Delayed Initiation of Antenatal Care among Pregnant Women in Indonesia: Findings from a Multi-Centered Cross-Sectional Study

Wiqodatul Ummah; Yanti Rosdiana; Woro Tri Utami

doi:10.30994/jnp.v9i4.1157

Authors

Wiqodatul Ummah Midwifery Study Program, Politeknik Kesehatan Wira Husada Nusantara Malang, Malang, Indonesia https://orcid.org/0000-0002-0867-913X
Yanti Rosdiana Faculty of Health Science, Universitas Tribhuwana Tungga Dewi, Malang, Indonesia https://orcid.org/0009-0007-9683-9562
Woro Tri Utami Midwifery Study Program, Politeknik Kesehatan Wira Husada Nusantara Malang, Malang, Indonesia https://orcid.org/0009-0001-1458-3484

DOI:

https://doi.org/10.30994/jnp.v9i4.1157

Keywords:

Antenatal Care, Indonesia, Late Initiation, Maternal Health, Pregnancy

Abstract

Background: Early initiation of antenatal care (ANC) is critical for optimizing maternal and neonatal health outcomes, yet late initiation remains a persistent challenge in many low- and middle-income countries.

Purpose: This study aimed to investigate the magnitude and factors associated with delayed initiation of antenatal care among pregnant women in Indonesia in Malang City and Malang Regency, Indonesia.

Methods: A facility-based cross-sectional study was conducted from May to July 2025 among 309 pregnant women selected using systematic random sampling from one hospital and two health centers. Delayed ANC initiation was defined as the first ANC visit after 12 completed weeks of gestation. Data were collected using a structured interviewer-administered questionnaire and medical record review, then analyzed using bivariable and multivariable logistic regression.

Results: The prevalence of delayed ANC initiation was 57.3% (95% CI: 51.7-62.9), indicating suboptimal utilization of maternal health services. Multivariable analysis revealed that low maternal education (AOR = 2.31; 95% CI: 1.42-3.76), unplanned pregnancy (AOR = 1.89; 95% CI: 1.12-3.19), lack of advice from health professionals (AOR = 2.67; 95% CI: 1.58-4.51), poor knowledge (AOR = 2.45; 95% CI: 1.51-3.98), longer distance to health facilities (AOR = 2.12; 95% CI: 1.18-3.81), and cultural beliefs discouraging early pregnancy disclosure (AOR = 1.87; 95% CI: 1.12-3.12) were significantly associated with delayed initiation.

Conclusion: Delayed ANC initiation is influenced by multiple socio-demographic, cognitive, behavioral, health system, and cultural factors. These findings highlight the need for policies that strengthen early pregnancy counseling, improve maternal health literacy, and enhance timely ANC initiation in Indonesia.

Downloads

Download data is not yet available.

References

Aduloju, O. P., Akintayo, A. A., Ade-Ojo, I. P., Awoleke, J. O., Aduloju, T., & Ogundare, O. R. (2026). Gestational age at initiation of antenatal care in a tertiary hospital, Southwestern Nigeria. Nigerian Journal of Clinical Practice, 19(6), 772–777. https://doi.org/10.4103/1119-3077.181398.

Ahmed, A. M., Ahmed, M. A., Ali, H. A., & Abdisalam, A. D. (2026). Timing of first antenatal care initiation and associated factors among pregnant women attending antenatal clinics in Hargeisa, Somaliland. BMC Pregnancy and Childbirth, 26(182). https://doi.org/10.1186/s12884-026-08690-5 (2026).

Alehegn, A., Id, A., Zeleke, L. B., & Jember, D. A. (2024). Individual and community level determinants of delayed antenatal care initiation in Ethiopia : A multilevel analysis of the 2019 Ethiopian Mini Demographic Health Survey. PLoS ONE, 19(5), 1–14. https://doi.org/10.1371/journal.pone.0300750.

Amsalu, A., Yalew, A., & Zemlak, A. (2025). Prevalence and determinants of late first antenatal care initiation in western Ethiopia: findings from a multi-centered cross-sectional study. Frontiers in Reproductive Health, 7(1551706). https://doi.org/10.3389/frph.2025.1551706.

