Factors Determining The Choice Of Health Care Facilities By Pregnant Women
The main aim of this study was to examine factors determining women’s preference for places to give birth in Addis Ababa, Ethiopia. A quantitative and cross-sectional community based study design was employed. Data was collected using structured questionnaire administered to 901 women aged 15–49 years through a stratified two-stage cluster sampling technique. Multinomial logistic regression model was employed to identify predictors of delivery care. More than three-fourth of slum women gave birth at public healthcare facilities compared to slightly more than half of the nonslum residents. Education, wealth quintile, the age of respondent, number of children, pregnancy intention, and cohabitation showed net effect on women’s preference for places to give birth. Despite the high number of ANC attendances, still many pregnant women especially among slum residents chose to deliver at home. Most respondents delivered in public healthcare institutions despite the general doubts about the quality of services in these institutions. Future studies should examine motivating factors for continued deliveries at home and whether there is real significant difference between the quality of maternal care service offered at public and private health facilities.
1.1 Background to the Study
Assurance of healthcare for all segments of the population with special attention given to the health needs of women and children was one of the top priorities in the Ethiopian Health Policy. The endorsement of MDG 5 in the HSDPs is an indication of the commitment or political will of the government towards reducing maternal mortality across the nation. Yet, Ethiopia’s health system is underdeveloped and underfinanced. While some progress has been made in providing basic health services to poor women and their children, the progress may be uneven because many people are not reached with services.
Ethiopia’s total health expenditure as a percentage of the gross domestic product (GDP) has remained stable at 4.3% for years. With emphasis given to publicly funded healthcare, out-of-pocket payment constitutes 42%. The public health sector is the main provider of primary healthcare and serves two-thirds of the population who cannot afford private healthcare. The main objective of the public sector service provision, as stated in the National Health Policy, is “to give comprehensive and integrated primary health care services in a decentralized and equitable fashion” .
Childbirth and its process are one of the most significant life events to a woman . The time of birth as well as shortly thereafter is the most dangerous period in a child’s life especially in the developing world. Hence the choice of place of delivery for a pregnant woman is an important aspect of maternal healthcare. The place of delivery is an important factor often related to the quality of care received by the mother and infant for influencing maternal and child healthcare outcomes. In Addis Ababa, the capital of Ethiopia, though the private health facilities (hospitals and clinics) outnumber public clinics , only 20% of deliveries take place in the private sectors and 17% of mothers deliver at home.
A significant proportion of mothers in developing countries still deliver at home unattended by skilled health workers (Montagu D, Yamey G, Visconti A, Harding A, Yoong J 2011). In diverse contexts, individual factors including maternal age, parity, education and marital status, household factors including family size, household wealth, and community factors including socioeconomic status, community health infrastructure, region, rural/urban residence, available health facilities, and distance to health facilities determine place of delivery and these factors interacting diverse ways in each context to determine place of delivery. In developing countries, pregnancy and childbirth are the leading causes of disability and death among women of reproductive age.
Indeed, the majority of maternal deaths occur either during or shortly after delivery. According to United Nations Children Fund (UNICEF 2009), pregnancy and childbirth related complications claim lives of at least 585,000 women every year in developing world. Pregnancy related problems include anemia, bleeding, infection, damage of the uterus, obstructed labor and abortion. Nearly all maternal deaths in developing countries occur among the vulnerable and disadvantaged population groups and yet most of these causes are preventable. Although the main causes of maternal mortality are well known and the knowledge as well as appropriate technology to reduce it has been available, maternal health problems are still highly prevalent in most African societies.
Statistics by (WHO 2010) found that 92% of women receive antenatal care from a trained health worker but when it comes to delivery time, most of them do not deliver at health units, but instead deliver elsewhere. It was estimated that about 15% of deliveries have complications that require skilled medical intervention. Yet only 53% of deliveries in developing countries take place with the assistance of a skilled birth attendant compared to 99% in developed countries. In resource-poor settings, home delivery is usually the cheapest option, but is associated with attendant risks of infection and lack of available equipment should complications occur. (Thind A. et al, 2008).
According to (Hogan, 2008), Ethiopia is among the top six high burden countries in which half of global maternal deaths occur, with an estimated maternal mortality ratio of 470 per 100, 000 live births. The most recent Ethiopian Demographic and Health Survey (EDHS 2011), very few mothers (34%) make at least one antenatal visit and even less receive delivery care from skilled birth attendants. It reports 28% of births were assisted by a traditional birth attendant (TBA) and 57 percent of births were assisted by a relative, or some other person.
1.2 Statement of the Problem
Basing on the fact that various efforts have been put in place by the Government of Ethiopia, through free maternity services to increase the percentage of mothers who deliver from the health facility under the assistance of a skilled health worker, the majority of mothers still deliver at home without skilled birth attendants. Statistics by the District Health information System (DHIS) indicate that only 36% of births in Addis Ababa are attended by a skilled birth attendant. This is way too far the targets set at the International Conference on Population and Development(ICPD) whose goal is to have more than 80% of deliveries assisted by skilled attendants globally by 2005, 85% by 2010 and 90% by 2015 (UNFPA 2010).
Home deliveries are poorly managed and inadequate care is offered during the critical hours of a woman’s life. This exposes the mother and the baby to health risks and complications which include anemia, bleeding, infection and if immediate interventions are not taken this can lead to death or damage of the reproductive organs. It is evident from reports that every day, almost 800 women die in pregnancy or childbirth worldwide. Evidence shows that infants whose mothers die are more likely to die before reaching their second birthday than infants whose mothers survive. And for every woman who dies, 20 or more experience serious complications (UNFPA 2010).
