title: Barriers to Utilization of Antenatal Care Services in Eastern Nepal.
abstract: BACKGROUND
  World Health Organization recommends at least four pregnancy check-ups for normal pregnancies. Ministry of Health and Population Nepal has introduced various strategies to promote prenatal care and institutional delivery to reduce maternal and child deaths. However, maternal health service utilization is low in some selected socio-economic and ethnic groups. Hence, this study aims to assess barriers to the recommended four antenatal care (4ANC) visits in eastern Nepal.
  
  
  METHODS
  A cross-sectional quantitative study was conducted in Sunsari district. A total of 372 randomly selected women who delivered in the last year preceding the survey were interviewed using a semi-structured questionnaire. Bivariate and multivariate logistic regression analysis was carried out to identify barriers associated with 4ANC visits.
  
  
  RESULTS
  More than two-third women (69%) attended at least 4ANC visits. The study revealed that women exposed to media had higher chance of receiving four or more ANC visits with an adjusted odds ratio (aOR = 3.5, 95% CI: 1.2-10.1) in comparison to women who did not. Women from an advantaged ethnic group had more chance of having 4ANC visits than respondents from a disadvantaged ethnic group (aOR = 2.4, 95% CI: 2.1-6.9). Similarly, women having a higher level of autonomy were nearly three times more likely (aOR = 2.9, 95% CI: 1.5-5.6) and richer women were twice (aOR = 2.3, 95% CI: 1.1-5.3) as likely to have at least 4ANC visits compared to women who had a lower level of autonomy and were economically poor.
  
  
  CONCLUSIONS
  Being from disadvantaged ethnicity, lower women's autonomy, poor knowledge of maternal health service and incentive upon completion of ANC, less media exposure related to maternal health service, and lower wealth rank were significantly associated with fewer than the recommended 4ANC visits. Thus, maternal health programs need to address such socio-cultural barriers for effective health care utilization.
authors: Karuna Foundation Nepal , Kathmandu , Nepal.
authors: Krishna Kumar
authors: KK
authors: Deo
authors: Nepal Health Sector Support Program, Ministry of Health and Population , Kathmandu , Nepal.
authors: Yuba Raj
authors: YR
authors: Paudel
authors: Saving Newborn Lives Program, Save the Children , Kathmandu , Nepal.
authors: Resham Bahadur
authors: RB
authors: Khatri
authors: Department of Community Medicine and Public Health, National Medical College , Birgunj , Nepal.
authors: Ravi Kumar
authors: RK
authors: Bhaskar
authors: Department of Community Medicine and Public Health, Institute of Medicine, Tribhuwan University , Kathmandu , Nepal.
authors: Rajan
authors: R
authors: Paudel
authors: Nepal Health Sector Support Program, Ministry of Health and Population , Kathmandu , Nepal.
authors: Suresh
authors: S
authors: Mehata
authors: Department of Community Medicine and Public Health, Institute of Medicine, Tribhuwan University , Kathmandu , Nepal.
authors: Rajendra Raj
authors: RR
authors: Wagle
keywords: Nepal; four antenatal care visits; socio-cultural factors; utilization