Open access Original research Simegnew Handebo ‍ ‍, Takele Gezahegn Demie, Getachew Tilahun Gessese, Berhanu Teshome Woldeamanuel, Tolesa Diriba Biratu To cite: Handebo S, Demie TG, Gessese GT, et al. Effect of women’s literacy status on maternal healthcare services utilisation in Ethiopia: a stratified analysis of the 2019 mini Ethiopian Demographic and Health Survey. BMJ Open 2023;13:e076869. doi:10.1136/ bmjopen-2023-076869 ► Prepublication history for this paper is available online. To view these files, please visit the journal online (http://dx.doi.​ org/10.1136/bmjopen-2023-​ 076869). Received 21 June 2023 Accepted 07 November 2023 © Author(s) (or their employer(s)) 2023. Re-­use permitted under CC BY-­NC. No commercial re-­use. See rights and permissions. Published by BMJ. School of Public Health, St Paul's Hospital Millennium Medical College, Addis Ababa, Ethiopia Correspondence to Simegnew Handebo; ​simegnewh@​gmail.c​ om ABSTRACT Objectives Maternal mortality remains unacceptably high in sub-­Saharan Africa with 533 maternal deaths per 100 000 live births, accounting for 68% of all maternal deaths worldwide. Most maternal deaths could be prevented by adequate maternal health service use. The study examined the effect of literacy status on maternal health services utilisation among reproductive-­age women in Ethiopia. Design A cross-­sectional study. Settings Ethiopia. Participants A weighted sample of 3839 reproductive-­ age women who gave birth in the last 5 years preceding the survey and whose literacy status was measured were included in this study. The survey used a two-­stage stratified cluster sampling technique. Primary and secondary outcome measures This study used a dataset from the recent Ethiopia Mini Demographic and Health Surveys. We assessed the maternal health service utilisation among reproductive-­age women. Multivariable logistic regression analyses were employed to assess the association between literacy status and maternal healthcare utilisation while controlling for other factors. Adjusted OR with a 95% CI was reported. Results About 63.8% of reproductive-­age women were illiterate. The prevalence of antenatal care (ANC) 1, ANC 4, skilled birth attendance and postnatal care (PNC) services utilisation was 74.9%, 43.5%, 51.9% and 32.0%, respectively. Literate women had significantly higher ANC 1, ANC 4, skilled birth attendance, and PNC services utilisation than illiterate women (p<0.001). Regional variation, wealth status, age at first birth, birth order and birth intervals were significantly associated with maternal healthcare utilisation among both literate and illiterate women. Similarly, ANC booking timing and utilisation, age of household head and religious affiliation were associated with institutional delivery and PNC utilisation. Conclusion Literate women had a significantly higher maternal healthcare services utilisation than illiterate, modified by sociodemographic and obstetric-­related factors. Hence, wholehearted efforts should be directed towards educating and empowering women. STRENGTHS AND LIMITATIONS OF THIS STUDY ⇒ The study used three reproductive healthcare utili- ⇒ ⇒ ⇒ ⇒ sation (ie, antenatal care, institutional delivery, and postnatal care) to measure maternal healthcare utilisation among reproductive-­age women in Ethiopia. The study used recent nationally representative data with a large sample size and the findings are generalisable to reproductive-­age women in Ethiopia, which will help policy-­makers and programmers create interventions at the national level. The Ethiopia Mini Demographic and Health Surveys relied on women’s reports, which might have social desirability and recall biases. The cross-­sectional nature of the study did not allow us to infer the temporal relationship between maternal healthcare service utilisation and the exposure variables. Since this study was a secondary analysis of Demographic and Health Survey data, important variables like access to healthcare facilities and the distribution of maternity healthcare services were not assessed. INTRODUCTION Globally, maternal mortality declined by 38% from 2000 to 2017. Yet, over 800 women continue to die each day due to pregnancy and childbirth-­related complications with the majority of deaths in low-­income and middle-­ income countries. The Sustainable Development Goals (SDGs) 3.1 sets out a goal to reduce the global maternal mortality ratio (MMR) to less than 70 per 100 000 live births, and not more than 140 per 100 000 live births in any country by 2030.1 2 Given the current progress, the world will fall short of the global SDG target by more than one million lives. Even though many nations have achieved tremendous progress, inequitable coverage of essential maternal and perinatal health Handebo S, et al. BMJ Open 2023;13:e076869. doi:10.1136/bmjopen-2023-076869 1 BMJ Open: first published as 10.1136/bmjopen-2023-076869 on 27 November 2023. Downloaded from http://bmjopen.bmj.com/ on July 24, 2024 by guest. Protected by copyright. Effect of women’s literacy status on maternal healthcare services utilisation in Ethiopia: a stratified analysis of the 2019 mini Ethiopian Demographic and Health Survey Open access Study population and sampling procedure The study used stratified and two-­ stage cluster sampling methods. First, each region was stratified into urban and rural areas. A total of 305 enumeration areas (EAs) (93 in urban and 212 in rural areas) were selected with probability proportional to the size of EA (number of households in EA) and with an independent selection in each sampling stratum. A household listing was carried out in all selected EAs from January through April 2019. In the second stage, a fixed number of 30 households per cluster were selected with an equal probability of systematic selection from the created household list. In the survey, 8663 households and 8855 women of reproductive age (aged 15–49) were included. All women aged 15–49, who were either permanent residents of the selected households or visitors who slept in the household the night before the survey, were eligible for the interview. A weighted sample of 3839 women who gave birth within 5 years preceding the survey and whose literacy status was measured in the survey was included in this study. Those women whose literacy status was not assessed were excluded from this analysis. The detailed 2 Handebo S, et al. BMJ Open 2023;13:e076869. doi:10.1136/bmjopen-2023-076869 Data source This study is based on data from the 2019 EMDHS, a national community-­based cross-­sectional study conducted from 21 March to 28 June 2019. The 2019 EMDHS is the second EMDHS and the fifth DHS conducted in Ethiopia. The Ethiopian Public Health Institute conducted the survey in collaboration with the Central Statistical Agency and the Federal Ministry of Health, with technical and financial support from development partners. The 2019 EMDHS generates data for measuring the progress of the health sector goals set under the Growth and Transformation Plan, which is closely aligned with the SDGs. BMJ Open: first published as 10.1136/bmjopen-2023-076869 on 27 November 2023. Downloaded from http://bmjopen.bmj.com/ on July 24, 2024 by guest. Protected by copyright. METHODS Study setting The study was conducted in Ethiopia. Ethiopia is the second-­most populous country in Africa, next to Nigeria with an estimated population of 114.96 million in 2020. Ethiopia is federally decentralised into nine regions and two city administrations.21 In the country, 48.9% (31,370,865) of adults (aged 15 years or above) are literate. Approximately 41.1% of the adult female population are literate. Youth