Postnatal Service Utilization and Associated Factors among Women who gave Birth in the last 12 months Prior to Study Period in Jimma Town, Southwest Ethiopia.

BACKGROUND: - Postnatal care is care (PNC) given to mother and new born within rst 42 days of delivery. Lack of care in this period may result in disability even death of either of mother or newborn or both. The aim of this study was to determine postnatal service utilization and associated factors among women, who gave birth in the last 12 months prior to May, 2019. METHODS: Community based cross-sectional study was conducted on 420 women who had given birth prior to May 1 to June 30, 2019(study period). The 17 kebeles of Jimma town is grouped into three similar groups based on occupation of majority of population. Three kebeles were randomly selected from each group. Data was collected using a pretested structured questionnaire. Descriptive statistic, such as frequencies, proportions and means were calculated. In bivariate logistic regression variables with p-value less than 0.25 were selected for multiple logistic analyses and multiple logistic regression was conducted. Finally signicantly associated variables were declared at p value less than 0.05. Result:-This study showed that prevalence of postnatal care utilization was 59.5%. Mothers who knew at least one danger signs which comes after delivery (AOR=11.5,(95%CI:5.56,22.7),who attended ANC (AOR=5.4, 95%CI:2.7,11.3 ), who get counseled to attend PNC ( AOR=14.9% CI :6.1,31.4),who attended at least primary school (AOR=2.3 ,95% CI:1.75,7.0),who did not travel more than 30 minutes to reach health facility(AOR=6.8,95% CI 3.4, 13.6 and those having more family size were more likely utilized postnatal service than their counterpart Conclusions: - In this study was very far (which is status

least one danger signs which comes after delivery (AOR=11.5,(95%CI:5.56,22.7),who attended ANC (AOR=5.4, 95%CI:2.7,11.3 ), who get counseled to attend PNC ( AOR=14.9% CI :6.1,31.4),who attended at least primary school (AOR=2.3 ,95% CI:1.75,7.0),who did not travel more than 30 minutes to reach health facility(AOR=6.8,95% CI 3.4, 13.6 and those having more family size were more likely utilized postnatal service than their counterpart Conclusions: -In this study utilization of postnatal care service was very far behind national target (which is 95% at the end of 2020, health sector transformational plan). Awareness about danger signs, educational status of the mother, counseling to attend to attend postnatal care, distance from health facility and family size were strongly associated with PNC utilization.

Background
Postnatal care is the care given to the mother and newborn for the rst six weeks after giving birth. This period is characterized by start of a new life for women and their partners as well as the beginning of new life for new born (1). It is a critical time in the lives of mothers and their babies. Majority of maternal and newborn deaths occur in the rst month following delivery. Almost 50% of maternal deaths occur within the rst day and 2/3 of deaths occur within rst seven days of postpartum period (2). In 2013, 2.8 million newborns died in their rst 30 days of life ─1 million of these newborns died on the rst 24 hour (3). Every year in Africa, at least 125,000 women and 870,000 newborns die in the rst week after birth (4).
It is recommended that mother and new born should have four visits: rst 24 hours, 48-72 hours, days 7-14, Six weeks. Lack of care during this period might result in signi cant morbidity as well as mortality of both the mother or her baby or both. Every woman and newborn should be closely monitored together after childbirth; both should be checked every 15 minutes for the rst 2 hours, then regularly for the next 24 hours since this period is critical time for PPH. The baby needs to be followed for respiration, temperature, breastfeeding, and bleeding and signs of infection from the cord . It is very important to protect women and newborns from complications after giving birth and provide important opportunity to assess the infant development to offer newborn care (5,6).
PNC services utilization is affected by several factors including maternal age, educational level of the women, occupational status of women and husbands, place of delivery, mode of delivery, number of pregnancies, awareness about obstetric related danger sign, and awareness about PNC Services (7,8).
The 2016 EDHS data showed that among women who gave birth in last 2 years only, 17 % of mother and 13 % newborn had PNC within 48 hours of delivery .The data also revealed that 19 % women utilized PNC within 6 weeks. This is lower than health sector transformational plan of the country, which is 95 %( 9, 10). Eighty six percent of newborns did not get the service at all. In Africa, half of maternal deaths occurs in the rst week of post-partum period; of this majority occurs in the rst week after childbirth by preventable causes of maternal deaths like hemorrhage and sepsis which are prevented by good postpartum follow up (11). In Oromia region southwest Ethiopia, the proportion of mothers who utilized PNC within two days of postpartum period was only 9 %. This low coverage of postnatal care in our country is causing high maternal and new born morbidity and mortality. It is also challenge for planning and implementing of PNC as well as many opportunities like counseling on exclusive breast feeding, PMTCT, providing of family planning and maternal and new born care are missed(12) (10). There was no study conducted in this study area. Therefore, the aim of study was determining postnatal service utilization and associated factors in Jimma town, Ethiopia.

