Neonatal care practice and factors affecting in Southwest Ethiopia: A mixed methods study

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Study Justification:
– Neonatal mortality can be prevented with appropriate care, but lack of such care leads to millions of neonatal deaths globally.
– The situation is particularly severe in Ethiopia.
– This study aims to determine the status of neonatal care and identify factors affecting it.
Highlights:
– The overall status of neonatal care practice in Southwest Ethiopia was found to be 59.5%.
– Skilled care at birth and receiving vaccination on the date of birth were identified as the worst practices.
– Factors affecting neonatal care included socio-demographic, economic, and obstetric factors.
– Appropriate birth spacing, birth limiting, and behavior change communication on the importance of neonatal care are recommended.
Recommendations:
– Improve access to skilled care at birth and ensure timely vaccination for newborns.
– Implement interventions to address socio-demographic, economic, and obstetric factors that affect neonatal care.
– Promote appropriate birth spacing and birth limiting.
– Conduct behavior change communication campaigns to raise awareness about the importance of neonatal care.
Key Role Players:
– Health professionals and service providers
– Traditional birth attendants
– Health extension workers
– Mothers and families
– Community leaders and organizations
– Government agencies and policymakers
Cost Items:
– Training and capacity building for health professionals and service providers
– Outreach programs and campaigns for behavior change communication
– Equipment and supplies for skilled care at birth
– Vaccination programs and supplies
– Monitoring and evaluation activities
– Research and data collection
– Administrative and coordination costs

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a mixed methods study involving both quantitative and qualitative data collection methods. The sample size was determined using appropriate statistical methods. The study provides detailed information on the study population, data collection methods, and data analysis techniques. However, the abstract does not mention specific limitations of the study or potential biases that may have influenced the results. To improve the evidence, the abstract could include a discussion of the limitations and potential biases, as well as recommendations for future research to address these limitations.

Background: A significant proportion of neonatal mortality can be prevented by the provision of the minimum neonatal care package. However, about 3 million neonates die each year globally because of lack of appropriate care. This situation is the worst in Ethiopia. Thus, the objective of this study was to determine the status of neonatal care and identify factors affecting. Methods: A mixed methods study involving both quantitative and qualitative methods was conducted from September 2012-December 2013 in Southwest Ethiopia. Randomly selected sample of 3463 mothers were interviewed to collect the quantitative data. Twelve in-depth interviews with purposively selected key informants and six focus-group discussions with purposively selected mothers were conducted for the qualitative data. Mixed-effects multilevel linear regression model was used to identify predictors of neonatal care practice by using STATA 13. Audio recording, transcription and thematic content analysis was done for the qualitative data. Results: The overall status of neonatal care practice was 59.5 % (95 % CI: 57.6 %, 61.3 %). Of the respondents, 53.8 % received tetanus toxoid, 23.8 % planed for birth, 41.9 % received at least one antenatal care and 43.0 % received adequate information during pregnancy. Only, 17.5 % received skilled care at birth and 95.0 % received social support. Of the neonates, 96.5 % received appropriate thermal care, 86.5 % received clean cord care, 64.1 % initiated breast-feeding within one hour, 91.5 % were on exclusive breast-feeding, 56.5 % received appropriate bathing and 8.1 % received vaccination on date of birth. Place of residence, maternal education, husband’s occupation, wealth quintiles, birth order and inter-birth interval were identified as predictors of neonatal care practice. Conclusions: The status of neonatal care practice was low in the study area. Skilled care at birth and receiving vaccination on date of birth were the worst practices. Factors affecting neonatal care existed both at cluster level and at the individual level and included socio demographic, economic and obstetric factors. Appropriate birth spacing, birth limiting and behaviour change communications on the importance of neonatal care are recommended.

