The study was conducted at Jimma Town Public Hospitals. Jimma town has two public hospitals, namely, Jimma Medical Center and Shanan Gibe Hospital, located 356 km from Addis Ababa, the capital city of Ethiopia. Jimma Medical Center covers approximately fifteen million people in its catchment area in the southwest part of Ethiopia. Jimma Medical Center is the leading teaching and tertiary hospital in Ethiopia, providing services for approximately 15,000 inpatients, 160,000 outpatient attendants, 11,000 emergency cases, and 3888 deliveries annually. Shanan Gibe Hospital is a general hospital; on average, it provides services for 2040 deliveries annually. The total estimated two-month average of women attending delivery and postpartum services at both hospitals was approximately 988 women. The data were collected from July 1-August 31, 2022.
Population, sampling procedure and data collection method
Primary data were collected from facility-based cross-sectional studies conducted at Jimma town public hospitals. The source population of the study included mothers who attended delivery and postpartum service. All mothers who were willing to participate and able to communicate participated in the study. The sample size of the study was determined by using a single population proportion formula. The estimated number of mothers who attended delivery and postpartum services at Jimma University and Shenen Gibe hospitals were taken by considering the average of the one-year monthly reports before data collection started from both hospitals. Then, the sample size was calculated by considering the estimated two-month reporting of both hospitals, which was 988.
The following assumptions were considered during calculations: Za/2= standard score value for 95% confidence level for two-sided normal distribution, which is 1.96; p= the proportion of recommended antenatal care utilization taken from relevant literature, which is 47.5%(20); and d’ margin of error, 0.05.
