A community based cross sectional quantitative design was conducted on April 03 to May 28, 2017 among women who had birth in the past one year preceding the study. The study was conducted in West Shoa Zone, Oromiya region, Ethiopia. The administrative center for West Shoa Zone is Ambo city which is located 112 km west of Addis Ababa, capital city of Ethiopia. The zone has 19 woredas with over 528 rural kebeles and 58 urban kebeles. Currently, the west shoa zone consists of 7 governmental hospitals, 92 health centers and 578 health posts.
- Women of reproductive age 15–49 years who gave birth in the last one year before the survey
- Women who lives in the study area at least for six months.
- Women with physical and mental illness were excluded from the study.
Sample size and sampling procedures
The sample size was calculated using single population proportion formula [(n = (Zά/2)2 p (1 - p)/d2)] using a proportion of mother’s seeking behavior, p = 73.8 % (Lakew et al 2015:109) with 5% of marginal error (d) and 95% confidence level, design effect of 2 to correct the design effect and 10% non-response rate yields final sample size was 654 respondents. Multi-stage random sampling technique was applied to select the study participants. Initially, five weredas was selected by simple random sampling from a total of 19 wereda of West shoa zone. Then the five woreds was stratified by residence (urban and rural kebeles), then the kebeles of the five woredas was allocated proportionally. Then the target population (women who get birth in the last 12 months) was allocated by proportionally to each urban and rural kebeles. Finally, eligible mothers who had birth in the past one year were interviewed consecutively until the required sample sizes were fulf
Variables used in this study consists of three dependent variables (antenatal care, safe delivery and postnatal care; each variable was dichotomous in nature) regarding seek skilled assistance to obstetric care. Definitions of these three dependent variables are:
- Antenatal Care indicates whether the mother received at least three antenatal care visits (coded as 1 and if care was not received, it is coded as zero (0). Full antenatal care has been defined as at least three antenatal care visits, consumed 90+ Iron and Folic Acid tablets and two or more tetanus toxoid injections taken.
- Safe Delivery indicates whether the delivery is assisted by skilled providers (coded as 1) if not coded as zero (0). Safe delivery is defined as either institutional delivery or if home delivery assisted by doctor, auxiliary nurse midwife, nurse, midwife, lady health visitor or other health personnel.
- Postnatal Care indicates whether the women received care from skilled providers within 42 days of the birth (If yes coded as 1, if not coded as 0)
The independent variables included the socio-demographic, obstetric and services related factors.
Socio-demographic factors: residence, age, ethnicity, religion, marital status, mother educational status, income, occupation, husband education, decision making
Obstetric characteristics: Parity, Age at first pregnancy, pregnancy planned, antenatal care visit, Knowledge and attitude towards skilled obstetrics services
Service Factors: Distance to facility, transport and telephone access
Skilled providers: Health professionals (midwife, doctor, nurse), who have been effectively educated and trained in the skills necessary to manage normal and complicated pregnancies, childbirth and the immediate postnatal period (WHO 2006).
Skilled obstetrics care: The elements of obstetric care needed for the management of normal and complicated pregnancy, delivery and the postpartum period by a competent health care provider with the necessary equipment and effective health care system including referral facilities for emergency obstetric care (WHO 2006).
Seek skilled assistance: respondents who sought assistance from Doctors, Nurses, Midwifes, or Health Officers for any one of the recent pregnancy complications.
Non-skilled providers: include health extension workers (HEWs), traditional birth attendants
(TBAs) and relatives or family members who cannot fulfill the definition of a skilled provider.
Transport access: includes availability of vehicle and transport (car, ambulance, bus, or bajaj), and comfortable road.
Knowledge on skilled obstetric care:
A total of six questions were given to the respondents to assess their level of knowledge on skilled obstetric services. Those who scored between 3–6 marks (above 50%) were said to have good knowledge, while those who scored between 0–2 marks (below 50%) were said to have a poor knowledge of skilled obstetric care.
Attitude towards skilled obstetric care:
Attitude related questions were graded according to Likert scale. Each item score between 1 to 4 points. The options were: 1 point for ‘Strongly agree’, 2 points for ‘agree, 3 points for ‘disagree’ and 4 points for ‘strongly disagree’. Then the collected answers were then converted to 1(Agree and Strongly agree) and 0 (Strongly disagree and Disagree). A total of four questions were given to assess the respondent’s attitude towards skilled obstetric care. Those who scored between 2–4 marks (50 % and above) were considered as having a positive attitude while those who scored between 0–1 marks (50% and below) were considered as negative attitude towards skilled obstetric care.
Practice of skilled obstetric care seeking:
A total of three questions relating to the respondent’s practice of seeking care from skilled provides in health institution for pregnancy, childbirth and postnatal. Those who scored above 50% were said to have good practice and those who scored below 50% were said to have poor practice.
Data collection tools
Interviewed administered structured questionnaire were used to collect the data. The questionnaire focused on socio-demographic characteristic, obstetric history, and service related factors includes infrastructure, knowledge, attitude and practice of women’s skilled assistance seeking for obstetric care. Training on data collection techniques was given for data collectors for two days before the actual work about the aim of study, sampling procedures, ways of administering and collecting the questionnaire and technique of interviewing was given. Each data were checked for completeness and consistency.
Data quality assurance
To assured the quality of data the following measures was undertaken. The questionnaire was initially prepared in English, translated to local language Afan Oromo, and back to English by different individuals to check for consistency of meaning. It was then pre-tested on 5% of the sample and necessary corrections and amendment was done. Six BSc Nurse/midwife data collectors were recruited. Training on data collection techniques was given to the data collectors for two days. The structured questionnaire was discussed in detail going through every question and clarification was provided.
Informed consent was obtained to ensure the willingness and confidentiality for all of the study subjects. Then the collected data was reviewed and cross checked for completeness and consistency by principal investigator on daily bases at the spot during the data collection time and necessary corrections and changes were made.
All filled questionnaires were checked daily for completeness, accuracy, clarity and consistency by the supervisors and the principal investigators and necessary corrections and changes were made. Completeness and consistency of variables during data entry and analysis was checked using frequency distributions and cross tabulations.
DATA PROCESSING AND ANALYSIS
Data were entered and cleaned using Epi Info software, and then exported to SPSS version 24.0 statistical software packages for analysis. Bivariate analysis between dependent and independent variables was performed separately using binary logistic regression.
The degree of association between independent and dependent variables was assessed using Odds ratio and other statistical tests with 95% confidence interval and P-value (<0.05). Bivariate and multivariate logistic regression analysis was employed to examine the relationship or statistical association between independent and outcome variables. Variables which have association in bivariate analysis were included in multivariate analysis. Then multivariate analysis using forward stepwise multiple logistic regression technique was done to evaluate independent effect of each variable on three dependents variables such as (antenatal care, institutional delivery and postnatal care) by controlling the effect of other variables. Finally the results were presented using tables, figure and texts.