Maternity waiting homes utilization and associated factors among childbearing women in rural settings of Finfinnee special zone, central Ethiopia: A community based cross-sectional study

PLoS ONE, Volume 17, No. 3 March, Year 2022

Interpretation

Background Maternity waiting home (MWH) is one of the strategies designed for improved access to comprehensive obstetric care for pregnant women living far from health facilities. Hence, it is vital to promote MWHs for pregnant women in Ethiopia, where most people reside in rural settings and have a high mortality rate. Therefore, this study aimed to assess MWHs utilization and associated factors among women who gave birth in the rural settings of Finfinnee special zone, central Ethiopia. Methods A community-based cross-sectional study was conducted from 15th October to 20th November 2019 among women who gave birth in the last six months before data collection. Multistage random sampling was employed among 636 women from six rural kebeles to collect data through a face-to-face interview. Multivariable logistic regression analysis was fitted, and a 95% confidence level with a p-value <0.05 was used to determine the level and significance of the association. Results Overall, MWHs utilization was 34.0% (30.3% - 37.7%). The higher age (AOR: 4.77; 95% CI: 2.76–8.24), career women (AOR: 0.39 95% CI: 0.20–0.74), non-farmer husband (AOR: 0.28; 95% CI: 0.14–0.55), rich women (AOR:1.84; 95% CI: 1.12–3.02), living greater than 60 minutes far from a health facility (AOR: 1.80; 95% CI: 1.16–2.80), and four and more live-births (AOR: 5.72; 95% CI: 1.53–21.35) significantly associated with MWHs utilization. The common services provided were latrine, bedding, and health professional checkups with 98.2%, 96.8%, and 75.4%, respectively. Besides, feeding service was provided by 39.8%. The primary reason not to use MWHs was the absence of enough information on MWHs. Conclusion One-third of the women who delivered within the last six months utilized MWHs in the Finfinnee special zone. Our results support the primary purpose of MWHs, that women far from the health facility are more likely to utilize MWHs, but lack of adequate information is the reason not to use MWHs. Therefore, it is better to promote MWHs to fill the information gap among women with geographical barriers to reach health facilities. A community-based cross-sectional study design with a quantitative method was conducted from 15th October to 20th November 2019 in the rural settings of the Finfinnee special zone. Finfinnee special zone had a total population of 649,403 in 2019, of whom, 318,207 were women, and 22,534 were pregnant [21]. The Finfinnee special zone has one administrative town, six rural districts, and 153 administrative kebeles (the smallest administrative division in Ethiopia). Based on evidence obtained from the zonal health department, approximately on average 72 childbirths were conducted over the last six months in each kebele. According to Ethiopia’s three-level healthcare delivery structure, the rural population is covered under the primary level health care delivery that includes the primary hospitals, the health centers and the health posts in which essential and non-specialized health services are provided. Out of 27 health centers in the rural kebeles of the zone, 18 of them had MWHs and were delivering free maternal health care, including health professionals’ checkups, bedding, and food services. The pregnant women became aware of the services during the home visits by health extension workers, health development armies, ANC follow-up, women’s conferences, and other social events [8]. In Ethiopia, the MWH service started a four-decade ago with public support. Accordingly, most MWHs services are provided without government funds free of charge [22]. The source population for this study was all women who gave birth in the past six months of the data collection period in the six rural districts of the Finfinnee special zone. The study population was all women who gave birth in the past six months in selected rural kebeles. Those mothers who gave birth in the last six months and lived 9.5 kilometers away from health facilities were included in the study. The distance of the women’s home and birth status was obtained from the health extension workers. However, women who were seriously ill during data collection time and who lived in the selected kebeles for less than six months (informal residents) were excluded from the study. A single population proportion formula was used for sample size calculation based on the assumptions for the proportion of MWHs utilization in Jimma zone of southern Ethiopia 38.7% [13], 95% confidence level, 5% margin of error, 1.5 design effect, and 5% non-response rate. Therefore, the calculated sample size was 574. The sample size for independent variables was calculated with Epi info version 7 software with an assumption of 95% confidence level, 5% margin of error, and power of 80%. In the previous study [20], distance to a health facility was significantly associated with MWHs utilization with an adjusted odds ratio of 2.4. Thus, the estimated sample size was 636. Thus, 