Utilization and factors associated with antenatal, delivery and postnatal Care Services in Tigray Region, Ethiopia: a community-based cross-sectional study

Maternal health is a key challenge globally. The unacceptably high levels of maternal mortality are frequently discussed in global health and development meetings. Although remarkable achievement has been made, still there is little or no progress in reducing maternal death in Sub-Saharan Africa (SSA) with only a 40% reduction since 2000. SSA and Southern Asia accounted for approximately 86% (254000) of the global maternal death. In 2017, fifteen countries including Ethiopia were categorized as “very high alert” or “high alert” to maternal mortality with the peak value of 1150 per 100,000 live birth in South Sudan [1]. Ethiopia is one of the countries with high MMR estimated at 412 deaths per 100,000 live births [2]. Even though there is no single, simple or straightforward intervention that can significantly decrease maternal mortality, studies have recommended strengthening the health system, use of skilled delivery attendants, and postnatal care services [3‐6].

Several factors that are related to social-cultural behavior, economic circumstances, and health systems have contributed to the overall high MMR in Ethiopia [7, 8].On the other hand, clinically, maternal mortality has been associated with unsafe abortion, hemorrhage, sepsis, or infection, a hypertensive disorder of pregnancy, and obstructed labor [4, 9]. Deaths because of these major causes could be associated with one of or a combination of the three delays: delay of deciding to seek medical care; delay of reaching health facilities after a decision is made to seek care; and delay of receiving appropriate health care services after reaching a health facility [1, 10].

The World Health Organization (WHO) has identified maternal health services such as antenatal care (ANC), institutional delivery, and postnatal care (PNC) as essential components of intervention needed to reduce maternal and child mortality [1, 3‐5]. Recently, WHO recommends pregnant women should have at least 8 visits during her pregnancy [11]. Therefore, the provision of a quality continuum of maternal health services (quality care during pregnancy, access to skilled delivery and emergency obstetric care, and early postnatal care) is pivotal for the reduction of maternal deaths.

The Ethiopian Health Sector Development Program (HSDP) that has been implemented in the last 20 years gives attention to attain universal access to Primary Health Care (PHC). This includes maternal health services for the whole population through the initiatives of the Health Extension Program (HEP). HEP’s main objective is to ensure access to promotive and preventive health services. House-to-house visits are conducted by health extension workers (HEWs) to trace pregnant women for ANC follow up and to advise them to visit a health facility for institutional delivery [12‐14]. To complement and support the services of HEWs, the government has introduced the women’s development army (WDA). It is a structure at the community level, comprised of one to five networks of women. WDA works together with HEW and provides services in other sectors like agriculture and education. Thus, one to five networks usually six networks create a large network of 30 women call women development groups, which has a leader and a secretary. Members of this group meet once a month to discuss health, agriculture, saving schemes, and education activities [14‐16].

Various studies from the setting have reported low utilization of institutional delivery and moderate use of the ANC services at 5–6% and 54–84.6% respectively [15, 16]. However, reports published by a governmental agency (Tigray Regional Health Bureau) and peer-reviewed articles have been inconsistent. The reported inconsistencies could be due to time delays in conducting operational research. Maternal utilization of ANC and institutional delivery services might have also changed due to recent interventions. The interventions included mobilization of the community by HEWs and WDA in terms of (a) tracing all pregnant women in their localities, (b) facilitating how expectant women can reach the main road, (c) reinforcement of ambulance service in transporting expectant women from the main road to the health centers and hospitals, (d) harmonization of labor and maternal death surveillance report (MDSR) [17].

Thus, this study aims to assess the utilization and factors associated with ANC, institutional delivery, and PNC services among women of reproductive age. And it would have an input in archiving the Sustainable Development Goals (SDGs).

The study assessed utilization and factors associated with maternal health services (ANC, delivery service, and PNC) among women of reproductive age, who had children aged from 45 days to 6 months. The study covered a quarter of the districts (13 districts) in the region. Rural and urban districts were represented proportionally. The maternal health services utilization was 58.2% for ANC visits of 4 and more, 88% for institutional delivery, and 40.3% for PNC service within 42 days. Factor associated with ANC 4+ visit on multiple logistic regression analyses were place of residence, possession of electronic media, and number of children. Partner involvement in the decision to use of ANC services, the contents of ANC discussed during the visit, residence (urban vs rural), birth preparedness, and ANC 4+ visit were factors associated with institutional delivery. Age of the women, number of children, and number of ANC visits were factors associated with the first PNC visit within 42 days.

The utilization of the first PNC service within 2 days after delivery was only 2.1%. Although we reported remarkable progress in the utilization of ANC and institutional delivery, the PNC service remains low. This finding is consistent with the report of Mini EDHS 2014. It was reported that the utilization of the first PNC visit within 24–48 h was low in Amhara (0.5%), Somali (2.6%) and Oromia (2.6%) regions [18]. Based on the WHO report the first 24–48 h of birth is of the greatest need for both the mother and the baby. Consequently, approximately half of women and 30–50% of neonates die within this period [19, 20]. The possible explanation for the low first PNC visits within 2 days of delivery might be due to little attention by the health workers at the grass-root level after a successful birth. Health workers seem to focus more on the survival of the woman during ANC and delivery than at PNC services. Attention given and efforts made by HEWs and WDGs to improve the utilization of the ANC and delivery don’t happen after a mother gave birth. This could be one of the reasons for the very low coverage and provision of immediate PNC services.

