Timely initiation of antenatal care and associated factors among pregnant women attending antenatal care in Southwest Ethiopia.

BACKGROUND: The timing of initiation of first antenatal care visit is paramount for ensuring optimal care and health outcomes for women and children. However, the existing evidence from developing countries, including Ethiopia, indicates that most pregnant women are attending antenatal care in late pregnancy. Thus, this study was aimed to assess timely initiation of antenatal care and associated factors among pregnant women attending antenatal care services in Southwest Ethiopia.
METHODS: Institutional based cross-sectional study was conducted among 375 pregnant women from April 15 to June 15, 2019 in Southwest Ethiopia. A structured and pre-tested face-to-face interviewer-administered questionnaire technique was used to collect data. Systematic random sampling technique was employed to recruit pregnant women. The data were entered into Epi data version 4.4.2 and analyzed using SPSS version 25. Frequency tables, charts and measures of central tendency were used to describe the data. The effect of each variable on timely initiation of antenatal care was assessed using bi-variable logistic regression. A multivariable logistic regression model was used to identify factors associated with timely initiation of antenatal care. The adjusted odds ratio with 95% confidence interval and p<0.05 was used to identify factors associated with timely initiation of antenatal care.
RESULTS: The study revealed that 41.9% of pregnant women started antenatal care timely. Pregnant women who had good knowledge of timely initiation of antenatal care (AOR = 3.8, 95% CI: 2.2-6.5), planned to be pregnant (AOR = 5.1, 95% CI: 2.9-8.9), being primigravida (AOR = 2.6, 95% CI: 1.4-4.7) and confirmed their pregnancy by urine test (AOR = 4.1, 95% CI: 2.4-6.9) were found to be significant predictors for timely initiation of antenatal care.
CONCLUSIONS: Despite the efforts made to make ANC visit services freely available, timely initiation of antenatal care among pregnant women in the study area was low. Pregnant women who had good knowledge of timely initiation of antenatal care, planned to be pregnant, being primigravida and confirmed pregnancy by urine test were found to be significant predictors for timely initiation of antenatal care. Therefore, efforts that strengthen awareness on antenatal care and its right time of commencement, increase pregnant women's knowledge of timing of antenatal care services and reducing unplanned pregnancies should be organized.

Background

Woman’s death during and following pregnancy and childbirth is a serious public health concern. About 295, 000 women died during and following pregnancy and childbirth in 2017 worldwide and 5.1 million babies are stillborn or die in first month of life [1] and 94% of all maternal deaths occur in low and lower middle-income countries [2]. Roughly two-thirds (196,000) of maternal deaths occurred in sub-Saharan Africa [3].

Women are screened for risk factors and receive appropriate advice, get tetanus toxoid vaccinations, health education and counseling on individual birth planning, intermittent presumptive treatment of malaria and iron supplementation during follow-up at the antenatal care (ANC) clinics. It is helpful to diagnose pre-existing health problems or to detect health complications. In turn, it leads to reduction in maternal mortality and morbidity [4].

Antenatal care from organized health care services has a paramount importance to ensure every pregnancy ends up with the delivery of a healthy child and keeping the health of the mother [5]. The World Health Organization (WHO) recommends that women and adolescent girls should have at least eight ANC contacts during pregnancy to improve perinatal outcomes and women’s experience of care. The first visit is recommended to be during the first trimester [6].

Late initiation of antenatal care affects the health of both a child and the mother. Late initiation and inadequate utilization of ANC during pregnancy contributes to adverse maternal health outcomes such as maternal mortality [7]. Early initiation of ANC allows health professionals to treat and manage other treatable health conditions such as congenital anomalies, syphilis, control hypertension, anemia, control HIV/AIDS transmitted from mother to child and prevention of malaria complications that the woman may develop during pregnancy [8, 9].

Studies revealed that socio-demographic characteristics of pregnant women, past experience of ANC service utilization, parity, knowledge of the timing of ANC and pregnancy, and gender-biased cultures are the main factors that influence use of timely ANC in developing countries [10, 11]. In sub-Saharan Africa, low ANC coverage, low frequency of visits and late attendance at first antenatal visit were found to be common problems [12].

Ethiopia has been implementing maternal and newborn health interventions and has achieved significant improvements in the coverage. ANC services are being given free of charge in all governmental health institutions. However, only 20% of women had their first ANC during the first trimester [13]. Studies conducted in Ambo and Mekele, Ethiopia showed that the timely initiation of ANC was 13.2% and 32.7%, respectively. Studies on timely initiation of ANC and its associated factors are conducted in different parts of Ethiopia [4, 7, 12, 14, 15]. However, there is scarcity of information on timely initiation and associated factors in the study area. In addition, specific empirical evidence is needed to tackle problems related to late initiation of antenatal care and improve the health of a child and the mother during and after pregnancy. Therefore, this study was aimed to determine timely initiation of ANC and associated factors among pregnant women attending antenatal care services in Agaro town health institutions, Southwest Ethiopia.

Methods and materials

Study design, area and period

Institution-based cross-sectional study design was conducted among pregnant women attending ANC services. The study was conducted from April 15 to June 15, 2019 in Agaro town, Southwest Ethiopia. Agaro town is located 390 km Southwest of Addis Ababa. The town has a population of 40,114 residents. Of these, 8,877 were women at the reproductive age (15–49 years). In the town, there were 8 governmental health facilities (two health centers, one governmental hospital and five health posts) and six private clinics. All health facilities that had well documented registration books and provided ANC services were included in the study. Of governmental health facilities, three of them (one hospital and two health centers) were included in the study. Of private health facilities, two private clinics were included in the study. The two-months report (January and February 2019) indicated that the number of pregnant women attending ANC services in the five eligible health facilities were 798 (338 from Agaro Hospital, 318 from Agaro health center, 54 from Razel health center, 42 from Yohannes clinic and 46 from Kegna clinic).

Population

All pregnant women who were attending antenatal care services at health facilities of Agaro town during the data collection period were included in the study and pregnant women who were seriously sick and unable to communicate during the study period were excluded from the study.

Sampling size and sampling procedures

The sample size was calculated using a single population proportion formula () [16] based on the following assumptions: the proportion of timely initiation of ANC in the previous study, p = 35.4% [17], level of significance, α = 5%, 95% confidence interval and margin of error, d = 5%. Adding a 10% non-response rate, the minimum sample size was 387 pregnant women.

All eligible health facilities were included in the study. The two-months report (January and February 2019) indicated that the number of pregnant women attending ANC services in the five eligible health facilities were 798 (338 from Agaro Hospital, 318 from Agaro health center, 54 from Razel health center, 42 from Yohannes clinic and 46 from Kegna clinic). Systematic random sampling technique was employed to recruit pregnant women. The total sample size (387) was proportionally allocated for the five health facilities depending on their client flow. The proportional allocation formula (ni = (n/N) *Ni) was used to determine the sample size for each health facility. Based on this, 164 pregnant women from Agaro hospital, 154 pregnant women from Agaro health center, 26 pregnant women from Razel health center, 21 pregnant women from Yohannes private clinic and 22 pregnant women from Kegna private clinic were recruited to the study. The sampling interval (K = N/n) for each health facility was 2. The starting point was determined by balloting and the second pregnant woman attending the ANC service was the first client recruited for the study. Then, every other pregnant woman who was attending ANC services was recruited at each health facility until the total sample size for this study was filled.

