Exploring barriers to the use of formal maternal health services and priority areas for action in Sidama zone, southern Ethiopia

Prevalence, underlying causes, and determinants of maternal near miss in Ethiopia: a systematic review and meta-analysis

Background

Maternal near miss (MNM) is one of the newly adopted assessment parameters to gauge the quality of maternity care. In Ethiopia, several studies have been conducted to investigate the incidence, underlying causes, and determinants of MNM. However, the findings from those studies vary greatly and are largely inconsistent. Thus, this review aims to more robustly estimate the pooled prevalence, identify underlying causes, and single out determinants of MNM in Ethiopia.

Methods

Studies were searched from international databases (PubMed/ Medline, Cochrane Library, and Embase databases) and other potential sites. All observational studies were included. Heterogeneity between studies was checked using Cochrane Q test statistics and I2 test statistics and small study effects were checked using Egger's statistical test at a 5% significance level. Outcome measures were overall and specific underlying causes (obstetrics hemorrhage, hypertensive disorder pregnancy, pregnancy-related infection) rates of MNMs per 10,000 live births.

Result

The meta-analysis included 43 studies consisting of 77240 MNM cases. The pooled prevalence MNM per 1000 live births in Ethiopia was 54.33 (95% CI: 33.93 to 85.89). Between-study heterogeneity was high (I2 = 100%, P < 0.0001), with the highest rate observed in Amhara region (384.54 per 1000). The prevalence of obstetrics hemorrhage (14.56 per 1000) was higher than that of hypertensive disorder pregnancy (12.67 per 1000) and pregnancy-related infections (3.55 per 1000) were identified as underlying causes. Various factors, including socio demographic characteristics, previous medical and obstetrics history as well as access to and quality of care obtained, were associated with MNM.

Conclusion

Almost six women encounter near miss among a hundred live births in Ethiopia. Obstetric hemorrhage and hypertensive disorder pregnancy were the most common underlying causes of MNM. Both individual and facility level determinants were found to be associated with MNM. Considering the magnitude and identified factors, tailored measures should be taken at every stage of the continuum of care.

Systematic review registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42023395259.

Key barriers to the provision and utilization of maternal health services in low-and lower-middle-income countries; a scoping review

BACKGROUND

The preservation and promotion of maternal health (MH) emerge as vital global health objectives. Despite the considerable emphasis on MH, there are still serious challenges to equitable access to MH services in many countries. This review aimed to determine key barriers to the provision and utilization of MH services in low- and lower-middle-income countries (LLMICs).

METHODS

In this scoping review, we comprehensively searched four online databases from January 2000 to September 2022. In this study, the approach proposed by Arksey and O'Malley was used to perform the review. Consequently, 117 studies were selected for final analysis. To determine eligibility, three criteria of scoping reviews (population, concept, and context) were assessed alongside the fulfillment of the STROBE and CASP checklist criteria. To synthesize and analyze the extracted data we used the qualitative content analysis method.

RESULTS

The main challenges in the utilization of MH services in LLMICs are explained under four main themes including, knowledge barriers, barriers related to beliefs, attitudes and preferences, access barriers, and barriers related to family structure and power. Furthermore, the main barriers to the provision of MH services in these countries have been categorized into three main themes including, resource, equipment, and capital constraints, human resource barriers, and process defects in the provision of services.

CONCLUSIONS

The evidence from this study suggests that many of the barriers to the provision and utilization of MH services in LLMICs are interrelated. Therefore, in the first step, it is necessary to prioritize these factors by determining their relative importance according to the specific conditions of each country. Consequently, comprehensive policies should be developed using system modeling approaches.

Community-Based Health Education Led by Women's Groups Significantly Improved Maternal Health Service Utilization in Southern Ethiopia: A Cluster Randomized Controlled Trial

OBJECTIVE

This study aimed to evaluate the effect of health education intervention (HEI) on maternal health service utilization (MHSU) in southern Ethiopia.

METHODS

From 10 January to 1 August 2023, a community-based, two-arm, parallel-group cluster randomized controlled trial (cRCT) was conducted among pregnant mothers in the Northern Zone of Sidama National Regional State, Ethiopia. We utilized multilevel mixed-effects modified Poisson regression with robust variance to control for the effects of clustering and potential confounders. The level of significance was adjusted for multiple comparisons.

RESULTS

The overall utilization of at least one antenatal care (ANC) visit was 90.2% in the treatment group and 59.5% in the comparator group (χ2 = 89.22, p < 0.001). Health facility delivery (HFD) utilization was considerably different between the treatment group (74.3%) and the comparator group (50.8%) (χ2 = 70.50, p < 0.001). HEI significantly increased ANC utilization (adjusted risk ratio [ARR]: 1.32; 99% CI: 1.12-1.56) and HFD utilization (ARR: 1.24; 99% CI: 1.06-1.46). The utilization of at least one postnatal care (PNC) service was 65.4% in the treatment group and 52.1% in the comparator group (χ2 = 19.51, p = 0.01). However, after controlling for the effects of confounders and clustering, the impact of HEI on PNC utilization was insignificant between the two groups (ARR: 1.15; 99% CI: 0.89-1.48).

CONCLUSION

A community-based HEI significantly increased ANC and HFD utilization but did not increase PNC utilization. Expanding the HEI with certain modifications will have a superior effect on improving MHSU.

TRIAL REGISTRATION NUMBER

NCT05865873.

Explaining changes in educational disparities in competent maternal health care services in urban and rural areas in Ethiopia

Introduction

Aggregate statistics of maternal health care services have improved in Ethiopia. Nevertheless, the country has one of the lowest Universal Health Coverage (UHC) service coverage indices, with slight improvement between 2000 and 2019. There are disparity studies that focus on a single dimension of inequality. However, studies that combine multiple dimensions of inequality simultaneously may have important policy implications for closing inequalities. In this study, we investigated education inequalities in the receipt of maternal health care services in rural and urban areas separately, and we examined whether these inequalities decreased, increased, or remained unchanged.

Methods

The data for the study came from the 2011 and 2016 Ethiopia Demographic and Health Surveys. Using women's education as a dimension of inequality, we separately analyzed inequalities in maternal health care services in urban and rural settings. Inequalities were measured through the Erreygers concentration index, second differences, and Relative Index of Inequality (RII). Whether inequalities changed over time was analyzed by relative and absolute measures. An Oaxaca-type decomposition approach was applied to explain changes in absolute disparities over time.

Results

There were glaring educational disparities in maternal health care services in urban and rural areas, where the services were more concentrated among women with better schooling. The disparities were more severe in urban than in rural areas. In urban areas, skilled birth service was the most unequal in both periods. Disparities in rural places were roughly similar for all services except that in 2011, postnatal care was the least unequal, and in 2016, skilled birth was the most unequal services. Trend analyses revealed that disparities significantly dropped in urban by absolute and relative measures. Conversely, in rural regions, the disparities grew by the concentration index measure for most services. The RII and second differences presented conflicting results regarding whether the gaps were increasing, shrinking, or remaining the same.

Conclusion

Substantial disparities in maternal health care services remained and even increased, as in rural areas. Different and targeted strategies are needed for urban and rural places to close the observed educational inequalities in these areas.

Receipt of core antenatal care components and associated factors in Ethiopia: a multilevel analysis

Background

Despite recent promising progress, maternal morbidity and mortality are still unacceptably high in Ethiopia. This is partly attributed to the lack of quality health services. Pregnant women may not receive adequate services that are essential to protect the health of women and their unborn children. This study aimed to examine the extent of receiving prenatal care components and associated factors in Ethiopia. It also assessed prenatal service use inequality between urban and rural residents.

Methods

The analysis was carried out using the 2016 Ethiopian Demographic and Health Survey (EDHS), which is nationally representative survey data. A weighted sample of 4,772 women nested within 595 communities who had live births five years preceding the survey was included in the study. Necessary adjustments were made to account for the design of the survey, and sampling weights were used to adjust for nonproportional allocation of the sample to strata. Bivariate and multivariable multilevel ordered logit models were used to analyze factors associated with receiving comprehensive ANC contents. Statistically significant predictors were identified at p value ≤ 0.05.

Results

Among those women who had at least one ANC visit, only 15% (95% CI: 13, 16) received six core elements of antenatal care. The proportion of mothers who had essential prenatal components in rural areas was less than 13 percentage points. Approximately 43% of women did not receive at least two doses of tetanus toxoid vaccines to protect them and newborn infants against this life-threatening disease. Moreover, the majority of them, particularly those in rural Ethiopia, were not informed about pregnancy danger signs. Mothers who had at least four ANC visits received more types of prenatal components compared to those who had fewer ANC visits. The multilevel regression analysis revealed that receiving adequate ANC content is positively associated with having more frequent ANC visits, attaining a higher education level, being a member of a household in the highest wealth quintile and residing in urban areas.

Conclusion

The evidence implies that the quality of maternal health services needs to be improved. Health programs and interventions should also give priority to rural areas where the majority of Ethiopian women reside.

Spatial distribution and determinants of barriers of health care access among female youths in Ethiopia, a mixed effect and spatial analysis

Access to healthcare services is a fundamental human right for every citizen, and it is the responsibility of the nation to guarantee that these services are acceptable, easily accessible, and timely. Barriers to accessing health services may have a detrimental effect on an individual's physical, and mental health, and overall quality of life. However, access to health care services is a common problem in developing countries. Therefore, this study aimed to investigate spatial distribution and determinants of barriers to healthcare access among female youths in Ethiopia. Secondary data analysis was conducted based on the Demographic and Health Surveys data conducted in Ethiopia. A total weighted sample of 6143 female youths aged 15-24 years old was included in this study. A mixed-effect analysis was employed to identify factors contributing to barriers to healthcare access among youths in Ethiopia. Adjusted Odds Ratio with 95% CI was used to declare the strength and significance of the association. The concentration index was used to assess wealth-related inequalities, while spatial analysis was used to explore the spatial distribution and significant windows of barriers to healthcare access. This study revealed that the magnitude of barriers to healthcare access among female youth was 61.3% with 95%CI (60.1 to 62.5) to at least one or more of the four reasons. Age 15-19 years old (AOR = 0.80, 95%CI 0.68 to 0.95), no formal education (AOR = 2.26, CI 1.61, 3.18), primary education (AOR = 2.21, CI 1.66, 2.95), marital status (AOR = 1.43, 95% CI 1.21, 1.70), poor household wealth (AOR = 1.63, 95% CI 1.31, 2.05), no Media exposure (AOR = 1.67, 95%CI 1.41-1.98), reside in rural areas (AOR = 1.63, 95%CI 1.05 to 2.54), and low community media exposure (AOR = 1.45, 95%CI 1.01-2.08) were significantly associated with barriers of health care service. Barriers to healthcare access were significantly and disproportionately concentrated in poor households. A non-random Barrier to healthcare access was observed in Ethiopia. Among the 9 regions, primary clusters were identified in only 4 regions (North Ormiya, Benishangul Gumuz, Gambella, and South Nation Nationality and Peoples regions. A significant proportion of female youths faced barriers to health care access Age, educational status, marital status, rural residency, low economic status, and media exposure were factors associated with barriers to health care access. Therefore, program planners and decision-makers should work on improving the country's economy to a higher economic level to improve the wealth status of the population, promote media exposure, and increase access to education.

