{"paper_id":"1cc3427e-a771-4e2e-8841-1949cf0462cd","body_text":"1\n1 The Association between Women’s Perception of Community Support for and \n2 Utilization of Maternity Healthcare Services in Ethiopia\n3\n4 Yongyi Lu 1*, Sally Safi1, Solomon Shiferaw2, Linnea A. Zimmerman1*\n5\n6 1 Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School \n7 of Public Health, Baltimore, MD, USA\n8 2 Department of Reproductive Health and Health Service Management, School of Public Health, \n9 Addis Ababa University, Addis Ababa, Ethiopia\n10 *Corresponding authors: \n11 Linnea A. Zimmerman, linnea.zimmerman@jhu.edu, Department of Population Family and \n12 Reproductive Health, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA\n13 Yongyi Lu, ylu137@alumni.jh.edu, Department of Population Family and Reproductive Health, \n14 Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA\n15\n16\n17\n18\n19\n20\n21\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 28, 2025. ; https://doi.org/10.1101/2025.09.25.25336698doi: medRxiv preprint \nNOTE: This preprint reports new research that has not been certified by peer review and should not be used to guide clinical practice.\n\n                  2\n22 Abstract\n23 Ethiopia has one of the highest maternal mortality ratios in sub-Saharan Africa. Many factors \n24 contribute, including limited access to and use of maternity care services. Community support \n25 plays an important role in influencing women’s utilization of such services. The objective of this \n26 study was to analyze the association between women’s perception of community support and their \n27 utilization of maternity healthcare services in Ethiopia while exploring how this association varies \n28 by urban and rural residence. Longitudinal data from the Performance Monitoring in Action \n29 Ethiopia was used. We excluded women who were postpartum at baseline, did not complete the \n30 six-week follow-up survey, and did not deliver a live birth. The total analytic sample for this study \n31 was 1,924. We used logistic regression to analyze the relationship between a woman’s perception \n32 of community support for the relevant component and the service utilization. Then, we included \n33 an interaction term between community perceptions and residence for each model. The proportion \n34 of women with four or more antenatal care visits, who gave birth in a health facility, and had \n35 postnatal care visits within 2 days postpartum are 49%, 52%, and 41%, respectively. Women’s \n36 access to comprehensive maternity care was 25%. Women who perceived their communities as \n37 “fully supportive” of comprehensive maternity care were about twice as likely to receive such care \n38 compared to women who perceived that the community was not fully supportive of comprehensive \n39 maternity care (aOR: 1.89, 95% CI: 1.49-2.38). Regarding the full continuum of care, urban \n40 women who perceive full support were significantly more likely to receive all components of \n41 care. Perceived community support is an important predictor of women's utilization of maternal \n42 care in Ethiopia. These findings highlight a key factor influencing care-seeking behavior and \n43 variation between urban and rural residence, contributing to ongoing disparities in healthcare \n44 access.\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 28, 2025. ; https://doi.org/10.1101/2025.09.25.25336698doi: medRxiv preprint \n\n                  3\n45 Introduction \n46 Sub-Saharan Africa has the highest burden of maternal mortality in the world, with around 85% \n47 of maternal deaths (1). Ethiopia, specifically, has one of the highest maternal mortality ratios in \n48 sub-Saharan Africa, with approximately 401 maternal deaths per 100,000 live births, recording the \n49 fourth largest number of maternal deaths in the world in 2020 (2–4). Many factors contribute to \n50 maternal mortality in Ethiopia, such as lack of transportation to health facilities, shortage of life-\n51 saving maternal supplies in health facilities, and lack of access to and utilization of the continuum \n52 of maternity care services, which includes four or more antenatal care (ANC) visits, use of facility-\n53 based delivery services, and receipt of postnatal care (PNC) for the mother within 48 hours of \n54 delivery (5–7). \n55 ANC is widely considered an essential service during pregnancy (8). ANC includes prevention, \n56 such as iron supplementation, toxoid immunization; treatment, such as treatment for sexually \n57 transmitted infections; and health education (9,10). Currently, Ethiopia has undertaken several \n58 intervention programs to promote ANC access and improve the quality of ANC services such as \n59 conducting health extension programs, having an organized community health structure, and \n60 implementing community-based health insurance (11). Recent estimates suggest that despite these \n61 efforts, ANC utilization remains low; estimates from the most recent DHS suggest that \n62 approximately 74% of women received at least one ANC visit from a skilled provider and only 43% \n63 received four or more visits (12). These figures also mask significant geographic variability, with \n64 approximately 84% of urban women receiving at least one visit and 59% receiving four or more \n65 relative to 71% and 37%, respectively, of rural women (12). \n66 Delivering in a health facility, with a skilled birth attendant, is the second critical component of \n67 the continuum of