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Assessing the Determinants of Maternal Healthcare Service Utilization and Effectiveness of Interventions to Improve Institutional Births in Jimma Zone, Ethiopia

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Assessing the Determinants of Maternal Healthcare Service Utilization and Effectiveness of Interventions to Improve Institutional Births in Jimma Zone, Ethiopia Assessing the determinants of maternal healthcare service utilization and effectiveness of interventions to improve institutional births in Jimma Zone, Ethiopia Jaameeta Kurji Thesis submitted to the University of Ottawa in partial fulfillment of the requirements for a Doctorate of Philosophy degree in Epidemiology School of Epidemiology and Public Health Faculty of Medicine University of Ottawa © Jaameeta Kurji, Ottawa, Canada, 2021 Table of Contents List of tables iv List of figures v Abbreviations vii Abstract viii Acknowledgements ix Preface x 1 Introduction 1.1 Organization of the thesis 1 1.2 Conceptual framework and objectives 3 1.3 Trends in maternal mortality 8 1.4 Safe motherhood and global commitments 11 1.5 Maternal mortality and access to maternal healthcare 13 1.6 Access to care and service utilization 13 2 Background 2.1 Overview of the healthcare system in Ethiopia 19 2.2 Definitions of maternal healthcare services 24 2.3 Status of maternal healthcare service use in Ethiopia 26 2.4 Factors influencing maternal healthcare service use 32 2.5 Maternity waiting homes 40 2.6 Role of community and religious leaders in maternal healthcare service use 52 3 Methods 3.1 Study setting 68 3.2 Evaluation of complex interventions 72 3.3 Sample size calculations for the cluster-randomized control trial 73 3.4 Household survey questionnaire design and data collection 76 3.5 Random selection of eligible women 78 3.6 The MWH+ intervention component 79 3.7 Spatial analytic methods 88 Trial analyses 97 4 What factors influence whether or not rural Ethiopian women use MWHs? 4.1 Article preface 106 4.2 Article content 107 5 How does maternal healthcare service use vary within rural Ethiopia? 5.1 Article preface 126 5.2 Article content 127 How do local contextual differences change what influences maternal healthcare service 6 use? 6.1 Article preface 152 6.2 Article content 153 7 Do MWH+ and trained local leaders increase use of maternal healthcare services? 7.1 Article preface 181 7.2 Article content 182 8 Discussion 8.1 Having social and financial resources favours MWH use 243 8.2 Context matters: local diversity in factors influencing maternal healthcare service use 246 8.3 Effect of functional MWHs and leader training on delivery care use in rural Ethiopia 248 Are maternity waiting homes operating in an enabling environment an effective strategy to 8.4 252 improve maternal healthcare service use? 8.5 Overall limitations and recommendations for future work 260 8.6 Conclusions 262 J.Kurji PhD thesis (2021) ii Table of Contents (continued) Chapter 1 Appendix A1.1 Overview of the Safe Motherhood project 272 A1.2 Overview of the local leader training intervention component 272 A1.3 Information brief prepared for the National Advisory Committee 273 Chapter 2 Appendix A2.1 Signal functions used to assess EmOC capacity 276 A2.2 Photographs of delivery rooms and postnatal wards at selected study sites 277 A2.3 Quality of evidence on factors associated with ANC use in Ethiopia 278 A2.4 Quality of evidence on factors associated with delivery care use in Ethiopia 279 A2.5 Quality of evidence on factors associated with PNC use in Ethiopia 281 A2.6 Photographs of selected MWHs within the study districts 283 A2.7 Correlations of MWHs with mortality and health outcomes 285 A2.8 Critique on meta-analysis of the effect of MWHs use on perinatal mortality in Africa 287 Chapter 3 Appendix A3.1 Ethical approvals obtained 297 A3.2 Trial protocol paper 304 A3.3 Sources of women’s household questions 315 A3.4 Photographs of upgraded MWHs at selected combined intervention sites 316 Chapter 4 Appendix A4.1 Construction of the asset-based wealth index 318 A4.2 MWH use model with distance instead of travel time 321 A4.3 Opinion piece on MWHs during crisis 323 Chapter 7 Appendix A7.1 Ancillary analysis methods 331 A7.2 Ancillary analysis results 335 J.Kurji PhD thesis (2021) iii List of Tables Table 1.1 Summary of data sources, outcomes of interest and overall analytic approach by thesis-objective 7 Table 3.1 Socio-demographic characteristics of women and men in Oromia compared to urban capital and national averages 71 Table 3.2 Characteristics of study districts in February 2016 prior to baseline survey 71 Table 3.3 Sensitivity analysis of sample size calculations 76 Table 3.4 List of hypothesized requirements essential for a functioning MWH+ 83 Table 3.5 Optimal distance bands calculated for each service 91 Table 4.1 Definitions of variables used to explore factors associated with women’s use of MWHs 113 Table 4.2 Individual-, household- and community-level characteristics of MWH users compared to non-users 116 Table 4.3 Reasons for MWH stay, and services received among women users 117 Table 4.4 Results from multivariable random effects logistic regression analysis of MWH use among women 118 Table 5.1 Operational definitions of analysis