Study settings
USAID Transform: Primary Health Care covers a total of 396 districts in the four largest regions of Ethiopia, (Amhara, Oromia, SNNP, and Tigray) where a total of 1,880 health centers provide health care to 53 million people. A health center is a health facility at the primary level of the health care system which provides promotive, preventive, curative and rehabilitative outpatient care including basic laboratory and pharmacy services with a capacity for 10 beds for emergency and delivery services (14). On average, a health center is designed to provide health care services to 25,000 people.
Study design and instruments
The study employed a retrospective cross-sectional study design and used program monitoring data collected from October to December 2019. USAID Transform: Primary Health Care project monitoring data was collected from the project intervention health centers during follow-up visits with the objective of providing on-site technical support and producing unbiased data for decision making. During this period, a total of 425 visits were made to randomly selected health centers. The analysis presented in this study are based on the collected data from the 425 facilities during supportive supervision visits.
Data collection
During facility support, data collection and entry is conducted on-site using an online electronic system and tablets. The system allows the questionnaires to be programmed and follows skip patterns based on previous responses. On a few occasions, the visit may be carried out by other experts who will use a paper format and then transfer the data to the online system.
Three types of data are collected during an on-site technical assistance visit. The first inquiries about health worker knowledge on the practices, the second is an observation of the availability of equipment and other relevant materials for care and the third involves a review of medical records. For this study, findings from the three types of data were used for analysis.
Variables of interest
The dependent variable of the study is consistent delivery of ENC by health care providers. It is a nominal variable that facilities those practicing all the ENC components to all cases to be labeled as “yes” and those that do not practice all, to be labeled as a “no”. The independent variable for this study includes other facility and input level variables (Table 1). They were included in the study to identify facility level attributes for observed differences between facilities in the consistent delivery of ENC. The variables based on findings from other studies and program implementation experience are described in the table below.
Table 1: Variables included in the analysis
Category
|
Components
|
Infrastructure related factors
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- Distance between facility and woreda capital (KM)
- Access to roads
|
Health workforce related factors
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- Availability of trained providers
- Availability of technical staff as per the standard
- Consistent partograph use
|
Facility readiness
|
- Availability of water
- Availability of electricity
- Presence of all the required laboratory investigations for ANC
- Availability of maternity waiting homes
- BEmONC signal functions
- Separate delivery rooms
- Availability of essential obstetric drugs in delivery rooms (vitamin K, TTC eye ointment and other obstetric drugs)
- Availability of newborn corners
- Established case review/audit system for maternal and newborn deaths
|
Interactions and experiences of care
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- High caseload facility
- Community scorecard performance
- Availability of women-friendly delivery services
|
Operational definition of terms
Consistent delivery of essential newborn care (CD-ENC) - A central goal of the project and the objective for its support to health workers and the health system. The data collectors randomly pick five cards from the months prior to the data collection date and check for what is recorded on the patient card. After review of each card, the data collectors then mark if ENC is practiced or not. The case is marked as ‘yes’ when all the five components of the package, (vitamin K, TTC eye ointment, chlorohexidine for cord care, early initiation of breastfeeding and thermal care) are recorded as having been provided.
Availability of trained providers - The facility having two or more providers trained on either BEmONC or ENC within the last three years.
Availability of technical staff as per the standard - The facility having 25 or more technical staff that provide services.
High caseload facility – The facility offering delivery services for more than 500 births per year.
Community scorecard (CSC) performance (Favorable user experiences) – A continuous variable - the community analyzes facility services and score them based on their personal perceptions of the services. As per the Ethiopian standard operating procedure, selected community representatives rate each facility’s performance based on the selected six indicators (1) compassionate, respectful and caring health workforce; (2) availability of services, biomedical equipment and pharmaceutical supplies; (3) patient waiting time; (4) health facility infrastructure; (5) ambulance service and management; and (6) clean and safe health facility (CASH).
Availability of newborn corners – A facility is labeled as having newborn corners when it has all the required equipment and materials in the labor and delivery rooms. The equipment and materials are: Ambu bag, suction machine, radiant warmer/heat source, oxygen source, fixed length board, resuscitator, weight scale, thermometer, stethoscope, mucus extractor, towel, cord care equipment, tube for feeding, sterile gloves, TTC eye ointment, vitamin K, CHX, syringe, feeding cup, ampicillin, and gentamicin.
Consistent use of partograph – A facility which exhibits correct use of partographs in the reviewed patient cards.
Have all the required laboratory investigations for ANC – The facility having tests for Rh blood group, hemoglobin, venereal disease research laboratory (VDRL)/RPR (rapid plasma reagin), urinalysis, provider initiated testing and counseling (PITC) for HIV, and hepatitis B surface antigen (HBsAg).
Data analysis
Data were managed using a web-based system, DHIS2 (15), and then exported to SPSS version 25 for statistical analysis. Descriptive statistics were formulated and presented in tables. Binary logistic regression was employed to assess the statistical association between the outcome variable and the independent variables. First, the assumptions for binary logistic regression model were checked and then bivariate analysis was used to identify candidate variables for multiple logistic regression analysis. All variables with p<0.2 in the bivariate analysis were identified as candidate variables. Then, multiple logistic regression analysis was performed using candidate variables to determine statistically significant predictors of the consistent delivery of ENC by adjusting for possible confounders. In addition, a variable that was significant from a program implementation point of view was included in the final model even if the bivariate inclusion criteria were not met. Finally, variables with a p value less than 0.05 from the logistic regression were declared as statistically significant. Adjusted odds ratio with 95% CI was estimated to identify predictors for consistent delivery of ENC. Multicollinearity between the study variables was diagnosed using a variance inflation factor (VIF), an eigenvalue, and a condition index. Large, greater than 5, VIF values indicate a high degree of collinearity or multicollinearity among the independent variables (16). Linearity of the continuous variables, distance between facility and woreda capital (KM) and community score card, with respect to the logit of the dependent variables were assessed via the Box-Tidwell (1962) procedure. The goodness-of-fit of the model was also checked using the Hosmer-Lemeshow test.
Ethical considerations
The study used project data that has been collected as part of follow-up monitoring visits to health centers. The results of the study did not distinguish the name of the district and other specific site identifiers. Therefore, JSI research and Training Institute, Inc’s Institutional Review Board (IRB) has determined that this activity is exempt from human subjects’ oversight (IRB #20-17E). As part of the activity, though, facility entry and document review were permissions sought from the health center management and staff.