Maternity continuum of care and its determinants among mothers who gave birth in Legambo district, South Wollo, northeast Ethiopia

Abstract Background Maternity continuum of care is the continuity of maternity health care services that a woman uses for antenatal care, skill birth attendant, and postnatal care. Maternal and child mortality is still big challenge in Ethiopia. Little is known about continuum of maternity care in Ethiopia and where the study area in the district revealed that there is a big discrepancy in the completion of maternity care. Objective Assessment of maternity continuum of care and associated factors among mothers who gave birth in Legambo district, South, Wollo, and northeast Ethiopia. Method A community‐based cross‐sectional study design was conducted among 732 mothers from Feb‐Mar 2020. Multistage sampling was used and data were collected through face‐to‐face interviewer‐administered semi‐structured questionnaire. Completed data were entered using Epi‐Data version 3.1, cleaned, and analyzed using SPSS version 25 Statistical Software. Descriptive statistics using Frequency, proportion, summary measures were done. Binary logistic regressions were and model fitness was checked by Hosmer and Lemeshow test which was not significant. Multivariable logistic regression was conducted and P value less than .05 and adjusted odds ratio with 95% confidence interval was considered as statistically significant. Result The prevalence of maternity continuum of care among mother was found 11.2% (95%, CI: 9.0‐13.8). Residence (AOR:1.837, CI:1.026‐3.288), planned pregnancy (AOR: 2.448, CI:1.361‐4.403), prepregnancy contraceptive utilization (AOR: 2.721, CI:1.469‐5.042), follow mass media (AOR: 2.33, CI:1.146‐4.736) and mother health care decision making autonomy (AOR: 3.712, CI:1.924‐7.161) were determinant factors to continuum of maternity care. Conclusion The prevalence of maternity continuum of care in the district was low. Information education and counseling about continuum of care are still crucial. Awareness creation for both clients and care provider will improve the service. Efforts on improving and cultivating those significant factors should be done by stakeholders.

Awareness creation for both clients and care provider will improve the service.
Efforts on improving and cultivating those significant factors should be done by stakeholders.

K E Y W O R D S
Ethiopia, Legamo district, maternity continuum of care 1 | BACKGROUND Maternity continuum of care is the continuity of maternity health care services that a woman uses the three recommended cares of antenatal care (ANC), skill birth attendant (SBA), and postnatal care (PNC). 1 It is one of an important long-term plan for reducing maternal and neonatal deaths and improving the health and well-being of mothers and newborns. 1,2 The preventable causes of maternal and neonatal death can be reduced with provision of appropriate maternal health care services in a continuum manner. 3,4 Previous works focused on the continuum of care for child survival but continuum of care also much important for maternal health.
A continuum of care links crucial interventions across the pregnancy, delivery, and postpartum stages. [4][5][6] Adherence to continuum of care increase clients and health providers satisfaction as well help in increasing the efficiency of the service. 7,8 The advantages of continuum of care (CoC) are that each stage builds on the success of the previous stage. 9,10 Worldwide the overall figure regarding the magnitude of maternity continuum of care is not well known but some studies shows that it ranges from 60% in Cambodia to 27% in Pakistan. 11,12 In Africa it ranges from 8% in Ghana to 31% in Nigeria. 13,14 Multi-level study in 2019 showed that the magnitude of maternity continuum of care in Ethiopia is 9.1%. 15 In 2017 Ethiopia has been considered as one of the 15 very high alert being fragile state high alert list countries 17 with maternal mortality ratio (MMR) 412per 100 000 live births. 18 According to Ethiopian demographic health survey (EDHS) women show some progress in maternal care utilization that at least four antenatal care from 32% to 43%, skilled delivery assistance from 28% to 50%, and postnatal care from 17% to 34% in EDHS 2016 and mini EDHS 2019 respectively. 18,19 Maternal and child mortality is still big challenge in Ethiopia.
EDHS indicates progress in separate/fragmented service use of good ANC first visit but after that skilled delivery is not satisfactory and very low postnatal care service use. So, the aim of this study is continuum of care with our discontinuation of ANC, skill birth, and postnatal continuously and its determinates. Little is known about continuum of maternity care in Ethiopia and where the study area in the district revealed that there is big discrepancy on completion of maternity cares.
Even though thus trends of reproductive health indicators from 2000 to 2019 showed that there is good progress of maternal health care services utilization, but the gap in the continuum of maternal health care services remains remarkably high. 20 Therefore, this study aimed to assess the proportion of maternity continuum of care and its associated factors among mothers in Legambo district, South Wollo, Northeastern Ethiopia. The finding will help in identifying the prevalence of completion of maternity continuum of care and factors determining it and possible and fruitful intervention can be designed. The generated information will support to health programmers, policy makers in designing targeted health and related intervention programs; that lead to improve maternity care utilization.

