Effects of continuity of maternal health services on immediate newborn care practices, Northwestern Ethiopia: multilevel and propensity score matching (PSM) modeling

  • Heliyon, Volume 8, No. 12, Year 2022

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Study Justification:
– Despite efforts to improve maternal and child health in Ethiopia, the neonatal mortality rate remains high.
– Immediate newborn care practices and continuity of maternal health services are crucial strategies to reduce neonatal mortality and morbidity.
– However, there is a lack of evidence on the effectiveness of continuity of maternal health services on immediate newborn care practices.
– This study aims to fill this gap by examining the magnitude and determinants of immediate newborn care practices.
Highlights:
– The study found that the magnitude of optimal immediate newborn care practices was low, with only 50.9% of newborns receiving optimal care.
– Factors such as partner education, ANC visits, timing of ANC initiation, IFA supplementation, decision-making power of women and partners, and newborn immunization were found to be determinants of immediate newborn care practices.
– The study also showed that completion of continuity of care in maternal health services (COC in MHS) significantly increased the likelihood of immediate newborn care practices.
Recommendations:
– Strengthen enabling factors such as partner education, immunization programs, IFA supplementation, early initiation and receiving of ANC services, and the decision-making power of women and partners.
– Scale up the continuum of care in maternal health services to improve immediate newborn care practices.
Key Role Players:
– Ministry of Health: Responsible for policy development and implementation of maternal and child health programs.
– Regional Health Bureaus: Responsible for coordinating and implementing health programs at the regional level.
– Health Facilities: Provide maternal and child health services and play a key role in promoting immediate newborn care practices.
– Community Health Workers: Provide health education and support to pregnant women and newborns at the community level.
– Non-Governmental Organizations: Support the implementation of maternal and child health programs and provide resources and technical assistance.
Cost Items for Planning Recommendations:
– Training and capacity building for healthcare providers on immediate newborn care practices.
– Development and dissemination of educational materials for pregnant women and their partners.
– Strengthening immunization programs and ensuring the availability of vaccines.
– Procurement of iron and folic acid supplements for pregnant women.
– Support for community health workers and their activities.
– Monitoring and evaluation of the implementation of recommendations.
Please note that the cost items provided are general examples and may vary depending on the specific context and resources available.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a prospective follow-up study with a large sample size, which strengthens the findings. The study used multilevel regression and propensity score matching models to analyze the data. However, the abstract does not provide information on the representativeness of the sample or the generalizability of the findings. To improve the evidence, future studies could consider using a more diverse sample and provide information on the external validity of the findings.

Background: Despite priority being given to maternal and child health programs in Ethiopia, the reduction of neonatal mortality rate is stagnant, which is more than double the national target. Immediate newborn care and continuity of maternal health services are comprehensive, wide-ranging, and core strategies to overcome neonatal mortality and morbidity. However, the evidence of immediate newborn care practices and the effectiveness of continuity of maternal health services on immediate newborn care practices are scarce. Hence, this study aimed to fill this gap. Methods: A prospective follow-up study was conducted from March 2020 to January 2021, among 2198 pregnant women screened from the study areas. The data were collected using pretested semi-structured questionnaires and a registration logbook. Data were coded, entered, cleaned, and analyzed using STATA software 14. Descriptive statistics, multilevel regression, and propensity score matching (PSM) models were computed. Finally, ICC (ρ), AOR, and coefficient (β) along with 95%CI were calculated and statistical significance was considered at a p-value < 0.05. Results: The magnitude of immediate newborn care practice was 50.9% (95%CI: 50.5%, 51.3%). Partner attended primary cycle school (AOR = 2.32), women attended ANC visit ≥4 (AOR = 2.69), initiated 1st ANC visit between 4–6 months of GA (AOR = 0.47), IFA supplementation (AOR = 2.99), women who make a decision (AOR = 2.25), women whose husband make a decision (AOR = 1.66) and immunizing the newborn (AOR = 2.46) were determinant factors of immediate newborn care practices. As treatment effect, completion of COC in MHS via time dimension (β = 0.31; 95%CI: 0.27, 0.35); whole key service MHS (β = 0.43; 95%CI: 0.39, 0.48) and COC via space dimension (β = 0.17; 95%CI: 0.12, 0.21) were significantly increased the likelihood of immediate newborn care practices. Conclusion: The magnitude of optimal immediate newborn care practices was low. Different enabling factors were discovered in the study. Therefore, strengthening those enabling factors such as partner education, immunization program, IFA supplementation, early initiation and receiving ANC services, the decision-making power of women and partners, as well as scaling up a continuum of care in maternal health services are strongly recommended.

