Intrauterine foetal and child growth in the context of Ethiopian Health system: Implications for Prenatal care : Intrauterine foetal growth and child linear growth in Ethiopia

Fostervekst og vekst hos små barn på den etiopiske landsbygd. Etiopia er fortsatt et av verdens fattigste land, og bruken av helsetjenester er lav. Mødre dødeligheten er også høy. Og, mange barn har både akutt og kronisk underernæring. Det er derfor behov for studier til å bedre forståelsen av fostervekst og barns vekst. Bedre innsikt av intrauterin fostervekst er en viktig for tidlig identifisering av normal og unormal fostervekst, noe som kan påvirke fødselsvekt ved fødselen og vekst i tidlig barndom. Målsetningen med denne avhandlingen var å måle intrauterin fostervekst, og se hvorledes barns lengdevekst var i de første to leveår. Avhandlingen vurderer også hvorledes slike mål kan brukes i den eksisterende mødre- og barnehelsetjenesten på den etiopiske landsbygd. Studien ble utført i den sentrale delen av Riftdalen i Etiopia. Omtrent 700 gravide kvinner ble undersøkt, og deres barn ble fulgt opp til de var omtrent to år. Studieområdet er et typisk landbruksområde, har gjentatte ganger vært rammet av tørke og hungersnød. Selv om det har vært matmangel i området, viser studien at intrauterin vekst er sammenlignbart med Verdens helseorganisasjon (WHO) og INTERGROWTH-21st referansene. Imidlertid er det mange barn som får en lav lengdevekst de først to år. Dette kan forklares både med faktorer under graviditeten og årsaker som oppstår i de tidlige barneårene. I den siste artikkelen i avhandlingen beskrives og analyseres hvorledes svangerskapsomsorgen fungerer sammenlignet med de nasjonale og WHOs retningslinjer. Det er betydelige mangler med dagens graviditetskontroller. Det er derfor viktig å styrke mor-barn helsearbeidet.Introduction Ethiopia is a country with a low coverage of antenatal care services. In 2019, only 43% of pregnant women had the recommended four antenatal care (ANC) visits during their pregnancy while 24% of women in Ethiopia had no ANC visits at all. Different national initiatives are underway to expand and improve maternal health services utilization. These are aligned with international and national agendas and goals. In the first 1000 days of life, starting from the time of conception, growth is viewed as a continuum between the foetal period, infancy, and early childhood. Foetal growth is dynamic. Defining normal or abnormal foetal growth requires the taking of serial measurements. If the foetal growth is abnormal, it can result in low birth weight or prematurity. Low birth weight and prematurity are major contributors of neonatal and infant mortality and morbidity. ANC is an important care point that has a positive influence in identifying pregnancy-related complications. It can also contribute to improved pregnancy outcomes. Ethiopia implemented the World Health Organization’s (WHO) focused ANC (FANC) model at all health facilities until February 2022, which was a goal orientated approach to delivering evidence-based interventions carried out at four critical times during pregnancy. Population specific foetal growth charts that can be used to monitor foetal growth patterns are lacking, particularly in areas affected by food insecurity and drought such as are found in Ethiopia. Moreover, the influence of intrauterine uterine growth on birth weight and early childhood growth has not been examined in this country. In addition, even though ANC is taken as an opportunity for influencing the well-being of pregnant mothers and growing foetus, the evidence supporting a relationship between ANC and adverse pregnancy outcomes is unclear in Ethiopia.   Objective The overall objective of this thesis was to examine intrauterine and child growth in a drought-affected rural area of Ethiopia in the context of the country’s health system. The first objective was to assess intrauterine uterine growth patterns in comparison to the WHO and the INTERGROWTH 21st intrauterine uterine growth standards. The second objective was to examine the influence of intrauterine foetal growth on length-for-age Z-score and weight-for-length Z-score in early childhood 11–24 months of age. The third objective was to assess the compliance of ANC utilization with national and WHO guidelines and whether adverse pregnancy outcomes were associated with the use of antenatal care services. Methods We conducted a prospective cohort study in the rural community of Adami Tullu district in the