Effect of checklist based box system interventions on improving institutional delivery among reproductive age women in Northwest Ethiopia: generalized structural equation modeling

Netsanet Belete Andargie, Gurmesa Tura Debelew, Netsanet Belete Andargie, Gurmesa Tura Debelew

Abstract

Background: Previous studies have shown that there is low utilization of institutional delivery in Ethiopia, as well as various factors contributing to this low utilization. Notably, there is paucity around interventions to improve institutional delivery. Hence, this study examines the effectiveness of checklist-based box system intervention on improving institutional delivery and to investigate the association through which the intervention is linked to institutional delivery.

Method: The study used data from a larger trial, on the effectiveness of checklist-based box system intervention on improving maternal health service utilization. In the intervention arm, mothers received regular community-level pregnancy screening and referral, service utilization monitoring boxes, drop-out tracing mechanisms, regular communication between health centers and health posts, and person-centered health education for mothers. This study used the existing government-led maternal health program as a control arm. A total of 1062 mothers who gave birth one-year before the survey were included in the final analysis. A difference-in-difference estimator was used to test the effectiveness of the intervention. Generalized structural equation modeling was used to examine the direct and/ indirect associations between the intervention and institutional delivery.

Result: Among participants, 403 (79.5%) mothers from intervention and 323 (58.2%) mothers from control clusters gave birth at health facilities. The result of the study revealed a 19% increase in institutional delivery in the intervention arm (19, 95%CI: 11.4-27.3%). In this study the pathway from checklist-based box system intervention to institutional delivery was mainly direct - (AOR = 3.32, 95%CI: 2.36-4.66), however, 33% of the effect was partially mediated by attendance of antenatal care four visits (AOR = 1.39, 95%CI: 1.02-1.92). The influence of significant others (AOR = 0.25, 95%CI: 0.15-0.43) and age (AOR = 0.03, 95%CI: 0.01- 0.09) had an inverse relation with institutional delivery.

Conclusion: The implementation of a checklist-based box system significantly increased institutional delivery utilization, both directly and indirectly by improving antenatal care four attendance. A larger-scale implementation of the intervention was recommended, taking the continuum of care approach into account.

Trial registration: ClinicalTrials.gov , NCT03891030 , Retrospectively registered on 26 March, 2019.

Keywords: Box system; Generalized structural equation modeling; Institutional delivery; Northwest Ethiopia.

Conflict of interest statement

The authors declare that they have no competing interests.

© 2021. The Author(s).

Figures

Fig. 1
Fig. 1
Hypothesized model for factors associated with institutional delivery: {Adjusted for age, month of initiation for the first ANC, influence}, January 2019-September 2020, Northwest Ethiopia (CBBSI-Checklist based box system intervention, BpCr-Birth Preparedness and complication readiness, DsK-Danger Signs Knowledge, FamSupp-Family support)
Fig. 2
Fig. 2
The effect of CBBSI on institutional delivery and the mediation effect of Antenatal four visits, birth preparedness and complication readiness and danger signs of labor and delivery, January 2019-September 2020, Northwest Ethiopia. (CBBSI-Checklist based box system intervention, BpCr-Birth Preparedness and complication readiness, DsK-Danger Signs Knowledge)
Fig. 3
Fig. 3
Participant flow diagram
Fig. 4
Fig. 4
Unstandardized parameter estimates of pathways from CBBS Intervention to institutional delivery, generalized structural equation modeling, January 2019-September 2020, Northwest Ethiopia, (DkS: Danger sign Knowledge, BPCR: Birth preparedness and complication readiness, Famsup: Family support, InstiDeli: Institutional delivery, Danger sign: Knowledge of labor and delivery danger signs, SocSupp: Social support, Fs: Family support)