Variables

The dependent variable was timely initiation of an antenatal care visit. The independent variables were identified by reviewing different literatures related to the topic of interest [10-15]. The list of variables were socio-demographic characteristics of pregnant women such as age of the mother, marital status, occupation, educational status, place of residence, and monthly income. The other independent variables were previous use of ANC services, parity, knowledge about time of first ANC, distance from health facility, cost of services, previous birth outcome, medical complications in previous pregnancy, intention of pregnancy and satisfaction with ANC services of previous pregnancy.

Data collection instruments and procedures

A structured and pre-tested face-to-face interviewer-administered closed-ended questionnaire was used to collect data. The questionnaire includes socio-demographic characteristics of pregnant women such as age of mother, marital status, occupation, educational status, residence, and monthly income. The other independent variables were previous use of ANC services, parity, knowledge on time of first ANC, distance from health facility, cost of services, previous birth outcome, medical complications in previous pregnancy, intention of pregnancy and satisfaction with ANC services of previous pregnancy [10-15]. Five trained female diploma nurses collected the data and the principal investigator and one supervisor supervised them. The data collectors were not employees of that institution.

The reliability of the questionnaire was checked using Cronbach’s alpha reliability test and the value was 0.83. To ensure the quality of data, the questionnaire was prepared in English, translated to local language, and translated back to English to check for consistency. The data collectors and supervisors were trained for a day on data collection tools and procedures. Pretest was done on 5% of the total sample size out of the study area prior to the time of actual data collection. Completeness and consistencies of the collected data were checked on a daily basis and feedback was given to data collectors based on findings.

Data processing and analysis

The collected data was checked, cleaned and entered into Epi Data version 4.4.2 and was exported to and analyzed by SPSS version 25 software. Descriptive statistics such as frequency table, mean, median and standard deviation were used to summarize the data. The dependent variable was dichotomous, that is, timely (within 16 weeks of gestation) or late visit to ANC (after 16 weeks of gestation). The association between each independent variable and timely initiation of antenatal care was assessed using a bi-variable logistic regression model. Variables with p-value < 0.2 in the bi-variable logistic regression were included in the final model (multivariable logistic regression). In the final model, an adjusted odds ratio with a 95% confidence interval and a p-value < 0.05 was used to declare statistical significance.

Ethical considerations

The study was conducted in accordance with the Declaration of Helsinki. Ethical clearance (CMHS 237/11/11) was obtained from the Institutional Review board of the College of Medicine and Health Sciences, Wollo University. Permission letter to conduct the study was obtained from Agaro town health office. Written informed consent was obtained from pregnant women after they were informed about the objectives and procedures of the study. The right to refuse participation any time they want were assured. Any involvement in the study was done after complete consent was obtained. They were informed that all data obtained from them would be kept confidential by using codes instead of any personal identifiers and was meant only for the purpose of the study.

Results

Socio-demographic characteristics of pregnant women

Out of 387 pregnant women initially included in this study, 375 responded to the interview, which gave a response rate of 96.9%. About 292 (77.9%) women were in the age group of 20 to 34 years. The age group ranges from 16 to 42 years and the mean age of the respondents were 25.5 years (± 5.6 years). Regarding the ethnicity and religion of respondents, 243 (64.8%) and 254 (67.7%) were Oromo and Muslim, respectively. Three hundred eighteen (84.8%) ANC attendees were married. About 153 (40.8%) pregnant women have attended primary school and 191 (50.9%) pregnant women were housewives by occupation (

Obstetric history of pregnant women

About 284 (75%) pregnant women had more than one previous pregnancy experience. Fifty-eight (20.4%) pregnant women have had abortions. About 279 (74.4%) pregnant women had given one birth or above. Of these, 39 (14%) have experienced stillbirth. Thirty-six (12.9%) women had experienced pregnancy related complications. Of pregnant women who have had birth experience, 237 (84.9%) of the women have attended ANC services at various facilities (

Knowledge of pregnant women on timing of antenatal care

About 353 (94.1%) pregnant women reported that ANC service is important and 314 (83.7%) and 343 (91.5%) respondents knew that early booking of the first ANC improves the health of the mother and fetal outcome, respectively. Concerning the knowledge of appropriate time to begin first ANC, only 211 (56.3%) pregnant women reported that it should be within 16 weeks of the pregnancy. One hundred eighty (48%) pregnant women knew that pregnant women required four and above ANC visits (

Current pregnancy characteristics of pregnant women

Of 375 pregnant women, 214 (57.1%) have planned to be pregnant. Pregnancy conformed through urine test by checking the HCG hormone was found to be 133 (35.5%). About 226 (60.3%) women were advised to start ANC. One hundred fifty-one (40.3%) pregnant women reported that they experienced pregnancy related complications before they started the ANC service. Of those having experienced pregnancy related complications, 119 (78.8%) started their ANC follow up because of the complication (

Timing of first ANC visit of pregnant women

About 157 (41.9%) pregnant women started their first ANC visit timely. The timing of the first ANC booking ranged from 4 weeks to 40 weeks of gestation and the mean time of the ANC visit was 18 weeks (± 5.50 weeks).

Factors associated with timely initiation of antenatal care

A multivariable logistic regression was done to identify independent predictors of timely initiation of ANC. As a result, the analysis revealed that pregnant women who were primigravida, having good knowledge of timely initiation of ANC, planned to be pregnant and confirmed pregnancy by urine test were significantly associated with timely initiation of antenatal care.

Pregnant women who were primigravida were 2.9 times more likely to initiate antenatal care timely as compared pregnant women who had pregnancy twice or more [AOR = 2.9, 95% CI: 1.6–5.3]. Pregnant women who had good knowledge of time of first ANC were about 3.8 times more likely to start first ANC visit timely as compared to their counterparts [AOR = 3.8, 95% CI: 2.2, 6.5]. Pregnant women with a planned pregnancy were 5.1 times more likely to start the first ANC visit timely as compared to those who had an unplanned pregnancy [AOR = 5.1, 95% CI: 2.9, 8.9]. Pregnant women who had confirmed their pregnancy by urine test were 4.1 times more likely to initiate ANC timely than those who confirmed pregnancy through a missed period. [AOR = 4.1, 95% CI = 2.4–6.9] (

Discussion

This study was aimed to determine the timely initiation of antenatal care and its associated factors among pregnant women attending antenatal care services in Agaro town health institutions, Southwest Ethiopia.

