Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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Determinants of institutional childbirth service utilisation among women of childbearing age in urban and rural areas of Tsegedie district, Ethiopia Desta Hailu, BSc, MSc (Lecturer)a,n, Hailemariam Berhe, BSc, MSc (Lecturer)b a b
Department of Nursing and Midwifery, Arba Minch University, Arba Minch, Ethiopia Department of Nursing, Mekelle University, Mekelle, Ethiopia
art ic l e i nf o
a b s t r a c t
Article history: Received 24 August 2013 Received in revised form 13 January 2014 Accepted 16 March 2014
Background: despite receiving greater attention, optimal maternal health remains a challenge in developing countries such as Ethiopia. Evidence from various studies shows that skilled attendance during childbirth is among the key strategies to reduce maternal mortality. However, in Ethiopia, the use of institutional childbirth services is very low. In Ethiopia, studies dealing with factors affecting women's use of institutional childbirth services are scarce and generally focus on urban settings. As such, this study aimed to explore the determinants of institutional childbirth service utilisation among urban and rural women who gave birth in the previous two years in Tsegedie district, Ethiopia. Methods: a community-based cross-sectional study was performed from 20 November 2012 to 30 June 2013 on 485 mothers. The participants were selected systematically using a multistage sampling technique. A pre-tested structured questionnaire, administered by an interviewer, was used to collect quantitative data. Focus group discussions and in-depth interviews were used to triangulate the evidence from the quantitative study. Bivariate and multivariate data analysis was performed using Statistical Package for the Social Sciences Version 17.0. Finding: this study found that 31.5% of the respondents used institutional childbirth services. The main reason for home birth was close attention from family (47%). Women's educational status [adjusted odds ratio (AOR) 5.3, 95% confidence interval (CI) 1.59–17.87], time taken to reach the nearest health facility (AOR 3.3, 95% CI 1.15–9.52), ultimate decision maker regarding the place of childbirth (AOR 3.7, 95% CI 1.08–12.63) and receipt of maternal and child health care information (AOR 9.4, 95% CI 2.4–36.38) were significantly associated with the use of institutional childbirth services. Conclusion: the proportion of births attended in health facilities was low in the study district. Women's educational status, distance to the nearest health facility, women's decision-making power and receipt of maternal and child health care information were important predictors of institutional childbirth service utilisation. This implies that women still lack physical and effective access to maternal health care services. Thus, improving community awareness about skilled providers and institutional childbirth, targeting women who prefer to give birth at home, is encouraged. Safe motherhood education using communication networks in rural and urban communities is crucial. Furthermore, it is recommended that essential obstetric care facilities (health centres) should be established within a reasonable distance of homes, women should be empowered and community midwives should be deployed. & 2014 Elsevier Ltd. All rights reserved.
Keywords: Institutional childbirth Determinant factors Cross-sectional study Tsegedie district
Background Despite receiving greater attention, maternal mortality remains a challenge in many developing countries, and progress towards Millennium Development Goal 5, to reduce maternal mortality by three-quarters between 1990 and 2015, has been particularly slow
n
Corresponding author at: 21, Arba Minch University, Arba Minch, Ethiopia. E-mail address: [email protected] (D. Hailu).
(United Nations, 2011). Each year, approximately 287,000 women die from complications related to pregnancy and childbirth, with 99% of these deaths occurring in developing countries. Maternal mortality has been shown to have large discrepancies between developed and developing countries; the maternal mortality rate (MMR) is 15 times higher in developing regions compared with developed regions (240 versus 16 per 100,000 live births) (World Health Organization, 2005). Sub-Saharan African countries have the highest MMR at 500 maternal deaths per 100,000 live births (Maternal Mortality Estimation Inter-Agency Group, 2010), and the MMR in Ethiopia
http://dx.doi.org/10.1016/j.midw.2014.03.009 0266-6138/& 2014 Elsevier Ltd. All rights reserved.
Please cite this article as: Hailu, D., Berhe, H., Determinants of institutional childbirth service utilisation among women of childbearing age in urban and rural areas of Tsegedie district, Ethiopia. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.03.009i
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D. Hailu, H. Berhe / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
is among the highest in the world (Federal Ministry of Health, 2010). According to the 2011 Ethiopian Demography and Health Survey (EDHS), the MMR was 676 per 100,000 live births, which is slightly higher than reported in the 2005 EDHS (673 per 100,000 live births) (Central Statistical Agency, 2011). Approximately 80% of maternal deaths worldwide have direct causes such as haemorrhage, infection, obstructed labour, unsafe abortion and high blood pressure (World Health Organization, 2005). Skilled birth attendance during labour, childbirth and the early postpartum period has a profound effect on maternal health. Evidence suggests that skilled birth attendants who are capable of preventing, detecting and managing major obstetric complications, together with equipment, drugs and other essential supplies, can make the difference between life and death for women and their newborn babies. This has been identified as a key strategy for improving maternal health and reducing maternal mortality (World Health Organization, 2005, 2010). However, in many developing countries, very few women give birth in health care facilities, assisted by skilled personnel, even among women with access to these services (UNDP, 2011). In subSaharan Africa, only 23% of births are attended by skilled health personnel, in comparison with an average of 65% globally (UNFPA, 2011). In Ethiopia, the proportion of births attended by skilled personnel is very much lower than in sub-Saharan African countries. According to the 2011 EDHS, only 10% of births were attended in health facilities in Ethiopia, and this has only increased by 4% in the last six years (Central Statistical Agency, 2011). Addressing maternal health is a complex issue, as challenges exist related to both supply and demand. This is particularly true in Africa, where a large proportion of mothers live in rural areas and cultural barriers continue to pose a challenge to health care delivery. Underutilisation of institutional childbirth services and increasing maternal mortality can be largely attributed to three delays in the childbearing process: delay in the decision to seek care; delay in reaching care; and delay in receiving care. The first delay (seeking care) occurs on the demand (women's) side, whereas the other two delays are more supply related. On the supply side, the availability, quality and cost of the health care services clearly influence maternal mortality outcomes. On the demand side, the cost of services, quality (both actual and perceived) of care, trust in health care staff and cultural barriers deter many women from seeking care, even when health services are available (UNDP, 2011). The Ethiopian Federal Ministry of Health, reproductive health departments and health bureaus of respective regions have made a concerted effort to increase skilled birth attendance and achieve Millennium Development Goal 5. Multipronged approaches have been applied at local and national levels to improve access to skilled birth attendance throughout the country, including activities such as training health care providers, increasing access to health facilities and allocating health resources more equitably among rural and urban areas (Federal Ministry of Health, 2010; Central Statistical Agency, 2011). However, in Ethiopia, use of institutional childbirth services is very low. Studies investigating determinants of the use of institutional childbirth service are scarce, and have generally focused on urban settings. As such, this study aimed to determine the use of institutional childbirth services and explore the determinants among urban and rural women who gave birth in the previous two years in Tsegedie district, Tigray region, Ethiopia.