variables used to describe maternal health care service use among women with a pregnancy outcome in 2016-2017 131 Table 5.2 Characteristics of PHCUs and sampled clusters in 2016 within Gomma, Seka Chekorsa and Kersa districts in Jimma Zone, Ethiopia 135 Table 5.3 Primary and main secondary household-level clusters of service use detected using Kulldorf spatial scan statistic 142 Table 6.1 Frequencies, percentages, district- and PHCU-level ranges of explanatory factors 161 Table 6.2 Results from global random effects logistic regression analysis of antenatal, delivery and postnatal care use 163 Table 7.1 Baseline characteristics of clusters and individuals by trial arm 194 Table 7.2 Effectiveness of interventions on improving institutional births and secondary outcomes (ANC, PNC) 195 J.Kurji PhD thesis (2021) iv List of Figures Chapter One Figure 1.1 Relationship between thesis foundational themes, research questions and research objectives 4 Figure 1.2 Overall conceptual model for thesis 5 Figure 1.3 Maternal mortality ratios (per 100,000 live births) of the world, Sub-Saharan Africa, East Africa and Ethiopia between 2000 and 2017 8 Figure 1.4 Predicted maternal mortality ratios per 100,000 live births by region in Ethiopia 9 Chapter Two Figure 2.1 Structure of the health system in rural Ethiopia 22 Figure 2.2 Levels of maternal healthcare service use between 2000 and 2019 in Oromia region 27 Figure 2.3 Regional variation in ANC use 28 Figure 2.4 Regional variation in delivery care use 29 Figure 2.5 Regional variation in PNC use in Ethiopia 29 Figure 2.6 Differences in ANC use between 2000 and 2019 by: (a) place of residence (rural vs. urban), (b) women's education level (none vs. secondary) and (c) household wealth (poorest vs least poor quintiles) in Ethiopia 30 Figure 2.7 Differences in delivery care use between 2000 and 2019 by: (a) place of residence (rural vs. urban) (b) women's education level (none vs. secondary) and (c) household wealth (poorest vs least poor quintiles) in Ethiopia 31 Figure 2.8 Differences in PNC use between 2000 and 2019 by: (a) place of residence (rural vs. urban), (b) women's education level (none vs. secondary) and (c) household wealth (poorest vs least poor quintiles) in Ethiopia 31 Chapter Three Figure 3.1 Study area map showing the location of: (a) Ethiopia (b) Jimma Zone in Oromia Region (c) study districts in Jimma Zone and (d) PHCUs in study districts. 69 Figure 3.2 Fundamental elements of our trial design 73 Figure 3.3 Flow chart of sample size calculations using Hooper & Bourke methodology 75 Figure 3.4 Framework of the essential elements of the MWH based on the World Health Organization health system building blocks 82 Figure 3.5 Roles and responsibilities of community and health system stakeholders in MWH implementation, outlined in the 2015 Ethiopian national MWH guidelines 86 J.Kurji PhD thesis (2021) v List of Figures (continued) Chapter Five Figure 5.1 Map of the study area showing primary health care unit (PHCU) catchment area boundaries, enrolled households and locations of health centres within PHCUs 130 Figure 5.2 Percentages of surveyed households within 2 km, between 2-5 km and more than 5 km from health centre by PHCU and district in Jimma Zone, Ethiopia 136 Figure 5.3 Choropleth maps highlighting correlation between household wealth and (a) ANC use (b) MWH use (c) Delivery care and (d) PNC use at PHCU-level 137 Figure 5.4 Choropleth maps highlighting correlation between women’s education and (a) ANC use (b) MWH use (c) Delivery care and (d) PNC use at PHCU-level 139 Figure 5.5 Hot and cold spots at kebele-level of (a) ANC (b) Delivery care use (c) PNC use in study districts in study districts 140 Figure 5.6 Clusters within kebeles of (a) ANC use (b) MWH use (c) Delivery care use (d) PNC use in study districts 141 Chapter Six Figure 6.1 Map of the study area showing locations of health centres in PHCUs, main towns, roads, PHCU and district boundaries 157 Figure 6.2 Maps of local association estimates (odds ratios) between ANC use and (a) information source (b) danger sign awareness (c) prior ANC use (d) wealth (e) decision making (f) planned pregnancy (g) parity (h) birth preparedness and (i) health facility type 166 Figure 6.3 Maps of local association estimates (odds ratios) between delivery care and (a) school attendance (b) information source (c) danger sign awareness (d) ANC use (e) prior delivery care use (f) attitude towards delivery care (g) companion support (h) wealth (i) parity (j) birth preparedness (k) health facility type 168 Figure 6.4 Maps of local association estimates (odds ratios) between PNC use and (a) danger sign awareness (b) delivery care use (c) assisted delivery mode (d) companion support 170 Chapter Seven Figure 7.1 Map of study districts depicting locations of health centres and Jimma Town 186 Figure 7.2 Timeline cluster diagram illustrating participant recruitment, randomization, outcome assessments and blinding status of the trial 190 Figure 7.3 CONSORT participant flow diagram 193 Figure 7.4 Bar charts of (a) dimensions of MWH awareness among women (b) reasons for no institutional delivery 196 Figure 7.5 Bar chart of MWH use and institutional births across PHCUs and over survey periods.
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