Minimizing the burden of preventable maternal mortality and morbidity must be accompanied by improvements along the continuum of care for mothers and children(1). The maternal and child health continuum of care involves integrated service delivery for mothers and children from prepregnancy to delivery, the postnatal period, and childhood, with evidence-based interventions along the continuum of care, organized by lifecycles and place of service delivery to improve maternal and child health(2, 3). The continuation of care throughout pregnancy, birth and after delivery has become a key program strategy for improving the health of mothers and newborns(2). It can reduce the yearly toll of half a million maternal deaths, 4 million neonatal deaths and 6 million child deaths(2).
Globally, an estimated 287,000 mothers died during and following pregnancy and childbirth in 2020. However, an estimated 800 mothers continue to die each day due to pregnancy and childbirth, with the majority of deaths occurring in low- and middle-income countries(4).
The status of the continuum of care (CoC) for maternal health care in low- and middle-income countries shows a decline in the use of services as mothers move along the continuum of care from pregnancy to childbirth and postnatally, and the greatest gap was observed between institutional delivery and postnatal care. The completion status differs from country to country(5).
A study conducted in Nepal showed that more than 41% of mothers received all three maternal and newborn health visits (at least four ANC visits, institutional delivery, and postnatal care (PNC) visits) across the CoC. There was a high risk of discontinuity of care during months or weeks prior to childbirth or around childbirth(6).
According to a study conducted in Cambodia, 60% of mothers received all three types of maternal care for their most recent birth(7). Approximately 52.6% of people in Indonesia continue to receive three levels of services: maternal, neonatal and child health (MNCH)(8). However, in India, only 17% of pregnant mothers utilized complete care, and 83% either did not seek any care or dropped out after seeking one or two services (9). Similarly, in Lao PDR, only 6.8% of mothers continued to receive all MNCH services(10).
Results in 17 sub-Saharan African (SSA) countries on the continuum of care for maternal, newborn, and child health show that only 3.4% of women completed all of the 11 maternal, newborn, and child health care interventions along the continuum of care (11). However, a multicountry analysis of recent demographic and health surveys in SSA showed that the pooled prevalence of completion of the maternity continuum of care was 35.81% (12). The lack of suitable care at all levels of the continuum has been related to unfavorable maternal and child health outcomes (2, 13). In SSA, only 25% of mothers received all CoCs from ANC to PNC, which varied from 17.9.0% in East Africa to 51.5% in southern Africa(14). In Kenya and Uganda, approximately 23% of neonatal deaths are attributable to an inadequate continuum of care (15).
Studies conducted in different regions of African countries on the continuum of care show wide gaps between countries. In Zambia, approximately 38.0% of mothers had a complete continuum of maternal healthcare(16). In Ghana, only 7.9% of mothers and children achieve continuous care throughout the pregnancy, delivery and postdelivery stages(17). Similarly, findings in Nigeria showed that only 6.5% of mothers completed the essential continuum of care. However, the decrease in the pathway increased from 17.5% at ANC to 20.2% at SBA and 30.9% at PNC(18). Another study conducted in Tanzania showed that only 10% of mothers received the recommended care package (at least four ANC visits, SBA, and at least one PNC visit), while 1% reported not having care at any stage (19). In Rwanda and Egypt, 33.8% and 50.4% of mothers, respectively, had a complete continuum of care(20, 21).
According to findings in Ethiopia, the prevalence of completion of maternity CoC was 25.82% (22). Another similar study reported that the pooled prevalence of maternal healthcare service utilization on a complete continuum was 25.51%(23). According to the 2016 EDHS, approximately 9.1% of mothers complete the CoC(24). Another study showed that among mothers who initiated ANC visits, only 6.56% of mothers used the entire continuum of care(25).