Materials and methods Study setting and period This study was conducted from October 2012 to June 2013 in Tsegedie district. Tsegedie district is located in the west of Tigray
region. The administrative town for Tsegedie district, Ketema Nigus, is located 876 km north west of Addis Ababa, the capital of Ethiopia. As projected from the 2007 Ethiopian census, Tsegedie district had a total population of 103,852. Women of childbearing age represent approximately 23,583 (22.7%) of the total population. Administratively, Tsegedie district is sub-divided into 26 rural and two urban kebeles (smallest administrative unit in Ethiopia). Most (91%) of the population live in rural areas and are economically dependent on farming. Tsegedie district is located 350 m above sea level, and most areas are characterised by desert conditions with an annual temperature of 35–38 1C (Central Statistical Agency, 2007). Concerning the health infrastructure, Tsegedie district has 22 health posts, seven health centres and one general hospital, all of which provide maternal and child health care services. Moreover, it has six private clinics and nine drug venders (Tsegedie District Health Office, 2011). Study design and population A community-based cross-sectional study using both quantitative and qualitative methods was undertaken among women of childbearing age, selected at random, who gave birth in the past two years. Women who were mentally and/or physically incapable, women who had not given birth at least once in the past two years, and/or women who had been residing in the study area for less than six months were excluded from the study. Sample size determination and sampling procedure A sample size of 485 was determined with the following assumptions: institutional childbirth service utilisation, 18.4%; margin of error, 5%; confidence interval, 95%; design effect, 2; and expected non-response rate, 5%. In total, four focus group discussions were held among women who had given birth at least once in the past two years and their husbands. On average, there were eight discussants per focus group (36 discussants in total). In-depth interviews were held with six health extension workers. Multistage sampling was used to select the study subjects. First, all the kebeles in Tsegedie district were clustered into urban and rural. One urban and eight rural kebeles were selected at random from two urban and 26 rural kebeles. The calculated sample size was proportionally allocated to urban (n ¼55) and rural (n ¼430). Frames of households were prepared for each kebele in collaboration with the kebele administrators. Households with a woman who had given birth in the past two years were selected using systematic random sampling from the existing sampling frame of households. To select the study participants, different sampling intervals were used for each kebele. Whenever more than one eligible respondent was found in the same selected household, one respondent was chosen using a lottery method. For households with no eligible women, the next household was selected. Subsequent households were included following the pre-determined order. After thorough analysis of the quantitative data and identification of areas that required further information, four focus group discussions were arranged among men and women (n¼ 36 discussants in total). Quantitative data were triangulated with qualitative evidence. Participants were selected through consultation with women's associations, and kebele and district administrators. Focus groups were matched for sex, marital and educational status. Six health extension workers assigned by the Ethiopian Ministry of Health as community-based primary health care providers were selected for in-depth interviews as they were closer to the community and had better awareness of women's knowledge and attitudes regarding obstetric danger signs. The sample sizes of
Please cite this article as: Hailu, D., Berhe, H., Determinants of institutional childbirth service utilisation among women of childbearing age in urban and rural areas of Tsegedie district, Ethiopia. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.03.009i
D. Hailu, H. Berhe / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
the focus groups and number of in-depth interviews were determined based on information saturation (no further focus group discussants were identified once the generation of new ideas ceased). Data collection methods A structured, interviewer-administered questionnaire, prepared in English and subsequently translated into Tigrigna (local language), was used to obtain information about sociodemographics, obstetric history, women's knowledge about obstetric danger signs and attitudes towards institutional childbirth services. Before data collection, the questionnaire was pre-tested on 5% of the sample (25 women) in one of the sub-districts (Maywedisalihay); this area was not included in the study. On the basis of the pre-test results, the time needed for interviews and the number of data collectors required were estimated. Nine female interviewers who had completed 10th grade, who were fluent in Tigrigna and who were familiar with local customs collected the data. Two health care workers with similar work experience were assigned to supervise data collection. To assess knowledge about danger signs and attitudes towards the use of institutional childbirth services, focus group discussions and in-depth interviews were conducted. Women were asked knowledge and attitude questions such as ‘How do you explain obstetric danger signs?’ and ‘Where do you think a woman should give birth?’. Focus groups for husbands and in-depth interviews were moderated by the principal investigator. As women were more likely to express their opinions openly in front of other females, the focus group discussions for women were moderated by a female registered nurse. Data were tape recorded by one female research assistant after thorough communication with the focus group discussants and in-depth interview participants. The data collectors and supervisors undertook two days of training before data collection regarding the aim of the study, data collection tool and procedures. Data processing and analysis Data were coded, entered and cleaned using EPI-INFO Version 3.5.1 (Centers for Disease Control and Prevention; Atlanta, GA, USA), and further cleaned and analysed using Statistical Package for the Social Sciences (SPSS) Version 16.0 (SPSS Inc., Chicago, IL, USA). Univariate and bivariate analyses were performed for quantitative data. Finally, multivariate analysis was undertaken using SPSS Version 16 for selected variables to determine their independent effects. Statistical tests such as χ2, odds ratio and 95% confidence intervals were employed as appropriate. Qualitative data were transcribed word by word by listening numerous times, translated into English, coded and categorised into key thematic areas using open code software by the principal investigator. The findings were finally presented in the form of narratives. Women's knowledge about obstetric danger signs was measured by the total number of correct spontaneous answers to 10 items about knowledge of pregnancy danger signs and 10 items about knowledge of labour and childbirth danger signs (minimum score of 0, maximum score of 10). Spontaneous knowledge refers to a respondent naming a sign without being asked about that sign by name. Only true obstetric complications reported spontaneously by individual respondents were included. Accordingly, two categories were developed for each pregnancy and childbirth danger sign:
Had knowledge about pregnancy danger signs: women who spontaneously mentioned at least two danger signs of pregnancy.
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Had no knowledge about pregnancy danger signs: women who did not spontaneously mention two danger signs of pregnancy.
Had knowledge about the danger signs of labour and child
birth: women who spontaneously mentioned at least two danger signs of labour and childbirth. Had no knowledge about the danger signs of labour and childbirth: women who did not spontaneously mention two danger signs of labour and childbirth.
Women were considered to have a favourable attitude towards the use of institutional childbirth services if they scored above the mean on 11 questions. Otherwise, they were considered to have an unfavourable attitude towards the use of institutional childbirth services. Ethical approval Ethical approval was granted by the review board of the College of Health Sciences, Addis Ababa University. Informed consent was obtained from each respondent. All responses were kept confidential and anonymous.
Findings Sociodemographic profile of respondents In total, 485 women who had given birth at least once in the two years preceding the survey were interviewed, and the response rate was 100%. One hundred and sixty-two (33.4%) respondents were aged 35–39 years, and the mean age was 32.8 [standard deviation (SD) 5.1] years. The majority of the respondents (n¼ 430, 88.7%) were rural dwellers, 362 (74.6%) were married, 424 (87.4%) were of Tigray ethnicity, 462 (95.3%) were orthodox, and 202 (41.6%) were housewives. Regarding their educational status, 264 (54.4) of the study subjects and 221 (57.6%) husbands were illiterate. Two hundred and eighty (72.9%) husbands were farmers, and 68 (17.7%) were merchants (Table 1). Obstetric characteristics of respondents The majority (n ¼331, 68.2%) of respondents got married between 15 and 19 years of age. Only 98 (20.2%) women conceived before 20 years of age, and the mean age at first pregnancy was 21.5 (SD 2.76) years. Regarding use of maternal health care services, 264 (54.4%) of the participants had attended at least one antenatal visit during their last pregnancy. Among those who attended antenatal visits, only 43 (16.3%) participants attended on four or more occasions. Among the women who received health education during their last antenatal visit, 201 (74.2%) were informed about the danger signs related to pregnancy and childbirth, and 220 (81.2%) were informed about the place of childbirth (Table 2). Use of institutional childbirth services The majority (n¼ 479, 98.8%) of all births were live births. Only 153 (31.5%) women gave birth at health facilities: 99 (64.7%) delivered at health centres and 54 (35.3%) delivered at hospitals. Among the women who gave birth at home, only 17 (5.1%) delivered under the supervision of a skilled birth attendant. During their last home birth, 56 (16.9%) women had encountered a health problem, such as vaginal bleeding (n ¼39, 11.4%) or retained placenta (n ¼16, 4.8%). The main reasons given for home birth were to get close attention from family (n¼ 156, 47%), disliking institutional childbirth
Please cite this article as: Hailu, D., Berhe, H., Determinants of institutional childbirth service utilisation among women of childbearing age in urban and rural areas of Tsegedie district, Ethiopia. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.03.009i
D. Hailu, H. Berhe / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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Table 1 Sociodemographic characteristics of respondents in Tsegedie district, Tigray region, North-west Ethiopia, June 2013. Sociodemographic characteristics
n
%
Place of residence Urban Rural
55 430
11.3 88.7
Age at interview (years) 15–19 20–24 25–29 30–34 35–39 Z40
8 15 103 140 162 57
1.6 3.1 21.2 28.9 33.4 11.8
Marital status Single Married Divorced Widowed Separated
24 362 50 27 22
4.9 74.6 10.3 5.6 4.5
Religion Orthodox Muslim Other
462 14 9
95.3 2.9 1.9
Ethnicity Tigray Amara Other
424 44 17
87.4 9.1 3.5
Women's educational status Unable to read and write Able to read and write Primary education Secondary education Z12 years of education
264 93 58 59 11
54.4 19.2 12 12.2 2.3
Occupation Housewife Farmer Employed Merchant Daily labourer Other
202 75 22 52 124 10
41.6 15.5 4.5 10.7 25.6 2.1
Husbands' educational status Unable to read and write Able to read and write Primary education Secondary education Z12 years of education
221 96 42 16 9
57.6 25 10.9 4.2 2.3
(n¼154, 46.4%), feeling comfortable when delivering at home (n¼126, 38%) and urgent labour (n¼101, 30.4%) (Fig. 1). Regarding the decision-making power of women, only 133 (27.4%) women were the ultimate decision makers regarding the place of childbirth during their last pregnancy.
Knowledge of women about danger signs of pregnancy and childbirth The most common danger signs mentioned spontaneously were vaginal bleeding, leg swelling and absence of fetal movement: 238 (49.1%), 202 (41.6%) and 159 (32.8%) respectively. Two hundred and eighty-five (58.8%) respondents mentioned at least two danger signs of pregnancy, and 170 (35.1%) respondents did not know any danger signs of pregnancy (Table 3). Almost all focus group discussants and in-depth interview participants reported that although significant progress has been made in the last few years, most women were not educated and were not familiar with most of the danger signs. Vaginal bleeding and decreased fetal movement were the most common obstetric complications mentioned as the danger signs of pregnancy.
Table 2 Obstetric characteristics of respondents in Tsegedie district, Tigray region, North-west Ethiopia, June 2013. Obstetric history
n
%
Age at first marriage (years) o 15 15–19 20–24 25–29
6 331 145 3
1.2 68.2 29.9 0.6
Age at first pregnancy (years) o 20 20–29 Z 30
98 378 9
20.2 77.9 1.9
Gravidity 1 2–4 Z5
54 298 133
11.1 61.4 27.4
Parity 1 2–4 Z5
55 302 128
11.3 62.3 26.4
Ever had stillbirth Yes No
26 459
5.4 94.6
ANC visit during previous pregnancies Yes No
125 321
28 72
ANC visit during last pregnancy Yes No
264 221
54.4 45.6
Number of ANC visits during last pregnancy (n¼ 264) 1 2–3 Z4
34 187 43
12.9 70.8 16.3
Received information about pregnancy and labour danger signs Yes No
201 70
74.2 25.8
Received information about place of childbirth Yes No
220 51
81.2 18.8
Received maternal and child health care information Yes No
228 257
47 53
ANC, antenatal care.
