Utilization of Institutional Delivery Service in a Predominantly Pastoralist Community of Northeast Ethiopia

Ethiopian journal of health sciences, Volume 28, No. 4, Year 2018

Interpretation

Background: Maternal mortality is high in sub-Saharan Africa, and most deaths occur around childbirth. In Ethiopia, most births happen at home without skilled delivery attendants, and particularly, the least utilization of skilled delivery is recorded in Afar Region. The factors that influence this utilization are not well documented in the region where utilization has been low. The aim of this study was to determine the prevalence of utilization of institutional delivery and associated factors. Methods: A cross-section study with pretested structural questionnaire was conducted from August 5 to September 27, 2015, among women who gave birth within 24 months preceding the survey. A multivariable logistic regression analysis was done to identify factors associated with utilization of institutional delivery. Results: Out of the total 1842 women, only 339(18.4%) of mothers reported having delivered their youngest child at a health facility. Home delivery was preferred due to cultural norms, low-risk perception, and distance from a health facility. The odds of delivering in a health facility were higher for mothers who attended at least four antenatal visits during the index pregnancy (AOR=3.08,95%CI=1.91-4.96), those whose husbands were educated to secondary school (AOR= 1.86, 95% CI=1.34-2.60), and those that had at least secondary school level education themselves (AOR=1.52, 95% CI=1.03-2.23). Conclusion: Utilization of institution delivery among Afar communities is very low, and less educated mothers are lagging behind. Women’s education and full attendance to antenatal care can help increase utilization of skilled delivery services. Qualitative studies to identify socio-cultural barriers are also essential. This study was conducted in Afar Regional State, one of the nine regions in Ethiopia. The study was carried out in 6 of the 32 districts: Mille, Dubti, Gawane, Amebra, Golina and Ewa districts. The majority of the population are pastoralists and Muslims. The study area has one regional hospital, three zonal hospitals, 14 health centers and 69 health posts. Health centers are the primary access point for delivery services. Health centers are equipped with basic delivery facilities and staffed with skilled delivery attendants. a total of 235 health workers in the facilities at the time of the study and cite 2016 Afar regional health bureau report. A community-based cross-sectional study was conducted from August 5 to September 27, 2015. The study participants were all women who had resided in the study area for the past six months and gave birth in the last 24 months preceding the study. The sample size for the study was calculated using single population proportion formula, which assumed institutional delivery service utilization of 6.8%(5), 95% confidence level, margin error of 2%, design effect of 3, and 10% non-response rate. Accordingly, the calculated sample size was 2009. A multistage sampling method was used to enroll study subjects. In the first stage, three out of five zones were selected randomly. Secondly, two districts per zone were randomly selected. Then, three kebeles per district (one urban and two rural) were randomly selected. Then, a census was conducted to identify eligible mothers. Those eligible mothers were proportionally allocated to each kebeles. Mothers were selected using simple random sampling methods based on the list obtained during the census. Data were collected through face-to-face interviews using structured questionnaire adapted from the Ethiopian Demographic and Health Survey and other published literature. Initially, the questionnaire was prepared in English and then translated into Afar-afa (local language). The questionnaire consists of socio-demographic characteristics of respondents such as age of the mother, place of residence, ethnicity, religion, level of education, occupation of the mother and that of the husband and family size. It also consists of obstetrics history such as service utilization, number of antenatal visits, place for delivery, gravidity, parity, pervious history of obstructed labor and history of abortion, kind of assistance received during childbirth and information on distance between home and the nearby health facility, reasons for preferring place of delivery and decision making about the place for childbirth. The questionnaire was pretested in Awash District, not selected for the survey. Following the pretest, a debriefing session was conducted with field supervisors and data collectors to make the necessary fine-tuning of the questionnaire. Data were collected by female nurses and health extension workers drawn from areas not included in the study. All data collectors were capable of conducting interviews in the local language (Afar-afa). Data collectors and supervisors were trained for three days by the principal investigator with emphasis on proper conduct of interviews, research ethics and data handling. In some villages, interviews were conducted either during the morning or late afternoon hours in order to capture eligible pastoralist mothers while they were at their residence. In such areas, the survey team members had to stay overnight in the study villages in order to conduct interviews. The principal investigator and two supervisors checked the completeness of questionnaires on a daily basis. Data entry and cleaning were done using EPI Data 3.1. Cleaned data were transferred onto SPSS version 20.0 for analysis. Both bivariate and multivariate logistic regression analyse were run to see the association of the independent variables with the outcome variable. Those variables with p-value < 0.05 in COR were included in the multivariate analysis. The crude and adjusted odds ratios were presented with their 95% confidence intervals. Ethical clearance for the study was obtained from the College of Health Sciences Ethical Review Committee at Mekelle University. Letters of permission to conduct the fieldwork was obtained from the Afar Regional Health Bureau and the local administration office in the study districts. Voluntary informed verbal consent was obtained from each study participant.