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fvuZZ8xH67/iz6f4Te73u8rr2edz2d9dUWjUDZKqr6d+tynV8TSwq1NTv97slPFVW+j9Th1YAE3m1m32vZHH9eAo6bTsAJq3jyuvae1853p7Qb5dpaVpvu0/PJ70mARZo+vWpy4e/j8Krxviquq/fbHg78mKtiYU/Z97Ylbu7bPblO9vOPfncesC6bqHc0d7eKqtkar/8j+X+JbPQ2ahBF2Y7rL65vdBmzEJgSmE3U2eTQ3huSj/l8SX1aUXlx1LLadp+eTx4CIRACn43A2aJK8dQf6bnhUvlad99pwrY/dajf8WE9Mw1T63nk+HRRRRC+vzKC8UiQKRMCCppOYquockzySHqU6uTc6nPkJ+dCIARC4DMQUNj0ts7W6m43+u7aq3Ygn4mfkS0x9WQ81Sdln5UeElVbXkB3G46GJIXAUQJODP34a8aJtWVXiV8sjEcmXn0MyFitk2yPT+NJHgIhEAIhEAK7FQ83I/8Mvd/IOs6Zku12+R4CawQcSwgeRJA7S/4PsvrvDxijCqj6rxLYrfLRNDlCDTv/UtUY9vi0TPIQCIEQCIEQ2CWqfBZZt9FmW3Oi5YaVtJ0AN/66i7K95Me2ZGcKAYQYclepjkOPR2NUewjB110vfPVdK/3UfORzbdx/7N5I60IgBEIgBEYEdomqkYOcO4dAvYlHVJ3DNF5CIARCIARC4JUEIqpeSXuhLt9BYzfGxDkeRfnICuHF94guCSUPgRAIgRAIgesQiKi6SF/4J/88jiL5yMn3fer7QAirpBAIgRAIgRAIgWsRiKi6SH/48r8vYCuq6v9V8l2gvM9zkU5LGCEQAiEQAiFQCERUFRivPEQ8sQvFIz0e7/mIjx2pWdK+Cq2Zbc6HQAiEQAiEQAi8lkBE1Wt5/12bu1I+2kMkKa5m4fjOlY8HZ3Y5HwIhEAIhEAIh8D4EIqpezJ1/DeBf+vkPLH3UN3us5/tUPhp8ccipLgRC4AYEfD3A9WXPD7C6LlmedWmUttQz8jeKxx+L1llz18dRDDkXAlclEFH14p7xv3XXl809V/+fkmFFUEkieQiEwIwAfzVc/3LYH2ojIdN9aFvXH8ohcLqw2lpPL6t46vG49vV6eoz5HgJ3IRBR9eKe8leeC1j97999YeEa71rVHSpEFgtWUgiEQAhAQMHS1w8Fy9qOD2tSFWRS5RzXTGfU09cuY+yxW2fyELgbgdydX9xj/gLkvSpEE/9Kob6AznX/D5UCjIWof14cdqoLgRC4KIGZKEKosG74A24Uvo/pRjauVYqyI/VQd/fHuYiqUa/k3J0JRFS9uPfYaeIXIIud/8jThYXz/mLzV2EXU3yvvx5fHH6qC4EQuBiBvqNkeAomxMwsKbzqbri2rkuuSUfqwaeiSv/kvY56LcchcEcCEVV37LXEHAIhEAL/EOCH1kw4LV2juD/eFE4Var+25Gvpmj6x6T8IFVVcqx93xyybPATuQiCi6i49lThDIARCYEBgSdAsXcNVF07Vfb+25GvpGj7dpRqJt1onx+7kb7HtZfM9BN6bQETVe/dA6g+BEAiBAwSWBM3SNarswqmG0a8t+Vq6hjhaul7r9Bj7vqvlteQhcGUCEVVX7p3EFgIhEAIrBGYCxHeqeMQ2Swon8p58NOejuEfqMQZ2n/ak2Uvxe3zENgTeg0BE1XtQT50hEAIhcBIBBMtItLhDNBJMVq3NSHj5yE7bR+pBiPHZm2Z17fUT+xB4NYH9o/3VEaa+EAiBEAiBKYG+o6RhF0We7zkCZvSoDTFUX4DfWw9+8eFOV6939t3drVr3zDbnQ+BqBCKqrtYjiScEQiAEdhJAvCBiTLMdqJHQ8RFg3a1SkHVBtLUeRBq2xLGURqLLGJfK5VoIXJVARNVVeyZxhUAIhMAOAgiU+hk99lOwdLGksKrlZ1VXG457PQq6buf3uivm7pfXyLNDNSOf83cgEFF1h15KjCEQAiEQAiEQApcnEFF1+S5KgCEQAiEQAiEQAncgEFF1h15KjCEQAiEQAiEQApcnEFF1+S5KgCEQAiEQAiEQAncgEFF1h15KjCEQAiEQAiEQApcnEFF1+S5KgCEQAiEQAiEQAncgEFF1h15KjCEQAiEQAiEQApcnEFF1+S5KgCEQAiEQAiEQAncgEFF1h15KjCEQAiEQAiEQApcnEFF1+S5KgCEQAiEQAiEQAncg8D+6WJ76Am0tnwAAAABJRU5ErkJggg==)
The estimated number of mothers who delivered postpartum at Jimma town Public Hospital was 988, for which fewer than 10,000 corrections were used.
