Only three out of ten women received adequate postnatal care in sub-Saharan Africa: evidence from 20 countries demographic and health surveys (2015–2022)

Abstract

Background

The magnitude of maternal and neonatal death and morbidity during the postnatal period remains too high. In contrast to the decline in global mortality rates, maternal and neonatal deaths continue to occur at the highest rate in sub-Saharan Africa. Appropriate care during the postpartum period is vital to prevent neonatal and maternal deaths. This study is aimed at delivering evidence on the pooled prevalence and associated factors of adequate postnatal care using the recent demographic and health surveys from 20 sub-Saharan African countries.

Methods

Data from the recent demographic and health surveys of 20 countries in sub-Saharan Africa conducted between 2015 and 2022 were used. A total weighted sample of 90,251 women aged 15–49 years with live births in the 2 years preceding the survey was included in the study. Multilevel logistic regression was used to determine the factors associated with the outcome variable. Intra-class correlation coefficient, likelihood ratio test, median odds ratio, and deviance (-2LLR) values were used for model comparison and fitness. Finally, variables with a p-value < 0.05 were declared statistically significant.

Results

The overall pooled prevalence of adequate postnatal care among women aged 15–49 years in SSA countries was 27.42% (95% CI: 27.13%, 27.71%). Factors like age [AOR = 1.10; 95% CI (1.05, 1.16)], educational status [AOR = 1.52; 95% CI (1.39, 1.67)], marital status [AOR = 0.83; 95% CI (0.79, 0.88)], working status [AOR = 0.81; 95% CI (0.78, 0.84)], media exposure [AOR = 1.05; 95% CI (1.01, 1.09)], sex of the household head [AOR = 1.13; 95% CI (1.08, 1.18)], household size [AOR = 1.07; 95% CI (1.03, 1.12)], number of ANC visits [AOR = 3.38; 95% CI (3.04, 3.75)], place of delivery [AOR = 3.77; 95% CI (3.57, 3.99)], prenatal community health workers visit [AOR = 1.45; 95% CI (1.39, 1.51)], and residence [AOR = 1.26; 95% CI (1.21, 1.32)] were significantly associated with adequate postnatal care.

Conclusion

Only nearly three out of ten women received adequate postnatal care in sub-Saharan African countries. Adequacy of postnatal care was determined by the age of respondents, educational status, current marital status, working status, media exposure, sex of the household head, household size, number of ANC visits, place of delivery, prenatal community health workers visit, and residence. Therefore, women’s empowerment through education, employment, and decision-making involvement; strengthening ANC service utilization and health facility delivery; information dissemination through media; promoting prenatal care through community health workers home-to-home visits; and giving special attention to unmarried, young, and non-working women are strongly recommended.

Background

The period starting immediately after birth and encompassing up to 42 days (the postnatal period) is a critical time for mothers, babies, spouses, fathers, caregivers, and families [1–3]. The magnitude of maternal and neonatal death and morbidity during this critical period remains too high, and efforts to enhance maternal health and support fostering newborn care have not been well exploited [4, 5]. To achieve the Sustainable Development Goals (SDGs) on maternal, child, and reproductive health by reducing maternal death rates and ending preventable newborn deaths, postnatal care (PNC) services are a key and basic element of the newborn, child, and maternal care continuum [6, 7].

The care of mothers after delivery and newborns, including the advancement of healthy practices, disease prevention, and identification and treatment of problems throughout the first six weeks after birth, are services expected to be delivered during PNC [8]. A large proportion of women and newborns obtain inadequate PNC during the first two days after delivery [9]. The median coverage for routine PNC within 24 h after birth did not achieve global targets for 2025 [10], which accounts for 71% and 64% for women and newborns, respectively [11]. The postpartum period is responsible for up to 30% of maternal deaths [5]. The risk of death in the first month after birth is high among infants, with an estimated global rate of 17 deaths per 1,000 live births [12, 13].

