BACKGROUND: Accessibility and utilization of antenatal care (ANC) service varies depending on different geographical locations, sociodemographic characteristics, political and other factors. A geographically linked data analysis using population and health facility data is valuable to map ANC use, and identify inequalities in service access and provision. Thus, this study aimed to assess the spatial patterns of ANC use, and to identify associated factors among pregnant women in Ethiopia. METHOD: A secondary data analysis of the 2016 Ethiopia Demographic and Health Survey linked with the 2014 Ethiopian Service Provision Assessment was conducted. A multilevel analysis was carried out using the SAS GLIMMIX procedure. Furthermore, hot spot analysis and spatial regressions were carried out to identify the hot spot areas of and factors associated with the spatial variations in ANC use using ArcGIS and R softwares. RESULTS: A one-unit increase in the mean score of ANC service availability in a typical region was associated with a five-fold increase in the odds of having more ANC visits. Moreover, every one-kilometre increase in distance to the nearest ANC facility in a typical region was negatively associated with having at least four ANC visits. Twenty-five percent of the variability in having at least four ANC visits was accounted for by region of living. The spatial analysis found that the Southern Nations, Nationalities and Peoples region had high clusters of at least four ANC visits. Furthermore, the coefficients of having the first ANC visit during the first trimester were estimated to have spatial variations in the use of at least four ANC visits. CONCLUSION: There were significant variations in the use of ANC services across the different regions of Ethiopia. Region of living and distance were key drivers of ANC use underscoring the need for increased ANC availability, particularly in the cold spot regions.