Introduction

Maternal complications resulted from child birth and lack of postnatal care service utilization do have their own significant figure to bring maternal deaths globally [1]. Health of women in reproductive age group depicts the indicator for unequal awareness for women between developed and developing countries. The death of women due to complicated pregnancy or child birth in developed and developing country shows a great difference as it has been quantified as 1 in 7 and 1 in 30, 000 deaths respectively [1,2].

In the recent last few years, greater attentions have been given for the health of women worldwide. The thematic areas for maternal health improvement have been planned in relation with Sustainable Development Goal (SDG) and targets to work with concerned bodies and other stake holders so as to reduce reproductive related problems and deaths among eligible women [3]. Newborn current health and feature health condition is highly related to the maternal health status and in each year, nearly 4 million newborns passed away before cerebrating their birth date of first month, indicating almost 40% of total deaths of under-five year children [4,5].

Almost all of these infant deaths occur in developing countries, with the highest number in far East countries like south Asia and the highest prevalence in sub-Saharan Africa. About 80% of loss of life for reproductive age group women in the world are contributed by inter-related causes such as preeclampsia, eclampsia, infections, obstructed labor and unsafe abortions [5,6].

A minimum of three postnatal care visits should be made regardless of any type of problems faced for both newborns and mothers to prevent further complications which may occur. The recommended time for both maternal and newborn care could be on day 3, between 1-2 weeks, and six weeks after giving birth. With regard to Federal Ministry of Health in Ethiopia put its own recommendation times, which suggests 6-24 hours, 3 days, 7 days and 6 weeks for postnatal care service utilization for both women and their off springs. The situation of health in the community can be determined in relation with the health status of women who are found in the society. Focusing on postnatal care service utilization should be considered as one of the most crucial maternal health care issue to prevent any type of negative impacts and challenges resulting from childbirth [7-9].

Being unable to get postnatal care during the recommended time intervals may bring unwanted outcomes like death or other health problems as well as missed opportunities to come with healthy behaviors, affecting women, newborns and later while children [10]. Most of mothers suffer with severe illness every year, related with reproduction and unspecified number of women are suffered with prolonged discomfort and disabilities. Types of outcomes with lack of postnatal care can include prolonged pain or discomfort, unable to move temporary or permanent effect on the organs of reproductive system or losing a chance for feature pregnancy or child bearing. Some of bad habits like gentile mutilation in some societies may also a major contributor for very dangers complication of women during child birth [11].

Severe obstetric bleeding is the dominant factor for the death of women regardless of developed and undeveloped countries. Post partum hemorrhage is highly fatal unless the management is taken on time [12]. Relatively higher number of infant and maternal death occurs within 48 hours after childbirth so that giving attention in these two days after childbirth is very important to manage any types of childbirth related complications. Therefore; attaining postnatal care is very mandatory for community health in general and maternal and infant health in particular. Taking care after delivery is unquestionable to catch up information in addition to reproductive health related issues like healthy life style behaviors and other issues especially non-communicable disease, becoming basic public health problems today in the world [13].

The World Health Organization (WHO) described that taking care after childbirth can be described as a service provided to the mother and her infant as soon as finishing the birth of the placenta and for the first consecutive six weeks after giving birth [14]. It is necessary because in this time the reproductive organs return to their pre-gravid state and lactation is started, the mother returns from the physical and emotional stress of Labor and the family makes away to the new baby [15].

Post-natal care services are to help or to ensure both maternal and new child to be healthy in the community in which they are going to be joint. Consultation, prevention, early diagnose and treating complications of the mother and newborn, referring the mother and new born for skilled personnel if any problem happens, helps to prevent any types of problems which may occur [15]. Visiting higher health institutions when it is above the capacities of the facilities which is found nearby of service users, counseling women about new born care, giving health education on how to breast feed, women food consumption, provide contraception service, counseling on the benefits of timely provision of immunization for the child are key components to be effective for health service providers. In the situations of limited resource, conducting discussion with the health care system program managers if possible within one day and if not within the first week after delivery can be used for making strategic plans to get expected outcomes later on [16].

