Contraceptive utilization and associated factors among HIV positive women on chronic follow up care in tigray region, northern ethiopia: A cross sectional study

PLoS ONE, Volume 9, No. 4, Year 2014

Interpretation

Background: In sub-Sahara Africa, more than 60% of all new HIV infections are occurring in women, infants and young children. Maternal to child transmission is responsible for 90% of childhood HIV infection. Preventing unwanted pregnancy among HIV positive women is imperative to reduce maternal and infant morbidity and mortality. Methods: A cross-sectional survey was conducted among 964 HIV positive women in selected 12 health centers of Tigray region. In this paper, analysis was restricted only for 847 women who were sexually active and non-pregnant. In each health center the number of study participants was allocated proportionally to the load of HIV positive women in chronic care clinics. The data were entered into EpiData version 3.1, and cleaned and analyzed using Stata version 11.1. Descriptive summary of data and logistic regression were used to identify possible predictors using odds ratio with 95% confidence interval and P-value of 0.05. Findings: Three hundred ninety four (46.5%) of all HIV positive women had intension to have more children. Three hundred seventy five (44.3%) were using contraceptive methods at time of survey. Injectable (70.7%) and male condom (47.6%) were most commonly used type of contraceptives. In the multivariable analysis, women who were urban dwellers (AOR = 2.55; 95% CI: 1.27, 5.02), completed primary education (AOR = 2.27; 95% CI: 1.12, 2.86) and those openly discussed about contraceptive methods with their husbands or sexual partners (AOR = 6.3; 95% CI: 3.42, 11.76) were more likely to use contraceptive. Women who have one or more living children were also more likely to use contraceptive compared with women with no child. Conclusion: Less than half of women used contraceptive methods. The use of condoms could impact unintended pregnancies and reduced risks of vertical and sexual transmission. Efforts to increase contraceptive utilization focusing on the barrier methods should be strengthen in HIV/AIDS chronic care units.©2014 Melaku, Zeleke. Tigray region has an estimated total population of 4,664,071, of which 2,367,032 are females. More than 80% of the population is estimated to be rural inhabitants [25]. According the regional health bureau report of 2012, Tigray had 14 hospitals, 205 health centers and 552 health posts [26]. Antenatal care surveillance data in 2009 reported that the HIV prevalence in Tigray was 2.2% (5.0% urban and 1.3% rural) [27]. The 2011 EDHS estimated that overall HIV adult prevalence (15–49 years) to be 1.8% (1.9% among women and 1.0% among men) [3]. In 2012, the Federal HIV/AIDS Prevention and Control Office (HAPCO) estimated that there were about 56,900 HIV positive individuals in the region [28]. HIV prevalence in Tigray varies widely across zones from 0.4% (Central zone) to 2.2% (Western) [29]. In the region there were 60 health centers which were supported by Ethiopian Network of HIV/AIDS Treatment, Care and Support (ENHAT-CS). All health centers provide services including HIV prevention, testing, treatment and care and all family planning methods free-of-charge. Family planning services include barrier, oral, and injectable contraceptive methods as well as family planning counseling from a trained family planning nurse. This study was conducted at chronic follow up care (both pre-ART and ART) clinics in 12 ENHAT-CS supported health centers in Tigray region ( Figure 1 ) from May to June 2013. This analysis is based on a cross-sectional survey data of HIV positive women seeking services at ENHAT-CS supported health centers in the region. Medical chart was reviewed to confirm HIV status, ART use history and other medical characteristics of HIV positive women. To be eligible to participate in the overall study, women were required to be 15–49 years of age, attending a chronic follow up care, competent to give informed consent, and willing to allow medical record review for the purposes of confirming HIV sero-status and other medical histories. We considered a woman to be ART user if she was taking ART at the time of interview. We considered woman to be pre-ART (not using ART) if she had never taken ART before. Twenty percent of ENHAT-CS supported health centers were selected with simple random sampling technique using lottery method. The numbers of health centers in each administrative zone (6 zones of the region) were determined proportionally considering the total number of ENHAT-CS supported health centers in each zone. The numbers of study participants in each health center were determined using proportion to population size (HIV positive women registered in the health centers). In this case, the number of women who were HIV positive and were on chronic follow up care was taken in to account to determine the number of samples in each health center ( Figure 2 ). To select each woman in each health center pre-arrival systematic random sampling technique was used. The first woman to contact was selected by lottery method after determining the interval between two study units. The analysis was restricted to 847 women aged 15–49 years who were sexually active, and were not pregnant. This was done to enhance the comparability of findings with other studies investigating reproductive and sexual health among HIV positive women. After confirming eligibility and seeking written informed consent, participants were asked to complete a 25–35 minute interviewer-administered questionnaire in local language called “Tigrenga”. Approximately 6 women were interviewed daily by a data collector at each heath center from May to June 2013. Data collectors were trained women from the local community who had previous research experience and were holders