Use pattern of maternal health services and determinants of skilled care during delivery in Southern Tanzania: Implications for achievement of MDG-5 targets

BMC Pregnancy and Childbirth, Volume 7, Year 2007

Interpretation

Background: Almost two decades since the initiation of the Safe motherhood Initiative, Maternal Mortality is still soaring high in most developing countries. In 2000 WHO estimated a life time risk of a maternal death of 1 in 16 in Sub- Saharan Africa while it was only 1 in 2800 in developed countries. This huge discrepancy in the rate of maternal deaths is due to differences in access and use of maternal health care services. It is known that having a skilled attendant at every delivery can lead to marked reductions in maternal mortality. For this reason, the proportion of births attended by skilled health personnel is one of the indicators used to monitor progress towards the achievement of the MDG-5 of improving maternal health. Methods: Cross sectional study which employed quantitative research methods. Results: We interviewed 974 women who gave birth within one year prior to the survey. Although almost all (99.8%) attended ANC at least once during their last pregnancy, only 46.7% reported to deliver in a health facility and only 44.5% were assisted during delivery by a skilled attendant. Distance to the health facility (OR = 4.09 (2.72-6.16)), discussion with the male partner on place of delivery (OR = 2.37(1.75-3.22)), advise to deliver in a health facility during ANC (OR = 1.43 (1.25-2.63)) and knowledge of pregnancy risk factors (OR 2.95 (1.65-5.25)) showed significant association with use of skilled care at delivery even after controlling for confounding factors. Conclusion: Use of skilled care during delivery in this district is below the target set by ICPD + of attaining 80% of deliveries attended by skilled personnel by 2005. We recommend the following in order to increase the pace towards achieving the MDG targets: to improve coverage of health facilities, raising awareness for both men and women on danger signs during pregnancy/delivery and strengthening counseling on facility delivery and individual birth preparedness. © 2007 Mpembeni et al; licensee BioMed Central Ltd. The study was a cross sectional study. Quantitative research methods were employed in the study which involved interviews to a random sample of women (age 14–50) who gave birth within one year prior to the survey using a structured questionnaire. The questionnaire was pre-tested in a similar population in a neighbouring district to test for clarity, validity and reliability of the questions after which the tool was revised accordingly and finalised for use. The study was conducted in the Mtwara rural district. Mtwara rural, one of the five districts that make up Mtwara region is located in the South Eastern corner of Tanzania. The district has a total population of 204,770 [11] and has a total of 34 health facilities, 4 being health centres and 30 being dispensaries. Normally at the dispensary the staff should include a clinical officer (Certificate holder in clinical medicine) and a Maternal and Child Health Aid (MCHA) while in the health centre there should be a Clinical Officer and 2 nurse midwives. Both health centres and dispensaries are supposed to provide basic emergency obstetric care services but sometimes not all the six core functions are available. The district has no hospital but the regional hospital (Ligula) serves as the first referral level for emergency obstetric care for this district where emergency obstetric care services are provided for 24 hrs. Few villages are located more than 80 km from the regional hospital but the majority of the populations is within 60 kilometres. The district has one ambulance stationed at the district headquarters and all health centres and 5 distant dispensaries were fitted with radio calls for communication in case of an emergency. The dispensaries in the district were recently provided with what are locally called cycle ambulances (bicycles fitted with locally made stretcher). During an emergency, relatives pick the cycle from the dispensary and use it to transport the patient to the dispensary or even to the hospital. Both the ambulance and the cycle ambulances are used free of charge. The district has a high maternal mortality ratio estimated at 600 per 100,000 live births and only a small proportion of women use of modern contraceptives (25%). This study was conducted as a baseline survey of an intervention study aimed at increasing skilled attendance during delivery and increasing referral compliance. A multistage cluster random sampling was employed to select the study sample. We first selected a random sample of 24 health facilities using simple random sampling technique. For each of the selected health facility, one village in its catchment area was selected randomly. In the selected village, a house to house survey was conducted and all women who had given birth within the previous one year were interviewed. Data entry and cleaning was done using EPI Info 6.04d program while data analysis was done using SPSS for Windows Version 11. A composite socio-economic status indicator (wealth index) was created using information on source of drinking water, type of toilet facilities, housing construction material, household assets, ownership of any form of transportation, ownership of animals, land ownership and source of family income. Data Reduction using the principle components and factor analysis was used to generate weighted scores from the above variables and normalized with a mean of zero and standard deviation of one. The resulting scores were then summed up within households, ranked and used to stratify the households into 5 levels of socio-economic status. A variable, knowledge of pregnancy danger signs, was arrived at but analyzing the number of danger signs the respondent mentioned spontaneously. Those who mentioned none were considered to have no knowledge, those respondents who mentioned up to three danger signs were considered to have low knowledge and those who mentioned 4 or more danger signs were considered to have moderate knowledge of pregnancy danger signs. None of the respondents was considered to have a high knowledge as none mentioned more than 8 out of a total of 17 risk factors printed on the antenatal card. The χ2 test was used to assess association between use of maternal health care services and socio-demographic variables, and other service characteristics. P-values of less than 0.05 were considered significant. Multiple logistic regression was used to assess individual effect of variables on use of skilled care attendance while adjusting for potential confounding variables.

