Postnatal care utilization among urban women in northern Ethiopia: cross-sectional survey

Postnatal care utilization among urban women in northern Ethiopia: cross-sectional survey Background: Postnatal care service enables health professionals to identify post-delivery problems including potential complications for the mother with her baby and to provide treatments promptly. In Ethiopia, postnatal care service is made accessible to all women for free however the utilization of the service is very low. This study assessed the utilization of postnatal care services of urban women and the factors associated in public health facilities in Mekelle city, Tigrai Region, Northern Ethiopia. Methods: A facility based cross sectional study design was used to assess post natal service utilization. Using simple random sampling 367 women who visited maternal and child health clinics in Mekelle city for postnatal care services during January 27 to April 2014 were selected. Data was entered and analyzed using SPSS Version 20.0 software. A binary and multivariable logistic regression was used to identify risk factors associated with the outcome variables. P-value less than 0.05 is used to declare statistical significance. Results: The prevalence of women who utilized postnatal care service was low (32.2%). Women who were private employees and business women were more likely to utilize postnatal care services (AOR = 6.46, 95% CI: 1.91–21.86) and (3.35, 95% CI: 1.10–10.19) respectively compared to house wives., Women who had history of one pregnancy were more likely to utilize the service (AOR = 3.19, 95% CI: 1.06–9.57) compared to women who had history of four and above pregnancies. Women who had knowledge of postnatal care service were also more likely to utilize postnatal care service (AOR = 14.46, 95% CI: 7.55–27.75) than women who lacked knowledge about the services. Conclusions: Postnatal care utilization in the study area is low. Knowledge on postnatal care services and occupation of women had positive impact on postnatal care service utilization. The Mekelle city administration health office and other stakeholders should support and encourage urban health extension workers and health facilities to strengthen providing health education to improve the knowledge of the women about the importance of postnatal care services. Keywords: Postnatal care, Utilization, Mekelle, Tigray, Ethiopia Background Ethiopia has been implementing high impact and cost- Ethiopia is one of the countries in Sub Saharan Africa effective health interventions as well as strengthening its (SSA) with markedly high maternal and neonatal mortal- health system to improve the health status of its popula- ity ratio and it was estimated at 676 maternal deaths per tion and reduce maternal and neonatal mortality. These 100,000 live births and neonatal mortality rate 37 deaths interventions include scale up of family planning pro- per 1000 live births in 2011 [1]. Neonatal death grams, training and deployment of more midwives, re- accounted for 62% of all infant deaths and 44% of all ferral system including pediatric referral system, service under-five deaths [1, 2]. integration, health extension program (HEP), routine immunization and wild polio reduction. And yet mater- nal and neonatal mortality rates remain high [3]. * Correspondence: arayaabrha@yahoo.com School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Gebrehiwot et al. BMC Women's Health (2018) 18:78 Page 2 of 10 The common medical causes for maternal deaths in- 10% (3.4% in 2000, 5.8% in 2005 and 7% in 2011) [1]. clude bleeding, high blood pressure, prolonged and The EDHS 2011 showed that 32% of women in urban obstructed labour, infections and unsafe abortion [4]. areas received a postnatal checkup from a health profes- Bleeding and infection following childbirth account for sional compared to 2% in rural women [4]. many maternal deaths [5]. Hemorrhage and sepsis There were few community based studies conducted accounted for 27.1 and 10.7% of maternal mortality in Ethiopia which depicted the magnitude of PNC ser- respectively [6] while preterm birth, asphyxia and vice utilization and associated factors. There has been severe infections contributed to two thirds of all neo- no facility based studies which showed the magnitude of natal death [4, 5]. PNC service utilization and associated factors among The postnatal period begins immediately after the urban women. This study addresses the extent and fac- birth of the baby and extends up to 6 weeks (42 days) tors affecting PNC service utilization among women after birth. The major purpose of postpartum and post- who visited health facilities for any maternal and child natal care is to maintain and promote the health of the health services in an urban setting. woman and her baby and to foster an environment that offers help and support to the extended family and com- Methods munity for a wide range of related health and social Study design and area needs [1, 5]. A facility based cross-sectional study was conducted Two thirds of maternal and newborn deaths occur in from January to April 2014 among all women who had a the first 2 days after birth [5]. Hence, having postnatal child aged 45 days up to 6 months and visited maternal care is important for both the mother and the child to and child health (MCH) clinic in selected public health avoid the risk of preventable death by treating complica- facilities in Mekelle city, Tigrai regional state, Ethiopia. tions arising from the delivery as well as to provide the Mekelle is the capital city of Tigrai regional state. The mother with important information on how to care for city has 7 sub administrative cities, 3 government hospi- herself and her child [2].The World Health Organization tals and 9 public health centers providing MCH services. (WHO) recommends postnatal visits within the first According to the Mekelle zonal health bureau profile, 24 h from birth, on day 3 (48–72 h) and between days the total population of the city in 2013 was estimated to 7–14 after birth, and 6 weeks after birth [7]. be 301,642 of which 147,804 were male and 153,837 fe- Postpartum care for the mother has conventionally fo- male. Women in the reproductive age group (15–45) cused on routine observation and examination of vaginal were 70,825 while children under 1 year were estimated blood loss, uterine involution, blood pressure and body to be 10,747 [14]. Women who were critically ill, women temperature [5]. Similarly, postnatal care for all new- who had mental health problems, and those unable to borns should include immediate and exclusive breast- provide informed consent or women with critically ill feeding, warming of the infant, hygienic care of the children were excluded from the study.. umbilical cord, and timely identification of danger signs with referral and treatment [8]. Postnatal care is the rou- Sample size and sampling technique tine care services that every woman and her baby should A total sample size of 367 was determined using single be offered, appropriate to their individual circumstances proportion formula. When calculating the sample size; it after the birth of the baby until the conclusion of the was assumed that a 95% confidence interval, 32% of postnatal period [9]. In the absence of postnatal follow- postnatal care utilization (taken from EDHS 2011), 5% up, numerous cases of puerperal infections become un- marginal error and 10% contingency. diagnosed and unreported [10]. Lack of care in postnatal Of the health facilities in the city (2 hospitals and 9 period from skilled providers may result in death or dis- health centers), seven (2 hospitals and 5 health centers) ability as well as missed opportunities to promote were selected. The selection of the health facilities was healthy behaviors affecting women, newborns, and chil- done randomly. The health facilities were further strati- dren [11]. fied by patient flow of the previous 3 months prior to Although PNC has several benefits and reduces mater- data collection and considering the average client flow at nal and child mortality significantly, postnatal service each health facility. The total sample size determined use is low in most of SSA countries [12]; In Ethiopia (367) was distributed proportionally to patient flow size PNC services are made accessible to all women for free, among the selected health facilities. however, the utilization of the services is very low [13]. To select each woman from a selected health facility, The findings of the three Ethiopian demographic health systematic random sampling was employed. The sam- th surveys (EDHS) showed an improvement in ANC pling interval (K ) among each study subject was utilization from 27% in 2000 to 28% in 2005 and to 34% calculated by dividing the study population of each in 2011 However, utilization of PNC remained below selected health facility to the sample size deployed to Gebrehiwot et al. BMC Women's Health (2018) 18:78 Page 3 of 10 each selected health facility. The first study subject was identified as independent predictors of PNC service th selected randomly from the range of (1 up to K ) and utilization. th thereafter every participant was selected every K interval until the sample size was obtained for all the Result selected health facilities. Socio demographic characteristics of women A total of 367 women participated in the study making a Data collection procedures response rate of 100%. One hundred twenty nine (35. A structured questionnaire was used to interview 1%) of the respondents came for immunization followed women (Additional file 1). The questionnaire was by 82(22.3%) care of sick baby, 78 (21.3%) family plan- adapted by reviewing relevant literature and question- ning, 37 (10.1%) care of sick mother, 34 (9.3%) both naire such as EDHS 2011 and WHO guideline for PNC. immunization of baby and family planning and 7(1.9%) The questionnaire was prepared first in the English lan- came for circumcision of baby (Table 1). guage and translated into Tigrigna, the local language The mean age of the respondents was 26.14 ± 4.67 years. and then translated back to English by people proficient Two hundred fifty six (69.8%) respondents reported that in both languages to maintain the consistency and con- their monthly family income was greater than 1500 tent of the questionnaire. Ethiopian