Women in Tigray, Ethiopia Who Attended the Recommended Number of Prenatal Visits were More Likely to Deliver in Health Institutions

Background Saving the lives of mothers and newborns requires prompt access to appropriate health services. Ethiopia is committed to improving access to maternity care by expanding the number of health facilities and health workers. However, institutional delivery is not yet universal, even when the service is free and available within a reasonable geographic distance. Objective To identify factors associated with institutional delivery service utilization in Adigrat town, Tigray Regional State, Ethiopia. Methods We conducted a community based cross-sectional study using mixed quantitative and qualitative approaches. Employing cluster sampling, we collected quantitative data through interviewer-administered questionnaires from 767 mothers from Adigrat town who gave birth within 2 years of the study. Bivariate and multivariate logistic regressions were used to identify factors associated with institutional delivery. We also collected qualitative data with two focus group discussions, which were thematically analyzed. Ethical approval was granted by the Institutional Review Board of Mekelle University, and informed consent was obtained from each participant. Results In our sample, 81% (621) of mothers  reported that their last deliveries were conducted at health institutions. Of the 682 women who received antenatal care services in their last pregnancy, 85% (580) had all 4 recommended antenatal care (ANC) visits. In multivariate analyses, institutional delivery was significantly higher among mothers who had 4 or more ANC visits (AOR= 1.99; 95%CI:1.09, 3.63) than those with fewer visits.  In addition, the odds of institutional delivery were higher among mothers who conceived for first time at the age of 20-34 years than those who conceived as teenagers. The qualitative findings suggested that the increased utilization of health institutions for delivery was due to efforts made by health extension workers. However mothers who delivered at health institutions expressed concern about how they were treated by care providers and the facilities’ hygienic conditions. Conclusions Strengthening the antenatal care services and improving the quality of delivery services can potentially help achieve universal institutional delivery in Ethiopia. Keywords: Institutional delivery; Antenatal care; Health extension workers; Home delivery; professionals’ approach; Ethiopi

Disrespectful Maternity Care Experiences Negatively Influence Future Intention to Use Institutional Delivery in Northern Ethiopia

Background Ethiopia has successfully increased antenatal care coverage substantially, but deliveries attended by skilled providers are still low. Disrespectful and abusive maternity care practices are believed to be among the factors deterring institutional delivery services. However, information on the relationship between women’s experience of disrespect and abuse (D&A) and their future intention to give birth at health facilities is lacking in our context. Therefore, the aim of this study was to examine the association between experiencing disrespectful care and future intention of women to utilize health facilities for delivery. Methods A cross-sectional study was conducted in Tigray, Ethiopia. Data were collected using a structured questionnaire. Women who had given birth in the health facilities in the twelve months preceding the study were interviewed. D&A was self reported by the women. Bivariable and multivariable logistic regression models were employed to examine the relationship between future intention of women to use institutional delivery services and their past experience of D and A while receiving maternity care services. Results A total of 1,031 women who delivered in health facilities in the last 12 months participated in the study. Of which, 156 (15.1%) reported having experienced two or more types of D&A while receiving labour and delivery care services. Experiences of D&A were strongly associated with the  intention to use the health facility in future deliveries. The odds of having no intention to use health facilities for future deliveries was extremely high among women who reported they had experienced D&A (aOR= 59.42; 95% CI: 30.082, 117.359). Conclusion Disrespectful and abusive experiences strongly deterred future use of maternal health services. In order to achieve the desired level of institutional delivery coverage in low- and middle-income countries, attention must be given to improve the manner in which services are offered. Keywords: Intention to deliver at a health facility, Respectful maternity care, Disrespect and abuse, Tigray, Ethiopia DOI: 10.7176/JHMN/72-01 Publication date:March 31st 202

Global, regional, and national under-5 mortality, adult mortality, age-specific mortality, and life expectancy, 1970–2016: a systematic analysis for the Global Burden of Disease Study 2016

