Original ResearchMaternal Health & Reproductive Services

Factors Affecting Utilization of Antenatal Care Services in Sana'a City, Yemen

Introduction and Rationale

Antenatal care (ANC) is a cornerstone of primary healthcare, widely recognised for its capacity to improve both maternal and neonatal outcomes. Through systematic monitoring of pregnancy, early detection of complications, provision of preventive interventions, and health education, antenatal care services reduce the risks of maternal mortality, stillbirth, neonatal death, and pregnancy-related morbidity. The World Health Organization has long recommended a minimum of four focused antenatal care visits during pregnancy — a threshold that many low- and middle-income countries continue to struggle to achieve.

Yemen faces particularly acute challenges in maternal healthcare. The country has one of the highest maternal mortality ratios in the region, with estimates reaching approximately 500 deaths per 100,000 live births. Health system infrastructure has been severely compromised by years of conflict, with over half of hospitals and health facilities rendered non-operational. Access to reproductive health services remains limited: only an estimated 25% of Yemeni women of reproductive age receive the recommended four or more antenatal care visits during pregnancy.

This cross-sectional community-based study, published in the Malaysian Journal of Public Health Medicine, sought to identify the specific factors affecting antenatal care utilisation among women of reproductive age in Sana’a City, Yemen’s capital and largest urban centre. Understanding these determinants is essential for designing targeted interventions to improve maternal healthcare uptake in a setting where every improvement in service utilisation can translate directly into lives saved.

Study Design and Methods

The researchers conducted a cross-sectional community-based study across six districts of Sana’a City, Yemen. Data were collected from 460 mothers who had given birth within the preceding six months. Face-to-face interviews were conducted at participants’ homes between September and December 2010, using a structured questionnaire that captured information on socio-demographic characteristics, obstetric history, antenatal care utilisation patterns, knowledge of pregnancy danger signs, and barriers to care-seeking.

The study sample was selected to represent the urban population of Sana’a City, with participants drawn from across the city’s districts to ensure geographic diversity. Statistical analysis employed bivariate and multivariate methods to identify factors independently associated with ANC utilisation, with significance set at P<0.05.

Key Findings

Antenatal Care Utilisation Rates

The study revealed that only 54% of mothers had made four or more antenatal care visits during their most recent pregnancy, falling well below international recommendations. While this figure represents somewhat better coverage than Yemen’s national average, it still indicates that nearly half of urban mothers in the capital city were not receiving adequate prenatal monitoring.

Approximately two-thirds of participants initiated their first antenatal visit during the first trimester of pregnancy, which is a positive finding. However, a critical concern emerged: the primary motivation for seeking initial care was the presence of health problems, and many women discontinued follow-up visits once they perceived themselves to be healthy. This pattern suggests that ANC was viewed primarily as a curative rather than preventive service, reflecting a fundamental gap in health literacy regarding the purpose and benefits of routine antenatal monitoring.

Barriers to Antenatal Care

The study identified multiple interacting barriers to adequate ANC utilisation. Among women who did not receive recommended care, the most frequently cited reasons included the absence of perceived health problems (suggesting that pregnancy in the absence of symptoms was not considered to require medical attention), high cost of antenatal care services, long waiting times at health facilities, and poor attitudes of healthcare staff.

Perhaps most concerning was the finding that 60% of participants were unaware of the danger symptoms associated with common pregnancy complications. This profound knowledge gap meant that many women lacked the ability to recognise warning signs that should prompt urgent medical attention, such as severe headache, blurred vision, vaginal bleeding, severe abdominal pain, or reduced foetal movement. Without this basic health literacy, women could not make informed decisions about when to seek care.

Socio-Demographic Determinants

Multivariate analysis revealed several socio-demographic factors independently associated with ANC utilisation. Maternal education emerged as one of the strongest predictors: women with higher educational attainment were significantly more likely to make adequate antenatal care visits. Place of residence within the city also influenced utilisation patterns, reflecting inequalities in access and availability of services across different urban zones.

Obstetric factors played a significant role as well. Age at first pregnancy, gravidity (total number of pregnancies), parity (number of previous births), unplanned pregnancy, and number of living children were all significantly associated with ANC utilisation (P<0.05). The number of antenatal visits was further influenced by maternal education, place of residence, and husband's employment status.

Discussion and Contextual Analysis

The findings from Sana’a City reflect broader patterns observed across low- and middle-income countries, where antenatal care utilisation is shaped by a complex interplay of individual, household, community, and health system factors. The prominence of maternal education as a determinant of care-seeking behaviour aligns with extensive international evidence demonstrating that education empowers women to recognise the value of preventive health services, navigate health systems, and advocate for their own healthcare needs.

The finding that women primarily sought care in response to perceived health problems, rather than for routine preventive monitoring, highlights a fundamental challenge in promoting antenatal care in settings where health literacy is limited. Educational interventions that emphasise the preventive purpose of ANC — including the early detection of conditions such as pre-eclampsia, gestational diabetes, anaemia, and foetal growth restriction that may present without obvious symptoms — are essential for shifting care-seeking behaviour toward a more proactive model.

The role of healthcare service quality, including staff attitudes and waiting times, as barriers to utilisation underscores the importance of supply-side interventions alongside demand-generation activities. Even when women are motivated to seek care, negative experiences with healthcare providers can discourage continued attendance. Training programmes focused on respectful maternity care and service delivery efficiency are therefore critical complements to health education campaigns.

Implications for Healthcare Policy

The study’s findings point to several actionable recommendations for improving antenatal care utilisation in Yemen and comparable settings. Future healthcare activities should focus on improving women’s awareness of the importance of continuing antenatal care throughout pregnancy, even in the absence of noticeable health problems. Community-based health education programmes, particularly those delivered through trusted community figures and peer support networks, may be effective in reaching women with limited formal education.

Addressing the knowledge deficit regarding pregnancy danger signs should be a priority, as this represents both a barrier to appropriate care-seeking and a direct risk factor for delayed recognition of obstetric emergencies. Interventions to reduce financial barriers to care, improve service quality, and extend operating hours to reduce waiting times would address the supply-side factors identified as deterrents to utilisation.

Limitations

The study was conducted in an urban setting (Sana’a City) and its findings may not be directly generalisable to rural areas of Yemen, where access to health services is typically more limited. Data collection relied on maternal self-report, which may be subject to recall bias regarding the number and timing of antenatal visits. The cross-sectional design precludes establishing causal relationships between identified factors and ANC utilisation. Additionally, the data were collected in 2010, and subsequent conflict in Yemen has dramatically altered the healthcare landscape, potentially rendering some findings less directly applicable to the current situation.

Significance for Public Health

Despite these limitations, this study makes an important contribution to the evidence base on maternal healthcare utilisation in Yemen, a country where maternal mortality remains unacceptably high. The identification of modifiable factors — particularly health literacy, service quality, and financial accessibility — provides a foundation for designing targeted interventions that could improve antenatal care uptake and, ultimately, maternal and neonatal outcomes in one of the world’s most challenging healthcare environments.

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