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Intention to Use Institutional Delivery and Associated Factors among ANC attendants in Wollaita Soddo Town, SNNPR, Ethiopia. Application of Theory of Planned Behavioral model By Temesgen Lera (BSc. MPH/RH) February, 2017
Presentation outline § Introduction § Objectives § Methods and Materials § Result and Discussion § Limitation of the study § Conclusion and recommendation § Acknowledgements § References
Introduction üAn estimated global total of 13. 6 million women have died in the 25 years between 1990 and 2015 due to maternal causes ( WHO , Trends in MM 1990 to 2015) üThe majority of maternal health complications and deaths occurred in low and middle income countries where three quarters of the deaths are due to preventable direct obstetric complications ü Intention of pregnant women to utilize institutional delivery is affected by socio-demographic variables; household monthly income, health institution, mother occupation and husband occupation had significant effect on the odds of giving birth at health institutions. üFive variables (perceived susceptibility, perceived barriers, self-efficacy, being able to make decision on her own and being informed where to deliver were predictors of the probability of giving birth at health institution. (Bayuet al. 2015) üIn Ethiopia, ANC coverage is 42% but the proportion of births occurring at health institutions is very low (16 %) and it is 14. 9% for SNNPR which is below the national average. ( MEDHS, 2014)
Theoretical framework External variables Demographic factors Age Occupational status Ethnicity Monthly income Religion Husbands’ education Beliefs that institutional delivery leads to certain outcomes Evaluation of the outcomes Beliefs that specific referents think I should/not utilize Institutional delivery Education status Obstetric Factors Gravity Trimester ANC started Parity Number of ANC V. Gestational age History of abortion Age at marriage History still birth Age at first pregnancy Informed delivery place Information given on danger signs Marital status Husbands’ occup. last place of delivery Pregnancy Status Attitudes towards Institutional delivery Subjective norm Motivation to comply with the specific referents. Control beliefs regarding institutional delivery Intention to Utilize Institution al delivery utilization behavior Perceived Behavioral control Perceived Power of the control Figure 1: -Conceptual framework Adapted from Theory of Planned Behaviour (Ajzen, 1991) 4 13/6/2016
Significance of the study ü The use of institutional delivery care services has been shown to be a complex behavioral phenomenon, determined by an individual’s behavioral intention, which in turn, is determined by attitude, the beliefs and perceived social norm and personal capabilities (PBC). ü Understanding women’s intended institutional delivery care utilization behavior is of paramount importance ü For the design of public health interventions for improving maternal health outcomes ü For the design of educational interventions focusing on improving maternal health outcomes ü For the design of Behavioral change communication on institutional delivery utilization Objectives General objective: § To assess intention to use institutional delivery and associated factors among ANC attendants in Wollaita Soddo town, 2016. Specific objectives: § To assess intention to use institutional delivery among ANC attendants in Wollaita Soddo town. § To identify factors associated with intention to use institutional delivery among ANC attendants in Wollaita Soddo town.
4. Methods and Materials 4. 1 Study area and period § The study was conducted in Wollaita Soddo town, § The study was carried out from March to April 2016 Study Design o A Community based cross-sectional study design was employed. Source Population o All pregnant women in Wollaita Soddo town. Study population o Randomly selected pregnant women in each household. Inclusion Criteria ØAll pregnant women who had ANC follow up during the study period were included. Exclusion Criteria ØPregnant women who were unable to respond and seriously ill
Sample Size Determination and Sampling Technique üThe sample size was computed by usingle population proportion formula based on the following : magnitude of intention for institutional delivery 74. 3%, (p = 0. 74) from study conducted in Debre Markos city East Gojam Zone, Ethiopia. üBy considering standard normal distribution the Z-value at 95 % confidence level (CI) is 1. 96, 5 % considered as margin of error. ü n = [(Zα/2)2 p (1 -p)/ d 2] = (1. 96)2 0. 74(1 -0. 74)/ (0. 05)2 ≈ 296 the final sample size calculated was 326 after considering 10 % allowance for non-response. Sampling technique üFrom 18 kebeles in the Wol/Soddo town, 6 kebeles were selected using SRS. ü In the selected kebeles there were 1060 pregnant women who had ANC visit in the health facilities from town health office data. üFor each selected kebele frame work was developed by taking households with the pregnant women who had at least one ANC visit in health facilities from urban health extension professionals’ record in the health post üThe sample size was distributed over 6 kebeles to obtain required number of study participants proportionally. üThen, their respective house number was listed from family folder and selected by simple random sampling (lottery) method until the proportional sample size was obtained. üFinally, the selected participant pregnant women were interviewed by going every household according to their respective household number.
Data management and analysis ü Data was collected by using pre-tested, structured questionnaire by an interviewer administrated questionnaire. § The data collected was checked for its completeness and consistency, coded, entered and cleaned by using Epi data version 3. 1 and exported to SPSS version 20. 00 statistical software. § Data for missing values was checked by frequency tables and data exploration. § Bivariate and Multiple logistic regression analysis were done § Variables with P-value <0. 25 was made candidate for Multivariable analysis § AOR with 95%CI was used to see statistically significant association. Data quality management § Questionnaire developed in English and translated to Amharic and translated back to English. § Questionnaire was pre-tested and Cronbach's Alpha was calculated. § Content validity was cross checked by maternal and reproductive health expert § Data collectors and supervisors was given training on the procedure of data collection. Ethical consideration and Dissemination § Ethical clearance was obtained from Jimma University Institutional Review Board(IRB) § The findings of the study was presented to JU.
