Educational inequalities and decomposition of the urban-rural disparities in maternal health care utilization in Ethiopia: further analysis of 2019 intermediate Ethiopian demography and health survey

Abstract

Introduction

The utilization of maternal health services is vital to prevent maternal and child health problems. However, there is limited evidence as to why rural women have lower utilization and educational inequality in maternal health services utilization in Ethiopia. Identifying the causes is the first step to achieving maternal and child health initiatives.

Objective

The objective of this study was to decompose the urban-rural disparities and educational inequalities in maternal health care utilization in Ethiopia.

Methods

The study used the 2019 Ethiopian Demography Health Survey. Blinder-Oaxaca decomposition and multivariate decomposition analyses were done on a weighted 3,926.7 women to see the urban-rural differences in maternal health service utilization by using Stata 17.0. For the educational inequality of maternal health service utilization, concentration curve and concentration index were used by using conindex. P value < 0.005 was used to declare association.

Result

84.89% of urban and 70.75% of rural residents use antenatal care and 73% of urban and 44% rural use institutional delivery. There was no urban-rural difference in postnatal care utilization. There was educational inequality in antenatal care (CIx 0.0926; p < 0.001), delivery care (CIx 0.2137; p < 0.001 and postnatal care (CIx 0.1272; p < 0.001) utilization in Ethiopia. 83.3% of antenatal care urban-rural difference was explained by women’s characteristics difference. Secondary (16.51%) and higher (23.01%) educational level difference of urban and rural women widening antenatal care utilization. Living regions (-1.33%) difference of urban and rural women mitigated antenatal care utilization. About 76.07% of the urban-rural difference in institutional delivery was explained by differences in the characteristics of women. Attending primary (3.76%), secondary (11.83%), and higher (8.44%) education, antenatal care (15.81%) difference of urban and rural women were widening institutional delivery utilization.

Conclusion

The urban-rural disparity in antenatal care and delivery care utilization is significant in the country. There were educational inequalities in maternal health service utilization. Attending, Secondary, higher, educational levels widening antenatal care and institutional delivery care utilization. Living regions mitigated antenatal care utilization. Antenatal care utilization widening institutional delivery utilization. Special attention is needed for rural women to improve maternal health service utilization through health extension workers and the women’s developmental army.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-024-20689-1.

Introduction

Maternal mortality is a global public health problem [1–5]. Globally, maternal mortality is decline in the last 25 years [4, 6–9]. But the burden is high in low income countries [2, 4, 6–9] including Ethiopia, where maternal health service coverage is a public health problem [10–13]. The burden would be potentially high in the third world for the next 10 years [6, 14, 15].

Pregnant women suffer from pregnancy-related complications [16–22]. Reproductive health is a global agendum for the last 50 years [23–26]. Despites the global efforts, reproductive health problems of women are not addressed [4, 16, 20, 27–32].

Improving maternal health is among the targets of the third Sustainable Development Goal (SDG) adopted by the international community [6]. Maternal health service is among the meanness to reduce maternal mortality ratio below 70 per 100,000 live births. But 295,000 maternal deaths were recorded due to pregnancy and child birth by the year 2017 [33]. In 2016, maternal death is the first cause of death among 15–29 years women and the second cause among reproductive age women [34].

Maternal health service includes antenatal care utilization, institutional delivery and post natal care utilization [35, 36]. Maternal health services are the corner stones to mitigate maternal and child mortality and morbidity [4, 8].

In Ethiopia, maternal mortality ratio is high (412 per 100,000 life birth) [37]. The country has reproductive strategy for the last 20 years. Maternal health services are available to the country side and included in health extension package. In the last 2 decades, maternal health service utilizations are increased in the country. But it still low [38].

Antenatal care is among the most effective interventions to mitigate maternal mortality and morbidity [39–41]. It is an entry point for delivery care, postnatal care, child, makes link between the health provider and, the client for further interventions [41–45]. During ANC pregnancy related complications, pre-existing health conditions are screened, diagnosed and appropriate interventions are delivered for pregnant women. Behavioral change communication on personal hygiene, utilization of available services and interventions are provided for the women and the family at large [39, 41, 43, 46–48].