Birr followed by 96 (26.2%) with monthly family Three data collectors who completed high school were income 500–1500 Birr and only 15 (4.1%) reported that recruited. The data collectors were given a 1 day training their monthly family income was less than 500 Birr. The on the objectives and relevance of the study: the con- majority 335 (91.3%) of respondents reported that they tents of the training were:, on how to ensure confidenti- lived within a walking distance of less than 30 min to the ality of information, understand the meanings of each nearest health facility. question in the questionnaire, how to approach partici- pants, how to follow ethical procedures and general in- Obstetric history of women formation on postnatal care follow up. Three hundred sixty two (98.8%) of the respondents re- A supervisor with a Bachelor of Science in midwifery ported that their last pregnancy was wanted. Three hun- was also recruited for the data collection. The supervisor dred twenty five (88.6%) of the respondents delivered in was responsible in the supervision and support of data health facilities and 322(99.1%) of them had visited ANC collectors, checking filled out questionnaire for com- at least once during pregnancy. Of the total respondents, pleteness daily and providing feedback for data collec- 42 (11.4%) had faced complication during delivery tors. In addition to the supervisor, the principal (Table 2). investigator (GG) is participated in the supervision of data collection. Knowledge of women on PNC services The Tigrigna version of the questionnaire was pre- One hundred seventy (46.3%) of the respondents knew tested among 18 women (5% of the total sample size) about the availability of PNC service at health facilities. who had visited MCH clinic. This pre-test was done in From these, 73 (42.9%) of the respondents said they health facilities which were not selected for this study. knew about the frequency of PNC visits (Table 2). Among those who knew about the presence of PNC Data processing and analysis services, 57 (33.5%) knew that PNC service is important Data was entered into a computer using SPSS window to get immunization for baby; 48 (28.2%) distinguished version 20.0 and cleaned. Descriptive statistics was that PNC is important to get family planning service; employed to calculate frequencies and display findings. thirty seven (21.8%) recognized PNC is important to Association was measured using binary logistic regres- prevent health problem of mother and baby arising sion. Based on bivariate analysis, variables that showed during delivery and post-delivery besides twenty eight significant association at (p < 0.05) were entered to mul- (16.5%) also identified that PNC service is useful to get tivariable analysis to select predictor variables of PNC counseling on feeding practice of baby. service utilization. The final model was built by using enter method Practice of PNC by women standard regression model building technique. Before Of the 367 respondents, only 118 (32.2%) had visited building the final model, multi co linearity effect was PNC clinic at least once within 42 days of delivery. From assessed using linear regression and the mean VIF > 5 the 118 respondents, 88 (74.6%), 27 (22.9%) and 3(2.5%) was used as cut off point. The final model was then had visited once, twice and three or more times respect- tested for its goodness of fit by Hosmer and Lemeshow ively. Women who visited within 15–42 days for the first p-value and p value > 0.05 was best fit. Finally, variables time were 61(51.7%) and women who visited within 7– that showed significant association at (P < 0.05) were 14 days for the first time were 34 (28.8%) while women Gebrehiwot et al. BMC Women's Health (2018) 18:78 Page 4 of 10 Table 1 Socio-demographic characteristics of women who Table 2 Obstetric history and knowledge on PNC service of visited public health facilities in Mekelle city Tigray, Ethiopia, women who visited public health facilities in Mekelle city, 2014 Tigray, Ethiopia, 2014 Variable – N = 367 Frequency Percent Variables - N = 367 Frequency N Percent % Age Number of pregnancy 15–19 16 4.4 One 141 38.4 20–24 124 33.7 Two 121 33.0 25–29 148 40.3 Three 61 16.6 30–34 52 14.2 Four and above 44 12.0 35+ 27 7.4 ANC visit (at least one) Religion Yes 344 93.7 Orthodox 317 86.3 No 23 6.3 Muslim 30 8.2 Frequency (Number) of ANC visit Catholic 12 3.3 < three 17 5.0 Protestant 8 2.2 Three 53 15.4 Marital Status Four and above 274 79.6 Married 318 86.6 Months of pregnancy at first visit of ANC Single 31 8.4 < four month 115 33.4 Others 18 5.0 At four month 111 32.3 Education At five month 68 19.8 Illiterate 75 20.4 > Five month 50 14.5 primary 99 27.0 Mode of delivery Secondary 99 27.0 Normal 323 88.0 College and above 94 25.6 Caesarean section 22 6.0 Occupation Instrumental 22 6.0 house wife 232 63.2 Source of information (N = 170) Governmental employee 60 16.3 Health professional 128 75.3 Private employee 27 7.4 Television 31 18.2 Merchant 26 7.1 Other 11 6.59 Daily work 22 6.0 Do you know required frequency of PNC visits (N = 170) Education of Husband Yes 73 42.9 Illiterate 42 11.4 No 97 57.1 Friends, neighbors and HEW primary 92 25.1 Secondary 97 26.4 college and above 136 37.1 during delivery, 26 (61.9%) had utilized PNC services Occupation of Husband and almost all 20 (95.2%) respondents who had previ- governmental employee 104 28.3 ous history of obstetrics problems had visited PNC private employee 103 28.1 services. Respondents who knew the time of visit of Merchant 72 19.6 PNC services, 52 (71.2%) had utilized PNC services daily work 88 24.0 (Table 3). widowed, separated and divorced Ninety two (35.9%), 23(24%) and only 3(20%) of the respondents with monthly family incomes greater than who visited within 3 days for the first time were 23 1500 Birr, between 500 and 1500 birr and less than 500 (19.4%) only. Birr respectively had utilized PNC services. One hun- Respondents who had visited ANC at least once 116 dred thirteen (33.7%) respondents who lived in a dis- (33.7%) had visited PNC clinics. Respondents who knew tance less than 30 min on foot and 5 (15.6%) the availability of PNC service 99 (71.2%) had visited respondents who lived greater than 30 min from the PNC services. Respondents who had faced complications health facility had utilized PNC service. Gebrehiwot et al. BMC Women's Health (2018) 18:78 Page 5 of 10 Table 3 PNC utilization of respondents who visited public health Table 3 PNC utilization of respondents who visited public health facilities in Mekelle city, Tigray, Ethiopia, 2014 facilities in Mekelle city, Tigray, Ethiopia, 2014 (Continued) Variable - N = 367 Yes = 118 No = 249 Total (367) Variable - N = 367 Yes = 118 No = 249 Total (367) Frequency Frequency Frequency Frequency Frequency Frequency No (%) No (%) No (%) No (%) No (%) No (%) Age Four and above 8(6.8) 36(14.5) 44(12.0) 15–19 year 6(5.1) 10 (4.0) 16 (4.4) Mode of delivery 20–24 year 39(33.1) 85(34.1) 124(33.8) Normal 97(82.2) 226(90.8) 323(88.0) 25–29 year 47(39.8) 101(40.6) 148(40.3) Instrumental 11(9.3) 11(4.4) 22(6.0) 30–34 year 15(12.7) 37(14.9) 52(14.2) Caesarean 10(8.5) 12(4.8) 22(6.0) 35+ 11(9.3) 16(6.4) 27(7.4) Religion Orthodox 99(83.9) 218(87.6) 317(86.4) Respondents’ reasons for visiting health facility Muslim 11(9.3) 19(7.6) 30(8.2) Among women who visited health facility, 45 (38.1%) Catholic 7(5.9) 5(2.0) 12(3.3) visited to have a PNC checkup while the rest visited ei- Protestant 1(0.8) 7(2.8) 8(2.2) ther because they were sick themselves, or their child Educational status was sick or to have their child immunized (Fig. 1). Illiterate 11(9.3) 64(25.7) 75(20.4) 5.4.2 Respondents reason for not utilizing of PNC service Primary 33(28) 66(26.5) 99(27.0) The majority of the respondents 184(73.9%) reported Secondary 27(22.9) 72(28.9) 99(27.0) that the reason for not utilizing of postnatal care service College and above 47(39.8) 47(18.9) 94(25.6) was that they did not know the availability of PNC ser- Marital status vices in the health facilities (Fig. 2). Married 103(87.3) 215(86.3) 318(86.6) Single 9(7.6) 22(8.8) 31(8.4) Contents of PNC service which women had received during their visit Separated 1(0.8) 5(2) 6(1.6) The report showed that of the women who had visited Divorced 1(0.8) 2(0.8) 3(0.8) PNC clinic, most 103 (87.3%) had received less than six Widowed 4(3.4) 5(2) 9(2.5) elements of postnatal care services; 36 (30.5%) received Occupation only two elements and 24 (20.3%) women received three House wife 56(47.5) 176(70.7) 232(63.2) elements of postnatal care service from fourteen ele- Governmental employee 27(22.9) 33(13.3) 60(16.3) ments mentioned above (Table 4). Private employee 18(15.3) 9(3.6) 27(7.4) Predictor variables of PNC service utilization Merchant 13(11) 13(5.2) 26(7.1) Bivariate and multivariate analyses were done to identify Day laborer 4(3.4) 18(7.2) 22(6.0) independent variables that show significant association Husbands Education for utilization of PNC services. All variables which Illiterate 10(8.5) 32(12.9) 42(11.4) showed statistically significant association with p-value Primary Education 21(17.8) 71(28.5) 92(25.1) < 0.05 during the bivariate analysis were entered to multivariate analysis and significance was decided at p- Secondary 28(23.7) 69(27.7) 97(26.4) value < 0.05 (Table 5). College and above 59(50) 77(30.9) 136(37.1) In bivariate analysis, women’s educational level and oc- Husband occupation cupation, husband’s education and occupation, walking Governmental employee 43(36.4) 61(24.5) 104(28.3) distance from health facility, number of pregnancies, Private employee 29(24.6) 74(29.7) 103(28.1) practice of ANC and knowledge PNC service availability Merchant 29(24.6) 43(17.3) 72(19.6) showed statistically significant association. In multivari- able analysis, women’s occupation, number of pregnan- Day laborer 17(14.4) 71(28.5) 88(24.0) cies and knowledge of postnatal care service availability Number of pregnancy showed statistically significant association on women One 51(43.2) 90(36.1) 141(38.4) PNC service utilization (Table 5). Two 37(31.4) 84(33.7) 121(33.0) As indicated in Table 5, women’s occupation showed Three 22(18.6) 39(15.7) 61(16.6) strong association with utilization of postnatal care Gebrehiwot et al. BMC Women's Health (2018) 18:78 Page 6 of 10 Fig. 1 Reasons for visiting PNC clinics of women who visited