References

    1. WHO . Recommendations on maternal health. The future of eco-labelling: making environmental product information systems effective. 2017.
    1. WHO . Making pregnancy safer: a strategy for action. Safe Motherhood Newsletter. 2009.
    1. Kwast BE, Liff JM. Factors associated with maternal mortality in Addis Ababa, Ethiopia. Int J Epidemiol. 1988;17(1):115–121. doi: 10.1093/ije/17.1.115.
    1. Ekele BA, Tunau KA. Place of delivery among women who had antenatal care in a teaching hospital. Acta Obstet Gynecol Scand. 2007;86(5):627–630. doi: 10.1080/00016340601134622.
    1. Graham H, Bell J, Bullough C. Can skilled attendance at delivery reduce maternal mortality in developing countries ? Safe motherhood strategies a review of the evidence. 2001.
    1. Darmstadt GL, Bhutta ZA, Cousens S, Adam T, Walker N, De Bernis L. Evidence-based, cost-effective interventions: how many newborn babies can we save? Lancet. 2005;365(9463):977–988. doi: 10.1016/S0140-6736(05)71088-6.
    1. UNICEF. The state of the world’s children: maternal and newborn health. New York: WHO; p. 1–168. 2009.
    1. Ayele GS, Melku AT, Belda SS. Utilization of skilled birth attendant at birth and associated factors among women who gave birth in the last 24 months preceding the survey in Gura Dhamole Woreda, Bale zone, Southeast Ethiopia. BMC Public Health. 2019;19(1):1–14. doi: 10.1186/s12889-019-7818-6.
    1. CSA . Ethiopia mini demographic and health survey: key indicators. 2019.
    1. Haruna U, Dandeebo G, Galaa SZ. Improving access and utilization of maternal healthcare services through focused antenatal care in Rural Ghana: a qualitative study. Adv Public Health. 2019;2019:1–11. doi: 10.1155/2019/9181758.
    1. Ministry of Health and Social Welfare, Tanzania. Focused antenatal care malaria and syphilis in pregnancy. Learner’s Guide for ANC Service Providers and Supervisors. 2009
    1. Hailu M, Gebremariam A, Alemseged F, Deribe K. Birth preparedness and complication readiness among pregnant women in Southern Ethiopia. PLoS One. 2011;6(6):e21432. doi: 10.1371/journal.pone.0021432.
    1. Anshebo D, Geda B, Mecha A, Liru A, Id RA. Utilization of institutional delivery and associated factors among mothers in Hosanna Town, Hadiya Zone, Southern study. 2020. pp. 1–12.
    1. Mitikie KA, Wassie GT, Beyene MB. Institutional delivery services utilization and associated factors among mothers who gave birth in the last year in Mandura district, Northwest Ethiopia. PLoS ONE.2020;15(12):e0243466. 10.1371/journal.pone.0243466.
    1. Bayu H, Fisseha G, Mulat A, Yitayih G, Wolday M. Missed opportunities for institutional delivery and associated factors among urban resident pregnant women in South Tigray Zone, Ethiopia: a community-based follow-up study. Global Health Action. 2015;8:1-8.
    1. Nigatu AM, Gelaye KA. Factors associated with the preference of institutional delivery after antenatal care attendance in Northwest Ethiopia. BMC Pregnancy and Childbirth. 2019;19:810.
    1. Federal Ministry of Health Ethiopia(FMoH) Health sector transformation plan -I. 2017. p. 142.
    1. Kurji J, Gebretsadik LA, Wordofa MA, Morankar S, Bedru KH, Bulcha G, et al. Effectiveness of upgraded maternity waiting homes and local leader training on improving institutional births : a cluster- randomized controlled trial in Jimma. 2020. pp. 1–15.
    1. Shiferaw S, Spigt M, Tekie M, Abdullah M, Fantahun M, Dinant GJ. The effects of a locally developed mHealth intervention on delivery and postnatal care utilization; a prospective controlled evaluation among health centres in Ethiopia. PLoS One. 2016;11(7):1–14. doi: 10.1371/journal.pone.0158600.
    1. Zerfu TA, Taddese H, Nigatu T, Tenkolu G, Khan DN, Biadgilign S, et al. Is deployment of trained nurses to rural villages a remedy for the low skilled birth attendance in Ethiopia? A cluster randomized-controlled community trial. PLoS One. 2018;13(10):1–12. doi: 10.1371/journal.pone.0204986.
    1. Andargie NB, Jebena MG, Debelew GT. Effectiveness of checklist-based box system interventions (CBBSI) versus routine care on improving utilization of maternal health services in Northwest Ethiopia: study protocol for a cluster randomized controlled trial. Trials. 2020;21(1):1–9. doi: 10.1186/s13063-019-4002-3.
    1. Asefa A, Gebremedhin S, Messele T, Letamo Y, Shibru E, Alano A, et al. Mismatch between antenatal care attendance and institutional delivery in south Ethiopia: a multilevel analysis. 2019. pp. 1–10.
    1. Fekadu A, Yitayal M, Alemayehu GA, Abebe SM, Ayele TA, Tariku A, et al. Frequent antenatal care visits increase institutional delivery at Dabat health and demographic surveillance system site, Northwest Ethiopia. 2019. p. 2019.
    1. Tesfaye G, Chojenta C, Smith R, Loxton D. Predisposing, enabling and need factors associated with skilled delivery care utilization among reproductive-aged women in Kersa district, eastern Ethiopia. Reprod Health. 2019;16(1):1–11. doi: 10.1186/s12978-019-0829-z.
    1. Ethiopian Demography and Zones, Amhara Regional State. .
    1. Kumar K. A beginner’s guide to structural equation modeling, 3rd edn. J R Stat Soc Ser A Stat Soc. 2012;175:828–829. doi: 10.1111/j.1467-985X.2012.01045_12.x.
    1. Fekadu GA, Kassa GM, Berhe AK, Muche AA, Katiso NA. The effect of antenatal care on use of institutional delivery service and postnatal care in Ethiopia: a systematic review and meta-analysis. 2018. pp. 1–11.
    1. Asseffa NA, Bukola F, Ayodele A. Determinants of use of health facility for childbirth in rural Hadiya zone, Southern. BMC Pregnancy Childbirth. 2016;16(335):1–9.
    1. Yoseph M, Abebe SM, Mekonnen FA, Sisay M, Gonete KA. Institutional delivery services utilization and its determinant factors among women who gave birth in the past 24 months in Southwest Ethiopia. BMC Health Serv Res. 2020;20(1):1–10. doi: 10.1186/s12913-020-05121-9.
    1. Id RS. Does delivery in private hospitals contribute largely to caesarean section births? A path analysis using generalised structural equation modelling. 2020. pp. 1–24.
    1. Tura G, Afework MF, Yalew AW. The effect of birth preparedness and complication readiness on skilled care use : a prospective follow-up study in Southwest Ethiopia. Reproductive Health. 2014;11(1):1–10.

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