Quality of Care in Family Planning Services in Ethiopia

Background Annually approximately 303,000 maternal deaths occurred globally in 2015, of which 99% occurred in Low-and Middle-income countries (LMIC). Estimates suggest that Ethiopia is one of the ten countries that account for about 60% of these maternal deaths. Studies demonstrate that use of Family Planning (FP) can contribute to reducing maternal deaths. While a proportion of women are using FP services, more than 214 million reproductive aged women in LMIC who desired to avoid or postpone pregnancy are not using any modern contraceptive methods. This trend in the use of FP services is also found in Ethiopia. Along with socio-demographic and cultural factors, the quality of care in FP services has been shown to influence the use of FP services. However, few studies have been conducted on the quality of care in FP services in Africa, and little evidence has been reported on the factors determining quality of care in FP services. While a few small studies that have assessed quality of care in FP services in Ethiopia, no study has identified systematically the factors associated with quality of care or the influence of facility type on quality of care. Aim The overall aim of the study is to identify the determinants and differences in quality of care in FP services. The overall study consisted of four interrelated studies each with their own inter-related but specific aim. These were: to assess and explore factors associated with quality of care in FP services in Africa (Study 1); to identify the client and facility-level determinants of quality of care in FP services in Ethiopia (Study 2); to compare the quality of FP services in private and public primary health care facilities and users’ characteristics of these facilities (Study 3), and since the use of FP guidelines was a factor in quality of care, the last study’s aim was to understand provider perspectives on barriers to and facilitators for FP guidelines use in FP services (Study 4). Methods This study employed a mix of study designs using three different methods and analytic approaches. Firstly, informed by a published systematic review protocol, a systematic review was conducted to evaluate the best available evidence on factors affecting the quality of care in FP services in Africa (Study 1). The systematic review included studies published between 1990 and 2016 in English. Quantitative studies reporting on factors affecting quality of care and qualitative studies exploring client and provider experiences and/or perceptions of the factors that determine quality of care in FP services were considered for inclusion in the review. For quantitative studies, client satisfaction was used as a measure of quality of care and was assessed in three ways: First, it was assessed using proxy questions reflecting client satisfaction on a range of issues such as waiting time, privacy for not being seen or heard by others, cleanliness of the facility, and costs of the services. Then clients’ responses for these questions were aggregated into a single variable using principal component analyses to create a measure either as a continuous or binary outcome in terms of satisfied or not satisfied; Secondly, using a likert scale in ten categories with the higher scale indicating greater satisfaction and then creating a binary variable using the mean as a cutoff point (i.e those who scored below the mean regarded as less satisfied while those who scored equal to or above the mean regarded as highly satisfied). Thirdly, using client’s overall satisfaction and then creating a binary outcome comprising satisfied or not satisfied. I performed separate synthesis of the two evidence types: the quantitative data were summarised in narrative and tables; the qualitative findings were synthesised using meta-aggregation. Secondly, informed by the findings of the systematic review, I conducted a quantitative analysis of secondary data (Study 2 and 3). More specifically, for Study 2, a multilevel mixed-effects modelling was conducted using the Ethiopian Services Provision Assessment (ESPA+) 2014 data to identify the client and facility-level determinants of quality of care in FP services as measured by client satisfaction in Ethiopia. In the analysis, while client and facility-level variables were considered as independent variables, client satisfaction was considered as an outcome variable. Client satisfaction was measured using clients’ exit interview responses to questions about the health service quality, assessed by the problems encountered by clients during their visit to health facilities for FP services. Clients’ responses on eleven questions that reflect clients’ perceptions of the quality of FP services were aggregated into an index using principal component analysis. Then, the aggregated index was dichotomised using the median score as cutoff point. Finally, a binary outcome of client satisfaction was devised as “more satisfied” if a score was greater or equal to the median cutoff point, and as “less satisfied” if a score was less than the median cutoff point. For Study 3, a combination of facility-based data from the ESPA+ 2014 dataset and community-based data from the Ethiopian Demographic and Health Survey (EDHS) 2016 dataset were employed. In the analysis, structural variables that reflected the material structure such as facility’s infrastructure (basic amenities) and availability of equipment and supplies and human resources such as health provider availability and trained provider availability were compared in public versus private primary health care facilities. The structural variables that reflected organisational structure such as presence of a quality assurance system and supervision in the past six months, availability of FP guidelines/protocols, and availability of a range of modern contraceptive methods were also compared in public versus private primary health care facilities. Survey logistic regression analysis was conducted to compare the structural quality of services, and a chi-square test was used to compare the characteristics of clients’/users’ who accessed FP services from these facilities. In Study 4, qualitative method was used to understand health providers’ perspectives on the use of FP guidelines in FP services. This study used in-depth interviews guided by a semi-structured interview guide. Twenty one participants were recruited from nine health facilities including two hospitals, five health centres, and two health posts in Gondar and Bahir Dar City administrations, Amhara region, Northwest Ethiopia. The audio-recorded interviews and notes taken were translated and transcribed into English by the lead author and entered into NVivo 11TM for data analysis and management. Thematic analysis according to the approach described by Braun and Clarke was employed for data analysis. Results In Study 1, the systematic review found few studies (eight quantitative studies and three qualitative studies) had been undertaken in a