Postnatal care is a care provided to women and their babies within 42 days after delivery [1]. A large proportion of maternal and neonatal deaths occur during the first 48 hours after delivery, and these first two days following delivery are critical for monitoring complications arising from the delivery [2].

World Health Organization (WHO) recommends that after an uncomplicated vaginal birth in a health facility, healthy mothers and newborns should receive care in the facility for at least 24 hours after birth. If birth is at home, the first postnatal contact should be as early as possible within 24 hours of birth. At least three additional postnatal contacts are recommended for all mothers and newborns, on day 3 (48- 72 hours), between days 7-14 after birth, and six weeks after birth [1]. Whereas Federal Ministry of Health (FMoH) of Ethiopia recommends three PNC care visits at 6-24 hours, 3 days, 6 days and 6 weeks [3-5].

The health of mothers is mostly regarded as an indicator the health of the society [6]. Postnatal care is regarded as one of the most important maternal healthcare services for the prevention of impairments and disabilities resulting from childbirth [7]. Lack of care during puerperium may result in death or disability as well as missed opportunities to promote healthy behaviors, affecting women, newborns, and children [8].

Millions of mothers more suffer severe illness each year, and unknown numbers are affected with lifelong disabilities [9-11]. Some of the long-term maternal complications in the postnatal period include chronic pain, impaired mobility, damage to the reproductive system and infertility [12]. Some women suffer genital prolapses after bearing several children. This condition is extremely uncomfortable and can lead to other complications in future pregnancies if not properly addressed in the postnatal period [13].

Ethiopia is one of the countries with high maternal mortality. The MMR was 871 per 100,000 in the year 2000; it was 673 per 100,000 live births in 2005 and 676 per 100,000 in 2011 [2]. Maternal deaths represent 30% of all deaths to women age 15-49, compared with 21% in the 2005 EDHS and 25% in the 2000 EDHS [2].

Poor women in remote areas are the least likely to receive adequate health care. This is especially true for regions with low numbers of skilled health workers, such as sub-Saharan Africa and South Asia. During the past decade, only 46% of women in low-income countries benefit from skilled care during childbirth. This means that millions of births are not assisted by a midwife, a doctor or a trained nurse. Other factors that prevent women from receiving or seeking care during pregnancy and childbirth are: poverty, distance, lack of information, inadequate services, and cultural practices [14,15].

The level of postnatal care coverage is extremely low in Ethiopia 18 percent. Of this only 13 percent of women received postnatal care within two days, as recommended. Among women who received a postnatal checkup, 8 percent were examined within 4 hours of delivery, 3 percent within 4-23 hours, 2 percent within 1-2 days, and 5 percent within 3-41 days of delivery [5].

The low coverage of postnatal care in Ethiopia is causing to continuous high maternal and new born morbidity and mortality that affects MDGs 4 and 5 [11]. It is also challenge for planning and implementing of PNC as well as many opportunities are missed with low PNC coverage including exclusive breastfeeding, PMTCT, providing of family planning and maternal and new born care [16].

The burden of low of postnatal care in Ethiopia is even greater for the large rural population due to poor access and utilization of maternal and new-born health services [17]. Despite the fact that no previously done studies existed in the study area (Hadiya Zone, SNNPR, Ethiopia) on factors associated with PNC service, MEDHS, 2014 report indicated that the level of PNC coverage was extremely low in SNNPR (15.4%) and only few (11.1%) of mothers were received PNC service within 48 hours after gave birth [5]. This indicates that the factors associated with utilization of PNC services still need strong due attention to be researcher so as to improve its utilization and also it is convincing that the available knowledge about the service utilization is insufficient. This study therefore intends to assess these anticipated bottlenecks of PNC service utilization and in addition fill some of the gaps of previously carried out literatures on similar topic with the view of improving utilization of the services.

A community based cross sectional study, which is supplemented by qualitative method was conducted in Lemo Woreda, Hadiya Zone, SNNPR, Ethiopia from March to April 2015. Lemo Woreda is one of the Woreda among ten Woredas and one town administration of Hadiya Zone with total population of148, 339. Lemo Woreda is situated 194 kms to the North West of the regional capital Hawassa and 230 kms to the South West of Addis Ababa [6].

