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  • Research article
  • Open Access
  • Open Peer Review

Quality of basic emergency obstetric and newborn care (BEmONC) services from patients’ perspective in Adigrat town, Eastern zone of Tigray, Ethiopia. 2017: a cross sectional study

BMC Pregnancy and Childbirth201919:190

https://doi.org/10.1186/s12884-019-2307-6

  • Received: 7 June 2018
  • Accepted: 22 April 2019
  • Published:
Open Peer Review reports

Abstract

Background

Most of the maternal and newborn deaths occur at birth or within 24 h of birth. Provision of quality Basic Emergency Obstetric and Neonatal Care (BEmONC) is very crucial and the current recommended intervention to prevent maternal and newborn morbidity and mortality.

Methods

An institution based cross-sectional study was conducted among mothers receiving at least one of the signal functions of BEmONC services. A total of 398 women were included in the study. The study participants were selected using a systematic random sampling method. Data was collected using structured interviewer-administered Tigrigna version questionnaire. Data were analyzed using SPSS version 20. Multi-variable logistic regression was used to control the effect of confounders.

Results

The perceived quality of BEmONC was 66.7%, which is poor. Clients scored lower quality rates on aspects such as the availability of necessary equipment, lack of clean and functional shower and toilet and administration of anti-pain during delivery and manual vacuum aspiration (MVA). Quality of BEmONC was lower among rural residents (AOR = 0.273, 95% CI: (0.151–0.830). Whereas, Presence of companion (AOR = 2.259; 95% CI: (3.563–13.452) were found with a higher score of quality of BEmONC compared to their counterparts.

Conclusion

The overall perception of quality of BEmONC services received was poor. Residence, ANC follow-up, and presence of companion during labor or delivery were found to have a significant association with the perceived quality of BEmONC services.

Keywords

  • Quality
  • Basic emergency obstetric and newborn care
  • Adigrat
  • Tigray
  • Ethiopia

Background

Worldwide, 15% of the expected births result in life-threatening complications during pregnancy, labor, delivery and post-partum period [1]. World Health Organization (WHO) designed and introduced Emergency Obstetric and Newborn Care (EmONC) to reduce maternal and infant mortality [2]. Though remarkable changes have been recorded, maternal and neonatal mortality rates in Ethiopia are among the highest in the World [3] .

A set of seven key obstetric services, or “signal functions,” has been identified as critical to basic emergency obstetric and newborn care (BEmONC): administration of parenteral antibiotics, administration of parenteral anticonvulsant, administration of parenteral uterotonic agents, removal of retained products (MVA), assisted vaginal delivery; manual removal of placenta and resuscitation of the newborn [4] .

As an intervention, the Federal Ministry of Health of Ethiopia is implementing EmONC services. Provision of quality EmONC service is mandatory to achieve the stipulated goals in the sustainable development goals at reducing the maternal and new-born mortality in Ethiopia and worldwide. According to the Ethiopian health care transformation plan, the health system over the last two decades has been focused on improving coverage of essential health service. It is time to pay great attention to the quality and equity of health service at all levels of the system and a lot remains to be done toward improving quality of care at each level of health system [5].

Quality health service is multidirectional; Donabedian’s theory incorporates participants rating in the advent of assessing the quality of health service delivered.

Taking into account the perspective of clients on the maternal and neonatal health care services enables to rate clients’ satisfaction concerning the services received from the healthcare providers [6]. In Ethiopia, there are studies which assessed availability of EmONC services [3, 79]. However, there is sub-optimal knowledge of quality BEmONC service from the clients’ perspective and experience [10]. Therefore, this study was conducted to describe the quality of BEmONC services and factors associated with it among mothers receiving these services. This will help to document the quality of EmONC service from the users’ perspective which is important to develop client centered BEmONC guidelines.

