Risk factors of dropout from institutional delivery among HIV positive antenatal care booked mothers within one year postpartum in Ethiopia: a case–control study

  • Archives of Public Health, Volume 80, No. 1, Year 2022

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Study Justification:
– The uptake of maternal healthcare services in Ethiopia is suboptimal, particularly among HIV-positive mothers.
– There is a lack of evidence on the predictors of dropout from maternity continuum of care among HIV-positive mothers in Ethiopia.
– This study aimed to provide valuable information on the risk factors associated with dropout from institutional delivery services among HIV-positive mothers in northwest Ethiopia.
Highlights:
– The study was conducted in Gondar City, Ethiopia, from May 01 to June 30, 2018.
– A total of 222 HIV-positive women were included in the study.
– Data were collected through structured questionnaires, face-to-face interviews, and chart reviews.
– The study found that factors such as maternal age, marital status, spousal occupation, family income, and obstetric complications were associated with dropout from institutional delivery among HIV-positive antenatal care booked mothers.
– The study highlights the importance of addressing social determinants of health, such as advanced maternal age, unmarried marital status, unemployed husband occupation, and low family income, to improve the continuity of maternity services for HIV-positive women.
Recommendations:
– Policy makers should focus on improving access to information on obstetric complications during antenatal care visits for HIV-positive women.
– Efforts should be made to target women in lower socio-economic strata and unmarried HIV-positive antenatal care attendees to ensure their retention in the continuum of maternity services.
Key Role Players:
– Health system administrators and managers
– Maternal health program coordinators
– Antiretroviral Therapy (ART) clinic staff
– Obstetricians and gynecologists
– Midwives and other healthcare providers
– Community health workers
Cost Items for Planning Recommendations:
– Training and capacity building for healthcare providers on addressing the specific needs of HIV-positive pregnant women
– Development and dissemination of educational materials on obstetric complications and the importance of institutional delivery
– Strengthening referral systems and transportation services for pregnant women
– Community outreach and awareness campaigns targeting HIV-positive women in lower socio-economic strata and unmarried attendees of antenatal care
– Monitoring and evaluation activities to assess the impact of interventions on reducing dropout from institutional delivery among HIV-positive mothers
Please note that the cost items provided are general suggestions and may vary based on the specific context and resources available in Ethiopia.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is rated 7 because it provides detailed information about the study design, data collection methods, and statistical analysis. However, it lacks information about the representativeness of the sample and potential biases. To improve the evidence, the abstract could include information about the inclusion and exclusion criteria for the study participants, the response rate, and any potential limitations or biases in the study design. Additionally, providing information about the generalizability of the findings to other populations or settings would strengthen the evidence.

Background: The uptake of maternal healthcare services remains suboptimal in Ethiopia. Significant proportions of antenatal care attendees give birth at home in the context of HIV. However, in Ethiopia, evidence is scarce on the predictors of dropout from maternity continuum of care among HIV-positive mothers. Therefore, this study aimed to supply valuable information on risk factors regarding dropout of HIV-positive mothers for institutional delivery services in northwest Ethiopia. Methods: A multicenter case–control study was conducted at governmental health facilities in Gondar City from May one to June 30/2018. A total of 222 HIV-positive women were included in the study. Data were collected using structured questionnaires and checklists through face-to-face interview and chart review; entered into EPI INFO version seven, and then exported to SPSS version 25. Both descriptive and analytical procedures were performed. Binary logistic regression analysis was undertaken. A significant association was declared based on the adjusted odds ratio (AOR) with its 95% CI and p-value of ≤ 0.05. Results: This study illustrates that maternal age of ≥ 35 years (AOR = 2.37; 95%CI: 1.13,5.13), unmarried marital relation (AOR = 3.28; 95%CI: 1.51, 7.13), unemployed spousal occupation (AOR = 3.91; 95%CI: 1.54, 9.91), family monthly income of ≤ 36 US dollar (AOR = 4.87; 95%CI: 2.08, 11.42) and no obstetric complication in the index pregnancy (AOR = 13.89; 95%CI: 2.73, 27.71) were positively associated with dropout from institutional delivery among HIV positive antenatal care booked mothers. Conclusion: In this study, the risk factors of dropout from institutional delivery in the context of HIV-positive women were connected to social determinants of health such as advanced maternal age, unmarried marital status, unemployed husband occupation, and low family income. Therefore, interacting with the health system by focusing on these women in lower socio-economic strata and unmarried HIV-positive ANC attendees, and increasing access to information on obstetric complications during the antenatal care visit would retain clients in the continuum of maternity services.

