Postnatal care utilisation and health beliefs among mothers in the Jazan region of Saudi Arabia: a cross-sectional study

Abstract

Background

The postnatal period is critical for preventing maternal and neonatal morbidity and mortality. Globally, a significant proportion of maternal and neonatal deaths occur within the first 6 weeks after delivery. Timely and adequate postnatal care (PNC) can detect and manage life-threatening complications; however, service utilisation remains alarmingly low in many low- and middle-income countries, including Saudi Arabia. Addressing the behavioural and perceptual factors that influence service use is essential for improving health outcomes.

Objectives

This study aimed to assess mothers’ utilisation of PNC services and examine how their health beliefs and sociodemographic characteristics influence this behaviour.

Design

A cross-sectional study guided by the Health Belief Model (HBM) was conducted to explore predictors of PNC utilisation.

Setting

Eight primary healthcare (PHC) centres were randomly selected from 179 PHC centres distributed in the different governorates of the Jazan region of Saudi Arabia.

Participants

A total of 464 mothers were surveyed between October and December 2023 using an interviewer-administered questionnaire.

Primary and secondary outcome measures

The primary outcome was PNC utilisation, defined by the number of postnatal visits. The independent variables included sociodemographic characteristics and HBM constructs (perceived susceptibility, benefits, barriers and cues to action).

Results

In terms of PNC utilisation, 80.0% of participants had two or fewer postnatal visits, whereas 20.0% had three or more postnatal visits. Perceived barriers had the strongest influence (mean score 2.51±0.87), followed by cues to action (2.43±0.89), susceptibility (1.92±0.72) and benefits (1.86±0.64). In the multivariate analysis, perceived barriers, cues to action and perceived susceptibility were significantly associated with PNC utilisation, with adjusted ORs of 1.679 (95% CI: 1.007 to 2.799), 0.470 (95% CI: 0.256 to 0.863) and 0.405 (95% CI: 0.197 to 0.832), respectively.

Conclusions

PNC utilisation in the Jazan region remains suboptimal. Perceptual factors, particularly barriers and cues to action, play a central role in service use. Health interventions targeting these beliefs and improving follow-up mechanisms may help increase PNC engagement and improve maternal and infant health outcomes in Saudi Arabia.

Introduction

The postnatal period is critical for the health and well-being of both the mother and newborns.¹ According to the WHO, a minimum of four postnatal care (PNC) contacts are recommended. If a birth occurs in a health facility, healthy women and newborns should remain under care for at least 24 hours. For home births, the first contact should occur as early as possible within 24 hours. Additional postnatal visits are advised at 48–72 hour, 7–14 days, and around the sixth week after birth.² In Saudi Arabia, the Ministry of Health recommends a postnatal visit in the first week and another visit between the fourth and sixth weeks at primary healthcare (PHC) facilities.³

The adequate utilisation of PNC services is essential for monitoring maternal recovery, identifying and managing postpartum complications and promoting the health of both mothers and infants.^{4 5} However, the utilisation of PNC services varies widely and is influenced by numerous factors that extend beyond the immediate postpartum period. Understanding these factors and their impact on postnatal service utilisation is crucial for improving maternal and neonatal health outcomes.^{4 6}

Previous studies have identified various factors that influence the utilisation of PNC services (figure 1). These factors include demographic characteristics such as age, level of education, occupational status of women and spouses, household economic status, place of delivery, birth order and awareness of obstetric-related danger signs and PNC services.⁴,¹¹ Additionally, women’s education plays a significant role, with higher levels of education associated with increased utilisation of PNC services.^{16 11},¹³

Figure 1. Conceptual model illustrating how sociodemographic characteristics and Health Belief Model (HBM) constructs influence postnatal care (PNC) utilisation. The model includes perceived susceptibility, perceived benefits, perceived barriers, cues to action and self-efficacy, all leading to behavioural intention and PNC utilisation (categorised as 0–2 visits vs 3+visits).

