The days and weeks following childbirth, known as the postnatal period, are essential in the lives of both mothers and newborns (1). This is a critical time for women and newborns. Major physical, social, and emotional changes occurred during this period; nonetheless, it is typically the most neglected period on the maternal and childcare continuum (2). The majority of maternal and neonatal deaths occur within the first 42 days, with over half of postpartum maternal deaths occurring within the first 24 h (3) and 66% occurring within the first week (4). In 2013, 2.8 million newborns died in their first month of life, with one million dying on the first day (5).

Despite an increase in the number of maternal and child health programs and global maternal health efforts, the risk of both maternal and neonatal death after childbirth remains high in developing countries (6). Almost all (99%) maternal and newborn mortality occur in developing countries, with South Asia and Sub-Saharan Africa (SSA) exhibiting the highest rates. Tragically, it is projected that 390 women will die in childbirth for every 100,000 live births in Sub-Saharan Africa by 2030 (7). This is more than five times the 2030 SDG target of fewer than 70 maternal deaths per 100,000 live births, and significantly higher than the European average of thirteen deaths per 100,000 live births in 2017 (7, 8). The increment in morbidity and death is typically the result of a lack of appropriate, suitable, or timely care during that period (9).

Preterm birth, birth asphyxia, and sepsis account for more than 75% of all neonatal deaths, while postpartum haemorrhage and infections account for 80% of maternal deaths (10). All of these are avoidable and manageable causes if high-quality care is provided during the early and early postpartum period (10, 11). Postnatal Care (PNC) is a constellation of services provided to the mother and newborn throughout the first 42 days of life, starting as soon as the expulsion of the placenta (11). It is crucial for the woman and her newborn to recognize and treat health problems during the postpartum period, as well as to provide information to the mother about her and her newborn’s health (3). In addition, the services provided during this period have significance in preventing physical and mental deterioration in post-natal mothers. An array of services provided during this pivotal period are promoting healthy behaviours such as breastfeeding, assessment and treatment of maternal and neonatal danger signs via proper cord examination and cleaning, measurement of newborn body temperature, and referral service to advanced care (11–13).

Integration of PNC with the existing health system is a practicable and viable solution for reducing the high burden of preventable maternal and neonatal morbidity and achieving maternal health-related Sustainable Development Goal (SDG) targets (14). Despite this only 48% of women in SSA had skilled delivery services, less than half received PNC contact within 2 days of childbirth, and only 13% of women who gave birth at home received postpartum visits within 2 days of delivery (4, 12). This means that PNC is one of the most neglected services among all reproductive and child health interventions.

Through a technical consultation process, the World Health Organization (WHO) recently updated global recommendations on the timing and content of PNC for women and newborns with a particular emphasis on resource-constrained settings in low-and middle-income countries (LMIC) (11). Regardless of where childbirth takes place, the WHO recommends that all mothers and newborns receive four postpartum visits: the first within the first 24 h, followed by the second, third, and fourth visits within 3–4, 7–14, and 42 days following child birth, respectively (11). Receiving adequate postnatal care, which includes clinical and non-clinical maternal and newborn care, health promotion, and health systems interventions, is one of the quality indicators in maternal health service provision and it plays a significant role in lowering preventable deaths in the postpartum period (15). However, existing studies in the SSA region (16–18) have focused mainly on the frequency of PNC visits, with little emphasis on the contents of care provided during visits.

Hence, this study aimed at investigating the magnitude of receiving an adequate care during PNC visits, and its predictors at the individual and community levels. The findings of this study will help policymakers, programme managers, and service providers in devising intervention plans by acting on individual and community-level variables that hinder the uptake of basic PNC packages. This, in turn, will reduce maternal and newborn deaths, enhance health outcomes, and promote community-based health systems and women-centered maternity care in the region.

According to the World Health Organization’s vision for quality of care, countries should shift their focus from focusing solely on coverage of maternal health services to offering essential elements of care during each service delivery (24). The current study used the most recent demographic health surveys to analyze the level of adequate service uptake during the early postpartum period and its predictors in SSA countries. The findings indicate that less than half (42.94%) of women in the region received adequate PNC services. Overall, the adequacy of service uptake use is still too low to accomplish the expected reduction in maternal and newborn mortality and morbidity (24). This might be due to several factors, including a lack of community awareness about the contents of care and their importance, a shortage of healthcare providers, poor road infrastructure, transport challenges, and inadequate medical supplies, all of which are prevailing within the region (25–27). Therefore, governments and other stakeholders in the health system must enhance their efforts to improve both access to and the quality of PNC services. To do this, they should work on increasing community awareness, lowering healthcare costs (by facilitating access to transportation), strengthening home visits, along with enhancing the quality of care at service delivery points and encouraging pregnant women to give birth at health facilities (28–30).

The study examined the influence of factors at the individual and community levels. Accordingly, receiving adequate PNC service was significantly associated with living in a southern sub-region, low acceptance of wife beating, reading newspapers, place of delivery, the timing of ANC, autonomy in decision-making, and quality of ANC.

The subregion in which the women resided was shown to be associated with receipt of adequate PNC, those women in the Southern subregion being more likely to receive it than those in the Central region. This may be partially explained by differences in socioeconomic and cultural conditions that may impede access to healthcare facilities and cause disparities in the use of maternal health services. Given the context of this study, the southern region is represented by South Africa, which is known for its strong economic standing and may account for the uptake of adequate PNC services. This result is consistent with previous studies relating geographic disparities to PNC use in various low-and middle-income countries (15, 31–33).

