Evaluation of a maternal health care project in South West Shoa Zone, Ethiopia: Before-and-after comparison

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Study Justification:
– Despite recent achievements in health targets, Ethiopia still faces challenges in health service delivery.
– The maternal health care project aimed to improve access to maternal and child health services in three districts in Ethiopia.
– This evaluation assesses the performance of the project based on four maternal health indicators.
Highlights:
– The project was associated with increased likelihood of pregnant women receiving three basic components of antenatal care (ANC) and being assisted by a skilled birth attendant (SBA) at delivery.
– The coverage of all three ANC components and SBA at delivery increased during the intervention period.
– The percent of health center deliveries increased from 7.3% to 35.6%.
– Efforts are still needed to improve the coverage of ANC and postnatal care (PNC).
Recommendations:
– Bolster the coverage of ANC and PNC services.
– Continue efforts to increase skilled birth attendance and utilization of health centers.
Key Role Players:
– Non-governmental organization (NGO): Doctors with Africa CUAMM
– Local partners: Zonal and district health authorities
– Health extension workers (HEWs)
– Health centers (HCs) and hospitals
– Women of reproductive age in the study districts
Cost Items for Planning Recommendations:
– Staffing and training for health extension workers
– Supplies and equipment for health centers and hospitals
– Outreach activities and supportive supervision
– Monitoring and evaluation activities
– Communication and awareness campaigns
– Transportation and logistics for service delivery
Please note that the cost items provided are general examples and may not reflect the actual cost of implementing the recommendations.

The strength of evidence for this abstract is 8 out of 10.
The evidence in the abstract is strong because it is based on a before-and-after study utilizing data collected through cross-sectional surveys. The study population consisted of 999 women, and logistic regression was used to assess changes in four maternal health indicators. The results show an increase in the coverage of antenatal care visits and skilled birth attendance. However, there was no significant change in the coverage of four antenatal care visits and postnatal care. To improve the evidence, future studies could consider using a randomized controlled trial design and include a larger sample size to increase statistical power.

Background: Despite recent achievements in health targets, Ethiopia still faces challenges in health service delivery. Between 2012 and 2015, a non-governmental organisation (NGO), Doctors with Africa CUAMM, implemented a multifaceted project aimed at improving access to maternal and child health services in three districts in Ethiopia. This paper evaluates the performance of this project, based on four maternal health indicators. Methods: A before-and-after study utilising data collected through cross-sectional surveys involving 999 women was conducted. The date of delivery was used to stratify the intervention period as follows: pre-intervention, early intervention, and late intervention. Changes during the intervention in the coverage of four antenatal care (ANC) visits, receipt of three basic components of ANC, skilled birth attendant (SBA) at delivery, and postnatal care (PNC) in seven days were assessed using logistic regression, adjusting for socio-demographic factors. Results: There was an increase in the coverage of receipt of all three ANC components and SBA at delivery between the pre-intervention period and the late intervention period. The percent of health centre deliveries increased from 7.3 % in the pre-intervention period to 35.6 % in the late intervention period. The odds of receiving all three components of ANC were twice higher in the late intervention period than in the pre-intervention period (OR 2.09; 95 % CI 1.12-3.89). The odds of SBA at delivery were five times higher in the late intervention period than in the pre-intervention period (OR 5.04; 95 % CI 2.53-10.06). There was no significant change in the coverage of four ANC visits and PNC after accounting for sociodemographic factors. Conclusions: This NGO implemented maternal health project in three districts in Ethiopia was associated with increased likelihood that a pregnant woman would receive three basic components of ANC and be assisted by a SBA at delivery. Increase in skilled birth attendance was driven by increased utilisation of health centres. More efforts are needed to bolster the coverage of ANC and PNC.

