Determinants of early postnatal care utilization among mothers in West Shoa Oromia, Ethiopia, an unmatched case-control study 2023

Abstract

The early postnatal period is a critical time for both mothers and newborns, as a large proportion of maternal and neonatal deaths occur within the first week after delivery. Globally, only about 48% of mothers receive postnatal care within the first two days after childbirth, with much lower coverage in low- and middle-income countries. Early postnatal care (EPNC) plays a vital role in identifying and managing complications and improving maternal and newborn survival. However, the utilization of early postnatal care services remains low in many countries, including Ethiopia. Therefore, this study aimed to identify the determinants of early postnatal care utilization among mothers who gave birth in the previous 12 months in Adea Berga District, West Shoa Zone, Oromia, Ethiopia. A community-based unmatched case–control study was conducted among 465 mothers (155 cases and 310 controls). Participants were selected through simple random sampling. Data were collected through structured face-to-face interviews. Data were entered into EpiData and analyzed using Stata version 17. Both bivariable and multivariable logistic regression analyses were performed. Adjusted odds ratios (AORs) with 95% confidence intervals (CIs) were calculated, and statistical significance was declared at p < 0.05. Among the 465 mothers included in the study, 64.7% received antenatal care follow-up and 55.7% delivered at health centers. In multivariable analysis, several factors were significantly associated with early postnatal care utilization. Mothers living in urban areas were (AOR = 4.6, 95% CI: 2.1–10.3). Married women were (AOR = 3.0, 95% CI: 1.5–6.3). Mothers who had antenatal care follow-up were (AOR = 2.8, 95% CI: 1.3–6.0). Similarly, employed women (AOR = 2.5, 95% CI: 1.3–5.1), women with primary education (AOR = 1.4, 95% CI: 1.2–7.5), and those with access to transportation (AOR = 2.5, 95% CI: 1.5–4.4) had higher odds of early postnatal care utilization. Early postnatal care utilization was significantly influenced by place of residence, marital status, maternal education, employment, antenatal care follow-up, and access to transportation. Interventions focusing on strengthening antenatal care services, improving access to transportation, and enhancing maternal awareness, especially in rural areas, are essential to increase early postnatal care utilization.

Introduction

Postnatal care (PNC) refers to the care given to the mother and her newborn baby immediately after the baby’s birth and for the first 42 days of life. The period from birth to the first 24 h is referred to as the immediate postnatal period. The period from Days 2 through 7 is defined as the early postnatal period (EPNC), and the period from Days 8 through 42 is the late postnatal period¹.

Maternal mortality remains a global challenge. In 2023, an estimated 260 000 women globally died from pregnancy- or childbirth-related causes, equivalent to approximately one maternal death every two minutes, a 4% decline in maternal mortality since 2000, yet progress remains insufficient to meet SDG targets². Maternal mortality ratio (MMR) is 15 times higher in developing than in developed regions³. Two regions, sub-Saharan Africa and South Asia, account for 86 per cent of maternal deaths worldwide. Sub-Saharan Africans suffer from the highest maternal mortality ratio, 533 maternal deaths per 100,000 live births, or 200,000 maternal deaths a year. This accounts for two-thirds, or 68%, of all maternal deaths that occur an¹ nually worldwide. South Asia follows, with a maternal mortality ratio of 163/100,000 maternal deaths a year, accounting for 19 per cent of the global total⁴. The high number of maternal deaths in some areas of the world reflects inequalities in access to quality health services and highlights the gap between the rich and the poor. The MMR in low-income countries in 2020 was 430 per 100 000 live births versus 13 per 100 000 live births in high-income countries².

Ethiopia’s maternal mortality ratio is also high, which is currently estimated at 401 maternal deaths per 100,000 live births⁵. In 2016, the maternal mortality ratio was 412 deaths per 100,000 live births, which is higher than the global average but an improvement from 673 deaths per 100,000¹ live births in 2005⁶. Another previous study conducted in Ethiopia reported that approximately 65% of maternal deaths occur within the first seven days after delivery, with about 45% occurring within the first 24 h postpartum^6,7.

