Trends and determinants of an acceptable antenatal care coverage in Ethiopia, evidence from 2005-2016 Ethiopian demographic and health survey; Multivariate decomposition analysis

  • Archives of Public Health, Volume 78, No. 1, Year 2020

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Study Justification:
This study aimed to analyze the trends and determinants of an acceptable antenatal care (ANC4+) visit in Ethiopia over the past 10 years. The justification for this study is that maternal health care service utilization is an important indicator for monitoring improvements in maternal and child health outcomes. Understanding the factors that contribute to the change in ANC4+ coverage can help inform policies and interventions to further improve maternal health care in Ethiopia.
Highlights:
– The rate of an acceptable ANC4+ visit increased from 16% in 2005 to 35% in 2016 among reproductive age women in Ethiopia.
– Factors such as residence, religion, husband’s educational attainment, and wealth status were found to be significant contributors to the improvements in ANC4+ coverage.
– Two-thirds of the overall change in ANC4+ coverage was attributed to changes in the behavior of the population, including factors such as religion, educational attainment (both women and husband), and residence.
Recommendations for Lay Reader:
– It is important for pregnant women in Ethiopia to receive an acceptable ANC4+ visit, as it is associated with better maternal and child health outcomes.
– Efforts should be made to improve ANC4+ coverage, particularly in rural communities, through interventions such as increasing women’s education and advancing healthcare facilities.
– Public awareness campaigns can help educate women about the benefits of ANC4+ visits and encourage them to seek appropriate care during pregnancy.
Recommendations for Policy Maker:
– Policies should be implemented to improve ANC4+ coverage in Ethiopia, with a focus on addressing the factors that contribute to the disparities in coverage, such as residence, religion, and wealth status.
– Investments should be made in improving healthcare facilities in rural communities to ensure access to quality ANC services.
– Efforts should be made to increase women’s education, as it has been found to be a significant factor in improving ANC4+ coverage.
Key Role Players:
– Ministry of Health: Responsible for developing and implementing policies and interventions to improve ANC4+ coverage.
– Healthcare Providers: Responsible for delivering quality ANC services and ensuring access to care.
– Community Health Workers: Play a crucial role in raising awareness about the importance of ANC4+ visits and providing education to pregnant women.
– Non-Governmental Organizations: Can support the implementation of interventions and provide resources to improve ANC4+ coverage.
Cost Items for Planning Recommendations:
– Training and capacity building for healthcare providers and community health workers.
– Infrastructure development and improvement of healthcare facilities in rural areas.
– Public awareness campaigns and educational materials.
– Monitoring and evaluation of ANC4+ coverage and outcomes.
– Research and data collection to inform evidence-based interventions.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a secondary analysis of cross-sectional population data from Ethiopia Demographic Health Surveys (EDHS) conducted in 2005, 2011, and 2016. The study used nationally representative datasets and employed multivariate decomposition analysis to identify factors contributing to the change in acceptable antenatal care visit over the last 10 years in Ethiopia. The study provides statistical analysis and presents trends and determinants of acceptable antenatal care coverage. However, the abstract does not mention the sample size, response rate, or any limitations of the study. To improve the evidence, it would be helpful to include these details and provide a clear statement of the study’s limitations.

