Determinants of Late Antenatal Care Bookings Among Pregnant Women in Mangwe District,Zimbabwe: A Quantitative Cross-Sectional Study

Abstract

Background:

Timely initiation of antenatal care is critical for reducing maternal and neonatal morbidity and mortality. Despite this, late initiation remains a significant public health challenge in rural Zimbabwe. This study aimed to assess the determinants of late antenatal care bookings among pregnant women in Mangwe District in 2025.

Methods:

A facility-based cross-sectional study was conducted between August 2024 and June 2025 among 171 pregnant women selected through systematic random sampling from five clinics. Data on socio-demographics, accessibility, and maternal factors were collected using a structured questionnaire deployed on Kobo Collect. The outcome variable was the timing of the first antenatal care visit, categorized as “late” (>20 weeks gestation). Data was analyzed in STATA version 15, using chi-square tests and multiple logistic regression to identify factors associated with late booking.

Results:

The prevalence of late antenatal care bookings was 50.9%. Significant determinants included lower educational attainment (p = 0.009), unemployment (p = 0.030), and a lack of knowledge about the importance of early antenatal care (p = 0.001). While not statistically significant in the final model, logistical barriers were highly prevalent, with 47.8% of late bookers reporting challenges in accessing care, primarily due to long distances and lack of transportation.

Conclusion:

Five in 10 women had late antenatal care bookings in Mangwe District, which is predominantly driven by educational, economic, and knowledge-based barriers. To decrease late antenatal care bookings, interventions must prioritize targeted community health education, economic empowerment initiatives, and practical solutions to overcome transport and distance challenges.

Keywords

antenatal care late booking maternal health quantitative Zimbabwe

Background

Antenatal care (ANC) is a cornerstone of maternal health care, providing a platform for the early detection and management of complications that contribute to maternal and neonatal morbidity and mortality globally.¹ Through skilled interventions, ANC aims to ensure the best possible health outcomes for both mother and child by preventing, detecting, and managing pregnancy-related risks.² The efficacy of these interventions, however, is heavily dependent on their timeliness. The World Health Organization (WHO) revised its guidelines in 2016 to recommend a minimum of eight contacts, with the first visit initiating within the first 12 weeks of gestation.¹ This early initiation is crucial for baseline assessments, including screening for HIV and sexually transmitted infections, managing chronic conditions like hypertension, and providing essential health education.¹

Despite global efforts and clear guidelines, the timely uptake of ANC remains a significant challenge, particularly in low- and middle-income countries. Globally, an estimated 82.6% of pregnant women attend their first ANC visit during the second or third trimester, a delay that contributes to ~515,000 maternal deaths annually from pregnancy and childbirth-related complications.^3,4 The situation in sub-Saharan Africa is particularly dire. In Nigeria, barriers such as poor infrastructure, unaffordable services, and long waiting times have been widely documented.^5,6 Similarly, studies in East London have highlighted accessibility and service delivery issues as critical deterrents.⁷

In Zimbabwe, the challenge is not necessarily the coverage of ANC but the timing and frequency of visits. National data indicates that pregnant women often present for their first ANC visit after 14 weeks and make fewer than the recommended number of visits, averaging only two per pregnancy.⁸ A concerning decline in early access was recorded, dropping from 69% in 2007 to 49% in 2009, a trend attributed to a deteriorating health system and limited government funding, which disproportionately affected low-income women.⁸ Rural districts like Mangwe in Matabeleland South Province epitomize these challenges. Characterized by underdevelopment and out-migration, the district’s population faces significant barriers to healthcare access.⁹ Recent district health data (Figure 1) reveals persistently high rates of late bookings, with some clinics, like Dingumuzi, recording 57 late bookings out of 86 total in the second quarter of 2024.¹⁰ This persistent trend underscores a critical gap between policy and practice at the local level.

Figure 1.

ANC bookings for five clinics in Mangwe District, Zimbabwe (Quarter 4, 2023–Quarter 2, 2024).

While the benefits of early ANC are unequivocal, a significant proportion of pregnant women in Mangwe District continue to book their first ANC visit late, potentially jeopardizing their health and that of their infants. The consistently high rates observed across the district’s clinics signal deep-rooted systemic, socio-demographic, and maternal factors that necessitate urgent investigation. Late booking delays essential medical interventions, increasing the risk of preventable complications such as vertical transmission of HIV, undiagnosed hypertensive disorders, and adverse birth outcomes. Therefore, there is a critical need to identify the specific determinants of late ANC booking in this context to inform the development of targeted, evidence-based interventions.

