Maternal social support and health facility delivery in Southwest Ethiopia.

BACKGROUND: Maternal mortality continues to decrease in the world but remain the most important health problems in low-income countries. Although evidence indicates that social support is an important factor influencing health facility delivery, it has not been extensively studied in Ethiopia. Therefore, this study aimed to assess the effect of maternal social support and related factors on health facility delivery in southwest Ethiopia. METHODS: A cross-sectional survey data on 3304 women aged 15-47 years in three districts of Ethiopia, were analyzed. Using multivariable logistic regression, we assessed the association between health facility birth, social support, and socio-demography variables. Adjusted odds ratios with 95% confidence intervals were used to identify statistically significant associations at 5% alpha level. RESULT: Overall, 46.9% of women delivered at health facility in their last pregnancy. Average travel time from closest health facility (AOR: 1.51, 95% CI 1.21 to 2.90), mean perception score of health facility use (AOR: 1.83, 95% CI 1.44 to 2.33), involvement in final decision to identify their place of childbirth (AOR: 2.12, 95% CI 1.73 to 2.58) had significantly higher odds of health facility childbirth. From social support variables, women who perceived there were family members and husband to help them during childbirth (AOR: 3.62, 95% CI 2.74 to 4.79), women who received continuous support (AOR: 1.97, 95% CI 1.20 to 3.23), women with companions for facility visits (AOR: 1.63, 95% CI 1.34 to 2.00) and women who received support from friends (AOR: 1.62, 95% CI 1.16 to 3.23) had significantly higher odds of health facility childbirth. CONCLUSIONS: Social support was critical to enhance health facility delivery, especially if women's close ties help facility delivery. An intervention to increase facility delivery uptake should target not only the women's general social supports, but also continuous support during childbirth from close ties including family members and close friends as these are influential in place of childbirth. Also actions that increase women's healthcare decision could be effective in improving health facility delivery.

Effectiveness of upgraded maternity waiting homes and local leader training on improving institutional births: a cluster-randomized controlled trial in Jimma, Ethiopia.

BACKGROUND: Maternity waiting homes (MWHs), residential spaces for pregnant women close to obstetric care facilities, are being used to tackle physical barriers to access. However, their effectiveness has not been rigorously assessed. The objective of this cluster randomized trial was to evaluate the effectiveness of functional MWHs combined with community mobilization by trained local leaders in improving institutional births in Jimma Zone, Ethiopia. METHODS: A pragmatic, parallel arm cluster-randomized trial was conducted in three districts. Twenty-four primary health care units (PHCUs) were randomly assigned to either (i) upgraded MWHs combined with local leader training on safe motherhood strategies, (ii) local leader training only, or (iii) usual care. Data were collected using repeat cross-sectional surveys at baseline and 21 months after intervention to assess the effect of intervention on the primary outcome, defined as institutional births, at the individual level. Women who had a pregnancy outcome (livebirth, stillbirth or abortion) 12 months prior to being surveyed were eligible for interview. Random effects logistic regression was used to evaluate the effect of the interventions. RESULTS: Data from 24 PHCUs and 7593 women were analysed using intention-to-treat. The proportion of institutional births was comparable at baseline between the three arms. At endline, institutional births were slightly higher in the MWH + training (54% [n = 671/1239]) and training only arms (65% [n = 821/1263]) compared to usual care (51% [n = 646/1271]). MWH use at baseline was 6.7% (n = 256/3784) and 5.8% at endline (n = 219/3809). Both intervention groups exhibited a non-statistically significant higher odds of institutional births compared to usual care (MWH+ & leader training odds ratio [OR] = 1.09, 97.5% confidence interval [CI] 0.67 to 1.75; leader training OR = 1.37, 97.5% CI 0.85 to 2.22). CONCLUSIONS: Both the combined MWH+ & leader training and the leader training alone intervention led to a small but non-significant increase in institutional births when compared to usual care. Implementation challenges and short intervention duration may have hindered intervention effectiveness. Nevertheless, the observed increases suggest the interventions have potential to improve women's use of maternal healthcare services. Optimal distances at which MWHs are most beneficial to women need to be investigated. TRIAL REGISTRATION: The trial was retrospectively registered on the Clinical Trials website ( https://clinicaltrials.gov ) on 3rd October 2017. The trial identifier is NCT03299491 .

