Effect of Implementing a Free Delivery Service Policy on Women's Utilization of Facility-Based Delivery in Central Ethiopia: An Interrupted Time Series Analysis

User Fee Exemption Policy Significantly Improved Adherence to Maternal Health Service Utilization in Bahir Dar City, Northwest Ethiopia: A Comparative Cross-Sectional Study

Background

Increasing free and skilled delivery is a top priority in the global effort to reduce maternal and newborn mortality. Reducing user-fees through exemption policy has contributed to universal health coverage. However, there is scant evidence regarding the effect of exempted maternal services on adherence to utilization in Ethiopia. Thus, this study aimed to assess the effect of fee exemption policy on adherence to maternal health service utilization and its predictors.

Methods

A community-based comparative cross-sectional study was conducted in Bahir Dar City. A two-stage multistage sampling was employed; 497 women participated. Data were collected by face-to-face interview; entered and cleaned using Epi-Data 3.1. SPSS version 25 was used for further analysis. Bivariable and multivariable logistic regression models were computed to assess the association between explanatory and outcome variables. An adjusted odds ratio with a 95% confidence interval was used to interpret the degree of association. The effect of fee exemption policy on adherence to maternal health service utilization was measured by propensity score matching.

Results

The overall adherence to maternal service utilization was 54.2%. Factors associated with adherence to maternal health service utilization were pregnancy complications [AOR: 4.1, 95% CI (2.32, 7.28)], secondary and above education [AOR: 4.6, 95% CI (1.38, 15.08)], early ANC1 booking [AOR: 3.1, 95% CI (1.83, 5.16)], autonomous women [AOR: 2.1, 95% CI (1.02, 4.39)], user fee exemption [AOR: 2.3, 95% CI (1.20, 4.47)] and high parity [AOR: 0.39, 95% CI (0.2, 0.75)]. User fee exemption induced a 22.7% increment in adherence to maternal service utilization (ATET=0.227, t=2.13).

Conclusion

User fee exemption policy significantly improved adherence to maternal health service utilization. Promoting a fee exemption policy through third-party financing can enhance maternal health service utilization adherence in hard-to-reach settings of Ethiopia by targeting mothers with higher pregnancies, no complications, no autonomy, and less education.

Optimized segmented regression models for the transition period of intervention effects

BACKGROUND

The interrupted time series (ITS) design is a widely used approach to examine the effects of interventions. However, the classic segmented regression (CSR) method, the most popular statistical technique for analyzing ITS data, may not be adequate when there is a transitional period between the pre- and post-intervention phases.

METHODS

To address this issue and better capture the distribution patterns of intervention effects during the transition period, we propose using different cumulative distribution functions in the CSR model and developing corresponding optimized segmented regression (OSR) models. This study illustrates the application of OSR models to estimate the long-term impact of a national free delivery service policy intervention in Ethiopia.

RESULTS

Regardless of the choice of transition length ([Formula: see text]) and distribution patterns of intervention effects, the OSR models outperformed the CSR model in terms of mean square error (MSE), indicating the existence of a transition period and the validity of our model's assumptions. However, the estimates of long-term impacts using OSR models are sensitive to the selection of L, highlighting the importance of reasonable parameter specification. We propose a data-driven approach to select the transition period length to address this issue.

CONCLUSIONS

Overall, our OSR models provide a powerful tool for modeling intervention effects during the transition period, with a superior model fit and more accurate estimates of long-term impacts. Our study highlights the importance of appropriate statistical methods for analyzing ITS data and provides a useful framework for future research.

'I believe respect means providing necessary treatment on time' - a qualitative study of health care providers' perspectives on disrespect and abuse during childbirth in Southwest Ethiopia

BACKGROUND

The majority of maternal deaths occur in low-income countries, and facility-based childbirth is recognised as a strategy to reduce maternal mortality. However, experiences of disrespect and abuse during childbirth are reported as deterrents to women's utilisation of health care facilities. Health care providers play a critical role in women's experiences during childbirth; yet, there is limited research on service providers' views of disrespect and abuse in Ethiopia. Therefore, this study aimed to explore providers' perspectives on disrespect and abuse during childbirth in a teaching hospital in Southwest Ethiopia.

