Health Science Journal

Background

The postnatal period is defined as the time just after delivery and through the first sixth weeks of life (1). The main aim of postnatal care services are early detection and treat complications of the mother and infant, counseling and service provision on baby care, breastfeeding, maternal nutrition, family planning and immunization of the infant (2).

Postnatal period is a crucial moment in identifying and responding to needs and complications, which are the most desirable and likely to influence the health and safety of the mother and the newborn (3). Whereas lack of care in this time period may result in death or disability as well as missed opportunities to promote healthy behaviors, affecting women, newborns, and children (4).

Besides, the majority of maternal and neonatal deaths, as well as a significant burden of long term morbidity occur during the postpartum period, providing appropriate PNC in the first hours and days after birth is an essential and effective strategy which averts and prevents most of maternal and child morbidity and mortality(1, 4).

Globally, the maternal mortality ratio is 216 deaths per 100, 000 live births in 2015 (5), and about 2.6 million newborns die in 2016 (6). Majority of maternal deaths (66%) and neonatal deaths (75%) occur during the first week of life. And more than half of these take place within a day of delivery(6, 7). Furthermore, 88% of maternal and 80% of newborn deaths occurs in Sub-Saharan Africa and South Asian countries (5, 6), particularly in Africa, 125,000 women and 870,000 newborns die in the first week after birth every year(8).

In Ethiopia, maternal mortality and morbidity levels are among the highest in the world. The estimated pregnancy-related mortality ratio (PRM) in the year 2016 is 412 per 100,000 live births(9), and the majority (67%) of deaths occurred in the postpartum period(10).The major The major causes of maternal death are hemorrhage, hypertension in pregnancy, obstructed labour, sepsis, and anemia, and severe bleeding usually occurring after the mother gave birth is the single most feared complication claiming the life of most mothers (53%)(10).

In fact, there is a remarkable progress to reduce mortality of children less than 5 years of age in Ethiopia, neonatal mortality accounts for 43% of all under-5 deaths(9),which shows an increment of 42% in the previous survey(11), and Ethiopia is among five countries where half of all newborn deaths are concentrated(6). Moreover, 2000, 2005, 2011 and 2016 Ethiopian Demographic and Health Surveys reported neonatal mortality rates of 49, 39, 37 and 29 per 1000 live births, respectively. But the decline in neonatal mortality rate by 41% over 16 years is substantially less than the decline in infant (50%) and under five (60%) mortality over the same period (9, 11-13).

Globally, PNC reaches even fewer women and newborns: less than half of women receive a PNC visit within 2 days of childbirth(14). And among 69 countries where more than 95% of all maternal and child deaths occur, only 1 in 5 women received PNC (15). Similarly, according to the Demographic and Health Survey (DHS) data from 23 African countries, only 13% of all women receive a postnatal visit within two days (8).

Likewise, the level of postnatal care coverage is extremely low in Ethiopia. Only 17% of women received postnatal check-up within two days after birth(9). Nevertheless, there is an improvement from the previous survey when only 12 %(11) received postnatal care during the first two days of delivery. Yet the great majority of women (81%) with a live birth did not receive a postnatal checkup at all (9).

Furthermore, different studies conducted in Ethiopia also showed that the estimated prevalence of PNC utilization ranges from 20.2% in Jabitehenan to 83.3% in Debre Birhan town (16-24).

Even though, there is a guideline and strategy on postnatal care follow-up in Ethiopia but not applied properly; there are little information and less practice in postnatal care follow up at the ground level in the community. Because of this, the government of Ethiopia developed the Health Extension Program (HEP) designed to improve the health status of families, with their full participation, using local technologies and the community’s skill and wisdom. The HEP draws on the same principles as Primary Health Care, but focuses on the improvement of prevention skills and behaviors within the household, and involves fewer facility-based services. The HEP is the main vehicle for bringing key maternal, neonatal and child health interventions to the community through the provision of staffed health posts with health extension workers (HEWs) who are trained to deliver 16 health care packages under four components. Among these four components family health service play a significant role in reducing maternal and child morbidity and mortality through educating the community to increase their awareness and knowledge regarding antenatal care, delivery practice and PNC. After 96 hours of training by HEWs, and adopting 12 of the 16 packages, a family graduates to become a HEP graduate or a model family (25-28).