care. Evidence suggests that prioritizing intrapartum care, that is ensuring that \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 28, 2025. ; https://doi.org/10.1101/2025.09.25.25336698doi: medRxiv preprint \n\n                  4\n68 women deliver with a skilled attendant in a facility that is ready to address an obstetric emergency, \n69 can significantly reduce maternal morbidity and mortality (13). Given the effectiveness of facility \n70 delivery, the WHO has long recommended that pregnant women give birth in a health facility to \n71 prevent maternal mortality (14). In Ethiopia, the Federal Ministry of Health introduced a policy of \n72 free delivery services in public health facilities in 2013 (15). However, the use of healthcare \n73 facilities for delivery is still very low in Ethiopia. According to the 2019 Ethiopia Demographic \n74 and Health Survey (DHS), only 48% of women who delivered a live birth in the five years prior \n75 to the survey were delivered in a health facility (12). As with ANC utilization, these numbers mask \n76 significant variation with almost 80% of urban women delivering in a facility relative to 20% of \n77 rural women. \n78 Globally, approximately 57% of maternal deaths occur in the postpartum period within 6 weeks \n79 (7). In Ethiopia, around 51% to 75% of maternal deaths occur during the postpartum period (7). \n80 To reduce maternal and infant deaths, the WHO suggests that both mother and infant should \n81 receive a PNC visit within one day (24 hours) of birth, no matter where the baby is born, and have \n82 a minimum of four PNC visits within the first six weeks after birth (16). Visits should include \n83 screening for obstetric complications, prevention of infectious diseases, general well-being \n84 management, breastfeeding promotion, and discussion of postpartum family planning options (17). \n85 PNC visits are also important opportunities to check mother and baby for danger signs such as low \n86 body temperature, shortness of breath, and fever (18). According to the 2019 Ethiopia DHS, only \n87 35% of newborns and 34% of women received PNC services within two days of birth, again with \n88 significant geographic disparity (48% of urban women received a PNC check for their health \n89 versus 29% of rural women) (12). There is evidence that utilization of PNC services is increasing, \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 28, 2025. ; https://doi.org/10.1101/2025.09.25.25336698doi: medRxiv preprint \n\n                  5\n90 however, overall use remains low; the utilization of PNC services among women increased from \n91 17% in 2016 to 34% in 2019 (19). \n92 Due to the generally low utilization of each component service, utilization of the entire continuum \n93 of maternal health services – four or more ANC visits, facility delivery, and receipt of a PNC visit \n94 within 48 hours after birth – remains well below optimal levels. Estimates in Ethiopia range from \n95 9% to 42 %, with urban women having approximately 2.8 times higher odds of completing the \n96 continuum than their rural counterparts (20). \n97 A number of barriers have been identified that impact use of each component service, in addition \n98 to the entire continuum of care. ANC utilization is negatively impacted by both supply-side factors, \n99 such as shortage of required materials and disrespectful care by providers, and demand-side factors, \n100 such as transport costs and partner approval (21). Reasons for the low rate of use of health facilities \n101 include a perceived high cost of delivery, lack of transportation, shortage of supplies, low level of \n102 awareness about complications of pregnancy, and cultural barriers (15). Some barriers to accessing \n103 PNC include lack of funding for PNC, lack of PNC priorities from obstetricians, and lack of \n104 supplies for PNC provision (22). \n105 Qualitative evidence suggests that community and cultural factors also impact receipt of maternal \n106 care services (21,23). One study in the Amhara region of Ethiopia found that communities \n107 supported facility delivery through taking care of children, managing household chores, and \n108 supporting transport costs and logistics (24). The study did not, however, explore whether or how \n109 normative support for different maternal health services affected use. Another study in areas \n110 surrounding Addis Ababa, the capital, found that community views of quality and utility of \n111 antenatal services were impactful on both women’s initial and return attendance (21).  Community \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 28, 2025. ; https://doi.org/10.1101/2025.09.25.25336698doi: medRxiv preprint \n\n                  6\n112 norms that facility delivery should only be used in case of emergency have been found to support \n113 high rates of home delivery in pastoralist communities (25). Conversely, as utilization of services \n114 has increased, more women may have had positive experiences, leading to higher community \n115 support for services (26). \n116 This qualitative evidence identifies ways that community factors can both inhibit and support \n117 utilization of maternity care services, but few quantitative studies in Ethiopia have explored this \n118 question, and none in relation to the effect of community support across the entire continuum of \n119 care. Teferi and colleagues found that if a woman perceived more community support for facility \n120 