Postnatal Care Utilization and Its Determinants in Loma District, Southwest Ethiopia: A Community Based Cross Sectional Study

Background: The postnatal period is a critical phase in the lives of mothers and newborn babies. Most maternal and infant deaths occur during this time. However, this is the most neglected period for the provision of quality care. The aim of this study was to assess the status of postnatal care and its determinants among women who gave birth within one year preceding the study in Loma district, South West Ethiopia. Methods: A community based cross sectional study was conducted in Loma district, South West Ethiopia. A multistage sampling technique was used. Data was collected using pre-tested questionnaires. Data was entered in to EpiData 3.1software and exported to SPSS version 20.0 for Bivariate and multivariate analysis. Results: More than a-third of mothers utilized postnatal care services. Urban as place of residence (AOR=3.7, 95% CI: 1.1, 13.2), being literate (AOR=3.3; 95% CI: 1.3, 8.5), being merchant (AOR=7.7; 95% CI: 1.4, 42.4), and delivery at health post (AOR=2.7; 95% CI: 1.0, 7.0) were found to be significantly associated with postnatal care service utilization. Conclusion: Place of residence, place of delivery, educational status and occupational status were found to be determinants of postnatal care service utilization.


Introduction
The Provision of Postnatal Care (PNC) services to the mother and their newborns within the first 42 days of life has been set up both with the objective to prevent and reduce maternal and neonatal deaths worldwide [1]. Care during this period is critical for the health and survival of both the mother and her newborn. Postnatal care is preeminently about the provision of a supportive environment in which a woman, her baby, and the wider family can begin their new life together. Many physiological and psychological changes that occur during the postnatal period determine their future well-being and health [2,3].
Globally, more than half a million women die each year from complications of pregnancy and childbirth [4,5]. A large proportion of maternal and neonatal deaths occur during the first 48 hrs after delivery. Every year, four million infants die within their first month of life, representing nearly 40 percent of all deaths of under 5 age children [6]. In Ethiopia 61% of maternal death takes place in the postpartum period and 58% of infant mortality rate occur in postnatal period [4,7].
It is an incontrovertible fact that PNC services help to safeguard women from complications following delivery and provide important opportunities to assess the infant's development. Moreover, PNC services help to offer newborn care (e.g. counseling on breast feeding and Preventing Mother -to-Child Transmission) and other services like immunization and family planning which are crucial for both the mother and the infant [2,5,8].
Thus, the principal objectives of PNC services are to support the mother and her family in the transition to a new family constellation, prevent, early diagnose and treat complications of the mother and infant, refer the mother and infant for specialist care when necessary, counsel on baby care, support breastfeeding, counsel on maternal nutrition, and supplementation if necessary, counsel and provide contraception service, and immunize the infant [2].
Despite its importance, this period is generally the most neglected in developing countries and most mothers and new born babies do not receive postnatal care services from a skilled health care provider during the critical first few days after delivery [1,2]. Neonatal mortality of Ethiopia was 37 per 1000 live births which is the highest in sub Saharan African countries [9]. Accordingly, in Ethiopia, 61% of maternal deaths and 58% of infant mortality rate takes place during this period. This problem is attributed by poor utilization of PNC and its low prevalence [4,6].
Thus indentifying the factors deter PNC service utilization is crucial for countries, like Ethiopia, with alarmingly high maternal and neonatal mortality rates. Therefore, the purpose of this study was to assess the postnatal care utilization and its determinants in Loma district, southwest Ethiopia.
In addition, eligible women in each selected kebele was enumerated and reassured with health extension workers. Then those eligible HHs were given codes/numbers and sampling frame was formed. Finally, study HHs were selected by using simple random sampling from sampling frame and mother who gave birth within the last one year preceding the survey were interviewed and if more than one eligible woman dwells in same house, only one was included in study randomly.
The data was collected on socio-demographic and obstetric characteristics, use of ANC, place of current delivery and delivery assistance. Besides; data was collected on variables such as information on first visit of mother, timing of first visit for mothers who took PNC, place of visit for check up and type of personnel provided the check up.

Data collection tool and procedure :
Interviewer administered structured questionnaire was used to collect the data. The questionnaire was adapted from Ethiopian Demographic Health Survey (EDHS) 2011 [7]. Three BSc degree holders & six diploma holder health professionals were participated in the data collection. Two supervisors were recruited from the adjacent woreda health office & participated. One day orientation was given to the data collectors and supervisors on the data collection tools and procedures by the principal investigators.

Data quality control:
The questionnaires were translated from English into the local language (Dawurot'uwa) & vice versa. A pre-test was conducted on 5% of the sample. Data collectors were trained on how to conduct the data collection. Daily supervision was held by field supervisors and the investigators. Data collectors were enabled to rectify incomplete and inconsistent data by supervisors at the time of data collection. Supervisors used to check all procedures and completeness of formats randomly. The collected data were rechecked before data entry.

Data processing and Analysis:
Data was analyzed by SPSS windows version 20. Frequencies and percentages of different variables were computed to summarize the data. Bivariate logistic regression model was fitted as a primary method of analysis. Based on the findings of bivariate analysis, variables having p <0.2 were entered into multivariate logistic regression analysis using the forward LR method. Finally, P<0.05 in multivariate analysis was used to declare determinants of postnatal care utilization.

Definition of terms:
Early Postnatal care: Proportion of women who attended post natal care at least once during the early post-partum period (within 7 days after delivery). is a health professional that is trained in the skills needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in the identification, management and referral of complications in women and newborns.