Even though, the coverage of ANC, institutional utilization increased for the last 20 years, still it the services are public health problems [49, 50]. Although the research was conducted in the country, all the studies were done at the local level, used a small sample size, and did not consider the urban-rural difference in a country where81% of the general and 80% of female populations live in rural part of the country and 24.1% and 54.4% of urban and rural women did not attend education at all respectively. The educational inequality of maternal health service utilization is not evidenced in the country. There was trend analysis on optimal antenatal care utilization which is different from antenatal care utilization. The decomposition analysis helps to decompose inequalities in maternal health service utilization in urban-rural settings. The findings might be used to develop effective strategies to minimize the urban-rural difference in the utilization of maternal health services and to reduce educational inequalities in accessing the services. So, the study aimed to identify urban-rural variation, and educational inequalities of maternal health service utilization in Ethiopia a by using decomposition analysis.

Method

Study setting and period

This research was carried out in Ethiopia, situated in the North-eastern region of Africa. The study utilized the intermediate dataset of the Ethiopian Demographic and Health Survey (EDHS) 2019, conducted by the Central Statistical Agency in collaboration with the Federal Ministry of Health (FMoH) and the Ethiopian Public Health Institute. Data were obtained through www.dhsprogram.com after a formal request, and access was granted following approval via email. The study employed a cross-sectional design, utilizing secondary data from the 2019 intermediate Ethiopian Demography and Health Survey.

Sampling procedure

The sample for the intermediate Ethiopian Demographic and Health Survey (EDHS) 2019 underwent a two-stage stratified selection process. Initially, regions were stratified, and within each region, further stratification occurred based on urban and rural distinctions, resulting in 21 sampling strata. A total of 305 enumeration areas (94 urban and 211 rural) were chosen with a probability proportional to Enumeration Area (EA) size within each stratum. In the second stage, households were systematically sampled in proportion to each EA. The analysis included a weighted total of 3,926.7 women, as illustrated in Fig. 1.

Fig. 1.

Sampling and exclusion procedures to identify the final sample size in intermediate 2019 EDHS

Study variables

The outcome variables of this study were urban-rural differences in maternal (Antenatal care, institutional delivery and postnatal care) health service utilization and educational inequality of maternal health care services utilization in Ethiopia. The independent variables include; women’s age, religion, current marital status, educational level, household wealth index, region and number of children.

Variable measurement: If a woman visited at least one ANC during her pregnancy, she was considered as having ANC follow-up and if a woman visited a health facility for follow-up within 42 days after delivery, she was considered as having postnatal follow-up [51]. Respondent’s education categorized into (no education, primary, secondary and higher education), Wealth index was classified as (poorest, poor, middle, richer and richest), parity (1, 2–4 and 5 and above), region (developed and developing). Amhara, Oromia, Tigray, SNNP, Addis Ababa and Dire Dawa are considered as developed and others as developing regions [52, 53].

Data management and analysis

Data management and statistical analyses were done by using Stata 17.0 software. Mean, median and percentages were used to describe the characteristics of the study population by area. The Pearson chi-square was used to examine whether ANC, Institutional delivery and postnatal care utilization was different in urban and rural women in Ethiopia. To explain the urban-rural disparities of ANC, institutional delivery and postnatal care among reproductive-age women, the Blinder-Oaxaca decomposition analysis was used [54]. This technique decomposes the differences in an outcome for two groups can be explained by differences in the level or distribution of the determinants of the outcome, differences in the impact of these determinants on the outcome and/or the interaction of the two [55]. The Oaxaca decomposition utilizes the high group (urban women in this study) as the reference group, weighting contrasts in attributes by the coefficients of urban women and contrasts in coefficients by the covariates of rural women. Regressions were performed for urban and rural women independently and afterward the assessed coefficients and covariates were utilized to compute the decompositions [56]. Consistent results using the different weights were thought to represent the robustness of the study outcome. The extension of the Oaxaca-Blinder method for non-linear dependent variables, Multivariate decomposition (mvdcmp) was used for detailed decomposition [57]. It is primarily intended for use in nonlinear decomposition and convenient methods for dealing with path dependency, as well as overcoming the identification problem associated with the selection of a reference category when dummy variables are included as Oaxaca. Mvdcmp determines the high-outcome group automatically and uses the low-outcome group as a reference [58].

