Barriers in physical access to maternal health services in rural Ethiopia.

BACKGROUND: Identifying women with poor access to health services may inform strategies for improving maternal and child health outcomes. The aim of this study was to explore risk factors associated with access to health facilities (in terms of physical distance) among women of reproductive age (15-49 years) in Dabat district, a rural area of north-western Ethiopia. METHODS: A randomly selected cross sectional survey of 1,456 rural households was conducted. Data were collected during home visits. Data on household assets and socio-demographic data (including age, education level, occupation, religion and ethnicity) were collected on 1,420 women. A geographic information system (GIS) was used to map locations of all households, the district health centre and the smaller health posts. Travel time from households to health facilities was estimated, incorporating information on the topography and terrain of the area. The primary outcomes were: 1) travel time from household to nearest health post 2) travel time from household to health centre. Analysis was conducted using multiple linear regression models and likelihood ratio tests. RESULTS: This study found evidence that educated women lived closer to health centres than uneducated women (adjusted mean difference (adj MD) travel time -41 min (95% CI: -50,-31)) in this community. Woman's age was also associated with distance to the health centre. Women aged 15-20 years were more likely to live in a poor access area compared with women aged 21-30 years (adj MD travel time -11 min (95% CI: -23, 0)), and with women aged 31-49 years (adj MD travel time -32 min (95% CI: -47,-17)). There was no evidence to suggest that travel time to the health centre was associated with household wealth. CONCLUSIONS: Our main aim was to address the almost total lack of research evidence on what socio-demographic characteristics of women of reproductive age influence access to health facilities (in terms of physical distance). We have done so by reporting that our study found an association that women with no education and women who are younger live, on average, further away from a health facility in this rural Ethiopian community. While we have generated this valuable information to those who are responsible for providing maternal and child health services locally, to fully understand access in health care and to promote equitable access to health care, our study could thus be extended to other components of access and explore how our findings fit into the wider context of other factors influencing maternal health outcomes and utilisation of maternal health services such as antenatal care or delivery at health facility

Community-based child care: household and health-facility perspectives. Dagu Baseline Survey, Ethiopia, December 2016 - February 2017

Ethiopia successfully met the child mortality Millennium Development Goal. An increased utilisation of primary care services for pregnant women, newborns and children is a prerequisite for further improvement in newborn and child survival. To address this under utilisation of services, the Federal Ministry of Health, together with implementing partners UNICEF and PATH, initiated the ‘Optimizing the Health Extension Program’ (OHEP) in four regions in Ethiopia

Prevention and treatment of suspected pneumonia in Ethiopian children less than five years from household to primary care.

AIM: Ethiopia has implemented the integrated community case management to reduce mortality in childhood diseases. We analysed prevention, care seeking and treatment of suspected pneumonia from household to health facility in Ethiopia. METHODS: Analyses were based on a survey in four regions that included modules covering 5714 households, 169 health posts with 276 health extension workers and 155 health centres with 175 staff. Caregivers of children aged 2-59 months responded to questions on awareness of services and care seeking for suspected pneumonia. Pneumonia-related knowledge of health workers was assessed. RESULTS: When a child had suspected pneumonia, 46% (95% CI: 25,68) sought care at health facilities, and 27% (95% CI: 12,51) received antibiotics. Forty-one per cent had received full immunisation. One-fifth (21%, 95%: 19,22) of the caregivers were aware of pneumonia treatment. Sixty-four per cent of the health extension workers correctly mentioned fast or difficult breathing as signs of suspected pneumonia, and 88% suggested antibiotics treatment. CONCLUSION: The caregivers' awareness of suspected pneumonia treatment and the utilisation of these services were low. Some of the health extension workers were not knowledgeable about suspected pneumonia. Strengthening primary health care, including immunisation, and enhancing the utilisation of services are critical for further reduction of pneumonia mortality

Geographic differences in maternal and child health care utilization in four Ethiopian regions; a cross-sectional study.

