Determinants of antenatal and delivery care utilization in Tigray region, Ethiopia: A cross-sectional study

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Study Justification:
– Maternal mortality rates in sub-Saharan Africa are still high, with Ethiopia being a major contributor.
– Limited information is available on the utilization of maternal health care services in rural areas of Ethiopia.
– This study aims to determine the prevalence of maternal health care utilization and explore its determinants among rural women in Tigray, Ethiopia.
Highlights:
– The study found that 54% of women received antenatal care (ANC) for their recent births, but only 4.1% gave birth at a health facility.
– Factors associated with ANC utilization were marital status, education, proximity of health facility to the village, and husband’s occupation.
– Factors associated with institutional delivery were parity, education, ANC advice, history of difficult/prolonged labor, and husband’s occupation.
– The study highlights the need to strengthen different aspects of the Health Extension Program (HEP) to improve maternal health in Tigray.
Recommendations:
– Increase awareness and education about the importance of ANC and institutional delivery.
– Improve access to health facilities by increasing the number of facilities and improving transportation infrastructure.
– Strengthen the Health Extension Program to provide better ANC advice and support for women during pregnancy.
– Address socio-demographic factors such as education and occupation to improve maternal health care utilization.
Key Role Players:
– Tigray Regional Health Bureau
– Samre-Saharti District Health Office
– Health Extension Workers (HEWs)
– Health center staff
– Community leaders and volunteers
– Non-governmental organizations (NGOs) working in maternal health
Cost Items for Planning Recommendations:
– Construction and maintenance of health facilities
– Training and capacity building for health workers
– Awareness campaigns and education materials
– Transportation infrastructure improvement
– Support for the Health Extension Program
– Monitoring and evaluation of maternal health programs

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is relatively strong, but there are some areas for improvement. The study design is a community-based cross-sectional survey, which provides valuable information. The response rate was high at 99%, and a large sample size of 1,113 women was used. The study also used both univariable and multivariable logistic regression analyses to determine the impact of various factors on ANC and institutional delivery service utilization. However, there are a few limitations that could be addressed to improve the evidence. Firstly, the study relies on self-reported data, which may be subject to recall bias. Secondly, the study only includes women who had given birth at least once in the five years prior to the survey, which may not capture the experiences of all women in the population. Additionally, the study does not include postnatal care (PNC), which is an important aspect of maternal health. To improve the evidence, future studies could consider using more objective measures of utilization, such as medical records, and include a broader range of women, including those who have not recently given birth. It would also be valuable to include PNC in the analysis to provide a more comprehensive understanding of maternal health care utilization.

Introduction. Despite the international emphasis in the last few years on the need to address the unmet health needs of pregnant women and children, progress in reducing maternal mortality has been slow. This is particularly worrying in sub-Saharan Africa where over 162,000 women still die each year during pregnancy and childbirth, most of them because of the lack of access to skilled delivery attendance and emergency care. With a maternal mortality ratio of 673 per 100,000 live births and 19,000 maternal deaths annually, Ethiopia is a major contributor to the worldwide death toll of mothers. While some studies have looked at different risk factors for antenatal care (ANC) and delivery service utilisation in the country, information coming from community-based studies related to the Health Extension Programme (HEP) in rural areas is limited. This study aims to determine the prevalence of maternal health care utilisation and explore its determinants among rural women aged 15-49 years in Tigray, Ethiopia. Methods. The study was a community-based cross-sectional survey using a structured questionnaire. A cluster sampling technique was used to select women who had given birth at least once in the five years prior to the survey period. Univariable and multivariable logistic regression analyses were carried out to elicit the impact of each factor on ANC and institutional delivery service utilisation. Results: The response rate was 99% (n=1113). The mean age of the participants was 30.4 years. The proportion of women who received ANC for their recent births was 54%; only 46 (4.1%) of women gave birth at a health facility. Factors associated with ANC utilisation were marital status, education, proximity of health facility to the village, and husband’s occupation, while use of institutional delivery was mainly associated with parity, education, having received ANC advice, a history of difficult/prolonged labour, and husbands’ occupation. Conclusions: A relatively acceptable utilisation of ANC services but extremely low institutional delivery was observed. Classical socio-demographic factors were associated with both ANC and institutional delivery attendance. ANC advice can contribute to increase institutional delivery use. Different aspects of HEP need to be strengthened to improve maternal health in Tigray. © 2013 Tsegay et al.; licensee BioMed Central Ltd.

