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Results All research participants expressed a preference for facility based delivery because of their awareness of obstetric complications, and related perceptions that facility-birth is safer for the mother and child. Dimensions of quality of care and the cost of services were identified as influencing decisions about whether to seek care in the public or private sector. Media campaigns, information from social networks and women’s experiences with healthcare providers and facilities influenced care-seeking decisions. Facility-based delivery is one of the proven interventions to reduce maternal and neonatal morbidity and mortality [ ]. In recent years the government of Ethiopia has established different approaches to increase facility based births, and reduce maternal mortality. Primary among them has been the expansion of health facilities that offer basic delivery services (vaginal birth for low risk women) to improve the proximity of maternal services, and instituting measures to ensure all maternal services (including obstetrical delivery, and where available, neonatal intensive care) in the public sector are free. While the geographic distribution of these facilities is uneven, it is estimated that almost all residents of Addis Ababa live within a five kilometer radius of a health facility that provides delivery services [ – ].

Urban Ethiopian women are significantly more likely than rural women to deliver in a health facility (54% versus 4%), and women living in Addis Ababa have the highest national percentage of institutional delivery, which was 82% in 2011 [, ]. As interventions to reduce the geographic and financial barriers to facility based maternal care are implemented across the country, it is important to understand the factors that have facilitated women’s decision to give birth in health facilities (hospitals or health centers). There is substantial evidence on why Ethiopian women do not deliver in facilities, including evidence that home based deliveries are considered normal, distance to health facilities is a barrier, and a lack of decision making power among pregnant women [ ]. A number of studies have identified social and demographic factors that are associated with increased facility-based delivery in Ethiopia. Being an urban resident, primipara status, antenatal care (ANC) attendance during the last pregnancy, women and their husband’s having secondary education or more and women’s knowledge about pregnancy and delivery services have been associated with facility-based delivery service utilization [ – ]. This study identified women’s reasons for seeking a facility-based birth in a population that tends to give birth in hospitals or health centers, and captured their perceptions of the quality of care they received during their most recent birth.

Increased understanding of the reasons women in Addis Ababa choose to deliver in facilities, how they select these facilities and their experiences of care can contribute to developing strategies to improve the uptake of facility-based maternity services. Thus, these findings may contribute to the development of interventions to promote increased uptake of facility-based maternal services in other regions of the country, and corresponding declines in maternal mortality and morbidity. Study setting This study was conducted in public health facilities that provide childhood immunization services. The government health centers that were sampled in this study, are part of the St. Paul’s Millennium College Hospital referral network, in Addis Ababa, Ethiopia. According to EDHS 2011, the total fertility rate was 1.5 children per woman in Addis Ababa [ ]. Study design, participants and sampling procedure A qualitative study was undertaken to understand the factors that have contributed to a woman’s choice to deliver in a health facility and her perception of the quality of care provided.

In 2009/10, the Ethiopian government started providing free antenatal care, delivery and postnatal in all public health centers. In Ethiopia, the first vaccination is normally scheduled at six weeks after birth.

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Postnatal women attending the first routine vaccination for their last born child (index child) in the study period from each of the participating urban health facilities in Addis Ababa were invited to participate. A purposive sampling procedure was used to identify women who were first time mothers as well as women who had had more than one birth from each health facility participating in the study. Sample size was determined using the principle of “saturation”—women were asked to participate in interviews until additional interviews did not provide additional evidence about the main themes of interest [ ]. In-depth interviews were conducted to gather information on personal experiences with seeking facility based care. Interviews were conducted by five researchers with graduate level training in qualitative methods. Informed consent was obtained from all respondents. Interviews were conducted using a semi-structured interview guide, which was prepared in Amharic (local language).

On average interviews took about 30 min. Each woman completed only one interview, but interviews were conducted during two time periods (August and December 2013). This allowed data collection and analysis to inform each other mutually [ ]. Analysis of the first round of data collection allowed for identification of themes and gaps in the information which were explored in greater depth during interviews conducted during the second period of data collection. Data analysis The tape recorded interviews were transcribed in Amharic and translated into English by the researchers. The translated data were exported into Open Code software to facilitate coding and analysis. Each translated document was coded line-by-line to flag ideas and statements related to the study objective, and then codes were grouped to identify themes that were related to the factors that influence women’s decision to seek institutional delivery.

A priori themes were coded based on the study objectives and emergent themes were identified based on the narratives of research participants. Ethical considerations Addis Continental Institute of Public Health ethical review board approved the study. Written informed consent was sought from each participant before the interview began, and after explaining the purpose of the study. The decision to participate in the study was not linked to the service participants were entitled to obtain. Written consent was archived at the Addis Continental Institute of Public Health data management unit.