The aim of PNC is to sustain and promote the health and welfare of women and newborns and nurture settings that offer assistance and support to women, fathers, caregivers, and families for a variety of social, health, and developmental requirements [8]. Appropriate care during labor and delivery and the postpartum period is vital to prevent neonatal deaths secondary to birth asphyxia and sepsis, as well as maternal deaths associated with postpartum hemorrhage, hypertensive disorders, and infections [14, 15]. The risk of both maternal and newborn death after childbirth is still high, despite the attention given to maternal and child health programs [16, 17]. In contrast to the decline in global mortality rates, maternal and neonatal deaths remained to occur at the highest rate in low- and middle-income countries (LMICs), including sub-Saharan Africa (SSA) [18].

Appropriate postnatal experiences, like receiving information, reassurance, and support in a consistent manner, are essential for all women giving birth and their newborns, arranging the platform for enhanced short- and long-term healthiness and well-being [8]. However, studies conducted elsewhere reported inadequate postnatal care utilization. A cross-sectional study conducted in Rwanda using evidence from the Rwanda demographic health survey 2020 showed that 44.3% of newborns received all the postnatal components [19]. Similarly, a cross-sectional study conducted in Ethiopia using evidence from the 2019 Ethiopian mini-demographic and health survey showed that only 16.14% of women had adequate postnatal care [20]. Previous studies also showed that age, educational status, parity, antenatal care (ANC) follow-up, media exposure, fieldworker visit, distance to a health facility, working status, permission to seek healthcare, ANC quality, and place of ANC were significantly associated with adequate postnatal care [19, 20].

Despite the presence of few studies conducted using data from a single country to determine the prevalence and determinants of adequate PNC, there has been no study done to date to estimate the pooled prevalence and associated factors of adequate PNC in SSA using pooled national survey data. Therefore, this study is aimed at delivering evidence on the pooled prevalence and associated factors of adequate postnatal care in SSA using the recent demographic and health survey (DHS) from 20 countries. Policymakers and program managers could use the findings of this study as an input to design proper intervention strategies at both national and regional levels to improve maternal and child health through appropriate and timely utilization of PNC services.

Methods and materials

Data sources, study design, and sampling

A cross-sectional pooled dataset using the recent DHS data from 20 SSA countries, which was conducted between 2015 and 2022, was employed. Demographic and health surveys from 20 SSA countries, including Angola (2015-16), Benin (2017-18), Burundi (2016-17), Ethiopia (2016), Gabon (2019-21), Gambia (2019-20), Guinea (2018), Kenya (2022), Liberia (2019-20), Mali (2018), Malawi (2015-16), Nigeria (2018), Rwanda (2019-20), Sierra Leone (2019), Senegal (2019), Tanzania (2022), Uganda (2016), South Africa (2016), Zambia (2018), and Zimbabwe (2015), were used. The data were appended to figure out the pooled prevalence of adequate postnatal care and its associated factors in SSA countries. Different datasets, including those for children, males, women, births, and households, are included in the survey for each country. For this study, the kid’s record (KR) file was used. The DHS is a nationwide survey, mostly collected every five years across LMICs. It makes cross-country comparison possible as it uses standard procedures for sampling, questionnaires, data collection, cleaning, coding, and analysis [21]. A total weighted sample of 90,251 women aged 15–49 years with live births in the 2 years preceding the survey was included in the current study (Table 1). The DHS employs a stratified, two-stage sampling technique [22]. The first stage involves the development of a sampling frame, consisting of a list of primary sampling units (PSUs) or enumeration areas (EAs), which covers the entire country and is usually developed from the latest available national census. The second stage is the systematic sampling of households listed in each cluster, or EA. Further information on the survey sampling strategies is available in the DHS guideline [23].

Table 1.

Sample size for prevalence and associated factors of adequate postnatal care among women aged 15–49 years in sub-saharan African countries

Country	Year of survey	Weighted sample (n)	Weighted sample (%)
Angola	2015-16	6,000	6.65
Benin	2017-18	5,657	6.27
Burundi	2016-17	5,454	6.04
Ethiopia	2016	4,242	4.70
Gabon	2019-21	2,592	2.87
Gambia	2019-20	3,554	3.94
Guinea	2018	3,241	3.59
Kenya	2022	4,144	4.59
Liberia	2019-20	2,363	2.62
Mali	2018	4,089	4.53
Malawi	2015-16	6,956	7.71
Nigeria	2018	13,342	14.78
Rwanda	2019-20	3,250	3.60
Sierra Leone	2019	4,129	4.58
Senegal	2019	2,582	2.86
Tanzania	2022	4,472	4.96
Uganda	2016	6,195	6.86
South Africa	2016	1,424	1.58
Zambia	2018	4,109	4.55
Zimbabwe	2015	2,456	2.72
Total sample size		90,251	100.00

