Postnatal Care Service Utilization and Associated Factors Among Mothers Who Gave Birth in Last Year: Community Based Cross Sectional Study in Adama, Ethiopia

Background: Postnatal period is generally the most neglected period, especially in developing countries. This study assessed postnatal care service utilization and associated factors among mothers who gave birth in the last one year in Adama Town, Oromia, Ethiopia. Methods: Community based Cross sectional study was employed in seven randomly selected kebeles` in Adama town. A total of 563 mothers was included. Data was collected by face to face interview. Data were entered into Epi Info version 7 and imported to SPSS version 20. Descriptive statistics were carried out to characterize the study population. Bivariate and Multivariable Logistic regression were used to identify the associated factors. Result: The mean age of respondents was 28 (SD±5. 01) Years. The prevalence of PNC utilization was 269 (47.7%) with (95% CI: 44.0, 51.8). Educational status (AOR, 2.27; 95% CI: 1.13, 4.57), mode of delivery (AOR, 5.08; 95% CI: 2.55, 10.10), Provision of PNC appointment (AOR, 2.09; 95% CI: 1.36, 3.25), and Mothers Knowledge (AOR, 5.68; 95%CI: 2.97, 10.87) showed statistically significant association with PNC service utilization. Conclusion: Postnatal care service utilization in this study is much lower than Health service transformation plan of the country. Factors like Educational status, Mode of Delivery, Appointment date, mother’s knowledge of PNC utilization were found to be significantly associated with PNC utilization.