![](data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAXcAAABUCAYAAAB5j3fSAAAOHUlEQVR4Ae2di5HUvBKFNwViIAVyIARiIAUyIAMyIAIiIAESIANymFvf1j38vY1sy/JjZPmoasq23jrdfdRqz86+PJyMgBEwAkZgOARehluRF2QEjIARMAIPk7uVwAgYASMwIAIm9wGF6iUZASNgBEzu1gEjYASMwIAImNwHFKqXZASMgBEwuVsHjIARMAIDImByH1CoXpIRMAJGwORuHTACRsAIDIiAyX1AoXpJRsAIGAGTu3XACBgBIzAgAib3AYXqJRkBI2AETO7WASNgBIzAgAiY3AcUqpd0HQR+/vz5+PLly+PDhw+Pl5eX1w/33759Ky7iz58/j69fvz7ev3//pj55lMXEM/18+vTp8e7du9f6XHn+/ft3rOr7AREwuQ8oVC/pOghA6BAuJE+CdEX0meAha8qo/+PHj9f65H3+/PmVuD9+/Phm4RA+/VMu4qdPjfmmsh+GQ8DkPpxIvaArIQDRfv/+/c2UIW7yM1mLmPH0c5In/+vXr79F8vD/Zvz/RpuHNpRc7ucxEDC5HyhHjFSGhPdEwjPjWCzvSR7YgdNw1xdDANJFP9CTmOSJc82JjYA2NYStunEjyP35+foImNwPkqGIneNwNCbuIXgMC2OE/J2MQERAm38majx8dGbKcydco/BL7C/eS+/QQ6exETC5HyhfGZrIPcY+GRZD5TjtZATQFRwCdAWdyMQOQtTRSVChHPIge3RJeSU0IXU8fjYA6ks3S3WdNwYCJvcT5IhBYXzRYLknzx7UCQLofAjpAvrABycg6kqcPqQsZ0H1uc4Re6zPxkHs3uQeUR3z3uR+sFwJwWB8Ofyil2Ol+OnBU3L3HSOA966Xo5mwRew4CyJ/8tgMtCnMLQ1dlJePPprg59C6fpnJ/WAZYqAYXiZxxVX9QvVgAVywe3nyOWQnh4BrTtoQal6SypPPm0fu08/XRsDkfrD85CllEleoxt7TwQK4aPc4BHxiEinLa68ti/W4x9EoORy5np+vjcBb7Tl5LXgOUlgpc8krOXlauw6nF2AciZWmQjUq9/VfBCA0TjvaFNGX/FXBf1v1nYOXjf5H3WDG0o/suctR4JpTSc+ol0+MtFMYx557RnGs56eQO96qlBHlk+GO6E2wpmyk8etoYAFJZc9+LDXbthqRETihK/I8IcYrJ9aCfmALIniucniyTlDG5sZHZeiP8Mikr36iw6QwIWM6/YsA+IibZLvgOnfCRhbUrfnksFkca659iyPzFHKXsUZlBDwWV/I0/hXBNXJkvCXBCAOEK0O9xqrOneUUGYHb1ckdnccGRMLoP8StTayENASP7sQTDO1LXjh6RV+Kx9M/uGFjc2RVGvcOebLJEsmCdyZmYTLXLvaVnTxkGcvn7kvy1fhT16eQuxTTpDYlFucLAcgJpY+OgMp8NQJ7IaDTD0QNL+GYQahxY+Q+b4pyStFTtaNt/MhByTrMM1zIySrWj/fa+PO4Nes+ndwVksBgWYSTEZhDQI7ASCe6ufW67DkIQNwlzxxSjaGTGOJiphB3zssroBy+y/1D3Eukjf6zcbSk08md3U3HD5N7i8ju00ZeEfpicr+P3M9eKTw0R9AxfJL1MD+X5s7mkEMy8s5L9ZUnrmwJydDHKnLXETmTM5OIuxv1SjtSrqd+uLKLOY2DgLwVyVhGgPcS9Qi9yR4NKOR66kfXcZDySq6AgMIz0uPaOWtjmNs8pvrSu5Wp8qX8VeROZ9Fo2X0UN4KcBQAGiNHmBDDx5QP35PFp3Z3yGH7uBwEIWmQsGXPMRFeiM0AeRhAT+kAbtaeNdIWrkxEAAThIOtJyrUUR/aP/tTwlHc76vTQuzjF2AUe2ptXkrp2IhWKg2UuP5I2nnlMUBvdrU2zfIky1aRl77Vxd//F3w0dX+EQvHUORPPLLJmGn8lZCV/st19axtQZfj0MAEsSWWz+1M4No+ZQiEnN94PCi92uTbKPEobV9rSZ3OpahsJvlFMm/ZBSRnFsINrbXPFquLWPntfp5GQF5PFOGodNeSZfoXbIt6dLy6P+1Vz8t19axa+bnOv0jIM5Zqwc6ubaEZHCasZktaRO5Tx1RZEAlMAQUdUywW0R3jbYi96njpcqPIvdroORZ9owARNvifXMahedaQjK0m7KZWqw2kfsUOY9E7lpLz9daYT+jnsi7tNEzH5WPQu4968lec3uGHk2NeXRYBo7Dg47hxKm55PxnhmSYi8k9SyQ972UQR/aTptzVo8jb5F735+lH6sleffekYDES0LK+ubWwcUDQLXFvhWSmohtz43JSYNytyeS+FUG3n0XgbuQ+C4YLL4UAuttCzixSIZm1L2CpzyY19QWDNQBejty37tTa3adCSmvAO6ouu75IUXE3vAe9fFTeUePv2a/W8SzPXfLecp2a+544ua++EMDGWomdlWCreOBrE2Oiqy1hoDyWyT0j8uRndm4IkZcw2v0RuN64ozB7Cf+MpZrcj0MZXUEvhDF6AamUNiOcGekO9Ygj8xxJZE1/x63q+T1vJfYeQjKgeDlyf77oz5uBjFHEzsgi/GiU581o/UginhLh0JvKuZYSRMRnqn2pzV3ydIqFjCBmPtKZ6HXq68mUUYdEWwg+xnZr+xsZ3yViB7+lkAl9oLPCuhYvyWmp/9r+VpO7JsDkowLFAecMUgpEHe6dphHA8KLxUVNkON2qrxLmj6xR+FLSekzuJXTm82RLkUSUFzdD7kv2Juw1itou9af6o13RUT7gUPrgZKHPSy9YdSpaiw/9I6e9HLfV5K4JMAk8gZx0JKG89N3Qpfa5v7s+axONuzhGB65TRNgbVlEXMIpIGsyVZ5E/68rlS+17W28P8ykRObokwuGeBHmRF/WrNP9Sf6V6V85D73TiQQ/nPmA2lyB+2k85vnNt4UvsYa+0itxRhLzwSOAsKJczWe1EOq7EOnsuZi9QeuinpCTKi15ZD3MtzQFdwBCyrKULXHM5zzKKki5RrvalMe+cB2mjF2BU8iwpjxspcpk6TYHjUn8jYQ2HRT2du5/DDEwoRwZrE3gzLs7vXmkVue81qPtZRkAbKR6WkryokvGqjq/3Q0DhFciB+6wfeKYQGGWQCEmbZ8lzX+rvfghfc8Um907lJgOL0xO5Q/gY55IXEdv6fnwEIG50ApKPBK9QaHQUQKOkYxGlqf5iHd/3i4DJvUE2KD0xOozjqISBxpAX4yiUwbEPjyvHqI+ai/u9DgIQuDx4zTo6BcrjukTu1Cn1F/vwfb8ImNxXyAYylWeUDWhFN65qBHZBQDF2eeRRP/XugoFwRuQscE+iDU5C/FJEbX+7TN6dHI6Ayb0SYoyFF1IYgDyhNZ67PCAZYuWwrnZxBI485aFL6CAkDXmLwGNIRvBRN34jRLocT39r+lO/vvaLgMm9UjaERKLXs9Zzx3Bow9VpfASiF71WV8ZHxys8AwGTewPKImp77g3g3aDJ1lMeELEhcEJ0MgKtCJjcG5AzuTeAdqMmW095QGVyv5HCHLRUk3sDsCb3BtBu2qRFV4DK5H5Thdlx2Sb3BjBrDBbjrP3QH6m2fq7XsAQ3OQmBGl0pTQUZOyxTQsZ5tQiY3GuRCvVqDDYT8NyzyD0M4dtBEKjRldJSl8h9Tp+OLCvN1Xl9ImByb5BLi8GqjYm8AfALN5Hc516+U1ZLyPbmL6wMJ0/d5N4AeI3B5m7VxuSekRn7WXI3uY8t5x5XZ3JfKRW+666/UuUPQWp/pVBGbnJfCfjFq0vuc+ReWuJSWKbUxnlGICJgco9ozNzLSKeOz0vHZbWvIXf+wjCOk9vEstKv+s0sw0UnIyC5m9xPBt7Dtf2bPeO2HgEZeSbqqZ4gbf1Zef71R/76EYKPvwsy1Y/zn4dA6ymPGSPfJYfheSvzyFdAwJ57p1LCsPH29I8E9NMHTJd7jL/0GyKdLudW09JGHk9Y8b6GtE3ut1KZQxZrcj8E1u2dQuyQAH/Kng1dYZv4o0/bR3QPPSGQZT41N975lH4QLNdnw4n19IuQ+Z1Rbb3cv5/7Q8Dk3p9MXmeEcUPiEDiGyEeJkA0vc53ujQDEjF4QttNGr3/MEU8HOulB7qoHidM26lFtvXujfp3Vm9w7lJWO9QrF6Ns5+o1uQjU5Dt/hMjylgxGQXkhPNBz6EZ0BiB5nAb2KidMh+Uq19VTf174R+E+yfc/zVrPDyEoeFcaI54VBiuhvBYwX+wYBkbO8cRUqX8+QP2SP566NQJ57/LZVbT3162vfCJjcO5QPxpk9c8VLFYOXkXY4fU/pJASkC+iKCJ5QHo5B9MiZDvqifMr4ZB1bU++kJXqYDQiY3DeAd1TTkmeuUE2Okx41B/d7DQQ45aET6AzkzbO+YaUVQPzk4TTIKdDGED332nrq19e+ETC5dyYfvRArfc1RnhdevJMRmEJAIRiVS6eWYu619dSvr30jYHLvSD7yznVszsYobwsjdDICJQRKL0VLebTNsfnaeqVxndcfAib3/mTiGRmB1QgQbhE54wTERBkOA6EZhWVwHLKHX1sv9u37fhEwufcrG8/MCFQhQJiOkB0vSEXeuSFkrpfyMT6vF7GqX1tP9X3tFwGTe7+y8cyMgBEwAs0ImNyboXNDI2AEjEC/CJjc+5WNZ2YEjIARaEbA5N4MnRsaASNgBPpFwOTer2w8MyNgBIxAMwIm92bo3NAIGAEj0C8CJvd+ZeOZGQEjYASaETC5N0PnhkbACBiBfhEwufcrG8/MCBgBI9CMgMm9GTo3NAJGwAj0i4DJvV/ZeGZGwAgYgWYETO7N0LmhETACRqBfBEzu/crGMzMCRsAINCNgcm+Gzg2NgBEwAv0i8D+0GLDl+TxsegAAAABJRU5ErkJggg==)