public health facilities in Mekelle city, Tigray, Ethiopia/2014, n = 118 service utilization. Accordingly, women who were pri- Discussion vate employees and business women were 6.46 and 3.34 The study assessed the level of postnatal care service times more likely to utilize postnatal care services (AOR utilization of women and identified factors that influence = 6.46, 95% CI: 1.91–21.86) and (3.35, 95% CI: 1.10–10. utilization of the service in women who visited the pub- 19) respectively in contrast to unemployed women or lic health facilities in Mekelle. The study showed that house wives. In addition, utilization of PNC services de- PNC utilization was low. The main reason reported for creased as the number of pregnancies increased. The not utilizing PNC service was lack of knowledge on the odds ratio of PNC service utilization of women who had availability of PNC service in public health facilities. Ac- history of one pregnancy was 3.2 times more likely cording to respondents, the contents of health informa- (AOR = 3.19, 95% CI: 1.06–9.57) in contrast to women tion on postnatal care services women received were who had a history of four and more pregnancies. low. The factors that showed significant associations Knowledge of women of PNC service availability with PNC service utilization were occupation of women, was yet another predictor variable for postnatal care number of pregnancies and knowledge on the availability service utilization. As knowledge of women of post- of PNC services. natal care service availability increased utilization of Overall, 32.2% women utilized PNC services at least PNC service increased. Women who had knowledge once. Although the study was conducted in women who of postnatal care service availability promoted by the visited public health facilities for any MCH service, the health facilities were 14.46 times more likely to utilization of postnatal care service was particularly low. utilize postnatal care service (AOR = 14.46, 95% CI: The finding was comparable with the findings of EDHS 7.55–27.75) than women who lacked knowledge of 2011, in which 32% of urban women had utilized the the services (Table 5). service [2]. However, the finding was higher than a Fig. 2 Reasons for not utilizing PNC service of women who visited public health facilities in Mekelle city, Tigray, Ethiopia/2014, n = 249 Gebrehiwot et al. BMC Women's Health (2018) 18:78 Page 7 of 10 Table 4 Contents of PNC service which women had received current study considered PNC service utilization pro- during their visit of women who visited public health facilities in vided by skilled health professionals in public health Mekelle city, Tigray Ethiopia 2014 N = 118 facilities. Type of service Frequency No (%) The major reason for not attending postnatal care ser- Mothers body temperature measurement 57(48.3) vice was lack of knowledge on the availability of PNC services. Although the majority of the respondents had Examination of breast 15(12.7) come for ANC and delivered in health facilities, they Examination for vaginal bleeding 39(33.1) didn’t know and hear about PNC service availability and Mothers blood pressure measurement 21(17.8) provision in health facilities. Counseling on exclusive breast feeding 13(11.0) Of the respondents who visited PNC services, the ma- Counseling on family planning 64(54.2) jority did so only once. Almost half of the respondents Counseling on HIV transmission 6(5.1) visited within 15–42 days for the first time.. Based on WHO recommendations on postnatal care service of the Counseling on care of baby 13(11.0) mother and newborn, mothers should visit for at least Counseling on baby danger signs 22(18.6) four times and the time of first visit should be within Counseling on personal hygiene 5(4.2) 24 h, to be followed on day 3 (48–72 h), between 7 and Immunization of baby 31(26.3) 14 days after birth, and 6 weeks after birth. The pre- Checking hygiene of cord 48(40.7) ferred early visits are within 7 days [7]. Nevertheless, Measuring body temperature of baby 5(4.2) findings of the current study indicated that the majority of women did not utilize PNC service as recommended Measuring weight of baby 81(68.6) by WHO and were late. Almost all women who had complications during PNC period had visited PNC similar study done in north Gondar, Ethiopia where only clinics. This implied that women visit health facilities 6.3% women utilized PNC service [11], another study only when they face complications and in illness. conducted in Jabitena district, Amhara region where 20. This study indcated no woman had received complete 2% women utilized the service [15] and a study done in service. The majority obtained less than five elements four regions of Ethiopia (Amhara, Oromia, Southern out of thirteen mentioned elements of PNC service Nations, Nationalities and People’s Region, and Tigrai) which are expected to be provided to a mother and new where only 10.6% women utilized PNC services [16]. born. Among the components of PNC services, the The possible reasons for the variations might be due highest missed opportunity was counseling of exclusive methodological differences of the studies and differences breast feeding where only 12% women had received the in study subject’s residence and the period. However, information from health providers during their PNC further investigation is needed to investigate and explain visit. The other element of PNC service with highest such variation. missed opportunity was measurement of blood pressure The finding of the current study was lower than stud- where only 17.8% of women received this service. Simi- ies conducted in Sidama zone, southern Ethiopia where larly, only 6.8% of the babies whose mothers’ visited 37.2% of the women utilized the PNC services [13] and health facility for PNC had their body temperature mea- much lower than a study conducted in Adwa, Tigrai, sured. This shows that the quality of PNC service pro- where 78.3% of the mothers utilized postnatal care ser- vided by public health facilities of the study area is poor vices [17]. This difference might be due to the difference when measured in terms of the content of the service in the operational definition of postnatal care service given. Thus, training and monitoring health workers to utilization of the studies. The study in Sidama zone, provide a standard PNC service is necessary. PNC service utilization was considered when the baby From the socio demographic characteristics of respon- had received full immunization; and as the study con- dents, age,women’s occupation was the predictor vari- ducted in Adwa, utilization of the service was considered able for utilization of PNC service. Respondents when women utilized PNC service within 6 months. employed on private firms and business women utilized However, the current study considered women who uti- PNC service better compared to unemployed or house lized PNC service within 6 weeks (not months). The wives. The result is similar to a study conducted in current study was also lower in PNC service utilization Bangladesh [19] where house wives were less likely to than a study in Gondar Zuria district where 66.83% utilize PNC service compared to employed women. The women utilized PNC service [18]. Almost half of the re- result of the current study was also similar to a study spondents in the study in Gondar Zuria, received PNC conducted in Adwa town, Tigrai, [17] where employed services from primary health care workers (known lo- women were more likely to utilize PNC service than cally as health extension workers-HEWs) while the women who had no job. This might suggest that women Gebrehiwot et al. BMC Women's Health (2018) 18:78 Page 8 of 10 Table 5 Predictor variables of PNC service utilization of women who visit public health facilities in Mekelle city, Tigray, Ethiopia /2014 n = 367 Utilization of PNC service Variable Yes, N(%) No, N(%) OR(95% CI) Adjusted OR(95% CI) Education Illiterate 11(14.7) 64(85.3) 1 1 Primary 33(33.3) 66(66.6) 2.91(1.355, 6.246)* 3.02(0.92, 9.85) Secondary 27(27.3) 72(72.7 2.18(1.00, 4.75) 1.09(0.31, 3. 89) College and above 47(50.0) 47(50.0) 5.81(2.73, 12.40)* 1.17(0.28, 4.88) Occupation House wife 56(24.1) 176(75.9) 1 1 Governmental employee 27(45.0) 33(55.0) 2.57(1.42, 4.64)* 1.38(0.56, 3.43) Private employee 18(66.7) 9(33.3) 6.29(2.67, 14.78)* 6.46(1.91, 21.86)* Merchant 13(50.0) 13(50.0) 3.14(1.37, 7.17)* 3.34(1.10, 10.19)* Day laborer 4(18.2) 22(81.8) 0.70(0.23, 2.15) 1.75(0.39, 7.85) Husband education Illiterate 10(23.8) 32(76.2) 1 1 Primary 21(22.8) 71(77.2) 0.95(0.40, 0.22) 0.34(0.08, 1.37) Secondary 28(28.9) 69(71.1) 1.30(0.56, 2.99) 0.32(0.07, 1.43) College and above 59(43.4) 77(56.6) 2.452(1.11, 5.39)* 0.49(0.10,2.48) Husband occupation Governmental employee 43(41.3) 61(58.7) 2.94(1.53, 5.68)* 1.36(0.48, 3.87) Private employee 29(28.2) 74(71.8) 1.64(0.83, 3.24) 0.85(0.33, 2.19) Merchant 29(40.3) 43(59.7) 2.82(1.39, 5.72)* 1.63(0.62, 4.27) Day laborer 17(193) 71(80.7) 1 1 Distance < 30 minuets 113(33.7) 222(66.3) 2.75(1.03, 7.33)* 1.90(0.55, 6.58) > 30 minuets 5(15.6) 27(84.4) 1 1 Number of pregnancies Four and above 8(18.2) 36(81.8) 1 1 One 51(36.2 90(63.8) 2.55(1.10, 5.90)* 3.35(1.10, 10.21)* Two 37(30.6) 84(69.4) 1.982(0.840, 4.676) 2.30(0.76, 7.02) Three 22(36.1) 39(63.9) 2.538(1.004, 6.417)* 2.28(0.69,7.54) ANC visit Yes 116(33.7) 228(66.6) 5.34(1.23, 23.18)* 1.01(0.15, 6.68) No 2(8.7) 21(91.3) 1 1 Knowledge about availability of PNC Yes 99(58.2) 71(41.8) 13.06(7.44, 22.93)* 14.46(7.53, 27.77)* No 19(9.6) 178(90.4) 1 1 *statically significant at P < 0.05 who have their own source of income are more empow- women who had one child. The result is similar to stud- ered and have a better chance of making decision on ies conducted in India [20] and Indonesia [21] where seeking health services. women with two or more children had utilized less post- Number of pregnancies was the other factor which natal care service than women who had a child for the was found to be predictor of PNC service utilization. first time. The current study findings corroborates with Women who had four and above children were less studies conducted in southern Ethiopia [13], in Jabitena likely to utilize postnatal care service compared to district, Amhara region [15], and in four regions of Gebrehiwot et al. BMC Women's Health (2018) 18:78 Page 9 of 