Most available data on ANC trends in Zimbabwe are outdated, and there is a paucity of recent, context-specific quantitative evidence from rural districts like Mangwe. This study aims to fill this gap by providing a contemporary analysis of the factors influencing ANC timing. The findings will be invaluable for local health authorities, policymakers, and program planners in designing effective strategies to improve early ANC uptake.

The general objective of this study was to assess the determinants of late bookings for ANC among pregnant women receiving care at selected clinics in Mangwe District.

Methods

Study area

The study was conducted in Mangwe District, a rural district in the Matabeleland South Province of Zimbabwe. According to the 2022 Zimbabwe National Census, the district has a population of 65,562 people. The district is served by 13 health facilities: three hospitals and 10 clinics, four of which are mission-owned. The study was conducted in five of these clinics: Tshitshi, Marula, Madabe, Dingumuzi, and Izimnyama, which were selected to provide a representative sample of the district’s diverse catchment areas. Mangwe is characterized by its rural setting, underdevelopment, and significant out-migration, which poses unique challenges for healthcare access.¹¹ The study area map is shown in Figure 2.

Figure 2.

Study area map (Mangwe District, Zimbabwe).

Study design

A facility-based quantitative cross-sectional study design was employed. This design was appropriate for determining the prevalence of late ANC booking and investigating associations between the outcome and various independent factors at a single point in time. The cross-sectional design is the established and most efficient method for achieving this, as it allows for the simultaneous measurement of the outcome (timing of first ANC visit) and a wide range of exposures (socio-demographic, systemic, and maternal factors) within a defined population.¹² The study was conducted between August 2024 and June 2025.

Study population and sampling

The target population was 306 pregnant women who attended ANC at the five selected clinics during the study period. The study population consisted of pregnant women attending ANC at these clinics during the data collection period who met the inclusion criteria. Inclusion criteria encompassed (1) pregnant women who attended ANC at one of the five selected clinics within the specified period; (2) willingness to provide informed consent; and, for participants below the age of 18, willingness of a legally authorized representative to provide consent; and (3) availability to complete the questionnaire. Exclusion criteria were (1) women who attended ANC but were critically ill or had a severe obstetric emergency requiring immediate intensive care; (2) those who attended ANC but were unwilling or unable to provide consent; and (3) individuals with severe health conditions that could impede participation.

Sample size determination and sampling procedure

The sample size was calculated using the Raosoft online sample size calculator.¹³ Using a confidence level of 95%, a margin of error of 5%, and a response distribution of 50%, the calculated sample size was 171. This was apportioned to each clinic using proportional allocation based on the average monthly ANC client load recorded at each facility in the quarter preceding the study. The allocated samples were Tshitshi (35), Marula (32), Madabe (33), Dingumuzi (46), and Izimnyama (25).

A systematic random sampling technique was used to select participants. The sampling frame for each clinic was the ANC attendance register for the study period. For each clinic, the sampling interval (k) was calculated separately by dividing the total number of eligible ANC attendees at that clinic during the data collection period by the clinic’s allocated sample size. The calculated intervals were then rounded to the nearest whole number to determine the sampling step. This resulted in a sampling interval of k = 2 for Tshitshi, Marula, and Madabe clinics, k = 3 for Dingumuzi clinic, and, due to its lower attendance, a de facto interval of k = 1 for Izimnyama clinic, meaning all eligible women attending Izimnyama during the period were invited to participate until the sample quota was reached. This method ensured a proportional and unbiased representation of women from each facility.

Data collection tool and procedure

Data were collected using a structured, pre-tested questionnaire. The tool was developed based on the study objectives and a review of relevant literature. It was divided into four sections: Section A socio-demographic data (age, marital status, education, occupation, income, residence, household size); Section B systemic factors (distance to clinic, common transport mode, challenges in accessing ANC, types of challenges faced); and Section C maternal factors (number of previous children, timing of first ANC visit, reasons for late booking, partner/family support, influence of cultural beliefs).

