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

Female Academic Career Development and Administrative Positions at Addis Ababa University: a Mixed-Method Study

AbstractBackground: In Ethiopia, the number of female in academia in general and in administrative positions and higher university ranks in specific is very small as compared to men. A slight change has been seen in recent years, where a few women have come to male-dominated administrative positions as university presidents, vice presidents, deans and directors with still insignificant increase in the number of full professors. Objective: This study assessed female faculty member's career development and involvement in administrative positions and explored challenges. Method: We used a sequential mixed-method study starting with a cross-sectional quantitative study among 888 faculty members. The quantitate data were analysed using descriptive statistics and regression models to identify independent predictors of administrative involvement using SPSS version 25 software. An exploratory qualitative study was done among eight purposively selected female faculty. NVivo10 data management software was used to code and categorize the transcripts. Result: We found that male faculty members were more likely to involve in administrative positions than their female counterparts [AOR (95%CI) 1.6(1.1, 2.4)]. Those who were provided housing facility by AAU [AOR (95%CI) 2.29 (1.61, 3.23)] and assistant professors and above [AOR (95%CI) 1.495 (1.01, 2.220)] were more likely to involve in an administrative position than their counterparts. The qualitative findings indicated that the low salary faculty earns, lack of networks and family responsibility have deterred females from taking administrative positions. Conclusion: Female faculty involvement in the university administrative position and career development is very low. Both structural and personal factors such as gender roles affected their professional enhancement in academic ranks and hence positions. Creating a conducive platform for female faculty development is recommended to increase their involvement in administrative positions. [Ethiop. J. Health Dev. 2021; 35(SI-2):30-39]Keywords: Addis Ababa University, administrative positions, career development, female academician, female facult

Gender Difference in Research Productivity and its Associated factors in Addis Ababa University: a Cross-Sectional study

AbstractBackground: Gender equity movements have increased the number of women going to higher institutions. However, the number of women participating in research is limited in creating a critical mass. Objective: To assess the gender gap in research and its associated factors determinants among faculty at Addis Ababa University. Method: We conducted a cross-sectional study from October 2018 to March 2019 using a structured self-administered questionnaire. University faculty who was lecturers and above level who served the University for more than a year were invited to participate in the study. Faculty were approached by data collection facilitators with graduate degrees and the secretory of the respective departments. We used descriptive and multivariate statistical methods to analyse the data. Result: Of the 888 study participants, 161 (18.1%) females faculty participated in the study. It was found that three hundred ninety-seven male academics (54.6%) and 50 female academics (31.1%) had ever published articles in peer-reviewed journals (p<0.001). Male faculty were more likely to publish in peer-reviewed journals than their female counterparts [AOR and (95% CI) [2.55 (1.68, 3.86)]. Faculty with a rank of assistant professors and above [AOR (95% CI) 3.47(2.31, 5.21)], those who have a Ph.D. as highest degree [AOR (95% CI) 2.98 (2.11, 4.19) and those who have affiliation with other institutions [AOR (95% CI) 2.59 (1.98, 3.56)], were more likely to publish in peer-reviewed journals than their counterparts. Conclusion: Female faculty were less likely to be involved in research than men counterparts. The University needs to narrow the gender gap in research by designing and implementing an appropriate intervention strategy. [Ethiop. J. Health Dev. 2021; 35(SI-2):15-21]Keywords: Addis Ababa University, female faculty, gender difference, publication, researc

Intrauterine growth patterns in rural Ethiopia compared with WHO and INTERGROWTH-21st growth standards: A community-based longitudinal study