Methods

Study area and design

The study was conducted in Ganta-Afeshum district, Eastern zone of Tigray which is located around 903 Kilometers to the North of Addis Ababa, the capital city of Ethiopia. It is one of the rural districts of Eastern zone of Tigray. An institution based cross sectional study was conducted among women receiving BEmONC services in 2017.

Sample size and sampling procedure

A total of 398 women receiving BEmONC services were included in the study. The sample size was computed using a single population proportion formula considering 62% proportion of mothers satisfied with delivery services in a study conducted previously [8] 95% confidence level, 5% margin of error and considering 10% of non-response rate.

There were three public health institutions providing BEmONC services in Adigrat during the data collection period, two health centres and one general hospital. All of these facilities were included in the study. Pre survey assessment was carried out to determine the average daily flow of mothers receiving the services in the hospital and health centers. Accordingly the expected number of attending women in the specified period of data collection, the sample size was proportionally allocated to the health centers and general hospital. Finally, individual study subject were selected from each facility by using systematic sampling techniques.

All women who were discharged after receiving at least one of the signal functions of BEmONC services were included in the study. However, eligible mothers who were referred to other health facilities or unable to respond for the questionnaire were excluded from the study.

Data collection procedure

Data collection tools were developed in English based on this study’s objectives to be addressed after reviewing relevant literature [11, 9]. The questionnaire was first prepared in the English language then translated to the local language, Tigrigna (also see Additional files 1 & 2). Back translation to English was also done by language experts to check its consistency. Three midwives with bachelors of Science (BSc) data collectors were recruited from Adigrat University as data collectors to fill the tools, and besides, one integrated emergency surgical officer was recruited to supervise the data collectors. Training was given to both the data collectors and the supervisor. The training focused on the objectives of the study, the data collection tool and procedures of the data collection and detailed contents of the tools. Further emphasis was given on the ethical issues of research and smooth and respect full approach with clients. The questionnaire was filled by face to face interaction with the clients after asking their willingness to participate in the study after briefly explaining its objective. Prior to implementation, the questionnaire was pretested and modifications made accordingly. Strict supervision was made by the supervisor and the principal investigator. Completed questionnaires were collected and assessed for consistency and completeness by the supervisor on daily basis.

Operational definitions

  • ➢ Quality- the extent to which health services for populations increased the likelihood of desired health outcomes and are consistent with current professional knowledge.

  • ➢ Magnitude of quality with the service: the responses “Strongly agree (very satisfied)” and “Agree (satisfied) ‟ will be classified as agree (satisfied) and responses “strongly disagree (very dissatisfied)”, “disagree (dissatisfied) ‟ and “neutral‟ as disagree (unsatisfied). Neutral responses will be classified as disagree (dissatisfied) considering that they might represent a way of expressing dissatisfaction in a modest way. This is likely because the interview is undertaken within the health facilities and mothers might be reluctant to express their dissatisfaction feeling of the services they received [9].

Level of quality score in percentage

Good quality- 75% and above.

Poor quality- 74.9% and below [9].

Patient perspective (experience) is feedback from patients on the course of receiving care or treatment, both the objective facts and their subjective views of it. The factual element is useful in comparing what people say they experienced against what an agreed care pathway or quality standard says should happen [12].

Measurement of quality

Donabedian’s framework

The Donabedian’s framework is based on three dimensions of quality; structure, process and outcome. These three are parameters from which inference can be drawn about quality of health care [6]. So, we used this framework to develop the questionnaire.

Data analysis

Data entry and clearing was done using Epi info. Data was analysed using statistical packages for social sciences version 20. Descriptive data analysis was done to describe the variables under study. Multivariable logistic regression analysis was done to see the independent effect of each variable on the outcome variable. Variables with p-value < 0.25 in the bi-variate analysis were included in the multivariable analysis. Multi-colinearity was checked using the variance inflation factor (VIF), and those with VIF greater than 10 were excluded from the model. Result is presented using Adjusted Odds Ratio (AOR) with its 95% Confidence Interval (CI). Significant association was declared at p value < 0.05.