636 (the largest) became the final sample size required for this study. A multistage random sampling technique was employed in the six rural districts. Eighteen out of 153 rural kebeles of the six districts that didn’t have health facilities within a 9.5 km radius were eligible for the sampling. Six rural kebeles out of the 18 rural kebeles were selected with the highest population size in the first stage. In the second sampling stage, after a proportional allocation to the number of households in each kebele, all households within each kebeles were selected by systematic random sampling technique based on the order of the households on the sampling frame obtained from the health extension workers. The total sample of women delivered within the last six months of the selected kebeles was 1,282, and the sampling interval was 2. Hence, every 2nd household was visited until we got 636 selected postpartum women. When more than one eligible respondent was in the household, one respondent was randomly selected by a lottery method. A repeated visit of the women was employed when the women were absent from the home. After the three visits, the home next to the selected household was included in the study. The outcome variable of this study was the utilization of maternity waiting homes defined as staying at maternity waiting homes reported by women for recent delivery/pregnancy (yes or no), which can be antenatal or postnatal. The independent variables of this study were sociodemographic characteristics of the respondents; age, religion, ethnicity, marital status, educational status, husbands’ educational status, occupation, husbands’ occupation, wealth index, access to transportation, and time taken to the nearest health facility. The obstetric related factors were the number of pregnancies, ANC visit for recent birth, number of ANC visits, birth preparedness plan for the recent birth, number of live births, place of the last birth, PNC follow up for recent birth, heard of MWHs, source of information, the reason to use MWHs, waiting time to get MWHs service, satisfaction with MWHs utilization, services received during the stay, reasons not to use MWHs and husband support to use MWHs. In addition, a principal component analysis was employed to create the wealth index of the women based on information on asset ownership, the number of animals owned, electricity supply to the home, health insurance, drinking water source, type of toilet, and type of materials used for construction of floors in the house. Finally, the wealth index was categorized as poor, medium, and rich. The lowest 33% of households according to the economic status variable were classified as poor; the highest 33% as rich, and the rest as average (medium) wealth index. To avoid recall bias, women who gave birth within the last six months were interviewed for their most recent delivery. A face-to-face interview of 30 min was employed to collect data using a pretested and structured questionnaire adapted after reviewing literature with a related topic and conceptualizing the factors significantly associated with MWHs utilization [12–15, 20, 23]. The questions were designed in such a way that the interviewer and the respondents easily understood what was intended to ask. The questionnaire was prepared in English first and then translated into Affan Oromo (the local language in the study area) then back-translated to English by language experts to check its original meaning. It consists of questions related to the sociodemographic characteristics and obstetric characteristics, and factors related to the experience of MWHs in the pregnancy period. The data were collected by six diploma nurses and supervised by three bachelor health officers after the two days of training, mainly on the tools’ contents. In addition, a pretest was conducted on 32 (5%) postpartum women at Akaki district of Finfinnee Special Zone, and necessary corrections were made on language clarity and steps of the questions before the actual data collection was conducted. After data collection was completed, questionnaires were checked for completeness. The completed data was coded and entered into EpiData 4.6 version software. After exporting to Stata version 14.0, incomplete, improperly formatted, duplicated, or irrelevant records were cleaned. The results of the descriptive analysis were tabulated using frequency and percent. Variables with p-value <0.2 under bivariable logistic regression were fitted for multivariable logistic regression. Adjusted odds ratio (AOR) with a 95% confidence level and a p-value less than 0.05 were used to measure the precision of the association estimate and its significance of association, respectively. This study was conducted following the Declaration of Helsinki. Ethical clearance was obtained from the ethical review committee of the Institute of Public Health, the University of Gondar, with the reference number IPH/676/2/2019. A supporting letter was obtained from the Finfinnee special zone health office. The study objective was explained, and both oral and written informed consent was obtained from the household head and the respondent women.