The Health Belief Model (HBM) provides a well-established theoretical framework for understanding individual health behaviours, particularly in preventive care and service uptake, including vaccination, cancer screening and maternal health services.¹⁴,¹⁷ The model comprises six different constructs designed to address an individual’s distinct perceptions of susceptibility, benefits, barriers, cues and self-efficacy. These constructions offer useful insights into individuals’ health-related behaviours, including their utilisation of healthcare services.^{18 19} Applying the HBM to the context of postnatal service utilisation allows for a comprehensive understanding of the factors that influence women’s decision-making and behaviours regarding PNC. This includes beliefs about their susceptibility to postpartum complications, the benefits of seeking PNC and the barriers they perceive when accessing these services. Additionally, cues to action and self-efficacy play important roles in prompting and empowering women to utilise PNC services. By considering these factors, healthcare professionals and researchers can develop targeted interventions and strategies to enhance postnatal service utilisation, ultimately improving maternal and neonatal health outcomes.²⁰,²²

Although HBM has been successfully applied to antenatal care behaviours in several studies,²³,²⁵ its application in the postnatal context, particularly in Saudi Arabia and the Jazan region, remains limited. Given the ongoing presence of cultural, informational and systemic barriers in maternal healthcare, the model is highly relevant for identifying modifiable psychological factors that contribute to inequalities in service utilisation. To address this gap, we conducted a cross-sectional study using the HBM to assess PNC utilisation among mothers in the Jazan region. This study aimed to examine the role of health beliefs and sociodemographic factors in shaping mothers' intentions and behaviours regarding PNC with the goal of informing targeted strategies to enhance service uptake and improve maternal and newborn outcomes in the region.

Materials and methods

Study design

This cross-sectional study was conducted in the Jazan region of Saudi Arabia between October and December 2023.

Study area

Jazan is a port city and the capital of the region. It is situated in the southwestern corner of Saudi Arabia and is straightforward to the north of the outskirt with Yemen. Jazan City is located on the shore of the Red Sea and serves as an expansive rural area, and the complete population is evaluated at 1, 567 and 547. The region was divided into 14 governorates based on the census 2017.

Determination of sample size and data collection

A multistage random sampling technique was used in this study. The region has 179 PHC centres distributed across different governorates. Eight PHC centres were randomly selected (online supplemental 1). Participants were recruited from the selected centres. The minimum sample size for this study was 464 based on the following assumptions:

$${\displaystyle \frac{\mathrm{n}=(\mathrm{Z}\mathrm{s}\mathrm{c}\mathrm{o}\mathrm{r}\mathrm{e}{)}^2\times \mathrm{P}\times (1-\mathrm{P})}{(\mathrm{C}\mathrm{o}\mathrm{n}\mathrm{f}\mathrm{i}\mathrm{d}\mathrm{e}\mathrm{n}\mathrm{c}\mathrm{e}\mathrm{i}\mathrm{n}\mathrm{t}\mathrm{e}\mathrm{r}\mathrm{v}\mathrm{a}\mathrm{l}{)}^2}}$$

where the CI is 95%, the Z score is 1.96 and the proportion (P) is 0.5. The mean sample size was 384. We added 20% as non-responders. The total sample size was 464.

Inclusion and exclusion criteria

The inclusion criteria consisted of mothers who had given birth, were within the postnatal period of 6 weeks to 3 months postpartum, and had sought PNC services at the selected PHC centres during the study period. During the recruitment process, the researchers explained the study objectives. Women who refused to participate in the study were also excluded. Informed written consent was obtained from all participants before the start of the study, and the questionnaires were completed when the mothers were present in their selected PHC centres.

Data collection and study measures

An interviewer-administered questionnaire was used for the data collection (see online supplemental appendix 1). The study included several measures to gather data, including age group, nationality, residency, level of education, marital status, monthly income, number of antenatal care visits, place and mode of delivery, maternal complications, parity, number of postnatal visits, PNC utilisation and constructs from the HBM. The HBM is a theoretical framework widely used in public health research to understand individuals' health-related behaviours and decision-making processes. It posits that people’s health-related actions are influenced by their perceptions of susceptibility to a health problem, perceived severity of the problem, potential benefits of taking preventive actions, perceived barriers to engaging in those actions and cues to action that prompt behavioural change. In this study, the HBM was applied to explore the factors influencing postnatal service utilisation among postpartum women in the Jazan region. Perceived susceptibility refers to an individual’s perception of their vulnerability to postnatal complications, which influences their motivation to seek care. Perceived benefits explore the advantages of postnatal services such as improved recovery and newborn care. Perceived barriers encompass obstacles such as financial constraints and cultural beliefs. Cues to action prompt individuals to seek care from healthcare providers, families, media campaigns or community outreach.^{14 22} Understanding these constructs helps identify awareness, motivators, barriers and effective strategies to improve PNC utilisation.

