Utilisation of Post-natal care services
We found that 42.8% of the participants had at least one PNC contact, which is slightly higher than that recorded in Ethiopia, Rwanda and Ghana [21–25]. On the other hand, it is lower than the reported prevalence of 48.4% for Malawi, 63% for Zambia and 78.4 % for Indonesia [26–28]. This observed PNC utilisation is lower than the 90% recommended PNC coverage by WHO , which continues to limit the early identification of postpartum complications among the women and the newborns in the country. This situation is particularly worrying because about 40% of the reported maternal and perinatal morbidity and mortality occur in the immediate postpartum period.
Factors associated with PNC utilisation.
The odds of PNC utilisation were almost two times higher among women that delivered by caesarean compared to those that delivered vaginally. This finding is not surprising and it is in line with many other studies across the globe, this is due to the fear for complications that may arise [23, 28]. Generally, patients that have undergone surgery are in most cases given extra attention by health personnel regarding awareness on the complications which come after delivery thus take the scheduled postnatal visits more seriously [23, 30]. In addition, women who have operative childbirths tend to have greater perceived susceptibility to a wide range of postoperative complications; therefore, frequent return to the health facilities would be the strategy to minimise these perceived risks and in return get the opportunity to utilise PNC [27, 31].
Several studies conducted in Uganda, Ethiopia, Malawi, Zambia and Tanzania, have shown that increased frequency of ANC contacts is associated with higher odds of PNC utilisation [24, 27, 28, 32, 33]. Similarly, in this study the odds of PNC utilisation were two times higher among woman who had eight or more ANC contacts compared to their counterparts who had fewer. This may be attributed to the fact that regular contact with health workers during ANC, accords more opportunities for education and counselling about the need to seek for health care services during and after pregnancy [28, 29, 34]. However, there is need to explore the mechanisms associated with increased odds of PNC utilisation among women who initiate ANC after the first trimester. Mothers who had at least one visit by a health field worker had higher odds of PNC utilisation, a finding similar to that of other studies done in similar contexts [35, 36]. The repeated contact with health workers during pregnancy through ANC services and visits by health field workers promote confidence and familiarity with the health system leading to increased trust in the health system . This emphasizes the need to build capacity among field health workers, so that they are empowered to counsel women to seek PNC services at the community level in addition to strengthening the services in the health facilities.
Belonging to richer wealth quintile was significantly associated with increased utilisation of PNC services, a finding similar to studies done in Guinea, Zambia and Ethiopia [26, 30, 37, 38]. Wealth index being a proxy of financial status means that women in higher wealth indices can easily afford the direct and indirect costs involved in accessing quality and timely healthcare. [39, 40]. Furthermore, women from wealthier households tend to be more enlightened and empowered hence have more decision making powers which enables them to have timely and more frequent healthcare access . Given that Sierra Leone has free maternal healthcare services , our results suggest that, apart from the cost of health services, other economic factors play a key role in influencing PNC utilisation. However, studies from countries like Rwanda, did not show any correlation between the financial status of women and their utilisation of PNC . The discrepancy may be attributed to the fact that Sierra Leone has not effectively implemented the free maternal healthcare services policy like Rwanda  and the higher poverty levels and the poorer road networks in Sierra Leone that make indirect maternal healthcare access costs a huge burden.
The odds of PNC utilisation among women who had no big problems seeking permission to access healthcare were more compared to their counterparts with big problems seeking permission for healthcare access. It is widely reported that empowering women to individually take decisions concerning their maternal health demands has greatly shown positive impact in the utilisation of services like PNC . The influence of spouses an family members in the women’s decision making towards seeking health care services has elsewhere been documented as a key factor limiting utilisation of services like PNC [28, 38].
Regarding mass media exposure, none of the mass media were significantly associated with PNC utilisation. However, exposure to radio and TV were marginally associated with PNC utilisation. Although exposure to media has been shown in previous studies to have a positive association with PNC utilisation , the low levels of education evidenced by over 52.7% women having no education and the fact that over 61.9% of the women reside in rural areas where access is hard and not sustainable due to the costs involved might partly explain the non-significant findings.
Women in the Eastern region had lower odds of PNC utilisation compared to women in the Western region. In Sierra Leone, the Western region has the largest concentration of health workers, is the most developed region, which also houses the capital and economic city of the country and hence has higher quality social amenities compared to other regions [41, 44]. Therefore, women in the Western region have easier access to health care facilities for PNC and are more likely to afford the direct and indirect costs involved in seeking PNC. However, more studies are needed to explore these regional differences in the utilisation of PNC. The role of regional disparities in explaining PNC utilisation has also been documented in previous studies in Malawi, Tanzania and Ghana [25, 28, 35].
Muslim women were more likely to utilise PNC compared to their Christian counterparts which finding was observed in a similar study done in Ghana . Muslims are a majority in Sierra Leone with over 78.7% of the women in our study which could lead to much influence and social support which social support could partly lead to increased utilisation of PNC services. Furthermore, it has also been documented that some Christians rely on spirituality and faith-based practices in seeking healthcare and in coping with illness [25, 45]. Hence, we partly reason that, the Christians might have relied on their faith, hence prioritising their faith over seeking PNC. We however recommend further studies on the influence of religion and PNC utilisation.
Our study revealed a negative association between parity and PNC utilisation, women of low parity had higher odds of utilising PNC compared to those of higher parity (5 and above). This has been observed in similar studies [31, 46, 47]. Women of low parity usually depend on the support of health professionals and their close relatives for postpartum care and they are usually very curious about their health and that of their baby. This may partly explain this observation of increased utilisation of PNC services in this category . On the other hand, multiparous women tend to have a sense of having gained enough experience when it comes to childbirth, hence have less fear for negative pregnancy outcomes associated with limited utilisation of maternal healthcare services . Furthermore, limited availability of time because of the extra responsibilities to take care of the other children might make it hard for these women to access maternal healthcare services for the selves and the newborn [48, 49].
Unexpectedly, women resident in urban areas and those who delivered at health facilities had lower odds of PNC utilisation compared to those who are resident in rural areas and those that had home deliveries respectively. Most studies have shown urban areas to be associated with better PNC utilisation [28, 30, 50] due to factors such as high concentration of health care facilities, having more educated and financially stable women . However, the reverse finding in our study could be partly attributed to the increasing numbers of urban poor population coupled with high standards of living and inequitable distribution of social amenities including public and private health facilities make it hard for low income women to access the services . Furthermore, the documented staff challenges such as poor delegation, favoritism and a lack of autonomy could partly affect quality of services in urban public health facilities which further limits access to these facilities [41, 44]. The efforts of the government to ensure better service delivery in less developed rural areas could also have contributed to this finding . However, more studies are needed to explore these rural-urban differences in the PNC utilisation. Several studies have shown women who utilised health facilities for childbirth to have had higher odds of PNC utilisation [22, 23, 30] contrary to our finding. However, Kante el al. and Mohan et al. found women who had delivered from home to have had higher odds of PNC utilisation compared to those who delivered from health facilities [34, 35]. This could be partly explained by the poor quality of care and experiences from the healthcare workers that women could have had during childbirth in the health facilities that demotivated them to return for PNC . Secondly, for PNC done in the community, it’s possible that the community health workers prioritise women who failed to deliver from a health facility and lastly, the need to get child health for the babies required for immunization and other services could have motivated women who had delivered from home to report to health facilities and end up receiving PNC .