Factors associated with compliance with the recommended frequency of postnatal care services in three rural districts of Tanzania

Of the 130 million live births that occur worldwide annually, an estimated 3.7 to 4 million deaths occur in the first 28 days of life contributing to 40 % of the total deaths in children under 5 years of age [1, 2]. About half of these deaths occur on the first day of life, and more than two-thirds within the first week of life [3]. About 99 % of all neonatal deaths occur in Low- and Middle-Income Countries (LMIC), and about half also occur at home and thus are at risk of being uncounted [2, 4].

In response to this problem, the World Health Organization (WHO) promotes basic postnatal care (PNC). Specifically, WHO recommends that mothers and newborns receive initial PNC care within the first 24 h after delivery and a minimum of three additional PNC visits within 48–72 h, and 7–14 days, and 6 weeks after delivery [5]. Recommendations concerning number, timing, and content of PNC are based on clustering of neonatal deaths at certain ages, common causes of neonatal death, and the most impactful timing for delivering interventions. The first 6 weeks of life can be divided into three phases, each represented by associated risks and corresponding priorities for the provision of care to the newborn. Care received involves monitoring for danger signs in the infant’s breathing, temperature, breastfeeding, and movement, as well as counseling the mother about healthy nutrition and lifestyle practices. The immediate postnatal period, corresponding to the first 24 h after birth, is associated with the greatest concentration of fatal risks to the newborn. These include birth asphyxia, trauma, breathing issues related to preterm birth, and sepsis. The early postnatal period, corresponding to days 2 through 7 is a period when sepsis, malaria, and other infectious disease risks are prominent. The late postnatal period extends from days 8 through 42 or weeks 2 through 6, when risks of childhood infections that are concentrated in week 1 remain as dominant causes of death, but at gradually diminishing levels of risk as days of age progress [6].

Research shows that achieving this recommended three clinical visit regimen of care at a 90 % level of coverage could avert up to 310,000 newborn deaths per year in Africa [7]. Evidence is not completely consistent, however. Some studies provide strong evidence of the link between PNC and neonatal survival [8, 9], while others have found no or weak associations [10, 11]. Particular PNC promoted practices for preterm deliveries, such as ‘kangaroo care’ reduce neonatal mortality when applied [7, 12–14], but implementation of this practice is often incomplete and suboptimal. Despite considerable evidence that the life-saving potential of PNC could be more effectively marshaled if implementation challenges are addressed, this component of primary health care has largely been overshadowed by the attention given to antenatal care (ANC) and promotion of the provision of skilled attendance at birth [10].

While there is mounting global investment in improving neonatal survival, there are often gaps in both the coverage and the quality of PNC services in much of the developing world. Often when PNC services are available, they are not comprehensive [15]. Most of studies also focused on the determinants of at least one component of PNC. Yet, WHO recommends at least three components of PNC [6].

In Tanzania, the coverage of health interventions is lowest during childbirth and the postnatal period [16], which are the periods when such care is most essential [2, 17]. Studies examining utilization of health services and health practices in general within Tanzania during the postnatal period are scarce, with most of the focus on perinatal services addressed instead to post-partum family planning, ANC, and midwifery care [18–25]. Several studies in LMIC have identified factors that are associated with PNC exposure: maternal educational attainment [26–31], household relative socioeconomic status [29–35], parental occupations and employment status [26, 28], and geographic factors, such as household distance to health facilities [29–34, 36–38]. Despite such results, however, evidence regarding factors influencing health care seeking behavior for PNC is inconsistent. Chakraborty et al. (2002), for example, found no significant effect of education or distance on utilization of health services during the postnatal period [39].

Few studies have looked into the factors associated with the WHO recommended frequency of PNC. This study is among the first to determine the extent to which mothers with recent pregnancies received the WHO recommended PNC services at a health facility or at a community with a traditional birth attendance or a village health worker (i.e., service utilization rate). Additionally, the study aims to identify individual characteristics and contextual factors associated with utilization of PNC among mothers with recent pregnancies in the Rufiji, Kilombero, and Ulanga districts of Tanzania.

The present study is among the first to determine maternal, newborn health, pregnancy, and household characteristic factors that are associated with compliance with the WHO recommended intensity of PNC. Just as Tanzania is predominantly rural (74 %), the focus of this study is a population of women from three rural districts where their the level of PNC utilization is related to predictors of care seeking for themselves and their newborns.

The rate of achieving at least one PNC visit among mothers and their newborns in our study area (65.5 %) was high relative to corresponding national estimates in rural areas (30.4 %) [16] and also high relative to levels observed in other sub-Saharan countries, such as Kenya 42.0 % [46], Malawi 50.0 % [47], Rwanda 19.2 % [48], Nigeria 34.1 % [28]. The high utilization rate for one visit found in this study may be an artifact of our decision to merge information about PNC received by the baby only, by the mother only, and by both the baby and the mother together, under the assumption that PNC services are benefiting both mothers and newborns. Nonetheless, the utilization rate for at least one PNC for mothers alone was 33 %, which is comparable to rural estimates in Tanzania.