Ethical consideration

This study was conducted in accordance with the principles of the Declaration of Helsinki and approved by the Jazan Health Ethics Committee of the Ministry of Health, Saudi Arabia (Reference No.: 2214 on 07/02/2022). Informed consent was obtained from all participants after they were fully briefed on the study objectives, procedures, potential risks and benefits. Participation was voluntary, and the respondents retained the right to withdraw at any time. Ethical procedures ensured respect for the participants’ autonomy, confidentiality and decision-making rights.

Pilot study and questionnaire validation

A pilot study was conducted with 20 female participants. This pilot study aimed to assess the relevance and effectiveness of this questionnaire. The internal consistency of the HBM constructs was evaluated using Cronbach’s α, a statistical measure that assesses the degree of interrelatedness among items within each construct.²⁶ The findings from the pilot study were used to refine and finalise the questionnaire for the main study, ensuring its validity and reliability in measuring participants' health beliefs and perceptions related to PNC utilisation. The data from the pilot study were not included in the final analysis of the main study.

Outcome definition

For analytical purposes, PNC utilisation was classified into two categories: ‘two or fewer visits’ and ‘three or more visits’. This binarisation conforms to national and international norms advocating for a minimum of two organised follow-up visits, in addition to the initial contact within 24 hours postbirth. Although we acknowledge that zero, one or two visits may vary in maternal experience and exposure, this classification was selected to represent a pragmatic threshold of sufficient vs insufficient participation in PNC services. A scheduled sensitivity analysis employing a multinomial logistic model was used to examine the robustness of this categorisation.

Data analysis

Statistical Package for Social Sciences (SPSS) v.26 was used to enter, process and analyse the data. Descriptive statistics, including frequency, percentage, mean and SE of the mean, were computed for the study measures, based on the measurement scale. Normality of the HBM constructs was assessed. Non-parametric tests, such as the Mann-Whitney U test and Kruskal-Wallis test, were employed to compare the differences in the HBM constructs between different categories of demographic and maternal characteristics. Spearman’s correlation analysis was conducted to examine the relationship between the HBM constructs. Logistic regression analysis was used to determine the predictors of PNC utilisation. In the logistic regression model, the following independent variables were included as predictors: marital status, residence, education level, income level, number of antenatal care visits, mode of delivery, maternal complications, age, parity and HBM constructs: perceived susceptibility, perceived benefits, perceived barriers and cues to action. The dependent variable in the study was PNC utilisation, categorised into two groups: ‘Two or less visits’ and ‘Three or more visits’. This variable represented the outcome of interest, indicating whether participants had a lower or higher level of PNC utilisation. Logistic regression analysis aimed to identify the predictors, including the independent variables mentioned earlier, associated with the likelihood of having three or more PNC visits compared with two or fewer visits. The associations were considered significant at p<0.05.

Patient and public involvement statement

The components of the questionnaire, including the framework of the HBM, were explained to the mothers involved in the pilot study to enhance its reliability and validity. The results of this study will be disseminated to the leaders in PHC centres as a reflection of the mother’s perception of PNC service utilisation and will be involved in the implementation of future interventions.