Variables of the study

Dependent variable

The outcome variable of this study was adequate postnatal care. It was considered when a woman received all five PNC components, which included the cord examined, the baby’s body temperature measured, counseling on newborn danger signs, counseling on breastfeeding, and observation of breastfeeding [24]. Women who had taken five of the five components of PNC were considered to have received adequate PNC (“yes = 1”), while those who had taken fewer than five of the components were considered to have not received adequate postnatal care (“no = 0”) [19, 20]. The information was obtained from the woman herself.

Independent variables

Both individual and community-level variables were considered due to the hierarchical nature of DHS data. Individual-level variables: respondent’s age (15–24 years, 25–34 years, 35–49 years), educational status (no education, primary education, secondary education, higher education), marital status (unmarried, married), working status (not working, working), media exposure (no, yes), household wealth index (poor, middle, rich), sex of the household head (male, female), having health insurance (no, yes), household size (1–4, 5–7, 8 and above), number of ANC visits during pregnancy (no visit, < 4 visits, ≥ 4 visits), place of delivery (home, health facility), and prenatal community health workers visit within the last 12 months (no, yes). Community-level variables: place of residence (urban, rural), community-level media exposure (low, high), community-level education (low, high), community poverty level (low, high), and community-level ANC utilization (low, high). These factors were generated by aggregating individual-level factors, as these factors were not directly accessible from DHS data.

Independent variable description

Media exposure

Generated by combining whether a respondent reads newspapers or magazines, listens to the radio, or watches television, and is coded as “yes” if the mother was exposed to at least one of these media and “no” otherwise.

Community-level of media exposure

The proportion of women who had been exposed to at least one media (television, radio, or newspaper) and categorized based on the national median value as low (communities with ≤ 50% of women exposed) and high (communities with > 50% of women exposed).

Community-level education

The proportion of women with a minimum primary level of education derived from data on respondents’ level of education. Then, it was categorized using the national median value into two categories: low (communities with ≤ 50% of women having at least primary education) and high (communities with > 50% of women having at least primary education).

Community-level ANC utilization

The proportion of women with a minimum of four or more ANC visits. It is categorized using the national median value as follows: low (communities with ≤ 50% of women have at least four ANC visits) and high (communities with > 50% of women have at least four ANC visits).

Community poverty level

An aggregated variable from household wealth status (proportion of women from poor and rich wealth status), and it was recoded as low and high community poverty level, likewise.

Data management and analysis

Data extracted from the recent DHS data sets were cleaned, recoded, and analyzed using STATA/SE version 14.0 statistical software. Sample weight was employed to manage sampling errors and non-responses. Continuous variables were categorized, and categorical variables were further recategorized. Descriptive analysis was carried out to present the data in frequencies and percentages. Both the individual and community-level variables were presented using descriptive statistics. The DHS data’s variables were organized in clusters; 90,251 women are nested within households, and households were nested within 1692 clusters. The assumptions of independent observations and equal variance across clusters were broken to employ the traditional logistic regression model. This is an indication that using a sophisticated model to take into account between-cluster factors is necessary. As a result, multilevel logistic regression was used to determine the factors associated with adequate PNC. Multilevel logistic regression follows four models: the null model (outcome variable only), model I (only individual-level variables), model II (only community-level variables), and model III (both individual and community-level variables). The model without independent variables (the null model) was used to check the variability of adequate PNC across the cluster. The association of individual-level variables with the outcome variable (Model I) and the association of community-level variables with the outcome variable (Model II) were assessed. In the final model (Model III), the association of both individual and community-level variables was fitted simultaneously with the outcome variable [25].