Concentration curve and concentration index

We examined education-related inequality in ANC, institutional delivery and postnatal care utilization in Ethiopia using both concentration curve and concentration index methods. Concentration curves were used to illustrate the extent to which ANC, institutional delivery and postnatal care utilization were unequally distributed across educational levels. The concentration curve plots the cumulative percentage of the outcome variables (y-axis) against the cumulative percentage of the population, ranked by educational level, beginning with the uneducated and ending with the highest educational level (x-axis). We used three separate concentration curves to visualize the distribution of ANC, institutional delivery and postnatal care utilization by educational status. A concentration curve below the diagonal line also called the line of perfect equality indicates that outcome variables are concentrated among the highly educated, also called pro-educated inequality, whereas a curve above the diagonal line indicates that they are concentrated among the uneducated, also called pro-uneducated inequality. Furthermore, we calculated the concentration index, a summary measure of the magnitude of educational-related inequality. The concentration index ranges from − 1 to 1, with zero indicating perfect equality, negative values indicating that the outcome variable is concentrated among the uneducated and positive values indicating that it is concentrated among the educated group [59]. The concentration indices were calculated using the conindex command in Stata version17.0.

Results

Characteristics of the respondents

A total of 3,927 women participated in the analysis, comprising 1,004 from urban areas and 2,923 from rural regions. In the urban cohort, the mean age was 28.42 years (± 6.19 standard deviation), while rural dwellers had a mean age of 28.73 years (± 6.88 standard deviation). The average age at the first birth for urban participants was 20.24 years (± 4.63 standard deviation), contrasting with rural residents at 18.17 years (± 3.95 standard deviation). In terms of educational attainment, 304 individuals (29.66%) in urban areas and 1,710 individuals (58.96%) in rural areas did not receive any formal education, as indicated in Table 1.

Table 1.

Socio-demographic characteristics of pregnant women in Ethiopia, intermediate EDHS 2019

Variable	Urban	Rural
Current age in years (mean)	28.42	28.73
Age at first birth (mean)	20.24	18.17
Religion
Orthodox	396 (38.59)	1,045 (36.02)
Muslim	304 (29.59)	1,036 (35.72)
Others*	327(31.82)	819 (28.25)
Educational status
No education	304 (29.66)	1,710 (58.96)
Primary	424 (41.32)	991 (34.16)
Secondary	179 (17.46)	165 (5.70)
Higher	119 (11.56)	34 (1.18)
Household Wealth index
poor	123 (12.02)	1524 (52.54)
middle	60 (5.85)	701 (24.18)
rich	843 (82.13)	675(23.28)
Marital status
Never married	5 (0.53)	15 (0.53)
Married	933 (90.9)	2,752 (94.88)
Widowed/ divorced	88 (8.57)	133 (4.59)
Parity
1	281 (27.33)	545 (18.78)
2–4	520 (50.62)	1,218 (41.99)
5 and above	226 (22.05)	1,138 (39.22)
Region
Developing	106 (10.35)	229 (8.54)
Developed	920 (89.65)	2,671 (91.46)

Urban-rural differences in the utilization of maternal health services

In Fig. 2, the utilization of antenatal, delivery care, and post-natal care in both urban and rural settings, as well as overall utilization in Ethiopia, is presented. The overall utilization of antenatal care stood at approximately 75%. Notably, urban residents exhibited a higher uptake at 84.89%, surpassing the 70.75% observed among rural residents. Institutional delivery accounted for 52% of births in Ethiopia, with a significant disparity between urban (73%) and rural (44%) residents (Fig. 2). The overall utilization of post-natal care in the country was approximately 14%. Chi square test indicates, both antenatal care and institutional delivery showed statistically significant differences between urban and rural dwellers, at (p-value < 0.001).