Community and health facility-linked prospective follow-up study design was employed in Benishangul-Gumuz Regional State (BGRS) from March 2020 to January 2021. The region is one of the eleven states of Ethiopia’s Federal Democratic Republic of Ethiopia. Assosa town is the capital city of the region, located 670 kms West of Addis Ababa, the capital city of Ethiopia. The region has three zones (namely Assosa, Metekel and Kemashi zone), three town administrative cities (namely Assosa town, Gilgel Beles town and Kemashi town), 21 districts/Woredas, 1 special district/Woredas (namely Mao-Komo Special Woreda) and 475 clusters/Kebeles (439 rural and 36 urban clusters/Kebeles). The region represents around 4.6% of the total land area of Ethiopia and most of the people in the region are sparsely populated [16]. All births that were registered as “live births” or “stillbirths” at the time of birth and born from women (registered as pregnant women during the baseline survey) in the Region were considered as source population. Whereas, the study participants were newborns registered as “live birth” or “stillbirth” (as declared by women, birth attendants, or health workers) at the time of birth and pregnant women within the selected districts/woredas which were selected by simple sampling techniques. This study aimed to look at the magnitude and determinant factors of immediate newborn care practice. Hence, to determine the sample size, two options of sample size determination were used to take a large sample size. The sample size for the first choice was computed using a single population proportion to look at the level of optimal immediate newborn care practice based on the following assumption: the proportion of newborns who received optimal immediate newborn care practice is 30.8% (p = 0.308) [17]. The margin of error is 5% (d = 0.05) with a 95% confidence interval (1.96) taken into consideration. Then, by taking a design effect of 2 and a non-response rate of 10% into account, the computed sample size was 719 neonates. Similarly, the second option of sample size was calculated to estimate the effect of determinant factors on receiving optimal immediate newborn care practices. Hence, two population proportion formula was employed to estimate the sample size for this study. For all conceivable determinant factors, the sample sizes were calculated. Among all the factors considered, women educational level provided the maximum sample size. The proportion of babies who were born from mothers that attended secondary school received optimal immediate newborn care practices is 29.5% (p1 = 0.295) whereas among mothers who not attended formal education is 13.6% (p2 = 0.136) [17]; P (pooled population proportion) = P1+P21+r was calculated (P = 0.22); r = ratio of exposure to non-exposure pregnant women equal to 1:1; a 95% level of confidence and 80% power, having a design effect of 2 and a non-response rate of 10%. Then, the sample size was 515 newborns babies. As a result, the maximum sample size calculated for this study was 719 newborns. Even though this study was part of large research work, the sample size was calculated for another objective found to be 2402 pregnant women [18]. After 11 months of follow-up and excluding abortion cases, the final sample size considered for this study was 2065 babies. Due to broad settings/areas included in this study, a multistage sampling technique was applied to select the study participants. Primarily, two zones and one town administration city were selected by simple random sampling (SRS) from three zones and three town administrations respectively. Secondly, four districts/“woredas” from the Assosa zone, two districts/“woredas” from the Metekel zone and two districts/“woredas” from the Assosa town administration were selected using simple random sampling (SRS) techniques. Thirdly, among the selected districts/woreda, 51 study clusters such as 7 kebeles from each district/“woreda” except Assosa district/“woreda” (10 kebeles) and five Administrative villages/“ketenas” from each district/“woreda of town administration were selected using simple random sampling (SRS) techniques. Finally, all pregnant women were enumerated using house-to-house visits in the selected kebeles/administrative villages/“ketenas” and all registered pregnant women were included in the study. All women who claimed a pregnancy of eight weeks or more, as defined by the loss of two consecutive menses, were deemed eligible and joined the study. The selected pregnant women were follow-up for an average of 11 months. Besides, the baseline house-to-house surveys, the public health facilities that serve the selected study areas were listed. As result, 46 health facilities (3 hospitals, 12 health centers and 31 health posts) were identified and included in the health facility-based survey. A semi-structured questionnaire was designed in English which was adapted from EDHS 2016 [9], National Technical Guidance for MPDSR 2017 [19], MCH Program Indicator Survey 2013 [20], tools from a survey conducted in Jimma Zone, Southwest Ethiopia [21], survey tools conducted in rural South Ethiopia [22] and other relevant different literature. Hence, to ensure the quality of data, training, pretest, supervision and use of local languages were made. Data were coded and entered into Epi Info version 7.2.2.6 to control logical mistakes. The data were then cleaned, edited and analyzed using STATA Software version 14. Descriptive statistics were computed for all variables. Bi-variable crude odds ratio and 95% confidence interval (CI) were used to select candidate variables for multivariable analysis (p < 0.25). A maximum likelihood estimate of the independent effect on the outcome variable was calculated at a significant level (P 10%). All included variables had VIF <10 which implied that no multi-collinearity effect. Even though the multistage sampling method was used because of the different levels of factors, a multilevel regression model was used by using STATA 14 to identify factors having significant associations with optimal newborn care practices. Kebeles/Administrative villages/“Ketenas” were considered as clusters and cluster level variables: place of residence, access to a health center and household wealth index were taken as higher level (level – 2). Even though pregnant women were nested within the community, individual-level variables such as socio-demographic, obstetric, information and maternal health services were taken as lower level (level – 1). The goodness of fit of the multilevel model was tested by the log-likelihood ratio (LR) test and found to be statistically significant so that data fit the model. Finally, propensity score matching was applied to estimate the effect of a continuum of care in maternal health services on optimal newborn care practices. This study was endorsed after obtaining ethical approval from concerned bodies. Ethical approval was obtained from the Research Review and Ethics Committee (REC) of the School of Public Health, College of Health Sciences, Addis Ababa University with protocol number SPH/3089/011 and the Institutional Review Board (IRB) of College of Health Sciences, Addis Ababa University with protocol number 048/19/SPH. The Benishangul Gumuz Regional Health Bureau provided legal approval letters to their respective local administrations before approaching study participants as well as local administrations. Written informed consent, as well as verbal consent, was obtained from each respondent before actual data collection and confidentiality of the data was strictly maintained.