The questionnaire was pre-tested on 10 pregnant women in a non-participating clinic, and ambiguous questions were refined for clarity and consistency. The final tool was deployed on the Kobo Collect platform for digital data collection, which enhanced data accuracy and streamlined the data management process. Data were collected by the principal researcher after obtaining informed consent (Supplemental Appendix).

The primary outcome variable for this study was the timing of the first ANC visit, which was operationalized as a binary variable: “Early” (booking at or before 20 weeks of gestation) and “Late” (booking after 20 weeks of gestation), a cutoff aligned with the WHO’s focused ANC model that schedules a pivotal visit at this gestational age. Independent variables were categorized into three thematic groups: socio-demographic factors (including age, educational attainment, occupation, and income); systemic factors (such as distance to the nearest clinic, primary mode of transport, and challenges faced in accessing care); and maternal factors (including parity, knowledge regarding the importance of early ANC, specific reasons for delay, and level of social support). This comprehensive set of variables was selected to provide a multifaceted analysis of the determinants influencing ANC booking timing.

Operational definitions

The key variables for this study were defined and operationalized as follows.

Outcome variable

Timing of the first ANC visit: This was operationalized as a binary variable based on the gestational age at the first booking: “early” (booking at or before 20 weeks of gestation) and “late” (booking after 20 weeks of gestation). While the WHO recommends the first ANC contact within the first 12 weeks of gestation, a cutoff of 20 weeks was used to define late booking in this study. This aligns with the operational definition used in the Zimbabwean health system for monitoring ANC timeliness and is consistent with several studies conducted in similar rural, resource-constrained settings in sub-Saharan Africa, where the first focused ANC visit is scheduled around 20 weeks. This cutoff aligns with the WHO’s focused ANC model that schedules a pivotal visit at this gestational age.

Independent variables

These were categorized into three thematic groups:

Socio-demographic factors: Included age (categorized), educational attainment (no formal, primary, secondary, tertiary), occupation (formal employment, self-employed, unemployed), and monthly household income (categorized).

Systemic factors: Included distance to the nearest health facility (categorized), primary mode of transport (walking, bicycle, private vehicle, other), and whether the participant faced challenges in accessing ANC services (yes/no).

Maternal factors: Included parity (number of children delivered before), knowledge regarding the importance of early ANC (derived from reported reasons for delay), specific reasons for late booking, and the level of social support from partner/family (yes/no).

Data analysis

Data was downloaded from Kobo Toolbox and imported into STATA version 15.1 (StataCorp LLC, College Station, Texas, USA) for analysis. Descriptive statistics (frequencies, percentages, means, and standard deviations) were used to summarize the characteristics of the study population. Bivariate analysis using Pearson’s chi-square test was conducted to assess associations between the independent variables and the outcome (late booking). A p < 0.05 was considered statistically significant. Variables that showed a significant association (p < 0.05) in the bivariate analysis were included in a multiple logistic regression model to identify independent predictors of late ANC booking, controlling for potential confounders. The results of the regression were presented as adjusted odds ratios with 95% confidence intervals.

Results

Socio-demographic characteristics of participants

A total of 171 pregnant women participated in the study, yielding a response rate of 100%. As summarized in Table 1, the demographic profile depicts a predominantly young population. The largest proportion was aged 20–29 years (39.2%), closely followed by those below 20 years (37.4%), indicating that over three-quarters (76.6%) of the respondents were under 30 years. The mean age was 24.7 years (±6.3 SD). In terms of residence, participants were fairly distributed across the five clinics, with Tshitshi (25.7%) and Madabe (22.8%) contributing the most. Marital status was almost evenly split between married (52.0%) and single (47.4%). Educationally, the majority (62.0%) had attained secondary education, while only a small fraction (2.9%) had tertiary education. A striking 64.9% of the women were unemployed, and, consequently, household income was low, with 59.6% earning below USD 50/month (see Table 1).

Table 1.

Socio-demographic characteristics of pregnant women attending antenatal care in selected clinics in Mangwe District, Zimbabwe (2025).