literacy rates were 71.1% and 67.8% among males and females, respectively.22 23 Regarding the healthcare system, Ethiopia’s health service is structured into a three-­tier system: primary, secondary, and tertiary levels of care. A primary healthcare unit comprises four health centres, five health posts within each health centre and a primary hospital. Each health post is responsible for a population of 3000–5000 people. The secondary level of care consists of general hospitals, which are referral centre for primary hospitals. The tertiary level of care comprises federally-­run, specialised, and university hospitals.24 interventions continues to be a barrier in many places. To promote maternal health and well-­being and meet the SDG objective for MMR, a worldwide multipartner initiative called Strategies for Ending Preventable Maternal Mortality was launched in 2015.1–4 Ethiopia has achieved significant improvements in maternal and child health.5 Ethiopia’s National Health Care Quality Strategy for 2016–2020 placed an ambitious goal to reduce the MMR from 412 to 199 per 100 000 live births by 2020. Maternal health service utilisation has been endorsed as the cost-­effective approach to alleviating the burden of maternal deaths.6 However, completion of the maternal health continuum of care is very low in Ethiopia and most are with considerable dropouts.7 The Ethiopian Demographic Health Survey 2016 reported that 62% of pregnant women had at least one antenatal care (ANC) visit, 26% had skilled delivery, and 16.5% of women received postnatal care (PNC).8 The EMDHS reported that 74% of women received at least one ANC, 43% had four or more ANC visits, 50% had a skilled birth attendance and 34% received PNC.9 Literacy is a strong predictor of maternal healthcare services utilisation.10 The literature also revealed an association between literacy and ANC, skilled birth attendance and PNC services utilisation.11 A study done in India revealed that literate women are more likely to receive ANC services than illiterate women. Literacy has an important role in improving institutional delivery and reducing postdelivery complications.12 Yadav et al and Amwonya et al reported maternal education, even at the primary level, is linked with a positive impact on maternal healthcare utilisation.13 14 Moreover, extended women’s years of schooling are associated with improved ANC utilisation, reduced maternal complications and short childbirth intervals, and unwanted pregnancies. It also enables women to have a good understanding, of economic resources, and autonomy to seek care.15 In Ethiopia, educational status of women is associated with a higher utilisation of a continuum of maternal healthcare services.16–18 Similarly, in sub-­Saharan African countries, encouraging female school enrolment is recommended to enhance ANC service utilisation.19 In contrast, a review found no association between PNC services use and mothers’ education.20 According to Dimbuene et al, the relationship between women’s education and maternal healthcare utilisation is largely contingent on socioeconomic circumstances at the household level, and the availability of maternal healthcare services across the nation. The household socioeconomic circumstance depicts the inequities in access to high-­quality maternal health services.11 In Ethiopia, the percentage of women with no education has decreased from 75% in 2000 to 40% in 2019.9 Hence, the study investigated the impact of women’s literacy on maternal healthcare service utilisation using three proxy measures of maternal healthcare utilisation namely: ANC, skilled birth attendance; and PNC services utilisation. Open access Measurement of variables The dependent variable of the study was maternal health service utilisation among reproductive-­age women. We used three basic reproductive health services namely: ANC, institutional delivery and PNC as a proxy measure of maternal health service utilisation. We categorised this variable into ‘Yes’ (when a woman had received the three services at a health facility) and otherwise ‘No’. The exposure variable was literacy status and other covariates/ independent variables were maternal age, marital status, religion, region, wealth index, place of residence, family size, sex of head of households, age of household head, births in the last 5 years, total children ever born, number of living children, age of respondent at first birth, number of under-­5 children, sex of the recent newborn, birth order, ANC 1, ANC 4, timing of first ANC and birth interval. The detailed categorisations of dependent and independent variables were presented in table 1. Table 1 List of variables used for analysis and their definition and measurement based on the 2019 Ethiopian Demographic Health Survey Variable name Description Maternal health service utilisation The utilisation of maternal health services is defined as a woman visiting and receiving care: ANC visits during pregnancy, institutional delivery and PNC visits within 42 days from health facilities and skilled professionals. ANC visits the women had in their recent pregnancy regardless of whosoever the provider of ANC service was. ANC was categorised as ‘Yes’ or ‘No and ANC 4 was coded ‘less than 4 ‘No’ and ‘4 and more’ as ‘Yes’. Antenatal care visits Institutional delivery Institutional delivery for the last child was categorised as ‘Yes’ for deliveries at governmental, private, and non-­governmental health facilities, and ‘No’ for home or other place deliveries. Postnatal care Postnatal care is the care given to the mother and newborn following birth until 42 days. Its response was categorised as ‘yes’ or ‘no’ Literacy status Literacy level was recoded as ‘Literate’ for women who had attended higher than secondary school and those who were able to read all or part of the sentence and ‘illiterate’ for the women who could not read at all. Place of residence It is the designation of the cluster or enumeration area as an urban area or a rural area. Maternal age The age of the women in the year was categorised as less than 24, 25–34 and 35–49 Religion Religion was categorised as Muslim, Orthodox, Protestant, and Others (catholic and traditional) Region The region where the mother resides is recorded as Tigray, Afar, Amhara, Oromia, Somali, Benishangul, South Nation Nationalities and Peoples (SNNP) (including newly formed Sidama and Southwest Ethiopia regions), Gambella, Harari, Addis Ababa, and Dire Dawa Sex of household head Women were asked who is the head of the household and answered as male/female Wealth index The wealth index was calculated using data on a household’s ownership of selected assets. Each household asset is assigned a weighted score generated through principal components analysis. The scores were standardised and summed, and it was grouped as poorest, poorer, middle, richer and richest. Family size It is the number of household members; recoded as ≤5 and above 5. Births in the last 5 years This variable is recoded as 1 birth, 2 births and 3 and above births Age of the respondent at first birth Recoded as less than 18 years, 18–24 years, and 25 and above years Age of household head Recoded as less than or equal to 29 years, 30–44, 46–59, and 60 and above years Birth order Birth order is the order number of the births from first to last, Recoded as less than or equal to 3, 4–6 and 7 and above. Birth interval The birth interval was defined as the duration of months between the birth of the index child and the subsequent live birth. It was recorded as a short birth interval for a birth interval less than 24 months, an optimal birth interval for 25–59 months, and a long