This community-based prospective follow up study, employing both quantitative and qualitative data collection methods, was conducted in Jimma Zone, Southwest Ethiopia from September 2012 to December 2013. Jimma Zone is one of the 17 Zones of the Oromia Regional State of Ethiopia. Administratively, the Zone is sub-divided in to 17 rural districts called ‘Woredas’ and two town administrations. According to the 2007 national population and housing census, the Zone has a total population of about 2.6 million, of whom 88.7 % are rural residents [19, 20]. Mothers who had given birth 28 days before the survey were the study populations for the quantitative method. The minimum required sample size for this study was determined by using Epi-Info V.3.5.1 based on the following assumptions. The status of neonatal care practice as determined by the mean score of composite variable (indices) was assumed to be 29 % (p = 0.29) (Gashaw A. Assessment of New Born Care Practices During the first week of life Among mothers in Addis Ababa, Ethiopia (Unpublished)). The allowed margin of error to be 3 % (d = 0.03) with 95 % level of confidence. In addition, as multistage-clustered sampling method was used, a design effect of 2 was considered. Finally, 10 % was added for non-responses and missed-to-follow up and the final sample size became 1934 mothers. This study was part of a bigger longitudinal study in which 3463 mothers were followed up. Therefore, to increase the precision of the estimates and power of the study, we included all the 3463 mothers in this study. A multistage-clustered sampling technique was used to identify the study participants. Initially, the Zone was stratified as town administration and rural districts called ‘Woredas’. Then, 5 districts were selected by simple random sampling from the 17 districts. At the second stage, 9 rural ‘Kebeles’ and 2 urban ‘Kebeles’ were selected from each selected district randomly. Jimma town administration and Agaro town administration have 13 and 5 ‘kebeles’, respectively and all were included purposefully. With this, in total, 73 clusters (‘Kebeles’) were included in the study from which 3682 pregnant women were enumerated and enrolled to the study at the baseline. All the enrolled pregnant women were followed till 28 days postpartum period and neonatal care practice was assessed at the end of neonatal period. To have in-depth understanding of neonatal care practices and contributing factors, 12 in-depth interviews (IDIs) and 6 Focus Group Discussions (FGDs) were conducted. The IDIs involved 4 service providers, 4 traditional birth attendants (TBAs) and 4 Health Extension Workers (HEWs) all of whom were selected purposively based on their close relation with mothers and neonates and assumed to be rich sources of information on the topic of the study. The FGDs involved purposively selected 8-10 mothers having post neonatal infants (1-6 months) each. The number of IDIs and FGDs were determined based on level of saturation of the required information. The data were collected by using pre-tested interviewer-administered structured questionnaires, which were adapted from related literatures. The indicators for the wealth index were adapted from Ethiopian Demographic and Health Survey (EDHS) [8]. Indicators for neonatal care practice were adapted from the World Health Organization (WHO) minimum neonatal care package [14]. The questionnaire was prepared in English, then translated to local languages ‘Afan Oromoo’ and Amharic and used to collect the data. The dependent variable for this study was neonatal care practice, which was a composite score (index) created from 12 items and treated as continuous variable. By taking ‘Kebeles’ as clusters, the independent variables were divided into two levels. Level-2 (higher level variables) included community or cluster-level variables such as place of residence, access to health centres and access to hospitals. Level-1 (lower- level variables) included individual and household characteristics such as: socio-demography, wealth quintiles and maternal obstetric factors. The detail description of each variable is given below (Tables 1 and ​and22). Description of variables and measurement for the study, Jimma Zone, Southwest Ethiopia, September 2012-December 2013 Description of variables and measurement for the study, Jimma Zone, Southwest Ethiopia, September 2012-April 2013 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 done by computing proportions and summary statistics. Wealth quintiles were determined by using Principal Component Analysis (PCA). Similarly, neonatal care practice, a continuous dependent variable, was created as a composite index (score) by using PCA. The index was created by including the 12 elements of the minimum neonatal care package described in Tables 1 and ​and22 above. Each variable were measured in terms of “Yes” or “No” response categories and later changed to dummy variables by assigning “1” for “Yes” responses and “0” for “No” responses for the PCA. While doing the PCA, colinearities between the independent variables were checked by producing correlation matrix. However, no correlation coefficient was 0.9 or above for a variable to be excluded. The Kaiser-Meyer-Olkin (KMO) measure of sampling adequacy was 0.74 (>0.50 is acceptable) and Bartlett’s Test of Sphericity was significant (p < 0.001). The importance of each variable for the model was checked by looking at the communalities and those variables having communalities  1.0 explaining 65.04 % of the total variance (>60 % is acceptable to use PCA). No variable was found to have complex structure or high loadings (> 0.4 in more than one component in the rotated component matrix). Inter-item consistencies for the variables making each component were checked by Cronbach’s alpha and all were > 0.7. The existence of outliers was checked by sorting each principal component by ascending order and all cases were within the range of ±3 factor scores. Finally, all the 4 components were added and an index (score), the continuous dependent variable, was created. The status of neonatal care practice was determined by dichotomizing the score based on the mean value of the score. As Jimma town administration and Agaro town administration were included purposefully, weighted analysis was done to avoid urban over representation and over estimation of the status of neonatal care practices. The weighted analysis was done based on the complex-sample survey procedure by considering the probability of exclusion at different stages and the non-responses. To identify factors affecting neonatal care practice, first, bivariate analysis was done to see associations between each independent variable and neonatal care practice. Then, all variables having p 10 were considered as suggestive of existence of multicollinearity). In addition, cross-level two-way interactions were checked. Beta (β) coefficients along with 95 % CI were used to show the strength of the associations and level of significance. The audio taped qualitative data were transcribed in to English language. Then, codes or terms were identified and tallied to come up with some categories, which later used to establish themes based on the objective of the study. Finally, thematic analysis was done and the findings were triangulated with the quantitative one. Ethical approval was obtained from the Institutional Review Board (IRB) of the College of Health Sciences of Addis Ababa University. In addition, written informed consent was obtained from each respondent before actual data collection.

