The uptake of WHO-recommended birth preparedness and complication readiness messages during pregnancy and its determinants among Ethiopian women: A multilevel mixed-effect analyses of 2016 demographic health survey

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Study Justification:
– The study aimed to assess the uptake of birth preparedness and complication readiness (BPCR) messages among Ethiopian women during pregnancy.
– The study focused on the determinants of BPCR message uptake and compliance with each key message.
– The study used nationally representative data from the 2016 Ethiopian Demographic and Health Survey.
– The findings of the study can provide valuable insights into the current status of BPCR message uptake in Ethiopia and inform interventions to improve maternal and newborn health.
Highlights:
– More than half (56.02%) of Ethiopian women received at least one BPCR message during their recent pregnancies.
– Factors associated with BPCR message uptake included wealth quintiles, number of births in the last five years, number of antenatal visits, and reading a newspaper at least once a week.
– Factors associated with compliance with key BPCR messages included the number of antenatal visits, permission to go to a health facility, and health insurance coverage.
– The overall uptake of BPCR messages and compliance with each message was found to be low in Ethiopia.
Recommendations for Lay Reader:
– Healthcare providers and managers should work to increase the number of antenatal visits for pregnant women.
– Policymakers should prioritize interventions that enhance women’s autonomy in decision-making, job opportunities, and economic capability to improve their health-seeking behavior.
– Local administrative bodies should focus on increasing household enrollment in health insurance schemes.
Recommendations for Policy Maker:
– Increase the number of antenatal visits by implementing strategies to improve access and utilization of antenatal care services.
– Implement activities and interventions that empower women, such as promoting women’s decision-making power, job opportunities, and economic capability.
– Enhance household enrollment in health insurance schemes to improve financial access to healthcare services.
Key Role Players:
– Healthcare providers and managers in the health sector.
– Policymakers and government officials.
– Local administrative bodies.
– Community leaders and organizations.
– Non-governmental organizations (NGOs) working in maternal and newborn health.
Cost Items for Planning Recommendations:
– Funding for increasing the number of antenatal visits, such as hiring additional healthcare providers and improving infrastructure.
– Resources for implementing activities and interventions to empower women, such as training programs and awareness campaigns.
– Budget for promoting household enrollment in health insurance schemes, including subsidies or incentives for enrollment.
– Costs associated with monitoring and evaluation of interventions and programs.
– Potential costs for collaboration and coordination among key role players, including meetings and workshops.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a population-based, nationally representative survey conducted in Ethiopia. The study used a large sample size and applied multilevel mixed-effects logistic and negative binomial regressions to analyze the data. The study reported adjusted odds ratios and incidence rate ratios with corresponding confidence intervals to assess the significant determinants of birth preparedness and complication readiness messages. However, the abstract does not provide information on the response rate of the survey or potential limitations of the study. To improve the evidence, the abstract could include the response rate and a brief discussion of limitations, such as potential biases or generalizability of the findings.