of Bachelor degree. In each health center, nurses with HIV/AIDS related training reviewed medical records of participants. The questionnaire assessed socio-demographic characteristics, fertility intentions, fertility history, contraceptive practice, and sexual history. The survey instrument was developed by organizing variables from previously conducted researches [10], [30], [31]. Medical records of HIV positive women were reviewed to confirm HIV status and other medical history, and to obtain all necessary clinical data including CD4 cell counts and WHO stage of disease using data extraction tool (checklist). The primary outcome was self-reported contraceptive use at the time of the survey. Contraceptive utilization refers to use of any form of either modern or traditional contraceptive methods to avoid or delay pregnancy. Current use of contraceptive method referred to respondents who responded positively for use of contraceptive methods at time of the survey to delay or avoid pregnancy. Contraceptive method queries included male and female condoms (restricted to those reporting “Always” use), injections (depomedroxyprogesterone acetate (DMPA) or norethisterone enantate), oral contraceptive pills, diaphragm, intrauterine devices (IUD), female tubal ligation, hysterectomy, and male partner sterilization. In addition, traditional methods (coitus interrupts and calendar method) were incorporated as part of the responses in the questionnaire. In assessing the contraceptive method profile, dual protection was defined as use of both a barrier contraceptive method (male condom) and use of a hormonal or permanent contraceptive method [32]. The explanatory variables were current receipt of ART, age, education, employment, current sexual partnership, number of living children, fertility intentions, and HIV clinical variables. “Sexual intercourse” were defined to refer specifically to “vaginal-penile penetrative sex between a man and a woman”. We define HIV-positive women on chronic care as women who had at least one visit to the selected pre-ART or ART units for care who may be receiving ART or not. Fertility intention was defined as HIV positive women on chronic follow up care would like to have child/children in the future. First code was given to the completed questionnaires and then data were entered into Epidata Version 3.1 database and transferred to STATA version 11.1 (Stata Corporation, College Station, TX, USA) statistical packages for analysis. Pretest of questionnaire was conducted out of study health centers. Supervisors had checked filled questionnaires and checklists for consistency, completeness and accuracy on daily base for all clients. Supportive supervision by investigators was also rendered for each data collectors and supervisors. Cleaning of data was done to check the consistency and completeness of the data set. Frequencies, proportions and summary statistics were used to describe the study population in relation to relevant variables. Both bivariable and multivariable logistic regression were used to identify significant predictors. The degree of association between independent and dependent variables was assessed using odds ratio with 95% confidence interval. Differences in contraceptive use between groups were reported using Pearson’s chi-square or score test for trends of odds for categorical variables. After testing for co-linearity [33] and interaction [34], all covariates with statistically significant associations in the bivariable analysis were included in multivariable logistic regression models to obtain adjusted estimates of the association between covariates and contraceptive use. All statistical tests were two-sided and considered statistical significant at P value of 0.05. ArcGIS version 10.0 was used to map study area and locate health centers. Information letters and written consent forms were available in English and “Tigrenga”. Ethical clearance was obtained from the Institutional Review Board of Mekelle University, College of Health Sciences. The members of Institutional Review Board were nominated by the management body of Mekelle University and consist of experts in the field of subject matter, Medical ethics and statistics. Permission letters were gained from Tigray regional health bureau, respective district health offices and health centers. After explaining the objective and contents of the study, written consent has been obtained from each respondent or next-of-kin when the respondent were under 18 years of age. Some of the study participants were unable to read and write. In this case, trained interviewers fully explained the purpose, process, benefits, and risks to all study participants before consent was obtained and inked index finger print was used as a signature. This consent procedure was reviewed and approved by Mekelle University College of Health Sciences Institutional Review Board. The information collected was purely used for research works and name of respondents has remained anonymous. All the interviews with study participants were made with strict privacy and assuring confidentiality. Each interview was conducted in a separate room which was prepared for this purpose. The participants were told that they have the right to either refuse to participate in the study or withdraw after responding for some of the questions. Respondents’ name and identity were not recorded, included and linked in the questionnaire. Data were kept confidential by locking in boxes with key and by password in the computer to avoid access of the data by third party. Only card numbers of the clients were used to review secondary data and link with the primary data of the clients. Similarly, the names of the clients have not been reviewed and were not recorded. The collected data also were not linked with the individual identity at all level of data processing and analysis.