This period is almost neglected in developing countries, mothers and newborn infants have no chance for Postnatal Care Services (PNC) from trained health care professionals in the recent time as it has been specified by WHO after delivery [17]. In the case of civilized nations actually majority of women and their newborns get postnatal care services but the pattern and time to take the service variation exists accordingly [17].

However, in uncivilized nations even the interest to take a care and to be counseled and advised after having birth was very poor and nearly 30% of mothers in North Eastern African countries get birth in health organizations, and very less number of women attend PNC service within the time intervals of 24 hours after giving child birth. Wherever mothers give birth within their home or in organized health facility, the services for postnatal care are often neglected. On the contrary, the availability of the health facilities alone may not be effective unless it fulfils all necessary equipments for the provision of the services for both newborn and maternal care [18,19]. Very few number of women, about 7% attended for postnatal care service utilization within 24 hours after their delivery as it has been recommended by WHO while half (51.5%) of them in Addis Ababa had ever used postnatal car services [20].

Therefore, it is important to make additional studies to describe the magnitude and associated factors of low level of postnatal care service utilization [21]. To sum up, the identification and prioritizing of factors affecting to have postnatal care service on reproductive age group women who had live birth in the recent last two years is necessary to have a feasible plan for feature improvement of postnatal care service utilization. It is hoped that assessing the prevalence of postnatal care service utilization status of women within the study area, will help to take immediate action and to promote care for planners, policy makers and stake holders for understanding on the issue as well as to serve as an important tool for possible interventions at individual, family, and community levels as well as the study area in particular, and the region in general. The study will also be used as a baseline data for researchers who want to conduct on the similar studies and this study has answered the following research questions what is the current prevalence of PNC service utilization? And what are the factors affecting to get PNC service utilization among the study participants?.

Methods

Study design, Area and Period

Cross-sectional type of study design was conducted on the community of selected kebeles. The study was conducted in Womberma woreda, West, Gojjam Zone, Amhara, Regional State, Ethiopia. The woreda has a total of 20 kebeles, one urban and ninety rural. The Woreda is located at a distance of 427 km from Addis Ababa, the capital city of Ethiopia and 172 km from Bahir Dar, which is the capital city of Amhara region and the study was conducted in April 2017.

Eligibility Criteria

All women who have live births in the recent last two years were the source populations for this study. Women who gave birth in the recent last two years and who resided in the area for six or more months before the study carried out were included. Mothers who have live births in the recent last two years and who were critically ill during the study period were excluded from the study.

Sample Size determination and Sampling Techniques

The sample size was determined by applying single population proportion formula and by assuming the prevalence of postnatal care service utilization among women in rural communities by taking 18% of prevalence rate of PNC service utilization EMDHS, considering a maximum margin of error as 5% in the study and at 95% CI, the sample size calculated was 500, with the study participants non-response rate of 10% and due to its multistage sampling nature of the study the design effect was considered and taken the numerical values of 2.

n= (1.96)²x0.18x0.82 = 227+22.7=249.7

     (0.05)²

To explain each:

z = Z value related with 95% level of significance = 1.96

p = prevalence rate for mothers who utilize PNC = 18% =0.18

d = margin of error or precession= (5%)

n= total sample size=

 (1.96)² x0.18x0.82 =227+22.7=249.7=250x2=500

  (0.05)²

Design effect₌₂

Study Variables

The outcome variable of the finding was Postnatal Care Service Utilization and its Associated factors. The independent variables were Socio-demographic variables like age, religion, educational level of mother, occupation of mother, current marital status, educational level of a husband, occupation of husband, ethnicity, Reproduction related variables like obstetric complication, postpartum complication, gravidity, parity, length of stay at health facility after delivery, previous history of PNC service, number of alive child, ANC service utilization. Health facility related variables like delivery attaining, place of delivery, advice on discharge.

Sampling Procedure

The eligible respondents for the study were selected by applying simple random sampling technique. In the woreda number of total kebeles were 20, one urban and nineteen rural kebeles, among these, five kebeles were selected by lottery method or by giving equal chance to be selected at stage one but all of these selected kebeles were from rural areas. At stage two (among 29,588 woreda households,4922 households have mothers who have live births in the recent last two years. From those households, 1478 households in selected kebeles who have live births in the recent last two years were enrolled using Health Extension Family folder registration books. Then at stage three 500 mothers who have live births in the recent last two years were selected using simple random sampling technique and proportional allocation to size to each kebeles. The mothers who have live birth in the recent past two years, before this study were interviewed. Per each household, one woman was participated in the study and three visits were made for absences in the first visits (Figure 1).

