Process Evaluation of Skilled Delivery Service in Hadiya Zone in Southern Nations, Nationalities, and Peoples Region, Ethiopia

  • Journal of Environmental and Public Health, Volume 2020, Year 2020

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Study Justification:
– Pregnancy-related death is a significant issue leading to maternal and newborn mortality and morbidity.
– Access to skilled health workers at delivery and emergency obstetric care can save three-quarters of mothers’ lives.
– This evaluation aimed to assess the implementation level of skilled delivery services and identify issues contributing to underutilization.
Highlights:
– The study focused on the availability, compliance, and acceptability of skilled delivery services in Hadiya Zone, Ethiopia.
– The evaluation design was cross-sectional, and data from 846 mothers who gave birth within one year prior to the study period were analyzed.
– Resource availability for health facilities, human resources, medical equipment, and rooms was found to be inadequate.
– Compliance with guidelines and targets for skilled delivery services, such as coverage, active management of third stage labor, and health information, was low.
– Acceptability of skilled delivery services, including aspects like welcoming, privacy, reassurance, follow-up, and cost, was found to be lacking.
Recommendations:
– Improve resource availability by addressing the inadequacy of health facilities, human resources, medical equipment, and rooms.
– Enhance compliance with guidelines and targets for skilled delivery services, focusing on increasing coverage, active management of third stage labor, and health information provision.
– Enhance the acceptability of skilled delivery services by addressing issues related to welcoming, privacy, reassurance, follow-up, cost, and episiotomy practices.
Key Role Players:
– Ministry of Health, Ethiopia
– Hadiya Zone Health Department
– District Health Departments
– Health Facility Administrators
– Skilled Birth Attendants
– Community Health Workers
– Non-Governmental Organizations (NGOs) working in maternal health
Cost Items for Planning Recommendations:
– Infrastructure improvement (construction, renovation)
– Procurement of medical equipment and supplies
– Training and capacity building for health workers
– Community awareness and education campaigns
– Monitoring and evaluation activities
– Support for referral systems and emergency obstetric care services

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong. The study design is cross-sectional, which limits the ability to establish causality. However, the study includes a large sample size of 846 mothers and employs statistical analysis using Epi Info and SPSS. The evaluation assesses skilled delivery service implementation using three dimensions (availability, compliance, and acceptability) and identifies major contributing issues for underutilization of the service. To improve the strength of the evidence, future studies could consider using a longitudinal design to establish causality and include a control group for comparison. Additionally, conducting qualitative research to gain a deeper understanding of the factors influencing service utilization would provide valuable insights.

Pregnancy-related death is a cause for maternal and newborn mortality and morbidity as well as an obstacle for economic growth. Three-quarters of mothers’ lives can be saved if women have access to a skilled health worker at delivery and emergency obstetric care. This evaluation was conducted to assess skilled delivery service implementation level by using three dimensions (availability, compliance, and acceptability) and identify major contributing issues for underutilization of the service. The evaluation design is cross-sectional. The study included 846 mothers who gave birth in Hadiya zone within one year prior to study period, using one year delivery records. Epi Info 3.5.3 and SPSS version 16 were employed for data analysis. Based on selected indicators, resource availability was inadequate for health facilities, human resource medical equipment, and rooms. On the compliance dimension, skilled delivery service coverage (34.8%), active management of third stage labor (32.7%), and health information at discharge and in postnatal care (PNC) visit (7.1%) critically complied with or poorly agreed to the guidelines and targets. Regarding skilled delivery service acceptability, welcoming, privacy keeping, reassurance during labor pain, follow-up, baby care, comfortability (rooms, beds, and clothing), cost of service, and episiotomy (without local anesthesia) were not acceptable.