Then, by adding a 10% nonresponse rate, the final minimum sample considered for the study was 305.
To obtain individual participants, first, proportional allocation to each hospital was made by considering the recent one-year average delivery and postpartum service utilized, which reached 648 at the Jimma Medical Center and 340 at Shanan Gibe Hospital. Then, the sampling interval (K) was calculated by dividing the total number of women by the above sample size (N/n=988/305=3). Every three mothers attending delivery and postpartum services were interviewed by using a systematic random sampling method after the first respondent was randomly selected via the lottery method.
The data were collected via a structured interviewer-administered questionnaire. . The items regarding the justification of wife-beating, household decision-making participation, and other age-related variables were adapted from the SWPER Global, which was validated by the DHS (21). Seven locus of control items were adapted from Psychological Coping Resources by Pearlin and Schooler(22). Self-esteem was measured by the Rosenberg self-esteem scale(23). Self-efficacy was measured by using the General Self-Efficacy Scale (GSES) developed by Schwarzer and Jerusalem and widely used across the world, including for women’s empowerment, and the reported Cronbach’s alphas were 0.76 - 0.90(24)(25). Women’s participation in the labor force was adapted from a previous study and measured through six items (26). The tool for freedom of mobility has 6 items adapted from previous women’s empowerment research (reported Cronbach’s α = .84)(27). The tool for measuring ANC utilization and sociodemographics was adapted from an existing survey in Ethiopia that reported a Cronbach’s alpha of 0.976(28). The data were collected by three female midwives under the supervision of one more experienced master’s of Scienceholder Midwifery professional. To maintain data quality, a pretest was performed on 10% of the sample population at Wallaga University Referral Hospital before actual data collection. Then, the data collection time was estimated, and tools such as rephrasing difficult-to-understand questions and logical order of questions were modified depending on the pretest.
