Determinants of postnatal care utilization in Tigray, Northern Ethiopia: A community based cross-sectional study

Introduction

The developing world has the highest prevalence of maternal and infant morbidity and mortality. Almost all (99%) of maternal and neonatal deaths occur in developing countries [1,2]. Most maternal and infant deaths occur in the first six weeks after childbirth [3, 4].

Neonates account for an increasing share of child deaths, reaching almost half (45%] of the burden of under-five mortality [3]. The postnatal period (the time just after delivery and through the first six weeks of life] is especially critical for newborns and mothers [5].

In low income countries, almost 40% of women experience complications after delivery and an estimated 15% develop potentially life-threatening problems [6]. Ethiopia, one of the countries in sub-Saharan Africa, is among the six countries that contribute to approximately 50% of the maternal deaths worldwide [7]. Ethiopia has a maternal mortality rate of 412 per 100,000 and an infant mortality rate of 48 per 1000 live births [8].

Postnatal care service is a fundamental element of the continuum of essential maternity care–which also includes antenatal care and skilled birth attendance. These three elements have been demonstrated to decrease maternal and neonatal morbidity and mortality in low- and middle-income countries, particularly when all three elements are available and utilized [9, 10]. However, the provision of skilled postnatal care is relatively poor compared with that given before and during childbirth[11]. Increasing access and utilization of postnatal care has been identified as a priority in prior research [12]. In Ethiopia, while approximately 62% of women received antenatal care from a skilled provider, only 7% received the recommended postnatal care within two days of delivery, the time identified by Safe Motherhood programs as critical for complication recognition [8].

Provision of postnatal care, using the World Health Organization (WHO) recommendations, includes four visits: within 24 hours of birth, two to three days, six to seven days, and at six weeks [11]. Low birth weight (LBW) infants, as well as HIV-positive mothers, require an extra two or three visits. Lack of appropriate care during this period could result in significant ill health and even death as most maternal and infant deaths occur during this time period [11]. Therefore, the purpose of this research project was to determine the factors associated with postnatal care utilization among women in the Tigray region of Ethiopia in an effort to inform future initiatives seeking to increase postnatal care utilization.

Materials and methods

We defined postnatal care as a woman and newborn receiving care from a nurse, midwife, or physician. While care provision by a health extension worker does have value, these workers may not have the equipment or skill necessary to measure important factors such as blood pressure or newborn weight.

Results

Discussion

Among women in the Tigray region of Ethiopia, only 8% received postnatal care within six weeks of delivery. Women were more likely to receive postnatal services if they knew about the services, lived in an urban area, had greater than a secondary education, had a cesarean birth, had at least four antenatal visits, and if the pregnancy was wanted. Our findings show an even lower proportion of women obtained postnatal care compared to previous studies done in Ethiopia. Estimates of postnatal care following delivery in prior studies range from 20.2% to 66.8% [8,17–20,21]. A possible explanation for the low attendance at postnatal care in Tigray could be that we only considered postnatal services given by skilled health professionals, whereas the comparative studies considered care given both by health extension workers and healthcare professionals. Additionally, it could be that in Tigray there is less value placed on postnatal care by the women, families and their healthcare providers.

About a quarter (385) of participants delivered at home. This is lower than previous studies done in other parts of Ethiopia. In West Shewa, Oromiya Region 85.6% reported a home delivery [18], while in Northwest Ethiopia 68.6% of women had home deliveries [20]. This decrease in births occurring outside the health facility could be due to recent efforts to use frontline extension workers to educate communities on the availability of health services provided by the government. However, there is question on if the same outreach is emphasizing the importance of postnatal care. In addition, in Tigray there is organized community health support women developmental army (representative of women who works mobilizing health of the community) and the linkage between this group and health extension to link the women to health facility delivery.

Approximately 90% of the mothers in our study received ANC services during their pregnancy, which is higher compared with a study done in Northwest Ethiopia which revealed that 76.6% of women received ANC service during their last pregnancy [20]. The possible explanation for this could be due to the well-organized women developmental army that works in health promotion in Tigray. What is concerning, is that despite the higher percentage of women attending antenatal care, so few women returned for postnatal care, suggesting that not enough emphasis is being placed on the importance of postnatal care. Mothers who attended four or more ANC visits were more likely to attend postnatal care, results similar to those reported in a study of postnatal care attendance in Amhara Region, Ethiopia[22]. Additionally, use of postnatal care was higher among women who had experienced problems during their delivery and/or mothers who had a cesarean birth, similar to a prior study in Northwestern Ethiopia [23].

The pattern of postnatal care usage is consistent with previous studies. Of all the participants who attended postnatal care, about 38% of them attended within 4–24 hours after delivery. This is similar to a study in Northwest Ethiopia where 34% of women who attended postnatal care visits attended early postnatal care [20]. Similar to other studies in both Ethiopia [20] and other countries [24], many women did not utilize postnatal services because they were not aware that the services existed, nor did they know the benefits.

Cultural practices have been associated with non-utilization of postnatal care in studies conducted in rural, China [24] and Bangladesh [25]. In this study only a small percentage (7.7%) of women indicated cultural beliefs such as postnatal mothers do not go outside before 12–45 days as a barrier to seeking postnatal care.

Socioeconomic factors influenced the likelihood of using postnatal care services. The mothers who completed at least a secondary education were more likely to utilize postnatal care services then women who had not. This is similar to findings of a study done in Jabitena District in Ethiopia [17]. Employment in mothers was significantly associated with postnatal care service utilization. The finding is similar to the findings in Northwest Ethiopia [17) and Nepal [24]. Women were also more likely to receive postnatal services if they lived in an urban area; consistent with a study in Ethiopia’s Amhara region, where urban residence was associated with postnatal care utilization [20]. Similar to findings of a study done in the Jabitena district, Amhara region, Ethiopia [17], we found that education about postpartum health or the benefits of postnatal care impacted use of services.

A significant and concerning finding was that a number of women reported disrespectful maternity care, being treated roughly or being shouted as a reason for not returning for postnatal care. Respectful maternity care is not only a basic human right, when healthcare providers are disrespectful it can result in sub-optimal healthcare utilization [25].

Limitations

The largest limitation of this study is that it was a cross-sectional study. The primary limitation of the cross-sectional study design is that because the exposure and outcome are simultaneously assessed, there is generally no evidence of a temporal relationship between exposure and outcome. Additionally, this study relied on self-report of the women rather than healthcare records of obstetric variables and postnatal care attendance. Lastly, participants were from one area in Ethiopia, therefore the findings from this study are not generalizable to other parts of Ethiopia or sub-Saharan Africa.

Conclusion and recommendation

Although the care given during the postpartum period is very important in preventing maternal and neonatal morbidity and mortality, postnatal care service utilization is very low in the Tigray region. Targeted interventions seeking to address this concern should be multifaceted and include both improving awareness about the need for postnatal care service and training of healthcare providers to provide respectful, quality care during pregnancy, labor, birth and beyond so that women are not deterred from seeking care during the postnatal period. Endeavors to increase awareness of the importance of postnatal care should be targeted not only to women, but also families and healthcare providers. Awareness should include information and education provided during prenatal care and prior to discharge following birth. More emphasis should be placed on the importance, as well as the components, of postnatal care in pre-service healthcare educational programs and continuing education with midwives, nurses and physicians. Further research should include the perspective of health care providers regarding the barriers to providing postnatal care to mothers. In addition, health extensions workers should focus educational efforts on the importance of care given during the postnatal period as well as during the pregnancy and birth.