Background Birth preparedness and complication readiness (BPCR) is a package of interventions recommended by the World Health Organization to improve maternal and newborn health and it is provided and implemented through a focused antenatal care program. This study aimed at assessing the uptake of birth preparedness and complication readiness messages, and compliance with each key message, among Ethiopian women during their recent pregnancies using the 2016 demographic health survey report. Methods The data for this study was taken from the Ethiopian Demographic and Health Survey, which was conducted from January to June 2016 and covered all administrative regions. STATA version 16 was used to analyze a total of 4,712 (with a weighted frequency of 4,771.49) women. A multilevel mixed-effects logistic, and multilevel mixed-effect negative binomial regressions were fitted, respectively. Adjusted odds ratio (AOR) and Incidence rate ratio (IRR) with their corresponding 95% confidence interval (CI) were used to report significant determinants. Results More than half, 56.02% [95% CI: 54.58, 57.41] of women received at least one birth preparedness and complication readiness message. Being in the richest wealth quintiles (AOR = 2.33; 95% CI: 1.43, 3.73), having two birth/s in the last five years (AOR = 1.54; 95% CI: 1.13, 2.10), receiving four or more antenatal visits(AOR = 3.33; 95% CI: 2.49, 4.45), and reading a newspaper at least once a week (AOR = 1.27; 95% CI: 1.07, 1.65) were the individual-level factors, whereas regions and residence(AOR = 1.54; 95% CI: 1.11, 1.96) were the community-level factors associated with the uptake of at least one BPCR message. On the other hand, receiving four or more antenatal visits (IRR = 2.78; 95% CI: 2.09, 3.71), getting permission to go to a health facility (IRR = 1.29; 95% CI: 1.028, 1.38), and not covered by health insurance schemes (IRR = 0.76; 95% CI: 0.68, 0.95) were identified as significant predictors of receiving key birth preparedness and complication readiness messages. Conclusion The overall uptake of the WHO-recommended birth readiness and complication readiness message and compliance with each message in Ethiopia was found to be low. Managers and healthcare providers in the health sector must work to increase the number of antenatal visits. Policymakers should prioritize the implementation of activities and interventions that increase women’s autonomy in decision-making, job opportunity, and economic capability to enhance their health-seeking behavior. The local administrative bodies should also work to enhance household enrollment in health insurance schemes.

