Introduction

The postnatal period, defined as the first six weeks after birth, is critical to the health and survival of mother and newborn [1]. The majority of maternal deaths, mainly due to hemorrhage, and many newborn deaths, mostly due to asphyxia, occur during the first day of birth [2, 3]. Other complications following childbirth that may affect women in the postpartum stage including sepsis, cardiovascular events, deep vein thrombosis, stroke, and embolism require immediate medical attention [4]. Furthermore, lack of care during this period may result in disability as well as create missed opportunities for promoting healthy behaviors affecting women, newborns and children [1, 5].

Although global maternal deaths have decreased by 43% from 532,000 in 1990 to 303,000 in 2015 [6], maternal morbidity and mortality remain a major challenge to health care systems. Worldwide, the maternal mortality rate is 216 per 100,000 live births with a large proportion of deaths due to early preventable or treatable pregnancy and childbirth complications. Low- and middle-income countries (LMIC) account for 99% of maternal deaths, with sub-Saharan African countries alone accounting for 66% [7, 8]. In Ethiopia, in 2016 the maternal mortality ratio (MMR) remains high which accounts for 412 maternal deaths per 100,000 live births [9].

In the continuum of maternal health care, antenatal care (ANC) and postnatal care (PNC) are the key strategies required to reduce maternal and newborn deaths [10]. ANC is an entry point for maternal and child care service utilization, and as such, has the capability of reducing both maternal and neonatal mortality by detecting at-risk pregnancy and managing the risk associated. ANC provides an opportunity to adequately prepare mothers for birth and for appropriate care of children by addressing relevant information and education concerning promoting the health, and prevention of disease [11]. Therefore, all pregnant women are recommended to have their first ANC visit within the first trimester of pregnancy at or before 16 weeks of gestation and to have a minimum of four ANC visits during pregnancy [11]. ANC is an important opportunity to identify and manage any medical complications [12]. Globally, 86% of pregnant women access ANC with skilled health personnel at least once and 65% receive at least four ANC visits. Whereas, in sub-Saharan Africa, only 52% and South Asia only 49% of women and had received at least four ANC visits [13]. In Ethiopia, in 2016 only 62% of women had any ANC visits during pregnancy, 32% of women had at least four ANC visits, and only 20% of women had their first ANC visit during the first trimester [9].

The World Health Organization (WHO) recommends that mothers and newborns should receive PNC in health facilities within at least 24 hours after birth if birth occurs in a health facility. For home births, the first postnatal contact should be as early as possible within 24 hours of birth. Additionally, at least three postnatal visits, on day 3 (48–72 hours), between 7–14 days, and at six weeks after birth are recommended for all mothers and newborns [14]. Safe motherhood programmers recommend that all women receive a health check within 2 days after delivery [9].

For both the mother and infant, early postnatal care is vital for providing essential information as well as detecting and treating childbirth-related complications. Most maternal and neonatal deaths occur during or immediately after childbirth [1, 9, 14]. Around half of the maternal and newborn deaths occur in the first 24 hours [15, 16]. The majority of maternal deaths can be reduced through increasing antenatal care, skilled care during childbirth, emergency obstetric care and postnatal care services [17, 18]. In Ethiopia, receiving appropriate postnatal care in the recommended time could avert neonatal mortality by 10–27% [16]. However, in spite of its potential role in reducing newborn and maternal deaths, postnatal care has been poorly utilized for the health and survival of both the mother and the newborn [14, 16]. For instance in Ethiopia, only 17% of women and 13% of newborns received their postnatal checkup within the first two days of delivery [9].

Improving the quality of antenatal care services is likely to contribute to rapid increases in postnatal care utilization and results in better health outcomes for women and newborns [19]. As a result, ANC utilization and timely initiation of PNC are considered critical to maternal health services to improve health outcomes for women and newborns. The objective of this study was to determine the association between antenatal care and timely postnatal care checkup among reproductive-age women in Ethiopia. We hypothesized that Ethiopian women who had timely and at least four ANC visits would be more likely to have a timely PNC checkup.

Methods

Inclusion and exclusion criteria

Of the total 15,683 women interviewed in the 2016 EDHS, only those who give birth in the two years preceding the survey were included in this analysis (n = 4,308). Women who had missing data on the variables of interest were excluded from the analysis (n = 227). The final sample consisted of 4,081 participants (Fig 1).

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Fig 1. Schematic presentation of sample selection from EDHS 2016 data set.

https://doi.org/10.1371/journal.pone.0258468.g001

Results

Sample characteristics

The majority (87.7%) of women lived in rural areas. Furthermore, 95.1%, 60.4% and 45.2% of women were married/living with a partner, had no formal education and lived in the poor wealth quintile, respectively. About 60.5% of women perceived that the distance to a nearby health facility as a barrier to PNC utilization. About 42.2% of the women were multiparous (had two to four pregnancies) and 37.4% were grand multiparous (had five or more pregnancies). Only 36.9% of women gave the most recent birth in the health facility while 37.7% were served by skilled birth attendants. Regarding ANC utilization patterns, 35.7% of women did not have any ANC visits. Only one-fourth (25.1%) of women had timely initiated recommended number of ANC visits (Table 1).

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Table 1. Descriptive statistics of women who gave birth in the 2 years before the survey, Ethiopia, 2016 DHS (N = 4081).

https://doi.org/10.1371/journal.pone.0258468.t001

Timely postnatal checkup

Among women who gave birth in the two years preceding the 2016 EDHS, only 16.5% of women had timely initiated postnatal checkups within two days of delivery. Furthermore, postnatal checkup significantly differed by a history of ANC follow-up, educational status, place of residence, working status, perceived distance from a nearby health facility, household wealth index, place of delivery and type of birth attendant (Table 2).