The magnitude of the clustering effect and the degree to which community-level factors explain the unexplained variance of the null model were quantified by checking the intra-class correlation coefficient (ICC) and proportional change in variance (PCV). A model with the lowest deviance was selected as the best-fitted model. Finally, variables with a p-value less than 0.05 and an adjusted odds ratio (AOR) with a 95% confidence interval (CI) were described as statistically significant variables associated with adequate PNC. The presence of multi-collinearity between covariates was checked by using a variance inflation factor (VIF) falling within acceptable limits of 1–10, indicating the absence of significant collinearity across independent variables.

Random-effect results

Random effects or measures of variation of the outcome variable were estimated using the median odds ratio (MOR), ICC, and PCV. The variation between clusters was measured by the ICC and PCV. Taking clusters as a random variable, the ICC reveals that the variation of adequate PNC between clusters is computed as ICC = VC/(VC + 3.29) × 100%. The MOR is the median value of the odds ratio between the area of the highest risk and the area of the lowest risk for adequate PNC when two clusters are randomly selected, using clusters as a random variable; MOR = 𝑒 ^0.95√VC. In addition, the PCV demonstrates the variation in the prevalence of adequate PNC explained by factors and computed as PCV = (Vnull-VC)/Vnull×100%, where Vnull = variance of the null model and VC = cluster-level variance [26]. The fixed effects were used to estimate the association between the likelihood of adequate PNC and individual and community-level independent variables.

Results

Individual- and community-level characteristics of study subjects

A total of 90,251 women aged 15–49 with live births in the 2 years preceding the survey took part in the present study. The mean age of women was 27.86 ± 0.02 years, and 45.19% of women fall in the age range of 25–34 years. The majority (85.89%) of women were married, and 35.85% of women had no formal education. More than two-thirds (69.82%) of women had jobs, and 63.33% of women had media exposure. More than three quarters (78.51%) of women reported that the sex of the household head was male, and 39.85% of women had 5–7 household members. The majority (91.16%) of women were not covered by health insurance, and 80.35% of women had not had prenatal community health workers visit in the last 12 months. More than half (58.83%) of women had at least four ANC visits during pregnancy, and 71.59% of women gave birth at a health facility. More than two-thirds (68.64%) of women were from rural areas, and 53.28% of women were from communities with low levels of media exposure. More than half (59.99%), 53.90%, and 51.49% of women were from communities with low levels of education, high poverty levels, and low levels of ANC utilization, respectively (Table 2).

Table 2.

Individual-and community-level characteristics of study subjects, pooled data from 20 SSA countries, DHS 2015–2022

Variables	Category	Frequency (n)	Percentage (%)
Respondent’s age	15–24 years	31,978	35.43
	25–34 years	40,779	45.19
	35–49 years	17,494	19.38
Educational status	No education	32,356	35.85
	Primary education	30,067	33.32
	Secondary education	23,999	26.59
	Higher education	3,829	4.24
Current marital status	Unmarried	12,736	14.11
	Married	77,515	85.89
Working status	Not working	27,241	30.18
	Working	63,010	69.82
Media exposure	No	33,098	36.67
	Yes	57,153	63.33
Household wealth index	Poor	43,271	47.94
	Middle	17,786	19.71
	Rich	29,194	32.35
Sex of the household head	Male	70,859	78.51
	Female	19,392	21.49
Having health insurance	No	74,666	91.16
	Yes	7,242	8.84
Household size	1–4	25,779	28.56
	5–7	35,961	39.85
	8 and above	28,511	31.59
Number of ANC visits	No visit	9,441	10.46
	< 4 visits	27,712	30.71
	≥ 4 visits	53,098	58.83
Place of delivery	Home	25,638	28.41
	Health facility	64,613	71.59
Prenatal health extension workers visit	No	66,554	80.35
	Yes	16,273	19.65
Place of residence	Urban	28,302	31.36
	Rural	61,949	68.64
Community-level media exposure	Low	48,082	53.28
	High	42,169	46.72
Community-level education	Low	54,142	59.99
	High	36,109	40.01
Community poverty level	Low	41,602	46.10
	High	48,649	53.90
Community-level ANC utilization	Low	46,472	51.49
	High	43,779	48.51

Pooled prevalence of adequate postnatal care and postnatal care utilization

In the current study, the overall pooled prevalence of adequate postnatal care among women aged 15–49 years in SSA countries was 27.42% (95% CI: 27.13%, 27.71%), and counseling on breastfeeding (46.64%) was a relatively more utilized PNC component, followed by cord examination (45.32%) (Fig. 1). The highest prevalence of adequate postnatal care was reported in South Africa (67.77%) and the lowest in Burundi (2.24%) (Fig. 2). The proportion of adequate postnatal care was higher among women who completed higher education (44.37%) and lower among women who had no formal education (18.26%) (Fig. 3).

