Predisposing, enabling and need factors associated with skilled delivery care utilization among reproductive-aged women in Kersa district, eastern Ethiopia

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Study Justification:
– Skilled delivery care utilization in Ethiopia is low compared to global goals, leading to high maternal morbidity and mortality.
– Understanding the factors associated with skilled delivery care utilization is crucial for improving maternal health outcomes.
– This study aims to explore the predisposing, enabling, and need factors associated with skilled delivery care utilization among reproductive-aged women in Kersa district, eastern Ethiopia.
Highlights:
– More than a quarter (30.8%) of the women surveyed used skilled delivery care for their most recent birth.
– Predisposing factors associated with skilled delivery care utilization include the presence of educated family members, receiving education on maternal health, previous use of skilled delivery care, and best friend’s use of maternal care.
– The enabling factor that predicted skilled delivery care use was the place of residence.
– Antenatal care attendance and pregnancy intention were significant need factors associated with skilled delivery care utilization.
Recommendations:
– Establish community-based peer education programs to increase awareness and knowledge about skilled delivery care.
– Improve access to family planning services to reduce unintended pregnancies.
– Increase antenatal care uptake to ensure early detection and management of pregnancy-related complications.
– Facilitate access to skilled delivery care in rural areas through the establishment of more health centers and health posts.
Key Role Players:
– Ministry of Health: Responsible for policy development and implementation of maternal health programs.
– Local government authorities: Involved in coordinating and supporting the implementation of community-based programs.
– Health Extension Workers: Provide primary healthcare services and can play a role in community-based peer education programs.
– Non-governmental organizations: Can provide support and resources for implementing maternal health interventions.
Cost Items for Planning Recommendations:
– Training and capacity building for health workers and community volunteers.
– Development and dissemination of educational materials for community-based peer education programs.
– Infrastructure development to improve access to skilled delivery care in rural areas.
– Provision of family planning services and commodities.
– Monitoring and evaluation of program implementation.
Note: The actual cost of implementing these recommendations will depend on various factors and needs to be determined through a detailed budgeting process.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on a community-based cross-sectional study with a large sample size (n=1294) and systematic sampling techniques were used to select participants. The study also used bivariate and multivariate logistic regression analyses to assess the association of factors with skilled delivery care utilization. However, to improve the evidence, the study could have included a control group for comparison and conducted a longitudinal study to establish causality.

Background: Skilled delivery care utilization in Ethiopia is still very low compared with the goal set by the global community for countries with the highest maternal mortality. As a result, the country is overburdened with high maternal morbidity and mortality. We aimed to explore the predisposing, enabling, and need factors associated with skilled delivery care utilization among reproductive-aged women in Kersa district, eastern Ethiopia. Methods: A community-based cross-sectional study was conducted with a total of 1294 women. The participants were selected using systematic sampling techniques. An interviewer-administered structured questionnaire aided by an electronic survey tool was used to collect data. Univariate analyses were conducted to describe the study sample. Bivariate and multivariate logistic regression analyses were carried out to elicit the association of predisposing, enabling, and need factors associated with skilled delivery care utilization. Separate multivariate models were fitted for primiparous and multiparous women categories. Odds ratios with 95% confidence intervals were used to assess statistical significance. Results: More than a quarter (30.8%) of the women surveyed used skilled delivery care for their most recent birth. Significant predisposing factors were as follows: presence of educated family member; receiving education on maternal health; previous use of skilled delivery care; and best friend’s use of maternal care. Place of residence was the enabling factor that predicted skilled delivery care use. Antenatal care attendance and pregnancy intention were significant need factors associated with skilled delivery care utilization. Conclusion: The findings of the study highlight the need for a concerted effort to establish community-based peer education programs; improve access to family planning services (to reduce unintended pregnancies); increase antenatal care uptake; and facilitate access to skilled delivery care in rural areas.