Prompted and encouraged by the success of the Health Extension Programme, Ethiopia has recently created an innovative volunteer system known as Women’s Health Development Army (WHDA). WHDA is a network consists of five women volunteers and make up a larger group of 30 led by a woman from model household, organised to promote health, prevent disease through community participation and empowerment. The WHDA has effectively facilitated the identification of local salient bottlenecks that hinder families from utilizing key Maternal, Neonatal and Child Health Services and to come up with locally grown and acceptable strategies for addressing ongoing issues (28).

Despite the above strategies in due course, still the postnatal periods is a neglected period, and continue to be regarded as having little value, but the greatest number of maternal and newborn deaths occur during this time. It is also among the lowest MNCH programmes along the continuum of care, especially in a rural area where 85.1% of women did not receive postnatal check-up (9).

However, different studies were conducted on postnatal care service utilization; there is no any study which was conducted in the study area. Significant heterogeneity in the prevalence across studies also shows that area-specific factors associated with PNC need further exploration. Moreover, this study also differs from previous studies done in Ethiopia in that, the role of WHDA and HEP graduation on PNC service utilization were not studied as a factor and has not yet been systematically analyzed.

Therefore, this study aimed to fill the existing information gap on PNC service utilization via identifying factors/predictors by providing empirical evidence-based data in rural Ethiopia, particularly in the study area.

Methods

Study Setting

This study was conducted in Bahir Dar zuria district, North West Ethiopia. The district has 32 rural kebeles (the smallest administrative unit in Ethiopia) with a total population of 218,213. Out of this, 106,142 were women. The Woreda has 12 public health centers and 32 Health posts. Health professionals were unevenly distributed in all health facilities and there were a total of 187 health professionals and 75 health extension workers. There were also 1320 one to thirty networks (WHDA) in the district (Bahir Dar zuria district health office report 2018).

Study Design and Period

A community based quantitative cross-sectional study was conducted from December 1, 2018, to January 30, 2019.

Eligibility Criteria

All women who gave birth six months prior to data collection regardless of the birth outcome, and live for at least six months in the district were included in the study. Women who were seriously ill to respond to the questionnaire were excluded from the study.

Sample Size Determination

The sample size was determined using a single population proportion formula considering 34.8% for the proportion of postnatal care utilization (31), 95% confidence level, 5% margin of error, a design effect of 2 and non-response rate 6%. The final sample size became 742.

Measurements

Postnatal care service utilization in this study was considered as woman who received at least one PNC service from health institutions following delivery till 42 days.

The knowledge of PNC was assessed using a 7 points scale. There were seven multiple choice questions that carried a total of seven correct responses. Each correct response was given a score of 1 and a wrong response a score of 0. Total points to be scored were 7 and the minimum was 0. For assessment, the median score was used in order to classify as good knowledge (those mothers who scored equal to or above the median score of knowledge questions asked on PNC) and poor knowledge (those mothers who scored less than median score of knowledge questions asked on PNC)

Women participation in decision making: if a woman make decisions alone or jointly with her husband or someone else.

Sampling Technique and Procedure

Multistage sampling technique was used to select study participants. In the first stage, from the total of 32 kebeles, 10 kebeles were selected using the lottery method. Then to obtain 742 study participants, the total sample size was allocated to each selected kebeles using population proportion to size. And HHs was selected using systematic random sampling technique. All women who gave birth in the last six months prior to data collection and reside in the selected HHs were eligible to be interviewed. Whenever more than one eligible respondent found in the same selected household, only one respondent was chosen by lottery method. For households with no eligible woman the immediate next household was selected and then, subsequent households were selected accordingly via the predetermined interval.

Study Variables

The dependent variable of the study was postnatal care utilization. The independent variables include; socio-demographic and economic variables (age, marital status, educational status of the mothers, educational status of the husband, mother's occupation, husband's occupation, women’s participation in decision making about own health care, being involved in women’s health development army, being graduated in HEP), knowledge on PNC and obstetric related factors (current total number of children, history of ANC attendance, place of delivery, mode of delivery and outcome of birth).

Data Collection Tool and Procedure

Data were collected using an interviewer-administered questionnaire that can address the objective of the study which is developed by reviewing different literature of previous similar studies. The data collection instrument was prepared initially in English and translated into local language (Amharic). Five diploma nurse data collectors and two BSC health officers as supervisors participated in the data collection process. One and half day training was given for data collectors and supervisors on how to approach participants, how to gather the appropriate information, procedures of data collection, the contents of the questionnaire and the objective of the study. 