Barriers Towards Obstetric Care Service Utilization in Ethiopia: An Explorative Qualitative Study

Background

Obstetric care has been at the center of both global and national agendas. More than 50% of pregnant mothers are still preferring to give birth at home with some even after having full antenatal care. However, a few literatures looked at contributing factors for this problem but they are not conclusive and do not consider different sociocultural context of Ethiopia and different health service related barriers. Hence, the aim of this study was to explore barriers to obstetric care service utilization in Ethiopia using the socio-ecological model.

Methods

Explorative qualitative study was employed involving key-informant interviews, in-depth interviews, and focus group discussions between October and December 2021; Individual, community, health system, and contextual barriers were explored. Atlas ti. Version 9 was used for analysis.

Result

Lack of awareness, unfavorable perception, lack of partner involvement, cultural barrier, shortage of supplies, poor infrastructure, provider-related factors, poor monitoring, and evaluation system, challenging topography, and conflict were the major barriers that hinder mothers from receiving obstetrics service in Ethiopia.

Conclusion

Lack of awareness, unfavorable perception, conflict, problems with health system structure and process, and cultural and geographical conditions were major barriers in Ethiopia. Therefore, packages of intervention is important to avail essential equipment, strengthening follow up system, create awareness, and increase access to health facilities is very important for service improvement by the government and non-governmental organizations. Additionally, implementing conflict resolution mechanism is important for addressing better obstetric service.

Structural, programmatic, and sociocultural intersectionality of gender influencing access-uptake of reproductive, maternal, and child health services in developing regions of Ethiopia: A qualitative study

BACKGROUND

Gender remains a critical social factor in reproductive, maternal, and child health and family planning (RMNCH/FP) care. However, its intersectionality with other social determinants of the RMNCH remains poorly documented. This study aimed to explore the influence of gender intersectionality on the access uptake of RMNCH/FP in Developing Regional States (DRS) in Ethiopia.

METHODS

We conducted a qualitative study to explore the intersectionality of gender with other social and structural factors and its influence on RMNCH/FP use in 20 selected districts in four DRS of Ethiopia. We conducted 20 Focus Group Discussions (FGDs) and 32 in-depth and key informant interviews (IDIs/KIIs) among men and women of reproductive age who were purposively selected from communities and organizations in different settings. Audio-recorded data were transcribed verbatim and analyzed thematically.

FINDINGS

Women in the DRS were responsible for the children and families' health care and information, and household chores, whereas men mainly engaged in income generation, decision making, and resource control. Women who were overburdened with household chores were not involved in decision-making, and resource control was less likely to incur transport expenses and use RMNCH/FP services. FP was less utilized than antenatal, child, and delivery services in the DRS,as it was mainly affected by the sociocultural, structural, and programmatic intersectionality of gender. The women-focused RMNCH/FP education initiatives that followed the deployment of female frontline health extension workers (HEWs) created a high demand for FP among women. Nonetheless, the unmet need for FP worsened as a result of the RMNCH/FP initiatives that strategically marginalized men, who often have resource control and decision-making virtues that emanate from the sociocultural, religious, and structural positions they assumed.

CONCLUSIONS

Structural, sociocultural, religious, and programmatic intersectionality of gender shaped access to and use of RMNCH/FP services. Men's dominance in resource control and decision-making in sociocultural-religious affairs intersected with their poor engagement in health empowerment initiatives that mainly engaged women set the key barrier to RMNCH/FP uptake. Improved access to and uptake of RMNCH would best result from gender-responsive strategies established through a systemic understanding of intersectional gender inequalities and through increased participation of men in RMNCH programs in the DRS of Ethiopia.

Maternal Third Delay and Associated Factors among Women Admitted for Emergency Obstetric Care in Public Hospitals in Sidama Regional State, Ethiopia

Background

Timing to get obstetric care is critical in preventing maternal death and disability. Maternal third delay, the delay in receiving care after reaching health facilities, involves factors related to organization, quality of care, patient referral, and availability of staff and equipment. However, data is limited on maternal third delay and its associated factors at higher health facilities in Ethiopia.

Objective

This study is aimed at assessing the magnitude of maternal third delay and associated factors among women admitted for emergency obstetric care in public hospitals in Sidama Regional State, Ethiopia, 2021.

Methods

An institution-based cross-sectional study was conducted from September to November 2021. Face-to-face interview with a structured questionnaire and data extraction from medical charts were carried out in selected 542 women (using systematic sampling method). The collected data were coded and entered using EpiData, and bivariable and multivariable logistic regression analyses were done using SPSS version 25. Statistical significances were declared at p value less than 0.05.

Results

Maternal third delay was identified among 29.3% (95%CI = 25.2 - 33.5) of the respondents. Additionally, women who arrived with a referral from other health facilities (AOR = 0.311, 95%CI = 0.181 - 0.534), well prepared for birth and its complications (AOR = 2.418, 95%CI = 1.51 - 3.869), self-employed (AOR = 0.223, 95%CI = 0.122 - 0.409), being a government employee (AOR = 0.157, 95%CI = 0.063 - 0.396), having ANC follow-up (AOR = 2.795, 95%CI = 1.318 - 5.928), and absence of health professional (AOR = 4.63, 95%CI = 2.857 - 7.50) were significantly associated with maternal third delay.

Conclusion

This study identified that maternal third delay was high, which indicates that women have not received emergency obstetric care in the recommended time range after they arrived at the health facilities.

Predictors of homebirth amidst COVID-19 pandemic among women attending health facilities in Wondo Genet, Sidama Region, Ethiopia: A case control study

BACKGROUND

In developing countries, home delivery increases the risk of maternal and perinatal mortality. Despite this, home deliveries account for a considerable share of deliveries in developing nations such as Ethiopia. Evidence on factors that affect homebirth is required for the measures needed to overcome these conditions.

OBJECTIVE

To identify predictors of homebirth among women attending health facilities in Wondo Genet, Sidama Region.

METHODS

Unmatched case-control study was conducted from May to June 2021 among 308 mothers (102 cases and 206 controls) who recently delivered and visited either postnatal care or sought immunization service at public health facilities of Wondo Genet. A structured interviewer-administered questionnaire was used to collect data. Epi-Data version 3.1 was used for data entry, and the Statistical Package for the Social Sciences (SPSS) version 20 was used for data analysis. Bivariate and multivariate logistic regression analyses were used to identify the determinants of homebirth. The association between the outcome variable and independent variables was declared statistically significant at a P-value < 0.05 with a 95% Confidence Interval (CI) in a multivariable model.

RESULTS

Rural residence [AOR: 3.41; 95%CI: 1.58-7.39], lifetime physical IPV [AOR: 2.35; 95%CI: 1.06-5.17], grand-multiparity [AOR: 5.36; 95%CI: 1.68-17.08], non-use of contraception before recent pregnancy [AOR: 5.82; 95%CI: 2.49-13.60], >30 min to reach health facility [AOR: 2.14; 95%CI: 1.02-4.51], and lack of facemask [AOR: 2.69; 95%CI: 1.25-5.77] were statistically significant predictors of homebirth.

CONCLUSION AND RECOMMENDATION

The access gap to maternity services should be narrowed between rural and urban women. Healthcare programs concerning women's empowerment could help reduce persistent intimate partner violence. Family planning needs to be promoted, and multiparous women should be counseled on the adverse obstetric consequences of homebirth. The devastating effect of the coronavirus disease 2019 pandemic on maternity services should be prevented.

Individual- and community-level determinants of maternal health service utilization in southern Ethiopia: A multilevel analysis

BACKGROUND

Maternal health service utilization decreases maternal morbidity and mortality. However, the existing evidence is inadequate to design effective intervention strategies in Ethiopia.

OBJECTIVES

This study aimed to examine the utilization of maternal health service and identify its determinants among women of reproductive age in southern Ethiopia.

DESIGN

A community-based cross-sectional study was conducted from October 21 to November 11, 2022 on a sample of 1140 women selected randomly from the Northern Zone of the Sidama region.

METHODS

Data were collected using the Open Data Kit mobile application and exported to Stata version 15 for analysis. We used a multilevel mixed-effects modified Poisson regression with robust standard error to identify determinants of maternal health service utilization.

RESULTS

Utilization of antenatal care, health facility delivery, and postnatal care was 52.0% (95% confidence interval: 49.0%, 55.0%), 48.5% (95% confidence interval: 45.6%, 51.4%), and 26.0% (95% confidence interval: 23.0%, 29.0%), respectively. Antenatal care use was associated with receiving model family training (adjusted prevalence ratio: 1.19; 95% confidence interval: 1.06, 1.35), knowledge of antenatal care (adjusted prevalence ratio: 1.54; 95% confidence interval: 1.31, 1.81), perceived quality of antenatal care (adjusted prevalence ratio: 1.02; 95% confidence interval: 1.01, 1.03), and having birth preparedness plan (adjusted prevalence ratio: 1.13; 95% confidence interval: 1.02, 1.25). The identified determinants of health facility delivery use were middle wealth rank (adjusted prevalence ratio: 1.35; 95% confidence interval: 1.03, 1.77), perceived quality of health facility delivery (adjusted prevalence ratio: 1.02; 95% confidence interval: 1.01, 1.03), antenatal care (adjusted prevalence ratio: 1.76; 95% confidence interval: 1.36, 2.26), and high community-level women literacy (adjusted prevalence ratio: 1.55; 95% confidence interval: 1.10, 2.19). Postnatal care use was associated with facing health problems during postpartum period (adjusted prevalence ratio: 1.79; 95% confidence interval: 1.18, 2.72), urban residence (adjusted prevalence ratio: 3.52; 95% confidence interval: 2.15, 5.78), knowledge of postnatal care (adjusted prevalence ratio: 1.11; 95% confidence interval: 1.04, 1.19), and low community-level poverty (adjusted prevalence ratio: 0.43; 95% confidence interval: 0.25, 0.73).

CONCLUSION

Maternal health service use was low in the study area and was influenced by individual- and community-level determinants. Any intervention strategies must consider multi-sectorial collaboration to address determinants at different levels. The programs should focus on the provision of model family training, the needs of women who have a poor perception, and knowledge of maternal health service at the individual level.

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.

Birth preparedness and complication readiness among husbands and its association with skilled birth attendance in southern Ethiopia

Introduction

Birth preparedness and Complication Readiness (BPCR) promotes prompt use of skilled delivery and readiness for any complications to reduce delays in the provision of emergency care. Husband’s involvement in preparation for childbirth is one way to mitigate life-threatening delays in providing care during childbirth. The current study assessed the association of the husband’s involvement in birth preparedness and complication readiness with the use of skilled birth attendants.

Method

A community-based cross-sectional study was conducted among 1,432 husbands. Study participants were selected from Arbaminch university health and demographic surveillance sites. Data were collected electronically using the Open Data Kit. The data were exported to STATA version 16 for analysis. Descriptive statistics were computed to describe the sociodemographic and reproductive variables of the study. The associations between birth preparedness and complication readiness practice and birth in the presence of a skilled birth attendant were assessed using multiple logistic regressions after adjusting for known confounders. Explanatory variables on bivariate logistic regression analysis were entered into multivariable logistic regression analysis, and a p-value of less than 0.05 was used to ascertain statistical significance.