Sample size was determined using single population estimation formula with assumption of 95% confidence interval, 5% degree of precision and 66.83% Prevalence of PNC service utilization [7]. Considering non-response rate of 10%, final total sample sizes was 352. Lemo Woreda has 35 kebeles. From these kebeles thirty percent (eleven kebeles) were selected randomly by lottery method. In the selected eleven kebeles, there were1592 mothers estimated to be eligible (women who gave birth within the last one year). Sampling frame which comprises a list of 1592 mothers was prepared using HEW registration book (family folder). Finally study participants in each Kebeles were selected by using computer generated random number sampling technique from sampling frame. For qualitative data four focus group discussions in two conveniently selected kebeles were conducted with 8-12 mothers, in each of the two kebeles one primiparous group, and the other multiparous group FGDs were conducted. FGD Participants were selected from the same registration book by purposive criterion sampling technique.

Pretested structured questionnaire consisted of variables on sociodemographic characteristics, Obstetric characteristics, knowledge, and attitudes of mothers towards PNC utilization, socio-cultural practices towards PNC and health institutional factors were used. In addition, FGD interview guide, audio tape recorder and note pad were used for collection of qualitative data. The questionnaire was prepared in English then it is translated into Hadiyissa which is the local language of the area and then back to English in order to ensure its consistency. Pre-test was conducted on 5% of the study population in another Woreda prior to the study. Based on the result the questionnaire was modified as necessary. Eleven diploma holder and two bachelor degree holder health professionals’ were recruited as interviewers and two bachelor degree holder health professionals’ were recruited supervisors’. Data collectors and supervisors were trained for one day about the objective, tools and process of data collection. Both data collectors and supervisors were fluent speakers of the local language. The principal investigator and supervisors were made a day to day on site supervision during the whole period of data collection and checked each questionnaire daily for completeness and consistency. Postnatal care service utilization was considered as mother who received at least one PNC service by health professional (midwife, nurse, health officer, and medical doctor or health extension worker) during the first six weeks starting immediately after the time of delivery.

The data gathered were edited, coded, cleaned, and entered into Epi-data version 3.1 and finally exported to SPSS version 16.0 statistical software for analysis. Different frequency tables, graphs and descriptive summaries were used to describe the study variables. Bivariate logistic regression analysis was used to see significant association between the outcome and independent variables. Variables with P-value < 0.05 in bivariate analysis were transferred to multivariable logistic regression. Odds ratios at 95% CI were computed to measure the strength of the association between the outcome and the explanatory variables. Multivariable logistic regressions were performed to identify the most significant predictors of postnatal care service utilization. P-value < 0.05 was considered as statistically significant.

Ethical clearance was obtained from the Institutional Review Board (IRB) of Jimma University, College of Health Sciences. Official letter was written from Department of Nursing and Midwifery. Other necessary permissions were gained from Hadiya Zone Health Department, Lemo Woreda Health Office, and finally from study Kebeles. Written and verbal consent was obtained from each participant after thorough explanation of the purpose and the procedures of the study. Participation in the study was on a voluntary basis and responses were kept confidential and anonymous.

The data were collected from a total of 352 mothers who gave birth 12 months prior to the study period from March to April, 2015 with a response rate of 100%. The mean age of the mothers was 29.79 years with a standard deviation ± 5.96 years. Regarding marital status, the majority 324 (92%) of participants were married followed by those who were widowed 12 (3.4%). Regarding family size, 69 (19.6%) were part of households with a family size of six persons. Concerning ethnicity, Hadiya is the majority ethnic group 254 (72.2%) in the study area followed by Kembata 42 (11.9%) and Silete 31 (8.8%) (Table 1).

Table 1: Socio-demographic characteristics of respondents in Lemo Woreda, Hadiya Zone, SNNPR, Ethiopia (March to April 2015).

Regarding birth order of the study participants, the majority of the mothers 234 (66.5%) gave birth to two or more babies (multipara), 59 (16.8%) gave birth to five or more babies (grand multipara) and also 59 (16.8%) gave birth to single baby (primipara). As to the number of surviving children, most the mothers have three surviving children on average. From the study participants 57(16.2%) had history of child deaths after birth within 42 days and of these, only 21(39.62%) of children were provided treatment before death.