AI Digest

Study Justification:

This study aimed to investigate the utilization of contraceptives among HIV positive women in the Tigray region of Northern Ethiopia. The justification for this study is based on the high rates of new HIV infections occurring in women, infants, and young children in sub-Saharan Africa. Preventing unwanted pregnancies among HIV positive women is crucial for reducing maternal and infant morbidity and mortality. Understanding the factors associated with contraceptive utilization can help inform interventions and policies to improve reproductive health outcomes for HIV positive women.

Highlights:

– The study found that less than half of HIV positive women in the Tigray region were using contraceptive methods.
– The most commonly used contraceptives were injectables and male condoms.
– Factors associated with contraceptive use included urban residence, completion of primary education, open discussion about contraceptive methods with partners, and having one or more living children.
– Increasing the use of barrier methods, such as condoms, could help reduce unintended pregnancies and the risks of vertical and sexual transmission of HIV.

Recommendations:

– Efforts should be made to strengthen the promotion and availability of contraceptive methods, particularly barrier methods, in HIV/AIDS chronic care units.
– Education and awareness campaigns should be conducted to increase knowledge about contraceptive methods and their importance in preventing unwanted pregnancies and reducing HIV transmission.
– Health centers and clinics should provide comprehensive family planning services, including counseling and access to a variety of contraceptive methods.
– Collaboration between healthcare providers, policymakers, and community organizations is essential to ensure the successful implementation of interventions aimed at improving contraceptive utilization among HIV positive women.

Key Role Players:

– Healthcare providers: Nurses and other healthcare professionals who provide HIV/AIDS care and family planning services.
– Policymakers: Government officials and policymakers responsible for developing and implementing reproductive health policies and programs.
– Community organizations: Non-governmental organizations and community-based organizations that can support and advocate for improved access to contraceptive services for HIV positive women.
– Researchers: Experts in the field of reproductive health and HIV/AIDS who can provide evidence-based recommendations for interventions and policies.

Cost Items for Planning Recommendations:

– Training and capacity building for healthcare providers on family planning counseling and contraceptive methods.
– Development and dissemination of educational materials and awareness campaigns.
– Procurement and distribution of contraceptive supplies, including condoms and injectables.
– Monitoring and evaluation of interventions to assess their effectiveness and make necessary adjustments.
– Collaboration and coordination activities between different stakeholders, including meetings and workshops.
– Research and data collection to inform future interventions and policies.

Strength of Evidence

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is strong, but there are some areas for improvement. The study design is cross-sectional, which limits the ability to establish causality. Additionally, the sample size is relatively small, which may affect the generalizability of the findings. To improve the evidence, future studies could consider using a longitudinal design to establish causality and increase the sample size to improve generalizability.