The study titled “Effects of continuity of maternal health services on immediate newborn care practices, Northwestern Ethiopia: multilevel and propensity score matching (PSM) modeling” was conducted from March 2020 to January 2021 in Benishangul-Gumuz Regional State, Ethiopia. The study aimed to investigate the impact of continuity of maternal health services on immediate newborn care practices.

The study found that the magnitude of optimal immediate newborn care practices was low, with only 50.9% of newborns receiving optimal care. Several factors were identified as determinants of immediate newborn care practices, including partner education, ANC visits, timing of ANC initiation, iron and folic acid supplementation, decision-making power of women and partners, and immunization of the newborn.

Based on the findings, the study recommends the following interventions to improve access to maternal health and enhance immediate newborn care practices:

1. Promote education for partners, particularly attending primary cycle school, as it was found to significantly increase the likelihood of immediate newborn care practices.

2. Encourage pregnant women to attend at least four ANC visits, as it was associated with higher rates of optimal immediate newborn care practices.

3. Emphasize the importance of initiating the first ANC visit between 4-6 months of gestational age, as it was found to positively influence immediate newborn care practices.

4. Ensure that pregnant women receive iron and folic acid supplementation, as it was associated with a higher likelihood of optimal immediate newborn care practices.

5. Empower women and their partners to make decisions regarding maternal and newborn care, as it was found to be a determinant factor for immediate newborn care practices.

6. Strengthen immunization programs to ensure that newborns receive timely vaccinations, as it was associated with higher rates of optimal immediate newborn care practices.

7. Scale up the continuum of care in maternal health services, including both time and space dimensions, to improve access to maternal health and enhance immediate newborn care practices.