Introduction
Postnatal care (PNC) is defined as a care given to the mother and her newborn baby immediately after the birth of the placenta to the first six weeks of life. PNC interventions are used for prevention of impairments and reduction of maternal and newborn mortality. [1,2] World Health Organization (WHO) recommends a total of four visits: on the first day (24 hours), 3 rd day (48-72 hours), between 6-7 days and 6 th weeks. Indeed, these contacts can be exercised in a health facility after discharge by Health care practitioners [3].
According to the WHO, only a small proportion of women in developing countries, less than 30%, receive postnatal care and in very poor countries and regions, as few as 5% of women receive such care [4]. Maternal mortality ratio (MMR) is 15 times higher in developing than in developed regions (16/100,000 live births) [5]. Sub-Saharan African countries (SSA) had the highest MMR 500 maternal deaths per 100,000 live births and current studies in Ethiopia showed that 46,000 mothers and 48 per 1,000 live births are died [6,7].
Study conducted in Brazil shows higher percent of women utilize postnatal care service more than many other developing counties, which is 77%. Study done in Shinyanga, India, rural district only 35% of women in the area visits health facilities for PNC services for at least once within 42 days [8]. In another study conducted in Tertiary Care Center of Delhi, Only 9.3% of women received postnatal care service after discharge from health institution [2]. In Kiambaa Sub County (75%), Bangladesh (73%), Nepal (72%) and Rwanda (71%) of women did not receive any PNC service. another Study from Tanzania indicated low utilization of maternal PNC services among women [9].
Study conducted in different area show that, factors like: Socio-demographic factors, (age, religion, occupation, education, Marital status, Family Income), Reproductive and Obstetric factors, like ANC follow up, Parity and gravidity, Prenatal follow up, delivery and post delivery related complications, mode of delivery, Advice and appointment on discharge significant association with PNC utilization [4,7,13,15,16].
Study done in Ruwanda show that older age of women was associated with low PNC utilization [17]. But in study conducted Bahi District (Tanzania), and Ethiopia (Lemo wereda, Dembecha, AbiAdi, Tigray and Holeta Town) maternal Age was not associated with PNC service utilization [5,8,11,18] Whereas studies conducted in Jijiga Town, Somali Regional State, Eastern Ethiopia, in Wolaita Zone, Southern Ethiopia, showed that young mothers were 3.5 times more likely to use antenatal and postnatal care service, Study done in Kenya show that marital status has no association with PNC service utilization [19]. But study in Ruwanda shows that, being married were associated with PNC utilization, that is similar with the result of study conducted in selected health centers, Addis Ababa, Ethiopia at (Entoto Fna Health Center, Gulele district) [4].
Whereas study in Tigray region, and in Jigjiga Town, Somali Regional State, Ethiopia, showed that marital status was highly significant association with utilization of maternity health service. This finding is similar with study conducted in Jabitena district, Amhara region [5,13].
In study conducted in India, maternal occupation has significant association with utilization of postnatal services [20]. Study conducted in Jabitena district and Assosa district showed that maternal occupation was not associated with PNC service [21].
Study from Ruwanda, Tanzania showed that economic status of women had statistically significant association with PNC utilization and Women from high income households were nearly 2 times more likely to use PNC services [22,23]. Study conducted in Gulele district, Addis Ababa and AbiAdi Tigray Region, showed that good income level of women were significantly associated with PNC utilization [4,18]. Study conducted in Delhi, Tanzania, Kenya, Uganda, and Indonesia and in Ethiopia (Gulele, in selected health center of Adiss Abeba, jabitna, Amhara rigion) shows that educational status of women was significantly association with PNC utilization [8,12,19,21,23].
A Community Based Mixed Study show that mothers who have good knowledge of postnatal care service utilization were more than 7 times more likely to utilize PNC service than those who have poor knowledge. Study conducted in Lemo distric of Hadiya zone, Debre Markos town, Jabitena District, Amhara Region showed that Knowledge on maternal complications during postnatal period were significantly associated with postnatal care service utilization [5]. In Gulele, Adiss Ababa, study showed that good Knowledge about postnatal care during antenatal care had significant effect on postnatal health care utilization, and knowing at least one danger sign of post-partum showed statistically significant association with postnatal health care service utilization [4,24]. Study in Tanzania and Kenya shows that Mothers who attended four or more ANC visits were more likely to use PNC services compared with mothers who did not attend ANC at all [14,23] And in Ethiopia, study conducted in Wolaita Zone, Southern Region, showed that, ANC service utilization at last pregnancy has shown statistically significant association [11]. In Gulele, Addis Ababa study shows, attending ANC had significant association on postnatal health care utilization [4]. Women who were getting antenatal and delivery care might have a positive association on the uptake of postnatal care which is similar with the studies conducted in Gondar Zuria district, Amhara region [7,14].
Study done in Lemo woreda shows, mothers who delivered by cesarean section were more likely to utilize PNC than mothers who delivered by spontaneous vaginal delivery (SVD) [5]. Similarly study in Debremarkos Town shows, mothers who delivered by cesarean section were 4.8 times more likely to get postnatal care services than mothers who delivered by SVD [24]. Study in selected Health center in Adiss Ababa, women who utilized PNC service in their previous delivery was more likely to utilized current PNC service [9]. The probability of utilizing postnatal care among women multigravida was decreased compared to Primegravid women [21].
In Lemo werda past history of maternal complication and PNC service utilization is significant, that is mothers who experienced obstetric problems during their last birth appear strongly motivated to seek postnatal care service [5]. Similarly in Debremarkos study conducted indicate that having delivery complication during child birth were 2.58 times more likely to utilize postnatal care services [24]. Study conducted In Abi Adi Town Tigry show that Last Year: Community Based Cross Sectional Study in Adama, Ethiopia mothers who know maternal postpartum period complications are more likely to have used postnatal care services [18]. Whereas in Jabitena district, mothers who had knowledge of at least one postpartum obstetric danger sign were 4 times more likely to utilize postnatal care service [21].
Place of delivery has also been an important role of postnatal care service utilization. Mothers who gave their last child birth in health institutions were about 4 times more likely to utilize postnatal care service [20]. Study conducted in Addis Ababa shows place of delivery of their last baby have significant association with utilization of PNC services [9,11]. Another studies, in Jibatena and Debre Markos, Amhara Region, shows that Mothers who gave birth their last child in health institutions were about 4 times and 1.68 times more likely to utilize postnatal care service respectively [21,24]. Study conducted in Debremarkos Town shows, live birth outcome were 2.7 times more likely to get postnatal care services than mothers who gave stillbirth [14].
Ethiopia is the second most populous country with over 100 million people [25]. And one of the poorest in Reproductive Health Service (RHS) levels as indicated by high rates of maternal morbidity and mortality. To address this problem, the country has had a significant expansion of health care facilities with more than 35,000 community health workers called Health Extension Workers (HEW) mainly engaged in maternal and child health activities [14]. Despite the Ethiopian government's effort to improve maternal health by increasing accessibility to health service but health service utilization is "unacceptably low" [26]. PNC coverage was limited to only 5% of the expected deliveries which was 4% less than Skilled Birth Attendants (SBA) coverage [13,27]. In this study, we tried to assess Postnatal Care Service Utilization and Associated Factors among Mothers Who Gave Birth in the Last One Year In Adama Town, Oromia, Ethiopia.