small proportion of African countries. While the quantitative studies were undertaken in Egypt, Kenya, Senegal, Ethiopia, Ghana, Tanzania, Namibia, the qualitative studies were undertaken in Kenya and Uganda. The studies were performed between 1995 and 2016. The limited evidence, assessed as being moderate to high quality suggested that quality of care in FP services was influenced by a range of client, provider and facility factors, as well as structural and process aspects of the facilities. Amongst the process factors, shorter client waiting time, presence of competent healthcare providers, provision/prescription of injectable methods, maintenance of privacy, and confidentiality were the most commonly identified factors positively associated with quality of care in FP services. For factors related to structure, good quality of stock was the most commonly identified factor positively associated with quality of care in FP services. In terms of the facility related factors, quality of care was associated with facility ownership in that privately-owned facilities and availability of FP guidelines were positively associated with better quality of care. The qualitative component of the systematic review pointed to additional factors associated with quality of care in FP services including access related factors such as ‘pre-requisites to be fulfilled by the clients and cost of services, provider workload, and providers’ behaviour. In Study 2, while both client and facility-level factors were shown to be associated with quality of care in FP services in Ethiopia, nearly one-third (32.8%) of the differences in the quality of care were attributed to the health facility level factors. At the client-level; provision of information on potential side effects of contraceptive method and number of history and physical assessments performed were positively associated with client satisfaction, long client waiting times (between 30 minutes to two hours) was negatively associated with client satisfaction. At the facility-level; facilities being in an urban location, and having FP guidelines/protocols for their providers were positively associated with client satisfaction. In Study 3, private health facilities appear relatively more deficient in terms of some important aspects of structural aspects of quality of services such as availability of trained staff, access to FP guidelines/protocols and access to a range of contraceptives than public health facilities. Private health facilities are better equipped with basic infrastructure component of the structural quality of services such as functional cell phones and water supply and equipment than public health facilities. Women who accessed FP services from private facilities were different from those who accessed these services in public facilities. They were more likely to reside in an urban area, to be Muslim, have a job, and have no or fewer number of children than women accessing FP services from public health facilities. In Study 4, healthcare providers identified a number of barriers affecting use of FP guideline. These included: lack of knowledge and lack of or inadequate access to guideline; lack of up-to-date information in the guideline, providers’ behaviour including limited reading of literature including clinical guidelines and religious beliefs/values against FP services provision; lack of support and supervision from managers; insufficient health workforce; and lack of or inadequate training about FP guideline. Healthcare providers also identified a few facilitators to FP guideline use including ease of access; managers who championed their use; and provision of training about FP guideline. Conclusion Overall, the findings showed that quality of care in FP services was influenced by multiple factors related to FP services clients, healthcare providers, and the health facility characteristics. In Ethiopia, the factors affecting quality of care in FP services were related to structure and process of care provision. The findings have also indicated that the structural quality of services in FP services were different between public and private health facilities. Moreover, the findings demonstrated the characteristics of women accessing FP services in private facilities were different from the characteristics of women accessing FP services in public facilities. The findings have also pointed to a set of factors affecting use of FP guidelines including lack of knowledge and lack of or insufficient access to the guidelines, providers’ personal religious beliefs, relying on prior knowledge and tradition rather than protocols and guidelines, insufficient health workforce, and lack of support from managers, and inadequate training on use of guidelines. These results provide important evidence for policy makers and stakeholders to develop effective strategies to help to further improve the quality of care in FP services in Ethiopia and thereby improve the uptake of FP services in that country. Moreover, the results showed that actions are needed at different levels targeting health systems and health facilities. Further studies are also required to explore the healthcare providers’ and managers’ views of factors affecting quality of care in FP services. Strengths of the study The thesis has a number of strengths. The thesis employed multiple but interrelated study deigns including systematic reviews, secondary data analysis, and qualitative interviews. The thesis examines determinants of quality of care from broader (Africa-level) to specific geographic locations (Amhara region). The thesis uses nationally representative datasets obtained from surveys conducted using standardised methodologies and data collection instruments. The qualitative study explored the barriers and facilitators of FP guidelines use for the first time in Ethiopia. Unique contributions of the thesis The findings of thesis has several contributions for policy and further research. In terms of policy implications, the thesis suggests that improving quality of care in FP services in Ethiopia and other LMIC requires improving structural and process components of quality of care. Moreover, it was found that structural components of quality of care could influence not only the outcome of quality of care but also the process of care provision in FP services. The thesis also suggests that, with its limitations, the Donabedian model of quality of care can serve as a lens through which quality of care in FP services could be measured. In terms of further research, the thesis indicates that: 1) exploring factors affecting quality of care from health providers and health managers’ viewpoint as it is useful to identify additional factors related to the healthcare system, 2) further studies are needed to explore how structural and process components of quality of care affecting long term outcomes of quality of care such as reduction in fertility and maternal mortality.Thesis (Ph.D.) -- University of Adelaide, School of Public Health, 201