The study was conducted in Hadiya zone, which is located in southern Ethiopia, 230 km from Addis Ababa. This skilled delivery service program evaluation was conducted from April 1 to April 30 2014, by focusing on its process through a formative approach, by using dimensions, such as availability, compliance, and acceptability. The evaluation design was cross-sectional. The required sample size of the study population is calculated using the formula for single population proportion according to the following assumption, where n = the required sample size, z = standard error corresponding to 95% confidence level = 1.96, p = the proportion of women attending institutional delivery, and since there were no previous similar study conducted on acceptability in the study area so, I will use p=0.5 to yield maximum sample size, d = the margin of error = 5%. Factor two is used for the design effect. The required sample size was determined by using one proportion formula: Since the sampling technique is multistage sampling, two is considered for design effect and sample size = 2 ∗ 384.16 = 768.32 and the nonresponse rate of 10%(77); the total sample size is 846 women who gave birth within the last year preceding the evaluation. According to EDHS 2011, urban births are notably higher to be delivered in a health facility than rural births (50% vs 4 %) [10]. The study area was stratified into urban and rural. There are ten rural and one town administration. Due to resources and cost reasons from rural districts, two were selected randomly by lottery method. The Capital Town, Hossana, was purposefully included in the sampling to represent the urban communities. From these three districts, six kebeles were randomly selected. From this, a total of six kebeles, sampling frame was prepared for mothers who gave birth during the last year. The allocated sample size for urban and rural stratum was obtained using probability proportional allocation to the size (PPS) of mothers found in each selected kebeles. Finally 846 mothers were randomly selected and interviewed. Document review. Resource availability of skilled birth attendants and health facilities for delivery service were reviewed from Hadiya zone 2006 Ethical Administrative Report document. The document review checklists and structured and semistructured questionnaires were translated into Amharic language and again back to English by another person who has the same level of language capacity on both languages as to ensure that the meaning is the same, culturally applicable, and consistent. The data collectors were experienced in health data collection, with a minimum qualification of diploma in nursing. The number of data collectors was twelve with six supervisors. One day training was conducted before data collection for all data collectors and supervisors. The training was conducted in the form of a thorough discussion, by focusing on the general objectives of the study, discussing the contents of the data collection tools one by one and the type of information needed to be handled and how to handle any possible questions as well as problems that may arise during data collection and discussions on how to maintain confidentiality and privacy. Data collection was started immediately after training. The collected data was checked daily and supervision also took place throughout the data collection by the principal investigator in addition to supervisors. The quantitative data from the mothers’ interview was cleaned, edited, and entered into Epi Info 3.5.3; then the data was exported to SPSS version 16; then the data were analyzed, interpreted, and presented. After analysis, the data were described and presented using tables and graphs. Ethical clearance was taken from the Research and Community Service Vice President Office of the Wachemo University and submitted to Hadiya Zone Health Department and a similar letter was obtained from the Zonal Health Department to selected districts, then to health facility and kebele. During data collection, the participants were informed and verbal consent was obtained, following an explanation about the purpose of the interview and no name of any individual was requested or registered. If no consent was gained from the 1st mother, then the next mother was considered. The study subject had full right to refuse totally and to withdraw at any time without precondition.

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

1. Mobile Health Clinics: Implementing mobile health clinics that can travel to remote areas, providing skilled delivery services and emergency obstetric care to women who do not have access to nearby health facilities.

2. Telemedicine: Introducing telemedicine services that allow pregnant women to consult with skilled health workers remotely, providing them with guidance and support throughout their pregnancy and during labor.

3. Community Health Workers: Training and deploying community health workers who can provide basic maternal health services, including antenatal care and postnatal care, in rural areas where access to skilled health workers is limited.

4. Public Awareness Campaigns: Launching public awareness campaigns to educate women and their families about the importance of skilled delivery services and the availability of maternal health services in their communities.

5. Financial Incentives: Introducing financial incentives, such as cash transfers or vouchers, to encourage women to seek skilled delivery services and overcome financial barriers that may prevent them from accessing maternal health care.

6. Infrastructure Improvement: Investing in the improvement of health facilities, including the availability of medical equipment, rooms, and trained health workers, to ensure that women have access to quality maternal health services.

7. Partnerships with Non-Governmental Organizations (NGOs): Collaborating with NGOs that specialize in maternal health to leverage their expertise and resources in expanding access to skilled delivery services in underserved areas.

8. Maternal Health Insurance: Establishing maternal health insurance schemes that provide coverage for skilled delivery services, ensuring that women can afford the necessary care during pregnancy and childbirth.

9. Transportation Support: Providing transportation support, such as ambulances or transportation vouchers, to help women in remote areas reach health facilities for skilled delivery services in a timely manner.

10. Quality Improvement Initiatives: Implementing quality improvement initiatives to address the issues identified in the evaluation, such as improving compliance with guidelines and targets, enhancing the acceptability of services, and ensuring resource availability in health facilities.

