Newborn postnatal care: gap in contact and effective coverage and discrepancy in response in Ethiopia

Abstract

Background

Access to quality postnatal care for newborns is crucial to eliminating preventable neonatal deaths. While some studies have examined contact coverage, there is limited evidence on effective (quality-adjusted) coverage. This study aimed to evaluate the gaps between contact and effective coverage, as well as discrepancies between reported newborn postnatal checks and the interventions received.

Methods

The data were obtained from the Ethiopian Mini-Demography and Health Survey 2019, and a weighted sample of 2,105 women aged 15 to 49 who had given birth within the two years prior to the survey was included. A multivariable regression analysis was performed to identify factors associated with contact coverage and effective coverage.

Results

Contact coverage of newborn postnatal care was 34.8%, while effective coverage was 10.4%. The study found that geographical region, antenatal care contact, and place of delivery were significantly associated with both contact and effective coverage. Additionally, household wealth status was significantly associated with contact coverage, while age and educational status were associated with effective coverage. The study also revealed a discrepancy between the reported postnatal checks and the actual interventions provided. The percentages of women who reported that a healthcare worker provided breastfeeding counseling, observed breastfeeding, checked the umbilical cord, measured temperature, and counseled on newborn danger signs but answered “no” to having a newborn postnatal check were 15.4%, 12.7%, 7.5%, 7.3%, and 6.6%, respectively.

Conclusions

This study identified a significant gap between contact and effective coverage, underscoring the need to strengthen access to quality care. Additionally, a notable discrepancy was found between reported postnatal checks and the actual care received, emphasizing the importance of strengthening data quality and validation mechanisms.

Background

Although neonatal mortality has noticeably decreased over the past three decades, dropping from 5 million in 1990 to 2.4 million in 2020, it still accounts for the majority (47%) of all under-5 deaths [1, 2]. In Ethiopia, newborn deaths account for 56% of under-five deaths and have recently risen, increasing from 28 to 33 per 1000 live births between 2016 and 2019 [3].

Comprehensive postpartum care (PNC) starts approximately an hour after placenta delivery and continues for six weeks [4]. It includes early complications detection, treatment, hygiene, breastfeeding guidance, birth spacing, immunization, and maternal nutrition, critical for the health of mothers and babies. The World Health Organization (WHO) advises postpartum care within 24 h of birth, with at least three more visits: within 48–72 h, between days 7 and 14, and at 6 weeks postpartum [5].

The first two days are vital for newborns, and inadequate care can lead to health problems. However, PNC use for mothers and babies is lower than for other health services. UNICEF 2022 reports that 69% of mothers and 66% of newborns worldwide receive health checks in this period [6]. Moreover, the uptake of newborn postnatal care varied across countries and regions, with 100% in Belarus and Cuba, 8% in Guatemala, and 10% in Somalia [2]. Additionally, despite the known discordance between mothers and babies [2, 7], most postnatal care studies in many countries focus on women [8], in some countries, the discrepancy reaches 70% [2].

Moreover, despite evidence showing that only 3% of newborn babies in sub-Saharan Africa have received the recommended interventions [9], studies on maternal and child health services often rely on crude or contact coverage (CC) metrics to evaluate health coverage. CC refers to the proportion of individuals or populations who interact with a healthcare service or intervention; it does not measure adherence to the care standard [10]. Effective coverage (quality-adjusted) measures health service use based on quality standards, considering both contact and quality. It shows the population in need who use and receive quality care [10]. However, there is limited evidence on effective coverage (EC) of newborn postnatal care within the first two days after birth, and existing evidence has shown a significant gap between contact and effective coverage, which ranges from 26 to 89% in the study conducted across 15 African countries [11].

In Ethiopia, further analysis of the 2016 Demographic and Health Survey revealed that postnatal care coverage for newborns was critically low at 13%, with effective coverage even lower at 9% [12]. However, to inform targeted and effective interventions, more up-to-date and comprehensive evidence is needed. Furthermore, discrepancies between reported newborn postnatal checks and the actual interventions received can be substantial, ranging from 1 to 16% in Africa [11]. Such inconsistencies in reporting risk undermine data-driven decision-making, potentially compromising patient outcomes. Understanding these gaps in Ethiopia is crucial to ensuring that newborns receive proper care.

Hence, the study aimed to assess the prevalence of contact and effective coverage, as well as the discrepancy in reported newborn postnatal checks and specific interventions received in Ethiopia.