Similarly, the most commonly mentioned danger signs of labour and childbirth were excessive vaginal bleeding, malpresentation and prolonged labour: 256 (52.8%), 171 (35.5%) and 151 (31.1%), respectively. Two hundred and ninety-nine (61.6%) respondents mentioned at least two danger signs of labour and childbirth, and 154 (31.8%) respondents did not know any danger signs of labour and childbirth (Table 4). Retained placenta, vaginal bleeding and labour lasting more than one day were the most common obstetric complications mentioned as the danger signs of labour and childbirth. Attitude of respondents towards institutional childbirth services Most participants agreed with the notions that all pregnant women are susceptible to childbirth complications and childbirth complications can be dangerous for women's health [n¼ 453 (93.4%) and n ¼439 (90.5), respectively]. However, 197 (40.6%) respondents disagreed that a woman should plan ahead of time where she should give birth, and 275 (56.7%) felt that being attended by a male health professional during childbirth is very shameful. Overall, 324 (66.8%) respondents had a favourable
Please cite this article as: Hailu, D., Berhe, H., Determinants of institutional childbirth service utilisation among women of childbearing age in urban and rural areas of Tsegedie district, Ethiopia. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.03.009i
D. Hailu, H. Berhe / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
Reasons for home delivery
Dislike of being assisted by male provider
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3 5.7 9.3 11.1 11.7 13.9 14.2 16.3
Traditional birth attendants were present Lack of money for transport Previous home delivery was normal Bad experience from previous facility delivery Health facility was far from home Bad approach of health workers Other family members influence Not being sick Husband influence Labor was urgent to reach health facility Feel comfortable when giving birth at home Dislike institutional delivery service To get close attention from family
21.1 23.5 30.4 38 46.4 47 0
20
40
60
80
100
Percentage of respondents Fig. 1. Reasons given for home birth among women in Tsegedie district, Tigray region, North-west Ethiopia, June 2013.
Table 3 Knowledge of women about danger signs of pregnancy in Tsegedie district, Tigray region, North-west Ethiopia, May 2013. Variables Severe vaginal bleeding Swelling of leg/face Reduced/absence of fetal movement Severe headache Increased blood pressure Persistent nausea and vomiting Severe abdominal cramps High fever Leakage of amniotic fluid without labour Blurring of vision
n
%
238 202 159 140 113 106 92 87 74 26
49.1 41.6 32.8 28.9 23.3 21.9 19 17.9 15.3 5.4
Table 4 Knowledge of women about danger signs of labour and childbirth in Tsegedie district, Tigray region, North-west Ethiopia, May 2013. Variables Vaginal bleeding Malpresentation/position Prolonged labour ( 412 hours) Retained placenta ( 4one hour) Severe continuous abdominal pain High fever Increased blood pressure Convulsion/loss of consciousness Cessation of labour pain Severe headache
n
%
256 171 151 146 130 129 121 116 73 47
52.8 35.3 31.1 30.1 26.8 26.6 24.9 23.9 15.1 9.7
attitude towards institutional childbirth services (Table 5). The majority of focus group discussants and in-depth interview participants indicated that a significant number of women did not have a positive attitude towards the use of institutional childbirth services because of multifaceted sociocultural factors. Maternal health service availability and accessibility factors Almost all (n¼ 482, 99.4%) participants reported that health facilities were available in their vicinity, and 455 (93.8%) knew that childbirth services were provided in those facilities. For women who reported that health facilities were available in their vicinity, 246 (50.7%) said that the nearest health facility was at least a onehour walk from their home. Three hundred and seventy-one
(76.5%) participants reported that transport was available from their home to the nearest health facility. Approximately threequarters (n¼ 125, 25.8%) of the participants reported that they had ever received childbirth services at their nearest health facility, and only 11 (2.3%) participants had been charged for these services. Regarding health care information, 228 (47%) participants had received maternal and child health care information, and health care workers were the main source of this information (n ¼ 216, 44.5%). Factors associated with use of institutional childbirth services On multivariate analysis, women's educational status, time taken to reach the nearest health facility, ultimate decision maker about place of childbirth and receipt of maternal and child health care information were found to be independent predictors of the outcome variable (Table 6). Level of education was found to be strongly associated with place of childbirth. Women with formal education were approximately five times [adjusted odds ratio (AOR) 5.3, 95% confidence interval (CI) 1.59–17.87] more likely to deliver in a health facility compared with women without formal education. Another strong predictor of place of childbirth was the time taken to reach the nearest health facility. Women who lived less than one hour from the nearest health facility were approximately three times (AOR 3.3, 95% CI 1.15–9.52) more likely to deliver in a health facility compared with women who lived one hour or more from the nearest health facility. Similarly, women who were the ultimate decision makers about the place of childbirth were approximately four times (AOR 3.7, 95% CI 1.08–12.63) more likely to give birth in a health facility compared with women who were not the ultimate decision makers about the place of childbirth. Health education was also significantly associated with place of childbirth. Women who received maternal and child health care information were approximately nine times more likely to give birth in a health facility compared with women who did not receive maternal and child health care information (AOR 9.4, 95% CI 2.4–36.38).
Discussion This community-based cross-sectional study identified factors that influenced the use of institutional childbirth services among
Please cite this article as: Hailu, D., Berhe, H., Determinants of institutional childbirth service utilisation among women of childbearing age in urban and rural areas of Tsegedie district, Ethiopia. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.03.009i
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D. Hailu, H. Berhe / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
Table 5 Attitudes of mothers towards institutional childbirth services in Tsegedie district, Tigray region, North-west Ethiopia, May 2013. Variables
Agree
All pregnant women are susceptible to childbirth complications Childbirth complications can be dangerous for the health of the woman Childbirth complications can be dangerous for the health of the newborn Most complications of labour are preventable with the help of a trained birth attendant A woman should plan ahead of time where she should give birth A woman should plan ahead of time how to get to the place where she should give birth Every pregnant woman needs a skilled attendant at childbirth Being attended by a male health professional during childbirth is very shameful It is very shameful to deliver on a delivery bed in a labour ward Women do not go to health facilities for childbirth because it is too expensive Women do not go to health facilities for childbirth because the health workers do not treat them with respect
women who gave birth in the past two years in urban and rural areas of Tsegedie district, Ethiopia. This study found that 31.5% of women in Tsegedie district used institutional childbirth services. This finding is higher than the results reported in the 2011 EDHS report: national (10%) and Tigray region (11.6%) (Central Statistical Agency, 2011). This may be due to advances in accessing and using maternal health care services in the study area since 2011. However, the rate found in this study is lower compared with results from India (60%) and Vietnam (57%) (Navaneetham and Dharmalingam, 2000; Ngo and Hill, 2011), possibly because mothers in these countries had better educational status and better access to maternal health care information. The rate found in the present study was also considerably lower compared with results from urban settings in the Democratic Republic of Congo (93.8%) (Abel Ntambue et al., 2012). This difference could be due to the fact that the study by Abel Ntambue et al. only included urban kebeles where the proportion of women with formal education was higher, health services were accessible in terms of minimal distance and transport, women had better decision-making autonomy, and women had better access to information than women in rural kebeles. In addition, this difference may be due to the difference in implementation of relevant health intervention programmes. Women's educational status was among the independent predictors of the use of institutional childbirth services. Women with formal education were five times more likely to use institutional childbirth services than women without formal education. This is consistent with study findings from Ethiopia (Abera and Belachew, 2006; Amano et al., 2012; Teferra et al., 2012), Uganda, Nigeria, Myanmar and Nepal (Wagle and Sabroe, 2004; Tann et al., 2007; Dhakal et al., 2011; Sein, 2011; Rai et al., 2012). Most focus group discussants and in-depth interview participants suggested similar conclusions. Supporting this notion, one focus group discussant stated that ‘almost all women in the district and particularly those mothers living in the rural settings are culturally bound against modern maternal health care services simply because they are not educated’. Possible explanations are that educated women may have better access to health service information, improved perceptions of the causes of disease and treatment, and the ability to use such information optimally. In addition, educated women have greater autonomy to make decisions and greater ability to use quality health care services. This study found that the use of institutional childbirth services was significantly associated with distance to the nearest health facility. Women who lived less than 1 hour from the nearest health facility were three times more likely to deliver in a health facility compared with women who lived 1 hour or more from the nearest health facility. Most focus group discussants and in-depth
Indifferent
Disagree
n
%
n
%
n
%
453 439 377 300 287 285 317 275 263 243 268
93.4 90.5 77.7 61.9 59.2 58.8 65.4 56.7 54.2 50.1 55.3
– – 2 4 6 3 7 3 7 15 4
– – 0.4 0.8 1.2 0.6 1.4 0.6 1.4 3.1 0.8
32 46 106 181 192 197 161 207 215 227 213
6.6 9.5 21.9 37.3 39.6 40.6 33.2 42.7 44.3 46.8 43.9
interview participants suggested similar conclusions. This study is in agreement with other cross-sectional studies undertaken in Ethiopia, Nepal and Kenya, where the probability of giving birth in a health facility was higher for women who lived less than 1 hour from the nearest health facility (Wagle and Sabroe, 2004; van Eijk et al., 2006; Dhakal et al., 2011; Amano et al., 2012; Teferra et al., 2012). This may be due to the higher transportation costs and lost production time associated with greater distance from a health facility, and potentially lower exposure to maternal and child health care information. Women's decision-making power was also found to be an independent predictor of the use of institutional childbirth services. In line with evidence from South-East Ethiopia, Lao People's Democratic Republic, Nepal and Kenya (Abera and Belachew, 2006; Fotso et al., 2009; Woldemicael and Tenkorang, 2010; Dhakal et al., 2011; Sychareun et al., 2012), women who were the ultimate decision maker about the place of childbirth were more likely to give birth in a health facility compared with women who were not the ultimate decision maker about the place of childbirth. Most of the focus group discussants and in-depth interview participants stated that the ultimate decision about the place of childbirth was generally made by the woman's husband, and this was felt to be one of the major factors with a negative effect on the use of institutional childbirth services. In contrast, a study undertaken in Metekel zone, Ethiopia found that women's decision-making autonomy had a negative effect on the use of institutional childbirth services. It revealed that women who were the ultimate decision maker about their place of childbirth were approximately six times less likely to use institutional childbirth services than women who were not the ultimate decision maker about their place of childbirth (Gurmesa and Abebe, 2008). This may be because, despite the social position of women, the strong cultural norm in the area was home birth; this could be due to low awareness about the importance of institutional childbirth (Gurmesa and Abebe, 2008). The present study also found that the receipt of health education was significantly associated with the use of institutional childbirth services. Women who received maternal and child health care information during their last childbirth were approximately nine times more likely to use institutional childbirth services compared with women who did not receive this information during their last childbirth. This is in agreement with a quasiexperimental study undertaken in Eretria, where women who received maternal and child health care information were more likely to use institutional childbirth services (p o0.05) (Gurmesa and Abebe, 2008). This can be explained by the fact that community participation and developing the capacity of women, their
