Maternal and newborn health services utilization in Jimma Zone, Southwest Ethiopia: A community based cross-sectional study

BMC Pregnancy and Childbirth, Volume 19, No. 1, Year 2019

Interpretation

Background: Majority of causes of maternal and newborn mortalities are preventable. However, poor access to and low utilization of health services remain major barriers to optimum health of the mothers and newborns. The objectives of this study were to assess maternal and newborn health services utilization and factors affecting mothers’ health service utilization. Methods: A community based cross-sectional survey was carried out on randomly selected mothers who gave birth within a year preceding the survey. The survey was supplemented with key informant interviews of experts/health professionals. Multivariable logistic model was used to identify factors associated with service utilization. Adjusted odds ratios (AORs) were used to assess the strength of the associations at p-value ≤0.05. The qualitative data were summarized thematically. Results: A total of 789 (99.1% response rate) mothers participated in the study. The proportion of the mothers who got at least one antennal care (ANC) visit, institutional delivery and postnatal care (PNC) were 93.3, 77.4 and 92.0%, respectively. Three-forth (74.2%) of the mothers started ANC lately and only 47.5% of them completed ANC4+ visits. Medium (4-6) family size (AOR: 2.3; 95% CI: 1.1, 4.9), decision on ANC visits with husband (AOR: 30.9; 95% CI: 8.3, 115.4) or husband only (AOR: 15.3; 95%CI: 3.8, 62.3) and listening to radio (AOR: 2.5; 95%CI: 1.1, 5.6) were associated with ANC attendance. Mothers whose husbands read/write (AOR: 1.6; 95% CI: 1.1, 2.), attended formal education (AOR: 2.8; 95% CI: 1.1, 6.8), have positive attitudes (AOR: 10.2; 95% CI: 25.9), living in small (AOR: 3.0; 95% CI: 1.2, 7.6) and medium size family (AOR: 2.3; 95% CI: 1.2, 4.1) were more likely to give birth in-health facilities. The proportion of PNC checkups among mothers who delivered in health facilities and at home were 92.0 and 32.5%, respectively. The key informants mentioned that home delivery, delayed arrival of the mothers, unsafe delivery settings, shortage of skilled personnel and supplies were major obstacles to maternal health services utilization. Conclusions: Health information communication targeting husbands may improve maternal and newborn health services utilization. In service training of personnel and equipping health facilities with essential supplies can improve the provider side barriers. The study was conducted in selected districts of Jimma Zone, which is located 352 kms from the capital Addis Ababa in southwest of Ethiopia. According to projection of 2007 population census, the zone has an estimated population of 3,261,371 (49.9% women) in the year 2017. From the total females, 23.1% were women in the child bearing age (WCBA), which imply a total of 753,377 WCBA residing in the zone. The zone consists of 20 rural districts and one special town administration (Agaro Town), 46 small urban and 512 rural kebeles (smallest formal administrative units). This study was conducted from 06 to 18 September 2017 as part of maternal and neonatal intervention baseline assessment of the rural districts. This was supplemented by key informant interviews of heads/experts of the district health offices and health centers. The study population for the questionnaire-based surveys of this study was WCBA who gave birth within one year preceding the survey. The heads/experts of district health offices and heads/experts of the heath institutions that have been at the position at least for six months during the survey were included into the key informant interviews. The data analyzed for this study are from a baseline study of maternal and newborn interventions, which has a control arm for the purpose of comparison after the intervention. Therefore, the sample size was determined using two-population proportion formula; considering 95% confidence interval, power of 80% to detect at least 10% difference between the two groups after the intervention. Based on previous community based study [7], the total sample size was estimated based on the study objective, using the variable which gives the largest sample size (#758) among the indicators of service utilization of WCBA. Assuming 5% non-response rate, the final sample size was estimated to be 796 respondents. Initially six districts (30% of the 20 districts) were selected purposely considering absence of other maternal and newborn intervention projects and their representativeness in terms of agroecological climate and physical accessibility to health services. Simple random sampling technique was employed to recruit the interviewed WCBA for the community-based study. A fresh list of mothers who gave births during a year preceding the study was obtained from health extension workers and used as sampling frames. The sample size was allocated to each selected kebele proportionally to the size of WCBA who fulfilled the inclusion criteria. Finally, selection of the study subjects was made randomly and independently based on the prepared list within each kebele until the required sample size was achieved (Fig. (Fig.11). schematic presentation of sampling procedures Furthermore, in-depth interviews of 30% of heads/experts of public health institutions and all district health offices of the districts were done. Accordingly, key informant interviews of 11 experts from public health institutions and six heads/experts of district health offices of the study districts were carried out. The WCBA data was collected by interviewer-administered questionnaire (Additional file 2) whereas interview guide (Additional file 1) was used for the in-depth interviews. Twelve (two per district) data collectors who hold bachelor degree in health science fields and who are trained for two days collected the survey data. Similarly, six master degree holders in health discipline supervised the quantitative data collection and conducted the qualitative study using guidelines prepared for these purposes. The data collection tools for the survey were pretested on 5% of the sample size outside the study setting before the commencement of the actual work. Sufficient training was given to data collectors and supervisors. In addition, the day-to-day activities of the data collection were closely supervised by the investigators. Data entry template was designed in EpiData version 3.1 to control error entries. Data were checked, cleaned, and entered into EpiData version 3.1. Afterwards, data were exported and analyzed using SPSS® (IBM SPSS Statistics for Macintosh, Version 21.0. Armonk, NY). Both descriptive statistics and multivariable analytical model were used to summarize the data and identify association of independent variables with outcomes of the study, respectively. Based on a previous study definition [36], respondents who could correctly identify at least three key danger signs related to pregnancy, labor and delivery were considered to be knowledgeable of the key danger signs, or otherwise not. Adjusted odds ratios (AORs) with their corresponding 95% CIs were used to assess the strength of the associations at p-value ≤ 0.05 cut-off point for statistical significance. Additionally, qualitative data was transcribed and analyzed thematically.