The percentage of timely initiation of ANC among pregnant women in the current study was consistent with studies conducted in Bahir Dar, Ethiopia and sub-Saharan Africa [18, 19]. However, the percentage was lower compared to a study done in Southeast Ethiopia [20]. The percentage was also lower than studies conducted in Nepal and Sindh, Pakistan [21, 22]. On the contrary, the percentage of timely initiation of ANC of the current study was higher compared to studies done in Dilla town [17] and Southern Ethiopia [12, 23]. ’The percentage was also higher compared to the finding of Tesfaye et al from a systematic review and meta-analysis of studies conducted in Ethiopia [7]. The possible reasons for this difference might be studies conducted in Southeast Ethiopia, Nepal and Sindh, Pakistan were on large sample size compared to the current study. In addition, the previous studies [7, 12, 14, 15, 17, 20–24] indicated that the difference in having previous experience of 1st ANC visit, getting advice about ANC visit, place of residence, cultures to reveal pregnancy at early time and educational status of the pregnant women might be the possible reasons.

Mothers who had no previous pregnancy experience were more likely to start first ANC visit timely compared to those with a gravidity of two and above. This finding was similar to a systematic review and meta-analysis study conducted in Ethiopia [7]. This might be because young women with first pregnancy and childbirth are more careful about pregnancy and, in turn, leads them to require antenatal care early compared to multigravida women. In addition, younger women might implement the advice they get from family members, neighbors, and health professionals more compared to the older ones. It might also be because multigravida women feel more confident [7] after previous experience and feel that they can manage the pregnancy process easily and there is no need to visit health facilities early.

This study revealed that pregnant women who had good knowledge of time of first ANC were more likely to start first ANC visit timely as compared to their counterparts. This study is in line with studies done in Mekele city, Ethiopia, and Ambo, Ethiopia [14, 15]. This might be because the more pregnant women know the time of first ANC visit, the more they know the advantages of commencing ANC visit. In turn, this might help them to start the ANC visit timely. Pregnant women who had an intention of getting pregnant were more likely to start first ANC visit timely as compared to those who had an unplanned pregnancy. This finding was in line with a study done in Arbaminch, Ethiopia [25]. This might be due to planned pregnancies being more cared for by pregnant women and their spouses and, in turn, enables the pregnant women to book for ANC timely.

Pregnant women who had confirmed pregnancy by urine test were more likely to initiate ANC timely than those who confirmed their pregnancy through a missed period. This finding was consistent with a study conducted in Halaba [26]. This could be because urine is done in health institutions and pregnant women are initiated to start ANC when they come to confirm pregnancy.

Overall, the current study implies that efforts are needed to increase pregnant women’s knowledge of antenatal care and its right time of commencement by providing information for pregnant women about the importance of utilizing timely ANC, pregnancy risks, and danger signs. Including both public and private health facilities to reflect the real timely initiation and associated factors of ANC in the study area was the strength of the study. The cross-sectional nature of the study could not allow us to make strong cause-effect associations and the generalizability of the study to a larger population might be limited since it was conducted at health institutions. Since the data were collected from an interviewer-administered questionnaire, there might be a possibility of social desirability bias.

Conclusions

Despite the efforts made to make ANC visit services freely available, timely initiation of antenatal care among pregnant women in the study area was low. Pregnant women who were primigravida, having good knowledge of timely initiation of ANC, planned to be pregnant, and confirmed pregnancy by urine test were significantly associated with timely initiation of antenatal care. Therefore, efforts that strengthen and maintain local information dissemination networks on antenatal care and its right time of commencement, increase pregnant women’s knowledge of the timing of ANC service by providing information about the importance of utilizing timely ANC, pregnancy risks, and danger signs and reducing unplanned pregnancies should be organized and implemented.

(RAR)

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(SAV)

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12 Jan 2022

Timely Initiation of Antenatal Care and Associated Factors among Pregnant Women Attending Antenatal Care in Southwest Ethiopia

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Reviewer #1: Thank you for giving me the opportunity to review this paper.

My comments are the following:

Background

The background should be written at a higher level as we can assume that readers have basic understanding of the topic. For example, ANC does not need to be defined.

The background should try to make a better link between timely initiation of ANC and maternal mortality

I would suggest using local or regional references when discussing factors influencing timely initiation ofANC. The references are also quite outdated and would recommend using more current references such as:

https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-020-03236-9

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7864666/

Methods

The methods should be re-written for better flow

The section of population is very repetitive and can be summarized in one sentence

Is Agari a rural, peri-urban or urban setting?

How did you choose the independent variables? Please include a brief discussion or some references.

A section on operational definition is not needed and can be incorporated earlier in the methods section

How many centres/ institutions were eligible? How did you choose the five centres? Did you expect to have differences between public and private institutions - is that why you selected a mix of both?

The section on Ethical Considerations should be shortened

Results

Please re-visit the titles of the different sections of the results. I would suggest perhaps consolidating some of these.

Discussion

Please structure the discussion to include strengths, limitations and policy implications

In the discussion, the authors make mention several times that the study findings are in keeping with findings of studies in other places in Ethiopia. Could you elaborate on whether these other places are similar to your study setting?

Please review the paper for English language/ grammar.

Reviewer #2: This descriptive study highlights an important issue in the unique setting of Town Agaro town in Ethiopia with potentials to be basis of actionable plans towards getting pregnant women to attend ANC in timely manner.

However the issues that should be addressed are

1. Impact of untimely ANC attendance was not well captured- maternal mortality was not linked to the issue under study; thus and also the rationale for the study in SW Ethiopia was unclear.

2. The Setting of study is not easily understood eg- a. what type of health institutions exist in Agaro from which the facilities used were drawn from?-private with fee for service , primary, secondary, etc? it should be described in setting

b. How did the authors selected the ones used.

c. What is meant by rural and urban areas in the same town as used as a variables

d. source of data/figures- such as a. number of pregnant women in the town.b. the two month report of 798 of which institution and whose data?

3.. Population- the term seriously sick as an exclusive criteria is subjective- does it mean mothers who were hospitalized?

4. Variables- Many Variables were not clearly defined-

a. is being a House wife synonymous with being economically unemployed?

b.,waiting time( where?-before seeing the health worker or collecting lab results?),

c. cost of services-( confusing as the background pointed to free services in Agora health facilities).

d. The cash / money classification in ETB means little if not explained, standardized or used in a socioeconomic classification.

e. satisfaction with services- How can a future event determine the timeliness of ANC, in other words satisfaction cant be assessed from the point at when they were yet to use the ANC services they were yet to use the ANC services; except it meant satisfaction with previous use

5. Ethics- while the single pregnant under 18yrs could have parental permission , a married minor is not a legal minor she may give consent by herself .

6. Results- within the tables, variables should be stated not as questions

7. The use of language - the word Lottery, i guess meant balloting, 'intention of pregnancy' should be planned or unplanned pregnancy.

8. Results should be discussed not re-stated in discussions. comparisons of trends or percentages with previous studies should be clear with possible reasons truely related to findings

Reviewer #3: Abstract

Methods: Line 31-32: The authors should revised the statement "Structured and pretested face-to-face

32 interview technique was used to collect data"

The authors should add the sampling method to the methods section.

Background

Lines 58-59: WHO has provided an updated recommended number of ANC visits and the authors should replace it with what they have in their manuscript currently.

Lines 65-67: The sentences in these lines lack adequate citations.

Line 68 and Line 72: its sub-Saharan Africa not Sub-Saharan Africa

Methods

The authors should provide more detailed description of the study setting highlighting the health facilities and if possible the interventions put in place to improve maternal health service utilization.