Tigray regional state is located in the northern part of the country and has an estimated total population of 4.3 million of which 50.8% are females. Eighty percent of the population are estimated to live in rural areas and the majority of the inhabitants are Christian [27]. The region is divided into seven zones and 47 weredas (districts), of which 35 are rural and 12 are urban. There is one specialised referral hospital as well as five zonal hospitals, seven district hospitals, 208 health centres and more than 600 health posts in the region. Coverage estimations from the Tigray Health Bureau indicate 75% are for ANC, 20% for skilled delivery, 13% for clean and safe deliveries (those attended by HEWs) and 90% for contraceptive use [28]. The study district of Samre-Saharti is located in the northern part of the state of Tigray, 55 km from the capital, Mekelle. The district has 23 tabias (sub-districts) and each tabia has a health post with two HEWs. There is one health centre (HC) in the district’s town which functions as a referral center to the four HCs stationed in the rural areas. Samre-Saharti has an estimated population of 124,499 of which 50.2% are female [26]. Women of reproductive age (15–49 years) constitute approximately 14,375 (23%) of the population and the number of deliveries in 2007 was estimated to be 646 [27]. The study design was a community-based cross-sectional survey. Of the 23 tabias in the district, four were difficult to reach due to floods and were therefore excluded, so 19 were included in the study. A lottery was drawn among the 19 tabias to sort their respective villages (kushets) randomly and then the cluster sampling technique was used to select the study population. The sample size for the study was determined using the single population proportion formula. Assuming the proportion of institutional delivery to be 6%, a 95% level of confidence, a 2% marginal error and a design effect of 2, and the required sample size was 1,115 women. The 30 clusters were chosen by population proportional to size sampling. Households were chosen after a random start at a central place in the village. A pen was spun and the data collectors walked to the edge of the village in the direction that the pen pointed, numbering all households along the way. A random number was chosen to identify one of these households as the starting household for the cluster and collection continued on the right-hand side of this starting house until the required number of individuals had been recruited for the sample. If neither household members nor a woman as per the selection criteria, were present at the time of the survey visit, the next closest household was chosen. A total of 1,115 households from the 19 tabias and 30 selected clusters were visited from August to September 2009. The units of analysis for this study were women (aged 15–49 years) who had given at least one live birth during the five years before the survey. A structured questionnaire was prepared in English, based on an existing tool and translated into the local language (Tigrigna) prior to the start of the fieldwork (Additional file 1). To ensure that the questions were clear and could be understood by both the enumerators and the respondents, the questionnaire was pretested and further refined based on the results. The questionnaire collected information on socio-demographic and obstetric characteristics, use of ANC and place of delivery. Fifteen HEW enumerators who were fluent in the local language and four supervisors with experience in maternal health service provision were selected for data collection. The supervisors were assigned to supervise the data collection process and perform quality checks. Three days of training were given to both the data collectors and the supervisors and were managed by the investigator. The training focused on the quality of the field operation (how to fill in the questionnaire, mock interviews and other practical exercises). Permission to carry out the study was obtained from the Tigray Regional Health Bureau and the Samre-Saharti District Health Office. Each respondent gave informed verbal consent after being told the purpose and procedures of the study. All responses were kept confidential and anonymous. Two response variables were created from questions included in the study questionnaire on ANC and place of delivery. ANC use was defined as whether the mother paid at least one visit to the health post during her pregnancy. Place of delivery was classified as home delivery or institutional delivery, the latter including births that took place at a health centre or at a health post. Despite its importance, PNC was not included in this study since this strategy is under developed in Tigray region. In order to study the influence of explanatory variables on the utilisation of ANC and place of delivery, several predictor variables were selected based on (national and international) literature, national guidelines, field observations and common local practices. The independent variables were categorised as follows. The ages of mothers were grouped as 16–29 years, 30–39 years and 40–49 years. Marital status was classified as married for those who were currently living with their partners, single for those who had never been married, divorced for those currently separated, and widowed for those who had lost their husbands. Respondents’ education was classified as illiterate, grade 1–4, grade 5–8 and grade 9–12 and above. Husbands´ occupation was classified as farmers, and other occupations (which included pay-in-cash jobs such as daily labourers, merchants and governmental employees). Proximity of residence to health facility was defined as the availability or not of a health facility in the village. Parity was grouped as 1–4, 5–7 and 8–11 children. History of obstructed and prolonged labour was defined as whether the mother had reported experience of difficult labour in a previous pregnancy. A question about receiving pregnancy advice or not during ANC visits was also included in the questionnaire. Data were collected, compiled and reviewed by the supervisors and then entered into Epi Info software, coded, cleaned, and finally imported into STATA version 10 software for analysis. Univariable logistic regression was carried out between the selected predictor variables and the outcomes (ANC and institutional delivery service utilisation). Those variables which were significant (i.e. with a p value<0.05) in the univariable logistic regression were selected and retained in the multivariable logistic model. Marital status, education, parity, health facility availability in kushet and husband’s occupation were included for the first outcome variable ANC. In addition to the mentioned variables, ANC attendance, ANC advice and difficult/prolonged labour were included in the adjusted models for the delivery care outcome variable. Both variables ‘Attended ANC’ and ‘ANC advice’ were included in the analysis despite potential collinearity (although correlation coefficient of 0.56 was observed in the analysis) because not all women attending ANC received advice and we wanted to capture this dimension. Odds ratios and their 95% confidence intervals (CIs) were calculated.