Please cite this article as: Hailu, D., Berhe, H., Determinants of institutional childbirth service utilisation among women of childbearing age in urban and rural areas of Tsegedie district, Ethiopia. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.03.009i
D. Hailu, H. Berhe / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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Table 6 Factors associated with institutional childbirth service utilisation among mothers in Tsegedie district, Tigray region, North-west Ethiopia, June 2013. Variables
Institutional childbirth
Crude
Adjusted
Yes
No
OR (95% CI)
OR (95% CI)
Age at interview (years) 15–24 25–29 30–34 Z 35
8 51 48 46
15 52 92 173
2 (0.8–5.02) 3.69 (2.23–6.11) 1.96 (1.22–3.16) 1.00
1.57 (0.01–23.4) 3.35 (0.75–15.0) 0.4 (0.12–1.57) 1.00
Marital status Married Other†
112 41
250 82
0.896 (0.58–1.39) 1.00
1.2 (0.21–7.16) 1.00
Educational status Formal education No formal education
84 69
44 288
7.97 (5.08–12.49) 1.00
5.3 (1.59–17.87)nn 1.00
Household monthly income (Ethiopian birr (20 Ethiopian birr = 1 US dollar)) 150–408 409–693 694–987 Z 988
18 36 61 38
74 163 76 19
1.00 0.91 (0.48 1.7) 3.3 (1.78–6.1) 8.2 (3.87–17.5)
1.00 0.23 (0.03–1.47) 0.76 (0.11–5.09) 1.36 (0.11–17.41)
Own radio/television Yes No
23 130
184 148
7.02 (4.3–11.5) 1.00
0.8 (0.69–11.32) 1.00
Gravidity 1 2–4 Z5
28 100 25
26 198 108
4.65 (2.3–9.26) 2.18 (1.3–3.58) 1.00
3.3 (0.06–181) 0.4 (0.02–9.47) 1.00
ANC visits during last childbirth Yes No
124 29
140 192
5.86 (3.7–9.28) 1.00
0.01 (0.00–3.7) 1.00
Number of ANC visits 1 2–3 Z4
9 93 29
25 101 14
1.00 2.56 (1.14–5.76) 5.8 (2.1–15.5)
1.00 0.7 (0.05–9.5) 3.2 (0.14–74.2)
Previous institutional childbirth Yes No
19 134
46 286
0.88 (0.5–1.56) 1.00
1.2 (0.27–5.82) 1.00
Attitude towards institutional childbirth Favourable Non-favourable
135 18
189 143
5.7 (3.3–9.7) 1.00
3.3 (0.67–16.07) 1.00
Received maternal and child health care information Yes No
135 18
93 239
19.27 (11.15–33.3) 1.00
9.4 (2.4–36.38)nn 1.00
Knowledge about danger signs of pregnancy Knowledgeable Not knowledgeable
139 14
146 186
12.6 (7–22.8) 1.00
1.6 (0.21–13.12) 1.00
Knowledge about danger signs of childbirth Knowledgeable Not knowledgeable
141 12
158 174
13 (6.9–24.2) 1.00
5.1 (0.59–44.20) 1.00
Time taken to reach nearest health facility (hours) o1 Z1
114 39
125 207
4.8 (3.2–7.4) 1.00
3.3 (1.15–9.52)n 1.00
Decision maker about place of childbirth Self Other‡
76 77
57 275
4.76 (3.1–7.2) 1.00
3.7 (1.08–12.63)n 1.00
ANC, antenatal care; OR, odds ratio; CI, confidence interval. †
Single, divorced, widowed or separated. Family, relatives. Significant at po 0.05. nn Significant at p o0.01. ‡
n
families and communities to better address their own health problems is known to increase safe motherhood behaviours, which are believed to reduce maternal mortality and birth complications.
Inconsistent with the findings of a study from Ethiopia (Amano et al., 2012), the present study also found that the main reason given by women for home birth was to get close attention from their families (47%).
Please cite this article as: Hailu, D., Berhe, H., Determinants of institutional childbirth service utilisation among women of childbearing age in urban and rural areas of Tsegedie district, Ethiopia. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.03.009i
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D. Hailu, H. Berhe / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
Limitations of the study When interpreting the findings of this study, some limitations should be considered. The cross-sectional nature of the data made it impossible to establish causal relationships. In addition, the data used in this study were self-reported, and were not validated using objective sources such as health facility cards. However, it is fair to assume that bias is less likely in childbirth-related events compared with other sensitive issues, and respondents were informed about the importance of giving accurate responses and assured about the confidentiality of their responses. Recall bias may also be a concern as women were asked for events that happened within the past two years. Finally, this study was based on a survey of women that was conducted up to two years after the birth of a child. Women who died after giving birth were not included in the study.
Conclusion Use of institutional childbirth services was very low despite substantial improvements compared with the national figure. Close attention from family, disliking institutional childbirth, and feeling comfortable when giving birth at home were the main reasons given for home birth. Almost all women who gave birth at home were attended by family members or relatives. Women's educational status, time taken to reach the nearest health facility, receipt of maternal and child health care information and ultimate decision maker about the place of childbirth were found to be independent predictors of the use of institutional childbirth services. This implies that women still lack physical and effective access to health care services. Recommendation In general, this study showed that a significant proportion of women were uneducated, unempowered and lacked appropriate health care information and access to health care facilities. Therefore, the Ethiopian Federal Ministry of Health and other concerned stakeholders, particularly those working in the areas of reproductive health, should strengthen existing strategies involving the provision of information, education and communication, targeting women, family and the general community to increase their awareness about institutional childbirth and its determinants. Furthermore, as education is an important factor for empowering women, policy makers should focus on encouraging women to pursue formal education. This study also recommends that health care facilities should allow some cultural birthing procedures at health facilities, such as allowing family members to be present when women give birth, and encouraging traditional birthing practices when they do not conflict with scientific medical practice (e.g. massaging their abdomen, preparing porridge immediately after childbirth at maternity units) to make women more likely to give birth at a health care facility. Moreover, health care providers should be more friendly and welcoming to women and their family members in terms of professional competency, being respectful and respecting the privacy of women during antenatal, childbirth and postnatal periods. Establishing health care facilities within a reasonable distance from homes, continuous provision of ambulance services and deployment of trained community-based midwives are also recommended. In addition, community-based support groups need to develop solidarity and use their full potential to perform behavioural change communication sessions continuously with women, husbands and the general community to ensure that they have good knowledge and attitudes towards institutional childbirth. Finally,
further research with robust analytical studies covering a wide range of samples is recommended to substantiate this finding for more generalisability.
Competing interests None declared.
Acknowledgements The authors wish to thank Addis Ababa University for sponsoring this study, Tigray Regional Health Bureau and Tsegedie District Health Office for facilitating the data collection process, and the study subjects for their participation. References Abel Ntambue, M.L., Françoise Malonga, K., Dramaix-Wilmet, M., Donnen, P., 2012. Determinants of maternal health services utilization in urban settings of the Democratic Republic of Congo. BMC Pregnancy Childbirth 12, 1–13. Abera, M., Belachew, T., 2006. Predictors of safe delivery service utilization in Arsi zone, South-East Ethiopia. Ethiop. J. Health Sci. 21, 101–113. Amano, A., Gebeyehu, A., Birhanu, Z., 2012. Institutional delivery service utilization in Munisa Woreda, South East Ethiopia: a community based cross-sectional study. BMC Pregnancy Childbirth 12, 105. Central Statistical Agency, 2007. Population and Housing Census of Ethiopia: Statistical Report for Tigray Region. Central Statistical Agency, Addis Ababa. Central Statistical Agency, 2011. Ethiopia Demographic and Health Survey. Central Statistical Agency, Addis Ababa. Dhakal, S., van Teijlingen, E., Raja, E.A., Dhakal, K.B., 2011. Skilled care at birth among rural women in Nepal: practice and challenges. J. Health Popul. Nutr. 29, 371–378. Federal Ministry of Health, 2010. Health Sector Development Programme IV 2010/ 11–2014/15. Federal Ministry of Health, Ethiopia. Fotso, J., Ezeh, A., Essendi, H., 2009. Maternal health in resource-poor urban settings: how does women's autonomy influence the utilization of obstetric care services? Reprod. Health 6, 1–8. Gurmesa, T., Abebe, G.M., 2008. Safe delivery service utilization in Metekel zone, North-West Ethiopia. Ethiop. J. Health Sci. 17, 213–222. Maternal Mortality Estimation Inter-Agency Group, 2010. WHO, UNICEF, UNFPA and World Bank Estimates. World Health Organization, Geneva (Available at: 〈http://www.unfpa.org/webdav/site/global/shared/documents/publications/ 2012/pdf〉) (last accessed 23 March 2013). Navaneetham, K., Dharmalingam, A., 2000. Utilization of Maternal Health Care Services. Centre for Development Studies, India. Ngo, A., Hill, P., 2011. The use of reproductive healthcare at commune health stations in a changing health system in Vietnam. BMC Health Serv. Res. 11, 1–9. Rai, R., Singh, P., Singh, L., 2012. Utilization of maternal health care services among married adolescent women: insights from the Nigeria Demographic and Health Survey, 2008. Womens Health Issues 22, e407–e414. Sein, K., 2011. Maternal health care utilization among ever married youths in Kyimyindaing Township, Myanmar. Matern. Child Health 16, 1021–1030. Sychareun, V., Hansana, V., Somphet, V., Xayavong, S., Phengsavanh, A., Popenoe, R., 2012. Reasons rural Laotians choose home deliveries over delivery at health facilities: a qualitative study. BMC Pregnancy Childbirth 12, 1–10. Tann, C.J., Kizza, M., Morison, L., et al., 2007. Use of antenatal services and delivery care in Entebbe, Uganda: a community survey. BMC Pregnancy Childbirth 7, 1–11. Teferra, A., Alemu, F., Woldeyohannes, S., 2012. Institutional delivery service utilization and associated factors among mothers who gave birth in the last 12 months in Sekela District, North West of Ethiopia. BMC Pregnancy Childbirth 12, 1–11. Tsegedie District Health Office, 2011. Report of the District Health Department. Tsegedie Health office, Tsegedie. UNFPA, 2011. Maternal Health Thematic Fund: Annual Report. Available at: 〈http:// www.unfpa.org/webdav/site/global/shared/documents/publications/2012/ MHTF%02011%20annual%20report%2008_2_2012.pdf〉 (last accessed 23 March 2013). United Nations, 2011. The Millennium Development Goals Report. United Nations, USA. Available at: 〈http://mdgs.un.org/unsd/mdg/Resources/Static/Products/Pro gress2011/1131339%20(E)%20MDG%20Report%202011_ Book 20LR.pdf〉 (last accessed 23 March 2013). UNDP, 2011. Assessing Progress in Africa towards the Millennium Development Goals. UNDP, USA. Available at: 〈http://web.undp.org/africa/documents/MDG/ full-report.pdf〉 (last accessed 23 March 2013). van Eijk, A.M., Bles, H.M., Odhiambo, F., et al., 2006. Use of antenatal services and delivery care among women in rural western Kenya: a community based survey. Reprod. Health 3, 1–9.