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

1. Mobile health (mHealth) interventions: Develop and implement mobile phone applications or text messaging services to provide pregnant women with information and reminders about antenatal care visits, vaccinations, and other important aspects of maternal health.

2. Community health worker training: Train and deploy community health workers who can provide education and support to pregnant women in rural areas, where access to healthcare facilities may be limited.

3. Telemedicine: Establish telemedicine services to enable pregnant women in remote areas to consult with healthcare providers and receive prenatal care remotely, reducing the need for travel.

4. Transportation support: Implement transportation programs or partnerships to provide pregnant women with reliable and affordable transportation to healthcare facilities for antenatal care visits and delivery.

5. Maternal waiting homes: Establish maternal waiting homes near healthcare facilities to accommodate pregnant women who live far away and need to stay close to the facility during the final weeks of pregnancy, reducing the risk of complications during childbirth.

6. Financial incentives: Introduce financial incentives, such as conditional cash transfers or vouchers, to encourage pregnant women to seek antenatal care and deliver at healthcare facilities.

7. Public-private partnerships: Foster collaborations between the government, private sector, and non-profit organizations to improve infrastructure, equipment, and staffing at healthcare facilities, ensuring quality maternal healthcare services are available and accessible.

8. Health education campaigns: Launch targeted health education campaigns to raise awareness about the importance of antenatal care, skilled birth attendance, and postnatal care, addressing cultural beliefs and misconceptions that may hinder access to maternal health services.

9. Maternity waiting homes: Establish maternity waiting homes near healthcare facilities to accommodate pregnant women who live far away and need to stay close to the facility during the final weeks of pregnancy, reducing the risk of complications during childbirth.

10. Task-shifting: Train and empower midwives, nurses, and other healthcare providers to perform tasks traditionally carried out by doctors, enabling them to provide comprehensive maternal healthcare services in areas with limited medical personnel.

These innovations aim to address the challenges identified in the study and improve access to maternal health services in Southwest Ethiopia.
AI Innovations Description
Based on the description provided, the following recommendation can be developed into an innovation to improve access to maternal health:

1. Strengthening Neonatal Care Services: Develop and implement comprehensive neonatal care services that provide the minimum neonatal care package to all mothers and newborns. This includes ensuring access to tetanus toxoid vaccination, antenatal care, skilled care at birth, appropriate thermal care, clean cord care, early initiation of breastfeeding, exclusive breastfeeding, and timely vaccinations.

2. Enhancing Health Education and Behavior Change Communication: Implement behavior change communication strategies to educate mothers and their families about the importance of neonatal care practices. This can be done through community-based health education programs, utilizing local languages and culturally appropriate messaging. Emphasize the benefits of neonatal care and address any misconceptions or cultural barriers that may hinder its uptake.

