{"paper_id":"ecca870c-1013-47e9-9055-84eb870c1cc3","body_text":"PregnAnZI-2_ANC_preprint \n1 \n \nDeterminants of delayed antenatal visit attendance in rural Burkina Faso: a 1 \ncross-sectional study 2 \nJoël D. Bognini1, Toussaint Rouamba1,2, Helen Brotherton3,4, Guétawendé J. W. Nassa1, Athanase M. 3 \nSomé1, Diagniagou Lankoandé1, Edmond Yabré Sawadogo5, Umberto D’Alessandro3, Halidou Tinto1, 4 \nAnna Roca3,6,7  5 \n 6 \nAffiliations  7 \n1. Institut de Recherche en Science de la Santé (IRSS), Unité de Recherche Clinique de Nanoro, 8 \nNanoro (URCN), Burkina Faso 9 \n2. Centre de Recherche en Epidémiologie, Biostatistique Et Recherche Clinique, Ecole de Santé 10 \nPublique, Université Libre de Bruxelles, Bruxelles, Belgium 11 \n3. Medical Research Council Unit The Gambia at London School of Hygiene and Tropical Medicine, 12 \nBanjul, The Gambia  13 \n4. Victoria Hospital Kirkcaldy, NHS Fife, UK 14 \n5. Ministère de la santé, Direction régionale du centre-ouest, Koudougou, Burkina Faso 15 \n6. ISGlobal, Campus Hospital Clínic-Universitat de Barcelona, Barcelona, Spain  16 \n7. ICREA, Pg. Lluís Companys 23, Barcelona, Spain 17 \n 18 \nCorresponding author & contact details: Joel D. Bognini, bogninijoel@gmail.com 19 \nKey words: antenatal visit, delay, first visit, pregnancy, Burkina Faso, West Africa 20 \nAbstract 21 \nIntroduction: The World Health Organization recommends a minimum of eight antenatal care (ANC) 22 \ncontacts, with the first visit occurring before the 12th week of gestation, as a strategy to enhance the 23 \npreparedness of women for institutional delivery and improve perinatal outcomes. The present study 24 \naims to assess the prevalence of delayed ANC attendance among pregnant women in rural Burkina 25 \nFaso and identify associated risk factors. 26 \nMethods: This is a secondary analysis of clinical data collected from a randomised-controlled trial 27 \n(clinicaltrials.gov ref: NCT03199547); conducted between 2018 and 2021 in rural Burkina Faso. We 28 \nestimated gestational age (GA) at the first ANC visit based on recall information on the last menstrual 29 \nperiod provided by study participants or, when such information was unavailable, symphysis-fundal 30 \nheight measurements taken by ANC nurses. We used descriptive methods followed by unadjusted and 31 \nadjusted logistic regression, informed by an original conceptual framework, to determine the 32 \nprevalence and risk factors associated with delayed first ANC visit, defined as occurring after the 12th 33 \nweek of gestation. A significance threshold was set at 0.05. 34 \nResults: Out of the 5250 women enrolled in the study, 2480 (47.2%) had data available from their first 35 \nANC visit, and 90.6% ( 2248/2480) of th ose women had gestational age estimates.  Most women 36 \n(n=2037/2248, 9 0.6%) attended their first ANC after the 1 4th week of gestation. The main factors 37 \nassociated with this delay were multiparity ≥ 4 pregnancies (OR=2.26, 95%CI [1.48 – 3.4], p < 0.001) 38 \nand first ANC visit attended during the dry season (OR=1.79, 95%CI [1.34 – 2.39], p < 0.001). 39 \nConclusion: Our study highlights that most pregnant women in rural Burkina Faso attended their first 40 \nANC visit later than the WHO recommended timeline , increasing their risk of poor delivery outcome . 41 \nAlthough we identified some factors that increased this risk of late ANC attendance, awareness raising 42 \ninterventions are required for the whole population as starting late seems to be the norm.  43 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 24, 2025. ; https://doi.org/10.1101/2025.10.22.25338535doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\nPregnAnZI-2_ANC_preprint \n2 \n \nIntroduction  44 \nThe antenatal and peripartum periods carry significant risks of morbidity and mortality for both 45 \nmothers and their newborns. In 2020, the global maternal mortality rate (MMR) was 216 deaths 46 \nper 100,000 live births [1]. In sub-Saharan Africa (SSA), the MMR was substantially higher, at 47 \n536 maternal deaths per 100,000 live births [2]. Furthermore, the neonatal mortality rate (NMR) 48 \nin SSA was estimated at 27 deaths per 1,000 live births in 2021 and this accounted for 45% of 49 \nglobal neonatal deaths [3].  