Quality Antenatal Care in Ethiopia: Insights into Provision, Utilisation, Barriers and Facilitators from a Mixed-Methods Study

Despite decades of progress, maternal and neonatal deaths during pregnancy, childbirth and immediately after childbirth remain alarmingly high, especially in sub-Saharan Africa (SSA), which accounted for 70% of the 260,000 maternal deaths and 46% of 2.3 million neonatal deaths globally in 2023. Within SSA, Ethiopia bears a high burden, with 195 maternal and 30 neonatal deaths per 100,000 and 1,000 live births respectively. Most of these deaths could be prevented through antenatal care (ANC), a package of healthcare during pregnancy aimed at promoting the health and well-being of pregnant women and their babies. ANC is most effective when provided and utilised in line with the World Health Organization’s guidelines for quality ANC, which recommend a minimum of four visits (recently increased to eight) covering specific interventions, with the first visit initiated within the first 12 weeks of pregnancy. However, the available evidence shows that the provision and utilisation of quality ANC remain suboptimal, especially in SSA. The prolonged conflict in Ethiopia has further aggravated the issue by restricting women’s access to services due to movement limitations and insecurity, and by preventing healthcare facilities from providing care because of damaged or destroyed infrastructure and the displacement of health professionals. While some studies have been conducted, gaps remain in understanding optimal ANC utilisation in SSA, as well as healthcare facilities’ readiness and the provision and utilisation of quality ANC at the national level in Ethiopia. The thesis aims to comprehensively assess optimal ANC utilisation in SSA, healthcare facilities’ readiness to provide quality ANC, the provision and utilisation of quality ANC in Ethiopia, and the factors influencing these outcomes. The study employed a sequential explanatory mixed-methods design, beginning with a systematic review of available evidence published between January 2002 and July 2024 and analysis of data from the 2021–22 Ethiopian Service Provision Assessment (ESPA) survey, followed by qualitative inquiry to explain and contextualise these findings.The review included studies that defined optimal ANC as having at least four or eight visits, identified through searches of PubMed, MEDLINE, EMBASE, CINAHL, and other relevant sources, with subgroup analyses conducted to estimate pooled prevalence and identify determinants for each category. A Poisson regression model was applied to assess factors associated with healthcare facilities’ readiness to deliver quality ANC and the provision of quality ANC, while a multilevel mixed-effects logistic regression model was used to examine individual- and facility-level factors influencing the timely initiation of ANC. In-depth interviews (IDIs) and focus group discussions (FGDs) with purposively selected 13 midwives and 22 pregnant women were conducted to further explore barriers and facilitators to quality ANC. Quantitative data were analysed using STATA version 16 (StataCorp LLC, College Station, TX, USA), while qualitative data were analysed using NVivo 12 software. Quantitative findings showed that ANC quality remains suboptimal. Across SSA, 49.7% of women attended ≥4 visits and 25.3% attended ≥8 visits. In Ethiopia, women received an average of 11 out of 24 recommended ANC interventions during their first visit, only 14.9% initiated ANC in a timely manner, and none of the 905 facilities assessed had all essential resources for quality ANC. Socio-demographic factors such as urban residence, planned pregnancy, maternal employment, husband’s education, partner involvement, and abortion history were positively associated with quality ANC provision and utilisation. In contrast, women attending rural facilities, health posts, or bypassing nearby facilities were less likely to receive and utilise quality care. Facility readiness also varied, with limited availability of medicines and commodities in clinics and rural facilities, but relatively better readiness in regions such as Afar, Amhara, and Somali. The qualitative findings helped explain these patterns, revealing multilevel barriers that underpin the observed quantitative gaps. These included reliance on analogue medical records, limited access to ultrasound services, midwives’ disengagement, and systemic resource constraints within facilities. From the demand side, women reported limited awareness, low trust in services, emergency-driven care-seeking, and financial challenges as key barriers to timely and adequate ANC utilisation. Conversely, both women and midwives highlighted facilitators such as pilot digitisation initiatives, affordable and geographically accessible services, collaborative and midwife-led models of care, and women’s active engagement during consultations. Together, the integrated findings demonstrate that suboptimal ANC quality in Ethiopia is driven by intersecting structural, provider, and individual-level factors, underscoring the need for context-specific, system-wide interventions. Specific recommendations include (i) ensuring adequate and well-resourced healthcare providers and efficient systems across all facilities, while addressing disparities by facility type, managing authority, location, and region; (ii) enhancing healthcare providers’ performance and motivation through targeted interventions, including preservice training, supportive supervision, continuing education, and recognition of their contributions; and (iii) expanding employment and health insurance, providing targeted health education on preventing unplanned pregnancies and the importance of ANC, encouraging early ANC initiation, and promoting the use of nearby healthcare facilities, especially in rural areas, to enable pregnant women to utilise quality ANC.