Most maternal deaths are preventable, as the health-care solutions to prevent or manage complications are well known. Contact with the health care within 48 h and before the end of the first week would be the most effective strategy for the mothers and their babies to reduce deaths. The care given for the first hours, days, and weeks after childbirth is critical not only for survival but also for the future of mothers and newborn babies because those periods are a critical time for both the mother and the newborn infant^1,8. All women need access to high-quality care in pregnancy, during and after childbirth. Maternal health and newborn health are closely linked. Skilled health professionals must attend all births, as timely management and treatment can make the difference between life and death for the women as well as for the newborns.

The Ethiopian government approves of this plan for enhancing the use of services. Over the past few years, a large number of health extension professionals have organized and connected health centers with health posts^9,10. Overall, prenatal and postpartum medical care is crucial to the survival and general well-being of both the mother and the child⁹. The Ethiopian Federal Ministry of Health advises scheduling three appointments for early postnatal care, ideally on days 3, 7, and 14 and 4–6 weeks after delivery⁹. The postnatal period needs follow-up using the World Health Organization (WHO) standard contact times⁸.

Prior research conducted in Ethiopia has mostly concentrated on determining the correlation between maternal attributes, such as wealth, education¹¹, residence, occupation, Antenatal Care (ANC) follow-up, institutional delivery, and distances from health institutions¹², with early postnatal check-ups. Despite the availability of the postnatal care service at all levels, the mothers and their new babies are not receiving this life-saving service. Evidence from local health facilities and the Adea Berga district health office shows that only 31% of mothers utilized early postnatal service within seven days of delivery. While the majority of mothers did not attend EPNC service or were addressed during home visits by HEWs in the first seven days after childbirth, unless mothers or their newborn babies got sick¹³. Despite some improvements in maternal health service utilization in Ethiopia, coverage remains suboptimal across the continuum of care. Only about 43% of women attended four or more antenatal care (ANC) visits, 48% of births were assisted by skilled birth attendants (SBA), and 34% of women received postnatal care (PNC)¹³. These figures indicate substantial gaps in the utilization of essential maternal health services. This study aims to identify determinants of early postnatal care service utilization among women in Adea Berga District, West Shoa Zone, using a case-control study, as previous studies in Ethiopia lack sufficient evidence on the association between early postnatal care utilization and determinant factors.

Methods and materials

Study design, setting and period

A community-based unmatched case-control study was conducted in Adea Berga District, West Shoa Zone, Oromia Region. The district is located 64 km from Addis Ababa, the capital of Ethiopia, and 114 km from Ambo town, the capital of West Shoa Zone. Adea Berga is divided into 34 rural and 3 urban kebeles, which are the smallest administrative units. The district has one primary hospital, five health centers, 35 health posts, and 15 private clinics. The estimated total population of Adea Berga District is 184,618, with 92,356 (50.1%) females and 92,262 males. Among these, approximately 22.3% (40856) are women of childbearing age (15–49 years), and about 3.47% (6406) are pregnant. In 2022, the district had 347 health workers, including health extension workers. All health centers and the hospital provide postnatal care services, and health extension workers also offer postnatal care at the health post level. The study was conducted from November 01 to December 01, 2023.

Population

Cases included all women who utilized the early postnatal care service within 12 months after delivery during data collection in selected Kebeles. Controls were all women who were within 12 months after delivery during data collection in selected Kebeles and did not utilize the early postnatal care service from the health care provider within 7 days of childbirth.

Inclusion and exclusion criteria

All mothers who gave birth within the past 12 months before the study period and resident at least six months in the Adea Berga district during data collection time were included in this study. Mothers unable to respond because of being mentally or critically ill during data collection were excluded from the study.

Sample size determination

The sample was calculated by using the double population proportion formula, and it was calculated through Epi Info version 7.2 with the assumption of a confidence level 95% (Z/2 = 1.96), power 80% (Z= 0.84), case to control ratio of 1:2. Where P1 is the proportion of cases exposed, and P2 is the proportion of controls exposed (Table 1).

Table 1.

Sample size calculation using Epi Info version 7.2 for the study populations on Determinant of Early Postnatal care Service utilization, by using different variables, 2023.

