Magnitude and Determinants of Postnatal Care Service Utilization in Farta District, South Gondar Zone, Amhara Region, Ethiopia.


 BackgroundThe low access to emergency obstetric care services in rural Ethiopia showed that maternal mortality was unlikely to significantly decline. Despite the prior attention given to MCH service to the rural communities, the achievements so far were not satisfactory.MethodsCross-sectional study was carried out among 737mothers in 11Keble’s and a multi-stage sampling technique was used to select the subjects and to assess the magnitude and determinants of postnatal care service utilization in Farta district, South Gondar Administrative Zone, Amhara Region, Ethiopia, in 2019.Binary logistic regression statistical model using the adjusted odds ratio (AOR) and 95% CI was used to identify determinants of PNC services utilization.ResultsThe magnitude of PNC services utilization in Farta District was 26.19 % [95% CI: (22.8-29.2)] with variations in between Kebeles. Having formal education of mother [95 % CI: 2.8(1.75-4.48)], birth at a health facility [95% CI: 3.18 (1.73-5.85)], counseling given during ANC visits [(95 %CI: 5.72(3.42-9.55)], complications during or after delivery [95%CI: 2.78(1.20-6.52)] and living within 5km of health facility [95 % CI: 2(1.29-3.10] were identified as determinants of PNC services utilization.ConclusionHaving formal education, counseling during ANC and facility delivery were positively associated whereas having no complications during or after delivery and residing far from a health facility were negatively associated with PNC services utilization. Tracing mechanisms for reaching pregnant women should be developed and strengthened to improve counseling services at home. Frequent support and supervision for remote Kebeles.


Background
The days and weeks following childbirth are a critical period for the lives of women and newborns. Most mothers and newborn deaths occur during the rst months after birth. In 2013, 2.8 million children died in the rst months of life of which 1 million have died in the rst days of life globally (1). In Africa, half of all postnatal maternal deaths occur during the rst 24 hours after delivery. Hemorrhage was being the leading immediate cause which accounted for 34%. Sub-Saharan Africa had the highest neonatal and maternal mortality in the Africa (1,5).
In Ethiopia, postnatal care was planned as a priority intervention in the Health Sector Development Program (HSDP) to increase the coverage to 78% by 2014 (2). Yet, the level of postnatal care coverage was extremely low in Ethiopia; Among women who had got PNC care services, 5% percent of women received postnatal care within 3 to 41 days (3). The maternal mortality ratio was 667per 100,000 live birth in 2013/2014GC while the excepted MMR was below 267 per 100,00live birth by 2015. This gure might even higher in rural settings. This was much attributed to poor postnatal care service at the community level (4). If routine PNC care service had been offered, 10% t0 27% of newborn deaths could have been avoided. In other words, high PNC coverage could save up to 310,000 newborn lives a year in Africa (5).
The fourth Health Sector Development Program (HSDP-V) promotes safer pregnancy through providing free MCH services, improving access and infrastructures of health services and enhancing training to primary health workers (6). The health sector in Ethiopia is organized into a three-tier system. The rst tier is the Primary Health care system which includes a primary hospital, which serves 60,000-100,000 people, health centers, serving 15,000-25,000 people each and Keble-level health posts, which serve 3,000-5,000 people. The second level consists of General hospitals that serve 1-1.5 million people. In the third tier, specialized hospitals are serving a patient population of 3.5-5 million (4,6). FMOH of Ethiopia instituted health care nancing reform (HCFR) which consists of exemption of maternal and child health services so as to decrease the health cost of mothers and families (4).
The low access to emergency obstetric care services in rural Ethiopia showed that maternal mortality was unlikely to signi cantly decline (7). Despite the prior attention given to MCH service to the rural communities, the achievements so far were not satisfactory.

Study design
A quantitative community-based cross-sectional study was conducted in Farta districts, in South Gondar Administrative Zone, in Amhara Region from February to June 2019.

Data Collection
Data was collected by data collectors from mothers by interviewing using a structured questionnaire at their actual residence after identifying all eligible mothers from HEWs record at the health post. Finally, if she was a volunteer to participate in the study, we took verbal consent and the interview commenced. For the data collection, two data collectors for each Keble were used. Data collectors were trained and have been living with the community for a long time.

Study Instrument
The questionnaire was prepared in the English language and then translated into Amharic language and then back to English by a language expert to check the consistency. Pre-tested structured questionnaires were used. Training has been given for data collectors and supervisors on the data collection tool and procedures. Data completeness was checked daily by the supervisor and principal investigator.

Study variables and Measures
We had 10 questions on socio-demographic characteristics of the respondent and the rest 32 questions were related to the reproductive health characteristics of the mothers which make up 42 questions in total.
Dependent variable EPINFO 7 was used for data editing and entry while Microsoft Excel 2010 was used for data cleaning and preparation. The analysis was done using Stata12. Data in EP INFO 7 was exported to Microsoft Excel 2010 for cleaning. The binary logistic regression model was applied and we analyzed each independent variable with simple logistic regression (bivariate analysis) and covariates whose p-value less than 0.2 were entered into multiple logistic regression models for nal analysis. Results were summarized and organized by tables and graphs. Frequencies and percentages of different variables concerning PNC service utilization status were calculated. The association between the dependent and independent variables was evaluated by using an adjusted odds ratio with 95% CI. Covariates having a p-value less than 0.05 have been considered as signi cantly associated with outcome variable and AOR was used to measure the strength of association.

