Why Do Women Deliver at Home? Multilevel Modeling of Ethiopian National Demographic and Health Survey Data

Background

Despite of the existing intensive efforts to improve maternal health in Ethiopia, the proportion of birth delivered at home remains high and is still the top priority among the national health threats.

Objective

The study aimed to examine effects of individual women and community-level factors of women’s decision on place of delivery in Ethiopia.

Methods

Data were obtained from the nationally representative 2011 Ethiopian Demographic and Health Survey (EDHS) which used a two-stage cluster sampling design with rural-urban and regions as strata. The EDHS collected data from a big sample size but our study focused on a sample of 7,908 women whose most recent birth was within five years preceding 2011 and 576 communities in which the women were living in. The data were analyzed using a two-level mixed-effects logistic regression to determine fixed-effects of individual- and community-level factors and random-intercept of between-cluster characteristics.

Results

In the current study, 6980 out of 7908 deliveries (88.3%) took place at home. Lower educational levels (OR=2.74, 95%CI:1.84,4.70; p<0.0001), making no or only a limited number of ANC visits (OR=3.72,95%CI:2.85, 4.83; p<0.0001), non-exposure to media (OR=1.51, 95%CI 1.13, 2.01; p=0.004), higher parity (OR=2.68, 95%CI:1.96,3.68; p<0.0001), and perceived distance problem to reach health facilities (OR=1.29, 95%CI:1.03,1.62; p=0.022) were positively associated with home delivery. About 75% of the total variance in the odds of giving birth at home was accounted for the between-community differences of characteristics (ICC=0.75, p<0.0001). With regard to community-level characteristics, rural communities (OR=4.67, 95%CI:3.06,7.11; p<0.0001), pastoralist communities (OR=4.53, 95%CI:2.81,7.28; p<0.0001), communities with higher poverty levels (OR=1.49 95%CI:1.08,2.22; p=0.048), with lower levels of ANC utilization (OR=2.01, 95%CI:1.42,2.85; p<0.0001) and problem of distance to a health facility (OR=1.29, 95%CI:1.03,1.62; p=0.004) had a positive influence on women to give birth at home.

Conclusions

Not only individual characteristics of women, but also community-level factors determine women’s decision to deliver at home.     

Outpatient Therapeutic Feeding Program Outcomes and Determinants in Treatment of Severe Acute Malnutrition in Tigray,Northern Ethiopia: A Retrospective Cohort Study

Background

Outpatient Therapeutic feeding Program (OTP) brings the services for management of Severe Acute Malnutrition (SAM) closer to the community by making services available at decentralized treatment points within the primary health care settings, through the use of ready-to-use therapeutic foods, community outreach and mobilization. Little is known about the program outcomes. This study revealed the levels of program outcome indictors and determinant factors to recovery rate.

Methods

A retrospective cohort study was conducted on 628 children who had been managed for SAM under OTP from April/2008 to January/2012. The children were selected using systematic random sampling from 12 health posts and 4 health centers. The study relied on information of demographic characteristics, anthropometries, Plumpy''Nut, medical problems and routine medications intakes. The results were estimated using Kaplan-Meier survival curves, log-rank test and Cox-regression.

Results

The recovery, defaulter, mortality and weight gain rates were 61.78%, 13.85%, 3.02% and 5.23 gm/kg/day, respectively. Routine medications were administered partially and children with medical problems were managed inappropriately under the program. As a child consumed one more sachet of Plumpy''Nut, the recovery rate from SAM increased by 4% (HR = 1.04, 95%-CI = 1.03, 1.05, P<0.001). The adjusted hazard ratios to recovery of children with diarrhea, appetite loss with Plumpy''Nut and failure to gain weight were 2.20 (HR = 2.20, 95%-CI = 1.31, 3.41, P = 0.001), 4.49 (HR = 1.74, 95%-CI = 1.07, 2.83, P = 0.046) and 3.88 (HR = 1.95, 95%-CI = 1.17, 3.23, P<0.001), respectively. Children who took amoxicillin and de-worming had 95% (HR = 1.95, 95%-CI = 1.17, 3.23) and 74% (HR = 1.74, 95%-CI = 1.07, 2.83) more probability to recover from SAM as compared to those who didn''t take them.

Conclusions

The OTP was partially successful. Management of children with comorbidities under the program and partial administration of routine drugs were major threats for the program effectiveness. The stakeholders should focus on creating the capacity of the OTP providers on proper management of SAM to achieve fully effective program.     

Meeting Community Health Worker Needs for Maternal Health Care Service Delivery Using Appropriate Mobile Technologies in Ethiopia

Background

Mobile health applications are complex interventions that essentially require changes to the behavior of health care professionals who will use them and changes to systems or processes in delivery of care. Our aim has been to meet the technical needs of Health Extension Workers (HEWs) and midwives for maternal health using appropriate mobile technologies tools.

Methods

We have developed and evaluated a set of appropriate smartphone health applications using open source components, including a local language adapted data collection tool, health worker and manager user-friendly dashboard analytics and maternal-newborn protocols. This is an eighteen month follow-up of an ongoing observational research study in the northern of Ethiopia involving two districts, twenty HEWs, and twelve midwives.

Results

Most health workers rapidly learned how to use and became comfortable with the touch screen devices so only limited technical support was needed. Unrestricted use of smartphones generated a strong sense of ownership and empowerment among the health workers. Ownership of the phones was a strong motivator for the health workers, who recognised the value and usefulness of the devices, so took care to look after them. A low level of smartphones breakage (8.3%,3 from 36) and loss (2.7%) were reported. Each health worker made an average of 160 mins of voice calls and downloaded 27Mb of data per month, however, we found very low usage of short message service (less than 3 per month).

Conclusions

Although it is too early to show a direct link between mobile technologies and health outcomes, mobile technologies allow health managers to more quickly and reliably have access to data which can help identify where there issues in the service delivery. Achieving a strong sense of ownership and empowerment among health workers is a prerequisite for a successful introduction of any mobile health program.