Variable	Category	Frequency	Percent (%)
Age	Below 20 years	64	37.4
	20–29 years	67	39.2
	30–39 years	31	18.1
	40 years and above	9	5.3
Place of residence	Dingumuzi	35	20.5
	Izimnyama	23	13.5
	Madabe	39	22.8
	Marula	30	17.5
	Tshitshi	44	25.7
Marital status	Divorced	1	0.6
	Married	89	52.0
	Single	81	47.4
Education level	No formal education	12	7.0
	Primary education	48	28.1
	Secondary education	106	62.0
	Tertiary education	5	2.9
Occupation	Formal employment	18	10.5
	Self-employed	42	24.6
	Unemployed	111	64.9
Monthly household income	Below USD 50	102	59.6
	USD 50–100	61	35.7
	Above USD 100	8	4.7

Prevalence and socio-demographic correlates of late ANC booking

The overall prevalence of late ANC booking (initiation after 20 weeks) was 50.9% (87/171). A further breakdown of booking timing shows that only 12.3% (21/171) of women booked early (before 12 weeks), while 36.8% (63/171) booked between 12 and 20 weeks, and 50.9% (87/171) booked after 20 weeks. This means that nearly nine out of 10 women (88.9%) missed the WHO-recommended first-trimester booking.

As shown in Table 2, bivariate analysis revealed significant associations between late booking and two key socio-demographic variables. There was a strong statistical association between the level of education and the timing of ANC booking (p = 0.009). A clear gradient is evident: among women with no formal education, 66.7% (8/12) booked late. This figure was 43.8% (21/48) for those with primary education, peaked at 58.5% (62/106) for those with secondary education, and was lowest at 20.0% (1/5) for those with tertiary education. This indicates that secondary education, while more prevalent, did not necessarily confer adequate knowledge or empowerment for early care-seeking, whereas tertiary education had a strong protective effect. Occupation was also significantly associated with booking timing (p = 0.030); unemployed women constituted 75.0% of the late bookers. Only 5.4% of late bookers were in formal employment, compared to 21.1% of the earliest bookers (before 12 weeks).

Table 2.

Association between socio-demographic characteristics and timing of first ANC visit among pregnant women in Mangwe District, Zimbabwe (2025).

Socio-demographic characteristics		Timing of first ANC visit
		Before 12 weeks		12–20 weeks		After 20 weeks
		Frequency	Percent	Frequency	Percent	Frequency	Percent	p value
Age	20–29 years	4	21.1%	26	43.3%	37	40.2%	0.248
	30–39 years	5	26.3%	11	18.3%	15	16.3%
	40 years and above	2	10.5%	5	8.3%	2	2.2%
	Below 20 years	8	42.1%	18	30.0%	38	41.3%
Village	Dingumuzi	4	21.1%	18	30.0%	13	14.1%	0.099
	Izimnyama	1	5.3%	9	15.0%	13	14.1%
	Madabe	7	36.8%	7	11.7%	25	27.2%
	Marula	1	5.3%	11	18.3%	18	19.6%
	Tshitshi	6	31.6%	15	25.0%	23	25.0%
Marital status	Divorced	0	0.0%	1	1.7%	0	0.0%	0.215
	Married	14	73.7%	29	48.3%	46	50.0%
	Single	5	26.3%	30	50.0%	46	50.0%
Highest level of education	No formal education	0	0.0%	4	6.7%	8	8.7%	0.009*
	Primary education	7	36.8%	20	33.3%	21	22.8%
	Secondary education	9	47.4%	35	58.3%	62	67.4%
	Tertiary education	3	15.8%	1	1.7%	1	1.1%
Occupation	Formal employment	4	21.1%	9	15.0%	5	5.4%	0.030*
	Self-employed	5	26.3%	19	31.7%	18	19.6%
	Unemployed	10	52.6%	32	53.3%	69	75.0%
Estimated household income per month	Above USD 100	3	15.8%	2	3.3%	3	3.3%	0.123
Estimated household income per month	Below USD 50	10	52.6%	33	55.0%	59	64.1%
	USD 50–100	6	31.6%	25	41.7%	30	32.6%

ANC: antenatal care.

p < 0.05.

Although not statistically significant, descriptive trends were notable and clinically important. A higher proportion of women under 20 (41.3% of late bookers) and those aged 20–29 (40.2%) booked late compared to older age groups. In fact, women below 20 years were the largest single age group among late bookers. Similarly, single women (50.0% of late bookers) were as likely to book late as married women (50.0%), but a much smaller proportion of single women (26.3%) managed to book before 12 weeks compared to married women (73.7%). Household income showed a clear descriptive trend: 64.1% of late bookers came from the poorest households (earning below USD 50/month), compared to 52.6% of the earliest bookers (see Table 2).