Serial Number	Variables	Confidence level	Power	P1	P2	AOR	Sample size			References
							Number of cases	Number of controls	Total
1	Educational level of mother (High school)	95%	80%	31.9%	10.7	3.2	68	136	204	(14)
2	Mother’s knowledge of at least one danger sign	95%	80%	92.9%	60.5%	11.6	22	44	66	(15)
3	ANC Follow-up	95%	80%	98%	85.6%	11	64	127	191	(15)
4	Distance from the health institution (on foot)	95%	80%	69%	83%	4	94	187	281	(14)
5	Place of delivery (Health institution)	95%	80%	32.3%	76.3%	7.11	46	92	138	(16)

Among the calculated sample sizes for the different exposure variables, the largest sample size was 281. After accounting for a 10% non-response rate and applying a design effect of 1.5, the final sample size was increased to 465. Accordingly, the study included 155 cases and 310 controls, giving a total sample of 465 mothers who had given birth within the previous 12 months (Table 1).

Sampling procedure

The study used a multistage random sampling technique; Kebeles were stratified into rural and urban. Eleven kebeles (ten rural and one urban) were selected using a simple random sampling technique (lottery method). The selected kebeles included Chanco, Birate, Gatira, Nabe, Ilu, Ketaba, Daku Kito, Odo Mojo, Ula Gora, Reji Makoda, Sire Berga, Maru Chobat, Eteya, and Enchini 01, with only one kebele representing the urban area. Together, these kebeles represented approximately 30% of the total population of Adea Berga District. The required sample size was then proportionally allocated to the selected kebeles based on the estimated number of mothers who had given birth in the previous 12 months. Prior to data collection, and in collaboration with local administrators and the district health office, a census was conducted in the selected kebeles with the support of health extension workers to identify and code households with eligible women. Separate sampling frames were prepared for cases and controls. Finally, study participants were selected using simple random sampling (lottery method) from the sampling frames, and home visits were conducted to interview the selected participants using their household identification numbers (Fig. 1).

Fig. 1.

Schematic Presentation of sampling procedure of the study participant in Adea Berga District, 2023.

Variables of the study

Dependent variable

The dependent variable for this study is the early postnatal care utilization status.

Independent variables

The Independent variables for this study are:

Socio-demographic factors include Age, Religion, Ethnicity, place of residence, family income, marital status, Family size, Occupation of maternal and partner, and educational status of maternal and partner.

Obstetric and health service use factors

ANC follow-up, Parity and gravidity, place of delivery, mode of delivery, encountered problem during delivery, plan to utilize PNC, and previous PNC utilization.

Maternal factors

Knowledge of the mother on the danger signs of post-partum, on the availability of PNC service and the mother’s service utilization.

Health institution and provider-related factors

Access to transportation, distance from the health facility and length of stay at a health facility after delivery, advice by a health professional on early postnatal care after discharge, awareness of early postnatal care service and appointment for service utilization.

Operational definition

Early postnatal care service

In this study, healthcare services that are provided in the period from Days 2 through 7 after delivery to the end of the first week of delivery, both for the mothers and newborn babies by health workers and health extension workers.

Early post-natal care utilized in this study refers to mothers who had at least one postnatal care check-up for the current delivery by health workers or health extension workers from 2 days up to 7 days following delivery.

Cases

Women who gave birth within the 12 months preceding the data collection in the selected kebeles and who utilized early postnatal care services from a health care provider within 7 days of childbirth.

Controls

Women who gave birth within the 12 months preceding the data collection in the selected kebeles and who did not utilize early postnatal care services from a health care provider within 7 days of childbirth.

Data collection tool and procedures

Data were collected by a face-to-face interview using a structured questionnaire, which was developed after reviewing other articles^3,14–20. The questionnaire was prepared first in English and translated into Afan Oromo and Amharic, and finally back to English to check the consistency. Six diploma nurse data collectors who were fluent in Afan Oromo and familiar with the local customs were selected, as well as two nurses with a B.Sc. in midwifery to act as supervisors to check each day for the completeness, clarity and consistency of the questionnaires and to give appropriate support during the data collection process.

Data quality control and management

Data quality was assured during data collection, the recoding, and the analysis phase. A two-day training was given to data collectors and supervisors on the objective of the study, contents of the questionnaire, confidentiality, the right of respondents, and how to collect data. A pretest on 5% of the sample was conducted at Meta Robi District one week before the actual data collection to check the reliability of the data collection instruments and findings. Data collectors and supervisors then discussed the questionnaire so that the tool could be modified for any inconsistencies and ambiguity before actual data collection. The whole data collection process was controlled by the Researcher. During data collection, the data collectors and supervisors were checked for consistency and completeness of data collected every day at the end of each data collection day, and necessary corrective measures were taken for the area where the difficulty was identified.