10 Ethiopia (Amhara, Oromia, Southern Nations, National- Acknowledgments We thank supervisors, data collectors, and study participants for taking part ities and People’s Region, and Tigrai) [16], where in the study. We would like also to extend our gratitude to all health utilization of postnatal care service was found to de- facilities included in the study for the support that they provided us in the crease as number of pregnancy increase. Women who undertaking the study. got four and more pregnancies were less likely to utilize Funding PNC compared to primi gravida women. More difficult We didn’t receive any funding from organizations. This study was conducted labor and complications are believed to occur among as part of the requirement for Ms. Genet Gebrehiwot (GG) for her fulfillment of obtaining a master’s degree in public health at Mekelle University. The women who become pregnant for the first time com- costs of the data collection were covered from her personal savings. pared to women with the second and above pregnancies [13]. Availability of data and materials Knowledge on postnatal care service availability was The dataset supporting the conclusions in this article is mainly included with in this article (tables and figures). The SPSS dataset is available with the found as a major factor that affects PNC service principal investigator of the study (GG) and can be shared upon an official utilization. Women who were knowledgeable on PNC request. However, the SPSS dataset cannot be shared online or to a third service were more likely to utilize PNC service com- party as we vowed to the research participants that the information that they have provided us will be kept confidential. pared with those who did not know. The result corrobo- rates with similar studies conducted in Nepal [22] and Authors’ contributions Tanzania where women who were aware on PNC service GG, AAM, and KA contributed to the initiation of the study, design, participating in organizing the data collection process and analysis of the availability were more likely to utilize the service than result. GG, AAM, GG and KA involved in the re-analysis of the data, writing of not [23]. the manuscript. All authors read and approved the final manuscript. The findings of this study should be interpreted with Ethics approval and consent to participate caution. First, this study was conducted at facility level Ethical clearance was obtained from the Institutional Review of Board, and institutional-based assessments of barriers to post- College of Health Sciences of Mekelle University. Permission letters was natal care may be associated with different barriers than obtained from Tigray regional health bureau to selected hospitals and health centers to undertake the study before the start of data collection. The aim those identified by community-based studies. Secondly, and purpose of the study was explained to each study participants. Unique the source of data for this study was based on self-report identification number was used to ensure confidentiality of individual client of respondents and no validation was done with other information. They were informed that data were not used for other purposes other than the objective of the study. After securing necessary permissions sources such as cards and registers. from two hospitals namely; Mekelle and Quiha and five health centers namely; Mekelle,Aynalem,Kasech, Adishumdhun and Lachi respectively. Written informed consent was obtained from all participants. Sixteen of the study participants were Conclusion between the ages of 16 to 19. These women may be considered as minors and The finding of this study revealed that utilization of consent might have been required from their parents or legal guardians. postnatal care service among women who visited public However, these women are women who gave birth and visited health facility for maternal and child health services on their own decision. Thus, we considered health facilities in Mekelle city was low. Although the these women as adult and took written consent from themselves. This approach majority of women were accessible to public health facil- is advised for postpartum women under 18 to secure their privacy. ities and the service is provided for free for all women, Competing interests utilization of the service was low. The main reason for The authors declare that they have no competing interests. not utilizing the service was lack of knowledge on post- natal care service provided in health facilities. The re- Publisher’sNote spondents who received PNC service reported the Springer Nature remains neutral with regard to jurisdictional claims in majority didn’t get a complete service for themselves published maps and institutional affiliations. and their babies. Author details Further, this study found women’s occupation, number 1 2 Mekelle Hospital, Mekelle, Tigrai, Ethiopia. School of Public Health, College of pregnancies and knowledge on the availability of post- of Health Sciences, Mekelle University, Mekelle, Ethiopia. Department of natal care service to be significantly associated with Midwifery, College of Health Sciences, Aksum University, Aksum, Ethiopia. utilization of postnatal care services. Received: 6 April 2016 Accepted: 30 April 2018 Additional file References 1. UNFPA: Trends in maternal health in Ethiopia: in-depth analysis of the EDHS Additional file 1: English Version Questionnaire. (DOC 220 kb) 2000–2011. Addis Ababa, December 2012 available: https://www.medbox. org/trends-in-maternal-health-in-ethiopia/download.pdf. Accessed 23 May Abbreviations 2. UNICEF, WHO, World Bank, UN-DESA Population division: Level &Trends in ANC: Antenatal Care; AOR: Adjusted Odds Ratio; EDHS: Ethiopian Child Mortality: Report 2013, Estimates Developed by Un Inter-agency Demographic Health Survey; HEP: Health Extension Program; Group for Child Mortality Estimation. Available: http://www.who.int/ MDGs: Millennium Development Goals; PNC: Postnatal Care; SSA: Sub- maternal_child_adolescent/documents/levels_trends_child_mortality_2013/ Saharan Africa; WHO: World Health Organization en/. Accessed 23 May 2018. Gebrehiwot et al. BMC Women's Health (2018) 18:78 Page 10 of 10 3. Federal Democratic Republic of Ethiopia Ministry of Health: Health sector Development program IV 2010/11–2014/15 final draft. 2010. Available: https://www.google.com/search?source=hp&ei=vNEFW- r5F9H5kwWt162oDQ&q=Health+sector+Development+program+IV +2010%2F11-2014%2F15+final+draft+2010&oq=Health+sector +Development+program+IV+2010%2F11-2014%2F15+final+draft+2010&gs_ l=psy-ab.3...1896.1896.0.3192.1.1.0.0.0.0.279.279.2-1.1.0....0...1c.2.64.psy-ab..0.0. 0....0.2u-n1Ao1Xoo. Accessed 23 May 2018. 4. Central Statistical Agency Ethiopia, ICF international. Ethiopia demographic and health Survey 2011. Addis Ababa, Ethiopia and Calverton, Maryland, USA; 2012. Available: https://dhsprogram.com/pubs/pdf/PR10/PR10.pdf. Accessed 23 May 2018. 5. World Health Organization. WHO technical consultation on postpartum and postnatal care. Geneva: WHO; 2010. 6. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller A-B, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2(6):e323–e33. 7. Organization Health Organization. WHO recommendations on postnatal care of the mother and newborn. Geneva: World Health Organization; 2014. 8. Sines E, Syed U, Wall S, Worley H. Postnatal care: a critical opportunity to save mothers and newborns. Policy Perspect Newborn Health. 2007:1–7. 9. Kosgey N. Factors influencing the timing of postnatal care services in Kenya. Kenya: University of Nairobi; 2009. 10. Langlois ÉV, Miszkurka M, Ziegler D, Karp I, Zunzunegui MV. Protocol for a systematic review on inequalities in postnatal care services utilization in low-and middle-income countries. Syst Rev. 2013;2(1):55. 11. Worku AG, Yalew AW, Afework MF. Factors affecting utilization of skilled maternal care in Northwest Ethiopia: a multilevel analysis. BMC Int Health Hum Rights. 2013;13(1):20. 12. Wang W, Alva S, Wang S, Fort A. Levels and trends in the use of maternal health services in developing countries. 2011. 13. Regassa N. Antenatal and postnatal care service utilization in southern Ethiopia: a population-based study. Afr Health Sci. 2011;11(3):390. 14. Mekelle Zonal Health Office. Mekelle zonal Health Bureau Annual Profile, Mekelle, Ethiopia. 2013. 15. Workineh YG, Hailu DA. Factors affecting utilization of postnatal care service in Jabitena district, Amhara region, Ethiopia. Sci J Public Health. 2014;23: 169–76. 16. Callaghan-Koru JA, Seifu A, Tholandi M, de Graft-Johnson J, Daniel E, Rawlins B, et al. Newborn care practices at home and in health facilities in 4 regions of Ethiopia. BMC Pediatr. 2013;13(1):198. 17. Hailerman, et al. Utilization and associated factors of postnatal care in Adwa town, Tigray, Ethiopia. ARPB. 2013;3(1) 18. Tesfahun F, Worku W, Mazengiya F, Kifle M. Knowledge, perception and utilization of postnatal care of mothers in Gondar Zuria District, Ethiopia: a cross-sectional study. Matern Child Health J. 2014;18(10):2341–51. 19. Islam M, Odland J. Determinants of antenatal and postnatal care visits among indigenous people in Bangladesh: a study of the Mru community. Rural Remote Health. 2011;11(2):1672. 20. Jat TR, Ng N, San Sebastian M. Factors affecting the use of maternal health services in Madhya Pradesh state of India: a multilevel analysis. Int J Equity Health. 2011;10(1):59. 21. Titaley CR, Hunter CL, Heywood P, Dibley MJ. Why don't some women attend antenatal and postnatal care services?: a qualitative study of community members’ perspectives in Garut, Sukabumi and Ciamis districts of west Java Province, Indonesia. BMC Pregnancy Childbirth. 2010;10(1):61. 22. Dhakal S, Chapman GN, Simkhada PP, Van Teijlingen ER, Stephens J, Raja AE. Utilisation of postnatal care among rural women in Nepal. BMC Pregnancy Childbirth. 2007;7(1):19. 23. Eliakimu ES. Assessment of maternal postnatal care utilization and associated factors among women infants aged 2–6 months in Shinyanga rural district, Shinyanga region: Muhimbili University of Health and Allied Sciences; 2010. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png BMC Women's Health Springer Journals

Postnatal care utilization among urban women in northern Ethiopia: cross-sectional survey