50 \nProfessional antenatal care (ANC) is crucial for improving pregnancy outcomes. The World 51 \nHealth Organization (WHO) recommends a minimum of eight ANC contacts, with the first visit 52 \noccurring before 12 weeks of gestation or during the first trimester of pregnancy [4]. Early 53 \nattendance and regular ANC follow -ups play a crucial role in preventing and managing 54 \nmaternal health problems and preparing women for institutional delivery [5–7]. Indeed, primary 55 \nrisk factors for perinatal mortality can be identified during pregnancy, and the utilisation of at 56 \nleast one early ANC visit by a skilled provider reduces the neonatal mortality rate by 39% in 57 \nSSA [7, 8]. A systematic review of 74 studies published between 2008 and 2018 across 23 58 \ncountries in SSA, including West African nations (Burkina Faso, Nigeria, Benin, Ghana, and 59 \nNiger), revealed that more than two-thirds of pregnant women attended ANC late, and up to 1 60 \nin 14 had their first visit during the third trimester of pregnancy [9].  61 \nLate ANC attendance is associated with  perinatal complications and adverse birth outcomes 62 \nsuch as increased risk of stillbirth, low birth weight, neonatal mortality and preterm delivery [5, 63 \n10–12]. These serious outcomes are important public health challenges  in Burkina Faso, with 64 \n31 preterm births per 1000 live births, and 22 stillbirths for 1000 total births in 2020 [13]. In 65 \nBurkina Faso, data from the Ministry of Health showed that the proportion of pregnant women 66 \nwho attended ANC late varied across geographic areas, ranging from 52% to 74% in 2018 [14] 67 \nand approximately 60% in 2020 [13]. Despite the implementation of free health care policy in 68 \nBurkina Faso in 2016, which aimed to improve access to health care services coverage and 69 \ntiming of ANC visits [15], there is no significant improvement of the situation [13]. To reduce 70 \nthe perinatal mortality rate even with the free policy, it is necessary to assess the determinants 71 \nof late ANC attendance in order to be able to implement strategies to improve earlier ANC 72 \nattendance in line with the WHO recommendations that the first prenatal consultation should 73 \nbe carried out during the first trimester (before 12 weeks of gestation) of pregnancy in an effort 74 \nto reduce perinatal mortality . Hence, it is important to determine the prevalence of delayed 75 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 24, 2025. ; https://doi.org/10.1101/2025.10.22.25338535doi: medRxiv preprint \n\nPregnAnZI-2_ANC_preprint \n3 \n \nANC attendance and assess its main determinants in rural Burkina Faso, in the context of a free 76 \nhealthcare policy for pregnant women and lactating mothers.  77 \nMethods 78 \nStudy design 79 \nThis is a secondary data analysis of a descriptive cohort from the PregnAnZI -2 project 80 \n(clinicaltrials.gov ref: NCT03199547); the latter is a phase III, double-blind, placebo-controlled 81 \nrandomised clinical trial conducted in The Gambia and Burkina Faso from 2017 to 2021. The 82 \ntrial procedures were reported elsewhere [16]. Briefly, women were approached for consent 83 \nduring ANC visits but were enrolled into the trial only during labour when oral intrapartum 84 \nazithromycin or placebo was administered, hence the allocation did not influence the attendance 85 \nor timing of ANC and both trial arms were included in this study. However, we have included 86 \nhere only the Burkina Faso cohort as it is more representative of a rural West African population 87 \ncompared to peri-urban Gambian participants. 