As to obstetric history, few 62 (17.60%) of the respondents had any pregnancy, child birth and, or purperium related problem before giving their last birth. Of them 45 (72.58%) have got treatment at the time of the problem. The main reasons for not receiving medical care during the time of problem as forwarded by the respondents include: not knowing the benefits of PNC 9 (52.9%) followed by lack of money for transport 5 (29.41%).

Three hundred four (86.4%) of mothers had ever heard of PNC services after delivery. Among mothers who heard of PNC services after delivery 207 (68%) were given information about PNC from health professionals, 35 (11.51%) from women developmental army, 42 (13.81%) from community conversation, 12(3.9%) from TBAs, 4 (1.3%) from television, 1 (0.3%) from radio and 3 (0.9%) were from other information sources. Majority 92% of the study participants were not knowledgeable about postnatalcare service (Table 2).

Table 2: Knowledge of respondents towards PNC service utilization in Lemo Woreda, Hadiya Zone, SNNPR, Ethiopia (March to April 2015).

Of the total respondents, 181 (51.4%) utilized postnatal care service after delivery within six weeks of their last birth. Among PNC users, majority 147 (81.21%) mothers attended one time, 31 (17.12%) attended two times and the rest three mothers (0.16%) attended three times. The data revealed that only 44 (12.5%) utilized PNC with in the first 48 hours after child birth in which majority of maternal and new born deaths have taken place (Figures 1 and 2) (Table 3).

Figure 1: The time mothers attended PNC after they have given birth,in Lemo Woreda, Hadiya Zone, SNNPR, Ethiopia (March to April 2015)

Figure 2: The main reasons mothers provided to attend PNC after they have given birth,in Lemo Woreda, Hadiya Zone, SNNPR, Ethiopia (March to April 2015)

Table 3: The reasons mothers reported why they did not obtain PNC services after delivery, in Lemo Woreda, Hadiya Zone, SNNPR, Ethiopia (March to April 2015).

Among PNC users, majority 121 (66.85%) of mothers initiated to attend PNC follow up due to the reason that their babies need immunization whereas very few 10 (0.6%) mothers were initiated due to the reason that they had faced excessive uterine bleeding just after they gave their last baby.

According to the data, the majority 88.10% of participant were agreed to the statement “The mother should follow PNC follow up within 42 days” whereas large proportion 66.50% of the study participants were against the statement “The health institution in which they usually served is equipped in material, man power and favorable for PNC service.” As to the study participants’ attitude, only 23% had favorable attitude towards postnatal care service (n=352) (Table 4).

Table 4: Mothers attitude towards PNC service utilization, in Lemo Woreda, Hadiya Zone, SNNPR, and Ethiopia (March to April 2015).

Majority 77.3% of respondents traveled on foot as means of transport to go to the health facility. It took a maximum of one hour on foot travel to reach to nearby health care facility for almost 75% of mothers and none of the mothers used ambulance or stretchers. As to the waiting time in the health care facilities, 33% of mothers responded that the waiting time is short.

Almost 74% of respondents reported that they have received at least one ANC during their last pregnancy. Of them, 95% were advised to deliver at health facilities. The data revealed only 33% of mothers gave their last births at health facilities with the help of skilled delivery attendant and among those mothers who delivered at health facilities, 99% of them were told to attend PNC.

Seventy percent of respondents have said that providers of their usual health facility handle them respectfully, maintain their privacy and they are confidential while they are providing any maternal health care services. One hundred fifty one (43%) mothers perceived healthcare providers approach to be good.

Regarding maternal decision making power, majority (81.5%) of mothers were able to decide to go to health facility for PNC follow up by them. For those mothers who couldn’t decide to go to health facility for PNC follow up, 80% of the decision was made by their husband’s followed by husband’s mothers 16%.

Regarding the socio-cultural practice that prevent mothers from attending PNC services, only 58(16.5%) of respondents replied that their culture has prevented them from attending PNC services. Among them, large proportion 38% has reported that inflammation “MICH” will kill them if they go out before 42 days during puerperium (n=58) (Figure 3).

