This study assessed the level of utilization and determinants of ANC, skilled birth attendant, and uptake of the different packages of PNC services in Kailahun District Sierra Leone. This study found that 100.0% of women received ANC services, of which 77.6% of them sought at least one ANC visit from a skilled ANC provider and 88.6% made 4 or more ANC visits as recommended by the World Health Organization. These findings are similar to reports in the Sierra Leone Demographic and Health Survey which showed that 98.0% of women received ANC from a skilled provider and 79.0% made 4 or more ANC visits . However, our results are also inconsistent with the Uganda Demographic and Health Survey UDHS 2016, which showed that 97.0% of women received ANC from a skilled provider but only 60.0% of the women made 4 or more ANC visits . The disparity between the present study and the UDHS may be related to the maternal demographic characteristics in both countries and the fact that the sample size in the UDHS was far larger, thus influencing the precision of the findings.
Regarding the timing of the first ANC, 54.5% of women sought their first ANC in the first trimester of pregnancy and this prevalence was higher than that obtained in the Sierra Leone Demographic and Health Survey 2019, where 44.0% made their first visit in the first trimester . This discrepancy could be attributed to the demographic survey having had a larger coverage area as compared to the present study. It has been recommended that all pregnant women should start their ANC in the first trimester . The findings of this research suggest that the use of ANC services was higher among urban residents (81.5%), which corroborates a study conducted in Holeta Town, Ethiopia where 86.7% of urban women used ANC services . According to the Sierra Leone Demographic Survey (2019), 73.0% of women in urban areas made 4 or more ANC visits which is slightly lower patronage as compared to our population. The high use of ANC services in urban areas may be because, Kailahun District has 87 peripheral health units and 3 hospitals, of which all the hospitals and most of the PHUs are in urban areas thus increasing access. Increased awareness and information sharing might also be related to the economic status of urban residents since women in urban areas have more physical and economic access to health facilities.
The findings of this study showed that the enabling (maternal age, marital status, ethnicity, parity, respondent education, and religion) and predisposing factors (residence, distance to the health facility, and husband’s education) were non-predictor of ANC service utilization. A study conducted in Holeta Town, Central Ethiopia found maternal age and education as predictors of ANC service utilization . In another study in Ghana, residence and education were major predictors of ANC services [1, 23, 24].
This research further indicated that the use of SDA was generally low. Only 35.9% of women had at least one delivery in 3 years before this study used SDA compared to 11.7% in a study in Ethiopia . The majority, 57.6, and 4.2% were delivered by Maternal and Child Health Aide (MCHA) and Traditional Birth Attendant (TBA) respectively, who are considered non-skilled. According to the Demographic and Health Survey (2019), 87% of deliveries were assisted by a skilled provider. The disparity between the DHS and this study may be related to the fact that our study did not consider MCHA and State Enrolled Community Health Nurses (SECHN) as skilled attendants. Kailahun District is one of the most remote areas in Sierra Leone, physical accessibility is a major challenge due to the bad road network, thus most healthcare workers find it difficult to travel, work and stay in the district which creates opportunities for non-skilled workers. The WHO has recommended that there should be a critical threshold of 23 skilled healthcare workers (doctors, nurses, and midwives) per 10,000 population . Nevertheless, it has been very difficult for Sierra Leone to cope with such recommendations due to the severe scarcity of qualified healthcare workers, thereby providing merely 2 skilled workers per 10,000 populations . The 10 years of civil war which ended in 2002 and the 2014 Ebola epidemic, all started in Kailahun District and left a huge impact on health service delivery in the district. Sierra Leone is among the world’s highest maternal death ratios at 1360 mortality per 100,000 births  because most women are not delivered by a SDA, and most ANC services are provided by non-skilled providers. It further found that 10.5 and 35.9% of deliveries took place at Maternal and Child Health Post (MCHP) and Community Health Post (CHP) respectively, which are facilities manned by non-skilled attendants.
This study found that the area of residence is a major determinant of SDA utilization. The use of skilled birth attendants was higher among urban residents than rural. These findings are consistent with other studies [5, 7]. The disparity in the utilization of MHC services may be due to the concentration of health facilities in urban areas combined with the high number of qualified birth attendants in urban areas and also the economic status of the urban residents. In the Kailahun district, there is an uneven distribution of health workers, most are found in urban areas. Distance to the health facility was considerably connected with the use of SDA. Women that walked 30–60 min or more than 60 min to access health care services were more likely to use SDA than those that walked less than 30 min. In another study conducted in Kenya, although the distance was cited as a barrier to MHC service utilization, 18% of women did not visit the nearest facility .
In the present study, the husband’s education was significantly associated with the use of a skilled delivery attendant. Women whose husbands had at least primary education were more inclined to use SDA than those whose husbands had no education which is consistent with other studies . Similarly, in another study conducted in Nigeria, husbands’ education played a key role in the utilization of SDA , research has shown that education increases health awareness and knowledge on the significance of MHC services and improves other forms of learning . This could be through; radio, the internet, written information, and a better cultural understanding. Educated husbands may provide more autonomy to their wives .
Our study found that the majority 97.5% of women received PNC services and 58.1% of them received it from MCHA. The 2013 Sierra Leone Demographic and Health Survey reported that 7.8% of PNC services were delivered by MCHA . The disparity between the national and district figures may be related to the fact that the Demographic Survey was done in the entire 16-district taking into consideration the major urban areas where good healthcare services are concentrated compared with Kailahun being one of the most remote districts. Also, due to the limited number of skilled providers in the district, most PNC services are provided by non-skilled providers.
In the present study, women’s residence, education of women, and husband’s education are significant predictors of the utilization of the standard PNC package. These observations are consistent with a study conducted in Ethiopia among women of reproductive age which reported a significant influence of respondent education and urban residence on the utilization of MHC services .
Some of the results of this study are similar to others reported, which have highlighted the importance of effective, efficient, and accessible Maternal healthcare services. Several issues specific to Sierra Leone were identified that suggest the influence of these socioeconomic factors on the utilization of MHC services and if these are not addressed in addition to the inadequate number of skilled attendants, Sierra Leone would continue to have high maternal and infant mortality ratios. Finally, our results show that investment in the training of skilled attendants, education, and rural healthcare would significantly improve the utilization of MHC service thus reducing maternal and infant mortality.
Limitation of study
Some of the respondents seemed to have difficulty in the recollection of events that had happened during the last 3 years before the study. Such women had difficulties in recalling or identifying the nature of healthcare services they received or the trained healthcare worker that provided the service. As a way of minimizing this challenge, the interviewers requested for participants’ ANC cards to fact-check their responses.
This study is externally valid and generalizable as the sample accurately represents the population and the characteristic of Kailahun District are similar to others in Sierra Leone. The households were proportionately distributed to urban and rural areas. We did not assess the healthcare facility and the health workers’ related factors that affect antenatal, postnatal, and skilled delivery utilization, all of which are known to be key determinants of maternal health care utilization. These are areas for further study.