Ethical consideration

Ethical clearance was obtained from Mekelle University College of health sciences institution review board (IRB) with serial No 046/09. Support letter was obtained from the Tigray Regional Health Bureau and Adigrat town health department and respective health institution to collect verbal data before field activities started. Verbal consent was obtained from the study subjects after explaining the study objectives and procedures. For the participants whose age is less than 18 years verbal informed consent was taken from their legal guardians. The participant’s personal identification was not included in the study questionnaire to maintain anonymity. Confidentiality was maintained throughout the study.

Results

Socio-demographic characteristics of respondents

A total of 398 mothers fully responded to the interview making 100% response rate. Near three fourth (71.4%) of the participants were from Adigrat general hospital. Majority (59.8%) of the participants completed high school education (7th to 12th grade), Ninety five percent of the participants were currently married. The mean age of the mothers was 27.4 years with standard deviation of (±5.55) years (Table 1).
Table 1

Socio-demographic characteristics of respondents in Adigrat, Eastern zone of Tigray, Ethiopia, 2017. (n = 398)

Variable

Frequency

Percent (%)

Age of respondents

 15-19yrs

23

5.8

 20-24yrs

103

25.9

 25-29yrs

139

34.9

 30-34yrs

86

21.6

 >35yrs

47

11.8

Residence

 Urban

318

79.9

 Rural

80

20.1

Religion

 Orthodox

353

88.7

 Muslim

35

8.8

 Catholic

10

2.5

Ethnicity

 Tigray

382

96

 Afar

12

3

 Amhara

4

1

Education

 No formal education

35

8.8

 1 to 6th

62

15.6

 7th to 12th

238

59.8

 Certificate/Diploma

42

10.6

 Degree and above

21

5.3

Occupation

 Government employed

63

15.8

 NGO/Private company employed

6

1.5

 Merchant/business

112

28.1

 House wife

202

50.8

 Student

15

3.8

Marital status

 Married

378

95

 Unmarried

20

5

Husband’s education

 No formal education

42

11.1

 1 to 6th

40

10.6

 7th to 12th

145

38.4

 Certificate/Diploma

84

22.2

 Degree and above

67

17.7

Husband’s occupation

 Governmental

123

32.5

 NGO/Private company

13

3.4

 Merchant/business man

155

41

 Daily laborer

51

13.5

 Un-employed

9

2.4

 Farmer

27

7.1

Monthly HH income

 0-1500ETB

76

19.04

 1501-3000ETB

189

47.5

 3001-4500ETB

75

18.8

 4501-6000ETB

51

12.8

 > 6000

4

1.1

 Unknown/Refusal

3

0.75

Current obstetric history of respondents

Out of the 398 mothers, 336 (84.4%) mothers had one to four pregnancies and 62 (15.6%) mothers were grand multiparas having 5 to 8 pregnancies. Three hundred seventy-eight mothers had antenatal care (ANC) follow up. Eighty-eight (22.1%) of the mothers were referred from other facilities. Spontaneous Vaginal Delivery (SVD) was the predominant mode of delivery (83.2%). Out of the total births observed, 7 neonatal deaths and 6 still births were recorded (Table 2).
Table 2

Current obstetric history of patients receiving BEmONC services in Adigrat town, Eastern zone of Tigray, 2017. (n = 398)