Abstract

Tigray region has an estimated total population of 4,664,071, of which 2,367,032 are females. More than 80% of the population is estimated to be rural inhabitants [25]. According the regional health bureau report of 2012, Tigray had 14 hospitals, 205 health centers and 552 health posts [26]. Antenatal care surveillance data in 2009 reported that the HIV prevalence in Tigray was 2.2% (5.0% urban and 1.3% rural) [27]. The 2011 EDHS estimated that overall HIV adult prevalence (15–49 years) to be 1.8% (1.9% among women and 1.0% among men) [3]. In 2012, the Federal HIV/AIDS Prevention and Control Office (HAPCO) estimated that there were about 56,900 HIV positive individuals in the region [28]. HIV prevalence in Tigray varies widely across zones from 0.4% (Central zone) to 2.2% (Western) [29]. In the region there were 60 health centers which were supported by Ethiopian Network of HIV/AIDS Treatment, Care and Support (ENHAT-CS). All health centers provide services including HIV prevention, testing, treatment and care and all family planning methods free-of-charge. Family planning services include barrier, oral, and injectable contraceptive methods as well as family planning counseling from a trained family planning nurse. This study was conducted at chronic follow up care (both pre-ART and ART) clinics in 12 ENHAT-CS supported health centers in Tigray region ( Figure 1 ) from May to June 2013. This analysis is based on a cross-sectional survey data of HIV positive women seeking services at ENHAT-CS supported health centers in the region. Medical chart was reviewed to confirm HIV status, ART use history and other medical characteristics of HIV positive women. To be eligible to participate in the overall study, women were required to be 15–49 years of age, attending a chronic follow up care, competent to give informed consent, and willing to allow medical record review for the purposes of confirming HIV sero-status and other medical histories. We considered a woman to be ART user if she was taking ART at the time of interview. We considered woman to be pre-ART (not using ART) if she had never taken ART before. Twenty percent of ENHAT-CS supported health centers were selected with simple random sampling technique using lottery method. The numbers of health centers in each administrative zone (6 zones of the region) were determined proportionally considering the total number of ENHAT-CS supported health centers in each zone. The numbers of study participants in each health center were determined using proportion to population size (HIV positive women registered in the health centers). In this case, the number of women who were HIV positive and were on chronic follow up care was taken in to account to determine the number of samples in each health center ( Figure 2 ). To select each woman in each health center pre-arrival systematic random sampling technique was used. The first woman to contact was selected by lottery method after determining the interval between two study units. The analysis was restricted to 847 women aged 15–49 years who were sexually active, and were not pregnant. This was done to enhance the comparability of findings with other studies investigating reproductive and sexual health among HIV positive women. After confirming eligibility and seeking written informed consent, participants were asked to complete a 25–35 minute interviewer-administered questionnaire in local language called “Tigrenga”. Approximately 6 women were interviewed daily by a data collector at each heath center from May to June 2013. Data collectors were trained women from the local community who had previous research experience and were holders of Bachelor degree. In each health center, nurses with HIV/AIDS related training reviewed medical records of participants. The questionnaire assessed socio-demographic characteristics, fertility intentions, fertility history, contraceptive practice, and sexual history. The survey instrument was developed by organizing variables from previously conducted researches [10], [30], [31]. Medical records of HIV positive women were reviewed to confirm HIV status and other medical history, and to obtain all necessary clinical data including CD4 cell counts and WHO stage of disease using data extraction tool (checklist). The primary outcome was self-reported contraceptive use at the time of the survey. Contraceptive utilization refers to use of any form of either modern or traditional contraceptive methods to avoid or delay pregnancy. Current use of contraceptive method referred to respondents who responded positively for use of contraceptive methods at time of the survey to delay or avoid pregnancy. Contraceptive method queries included male and female condoms (restricted to those reporting “Always” use), injections (depomedroxyprogesterone acetate (DMPA) or norethisterone enantate), oral contraceptive pills, diaphragm, intrauterine devices (IUD), female tubal ligation, hysterectomy, and male partner sterilization. In addition, traditional methods (coitus interrupts and calendar method) were incorporated as part of the responses in the questionnaire. In assessing the contraceptive method profile, dual protection was defined as use of both a barrier contraceptive method (male condom) and use of a hormonal or permanent contraceptive method [32]. The explanatory variables were current receipt of ART, age, education, employment, current sexual partnership, number of living children, fertility intentions, and HIV clinical variables. “Sexual intercourse” were defined to refer specifically to “vaginal-penile penetrative sex between a man and a woman”. We define HIV-positive women on chronic care as women who had at least one visit to the selected pre-ART or ART units for care who may be receiving ART or not. Fertility intention was defined as HIV positive women on chronic follow up care would like to have child/children in the future. First code was given to the completed questionnaires and then data were entered into Epidata Version 3.1 database and transferred to STATA version 11.1 (Stata Corporation, College Station, TX, USA) statistical packages for analysis. Pretest of questionnaire was conducted out of study health centers. Supervisors had checked filled questionnaires and checklists for consistency, completeness and accuracy on daily base for all clients. Supportive supervision by investigators was also rendered for each data collectors and supervisors. Cleaning of data was done to check the consistency and completeness of the data set. Frequencies, proportions and summary statistics were used to describe the study population in relation to relevant variables. Both bivariable and multivariable logistic regression were used to identify significant predictors. The degree of association between independent and dependent variables was assessed using odds ratio with 95% confidence interval. Differences in contraceptive use between groups were reported using Pearson’s chi-square or score test for trends of odds for categorical variables. After testing for co-linearity [33] and interaction [34], all covariates with statistically significant associations in the bivariable analysis were included in multivariable logistic regression models to obtain adjusted estimates of the association between covariates and contraceptive use. All statistical tests were two-sided and considered statistical significant at P value of 0.05. ArcGIS version 10.0 was used to map study area and locate health centers. Information letters and written consent forms were available in English and “Tigrenga”. Ethical clearance was obtained from the Institutional Review Board of Mekelle University, College of Health Sciences. The members of Institutional Review Board were nominated by the management body of Mekelle University and consist of experts in the field of subject matter, Medical ethics and statistics. Permission letters were gained from Tigray regional health bureau, respective district health offices and health centers. After explaining the objective and contents of the study, written consent has been obtained from each respondent or next-of-kin when the respondent were under 18 years of age. Some of the study participants were unable to read and write. In this case, trained interviewers fully explained the purpose, process, benefits, and risks to all study participants before consent was obtained and inked index finger print was used as a signature. This consent procedure was reviewed and approved by Mekelle University College of Health Sciences Institutional Review Board. The information collected was purely used for research works and name of respondents has remained anonymous. All the interviews with study participants were made with strict privacy and assuring confidentiality. Each interview was conducted in a separate room which was prepared for this purpose. The participants were told that they have the right to either refuse to participate in the study or withdraw after responding for some of the questions. Respondents’ name and identity were not recorded, included and linked in the questionnaire. Data were kept confidential by locking in boxes with key and by password in the computer to avoid access of the data by third party. Only card numbers of the clients were used to review secondary data and link with the primary data of the clients. Similarly, the names of the clients have not been reviewed and were not recorded. The collected data also were not linked with the individual identity at all level of data processing and analysis.

