Unintended pregnancies and the use of maternal health services in southwestern Ethiopia

BMC International Health and Human Rights, Volume 13, No. 1, Year 2013

Interpretation

Background: The benefits of maternal health care to maternal and neonatal health outcomes have been well documented. Antenatal care attendance, institutional delivery and skilled attendance at delivery all help to improve maternal and neonatal health. However, use of maternal health services is still very low in developing countries with high maternal mortality including Ethiopia. This study examines the association of unintended Pregnancy with the use of maternal health services in Southwestern Ethiopia. Methods. Data for this study come from a survey conducted among 1370 women with a recent birth in a Health and Demographic Surveillance Site (HDSS) in southwestern Ethiopia. An interviewer administered questionnaire was used to gather data on maternal health care, pregnancy intention and other explanatory variables. Data were analyzed using STATA 11, and both bivariate and multivariate analyses were done. Multivariate logistic regression was used to assess the association of pregnancy intention with the use of antenatal and delivery care services. Unadjusted and adjusted odds ratio and their 95% confidence intervals are reported. Results: More than one third (35%) of women reported that their most recent pregnancy was unintended. With regards to maternal health care, only 42% of women made at least one antenatal care visit during pregnancy, while 17% had four or more visits. Institutional delivery was only 12%. Unintended pregnancy was significantly (OR: 0.75, 95% CI, 0.58-0.97) associated with use of antenatal care services and receiving adequate antenatal care (OR: 0.67, 95% CI, 0.46-0.96), even after adjusting for other socio-demographic factors. However, for delivery care, the association with pregnancy intention was attenuated after adjustment. Other factors associated with antenatal care and delivery care include women’s education, urban residence, wealth and distance from health facility. Conclusions: Women with unintended pregnancies were less likely to access or receive adequate antenatal care. Interventions are needed to reduce unintended pregnancy such as improving access to family planning information and services. Moreover, improving access to maternal health services and understanding women’s pregnancy intention at the time of first antenatal care visit is important to encourage women with unintended pregnancies to complete antenatal care. © 2013 Wado et al.; licensee BioMed Central Ltd. This is a cross-sectional study conducted in Gilgel Gibe Health and Demographic Surveillance System (HDSS) in Jimma zone, Southwestern Ethiopia, which is located at 260 kilometers to the southwest of Addis Ababa. The study population was women, of age 15–49 years, with a live birth in the two years before the survey (March 2012). The HDSS at the Gilgel Gibe site in southwestern Ethiopia is used to collect vital events data by Jimma University. Accordingly, data on all births occurring in the site is collected through an update of multiple times in a year. Participants were then drawn from eleven sub-districts (kebelesa) in HDSS using a simple random sampling procedure. In this HDSS area consisting of over 55,000 people, there were 3293 women with a live birth in the 2 years before the survey date, of which 1456 were randomly selected for the present study. A sample size of 1456 was calculated for the study using two population proportion formula, assumptions of the prevalence of ANC use (50%) and difference of 8% between women with intended and unintended pregnancies, and power of 80%. Data were collected by ten trained female data collectors who had a diploma level training and experience in data collection. They were closely supervised by supervisors who had better experience in data collection. The data collectors had five days of training on how to administer the questionnaire including practice interviewing, role playing and addressing ethical issues. After the training, a pilot study was done and information from the pilot study was used to finalize the questionnaire. A structured questionnaire originally developed in English and translated to local language (Oromo) was used to collect data. Data on maternal health care, pregnancy intention and other explanatory variables were gathered using interviewer administered structured questionnaire. Ethical approval was obtained from the College of Health Sciences, Addis Ababa University. Moreover, participants were asked for informed consent, and participation in the study was fully voluntary. Consent form was translated to local language (Oromo) and was read to every participant before starting the interview. In this study, maternal health care refers to the use of antenatal care during pregnancy and delivery at a health facility. Women were asked whether they have used any antenatal care during their most recent pregnancy and whether they delivered at a health facility. The two variables were measured on a binary scale as ‘yes’ for those who used the services, and ‘no’ for those who did not use the services. For antenatal care, we examined two measures of women’s use of antenatal care. The first is receiving any antenatal care, named hereafter as ‘antenatal care use’. The second is making adequate number of antenatal care visits – defined based on recommendations from a World Health Organization (WHO) which stated that a woman without complications should have at least four antenatal care visits, the first of which should take place during the first trimester. The key independent variables were measured in the following ways. Pregnancy intention was measured using the standard DHS approach, which asks women to recall their feelings at the time they became pregnant; “At the time you became pregnant, did you want to become pregnant then, did you want to wait until later, or did you not want to have any (more) children at all?”. The responses are: (1) wanted then “intended”, (2) wanted to happen later “mistimed”; (3) did not want at all “unwanted”. Mistimed and unwanted pregnancies were then grouped together as “unintended pregnancies”. Other explanatory variables included age (coded as 15–24, 25–34 and 35–49), women’s education (coded as no education, primary and secondary and above), place of residence, wealth index, distance from health facility, presence of pregnancy related morbidity, parity, ever use of modern family planning and time of pregnancy recognition. The wealth index was computed from ownership of the following household assets: radio, television, electricity, refrigerator, toilet, farm land, and quantity of animals such as cattle, sheep, and goats. Principal Component Analysis (PCA) was run, and four principal components with eigenvalues greater than one were summed to obtain wealth index values [39]. The resulting index was then divided into three categories representing poor, middle and wealthy. Distance from health facility was asked in walking hours or minutes; ‘How long it takes to walk on foot from their home to the nearest health facility providing maternal health services?’. Moreover, women were asked whether they have experienced any illness during pregnancy. Time of pregnancy recognition refers to the approximate gestational age at which the women found out that she was pregnant. Similarly, women’s participation in decision making was measured by asking the following questions; “who makes decisions in your household about: (1) obtaining health care for yourself; (2) large household purchases; (3) household purchases for daily needs; and (4) visits to family or relatives?”. The responses were: (1) respondent alone, (2) respondent and husband/partner, (3) husband/partner alone, (4) someone else. Women are considered to participate in a decision if they usually make that decision alone or jointly with their husbands. Then a composite index was constructed by grouping women into two categories: women who have any say (alone or jointly) in all four household decisions, indicating a higher level of empowerment, and women who do not have any say in one or more decisions. Data were analyzed using STATA software version 11. First, a descriptive analysis of the characteristics of study population was made. Bivariate analysis was done to compare use of maternal health care among different groups using chi-square test. Multivariate logistic regression was done to identify factors that are independently and significantly associated with use of antenatal care and delivery care services. Unadjusted and adjusted odds ratio and their 95% confidence intervals are reported. Multicollinearity of variables was checked using variance inflation factor.