AI Digest

Study Justification:

– Majority of maternal and newborn mortalities are preventable, but access to and utilization of health services remain barriers.
– This study aims to assess maternal and newborn health services utilization and identify factors affecting utilization.
– The findings will provide valuable insights for improving health services and reducing maternal and newborn mortalities.

Highlights:

– 789 mothers participated in the study, with a high response rate of 99.1%.
– Proportions of mothers receiving at least one antenatal care (ANC) visit, institutional delivery, and postnatal care (PNC) were 93.3%, 77.4%, and 92.0% respectively.
– Factors associated with ANC attendance included medium family size, decision on ANC visits with husband or husband only, and listening to the radio.
– Factors associated with giving birth in health facilities included husbands who can read/write, attended formal education, have positive attitudes, and living in small or medium-sized families.
– PNC checkups were higher among mothers who delivered in health facilities compared to those who delivered at home.
– Key informants identified home delivery, delayed arrival of mothers, unsafe delivery settings, shortage of skilled personnel, and supplies as major obstacles to maternal health services utilization.

Recommendations:

– Health information communication targeting husbands may improve maternal and newborn health services utilization.
– In-service training of personnel and equipping health facilities with essential supplies can improve provider-side barriers.

Key Role Players:

– District health offices
– Health centers
– Health extension workers
– Public health institutions
– Experts in maternal and newborn health

Cost Items for Planning Recommendations:

– Training programs for health personnel
– Equipment and supplies for health facilities
– Communication materials for health information targeting husbands
– Monitoring and evaluation activities to assess the impact of interventions
Please note that the cost items provided are general categories and not actual cost estimates.

Strength of Evidence

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong, with a high response rate and a large sample size. The study utilized a community-based cross-sectional survey and included key informant interviews. Multivariable logistic regression was used to identify factors associated with service utilization. The study also provided adjusted odds ratios and qualitative data analysis. To improve the evidence, the abstract could include more information on the sampling procedure and the representativeness of the selected districts. Additionally, providing more details on the training given to data collectors and supervisors would enhance the study’s transparency.