Fig. 1.

Prevalence of adequate postnatal care and PNC utilization among women aged 15–49 years in sub-Saharan African countries, DHS 2015–2022 (n = 90,251)

Fig. 2.

Prevalence of adequate postnatal care by country among women aged 15–49 years in sub-Saharan African countries, DHS 2015–2022 (n = 90,251)

Fig. 3.

Prevalence of adequate postnatal care by educational status among women aged 15–49 years in sub-Saharan African countries, DHS 2015–2022 (n = 90,251)

Measures of variation and model fitness

A null model was used to determine whether the data supported the decision to assess randomness at the community level. Findings from the null model showed that there were significant differences in adequate postnatal care between communities, with a variance of 0.1060767 and a P value of 0.000. The variance within clusters contributed 96.88% of the variation in adequate postnatal care, while the variance across clusters was responsible for 3.12% of the variation. In the null model, the odds of adequate postnatal care differed between higher- and lower-risk clusters by a factor of 1.36 times. The intra-class correlation value for Model I indicated that 2.51% of the variation in adequate postnatal care accounts for the disparities between communities. Then, with the null model, we used community-level variables to generate Model II. According to the ICC value from Model II, cluster variations were the basis for 2.54% of the differences in adequate postnatal care. In the final model (model III), which attributed approximately 2.35% of the variation in the likelihood of adequate postnatal care to both individual and community-level variables, the likelihood of adequate postnatal care varied by 1.31 times across low and high adequate postnatal care (Table 3).

Table 3.

Model comparison and random effect analysis for adequate postnatal care and its associated factors in SSA countries, DHS 2015–2022 (n = 90,251)

Parameter	Null model	Model I	Model II	Model III
Variance	0.1060767	0.084649	0.0856022	0.0791072
ICC	3.12%	2.51%	2.54%	2.35%
MOR	1.36	1.32	1.33	1.31
PCV	Reference	20.20%	19.30%	25.42%
Model fitness
LLR	-52795.728	-39550.446	-52258.184	-39492.652
Deviance	105,591.456	79,100.892	104,516.368	78,985.304

ICC: Intra cluster correlation; LLR: log-likelihood ratio; MOR: median odds ratio; PCV: Proportional change in variance

Individual and community-level factors associated with adequate postnatal care

In the final fitted model (model III) of multivariable multilevel logistic regression, the respondent’s age, educational status, current marital status, working status, media exposure, sex of the household head, household size, ANC visits attended during pregnancy, place of delivery, prenatal health extension workers visits in the last 12 months, and residence were significantly associated with adequate postnatal care among women in sub-Saharan African countries.

The odds of adequate postnatal care were 1.10 times higher among women aged 35–49 years compared with those aged 15–24 years [AOR = 1.10; 95% CI (1.05, 1.16)]. Women who completed primary, secondary, and higher education were 1.18, 1.47, and 1.52 times more likely to have adequate postnatal care compared with those who had no education, respectively [AOR = 1.18; 95% CI (1.13, 1.23)], [AOR = 1.47; 95% CI (1.40, 1.55)], and [AOR = 1.52; 95% CI (1.39, 1.67)]. Unmarried women were 17% less likely to have adequate postnatal care compared with their counterparts [AOR = 0.83; 95% CI (0.79, 0.88)]. Non-working women were 19% less likely to have adequate postnatal care compared with working women [AOR = 0.81; 95% CI (0.78, 0.84)]. Women who had media exposure were 1.05 times more likely to have adequate postnatal care compared with those who had no exposure to media [AOR = 1.05; 95% CI (1.01, 1.09)]. Female household heads increase the odds of adequate postnatal care by 1.13 times [AOR = 1.13; 95% CI (1.08, 1.18)].