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Medicine & Public Health; Gynecology; Maternal and Child Health; Reproductive Medicine
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Abstract

Background: Postnatal care service enables health professionals to identify post-delivery problems including potential complications for the mother with her baby and to provide treatments promptly. In Ethiopia, postnatal care service is made accessible to all women for free however the utilization of the service is very low. This study assessed the utilization of postnatal care services of urban women and the factors associated in public health facilities in Mekelle city, Tigrai Region, Northern Ethiopia. Methods: A facility based cross sectional study design was used to assess post natal service utilization. Using simple random sampling 367 women who visited maternal and child health clinics in Mekelle city for postnatal care services during January 27 to April 2014 were selected. Data was entered and analyzed using SPSS Version 20.0 software. A binary and multivariable logistic regression was used to identify risk factors associated with the outcome variables. P-value less than 0.05 is used to declare statistical significance. Results: The prevalence of women who utilized postnatal care service was low (32.2%). Women who were private employees and business women were more likely to utilize postnatal care services (AOR = 6.46, 95% CI: 1.91–21.86) and (3.35, 95% CI: 1.10–10.19) respectively compared to house wives., Women who had history of one pregnancy were more likely to utilize the service (AOR = 3.19, 95% CI: 1.06–9.57) compared to women who had history of four and above pregnancies. Women who had knowledge of postnatal care service were also more likely to utilize postnatal care service (AOR = 14.46, 95% CI: 7.55–27.75) than women who lacked knowledge about the services. Conclusions: Postnatal care utilization in the study area is low. Knowledge on postnatal care services and occupation of women had positive impact on postnatal care service utilization. The Mekelle city administration health office and other stakeholders should support and encourage urban health extension workers and health facilities to strengthen providing health education to improve the knowledge of the women about the importance of postnatal care services. Keywords: Postnatal care, Utilization, Mekelle, Tigray, Ethiopia Background Ethiopia has been implementing high impact and cost- Ethiopia is one of the countries in Sub Saharan Africa effective health interventions as well as strengthening its (SSA) with markedly high maternal and neonatal mortal- health system to improve the health status of its popula- ity ratio and it was estimated at 676 maternal deaths per tion and reduce maternal and neonatal mortality. These 100,000 live births and neonatal mortality rate 37 deaths interventions include scale up of family planning pro- per 1000 live births in 2011 [1]. Neonatal death grams, training and deployment of more midwives, re- accounted for 62% of all infant deaths and 44% of all ferral system including pediatric referral system, service under-five deaths [1, 2]. integration, health extension program (HEP), routine immunization and wild polio reduction. And yet mater- nal and neonatal mortality rates remain high [3]. * Correspondence: arayaabrha@yahoo.com School of Public Health, College of Health Sciences, Mekelle University, Mekelle, Ethiopia Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Gebrehiwot et al. BMC Women's Health (2018) 18:78 Page 2 of 10 The common medical causes for maternal deaths in- 10% (3.4% in 2000, 5.8% in 2005 and 7% in 2011) [1]. clude bleeding, high blood pressure, prolonged and The EDHS 2011 showed that 32% of women in urban obstructed labour, infections and unsafe abortion [4]. areas received a postnatal checkup from a health profes- Bleeding and infection following childbirth account for sional compared to 2% in rural women [4]. many maternal deaths [5]. Hemorrhage and sepsis There were few community based studies conducted accounted for 27.1 and 10.7% of maternal mortality in Ethiopia which depicted the magnitude of PNC ser- respectively [6] while preterm birth, asphyxia and vice utilization and associated factors. There has been severe infections contributed to two thirds of all neo- no facility based studies which showed the magnitude of natal death [4, 5]. PNC service utilization and associated factors among The postnatal period begins immediately after the urban women. This study addresses the extent and fac- birth of the baby and extends up to 6 weeks (42 days) tors affecting PNC service utilization among women after birth. The major purpose of postpartum and post- who visited health facilities for any maternal and child natal care is to maintain and promote the health of the health services in an urban setting. woman and her baby and to foster an environment that offers help and support to the extended family and com- Methods munity for a wide range of related health and social Study design and area needs [1, 5]. A facility based cross-sectional study was conducted Two thirds of maternal and newborn deaths occur in from January to April 2014 among all women who had a the first 2 days after birth [5]. Hence, having postnatal child aged 45 days up to 6 months and visited maternal care is important for both the mother and the child to and child health (MCH) clinic in selected public health avoid the risk of preventable death by treating complica- facilities in Mekelle city, Tigrai regional state, Ethiopia. tions arising from the delivery as well as to provide the Mekelle is the capital city of Tigrai regional state. The mother with important information on how to care for city has 7 sub administrative cities, 3 government hospi- herself and her child [2].The World Health Organization tals and 9 public health centers providing MCH services. (WHO) recommends postnatal visits within the first According to the Mekelle zonal health bureau profile, 24 h from birth, on day 3 (48–72 h) and between days the total population of the city in 2013 was estimated to 7–14 after birth, and 6 weeks after birth [7]. be 301,642 of which 147,804 were male and 153,837 fe- Postpartum care for the mother has conventionally fo- male. Women in the reproductive age group (15–45) cused on routine observation and examination of vaginal were 70,825 while children under 1 year were estimated blood loss, uterine involution, blood pressure and body to be 10,747 [14]. Women who were critically ill, women temperature [5]. Similarly, postnatal care for all new- who had mental health problems, and those unable to borns should include immediate and exclusive breast- provide informed consent or women with critically ill feeding, warming of the infant, hygienic care of the children were excluded from the study.. umbilical cord, and timely identification of danger signs with referral and treatment [8]. Postnatal care is the rou- Sample size and sampling technique tine care services that every woman and her baby should A total sample size of 367 was determined using single be offered, appropriate to their individual circumstances proportion formula. When calculating the sample size; it after the birth of the baby until the conclusion of the was assumed that a 95% confidence interval, 32% of postnatal period [9]. In the absence of postnatal follow- postnatal care utilization (taken from EDHS 2011), 5% up, numerous cases of puerperal infections become un- marginal error and 10% contingency. diagnosed and unreported [10]. Lack of care in postnatal Of the health facilities in the city (2 hospitals and 9 period from skilled providers may result in death or dis- health centers), seven (2 hospitals and 5 health centers) ability as well as missed opportunities to promote were selected. The selection of the health facilities was healthy behaviors affecting women, newborns, and chil- done randomly. The health facilities were further strati- dren [11]. fied by patient flow of the previous 3 months prior to Although PNC has several benefits and reduces mater- data collection and considering the average client flow at nal and child mortality significantly, postnatal service each health facility. The total sample size determined use is low in most of SSA countries [12]; In Ethiopia (367) was distributed proportionally to patient flow size PNC services are made accessible to all women for free, among the selected health facilities. however, the utilization of the services is very low [13]. To select each woman from a selected health facility, The findings of the three Ethiopian demographic health systematic random sampling was employed. The sam- th surveys (EDHS) showed an improvement in ANC pling interval (K ) among each study subject was utilization from 27% in 2000 to 28% in 2005 and to 34% calculated by dividing the study population of each in 2011 However, utilization of PNC remained below selected health facility to the sample size deployed to Gebrehiwot et al. BMC Women's Health (2018) 18:78 Page 3 of 10 each selected health facility. The first study subject was identified as independent predictors of PNC service th selected randomly from the range of (1 up to K ) and utilization. th thereafter every participant was selected every K interval until the sample size was obtained for all the Result selected health facilities. Socio demographic characteristics of women A total of 367 women participated in the study making a Data collection procedures response rate of 100%. One hundred twenty nine (35. A structured questionnaire was used to interview 1%) of the respondents came for immunization followed women (Additional file 1). The questionnaire was by 82(22.3%) care of sick baby, 78 (21.3%) family plan- adapted by reviewing relevant literature and question- ning, 37 (10.1%) care of sick mother, 34 (9.3%) both naire such as EDHS 2011 and WHO guideline for PNC. immunization of baby and family planning and 7(1.9%) The questionnaire was prepared first in the English lan- came for circumcision of baby (Table 1). guage and translated into Tigrigna, the local language The mean age of the respondents was 26.14 ± 4.67 years. and then translated back to English by people proficient Two hundred fifty six (69.8%) respondents reported that in both languages to maintain the consistency and con- their monthly family income was greater than 