Data Collection Methods

Since our study was quantitative, closed ended written questionnaire formats were used for data collection. Data were collected by twelve health professionals in the woreda. Training on the standard procedures and the technique and the approaches they should follow during the data collections were well explained for them. The contents on questionnaires were briefly described to reduce interviewer bias. Each woman who promoted the eligibility criteria in the study area for data collection, would have their own codes. The questionnaires were filled side by side as the interviewing Process was going on.

Data Processing and Analysis

After giving unique code for each created template, the data were entered by the principal investigator by using Epi-data version 3.1 software. When the entry had been completed the data were exported in to SPSS version 20 software for further analysis. Missed values and outliers were checked by using frequencies. The identified errors from frequency distribution were revised by referring the pre-coded document. Frequencies, mean and standard deviations were computed for describing of the study population in terms of their socio-demographic and other explanatory variables.

Significance values for p values corresponding with crude and adjusted odds ratios with 95% confidence intervals were determined. To identify whether the association exists or not between the different predictor variables and outcome variables, first binary relationships between each independent variable and outcome variable was investigated, by using a binary logistic regression model to control confounders. Factors with a p-value <0.2 in binary logistic regression analysis were further taken into multiple variable logistic regression model analysis. Odds Ratio (OR) was used as a measure of association for the pre-determined study design and p-values < 0.05 was taken as statistically significant. The results were presented in the form of texts, tables and figures accordingly.

Ethical Approval

This study was done after it had been approved by Debre Markos University Medicine and health sciences organized ethical review committee and permission was obtained from Womberma woreda administrative health office. All the study participants were told about the aim of the study and finally their full voluntariness was made to be sure before starting the interview. If there were any complains among the study participants during interview, their rights were made sure to terminate the interview.

Results

Socio-demographic Variables

The total number of participants included in this study were 500 with their response rate of 97% in selected 5 kebeles of womberma woreda. Less than half of the respondents196 (39.2%) belong to the age group of 25-34 years and 158(31.6%) belong to the age group of 15-24 years and 146(29.2%) were > 34 years. The mean age with the standard deviations (± SD) of study participants was 29.51 ± 7.53 years. With regard to religion majority of them 456(91.2%) were orthodox Christians, 35(7%) Muslims and 9(1.8%) were protestants. With regard to educational level 241(48.2%) of respondents were, unable to read and write, 144(22.8%) able to read and write 50(10%) elementary and secondary school and 18(3.6%) were preparatory school 27(5.4%) were college and above. With regard to occupation 208(41.6%) were house wife, 223(44.6%) were farmers, 34(6.8%) were students 28(5.6%) were government employee and 7(1.4%) were private employee (table1).

Reproductive Health Related Variables

About 424(84.6%) of respondents had not experienced history of abortion, the rest 76(15.4%) had experienced history of abortion up to our study period. About 433(86.6%) of the respondent had ≤5 pregnancies and 67(13.4%) had >5 pregnancies up to our study period. More than 3/4^th407(81.4%)had ≤4 live births and 93(18.6%) had >4 live births up to our study period. About 298(59.6%) had planned and supported deliveries whereas 139(27.8%) had not planned and supported and 63(12.6%) had not planned and not supported deliveries. Among the respondents who had ANC visits were 363(72.6%) and those who had not got ANC visits were 137(27.4%). Nearly 3/4^ths 396(79.1%) respondents had no complication during delivery whereas about 104(20.9%) had complications during their delivery (table 2).

Factors Associated with Postnatal Care Service Utilization

Factors with a p-value <0.2 in the binary logistic regression analysis, number of pregnancy, number of total live birth, history of utilizing PNC service, time for family planning utilization after delivery, history of utilizing ANC service and number of ANC visits made were entered into the multiple variable logistic regression analysis to control for potential confounders. Number of pregnancy [AOR(95%CI) =0.299(0.113,0.788)], Time of FP utilization after delivery of [AOR(95%CI) =3.42(1.031,11.41)] and PNC service utilization in previous delivery [AOR(95%CI) =2.75(1.185,6.425)] were significantly associated factors with postnatal care service utilization of study participants when it was further analyzed with multiple logistic regression (table 3).