Variables

Frequency

%

Gravidity

 Primi

336

84.4

 Multi

62

15.6

ANC follow-up

 Yes

378

95.0

 No

20

5.0

Desire of current pregnancy

 Wanted

345

86.7

 Unwanted

53

13.3

Type of visit

 Direct/ Planned

310

77.9

 Referred

88

22.1

Mode of transportation

 Ambulance

288

72.4

 Public transportation

102

25.6

 By foot

8

2.0

Time waited to receive service

 < 15 min

381

95.7

 15-30 min

14

3.5

 30 min-1 h

3

0.8

Presence of companion

 Yes

155

38.9

 No

243

61.1

Mode of delivery

 SVD

331

83.2

 AVD

37

9.3

 Abortion

30

7.5

Health outcome of mother after delivery

 Normal

340

85.4

 With complication

58

14.6

Birth outcome of the neonate

 Live birth

355

89.2

 Neonatal death

7

1.8

 Still birth

6

1.5

Health problem on neonate

 No

337

84.7

 Yes

25

6.3

Payment

 No

391

98.2

 Yes

7

1.8

Quality of BEmONC services from patients’ perspective

Structure

When we see the overall mothers’ perspective of quality in terms of input, 164 (41.2%) mothers scored above 85% or stated it as good quality. Lack of necessary equipment (30.2%) was the major contributing factor for the reported poor quality of (Table 3).
Table 3

Input (structural) factors of quality of BEmONC, in Adigrat town, 2017. (n = 398)

Variable

Good N (%)

Poor N (%)

Necessary equipment availability

278(69.8)

120(30.2)

Adequate no of health providers

327(82.2)

71(17.8)

Sufficient rooms, beds and space

344(86.4)

54(13.6)

Sanitation

344(86.4)

54(13.6)

Functional and clean shower and toilet

267(67.1)

131(32.9)

Process

Mothers perspective of quality in terms of process, 180 (45.2%) of them scored above 75% or stated as good quality. The major contributing factor for the poor quality was failure of health professionals to counsel the clients (12.3%) on how to take care of their newborn baby (Table 4).
Table 4

Process factor of quality of BEmONC in Adigrat town, 2017. (n = 398)

Variable

Good N (%)

Poor N (%)

Respect and courtesy by the health providers

383 (96.2)

15 (3.8)

The environment where you were laboring was comfortable.

368 (92.5)

30 (7.5)

Active follow up on the progress of labor/abortion.

368 (92.5)

30 (7.5)

Permission before applying any procedures and examination

364 (91.5)

34 (8.5)

explained the labor progress to you by using your local and clear language

351 (88.2)

47 (11.8)

different member of staff have given you similar advice or information

367 (92.9)

31 (7.1)

Health workers spent enough time for examination.

372 (93.5)

26 (6.5)

verbally encouraged praised and reassured

387 (97.2)

11 (2.8)

got enough care and support during the time of labor.

373 (93.7)

25 (6.3)

Confidence and competence of health providers

379 (95.2)

19 (4.8)

Privacy well kept

385 (96.7)

13 (3.3)

Got enough care and support during delivery/abortion

384 (96.7)

13 (3.3)

Availability of health providers

349 (87.7)

49 (12.3)

support from the staff in breast- feeding

325 (91.3)

31 (8.7)

Received counseling on how to take care of your baby

243 (68.2)

113 (31.8)

Your baby received enough care and support.

316 (90.5)

43 (9.5)

Receive adequate anti pain while MVA was performed

10 (33.3)

20 (66.7)

Outcome (satisfaction)

In the satisfaction section of the quality, 138 (34.7%) mothers stated as good (satisfied). In this dimension of quality, the overall counseling that were given to patients and involving them in making decision contribute for the poor provision of quality of care (Table 5).
Table 5

The output (satisfaction) factors of quality of BEmONC from patients’ perspective, in Adigrat town, 2017. (n = 398)

S No

Variable

Good N (%)

Poor N (%)

1

Respect

387 (97.2)

11 (2.8)

2

Professional respect for your privacy

387 (97.2)

11 (2.8)

3

The number of health workers

349 (87.6)

49 (12.4)

4

Health workers competency and confidence

379 (95.2)

19 (4.8)

5

Communication between doctor, nurse and other health staff

364 (91.4)

34 (8.6)

6

Involved you in decision

352 (88.7)

45 (11.3)

7

The overall Counseling that were given in your stay.