88 \nStudy site 89 \nBurkina Faso is a West African country with  approximately 20 million inhabitants, where the 90 \nmain livelihood is agriculture. There are two seasons: a dry season (November to May) and a 91 \nrainy season (June to October). Women of childbearing age represent 24.1% of the population, 92 \nwith a fertility rate in 2020 of 5 children per woman  [17, 18]. At the national level, in 2020 93 \nnearly three-quarters of pregnant women attended one ANC visit , and among them, one-quarter 94 \nattended  during the first trimester of pregnancy [13]. Regarding adverse perinatal outcomes in 95 \nBurkina Faso, the stillbirth rate was 22 per 1000 live births, NMR of 64 per 1000 live births, 96 \nand MMR of 147 per 100,000 live births in 2020 [13]. Since 2016, all services offered at health 97 \nfacilities are free of charge for pregnant women, lactating mothers, and children under 5 years. 98 \nThe present study was conducted in the Nanoro Health District catchment area located at 99 \napproximately 85 km from Ouagadougou, the capital of Burkina Faso. This is a rural area with 100 \nANC services provided by midwives at government primary health centres. 101 \nParticipants  102 \nThis study included pregnant women aged 16 and above recruited in the PregnANZI-2 trial and 103 \nwho delivered at the study health facility with ANC services available. Women were excluded 104 \nif: they had a known acute or chronic condition (e.g. HIV infection, diabetes mellitus); had a 105 \nplanned caesarean section or anticipated referral to a tertiary referral facility; known severe 106 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 24, 2025. ; https://doi.org/10.1101/2025.10.22.25338535doi: medRxiv preprint \n\nPregnAnZI-2_ANC_preprint \n4 \n \nfoetal congenital malformation; macrolide allergy or use of medication known to increase the 107 \nQT interval during two weeks preceding delivery [16]. 108 \nStudy procedures 109 \nWritten informed consent for participation in the PregnAnZI -2 trial was taken during ANC 110 \nvisits and verbally confirmed during labour. Socio-demographic, epidemiological, and clinical 111 \ninformation were collected by trained research nurses during labour and the immediate post -112 \npartum period (typically 6 -24h after delivery)  using the handheld  Maternal and Child Health 113 \nbook and maternal direct questioning, as per PregnAnZI-2 trial procedures [16]. 114 \nOutcome measures and variables of interest 115 \nThe outcome of interest is a binary variable; delayed ANC attendance (yes or no) defined as 116 \nfirst visit after 1 4th week of gestation. This variable was generated using the gestational age 117 \n(GA) recorded during the first ANC visit to classify weeks of pregnancy. We estimated GA at 118 \nthe first ANC visit based on recall information of the last menstrual period (LMP) provided by 119 \nstudy women or when such information was not recalled by the women, we used symphysis -120 \nfundal height measurements assessed by the government facility  nurses. The correlation 121 \nbetween fundal height and the GA in weeks was previously reported to have a prediction error 122 \nranging between 13.9 and 14.9 days [19]. Gold standard dating methods using first trimester 123 \nultrasound scanning were not available either as part of routine antenatal care or in association 124 \nwith PregnAnZI-2 trial. 125 \nTo explore factors associated with delayed ANC attendance, we developed an original  126 \nconceptual framework based on the literature review and plausible associations (Figure 1).  127 \nAlthough existing frameworks exist for measuring ANC quality of care [20] and for ANC in 128 \nwell-resourced settings [21], we did not identify any conceptual frameworks relevant to our 129 \npopulation of West African women living in a rural low-resource setting. Hence, we developed 130 \nan original one. The conceptual framework guided our choice of variables for the univariate, 131 \nunadjusted analyses and informed the development of adjusted analy tical models . The 132 \ncategories for these variables were selected based on a preliminary analysis of the data to 133 \nconsider small cell sizes, and similar outcomes in adjacent ordered or related categories.  