delivery, she had higher odds of expressing a preference for facility delivery, but they did not \n121 assess whether perceived community support was associated with facility delivery itself (27). \n122 Mamo and colleagues found that women who perceived greater support from partners, family \n123 members, and friends to deliver in a facility were significantly more likely to do so (28). Significant \n124 gaps remain, however, as few studies have explored the effect of community support on postnatal \n125 care, on the continuum of care more broadly, or how the influence of community support may \n126 differ by residence and contribute to the differentials in utilization by urban and rural residence \n127 identified above. \n128 Due to persistent maternal mortality and poor utilization of ANC, facility-based delivery, and PNC \n129 in Ethiopia, many previous studies have analyzed other factors affecting the utilization of these \n130 maternity healthcare services such as education, mass media, and family size (29,30). However, \n131 to our knowledge, no study has examined how women’s perception of community support \n132 influences the utilization of each component and the entirety of the continuum of care in Ethiopia, \n133 nor whether these differ by residence. It is important to understand community-level support of \n134 ANC, PNC, and facility-based delivery and how this may affect women’s utilization of these \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 28, 2025. ; https://doi.org/10.1101/2025.09.25.25336698doi: medRxiv preprint \n\n                  7\n135 healthcare services. Our objective is thus to 1) identify the relationship between perceived \n136 community support for each service (ANC, facility delivery, and PNC) with receipt of the service; \n137 2) to identify whether greater community support is associated with completing the entire \n138 continuum of care; and 3) whether the influence of each differs by urban versus rural residence. \n139 Materials and Methods \n140 Ethical Clearance\n141 All procedures were reviewed and approved by Addis Ababa University, College of Health \n142 Sciences (AAU/CHS) (Ref: AAUMF 01-008) and the Johns Hopkins University Bloomberg \n143 School of Public Health (JHSPH) Institutional Review Board (FWA00000287) and carried out in \n144 accordance with relevant guidelines and regulations. Verbal informed consent was obtained from \n145 all of the participants. The IRB approves verbal consent procedures (without a need for written \n146 consent) for simple surveys without any invasive procedures in an environment where literacy is \n147 low. Women under the age of 18 who are married are considered emancipated minors and are able \n148 to provide informed consent. No unemancipated minors were included in this survey.\n149 Data sources\n150 This longitudinal study used data from the Performance Monitoring for Action (PMA) Ethiopia \n151 project. PMA Ethiopia is a collaboration between the Johns Hopkins Bloomberg School of Public \n152 Health, the Ethiopian Federal Ministry of Health (FMoH), and Addis Ababa University (AAU). \n153 PMA Ethiopia implemented a longitudinal survey of pregnant and postpartum women, which \n154 focused on maternal and newborn health and reproductive health topics (31). Women were \n155 enrolled during pregnancy or within six weeks postpartum and completed baseline interviews at \n156 enrollment and follow-up interviews at six weeks, six months and one year postpartum. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 28, 2025. ; https://doi.org/10.1101/2025.09.25.25336698doi: medRxiv preprint \n\n                  8\n157 Two datasets from the PMA Ethiopia panel survey were used for this analysis: the baseline survey, \n158 conducted from September 15, 2019 to December 30, 2019, and the 6-week follow-up survey, \n159 conducted throughout September 22, 2019 to June 26, 2020. The panel study was conducted using \n160 a multi-stage design in six regions - Addis Ababa, Afar, Amhara, Oromia, Tigray, and Southern \n161 Nations, Nationalities, and People’s region. 1 Urban and rural stratification was applied within \n162 Amhara, Oromia, Tigray and SNNP. In the first stage of sampling, a total of 216 enumeration areas \n163 (EAs), were randomly selected using probability-proportional-to-size. In the second stage of \n164 sampling, all households in the selected EAs were listed and census of all household members was \n165 conducted. All women between the ages of 15-49 were screened for eligibility (self-reported \n166 pregnancy or less than six weeks postpartum) and, if eligible, were invited to participate in the \n167 survey. At the baseline interview, resident enumerators explained the study's purpose and read the \n168 approved consent language to the women approached for consent (31). In accordance with the \n169 National Research Ethics Review Guidelines in Ethiopia, oral consent was granted due to \n170 widespread illiteracy (32). During each follow-up, women were asked if they still agreed to \n171 participate and if they had any questions (31). Women under age 18 are considered to be \n172 emancipated minors within Ethiopia if they are married. No unemancipated minors were included \n173 in this study. \n174 A total of 2,855 women participated in the baseline interview and 2,669 women participated in the \n175 6-week follow-up survey. The exclusion criteria in this study were women who were postpartum \n176 at baseline (n=616), did not complete