These recommendations can serve as a basis for developing innovative interventions and strategies to improve access to maternal health and enhance immediate newborn care practices in Ethiopia. The study was published in Heliyon, Volume 8, No. 12, Year 2022.
AI Innovations Description
The study titled “Effects of continuity of maternal health services on immediate newborn care practices, Northwestern Ethiopia: multilevel and propensity score matching (PSM) modeling” aims to investigate the impact of continuity of maternal health services on immediate newborn care practices in Ethiopia. The study was conducted from March 2020 to January 2021 in Benishangul-Gumuz Regional State.

The study found that the magnitude of optimal immediate newborn care practices was low, with only 50.9% of newborns receiving optimal care. Several factors were identified as determinants of immediate newborn care practices, including partner education, ANC visits, timing of ANC initiation, iron and folic acid supplementation, decision-making power of women and partners, and immunization of the newborn.

The study recommends strengthening these enabling factors to improve access to maternal health and enhance immediate newborn care practices. Specifically, the following recommendations are suggested:

1. Partner education: Promote education for partners, particularly attending primary cycle school, as it was found to significantly increase the likelihood of immediate newborn care practices.

2. ANC visits: Encourage pregnant women to attend at least four ANC visits, as it was associated with higher rates of optimal immediate newborn care practices.

3. Timing of ANC initiation: Emphasize the importance of initiating the first ANC visit between 4-6 months of gestational age, as it was found to positively influence immediate newborn care practices.

4. Iron and folic acid supplementation: Ensure that pregnant women receive iron and folic acid supplementation, as it was associated with a higher likelihood of optimal immediate newborn care practices.

5. Decision-making power: Empower women and their partners to make decisions regarding maternal and newborn care, as it was found to be a determinant factor for immediate newborn care practices.

6. Immunization: Strengthen immunization programs to ensure that newborns receive timely vaccinations, as it was associated with higher rates of optimal immediate newborn care practices.

7. Continuum of care: Scale up the continuum of care in maternal health services, including both time and space dimensions, to improve access to maternal health and enhance immediate newborn care practices.

These recommendations can serve as a basis for developing innovative interventions and strategies to improve access to maternal health and enhance immediate newborn care practices in Ethiopia.
AI Innovations Methodology
To simulate the impact of the main recommendations on improving access to maternal health, you can consider the following methodology:

1. Identify the target population: Determine the population that will be the focus of the intervention, such as pregnant women in a specific region or community.

2. Baseline data collection: Collect data on the current status of maternal health services and immediate newborn care practices in the target population. This can include information on ANC visits, partner education, timing of ANC initiation, iron and folic acid supplementation, decision-making power, and immunization rates.

3. Introduce the interventions: Implement the recommended interventions in the target population. This can involve promoting partner education, encouraging ANC visits, emphasizing the importance of timing of ANC initiation, ensuring iron and folic acid supplementation, empowering women and partners in decision-making, and strengthening immunization programs.

4. Post-intervention data collection: After a specified period of time, collect data on the impact of the interventions. This can include measuring changes in immediate newborn care practices, ANC attendance rates, partner education levels, and other relevant factors.

5. Data analysis: Analyze the data to assess the impact of the interventions on improving access to maternal health. This can involve comparing the pre- and post-intervention data to identify any significant changes in immediate newborn care practices and other relevant factors.

6. Evaluation: Evaluate the effectiveness of the interventions based on the data analysis. Assess whether the recommended interventions have led to improvements in access to maternal health and immediate newborn care practices.

7. Adjustments and scaling up: Based on the evaluation results, make any necessary adjustments to the interventions and consider scaling up successful interventions to reach a larger population.

By following this methodology, you can simulate the impact of the main recommendations on improving access to maternal health and inform future interventions and strategies in Ethiopia.

Statistics:
Authors: 3
Identifiers:
DOI: 10.1016/j.heliyon.2022.e12020
ISSN: 24058440
Research Areas:
Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Sexual and Reproductive Health, Social Determinants
Study Countries:
Ethiopia
Study Design:
Case-Control Study, Cohort Study, Cross Sectional Study, Grounded Theory, Quasi Experimental Study
Study Approach:
Quantitative
Participants Gender:
Female
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