134 \n 135 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 24, 2025. ; https://doi.org/10.1101/2025.10.22.25338535doi: medRxiv preprint \n\nPregnAnZI-2_ANC_preprint \n5 \n \nData management and statistical analyses 136 \nAll data were electronically captured using the REDCap software, version 8.9.2, with internal 137 \nvalidation and consistency checks.  Descriptive statistics (percent age, mean , and standard 138 \ndeviations) were performed to determine the prevalence of all independent variables. Logistic 139 \nregression was used to assess the association between each covariate and to generate crude odds 140 \nratio and 95% confidence intervals (CI) . Variables with p -value < 0.20 from the unadjusted 141 \nanalyses that were part of the conceptual framework were included in the adjusted models. A 142 \np-value < 0.05 was considered as statistically significant. All analyses were conducted using 143 \nStata 15. 144 \nResults 145 \nCharacteristics of the study population 146 \nOverall, 42.8% (2248/5250) of enrolled women had available information regarding the timing 147 \nof their first ANC visit and were included in the analysis. Out of them, 1% recalled their LMP 148 \nand in the remaining 99% fundal heigh t measurements were taken by a study nurse. 149 \nDemographic and epidemiological characteristics of women included, and those who were not 150 \nincluded in the study were not statistically significant ly different, except that the  included 151 \nwomen were slightly younger (Supplementary Table 1). For included women, mean age was 152 \n26.5 years, and more than half were multiparous . Around 58% of pregnant women attended 153 \ntheir first ANC during the dry season (November-May), 9% and 3% had history of miscarriage 154 \nand stillbirth respectively (Table 1). Overall, 2037/2248 (90.6%) of women attended their first 155 \nANC visit after 1 4 weeks of gestation . The majority of these pregnant women (75.7%, 156 \n1701/2248) had their first ANC visit during the second trimester, and 14.9% (336/2248) during 157 \nthe third trimester of their pregnancy (Figure 2).  158 \nDeterminants of delayed ANC attendance 159 \nParity and season of the first ANC visit were associated with delayed ANC attendance 160 \naccording to the adjusted regression model. Multiparous women pregnant for fourth or more 161 \ntime had an increased odds of starting ANC visits at > 14 weeks of gestation compared to 162 \nwomen in their second pregnancy (OR=2. 26 95%CI [1.48 – 3.35], p < 0.001). Women who 163 \nattended their first ANC visit during the dry season were more likely to attend after 14 weeks 164 \nof gestation compared to those attending for the first time during the rainy season (OR=1.7 9, 165 \n95%CI [1.3 4 – 2.39], p < 0.001) (Table 1).  Even though , we found statistically significant 166 \ndifferences for the prevalence of delayed ANC attendance between parity groups, less than 15% 167 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 24, 2025. ; https://doi.org/10.1101/2025.10.22.25338535doi: medRxiv preprint \n\nPregnAnZI-2_ANC_preprint \n6 \n \nof women within each parity group had their first ANC visit on time; and the same applies to 168 \nboth seasons.  169 \nDiscussion 170 \nThis large cohort study highlights that most pregnant women in rural Burkina Faso do not attend 171 \ntheir first ANC visit before the 14th week of gestation, even after the implementation of a free 172 \nnational healthcare policy. This delay occurs across all age groups, ethnic groups, parities and 173 \nseasons.  174 \nIn our study, at least 9 0% of relatively healthy pregnant women living in rural Burkina Faso 175 \nattended their ANC visits after the 1 4th week of gestation, later than the WHO recommended 176 \ntimeline. This figure exceeds the delayed ANC attendance previously reported from Burkina 177 \nFaso at national level (62.2% to 64.3%)  [22]. Similar rates of late ANC attendance were 178 \nreported at another health district level (62.9%)  located in the Cent re-North of Burkina Faso 179 \n[23]. Prevalence of delayed ANC attendance also varies between countries across West Africa, 180 \nranging from 85.3% in Nigeria  [24] to 57.7% in Ghana [25]. Elsewhere in Africa, delayed 181 \nANC attendance rates are also a concern as reported in rural Ethiopia, Eastern Africa (60.5%) 182 \n[23, 26, 27], albeit not as high as observed in our study. 