Fig. 2.

utilization antenatal care, institutional delivery and post-natal care services in Ethiopia stratified by their residency, 2019

As maternal age advances, the disparity between urban and rural areas in the utilization of antenatal care, institutional delivery, and postnatal care widens. The most substantial difference, at 36.34%, in institutional delivery was noted among women aged 35–49 years. With increasing educational attainment, the urban-rural differences in the utilization of antenatal care, institutional delivery, and postnatal care generally decrease, except for the highest educational level. Notably, the most significant difference (8.31) in postnatal care utilization was observed among women with higher educational levels, as outlined in Table 2.

Table 2.

Urban-rural difference on antenatal care, institutional delivery and postnatal care utilization in Ethiopia, 2019

Variables	% of Antenatal care utilization			% of institutional delivery			% of post-natal care utilization
	Urban	Rural	Deference	Urban	Rural	Deference	Urban	Rural	Deference
Current age
15–19	69.05	69.12	-0.07	57.62	56.83	0.79	21.28	15.43	5.85
20–34	92.00	70.49	21.51	74.02	45.65	28.37	15.64	12.30	3.34
35–49	85.03	61.93	23.1	72.78	36.44	36.34	19.29	12.75	6.54
Age at 1st birth
<= 19	84.92	68.06	16.86	65.65	42	23.65	13.15	13.73	-0.58
> 19	94.23	69.03	25.2	81.16	48.13	33.03	20.6	10.23	10.37
Religion
Orthodox	97.83	82.01	15.82	85.65	49.99	35.66	21.42	15.16	6.26
Muslim	84.41	58.95	25.46	83.72	40.69	43.03	15.46	11.47	3.99
Others*	86.56	70.01	16.55	47.52	40.50	7.02	11.91	10.78	1.13
Educational status
No education	77.94	59.23	18.71	53.65	33.28	20.37	13.44	10.99	2.45
Primary	89.59	79.38	10.21	74.53	54.25	20.28	15.59	13.85	1.74
Secondary	98.45	92.31	6.14	90.52	82.41	8.11	23.32	22.30	1.02
Higher	98.84	96.61	2.23	90.24	96.27	-6.03	18.45	10.14	8.31
Household Wealth index
poor	69.89	58.23	11.66	45.15	30.90	14.25	21.12	10.07	11.05
middle	60	79.14	-19.14	23.09	48.48	-25.39	15.35	15.03	0.32
rich	92.85	87.19	5.66	80.56	68.85	11.71	16.08	15.77	0.31
Marital status
Currently not married	81.90	70.74	11.16	65.23	44.39	20.84	13.53	20.00	-6.47
Currently Married	90.66	68.21	22.45	73.72	43.96	29.76	16.96	12.20	4.76
Parity
1	92.9	77.45	15.45	87.90	66.54	21.36	12.75	16.79	-4.04
2–4	92.13	71.08	21.05	72.78	44.01	28.77	22.00	11.55	10.45
5 and above	76.88	61.2	15.68	54.78	33.16	21.62	9.15	11.72	-2.57
Region									0
Developed	92.49	75.63	16.86	74.21	45.78	28.43	17.38	13.22	4.16
Developing	81.78	57.36	24.42	61.94	23.05	38.89	10.44	5.43	5.01
Attending antenatal care
No				25.83	11.32	14.51	2.59	3.08	-0.49
Yes				81.33	57.49	23.84	19.11	16.54	2.57
Institutional delivery
No							10.47	7.47	3
Yes							18.88	18.83	0.05

Educational inequality of maternal health service utilization

Figure 3 displays the concentration curve elucidating the distribution of antenatal care (ANC) service utilization in Ethiopia. The curve notably positions below the equality line (red dashed line), indicating a disproportionately high concentration of ANC service utilization among highly educated women. The Concentration Index (CIx) for ANC service utilization was calculated at 0.0926 (standard error: 0.0053; p < 0.00), affirming this uneven distribution of ANC utilization with educational status. Similarly, the concentration curves are situated beneath the equality line for institutional delivery and postnatal care utilization, signaling an unevenly high concentration of these services among highly educated women. The CIx values for institutional delivery and post-natal care service utilizations were 0.2137 (standard error: 0.0082; p < 0.00) and 0.1272 (standard error: 0.0232; p < 0.00), respectively.

Fig. 3.