The role of family planning counselling during maternal and child health services in postpartum modern contraceptive uptake in Ethiopia: A national longitudinal study

Family planning counselling can help improve the postpartum modern contraceptive uptake. However, studies in Ethiopia indicate inconsistent effects of integrated family planning counselling on postpartum modern contraceptive uptake. This study aimed to determine the extent of family planning counselling and its role in improving postpartum contraceptive uptake among women in Ethiopia. We used the Performance Monitoring for Action (PMA) Ethiopia panel survey data, a community-based prospective cohort study. Randomly selected pregnant women were recruited at the baseline interview and followed by six weeks and six months postpartum. A weighted generalised linear model fitted with a Poisson distribution and a log link function was used to estimate the adjusted relative risk (aRR) and 95% Confidence Interval (CI) of modern contraceptive uptake. The coverages of family planning counselling provision during ANC, prior to discharge and child immunisation were 20%, 27% and 23%, respectively. The modern contraceptive uptakes by six weeks and six months postpartum were 18% and 36%, respectively. Family planning counselling prior to discharge from the facility was associated with increased modern contraceptive uptake by six weeks (aRR 1.25; 95% CI 0.94, 1.65) and six months postpartum periods (aRR 1.07; 95% CI 0.90, 1.27). Moreover, women who received family planning counselling during child immunisation were 35% more likely to use modern contraceptives by six months postpartum (aRR 1.35;95% CI 1.12, 1.62). However, counselling during ANC visits was not associated with modern contraceptive uptake by either six weeks or six months postpartum. A significant proportion of women had missed the opportunity, and the postpartum modern contraceptive uptake was low. Despite these, family planning counselling prior to discharge from the facility and during child immunisation improved the postpartum modern contraceptive uptake. However, our finding revealed insufficient evidence that family planning counselling during ANC is associated with postpartum modern contraceptive uptake

Condom utilization and sexual behavior of female sex workers in Northwest Ethiopia: A cross-sectional study