Background: an acceptable antenatal care (ANC4+) is defined as attending at least four antenatal care visit, received at least one dose of tetanus toxoid (TT) injections and consumed 100 iron-folic acids (IFA) tablets/syrup during the last pregnancy. Since maternal health care service utilization continues to be an essential indicator for monitoring the improvements of maternal and child health outcomes. This study aimed to analyze the trends and determinants that contributed to the change in an acceptable antenatal care visit over the last 10 years in Ethiopia. Methods: Nationally representative repeated cross-sectional survey was conducted using 2005, 2011, and 2016 Ethiopian Demographic and Health Survey datasets. The data were weighted and analyzed by STATA 14.1 software. Multivariate decomposition regression analysis was used to identify factors that contribute for the change in an acceptable antenatal care visit. A p-value < 0.05 was taken to declare statistically significant predictors to acceptable antenatal care visit. Results: among the reproductive age women the rate of an acceptable antenatal care visits was increased from 16% in 2005 to 35% in 2016 in Ethiopia. In the multivariate decomposition analysis, about 29% of the increase in acceptable antenatal care visit was due to a difference in composition of women (endowments) across the surveys. Residence, religion, husband educational attainment, and wealth status was the main source of compositional change factors for the improvements of an acceptable antenatal care visit. Almost two-thirds of an overall change in acceptable antenatal care visit was due to the difference in coefficients/ change in behavior of the population. Religion, educational attainment (both women and husband), and residence are significantly contributed to the change in full antenatal care visit in Ethiopia over the last decades. Conclusion: Besides the relevance of receiving an acceptable antenatal care visit for pregnant women and their babies, an acceptable antenatal care visit was slightly increased over time in Ethiopia. Women’s characteristics and behavior change were significantly associated with the change in acceptable antenatal care visits. Public interventions needed to improve acceptable antenatal care coverage, women’s education, and further advancing of health care facilities in rural communities should be done to maintain the further improvements acceptable antenatal care visits.

This study was based on a secondary analysis of cross-sectional population data from Ethiopia Demographic Health Surveys (EDHS) 20,005, 2011, and 2016 to investigate trends and the factors associated with ANC4+ in Ethiopia. So far, in Ethiopia, four consecutive surveys were conducted in the cross-sectional years of 2000, 2005, 2011, and 2016 respectively. Similar to other demographic and health surveys, the principal objective Ethiopian Demographic and Health Survey (EDHS) was to offer current and consistent data on fertility and family planning behavior, child mortality, adult and maternal mortality, children’s nutritional status, use of maternal and child health services, as well as data, were collected on knowledge and attitudes of women and men about sexually transmitted diseases and HIV/AIDS and evaluated potential exposure to the risk of HIV infection by exploring high-risk behaviors and condom use. The sampling frame used for the 2016 EDHS was the Ethiopia Population and Housing Census (EPHC), which was conducted in 2007 by the Ethiopia Central Statistical Agency. The census frame is a complete list of 84,915 enumeration areas (EAs) created for the 2007 PHC. An EA is a geographic area covering on average 181 households. The sampling frame contains information about the EA location, type of residence (urban or rural), and an estimated number of residential households. Except for EAs in six zones of the Somali region, each EA has accompanying cartographic materials. These materials delineate geographic locations; boundaries, main access, and landmarks in or outside the EA that help identify the EA. In Somali, a cartographic frame was used in three zones where sketch maps delineating the EA geographic boundaries were available for each EA; in the remaining six zones, satellite image maps were used to provide a map for each EA. The outcome variable was ‘ANC4+’. A woman was counted as having acceptable ANC, if she had to get four ANC visits, received at least one dose of tetanus toxoid (TT) injections and consumed 100 iron-folic acids (IFA) tablets/syrup during the last pregnancy. The predictor variables are Socio-demographic Characteristics: Age, Marital status, Level of education, media exposure, and occupation Socio-cultural factors: Unplanned Pregnancy, Fear of testing for HIV status, knowledge about ANC benefits, Peer influence, TBA influence, decision-making authority Obstetric factors and Economic factors: Gravida, Parity, Complications during pregnancy, history of abortion, history of stillbirth, trimester of pregnancy and wealth status The data were cleaned and analyzed using STATA14 software and the data was weighted for analysis. The trend was assessed using descriptive analysis by selected explanatory variables of the study population as well as the trend was assessed separately from 2005 to 2011, 2011–2016, and 2005–2016. Multivariate decomposition analysis of change in ANC4+ was employed to answer the major factors contributing to the difference in the percentage of ANC4+ over the study period. This methods are used for many purposes in economic, demography, and other specialties. The present analysis focused on how the ANC4+ rate responds to difference in women’s characteristics and how these factors shape the differences across surveys conducted at different times. The analysis was a regression analysis of the difference in the percentage of ANC4+ rate between EDHS 2005 and 2016. The multivariate decomposition analysis was to identify the source of difference in the percentage of ANC4+ in the last 10 years. Both the difference in composition (Endowment) of the population and the difference in the effect of characteristics (Coefficients) between the surveys is essential to identify the factors contributing to the increase in ANC4+ rate overtime. The multivariate decomposition analysis for nonlinear response model utilizes the output from a logistic regression model since it is “a binary outcome” to parcel out the observed difference in ANC4+ into components. The difference in the rate of ANC4+ between the surveys can be attributed to the compositional difference in population (difference characteristics or endowment) and the difference in the effect of explanatory variable (difference in coefficients) between the surveys. Logit based decomposition analysis technique was used for the analysis of factors contributing to the change in ANC4+ rate over time to identify factors contributing to the ANC4+ in the last 10 years. The change of ANC4+ over time can be attributed to the compositional difference between the surveys and difference in the effect of selected covariates. Hence, the observed difference in ANC4+ between the surveys is additively decomposed into characteristics (or endowments) component and a coefficient (or effect of characteristics) component. For the decomposition analysis, the 2005 EDHS data appended to the 2016 EDHS data by using the command “append”. Since all variables are coded before merging in similar situation. The mean difference in Y between groups A and B can be decomposed as: For our logistic regression, the logit or log-odds of ANC4+ is taken as: The E component refers to the part of the differential owing to differences in endowments or characteristics. The C component refers to that part of the differential attributable to differences in coefficients or effects [24]. The equation can be presented as: The recently developed multivariate decomposition for the non-linear model was used for the decomposition analysis of ANC4+ using mvdcmp STATA command [24].