Methods
The study was a community based cross-sectional conducted in Jimma town, Southwest Ethiopia, Sample Size Determination and Sampling Procedure Sample size determination: Sample size was determined by sing the single population proportion formula by taking prevalence of PNC utilization 47.9% (p=0.47) which is obtained from a study conducted in Halaba Kuluto, southern, Ethiopia (13), 5% margin of error, 95% con dence level (Z= 1.96), and 10 % nonresponse, a sample of 420 participants was needed.
Sampling Procedure: Systematic random sampling was used to select the required sample from the 17 Kebeles in Jimma town: First, the Kebeles were strati ed into three similar groups based on occupation of the majority of population and then three kebeles (Jiren, Ginjo and H/Mentina) were randomly selected from each stratum. Sampling frame which comprises a list of 1337 eligible mothers (who gave birth in the last 12 months) was prepared using Health Extension Workers registration and study subjects are selected with a k value of three.
Inclusion criteria: All women who gave birth in Jimma town 12 months prior to study period is included in this study Exclusion criteria: Those women who had di culty in communication due to severe illness were excluded from the study Data collection tools Structured interview questionnaire was prepared and implemented after reviewing literature (13)(14)(15)(16)(17). The questionnaires was prepared in English then translated to Amharic and Afan Oromo to check its consistency, and then it was translated back to English by well experienced experts of both languages. Data was collected by trained two midwives and one nurse who are familiar with local language after taking 2 days training Data processing and analysis: After checking, coding and organization of the collected the collected data, the completed questionnaires were entered into EPI-data version 3.1 and exported to Statistical Package for Social Science (SPSS) version 21. In the descriptive statistical analysis, frequencies, proportion and mean were calculated and the results of the analysis were presented in texts, tables and graphs as appropriate. Independent variables having P<0.25 on binary logistic regression analysis were considered as candidates for multiple logistic regression analysis.
Multiple logistic regression analysis was conducted to identify factors affecting postnatal service utilization. The nal model was tted using enter variable selection methods. Before using model, tness was checked. It was good t. I.e. Hosmer and Lemeshow Test model adequacy p-value 0.46; overall percentage classi cation table is 82.2% and Nagelkerke R Square 60%. Signi cant independent predictors were declared at p-value less than 0.05, and AOR was used measure strength of association.

Socio Demographic Characteristic
The total eligible sample size of 420 participated in the study which yielded a response rate about 100%. The age of the participants ranged from 14-39 years with mean age of 27.4 (SD = 4.5) years and 385(91.7%) of respondents were married. Regarding the religion of the respondents, 203(48.3%) were Muslims followed by orthodox 137(32.6%). Regarding to ethnicity 189(45%) were Oromos and followed by Amhara 63(15%). Almost half of respondent's monthly income was greater than two thousand ve hundred 207(49.3%) ( Table 1) at end of the document. Access and Availability of PNC service: -Most of respondents were using public transport to go health facilities, and half of respondents' reported that it takes 30 minute-1 hr. to reach to health facility (Table 2).  Binary logistic regression analysis: Binary logistic regression analysis was done to select candidate variables for multiple logistic regression analysis. From bivariate: age, family size, marital status, income, mother education, husband education, place of delivery, means of transport, ANC attendance, distance and self-decision, knowledge about danger signs mother which comes following delivery, and counseling to follow PNC, were candidates for multivariable logistic regression analysis

Multivariable logistic regression
From multivariable logistic regression analysis, knowledge about maternal danger signs which come after delivery, Family size, ANC follow up, educational status of the mother, counseling mother to follow PNC after delivery and distance from health facility were signi cantly associated with PNC utilization.
Those mothers who knew danger signs which comes after delivery were 11.5 times (AOR 11.5, 95% CI: 5.8, 22.7) more likely to utilize PNCs than mother were not aware of these post-partum complications. Similarly mothers who have ANC follow were 5.4 times (AOR = 5.4, 95% CI: 2.6, 11.3) more likely to utilized than who did not attend ANC during their last pregnancy.
Moreover ,women who were counseled to attend PNC during their last delivery were 14 times more likely to get postnatal care service than mothers who did not counseled ( AOR = 14, 95% CI :6.1, 31.4).Level of education is signi cantly associated with PNCS utilization, mothers who completed high school and college and above were 6.8 times and 11.7 more likely to utilize than mothers who were unable to read and write (AOR = 6.8, 95% CI: 2.2, 20.94, AOR = 11.7, 95% CI 3.5, 38.9) respectively.
Family size was signi cantly associated with postnatal care service utilization, for one person increment in family size, PNCS utilization increased nearly one times(β = 0.67). Those mothers who live close to health facility, that means distance which takes less than 30 minutes with available transport were 6.8 times more likely to utilized than those living far from health facility (AOR = 6.8, 95% CI 3.4, 13.6) ( Table 4).

