Utilization of Ambulance Services and Associated Factors during Pregnancy and Labor Among Lactating Mothers in Buno Bedele Zone, Southwest Ethiopia

Abstract

In Ethiopia, the use of ambulance services for urgent obstetric care improved institutional delivery and reduced maternal mortality. However, poor infrastructure, delayed response from dispatchers, and other socioeconomic factors influence service utilization. The present study assessed the utilization of ambulance services and associated factors during pregnancy and labor among lactating mothers in the Buno Bedele administrative zone of Southwest Ethiopia. Community-based cross-sectional study design with a sample of 792 lactating mothers was carried out. A multi-stage sampling technique was employed, and data were collected through structured questionnaire, and focus group discussions (FGD). Among the 792 study participants, 618 (78%) had antenatal care (ANC) follow up and 705 (89%) were aware of information on the availability of free ambulance services. Eighty one percent study participants requested for ambulance services, and 576 (79%) utilized during their pregnancy and delivery periods. Awareness of free ambulance service (AOR = 3, 95% CI [1.4, 7.1], P = .006), maternal formal education (AOR = 3.9, 95% CI [1.46, 9.8], P = .006) and ANC follow up (AOR = 4.5, 95% CI [8.9, 23.3], P = .001) were identified factors responsible for enhanced ambulance services utilization in the study area. The finding of the present study revealed that pregnant women had a higher tendency to use ambulance services during their obstetric emergency. However, poor communication and road infrastructure, as well as delayed dispatcher response hampered better service utilization.

Background

Globally, hundred thousands of mothers and newborns die from pregnancy and delivery related complications yearly. According to the WHO, (2015) reports, an estimated 300 000 women lost their lives during pregnancy and childbirth.^1,2 Majority of the death reports are from low and middle income countries; sub-Sahara region taking the highest burden.³ In sub-Sahara Africa, an estimated 546 maternal deaths per 100 000 live births are reported.^3,4 Despite interventional efforts to improve accessibility to obstetric emergency services (skilled care at birth, timely emergency obstetric care, and immediate newborn care), results yet to be satisfactory.^5,6

Ambulance service also known as paramedic services or emergency medical service (EMS) is an integral part of obstetric emergency services and provides urgent supportive treatments to illnesses and injuries.⁷ An ambulance is equipped with medical facilities and experts; able to deliver pre-clinical emergency management and rapidly transport to the decisive care.⁸ Utilization of ambulance enhances birth at health facility, which is one of the most essential approaches to reduce maternal death, stillbirths and neonatal mortality in low and middle-income countries (LMICs).^9,10

Several reports estimated, more than 75% of maternal death could be associated with late arrival of women to emergency obstetric care facilities.^4,11 In low income countries, lack of ambulance services to reach health facilities with emergency obstetric care is a major contributor factor to delay. In sub-Sahara African region, reports showed that more than 35% of maternal death are directly associated with lack of ambulance service during obstetric emergency.^{12 -14}

Ambulance service utilization for obstetric emergency care in Ethiopia is estimated to be 61.4%.¹⁵ Federal Ministry of Health (FMoH) and regional heath offices have been distributing ambulances to health facilities and played paramount role to attain institutional delivery. However, several factors hindered utilization and narrowed the expected successes with respect to maternal health services in general and institutional delivery in particular.¹⁶ Some of identified factors related with low utilization of ambulance services in the country are; poor and inaccessible road infrastructure, unavailability of functional ambulance, poor communication networks, and delayed response from dispatchers.^15,16

Government supplied free of cost ambulance services were initiated in the study sites for the purpose of promoting institutional delivery. However, the status of utilization and factors related to the service is not known. The present study thus aimed to assess status of ambulance service utilization and associated factors during an obstetric emergency in the Buno Bedele administrative zone, Southwest Ethiopia.

Methods

Study design and setting

A community-based cross-sectional and mixed method study was carried out in selected districts of Buno Bedele administrative zone, Southwest Ethiopia. The total population of the zone is estimated to be 829 663 according to the 2013 national population projection report. One general and 2 primary hospitals, 32 health centers, and 246 health posts were available in the zone serving the community. A total of 25 ambulances were functional during the data collection period. Women aged (15-49 years old) who gave birth between June 2018 and May 2019 was included in the study.

Sample size determination

Quantitative data

The sample size for the quantitative study was determined using single population proportion formula; [n = Z/(α/₂)² × P × (1−P)/d²] considering 95% confidence of interval (CI). Percentage of ambulance service utilization was not known in the study area and thus 50% (P = .5) proportion rate was considered. The estimated samples size thus became 384 lactating mothers. Five percent of the total estimated sample size for withdrawal or missed data were added and the sample size increased to 402. The absolute sample size then multiplied by 2 and the total sample size was 804.

