2. Volume 28, Special Issue, 2014, 1-43 ISSN 1021-6790
http://www.etpha.org http://www.ajol.info/
yx!T×ùÃyx!T×ùÃyx!T×ùÃyx!T×ùÃ ----@Â L¥T m{/@T@Â L¥T m{/@T@Â L¥T m{/@T@Â L¥T m{/@T
The
Ethiopian
Journal
Of
Health
Development
Joint Scholarly Publication of the Ethiopian Public Health Association and the School of
Public Health, College of Health Sciences, Addis Ababa University
Editor-in-Chief
Damen Haile
Mariam
Associate Editor
Ahmed Ali
Special Issue
On
Academic-Private Sector Collaboration in
Public Health Operations Research
(School of Public Health, Addis Ababa University &
the Integrated Family Health Program (IFHP))
1
1
These studies are made possible by the generous support of the American people through the United States Agency for International
Development (USAID). The contents are the responsibility of the Integrated Family Health Program (IFHP) and do not necessarily
reflect the views of USAID or the United States Government.
3. Volume 28, Special Issue, 2014, 1-43 ISSN 1021-6790
http://www.etpha.org http://www.ajol.info/
1 Editorial: Academic-private sector collaboration in public health operations research (PHOR): The
case of Addis Ababa University Scool of Public Health (AAU-SPH) and the Integrated Family
Health Program (IFHP). Adamu Addisse, Seifu Hagos, Girma Kassie, Tariku Nigatu, Mengistu Asnake
6 Magnitude and factors that affect males’ involvement in deciding partners’ place of delivery in Tiyo
District of Oromia Region, Ethiopia. Wassie Lingerh, Bekele Ababeye, Ismael Ali, Tariku Nigatu,
Heran Abebe, Getnet Mitike, Mitike Molla
14 Identification of factors associated with method shift from short-acting to long-acting methods of contraception
in Amhara Region of Ethiopia. Habtu Atnafu, Yigzaw Dires, Amare Yeshambaw, Seid Ali, Wondimu
Gebeyehu,Shewangizaw Bereda, Fikre Enqusilassie, Alemayehu Mekonnen, Adamu Addissie, Seifu Hagos
20 Magnitude and predictors of skilled delivery service utilization: A health facility-based, cross-
sectional study in Tigray. Tesfaye Gebru, Desta Gebre-Egziabher, Kelali Tsegay, Brhane Hadera, Mesfin
Addisse, Worku Tefera, Adamu Addisse, Seifu Hagos
26 Utilization of Prevention of Mother to Child transmission (PMTCT) services and factors that affect
knowledge and service uptake among pregnant women attending antenatal care in East Hararge
Zone of Oromia Regional State. Megersa Gobena, Tariku Nigatu, Belay Ymam, Adeba Tasisa, Daniel
Wagaw, Fufa Birmechu, Daniel Keba, Ahmed Ali, Wubgzier Makonnen, Adamu Addisse, Seifu Hagos
36 Assessment of health care seeking behavior of caregivers for common childhood illnesses in Shashogo
Woreda, Southern Ethiopia. Bekele Demissie, Berhanu Ejie, Habtamu Zerihun, Zergu Tafese, Getu
Gamo, Tilahun Tafese, Abera Kumie, Jemal Haider, Adamu Addisse, Seifu Hagos
5. 1
Addis Ababa University, School of Public Health;
2
Integrated Family Health Program, Ethiopia.
EDITORIAL
Academic-private sector collaboration in public health operations
research (PHOR): The case of Addis Ababa University School of
Public Health (AAU-SPH) and the Integrated Family Health Program
(IFHP)
Adamu Addisse1
, Seifu Hagos1
, Girma Kassie2
, Tariku Nigatu2
, Mengistu Asnake2
Background
Universities are recognized as sources of
knowledge, innovation and technological
advances. Across the globe, they are being
positioned as strategic assets in innovation and
economic competitiveness, and as
problemsolvers for socio-economic issues
affecting their societies. Synergies between higher
education institutions and industry play a critical
role in securing and leveraging additional
resources by promoting innovation and
technology transfer (1). Universities need to work
to understand the factors that support or
undermine human development and monitor
ways whereby such development can be used to
enhance the quality of life. For universities to be
able to play this role effectively, it is vital that
they create a new equilibrium between education,
research, and service and define new strategies
for assisting society in addressing the more
urgent problems of development. By forming
coalitions with other institutions, government
and society, they can, assist in creatinga national
agenda fordevelopment issues (2, 3).
Academic institutions such as schools of public
healthhave traditionally focused mainly on
training and research–where academics focus on
training and research while service agencies
(governmental and non-governmental) focus on
serving the public. There are various guiding
documents for engaging academic Institutions in
service and industry including the Bayh-Dole Act
of 1980 (4). That 1980 encourages technology
transfer from universities to industry, with
resources financial facilitated among academics,
biomedical researchers, and the biotechnology
industry. Over the years, the basic the necessity
for academic institutions in the provision of
service has been emphasized and various forms
of collaborations have evolved. Various
collaborative models are documented in Africa
between academic and public healthservice
agencies in areas of training human resources and
research (4, 5) as well as between the public
health system and academic institutions such as
schools of public health (4-12).
The Ethiopian health system is in dynamic
change all the time with relatively rapid
developments especially in the last two decades
interms of new health policies, programs, and
growth. Therefore, public and private sectors
need to identify their challenges, the challenges,
and come up with practical and viable solutions
to adapt to the changing environment through
operations research. This type of research in
health care is crucial foridentifying health
priorities and operations problems by producing
evidence for planning and decision-making to
improve health care services. Although it is
critical, operations research has not been pursued
in a coordinated manner during the first and
second Health Sector Development Program
(HSDP) period. However, improvements have
been observed in HSDP III and IV. Research
and technology transfer is one of the core
processes redesigned as part of the business
processing re-engineering during the last HSDP
(13).
The Deputy Prime Minister of the Federal
Democratic Republic of Ethiopia, during a
meeting on university and industry collaboration,
said that universities need to work closely with
industries in Ethiopia to identify and solve
operational problems of industries through
research and advisory so that Ethiopia would
6. 2 Ethiop. J. Health Dev.
Ethiop. J. Health Dev. 2014;(Special Issue 1)
soon join the middle income countries. This
statement indicates that governments are
increasingly acknowledging the importance of
higher learning institutions as strategic actors in
national economic development, given their
potential in upgrading the knowledge and skill of
the workforce and their contribution to process
and product innovation (14).
Partnerships between academic institutions and
private industryallow academicians and health
practitioners to exchange experiences and
resources can lead to rapid development.
Examples of such collaborations and
engagements of universities include the
involvement of US universities as contractors and
sub-grantees to the PEPFAR grant/initiative in
various African countries, including Ethiopia.
However, even such initiatives fail to be typical
models of collaborations since the in-country
programs of each initiative function as public
health service agencies. Moreover, the existing
collaborations have not reached expectations and,
so far, there is no clear collaborative channel or
mechanism between academia and service
institutions.
The current collaboration between the School
Public Health (SPH) of Addis Ababa University
and the Integrated Family Health Program
(IFHP) stared with the objective of enhancing
the capacity of the IFHP staff to undertake
operations research and to strengthen and
expand the school’s linkage, presence, and
engagements in the community to solve
problems that hinder better health outcomes.
The partnership convened regional health
bureaus (RHB) and IFHP staff from across four
regions. The two partnersinitiated IFHP staff-led
research studies with the expectation that
findings would inform the partnership’s own
program implementation and guide its future
direction.
The collaborating partners
Addis Ababa University (website address:
http://www.aau.edu.et/), where the SPH is
housed, was established in 1950. It is the oldest
and largest higher education institution in
Ethiopia. The university has made remarkable
contributions to the country by providing with
trained manpower, research, and community
services– the pillars of the university’s mission.
Addis Ababa University’s College of Health
Sciences houses the School Public Health, the
School of Medicine, the School of Pharmacy, the
School of Allied Health Sciences, and the
teaching hospital. The College of Health Sciences
strives to be a center of excellence in health-
related issues.The SPH, founded in 1964 as the
Department of Community Health of the Faculty
of Medicine, is the oldest national public health
training institution in Ethiopia. Over the years it
has been providing both undergraduate training
of medical students and post-graduate training in
public health master’s (MPH) and doctorate
(PhD) levels. The Department of Community
Health transformed itself to the School of Public
Health in October 2010.
The Integrated Family Health Program (IFHP) is
a USAID-funded health program implemented
by Pathfinder International Ethiopia (PIE) and
John Snow, Inc. (JSI) in partnership with the
Consortium of Reproductive Health Associations
(CORHA) and other local partners. The program
operates within the framework of the Ethiopian
government’s Health Sector Development
Program (HSDP) in general, and the Health
Extension Programin particular, in 301 woredas.
The program focuses on family planning,
reproductive health, and maternal, newborn, and
child health.
The program has a mechanism to systematically
learn from its own program implementation in
order to promote evidence-based practices,
inform policy, and advise future program
investments. IFHP’s strategies are designed to
benefit from adaptation to the differing socio-
demographic and health systems contexts. The
program fosters the sharing of model practices
and success stories in addition to commissioning
and collaborating with stakeholders in the
conduct of operations research projects. Through
close partnership with the RHBs that oversee its
operations areas, IFHP draws upon the ability of
its local implementers to identify and respond to
implementation challenges with solutions
relevant to their local contexts based on scientific
evidence.
7. Academic agency, public health agency, collaboration, operations research 3
Ethiop. J. Health Dev. 2014;(Special Issue 1)
The collaboration process
The current collaborationbetween the two
institutions wasinitiated by the request from
IFHP. The phases in the collaboration
includedneed identification, planning,
implementation, and monitoring. Need
identification was carried out on two levels: first,
building capacity of IFHP and RHB staff, and,
second, the identification of specific research
problems. Once the needs were articulated,
communications between SPH and IFHP began.
Each partner identified a leader who could
facilitate the planning and consensus building
process, and, subsequently, the heads of the SPH
and the IFHP signed a memorandum of
understanding.
Implementing and monitoring were other core
components, which included two week-long
training and field-work accompanied by
mentorship of advisors from the SPH. The first
training focused on problem identification and
proposal writing, giving the trainees the
opportunity to develop proposals in consultation
withthe advisors, finalize ethical clearance, and
collect data. The second training focused on
analysis and report writing. Following the
training, each research team entered and analyzed
data and produced reports with the support of
their respective advisors.
