Background: Despite global efforts, maternal and child mortality remains a major health problem in many developing countries including Ethiopia. The continuum of care before and during pregnancy, childbirth, and after delivery has become a comprehensive strategy to improve maternal and child health. While individual coverage of these interventions has been well- described, little is known about the completion of the full package of the continuum in Ethiopia in general and the study area in particular. Furthermore, existing pieces of literature focus on individual and household determinants with little attention given to community characteristics and health delivery environment. Therefore, it is essential to understand where the study area stands in the continuum of care and where the gaps are in seeking care along the continuum of the maternal care pathway, and the factors affecting maternal service uptake at various levels. Objectives: This study was aimed at 1) assessing the levels of service use and linkages along the continuum of maternal care pathway; 2) identifying factors that are associated with women’s continuation in receiving services from pregnancy to post-delivery, and 3) examining pregnant women’s satisfaction on the quality of routine antenatal care services rendered at public health facilities. Methods: The study was conducted in West Gojjam Zone, Northwest Ethiopia from June to August 2018. A community-based study was linked to facility data. In the community-based study, data were obtained from 1281 women who gave birth in the last 12 months before the survey from a two-stage cluster sampling. Data were collected via face-to-face interview using a pretested semi-structured questionnaire. In the facility-based study, antenatal care quality was measured in terms of structure and process of service provision, and pregnant women’s satisfaction as the outcome of service provision. For the latter study, a combination of different data collection methods were conducted to obtain data from 795 women attending antenatal care and 41 health providers working at 15 public facilities in five districts of the Zone. The collected data were entered into Epi-info version 7.0 and analyses were made using SPSS for windows version 25 and Stata 14.0 software programs. The data for different outcome variables were analyzed separately by using appropriate statistical methods depending on the specific nature of the variables under consideration. Given the nested nature of the data, multilevel logistic regression models with random effects at the kebele level were done to assess the predictors of retention on the continuum of maternity care and the timing of the first antenatal visit. Whereas, the shared frailty survival analysis and partial proportional odds models respectively were applied to analyze factors associated with postpartum family planning utilization and pregnant women’s satisfaction with antenatal care services. P-value of less than 0.05 at 95% confidence interval was considered to determine statistical significance. For all the models, independent variables to be included in the multivariable models were selected when the P-value was <0.2 in the bivariate analysis. Besides, multicollinearity among the covariates was checked using the variance inflation factors (VIFs) and VIF >10 was considered as suggestive of the existence of collinearity in this study. Results: The study revealed that only 12.1% of women completed the continuum of maternal care services (ANC4+, facility delivery, and PNC within 2 days after birth); while 25.1% of them did not receive any care during their recent births. The greatest gap and contributor to discontinued care was observed at PNC within 2 days of delivery 243(61.1%). The median time-to- contraceptive use (9.2months) after birth shows a delayed initiation of family planning. There were commonalities and differences in the predictors of the three indicators of maternal health service utilization. In this regard, while some factors were significant predictors for one or more indicators of maternal service utilization, early initiation (aOR = 7.53, 95%CI, 2.94, 19.29) with proper contents of ANC (aOR = 3.31, 95%CI, 1.08, 10.16) were the most important predictors for the completion of the continuum of care. Overall, 78.4% (95% CI: 75.6%, 80.9%) of women started their first ANC at 4 months of gestation or later and significant heterogeneity was observed between clusters. At level-1, women with intended pregnancy (aOR=0.31; 95% CI: 0.12, 0.79), and being knowledgeable about the timing (aOR=0.43; 95% CI: 0.25, 0.75) and pregnancy-related complications (aOR=0.16; 95% CI: 0.10, 0.26) were less likely to delay their first ANC visit than their counterparts. A one- kilometer increase in distance to the nearest facility was associated with a 4% increase in the odds of having late ANC booking(aOR=1.04; 95% CI, 1.01–- 1.08). Of all the respondents, 59.1% (95% CI: 56.8%–62.2%) had started using modern contraceptive methods within 12 months after birth. By the second month after delivery, only 11.1% of the women started using contraception but increased steadily to 25.9%, 37.7%, and 59.5% at 6, 9, and 12 months, respectively. The most preferred contraceptive method was injectable (71.5%) followed by implants (21.5%). Women with at least primary education (aHR = 1.29; 95%CI: 1.02, 1.66), attending four or more antenatal care visits (aHR = 1.59; 95% CI: 1.22, 2.06), with timely initiation of antenatal care (aHR = 2.03; 95% CI: 1.28, 3.21), and early postnatal checkups (aHR = 1.39; 95% CI: 1.12, 1.73) were strong predictors for earlier initiation of modern contraception. Pertaining to women’s satisfaction with ANC services rendered at public health facilities, almost one-third (31.7%) of women were not satisfied with the care they received. Process quality indicators better-predicted client satisfaction than structural attributes. In relation to this, better scores in history taking [OR1=OR2; 1.81 (95% CI 1.25, 2.60)], counseling [OR1 = OR2; 1.89 (95% CI 1.33, 2.69)], and screeningfor basic laboratory services [OR1= OR2; 18.10 (95% CI 11.52, 28.39)] were associated with achieving a higher satisfaction. We also observed a significant but lower satisfaction among women during the late trimester of pregnancy [OR1 = OR2, 0.87 (95% CI 0.78, 0.97)]. Yet, better in structural quality dimension did not bring about greater client satisfaction. Conclusions and recommendations: Despite the provision of charge-free services in all public health facilities, maternal health care were, in general, of poor quality, and retention within the continuum of care from pregnancy to post-delivery was extremely low in the study area. The results also demonstrated a delayed initiation of family planning after birth. The findings indicated that skilled maternal service utilization was multifactorial and factors influencing each of the indicators of skilled maternal care utilization revealed to operate at individual/ household, community, and facility-levels, suggesting interventions to reflect the relative roles of the various underlying factors. Notably, utilization of each level of maternal care was related to the next level of care. The positive link between the timing and contents of antenatal care with subsequent maternal services suggests the indispensable role of quality antenatal care as a bridge for other maternal services. Thus, a significant change to the delivery of quality antenatal care should be seen as a priority for health care planners in promoting subsequent maternal services. It is also important for interventions to pay special attention to the needs of rural residents, women of unintended pregnancy, and uneducated women who were the least likely to use the continuum of maternal health services. Also, the findings indicated that the facilities’ preparedness was not sufficient to provide good- quality services and to ensure client satisfaction. The attitudes and practices of health workers were identified as important factors affecting antenatal client satisfaction in these settings. Keywords: maternity, antenatal, birth, postpartum, family planning, contraception, quality, structure, process, continuum.