Data Processing and Analysis

The collected data were entered in to Epi-Info version 3.5.1 and exported to SPSS version 20.0 for analysis. Frequency and percentage were used for the descriptive part and logistic regression model was used to identify the statistically significant variables. Variables that were statistically significant with p-value<0.2 at bi-variable logistic regression were entered to multivariable analysis. The multivariable logistic regression was used to identify variables which are statistically significant with p-value<0.05 and odds ratio with 95 % confidence interval was computed to determine the level of significance.

Result

Socio-Demographic Characteristics of Respondents

From 742 eligible women in the selected sample, 708 (95.4%) of them responded to the questionnaire. About 79.7% (564) respondents were between the ages 20 to 34 with a mean age of 28.2± (4.8 SD) and 84.9% (601) were married. Almost 56% of respondents were involved in WHDA (1 to 5 and 1 to 30 network) and 61% of respondents were graduated in HEP previously. Regarding women’s autonomy 75.9% of respondents involved in decision making on health issues (Table 1).

Variables	Frequency (n)	Percentage (%)
Age of respondents
<20	56	7.9
20-34	564	79.7
35-49	88	12.4
Marital status
Married	601	84.9
Unmarried?	107	15.1
Religion
Orthodox	645	91.1
Muslim	63	8.9
Educational status of respondents
No education	663	93.6
Primary education	22	3.1
Secondary education & above	23	3.3
Occupation of respondents
Housewife	507	71.6
Farmer	82	11.6
Merchant	86	12.1
Daily laborer	33	4.7
Husband’s educational status
No education	566	94.2
Primary education	22	3.7
Secondary education & above	13	2.1
Husband’s occupation
Farmer	477	79.4
Merchant	112	18.6
Daily laborer	12	2.0
Involvement of WHDA
Yes	396	55.9
No	312	44.1
Graduated in HEP
Yes	431	60.9
No	277	39.1
Women’s participation in decision making
about own health care
Yes	536	75.7
No	172	24.3
about major HH purchases
Yes	512	72.3
No	196	27.7
about visit to family & relatives
Yes	501	70.7
No	207	29.3

Table 1: Socio-demographic characteristics of respondents in Bahir Dar Zuria district, North West Ethiopia, 2019.

N.B: ? = Divorced, Widowed, Single, Separated

Obstetric History of Respondents

Majority of the respondents 499 (70.5%) received ANC service during their last pregnancy. Among these 128 (25.7%) received four times and above. While only 340 (48%) of respondents delivered in health facilities (Table 2).

Variables	Frequency (n)	Percentage (%)
Birth order
1	128	18.11
2-3	402	56.8
4-5	160	22.6
6+	18	2.5
ANC visit for the last pregnancy
Yes	499	70.5
No	209	29.5
Number of ANC visit
1-3	371	74.3
Four & above	128	25.7
Place of delivery
Home	368	52
Health facility	340	48
Mode of delivery
Spontaneous vaginal	590	83.3
C/S& Instrumental	118	16.7
Outcome of birth
Alive	609	86
Still birth	99	14

Table 2: Obstetric history of respondents in Bahir Dar Zuria district, North West Ethiopia, 2019.

Knowledge on Postnatal Care of Respondents

From the total of 708 respondents 377 (53.3%) had good knowledge about PNC. Regarding the knowledge about danger signs 489 (69%) and 694 (98%) were aware of at least one danger sign of the mother and the newborn during postpartum period respectively (Table 3).

Variable	Frequency (n)	Percentage (%)
Knowledge on PNC
Good	377	53.3
Poor	331	46.7
Knowledge on availability of PNC
Yes	412	58.2
No	296	41.8
Knowledge on advantage of PNCYes	578	81.7
No	130	18.3
For whom PNC is necessary
Those who gave birth at home	261	36.87
Those who gave birth at h/ facility	124	17.51
Those who gave birth at home & h/ facility	323	45.62
Know at least one danger sign of new born during postpartum
Yes	694	98
No	14	2
Know at least one maternal danger sign during postpartum
Yes	489	69.1
No	219	30.9

Table 3: Knowledge of Respondents towards PNC in Bahir Dar zuria district, North West Ethiopia, 2019.

