Assessment of equity in provision and utilization of maternal and child health programs in butajira, southern ethiopia

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6.2. Strengths and Limitations of the Study

6.2.1. Strengths

Among the strengths of this study is that it has incorporated both household survey and health facility record reviews.

It has also obtained nearly 100% of response rate in the household survey.

Multivariate analysis were used together to control the possible confounding effect of covariates

Random selection of both the case and the control groups were used and blinding of data collectors to overcome selection and observer bias.

6.2.2. Limitations

Among the limitations, on the other hand, are included:

The outcome variable used for selection of cases and controls were using ANC and this might not be applicable for other services.
For the health facility survey, distances was estimated using map reading after the data was collected and PAs not on the map were excluded.
The study was retrospective case control with potential of recall bias.
Complete information was not available for some subjects in the health facility record review and hence those subjects were excluded from analysis, which might change the picture.

6.3. Conclusions

In the study, the government health care units in general and primary health care units in particular were reported the most accessible in 98% and 93% of respondents respectively. Additionally, with health facility record review, it was observed that the numbers of health care units in general and that of primary health care units in particular had significantly increased over the recent years. But the lower health care units such as health posts/stations, which take the lion share in numbers, were not staffed with trained health professionals and hence not involved in provision of preventive MCH services. Only three (one hospital and two health centers) out of 26 health facilities available in the two districts were providing preventive MCH services during 1996 EC.
Among different socio-demographic factors, occupation of household head, mother's education and husband's education was associated with utilization of health services. Households who used the service were 2.89 times more likely to have non-farmer heads of households, and 2.81 times more likely to have mothers and 1.99 times more likely to have fathers with some schooling. Testing this association further with multinomial logistic regression, only mothers' having schooling is associated with service use (X2=8.57, p<0.05).
In study, utilization of preventive MCH services was found to be inequitable across urban and rural population. Mothers who used the service more likely to be an urban resident with the odds of being an urban resident to be 3.86 times higher for cases than controls (X²=18.71, p<0.001).
From health facility record review, it was observed that from all FP, ANC, delivery and EPI service users, 54%, 23%, 45% and 38%, were from urban residents. Among mothers who gave birth at health facility, there was a recorded history of ANC follow up for 88% of urban mothers but only to 65% of rural mothers (X²=40.1, p<0.001), 97.4% of urban mothers gave birth to live baby while this was true in 92% of rural mothers (X²=6.46, p<0.05). Additionally, while urban children accounted for 58% of all fully immunized and 25% of partially immunized children, their rural counterpart accounted for 42% of all fully immunized and 75% of all partially immunized children for EPI (X²=238.7, p<0.001). This may be that urban women tend to have better access to health facility and other promotional activities that are urban based.
Equity in utilization of preventive MCH services was also affected by socio-economic status of the households. Mothers who used the service were more likely to have average households annual income level of more than 1000 birr than non- users; with the odds of having average annual income level of more than 1000 birr being 2.35 times higher for cases.

Living distance from health facility were also associated with utilizing health services in that 61% of users but 47% of non users were from a walking distance of less than an hour from health facility (X²=6.67, p<0.05).

From health facility record review, among mothers who gave birth at health facility there was a recorded history of ANC follow up for 86% of mothers living within a distance of 6km but for 66% of mothers living in a distance of more 6km, (X²=29.3, p<0.001), 98% of mothers living within a distance of 6km gave birth to live baby while this was true in 91% of mothers living in a distance of more 6km (X²=12.83, p<0.001). Additionally, while children from a living distance of less than 6km accounted for 73% of all fully immunized and 49% of partially immunized children, those living in a distance of more 6km accounted for 27% of all fully immunized and 51% of partially immunized children for EPI (X²=126.2, p<0.001).

6.4. Recommendations

After analyzing the major finding of this study, the following recommendations are forwarded:

Mothers and fathers education was found to be among the determining factor for health services utilization. Therefore providing appropriate information, Education, and Communication (IEC), concerning the utilization of maternal and child health services, which is tailored to the area, through the current health extension program has to be encouraged.
Income level of households was found as one of the predictor of health services utilization. This indicates that the government, together with expanding health facilities, has to intensify the current effort of poverty reduction.
The rates of utilization of health services were different by occupation of heads of households and income level, more research is needed to identify the reasons for this difference, and why, even though the service cost is free, income level affect the utilization rates.
Positive discrimination may be needed to provide outreach and other innovative schemes to make it easier for people to use services in low utilization areas such as among the poor and those residing in rural areas.