Study Area
The study was conducted in Adama Town, Oromia Region, Ethiopia, which is located 99 km Southeast of Addis Ababa, Ethiopia. Adama town has 14 urban and 4 rural kebeles. The town has a total population of 341,796, 170,842 (50%) males and 170,953 (50%) females, Adama Town has 1 government hospital, 7 government health centers, 4 private hospitals, 94 private clinics, 2 Non-Governmental RH clinics and 108 drug stores and Pharmacies. PNC service is being delivered in all hospitals, government health centers, and Non-Governmental clinics and MCH Special Private Clinics.

Study Design and Period
Community based cross-sectional study design was employed to determine the level of postnatal care service utilization and associated factors among mothers in Adama Town, Oromia Region, Ethiopia from October 1/2020 to December 30/2020.

Source Population
All women of reproductive age (15-49 years) who live in Adama town.

Study Population
All women of reproductive age (15 to 49 years), who gave birth in the last one year before the study period.

Inclusion Criteria
Mothers who gave birth within one year and who have voluntarily agreed to participate in the study were included.

Exclusion Criteria
Mothers who were not mentally capable of being giving information for interviewer and Mothers who gave birth to baby before one year were also excluded.

Sample Size Determination
The required sample size of this study was determined using single population proportion formula. Proportion of PNC utilization of 33.5% [24]. Margin of error, confidence level and non-response rate was assumed to be 4%, 95% and 5% respectively.
After adding a 5% non-response rate to determine the final sample size is 563 for the study.

Sampling Procedure
Cables were stratified into two (Urban and rural). Then, from all stratums a totals of seven Kebeles were randomly selected. The Sample size was allocated proportionally to each selected kebeles. The initial interviewed household was selected by simple Random Sampling from the kebele. The subsequent households were selected every 10 th household. In the case of no eligible woman identified in the selected household, the next household was visited. Whenever, more than one eligible respondent found in the same selected household only one respondent was chosen by lottery method to avoid intra household correlation. Revisits were made in case eligible respondents were not available at the time of the data collection. In the absence of child bearing woman in sampled household, interviewer interviewed a woman who lives in the next household.
Total participants allocated for each selected kebeles were calculated by the formula of n f = n/N × sample size, and gave that:

Data Collection Procedures (Instruments, Personnel, Measurements)
Structured and semi structured questionnaire was adapted after reviewing relevant studies. The questionnaire was prepared in English then translated into local languages (Afan Oromo and Amharic), then back to English in order to ensure its consistency. The final version of the questionnaire was used for data collection. Five university students were recruited as interviewers and two BSC Nurses were recruited as supervisors. Data collection was conducted by a face to face interview with women having less than one year's old child at the participant home.

Data Quality Assurance
Two days training was given for both data collectors and supervisors. To check the clarity and validity of the questionnaire and gap in data collection, Pre-test was conducted on 5% of the study population out of selected kebeles. Discussion was made based on the result of the pretest to make necessary corrections. During data collection the principal investigator & supervisors checked the data for its completeness, accuracy and clarity on daily bases.

Data Processing and Analysis
The questionnaire was checked for completeness, cleaned, coded and entered into epi-info version 7 and finally exported to SPSS version 20 software for analysis. Frequency table, proportion and numerical summary measures were used to describe the study variables. Bivariate logistic regression was used to see a significant association between the outcome and independent variables. The variables with p value of < 0.25 on bivariate analyses were taken to multivariable logistic regression to identify the independent predictors of PNC utilization. Collinearity and Assumption of goodness of fit were checked using Hoshmer and lemshow test. Finally, the model was built with backward elimination with 95% confidence level with its corresponding p-value < 0.05 and was considered statistically significant. To indicate strength of association, the odds ratio was used as a measure of effect and results from the multivariable logistic regression was reported in the form of adjusted odds ratios (AORs).

Socio-Demographic Characteristics of Participants
A total of 563 mothers of reproductive age who gave birth in the last one year prior to this study were interviewed with a 100% response rate. (36.9%) participants were at the age of 25-29 years with the mean age of the respondents was 28.00 (SD±5.01) years. Regarding the religion of study participants, 270 (48.0%) of them were orthodox, Concerning ethnic group 245 (43.5%) were Oromo in the area. Regarding to the marital status of respondents 469 (83.3%) was married. Concerning to educational status 186 (33.0%) was at the level of secondary school and participant husband's educational status, 158 (33.7%) were attended secondary school, regarding their Occupational status more than one-third 220 (39.1%) of respondents were Housewives and 182 (38.%). The respondent husbands were employed. (For detail description sees Table 1).