METHOD

Qualitative study was conducted in a tertiary teaching hospital in Jimma Ethiopia. In-depth interviews were conducted with 32 purposefully selected health care providers, including midwives, obstetrics and genecology resident's, senior obstetricians and nurses. Interviews were audio-recorded, transcribed and thematically analysed using the qualitative data analysis software program MAXQDA.

RESULTS

Three major themes were identified from the health care providers' perspectives: (1) respectful and abuse-free care, (2) recognised disrespect and abuse; and (3) drivers of women's feelings of disrespect and abuse. The first theme indicates that most of the participants perceived that women were treated with respect and had not experienced abuse during childbirth. The second theme showed that a minority of the participants recognised that women experienced disrespect and abuse during childbirth. The third theme covered situations in which providers thought that drivers for women felt disrespected.

CONCLUSION

Most providers perceived women's experiences as respectful, and they normalized, and rationalized disrespect and abuse. The effect of teaching environment, the scarcity of resources has been reported as a driver for disrespect and abuse. To ensure respectful maternity care, a collaborative effort of administrators, teaching institutions, professional associations and researchers is needed. Such collaboration is essential to create a respectful teaching environment, ensure availability of resources, sustained in-service training for providers, and establishing an accountability mechanism for respectful maternity care.

Factors associated with institutional delivery among mothers who gave birth within 1 year prior to the study at Gilgelbelles town, Northwest Ethiopia: a mixed-methods study

OBJECTIVES

This study aimed to assess factors associated with institutional delivery among mothers who had delivered within 1 year prior to the study at Gilgelbelles town, Northwest, Ethiopia.

DESIGN

A community-based mixed-methods study was conducted from 1 February 2020 to 2 March 2020.

SETTING

This study was conducted at Gilgelbelles town, Northwest Ethiopia.

PARTICIPANTS

Included 422 mothers who delivered 1 year prior to the study at Gilgelbelles town.

OUTCOME MEASURES

Utilisation of institutional delivery and factors associated with institutional delivery.

METHODS

The quantitative data were collected by the simple random sampling technique, entered into Epi data V.3.1, and analysed using SPSS V.23.0. The qualitative data were collected by using in-depth interviews and thematic analysis was done manually to supplement the quantitative result.

RESULTS

In this study, 39.6% (95% CI=34.8 to 44.3) of mothers were given childbirth at the health facility. In multivariable analysis maternal age group of 15-20 years, secondary and above educational level, good knowledge on danger signs of obstetric, antenatal care visits, good awareness of birth preparedness and complications readiness plan, getting married after the age of 18 years, faced at least one complication during pregnancy, less than two children, travelled <30 min to reach a nearby health facility, having decision making power and not practised traditional malpractice during labour were significantly associated with institutional delivery. The qualitative result shows that cultural factors of the society and the lack of adequate delivery material in the health facility were identified as the major reason for the low utilisation of institutional delivery services.

CONCLUSION

This study showed that the proportion of institutional delivery was low. Sociodemographic, reproductive and knowledge-related factors were associated with institutional delivery. This indicates a need of taking appropriate interventions by integrating other stakeholders to increase the utilisation of institutional delivery services.

Effects of the free healthcare policy on health services' usage by children under 5 years in Burkina Faso: a controlled interrupted time-series analysis

OBJECTIVES

This study aimed to analyse, at national level, the effects of the free healthcare policy for children on the use of health services by children under five in Burkina Faso. We hypothesised that this policy has led to an immediate and sustained increase in the use of health services for these children in the country.

SETTING

We conducted a controlled interrupted time series. Monthly data at district level, spanning from January 2013 to December 2018 and corresponding to 72 monthly data points (39 before and 33 after), were extracted from the Burkina Faso National Health Information System. The analysed dataset included data from all the 70 health districts of the country.

PARTICIPANTS

The study consisted of aggregated data from children under five as the target for the policy with children aged between 5 and 14 years old as control group.

INTERVENTION

The intervention was the introduction of the free healthcare policy for women and children under 5 years from April 2016.

OUTCOME

The primary outcome was the monthly mean rate of health services visits by children.