The study relied on population-based, nationally representative data from the 2016 Ethiopian Demographic and Health Survey (DHS), the fourth in a series of standardized national-level population and health surveys carried out as part of the global Demographic and Health Survey (DHS) program [4]. Ethiopia is in North-eastern (horn of) Africa, between 3° and 15° North latitude and 33° 48° and East longitudes. Ethiopia’s healthcare system is divided into three levels: primary, secondary, and tertiary care. Primary hospitals, health centers, and health posts provide primary care, general hospitals provide secondary care, and specialized hospitals provide tertiary care. The survey was conducted from January 18, 2016, to June 27, 2016, by the Central Statistical Agency (CSA) in collaboration with the Federal Ministry of Health (FMOH) and the Ethiopian Public Health Institute, with technical assistance from ICF International and financial support from USAID, the government of the Netherlands, the World Bank, Irish Aid, and UNFPA. Data of the study participants were accessed on October 23, 2022 from DHS website, their URL: www.dhsprogram.com by contacting them via personal email communication with a possible justification for the data request. Permission was granted via email after reviewing the account. A cross-sectional study design using secondary data from 2016 EDHS was conducted. The source population consisted of 15,683 women who had given birth within five years preceding the survey. The study population consisted of 4,712 women who had complete information on the uptake of BPCR messages during their ANC visit, as well as the contents of those messages, and the entire analyses were conducted on them. Due to a lack of information on service uptake, a total of 10,971 respondents were excluded from the analysis (Missing values). The 2007 Ethiopia Population and Housing Census sampling frame was used, which included 84,915 enumeration areas (EAs), with each EA covering 181 households. A stratified two-stage cluster design was used to select respondents, as each region was stratified into urban and rural areas. The first step was to select 645 clusters (202 urban and 443 rural areas) with a probability proportional to the size of the enumeration area and independent selection within each stratum. The household listing was completed in all of the selected EAs between September and December 2015. The second stage involved the selection of 28 households per cluster using an equal probability systematic selection of eligible women aged 15–49 years. With a response rate of 94.6%, a sample of 16,650 households and 15,683 women aged 15–49 years was identified. Furthermore, the survey design and methodology were detailed in the 2016 EDHS [4]. This study had two outcome variables. The first outcome variable. Was the receipt of BPCR messages during ANC visits which was assessed by the question “During any of your antenatal visits were you told about BPCR?” If a mother said “Yes,” the response was labeled as 1, otherwise it was labeled as 0. The second outcome variable. Was the number of WHO-recommended BPCR messages received by a mother during pregnancy which was assessed using six items. Those key messages were about determining the place of birth, obtaining necessary supplies for childbirth, preparing emergency transportation, saving money for emergency expenses, identifying companions during labor and childbirth, and securing potential blood donors. Information on these six key BPCR messages was derived from the response to the question: Were you told about your Place of birth? Were you told about supplies needed for birth? Were you told about emergency transportation?… The answers were recorded as Yes (= 1) or No (= 0). During the same pregnancy, a single mother may be informed about the place of birth or the supplies required for childbirth several times. However, because the mother was asked to report any messages she received at least once, any response was recorded as a single message. Based on the responses, a composite index of BPCR was created, which is simply a count of the number of key messages received. The variable had a minimum value of zero indicating that no BPCR messages were delivered to the women and a maximum value of six indicating that the women received all six key messages. A similar type of content index was used by other recent studies [22, 23]. Religion, ethnicity, age, place of residence (urban and rural), educational level (no education, primary, secondary, and higher), husband’s education (no education, primary, secondary, higher), and wealth status of women’s household were considered from socioeconomic and demographic characteristics of women. The wealth index was divided into five categories: poorest, poorer, middle, richer, and richest. The wealth quintile of women’s households in the EDHS is a composite indicator based on housing characteristics and ownership of household durable goods that was calculated using principal component analysis. Obstetric characteristics like parity (nulliparous, primiparous, multiparous, and grand multiparous), gravidity, the total number of birth in the last five years, pregnancy status when she became pregnant (wanted, mistimed, unwanted), total children ever born, ever had a termination of pregnancy. Maternal health service-related characteristics like the frequency of Antenatal care visits, place of receiving ANC (home, public, private, and NGO), contraceptive use (Yes or No), the decision-making power on own health care (self-decision/joint decision with husband, husband alone, and other), covered by health insurance(Yes or No), and exposure to the newspaper, radio, and television (not at all, less than once a week or at least once a week) were considered. Furthermore, problems encountered by women in accessing medical help for themselves, such as distance to a health facility, obtaining permission to visit a health facility, and obtaining the money required for treatment, were assessed and rated as a big problem or not a big problem. Some of the behavioral characteristics of the respondents like alcohol consumption and cigarette smoking were assessed with a “Yes” or “No” response. The necessary data from EDHS 2016 report were checked for consistency and missing values. STATA/SE version 16.0 was