Oromia Regional State in south central Ethiopia from July 2016 to November 2018. We included 704 pregnant women, with a gestational age of less than 24 weeks and followed them to delivery. We followed the children until they were 24 months postnatal. At enrolment, we collected data on maternal, sociodemographic and household characteristics. We also collected data on maternal weight, blood pressure, mid upper arm circumference (MUAC), haemoglobin, and malaria test results at 26, 30, and 36 weeks of gestation. We obtained foetal biometric measurements (head circumference, biparietal diameter, abdominal circumference, and femoral length) and estimated foetal weight using ultrasound at each visit. We subsequently followed the new-borns postnatally and measured their lengths and weights once at the age of 11-24 months. Foetal weight was estimated using the Hadlock algorithm, and the 5th, 10th, 25th, 50th, 75th, 90th, and 95th centiles were generated from this model. We compared the Z-scores and percentiles of biometric measurements and estimated foetal weight with the INTERGROWTH 21st and WHO multicentre foetal growth reference standards (Paper I). After birth, we measured the weights and lengths of 554 children at age of 11–24 months. The birth-weight-for-gestational-age Z-score was calculated using INTERGROWTH 21st international new-born birth standards. We determined Z-scores of length-for-age, weight-for-age and weight-for-length of the children using the 2006 WHO child growth standards. We used a multilevel mixed effect linear regression model to examine the influence of foetal biometric measurements, new-born (birth weight, gestational age at delivery, sex), maternal (age, height, education, occupation, parity) and household (household wealth, family size) characteristics on birth weight, child length-for-age and weight-for-age (Paper II). We used the WHO and national ANC guidelines to compare the service utilization patterns, and collected data on ANC utilization among 704 pregnant women at three prescheduled visits during pregnancy and at birth. Data on the extent of antenatal care content received, timing of antenatal care, location of antenatal care, and location and mode of delivery were obtained by interviewing the pregnant women. Adverse pregnancy outcomes was computed as the sum of preterm birth, intrauterine foetal deaths, and stillbirths (Paper III). Results The distribution of biometric measurements and estimated foetal weight in our study were similar to the WHO and INTERGROWTH-21st references. Most measurements were between -2 and +2 of the reference Z-scores. Based on the smoothed percentiles, the 5th, 50th, and 95th percentiles, our study had similar distribution patterns to the WHO chart, and the 50th percentile was similar to the INTERGROWTH-21st chart (Paper I). We found that foetal factors, duration of pregnancy, child age, maternal height and family size were the main predictors of linear growth. Both birth weights and linear growth were influenced by early intrauterine foetal growth. Birth weight was also influenced by foetal growth during late pregnancy. Environmental factors had more influence on the child’s linear growth compared to their effect on birth weight. We observed a large variation in length-for-age Z-score (30%) and weight-for-length Z-score (22%) among kebeles (local wards) than in the birth weight of new-borns (11%) indicating more heterogeneity in clusters for length-for-age Z-score and weight-for-length Z-score than for birth weight (Paper II). We found that pregnant mothers had a poor compliance of ANC utilization compared to the national and the WHO guidelines. In addition, we found that the current FANC utilization status were not associated with the adverse pregnancy outcomes that we measured (Paper III). Conclusions In conclusion, this thesis demonstrated that; (i) foetal growth patterns were similar to the INTERGROWTH-21st and the WHO multicentre foetal growth reference standards, (ii) early intrauterine foetal growth affected both birth weight and linear growth while foetal growth during late pregnancy influenced birth weight only. In addition, there was more influence of environmental factors on child linear growth compared to their effects on birth weight and, (iii) ANC service utilization is low in the context of national and WHO guidelines. In addition, there was no association between the current focused antenatal health care service and adverse pregnancy outcomes.  Doktorgradsavhandlin