birth interval for 60 and above months of birth interval. Timing of first antenatal check Timing for the first ANC ANC, antenatal care. Handebo S, et al. BMJ Open 2023;13:e076869. doi:10.1136/bmjopen-2023-076869 3 BMJ Open: first published as 10.1136/bmjopen-2023-076869 on 27 November 2023. Downloaded from http://bmjopen.bmj.com/ on July 24, 2024 by guest. Protected by copyright. methodological procedure was presented in the full EMDHS 2019 report.9 Open access of illiterate and 51.2% of literate women had used PNC services (p<0.001). A significant association was observed between women’s literacy status and maternal healthcare utilisation among reproductive-­age women in Ethiopia (p<0.001). Prevalence of maternal health service utilisation In this study, ANC 1, ANC 4, skilled birth attendance and PNC utilisation with 95% CI was 74.9% (73.5% to 76.2%), 43.5% (42.0% to 45.1%), 51.9% (50.3% to 53.4%) and 32.0% (30.6% to 33.5%), respectively. ANC 1 visit was significantly higher among literate women (87.9%) than illiterate counterparts (67.5%) during their last pregnancy (p<0.001). Similarly, a significantly higher proportion of literate women (73.3%) gave birth at health facilities as compared with illiterate women (39.7%) during their recent pregnancy (p<0.001). Only 21.1% Factors associated with maternal health service utilisation Antenatal care In multivariable analysis, the odds of ANC utilisation were 2.33 and 2.01 times higher among illiterate women aged 25–34 years (AOR=2.33; 95% CI 1.57 to 3.45) and 35–49 years (AOR=2.01; 95% CI 1.22 to 3.33) as compared with illiterate women aged less than 24 years, respectively. The odds of ANC utilisation was 80% (AOR=0.20; 95% CI 0.07 to 0.53), 67% (AOR=0.33; 95% CI 0.17 to 0.62), 81% (AOR=0.19; 95% CI 0.10 to 0.39), 95% (AOR=0.05; 95% CI 0.02 to 0.12), and 75% (AOR=0.25; 95% CI 0.12 to 0.50) lower among illiterate women living in Afar, Amhara, Oromia, Somali and SNNP regions as compared with illiterate women living in Tigray region, respectively. The odds of ANC utilisation among illiterate women from households with poorer, middle, richer and richest wealth status were 2.00 (AOR=2.00; 95% CI 1.54 to 2.61), 2.78 (AOR=2.78; 95% CI 2.05 to 3.77), 2.93 (AOR=2.93; 95% CI 2.11 to 4.08), and 3.56 (AOR=3.56; 95% CI 2.06 to 6.17) times higher as compared with those from households with poorest wealth status. Illiterate women living in female-­headed households have 28% (AOR=0.72; 95% CI 0.59 to 0.88) lower odds of ANC utilisation as compared with their counterparts. Illiterate women aged 25 years and higher during their first birth were 57% (AOR=0.43; 95% CI 0.26 to 0.71) less likely to use ANC than illiterate women who had their first birth before the age of 18 years old. The odds of using ANC were 39% (AOR=0.61; 95% CI 0.43 to 0.87) and 57% (AOR=0.43; 95% CI 0.27 to 0.66) lower for birth orders of four to six and seven and above when compared with birth orders of less than three, respectively. A month increase in the birth interval was associated with 1.01 (AOR=1.01; 95% CI 1.001 to 1.011) times higher odds of ANC utilisation (table 3). The odds of ANC utilisation were two times higher among literate women aged 25–34 years (AOR=2.01; 95% CI 1.15 to 3.52) as compared with those aged less than 24 years. The odds of ANC utilisation among literate women living in rural areas were 3.24 (AOR=3.24; 95% CI 1.88 to 5.59) times higher than the urban counterparts. The odds of ANC utilisation was 88% (AOR=0.12; 95% CI 0.03 to 0.45), 98% (AOR=0.02; 95% CI 0.002 to 0.11), and 95% (AOR=0.05; 95% CI 0.01 to 0.18) lower among literate women living in Oromia, Somali and SNNP regions as compared with those living in Tigray region, respectively. The odds of ANC utilisation among literate women from households with poorer, middle, richer and richest wealth status were 3.72 (AOR=3.72; 95% CI 1.88 to 7.36), 6.26 (AOR=6.26; 95% CI 3.41 to 11.47), 14.70 (AOR=14.70; 95% CI 7.54 to 28.66), and 94.10 (AOR=94.10; 95% CI 37.30 to 237.35) times higher as compared with poorest wealth status. The 4 Handebo S, et al. BMJ Open 2023;13:e076869. doi:10.1136/bmjopen-2023-076869 Patient and public involvement This research was done without involving the patient in the design and implementation. RESULTS Sociodemographic characteristics of the respondents A total of 3839 reproductive-­age women were included in the analysis. Three-­ fourths (74.1%) of them were rural residents. About one-­third (30.4%) of women were aged 25–29 years. About (37.5%) were affiliated with the Orthodox religion and 39.5% were from the Oromia region. More than half (51.2%) of the women had no education and only 4.0% attended higher education. Nearly half (50.2%) of the women had more than five family size. In this study, 21.1% of women were living in low-­ income households. The majority (87.3%) of the women live in male-­headed households (table 2). Obstetric-related characteristics of the respondents More than half (53.7%) and 56.8% of the respondents had one to three ever-­born and live children, respectively. Out of the respondents, 52.5% were aged less than 18 years during their first birth. About 64.4% of the women had one birth in the past 5 years. More than half (52.3%) of women had a male child of their recent birth. The literacy status of the respondents Concerning the literacy status, nearly two-­thirds (63.8%) of reproductive-­age women were illiterate. BMJ Open: first published as 10.1136/bmjopen-2023-076869 on 27 November 2023. Downloaded from http://bmjopen.bmj.com/ on July 24, 2024 by guest. Protected by copyright. Data management and analysis The weighted data were used for the analysis to get reliable statistical estimates that compensate for the unequal probability of selection between strata and the non-­response rate among study participants. Descriptive and summary statistics were conducted using STATA V.14 software. A detailed explanation of the weighting procedure can be found in the EMDHS methodology report.9 Multicollinearity was checked using variance inflation factors and the value of all variables in the final model was less than 5. Bivariate and multivariable binary logistic regression was employed. Variables having a p value of less than 0.25 in the bivariate analysis were candidates for the multivariable logistic regression analysis. Adjusted OR (AOR) with corresponding 95% CI were reported. The threshold for statistical significance was set at p<0.05. Open access Variable Description Weighted frequency (n) Per cent (%) Age of the respondents Less than 24 25–34 968 1948 25.2 50.8 35–49 923 24.0 Urban 996 25.9 Rural 2843 74.1 Single 20 0.5 Married 3604 93.9 Separated/widowed/divorced 215 5.6 No education 1967 51.2 Primary 1381 36 Secondary 338 8.8 Place of residence Marital status Educational level Religion Higher 153 4 Muslim 1273 33.2 Orthodox 1439 37.5 Protestant 1064 27.7 Others 63 1.6 Tigray 286 7.5 Afar 51 1.3 Amhara 839 21.9 Oromia 1516 39.5 Somali 155 4 Benishangul 46 1.2 SNNPR 776 20.2 Gambela 12 0.3 Harari 11 0.29 Addis Ababa 125 3.2 Dire Dawa 21 0.6 ≤5 1913 49.8 >5 1926 50.2 Poorest 777 20.2 Poorer 807 21.1 Middle 754 19.6 Richer 699 18.2 Richest 802 20.9 Male 3350 87.3 Female 489 12.7 ≤ 29 812 21.1 30–44 2068 53.9 45–59 ≥ 60 675 284 17.6 7.4 * Region Family size Wealth index Sex of household head Age of Household head *Catholic and traditional. odds of ANC utilisation was 2.71 (AOR=2.71; 95% CI 1.68 to 4.36) times higher among literate women aged 18–24 years during their first birth than literate women aged below 18 during their first birth. Literate women aged 25 years and higher during their first birth were 67% (AOR=0.33; 95% CI 0.14 to 