used for cleaning, recoding, variable generation, labeling, and analysis. The sample allocation to different regions, as well as urban and rural settings, was not proportional in the EDHS. As a result, sample weights were used to estimate proportions and frequencies to account for disproportionate sampling and non-response. The weighting procedure was thoroughly explained in the 2016 EDHS report [4]. Descriptive statistics were computed to describe the characteristics of the overall sample respondents (mothers) across a set of covariates. The use of a multilevel modeling approach accounts for the EDHS data’s hierarchical nature, as households were selected within EA clusters. There may be unobserved cluster characteristics influencing BPCR message uptake among women, such as the availability and accessibility of health services, cultural norms, and predominant health beliefs [4]. Thus multilevel mixed-effects models (cluster/region-specific random effects) were applied to identify the predictors. Accordingly, two different modes of analysis were implemented to estimate both the independent (fixed) and community-level (random) effect of the explanatory variables on our dependent variables: i. First, to examine the relationship between each predictor and the first outcome variable(a receipt of at least one BPCR message), a multilevel bivariable logistic regression analysis was performed. In this analysis, variables with p-values less than 0.25 were candidates for a multilevel multivariable mixed-effect logistic regression analysis. Then a multilevel mixed‑effects logistic regression analysis was run. In a multivariable multilevel mixed-effect logistic analysis, four models with the variables of interest were fitted, and the best-fitting model was chosen. Model-I is a null model, Model II is a model with only individual-level factors, Model III is a model with only community-level factors, and Model IV is a full model. The full model (Model IV) was fitted to examine the effect of individual and community-level predictors on the outcome variable at the same time. The adjusted odds ratio with the corresponding 95% confidence interval was computed and reported to demonstrate the strength of the association and its significance. Variables having a p-value <0.05 were considered as having a significant association with the outcome variable. The model comparison was done using deviance and the fourth model with the lowest deviance was selected as the best-fitted model ii. To identify factors associated with the secondary outcome variable (a receipt of the recommended number of BPCR messages), a generalized linear model (GLM) with a multilevel mixed-effect negative binomial regression was run. Since the number of key BPCR messages received is a non-negative integer (count), most of the recent thinking in the field has used the Poisson regression model as a starting point [24, 25]. The most serious limitation of Poisson regression is that it assumes that the variance of the count response variable’s distribution is equal to its mean, which is known as the assumption of equidispersion. If this assumption is breached, the Poisson regression model’s estimates remain consistent but produce incorrect inferences about the parameters [26]. In the current case, the mean and the variance of the count outcome variable were 1.25 and 2.51, respectively. As a result of the assumption being violated, the data were over-dispersed, and a multilevel mixed-effect negative binomial regression model was fitted [25, 27]. Independent t-tests and analysis of variance (ANOVA) were used to determine whether there were statistically significant differences in the mean number of BPCR messages across each categorical variable. Those variables with p-values less than 0.05 were eligible for a multilevel mixed-effect negative binomial regression using a generalized linear model (GLM) to identify the determinants of the number of BPCR messages uptake. During multivariable multilevel mixed-effect negative binomial regression, four models with the variables of interest were fitted, and the best-fitting model was chosen. Model-I is a null model, Model II is a model with only individual-level factors, Model III is a model with only community-level factors, and Model IV is a full model. The full model (Model IV) was fitted to examine the effect of individual and community-level predictors on the outcome variable at the same time. Finally, the incident rate ratio (IRR) with a 95% confidence interval was reported, and statistical significance was determined at a p-value less than 0.05. Measures of random effect like Intra-class correlation coefficient (ICC), a proportional change in variance (PCV), and median odds ratio (MOR) were estimated. ICC explains the cluster variability, while MOR can quantify unexplained cluster variability (heterogeneity). In both cases (first and second outcome variables), the results of the random effects model showed the presence of variations of the random factor in the null model, indicating the existence of variation in the receipt of BPCR messages. Thus, to account for this variation, a multilevel mixed-effect logistic regression (for the first outcome variable) and a multi-level mixed-effect binomial regression (for the second outcome variable) model were considered for further analysis (Tables ​(Tables55 and ​and6).6). Model IV had the lowest AIC value in both cases (primary and secondary outcome variables) and was selected as the best model fit for the data. Furthermore, as fitted models progressed from the empty model (Model-I) to Model-II, Model-III, and Model-IV, the value of the deviance (-2*log-likelihood) results consistently decreased, indicating that the fitted models were a better fit to the data. Key: 1: Reference category; AOR = Adjusted odds ratio ** Statistically significant at p-value <0.05 Key: 1: Reference category; IRR = Incidence rate ratio * Statistically significant at p-value <0.05 Following registration with possible justification, ICF International granted permission to access the dataset used for this study. The retrieved data were only used for the registered research, and data were not shared with anyone other than the coresearchers. The information was kept private, and no attempt was made to identify any household or individual respondent.