The study was conducted in Kersa district, East Hararghe zone, Oromia region, eastern Ethiopia. Kersa town, the capital of the district, is located 486 kms from Addis Ababa, the capital city of Ethiopia. The total population of the district was 205,628, as of the 2014 population projection for Ethiopia. In the district, there were 38 kebeles (the lowest administrative unit in Ethiopia consisting of 5000 people or 1000 households) or so-called subdistricts. From the 38 kebeles, three were urban, and 35 were rural [29, 30], and 24 kebeles were under the Health and Demographic Surveillance System (HDSS). There were seven health centres, 34 health posts and eight private pharmacies in the district. The health centres routinely provide the recommended packages of ANC, skilled delivery care and postnatal care. Based on a recent report from the district health office, the health coverage of the district was 80% [31]. The study was conducted from June to August 2017. A community-based cross-sectional study was implemented. The population for the study were all reproductive-aged women living in the Kersa district. Only women who had at least one birth within the previous 3 years, had lived in the district for more than 6 months, and had delivered their most recent baby after 28 weeks of gestation were included. Women who were critically ill, and physically or mentally disabled were excluded from the study. The total sample size for the study (n = 1320) was primarily calculated for a study on maternal health service utilization and associated factors in Kersa district, eastern Ethiopia using different parameters. Twenty-five percent of the total 38 kebeles in the district (i.e. 10 kebeles) were included in the study to ensure optimum sample representation. Of the included kebeles, two were urban, and eight were rural. The study district was first stratified into urban and rural kebeles, and these were further classified into HDSS and non-HDSS kebeles. A proportional number of study kebeles were then selected from each stratum using simple random sampling technique. To select the individual study participants, first, the number of households having at least one eligible woman was determined in each kebele using the Health Extension Workers’ logbook. Since the number of households with eligible women varied among the included kebeles, the total sample size of the study was proportionally allocated to each selected kebele. The total calculated sample size was then proportionally allocated to each kebele based on the determined number of households with eligible women for each kebele. The study participants were drawn from the list of households having eligible women using systematic random sampling techniques. The participants were recruited at the time of the survey based on a pre-identified list of randomly selected households. In the event of two or more eligible women being in the same household, only one woman was randomly selected and interviewed to avoid intra-household correlations. Skilled delivery care utilization: women who have received delivery care from a skilled health worker (doctors, midwives/nurses, or health officers) at the time of labour and parturition of their most recent baby irrespective of the setting in which the birth occurs. A supervisor and eight enumerators were involved in the data collection process. The data were collected using a structured questionnaire administered by face to face interviews at the participant’s home. The survey questionnaire was adapted from relevant literature [32–36] that addresses maternal health service utilization. Variables were measured using closed ended questions and participants were queried about basic socio-demographic variables; reproductive histories; primary health care services; health promotion and women’s autonomy; pregnancy status and maternal health service utilization; social network; and, social support. Using the translation-back-translation method, first, the original English version of the questionnaire was translated to the local language, Oromiffa. The Oromiffa version was then translated back into English by a translator who was not involved in the first phase of the translation process. The interviews were conducted using the local language. An off-line mode of digital data collection software (Survey Gizmo) installed on iPads was used to collect the responses. Kersa HDSS resident enumerators fluent in the local language conducted the individual interviews. A field supervisor and the lead author closely monitored the data collection at the field level. Pre-testing of the tool was carried out on 5% of the sample of women in the adjacent district. Necessary refinements were made on the tool based on the pre-test findings. We recruited and employed experienced local data collectors and a supervisor. Intensive training was provided to the data collectors and the supervisor on the objectives of the study, methodology, and sampling procedures and how to use the iPads for collecting responses. The use of iPads during data collection prevented the potential for incomplete responses and missing values. At the field level, 10% of the interviewed women were re-interviewed by the supervisor to check the validity of the responses. During the quality check, if the supervisor found any invalid response on the Survey Gizmo, the interviewer revisited the house and interviewed the woman again. The enumerators uploaded the responses daily to the online version of Survey Gizmo. The responses were then double-checked daily by the lead author for any inconsistencies. Data were analyzed using SPSS version 23 software package. We conducted the transformation of some of the variables to allow for undertaking a meaningful analysis. For the transformation, we used either recoding (through collapsing categories of some nominal variables and categorizing continuous variables) or creating new variables from the existing ones using statistical computation techniques. Univariate analyses were conducted to descriptively summarize the characteristics of the sample population. The existence of multicollinearity between covariates was determined using a Variance Inflation Factor value less than five. The multivariate model fitness was verified using Hosmer-Lemeshow test. Bivariate logistic regression analysis was carried out to compare utilization of skilled delivery care among different groups using p-value. Variables that showed statistical association at a p-value less than 0.05 from each set of variables in the bivariate analysis were entered into the final full multivariate logistic regression model. Two multivariate logistic regression models were fitted (Model 1 for multiparous women and Model 2 for primiparas women) to identify factors associated with skilled delivery care utilization. The measure of association using Adjusted Odds Ratios (AOR) with Confidence Intervals (CI) was used to assess the direction as well as the strength of the association between the explanatory and the outcome variables. The study was conducted after securing ethical approval from the Human Research Ethics Committee of the University of Newcastle, Australia and the Institutional Health Research Ethics Review Committee of College of Health and Medical Sciences, Haramaya University, Ethiopia. Informed verbal consent was obtained from each respondent before commencing the interviews. The confidentiality of the respondents was ensured by avoiding personal identification details. During house-to-house interviews, the participants’ privacy was maintained by carrying out the interviews in a separate place in their residence where auditory and visual privacy was assured.

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

1. Community-based peer education programs: Establishing programs where trained community members educate and raise awareness about maternal health can help disseminate important information and encourage women to seek skilled delivery care.