Results

Table 1 presents the maternal demographic and obstetric characteristics of the participants (n=464). The table reveals that 2.2% of the participants were 20 years and below, while 34.7% 48.5% and 14.7% fell into the age groups 21–30 years, 31–40 years and 41 years and older, respectively. The majority of participants (95.9%) were Saudi nationals and 4.1% were non-Saudi. Regarding residency, 87.1% lived in urban areas, while 12.9% lived in rural areas. In terms of education, 8.8% had non-formal education, 13.1% had less than secondary education, 41.4% had completed secondary education and 36.6% had education beyond the secondary level. Most participants were married (92.0%), 5.6% were divorced and 2.4% were widowed. Regarding monthly income, 41.2% had a monthly income of less than 5000 SR, 18.1% had an income between 5000 and 10 000 SR, 26.9% had an income between 10 000 and 15 000 SR and 13.8% had an income above 15 000 SR. In addition, 24.1% had no available income information (NIL). The number of antenatal care visits varied, with 24.1% having no visits, 49.1% having one to four visits, and 26.7% having five to eight visits. The majority of participants delivered at governmental facilities (84.7%) compared with private facilities (15.3%). Vaginal delivery was the most common mode of delivery (83.1%), followed by caesarean section (17.0%). Maternal complications occurred in 43.3% of participants, while 56.7% did not experience any complications. In terms of parity, 7.8% had one delivery, 66.4% had two to four deliveries and 25.9% had five deliveries or more.

Table 1. Maternal demographic and their effects on the HBM constructs (n=464).

Characteristic	N(%)	Perceived susceptibility	Perceived benefits	Perceived barriers	Cues to action
Age Group
20 years and below	10 (2.2)	1.78±0.28	1.70±0.22	2.47±0.29	2.23±26
21 to 30 years	161 (34.7)	1.81±0.05	1.81±0.05	2.44±0.07	2.37±0.07
31 to 40 years	225 (48.5)	1.96±0.05	1.90±0.04	2.52±0.06	2.43±0.06
41 years and more	68 (14.7)	2.03±0.09	1.86±0.08	2.64±0.11	2.64±0.11
Nationality of the participants
Saudi	445 (95.9)	1.91±0.03	1.85±0.02	2.52±0.04	2.43±0.04
Non-Saudi	19 (4.1)	1.91±0.21	1.95±0.21	2.17±0.26	2.36±0.28
Residency
Urban	404 (87.1)	1.95±0.03	1.91±0.03	2.55±0.04	2.49±0.04
Rural	60 (12.9)	1.68±0.08	1.53±0.06	2.26±0.12	2.05±0.10
Level of education
Non formal education	41 (8.8)	1.70±0.13	1.63±0.11	1.97±0.15	2.02±0.16
Lesss than secondary	61 (13.1)	1.85±0.10	1.87±0.09	2.24±0.11	2.30±0.11
Secondary completed	192 (41.4)	1.98±0.05	1.94±0.04	2.47±0.05	2.58±0.07
More than secondary completed	170 (36.6)	1.92±0.05	1.82±0.05	2.78±0.07	2.41±0.06
Marital Status
Married	427 (92.0)	1.91±0.03	1.84±0.03	2.50±0.04	2.41±0.04
Divorced	26 (5.6)	2.02±0.15	1.97±0.15	2.82±0.17	2.82±0.20
Widow	11 (2.4)	2.13±0.21	2.15±0.26	2.18±0.20	2.25±0.20
Monthly income
<5000 SR	191 (41.2)	1.86±0.05	1.80±0.04	2.14±0.06	2.31±0.08
> 5000 and <10 000 SR	84 (18.1)	2.12±0.08	1.97±0.07	2.60±0.10	2.48±0.09
>10 000 and < 15 000 SR	125 (26.9)	1.89±0.07	1.90±0.06	2.76±0.07	2.58.07
> 15 000 SR	64 (13.8)	1.86±0.09	1.79±0.08	2.99±0.10	2.44±0.08
Number of antenatal care visits
NIL	112 (24.1)	1.93±0.08	1.83±0.07	2.13±0.08	2.04±0.08
1 to 4	228 (49.1)	1.99±0.05	1.91±0.04	2.51±0.06	2.62±0.06
5 to 8	124 (26.7)	1.86±0.06	1.78±0.05	2,84±0.07	2.45±0.06
Place of delivery
Governmental	393 (84.7)	1.91±0.04	1.85±0.03	2.43±0.04	2.43±0.05
Private	71 (15.3)	1.94±0.10	1.90±0.09	2.94±0.11	2.42±0.09
Mode of delivery
Vaginal Delivery	385 (8.3)	1.92±0.04	1.88±0.03	2.43±0.04	2.45±0.05
Caesarean section	79 (17.0)	1.88±0.09	1.76±0.07	2.92±0.09	2.33±0.08
Maternal complication
Yes	201 (43.3)	1.74±0.05	1.78±0.05	2.22±0.06	2.10±0.06
No	263 (56.7)	2.05±0.04	1.92±0.04	2.73±0.05	2.69±0.05
Parity
One Delivery	36 (7.8)	2.02±0.15	1.94±0.12	2.29±0.15	2.22±0.15
Two to four deliveries	308 (66.4)	1.89±0.04	1.85±0.04	2.55±0.05	2.45±0.05
Five deliveries and more	120 (25.9)	1.97±0.07	1.85±0.06	2.47±0.08	2.45±0.08