| Study design, period, and area
Community-based cross-sectional study was conducted from February 25 to March 25, 2020. The study was carried out in Legambo District, South Wollo Zone, and Northeastern Ethiopia. Based on CSA in 2020 projection, the total population of the area had been projected to be 203 676 of which 50.38% were women. In the district, there are nine health centers one hospital and 11Private clinics. In the district, the annual estimated delivery of mothers was 6863 and half of it was be in 6 months according to Legambo district health office. 20

| Population and eligibility criteria
All women who gave birth and found in between first week to 6 months of postpartum period in Legambo district were source population. Those mothers who gave birth and found in between first week to 6 months of postpartum period in randomly selected kebeles were study population. Mothers who gave birth and found in between first week to 6 months after giving birth in the district before data collection were included and mothers who were not able to communicate due to known medical problems were excluded.

| Sample size determination and procedure
Sample size had been estimated using single population proportion formula with the assumptions of 5% margin of error, 95% confidence interval, non-response rate 10%, and 67.8% as a proportion maternity continuum of care completion in Debre Markos, Ethiopia. 23 Sample size considering factors affecting maternity continuum of care were calculated using Epi Info version 7.3.2.1 using factors exposure to media, Place of residence and birth preparedness, and complication readiness. 15,22,23 Sample size obtained from factor birth preparedness and complication readiness (n = 366) was the largest, then n = 366*2 (design effect) n = 732 used as the final sample size. Multistage sampling method was conducted. First stage from 40 kebeles in the district 30% which were 12 kebeles had been selected by lottery method. Second stage from selected kebelles the individual mothers were selected using the list of mothers who delivered in each selected kebeles from the first week to 6 months of postpartum prior to data collection, then the sample size was distributed proportionally to each 12 kebeles. Study participants were selected randomly from the sampling frame from each selected kebeles.

| Data collection tool and procedure
Data were collected through pre-tested structured face-to-face interview. The structured questionnaires were prepared in a local language, Amharic, to make it simple and understandable. A total of five diploma midwives for data collection and one BSc public health officers as supervisors were involved. The data collector and the women developmental army were gone home to home. Mothers who were absent on the time of data collection were checked for the other day and mothers who were totally absent were replaced by the next neighbored mother.

| Data quality control
The questionnaire was first prepared in English and then translated to Amharic and finally translated again to English by different individuals to check its translation accuracy and consistency. The trained data collectors were supervised during data collection and each questionnaire was checked for completeness on a daily basis. The questionnaire was pretested to check the response, languages clarity, and its appropriateness at Kelala district with (5%) of sample size.

| Data management and analysis
Data were entered using Epi Data version 3.1 and exported to SPSS version 25.0 for analysis. Descriptive and analytical statics were done. Model fitting was checked by Hosmer and Lemshow test. Factors that show in bivariate analysis which had P-value less than .25 were entered in to multivariable logistic regression models. The strength of statistical association had been measured by adjusted odds ratio, at 95% confidence intervals, and P-value <.05 was considered as significant variable.

| Operational definition
Maternity continuum of care: Women have four or more ANC visits by skilled provider plus Have had childbirth aided by skilled birth attendant (SBA) and Who attend postnatal care (PNC) three times at the health facility or by community health extension worker during their home visits within 24 hours, 26-28 within 3 days, 27,29-31 and within a week. 27 Autonomy for health care decision-making: A woman said to have decision-making power on seeking maternal health care service if she alone or with her husband decide on seeking service. 13 Women said to be exposed to media if she Read a newspaper/ listen to radio/watch television at least once a week are considered to be regularly exposed to that form of media. 18 3 | RESULT

| Socio demographic characteristics
A total of 732 participants were enrolled in the study yields 100% response rate. The median age of the participants was 30 years it ranges between 18 and 44 years. from the study participants 464 (63.4%) were married and 547 (74.7%) were live in rural area (Table 1).

| Autonomy and women's factor
Greater than half of the participants were used mass media and were not autonomies to make decision to get the health care as they need it. About 435 (59.4%) of the participants were not have information on the key pregnancy danger signs and 365 (49.9%) had not hear about the postnatal care service ( Table 2).

| Obstetric and maternity characteristics
The median ages of mothers at their first birth were 22 years and it ranges between 14 and 39 years. Greater than half of the participants did not plan for their last pregnancy. About three fourth of the participants did not us contraceptive before their last pregnancy and did not prepare for birth and for its complication if it happens (Table 3).

| Proportion of maternity continuum of care
The prevalence of maternity continuum of care in the district was 11.2%; (95%, CI: 9.0-13.8). According to this study skilled birth attendant was 33.9%, postnatal care service uptake was 13.2% and four and above ANC was 28.6%, Four ANC and skilled birth attendant together was 13.8%.