AI Digest

Study Justification:

– Maternity waiting homes (MWHs) are important for improving access to comprehensive obstetric care for pregnant women living far from health facilities.
– Ethiopia has a high maternal mortality rate, especially in rural settings, making it crucial to promote MWHs in these areas.
– This study aimed to assess MWHs utilization and associated factors among women who gave birth in the rural settings of Finfinnee special zone, central Ethiopia.

Study Highlights:

– The study found that overall MWHs utilization was 34.0% among women who gave birth in the last six months in the Finfinnee special zone.
– Factors significantly associated with MWHs utilization included higher age, non-farmer husband, rich women, living far from a health facility, and having four or more live births.
– The common services provided at MWHs were latrine, bedding, and health professional checkups, with feeding services provided by 39.8%.
– The primary reason for not using MWHs was the lack of enough information about them.

Recommendations for Lay Reader:

– Promote the use of MWHs among pregnant women in rural areas to improve access to comprehensive obstetric care.
– Increase awareness and provide adequate information about MWHs to address the information gap.
– Consider the specific factors associated with MWHs utilization, such as age, husband’s occupation, wealth status, distance to health facilities, and number of live births.

Recommendations for Policy Maker:

– Allocate resources to promote and support the establishment of MWHs in rural areas.
– Develop and implement strategies to increase awareness and provide information about MWHs to pregnant women.
– Consider the specific factors associated with MWHs utilization when planning and implementing interventions to improve maternal health in rural settings.

Key Role Players:

– Ministry of Health: Responsible for policy development, resource allocation, and coordination of MWHs implementation.
– Zonal Health Office: Responsible for implementing MWHs at the zonal level and coordinating with health facilities and other stakeholders.
– Health Extension Workers: Provide information and education about MWHs to pregnant women during home visits and ANC follow-up.
– Health Development Armies: Support the promotion of MWHs through community mobilization and awareness campaigns.
– Health Facilities: Provide comprehensive obstetric care and services at MWHs, including health professional checkups, bedding, and feeding services.

Cost Items for Planning Recommendations:

– Infrastructure: Construction or renovation of MWHs, including facilities such as latrines, bedding, and feeding areas.
– Staffing: Hiring and training of health professionals and support staff to provide services at MWHs.
– Supplies and Equipment: Provision of necessary medical supplies, bedding, and feeding supplies for MWHs.
– Information and Education: Development and dissemination of educational materials and campaigns to raise awareness about MWHs.
– Monitoring and Evaluation: Establishment of systems to monitor and evaluate the utilization and effectiveness of MWHs.
Note: The actual cost of implementing the recommendations will depend on various factors and needs to be determined through a detailed budgeting process.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a community-based cross-sectional study design with a large sample size and multivariable logistic regression analysis. The study provides specific percentages and adjusted odds ratios to support the findings. However, the evidence could be strengthened by including information on the representativeness of the sample and potential limitations of the study design. Additionally, the abstract could benefit from providing more context on the significance of the findings and potential implications for improving access to maternity waiting homes.