Methods

Data source and sampling technique

This study used the Mini-Ethiopian Demographic Health Survey (EDHS) 2019, a nationally and regionally representative cross-sectional survey. The EDHS employs a two-stage stratified cluster sampling method. In the first stage, 305 EAs were selected; in the second, 30 households per cluster were chosen using an equal-probability systematic selection procedure. The data were collected from March 21 to June 28, 2019. All women aged 15 to 49 years who gave birth in the two years prior to the survey were the study population for this study. A total of 2,105 women with their most recent live births were included in the final analysis [13]. For more information on the methodology of mini-EDHS 2019, please see this link: https://dhsprogram.com/publications/publication-FR363-DHS-Final-Reports.cfm.

Measurements

Outcome variables

Contact coverage (postnatal check), effective coverage, and discrepancies in response between reported postnatal checks and reported specific interventions were the main objectives of this study, defined in accordance with WHO recommendations and previous studies [11, 14, 15]. Contact coverage is defined as CC = U/N, where U is the use of the intervention among the population in need, and N is the population in need of an intervention. Whereas the definition of effective coverage has three critical components: quality, utilization, and need. Effective coverage is defined as EC = U/N *Q, where Q is the quality of the intervention defined as “the ratio of health gain delivered through an intervention to the maximum possible gain given the ideal quality. The difference between contact coverage and effective coverage, known as the quality-coverage gap (CC-EC), refers to those who had a postnatal check but did not receive the expected care. In this study, the intervention was a postnatal check for newborns within the first two days of life (U) among most recent live births that occurred within the two years before the survey (N) and the expected components of the intervention included checking the umbilical cord, measuring temperature, counseling on newborn danger signs, providing breastfeeding counseling, and observing breastfeeding was the quality of the intervention (Q). Another objective was response discrepancy, defined as a newborn receiving a specific intervention but reported as not undergoing a postnatal check, or where a woman reported that a healthcare worker provided a specific intervention but reported “no” to having a newborn postnatal check question. Women who had given birth within the two years preceding the survey were asked if their recent babies received a postnatal check-up within the first two days after birth, as well as the type of postnatal interventions provided by healthcare providers.

Data management and analysis

Descriptive statistics were used to summarize the distribution of participants’ characteristics and the distribution of contact and effective coverage based on these characteristics. The chi-square test was employed to determine the differences in contact and effective coverage between groups. Variables that showed statistical significance at the chi-square test with a p-value < 0.05 were included in the multivariable regression analysis to assess the independent effects of each variable on contact and effective coverage of newborn postnatal care. The results from the multivariable regression are presented as adjusted odds ratios with 95% confidence intervals (CI), with statistical significance defined as p < 0.05. STATA software version 15.1 was utilized for the analysis. We applied weights to account for disproportionate sampling and non-response. Additionally, the “svyset” command was used to address the effects of the complex sample survey.

Results

Sociodemographic characteristics

A total of 2,105 women who had given birth in the two years preceding the survey were included, with a mean age of them was 27.6 years and a standard deviation of 0.2. Almost half of them (49.2%) were aged between 25 and 34, while one-third (32.4%) were aged between 15 and 24. About 32% of women had no formal education, and only 14% had completed secondary school or higher education. Nearly half (43.2%) of the participants were from low-income households, while 38.1% were from wealthier ones. Around 44% of women had four or more ANC contacts during pregnancy, whereas 26.1% had none. Approximately 46% of women delivered at home, and 35.5% had access to radio or television at their residence (Table 1).

Table 1.

Sociodemographic characteristics, contact coverage, and effective coverage of newborn postnatal care among women who gave birth in the last two years preceding the survey, EDHS 2019, Ethiopia (n = 2105)

Variables	Frequency (%)	Contact coverage (%)	Effective coverage (%)
Mothers' age
15-24	32.4	37.5	7.3
25-34	49.2	33.2	12.2
35-49	18.4	34.5	11.1
Mothers’ education		***	***
No education	46.4	22.3	7.1
Primary Education	39.9	39.9	8.6
Secondary	13.6	62.5	26.9
Marital status
Not in union	5.0	32.3	5.8
In-union	95.0	35.0	10.7
Wealth index		***	***
Poor	43.2	19.4	5.4
Middle	18.6	33.6	8.1
Rich	38.1	52.9	17.2
Residence		**	**
Urban	26.3	48.4	16.3
Rural	73.7	30.0	8.3
Region		***	***
Developed	86.7	34.4	9.3
Developing	9.7	22.1	9.2
City	3.6	78.4	41.4
ANC contacts		***	***
No	26.1	6.6	0.9
1-3 contacts	29.9	28.1	8.8
4 or more contacts	44.0	56.1	17.1
Place of delivery		***	***
Elsewhere	46.0	2.3	1.7
Health facility	54.0	62.5	17.8
Birth interval		***
<24 months	14.7	21.3	10.9
>=24 months	61.2	33.2	10.2
Primi	24.1	47.3	10.7
Sex of baby
Male	51.5	34.8	9.6
Female	48.5	34.8	11.3
Media exposure		***	***
No	64.5	25.7	6.5
Yes	35.5	51.5	17.5

