All the member countries of the United Nations (UN) including Bangladesh pledged to reduce the maternal mortality rate to less than 70 deaths per 100,000 live births by 2030 [1]. However, pregnancy-related preventable morbidity and mortality still remain unacceptable in many low- and middle-income countries (LMICs) like Bangladesh [2]. It is evident that this high maternal morbidity and mortality rate is associated with inadequate maternal pregnancy care [2]. Moreover, maternal mortality, pregnancy-related complications, and adverse pregnancy outcomes could substantially be averted through early detection of complications and ensuring proper pregnancy care [3–5].

The World Health Organization (WHO) envisions a world where “every pregnant woman and newborn receives quality care throughout the pregnancy, childbirth, and the postnatal period” [6]. WHO recommends that adequate healthcare for a normal pregnancy that has no complications should have at least four Antenatal Care (ANC) visits from a skilled healthcare professional, with the first visit occurring within the first trimester (first 3 months of pregnancy) [7]. ANC comprises the care provided by a qualified doctor, nurse, midwife, family welfare visitor, community skilled birth attendant, medical assistant, etc. to pregnant women to ensure the best health conditions for both mother and baby during pregnancy [5]. Moreover, during these visits, the mothers should have several health services, including taking body weight, checking blood pressure, testing blood samples, testing urine samples, performing ultrasonograms, and giving information on pregnancy complications to the mother. In addition, women should take adequate dosage of iron/folic acid (IFA) supplementation during pregnancy, as inadequate intake of these nutrients may have a negative impact on maternal health, fetal development, and pregnancy outcomes [8–10].

In developing countries like Bangladesh, various factors including age, lower educational level of women and their partner [11–13], lower socio-economic status [11–14], higher parity [12–14], intimate partner violence [15], lack of women’s decision making power, [16] etc. contribute to lower use of antenatal care. Similarly, women with unintended pregnancies have been documented to make inadequate ANC visits and delay the initiation of the first visit [11, 14, 17, 18]. Pregnancies are considered unintended when the pregnancies are unwanted (i.e., when no children, or no more children, are desired) or mistimed (i.e., they occur earlier than expected). Besides, women with unintended pregnancies are supposed to have less attention from their partner, and family members which leads to lower use of self-care as well. Thus, poor utilization of ANC increases pregnancy related complications (i.e., unfavorable pregnancy outcome, maternal morbidity, and mortality) and obstetric complications (i.e., premature birth, low birth weight, and neonatal death) [3, 4].

Bangladesh aims to reduce the maternal mortality ratio to 121 deaths per 100,000 live births, and the neonatal mortality rate to 18 deaths per 1,000 live births by 2022 to achieve the goals of its government’s 4th Health, Population, and Nutrition Sector Program. The percentage of women receiving any ANC from medically trained persons has increased from 42% in 2004 to 82% in 2018, and at least four ANC visits have increased from 17% in 2004 to 47% in 2018 [19]. However, the use of modern contraceptives has been almost stagnant during the last decade (from 48% in 2004 to 52% in 2018), and unintended pregnancy is still prevailing here (21% in 2018) [19]. It is evident that women with unintended pregnancies are at greater risk of not taking adequate ANC visits and delaying the initiation of the first ANC visits in Bangladesh [11, 14, 20].

We found two studies [11, 14] that reported the effect of unintended pregnancy on the use of ANC among Bangladeshi women. However, they focused on a limited number of ANC components, namely, receiving at least one ANC visit, and the required number of ANC visits. These studies did not include the timely initiation of first ANC visit and the quality of ANC services which are recommended by the WHO. The studies also did not conduct any predictive analysis for taking supplementary IFA during pregnancy, a crucial component of ANC for preventing anemia during pregnancy. Therefore, a further comprehensive investigation is required for better insights covering all the important indicators of ANC in Bangladesh. To extend the previous work and fill this knowledge gap, we conducted the current study to examine the association between pregnancy intention and ANC-seeking behaviors (timing of the initiation of the first ANC visit, adequacy of ANC visits, and coverage of all ANC services) among women in Bangladesh using the latest nationally representative data. While defining the quality of ANC coverage, we included all six recommended items of ANC services. Additionally, the current study assessed the practice of taking an adequate dosage of IFA supplements and explored its association with pregnancy intention. The study also revealed the factors of unintended pregnancy in Bangladesh. Thus, the study findings might contribute to policy design to reduce unintended pregnancy and augment the uptake of proper ANC.

