Socio-demographic characteristics of study subjects
The mean age of mothers at the time of interview was 30.96 + 7.215 years. Fifty percent of mothers were between 25 and 36 years of age. Concerning educational status, 638 (71.4%) of mothers did not attend formal education. Seven hundred sixty eight (85.5%) of mothers were married and 662 (74%) of mothers were housewife.
A total of sixteen HEWs who are working in 10 health posts were included in the study. The mean age of these HEWs was 26 + 3.67 years and 13 (81.3%) of them were married. The average walking distance from health post to furthest home were 2:55 (95% CI: 1:10 – 3:20) hours.
Coverage of FANC
In this study, 752 mothers visit or visited by any kind of health care providers at least once making the overall antenatal care coverage of 83.7% (95% CI: 81.28 – 86.12). HEWs contacted 397 or 44.2% (95% CI, 40.95 – 47.45) mothers and the rest contacted by skilled providers. The mean time of first antenatal care visit was 4.14 + 2 months with 259 (42.7%) of mothers had seen by health care providers within the first trimester (12weeks) of gestation.
Frequency of FANC service utilization
The mean number of antenatal visit was 3 + 1.6 and on average 34.97% (95% CI: of 31.56 – 38.39) of mothers received at least four antenatal care visit for their recent pregnancy (See figure1). Increasing the number of antenatal visit results in increasing the contents delivered to mothers in this study which was indicated as one, two, three and four plus antenatal care visit was accompanied by two, eight, sixteen and twenty mothers who received the whole contents of FANC (See figure 1 for the detail).
Components of FANC
On average 46 or 6.12% (95% CI: 4.40-7.83) of mothers received all the components of focused antenatal care. In this study, mothers who received all the required components of focused antenatal care by health extension workers were 33(4.3%) while by skilled providers were 13(1.7%) (See table 1).
The overall weighted average FANC package intervention fidelity was 49.78% (95% CI: 47.73 – 51.83). Only 20 (2.2%) of mothers received all the recommended FANC package intervention with full fidelity. The weighted average FANC intervention fidelity by HEWs were 62.02% (95% CI: 59.71 – 64.32) and by skilled providers were 56.57% (95% CI: 53.94 – 59.19).
Provider related factors
Twelve (75%) of the health extension workers ever trained on FANC package while 2 (12.5%) received current refreshment training within the last three months prior to data collection. Only two of the health posts were supervised weekly from the catchment health center and 9 (56.3%) of the health extension workers got on gob assistance for difficult cases. The average time to walk from the health post to furthest house by HEWs is 2:30 hours with the maximum of 4:00 hours. Nine of the health extension workers believe that they are able to give FANC (self-efficacious).
HEWs were asked about the implementation of support/facilitation strategies set by the ministry of health. These support strategies were assessed from health center, woreda health offices, community and development army perspectives. Seventy percent of the HEWs reported that the implementation of support from the community, health development army and Woreda health office were lower than expected.
Quality of service delivery
One hundred (16.3%) of mothers didn’t receive antenatal care, of whom 489 (65.03%) and 706 (93.88%) of mothers did not get the required number and contents of FANC package respectively.
Only 180 (20%) of mothers are within 15 minute walking distance while 333 (37.1%) of them walked more than 45 minutes to reach to health post. Of those mothers who received antenatal care service, 685 (91.1%) was self-referral. One hundred eighty seven (20.8%) of mothers encountered pregnancy related problem in their previous pregnancy.
No health post were having all the required functional equipment and medical supplies for focused antenatal care services. Birth preparedness and complication readiness form (80%) supervision checklist (70%), blood pressure cuff (50%), pregnant women registration book (30%), stethoscope (40%) and tape measure (40%) were the most frequently mentioned unavailable equipment in the respective health posts.
Facilitators’ and barriers’
To select the appropriate statistical model for the hierarchal nature of the data, intra-class correlation coefficient (ICC) was computed by running the intercept only model. The ICC in this model was 17.73% indicated that 17.73% of the variation in FANC package intervention fidelity is explained by health post (cluster) level factors. Therefore, multilevel linear regression model was appropriate.
In the first level model, maternal age, distance from the health post, maternal education, problems in the previous pregnancy, husband’s education and total number of abortion were considered. Support/facilitation strategies, distance from the farthest household and availability of supplies in the health post were considered in the second level model. Finally, three variables were found to be statistically significant facilitators for FANC package intervention fidelity (See table 2 for the detail). In the final model the ICC was reduced to 4.7% and both AIC and BIC was decreased from 334.6 and 349.0 to 147.3 and 180.4 respectively from the initial model.