BACKGROUND: Detailed assessments of mortality patterns, particularly age-specific mortality, represent a crucial input that enables health systems to target interventions to specific populations. Understanding how all-cause mortality has changed with respect to development status can identify exemplars for best practice. To accomplish this, the Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) estimated age-specific and sex-specific all-cause mortality between 1970 and 2016 for 195 countries and territories and at the subnational level for the five countries with a population greater than 200 million in 2016. METHODS: We have evaluated how well civil registration systems captured deaths using a set of demographic methods called death distribution methods for adults and from consideration of survey and census data for children younger than 5 years. We generated an overall assessment of completeness of registration of deaths by dividing registered deaths in each location-year by our estimate of all-age deaths generated from our overall estimation process. For 163 locations, including subnational units in countries with a population greater than 200 million with complete vital registration (VR) systems, our estimates were largely driven by the observed data, with corrections for small fluctuations in numbers and estimation for recent years where there were lags in data reporting (lags were variable by location, generally between 1 year and 6 years). For other locations, we took advantage of different data sources available to measure under-5 mortality rates (U5MR) using complete birth histories, summary birth histories, and incomplete VR with adjustments; we measured adult mortality rate (the probability of death in individuals aged 15-60 years) using adjusted incomplete VR, sibling histories, and household death recall. We used the U5MR and adult mortality rate, together with crude death rate due to HIV in the GBD model life table system, to estimate age-specific and sex-specific death rates for each location-year. Using various international databases, we identified fatal discontinuities, which we defined as increases in the death rate of more than one death per million, resulting from conflict and terrorism, natural disasters, major transport or technological accidents, and a subset of epidemic infectious diseases; these were added to estimates in the relevant years. In 47 countries with an identified peak adult prevalence for HIV/AIDS of more than 0·5% and where VR systems were less than 65% complete, we informed our estimates of age-sex-specific mortality using the Estimation and Projection Package (EPP)-Spectrum model fitted to national HIV/AIDS prevalence surveys and antenatal clinic serosurveillance systems. We estimated stillbirths, early neonatal, late neonatal, and childhood mortality using both survey and VR data in spatiotemporal Gaussian process regression models. We estimated abridged life tables for all location-years using age-specific death rates. We grouped locations into development quintiles based on the Socio-demographic Index (SDI) and analysed mortality trends by quintile. Using spline regression, we estimated the expected mortality rate for each age-sex group as a function of SDI. We identified countries with higher life expectancy than expected by comparing observed life expectancy to anticipated life expectancy on the basis of development status alone. FINDINGS: Completeness in the registration of deaths increased from 28% in 1970 to a peak of 45% in 2013; completeness was lower after 2013 because of lags in reporting. Total deaths in children younger than 5 years decreased from 1970 to 2016, and slower decreases occurred at ages 5-24 years. By contrast, numbers of adult deaths increased in each 5-year age bracket above the age of 25 years. The distribution of annualised rates of change in age-specific mortality rate differed over the period 2000 to 2016 compared with earlier decades: increasing annualised rates of change were less frequent, although rising annualised rates of change still occurred in some locations, particularly for adolescent and younger adult age groups. Rates of stillbirths and under-5 mortality both decreased globally from 1970. Evidence for global convergence of death rates was mixed; although the absolute difference between age-standardised death rates narrowed between countries at the lowest and highest levels of SDI, the ratio of these death rates-a measure of relative inequality-increased slightly. There was a strong shift between 1970 and 2016 toward higher life expectancy, most noticeably at higher levels of SDI. Among countries with populations greater than 1 million in 2016, life expectancy at birth was highest for women in Japan, at 86·9 years (95% UI 86·7-87·2), and for men in Singapore, at 81·3 years (78·8-83·7) in 2016. Male life expectancy was generally lower than female life expectancy between 1970 and 2016, an

Healthcare Access and Quality Index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990-2015 : a novel analysis from the Global Burden of Disease Study 2015