BACKGROUND: Maternal and child health (MCH) care utilization often vary with geographic location. We analyzed the geographic distribution and determinants of utilization of four or more antenatal care visits, health facility delivery, child immunization, and care utilization for common childhood illnesses across four Ethiopian regions. METHODS: A cross-sectional community-based study was employed with two-staged stratified cluster sampling in 46 districts of Ethiopia. A total of 6321 women (13-49 years) and 3110 children below the age of 5 years residing in 5714 households were included. We performed a cluster analysis of the selected MCH care utilization using spatial autocorrelation. We identified district-specific relationships between care coverage and selected factors using geocoded district-level data and ordinary least squares and hotspot analysis using Getis Ord Gi*. RESULTS: Of the 6321women included in the study, 714 had a live birth in the 12 months before the survey. One-third of the women (30, 95% CI 26-34) had made four or more antenatal visits and almost half of the women (47, 95% CI 43-51) had delivered their most recent child at a health facility. Nearly half of the children (48, 95% CI 40-57) with common childhood illnesses (suspected pneumonia, diarrhoea, or fever) sought care at the health facilities. The proportion of fully immunized children was 41% (95%, CI 37-45). Institutional delivery was clustered at district level (spatial autocorrelation, Moron's I = 0.217, P < 0.01). Full immunization coverage was also spatially clustered (Moron's I = 0.156, P-value < 0.1). Four or more antenatal visits were associated with women's age and parity, while the clustering of institutional delivery was associated with the number of antenatal care visits. Clustering of full immunization was associated with household members owning a mobile phone. CONCLUSIONS: This study showed evidence for geographic clustering in coverage of health facility deliveries and immunization at the district level, but not in the utilization of antenatal care and utilization of health services for common childhood illnesses. Identifying and improving district-level factors that influenced these outcomes may inform efforts to achieve geographical equitability and universal health coverage

Caregivers' and Health Extension Workers' Perceptions and Experiences of Outreach Management of Childhood Illnesses in Ethiopia: A Qualitative Study.

INTRODUCTION: Ethiopian Health Extension Workers provide facility-based and outreach services, including home visits to manage sick children, aiming to increase equity in service coverage. Little is known about the scope of the outreach services and caregivers' and health workers' perceptions of these services. We aimed at exploring mothers' and health extension workers' perceptions and experiences of the outreach services provided for the management of childhood illnesses. METHODS: Four focus groups and eight key informant interviews were conducted. A total of 45 community members participated. Interviews were recorded, transcribed verbatim, and translated into English. We applied thematic content analysis, identified challenges in providing outreach services, and suggestions for improvement. We balanced the data collection by selecting half of the participants for interview and focus group discussions from remote areas and the other half from areas closer to the health posts. RESULTS: Mothers reported that health extension workers visited their homes for preventive services but not for managing childhood illnesses. They showed lack of trust in the health workers' ability to treat children at home. The health extension workers reported that they provide sick children treatment during outreach services but also stated that in most cases, mothers visit the health posts when their child is sick. On the other hand, mothers considered distance from home to health post not to be a problem if the quality of services improved. Workload, long distances, and lack of incentives were perceived as demotivating factors for outreach services. The health workers called for support, incentives, and capacity development activities. CONCLUSIONS: Mothers and health extension workers had partly divergent perceptions of whether outreach curative services for children were available. Mothers wanted improvements in the quality of services while health workers requested capacity development and more support for providing effective community-based child health services

Distance, difference in altitude and socioeconomic determinants of utilisation of maternal and child health services in Ethiopia: a geographic and multilevel modelling analysis.

Objective We assessed whether geographic distance and difference in altitude between home to health facility and household socioeconomic status were associated with utilisation of maternal and child health services in rural Ethiopia. Design Household and health facility surveys were conducted from December 2018 to February 2019.SettingForty-six districts in the Ethiopian regions: Amhara, Oromia, Tigray and Southern Nations, Nationalities, and Peoples. Participants A total of 11 877 women aged 13-49 years and 5786 children aged 2-59 months were included.Outcome measuresThe outcomes were four or more antenatal care visits, facility delivery, full child immunisation and utilisation of health services for sick children. A multilevel analysis was carried out with adjustments for potential confounding factors. Results Overall, 39% (95% CI: 35 to 42) women had attended four or more antenatal care visits, and 55% (95% CI: 51 to 58) women delivered at health facilities. One in three (36%, 95% CI: 33 to 39) of children had received full immunisations and 35% (95% CI: 31 to 39) of sick children used health services. A long distance (adjusted OR (AOR)=0.57; 95% CI: 0.34 to 0.96) and larger difference in altitude (AOR=0.34; 95% CI: 0.19 to 0.59) were associated with fewer facility deliveries. Larger difference in altitude was associated with a lower proportion of antenatal care visits (AOR=0.46; 95% CI: 0.29 to 0.74). A higher wealth index was associated with a higher proportion of antenatal care visits (AOR=1.67; 95% CI: 1.02 to 2.75) and health facility deliveries (AOR=2.11; 95% CI: 2.11 to 6.48). There was no association between distance, difference in altitude or wealth index and children being fully immunised or seeking care when they were sick. Conclusion Achieving universal access to maternal and child health services will require not only strategies to increase coverage but also targeted efforts to address the geographic and socioeconomic differentials in care utilisation, especially for maternal health. Trial registration number ISRCTN12040912

