Socio-demographic characteristics
Mean age of women at the time of interview was 30.96 + 7.22 years. Of 898 women, 449 (50%) were between 25 and 36 years of age. Six hundred thirty eight (71.4%) of women did not attend any formal education, 768 (85.5%) were married and 662 (74%) of them were housewives.
HEWs’ mean age was 26 + 3.67 years and 13 (81.3%) of them were married and they walked an average of around 3 hours (95% CI: 2:05 – 3:05) to reach to the most far away mother’s home.
Coverage of FANC
Seven hundred fifty two of 898 women were contacted health care providers at least once during their recent pregnancy, making an overall antenatal care coverage of 83.7% (95% CI: 81.28 – 86.12). Out of those 752 women who have got ANC in their recent pregnancy, 397 (52.8%; 95% CI: 52.7 – 52.9) provided by HEWs and 355 (47.2%; 95% CI: 47.1 – 47.3) by skilled providers. Mean time of first antenatal care visit was 4.14 + 2 months. Interestingly, 344/752 (45.7%, 95% CI: 44.1 – 47.7) attended ANC in the first trimester of gestation (less than 12 weeks).
Frequency and Contents of FANC
Mean number of antenatal visits were 3 + 1.6, and 263/752 women (35.0%; 95% CI: 31.6 – 38.4) attended at least four ANC visits. Higher numbers of antenatal visits were related with increased FANC package contents provided to mothers. In this study women who received one, two, three and > 4 ANC visit is accompanied by two, eight, sixteen and twenty mothers who received the whole contents of FANC (Figure 1).
Only 46/752 women (6.1%; 95% CI 4.4 - 7.8) received all contents of FANC. Thirty three of those (4.3%) received care from HEWs and 13 (1.7%) from skilled providers (Table 1 for the detail).
Table 1. Components of focused antenatal care package provided by HEWs and skilled providers’ qualification in South Wollo Zone, Ethiopia.
Contents
|
Number of mothers (%)
|
By HEWs (%)
|
By skilled provider (%)
|
Weight measured
|
Yes
|
629 (83.6)
|
296 (47.1)
|
333 (52.9)
|
No
|
123 (16.4)
|
101 (82.1)
|
22 (17.9)
|
Height measured
|
Yes
|
488 (64.9)
|
252 (51.6)
|
236 (48.4)
|
No
|
264 (35.1)
|
145 (54.9)
|
119 (45.1)
|
Blood pressure measured
|
Yes
|
558 (74.2)
|
305 (54.7)
|
253 (45.3)
|
No
|
194 (25.8)
|
92 (47.4)
|
102 (52.6)
|
Advised for institutional birth
|
Yes
|
686 (91.2)
|
372 (54.2)
|
314 (45.8)
|
No
|
66 (8.8)
|
25 (37.9)
|
41 (62.1)
|
Advised for BPCR*
|
Yes
|
645 (85.8)
|
350 (54.3)
|
295 (45.7)
|
No
|
107 (14.2)
|
47 (43.9)
|
60 (56.1)
|
Advised on danger signs during pregnancy and birth
|
Yes
|
606 (80.6)
|
327 (54.0)
|
279 (46.0)
|
No
|
146 (19.4)
|
70 (47.9)
|
76 (52.1)
|
Advised on personal hygiene
|
Yes
|
695 (92.4)
|
372 (53.5)
|
323 (46.5)
|
No
|
57 (7.6)
|
25 (43.9)
|
32 (56.1)
|
Advised for PMTCT*
|
Yes
|
633 (84.2)
|
320 (50.6)
|
313 (49.4)
|
No
|
119 (15.8)
|
77 (64.7)
|
42 (35.3)
|
Advised and screened for STI*
|
Yes
|
622 (82.7)
|
308 (49.5)
|
314 (50.5)
|
No
|
130 (17.3)
|
89 (68.5)
|
41 (31.5)
|
Advised for bed net use
|
Yes
|
527 (70.1)
|
299 (56.7)
|
228 (43.3)
|
No
|
225 (29.9)
|
98 (43.6)
|
127 (56.4)
|
Mothers tested for HIV
|
Yes
|
678 (90.2)
|
345 (509)
|
333 (49.1)
|
No
|
74 (9.8)
|
52 (70.3)
|
22 (29.7)
|
Advised for nutrition during pregnancy
|
Yes
|
634 (84.3)
|
350 (55.2)
|
284 (44.8)
|
No
|
118 (15.7)
|
47 (39.8)
|
71 (60.2)
|
Told to seek care for pregnancy danger signs
|
Yes
|
669 (89.1)
|
363 (54.3)
|
306 (45.7)
|
No
|
82 (10.9)
|
34 (41.5)
|
48 (58.5)
|
Number of TT* vaccine received
|
No
|
58 (7.7)
|
23 (39.7)
|
35 (60.3)
|
TT1
|
287 (38.2)
|
185 (64.5)
|
102 (35.5)
|
TT2+
|
407 (54.1)
|
189 (46.4)
|
218 (53.6)
|
Iron folic acid received
|
Yes
|
425 (56.5)
|
203 (47.8)
|
222 (52.2)
|
No
|
327 (43.5)
|
194 (59.3)
|
133 (40.7)
|
Referred for institutional birth
|
Yes
|
475 (63.2)
|
284 (59.8)
|
191 (40.2)
|
No
|
277 (36.8)
|
113 (40.8)
|
164 (59.2)
|
Expected date of birth told
|
Yes
|
462 (61.4)
|
228 (49.4)
|
234 (50.6)
|
No
|
290 (38.6)
|
169 (58.3)
|
121 (41.7)
|
*BPCR- Birth preparedness & complication readiness, PMTCT- Prevention of mother to child transmission of HIV, STI- Sexually transmitted infection, TT-Tetanus toxoid
Overall weighted average FANC package intervention fidelity (implementation as planned or average number of FANC package interventions women received) was 0.498 (49.8%; 95% CI 47.7 – 51.8); HEWs provided 0.62 (62.0%; 95% CI: 59.7 – 64.3) while skilled providers provided 0.566 (56.6%; 95% CI 53.9–59.2). Only 20 women (2.2%) received the whole recommended FANC package with full fidelity.
