'The false reporter will get a praise and the one who reported truth will be discouraged': a qualitative study on intentional data falsification by frontline maternal and newborn healthcare workers in two regions in Ethiopia

INTRODUCTION: Health Management Information Systems (HMIS) are vital to ensure accountability and for making decisions including for tracking the Sustainable Development Goals. The Ethiopia Health Sector Transformation Plan II includes preventing data falsification as a major strategic initiative and our study aimed to explore the reasons why healthcare providers intentionally falsify maternal and newborn health (MNH) data in two regions of Ethiopia. METHODS: We conducted a qualitative study in two hospitals, four health centres and their associated health posts in Oromia and Amhara regions. We conducted 45 in-depth interviews with health facility managers, quality improvement (QI) focal persons, health information technicians, MNH care providers, Health Extension Workers and QI mentors. Data were collected in local languages and transcribed in English. During analysis we repeatedly read the transcripts, coded them inductively using NVivo V.12, and categorised the codes into themes. RESULTS: Participants were hesitant to report personal data falsification but many reported that falsification is common and that they had experienced it in other facilities or had been told about it by other health workers. Falsification was mostly inflating the number of services provided (such as deliveries). Decreasing the number of deaths or reclassifying neonatal death into stillbirths was also reported. An overarching theme was that the health system focuses on, and rewards, the number of services provided over any other metric. This focus led to both system and individual level incentives for falsification and disincentives for accurate reporting. CONCLUSION: Our finding suggests that to reduce facility level data falsification policy makers might consider disentangling reward and punishments from the performance reports based on the routine HMIS data. Further studies examining the high-level drivers of falsification at regional, national and global levels and effective interventions to address the drivers of data falsification are needed

Understanding the importance of non-material factors in retaining community health workers in low-income settings: a qualitative case-study in Ethiopia.

OBJECTIVES: The motivation and retention of community health workers (CHWs) is a challenge and inadequately addressed in research and policy. We sought to identify factors influencing the retention of CHWs in Ethiopia and ways to avert their exit. DESIGN: A qualitative study was undertaken using in-depth interviews with the study participants. Interviews were audio-recorded, and then simultaneously translated into English and transcribed for analysis. Data were analysed in NVivo 12 using an iterative inductive-deductive approach. SETTING: The study was conducted in two districts each in the Tigray and Southern Nations, Nationalities and People's Republic (SNNPR) regions in Ethiopia. Respondents were located in a mix of rural and urban settings. PARTICIPANTS: Leavers of health extension worker (HEW) positions (n=20), active HEWs (n=16) and key informants (n=11) in the form of policymakers were interviewed. RESULTS: We identified several extrinsic and intrinsic motivational factors affecting the retention and labour market choices of HEWs. While financial incentives in the form of salaries and material incentives in the form of improvements to health facility infrastructure, provision of childcare were reported to be important, non-material factors like HEWs' self-image, acceptance and validation by the community and their supervisors were found to be critical. A reduction or loss of these non-material factors proved to be the catalyst for many HEWs to leave their jobs. CONCLUSION: Our study contributes new empirical evidence to the global debate on factors influencing the motivation and retention of CHWs, by being the first to include job leavers in the analysis. Our findings suggest that policy interventions that appeal to the social needs of CHWs can prove to be more acceptable and potentially cost-effective in improving their retention in the long run. This is important for government policymakers in resource constrained settings like Ethiopia that rely heavily on lay workers for primary healthcare delivery

Preterm care during the COVID-19 pandemic: A comparative risk analysis of neonatal deaths averted by kangaroo mother care versus mortality due to SARS-CoV-2 infection.

BACKGROUND: COVID-19 is disrupting health services for mothers and newborns, particularly in low- and middle-income countries (LMIC). Preterm newborns are particularly vulnerable. We undertook analyses of the benefits of kangaroo mother care (KMC) on survival among neonates weighing ≤2000 g compared with the risk of SARS-CoV-2 acquired from infected mothers/caregivers. METHODS: We modelled two scenarios over 12 months. Scenario 1 compared the survival benefits of KMC with universal coverage (99%) and mortality risk due to COVID-19. Scenario 2 estimated incremental deaths from reduced coverage and complete disruption of KMC. Projections were based on the most recent data for 127 LMICs (~90% of global births), with results aggregated into five regions. FINDINGS: Our worst-case scenario (100% transmission) could result in 1,950 neonatal deaths from COVID-19. Conversely, 125,680 neonatal lives could be saved with universal KMC coverage. Hence, the benefit of KMC is 65-fold higher than the mortality risk of COVID-19. If recent evidence of 10% transmission was applied, the ratio would be 630-fold. We estimated a 50% reduction in KMC coverage could result in 12,570 incremental deaths and full disruption could result in 25,140 incremental deaths, representing a 2·3-4·6% increase in neonatal mortality across the 127 countries. INTERPRETATION: The survival benefit of KMC far outweighs the small risk of death due to COVID-19. Preterm newborns are at risk, especially in LMICs where the consequences of disruptions are substantial. Policymakers and healthcare professionals need to protect services and ensure clearer messaging to keep mothers and newborns together, even if the mother is SARS-CoV-2-positive. FUNDING: Eunice Kennedy Shriver National Institute of Child Health & Human Development; Bill & Melinda Gates Foundation; Elma Philanthropies; Wellcome Trust; and Joint Global Health Trials scheme of Department of Health and Social Care, Department for International Development, Medical Research Council, and Wellcome Trust

Small and sick newborn care during the COVID-19 pandemic: global survey and thematic analysis of healthcare providers' voices and experiences.

