Background: Ending preventable maternal mortality remains an unfinished agenda and one of the world’s most critical challenges. Skilled care at birth is one of the crucial strategies that help to prevent deaths that occur during delivery. Maternity waiting homes have been endorsed to facilitate access to skilled care during intra-partum and post-partum periods for women living in rural areas. However, the majority of pregnant mothers in Ethiopia do not use this service; hence, this study aimed to assess the predictors of intention to use maternity waiting home. Methods: A community-based cross-sectional study was conducted from March 15 to June 20, 2018 in Bench Maji Zone, Southwest Ethiopia. A multistage sampling technique was used. The data were collected by trained data collectors using a structured pre-tested questionnaire. Data were entered into the epi data manager version 4.0.2.101 and exported to SPSS version 21 for analysis. The correlation among constructs of the theory of planned behavior was estimated. A hierarchical linear regression was used to identify predictors of intention to use maternity waiting home, and α value of less than 5% was used as a level of significance. Results: A total of 829 women were interviewed. The mean age of respondents was 27.1 (±5.2) years. Thirty-nine percent of the respondents used maternity waiting home previously. The attitude (β =0.12, p<0.001), subjective norm (β =0.47, p<0.001), perceived behavioral control (β =0.42, p<0.001), and ANC use during current pregnancy (β =0.07, p=0.030) were predictors of intension to use maternity waiting homes. R square was calculated to be 81%. Conclusion: The intention to use maternity waiting homes was significantly associated with antenatal care use, attitude, subjective norm, and perceived behavioral control. Thus, multidimensional interventions are important to increase the intension to use MWH.
A community-based cross-sectional study was conducted in Bench Maji Zone, Southern Nations, Nationalities and Peoples Region from March 15 to June 20, 2018. The zone’s capital city, Mizan-Aman is located 561 km away from Addis Ababa in the Southwest direction. Bench-Maji zone is divided into one urban district (Mizan-Aman), five pastoral/semi-pastoral districts (Surma, Maji, Meint Goldia, Meint Shesha, and Bero districts) and five agrarian districts (Sheko, Semen-Bench, Debub-Bench, Shey-Bench, and Guraferda districts). The zone had 1 hospital, 40 health centers, 300 health posts, and 31 functional maternity waiting homes during the study period. The service given in MWH includes shelter in the health facility, food, water and other supports. The fund for MWH covered by government and also contributed by local residents. There are recruited staffs who facilitate the services in MWH. The zonal health department’s annual report of 2016/17 indicated that only 42.07% of the eligible mothers used maternity waiting home.28 Source population: source populations were all pregnant mothers residing in rural area of Bench Maji Zone, southwest Ethiopia. Study population: study populations were randomly selected pregnant women who were living in rural area of Bench Maji Zone, southwest Ethiopia during the data collection period. The sampling unit and study unit were individual pregnant woman. Eligibility criteria: pregnant women those lived at least 6 months prior to the study in the study area were included while pregnant women who were severely sick and unable to respond to an interview during the data collection period were excluded from the study. The sample size was calculated using sample size determination formula for single population proportion () with assumptions of: 50% proportion of intended women to use maternity waiting home (p), 95% confidence level (Zα/2=1.96), 5% margin of error (d), and a design effect of 2. After adding 10% for non-response, the final sample size became 846. Multistage sampling technique used to recruit study participants. The study area (Bench-Maji zone) is stratified into five pastoral or semi-pastoral districts and five agrarian districts. This is due to health service coverage and its utilization differs across pastoral and agrarian communities. Then, three districts from each stratum were randomly selected to include at least 30% of the districts in the study. The selected districts were further stratified into kebeles (administrative units below district in Ethiopia). In the same way, 30% of kebeles were selected from each district using simple random sampling technique. The sample was proportionally allocated to each kebele based on the total number of pregnant mothers (Figure 1). Finally, the required sample randomly selected from kebeles that were included in the study by using family folders registry as sampling frame. Family folder is a registry book containing family profiles in the kebele. Schematic presentation of sampling procedure in assessment of predictors’ intention to use maternity waiting home in Bench Maji Zone, South West Ethiopia, 2018. A structured questionnaire was adapted from previously conducted studies and has the following parts, including socio-demographic, obstetric history, attitude, subjective norm, perceived behavioral control, and intention and past experiences of using maternity waiting home.22,29–31 The questionnaire was translated into the local language (Amharic) by persons who are proficient in both languages and have a good knowledge of the subject matter. Then, the questionnaire was pre-tested on a 5% total sample size in a district that was not selected for the actual study. Modifications were made based on pretest finding like sequence, grammatical issues and the time it takes to conduct the study was estimated. In addition, it had used in previously conducted studies the internal consistency was checked for components of theory of planned behavior after the pretest. The cronbach alpha for each item was greater than 0.7 (Table 1). Fifteen experienced BSc public health professionals and three MPH supervisors were recruited and trained for