Influence of Mass Media on Institutional Delivery Service Utilization among Ethiopian Women: Insights from the 2016 Demographic and Health Survey
1Health Research Development Directorate, Amhara Public Health Institute, Bahir Dar, Ethiopia
2Department of Health Promotion and Health Behavior, Institute of Public Health, College of Medicine and Health Sciences, University of Gondar, Ethiopia.
*Corresponding Author: Adane Nigusie; Email: adane2009ec@gmail.com, Phone: +251-913673758, P.O.Box: 477,
Introduction: Globally, the rapid advancement of technology has significantly expanded the reach of mass media, exposing a large portion of the world's population to diverse information sources. Mass media encompass various technologies that distribute information, ideas, and opinions to broad and targeted audiences. In this context, mass media can play a critical role in addressing significant issues, such as the low utilization of institutional delivery services, which remains a major challenge in developing countries like Ethiopia.
Objective: This study aims to assess the influence of mass media on the utilization of institutional delivery services among women in Ethiopia, utilizing data from the 2016 EDHS.
Methods :The study used data from the published reports of Ethiopian Demographic and Health Surveys-2016.
Results: Nearly twenty-eight percent (27.7%) of the respondents were exposed to radio, followed by television (19.6%) and newspapers (7.1%). Multivariable logistic regression analyses showed that mothers exposed to mass media were more likely to utilize institutional delivery services (AOR 1.25; 95% CI 1.10, 1.42). Place of residence, specifically rural areas (AOR 0.20; 95% CI 0.16, 0.25), educational status (primary school: AOR 1.98; 95% CI 1.76, 2.24; secondary school: AOR 6.12; 95% CI 4.59, 8.17; higher education: AOR 8.21; 95% CI 4.72, 14.30), and wealth index (poorer: AOR 1.72; 95% CI 1.44, 2.06; middle: AOR 1.97; 95% CI 1.65, 2.36; richer: AOR 2.11; 95% CI 1.76, 2.54; richest: AOR 3.19; 95% CI 2.52, 4.03) were significantly associated with institutional delivery service utilization.
Conclusion: The study reveals that exposure to mass media significantly increases the likelihood of utilizing institutional delivery services among women in Ethiopia. Additionally, factors such as urban residency, higher educational attainment, and greater wealth are positively associated with higher rates of institutional delivery service utilization. These findings highlight the importance of mass media and socio-economic factors in improving maternal health service uptake.
Keywords: Institutional delivery, Mass media, Ethiopia.
የጥናቱ መግቢያ፡- በዓለም አቀፍ ደረጃ፣ የቴክሎጂ ፈጣን እድገት የብዙኀን መገናኛ ተደራሽነትን በከፍተኛ ሁኔታ እንዲጨምር አድርጓል፤ ሰፊውን የዓለም ህዝብ ክፍል ለመገናኛ ብዙኀን እንዲጠቀም አስችሏል። መገናኛ ብዙኀን መረጃዎችን፣ ሐሳቦችንና አስተያየቶችን ለውስን እና ሰፊ ታዳሚዎች ለማሰራጨት የተለያዩ የሚዲያ ቴክሎጂዎችን ይጠቀማል። ኢትዮጵያን ጨምሮ በማደግ ላይ ባሉ ሀገሮች የተቋማዊ ወሊድ አገልግሎት አጠቃቀም አሁንም በጣም ዝቅተኛ ነው።
የጥናቱ ዓላማ፡- የዚህ ጥናት ዓላማ ከ2016 ዓ ም የኢትዮጵያ ዲሞግራፊክና ጤና ዳሰሳ የተገኘውን መረጃ በመጠቀም የመገናኛ ብዙኀን በኢትዮጵያ ውስጥ ባሉ ሴቶች የተቋማዊ ወሊድ አገልግሎት አጠቃቀምን ላይ ያለውን ተፅዕኖ ማጥናት ነው።
የጥናቱ ስልት፡- ይህ ጥናት የ2016 ዓ ም የኢትዮጵያ ዲሞግራፊክና ጤና ዳሰሳ መረጃን በመጠቀም የተሰራ ነው።