INTRODUCTION: The COVID-19 pandemic is disrupting health systems globally. Maternity care disruptions have been surveyed, but not those related to vulnerable small newborns. We aimed to survey reported disruptions to small and sick newborn care worldwide and undertake thematic analysis of healthcare providers' experiences and proposed mitigation strategies. METHODS: Using a widely disseminated online survey in three languages, we reached out to neonatal healthcare providers. We collected data on COVID-19 preparedness, effects on health personnel and on newborn care services, including kangaroo mother care (KMC), as well as disruptors and solutions. RESULTS: We analysed 1120 responses from 62 countries, mainly low and middle-income countries (LMICs). Preparedness for COVID-19 was suboptimal in terms of guidelines and availability of personal protective equipment. One-third reported routine testing of all pregnant women, but 13% had no testing capacity at all. More than 85% of health personnel feared for their own health and 89% had increased stress. Newborn care practices were disrupted both due to reduced care-seeking and a compromised workforce. More than half reported that evidence-based interventions such as KMC were discontinued or discouraged. Separation of the mother-baby dyad was reported for both COVID-positive mothers (50%) and those with unknown status (16%). Follow-up care was disrupted primarily due to families' fear of visiting hospitals (~73%). CONCLUSION: Newborn care providers are stressed and there is lack clarity and guidelines regarding care of small newborns during the pandemic. There is an urgent need to protect life-saving interventions, such as KMC, threatened by the pandemic, and to be ready to recover and build back better

Level and correlates of disrespect and abuse among newborns in selected public hospitals of Addis Ababa, Ethiopia

Abstract Background The provision of respectful and dignified maternal and newborn care is an important component of the quality of childbirth care. Although a growing body of evidence was generated on disrespect and abuse (D&A) of women during childbirth in the past decade there is limited evidence on D&A experienced by newborns. Our study aimed to determine the level of and factors associated with D&A among newborns. Methods We conducted the study in three public hospitals in Addis Ababa. We directly observed childbirth care starting from the first stage of labor through two hours after the birth of 498 mother–baby dyads. We used frequencies and percentages to describe different forms of D&A among newborns. We used binary and multivariable logistic regression analysis to assess the association between the D&A among newborns and independent variables. Result All of the newborns 496/496 (100%) experienced at least one form of D&A. Physical abuse was experienced by 41.1% of newborns in the form of unnecessary airway suctioning (23.2%) or slapping or holding upside down (33.5%). Additionally, 42.3% weren’t dried immediately after birth, 9.1% weren’t placed on the mother’s abdomen skin-to-skin, 61.7% had their cord cut before 1 min of birth, 34.9% weren’t breastfed within an hour of birth, 24.2% didn’t receive vitamin K and 1.8% didn’t receive tetracycline. All newborns who developed complications (69/69) received treatments without the consent of parents/caregivers. Moreover, 93.6% of parents/caregivers didn’t receive explanations regarding newborn care while the lack of breastfeeding counseling and thermal support during the immediate post-partum period was 87.3%. The likelihood of D&A was higher among newborns who were preterm (AOR = 2.02; 95% CI: 1.11–3.69), female (AOR = 2.01; 95% CI: 1.37–2.95), delivered assisted by instrument (AOR = 2.19; 95%CI: 1.20–3.99), whose mothers reside in rural areas (AOR = 1.97; 95%CI: 1.22–3.20), born from unmarried mothers (AOR = 2.77; 95%CI (1.26–6.06) and whose mothers received fewer than four-time antenatal care (ANC) visits (AOR = 2.37; 95%CI: 1.42–3.96). Conclusion Our study found a high magnitude D&A among newborns. Gestational age at birth, sex of the newborn, maternal residence, maternal marital status, number of ANC visits, and mode of delivery were statistically significantly associated with D&A among newborns

Health system barriers to the first dose of measles immunization in Ethiopia: a qualitative study

Abstract Background Ethiopia has made considerable progress toward measles elimination. Despite ongoing efforts, the country remains among those with the highest number of children missing their initial dose of measles vaccine, and the disease continues to be a public health emergency. The barriers within the health system that hinder the first dose of measles immunization have not been thoroughly investigated. This study aims to identify these barriers within the Ethiopian context. Methods Qualitative research, using purposive expert sampling to select key informants from health organizations in Addis Ababa, Ethiopia was employed. We conducted in-depth face-to-face interviews using a semi-structured interview guide. A thematic analysis based on the World Health Organization’s health systems building blocks framework was conducted. Results The study uncovered substantial health system barriers to the uptake of the first dose of the measles vaccine in Ethiopia. These barriers include; restricted availability of immunization services, vaccine stockouts, shortage of cold chain technologies, data inaccuracy resulting from deliberate data falsification or accidental manipulation of data, as well as data incompleteness. Conclusion Our research highlighted significant health system barriers to MCV1 immunization, contributing to unmet EPI targets in Ethiopia. Our results suggest that to accelerate the country towards measles elimination, there is an urgent need to improve the health systems components such as service delivery, information systems, as well as access to vaccine and cold chain technologies

Motivation questions included in survey, source, and domain from April 15–May 10, 2018.

Motivation questions included in survey, source, and domain from April 15–May 10, 2018.</p

Questionnaire used for data collection in ODK file was prepared in both local (Amharic) and English language.

(XLSX)</p

Table A1.

Results from ordered logit model showing factors associated with overall motivation among participants form four regions April 15- May10, 2018. (PDF)</p