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Determinants of institutional childbirth service utilisation among women of childbearing age in urban and rural areas of Tsegedie district, Ethiopia Desta Hailu, BSc, MSc (Lecturer)a,n, Hailemariam Berhe, BSc, MSc (Lecturer)b a b
Department of Nursing and Midwifery, Arba Minch University, Arba Minch, Ethiopia Department of Nursing, Mekelle University, Mekelle, Ethiopia
art ic l e i nf o
a b s t r a c t
Article history: Received 24 August 2013 Received in revised form 13 January 2014 Accepted 16 March 2014
Background: despite receiving greater attention, optimal maternal health remains a challenge in developing countries such as Ethiopia. Evidence from various studies shows that skilled attendance during childbirth is among the key strategies to reduce maternal mortality. However, in Ethiopia, the use of institutional childbirth services is very low. In Ethiopia, studies dealing with factors affecting women's use of institutional childbirth services are scarce and generally focus on urban settings. As such, this study aimed to explore the determinants of institutional childbirth service utilisation among urban and rural women who gave birth in the previous two years in Tsegedie district, Ethiopia. Methods: a community-based cross-sectional study was performed from 20 November 2012 to 30 June 2013 on 485 mothers. The participants were selected systematically using a multistage sampling technique. A pre-tested structured questionnaire, administered by an interviewer, was used to collect quantitative data. Focus group discussions and in-depth interviews were used to triangulate the evidence from the quantitative study. Bivariate and multivariate data analysis was performed using Statistical Package for the Social Sciences Version 17.0. Finding: this study found that 31.5% of the respondents used institutional childbirth services. The main reason for home birth was close attention from family (47%). Women's educational status [adjusted odds ratio (AOR) 5.3, 95% confidence interval (CI) 1.59–17.87], time taken to reach the nearest health facility (AOR 3.3, 95% CI 1.15–9.52), ultimate decision maker regarding the place of childbirth (AOR 3.7, 95% CI 1.08–12.63) and receipt of maternal and child health care information (AOR 9.4, 95% CI 2.4–36.38) were significantly associated with the use of institutional childbirth services. Conclusion: the proportion of births attended in health facilities was low in the study district. Women's educational status, distance to the nearest health facility, women's decision-making power and receipt of maternal and child health care information were important predictors of institutional childbirth service utilisation. This implies that women still lack physical and effective access to maternal health care services. Thus, improving community awareness about skilled providers and institutional childbirth, targeting women who prefer to give birth at home, is encouraged. Safe motherhood education using communication networks in rural and urban communities is crucial. Furthermore, it is recommended that essential obstetric care facilities (health centres) should be established within a reasonable distance of homes, women should be empowered and community midwives should be deployed. & 2014 Elsevier Ltd. All rights reserved.
Keywords: Institutional childbirth Determinant factors Cross-sectional study Tsegedie district
Background Despite receiving greater attention, maternal mortality remains a challenge in many developing countries, and progress towards Millennium Development Goal 5, to reduce maternal mortality by three-quarters between 1990 and 2015, has been particularly slow
n
Corresponding author at: 21, Arba Minch University, Arba Minch, Ethiopia. E-mail address: [email protected] (D. Hailu).
(United Nations, 2011). Each year, approximately 287,000 women die from complications related to pregnancy and childbirth, with 99% of these deaths occurring in developing countries. Maternal mortality has been shown to have large discrepancies between developed and developing countries; the maternal mortality rate (MMR) is 15 times higher in developing regions compared with developed regions (240 versus 16 per 100,000 live births) (World Health Organization, 2005). Sub-Saharan African countries have the highest MMR at 500 maternal deaths per 100,000 live births (Maternal Mortality Estimation Inter-Agency Group, 2010), and the MMR in Ethiopia
http://dx.doi.org/10.1016/j.midw.2014.03.009 0266-6138/& 2014 Elsevier Ltd. All rights reserved.
Please cite this article as: Hailu, D., Berhe, H., Determinants of institutional childbirth service utilisation among women of childbearing age in urban and rural areas of Tsegedie district, Ethiopia. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.03.009i
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D. Hailu, H. Berhe / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
is among the highest in the world (Federal Ministry of Health, 2010). According to the 2011 Ethiopian Demography and Health Survey (EDHS), the MMR was 676 per 100,000 live births, which is slightly higher than reported in the 2005 EDHS (673 per 100,000 live births) (Central Statistical Agency, 2011). Approximately 80% of maternal deaths worldwide have direct causes such as haemorrhage, infection, obstructed labour, unsafe abortion and high blood pressure (World Health Organization, 2005). Skilled birth attendance during labour, childbirth and the early postpartum period has a profound effect on maternal health. Evidence suggests that skilled birth attendants who are capable of preventing, detecting and managing major obstetric complications, together with equipment, drugs and other essential supplies, can make the difference between life and death for women and their newborn babies. This has been identified as a key strategy for improving maternal health and reducing maternal mortality (World Health Organization, 2005, 2010). However, in many developing countries, very few women give birth in health care facilities, assisted by skilled personnel, even among women with access to these services (UNDP, 2011). In subSaharan Africa, only 23% of births are attended by skilled health personnel, in comparison with an average of 65% globally (UNFPA, 2011). In Ethiopia, the proportion of births attended by skilled personnel is very much lower than in sub-Saharan African countries. According to the 2011 EDHS, only 10% of births were attended in health facilities in Ethiopia, and this has only increased by 4% in the last six years (Central Statistical Agency, 2011). Addressing maternal health is a complex issue, as challenges exist related to both supply and demand. This is particularly true in Africa, where a large proportion of mothers live in rural areas and cultural barriers continue to pose a challenge to health care delivery. Underutilisation of institutional childbirth services and increasing maternal mortality can be largely attributed to three delays in the childbearing process: delay in the decision to seek care; delay in reaching care; and delay in receiving care. The first delay (seeking care) occurs on the demand (women's) side, whereas the other two delays are more supply related. On the supply side, the availability, quality and cost of the health care services clearly influence maternal mortality outcomes. On the demand side, the cost of services, quality (both actual and perceived) of care, trust in health care staff and cultural barriers deter many women from seeking care, even when health services are available (UNDP, 2011). The Ethiopian Federal Ministry of Health, reproductive health departments and health bureaus of respective regions have made a concerted effort to increase skilled birth attendance and achieve Millennium Development Goal 5. Multipronged approaches have been applied at local and national levels to improve access to skilled birth attendance throughout the country, including activities such as training health care providers, increasing access to health facilities and allocating health resources more equitably among rural and urban areas (Federal Ministry of Health, 2010; Central Statistical Agency, 2011). However, in Ethiopia, use of institutional childbirth services is very low. Studies investigating determinants of the use of institutional childbirth service are scarce, and have generally focused on urban settings. As such, this study aimed to determine the use of institutional childbirth services and explore the determinants among urban and rural women who gave birth in the previous two years in Tsegedie district, Tigray region, Ethiopia.
