Associations between increased intervention coverage for mothers and newborns and the number and quality of contacts between families and health workers: An analysis of cluster level repeat cross sectional survey data in Ethiopia
Associations between increased intervention coverage for mothers and newborns and the number and quality of contacts between families and health workers: An analysis of cluster level repeat cross sectional survey data in Ethiopia
Elizabeth Allen 0 1
Joanna Schellenberg 0 1
Della Berhanu 0 1
Simon Cousens 0 1
Tanya Marchant 0 1
0 London School of Hygiene and Tropical Medicine , London , United Kingdom
1 Editor: Mahfuzar Rahman , BRAC , BANGLADESH
Survival of mothers and newborns depends on life-saving interventions reaching those in need. Recent evidence suggests that indicators of contact with health services are poor proxies for measures of coverage of life saving care and attention has shifted towards the quality of care provided during contacts.
Methods and findings
Regression analysis using data from representative cluster-based household surveys and
surveys of the frontline health workers and primary health facilities in four regions of Ethiopia
in 2012 and 2015 was used to explore associations between increased numbers of contacts
or improvements in quality and any change in the coverage of interventions (intervention
coverage). In pregnancy, in multiple regression, an increase in the quality indicator `focused
ANC behaviours' was associated with a change in both the coverage of iron
supplementation and syphilis prevention ((regression coefficients (95% CI)) 0 06 (0 01, 0 11); 0 07 (0 04,
0 10)). This equates to a 0.6% increase in the proportion of women taking iron
supplementation and a 0.7% in women receiving syphilis prevention for a 10% increase in the quality
indicator `focused ANC behaviours'. At delivery, in multiple regression the quality indicator
`availability of uterotonic supplies amongst birth attendants' was associated with improved
coverage of prophylactic uterotonics (0 72 (0 50, 0 94)). No evidence of any relationships
between contacts, quality and intervention coverage were observed within the early
Increases in both contacts and in quality of care are needed to increase the coverage of life
saving interventions. For interventions that need to be delivered at multiple visits, such as
Competing interests: The authors have declared
that no competing interests exist.
antenatal vaccination, increasing the number of contacts had the strongest association with
coverage. For those relying on a single point of contact, such as those delivered at birth, we
found strong evidence to support current commitments to invest in both input and process
Improving the survival of mothers and newborns depends on life-saving interventions
reaching those in need [
]. In the context of maternal and newborn health in high-mortality settings
these interventions include both biomedical interventions delivered by health care workers
such as the use of prophylactic uterotonics during the third stage of labour and behaviours
practised by health care workers or by families such as avoiding newborn infection by putting
nothing harmful on the newborn cord.
Many of the interventions best delivered in a health facility by skilled health workers
(doctor, nurse, midwife) are difficult to measure during household surveys because families
interviewed cannot be assumed to provide reliable reports, especially for events around the time of
]. Consequently, maternal and newborn measurement practice has been to use
indicators of contact with health services at different points along the continuum from pregnancy
to postnatal period as proxy measures for the coverage of life saving care. However, a growing
body of evidence suggests that such contact coverage estimates are poor proxies for life saving
effects . Attention has therefore shifted towards the quality of care and interventions
delivered during contacts [
Ethiopia is a country with ambitious targets to reduce maternal and newborn mortality.