A multicenter case–control study was conducted from May 01 to June 30/2018. The study was undertaken in Gondar city’s public health institutions. Gondar city is located 750 km away from Addis Ababa-the capital city of Ethiopia. According to the 2018/19 population projection, the total population size of the city is estimated to be 338,646, of whom, about 23.58% were women in the reproductive age group [18]. In Gondar city, there are nine public health facilities: one comprehensive specialized hospital and eight public health centers. In addition, there are three private maternity specialty clinics and one private primary hospital. All health facilities are currently providing maternal health care services. We included ANC-booked HIV-positive women under care at Antiretroviral Therapy (ART) clinics in public health institutions in Gondar city within one year postpartum. Cases and controls were assigned based on the respondents’ place of delivery for their youngest child. Accordingly, ANC-booked HIV-positive women who underwent home delivery have been assigned to the case group, whereas, those ANC-booked HIV-positive women who gave birth at the health facility were enrolled in the control group. The sample size for the study was determined using Open Epi version 3 software, by considering the following parameters; level of significance – 95%, power – 80%, ratio of cases to controls – 1: 3, the proportion of controls with ≤ 3 number of ANC – 29.25%, Odds Ratio (OR) – 2.55, percent of cases with ≤ 3 number of ANC visits – 52.56% from a previous similar study done in Southern Ethiopia [8]. Thus, the minimum adequate sample size for this study was obtained to be 202. By considering a 10% non-response rate, the final sample size is turned to be 222 individuals (56 cases and 166 controls). We included all women who fulfilled the case and control definition incomplete ascertainment fashion till the required sample size for cases and controls were obtained respectively. The outcome variable for this study is a dropout from institutional delivery and which was dichotomized as “Case” and “Control”. Whereas, the explanatory variables included: socio-demographic variables such as the age of the mother, age of the child, sex of the child, religion, marital status, residence, mother’s educational status, spousal educational status, mother’s occupational status, spousal occupational status, Radio/TV and monthly income, and obstetric related variables including gravidity, parity, time of ANC initiation, number of ANC visit, duration of rupture of membrane (ROM), obstetric complication during pregnancy, duration of labor, duration of ART drug initiation and provision of counseling about PMTCT at the health facility. Stand for both ART and PMTCT clinics. Those HIV-positive women who have received at least one antenatal care and registered from at least one of the public health facilities in Gondar city during the most recent pregnancy. ANC booked women who delivered the indexed child at home. ANC booked HIV-positive women giving birth at home within one year before the data collection date and attending ART clinic during the data collection period. ANC booked HIV-positive women giving birth at health institutions within one year before the data collection date and attending ART clinics during the data collection period. Data were collected by using pretested and structured questionnaires through a face-to-face interview. In addition, a checklist was used to extract certain variables via a medical chart review. Ten unemployed midwifery graduates (i.e., 8 diploma midwives for data collection and 2 BSc midwives for supervision) were recruited for the data collection process. A one-day training was provided. Pretest was done on 5% of the sample size. The necessary revision was then made on the tools after the pretest for further clarity. Daily supervision has been undertaken and the respective feedbacks have been provided. The questionnaire was adapted from different previous related literature [8, 19–21] and prepared first in English then translated into Amharic (local language), and finally back to English to maintain the consistency of the tool. Each questionnaire was reviewed daily for completeness and clarity. Furthermore, the data collectors have checked the questionnaire for completeness ahead of leaving the respondents. We checked, coded, and entered the Data into EPI INFO version 7. Then, we exported the data to SPSS version 25 for analysis. We processed the data for both descriptive and analytical statistics. Descriptive statistics such as frequency, percent, and median were yielded and reported in texts and tables. Analytical statistical procedures were made via a Binary logistic regression model to identify risk factors of dropout from institutional delivery. Both bivariable and multivariable logistic regression analyses were performed. Both COR and AOR with the corresponding 95% CI were computed. Finally, the level of significance was decided based on AOR with its 95% CI at a p-value of ≤ 0.05.

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 SMS-based systems to provide pregnant women with information and reminders about antenatal care visits, institutional delivery, and postpartum care. This can help overcome barriers such as lack of awareness or forgetfulness.

2. Community-based interventions: Implement community health worker programs to reach pregnant women in remote or underserved areas. Trained community health workers can provide education, counseling, and support for antenatal care, institutional delivery, and postpartum care.

3. Financial incentives: Introduce financial incentives, such as conditional cash transfers or vouchers, to encourage pregnant women to seek antenatal care and deliver in health facilities. This can help address financial barriers and increase utilization of maternal health services.

4. Telemedicine: Establish telemedicine services to enable remote consultations between pregnant women and healthcare providers. This can improve access to specialized care, especially for women in rural areas who may have limited access to obstetricians or other specialists.

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

6. Public-private partnerships: Foster collaborations between public and private sectors to expand access to maternal health services. This can involve leveraging private sector resources and expertise to improve service delivery, increase availability of skilled healthcare providers, and enhance the quality of care.