Outcome of the collaboration and lessons
learned
As a result of the joint venture, more than 25
IFHP and RHB personnel received training on
research methods. In addition, five operations
research projects were designed and successfully
carried out. In the process, the staff of IFHP
obtained theoretical and practical knowledge and
skills in undertaking quantitative and qualitative
research. They were involved in selecting
research topics, developing research proposals,
processing ethical reviews, training data
collectors, supervising the data collection process,
entering and cleaning the data, analyzing and
interpreting the data, writing reports, and
developing research manuscripts for publication
and to the wider public (Table 1). The
manuscripts of each have been issued in this
volume and were jointly authored by the SPH
advisors and IFHP staff.
Table 1: Research projects funded by USAID undertaken by the collaborative effort, including their objectives
and the regions where the research wasconducted.
The SPH also used the opportunity to provide
support to the community, particularly in helping
the IFHP identify health problems in the
community in an effort to provide viable options
and solutions for improved health outcomes.The
collaborative undertaking mutually benefited the
collaborators in many ways. The most important
reasons why the collaboration worked and
produced results were:
Region
(Team)
Operations research titles Objective(s)
Oromia
(Country team)
Determinants of male involvement in
supporting partners to access institutional
delivery
To assess male partners’ involvement in
deciding their spouses’ place of delivery and
identified factors associated with it in Tiyo
woreda of Arsi zone, Ethiopia
Oromia
(Regional team)
Facilitators of uptake and use of prevention of
mother-to-child transmission of HIV services
To identify factors that influence utlization of
services provided by health facilities to
prevent the transmission of HIV from mothers
to their children
Tigray
(Regional team)
Factors that influence the use of delivery
services with a skilled birth attendant
To assess advantages of skilled birth
attendant and associated factors
Amhara
(Regional team)
Assessment of factors associated with
method change from short-acting to long-
acting and permanent contraceptive methods
To assess factors associated with method
change from short-acting to long-acting and
permanent contraceptive methods in five
zones of Amhara region.
SNNPR
(Regional team)
Caregivers’ health-care-seeking behavior for
common childhood illnesses
To assess the status of health-care-seeking
behavior of caregivers for childhood illnesses
and associated factors
8. 4 Ethiop. J. Health Dev.
Ethiop. J. Health Dev. 2014;(Special Issue 1)
1. Dynamics of science and research methods –
universities are stronger in this aspect of
continuously updating knowledge and
sharpening research skills;
2. Service-providing agencies (government and
non-government) areatthe forefront of
providing service to the community.As a
result of their activities, they face various
challenges that need solutions based on
scientific evidence. Thus, fertile ground exists
for the two parties to collaborate and take
advantage of each other’s expertise;
3. Collaboration provides synergy and fosters
bi-directional learning; and
4. Joint efforts help to pool resources and
improve efficiency.
An article published by The Lancet shows that
partnership between academic institutions and
service delivery systems help build effective
interfaces between the collaborating institutions
and the community, andresults in more effective
public-private partnership (15). Similarly, the
collaboration between the SPH and the IFHP has
resulted in the transfer of knowledge and skills
that may lead to the achievement of the desired
health outcomes in the community, which is the
common goal shared by both institutions.
According to Chika Charles et al. (16),
collaborative relationships and partnerships
between universities and the private sector,
particularly NGOs, alsoserve multiple purposes.
For example, in helping expose and frame
research questions, allowing interaction
throughout the research process, supporting data
collection and analysis, and providing outlets for
sharing, feedback and dissemination. This has
also been reflected in the partnership between
SPH and IFHP.
Challenges
These achievements were not obtained without
challenges. One main challenge was the busy
schedules of the participants and the academic
mentors. This obstacle resulted in the various
regions keeping to different project schedules
instead of the original one prescribed. Despite
the coordinators’ repeated encouragement and
reminders about deadlines to the partners, the
process timeline was eventually adjusted to
accommodate the unforeseen delays. Moreover,
unexpected negotiation and consensus were
necessary before the five teams were able to agree
on a common timeframe for the training
workshops. Finally, the ethical review process for
the proposals was not uniform among the
regions and the requirements for each varied
significantly. The regional health offices tried to
facilitate this process to create uniformity among
all of the participants.
Conclusion
The IFHP SPH partnership in PHOR has
demonstrated the feasibility of this partnership
model which can be further and better utilized to
address prevalent operational public health
problem in the Ethiopian setting. Therefore, we
recommend the adoption of similar approaches
in Ethiopia and beyond in order to synergize
efforts towards meeting the goals of delivering
quality public health services.
References
1. Hernes G, Martin M. Management of
university industry linkages. Results from the
policy forum held at IIEP. Paris;
IIEP/UNESCO, 2000.
2. UNESCO. International conference on
education, 38th session, Geneva, 10-19
November 1981. Paris; UNESCO, 1982.
3. UNESCO. Study service: A tool of
innovation in higher education. Paris;
UNESCO, 1984.
4. The Bayh-Dole Act or Patent and Trademark
Law Amendments Act. Pub. L. 96-517, USA,
December 12, 1980.
5. Editorial. Universities in transition to
improve population health: A Tanzanian case
study. Journal of Public Health Policy 2012; 33:
S1, S3-S12.
6. Beyes N, Academic program partnership for
operational research: A TREAT TB initiative
in South Africa, 42nd Union World
Conference on Lung Health, 26-30, October
2011, Lillie, France.
7. Schieve LA, Handler A, Gordon AK, Ippoliti
P, Turnock BJ. Public health practice linkages
between schools of public health and state
health agencies: Results from a three-year
9. Academic agency, public health agency, collaboration, operations research 5
Ethiop. J. Health Dev. 2014;(Special Issue 1)
survey. J Public Health Management Practice
1997; 3(3):29 -36.
8. Gordon AK, Chung K, Handler A, Turnock
BJ, Schivelve LA, Ippoloti P. Final report on
public health practice linkages between
schools of public health and state health
agencies: 1992-1996. J Public Health
Management Practice 1999; (3):25-34.
9. Keck CW. Lessons Learned from an
academic health department. J Public Health
Management Practice 2000; 6(1):47-52.
10. Livingood WC, Goldhagen J, Little WL,
Gornto J, Hou T. Assessing the status of
partnerships between academic institutions
and public health agencies. Framing health
matters. Am J Public Health 2007;97(4):659-
666.
11. Nolle KC. Nevada's academic practice
collaboration: Public health preparedness
possibilities outside an academic center.
Public Health Reports 2005; 120
(Supplement1):100-120,.
12. Mier N, Establishing successful binational
academic collaborations in minority health
research. Public Health Reports 2005; 120:471-
475.
13. Federal Ministry of Health (FMOH),
Ethiopia. Health Sector Development
Program IV (HSDP IV). FMOH; Addis
Ababa, 2010.
14. Ethiopian Television. Ethiopian news [cited
09 December 2013]; Available at:
URL:http://www.diretube.com/ethiopian-
news/university-industry-linkage-to-be-
assembled-video_a5dbd8776.html.
15. Dzau VJ, Ackerly DC, Sutton-Wallace P,
Merson MH, Williams RS, Krishnan KR,
Taber RC, et al. The role of academic health
science systems in the transformation of
medicine. The Lancet 2010; 375(9718):949 -
953.
16. Charles AC, Hayman R, Mdee A, Akuni J,
Lall P, Stevens D. Academic-NGO
collaboration in international development
research: A reflection on the issues. Working
Paper. September 2012.
10. 1
Integrated Family Health Program, POBox 12655, Wassie Lingerih Tel:251911954141
Email: wlingerih@ifhp.orgAddis Ababa, Ethiopia;
2
Addis Ababa University, School of Public Health, Addis Ababa, Ethiopia.
Magnitude and factors that affect males’ involvement in
deciding partners’ place of delivery in Tiyo District of Oromia
Region, Ethiopia
Wassie Lingerh1
, Bekele Ababeye1
, Ismael Ali1
, Tariku Nigatu1
, Heran Abebe1
, Getnet Mitike2,
Mitike Molla2
,
Adamu Addisse2
, Seifu Hagos2
Abstract
Background: Skilled birth attendants at health facilities reduce the death toll on mothers and newborns significantly.
To the knowledge of the investigators, male involvement in deciding on the partners’ place of delivery and factors that
affect male involvement have not been studied adequately in the Ethiopian context.
Objective: The study set out assess male partners’ involvement in deciding on their spouses’ place of delivery and to
identify factors associated with this involvement in the Tiyo District (Woreda) of Arsi Zone, Ethiopia.
Methods: A community-based cross-sectional survey was taken between January and February 2012 in Tiyo district
of Oromia Region. The study involved both quantitative and qualitative methods. A list of males, whose partners gave
birth within 12 months prior to the survey, was prepared. A total of 999 men were included in the study. In addition,
separate male and female focus group discussions (FGDs) were need to obtain additional information and to
triangulate the quantitative findings. Data were collected using interviewer-administered questionnaires and a FGD
guide. Descriptive and analytical statistics were calculated to summarize the data and explore associations.
Results: The majority of respondents were farmers (93.4%) and had some formal education (84.6). Joint partners’
source of income (OR=4.25, 95%CI: 1.77- 10.2), making joint decision on antenatal care (ANC) service uptake
(OR=3.61,95% CI: 1.52-8.57), history of previous institutional delivery (OR=2.10, 95%CI: 1.15-3.85) and owning
radio and tape-recorder (OR=1.77, 95%CI, 1.20-2.85) were significantly associated with male involvement in deciding
their spouses’ place of delivery. Qualitative findings showed a low level of awareness of the benefit of health facility
use for delivery, low level of knowledge of danger signs related to pregnancy and delivery, and traditional and cultural
influences about perceptions.
Conclusion: Girls and women should be empowered by education and income-generating activities and male-targeted
messages should be applied through mass media to motivate male partners to be involved in jointly deciding their
spouses’ place of delivery. Health care providers should design a mechanism to involve male partners during ANC to
jointly counsel partners on danger signs, birth preparedness, and complication readiness. Traditional and cultural
barriers need to be addressed and made related to local context in tailored activities based on evidence from research.
[Ethiop. J. Health Dev. 2014; (Special Issue 1):6-13]
Background
Globally, more than 536,000 maternal and 8 million
perinatal deaths occur every year (1). Maternal deaths are
the ‘tip of the iceberg’ of the potential dangers faced by
childbearing women in many parts of the world. For
example, more than 1.4 million women survive severe
life-threatening complications (maternal near-miss) and
an additional 9.5 million women suffer from severe and
debilitating conditions, such as fistula and infertility (2).
Sub-Saharan African countries account for over 90% of
maternal and neonatal deaths. Ethiopia is one of the six
countries that account for 50% of maternal deaths
globally (3).
Over 60% of maternal and newborn deaths occur during
labor, delivery, and the first days of postnatal period.