JScholar Publishers
Skilled deliveries:Proportion of births attended by skilled health personals.

Socio-Demographic Characteristics :
A total of 694 study participants were involved in the study with 97% of response rate. Majority 547(81.3%) of the respondents were residing in rural area. The mean age of the mothers was 30(+7) years. About 661(98.2%) of the respondents were married whereas 559(83.1%) were protestant religion followers. Dawro, 641 (95.2%), was the dominant ethnic group. Regarding their educational status and occupation of the study participants, 483 (71.8%) and 573 (85.1%) were literate and house wives, respectively. Majority, 611(90.8%), of the study participants had more than four family members (Table  1).

Maternal health service utilization and Obstetric Characteristics :
The study revealed that the level of ANC and PNC service utilizations were 296(44.0%) and 247(36.7%), respectively. Besides, slightly more than half, 341(50.7%), of study participants had history of pregnancy three to five times. About one-fourth (25.2%) of the mothers had attended skilled delivery services, while 186(27.6%) of the mothers gave their last birth at home (Table 2&3).

Knowledge of Women on Complication Related to Pregnancy and source of health information
Majority, 621(92.3%), of the mothers had knowledge about danger sign that could occur during pregnancy /labor. Large number of women had knowledge of complications related to delivery and labor, of which 541(80.4%) mentioned prolonged labor. Besides, 338(50.2%) of mothers got information from health professionals including health extension workers whereas 227(33.7%) of them reported to have got through Health Development Army (HAD) network (Table 4).

Determinants of Postnatal Care Utilization
The multivariate logistic regression analysis revealed place of residence, educational status, occupational status and place of delivery were significantly associated with postnatal care utilization.
Accordingly, women who gave birth at health institutions were nearly three times (AOR=2.7, 95% CI: 1.1, 7.0) more likely to attend postnatal care services as compared to women who delivered at home. Besides, women who were literate were three times (AOR=3.3; 95% CI: 1.3, 8.5) more likely to utilize postnatal care service as compared to those women who were illiterate. Moreover, those women who resided in urban setup were nearly four times (AOR=3.7; 95% CI: 1.1, 13.2) more likely to attend postnatal care services compared to those women's who resided in rural community (

Discussion
This study had focused on the utilization of postnatal care and its determinants. The study revealed that the proportion of postnatal care service utilization was 36.7%. This finding is lower than the findings of studies conducted in Cambodia, Nepal and Ethiopia [3,12,13]. The difference might happened due to the fact that majority of the participants were rural settings; who might have less access to health facilities with integrated maternal health services. In contrast, this finding is higher than the overall national average of EDHS finding of 2011 [7] and other study done in Jabitena district of Amhara Region, Ethiopia [14]. This may be attributed to the time difference that there could be improvement in accessing and utilizing health care service through time.
Literate mothers showed better utilization of postnatal care services as compared to illiterate women. This result is similar with findings from studies conducted in Ethiopia, Indonesia, and India [14,15,16]. This could be explained by the fact that education has a valuable input in enhancing female autonomy and help women develop greater confidence and capability to make decisions about their own health. Thus, literate women seek out higher quality health services and have greater ability to use health care inputs that offer better health outcomes. Besides, urban mothers were 3.7 times more likely to receive PNC services than rural mothers. This was in line with the evidence from EDHS 2011 [7], Cambodia [3] and Nepal [12] in which urban mothers were more likely to receive PNC services than rural mothers from both health professionals and non-health professionals. This might be due to the fact that urban women may have information from different sources on PNC services or because of the availability of a good number of health institutions in urban areas.
With regard to influence of mother's occupation on postnatal care services, mothers who were housewives were less likely to attend postnatal care services as compared to those who were merchants. It is reasonable to assume that women who entirely own household responsibility as housewife may be unable to attend postnatal care services due to their tiresome indoor works; which may limit them from seeking maternal health care services. Accordingly, mothers who were merchants were more likely to be aware of the benefits of obtaining postnatal care services through different media such as television and newspapers than their counterparts that most of the time housewives stay at home with family responsibility. This finding suggests that there is a need to provide postnatal care services through alternative community based approaches to address these groups.
Mothers who had delivered their last baby in health institution utilized postnatal care services more likely when compared with those who delivered at home. This finding is similar with study findings from India, Cambodia, Nepal and Ethiopia [17,3,12,13]. This may be attributed to the fact that women who gave their last birth in health institution have greater opportunity to get exposed to health education related to PNC services at the time of delivery and thus get access to learn about the types, benefits and availabilities of PNC services during their stay in the health institutions.

Conclusion
The level of postnatal care service utilizations was found to be only a-third. Postnatal care utilization was positively associated with place of residence, educational status, occupational status and place of delivery. Accordingly; living in rural area, low literacy status, engaged in laborious government office works and home delivery were found to be determinants of postnatal care utilization.

Recommendation
Federal Ministry of Health in collaboration with Ministry of Education should work on better access of women education. Regional Health Bureaus should focus their intervention on improvement of institutional delivery. Besides; Zonal and District Health Offices in collaboration with other stakeholders should work hard to improve the postnatal care utilization of women living in rural area. Further study should be conducted on the partners' influence and health institution based factors on postnatal care utilization to have full picture of the determinant factors.

Ethical approval and consent to participaten
Before the actual data collection; the proposal was presented to Jimma University, Department of Epidemiology, and then ethical clearance letter was obtained. The participants were well informed about the purposes of the study, and oral consents were obtained accordingly. The participants' rights to refuse or withdraw from participating in the study and confidentiality issues were considered.