Study variables, operational definitions and measurements
The dependent variable was ANC antenatal care. The frequency of ANC contact with skilled health care professionals at health facilities was dichotomized based on previous research. A minimum of 4 contacts were coded as “1” or adequate, otherwise coded as “0”(28). The independent variables are child marriage, adolescent pregnancy, education, household decision making, attitudes toward violence, freedom of mobility, locus of control, self-esteem, self-efficacy, participation in the labor force and other covariates, such as personal factors, including parity, pregnancy intentions, and awareness about the importance of ANC. Obstetric factors such as pregnancy complications, family planning utilization, early initiation of ANC, knowledge of danger signs and complications and sociodemographic factors such as residence, age, and religion.
Operational definition
Weekly media exposure: At least once per week, women are exposed to media such as radio, television, the internet and newspapers and are coded as ‘1’ if they utilize other means coded as ‘0’(21,29).
Decision making: The total score for the decision-making power items was 10. Hence, women who scored five or more points were categorized as having high decision-making power and coded as ‘1’, whereas those who scored less than five points were categorized as having low decision-making power and coded as ’0’ (30).
Freedom of mobility responses from the 6 items, which were coded as 0 (not at all), 1 (jointly) or 2 (alone), were summed; those with a total score ≤9 were considered to have low freedom of movement (reported Cronbach’s α = .84)(27) and were coded as 0; otherwise, they were coded as ‘1’.
The self-efficacy tool is composed of ten items scored on a 4-point Likert scale. The overall score ranged from 10 to 40. The participants had to choose between four alternatives scored as exactly true =4, moderately true =3, hardly true=2, and not all true=1. A participant was considered to have a high score if she scored greater than 25 and was coded as ‘1’ unless it was coded as ‘0’.
Self-esteem The scale is composed of ten items scored on a 4-point Likert scale ranging from strongly agree (4) to agree (3), disagree (2), and strongly disagree (1). The five negative statements were reverse coded. The participants were dichotomized as having low or high self-esteem if their score ranged from 10 to 25 and as having high self-esteem if she scored from 25 to 40.
Locus of control seven-point scale items were used, and a single index for locus of control was created. The total score thus ranged from 5 to 35, with scores greater than 17.5 indicating a more internal locus of control and being coded as ‘1’; otherwise, they were coded as ‘0’.(31)
Women’s participation in labor work All items are scored from 18 points, and if a woman scored less than 9 points, she was disempowered and coded as “0”, while if she scored greater than 9 points, she was coded as “1” and empowered(26).
Postpartum care: Postpartum care is care that is provided to a mother and newborn baby after delivery and within the first 42 days after childbirth. This study included women who were in the immediate postpartum period (within the first 24 hours after delivery)(32).
Knowledge of danger signs and complications: Respondents were asked multiple-choice questions about danger signs of pregnancy and complications, and those who correctly mentioned greater and 5 were categorized as having good knowledge about danger signs or complications, respectively.(28,30)
Education: Depending on their year of schooling, they were coded as ‘0’ no formal education, ’1’ elementary, ’2’ secondary, and ‘3’ tertiary or above.
Data analysis, processing and presentation
The data were checked, coded and edited properly, entered into Epidata Version 4.6 and then exported to SPSS Version 26 for analysis. Then, the data were recoded for analysis, and further cleaning was performed. Descriptive analysis was performed. Then, the variables were categorized depending on their operationalization and recoded. All women’s empowerment dimensions and other covariates were entered into bivariate logistic regression analysis, and independent variables with P<0.25 were considered candidates for multivariable logistic regression analysis. According to the multivariate logistic regression model, variables with P<0.05 were considered to be significantly associated with antenatal care utilization. The Hosmer and Lemeshow goodness of fit test revealed that the selected model was a good model fit for the data set since the P value was 0.316. The relationship between women’s empowerment dimension and ANC4+ utilization was evaluated after adjusting for the covariates by using an adjusted odds ratio at a 95% confidence interval and a P value < 0.05 to declare significant associations. Finally, the findings are presented in the text, tables, and graphs.