RESULTS

Among the children under five, the rate of visits increased of 57% (incidence rate ratio (IRR)=1.57; 95% CI 1.2 to 2.0) in the month immediately following the launching of the free healthcare policy. An increase in the rate of health facility visits of 1% (IRR=1.01; 95% CI 1.0 to 1.1) per month was also noted during postintervention. Compared with the control group, we observed an increase in the rate of visits of 2.5% (IRR=1.025; 95% CI 1.023 to 1.026) per month.

CONCLUSION

Findings suggest that the free healthcare policy increased the use of health facilities for care in Burkina Faso immediately after the implementation of the policy with a small increase in the rate overtime. Strategies to maintain the policy effect over time are necessary.

Area of focus to handle delays related to maternal death in Ethiopia

Background

Maternal delay factors, together with medical factors, have a substantial role in determining maternity outcomes. Although several studies were conducted on delay factors that contribute to maternal death in Ethiopia, the studies were mostly focused either on an individual or at a provincial level factor with a limited number of study participants. In response to this gap, this study is aimed at exploring the magnitude and factors related to delay factors that contribute to maternal death in Ethiopia.

Methods

The study used maternal death surveillance data collected from different regions of Ethiopia, compiled between 2013 and 2021. A total of 4530 maternal deaths were reviewed during the study period. A Multilevel multinomial logistic regression model was applied to examine factors associated with delays related to maternal death. An adjusted relative risk ratio with a 95% confidence interval was stated and variables with p-values less than 0.05 were declared as significant predictors of maternal delay.

Result

Delay three (delay in receiving adequate and appropriate care once reached a health facility) has contributed to 36.3% of maternal deaths followed by delay one (delay in deciding to seek care when experiencing an obstetric emergency) and delay two (delay in reaching to an appropriate obstetric facility) where each of them contributed to 36.1% and 27.6% of maternal deaths respectively. In the multivariate multilevel multinomial model, maternal age, education status, and place of death were among the individual level factors associated with both delay two and delay three. Conversely, marital status and ANC follow-up were associated with delay two alone, while the timing of maternal death was associated with delay three. Residence and type of facility were provincial-level factors linked with both delay two and delay three, while the type of region was related to delay three of maternal death.

Conclusion

Both delay one and three have a major contribution to maternal death in Ethiopia. Individual and provincial level factors played an important role in determining delays related to maternal death. Therefore, it is crucial to account for measures that provide emphasis on the area of raising awareness on the utilization of Antenatal care (ANC) service, improving facility readiness to handle obstetrics emergencies, and narrowing down inequality among regions in service provision.

Alleviating the burden of diabetes with Health Equity Funds: Economic evaluation of the health and financial risk protection benefits in Cambodia

In Cambodia, diabetes caused nearly 3% of the country’s mortality in 2016 and became the fourth highest cause of disability in 2017. Providing sufficient financial risk protection from health care expenditures may be part of the solution towards effectively tackling the diabetes burden and motivating individuals to appropriately seek care to effectively manage their condition. In this study, we aim to estimate the distributional health and financial impacts of strategies providing financial coverage for diabetes services through the Health Equity Funds (HEF) in Cambodia. The trajectory of diabetes was represented using a Markov model to estimate the societal costs, health impacts, and individual out-of-pocket expenditures associated with six strategies of HEF coverage over a time horizon of 45 years. Input parameters for the model were compiled from published literature and publicly available household survey data. Strategies covered different combinations of types of diabetes care costs (i.e., diagnostic services, medications, and management of diabetes-related complications). Health impacts were computed as the number of disability-adjusted life-years (DALYs) averted and financial risk protection was analyzed in terms of cases of catastrophic health expenditure (CHE) averted. Model simulations demonstrated that coverage for medications would be cost-effective, accruing health benefits ($27 per DALY averted) and increases in financial risk protection ($2 per case of CHE averted) for the poorest in Cambodia. Women experienced particular gains in health and financial risk protection. Increasing the number of individuals eligible for financial coverage also improved the value of such investments. For HEF coverage, the government would pay between an estimated $28 and $58 per diabetic patient depending on the extent of coverage and services covered. Efforts to increase the availability of services and capacity of primary care facilities to support diabetes care could have far-reaching impacts on the burden of diabetes and contribute to long-term health system strengthening.