Discussion

This study was conducted to determine the postnatal care service utilization of the study participants. Poor postnatal care service utilization and postnatal care related health problems highly influence the health of a huge number of women in the world [22]. The studies which was done in Lemo woreda of Ethiopia showed that the determined prevalence of postnatal care services utilization during that study period was 51.4%. The reasons described for not getting postnatal care services in that area were lack of knowledge on benefits of postnatal care (59%), due to being busy on other household activities (38.6%) and due to socio-cultural activities being practiced during postnatal period (20.4%). But this study revealed that the prevalence for utilizing postnatal care service was 16% in the study area, particularly in womberma woreda, which is low as compared with the studies done in Lemo woreda of Ethiopia though, it was relatively good as compared with other countries [23]. The little discrepancy between this study and EDHS of 2011 may be related to the sampling techniques used in this study or variations in the study methods from place to place, which may need further investigation and in addition to this, sources of population at which the sample was taken would be contributing factors for this slight difference [21,24,26].

A study done in Nepal revealed that 43.2% described receiving postnatal care within the first six weeks of child birth, while 40.9% described as they have attended postnatal care services following their child birth as soon as possible. While a study done in Brazil found that higher number of postnatal care utilization than many other developing counties which is 77% [24]. The reason for this discrepancy between each country may be due to socioeconomic development, and political attention differences in relation with maternal health and postnatal care service utilizations of the whole women at reproductive age group (15-49) [13,17,21]. The 2011 Ethiopian national DHS data found that the prevalence of postnatal care coverage is lower in Ethiopia. The large number of women accounting (92%) with a live birth in the recent last five years did not get a postnatal service care. From women who got a postnatal care services, about 4% had examined within the first 4 hours of child birth, 2% had taken PNC within 4-23 hours, 1% and 2% within 1-2 days and 3-41 days following their delivery respectively. The total of 7% women had attended postnatal care services within two days of delivery as the studied document has shown [25].

A study done in Nepal showed that mothers who were living in the urban areas, from wealthy families who had a good educational level, whose partners had attended formal education, who give child birth in a health facility, who had taken ≥4 antenatal visits, and whose delivery was attended by a skilled health professional were more likely to report attending at least one postnatal care visit [27]. While a study done in Brazil found that women with lower income, those with lower level of education, mothers living alone or without their husbands, women who delivered vaginally and those who were not helped by skilled health professionals, were less likely to receive postnatal care [28].

According to this study number of pregnancy, previous history of postnatal care and time for starting family planning after delivery were factors which were significantly associated with utilization of postnatal care services. Women who had taken postnatal care service utilization were 71% less likely to have >5 pregnancies in this study than those who do not attained postnatal care service utilization. The reason for this may be those who have postnatal care may be more knowledgeable than those who do not attain postnatal care service. Women who have knowledge or experience of postnatal care service utilization in their previous delivery were 2.75 times more likely to attain postnatal care service utilization for their current delivery. The reason for this maybe they may be thought by health professionals about the benefits of postnatal care to have updated information throughout their life. The study participants who have frequent postnatal care service utilization were 3.42 times more likely to come for family planning at the time of less than or equal to one year (≤1) than those who do not attain postnatal care service utilization and who come more than one-year period for their family planning after delivery. Factors which were found in our study were different from other studies, this may be due to differences in the study types and sampling techniques which are done in different places accordingly [24,31,33].

A study on the assessment of variables affecting postnatal care services was conducted in Western Gojjam district, Amhara regional state and found that among the socio demographic factors, the key predictor for PNC utilization was educational status of the respondents. A participant whose level of education was secondary school and above showed better utilization of PNC service as compared with women who cannot read and write [29]. The major factor predicting postnatal care service utilization was place of delivery. Mothers who delivered their last baby in health institution utilized PNC services when compared with those who delivered at home, mothers who decided by themselves utilized PNC services as compared to those who did not decide by themselves. In addition to these, mothers who had exposure at least for one postpartum obstetric danger sign were utilizing PNC service as compared to those who were not ever exposed for postpartum obstetric danger signs [30,31,34].