Reproductive and Obstetric Characteristics
More than half (68.1%) of respondents were multigravida and 518 (92.0%) of participants had at least one ANC follow up during their current birth. As to mode of delivery, Three-fourth (79.3%) of respondents delivered by spontaneous vertex delivery, followed by Cesarean section 104 (18.6%). Of mothers 552 (98.0%) gave birth to their last child in health institution. Regarding obstetric complication, less than one-fourth 116 (20.6%) of respondents experienced at least one complication after delivery. Regarding to advice and telling appointment date before discharge from health facility, 279 (50.3%) of respondents was advised about PNC service and more than 1/3 rd of mothers 200 (36.3%) were appointed to return back to PNC service ( Table 2).

Utilization of Postnatal Care Service Among Mothers
Of the total respondents 268 (47.6%) with (95% CI: 44.0, 51.8) mothers utilized postnatal care service. With regard to attending time of PNC only 12 (4.5%) of mothers use the PNC service within 48 hours and 200 (74.7%) mothers were visiting one time. Concerning source of information, the majority 177 (66.0%) of respondents got information from Mass midia (TV/Radio), followed by during ANC follow up 68 (25.4%) and others from their friends and rilatives 23 (8.6%). Overall, 295 (52.3%) of mothers did not use Postnatal care service at their last delivery. The reason explained by participants were, the majority 133 (45.1%) of them had lack of information on the importance of PNC service.

Attitude of Respondents About PNC Services Utilization
To asses mother`s attitude, a 5-point Likert scale type questions were prepared. Of the study respondents 347 (61.7%) were agreed that advice about PNC service should be provided during ANC follow up. About 288 (51.2%) of mothers agreed on PNC importance and that it can minimize morbidity and mortality of mothers and newborn. Regarding to the time of PNC service follow up 376 (66.8%) of mothers agreed to use PNC within 42 days, whereas, 53 (9.4%) were neutral whether the time is 42 days or not. The majority 411 (73.0%) of mothers has a positive attitude toward PNC utilization.

Respondent's Knowledge Level About Postnatal Care Utilization
More than half 297 (52.8%) of mothers have not heard information about PNC, and 331 (58.8%) mothers did know the correct time when to use PNC service. 318 (56.5%) of mothers know about the recommended number of PNC service follow up. Two third 341 (60.6%) of mothers did know the service provided during their postnatal period. From all PNC users, 198 (35.1%) had moderate knowledge, 261 (46.4%) low knowledge and the least 104 (18.5%) high knowledge.

Factors Associated with PNC Service Utilization
To identify the association of independent variables with dependent variable both bavariate and multi variable logistic regression analysis was used. The variables that had significant association to the dependent variables at P-values less than 0.25 were entered into multi variable logistic regression. Only four of them (Maternal Education, Mode of delivery, Appointment for PNC service and Respondents Knowledge about PNC service Utilization) has shown a statistically significant association at P<0.05.
Mothers who attend above secondary school were more than 2 times (AOR, 2.09; 95% CI: 1.09, 3.98) more likely to utilize postnatal care service compared to those having no formal education mothers. The odds of having postnatal care appointment date after delivery were 2.6 times (AOR, 2.55; 95% CI: 1.71, 3.82) more likely to use postnatal care service than their counterparts.
Similarly, those mothers who gave birth by cesarean section were 5 times (AOR, 4.87; 95% CI: 2.77, 8.57) more likely to utilize postnatal care service compared to mothers who gave birth by spontaneous vaginal delivery. Mothers having high Knowledge about PNC importance were 4 times (AOR, 4.07; 95% CI: 2.30, 7.22) more likely to utilize PNC service compared to those mothers who have low Knowledge.