The Ethiopian Federal Ministry of Health (FMOH) 2015 ªHealth Sector Transformation
] committed to reduce the country's maternal mortality ratio from 420/100,000 live
births in 2013 to 199/100,000 in 2020, and the neonatal mortality rate from 28/1,000 live births
in 2013 to 10/1,000 in 2020. It describes the pathway to achieving these targets as including
near universal coverage of at least four antenatal care visits, skilled attendance at delivery, and
postnatal care for every pregnant woman and her newborn. This plan builds on the 2003
ªAccelerated Expansion of Primary Health Care Coverage,º comprehensive Health Extension
Program (HEP) which recognised the huge gap between need and availability of health care
services in the country. Now, in recognition of the importance of quality delivery care [
the 2015 Health Sector Transformation Plan specifically targets improvement in the quality of
care provided to mothers and newborns in addition to enhancing demand and increasing
In this context of rapid improvement from low coverage of contacts between families and
the health system [
] at the same time as strengthening the availability of quality life-saving
care in facilities [
], evidence from Ethiopia can provide important insights into the
relationship between changes in contacts, quality and intervention coverage for mothers and
newborns. Using linked household survey data and skilled birth attendant interviews from four
regions of Ethiopia collected in 2012 and in 2015 (DOI: 10.17037/DATA.129), this study
aimed to strengthen the evidence base on the importance of quality of contacts between
families and health workers in addition to the role of the number of contacts alone. We examined
the associations between increases in contact coverage and increases in quality of care and
how these are associated with the coverage of life saving interventions in Ethiopia during this
time. Details of contact and quality indicators and lifesaving interventions are given in the
2 / 13
This work was a secondary analysis carried out as part of a programme of research to
understand what works, where and how to improve maternal and newborn health in selected
highmortality settings [
]. In Ethiopia, representative cluster-based household surveys and
surveys of the frontline health workers and primary health facilities assigned to provide routine
maternal and newborn health services to those households were performed in the four regions
of Oromia, Tigray, Amhara and Southern Nations Nationalities and Peoples (SNNP) in 2012
and again in 2015. In Ethiopia, primary care is organized at the woreda (district) level within
primary healthcare units which each include a health centre and several rural health posts
where Health Extension Workers provide basic services and refer patients in need, including
for care at birth. In addition, a primary hospital provides referral care within each woreda.
Health Extension Workers connect with communities through local volunteers known as the
Women's Development Army.
Data collection methods
The survey included household and facility surveys linked at the cluster level. Data collection
methods used in 2012 have previously been described [
]. The same methods were applied
in 2015, including returning to the same clusters. Each survey was treated as a cross sectional
with no attempt made to repeat or to avoid interviews with the same individual women.
Ethiopia is organised by region, zone, woreda (district), kebele (similar to a ward; the lowest
level of census population data) and gote (proxy for village). The 2012 survey included 80
clusters which were sampled from 76 woreda across the four regions. Sampling of clusters
was performed by listing all woreda geographically from north to south of the country,
listing kebeles and their population size alphabetically within each woreda, and systematically
sampling 80 kebeles with probability proportional to population size. Gotes within each of
these 80 kebele were listed and one gote per kebele selected using simple random sampling.
For the household survey, at each selected gote, all households were listed and gotes
segmented into groups of 75 or fewer households: field teams randomly selected one segment
from each gote as the cluster to be surveyed. All households within each selected cluster were
visited and all resident women aged 13±49 who had given birth in the last 12 months
interviewed using a modular questionnaire that included information about the demographics of
the household, recent birth history, and experience of care around the time of the most
For the facility survey, at each sampled cluster, the health centre allocated to provide routine
antenatal, intrapartum and postnatal care to the selected cluster was surveyed for facility
readiness, including information about stocks and supplies, staffing, and the volume of events
taking place in that facility. In addition, the staff member who attended the last delivery recorded
in the maternity register was interviewed about that birth event. All birth attendants were
eligible for this interview which was designed to reflect the most recent birth experience in the
facility. The sample size for the surveys in each year are shown in Table 1. The same health
centres were surveyed at both time points.
This led to two sources of data for this analysis; household data and birth attendant data
collected during the facility survey. All coverage estimates for contacts and lifesaving
interventions are population level estimates, derived from the household survey. Measures of input
and process quality were derived from the birth attendant data and incorporated by linking
individual women's reports from the household surveys to data about the cadre of the health
worker who provided care to the woman.