the six-week follow-up survey (n=175), and who did not \n177 deliver a live birth (n=140). The total analytic sample for this study was 1,924. \n1 Initial study design and sampling took place prior to the creation of three new regions from within SNNPR and \nthus represents estimates within the previous administrative borders of SNNP. \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 28, 2025. ; https://doi.org/10.1101/2025.09.25.25336698doi: medRxiv preprint \n\n                  9\n178 Measures\n179 Outcome measures\n180 Our dependent variables (outcomes) were based on survey questions that assessed women’s \n181 utilization of maternity care. Using the 6-week follow-up survey, we assessed four measures: \n182 (1) receipt of four or more ANC visits from a trained provider, including a health extension \n183 worker (HEW),\n184 (2) delivered in a health facility, and\n185 (3) received PNC within 2 days of giving birth. Women were classified as receiving PNC \n186 if a trained provider visited them in their home and discussed their health, they visited a trained \n187 provider at a facility and discussed their health, or in the case of women who delivered in a facility, \n188 if someone checked on their health prior to discharge.\n189 (4) receipt of all three of the above components comprehensive maternity care. \n190 Key independent variables\n191 Our independent variables (predictors) were based on categorical measures from the baseline \n192 survey assessing women's perception of community support for specific maternity healthcare \n193 services. Specifically, we assessed three measures using the following questions from the baseline \n194 survey: \n195 (1) Do most, some, few, or no people in your community encourage women to deliver at \n196 a facility? \n197 (2) Do most, some, few, or no people in your community encourage going to antenatal \n198 care?\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 28, 2025. ; https://doi.org/10.1101/2025.09.25.25336698doi: medRxiv preprint \n\n                  10\n199 (3) Do most, some, few, or no people in your community encourage women to seek \n200 postnatal care? \n201 The response options for the above three questions included: no people, few people, some people, \n202 and most people. For our analysis of each specific service, we collapsed the first two categories \n203 into “no or few people.” “Do Not Know” was included as a potential option, however, the number \n204 of \"do not know\" responses ranged from 1.46% (n=28) for community support of antenatal care \n205 to 2.08% (n=40) for community support of postnatal care. The small sample sizes did not allow \n206 for sufficient power to detect differences in this group and thus, were treated as missing.\n207 We also created a dichotomous measure for perceived community support for all types of \n208 maternity care. Respondents who answered “most people” for each of the above three questions  \n209 were classified into a “High support” category and all other respondents were classified in a \n210 “Lower support” category. \n211 Adjustment variables\n212 We identified sociodemographic variables that we hypothesized were likely to confound the \n213 relationship of perceived community support and receipt of each service, including maternal age \n214 (categorical variable in five-year age groups), education (categorical variable indicating none, \n215 primary, secondary and above), household wealth quintile, and region. Due to almost universal \n216 marriage in this population of currently pregnant women, we did not adjust by marital status. \n217  Analysis \n218 Exploratory analyses were used to describe the study sample and summarize missingness. For each \n219 component of the continuum of care and for the entire continuum, we used logistic regression to \n220 analyze the relationship between a woman’s perception of community support for the relevant \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 28, 2025. ; https://doi.org/10.1101/2025.09.25.25336698doi: medRxiv preprint \n\n                  11\n221 component and the utilization of that service. To determine if the influence of community support \n222 differed by urban versus rural residence, we then included an interaction term between community \n223 perceptions and residence for each model. All analyses accounted for complex survey design \n224 through the application of survey weights and accounting for clustering within EAs. All analyses \n225 were conducted using Stata 18 SE (33). \n226 Results\n227 Table 1 shows the distribution of characteristics of the sample, with weighted percentages. About \n228 half of the women (55%) were aged 20-29 and 42% had never attended school.  In terms of \n229 perceptions of community support for maternity care, forty-nine percent (49%) of respondents \n230 indicated that they felt that most people in their community encouraged pregnant women to seek \n231 ANC. Fifty-two percent (52%) of respondents felt that most people in their community encouraged \n232 pregnant women to give birth in a health facility. Forty-one percent (41%) felt that most people in \n233 the community encouraged women who had given birth to seek PNC. In terms of use of maternity \n234 care, 44% of respondents indicated that they had 4 or more ANC visits, 55% indicated that they \n235 delivered in a health facility, 39% reported they had a PNC visit within 2 days and 25% reported \n236 they had received all these services.