Implementation of the 'Optimising the Health Extension Program' Intervention in Ethiopia: A Process Evaluation Using Mixed Methods.

An intervention called 'Optimising the Health Extension Program', aiming to increase care-seeking for childhood illnesses in four regions of Ethiopia, was implemented between 2016 and 2018, and it included community engagement, capacity building, and district ownership and accountability. A pragmatic trial comparing 26 districts that received the intervention with 26 districts that did not found no evidence to suggest that the intervention increased utilisation of services. Here we used mixed methods to explore how the intervention was implemented. A fidelity analysis of each 31 intervention activities was performed, separately for the first phase and for the entire implementation period, to assess the extent to which what was planned was carried out. Qualitative interviews were undertaken with 39 implementers, to explore the successes and challenges of the implementation, and were analysed by using thematic analysis. Our findings show that the implementation was delayed, with only 19% (n = 6/31) activities having high fidelity in the first phase. Key challenges that presented barriers to timely implementation included the following: complexity both of the intervention itself and of administrative systems; inconsistent support from district health offices, partly due to competing priorities, such as the management of disease outbreaks; and infrequent supervision of health extension workers at the grassroots level. We conclude that, for sustainability, evidence-based interventions must be aligned with national health priorities and delivered within an existing health system. Strategies to overcome the resulting complexity include a realistic time frame and investment in district health teams, to support implementation at grassroots level

National routine data for low birthweight and preterm births: Systematic data quality assessment for United Nations member states (2000-2020).

OBJECTIVE: Low birthweight (700 million live births. The WHO data quality framework was adapted to undertake standardised data quality assessments. MAIN OUTCOME MEASURES: Availability, reporting quality, internal and external consistency of low birthweight and preterm data. RESULTS: Most United States Member States (64%: 124/195) had national data on low birthweight and (40%: 82/195) had data on preterm birth. Routine data system reporting was highest in North America, Australasia and Europe, where more than 95% live births had data on low birthweight and over 75% had data preterm births. In contrast, data reporting was lowest in sub-Saharan Africa (13% for low birthweight, 8% for preterm births) and Southern Asia (16% for low birthweight, 5% for preterm births). Most countries collect individual-level data; but, aggregate data reporting from hospital-based systems remain common in sub-Saharan Africa and Southern Asia. While data quality was generally high in North America, Australasia and Europe, gaps remain in the availability of gestational age metadata. Consistency between low birthweight and preterm rates were poor in Southern Asia and sub-Saharan Africa regions across time. There was high external consistency between low birthweight rates obtained from routine administrative data compared with low birthweight rates obtained from survey data for countries with high data quality. CONCLUSIONS: Sub-Saharan Africa and South Asia countries have data gaps but also opportunities for rapid progress. Most births occure in facilities, electronic health information systems already include low birthweight, and adding accurate gestational age including with ultrasound assessment is becoming increasingly attainable. Moving toward the collection of individual level data would enable monitoring of quality of care and longer-term outcomes. This is crucial for every child and family and essential for measuring progress towards relevant sustainable development goals. The assessment will inform countries' actions for data quality improvement at national level and use of data for impact

District health management and stillbirth recording and reporting: a qualitative study in the Ashanti Region of Ghana