These deaths can be prevented by making skilled birth
attendants (SBAs) available for every delivery and by
ensuring access to Basic Emergency Obstetrics and
Newborn Care (BEm ONC) for all complications (4, 5).
The use of SBAs at health facilities varies widely among
countries. As many as 99% of deliveries were attended
by SBAs in developed countries compared to only 33.7%
in eastern African countries (5).The rate is much lower in
Ethiopia, where service uptake is expected to rise from
the current level of 10% to 60% by the end of 2015 (6,
7).
Involvement of males in reproductive health is an
important step in reducing maternal and newborn deaths
and for achieving Millennium Development Goals
(MDGs) 4 and 5 (8). According to most studies, male
partner involvement in maternal and child health care
remains low in many sub-Saharan African countries (9).
Though the role of men in maternity care is under-studied
in Africa, open discussion between partners on where to
give birth improves skilled delivery service uptake at
health facilities (10). Peer-led, culturally sensitive
community education increases males’ involvement and
improves service uptake (11). Studies conducted in
different countries indicate that social, cultural, and
religious factors play a paramount role in SBA service
uptake. Gender inequality, harmful traditional practices,
the low social status of women, limited female
11. Magnitude and factors that affect males’ involvement in deciding partners’ place of delivery in Tiyo 7
Ethiop. J. Health Dev. 2014;(Special Issue 1)
involvement in decision making, family members’
influence and decisions, and women’s limited influence
over their families are key factors in SBA service uptake
(12). In addition, religious reasons, poor attitude of health
workers, and the poor quality of care are related to low
service uptake (13). Skilled antenatal care (ANC)
attendance declines from the first to the fourth visit,
resulting in low skilled delivery service uptake. The
reasons also include no-access-related ones, such as socio
cultural and economic factors, which play an important
role in women’s health-seeking behavior during
childbirth (14). In rural Ethiopian, male partners are
gatekeepers to the family including for health service use.
They usually prefer home delivery for their partners
because of cultural influences and fear of expenses
associated with medical and transport services (15).
The Integrated Family Health Program (IFHP) is a
comprehensive maternal and newborn health intervention
in 20 districts with the objective of improving access to
and utilization of skilled delivery services at health
facilities. The project has been implemented for the past
three years and has achieved varying degrees of
improvement across the districts. Service use did not
increase uniformly across the sites and the findings of
this operational research will be utilized to address
challenges.
In the Ethiopian context, males are close to their partners,
the owners of significant household resources, and the
primary decision makers. Therefore, understanding the
factors that affect their involvement in selecting their
spouses’ place of delivery is important to inform the
efforts of policy makers, program planners, and health
care providers to improve health facility delivery service
utilization. This study was made to assess male
involvement in selecting their spouses’ place of delivery
and to identify factors that influence their involvement,
with the intent of using the findings to improve the
program, in designing and improving similar programs,
and to informrelevant policymaking.
Methods
Study Area, Study Design, Study Population, and Data
Collection:
A cross-sectional study was carried out in Tiyo Woreda
of Arsi Zone of Oromia Regional State of Ethiopia from
January to February 2012. The study involved both
quantitative and qualitative methods sequentially. The
quantitative data were collected during the first two
weeks of January 2012 followed by the qualitative data
collection. A structured, pretested, interviewer
administered questionnaire was used for the quantities
survey and focus group discussions were used to collect
the qualitative data. The study participants for the
quantitative survey cause men aged 18 years or more
whose spouses gave birth within 12 months prior to the
survey and living in the selected kebeles.
Sample size and sampling technique: The sample size
for the study was calculated using single population
proportion formula, taking p= 50 %, precision of 5% , at
95% confidence level, a design effect of 2 for cluster
sampling method and 30% for non-response gave a
sample size of 999. Tiyo Woreda was selected
purposively because it is within IFHP’s support zone.
Among Tiyo Woredas’ 16 kebeles, 8 were selected using
a simple random sampling technique. Households in each
kebele with men aged 18 years or above and whose
spouses gave birth within 12 months prior to the survey
were listed. Then the number of households to be
selected from each kebele was determined using PPS.
Finally, the required number of households from each
kebele was selected using a simple random sampling
technique.
Six focus group discussions (FDGs) (3 male and 3
female) were conducted. The men and women with
partners were selected purposively to participate in the
FGDs each consisting 6 to 12 participants. The FGDs
were moderated by experienced facilitators using an FGD
guide.
Operational definitions:
• Male partner: male who has a spouse, whether
with formal marriage or informal union.
• Male involvement: males who were involved in
deciding their spouses’ delivery place alone or
together with their spouses, family members, or
another individual. This included deciding a
health facility, a health post (HP), home,
ortraditional birth attendant’s (TBA) home as a
place of birth.
• Joint partners’ source of income: households
with incomes generated from both the man and
the woman, in formal or informal union.
Data Management and Analysis:
Each questionnaire was checked for consistency and
completeness during data collection. Then, the
questionnaires were entered and cleaned before analysis.
Analysis of the cleaned data was done using SPSS
version 20. The result of the study is presented using
tables and graphs. Percentages and frequencies were
calculated to describe the data and chi square tests and
logistic regression were used to explore associations
between dependent and independent variables. The
qualitative data was analyzed using open code software
package version 3.6.2.0, transcribed and summarized
under each theme and presented textually.
Ethical Considerations:
Ethical clearance was obtained from the Oromia
Regional State Health Bureau. Permissions were also
secured from local officials at data collection sites. The
objectives of the study were explained to study
participants. Potential harms and benefits of the study
were explained to each respondent and then informed
12. 8 Ethiop. J. Health Dev.
Ethiop. J. Health Dev. 2014;(Special Issue 1)
consent was obtained. The respondents were allowed to
withdraw from the interview at anytime they wished and
participation was completely voluntary. The data
obtained were handled with confidentiality. No personal
identifiers, such as names, were used during data
collection, analysis, or report writing.
Results
The response rate for this study was 100%. Four hundred
and eighteen (41.8%) of the respondents were between
the ages 25 and 34 years. The median age was 34 years
(IQR: 28 to 40 years). The majority (933 or 93.4%) of
them were farmers, had some formal education (845 or
84.6%), and were married (743 or 74.4%). A quarter (255
or 25.6%) of the respondents cohabited with their female
partners without formal marriage. Nearly all (987 or
98.9%) were currently living with their female spouses
and 94 (9.4%) were in polygamous marital unions. About
half of the respondents owned radios (569 or 57%) and
mobile phones (451 or 45.2%), (see Table 1).
Similarly, the median age of male FGD participants was
39 years (IQR: 32 to 40 years) with two-thirds 17(68%)
of them being farmers and educated. All female FGD
participants were in the age range of 15 to 45 years, most
(16 or 84.1%) were educated, more than half (11 or
57.8%) were housewives, and more than one-third (6 or
31.6%) were farmers (see Table 2).
Table 1: Socio-demographic characteristics of
respondents who participated in the survey in Tiyo, Arsi
(n=999)
Variable Respondents n (%)
Age in years
18-24 82 (8.2)
25-34 418 (41.8)
35-44 345 (34.5)
45 + 153 (15.3)
Ethnicity
Oromo 812 (81.4)
Amhara 177 (17.7)
Gurage 9 (0.9)
Religion
Orthodox 424 (42.5)
Muslim 547 (54.8)
Catholic 5 (0.5)
Protestant 19 (1.9)
Other 3 (0.3)
Type of union
Married 743 (74.4)
Living together 255 (25.6)
Currently living with spouse
Yes 987 (98.9)
No 11 (1.1)
How many years have you been
together
Less than 1 10 (1.0)
1-5 312 (31.3)
6-10 244 (24.4)
More than 10 432 (43.3)
Age in years at first marriage
12-19 192 (19.2)
20-24 423 (42.4)
25-34 331 (33.2)
35 or more 52 (5.2)
Do you have another marriage
Yes 94 (9.4)
No 904 (90.6)
Ever attended formal school
Yes 843 (84.6)
No 154 (15.4)
Educational status
Up to grade 4 173 (20.5)
Grade 5 to 8 457 (54.3)
Grade 9 to 10 166 (19.7)
Preparatory 29 (3.4)
Preparatory plus 17 (2.0)
Occupation
Farmer 934 (93.4)
Government employee 22 (2.2)
Merchant(trader) 18 (1.8)
Student 4 (0.4)
Daily laborer 20 (2.0)
Number of rooms in your house
1 451 ( 45.2)
2-3 487 (48.8)
More than 3 60 (6.0)
Possession of household/personal
goods
Radio and tape-recorder 206 (20.6)
Radio 569 (57.0)
Mobile phone 451 (45.2)
Television(TV) 53 (5.3)
No TV, radio, tape, or mobile phone 161 (16.1)
13. Magnitude and factors that affect males’ involvement in deciding partners’ place of delivery in Tiyo 9
Ethiop. J. Health Dev. 2014;(Special Issue 1)
Table 2: Socio-demographic characteristics of
respondents who participated in FGD in Tiyo, Arsi
Zone
Variable Respondents n (%)
Age in years
Male
25-34 9 (36)
35-44 6 (24)
45+ 10 (40)
Type of union
Female
Married 18 (94.7)
Not married 1 (5.3)
Educational status
Male
Not educated 8 (32)
Primary level school 4 (16)
Secondary level school and
above
13 (52)
Females
Not educated 3 (15.7)
Primary level school 3 (15.7)
Secondary level school and
above
13 (68.4)
Occupation
Males
Farmer 17 (68)
Small business 3 (12)
Teacher 1 (0.4)
Not working 4 (16)
Females
Farmer 6 (31.6%)
Housewife 11 (57.8)
Self-employed 1 (5.3%)
Daily laborer 1 (5.3%)
In this study, male involvement is defined as decisions
made by men in choosing the place of delivery for their
female partners. This was ascertained by asking who
decided the place of delivery for the last pregnancy. The
study showed high (903 or 90.4%) male involvement in
deciding the place of delivery regardless of the place of
delivery. The involvement was relatively higher among
men whose spouse delivered at health facilities (Figure
1). In this study, 260 (26%) men responded that their
spouses delivered at health facilities (hospital or health
center) and the majority (725or 72.6%) responded that
their spouses gave birth at home (Figure 2). Among
respondents, whose spouses gave birth at health facilities,
most (252 or 97%) of them accompanied their spouses to
the health facilities at the time of delivery (Figure 3).
Male FGD participants agreed that attending ANC is
important and one male group believe that permission
from the husbands was needed to start ANC. As for place
of delivery place, most male FGD participants identified
home as the best place for giving birth. This finding is
similar to that of the quantitative study. Most male FGD
participants were not able to identify danger signs
(symptoms) related to pregnancy or delivery. In one male
group, all agreed that pregnancy and childbirth are not
associated with dangerous health problems. The female
groups also could not adequately identify the dangerous
health problems.
