The effect of birth preparedness and complication readiness on skilled care use: A prospective follow-up study in Southwest Ethiopia

Background: Skilled care during and immediately after delivery has been identified as one of the key strategies in reducing maternal mortality. However, recent estimates show that the status of skilled care during delivery remained very low in Ethiopia. Birth preparedness and complication readiness has been implemented as comprehensive strategy to fill this gap. However, its effectiveness in improving skilled care use hasn’t been well studied. Objective. The objective of this study was to determine the effect of birth preparedness and complication readiness on skilled care use in Southwest Ethiopia. Methods. A prospective follow-up study was conducted from September 2012-April 2013 in Southwest Ethiopia among randomly selected 3472 mothers. Data were collected by using pre-tested interviewer administered questionnaires and analyzed by using SPSS for windows V.20.0 and STATA 13. Mixed-effects multilevel logistic regression model was used to look at the relation between birth preparedness and complication readiness plan and skilled care use and identify other determinant factors. Results: The status of skilled care use was 17.5% (95% CI: 16.2%, 18.8%). Factors affecting skilled care use existed both at the community as well as individual levels. Planning to use skilled care during pregnancy was found to increase actual use significantly (OR = 2.24; 95%CI: 1.60, 3.15). Place of residence, access to basic emergency obstetric care, maternal education, husband’s occupation, wealth quintiles, number of pregnancy, inter-birth interval, knowledge of key danger signs during labor and ANC use were identified as factors affecting skilled care use. Conclusions: The status of skilled care use was found to be low in the study area. Birth preparedness and complication readiness had significant effect on skilled care use. Socio-demographic, economic, access to health facility, maternal obstetric factors and antenatal care were identified as determinant factors for skilled care use. Designing appropriate interventions to improve information, education and communication, antenatal care use, family planning and knowledge of key danger signs are recommended.