Aynalem, B. Y., Melesse, M. F., & Bitewa, Y. B. (2023). Cultural Beliefs and Traditional Practices During Pregnancy, Child Birth, and the Postpartum Period in East Gojjam Zone, Northwest Ethiopia: A Qualitative Study. Women’s Health Reports, 4(1), 415–422. https://doi.org/10.1089/whr.2023.0024.

Aziz Ali, S., Ahmed Dero, A., Aziz Ali, S., & Bano Ali, G. (2018). Factors affecting the utilization of antenatal care among pregnant women: A literature review. Journal of Pregnancy and Neonatal Medicine, 2(2), 41–45. 10.35841/neonatal-medicine.2.2.41-45.

Belete, A. G., Debere, M. K., Gurara, M. K., & Sidamo, N. B. (2024). Time to initiation of antenatal care and its predictors among pregnant women who delivered in Arba Minch town public health facilities , Gamo Zone , southern Ethiopia , 2023 : a retrospective follow ‑ up study. Reproductive Health, 21(73), 1–10. https://doi.org/10.1186/s12978-024-01818-w.

Chewe, M. M., Muleya, M. C., & Maimbolwa, M. (2016). Factors associated with late antenatal care booking among pregnant women in Ndola District, Zambia. African Journal of Midwifery and Women’s Health, 10(4). https://doi.org/10.12968/ajmw.2016.10.4.169.

Debelo, B., & Danusa, K. (2022). Level of late initiation of antenatal care visit and associated factors amongst antenatal care attendant mothers in Gedo General Hospital, West Shoa Zone, Oromia Region, Ethiopia. Front Public Health, 10(86). https://doi.org/10.3389/fpubh.2022.866030.

Demissie, K. ., Jejaw, M., & Wondimu, B. . (2024). Only 9% of mothers have eight and more ANC visit in 14 sub-saharan African countries; evidence from the most recent DHS 2018–2023: a multilevel analysis. BMC Public Health, 24(1631). https://doi.org/10.1186/s12889-024-19145-x.

Dibaba, B., Bekena, M., Dingeta, T., Refisa, E., Bekele, H., Nigussie, S., & Amentie, E. (2024). Late initiation of antenatal care and associated factors among pregnant women attending antenatal clinic at Hiwot Fana Comprehensive Specialized Hospital, Eastern Ethiopia: a cross-sectional study. Front Glob Womens Healt, 27(5). https://doi.org/10.3389/fgwh.2024.1431876.

Edgard-Marius, O., Charles, S. J., Jacques, S., Capo-Chichi, G. J., Virginie, M. A., Ibrahim, M. A., & Laurent, O. T. (2025). Determinants of Low Antenatal Care Services Utilization during the First Trimester of Pregnancy in Southern Benin Rural Setting. Universal Journal of Public Health, 3(5), 220–228. https://doi.org/10.13189/ujph.2015.030507.

Ejeta, E., Dabsu, R., Zewdie, O., & Merdassa, E. (2017). Factors determining late antenatal care booking and the content of care among pregnant mother attending antenatal care services in East Wollega administrative zone, West Ethiopia. Pan African Medical Journal, 27(184). https://doi.org/10.11604/pamj.2017.27.184.10926.

Erega, B. B., Zeru, A. A., Mekuriaw, B. Y., Arage, R. B., Goshu, Y. A., Ferede, W. Y., Ayele, M., Yilak, G., & Tilahun, B. D. (2024). Women living in the region under an emergency command post are experiencing delays in reaching health facilities : a multi- center cross-sectional study. BMC Health Services Research, 24(1304).

Eshetu, D., Aschalew, Z., Bante, A., & Negesa, B. (2024). Delay in reaching health facilities for emergency obstetric care and associated factors among postpartum mothers at Bale zones , Ethiopia . A cross-sectional study. PLOS GLOBAL PUBLIC HEALTH, 4(2), 1–11. https://doi.org/10.1371/journal.pgph.0002964.

Fischer, N. C., Friedman, V., Martinez-Reyes, M. A., Hao, H., Chowdhury, T. A., Starr, D. A., & Quinn, C. C. (2022). The ANC-1 (Nesprin-1/2) organelle-anchoring protein functions through mitochondria to polarize axon growth in response to SLT-1. PLoS Genetics, 18(1). https://doi.org/10.1371/journal.pgen.1010521.

Girma, N., Abdo, M., & Kalu, S. (2023). Late initiation of antenatal care among pregnant women in Addis Ababa city, Ethiopia: a facility based cross-sectional study. BMC Women’s Health, 23(13). https://doi.org/10.1186/s12905-022-02148-4.

