Continuum of maternity care among rural women in Ethiopia: does place and frequency of antenatal care visit matter?

The ministry of health (MOH) of Ethiopia recommends 4 or more focused antenatal care (ANC) visits at health centre (HC) or at a higher level of health facility (HF). In Ethiopia, few studies investigated time dimension of maternal health continuum of care but lack data regarding place dimension and its effect on continuum of care. The aim of this study is to estimate effect of place of ANC-1 visit and adherence to MOH's recommendations of MOH for ANC visits on continuum of care rural in Ethiopia. We used data collected from 1431 eligible women included in the National Health Extension Program (HEP) assessment survey that covered 6324 households from 62 woredas in nine regions. The main outcome variable is continuum of care (CoC), which is the uptake of all recommended ANC visits, institutional delivery and postnatal care services. Following descriptive analysis, Propensity Score Matching was used to estimate the effect of place of ANC-1 visit on completion of CoC. Zero inflated Poisson regression was used to model the effect of adherence to MOH recommendation of ANC visits on intensity of maternal health continuum of care. Only 13.9% of eligible women completed the continuum of care, and place of first antenatal care (ANC) visit was not significantly associated with the completion of continuum of care (β = 0.04, 95% CI = -0.02, 0.09). Adherence of ANC visit to the MOH recommendation (at least 4 ANC visits at higher HFs than health posts (HPs)) increased the likelihood of higher intensity of continuum of care (aIRR = 1.29, 95% CI: 1.26, 1.33). Moreover, the intensity of continuum of care was positively associated with being in agrarian areas (aIRR = 1.17, 95% CI: 1.06, 1.29), exposed to HEP (IRR = 1.22, 95% CI: 1.16, 1.28), being informed about danger signs (aIRR = 1.14, 95% CI: 1.11, 1.18) and delivery of second youngest child at HF (IRR = 1.16, 95% CI: 1.13, 1.20). Increasing age of women was negatively associated with use of services (IRR = 0.90, 95% CI: 0.87, 0.94). Completion of maternal health continuum of care is very low in Ethiopia, however most of the women use at least one of the services. Completion of continuum of care was not affected by place of first ANC visit. Adherence to MOH recommendation of ANC visit increased the intensity of continuum of care. Intensity of continuum of care was positively associated with residing in agrarian areas, HEP exposure, danger sign told, delivery of second youngest child at health facility. To boost the uptake of all maternal health services, it is crucial to work on quality of health facilities, upgrading the infrastructures of HPs and promoting adherence to MOH recommendations of ANC visit. Maternal health continuum of care is an integrated service delivery of antenatal care, facility delivery and postnatal care on appropriate time and place. Continuum of care averts more maternal mortality than individual service provision. In Ethiopia a small percent of women complete continuum of care. Previous studies in Ethiopia explored the effect of time on CoC, however the effect of place of service delivery on subsequent continuum of care were not addressed. This study, therefore, assessed the effect of place of service delivery on completion of subsequent continuum of care using data from 1431 fixed cohort of women during the National HEP assessment survey.The proportion of women who took all essential maternal health services was very low. Whether first antenatal care is at health post or at health centre did not have a significant effect on the completion of maternal health continuum of care. Adherence to the existing recommendations of Ministry of Health for antenatal care visit increases the uptake of maternal health continuum of care. Better completion of maternal health services was observed in agrarian than pastoralist areas, among those who have exposure to health extension program, who have information about danger signs, and who deliver their previous child at health facility. We can conclude that good implementation of the health extension program, and improving service quality at health facilities increase the uptakes of maternal health service. Moreover, promoting adherence of women to the ministry of health ANC recommendations increase uptakes.

© 2021. The Author(s).