Discussion
This study assessed PNC service utilization and associated factors among women who gave birth 12 months prior to study period. The result showed that among 420 respondents, 250 (59.5%) utilized PNC within 6 weeks of postpartum period. This nding is higher than 19% of national PNC service utilization coverage of EDHS2016 (9) and studies conducted in some parts of Ethiopia: Halaba kulito, southern part of Ethiopia 47.5% (13), Jabitina district,Amhara region 20.2%,(14) Northern Shoa 28.4% (15), and in Lemo woreda,haddiya zone 51.4% (16). In reverse lower than study conducted in different parts the country, very far behind from national target of health sector transformational plan which is 95 percentages at the end of 2020(10) and abroad country. Gondar Zuriya 66.8% (17) and 65.6% of Addis Abebe 89.2% ( 18). Eastern Nepal 98% (19) .This variations may be due to differences in socioeconomic status, variations in geography, time between current and previous study and access to health facilities and services .This result is comparable with study conducted Shebe Shombo district Jimma Zone 58.5% (20). This similarity may be due to similar study design and socio demographic characteristics because they are found in the same region.
Awareness about danger signs and symptoms which comes after delivery was signi cantly associated with PNCS utilization. This evidence is supported by study conducted at Halaba kulito (13), Lemo, Haddiya zone (16), From study conducted in Jabitina district those mothers who knew at least one danger signs which comes after delivery utilizes 4 times higher than those who fail to mention any of danger signs of pregnancy (14).
From this study, those respondents who had ANC follow up during their last pregnancy was 5 times more utilize than those who did not have ANC. Similar nding is revealed from different studies: about 6 times in lemo haddiya zone(16), 2 times in Gondar zuria district (17),3 times in Arse Zone (20) about 9 times in shebe sombo district (20).
This study revealed that counseling mothers to follow PNC is strong predictor of PNC utilization. Those mothers counseled to attend PNC service was 14 times likely to utilize PNC than their counterparts. This study is consistent with study done in halaba(13) and 10 times Shebe Sombo (20).
Educational status of respondents have positive association with PNC utilization, those mothers who attended college and above were 11 times more utilized than mother who can't read and write; which is consistent with study done in Arsi zone (21) and Jabitina Amhara region (14).This evidence is supported by study done abroad from Ethiopia; Pakistan (11)and Nigeria (22) showing educated women empowered over decision making for utilization of health service, increased knowledge and awareness.
Utilization of PNC is affected by distance from health facility. In this study, those respondents who travel less than 30 minutes to health facility was more likely to utilize than their counterparts (AOR = 6.8). This nding is consistent with studies conducted in Gondar zuria distric (17). The study conducted at Arse zone showed, mothers who travel at most 1 hour to nearest health facility utilized 3 times more utilized than those who travel more than 1 hour (21).
In this study, addition in family size is associated with PNC utilization, for one addition in family size PNCS utilization is increased nearly one times; this nding is supported by study done in Belgaum of Karnataka, India (7). This indicates that mothers need help from family to utilize postnatal care services.

Conclusion
Post natal care service utilization in this study area was low. Counseling to have PNC, presence of ANC follow up during their last delivery, awareness about danger signs and symptoms which comes after delivery, educational status of the mothers, distance from health institutions and family size were variables strongly associated with PNCS utilization.

Recommendation:
Authors recommended health professionals, health facilities. To council and appoint mothers to follow PNC, to council on danger signs and symptoms which comes after delivery and to strengthen the existing policies and strategies to increase mother's level of awareness about PNC through education, information provision, and communication.

Declarations
Ethics approval and consent to participate: Ethics approval was obtained from IRB of Jimma University. Letter of cooperation obtained from Jimma Zone Health Department. Verbal consent was obtained from each participants and husbands for those who are below age of 16, after informing them about the research.
Consent for publication: Not applicable.
Availability of data and material: data used to support the ndings of this study are available within the paper.
Competing Interests: there is no competing interest.
Funding: Jimma University Institute of Health examined the proposal; approved data collection, evaluated the result and funded this study.
Authors' contributions Abera B: had contributed a lot on conception, acquisition of data, analysis and interpretation of data, and Araya F, Rad M and Yesuf E had revised the paper from proposal development to manuscript preparation. All authors read and approved the nal version of manuscript.