Introduction: Sexually transmitted infections are among the most important public health problems in the world. People who indulge in unsafe sex, such as female sex workers are the most at risk population groups due to multiple sexual partners and inconsistent condom use. The aim of this study was to assess condom utilization and sexual behavior of female sex workers in Gondar town, Northwest Ethiopia. Methods: A quantitative cross-sectional study triangulated with qualitative method was conducted from March 20 - April 10, 2014 in Gondar town. The quantitative data were collected through interviewing 488 female sex workers while in-depth interview was administered to collect qualitative data from 10 female sex workers. The collected data were entered into EPI-INFO version 3.5.3 and exported to SPSS version 20.0 software for analysis. Logistic regression analysis was done to determine the association between condom utilization and independent variables. Results: This study revealed that less than half (47.7%) of the respondents utilized condom with any type of client. Secondary education or above, perceiving themselves at risk of HIV/AIDS infection, having awareness that sexually transmitted infections could increase HIV infection, being tested for HIV/AIDS in the last 12 months, and having lower number of clients in a month were positively associated with condom utilization. Conclusion: This finding depicted that condom utilization was low among female sex workers. Thus, developing and implementing target oriented behavioral change and communication strategies are needed to prevent the risk of acquiring HIV/AIDS and other sexually transmitted infections in female sex workers.Keywords: Female sex worker, Condom utilization, AIDS, STIs, Ethiopi

Bias in exposure-outcome associations when using left truncated birth datasets.

Objectives Restriction to the analysis of births that survive past a specified gestational age (typically 20 weeks gestation) can lead to biased exposure-outcome associations. The objective is to estimate the influence of bias resulting from using a left truncated dataset to ascertain exposure-outcome associations in perinatal studies. Approach We simulated the magnitude of bias under a collider-stratification mechanism for the association between the exposure of advancing maternal age (≥ 35 years) and the outcome of stillbirth. This bias occurs when the cause of restriction (early pregnancy loss) is influenced by both the exposure and unmeasured factors that also affect the outcome. Simulation parameters were based on an original birth cohort from Western Australia and a range of plausible values for the prevalence of early pregnancy loss (< 20 gestational weeks), an unmeasured factor U and the odds ratios for the selection effects. Selection effects included the effects of maternal age on early pregnancy loss, U on early pregnancy loss, and U on stillbirth. We then compared the simulated scenarios with the results from the original cohort in which bias was unadjusted. Results We found the overall magnitude of bias to be minimal in the association between advancing maternal age and stillbirth. The findings indicate that the stronger the effect of the unmeasured U on early pregnancy loss and stillbirth, the greater the departure from the null. When we compared the simulated model with the results of the original cohort, we found evidence of marginal downward bias which was most prominent for women aged 40+ years. Discussion Our simulations demonstrated a marginal downward bias in the association between advancing maternal age and stillbirth. We recommend that future studies should quantify the extent of such bias when using left truncated birth datasets to determine exposure-outcome associations

Short interpregnancy interval and its predictors in Ethiopia: implications for policy and practice.

Introduction: interpregnancy interval (IPI) is the time elapsed between the birth of one live child and the conception of subsequent pregnancies. Several studies in Ethiopia indicated a high prevalence of a short interbirth interval - a proxy indicator of IPI. However, these studies were prone to selection bias as they did not include women who did not go on to have another pregnancy. Therefore, this study estimated the incidence of short IPI (< 24 months) and its risk factors among women who had at least one child in Ethiopia. Methods: we used a retrospective analysis of a cross-sectional study from the nationally representative Ethiopian Mini Demographic and Health Survey (EMDHS) conducted in 2019. The event was defined as the conception of the subsequent pregnancy within 24 months following the last child. A weighted Cox Proportional Hazard model was used to estimate the adjusted hazard ratios (aHR) and 95% confidence intervals (CIs). Results: the incidence of short IPI was 6%. Rural residence, being young age, low educational attainment, having the last child died and having female last birth were the risk factors for short IPI. However, having higher parity, attending Antenatal Care (ANC) visits, being delivered at a health facility, and receiving Postnatal Care (PNC) visits were the protective factors for short IPI. Conclusion: the incidence of short IPI in Ethiopia was considerable. Sociodemographic and health service-related factors determine the short IPI. Hence, considering the immediate and long-term health and socioeconomic consequences of short IPI, the Ethiopian government should implement holistic and multisectoral interventions

Associations between endometriosis and adverse pregnancy and perinatal outcomes: a population-based cohort study.