የጥናቱ ውጤት፡- ወደ 28 በመቶ (27.7 በመቶ) የሚሆኑት መረጃ ሰጪዎች ሬዲዮ፣ 19.6 በመቶ የሚሆኑት ደግሞ ቴሌቪዥን እና 7.1 በመቶ መረጃ ሰጪዎች ጋዜጦችን ተጠቃሚ ነበሩ። ሁለገብ የሆነዉ ሎጂስቲክስ ሪግሬሽን እንደሚያሳየው (multivariable logistic regression) ትንታኔዎች የመጨረሻ ውጤቶች እንደሚያሳዩት ለመገናኛ ብዙኀን የተጋለጡ እናቶች የተቋማዊ ወሊድ አገልግሎት የመጠቀም እድላቸው ከፍተኛ ነው (AOR1.25፤ 95% CI 1.10፣ 1.42)። የመኖሪያ ቦታ በተለይም የገጠር አካባቢዎች (AOR 0.20፤ 95% CI 0.16፣ 0.25)፣ የትምህርት ደረጃ (የመጀመሪያ ደረጃ ትምህርት፡- AOR 1.98፤ 95% CI 1.76፣ 2.24፤ ሁለተኛ ደረጃ ትምህርት፡- AOR 6.12፤ 95% CI 4.59፣ 8.17፤ ከፍተኛ ትምህርት፡- AOR 8.21፤ 95% CI 4.72፣ 14.30)፣ እና የሀብት ደረጃ (ደሃ፡- AOR 1.72፤ 95% CI 1.44፣ 2.06፤ መካከለኛ፡- AOR 1.97፤ 95% CI 1.65፣ 2.36፤ ሀብታም፡- AOR 2.11፤ 95% CI 1.76፣ 2.54፤ በጣም ሀብታም፡- AOR 3.19፤ 95% CI 2.52፣ 4.03) የተቋማዊ ወሊድ አገልግሎት አጠቃቀም ጋር በእጅጉ የተያያዙ ናቸው።
የጥናቱ ማጠቃለያ፡- ጥናቱ በኢትዮጵያ ውስጥ የሴቶች ለመገናኛ ብዝኀን መጋለጥ የተቋማዊ ወሊድ አገልግሎት የመጠቀም እድልን በከፍተኛ ሁኔታ እንደሚጨምር አሳይቷል። በተጨማሪም እንደ የከተማ ነዋሪነት፣ ከፍተኛ የትምህርት ደረጃና ከፍተኛ የሀብት መጠን ያሉ ምክንያቶች ከከፍተኛ የተቋማዊ ወሊድ አገልግሎት አጠቃቀም መጠን ጋር አዎንታዊ ቁርኝት አላቸው። እነዚህ ግኝቶች የእናቶች የጤና አገልግሎትን ለማሻሻል የመገናኛ ብዙኀንና ማኅበረ-ኢኮኖሚያዊ ምክንያቶች አስፈላጊ መሆናቸውን አሳይተዋል።
ቁልፍ ቃላት፡- የተቋማዊ ወሊድ አገልግሎት ፣ መገናኛ ብዙኀን ፣ ኢትዮጵያ
In 2020, there were an estimated 287,000 maternal deaths globally1. Developing countries bear a disproportionate burden of maternal deaths, with about 87% of these deaths occurring in Sub-Saharan Africa and South Asia2. Ethiopia experiences a high maternal mortality rate of 412 deaths per 100,000 live births. However, with the implementation of effective interventions, this rate has the potential to decrease significantly3.
For improved maternal and newborn survival outcomes, timely and appropriate healthcare during pregnancy and childbirth is crucial. Studies indicate that mass media is a potent and effective tool for health education and behavioral change 4, 5. For instance, research conducted in Tanzania demonstrated that mass media campaigns influenced intentions to use female condoms 6. A study in Nigeria indicated that individuals exposed to mass media were more likely to engage in discussions about HIV/AIDS with a partner and to understand the role of condom use in reducing HIV transmission risk, compared to those who were not exposed 7.
Furthermore, research on maternal health in Indonesia, Bangladesh, and India showed that exposure to mass media campaigns correlated with increased utilization of prenatal, postnatal, and delivery care services 8-11. Mass media encompasses a range of technologies used to disseminate diverse information, ideas, and perspectives to broad and specific audiences through publishing, broadcasting, or spoken communication 12.
Improving public health through mass media can often feel like navigating a vast network of roads without road signs, prompting questions about whether you are progressing in the right direction toward your destination 13. Mass media plays a pivotal role in disseminating information about health and medical treatments, with considerable attention given to the relationship between clinical trial investigators and pharmaceutical manufacturers 14, 15.
However, mass media can also play a beneficial role in public health 16, 17. Its influence is rapidly expanding, promoting ongoing social change, particularly in developing nations. Mass media serves as a crucial tool for public health by disseminating information on health and maternal health 18-21. Researchers have identified various influences and factors associated with mass media that can affect people’s perceptions and behavior 22. However, to the best of our knowledge, no previous study has investigated the influence of mass media on institutional delivery service utilization in Ethiopia.