Results

Mean age of respondents was 33.7 (SD ± 6.2) years. Of all the respondents, 140 (10.3%) had made at least three preparations according to birth preparedness and complication readiness. After controlling for confounders through multivariable logistic regression, giving birth in the presence of a skilled birth attendant consistently increased with husbands involved in birth preparedness and complication readiness (AOR = 4.1, 95% CI: 2.5–6.9). Husbands whose wives had complications during previous pregnancy were 33% less likely to have skilled birth attendants (AOR = 0.67, 95% CI: 0.49–0.917). Moreover, husbands whose houses were near the health facilities were more likely to have skilled birth attendants for their wives (AOR = 3.93, 95% CI: 2.57–6.02).

Conclusion

Husband’s involvement in birth preparedness and complication readiness is strongly associated with using skilled birth attendants in Ethiopia. It is imperative that when designing husband’s involvement programs targeting birth preparedness and complication readiness, programs and strategies should focus on enhancing activities that are inclusive of husbands in birth preparedness and complication education.

"If I Was Educated, I Would Call the Ambulance and Give Birth at the Health Facility"-A Qualitative Exploratory Study of Inequities in the Utilization of Maternal, Newborn, and Child Health Services in Northern Ethiopia

In earlier studies, we have shown that the utilization of maternal health services in rural Ethiopia was distributed in a pro-rich fashion, while the coverage of child immunization was equitably distributed. Hence, this study aimed to explore mothers' and primary healthcare workers' perceptions of inequities in maternal, newborn, and child health services in rural Ethiopia, along with the factors that could influence such differentials. A qualitative study was conducted from November to December 2019 in two rural districts in Tigray, Ethiopia. Twenty-two in-depth interviews and three focus group discussions were carried out with mothers who had given birth during the last year before the survey. We also interviewed women's development group leaders, health extension workers, and health workers. The final sample was determined based on the principle of saturation. The interviews and focus group discussions were audiotaped, transcribed, translated, coded, and analyzed using thematic analysis. Two major themes emerged during the analysis that characterized the distribution of the service utilization and perceived causes of inequity. These were: (1) perceptions of the inequity in the use of maternal and child health services, and (2) perceived causes of inequity in maternal and child health service utilization. The mothers perceived antenatal care, facility-based delivery, and care-seeking for sick children to be inequitably distributed, while immunization was recognized as an equitable service. The inequity in the maternal and child health services was linked to poverty, lack of education, lack of access, and poor-quality services. The poor, the uneducated, and women who were distant from health facilities had a low utilization rate of services. The weak implementation of community-based equity-oriented policies, such as community-based health insurance, was perceived to result in health inequities. Mothers and primary healthcare providers in rural Ethiopia experienced weaknesses in delivering equitable services. The narratives could inform efforts to provide universal health coverage for mothers, newborns, and children by improving access and empowering women through poverty alleviation and education.

Challenges in postnatal care provision in Ethiopia

Background

Most maternal deaths occur during the first 48 h after delivery; thus, a critical time for monitoring possible complications arising from the delivery. Quality postnatal care can contribute to a decrease in maternal mortality and morbidity rates. Despite the importance of postnatal care, it is generally a neglected aspect of maternal and child health services in most developing countries, including Ethiopia.

Objectives

The objective of the study was to describe the challenges experienced by postnatal care providers and coordinators in providing postnatal care in the Ethiopian context.

Methods

A quantitative cross-sectional descriptive study was conducted and data were gathered from 422 postnatal care providers and coordinators during November 2018. A simple random sampling technique was used to select the respondents and the data were gathered through a self-administered questionnaire. The data were cleaned, coded and entered into the Statistical Package for Social Sciences (SPSS) version 21 for analysis. Open-ended questions for qualitative enhancement were open-coded and thematically analyzed.

Results

The findings revealed a lack of physical resources; infrastructure problems; cultural concerns; inadequate capacity building; inaccessibility of health services; unavailability of guidelines; a lack of communication with healthcare users and poor monitoring and evaluation as challenges.

Conclusion

To improve postnatal care in Ethiopia and, ultimately, mother and child health, the challenges experienced by postnatal care providers and coordinators have to be dealt with. A strategic action plan with the active involvement of all stakeholders must be developed and implemented to deal with the challenges and improve postnatal care.

Health Care Readiness in Management of Preeclampsia/Eclampsia in Ethiopia: Evidence from National Facility-Based Survey

Background

Early case detection, treatment, and timely referral for better services can significantly reduce the negative outcomes of preeclampsia and eclampsia. However, evidence on health facilities' readiness to provide such services and the associated challenges is limited in Ethiopia. Therefore, this study aimed to assess the readiness of Ethiopian health care facilities to manage preeclampsia and eclampsia.

Methods

This study used the 2016 Ethiopia national emergency management of obstetrics and newborn care (EmONC) survey. This survey was a national cross-sectional census of health facilities that provided delivery services. Data on facility infrastructure, equipment and supplies were collected through a facility checklist, and interview health provider experiences. Cross tabulation, summarisation and chi square tests by facility type, location, and management authority were conducted.

Results

There were 3804 health facilities included in the survey across all regions of Ethiopia. The majority of facilities (92%) were public/government managed with only 1% of available hospitals located in rural areas. Poor availability of dipsticks for proteinuria tests (55.3%), caesarean sections (7.9%), and ambulance services (18.4%) were reported across health facilities with high variations in terms of facility type, location, and type of managing authority. Diazepam was a widely available anticonvulsant compared with magnesium sulfate (MgSO₄), with more available in private for-profit facilities compared with public facilities. Nearly one third of health care providers were not trained to administer MgSO₄ intravenously. The result indicated that the chi-square test was statistically significant at P < 0.001.

Conclusions and Recommendations

There were notable gaps in readiness of facilities in detection and management of preeclampsia/eclampsia that increase maternal and perinatal mortality in Ethiopia. Therefore, availability of essential supplies, medications, and referrals are required. In addition, refresher training to healthcare providers on screening, diagnosis and management of preeclampsia/eclampsia and continuous supervision should be provided.

Coverage and factors associated with completion of continuum of care for maternal health in sub-Saharan Africa: a multicountry analysis

Background

Many maternal and neonatal deaths are largely preventable by expanding the continuum of care (at least four antenatal visits, skilled birth attendance and postnatal care). Even though ensuring the Continuum of Care (CoC) has advantages over separate services, evidence from the globe suggests that completion of the CoC for maternal health is very low. From our search of the literature, there is limited evidence on the completion of the entire CoC and its associated factors in sub-Saharan Africa (sSA). Therefore, this study aimed to assess coverage and associated factors of completion of the CoC for maternal health in sSA.

Methods

Data for the study were drawn from a recent nationally representative survey of 32 Demographic and Health Surveys (DHS). A total weighted sample of 225,135 women of reproductive-age, who gave birth in the two preceding years were included. Due to the hierarchical nature of DHS data, a multilevel logistic regression model was applied to investigate individual and community-level factors that may influence completion of CoC. Adjusted Odds Ratios (aORs) with 95% Confidence Interval (CI) were reported and variables with 95% CI not including 1 were considered as significant factors of the completion of CoC.

Results

Only, 56,172 (25.0%; 95% CI, 20.5%, 29.4%) of the women in sSA utilized the CoC for maternal health which varied from 11,908 (17.9.0%) in East Africa to 7,418 (51.5% in Southern Africa. Factors associated with higher odds of CoC were women aged 24–34 years (aOR 1.22, 95% CI: 1.17, 1.25), aged ≥ 35 years (aOR 1.40, 95% CI: 1.35, 1.47), attending primary education (aOR 1.44, 95% CI: 1.41, 1.49), secondary education (aOR 1.95, 95% CI: 1.89, 2.03), higher education (aOR 2.15, 95% CI: 2.01, 2.25), having mass media exposure (aOR 1.35, 95% CI: 1.28, 1.39), women from female-headed households (aOR 1.18, 95% CI: 1.15, 1.21) and women from communities with high maternal education (aOR 1.12, 95% CI: 1.09, 1.16). However, perceiving distance from the health facility as a big problem (aOR 0.88, 95% CI: 0.85, 0.91), residing in rural areas (aOR 0.78, 95% CI: 0.75, 0.81), delayed ANC initiation (aOR 0.43, 95% CI: 0.41, 0.47) and unintended pregnancy (aOR 0.87, 95% CI: 0.84, 0.91) were associated with lower odds of CoC.

Conclusion

This study showed a low proportion of women, who utilized the CoC in sSA. Both individual and community-level factors were associated with CoC completion rates among women in sSA. Therefore, policymakers in sSA must consider both individual and community-level factors and undertake multi-sectorial approaches to address barriers of CoC at different levels.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04757-1.

Socioeconomic inequality in barriers for accessing health care among married reproductive aged women in sub-Saharan African countries: a decomposition analysis

BACKGROUND

Accessibility of health care is an essential for promoting healthy life, preventing diseases and deaths, and enhancing health equity for all. Barriers in accessing health care among reproductive-age women creates the first and the third delay for maternal mortality and leads to the occurrence of preventable complications related to pregnancy and childbirth. Studies revealed that barriers for accessing health care are concentrated among individuals with poor socioeconomic status which creates health inequality despite many international organizations top priority is enhancing universal health coverage. Therefore, this study aimed to assess the presence of socioeconomic inequality in barriers for accessing health care and its contributors in Sub-Saharan African countries.

METHODS

The most recent DHS data of 33 sub-Saharan African countries from 2010 to 2020 were used. A total sample of 278,501 married reproductive aged were included in the study. Erreygers normalized concentration index (ECI) and its concentration curve were used while assessing the socioeconomic-related inequality in barriers for accessing health care. A decomposition analysis was performed to identify factors contributing for the socioeconomic-related inequality.

RESULTS

The weighted Erreygers normalized Concentration Index (ECI) for barriers in accessing health care was - 0.289 with Standard error = 0.005 (P value < 0.0001); indicating that barriers in accessing health care was disproportionately concentrated among the poor. The decomposition analysis revealed that wealth index (42.58%), place of residency (36.42%), husband educational level (5.98%), women educational level (6.34%), and mass media exposure (3.07%) were the major contributors for the pro-poor socioeconomic inequalities in barriers for accessing health care.

CONCLUSION

In this study, there is a pro-poor inequality in barriers for accessing health care. There is a need to intensify programs that improve wealth status, education level of the population, and mass media coverage to tackle the barriers for accessing health care among the poor.

Community health workers and health equity in low- and middle-income countries: systematic review and recommendations for policy and practice

Background

The deployment of Community Health Workers (CHWs) is widely promoted as a strategy for reducing health inequities in low- and middle-income countries (LMIC). Yet there is limited evidence on whether and how CHW programmes achieve this. This systematic review aimed to synthesise research findings on the following questions: (1) How effective are CHW interventions at reaching the most disadvantaged groups in LMIC contexts? and (2) What evidence exists on whether and how these programmes reduce health inequities in the populations they serve?

Methods

We searched six academic databases for recent (2014–2020) studies reporting on CHW programme access, utilisation, quality, and effects on health outcomes/behaviours in relation to potential stratifiers of health opportunities and outcomes (e.g., gender, socioeconomic status, place of residence). Quantitative data were extracted, tabulated, and subjected to meta-analysis where appropriate. Qualitative findings were synthesised using thematic analysis.