*Significant at <0.05, ** significant at <0.01, and *** significant at <0.001 at chi-square test analysis

Contact coverage, effective coverage, and quality-coverage gap

Postnatal care contact coverage (postnatal check) for newborns was 34.8% (95% CI: 31.7, 38.0), while effective coverage (receiving the full content of care) was considerably lower at 10.4% (95% CI: 10.2, 10.6). This revealed a substantial gap, 24.4% (95% CI: 21.3, 26.8), between contact and effective coverage (Fig. 1).

Fig. 1.

Percentage of contact coverage, effective coverage, quality-coverage gap, and specific intervention coverage among women who had given birth in the two years preceding the survey, EDHS 2019 (n = 2,105)

Both contact and effective coverage varied significantly with maternal education level. The contact coverage was 22.3% among women with no formal education, whereas it was 62.5% among those with secondary or higher education. Similarly, effective coverage was just 7.1% among women with no formal education, compared to 26.9% for women with secondary or higher education. A similar pattern was seen by place of delivery. Contact coverage was 2.3% and effective coverage 1.7% for women who delivered outside health facilities, while it was 62.5% and 17.8% respectively, for women who delivered in health facilities. Additionally, contact and effect coverage for newborn PNC differed significantly based on wealth index, ANC contacts, media exposure, residence, and region. Besides, contact coverage varied by birth interval (Table 1).

Response discrepancy

As Fig. 1 shows, 50% of women reported receiving at least one newborn care service. However, only 34.8% reported having a newborn postnatal check, highlighting a significant discrepancy in responses. Figure 2 also shows that about 15% of women reported receiving breastfeeding counseling from a healthcare worker but answered “no” to having a newborn postnatal check. About 7% of women reported receiving counseling on newborn danger signs yet answered “no” to having a newborn postnatal check. Additionally, 1.8% of women reported that a healthcare provider delivered all five care components but answered “no” to having a newborn postnatal check (Fig. 2).

Fig. 2.

Percentage of women who reported receiving specific newborn care interventions but not a postnatal check (response discrepancies), among women who had given birth in the two years preceding the survey, EDHS 2019 (n = 2,105)

Factors associated with contact and effective coverage of newborn postnatal care

In the multivariable regression analysis, variables region, wealth index, ANC contacts, and place of delivery were statistically associated with contact coverage of newborn postnatal care, whereas variables maternal age, maternal education, region, ANC contacts, and place of delivery were statistically significant for effective coverage of newborn postnatal care. The odds of contact coverage among women from middle and rich households were 1.49 (95% CI: 1.01, 2.18) and 1.31 (95% CI: 0.93, 1.85) times higher, respectively, compared to women from poor households. The odds of contact coverage among women from city administrative regions was 1.53 (95% CI: 1.04, 2.25) times higher compared to women from developed regions. Similar trends were observed among those who had ANC visits. Having 1 to 3 and four or more ANC contacts significantly increased the odds of contact coverage (aOR = 1.88, 95% CI: 1.22, 2.89; aOR = 3.25, 95% CI: 2.11, 4.99). The odds of contact coverage among women who delivered at a health facility was 34.6 (95% CI: 23.39, 51.28) times higher compared to women delivered at home or elsewhere.

Maternal age was significantly associated with effective coverage of newborn postnatal care. The odds of effective coverage among women aged 25–34 and 35–49 were 1.90 (95% CI: 1.34, 2.68) and 2.40 (95% CI: 1.49, 3.85) times higher than those of women aged 15–24, respectively. The odds of effective coverage among women from city administrative regions and developing regions were 1.68 (95% CI: 1.19, 2.38) and 1.98 (95% CI: 1.27, 3.07) times higher than among women from developed regions, respectively. Women with secondary or more education showed trends toward increased odds of effective coverage (aOR = 1.56, 95% CI: 1.02, 2.38). Similar trends were observed among women who had four or more ANC contacts (aOR = 2.53, 95% CI: 1.27, 5.03) and delivered at a health facility (aOR = 17.85, 95% CI: 8.97, 35.54) (Table 2).