Materials and methods Study setting and period This study was conducted from October 2012 to June 2013 in Tsegedie district. Tsegedie district is located in the west of Tigray
region. The administrative town for Tsegedie district, Ketema Nigus, is located 876 km north west of Addis Ababa, the capital of Ethiopia. As projected from the 2007 Ethiopian census, Tsegedie district had a total population of 103,852. Women of childbearing age represent approximately 23,583 (22.7%) of the total population. Administratively, Tsegedie district is sub-divided into 26 rural and two urban kebeles (smallest administrative unit in Ethiopia). Most (91%) of the population live in rural areas and are economically dependent on farming. Tsegedie district is located 350 m above sea level, and most areas are characterised by desert conditions with an annual temperature of 35–38 1C (Central Statistical Agency, 2007). Concerning the health infrastructure, Tsegedie district has 22 health posts, seven health centres and one general hospital, all of which provide maternal and child health care services. Moreover, it has six private clinics and nine drug venders (Tsegedie District Health Office, 2011). Study design and population A community-based cross-sectional study using both quantitative and qualitative methods was undertaken among women of childbearing age, selected at random, who gave birth in the past two years. Women who were mentally and/or physically incapable, women who had not given birth at least once in the past two years, and/or women who had been residing in the study area for less than six months were excluded from the study. Sample size determination and sampling procedure A sample size of 485 was determined with the following assumptions: institutional childbirth service utilisation, 18.4%; margin of error, 5%; confidence interval, 95%; design effect, 2; and expected non-response rate, 5%. In total, four focus group discussions were held among women who had given birth at least once in the past two years and their husbands. On average, there were eight discussants per focus group (36 discussants in total). In-depth interviews were held with six health extension workers. Multistage sampling was used to select the study subjects. First, all the kebeles in Tsegedie district were clustered into urban and rural. One urban and eight rural kebeles were selected at random from two urban and 26 rural kebeles. The calculated sample size was proportionally allocated to urban (n ¼55) and rural (n ¼430). Frames of households were prepared for each kebele in collaboration with the kebele administrators. Households with a woman who had given birth in the past two years were selected using systematic random sampling from the existing sampling frame of households. To select the study participants, different sampling intervals were used for each kebele. Whenever more than one eligible respondent was found in the same selected household, one respondent was chosen using a lottery method. For households with no eligible women, the next household was selected. Subsequent households were included following the pre-determined order. After thorough analysis of the quantitative data and identification of areas that required further information, four focus group discussions were arranged among men and women (n¼ 36 discussants in total). Quantitative data were triangulated with qualitative evidence. Participants were selected through consultation with women's associations, and kebele and district administrators. Focus groups were matched for sex, marital and educational status. Six health extension workers assigned by the Ethiopian Ministry of Health as community-based primary health care providers were selected for in-depth interviews as they were closer to the community and had better awareness of women's knowledge and attitudes regarding obstetric danger signs. The sample sizes of
Please cite this article as: Hailu, D., Berhe, H., Determinants of institutional childbirth service utilisation among women of childbearing age in urban and rural areas of Tsegedie district, Ethiopia. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.03.009i
D. Hailu, H. Berhe / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
the focus groups and number of in-depth interviews were determined based on information saturation (no further focus group discussants were identified once the generation of new ideas ceased). Data collection methods A structured, interviewer-administered questionnaire, prepared in English and subsequently translated into Tigrigna (local language), was used to obtain information about sociodemographics, obstetric history, women's knowledge about obstetric danger signs and attitudes towards institutional childbirth services. Before data collection, the questionnaire was pre-tested on 5% of the sample (25 women) in one of the sub-districts (Maywedisalihay); this area was not included in the study. On the basis of the pre-test results, the time needed for interviews and the number of data collectors required were estimated. Nine female interviewers who had completed 10th grade, who were fluent in Tigrigna and who were familiar with local customs collected the data. Two health care workers with similar work experience were assigned to supervise data collection. To assess knowledge about danger signs and attitudes towards the use of institutional childbirth services, focus group discussions and in-depth interviews were conducted. Women were asked knowledge and attitude questions such as ‘How do you explain obstetric danger signs?’ and ‘Where do you think a woman should give birth?’. Focus groups for husbands and in-depth interviews were moderated by the principal investigator. As women were more likely to express their opinions openly in front of other females, the focus group discussions for women were moderated by a female registered nurse. Data were tape recorded by one female research assistant after thorough communication with the focus group discussants and in-depth interview participants. The data collectors and supervisors undertook two days of training before data collection regarding the aim of the study, data collection tool and procedures. Data processing and analysis Data were coded, entered and cleaned using EPI-INFO Version 3.5.1 (Centers for Disease Control and Prevention; Atlanta, GA, USA), and further cleaned and analysed using Statistical Package for the Social Sciences (SPSS) Version 16.0 (SPSS Inc., Chicago, IL, USA). Univariate and bivariate analyses were performed for quantitative data. Finally, multivariate analysis was undertaken using SPSS Version 16 for selected variables to determine their independent effects. Statistical tests such as χ2, odds ratio and 95% confidence intervals were employed as appropriate. Qualitative data were transcribed word by word by listening numerous times, translated into English, coded and categorised into key thematic areas using open code software by the principal investigator. The findings were finally presented in the form of narratives. Women's knowledge about obstetric danger signs was measured by the total number of correct spontaneous answers to 10 items about knowledge of pregnancy danger signs and 10 items about knowledge of labour and childbirth danger signs (minimum score of 0, maximum score of 10). Spontaneous knowledge refers to a respondent naming a sign without being asked about that sign by name. Only true obstetric complications reported spontaneously by individual respondents were included. Accordingly, two categories were developed for each pregnancy and childbirth danger sign:
Had knowledge about pregnancy danger signs: women who spontaneously mentioned at least two danger signs of pregnancy.
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Had no knowledge about pregnancy danger signs: women who did not spontaneously mention two danger signs of pregnancy.
Had knowledge about the danger signs of labour and child
birth: women who spontaneously mentioned at least two danger signs of labour and childbirth. Had no knowledge about the danger signs of labour and childbirth: women who did not spontaneously mention two danger signs of labour and childbirth.
Women were considered to have a favourable attitude towards the use of institutional childbirth services if they scored above the mean on 11 questions. Otherwise, they were considered to have an unfavourable attitude towards the use of institutional childbirth services. Ethical approval Ethical approval was granted by the review board of the College of Health Sciences, Addis Ababa University. Informed consent was obtained from each respondent. All responses were kept confidential and anonymous.
Findings Sociodemographic profile of respondents In total, 485 women who had given birth at least once in the two years preceding the survey were interviewed, and the response rate was 100%. One hundred and sixty-two (33.4%) respondents were aged 35–39 years, and the mean age was 32.8 [standard deviation (SD) 5.1] years. The majority of the respondents (n¼ 430, 88.7%) were rural dwellers, 362 (74.6%) were married, 424 (87.4%) were of Tigray ethnicity, 462 (95.3%) were orthodox, and 202 (41.6%) were housewives. Regarding their educational status, 264 (54.4) of the study subjects and 221 (57.6%) husbands were illiterate. Two hundred and eighty (72.9%) husbands were farmers, and 68 (17.7%) were merchants (Table 1). Obstetric characteristics of respondents The majority (n ¼331, 68.2%) of respondents got married between 15 and 19 years of age. Only 98 (20.2%) women conceived before 20 years of age, and the mean age at first pregnancy was 21.5 (SD 2.76) years. Regarding use of maternal health care services, 264 (54.4%) of the participants had attended at least one antenatal visit during their last pregnancy. Among those who attended antenatal visits, only 43 (16.3%) participants attended on four or more occasions. Among the women who received health education during their last antenatal visit, 201 (74.2%) were informed about the danger signs related to pregnancy and childbirth, and 220 (81.2%) were informed about the place of childbirth (Table 2). Use of institutional childbirth services The majority (n¼ 479, 98.8%) of all births were live births. Only 153 (31.5%) women gave birth at health facilities: 99 (64.7%) delivered at health centres and 54 (35.3%) delivered at hospitals. Among the women who gave birth at home, only 17 (5.1%) delivered under the supervision of a skilled birth attendant. During their last home birth, 56 (16.9%) women had encountered a health problem, such as vaginal bleeding (n ¼39, 11.4%) or retained placenta (n ¼16, 4.8%). The main reasons given for home birth were to get close attention from family (n¼ 156, 47%), disliking institutional childbirth
Please cite this article as: Hailu, D., Berhe, H., Determinants of institutional childbirth service utilisation among women of childbearing age in urban and rural areas of Tsegedie district, Ethiopia. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.03.009i
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Table 1 Sociodemographic characteristics of respondents in Tsegedie district, Tigray region, North-west Ethiopia, June 2013. Sociodemographic characteristics
n
%
Place of residence Urban Rural
55 430
11.3 88.7
Age at interview (years) 15–19 20–24 25–29 30–34 35–39 Z40
8 15 103 140 162 57
1.6 3.1 21.2 28.9 33.4 11.8
Marital status Single Married Divorced Widowed Separated
24 362 50 27 22
4.9 74.6 10.3 5.6 4.5
Religion Orthodox Muslim Other
462 14 9
95.3 2.9 1.9
Ethnicity Tigray Amara Other
424 44 17
87.4 9.1 3.5
Women's educational status Unable to read and write Able to read and write Primary education Secondary education Z12 years of education
264 93 58 59 11
54.4 19.2 12 12.2 2.3
Occupation Housewife Farmer Employed Merchant Daily labourer Other
202 75 22 52 124 10
41.6 15.5 4.5 10.7 25.6 2.1
Husbands' educational status Unable to read and write Able to read and write Primary education Secondary education Z12 years of education
221 96 42 16 9
57.6 25 10.9 4.2 2.3
(n¼154, 46.4%), feeling comfortable when delivering at home (n¼126, 38%) and urgent labour (n¼101, 30.4%) (Fig. 1). Regarding the decision-making power of women, only 133 (27.4%) women were the ultimate decision makers regarding the place of childbirth during their last pregnancy.
Knowledge of women about danger signs of pregnancy and childbirth The most common danger signs mentioned spontaneously were vaginal bleeding, leg swelling and absence of fetal movement: 238 (49.1%), 202 (41.6%) and 159 (32.8%) respectively. Two hundred and eighty-five (58.8%) respondents mentioned at least two danger signs of pregnancy, and 170 (35.1%) respondents did not know any danger signs of pregnancy (Table 3). Almost all focus group discussants and in-depth interview participants reported that although significant progress has been made in the last few years, most women were not educated and were not familiar with most of the danger signs. Vaginal bleeding and decreased fetal movement were the most common obstetric complications mentioned as the danger signs of pregnancy.