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Hypotheses and covariates
1 The 2015 survey teams returned to precisely the same geographical location as surveyed in 2012
2 The cluster size was increased from 50 households in 2012 to 75 households per cluster in 2015
3 In 2012 no women with a birth in the 12 months prior to survey were identified in 1 household cluster (included in
4 Used for linking with household interviews, linked by cadre of health worker each woman reported having contact
The research question that led to the secondary analysis of the data was whether a change in
the coverage of life saving interventions had occurred over time, and what the relative
contribution of an increased number of contacts or improvements in quality had been to such
change. An analysis plan was written in 2015 prior to analysing the data (S1 File Prospective
Analysis Plan), informed by consensus in the global literature about the need to increase
coverage of life saving interventions delivered to mothers and newborns by frontline health
]. For antenatal care, intrapartum care, and postnatal care we defined key indicators
of contact, quality, and intervention coverage (Table 2) that could plausibly be hypothesised to
8 health worker behaviours of focused 2 8 (2 4,
antenatal care including weight, 3 2)
height, blood pressure measured,
urine and blood tested, counselled on
danger signs, birth preparedness and
5 preparations including finances,
transport, food and identified a birth
attendant and a facility
Any iron supplementation received
Two doses last three years or five in
5 / 13
lie along one pathway (Table 3). For example, in pregnancy we hypothesised that an increase
in coverage of iron supplementation could be achieved through an increase in number of
ANC contacts, or through an increase in number of health worker behaviours for focussed
ANC (Table 2), independently of the number of visits made, or some combination of both.
For the intrapartum period, we hypothesised that an increase in coverage of prophylactic
uterotonics during the third stage of labour could be achieved through an increase in coverage
of skilled birth attendance; doctor, nurse, midwife, or through an increase in availability of
uterotonics amongst all birth attendants, or some combination of both. During the postnatal
period, we hypothesised that an increase in exclusive breastfeeding for the first 3 days of life
could be achieved through an increase in coverage of postnatal care within 2 days of birth, or
through an increase in knowledge of the importance of breastfeeding amongst frontline
workers making postnatal care visits, or some combination of both. Across stages in the continuum
from pregnancy to the postnatal period, we hypothesised that an increase in clean cord care
could be achieved through an increase in coverage of ANC, or through an increase in
appropriate birth preparations made by the mother, or some combination of both. Details of the
creation of composite indicators are given in Table 2.
Cluster level summaries (proportions for binary indicators and means for continuous
indicators) of the indicators for `contact', `quality' and `intervention coverage' were calculated in
2012 (baseline) and 2015 (endline) (Table 2).
Initial simple regression analyses were carried out using linear regression, regressing the
cluster level mean difference in `intervention coverage' indicators on the cluster level mean
difference in indicators of `contact' and `quality' between 2012±2015. The analysis adjusted for
baseline cluster level summaries of `contacts' or `quality' and of `coverage of critical
interventions' (equation 1). Analysis was restricted to the hypothesised relationships between change
in contacts, quality and interventions described in Table 3. Multiple linear regression models
were then fitted regressing the cluster level mean difference in `intervention coverage'
indicators on the mean difference in any indicators of `contact' and `quality' that had shown an
association in the initial analysis. Again, all analysis adjusted for baseline cluster level summaries of
both `contacts' or `quality' and of `intervention coverage'.
Analysis was at the cluster level and included all 80 clusters present at baseline and endline.
All analysis was done in Stata 14 [
Equations used were of the form `cluster level change in intervention coverage between
2012 and 2105' = `cluster change in quality or contact indicator between 2012 and 2105' +
`2012 (baseline) intervention coverage' + `2012 (baseline) quality or contact indicator'.
In Ethiopia, national level support was obtained from the Ministry of Health in Ethiopia, and
ethical approval from the Ministry of Science and Technology; at the Regional level, approval
was granted by the Regional IRBs in Amhara, Oromia, SNNP, and Tigray. Written informed
consent was obtained from all participants and the information provided included description
of this analysis.