All participants received a unique identification number that was used on the recorded interviews, on the transcripts and also during publication. The entire interview was recorded, and after transcription, the cassette was discarded. Access to the raw data was limited only the research team members. To ensure privacy, all interviews were conducted in a private room within the health facility. Eighteen women were invited to participate and 16 accepted. Two women refused to participate due to their busy schedule. Fifteen out of sixteen of the participants were married.

The mean age of the participants was 27 years with a standard deviation (SD) of 4.08 years. The mean parity of the participants were 2.06 with a SD of 1.39. Four women delivered via C-section; the other twelve had vaginal births.

Ten women delivered in public facilities (health center or hospital), five delivered in private facilities and one delivered at home (Table ). This research suggests that facility-based childbirth is a preferred norm in Addis Ababa, indicating that sociocultural barriers to facility delivery that have been identified as important in other Ethiopian settings can be overcome [,,, – ]. Overall, women in this study had been convinced, through media campaigns and interactions with the health system, that facility based births were best for both the mother and the child. This study supports findings from other studies that suggest that having access to information through modern media influences women’s knowledge about delivery risks and availability of services [ ]. In addition to media reports about complications, women explained that they selected particular facilities because of their own and their family and friends’ experiences [, ]. This suggests that in Addis Ababa, social networks are important sources for information for decision-making. Women identified cleanliness and respectful, supportive provider attitudes as important pull factors.

These findings complement other research with Ethiopian women that has identified poor patient-provider interactions as a barrier to seeking facility-based delivery [ ]. In this study, women’s reports of experiencing disrespect and abuse were rare, with only one woman identifying that she had been abused. This is another encouraging improvement, as the government expands access to affordable and acceptable facility delivery for all women [, ]. In other studies, cost has been cited as a clear barrier to women seeking facility based care [, ].

The Ethiopian Government’s efforts to ensure free maternal services in public facilities appears to be working; participants who delivered in the public sector health facilities stated that previously they paid some amount of money during ANC, delivery and postnatal care, and now they didn’t pay anything. Women also expressed that this encouraged women to seek care in public facilities. This finding agrees with other research that has associated insurance coverage and fee exemptions with higher facility-based delivery rates [, ]. Bluesoleil Crack Windows 7. Studies have shown that women report better quality of care in private facilities, but that cost can be a deterrent [ ]. It is encouraging that when many women, who participated in this study, compared the quality of care received at public and private institutions they noted that there was no real difference, except cost.

However, for other women better perceived quality of intrapersonal care was a motivating factor for women to deliver in private facilities. Limitations Our sample consisted of women and children who survived birth. It has been shown that poor quality of care impacts maternal and child survival [, ], so our data may be biased towards higher quality of care. Also our respondents were invited to participate at child vaccination clinics, which may indicate that they are more aware or more compliant with health education campaigns and advice given by healthcare providers than other women, and thus may have more positive perceptions of facility-based birth [, ].

Additionally the small number of respondents limits the generalizability of the study findings beyond similar groups of urban women. In this urban setting, facility-based childbirth has become a preferred norm. Women noted fear of obstetric complications and awareness of free delivery services because of media campaigns as primary motivations for seeking facility-based care. This study also highlighted that information gathered from social networks and women’s own experiences with health facilities and healthcare providers before delivery were important for determining where women sought labor and delivery services. Cleanliness, respectful care from providers and cost were key factors identified by women as influencing their decisions and perceptions of quality of care. This suggests that the Ethiopian Government’s efforts to expand access to services by improving infrastructure and removing financial barriers to facility based care must be complemented by efforts to ensure that the care accessed by women is acceptable and of high quality.

The importance of social networks and women’s experiences with healthcare facilities and providers prior to delivery for influencing where they chose to give birth suggests that creating opportunities for women and other community members to appreciate the increasing availability and quality of maternity care by visiting facilities could be effective for promoting facility-births as a preferred norm in other areas of Ethiopia. Acknowledgments We would like to acknowledge the mothers who agreed to participate in this study. This project was supported by the Maternal Health Task Force at the Harvard T. Chan School of Public Health through Grant #1 from the Bill & Melinda Gates Foundation. Tamil Kendall’s postdoctoral fellowship was supported by the Canadian Institutes of Health Research and the Maternal Health Task Force.

We would also like to acknowledge the support this project has received from the FMOH and the AARHB.