Postnatal Care Utilization

The prevalence of postnatal care utilization was 35.6 %( 95%CI=31.90, 39.30) within 42 days after delivery (Figure 1).

Figure 1: Proportion of PNC service utilization of respondents in Bahir Dar zuria district, North West Ethiopia, 2019.

• Utilized PNC service
• Not utilized PNC service 

Among the women who received PNC, 65 (26%) of them were examined within two days of postpartum, 53 (21%) were examined during three to seven days of postpartum and the rest 133 (53%) were examined during eight days to forty-one days of postpartum (Figure 2).

Figure 2: Timing of first postnatal check-up among respondents in Bahir Dar zuria district, North West Ethiopia, 2019.

Factors Associated with Postnatal Care Utilization

In a multi-variable logistic regression; being involved in WHDA, being graduated in HEP, history of ANC attendance, place of delivery, outcome of birth and knowledge on PNC service had statistically significant association at p-value <0.05 with postnatal care utilization (Table 4).

Variables	PNC service utilization		COR 95%CI	AOR 95%CI
	Yes	No
Age
<20	28	28	1	1
20-34	201	363	2.83 (1.39,5.73)*	0.87 (0.25,2.46)
35-49	23	65	1.56 (0.94,2.6)	0.34 (0.9,1.32)
Being involved in WHDA
No	35	277	1	1
Yes	217	179	9.6 (6.41,14.4)**	11.26 (6.41,19.8)**
Being graduated in HEP
No	34	243	1	1
Yes	218	213	7.32 (4.88,10.97)*	5.05 (2.88,8.87)**
Participation in decision making about their ownhealth care
No	40	131	1	1
Yes	213	324	2.14 (1.43,3.16)*	1.34 (0.6,2.97)
ANC attendance
No	14	195	1	1
Yes	238	261	12.7 (7.18,22.46)**	6.83 (3.26,14.27)**
Place of delivery
Home	56	312	1	1
Health facility	196	144	7.6 (5.31,10.83)**	3.30 (1.92,5.68)**
Outcome of birth
Alive	241	368	1	1
Still birth	11	88	0.19 (0.1,0.37)**	0.22 (0.1,0.5)**
Knowledge on PNC
Good	231	146	23.4 (14.3,38.1)**	16.74 (9.08,30.86)**
Poor	21	310	1	1

Table 4: Factors determine PNC service utilization of respondents in Bahir Dar zuria district, North West Ethiopia, 2019.

N.B *=statistically significant at p<0.005 ** =statistically significant at p<0.00

1= Reference category

Being involved in WHDA and being graduated in HEP were showed strong statistical association (p-value<0.001) with the level of PNC utilization. Women who were involved in WHDA were 11 times (AOR = 11.26, 95%CI=6.41, 19.79) more likely to utilize PNC services as compared with those who were not involved. Similarly, women who were graduated in HEP were 5 times (AOR=5.05, 95%CI=2.88, 8.87) more likely to utilize PNC services as compared to those who were not graduated.

PNC service utilization was highly associated with history of ANC attendance. Women who attended ANC follow up were 7 times (AOR=6.83, 95%CI=3.26, 14.27) more likely to utilize PNC services as compared to those who did not attend.

PNC service utilization regarding place of delivery showed strong statistical significant association in the manner that women who delivered in health facilities were 3 times (AOR=3.3, 95%CI=1.92, 5.68) more likely to utilize PNC services as compared to those who delivered in home.

Moreover, women with still birth outcome were 78% less likely to utilize PNC services than those with live birth.

Knowledge on PNC showed strong statistical significant association with PNC service utilization. Mothers who had good knowledge were almost 17 times (AOR=16.74, 95%CI=9.08, 30.86) times more likely to utilize PNC services than who had poor knowledge.

Discussion

This study showed that utilization of postnatal care was 36.5 %( 95%CI=31.90, 39.30), which is comparable with study results in Dembecha, Ethiopia (34.8%)(19), Sidamo, Ethiopia (37.2% ) (20), Loma, Ethiopia(36.7%)(21), Debre Markos, Ethiopia (33.5% )(22)and India (35%) (29).

