Level of completion of the maternal health care continuum and its determinants among rural women in East Shoa Zone, Eastern Ethiopia: A multilevel analysis

Background The maternal continuum of care (CoC) is a key strategy for reducing maternal and neonatal morbidity and mortality. In this study, CoC completion was defined as receiving at least four antenatal care visits, skilled birth attendance and postnatal care within 48 hours after chilbirth. Despite continued national efforts to improve maternal health service utilization, CoC completion remains low in Ethiopia, particularly in rural areas. This study assessed the level of CoC completion and its associated factors among rural women in East Shoa Zone, Eastern Ethiopia. Methods A community-based cross-sectional study linked to health facility data was conducted from November 5 to December 5, 2024. Using multistage sampling, 1,038 women who had given birth within the 12 months preceding the interview date were selected. Household data were collected through face-to-face interviews and facility readiness was assessed by direct observation using a SARA-adapted checklist. Multilevel logistic regression was used to identify factors associated with CoC completion. Results were reported as adjusted odds ratios with 95% confidence intervals. Results Among 1,038 women invited to participate, 997 completed the interview, yielding a 96.1% response rate. Overall, 23.2% (95% CI: 20.6, 25.9) of women completed the maternal continuum of care. CoC completion was associated with secondary or higher education (AOR = 3.27; 95% CI: 1.37,7.79), early ANC initiation (AOR = 5.16; 95% CI: 3.01,8.83), knowledge of pregnancy danger signs (AOR = 3.89; 95% CI: 1.81,8.37), high facility readiness (AOR = 5.19; 95% CI: 1.48,18.16), travel time of less than one hour (AOR = 1.87; 95% CI: 1.01,3.17), and higher household wealth (AOR = 2.57; 95% CI: 1.41,4.67). Conclusion Completion of the maternal continuum of care among rural women in East Shoa Zone was low with substantial dropout across successive stages. Both individual and health-system-level factors influenced CoC completion. Context-specific multilevel interventions should combine demand-side strategies that improve women’s awareness, preparedness, decision-making capacity and early initiation of maternal health care with supply-side measures that strengthen health facility readiness.