Figure1: Male involvement in deciding their spouses’ place of delivery in the last pregnancy by place of
respondent’s spouse’s delivery place, Tiyo Woreda, January 2012
14. 10 Ethiop. J. Health Dev.
Ethiop. J. Health Dev. 2014;(Special Issue 1)
hospital
17%
health
center
9%
health
post
1%
Home
73%
3%
97%
Yes
No
Figure 2: Spouse’s delivery place for the last
pregnancy, Tiyo Woreda, January 2012
Figure 3: Male partners accompanying their spouse
to facility during delivery
In this study, there was no statistical significant
difference in the median age of males who were involved
in decision making and those who were not. Upon binary
logistic regression, the odds of respondents, whose
spouses delivered their last baby at health facilities
(OR=2.20, 95%CI: 1.22-3.94), those whose family
income came from both partners (OR=4.25, 95%CI:1.77-
10.2), those who decided jointly on ANC service uptake
(OR=3.61,95%CI:1.52-8.57), and those with a radio and
tape-recorder (OR=1.77, 95%CI:1.20-2.85) were
significantly higher in involvement in selecting the place
of delivery compared to those who were not. Male
partners, whose spouses gave birth of their last pregnancy
at a health facility (OR=2.10, 95%CI: 1.15- 3.85), joint
family income (OR=4.06, 95%CI, 1.63-10.1), joint
decision making on going for ANC service (OR=3.61,
95%CI, 1.52-8.57), and ownership of radio and tape-
recorder (OR=1.77, 95%CI, 1.20-2.85) remained
statistically significant in multivariate logistic regression
(Table 3).
Table 3: Determinants of male involvement in Tiyo Woreda, Arsi, 2012 (n=999)
Variable Male Involvement COR (CI) AOR (IC)
Yes No
Place of delivery of spouses last pregnancy
Health facility 246 14 2.20 (1.22, 3.94)* 2.10 (1.15, 3.85)**
Home or health post 657 82 1.0 1.0
Family source of income
Own and spouse’s earnings 13 282 4.25 (1.77, 10.2)* 4.06 (1.63, 10.1)**
Own earnings 73 566 1.52 (0.74, 3.12) 1.28 (0.60, 2.72)
Others’ (relatives) 10 51 1.0 1.0
Decision maker on ANC attendance during last
pregnancy
Self with spouse jointly 723 56 3.83 (1.66, 8.81)* 3.61 (1.52, 8.57)**
Spouse 81 16 1.50 (0.58, 3.89) 1.41 (0.53, 3.78)
Self 68 16 1.26 (0.48, 3.26) 1.46 (0.43, 3.14)
Other 27 8 1.0 1.0
Radio and Tape-recorder ownership
Yes 196 10 2.39 (1.22,4.70)* 1.77 (1.20,2.85)**
No 703 86 1.0 1.0
**Statistically significant.
Additional factors affecting male involvement in decision
making about spouses’ place of delivery identified
through FGDs included the influence of TBAs in favor of
home delivery and cultural influences preventing facility
delivery. The male FGD participants unanimously ruled
out religious belief or cost of services as factors
preventing skilled delivery service use. A 40-year-old
male discussant said:
“From my clan, there are traditional believes that
prohibit women from visiting health facilities. In my
opinion, my relatives are not willing to allow pregnant
15. Magnitude and factors that affect males’ involvement in deciding partners’ place of delivery in Tiyo 11
Ethiop. J. Health Dev. 2014;(Special Issue 1)
women to visit health facility due to poor awareness of
the benefits of health facilities”.
Female FGD participants identified lack of awareness of
benefits of delivering in health facilities, cultural beliefs,
lack of privacy at health facilities, exposure to long
procedures, lack of support from male partners, and lack
of money as factors that force pregnant women to give
birth at home despite the fact that health facilities are
clean and provide better services.
In contrast to the survey findings, male FGD participants
mentioned that young, educated males were more
involved in selecting health facility as a place of delivery
than those who are elderly and less educated. They
stated:
“There is a problem of accepting maternal-related
education by those male partners who have no education.
Those who are educated visit health facilities. There is no
difference in visiting health facilities because differences
in economic status”.
The female FGD participants identified the influence of
in-laws’ preference for local TBAs for labor and delivery
attendance over health facilities. The female FGD
discussants expressed that male partners, who are
respected by the community members are involved in
selecting health facilities for delivery.
Female FGD discussants explained:
“Those men who have good reputation and acceptance in
communities, are usually good in supporting their
spouses to go to health facilities for ANC and delivery
services. There are no socio-cultural barriers hindering
males from participating in supporting their spouses to
attend facility-based delivery”.
Moreover, both male and female discussants stressed the
importance of the health extension workers in improving
male involvement in selecting the health facility for
delivery services.
Discussion
The study findings revealed a high proportion of male
involvement (90.4%). This proportion is even higher
among respondents whose spouses gave birth at health
facilities (95%). Among respondents, whose spouses
gave birth at home, 89% of males were involved in
selecting the home as the place for delivery. The male
and female FGD participants could not identify most of
the danger signs associated with pregnancy, delivery, and
the immediate postpartum period.
This study showed a relatively higher level of male
involvement than did other studies in Africa. In one study
in Uganda, only about half (56%) of male partners were
involved in deciding spouses’ place of delivery (16).
Among women, who gave birth at the health facilities,
this study showed a higher level (96.9%) of males
accompanying their spouses compared to 43% in other
studies (9, 17). The degree of male involvement ranges
from an absolute male decision to joint decision making,
as seen in a study in Tanzania (11). This survey identified
important factors that have a significant influence on
male partner involvement. The respondents’ spouses’
place of last delivery was a factor; respondents, whose
spouses delivered at a health facility, were twice as likely
to be involved in selecting the delivery place as
respondents whose spouses delivered at home
(OR=2.10,95% CI:1.15-3.85). This may be because of
male partners’ awareness of the benefits of using
facilities. This finding is similar to a study of northern
Uganda that found that spouses’ prior skilled delivery
service attendance is significantly associated with male
involvement at subsequent skilled ANC service (17).
This study showed that males, whose spouses utilized
professional delivery care, provided emotional and
informational support to their partners during delivery.
For example, a female FGD participant stated:
“Those men who have a good reputation and acceptance
in communities are usually good in supporting their
spouses to go for health facility ANC and delivery
services.”
This may be because of relatively better behavioral,
economic, and educational status of males preferring
health facilities for its better outcome, as found in a study
in Bangladesh (18).
The odds of male involvement in this decision in couples
with a joint source of family income coming from both
partners is four times greater than those with an income
from only one of them (OR=4.06, 95%CI: 1.63-10.1).
This may be due to the fact that additional sources of
income gave male partners the power to be able to cover
related costs. It may also be due to male partners’ attitude
towards economically supportive spouses, making them
more responsible and accountable as women with own
income practices their right. This study is similar to a
study from Uganda that, showed males, whose spouses
have formal occupation (employed) were significantly
involved for their spouses’ birth preparedness and ready
to result to health facilities in the case of complication
readiness (BPCR) at health facilities (where identifying
health facility for delivery service is among BPCR) than
those with spouses of casual workers or housewives (9).
Decision on ANC visit was a factor for male
involvement; respondents who decided jointly on
attending ANC service for recent pregnancy were more
than 3 times (OR=3.61, 95%CI: 1.52-8.57) more likely to
be involved in decision compared to respondents who did
not decide jointly for ANC attendance. This shows male
partners’ commitment and open discussion between
partners. It may be due to male partner’s knowledge on
16. 12 Ethiop. J. Health Dev.
Ethiop. J. Health Dev. 2014;(Special Issue 1)
the benefit of using health facilities use influencing for
involvement also for delivery place.
This study showed that male partners, who own radios
and tape-recorders were significantly more involved in
deciding their spouses’ place of delivery place (OR=1.77,
95% CI: 1.20-2.85) than those who did not. This may be
due to the exposure to mass media and the new health
information and knowledge from it and thus taking to
new practices. As an important health issue, maternal and
newborn health is among the main current topics of
health education broadcasted over the radio. Hence,
exposure to radio makes male partners more likely to
understand the extent of potential problems, which
causes them to be involved in selecting health facilities
for delivery. This finding is similar to a study conducted
in Uganda where ownership of household assets like a
radio was found to be correlated with a high level of SBA
uptake involving spouses (16). In another study also from
in Uganda, women, who resided in a place longer than a
one-hour walk or more than 5km from the nearest health
facility, were less likely to use SBAs (16, 17). However,
in this survey, distance to facilities from the residence
(by foot) had no influence on male involvement.
Educated women had better pregnancy outcomes than
uneducated ones, as the forms usually selected health
facilities for delivery service in consultation with their
partners (13). However, education level of male partners
had no influence on male involvement in using skilled
maternity services (9, 17). Similarly, this survey showed
no relationship between male involvement and male
partners’ or their spouses’ level of education.
Paradoxically, the male and female FGDs in this study
showed the level of male partner education influenced
male partner involvement in deciding in favor of
delivering at health facilities.
The FGD result showed that husbands, who have respect
and recognition in their communities chose the health
facilities for the place of delivery. A similar qualitative
study in Bangladesh showed male partners with good
social relationships and social norms and who consider
taking care of their partners as a social norm were
involved in selecting the place of delivery (18). This
study’s FGDs found that it was necessary for the come to
obtain male partners’ permission to attend skilled
maternity services, which is similar to another study in
Ethiopia (19).
The strength of the study is believed to be its
methodology with an adequate sample size and its being
supplement by a qualitative study. The limitations
include not having other studies with a similar
methodology to compare it to.
This study found that jointly earned partners’ family
income, joint partners’ decision making about attending
ANC services, delivery at the health facilities for the
previous pregnancy, and ownership of a radio and tape-
recorder were statistically significant after multivariate
logistic regression. Among the respondents whose
spouses gave birth at health facilities, 98.3% of them said
they were confident in the quality of the delivery service
provided at the facilities, but 16.5% of them said their
spouse waited for a long time to get the service after they
arrived at the health facilities.
Conclusions and Recommendations
There was high proportion of male partner involvement
in deciding the location of delivery, both when the
preference was for health facility delivery and for home
delivery. Empowering women, especially in terms of
economic self-sufficiency, will increase male partners’
involvement positively for facility use. Girls’ education
and targeting women with income-generating businesses
are among the mechanism of empowerment. Low levels
of knowledge and awareness of dangerous health
problems associated with pregnancy and delivery, in-
laws’ attitudes, and cultural practices are barriers to male
involvement in selecting facility deliveries.