The number of postnatal visits and PNC utilisation among the participants are shown in table 2. The data show that 100% of the participants received PNC within 24 hours, 43.3% had postnatal visits within 48 to 72 hours, and 14.7% and 17.0% in the first week and in four to six weeks of PHC, respectively.

Table 2. Postnatal care utilisation.

Characteristic	N(%)
Postnatal visits
Postnatal care in the first 24 hours	464(100)
Postnatal care in 48 to 72 hours	201 (43.3)
Postnatal care in the first week in primary healthcare	68 (14.7)
Postnatal care at 4 to 6 weeks in primary healthcare	79 (17.0)
Number of postnatal visits
One postnatal visit	230 (49.6)
Two postnatal visits	141 (30.4)
Three postnatal visits	72 (15.5)
Four postnatal visits	21 (4.5)
Postnatal care utilisation
Two or less visit	371 (80.0)
Three or more	93 (20.0)

The data showed that 49.6% of participants had one postnatal visit, 30.4% had two postnatal visits, 15.5% had three postnatal visits and 4.5% had four postnatal visits. In terms of PNC utilisation, 80.0% of participants had two or fewer postnatal visits, whereas 20.0% had three or more postnatal visits. This study provides insights into the frequency of postnatal visits and utilisation of PNC among participants, indicating that the majority had a limited number of visits, while a notable proportion had a higher frequency of PNC.

Table 3 presents the HBM constructs for 464 participants, revealing key insights into their descriptions, correlations and reliability. Scores suggest perceived barriers hold the strongest influence (mean score 2.51±0.87), followed by cues to action (2.43±0.89), susceptibility (1.92±0.72), and benefits (1.86±0.64). Notably, all constructs exhibited moderate variability (SD 0.64–0.89). Interestingly, all HBM constructs significantly correlated with each other at a 0.01 level, ranging from 0.363 (benefits and barriers) to 0.485 (barriers and cues to action), highlighting their potential interdependence. Moreover, the high Cronbach’s α values (>0.938) across all constructs demonstrated the strong internal consistency and reliability of the measures used.

Table 3. Descriptive, correlation and reliability of health belief model constructs.

HBM construct	Mean+SD(Min, Max)	Perceived susceptibility	Perceived benefits	Perceived barriers	Cues to action	Cronbach’s α
Perceived susceptibility	1.92+0.72 (1.00, 4.40)	1				0.867
Perceived benefits	1.86+0.64 (1.00, 4.13)	0.590*	1			0.945
Perceived barriers	2.51+0.87 (1.00,5.00)	0.363*	0.380*	1		0.947
Cues to action	2.43+0.89	0.420*	0.453*	0.485*	1	0.938

^*Correlation is significant at the 0.01 level(2-tailed).