Different studies conducted in southern Ethiopia revealed that, overall, only 15.5% of women in Arba Minch Zuriya (9.7%) (26), only 11.3% in Hadiya (27) and only 15.5% in Guragie completed all components of the continuum of care (28). The proportion of women who completed the maternity care continuum in the Amhara region also varied in different study areas. For instance, it ranges from 6.9% in Gondar zuriya and Wogera, 11.2% in South Wollo, Legambo district, 21.60% in North Gondar, 37.2% in Debre Birhan, 37.6% in Ebinat and 45% in the Enemay district, East Gojjam (29–34). Generally, in Ethiopia, only 32% of mothers had at least four ANC visits during their last pregnancy, only 26% used institutional delivery, and 17% of mothers and 13% of newborns received PNC, suggesting high dropout rates between each care level(35). However, maternal and health care utilization is still low in relation to the effort taken, and the completion of CoC status is not well known(5).
Studies have shown that sociodemographic factors are significantly associated with all elements of the continuum of maternal health care (36). The mothers age (19, 21), residence (9, 15, 19, 22, 27), educational status (9, 11, 12, 15, 16, 20, 21, 23, 27, 29, 34), marital status (20, 25), socioeconomic status (17, 19–22, 25, 27), employment status (23–26), and exposure to media (9, 11, 15, 20–22, 25, 28, 34) and mothers’ autonomy in decision-making (11, 12, 15, 22, 24, 27, 29) significantly contributed to the utilization of a continuum of maternal health care services. The maternal and child health continuum of care was determined by different maternal and child health service-related factors. Previous studies revealed that distance to the health facility (11, 12, 15, 19, 20, 22, 25, 28, 34), previous health provider counseling (19), maternal health service provision during pregnancy (21, 24, 37), newborn immunization (37), pregnancy complication status (12, 24, 25, 27, 29) and health insurance coverage (11, 20, 24, 34) also affect the continuity of care. Moreover, obstetric-related factors such as early initiation of antenatal care visits (11, 12, 16, 22, 23, 26–29, 38), a history of pregnancy termination (12), maternal complications during pregnancy (17, 20, 21, 25, 27, 39), parity and birth order (20, 21, 27) and complicated delivery (19) also affect the continuum of care. Prepregnancy contraceptive utilization, birth preparedness and complication readiness, and having a planned pregnancy were significantly associated with the completion of maternity continuum care in Ethiopia (22, 23, 26–29, 38).
The World Health Organization and United Nations Population Fund (UNFPA) launched the Ending Preventable Maternal Mortality Initiative by 2025 to help countries reduce preventable maternal deaths by strengthening tailoring responses for maternal health along the continuum of care (40, 41). However, worldwide, there is currently an off-track need to meet sustainable development goals (SDGs) targets 3.1 and 3.2 for reducing maternal deaths by 2030. Hence, the maternal and child continuum of care provides a systematic framework for delivering effective interventions at different levels of service delivery during pregnancy, childbirth and the postpartum period at various levels of service delivery(42). A greater emphasis on the continuum of care for maternal health and child health services to mothers before and after giving birth, as well as to infants and children, is vital to effectively decrease unfavorable health outcomes(43).
Completion of maternal CoC is very low, and non-adherence to the continuum of care remains a significant challenge in Ethiopia(34). This number is very low compared to findings from most resource-limited settings(34, 44). Although studies have been carried out on the level of the continuum of care, most studies have focused only on maternal health services (14, 30, 31, 34, 39, 44), and the completion of the comprehensive MCH continuum of care is not well known. It is crucial to obtain evidence about the status of the MCH continuum of care and contributing factors to strengthen health systems for a holistic approach to reduce adverse maternal and child health impacts.
Maternal and child health services are inseparably linked, and an integrated approach to care is essential(7). The maternal and child health continuum of care is an essential approach for considering mothers and children as units rather than as separate individuals(45). As a result, it is imperative to assess the completion of the MCH continuum of care by considering additional maternal and child health continuums of care measurement indicators, such as childhood immunization, breastfeeding practices for children and modern family planning methods for mothers. Successful program implementation to improve the continuum of care relies on a better understanding of the level of maternal and child health continuum of care, identifying where the gaps are in seeking care along the pathway and what factors contribute to the gaps(7). The identification of possible factors for the completion of the MCH continuum of care in the area will have a greater impact on the design of different programs that are effective at increasing awareness of risk factors for the community and improving the completion of the MCH continuum of care. Therefore, this study aimed to assess the comprehensive maternal and child health continuum of care and associated factors among mothers who had children aged 12–23 months in the West Gondar Zone, Northwest Ethiopia.