Introduction
Even though the global Maternal Mortality Ratio (MMR) and neonatal mortality over the last two and three decades have shown an annual 2.9% and a 2.5% decline respectively [
1,
2], the problem is still pressing in Low and Middle-Income Countries (LMIC). MMR is disproportionately higher in low-income regions: for instance, from the total pregnancy and childbirth-related maternal mortality, 7 out of 10 were from Sub-Saharan Africa (SSA) countries [
3,
4]. As a result, the MMR in low-income countries is about 479 per 100,000 live births, whereas it is 41 per 100,000 live births in high-income countries [
5]. In Ethiopia, about 112,000 newborn babies and 14,000 mothers die each year due to preventable causes [
6,
7].
To bring this to an end, in 2015, the World Health Organization (WHO) launched a strategy to End Preventable Maternal Mortality (EPMM) through the maternal health service continuum across the stages of pregnancy, delivery, and postpartum periods [
8]. By then, to meet the WHO's global target of reducing MMR to less than 70 per 100,000 live births on one side, and to lower neonatal mortality to less than 12 per 1000 Live births by 2030 on the other hand [
9]. In Ethiopia, as part of the strategies, the government identified maternal, newborn, and child health as a priority agenda aiming to reduce the MMR from 412 to 42 per 100,000 live births by the end of 2035. In addition, with a thorough investment in maternal health services, neonatal mortality was planned to be reduced to 21 per 1000 live births in 2024/25 [
10‐
12].
The maternity continuum of care is integrated care; to provide essential health care packages during pregnancy, childbirth, and postnatal periods. It is a focal point of health systems in many countries to minimize preventable maternal loss and complications in most instances and to make pregnancy and childbirth a positive experience in other cases [
13]. The provision of the three integrated care including; antenatal care (ANC), delivery in a health facility, and postnatal care (PNC), as a continuum has gained global attention as one of the strategies to improve maternal and neonatal health outcomes [
14]. As the evidence shows, complete coverage of the maternity continuum of care could avert an estimated 71% maternal mortality ratio (MMR) [
15], and 56% of neonatal death worldwide [
16].
As evidence suggests failing to obtain any of the care along the continuum is associated with discontinuity between maternal and child health programs which results in unfavorable maternal and neonatal outcomes [
14,
17,
18]. Although studies show the completion of maternity services in Ethiopia, the findings are either limited to some geographic area/region, [
15,
19], or the results present inconsistent figures ranging from 14 to 47% or focus on some services [
15,
16,
20,
21]. In this paper, we set out to examine the degree of retaining clients within the continuum of maternity care in Ethiopia using recent nationally representative data. We also report on predictors of retention along the continuum of care and at completion.
Discussion
Reliant on the plausible benefit of completion of the recommended service during and after pregnancy, the maternity continuum of care got attention all over the world as a critical health intervention intending to improve both maternal and child health outcomes [
31]. Respectively, the practice obtained recognition in Ethiopia a couple of decades back, and as a result maternal, and child mortality has reduced by half from the devastating Figure [
32]. Despite the dramatic achievements from the lowest base, maternal death and morbidities are still stagnant which is partly attributable to the dropout of women from the recommended services during pregnancy, delivery, and post-partum periods. This study assessed women's level of accomplishment in care and the possible predictors of success.
The study found that of all women who gave birth within five years preceding the survey, only around one-fifth of them went through all the services during pregnancy, childbirth, and postpartum periods. This finding is in line with a report from the primary health care project in northern Ethiopia (21.6%) [
21] and with a national study (21.5%) in the year 2019 [
29]. It is revealed as there are improvements regarding completion of service as compared to previous studies like EDHS in 2016 [
33], other local studies [
34,
35], and SSA and South Asia [
4,
36]. The improvement may be attributed to the Ethiopian government's and collaborators’ massive effort for implementing initiatives throughout the nation [
37,
38]. Despite the progress made the figure is quite low compared to the findings in other developing countries like Pakistan (27%) [
39], Zambia (38%) [
18], Ghana (66%) [
40], Cambodia (50%) implicating the need for an immense effort.
