Abstract
<title>Abstract</title> <p>Background Benin recorded a decline in ANC4 + coverage from 63% in 2001 to 53.4% in 2017-18, well below universal targets. Standard single-level analyses document individual barriers but cannot quantify hierarchical clustering or map geographic concentration of ANC4 + disparities. Objectives (i) To estimate individual, community, and geographic determinants of completing four or more antenatal care visits (ANC4+) in Benin; (ii) to quantify cluster- and department-level variance; and (iii) to characterise spatial autocorrelation of ANC4 + rates across Benin’s 12 departments. Methods Data from the 2017-18 Benin Demographic and Health Survey (n = 8,766 women with a recent live birth) were analysed using three-level random-intercept logistic regression (women nested within clusters within departments), four sequential models (M0–M3), and spatial analysis (Global Moran’s I, LISA) with queen contiguity weights. Results Overall ANC4 + prevalence was 53.4%. The null model attributed 9.8% of total variance to cluster-level and 18.4% to department-level clustering. Household wealth was the dominant determinant (poorest vs. richest: aOR = 0.38 [0.29–0.49]); secondary or higher education (aOR = 1.42) and higher birth order (aOR = 0.54 for fifth + vs. first) were also significant. Community education level was the sole contextual determinant retaining significance after individual adjustment (Low vs. High: aOR = 0.74). Global Moran’s I was strongly positive (I = 0.712, p < 0.0001); LISA identified a Low-Low cluster in four northern and a High-High cluster in two southern departments. Conclusions ANC4 + in Benin is shaped by individual socioeconomic resources, community education endowment, and strong geographic clustering. Effective strategies must prioritise northern departments while targeting individual wealth barriers and community-level educational capital.</p>