Influence of intrauterine factors on birth weight and on child linear growth in rural Ethiopia: A prospective cohort study

Introduction Little is known about the influence of intrauterine fetal factors on childhood growth in low-income countries. The objective of this study was to examine the influence of intrauterine fetal growth on child linear growth in rural Ethiopia. Methods We conducted a prospective community-based cohort study from July 2016 to October 2018. All pregnant women with gestational age of 24 weeks or below living in 13 kebeles, in central Ethiopia were enrolled. The fetuses were followed from pregnancy up to 11–24 months after birth. We measured biparietal diameter, head circumference, femoral length, and abdominal circumference at 26, 30 and 36 weeks of pregnancy. At birth, we measured infant weight. At 11–24 months of age, z-scores of length- for- age, and weight-for-length were calculated. A multilevel, mixed-effect, linear regression model was used to examine the influence of fetal, newborn, maternal, household factors and residence area on child linear growth. Results We included 554 children. The prevalence rate of stunting was 54.3% and that of wasting was 10.6%. Fetal biparietal diameter, head circumference, and abdominal circumference, were significantly associated with birth weight. Femoral length z-score in early pregnancy, gestational age at delivery and child age were significantly associated with length-for-age z-score. Family size was significantly associated with length-for-age z-score. Family size and maternal height were associated with weight-for-height z-score. There was a large variation in length-for-age z-score (Intra cluster correlation, or ρ (rho) = 0.30) and weight-for-length z-score (ρ = 0.22) than of birth weight of new-born (ρ = 0.11) in kebeles indicating heterogeneity in clusters for length-for-age z-score and weight-for-length z-score than birth weight. Conclusions Child linear growth was influenced by fetal growth, duration of pregnancy, maternal height, and family size. Environmental factors that are associated with the area of residence play a bigger role for linear growth than for birth weight.publishedVersio

Anaemia among children in a drought affected community in south-central Ethiopia.

INTRODUCTION: As part of a field trial (PACTR201411000882128) to provide evidence on the combined use of long-lasting insecticidal nets and indoor residual spray for malaria prevention, we measured haemoglobin values among children aged 6 to 59 months. The aim of this study was to estimate the prevalence of anaemia, and to determine the risk factors of anaemia and change in haemoglobin value in Adami Tullu district in south-central Ethiopia. METHODS: Repeated cross-sectional surveys among 2984 children in 2014 and 3128 children in 2015; and a cohort study (malaria as exposure and anaemia as outcome variable) were conducted. The study area faced severe drought and food shortages in 2015. Anaemia was diagnosed using HemoCue Hb 301, and children with haemoglobin <11 g/dl were classified as anaemic. Multilevel and Cox regression models were applied to assess predictors of anaemia. RESULTS: The prevalence of anaemia was 28.2% [95% Confidence Interval (CI), 26.6-29.8] in 2014 and increased to 36.8% (95% CI, 35.1-38.5) in 2015 (P<0.001). The incidence of anaemia was 30; (95% CI, 28-32) cases per 100 children years of observation. The risk of anaemia was high (adjusted Hazard Ratio = 10) among children with malaria. Children from poor families [Adjusted Odds Ratio (AOR); 1.3; 95% CI, 1.1-1.6)], stunted children (AOR 1.5; 95% CI; 1.2-1.8), and children aged less than 36 months (AOR; 2.0; 95% CI, 1.6-2.4) were at risk of anaemia compared to their counterparts. There was no significant difference in risk of anaemia among the trial arms. CONCLUSIONS: Young age, stunting, malaria and poverty were the main predictors of anaemia. An increase in the prevalence of anaemia was observed over a year, despite malaria prevention effort, which could be related to the drought and food shortage. Therefore, conducting trials in settings prone to drought and famine may bring unexpected challenges

Long-lasting insecticidal nets and indoor residual spraying may not be sufficient to eliminate malaria in a low malaria incidence area: results from a cluster randomized controlled trial in Ethiopia.

