Effect of enhanced reminders on postnatal clinic attendance in Addis Ababa, Ethiopia: a cluster randomized controlled trial

Figures & data

Figure 1. Flow diagram of trial randomization, allocation, follow up and analysis.

Figure 2. Proportion of postnatal visit compliance among the intervention and control groups.

Table 1. Baseline socioeconomic and demographic characteristics of the study groups.

Characteristics	Intervention n = 175	Control n = 175	Overall N = 350	p-value
	n (%)	n (%)	n (%)
Age (Mean ± SD (yrs.))	25.7 ± 5.3	26.1 ± 5.6	25.9 ± 5.4	0.51^a
Educational level
No Formal Education	40(22.9)	33(18.9)	73(20.9)	0.60
Primary Education	61(34.8)	56(32.0)	117(33.4)
Secondary Education	47(26.8)	53(30.3)	100(28.5)
Higher Education	27(15.4)	33(18.9)	60(17.1)
Occupational status
Civil Servant	41(23.4)	40(22.9)	81(23.1)	0.48
Self Employed	31(17.7)	37(21.1)	68(19.4)
Student	81(46.3)	69(39.4)	150(42.8)
Daily Laborer	22(12.6)	29(16.6)	51(14.6)
Marital status
Single	32(18.3)	53(30.3)	85(24.3)	0.07
Married	133(76.0)	112(64.0)	245(70)
Widowed	10(5.7)	10(5.7)	20(5.7)
Husband educational status (n = 133)
No formal Education	9(6.8)	9(8.1)	18(7.3)	0.80
Primary education	21(15.8)	16(14.3)	37(15.1)
Secondary education	37(27.8)	27(24.0)	64(26.1)
Higher education	66(49.6)	60(53.7)	126(51.5)
Husband occupational status (n = 133)
Civil Servant	55(41.4)	49(43.8)	104(42.4)	0.73
House wife	27(20.3)	23(20.5)	50(20.4)
Daily Laborer	27(20.3)	26(23.2)	53(21.6)
Student	24(18.0)	14(12.5)	38(15.5)
Ethnicity
Amhara	80(45.7)	87(49.7)	167(47.7)	0.69
Oromo	46(26.3)	46(26.3)	92(26.3)
Tigre	16(9.1)	17(9.7)	33(9.4)
Gurage	33(18.9)	25(14.3)	58(16.6)
Religion
Christianity	127(72.6)	128(73.1)	255(72.9)	0.55
Islam	46(26.3)	43(24.6)	89(25.4)
African traditional religion	2(1.1)	4(2.3)	6(1.7)
Family Size
1–2	23(13.2)	22(12.6)	45(12.8)	0.61
3–5	125(71.4)	119(68.0)	244(70.0)
>5	27(15.4)	34(19.4)	61(17.2)
Decision maker at the household level
Self	94(53.7)	85(48.6)	179(51)	0.31
Husband	59(33.7)	58(33.1)	117(33)
Other Family Member`	22(12.6)	32(18.3)	54(15.4)
Perceived distance to health facility
Big problem	59(33.7)	64(36.6)	123(35.1)	0.53
Not a big problem	116 (66.3)	111(63.4)	227(64.9)
Parity
1	80(45.7)	78(44.6)	158(45)	0.971
2–4	77(44.0)	78(44.6)	155(44.3)
≥5	18(10.3)	19(10.8)	37(10.6)

aindependent t test, p-value of the Pearson’s chi square test.

Table 2. Baseline maternal health-care services utilization by women in the intervention and control groups.

Maternal health-care utilization	Intervention n = 175	Control n = 175	Overall N = 350	p-value
	n (%)	n (%)	n (%)
Had postnatal care for the last child
Yes	47(26.9)	52(29.7)	99(28.3)	0.55
No	128(73.1)	123(70.3)	251(71.1)
Level of compliance with PNC visits for the last child
No PNC	130(74.3)	125(71.4)	255(72.9)	0.77
Partial PNC	27(15.4)	32(18.3)	59(16.9)
Full PNC	18(10.3)	18(10.2)	36(10.3)
Qualification of past postnatal attendants
Medical Doctor	3(6.4)	6(12.0)	9(9.3)	0.71
Health officer	8(17.02)	9(18.0)	17(17.5)
Midwife	29(61.7)	26(52.0)	55(56.7)
Nurse	7(14.9)	9(18.0)	16(16.5)
Number of ANC visit for the index pregnancy
<4 ANC visit	51(29.1)	63(36.0)	114(32.6)	0.171
4+ ANC Visit	124(70.9)	112(64.0)	236(67.4)
The index pregnancy was wanted
Yes	114(65.1)	113(64.6)	227(64.9)	0.911
No	61(34.9)	62(35.4)	123(35.1)

p-value of the Pearson’s chi square test.

Table 3. bivariate ordinal logistic regression analysis for association between postnatal care compliance and explanatory factors.

