A cross-sectional survey was undertaken in August-November 2009 to assess utilization to maternal health services by women in rural villages in Ethiopia.
The study was conducted in Tigray region, Ethiopia. Tigray is one of the nine regions and the northernmost regional state of Ethiopia. The 2007 Ethiopian census showed the population of the region to be 4.3 million of which 80% lived in rural areas and 51% were female . The poor health status of Tigray region is comparable to the rest of the country, showing high infant mortality rate (67/1000), low institutional delivery (8.6%), high HIV prevalence (2.7%), and low family planning utilization (16.5%) . This study was done in three rural districts. The districts studied were Alaje from the Southern Zone, Saesi Tsadamba from the Eastern Zone and Degua Tembien from the South Eastern Zone of Tigray. These districts were selected purposefully in consultation with Tigray regional health bureau. We considered accessibility of the districts to carry out the research in terms of transport. Out of the total 72 kebeles in these districts, 13 of them had health centers. Twelve of them did not have any health facility. The rest 47 rural kebeles were with only health post. From each selected district, three rural kebeles were selected. Rural kebeles with no functional health posts were excluded from the selection. Rural kebeles who have health facilities other than health posts were not also included in the study. All the selected kebeles were with functional health posts and HEWs.
We employed the Statcalc sample size calculation for cross-sectional study module of EPI-info version 2002 to determine sample size for our study. A total sample size of 726 households was determined by considering 95% confidence interval, 80% power of study; 1:1 comparison among districts, a contraceptive prevalence rate of 16.2% for Tigray region taken from EDHS 2005, and we assumed that the proportion of contraceptive users would be two times when we did our data collection in 2009.
Women with under-five children from the nine selected kebeles who were willing and healthy enough to be interviewed were identified to participate in the survey. To select the study participants a sampling frame of households with women who had under-five children was developed from the log book of the HEWs. These log books of HEWs have a list of households in their kebeles. Using systematic random sampling, we selected an average of 80 women with under-five children from each kebele. There was no refusal to participate. When the woman selected for an interview was not available, a neighbouring woman was interviewed. A total of 726 women were interviewed and data from 725 women were included in the analysis; 1 questionnaire was useless because of its incompleteness.
We collected data on women’s utilization of family planning, antenatal care, delivery care, postnatal care, HIV testing and use of iodized salt. Data on women’s utilization of maternal health services by type of health workers were collected. The questionnaire was initially developed in English and then translated to the local language, ‘Tigrigna’. The questionnaire was pre-tested among 20 mothers to assure clarity of concepts for respondents.
The data were collected by six data collectors who had completed high school and who had experience in doing questionnaire interviews. Additional training was given for the data collectors to help them understand the nature of the study and the questions. Completed questionnaires were checked for completeness and consistency at the time of interview by supervisors. To ensure rigor in the study, supervisors re-checked the responses for a randomly selected 5% of the questionnaires by going back to the woman’s house. Re-checking showed no major problems in data collection.
Outcome variables and definitions
Utilization of maternal health services was collected using the following variables: 1. Family planning: whether the woman has been using contraceptives during the interview period (current utilization) or whether the woman has ever used contraceptives in her lifetime (ever utilization). 2. Antenatal care (ANC): whether the woman attended a health facility for antenatal care (ANC) at least once in her last successful pregnancy. 3. Health facility delivery: whether the woman gave birth at a health facility for her youngest child. 4. Postnatal care (PNC): whether a health professional or community health worker visited the woman at her home within 24 hours of the birth of her youngest child. 5. HIV testing: whether the woman had ever had an HIV test by the time of interview. 6. Use of iodized salt: whether iodized cooking salt (with 15 parts per million based on salt testing kits) was found in the woman’s house. This was considered as one of the maternal health services because educating women on utilization of iodized salt and distributing subsidized iodized salt are among the tasks of HEWs.
In addition we measured several other variables such as age, educational status, marital status, religion, year of enrolment into the HEP, household status in relation to working towards graduation or graduated as model family and participation in income generating activities (IGAs). A model family is by definition a family which has fulfilled all the packages of the HEP. Prior to the data collection we checked log books of HEWs on this information. We found the log books had incomplete and inconsistent information on whether a family completed all the packages of the program or not. Hence for this study we took the woman’s word whether she said her household had been working towards graduation or graduated as model family or not. IGAs are government or community-initiated activities for local people to earn some money. These IGAs include irrigation schemes, micro-finance credit, safety net, cattle rearing, poultry production and bee keeping.
Data management and analysis
Frequencies of utilization of specific maternal health services were calculated. To estimate changes in the utilization of maternal health services over the years, we compared our findings with findings of the EDHS 2005. The EDHS 2005 was a nationally representative survey of 14,070 women aged 15–49. The data collection of this survey was conducted from April 27-August 30, 2005.
To investigate which factors were associated with good utilization of maternal health service, we used logistic regression. To calculate Adjusted Odds Ratios (AOR) we included all independent variables in one model. The dependent variable was computed by combining the six outcome variables. Using the mean (3.01) as a cutoff point, we categorized utilization of maternal health services into two categories. Women who had utilized 4 and more maternal health services were defined as having good utilization of maternal health services, while those who had utilized less than 4 were considered as having poor utilization of maternal health services. Women’s response for questions on religion, marital status and occupation were virtually the same. Therefore, these variables were not used in the analysis.
The study was approved by the ethics committee at the College of Health Sciences of Mekelle University, Ethiopia which offered a letter with reference number CHS/236/A-16/09 dated on 05/March/09. Study participants were informed about the purpose of the study, anticipated benefits, how they were chosen to participate, data collection procedures and their full right to refuse, withdraw from part or all of the study. The participant’s name was kept confidential. Verbal informed consent was obtained from each study participant. Verbal consent instead of written consent was chosen as most of the questions in the survey were not sensitive and a great number of rural women in Ethiopia are unable to read and write.