1500 tent of the questionnaire. Ethiopian Birr followed by 96 (26.2%) with monthly family Three data collectors who completed high school were income 500–1500 Birr and only 15 (4.1%) reported that recruited. The data collectors were given a 1 day training their monthly family income was less than 500 Birr. The on the objectives and relevance of the study: the con- majority 335 (91.3%) of respondents reported that they tents of the training were:, on how to ensure confidenti- lived within a walking distance of less than 30 min to the ality of information, understand the meanings of each nearest health facility. question in the questionnaire, how to approach partici- pants, how to follow ethical procedures and general in- Obstetric history of women formation on postnatal care follow up. Three hundred sixty two (98.8%) of the respondents re- A supervisor with a Bachelor of Science in midwifery ported that their last pregnancy was wanted. Three hun- was also recruited for the data collection. The supervisor dred twenty five (88.6%) of the respondents delivered in was responsible in the supervision and support of data health facilities and 322(99.1%) of them had visited ANC collectors, checking filled out questionnaire for com- at least once during pregnancy. Of the total respondents, pleteness daily and providing feedback for data collec- 42 (11.4%) had faced complication during delivery tors. In addition to the supervisor, the principal (Table 2). investigator (GG) is participated in the supervision of data collection. Knowledge of women on PNC services The Tigrigna version of the questionnaire was pre- One hundred seventy (46.3%) of the respondents knew tested among 18 women (5% of the total sample size) about the availability of PNC service at health facilities. who had visited MCH clinic. This pre-test was done in From these, 73 (42.9%) of the respondents said they health facilities which were not selected for this study. knew about the frequency of PNC visits (Table 2). Among those who knew about the presence of PNC Data processing and analysis services, 57 (33.5%) knew that PNC service is important Data was entered into a computer using SPSS window to get immunization for baby; 48 (28.2%) distinguished version 20.0 and cleaned. Descriptive statistics was that PNC is important to get family planning service; employed to calculate frequencies and display findings. thirty seven (21.8%) recognized PNC is important to Association was measured using binary logistic regres- prevent health problem of mother and baby arising sion. Based on bivariate analysis, variables that showed during delivery and post-delivery besides twenty eight significant association at (p < 0.05) were entered to mul- (16.5%) also identified that PNC service is useful to get tivariable analysis to select predictor variables of PNC counseling on feeding practice of baby. service utilization. The final model was built by using enter method Practice of PNC by women standard regression model building technique. Before Of the 367 respondents, only 118 (32.2%) had visited building the final model, multi co linearity effect was PNC clinic at least once within 42 days of delivery. From assessed using linear regression and the mean VIF > 5 the 118 respondents, 88 (74.6%), 27 (22.9%) and 3(2.5%) was used as cut off point. The final model was then had visited once, twice and three or more times respect- tested for its goodness of fit by Hosmer and Lemeshow ively. Women who visited within 15–42 days for the first p-value and p value > 0.05 was best fit. Finally, variables time were 61(51.7%) and women who visited within 7– that showed significant association at (P < 0.05) were 14 days for the first time were 34 (28.8%) while women Gebrehiwot et al. BMC Women's Health (2018) 18:78 Page 4 of 10 Table 1 Socio-demographic characteristics of women who Table 2 Obstetric history and knowledge on PNC service of visited public health facilities in Mekelle city Tigray, Ethiopia, women who visited public health facilities in Mekelle city, 2014 Tigray, Ethiopia, 2014 Variable – N = 367 Frequency Percent Variables - N = 367 Frequency N Percent % Age Number of pregnancy 15–19 16 4.4 One 141 38.4 20–24 124 33.7 Two 121 33.0 25–29 148 40.3 Three 61 16.6 30–34 52 14.2 Four and above 44 12.0 35+ 27 7.4 ANC visit (at least one) Religion Yes 344 93.7 Orthodox 317 86.3 No 23 6.3 Muslim 30 8.2 Frequency (Number) of ANC visit Catholic 12 3.3 < three 17 5.0 Protestant 8 2.2 Three 53 15.4 Marital Status Four and above 274 79.6 Married 318 86.6 Months of pregnancy at first visit of ANC Single 31 8.4 < four month 115 33.4 Others 18 5.0 At four month 111 32.3 Education At five month 68 19.8 Illiterate 75 20.4 > Five month 50 14.5 primary 99 27.0 Mode of delivery Secondary 99 27.0 Normal 323 88.0 College and above 94 25.6 Caesarean section 22 6.0 Occupation Instrumental 22 6.0 house wife 232 63.2 Source of information (N = 170) Governmental employee 60 16.3 Health professional 128 75.3 Private employee 27 7.4 Television 31 18.2 Merchant 26 7.1 Other 11 6.59 Daily work 22 6.0 Do you know required frequency of PNC visits (N = 170) Education of Husband Yes 73 42.9 Illiterate 42 11.4 No 97 57.1 Friends, neighbors and HEW primary 92 25.1 Secondary 97 26.4 college and above 136 37.1 during delivery, 26 (61.9%) had utilized PNC services Occupation of Husband and almost all 20 (95.2%) respondents who had previ- governmental employee 104 28.3 ous history of obstetrics problems had visited PNC private employee 103 28.1 services. Respondents who knew the time of visit of Merchant 72 19.6 PNC services, 52 (71.2%) had utilized PNC services daily work 88 24.0 (Table 3). widowed, separated and divorced Ninety two (35.9%), 23(24%) and only 3(20%) of the respondents with monthly family incomes greater than who visited within 3 days for the first time were 23 1500 Birr, between 500 and 1500 birr and less than 500 (19.4%) only. Birr respectively had utilized PNC services. One hun- Respondents who had visited ANC at least once 116 dred thirteen (33.7%) respondents who lived in a dis- (33.7%) had visited PNC clinics. Respondents who knew tance less than 30 min on foot and 5 (15.6%) the availability of PNC service 99 (71.2%) had visited respondents who lived greater than 30 min from the PNC services. Respondents who had faced complications health facility had utilized PNC service. Gebrehiwot et al. BMC Women's Health (2018) 18:78 Page 5 of 10 Table 3 PNC utilization of respondents who visited public health Table 3 PNC utilization of respondents who visited public health facilities in Mekelle city, Tigray, Ethiopia, 2014 facilities in Mekelle city, Tigray, Ethiopia, 2014 (Continued) Variable - N = 367 Yes = 118 No = 249 Total (367) Variable - N = 367 Yes = 118 No = 249 Total (367) Frequency Frequency Frequency Frequency Frequency Frequency No (%) No (%) No (%) No (%) No (%) No (%) Age Four and above 8(6.8) 36(14.5) 44(12.0) 15–19 year 6(5.1) 10 (4.0) 16 (4.4) Mode of delivery 20–24 year 39(33.1) 85(34.1) 124(33.8) Normal 97(82.2) 226(90.8) 323(88.0) 25–29 year 47(39.8) 101(40.6) 148(40.3) Instrumental 11(9.3) 11(4.4) 22(6.0) 30–34 year 15(12.7) 37(14.9) 52(14.2) Caesarean 10(8.5) 12(4.8) 22(6.0) 35+ 11(9.3) 16(6.4) 27(7.4) Religion Orthodox 99(83.9) 218(87.6) 317(86.4) Respondents’ reasons for visiting health facility Muslim 11(9.3) 19(7.6) 30(8.2) Among women who visited health facility, 45 (38.1%) Catholic 7(5.9) 5(2.0) 12(3.3) visited to have a PNC checkup while the rest visited ei- Protestant 1(0.8) 7(2.8) 8(2.2) ther because they were sick themselves, or their child Educational status was sick or to have their child immunized (Fig. 1). Illiterate 11(9.3) 64(25.7) 75(20.4) 5.4.2 Respondents reason for not utilizing of PNC service Primary 33(28) 66(26.5) 99(27.0) The majority of the respondents 184(73.9%) reported Secondary 27(22.9) 72(28.9) 99(27.0) that the reason for not utilizing of postnatal care service College and above 47(39.8) 47(18.9) 94(25.6) was that they did not know the availability of PNC ser- Marital status vices in the health facilities (Fig. 2). Married 103(87.3) 215(86.3) 318(86.6) Single 9(7.6) 22(8.8) 31(8.4) Contents of PNC service which women had received during their visit Separated 1(0.8) 5(2) 6(1.6) The report showed that of the women who had visited Divorced 1(0.8) 2(0.8) 3(0.8) PNC clinic, most 103 (87.3%) had received less than six Widowed 4(3.4) 5(2) 9(2.5) elements of postnatal care services; 36 (30.5%) received Occupation only two elements and 24 (20.3%) women received three House wife 56(47.5) 176(70.7) 232(63.2) elements of postnatal care service from fourteen ele- Governmental employee 27(22.9) 33(13.3) 60(16.3) ments mentioned above (Table 4). Private employee 18(15.3) 9(3.6) 27(7.4) Predictor variables of PNC service utilization Merchant 13(11) 13(5.2) 26(7.1) Bivariate and multivariate analyses were done to identify Day laborer 4(3.4) 18(7.2) 22(6.0) independent variables that show significant association Husbands Education for utilization of PNC services. All variables which Illiterate 10(8.5) 32(12.9) 42(11.4) showed statistically significant association with p-value Primary Education 21(17.8) 71(28.5) 92(25.1) < 0.05 during the bivariate analysis were entered to multivariate analysis and significance was decided at p- Secondary 28(23.7) 69(27.7) 97(26.4) value < 0.05 (Table 5). College and above 59(50) 77(30.9) 136(37.1) In bivariate analysis, women’s educational level and oc- Husband occupation cupation, husband’s education and occupation, walking Governmental employee 43(36.4) 61(24.5) 104(28.3) distance from health facility, number of pregnancies, Private employee 29(24.6) 74(29.7) 103(28.1) practice of ANC and knowledge PNC service availability Merchant 29(24.6) 43(17.3) 72(19.6) showed statistically significant association. In multivari- able analysis, women’s occupation, number of pregnan- Day laborer 17(14.4) 71(28.5) 88(24.0) cies and knowledge of postnatal care service availability Number of pregnancy showed statistically significant association on women One 51(43.2) 90(36.1) 141(38.4) PNC service utilization (Table 5). Two 37(31.4) 84(33.7) 121(33.0) As indicated in Table 5, women’s occupation showed Three 22(18.6) 39(15.7) 61(16.6) strong association with utilization of postnatal care Gebrehiwot et al. BMC Women's Health (2018) 18:78 Page 6 of 10 Fig. 1 Reasons