Results

One hundred sixty-seven studies met the search criteria, reporting on CHW interventions in 33 LMIC. Quantitative synthesis showed that CHW programmes successfully reach many (although not all) marginalized groups, but that health inequalities often persist in the populations they serve. Qualitative findings suggest that disadvantaged groups experienced barriers to taking up CHW health advice and referrals and point to a range of strategies for improving the reach and impact of CHW programmes in these groups. Ensuring fair working conditions for CHWs and expanding opportunities for advocacy were also revealed as being important for bridging health equity gaps.

Conclusion

In order to optimise the equity impacts of CHW programmes, we need to move beyond seeing CHWs as a temporary sticking plaster, and instead build meaningful partnerships between CHWs, communities and policy-makers to confront and address the underlying structures of inequity.

Trial registration

PROSPERO registration number CRD42020177333.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12939-021-01615-y.

Prevalence and determinants of maternal healthcare utilisation among young women in sub-Saharan Africa: cross-sectional analyses of demographic and health survey data

BACKGROUND

Maternal health constitutes high priority agenda for governments across the world. Despite efforts by various governments in sub-Saharan Africa (SSA), the sub-region still records very high maternal mortality cases. Meanwhile, adequate utilization of maternal healthcare (antenatal care [ANC], skilled birth attendance [SBA], and Postnatal care [PNC]) plays a vital role in achieving improved maternal health outcomes. We examined the prevalence and determinants of maternal healthcare utilization among young women in 28 sub-Saharan African countries using data from demographic and health surveys.

METHODS

This was a cross-sectional study of 43,786 young women aged 15-24 years from the most recent demographic and health surveys of 28 sub-Saharan African countries. We adopted a multilevel logistic regression analysis in examining the determinats of ANC, SBA, and PNC respectively. The results are presented as adjusted Odds Ratios (aOR) for the logistic regression analysis. Statistical significance was set at p < 0.05.

RESULTS

The prevalence of maternal healthcare utilisation among young women in SSA was 55.2%, 78.8%, and 40% for ANC, SBA, and PNC respectively with inter-country variations. The probability of utilising maternal healthcare increased with wealth status. Young women who were in the richest wealth quintile were, for instance, 2.03, 5.80, and 1.24 times respectively more likely to utilise ANC (95% CI = 1.80-2.29), SBA (95% CI = 4.67-7.20), and PNC (95% CI = 1.08-1.43) than young women in the poorest wealth quintile. Young women who indicated having a barrier to healthcare utilisation were, however, less likely to utilise maternal healthcare (ANC: aOR = 0.83, 95% CI = 0.78-0.88; SBA: aOR = 0.82, 95% CI = 0.75-0.88; PNC: aOR = 0.88, 95% CI = 0.83-0.94).

CONCLUSION

While SBA utilisation was high, we found ANC and PNC utilisation to be quite low among young women in SSA with inter-country variations. To accelerate progress towards the attainment of the Sustainable Development Goal (SDG) targets on reducing maternal mortality and achieving universal health coverage, our study recommends the adoption of interventions which have proven effective in some countries, by countries which recorded low maternal healthcare utilisation. The interventions include the implementation of free delivery services, training and integration of TBAs into orthodox maternal healthcare, improved accessibility of facilities, and consistent public health education. These interventions could particularly focus on young women in the lowest wealth quintile, those who experience barriers to maternal healthcare utilisation, uneducated women, and young women from rural areas.

Barriers to Maternal and Child Health Care Service Uptake in Assosa Zone, Benishangul Gumuz Region, Ethiopia: A Qualitative Study

Background

Ethiopia has reduced maternal mortality from 871 to 412 per 100,000 live births between 2000 and 2016. In 2019, under-5 mortality rates in Ethiopia were 55 deaths per 1,000 live births. Benishangul Gumuz was the second-largest region in the under-5 mortality rate (98/1,000 live births) in the country. Maternal and child health care service uptake is an important indicator of health outcomes. This study is aimed at exploring major barriers to maternal and child health care uptake in Assosa Zone.

Methods

This study was conducted in the Bambasi, Menge, and Sherkole districts of the Assosa Zone from July 17 to August 31/2019. The study explored the life experience of study participants about MCH services. The sampling technique was purposive, and data collection methods were focus group discussions, key informant interviews, and in-depth interviews. Data were analyzed thematically.

Result

The main barriers to child health care services were financial problems, lack of knowledge, preference of traditional medicines for a sick child, women having no time to care for their sick child, poor roads. poor health facility readiness, the poor economy of families, lack of ambulance, cultural and traditional beliefs, providers being male, and unprofessional behaviors which were the major barriers hindering the uptake of maternal health service utilization.

Conclusion

Poor health facility readiness, indirect costs, inaccessibility to health facilities, and cultural and traditional practices were among the major barriers to service uptake identified by this research in the study area.

Utilization of Skilled Birth Attendance among Mothers Who Gave Birth in the Last 12 Months in Kembata Tembaro Zone

BACKGROUND

Skilled delivery is considered the single most important strategy in preventing maternal and neonatal morbidity and mortality. It ensures safe birth, reduces actual and potential complications, and increases the survival of most mothers and newborns.

OBJECTIVE

To identify determinants of the utilization of skilled birth attendance among women who gave birth in the last 12 months in the Kembata Tembaro zone, Southern Ethiopia, 2020.

METHODS

A community-based cross-sectional study was employed from 1 April 2020 to 30 April 2020 among women who gave birth in the last 12 months in the Kembata Tembaro zone. Six hundred twenty-four mothers were recruited for the study as eligible participants. Multistage stratified sampling was used to select three districts and one town administrative unit of the study area. The data were collected and verified for their completeness, followed by editing and coding. Multivariate analysis was performed using the backward LR method to identify factors independently associated with the dependent variable. Statistical significance was declared at a p value of less than 0.05, and the strength of statistical association was measured by adjusted odds ratio and 95% confidence interval.

RESULT

Of 624 study subjects sampled, 607 provided information with a response rate of 97.3%. In this study, 309 (50.9%) women had their last birth at health facilities attended by skilled birth attendants. Place of residence (AOR (95% CI) = 0.33 (0.22,0.58)); age at interview (AOR (95% CI = 3.41 (1.57,5.45)); maternal education (AOR (95% CI) = 1.50 (1.34, 4.19)); history of still birth (AOR (95% CI) = 3.85 (2.14,6.91)); maternal occupation (AOR (95% CI) = 3.35 (1.79,6.27)); husband occupation (AOR (95% CI) = 2.69 (1.70,7.09)); ANC visit (AOR (95% CI) = 4.62 (3.12,7.32)); knowledge of obstetric complications (AOR (95% CI) = 3.10 (1.37,5.21)); and final decision-making about place of delivery (AOR (95% CI) = 3.64 (1.70,7.99)) were significantly associated with the use of skilled birth attendance.

CONCLUSION

In this study, nearly half of the mothers used skilled birth attendance. Place of residence, age at interview, maternal education, history of still birth, maternal occupation, husband occupation, antenatal visit, knowledge about obstetric complications, and final decision-maker about place of delivery were determinants of the use of skilled attendance delivery.

Perception and Experience of Health Extension Workers on Facilitators and Barriers to Maternal and Newborn Health Service Utilization in Ethiopia: A Qualitative Study

Background: Health extension workers (HEWs) have substantial inputs to reduce maternal and newborn morbidity and mortality in Ethiopia. However, their perceptions and experiences were not well understood. Therefore, this study aimed to explore their perceptions and experiences on facilitators and barriers to maternal and newborn health services in Ethiopia. Methods: A descriptive qualitative study was conducted from 8–28 April 2021 in Oromia, Amhara and Southern Nation, Nationality, and People’s Regional State of Ethiopia. Focused group discussions were made with purposively selected 60 HEWs. The data were transcribed verbatim and translated into English. An inductive thematic analysis was carried out using Atlas ti.7.1. The findings were presented in major themes, categories, and sub-categories with supporting quote(s). Results: The findings were categorized into two major themes (i.e., facilitators and barriers) and seven sub-themes. Community-related facilitators encompass awareness and behavior at the individual, family, and community. Significant others such as traditional birth attendants, religious leaders, women developmental armies, and kebele chairman substantially contributed to service utilization. Availability/access to infrastructures such as telephone, transportation services, and solar energy systems facilitated the service utilization. Furthermore, health facility-related facilitators include the availability of HEWs; free services; supervision and monitoring; maternity waiting rooms; and access to ambulance services. Maternal and newborn health services were affected by community-related barriers (i.e., distance, topography, religious and socio-cultural beliefs/practices, unpleasant rumors, etc.,), health facility-related barriers (i.e., health worker’s behaviors; lack of logistics; lack of adequate ambulance service, and placement and quality of health post), and infrastructure (i.e., lack or poor quality of road and lack of water). Conclusions: The HEWs perceived and experienced a wide range of facilitators and barriers that affected maternal and newborn health services. The study findings warrant that there was a disparity in behavioral factors (awareness, beliefs, and behaviors) among community members, including pregnant women. This underscores the need to design health education programs and conduct social and behavioral change communication interventions to address individuals, families, and the broader community to enhance maternal and newborn health service utilization. On the other hand, the health sector should put into practice the available strategies, and health workers provide services with empathy, compassion, and respect.

Community's experience and perceptions of maternal health services across the continuum of care in Ethiopia: A qualitative study

BACKGROUND

Continuum of care is an effective strategy to ensure that every woman receives a series of maternal health services continuously from early pregnancy to postpartum stages. The community perceptions regarding the use of maternal services across the continuum of care are essential for utilization of care in low-income settings but information in that regard is scanty. This study explored the community perceptions on the continuum of care for maternal health services in Ethiopia.

METHODS

This study employed a phenomenological qualitative research approach. Four focus group discussions involving 26 participants and eight in-depth interviews were conducted with women who recently delivered, community health workers, and community leaders that were purposively selected for the study in West Gojjam zone, Amhara region. All the interviews and discussions were audio-taped; the records were transcribed verbatim. Data were coded and analyzed thematically using ATLAS.ti software.

RESULTS

We identified three primary themes: practice of maternal health services; factors influencing the decision to use maternal health services; and reasons for discontinuation across the continuum of maternal health services. The study showed that women faced multiple challenges to continuously uptake maternal health services. Late antenatal care booking was the main reasons for discontinuation of maternal health services across the continuum at the antepartum stage. Women's negative experiences during care including poor quality of care, incompetent and unfriendly health providers, disrespectful care, high opportunity costs, difficulties in getting transportation, and timely referrals at healthcare facilities, particularly at health centers affect utilization of maternal health services across the continuum of care. In addition to the reverberation effect of the intrapartum care factors, the major reasons mentioned for discontinuation at the postpartum stage were lack of awareness about postnatal care and service delivery modality where women are not scheduled for postpartum consultations.

CONCLUSION

This study showed that rural mothers still face multiple challenges to utilize maternal health services as recommended by the national guidelines. Negative experiences women encountered in health facilities, community perceptions about postnatal care services as well as challenges related to service access and opportunity costs remained fundamental to be reasons for discontinuation across the continuum pathways.