AI Digest

Study Justification:

– The study aims to examine the association between unintended pregnancies and the use of maternal health services in southwestern Ethiopia.
– This is important because the benefits of maternal health care to maternal and neonatal health outcomes have been well documented, but the use of maternal health services is still very low in developing countries, including Ethiopia.
– Understanding the factors that influence the use of maternal health services can help inform interventions and policies to improve access and utilization of these services.

Study Highlights:

– More than one third (35%) of women reported that their most recent pregnancy was unintended.
– Only 42% of women made at least one antenatal care visit during pregnancy, while 17% had four or more visits.
– Institutional delivery was only 12%.
– Unintended pregnancy was significantly associated with lower use of antenatal care services and receiving adequate antenatal care, even after adjusting for other socio-demographic factors.
– Factors associated with antenatal care and delivery care include women’s education, urban residence, wealth, and distance from health facility.

Study Recommendations:

– Interventions are needed to reduce unintended pregnancies, such as improving access to family planning information and services.
– Improving access to maternal health services and understanding women’s pregnancy intention at the time of first antenatal care visit is important to encourage women with unintended pregnancies to complete antenatal care.

Key Role Players:

– Ministry of Health: Responsible for implementing policies and programs related to maternal health care and family planning.
– Health care providers: Responsible for delivering maternal health services and providing information on family planning.
– Community health workers: Responsible for educating and raising awareness about maternal health care and family planning in the community.
– Non-governmental organizations (NGOs): Can provide support and resources for implementing interventions to reduce unintended pregnancies and improve access to maternal health services.

Cost Items for Planning Recommendations:

– Training and capacity building for health care providers and community health workers.
– Development and dissemination of educational materials on family planning and maternal health care.
– Outreach and awareness campaigns to promote the importance of antenatal care and institutional delivery.
– Provision of family planning services and contraceptives.
– Infrastructure development to improve access to health facilities in rural areas.
– Monitoring and evaluation of interventions to assess their effectiveness and make necessary adjustments.

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 provides data from a survey conducted among 1370 women in southwestern Ethiopia, which adds to the credibility of the findings. The study uses multivariate logistic regression to assess the association of pregnancy intention with the use of antenatal and delivery care services, which strengthens the analysis. However, the study is limited to a specific region in Ethiopia, which may limit the generalizability of the findings. To improve the strength of the evidence, future research could include a larger and more diverse sample to increase external validity.

Abstract

This is a cross-sectional study conducted in Gilgel Gibe Health and Demographic Surveillance System (HDSS) in Jimma zone, Southwestern Ethiopia, which is located at 260 kilometers to the southwest of Addis Ababa. The study population was women, of age 15–49 years, with a live birth in the two years before the survey (March 2012). The HDSS at the Gilgel Gibe site in southwestern Ethiopia is used to collect vital events data by Jimma University. Accordingly, data on all births occurring in the site is collected through an update of multiple times in a year. Participants were then drawn from eleven sub-districts (kebelesa) in HDSS using a simple random sampling procedure. In this HDSS area consisting of over 55,000 people, there were 3293 women with a live birth in the 2 years before the survey date, of which 1456 were randomly selected for the present study. A sample size of 1456 was calculated for the study using two population proportion formula, assumptions of the prevalence of ANC use (50%) and difference of 8% between women with intended and unintended pregnancies, and power of 80%. Data were collected by ten trained female data collectors who had a diploma level training and experience in data collection. They were closely supervised by supervisors who had better experience in data collection. The data collectors had five days of training on how to administer the questionnaire including