347 (87.2)

51 (12.8)

8

Overall care and support, given

374 (93.9)

24 (6.1)

9

Care and support given for your newborn

334 (91.5)

31 (8.5)

The overall quality of BEmONC services from patients’ perspective

Quality in this study was assessed by combining the three dimensions the input, process and outcome. The quality is classified as good quality if it scored 75% and above. Otherwise it is classified as poor quality. The overall quality of BEmONC services from patients’ perspective conducted in this study was 66.3% with 95% CI (61.6, 71.4), P-value 0.04.

Factors associated with the quality of BEmONC services from patient’s perspective

On multi-variable, women who came from the rural area had lower odds of quality service (AOR = 0.273; 95%CI: 0.15–0.83). On the other side, women who had ANC follow up had higher odds of quality BEmONC service (AOR = 0.004) 95% CI (0.091 (0.011–0 .723). Moreover, those mothers who were accompanied by their relatives during their labor were with 7 times higher odds of good quality BEmONC service (AOR = 6.9; 95% CI: (6.923 (3.563–13.452) compared to their counterparts (Table 6).
Table 6

Association of quality of BEmONC services from patient’s perspective in bivariate and multivariate analysis, in Adigrat town eastern zone of Tigray, 2017

Variable

Good

Poor

COR

AOR

CI 95%

P value

Residence

 Urban

222

96

 

1.0

  

 Rural

42

38

0.47

0.273

0.15–0.83

0.028*

Education

 No formal education

17

18

0.37

0.071

0.08–3.68

0.54

 1 to 6th

41

21

0.78

0.334

0.16–4.97

0.91

 7th to 12th

162

76

0.85

0.083

0.16–2.66

0.56

 Certificate/Diploma

29

13

4.00

2.303

0.39–21.5

0.18

 Degree and above

15

6

 

1.0

  

Husband’s education

 No formal education

23

19

 

1.0

  

 1st to 6th

23

17

0.47

0.060

0.20–5.36

0.950

 7th to 12th

106

39

0.53

1.207

0.10–1.63

0.206

 Certificate/Diploma

59

25

1.07

0.683

0.25–1.88

0.478

 Degree and above

48

19

0.72

0.912

0.13–2.63

0.209

Husband’s Occupation

 Governmental

86

37

 

1.0

  

 NGO

8

5

1.36

0.61

0.20–5.36

0.950

 Private(merchant)

110

45

0.94

0.402

0.10–1.63

0.206

 Daily laborer

32

19

1.43

1.88

0.25–1.88

0.478

 Unemployed

6

3

0.99

0.410

0.13–1.56

0.209

 Farmer

17

10

1.17

0.764

0.20–5.36

0.875

Gravidity

 Primi-gravida

228

108

0.91

0.957

0.377–1.141

0.837

 Multi-gravida

36

26

 

1

  

ANC Follow-up

 Yes

254

124

2.04

0.004

0.01–0 .72

0.000*

 No

10

10

 

1.0

  

Wanted status of pregnancy

 Wanted

241

104

3.02

0.946

0.59–3.80

0.952

 Unwanted

23

30

 

1.0

  

Type of visit

 Planned(direct)

216

94

1.91

0.520

0.24–1.08

0.083

 Referred

48

40

 

1.0

  

Presence of companion

 Yes

136

19

6.43

2.259

3.56–13.4

0.002*

 No

128

115

 

1.0

  

Mode of delivery

 SVD

240

91

4.55

1.692

0.110

0.641

 AVD

13

24

0.93

0.632

0.039

0.938

 Abortion

11

19

 

1.0

  

Health outcome of the mother

 Normal

241

99

3.704

0.232

1.191–4.998

0.519

 With complication

23

35

 

1.0

  