Materials

N/A

Innovations

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

1. Mobile health (mHealth) interventions: Develop mobile applications or text messaging services to provide information and reminders about contraceptive methods, family planning, and maternal health care. This can help increase awareness and knowledge among HIV positive women, and improve adherence to contraceptive use.

2. Community-based interventions: Implement community outreach programs to educate and empower women about contraceptive methods and family planning. This can involve training community health workers to provide counseling and distribute contraceptives, as well as organizing community events to raise awareness and address cultural barriers.

3. Integration of services: Strengthen the integration of HIV care and family planning services within health centers. This can involve training healthcare providers to offer comprehensive care, including counseling on contraceptive options, and ensuring the availability of a wide range of contraceptive methods.

4. Male involvement: Promote the involvement of male partners in family planning decisions and contraceptive use. This can be done through targeted education and counseling sessions for men, as well as initiatives to encourage open communication between couples about contraceptive methods.

5. Task-shifting: Train and empower nurses and other healthcare providers to provide contraceptive counseling and services. This can help alleviate the burden on doctors and increase access to contraceptive methods, especially in resource-limited settings.

6. Supply chain management: Strengthen the supply chain management system for contraceptives to ensure consistent availability and accessibility. This can involve improving forecasting and procurement processes, as well as implementing strategies to reduce stockouts and wastage.

7. Quality improvement initiatives: Implement quality improvement initiatives to enhance the overall quality of maternal health services. This can involve regular monitoring and evaluation of service delivery, as well as training healthcare providers on best practices and standards of care.

8. Peer support networks: Establish peer support networks for HIV positive women, where they can share experiences, provide emotional support, and exchange information about contraceptive methods and maternal health care. This can help reduce stigma and create a supportive environment for women to access and use contraceptives.

9. Financial incentives: Explore the use of financial incentives, such as conditional cash transfers or vouchers, to encourage HIV positive women to use contraceptives and access maternal health services. This can help overcome financial barriers and increase utilization rates.

10. Research and innovation: Invest in research and innovation to develop new contraceptive methods that are safe, effective, and tailored to the needs of HIV positive women. This can involve collaborations between researchers, pharmaceutical companies, and healthcare providers to identify and address gaps in contraceptive options.