The following were missed opportunities in ANC service
delivery for SBAs to include male partners and should be
an area of focus: joint counseling of partners on danger
signals, benefit of health facility use, birth preparedness,
and complication readiness. There should be male
targeted health education and other behavior changing
activities based on studies that identify cultural,
traditional, and social barriers at the local levels. Mass
media should target males using tailored messages.
Awider study on male involvement in delivery service
uptake should be conducted to understand other factors
that are not addressed in this study.
References
1. WHO, UNICEF, UNFP and World Bank. Maternal
mortality in 2005, Geneva; WHO, 2000.
2. Philippi V, Ronsmans C, Campbel O, Graham J.W,
Mills A, Borgh JI, et al. Maternal health in poor
countries: The broader context and a call for action.
The Lancet 2006; 368((9546):1535-41.
3. Hogan MC, Foreman KJ, Naghavi M, Ahn SY,
Wang M, Makela SM, et al. Maternal Mortality for
181 countries, 1980-2008: A systematic analysis of
progress towards Millennium Development Goal 5.
The Lancet 2010; 375(9726):1609 – 1623.
4. Ronsmans C, Graham JW. Maternal mortality: Who,
when, where, and why. The Lancet 2006;
368(9542):1189-200.
5. Adegoke AA, Van den Broek N. Skilled birth
attendant lesson learnt. BJOG 2009; 116
(supplement):1033-30).
6. Central Statistical Agency [Ethiopia] and ICF
International. Ethiopia demographic and health
survey 2011. Addis Ababa, Ethiopia and Calverton,
Maryland, USA, 2012.
17. Magnitude and factors that affect males’ involvement in deciding partners’ place of delivery in Tiyo 13
Ethiop. J. Health Dev. 2014;(Special Issue 1)
7. Federal Ministry of Health (FMOH), Ethiopia.
Health Sector Development Program IV. Addis
Ababa; FMOH, 2010.
8. Berhane Y. Male involvement in reproductive
health. Ethiop J Health Dev 2006; 20 (3):135-136.
9. Kakaire O, Kaye DK. Osinde MO. Male
involvement in birth preparedness and complication
readiness for emergency obstetric referrals in rural
Uganda. Reproductive Health 2011; 8:12. doi:
10.1186/1742-4755-8-12.
10. Mpembeni RNM, Killewo JZ, Leshabari MT,
Massawe SN, Jahn A, Mushi D, et al. Use pattern of
maternal health services and determinants of
skilledcare during delivery in Southern Tanzania:
Implications for achievement of MDG-5 targets.
BMC Pregnancy Childbirth 2007; 7:29. doi:
1086/1471-2393-7-29.
11. Magoma M, Requego J, Campbell OM, Cousens S,
Filippi V. High ANC coverage and low skilled
attendance in a rural Tanzanian district: A case for
implementing a birth plan intervention. BMC
Pregnancy Childbirth 2010; 10:13. doi:
10.1186/1471-2393-10-13.
12. Baral YR, Lyons K, Skinner J, van Teijlingen ER.
Determinants of skilled birth attendants for delivery
in Nepal, Kathmandu Univ Med J 2010; 8(31):325-
32.
13. Reuben K. Esena, Mary-Margaret Sappor. Factors
associated with the utilization of skilled delivery
services in the Ga East Municipality of Ghana Part
2: Barriers to skilled delivery. International Journal
of Scientific & Technology Research 2013; 2(8):195-
207.
14. Carter A. Factors that contribute to the low uptake of
skilled care during delivery in Malindi, Kenya
(2010). Independent Study Project (ISP) Collection.
Paper 821 [cited 2013]; Available at: URL:
http://digitalcollections.sit.edu/isp_collection/821
2010.
15. Warren C. Care seeking for maternal health:
Challenges remain for poor women. Ethiop. J.
Health Dev 2010; 24 Special Issues 1:100-10
16. Kabakyenga JK, Ostergren PO, Turyakira E,
Pettersson KO. Influence of birth preparedness,
decision-making on location of birth and assistance
by skilled birth attendants among women in south-
western Uganda. PLoS ONE 2012; 7(4): e35747.
doi:10. 10.1371/journal.pone.0035747.
17. Tweheyo R, Konde-Lule J, Tumwesigye N, Sekandi
J. Male partner attendance of skilled antenatal care
in peri-urban Gulu District, Northern Uganda. BMC
Pregnancy and Childbirth 2010; 10:53
doi:10.1186/1471-2393-10-53.
18. Story T.W., Burgard S.S., Lori R.J, Taleb F., Ali
A.N., Hoque E.D. Husbands’ involvement in
delivery care utilization in rural Bangladesh: A
qualitative study. BMC Pregnancy Childbirth 2012
12:28.
19. Biratu BT, Lindstrom DP. The influence of
husbands’ approval on women’s use of prenatal care:
Results from Yirgalem and Jimma Towns,
Southwest Ethiopia. Ethiop J Health Dev 2006;
20(2):84-92.
18.
19. 1
Integrated Family Health Program, P.o.Box 1841, Bahir Dar, Ethiopia, Habtu Atnafu E-mail
HAtnafu@pathfinder.org, P.O. Box 1841;
2
Addis Ababa University, School of Public Health, Addis Ababa, Ethiopia.
Identification of factors associated with method shift from
short-acting to long-acting methods of contraception in
Amhara Region of Ethiopia
Habtu Atnafu1
, Yigzaw Dires1
, Amare Yeshambaw1
, Seid Ali1
, Wondimu Gebeyehu1
, Shewangizaw Bereda1
, Fikre
Enqusilassie2
, Alemayehu Mekonnen2
, Adamu Addisse2
, Seifu Hagos2
Abstract
Background: Maternal and child death in developing countries is very high. Every year, an estimated 287,000 women
die because of pregnancy-related complications worldwide. Family planning can prevent at least 25% of all maternal
deaths by allowing women to delay motherhood, prevent unintended pregnancies, and avoid unsafe abortions family
planning also protects women from sexually transmitted infections (STIs), including HIV, and allows them to stop
childbearing when they have reached their reproductive goals.
Objective: To identify factors associated with the change shift from short-acting to long-acting methods of
contraception in Amhara Region of Ethiopia.
Methods: A descriptive, cross-sectional, quantitative, facility-based study was carried out on 986 women of
reproductive age who were currently using short-acting family planning methods in 17 health centers.
Results: Out of the 986 short-acting family planning users interviewed, 18.2% explained their intention to shift from
short-acting to long-acting methods of contraception. Among those had the intention to change to long-acting methods
of contraception, 95.6 % preferred for implants. 4.4% of them had the intention to shift to the intrauterine
contraceptive device (IUCD). The main reason for shifting to long-acting methods of contraception was delaying
having their next child (88.9% of respondents). Fear of side effects and desire to have more children were mentioned
by 69.3% and 16.6%, respectively, as the main reasons for not changing to long-acting methods.
Conclusion and Recommendations: This study showed that a considerable proportion of women had the intention to
change from short-acting to long-acting methods of contraception. Having information about long-acting methods and
not planning to have children in the future were found to be the main factors in the intention to change from short-
acting to long-acting methods. We recommend providing of comprehensive family planning counseling and services
by health workers and health extension workers and strengthening behavioral change interventions to change negative
attitudes at the community level. [Ethiop. J. Health Dev. 2014; (Special Issue 1):14-19]
Introduction
Ethiopia is one of the countries with the highest
maternal mortality ratio, estimated at 676/100,000 live
births and the lifetime risk of maternal death is 1 in 14
(1). Additionally, contraceptive coverage is very low
and reported at 29% among currently married women.
The demand for contraception among currently married
women is also high; the unmet demand for
contraception is reported at 25%. In the study area, the
Amhara region, the contraceptive prevalence rate
(CPR) and total fertility rate (TFR) are 33.9% and
4.2%, respectively (2).
Family planning can prevent at least 25% of all maternal
deaths by allowing women to delay motherhood, prevent
unintended pregnancies, and avoid unsafe abortions. It
also protects women from sexually transmitted infections
(STIs), including HIV, and allows them to stop
childbearing when they have attained their reproductive
goals. By spacing births, family planning can prevent an
average of one in four infant deaths in developing
countries. Adequate birth spacing can also improve the
survival of the next older brother or sister (3).
Most family planning users in Ethiopia prefer to use
short-acting family planning methods. According to the
Ethiopian Demographic and Health Survey (EDHS)
2011 report, short-acting family planning methods
accounted for 23.1% of use among the total modern
contraceptive users. Similarly, in Amhara region, the
magnitude of short-acting family planning methods use
is 28%. On the other hand, the prevalence of use of
long-acting family planning (LAFP) methods is 4.3%
(4% implant and 0.3% IUCD) (2).
20. Identification of factors associated with method shift from short-acting to long acting contraception 15
Ethiop. J. Health Dev. 2014;(Special Issue 1)
A study done elsewhere in Ethiopia among married
women revealed that 67% of women were currently
using at least one family planning method and most
obtained the methods from the public health sector.
Short-acting methods such as pills and injectables, were
the most commonly used methods. Family planning
practice was significantly associated with willingness to
use long-acting or permanent FP methods in the future
and with spousal attitudes about family planning (4).
Educational status was positively associated with higher
awareness, favorable attitude, and practice of family
planning (5).
Studies in the US and England indicated that in the
choice of a long-acting method, the potential for
forgetting to take short-acting family planning methods
was an important factor in utilization long-acting family
planning methods (6, 7). Similar studies from Turkey,
Uganda, and England showed that provider bias,
misconceptions and fears, gender, related power
relations, poor information, and incorrect beliefs about
safety and side effects were reasons for poor utilization
of long-acting and permanent family planning methods
(8-10).
Short-acting family planning use is high in Ethiopia,
even though there are different methods and trained
health workers to provide the services. There are few
studies examining the factors associated with the
relatively high usage of short-acting methods and the
lower utilization of long-acting methods. Hence, this
study tries to identify respondents’ main reasons for
shifting from short-acting to long-acting methods of
contraception in Amhara region.
Methods
Study Design:
A descriptive cross-sectional quantitative facility-based
study was carried out.
Study Area and Period:
The study was done in five zones of Amhara Region:
East Gojjam, North Gondar, South Gondar, North Wollo
and Waghimera. Seventeen health centers were selected
among the 34 LAFP backup service health centers. The
study was carried out in January 2012.
Sample Size and Sampling:
Sample size was determined using a single proportion
formula. The following assumptions were used to
calculate the sample size: Magnitude of method shift was
taken as 70% from a study done in Addis Ababa, 3%
margin of error, and 95% confidence interval. Adding
10% of non-response rate, the total sample size was 986.