Abstract

The study was conducted in selected districts of Jimma Zone, which is located 352 kms from the capital Addis Ababa in southwest of Ethiopia. According to projection of 2007 population census, the zone has an estimated population of 3,261,371 (49.9% women) in the year 2017. From the total females, 23.1% were women in the child bearing age (WCBA), which imply a total of 753,377 WCBA residing in the zone. The zone consists of 20 rural districts and one special town administration (Agaro Town), 46 small urban and 512 rural kebeles (smallest formal administrative units). This study was conducted from 06 to 18 September 2017 as part of maternal and neonatal intervention baseline assessment of the rural districts. This was supplemented by key informant interviews of heads/experts of the district health offices and health centers. The study population for the questionnaire-based surveys of this study was WCBA who gave birth within one year preceding the survey. The heads/experts of district health offices and heads/experts of the heath institutions that have been at the position at least for six months during the survey were included into the key informant interviews. The data analyzed for this study are from a baseline study of maternal and newborn interventions, which has a control arm for the purpose of comparison after the intervention. Therefore, the sample size was determined using two-population proportion formula; considering 95% confidence interval, power of 80% to detect at least 10% difference between the two groups after the intervention. Based on previous community based study [7], the total sample size was estimated based on the study objective, using the variable which gives the largest sample size (#758) among the indicators of service utilization of WCBA. Assuming 5% non-response rate, the final sample size was estimated to be 796 respondents. Initially six districts (30% of the 20 districts) were selected purposely considering absence of other maternal and newborn intervention projects and their representativeness in terms of agroecological climate and physical accessibility to health services. Simple random sampling technique was employed to recruit the interviewed WCBA for the community-based study. A fresh list of mothers who gave births during a year preceding the study was obtained from health extension workers and used as sampling frames. The sample size was allocated to each selected kebele proportionally to the size of WCBA who fulfilled the inclusion criteria. Finally, selection of the study subjects was made randomly and independently based on the prepared list within each kebele until the required sample size was achieved (Fig. (Fig.11). schematic presentation of sampling procedures Furthermore, in-depth interviews of 30% of heads/experts of public health institutions and all district health offices of the districts were done. Accordingly, key informant interviews of 11 experts from public health institutions and six heads/experts of district health offices of the study districts were carried out. The WCBA data was collected by interviewer-administered questionnaire (Additional file 2) whereas interview guide (Additional file 1) was used for the in-depth interviews. Twelve (two per district) data collectors who hold bachelor degree in health science fields and who are trained for two days collected the survey data. Similarly, six master degree holders in health discipline supervised the quantitative data collection and conducted the qualitative study using guidelines prepared for these purposes. The data collection tools for the survey were pretested on 5% of the sample size outside the study setting before the commencement of the actual work. Sufficient training was given to data collectors and supervisors. In addition, the day-to-day activities of the data collection were closely supervised by the investigators. Data entry template was designed in EpiData version 3.1 to control error entries. Data were checked, cleaned, and entered into EpiData version 3.1. Afterwards, data were exported and analyzed using SPSS® (IBM SPSS Statistics for Macintosh, Version 21.0. Armonk, NY). Both descriptive statistics and multivariable analytical model were used to summarize the data and identify association of independent variables with outcomes of the study, respectively. Based on a previous study definition [36], respondents who could correctly identify at least three key danger signs related to pregnancy, labor and delivery were considered to be knowledgeable of the key danger signs, or otherwise not. Adjusted odds ratios (AORs) with their corresponding 95% CIs were used to assess the strength of the associations at p-value ≤ 0.05 cut-off point for statistical significance. Additionally, qualitative data was transcribed and analyzed thematically.

Materials

Innovations

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

1. Mobile Health (mHealth) Applications: Develop mobile applications that provide information and reminders about antenatal care visits, institutional delivery, and postnatal care. These apps can also educate women about key danger signs during pregnancy, labor, and delivery.

2. Telemedicine: Implement telemedicine services to connect pregnant women in remote areas with healthcare professionals. This would allow them to receive medical advice, consultations, and monitoring without having to travel long distances.

3. Community Health Workers: Train and deploy community health workers to provide maternal health services, education, and support in rural areas. These workers can conduct home visits, assist with antenatal and postnatal care, and refer women to health facilities when necessary.

4. Health Information Campaigns: Launch targeted health information campaigns that specifically involve husbands and other family members. These campaigns can emphasize the importance of maternal health services and encourage family support for women to access and utilize these services.

5. Strengthening Health Facilities: Improve the infrastructure, staffing, and availability of essential supplies in health facilities to address the barriers mentioned in the study. This would ensure that women have access to safe delivery settings and skilled personnel during childbirth.

6. Financial Incentives: Introduce financial incentives, such as conditional cash transfers or vouchers, to encourage women to seek and utilize maternal health services. This can help offset the costs associated with transportation, facility fees, and other expenses.