Systemic factors and their association with late ANC booking

The findings paint a picture of significant accessibility challenges that form the backdrop against which care-seeking decisions are made. As detailed in Table 3, only 25.1% of women lived within 5 km of the nearest clinic. The majority lived between 5 and 10 km (35.7%) or 11 and 20 km (29.2%) away, and 9.9% resided more than 20 km from a health facility. This means that nearly three-quarters (74.9%) of all pregnant women in the study lived beyond the 5 km distance often considered acceptable for primary healthcare access.

Table 3.

Systemic factors reported by pregnant women attending antenatal care in Mangwe District, Zimbabwe (2025).

Category	Response options	Frequency (n)	Percent (%)
Distance to nearest clinic	<5 km	43	25.1
	5–10 km	61	35.7
	11–20 km	50	29.2
	More than 20 km	17	9.9
Common means of transport	Walking	70	40.9
	Bicycle	39	22.8
	Private vehicle	13	7.6
	Others	33	19.3
If other (transport)	Scotch cart	16	9.4
Faced challenges accessing antenatal care	Yes	72	42.1
Faced challenges accessing antenatal care	No	99	57.9
Types of challenges faced (n = 72)	Long waiting times	19	26.4
	Lack of transportation	20	27.8
	Clinic hours didn’t suit schedule	6	8.3
	Other (please specify)	27	29.2
If other (challenges; n = 27)	Cultural beliefs	1	3.7
	Lack of motivation (“too lazy”)	1	3.7
	Distance issues	2	7.4
	Mental or medical issues	3	11.1
	Negative staff experience	1	3.7
	Not around at the time of appointment	10	37.1
	Stigma and discrimination	7	25.9
	Work or school commitments	2	7.4

The reliance on non-motorized or slow transport was profound. When asked about their common means of transport to the clinic, 50.7% reported walking, 28.3% used bicycles, and 9.4% used scotch carts. Combined, this shows that 88.4% of women relied on non-motorized transport. Only 9.4% had access to a private vehicle.

A substantial 42.1% of all respondents reported facing challenges in accessing ANC services. This figure was driven largely by women who booked late, 47.8% of whom reported challenges, compared to only 21.1% of those who booked before 12 weeks. Among those who faced challenges, the most frequently cited issue was a lack of transportation (reported by over 70% across booking groups). Other notable challenges included long waiting times (36.5% of those facing challenges) and “other” factors (51.9%), which, upon specification, included stigma and discrimination (4.1% of all respondents), being out of the country/area (5.8%), work commitments (1.2%), and mental or medical issues (1.8%; see Table 3).

In the bivariate analysis (Table 4), none of the individual systemic factors (distance, transport mode, type of challenge) showed a statistically significant association with late booking at the p < 0.05 level. However, the variable “faced challenges in accessing ANC services” approached significance (p = 0.091). A notably higher proportion of women who booked late (47.8%) reported facing challenges compared to those who booked early (21.1% before 12 weeks; 40.0% between 12 and 20 weeks). This suggests that while systemic barriers are widespread, they may have a cumulative or threshold effect that contributes to delay. It is also noteworthy that among the small group who booked before 12 weeks, the most common challenge was also lack of transport (75%), indicating that even highly motivated women face these barriers, but somehow overcome them (see Table 4).

Table 4.

Maternal factors among pregnant women attending ANC in Mangwe District, Zimbabwe (2025).

Category	Response options	Frequency (n)	Percent (%)
Number of children previously delivered	None	61	35.7
	1–2	81	47.4
	3–4	20	11.7
	Five or more	9	5.3
Stage of first ANC visit (current pregnancy)	Before 12 weeks	21	12.3
	12–20 weeks	63	36.8
	After 20 weeks	87	50.9
Reasons for booking after 12 weeks (select all that apply)	Lack of transportation	62	32.6
	Fear of judgment or stigma	55	28.9
	Cultural beliefs	7	3.7
	Other (please specify)	66	34.7
If other (late booking reasons)	Avoiding too many clinic visits	2	1.2
	Did not want to go/felt lazy/stubborn	5	2.9
	Financial constraints/preparation	2	1.2
	Gathering funds for the coming baby	1	0.6
	Health worker attitudes/system issues	2	1.2
	Mental or emotional readiness	2	1.2
	Not available	3	1.8
	Past experience (no complications)	3	1.8
	Unaware of pregnancy or ANC schedule	4	2.3
	Wanted to confirm pregnancy first	6	3.5
	Was outside the country (e.g., Botswana/SA)	17	9.9
	Work-related commitments	9	5.3
Partner or family support for ANC	Yes	115	67.3
Partner or family support for ANC	No	56	32.7
Do cultural beliefs influence ANC decisions?	Yes	10	5.8
	No	161	94.2

ANC: antenatal care.