This community based prospective follow-up study was conducted in Jimma Zone, located 346kms Southwest of Addis Ababa, the capital city of Ethiopia, from September 2012-April 2013. Jimma Zone is one of the 17 Zones of the Oromia Regional State of Ethiopia, which was named for the former Kingdom of Jimma and absorbed into the former province of Kaffa in 1932. The Zone has a total of 17 rural districts called ‘Woredas’ and two town administrations with an estimated total population of about 2.6 million and a male-to-female ratio of 1.01:1. The great majority (89%) of the population of the Zone were rural residents. The Zone has a total of 521,506 households with an average household size of 4.77 persons per a household. The potential health service coverage of the zone for the year 2011 was about 52% [13,14]. The source or target population considered for this study was all women who had given birth during the study period, from September 2012-April 2013 in Jimma Zone. However, as this was a prospective follow-up study, the study participants were all pregnant women identified based on the sampling procedure and enrolled in the study at a base line and had been followed till 28 days post-partum period. At the baseline, the status of BP & CR and affecting factors were studied which is under review for publication on Pan African Medical Journal. This study was the intermediate one collected during the second phase just at the end of neonatal period. The final study, determinants and causes of neonatal mortality, is again on peer review process for publication on Plos One. The minimum required sample size for this study was determined by using Epi-Info V.3.5.1. by considering two sample comparisons of proportions based on the following assumptions. The outcome variable was skilled care use and the explanatory variable was BP & CR plan. As there was no similar study conducted in the country to be used as a base to determine the sample size, study from other developing country was used. In a study done in India, BP & CR was found to increase the skilled care use by 80% [11]. In Ethiopia, the proportion of women attended by skilled delivery attendant was 10% and this was taken as the proportion among non-exposed group (P1 = 0.1) [8]. The proportion of women attended by skilled attendant among exposed (prepared for birth and its complication) was estimated to be 18% (P2 = 0.18) to detect 8% difference or 80% increment. A level of confidence of 95% and power of 90% were considered. In addition, the coverage of exposure from the general population was estimated to be 22% [15]. Thus, a ratio of 1:4 (r = 4) was used for exposed-to-non-exposed. A design effect of 2 was also considered because of the multistage clustered sampling techniques. Finally, 10% was added for non responses and miss to follow-up and the final sample size became 2603 mothers. However, this study was part of a big longitudinal study in which 3612 pregnant women had been on follow-up to look at the determinants of neonatal mortality. As a result, after excluding lost-to-follow-up and abortion cases, 3472 mothers were included in the analysis of this study. Multi-stage clustered sampling technique was used to identify pregnant women for the study. Initially, the Zone was stratified as Town Administrations (2 in number) and rural districts (17 in number). Then, at first stage, 5 districts were selected randomly from the 17 rural districts (‘Woredas’). At second stage, all the selected 5 districts were stratified in to urban and rural ‘Kebeles’ (A ‘kebele’ is the smallest administrative unit having 5000 population in average and considered as clusters in this study). Then, by simple random sampling method, 9 rural ‘Kebeles’ and 2 urban ‘Kebeles’ were selected from each selected district. Jimma town administration and Agaro town administration have 13 and 5 ‘Kebeles’ respectively and all were included purposefully. Then, for all the selected ‘kebeles’, pregnant women were enumerated by using house-to-house visit and all obtained and registered were included in the study. All women who reported to have pregnancy of 12 weeks or above as defined by loss of three consecutive menses were considered as eligible and enrolled in the study. Pre-tested interviewer administered structured questionnaire was adapted from the safe motherhood questionnaire developed by maternal and neonatal health program of JHPIEGO to measure the composite variable for birth preparedness and complication readiness [9]. The indicators for the wealth index were adapted from EDHS [8]. To control the quality of data, training, pretest, supervision and use of local languages were made. The collected data were coded and entered into EpiData V.3.1 to minimize logical errors and design skipping patterns. Then, the data were exported to SPSS for windows version 20.0 for cleaning, editing and analysis. Descriptive analysis was made by computing proportions and summary statistics. Socio-economic quintiles were determined by using Principal Component Analysis (PCA). As Jimma and Agaro town administrations were both purposefully included, the status of skilled care use was estimated by calculating weighted percentage based on the complex sample survey procedure. Bivariate analysis was done by using cross-tabulation to see associations between each independent variable and skilled care use. All variables having P < 0.25 were considered as candidates for the final model. As multistage clustered sampling method was used because of the different levels of factors, mixed-effects multilevel logistic regression model was used by using STATA 13 to identify factors having significant association with skilled care use. ‘Kebeles’ were considered as clusters and kebele level variables such as place of residence and access to basic emergency obstetric care (BEmOC) and comprehensive emergency obstetric care (CEmOC) were taken as higher level (level-2). Mothers were nested within their households and the community. As a result, maternal individual variables including socio-demographic, economic, obstetric and BP & CR were taken as lower level (level-1). Goodness of fit of the multilevel model was tested by the log likelihood ratio (LR) test. Multicollinearity between the independent variables was assessed by using variance inflation factor (VIF). As all included variables had VIF < 10, no multicollinearity was detected. In addition cross-level two-way interactions were checked; but, no significant interaction was detected. Ethical approval was obtained from the Institutional Review Board (IRB) of College of Health Sciences of Addis Ababa University. Necessary permission was secured from all local administrators. Written informed consent was obtained from each respondent before actual data collection. Issues of confidentiality were maintained by removing any identifiers from the questionnaire. To protect vulnerable group, data collectors were trained to maintain confidentiality and provide necessary health information based on the need of the participants, but not an intervention. A package of interventions measured as a composite variable of 5 items: planed to save money, planed to arrange transport, planed to give birth in health facility, planed to be attended by skilled attendant and planed to arrange blood donor. Mothers who fulfilled three or more of the five items were considered as ‘well prepared’ and otherwise ‘not well prepared’. The blood donation system in Ethiopia is based on both volunteer donors and replacement based. In this study, women who had identified volunteer family member to donate the blood during delivery if needed were considered as arranged blood donor and otherwise not. Delivery attended in health facilities (hospital, health center or private clinics) attended by skilled attendants (doctor, midwife, nurse, health officer or unspecified health worker who has a training of Diploma or above). Delivery attended at health post by HEW was not considered as skilled care.

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• debelew, gurmesa tura
• fantahun, mesganaw
• yalew, alemayehu worku