Sampling procedures

Three districts (Bedele, Meko, and Gechi) were selected considering their residential landscape, proximity to the zonal town, and easy transport accessibility. The selected districts comprised 89 kebeles and one-third was included in the study. Approximately 27 proportional numbers of study participants were recruited from each kebele using a systematic sampling technique. They were then undergone in depth interviews.

Qualitative data

To triangulate the quantitative data, qualitative information about factors associated with ambulance service utilization was carried out. Three kebeles were chosen at random from each district included in the study. Ten study participants were selected on the basis of their educational status, parity, and ANC follow-up experiences from each selected kebeles. They were then subjected to a 1-hour FGD led by 2 midwives using a pre-determined checklist.

Data collection and quality assurance

Qualitative data were collected through FGD. Three FGD were held, one per each selected district in the randomly selected kebeles. The FGD comprised 10 mothers arranged for 1-hour duration of discussion. Two trained midwives facilitated the discussion using the pre-established checklist. Similarly, data related to sociodemographic characteristics were collected using a structured questionnaire. The questionnaire was adopted from Ethiopian Demographic and Health Survey (EDHS), 2014.¹⁷ It was first prepared in English and then translated to the local language “Affan Oromo” and “Amharic.” Then, a pretest was carried out among 5% of the total sample size in the nearby districts. In addition, 1-day data collection training was given to data collectors and close supervision was held to maintain data quality. Only one study participant from a household who met the inclusion criteria was interviewed.

Ethics approval and consent to participate

Institutional Research Ethics Review Committee of Mettu University has granted ethical approval of the study. The committee declared that verbal informed consent was permitted. Zonal Health Bureau provided a permission letter. Informed consent was obtained from all study participants and every response was treated with confidentiality and anonymous. All methods were performed in accordance with the Declaration of Helsinki.

Statistical analysis

SPSS version-20 software was used for the analysis of the quantitative data. Binary logistic regression was considered to assess the effect of independent variables on the dependent variables. The P-value of bivariate analysis less than .25 was exported for multivariate regression analysis to determine the predictor variables for ambulance services utilization. P < .05 was considered statistical significance. Qualitative data collected through FGDs were transcribed and translated into English, coded manually and organized into sub-themes, and finally summarized in narrative form.

Results

Sociodemographic characteristics

Among the 804 study participants recruited for data collection in the beginning of the study, 792 (98.5%) were completed. Majority (53%) of lactating mothers included in the study were adults (⩾30 years of old) and 94% were married. Regarding to maternal educational status, those who attended formal education were the majority (63%), yet, more than 87% of them were farmers and house wives (Table 1).

Table 1.

Sociodemographic characteristics of the study participants in Buno Bedele zone, Southwest Ethiopia, 2019.

Variables		Frequency	%
Age	15-29	369	47
	⩾30	423	53
Marital status	Married	742	94
	Single	23	3
	Divorced	19	2
	Widowed	8	1
Occupation	Farmer	392	49
	Daily laborer	51	6
	Merchant	25	3
	House wife	302	38
	Employee	22	3
Education status	Not attended	293	37
	Formal education	499	63

Ambulance utilization status

One hundred sixty-eight (21.2%) of the study participants did not use ambulance service during their obstetric emergency. Reasons such as unavailability (45%) and non-functionality (25%) of ambulances followed by communication problems (19%) were mentioned. However, only 3% of them tended to give birth at home (Table 2).

Table 2.

Reason for not using ambulance services among the study participants in Buno Bedele zone, Southwest Ethiopia, 2019.

Reason for not using ambulance	Frequency	%
Road inaccessibility	14	8
Ambulance unavailability	76	45
Ambulance non-functionality	42	25
Tendency of birth at home	5	3
Don’t know call number	18	11
Communication network problem	13	8
Total	168	100

Majority (88.8%) of mothers who participated in the study were aware of the availability of free ambulance service during an obstetric emergency, 77.5% had ANC follow-up schedule and 81.2% had the call number of ambulance dispatchers. Similarly, mothers who were greater than 30 years of old (42.2%) and who had formal education (58.1%) better utilized ambulance service during their obstetric emergencies compared with their counterparts (Table 3).

Table 3.

Factors associated with ambulance services utilization among the study participants in Buno Bedele zone, Southwest Ethiopia, 2019.