Figure 3: Socio-cultural reasons that prevented mothers from attending PNC, in Lemo Woreda, Hadiya Zone, SNNPR, Ethiopia (March to April 2015)

Bivariate analysis of the data revealed that, maternal age, husband education, maternal occupation, household average monthly income, parity, information heard about PNC, maternal knowledge on potential postnatal danger sign and symptom, previous history of obstetric complication before last birth, ANC attendance before giving last birth, place of delivery, distance of residence from health facility, maternal decision making power and cultural practices during puerperium were statistically significant to the outcome variable. After entering the above candidate variables in to multivariable logistic regression model, maternal knowledge on postnatal danger signs, previous experience of obstetric complication, previous history ANC attendance, place of delivery, and socio-cultural practices during puerperium found to be statistically significant factors for PNC service utilization.

Knowledge on potential postnatal danger sign and symptom has showed strong statistical association with PNC service utilization. Mothers who spontaneously mentioned at least one postpartum obstetric danger sign were 4.5 times (AOR: 4.46, 95% CI: (2.15, 9.24)) more likely to utilize postnatal care service than those who failed to mention any of the obstetric danger signs during puerperium. Similarly, the odds of having obstetric complication before last birth has showed strong statistical association with PNC service utilization. Mothers who had history of obstetric complication before last birth were about 5 fold (AOR= 4.52, 95% CI: (1.63, 12.54)) more likely to utilize PNC service than mothers who have no history obstetric complication before last birth.

ANC attendance before giving last birth is also one of the associated factors for PNC service utilization. Mothers who have at least one ANC attendance before giving their last birth were 6 times (AOR= 6.34, 95% CI: (2.33, 17.23)) more likely to utilize PNC service than those mothers who have no history of ANC attendance at all. Likewise, place of delivery has also been an important predictor of postnatal care service utilization. Mothers who gave their last birth in health institutions were about 8 times (AOR: 7.94, 95% CI: (3.12, 20.18)) more likely to utilize PNC service than those mothers who gave their last birth at home.

Postnatal care service utilization is also associated with cultural practices during puerperium. Mothers who were prevented by cultural practices to attend PNC services were 93% (AOR: 95% CI: (AOR: 0.07, 95% CI: 0.02, 0.24)) less likely to utilize PNC service than those mothers who were not prevented by cultural practices.

This community based cross sectional study which is supplemented by qualitative method assessed postnatal care service utilization and associated factors among mothers who give birth 12 months prior to the study period in Lemo Woreda, Hadiya Zone, SNNPR, Ethiopia. The result showed that among the 352 postpartum mothers, 181 (51.40%) obtained PNC during the six weeks following delivery. This result is high as compared with studies done in Sidama Zone, SNNPR (37.2%) [8], Jabitena District, Amhara (20.20%) [9], Abi Adi, Tigray (11.90%) [10], Nigeria (41.20%) [11] and Nepal (43.2%) [12]. This may be attributed to the time difference for there could be improvement in accessing and utilizing health care service through time and other factors could be attributed to place, and social context variation between this study and previous studies.

In view of addressing the second objective, an attempt was made to examine the associations between various explanatory variables and the outcome variable. The study identified four variables which have strong positive and one variable which have strong negative significant associations with PNC service utilization.

Knowledge on potential postnatal danger signs and symptoms has a strong positive association with PNC utilization. Mothers who were knowledgeable for at least one potential postnatal danger sign and symptom were more likely to utilize PNC service as compared to those who did not mentioned any postpartum danger signs and symptoms. This finding is supported by local studies conducted in Jabitena District, Amhara region [9], Goba woreda, Oromia region [13], and in addition it is similar with a study conducted in Uganda [14]. This can be justified that knowledge on obstetric danger signs and symptom during puerperium is an important factor in motivating mothers and their families to attend health care service at the earliest opportunity with the intention of prevention, early detection and getting managed their obstetric danger signs and symptoms.

This study revealed that ANC attendance before giving last birth is a strong predictor of PNC service utilization. Mothers who have attended at least one ANC visit before giving their last birth were more likely to utilize PNC service than those mothers who have not attended ANC visit at all. This result is in line with the studies conducted in Gondar Zuria district, Amhara region [7], and studies done in Rural Ethiopia [15], Nepal [12], and Pakistan [16]. Evidence gathered from the FGD participants was also in agreement with the finding.

“…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.…” (A 27 years-old mother, Dacho kebele). However, this result is in contrast with the study carried out in Adwa, Tigray region, which showed that ANC follow up before giving last birth has no significant association with PNC service utilization [17]. The possible explanation for the strong positive association between ANC attendance and PNC service utilization might be that mothers and their families receive health education and counseling during ANC visits and thus get access to learn about the benefits of PNC services follow up in health care facilities.