Concentration curve of antenatal care institutional deliver and post natal care by educational status

Detailed decomposition

Statistical variations were observed in antenatal care and institutional delivery between urban and rural residents in Ethiopia, while no such disparity was found in postnatal care utilization. Of the urban-rural difference in antenatal care utilization, 83.3% could be attributed to divergences in women’s characteristics. Educational status, religion, marital status, and geographical arrangement significantly contributed to the difference in antenatal care utilization. Positive coefficients widened the gap, while negative coefficients mitigated it. Disparities in secondary and higher educational levels contributed to a 16.51% and 23.01% widening of antenatal care utilization, respectively. Urban-rural differences in marital status and living regions mitigated antenatal care utilization by -2.6% and − 1.33%, respectively. Difference in the behavior of the rural and urban women accounts about 16.7% of disparities in antenatal care utilization. However, this effect did not demonstrate statistical significance between urban and rural women.

About 76.07% of the urban-rural difference on institutional delivery was due to differences in characteristics of women. The difference of institutional delivery was significantly attributed to attending primary (3.76%), secondary (11.83%), and higher (8.44%) educational status of women, having 2 to 4 children (-6.1%), following Muslim religion (-3.62) and attending antenatal care (15.81%). Difference in the behavior of the rural and urban women accounts about 23.93% of disparities in institutional delivery utilization. However, the effect had no statistical difference between urban and rural women (Table 3).

Table 3.

Detailed decomposition antenatal care, institutional delivery and postnatal care by place of residence in Ethiopia, 2019

Utilization of services	ANC			Delivery care			Postnatal care
	Coefficient	P value	%	Coefficient	P value	%	Coefficient	P value	%
Decomposition
Row difference	0.14	< 0.001		0.29	< 0.001		0.04	0.057
Explained	0.12	0.001	83.3	0.22	< 0.001	76.07	-0.05	0.352	-112.37
Unexplained	0.02	0.623	16.7	0.07	0.341	23.93	0.09	0.128	212.37
Endowment (Explained component) = difference in characteristics (E)
Current age
15–19
20–34	0.005	0.37	3.32	0.002	0.851	0.69	-0.021	0.524	-50.85
35–49	0.001	0.968	0.15	-0.009	0.371	-2.96	0.011	0.637	27.03
Age at 1st birth
<= 19
> 19	0.008	0.07	6.14	0.001	0.992	0.03	0.016	0.440	39.47
Religion
Orthodox
Muslim	0.003	0.215	2.37	-0.01	0.017*	-3.62	0.001	0.961	0.79
Others*	-0.005	0.001*	-3.48	-0.009	0.001*	-3.14	-0.002	0.577	-5.77
Educational status
No education	Reference
Primary	0.002	0.329	1.52	0.011	0.028*	3.76	0.002	0.801	5.09
Secondary	0.023	0.002*	16.51	0.034	0.001*	11.83	0.015	0.536	36.58
Higher	0.035	< 0.001*	23.01	0.024	0.036*	8.44	0.004	0.793	9.58
Household Wealth index
poor
middle	0.004	0.656	2.94	0.01	0.469	6.89	0.01	0.767	25.79
rich	0.041	0.103	28.78	0.104	0.146	35.97	-0.204	0.288	-503.93
Marital status
Currently not married	Reference
Currently Married	-0.003	0.048*	-2.60	-0.007	0.068	-2.35	-0.001	0.905	-1.42
Parity
1	Reference
2–4	-0.005	0.176	-3.79	-0.018	0.014*	-6.1	0.022	0.425	53.86
5 and above	0.005	0.566	3.67	0.032	0.067	11.28	0.002	0.958	4.02
Region
Developed	Reference
Developing	-0.002	0.005*	-1.33	-0.001	0.499	-0.45	-0.004	0.299	-10.7
Attending antenatal care
No				Reference
Yes				0.045	0.001*	15.81	0.081	0.502	200.23
Institutional delivery
No
Yes							0.027	0.608	66.08
Due to Difference in Coefficients (C)
Current age
15–19
20–34	0.031	0.662	22.025	0.05	0.66	17.22	-0.175	0.343	-432.75
35–49	-0.006	0.84	-4.23	0.038	0.391	13.37	-0.058	0.413	-144.39
Age at 1st birth
<= 19
> 19	0.022	0.232	16.1	-0.001	0.951	-0.46	0.057	0.12	141.92
Religion
Orthodox
Muslim	-0.002	0.908	-1.57	0.05	0.056	17.42	-0.002	0.955	-4.01
Others*	-0.028	0.259	-19.83	-0.051	0.03	-17.73	-0.002	0.934	-5.04
Educational status
No education	Reference
Primary	-0.015	0.551	-6.75	0.027	0.288	9.21	0.006	0.831	14.99
Secondary	0.004	0.427	3.09	0.005	0.363	1.89	0.001	0.931	1.28
Higher	-0.001	0.690	-0.39	-0.002	0.396	-0.67	0.001	0.508	3.16
Household Wealth index
poor
middle	-0.019	0.342	-13.47	-0.04	0.27	-13.93	-0.014	0.686	-35.44
rich	0.001	0.987	0.11	0.001	0.976	0.28	-0.056	0.188	-137.71
Marital status
Currently not married	Reference
Currently Married	-0.003	0.334	-2.72	0.126	0.171	43.49	-0.007	0.299	-16.24
Parity
1	Reference
2–4	-0.033	0.310	-23.64	-0.03	0.426	-10.31	0.104	0.167	257.28
5 and above	-0.01	0.708	-7.19	-0.016	0.702	-5.7	0 0.023	0.649	57.1
Region
Developed	Reference
Developing	-0.001	0.913	-0.24	-0.001	0.9	-0.28	-0.004	0.674	-8.76
Attending antenatal care
No
Yes				-0.01	0.885	-3.47	0.091	0.619	223.73
Institutional delivery
No
Yes							-0.018	0.68	-43.96