These innovations can help address the challenges identified in the evaluation and improve access to skilled delivery services, ultimately reducing maternal and newborn mortality and morbidity.
AI Innovations Description
Based on the description provided, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Strengthening resource availability: Address the inadequate availability of resources such as health facilities, human resources, medical equipment, and rooms. This can be achieved by increasing funding and investment in the healthcare system, improving infrastructure, and ensuring an adequate supply of skilled birth attendants and necessary medical equipment.

2. Enhancing compliance with guidelines and targets: Improve the compliance level of skilled delivery service by implementing training programs for healthcare providers to ensure they adhere to guidelines and protocols. This can include training on active management of third stage labor, providing health information during discharge and postnatal care visits, and other essential aspects of maternal care.

3. Improving acceptability of skilled delivery service: Address the factors that contribute to the low acceptability of skilled delivery service, such as welcoming and privacy keeping, reassurance during labor pain, follow-up, baby care, comfortability (rooms, beds, and clothing), cost of service, and episiotomy (without local anesthesia). This can be achieved by implementing patient-centered care approaches, improving the physical environment of healthcare facilities, and addressing any cultural or financial barriers that may exist.

4. Strengthening rural healthcare services: Given the significant disparity in institutional delivery rates between urban and rural areas, focus on improving access to skilled delivery services in rural communities. This can be done by increasing the number of healthcare facilities in rural areas, providing transportation options for pregnant women, and implementing community-based interventions to raise awareness about the importance of skilled delivery services.

5. Continuous monitoring and evaluation: Establish a system for ongoing monitoring and evaluation of skilled delivery services to identify any gaps or areas for improvement. This can include regular assessments of resource availability, compliance with guidelines, and acceptability of services. Feedback from mothers and healthcare providers should be incorporated into the evaluation process to ensure the effectiveness of implemented interventions.

By implementing these recommendations, it is expected that access to maternal health services will be improved, leading to a reduction in maternal and newborn mortality and morbidity rates, as well as contributing to overall economic growth.
AI Innovations Methodology
To improve access to maternal health, here are some potential recommendations:

1. Strengthening Health Facilities: Ensure that health facilities have adequate resources, including medical equipment, rooms, and skilled health workers, to provide quality maternal health services.

2. Enhancing Compliance with Guidelines: Improve compliance with guidelines and targets for skilled delivery services, such as increasing coverage of skilled delivery services, active management of third stage labor, and providing health information during discharge and postnatal care visits.

3. Improving Acceptability of Services: Enhance the acceptability of skilled delivery services by focusing on factors such as welcoming and privacy keeping, reassurance during labor pain, follow-up care, baby care, comfortability of facilities, cost of services, and ensuring pain management procedures are carried out with local anesthesia.

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

1. Baseline Data Collection: Gather data on the current state of access to maternal health services, including indicators such as the proportion of women attending institutional delivery, compliance with guidelines, and acceptability of services.

2. Intervention Design: Develop a plan to implement the recommended innovations, taking into account the specific context and resources available. This may involve training health workers, improving infrastructure, and implementing protocols and guidelines.

3. Implementation: Carry out the interventions according to the designed plan, ensuring proper training and support for health workers, and monitoring the implementation process.

4. Data Collection: Collect data on the impact of the interventions, including indicators related to access to maternal health services, compliance with guidelines, and acceptability of services. This can be done through surveys, interviews, and record reviews.

5. Data Analysis: Analyze the collected data to assess the impact of the interventions on improving access to maternal health services. Compare the post-intervention data with the baseline data to identify any changes or improvements.

6. Evaluation and Recommendations: Evaluate the effectiveness of the interventions and identify any areas that may require further improvement. Based on the findings, make recommendations for scaling up successful interventions and addressing any remaining challenges.

By following this methodology, it will be possible to assess the impact of the recommended innovations on improving access to maternal health and make informed decisions on how to further enhance maternal health services.


Statistics:
Citations: 1
Identifiers:
DOI: 10.1155/2020/4717520
ISSN: 16879805
Research Areas:
Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Workforce
Study Countries:
Ethiopia
Study Design:
Cohort Study, Cross Sectional Study, Exploratory Study, Grounded Theory, Phenomenological Study
Study Approach:
Quantitative
Participants Gender:
Female
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