Uncovering spatial variation in maternal healthcare service use at subnational level in Jimma Zone, Ethiopia.

BACKGROUND: Analysis of disaggregated national data suggest uneven access to essential maternal healthcare services within countries. This is of concern as it hinders equitable progress in health outcomes. Mounting an effective response requires identification of subnational areas that may be lagging behind. This paper aims to explore spatial variation in maternal healthcare service use at health centre catchment, village and household levels. Spatial correlations of service use with household wealth and women's education levels were also assessed. METHODS: Using survey data from 3758 households enrolled in a cluster randomized trial geographical variation in the use of maternity waiting homes (MWH), antenatal care (ANC), delivery care and postnatal care (PNC) was investigated in three districts in Jimma Zone. Correlations of service use with education and wealth levels were also explored among 24 health centre catchment areas using choropleth maps. Global spatial autocorrelation was assessed using Moran's I. Cluster analyses were performed at village and household levels using Getis Ord Gi* and Kulldorf spatial scan statistics to identify cluster locations. RESULTS: Significant global spatial autocorrelation was present in ANC use (Moran's I = 0.15, p value = 0.025), delivery care (Moran's I = 0.17, p value = 0.01) and PNC use (Moran's I = 0.31, p value < 0.01), but not MWH use (Moran's I = -0.005, p value = 0.94) suggesting clustering of villages with similarly high (hot spots) and/or low (cold spots) service use. Hot spots were detected in health centre catchments in Gomma district while Kersa district had cold spots. High poverty or low education catchments generally had low levels of service use, but there were exceptions. At village level, hot and cold spots were detected for ANC, delivery care and PNC use. Household-level analyses revealed a primary cluster of elevated MWH-use not detected previously. Further investigation of spatial heterogeneity is warranted. CONCLUSIONS: Sub-national variation in maternal healthcare services exists in Jimma Zone. There was relatively higher poverty and lower education in areas where service use cold spots were identified. Re-directing resources to vulnerable sub-groups and locations lagging behind will be necessary to ensure equitable progress in maternal health.

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.

Utilization of key preventive measures for pregnancy complications and malaria among women in Jimma Zone, Ethiopia.

BACKGROUND: In Ethiopia, malaria infections and other complications during pregnancy contribute to the high burden of maternal morbidity and mortality. Preventive measures are available, however little is known about the factors influencing the uptake of maternal health services and interventions by pregnant women in Ethiopia. METHODS: We analyzed data from a community-based cross-sectional survey conducted in 2016 in three rural districts of Jimma Zone, Ethiopia, with 3784 women who had a pregnancy outcome in the year preceding the survey. We used multivariable logistic regression models accounting for clustering to identify the determinants of antenatal care (ANC) attendance and insecticide-treated net (ITN) ownership and use, and the prevalence and predictors of malaria infection among pregnant women. RESULTS: Eighty-four percent of interviewed women reported receiving at least one ANC visit during their last pregnancy, while 47% reported attending four or more ANC visits. Common reasons for not attending ANC included women's lack of awareness of its importance (48%), distance to health facility (23%) and unavailability of transportation (14%). Important determinants of ANC attendance included higher education level and wealth status, woman's ability to make healthcare decisions, and pregnancy intendedness. An estimated 48% of women reported owning an ITN during their last pregnancy. Of these, 55% reported to have always slept under it during their last pregnancy. Analysis revealed that the odds of owning and using ITNs were respectively 2.07 (95% CI: 1.62-2.63) and 1.73 (95% CI: 1.32-2.27) times higher among women who attended at least one ANC visit. The self-reported prevalence of malaria infection during pregnancy was low (1.4%) across the three districts. We found that young, uneducated, and unemployed women presented higher odds of malaria infection during their last pregnancy. CONCLUSION: ANC and ITN uptake during pregnancy in Jimma Zone fall below the respective targets of 95 and 90% set in the Ethiopian Health Sector Transformation Plan for 2020, suggesting that more intensive programmatic efforts still need to be directed towards improving access to these health services. Reaching ANC non-users and ITN ownership and use as part of ANC services could be emphasized to address these gaps.