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Table 2. Characteristics of the study sample by postnatal checkup within 2 days of delivery (N = 4081).

https://doi.org/10.1371/journal.pone.0258468.t002

Association between antenatal care utilization pattern and timely postnatal checkup

After controlling for all other variables, antenatal care use was significantly associated with timely postnatal care checkups. Compared to women with no ANC visit, women who had at least four timely ANC visits had higher odds of timely postnatal checkups (aOR: 2.50; 95%CI: 1.42–4.42). Similarly, compared to women with no ANC visit, women who had at least four delayed ANC visits had higher odds of timely postnatal checkups (aOR: 2.46; 95%CI: 1.22–4.97). Additionally, women who had secondary and above education (aOR: 1.64; 95%CI: 1.03–2.60) compared to those who had no formal education, those who perceived distance to the nearby health facility was not a significant barrier (aOR: 1.55; 95%CI: 1.15–2.09) compared to those who perceived distance as a significant problem, primiparous (aOR: 0.34; 95%CI: 0.19–0.61) compared to grand multiparous, and those who had institutional delivery (aOR: 14.55; 95%CI: 2.21–95.77) compared to those who had home delivery were also significantly associated with timely initiation of PNC checkup (Table 3).

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Table 3. Association between ANC follow up pattern and timely postnatal checkup (N = 4081).

https://doi.org/10.1371/journal.pone.0258468.t003

Discussion

In a nationally representative sample of Ethiopian women, we found that having the recommended ANC visits were positively associated with timely utilization of PNC services. This association appeared to be independent of confounders such as maternal socio-demographic and obstetric characteristics. Our results contribute to the emerging evidence on the importance of having the recommended number of ANC visits to the timely initiation of PNC checkups.

Women who started their first antenatal visit in the recommended timeframe and had at least four antenatal care visits were more likely to utilize PNC than their counterparts. This finding is consistent with the findings of several studies that showed that a higher number of ANC visits is an important determinant of PNC utilization [25, 27–32]. Because ANC is a time when mothers are educated about childbirth and childcare practices, those who follow the ANC guidelines might be better informed about PNC guidelines. This assertion is supported through qualitative studies. Belachew et al. (2016) illustrated this point with the following focus group discussion quote, “I had repeated ANC visits during my previous two pregnancies and the health providers provided me cares such as complete physical assessment, I was given red tablets for free and told to swallow one per day, I was counseled about danger signs of pregnancy and also I was told the benefits of institutional delivery and postnatal care. That is why I prefer to deliver my children in a health facility and I attended postnatal care.…”page 6, [30]. Increased numbers of antenatal visits might give opportunities to women to learn about birth preparedness, potential complications during pregnancy and labor [33]. The provision of counseling and health education to mothers by skilled health care providers at the time of ANC visits also plays a critical role. As a result, they might be more likely to follow recommendations, including recommended PNC protocol [24].

Compared to women gave birth at home, women who gave birth at health institution had higher odds of having timely PNC checkups compared to those women gave birth at home. This finding was consistent with other studies that showed that women who gave birth at health institutions had higher odds of having PNC checkups [25, 27, 28, 30–32, 34, 35]. Since all women who deliver at health facilities with an uncomplicated vaginal birth are expected to stay in the facility for at least 24 hours after birth, they are likely to receive PNC before discharge [14]. Additionally, women may be advised to return for future visits and be more comfortable with the setting than those who deliver at home. Women who deliver at a facility are also more likely to have the ability to overcome cultural, geographic, financial and other barriers related to health care access [27].

Primiparous women were 66% less likely to utilize postnatal checkups timely as compared with grand multiparous women. Whereas past researchers have found no association between parity and PNC utilization [35–37], the present study has shown a lower likelihood of timely PNC checkups among primiparous women. Previous experience with pregnancy complications may increase the likelihood of seeking post-natal care within two days to avoid similar complications. The fear associated with previous complications may compel women to seek regular care [35]. Primiparous women, with no history to learn from, are, therefore, less likely to have a fear of complications [29]. More research is needed to confirm this finding. In addition, this analysis found that the odds of having a timely PNC checkup were higher among women whose educational status was secondary/higher as compared to those with no formal education. This result was in line with a number of studies showing a higher likelihood of PNC checkups among women with some education [25, 27–29]. The higher maternal educational attainment, the more likely the awareness and knowledge of benefits to be derived to comply with more health recommendations; this is in part due to the fact that they may understand better. Additionally, women who are educated are more likely to have paid employment and to contribute to the household expenditure and consumption and that means more power in the decision-making process in household issues including utilization of health services [32].

Mothers who did not perceive the distance to the nearest health facility as a problem had higher odds of timely PNC checkups as compared to those who perceived distance to a health facility as a significant barrier. This finding is consistent previous studies [27, 29, 38]. Physical proximity to health services is a major problem, especially in rural villages with poor road conditions. Participants in a qualitative study complained that they needed to walk for up to two hours to reach the nearest health center. The situation became worse during the rainy season when the road was slippery [25]. It is, therefore, not surprising that distance from a healthcare facility is a significant barrier to timely and recommended PNC utilization.

Conclusions

The initiation of postnatal care within two days of delivery in Ethiopia is very low. Utilizing the recommended number of ANC visits, starting it at an early stage of pregnancy was positively associated with the timely initiation of postnatal care. Even women, who had not initiated ANC in the recommended time frame but had had the recommended number of visits, had higher odds of appropriate PNC. Thus, strengthening the existing maternal and child health program to adhere to the recommended number of ANC is likely to improve adherence to PNC protocols.

Acknowledgments

We are grateful to the DHS Program for providing us permission to use the 2016 EDHS data for this analysis.