183 \nReasons for the high prevalence of delayed ANC attendance in our rural West African study 184 \npopulation are likely multifactorial. Potential factors include local beliefs that revealing 185 \npregnancy too early would result in miscarriage, financial constraints for transport to health 186 \nfacilities, and limitation in the availability and quality of the ANC services. These issues are 187 \nnot unique to Burkina Faso as they have been observed also in South Africa, Tanzania and other 188 \nAfrican countries [28–30], as depicted in the framework. This framework could facilitate the 189 \nidentification of factors for delay at first ANC visit in similar contexts for other studies. The 190 \nwidespread delay in ANC attendance poses significant risks as it exposes pregnant women to 191 \nadverse pregnancy outcomes [31] by missing early preventive care and the timely identification 192 \nof maternal, foetal and obstetric complications. To address this, emphasising the importance of 193 \nearly ANC visits both at health facility level and in the communities through primary health 194 \nworkers could enhance awareness and promote earlier engagement with ANC services , as 195 \ndemonstrated in Ethiopia [32] and Uganda [33], where pregnant women with knowledge of 196 \nappropriate ANC timings were more likely to initiate care timely. In Burkina Faso, despite free 197 \nANC services, economic barriers such as the cost of specialised tests, transportation and the 198 \nindirect economic impact of time spent away from formal or domestic work still pose a 199 \nsignificant challenge. Innovative evidence -based solutions are needed to overcome these 200 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 24, 2025. ; https://doi.org/10.1101/2025.10.22.25338535doi: medRxiv preprint \n\nPregnAnZI-2_ANC_preprint \n7 \n \nbarriers and ensure more women can access timely to ANC. Also, introducing a more flexible 201 \nANC schedule system could further improve the early attendance. 202 \nAlthough most women were late to their first ANC visit, we identified two important 203 \ndeterminants: multiparity and season of first ANC visit. Consistent with previous studies from 204 \nEthiopia [32] and Nigeria [34], multiparous women in our study were more than twice as likely 205 \nto have delayed ANC attendance compared to women during their second pregnancy. A 206 \npossible explanation, supported by a qualitative study in Cameroon, is that women with 207 \nextensive previous experience of pregnancy gain confidence in their own ability to manage their 208 \npregnancies and perceive early healthcare as less critical [35]. An alternative explanation could 209 \nbe that attitudes were shaped by the women’s previous negative experiences in the health 210 \nfacility, such as long waiting times and poor quality of care, as highlighted in a study from 211 \nPapua New Guinea [36].  212 \nWe observed an association between season of first ANC visit and timely attendance, with 213 \nincreased risk of delay during the dry season. This finding may be linked to domestic work 214 \ndemands for pregnant women, as reported in an Ethiopian study where the time constraints 215 \nlinked to household activities represented more than 24% of reasons for delayed ANC 216 \nattendance [27]. During the dry season in rural Burkina Faso there are various cultural activities 217 \nwhich coincide with the harvest campaign, including mask dances and funeral ceremonies [37–218 \n39], hence women are busy with domestic duties and this may impact on the attendance of their 219 \nfirst ANC visit. Even though we identified two determinants of delayed first ANC visit, most 220 \nwomen were at risk of being late and therefore any intervention to improve early ANC 221 \nattendance should ideally target all of them. 222 \nThis study has some limitations that need to be considered when interpreting the results. Firstly, 