Characteristics	Utilization practice		COR (95% CI)	AOR (95% CI)	P-value
	Yes	No
Parity
>5	427	121	0.84 (0.59, 1.2)	0.11 (0.60, 2.10)	.71
<5	197	47	1.0	1.0
ANC follow up
Yes	556	58	15.5 (10.3-23.3)	4.5 (8.9, 23.3)	.001
No	68	110	1.0	1.0
Information of free ambulance services
Yes	559	144	1.4 (0.9-2.4)	3 (1.4, 7.1)	.006
No	65	24	1.0	1.0
Ambulance call number knowledge
Yes	558	85	8.3 (5.5-12.2)	6.2 (3.7, 10.2)	.001
No	66	83	1.0	1.0
Tendency
Yes	585	132	4 (2.5, 6.7)	1.2 (0.63, 2.5)	.53
No	39	36	1.0	1.0
Information source
HEW	584	128	3.9 (1.8, 8.5)	4.3 (1.4, 13.4)	.011
PHCU officer	9	6	1.3 (0.4, 4.6)	2.4 (0.5, 12.3)	.281
Ambulance driver	16	21	0.7 (0.2, 1.8)	1.3 (0.3, 5.1)	.698
Others	15	13	1.0	1.0
Road accessibility
Accessible	527	125	1.9 (1.2, 2.8)	1.9 (1.1, 3.5)	.025
Inaccessible	97	43	1.0	1.0
Age category
15-29	290	79	0.98 (0.70-1.4)	1.7 (1.1, 2.8)	.02
⩾30	334	89	1.0	1.0
Educational status
Formal education	460	39	9.3 (6.5-20.1)	3.79 (1.46-9.80)	.006
Not attended	164	129	1.0	1.0

Abbreviations: AOR, adjusted odd ratios; COR, crude odd ratio; HEWs, health extension workers; PHCU, public health coordination unites.

Factors associated with ambulance utilization

Binary logistic regression was conducted to determine major responsible factors for better utilization of ambulance service during obstetric emergency cases of the study participants. From univariate analysis, ANC follow up, information on free ambulance service, knowledge of ambulance call number, maternal age and education were identified predictors for ambulance service utilization. Since, univariate analysis ignores the relationship between independent variables; we used multivariate analysis for producing a valid conclusion about the population parameter. The multivariate logistic regression thus shows, lactating mothers who had ANC follow-up schedules were 4.5 times (AOR = 4.5, 95% CI [8.9, 23.3], P = .001) more likely to utilize ambulance services than those who did not. Similarly, mothers who were aware of free ambulance service and those who knew ambulance call numbers were 3 times (AOR = 3, 95% CI [1.4, 7.1], P = .006) and 6 times (AOR = 6, 95% CI [3.7, 10.2], P = .001) more likely utilized ambulance than their counterparts respectively. However, less likely ambulance service utilization was recorded among mothers who had high parity experience (AOR = 0.11, 95% CI [0.60, 2.10], P = .71) (Table 3).

Qualitative findings

The qualitative data collected from each sampled kebeles comprised of 10 mothers and 2 trained midwife as moderator and information recorder. For each FGD, a 1 hour discussion was carried out. Mothers expressed their view and ideas freely guided by a pre-established checklist. The mean age of the FGD interviewee was 36.3 ± 5.7 years old. The majority (93.7%) of them had frequent experience in utilizing ambulance services during their obstetric emergency. They described factors responsible for inaccessibility and failure of ambulance service utilization during their obstetric emergency. The findings of the discussions were then organized into 3 sub-themes accordingly.

Sub-theme 01. Absence and dysfunction of ambulance

Due to the lack of field vehicles in the government administrative offices in the study area, ambulances were called upon to perform additional tasks such as providing service to office managers and expertise during field work. The other factor is that ambulances frequently break down and remain unrepaired for an extended period of time, which is one of the other significant impediments to ambulance service utilization while comparing with the expected outcome. Similar data from the quantitative study (Table 2) also revealed that unavailability and non-functionality of ambulance comprised more than 70% causes of ambulance service interruption. The following verbatim illustrates the extent of the situation as:

“When we called for Ambulance service during our emergency obstetric cases, the dispatcher responded to us the ambulance has gone to other town such as “Jimma, Nekemete” and nearby villages to transport office managers and expertise. Most frequently they also replied us ambulance were broken and not maintained too long” [Mothers who participated in the FGD]

Sub-theme 02. Poor communication and delayed response

Communication disruption was one of the other important factors that decreased rate of ambulance service utilization in the study areas. The study area is characterized by the deciduous forest, mountainous topography and rainy climate that played role for a significant reduced telecommunication and electricity power supply infrastructures. Table 2 also showed that, 8% of the respondents replayed, they were facing difficulty of reaching out ambulance dispatchers because of telecom signal interruption. The following quotes furthermore describe the situation:

