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FACTORS
DETERMINING THE CHOICE OF HEALTH CARE FACILITIES BY PREGNANT WOMEN
INTRODUCTION
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.
Introduction
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 [1] . 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 [2] . Yet, Ethiopia’s health
system is underdeveloped and underfinanced [3] . 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 [4] .
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% [5] . 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 .
This study
aims to systematically explore the differences and the factors that influence
women’s preferences for places to give birth in Addis Ababa. It is envisaged
that a clear understanding of such factors is key in building a responsive
maternal healthcare system and improving health outcomes in Ethiopia.
2. Research
Design and Methods
2.1.
Sampling and Data Collection
Addis Ababa,
the study area, is divided into 10 subcities and each subcity is further
divided into several small administrative units called Kebeles. In the 2007
Ethiopia Housing and Population Census, Kebeles were further subdivided into
enumeration areas (EAs). An EA is a geographic area consisting of a convenient
number of dwelling units which was used as a counting unit for the census. The
average number of households (HHs) per EA in urban Ethiopia is 169. The number
of clusters (EAs) in Addis Ababa was about 3865 [3].
Because of
the different levels of political or administrative structures and wider
geographic areas, cluster sampling technique was employed for this study. The
study employed a stratified, two-stage cluster design. Since Addis Ababa is
entirely urban, stratification was achieved by using the subcities (10 strata).
Using the 2007 Population and Housing Census data, in the first stage 30
enumeration areas (EAs) were selected independently from all the strata with
probability proportional to (EA) size (PPS) of households. In the second stage,
906 households were selected with PPS of households in each EA. The systematic
random sampling of the eligible households was done based on the number of
households recorded during the complete listing of households in each EA during
the last EDHS 2011 [3]. To minimize sampling errors that may arise due to
changes in the years after the last enumeration (complete household listing),
approaching the subcity and Kebele administrations as well as community members
in the respective EAs was an important step in the survey process. It was
necessary to be aware of and be sensitive to the various community level
dynamics in the study area. Hence, the demolition of significant portions of
four EAs from four strata due to the city’s reconstruction process was the
major change reported and verified by the first author. Three EAs were replaced
by other randomly selected three adjacent EAs and remaining households of the
fourth EA were completed from a section of a randomly selected adjacent EA.
In this
study verbal face-to-face interview was administered using a structured
questionnaire. Recall bias was taken into consideration during the development
of the questionnaire. Therefore, women were asked about their most recent or
last birth and the date of birth of the child was asked. Ethical clearance was
obtained from the National Research Ethics Review Committee of the Ministry of
Science and Technology, Ethiopia. The target population was all women of 15–49
years of age who have experienced at least one birth in the last 1–3 years
before the date of data collection, December 2013–January 2014.
2.2.
Description of Variables
The
independent variables for this study were selected based on a modified version
of the Behavioural Model of Health Services. The model distinguished three sets
of factors related to healthcare seeking behaviour of individuals: the
predisposing, enabling, and need factors.
Under the
predisposing factors, demographic variables such as age, number of living
children, current marital status, and pregnancy intention related to last
childbirth and social structure variables such as education, occupation, and ethnicity
were considered at individual, household, and community levels. As regards
pregnancy intention, women were asked about their recent births whether they
wanted it then, wanted it later, or did not want to have any more children at
all. In the analyses, the intention status of the birth was further defined as
a dichotomy variable: intended for births wanted by then versus unintended for
being either mistimed or unwanted by then. Women’s education was defined here
as the highest level of schooling attended regardless of whether the woman
completed the level.
Under the
enabling factors, individual and family resource indicator variables including
housing tenure, health insurance, and wealth quintile were included. Those who
visited health facility for ANC were also asked whether there was an
organization or agency that either partially or fully covered their expenses
and the responses were grouped as “yes” or “no.” Housing tenure was categorised
as the house in which the respondent lives is either owned by her or not owned
by her, that is, owned versus rental. The type of residence was categorised as
slum and nonslum residences based on the five indicators including access to
improved water, access to improved sanitation, sufficient living area, durability
of housing, and secure tenure (housing tenure) developed by United Nations
Human Settlements Programme
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