The determinants of 5th minute low Apgar score among newborns who delivered at public hospitals in Hawassa City, South Ethiopia

BACKGROUND

Newborn morbidity and mortality are forecasted using the Apgar scores. Obstetricians worldwide have used the Apgar score for more than half a century for the assessment of immediate newborn conditions. It is a simple and convenient evaluation system that offers a standardized and effective assessment of newborn infants. Neonatal morbidity and mortality can be reduced if high-risk neonates are identified and managed adequately. This study aimed to assess the determinants of 5th minute low Apgar score among newborns at Public hospitals in Hawassa city, South Ethiopia.

METHODS

A hospital-based unmatched case-control study was conducted at Public Hospitals in Hawassa city. Data were collected from 134 cases and 267 controls using a structured and pre-tested questionnaire by observing, interviewing, and reviewing patient cards. Newborns who delivered with a 5th minute Apgar score < 7 were considered as cases; whereas a similar group of newborns with a 5th minute Apgar score of ≥ 7 were categorized as controls. A consecutive sampling technique was employed to recruit cases, while a simple random sampling technique was used to select controls. Data entry and analysis were performed using Epi Data version 3.1 and SPSS version 20 respectively. Binary and multivariable analyses with a 95 % confidence level were performed. In the final model, variables with P < 0.05 were considered statistically significant.

RESULTS

After controlling for possible confounding factors, the results showed that lack of physical and emotional support during labor and delivery [AOR = 3.5, 95 %CI:1.82-6.76], rural residence [AOR = 4, 95 %CI: 2.21-7.34], lack of antenatal care follow up [AOR = 3.5, 95 % CI: 1.91-6.33], anemia during pregnancy [AOR = 2.3,95 %CI: 1.10-4.71] and low birth weight [AOR = 6.2, 95 %CI: 2.78-14.03] were determinant factors of low Apgar scores. The area under the Apgar score ROC curve was 87.4 %.

CONCLUSIONS

Lack of physical and emotional support, rural residence, lack of ANC follow-up, low birth weight, and anemia during pregnancy were determinant factors of a low Apgar score. `Effective health education during preconception about anemia during pregnancy and ANC will help in detecting high-risk pregnancies that lead to a low Apgar score. In addition to the standard care of using electronic fetal monitoring, increasing access to compassion ships during labor and delivery is recommended.

Exploring providers' perceived barriers to utilization of antenatal and delivery services in urban and rural communities of Ebonyi state, Nigeria: A qualitative study

OBJECTIVE

To determine providers' perceived barriers to utilization of antenatal and delivery services in urban and rural communities of Ebonyi state, Nigeria.

METHODS

A descriptive exploratory study design was used. Qualitative data was collected through the use of a pre-tested interview guide. Twelve providers participated in the study in urban and rural communities of Ebonyi State, Nigeria. They included nine officers in charge of primary health centers, two Chief Nursing Officers of a tertiary health institution and mission hospital and one Medical Officer-in-charge of a General hospital. QDA Miner Lite v2.0.6 was used in the analysis of the data.

RESULTS

Most providers in urban and rural communities attributed good utilization of maternal health services to delivery of quality care. Most providers in urban linked poor utilization to poor health seeking behavior of women. In rural, poor utilization was credited to poor attitude of health workers. Few of participants (urban and rural) pointed out the neglect of primary health centers resulting in poor utilization. Most participants (urban and rural) considered ignorance as the main barrier to using health facilities for antenatal and delivery services. Another constraint identified was cost of services. Most participants attested that good provider attitude and public enlightenment will improve utilization of health facilities for antenatal and delivery care. All participants agreed on the need to involve men in matters related to maternal healthcare.

CONCLUSIONS

Participants were aware of values of good provider attitude and this is commendable. This combined with the finding of poor attitude of health workers necessitates that health workers should be trained on quality of care. There is need for public enlightenment on need to utilize health facilities for antenatal and delivery services. Community ownership of primary health centers especially in rural communities will enhance utilization of such facilities for maternal healthcare services and should be encouraged. Involvement of men in matters related to maternal healthcare may have a positive influence in improving maternal health in Nigeria.

Factors influencing mothers' decisions regarding obstetrical care in Western Kenya: a mixed-methods study

Background

Siaya County in Western Kenya has one of the highest maternal mortality rates in Kenya. We sought to elucidate factors that influence mothers’ decisions regarding where to seek obstetrical care, to inform interventions that seek to promote effective use of obstetric services and reduce maternal mortalities. To guide our research, we used the “Three Delays Model”, focusing on the first delay—seeking care. While interventions to reduce maternal mortalities have focused on addressing delays in accessing and receiving care, context-specific data on drivers of the first delay are scarce.

Methods

We used a mixed-method study to assess how maternal decision-making of birth location is influenced by personal, contextual, and cultural factors. We conducted structured interviews with women aged 14 years or older living in Siaya, Bondo, and Yala, rural districts in Western Kenya. We then conducted focus group interviews with a subset of women to elucidate this question: How do drivers of the first delay (i.e., seeking care) affect the decision to seek home versus hospital delivery, potentially negatively influencing maternal mortality.

Results

Three hundred and seven women responded to the surveys, and 67 women (22%) from this group participated in focus group interviews. Although we focused on type 1 delays, we discovered that several factors that impact type 2 and type 3 delays directly contribute to type 1 delays. Our findings highlighted that factors influencing women’s decisions to seek care are not simply medical or cultural but rather contextual, involving many elements of life, particularly in rural communities.

Conclusions

It is imperative to address multiple-level factors that influence women’s decisions to seek care and have in-hospital deliveries. To curtail maternal mortality in rural Western Kenya and comparable settings, targeted interventions must take into consideration these important influencers.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12905-021-01355-9.

Spatial variability in factors influencing maternal health service use in Jimma Zone, Ethiopia: a geographically-weighted regression analysis

BACKGROUND

Persisting within-country disparities in maternal health service access are significant barriers to attaining the Sustainable Development Goals aimed at reducing inequalities and ensuring good health for all. Sub-national decision-makers mandated to deliver health services play a central role in advancing equity but require appropriate evidence to craft effective responses. We use spatial analyses to identify locally-relevant barriers to access using sub-national data from rural areas in Jimma Zone, Ethiopia.

METHODS

Cross-sectional data from 3727 households, in three districts, collected at baseline in a cluster randomized controlled trial were analysed using geographically-weighted regressions. These models help to quantify associations within women's proximal contexts by generating local parameter estimates. Data subsets, representing an empirically-identified scale for neighbourhood, were used. Local associations between outcomes (antenatal, delivery, and postnatal care use) and potential explanatory factors at individual-level (ex: health information source), interpersonal-level (ex: companion support availability) and health service-levels (ex: nearby health facility type) were modelled. Statistically significant local odds ratios were mapped to demonstrate how relevance and magnitude of associations between various explanatory factors and service outcomes change depending on locality.

RESULTS

Significant spatial variability in relationships between all services and their explanatory factors (p < 0.001) was detected, apart from the association between delivery care and women's decision-making involvement (p = 0.124). Local models helped to pinpoint factors, such as danger sign awareness, that were relevant for some localities but not others. Among factors with more widespread influence, such as that of prior service use, variation in estimate magnitudes between localities was uncovered. Prominence of factors also differed between services; companion support, for example, had wider influence for delivery than postnatal care. No significant local associations with postnatal care use were detected for some factors, including wealth and decision involvement, at the selected neighbourhood scale.

CONCLUSIONS

Spatial variability in service use associations means that the relative importance of explanatory factors changes with locality. These differences have important implications for the design of equity-oriented and responsive health systems. Reductions in within-country disparities are also unlikely if uniform solutions are applied to heterogeneous contexts. Multi-scale models, accommodating factor-specific neighbourhood scaling, may help to improve estimated local associations.

Effect of Delays in Maternal Access to Healthcare on Neonatal Mortality in Sierra Leone: A Social Autopsy Case-Control Study at a Child Health and Mortality Prevention Surveillance (CHAMPS) Site

INTRODUCTION

In low-resource settings, a social autopsy tool has been proposed to measure the effect of delays in access to healthcare on deaths, complementing verbal autopsy questionnaires routinely used to determine cause of death. This study estimates the contribution of various delays in maternal healthcare to subsequent neonatal mortality using a social autopsy case-control design.

METHODS

This study was conducted at the Child Health and Mortality Prevention Surveillance (CHAMPS) Sierra Leone site (Makeni City and surrounding rural areas). Cases were neonatal deaths in the catchment area, and controls were sex- and area-matched living neonates. Odds ratios for maternal barriers to care and neonatal death were estimated, and stratified models examined this association by neonatal age and medical complications.

RESULTS

Of 53 neonatal deaths, 26.4% of mothers experienced at least one delay during pregnancy or delivery compared to 46.9% of mothers of stillbirths and 18.6% of control mothers. The most commonly reported delay among neonatal deaths was receiving care at the facility (18.9%). Experiencing any barrier was weakly associated (OR 1.68, CI 0.77, 3.67) and a delay in receiving care at the facility was strongly associated (OR 19.15, CI 3.90, 94.19) with neonatal death.

DISCUSSION

Delays in healthcare are associated with neonatal death, particularly delays experienced at the healthcare facility. Heterogeneity exists in the prevalence of specific delays, which has implications for local public health policy. The findings and conclusions in this report are those of the author(s) and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Maternal Satisfaction and Factors Associated with Institutional Delivery Care in Central Ethiopia: a Mixed Study

BACKGROUND

Women satisfaction recognized as an important outcome of the maternal health care delivery system. Despite the Ethiopian federal ministry of health implemented compassionate, respectful, and caring as one of the health sector transformation agendas to increase health service utilization, the level of maternal satisfaction of institutional delivery is still low. This study aimed to assess maternal satisfaction and factors associated with institutional delivery care in central Ethiopia.

METHODS

Community-based cross-sectional study, which involved quantitative study supplemented with qualitative methods were employed. Mothers were proportionally allocated to each selected kebele according to the number of their size. Data were collected by a face-to-face interview using a standardized questionnaire to determine the level of maternal satisfaction with birth care. The result was presented using texts, percentages, and tables. Bivariate and multivariate logistic regressions were performed between dependent and independent variables at 95% confidence intervals and a P-value < 0.05 to show a significant association. In the qualitative part, data were transcribed carefully and analyzed thematically.

RESULTS

The overall a total of 451 respondents participated in this study making a response rate of 98%. The level of maternal satisfaction was 36.6% in this study. Spontaneous vaginal deliveries (SVD) (AOR: 7.33, CI: 2, 26.79), being attended by female sex health workers (AOR: 1.54, CI: 1.04, 2.28), receiving ambulance service to arrive at health facilities (AOR: 7.84, CI: 2, 61.63), utilizing of maternal waiting areas AOR: 1.72, CI: 1.09, 2.66), and respectful care (AOR=1.55, CI: 1.03, 2.34) were factors associated with maternal satisfaction. From qualitative study, three themes and ten categories have emerged.

CONCLUSION

Maternal satisfaction towards the delivery service was low. SVD, being attended by female sex health workers, ambulance service, cleaned delivery room, and respectful care were factors associated with maternal satisfaction. The health facilities in the study areas need to work on improving health facility cleanliness, health workers' compassionate and respectful care, and providing ambulance service as a main means of transportation for laboring mothers.