PURPOSE To examine the association between endometriosis and adverse pregnancy and perinatal outcomes (preeclampsia, placenta previa, and preterm birth). METHODS A population-based retrospective cohort study was conducted among 468,778 eligible women who contributed 912,747 singleton livebirths between 1980 and 2015 in Western Australia (WA). We used probabilistically linked perinatal and hospital separation data from the WA data linkage system's Midwives Notification System and Hospital Morbidity Data Collection databases. We used a doubly robust estimator by combining the inverse probability weighting with the outcome regression model to estimate adjusted risk ratios (RR) and 95% confidence intervals (CIs). RESULTS There were 19,476 singleton livebirths among 8874 women diagnosed with endometriosis. Using a doubly robust estimator, we found pregnancies in women with endometriosis to be associated with an increased risk of preeclampsia with RR of 1.18, 95% CI 1.11-1.26, placenta previa (RR 1.59, 95% CI 1.42-1.79) and preterm birth (RR 1.45, 95% CI 1.37-1.54). The observed association persisted after stratified by the use of Medically Assisted Reproduction, with a slightly elevated risk among pregnancies conceived spontaneously. CONCLUSIONS In this large population-based cohort, endometriosis is associated with an increased risk of preeclampsia, placenta previa, and preterm birth, independent of the use of Medically Assisted Reproduction. This may help to enhance future obstetric care among this population

Partograph utilization and associated factors among obstetric care providers in North Shoa Zone, Central Ethiopia: a cross sectional study

Background: Globally, prolonged and obstructed labor contributed to 8% of maternal deaths which can be reduced by proper utilization of partograph during labor. Methods: An Institution based cross-sectional study was conducted in June, 2013 on 403 obstetric care providers. A pre-tested and structured questionnaire was used to collect data. Data was entered to EpiInfo version 3.5.1 statistical package and exported to SPSS version 20.0 for further analysis. Logistic regression analyses were used to see the association of different variables. Results: Out of 403 obstetric care providers, 40.2% utilized partograph during labor.Those who were midwives by profession were about 8 times more likely to have a consistent utilization of the partograph than general practitioners (AOR=8. 13, 95% CI: 2.67, 24.78). Similarly, getting on job training (AOR=2. 86, 95% CI: 1.69, 4.86), being knowledgeable on partograph (AOR=3. 79, 95% CI: 2.05, 7.03) and having favorable attitude towards partograph (AOR=2. 35, 95% CI: 1.14, 4.87) were positively associated with partograph utilization. Conclusion: Partograph utilization in labor monitoring was found to be low. Being a midwife by profession, on job training, knowledge and attitude of obstetric care providers were factors affecting partograph utilization. Providing on job training for providers would improve partograph utilization. Keywords: ,

Knowledge of Pregnant Women on Mother-to-Child Transmission of HIV in Meket District, Northeast Ethiopia