Gross, K., Alba, S., Glass, T. R., Schellenberg, J. A., & Obrist, B. (2022). Timing of antenatal care for adolescent and adult pregnant women in south-eastern Tanzania. BMC Pregnancy Childbirth, 12(1), 1–12. https://doi.org/10.1186/1471-2393-12-16.

Iskandar, S. I., Aryanto, S., Prawitasari, S., & Wiratama, B. S. (2025). Strengthening the first antenatal visit to improve maternal health: results from a cross-sectional study in Bantul, Indonesia. BMC Pregnancy Childbirth, 25(911). https://doi.org/10.1186/s12884-025-08038-5.

Islam, M. H., Jubayer, A., Nayan, M. M., Nowar, A., & Islam, S. (2023). Maternal Pregnancy Intention and Antenatal Care Seeking Behaviors in Bangladesh: Evidence From Bangladesh Demographic and Health Survey. International Journal of Public Health, 68(1605944). https://doi.org/10.3389/ijph.2023.1605944.

Islam, M. S., Noor, S. T. A., Asha, R. A., Islam, R. B., & Rahman, F. (2026). Factors associated with early initiation of antenatal care in Bangladesh: a survival analysis using Bangladesh Demographic and Health Survey 2022. BMJ Open, 16(1). https://doi.org/10.1136/bmjopen-2025-104709.

Kase, B. F., Seifu, B. L., Mare, K. U., Shibeshi, A. H., & Asebe, H. A. (2025). Time to first antenatal care visit and its predictors among women in Kenya : Weibull gamma shared frailty model (based on the recent 2022 KDHS data). BMC Pregnancy and Childbirth, 25(50). https://doi.org/10.1186/s12884-025-07178-y.

Kassa, B. G., Tiruneh, G. A., & Solomon, A. A. (2023). Delay in reaching health facilities and its associated factors among mothers giving birth in South Gondar zone hospitals, Northwest Ethiopia, 2020: A facility-based cross-sectional study. Frontiers Global Women’s Health, 4. https://doi.org/10.3389/fgwh.2023.916978.

Khatri, R. ., Mengistu, T. ., & Assefa, Y. (2022). Input, process, and output factors contributing to quality of antenatal care services: a scoping review of evidence. BMC Pregnancy Childbirth, 22(97). https://doi.org/10.1186/s12884-022-05331-5.

Kidie, A. A., Asmamaw, D. B., Belachew, T. B., Fetene, S. M., Zegeye, A. F., & Tamir, T. T. (2019). Socioeconomic inequality in timing of ANC visit among pregnant women in Ethiopia. Frontiers in Public Health, 12(1243433). https://doi.org/10.3389/fpubh.2024.1243433.

Mulatu, S., Mekonnen, G. B., Tsehay, Y. T., Mamo, S. T., & Mulatu, G. (2025). Early antenatal care ( ANC ) booking and associated factors among pregnant women attending ANC services at public health facilities in Bahir Dar City Administration , Northwestern Ethiopia , 2023 : a cross-sectional study. BMC Pregnancy and Childbirth, 25(1255). https://doi.org/10.1186/s12884-025-08450-x.

Nalubwama, H., Ayadi, A. M. El, Harper, C. C., Byamugisha, J., Walker, D., Tsai, A. C., Ohren, B. E., Senoga, U., Krezanoski, P. J., Camlin, C. S., & Comfort, A. B. (2025). Delayed pregnancy disclosure , attributed social factors and implications for antenatal care initiation : a qualitative study among Ugandan women and their partners. Reproductive Health, 22(90). https://doi.org/10.1186/s12978-025-02040-y.

Nigatu, S. ., & Birhan, T. . (2023). The magnitude and determinants of delayed initiation of antenatal care among pregnant women in Gambia; evidence from Gambia demographic and health survey data. BMC Public Health, 23(599). https://doi.org/10.1186/s12889-023-15506-0.

Okedo-Alex, I. N., Akamike, I. C., Ezeanosike, O. B., & Uneke, C. J. (2019). Determinants of antenatal care utilisation in sub-Saharan Africa: A systematic review. BMJ Open, 9(10). https://doi.org/10.1136/bmjopen-2019-031890.