On the other hand, completion of the care had greater disparities across the regions, it was higher in the 2 city administrations; Addis Ababa (64.1%), Dire Dawa (33.5%), and Tigray region (45.2%), but it was unacceptably low in Somalia region (2.9%). This regional variation is similar to the synthesized information from previous studies in Ethiopia and other developing countries [
33,
41‐
43]. The higher percentage of women who completed the continuum of care in the city is possibly due to the relatively better access to care so there is no way to discontinue the care due to transportation costs or, long walking hours to reach the facility [
44]. In addition, formally employed women are abundant in urban areas, and most likely to be educated, which gives a woman better insight and understanding of the worthiness to follow the course. On the other hand, another national study indicated that despite the tremendous progress in health, it remains uneven between regions and cities [
45].
Related to the above scenario attending the care at each spot has been shown to favor urban women more than those agrarian and pastoralists; obtaining the three services was like a fantasy for the pastoralist women. This finding is supported by earlier studies in Ethiopia [
15,
46,
47]. In the pastoralist community, where cattle breeding is the main economic activity to support living, most people travel a lot to find grazing land and water for their cattle making accessing the health centers more challenging and [
48] creating a bottleneck to care-seeking, and facilities available were poorly equipped. A study from one of the pastoralist areas in Ethiopia concluded that more than 85% of MM in the region were due to direct obstetric causes while according to the WHO estimate among all MMs around the globe, nearly 70% were attributable to direct obstetric causes [
49]. This implies a higher burden of MM associated with the childbearing process in the pastoralist regions.
The overall completion of care was associated with women’s level of education. Those with secondary, and higher education were two times more likely to complete the course of care than those uneducated. This finding is commensurate with various earlier reports [
50‐
53]. Education often plays a preventive role which gives women a positive influence to adhere to care either through enhancing their socio-economic status [
54] or through boosting their knowledge and confidence.
Wealth status was a major characteristic, which had a strong effect on completing the continuum of care. Compared to the poorest, those in the other categories of wealth were more likely to go through all services, and the probability of service use increases as the wealth of the woman increases. Furthermore, wealth status is the only variable that had an effect at each step along the way to the continuum of maternity care. It affects ANC use, it also affects institutional delivery among those who had four or more ANC, and has an effect on the full continuum of maternity care. In studies conducted in Ethiopia, the pro-rich inequalities in maternal health are higher and are, even increasing compared to the previous period [
55]. In addition, it is illustrated that in developing countries wealth-related inequalities in utilizing maternal health are overwhelming, especially in Asia and Africa, and yet are higher than inequalities for child vaccination [
56,
57].
Another important issue in the completion of maternal health services is the timing of the initiation of the first ANC. Women who initiated the first ANC in the first trimester of pregnancy had more chance of attending all four recommended ANC contacts and completing the continuum of care. It is certain that if a woman starts the first ANC during the early pregnancy stages, she can get sufficient time to attend all the other ANC contacts so that she would have a better chance to complete the continuum. A similar study that was conducted in Kenya reported that women who initiated the ANC contact timely were three times more likely to complete all the recommended maternal health services [
58].
On the other hand, the chance of completion of care in this study drops by half for the third child of the household compared to the first child. This finding is in line with what was found in the other three African countries [
59]. This could be related to either a woman's encounter with inadequately person-centered care or a disrespectful experience during her prior health facility contacts, which may lead to an unfavorable perception about seeking care at a health facility during pregnancy and childbirth [
60‐
63]. Alternatively, the women who had prior maternity care at a health facility may have the perception of having the required experience and knowledge to handle the circumstances surrounding pregnancy and childbirth [
58].
Conclusion and recommendations
Despite the efforts by all stakeholders, the overall completion of the maternity continuum of care is very low in Ethiopia. There was also region-to-region variation, where a higher completion of care in the two city administrations, Addis Ababa, Dire Dawa, and Tigray region. We have also found inequality of service use because of women’s background characteristics like level of education and wealth status. The significant dropout of those pregnant women who received the first ANC contact should alert maternal health program managers to find innovative approaches to retain women in the continuum. Such an approach shall aim to empower women through improved educational experience and economic standing by working with other relevant sectors. Furthermore, awareness creation interventions for the pregnant woman and her family would have the potential to raise early initiation of ANC. Lastly, future research has to investigate the reason behind higher regional variations in the continuum of care .
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