0.82) less likely to use Handebo S, et al. BMJ Open 2023;13:e076869. doi:10.1136/bmjopen-2023-076869 5 BMJ Open: first published as 10.1136/bmjopen-2023-076869 on 27 November 2023. Downloaded from http://bmjopen.bmj.com/ on July 24, 2024 by guest. Protected by copyright. Table 2 Sociodemographic characteristics of reproductive-­age women who gave birth in the last 5 years in Ethiopia, 2019 (n=3839) Open access ANC utilisation Illiterate Variables Age of the respondent Place of residence Religion Region Family size Wealth index Sex of household head Sex of the current child Age at first birth Description COR (95% CI) Literate AOR (95% CI) COR (95% CI) AOR (95% CI) Less than 24 1 1 1 1 25–34 1.21 (0.97 to 1.52) 2.33 (1.57 to 3.45)* 1.52 (1.06 to 2.16) 2.01 (1.15 to 3.52)* 35–49 0.81 (0.64 to 1.04) 2.01 (1.22 to 3.33)* 0.70 (0.44 to 1.11) 0.83 (0.34 to 2.01) Urban 1 1 1 1 Rural 0.59 (0.46 to 0.76) 0.82 (0.57 to 1.17) 0.64 (0.45 to 0.89) 3.24 (1.88 to 5.59)* Muslim 1 1 1 1 Orthodox 2.58 (2.09 to 3.18) 0.95 (0.65 to 1.39) 1.89 (1.20 to 2.96) 0.74 (0.40 to 1.39) Protestant 1.59 (1.29 to 1.96) 0.81 (0.60 to 1.08) 0.56 (0.37 to 0.83) 1.29 (0.73 to 2.28) Others 0.67 (0.38 to 1.16) 0.57 (0.31 to 1.04) 0.16 (0.05 to 0.57) 0.26 (0.06 to 1.20) Tigray 1 1 1 1 Afar 0.14 (0.06 to 0.31) 0.20 (0.07 to 0.53)* 0.31 (0.02 to 5.90) 1.33 (0.05 to 37.38) Amhara 0.37 (0.20 to 0.68) 0.33 (0.17 to 0.62)* 0.52 (0.15 to 1.80) 0.54 (0.14 to 2.05) Oromia 0.17 (0.10 to 0.31) 0.19 (0.10 to 0.39)* 0.16 (0.05 to 0.51) 0.12 (0.03 to 0.45)* Somali 0.03 (0.02 to 0.07) 0.05 (0.02 to 0.12)* 0.02 (0.004 to 0.07) 0.02 (0.002 to 0.11)* Benishangul 0.35 (0.12 to 0.99) 0.50 (0.15 to 1.62) 0.31 (0.04 to 2.63) 0.46 (0.04 to 5.21) SNNPR 0.25 (0.14 to 0.46) 0.25 (0.12 to 0.50)* 0.06 (0.02 to 0.17) 0.05 (0.01 to 0.18)* Gambela 0.46 (0.05 to 4.47) 0.38 (0.03 to 5.80) 0.28 (0.01 to 6.57) 0.28 (0.01 to 10.01) Harari 0.25 (0.04 to 1.436) 0.18 (0.02 to 1.33) 0.35 (0.01 to 21.07) 0.11 (0.001 to 11.25) Addis Ababa 1.13 (0.22 to 5.88) 0.84 (0.04 to 16.94) 0.73 (0.15 to 3.57) 0.27 (0.05 to 1.61) Dire Dawa 0.29 (0.07 to 1.24) 0.32 (0.06 to 1.72) 0.44 (0.02 to 10.04) 0.16 (0.01 to 4.79) ≤5 1 1 1 1 >5 0.58 (0.49 to 0.69) 0.79 (0.59 to 1.08) 0.47 (0.34 to 0.65) 0.65 (0.39 to 1.06) Poorest 1 1 1 1 Poorer 2.37 (1.89 to 2.96) 2.00 (1.54 to 2.61)* 5.40 (3.00 to 9.74) 3.72 (1.88 to 7.36)* Middle 3.13 (2.43 to 4.04) 2.78 (2.05 to 3.77)* 4.94 (3.02 to 8.10) 6.26 (3.41 to 11.47)* Richer 3.40 (2.59 to 4.48) 2.93 (2.11 to 4.08)* 8.58 (5.06 to 14.55) 14.70 (7.54 to 28.66)* Richest 7.61 (4.93 to 11.73) 3.56 (2.06 to 6.17)* 35.30 (19.00 to 65.60) 94.10 (37.30 to 237.35)* Male 1 1 1 1 Female 0.73 (0.56 to 0.95) 1.01 (0.71 to 1.44) 1.49 (0.91 to 2.43) 0.86 (0.45 to 1.66) Male 1 1 1 1 Female 0.78 (0.66 to 0.92) 0.72 (0.59 to 0.88)* 1.12 (0.81 to 1.55) 0.93 (0.62 to 1.39) ≤ 18 1 1 1 1 18–24 0.98 (0.81 to 1.17) 0.81 (0.63 to 1.03) 3.41 (2.36 to 4.93) 2.71 (1.68 to 4.36)* ≥ 25 0.72 (0.51 to 1.01) 0.43 (0.26 to 0.71)* 2.32 (1.29 to 4.16) 0.33 (0.14 to 0.82)* Births in the past 5 years One 1 1 1 1 Two 0.60 (0.50 to 0.72) 0.88 (0.70 to 1.12) 0.49 (0.35 to 0.69) 1.06 (0.68 to 1.67) Three and above 0.41 (0.29 to 0.59) 0.99 (0.64 to 1.53) 0.32 (0.09 to 1.08) 0.48 (0.10 to 2.39) ≤3 1 1 1 1 4–6 0.68 (0.56 to 0.830 0.61 (0.43 to 0.87)* 0.80 (0.52 to 1.22) 0.99 (0.48 to 2.05) ≥7 0.42 (0.33 to 0.52) 0.43 (0.27 to 0.66)* 0.17 (0.10 to 0.29) 0.38 (0.14 to 1.03) Birth interval 1.016 (1.012 to 1.02) 1.01 (1.001 to 1.011)* Hosmer and Lemeshow goodness-­of-­fit test P=0.2749 Birth order P=0.2289 *P<0.05. ANC, antenatal care; AOR, adjusted OR; COR, crude OR. 6 Handebo S, et al. BMJ Open 2023;13:e076869. doi:10.1136/bmjopen-2023-076869 BMJ Open: first published as 10.1136/bmjopen-2023-076869 on 27 November 2023. Downloaded from http://bmjopen.bmj.com/ on July 24, 2024 by guest. Protected by copyright. Table 3 Bivariate and multivariable analysis of antenatal care utilisation among illiterate and literate reproductive-­age women who gave birth in the last 5 years in Ethiopia, 2019 (n=3839) Open access Institutional delivery In the multivariable analysis, illiterate women who had their first and fourth ANC visit were 5.30 (AOR=5.30; 95% CI 4.00 to 7.02) and 2.28 (AOR=2.28; 95% CI 1.84 to 2.83) times more likely to give birth at health institution as compared with their counterparts. The odds of institutional delivery was 40% (AOR=0.60; 95% CI 0.42 to 0.84), 62% (AOR=0.38; 95% CI 0.28 to 0.51), and 59% (AOR=0.41; 95% CI 0.19 to 0.92) lower among illiterate women affiliated with Orthodox, Protestant and other religion (Catholic and traditional) as compared with women affiliated with Muslim religion. The odds of institutional delivery was 63% (AOR=0.37; 95% CI 0.14 to 0.99) lower among illiterate women living in the Afar region as compared with those living in the Tigray region. Illiterate women who had more than five family sizes were 33% (AOR=0.67; 95% CI 0.51 to 0.87) less likely to deliver at health institutions than those who had less than five family size. The odds of institutional delivery was 1.93 (AOR=1.93; 95% CI 1.45 to 2.56), 2.20 (AOR=2.20; 95% CI 1.62 to 2.98), 3.34 (AOR=3.34; 95% CI 2.41 to 4.63), and 5.71 (AOR=5.71; 95% CI 3.53 to 9.25) times higher among illiterate women with poorer, middle, richer and richest income status as compared with those with poorest wealth status. Illiterate women who had three and above births in the last 5 years have 61% (AOR=0.39; 95% CI 0.23 to 0.67) lowers odds of institutional delivery as compared with those who had only one birth. The odds of institutional delivery was 33% (AOR=0.67; 95% CI 0.43 to 0.87) lower for birth orders of four to six compared with birth orders of less than three (table 4). Literate women who had fourth ANC visit were 1.71 (AOR=1.71; 95% CI 1.22 to 2.41) times more likely to deliver at health institutions as compared with their counterparts. Compared with literate women who are affiliated with Muslim religion, those affiliated with Orthodox, Protestant and other religion has 51% (AOR=0.49; 95% CI 0.29 to 0.82), 76% (AOR=0.24; 95% CI 0.15 to 0.40), and 97% (AOR=0.03; 95% CI 0.003 to 0.20) lower odds of institutional delivery, respectively. The odds of institutional delivery was 53% (AOR=0.47; 95% CI 0.23 to 0.94) and 66% (AOR=0.34; 95% CI 0.16 to 0.72) lower among literate women living in Amhara and Oromia regions as compared with literate women living in Tigray region, respectively. The odds of institutional delivery among literate women with poorer, middle, richer and richest income status was 2.65 (AOR=2.65; 95% CI 1.25 to 5.62), 3.73 (AOR=3.73; 95% CI 1.88 to 7.39), 8.87 (AOR=8.87; 95% CI 4.28 to 18.36), and 17.74 (AOR=17.74; 95% CI 7.81 to 40.31) times higher as compared with those with poorest income status, respectively. Literate women aged 25 and higher years during their first birth have 2.56 (AOR=2.56; 95% CI 1.13 to 5.77) times higher odds of institutional delivery than women who had their first birth before 18 years. Literate women who had two births Handebo S, et al. BMJ Open 2023;13:e076869. doi:10.1136/bmjopen-2023-076869 in the last 5 years have 45% (AOR=0.55; 95% CI 0.38 to 0.79) lower odds of institutional delivery as compared with those woman who had one birth. Seven and above birth order was associated with 3.43 (AOR=3.43; 95% CI 1.12 to 10.49) times higher odds of institutional delivery as compared with less than three birth order. One month increase in time of first ANC was associated with 2% (AOR=0.98; 95% CI 0.96 to 0.99) lower odds of institutional delivery. Literate women living in household heads aged 30–44 and 45–59 years were 56% (AOR=0.44; 95% CI 0.28 to 0.70) and 