Indicator definitions and point estimates for 2012 and 2015 are shown in Table 2. The
coverage of at least four antenatal care visits doubled (22% to 45%) and there was some evidence
that antenatal care quality improved (measured by more women receiving recommended
6 / 13
Coverage of stated
health worker behaviours for focussed antenatal care) as did coverage of two of the three
lifesaving interventions iron supplementation (16% to 41%) and syphilis testing (8% to 13%). For
delivery, the coverage of skilled attendance at birth more than doubled (18% to 51%) but the
Change in coverage of tetanus
Coefficient (95% CI)
0 17 (-0 12, 0 47)
0 04 (-0 01, 0 09)
0 02 (-0 11, 0 15)
indicators of quality and intervention coverage presented a mixed picture. Improved birth
attendant knowledge of management of heavy bleeding and increased availability of
uterotonics were observed, both consistent with higher coverage of prophylactic uterotonics to
prevent post-partum haemorrhage. Coverage of delayed bathing (37% to 54%) and immediate
breastfeeding (44% to 62%) also increased. Conversely no change in birth attendant knowledge
of immediate newborn care (thermal care) was observed and no increase in the coverage of
immediate drying, wrapping, or clean cord care, although the percentage of newborns who
had nothing harmful put on their cords improved. Coverage and quality of postnatal care
for newborns within two days of birth remained very low and no change was observed for
exclusive breastfeeding for the first three days of life, coverage of which was already high at
Results from the regression analysis of indicators of coverage of critical interventions on
indicators of contacts and quality are shown in Tables 3, 4 and 5 and described below.
In simple regression, for contacts, an increase in the proportion of women receiving four or
more ANC contacts was associated with an increase in the coverage of all critical interventions
in pregnancy; iron supplementation (regression coefficient (95% CI); 0 33 (0 10, 0 56)),
tetanus toxoid prevention (0 37 (0 14, 0 60)), and syphilis testing (0 28 (0 13, 0 43)). This indicates
that for every 10 percentage points increase in the coverage of women receiving four or more
ANC contacts, the coverage of iron supplementation increased by 3 3 percentage points, the
coverage of tetanus toxoid prevention by 3 7 percentage points and the coverage of syphilis
testing by 2 8 percentage points.
In simple regression, for quality, there was evidence that both an increase in the number of
health worker behaviours for focused ANC (Table 3) [
] and an increase in the number of
items prepared for birth by the end of pregnancy were associated with an increase in the
coverage of the critical interventions in pregnancy; iron supplementation (0 07 (0 04, 0 11); 0 19
(0 09, 0 29)), tetanus toxoid prevention (0 06 (0 02, 0 09); 0 12 (0 02, 0 23)) and syphilis testing
(0 07 (0 05, 0 09); 0 14 (0 08, 0 21)).
In multiple regression of coverage of tetanus toxoid prevention (Table 4) on the change in
contacts (the proportion of women receiving four or more ANC visits), the change in quality
Change in coverage of uterotonics
Coefficient (95% CI) p value
0 09 (-0 18, 0 36) 0 50
0 03 (-0 01, 0 07) 0 16
0 72 (0 50, 0 94) <0 001
8 / 13
(number of health worker behaviours for focused ANC and the change in the number of items
prepared for birth by the end of pregnancy) and baseline cluster level summaries, all
associations were attenuated suggesting collinearity between the variables. The correlation between a
change in the proportion of women who had at least four ANC visits and a change in the
number of components of focused ANC received was 0 59; the correlation between a change in the
proportion of women who had at least four ANC visits and a change in the number of items
prepared for birth by the end of pregnancy was 0 26 and the correlation between a change in
the two measures of quality was 0 45. The strongest remaining association was between an
increase in contacts as measured by the proportion of women receiving four or more ANC
visits (0 17 (-0 12, 0 47)) and change in coverage of tetanus toxoid protection.