BACKGROUND: Conflicting results exist on the added benefit of combining long-lasting insecticidal nets (LLINs) with indoor residual spraying (IRS) to control malaria infection. The main study objective was to evaluate whether the combined use of LLINs and IRS with propoxur provides additional protection against Plasmodium falciparum and/or Plasmodium vivax among all age groups compared to LLINs or IRS alone. METHODS: This cluster-randomized, controlled trial was conducted in the Rift Valley area of Ethiopia from September 2014 to January 2017 (121 weeks); 44 villages were allocated to each of four study arms: LLIN + IRS, IRS, LLIN, and control. Each week, 6071 households with 34,548 persons were surveyed by active and passive case detection for clinical malaria. Primary endpoints were the incidence of clinical malaria and anaemia prevalence. RESULTS: During the study, 1183 malaria episodes were identified, of which 55.1% were P. falciparum and 25.3% were P. vivax, and 19.6% were mixed infections of P. falciparum and P. vivax. The overall malaria incidence was 16.5 per 1000 person-years of observation time (PYO), and similar in the four arms with 17.2 per 1000 PYO in the LLIN + IRS arm, 16.1 in LLIN, 17.0 in IRS, and 15.6 in the control arm. There was no significant difference in risk of anaemia among the trial arms. CONCLUSIONS: The clinical malaria incidence and anaemia prevalence were similar in the four study groups. In areas with low malaria incidence, using LLINs and IRS in combination or alone may not eliminate malaria. Complementary interventions that reduce residual malaria transmission should be explored in addition to LLINs and IRS to further reduce malaria transmission in such settings. Trial registration PACTR201411000882128 (08 September 2014)

Experience of Research Undertaking among Women Academia at Addis Ababa University: a Qualitative Study

AbstractBackground: As a pioneer University in the Country, Addis Ababa University engages itself in collaborative and local research undertakings along with teaching, community engagements and technology transfer. Despite its long engagement in research, the participation of women academia in research is limited as manifested by their low research productivity in terms of publication in peer-reviewed scientific journals. However, the reasons for their low research participation are less known and needs further exploration. Objective: To explore the experience of research undertakings among women academia at Addis Ababa University. Method: We conducted an exploratory qualitative study using a phenomenological approach among women academia. Eight women who have been working in the University with a rank of a lecturer having at least two years participated in in-depth interviews. We used NVivo10 software to code and categorize the transcripts. Result: Our study revealed that only a few senior informants with more than 10 years of stay at the University had a better experience in applying for national and international research grants. Although all the participants said they had ever undertaken research, their publication track in peer-reviewed journals is limited. Social and economic factors, lack of networking, low salary and family responsibility, limited internet and library access, and lack of research skill among young faculty were raised as impediments to undertake research. Conclusion: This study has indicated that women in academia had limited research engagement in terms of grant application and publication in peer reviewed scientific journals. Balancing work and family life, low salary, lack of access to common University facilities were some of the challenges. While structural change ensures gender equality at a long time, addressing the gender gap in research is the responsibility of AAU. [Ethiop. J. Health Dev. 2021; 35(SI-2):22-29]Keywords: Addis Ababa University, experience of research, women in academi

Cohabitation duration, obstetric, behavioral and nutritional factors predict preeclampsia among nulliparous women in West Amhara Zones of Ethiopia: Age matched case control study.

BACKGROUND:Preeclampsia is a major cause of maternal and perinatal mortality in developing countries. Identifying its risk factors is essential for early diagnosis and management. However, there has been a paucity of information on predictors of preeclampsia among nulliparous women in a resource limited setting. This study bridges the gap in this regard by examining the association of cohabitation duration, obstetric, behavioral and nutrition factors with preeclampsia among nulliparous women in West Amhara Zones of Ethiopia. METHODS:Age matched case-control study design was employed among 110 preeclamptic and 220 non-preeclamptic women who came for delivery services at Felege Hiwot, Addis Alem, and Debre Tabor hospitals. Double population proportion formula with an assumption of 95% confidence interval, 80% power and a 2:1 control to case ratio was used to calculate sample size. Epi data 3.1 and SPSS 20 were used for data entry and analysis, respectively. Magnitudes of cohabitation duration, obstetric, behavioral and nutritional factors among nulliparous women with preeclampsia and their controls were calculated and the differences were tested with a Chi-square test. Conditional bivariable and multivariable logistic regression analysis were fitted to identify predictors of preeclampsia. Odds ratio along with their 95% confidence interval were used to identify the strength, direction and significance of association. Ethical clearance was secured from the research ethics committee of the School of Public Health in Addis Ababa University. RESULTS:A total of 107 cases and 214 controls completed the interview giving a response rate of 97.27% for both cases and controls. Short cohabitation duration (AOR = 2.13, 95% CI (1.10, 4.1)), unplanned pregnancy (AOR = 2.35, 95% CI (1.01, 5.52)), and high body weight (AOR = 2.00, 95% CI (1.10, 3.63)) were found to be significant risk factors for preeclampsia. Whereas, antenatal advice about nutrition (AOR = 0.52, 95% CI (0.29, 0.96)), vegetable intake (AOR = 0.42, 95% CI (0.22, 0.82)) and fruit intake during pregnancy (AOR = 0.45, 95% CI (0.24, 0.87)) were protective factors for preeclampsia. CONCLUSION:Special attention should be given to nulliparous women with short cohabitation duration, unplanned pregnancy, and high body weight to minimize the effect of preeclampsia. Nutritional counseling shall be stressed during antenatal care follow ups