Sampling size and sampling procedure

The authors should provide the formula used to calculate the sample size and support it with the appropriate reference.

The authors should categorically state the sampling method employed in the and clearly describe how it was used to recruit the pregnant women.

Data collection

How did the authors check for the reliability and validity of the questionnaire?

Analysis

Did the authors apply weighting in the analysis?

Ethical consideration

The authors should provide the ethical clearance number.

Results

Table 3 and Table 4: The authors should make sure that all the variables that look like questions have been revised to look like variables.

Line 200 and 211: The headings in these lines should be changed to sentence case.

Why did the authors not perform regression analysis for the variables in Table 1 and Table 2. Any special reason for not doing so??

I suggest the authors reanalyze the data to include those variables in the regression analysis.

Reviewer #4: I appreciate the work of the authors on identifying the factors associated with timely initiation of antenatal care in southwest Ethiopia. The authors highlight a major public health concern with widespread implications in an understudied population. Conclusions are both valid and meaningful. However, I have highlighted below some significant analytical concerns that should be addressed in the paper:

MAJOR COMMENTS

The manuscript would benefit from heavy editorializing. The grammar can be strengthened to avoid detraction from the value of the study.

INTRODUCTION

-I appreciate that the authors keep the introduction short and succinct.

METHODS

-The description of the sampling method is a bit unclear. The authors write that the proportion of timely initiation of ANC is 35.4%. Was this number calculated from the present study, or from the cited 2014 manuscript? What is the rationale for assuming there is a 10% non-response rate? Could the authors please expand upon the lottery method mentioned in lines 122-123?

-The authors would benefit from further discussion of the format of the questionnaire used to collect data. Were questions open-ended, agree/disagree, yes/no, etc.?

RESULTS

-The authors write that 20% of women with prior pregnancies had an abortion. Were these all results of elective procedures, or does this figure include miscarriages?

-How did mothers know they were experiencing complications (UTIs/high blood pressure) before their first ANC visit? Did the first visit encourage them to seek subsequent care?

DISCUSSION

-What is the rationale for comparing southwest Ethiopia to Nepal and Pakistan? The nations and cultures are entirely different, and although all three countries are low-to-middle income regions, it doesn't make sense to compare them directly in this context.

-Although it is logical, are there any sources that can support the claim that women who have other children feel more confident and therefore are less likely to seek timely care? If not, please mention that formal analyses have not confirmed the authors' suspicions.

CONCLUSION

-The manuscript would benefit from a brief expansion of recommended public health practices.

Reviewer #5: The introduction has set a good context for the study and methods are sound and clearly outline the procedures. This is a well written paper. However a few comments were observed below.

Introduction

There is a paper quoted here: ''WHO Geneva. Carla A, Tessa W, Blanc A, Van P, et al. ANC in developing countries, 352 promises, achievements, and missed opportunities; an analysis of trends, levels and 353 Differentials, 1990-2001. 2003''. This research from 2003 is quite old. It would be beneficial to more recent evidence to give us a better picture and trend of timing of ANC visits.

Discussion

Expatiate on efforts to be made to increase pregnant women’s knowledge on ANC and the right time for commencement, to include some practical examples.

Why was the more recent EHDS from 2019 not used? The maternal health care chapter contains information ANC timing.

**********

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Reviewer #1: No

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Reviewer #3: No

Reviewer #4: No

Reviewer #5: Yes: Fatima Abdulaziz Sule

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21 Feb 2022

Response to Reviewers and Editor

Firstly, I would like to thank editor and reviewers for your valuable and constructive comments and questions that are helpful for improving the quality of the manuscript. The responses for each point are done as follows.

To Editor

1. The manuscript is done based on the journal requirements

2. The questionnaire as a supporting information is separately attached

3. The data availability statement is described within the manuscript

4. Regarding providing repository information, we have changed our mind. We will provide the necessary information upon request by the journal.

5. Ethics statement out of the methods section is deleted

6. Regarding some minor occurrence of overlapping text with the following publication (http://www.bioline.org.br/request?rh13063), we checked it and by now the whole manuscript is revised to avoid any overlap.

Response to Reviewers

Reviewer #1: Thank you for giving me the opportunity to review this paper.

My comments are the following:

Background

• The background should be written at a higher level as we can assume that readers have basic understanding of the topic. For example, ANC does not need to be defined.

Response: The whole background section is revised and necessary changes are made to make it at higher level and the definition of ANC is removed.

• The background should try to make a better link between timely initiation of ANC and maternal mortality

Response: A statement that describes the link between timely initiation of ANC and maternal mortality is added in the revised manuscript (please see paragraphs 3 & 4 of the current version)

• I would suggest using local or regional references when discussing factors influencing timely initiation of ANC. The references are also quite outdated and would recommend using more current references such as:

https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-020-03236-9

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7864666/

Response: Local and regional references are used to discuss the factors associated with timely initiation of ANC (Please see references 10-12) and all outdated references are replaced by the current references including the references you suggested us. (Please see references 1-15)

Methods

• The methods should be re-written for better flow

Response: Correction is made throughout the methods section to make the flow better.

• The section of population is very repetitive and can be summarized in one sentence

Response: Summarized in one sentence and the repetition is corrected (Please see population section of the revised manuscript)

• Is Agaro a rural, peri-urban or urban setting?

Response: Agaro is an urban setting. However, clients are coming from both the town and the surrounding rural areas to get ANC services.

• How did you choose the independent variables? Please include a brief discussion or some references.

Response: The description and the references are included (Please see the variables section of the revised manuscript)

• A section on operational definition is not needed and can be incorporated earlier in the methods section

Response: Deleted as per your suggestion.

• How many centres/ institutions were eligible? How did you choose the five centres? Did you expect to have differences between public and private institutions - is that why you selected a mix of both?

Response: In the town, there were two health centers, one governmental hospital, six private clinics and five health posts. Of these, five health facilities (three government health institutions (one hospital and two health centers) and two private clinics) that had well documented registration books and providing ANC services were eligible and included in the study. (Please see study design, area and period section). Yes, we expect differences between public and private institutions and mostly researchers are focusing on public facilities only. So, to ensure the external validity of the findings to similar settings both public and private facilities were included.

• The section on Ethical Considerations should be shortened

Response: Shortened as per your comment (Please see Ethical Considerations section of the revised manuscript)

Results

• Please re-visit the titles of the different sections of the results. I would suggest perhaps consolidating some of these.

Response: Revisit is done on the titles of the different section of the results. However, consolidating the titles was not made because each title discusses different issues and have its own table.

Discussion

• Please structure the discussion to include strengths, limitations and policy implications

Response: Strengths, limitations and policy implications are included (Please see the last paragraph of the discussion section)

In the discussion, the authors make mention several times that the study findings are in keeping with findings of studies in other places in Ethiopia. Could you elaborate on whether these other places are similar to your study setting?

Response: Some of the studies are conducted in Southern Ethiopia relatively nearest to the current study area. Some others are conducted in Northwest and Eastern Ethiopia. Overall, most of the areas are similar to the study setting. Some others are different. The health service provision culture in Ethiopia is more or less similar. However, there might be variation in terms of providing 1st ANC visit and the factors associated to it from area to area within the country. That’s why the current study is conducted to appreciate that difference and design appropriate area specific interventions.

