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  • Research article
  • Open Access
  • Open Peer Review

The effect of antenatal care on use of institutional delivery service and postnatal care in Ethiopia: a systematic review and meta-analysis

BMC Health Services Research201818:577

https://doi.org/10.1186/s12913-018-3370-9

  • Received: 10 November 2017
  • Accepted: 9 July 2018
  • Published:
Open Peer Review reports

Abstract

Background

Although there are many initiatives to improve maternal health services use, utilization of health facility delivery and postnatal care services is low in Ethiopia. Current evidence at global level showed that antenatal care increases delivery and postnatal care services use. But previous studies in Ethiopia indicate contrasting results. Therefore, this meta-analysis was done to identify the effect of antenatal care on institutional delivery and postnatal care services use in Ethiopia.

Methods

Studies were searched from databases using keywords like place of birth, institutional delivery, and delivery by a skilled attendant, health facility delivery, delivery care, antenatal care, prenatal care and postnatal care and Ethiopia as search terms. The Joanna Briggs Critical Appraisal Tools and the Preferred Reporting Items for Systematic Review and Meta-Analyses were used for quality assessment and data extraction. Data analysis was done using STATA 14. Heterogeneity and publication bias were assessed using I2 test statistic and Egger’s test of significance. Forest plots were used to present the odds ratio (OR) with 95% confidence interval (CI).

Result

A total of 40 articles with a total sample size of 26,350 were included for this review and meta-analysis. Mothers who had attended one or more antenatal care visits were more likely (OR = 4.07: 95% CI 2.75, 6.02) to deliver at health institutions compared to mothers who did not attend antenatal care. Similarly, mothers who reported antenatal care use were about four times more likely to attend postnatal care service (OR 4.11, 95% CI: 3.32, 5.09).

Conclusion

Women who attended antenatal care are more likely to deliver in health institutions and attend postnatal care. Therefore, the Ethiopian government and other stakeholders should design interventions that can increase antenatal care uptake since it has a multiplicative effect on health facility delivery and postnatal care services use. Further qualitative research is recommended to identify why the huge gap exists between antenatal care and institutional delivery and postnatal care services use in Ethiopia.

Keywords

  • Antenatal care
  • Postnatal care
  • Institutional delivery
  • Ethiopia
  • Meta-analysis

Background

About 303,000 mothers died from pregnancy and childbirth related causes in 2015. Majority (99%) of the deaths occurred in developing countries. Most of these deaths were from Sub-Sahara Africa [1, 2]. In Ethiopia, an estimated 11,000 mothers died due to pregnancy and childbirth related causes in 2015 [1, 3].

Globally, the major causes for maternal mortality are obstetric hemorrhage, hypertension, abortion, sepsis, HIV, preexisting medical disorders and other indirect causes like anemia [2, 46]. These are also causes of death for Ethiopian mothers [3, 710]. Most causes of maternal and child deaths are preventable or treatable with proven, cost-effective interventions [1117]. A study conducted in India showed that 90% of maternal deaths would have been prevented if immediate decisions and appropriate care had been given at the time of delivery [18]. Provision of effective delivery care can prevent 113,000 maternal deaths annually [19].

Antenatal, delivery and postnatal care are among the key health sector interventions for maternal and child survival [2028]. Many studies identified that antenatal care interventions reduce maternal and child mortalities and morbidities [2934]. Institutional delivery can reduce the risk of neonatal mortality by 29% in low and middle-income countries [35, 36]. A study done in Southern and central India showed that increased institutional delivery is associated with decrease in stillbirth and perinatal mortality [37]. Similarly, skilled attendant at delivery can prevent and treat life-threatening conditions that may occur at the time of delivery [3841]. Postnatal care is also a crucial time to tackle most causes of maternal and child mortality [4245].

The Ethiopian government developed many strategies and programs to improve maternal and child health. For example, all maternal health services are provided free in Ethiopia [4548]. The Health Extension program is another strategy which brought a tangible effect on family health [48, 49]. The Ethiopian government set an ambitious plan to increase four or more ANC visits, delivery and postnatal care services use to 95, 90, and 95% respectively at the end of 2020 although the current level of these services use is low [50, 51].

Antenatal care is an opportunity to promote mothers to use other maternal health services [34, 45, 52, 53]. Women who attended ANC are expected to use health facility delivery and attend postnatal care services. Yet, the situation is different in Ethiopia. According to the 2016 Ethiopian demographic and health survey, the proportion of women who attended ANC, health facility delivery and postnatal care is low compared to the national targets. Moreover, the proportion of mothers who delivered at health institutions (26%) and attended postnatal care (17%) is much lower than those who attended ANC (64%) [50, 51]. Therefore, this review and meta-analysis were done to identify the effect of ANC on institutional delivery and postnatal care services use in Ethiopia. The result of this review and meta-analysis will help to identify whether antenatal care attendance has an effect on health facility delivery and postnatal care services use in Ethiopia.