Timing and quality of ANC were identified as significant predictors of adequate PNC and this was supported by studies conducted in India, Rwanda, Sierra Lion, Zambia, Malawi, and Nigeria (15, 31, 34–37). This could be explained by the fact that if a woman begins prenatal visits early (1st Trimester), she is more likely to receive the desired frequency of visits and counseling sessions. This may result in having enough information about PNC, its value, contents, and when and where to receive it, all of which raise the likelihood that she will receive adequate service (15, 38). Additionally, those women would have easy access to information about potential complications during the postpartum period and their related danger signs, all of which would boost their health-seeking behavior, and raise the possibility of receiving adequate services (39).

Birth at a health facility was also found to be positively associated with receiving adequate PNC service. This was in tandem with studies conducted in Low and Middle-income Countries (40), Indonesia (41), Kenya (42), Uganda (43), and Ethiopia (44). This could be due to healthcare providers informing mothers about the subsequent PPV at home, supported by birth notification following delivery to community health workers to give postpartum care at home visits, as documented by several African countries (44–46). Additionally, they have more chances to get information about the advantages and availability of PNC services at the community level during their stay at maternity wards, which also increases the uptake of adequate PNC (47).

The odds of receiving adequate PNC is found to be higher among women who gave their last birth by Caesarean section(CS) and this was supported by findings of studies conducted in Ethiopia (47). This may be because almost all of the women who underwent CS stayed at a healthcare center for at least 48–72 h, and as reported in many studies, this increased the likelihood that they would receive adequate PNC (44, 48, 49). Furthermore, the women themselves become more wary of postoperative complications, which would also raise their health-seeking behavior. However, it should be stressed that healthcare providers should take into account any potential hazards of CS in the woman’s future life, and they should do so in the context of strong clinical indications (50). In other words, non-medical justifications for CS delivery should be discouraged to the acceptable level advised by WHO (5–15%) (51) to tackle the possible health hazards following the procedure.

Women who exhibited high autonomy in decision-making power had higher odds of receiving adequate PNC services and this was in tandem with studies conducted in LMICs (52), Bangladesh (23), Nepal (53), and Ethiopia (13). This may be because as women attain greater autonomy in their mobility, household purchases, and healthcare decisions, they are less likely to face restraints from their husbands or other family members and are therefore more likely to use MNCH services (54). Women in the SSA region, where a patriarchal society is prevalent, are known to have a gross power imbalance when it comes to maternal and child health service usage because they lack the final say in important decisions that have an impact on their health and well-being (52, 55). Hence, regional and national government agencies have to collaborate in their effort to enhance women’s autonomy through initiatives like education, job opportunities, and finance that boost their ability for independence and decision-making.

When compared to their counterparts, women who were exposed to newspapers and magazines had a greater chance of receiving adequate PNC. Women who have access to this media outlet may also be more well-educated, come from a good socioeconomic background, reside close to health facilities, and have higher levels of health literacy, all of which may increase the likelihood that they will receive adequate postnatal services (15, 34, 56). Thus, media organizations and maternal health service programs should collaborate to ensure that women can access media platforms with adequate and comprehensive maternal health information.

Finally, having a high acceptance toward wife beating was also found to be negatively associated with the receipt of adequate PNC service. This was in line with other studies conducted in Bangladesh, Palestine, Albania, and Ethiopia (20, 57–59). This may be the case because a woman who perceives such violence to be “highly justifiable” will likely be aware of her lessened entitlement, confidence, and status as well as how this may negatively reflect on her sense of empowerment to access maternal health services (60, 61). Violence against women has drastically increased over the past few decades from being seen as a private or family issue to being seen as a social and public health concern with serious effects on health and the uptake of reproductive health services (62). The availability of services is frequently given top priority in most programs and interventions in SSA countries. However, studies indicate that merely having an accessible service scheme does not ensure that women will use it unless the government works to empower women and boost their self-esteem so that they can resist the societal dominance of gender stereotypes (22, 62).

The current study has strengths as well as drawbacks. Firstly, this is the first study in the SSA region to examine the adequacy of PNC services received during immediate PPP by focusing on the contents of care. Secondly, using multilevel mixed-effect models, the effects of individual-and community-level factors on the uptake of adequate PNC have been examined both separately and collectively for better parameter estimates. This is essential for creating effective interventions. Finally, the most recent nationally representative datasets from 18 SSA nations have been used, and this makes it easy to generalize our findings to all women in the region. Despite the aforementioned strengths, there are some limitations in the study. Due to the cross-sectional nature of the study, it can be difficult to deal with social desirability and recall bias and also difficult to establish the cause-and-effect relationship between outcomes and exposures.

The results showed low coverage of adequate PNC service in SSA countries, indicating that the WHO recommendation for positive postpartum experiences was not implemented satisfactorily. Living in the southern sub-region, institutional delivery, early initiation of ANC, delivery by CS, autonomy in decision-making, attitude towards wife-beating, and reading newspapers were identified as predictors of receipt of adequate PNC service. The Federal Ministry of Health and healthcare managers in each country should enhance their efforts to devise interventions that promote women’s empowerment to enhance their autonomy in decision-making and reduce attitudes towards wife beating. Healthcare providers ought to strive to provide skilled delivery services and early initiation of ANC, along with comprehensive education about the value of receiving adequate PNC service.

Publicly available datasets were analyzed in this study. This data can be found at: https://www.dhsprogram.com.

The requirement of ethical approval was waived for the studies involving humans because ICF International granted permission. The studies were conducted in accordance with the local legislation and institutional requirements. The participants provided their written informed consent to participate in this study.

AH: Conceptualization, Formal analysis, Methodology, Project administration, Resources, Software, Validation, Writing – original draft, Writing – review & editing. AT: Formal analysis, Methodology, Writing – review & editing. LT: Methodology, Writing – review & editing.