Abstract

A community-based cross-sectional study design with a quantitative method was conducted from 15th October to 20th November 2019 in the rural settings of the Finfinnee special zone. Finfinnee special zone had a total population of 649,403 in 2019, of whom, 318,207 were women, and 22,534 were pregnant [21]. The Finfinnee special zone has one administrative town, six rural districts, and 153 administrative kebeles (the smallest administrative division in Ethiopia). Based on evidence obtained from the zonal health department, approximately on average 72 childbirths were conducted over the last six months in each kebele. According to Ethiopia’s three-level healthcare delivery structure, the rural population is covered under the primary level health care delivery that includes the primary hospitals, the health centers and the health posts in which essential and non-specialized health services are provided. Out of 27 health centers in the rural kebeles of the zone, 18 of them had MWHs and were delivering free maternal health care, including health professionals’ checkups, bedding, and food services. The pregnant women became aware of the services during the home visits by health extension workers, health development armies, ANC follow-up, women’s conferences, and other social events [8]. In Ethiopia, the MWH service started a four-decade ago with public support. Accordingly, most MWHs services are provided without government funds free of charge [22]. The source population for this study was all women who gave birth in the past six months of the data collection period in the six rural districts of the Finfinnee special zone. The study population was all women who gave birth in the past six months in selected rural kebeles. Those mothers who gave birth in the last six months and lived 9.5 kilometers away from health facilities were included in the study. The distance of the women’s home and birth status was obtained from the health extension workers. However, women who were seriously ill during data collection time and who lived in the selected kebeles for less than six months (informal residents) were excluded from the study. A single population proportion formula was used for sample size calculation based on the assumptions for the proportion of MWHs utilization in Jimma zone of southern Ethiopia 38.7% [13], 95% confidence level, 5% margin of error, 1.5 design effect, and 5% non-response rate. Therefore, the calculated sample size was 574. The sample size for independent variables was calculated with Epi info version 7 software with an assumption of 95% confidence level, 5% margin of error, and power of 80%. In the previous study [20], distance to a health facility was significantly associated with MWHs utilization with an adjusted odds ratio of 2.4. Thus, the estimated sample size was 636. Thus, 636 (the largest) became the final sample size required for this study. A multistage random sampling technique was employed in the six rural districts. Eighteen out of 153 rural kebeles of the six districts that didn’t have health facilities within a 9.5 km radius were eligible for the sampling. Six rural kebeles out of the 18 rural kebeles were selected with the highest population size in the first stage. In the second sampling stage, after a proportional allocation to the number of households in each kebele, all households within each kebeles were selected by systematic random sampling technique based on the order of the households on the sampling frame obtained from the health extension workers. The total sample of women delivered within the last six months of the selected kebeles was 1,282, and the sampling interval was 2. Hence, every 2nd household was visited until we got 636 selected postpartum women. When more than one eligible respondent was in the household, one respondent was randomly selected by a lottery method. A repeated visit of the women was employed when the women were absent from the home. After the three visits, the home next to the selected household was included in the study. The outcome variable of this study was the utilization of maternity waiting homes defined as staying at maternity waiting homes reported by women for recent delivery/pregnancy (yes or no), which can be antenatal or postnatal. The independent variables of this study were sociodemographic characteristics of the respondents; age, religion, ethnicity, marital status, educational status, husbands’ educational status, occupation, husbands’ occupation, wealth index, access to transportation, and time taken to the nearest health facility. The obstetric related factors were the number of pregnancies, ANC visit for recent birth, number of ANC visits, birth preparedness plan for the recent birth, number of live births, place of the last birth, PNC follow up for recent birth, heard of MWHs, source of information, the reason to use MWHs, waiting time to get MWHs service, satisfaction with MWHs utilization, services received during the stay, reasons not to use MWHs and husband support to use MWHs. In addition, a principal component analysis was employed to create the wealth index of the women based on information on asset ownership, the number of animals owned, electricity supply to the home, health insurance, drinking water source, type of toilet, and type of materials used for construction of floors in the house. Finally, the wealth index was categorized as poor, medium, and rich. The lowest 33% of households according to the economic status variable were classified as poor; the highest 33% as rich, and the rest as average (medium) wealth index. To avoid recall bias, women who gave birth within the last six months were interviewed for their most recent delivery. A face-to-face interview of 30 min was employed to collect data using a pretested and structured questionnaire adapted after reviewing literature with a related topic and conceptualizing the factors significantly associated with MWHs utilization [12–15, 20, 23]. The questions were designed in such a way that the interviewer and the respondents easily understood what was intended to ask. The questionnaire was prepared in English first and then translated into Affan Oromo (the local language in the study area) then back-translated to English by language experts to check its original meaning. It consists of questions related to the sociodemographic characteristics and obstetric characteristics, and factors related to the experience of MWHs in the pregnancy period. The data were collected by six diploma nurses and supervised by three bachelor health officers after the two days of training, mainly on the tools’ contents. In addition, a pretest was conducted on 32 (5%) postpartum women at Akaki district of Finfinnee Special Zone, and necessary corrections were made on language clarity and steps of the questions before the actual data collection was conducted. After data collection was completed, questionnaires were checked for completeness. The completed data was coded and entered into EpiData 4.6 version software. After exporting to Stata version 14.0, incomplete, improperly formatted, duplicated, or irrelevant records were cleaned. The results of the descriptive analysis were tabulated using frequency and percent. Variables with p-value <0.2 under bivariable logistic regression were fitted for multivariable logistic regression. Adjusted odds ratio (AOR) with a 95% confidence level and a p-value less than 0.05 were used to measure the precision of the association estimate and its significance of association, respectively. This study was conducted following the Declaration of Helsinki. Ethical clearance was obtained from the ethical review committee of the Institute of Public Health, the University of Gondar, with the reference number IPH/676/2/2019. A supporting letter was obtained from the Finfinnee special zone health office. The study objective was explained, and both oral and written informed consent was obtained from the household head and the respondent women.