Methods

Search strategy

We used the EndNote software and searched databases to retrieve studies for this review and meta-analysis. The search terms used were: place of birth, institutional delivery, delivery by a skilled attendant, health facility delivery, delivery care, antenatal care, prenatal care and postnatal care and Ethiopia. The main databases searched were PUBMED, MEDLINE, Google Scholar, web of science and African journal online (AJOL). After identifying the key literatures, their references were screened to retrieve additional articles.

Evaluation of evidence

To evaluate the quality of the papers, the Joanna Briggs Critical Appraisal Tools for review and meta-analysis was used. The AACODS (Authority, Accuracy, Coverage, Objectivity, Date, and Significance) was used to evaluate the quality of the articles [54, 55].

Inclusion criteria

The following criteria were used to include studies in this meta-analysis.
  • Design: studies with all study design

  • Publication status: both published and unpublished reports

  • Language: literatures reported or published in English

  • Publications or report year: papers published or reported up to September 05, 2017

  • Place of study: studies that were conducted in Ethiopia regardless of the study setting (community-based or institution based).

  • Outcome reported: studies that reported the study outcomes (ANC and institutional delivery or ANC and postnatal care) or both

Data abstraction

This review was conducted from July 15 to September 05, 2017. The review followed the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) flow chart to identify and select relevant studies for this analysis. Initially, duplicated retrievals were removed. Then, studies whose titles were irrelevant for this study were excluded. After that, the abstracts were assessed and screened based on the exposure and outcome variables. At this stage, studies that were not relevant for this analysis were excluded. For the remaining articles, the full text was assessed. The eligibility of these articles was assessed based on the pre-set inclusion criteria. When articles did not have adequate data, corresponding authors of the research articles were contacted. All authors conducted the review independently and an agreement was reached through discussion when needed.

Heterogeneity and publication bias

Heterogeneity among the included studies was checked by using I2 test statistic [56]. Heterogeneity was declared at p ≤ 0.05. Publication bias was also checked by using Egger’s test. A p-value of less than 0.05 was used to declare statistical significance of publication bias [57]. For studies which showed the presence of publication bias, the Duval and Tweedie nonparametric trim and fill analysis was conducted to account for the publication bias [58].

Data analysis

The analysis to identify the effect of ANC visits on institutional delivery service use was divided into two parts. The first analysis was to identify the effect of one or more ANC visits on institutional delivery service use and the second was an analysis of the effect of four or more ANC visits on institutional delivery service use.

Data were extracted from each study using data abstraction format prepared on Microsoft Excel. Then, the data were exported to STATA 14 for meta-analysis.

Results

Description of the studies

A total of 1236 records related to the review topics were identified. Ninety articles were removed because they were duplicates. Another 1139 articles were removed from the list after screening their title and abstracts. Then, full article review and screening was done for 59 studies. From these, a total of 20 articles were excluded for not reporting one or more of the outcome variable. Finally, 40 studies were included in the analysis (Fig. 1, Tables 1, 2 and 3).
Fig. 1
Fig. 1

Diagrammatic presentation of the procedure for selection of studies included to study the effect of antenatal care on institutional delivery service use and postnatal care in Ethiopia

Table 1

Characteristics of studies included to study the effect of ANC visit on institutional delivery service use in Ethiopia

S.No

Author and Year

Study area

Study period

Study design

Sample size

ANC attendance

Institutional delivery

Yes

No

1

Tekelab et al., 2015 [62]

East Wollega, Oromia

January, 2015

CB cross sectional

801

Yes

240

254

No

77

277

2

Tsegay et al., 2013 [63]

Samri-Saharity District, Tigray

Not reported

CB cross sectional

1115

Yes

39

563

No

7

504

3

Hailu et al., 2014 [64]

Tsegedie District, Tigray

November 2012 to June 2013

CB cross sectional

485

Yes

124

140

No

29

192

4

Feyissa et al., 2014 [59]

East Wollega, Oromia

September to October, 2013

Unmatched case control

320

Yes

73

168

No

7

72

5

Mengesha et al., 2013 [60]

Dabat District, Amhara

October 2009 to August, 2012

Nested case control

1065

Yes

213

852

No

152

159

6

Abebe et al., 2012 [61]

