The main goal of the study was to determine the time to initiation of ANC visit and its predictors among pregnant women who delivered in Arba Minch town public health facilities, Gamo zone, Southern Ethiopia, 2023. The overall median time to ANC initiation was 18 weeks. Being an urban resident, having a tertiary and above level of education, having pregnancy-related complications in a previous pregnancy, not having previous antenatal care visit and unplanned pregnancy were found to be the predictors for the time to initiation of antenatal care visit.

According to this study, the median time to ANC initiation was 18 weeks, meaning half of the pregnant women start their ANC visit after 18 weeks of their pregnancy, which is not in line with the 2016 WHO ANC recommendation which is before 12 weeks; this, in turn, implies that many women are at risk of several obstetric complications which may lead to maternal and neonatal morbidity and mortality. This finding is consistent with a study from low and middle-income countries (Malawi, Zambia, Uganda, Yemen, and Mali) [20] and Afghanistan [21] which is 4 months. However, the median time to ANC initiation was earlier as compared to the study performed in Nigeria [15, 22] which is 6 months, which may be due to differences in the study setting: the participants from this study were mainly from an urban area where women had access to education, media and health facilities whereas the study in Nigeria was from the Nigerian demographic and health survey where the majority of the women were from rural areas [15, 22]. The median time to ANC initiation was later than the findings from Paraguay, Indonesia and Cambodia [20]. This variation might be due to socio-demographic and, socio-economic differences.

In this study, place of residence was a significant predictor for time to initiation of ANC visit. Women who reside in urban areas initiate ANC visits earlier than those who live in rural areas. It is in line with a study conducted in Ethiopia [23, 24], Nepal [25], Nigeria [15, 22, 26], and Bangladesh [27]. Similarly, a study performed in low- and middle-income countries stated that women who initiated ANC early were mainly from urban areas [20]. Women from urban areas may be aware of the importance of early ANC initiation and its role in ensuring maternal and child health as they have better educational opportunities [28] and easy access to various media outlets [29]. Additionally, the geographical location of urban areas offers a distinct advantage in terms of healthcare accessibility. Urban regions are typically well-equipped with a variety of healthcare facilities, including hospitals, clinics, maternity centres, and specialized healthcare providers. The proximity of these facilities to residential areas may reduce travel time and logistical challenges, making it easier and more convenient for urban women to access ANC services timely [30, 31].

According to the findings of this study, the level of education of the women was found to be a significant predictor for the time to initiation of ANC visits. Women who have a tertiary and above level of education initiate their ANC visit earlier than those with secondary and primary levels, which is consistent with a study conducted in Ethiopia [8, 12, 14, 18], Nepal [25], Nigeria [15, 22, 26], and Bangladesh [27]. Education enhances women’s capabilities, particularly in understanding and accessing healthcare services [32]. Women with higher educational levels tend to initiate ANC earlier as they have easy access to health-related information and can easily comprehend information conveyed in various formats and methods [24]. Furthermore, educated women are empowered to make independent health decisions, allowing them to take charge of their own healthcare choices, including when and how to initiate ANC, based on their informed understanding and knowledge [32, 33].

Similarly, pregnancy-related complications were found to be another predictor for the time to initiation of ANC visits. Women who faced pregnancy-related complications in their previous pregnancy were more likely to initiate their ANC visit earlier than their counterparts, which is in line with the findings from Ethiopia [23, 34], Rwanda [35] and Tanzania [36]. Women who have previously experienced pregnancy complications or adverse outcomes are more proactive in seeking early ANC services for subsequent pregnancies [37]. Their past experiences may alert them to prioritize comprehensive ANC to prevent similar complications from recurring and to ensure better pregnancy outcomes. Having encountered challenges during a previous pregnancy, these women are often more informed and aware of the potential risks and complications associated with pregnancy. This heightened awareness can motivate them to be more diligent and attentive towards their antenatal health, prompting them to seek timely medical advice and interventions through ANC services [38]. ANC visits in previous pregnancies were found to be another predictor for the time to initiation of ANC visits. Women who had not had ANC service in their previous pregnancy initiated their ANC visit later than those who had. This is in line with the studies from Ethiopia [39, 40], and Afghanistan [21]. Health facilities often serve as crucial platforms for health education and promotion. Women attending ANC previously could receive information, guidance, and counselling on various aspects of pregnancy, ANC, and childbirth. These educational sessions empower them with knowledge related to maternal and child health thus enabling the timely initiation of ANC visits [41]. Women who have no previous ANC experience may not know the services given during ANC, so, they may fear and feel unfamiliar with getting ANC service in health facilities timely [39].

Furthermore, the intention of pregnancy is found to be a predictor for the time to initiation of ANC visits. Women who had unplanned pregnancies were found to initiate ANC visits later than those who had planned pregnancies, which is in line with the studies performed in Nepal [25], Afghanistan [21], Gambia [42], South Africa [43] and south and southwest Ethiopia [13, 44]. Women who find themselves with unplanned pregnancy may experience a range of emotions, including anxiety, sadness or regret. This emotional turmoil can affect their acceptance and attitude towards the pregnancy and can result in late ANC initiation [45]. Additionally, the unexpected nature of unplanned pregnancies can result in delayed recognition and awareness of their pregnancy status and can lead to late ANC initiation [46]. Furthermore, If the partner is not in favour of the pregnancy, he may exert control or dominance over the woman’s healthcare decisions, refusing to grant permission or accompany her to ANC appointments, further restricting her access to essential ANC services [47].

Knowledge and attitude about ANC were not measured due to the retrospective nature of the study. The outcome variable for different women was measured differently as there are different methods for gestational age measurement like; ultrasound measurement, and gestational age based on the last normal menstrual period.