Maternal mortality and maternal health service utlization in Eastern Ethiopia: The case of Kersa district

Background: In Ethiopia, the maternal mortality ratio is among the highest in the world. The high burden of maternal mortality is associated with the non-use of maternal health services. Although there have been notable improvements in the uptake of maternal health services, the rate remains unacceptably low. The purpose of this thesis is to synthesize existing literature on delayed antenatal care use in Ethiopia, and to investigate maternal mortality and maternal health service utilization at the community level in eastern Ethiopia. Methods: In order to determine the magnitude and predictors of delayed initiation of antenatal care, systematic review and meta-analyses were conducted. To explore the magnitude, trends, and causes of maternal mortality, a secondary surveillance data analysis was performed. To examine the level of, and factors associated with maternal health service utilization, a community survey was conducted. The community survey involved both quantitative and qualitative studies. For the quantitative study, a total of 1320 eligible women were recruited to complete an interviewer-administered house-to-house survey. Bivariate and multivariate logistic regression analyses were carried out to measure associations. For the qualitative study, thirteen focus group discussions were conducted with a total of eighty-eight participants to assess delaying factors for maternal health service utilization. The qualitative data were imported into NVIVO version 11 and analyzed thematically. Results: The systematic review and meta-analyses show that the pooled prevalence of delayed antenatal care in Ethiopia was 64% (95% CI: 57%, 70%). The secondary data analysis reveals that the maternal mortality ratio from 2008 to 2014 was 324 per 100,000 live births (95% CI: 256, 384). The most common direct cause of maternal death was postpartum haemorrhage, followed by hypertensive disorders of pregnancy. The secondary data analysis further indicates that only 26% of the deceased mothers had attended at least one antenatal care visit. The community survey findings demonstrate that 53.6%, 30.8%, and 7.3% of women attended antenatal, skilled delivery, and postnatal care for the index child, respectively. Best friend’s use of maternal care, wealth index, husband’s attitude towards care, and awareness of pregnancy complications were strong predictors of antenatal care utilization. Presence of an educated family member, receipt of maternal health education, prior use of skilled delivery care, best friend’s use of maternal care, place of residence, pregnancy intention, and use of antenatal care were associated with skilled delivery care attendance. Similarly, receipt of maternal health education, best friend’s use of maternal care, living in the female-headed household, and experience of postpartum complications predicted postnatal care utilization. The qualitative study identified a range of contextual delaying factors for maternal health service utilization. These delaying factors were generally linked to restrictive socio-cultural practices, the poor social status of women, and underdeveloped community and health infrastructures. Conclusion: The magnitude of maternal mortality remains high in Ethiopia. The direct causes of maternal mortality include haemorrhage and hypertension, both of which can be prevented and treated using maternal health services. Yet, the uptake of maternal health services remains low, and, as a result, maternal mortality remains high. The current study demonstrates that education, best friend’s use of care, receiving education on maternal health, women’s social and economic empowerment, husband’s involvement, quality of maternal care, and Health Extension Workers’ home visits can increase service use and therefore decrease maternal mortality. Context-specific interventions should focus on targeting these factors to reduce maternal mortality in the future.