Missed opportunities for institutional delivery and associated factors among urban resident pregnant women in South Tigray Zone, Ethiopia: A community-based follow-up study

  • Global Health Action, Volume 8, No. 1, Year 2015

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Study Justification:
The study aimed to identify factors affecting unplanned home delivery among urban resident pregnant women in South Tigray Zone, Ethiopia. This research was important because the presence of a skilled birth attendant at every delivery is crucial in reducing maternal mortality and morbidity. In Ethiopia, the proportion of births attended by skilled personnel in urban settings can be as low as 10%. Understanding the factors contributing to unplanned home delivery in urban areas with relatively good access to healthcare institutions is essential for improving maternal and child health outcomes.
Study Highlights:
– The study revealed that 28.8% of pregnant women who planned for institutional delivery ended up delivering at home, missing the opportunity for modern delivery assistance.
– Significant predictors of unplanned home delivery included being single, illiterate, not attending antenatal clinics, not experiencing obstetric complications, having poor autonomy, and lacking birth preparedness and complication readiness.
– Educational status, antenatal care status, lack of obstetric complications, poor autonomy, and lack of birth preparedness and complication readiness were identified as important factors influencing unplanned home delivery.
Study Recommendations for Lay Reader:
– Pregnant women should prioritize attending antenatal clinics to receive proper care and guidance throughout their pregnancy.
– Education and awareness programs should be implemented to emphasize the importance of skilled birth attendants and the risks associated with unplanned home delivery.
– Efforts should be made to improve women’s autonomy and decision-making power regarding their healthcare choices.
– Birth preparedness and complication readiness should be promoted to ensure that pregnant women are well-prepared for any potential complications during delivery.
Study Recommendations for Policy Maker:
– Increase access to antenatal care services in urban areas to ensure that pregnant women receive the necessary care and guidance.
– Implement educational programs to improve literacy rates among women, which can positively impact their healthcare decision-making.
– Strengthen healthcare systems to provide comprehensive obstetric care, including the availability of skilled birth attendants.
– Develop and implement policies that promote women’s autonomy and empower them to make informed decisions about their healthcare.
– Invest in community-based interventions that promote birth preparedness and complication readiness among pregnant women.
Key Role Players:
– Health extension workers: They play a crucial role in identifying and referring pregnant women to healthcare institutions for antenatal care and delivery.
– Midwives: They provide obstetric care and support during delivery, ensuring safe and skilled assistance.
– Health institution supervisors: They oversee the data collection process and ensure its accuracy and quality.
– Institutional Review Board (IRB): They provide ethical clearance for the study, ensuring the protection of participants’ rights and welfare.
– South Tigray Zone Health Bureau: They collaborate with researchers and provide permission for the study, facilitating its implementation.
Cost Items for Planning Recommendations:
– Training programs for health extension workers and midwives to enhance their skills and knowledge in providing quality maternal and child health services.
– Development and dissemination of educational materials and campaigns to raise awareness about the importance of skilled birth attendants and the risks of unplanned home delivery.
– Strengthening healthcare infrastructure and facilities to ensure access to comprehensive obstetric care.
– Implementation of community-based interventions, such as birth preparedness and complication readiness programs, including training and awareness campaigns.
– Monitoring and evaluation activities to assess the effectiveness of interventions and make necessary adjustments.
Please note that the provided cost items are general suggestions and may vary based on the specific context and resources available.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is relatively strong, but there are some areas for improvement. The study design, a community-based follow-up study, provides a good foundation for gathering data. The sample size of 522 study participants is also adequate. The statistical analysis using SPSS version 16.0 adds to the strength of the evidence. However, there are a few areas that could be improved. First, the abstract does not mention the specific methods used for data collection, which could affect the reliability of the findings. Second, the abstract does not provide information on the response rate, which is important for assessing the representativeness of the sample. Finally, the abstract does not mention any limitations of the study, which would be helpful for interpreting the results. To improve the evidence, the authors could provide more details on the data collection methods, report the response rate, and acknowledge any limitations of the study.