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 text messaging services to provide pregnant women with information and reminders about antenatal care visits, nutrition, and other important aspects of maternal health.

2. Telemedicine: Implement telemedicine programs that allow pregnant women in rural areas to consult with healthcare providers remotely, reducing the need for travel and increasing access to medical advice and support.

3. Community health worker training: Strengthen the training and capacity of community health workers, such as Health Extension Workers (HEWs) in Ethiopia, to provide comprehensive maternal health services, including antenatal care and skilled delivery attendance.

4. Transportation support: Establish transportation systems or programs to ensure that pregnant women in remote areas have access to transportation for antenatal care visits and emergency obstetric care.

5. Facility upgrades: Improve the infrastructure and equipment of health facilities in rural areas to provide quality maternal health services, including skilled delivery attendance and emergency obstetric care.

6. Financial incentives: Implement financial incentive programs to encourage pregnant women to seek antenatal care and deliver in health facilities, such as conditional cash transfers or vouchers for maternal health services.

7. Community awareness campaigns: Conduct community-based awareness campaigns to educate pregnant women and their families about the importance of antenatal care and skilled delivery attendance, addressing cultural beliefs and barriers to accessing maternal health services.

8. Partnerships with traditional birth attendants: Collaborate with traditional birth attendants to improve their skills and knowledge on safe delivery practices, and establish referral systems to ensure timely access to emergency obstetric care when needed.

9. Integration of maternal health services: Integrate maternal health services with other healthcare services, such as family planning and child health services, to provide comprehensive care for women and their families.

10. Research and data collection: Conduct further research and data collection to identify specific barriers to accessing maternal health services in rural areas and develop targeted interventions to address these barriers effectively.