Based on the information provided, the study focused on assessing the uptake of birth preparedness and complication readiness (BPCR) messages among Ethiopian women during their pregnancies. The study identified several factors associated with the uptake of BPCR messages, including wealth quintiles, number of births in the last five years, antenatal care visits, and exposure to media.

To improve access to maternal health, here are some potential recommendations based on the findings of the study:

1. Increase the number of antenatal care visits: The study found that women who received four or more antenatal visits were more likely to receive BPCR messages. Encouraging pregnant women to attend regular antenatal care visits can help ensure they receive important health messages and interventions.

2. Improve women’s economic capability: The study found that being in the richest wealth quintiles was associated with a higher uptake of BPCR messages. Policymakers should prioritize interventions that enhance women’s economic capability, such as providing job opportunities and promoting financial inclusion, to improve their health-seeking behavior.

3. Enhance women’s decision-making power: The study highlighted the importance of women’s autonomy in decision-making for their own healthcare. Efforts should be made to empower women and involve them in decision-making processes regarding their health, including birth preparedness and complication readiness.

4. Increase health insurance coverage: The study found that women not covered by health insurance schemes were less likely to receive key BPCR messages. Expanding health insurance coverage and ensuring its accessibility to all pregnant women can help improve access to maternal health services.

5. Strengthen health education and communication: The study showed that exposure to media, such as newspapers, was associated with a higher uptake of BPCR messages. Investing in health education and communication programs that utilize various media channels can help disseminate important maternal health messages to a wider audience.

6. Address geographical disparities: The study identified regional and rural-urban residence as community-level factors associated with the uptake of BPCR messages. Efforts should be made to address geographical disparities in access to maternal health services, ensuring that women in all regions and rural areas have equal access to quality care.

These recommendations aim to improve access to maternal health by addressing individual and community-level factors identified in the study. Implementing these innovations can contribute to better maternal and newborn health outcomes in Ethiopia.
AI Innovations Description
The study you described focuses on the uptake of birth preparedness and complication readiness (BPCR) messages among Ethiopian women to improve maternal and newborn health. The study found that the overall uptake of these messages was low. Several factors were identified as determinants of the uptake of BPCR messages.

Individual-level factors that were associated with the uptake of at least one BPCR message included being in the richest wealth quintiles, having two or more births in the last five years, receiving four or more antenatal visits, and reading a newspaper at least once a week. Community-level factors that were associated with the uptake of BPCR messages included the region and residence of the women.

The study also identified predictors of receiving the recommended number of BPCR messages. These predictors included receiving four or more antenatal visits, getting permission to go to a health facility, and not being covered by health insurance schemes.

Based on the findings of the study, the researchers made several recommendations to improve access to maternal health. These recommendations include:

1. Increasing the number of antenatal visits: Managers and healthcare providers in the health sector should work to increase the number of antenatal visits. This can help ensure that women receive the necessary BPCR messages and information to improve their maternal and newborn health.

2. Enhancing women’s autonomy and economic capability: Policymakers should prioritize the implementation of activities and interventions that increase women’s autonomy in decision-making, job opportunities, and economic capability. This can empower women to make informed decisions about their health and seek appropriate healthcare services.

3. Improving household enrollment in health insurance schemes: Local administrative bodies should work to enhance household enrollment in health insurance schemes. This can help ensure that women have access to affordable and quality maternal healthcare services.

By implementing these recommendations, it is hoped that access to maternal health will be improved, leading to better health outcomes for mothers and newborns in Ethiopia.
AI Innovations Methodology
Based on the provided information, the study aimed to assess the uptake of birth preparedness and complication readiness (BPCR) messages among Ethiopian women during their pregnancies. The study used data from the 2016 Ethiopian Demographic and Health Survey (DHS), which is a nationally representative survey conducted by the Central Statistical Agency (CSA) in collaboration with the Federal Ministry of Health (FMOH) and the Ethiopian Public Health Institute.

The methodology used in the study involved analyzing the data using STATA version 16. A multilevel mixed-effects logistic regression was used to examine the factors associated with the uptake of at least one BPCR message. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) were used to report significant determinants. Additionally, a multilevel mixed-effect negative binomial regression was used to identify the predictors of receiving the recommended number of BPCR messages. Incidence rate ratios (IRR) with 95% CI were reported for significant predictors.

The study considered various individual-level factors such as wealth quintiles, number of births in the last five years, number of antenatal visits, and reading frequency of newspapers. Community-level factors such as regions and residence were also considered. The study analyzed the association between these factors and the uptake of BPCR messages.

The study found that the overall uptake of BPCR messages in Ethiopia was low. Factors such as wealth quintiles, number of antenatal visits, and reading frequency of newspapers were associated with the uptake of at least one BPCR message. Factors such as number of antenatal visits, permission to go to a health facility, and health insurance coverage were identified as predictors of receiving the recommended number of BPCR messages.

In conclusion, the study highlights the need to increase the number of antenatal visits and prioritize interventions that enhance women’s autonomy and health-seeking behavior. The findings can inform policymakers, managers, and healthcare providers in the health sector to improve access to maternal health services in Ethiopia.

Please note that the information provided is a summary of the study’s methodology and findings. For a more detailed understanding, it is recommended to refer to the original study.

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