Table 2 Obstetric characteristics of respondents in Tsegedie district, Tigray region, North-west Ethiopia, June 2013. Obstetric history
n
%
Age at first marriage (years) o 15 15–19 20–24 25–29
6 331 145 3
1.2 68.2 29.9 0.6
Age at first pregnancy (years) o 20 20–29 Z 30
98 378 9
20.2 77.9 1.9
Gravidity 1 2–4 Z5
54 298 133
11.1 61.4 27.4
Parity 1 2–4 Z5
55 302 128
11.3 62.3 26.4
Ever had stillbirth Yes No
26 459
5.4 94.6
ANC visit during previous pregnancies Yes No
125 321
28 72
ANC visit during last pregnancy Yes No
264 221
54.4 45.6
Number of ANC visits during last pregnancy (n¼ 264) 1 2–3 Z4
34 187 43
12.9 70.8 16.3
Received information about pregnancy and labour danger signs Yes No
201 70
74.2 25.8
Received information about place of childbirth Yes No
220 51
81.2 18.8
Received maternal and child health care information Yes No
228 257
47 53
ANC, antenatal care.
Similarly, the most commonly mentioned danger signs of labour and childbirth were excessive vaginal bleeding, malpresentation and prolonged labour: 256 (52.8%), 171 (35.5%) and 151 (31.1%), respectively. Two hundred and ninety-nine (61.6%) respondents mentioned at least two danger signs of labour and childbirth, and 154 (31.8%) respondents did not know any danger signs of labour and childbirth (Table 4). Retained placenta, vaginal bleeding and labour lasting more than one day were the most common obstetric complications mentioned as the danger signs of labour and childbirth. Attitude of respondents towards institutional childbirth services Most participants agreed with the notions that all pregnant women are susceptible to childbirth complications and childbirth complications can be dangerous for women's health [n¼ 453 (93.4%) and n ¼439 (90.5), respectively]. However, 197 (40.6%) respondents disagreed that a woman should plan ahead of time where she should give birth, and 275 (56.7%) felt that being attended by a male health professional during childbirth is very shameful. Overall, 324 (66.8%) respondents had a favourable
Please cite this article as: Hailu, D., Berhe, H., Determinants of institutional childbirth service utilisation among women of childbearing age in urban and rural areas of Tsegedie district, Ethiopia. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.03.009i
D. Hailu, H. Berhe / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
Reasons for home delivery
Dislike of being assisted by male provider
e5
3 5.7 9.3 11.1 11.7 13.9 14.2 16.3
Traditional birth attendants were present Lack of money for transport Previous home delivery was normal Bad experience from previous facility delivery Health facility was far from home Bad approach of health workers Other family members influence Not being sick Husband influence Labor was urgent to reach health facility Feel comfortable when giving birth at home Dislike institutional delivery service To get close attention from family
21.1 23.5 30.4 38 46.4 47 0
20
40
60
80
100
Percentage of respondents Fig. 1. Reasons given for home birth among women in Tsegedie district, Tigray region, North-west Ethiopia, June 2013.
Table 3 Knowledge of women about danger signs of pregnancy in Tsegedie district, Tigray region, North-west Ethiopia, May 2013. Variables Severe vaginal bleeding Swelling of leg/face Reduced/absence of fetal movement Severe headache Increased blood pressure Persistent nausea and vomiting Severe abdominal cramps High fever Leakage of amniotic fluid without labour Blurring of vision
n
%
238 202 159 140 113 106 92 87 74 26
49.1 41.6 32.8 28.9 23.3 21.9 19 17.9 15.3 5.4
Table 4 Knowledge of women about danger signs of labour and childbirth in Tsegedie district, Tigray region, North-west Ethiopia, May 2013. Variables Vaginal bleeding Malpresentation/position Prolonged labour ( 412 hours) Retained placenta ( 4one hour) Severe continuous abdominal pain High fever Increased blood pressure Convulsion/loss of consciousness Cessation of labour pain Severe headache
n
%
256 171 151 146 130 129 121 116 73 47
52.8 35.3 31.1 30.1 26.8 26.6 24.9 23.9 15.1 9.7
attitude towards institutional childbirth services (Table 5). The majority of focus group discussants and in-depth interview participants indicated that a significant number of women did not have a positive attitude towards the use of institutional childbirth services because of multifaceted sociocultural factors. Maternal health service availability and accessibility factors Almost all (n¼ 482, 99.4%) participants reported that health facilities were available in their vicinity, and 455 (93.8%) knew that childbirth services were provided in those facilities. For women who reported that health facilities were available in their vicinity, 246 (50.7%) said that the nearest health facility was at least a onehour walk from their home. Three hundred and seventy-one
(76.5%) participants reported that transport was available from their home to the nearest health facility. Approximately threequarters (n¼ 125, 25.8%) of the participants reported that they had ever received childbirth services at their nearest health facility, and only 11 (2.3%) participants had been charged for these services. Regarding health care information, 228 (47%) participants had received maternal and child health care information, and health care workers were the main source of this information (n ¼ 216, 44.5%). Factors associated with use of institutional childbirth services On multivariate analysis, women's educational status, time taken to reach the nearest health facility, ultimate decision maker about place of childbirth and receipt of maternal and child health care information were found to be independent predictors of the outcome variable (Table 6). Level of education was found to be strongly associated with place of childbirth. Women with formal education were approximately five times [adjusted odds ratio (AOR) 5.3, 95% confidence interval (CI) 1.59–17.87] more likely to deliver in a health facility compared with women without formal education. Another strong predictor of place of childbirth was the time taken to reach the nearest health facility. Women who lived less than one hour from the nearest health facility were approximately three times (AOR 3.3, 95% CI 1.15–9.52) more likely to deliver in a health facility compared with women who lived one hour or more from the nearest health facility. Similarly, women who were the ultimate decision makers about the place of childbirth were approximately four times (AOR 3.7, 95% CI 1.08–12.63) more likely to give birth in a health facility compared with women who were not the ultimate decision makers about the place of childbirth. Health education was also significantly associated with place of childbirth. Women who received maternal and child health care information were approximately nine times more likely to give birth in a health facility compared with women who did not receive maternal and child health care information (AOR 9.4, 95% CI 2.4–36.38).
Discussion This community-based cross-sectional study identified factors that influenced the use of institutional childbirth services among
Please cite this article as: Hailu, D., Berhe, H., Determinants of institutional childbirth service utilisation among women of childbearing age in urban and rural areas of Tsegedie district, Ethiopia. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.03.009i
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Table 5 Attitudes of mothers towards institutional childbirth services in Tsegedie district, Tigray region, North-west Ethiopia, May 2013. Variables
Agree
All pregnant women are susceptible to childbirth complications Childbirth complications can be dangerous for the health of the woman Childbirth complications can be dangerous for the health of the newborn Most complications of labour are preventable with the help of a trained birth attendant A woman should plan ahead of time where she should give birth A woman should plan ahead of time how to get to the place where she should give birth Every pregnant woman needs a skilled attendant at childbirth Being attended by a male health professional during childbirth is very shameful It is very shameful to deliver on a delivery bed in a labour ward Women do not go to health facilities for childbirth because it is too expensive Women do not go to health facilities for childbirth because the health workers do not treat them with respect
women who gave birth in the past two years in urban and rural areas of Tsegedie district, Ethiopia. This study found that 31.5% of women in Tsegedie district used institutional childbirth services. This finding is higher than the results reported in the 2011 EDHS report: national (10%) and Tigray region (11.6%) (Central Statistical Agency, 2011). This may be due to advances in accessing and using maternal health care services in the study area since 2011. However, the rate found in this study is lower compared with results from India (60%) and Vietnam (57%) (Navaneetham and Dharmalingam, 2000; Ngo and Hill, 2011), possibly because mothers in these countries had better educational status and better access to maternal health care information. The rate found in the present study was also considerably lower compared with results from urban settings in the Democratic Republic of Congo (93.8%) (Abel Ntambue et al., 2012). This difference could be due to the fact that the study by Abel Ntambue et al. only included urban kebeles where the proportion of women with formal education was higher, health services were accessible in terms of minimal distance and transport, women had better decision-making autonomy, and women had better access to information than women in rural kebeles. In addition, this difference may be due to the difference in implementation of relevant health intervention programmes. Women's educational status was among the independent predictors of the use of institutional childbirth services. Women with formal education were five times more likely to use institutional childbirth services than women without formal education. This is consistent with study findings from Ethiopia (Abera and Belachew, 2006; Amano et al., 2012; Teferra et al., 2012), Uganda, Nigeria, Myanmar and Nepal (Wagle and Sabroe, 2004; Tann et al., 2007; Dhakal et al., 2011; Sein, 2011; Rai et al., 2012). Most focus group discussants and in-depth interview participants suggested similar conclusions. Supporting this notion, one focus group discussant stated that ‘almost all women in the district and particularly those mothers living in the rural settings are culturally bound against modern maternal health care services simply because they are not educated’. Possible explanations are that educated women may have better access to health service information, improved perceptions of the causes of disease and treatment, and the ability to use such information optimally. In addition, educated women have greater autonomy to make decisions and greater ability to use quality health care services. This study found that the use of institutional childbirth services was significantly associated with distance to the nearest health facility. Women who lived less than 1 hour from the nearest health facility were three times more likely to deliver in a health facility compared with women who lived 1 hour or more from the nearest health facility. Most focus group discussants and in-depth