AI Digest

Study Justification:

– Maternal mortality is high in sub-Saharan Africa, with most deaths occurring around childbirth.
– In Ethiopia, most births happen at home without skilled delivery attendants.
– The least utilization of skilled delivery is recorded in Afar Region.
– The factors that influence this low utilization are not well documented in the region.

Study Highlights:

– The study aimed to determine the prevalence of utilization of institutional delivery and associated factors in Afar Region, Ethiopia.
– A cross-sectional study was conducted among women who gave birth within 24 months preceding the survey.
– Only 18.4% of mothers reported delivering their youngest child at a health facility.
– Home delivery was preferred due to cultural norms, low-risk perception, and distance from a health facility.
– Factors associated with higher utilization of institutional delivery included attending at least four antenatal visits, husbands’ education to secondary school level, and mothers’ education to at least secondary school level.
– The study highlights the importance of women’s education and full attendance to antenatal care in increasing utilization of skilled delivery services.

Study Recommendations:

– Increase awareness and education on the benefits of institutional delivery among the Afar communities.
– Improve access to antenatal care services and encourage women to attend at least four visits during pregnancy.
– Provide education and support to husbands and families to promote the importance of skilled delivery.
– Conduct qualitative studies to identify and address socio-cultural barriers to institutional delivery.

Key Role Players:

– Ministry of Health: Responsible for policy development and implementation of interventions to improve institutional delivery services.
– Regional Health Bureau: Responsible for coordinating and overseeing healthcare services in the Afar Region.
– Health Centers and Hospitals: Provide delivery services and need to be adequately staffed and equipped.
– Community Health Workers: Play a crucial role in educating and mobilizing the community towards utilizing institutional delivery services.
– Non-Governmental Organizations (NGOs): Can provide support in terms of education, training, and resources to improve institutional delivery services.

Cost Items for Planning Recommendations:

– Education and awareness campaigns: Printing of educational materials, community meetings, and media campaigns.
– Training programs: Training healthcare providers, community health workers, and volunteers on maternal health and delivery services.
– Infrastructure improvement: Upgrading health centers and hospitals to ensure they have the necessary facilities for safe deliveries.
– Transportation: Providing transportation options for pregnant women to reach health facilities.
– Monitoring and evaluation: Establishing systems to monitor the implementation and impact of interventions.
Please note that the provided cost items are general suggestions and the actual cost will depend on the specific context and implementation plan.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study utilized a cross-sectional design and a multivariable logistic regression analysis to identify factors associated with utilization of institutional delivery. The sample size was calculated using an appropriate formula, and a multistage sampling method was used to enroll study subjects. Data were collected through face-to-face interviews using a structured questionnaire adapted from established sources. However, the study did not provide information on the response rate, which could affect the generalizability of the findings. Additionally, the study relied on self-reported data, which may be subject to recall bias. To improve the strength of the evidence, future studies could consider using a longitudinal design to establish causality and include objective measures of utilization of institutional delivery services.