practice interviewing, role playing and addressing ethical issues. After the training, a pilot study was done and information from the pilot study was used to finalize the questionnaire. A structured questionnaire originally developed in English and translated to local language (Oromo) was used to collect data. Data on maternal health care, pregnancy intention and other explanatory variables were gathered using interviewer administered structured questionnaire. Ethical approval was obtained from the College of Health Sciences, Addis Ababa University. Moreover, participants were asked for informed consent, and participation in the study was fully voluntary. Consent form was translated to local language (Oromo) and was read to every participant before starting the interview. In this study, maternal health care refers to the use of antenatal care during pregnancy and delivery at a health facility. Women were asked whether they have used any antenatal care during their most recent pregnancy and whether they delivered at a health facility. The two variables were measured on a binary scale as ‘yes’ for those who used the services, and ‘no’ for those who did not use the services. For antenatal care, we examined two measures of women’s use of antenatal care. The first is receiving any antenatal care, named hereafter as ‘antenatal care use’. The second is making adequate number of antenatal care visits – defined based on recommendations from a World Health Organization (WHO) which stated that a woman without complications should have at least four antenatal care visits, the first of which should take place during the first trimester. The key independent variables were measured in the following ways. Pregnancy intention was measured using the standard DHS approach, which asks women to recall their feelings at the time they became pregnant; “At the time you became pregnant, did you want to become pregnant then, did you want to wait until later, or did you not want to have any (more) children at all?”. The responses are: (1) wanted then “intended”, (2) wanted to happen later “mistimed”; (3) did not want at all “unwanted”. Mistimed and unwanted pregnancies were then grouped together as “unintended pregnancies”. Other explanatory variables included age (coded as 15–24, 25–34 and 35–49), women’s education (coded as no education, primary and secondary and above), place of residence, wealth index, distance from health facility, presence of pregnancy related morbidity, parity, ever use of modern family planning and time of pregnancy recognition. The wealth index was computed from ownership of the following household assets: radio, television, electricity, refrigerator, toilet, farm land, and quantity of animals such as cattle, sheep, and goats. Principal Component Analysis (PCA) was run, and four principal components with eigenvalues greater than one were summed to obtain wealth index values [39]. The resulting index was then divided into three categories representing poor, middle and wealthy. Distance from health facility was asked in walking hours or minutes; ‘How long it takes to walk on foot from their home to the nearest health facility providing maternal health services?’. Moreover, women were asked whether they have experienced any illness during pregnancy. Time of pregnancy recognition refers to the approximate gestational age at which the women found out that she was pregnant. Similarly, women’s participation in decision making was measured by asking the following questions; “who makes decisions in your household about: (1) obtaining health care for yourself; (2) large household purchases; (3) household purchases for daily needs; and (4) visits to family or relatives?”. The responses were: (1) respondent alone, (2) respondent and husband/partner, (3) husband/partner alone, (4) someone else. Women are considered to participate in a decision if they usually make that decision alone or jointly with their husbands. Then a composite index was constructed by grouping women into two categories: women who have any say (alone or jointly) in all four household decisions, indicating a higher level of empowerment, and women who do not have any say in one or more decisions. Data were analyzed using STATA software version 11. First, a descriptive analysis of the characteristics of study population was made. Bivariate analysis was done to compare use of maternal health care among different groups using chi-square test. Multivariate logistic regression was done to identify factors that are independently and significantly associated with use of antenatal care and delivery care services. Unadjusted and adjusted odds ratio and their 95% confidence intervals are reported. Multicollinearity of variables was checked using variance inflation factor.