• Please review the paper for English language/ grammar.

Response: The whole manuscript is revised to correct grammatical and writing errors.

Reviewer #2: This descriptive study highlights an important issue in the unique setting of Town Agaro town in Ethiopia with potentials to be basis of actionable plans towards getting pregnant women to attend ANC in timely manner.

However, the issues that should be addressed are:

1. Impact of untimely ANC attendance was not well captured- maternal mortality was not linked to the issue under study; thus, and also the rationale for the study in SW Ethiopia was unclear.

Response: Impact of untimely initiation of ANC is discussed and linked to maternal mortality (please see paragraph 4 of the current version) and the rationale for the study is revised (please see the last paragraph of the background section)

2. The setting of study is not easily understood eg- a. what type of health institutions exist in Agaro from which the facilities used were drawn from? private with fee for service, primary, secondary, etc? it should be described in setting

Response: In the town, there were two health centers, one governmental hospital, six private clinics and five health posts. Of these, three government health institutions (one hospital and two health centers) and two private clinics that had well documented registration books and providing ANC services were eligible and included in the study. (Please see study design, area and period section).

b. How did the authors selected the ones used.

Response: All health facilities that had well documented registration books and were providing ANC services were eligible and included in the study. Then, the sample size was proportionally allocated to each eligible health facility as per their client flow.

c. What is meant by rural and urban areas in the same town as used as a variables

Response: Though the health facilities are found in the town, the clients were coming from both urban area (Agaro town) and rural areas surrounding the town to get ANC services. That is why, the variable place of residence was used.

d. source of data/figures- such as a. number of pregnant women in the town. b. the two-month report of 798 of which institution and whose data?

Response: The detail description is made (Please see study design, area and period section).

3.. Population- the term seriously sick as an exclusive criterion is subjective- does it mean mothers who were hospitalized?

Response: It doesn’t mean hospitalized mothers. What we excluded were pregnant women who came to the health facilities for ANC service but unable to make the interview due to their sickness.

3. Variables- Many Variables were not clearly defined-

a. is being a House wife synonymous with being economically unemployed?

Response: Being a house wife in our context is if a pregnant woman is engaged in raising children and taking care of her family and the family income is based on husband’s income. So, housewives are economically unemployed.

b. waiting time (where? -before seeing the health worker or collecting lab results?),

Response: Waiting time is deleted from the variables list since it is not discussed in the results section.

c. cost of services- (confusing as the background pointed to free services in Agaro health facilities).

Response: Since private health facilities were included in the study cost of service (paid for service) is included in the variables list.

d. The cash/money classification in ETB means little if not explained, standardized or used in a socioeconomic classification.

Response: It was done based on previous studies for sake of comparison. However, it was not found to be significant in the current study.

e. satisfaction with services- How can a future event determine the timeliness of ANC, in other words satisfaction can’t be assessed from the point at when they were yet to use the ANC services, they were yet to use the ANC services; except it meant satisfaction with previous use

Response: That was writing error. Corrected as ‘satisfaction with ANC services for previous pregnancy’.

4. Ethics- while the single pregnant under 18yrs could have parental permission, a married minor is not a legal minor she may give consent by herself.

Response: Thank you for the lesson you thought us. we removed that part. (Please see Ethical Considerations section of the revised manuscript)

5. Results- within the tables, variables should be stated not as questions

Response: All variables stated in question form are changed to statement form (Please see tables 3 and 4)

6. The use of language - the word Lottery, i guess meant balloting, 'intention of pregnancy' should be planned or unplanned pregnancy.

Response: The issue of lottery method is described in the current version of sample size and sampling procedures section. (Please see sample size and sampling procedures section of the current version). The variable ‘pregnancy planned’ is changed as ‘intention of pregnancy’ and the categories are changed as ‘planned pregnancy and unplanned pregnancy’. (Please see table 4)

7. Results should be discussed not re-stated in discussions. comparisons of trends or percentages with previous studies should be clear with possible reasons truly related to findings

Response: The problem of re-stating is corrected and we tried to clarify the possible reasons for comparisons of trends or percentages with the previous studies.

Reviewer #3:

Abstract

• Methods: Line 31-32: The authors should revise the statement "Structured and pretested face-to-face interview technique was used to collect data"

Response: Changed as “A structured and pre-tested face-to-face interviewer-administered questionnaire was used to collect data.”

• The authors should add the sampling method to the methods section.

Response: Added as “Systematic random sampling technique was employed to recruit pregnant women.”

Background

• Lines 58-59: WHO has provided an updated recommended number of ANC visits and the authors should replace it with what they have in their manuscript currently.

Response: Replaced (please see paragraph 3 of the current version)

• Lines 65-67: The sentences in these lines lack adequate citations.

Response: Citations are added (please see paragraph 1 of the current version)

• Line 68 and Line 72: its sub-Saharan Africa not Sub-Saharan Africa

Response: Corrected (please see paragraphs 1 and 5 of the current version)

Methods

• The authors should provide more detailed description of the study setting highlighting the health facilities and if possible, the interventions put in place to improve maternal health service utilization.

Response: The detail description of the study setting is made (Please see study design, area and period section).

Sampling size and sampling procedure

• The authors should provide the formula used to calculate the sample size and support it with the appropriate reference.

Response: The formula is provided with appropriate reference (Please see reference 16)

• The authors should categorically state the sampling method employed in the and clearly describe how it was used to recruit the pregnant women.

Response: Brief description is made in the current version of sample size and sampling procedures section.

Data collection

• How did the authors check for the reliability and validity of the questionnaire?

Response: We checked the reliability of the questionnaire using Cronbach’s alpha reliability test and the value was 0.83. The validity of the questionnaire was checked by conducting pre-test, training supervisors and data collectors and translating the questionnaire to the local language and translating back to English. (Please see Data collection instruments and procedures section of the current version)

Analysis

• Did the authors apply weighting in the analysis?

Response: We didn’t apply weighting in the analysis.

Ethical consideration

• The authors should provide the ethical clearance number.

Response: We put the ethical clearance number (Please see Ethical Considerations section of the revised manuscript)

Results

• Table 3 and Table 4: The authors should make sure that all the variables that look like questions have been revised to look like variables.

Response: All variables stated in question form are changed to statement form (Please see tables 3 and 4)

• Line 200 and 211: The headings in these lines should be changed to sentence case.

Response: The headings are changed to sentence case.

• Why did the authors not perform regression analysis for the variables in Table 1 and Table 2? Any special reason for not doing so?? I suggest the authors reanalyze the data to include those variables in the regression analysis.

Response: We did regression analysis for all the variables included in the study including those listed in Table 1 and Table 2. However, only four variables (including gravidity from table 2) in table 5 were found to be significantly associated with timely initiation of antenatal care.

Reviewer #4:

I appreciate the work of the authors on identifying the factors associated with timely initiation of antenatal care in southwest Ethiopia. The authors highlight a major public health concern with widespread implications in an understudied population. Conclusions are both valid and meaningful. However, I have highlighted below some significant analytical concerns that should be addressed in the paper:

MAJOR COMMENTS

The manuscript would benefit from heavy editorializing. The grammar can be strengthened to avoid detraction from the value of the study.