for visiting PNC clinics of women who visited public health facilities in Mekelle city, Tigray, Ethiopia/2014, n = 118 service utilization. Accordingly, women who were pri- Discussion vate employees and business women were 6.46 and 3.34 The study assessed the level of postnatal care service times more likely to utilize postnatal care services (AOR utilization of women and identified factors that influence = 6.46, 95% CI: 1.91–21.86) and (3.35, 95% CI: 1.10–10. utilization of the service in women who visited the pub- 19) respectively in contrast to unemployed women or lic health facilities in Mekelle. The study showed that house wives. In addition, utilization of PNC services de- PNC utilization was low. The main reason reported for creased as the number of pregnancies increased. The not utilizing PNC service was lack of knowledge on the odds ratio of PNC service utilization of women who had availability of PNC service in public health facilities. Ac- history of one pregnancy was 3.2 times more likely cording to respondents, the contents of health informa- (AOR = 3.19, 95% CI: 1.06–9.57) in contrast to women tion on postnatal care services women received were who had a history of four and more pregnancies. low. The factors that showed significant associations Knowledge of women of PNC service availability with PNC service utilization were occupation of women, was yet another predictor variable for postnatal care number of pregnancies and knowledge on the availability service utilization. As knowledge of women of post- of PNC services. natal care service availability increased utilization of Overall, 32.2% women utilized PNC services at least PNC service increased. Women who had knowledge once. Although the study was conducted in women who of postnatal care service availability promoted by the visited public health facilities for any MCH service, the health facilities were 14.46 times more likely to utilization of postnatal care service was particularly low. utilize postnatal care service (AOR = 14.46, 95% CI: The finding was comparable with the findings of EDHS 7.55–27.75) than women who lacked knowledge of 2011, in which 32% of urban women had utilized the the services (Table 5). service [2]. However, the finding was higher than a Fig. 2 Reasons for not utilizing PNC service of women who visited public health facilities in Mekelle city, Tigray, Ethiopia/2014, n = 249 Gebrehiwot et al. BMC Women's Health (2018) 18:78 Page 7 of 10 Table 4 Contents of PNC service which women had received current study considered PNC service utilization pro- during their visit of women who visited public health facilities in vided by skilled health professionals in public health Mekelle city, Tigray Ethiopia 2014 N = 118 facilities. Type of service Frequency No (%) The major reason for not attending postnatal care ser- Mothers body temperature measurement 57(48.3) vice was lack of knowledge on the availability of PNC services. Although the majority of the respondents had Examination of breast 15(12.7) come for ANC and delivered in health facilities, they Examination for vaginal bleeding 39(33.1) didn’t know and hear about PNC service availability and Mothers blood pressure measurement 21(17.8) provision in health facilities. Counseling on exclusive breast feeding 13(11.0) Of the respondents who visited PNC services, the ma- Counseling on family planning 64(54.2) jority did so only once. Almost half of the respondents Counseling on HIV transmission 6(5.1) visited within 15–42 days for the first time.. Based on WHO recommendations on postnatal care service of the Counseling on care of baby 13(11.0) mother and newborn, mothers should visit for at least Counseling on baby danger signs 22(18.6) four times and the time of first visit should be within Counseling on personal hygiene 5(4.2) 24 h, to be followed on day 3 (48–72 h), between 7 and Immunization of baby 31(26.3) 14 days after birth, and 6 weeks after birth. The pre- Checking hygiene of cord 48(40.7) ferred early visits are within 7 days [7]. Nevertheless, Measuring body temperature of baby 5(4.2) findings of the current study indicated that the majority of women did not utilize PNC service as recommended Measuring weight of baby 81(68.6) by WHO and were late. Almost all women who had complications during PNC period had visited PNC similar study done in north Gondar, Ethiopia where only clinics. This implied that women visit health facilities 6.3% women utilized PNC service [11], another study only when they face complications and in illness. conducted in Jabitena district, Amhara region where 20. This study indcated no woman had received complete 2% women utilized the service [15] and a study done in service. The majority obtained less than five elements four regions of Ethiopia (Amhara, Oromia, Southern out of thirteen mentioned elements of PNC service Nations, Nationalities and People’s Region, and Tigrai) which are expected to be provided to a mother and new where only 10.6% women utilized PNC services [16]. born. Among the components of PNC services, the The possible reasons for the variations might be due highest missed opportunity was counseling of exclusive methodological differences of the studies and differences breast feeding where only 12% women had received the in study subject’s residence and the period. However, information from health providers during their PNC further investigation is needed to investigate and explain visit. The other element of PNC service with highest such variation. missed opportunity was measurement of blood pressure The finding of the current study was lower than stud- where only 17.8% of women received this service. Simi- ies conducted in Sidama zone, southern Ethiopia where larly, only 6.8% of the babies whose mothers’ visited 37.2% of the women utilized the PNC services [13] and health facility for PNC had their body temperature mea- much lower than a study conducted in Adwa, Tigrai, sured. This shows that the quality of PNC service pro- where 78.3% of the mothers utilized postnatal care ser- vided by public health facilities of the study area is poor vices [17]. This difference might be due to the difference when measured in terms of the content of the service in the operational definition of postnatal care service given. Thus, training and monitoring health workers to utilization of the studies. The study in Sidama zone, provide a standard PNC service is necessary. PNC service utilization was considered when the baby From the socio demographic characteristics of respon- had received full immunization; and as the study con- dents, age,women’s occupation was the predictor vari- ducted in Adwa, utilization of the service was considered able for utilization of PNC service. Respondents when women utilized PNC service within 6 months. employed on private firms and business women utilized However, the current study considered women who uti- PNC service better compared to unemployed or house lized PNC service within 6 weeks (not months). The wives. The result is similar to a study conducted in current study was also lower in PNC service utilization Bangladesh [19] where house wives were less likely to than a study in Gondar Zuria district where 66.83% utilize PNC service compared to employed women. The women utilized PNC service [18]. Almost half of the re- result of the current study was also similar to a study spondents in the study in Gondar Zuria, received PNC conducted in Adwa town, Tigrai, [17] where employed services from primary health care workers (known lo- women were more likely to utilize PNC service than cally as health extension workers-HEWs) while the women who had no job. This might suggest that women Gebrehiwot et al. BMC Women's Health (2018) 18:78 Page 8 of 10 Table 5 Predictor variables of PNC service utilization of women who visit public health facilities in Mekelle city, Tigray, Ethiopia /2014 n = 367 Utilization of PNC service Variable Yes, N(%) No, N(%) OR(95% CI) Adjusted OR(95% CI) Education Illiterate 11(14.7) 64(85.3) 1 1 Primary 33(33.3) 66(66.6) 2.91(1.355, 6.246)* 3.02(0.92, 9.85) Secondary 27(27.3) 72(72.7 2.18(1.00, 4.75) 1.09(0.31, 3. 89) College and above 47(50.0) 47(50.0) 5.81(2.73, 12.40)* 1.17(0.28, 4.88) Occupation House wife 56(24.1) 176(75.9) 1 1 Governmental employee 27(45.0) 33(55.0) 2.57(1.42, 4.64)* 1.38(0.56, 3.43) Private employee 18(66.7) 9(33.3) 6.29(2.67, 14.78)* 6.46(1.91, 21.86)* Merchant 13(50.0) 13(50.0) 3.14(1.37, 7.17)* 3.34(1.10, 10.19)* Day laborer 4(18.2) 22(81.8) 0.70(0.23, 2.15) 1.75(0.39, 7.85) Husband education Illiterate 10(23.8) 32(76.2) 1 1 Primary 21(22.8) 71(77.2) 0.95(0.40, 0.22) 0.34(0.08, 1.37) Secondary 28(28.9) 69(71.1) 1.30(0.56, 2.99) 0.32(0.07, 1.43) College and above 59(43.4) 77(56.6) 2.452(1.11, 5.39)* 0.49(0.10,2.48) Husband occupation Governmental employee 43(41.3) 61(58.7) 2.94(1.53, 5.68)* 1.36(0.48, 3.87) Private employee 29(28.2) 74(71.8) 1.64(0.83, 3.24) 0.85(0.33, 2.19) Merchant 29(40.3) 43(59.7) 2.82(1.39, 5.72)* 1.63(0.62, 4.27) Day laborer 17(193) 71(80.7) 1 1 Distance < 30 minuets 113(33.7) 222(66.3) 2.75(1.03, 7.33)* 1.90(0.55, 6.58) > 30 minuets 5(15.6) 27(84.4) 1 1 Number of pregnancies Four and above 8(18.2) 36(81.8) 1 1 One 51(36.2 90(63.8) 2.55(1.10, 5.90)* 3.35(1.10, 10.21)* Two 37(30.6) 84(69.4) 1.982(0.840, 4.676) 2.30(0.76, 7.02) Three 22(36.1) 39(63.9) 2.538(1.004, 6.417)* 2.28(0.69,7.54) ANC visit Yes 116(33.7) 228(66.6) 5.34(1.23, 23.18)* 1.01(0.15, 6.68) No 2(8.7) 21(91.3) 1 1 Knowledge about availability of PNC Yes 99(58.2) 71(41.8) 13.06(7.44, 22.93)* 14.46(7.53, 27.77)* No 19(9.6) 178(90.4) 1 1 *statically significant at P < 0.05 who have their own source of income are more empow- women who had one child. The result is similar to stud- ered and have a better chance of making decision on ies conducted in India [20] and Indonesia [21] where seeking health services. women with two or more children had utilized less post- Number of pregnancies was the other factor which natal care service than women who had a child for the was found to be predictor of PNC service utilization. first time. The current study findings corroborates with Women who had four and above children were less studies conducted in southern Ethiopia [13], in Jabitena likely to utilize postnatal care service compared to district, Amhara region [15], and in four regions of Gebrehiwot et al. BMC