This study highlights the association of maternal pregnancy intention with their utilization of ANC among women aged 15–49 years who had a live birth in the 3 years preceding the 2018 BDHS survey in Bangladesh. In this study, approximately one-fifth of the women reported that their last pregnancy was unintended (wanted later/not wanted at all). Age of the women, residence area, educational level of the women, wealth index, family size, and currently using of contraception significantly influence their pregnancy intention. About 8% of the women did not have any ANC visits during their last pregnancy. Among those who had at least one ANC visit, approximately two-fifth (40.4%) initiated their first visit within the first trimester (first 3 months) of their pregnancy. About half of them had at least four ANC visits, and more than three-fourths of them received their supplementary iron tablets/syrup during their previous pregnancy. However, the adequacy of IFA dosage was only among one-fifth of them (22.2%). Moreover, only one-fourth of them received all ANC services (taking body weight, checking blood pressure, testing blood samples, testing urine samples, performing ultrasonograms, and giving information on pregnancy complications to the mother). The multivariate analyses showed that women with unintended pregnancy were less likely to receive their first ANC visit within the first 3 months, to receive four or more ANC visits and to receive all ANC services than those with intended pregnancy. However, receiving adequate IFA supplements during pregnancy did not significantly vary with pregnancy intention. Other determinants of the ANC were the age of the women, educational level of the women and their partner, type of residential area, division, parity, and wealth quintiles.

Consistent with previous studies [11, 14, 17, 18, 26], our findings showed that women who conceived unintentionally were late in initiating ANC visits to a qualified health professional. This association could be explained in several ways. First, when it is unintended pregnancy, they might be late in recognizing it, and in corollary, they are late in taking their first ANC visit [27]. Another explanation could be that when they conceive unintentionally, they might be mentally unprepared, disturbed, and afraid of sharing it with their partners, family members, or others and confused about whether it should be taken or aborted. Moreover, they might not be financially prepared to take ANC from a qualified health professional. Hence, they are late in initiating the first ANC visit to a qualified health professional during an unwelcome pregnancy.

In addition, our study findings also highlighted that the adequacy of ANC visits (i.e., at least four ANC visits) and the quality of ANC services among pregnant women were also linked with their pregnancy intention. Women with unintended pregnancies were less likely to receive four or more ANC visits, and all ANC services than women with intended pregnancies. Similar findings were reported by previous studies in Bangladesh [11, 14] and other LMICs [17, 28, 29]. One possible reason could be their emotional and financial unpreparedness for meeting the demands of pregnancy, childbearing, and care of themselves and the developing fetus during pregnancy. Moreover, inadequate support and nonchalant attitudes of the partner and other family members toward this unwelcome pregnancy might restrict them from taking adequate maternal care from a qualified health professional. However, maternal pregnancy intention was not significantly linked with taking adequate IFA supplements during pregnancy. This finding was analogous to a study in Ethiopia [30] that concluded that taking supplementary iron tablets during pregnancy did not significantly vary with maternal pregnancy intention. Although the coverage of IFA supplementation was higher, the adequacy of the dosage of IFA was poor. The possible cause behind the high coverage of IFA supplements, irrespective of their pregnancy intention, could be the free and wide availability of iron and folic acid tablets at the local pharmacies, community clinics and public hospitals in Bangladesh. Evidence warns that late initiation of ANC visits, inadequate ANC visits, inadequate ANC services, and inadequate IFA tablets might cause complications during pregnancy, delivery, maternal mortality, still birth, low birth weight (LBW), neonatal mortality, etc. [3, 4, 31]. Therefore, health providers, especially at the community level, could be trained to identify unintended pregnancies and provide culturally appropriate support and care to women with unintended pregnancies.