Women with a household size of 5–7 and ≥ 8 were 1.07 and 1.05 times more likely to have adequate postnatal care compared with those who have 1–4 household members, respectively [AOR = 1.07; 95% CI (1.03, 1.12)] and [AOR = 1.05; 95% CI (1.00, 1.10)]. Women who attended < 4 and ≥ 4 ANC visits during pregnancy were 2.34 and 3.38 times more likely to have adequate postnatal care compared with women with no visit, respectively [AOR = 2.34; 95% CI (2.11, 2.61) and [AOR = 3.38; 95% CI (3.04, 3.75)]. The odds of adequate postnatal care were 3.77 times higher among women who gave birth at a health facility than those who delivered at home [AOR = 3.77; 95% CI (3.57, 3.99)]. Women who had prenatal community health workers visit in the last 12 months were 1.45 times more likely to have adequate postnatal care compared with their counterparts [AOR = 1.45; 95% CI (1.39, 1.51)]. Similarly, women who reside in urban areas were 1.26 times more likely to have adequate postnatal care compared with those who reside in rural areas [AOR = 1.26; 95% CI (1.21, 1.32)] (Table 4).

Table 4.

Multivariable multilevel logistic regression analysis of individual and community-level factors associated with adequate postnatal care among women in SSA countries, DHS 2015–2022

Variables	Category	Model I AOR (95% CI)	Model II AOR (95% CI)	Model III AOR (95% CI)
Respondent’s age	15–24 years	1		1
	25–34 years	0.99 (0.95, 1.03)		0.98 (0.94, 1.02)
	35–49 years	1.11 (1.05, 1.17)*		1.10 (1.05, 1.16)*
Educational status	No education	1		1
	Primary education	1.16 (1.11, 1.22)*		1.18 (1.13, 1.23)*
	Secondary education	1.50 (1.42, 1.57)*		1.47 (1.40, 1.55)*
	Higher education	1.57 (1.44, 1.72)*		1.52 (1.39, 1.67)*
Current marital status	Unmarried	1		1
	Married	0.82 (0.78, 0.87)*		0.83 (0.79, 0.88)*
Working status	Not working	1		1
	Working	0.80 (0.77, 0.83)*		0.81 (0.78, 0.84)*
Media exposure	No	1		1
	Yes	1.06 (1.02, 1.11)*		1.05 (1.01, 1.09)*
Wealth index	Poor	1		1
	Middle	1.00 (0.95, 1.05)		0.98 (0.93, 1.03)
	Rich	1.03 (0.99, 1.08)		0.94 (0.90, 101)
Sex of the household head	Male	1		1
	Female	1.14 (1.09, 1.19)*		1.13 (1.08, 1.18)*
Having health insurance	No	1		1
	Yes	0.95 (0.89, 1.01)		0.94 (0.89, 1.01)
Household size	1–4	1		1
	5–7	1.07 (1.02, 1.12)*		1.07 (1.03, 1.12)*
	8 and above	1.05 (1.00, 1.10)*		1.05 (1.00, 1.10)*
Number of ANC visits	No visit	1		1
	< 4 visits	2.33 (2.10, 2.60)*		2.34 (2.11, 2.61)*
	≥ 4 visits	3.39 (3.05, 3.76)*		3.38 (3.04, 3.75)*
Place of delivery	Home	1		1
	Health facility	3.80 (3.59, 4.02)*		3.77 (3.57, 3.99)*
Prenatal health extension workers visit	No	1		1
	Yes	1.44 (1.38, 1.50)*		1.45 (1.39, 1.51)*
Place of residence	Urban		1.64(1.58,1.69)*	1.26 (1.21, 1.32)*
	Rural		1	1
Community-level media exposure	Low		1	1
	High		1.16(1.10,1.23)*	1.01 (0.96, 1.07)
Community-level education	Low		1	1
	High		1.15(1.09,1.22)*	0.97 (0.92, 1.03)
Community poverty level	Low		0.93(0.88,0.98)*	0.93 (0.87, 1.01)
	High		1	1
Community-level ANC utilization	Low		1	1
	High		1.13(1.07,1.19)*	0.99 (0.93, 1.04)