\n237\n238\n239\n240\n241\n242\n243\n244\n245\n246\n247\n248\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 28, 2025. ; https://doi.org/10.1101/2025.09.25.25336698doi: medRxiv preprint \n\n                  12\n249\n250\n251\n252\n253 Table 1 Sociodemographic characteristics of respondents (n=1,924)\nSociodemographic characteristics Unweighted n Weighted  n %\nRegion\nTigray 336 138 7.2\nAfar 157 36 1.9\nAmhara 333 398 20.7\nOromia 472 841 43.7\nSNNP 454 443 23.0\nAddis 172 69 3.6\nWomen’s age (in years)\n15-19 166 193 10.0\n20-24 470 476 24.8\n25-29 616 572 29.8\n30-34 366 368 19.1\n≥35 306 315 16.4\nHousehold wealth index\nLowest quintile 350 377 19.6\nLower quintile 293 385 20.0\nMiddle quintile 306 398 20.7\nHigher quintile 354 383 19.9\nHighest quintile 621 381 19.8\nEducation level\nNever attended 754 808 42.0\nPrimary 683 751 39.0\nSecondary, technical or higher 487 366 19.0\nMarital status\nCurrently married and living with a man 1877 1885 98.0\nNot currently partnered 47 39 2.0\nPerceptions of community support for maternal care Unweighted n Weighted  n %\nWoman’s perception of community support for ANC 1,896 1,896\nNo or few people 492 533 28.1\nSome people 391 432 22.8\nMost people 1023 931 49.1\nWoman’s perception of community support for delivery at a facility 1891 1891\nNo or few people 487 531 28.0\nSome people 314 376 19.9\nMost people 1090 984 52.0\nWoman’s perception of community support for PNC 1884 1884\nNo or few people 637 681 36.2\nSome people 408 436 23.1\nMost people 839 767 40.7\nWoman’s perception of community support for comprehensive maternity carea 1867 1867\nNot fully supportive community 1177 1274 68.2\nFully supportive communityb 690 593 31.8\nReceipt of maternity care Unweighted n Weighted  n %\nReceived 4+ ANC visits\nNo 990 1,088 56.5\nYes 934 836 43.5\nDelivered in a health facility\nNo 749 875 45.5\nYes 1175 1,049 54.5\nReceived PNC within 2 days postpartum\nNo 1069 1,170 60.8\nYes 855 754 39.2\nReceived 4 + ANC visits, delivered at health facility, and received PNC \nNo 1338 1,445 75.1\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 28, 2025. ; https://doi.org/10.1101/2025.09.25.25336698doi: medRxiv preprint \n\n                  13\nYes 586 479 24.9\n254 a Comprehensive maternity care = 4+ ANC visits + facility delivery + PNC \n255 b Fully supportive community = women who indicated that “most people” in community encourage receipt \n256 of ANC, facility delivery, and receipt of PNC\n257 Results from the logistic regression analysis examining the association of community support for \n258 maternity services with women’s utilization of such services are presented in Table 2. Across all \n259 components of the continuum of care, greater perceived support was associated with higher odds \n260 of completing each component. For example, women who felt that some people in the community \n261 encouraged the use of ANC had 2.35 times higher odds (95% CI: 1.70-3.26) of completing 4+ \n262 ANC visits and women who felt that most people encouraged utilization of ANC had more than \n263 three times higher odds compared to women who felt there was less community support for ANC \n264 (aOR: 3.15, 95% CI: 2.37-4.17). These findings were similar for both facility delivery and \n265 postnatal care, with progressively higher odds associated with more perceived support. Lastly, \n266 women living in communities that they perceived to be “fully supportive” of encouraging \n267 comprehensive maternity care were about twice as likely to receive comprehensive maternity care \n268 than women who perceived that the community was not fully supportive of perinatal care (aOR: \n269 1.89, 95% CI: 1.49-2.38).\n270\n271\n272\n273\n274\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 28, 2025. ; https://doi.org/10.1101/2025.09.25.25336698doi: medRxiv preprint \n\n                  14\n275\n276 Table 2. Association between perceived community support for maternity health services with \n277 women’s utilization of such services\nCrude OR (95% CI) Adjusted OR (95% CI) \nVariables (n=1,924) OR 95% CI P-value aOR 95% CI P-value\nOutcome: Receipt of 4+ ANC visits\nPortion of community that encourages utilization of \nANC       \nNo/few people ref ref\nSome people 3.19 (2.37, 4.30) 0.000 2.35 (1.70, 3.26) 0.000\nMost people 6.66 (5.17, 8.58) 0.000 3.15 (2.37, 4.17) 0.000\nOutcome: Facility delivery\nPortion of community that encourages facility delivery \nNo/few people ref ref\nSome people 2.30 (1.72, 3.09) 0.000 1.96 (1.39, 2.77) 0.000\nMost people 7.79 (6.13, 9.90) 0.000 3.04 (2.27, 4.08) 0.000\nOutcome: Receipt of PNC visit within 2 days\nPortion of community that encourages utilization of \nPNC \nNo/few people ref ref\nSome people 1.85 (1.42, 2.41) 0.000 1.45 (1.07, 1.95) 0.015\nMost people 3.64 (2.91, 4.54) 0.000 1.96 (1.52, 2.54) 0.000\nOutcome: Receipt of comprehensive maternity care\nPortion of community that encourages comprehensive \nmaternity care a\nNot fully supportive community ref ref\nFully supportive community b 3.39 (2.76, 4.16) 0.000 1.89 (1.49, 2.38) 0.000\na Comprehensive maternity care = 4+ ANC visits + facility delivery + PNC \nb Fully supportive community = women who indicated that “most people” in community encourage receipt of ANC, facility \ndelivery, and receipt of PNC\n278\n279 Table 3 demonstrates if and how these effects differ based on urban and rural residence. For ANC, \n280 there are significant differences in utilization based on perceived support (aOR some:3.84, 95%CI: \n281 1.98-7.43 and aOR most: 6.18, 95% CI: 3.55-10.78) and between urban and rural women \n282 (aOR rural:0.42: 95% CI: (0.24-0.75), however, there is no evidence that the effect of perceived \n283 support differs by residence based on the interaction terms (aOR some*rural 0.67, 95% CI: 0.32-1.42 \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 28, 2025. ; https://doi.org/10.1101/2025.09.25.25336698doi: medRxiv preprint \n\n                  15\n284 and aOR most*rural 0.68, 95% CI: 0.36-1.27). There is a similar relationship for facility delivery, \n285 though the statistical significance among women who perceive some support is attenuated. \n286 There is evidence of interaction between community support and residence for both receipt of PNC \n287 and the full continuum of care, however. When accounting for interaction, the main effect of \n288 community support on PNC utilization is no longer significant - among urban women, there is no \n289 difference in the odds of receiving PNC by level of perceived community support. The main effect \n290 of residence remains significant; among women who perceive little support in the community, \n291 those who live in rural areas have significantly lower odds of utilizing PNC than women who live \n292 in urban areas (aOR:0.10, 95% CI: 0.06-0.15). The interaction, however, demonstrates that the \n293 effect of community support is significantly stronger among rural women, with perceived levels \n294 of community support being strongly associated with increased odds of PNC utilization \n295 (aOR some*rural 2.60, 95% CI: 1.39-4.84 and aOR most*rural 2.27, 95% CI: 1.34-3.85). Regarding the \n296 full continuum of care, the main effects of both perceived support (aOR full support 1.81, 95% CI: \n297 1.33-2.45) and residence (aOR rural 0.15, 95% CI: 0.13-2.45) retain statistical significance; among \n298 urban women, women who perceive full support are significantly more likely to receive all \n299 components of care while among women who perceive low support, rural women are significantly \n300 less likely to receive all components relative to urban women.  As with PNC utilization, the effect \n301 of perceiving full support is stronger among rural women than among urban women (aOR full \n302 support*rural 1.57, 95%CI: 1.00-2.45). \n303\n304\n305\n306\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 28, 2025. ; https://doi.org/10.1101/2025.09.25.25336698doi: medRxiv preprint \n\n                  16\n307 Table 3. Interaction effects of community perceptions and residence on maternity care utilization \nVariable OR 95% CI P-value\nOutcome: Receipt of 4+ ANC visits\nPortion of community that encourages utilization of ANC \nNo/few people reference\nSome people 3.84 (1.98, 7.43) 0.000\nMost people 6.18 (3.55, 10.78) 0.000\nResidence\nUrban reference\nRural 0.42 (0.24, 0.75) 0.003\nInteraction term \nSome people * rural 0.67 (0.32, 1.42) 0.298\nMost people * rural 0.68 (0.36, 1.27) 0.227\nOutcome: Receipt facility delivery\nPortion of community that encourages utilization of facility \ndelivery\nNo/few people reference\nSome people 3.23 (0.97, 10.74) 0.056\nMost people 5.54 (2.53, 12.12) 0.000\nResidence\nUrban reference\nRural 0.06 (0.03, 0.13) 0.000\nInteraction term \nSome people * rural 0.67 (0.19, 2.34) 0.529\nMost people * rural 0.80 (0.35, 1.83) 0.593\nOutcome: Receipt PNC within 2 days\nPortion of community that encourages utilization of PNC \nwithin 2 days of delivery\nNo/few people reference\nSome people 0.83 (0.49, 1.40) 0.477\nMost people 1.37 (0.89, 2.11) 0.150\nResidence\nUrban reference\nRural 0.10 (0.06, 0.15) 0.000\nInteraction term \nSome people * rural 2.60 (1.39, 4.84) 0.003\nMost people * rural 2.27 (1.34, 3.85) 0.002\nOutcome: Receipt of comprehensive maternity care\nPortion of community that encourages comprehensive \nmaternity care* \nNot fully supportive community reference\nFully supportive community** 1.81 (1.33, 2.45) 0.000\nResidence\nurban reference\nrural 0.15 (0.132, 2.45) 0.000\nInteraction term \nSome people * rural reference\nMost people * rural 1.57 (1.00, 2.45) 0.049\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 28, 2025. ; https://doi.org/10.1101/2025.09.25.25336698doi: medRxiv preprint \n\n                  17\n308 Discussion\n309 To our knowledge, this is the first study to quantitatively examine the association between \n310 women’s perception of community support for and utilization of maternity healthcare services \n311 across the continuum of care in Ethiopia. We find that perceived support from the community \n312 significantly influences the likelihood of receiving care across each component of the continuum \n313 and across the full continuum, with the effect being stronger amongst rural women for completion \n314 of PNC and the full continuum. \n315 Our findings suggest that when women feel that at least some people in their community are \n316 supportive of maternal health services, they are more likely to receive these services and that this \n317 applies across the entire continuum of care. This is consistent with previous qualitative studies \n318 indicating that communities have considerable influence on the receipt of services. For example, \n319 a study in Addis Ababa highlighted that community members felt there was little utility to \n320 receiving ANC services and discouraged women from accessing this care (21). Similarly, women \n321 who received poor quality delivery services discouraged others from