Study sites were selected proportionally according to the
number of backup service providing health centers in
each zone. A lottery method was then used to select the
study health centers in each zone. The required number
of clients was allocated proportionally to each health
center according to the client flow taken from the sample
health centers prior to the data collection period. Study
participants were selected by using a systematic sampling
technique. Every other short-acting family planning user
was included in the study until the required sample size
was obtained.
Data were collected by using a structured questionnaire
which was translated from English to Amharic and back
to English to ensure consistency.
Data Collection:
Seventeen female data collectors, who had diploma in
nursing and five supervisors with diplomas and above
with experience in health related fields, were recruited.
Two-day training was provided to data collectors and
supervisors that focused on the objectives of the study,
interview techniques, and contents of the questionnaire.
Data Analysis:
Data were coded and labeled with the SPSS statistical
software version 15, and then entered into the pre-coded
SPSS sheet. Data cleaning was done by running
frequency tables in the SPSS to ensure uniformity with
hard copy and its completeness.
Data were compiled and summarized by using tables and
graphs. Odds ratio with 95% confidence intervals were
calculated using bivariate and multivariate logistic
regression to assess associations between the independent
and the dependent variables.
Results
The majority (88.7%) of the respondents were married.
The average family size per household was found to be
4.4. Five hundred twenty-eight (53.6 %) respondents
were illiterate, 162 (16.4%) could read and write, and 95
(9.6 %) had above grade 10 schooling. The majority
(43.7%) were housewives and 23.5% were farmers.
Of the 986 mothers, 863 (87.5 %) were using inject able
contraceptives, followed by pills (16.2%) at the time of
the study.
Seven hundred thirty-nine (74.8%) said that the choice
was made by themselves. Spouse’s and friends’
21. 16 Ethiop. J. Health Dev.
Ethiop. J. Health Dev. 2014;(Special Issue 1)
involvement in the choice of family planning method
were 9.3% and 1.9%, respectively. Fifty-one respondents
(5.2%) replied that health professionals (health workers
and health extension workers) chose the method for
them.
Among the total respondents, 800 (81%) replied that they
had ever heard about long-acting methods of
contraception. Four hundred and sixty-four (58%) had
information on Implanon compared to other methods.
Regarding the source of information: 41.8 %heard from
health workers, 15.7% from health extension workers,
and 34.3% had information from other sources such as
spouse, friends, neighbors, and other people.
One hundred eighty respondents (18.2%) had the
intention to change from short-acting to long-acting
methods. Among the 180 respondents who wanted to
shift to long-acting methods of contraception, 68.9%
preferred Implanon, 24.4% preferred Jadelle, and 4.4%
preferred IUCD (Figure1).
68.9
24.4
4.4 2.3
0
10
20
30
40
50
60
70
80
90
100
Implanon Jaddele IUCD Others
Figure 1: Respondent’s preference for long-acting methods of contraception, Amhara Region, January 2012
Of those who stated a desire to change, the main reason
given for changing from short-acting to long-acting
methods of contraception was delaying having their next
child (160 o r88.9%). Reasons for not changing to long-
acting methods of were: fear of side effects (69.3%) such
as headache, interference with workload, irregular
vaginal bleeding, and a desire to have more children
(16.6%) (Table 1).
Five hundred and two (50.8%) respondents said using
long-acting methods of contraception for a long time
could have health risks. Seven hundred thirty-four
(74.3%) said using long-acting methods will cause health
problems during pregnancy and delivery, and 202
(20.4%) responded that it may cause infertility.
Two hundred seventy-three (27.7%) replied that some
long-acting family planning methods of contraception
like IUCD could cause uterine problem. On the other
hand, 100 (10.2%) women responded that long-acting
methods of contraception could reduce women’s sexual
desire.
Table 1: Intention and reasons given for method
changing from short-acting to long-acting methods of
contraception, Amhara Region, January 2012
Characteristics Number Percent
Intention to change N=986
Yes 180 18.2
No 806 81.8
Type of FP to change N=180
Implant 172 95.5
IUCD 8 4.5
Reason for intention to change N=180
Spacing 160 88.9
Fear of side effects of the current
method 20 11.1
Reason for not to change N=795
Desire for more children 132 16.6
Fear of side effects 552 69.4
Service unavailability 13 1.6
Fear of procedure 47 5.9
Spouse/family pressure 26 3.3
Peer pressure 4 0.5
Service free 4 0.5
Other 17 2.1
22. Identification of factors associated with method shift from short-acting to long acting contraception 17
Ethiop. J. Health Dev. 2014;(Special Issue 1)
In the bivariate analysis, socio-demographic variables
such as education, income, family size, and occupation
did not have a statistically significant association with the
intention to change from short-acting to long-acting
methods of contraception.
Those who had ever heard about long-acting methods
were 1.93 times more likely to use the methods COR
(95%CI = 1.93 (1.18, 3.12)) than those without such
information. A plan not to have children in the future had
a positive and statistically significant association with a
intention to use long-acting methods of contraception
with COR (95%CI = 1.62 (1.17, 2.24)).
There was no significant statistical difference between
respondents’ expectation of health problems during
pregnancy and delivery and their intention to use long-
acting methods COR (95%CI =1.09 (0.76, 1.57)).
Respondents’ perception of not having health risks when
using long-acting methods for a longer time was found to
be positively associated with intention to use with COR
(95%CI = 2.74 (1.94, 3.87)). Those respondents who
believed that using long-acting methods would not cause
health risks were 2.74 times more likely to use them than
those who expected them to cause health risks.
In the multivariate analysis, among the respondents’
conditions of knowledge and perception characteristics,
ever having heard about long-acting methods no, plan to
have children sometime in the future, and a belief that
using long-acting contraception would not cause health
problems remained statistically significantly associated
with the intention to use them. In their order they are
significantly associated with intention to use long-acting
methods of contraception with an adjusted AOR (95%CI
= of 2.31(1.40, 3.81), 1.93(1.37, 2.72) and 2.58 (1.73,
3.83)) (Table 2).
Table 2: Factors associated with intention to use long-acting family planning methods, Amhara, January 2012.
Characteristics Number Intention to use LAFP Methods
COR (95% CI) AOR (95% CI)
Education
Illiterate 92 1
Primary school completed 48 0.77 (0.51, 1.17)
Secondary and above 40 0.78 (0.48, 1.24)
Family size
1-4 105 1
5 and above 75 1.15 (0.83, 1.6)
Ever heard about LAFP
Yes 159 1.93 (1.18, 3.12) 2.31 (1.4, 3.81)
No 21 1 1
Plan for having children in the future
Yes 97 1 1
No 83 1.62 (1.17, 2.24) 1.93 (1.37, 2.72)
Expectation of any health problem
Yes 56 1
No 124 2.74 (1.94, 3.87) 2.58 (1.73, 3.83)
Using LAFP causes sterility
Yes 30 1
No 150 1.35 (0.88, 2.07)
Using LAFP causes permanent health problem
Yes 56 1
No 124 2.41 (1.59, 3.64) 1.65 (1.00, 2.72)
Using LAFP could cause cancer
Yes 22 1
No 156 1.21 (0.74, 1.97)
Discussion
A considerable proportion of women had the intention to
change from short-acting to long-acting methods of
contraception. Information about long-acting methods of
contraception and limiting births were the main factors
influencing intention to the change from short-acting to
long-acting methods.
Many previous studies had shown that women’s
education is an important predictor of the use of long-
acting methods of contraception, as it increases
awareness and decision-making abilities (5, 13). In this
study, however, education was not found to be
significantly associated with the intention to method for
23. 18 Ethiop. J. Health Dev.
Ethiop. J. Health Dev. 2014;(Special Issue 1)
choosing long-acting methods of contraception. A
possible explanation for this is the similar educational
level of respondents. Respondents’ family size was not
associated with the change to long-acting methods.
The findings of the EDHS 2011 and those of our study on
the use of long-acting methods of contraception in
Amhara region are different. The difference may be, in
this study, respondents were short-acting of using of
methods during the interview period and the findings
from EDHS 2011 were collected from main women of
reproductive age.
The intention to change to long-acting methods among
women who are currently using short-acting ones was
lower than in a similar study done in Rwanda (16). The
difference may be due to socio-demographic differences
between the family planning users in the two countries.
The current study’s findings also differed from those of a
study done in Addis Ababa (17). Different study periods
and the study set-ups may be the reasons for the
differences in the results.
Consistent with other studies done in different places,
perception of health problems during pregnancy and
delivery, a plan to have children in the future, and having
information about long-acting methods were statistically
significant factors(15).
This study attempted to answer questions related to the
use of long-acting methods in Ethiopia. Hence, we
believe the study adds to the limited amount of
information available in our country.
This study was facility-based and the respondents were
current users of family planning services who came to the
health facility. Therefore, the study findings may not be
generalizable to women in the community, which is a
limitation of the study.
Conclusion
In conclusion, the intention to change to long-acting
methods of contraception was considerably high.
Information on long-acting methods perception of not
having risks, and a positive attitude towards long-acting
methods were the main reasons for changing to the long-
acting methods.
Proving comprehensive family planning counseling and
services by health can providers and health extension
workers and strengthening behavioral change
interventions to change negative attitudes at the
community level are recommended.
References
1. Population Action International (FAI). How family
planning protects the health of women, men and
children. 2006.
2. Central Statistics Authority (CSA) and ORC Marco.
Ethiopian Demographic and Health Survey (DHS).
1996: Addis Ababa, 2005.
3. Barbara S. Family Planning Saves Lives, Third
Edition. Washington DC; USA, 1996.
4. International Nursing Research (INR). Family
planning practice and related factors of married
women in Ethiopia. Seoul; Korea. 2010.
5. Ismail S. Men's knowledge, attitude and practices of
family planning in North Gondar. Ethiopia Med J
1998; 36(4):261-71.
6. Grimes D. Forgettable contraception. Family Health
International, Research Triangle Park, NC; USA,
2009.
7. Rai K, Gupta S, Cotter S. Experience with Implanon
in a Northeast London family planning clinic. Eur J
Contraceptive Reprod Health Care. 2004; 9(1):39-
46.
8. Finger W. Method choice involves many factors.
Network. 1994 Dec; 15(2):14-7.
9. Nalwadda G, Mirembe F, Byamugisha J, Faxelid E.
Persistent high fertility in young people recount
obstacles and enabling factors to the use of
contraceptives. BMC Public Health 2010 Sep 3;
10:530.
10. Glasier A, Scorer J, Bigrigg A. Attitudes of women
in Scotland to contraception: A qualitative study to
explore the acceptability of long-acting methods. J
Fam Plann Reprod Health Care 2008 Oct;
34(4):213-7.