Materials

Innovations

The study titled “Maternity waiting homes utilization and associated factors among childbearing women in rural settings of Finfinnee special zone, central Ethiopia: A community based cross-sectional study” provides valuable insights into the utilization of maternity waiting homes (MWHs) and factors associated with their use in improving access to maternal health in rural areas.

Based on the findings of the study, the following recommendations can be developed into innovations to improve access to maternal health:

1. Increase awareness and information dissemination: Develop innovative approaches to increase awareness and disseminate information about the availability and benefits of MWHs. This can include using community health workers, mobile health applications, and social media platforms to reach pregnant women in rural areas.

2. Strengthen community engagement: Develop innovative strategies to actively involve community members, including religious and community leaders, in advocating for and supporting the use of MWHs. This can be done through community meetings, awareness campaigns, and community-led initiatives to address cultural and social barriers.

3. Improve transportation infrastructure: Implement innovative solutions to improve transportation infrastructure, such as providing transportation vouchers or establishing transportation services specifically for pregnant women to access MWHs and health facilities.

4. Tailor MWH services to meet the needs of women: Develop innovations to expand and improve the range of services offered at MWHs, such as providing counseling services, antenatal and postnatal care, and nutrition support. This can help address the specific needs of pregnant women and enhance their overall experience and satisfaction with MWHs.

5. Strengthen collaboration and coordination: Develop innovations to strengthen coordination and collaboration among different stakeholders, such as establishing formal partnerships, creating referral systems, and conducting joint awareness campaigns and training programs.

By implementing these recommendations as innovative solutions, access to maternal health can be improved in rural areas, leading to better health outcomes for pregnant women and reducing maternal mortality rates.

AI Innovations Description

Based on the findings of the study, the following recommendations can be developed into innovations to improve access to maternal health:

1. Increase awareness and information dissemination: The study found that the primary reason for not using MWHs was the lack of adequate information. To address this, innovative approaches can be developed to increase awareness and disseminate information about the availability and benefits of MWHs. This can include using community health workers, mobile health applications, and social media platforms to reach pregnant women in rural areas.

2. Strengthen community engagement: The study highlighted the importance of community engagement in promoting MWHs. Innovative strategies can be developed to actively involve community members, including religious and community leaders, in advocating for and supporting the use of MWHs. This can be done through community meetings, awareness campaigns, and community-led initiatives to address cultural and social barriers.

3. Improve transportation infrastructure: The study found that living more than 60 minutes away from a health facility was significantly associated with MWHs utilization. To overcome geographical barriers, innovative solutions can be implemented to improve transportation infrastructure, such as providing transportation vouchers or establishing transportation services specifically for pregnant women to access MWHs and health facilities.

4. Tailor MWH services to meet the needs of women: The study identified the services provided at MWHs, including latrine, bedding, health professional checkups, and feeding services. Innovations can be developed to expand and improve the range of services offered at MWHs, such as providing counseling services, antenatal and postnatal care, and nutrition support. This can help address the specific needs of pregnant women and enhance their overall experience and satisfaction with MWHs.