3. Improving Access to Maternal Health Services: Address the factors identified as predictors of neonatal care practice, such as place of residence, maternal education, husband’s occupation, wealth quintiles, birth order, and inter-birth interval. Develop strategies to improve access to maternal health services, including antenatal care, skilled birth attendance, and postnatal care, particularly in rural areas and among disadvantaged populations.

4. Strengthening Health Systems: Enhance the capacity of health facilities and health workers to provide quality maternal and neonatal care. This includes training healthcare providers on evidence-based practices, ensuring the availability of essential supplies and equipment, and improving the overall quality of care. Strengthen referral systems to ensure timely access to higher-level care when needed.

5. Engaging Community Health Workers: Utilize community health workers, such as Health Extension Workers (HEWs), to deliver maternal and neonatal care services at the community level. Train and equip these frontline healthcare providers to provide essential care, conduct health education sessions, and facilitate referrals to higher-level facilities when necessary.

6. Monitoring and Evaluation: Establish a robust monitoring and evaluation system to track the implementation and impact of the recommended interventions. Regularly collect and analyze data on neonatal care practices, service utilization, and health outcomes to identify areas for improvement and inform evidence-based decision-making.

By implementing these recommendations, it is expected that access to maternal health services and neonatal care practices will improve, leading to a reduction in neonatal mortality and improved maternal and child health outcomes.
AI Innovations Methodology
Based on the information provided, here are some potential recommendations for improving access to maternal health:

1. Strengthening Antenatal Care (ANC) Services: Increase the coverage and quality of ANC services to ensure that pregnant women receive adequate information, counseling, and support during pregnancy. This can include promoting early and regular ANC visits, providing comprehensive health education, and offering necessary tests and screenings.

2. Enhancing Skilled Care at Birth: Improve access to skilled birth attendants and ensure that all women have access to a safe and clean birthing environment. This can involve training and deploying more skilled birth attendants, improving infrastructure and equipment in health facilities, and promoting the use of birth plans and emergency preparedness.

3. Promoting Postnatal Care (PNC): Increase awareness and utilization of postnatal care services to ensure that mothers and newborns receive appropriate care and support during the critical postpartum period. This can include providing home visits by trained health workers, promoting exclusive breastfeeding, and offering postnatal check-ups and vaccinations.

4. Strengthening Health Systems: Improve the overall health system capacity to deliver maternal health services effectively and efficiently. This can involve increasing the availability and accessibility of health facilities, ensuring a sufficient supply of essential medicines and equipment, and strengthening health information systems for monitoring and evaluation.

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

1. Baseline Data Collection: Collect data on the current status of maternal health access, including indicators such as ANC coverage, skilled birth attendance, postnatal care utilization, and maternal and neonatal mortality rates.

2. Intervention Design: Develop a detailed plan for implementing the recommended interventions, including specific strategies, activities, and timelines. Consider the resources and infrastructure needed to implement the interventions effectively.

3. Simulation Modeling: Use simulation modeling techniques to estimate the potential impact of the interventions on improving access to maternal health. This can involve creating a mathematical model that incorporates relevant variables and parameters, such as population size, health facility capacity, and utilization rates. The model can be used to simulate different scenarios and assess the potential outcomes of the interventions.

4. Data Analysis: Analyze the simulation results to determine the projected changes in maternal health access indicators, such as increased ANC coverage, skilled birth attendance rates, and postnatal care utilization. Compare the results to the baseline data to assess the effectiveness of the interventions.

5. Sensitivity Analysis: Conduct sensitivity analysis to assess the robustness of the simulation results and identify key factors that may influence the outcomes. This can involve varying the input parameters and assumptions to test the sensitivity of the model and explore different scenarios.

6. Policy Recommendations: Based on the simulation results, provide evidence-based policy recommendations for improving access to maternal health. Consider the potential costs, benefits, and feasibility of implementing the interventions, and prioritize actions based on their expected impact.

Overall, the methodology should involve a combination of quantitative data analysis, simulation modeling, and policy analysis to provide a comprehensive assessment of the potential impact of the recommended interventions on improving access to maternal health.

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