A qualitative exploration of barriers to health-facility-based delivery in Bomachoge-Borabu and Kaloleni, Kenya

OBJECTIVE

To explore barriers to utilization of health-facility-based delivery in Kenya, use of which is associated with reduced maternal mortality.

METHODS

In April 2017, a qualitative study utilizing key informant interviews (KIIs) and focus group discussions (FGDs) was carried out in Bomachoge-Borabu and Kaloleni, Kenya. Twenty-four KIIs were performed including health service providers, community health workers, religious leaders, local government representatives, Ministry of Health representatives, and representatives of women's organizations. Sixteen FGDs were held separately with adolescent females, adult females, adult males, and Community Health Committee members. Data were transcribed, coded, and categorized thematically to illustrate supply-side and demand-side barriers to use of health-facility-based delivery services.

RESULTS

Supply-side barriers included staff shortages, inadequate supplies and space, poor interpersonal relations, few trained staff, long distance to services, poor transport infrastructure, and limited service hours. Demand-side barriers included financial constraints, limited spousal support, observance of birthing traditions, limited knowledge on importance of health-facility-based delivery, and fear of health-facility procedures.

CONCLUSIONS

Diverse barriers continue to influence use of health-facility-based delivery services in Kenya. Practical, integrated interventions are urgently needed to reduce barriers noted, to further reduce the maternal mortality rate.

Barriers to accessing healthcare among women in Ghana: a multilevel modelling

BACKGROUND

Women's health remains a global public health concern, as enshrined in the Sustainable Development Goals. This study, therefore, sought to assess the individual and contextual factors associated with barriers to accessing healthcare among women in Ghana.

METHODS

The study was conducted among 9370 women aged 15-49, using data from the 2014 Ghana Demographic and Health Survey. Barrier to healthcare, derived from four questions- whether a woman faced problems in getting money, distance, companionship, and permission to see a doctor-was the outcome variable. Descriptive and multilevel logistic regression analyses were carried out. The fixed effect results of the multilevel logistic regression analyses were reported using adjusted odds ratios at a 95% confidence interval.

RESULTS

More than half (51%) of the women reported to have at least one form of barrier to accessing healthcare. Women aged 45-49 (AOR = 0.65, CI: 0.49-0.86), married women (AOR = 0.71, CI:0.58-0.87), those with a higher level of education (AOR = 0.51, CI: 0.37-0.69), those engaged in clerical or sales occupation (AOR = 0.855, CI: 0.74-0.99), and those who were covered by health insurance (AOR = 0.59, CI: 0.53-0.66) had lower odds of facing barriers in accessing healthcare. Similarly, those who listened to radio at least once in a week (AOR =0.77, CI: 0.66-0.90), those who watched television at least once a week (AOR = 0.75, CI: 0.64-0.87), and women in the richest wealth quintile (AOR = 0.47, CI: 0.35-0.63) had lower odds of facing barriers in accessing healthcare. However, women who were widowed (AOR = 1.47, CI: 1.03-2.10), those in the Volta Region (AOR 2.20, CI: I.38-3.53), and those in the Upper West Region (AOR =2.22, CI: 1.32-3.74) had the highest odds of facing barriers to healthcare accessibility.

CONCLUSION

This study shows that individual and contextual factors are significant in predicting barriers in healthcare access in Ghana. The factors identified include age, marital status, employment, health insurance coverage, frequency of listening to radio, frequency of watching television, wealth status, and region of residence. These findings highlight the need to pay critical attention to these factors in order to achieve the Sustainable Development Goals 3.1, 3.7, and 3.8. It is equally important to strengthen existing strategies to mitigate barriers to accessing healthcare among women in Ghana.

Individual and contextual factors associated with barriers to accessing healthcare among women in Papua New Guinea: insights from a nationwide demographic and health survey

BACKGROUND

This study sought to assess the individual and contextual factors associated with barriers to accessing healthcare among women in Papua New Guinea.

METHODS

The study was conducted among 14 653 women aged 15-49 y using data from the 2016-2018 Papua New Guinea Demographic and Health Survey. The outcome variable was barriers to accessing healthcare. Descriptive and multilevel logistic regression analyses were conducted. Statistical significance was declared at P < 0.05.

RESULTS

Women aged 15-19 y were more likely to experience at least one barrier compared with those aged 40-49 y (adjusted OR [AOR]=1.48; 95% CI 1.18 to 1.86). Women with secondary/higher education (AOR=0.68; 95% CI 0.57 to 0.81), women in the richest wealth quintile (AOR=0.36; 95% CI 0.28 to 0.46) and those in the least disadvantaged socioeconomic status (AOR=0.46; 95% CI 0.33 to 0.64) had lower odds of having challenges with at least one barrier to healthcare. However, living in rural areas increased the odds of facing at least one barrier to healthcare (AOR=1.87; 95% CI 1.27 to 2.77).

CONCLUSIONS

This study has demonstrated that both individual and contextual factors are associated with barriers to healthcare accessibility among women in Papua New Guinea. To enhance the achievement of the Sustainable Development Goals 3.1, 3.7 and 3.8, it is critical to deem these factors necessary and reinforce prevailing policies to tackle barriers to accessing healthcare among women in Papua New Guinea.

Results-based financing to increase uptake of skilled delivery services in The Gambia: using the 'three delays' model to interpret midline evaluation findings

Background

Delays in accessing skilled delivery services are a major contributor to high maternal mortality in resource-limited settings. In 2015, the government of The Gambia initiated a results-based financing intervention that sought to increase uptake of skilled delivery. We performed a midline evaluation to determine the impact of the intervention and explore causes of delays.

Methods

A mixed methods design was used to measure changes in uptake of skilled delivery and explore underlying reasons, with communities randomly assigned to four arms: (1) community-based intervention, (2) facility-based intervention, (3) community- and facility-based intervention, and (4) control. We obtained quantitative data from household surveys conducted at baseline (n = 1423) and midline (n = 1573). Qualitative data came from semi-structured interviews (baseline n = 20; midline n = 20) and focus group discussions (baseline n = 27; midline n = 39) with a range of stakeholders. Multivariable linear regression models were estimated using pooled data from baseline and midline. Qualitative data were recorded, transcribed, translated and thematically analyzed.

Results

No increase was found in uptake of skilled delivery services between baseline and midline. However, relative to the control group, significant increases in referral to health facilities for delivery were found in areas receiving the community-based intervention (beta = 0.078, p < 0.10) and areas receiving both the community-based and facility-based interventions (beta = 0.198, p < 0.05). There was also an increase in accompaniment to health facilities for delivery in areas receiving only community-based interventions (beta = 0.095, p < 0.05). Transportation to health facilities for delivery increased in areas with both interventions (beta = 0.102, p < 0.05). Qualitative data indicate that delays in the decision to seek institutional delivery usually occurred when women had limited knowledge of delivery indications. Delays in reaching a health facility typically occurred due to transportation-related challenges. Although health workers noted shortages in supplies and equipment, women reported being supported by staff and experiencing minimal delays in receiving skilled delivery care once at the facility.

Conclusions

Focusing efforts on informing the decision to seek care and overcoming transportation barriers can reduce delays in care-seeking among pregnant women and facilitate efforts to increase uptake of skilled delivery services through results-based financing mechanisms.

Assessing the effect of pregnancy intention at conception on the continuum of care in maternal healthcare services use in Bangladesh: Evidence from a nationally representative cross-sectional survey

Background

The Continuum of Care (CoC; defined as accessing the recommended healthcare services during pregnancy and the early postpartum period) is low in lower-middle-income countries (LMICs). This may be a major contributor to the high rates of pregnancy-related complications and deaths in LMICs, particularly among women who had an unintended pregnancy. With a lack of research on the subject in Bangladesh, we aimed to examine the effect of unintended pregnancy on CoC.

Methods

Data from 4,493 mother-newborn dyads who participated in the cross-sectional 2014 Bangladesh Demographic and Health Survey were analysed. Women’s level of CoC was generated from responses to questions on the use and non-use of three recommended services during the course of pregnancy: four or more antenatal care (ANC) visits, skilled birth attendance (SBA) during delivery, and at least one postnatal care (PNC) visit within 24 hours of giving birth. Global recommendations of service use were used to classify CoC as high (used each of the recommended services), moderate (used at least two of the three recommended services), and low/none (no PNC, no SBA, and ≤3 ANC visits). Women’s pregnancy intention at the time of conception of their last pregnancy (ending with a live birth) was the major exposure variable, classified as wanted, mistimed, and unwanted. Unadjusted and adjusted (with individual-, household-, and community-level factors) multilevel multinomial logistic regression models were used to assess the association between unintended pregnancy and level of CoC.

Results

In Bangladesh, the highest level of CoC occurred in only 12% of pregnancies that ended with live births. This figure was reduced to 5.6% if the pregnancy was unwanted at conception. The antenatal period saw the greatest drop in CoC, with 65.13% of women receiving at least one ANC visit and 26.32% having four or more ANC visits. Following the adjustment of confounders, an unwanted pregnancy was found to be associated with 39% and 62% reduced odds of women receiving moderate and high levels of CoC, respectively, than those with a wanted pregnancy. Having a mistimed pregnancy was found to be associated with a 31% reduction in odds of women achieving a high CoC than women with a wanted pregnancy.

Conclusion

Almost nine in ten women did not achieve CoC in their last pregnancy, which was even higher when the pregnancy was unintended. Given that the ANC period has been identified as a critical time for intervention for these women, it is necessary for policies to scale up current maternal healthcare services that provide in-home maternal healthcare services and to monitor the continuity of ANC, with a particular focus on women who have an unintended pregnancy. Integration of maternal healthcare services with family planning services is also required to ensure CoC.

Mixed effects analysis of factors associated with barriers to accessing healthcare among women in sub-Saharan Africa: Insights from demographic and health surveys

Background

Access to healthcare is one of the key global concerns as treasured in the Sustainable Development Goals. This study, therefore, sought to assess the individual and contextual factors associated with barriers to accessing healthcare among women in sub-Saharan Africa (SSA).

Materials and methods

Data for this study were obtained from the latest Demographic and Health Surveys (DHS) conducted between January 2010 and December 2018 across 24 countries in SSA. The sample comprised 307,611 women aged 15–49. Data were analysed with STATA version 14.2 using both descriptive and multilevel logistic regression modelling. Statistical significance was set at p<0.05.

Results

It was found that 61.5% of women in SSA face barriers in accessing healthcare. The predominant barriers were getting money needed for treatment (50.1%) and distance to health facility (37.3%). Women aged 35–39 (AOR = 0.945, CI: 0.911–0.980), married women (AOR = 0.694, CI: 0.658–0.732), richest women (AOR = 0.457, CI:0.443–0.472), and those who read newspaper or magazine at least once a week (AOR = 0.893, CI:0.811–0.983) had lower odds of facing barriers in accessing healthcare. However, those with no formal education (AOR = 1.803, CI:1.718–1.891), those in manual occupations (AOR = 1.551, CI: 1.424–1.689), those with parity 4 or more (AOR = 1.211, CI: 1.169–1.255), those who were not covered by health insurance (AOR = 1.284, CI: 1.248–1.322), and those in rural areas (AOR = 1.235, CI:1.209–1.26) had higher odds of facing barriers to healthcare access.