Data analysis

After data collection, data were checked for completeness and coded, cleaned, and entered into Epi Data version 4.6 and then exported to Stata version 17 for further statistical analysis. Descriptive statistics such as tables, graphs, pie charts, and proportions were used to present the data. The association between independent variables and the dependent variable was initially assessed using the chi-square test. Variables with a p-value < 0.25 in the bivariable logistic regression analysis were entered into the multivariable logistic regression model to identify factors independently associated with the outcome variable. Variables with Adjusted odds ratio (AOR) and a p-value less than 0.05 at 95% confidence interval in multivariable logistic regression were considered statistically significant. Goodness of fit model (Hosmer and Lemeshow) was used to select the best multivariable model, which was the p-value = 0.7531, as the p-values were greater than 5% level of significance, the result indicating that the data was a good fit.

Ethical consideration

The institutional review board of Ambo University, College of Medicine and Health Sciences Review Committee approved the study. After explaining the purpose of the evaluation, written informed consent was obtained from all participants above the age of 18. For minor participants (less than 18 years of age), consent was obtained from the parents/guardians. All participants were informed about their right to withdraw from the study if they faced any inconvenience or discomfort at any time during the data collection. The name of the respondent was not recorded on the questionnaire, and confidentiality was assured. This research was carried out in accordance with the Helsinki Declaration and regulations.

Results

Sociodemographic characteristics of participants

A total of 465 participants were enrolled in the study, comprising 155 cases and 310 controls, achieving a 100% response rate. The mean age of mothers was 28 ± 5 years among cases and 27 ± 4 years among controls. Among the participants, 67.7% of cases and 96.1% of controls were rural residents. The majority of the participants in this study were ethnically Oromo. Among total participants, the majority 86.5% cases and 77.4% controls were married. Of the total participants, 62.6% among cases and 23.2% controls had greater than 2000 income per month (Table 2).

Table 2.

The distribution of Socio-demographic characteristics of Women in West Shoa, Ethiopia, 2023.

Variables	Total n (%)	Cases (n = 155) n (%)	Controls (n = 310) n (%)	p-value)
Place of residence				< 0.001
Urban	62 (13.3)	50 (32.3)	12 (3.9)
Rural	403 (86.7)	105 (67.7)	298 (96.1)
Age in years				< 0.001
15–20	22 (4.7)	8 (5.2)	14 (4.5)
21–25	136 (29.3)	39 (25.2)	97 (31.3)
26–30	212 (45.6)	55 (35.5)	157 (50.7)
31–40	95 (20.4)	53 (34.2)	42 (13.6)
Ethnicity				0.304
Oromo	417 (89.9)	136 (87.7)	281(90.7)
Amhara	37 (8.0)	13 (8.4)	24 (7.7)
Tigray	11(2.4)	6 (3.9)	5 (1.6)
Religion				0.09
Orthodox	304 (65.4)	85 (54.8)	219 (70.7)
Muslim	28 (6.0)	13 (8.4)	15 (4.8)
Protestant	98 (21.1)	42 (27.1)	56 (18.1)
Others	35 (7.5)	15 (9.7)	20 (6.5)
Family size				0.061
1–3	146 (31.4)	30 (19.4)	116 (37.4)
4–6	291(62.6)	110 (71.0)	181(58.4)
> 6	28 (6.0)	15 (9.7)	13 (4.2)
Marital status				0.021
Unmarried	49 (10.5)	7 (4.5)	42 (13.6)
Married	374 (80.4)	134 (86.5)	240 (77.4)
Widowed	18 (3.9)	8 (5.2)	10 (3.2)
Divorced	24 (5.2)	6 (3.9)	18 (5.8)
Maternal Educational level				< 0.001
No formal education	129 (27.7)	36 (23.2)	93 (30.0)
Primary	166 (35.7)	31 (20.0)	135 (43.6)
Secondary	107 (23.0)	58 (37.4)	49 (15.8)
Diploma and above	63 (13.6)	30 (19.4)	33 (10.7)
Husband’s educational level				< 0.001
No formal education	92 (24.1)	24 (17.7)	68 (27.9)
Primary	138 (36.3)	22 (16.2)	116 (47.5)
Secondary	77 (20.3)	45 (33.1)	32 (13.1)
Diploma and above	73 (19.2)	45 (33.1)	28 (11.5)
Maternal Occupation				< 0.001
Housewife	253 (54.4)	80 (51.6)	173 (55.8)
Merchant	81 (17.4)	38 (24.5)	43 (13.9)
Employed	54 (11.6)	27 (17.4)	27 (8.7)
Others	77 (16.6)	10 (6.5)	67 (21.6)
Husband occupation				< 0.001
Farmer	250 (66.0)	74 (54.4)	176 (72.4)
Employed	69 (18.2)	43 (31.6)	26 (10.7)
Others	60 (15.8)	19 (13.9)	41 (16.9)
Monthly income (in Birr)				< 0.001
<=500	73 (15.7)	10 (6.5)	63 (20.3)
501–1500	127 (27.3)	21 (13.6)	106 (34.2)
1501–2000	96 (20.7)	27 (17.4)	69 (22.3)
> 2000	169 (36.3)	97 (62.6)	72 (23.2)