Response: The whole manuscript is revised to correct grammatical and writing errors.

INTRODUCTION

• I appreciate that the authors keep the introduction short and succinct.

Response: We tried to make it short and succinct by not missing the necessary information that should be included.

METHODS

• The description of the sampling method is a bit unclear. The authors write that the proportion of timely initiation of ANC is 35.4%. Was this number calculated from the present study, or from the cited 2014 manuscript? What is the rationale for assuming there is a 10% non-response rate? Could the authors please expand upon the lottery method mentioned in lines 122-123?

Response: We tried to describe the sampling method clearly. The proportion of timely initiation of ANC, 35.5% was taken from the cited 2014 paper to estimate the sample size of the current study. The rationale for taking 10% non-response rate was to compensate invalid filled questionnaires due to incompleteness and writing errors. The way the lottery method used to recruit the first pregnant women (starting point) is more briefed in the current version of the manuscript.

• The authors would benefit from further discussion of the format of the questionnaire used to collect data. Were questions open-ended, agree/disagree, yes/no, etc.?

Response: The questions included in the questionnaire were closed-ended (Please see Data collection instruments and procedures section of the current version)

RESULTS

• The authors write that 20% of women with prior pregnancies had an abortion. Were these all results of elective procedures, or does this figure include miscarriages?

Response: It includes both elective procedures and miscarriages based on the report we got from pregnant women through the interviewer-administered questionnaire.

• How did mothers know they were experiencing complications (UTIs/high blood pressure) before their first ANC visit? Did the first visit encourage them to seek subsequent care?

Response: It is talking about the complications for the previous pregnancy. When they attended their previous ANC, they knew their overall complication status.

DISCUSSION

• What is the rationale for comparing southwest Ethiopia to Nepal and Pakistan? The nations and cultures are entirely different, and although all three countries are low-to-middle income regions, it doesn't make sense to compare them directly in this context.

Response: Primarily, we tried to compare the study findings to the previous findings in other places of Ethiopia. To expand the comparison outside Ethiopia, we selected countries like Nepal, Pakistan and so on from developing countries. So, the rationale is expanding comparison of the findings to other developing countries assuming that they are similar in terms of health service utilization including ANC visit.

• Although it is logical, are there any sources that can support the claim that women who have other children feel more confident and therefore are less likely to seek timely care? If not, please mention that formal analyses have not confirmed the authors' suspicions.

Response: The explanation was based on evidence (Please see reference 25).

CONCLUSION

• The manuscript would benefit from a brief expansion of recommended public health practices.

Response: Modification is made

Reviewer #5: The introduction has set a good context for the study and methods are sound and clearly outline the procedures. This is a well written paper. However, a few comments were observed below.

Introduction

• There is a paper quoted here: ''WHO Geneva. Carla A, Tessa W, Blanc A, Van P, et al. ANC in developing countries, 352 promises, achievements, and missed opportunities; an analysis of trends, levels and 353 Differentials, 1990-2001. 2003''. This research from 2003 is quite old. It would be beneficial to more recent evidence to give us a better picture and trend of timing of ANC visits.

Response: Thank you really. All old references are removed and replaced by the recent ones (please see references 1-15 of the current version)

Discussion

• Expatiate on efforts to be made to increase pregnant women’s knowledge on ANC and the right time for commencement, to include some practical examples.

Response: Modification is done with some practical examples. (Please see the last paragraph of the discussion section)

• Why was the more recent EHDS from 2019 not used? The maternal health care chapter contains information ANC timing.

Response: We used EDHS 2016 report to cite the information ‘only 20% of women had their first ANC during the first trimester’. However, the mini-EDHS 2019 doesn’t have information regarding the percentage of women who had their first ANC during the first trimester. When the full 2019 EDHS is released, it might be included.

Submitted filename: Response to Reviewers.docx

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26 Apr 2022

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Staff Editor

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

Reviewer #3: All comments have been addressed

Reviewer #5: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #5: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #5: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: Yes

Reviewer #5: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: No

Reviewer #3: Yes

Reviewer #5: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: This study has been conducted rigorously, with large enough sample size to represent the population of interest.The data supports the overall conclusion of the authors, however the major areas the authours need to look into is the language - words or sentences used caused difficulty in comprehension

1. the authors may be unwittingly passing the message that WHO has a 'recommended proportion of women' that should have timely ANC visit from the statements in lines 44, 77, 78- it should be re-worded .

2- in the Result section

i. variables should not be stated as questions

ii. line 198- 'Times of ANC visit' rather - ' frequency of ANC visits'

iii. Line 209 Does this complication made you start ANC rather -' ANC attendance due to complications' [ should also not be in question format ]

3. in line 243-247- in discussing and comparing the proportion /percentage of women with timely ANC visit , the reseachers repeatedly mention the phrase ' the finding was lower/ much higher' - it should be stated that it is percentage which is being discussed.

4. In proferring possible underlying in discussion of findings - many were stating random reasons with little scientific or factual evidence or citations eg- line 248 possible reasons for differences between current finding and other studies, the authors gave a string of reasons - " awareness, service coverage committement and training of healthworkers " but no explanation, discussion or citations

Recommended that the authors get help in re-writing for sense and flow before resubmission. Also some more effort into providing contextual and logical hypothesis /premise for various findings which would be beneficial to the authors and reader alike.

Reviewer #3: (No Response)

Reviewer #5: (No Response)

**********

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Reviewer #2: No

Reviewer #3: No

Reviewer #5: No

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3 Jun 2022

Response to Reviewers and Editor

Firstly, we would like to thank the academic editor and reviewers for your additional valuable and constructive comments and questions that are helpful for improving the quality of the manuscript. The responses for each point are as follows.

To Academic Editor

• The points raised by reviewer #2 are addressed.

• A rebuttal letter, Revised Manuscript with Track Changes and Manuscript without track changes are prepared.

Response to Reviewers

Reviewer #2: This study has been conducted rigorously, with a large enough sample size to represent the population of interest. The data supports the overall conclusion of the authors, however the major areas the authors need to investigate are the language - words or sentences used caused difficulty in comprehension

1. the authors may be unwittingly passing the message that WHO has a 'recommended proportion of women' that should have timely ANC visit from the statements in lines 44, 77, 78- it should be re-worded.

Response: Thank you for your critical comment. Revision is done (Please see the conclusion part of the abstract and the conclusion section in the main document)

2. in the Result section

i. variables should not be stated as questions

Response: Corrected (Please see table 2)

ii. line 198- 'Times of ANC visit' rather - ' frequency of ANC visits'

Response: Corrected (Please see Table 3)

iii. Line 209 Does this complication made you start ANC rather -' ANC attendance due to complications' [should also not be in question format]

Response: Corrected (Please see Table 4)

3. in line 243-247- in discussing and comparing the proportion /percentage of women with timely ANC visit, the researchers repeatedly mention the phrase ' the finding was lower/ much higher' - it should be stated that it is percentage which is being discussed.