Background National levels of personal health-care access and quality can be approximated by measuring mortality rates from causes that should not be fatal in the presence of effective medical care (ie, amenable mortality). Previous analyses of mortality amenable to health care only focused on high-income countries and faced several methodological challenges. In the present analysis, we use the highly standardised cause of death and risk factor estimates generated through the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) to improve and expand the quantification of personal health-care access and quality for 195 countries and territories from 1990 to 2015. Methods We mapped the most widely used list of causes amenable to personal health care developed by Nolte and McKee to 32 GBD causes. We accounted for variations in cause of death certification and misclassifications through the extensive data standardisation processes and redistribution algorithms developed for GBD. To isolate the effects of personal health-care access and quality, we risk-standardised cause-specific mortality rates for each geography-year by removing the joint effects of local environmental and behavioural risks, and adding back the global levels of risk exposure as estimated for GBD 2015. We employed principal component analysis to create a single, interpretable summary measure-the Healthcare Quality and Access (HAQ) Index-on a scale of 0 to 100. The HAQ Index showed strong convergence validity as compared with other health-system indicators, including health expenditure per capita (r= 0.88), an index of 11 universal health coverage interventions (r= 0.83), and human resources for health per 1000 (r= 0.77). We used free disposal hull analysis with bootstrapping to produce a frontier based on the relationship between the HAQ Index and the Socio-demographic Index (SDI), a measure of overall development consisting of income per capita, average years of education, and total fertility rates. This frontier allowed us to better quantify the maximum levels of personal health-care access and quality achieved across the development spectrum, and pinpoint geographies where gaps between observed and potential levels have narrowed or widened over time. Findings Between 1990 and 2015, nearly all countries and territories saw their HAQ Index values improve; nonetheless, the difference between the highest and lowest observed HAQ Index was larger in 2015 than in 1990, ranging from 28.6 to 94.6. Of 195 geographies, 167 had statistically significant increases in HAQ Index levels since 1990, with South Korea, Turkey, Peru, China, and the Maldives recording among the largest gains by 2015. Performance on the HAQ Index and individual causes showed distinct patterns by region and level of development, yet substantial heterogeneities emerged for several causes, including cancers in highest-SDI countries; chronic kidney disease, diabetes, diarrhoeal diseases, and lower respiratory infections among middle-SDI countries; and measles and tetanus among lowest-SDI countries. While the global HAQ Index average rose from 40.7 (95% uncertainty interval, 39.0-42.8) in 1990 to 53.7 (52.2-55.4) in 2015, far less progress occurred in narrowing the gap between observed HAQ Index values and maximum levels achieved; at the global level, the difference between the observed and frontier HAQ Index only decreased from 21.2 in 1990 to 20.1 in 2015. If every country and territory had achieved the highest observed HAQ Index by their corresponding level of SDI, the global average would have been 73.8 in 2015. Several countries, particularly in eastern and western sub-Saharan Africa, reached HAQ Index values similar to or beyond their development levels, whereas others, namely in southern sub-Saharan Africa, the Middle East, and south Asia, lagged behind what geographies of similar development attained between 1990 and 2015. Interpretation This novel extension of the GBD Study shows the untapped potential for personal health-care access and quality improvement across the development spectrum. Amid substantive advances in personal health care at the national level, heterogeneous patterns for individual causes in given countries or territories suggest that few places have consistently achieved optimal health-care access and quality across health-system functions and therapeutic areas. This is especially evident in middle-SDI countries, many of which have recently undergone or are currently experiencing epidemiological transitions. The HAQ Index, if paired with other measures of health-systemcharacteristics such as intervention coverage, could provide a robust avenue for tracking progress on universal health coverage and identifying local priorities for strengthening personal health-care quality and access throughout the world. Copyright (C) The Author(s). Published by Elsevier Ltd.Peer reviewe

Mothers’ experience of disrespect and abuse during maternity care in northern Ethiopia

Background: The provision of respectful and satisfactory maternity care is essential for promoting timely care-seeking behaviour, and ultimately ensuring the health and well-being of mothers and their babies. Disrespectful and abusive care has been recognized as one of the barriers to seeking timely maternity health services. However, the issue has not been adequately researched in community settings in low- and middle-income countries using validated measurement tools. Objective: This study was conducted to assess the extent of, and factors associated with, disrespectful and abusive maternity care reported by women who utilized facility-based delivery services in northern Ethiopia. Methods: We conducted a community-based cross-sectional study in Tigray, northern Ethiopia. Women who gave birth in the preceding year and visited health institutions for these deliveries were selected using a multistage cluster sampling procedure. Data were collected using a pretested questionnaire. Six domains of disrespect and abuse (D and A) were included in the questionnaire. Socio-demographic and obstetric related factors associated with D and A were tested using a negative binomial regression model. Results: Of the 1125 women in the sample, 248 (22%; 95% CI: 19.8%, 24.4%) reported at least one incident of D and A during delivery at a public health facility in northern Ethiopia. Higher incidents of D and A were reported by women who were older than 19 years at the time of delivery (aIRR = 2.649 (95% CI: 1.455, 4.825) compared to younger women. Incidents of D and A were reported more by women residing in urban areas, by women educated to the ninth grade and above, by women who experienced longer labour duration, and also by women who were not permitted to have support persons attend labour and delivery. Conclusions: A fifth of the women reported D and A while receiving care during labour and delivery. Policies and practices aimed at ensuring universal coverage for institutional deliveries need to promote respectful maternity care for women in all facilities

Appropriate Weaning Practice and Associated Factors among Infants and Young Children in Northwest Ethiopia

Background. The right nutrition from the start of a pregnancy to the child’s second birthday has a profound impact on the future health, wellbeing, and success of a child. This can be achieved through proper maternal nutrition during pregnancy, exclusive breastfeeding, and appropriate weaning practice. Objective. This study was aimed at assessing appropriate weaning practice and associated factors among infants and young children aged 6–23 months in Feres Bet Town, Northwest Ethiopia. Methods. A community based cross-sectional study was conducted among 351 children aged 6–23 months. Simple random sampling technique was used to select study participants. Interviewer administered questionnaires were used. Bivariate and multivariable logistic regression analyses were employed to identify factors associated with appropriate weaning practice. Results. Nearly quarter (23.9%) of mothers have practiced appropriate weaning. Proportion of children who started consumption of weaning food timely and met the recommended dietary diversity was 61.5% and 43.9%, respectively. Child age [AOR (Adjusted Odds Ratio): 7.04], husband’s occupation [AOR: 6.85], and maternal weaning advice [AOR: 4.38] were positively associated with appropriate weaning practice, while family size [AOR: 0.28] showed negative association. Conclusion. Appropriate weaning practice was found to be low. Health education at community level and one-on-one advice for mothers in health institutions are highly recommended to improve appropriate weaning