Bahir Dar Special Zone, Amhara

July, 2010

Unmatched case control

324

Yes

205

57

No

11

51

7

Abeje et al., 2014 [65]

Bahir Dar city administration,

Jun to July, 2012

CB cross sectional

484

Yes

359

54

No

20

14

8

Asres et al., 2015 [66]

Sheka zone, SNNP

February to March, 2008

CB cross sectional

554

Yes

319

126

No

13

96

9

Odo et al., 2014 [67]

Goba town, Oromia

April, 2013

CB cross sectional

580

Yes

247

231

No

17

67

10

Amano, 2012 [68]

Munisa Woreda, Oromia

April, 2011

CB cross sectional

855

Yes

74

223

No

31

527

11

Teferra et al., 2012 [69]

Sekela District, Amhara

August, 2010

CB cross sectional

371

Yes

42

3

No

206

120

12

Worku et al., 2013 [70]

North Gondar Zone, Amhara

January to March, 2012

CB cross sectional

1668

Yes

103

58

No

145

170

13

Bayu et al., 2015 [71]

Southern Zone, Tigray

January to August 2014

CB follow up

522

Yes

263

82

No

68

52

14

Melaku et al., 2014 [72]

Kilite Awulalo, Tigray

September 2009 to August 2012

CB, longitudinal

2361

Yes

536

1270

No

106

449

15

Abera et al., 2011 [73]

Arsi Zone, Oromia

February to March, 2006

CB cross sectional

1089

Yes

162

482

No

14

416

16

Tura G, 2008 [74]

Metekel Zone, B/Gumuz

January to March, 2007

CB cross sectional

1060

Yes

108

409

No

17

504

17

Nigussie et al., 2004 [75]

North Gondar Zone, Amhara

November to December, 2002

CB cross sectional

1248

Yes

147

421

No

21

653

18

Tura et al., 2014 [76]

Jimma Zone, Oromia

September 2012–April 2013

CB follow up study

3472

Yes

954

1680

No

110

728

19

Arba et al., 2016 [77]

Wolayta & Dawuro Zones, SNNPR

February to March, 2015

CB cross sectional

1000

Yes

326

435

No

33

163

20

Bayu et al., 2015 [78]

Debremarkos town, Amhara

January to July, 2012

CB, follow up

422

Yes

232

116

No

13

31

21

Darega et al., 2016 [79]

Abuna Gindeberet District, Oromia

March, 2013

CB cross sectional

703

Yes

98

481

No

3

121

22

Demilew et al., 2016 [80]

Dangila district, Amhara

February, 2015

CB cross sectional

780

Yes

134

377

No

6

246

23

Fikre and Demissie, 2012 [81]

Dodota District, Oromia

January, 2011

CB cross sectional

506

Yes

75

340

No

17

74

24

Habte and Demissie, 2015 [82]

Cheha District, SNNPR

December 2012 to January 2013

CB cross sectional

845

Yes

251

483

No

2

80

25

Kebede et al., 2013 [83]

Chilga, Amhara

March to June 2012

CB cross sectional

475

Yes

54

218

No

19

184

26

Kenea and Jisha, 2017 [84]

Dale Wabera District, Oromia

2014

CB cross sectional

588

Yes

215

185

No

45

122

27

Kidanu et al., 2017 [85]

Dembecha District, Amhara

March, 2015

CB cross sectional

700

Yes

6

45

No

223

400

28

Tadele & Lamaro, 2017 [86]

Bench Maji, SNNPRS

September, 2015

CB cross sectional

800

Yes

574

109

No

25

57

29

Wako & Kassa, 2017 [87]

Liben District, Oromia

June, 2015

CB cross sectional

876

Yes

76

444

No

34

237

30

Yigezu and Kitila, 2015 [88]

Jimma town, Oromia

February to April, 2014

CB cross sectional

281

Yes

165

63

No

18

31

CB Community based

Table 2

Characteristics of studies included to study the effect of number of ANC visits on institutional delivery service use in Ethiopia

S. No

Author and year

Study area

Study period

Study design

Sample size

Number of ANC visits

Institutional delivery

Yes

No

1

Hailu et al., 2014 [64]

Tsegedie District, Tigray

November 2012 to June 2013

CB cross sectional

485

≥4+

29

14

< 4

102

126

2

Feyissa et al., 2013 [59]

East Wollega, Oromia

September to October 2013

Unmatched case control

320

≥4+

48

79

< 4

25

89

3

Mengesha et al., 2013 [60]

Dabat District, Amhara

October 2009 to August 2012

Nested case control

1065

≥4+

152

159

< 4

61

693

4

Odo et al., 2014 [67]