Discussion

The present study was conducted to determine the pooled prevalence and associated factors of adequate postnatal care among women aged 15–49 years in SSA countries. The study revealed that the pooled prevalence of adequate postnatal care among women aged 15–49 years in SSA countries was 27.42%. This finding was higher than a study conducted in Ethiopia (16.14%) [20]. On the other hand, the current finding was lower than a study conducted in Rwanda (44.3%) [19]. The possible justification for this inconsistency might be due to differences in sample size, geographical variation, study setting, sociocultural differences, and differences in postnatal care service accessibility between countries. The discrepancy might also be due to differences in the knowledge and attitude of women towards postnatal care service components and their utilization. As a result, raising mothers’ awareness of PNC components through tailored ANC education and ongoing training for PNC providers is needed to improve the uptake of adequate postnatal care.

This study also identified factors significantly associated with adequate postnatal care. Accordingly, older women were more likely to have adequate PNC than younger women. This finding was consistent with studies conducted in Ethiopia [20] and Malawi [27]. This might be due to the fact that older women have experience with birth and are more autonomous, which enables them to utilize postnatal care services more than younger women. Educated women had higher odds of adequate postnatal care. This finding was in agreement with studies conducted in Ethiopia [20], Tigray, Northern Ethiopia [28], and Nigeria [29]. This might be due to the fact that educated women realize the importance of adequate PNC and have a higher chance of knowing where to get it than uneducated women [30]. Education can enable women to gain access to health-related information, the message to obtain healthcare services, and the significance of the available services. Educated women might also have a higher wealth status, which contributes to their higher autonomy in decision-making about their health service utilization [31]. Unmarried women were less likely to have adequate postnatal care compared with their counterparts. This finding was in line with studies conducted in Ethiopia [32], Nigeria [33], and Ghana [34]. This might be due to the fact that married women who live with their partners may get more support from them than unmarried women. Non-working women were less likely to have adequate postnatal care compared with working women. This finding was consistent with a study conducted in Malawi [27]. However, the current finding was in contrast with a study conducted in Rwanda, in which being a working mother was associated with lower odds of adequate PNC [19]. The higher odds of adequate PNC among working mothers in this study might be explained by the fact that working women have a higher opportunity to access maternal services because of their economic independence [35]. This implies that information dissemination on the importance of adequate PNC utilization among non-working women is needed.

Likewise, women who had media exposure were more likely to have adequate postnatal care. This finding was in agreement with a study conducted in Rwanda [19]. This might be due to the fact that media exposure is positively associated with maternal healthcare utilization, including PNC. Evidence showed that women exposed to mass media were 36–94% more likely to receive postpartum check-ups [36]. In addition, exposure to mass media (radio, newspapers, and television) was a positive predictor of PNC utilization [37]. This implies that policymakers and program managers should finance resources in the design and execution of educational programs on maternal health service utilization through media to improve women’s PNC service uptake in SSA. A female-headed household was associated with higher odds of adequate postnatal care. This finding was inconsistent with a study conducted in Sierra Leone, in which belonging to a female-headed household was associated with lower odds of utilizing PNC [38]. The higher odds of adequate PNC among female-headed households in our study might be explained by the fact that women’s empowerment is associated with increased utilization of health services, including PNC [39]. Women with a household size of 5–7 and ≥ 8 were more likely to have adequate postnatal care compared with those who have 1–4 household members. This finding was in line with studies conducted in Ethiopia [40] and India [41]. This might be because women might get help from family to utilize adequate PNC services.