data collection and supervision, respectively. The training was given for 3 days and included how to ensure confidentiality, tool understanding, and interview techniques as training elements. The data were collected through a face-to-face interview and the supervisors and principal investigators supervised the process on a daily basis. Internal Consistency of Constructs Theory of Planned Behaviors Dependent variable was the intention to use the maternity waiting home. Independent variables were socio-demographic characteristics (age, religion, educational status, occupational status, monthly income, ethnicity, and marital status), ANC visit during the current pregnancy, birth experiences, previous place of delivery, past MWH use, parity, constructs of theory of planned behavior (direct attitude, indirect attitude, direct subjective norm, indirect subjective norm, direct perceived behavioral control, and indirect perceived behavioral control). The intention to use MWH: was measured using four items on 5-point Likert scale responses (strongly agree (5), agree (4), not neutral (3), disagree (2), and strongly disagree (1)). The item scores were summed to give a composite score, and the score approaching the maximum sum score of the total items was considered as a high report of intention to use MWH. The mean of the sum score was also used to categorize the intention as intended and not intended if they were scored at or above mean and below mean, respectively. The direct attitude toward the use of MWH was measured using five semantic differential scales. Respondents rate their feelings toward staying in WHM for institutional delivery for approximately 15 days before giving birth on bipolar adjectives (bad (1) to good (5), useless (1) to useful (5), unpleasant (1) to pleasant (5), boring (1) to interesting (5)). The score of approaching the maximum sum score was considered a positive attitude toward MWH use. Behavioral belief: was measured by eight items which answered on 5-point Likert scales (strongly disagree (1) to strongly agree (5)). The respondents asked to rate their beliefs about the outcomes of using MWH. For instances “staying in MWH for institutional delivery helps me to be attended by health professionals, and prevent myself from death related to delivery” Evaluation of the outcome of MWH uses was measured by eight items that addressed the evaluation consequences using MWH. For instance, a statement “for me getting delivery assisted by health professionals prevent myself from death related to delivery” was rated on five scale ranging from very bad (1) to very good (5). Each behavioral belief item was multiplied by the score of evaluation of the outcome to create a new variable (indirect attitude) that represents the weighted score for each behavioral belief. Direct subjective norm: was measured by four items Likert scales. The respondents were asked to rate the four statements that address how important persons (husband, father, mother, and health extension worker) in their lives would perceive their stay at MWH for institutional for 15 days before birth on five scales ranging from strongly disagree (1) to strongly agree (5). The four items were summed to form a direct subjective norm score, and the highest score highest influences of the important reference. Normative belief: was measured by six items, and the response for each item ranged from 1 (strongly disagree) to 5 (strongly agree). The items measure mothers’ beliefs of how important referents think the use of MWH. Motivation to comply with belief: was assessed using six items, on a 5-point Likert scale. Finally, each item score of normative belief was weighted against the score of motivation to comply with belief, and by summing up all the product scores, the new composite scores of the indirect subjective norm were created. Direct perceived behavioral control (PBC): was measured using semantic differential scales that address the amount of the control participants perceived regarding MWH. For instance, the statement “staying in MWH for institutional delivery for fifteen days before delivery” was rated on bi-polar differential scales ranging from difficult (1) too easy (5), not under my controls (1) to under my control (5), sudden (1) to planned (5), and conditional (1) to conditional (5). The four items were summed to form the PBC score, and the high score, the less difficult to use MWH. Control belief: was measured by items that responded on 5-point Likert scale. The control beliefs included the belief that one had sufficient money for transportation or walked a long distance to MWH, getting enough food at MWH, able to stay even alone at MWH, getting a person caring for a family left at home and celebrating traditional ceremony (coffee ceremony) at MWH. Perceived power: was also measured with six items on 5-point Likert scale. Perceived power was the weighted impact of those control factors in facilitating or inhibiting the behavior (transportation, distance, food, staying alone, the person caring family left in a home, and celebrating valued ceremony). Finally, each item score of control belief was weighted against the score of perceived power, and by summing up all the product scores, the new composite scores of the indirect perceived behavioral control (PBC). Data were entered into the epi data version manager version 4.0.2.101 and exported to SPSS version 21 for analysis. Descriptive statistics such as frequency, percent, mean, and standard deviation were calculated for different variables. The correlations between different TPB constructs were assessed using Pearson’s correlation coefficient. Simple linear regression and multiple hierarchical linear regression analysis was done to identify the predictors of intention to use MWH, and α value of less than 0.05 considered statistically significant. Standardized β coefficients with its confidence interval and R2 values were used to interpret the effects and variability of the dependent variable, respectively.
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