Maternal health services have been improved upon in all the health centers in the region. However, many women do not utilize these facilities and instead seek delivery care from high risk places. Giving birth without the assistance of a skilled birth attendant can pose life threatening situations incase complications occur during the process. This study, therefore, was set to investigate factors that influence the choice of health care facilities by pregnant women in Addis ababa.
1.3 Objective of the Study
This study aims to systematically explore the differences and the factors that influence women’s preferences for places to give birth in Addis Ababa.
Specifically it aims:
- To determine the Socioeconomic and Demographic Characteristics of the pregnant women.
- To examine the determinants of choice of healthcare facilities by pregnant women.
1.4 Research Question
The study seeks to answer the following research questions
- What is the Socioeconomic and Demographic Characteristics of the pregnant women?
- What are the determinants of choice of healthcare facilities by pregnant women?
1.5 significance of the Study
The findings of this study may have both theoretical and practical implications for the future of suitability of place of delivery in Addis Ababa. Theoretically, the study may contribute to the advancement of knowledge about factors determining the choice of place of delivery in Ethiopia specifically Addis Ababa. The study might also have practical significance in that, it may assist in determining the level of utilization of SBAs and TBAs at birth. The findings may be of immediate benefit to the Ministry of Health in the formulation of future public health policies aimed at integrating TBAs in the health system as agents of change to enhance places of delivery. Similarly, results of this study may enlighten the public especially mothers and spouses on the importance of considering a suitable and safe place of delivery. In addition, this can lead to appropriate interventions by non-governmental organizations and other key stakeholders that have established or intend to establish reproductive health programs. The study may also forms a base on which others can develop their studies based on the gaps identified.
1.6 Scope / Limitation of the Study
This study will be carried out with Addis Ababa as the case study, its divided into 10 sub-cities and each sub-city is further divided into several small administrative units called Kebeles.
Limitations of the Study
The limitations of the study were; inadequate time to collect data, therefore two research assistants were hired to assist in carrying out the task.
Cases of respondents not cooperating were experienced and even some had to withdraw from the exercise after answering some questions because they were not convinced if the study was done for genuine reasons.
1.7 Definition of Terms Used in the Study
This refers to all females of reproductive age that is, 15 years to 49 years of age.
Choice of Place of Delivery:
This is the preferred option by the women who are giving birth; it could either be home, health facility or assisted by traditional birth attendant.
No. of Children:
This refers to the number of children a woman has at the time of making the choice.
No. of Household Members:
This refers to the number people in a particular household.
This refers to whether a person is married, single, divorced or widowed.
Level of Education:
This refers to the level of schooling a person has reached, that is, primary education, secondary or tertiary education.
This entails the care that is given to women who are expectant or pregnant.
This is the person who makes a choice regarding family issues.
This is the type of work that a person does.
Level of Monthly Household Income:
This refers to the total monthly earnings in a given family.
This refers to what is used to move from one place to another, that is, on foot, motorbike, private or public means
Conclusion and Recommendation
Despite the high number of ANC attendances among mothers in the study area, a notable number of pregnant women especially among slum residents still chose to deliver at home. While women’s perception of the private sector in Addis Ababa is that it offers better quality services than that offered in the public facilities, still most respondents preferred to deliver in public healthcare institutions despite the general doubts about the quality of services delivered. The preferences were attributed to short distance and perceived as well as experienced low cost of care at public facilities. The observation that utilisation of health facilities was high among younger age groups compared to older women was interesting and factors that demotivate older women from utilising health facilities need to be studied further. To prevent women from reverting back to home delivery, effective communication and particularly counselling of women during ANC visits about the danger signs and complications of pregnancy and childbirth should be enhanced, and concerted effort should be made to encourage every pregnant woman to attend ANC services. Efforts should be directed at the healthcare facilities so that they should provide quality ANC services.
In interpreting this study’s findings, it is advisable to consider some of the limitations of the study. The cross sectional nature of the data does not allow making causal inferences about the relationship between delivery care and the risk factors. It is important to keep in mind that the analysed data includes information reported by mothers only from last pregnancies or child births. This study did not collect data about the views and practices of service providers related to quality of services. The study was also limited to the capital city and findings might not reflect the situation of the rest of the country.
The following recommendations may help women in Addis Ababa and Ethiopia at large to make a better choice when the time to give birth reaches.
1. Demographic Factors
Advocacy to all women of child bearing age on importance of hospital deliveries, this can be done by the Ministry of Health, Ngo’s and community based organizations. Mothers should be made aware that each pregnancy has its own challenges having delivered before does not put them out of risk.
2. Social Factors
Involvement of husbands as key decision makers in the choice of place of delivery during antenatal clinic visits could be one of the best strategies in reduction of home deliveries.
3. Economic Factors
The government should focus more on women empowerment through creating entrepreneurship opportunities for them as a measure to make them financially stable and this could of a positive impact on the choices they make during delivery.
4. Antenatal Clinic Attendance
During antenatal clinic visits health workers should emphasize more on issues like early signs of labour, birth preparedness and expected dates of delivery as a step to reduce home deliveries. They should also encourage mothers to be accompanied by their husbands during these visits.
Health workers should increase the coverage of antenatal care by reaching out to women at the community level through outreach programmes that are geared towards creating awareness that antenatal clinic visits are important for them when they are expectant.
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