These innovations aim to address the challenges identified in the study and improve access to maternal health services in Tigray, Ethiopia.
AI Innovations Description
Based on the information provided, the study conducted in Tigray, Ethiopia identified several factors associated with the low utilization of maternal health services, including antenatal care (ANC) and institutional delivery. The study found that only 54% of women received ANC for their recent births, and only 4.1% gave birth at a health facility.

The study recommended several strategies to improve access to maternal health services in Tigray:

1. Strengthen the Health Extension Programme (HEP): The study highlighted the need to strengthen different aspects of the HEP to improve maternal health in Tigray. This could include increasing the number of trained Health Extension Workers (HEWs) and improving their capacity to provide comprehensive maternal health services.

2. Increase awareness and education: The study found that education was associated with ANC and institutional delivery utilization. Therefore, efforts should be made to increase awareness and education among women and their families about the importance of ANC and delivering in a health facility.

3. Improve proximity to health facilities: The study identified proximity to health facilities as a factor influencing ANC utilization. Efforts should be made to improve access to health facilities, especially in rural areas, by increasing the number of health centers and health posts.

4. Strengthen ANC advice: The study found that receiving ANC advice was associated with increased institutional delivery utilization. Therefore, efforts should be made to ensure that all women attending ANC receive comprehensive advice on the benefits of delivering in a health facility.

5. Address socio-demographic factors: The study found that socio-demographic factors such as marital status and husband’s occupation were associated with ANC and institutional delivery utilization. Addressing these factors, such as promoting gender equality and improving economic opportunities for women, could help improve access to maternal health services.

Overall, the study recommended a multi-faceted approach to improve access to maternal health services in Tigray, including strengthening the Health Extension Programme, increasing awareness and education, improving proximity to health facilities, strengthening ANC advice, and addressing socio-demographic factors.
AI Innovations Methodology
Based on the information provided, here are some potential recommendations to improve access to maternal health in Tigray, Ethiopia:

1. Strengthen the Health Extension Programme (HEP): The HEP plays a crucial role in providing maternal health services in rural areas. By investing in training and capacity building for Health Extension Workers (HEWs), the program can be strengthened to improve the quality and accessibility of maternal health services.

2. Improve infrastructure and transportation: Enhancing the availability and accessibility of health facilities in rural areas can encourage more women to seek antenatal care and deliver in health facilities. Additionally, improving transportation options can help overcome geographical barriers and ensure timely access to emergency obstetric care.

3. Increase community awareness and education: Conducting community-based awareness campaigns and educational programs can help dispel myths and misconceptions surrounding maternal health, encourage women to seek care, and promote the importance of skilled delivery attendance.

4. Enhance collaboration between healthcare providers: Strengthening collaboration between different healthcare providers, including traditional birth attendants, midwives, and doctors, can improve the continuum of care for pregnant women and ensure a smooth referral system for emergency obstetric care.

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 key indicators that reflect access to maternal health, such as the proportion of women receiving antenatal care, the proportion of institutional deliveries, and maternal mortality rates.

2. Collect baseline data: Gather data on the current status of maternal health access in the target area, including information on the indicators identified in the previous step.

3. Develop a simulation model: Create a simulation model that incorporates the identified recommendations and their potential impact on the selected indicators. This model should consider factors such as population size, healthcare infrastructure, transportation availability, and community awareness.

4. Input data and run simulations: Input the baseline data into the simulation model and run multiple simulations to assess the potential impact of the recommendations on the selected indicators. Adjust the parameters of the recommendations (e.g., coverage, effectiveness) to explore different scenarios.

5. Analyze results: Analyze the results of the simulations to determine the potential impact of the recommendations on improving access to maternal health. Compare the outcomes of different scenarios to identify the most effective strategies.

6. Refine and validate the model: Continuously refine and validate the simulation model based on new data and feedback from stakeholders. This will ensure that the model accurately reflects the real-world context and can be used for future decision-making.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of different recommendations and make informed decisions to improve access to maternal health in Tigray, Ethiopia.

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