The aims of this paper were to assess the influence of mass media on the utilization of institutional delivery services among women in Ethiopia, to examine the evolving familiarity status with notable differences, and to identify areas where exposure to mass media needs improvement. Additionally, we aimed to discern best practices in mass media usage through its trends.
Ethiopia is located in the eastern region of Africa and has a population of over 100 million, divided into 11 administrative provinces known as regions. The country falls into the low development category according to recent socioeconomic assessments. Approximately 85% of the population resides in rural areas, with agricultural trade emerging as the dominant sector of the economy23.
The data utilized in this study were sourced from the 2016 Ethiopian Demographic and Health Survey (EDHS), which is a component of the global Demographic and Health Surveys (DHS) project funded by the United States Agency for International Development (USAID). The survey was carried out by the Federal Ministry of Health and the Central Statistical Agency (CSA) of Ethiopia from September 2015 to June 2016. It involved interviews with a nationally representative sample of 7,193 women from 16,650 households. The final analysis included 7,193 women who had given birth at least once within the two to five years preceding the survey.
The Ethiopian Demographic and Health Survey (EDHS) is a nationally representative survey designed to meet the monitoring and evaluation requirements of the Health, Population, and Nutrition Sector Development Program. Its principal objective is to furnish data to program managers and policymakers for effective intervention strategy formulation and implementation. The survey aims to collect evidence on critical national indicators of social progress, encompassing fertility rates, childhood mortality rates, maternal and child health, as well as the nutritional status of mothers and children. Additionally, it assesses factors such as exposure to mass media and awareness of, and attitudes towards, communicable and non-communicable diseases.
The survey employs a population-based, cross-sectional data collection method. For the 2016 EDHS, the sample was designed to provide population and health indicators at both national and regional levels. The sample was representative of Ethiopia's 11 geographic/administrative regions and was selected using a stratified, two-stage cluster design. In the first stage, Enumeration Areas (EAs) served as sampling units, with 645 EAs selected (including 202 urban and 443 rural areas). In the second stage, households were sampled, resulting in a total of 16,650 households being selected. All women aged 15–49 years who had given birth within the five years preceding the survey and were permanent residents of the selected households were eligible for interview. Data collection utilized a structured and pretested questionnaire, and interviews were conducted in the local language 3.
The dependent variable in this study is institutional delivery service utilization, defined as women aged 15–49 years who utilized delivery services for their most recent birth. The independent variables include exposure to mass media through television, radio, newspaper, and contact with a health worker. Additionally, socio-demographic variables such as age, sex, marital status, religion, ethnic group, residence, family size, wealth index, education, occupation, experience of maternal health service, husband's education, and decision-making for maternal health service use are considered.
Data analysis was conducted using STATA version 14 software. The unit of analysis comprised women who had given birth at a health facility with the assistance of health professionals within the five years prior to the data collection period. The analysis utilized weighted data to adjust for sample design effects and non-response rates, ensuring accurate estimates of standard errors. Bivariate analysis was performed to identify associations between dependent and independent variables, with all variables having a p-value of ≤0.2 in the bivariate analysis included in the multivariable logistic model to assess the independent effect of each variable. Adjusted odds ratios (AOR) with a 95% confidence interval and a p-value < 0.05 were used to ascertain the presence of associations between dependent and independent variables.
Approximately 27.7% of the participants reported exposure to radio, followed by television at 19.6%, and newspapers at 7.1% (Table 1).
Table 1 Women exposure to mass media as a source of information about health (weighted), EDHS 2016.
Mass media | Frequency |
Percentage |
---|---|---|
Television | 1488 | 19.6 |
Radio | 2099 | 27.7 |
Newspaper | 540 | 7.1 |
Non-users | 4969 | 65.5 |
Most of the mothers (69.7%) were within 20 to 35 age group. Over half of the mothers (63.1%) had no formal education. A small percentage of mothers participated from Harari (0.23%), Gambela (0.27%), and Dire-Dawa (0.44%). The vast majority of participants (87.23%) resided in rural areas (Table 2).
Table 2 Characteristic of the women with exposure status of mass media (Weighted), EDHS 2016.