Maternal factors and their association with late ANC booking

As presented in Table 5, the maternal factors provide crucial insights into the reasons behind delayed care. Nearly half of the respondents (47.4%) had delivered one to two children previously, and 35.7% were first-time mothers. When asked about the reasons for booking after 12 weeks (a question directed at those who booked late), the most powerful predictor emerged: 52.7% of late bookers stated they “did not know the importance of early ANC booking,” and this reason was strongly associated with late booking (p = 0.001). In stark contrast, not a single woman who booked before 12 weeks cited this reason. Other common reasons among late bookers included lack of transportation (41.8%) and fear of judgment or stigma (38.5%). A large proportion (45.1%) selected “other” reasons, which, upon further specification, included being outside Zimbabwe (e.g., in Botswana or South Africa, 9.9% of all respondents), work-related commitments (5.3%), and various personal reasons such as financial constraints, emotional unpreparedness, and past negative pregnancy experiences.

Table 5.

Association between parity, psychosocial factors, and timing of first ANC visit among pregnant women in Mangwe District, Zimbabwe (2025).

Maternal/psychosocial factors		Timing of first ANC visit
		Before 12 weeks		12–20 weeks		After 20 weeks
		Frequency	Percent	Frequency	Percent	Frequency	Percent	p value
Number of children delivered before		0	0.0%	0	0.0%	8	8.7%	.073
	1–2	6	31.6%	27	45.0%	43	46.7%
	3–4	4	21.1%	10	16.7%	6	6.5%
	Five or more	2	10.5%	3	5.0%	3	3.3%
	None	7	36.8%	20	33.3%	32	34.8%
Reasons for booking late	Did not know the importance of early ANC booking	0	0.0%	28	47.5%	48	52.7%	0.001*
	Lack of transportation	0	0.0%	24	40.7%	38	41.8%
	Fear of judgment or stigma	0	0.0%	20	33.9%	35	38.5%
	Cultural beliefs	0	0.0%	3	5.1%	4	4.4%
	Other (please specify)	7	100.0%	18	30.5%	41	45.1%
Partner or family support to seek ANC	No	4	21.1%	18	30.0%	28	30.4%	0.186
Partner or family support to seek ANC	Yes	15	78.9%	38	63.3%	51	55.4%	0.186
Cultural beliefs influencing decision to seek ANC	No	19	100.0%	56	93.3%	86	93.5%	0.515
Cultural beliefs influencing decision to seek ANC	Yes	0	0.0%	4	6.7%	6	6.5%	0.515

ANC: antenatal care.

p < 0.05.

Two important protective factors were also examined. The vast majority of women (94.2%) reported that cultural beliefs did not influence their decision to seek ANC, and this was not a significant factor. However, partner or family support was common (67.3% of all women) and showed a positive, though not statistically significant (p = 0.186), trend: 78.9% of early bookers (before 12 weeks) had support, compared to 55.4% of the latest bookers (after 20 weeks; see Table 5).

Table 5 further explores these associations. Parity (number of children delivered before) was not significantly associated with booking timing (p = 0.073), though women with one to two previous children showed a higher tendency to book late (46.7% of late bookers) compared to nulliparous women (34.8%). This challenges the assumption that first-time mothers are always the most likely to delay care and suggests that multiparous women with prior uneventful pregnancies may develop a false sense of security, leading to complacency in subsequent pregnancies (see Table 5).

Discussion

This study provides a detailed quantitative assessment of the determinants of late ANC booking in Mangwe District, Zimbabwe, revealing a complex interplay of socio-economic, educational, and perceptual factors. The finding that half (50.9%) of the pregnant women initiated ANC after 20 weeks of gestation is alarming and consistent with earlier reports from Zimbabwe that highlighted suboptimal timing despite high overall coverage visits.⁸ Even more concerning is that only 12.3% of women achieved the gold standard of booking within the first trimester, indicating that the WHO’s revised recommendations have not yet translated into practice in this rural setting. This high prevalence underscores a critical failure in the initial phase of the maternal healthcare continuum.