Results
Demographic and Socio-economic characteristics of the respondents A total of 737 mothers participated in the study. The mean age of the respondents was 26.7(SD 5.6±). The majority of them were age -group 25 to 34. More than half of the respondents were unable to read and write. Less than 1% of them were employed and 99.19% were housewives. Three hundred sixty-ve (49.53%) had 1 to 3 children. The mean monthly income of the household was 963.6364 ETB (Table :1 (8,9). This difference may be because those studies included residents in an urban setting (main towns of the district) which makes the magnitude bigger and the sample size was also small as compared to this study. On the other hand, the nding of this study is higher as compared to the secondary analysis of EDHS 2011(2%) (10). This difference is explained by the fact that government efforts on the reduction of maternal death have been strengthened and there is a time difference. The different reasons are given for not having PNC and among those reasons, the most frequent one was (46.69%) I and my baby were not sick.
The study also showed that mothers who had formal education were 2.8 times (95% CI: 2.8(1.75-4.48)) more likely to use PNC services than mothers who had no education. Education makes mothers understand the bene ts of PNC and promotes healthcare-seeking behavior. But the educational status of the husband was found not statistically signi cantly associated with PNC services utilization. This shows that mother education plays a vital role in PNC services utilization than husbands. The result is consistent with studies in Dembecha in Ethiopia, secondary analysis of EDHS analysis, Kenya, Nigeria (8,(10)(11)(12) Concerning ANC, ANC visits were not statistically associated with PNC services utilization which is contradicting to the study Hossina Ethiopia, Kenya, India, and Ethiopia (11,13,14). The absence of association between ANC visits and PNC service use which was observed in this study might be due to there was strong motivation among mothers towards ANC services utilization than PNC. From this nding, it is clear that counseling is vital besides frequent ANC visits for women to use PNC services.
Regarding counseling, mothers who got counseling were 5.72 times (95% CI: 5.72(3.42-9.55)) more likely to use PNC services than women who did not get counseling. Mothers who got counseling about the importance of PNC services and dangers in the postnatal period will understand the bene t and utilize PNC. This in line with a study in Addis and Abi-Adi town in Ethiopia, and in Nepal (15)(16)(17) Place of delivery was found one of the strongest predictors of PNC services utilization. Mothers who delivered at a health facility were3.18 times more likely to use PNC services than mothers who gave birth at home. This is because women who give birth at a health facility might get counseling. Moreover, attending ANC services as recommended might increase women understanding of the dangers associated during or after delivery as far as good counseling was offered. This will ultimately increase the chance of PNC services uptake. This result is supported by studies in Zimbabwe and Debermarkose and Asela town in Ethiopia (18)(19)(20).
This study showed that mothers who had a complication during or after delivery were more likely to utilize PNC services than mothers who did not [95% CI: 2.78(1.20-6.52)]. This is attributed to the health problem which mother and their baby have. Mothers with a complication during or after delivery might get more attention from health personals. On the other hand, those who have no complications may feel as if no more danger will come to them afterward and they will get less emphasis and thus will not come back to the health facility. This nding agrees with the study in Pal stain, Tanzania, and Debermarkose, Ethiopia (19,21,22).
In line with the objectives of the study, distance from the health facility was found strongly associated with PNC services utilization. Mothers who reside within 5km of a health center or hospital were 2 times more likely to use PNC services than mothers who found far from 5km. This is because mothers who are living far from the health facility are feeling tired of getting there. In addition, there might be infrequent support and supervision from stakeholders. This shows geographic proximity plays a vital role in accessing maternity services This is in line with the study done in Zimbabwe and Abuna-Ginderberet, Ethiopia(9,18).

Signi cance of the Study
The postnatal period is a critical period for the lives of the mother as well as the newborn. This because most maternal and newborn deaths occur after the delivery of the baby. Hence, postnatal care at the place of delivery for the mothers and newborn is critical In Ethiopia, mortality has not been signi cantly decreased and PNC service utilization was by far very low in Farat woreda. Reason for underutilization of PNS were different from place to place .Previous studies in other region of Ethiopia mainly focused in urban community ignoring the most in need.
Despite the fact that there have been government and nongovernmental initiatives which have been working on maternal health, the outcomes of those programs were not contributing much as to maternal health was concerned. To effectively address those problems, it is very important to scienti cally identify socio-demographic characteristics of women in each district and assess factors contributing to low PNC service utilization with particular emphasis on the rural communities where the problem ware more pronounced.

Conclusion
The magnitude of PNC services utilization was low.
PNC services utilization was low compared with ANC use and facility delivery.
Facility delivery, having formal education of women and counseling given during ANC visits were positively associated with PNC services utilization Having no complication during or after delivery and living far from a health facility were negatively associated with PNC services utilization.

Recommendations
1. To Minster of Health and Amhara Regional Health Burro Placing a system to trace women who are pregnant to enhance the uptake of counseling at home. Before data collection ethical clearance will be obtained from the Institutional Review Board of the University of Gondar, Institute of Public Health. O cial permission letters will be obtained from Farta district Health O ce. Only those who gave verbal consent will be involved in the study. Questionnaire will be administered anonymously at respondent home .Con dentiality of information obtained from the study participant will be assured by all data collectors and the principal investigators.

Consent for publication
Not applicable Availability of data and material: The data are available at hand

Competing interests
The Authors declare that there is no any competing interest Funding: There is no funding

Authors contributions
Wondimu Girma (WG) designed the study, participated in the data quality control, analyzed the data, and drafted the paper, Tadesse Wuletaw (TW) assisted with the design, approved the proposal, and revised drafts of the paper and Abaynew Honelign (AH) assisted with the design, approved the proposal, and revised drafts of the paper. All authors read and approved the manuscript.
All authors made signi cant contribution from conception of the idea up to interpretation of the paper.
They are also agreed on which journal to submit the publications.

Figure 1
Reasons for not using PNC services