Multilevel analysis of factors associated with maternal and newborn health service utilization in rural Ethiopia: individual, communal and provider level determinants of care Público

Abstract

Ethiopia has some of the world's highest maternal and newborn mortality rates, and presently
over 90 percent of births occur in home settings. Severe health workforce shortages indicate that
home-based strategies delivered by community level health workers present the only viable
solution for the short to medium term. In response, the Ethiopian government has rapidly scaled
up over 30,000 Health Extension Workers (HEWs), who serve as the first line of care at the
community level. However, HEWs' impact on mortality has been limited.

Cross-sectional baseline survey data from the Maternal and Newborn Health in Ethiopia
Partnership (MaNHEP) was used for Amhara and Oromiya Regions, Ethiopia. A multilevel,
clustered data analysis was performed to link individual, community and provider-level factors
associated with receipt of antenatal (ANC), delivery and postnatal care (PNC) from skilled
providers or HEWs. Additionally, factors associated with use of misoprostol for postpartum
hemorrhage (PPH) were assessed.

Knowledge of home-based life saving skills was significantly associated with receipt of ANC,
PNC and use of misoprostol. Women with a high level of knowledge were nearly twice as likely
to have received antenatal care [OR: 1.94 (1.14, 3.26)], and nearly five-times more likely to have
received postnatal care [OR: 4.58 (1.35, 15.49)]. Women's level of adherence to potentially
harmful traditional practices was also a significant factor; women with low adherence were nearly
twice as like to have received ANC [OR: 1.98 (1.11, 3.54)], and four times as likely to have
received delivery care [OR: 3.98 (1.88, 8.43)]. Women's trust in HEWs' abilities and HEWs'
frequency of interaction with other frontline health workers were also significantly associated
with receipt of ANC. Furthermore, patterns of association between women's education and
income status and that of her spouse indicate the important role husbands play in care seeking
decision-making.

This study demonstrates that interventions focused on community-level health education and
behavior change could significantly improve receipt of care from skilled providers and HEWs.
Furthermore, coordination amongst frontline health workers and inclusion of husbands in health
messaging could increase coverage and continuity of care.

Table of Contents

Table of Contents

Maternal and Newborn Health: Global Perspective....................................................................... 2
Maternal and Newborn Health: Ethiopia ..................................................................................... 3
Mortality Trends ...................................................................................................................... 4
Maternal and Newborn Health Care Content and Trends .............................................................. 9
Determinants of Maternal and Newborn Mortality and Care Utilization ......................................... 11
Direct Causes of Mortality ....................................................................................................... 11
Sociocontextual Factors .......................................................................................................... 11
Ethiopian Federal Ministry of Health Policy: Goals and Programs ................................................ 14
Ethiopian Health Extension Program and Health System ........................................................... 14
Goals and Targets .................................................................................................................. 17
Impact on Maternal and Newborn Health .................................................................................. 17
Use of Misoprostol for Postpartum Hemorrhage ......................................................................... 19
Maternal and Newborn Health in Ethiopia Partnership (MaNHEP) ................................................. 22
Project Design ........................................................................................................................ 22
Chapter II: Methods ................................................................................................................ 25
Study Questions and Hypotheses ............................................................................................... 26
Population ................................................................................................................................ 27
Sample .................................................................................................................................. 27
Study Design ............................................................................................................................ 30
Analysis ..................................................................................................................................... 36
Chapter III. Results ........................................................................................................................ 40
Contextual Findings ................................................................................................................... 41
Women with a Pregnancy in the Prior Year (MOMs Survey) ............................................... 41
Adult Men and Women Over 18 Years of Age (ADULTs Survey) ...................................... 46
Health Extension Workers (FLWs Survey) ........................................................................... 49
Distance to Health Centers ..................................................................................................... 53
Study Question 1: Antenatal Care from a Skilled Provider or HEW ......................................... 54
Study Question 2: Delivery Care from a Skilled Provider or HEW .......................................... 58
Study Question 3: Postnatal Care Visit within Two Days of Birth for Mother or Newborn from
a Skilled Provider or HEW ........................................................................................................ 61
Study Question 4: Use of Misoprostol for Postpartum Hemorrhage (Oromiya Region) ........... 64
Chapter IV. Discussion .................................................................................................................. 67

Knowledge of HBLSS Package ................................................................................................. 68
Adherence to Potentially Harmful Traditional Practices ........................................................... 70
Trust in HEWs ........................................................................................................................... 71
Continuum of Care and HEW Interaction .................................................................................. 73
Strengths and Limitations .......................................................................................................... 77
Chapter V. Public Health Implications and Future Directions ..................................................... 79
Public Health Implications ......................................................................................................... 80
Future Directions ....................................................................................................................... 82
VI. References ............................................................................................................................... 83
VII. Tables ..................................................................................................................................... 98
VIII. Figures ................................................................................................................................. 148
IX. Appendices ............................................................................................................................ 151

About this Master's Thesis

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School	Rollins School of Public Health
Department	Epidemiology
Subfield / Discipline	Global Epidemiology - MPH & MSPH
Degree	MPH
Submission	Master's Thesis
Language	English
Research Field	Health Sciences, Public Health
Palavra-chave	frontline health workers newborn multilevel health service utilization maternal
Committee Chair / Thesis Advisor	Kramer, Michael M, Emory University Stephenson, Robert, Emory University
Partnering Agencies	Does not apply (no collaborating organization)

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