Indifferent
Disagree
n
%
n
%
n
%
453 439 377 300 287 285 317 275 263 243 268
93.4 90.5 77.7 61.9 59.2 58.8 65.4 56.7 54.2 50.1 55.3
– – 2 4 6 3 7 3 7 15 4
– – 0.4 0.8 1.2 0.6 1.4 0.6 1.4 3.1 0.8
32 46 106 181 192 197 161 207 215 227 213
6.6 9.5 21.9 37.3 39.6 40.6 33.2 42.7 44.3 46.8 43.9
interview participants suggested similar conclusions. This study is in agreement with other cross-sectional studies undertaken in Ethiopia, Nepal and Kenya, where the probability of giving birth in a health facility was higher for women who lived less than 1 hour from the nearest health facility (Wagle and Sabroe, 2004; van Eijk et al., 2006; Dhakal et al., 2011; Amano et al., 2012; Teferra et al., 2012). This may be due to the higher transportation costs and lost production time associated with greater distance from a health facility, and potentially lower exposure to maternal and child health care information. Women's decision-making power was also found to be an independent predictor of the use of institutional childbirth services. In line with evidence from South-East Ethiopia, Lao People's Democratic Republic, Nepal and Kenya (Abera and Belachew, 2006; Fotso et al., 2009; Woldemicael and Tenkorang, 2010; Dhakal et al., 2011; Sychareun et al., 2012), women who were the ultimate decision maker about the place of childbirth were more likely to give birth in a health facility compared with women who were not the ultimate decision maker about the place of childbirth. Most of the focus group discussants and in-depth interview participants stated that the ultimate decision about the place of childbirth was generally made by the woman's husband, and this was felt to be one of the major factors with a negative effect on the use of institutional childbirth services. In contrast, a study undertaken in Metekel zone, Ethiopia found that women's decision-making autonomy had a negative effect on the use of institutional childbirth services. It revealed that women who were the ultimate decision maker about their place of childbirth were approximately six times less likely to use institutional childbirth services than women who were not the ultimate decision maker about their place of childbirth (Gurmesa and Abebe, 2008). This may be because, despite the social position of women, the strong cultural norm in the area was home birth; this could be due to low awareness about the importance of institutional childbirth (Gurmesa and Abebe, 2008). The present study also found that the receipt of health education was significantly associated with the use of institutional childbirth services. Women who received maternal and child health care information during their last childbirth were approximately nine times more likely to use institutional childbirth services compared with women who did not receive this information during their last childbirth. This is in agreement with a quasiexperimental study undertaken in Eretria, where women who received maternal and child health care information were more likely to use institutional childbirth services (p o0.05) (Gurmesa and Abebe, 2008). This can be explained by the fact that community participation and developing the capacity of women, their
Please cite this article as: Hailu, D., Berhe, H., Determinants of institutional childbirth service utilisation among women of childbearing age in urban and rural areas of Tsegedie district, Ethiopia. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.03.009i
D. Hailu, H. Berhe / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
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Table 6 Factors associated with institutional childbirth service utilisation among mothers in Tsegedie district, Tigray region, North-west Ethiopia, June 2013. Variables
Institutional childbirth
Crude
Adjusted
Yes
No
OR (95% CI)
OR (95% CI)
Age at interview (years) 15–24 25–29 30–34 Z 35
8 51 48 46
15 52 92 173
2 (0.8–5.02) 3.69 (2.23–6.11) 1.96 (1.22–3.16) 1.00
1.57 (0.01–23.4) 3.35 (0.75–15.0) 0.4 (0.12–1.57) 1.00
Marital status Married Other†
112 41
250 82
0.896 (0.58–1.39) 1.00
1.2 (0.21–7.16) 1.00
Educational status Formal education No formal education
84 69
44 288
7.97 (5.08–12.49) 1.00
5.3 (1.59–17.87)nn 1.00
Household monthly income (Ethiopian birr (20 Ethiopian birr = 1 US dollar)) 150–408 409–693 694–987 Z 988
18 36 61 38
74 163 76 19
1.00 0.91 (0.48 1.7) 3.3 (1.78–6.1) 8.2 (3.87–17.5)
1.00 0.23 (0.03–1.47) 0.76 (0.11–5.09) 1.36 (0.11–17.41)
Own radio/television Yes No
23 130
184 148
7.02 (4.3–11.5) 1.00
0.8 (0.69–11.32) 1.00
Gravidity 1 2–4 Z5
28 100 25
26 198 108
4.65 (2.3–9.26) 2.18 (1.3–3.58) 1.00
3.3 (0.06–181) 0.4 (0.02–9.47) 1.00
ANC visits during last childbirth Yes No
124 29
140 192
5.86 (3.7–9.28) 1.00
0.01 (0.00–3.7) 1.00
Number of ANC visits 1 2–3 Z4
9 93 29
25 101 14
1.00 2.56 (1.14–5.76) 5.8 (2.1–15.5)
1.00 0.7 (0.05–9.5) 3.2 (0.14–74.2)
Previous institutional childbirth Yes No
19 134
46 286
0.88 (0.5–1.56) 1.00
1.2 (0.27–5.82) 1.00
Attitude towards institutional childbirth Favourable Non-favourable
135 18
189 143
5.7 (3.3–9.7) 1.00
3.3 (0.67–16.07) 1.00
Received maternal and child health care information Yes No
135 18
93 239
19.27 (11.15–33.3) 1.00
9.4 (2.4–36.38)nn 1.00
Knowledge about danger signs of pregnancy Knowledgeable Not knowledgeable
139 14
146 186
12.6 (7–22.8) 1.00
1.6 (0.21–13.12) 1.00
Knowledge about danger signs of childbirth Knowledgeable Not knowledgeable
141 12
158 174
13 (6.9–24.2) 1.00
5.1 (0.59–44.20) 1.00
Time taken to reach nearest health facility (hours) o1 Z1
114 39
125 207
4.8 (3.2–7.4) 1.00
3.3 (1.15–9.52)n 1.00
Decision maker about place of childbirth Self Other‡
76 77
57 275
4.76 (3.1–7.2) 1.00
3.7 (1.08–12.63)n 1.00
ANC, antenatal care; OR, odds ratio; CI, confidence interval. †
Single, divorced, widowed or separated. Family, relatives. Significant at po 0.05. nn Significant at p o0.01. ‡
n
families and communities to better address their own health problems is known to increase safe motherhood behaviours, which are believed to reduce maternal mortality and birth complications.
Inconsistent with the findings of a study from Ethiopia (Amano et al., 2012), the present study also found that the main reason given by women for home birth was to get close attention from their families (47%).
Please cite this article as: Hailu, D., Berhe, H., Determinants of institutional childbirth service utilisation among women of childbearing age in urban and rural areas of Tsegedie district, Ethiopia. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.03.009i
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D. Hailu, H. Berhe / Midwifery ∎ (∎∎∎∎) ∎∎∎–∎∎∎
Limitations of the study When interpreting the findings of this study, some limitations should be considered. The cross-sectional nature of the data made it impossible to establish causal relationships. In addition, the data used in this study were self-reported, and were not validated using objective sources such as health facility cards. However, it is fair to assume that bias is less likely in childbirth-related events compared with other sensitive issues, and respondents were informed about the importance of giving accurate responses and assured about the confidentiality of their responses. Recall bias may also be a concern as women were asked for events that happened within the past two years. Finally, this study was based on a survey of women that was conducted up to two years after the birth of a child. Women who died after giving birth were not included in the study.
Conclusion Use of institutional childbirth services was very low despite substantial improvements compared with the national figure. Close attention from family, disliking institutional childbirth, and feeling comfortable when giving birth at home were the main reasons given for home birth. Almost all women who gave birth at home were attended by family members or relatives. Women's educational status, time taken to reach the nearest health facility, receipt of maternal and child health care information and ultimate decision maker about the place of childbirth were found to be independent predictors of the use of institutional childbirth services. This implies that women still lack physical and effective access to health care services. Recommendation In general, this study showed that a significant proportion of women were uneducated, unempowered and lacked appropriate health care information and access to health care facilities. Therefore, the Ethiopian Federal Ministry of Health and other concerned stakeholders, particularly those working in the areas of reproductive health, should strengthen existing strategies involving the provision of information, education and communication, targeting women, family and the general community to increase their awareness about institutional childbirth and its determinants. Furthermore, as education is an important factor for empowering women, policy makers should focus on encouraging women to pursue formal education. This study also recommends that health care facilities should allow some cultural birthing procedures at health facilities, such as allowing family members to be present when women give birth, and encouraging traditional birthing practices when they do not conflict with scientific medical practice (e.g. massaging their abdomen, preparing porridge immediately after childbirth at maternity units) to make women more likely to give birth at a health care facility. Moreover, health care providers should be more friendly and welcoming to women and their family members in terms of professional competency, being respectful and respecting the privacy of women during antenatal, childbirth and postnatal periods. Establishing health care facilities within a reasonable distance from homes, continuous provision of ambulance services and deployment of trained community-based midwives are also recommended. In addition, community-based support groups need to develop solidarity and use their full potential to perform behavioural change communication sessions continuously with women, husbands and the general community to ensure that they have good knowledge and attitudes towards institutional childbirth. Finally,
further research with robust analytical studies covering a wide range of samples is recommended to substantiate this finding for more generalisability.
Competing interests None declared.
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Please cite this article as: Hailu, D., Berhe, H., Determinants of institutional childbirth service utilisation among women of childbearing age in urban and rural areas of Tsegedie district, Ethiopia. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.03.009i
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Please cite this article as: Hailu, D., Berhe, H., Determinants of institutional childbirth service utilisation among women of childbearing age in urban and rural areas of Tsegedie district, Ethiopia. Midwifery (2014), http://dx.doi.org/10.1016/j.midw.2014.03.009i