Abstract

This study was conducted in Afar Regional State, one of the nine regions in Ethiopia. The study was carried out in 6 of the 32 districts: Mille, Dubti, Gawane, Amebra, Golina and Ewa districts. The majority of the population are pastoralists and Muslims. The study area has one regional hospital, three zonal hospitals, 14 health centers and 69 health posts. Health centers are the primary access point for delivery services. Health centers are equipped with basic delivery facilities and staffed with skilled delivery attendants. a total of 235 health workers in the facilities at the time of the study and cite 2016 Afar regional health bureau report. A community-based cross-sectional study was conducted from August 5 to September 27, 2015. The study participants were all women who had resided in the study area for the past six months and gave birth in the last 24 months preceding the study. The sample size for the study was calculated using single population proportion formula, which assumed institutional delivery service utilization of 6.8%(5), 95% confidence level, margin error of 2%, design effect of 3, and 10% non-response rate. Accordingly, the calculated sample size was 2009. A multistage sampling method was used to enroll study subjects. In the first stage, three out of five zones were selected randomly. Secondly, two districts per zone were randomly selected. Then, three kebeles per district (one urban and two rural) were randomly selected. Then, a census was conducted to identify eligible mothers. Those eligible mothers were proportionally allocated to each kebeles. Mothers were selected using simple random sampling methods based on the list obtained during the census. Data were collected through face-to-face interviews using structured questionnaire adapted from the Ethiopian Demographic and Health Survey and other published literature. Initially, the questionnaire was prepared in English and then translated into Afar-afa (local language). The questionnaire consists of socio-demographic characteristics of respondents such as age of the mother, place of residence, ethnicity, religion, level of education, occupation of the mother and that of the husband and family size. It also consists of obstetrics history such as service utilization, number of antenatal visits, place for delivery, gravidity, parity, pervious history of obstructed labor and history of abortion, kind of assistance received during childbirth and information on distance between home and the nearby health facility, reasons for preferring place of delivery and decision making about the place for childbirth. The questionnaire was pretested in Awash District, not selected for the survey. Following the pretest, a debriefing session was conducted with field supervisors and data collectors to make the necessary fine-tuning of the questionnaire. Data were collected by female nurses and health extension workers drawn from areas not included in the study. All data collectors were capable of conducting interviews in the local language (Afar-afa). Data collectors and supervisors were trained for three days by the principal investigator with emphasis on proper conduct of interviews, research ethics and data handling. In some villages, interviews were conducted either during the morning or late afternoon hours in order to capture eligible pastoralist mothers while they were at their residence. In such areas, the survey team members had to stay overnight in the study villages in order to conduct interviews. The principal investigator and two supervisors checked the completeness of questionnaires on a daily basis. Data entry and cleaning were done using EPI Data 3.1. Cleaned data were transferred onto SPSS version 20.0 for analysis. Both bivariate and multivariate logistic regression analyse were run to see the association of the independent variables with the outcome variable. Those variables with p-value < 0.05 in COR were included in the multivariate analysis. The crude and adjusted odds ratios were presented with their 95% confidence intervals. Ethical clearance for the study was obtained from the College of Health Sciences Ethical Review Committee at Mekelle University. Letters of permission to conduct the fieldwork was obtained from the Afar Regional Health Bureau and the local administration office in the study districts. Voluntary informed verbal consent was obtained from each study participant.

Materials

N/A

Innovations

Based on the information provided, here are some potential recommendations to improve access to maternal health in the Afar Region of Ethiopia:

1. Increase awareness and education: Implement community-based education programs to raise awareness about the importance of institutional delivery and the risks associated with home births. This can be done through health campaigns, community meetings, and the use of local media.

2. Improve antenatal care services: Strengthen antenatal care services by ensuring that pregnant women have access to regular check-ups, including at least four antenatal visits during their pregnancy. This can be achieved by training and deploying more skilled healthcare providers to the region and improving the availability of essential medical supplies.

3. Address cultural norms and beliefs: Conduct qualitative studies to identify and understand the socio-cultural barriers that prevent women from utilizing institutional delivery services. This information can then be used to develop targeted interventions that address these specific barriers and promote behavior change.

4. Enhance transportation infrastructure: Improve the transportation infrastructure in the region to reduce the distance and travel time between communities and health facilities. This can be done by constructing and maintaining roads, providing ambulances or other means of transportation, and establishing referral systems to ensure timely access to emergency obstetric care.

5. Involve husbands and male community members: Engage husbands and male community members in maternal health initiatives to promote their support and involvement in decision-making regarding place of delivery. This can be achieved through community sensitization programs that emphasize the importance of male involvement in maternal health and encourage men to accompany their wives to antenatal care visits and delivery.

6. Strengthen healthcare facilities: Invest in improving the capacity and quality of healthcare facilities in the region, particularly health centers that serve as the primary access point for delivery services. This includes ensuring that facilities are adequately staffed with skilled delivery attendants, equipped with necessary medical supplies and equipment, and provide a safe and supportive environment for childbirth.

7. Monitor and evaluate progress: Establish a robust monitoring and evaluation system to track the progress of interventions aimed at improving access to maternal health. This will help identify areas of success and areas that require further attention, allowing for adjustments and improvements to be made as needed.

It is important to note that these recommendations are based on the specific context of the Afar Region in Ethiopia and may need to be adapted to suit the unique needs and challenges of other regions or countries.

AI Innovations Description

Based on the study conducted in Afar Region, Ethiopia, the following recommendations can be developed into an innovation to improve access to maternal health:

1. Increase awareness and education: Implement community-based education programs to raise awareness about the importance of institutional delivery and the risks associated with home births. This can be done through health campaigns, community meetings, and the use of local media.