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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 (mHealth) Solutions: Develop and implement mobile applications or text messaging services that provide pregnant women with information and reminders about antenatal care visits, as well as access to healthcare providers for consultations and support.

2. Community Health Workers: Train and deploy community health workers to provide education, counseling, and support to pregnant women in rural areas, where access to healthcare facilities may be limited. These workers can also help identify and refer high-risk pregnancies for appropriate care.

3. Telemedicine: Establish telemedicine networks to connect healthcare providers in urban areas with pregnant women in remote or underserved areas. This would allow for remote consultations, monitoring, and guidance throughout the antenatal care process.

4. Financial Incentives: Implement financial incentives, such as conditional cash transfers or vouchers, to encourage pregnant women to attend antenatal care visits. This could help offset the costs associated with transportation and other barriers to accessing care.

5. Maternal Waiting Homes: Establish maternal waiting homes near healthcare facilities to accommodate pregnant women who live far away and need to travel for antenatal care. These homes would provide a safe and comfortable place for women to stay before and after their appointments.

6. Public-Private Partnerships: Foster collaborations between the government, private sector, and non-profit organizations to improve infrastructure, equipment, and staffing at healthcare facilities. This would help ensure that pregnant women have access to quality antenatal care services.

7. Health Education Campaigns: Launch targeted health education campaigns to raise awareness about the importance of antenatal care and address cultural or social barriers that may prevent women from seeking care. These campaigns could use various media channels, including radio, television, and community outreach programs.

8. Integration of Services: Integrate antenatal care services with other maternal and child health interventions, such as immunizations and family planning. This would streamline service delivery and ensure comprehensive care for women throughout their reproductive journey.

9. Task Shifting: Train and empower lower-level healthcare providers, such as nurses and midwives, to deliver antenatal care services. This would help alleviate the burden on doctors and increase the availability of care in resource-limited settings.

10. Quality Improvement Initiatives: Implement quality improvement initiatives at healthcare facilities to ensure that antenatal care services are delivered in a timely, respectful, and evidence-based manner. This could involve regular monitoring, feedback, and training for healthcare providers.

It is important to note that these recommendations are based on the information provided and may need to be tailored to the specific context and needs of Ethiopia.
AI Innovations Description
Based on the information provided, the recommendation to improve access to maternal health in Ethiopia is as follows:

1. Strengthen women’s education: Women’s educational attainment has been identified as a significant factor contributing to the improvement of acceptable antenatal care (ANC) visits. Implementing interventions to improve women’s education, particularly in rural communities, can help increase awareness and knowledge about the importance of ANC and encourage women to seek appropriate care during pregnancy.