However, this finding is higher as compared to EDHS, 2016 (17%)(9), studies in Jabitehenan, Ethiopia (20.2%)(16), Nigeria (14%)(30), Kenya (14.2%)(31), and lower as compared to studies in Adwa, Ethiopia (78.3% )(17), Gondar, Ethiopia(66.8% )(18), Debere Birhan, Ethiopia (83.3% )(24), Egypt (48.7%)(32), Cambodia (61% )(33) and Baghdad (42% )(34). The difference might be attributed to the time of the study, study population, study setting, study design, study area, sample size, and socio-demographic characteristics. For instance, the studies in Adwa and Debre Birhan were conducted in urban areas unlike our study, and a study in Egypt used a smaller sample size as compared to the current study.

Besides, the current study revealed that history of ANC visit has a significant association with PNC utilization. This is consistent with the study findings of Gondar, Ethiopia(18) and Dembecha, Ethiopia (19). This could be owing to women’s contact with the health care providers during ANC visit, increase the chance to get exposed to health education and counseling related to PNC service and its benefits, impels them to use the service. While antenatal care programs may not be the entire solution to reducing maternal mortality, our findings showed that making antenatal care visit was beneficial, and may also lead towards a greater uptake of PNC services.

Similarly, women gave birth in health facilities were more likely to utilize PNC than those who delivered at home, which is in agreement with study findings in Jabitehenan, Ethiopia(16), Gondar, Ethiopia(18), Debre Markos, Ethiopia (22), Halaba, Ethiopia (23), Debre Birhan, Ethiopia(24), Nigeria(30), Cambodia (33) and Nepal(35). FGD result also showed that women who delivered in their home did not seek PNC services. The possible reason might be women who gave birth in health facilities could be exposed to the availability of PNC service during their stay in the health institution for giving birth and after delivery.

Furthermore, knowledge on PNC is another factor that has a strong statistically significant association with PNC utilization. This finding is similar with studies in Jabitehenan, Ethiopia(16), Gondar, Ethiopia(18), Debre Birhan, Ethiopia(24), Cambodia (33) and Baghdad(34), except the study finding of Adwa, Ethiopia (17) that revealed disparate finding with the current study. This could be explained in the fact that good knowledge on PNC, services given and danger sign and symptoms during the postpartum period will motivate mothers to attend PNC with the intention of prevention, early detection and getting managed their postpartum complications, and for women to use PNC services, they must know about the services.

Another factor that was shown a significant association with PNC utilization is the birth outcome. This is consistent with the study finding in Debre Markos, Ethiopia (22).This impact could be partly explained by a lack of awareness about PNC, the benefit, and type of service provided during the postpartum period.

Concerning more pertinent findings in this study that were shown to have a strong statistical association with PNC utilization were being involved in WHAD and being graduated in HEP.

Women who were graduated in HEP were more likely to utilize PNC services than those who were not graduated. This might be due to the fact that, women from model families (graduated in HEP) are equipped with knowledge and skill necessary to practice maternal health services available like PNC. In addition, a family to be certified as a model they are expected to use and model maternal health services, which raise their PNC utilization.

Regarding WHDA, women who were involved in WHDA were more likely to utilize PNC services as compared to those who were not involved. The possible reason might be due to WHDA leaders mobilize and educate the community to take up key MNCH services including PNC through disseminating essential health messages during door to door visit and weekly meeting with their respective members. They also identify and help women needing PNC to utilize the service, which increases women’s engagement and health-seeking behavior towards PNC service.

Strength and limitation of the study

Six months’ time period was chosen to minimize recall bias since women were asked for events which have already happened. Despite the above strengths, the study has a limitation. This study utilized cross sectional study design, hence it is difficult to establish causal relationship between the independent and the outcome variables.

Conclusion

In general, the study has revealed that PNC service utilization in this study area was lower than what was planned to achieve in growth and transformation plan two of Ethiopia.

The most pertinent findings this study revealed were being involved in WHDA and being graduated in HEP that has shown a statistically significant association with PNC utilization. Likewise, other factors found to have significant association with PNC utilization were history of ANC attendance, place of delivery, outcome of birth and knowledge on PNC.

Therefore, addressing these factors with a cumulative effort in different level of the health care system of Ethiopia will increase the uptake of PNC services, and in the long run it will minimize maternal and neonatal morbidity and mortality of the community.

39763

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