Materials

N/A

Innovations

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

1. Mobile health (mHealth) interventions: Develop mobile applications or text messaging services to provide pregnant women with information on antenatal care, delivery care, and family planning. These interventions can also send reminders for appointments and provide educational resources.

2. Community-based interventions: Implement community health worker programs to provide education and support to pregnant women in rural areas. These workers can conduct home visits, provide counseling, and refer women to health facilities for antenatal and delivery care.

3. Telemedicine: Use telecommunication technologies to connect pregnant women in remote areas with healthcare providers. This can enable remote consultations, monitoring of high-risk pregnancies, and timely referrals to higher-level facilities when necessary.

4. Integration of maternal health services: Improve coordination and integration of antenatal care, delivery care, and postnatal care services. This can ensure continuity of care and reduce barriers to accessing multiple services.

5. Financial incentives: Implement financial incentive programs to encourage pregnant women to seek antenatal and delivery care. This can include conditional cash transfers or vouchers that can be used to cover transportation costs or facility fees.

6. Quality improvement initiatives: Implement quality improvement programs in health facilities to ensure that pregnant women receive high-quality care. This can include training healthcare providers, improving infrastructure and equipment, and strengthening referral systems.

7. Addressing cultural and social barriers: Develop culturally sensitive interventions that address social norms, beliefs, and practices that may hinder access to maternal health services. This can involve community engagement, awareness campaigns, and involvement of community leaders.

It is important to note that the specific context and needs of the population should be considered when implementing these innovations.

AI Innovations Description

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

1. Improve access to family planning information and services: Unintended pregnancies were found to be significantly associated with lower utilization of antenatal care services. Therefore, it is important to focus on reducing unintended pregnancies by providing comprehensive family planning information and services to women and couples.

