2019 Cross Sectional

Performance Monitoring for Action Ethiopia (PMA Ethiopia) builds on the previous success of PMA2020/Ethiopia and PMA Maternal and Newborn Health study in the Southern Nations, Nationalities and Peoples Region (SNNP). PMA Ethiopia is a five-year project implemented in collaboration with Addis Ababa University, Johns Hopkins University, and the Federal Ministry of Health. It measures key reproductive, maternal and newborn health (RMNH) indicators.  

Cross-sectional data, including a health facility-based survey, are collected annually in all regions. Longitudinal data (following pregnant women through one year postpartum) are collected in two cohorts of women (2019-2021 and 2021-2023) in four large, predominantly agrarian regions: Tigray, Oromiya, Amhara, and Southern Nations, Nationalities, and Peoples’ Region, and one urban region, Addis Ababa. Afar is included in the first cohort (2019-2021) of the longitudinal survey. 

PMAET 2019 Cross-sectional survey used a two-stage cluster design with urban-rural, and major regions as strata, sampling across all 11 geographical regions in Ethiopia. A total of 265 enumeration areas (EAs) selected from the master sample frame of the Central Statistical Agency.  

A census of all households within selected EAs was done in the panel survey regions:  Tigray, Oromiya, Amhara, SNNP, Addis Ababa, and Afar. This census served as the sampling frame for both cross-sectional survey and identification of women for panel survey. The census will again be conducted in year three of the five-year PMA survey period. A standard household listing, which involved identification of all households but no generation a complete list of household participants, was conducted in non-panel survey regions: Dire Dawa, Harare, Somali, Benishangul-Gumuz, and Gambella. This household listing served as the sampling frame in the non-panel regions and is planned to be updated bi-annually. 

After completion of census/household listing, a cross-section of 35 households were randomly selected from within each enumeration area. All women age 15-49 years in the selected households were eligible for the cross-sectional survey. Facilities were selected based on whether the EAs selected for the household sample fall within their catchment area. All public SDPs that served the EAs and up to 3 private facilities were also selected for each EA.  

The final sample for cross-sectional survey was designed to provide regional level estimates of modern contraceptive prevalence rate (mCPR) among all women with a 5% margin-of-error or less.  

PMA uses standardized questionnaires to gather data about households, individual females and health facilities that are generally comparable with other existing national surveys. Prior to launching the survey in each country, local experts review and modify these questionnaires to ensure all questions are appropriate to each setting. Three questionnaires were used to collect PMA Ethiopia 2019 Cross-sectional survey data: the household questionnaire, the female questionnaire, and service delivery point questionnaire. 

The household questionnaire gathers basic information about the household, such as ownership of livestock and durable goods, as well as characteristics of the dwelling unit, including wall, floor and roof materials, water sources, and sanitation facilities. This information is used to construct a wealth quintile index. The household questionnaire also captures age, sex, and marital status for all usual members of the household or visitors who slept in the household the night before.   

The female questionnaire gathers specific information on education, migration; fertility and fertility preferences; family planning access, choice and use; empowerment; quality of family planning services; and exposure to family planning messaging in the media. In addition, the female questionnaire gathers data from women who were pregnant and recently postpartum women on key indicators of maternal health such as receipt and quality of antenatal care and delivery experience.  

The service delivery point questionnaire gathered the information on infrastructure and staffing, in addition to questions that focus on commodity availability and provider readiness. Facility questions cover the range of commodities and services provided in the RMNH continuum, including, to family planning services.  

All PMA questionnaires are administered using Open Data Kit software and Android smartphones. The PMA Ethiopia questionnaires appeared in the three local languages (Amharic, Afan, Oromo, and Tigrigna), in addition to English. The questionnaires were translated using available translations from similar population surveys and experts in translation. The interviews were conducted in the local languages.  

Training 

The PMA Ethiopia fieldwork training started with a training of the entire field staff. The trainings started with a training of trainers (TOT)was held from July 31st to August 3rd 2019 in Addis Ababa. This was followed by a series of resident enumerator (REs) trainings from August 20th to September 7, 2019. The trainings were led by staff PMA staff from the Bill & Melinda Gates Institute for Population and Reproductive Health and Addis Ababa University.  

Throughout the trainings, all field staff were evaluated based on their performance on several written and phone-based assessments and class participation. All training participants were given in-depth instructions on survey protocols, the questionnaires and guidance for conducting interviews using an Android phone.  

The resident enumerator training was conducted primarily in Amharic, whereas some small group sessions were conducted in Afan, Oromo, and Tigrigna. 

Data Collection & Processing 

Data collection was conducted between October and December 2019. Unlike traditional paper-and-pencil surveys, PMA uses Open Data Kit (ODK)Collect, an open-source software application, to collect data on mobile phones. All the questionnaires were programmed using this software and installed onto all project smartphones. The ODK questionnaires are programmed with automatic skip-patterns and built-in response constraints to reduce data entry errors. 

The ODK application enabled REs and supervisors to collect and transfer survey data to a central ODK Aggregate cloud server. This instantaneous aggregation of data also allowed for concurrent data processing and course corrections while PMA was still active in the field. Throughout data collection, the central staff at AAU in Ethiopia and the data manager at the Bill & Melinda Gates Institute at Johns Hopkins in Baltimore, Maryland routinely monitored the incoming data and notified field staff of any potential errors, missing data or problems found with form submissions on the central server. 

The use of mobile phones combined data collection and data entry into one step; therefore, data entry was completed when the last interview form was uploaded at the end of data collection in December. 

Once all data were on the server, data analysts cleaned and de-identified the data, applied survey weights and prepared the final data set for analysis using Stata® version 14 software. 

REs in each enumeration area (EA) administered the household and female questionnaires in the selected households, and the SDP questionnaire for sampled private SDPs.  

The field supervisors administered the SDP questionnaire at all public SDPs that serve each EA; the lowest, second lowest and third lowest-level public health SDPs (health post, health center, and district hospital) designated to serve each EA population. 

In PMAET 2019 cross-sectional survey, a total of 9,254 households were selected to participate in the survey and of these households 9,196 were found to be occupied at the time of the fieldwork. Of the occupied households, 9,108 consented to and completed a household-level interview. The response rate for the household level was higher in the rural (99.5%) relative to the urban (98.4%) EAs.  

In the occupied households that completed the interviews, a total of 8,975 eligible women aged 15 to 49 years were identified. Overall, 98.5% of the eligible women were available, consented to and completed the female questionnaire. The female response rate was higher in the rural (98.8%) relative to the urban (98.0%) EAs. Only de facto females are included in the cross-sectional analyses. The final completed de facto female sample size was 8,837.   

The final service delivery point (SDP) sample included 817 facilities, of which 800 (97.9%) completed the interviews.  

Weights were adjusted for non-response at the household and individual levels and applied to all household and individual estimates in this report. SDP estimates are not weighted. 

To view the sample errors for the PMA indicators described above, download the full SOI report here. For more information about PMA indicators, including estimate type and base population, click here.