BACKGROUND: Despite global efforts to reduce maternal and neonatal mortality, stillbirths remain a significant public health challenge in many low- and middle-income countries. District health systems, largely seen as the backbone of health systems, are pivotal in addressing the data gaps reported for stillbirths. Available, accurate and complete data is essential for District Health Management Teams (DHMTs) to understand the burden of stillbirths, evaluate interventions and tailor health facility support to address the complex challenges that contribute to stillbirths. This study aims to understand stillbirth recording and reporting in the Ashanti Region of Ghana from the perspective of DHMTs. METHODS: The study was conducted in the Ashanti Region of Ghana. 15 members of the regional and district health directorates (RHD/DHD) participated in semi-structured interviews. Sampling was purposive, focusing on RHD/DHD members who interact with maternity services or stillbirth data. Thematic analyses were informed by an a priori framework, including theme 1) experiences, perceptions and attitudes; theme 2) stillbirth data use; and theme 3) leadership and support mechanisms, for stillbirth recording and reporting. RESULTS: Under theme 1, stillbirth definitions varied among respondents, with 20 and 28 weeks commonly used. Fresh and macerated skin appearance was used to classify timing with limited knowledge of antepartum and intrapartum stillbirths. For theme 2, data quality checks, audits, and the district health information management system (DHIMS-2) data entry and review are functions played by the DHD. Midwives were blamed for data quality issues on omissions and misclassifications. Manual entry of data, data transfer from the facility to the DHD, limited knowledge of stillbirth terminology and periodic closure of the DHIMS-2 were seen to proliferate gaps in stillbirth recording and reporting. Under theme 3, perinatal audits were acknowledged as an enabler for stillbirth recording and reporting by the DHD, though audits are mandated for only late-gestational stillbirths (> 28 weeks). Engagement of other sectors, e.g., civil/vital registration and private health facilities, was seen as key in understanding the true population-level burden of stillbirths. CONCLUSION: Effective district health management ensures that every stillbirth is accurately recorded, reported, and acted upon to drive improvements. A large need exists for capacity building on stillbirth definitions and data use. Recommendations are made, for example, terminology standardization and private sector engagement, aimed at reducing stillbirth rates in high-mortality settings such as Ghana

Protocol for the evaluation of a complex intervention aiming at increased utilisation of primary child health services in Ethiopia: a before and after study in intervention and comparison areas.

BACKGROUND: By expanding primary health care services, Ethiopia has reduced under-five mor4tality. Utilisation of these services is still low, and concerted efforts are needed for continued improvements in newborn and child survival. "Optimizing the Health Extension Program" is a complex intervention based on a logic framework developed from an analysis of barriers to the utilisation of primary child health services. This intervention includes innovative components to engage the community, strengthen the capacity of primary health care workers, and reinforce the local ownership and accountability of the primary child health services. This paper presents a protocol for the process and outcome evaluation, using a pragmatic trial design including before-and-after assessments in both intervention and comparison areas across four Ethiopian regions. The study has an integrated research capacity building initiative, including ten Ph.D. students recruited from Ethiopian Regional Health Bureaus and universities. METHODS: Baseline and endline surveys 2 years apart include household, facility, health worker, and district health office modules in intervention and comparison areas across Amhara, Southern Nations Nationalities and Peoples, Oromia, and Tigray regions. The effectiveness of the intervention on the seeking and receiving of appropriate care will be estimated by difference-in-differences analysis, adjusting for clustering and for relevant confounders. The process evaluation follows the guidelines of the UK Medical Research Council. The implementation is monitored using data that we anticipate will be used to describe the fidelity, reach, dose, contextual factors and cost. The participating Ph.D. students plan to perform in-depth analyses on different topics including equity, referral, newborn care practices, quality-of-care, geographic differences, and other process evaluation components. DISCUSSION: This protocol describes an evaluation of a complex intervention that aims at increased utilisation of primary and child health services. This unique collaborative effort includes key stakeholders from the Ethiopian health system, the implementing non-governmental organisations and universities, and combines state-of-the art effectiveness estimates and process evaluation with capacity building. The lessons learned from the project will inform efforts to engage communities and increase utilisation of care for children in other parts of Ethiopia and beyond. TRIAL REGISTRATION: Current Controlled Trials ISRCTN12040912, retrospectively registered on 19 December, 2017