The study analysis identified a clear profile of vulnerability where multiple disadvantages intersect. The significant association between lower educational attainment and late booking (p = 0.009) is congruent with a substantial body of literature.^5,14 However, the data reveal a nuanced picture: while women with no formal education were at high risk, the largest absolute number of late bookers came from the group with secondary education. This suggests that mere school attendance is insufficient; the content and quality of health education, both in schools and in the community, may be lacking. Education is a key social determinant of health, but it must be health-literacy-specific to empower women to navigate the health system and make informed, autonomous decisions regarding their care.

Similarly, unemployment emerged as a significant economic barrier (p = 0.030). The lack of personal income exacerbates financial dependency and limits a woman’s ability to cover direct costs (like transport) and indirect costs (such as lost income or childcare) associated with clinic visits, even within a nominally free public health system.¹⁵ The demographic profile of our sample, predominantly young, with low formal education and high unemployment, paints a picture of a group with limited socio-economic agency, which directly translates into delayed health-seeking behavior. The descriptive trend with income, though not statistically significant, further supports the role of poverty as a foundational barrier.

One of the most notable findings of this study is the significant impact of knowledge gaps. The finding that over half of the late bookers cited not knowing the importance of early ANC as their primary reason (p = 0.001) points to a profound failure of health education and messaging in this community. This suggests that the barrier is not merely physical or financial but also informational and cognitive. Women cannot be expected to seek early care if they are not aware of its critical importance for screening conditions like HIV and hypertension, which are manageable with early detection. This finding is supported by studies in similar contexts, which emphasize that improving knowledge is a fundamental prerequisite for improving health service utilization.^16,17 The absence of this reason among all early bookers powerfully confirms that knowledge is a decisive factor.

Furthermore, fear of judgment or stigma was a notable secondary reason, particularly among late bookers. This aligns with qualitative studies that identify stigma, especially for young, unmarried, or first-time mothers, as a powerful psychological deterrent.¹⁸ The fear of being shamed or judged by healthcare providers or community members can lead women to conceal their pregnancies for as long as possible, thereby delaying ANC initiation.¹⁹ The nearly equal proportion of single and married women among late bookers, contrasted with the dominance of married women among the earliest bookers, hints at the potential for heightened stigma or lack of social support for unmarried mothers, deterring them from presenting early.

While distance, transport mode, and specific challenge types did not achieve statistical significance in our model, their pervasive presence cannot be dismissed. The fact that nearly half of the late bookers reported facing access challenges (compared to just over a fifth of the earliest bookers) is highly suggestive. The ubiquity of these barriers such as long distances, reliance on walking, and frequent unavailability of transport may mean they affect nearly everyone in the population, thus diluting their discriminatory power in a bivariate analysis. This phenomenon, where a near-universal exposure loses its statistical association with an outcome, is well-documented in public health research in highly homogenous, disadvantaged settings.²⁰

However, their effect is likely realized through interaction with other factors. For instance, a woman who is unemployed (economic barrier) and lacks knowledge (informational barrier) will be far less motivated to overcome a 10 km walk (physical barrier) to attend an ANC clinic. The “other” reasons for late booking, such as being out of the country, highlight another layer of complexity: the economic migration patterns in Mangwe District directly disrupt healthcare continuity for pregnant women. Therefore, the lack of statistical significance should not be misinterpreted as a lack of importance; rather, it indicates that these systemic issues are a foundational part of the challenging environment in which these women live. They are the “walls” of the room in which the decision to delay care is made.

The non-significant result for parity (p = 0.073) nonetheless reveals an important pattern. The tendency for women with one to two children to book later could be attributed to a “false reassurance” effect from previous uneventful pregnancies, reducing their perceived urgency for early care. Meanwhile, the positive trend between partner/family support and early booking, while not statistically significant, aligns with the social support theory.²¹ Support likely operates by providing practical help (transport, funds) and emotional encouragement, reducing the perceived burden of seeking care.