Unveiling the factors influencing PNC utilisation, table 4 shows both individual and combined effects. Univariate analysis highlighted increased utilisation among rural residents, individuals with higher education and income, those with more antenatal care visits,and those experiencing caesarean sections, maternal complications, or being 41–45 years old. Interestingly, the HBM constructs revealed decreased utilisation with higher perceived barriers but increased use with higher perceived benefits and cues to action. Table 4 presents a summary of the multivariate analysis examining the factors influencing PNC utilisation, focusing on adjusted odds ratios (AOR). Moving beyond individual factors, multivariate analysis presents adjusted ORs considering interacting effects, offering a nuanced understanding of PNC utilisation patterns. This table shows several significant associations. Rural residents were 18.62 times more likely to utilise PNC than urban residents (AOR 18.622, CI 5.104 to 67.940). Higher income levels showed a positive association with PNC utilisation, with increasing ORs for income brackets above 5000 SR. Income>5000 and <10 000 SR was 3.95 times more likely (AOR 3.949, CI 0.650 to 23.980), income>10 000 & <15 000 SR was 53.86 times more likely (AOR 53.864, CI 10.147 to 285.925) and income >15 000 SR was 153.95 times more likely (AOR 153.947, CI 25.503 to 929.287). More antenatal care visits were associated with a higher likelihood of PNC utilisation. One to four visits were 3.85 times more likely (AOR 3.848, CI 0.798 to 18.545) and five to eight visits were 9.85 times more likely (AOR 9.854, CI 2.006 to 48.400). However, individuals aged 41 and above were 0.05 times less likely to utilise PNC compared with those aged 20 and below (AOR 0.046, CI 0.003 to 0.756). In multivariate analysis, perceived susceptibility was significantly associated with PNC utilisation, with an AOR of 0.405 (95% CI: 0.197 to 0.832). This finding suggests that individuals who perceive higher susceptibility have significantly lower odds of utilising PNC. However, the perceived benefits did not reach statistical significance in the multivariate analysis, with an AOR of 0.501 (95% CI: 0.226 to 1.111). Although there is a trend suggesting a potential association, the CI includes a value of one, indicating that the relationship is not statistically significant. Perceived barriers had a significant impact on utilisation, with an AOR of 1.679 (95% CI: 1.007 to 2.799). This implies that individuals who perceive more barriers have significantly higher odds of not using PNC. Furthermore, cues to action demonstrated a significant association, with an AOR of 0.470 (95% CI: 0.256 to 0.863). This indicates that individuals who receive fewer cues or reminders to seek PNC have significantly lower odds of using it. These findings highlight the importance of addressing perceived barriers and enhancing cues to action to improve PNC utilisation rates and promote better maternal and infant health outcomes.

Table 4. Univariate and Multivariate Analysis.

Predictors	OR	Lower CI	Upper CI	AOR	Lower CI	Upper CI
Marital Status
Married (REF)
Divorced	0.152	0.020	1.136	0.110	0.008	1.487
Widow	1.424	0.370	5.479	57.640*	5.923	560.874
Residency
Urban (REF)
Rural	4.563*	2.574	8.089	18.622*	5.104	67.940
Education
Non formal education (REF)
less than secondary	2.528	0.498	12.831	8.145	0.667	99.454
Secondary completed	4.655*	1.075	20.155	5.496	0.543	55.579
More than secondary completed	7.451*	1.730	32.091	3.694	0.347	39.302
Income
<5000 SR (REF)
> 5000 & <10 000 SR	3.596	0.988	13.096	3.949	0.650	23.980
>10 000 & < 15 000 SR	24.515*	8.520	70.543	53.864*	10.147	285.925
> 15 000 SR	77.917*	25.622	236.949	153.947*	25.503	929.287
Number of antenatal care visit
NIL (REF)
One to four	4.408*	1.519	12.795	3.848	0.798	18.545
Five to eight	22.970*	7.969	66.209	9.854*	2.006	48.400
Mode of delivery
Vaginal Delivery (REF)
Caesarean section	3.365*	1.986	5.699	2.354	0.989	5.603
Maternal complication
Yes (REF)
No	1.907*	1.176	3.095	1.154	0.506	2.636
Age
20 years and below (REF)
21 to 30 years	0.916	0.185	4.535	0.111	0.008	1.545
31 to 40 years	1.114	0.229	5.415	0.193	0.014	2.576
41 years and more	0.857	0.161	4.554	0.046*	0.003	0.756
Parity
One Delivery (REF)
Two to four deliveries	2.829	0.840	9.523	1.193	0.146	9.755
Five deliveries and more	3.194	0.908	11.227	1.753	0.192	16.004
HMB constructs
Perceived susceptibility	0.404*	0.272	0.598	.405*	0.197	0.832
Perceived benefits	0.457*	0.306	0.684	0.501	0.226	1.111
Perceived barriers	1.577*	1.210	2.057	1.679*	1.007	2.799
Cues to action	0.760*	0.581	0.994	0.470*	0.256	0.863

^*Significant at the 0.05 level.