67% (AOR=0.33; 95% CI 0.17 to 0.64) less likely deliver at health institution than women living in household headed by less than 29 years old (table 4). Postnatal care In the multivariable analysis, illiterate women who had first and fourth ANC visit were 5.72 (AOR=5.72; 95% CI 3.65 to 8.99) and 1.88 (AOR=1.88; 95% CI 1.46 to 2.42) times more likely used PNC as compared with their counterparts. The odds of PNC utilisation was 44% (AOR=0.56; 95% CI 0.39to 0.81) lower among illiterate women affiliated with the Protestant religion as compared with those affiliated with Muslim religion. The odds of PNC utilisation was 40% (AOR=0.60; 95% CI 0.38 to 0.96) and 52% (AOR=0.48; 95% CI 0.28 to 0.83) lower among illiterate women living in Amhara and Oromia regions as compared with those living in Tigray region, respectively. Illiterate women with poorer (AOR=1.52; 95% CI 1.04 to 2.22), middle (AOR=1.72; 95% CI 1.15 to 2.56), richer (AOR=2.56; 95% CI 1.70 to 3.85), and richest (AOR=3.98; 95% CI 2.29 to 6.91) wealth status were more likely used PNC as compared with those in poorest income status. Illiterate women with optimal (AOR=1.46; 95% CI 1.01 to 2.12) and long (AOR=1.85; 95% CI 1.16 to 2.97) interbirth intervals were associated with higher odds of PNC utilisation as compared with short inter-­ birth interval. Illiterate women living in household head aged 30–44 and 45–59 years were 2.57 (AOR=2.57; 95% CI 1.56 to 4.22) and 2.69 (AOR=2.69; 95% CI 1.53 to 4.71) times more likely to use PNC than those living in household head aged less than 29 years (table 5). The odds of PNC utilisation was 38% (AOR=0.62; 95% CI 0.39 to 0.99) lower among literate women affiliated with Protestant religion as compared with women affiliated with Muslim religion. The odds of PNC utilisation was 52% (AOR=0.48; 95% CI 0.26 to 0.88), 68% (AOR=0.32; 95% CI 0.16 to 0.61) and 56% (AOR=0.44; 95% CI 0.21 to 0.92) lower among literate women living in Amhara, Oromia and SNNP regions as compared with those living in Tigray region, respectively. Literate women in richer wealth status were 4.51 (AOR=4.51; 95% CI 1.90 to 10.71) times more likely to use PNC compared with the poorest counterparts. Literate women aged 25 and higher years during their first birth were 4.03 (AOR=4.03; 95% CI 1.78 to 9.15) times higher odds of PNC utilisation than women who had their first birth before 18 years. One month delay in the timing of first ANC was associated with 13% 7 BMJ Open: first published as 10.1136/bmjopen-2023-076869 on 27 November 2023. Downloaded from http://bmjopen.bmj.com/ on July 24, 2024 by guest. Protected by copyright. ANC than those who had their first birth before 18 years (table 3). Open access Institutional delivery Illiterate Variables ANC 1 ANC 4 Age of the respondent Place of residence Religion Region Family size Wealth index Sex of household head Sex of the current child Age at first birth Births in the past 5 years Birth order Timing of first ANC Description Literate COR (95% CI) AOR (95% CI) No 1 1 Yes 8.74 (6.89 to 11.10) 5.30 (4.00 to 7.02)* COR (95% CI) AOR (95% CI) 1 No 1 1 1 Yes 4.44 (3.72 to 5.30) 2.28 (1.84 to 2.83)* 4.51 (3.50 to 5.82) 1.71 (1.22 to 2.41)* Less than 24 1 1 1 1 25–34 0.75 (0.60 to 0.92) 0.72 (0.51 to 1.01) 0.85 (0.65 to 1.10) 0.68 (0.44 to 1.04) 35–49 0.72 (0.57 to 0.92) 1.01 (0.64 to 1.58) 0.95 (0.64 to 1.42) 0.62 (0.28 to 1.38) Urban 1 1 1 1 Rural 0.45 (0.36 to 0.56) 0.98 (0.70 to 1.36) 0.36 (0.27 to 0.46) 1.37 (0.83 to 2.25) Muslim 1 1 1 1 Orthodox 1.15 (0.95 to 1.39) 0.60 (0.42 to 0.84)* 1.23 (0.89 to 1.70) 0.49 (0.29 to 0.82)* Protestant 0.81 (0.66 to 0.99) 0.38 (0.28 to 0.51)* 0.35 (0.26 to 0.48) 0.24 (0.15 to 0.40)* Others 0.38 (0.20 to 0.76) 0.41 (0.19 to 0.92)* 0.05 (0.01 to 0.28) 0.03 (0.003 to 0.20)* Tigray 1 1 1 1 Afar 0.25 (0.11 to 0.54) 0.37 (0.14 to 0.99)* 0.60 (0.09 to 3.91) 1.38 (0.10 to 18.52) Amhara 0.59 (0.40 to 0.85) 0.70 (0.46 to 1.08) 0.49 (0.27 to 0.91) 0.47 (0.23 to 0.94)* Oromia 0.46 (0.32 to 0.65) 0.73 (0.44 to 1.20) 0.23 (0.13 to 0.41) 0.34 (0.16 to 0.72)* Somali 0.21 (0.12 to 0.35) 0.94 (0.46 to 1.91) 0.12 (0.04 to 0.36) 0.38 (0.04 to 3.68) Benishangul 1.04 (0.46 to 2.34) 1.66 (0.61 to 4.49) 0.60 (0.16 to 2.32) 0.81 (0.15 to 4.40) SNNPR 0.63 (0.43 to 0.92) 1.25 (0.75 to 2.09) 0.18 (0.10 to 0.31) 0.65 (0.29 to 1.48) Gambela 1.47 (0.24 to 9.05) 2.34 (0.25 to 21.85) 0.60 (0.07 to 5.14) 2.16 (0.13 to 36.08) Harari 1.01 (0.21 to 4.78) 0.88 (0.14 to 5.61) 2.04 (0.03 to 124.51) 0.86 (0.01 to 81.44) Addis Ababa 4.53 (1.30 to 15.79) 1.37 (0.35 to 5.41) 4.16 (1.16 to 14.98) 3.17 (0.58 to 17.27) Dire Dawa 0.96 (0.28 to 3.24) 0.78 (0.17 to 3.53) 3.56 (0.10 to 128.40) 2.69 (0.02 to 438.99) ≤5 1 1 1 1 >5 0.49 (0.42 to 0.58) 0.67 (0.51 to 0.87)* 0.59 (0.46 to 0.76) 0.89 (0.56 to 1.41) Poorest 1 1 1 1 Poorer 2.46 (1.93 to 3.14) 1.93 (1.45 to 2.56)* 2.62 (1.55 to 4.42) 2.65 (1.25 to 5.62)* Middle 2.74 (2.11 to 3.55) 2.20 (1.62 to 2.98)* 2.80 (1.75 to 4.48) 3.73 (1.88 to 7.39)* Richer 4.28 (3.27 to 5.61) 3.34 (2.41 to 4.63)* 7.12 (4.38 to 11.55) 8.87 (4.28 to 18.36)* Richest 10.44 (7.34 to 14.87) 5.71 (3.53 to 9.25)* 23.93 (14.55 to 39.37) 17.74 (7.81 to 40.31)* 1 Male 1 1 1 Female 0.87 (0.67 to 1.14) 0.94 (0.67 to 1.32) 2.11 (1.14 to 3.09) 0.77 (0.44 to 1.34) Male 1 1 1 1 Female 0.90 (0.76 to 1.05) 0.95 (0.78 to 1.15) 0.98 (0.77 to 1.24) 0.75 (0.53 to 1.04) ≤ 18 1 1 1 1 18–24 1.06 (0.89 to 1.26) 0.99 (0.79 to 1.24) 1.84 (1.43 to 2.36) 1.33 (0.91 to 1.93) ≥ 25 1.20 (0.86 to 1.70) 1.16 (0.71 to 1.87) 3.90 (2.33 to 6.55) 2.56 (1.13 to 5.77)* One 1 1 1 1 Two 0.78 (0.66 to 0.93) 1.14 (0.91 to 1.41) 0.48 (0.37 to 0.62) 0.55 (0.38 to 0.79)* Three and above 0.24 (0.15 to 0.39) 0.39 (0.23 to 0.67)* 0.45 (0.15 to 1.35) 0.36 (0.05 to 2.36) ≤3 1 1 1 1 4–6 0.50 (0.41 to 0.60) 0.67 (0.48 to 0.92)* 0.63 (0.46 to 0.85) 1.76 (0.98 to 3.15) ≥7 0.43 (0.35 to 0.55) 0.69 (0.45 to 1.05) 0.40 (0.24 to 0.66) 3.43 (1.12 to 10.49)* 0.98 (0.97 to 0.99) 0.98 (0.96 to 0.99)* Continued 8 Handebo S, et al. BMJ Open 2023;13:e076869. doi:10.1136/bmjopen-2023-076869 BMJ Open: first published as 10.1136/bmjopen-2023-076869 on 27 November 2023. Downloaded from http://bmjopen.bmj.com/ on July 24, 2024 by guest. Protected by copyright. Table 4 Bivariate and multivariable analysis of institutional delivery among illiterate and literate reproductive age women who gave birth in the last 5 years in Ethiopia, 2019 (n=3839) Open access Institutional delivery Illiterate Variables Age of the household head Description Literate COR (95% CI) AOR (95% CI) COR (95% CI) AOR (95% CI) ≤ 29 1 1 1 1 30–44 0.88 (0.70 to 1.10) 1.18 (0.85 to 1.64) 0.68 (0.50 to 0.91) 0.44 (0.28 to 0.70)* 45–59 0.98 (0.75 to 1.27) 1.38 (0.93 to 2.06) 0.41 (0.28 to 0.61) 0.33 (0.17 to 0.64)* above 60 0.69 (0.47 to 0.99) 0.78 (0.49 to 1.23) 0.52 (0.33 to 0.83) 0.49 (0.24 to 1.01) Hosmer and Lemeshow goodness-­of-­fit test P=0.1086 P=0.2815 *P<0.05. ANC, antenatal care; AOR, adjusted OR; COR, crude OR. (AOR=0.87; 95% CI 0.77 to 0.99) lower odds of PNC utilisation (table 5). DISCUSSION This study examined the relationship between literacy status and maternal healthcare utilisation among reproductive age women in Ethiopia. In this study, the prevalence of ANC 1, ANC 4, skilled birth attendance, and PNC utilisation is 74.9%, 43.5%, 51.9% and 32.0%, respectively. In contrast to this, a review study reported that only a quarter (25.5%) of the women have used a complete continuum of care (ANC 4 visits, skilled birth attendant and PNC) in Ethiopia.16 Another review study reported that 64%, 31% and 32% of women in Ethiopia used ANC, institutional delivery and PNC services, respectively.17 18 20 In sub-­Saharan African countries, 58.5%, 66% and 52.48% of