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Among Millennium Development Goals, achieving the fifth goal (MDG-5) of reducing maternal mortality poses the greatest challenge in Sub-Saharan Africa. Ethiopia has one of the highest maternal mortality ratios in the world with unacceptably low maternal health service utilization. The Government of Ethiopia introduced an innovative community-based intervention as a national strategy under the Health Sector Development Program. This new approach, known as the Health Extension Program, aims to improve access to and equity in essential health services through community based Health Extension Workers. Objective. The objective of the study is to assess the role of Health Extension Workers in improving women’s utilization of antenatal care, delivery at health facility and postnatal care services. Methods. A cross sectional household survey was conducted in early 2012 in two districts of northern and south central parts of Ethiopia. Data were collected from 4949 women who had delivered in the two years preceding the survey. Logistic regression analysis was performed to determine the association between visit by Health Extension Workers during pregnancy and use of maternal health services, controlling for the effect of other confounding factors. Results: The non-adjusted analysis showed that antenatal care attendance at least four times during pregnancy was significantly associated with visit by Health Extension Workers [Odds Ratio 3.46(95% CI 3.07,3.91)], whereas health facility delivery (skilled attendance at birth) was not significantly associated with visit by Health Extension Workers during pregnancy [Odds Ratio 0.87(95% CI 0.25,2.96)]. When adjusted for other factors the association of HEWs visit during pregnancy was weaker for antenatal care attendance [Adjusted Odds Ratio: 1.35(95% CI: 1.05, 1.72)] but positively and significantly associated with health facility delivery [Adjusted Odds Ratio 1.96(1.25,3.06)]. Conclusion: In general HEWs visit during pregnancy improved utilization of maternal health services. Health facility delivery is heavily affected by other factors. Meaningful improvement in skilled attendance at birth (health facility delivery) should include addressing other factors on top of visits by HEWs during pregnancy and specific target oriented interventions during visits by HEWs to support skilled attendance at birth. © 2014 Afework et al.; licensee BioMed Central Ltd.
A community based cross sectional study was conducted in two of the nine administrative regions of the Ethiopia—Tigray in the north; and the Southern Nations, Nationalities, and People’s Region (SNNPR) in the south. These study areas were selected purposefully. These two regions are home to a university that is currently being mentored by Addis Ababa University (AAU) and run a health and demographic surveillance system (HDSS) in the selected for the study districts. Maternal health service utilization indicators in the selected regions indicate Tigray has ANC at least once levels of 65%, SAB (11.6%), and post natal visits in the first 2 days. SNNPR had ANC at least once rate of 41%, SAB (6.2%), and postnatal visit in the first 2 days (5.5%) [4]. We selected 12 kebeles from the two districts namely Wukro in northern Ethiopia and Butajira in south central Ethiopia. Six kebeles each were selected using simple random sampling procedure from HDSS sites and non-HDSS sites in each district to control the effect exposure to health and demographic surveillance activities. These 12 Kebeles were selected proportionally from urban and rural areas, 2 from urban kebeles and 10 from rural kebeles. The study population included all women 15–49 of age, married or unmarried, who delivered within last two years in the selected kebeles, irrespective of the status of birth outcome whether live birth or stillbirth. The Ethiopian Crude Birth Rate (CBR) was estimated at 34.5/1000 midyear population [4]. With this CBR on an average we expected to have about 104 births per year in a kebele with an approximate population size of 3000. In 12 kebeles in each of the two districts, about 2496 deliveries were expected per site during 2 years of retrospective observation period. Thus, we expected about 4992 women as the target population in these study areas for this and other studies which assessed differentials in health service utilization by different determinants. Of the 4981 women approached for the interview 14 women were not available for interview after repeat visits and 18 questionnaires were discarded because of inconsistencies. A total of 4949 (99, 3%) women were finally included in the study. Home visit by a HEW at least once during pregnancy was taken as the independent variable of interest and ANC visit at least four times and skilled attendance at birth (health facility delivery) as the dependent variable. Initial sample size calculations for this and other studies on maternal health service utilization were based on SAB rate of 16% around the time of the survey [8]. With the sample of women included in the study a difference of 4% would be detected between those who were visited by HEWs at least once and those not visited with a power of 80% and a maximum design effect of 2. Ethical approval for this study was obtained from the Institutional Review Board Office, John Hopkins Bloomberg School of Public Health and Institutional Review Board of the College of Health Sciences, Addis Ababa University. Data collection was conducted by twenty trained and experienced female interviewers, who were high school graduates using questionnaire that contained socio-demographic characters tics of the respondents, visit by HEWs during pregnancy and use of maternal health services. Data collection activities were monitored by two supervisors in each study district. The supervisors had a minimum of a bachelor degree education and previous experience in supervising community based data collection. A sampling list of household members was constructed through a census of households and eligible women who had delivered during the previous two years were identified. All eligible women who voluntarily consented participated in the study after listening to the interviewer reading the informed consent. Supervisors randomly interviewed about 4% of the women for checking the reliability of responses as a part of data quality monitoring. A pretest was conducted in a district not selected for the study and some revisions were made on the questionnaire to improve clarity and understandability by the respondents. Data were double entered in a customized data entry program by experienced data clerks. Data analysis was performed using STATA 12 (Stata Corp, Texas). Data quality was checked by examining missing responses, inappropriate values, and violation of skip rules. A wealth index score was constructed for each household with a principal component analysis of household durable goods, household structure conditions (eg, materials used to construct wall, roof, floor of houses, type of toilets), and land possessions. Households were ranked according to the total wealth score and then divided into wealth quintiles as a proxy of household socio-economic status. We examined the distribution of socio-demographic characteristics of the study population, the coverage of maternal health services and association between visit by HEWs and other factors with use of maternal health services (Antenatal Care at least four times, Institutional Delivery including health posts, health centers and hospitals and Postnatal Care within three days). Multi collinearity was checked by calculating variance inflation factor (VIF) and we applied complex survey data analysis specifying survey design and sampling unit (kebeles). The variance was adjusted with Taylor linearized variance estimation method. Multivariate logistic regression analysis adjusted for cluster level sampling (kebele) was then run to control for the effect of other factors for which literature review showed association with maternal health service utilization (Eg 13.). Odds ratios (95% confidence intervals) were calculated to determine the association between antenatal care attendance at least four times, institutional delivery, postnatal care within three days of delivery and predictor variables.
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