Women who attended ANC visits during pregnancy were more likely to have adequate postnatal care compared with women with no visits. This finding was in agreement with studies conducted in Ethiopia [20], Tigray, Northern Ethiopia [28], Rwanda [19], Nigeria [29], and Sierra Leone [38]. This might be due to the fact that regular contact with healthcare professionals during ANC accords more chances for counseling concerning the necessity to seek healthcare services during pregnancy and after delivery. Mothers with ANC attendance are more likely to be informed on key PNC information like its significance, components, and when and where to receive it, leaving them with higher chances of receiving adequate PNC [42]. Furthermore, women can obtain information on birth preparedness and what to do during the postnatal period during ANC visits. The odds of adequate postnatal care were higher among women who gave birth at a health facility than those who delivered at home. This finding was in line with a study conducted in Malawi [27] and Nepal [35]. This might be attributed to the role of counseling in increasing awareness among postnatal women during post-delivery and prior discharge home, as women who gave birth at a health facility had a greater chance of acquiring PNC service-related information from healthcare professionals. Similarly, women who had prenatal community health workers visit in the last 12 months were more likely to have adequate postnatal care. This finding was consistent with studies conducted in Rwanda [19] and Sierra Leone [38]. This might be due to the fact that prenatal visits by community health workers promote confidence and understanding about the healthcare system, leading to better trust in the healthcare system [43]. Community health workers encouraging and reminding women about the significance of adequate PNC utilization could also contribute to achieving adequate PNC components. This implies that community health workers capacity building and empowerment are needed to improve PNC service utilization among women at the community level. Furthermore, women who reside in urban areas were more likely to have adequate postnatal care. This finding was in agreement with studies conducted in Ethiopia [28] and Malawi [27]. This might be due to the fact that women in urban areas have good access to health facilities. The availability of qualified staff, adequate space, and sufficient supply in urban areas might also contribute to the higher odds of adequate PNC among women from urban residences. Besides, women in urban areas are also more likely to utilize maternal healthcare services than those from rural areas, including postnatal care.

Strengths and limitations of the study

The current study has the following strengths: First, a large sample size with weighted nationally representative data from 20 sub-Saharan African countries was used. Second, a multilevel mixed-effects analysis was employed to accommodate the hierarchical nature of the DHS data and get a reliable estimate. Third, policymakers and program managers could use the findings of this study as an input to design proper intervention strategies at both national and regional levels to improve maternal and child health, as pooled countrywide survey data is used. This study also had some limitations. Firstly, the findings of the present study might be influenced by social desirability and recall biases, as the DHS survey was based on study subjects’ self-reports. Secondly, we could not show the cause-and-effect relationship of variables due to the cross-sectional nature of the data. Besides, because the data were secondary, we were unable to include factors that might affect the adequacy of PNC, like availability of services to be utilized, delivery on the way to health facilities, and timing of media exposure.

Conclusion

Only nearly three out of ten women received adequate postnatal care in SSA countries. Adequacy of postnatal care was determined by the age of respondents, educational status, current marital status, working status, media exposure, sex of the household head, household size, number of ANC visits, place of delivery, prenatal community health workers visit, and residence. Therefore, women’s empowerment through education, employment, and decision-making involvement; strengthening ANC service utilization and health facility delivery; information dissemination through media; promoting prenatal care through community health workers home-to-home visits; and giving special attention to unmarried, young, and non-working women are strongly recommended to improve postnatal care adequacy and utilization.

Abbreviations

ANC

Antenatal care

AOR

Adjusted odds ratio

CI

Confidence interval

DHS

Demographic and health survey

ICC

Intra-class correlation coefficient

LMICs

Low- and middle-income countries

MOR

Median odds ratio

PCV

Proportional change in variance

PNC

Postnatal care

SSA

Sub-saharan africa

VIF

Variance inflation factor

WHO

World health organization

Author contributions

Conceptualization, data curation, formal analysis, investigation, methodology, and software were done by E.G.M, B.S.W, and A.F.Z. Supervision and validation were done by E.G.M, T.T.T, and A.F.Z. Visualization and writing the original draft were done by E.G.M, B.S.W, and T.T.T. Writing, reviewing, and editing were done by E.G.M, A.F.Z, T.T.T, and B.S.W. All authors gave final approval of the version to be published, have agreed on the journal to which the article has been submitted, and agree to be accountable for all aspects of the work.

Funding

Not applicable.

Data availability

The data from the 20 SSA countries is publicly available online at (https://dhsprogram.com/data/available-datasets.cfm).

Declarations

Ethical approval and consent to participate

Permission was granted to download and use the data from https://dhsprogram.com/data/available-datasets.cfm before conducting the study. Ethical clearance was obtained from the Institutional Review Board of the DHS Program, ICF International. The procedures for DHS public-use data sets were approved by the Institutional Review Board. Identifiers for respondents, households, or sample communities were not allowed in any way, and the names of individuals or household addresses were not included in the data files. The number for each EA in the data file does not have labels to show their names or locations. There were no patients or members of the public involved since this study used a publicly available data set.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.