AI Digest

Study Justification:

– Maternal mortality rates are still high in developing countries, despite efforts to improve maternal health.
– Access and use of maternal health care services play a significant role in reducing maternal mortality.
– Having a skilled attendant at every delivery can greatly reduce maternal mortality.
– Monitoring the proportion of births attended by skilled health personnel is important for tracking progress towards achieving MDG-5 targets.

Study Highlights:

– The study interviewed 974 women who gave birth within one year prior to the survey.
– Almost all women (99.8%) attended antenatal care at least once during their last pregnancy.
– However, only 46.7% reported delivering in a health facility and only 44.5% were assisted by a skilled attendant during delivery.
– Factors associated with the use of skilled care during delivery included distance to the health facility, discussion with the male partner on place of delivery, advice to deliver in a health facility during antenatal care, and knowledge of pregnancy risk factors.

Study Recommendations:

– Improve coverage of health facilities to increase access to skilled care during delivery.
– Raise awareness among both men and women on danger signs during pregnancy and delivery.
– Strengthen counseling on facility delivery and individual birth preparedness.

Key Role Players:

– Health facility staff, including clinical officers, nurse midwives, and maternal and child health aids.
– District health officials responsible for planning and implementing maternal health programs.
– Community health workers who can provide education and support to pregnant women and their families.
– Male partners who can play a role in decision-making regarding place of delivery.

Cost Items for Planning Recommendations:

– Infrastructure: Construction or renovation of health facilities to improve coverage.
– Equipment and supplies: Provision of necessary medical equipment and supplies for safe deliveries.
– Training: Training programs for health care providers on skilled care during delivery.
– Awareness campaigns: Costs associated with raising awareness among the community on danger signs and the importance of facility delivery.
– Counseling services: Resources needed to strengthen counseling services during antenatal care visits.
– Transportation: Provision of ambulances or cycle ambulances for emergency transportation to health facilities.
Please note that the cost items provided are general categories and the actual costs would depend on the specific context and needs of the district.

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 employed quantitative research methods and interviewed a random sample of 974 women who gave birth within one year prior to the survey. The study was conducted in the Mtwara rural district in Tanzania. The results showed that only 46.7% of women delivered in a health facility and only 44.5% were assisted by a skilled attendant. The study identified several factors associated with the use of skilled care during delivery. The study provides actionable steps to improve the situation, such as improving coverage of health facilities, raising awareness about danger signs during pregnancy/delivery, and strengthening counseling on facility delivery and birth preparedness. However, the abstract does not provide information on the sampling method used or the response rate, which could affect the generalizability of the findings. Additionally, the abstract does not mention any limitations of the study or potential biases. To improve the evidence, future studies could include a more detailed description of the sampling method, response rate, and potential limitations.

