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A Multilevel Analysis Using Mixed Method Investigation in North Gondar Zone, North West Ethiopia

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A Multilevel Analysis Using Mixed Method Investigation in North Gondar Zone, North West Ethiopia DETERMINANTS OF SKILLED MATERNAL CARE UTILIZATION: A MULTILEVEL ANALYSIS USING MIXED METHOD INVESTIGATION IN NORTH GONDAR ZONE, NORTH WEST ETHIOPIA ABEBAW GEBEYEHU WORKU PhD DISSERTATION FOR THE DEGREE OF DOCTOR OF PHILOSOPHY (PhD) IN PUBLIC HEALTH ADDIS ABABA UNIVERSITY, ETHIOPIA September 2013 ADDIS ABABA UNIVERSITY SCHOOL OF GRADUATE STUDIES DETERMINANTS OF SKILLED MATERNAL CARE UTILIZATION: A MULTILEVEL ANALYSIS USING MIXED METHOD INVESTIGATION IN NORTH GONDAR ZONE, NORTH WEST ETHIOPIA A DISSERTATION SUBMITTED TO THE SCHOOL OF GRADUATE STUDIES OF ADDIS ABABA UNIVERSITY IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY (PhD) IN PUBLIC HEALTH BY ABEBAW GEBEYEHU WORKU SUPERVISORS Dr. ALEMAYEHU WORKU Prof. MESGANAW FANTAHUN Prof. HENRY MOSLEY ADDIS ABABA UNIVERSITY, COLLEGE OF HEALTH SCIENCES, SCHOOL OF PUBLIC HEALTH September 2013 I DISSERTATION APPROVAL ADDIS ABABA UNIVERSITY SCHOOL OF GRADUATE STUDIES DETERMINANTS OF SKILLED MATERNAL CARE UTILIZATION: A MULTILEVEL ANALYSIS USING MIXED METHOD INVESTIGATION IN NORTH GONDAR ZONE, NORTH WEST ETHIOPIA BY ABEBAW GEBEYEHU WORKU SCHOOL OF PUBLIC HEALTH, ADDIS ABABA UNIVERSITY APPROVED BY THE EXAMINING BOARD ________________________ ___________________ Chairman, Examining Board Signature and date ________________ Primary Supervisor Signature and date ___________________________ ________________ Secondary Supervisor Signature and date _________________ ________________ External Examiner Signature and date _______________ ________________ Internal Examiner Signature and date _________________ ________________ Internal Examiner Signature and date II Original Papers This dissertation is based on the following five papers, which will be referred to in the text by their Roman numerals: I. Worku AG, Yalew AW, Afework MF. Most women do not seek maternal care for normal conditions: The experiences of rural women in North Gondar, Ethiopia. (Under review the Pan African Medical Journal) II. Worku AG, Yalew AW, Afework MF. Maternal Complications and Women's Behavior in Seeking Care from Skilled Providers in North Gondar, Ethiopia. PloS one. 2013;8(3). III. Worku AG, Yalew AW, Afework MF. Availability and components of maternity services according to providers and users perspectives in North Gondar, northwest Ethiopia. BMC Reproductive Health 2013; 10:43. IV. Worku AG, Yalew AW, Afework MF. Factors affecting utilization of skilled maternal care in Northwest Ethiopia: a multilevel analysis. BMC International Health and Human Rights. 2013;13(1). V. Worku AG, Yalew AW, Afework MF. The Contributions of Maternity Care to Reducing Adverse Pregnancy Outcomes: A Cohort Study in Dabat District, Northwest Ethiopia. Matern Child Health J. 2013. III Acronyms and Abbreviations AAU Addis Ababa University AIDS Acquired Immuno Deficiency Syndrome ANC Antenatal Care AOR Adjusted Odds Ratio CDC Center for Disease Prevention and Control CI Confidence Interval COR Crude Odds Ratio CSA Central Statistical Agency DHRC Dabat health and Research Center DHS Demographic Heath Survey EDHS Ethiopia Demographic Heath Survey EmOC Emergency Obstetric Care EOC Essential obstetric care FANC Focused antenatal care FMOH Federal ministry of health GDP Gross domestic product HDSS Health and Demographic Surveillance System HEWs Health Extension Workers HIMS Health Information Management System HIV Human Immunodeficiency Virus IP Infection prevention IRB Institutional Review Board IUGR Intra Uterine Growth Retardation LBW Low Birth Weight LSS Life saving skills MDGs Millennium development goals MVA Manual vacuum aspiration NGOs Nongovernmental Organizations OR Odds Ratio PAC Post Abortion Care IV PCA Principal Component Analysis PI Principal Investigator PIH Pregnancy Induced Hypertension PMTCT Prevention of mother to child transmission of HIV PNC Postnatal Care PROM Premature Rupture of Membrane RR Relative Risk SBAs Skilled Birth Attendants SD Standard Deviation SNNPRS Southern Nations, Nationalities, and Peoples Regional State SPSS Statistical Package for the Social Sciences STIs Sexually Transmitted Infections TBAs Traditional Birth Attendants UN United Nations UNDP United Nations Development Program UNICEF United Nations International Children's Emergency Fund VCT Voluntary counseling and testing VIF Variance Inflation Factor WHO World Health Organization V Glossary of Operational Definitions and Concepts Basic signal functions: include parenteral antibiotics, anticonvulsants and oxytocics, manual removal of placenta, removal of retained products, assisted vaginal