2. Improve antenatal care services: Strengthen antenatal care services by ensuring that pregnant women have access to at least four antenatal visits during their pregnancy. This can be achieved by training and deploying more skilled healthcare providers to rural areas, where access to healthcare is limited.

3. Address cultural norms and beliefs: Conduct qualitative studies to identify and address socio-cultural barriers that prevent women from utilizing institutional delivery services. Engage with community leaders, traditional birth attendants, and religious leaders to promote the benefits of skilled delivery and dispel misconceptions.

4. Improve infrastructure and transportation: Enhance the availability and accessibility of health facilities by investing in the construction and upgrading of health centers in rural areas. Additionally, establish reliable transportation systems, such as ambulances or mobile clinics, to ensure that women can reach healthcare facilities in a timely manner.

5. Involve male partners: Promote male involvement in maternal health by educating husbands about the importance of skilled delivery and encouraging their support in decision-making regarding the place of childbirth. This can be achieved through community sensitization programs and targeted interventions for men.

6. Strengthen healthcare workforce: Increase the number of skilled healthcare providers, particularly midwives, in rural areas to ensure that there is an adequate workforce to provide quality maternal healthcare services. Provide training and incentives to attract and retain healthcare professionals in underserved areas.

7. Monitor and evaluate progress: Establish a robust monitoring and evaluation system to track the progress of maternal health interventions and identify areas for improvement. Regularly collect data on institutional delivery rates, antenatal care utilization, and other relevant indicators to inform evidence-based decision-making.

By implementing these recommendations, it is expected that access to maternal health services will improve, leading to a reduction in maternal mortality rates in the Afar Region and similar settings.

AI Innovations Methodology

Based on the provided information, here are some potential recommendations to improve access to maternal health in the Afar Region of Ethiopia:

1. Increase awareness and education: Implement community-based education programs to raise awareness about the importance of skilled delivery attendants and the risks associated with home births. This can be done through community meetings, health campaigns, and the use of local media.

2. Improve access to antenatal care: Strengthen the availability and accessibility of antenatal care services in the region. This can include increasing the number of health centers and health posts, ensuring they are adequately staffed with skilled healthcare providers, and providing training to healthcare workers on antenatal care practices.

3. Address cultural norms and beliefs: Conduct culturally sensitive interventions to address the cultural norms and beliefs that contribute to the preference for home births. This can involve engaging with community leaders, religious leaders, and traditional birth attendants to promote the benefits of institutional delivery and dispel misconceptions.

4. Enhance transportation infrastructure: Improve transportation infrastructure, particularly in rural areas, to reduce the distance and travel time between communities and health facilities. This can include building and maintaining roads, providing transportation subsidies or vouchers for pregnant women, and establishing emergency transportation systems.

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

1. Define indicators: Identify key indicators to measure the impact of the recommendations, such as the percentage of women utilizing institutional delivery services, the number of antenatal care visits, and the reduction in maternal mortality rates.

2. Collect baseline data: Gather baseline data on the current utilization of institutional delivery services, antenatal care visits, and maternal mortality rates in the Afar Region. This can be done through surveys, interviews, and data from health facilities and government reports.

3. Develop a simulation model: Create a simulation model that incorporates the identified recommendations and their potential impact on the selected indicators. This model should consider factors such as population size, geographical distribution, cultural norms, and healthcare infrastructure.

4. Input data and run simulations: Input the baseline data into the simulation model and run multiple simulations to estimate the potential impact of the recommendations. Adjust the parameters of the model based on the expected effects of each recommendation.

5. Analyze results: Analyze the results of the simulations to determine the potential improvements in access to maternal health services. This can include quantifying the increase in institutional delivery rates, the number of additional antenatal care visits, and the potential reduction in maternal mortality rates.

6. Validate and refine the model: Validate the simulation model by comparing the simulated results with real-world data and feedback from healthcare providers and stakeholders. Refine the model based on the validation process to improve its accuracy and reliability.

7. Communicate findings: Present the findings of the simulation study to policymakers, healthcare providers, and other relevant stakeholders. Use the results to advocate for the implementation of the recommended interventions and to guide decision-making processes related to improving access to maternal health services in the Afar Region.

Authors & Co-Authors

Statistics:

Citations: 10

Authors: 5

Identifiers:

DOI: 10.4314/ejhs.v28i4.6

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

Study Approach:

Mixed-methods, Qualitative, Quantitative

Participants Gender:

Female