Discussion

The objective of this study was to examine the urban-rural disparities and educational inequalities in maternal health care service utilization in Ethiopia by using mini EDHS 2019.

There was a statistical disparity in urban-rural ANC utilization in Ethiopia. The finding was supported by findings from Ethiopia [60] and Indonesia [61]. Even though the prevalence of ANC is low, the utilization is higher in urban residents than rural residents in Ethiopia. The urban-rural discrepancy might be due to the availability of health facilities in urban areas [62–66], Health care facilities in rural areas are usually located centrally, making it difficult for many women in such areas to access them easily, thereby causing a low use of such services, more experts are found in urban areas [64, 67, 68]. Moreover, urban women have good knowledge and information about ANC [65, 69].

83.3% of the urban-rural difference in antenatal care utilization was due to differences in the characteristics of women. In the decomposition analysis, marital status, region, and educational level of mothers, contributed to the urban–rural disparity in antenatal care use. The finding is supported by previous findings [70, 71]. Among the compositional factors, a very significant contribution to the positive disparities of urban-rural ANC utilization was due to maternal educational status. 17.46% and 11.56% of urban residents were attending secondary and higher education, and 5.7% and 1.18% of rural residents were attending secondary and higher education respectively (Table 1). A higher proportion of women attending secondary and higher education in urban areas increase the gap in ANC utilization. The result implies that to reduce the urban rural difference, education is very important on which Ethiopia launches universal educational coverage for the last 3 decades. In comparison to urban areas, where educational opportunities may be more readily available, rural areas often face challenges in providing access to education. This can result in lower levels of education among women in rural areas, which in turn can contribute to disparities in ANC utilization. There is educational inequality (CIx = 0.0926, p < 0.001) of using ANC in Ethiopia. The finding is in line with previous findings [9, 61]. The result implies, to improve as well as to reduce inequalities of ANC utilization, education is crucial.

Marital status mitigates urban rural difference of ANC by -2.6%. That is being married increases ANC utilization. This finding is significant as it highlights the importance of addressing urban-rural disparities in marital status in order to improve access to antenatal care services. Unmarried women were less likely to utilize antenatal care services compared to married women [66, 72]. This suggests that addressing urban-rural differences in marital status could indeed have a significant impact on improving access to antenatal care.