Place of delivery was significantly associated with PNC service utilization. Mothers who gave their last birth in health institutions were more likely to utilize PNC service than those mothers who were gave their last birth at home. This result is also nearly consistent with locally done findings in Amhara region [7,9], and other studies from abroad [12,18]. Comparable evidence was also gathered from FGD participants.

“…. I always prefer institutional birth to home birth because traditional birth attendants do not wear gloves and they may not use clean equipment. In contrast, health care providers wear gloves, use clean equipment and medications for attending delivery…” (A 25 years-old mother, Secharoma kebele). The possible explanations for this could be mothers who gave their last birth in health care facilities and their families have a better chance to obtain health education and counseling on benefits of the PNC services from skilled attendants during their stay in the health care facilities.

With regard to maternal experience obstetric of complication, this study realized that association between past history of maternal complication and PNC service utilization is significant. Mothers who experienced obstetric problems before their last birth appear strongly motivated to seek postnatal care than mothers who had no experience of obstetric complication. This result is supported by a local study done in Gondar [19], and other abroad study done in Nepal [20]. This finding is also evidenced by FGD participants.

“…I am afraid of missing PNC because it will benefit mothers as well as their children. I never forget what happened just after my third child birth at home. Soon after gave birth I experienced a severe bleeding for which the traditional birth attendant in our locality told me as it is commonly happened in all delivering mothers and encouraged me not to worry about it. Later I became tired of f and even I lost my consciousness. Thanks to health care providers at Hossana Hospital next to God who helped me to save my life and to speak in front of you. If I had delivered at health facilities by the help of skilled attendants, I wouldn’t have suffered a lot…”. (A 30 years-old mother, Secharoma kebele) However, this result contradicts a previous study carried out in Bangladesh which indicated that mothers who had history of obstetric complication before last birth less likely to utilize PNC services [21]. The possible explanations for the strong positive association between experience of maternal complication and PNC service utilization might be that mothers may fear complications which might reoccur during puerperium or mothers and their families may perceive signs of obstetric complication earlier and initiated to seek medical care.

As to the cultural practices preventing mothers from PNC follow up, this study indicated that mothers who were prevented by cultural practices to attend PNC services were less likely to utilize PNC service than those mothers who were not prevented by cultural practices. Other studies conducted in Ethiopia and abroad have shown almost near to similar findings [12,22,23]. The participants in FGDs also stated that some cultural practices during puerperium negatively affect utilization of the PNC service:

“...We still have many elderly mothers in our locality who discourage going to a health facility for PNC service. They (elderly mothers) usually claim as it is not our tradition to go out of home for postnatal mother before 6 weeks because she (postnatal mother) will suffer from inflammation (MICH) if she moves out of home. In addition, it is believed that postnatal mothers wouldn’t have enough energy to go out of home before 6 weeks of delivery…” (A 23 years-old mother, Dacho kebele). However, a study done in Abi Adi, Tigray has revealed that there is no significant association between cultural practices and PNC follow up [10]. The possible explanations for the association between cultural praactices and PNC follow up could be the local health authorities or health care providers of the study area might not adequately addressed essential interventions which explain and discourage harmful traditional practices during puerperium for targeted population groups both at the community and facility level.

The current study found more than half of the study participants in Lemo Woreda utilized postnatal care service and this result is relatively higher as compared to some of the previous evidences. But postnatal care service utilization within the most critical period (first 48 hours after delivery) was very low. The most cited reason for missing postnatal care service is lack of knowledge on the benefit and timing of postnatal care. Maternal knowledge on postnatal danger sign, past experience of obstetric complication, ANC attendance, place of delivery, and cultural practices during puerperium found to be independent predictors for PNC service utilization.

We would like to thank the followings for their contribution: Jimma University, College Health Sciences, for providing us ethical clearance; Hadiya Zone Health Department, Lemo Woreda Health Office, our data collectors, Study participants and others who participated directly or indirectly in this study.

Mr. Tamiru Belachew; wrote the proposal, participated in data collection, analyzed the data and drafted the paper. Professor Tefera Belachew and Mr. Ayanos Taye approved the proposal, participated in data analysis and revised subsequent draft of the paper. All authors read and approved the final manuscript.

The authors declare that they have no competing interests.