The project was implemented in Wolisso, Goro and Wonchi districts of South West Shoa Zone, Oromia region in central Ethiopia. The districts are located about 115 km south-west of Addis Ababa, the capital of Ethiopia. The three districts had a combined population of about 398,000 inhabitants in 2014 and are served by one hospital (St. Luke Catholic Hospital), which also acts as a zonal referral hospital, 18 HCs and 89 health posts (HPs). The hospital is a private non-profit facility and hence had a system of user fees before the project began. In Ethiopia, maternity services are usually provided at hospitals and HCs. HCs, which are designed to serve a catchment population of 25,000 people, are expected to provide a full range of routine maternal health services plus emergency obstetric care services except blood transfusion and caesarean section, which can only be provided at hospital level [14]. HPs are run by salaried health extension workers (HEWs) who are mainly female community members with high school-level education and have been trained for one year to provide preventive, promotive and selective curative health services. HEWs increase the knowledge and skills of communities to deal with preventable diseases and to utilise health services provided at HCs and hospitals, and also provide care to women during pregnancy, childbirth and postnatal periods either in HPs or in households [14–16]. Thus, they spend about 75 % of their time conducting outreach activities and the rest at HPs. All the HCs and HPs in the study area are government owned and provide maternal health services free-of-charge as per the national policy. The project was embedded in the health system of the districts, and during its course, the following activities were conducted to improve maternal and neonatal health care: A detailed work plan guided the implementation of the project. Monitoring of the project was conducted jointly by CUAMM and local partners (zonal and district health authorities) through quarterly review meetings, quarterly activity and financial reports, planned field visits and supportive supervision. This study utilised before-and-after intervention design based on data collected through two cross-sectional surveys. The study population consisted of women of reproductive age who delivered within two years preceding each survey, in the study districts. Data were collected through household surveys conducted in February 2013 and March 2015. The surveys utilised similar methods and tools (questionnaires). The questionnaires were adapted from the UNICEF’s Multiple Cluster Indicator Survey questionnaires and JHPIEGO’s tools for monitoring birth preparedness and complication readiness [18], and were pretested and translated into Oromo language. During each survey, women who delivered within two years preceding each survey were asked questions related to care during pregnancy, delivery and after delivery of the youngest child. Data were also collected on household and socio-demographic characteristics, birth preparedness, knowledge of pregnancy related danger signs, perceptions towards maternal health care and perceived quality of care. The surveys utilised multistage sampling using a modified Expanded Program for Immunisation’s random walk method [19] to select study subjects. The first stage involved selection of villages and the second stage involved selection of eligible women in the selected village. Details of the sampling method are available elsewhere [12]. The first survey collected data from a sample of 500 women estimated assuming institutional delivery coverage of 20 %, an absolute precision of 0.05, and a Z score value of 1.96 for 95 % confidence interval and a design effect of 2. Due to limited resources, the second survey included a similar number of women. This evaluation was sufficiently powered (>95 %) to detect significant differences at 5 % alpha level between the pre-intervention period and the late intervention period for all the outcomes except for PNC as shown in the Additional file 1. Each survey had a reference period of preceding two years (Fig. 1). This implies that the reference period of the surveys was the entire duration of the project plus a period of 14 months before the start. Although the project began in April 2012, the first four months were spent on preparatory activities such as hiring of staffs and procurement of supplies, and so the actual intervention period began in August 2012. For the purpose of this evaluation, we have defined the intervention period (the exposure variable) based on the month and year that the woman delivered into three periods i.e. pre-intervention period (February 2011 to July 2012), early intervention period (August 2012 to December 2013) and late intervention period (January 2014 to March 2015). Timeline of the project and household surveys (not drawn to scale) We based this evaluation on four outcomes: 1) Attendance of at least four visits of ANC provided by a health professional or a health extension worker; 2) receipt of all three basic services during antenatal care: blood pressure measurement, blood sample taken, urine sample taken; 3) delivery assisted by a skilled birth attendant (SBA) i.e. a doctor, a nurse, a midwife, or a health officer; and 4) receipt of PNC within seven days of delivery by a health professional or a health extension worker. The surveys collected data on district, urban/rural residence, woman’s age; parity; education level; marital status; ethnicity; and religion, index child’s age in months, partner’s education, and distance to the nearest health facility with maternity services. Data were also collected on attitude towards maternal health care, perceived quality of maternal health care at nearest health facility, knowledge of pregnancy danger signs, and birth preparedness. These later four variables were considered to be intermediate outcomes. We derived wealth index through factor analysis of household assets, housing material, and access to water and sanitation services. We used the first of the factor scores to represent the wealth index [20]. We derived maternal health attitude score using factor analysis of eight Likert scale questions that explored perceptions of women towards birth preparedness; male involvement in maternal health; and barriers to institutional childbirth as described elsewhere [12, 18]. We analysed data in Stata version 12 using survey commands to account for the complex sampling design. We assessed the sociodemographic characteristics of women across the intervention periods using descriptive statistics and design based F tests. We cross tabulated the intermediate outcome variables namely: knowledge of pregnancy danger signs, attitude towards maternal health, perceived quality of care, attendance of any ANC and birth preparedness against the intervention periods and assessed linear trends across the periods. To assess the effect of the intervention on each outcome variable, we used logistic regression models to obtain odds ratios (ORs) and 95 % confidence intervals (CIs). The ORs were adjusted for woman’s age, place of residence, wealth index tertile, parity, partner’s education, woman’s education and religion. We used the pre-intervention period as the reference category in all analyses. We explored for linear effects by entering, in the models, the intervention period as a continuous variable.

Based on the provided information, here are some innovations that could be recommended to improve access to maternal health:

1. Mobile Health (mHealth) Solutions: Implementing mobile health technologies, such as SMS reminders for antenatal care appointments and postnatal care follow-ups, can help improve access to maternal health services by providing timely and personalized information to pregnant women.

2. Community Health Worker (CHW) Programs: Expanding and strengthening community health worker programs can improve access to maternal health services, especially in remote or underserved areas. CHWs can provide essential maternal health services, including antenatal care, delivery assistance, and postnatal care, within their communities.

3. Telemedicine: Introducing telemedicine services can enhance access to maternal health care by allowing pregnant women to consult with healthcare providers remotely. This can be particularly beneficial for women living in rural areas with limited access to healthcare facilities.