Reproductive and obstetric characteristics

The majority of participants had antenatal follow-up during the pregnancy of the index child, with 89% among cases and 52.6% among controls reporting such a history. Of the total participants, 76% cases and 63.9% controls were multipara. More than half, 62.6% of cases and 52.3% of controls, delivered their child in a health center. Almost all, 91% cases and 93% of controls, were live births (Table 3).

Table 3.

Reproductive and obstetric characteristics of Women in West Shoa, Ethiopia, 2023.

Variables	Total n (%)	Cases (n = 155) n (%)	Controls (n = 310) n (%)	p-value)
ANC follow-up				< 0.001
Yes	301 (64.7)	138 (89.0)	163 (52.6)
No	164 (35.2)	17 (11.0)	147 (47.4)
Parity				0.005
Primipara	128 (27.5)	28 (18.1)	100 (32.3)
Multipara	316 (68.0)	118 (76.1)	198 (63.9)
Grand multipara	21(4.5)	9 (5.8)	12 (3.9)
Place of delivery				< 0.001
Health center	259 (55.7)	97 (62.6)	162 (52.3)
Hospital	77 (16.6)	40 (25.8)	37 (11.9)
At home	129 (27.7)	18 (11.6)	111 (35.8)
Mode of delivery				0.004
Spontaneous vaginal delivery	353 (75.9)	106 (68.4)	247 (79.7)
Assisted delivery	85 (18.3)	33 (21.3)	52 (16.8)
Caesarian section	27 (5.8)	16 (10.3)	11 (3.6)
Abortion history				0.005
Yes	61 (13.1)	27 (17.4)	34 (11.0)
No	404 (86.9)	128 (82.6)	276 (89.0)
Immediate Fetal Outcome				0.679
Live birth	428 (92.0)	141 (91.0)	287 (92.6)
Still birth	26 (5.6)	9 (5.9)	17 (5.5)
Neonatal death	11 (2.4)	5 (3.2)	6 (1.9)
Previous PNC utilization				< 0.001
Yes	158 (34.0)	97 (62.6)	61 (19.7)
No	307 (66.0)	58 (37.4)	249 (80.3)
Time you get EPNC service				0.027
Within 24–48 h	57 (36.8)	57 (37.0)	0 (0.0)
within 49–79 h	79 (50.8)	79 (51.3)	0 (0.0)
4–6 days	19 (12.3)	19 (11.7)	0 (0.0)
Number of ANC Visits				< 0.001
0	162 (34.84)	16 (10.06)	146 (47.71)
1–3	64 (13.76)	17 (10.69	47 (15.36)
>=4	239 (51.40)	126 (79.25)	113 (36.93)

Approximately 24% of controls and 17% of cases out of all respondents reported having issues with vaginal bleeding (Fig. 2).

Fig. 2.

Mother’s problem encounter during early postnatal care services in West Shoa, Ethiopia, 2023.

Among participants in the control group, almost half (46%) were unaware of the benefits of early postnatal care (Fig. 3).

Fig. 3.

Respondents’ reasons for not attending early postnatal care services in West Shoa, Ethiopia, 2023.

Of the total respondents, 41% of cases and around 1% of controls were informed by a medical professional during delivery about early postnatal care services (Fig. 4).

Fig. 4.

Respondents receiving information about early postnatal care services from health professionals in West Shoa, Ethiopia, 2023.