Table 2.

Factors associated with contact and effective coverage of newborn postnatal care among women who gave birth in the last two years preceding the survey, EDHS 2019, Ethiopia (n = 2105)

	Contact coverage	Effective coverage
Variables	aOR (95%CI)	aOR (95%CI)
Mothers' age
15-24		1
25-34	-	1.90 (1.34, 2.68) ***
35-49		2.40 (1.49, 3.85) ***
Mothers’ education
No education	1	1
Primary Education	1.20(0.91, 1.60)	1.17 (0.81, 1.70)
Secondary	1.07 (0.75, 1.53)	1.56 (1.02, 2.38) *
Wealth index
Poorer	1	1
Middle	1.49 (1.01, 2.18) *	1.26 (0.79, 2.00)
Rich	1.31 (0.93, 1.85)	0.72 (0.46, 1.13)
Residence
Urban	1	1
Rural	1.23(0.89, 1.70)	1.00 (0.67, 1.49)
Region
Developed	1
Developing	1.17 (0.89, 1.54)	1.68 (1.19, 2.38) **
City	1.53 (1.04, 2.25) *	1.98 (1.27, 3.07) **
Birth interval
<24 months	1	-
>=24 months	1.19 (0.81, 1.75)
Prime	0.98 (0.64, 1.49)
ANC contacts
No	1	1
1-3 contacts	1.88 (1.22, 2.89) **	1.88 (0.93, 3.76)
4 or more contacts	3.25 (2.11, 4.99) ***	2.53 (1.27, 5.03) **
Place of delivery
Home	1
Other health facility	34.60 (23.39, 51.28) ***	17.85 (8.97, 35.54) ***
Media
No	1
Yes	1.07 (0.80, 1.43)	1.10 (0.76, 1.58)

1 reference, * significant at <0.05, ** significant at <0.01, and *** significant at <0.001, aOR Adjusted odds ratio, CI Confidence interval, - not eligible for multivariable regression analysis

Discussion

The findings of this study highlight significant quality gaps and reporting inconsistencies, providing essential insights for policymakers to enhance care quality and data accuracy in maternal and child health. Our study found that the prevalence of contact coverage for newborn postnatal care was 34.8% (95% CI: 31.7, 38.0), notably higher than previous studies conducted in Ethiopia (13.2%) [12] and Zambia (16%) [16]. One possible reason could be the recent increase in institutional delivery coverage [16]. Institutional delivery provides an opportunity for pre-discharge health assessments and education on postpartum maternal and newborn care. A study conducted in 15 African countries found that coverage of newborn postnatal checks varies by country, from 13 to 78% [11]. The lower coverage of postnatal checks for newborns and the disparities in coverage between countries may relate to differences in healthcare infrastructure and access to services [17].

This study demonstrates that the newborn postnatal check may not adequately reflect the quality of care received, due to a substantial quality-coverage gap. Effective coverage of newborn postnatal care was only 10.4% (95% CI: 10.2, 10.6), indicating a significant discrepancy between service contact and the quality of care delivered, a gap of 24.4% (95% CI: 21.3, 26.8). Similar findings have been reported in Ethiopia, where effective coverage was estimated at 9% [12]. A multi-country study across 15 African nations also highlighted large disparities between contact and effective coverage, ranging from 26% in Malawi to 89% in Burundi [9, 11]. This gap may be attributed to factors such as inadequate training and a lack of provider commitment to quality care [18].

Multivariable regression analysis revealed that women who attended antenatal care (ANC) and delivered in a health facility were significantly more likely to receive both contact and effective coverage of newborn postnatal care. This finding is consistent with previous studies [19, 20]. The possible reason might be that continuity of care enables them to receive comprehensive education about the importance of postnatal care services. Women who engage with ANC and facility-based delivery are generally more informed and better connected to healthcare systems, which enhances their access to, and utilization of, quality care for themselves and their newborns.

Our study also found that women from city administrative regions were more likely to receive postnatal checkups as well as effective coverage of newborn postnatal care. This finding was supported by previous studies [12, 19]. The possible reason could be that in urban areas there are often more healthcare facilities, better transportation, and infrastructure, making it easier for women to access postnatal care services. Addis Ababa, being the capital city, may have a better-developed healthcare infrastructure and resources, such as well-equipped hospitals, skilled healthcare professionals, and access to essential medical supplies, compared to other regions, contributing to higher-quality newborn care.

