Determinants of Skilled Maternal Care Utilization: a Multilevel Analysis Using Mixed Method Investigation in North Gondar Zone, North West Ethiopia
Creators: name: Gebeyehu, Abebaw
Publisher: name: National Academic Digital Repository of Ethiopia
Year: 2013

description: Historical and ecological evidences indicate that maternal care by skilled providers is one of the key strategies for maternal survival. However, the rate of maternal service utilizations and reduction of maternal mortality are very low in Ethiopia. Several factors, which vary according to different contexts and operate at different levels, can affect the utilization of skilled maternal care. Hence, a level-by-level analysis of all sources of poor skilled maternal care utilization has strategic relevance for the country. Objective This study was designed to describe skilled maternal care utilization and to identify associated factors operating at different levels Methods The study included a linked facility and population-based survey to assess the availability, utilization and correlates of maternal service utilization, and a prospective cohort study to evaluate the effect of the available skilled maternal care in reducing adverse pregnancy outcomes. The linked survey was conducted over three months (January - March 2012) in twelve randomly selected kebeles, their nearby twelve health centers, and three hospitals of North Gondar Zone, while the cohort study was conducted in 10 kebeles of Dabat district from December 1, 2011 to August 31, 2012 on 763 pregnant women. Data on potential correlates of skilled maternal care utilization were gathered using quantitative and qualitative data collection techniques. In the cohort study, data was collected at four time points: first contact, during the 9th month of pregnancy, within one week after delivery, and on the forty-second day of postpartum. During analysis, the effect of potential confounders was controlled using logistic regression models. The effect of cluster variation and a number of individual, communal (kebele), and facility-related variables for skilled maternal care utilization was examined using the multilevel modelling. Results All indicators of skilled maternal care service utilization were very low in North Gondar. Out of the total 1668 women, only 32.3%, 13.8%, and 6.3% utilized skilled providers for their routine XIV antenatal, delivery, and postnatal care, respectively. Most of these services were at health centers by nurses or midwives. Of the 476 women who faced complications, 248 (52.1%, 95% CI: 47.6%, 56.6%) sought assistance from a skilled provider. Antenatal and delivery care were available in most of the visited facilities. However, important components of both the routine and emergency maternity services were incomplete. Signal functions including the administration of anticonvulsants and assisted vaginal delivery were missing in seven and five of the 12 health centers, respectively. The proportion of women according to the type of service they received at the time of their antenatal care was 79% (blood pressure checkup), 35% (urine testing), 45% (tetanus immunization), 64% (iron supplementation), 51% (birth preparedness counseling) and 71% (HIV testing). During delivery, only 24% of the providers used partograph consistently. In many of the facilities, important pieces of equipment were either absent or not functional. Most of the health centers also lacked laboratory tests, such as VDRL, hemoglobin, urine protein, and cross match. Interviewed midlevel providers had no adequate training on essential procedures like assisted vaginal delivery (vacuum extraction), manual vacuum aspiration, or evacuation and curettage. In addition, about one-third of the providers had no skill to manage preeclampsia and post-abortion complications. The multilevel analysis showed a significant heterogeneity among clusters for each indicator of skilled maternal care utilization (ANC, delivery and PNC). At the individual level, preference for skilled providers and previous experience of antenatal care were consistently strong predictors of all indicators of skilled maternal care utilization. First birth order, maternal education, and awareness about health facilities to get skilled professionals were significantly associated with skilled antenatal and delivery care utilization. At this level, variables related to awareness and perceptions were more important. At communal and facility level; cost requirements at health facilities, having different sources of income to cover transport and service costs, and the availability of important service components at health facilities were among the factors affecting skilled maternal care, especially delivery service. Seeking skilled care for complications was significantly affected by wealth, ANC use, and the readiness of a woman for possible complications. The follow-up study showed that the chance of the occurrence of adverse pregnancy outcomes was reduced by 9% (OR=0.91; 95% CI: 0.43, 1.69) among mothers with less than four ANC visits and by 25% (OR=0.75; 95% CI: 0.25, 2.75) among mothers with four or more ANC visits. XV In addition, delivery by a skilled attendant showed a 31% (OR=0.69; 95% CI: 0.36, 1.33) reduction in the occurrence of complications and death during delivery and postpartum period. However, the findings were not significant. Providing incomplete service (poor quality of care) was considered as the major explanation for the insignificant effects. Conclusions Most women did not use skilled care for the routine antenatal, delivery, and postnatal care. Nearly half of the women who faced complications also did not seek skilled maternal care. Both the routine and emergency maternity cares lack the full components of important services. Lack of facilities in the health institution and deficiencies in the skills of providers were the major reasons for missing essential components of maternal services. In general, the utilization of skilled maternal care depends on the separate and joint effects of individual, communal, and health facility level factors. Beyond its effect on health-seeking behavior of mothers, providing incomplete (poor quality) maternal service was an obstacle to the achievement of the goals of reducing morbidity and mortality. Therefore, the available skilled maternal care showed an insignificant reduction in adverse pregnancy outcomes (complications and deaths). Recommendations In order to create better community awareness and perception about skilled providers and their care, safe motherhood education, especially on the risk of pregnancy and the benefits of skilled maternal care should be promoted using the available communication networks in the rural communities. Such interventions should target underprivileged women. ANC service should be expanded through outreach programs and domiciliary service to attain higher coverage in all types of skilled maternal care. Improving the quality of both the routine and emergency maternity services (providing important service components) is the most urgent intervention to achieve the goals of maternal health programs. Providing in-service training and the necessary equipment as well as ensuring continuum of care and monitoring the health facility using the signal functions in regular bases are the major activities for effective maternal care.