Abel Endawkie ^1,2* Shimels D. Kebede ² Kaleab M. Abera ² Eyob Tilahun Abeje ² Ermias B. Enyew ² Chala Daba ² Lakew Asmare ² Fekade Demeke Bayou ² Mastewal Arefaynie ² Anissa Mohammed ² Abiyu A. Tareke ³ Awoke Keleb ² Natnael Kebede ² Yawkal Tsega ²

• ¹ Department of Epidemiology and Biostatistics, College of Medicine and Health Science, Wollo University, Dessie, Ethiopia
• ² Wollo University, Dessie, Amhara, Ethiopia
• ³ Amref Health Africa, Dar es Salaam, Tanzania

Background: Antenatal care (ANC) is an important component of maternal and child health care. The World Health Organization (WHO) recommends that pregnant women book their ANC contact at or before 12 weeks of gestational age. However, in East Africa, the evidence following WHO recommendations is limited. Therefore, this study aimed to determine the time to ANC booking and its predictors among pregnant women in East Africa. Method: This study was conducted among 86,662 pregnant women in East Africa. The time to ANC booking was estimated using the Kaplan-Meier survival estimate (K–M). A Weibull gamma shared frailty model was used to determine predictors of time to the first ANC visit. Adjusted hazard ratio (AHR) with 95% confidence interval (CI) was reported. Result: The median time to ANC booking among pregnant women in East Africa was 4±2 months. Maternal education primary (AHR= 1.01, 95%CI: 1.02, 1.25), secondary (AHR= 1.03, 95%CI: 1.02, 1.05), and higher (AHR= 1.40, 95%CI: 1.30,1.50), husband's education primary (AHR=1.08, 95% CI: 1.06,1.09), secondary (AHR= 1.12, 95%CI: 1.10,1.13), and higher (AHR= 1.08, 95% CI: 1.07,1.10) as compared to with no education, wealth status middle (AHR= 1.66, 95% CI: 1.60,1.70); richest (AHR: 1.60, 95% CI: 1.56,1.73), high community-level maternal literacy (AHR= 1.05, 95% CI: 1.04, 1.06), high community-level poverty (AHR= 0.99, 95%CI: 0.98, 0.99), previous cesarean section (CS) (AHR= 1.35, 95% CI: 1.33, 1.39), and unwanted pregnancy (AHR= 0.74, 95% CI: 0.72, 0.77) were predictors of the time to ANC booking. Conclusion: The median time to ANC booking among pregnant women in East Africa is too later than the new WHO recommendation. Maternal and husband education, high community-level maternal literacy, better household, and community-level wealth index, and previous CS increase the early ANC booking. However, unwanted pregnancy lowers the early ANC booking. Therefore, strengthening system efforts to improve maternal and husband's educational status, women's education encouragement in the community, and economic support for low-wealth status women and poor community and encouraging wanted pregnancy and provide accessible counseling services for women facing unwanted pregnancies will help to encourage early ANC booking among pregnant women in East Africa.