In this study, women from middle-income households were more likely to undergo postnatal checks compared to those from poor households. This finding was also supported by previous studies conducted in Ethiopia and low-income countries [12, 21]. The possible explanation could be linked to transportation and other expenses; nevertheless, women from rich households don’t exhibit a noteworthy contrast; it may be that those from middle-income households have better access to healthcare facilities, highlighting that wealth alone doesn’t ensure enhanced healthcare utilization.

This study also showed that women over 25 or older were more likely to have effective coverage of newborn care compared to younger women. The possible explanation might be that older women may have more experience and knowledge about pregnancy, childbirth, and newborn care due to having had previous pregnancies [22]. This experience could contribute to a better understanding of the importance of quality newborn care and the adoption of recommended practices. Moreover, women with secondary or higher education were more likely to have effective coverage of newborn care. This could be attributed to the fact that advanced educational levels are frequently linked with better health-seeking practices, enabling women to access and utilize essential neonatal healthcare [23].

The study also examined the inconsistency between reported postnatal checks and the actual receipt of specific newborn postnatal care interventions. In this study, the prevalence of newborn postnatal checks was 35%. However, 50% of the women reported that healthcare professionals provided at least one specific intervention. Approximately 15% and 13% of women stated that healthcare providers counseled them on breastfeeding and observed breastfeeding, respectively, yet they reported “no” to the question about having a postnatal check. Moreover, 7.3% of women reported having their newborn’s temperature measured, and 6.6% reported receiving counseling on newborn danger signs, yet they reported that they did not have a postnatal check. A previous study similarly found a discrepancy between reported postnatal checks and actual umbilical cord checks received, with this discrepancy ranging from 1% in Burundi to 16% in Malawi [11]. The observed discrepancy might be due to the confusion between intrapartum care and postnatal care. Intrapartum care covers labor, delivery, and placenta expulsion, while postnatal care covers mother and newborn care from the first hour to 6 weeks postpartum [24]. Evidence showed that the percentages of postnatal care coverage drop significantly when first-hour postnatal checks are considered purely intrapartum care [7]. A provider may offer health checks for newborns and mothers multiple times and in various settings such as labor, postnatal, home, and outpatient clinics; however, women might remember individual interventions but not recognize them as part of postnatal care [25]. The lack of agreement on when the postnatal period begins and the need for a clear cutoff for measuring postnatal care continue to be major challenges. Another possible factor contributing to this situation could be the partial fulfilment of the translation of postnatal care aspects. DHS questions are not formally translated into less commonly spoken languages. Instead, interviewers were directed to adjust the question wording to local dialects and cultural nuances without altering the question’s intended meaning [26]. The Ethiopian DHS question has only been translated into three major languages: Amharic, Tigrigna, and Oromiffa, although Ethiopia is home to over 80 different languages [27].

The data for this study come from large, nationally representative surveys and highlight the gap between contact and effective coverage of newborn postnatal care, as well as discrepancies between the reported postnatal check and specific interventions. This information may help policymakers ensure access to all and improve the quality of care. It is also an important finding for the DHS program to evaluate the postnatal care measurement tool. However, this study may face some limitations. Postnatal care for newborns was assessed through self-reports from participants, which could introduce subjective bias. Additionally, several important variables, such as household income, political and economic context, healthcare access, and spousal support, were not included in the analysis, as they are not captured in the primary data collection.

Conclusions

This study reveals substantial gaps between contact and effective coverage of newborn postnatal care in Ethiopia: although one-third of newborns received postnatal checks, only 10% received quality-adjusted care. This suggests that crude coverage measures may overstate actual service impact. Antenatal visits and facility births were strong predictors of both contact and effective coverage, highlighting the need to strengthen the maternal-newborn care continuum. Maternal education and income also play vital roles in improving access and care quality. Discrepancies between reported postnatal checks and actual care received emphasize to strengthen data quality and validation mechanisms.

Abbreviations

ANC

Ante Natal care

CC

Contact Coverage

EC

Effective Coverage

EDHS

Ethiopian Demographic and Health Survey

DHS

Demographic and Health Survey

Authors’ contributions

MBA: Conception, analysis, writing, editing, and reviewing and preparing the manuscript, AMD: assist editing. All authors read and approved the final manuscript.

Funding

The authors did not receive any funding for this study or publication of this article.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

After a request letter submitted to the Demographic and Health Surveys (DHS) program, the International Review Board of DHS program data archivists authorized us to download the data set and use it for this study. The data set was not shared or passed on to other organizations or individuals, and it was kept strictly confidential. The primary data were collected by national and international ethical norms.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.