11. Balaiah D, Naik DD, Ghule M, Tapase P.
Determinants of spacing contraceptive use among
couples in Mumbai: A male perspective. J Biosoc
Sci 2005 Nov; 37(6):689-704.
12. China. Zhang XJ, Wang GY, Shen Q. Current status
of contraceptive use among rural married women in
Anhui Province. BJOG 2009; 116(12):1640-5.
13. Tuladhar H, Marahatta R. Awareness and practice of
family planning methods in women attending
gynecology outpatient clinics Nepal Medical College
Teaching Hospital. Nepal Med Coll J 2008;
10(3):184-91.
14. Weldegerima B, Denekew A. Women's knowledge,
preferences, and practices of modern contraceptive
methods in Woreta, Ethiopia. Res Social Adm Pharm
2008; 4(3):302-7.
15. Chigbu B, Onwere S, Aluka C, Kamanu C, Okoro O,
Feyi-Waboso P. Contraceptive choices of women in
rural Southeastern of Obstetrics and Gynecology,
Abia State University Teaching Hospital Aba,
Nigeria. Niger J Clin Pract. 2010;13(2):195-9.
16. Dhont N, Ndayisaba GF, Peltier CA, Nzabonimpa A,
Temmerman M, van de Wijgert J. Improved access
increases postpartum uptake of contraceptive
implants among HIV-positive women in Rwanda.
24. Identification of factors associated with method shift from short-acting to long acting contraception 19
Ethiop. J. Health Dev. 2014;(Special Issue 1)
The European Journal of Contraception and
Reproductive Health Care 2009; 14(6):420-5.
17. Argina H, Lukman HY. Norplant implants in
Ethiopia. Gandhi Memorial Hospital, Addis Ababa.
East Afr Med J 1997; 74(4):258-62.
25.
26. 1
Integrated Family Health Program, P.O. Box 428, Mekelle, Ethiopia;
2
Addis Ababa University, School of Public Health, Addis Ababa, Ethiopia.
Magnitude and predictors of skilled delivery service
utilization: A health facility-based, cross-sectional study in
Tigray
Tesfaye Gebru1
, Desta Gebre-Egziabher1
, Kelali Tsegay1
, Brhane Hadera1
, Mesfin Addisse2
, Worku Tefera2
,
Adamu Addisse2
,Seifu Hagos2
Abstract
Background: A skilled birth attendant for every pregnant woman during childbirth is the most crucial intervention for
improving maternal and child health. Ethiopia has a maternal mortality ratio of 676 per 100,000 live births. The
majority of births are delivered at home and the proportion of deliveries assisted by a skilled attendant is very low at
10%.
Objective: To assess utilization of skilled delivery service and associated factors.
Methodology: A facility-based, cross-sectional survey was taken in 35 randomly selected health centers in March
2012, targeting women who had delivered 12 months prior to the survey and had come for EPI services for their
children under the age of one. A total of 911 women were interviewed using a pretested, structured questionnaire.
Result: Among the study subjects, 46.8% used skilled delivery service, and mothers’ level of education, knowledge on
delivery complications, family monthly income, and distance to health facility were significantly related to the used of
the delivery service. Women with at least primary education were two times more likely (AOR=2.19 and
95%CI=1.33-3.61) to utilize skilled delivery service. Women who have knowledge of delivery complication were
greater than three times more likely to have skilled delivery (AOR =3.577 and 95%CI=1.50-11.121). Women with
monthly family income greater than ETB 500 were two times more likely (AOR=2.438 and 95%CI= 1.256-4730) to
use skilled delivery service. Women whose had to travel to a health facility less than an hour were four times more
likely to have a skilled birth attendant (AOR=4.01, 95% CI=2.30-7.00).
Conclusion and Recommendations: This study revealed a very high proportion of mothers had skilled birth attendant
(46.8%). Knowledge about delivery complications, education level, household income, and distance from health
facility were linked to skilled-delivery attendance of mothers. Convenient availability and accessibility of health
facilities and promotion of antenatal care follow-up with maternal and child health information particularly on delivery
complications or danger signs were vital for the increased utilization of a skilled delivery attendance. [Ethiop. J.
Health Dev. 2014; (Special Issue 1):20-25]
Introduction
Skilled birth attendance refers to professionally trained
health workers with the skills necessary to manage a
normal delivery and diagnosis incase complications. This
usually refers to a doctor, midwife or health officer and
nurse. Skilled attendants must be able to manage a
normal labor and delivery and recognize complications
early on. Should a problem arise, the skilled attendant
should be able to perform essential interventions, start
treatment, and supervise the referral of the mother to the
next level of care, if necessary (1, 2).
The World Health Organization (WHO) estimates that
globally only 43 percent of women have access to skilled
care during deliveries and the rest are exposed to
unskilled delivery service (2). The organization has
identified lack of access to skilled delivery services as a
hindrance to efforts in improving the health of women
especially during delivery. In this regard, the United
Nations has identified the necessity to reduce maternal
mortality by three quarters by 2015. Even though this
objective of the Millennium Development Goals has been
well promoted, relatively little progress given the (MMR
676/100.000) has been made so far (3).
Ethiopia has a maternal mortality ratio (MMR) of 676 per
100,000 live births. Moreover, the majority of births are
delivered at home without any supervision by skilled
health workers. National estimates indicate that only 10
percent of deliveries were assisted by health
professionals. In the study area, Tigray region, only 10.8
percent of deliveries were assisted by skilled service
providers (4). Therefore, this study was carried out to
measure the proportion of women who delivered with the
assistance of a skilled birth attendant and to identify
factors that influence utilization of the service.
Methods
Study Setting:
The study was done in Tigray region, which is one of the
northern regional states of Ethiopia, administratively
divided into seven zones, 46 woredas, and 710 kebeles
with a total population of 4,541,724. In the region, there
are one referral, five zonal and six district hospitals,
about 200 health centers, including recently upgraded
ones, and 590 health posts (5).The Tigray Region IFHP
operates in all woredas of the southern and eastern zones,
in seven sub-cities of Mekelle Special Zone, in nine
27. Magnitude and predictors of skilled delivery service utilization 21
Ethiop. J. Health Dev. 2014;(Special Issue 1)
woredas in the central zone and two woredas of the
southeast zone of the region. These 35 woredas consist of
546 kebeles and 2,945,034 people (65 percent of the
region’s population). The people who live here may
receive primary health care services in 127 health centers
(HCs) and 320 health posts (HPs) (5).
Study Design and Sampling:
We used a facility-based cross-sectional study design.
The study took place in March 2012.
The sample size was calculated using the single-
proportion formula with the following assumptions:
skilled birth attendant (SBA) utilization in the region:
10.8% (4); 95% level of confidence; 3% margin of error;
and with a design effect of 2. The total sample size
calculated was thus 911.
We used simple random sampling technique to select
HCs. All mothers who gave birth 12 months prior to the
study period and, who did visit the selected health
centers’ child immunizations service during the data
collection period, were included. Data were collected
using a pre-tested, structured questionnaire written in the
local language (Tigrigna). We used trained health
professionals as data collectors.
Data Analysis:
Data were entered in MS Access. We used SPSS version
16 for data analysis. Bivariate analysis was employed to
determine crude associations and multivariate regression
analysis to determine predictors while adjusting for other
factors.
Results
Socio-demographic characteristics:
For this study, a total of 911 women were interviewed
with 100% response rate. The mean (SD) age of
respondents was 27.04 (6.29 years). The majority of the
respondents were illiterate (53.2 percent), married (92.1
percent) and followers of Orthodox Christianity (96.4
percent).The mean (SD) family size of the study
respondents was 4.8+ 1.922 (Table 1).
Obstetric History and ANC Experience:
The mean (SD) mothers’ age at first pregnancy was
19.34+2.99 years. Among the respondent mothers, 50%
of them had 2-4 live births, 30 percent a single live birth,
while the rest had >5 live births. The mean (SD) parity
was 2.98 (1.89). Nine out of ten of the respondents
attended antenatal care (ANC) at least once, while a
greater proportion (52.8 percent) attended at least four
times for the last pregnancy (Table 2). All of the mothers
(99.9%) were informed to deliver in a health facility
during their ANC follow up, while 89.7% of them were
recommended to use a health professional during their
delivery.
Actual Delivery Practices:
The proportion of SBA was 46.8%, which is a very high
in comparisons with national and regional averages with
most (95.4%) being attended by skilled health
professionals. This high proportion of SBA is attributed
to by the referral linkage of the primary health care unit
(PHCU) and the work of the health development army.
Table 1: Selected socio-demographic characteristics
of respondents in Tigray Region, March 2012, (n=911)
Variable Count Percent
Age of respondent
15-19 88 9.7
20-24 272 29.9
25-29 221 24.3
30-34 171 18.8
35+ 158 17.3
Marital Status
Married 834 92.1
Divorced 51 5.6
Single 17 1.9
Widowed 4 0.4
Religion
Orthodox 877 96.4
Muslim 32 3.5
Catholic 1 0.1
Women educational status
Illiterate 426 46.9
Non-formal
Education 45 5
Grade 1-4 105 11.6
Grade 5-8 181 19.9
High school (9-10) 102 11.2
Preparatory (11-12) 50 5.5
Family size
3 256 28.1
4-6 466 51.2
≥7 188 20.7
Women occupational status
Housewife 508 55.8
Government
Employee 48 5.3
Private employee 311 34.1
Unemployed 24 2.6
Students 11 1.2
Family monthly income (Birr)
≤250 280 31.5
251-500 308 34.7
>501 300 33.8
Reasons given by those who delivered at home include
usual practice, 166 (34.2%); feel more comfortable, 21
percent; missing expected date of delivery, 19.2%; close
attention from relatives, 15.5% ;“I dislike the service in
the health facility”, 2.3%; and long distance and
unwelcoming health workers, 8.8%. In contrast, reasons
for institutional delivery include better service in the
28. 22 Ethiop. Health Dev.
Ethiop. J. Health Dev. 2014;(Special Issue 1)
health facility, 351 (82.4%); better outcomes from health
institution, 224 (52.6%); poor outcomes from home
delivery, 202 (47.4%); informed to deliver in a health
facility, 146 (34.3%); and facility being close to where I
live, 26 (6.1%).