Goba town, Oromia

April, 2013

CB cross sectional

580

≥4+

50

32

< 4

196

200

5

Tura et al., 2014 [76]

Jimma zone, Oromia

September 2012 to April 2013

CB follow up study

3472

≥4+

633

595

< 4

321

1085

6

Alemayehu & Mekonnen, 2015 [89]

Ankasha Gagusa woreda, Amhara

February, 2014

CB cross sectional

373

≥4+

23

22

< 4

41

199

7

Kasaye et al., 2017 [90]

Debremarkos town, Amhara

January, 2016

CB cross sectional

518

≥4+

154

14

< 4

221

113

8

Tadele and Lamaro, 2017 [86]

Bench Maji, SNNPRS

September, 2015

CB cross sectional

800

≥4+

427

21

< 4

147

88

9

Desalegn et al., 2014 [91]

Fogera District, Amhara

February – April, 2013

CB cross sectional

412

≥4+

61

42

< 4

65

231

10

Kibret, 2015 [92]

Gozamen District, Amhara

March to April, 2014

CB cross sectional

499

≥4+

44

48

< 4

79

326

CB Community based

Table 3

Characteristics of studies included to study the effect of antenatal care on post natal follow up in Ethiopia

S.No

Author and year

Study area

Study period

Study design and setting

Sample size

ANC attendance

PNC attendance

Yes

No

1

Tesfahun et al., 2014 [93]

Gondar Zuria district, Amhara

April–August 2011

Community based cross sectional

836

Yes

550

155

No

59

56

2

Darega et al., 2016 [79]

Abuna Gindeberet District, Oromia

March, 2013

Community based cross sectional

703

Yes

210

369

No

13

111

3

Limenih et al., 2016 [94]

Debremarkos town, Amhara

November, 2014

Community based cross sectional

588

Yes

138

163

No

59

228

4

Birhanu et al., 2016 [95]

Addis Ababa

April–May, 2016

Institution based cross sectional

422

Yes

273

139

No

4

6

5

Hordofa et al., 2015 [96]

Dembecha District, Amhara

July–August, 2013

Community based cross sectional

788

Yes

234

333

No

22

147

6

Abosse et al. 2015, [97]

Hadya Zone, SNNPRS

January–February 2009

Community based cross sectional

710

Yes

154

442

No

3

92

The studies were conducted from 2011 to 2017. Most of the studies were from the four major regions of Ethiopia, 11 from Oromia, 17 from Amhara, 4 from Tigray and 5 from South Nations, nationalities and people’s regional state. The sample size of the included studies ranged from 281 to 3472 participants. In terms of study design, all except three were cross-sectional (Tables 1, 2 and 3).

Effect of ANC on institutional delivery service use

A total of 30 studies with 26,350 sample size were included to estimate the effect of ANC on institutional delivery service use. The study populations for all the 30 studies were reproductive-age women who were pregnant or had given birth within 5 years of the survey. The studies were conducted from 2004 to 2016 (Table 1). Three of the studies were case-control [5961] and the remaining 27 studies were community-based cross-sectional or follow up studies [6288].

This analysis identified that mothers who had one or more antenatal care visits were about four times more likely (OR = 4.07: 95% CI 2.75, 6.02) to deliver at health facilities compared to mothers who had not attended ANC (Fig. 2).
Fig. 2
Fig. 2

Effect of any antenatal care visit on institutional delivery service use in Ethiopia

Additionally, ten articles were included to assess the effect of four or more ANC visits on institutional delivery service use. The studies were conducted from 2013 to 2017. The total number of women included in this analysis was 8524. Two of the studies were case-control [59, 60] and the other eight were cross-sectional studies [64, 67, 76, 86, 8992]. The sample size of the studies ranged from 320 to 3472. The studies included in this subgroup analysis showed high heterogeneity (I2 = 87.8, P ≤ 0.001) but non-significant publication bias (Egger’s test = 0.780). Using the random effect model analysis, women who had four or more ANC visits were 4.38 times more likely to deliver in health facilities compared to women who reported fewer ANC visits (OR 4.38, 95% CI: 2.96, 6. 48) (Fig. 3).
Fig. 3
Fig. 3

Effect of four or more antenatal care visits on institutional delivery service use in Ethiopia

Effect of ANC on postnatal care service use

Six articles with a total sample size of 4047 women were included in this analysis. All except one (institution based) were community-based cross-sectional studies [79, 9397]. There was no statistically significant heterogeneity and publication bias among the studies (I2 = 14.7, P = 0.320 and Egger’s test = 0.231, respectively). The analysis indicated that mothers who attended ANC were about four times more likely to use postnatal care service (OR 4.11, 95% CI: 3.32, 5.09) (Fig. 4).
Fig. 4
Fig. 4

Effect of antenatal care visit on postnatal care service use in Ethiopia

Discussion

Antenatal care has been used as a strategy to reduce maternal and neonatal morbidities and mortalities. Various approaches and strategies have been implemented to improve the effectiveness of ANC in developing countries [52, 98, 99]. Currently, most developing countries including Ethiopia are using the focused ANC approach which was developed by WHO [100, 101].