delivery and neonatal resuscitation (at basic emergency obstetric care facility) Comprehensive signal functions: refers basic signal functions with the addition of cesarean delivery and blood transfusion (at comprehensive emergency obstetric care facility) (1). Early neonatal mortality: is a neonatal death in the first week of life. Eclampsia: represented by occurrence of convulsions. Enabling environment: In the context of safe motherhood, describes a context that provides a skilled attendant with the backup support to perform routine deliveries and make sure that women with complications receive prompt emergency obstetric care. It essentially means a well- functioning health system, including equipment and supplies; infrastructure and transport; electrical, water and communication systems; human resources policies, supervision and management; and clinical protocols and guidelines. Hemorrhage: Can be antepartum or postpartum Antepartum hemorrhage: refers severe bleeding before and during labour: placenta praevia, placental abruption Postpartum hemorrhage: refers to any of the following; postpartum bleeding that requires treatment (e.g. provision of intravenous fluids, uterotonic drugs or blood), retained placenta, severe bleeding from lacerations (vaginal or cervical), vaginal bleeding in excess of 500 ml after childbirth and more than one pad soaked in blood in 5 minutes. Maternal death: is the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental or incidental causes (2). Maternal mortality ratio: refers the number of maternal deaths in a year per 100,000 live births during the same year. It measures the risk of maternal death among pregnant or recently pregnant women. Maternal (obstetric) complications: refers maternal morbidities suffered during pregnancy through the postpartum period of 42 days and that may directly cause maternal deaths. Obstetric or maternal complications are acute conditions including antepartum or postpartum hemorrhage, VI prolonged or obstructed labor, postpartum sepsis, complications of abortion, pre- eclampsia/eclampsia, ectopic pregnancy, and ruptured uterus (3). Neonatal mortality: is death of a neonate in the first month of life. Non-skilled attendants: refers maternal care providers who are not trained to proficiency in the skills necessary to manage or refer obstetric complications. Non-skilled attendants include TBAs (trained or untrained), relatives and other community workers with brief health training. In this study, the TBAs (trained or untrained), relatives and HEWs are categorized under non- skilled providers. Skilled maternal care (or skilled care): refers to the care provided to a woman and her newborn during pregnancy, childbirth and immediately after birth by an accredited and competent health care provider (skilled attendant) that can be provided at different levels (home, health centers or hospitals) (4, 5). Skilled attendants A skilled birth attendant is medically qualified provider with midwifery skills (midwife, nurse or doctor) who has been trained to proficiency in the skills necessary to manage normal deliveries and diagnose, manage, or refer obstetric complications (6). Midwifery skills are a defined set of cognitive and practical skills that enable the individual to provide basic health care services throughout the continuum of pregnancy, childbirth and postnatal period and to provide first aid for obstetric complications and emergencies, including life-saving measures when needed (6). In this study, midwives, nurses, health officers and doctors including obstetricians were considered as skilled providers. The principal categories of skilled attendants include: 1. Midwives (including nurse-midwives): Persons who, having been regularly admitted to an educational program duly recognized in the country, in which it is located, have successfully completed the prescribed course of studies in midwifery and acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery. 2. Nurses with midwifery skills: refers nurses who have acquired midwifery knowledge and skills either as a result of midwifery being part of their nursing curricula or through special post basic training in midwifery. VII 3. Health officers with midwifery skills: are those trained for four years to get their Bachelors degree and they work as clinician in the rural set up (health centers). They acquired midwifery knowledge and skills as a result of midwifery being part of their curricula 4. Doctors with midwifery skills: refers medical doctors who have acquired competency in midwifery skills through specialist education and training, either during their pre-service education or as part of a post-basic program of studies. 5. Obstetricians: refers medical doctors who have specialized in the medical
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