7. Collaborations and Partnerships: Foster collaborations and partnerships between government agencies, non-governmental organizations, and private sector entities to pool resources and expertise in addressing the barriers to maternal health services utilization.

These innovations have the potential to improve access to maternal health services, increase utilization rates, and ultimately reduce maternal and newborn mortalities in the study area.

AI Innovations Description

Based on the study conducted in Jimma Zone, Southwest Ethiopia, there are several recommendations that can be used to develop innovations to improve access to maternal health:

1. Health information communication targeting husbands: The study found that involving husbands in decision-making regarding antenatal care (ANC) visits was associated with higher ANC attendance. Therefore, developing innovative strategies to educate and engage husbands in maternal health can improve utilization of maternal health services.

2. In-service training of personnel: The study identified a shortage of skilled personnel as a major obstacle to maternal health services utilization. Providing ongoing training and professional development opportunities for healthcare providers can enhance their knowledge and skills, leading to improved quality of care and increased utilization of services.

3. Equipping health facilities with essential supplies: Another barrier to maternal health services utilization mentioned in the study was the shortage of essential supplies in health facilities. Ensuring that health facilities have adequate and reliable supplies of medications, equipment, and other necessary resources can improve the accessibility and quality of maternal health services.

4. Improving access to health facilities: The study found that women living in small and medium-sized families were more likely to give birth in health facilities. Innovations that improve transportation infrastructure, such as providing ambulances or establishing mobile health clinics, can help overcome geographical barriers and increase access to health facilities for pregnant women.

5. Promoting positive attitudes towards maternal health: The study found that women whose husbands had positive attitudes towards maternal health were more likely to give birth in health facilities. Implementing community-based interventions, such as awareness campaigns and community dialogues, can help promote positive attitudes towards maternal health and encourage women to seek care.

Overall, these recommendations highlight the importance of addressing both demand-side and supply-side barriers to improve access to maternal health services. By implementing innovative strategies that target husbands, healthcare providers, and the overall healthcare system, it is possible to enhance utilization of maternal health services and ultimately improve maternal and newborn health outcomes.

AI Innovations Methodology

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

1. Health Information Communication: Targeting husbands with health information can improve maternal and newborn health services utilization. This can be done through educational campaigns, community outreach programs, and the use of mass media platforms such as radio and television.

2. In-Service Training: Providing training to healthcare personnel on maternal health issues and equipping them with essential skills can help overcome provider-side barriers. This includes training on safe delivery practices, emergency obstetric care, and postnatal care.

3. Strengthening Health Facilities: Ensuring that health facilities have adequate supplies, equipment, and skilled personnel is crucial for improving access to maternal health services. This can be achieved through infrastructure development, procurement of necessary medical supplies, and recruitment and retention of qualified healthcare professionals.

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

1. Define the indicators: Identify key indicators that measure access to maternal health services, such as the proportion of women receiving antenatal care, institutional delivery rates, and postnatal care utilization.

2. Baseline data collection: Collect baseline data on the selected indicators from the target population. This can be done through surveys, interviews, or existing health records.

3. Introduce the recommendations: Implement the recommended interventions, such as health information campaigns, in-service training programs, and facility strengthening initiatives.

4. Monitoring and data collection: Continuously monitor the implementation of the interventions and collect data on the selected indicators. This can be done through regular surveys, interviews, or health facility records.

5. Analyze the data: Analyze the collected data to assess the impact of the interventions on the selected indicators. Compare the post-intervention data with the baseline data to determine any improvements in access to maternal health services.

6. Evaluate the results: Evaluate the results of the analysis to determine the effectiveness of the recommendations in improving access to maternal health. Identify any challenges or areas for further improvement.

7. Adjust and refine: Based on the evaluation results, make any necessary adjustments or refinements to the interventions to optimize their impact on improving access to maternal health.

By following this methodology, it is possible to simulate the impact of the recommendations on improving access to maternal health and make informed decisions on how to further enhance maternal health services in the study area.

Author

Dima Health

Statistics:

Citations: 11

Identifiers:

DOI: 10.1186/s12884-019-2335-2

Research Areas:

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

Study Countries:

Ethiopia

Study Design:

Cross Sectional Study, Grounded Theory, randomised-control-trial

Study Approach:

Mixed-methods, Qualitative, Quantitative

Participants Gender:

Female