified from medical charts. Data were entered into EPI info-7 and analyzed using SPSS version 20. Bivariate and multivariate logistic regression analyses were performed; p-value <0.05 was considered statistically significant.

**Key Results:** The response rate was 100% (425 participants). Mean maternal age was 25.7 years (SD ±5.5); 61.9% lived in urban areas; 89.6% were married; 26.8% had primary education; 28.2% were housewives. The prevalence of late first ANC booking (≥16 weeks gestation) was 70.0% (95% CI: 65.65–74.35). Among late bookers, 77.4% had an inappropriate perception of ANC starting time, 66.0% were unaware of pregnancy danger signs, and 49.5% were unaware of service delivery during working hours. Multivariate analysis identified four independent predictors of late ANC booking: (1) Unplanned pregnancy: women with unplanned pregnancies were 2.63 times more likely to book late [AOR = 2.63, 95% CI: 1.18–5.85]; (2) Inappropriate perception of ANC starting time: women who believed ANC should start after 4 months were 4.1 times more likely to book late [AOR = 4.1, 95% CI: 1.9–8.83]; (3) Lack of awareness of pregnancy danger signs: women unaware of danger signs had 6.76 times higher odds of late booking [AOR = 6.76, 95% CI: 2.83–16.1]; (4) Unawareness of service delivery during working hours: women unaware of service hours were less likely to be late [AOR = 0.44, 95% CI: 0.19–0.98]. Common reasons cited for late attendance included feeling healthy (23.2%), perceiving it was the right time (22.9%), long waiting times (17.8%), being too busy (14.1%), distance (11.1%), and COVID-19 concerns (7.4%).

**Clinical Implications:** The high prevalence of late ANC booking (70%) in this setting indicates a major gap in achieving timely maternal healthcare access. The strong associations with modifiable factors—particularly lack of awareness about danger signs and misperceptions about optimal ANC timing—suggest that community-based health education interventions could substantially improve early booking rates. Health extension programs should prioritize educating women and families about pregnancy danger signs and the importance of initiating ANC within the first trimester. Additionally, health facilities should ensure services are accessible throughout working hours and address barriers such as long waiting times and inconvenient booking systems. The finding that unplanned pregnancy increases risk of late booking underscores the need for family planning integration with maternal health services.