4. Transportation Support: Providing transportation support, such as ambulances or transportation vouchers, can help overcome geographical barriers and ensure that pregnant women can reach healthcare facilities in a timely manner for antenatal care, delivery, and postnatal care.

5. Financial Incentives: Offering financial incentives, such as cash transfers or conditional cash transfers, can encourage pregnant women to seek and utilize maternal health services. These incentives can help offset the costs associated with accessing healthcare and improve overall access to maternal health services.

6. Quality Improvement Initiatives: Implementing quality improvement initiatives in healthcare facilities can enhance the overall quality of maternal health services, making them more attractive and accessible to pregnant women. This can include training healthcare providers, improving infrastructure, and ensuring the availability of essential equipment and supplies.

7. Public Awareness Campaigns: Conducting public awareness campaigns about the importance of maternal health and the available services can help increase demand for and utilization of maternal health services. These campaigns can be conducted through various channels, including mass media, community outreach programs, and social media.

It is important to note that the specific recommendations for improving access to maternal health should be tailored to the local context and needs of the target population.
AI Innovations Description
Based on the evaluation of the maternal health care project in South West Shoa Zone, Ethiopia, the following recommendations can be developed into an innovation to improve access to maternal health:

1. Strengthening Antenatal Care (ANC) Services: The project showed an increase in the coverage of receipt of all three ANC components. To further improve access to ANC, innovative approaches can be implemented such as mobile ANC clinics that reach remote areas, telemedicine consultations for ANC check-ups, or community-based ANC services provided by trained community health workers.

2. Enhancing Skilled Birth Attendance (SBA): The project demonstrated a significant increase in the odds of receiving SBA at delivery. To sustain and further improve this, innovative solutions can include training and deploying more skilled birth attendants, promoting the use of midwives and community health workers for deliveries, and implementing incentives or subsidies for women to deliver at health facilities.

3. Improving Postnatal Care (PNC): The project did not show a significant change in the coverage of PNC. To address this, innovative strategies can be implemented such as home-based postnatal care visits by trained community health workers, mobile PNC clinics, or telemedicine consultations for postnatal check-ups.

4. Strengthening Health Facilities: The project showed an increase in health center deliveries, indicating the importance of accessible and well-equipped health facilities. Innovations can include improving infrastructure and equipment in health centers, ensuring availability of essential drugs and supplies, and implementing quality improvement initiatives to enhance the overall quality of maternal health services.

5. Community Engagement and Education: To further improve access to maternal health, innovative approaches can focus on community engagement and education. This can include community awareness campaigns on the importance of maternal health, promoting male involvement in maternal health, and empowering women through education and awareness programs.

By implementing these recommendations as innovative solutions, access to maternal health can be improved, leading to better health outcomes for mothers and children in Ethiopia.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations to improve access to maternal health:

1. Strengthening Health Centers: Focus on improving the capacity and resources of health centers to provide comprehensive maternal health services, including antenatal care, skilled birth attendance, and postnatal care. This can involve training healthcare providers, ensuring the availability of necessary equipment and supplies, and improving infrastructure.

2. Community-Based Interventions: Implement community-based interventions to increase awareness and knowledge about maternal health, promote birth preparedness, and encourage women to seek timely and appropriate care during pregnancy, childbirth, and the postnatal period. This can involve engaging community health workers and local leaders to conduct health education sessions, home visits, and community mobilization activities.

3. Mobile Health (mHealth) Solutions: Utilize mobile technology to improve access to maternal health information and services. This can include sending SMS reminders for antenatal care visits, providing access to teleconsultations with healthcare providers, and delivering health education messages through mobile applications.

4. Transportation Support: Address transportation barriers by providing transportation support for pregnant women to reach healthcare facilities. This can involve establishing transportation networks, providing vouchers for transportation services, or implementing community-based transportation initiatives.

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

1. Define the indicators: Identify specific indicators that reflect improved access to maternal health, such as the percentage of women receiving antenatal care, skilled birth attendance, or postnatal care within a specified time frame.

2. Collect baseline data: Gather data on the current status of the selected indicators before implementing the recommendations. This can be done through surveys, interviews, or existing data sources.

3. Implement the recommendations: Introduce the recommended interventions in the target area or population. Ensure proper implementation and monitoring of each intervention.

4. Collect post-intervention data: After a sufficient period of time, collect data on the selected indicators again to assess the impact of the implemented recommendations. This can be done using the same methods as the baseline data collection.

5. Analyze the data: Use statistical analysis techniques, such as logistic regression or chi-square tests, to compare the pre- and post-intervention data and determine the impact of the recommendations on improving access to maternal health.

6. Interpret the results: Evaluate the findings to understand the effectiveness of the recommendations in improving access to maternal health. Identify any significant changes in the selected indicators and assess the overall impact of the interventions.

7. Adjust and refine: Based on the results, make any necessary adjustments or refinements to the recommendations to further enhance their effectiveness in improving access to maternal health.

It is important to note that the methodology described above is a general framework and can be adapted based on the specific context and resources available for the evaluation.

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