attending services, a finding \n322 which was echoed in a similar study in Kenya (34). These studies, which focus on only one \n323 component of the continuum, demonstrate the critical role that community support plays in \n324 women’s utilization of specific maternity care services. No studies that we could find examined \n325 the influence of community support across all components of the continuum of care, limiting our \n326 ability to compare this finding; nonetheless, that each component was consistently associated with \n327 higher uptake of services points to the importance of building community support for each service \n328 in order to increase utilization of the entire continuum. We also found that, while women generally \n329 considered that at least some people in their community encouraged care seeking, between one in \n330 four and one in three, depending on the service, reported that either no or few people supported \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 28, 2025. ; https://doi.org/10.1101/2025.09.25.25336698doi: medRxiv preprint \n\n                  18\n331 them. This points to the continued need to address community opinions on maternal health services \n332 and improve perceptions of the need for and quality of services. Understanding the specific beliefs \n333 associated with each service and barriers that prevent engagement is crucial for improving \n334 women's utilization of services.\n335 Additionally, we found that across the entire continuum of services, urban women were \n336 consistently more likely to utilize services than rural women, but that the effect of perceived \n337 community support was significantly stronger among rural women for receipt of PNC services and \n338 for completing the entire continuum. Disparities in use of maternal health services between urban \n339 and rural women in Ethiopia have been well documented in other studies (35–37). There are a \n340 number of reasons why these disparities exist, including access-related challenges (38,39) and \n341 socioeconomic differences such as education and wealth (40,41), but few studies have examined \n342 whether and how specific factors, and particularly community support, differ in their effect based \n343 on residence. A study in Morocco demonstrated that restrictive gender norms impacted sexual and \n344 reproductive healthcare-seeking behavior more strongly for rural than urban women (42), while in \n345 Ethiopia, community-level gender norms were significantly related to experience of childhood \n346 violence in rural, but not urban, areas (43). While there are no studies that we could find that \n347 include a comparative perspective of the influence of community support on maternal health care-\n348 seeking by residence, our results indicate that difference do exist and are important to consider, at \n349 least for services that are less commonly used such as PNC. Perceptions of community support for \n350 postnatal care may be particularly impactful in rural areas, where women traditionally have less \n351 autonomy to make individual decisions due to less access to economic resources, and persistence \n352 of conservative patriarchal norms, prioritizing husband and extended family decision-making (44). \n353 Conversely, in urban areas, women may have greater access to individual financial resources and \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 28, 2025. ; https://doi.org/10.1101/2025.09.25.25336698doi: medRxiv preprint \n\n                  19\n354 traditional norms are frequently weaker (43,45), thus the effect of perceived community support \n355 may have less influence on individual decisions around care. Understanding community \n356 perceptions of the need for PNC care, particularly in rural areas, in order to design effective \n357 community-based interventions may serve as a means to reduce disparities in urban and rural \n358 utilization.\n359 Our study has several strengths. First, this study used longitudinal data collected amongst a \n360 representative sample of currently pregnant women who were asked to report on their perceptions \n361 of community support prior to utilization of services (with the potential exception of ANC), which \n362 reduces concerns about temporality. Additionally, we utilized a novel measure of perceived \n363 community support, asking women to report on the community in general, rather than rely on \n364 aggregate measures of individual data, which are generally used to measure community influences \n365 (46–48). As these data are generally collected only among women age 15-49, they fail to capture \n366 the opinions of other individuals in the community (46), who are likely impactful in determining \n367 care-seeking behavior. Finally, we explore the modifying effect of residence on the effect of \n368 perceived support, providing more evidence into how mechanisms that influence care seeking may \n369 differ between urban and rural women and explain disparities in care.  