Osman, W. A., Abdullahi, A. A. M., Ahmed, H. M., Osman, K. A., Abdiwali, A. A., & Hussein, A. M. (2025). Factors Affecting Antenatal Care Attendance among Pregnant Women in Mogadishu, Somalia. Sage Open Nursing, 11. https://doi.org/10.1177/237796082513914.

Paunno, M., Amiruddin, R., Masni, M., & Ahmad, M. (2024). Stillbirth prevention with counseling during antenatal care visits in pregnant women: A systematic review. Science, Engineering and Health Studie, 18(24050009). https://doi.org/10.69598/sehs.18.24050009.

Prasetyo, A., Hariastuti, I., Sugiharti, S., Wijayanti, UT Wahyudianto, H., Fuada, N., Tjandrarini, D., Kusrini, I., Widodo, Y., Rachmawati, R., Salimar, & Setyawati, B. (2025). Nutritional and health factors influencing first antenatal visit among pregnant women in Indonesia. Frontiers in Public Health, 13(12), 1–7. https://doi.org/10.3389/fpubh.2025.1715230.

Simkhada, B., Teijlingen, E. R. van, Porte, M., & Padam Simkhada. (2026). Factors Affecting the Utilization of Antenatal Care in Developing Countries: Systematic Review of the Literature. Journal of Advanced Nursing, 61(3). https://doi.org/10.1111/j.1365-2648.2007.04532.x.

Tanou, M., Kishida, T., & Kamiya, Y. (2021). The effects of geographical accessibility to health facilities on antenatal care and delivery services utilization in Benin: a cross-sectional study. Reproductive Health, 18(205). https://doi.org/10.1186/s12978-021-01249-x.

Tchibozo, E. M. C., Gado, T. A. A., Sonou, Y. C. H., Amidou, S. A., Lacroix, P., Houinato, D. S., & Bezanahary, H. (2025). Late initiation of antenatal care and its associated factors among pregnant women in Benin : a facility based cross-sectional study. BMC Pregnancy and Childbirth, 2. https://doi.org/10.1186/s12884-025-08170-2.

Tesfaye, M., Dessie, Y., Demena, M., & Yosef, T. (2021). Late antenatal care initiation and its contributors among pregnant women at selected public health institutions in Southwest Ethiopia. Pan African Medical Journal, 39(264).

Tola, W., Negash, E., Sileshi, T., & Wakgari, N. (2021). Late initiation of antenatal care and associated factors among pregnant women attending antenatal clinic of Ilu Ababor Zone, southwest Ethiopia: A cross-sectional study. PLoS One, 16(1). https://doi.org/10.1371/journal.pone.0246230.

Tolefac, P. ., Halle-Ekane, G. ., & Agbor, V. . (2017). Why do pregnant women present late for their first antenatal care consultation in Cameroon? Maternal Health, Neonatology and Perinatology, 3(29). https://doi.org/10.1186/s40748-017-0067-8.

Tunçalp, Pena-Rosas, J. P., Lawrie, T., Bucagu, M., Oladapo, O. T., Portela, A., & Metin Gülmezoglu, A. (2017). WHO recommendations on antenatal care for a positive pregnancy experience—going beyond survival. BJOG: An International Journal of Obstetrics and Gynaecolog, 124(6), 860–862. https://doi.org/10.1111/1471-%0A0528.14599%0D.

Urmale, K., Id, M., Andargie, G. G., Moloro, A. H., Mohammed, A. A., Mohammed, O. A., Wengoro, B. F., Kussia, B., Id, L., Hadaro, T. S., Leyto, S. M., Mamo, P. O., Hedato, A. H., Seifu, B. L., Wondmeneh, G., Ebrahim, O. A., & Sabo, K. G. (2025). Late initiation of antenatal care visit amid implementation of new antenatal care model in Sub-Saharan African countries : A multilevel analysis of multination population survey data. PLoS ONE, 20(1), 1–14. https://doi.org/10.1371/journal.pone.0316671.

Wolde, H. F., Tsegaye, A. T., & Sisay, M. M. (2019). Late initiation of antenatal care and associated factors among pregnant women in Addis Zemen primary hospital, South Gondar, Ethiopia. Reproductive Health, 16(1). https://doi.org/10.1186/s12978-019-0745-2.

World Health Organization. (2023). Trends in Maternal Mortality 2000 to 2020.