Provider-related factors
Twelve (75%) of the HEWs were ever trained on FANC package while only 2 (12.5%) of them received refreshment training in the last three months. Only two health posts were supervised weekly from the catchment health center and 9 (56.3%) HEWs received onsite assistance for difficult cases. Nine of them responded that they were able to provide FANC.
Support strategies set by Ministry of Health were assessed from health center, district health offices, community and development armies’ perspective. Eleven (68.8%) HEWs reported that implementation of support either from the community, health development armies or district health office was lower than the planned standard.
Women-related factors
Only 180 women (20%) were living within 15-minutes’ walking distance from the health post, while 333 (37.1%) of them had to travel > 45 minutes on foot. Of those who received antenatal care, 685 (91.1%) were self-referrals. One hundred eighty seven (20.8%) encountered pregnancy-related problems like bleeding, convulsions or high temperature in their previous pregnancies.
Organizational-related factors
No health post had all required functional equipment and medical supplies for FANC. Birth preparedness and complication readiness forms, supervision checklists, blood pressure cuffs, pregnant women registration books, stethoscopes and tape measures were the most frequently mentioned unavailable items in health posts.
Facilitators’ and barriers’ of FANC intervention fidelity
The ICC observed in the model was 17.7%, which indicates that 17.7% of the variation in FANC package intervention fidelity is explained by health post (cluster) level factors. This shows FANC package intervention fidelity varies between health posts and there are health post level factors which affect implementation of the package.
In the first level model, maternal age, distance from the health post, maternal education, pregnancy-related problems in previous pregnancies, partner’s education and total number of abortions were considered. Facilitation strategies, distance from the farthest household and availability of supplies in the health post were considered in the second level model. Finally, pregnancy-related problems in previous pregnancies, partner’s education and facilitation strategies were found to be statistically significant facilitators for FANC package intervention fidelity (Table 2). In this study, women with pregnancy-related problems in previous pregnancies had a 9% unit increase of FANC package intervention fidelity as compared to those without. Women who had formally educated partners had an 8% unit increase in the levels of FANC package intervention fidelity in recent pregnancies as compared to their counterparts. An average increased implementation of health post level facilitation strategies resulted in a 4% unit increase in the level of FANC package intervention fidelity.
Table 2. The following table shows the initial (maternal level) and final (combined) variables with the corresponding beta coefficient and confidence intervals of mixed effect model.
Variables
|
Estimate
|
95% Confidence interval
|
Level 1 variables
|
Age of mothers (in years)
|
0.004
|
0.0003 - 0.008
|
Maternal problems in previous pregnancy
|
No
|
1
|
|
Yes
|
0.06
|
0.01 - 0.11
|
Total number of abortions
|
0.01
|
0.005 - 0.022
|
Husband education
|
No formal education
|
1
|
|
Attend formal education (1-8)
|
0.10
|
0.05 - 0.15
|
Combined model
|
Pregnancy related-medical problems in previous pregnancy
|
No
|
1
|
|
Yes
|
0.09
|
0.02 - 0.15
|
Husband education
|
No formal education
|
1
|
|
|
Attend formal education (1-8)
|
0.08
|
0.02 - 0.13
|
Implementation of supportive/ facilitation strategy
|
0.04
|
0.02 - 0.05
|
In the final model, ICC was reduced to 4.7% and both Akaike’s Information Criteria (AIC) and Bayesian Information Criteria (BIC) decreased to 187.3 and 168.6 from the initial model (AIC 334.6 and BIC 349.0).