Factors associated with maternity waiting home use among women in Jimma Zone, Ethiopia: a multilevel cross-sectional analysis.

OBJECTIVE: To identify individual-, household- and community-level factors associated with maternity waiting home (MWH) use in Ethiopia. DESIGN: Cross-sectional analysis of baseline household survey data from an ongoing cluster-randomised controlled trial using multilevel analyses. SETTING: Twenty-four rural primary care facility catchment areas in Jimma Zone, Ethiopia. PARTICIPANTS: 3784 women who had a pregnancy outcome (live birth, stillbirth, spontaneous/induced abortion) 12 months prior to September 2016. OUTCOME MEASURE: The primary outcome was self-reported MWH use for any pregnancy; hypothesised factors associated with MWH use included woman's education, woman's occupation, household wealth, involvement in health-related decision-making, companion support, travel time to health facility and community-levels of institutional births. RESULTS: Overall, 7% of women reported past MWH use. Housewives (OR: 1.74, 95% CI 1.20 to 2.52), women with companions for facility visits (OR: 2.15, 95% CI 1.44 to 3.23), wealthier households (fourth vs first quintile OR: 3.20, 95% CI 1.93 to 5.33) and those with no health facility nearby or living >30 min from a health facility (OR: 2.37, 95% CI 1.80 to 3.13) had significantly higher odds of MWH use. Education, decision-making autonomy and community-level institutional births were not significantly associated with MWH use. CONCLUSIONS: Utilisation inequities exist; women with less wealth and companion support experienced more difficulties in accessing MWHs. Short duration of stay and failure to consider MWH as part of birth preparedness planning suggests local referral and promotion practices need investigation to ensure that women who would benefit the most are linked to MWH services.

A quality assessment of Health Management Information System (HMIS) data for maternal and child health in Jimma Zone, Ethiopia.

Health management information system (HMIS) data are important for guiding the attainment of health targets in low- and middle-income countries. However, the quality of HMIS data is often poor. High-quality information is especially important for populations experiencing high burdens of disease and mortality, such as pregnant women, newborns, and children. The purpose of this study was to assess the quality of maternal and child health (MCH) data collected through the Ethiopian Ministry of Health's HMIS in three districts of Jimma Zone, Oromiya Region, Ethiopia over a 12-month period from July 2014 to June 2015. Considering data quality constructs from the World Health Organization's data quality report card, we appraised the completeness, timeliness, and internal consistency of eight key MCH indicators collected for all the primary health care units (PHCUs) located within three districts of Jimma Zone (Gomma, Kersa and Seka Chekorsa). We further evaluated the agreement between MCH service coverage estimates from the HMIS and estimates obtained from a population-based cross-sectional survey conducted with 3,784 women who were pregnant in the year preceding the survey, using Pearson correlation coefficients, intraclass correlation coefficients (ICC), and Bland-Altman plots. We found that the completeness and timeliness of facility reporting were highest in Gomma (75% and 70%, respectively) and lowest in Kersa (34% and 32%, respectively), and observed very few zero/missing values and moderate/extreme outliers for each MCH indicator. We found that the reporting of MCH indicators improved over time for all PHCUs, however the internal consistency between MCH indicators was low for several PHCUs. We found poor agreement between MCH estimates obtained from the HMIS and the survey, indicating that the HMIS may over-report the coverage of key MCH services, namely, antenatal care, skilled birth attendance and postnatal care. The quality of MCH data within the HMIS at the zonal level in Jimma, Ethiopia, could be improved to inform MCH research and programmatic efforts.