It is important to note that the specific context and needs of the target population should be considered when implementing these innovations. Additionally, rigorous evaluation and monitoring should be conducted to assess their effectiveness and impact on improving access to maternal health.
AI Innovations Description
Based on the information provided, here is a recommendation that can be used to develop an innovation to improve access to maternal health:

1. Targeted interventions for high-risk groups: The study identified several risk factors associated with dropout from institutional delivery among HIV-positive antenatal care booked mothers, such as advanced maternal age, unmarried marital status, unemployed husband occupation, and low family income. To improve access to maternal health, it is recommended to develop targeted interventions specifically tailored to these high-risk groups. This can include providing additional support, resources, and information to address their specific needs and challenges.

2. Strengthening antenatal care services: Since the study found that the absence of obstetric complications during pregnancy was positively associated with dropout from institutional delivery, it is important to strengthen antenatal care services to ensure that pregnant women receive comprehensive and timely care. This can involve improving the quality and availability of antenatal care, increasing the number of ANC visits, and providing counseling and education on obstetric complications and the importance of institutional delivery.

3. Enhancing social support networks: The study highlighted the importance of social determinants of health, such as marital status and family income, in influencing dropout from institutional delivery. To address this, it is crucial to enhance social support networks for pregnant women, particularly those who are unmarried or have low family income. This can be done through community-based programs that provide emotional, financial, and practical support to pregnant women, as well as by involving family members and community leaders in promoting the importance of institutional delivery.

4. Improving access to information: The study emphasized the need to increase access to information on obstetric complications during antenatal care visits. To achieve this, innovative approaches can be developed, such as using mobile health technologies to deliver targeted and personalized information to pregnant women. This can include text messages, voice calls, or mobile applications that provide information on pregnancy, childbirth, and the benefits of institutional delivery.

5. Strengthening collaboration between health systems: To improve access to maternal health, it is essential to strengthen collaboration between different components of the health system, including antenatal care, HIV/AIDS services, and maternity care. This can involve integrating services, improving referral systems, and ensuring effective communication and coordination between different healthcare providers. By working together, healthcare providers can ensure that HIV-positive pregnant women receive comprehensive and continuous care throughout the maternity continuum.

Overall, by implementing these recommendations, it is possible to develop innovative strategies that improve access to maternal health for HIV-positive antenatal care booked mothers in Ethiopia and similar contexts.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations to improve access to maternal health for HIV-positive mothers in Ethiopia:

1. Strengthening antenatal care services: Enhance the quality and availability of antenatal care services, including comprehensive HIV testing and counseling, regular monitoring of HIV-positive mothers, and provision of necessary medications and interventions.

2. Promoting institutional delivery: Implement strategies to encourage HIV-positive mothers to deliver in health facilities, such as providing incentives, ensuring privacy and confidentiality, and addressing cultural and social barriers.

3. Addressing social determinants of health: Develop interventions that target the social determinants of health, such as poverty, unemployment, and marital status, by providing economic support, vocational training, and social support networks.

4. Increasing awareness and education: Conduct community-based awareness campaigns to educate HIV-positive mothers and their families about the importance of institutional delivery, the risks of home delivery, and the available maternal health services.

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

1. Define the target population: Identify the specific group of HIV-positive mothers who are at risk of dropout from institutional delivery services.

2. Collect baseline data: Gather information on the current status of access to maternal health services among the target population, including the percentage of mothers who deliver at home, the reasons for dropout, and the existing barriers.

3. Develop a simulation model: Create a mathematical model that incorporates the identified risk factors and interventions. This model should simulate the impact of the recommendations on improving access to maternal health, taking into account factors such as population size, demographic characteristics, and healthcare infrastructure.

4. Input data and parameters: Input the collected baseline data and relevant parameters into the simulation model, such as the effectiveness of the interventions, the coverage of the interventions, and the time frame for implementation.

5. Run simulations: Run multiple simulations using different scenarios to assess the potential impact of the recommendations on improving access to maternal health. This could include varying the coverage and effectiveness of the interventions, as well as considering different population sizes and demographic characteristics.

6. Analyze results: Analyze the simulation results to determine the projected changes in access to maternal health services, such as the percentage of mothers delivering in health facilities, the reduction in dropout rates, and the potential improvements in maternal and child health outcomes.

7. Validate and refine the model: Validate the simulation model by comparing the projected results with real-world data, if available. Refine the model based on feedback and additional data to improve its accuracy and reliability.

8. Communicate findings: Present the findings of the simulation study to relevant stakeholders, such as policymakers, healthcare providers, and community leaders, to inform decision-making and prioritize interventions for improving access to maternal health services.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of different interventions and make informed decisions to improve access to maternal health for HIV-positive mothers in Ethiopia.


Statistics:
Citations: 1
Identifiers:
DOI: 10.1186/s13690-022-00819-0
ISSN: 07787367
Research Areas:
Community Interventions, Disparities, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants, Workforce
Study Countries:
Ethiopia
Study Design:
Case-Control Study, Cross Sectional Study, Grounded Theory, randomised-control-trial
Study Approach:
Quantitative
Participants Gender:
Female
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