Conclusion

The prevalence of postnatal care service utilization was still poor as compared to previous studies. Previous history of postnatal care service utilization, number of pregnancies and time to attained family planning after delivery were significantly associated with postnatal care service utilization of the study participants. The factors associated with postnatal care service utilization were closely related to obstetric characteristic variables of this study. Low coverage of postnatal care service utilization is the single greatest threat to the public health. To overcome this problem the following recommendations are forwarded. Especial attention should be given for postnatal care education, particularly for women who belong to the age group of 15-49 years. Community based discussion by focusing on postnatal care issues should be strengthen. Gender equality should be practiced to reduce work load of women and so as to allow women to have postnatal care services on time. Agricultural, educational and health sectors in collaboration should focus on practices of trained staffs, because there were lower commitments and practices among trained staffs to intervene the problem of low coverage of PNC in the community. Health extension workers should focus on encouraging good practices of women for postnatal care services. Urgent action is needed to tackle lower attitude of women for postnatal care service utilization.

Acknowledgments

We would like to acknowledge Debre Markos University, College of Medicine and Health Sciences, Wombwrma Woreda district health office, supervisors, data collectors and the study participants.

Availability of Data

The datasets used during the current study are available from the corresponding author on reasonable request.

Authors’ Contribution

Belachew Golla, participated in study design selection, data collection activities, data analysis and interpretation. Sileshi Berihun, Mekuanint Taddele and Yihalem Abebe also participated in data analysis, interpretation and drafting the manuscript.

Conflict of Interests

The authors declare that they have no competing interests.

Figure 1:  Presentation of sampling procedure.

Table 1: Socio-demographic varibles by percentage distribution of the study participants Womberma woreda, West Gojjam Zone, North West Ethiopia ,2017.

Table 2: Reproductive related variables of the study participants in Womberma Woreda, West Gojjam Zone, North West Ethiopia ,2017.

Table 3: Factors associated with postnatal care service utilization among women, result from logistic regression analyses, womberma woreda, West Gojjam Zone, North West Ethiopia, 2017.