We do note limitations in \n370 our data, including that our measure was non-specific in is wording. “Support” can entail any \n371 number of actions or behaviors, but we were intentionally vague to allow the respondent to \n372 interpret support as she saw fit. Additional research is needed to understand the components of \n373 community support and its specific impact on women's utilization of maternal health services. \n374 Additionally, while we collection information from women on their perceptions of community \n375 support, we did not collect information from male partners and other community members who \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 28, 2025. ; https://doi.org/10.1101/2025.09.25.25336698doi: medRxiv preprint \n\n                  20\n376 influence decisions. Continued research to understand beliefs amongst a more diverse population \n377 than women of reproductive age would help to identify barriers to care. \n378 Conclusions\n379 Perceived community support is an important predictor of women's utilization of maternal care in \n380 Ethiopia. These findings shed light on an important mechanism to care-seeking, and how it differs \n381 by urban and rural residence, contributing to ongoing disparities in care between urban and rural \n382 women.  We note that while support is generally high across the continuum, at least one in four \n383 women report that few or no people support care-seeking, highlighting a lack of awareness of \n384 services that are important to address. Additional research is needed to better understand the \n385 reasons for this lack of support, particularly towards services in the postpartum period when the \n386 majority of maternal and newborn mortality occur.\n387\n388 Declarations\n389 Abbreviations\n390 ANC: Antenatal Care\n391 PNC: Postnatal Care\n392 AAU/CHS: Addis Ababa University, College of Health Sciences\n393 JHSPH: Johns Hopkins University Bloomberg School of Public Health\n394 PMA: Performance Monitoring for Action \n395 FMoH: Ethiopian Federal Ministry of Health \n396 EAs: Enumeration Areas\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 28, 2025. ; https://doi.org/10.1101/2025.09.25.25336698doi: medRxiv preprint \n\n                  21\n397 Ethical declarations\n398 Ethics approval and consent to participate\n399 PMA Ethiopia received ethical approval from Addis Ababa University, College of Health Sciences \n400 (AAU/CHS) (Ref: AAUMF 01-008) and the Johns Hopkins University Bloomberg School of \n401 Public Health (JHSPH) Institutional Review Board (FWA00000287). Verbal informed consent \n402 was obtained from all of the participants. The IRB approves verbal consent procedures (without a \n403 need for written consent) for simple surveys without any invasive procedures in an environment \n404 where literacy is low. Women under the age of 18 who are married are considered emancipated \n405 minors and are able to provide informed consent. No unemancipated minors were included in this \n406 survey. Detailed information about the ethical guidelines can be found in the National Research \n407 Ethics Review Guidelines (http://www.ccghr.ca/wp-content/uploads/2013/).\n408 Consent for publication\n409 Not applicable.\n410 Availability of data and materials\n411 The datasets generated during the study are publicly available from the PMA website \n412 (https://www.pmadata.org/data/available-datasets).\n413 Competing interests\n414 The authors declare that they have no competing interests.\n415 Funding\n416 This work was supported, in whole, by the Gates Foundation [INV 009466] \n417 https://www.gatesfoundation.org/. Under the grant conditions of the Foundation, a Creative \n418 Commons Attribution 4.0 Generic License has already been assigned to the Author Accepted \n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 28, 2025. ; https://doi.org/10.1101/2025.09.25.25336698doi: medRxiv preprint \n\n                  22\n419 Manuscript version that might arise from this submission. LAZ received the award. Sponsors \n420 played no role in the study design, data collection and analysis, decision to publish, or preparation \n421 of the manuscript.\n422 Author information\n423 Authors and Affiliations\n424 Department of Population Family and Reproductive Health, Johns Hopkins Bloomberg School of \n425 Public Health, Baltimore, MD, USA\n426 Yongyi Lu & Sally Safi & Linnea A. Zimmerman\n427 Department of Reproductive Health and Health Service Management, School of Public Health, \n428 Addis Ababa University, Addis Ababa, Ethiopia\n429 Solomon Shiferaw\n430 Contributions\n431 YL, S. Safi, and LAZ conceived of the study design. YL analyzed the data and wrote the draft. \n432 YL, S. Safi, and LAZ reviewed results and contributed to interpretation. LAZ, S. Safi, and \n433 S.Shiferaw critically reviewed the manuscript. YL, S. Safi, S.Shiferaw, and LAZ revised the final \n434 version of the manuscript. All authors contributed to the article and approved the submitted version. \n435 Corresponding author\n436 Correspondence to Linnea A. Zimmerman and Yongyi Lu. \n437 Acknowledgments\n438 The PMA Ethiopia project relies on the work of many individuals, both in the United States and \n439 in survey countries. Thanks to the Ethiopia country team and resident enumerators who are \n440 ultimately responsible for the success of PMA Ethiopia.\n441\n . 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CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 28, 2025. ; https://doi.org/10.1101/2025.09.25.25336698doi: medRxiv preprint \n\n                  27\n582\n583\n584\n585\n586\n587\n . CC-BY 4.0 International licenseIt is made available under a \n is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.(which was not certified by peer review)preprint \nThe copyright holder for thisthis version posted September 28, 2025. ; https://doi.org/10.1101/2025.09.25.25336698doi: medRxiv preprint","source_license":"CC-BY-4.0","license_restricted":false}