Knowledge of pregnant women on the three periods of mother-to-child transmission (MTCT) of HIV has implication for child HIV acquisition. This study aims to assess the knowledge of pregnant women on mother-to-child transmission of HIV and to identify associated factors in Meket district, northeast Ethiopia. Logistic regression models were fitted to identify associated factors. Adjusted odds ratios (AOR) with 95% confidence intervals (CI) were used to determine the presence and strength of association. About onefifth (19%) of women were knowledgeable on mother-to-child transmission of HIV (95% CI: 15.5%, 22.4%). Being urban resident (AOR: 2.69, 95% CI: 1.48, 4.87), having primary education (AOR: 2.41, 95% CI: 1.03, 5.60), reporting receiving information on HIV from health care providers (AOR: 3.24, 95% CI: 1.53, 6.83), having discussion with partner about mother-to-child transmission of HIV (AOR: 2.64, 95% CI: 1.59, 4.39), and attending antenatal care (AOR: 5.80, 95% CI: 2.63, 12.77) were positively associated with increased maternal knowledge of mother-to-child transmission of HIV. Knowledge of mother-to-child transmission of HIV among pregnant women was low. Providing information, especially for rural women and their partners, is highly recommended. Background Vertical transmission of Human Immunodeficiency Virus (HIV) is still a major challenge in the world, especially in developing countries Without any intervention, the risk of a baby getting HIV infection from an infected mother ranges from 15% to 25% in the developed nations and from 25% to 35% in developing countries. HIV transmission rate and timing are estimated to be 5% to 10% during pregnancy, 10% to 15% during delivery and 5% to 20% through breast-feeding. In general mother to child transmission contributes 15-45% of HIV acquisition for children The national adult HIV prevalence in Ethiopia is 1.2% It is estimated that 138, 906 children less than 15 years are living with HIV in 2014. There are an estimated 3,886 new infections each year due to mother-to-child transmission According to Ethiopian Demographic and Health Survey (EDHS) report, about three-quarters of reproductive aged women know that HIV can be transmitted to a baby through breastfeeding Maternal knowledge on MTCT is a corner stone of effective implementation of the World Health Organization (WHO) recommendation of the four-pronged approach to reduce mother-to-child transmission of HIV Despite the large challenge of vertical transmission of HIV, there were also limited community-based studies on women knowledge on mother-to-child transmission of HIV. Hence, this study attempts to fill the gap through assessing the level of knowledge of MTCT of HIV and its associated factors at Meket district, Northeast Ethiopia. Methods Study Design, Population, and Setting. A communitybased cross-sectional study design was conducted in Meket district, northeast Ethiopia, from March 8 to 21, 2014. Meket district is located 665 km north of Addis Ababa, the Ethiopian capital city. The district has an estimated population size of 254,520 of which 59,939 are reproductive aged women, and an estimated 8,246 were pregnant women. Those pregnant women are living in Meket district were constituted our study population. Sample Size and Sampling Procedure. Sample size was determined using single population proportion formula with the assumptions of 95% level of confidence, 12% proportion of knowledgeable women on MTCT of HIV Operational Definitions. In the present study, pregnant woman was regarded as being knowledgeable on MTCT if she correctly identified the three different modes/periods of MTCT of HIV; otherwise she was classified as nonknowledgeable. Comprehensive knowledge of HIV was also measured if a pregnant woman correctly identified three modes of transmission of HIV (unsafe sexual practice, blood transfusion, and MTCT) and recognized two common misconceptions. Comprehensive knowledge about HIV/AIDS was measured after posing the following questions: (1) knowing that condom use and limiting sex partners to one uninfected partner are HIV prevention methods, (2) being aware that a healthy-looking person can have HIV, and (3) rejecting the two most common local misconceptions, that is, HIV/AIDS can be transmitted through mosquito bites and by supernatural means in Ethiopia Data Collection Procedures. Data were collected using pretested, structured, and interviewer administered questionnaire. The questionnaire was prepared after reviewing relevant literatures. Five female nurses supervised by two BSc health professionals collected the data. For eligible women who were not at home during our first attempt, the interviewers revisited the participant&apos;s home at least two times before excluding the participant. Training was given to the data collectors about informed consent, techniques of interviewing, data collection procedures, and different sections of the questionnaire. Supervisors and principal investigators checked the questionnaire on its completeness and consistency on the daily basis. Data Processing and Analysis. The data were entered into EPI info version 3.5.3 statistical software and then sorted, cleaned, and analyzed by using SPSS version 20 statistical package. Descriptive statistics were done to describe the study participants in relation to relevant variables. Both bivariate and multiple logistic regression analyses were carried out to see the effect of sociodemographic factors, maternal condition factors, and other factors on the knowledge of MTCT of HIV and to control cofounding. Odds ratios with 95% CI were computed to identify factors associated with mothers&apos; MTCT knowledge. Ethical Consideration. Ethical