Characteristics | Number (%) | Exposed (n=2620) | Non-exposed (n=4969) | P-value* | |
---|---|---|---|---|---|
Age | <20 | 339(4.5%) | 115 | 224 | 0 |
20-35 | 5291(69.7%) | 1966 | 3325 | ||
>35 | 1959(25.8%) | 538 | 1421 | ||
Region | Tigray | 537(7.1%) | 238 | 299 | 0 |
Afar | 71(0.94%) | 23 | 48 | ||
Amhara | 1632(21.5%) | 501 | 1131 | ||
Oromia | 3129(3.5%) | 1083 | 2046 | ||
Somali | 269(3.5%) | 34 | 235 | ||
Benishangul | 81(1.1%) | 21 | 60 | ||
SNNPR | 1601(21.1%) | 497 | 1104 | ||
Gambela | 21(0.27%) | 8 | 13 | ||
Harari | 17(0.23%) | 9 | 8 | ||
Addis Abeba | 198(2.6%) | 189 | 9 | ||
Dire-Dawa | 33(0.44%) | 17 | 16 | ||
Educational status of the respondent | No education | 4791(63.1%) | 1123 | 3668 | 0 |
Primary | 2150(28.3%) | 935 | 1215 | ||
Secondary | 420(5.5%) | 343 | 77 | ||
Higher | 230(3.02%) | 220 | 8 | ||
No education | 3,346(47.07%) | 739 | 2607 | 0 | |
Educational status of the husband | Primary | 2731(38.42%) | 1004 | 1727 | |
Secondary | 613(8.62%) | 377 | 236 | ||
Higher | 419(5.89%) | 346 | 73 | ||
Number of families | <5 | 3636(47.9%) | 1423 | 2213 | 0 |
>5 | 3954(52.09%) | 1197 | 2757 | ||
Wealth Index combined | Poorest | 1651(21.76%) | 232 | 1419 | 0 |
Poorer | 1654(21.79%) | 305 | 1349 | ||
Middle | 1588(20.93%) | 429 | 1159 | ||
Richest | 1427(18.80%) | 643 | 784 | ||
Richer | 1269(16.72%) | 1011 | 258 | ||
Place of residence | Urban | 969(12.77%) | 782 | 187 | 0 |
Rural | 6621(87.23%) | 1838 | 4783 |
Residence, respondent's education level, family size, and wealth index demonstrated significant associations with exposure to mass media in the univariate analysis. The final results of the multiple logistic regression analyses indicated that mothers exposed to mass media were more likely to utilize institutional delivery services (AOR 1.25; 95% CI 1.10, 1.42). Additionally, rural residence (AOR 0.20; 95% CI 0.16, 0.25), primary school education level (AOR 1.98; 95% CI 1.76, 2.24), secondary school education level (AOR 6.12; 95% CI 4.59, 8.17), higher education level (AOR 8.21; 95% CI 4.72, 14.30), as well as poorer wealth index (AOR 1.72; 95% CI 1.44, 2.06), middle wealth index (AOR 1.97; 95% CI 1.65, 2.36), richer wealth index (AOR 2.11; 95% CI 1.76, 2.54), and richest wealth index (AOR 3.19; 95% CI 2.52, 4.03) were significantly associated with institutional delivery service utilization (Table 3).
Table 3 Influence of mass media exposure on institutional delivery service utilization using a logistic regression model (weighted)
Variables | Institutional delivery | COR with 95%CI | AOR with 95%CI | ||
---|---|---|---|---|---|
yes | No | ||||
Media exposure | Not Exposed | 1194 | 3775 | 1 | 1 |
Exposed | 1329 | 1291 | 3.26(2.94,3.60) | 1.25(1.10,1.42) | |
Educational status | No education | 1036 | 3755 | 1 | 1 |
Primary | 927 | 1222 | 2.75(2.46,3.07) | 1.98(1.76,2.24) | |
Secondary | 346 | 74 | 17.01(13.11,22.08) | 6.12(4.59,8.17) | |
Higher | 214 | 16 | 49.99(29.72,84.76) | 8.21(4.72,14.30) | |
Family size | >5 | 1452 | 2184 | 1 | 1 |
<5 | 1071 | 2882 | 1.79(1.62,1.97) | 1.20(1.07,1.34) | |
Residence | Urban | 816 | 153 | 1 | 1 |
Rural | 1707 | 4914 | 0.06(0.05,0.08) | 0.20(0.16,0.25) | |
Wealth index | poorest | 250 | 1402 | 1 | 1 |
poorer | 409 | 1245 | 1.85(1.55,2.20) | 1.72(1.44,2.06) | |
middle | 449 | 1140 | 2.21(1.86,2.63) | 1.97(1.65,2.36) | |
Richer | 485 | 942 | 2.89(2.43,3.44) | 2.11(1.76,2.54) | |
richest | 931 | 339 | 15.43(12.85,18.54) | 3.19(2.52,4.03) |
The role of mass media in influencing institutional delivery service utilization is a critical aspect of our study's discussion, shedding light on its impact on healthcare decision-making among women. Our findings reveal intriguing associations between exposure to mass media and the likelihood of opting for institutional delivery services, prompting deeper exploration of this dynamic relationship. According to our research, 27.7% and 19.6% of the respondents reported exposure to radio and TV at least once a week, respectively. These figures are notably lower compared to national data gathered by the 2011 Nepal Demographic Health Survey, which estimated that 44% of women across the country listen to the radio, and 47% watch TV at least once a week 24. This variance in exposure levels could be attributed to the greater spread of radio stations and TV channels in Nepal compared to Ethiopia.