Maternal and health services provider-related factors

Of the total, 80% of cases and 42% of controls had access to transportation. In total, 73.6% of cases involved public services. Nearly all participants, 98.7% of cases and 41.4% of controls, had received guidance from a healthcare professional regarding postpartum danger signs. Out of all the participants, 40% of the controls and 94% of the cases had good contact with the healthcare professional while the services were being delivered (Table 4).

Table 4.

Maternal and health services provider-related factors affecting early postnatal utilization in West Shoa, Ethiopia, 2023.

Variables	Total n (%)	Cases (n = 155) n (%)	Controls (n = 310) n (%)	p-value)
Access to transportation				< 0.001
Yes	254 (54.6)	124 (80.0)	130 (41.9)
No	211 (45.4)	31 (20.0)	180 (58.1)
Means of transport				< 0.001
On foot	208 (44.7)	39 (25.3)	169 (54.5)
Traditional transportation	13 (2.8)	1 (0.7)	12 (3.9)
Ambulance	10 (2.2)	1 (0.7)	9 (2.9)
Public services	234 (50.3)	114 (73.6)	120 (38.7)
Effective communication during Service delivery				< 0.001
Yes	228 (63.5)	146 (94.2)	82 (40.2)
No	131 (36.5)	9(5.8)	122 (59.8)
Awareness of early postnatal care service				< 0.001
Yes	226 (61.8)	151 (98.1)	75 (35.4)
No	140 (38.3)	3 (2.0)	137 (64.6)
health care provider, Compassionate and respectful				< 0.001
Yes	217 (60.5)	138 (89.0)	79 (38.7)
No	142 (39.6)	17 (11.0)	125 (61.3)
Get advice on postpartum danger signs.				< 0.001
Yes	243 (65.0)	152 (98.7)	91 (41.4)
No	131 (35.0)	2 (1.3)	129 (58.6)
Appointment for service utilization				< 0.001
Yes	196 (53.7)	134 (87.0)	62 (29.4)
No	169 (46.3)	20 (13.0)	149 (70.6)
Danger sign during the postnatal period				0.623
Yes	243 (52.3)	154 (99.4)	89 (28.7)
No	222 (47.7)	1(0.7)	221 (71.3)
Availability of PNC service near HF				0.11
Yes	184 (39.6)	127 (81.9)	57 (18.4)
No	281 (60.4)	28 (18.1)	253 (81.6)
Do you know advantage of EPNC services				0.45
Yes	217 (46.7)	151 (97.4)	66 (21.3)
No	248 (53.3)	4 (2.6)	244 (78.7)

Determinants of early postnatal care

In the bivariable regression analysis, place of residence, monthly income, marital status, maternal education, maternal occupation, place of delivery, ANC follow-up, mode of delivery, abortion history, and access to transportation were candidates for the multivariable logistic regression analysis. In the multivariable logistic regression analysis, women’s urban residence, marital status, maternal education level, maternal occupation, ANC follow-up, and access to transportation were the determinants of early postnatal care. Some variables that showed a significant association in the chi-square analysis were excluded from the multivariable logistic regression model because of missing data, which might have reduced the statistical power of the study.

Mothers who lived in urban areas were 4.6 times more likely to utilize early postnatal care services compared to those who lived in rural areas (AOR: 4.6, 95% CI: 2.1, 10.3). The odds of utilizing early PNC services were three times more likely among married women compared to their counterparts (AOR: 3.0, 95% CI: 1.5, 6.3). Mothers who did attend ANC were 2.8 times more likely to utilize early postnatal care compared to those who did not attend ANC (AOR: 2.8, 95% CI: 1.3, 6.0). The odds of early PNC care utilization were 1.4 times higher among women who attended primary school compared to those who did not attend any formal education (AOR: 1.4, 95% CI: 1.2, 7.5). The odds of early PNC care utilization were 2.5 times higher among employed women compared to others (AOR: 2.5, 95% CI: 1.3, 5.1), and the odds of early postnatal care utilization were 2.5 times higher among mothers with access to transport to a health center compared to those who did not have access to transportation (AOR: 2.5, 95% CI: 1.5, 4.4) (Table 5).

Table 5.

Bivariable and Multivariable logistic regression analysis for determinants of early postnatal care in West Shoa, Ethiopia, 2023.