clearance was obtained from the Research and Ethical Review Committee (REC) at the Institute of Public Health, College of Medicine and Health Science of University of Gondar. Permission letter was secured from Meket District Health Office. Written informed consent was taken from each study participant after reading the consent form. The purpose and benefit of the study and their right to withdraw at any time were also delivered to each participant prior to the interview. Confidentiality of the information was maintained throughout by using anonymity identifiers, keeping their privacy by interviewing them individually. Results Sociodemographic Characteristics of Pregnant Women. Five hundred forty-two pregnant women participated in the study (97.5% response rate). The majority (85.4%) were rural dwellers. The mean age of the study participants was 29.45 years (SD = 5.4). Four hundred and sixty (84.9%) were married, 196 (36.2%) were able to read and write, and nearly four-fifths (80.1%) were homemaker ( Journal of Pregnancy 3 Knowledge of Pregnant Women on MTCT. One hundred three (19%) (95% CI: 15.5%, 22.4%) were knowledgeable on MTCT of HIV. Most (84.5%) heard about mother to child transmission of HIV. Among those who heard MTCT, more than two-thirds (70.7%) mentioned labor/delivery as a time of HIV transition from mother to child. 225 (41.5%) pregnant women identified at least two periods of motherto-child transmission of HIV. Nearly two-thirds (63.8%) had comprehensive knowledge on HIV/AIDS, and another equivalent proportion of women heard about PITC Factors Associated with Knowledge of Pregnant Women on MTCT of HIV. In multivariable analysis, higher levels of maternal education status, having received information about HIV from health professionals, and reported discussion of MTCT and ANC with their partners were positively associated with knowledge of mother-to-child transmission of HIV. Those women who live in the urban settings were about three more like to be knowledgeable than their rural counterparts (AOR: 2.69, CI (1.48, 4.87)). Those literate mothers were about three times more likely to be knowledgeable than who did not read and write (AOR: 3.25, CI (1.55, 6.78)). Likewise, a woman was 2.41 times more likely to be knowledgeable if she had completed primary school as compared to those who did not read and write (AOR: 2.41, CI (1.04, 5.60)). Pregnant women who received information on HIV from health care providers were about three times more likely to be knowledgeable than women who had not received information (AOR: 3.24, CI (1.54, 6.83)). Women who had discussions with their partner were more likely to be knowledgeable than those who had not (AOR: 5.80, CI (2.63, 12.78)). Correspondingly, mothers who discussed MTCT with their partners were more likely to be knowledgeable than those who had not (AOR: 2.64, CI (1.59, 4.39)) Discussion Being knowledgeable on MTCT of HIV and the fact that the risk of transmission can be reduced by using antiretroviral drugs are critical in reducing MTCT of HIV. This can contribute greatly towards the achievement of the Millennium Development Goals related to HIV. This study revealed that 19% (95% CI: 15.5%, 22.4%) of respondents were knowledgeable on MTCT of HIV. This result is in line with a cross-sectional study conducted at Temeke District Hospital, Dar Es Salaam (15.7%) In the present study, nearly two-thirds of pregnant women had comprehensive knowledge on HIV/AIDS which is higher than studies in Yaoundé (23%) Knowledge of pregnant women on MTCT of HIV among pregnant women was significantly varied based on their place of residence. Those pregnant women residing in urban areas were more likely to be knowledgeable when compared to the rural residents. This finding is in line with studies conducted at Gondar and Hawassa towns in Ethiopia In this study, pregnant women who discussed and received information about HIV/AIDS from health care providers were more knowledgeable. They were found to be three times more likely to be knowledgeable than those who had not. Spouse discussion on antenatal care follow-up was also positively associated with knowledge of MTCT. Those pregnant women who had discussions with their partners were six times more likely to be knowledgeable than those who had not discussed the issue. This is similar to reports from other studies Pregnant women may receive information from a variety of sources about health services. Spouses having delivered information and participated in discussions about MTCT of HIV with their wives (40.6%) were associated with good knowledge of the subject. Accordingly, pregnant women who had discussion with their partners were more than two times more likely to have good knowledge of MTCT. This might be because partner discussion in this regard could enhance their knowledge. This study tried to assess pregnant women who did not attend health care facilities for ANC and HIV concerning their knowledge about MTCT of HIV. However, because of financial and time constraints, this study did not include the knowledge part of prevention of mother-to-child transmission of HIV. Conclusions Despite many efforts, the knowledge of pregnant women on mother-to-child transmission of HIV is low. If pregnant woman resides in urban environment, she attends school, if she receives information on HIV from health care providers, and if she attends antenatal care, she is more likely to be knowledgeable on MTCT of HIV. Strengthening women education and by reaching previously inaccessible parts of the community, integration of HIV, prevention of MTCT, and ANC service, is highly recommended. Moreover, strengthening discussion of MTCT with spouses is important