Background: Every pregnant woman is considered to be at risk and some risks may not always be foreseeable or detectable. Therefore, the presence of a skilled birth attendant at every delivery is considered to be the most critical intervention in reducing maternal mortality and morbidity. In Ethiopia, the proportion of births attended by skilled personnel in urban settings can be as low as 10%. Therefore, the main purpose of this research was to identify factors affecting unplanned home delivery in urban settings, where there is relatively good access in principle to modern healthcare institutions. Design: A community-based follow-up study was conducted from 17 January 2014 to 30 August 2014, among second- and third-trimester pregnant women who had planned for institutional delivery in South Tigray Zone. A systematic sampling technique was used to get a total of 522 study participants. A pre-tested and structured questionnaire was used to collect relevant data. Bivariate and multivariate data analyses were performed using SPSS version 16.0. Results: The study revealed that among 465 pregnant women who planned for institutional delivery, 134 (28.8%) opted out and delivered at their home (missed opportunity). Single women (AOR 2.34, 95% CI 1.17-4.68), illiterate mothers (AOR 6.14, 95% CI 2.20-17.2), absence of antenatal clinic visit for indexed pregnancy (AOR 3.11, 95% CI 1.72-5.61), absence of obstetric complications during the index pregnancy (AOR 2.96, 95% CI 1.47-5.97), poor autonomy (AOR 2.11, 95% CI 1.27-3.49), and absence of birth preparedness and complication readiness (AOR 3.83, 95% CI 2.19-6.70) were significant predictors of unplanned home delivery. Conclusions: A significant proportion of pregnant women missed the opportunity of modern delivery assistance. Educational status, antenatal care status, lack of obstetric complications, poor autonomy, and lack of birth preparedness and complication readiness were among the important predictors of unplanned home delivery.

A community-based follow-up study was conducted in South Tigray Zone from 17 January 2014 to 30 August 2014 among urban resident pregnant women in their second or third trimesters. Alamata, the capital city of the zone, is located 560 km north-east of Addis Ababa, the capital city of Ethiopia. Each town (Alamata, Mehoni, and Maichew) in the zone has at least one health institution that can provide maternal and child health services. The potential study population comprised all pregnant women who were in their second or third trimester of pregnancy at the time of survey. Respondents were identified using a systematic sampling technique from a list of second- or third-trimester pregnant women obtained from health extension workers in each kebele of the respective towns. Proportional sample size allocation was used to select a representative sample from the three towns. The sample size was determined using a single population proportion formula considering the following assumptions: magnitude of missed opportunity of institutional delivery in urban context 50%, 4.5% level of significance (α=0.045). The final sample size was adjusted for a non-response rate of 10% and the total sample arrived at was 522. The outcome variable, missed opportunity of institutional delivery, identified the pregnant women who planned for institutional delivery but unfortunately ended up with home child birth. Data were collected through face-to-face interviews using a structured and pre-tested questionnaire while conducting house-to-house survey. Final-year diploma midwifery students who were capable of taking obstetric histories collected the data. Two midwives from the health institution supervised the data-collection process. The data collection had two phases. In phase I, pregnant women were interviewed to assess their socio-demographic profile, preference about place of delivery (home or health institution) and some factors associated with their planned place of delivery. In phase II, the pregnant women who had been interviewed in phase I were revisited after 6 months to determine their actual place of delivery and the associated factors for their actual place of delivery (home or health institution). Data analysis was performed using SPSS version 16.0. Variables reaching a p-value of 0.2 on bivariate analysis were included in multiple logistic regression analysis and p-values of <0.05 were considered significant. The degree of association between the independent and dependent variables was analysed using odds ratios with 95% confidence intervals. Ethical clearance was obtained from the Institutional Review Board (IRB) of Mekelle University, College of Health Sciences. A formal letter of cooperation was sent to South Tigray Zone Health Bureau and a formal letter of permission was obtained. Finally, written informed consent was obtained from each pregnant woman.

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Based on the information provided, here are some potential innovations that could improve access to maternal health:

1. Mobile health clinics: Implementing mobile health clinics that can travel to different urban areas, providing maternal health services and skilled birth attendants to pregnant women who may not have easy access to healthcare institutions.

2. Community health workers: Training and deploying community health workers who can provide education, support, and basic maternal health services to pregnant women in urban areas, ensuring they have the necessary information and resources for a safe delivery.

3. Telemedicine: Utilizing telemedicine technology to connect pregnant women in urban areas with healthcare professionals, allowing them to receive virtual consultations, guidance, and support throughout their pregnancy and delivery.

4. Birth preparedness and complication readiness programs: Implementing comprehensive programs that educate pregnant women in urban areas about the importance of birth preparedness and complication readiness, ensuring they have the necessary knowledge and resources to plan for a safe delivery.

5. Financial incentives: Introducing financial incentives or subsidies for pregnant women in urban areas who choose to deliver in healthcare institutions, making it more affordable and accessible for them to receive skilled birth attendance.