women used ANC, institutional delivery and PNC services, respectively.25–27 The discrepancy may be due to differences in access to healthcare facilities and sociodemographic factors. Consistency with previous literature,11 17 18 our study found that maternal literacy is positively correlated with maternal health service utilisation. In contrast to their illiterate counterparts, literate women had a higher likelihood of receiving ANC 1 (literate vs illiterate, 87.9% vs 67.5%), ANC 4 (59.4% vs 34.5%), skilled birth attendance (73.3% vs 39.7%), and PNC (51.2% vs 21.1%). In line with this, studies frequently pointed out that a higher maternal education is associated with increased maternal healthcare utilisation, even after controlling socioeconomic factors.11 28 29 This might be because literate women are better able to obtain, comprehend, evaluate and use health information when making decisions. Moreover, literate women have better access to economic opportunities, improved employment status and autonomy, seek out residence with adequate resources, can recognise illness signs, and are more responsive to health-­enhancing measures, which enable them to use maternal healthcare.30 31 According to Adane et al, education increases women’s concern for their health status, freedom of choice and ability to pay for healthcare services, which ultimately increases their use of healthcare services.18 Education and health complement and support each other. Years of formal education are a widely accepted indicator of social status and have been commonly used to explore social inequalities.32 Women’s literacy is an important determinant of maternal healthcare service utilisation. However, the association between women’s literacy and maternal healthcare utilisation is not linear; rather it is modified by socioeconomic factors.11 A positive association is reported between them even in adverse socioeconomic situations.33 Yet, lack of literacy is underlined as one of the stressors affecting women during pregnancy and childbirth, creating vulnerability and increasing the likelihood of negative outcomes.34 In this study, higher age groups, higher wealth status and increased birth interval were positively associated with ANC service utilisation among illiterate women whereas living in Afar, Amhara, Oromia, Somali and SNNP regions, living in female-­ headed households, higher age at first delivery, and higher birth orders were negatively associated with ANC service utilisation among illiterate women. Then again, ANC utilisation among literate women was positively associated with being aged 25–34 years, living in rural areas, having a higher wealth status and giving first birth at the age between 18 and 24 years. It was inversely associated with living in Oromia, Somali and SNNP regions and gave first birth at age 25 and higher years. In line with this finding, review studies reported that ANC use is affected by maternal education, urban residence, older/increasing age, availability and cost of services, socioeconomic status, women’s employment and media exposure.19 35 Thus, addressing regional variation in the distribution of healthcare facilities, improving women’s economic status and fostering women’s self-­confidence are key areas to improve ANC utilisation in Ethiopia. Skilled birth attendance was higher among illiterate women who had first and fourth ANC visits, and a higher wealth status. Contrarily, it was negatively associated with being affiliated with Orthodox, Protestant and other religions, living in the Afar region, having more than five families, giving three and above births in the last 5 years, and for four to six birth orders. Attending the fourth ANC Handebo S, et al. BMJ Open 2023;13:e076869. doi:10.1136/bmjopen-2023-076869 9 BMJ Open: first published as 10.1136/bmjopen-2023-076869 on 27 November 2023. Downloaded from http://bmjopen.bmj.com/ on July 24, 2024 by guest. Protected by copyright. Table 4 Continued Open access Postnatal care use Illiterate Variables ANC 1 ANC 4 Age of the respondent Description Literate COR (95% CI) AOR (95% CI) No 1 1 Yes 11.02 (7.50 to 16.19) 5.72 (3.65 to 8.99)* COR (95% CI) AOR (95% CI) 1 No 1 1 1 Yes 3.96 (3.24 to 4.85) 1.88 (1.46 to 2.42)* 3.36 (2.69 to 4.21) 1.42 (0.97 to 2.10) Less than 24 1 1 25–34 1.21 (0.96 to 1.52) 1.44 (0.86 to 2.40) 35–49 1.37 (0.97 to 1.95) 1.10 (0.56 to 2.15) 1 1 Place of residence Urban 1 1 Rural 0.59 (0.46 to 0.76) 1.32 (0.88 to 1.99) 0.56 (0.45 to 0.69) 1.09 (0.68 to 1.75) Religion Muslim 1 1 1 1 Orthodox 1.89 (1.51 to 2.37) 1.09 (0.74 to 1.61) 1.57 (1.21 to 2.05) 0.90 (0.57 to 1.44) 0.62 (0.39 to 0.99)* Protestant 0.93 (0.71 to 1.22) 0.56 (0.39 to 0.81)* 0.52 (0.39 to 0.70) Others 0.35 (0.12 to 1.01) 0.48 (0.15 to 1.53) 0.03 (0.001 to 1.17) 0.07 (0.001 to 7.59) Tigray 1 1 1 1 Afar 0.22 (0.90 to 0.56) 0.75 (0.24 to 2.37) 0.52 (0.12 to 2.13) 0.87 (0.10 to 7.61) Amhara 0.48 (0.32 to 0.70) 0.60 (0.38 to 0.96)* 0.45 (0.29 to 0.69) 0.48 (0.26 to 0.88)* Oromia 0.25 (0.17 to 0.36) 0.48 (0.28 to 0.83)* 0.27 (0.18 to 0.41) 0.32 (0.16 to 0.61)* Somali 0.11 (0.06 to 0.23) 0.83 (0.33 to 2.07) 0.17 (0.05 to 0.53) 0.97 (0.15 to 6.44) Benishangul 0.71 (0.31 to 1.64) 1.31 (0.46 to 3.72) 0.50 (0.18 to 1.37) 0.53 (0.13 to 2.16) SNNPR 0.37 (0.25 to 0.55) 0.78 (0.45 to 1.37) 0.23 (0.15 to 0.35) 0.44 (0.21 to 0.92)* Gambela 0.70 (0.11 to 4.35) 1.02 (0.10 to 10.13) 0.55 (0.11 to 2.79) 1.10 (0.10 to 11.94) Harari 0.57 (0.11 to 3.06) 0.78 (0.10 to 6.12) 0.63 (0.09 to 4.55) 0.79 (0.05 to 11.82) Addis Ababa 2.55 (0.97 to 6.72) 2.60 (0.66 to 10.24) 1.15 (0.64 to 2.05) 1.14 (0.50 to 2.62) Dire Dawa 0.66 (0.18 to 2.38) 0.92 (0.18 to 4.70) 0.64 (0.16 to 2.49) 0.46 (0.07 to 3.12) Family size ≤5 1 1 1 1 >5 0.68 (0.56 to 0.83) 1.05 (0.75 to 1.47) 0.91 (0.73 to 1.14) 1.19 (0.82 to 1.72) Wealth index Poorest 1 1 1 1 Poorer 1.88 (1.37 to 2.57) 1.52 (1.04 to 2.22)* 1.91 (1.05 to 3.48) 0.95 (0.37 to 2.43) Middle 2.27 (1.64 to 3.14) 1.72 (1.15 to 2.56)* 2.95 (1.72 to 5.05) 2.08 (0.88 to 4.89) Richer 3.27 (2.36 to 4.54) 2.56 (1.70 to 3.85)* 5.75 (3.37 to 9.79) 4.51 (1.90 to 10.71)* Richest 7.26 (5.06 to 10.43) 3.98 (2.29 to 6.91)* 7.92 (4.76 to 13.17) 1.96 (0.78 to 4.91) Male 1 1 Female 1.60 (1.20 to 2.14) 0.89 (0.53 to 1.49) 1 Region Sex of household head Age at first birth Births in the past 5 years Birth order Birth interval ≤ 18 1 1 1 18–24 1.20 (0.98 to 1.47) 1.24 (0.95 to 1.61) 1.49 (1.19 to 1.87) 1.05 (0.73 to 1.49) ≥ 25 0.90 (0.58 to 1.39) 1.08 (0.61 to 1.91) 5.13 (3.35 to 7.86) 4.03 (1.78 to 9.15)* One 1 1 1 1 Two 0.72 (0.58 to 0.89) 1.24 (0.93 to 1.66) 0.69 (0.54 to 0.87) 1.09 (0.73 to 1.63) Three and above 0.20 (0.10 to 0.41) 0.46 (0.21 to 1.01) 1.01 (0.35 to 2.93) 1.88 (0.40 to 8.78) ≤3 1 1 4–6 0.71 (0.57 to 0.88) 0.75 (0.53 to 1.07) ≥7 0.66 (0.51 to 0.86) 0.98 (0.63 to 1.51) Short birth interval 1 1 1 1 Optimal birth interval 2.28 (1.65 to 3.15) 1.46 (1.01 to 2.12)* 0.98 (0.69 to 1.38) 1.21 (0.78 to 1.89) Long birth interval 1.85 (1.16 to 2.97)* 1.50 (1.01 to 2.24) 1.36 (0.77 to 2.42) 3.88 (2.69 to 5.59) Continued 10 Handebo S, et al. BMJ Open 2023;13:e076869. doi:10.1136/bmjopen-2023-076869 BMJ Open: first published as 10.1136/bmjopen-2023-076869 on 27 November 2023. Downloaded from http://bmjopen.bmj.com/ on July 24, 2024 by guest. Protected by copyright. Table 5 Bivariate and multivariable analysis of postnatal care use among illiterate and literate reproductive-­age women who gave birth in the last 5 years in Ethiopia, 2019 (n=3839) Open access Postnatal care use Illiterate Literate Variables Description COR (95% CI) AOR (95% CI) COR (95% CI) AOR (95% CI) Age of the household head ≤ 29 1 1 1 1 30–44 1.38 (1.03 to 1.84) 2.57 (1.56 to 4.22)* 0.94 (0.74 to 1.20) 0.63 (0.37 to 1.06) 45–59 1.48 (1.06 to 2.06) 2.69 (1.53 to 4.71)* 0.86 (0.60 to 1.23) 1.29 (0.64 to 2.62) above 59 1.27 (0.80 to 2.00) 1.92 (0.96 to 3.82) 0.71 (0.47 to 1.07) 1.10 (0.48 to 2.52) 0.93 (0.89 to 0.98) 0.87 (0.77 to 0.99)* Timing of first ANC visit Hosmer and Lemeshow goodness-­of-­fit test P value 0.2616 P value 0.060 *P<0.05. ANC, antenatal care; AOR, adjusted OR; COR, crude OR. visit, having a higher wealth status, being aged 25 and higher at first birth, and for seven and above birth order were positively associated with skilled birth among literate women. The skilled birth was lower for literate women in the Amhara and Oromia regions, who were affiliated with the Orthodox, Protestant and other religions, had given birth twice within the past 5 years, had delayed their first ANC by 1 month, and were in household heads aged 30–44 and 45–59 years. In line with the findings, a systematic review reported that maternal age at first pregnancy, residence setting, educational status of mothers and frequency of ANC follow-­up positively associated with institutional delivery service utilisation.18 In sub-­Saharan African countries, skilled delivery declined with increased age and rural residence but increased with the level of education and wealth status.26 A study also reported that urban residents, having fewer children, repeated prenatal care visits and mass-­media exposure are associated with increased skilled delivery.36 This implies that making health institutions easily accessible, enhancing ANC service utilisation, ANC booking time and increasing age at first birth is crucial to improve health institution delivery in Ethiopia. Among illiterate women, attending the first and fourth ANC visit, a higher wealth status, optimal and long birth intervals, living in household head aged 30–44 and 45–59 years were positively associated with PNC utilisation whereas being affiliated with the Protestant religion and living in Amhara and Oromia regions were negatively associated with PNC utilisation among illiterate women. Yet PNC utilisation among literate women was positively associated with richer wealth status and being aged 25 years and higher at first birth. However, being affiliated with the Protestant religion, living in Amhara, Oromia and SNNP regions, and having a month delay in the first ANC was negatively associated with PNC utilisation. A study in Ethiopia reported that ANC, urban residence and skilled delivery had a positive effect on PNC utilisation.20 Similarly, in sub-­Saharan Africa, ANC visits, place of delivery and access to healthcare are determinants of PNC utilisation.27 Handebo S, et al. BMJ Open 2023;13:e076869. doi:10.1136/bmjopen-2023-076869 Overall, girls' and women’s literacy is the world’s best investment with the widest ranging returns.37 Many of the health disadvantages associated with low maternal literacy could be addressed through universal access to education. Empirical evidence from 108 countries over 20 years has shown that, if every woman had a primary education, maternal deaths could fall 66% and save an estimated 189 000 lives per year. The impact of education is particularly greater in sub-­Saharan Africa, where education is attributable to a reduction of maternal mortality from 500 to 150 deaths per 100 000 live births.37 38 According to Kim, women’s literacy has an impact on their autonomy in seeking healthcare and institutional delivery. Women’s literacy needs to be conceptualised in light of its effects on their cognitive abilities, socioeconomic status and autonomy in decisions, which have significant implications on maternal healthcare utilisation.39 Indeed, empowering women through education is an initial point towards enhancing household socioeconomic status, health knowledge and skill, and autonomy in decision-­ making, which ultimately increases maternal healthcare service utilisation.37 39 40 Besides, educated girls are more likely to delay marriages and pregnancy, and are well informed about what to do before, during and after pregnancy. Thus, women’s literacy will offset the inequities in access to high-­quality maternal health services and is associated with their overall health and well-­being. CONCLUSION Our study found that there was a significant association between literacy and the utilisation of maternal healthcare services though other sociodemographic factors also play a significant role. Regional variation, wealth status, age at first birth, birth order and intervals were found significant factors associated with maternal healthcare service utilisation. Similar to this, ANC booking timing and utilisation, age of household head and religious affiliation were associated with institutional delivery and PNC utilisation. More literate women are better equipped to use maternal healthcare services, which leads to a 11 BMJ Open: first published as 10.1136/bmjopen-2023-076869 on 27 November 2023. Downloaded from http://bmjopen.bmj.com/ on July 24, 2024 by guest. Protected by copyright. Table 5 Continued Open access Acknowledgements The authors want to acknowledge Measure DHS data archive, ICF International for providing us with the datasets for further analysis. Contributors SH conceptualised and conceived the study. All authors carried out the statistical analysis. All authors conducted the literature review; SH and TGD wrote the draft manuscript; GTG, TGD and BTW reviewed and commented the draft manuscript. SH was responsible for the overall content as the guarantor. All authors read and approved the final version of the manuscript. Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-­for-­profit sectors. Competing interests None declared. Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research. Patient consent for publication Consent obtained directly from patient(s) Ethics approval This research used secondary data from DHS repository. Permission was obtained from the Measure DHS program to access and analyse the data (https://dhsprogram.com/). The data were anonymous when we accessed for analysis. Informed consent was taken from all participant after informed consent statement was read for them. The procedure of the survey including oral informed consent have been reviewed and approved the Ethiopia Health and Nutrition Research Institute Review Board, the National Research Ethics Review Committee at the Ministry of Science and Technology, and the Institutional Review Board of ICF International and the Centers for Disease Control and Prevention. The study was carried out in accordance with relevant guidelines and regulations (Declaration of Helsinki). The confidentiality of the data was maintained. Participants gave informed consent to participate in the study before taking part. Provenance and peer review Not commissioned; externally peer reviewed. Data availability statement Data are available upon reasonable request. This study used publicly available data from DHS measure. The data used in this study can be accessed from the DHS Measure upon reasonable request: https://​ dhsprogram.com/data/available-datasets.cfm Open access This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-­commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-­commercial. See: http://creativecommons.org/licenses/by-nc/4.0/. ORCID iD Simegnew Handebo http://orcid.org/0000-0002-2548-7180 REFERENCES 1 World Health Organization. Trends in Maternal Mortality: 2000 to 2017: Estimates by WHO, UNICEF, UNFPA, World Bank Group and the United Nations Population Division. Geneva: World Health Organization, 2019. 