Antenatal care utilization and compliance with national and WHO guidelines in rural Ethiopia: a cohort study

Background Antenatal health care utilization has the potential to influence maternal and new-born health. In this study, we assessed compliance of antenatal care utilization with national and World Health Organization (WHO) guidelines. We also examined association of antenatal care utilization with adverse pregnancy outcomes as secondary outcome. Methods This was a community-based cross sectional study conducted from July 2016 to November 2017 in rural south-central Ethiopia. We described antenatal care received by pregnant women, whom we followed at three prescheduled visits during pregnancy and collected birth data at time of delivery. Extent of antenatal care content received, timing of antenatal care, place of antenatal care and place and mode of delivery were obtained and computed in accordance with national and WHO guidelines. For adverse pregnancy outcomes, computed as sum of low birth weight, preterm birth, intrauterine foetal death, and stillbirth, the exposure variable used was antenatal care utilization. Results Seven hundred and four (704) women participated in the study, and 536 (76.1%) had attended at least one antenatal care visit. Among women who attended antenatal care visit, majority, 421 (79.3%), had done so at health centres and hospitals, while 110 (20.7%) attended at health post. Average number of antenatal care visits was 2.5, which is less than that recommended in national and WHO guidelines. Only 18 (2.6%) women had attended antenatal care in their first trimester, which is low in contrast to the expected 100% specified in the guidelines. Less than half (47%) of the women delivered in a health facility. This is in contrast to the 100% expected health institution deliveries. Low birth weight was 7.9% (n = 48), and preterm birth was 4.9% (n = 31). There were 12 twin pregnancies, three stillbirths, 11 spontaneous abortions, and two intrauterine foetal deaths. We did not find significant association between adverse pregnancy outcomes and antenatal care utilization (COR = 1.07, 95% CI 0.62, 1.86). Conclusion This study showed that antenatal care service utilization in the study area was markedly low compared to that recommended in national and WHO guidelines. The obtained antenatal health care utilization was not associated with the registered adverse pregnancy outcomes.publishedVersio

Influence of intrauterine factors on birth weight and on child linear growth in rural Ethiopia: A prospective cohort study

Introduction Little is known about the influence of intrauterine fetal factors on childhood growth in low-income countries. The objective of this study was to examine the influence of intrauterine fetal growth on child linear growth in rural Ethiopia. Methods We conducted a prospective community-based cohort study from July 2016 to October 2018. All pregnant women with gestational age of 24 weeks or below living in 13 kebeles, in central Ethiopia were enrolled. The fetuses were followed from pregnancy up to 11–24 months after birth. We measured biparietal diameter, head circumference, femoral length, and abdominal circumference at 26, 30 and 36 weeks of pregnancy. At birth, we measured infant weight. At 11–24 months of age, z-scores of length- for- age, and weight-for-length were calculated. A multilevel, mixed-effect, linear regression model was used to examine the influence of fetal, newborn, maternal, household factors and residence area on child linear growth. Results We included 554 children. The prevalence rate of stunting was 54.3% and that of wasting was 10.6%. Fetal biparietal diameter, head circumference, and abdominal circumference, were significantly associated with birth weight. Femoral length z-score in early pregnancy, gestational age at delivery and child age were significantly associated with length-for-age z-score. Family size was significantly associated with length-for-age z-score. Family size and maternal height were associated with weight-for-height z-score. There was a large variation in length-for-age z-score (Intra cluster correlation, or ρ (rho) = 0.30) and weight-for-length z-score (ρ = 0.22) than of birth weight of new-born (ρ = 0.11) in kebeles indicating heterogeneity in clusters for length-for-age z-score and weight-for-length z-score than birth weight. Conclusions Child linear growth was influenced by fetal growth, duration of pregnancy, maternal height, and family size. Environmental factors that are associated with the area of residence play a bigger role for linear growth than for birth weight