Conclusion

Both individual and contextual factors are associated with barriers to healthcare accessibility in SSA. Particularly, age, marital status, employment, parity, health insurance coverage, exposure to mass media, wealth status and place of residence are associated with barriers to healthcare accessibility. These factors ought to be considered at the various countries in SSA to strengthen existing strategies and develop new interventions to help mitigate the barriers. Some of the SSA African countries can adopt successful programs in other parts of SSA to suit their context such as the National Health Insurance Scheme (NHIS) and the Community-based Health Planning and Services concepts in Ghana.

Reducing Disrespect and Abuse of Women During Antenatal Care and Delivery Services at Injibara General Hospital, Northwest Ethiopia: A Pre-Post Interventional Study

Introduction

Disrespect and abuse during pregnancy and childbirth continue to be a barrier for the utilization and quality of care in maternal health services. This study was therefore aimed at reducing the disrespect and abuse of mothers during antenatal care and delivery services at Injibara general hospital, northwest Ethiopia.

Materials and Methods

A pre–post interventional mixed method design was conducted among a total of 738 randomly selected mothers who attended antenatal care and delivery services from November 1, 2018 to May 20, 2019. To collect the data, exit interview using an interviewer-administered structured questionnaire was used. Provision of training, preparation of standard written guidelines and protocols, waiting room construction, availing screening or curtain, equipment, essential drugs and supplies, supportive supervision and mentoring, and staff motivation were the lists of interventions applied to decrease disrespect and abuse. Descriptive statistics and independent t-test were computed. The independanet t-test is used because the study populations at the baseline and endline were different. A p-value of <0.05 and a mean difference with 95% CI was used to test the significance of the interventions.

Results

The study revealed that disrespect and abuse during pregnancy and childbirth decreased from 71.8% at baseline to 15.9% at the end-line with a 55.9% change (mean difference: 0.56, 95% CI: 0.55–0.57). Alongside, the magnitude on the subscales of disrespect and abuse (physical abuse, non-consented care, non-confidential care, non-dignified care, discrimination and neglected care) was decreased at post-intervention, compared with the baseline.

Conclusion

Respectful maternal healthcare after the intervention was significantly improved. The finding suggests that provision of training to healthcare providers, written policies and procedures that describe the responsibilities of healthcare providers in the respectful maternal care process, improving facility infrastructure, availing supplies, regular supportive supervision and mentoring and motivation of high-performance employees have the potential to enhance respectful maternal care. Therefore, incorporating such training into pre-service curricula and in‐service training of healthcare workers may indorse the practice of respectful maternal care.

Factors associated with the perceived barriers of health care access among reproductive-age women in Ethiopia: a secondary data analysis of 2016 Ethiopian demographic and health survey

Background

Health care access is the timely use of personal health services to achieve the best health outcomes. Problems in accessing health care among reproductive-age may lead to various adverse health outcomes like death and disabilities. Therefore, this study aimed to identify factors associated with the perceived barriers of healthcare access among reproductive-age women in Ethiopia.

Method

This study was based on secondary data sources from the 2016 Ethiopia Demography and Health Survey. The individual women record (IR) file was used to extract about 15, 683 women for the final analysis from the largest dataset. A composite variable of health care access was created from four questions used to rate health care access problems among women of reproductive age. To identify factors associated with the perceived barriers of health care access among reproductive-age women, generalized estimating equation (GEE) model was fitted. Crude and adjusted odds ratio (AOR) with a 95% confidence interval (CI) computed to assess the strength of association between independent and outcome variables.

Results

This study revealed that the magnitude of perceived barriers of healthcare access among reproductive-age women was 69.9% with 95%CI (69.3 to 70.7) to at least one or more of the four reasons. Rural resident (AOR = 2.13, 95%CI: 1.79 to 2.53), age 35–49 years (AOR = 1.24, 95%CI: 1.09 to 1.40), divorced/separated (AOR = 1.34, 95%CI: 1.17 to 1.54), had no health insurance coverage (AOR = 1.19, 95%CI: 1.01 to 1.45), poorer (AOR = 2.09,95%CI: 1.86 to 2.35) and middle wealth (AOR = 1.57,95%CI:1.38 to 1.79), no education (AOR = 2.30, 95%CI:1.95 to 2.72), primary education (AOR = 1.84, 95%CI: 1.58 to 2.15) and secondary education (AOR = 1.31, 95%CI: 1.13 to 1.51) were factors associated with the perceived barriers of health care access.

Conclusion

A significant proportion of women of reproductive age faced barriers to healthcare access, of which money and distance were the most frequently perceived barriers. Divorced/separated marital status, old age, rural dwelling, no health insurance coverage, low economic situation, and level of education were factors associated with perceived barriers. These findings suggest further strengthening and improving health care access to those women with low socio-economic status for the realization of universal health coverage.

Community Acceptance and Utilization of Maternal and Community-Based Neonatal Care Services Provided by Health Extension Workers in Rural Sidama Zone: Barriers and Enablers: A Qualitative Study

Purpose

This study assessed the community acceptance and utilization of maternal and community-based neonatal care services, its barriers, and enablers in southern Ethiopia, 2019.

Methods

An exploratory qualitative study was conducted among mothers, health extension workers, their supervisors and coordinators in four districts of Sidama Zone, Hawassa University Demographic Surveillance Site. An in-depth interview has been carried out with eight health extension workers and eight program coordinators and supervisors, while four focus group discussions were held with eligible mothers. Digital recording was applied to record the interview and discussion followed by transcription and thematic analysis through open code.

Results

Study findings reveal that services provided by health extension workers at community level for mothers and their children are highly appreciated and recognized by the community. Most of the communities are free from wrong perception regarding the practices. Their performance was better in focused antenatal care, but postnatal care and community-based neonatal care were reported to be insignificant. Knowledge and skills of HEWs was based on their extended experiences. The challenges and opportunities include workload, road inaccessibility, poor supervision, inadequate drugs and equipment supply, shortage of man power and budget at health posts, distance and topography factors of homes from health posts making the visits more difficult, etc. To improve uptake of the services, increasing the number of health extension workers in the heath post, supportive supervision, continuous essential drugsm and medical supplies were suggested by participants.

Conclusion

This study shows that services provided by health extension workers for mothers and their neonates are highly appreciated by the community, and there is better change in focused antenatal care services, but postnatal care and sick newborn care are still low. Therefore, maternal and neonatal programs should focus on the postnatal home visits and sick newborn care through solving identified barriers.

Individual, Household, and Contextual Factors Influencing the Timing of the First Antenatal Care Attendance in Northwest Ethiopia: A Two-Level Binary Logistic Regression Analysis

Background

Early antenatal visit is critical for the health and well-being of mothers and babies. However, various individual, family level, and contextual factors influence the timely initiation of antenatal care.

Objective

The aim of this study was to examine individual, household, and community-level factors associated with the timing of first ANC visit among mothers who gave birth in the last twelve months before the survey.

Methods

A community-based cross-sectional study was conducted in June 2018. A multistage cluster sampling technique was applied, and a sample of 898 women was considered. Data were collected using a questionnaire and checklist. The analysis was made using SPSS. A multilevel logistic regression with random effects at the kebele level was developed to assess the predictors of late initiation of antenatal care. Odds ratio with 95% confidence intervals was used to measure association while the intra-class correlation coefficient and the median odds ratio were used to measure variations.

Results

Overall, 78.4% (95% CI: 75.6, 80.9) of women started their first ANC in 4 months of gestation or later and significant heterogeneity was observed between clusters. At level 1, women with intended pregnancy (aOR=0.31; 95% CI: 0.12, 0.79), and being knowledgeable about the timing (aOR=0.43; 95% CI: 0.25, 0.75) and pregnancy-related complications (aOR=0.16; 95% CI: 0.10, 0.26) were less likely to delay their first ANC visit. Conversely, the odds of late ANC visit was higher among women with no formal education (aOR=4.08, 95% CI: 2.20, 7.55). Distance to the health facility (aOR=1.04; 95% CI, 1.01-1.08) was the only level-2 significant predictor.

Conclusion

The study revealed that late ANC initiation was rampant. Several factors operating at different levels were associated with late ANC visits; yet, the role of individual-level factors was relatively stronger. Hence, awareness creation is essential to the underprivileged community using the available communication networks.

Religious, socio-cultural norms and gender stereotypes influence uptake and utilization of maternal health services among the Digo community in Kwale, Kenya: a qualitative study

Background

Maternal health outcomes in resource-limited settings are typically influenced by supply-side factors affecting the provision of quality health services. The extent to which demand-side factors contribute to this influence is unclear. We aimed to explore how individual and community-wide factors influenced uptake and utilization of maternal health services among the Digo community residing in Kwale County of coastal Kenya.

Methods

Between March and December 2015, we conducted 5 focus group discussions (FGDs) and 15 in-depth interviews (IDIs) with members of the Digo community predominant in Kwale county, Kenya. Respondents were sampled purposively and included female (pregnant and postpartum) as well as male adult community members. A thematic content analytic approach was used.

Results

There were a total of 47 FGD respondents, including 15 (32%) females with a median (interquartile, IQR) age of 38 (27–55) years and 6 (3–8) children. Majority (40%) reported attaining secondary-level education. All IDI respondents were female with a median (IQR) age of 27 (24–35) years and 4 (2–5) children. Majority (80%) had attained primary-level education. We found that religious and socio-cultural norms as well as gender stereotypes were important influences on the uptake and utilization of maternal health services, including facility-based delivery and contraception. Key amongst this was the unspoken deference to the counsel of a prominent matriarchal figure in the decision-making process.

Conclusions

Among the Digo community of coastal Kenya, a unique social-cultural context comprising of a religious and gendered value belief system influences women’s reproductive health and rights. These findings highlight the important role of demand-side factors in influencing maternal health outcomes. In addition to addressing supply-side factors, programs in such settings should aim to address factors that leverage inherent social capital to drive demand for maternal health services ensuring that they are not only effective, but also responsive to the local context.

Mother's satisfaction with the existing labor and delivery care services at public health facilities in West Shewa zone, Oromia region, Ethiopia

BACKGROUND

Mothers' satisfaction with care during childbirth is indicators of the quality care which affects skilled birth attendance. Negative client's experiences at health facilities cause them to delay or avoid seeking care, which highlights services providers should consider and act on the expectations and experiences of women and their families. Though there are few studies conducted in Ethiopia on maternal satisfaction with Labor and Delivery (LAD) services, there is no study conducted in the study area. Therefore the study aims to assess the mother's satisfaction with existing LAD services and associated factors at all levels of health care in the West Shewa zone.

METHODS

An institution-based cross-sectional study was conducted at public health facilities in West Shewa zone, Central Ethiopia. A systematic sampling technique was used to select 560 respondents by using their delivery registration number and data were collected through face to face interview. Mothers were considered satisfied if they responded satisfied/very satisfied with 75% or more of the questions assessing satisfaction. Binary and multivariable logistic regression analysis was used to identify associated factors.