Women's Health (2018) 18:78 Page 9 of 10 Ethiopia (Amhara, Oromia, Southern Nations, National- Acknowledgments We thank supervisors, data collectors, and study participants for taking part ities and People’s Region, and Tigrai) [16], where in the study. We would like also to extend our gratitude to all health utilization of postnatal care service was found to de- facilities included in the study for the support that they provided us in the crease as number of pregnancy increase. Women who undertaking the study. got four and more pregnancies were less likely to utilize Funding PNC compared to primi gravida women. More difficult We didn’t receive any funding from organizations. This study was conducted labor and complications are believed to occur among as part of the requirement for Ms. Genet Gebrehiwot (GG) for her fulfillment of obtaining a master’s degree in public health at Mekelle University. The women who become pregnant for the first time com- costs of the data collection were covered from her personal savings. pared to women with the second and above pregnancies [13]. Availability of data and materials Knowledge on postnatal care service availability was The dataset supporting the conclusions in this article is mainly included with in this article (tables and figures). The SPSS dataset is available with the found as a major factor that affects PNC service principal investigator of the study (GG) and can be shared upon an official utilization. Women who were knowledgeable on PNC request. However, the SPSS dataset cannot be shared online or to a third service were more likely to utilize PNC service com- party as we vowed to the research participants that the information that they have provided us will be kept confidential. pared with those who did not know. The result corrobo- rates with similar studies conducted in Nepal [22] and Authors’ contributions Tanzania where women who were aware on PNC service GG, AAM, and KA contributed to the initiation of the study, design, participating in organizing the data collection process and analysis of the availability were more likely to utilize the service than result. GG, AAM, GG and KA involved in the re-analysis of the data, writing of not [23]. the manuscript. All authors read and approved the final manuscript. The findings of this study should be interpreted with Ethics approval and consent to participate caution. First, this study was conducted at facility level Ethical clearance was obtained from the Institutional Review of Board, and institutional-based assessments of barriers to post- College of Health Sciences of Mekelle University. Permission letters was natal care may be associated with different barriers than obtained from Tigray regional health bureau to selected hospitals and health centers to undertake the study before the start of data collection. The aim those identified by community-based studies. Secondly, and purpose of the study was explained to each study participants. Unique the source of data for this study was based on self-report identification number was used to ensure confidentiality of individual client of respondents and no validation was done with other information. They were informed that data were not used for other purposes other than the objective of the study. After securing necessary permissions sources such as cards and registers. from two hospitals namely; Mekelle and Quiha and five health centers namely; Mekelle,Aynalem,Kasech, Adishumdhun and Lachi respectively. Written informed consent was obtained from all participants. Sixteen of the study participants were Conclusion between the ages of 16 to 19. These women may be considered as minors and The finding of this study revealed that utilization of consent might have been required from their parents or legal guardians. postnatal care service among women who visited public However, these women are women who gave birth and visited health facility for maternal and child health services on their own decision. Thus, we considered health facilities in Mekelle city was low. Although the these women as adult and took written consent from themselves. This approach majority of women were accessible to public health facil- is advised for postpartum women under 18 to secure their privacy. ities and the service is provided for free for all women, Competing interests utilization of the service was low. The main reason for The authors declare that they have no competing interests. not utilizing the service was lack of knowledge on post- natal care service provided in health facilities. The re- Publisher’sNote spondents who received PNC service reported the Springer Nature remains neutral with regard to jurisdictional claims in majority didn’t get a complete service for themselves published maps and institutional affiliations. and their babies. Author details Further, this study found women’s occupation, number 1 2 Mekelle Hospital, Mekelle, Tigrai, Ethiopia. School of Public Health, College of pregnancies and knowledge on the availability of post- of Health Sciences, Mekelle University, Mekelle, Ethiopia. Department of natal care service to be significantly associated with Midwifery, College of Health Sciences, Aksum University, Aksum, Ethiopia. utilization of postnatal care services. Received: 6 April 2016 Accepted: 30 April 2018 Additional file References 1. UNFPA: Trends in maternal health in Ethiopia: in-depth analysis of the EDHS Additional file 1: English Version Questionnaire. (DOC 220 kb) 2000–2011. Addis Ababa, December 2012 available: https://www.medbox. org/trends-in-maternal-health-in-ethiopia/download.pdf. Accessed 23 May Abbreviations 2. UNICEF, WHO, World Bank, UN-DESA Population division: Level &Trends in ANC: Antenatal Care; AOR: Adjusted Odds Ratio; EDHS: Ethiopian Child Mortality: Report 2013, Estimates Developed by Un Inter-agency Demographic Health Survey; HEP: Health Extension Program; Group for Child Mortality Estimation. Available: http://www.who.int/ MDGs: Millennium Development Goals; PNC: Postnatal Care; SSA: Sub- maternal_child_adolescent/documents/levels_trends_child_mortality_2013/ Saharan Africa; WHO: World Health Organization en/. Accessed 23 May 2018. Gebrehiwot et al. BMC Women's Health (2018) 18:78 Page 10 of 10 3. Federal Democratic Republic of Ethiopia Ministry of Health: Health sector Development program IV 2010/11–2014/15 final draft. 2010. Available: https://www.google.com/search?source=hp&ei=vNEFW- r5F9H5kwWt162oDQ&q=Health+sector+Development+program+IV +2010%2F11-2014%2F15+final+draft+2010&oq=Health+sector +Development+program+IV+2010%2F11-2014%2F15+final+draft+2010&gs_ l=psy-ab.3...1896.1896.0.3192.1.1.0.0.0.0.279.279.2-1.1.0....0...1c.2.64.psy-ab..0.0. 0....0.2u-n1Ao1Xoo. Accessed 23 May 2018. 4. Central Statistical Agency Ethiopia, ICF international. Ethiopia demographic and health Survey 2011. Addis Ababa, Ethiopia and Calverton, Maryland, USA; 2012. Available: https://dhsprogram.com/pubs/pdf/PR10/PR10.pdf. Accessed 23 May 2018. 5. World Health Organization. WHO technical consultation on postpartum and postnatal care. Geneva: WHO; 2010. 6. Say L, Chou D, Gemmill A, Tunçalp Ö, Moller A-B, Daniels J, et al. Global causes of maternal death: a WHO systematic analysis. Lancet Glob Health. 2014;2(6):e323–e33. 7. Organization Health Organization. WHO recommendations on postnatal care of the mother and newborn. Geneva: World Health Organization; 2014. 8. Sines E, Syed U, Wall S, Worley H. Postnatal care: a critical opportunity to save mothers and newborns. Policy Perspect Newborn Health. 2007:1–7. 9. Kosgey N. Factors influencing the timing of postnatal care services in Kenya. Kenya: University of Nairobi; 2009. 10. Langlois ÉV, Miszkurka M, Ziegler D, Karp I, Zunzunegui MV. Protocol for a systematic review on inequalities in postnatal care services utilization in low-and middle-income countries. Syst Rev. 2013;2(1):55. 11. Worku AG, Yalew AW, Afework MF. Factors affecting utilization of skilled maternal care in Northwest Ethiopia: a multilevel analysis. BMC Int Health Hum Rights. 2013;13(1):20. 12. Wang W, Alva S, Wang S, Fort A. Levels and trends in the use of maternal health services in developing countries. 2011. 13. Regassa N. Antenatal and postnatal care service utilization in southern Ethiopia: a population-based study. Afr Health Sci. 2011;11(3):390. 14. Mekelle Zonal Health Office. Mekelle zonal Health Bureau Annual Profile, Mekelle, Ethiopia. 2013. 15. Workineh YG, Hailu DA. Factors affecting utilization of postnatal care service in Jabitena district, Amhara region, Ethiopia. Sci J Public Health. 2014;23: 169–76. 16. Callaghan-Koru JA, Seifu A, Tholandi M, de Graft-Johnson J, Daniel E, Rawlins B, et al. Newborn care practices at home and in health facilities in 4 regions of Ethiopia. BMC Pediatr. 2013;13(1):198. 17. Hailerman, et al. Utilization and associated factors of postnatal care in Adwa town, Tigray, Ethiopia. ARPB. 2013;3(1) 18. Tesfahun F, Worku W, Mazengiya F, Kifle M. Knowledge, perception and utilization of postnatal care of mothers in Gondar Zuria District, Ethiopia: a cross-sectional study. Matern Child Health J. 2014;18(10):2341–51. 19. Islam M, Odland J. Determinants of antenatal and postnatal care visits among indigenous people in Bangladesh: a study of the Mru community. Rural Remote Health. 2011;11(2):1672. 20. Jat TR, Ng N, San Sebastian M. Factors affecting the use of maternal health services in Madhya Pradesh state of India: a multilevel analysis. Int J Equity Health. 2011;10(1):59. 21. Titaley CR, Hunter CL, Heywood P, Dibley MJ. Why don't some women attend antenatal and postnatal care services?: a qualitative study of community members’ perspectives in Garut, Sukabumi and Ciamis districts of west Java Province, Indonesia. BMC Pregnancy Childbirth. 2010;10(1):61. 22. Dhakal S, Chapman GN, Simkhada PP, Van Teijlingen ER, Stephens J, Raja AE. Utilisation of postnatal care among rural women in Nepal. BMC Pregnancy Childbirth. 2007;7(1):19. 23. Eliakimu ES. Assessment of maternal postnatal care utilization and associated factors among women infants aged 2–6 months in Shinyanga rural district, Shinyanga region: Muhimbili University of Health and Allied Sciences; 2010.

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BMC Women's HealthSpringer Journals

Published: May 30, 2018

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