'I wanted to go, but they said wait': Mothers' bargaining power and strategies in care-seeking for ill newborns in Ethiopia

INTRODUCTION: To prevent the 2.6 million newborn deaths occurring worldwide every year, health system improvements and changes in care-taker behaviour are necessary. Mothers are commonly assumed to be of particular importance in care-seeking for ill babies; however, few studies have investigated their participation in these processes. This study explores mothers' roles in decision making and strategies in care-seeking for newborns falling ill in Ethiopia. METHODS: A qualitative study was conducted in Butajira, Ethiopia. Data were collected during the autumn of 2015 and comprised 41 interviews and seven focus group discussions. Participants included primary care-takers who had experienced recent newborn illness or death, health care workers and community members. Data were analysed using thematic analysis. RESULTS: Choices about whether, where and how to seek care for ill newborns were made through cooperation and negotiation among household members. Mothers were considered the ones that initially identified or recognised illness, but their actual opportunities to seek care were bounded by structural and cultural constraints. Mothers' limited bargaining power, contained by financial resources and gendered decision making, shaped their roles in care-seeking. We identified three strategies mothers took on in decision making for newborn illness: (a) acceptance and adaptation (to the lack of options), (b) negotiation and avoidance of advice from others, and (c) active care-seeking and opposition against the husband's or community's advice. CONCLUSION: While the literature on newborn health and parenting emphasizes the key role of mothers in care-seeking, their actual opportunities to seek care are shaped by factors commonly beyond their control. Efforts to promote care-seeking for ill children should recognise that mothers' capabilities to make decisions are embedded in gendered social processes and financial power structures. Thus, policies should not only target individual mothers, but the wider decision making group, including the head of households and extended family

Adopting an ethical approach to migration health policy, practice and research

Migration health is affected by decision making at levels ranging from global to local, both within and beyond the health sector. These decisions impact seeking, entitlements, service delivery, policy making and knowledge production on migration health. It is key that ethical challenges faced by decision makers are recognised and addressed in research and data, clinical practice and policy making on migration health. An ethical approach can provide methods to identify ethical issues, frameworks for systematising information and suggesting ethically acceptable solutions, and guidance on procedural concerns and legitimate decision making processes. By unpacking dilemmas, conflicts of interests and values at stake, an ethical approach is relevant for all who make decisions about migration health policy and practice. Adopting an ethical approach to migration health benefits governments, organisations, policy makers, health workers, data managers, researchers and migrants themselves. First, it highlights the inherent normative questions and trade-offs at stake in migration health. Second, it assists decision makers in deciding what is the ethically justifiable thing to do through an ‘all things considered’ approach. Third, ethical frameworks and technical guidance set normative and practical standards for decision makers facing ethical questions – from ‘bedside rationing’ to collection of big data or in policy making – that can ensure that migrants’ interests are considered. Fourth, there is a need for greater transparency and accountability in decision making, as well as meaningful participation of migrant groups. An ethical approach connects to public health, economic and human rights arguments and highlights the urgent need to mainstream concerns for migrants in global and national health responses

Newborn health benefits or financial risk protection? An ethical analysis of a real-life dilemma in a setting without universal health coverage

Introduction High healthcare costs make illness precarious for both patients and their families’ economic situation. Despite the recent focus on the interconnection between health and financial risk at the systemic level, the ethical conflict between concerns for potential health benefits and financial risk protection at the household level in a low-income setting is less understood. Methods Using a seven-step ethical analysis, we examine a real-life dilemma faced by families and health workers at the micro level in Ethiopia and analyse the acceptability of limiting treatment for an ill newborn to protect against financial risk. We assess available evidence and ethical issues at stake and discuss the dilemma with respect to three priority setting criteria: health maximisation, priority to the worse-off and financial risk protection. Results Giving priority to health maximisation and extra priority to the worse-off suggests, in this particular case, that limiting treatment is not acceptable even if the total well-being gain from reduced financial risk is taken into account. Our conclusion depends on the facts of the case and the relative weight assigned to these criteria. However, there are problematic aspects with the premise of this dilemma. The most affected parties—the newborn, family members and health worker—cannot make free choices about whether to limit treatment or not, and we thereby accept deprivations of people’s substantive freedoms. Conclusion In settings where healthcare is financed largely out-of-pocket, families and health workers face tragic trade-offs. As countries move towards universal health coverage, financial risk protection for high-priority services is necessary to promote fairness, improve health and reduce poverty

Towards universal health coverage: including undocumented migrants

As countries throughout the world move towards universal health coverage, the obligation to realise the right to health for undocumented migrants has often been overlooked. With unprecedented millions on the move – including refugees, asylum seekers, internally displaced persons, and returnees – undocumented migrants represent a uniquely vulnerable subgroup, experiencing particular barriers to health related to their background as well as insecure living and working conditions. Their legal status under national law often restricts access to, and affordability of, healthcare services. While striving to ensure health for all, national governments face challenging priority setting dilemmas in deciding: who to include, which services to provide, and how to cover out-of-pocket expenses. Building on comparative experiences in Norway, Thailand and the United States – which reflect varied approaches to achieving universal health coverage – we assess whether these national approaches provide rights-based access to affordable essential healthcare services for undocumented migrants. To meet the shared Sustainable Development Goal on universal health coverage, the right to health must be realised for all persons – including undocumented migrants. To ensure universal health coverage in accordance with the right to health, governments must evaluate laws, regulations, policies and practices to evaluate: whether undocumented migrants are included, to which services they have access, and if these services are affordable. Achieving universal health coverage for everyone will require rights-based support for undocumented migrants

What if the baby doesn't survive? Health-care decision making for ill newborns in Ethiopia