Women suffer more from disrespectful and abusive care than from the labour pain itself : a qualitative study from Women's perspective

Background: Utilization of institutional delivery services could be hampered by women's experience of disrespectful and abusive care during childbirth. However, such experiences are not well documented and taken into consideration id planning maternal health services in many developing countries. The aim of this study was to describe women's experience of disrespect and abuse during giving birth at health facilities in northern Ethiopia. Methods: A qualitative phenomenological study was conducted in Tigray, Ethiopia. Focus group discussions (FGDs) with primipara and multipara women were conducted to collect the necessary information. All study participants had their last delivery at a health facility in the year preceding the study. A semi-structured discussion guide was used to elicit discussion. Discussions were audio recorded and transcribed verbatim in the local language and then translated to English. Data were analyzed using thematic analysis approach assisted by the Open Code qualitative data management software. Results: The study participants described disrespect and abuse as serious obstacles to utilization of maternal health services. Women reported experiencing feelings of being infantilized, losing self-control, being overlooked, being informed bad news without proper preparation, repeated examination without being properly communicated/ informed, disallow companions, and left unattended during labor. Facility related issues include women's perception of incompetence of professionals attending delivery, unhygienic facilities, and unavailability of basic supplies. Conclusion: Women consider health facilities not fully prepared to provide respectful maternal care. Sustainable increase in institutional delivery requires ensuring quality, compassionate and caring services in all health facilities

Frequency and patterns of first- and second-line drug resistance-conferring mutations in Mycobacterium tuberculosis isolated from pulmonary tuberculosis patients in a cross-sectional study in Tigray Region, Ethiopia

Objectives Tuberculosis (TB) is a preventable and treatable infectious disease, but the continuing emergence and spread of multidrug-resistant TB is threatening global TB control efforts. This study aimed to describe the frequency and patterns of drug resistance-conferring mutations of Mycobacterium tuberculosis (MTB) isolates detected from pulmonary TB patients in Tigray Region, Ethiopia. Methods A cross-sectional study design was employed to collect sputum samples from pulmonary TB patients between July 2018 to August 2019. Culture and identification tests were done at Tigray Health Research Institute (THRI). Mutations conferring rifampicin (RIF), isoniazid (INH) and fluoroquinolone (FQ) resistance were determined in 227 MTB isolates using GenoType MTBDRplus and GenoType MTBDRsl. Results Mutations conferring resistance to RIF, INH and FQs were detected in 40/227 (17.6%), 41/227 (18.1%) and 2/38 (5.3%) MTB isolates, respectively. The majority of mutations for RIF, INH and FQs occurred at codons rpoB S531L (70%), katG S315T (78%) and gyrA D94Y/N (100%), respectively. This study revealed a significant number of unknown mutations in the rpoB, katG and inhA genes. Conclusion High rates of mutations conferring resistance to RIF, INH and FQs were observed in this study. A large number of isolates showed unknown mutations, which require further DNA sequencing analysis. Periodic drug resistance surveillance and scaling-up of drug resistance testing facilities are imperative to prevent the transmission of drug-resistant TB in the community

Trends and causes of neonatal mortality from 2010 to 2017 at a Health and Demographic Surveillance site in Northern Ethiopia

Background Half of global under-five mortalities is neonatal. The highest rates are found in low-income countries such as Ethiopia. Ethiopia has made progress in reducing under-five mortality, but neonatal mortality remains high. Evidence collected continuously at the community level is crucial for understanding the trends and causes of neonatal mortality. Objectives To analyse the trends and causes of neonatal mortality at the Kilte-Awlelo Health and Demographic Surveillance System (KAHDSS) site in Ethiopia from 2010 to 2017. Methods A descriptive study was conducted using data from neonates born between 2010 and 2017 at the KAHDSS site. Data were collected using interviewer-administered questionnaires. Causes of death were examined, and neonatal mortality trends were described using simple linear regression. Results The overall average neonatal mortality rate was 17/1000 live births (LBs). The rate increased from 12 per 1000 LBs in 2010 to 15 per 1000 LBs in 2017. The majority of neonatal deaths occurred during the first week of life, and more than one-half died at home. The leading causes were sepsis, pre-term birth (including respiratory distress), disease related to the perinatal period, birth asphyxia, and neonatal pneumonia. Conclusions The high neonatal mortality in Ethiopia requires urgent attention and action. Sepsis, preterm birth, perinatal diseases, asphyxia, and neonatal pneumonia are the leading causes of death in neonates. Facility- and community-based health services should target the leading causes of neonatal deaths