2. Improved access to family planning services: Ensuring that women have access to a range of contraceptive methods and family planning services can help reduce unintended pregnancies, which in turn can lead to better maternal health outcomes.

3. Increased antenatal care uptake: Encouraging pregnant women to attend regular antenatal care visits can help identify and address any potential complications early on, improving the chances of a safe delivery.

4. Facilitated access to skilled delivery care in rural areas: Implementing strategies to improve access to skilled delivery care in rural areas, such as mobile clinics or transportation services, can help overcome geographical barriers and ensure that women in remote areas can access the care they need.

These innovations, along with other interventions, can contribute to improving access to maternal health and reducing maternal morbidity and mortality rates.
AI Innovations Description
Based on the findings of the study, here is a recommendation that can be developed into an innovation to improve access to maternal health:

Establish community-based peer education programs: The study found that receiving education on maternal health and the previous use of skilled delivery care were significant predisposing factors associated with skilled delivery care utilization. Therefore, developing community-based peer education programs can help increase awareness and knowledge about the importance of skilled delivery care among reproductive-aged women. These programs can be implemented by training and empowering local women who have already utilized skilled delivery care to serve as peer educators. They can provide information, support, and guidance to pregnant women and their families, addressing any misconceptions or fears they may have about skilled delivery care.

The innovation can include the following components:
1. Identification and training of peer educators: Identify women who have successfully utilized skilled delivery care and provide them with comprehensive training on maternal health, including the benefits of skilled delivery care, the importance of antenatal care, and the availability of services in their community.
2. Community engagement: Organize community meetings, workshops, and awareness campaigns to disseminate information about skilled delivery care and the role of peer educators. Engage local leaders, community organizations, and religious institutions to support and promote the program.
3. Peer-to-peer support: Establish a system where pregnant women can connect with peer educators for guidance and support throughout their pregnancy journey. This can be done through regular meetings, phone calls, or even online platforms.
4. Monitoring and evaluation: Implement a monitoring and evaluation system to assess the effectiveness of the program. Collect data on the number of women reached, changes in knowledge and attitudes towards skilled delivery care, and the utilization of services. Use this data to continuously improve and adapt the program.

By implementing community-based peer education programs, pregnant women in rural areas of Ethiopia can receive accurate information, support, and encouragement to utilize skilled delivery care. This innovation can help address the predisposing, enabling, and need factors identified in the study and ultimately improve access to maternal health services, reducing maternal morbidity and mortality.
AI Innovations Methodology
Based on the provided study, here are some potential recommendations for innovations to improve access to maternal health:

1. Community-based peer education programs: Establishing programs that educate and empower community members, particularly women, to become peer educators on maternal health. These peer educators can provide information, support, and guidance to pregnant women and new mothers in their communities, helping to increase awareness and utilization of skilled delivery care.

2. Improved access to family planning services: Strengthening and expanding family planning services to reduce unintended pregnancies. This can include increasing the availability and accessibility of contraceptives, providing comprehensive family planning counseling, and addressing cultural and social barriers to family planning.

3. Increased antenatal care uptake: Implementing strategies to encourage pregnant women to seek and attend antenatal care services. This can involve community outreach programs, health education campaigns, and incentives for early and regular antenatal care visits.

4. Facilitating access to skilled delivery care in rural areas: Addressing the geographical barriers faced by women in rural areas by improving transportation infrastructure, establishing mobile health clinics, and ensuring the availability of skilled birth attendants in remote areas.

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

1. Data collection: Gather baseline data on the current utilization of skilled delivery care, as well as information on the predisposing, enabling, and need factors identified in the study.

2. Model development: Develop a simulation model that incorporates the identified factors and their relationships with skilled delivery care utilization. This model can be based on statistical regression analysis, using the data collected in the study.

3. Scenario development: Create different scenarios that represent the potential impact of the recommended innovations. For example, one scenario could simulate the effect of implementing community-based peer education programs, while another scenario could simulate the impact of improving access to family planning services.

4. Parameter estimation: Estimate the parameters of the simulation model based on available data and expert knowledge. This may involve conducting additional surveys or literature reviews to gather relevant information.

5. Simulation runs: Run the simulation model using the different scenarios and parameter values. This will generate estimates of the potential impact of each recommendation on improving access to skilled delivery care.

6. Analysis and interpretation: Analyze the simulation results to assess the effectiveness of each recommendation and compare their potential impacts. This can involve comparing the changes in skilled delivery care utilization rates, identifying key factors that contribute to the improvements, and evaluating the cost-effectiveness of each recommendation.

By following this methodology, policymakers and stakeholders can gain insights into the potential benefits and challenges of implementing different innovations to improve access to maternal health. This can inform decision-making and resource allocation for maternal health programs and interventions.

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