Strengths and limitations of the study

This study possesses several notable strengths, including its quantitative cross-sectional design which allowed for the efficient assessment of prevalence and associated factors among a robust sample size of 171 participants, selected via systematic random sampling to enhance representativeness. The use of a structured digital questionnaire (Kobo Collect) improved data accuracy and consistency, while the analysis employing both bivariate and multivariate statistics identified key independent predictors of late booking. However, the findings must be interpreted in light of certain limitations. The cross-sectional nature of the study precludes the establishment of causal relationships between the identified factors and the outcome. Furthermore, as the study was facility-based, it exclusively captured the experiences of women who had eventually accessed ANC services, thereby potentially excluding the most marginalized women who never present at a clinic and leading to an underestimation of the true barriers. Reliance on self-reported data for gestational age and reasons for delay is also subject to potential recall and social desirability biases.

Conclusion and recommendations

This study conclusively demonstrates that late initiation of ANC is a severe and multifaceted problem in Mangwe District. Five in 10 pregnant women (50.9%) attending selected clinics in 2025 initiated ANC after 20 weeks of gestation. It is not a random occurrence but a predictable outcome shaped by a convergence of vulnerability factors, primarily lower educational attainment, unemployment, and a critical lack of knowledge regarding the importance of early ANC. While formidable logistical barriers of distance and transport affected the entire population, they compounded the disadvantages faced by these vulnerable women. Addressing this issue requires moving beyond simply providing ANC services to actively enabling their timely utilization. Therefore, we recommend a multi-level intervention strategy: (1) intensifying targeted, community-based health education to specifically address the knowledge gap identified as a primary reason for delay; (2) integrating economic empowerment initiatives with maternal health services to mitigate the financial barriers associated with unemployment and low income; and (3) implementing practical system adaptations, such as mobile clinics and stigma-free service training, to overcome the pervasive access challenges documented in this study.

Supplemental Material

sj-docx-1-smo-10.1177_20503121261430430 – Supplemental material for Determinants of Late Antenatal Care Bookings Among Pregnant Women in Mangwe District, Zimbabwe: A Quantitative Cross-Sectional Study

Supplemental material, sj-docx-1-smo-10.1177_20503121261430430 for Determinants of Late Antenatal Care Bookings Among Pregnant Women in Mangwe District, Zimbabwe: A Quantitative Cross-Sectional Study by Sidumisile Sibanda, Methembe Yotamu Khozah and Perez Livias Moyo in SAGE Open Medicine

Footnotes

Author note

S.S. is a BSc Public Health student at the National University of Science and Technology in Zimbabwe. This article was part of the research project that was a partial fulfilment of the BSc in Public Health. P.L.M. and M.Y.K. are Master of Science Degree in Environmental Health holders at the National University of Science and Technology in Zimbabwe. The authors are both Lecturers in the Department of Environmental Health in the Faculty of Environmental Science at the National University of Science and Technology.

ORCID iDs

Methembe Yotamu Khozah

Perez Livias Moyo

Ethical considerations

Ethical approval was granted by the Institutional Review Board of the National University of Science and Technology, Zimbabwe (ref: NUST/IRB/2025/55). Permission was also obtained from the Mangwe District Medical Officer and the respective clinic heads. All the methods were performed in accordance with the relevant guidelines and regulations (Declaration of Helsinki).

Conflict of interest statement

The authors declare that they have no competing interests.

Consent to participate

Written informed consent was obtained from all the participants. For participants who were illiterate or had no formal education, the consent form was read aloud in the local language (isiNdebele) by a trained research assistant, and consent was indicated by a thumbprint, which was witnessed by an independent, literate third party (a clinic staff member not involved in data collection). For minors (participants under 18 years of age), written assent was obtained from the participant alongside written informed consent from a legally authorized representative.

Consent for publication

Written informed consent for publication of anonymized data was obtained from all the participants.

Author contributions

S.S.: conceptualization, data curation, formal analysis, investigation, methodology, project administration, writing – original draft. M.Y.K. and P.L.M.: conceptualization, formal analysis, methodology, supervision, validation, visualization, writing – review and editing. All the authors read and approved the final article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Data availability statement

The datasets generated and analyzed during the current study are not publicly available to protect participant confidentiality, but are available from the corresponding author on reasonable request.

Supplemental material

Supplemental material for this article is available online.

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Supplementary Material

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