Variables	EPNC status		COR(95%CI)	AOR(95%CI)	P-value
	Cases	Controls
Residence
Urban	50	12	11.8 (6.1, 23.1)	4.6(2.1, 10.3)	0.001*
Rural	105	298	1	1
Monthly income(in Birr)
<=500	10	63	1	1
501–1500	21	106	1.3(0.6, 2.8)	0.7(0.3, 1.9)	0.483
1501–2000	27	69	2.5(1.1, 5.5)	1.2(0.4, 3.1)	0.75
> 2000	97	72	8.5(4.1, 17.7)	2.6(0.9, 6.9)	0.059
Marital status
Currently unmarried	21	70	1	1
Currently married	134	240	1.9 (1.1, 3.2)	3.0 (1.47, 6.3)	0.003*
Maternal educational level
No formal education	36	93	1	1
Primary	31	135	0.6(0.3, 1.0)	1.4(1.2, 7.5)	0.006*
Secondary	58	49	3.1(1.8, 5.3)	1.5(0.7, 3.1)	0.282
Diploma and above	30	33	2.4(1.3, 4.4)	1.1(0.3, 4.3)	0.92
Maternal occupation
Housewife	46	173	0.6 (0.4, 0.1)	0.7 (0.4, 1.3)	0.297
Employed	61	27	3.1(1.5, 6.3)	2.5 (1.3, 5.1)	0.010*
Others	48	110	1	1
Place of delivery
Health center	97	162	3.7(2.1, 6.5)	1.8(0.8, 4.3)	0.154
Hospital	40	37	6.7(3.4, 13.0)	2.6(0.8, 8.0)	0.101
At home	18	111	1	1
ANC follow-up
Yes	138	163	7.3 (4.2, 12.7)	2.8 (1.3, 6.0)	0.009*
No	17	147	1	1
Access to transportation
Yes	124	130	5.5 (3.5, 8.7)	2.5 (1.5, 4.4)	0.001*
No	31	180	1	1
Abortion history
Yes	27	34	1.7 (1.0, 3.0)	1.2(0.6, 2.4)	0.69
No	128	276	1	1
Mode of delivery
Spontaneous vaginal delivery	106	247	1	1
Assisted delivery
Caesarian section	33	52	1.5(0.9, 2.4)	1.2(0.6, 2.3)	0.678
	16	11	3.4(1.5, 7.6)	1.0(0.3, 3.4)	0.984

*statistically significant at 5% level of significance, COR: crude odds ratio, AOR: adjusted odds ratio, CI: confidence interval, 1: referenced category.

Discussion

This study examined the determinants of early postnatal care utilization among mothers who had given birth within the previous 12 months in the Adea Berga district, West Shoa zone, Ethiopia. The study findings revealed that place of residence, marital status, maternal educational level, maternal occupation, mothers who were ANC follow-ups and access to transportation were statistically significant factors for early postnatal care utilization services.

The results of this study showed that women are about five times more likely to use early postnatal care services if they live in urban areas. This study is consistent in Ghana²¹. This might be because the majority of the women in the rural areas are not able to afford the cost of transport to these health facilities. On the other hand, better access to communication, education, and information services is often more common in cities, which may increase a mother’s use of EPNC services. In addition, greater awareness of health promotion programs and access to services among urban women could have a positive impact on the utilization of health care services²².

The study indicates that married women were three times more likely to utilize early postnatal care compared to their unmarried counterparts. This trend is consistent with other research conducted in regions like Ethiopia, specifically Adwa Town, where married mothers were more likely to attend early PNC services²³. Married women may have more support systems in place, such as spouses or families, which can facilitate access to health services, including postnatal care. The other reason could be that health professionals often provide counselling during antenatal care (ANC) visits, which can motivate married women to seek early PNC services. As such, the relationship between marital status and PNC utilization can also reflect the degree of awareness and knowledge passed on to these women regarding postnatal care.

Maternal educational level was a significantly important determinant. The odds of women utilizing early postnatal care were 1.4 times higher among those who had attended only primary school than among those with no formal education. The finding is in agreement with the study conducted in Ethiopia^14,24,25 and Uganda²⁶. Better education may be the cause of this since it increases information access and risk perception, both of which lead to an increase in health-seeking behaviour.

