ANC serves as a tool to reduce maternal and perinatal morbidity and mortality by identifying women with an increased risk of pregnancy complication earlier during pregnancy and ensuring referral to an appropriate level of care (8). It is an entry point to maternal healthcare service utilization whereby the subsequent maternal health service utilizations largely depend on(12,17). Our finding suggests that a sizable number of women (43.9%) had a poor utilization of ANC that necessitates the need to induce demand for ANC utilization in the communities and particularly among women.
There were a few early quitters (9.5%) that included mothers that had a good ANC follow up but delivered outside a health facility unassisted by trained health personnel and missed the benefit of postnatal care. For these women, somehow ANC is not being translated to delivery and postnatal care utilization. Many factors might contribute to this gap including lack of awareness of the signs of labor, deficiency of exposure to information on delivery care, absence of problem during the current pregnancy, and absence of complications during previous births(18,19). Unassisted delivery carries a substantial risk in that unskilled attendants can hardly predict and manage serious complications which will lead to deaths of mothers during and after child birth (20).Thus, promotion and comprehensive education on the early signs of labor and birth preparedness and complication readiness need to be provided during the ANC sessions to translate the ANC uptake to delivery care and improve the overall maternal healthcare service utilization.
Our analysis also revealed that the magnitude of utilization of all the packages of maternal healthcare service is extremely low (6.1%). We also noted that in all the five identified trajectories, the utilization of early postnatal care is exceedingly poor. Furthermore, regardless of the route of progression, a large portion (40.5%) of the mothers proceeded up to delivery care very well and failed to have had a postnatal care. This finding suggests that an improvement in the utilization of postnatal care alone will contribute to an approximately 43% increase in uptake of beneficial maternal healthcare services.
The trajectories have shown spatial variation across regional states. The multivariable analysis indicated that women residing in Oromia regional states were highly likely to follow the least favorable trajectory of maternal healthcare service utilization. The finding is consistent with demographic and health survey report of 2016, a period closer to our baseline data collection time (5). Spatial specific planning, implementation, and monitoring and evaluation of activities might help reduce the inequalities in maternal healthcare service utilization across regional states.
Religion is considered to have an influence over maternal healthcare utilization in some recent studies (10–12,19). However, the relationship is best understood with the present study as our finding shows the point where religion stimulates and fails to stimulate maternal healthcare utilization. Christian women barely attempt to utilize any maternal healthcare services as compared to Non-Christian women. However, the two groups of women followed similar trajectories beyond ANC utilization, that is, Non-Christian women didn’t maintain the advantage they had at an early stage of the trajectory beyond antenatal care utilization.
Parity was shown to have negatively influenced the uptake of maternal health care services (11,12,19). Contrary to these reports, in our work, it is rather age of the mother that had a significant association with the type of the trajectory. Consistent with a finding reported in a study conducted by Rurangirwa and colleagues (21), older women (35+ years) were very much unlikely to seek maternal healthcare and take the least ideal trajectory. Contrarily, Agunwa et al. (9) reported that age positively predicted delivery care. In our study, it may rather be the cumulated experience of older women in pregnancy and child birth that led them to select an unsatisfactory utilization of maternal healthcare service.
Maternal educational achievement is another factor that dictates the trajectory that mothers had taken during their last pregnancy and child birth. It serves as a stimulant for an uptake of maternal healthcare services when women have an educational level beyond primary school. The finding is consistent with reports of previous studies conducted in Ethiopia (18,22) and other African countries (9–11). Better educated women had a relatively enhanced autonomy over their health seeking behavior than less informed women. Education may also play a role by providing better access to information that in turn would help expand choices of women. However, there are studies that are methodologically different from our study and reported a null finding(17,21). These studies considered only a segment from the spectrum of maternal healthcare service utilization while our study looked at the continuum of care.
Table 5: Result of generalized ordered logit model for maternal healthcare utilization, 2016
While women residing in the poorest households intended to follow the undesired route, women of the richest households tend to seek a better utilization of maternal healthcare services. In the study area, the presence of a significant pro-rich inequality in maternal healthcare service utilization have been reported (13).Likewise, studies done in Ethiopia and Ghana corroborate with our finding (10,12). This may be due to the fact that women of the richest households have a better access to resources that would enable them purchase the services even from private health facilities.
Recognition of danger signs by the women during pregnancy, delivery and postnatal period and BPCR are crucial for timely action, management of complications and child birth. The level of both knowledge of obstetric danger signs and BPCR are unsatisfactorily low in the present study. Regardless, it was found that women who had a good BPCR had an improved level of maternal healthcare utilization than those who were not. A prior arrangement made on part of the mother such as identification of the birth attendant and facility gives expectant mothers an impulse to utilize delivery and postnatal care (23,24). Our finding agrees with previous studies that reported BPCR predicted better use of maternal healthcare services (14,25).
The present study attempted to consider an approach that has not been considered in previous researches of maternal healthcare service utilization. Our approach considered combining all the maternal healthcare service utilization indicators to explore the trails of service utilization that mothers had taken during their most recent pregnancy. On the other hand, our study entirely depended on retrospective responses of mothers about their most recent pregnancy and events surrounding the pregnancy. Thus, as with all observational studies, the responses are not immune to recall errors that might add due to memory lapses or event omissions. A follow up study is commendable to study such events with minimized recall errors.
In conclusion, five different trajectories were identified and the magnitude of a beneficial utilization was very small. The magnitude of discontinuation after uptake of ANC pales in comparison to the rate of withdrawal towards the end of the continuum of care. Additionally, it has been observed that an equally appalling situation prevails at the start of the continuum of care. Spatial differentiated plan needs to be introduced to improve the uptake of maternal healthcare service. The less affluent, the uninformed and older women shall be given an awareness raising health education. Finally, given its strength of association, women, their families and communities need to be encouraged to effectively plan their births and learn to deal with complications.