223 \nwe used data from a selected population participating in a randomised controlled trial, which 224 \ncould have introduced potential bias by excluding women with serious health problems or those 225 \nnot willing to participate. Secondly, gestation al age was estimated using inaccurate measures 226 \n(last menstrual period and symphysis -fundal height), limiting the accuracy of the estimations 227 \nand potentially misclassifying the primary outcome. However, we mitigated this risk by using 228 \nan established method with precision of 2 weeks  to minimise the misclassification errors. A 229 \nthird limitation is the selection bias towards pregnant women with available data to estimate 230 \nthe gestational age. However, comparison of baseline characteristics for included and excluded 231 \npregnant women did not identify any major differences in their characteristics , hence bias is 232 \nassumed to be minimal . Lastly, as this analysis used an existing dataset, we were unable to 233 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 24, 2025. ; https://doi.org/10.1101/2025.10.22.25338535doi: medRxiv preprint \n\nPregnAnZI-2_ANC_preprint \n8 \n \nassess all potential variables associated with delayed ANC attendance . Hence, there is a need 234 \nfor further qualitative and quantitative research to understand determinants of timely attendance 235 \nof ANC for rural West African populations.  236 \nConclusion 237 \nOur study identified a very high proportion of pregnant women in rural Burkina Faso attending 238 \ntheir ANC visits later than the WHO recommended timeframe with multiparity and dry season 239 \nthe main determinants of delayed ANC initiation . This delay poses significant public health 240 \nconcerns by limiting the opportunities for maternal and antepartum preventive services. Merely 241 \nproviding free access to ANC or implementing national policies has proven to be insufficient 242 \nin ensuring women starting their ANC on time. There is a pressing need for further research to 243 \nunderstand the context-specific reasons behind these delays to optimise maternal and perinatal 244 \nhealth outcomes effectively.   245 \nDECLARATIONS 246 \nEthics approval and consent to participate 247 \nThe trial was approved by the ‘’Comité d’Ethique pour la Recherche en Santé (CERS)’’ and the Ministry 248 \nof Health of Burkina Faso, The Gambia Government/MRCG (Medical Research Council Unit The 249 \nGambia) Joint Ethics Committee and the LSHTM Ethics Committee. All women provided written 250 \ninformed consent during antenatal care visits and were free to withdraw at any time. 251 \nConsent to publish  252 \nNot applicable.  253 \nAvailability of data and materials   254 \nData may be obtained from a third party and are not publicly available. Qualified researchers may 255 \nrequest access with the Gambia Government/MRC Joint Ethics Committee. The review process and 256 \nrelease of data will be facilitated by MRC Unit The Gambia (http://www.mrc.gm/) through the Head of 257 \nGovernance at MRCG. Access will not be unduly restricted.  258 \nCompeting interests  259 \nThe authors declare that they have no competing interests.  260 \nFunding 261 \nThe PregnAnZI-2 trial was funded by a grant from the UKRI under the Joint Global Health Trial Scheme 262 \n(JGHT) (ref: MC_EX_MR/P006949/1) and the Gates Foundation (Ref: OPP1196513). The funders and 263 \nstudy sponsor (MRCG) had no role in the study design, collection, analysis, or interpretation of data, 264 \nwriting of the article nor the decision to submit for publication. 265 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 24, 2025. ; https://doi.org/10.1101/2025.10.22.25338535doi: medRxiv preprint \n\nPregnAnZI-2_ANC_preprint \n9 \n \nAuthors’ contributions 266 \nJ.D.B. conceptualised this study with input from U .dA., H .B., H .T., A .R. Data collection was 267 \ncoordinated by J .D.B., and PregnAnZI-2 field teams in Burkina Faso. J .D.B. performed the analysis 268 \nwith full access to the data and input from T .R. J.D.B. drafted the initial manuscript with input from 269 \nH.B., A.R., H.T., T.R., A.M.S., G.J.W.N., E.Y.S, D.L. All authors contributed to the final version. H.T. 270 \nand A.R. gave oversight to the work as guarantors and accepted full responsibility for the finished work 271 \nand controlled the decision to publish.  