About 76.07% of the urban-rural difference on institutional delivery was due to differences in characteristics of women. The finding is in line with [73]. Difference due to coefficients accounts for about 23.93% of disparities in institutional delivery. However, the effect had no statistical difference between urban and rural women. The variation in delivery care utilization between urban and rural areas in Ethiopia may be attributed to factors such as the lower socioeconomic status of rural women, limited access to ANC services, and limited access to media. The descriptive statistics reveal that nearly a third (71%) of pregnant women in rural areas did not receive any ANC. In contrast, 85% of women in urban areas receive at least one ANC follow-up. It is evident that wealthier women in urban areas have better access to information on maternal and child health through various media channels, which facilitates their utilization of ANC services and ultimately leads to giving birth at a healthcare facility.

Educational status difference increases the gap on institutional delivery utilization among urban and rural women in Ethiop. If rural women attend primary (3.76%)/ secondary (11.83%) and higher (8.44%) education the gap might be reduced by 3.76%, 11.83% and 8.44%. respectively the result is similar with previous study [73]. In Ethiopia, 11.56% of urban women and 1.18 of rural women were attending higher educational status (Table 1) There is educational inequality (CIx = 0.2137, p < 0.001) of using institutional delivery in Ethiopia.

The number of children mitigates the urban rural difference in institutional delivery utilization. If the number of children, the urban women had the number of rural women, institutional delivery gap might be widening by 6.1% [73, 74]. Similarly if rural women attend ANC like urban women the gap in institutional delivery might be reduced by 15.81% [73, 74]. ANC empowers women on knowledge, risk recognition and institutional delivery utilization [75–77].

Even though there was no significant urban rural difference on postnatal care utilization. There is educational inequality (CIx = 0.1272, p < 0.001) of post natal care utilization in Ethiopia. The finding is supported with previous researches [78–81]. This low utilization adversely affects maternal and child health by increasing the risk of infections, hemorrhage, and insufficient support for breastfeeding, which can lead to failure to thrive and higher neonatal mortality rates. Additionally, it can contribute to postpartum depression and other mental health challenges, resulting in prolonged suffering. Furthermore, inadequate postnatal care limits essential education on family planning, nutrition, and immunizations. Therefore, enhancing access to and the quality of postnatal care services is vital for reducing morbidity and mortality rates among mothers and infants [82].

The result of this study was more representative than other studies and the analysis shows the urban-rural difference and the source of difference on utilization of maternal health services. Despite this strength, the result may be prone to recall bias because the data were collected from a history of the event and some variables were missed since the data set was intermediate. Due to the nature of the data set, quality related data, previous exposure variables, paternal and institutional variables were not included.

Conclusion: ANC utilization and institutional delivery had a significant discrepancy in urban-rural women (urban women use the services better than the rural women). Maternal characteristics contribute more than 75% of the urban-rural difference on ANC and institutional delivery utilization. But postnatal care utilization was similarly low in urban and rural areas. There was educational inequality on ANC, institutional and postnatal care utilization in Ethiopia.

Attending, Secondary, higher, educational levels widening and living regions mitigated antenatal care utilization. Primary, secondary and higher education and antenatal care utilization were widening institutional delivery utilization. Advocacy and behavioral change communication should be area of attention for rural women to improve maternal health service utilization through health extension workers and women developmental army. Further, research is needed to have information on the effect of quality of service on maternal health service utilization.

Electronic supplementary material

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Abbreviations

ANC

Antenatal Care

CSA

Central Statistics Agency

EA

Enumeration Area

Author contributions

MA: initiated the research concept, analyze and interpreted the data; AM, AAT, AK, NK, YT AE, SDK, KM, ETA, EB, CD, LA and FDB: wrote the manuscript; all authors: critically revise, read and approved the final manuscript. All authors have equal participation.

Funding

There is no specific funding for this study.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethical approval and consent to participate

Ethical clearance was obtained from Ethical Review Committee of Wollo University College of Medicine and Health Science. An authorization letter to download EDHS-2019 data set was also obtained from CSA after requesting www.measuredhs.comwebsite. The requested data were treated strictly confidential and was used only for the study purpose. Complete information regarding the ethical issue was available in the EDHS-2019 report.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.