Despite efforts to improve access to and quality of care for newborns, the first month after birth remains the most dangerous period of life. Given high neonatal mortality in low-income countries, saving newborn lives is a key priority for global and national health policy agendas. However, little is known about how these policies resonate with local understandings, experiences and household priorities. In this qualitative study we examined families' decision making and health-care-seeking in Butajira, Ethiopia. Data were collected through observation in hospital, in-depth interviews (41), and focus group discussions (7) with family members, health-care workers, and community members (October–November 2015). Transcripts and field notes were analyzed inductively using qualitative content analysis. Findings indicate that newborn health was not always the family's priority. Local perceptions of newborns as not yet useful members of the household alongside costly health-care services delayed decision making and care-seeking. While sickness was recognized as dangerous for the ill newborn, seeking health-care could be harmful for the economic survival of the family. In a resource-constrained setting, families' focused on productive assets in order to minimize long-term risks, and waited before seeking newborn health-care services. Until the baby had survived the first vulnerable weeks and months of life, the unknown newborn was not yet seen as a social person by the community. Personhood evolved progressively as the baby became a part of the family. A newborn death was surrounded by silence, and families received minimal support from traditional financial associations, iddirs. Decisions regarding health-care were contingent upon families' understandings of newborns and their resource-constrained circumstances. Improving newborn health involves recognizing why families choose to (not) seek health-care, and their actual opportunities and constraints in making such decisions. The everyday realities of vulnerable newborns must be at the center of global and national policy discussions and local implementation

Selling my sheep to pay for medicines - household priorities and coping strategies in a setting without universal health coverage

BACKGROUND: The first month of life is the period with the highest risk of dying. Despite knowledge of effective interventions, newborn mortality is high and utilization of health care services remains low in Ethiopia. In settings without universal health coverage, the economy of a household is vulnerable to illness, and out-of-pocket payments may limit families' opportunities to seek health care for newborns. In this paper we explore intra-household resource allocation, focusing on how families prioritize newborn health versus other household needs and their coping strategies for managing these priorities. METHODS: A qualitative study was conducted in 2015 in Butajira, Ethiopia, comprising observation, semi-structured interviews, and focus group discussions with household members, health workers, and community members. Household members with hospitalized newborns or who had experienced neonatal death were primary informants. RESULTS: In this predominantly rural and poor district, households struggled to pay out-of-pocket for services such as admission, diagnostics, drugs, and transportation. When newborns fell ill, families made hard choices balancing concerns for newborn health and other household needs. The ability to seek care, obtain services, and follow medical advice depended on the social and economic assets of the household. It was common to borrow money from friends and family, or even to sell a sheep or the harvest, if necessary. In managing household priorities and high costs, families waited before seeking health care, or used cheaper traditional medicines. For poor families with no money or opportunity to borrow, it became impossible to follow medical advice or even seek care in the first place. This had fatal health consequences for the sick newborns. CONCLUSIONS: While improving neonatal health is prioritized at policy level in Ethiopia, poor households with sick neonates may prioritize differently. With limited money at hand and high direct health care costs, families balanced conflicting concerns to newborn health and family welfare. We argue that families should not be left in situations where they have to choose between survival of the newborn and economic ruin. Protection against out-of-pocket spending is key as Ethiopia moves towards universal health coverage. A necessary step is to provide prioritized newborn health care services free of charge

Complete breeding failures in ivory gull following unusual rainy storms in North Greenland

Natural catastrophic events such as heavy rainfall and windstorms may induce drastic decreases in breeding success of animal populations. We report the impacts of summer rainfalls on the reproductive success of ivory gull (Pagophila eburnea) in north-east Greenland. On two occasions, at Amdrup Land in July 2009 and at Station Nord in July 2011, we observed massive ivory gull breeding failures following violent rainfall and windstorms that hit the colonies. In each colony, all of the breeding birds abandoned their eggs or chicks during the storm. Juvenile mortality was close to 100% at Amdrup Land in 2009 and 100% at Station Nord in 2011. Our results show that strong winds associated with heavy rain directly affected the reproductive success of some Arctic bird species. Such extreme weather events may become more common with climate change and represent a new potential factor affecting ivory gull breeding success in the High Arctic

Reporting of ethical approval and informed consent in clinical research published in leading nursing journals : a retrospective observational study

Background: Ethical considerations play a prominent role in the protection of human subjects in clinical research. To date the disclosure of ethical protection in clinical research published in the international nursing journals has not been explored. Our research objective was to investigate the reporting of ethical approval and informed consent in clinical research published in leading international nursing journals. Methods: This is a retrospective observational study. All clinical research published in the five leading international nursing journals from the SCI Journal Citation Reports between 2015 and 2017 were retrieved to evaluate for evidence of ethical review. Results: A total of 2041 citations have been identified from the contents of all the five leading nursing journals that were published between 2015 and 2017. Out of these, 1284 clinical studies have been included and text relating to ethical review has been extracted. From these, most of prospective clinical studies (87.5%) discussed informed consent. Only half of those (52.9%) reported that written informed consent had been obtained; few (3.6%) reported oral consent, and few (6.8%) used other methods such as online consent or completion and return of data collection (such as surveys) to denote assent. Notably, 36.2% of those did not describe the method used to obtain informed consent and merely described that “consent was obtained from participants or participants agreed to join in the research”. Furthermore, whilst most of clinical studies (93.7%) mentioned ethical approval; 92.5% of those stated the name of ethical committee and interestingly, only 37.1% of those mentioned the ethical approval reference. The rates of reporting ethical approval were different between different study type, country, and whether financial support was received (all P<0.05). Conclusion: The reporting of ethics in leading international nursing journals demonstrates progress, but improvement of the transparency and the standard of ethical reporting in nursing clinical research is required