Response: Corrected (Please see the second paragraph of the discussion section)

4. In proffering possible underlying in discussion of findings - many were stating random reasons with little scientific or factual evidence or citations e.g.- line 248 reasons for differences between current finding and other studies, the authors gave a string of reasons - " awareness, service coverage commitment and training of health workers " but no explanation, discussion, or citations

Response: Corrected (Please see the second paragraph of the discussion section)

Submitted filename: Response to Reviewers.docx

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19 Jul 2022

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We look forward to receiving your revised manuscript.

Kind regards,

Avanti Dey, PhD

Staff Editor

PLOS ONE

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: (No Response)

Reviewer #3: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: No

Reviewer #3: Yes

**********

6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: A. While the authors have attempted to address some of the comments , they failed to work on the general manuscript to improve its intelligibility in standard English as preiuosly advised - this is the major weaknes of this manuscript. They may do well to employ the services of an editor to help with the written language.

B.

Explanations for findings are not satisfactory mostly differences were just generic, not much specific explanations of differences between thier findings and the cited works - eg in line 261-266 " The possible reasons for this difference might be due to the difference in accessing information regarding timely initiation of antenatal care visit, advocating the importance of timely initiation of antenatal care, and advising pregnant women on the early booking of ANC, educational status of the pregnant women (14-15, 26). In addition, methodological variations among studies and the difference socio-demographic characteristics of the study participants might be the possible reasons-

C... specific isssues that should have been worked on and still noted are stated below

1. line 27- should be- late in pregnancy , not in their late pregnancy; check and reword line47; line 50-60

2.line 87- the statement -"That is lower than the WHO standard (14, 15)' .-the statement s makes little sense and references dont match the statement (14 and 15)

3.line 67- ensure - not assure

4.line 100- better desciption of health facilties and number is needed eg- state total numbr of all the goernment health facilities and priate seperatly, then state the numer used in the study

5.line-121-'included in' not included to th study as written

6. line 118-121- repitatation of line 100- theat section is just for sample size determination

7. line 131- sampling interval (K = N/n) was 2- ...2 can only be for 1 halth facilty , not be same for different study sites with different proportionaly chosen sample sizes and total population

8.line 132- should be ...By balloting not lottery

9.line 197 - should be- fifty eight (20.4%) pregnant women have had abortions ..not ..."Of those pregnant women who have had pregnancy experience, 58 (20.4%) of them have experienced abortion."

10.line 198--200- thirty six(12.9%)Women had experienced pregnancy related complications....,- not ...Women who have faced various pregnancy related complications (pregnancy induced hypertension, anemia, eclampsia, pre-eclampsia) that required hospitalization or additional treatment were 36 (12.9%).

11.line 211- 212 - the women are not reporting , its the knowledge the study tested - so saying One hundred eighty (48%) pregnant women reported that four and above ANC visits are needed for pregnant women during normal pregnancy is not quite right--- rather say 48% had knowledge that (or knew that) pregnant women required four and above ANC visits

12.line 219- 223- how can the women know that they had high Diastolic BP and UTI before ANC???? and started ANC for this cause? Do they have home visits from health workers that test and disgnose them at home before presenting?

13.line 260-261- shoul be- 'The percentage was also higher compared to the finding of xxx% from a systematic review and meta-analysis of studies conducted in Ethiopia'.. not .....The percentage was also higher compared to a systematic review and meta-analysis study conducted in Ethiopia

14.line 277-281- This might be because the more pregnant women know the time of first ANC visit, the more their timely initiation of ANC service will increase ...... this is not an explanation , the authors are stating/repeating the results in a different manner

Reviewer #3: (No Response)

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Reviewer #2: No

Reviewer #3: No

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20 Jul 2022

Response to Reviewers and Editor

Firstly, we would like to thank the academic editor and reviewers for your additional valuable and constructive comments and questions that are helpful for improving the quality of the manuscript. The responses for each point are done as follows.

To Academic Editor

• The points raised by reviewer #2 such as clarifications in the reporting, methodology justification, and language/copyediting and the specific issues raised are addressed.

• A rebuttal letter, Revised Manuscript with Track Changes and Manuscript without track changes are prepared.

Response to Reviewers

Reviewer #2:

A. While the authors have attempted to address some of the comments , they failed to work on the general manuscript to improve its intelligibility in standard English as preiuosly advised - this is the major weaknes of this manuscript. They may do well to employ the services of an editor to help with the written language.

• Response: From cover page to last page revision is made to correct writing and grammatical errors as indicated in the tracked changed manuscript.

B. Explanations for findings are not satisfactory mostly differences were just generic, not much specific explanations of differences between thier findings and the cited works - eg in line 261-266 " The possible reasons for this difference might be due to the difference in accessing information regarding timely initiation of antenatal care visit, advocating the importance of timely initiation of antenatal care, and advising pregnant women on the early booking of ANC, educational status of the pregnant women (14-15, 26). In addition, methodological variations among studies and the difference socio-demographic characteristics of the study participants might be the possible reasons-

• Response: Big revision is made on the explanations (Please see lines 267-280 of the track changed manuscript)

C... specific isssues that should have been worked on and still noted are stated below

1. line 27- should be- late in pregnancy , not in their late pregnancy; check and reword line47; line 50-60

• Response: Changes are made as per the request. (Please see lines 27, 48 and 59 of the track changed manuscript)

2.line 87- the statement -"That is lower than the WHO standard (14, 15)' .-the statement s makes little sense and references dont match the statement (14 and 15)

• Response: Thank you. The statement doesn’t go with the sentences before and after it. So, it is deleted from the manuscript. References 14 and 15 match with the sentence after it and they are included there. (Please see line 87 of the track changed manuscript)

3.line 67- ensure - not assure

• Response: Corrected. (Please see line 67 of the track changed manuscript)

4.line 100- better desciption of health facilties and number is needed eg- state total numbr of all the goernment health facilities and priate seperatly, then state the numer used in the study

• Response: The description is corrected. (Please see lines 101-106 of the track changed manuscript)

5.line-121-'included in' not included to th study as written

• Response: Corrected. (Please see line 124 of the track changed manuscript)

6. line 118-121- repitatation of line 100- theat section is just for sample size determination

• Response: The repeated part is deleted. (Please see lines 121-124 of the track changed manuscript)

7. line 131- sampling interval (K = N/n) was 2- ...2 can only be for 1 halth facilty , not be same for different study sites with different proportionaly chosen sample sizes and total population

• Response: The sampling interval calculated for each health facility was the same. Since it was proportionally allocated, the sampling interval was the same. It was approximately 2 for each health facility. Modification is done to indicate that the sampling interval was the same for each health facility (Please see line 134 of the track changed manuscript)

8.line 132- should be ...By balloting not lottery

• Response: Corrected (Please see line 135 of the track changed manuscript)

9.line 197 - should be- fifty eight (20.4%) pregnant women have had abortions ..not ..."Of those pregnant women who have had pregnancy experience, 58 (20.4%) of them have experienced abortion."

• Response: Thank you. Corrected as suggested (Please see lines 200-201 of the track changed manuscript)

10.line 198--200- thirty six(12.9%)Women had experienced pregnancy related complications....,- not ...Women who have faced various pregnancy related complications (pregnancy induced hypertension, anemia, eclampsia, pre-eclampsia) that required hospitalization or additional treatment were 36 (12.9%).