Table 2: Obstetric history and ANC experience of the
respondents in Tigray Region, March 2012, (n=911)
Variables Count Percent
Live births
1 263 29.1
2-4 445 49.2
≥5 195 21.5
ANC Visit
Yes 829 91
No 82 9
ANC visits
1 4 4.8
2-3 350 42.4
4 342 41.4
>4 94 11.3
Age at first pregnancy
≤20 549 60.4
21-29 353 38.8
≥30 6 0.7
Received information on
pregnancy and delivery-
related complication
Yes 790 95.5
No 36 4.4
Mothers’ knowledge, attitude on places of delivery and
perceptions of family, relatives, and community during
the last delivery: Among mothers who delivered at a
health facilities (HF), nearly all 424 (99.8%) had good
attitude towards SBA. Out of the total 829 (91%) women
who visited a HF for ANC during their pregnancy only
half, 426 (51.4%), of them had attended skilled delivery
and about two-thirds of the respondents, 602 (66.1%),
were knowledgeable on the danger signs that can occur
during pregnancy. Nine of the ten, 780 (90%),
respondents had information that HFs referred mothers to
higher HF in case of emergency during delivery. Two-
thirds of the respondents expressed that their husbands
preferred the use of SBAs (69.3%), while 3 out of 5
reported other family members and relatives (60.7%)
preferred SBAs. However, a number of husbands, 275
(30.7%) and family members and relatives, 352 (39.4%)
still preferred to use traditional birth attendants (TBA) or
family members and neighbors (Table 3).
Client satisfaction with institutional delivery: Among the
clients who facilities to delivery (n=426), there was high
satisfaction with the time the health worker spent with
the client, cleanliness of the delivery place, cleanliness of
instruments and equipment used by the health worker, the
courtesy and respect offered, measures taken to ensure
privacy and comfort, and professional competency and
skill of the health worker (ranging from 99.1-97.9%).
Table 3: Predisposing, enabling, and reinforcing
factors in utilization of SBA in Tigray Region, March
2012, ( n=426)
Variables Frequency Percent
Availability of HF which
gives SBA
Yes 797 87.6
No 37 4.1
Don’t know 76 8.4
Heard about referral to
higher health facilities
Yes 780 90
No 87 10
Husband preference for
delivery attendant
Delivery with health
professional 621 69.3
Delivery without health
professional support 290 30.7
Family preference for
delivery attendant
Delivery with health
professional 543 60.7
Delivery without health
professional 368 39.3
Socio-demographic factors influencing utilization of
skilled delivery service: Binary logistic regression was
applied to determine predictors of utilization of skilled
delivery services. The result showed that socio-
demographic variables, women’s education, and monthly
family income were significantly associated with SBA
(p-values<0.05). Women with secondary education and
monthly income greater than 500 ETB were more likely
to utilize SBA [OR=3.173 (95%CI: 1.151-8.742)] and
[OR=2.438 (21.256-4.734)] respectively (Table 4).
Obstetric factors influencing utilization of skilled
delivery service: When the obstetric factors, ANC visit,
age at first pregnancy, presence of pregnancy and
delivery complications (danger signs), distance to HFs
that provide skilled delivery service, and knowledge
about referral to higher HFs were adjusted, women’s
knowledge of delivery complications and distance to HF
remained significantly associated; women, who knew
about delivery complications or danger signs are three
times more likely to utilize SBA [AOR=3.577
95%CI=1.150-11.121)]. While ANC visit was highly
associated during bivariate logistic regression, no
significant association with SBA was observed during
multivariate regression when the interest was to find the
frequency of ANC visits (Table 4).
29. Magnitude and predictors of skilled delivery service utilization 23
Ethiop. J. Health Dev. 2014;(Special Issue 1)
Table 4: Socio-demographic factors influencing utilization of skilled delivery service in Tigray Region, March 2012,
(n=426)
Variables Utilization of SBA Crude ORs (95%CI) AORs (95%CI) P-value
Yes No
Educational status
Non-formal education 16 29 1 1 0.018**
1-4 50 55 1.648 (.802-3.387) 1.372 (.538-3.502)
5-8 92 89 1.874 (.953-3.685) .971 (.402-2.343)
9-10 77 25 5.582 (2.613-11.925)**
3.173 (1.151-
8.742)**
>10 42 8 9.516 (3.601-25.144)** 2.698 (.645-11.291)
Occupation
Farmer 89 168 1
Government employee 41 7 11.056 (4.765-5.654)** 1 0.314
Private /petty trade 44 18 4.614 (2.518-8.455)** 1.219 (.294-5.058)
Housewife 226 282 1.513 (1.109-2.064)** 2.955 (.974-8.967)
Student /unemployed 25 10 4.719 (2.170-10.264)** 1.117 (.571-2.184)
2.046 (.582-7.195)
Family monthly income
<=250 121 159 1 1 0.026**
251-500 107 201 .700 (0.501-0.967)** 1.394 (.726-2.677)
>=501 188 112 2.206 (1.562-3.076)**
2.438 (1.256-
4.730)**
Family size
<=3 145 111 1 1 0.651
4_6 217 249 2.531 (1.714-3.783)** 0.633 (.085-4.694)
>=7 64 124 1.689 (1.187-2.402)** 0.484 (.085-2.772)
Total number of live births
1 149 114 2.941 (1.991-4.343)** 2.072 (.256-16.784)
2_4 213 232 2.066 (1.446-2.950)** 2.987(.483-18.479)
>=5 60 135 1 1 0.414
Number of ANC visit
1 8 32 1 1 0.139
2_3 343 349 3.931 (1.786-8.653)** 4.559 (.758-27.440)
>=4 67 30 8.933 (3.682-21.675)** 6.877 (.996-47.463)
Distance to HF
<=1 hour 82 274 5.731 (4.221-7.781)**
4.017 (2.302-
7.009)**
>1 hour 319 186 1 1 0.000**
Knowledge on referral
Yes 382 398 3.952 (2.284-6.838)** 1.586 (.566-4.444)
No 17 70 1 1 0.38
Knowledge of pregnancy danger
signs mentioned
None 109 198 1 1 0.206
One 137 118 2.109 (1.502-2.961)** 1.736 (0.866-3.479)
Two – three 154 149 1.877 (1.357-2.597)** 1.702 (.851-3404)
More than three 26 20 2.361 (1.260-4.425)** .727(.198-2.671)
Knowledge of delivery danger
signs mentioned
None 62 157 1 1 0.044**
One 125 101 3.134 (2.114-4.647)** 1.044 (.465-2.341)
Two – three 188 189 2.519 (1.763-3.598)**
2.163 (1.002-
4.665)**
More than three 51 38 3.399 (2.035-5.675)**
3.577 (1.150-
11.121)**
Discussion
From the results of this study, the proportion of
institutional delivery was far more common than the
country’s average. This high proportion of SBA use
attributes contributed by the referral linkage of the
primary health care unit (PHCU) and the role played the
health development army. The study revealed that
utilization of SBA is very close to the national level in
urban settings (49.8%), while it is less than that of Addis
Ababa (82.3%) it is more than that of Dire Dawa
(39.7%). However, the finding on the
utilizationSBAfrom this study is by far higher than the
30. 24 Ethiop. Health Dev.
Ethiop. J. Health Dev. 2014;(Special Issue 1)
national average for rural settings, which is 4.1%,
according to the Central Statistics Authority (4).
From the result of this study, better service in HF, better
outcomes from institutional delivery, information
received from health professionals to deliver in HF, and
the closeness of HF were the reasons mentioned by the
respondents for using skilled delivery service. A study
done in Addis Ababa also revealed that the reasons for
preferring to deliver in services in HFs were the high
quality of service, followed by a closeness of health
institution, and the approach of good health workers (6).
The significant associated factors from the study
including women’s education, family monthly income,
distance to HFs, and knowledge about possible delivery
complication or danger signs were consistent with
findings of other similar studies (4, 6).
Women with secondary and above educational level were
more likely to use to go for skilled delivery. The reason
for education being such an important a predictor for
utilization of skilled delivery services could be explained
by the power education gives women tomake decisions
about their own health (4, 7).
Those who know the presence of delivery complication
were more likely to use SBA. Similarly, a study from
Ghana also stated that 64 percent of women who died of
delivery complications had sought help from a traditional
birth medication going to HF (8). Studies from India and
Iraq showed that lack of recognition of seriousness of
health problems related to delivery complications
wereamong the reason for not using available health care
that accounts for half of maternal deaths (9). A
community-based study done in Addis Ababa on
maternal mortality also found that one of the reason for
not having ANC was a low level of awareness about the
problems of child bearing (6). With regard to family
influence on SBA, the husbands and family members of a
large proportion of women in this study did not
recommend the women go to HF for SBA, at least as a
first preference.
With regard to access to HFs, those who were traveling
less than an hour (walking) were four times more likely
to utilize SBA. Improving access to services has been a
primary strategy for increasing health-service utilization
in developing countries, including Ethiopia (HSDP IV).
Several studies have stressed the importance of access to
HF as a factor affecting their utilization. Studies indicate
that one of the reasons for choosing not to use available
SBA is poor access to HFs because of long and poor road
conditions both in dry and wet seasons, as well as the
shortages of vehicles.
Limitations
. As a facility-based cross-sectional study it shares the
limitation of both facility-based studies, lack of
representativeness of total population, and those of a
cross-sectional nature, havinga one-time view and
weaker evidence, and others of a cross-sectional
nation.
. The study falls short of providing client-provider
interaction to address the effect of skilled delivery
attendant on utilization, especially from the
provider’s perspective.
. It would have been more appropriate to use non-
health worker data collectors to avoid the possibility
of bias.
Conclusion and Recommendations
Based on the study being facility-based it can be
concluded that institutional delivery in Tigray is far
common than the country’s average.Distances to HFs and
Women’s knowledge about delivery complications or
danger signs are the two most relevant factors affecting
SBA in Tigray. Women’s educational status and family
monthly income are also found to be important predictors
for SBA utilization. Based on this, the following
recommendations are made:
. Access to HFshould be improved for better
utilization of skilled delivery services.
. Health professionals should promote ANC follow up
and provide information on the problems of
pregnancy and delivery complications; health
promotion on the importance of SBA at every child
birth for every woman who came to HF in general
and at ANC visit in particular.
. Community health activities such as community
awareness programs, home visit, and community-
based delivery systems must focus on those who are
illiterate, who do not get MCH information and who
do not come for ANC.
. Community-based (health-facility linked)
prospective cohort studies to identify predictors of
SBA are recommended for the future.
Acknowledgements
We are grateful to the Addis Ababa University School of
Public Health for the technical assistance provided during
the process of the research design and implementation.
We are also grateful for the staff members from woreda
health offices and health centers who diligently
participated in the data collection process. Thank you to
the women who participated in the study and to the
Integrated Family Health Program (IFHP) for its
financial support to conduct the research.
References
1. World Health Organization (WHO)> Statement.
Geneva; WHO, 1999.
2. World Health Organization (WHO). Reduction of
maternal mortality: A joint
WHO/UNFPA/UNICEF/World Bank Report.
Geneva; WHO, 2011.