According to the findings of this study, being employed is related to early postnatal care. Women whose occupational status was employed had 2.5 times higher odds of utilizing early postnatal care compared to their counterparts. The finding is in line with the study conducted in Adwa town, Butajira, southern Ethiopia^23,27, and may be because employed women have their own income and can meet their service and transportation costs. ANC follow-up was another significant variable in this investigation. The odds of women utilizing early postnatal care were 2.8 times higher among those who had followed up on ANC at the time of pregnancy compared to those not visit ANC at health facilities. The finding is consistent with previous studies conducted in Ethiopia^14–16,28. The reason might be that ANC visits provide an excellent opportunity for providers to provide appropriate counselling on postnatal danger signs and symptoms and to improve women’s knowledge of potential postpartum complications and the benefits of EPNC services. Consequently, compared to women who attend less than four prenatal care appointments, women who attend the WHO-recommended four or more visits are more likely to use EPNC.

Access to transportation was also a statistically significant factor. Women who had access to transportation had approximately three times the odds of utilizing early postnatal care. Other studies carried out in Ethiopia support this finding^19,29,30. The reason behind this may be mothers getting tired and the cultural influence to walk long distances during the day to the health facility. In addition, when health facilities are distant, access to routine maternal health services and emergency care is reduced due to relatively high costs in paying for the transport system.

Implications of the findings

The findings of this study have important implications for improving maternal and newborn health services in Ethiopia. The strong association between urban residence and early postnatal care (EPNC) utilization indicates persistent rural–urban disparities in access to maternal health services. This suggests the need for targeted interventions to improve service accessibility in rural areas, including strengthening community-based postnatal follow-up through health extension workers and expanding outreach services. The significant association between antenatal care (ANC) follow-up and EPNC utilization also highlights the importance of ANC as an entry point for promoting postnatal care. Integrating counselling on postnatal care during ANC visits and ensuring that mothers receive clear postnatal appointments before discharge could improve timely utilization of EPNC services.

Maternal education, employment status, and access to transportation were also significant determinants of early postnatal care utilization, indicating that socioeconomic and structural factors influence mothers’ health-seeking behaviour. Improving women’s education and economic empowerment may enhance awareness and decision-making capacity regarding maternal health services. In addition, improving transportation access and strengthening referral systems may reduce geographic barriers that prevent mothers from reaching health facilities within the recommended time. The association between marital status and EPNC utilization further suggests the importance of family and partner support; therefore, involving partners and families in maternal health education programs could help increase early postnatal care utilization.

Strengths and limitations

The unmatched case–control approach allowed for the comparison of multiple potential determinants between mothers who utilized EPNC and those who did not, making it possible to explore a wide range of associated factors. However, there are some limitations. First, as data were collected retrospectively, there is a risk of recall bias, especially in reporting the timing and content of postnatal care visits, which may lead to misclassification of cases and controls. Efforts were made to minimize this by cross-checking responses with maternal health cards where available. Second, the use of an unmatched case–control design may introduce selection bias if the controls were not fully representative of the source population from which the cases arose. Third, because of the observational case–control design, causal relationships cannot be definitively established. While the analysis adjusted for several potential confounders, unmeasured variables such as cultural beliefs, quality of interpersonal care, and informal support systems could still influence EPNC utilization. Finally, since the study was conducted in selected districts within one zone of the Oromia Region in Ethiopia, the findings may have limited generalizability to other districts in the entire zone.

Conclusion and recommendations

This study identified key determinants influencing early postnatal care utilization among mothers in Adea Berga District. These include residence, marital status, education level, occupation, ANC follow-up, and transportation access. To enhance EPNC utilization and maternal-newborn outcomes, the following actions are recommended:

• Strengthen community education on the importance of early postnatal care.

• Enhance ANC services as an entry point to postnatal care.

• Improve transportation infrastructure to increase access, especially in rural areas.

• Encourage collaborative efforts between health extension workers, community leaders, and the district health office.

Abbreviations

ANC

Antenatal care

EBF

Exclusive Breastfeeding

EPNC

Early postnatal care

MMR

Maternal Mortality Ratio

MNCH

Maternal, Newborn and Child Health

PNC

Postnatal care

SSA

Sub-Saharan African countries

WHO

World Health Organization

Author contributions

F.SH was involved in the conception, design, and analysis of the study, drafting of the manuscript and reviewing the manuscript. FS interpretation, analysis, drafting of the manuscript, and reviewing the manuscript. ET and BT were supervising and reviewing the manuscript. All authors read and approved the final manuscript.

Data availability

Data will be available upon reasonable request from the correspondingauthor.

Declarations

Competing interests

The authors declare no competing interests.