Socio-demographic factors such as age, type of residential area, educational level of the women, educational level of their partner, wealth index, parity, etc., were significantly linked with the utilization of ANC. Comparatively educated women and women with an educated partner were more likely to receive their first ANC visit within the first 3 months of pregnancy, to receive at least four ANC visits, to receive all the components of ANC services, and to take supplementary iron tablets. Similar findings were found in previous studies in Bangladesh [11, 12, 14, 16, 20, 23, 32, 33] and other LMICs [13, 22, 29, 30, 32, 34]. The educated women and their educated partner might have adequate knowledge about maternal healthcare and are aware of the importance of taking sufficient ANC, which in turn might improve their health-seeking behavior, leading to greater utilization of an optimum level of healthcare during pregnancies [20, 35]. Moreover, educated mothers are more likely to be empowered and have decision-making power within the household regarding their pregnancies and their own healthcare. Therefore, policies aimed at improving the educational level of the mother, their partner, and other family members could be emphasized to foster the utilization of optimum care of mothers during pregnancies.

Consistent with previous studies in Bangladesh [11, 12, 14, 16, 20, 23, 36] and other LMICs [13, 22, 29, 37–41], our findings revealed that household wealth status is a significant predictor of ANC utilization. Receiving the first ANC visit within 3 months, receiving four or more ANC visits, taking all ANC services, and taking adequate supplementary tablets/syrup tended to be higher with their wealth quintiles. This relation was significant irrespective of their pregnancy intention. Higher wealth status had positive effect in ANC utilization among both groups of women (with intended and unintended pregnancy). Measures aimed at improving the living standard of the people, reducing the cost of taking maternal healthcare, and providing incentives could be taken to optimize the utilization of ANC by health professionals.

In agreement with other studies [12–14, 16, 20, 22, 23, 39], our study findings showed that as the number of children of a women increases, the utilization of optimum ANC from health professionals decreases. The cause of this negative association between the women’s parity and utilization of optimum ANC could be their experience from the previous pregnancy, the cost of healthcare in the previous pregnancy, and less excitement during the current pregnancy compared to earlier pregnancy [42].

Moreover, women from rural areas were less likely to receive optimum healthcare services during their pregnancies compared to women from urban areas. Similar findings were also reported in previous studies [13, 16, 20, 22, 23, 38, 41]. The lower utilization of adequate ANC services among rural women might be linked to their lower economic condition, unawareness, superstitions, limited availability of health facilities, etc. Policies to improve health facilities at rural community clinics and raising awareness regarding maternal healthcare could be an appropriate option to facilitate the optimum utilization of ANC services during pregnancy.

The study has strengths as well as some unavoidable limitations. One of its strengths lies in its nationally representative survey data, which makes it possible to generalize the findings at the national and sub-national levels. This study extends the previous work on the effect of maternal pregnancy intention and ANC utilization using all the important ANC indicators. Moreover, the study findings might have important policy implications for further improvement of healthcare services and their optimal utilization during pregnancies. Since unintended pregnancy has a negative effect on the utilization of ANC, policies could be taken to promote the effective use of contraceptives to reduce unintended pregnancy. The study also indicated that the educational of the women could contribute to reduce unintended pregnancies and to foster the uptake of proper ANC. Thus, the findings of the study could be a guide to enhance health education for women especially focusing on the importance and ways of family planning, proper pregnancy care. Nevertheless, the study should be considered with some limitations. Since the study was based on retrospective data on pregnancy intention and ANC seeking, it might impose recall bias. Moreover, the study only reports pregnancy intention and antenatal care seeking behavior of the women with a live birth 3 years preceding the survey. As a result, the information of women who terminated the pregnancy and women who still had a birth was unknown. In addition, due to the cross-sectional nature of the data, the study can only provide evidence of statistical association, and cause-effect relationships cannot be inferred. However, as suggested by Markovitaz et al. [43], cross-sectional studies may be a better source of data for policy judgments in the public health community than longitudinal studies when risk factors vary more across space at a fixed moment in time than at a fixed location across time. Lastly, we could not include other variables that might have explained our outcome variables (i.e.; cost of care, availability, and accessibility of health facilities) because we used secondary data.