• Response: Thank you. Corrected as suggested (Please see lines 203-204 of the track changed manuscript)

11.line 211- 212 - the women are not reporting , its the knowledge the study tested - so saying One hundred eighty (48%) pregnant women reported that four and above ANC visits are needed for pregnant women during normal pregnancy is not quite right--- rather say 48% had knowledge that (or knew that) pregnant women required four and above ANC visits

• Response: Thank you. Corrected as suggested (Please see lines 217-218 of the track changed manuscript)

12.line 219- 223- how can the women know that they had high Diastolic BP and UTI before ANC???? and started ANC for this cause? Do they have home visits from health workers that test and disgnose them at home before presenting?

• Response: This finding was obtained from self-report during the interview. Changes are made to indicate this. (Please see lines 226-229 of the track changed manuscript)

13.line 260-261- shoul be- 'The percentage was also higher compared to the finding of xxx% from a systematic review and meta-analysis of studies conducted in Ethiopia'.. not .....The percentage was also higher compared to a systematic review and meta-analysis study conducted in Ethiopia

• Response: Changes are made (Please see lines 267-270 of the track changed manuscript)

14. line 277-281- This might be because the more pregnant women know the time of first ANC visit, the more their timely initiation of ANC service will increase ...... this is not an explanation , the authors are stating/repeating the results in a different manner

• Response: Changes are made (Please see lines 293-297 of the track changed manuscript)

Submitted filename: Response to Reviewers.docx

Click here for additional data file.

4 Aug 2022

Timely Initiation of Antenatal Care and Associated Factors among Pregnant Women Attending Antenatal Care in Southwest Ethiopia

PONE-D-21-21466R3

Dear Dr. Bazie,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Hugh Cowley

Staff Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #2: All comments have been addressed

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #2: Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #2: Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #2: Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #2: Yes

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Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #2: The autores have addreeesed the issues i was concerned over, there is no significant problems with legilibilty of the manuscript

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Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #2: No

**********

8 Aug 2022

PONE-D-21-21466R3

Timely Initiation of Antenatal Care and Associated Factors among Pregnant Women Attending Antenatal Care in Southwest Ethiopia

Dear Dr. Bazie:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Mr Hugh Cowley

Staff Editor

PLOS ONE

Table 1

Socio-demographic characteristics of pregnant women at Agaro town health institutions, Southwest Ethiopia, June 2019 (n = 375).

Variables	Number	Percentage
Age
15–19	51	13.6
20–34	292	77.9
35+	32	8.5
Residence
Rural	154	41.1
Urban	221	58.9
Marital status
Single	23	6.1
Married	318	84.8
Divorced	23	6.1
Widowed	11	2.9
Religion
Muslim	254	67.7
Orthodox Christian	78	20.8
Protestant	37	9.9
Others*	6	1.6
Ethnicity
Oromo	243	64.8
Amhara	54	14.4
Gurage	31	8.3
Silte	22	5.9
Others**	25	6.6
Educational status
No formal education	82	21.9
Primary school (1–8)	153	40.8
Secondary school (9–12)	96	25.6
Above secondary school	44	11.7
Occupational status
Government employee	45	12.0
Private worker	108	28.8
House wife	191	50.9
Student	31	8.3
Family monthly income in ETB
<1550	96	25.6
1550–5000	249	66.4
>5000	30	8.0

Others*: Waqefeta, Jehovah witness,

Others**: Tigre, Wollaita, Kefa, Dawro

Table 2

Past obstetric history of pregnant women attending ANC services at Agaro town health institutions, Southwest Ethiopia, June 2019.

Variable	Number	Percentage
Gravidity (n = 375)
Primigravida	91	24.3
Multigravida	284	75.7
History of abortion (n = 284)
Yes	58	20.4
No	226	79.6
Parity (n = 375)
Nulliparous	96	25.6
Parity 1 and above	279	74.4
History of still birth (n = 279)
Yes	39	14.0
No	240	86.0
Previous pregnancy complication (n = 279)
Yes	36	12.9
No	243	87.1
ANC visit for previous pregnancy (n = 279)
Yes	237	84.9
No	42	15.1
Advice when to start ANC for previous pregnancy (n = 237)
Yes	186	78.5
No	51	21.5
Satisfaction with ANC services for previous pregnancy (n = 237)
Yes	143	60.3
No	94	39.7

Table 3

Knowledge of pregnant women on timing of first ANC booking at Agaro Town health institutions, Southwest Ethiopia, June 2019.

Variables	Number	Percentage
ANC is important
Yes	353	94.1
No	22	5.9
The right time to start ANC
Within 16 weeks	211	56.3
After the 16 weeks	164	43.7
Timing of ANC improves outcome of the fetus
Yes	314	83.7
No	61	16.3
Timing of ANC improves outcome of the mother
Yes	343	91.5
No	32	8.5
Frequency of ANC visit
One	15	4.0
Two-three	125	33.3
Four-six	180	48.0
More than six	55	14.7
All pregnant women are at risk of pregnancy complication
Yes	247	65.9
No	128	34.1
Difference between primiparous and multiparous in timing of first ANC visit
Yes	204	54.4
No	171	45.6

Table 4

Current pregnancy characteristics for pregnant women attending ANC at Agaro town Health institutions, Southwest Ethiopia, June 2019.

Variables	Number	Percentage
Intention of pregnancy (n = 375)
Planned	214	57.1
Unplanned	161	42.9
Pregnancy related complications for current pregnancy (n = 375)
Yes	151	40.3
No	224	59.7
ANC attendance due to complications (n = 151)
Yes	119	78.8
No	32	21.2
Means of conforming pregnancy (n = 375)
Missed period	242	64.5
By urine test	133	35.5
Paid for service (n = 375)
Yes	55	14.7
No	320	85.3
Advice when to start ANC (n = 375)
Yes	226	60.3
No	149	39.7
Source of advice (n = 226)
Husband	66	29.2
Friend	60	26.5
Other family member	37	16.4
Media	13	5.8
Health professionals	50	22.1

Table 5

Factors associated with timely initiation of ANC among pregnant women at Agaro town health institution, Southwest Ethiopia, June 2019.

Variables	Timely ANC	Late ANC	COR	AOR
	initiation (No)	Initiation (No)	95% CI	95% CI
Knowledge on ANC
Yes	137	118	4.7 [3.0–7.5]	3.8 [2.2, 6.5]
No	20	100	1	1
Gravidity
Primigravida	60	31	3.7 [2.3–6.1]	2.6 [1.6, 5.3]
Multigravida	97	187	1	1
Intention of pregnancy
Planned	123	95	4.9 [3.1–7.8]	5.1 [2.9, 8.9]
Unplanned	33	124	1	1
Pregnancy checking method
By menstruation	68	174	1	1
By using urine test	89	44	5.2 [3.3–8.2]	4.1 [2.4, 6.9]

Keys: ANC: Antenatal care; AOR: Adjusted odds ratio; CI: Confidence interval; COR: Crude odds ratio