Abstract

The study was a cross sectional study. Quantitative research methods were employed in the study which involved interviews to a random sample of women (age 14–50) who gave birth within one year prior to the survey using a structured questionnaire. The questionnaire was pre-tested in a similar population in a neighbouring district to test for clarity, validity and reliability of the questions after which the tool was revised accordingly and finalised for use. The study was conducted in the Mtwara rural district. Mtwara rural, one of the five districts that make up Mtwara region is located in the South Eastern corner of Tanzania. The district has a total population of 204,770 [11] and has a total of 34 health facilities, 4 being health centres and 30 being dispensaries. Normally at the dispensary the staff should include a clinical officer (Certificate holder in clinical medicine) and a Maternal and Child Health Aid (MCHA) while in the health centre there should be a Clinical Officer and 2 nurse midwives. Both health centres and dispensaries are supposed to provide basic emergency obstetric care services but sometimes not all the six core functions are available. The district has no hospital but the regional hospital (Ligula) serves as the first referral level for emergency obstetric care for this district where emergency obstetric care services are provided for 24 hrs. Few villages are located more than 80 km from the regional hospital but the majority of the populations is within 60 kilometres. The district has one ambulance stationed at the district headquarters and all health centres and 5 distant dispensaries were fitted with radio calls for communication in case of an emergency. The dispensaries in the district were recently provided with what are locally called cycle ambulances (bicycles fitted with locally made stretcher). During an emergency, relatives pick the cycle from the dispensary and use it to transport the patient to the dispensary or even to the hospital. Both the ambulance and the cycle ambulances are used free of charge. The district has a high maternal mortality ratio estimated at 600 per 100,000 live births and only a small proportion of women use of modern contraceptives (25%). This study was conducted as a baseline survey of an intervention study aimed at increasing skilled attendance during delivery and increasing referral compliance. A multistage cluster random sampling was employed to select the study sample. We first selected a random sample of 24 health facilities using simple random sampling technique. For each of the selected health facility, one village in its catchment area was selected randomly. In the selected village, a house to house survey was conducted and all women who had given birth within the previous one year were interviewed. Data entry and cleaning was done using EPI Info 6.04d program while data analysis was done using SPSS for Windows Version 11. A composite socio-economic status indicator (wealth index) was created using information on source of drinking water, type of toilet facilities, housing construction material, household assets, ownership of any form of transportation, ownership of animals, land ownership and source of family income. Data Reduction using the principle components and factor analysis was used to generate weighted scores from the above variables and normalized with a mean of zero and standard deviation of one. The resulting scores were then summed up within households, ranked and used to stratify the households into 5 levels of socio-economic status. A variable, knowledge of pregnancy danger signs, was arrived at but analyzing the number of danger signs the respondent mentioned spontaneously. Those who mentioned none were considered to have no knowledge, those respondents who mentioned up to three danger signs were considered to have low knowledge and those who mentioned 4 or more danger signs were considered to have moderate knowledge of pregnancy danger signs. None of the respondents was considered to have a high knowledge as none mentioned more than 8 out of a total of 17 risk factors printed on the antenatal card. The χ2 test was used to assess association between use of maternal health care services and socio-demographic variables, and other service characteristics. P-values of less than 0.05 were considered significant. Multiple logistic regression was used to assess individual effect of variables on use of skilled care attendance while adjusting for potential confounding variables.

Materials

N/A

Innovations

The study mentioned in the description provides several recommendations to improve access to maternal health and achieve the MDG-5 targets. These recommendations are based on the findings of the study and aim to address the factors that contribute to low utilization of skilled care during delivery. The recommendations are as follows:

1. Improve coverage of health facilities: This can be achieved by increasing the number of health facilities and ensuring their accessibility to the population. Innovations for this recommendation could include building new health facilities in underserved areas, improving transportation infrastructure to facilitate access to existing facilities, and implementing mobile health clinics to reach remote populations.