2. Increase awareness and education on the benefits of maternal health care: Many women in the study population had low utilization of antenatal care and institutional delivery services. This highlights the need for increased awareness and education on the importance of maternal health care for both maternal and neonatal health outcomes. Information campaigns and community-based education programs can be implemented to address this issue.

3. Enhance availability and accessibility of maternal health services: Factors such as distance from health facilities were found to be associated with lower utilization of maternal health services. To improve access, it is important to ensure that health facilities providing maternal health services are available and easily accessible to women in rural areas. This can be achieved by establishing more health facilities or mobile clinics in underserved areas.

4. Empower women and promote their participation in decision-making: Women’s empowerment and participation in decision-making were found to be associated with higher utilization of maternal health services. Efforts should be made to empower women by promoting their involvement in decision-making processes related to their own health and the health of their families. This can be done through community-based women’s groups, education programs, and advocacy for women’s rights.

5. Strengthen healthcare systems and infrastructure: In order to improve access to maternal health services, it is crucial to strengthen healthcare systems and infrastructure. This includes training and equipping healthcare providers, ensuring the availability of essential drugs and supplies, and improving the quality of care provided at health facilities.

By implementing these recommendations, it is possible to develop innovative strategies to improve access to maternal health and ultimately reduce maternal mortality rates in developing countries like Ethiopia.

AI Innovations Methodology

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

1. Improve access to family planning information and services: Unintended pregnancies were found to be significantly associated with lower utilization of antenatal care services. By increasing access to family planning information and services, women can have more control over their reproductive choices and reduce the number of unintended pregnancies.

2. Increase availability and accessibility of maternal health services: The study found that institutional delivery was only 12%, indicating a need to improve access to health facilities for delivery. This can be achieved by increasing the number of health facilities in rural areas, improving transportation infrastructure, and ensuring that health facilities are adequately staffed and equipped to provide quality maternal health services.

3. Enhance education and awareness: Women’s education was found to be associated with higher utilization of antenatal and delivery care services. Therefore, efforts should be made to improve access to education for women, especially in rural areas. Additionally, raising awareness about the importance of maternal health care and the available services can help overcome cultural and social barriers that may prevent women from seeking care.

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, such as the percentage of women receiving antenatal care, the percentage of women delivering at a health facility, and the percentage of women receiving adequate antenatal care.

2. Collect baseline data: Gather data on the current status of these indicators in the target population. This can be done through surveys, interviews, or existing data sources.

3. Develop a simulation model: Create a model that simulates the impact of the recommendations on the selected indicators. This model should take into account factors such as population size, geographical distribution, and existing healthcare infrastructure.

4. Input data and assumptions: Input the baseline data into the simulation model and make assumptions about the potential impact of the recommendations. For example, assume that improving access to family planning services will reduce unintended pregnancies by a certain percentage, or assume that increasing the number of health facilities will lead to a certain increase in institutional deliveries.

5. Run the simulation: Use the simulation model to calculate the projected changes in the selected indicators based on the input data and assumptions. This can be done by running multiple iterations of the model to account for different scenarios and uncertainties.

6. Analyze the results: Examine the output of the simulation to understand the potential impact of the recommendations on improving access to maternal health. This can include comparing the projected changes in the selected indicators to the baseline data, identifying any disparities or challenges that may arise, and assessing the overall effectiveness of the recommendations.

7. Refine and adjust: Based on the analysis of the simulation results, refine the recommendations and adjust the simulation model as needed. This iterative process can help optimize the proposed interventions and ensure that they are tailored to the specific context and needs of the target population.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of different interventions on improving access to maternal health and make informed decisions about resource allocation and implementation strategies.

Author

Dima Health

Statistics:

Citations: 51

Identifiers:

DOI: 10.1186/1472-698X-13-36

Research Areas:

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

Study Countries:

Ethiopia

Study Design:

Case-Control Study, Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Female