Discussion

PNC services comprise a range of essential interventions aimed at improving the survival and well-being of mothers and newborns. While much of the existing research on maternal health has centred on antenatal and delivery services, comparatively less attention has been paid to the determinants of PNC utilisation. Consistent with findings from previous local studies conducted in the Jazan²⁷ and Najran²⁸ regions of Saudi Arabia, our results revealed significant sociodemographic disparities in PNC uptake. However, by incorporating the constructs of the HBM, our study offers additional insight into the cognitive and motivational pathways, such as perceived barriers and cues to action, through which these sociodemographic factors may influence health-seeking behaviours. This approach enhances our understanding of the underlying drivers of postnatal use in the Saudi context.

Our findings revealed that only 20% of mothers completed three or more PNC visits, reflecting a trend consistent with low- and middle-income countries (LMICs).^{24 29 30} This finding aligns with studies conducted in Nigeria (22%), Myanmar (25.2%), Southern Ethiopia (23.9%), Punjab (25.9%), Northern Shoa, andEthiopia (28.4%),²³,²⁵³¹ but it is higher than those in Malawi (13.7) and India (15.5%).^{24 29 30} This low level of PNC utilisation may be attributed to limited awareness or insufficient knowledge among the respondents.

In our study, widowed women had significantly higher odds of utilising PNC services, which contrasts with findings from other studies that reported lower odds among this group.³² This discrepancy may be explained by the supportive environment offered through PNC services, where widowed women can receive emotional support, counselling and opportunities to connect with others facing similar life circumstances.

Interestingly, multivariate analysis highlighted increased PNC utilisation among rural residents, which aligns with a study conducted in Malawi.¹² This is in contrast to some studies conducted in Afghanistan and meta-analyses conducted in sub-Saharan Africa.^{7 33} In general, urban areas have better access to PNC services and greater exposure to health promotion programmes. Effective healthcare in rural areas is an essential component of promoting health and health outcomes and is seen as a foundation of health equity. Saudi Arabia’s strong rural health network may explain its higher uptake in these settings.

As expected, women who received the WHO-recommended number of antenatal care visits³⁴ were associated with a higher likelihood of PNC utilisation services. This finding is consistent with those of other studies.^{7 13 24} This could be explained by the exposure of health workers, who can deliver information about PNC.

Our study showed that individuals aged 41 and above were 0.05 times less likely to utilise PNC compared with those aged 20 and below. This finding is in line with those of other studies conducted worldwide.^{35 36} Younger women showed more PNC utilisation than their older counterparts who had previous experience with previous deliveries that passed peacefully, so they considered themselves to be less susceptible to complications.

While several studies have identified education as a key determinant of care utilisation,^{37 38} we did not observe a significant association in our analysis. This may be due to local differences in health service availability, community-level knowledge dissemination or cultural beliefs, which may mediate the impact of formal education on healthcare behaviour.

Our study found no significant association between PNC utilisation and parity, a finding echoed by studies from India and rural Tanzania.^{29 39} In health systems where maternal care is universally available or culturally normative, parity may not strongly influence decision making. Additionally, similarities in study design (ie, facility-based, cross-sectional surveys) may have contributed to these consistent findings, unlike more detailed community-based or qualitative research.

Interestingly, our study did not find a significant association between PNC utilisation and delivery by caesarean section or the presence of maternal complications. This contrasts with findings from studies conducted in other regions, where women who underwent caesarean section or experienced complications were more likely to seek PNC services.^{6 36 40} Cultural beliefs about healing, limited health literacy about post-surgical risks or a lack of proactive reminders may explain these differences. Another possibility is that women with complications receive more attention and advice during hospital stay, which may paradoxically reduce their perceived need for follow-up visits. These factors highlight the complexity of health-seeking behaviours and suggest that even high-risk cases require targeted health education to reinforce the value of continued PNC.