Birth outcome of the neonate

 Live birth

248

107

0.245

1.184

0.02–1.6

0.995

 Neonatal death

2

5

0.772

.886

0.35–3.31

0.956

 Still birth

3

3

 

1.0

  

Health problem on neonate

 Yes

16

9

4.555

0.019

0.110

0.223

 No

235

102

0.936

0.134

0.039

0.083

Any payment for the servicea

 Yes

3

4

0.374

1.433

0.21–11.1

0.571

 No

261

130

 

1.0

  

Necessary equipment availability

 Agree

199

65

1.765

1.399

0.70–2.64

0.291

 Disagree

85

49

 

1.0

  

Adequate no of health providers

 Agree

35

12

0.956

0.879

0.188–1.067

0.082

 Disagree

229

122

 

1.0

  

Sufficient rooms, beds and space

 Agree

204

60

1.898

1.891

0.972–4.157

0.060

 Disagree

86

48

 

1.0

  

Functional and clean shower and toilet.

 Agree

65

49

1.649

0.971

0.822 -2.96

0.191

 Disagree

199

85

 

1.0

  

Permission before applying any procedures and examination

 Agree

247

17

1.831

1.528

0.545–4.27

0.420

 Disagree

119

15

 

1.0

  

verbally encouraged praised and reassured

 Agree

253

10

0.355

0.291

0.041–2.465

0.254

 Disagree

132

2

 

1.0

  

Confidence and competence of health providers

 Agree

251

13

3.387

1.587

0.519–5.29

0.266

 Disagree

114

20

 

1.0

  

Privacy well kept

 Agree

257

7

1.323

6.911

0.673–12.7

0.082

 Disagree

129

5

 

1.0

  

Received counseling on how to take care of your baby

 Agree

170

94

1.464

1.51

0.938–2.33

0.068

 Disagree

65

69

 

1.0

  

Receive adequate anti pain while MVA was performed

 Agree

24

240

0.746

1.597

0.812–3.14

0.175

 Disagree

18

116

 

1.0

  

Respect and courtesy from the health professionals

 Satisfied

258

6

2.250

1.988

0.267–15.97

0.377

 Dissatisfied

130

4

 

1.0

  

The boldface with asterisk [*] entries show the variables that have a significant association with the quality of BEmONC services from patients perspective in Adigrat town, Eastern zone of Tigray, Ethiopia

Discussion

The overall magnitude of good quality from patients’ perspective was 66.7% with 95% CI (61.6, 71.4).This result was comparable with the study conducted in Northern region of Ethiopia on the perceived quality of delivery and newborn care services which was 65.62% [11].

Providing quality service is not optional, it is a must to decrease the complications and mortality of the mother as well as their newborn babies. However, a significant number of women rated the service as poor. Lack of the necessary equipment and the quality of counseling on caring for the newborn baby was among the major components poorly addressed in the BEmONC service. Clients could not rely on or be satisfied with a health institution which could not fulfill equipment necessary for the services. After delivery, mother’s attention and care is for her newborn and most of the time women who do not have the experience depend on health providers to give them information on how to take of their newborns. But failure to give this information will have a negative effect for the mothers’ rating on the quality of service. On the contrary, patients experienced higher quality on how the health providers verbally encouraged them during labor pain.

Rural residents were at lower odds of perceived quality of BEmONC service. This could be explained by the difference in the level of expectations between the urban and rural residents. Residence has significant association with the quality in this study. This shows that women who live in urban residence have 53 times higher odds of receiving good quality service compared with those coming from rural residence; this result could be due to decreased level of expectation than those who live urban.

ANC follow up had significant association with the quality of the services (p ≤ 0.001) showing that women who did not have ANC follow-up score the quality 96 times higher than those who had the follow-up. This response could be because mothers who had the follow-up are aware of the care that is given during delivery because they are counseled during the follow-up, so they tend to score the quality higher. Similarly a study conducted in rural Tanzania shows there is a significance association with the perceived quality of care (p = 0.004) [13].