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-- Regards Bob Peel, Microsoft MVP - Money For UK tips & fixes see. For wishes or suggestions see or for UK wishes I do not respond to any emails that I have not specifically asked for. 'Eric' wrote in message news. >Can anyone help? >I keep getting the message >'you cannot perform this operation at the moment. There is an online >operation in progress, Please try again later' >when ever I try to archive.

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>>M2005 does a lot of things in background so it can take a while to shut >everything down. >>-- >Regards >Bob Peel, >Microsoft MVP - Money >>For UK tips & fixes see >. >For wishes or suggestions see >>or for UK wishes >>I do not respond to any emails that I have not specifically asked for. >>'Eric' wrote in message >news. >>Can anyone help?

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-- Regards Bob Peel, Microsoft MVP - Money For UK tips & fixes see. For wishes or suggestions see or for UK wishes I do not respond to any emails that I have not specifically asked for. 'Eric' wrote in message news. >Thanks Bob >The version is 14.0.120.730 >Thanks for the advice.

>>>'Bob Peel MVP' wrote: >>>Do you mean archive or backup? If the former I strongly suggest you >>don't - >>>>>>However the on-line operation is either Money trying to download a large >>patch or trying to update share/currency prices. If you do Help >About >>what >>version no do you get? If it is 14.0.*.1105 then you do have the latest >>version so it must just be downloading share prices etc. >>>>M2005 does a lot of things in background so it can take a while to shut >>everything down. >>>>-- >>Regards >>Bob Peel, >>Microsoft MVP - Money >>>>For UK tips & fixes see >>. >>For wishes or suggestions see >>>>or for UK wishes >>>>I do not respond to any emails that I have not specifically asked for.

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>>-- >Regards >Bob Peel, >Microsoft MVP - Money >>For UK tips & fixes see >. >For wishes or suggestions see >>or for UK wishes >>I do not respond to any emails that I have not specifically asked for.

>>'Eric' wrote in message >news. >>Thanks Bob >>The version is 14.0.120.730 >>Thanks for the advice. >>>>>>'Bob Peel MVP' wrote: >>>>>Do you mean archive or backup? If the former I strongly suggest you >>>don't - >>>>>>>>>However the on-line operation is either Money trying to download a large >>>patch or trying to update share/currency prices.

If you do Help >About >>>what >>>version no do you get? If it is 14.0.*.1105 then you do have the latest >>>version so it must just be downloading share prices etc. >>>>>>M2005 does a lot of things in background so it can take a while to shut >>>everything down.

>>>>>>-- >>>Regards >>>Bob Peel, >>>Microsoft MVP - Money >>>>>>For UK tips & fixes see >>>. >>>For wishes or suggestions see >>>>>>or for UK wishes >>>>>>I do not respond to any emails that I have not specifically asked for. >>>>>>'Eric' wrote in message >>>news. >>>>Can anyone help? >>>>I keep getting the message >>>>'you cannot perform this operation at the moment. There is an online >>>>operation in progress, Please try again later' >>>>when ever I try to archive. I am on broadband, but I do not want to go >>>>online with Money.

>>>>>>>>-- >>>>Thanks >>>>Eric >>>>>>>>>>>>>>>. Glad to hear that you've got there! -- Regards Bob Peel, Microsoft MVP - Money For UK tips & fixes see.

For wishes or suggestions see or for UK wishes I do not respond to any emails that I have not specifically asked for. 'Eric' wrote in message news. >Thanks Bob >Sorted, I noticed that my firewall was also restricting Money's web >access. >Now this is sorted, everythings ok. >Thanks again for your help. >>'Bob Peel MVP' wrote: >>>OK it is definitely trying to download the latest patch - which you do >>really need! >>>>You should load Money and open the sample.mny file (it's usually in the >>same >>directory as your 'real'.mny file) and let the download happen.

>>>>Depending on your connection it may take a while. >>>>-- >>Regards >>Bob Peel, >>Microsoft MVP - Money >>>>For UK tips & fixes see >>. >>For wishes or suggestions see >>>>or for UK wishes >>>>I do not respond to any emails that I have not specifically asked for. >>>>'Eric' wrote in message >>news.

>>>Thanks Bob >>>The version is 14.0.120.730 >>>Thanks for the advice. >>>>>>>>>'Bob Peel MVP' wrote: >>>>>>>Do you mean archive or backup? If the former I strongly suggest you >>>>don't - >>>>>>>>>>>>However the on-line operation is either Money trying to download a >>>>large >>>>patch or trying to update share/currency prices. If you do Help >>>>>About >>>>what >>>>version no do you get? If it is 14.0.*.1105 then you do have the >>>>latest >>>>version so it must just be downloading share prices etc.

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