Introduction Children’s well-being is highly influenced by their fetal growth. Adequate intrauterine growth (IUG) is a basic feature of a healthy pregnancy. The aim of our study was to assess IUG patterns in a rural and drought-affected population in the Rift Valley area of the Adami Tullu district in Oromia, Ethiopia. Methods We conducted a longitudinal, community-based study of IUG patterns utilizing serial ultrasound measurements. Data were collected for 17 months, from July 2016 to November 2017. We included 675 singleton foetuses ≤ 24 weeks old, based on ultrasound-derived estimates of gestational age, and followed them until delivery. We obtained head circumference, biparietal diameter, abdominal circumference, femur length, and estimated fetal weight at 26, 30, and 36 weeks. Fetal weight was estimated using the Hadlock algorithm, and the 5th, 10th, 25th, 50th, 75th, 90th, and 95th centiles were developed from this model. We compared the biometric measurements and fetal weight data from our study to the World Health Organization (WHO) and INTERGROWTH-21st fetal growth reference standards. Results Distribution of the biometric measurements and estimated fetal weights in our study were similar to those for 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 of our study had similar distribution patterns to the WHO chart, and the 50th percentile had a similar pattern to the INTERGROWTH-21st chart. Conclusions Our study determined fetal growth patterns in a drought-affected rural community of Ethiopia using common ultrasound biometric measurements. We found similar IUG patterns to those indicated in the WHO and INTERGROWTH-21st fetal growth reference standards

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

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

Development and validation of a risk score to predict low birthweight using characteristics of the mother : analysis from BUNMAP cohort in Ethiopia

At least one ultrasound is recommended to predict fetal growth restriction and low birthweight earlier in pregnancy. However, in low-income countries, imaging equipment and trained manpower are scarce. Hence, we developed and validated a model and risk score to predict low birthweight using maternal characteristics during pregnancy, for use in resource limited settings. We developed the model using a prospective cohort of 379 pregnant women in South Ethiopia. A stepwise multivariable analysis was done to develop the prediction model. To improve the clinical utility, we developed a simplified risk score to classify pregnant women at high- or low-risk of low birthweight. The accuracy of the model was evaluated using the area under the receiver operating characteristic curve (AUC) and calibration plot. All accuracy measures were internally validated using the bootstrapping technique. We evaluated the clinical impact of the model using a decision curve analysis across various threshold probabilities. Age at pregnancy, underweight, anemia, height, gravidity, and presence of comorbidity remained in the final multivariable prediction model. The AUC of the model was 0.83 (95% confidence interval: 0.78 to 0.88). The decision curve analysis indicated the model provides a higher net benefit across ranges of threshold probabilities. In general, this study showed the possibility of predicting low birthweight using maternal characteristics during pregnancy. The model could help to identify pregnant women at higher risk of having a low birthweight baby. This feasible prediction model would offer an opportunity to reduce obstetric-related complications, thus improving the overall maternal and child healthcare in low- and middle-income countries

Mycotoxins exposure of lactating women and its relationship with dietary and pre/post-harvest practices in rural Ethiopia

Mycotoxins can be transferred to breast milk during lactation. Hence, the presence of multiple mycotoxins (aflatoxins B1, B2, G1, G2, and M1, alpha and beta zearalanol, deoxynivalenol, fumonisins B1, B2, B3, and hydrolyzed B1, nivalenol, ochratoxin A, ochratoxin alpha, and zearalenone) in breast milk samples was assessed in our study. Furthermore, the relationship between total fumonisins and pre/post-harvest and the women's dietary practices was examined. Liquid chromatography coupled with tandem mass spectrometry was used to analyze the 16 mycotoxins. An adjusted censored regression model was fitted to identify predictors of mycotoxins, i.e., total fumonisins. We detected only fumonisin B2 (15% of the samples) and fumonisin B3 (9% of the samples) while fumonisin B1 and nivalenol were detected only in a single breast milk sample. No association between total fumonisins and pre/post-harvest and dietary practices was found (p < 0.05). The overall exposure to mycotoxins was low in the studied women, although fumonisins contamination was not negligible. Moreover, the recorded total fumonisins was not associated with any of the pre/post-harvest and dietary practices. Therefore, to better identify predictors of fumonisin contamination in breast milk, longitudinal studies with food samples in addition to breast milk samples and with larger sample sizes are needed for the future