In multiple regression of coverage of iron supplementation and syphilis prevention
(Table 4) on the change in the proportion of women receiving four or more ANC visits, the
change in the number of behaviours for focused ANC, the change in the number of items
prepared for birth by the end of pregnancy and their baseline cluster level summaries, an increase
in the quality indicator focused ANC behaviours remained associated with a change in both
the coverage of iron supplementation and syphilis prevention (0 06 (0 01, 0 11); 0 07 (0 04,
In simple regression analysis for contacts, an increase in the number of deliveries with a skilled
attendant at birth was associated with an increase in the coverage of delayed bathing (0 41
(0 22, 0 59)) and an increase in the coverage of uterotonics (0 61 (0 29, 0 93)), but not with an
increase in the essential immediate newborn care indicators immediate breastfeeding, drying
or wrapping (Table 3)
For quality, there was also evidence of an increase in knowledge about management of
heavy bleeding amongst birth attendants and an increase in the availability of uterotonic
supplies amongst birth attendants and both were associated with higher coverage of uterotonics
(0 84 (0 66, 1 02); 0 09 (0 04, 0 14)) (Table 3).
In multiple regression of change in coverage of uterotonics on change in coverage of skilled
attendant at birth, change in knowledge about management of heavy bleeding amongst birth
attendants, change in the availability of uterotonic supplies for birth attendants and their
baseline cluster level summaries, only the quality indicator change in the availability of uterotonic
supplies amongst birth attendants remained associated with a change in the coverage of
uterotonics (0 72 (0 50, 0 94)) (Table 5).
There were no associations observed for either an increase in postnatal contacts or an increase
in postnatal indicators of quality (a score composed from number of components of
recommended post-natal care behaviours delivered (Table 2)) and an increase in coverage of
postnatal critical interventions, however there was little scope for improvement in these indicators
given the high coverage at baseline.
Across stages along the continuum from pregnancy to postnatal
Similarly, no associations were observed between either an increase in ANC contacts or an
increase in the number of recommended preparations a woman made for her delivery and
either change in coverage of hand washing with soap by birth attendants (women delivering at
home only), or change in the number of newborns with clean cord care.
9 / 13
This analysis aimed to determine the extent to which increased frequency or improved quality
of contacts were associated with observed changes in intervention coverage for mothers and
newborns in Ethiopia.
We found measures of quality to be consistently associated with coverage, but the relative
contribution of increased number of contacts or improvements in quality to increases in
coverage was not consistent across the different interventions examined.
In pregnancy, women who made more visits had higher coverage of tetanus toxoid
protection independent of the quality indicators measured: this makes sense given that multiple
ANC visits are needed to deliver multiple doses. But iron supplementation and syphilis testing,
both of which can be provided at a single visit, had a stronger association with indicators of
quality suggesting that women attending better quality facilities were more likely to receive
these one-off interventions.
At delivery, a strong relationship emerged between more birth attendants having
uterotonics available and improved coverage of prophylactic uterotonics to prevent post-partum
haemorrhage, in the absence of any improvements in knowledge of their importance. In this
example, successful delivery of the intervention is dependent on both availability of the
commodity (input quality) and health worker use of it (process quality). The regression coefficient
of 0 84 (0 72 adjusted) suggests that health worker behaviour was very good with respect to
this aspect of care with a 0 8% increase in the proportion of women receiving a uterotonic for
every 1% increase in the availability of uterotonics with the limiting factor being availability.
Many lifesaving interventions at delivery rely on the behaviours of birth attendants rather than
equipment or commodities, essential immediate newborn care providing good examples of
this. Analysis of initiation of immediate breastfeeding, immediate drying and wrapping, and
delayed bathing of the newborn revealed that only delayed bathing was associated with an
increase in coverage of skilled attendance at birth, suggesting that, in 2015, the other
behaviours had not yet become the accepted norm irrespective of health worker knowledge of them.
Finally, considerable missed opportunities were revealed for the delivery of lifesaving care
across the continuum from pregnancy to newborn periods. We found no evidence of a
pathway linking increased antenatal or delivery contacts to improved quality and intervention
coverage within the early postnatal period, and coverage of early postnatal checks remained very
low. In the context of increased facility delivery with early discharge, there is a need to
re-evaluate the model for providing care to newborns within 2 days of birth to make sure they do not
fall between community and facility structures.