272 \nAcknowledgements 273 \nThe authors wish to thank Medical Research Council Unit, The Gambia at LSHTM for allowing 274 \naccess to the data, the research staff, and all the participants of Nanoro health district for accepting to 275 \ntake part in the study.276 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 24, 2025. ; https://doi.org/10.1101/2025.10.22.25338535doi: medRxiv preprint \n\nPregnAnZI-2_ANC_preprint \n10 \n \nReferences  277 \n1. Alkema L, Chou D, Hogan D, Zhang S, Moller A-B, Gemmill A, et al. 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CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 24, 2025. ; https://doi.org/10.1101/2025.10.22.25338535doi: medRxiv preprint \n\nPregnAnZI-2_ANC_preprint \n13 \n \nFigures 405 \n 406 \n 407 \nFigure 1. Conceptual framework to understand determinants of pregnant women’s timely use 408 \nof antenatal care services  409 \n 410 \n 411 \nFigure 2: Flowchart showing the inclusion of relatively healthy pregnant women in the study.412 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 24, 2025. ; https://doi.org/10.1101/2025.10.22.25338535doi: medRxiv preprint \n\nPregnAnZI-2_ANC_preprint \n14 \n \nTables 413 \nTable 1: Characteristics associated with delayed ANC attendance in rural Burkina Faso. 414 \n Total Delayed ANC visit attendance Unadjusted analysis Adjusted analysis \nCharacteristics Total \n2248 (100%) \nNo \n211 (9.4%) \nYes \n2037 (90.6%) OR CI 95% p-value OR CI 95% p-value \nAge of the pregnant \nwoman (Years) \n   \n  0.01*   0.28 \nAge (mean, SD) 26.51 (6.33) 24.49 (5.69) 26.72 (6.35)       \n20 – 35 1,680 (74.73) 159 (9.46) 1521 (90.54) 1   1   \n15 – 19 362 (16.11) 43 (11.88) 319 (88.12) 0.77  [0.54 -1.10]  1.33 [0.81 – 2.20]  \n> 35 206 (9.16) 09 (4.37) 197 (95.63) 2.28 [1.15 – 4.55]  1.49 [0.73 – 3.05]  \nMothers’ ethnicity      0.37    \nMossi 2,077 (92.39) 197 (9.48) 1,880 (90.52) 1      \nGurunsi 144 (6.41) 10 (6.94) 134 (93.06) 1.40 [0.72 – 2.71]     \nOthers 27 (1.20) 4 (14.81) 23 (85.19) 0.60 [0.20 – 1.75]     \nHusbands’ ethnicity      0.55    \nMossi 2,070 (92.08) 197 (09.52) 1,897 (90.48) 1      \nGurunsi 143 (6.36) 10 (06.99) 133 (93.01) 1.39 [0.72 – 2.70]     \nOthers 35 (1.56) 4 (11.43) 31 (88.57) 0.81 [0.28 – 2.33]     \nPeriod of the ANC visit \ncommencement \n   \n  < 0.001*   < 0.001 \nRainy (June-October) 947 (42.13) 116 (12.25) 831 (87.75) 1   1   \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 24, 2025. ; https://doi.org/10.1101/2025.10.22.25338535doi: medRxiv preprint \n\nPregnAnZI-2_ANC_preprint \n15 \n \nDry (November-May) 1,301 (57.87) 95 (7.30) 1,206 (92.70) 1.77 [1.33 – 2.35]  1.79 [1.34 – 2.39]  \nParity      < 0.001*   < 0.001 \nPara 2 347 (15.44) 43 (12.39) 204 (87.61) 1   1   \nPrimiparous 438 (19.48) 59 (13.47) 379 (86.53) 0.90 [0.59 – 1.38]  0.77 [0.46 – 1.27]  \nPara 3 335 (14.90) 44 (13.13) 291 (86.87) 0.93 [0.59 – 1.46]  0.93 [0.59 – 1.47]  \nPara ≥ 4 1,128 (50.18) 65 (5.76) 1,063 (94.24) 2.31 [1.54 – 3.47]  2.26 [1.48 – 3.45]  \nHistory of miscarriage      0.23    \nNo 2,043 (90.88) 187 (9.15) 1,856 (90.85) 1      \nYes 205 (9.12) 24 (11.71) 181 (88.)29 0.65 [0.59 – 4.58]     \nHistory of stillbirth      0.33    \nNo 2,181 (97.02) 207 (9.49) 1,974 (90.51) 1      \nYes 67 (2.98) 4 (5.97) 64 (94.03) 1.96 [0.61 – 6.31]     \n* Variables included in the adjusted model. 415 \nAbbreviations: ANC = Antenatal care; CI = Confidence interval; OR = Odds ratio; SD = Standard deviation 416 \n . CC-BY 4.0 International licenseIt is made available under a \nperpetuity. \n is the author/funder, who has granted medRxiv a license to display the preprint in(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted October 24, 2025. ; https://doi.org/10.1101/2025.10.22.25338535doi: medRxiv preprint","source_license":"CC-BY-4.0","license_restricted":false}