This study identified that women who attended ANC were about four times more likely to use institutional delivery services. This finding was in line with a meta-analyses conducted in Africa [102, 103] and DHS based data analysis in Nigeria [104]. The reason for this finding is that ANC is an opportunity for health promotion [105]. Therefore, women who attended ANC are more likely to have better information about benefits of institutional delivery service use and this may have impacted the subsequent health service use. Additionally, pregnant women attending ANC have the chance to acclimatize to the health facility environment. This may have helped them avoid unnecessary fear and stress related to institutional delivery service use. Furthermore, mothers who attended antenatal care are more likely to be better informed about danger signs and obstetric complications which may arise during labor and delivery. Antenatal care is also an opportunity for a pregnant woman to establish an informal forum which will help them to discuss and share information about their pregnancies and benefits of health facility delivery [46, 50, 57, 58].

The subgroup analysis showed four or more ANC visits had a similar effect on health facility delivery compared to fewer ANC visits. The reason for this may be that health professionals in developing countries provide all the information and health promotion activities needed for the mother on the first visit to avoid missed opportunities as the woman’s return for the subsequent visits is not guaranteed [51, 105].

The current review also found that women who attended antenatal care were more likely to use postnatal care services. This finding is similar to studies conducted in Nigeria, Nepal, and Zambia [104, 106, 107]. It is theoretically plausible to think that mothers who attended ANC had received adequate counseling and information about postnatal care during the ANC session. Additionally, women may set birth plans in consultation with the ANC provider which in turn will increase delivery and postnatal service use [108].

This review had large sample size, which meant that it could detect the effect of ANC on institutional delivery and postnatal care services use. The analysis included all studies conducted in Ethiopia. But this meta-analysis does not address other factors that affect institutional delivery service use and postnatal care. In addition, this meta-analysis did not answer why institutional delivery and PNC services use remained low compared to ANC services use in Ethiopia. Evidence to identify the effect of ANC on PNC is limited. Therefore, we recommended further studies to identify the root cause for the huge difference in the proportion of women who attended ANC and PNC.

Conclusion

This review and meta-analysis revealed that mothers who attended ANC are more likely to use institutional delivery service and postnatal care. Mothers who attended ANC visits were more likely to deliver at health institutions. Similarly, women who attended ANC were more likely to attend postnatal care services. Therefore, the Ethiopian government and other stake holders need to exert collaborative effort to increase ANC service use since it has multiplicative on delivery and postnatal care services use.

Abbreviations

AIDS: 

Acquired immune deficiency syndrome

ANC: 

Antenatal care

DHS: 

Demographic and health survey

EDHS: 

Ethiopian demographic and health survey

HIV: 

Human immune virus

OR: 

Odds ratio

SSA: 

Sub-Saharan Africa

UN: 

United Nations

UNICEF: 

United Nations International Children’s Emergency fund

WHO: 

World Health Organization

Declarations

Acknowledgements

The authors would like to thank all the authors and publishers of the original studies.

Authors’ contributions

GAF conceived the study. GAF and all others (GMK, AKB, AAM, and NAK) involved in the abstraction of the data, analysis, and writing of the study. The final manuscript was read and approved by all authors.

Authors’ information

GAF is an assistant professor of Reproductive and Child health in Bahir Dar University, School of Public Health. GMK, AKB, AAM, and NAK are lecturers in Debremarkos University College of Health Sciences, Adigrat University, College of Health Sciences, University of Gondar, Institute of Public Health and Wolaytasodo University College of health sciences respectively.

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
School of Public Health, College of Medicine and Health Sciences, Bahir Dar University, P.O.Box 79, Bahir Dar, Ethiopia
(2)
College of Health Sciences, Debre Markos University, Debre Markos, Ethiopia
(3)
College of Medicine and Health Science, Adigrat University, Adigrat, Tigray, Ethiopia
(4)
Department of Epidemiology and Biostatistics, Institute of public health, University of Gondar, Gondar, Ethiopia
(5)
Department of Nursing, College of Health Sciences and Medicine, Woliata Sodo University, Woliata Sodo, Ethiopia

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