This research was carried out across the four most populous regions of Ethiopia where the
coverage of contacts, of quality, and the majority of interventions for mothers and newborns
was suboptimal at the outset but showed evidence of marked improvement over the three year
period. From a very low baseline, we observed improvement between 2012±2015 in the
coverage and quality of antenatal and intrapartum care with changes of over 20 percentage points in
some indicators such as the coverage of at least four antenatal care visits, the coverage of iron
supplementation and the coverage of skilled attendants at birth. However immediate newborn
interventions and the coverage and quality of postnatal care checks lagged behind Over a
decade ago the government committed to increase demand for and availability of health
services everywhere and, through a comprehensive mix of multi-sectoral strategies, made
remarkable progress to this end [
]. A large number of external partners played a role in supporting
the government, testing for example quality improvement initiatives [
], improving access to
emergency transport [
] strengthening community linkages [
], and institutionalising
maternal death surveillance and response systems [
]. Current government priorities, as
10 / 13
described in the Health Sector Transformation Plan, clearly define targets to improve the
quality, not only the quantity, of health care provided. This includes focussing on ensuring the
basic foundations of health care, particularly important in the context of continued constraints
in the availability of emergency obstetric care [
], but also focussing on the quality of
health worker behaviours. This commitment is highly consistent with the growing body of
evidence that shows limited association between the availability of supplies for different health
needs and appropriate usage by health workers [
]. The analysis presented here suggests that
to achieve the national 2020 targets for maternal and newborn health the country will need
both a catch up and keep up strategy±continuing to increase demand for contacts, continuing
to strengthen and expand the foundations of the health system, while also improving the
experience of health care users when they reach care.
A particular strength of the work was to evaluate the coverage of contacts and the quality of
care provided simultaneously, as co-drivers for improving health, rather than consider these as
independent constructs [
]. But a number of limitations exist. The analysis has change in
coverage of lifesaving interventions as an endpoint, not mortality. While it is commonly
understood that coverage is the essential penultimate step on the pathway towards improved
1, 12, 24
] it provides less certainty than evidence of actual mortality impact. Analyses
were conducted at the cluster level thus the ecological fallacy (potential mis-interpretation
about the nature of individuals relative to the group to which those individuals belong) cannot
be ruled out. Further, the analysis was predominantly driven by supply side factors (equipment
and health worker behaviours) because many of the interventions examined were dependent
on actions within health facilities: we did not account for the individual preferences of women
and their families which may also have played a role in the intervention coverage. Measures of
quality were illustrative not comprehensive. The World Health Organization has presented its
vision of quality care for mothers and newborns [
] but there is little standardisation as yet
around definitions and measures: the input and process quality hypotheses tested here are
plausible but we acknowledge that they could have been constructed differently. Further, we
used some proxy measures for quality, including linking frontline worker data to household
observations to compensate for information about quality that mothers were not able to
]. Finally, whilst we believe that the associations that remained significant in the
multiple regression analysis are plausible and relevant to public health we carried out a large
number of statistical tests and made no adjustment for multiple testing which may have led to
false positive findings. We therefore urge cautious interpretation.
This analysis of change in Ethiopia between 2012 and 2015 provides three important pieces of
evidence for action. First, improvements in the quality of care were independently associated
with increased coverage of critical antenatal and intrapartum interventions, supporting the
current commitment to invest in quality [
]. Second, that investment in quality needs to
go beyond the inputs of the health service in terms of supplies and commodities and also
include mechanisms for supporting the process of care through best practice by health
workers. Third, that urgent attention is required to improve postnatal care, and more focus is
needed on care that integrates opportunities for both the mother and newborn.
S1 File. Prospective analysis plan.
11 / 13
We thank Keith Tomlin for his help with the electronic data capture.
Conceptualization: Joanna Schellenberg.
Data curation: Tanya Marchant.
Formal analysis: Elizabeth Allen.
Funding acquisition: Joanna Schellenberg, Tanya Marchant.
Methodology: Elizabeth Allen, Joanna Schellenberg, Della Berhanu, Simon Cousens.
Writing ± original draft: Elizabeth Allen, Tanya Marchant.
Writing ± review & editing: Joanna Schellenberg, Della Berhanu, Simon Cousens, Tanya
12 / 13
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