RESULTS

The overall proportion of mothers who were satisfied with the current LAD care services were 60.8%. The main areas of dissatisfaction were; accessibility and cleanness of toilets/shower 72.6%, overall cleanness of the facility/including waiting-area 40.1% and presence of support a person during birth 38.0%. The presence of cultural practices (AOR = 2.5), discussion on the place of delivery with health worker during ANC (AOR = 1.75), providers asks for consent before procedure (AOR = 2.77), encouraging companion to remain with mother (AOR = 2.22), never leave mother alone or unattended (AOR = 2.56), giving periodic updates on status and progress of labor (AOR = 2.04) and explaining what is being done and to expect during LAD (AOR = 2.20) were factors identified to be significantly associated with satisfaction on LAD services.

CONCLUSION

The overall satisfaction of mothers with LAD services at public health facilities in the West-Shewa zone was relatively low. Presence of cultural practices, discussion on the place of delivery, asking for consent before the procedure, encouraging companion to remain with mothers and explaining what is being done were factors identified. Therefore, all stakeholders have to emphatically work on those identified factors to improve mothers' satisfaction with LAD services.

Women's retention on the continuum of maternal care pathway in west Gojjam zone, Ethiopia: multilevel analysis

Background

The continuum of maternal care has been one of the effective approaches for improving the health of mothers and newborns. Although large numbers of Ethiopian women do not use maternal health services, points of drop out along the continuum are not understood well. Understanding of a particular point of maternal care dropout on the continuum, however, helps governments make effective interventions. This study aimed to assess the extent of women’s service utilization and the factors affecting retention on the continuum of care in West Gojjam Zone, Ethiopia.

Methods

A community-based study linked to health facility data was conducted in June 2018. Data were obtained from 1281 mothers who gave birth to their last baby within the preceding 12 months from a two-stage cluster sampling. Data were collected via face-to-face interviews using a pretested questionnaire. Multilevel logistic regression models were used to examine the effects of individual and cluster-level factors on key elements of the continuum of care. The measure of fixed effects was expressed as Odds Ratio with 95% confidence interval.

Results

The study revealed that only 12.1% of women completed the continuum of maternal care services (ANC4+, SBA, and PNC within 2 days after birth); while 25.1% of them did not receive any care during their recent births. There were commonalities and differences in the predictors of the three indicators of maternal health service utilization. Variables related to services received during antenatal care such as early initiation of ANC (AOR = 7.53, 95%CI, 2.94, 19.29) and receiving proper contents (AOR = 3.31, 95%CI, 1.08, 10.16) were among the predictors significantly associated with the completion of the continuum of care.

Conclusions

The continuum of maternal care completion rate was extremely low, indicating that women were not getting the maximum possible health benefit from existing health services. The results also revealed that maternal health service utilization was influenced by factors operating at various levels-individual, household, community, and health facility. Since antenatal care is considered an entry point for the subsequent use of maternal services, strategies that aimed to improve maternal health service utilization should target early initiation and antenatal care quality.

Inequalities in Rotavirus Vaccine Uptake in Ethiopia: A Decomposition Analysis

A previous study in Ethiopia reported significant variation in rotavirus vaccine uptake across socioeconomic strata. This study aims to quantify socioeconomic inequality of rotavirus vaccine uptake in Ethiopia and to identify the contributing factors for the inequality. The concentration curve (CC) and the Erreygers Normalized Concentration Index (ECI) were used to assess the socioeconomic related inequality in rotavirus vaccine uptake using data from the 2016 Ethiopian Demographic and Health Survey. Decomposition analysis was conducted to identify the drivers of inequalities. The CC for rotavirus vaccine uptake lay below the line of equality and the ECI was 0.270 (p < 0.001) indicating that uptake of rotavirus vaccine in Ethiopia was significantly concentrated among children from families with better socioeconomic status. The decomposition analysis showed that underlining inequalities in maternal health care services utilization, including antenatal care use (18.4%) and institutional delivery (8.1%), exposure to media (12.8%), and maternal educational level (9.7%) were responsible for the majority of observed inequalities in the uptake of rotavirus vaccine. The findings suggested that there is significant socioeconomic inequality in rotavirus vaccine uptake in Ethiopia. Multi-sectoral actions are required to reduce the inequalities, inclusive increasing maternal health care services, and educational attainments among economically disadvantaged mothers.

Magnitude of disrespectful and abusive care among women during facility-based childbirth in Shambu town, Horro Guduru Wollega zone, Ethiopia

BACKGROUND

Disrespectful care during childbirth causes suffering and discourages women from seeking facility-based care. It is one of the silent causes of maternal mortality and morbidity worldwide, but not yet well recorded especially in developing countries. The aim of this study was to measure the magnitude of disrespect and abusive behaviors of health professionals during childbirth and associated factors.

METHOD

Community based cross-sectional study design was employed among 321 women who gave birth in public health facilities of Shambu town, Ethiopia, between January 01 and December 31, 2018. Simple random sampling was used to select the study participants. Data were collected using a semi-structured interviewer administered questionnaire. Prevalence of disrespect and abuse was measured by using seven categories of disrespect and abuse with their respective verification criteria. The data were entered into Epi-data 3.1 and then transported to SPSS version 23.0. Logistic regression models were fitted to determine the presence of statistically significant associations between the dependent and independent variables at p-value <0.05 and AOR values with 95% confidence interval.

RESULTS

Out of 321 sampled respondents, 316 participated in this study with response rate of 98.4%. The overall prevalence of disrespect and abuse was 78.2% (95% CI: 73.5-83.2). The most common forms disrespect and abuse encountered by the mothers were: unconsented care (86.1%), non-dignified care (37.3%), lack of privacy (33.9%), physical abuse (21.5%) and neglectful care (13.3%). Mother's occupational status, increasing number of antenatal care visits and giving birth in a hospital setting were significantly associated with disrespect and abuse during facility-based childbirth.

CONCLUSION

Though government interventions are in place, excessive levels of disrespect and abusive practices during facility-based childbirth persisted to be important problems in the study area. To address the unnecessary suffering, health policy makers and program designers should develop strategies to enhance respectful maternity care approaches. Health managers and health professionals should do their best to provide high quality, client-centered care in health facilities so that women are not discouraged from using them. We also recommend knowledge exchange with development partners to determine which practices will be adaptable and helpful to address the problem of mistreatment of women in health care facilities.

Effectiveness of upgraded maternity waiting homes and local leader training in improving institutional births among women in the Jimma zone, Ethiopia: study protocol for a cluster-randomized controlled trial

Background

Ethiopia is one of the ten countries in the world that together account for almost 60% of all maternal deaths. Recent reductions in maternal mortality have been seen, yet just 26% of women who gave birth in Ethiopia in 2016 reported doing so at a health facility. Maternity waiting homes (MWHs) have been introduced to overcome geographical and financial barriers to institutional births but there is no conclusive evidence as to their effectiveness. We aim to evaluate the effects of upgraded MWHs and local leader training in increasing institutional births in the Jimma zone of Ethiopia.

Methods

A parallel, three-arm, stratified, cluster-randomized controlled trial design is being employed to evaluate intervention effects on institutional births, which is the primary outcome. Trial arms are: (1) upgraded MWH + religious/community leader training; (2) leader training alone; and (3) standard care. Twenty-four primary health care unit catchment areas (clusters) have been randomized and 3840 women of reproductive age who had a pregnancy outcome (livebirth, stillbirth or abortion) are being randomly recruited for each survey round. Outcome assessments will be made using repeat cross-sectional surveys at baseline and 24 months postintervention. An intention to treat approach will be used and the primary outcome analysed using generalized linear mixed models with a random effect for cluster and time. A cost-effectiveness analysis will also be conducted from a societal perspective.

Discussion

This is one of the first trials to evaluate the effectiveness of upgraded MWHs and will provide much needed evidence to policy makers about aspects of functionality and the community engagement required as they scale-up this programme in Ethiopia.

Trial registration

ClinicalTrial.gov, NCT03299491. Retrospectively registered on 3 October 2017.

Nomads' perceptions of quality, accessibility, and affordability of health services as determinants of using skilled birth attendants in Gossi, Mali

AIM

More than half of all maternal deaths worldwide occur in sub-Saharan Africa (SSA). For nomadic pastoralists (30 to 60 million) in SSA, the risk of maternal death is very high because of the low proportion of assisted deliveries in the areas where they live. The objective of this research was to understand the determinants of using skilled birth attendants in relation to the perceptions of quality, geographic accessibility, and financial affordability of health services by nomadic women.

METHODS

We used a qualitative research design, inspired by ethnography. Research was conducted in the commune of Gossi (Mali), where 90% of the population is nomadic. The study population consisted of 26 nomadic women living in their camps. Saturation and diversification guided sampling. Semi-structured individual interviews and non-participant observation enabled concomitant data collection. Thematic content analysis was performed using QDA Miner software.

RESULTS

Our results show that only 10 women used assisted childbirth for their last delivery. These women thought that health workers were competent and well trained, and they liked the fact that these workers were recruited locally. Similarly, these 10 women deemed the health workers' attitude acceptable and appreciated their availability. In contrast, the majority of participants (16 women) were prevented or discouraged from using skill birth attendants. Some of them did not use them because they were afraid of being undressed, of giving birth on a table, and especially of male staff. They also said that they did not have access to information about health services. In addition, respondents considered health services very difficult to access due to distances, unavailable means of transportation, and costs perceived as being expensive.

CONCLUSION

Our results identify several determinants of the use or non-use of skilled birth attendants by nomadic women in relation to the context and way of life. In addition, our findings call for future research to better understand these determinants and to deepen, refine, and test emerging strategies that seem potentially hopeful with respect to facilitating the use of skilled birth attendance in SSA.

Preferences for formal and traditional sources of childbirth and postnatal care among women in rural Africa: A systematic review

Background

The underutilization of formal, evidence-based maternal health services continues to contribute to poor maternal outcomes among women living in rural Africa. Women’s choice of the type of maternal care they receive strongly influences their utilization of maternal health services. There is therefore a need to understand rural women’s preferred choices to help set priorities for initiatives attempting to make formal maternal care more responsive to women’s needs. The aim of this review was to explore and identify women’s preferences for different sources of childbirth and postnatal care and the factors that contribute to these preferences.

Methods

A systematic literature search was conducted using the Ovid Medline, Embase, CINAHL, and Global Health databases. Thirty-seven studies that elicited women’s preferences for childbirth and postnatal care using qualitative methods were included in the review. A narrative synthesis was conducted to collate study findings and to report on patterns identified across findings.

Results

During the intrapartum period, preferences varied across communities, with some studies reporting preferences for traditional childbirth with traditional care-takers, and others reporting preferences for a formal facility-based childbirth with health professionals. During the postpartum period, the majority of relevant studies reported a preference for traditional postnatal services involving traditional rituals and customs. The factors that influenced the reported preferences were related to the perceived need for formal or traditional care providers, accessibility to maternal care, and cultural and religious norms.

Conclusion

Review findings identified a variety of preferences for sources of maternal care from intrapartum to postpartum. Future interventions aiming to improve access and utilization of evidence-based maternal healthcare services across rural Africa should first identify major challenges and priority needs of target populations and communities through formative research. Evidence-based services that meet rural women’s specific needs and expectations will increase the utilization of formal care and ultimately improve maternal outcomes across rural Africa.