Although three PNC service encounters are recommended within 6 weeks after childbirth, only 10.4 % of the deliveries were associated with this level of care. The low level of complete PNC compliance may arise from a combination of structural determinants, such as poor access to services, low coverage of PNC services at formal health facilities and perceived lack of services at such facilities by mothers, perceived lack of importance of seeking PNC services, a shortage of community providers making routine home visits, costs and transportation difficulties, and other cultural, geographic or financial barriers [15, 20, 49]. Global experts advise that in situations of poor utilization of formal health care systems, PNC should be provided by community health workers who are trained to provide such care during routine home visits [15, 49]. Our study found that only 8.4 % of mothers and their newborns received PNC visit at home from community health workers. The Connect Project’s trained cadre of community health workers can directly address this health need [41].

Regarding the issue of the factors associated with compliance with WHO recommended frequency of PNC services, mothers who declared that the pregnancy was unwanted, those who did not attended more frequently to ANC services or those who had low knowledge of risk factors during delivery and the postnatal period were less likely to utilize PNC services, results confirmed by another study in rural Tanzania [50] and Ethiopia [51]. Qualitative research from a similar study in rural Southern of Tanzania showed that mothers stated reasons for not frequently seeking PNC services including negligence and unplanned pregnancy and overall lack of knowledge of danger signs of newborn illness [20]. Our findings also showed that delivering at the health facility had a negative effect on the frequency of PNC, results confirmed by another study from the same region of Tanzania (Morogoro) [26]. However, our results with interaction terms showed that when ANC visit is low, the place of delivery had no statistically significant effect on PNC visit. However, the high attendance to ANC services had a positive and significant effect on number of PNC visit. That indicates that the facility delivery represents missed opportunity to promote PNC cares benefit for mothers and their newborns. This finding suggests that there is a need to improve the quality of maternal health care services during childbirth (counseling or health education and promotion) [52].

Our findings showed that sick newborns were more likely to be cared for than healthy newborns. Research from rural women in Nepal showed that health problems were significantly associated with having PNC [53]. That care was sough because of the health status of mothers and their newborns. Then, PNC is not functioning as prevention care. It is rather a parental response to illness during the postnatal period. Least healthy newborns would be receiving the most intensive care.

Our findings showed that the district of residence remains a predictor of service utilization. The low rate among mothers from Ulanga compared to those from Rufiji and Kilombero districts could be associated with the higher physical access to health facilities and lower density of health facilities in Ulanga compared to Rufiji and Kilombero. Compared to previous studies, which have demonstrated that a higher physical accessibility may increase maternal services utilization in Tanzania [50], Ghana [54] and Nepal [55], our results have not shown strong evidence that mothers who lived near to a health facility attended more frequently PNC services as compared to those who lived far from a health facility.

Consistent with prior empirical studies [56], the age of the mother had an independent influence on PNC utilization. This fact could be related to the risk factors associated with young mothers. Ethnicity and to a lesser extant, religion had a independent influence on PNC utilization in the study area as shown also in previous studies [57]. This could be explained by the underlying cultural beliefs and values systems of different ethnic groups, which influence health perceptions, needs, and behavior of their group members. Our study does provide the relative importance of ANC attendance in facilitating or hindering the utilization of PNC services. However, one review of ten studies that used similar multivariate analysis found that it was not possible to assess whether one specific factor was more important that the others in determining utilization [58]. The authors concluded that to be most effective, PNC interventions should address all barriers to utilization comprehensively and not target single barriers in isolation.

Overall, our study highlights the need for further research and program efforts aimed at increasing utilization of PNC services during this period of high risk for mothers and their newborns. In particular, there is a need to explore effective means of promoting routine preventive care PNC. Further research into utilization of PNC should combine individual level behavior data with child survival and neonatal mortality data to examine the link between health seeking behavior and health outcomes.

Despite the remarkable success in reducing child mortality [59], Tanzania has made no significant progress in reducing newborn deaths. An understanding of the factors that influence utilization of PNC by mothers and their newborns is helpful in identifying possible reasons for use and non-use. While the results of this study illuminate such reasons, further research is needed to contextualize the influence of these multi-level factors on individual utilization of PNC. To achieve the WHO recommended number of PNC in rural Tanzania, our findings suggest the need to provide PNC through the community-based primary health care and to improve the quality of maternal health services (counseling and education), during antennal and postnatal periods. Such an understanding can inform the Ministry of Health and Social Welfare in Tanzania in the formulation of national and local policies and programs to increase PNC utilization rates, with the ultimate goal of reducing preventable deaths taking place in the high risk postnatal period and beyond.