“During our obstetric and gynecological emergency cases, we have been facing difficulty of electricity for mobile battery charge and poor telecom signal which interrupted telephone communication with ambulance dispatchers. With multiple trials, we might access the signals and reached the message to the dispatchers and they responded they sent ambulance to us yet no ambulance arrived home. Some time, they either deliberately switched their phone or made the phone out of service, and then, they blamed the infrastructure.” [Mothers participated in the FGD]

Sub-theme 03. Road inaccessibility

Relatively the poor road infrastructures particularly in kebeles which are not located along the national main highway, the type of roads were earthen and gravel which significantly hampered transportation system. The problem became worse during rainy season even sometimes were challenging on foot walk too. Eight percent of the study participants also replied that road inaccessibility was a major challenge (Table 2) for better service utilization. The following transcript illustrates the situation as:

“While we waited too long for ambulance services, our labour progressed and we gave birth spontaneously at home, the ambulance then reached and the driver answered that he was stacked at mud because of the heavy rain.” [Mothers who participated in the FGD]

Discussion

Maternal and neonatal mortality rate can be reduced with proper functioning of integrated EMS in developing countries like Ethiopia. Ambulance service utilization during obstetric emergency case by far among EMS components which plays significant role in this regards. In the present study therefore, we assessed status of ambulance service utilization during obstetric emergency case in Buno Bedele administrative zone of the Southwest Ethiopia. The result then showed that the majority (79%) of study participants utilized ambulances for institutional delivery. The present finding was slightly higher than the report from resource-poor settings of Uganda (66%),¹⁸ Addis Ababa, Ethiopia (61.4%),¹⁵ and Mekele city, Ethiopia (66.8%).¹⁹ It is also much higher than the national ambulance utilization status of the country.¹⁶ The variations could be explained that the scope of the present study is bounded only to lactating mothers while the other studies carried out in the general population.

Disproportionately, another report from Mekele city by Takele et al showed, only 38% of study participants utilized ambulance service during their obstetric emergency cases whereas a similar study was conducted among the general population of the city.²⁰ These discrepancies could be associated with 2 reasons. First, the difference of study target groups; in the present study, the target group was tightened to labor cases only, and the second justifying reason could be the availability of alternative transportation mechanisms in Mekele city and labor mothers might not wait until free ambulance service was served.

In the present study, mothers who had ANC follow-up schedules and information on free ambulance services for obstetric emergencies were 4.5 and 3 times more likely to use ambulances respectively. A report from Mekele city also showed that awareness regarding free ambulance service utilization and ANC follow-up experiences were contributing to a significantly higher tendency to utilize the service than those who did not.^12,20 The reason could be mothers who had ANC, might have opportunities to get adequate counseling services on birth preparedness and readiness planning by health workers. In addition, they could also have a discussion with their peer groups on the importance of skilled birth attendants.

Likewise, mothers who had formal education were having a higher tendency toward utilizing ambulance services in the present study, which is in line with the report from Brazil and South Africa,²¹ India,²² and Mekele city, Ethiopia.¹⁹ The justification could be education increased the level of communication, confidence, and access to more information which assisted them to have a better understanding of health and related issues.

Regarding maternal age, the present study revealed that mothers who were greater than 30 years old were 1.7 times more likely to utilize the service. However, a contrasting finding was reported from Brazil, South Africa, and Mekele city, Ethiopia in which mothers below the age of 30 years were utilized ambulances better.^19,21 This inconsistency could be attributed to the fact that in the present study, the setting was rural and younger mothers might not have experience in utilizing an ambulance and lack of prior preparedness, which decreased confidence and became more ashamed than elders.

Absence of ambulances, poor communication signals and road inaccessibility, were major deterrents for delaying emergency obstetric medical responses in this study. In other previously reported studies, such as in Mekele city,^19,20 the aforementioned factors may not have negative impacts on the level of ambulance service utilization due to the availability of better telecom signals, good road infrastructure, and alternative transportation mechanisms such as privately owned ambulances.

Conclusion

Despite the fact that utilization of ambulance services among mothers is relatively good in the study area, more could be realized through improved communication network, maintenance services and road facilities. Furthermore educating young mothers on the essentials of ANC and emergency obstetric managements could sensitize and improve ambulance uptake services.

Limitations

The large sample size is the main strength of the present study. However, generalizability is limited owing to the sampling method. Samples were collected only from areas where roads, telecom, and other basic infrastructures are relatively “better.” Therefore, caution should be considered in attempting to generalize the finding to the different particularly remote areas of the study coverage.