	PNC visit compliance
Characteristics	No PNC n (%)	Partial PNC n (%)	Full PNC n (%)	COR (95% CI)
Study group
Intervention	65(19)	92(27)	16(4.6)	2.03(1.34,3.08) *
Control	93(27.2)	66(19.3)	10(3)	ref
Occupation
Civil Servant	17(5)	50(14.6)	13(3.8)	5.68(2.85,11.28) *
Student	76(22.2)	63(18.4)	11(3.2)	1.54(0.85,2.82)
Daily Laborer	29(8.5)	18(5.3)	1(0.3)	0.95(0.44,2.05)
Self Employed	36(10.5)	27(7.9)	1(0.3)	ref
Educational level
No Formal Education	31(9)	38(11.1)	3(0.88)	ref
Primary education	62(18)	51(14.9)	1(0.3)	0.54(0.29,0.99) *
Secondary education	47(13.7)	42(12.3)	8(2.34)	0.81(0.43,1.51)
Higher education	18(5.3)	27(5.3)	14(4.09)	3.56(1.71,7.38) *
Husband’s educational status (n = 133)
No Formal Education	8(3.1)	12(4.6)	2(0.77)	ref
Primary education	25(9.6)	15(5.8)	1(0.4)	0.20(0.06,1.63) *
Secondary education	51(19.7)	15(5.8)	1(0.4)	0.12(0.04,0.36) *
Higher education	39(15)	69(26.6)	21(8.1)	1.42(0.57,3.55)
Husband’s occupational status (n = 133)
Civil Servant	36(14)	61(23.5)	14(5.4)	1.52(0.69,3.37)
Self Employed	37(14.3)	15(5.8)	1(0.4)	0.28(0.17,0.71) *
Daily Laborer	33(33)	20(7.7)	2(0.8)	0.45(0.18,1.08)
Student	17(6.5)	15(5.8)	8(3.1)	ref
PNC visits compliance for the last child
No PNC	137(40.1)	98(28.6)	12(3.5)	ref
Partial PNC	16(4.7)	41(12)	2(0.6)	3.79(2.06,6.98) *
Full PNC	5(1.5)	19(5.5)	12(3.5)	13.86(6.23,30.8) *
Number of ANC visit for the index child
<4 ANC	72(21)	35(10.2)	1(0.3)	ref
4+ ANC	86(25)	123(35.9)	25(7.3)	3.55(2.17,5.79) *
Parity
1–2	112(32.7)	104(30.4)	15(4.4)	ref
3–4	28(8.2)	37(10.8)	10(3)	1.74(1.09,2.71) *
≥5	18(5.2)	17(5)	1(0.3)	1.23(0.61,2.65) *
Sex of the newborn
Male	84(24.5)	80(23.4)	14(4.1)	ref
Female	74(21.6)	78(22.8)	12(3.5)	1.02(0.67,1.55)
Current pregnancy wanted
Yes	95(27.8)	108(31.6)	24(7)	1.99(1.27,3.12) *
No	63(18.4)	50(14.6)	2(0.6)	ref
Perceived distance to health facility
Big problem	28(8.2)	12(3.5)	2(0.6)	ref
Not a big problem	130(38)	146(46.2)	24(7.1)	2.37(1.16,4.87) *

p-value*: <0.05 COR; crude odds ratio 95% CI: confidence interval (95%); ref: reference group.

Table 4. Multilevel model, random effect size and variability among the cluster factors and postnatal compliance.

	PNC visit compliance
Characteristics	Model I^a AOR (95% CI)	Model II^b AOR (95% CI)
Group
Intervention		2.98(1.51,5.81) *
Control		ref
Occupation
Civil Servant		1.6(1.02,6.24) *
Student		0.64(0.34,2.38)
Daily Laborer		2.42(0.42,12.18)
Self Employed		ref
Highest Level Educational Attainment
No Formal Education		ref
Primary education		1.31(0.51,3.33)
Secondary education		1.04(0.36,3.01)
Higher education		1.921(0.63,5.83)
Husband Educational Status
No Formal Education		ref
Primary education		0.06(0.01,0.35) *
Secondary education		0.03(0.01,0.12) *
Higher education		1.73(0.38,7.79)
Level of compliance with PNC visits for the last child
No PNC		ref
Partial PNC (1–2)		2.90(1.08,7.75) *
Full PNC		3.29(1.55,10.3) *
Number of ANC visit
<4 ANC		ref
4+ ANC		1.54(1.09,2.59) *
Parity
1–2		1.44(1.09,21.40) *
3–4		1.47(0.41,21.40)
≥5		ref
Current Pregnancy Wanted
Yes		2.23(0.59,8.41) *
No		ref
Decision making
Self		2.34(1.25,4.59) *
Husband		1.36(0.68,2.71)
Other relatives and families		ref
Perceived distance to health facility
Big problem		ref
Not a big problem		1.25(0.38,4.11)
Random effect parameters	Model I	Model II
Community level Variance (SE)	0.324 (0.06, 2.03) (18.2%)	0.79(0.23,0.89) (50%)
ICC (%)	8.9%	19.4%
Model fit statistics
Log-likelihood	−310.5	−164.36
AIC	627	378

Note: ^a Empty model which contains no explanatory variables (intercept only model) but partition the variance into two component parts, ^b Model II: model which contains individual level variables equated by cluster level variable (health centers) AIC = Akaike information criterion, CI = confidence interval, ref = reference category, SE = standard error, ICC = intracluster correlation coefficient.

Log-likelihood = this is the log-likelihood of the fitted model. The value of the log likelihood (−164.36) in model II indicates a better fit

*: significant at 5% level of significance.

Table 5. Acceptability of the reminders for postnatal appointment[n = 124].

Acceptability	n	%
The reminder was helpful to visit health center during your postnatal
Helpful	114	91.9
Not helpful	8	6.45
Not sure	2	1.6
Recommend reminders to family member or friend
Yes	113	91.1
Not sure	11	8.9
Total	124	100