1. Central Statistical Agency [Ethiopia] and ICF International (2012) Ethiopian Demographic and Health Survey2011.Addis Ababa, Ethiopia and Calverton, Maryland, USA: Central statistical Agency and ICF international.
2. Fikrewold H, Daniel S (2010) Demographic and health research DHS working papers.
3. Federal Democratic Republic of Ethiopia (2008) population census commission. Summary and statistical report of population and housing census.
4. Nigatu D, Gebremariam A, Abera M, Deribe K (2014) Factors associated with women’s autonomy regarding maternal and child health care utilization in bale zone. BMC women’s health 2: 18-22.
5. Kalkidan B (2007) cultural practices that affect the status of women in Beneshangul Gumze, mandura woreda. Addis Ababa University 1: 37-38.
6. Aregay A, Alemayehu M, Assefa H, Wondeweson W (2014) Factors associated with maternal health care services in Enderta District, Tigray, Northern Ethiopia: A cross sectional study. American Journal of Nursing Science 6: 117-125.
7. Araya M, Mark S, Yohannes K, Kifle Y, Schaay N, Sanders D, Blanco R, et al. (2012) The role of health extension workers in improving utilization of maternal health services. BMC Health Services Research 12: 6-7.
8. Koblinsky M (2012) Reducing maternal mortality and increasing use of skilled birth attendance. Ethiopian Journal of Reproductive Health, 4: 9-10.
9. United Nations General Assembly (2001) Road Map toward the Implementation of the United Nations Millennium Declaration: Report of the Secretary General. New York: United Nations.
10. Sines E, Syed U, Wall S, Worley H (2007) Save the children. Postnatal Care a Critical Opportunity to Save Mothers.
11. Central Statistical Agency (2011) Ethiopia Demographic and Health Survey: Addis Ababa: Central statistical agency.
12. World health organization (2005) Make every mother and child count. Switzerland: World Health Organization.
13. Save the children (2012) Postnatal Care: A Critical Opportunity to Save Mothers and Newborns. Washington, DC; population reference bureau.
14. United Nations Children’s Fund (UNICEF) (2009) Maternal and Newborn Health where do westand: New York, Unicef.
15. Fort AL, Kothari MT, Abderrahim N (2006) Postpartum Care: Levels and Determinants in Developing Countries. In DHS Comparative Reports No 15 Calverton, Maryland USA: Macro International Inc.
16. Khanal V, Adhikari M, Karkee R, Gavidia T (2014) Factors associated with the utilization of postnatal care services among the mothers of Nepal: analysis of Nepal Demographic and Health Survey 2011. BMC Women's Health 14: 19.
17. Matijasevich A, Santos S, Silveira M, Domingues M, Barros A et al. (2009) Inequities in maternal postnatal visits among public and private patients: 2004 Pelotas cohort study. BMC Public Health.
18. Gebeyehu Y, Desta W, Hailu A (2014) Factors Affecting Utilization of Postnatal Care Service in Jabitena District, Amhara Region, Ethiopia. Science Journal of Public Health 2: 169-176.
19. World Health Organization (2010) WHO Technical Consultation on Postpartum and Postnatal Care. Geneva: WHO.
20. Central Statistical Agency[Ethiopia] (2014) Ethiopia mini Demographic and Health survey, 2014. Addis Ababa, Ethiopia.
21. Low P, Paterson J, Wouldes T, Carter S, Williams M, et al. (2005) Factors affecting antenatal care attendance by mothers of Pacific infants living in New Zealand. The New Zealand Medical Journal Pg No: 118.
22. Beeckman K, Louckx F, Putman K (2011) Predisposing, enabling and pregnancy-related determinants of late initiation of prenatal care. Maternal and Child Health Journal 15: 1067-1075.
23. Adekunle C, Filippi V, Graham W, Onyemunwa P, Udjo E (1990) Patterns of maternity care among women in Ondo States, Nigeria. Determinants of health and mortality in Africa, Demographic and Health Survey Further Analysis Series, New York: The Population Council 10: 1-45.
24. Mekonnen Y, Mekonnen A (2003) Factors influencing the use of maternal healthcare Services in Ethiopia. J Health Popul Nutr 21: 374-382.
25. Mekonnen Y (2003) Patterns of maternity care service utilization in Southern Ethiopia Evidence from a community and family survey. Ethiop J Health Dev 17: 27-33.
26. WHO (2007) Maternal mortality in (2005) estimates developed by WHO, UNICEF, UNFPA, and the World Bank Geneva WHO 15: 1-4.
27. Friberg IK, Kinney MV, Lawn JE, Kerber KJ, Odubanjo MO, et al. (2010) Sub-Saharan Africa’s mothers, newborns, and children: how many lives could be saved with targeted health interventions?. PLoS Med 21: 7.
28. Stella B, Adesegun F (2009) Determinants of use of maternal health services in Nigeria-looking beyond individual and household factors. Pregnancy and Childbirth. Pg No: 9.
29. Zeine A, Mirkuzie W, Shimeles O (2010) Factors Influencing Antenatal Care Service Utilization in Hadiya Zone. Ethiop j Health Sci 20: 77-79.
30. Yarede M, Asnakech M (2002) Utilization of maternal health services in Ethiopia. Ethiopia health and nutrient institute; Calverton, Maryland, USA.
31. Jose L, Ruth G, Valentín H, Angel G (2013) Factors Associated with Maternal Mortality in Sub-Saharan Africa. BMC Public Health. Pg No: 9.
32. Burchett H, Mayhew S (2009) Maternal mortality in low-income countries: what interventions have been evaluated and how should the evidence base be developed further?. Int J Gynaecol Obstet 105: 78-81.
33. Regassa N (2001) Antenatal and postnatal care service utilization in southern Ethiopia: a population-based study. Afr Health Sci 11: 390-397.
34. Singh PK, Rai RK, Alagarajan M, Singh L (2012) Determinants of Maternity Care Services Utilization among Married Adolescents in Rural India. PLoS ONE 7: 31666.