5. Result and Discussion ü A total of 326 pregnant women were included. ü The mean age of the respondents was 23. 43 ± 4. 259 SD. Intention to use institutional delivery for current pregnancy Figure 2 Intention of pregnant women to use institutional delivery for their current pregnancy Wollaita Soddo, 2016.
Table 1 - Multiple logistic regression analysis of distal factors associated with intention of pregnant women 10 to utilize institutional delivery Wollaita Soddo, May 2016. Variables Intention F(%) Health Facility COR (95%) AOR( 95%CI) Home Husband’s occupational status 156(81. 67) Employed Not employed 90(66. 66) 35(18. 3) 45(33. 33) 2. 229(1. 335, 3. 72) 1. 00 2. 2(1. 308, 3. 7) 1. 00 Gestational Age in Months 3 -5 101(71. 1) 6 -9 145(78. 8) 41(28. 9) 39(21. 2) 0. 66(0. 301, 1. 217) 1. 00 0. 699(0. 322, 1. 515) 1. 00 Informed pregnancy and delivery complication Yes No Informed about delivery places Yes No 197(77. 3) 47(68. 1) 58(22. 7) 22(31. 9) 1. 59(0. 886, 2. 853) 1. 00 0. 613(0. 255, 1. 478) 1. 00 221(78. 4) 25(56. 8) 61(21. 6) 19(43. 2) 2. 753(1. 422, 5. 33) 1. 00 2. 658(1. 357, 5. 207) 1. 00 13/6/2016
Table-2 Multiple logistic regression analysis of Proximal factors affecting intention to use institutional 11 delivery Wollaita Soddo, 2016. Variables COR (95%) AOR( 95%CI) Attitude 0. 905(0. 827, 0. 994) 0. 911(0. 83, 0. 971) Subjective Norms Positive Negative 1. 089(1. 023, 1. 16) 1. 087(1. 02, 1. 158) Perceived behavioral control Confident Not confident 0. 844(0. 698, 1. 021) 0. 913(0. 746, 1. 118) 13/6/2016
Result and discussion… • This study revealed that prevalence of intention to use institutional delivery services in current pregnancy is 246(75. 5%) 95%CI 2. 4±(70. 3, 80. 1). • This finding is in line with study conducted in Debre Markos town which showed 292(74. 3%) of pregnant women intended to use institutional delivery among ANC attendants. (Bayuet al. 2015). This consistency in proportion might be due to increased willingness of pregnant women to deliver in health facility for the past five years due to increased work on maternal and child health by promoting institutional delivery. • This study showed that majority of mothers 236(72. 4%) had favorable (good) attitude towards institutional delivery utilization. This is different from study conducted in Debre Markos which showed 98 (50. 4%) have good attitudes towards institutional delivery. (Bayuet al. 2015) This difference might be due to current extensive work on information, education and communication on advantages of institutional delivery service utilization in different parts of Ethiopia.
Result and discussion… • This study showed that among the sociodemographic variables husband’s occupational status had statistically significant association with intention to use institutional delivery AOR=2. 2(1. 308, 3. 7). • This study is consistent with study conducted in West Shewa Zone of Oromia which showed that husband occupation had significant effect on the odds of giving birth at health institutions AOR=2. 84 (1. 02 -7. 85) . ( Dida etal , 2014) This might be due to employed husbands’ had access to information on maternal service utilization and they may initiate their wives to use institutional delivery service. • This study showed that among psychosocial variables , attitude and subjective norms significantly affect the odds of intending to utilize institutional delivery among ANC attendants in contrast to study conducted in Kalomo Zambia which identified women’s perceived behavioral control as one of the most important factors influencing mothers intention to utilize institutional delivery among ANC followers. (C. Sialubanje et al. 2014) • This difference might be due to women’s low level awareness regarding institutional delivery service utilization in the study area. Limitation of the study ü The cross-sectional design of the study made it not possible to identify causal relationship between intention and the hypothesized predictor variables from the TPB model. ü Since the focus of the study was on only on town, these respondents may not represent the views of rural district pregnant mothers in study area.
Conclusion and recommendation • The proportion of intention of pregnant women to utilize institutional delivery is low in the study area. • The study conclude that the intention of giving birth at health institution is statistically significantly associated with being informed by health professionals about the place of delivery and Husband’s occupational status. Recommendation Health care providers • Have to counsel all ANC clients on danger signs during pregnancy and delivery places to promote ID. • Have to counsel all ANC pregnant women with their husbands Town health office • Address all pregnant women in the town to start ANC early through integrated work by local media and urban health extension professionals Researchers • May not be generalized to all pregnant women in rural settings it deems further study particularly in rural setting. • This study was Cross-sectional in design, so I recommend researchers to conduct study using strong designs (follow -up study). References. pptx
Acknowledgements § I would like to thank üDepartment of Population and Family health, College of Health Sciences, JU ü My advisors. üSoddo town health office üMy study subjects üMy friends üMy wife , Elsabeth Abate 15 13/6/2016
THANK YOU! 16 13/6/2016