In comparison to the results of the Ethiopian mini EDHS 2014 and other previous studies, our findings of the utilization of ANC visit of 4⁺ (58.2%), institutional delivery service (88%) and PNC service of the first visit within 42 days (40.3%) were remarkably higher [15, 16, 18, 21‐23]. The better ANC and institutional delivery service utilization were also reported in a recent study [24]. This remarkable improvement in maternal health services utilization over a short period may be attributed to the high level of political commitment and sustained community mobilization through the HEP and WDA [25]. Besides, the Ethiopian Federal Ministry of Health (FMoH) strategy for the identification of any maternal death at the grassroots level within the concept of a maternal death surveillance report (MDSR) might have contributed to the increased service utilization. The government of Ethiopia has also introduced a new strategy for community mobilization known as WDA and commonly referred to as one of five networks for women to discuss and share their experiences on health-related issues [26]. These interventions may have contributed to the remarkable increment of institutional delivery from 25 to 88%. However, the sustainability of these interventions would require a continuous political commitment to maintain the achievements registered within a few years. This might be ensured by empowering women to bring a behavioral change and seeking maternal health series utilization without the influence of their husbands. Given that many studies have documented the achievements of the interventions, further studies must identify the best practices and strategies that contributed to the success of replicability in other settings.

This study reported that having one of electronic media was a significant predictor of the use of ANC 4⁺ service. The presence of the media might expose women with information on the importance of the ANC and other health-related information. This might have influenced women to develop positive behavior towards health service utilization. Therefore, it would be helpful to disseminate health information through electronic media. In particular, these days the proportion of women with mobile phones and places with mobile network coverage is increasing even in rural areas. Thus, taking advantage of such technologies may improve maternal health services utilization.

Place of residence was found to be a significant factor associated with ANC 4⁺ and institutional delivery. ANC should be received early in the pregnancy and continued until delivery to minimize or rather avoid adverse pregnancy outcomes. Referring to WHO recommendation a woman without complications should have at least four antenatal visits, the first of which should take place during the first trimester [3]. However, our findings on institutional delivery were similar to previous studies [22, 23, 27]. Easy access to most health facilities, highly educated creating better awareness, and improving the infrastructure of urban than rural residents, led to better utilization of maternal health services.

The ANC services are the most important contact point for mothers with health care providers, where information about risks related to pregnancy and delivery might be provided. Furthermore, ANC service utilization is a significant factor associated with a woman’s choice of where to deliver [3]. Hence in this study, we confirmed that a woman who had four or more visits was more likely to deliver at the health facility and attend her first PNC visit within 42 days of delivery. Our finding is in agreement with WHO guidelines, which recommends increasing the number of ANC visits since there is strong evidence with planning and having institutional delivery. This finding is also similar to other previous studies [21‐23, 28].

Partner involvement in the ANC care and discussion of the contents of ANC during the visit of mother to a health facility was significantly associated with institutional delivery. Involving the husband in ANC service could be one potent factor for enhancing institutional delivery in developing countries like Ethiopia, where the husbands are mostly the breadwinners. Furthermore, the contents of services offered and the kind of information given to the woman during ANC visits are also important components of quality care. These services raise awareness of the danger signs during pregnancy, delivery, and postnatal period. Thus improving their health-seeking behavior, and reinforces them to practice birth preparedness [3]. This is reaffirmed by this study since we reported that mothers who discussed the contents of the ANC with the health care providers were more likely to deliver at the health institution. This might imply that providing a woman with comprehensive information on the contents of ANC could build their knowledge and enhances institutional delivery.

Although this study included 13 districts in the Tigray region, Ethiopia, women living in very remote areas with no access to transportation or far from an hour walking distance from the center of the selected villages (Kebeles) were not reached. Income level of women which is one of the factors that affect maternal health service utilization was not also directly assessed. Rather, we tried to assess the income level indirectly through the presence of electronic media by assuming that people with good income will have a better chance of possessing one of the electronic media. Thus, the findings of this study should be interpreted with due consideration of these limitations.

The maternal health service, including 4 or more ANC visits and institutional delivery among women who gave birth within the 6 months before the study period was high. Despite the high coverage of 4 or more ANC visits and institutional delivery, the postnatal care services within 2 days and 42 days after birth was low. Residing in urban areas, possession of electronic media and the number of children could influence the utilization of four or more ANC visits, whereas having partner involvement in the decision to use ANC service, the distance of walking time of less than 30 min to the nearest health facility, discussing the contents of the ANC during a visit, residing in urban areas, having birth preparedness and four or more ANC visits were the factors making a difference in institutional delivery. All actors need to collaborate for keeping the momentum in mobilizing the HEP and women’s development groups to readdress the improved utilization of the early PNC visit.