Pathology of Camel Tuberculosis and Molecular Characterization of Its Causative Agents in Pastoral Regions of Ethiopia

A cross sectional study was conducted on 906 apparently healthy camels slaughtered at Akaki and Metehara abattoirs to investigate the pathology of camel tuberculosis (TB) and characterize its causative agents using postmortem examination, mycobacteriological culturing, and multiplex polymerase chain reaction (PCR), region of difference-4 (RD4)-based PCR and spoligotyping. The prevalence of camel TB was 10.04% (91/906) on the basis of pathology and it was significantly higher in females (χ2 = 4.789; P = 0.029). The tropism of TB lesions was significantly different among the lymph nodes (χ2 = 22.697; P = 0.002) and lung lobes (χ2 = 17.901; P = 0.006). Mycobacterial growth was observed in 34% (31/91) of camels with grossly suspicious TB lesions. Upon further molecular characterization using multiplex PCR, 68% (21/31) of the colonies showed a positive signal for the genus Mycobacterium, of which two were confirmed Mycobacterium bovis (M. bovis) by RD4 deletion typing. Further characterization of the two M. bovis at strains level revealed that one of the strains was SB0133 while the other strain was new and had not been reported to the M. bovis database prior to this study. Hence, it has now been reported to the database, and designated as SB1953. In conclusion, the results of the present study have shown that the majority of camel TB lesions are caused by mycobacteria other than Mycobacterium tuberculosis complex. And hence further identification and characterization of these species would be useful towards the efforts made to control TB in camels

Association between skilled maternal healthcare and postpartum contraceptive use in Ethiopia

Abstract Background The postpartum period provides an important opportunity to address unmet need for contraception and reduce short birth intervals. This study aims to assess the association between skilled maternal healthcare and postpartum contraceptive use in Ethiopia. Methods Data for this analysis come from the 2011 to 2016 Ethiopian Demographic and Health Surveys (EDHS) and include nearly 5000 married women of reproductive age with a recent birth. Multivariate logistic regression was conducted to investigate the relationship between skilled maternal healthcare and postpartum contraceptive use. Results Between rounds of the 2011 and 2016 EDHS, the postpartum contraceptive prevalence increased from 15 to 23% and delivery in public facilities, use of skilled birth assistance, and skilled antenatal care also grew. In both survey rounds, educated women had approximately twice the odds of postpartum contraceptive use, compared with non-educated women, while an initially significant relationship between wealth and postpartum contraceptive use diminished in significance by 2016. Women with a desire to limit future pregnancy had five to six times the odds of postpartum contraceptive use in both survey rounds, and women in 2016 – unlike those in 2011 – with a desire to delay pregnancy were significantly more likely to use contraception (adjusted odds ratio (AOR) = 4.38, 95% CI: 1.46-13.18) compared to women who wanted another child soon. In 2011, no statistically significant associations were found between any maternal healthcare and postpartum contraceptive use. In contrast, in 2016, postpartum contraceptive use was significantly associated with an institutional delivery (AOR = 1.71, 95% confidence interval (CI): 1.12-2.62) and skilled antenatal care (AOR = 2.41, 95% CI: 1.41-4.10). No significant relationship was observed in either survey round between postpartum contraceptive use and skilled delivery or postnatal care. Conclusions A comparison of postpartum women in the 2011 and 2016 EDHS reveals increased use of both contraception and skilled maternal healthcare services and improved likelihood of contraceptive use among women with an institutional delivery or antenatal care, perhaps as a result of increased attention to postpartum family planning integration. Additionally, results suggest postpartum women are now using contraception to space future pregnancies, with the potential to help women achieve more optimal birth intervals