Our study revealed a negative association between perceived susceptibility and PNC utilisation, implying that women who perceive themselves as less susceptible to postnatal health issues utilise PNC services less. A similar perception was reported in an Iranian study, in which many women did not believe they were at risk of postpartum complications.⁴¹ Although our study focused on PNC, other studies have shown similar patterns in different domains. For example, Aldohaian et al found that Saudi women who did not perceive themselves as susceptible to cervical cancer were less likely to seek screening services.⁴² Similarly, in China, women’s perceived susceptibility to diabetes following gestational diabetes was positively linked to their likelihood of returning for glucose testing.⁴³ These examples support the broader application of the HBM across different health behaviours and highlight how perceptions can drive or inhibit service use.

We also found that higher perceived barriers were associated with lower PNC utilisation. This is consistent with findings from Rwanda, where high perceived barriers (eg, distance to facilities and lack of knowledge) limited antenatal care attendance.²⁴ In contrast, a Tanzanian study reported lower perceived barriers, possibly due to differences in health infrastructure and educational efforts in that setting.¹⁷ These contextual differences, particularly in healthcare access and outreach strategies, may explain some inconsistencies across settings.

Our study showed no relationship between perceived benefits and PNC utilisation, meaning that women perceived no advantages or positive outcomes from utilising PNC services. This finding is in line with that of a study conducted in Iran, which showed that the mean perceived benefit in the intervention and control groups was not significantly different before training. This finding is contrary to studies done in Saudi Arabia and China.^{42 43} This reflects the lack of knowledge that PNC can diagnose postnatal complications in a timely manner and reduce dangerous sequelae.

Regarding cues to action that show a negative relationship with PNC utilisation, women who receive fewer reminders or cues to seek PNC have significantly lower odds of utilising it. This mirrors the findings from Ghana, where women with fewer birth preparedness activities and healthcare touchpoints were less likely to deliver with skilled attendants.⁴⁴ This underscores the role of proactive communication and reminders in shaping maternal behaviours.

The results of this survey are consistent with a growing body of literature supporting the predictive role of HBM constructs in the utilisation of health services. For example, Abdallah et al in a recent systematic review found that individuals’ perceptions of their self-efficacy, susceptibility and perceived benefits significantly determined the enhancement of preventive services for clinical conditions such as cervical cancer.⁴⁵ In line with this, Anokye et al found in a separate thorough review that programmes like cardiovascular screening not only changed people’s behaviour but also made them more likely to use preventive care services in the future.⁴⁶ These results show that psychological factors, such as how vulnerable people feel and how confident they are in their ability to perform health-related actions, are important in determining who will use services such as PNC. By identifying similar patterns across diverse health domains, our study reinforces the broader applicability of the HBM in understanding and addressing service-uptake challenges, including maternal health.

A key strength of this study is the use of a validated theory-based tool (HBM) and a robust sample size with multistage random sampling. However, the cross-sectional design limits causal inference and the use of self-reported data may introduce recall or social desirability biases. Future studies may benefit from longitudinal or mixed-method approaches to better understand how beliefs and behaviours evolve over time.

Conclusions

The mothers in this study exhibited a low utilisation of PNC services. This study reported that PNC service utilisation was higher among women who were in rural areas and were widowed and those of wealthier backgrounds; high intake of antenatal services enhanced utilisation of PNC services. Perceived barriers and cues of action are important determinants of PNC service utilisation. This study underscores the need for tailored health promotion strategies that consider mothers’ perceptions and beliefs regarding PNC services. We recommend that the Ministry of Health in Saudi Arabia and PHC administrators strengthen health education initiatives aimed at reducing perceived barriers and enhancing cues to action related to PNC utilisation. We also suggest that healthcare providers, including midwives and physicians, integrate targeted counselling on the importance of postnatal visits during antenatal care sessions. These actions can help address the behavioural determinants identified through the HBM. Additionally, we recommend that future researchers should consider longitudinal or interventional study designs to further explore and validate these associations.

Data availability statement

Data are available upon reasonable request.