Discussion
The result of this study shows that prevalence of PNC is 47.6% and factors like Maternal Education, Mode of delivery, PNC appointment and Mothers Knowledge showed significant association with PNC utilization.
The results of the current Study were relatively higher than the finding from study in Kenya (9.3%), and in Ethiopia (Somalia region (8.4%), Abi Adi (11.9%), Jabitena district (20.2%), Debre Markos Town, (33.5%) and in Denbecha (34.8%)) But lower than the finding from studies conducted in Tanzania (70.8%), and in Ethiopia (Lemo wereda (51.4%), Entoto fana Health center, Gulele sub city (76.2%), and Gondar Zuria district (66.8%) [4,5,7,[11][12][13][14]. This discrepancy may be due to educational status of the mothers, access to information/awareness of respondents to the use of postnatal care service. Maternal knowledge, counsel/advise and mothers who delivered in health institution to come back for postnatal care, maternal attitude have a positive effect on the importance of PNC service.
Maternal education has a strong positive association with PNC utilization. Mothers who attended secondary and above education were 2 times more likely to utilize PNC service as compared to those mothers who had no formal education. This finding was similar with study conducted in Tanzania and in Ethiopia; Gulele sub city, Addis Ababa, and Abi-Adi which shows that non educated mothers were (86%) and (95%) less likely to utilize PNC service respectively compared to educated women [4,18]. The result of current study was supported by the National survey and other studies report that, postnatal service utilization increases with women educational level [2, 4-6, 14, 18, 21]. This could be due to the fact that education has a valuable input in enhancing female autonomy and help develop greater concern about their health.
Utilization of postnatal care was significantly influenced by mode of delivery. Mothers who gave birth by cesarean section were 5 times more likely to get postnatal care service than mothers who delivered by spontaneous vaginal delivery. This is in line with study conducted in Debre Markos Town, Amhara Regional State, Ethiopia, in which mothers who delivered by cesarean section were 4.8 times more likely to get postnatal care service than who delivered by spontaneous vaginal delivery [24]. This might be due to fear of occurrence of complication and to prevent further complication which may result in increased care seeking behavior of the mothers. The other factor associated with PNC utilization was appointment date given to mothers after delivery by health professionals. Mothers who appointed for PNC service were 2 times more likely to use the PNC service than counterparts. The result of this study is similar with the study conducted in selected Health centers in Addis Ababa town which showed that, women who were appointed after institutional delivery were more than 3 times more likely to utilize PNC service than their counterparts [9]. This may be due to that health care professionals might have informed the mothers about the benefits of PNC.
In the current study, mothers who have high Knowledge about postnatal care service and its importance were 4 times more likely to utilize the service. This result is in line with the study conducted in Debre Markos Town, Amhara, Abi Adi Town, Tigray and Wolayita Zone, Southern Ethiopian [11,18,24]. This can be explained by the fact that women having information, knowledge about the importance of PNC service, the service provided and the recommended time for PNC follow up may has high PNC services utilization seeking behavior.

Strength
Training was given for data collectors and supervisors. Primary data were collected by trained female data collectors.
New data collected by face to face interview. Since the study was community based, the result of this study can be generalized to the general population.

Limitation
The study design was cross-sectional, hence, the cause and effect relationship of variables were difficult to ascertain and it may not able to establish a temporal relationship.
Finally, recall bias was more likely since women were asked for events which have already happened within the past one year prior to this study.

Conclusion
The finding of this study indicated that PNC service utilization is still low, because more than 50% of women are not utilizing PNC service. Factors like Maternal Education, Mode of delivery, PNC appointment, Mothers Knowledge were found independent predictors of PNC utilization. Low utilization of PNC may contribute to increased maternal morbidity and mortality which is high in our country.

Recommendations
Government and stakeholders should work hard on increasing knowledge of community on the benefits of PNC service, Strengthen the provision of information, education and communication about postnatal care service.
All health care providers should encourage and provide post-delivery appointment for PNC service for all mothers.
Health workers should give attention to women who give birth by spontaneous vaginal delivery. Because mothers who give birth by SVD may assume that all the delivery process is normal, nothing can be occurred. But this may not be true always. Post-delivery problems may occur within 42 days. Therefore, attention should be given to mothers who give birth by SVD.

Ethical Considerations
Ethical clearance was obtained from the Institutional Review Board of Adama Hospital Medical College. Permission and supportive letters were received from the Adama Town Health Bureau and verbal consent was obtained from each respondent before an interview after informing the purpose and importance of the study, each participant was given full right to refuse/ to reply and discontinue the interview if any inconvenience or if she or He was not comfortable about the questionnaire. Confidentiality was assured throughout the study period. Personal identifiers were not included in the questionnaires to ensure participants' confidentiality.

Consent for Publication
Not applicable.

Availability of Data and Material
All data sets used and/or analyzed during the current study are available from the corresponding authors on reasonable request.