2 Moran AC, Jolivet RR, Chou D, et al. A common monitoring framework for ending preventable maternal mortality, 2015-­ 2030: phase I of a multi-­step process. BMC Pregnancy Childbirth 2016;16:250. 3 World Health Organization. Strategies Toward Ending Preventable Maternal Mortality (EPMM). Geneva: World Health Organization, 2015. 12 4 WHO and UNFPA. Ending preventable maternal mortality (EPMM). Angew Chemie Int Ed 2021;6:951–2. 5 Ambel AA, Andrews C, Bakilana AM, et al. Examining changes in maternal and child health inequalities in Ethiopia. Int J Equity Health 2017;16:152. 6 MOH. ETHIOPIAN NATIONAL HEALTH CARE QUALITY STRATEGY 2016-­2020: transforming the quality of health care in Ethiopia. 2016. Available: file:///C:/Users/PC/Downloads/ethiopian-national-healthcare-quality-strategy (1).pdf 7 Dadi TL, Medhin G, Kasaye HK, et al. Continuum of maternity care among rural women in Ethiopia: does place and frequency of antenatal care visit matter? Reprod Health 2021;18:220. 8 Central Statistical Agency (CSA) [Ethiopia] and ICF. Ethiopia Demographic and Health Survey 2016. Addis Ababa, Ethiopia, and Rockville, Maryland, USA: CSA ICF, 2016: 1–551. 9 Ethiopian Demographic and Health Surve. Ethiopia mini demographic and health survey 2019: key indicators; 2019. 10 Tripathi P, Singh N. A need for maternal health literacy to promote maternal and neonatal health: a review. 2019;9(August):467–72. Available: https://www.ijhsr.org/IJHSR_Vol.9_Issue.8_Aug2019/66.​ pdf 11 Tsala Dimbuene Z, Amo-­Adjei J, Amugsi D, et al. Women’s education and utilization of maternal health services in Africa: a multi-­country and socioeconomic status analysis. J Biosoc Sci 2018;50:725–48. 12 Ray S, Bhandari P, Prasad JB. Utilization pattern and associated factors of maternal health care services in Haryana, India: a study based on district level household survey data. Int J Reprod Contracept Obstet Gynecol 2018;7:1154. 13 Arvind KY, Sahni1 B, Kumar D, et al. Effect of women’s and partners’ education on maternal health - care services utilization in five empowered action group states of India: an analysis of 13, 443 women of reproductive age. 2021:231–7. 14 Amwonya D, Kigosa N, Kizza J. Female education and maternal health care utilization: evidence from Uganda. Reprod Health 2022;19:142. 15 Weitzman A. The effects of women's education on maternal health: evidence from Peru. Soc Sci Med 2017;180:1–9. 16 Addisu D, Mekie M, Melkie A, et al. Continuum of maternal healthcare services utilization and its associated factors in Ethiopia: a systematic review and meta-­analysis. Womens Health (Lond) 2022;18:17455057221091732. 17 Tekelab T, Chojenta C, Smith R, et al. Factors affecting utilization of antenatal care in Ethiopia: a systematic review and meta-­analysis. PLoS One 2019;14:e0214848. 18 Nigusie A, Azale T, Yitayal M. Institutional delivery service utilization and associated factors in Ethiopia: a systematic review and META-­ analysis. BMC Pregnancy Childbirth 2020;20:364. 19 Okedo-­Alex IN, Akamike IC, Ezeanosike OB, et al. Determinants of Antenatal care utilisation in sub-­Saharan Africa: a systematic review. BMJ Open 2019;9:e031890. 20 Eshetu E, Chaka EE, Abdurahman AA, et al. Utilization and determinants of postnatal care services in Ethiopia: A systematic review and meta-­analysis. Ethiop J Health Sci 2015. 21 Dutch Ministry of Foreign Affairs. Country of origin information report Ethiopia. Dir. Sub-­Saharan Africa; 2021. 22 UNESCO. Ethiopia population literacy based on the latest data published by UNESCO Institute for Statistics. 2016. Available: https://uis.unesco.org/en/country/et 23 Country Meters. Ethiopia population. 2023. Available: https://​ countrymeters.info/en/Ethiopia 24 Debie A, Khatri RB, Assefa Y. Contributions and challenges of healthcare financing towards universal health coverage in Ethiopia: a narrative evidence synthesis. BMC Health Serv Res 2022;22:866. 25 Tessema ZT, Teshale AB, Tesema GA, et al. Determinants of completing recommended antenatal care utilization in sub-­Saharan from 2006 to 2018: evidence from 36 countries using demographic and health surveys. BMC Pregnancy Childbirth 2021;21:192. 26 Adde KS, Dickson KS, Amu H. Prevalence and determinants of the place of delivery among reproductive age women in sub-­Saharan Africa. PLoS One 2020;15:e0244875. 27 Tessema ZT, Yazachew L, Tesema GA, et al. Determinants of postnatal care utilization in sub-­Saharan Africa: a meta and multilevel analysis of data from 36 sub-­Saharan countries. Ital J Pediatr 2020;46:175. 28 Misganaw AC, Worku YA. Assessment of sexual violence among street females in Bahir-­Dar town, North West Ethiopia: a mixed method study. BMC Public Health 2013;13:825. 29 Rai RK, Singh PK, Singh L. Utilization of maternal health care services among married adolescent women: insights from the Nigeria demographic and health survey, 2008. Women’s Health Issues 2012;22:e407–14. Handebo S, et al. BMJ Open 2023;13:e076869. doi:10.1136/bmjopen-2023-076869 BMJ Open: first published as 10.1136/bmjopen-2023-076869 on 27 November 2023. Downloaded from http://bmjopen.bmj.com/ on July 24, 2024 by guest. Protected by copyright. world where pregnancy-­related complications, maternal mortality and child mortality are declining. Thus, literacy levels and modifying sociodemographic and obstetric-­ related factors should be considered when designing public health interventions and women’s empowerment programmes. For instance, such programmes need to stratify the interventions according to the literacy level of the women. We recommend further research to be done considering access to healthcare facilities, the distribution of maternity healthcare services, and community norms, culture and beliefs towards maternity healthcare services. Open access 35 Simkhada B, Teijlingen ER van, Porter M, et al. Factors affecting the utilization of antenatal care in developing countries: systematic review of the literature. J Adv Nurs 2008;61:244–60. 36 Gebremichael SG, Fenta SM. Determinants of institutional delivery in sub-­Saharan Africa: findings from demographic and health survey (2013-­2017) from nine countries. Trop Med Health 2021;49:45. 37 Sperling GB, Winthrop R. What Works in Girls’ Education: Evidence for the World’s Best Investment. 2016. 38 UNESCO. Teaching and learning: achieving quality for all gender summary. UNESCO; 2014. 39 In KS. The impact of mothers’ education on maternal health seeking practices in Uganda: evidence from the demographic and health surveys. 2017 40 Chopra I, Juneja SK, Sharma S. Effect of maternal education on antenatal care utilization, maternal and perinatal outcome in a tertiary care hospital. Int J Reprod Contracept Obstet Gynecol 2018;8:247. Handebo S, et al. BMJ Open 2023;13:e076869. doi:10.1136/bmjopen-2023-076869 13 BMJ Open: first published as 10.1136/bmjopen-2023-076869 on 27 November 2023. Downloaded from http://bmjopen.bmj.com/ on July 24, 2024 by guest. Protected by copyright. 30 Barman B, Saha J, Chouhan P. Impact of education on the utilization of maternal health care services: an investigation from National family health survey (2015–16) in India. Children and Youth Services Review 2020;108:104642. 31 Smith-­Greenaway E. Maternal reading skills and child mortality in Nigeria: a reassessment of why education matters. Demography 2013;50:1551–61. 32 Morrisson C, Jütting JP. Women’s discrimination in developing countries: a new data set for better policies. World Dev 2005;33:1065–81. 33 Grown C, Gupta GR, Pande R. Taking action to improve women's health through gender equality and women's empowerment. Lancet 2005;365:541–3. 34 Filippi V, Ronsmans C, Campbell OMR, et al. Maternal health in poor countries: the broader context and a call for action. Lancet 2006;368:1535–41.