| Determinant factors associated with maternity continuum of care
After excluding those variable with p value greater than 0. 25

| DISCUSSION
This study assessed maternity continuum of care and associated factors among mothers who gave birth in Legambo District, South, Wollo Northeast Ethiopia. The overall prevalence of maternity continuum of care was 82 (11.2%) 95%, CI: 9.0-13.8. It was consistence with the study done in Ghana (8%) and Tanzania (10%) from Africa. 13,25 and as well as it is consistence to the prevalence found in the study conducted in ArbaMinch (9.7%) and with the multilevel study conducted in Ethiopia which is (9.1%) 15,22 despite this the present study was smaller than the study done in Cambodia (60%) and Pakistan (27%). 11,12 This difference is because of that in sub-Saharan Africa women and mothers live in poor accessibility to health institution and T A B L E 1 Socio demographic characteristics of the mothers who gave birth in the last 6 months at Legambo district, South Wollo, northeast Ethiopia (n = 732) those health facilities are not well equipped that hinders mothers from using the services. This is also supported by study done on the determinates of women access to health care service in sub-Saharan Africa. 26 Besides, the prevalence in the present study was lower than study done in Debre Markos(67.8%) 23 which might be due to, the proportion of mother with Tertiary(college and above) education was much higher in study done in Debre Markos (42.1%) 23 than the present study (3.8%), for that matter the more educated the mother the more she can read and acquire knowledge and can balance the benefit times more likely to get the maternity continuum of care than their counter parts respectively. 11,13,14,21,24 And another explanation would be the difference in setting of study area in which study done in Debre Markos was in urban town which is the zonal capital of East Goijam Zone, whereas the present study was from rural kebeles dominated wereda, in which greater than In the present study mothers who planned their pregnancy were 2.4 times more likely have completion of maternity care compared to non-planed. Which is in line with study conducted in Ghana as well as studies conducted in Ethiopia in Arbaminch zuria wereda 2019 and Debremarkos town 2019 in which mothers who plan their pregnancy were 1.75, 3.4, 3.4times more likely had completion of maternity continuum of care than their counter parts respectively. 18,19 This can be explained by as, in this study, more than 50% of unmarried (not in union) women's pregnancies were unplanned, so that they might not accept their pregnancies to themselves and hide it to others because mostly pregnancies without marriage were highly stigmatized. 27 and which is supported by study conducted in Ghana in 2015 that those married were 69%more likely to attend the maternity continuum of care than their counter parts. 13 In the present study mothers who follow media were 2.3 times more likely to get the maternity continuum of care than their counterparts. And this is in line with the study done in Pakistan 2017 and Ethiopia in Debre markos town 2019 in which mothers who follow media were1.45 and 2.62 times more likely to complete the maternity continuum of care respectively. 11,23 This can be explained as mothers who have access to media can get more information and promotion on maternal health care service that also brief the services that can be accessed to the nearby health institutions which encourage the mother use and be familiar to the maternal health services. This explanation is supported by the study done in South Asia 2019 on mass media exposure and maternal healthcare utilization in which Women exposed to mass media were 39% to 113% more likely to receive antenatal care, 17% to 99% more likely to deliver their babies by skilled birth attendants, and 24% to 95% more likely to receive postpartum check-ups after their delivery across countries. 28 In this study Mothers who used prepregnancy contraceptives were 2.7 times more likely to complete maternity care compared to their counter parts. it is consistence with the study done in Arbaminch zurai wereda that mothers who us prepregnancy contraceptive were3.9 times more likely to get the maternity continuum of care than their counter parts. 15,22,23 The reason behind might be women's who utilized prepregnancy contraception were well informed about the next maternal and newborn services and set plans with health professional for next services. This explanation also supported by findings from a systematic review and meta-analysis on preconception care where the odds of attending antenatal care for women who were counseled about subsequent services during preconception period were 39% higher when compared to their counter parts. 29 In the current study mothers who were autonomies in health care Abbreviations: AOR, adjusted odd ratio; CI, confidence interval; COR, crude odd ratio. *P < .05. **P < .01. ***P < .001.
someone else to decide on her health issue. and this explanation also supported by study done on women's autonomy in health care decision-making in developing countries. 30

| LIMITATION OF THE STUDY
Social desirability and recall bias, maybe introduced in the time of data collection and temporal relation between dependent and independent variable cannot be established since it is cross sectional study.

| CONCLUSION AND RECOMMENDATION
The prevalence of maternity continuum of care in the district was relatively low. Residence, planned pregnancy, prepregnancy contraceptive utilization, mass media follow, and autonomy of the mother on health

CONFLICT OF INTEREST
The authors declare that there are no conflicts of interest regarding the publication of this paper.

TRANSPARENCY STATEMENT
The lead author (Niguss Cherie) affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned have been explained.

DATA AVAILABILITY STATEMENT
The data supporting the findings of this study are available from the corresponding author upon request. The corresponding author had full access to all of the data in this study and takes complete responsibility for the integrity of the data and the accuracy of the data analysis.

ETHICS STATEMENT
Ethics approval and informed consent: Ethical and aware verbal consent was approved ethical review board of Wollo University, school of medication and Health Sciences. The study complies with the Declaration of Helsinki and fulfills moral assumptions. Every study participant was communicated clearly concerning the target of the study to get their consent, their full right to withdraw or refuse to participate.
Privacy was kept during data collection.