The findings of the study are decisive in achieving SDG, the global target of reducing the maternal mortality ratio to less than 70 per 100,000 births [22]. Also, it was vital for the global strategy, aimed at ending preventable maternal mortality through enlightening predictors of inequalities in access to and quality of maternal, and newborn health care services in different clusters of the Ethiopian community [1]. Therefore, identifying maternal characters and community-level determinants of postnatal care has a great contribution in designing different interventions for improving maternal and child health.
This study found different individual and community-level determinants of postnatal care service utilization were identified. In this study, 36.5% of the total variance in the odds of postnatal care utilization was accounted for the characteristics of between-cluster variation. While 7.1% at maternal and 6.8% in community-level variation were identified. We found much higher values than a cross-sectional study in remote and poorest rural communities of Zambia in 2012, which revealed 22% and study in Nigeria 10.35% [23], variance in the use of PNC within 48 hours were attributable to the variations across community clusters [24]. This implies the issues of equity in postnatal care services for availability and accessibility were still a great challenge for the community.
This study found that women who gave birth by cesarean section were 1.66 times higher odds of using postnatal care services within the first two days compared to those given birth by another mode of delivery. This is in good agreement with the study in rural Tanzania in 2015 revealed cesarean section delivery was positively associated with postnatal care use [25]. This might be women who gave birth by cesarean section stay at the facility for about two days for which they receive a postnatal check-up.
In another way, women who gave birth at the health facilities were twice more likely to utilize postnatal care as compared to those delivered at home. This substantiates previous findings in the study in different parts of Ethiopia like Tigray and SNNPR, [9–11, 25] and Tanzania [25]. This might be clients who visit the health facility would have different health-seeking behaviors with those never attended health facility.
There is significant administrative regional variation in postnatal care use in Oromia, Somali, Benishangul, SNNPR, Gambela, Afar, and Dire Dawa which less likely to utilize postnatal care utilization as compared to Addis Ababa city administrative area. While there is no significant difference between residents of Harari city, Amhara regional state, and Tigray regional state as compared to Addis Ababa city. Variation in postnatal care service utilization varies was also observed in different parts of Ethiopia [8–10, 26, 27] and West African countries [20]. There are several possible explanations for this finding, first the difference in geographic accessibility of the postnatal care services due to topography and unfavorable roads for the mothers in rural areas of Ethiopia; second, there was a difference in local cultures and beliefs in different areas of the country; third, the difference in urbanized geographical areas among different regions.
Being in the higher community level antenatal care coverage were 1.5 times more likely to utilize post-natal care services. Our findings appear to be well supported by a multilevel analysis of DHS in sub-Saharan Africa in 2014, which found significant associations between four or more antenatal care visits and ever breastfed with both outcomes [28]. The results point to the likelihood of information diffusion for postnatal care utilization in the community.
Being a resident of higher community-level wealth was l.4 times more likely to utilize post-natal care services. This concurs well with the study in West Africa in 2018, which revealed community-level poverty was a significant determinant of postnatal care use [20]. This would appear to indicate that a wealthy community was more probability of getting health information and reside in urban areas.
A community who perceived the distance to a health facility as a big problem were 22% less likely to utilize postnatal care as compared to their counterparts. We believe that no other authors have found that postnatal care utilization is less likely in the community who perceived the distance of health facility as a big problem. There is a good probability that community telling can influence any health care service utilization.
This study provides strong evidence in utilizing community-based representative data of DHS and the use of multilevel mixed-effects analysis which bring disaggregated data on individual characteristics and community-level determinants for designing contextual interventions.
We are aware that our research may have three limitations. The first is findings are based on quantitative data only which cannot explore the detailed reasons in the community for low levels of postnatal care use. The second is excluding men’s and other community-level significant others view, may not give fully address the community-level determinants. Lastly, the information on postnatal care provided by mothers was retrospective and those women who had given birth 2 years ago can't probably remember accurately the service they received. These limitations are evidence of the DHS women’s data not inclusive of the above problems.