6. Public-private partnerships: Collaborating with private healthcare providers to establish more healthcare institutions in urban areas, increasing the availability and accessibility of skilled birth attendants for pregnant women.

7. Transportation support: Providing transportation support, such as free or subsidized transportation services, to pregnant women in urban areas who may face challenges in accessing healthcare institutions for delivery.

These innovations aim to address the identified factors affecting unplanned home delivery in urban settings and improve access to skilled birth attendance for pregnant women in South Tigray Zone, Ethiopia.
AI Innovations Description
Based on the research findings, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Strengthening Antenatal Care: Implement strategies to increase antenatal clinic visits for pregnant women, especially those in urban settings. This can be achieved through community outreach programs, health education campaigns, and providing incentives for attending antenatal care appointments.

2. Enhancing Education and Awareness: Develop educational programs targeting illiterate mothers and single women to increase their knowledge about the importance of institutional delivery and the risks associated with home births. This can be done through community workshops, radio programs, and the use of visual aids.

3. Promoting Birth Preparedness and Complication Readiness: Implement interventions to improve birth preparedness and complication readiness among pregnant women. This can include providing information on emergency transport options, encouraging the creation of birth plans, and ensuring access to emergency obstetric care services.

4. Empowering Women: Address factors related to poor autonomy by promoting women’s empowerment and gender equality. This can be achieved through initiatives that provide women with access to education, economic opportunities, and decision-making power within their households.

5. Strengthening Health Systems: Improve the availability and quality of maternal health services in urban settings. This can involve increasing the number of skilled birth attendants, improving infrastructure and equipment in health facilities, and ensuring the availability of essential drugs and supplies.

By implementing these recommendations, it is possible to reduce the number of missed opportunities for institutional delivery and improve access to maternal health services in urban settings.
AI Innovations Methodology
To improve access to maternal health in urban settings, the following innovations and recommendations can be considered:

1. Mobile Health (mHealth) Applications: Develop and implement mobile applications that provide pregnant women with information on antenatal care, birth preparedness, and the nearest healthcare facilities. These apps can also send reminders for appointments and provide access to teleconsultations with healthcare providers.

2. Community Health Workers (CHWs): Train and deploy CHWs in urban areas to provide education, support, and referrals for pregnant women. CHWs can conduct home visits, assist with birth preparedness, and provide information on the importance of skilled birth attendants.

3. Transportation Support: Establish transportation systems or partnerships to ensure pregnant women have access to reliable and affordable transportation to healthcare facilities. This can include subsidized transportation vouchers, community-based transportation services, or partnerships with ride-sharing companies.

4. Maternity Waiting Homes: Establish maternity waiting homes near healthcare facilities to accommodate pregnant women who live far away. These homes provide a safe and comfortable place for women to stay during the final weeks of pregnancy, ensuring they are close to the facility when labor begins.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Baseline Data Collection: Collect data on the current rates of institutional delivery, missed opportunities, and factors affecting unplanned home delivery in urban settings. This can be done through surveys, interviews, and analysis of existing health records.

2. Intervention Design: Develop a simulation model that incorporates the recommended innovations and their potential impact on access to maternal health. This model should consider factors such as the population size, availability of resources, and existing healthcare infrastructure.

3. Data Input: Input relevant data into the simulation model, including the number of pregnant women, the coverage and effectiveness of the interventions, and any other relevant variables.

4. Simulation Run: Run the simulation model to simulate the impact of the recommendations on improving access to maternal health. This can include estimating the number of additional women who would have access to skilled birth attendants, the reduction in missed opportunities, and the potential decrease in maternal mortality and morbidity.

5. Sensitivity Analysis: Conduct sensitivity analysis to assess the robustness of the simulation results. This involves testing the model with different input parameters to determine the range of potential outcomes.

6. Evaluation and Monitoring: Continuously evaluate and monitor the implementation of the recommendations to assess their effectiveness and make any necessary adjustments. This can involve collecting data on the actual impact of the interventions and comparing it to the simulated results.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of these recommendations on improving access to maternal health in urban settings and make informed decisions on their implementation.


Statistics:
Citations: 35
Identifiers:
DOI: 10.3402/gha.v8.28082
Research Areas:
Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Workforce
Study Countries:
Ethiopia
Study Design:
Cohort Study, Cross Sectional Study, Grounded Theory, randomised-control-trial
Study Approach:
Quantitative
Participants Gender:
Female
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