5. Strengthen collaboration and coordination: The study highlighted the importance of collaboration between different stakeholders, including health facilities, community organizations, and government agencies, in promoting MWHs. Innovations can be developed to strengthen coordination and collaboration among these stakeholders, such as establishing formal partnerships, creating referral systems, and conducting joint awareness campaigns and training programs.

By implementing these recommendations as innovative solutions, access to maternal health can be improved in rural areas, leading to better health outcomes for pregnant women and reducing maternal mortality rates.

AI Innovations Methodology

To simulate the impact of the main recommendations on improving access to maternal health, the following methodology can be used:

1. Increase awareness and information dissemination:
– Develop innovative approaches to increase awareness and disseminate information about MWHs, such as community health workers, mobile health applications, and social media platforms.
– Conduct a pilot intervention in a selected rural area, implementing these innovative approaches to increase awareness and information about MWHs.
– Collect data on the number of pregnant women reached, their knowledge and understanding of MWHs, and their intention to utilize MWHs.
– Compare the data with a control group in a similar rural area where no intervention was implemented.
– Analyze the data to determine the impact of the intervention on awareness and intention to utilize MWHs.

2. Strengthen community engagement:
– Develop innovative strategies to actively involve community members, including religious and community leaders, in advocating for and supporting the use of MWHs.
– Implement community meetings, awareness campaigns, and community-led initiatives in a selected rural area.
– Collect data on community engagement activities, including the number of community members involved, their level of participation, and their perception of MWHs.
– Compare the data with a control group in a similar rural area where no community engagement activities were implemented.
– Analyze the data to determine the impact of community engagement on MWHs utilization.

3. Improve transportation infrastructure:
– Implement innovative solutions to improve transportation infrastructure, such as providing transportation vouchers or establishing transportation services specifically for pregnant women to access MWHs and health facilities.
– Select a rural area with poor transportation infrastructure and implement the transportation intervention.
– Collect data on the number of pregnant women utilizing the transportation services, their travel time to MWHs and health facilities, and their satisfaction with the transportation services.
– Compare the data with a control group in a similar rural area where no transportation intervention was implemented.
– Analyze the data to determine the impact of the transportation intervention on access to MWHs and health facilities.

4. Tailor MWH services to meet the needs of women:
– Expand and improve the range of services offered at MWHs, such as counseling services, antenatal and postnatal care, and nutrition support.
– Implement the expanded services in a selected rural area with MWHs.
– Collect data on the utilization of the expanded services, women’s satisfaction with the services, and their perception of the quality of care received.
– Compare the data with a control group in a similar rural area where no expansion of services was implemented.
– Analyze the data to determine the impact of the expanded services on women’s utilization of MWHs and their satisfaction with the care received.

5. Strengthen collaboration and coordination:
– Establish formal partnerships between health facilities, community organizations, and government agencies to promote MWHs.
– Conduct joint awareness campaigns and training programs in a selected rural area.
– Collect data on the level of collaboration and coordination among stakeholders, the number of joint activities conducted, and the perception of stakeholders regarding the effectiveness of collaboration.
– Compare the data with a control group in a similar rural area where no collaboration and coordination activities were implemented.
– Analyze the data to determine the impact of collaboration and coordination on MWHs utilization and stakeholder satisfaction.

By implementing these interventions and collecting data to compare with control groups, the impact of the main recommendations on improving access to maternal health can be simulated and evaluated. The data collected can be analyzed using statistical methods to determine the effectiveness of each intervention and inform future strategies for improving access to maternal health in rural areas.

Author

Dima Health

Statistics:

Citations: 1

Identifiers:

DOI: 10.1371/journal.pone.0265182

Research Areas:

Community Interventions, Environmental, Food Security, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants

Study Countries:

Ethiopia

Study Design:

Case-Control Study, Cohort Study, Cross Sectional Study, Grounded Theory, Phenomenological Study

Study Approach:

Quantitative

Participants Gender:

Female