2. Enhance healthcare facilities in rural communities: Access to healthcare facilities is crucial for pregnant women to receive adequate ANC. Investing in the development and improvement of healthcare facilities in rural areas can help overcome geographical barriers and ensure that women have access to quality ANC services.

3. Address socio-cultural factors: Socio-cultural factors, such as fear of testing for HIV status and influence from traditional birth attendants (TBAs), can impact women’s utilization of ANC services. Implementing targeted interventions to address these factors, such as providing education on the benefits of ANC and promoting the involvement of TBAs in the referral system, can help overcome barriers and increase ANC coverage.

4. Focus on economic empowerment: Economic factors, such as wealth status, have been identified as determinants of ANC utilization. Implementing programs that focus on economic empowerment, such as providing income-generating opportunities and financial support for pregnant women, can help improve access to ANC services, particularly for women from disadvantaged backgrounds.

5. Continuously monitor and evaluate progress: Regular monitoring and evaluation of ANC coverage and utilization is essential to track progress and identify areas for improvement. Collecting and analyzing data on trends and determinants of ANC utilization, as done in this study, can provide valuable insights for policymakers and healthcare providers to develop targeted interventions and strategies.

By implementing these recommendations, it is possible to improve access to maternal health services, specifically ANC, in Ethiopia and contribute to better maternal and child health outcomes.
AI Innovations Methodology
Based on the information provided, here are some potential recommendations to improve access to maternal health:

1. Strengthening healthcare infrastructure: Investing in the development and improvement of healthcare facilities, particularly in rural areas, can help increase access to maternal health services. This includes ensuring the availability of skilled healthcare providers, essential medical equipment, and necessary medications.

2. Enhancing community-based interventions: Implementing community-based interventions, such as training and empowering local health workers, can improve access to maternal health services. These workers can provide basic antenatal care, educate pregnant women about the importance of seeking care, and facilitate referrals to higher-level healthcare facilities when needed.

3. Promoting maternal health education: Increasing awareness and knowledge about maternal health among women and their families can encourage early and regular antenatal care visits. This can be achieved through targeted health education campaigns, workshops, and the use of multimedia platforms to disseminate information.

4. Addressing socio-cultural barriers: Identifying and addressing socio-cultural barriers that prevent women from accessing maternal health services is crucial. This may involve engaging with community leaders, religious institutions, and traditional birth attendants to promote the importance of antenatal care and safe delivery practices.

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

1. Define the indicators: Identify specific indicators that measure access to maternal health, such as the percentage of women receiving the recommended number of antenatal care visits or the percentage of women delivering in a healthcare facility.

2. Collect baseline data: Gather data on the current status of the selected indicators. This can be done through surveys, interviews, or analysis of existing data sources, such as the Ethiopian Demographic and Health Survey.

3. Develop a simulation model: Create a simulation model that incorporates the potential impact of the recommended interventions on the selected indicators. This model should consider factors such as population demographics, healthcare infrastructure, and socio-cultural dynamics.

4. Input intervention scenarios: Define different scenarios that represent the implementation of the recommended interventions. This could include variations in the scale, timing, and coverage of each intervention.

5. Run simulations: Use the simulation model to run multiple iterations of each intervention scenario. This will allow for the estimation of the potential impact on the selected indicators.

6. Analyze results: Analyze the simulation results to determine the effectiveness of each intervention scenario in improving access to maternal health. Compare the outcomes of different scenarios to identify the most promising interventions.

7. Refine and validate the model: Continuously refine and validate the simulation model based on feedback from experts and stakeholders. This will ensure that the model accurately represents the real-world context and provides reliable predictions.

By following this methodology, policymakers and healthcare stakeholders can gain insights into the potential impact of different interventions on improving access to maternal health. This information can guide decision-making and resource allocation to maximize the effectiveness of efforts to enhance maternal health services.


Statistics:
Citations: 3
Identifiers:
DOI: 10.1186/s13690-020-00510-2
ISSN: 07787367
Research Areas:
Community Interventions, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants
Study Countries:
Ethiopia
Study Design:
Cross Sectional Study
Study Approach:
Quantitative
Participants Gender:
Male & Female
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