The current study revealed that mass media had a positive impact on the utilization of institutional delivery services. These findings are consistent with other studies conducted in Ethiopia, Uganda, Bangladesh, and India, where women with access to media were more likely to use maternal healthcare services compared to those without access25-27.
Respondents from urban areas had higher odds of seeking institutional delivery compared to those from rural areas. This finding is consistent with studies conducted in various regions of Ethiopia 28,29. Possible reasons for these findings include higher levels of education among mothers in urban areas, better access to healthcare services and transportation, increased decision-making autonomy among mothers, greater awareness of pregnancy and delivery complications, and improved access to information compared to rural areas.
On the other hand, respondents' educational status—those with primary school, secondary school, and higher educational levels—showed higher odds of seeking institutional delivery compared to those with no education. This finding is consistent with studies conducted in various parts of Ethiopia, Nigeria, Pakistan, and Kenya29-37. The possible reasons for this trend could include factors such as better awareness and understanding of maternal health issues among educated individuals, improved access to healthcare services and information, increased decision-making autonomy, and greater ability to navigate healthcare systems among those with higher levels of education. Additionally, education may empower individuals to recognize the importance of seeking institutional delivery services and overcome barriers to accessing them38.
The majority of study participants in the current study resided in rural areas. In these settings, reaching all participants through health workers is challenging. Therefore, mass media emerges as the primary option to reach families and communities, disseminating messages about the importance of institutional delivery and the availability of such services in their communities. The study findings revealed evidence that mass media has a positive effect on the utilization of institutional delivery services.
A notable limitation of our study is the lack of correlation between education levels across regions and urban-rural divides in relation to wealth quintiles. Consequently, further research is warranted to explore variations across different geographic regions of Ethiopia.
Mass media, as a primary mode of information communication technology, holds significant influence over people's perceptions and behaviors. Exposure to mass media has the potential to bring about positive changes or prevent negative trends among large population groups. Our study indicates a an association between exposure to mass media and the utilization of institutional delivery services, with mothers exposed to mass media being more inclined to seek delivery at health facilities. These findings highlight the potential benefit of utilizing mass media in rural settings to promote institutional delivery service utilization in Ethiopia.
The authors would like to acknowledge Measure DHS for granting access to the 2016 DHS dataset for Ethiopia.
AOR-Adjusted Odds Ratio
CI- Confidence Interval
COR-Crude Odd Ratio
CSA- Central Statistical Agency
EAs-Enumeration Areas
EDHS-Ethiopian Demographic and Health Survey
USAID -United States Agency for International Development
Since this study involved a secondary analysis of publicly available survey data from the MEASURE DHS program, ethical approval and participant consent was not required. Permission to use the data was obtained from the DHS Program, and it was downloaded from http://www.dhsprogram.com with their authorization. The procedures for DHS public-use datasets, as approved by the Institution Review Board, ensure that respondents, households, or sample communities cannot be identified from the data. The data files do not contain names of individuals or household addresses. Therefore, ethical approval and consent to participate were not applicable to this study, as it is based on nationally representative EDHS data.
Not applicable.
The 2016 EDHS data used in this study are third-party from the Demographic and Health Surveys Program website (https://dhsprogram.com/data/available-datasets.cfm) and can be accessed following the protocol outlined in the method section.
The authors declare that they have no competing interests.
There is no funding for this manuscript.
AdN: contributes to the study design, data organization, analysis, and write-up; AmN contributes to the write-up and the overall supervision of the study from its inception. Both authors read and approved the final manuscript.
AdN is a senior Public Health researcher at Amhara Public Health Institute