AI Innovations Description

Based on the information provided, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Strengthening Family Planning Services: The study found that less than half of the HIV positive women were using contraceptive methods. To improve access to maternal health, it is recommended to strengthen family planning services in the Tigray region. This can be done by increasing the availability and accessibility of contraceptive methods, including barrier methods such as condoms, which can help prevent unintended pregnancies and reduce the risk of vertical and sexual transmission of HIV.

2. Education and Awareness: The study found that women who had completed primary education were more likely to use contraceptives. Therefore, it is important to focus on education and awareness programs to increase knowledge about the benefits of contraceptive use among HIV positive women. These programs can be conducted in health centers, schools, and community settings to reach a wider audience.

3. Partner Involvement: The study found that women who openly discussed contraceptive methods with their husbands or sexual partners were more likely to use contraceptives. Encouraging partner involvement and communication can help improve contraceptive utilization among HIV positive women. This can be done through couple counseling sessions and educational materials that emphasize the importance of shared decision-making in family planning.

4. Integration of Services: The study was conducted in chronic follow-up care clinics for HIV positive women. To improve access to maternal health, it is recommended to integrate family planning services with HIV care and treatment services. This can ensure that HIV positive women receive comprehensive care that includes both prevention of mother-to-child transmission of HIV and access to contraceptive methods.

5. Community Engagement: To address the low contraceptive utilization rate, it is important to engage the community in promoting maternal health. This can be done through community outreach programs, peer education, and involvement of community leaders and influencers. By involving the community, stigma and misconceptions surrounding contraceptive use can be addressed, leading to increased acceptance and utilization of contraceptives among HIV positive women.

Overall, the recommendation is to develop an innovative approach that combines strengthening family planning services, education and awareness, partner involvement, integration of services, and community engagement to improve access to maternal health for HIV positive women in the Tigray region.

AI Innovations Methodology

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

1. Increase awareness and education: Implement comprehensive education programs to raise awareness about the importance of maternal health and the available services. This can be done through community outreach programs, workshops, and campaigns targeting both women and men.

2. Strengthen family planning services: Improve access to and availability of contraceptive methods, including barrier methods, oral contraceptives, and injectables. This can be achieved by training healthcare providers, ensuring a steady supply of contraceptives, and integrating family planning services into existing healthcare facilities.

3. Enhance antenatal care services: Improve the quality and accessibility of antenatal care services, including regular check-ups, screenings, and counseling. This can help identify and address any potential complications early on, ensuring a safe and healthy pregnancy.

4. Promote male involvement: Encourage the involvement of male partners in maternal health by providing education and counseling on the importance of their support. This can help create a supportive environment for women and increase their access to necessary care.

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

1. Define the indicators: Determine the key indicators that will be used to measure the impact of the recommendations. This could include metrics such as contraceptive utilization rate, antenatal care coverage, and maternal mortality rate.

2. Collect baseline data: Gather data on the current status of maternal health in the target population, including contraceptive utilization rates, antenatal care coverage, and maternal mortality rates. This will serve as a baseline for comparison.

3. Implement the recommendations: Introduce the recommended interventions, such as awareness campaigns, improved family planning services, and enhanced antenatal care. Ensure proper implementation and monitor the progress of each intervention.

4. Collect post-intervention data: After a sufficient period of time, collect data on the impact of the interventions. This could include measuring changes in contraceptive utilization rates, antenatal care coverage, and maternal mortality rates.

5. Analyze the data: Compare the post-intervention data with the baseline data to assess the impact of the recommendations. Use statistical analysis to determine the significance of any observed changes.

6. Draw conclusions and make recommendations: Based on the analysis of the data, draw conclusions about the effectiveness of the interventions in improving access to maternal health. Identify any gaps or areas for further improvement and make recommendations for future interventions.

7. Monitor and evaluate: Continuously monitor and evaluate the impact of the interventions over time. This will help identify any long-term trends and ensure that the improvements in access to maternal health are sustained.

By following this methodology, it will be possible to simulate the impact of the recommendations on improving access to maternal health and make evidence-based decisions for future interventions.

Author

Dima Health

Statistics:

Citations: 30

Identifiers:

DOI: 10.1371/journal.pone.0094682

Research Areas:

Community Interventions, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health

Study Countries:

Ethiopia

Study Design:

Case-Control Study, Cross Sectional Study

Study Approach:

Mixed-methods, Quantitative, Systematic Review

Participants Gender:

Male & Female