Reproductive Health Right Practice among Preparatory School Female Students of Assela Town, Arsi Zone, Oromia Regional State, Ethiopia

Introduction. Knowledge and practice toward reproductive health right (RHR) is critical to protect young women, especially school girls, from unwanted reproductive outcomes as improving access to reproductive health services. However, the majority of young people including female secondary school students in Ethiopia have very little knowledge on the youth’s reproductive health rights. The aim of this study was to assess knowledge and practice toward reproductive health right among preparatory female students in Assela Town, Arsi Zone, Ethiopia. Methods. A study was conducted among 403 preparatory school female students in Assela Town. Simple random sampling was employed to select the subjects, and a self-administered questionnaire was used to collect data. The collected data were entered using EPI Info version 3.5.4 and exported to SPSS version 21 for analysis. Descriptive and logistic regression analysis was carried out. Result. Sixty percent of girls discussed reproductive issues openly with their peers. About 94% of the respondents knew, at least, one contraceptive method; injectable (91.2%) was the most known type of contraceptives. Marital status, father occupation, discussion on sexual and reproductive issues, and having sexual partners were affecting the practice of reproductive health rights. Conclusions. Knowledge of the students was moderate on reproductive health right which was 70%. Practice of sexual and reproductive health rights was 22.6% among the study participants. It is recommended that promotion on sexual and reproductive health right through media is important

Do Health and Demographic Surveillance Systems benefit local populations? Maternal care utilisation in Butajira HDSS, Ethiopia

Background: The benefits of Health and Demographic Surveillance sites for local populations have been the topic of discussion as countries such as Ethiopia take efforts to achieve their Millennium Development Goal targets, on which they lag behind. Ethiopia's maternal mortality ratio is very high, and in the 2011 Ethiopia Demographic and Health Survey (2011 EDHS) it was estimated to be 676/100,000 live births. Recent Global Burden of Disease (GBD) and estimates based on the United Nations model reported better, but still unacceptably high, figures of 497/100,000 and 420/100,000 live births for 2013. In the 2011 EDHS, antenatal care (ANC) utilization was estimated at 34%, and delivery in health facilities was only 10%. Objectives: To compare maternal health service utilization among populations in a Health and Demographic Surveillance System (HDSS) to non-HDSS populations in Butajira district, south central Ethiopia. Design: A community-based comparative cross-sectional study was conducted in January and February 2012 among women who had delivered in the 2 years before the survey. Results: A total of 2,296 women were included in the study. One thousand eight hundred and sixty two (81.1%) had attended ANC at least once, and 37% of the women had attended ANC at least four times. A quarter of the women delivered their last child in a health facility. Of the women living outside the HDSS areas, 715 (75.3%) attended ANC at least once compared to 85.1% of women living in the HDSS areas [adjusted odds ratio (AOR) 0.59; 95% CI 0.46, 0.74]. Of the women living outside the HDSS areas, only 170 (17.9%) delivered in health facilities and were assisted by skilled attendants during delivery, whereas 30.0% of those living in HDSS areas delivered in health facilities (AOR 0.66; 95% CI 0.48, 0.91). Conclusion: This paper provides possible evidence that living in an HDSS site has a positive influence on maternal health. In addition, there may be a positive influence on those living nearby or in the same district where an HDSS is located even when not included in the surveillance system