Women who were accompanied by their relatives were with 7 times higher odds of receiving good perceived quality service. This was also documented in other study where women who had continuous support from their relatives during labor and delivery were more likely to be satisfied than women who did not have support [14, 15].

Limitation of the study

  • ➢ Using only one method to assess the quality of the service, that is based on the response of the clients alone which may be affected by the social desirability bias and interviewers bias.

  • ➢ The study being in the health institution might give response favoring the care providers.

  • ➢ The cross sectional nature of the study makes difficult to establish the cause and effect relationship between the perceived quality and explanatory variables.

Conclusion

This study revealed that the overall quality of BEmONC services from patients’ perspective was poor. Clients scored lower quality rates on aspects such as availability of necessary equipment, lack of clean and functional shower and toilet and administration of anti-pain during labor and MVA are some of the factors.

Though it is in line with the available literatures, significant number of the women rated the quality of service poor indicating mismatch between the participants’ expectation and service delivered by the providers. Rating the service as poor was higher among rural resident women. On the contrary, good quality rating was higher among those women who had ANC and were accompanied by their relatives during their labor. Lower rate of quality was reported on the availability of equipment, and client provider communication.

Abbreviations

AOR: 

Adjusted odds ratio

BEmONC: 

Basic Emergency Obstetric and Newborn Care

COR: 

Crude odds ratio

EDHS: 

Ethiopia Demographic Health Survey

EMOC: 

Emergency Obstetric Care

HSDP: 

Health System Development Plan

HSTP: 

Health System Transformation Plan

MDG: 

Millennium Development Goals

MMR: 

Maternal Mortality Ratio

QOC: 

Quality of care

UNFPA: 

United Nations Population Fund

UNICEF: 

United Nations Children’s Fund

WHO: 

World Health Organization

Declarations

Acknowledgements

We would like to extend our gratefulness to Mekelle University for funding this research project. We would like to extend our heartfelt thanks to Tigray Regional Health Bureau for allowing us to conduct this study in Adigrat District. We also would like to acknowledge Adigrat District health office for their cooperation and giving all the necessary information. Our appreciation and thanks is also forwarded to all supervisors and data collectors of this study, as well as the study participants for their cooperation and providing us relevant information.

Funding

Mekelle University provided the financial support. The funding organization has no role in design of the study, data collection, analysis, and interpretation of data and in writing the manuscript.

Availability of data and materials

The datasets during and/or analyzed during the current study is available from the corresponding author on reasonable request.

Authors’ contributions

BB carried out the conception and designing the study, performed statistical analysis and wrote the manuscript. BF performed statistical analysis. BB, SW, HG, BF, AG, and SK critically evaluated and made progressive suggestions throughout the study. All of the authors read and approved the final draft of the manuscript.

Authors’ information

BB (MSc. In Midwifery), Lecturer in Adigrat University, SW (MSc. In Maternity and RH), HG (MSc in Maternity and RH) PhD candidate at Mekelle University, BF (MPH in Epidemiology and Biostat), SK (MSc in IESO), AG (MPH in Epidemiology), PhD candidate at Addis Ababa University

Ethics approval and consent to participate

Ethical approval was obtained from Mekelle University ethical clearance committee and oral informed consent was taken from the study participants. Verbal consent was obtained from the study subjects after explaining the study objectives and procedures. For the participants whose age is less than 18 years verbal informed consent was taken from their legal guardians.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

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Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Department of Midwifery, College of Medicine and Health Science, Adigrat University, Adigrat, Ethiopia
(2)
Department of Midwifery, College of Health Science, Mekelle University, Mekelle, Ethiopia
(3)
Department of Public health, College of Medicine and Health Science, Adigrat University, Adigrat, Ethiopia
(4)
Edagahamus Health Center, Eastern Zone of Tigray, Tigray, Ethiopia

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Copyright

© The Author(s). 2019

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