2. Raise awareness for both men and women on danger signs during pregnancy/delivery: Innovations for this recommendation could include community-based education programs that provide information on the signs and symptoms of complications during pregnancy and delivery. This could involve the use of community health workers, mobile health units, and multimedia campaigns to disseminate information to the target population.

3. Strengthen counseling on facility delivery and individual birth preparedness: Innovations for this recommendation could include integrating counseling services into antenatal care visits, providing information on the importance of facility delivery and birth preparedness through interactive educational materials, and utilizing technology such as mobile phone applications to deliver personalized counseling messages.

These recommendations highlight the importance of improving infrastructure, increasing knowledge and awareness, and enhancing counseling services to improve access to maternal health services. By implementing these recommendations, it is hoped that the rates of maternal mortality will decrease and progress towards achieving the MDG-5 targets will be made.

AI Innovations Description

1. Improve coverage of health facilities: The study found that distance to the health facility was significantly associated with the use of skilled care during delivery. Therefore, increasing the number of health facilities and ensuring their accessibility to the population can help improve access to maternal health services.

2. Raise awareness for both men and women on danger signs during pregnancy/delivery: The study found that knowledge of pregnancy risk factors was significantly associated with the use of skilled care during delivery. Therefore, raising awareness among both men and women about the signs and symptoms of complications during pregnancy and delivery can help encourage timely and appropriate utilization of maternal health services.

3. Strengthen counseling on facility delivery and individual birth preparedness: The study found that receiving advice to deliver in a health facility during antenatal care was significantly associated with the use of skilled care during delivery. Therefore, strengthening counseling services during antenatal care visits and providing information on the importance of facility delivery and birth preparedness can help increase the utilization of skilled care during delivery.

AI Innovations Methodology

To simulate the impact of the main recommendations on improving access to maternal health, a potential methodology could involve the following steps:

1. Identify the target population: Determine the population that will be included in the simulation, such as women of reproductive age in a specific geographic area.

2. Collect baseline data: Gather information on the current utilization of skilled care during delivery, including the percentage of women delivering in health facilities and being assisted by skilled attendants. This data can be obtained through surveys or existing health records.

3. Implement interventions: Introduce the recommended interventions, such as improving coverage of health facilities, raising awareness on danger signs, and strengthening counseling services. This may involve increasing the number of health facilities, conducting awareness campaigns, and enhancing training for healthcare providers.

4. Monitor and evaluate: Track the implementation of the interventions and collect data on their effectiveness. This can be done through surveys, interviews, or monitoring health facility records. Measure the changes in the percentage of women delivering in health facilities and being assisted by skilled attendants.

5. Analyze the data: Use statistical analysis to assess the impact of the interventions on access to maternal health services. Compare the baseline data with the post-intervention data to determine if there has been an increase in the utilization of skilled care during delivery.

6. Interpret the results: Evaluate the findings to determine the extent to which the interventions have improved access to maternal health. Assess whether the recommendations have been successful in achieving the desired outcomes and meeting the MDG-5 targets.

7. Adjust and refine: Based on the results, make any necessary adjustments or refinements to the interventions. This may involve scaling up successful interventions, addressing any barriers or challenges identified during the simulation, and continuing to monitor progress.

By following this methodology, researchers and policymakers can gain insights into the potential impact of the recommendations on improving access to maternal health services. This information can inform decision-making and guide the implementation of effective interventions to achieve the MDG-5 targets.

Author

Dima Health

Statistics:

Citations: 228

Identifiers:

DOI: 10.1186/1471-2393-7-29

Research Areas:

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

Study Countries:

Tanzania

Study Design:

Cross Sectional Study, randomised-control-trial

Study Approach:

Quantitative

Participants Gender:

Male & Female