Child vaccination in sub-Saharan Africa: Increasing coverage addresses inequalities.

BackgroundVaccines have substantially contributed to reducing morbidity and mortality among children, but inequality in coverage continues to persist. In this study, we aimed to examine inequalities in child vaccination coverage in sub-Saharan Africa.MethodsWe analysed Demographic and Health Survey data in 25 sub-Saharan African countries. We defined full vaccination coverage as a child who received one dose of bacille Calmette-Guérin vaccine (BCG), three doses of diphtheria, pertussis, and tetanus vaccine (DTP 3), three oral polio vaccine doses (OPV 3), and one dose of measles vaccine. We used the concentration index (CCI) to measure wealth-related inequality in full vaccination, incomplete vaccination, and zero-dose children within and between countries. We fitted a multilevel regression model to identify predictors of inequality in receipts of full vaccination.ResultsOverall, 56.5% (95% CI: 55.7% to 57.3%) of children received full vaccination, 35.1% (34.4% to 35.7%) had incomplete vaccination, while 8.4% (95% CI: 8.0% to 8.8%) of children remained unvaccinated. Full vaccination coverage across the 25 sub-Saharan African countries ranged from 24% in Guinea to 93% in Rwanda. We found pro-rich inequality in full vaccination coverage in 23 countries, except for Gambia and Namibia, where we found pro-poor vaccination coverage. Countries with lower vaccination coverage had higher inequalities suggesting pro-rich coverage, while inequality in unvaccinated children was disproportionately concentrated among disadvantaged subgroups. Four or more antenatal care contracts, childbirth at health facility, improved maternal education, higher household wealth, and frequently listening to the radio increased vaccine uptake.ConclusionsContinued efforts to improve access to vaccination services are required in sub-Saharan Africa. Improving vaccination coverage and reducing inequalities requires enhancing access to quality services that are accessible, affordable, and acceptable to all. Vaccination programs should target critical social determinants of health and address barriers to better maternal health-seeking behaviour

Predictors of recovery rate among undernourished HIV-positive adults treated with ready-to-use therapeutic food at Debre Markos Comprehensive Specialized Hospital: A retrospective cohort study

Background Nutritional support is becoming more widely acknowledged as a crucial component of the key package of care for HIV/AIDS patients. This nutritional support is exceptionally important for patients in sub-Saharan Africa, including Ethiopia, where HIV/AIDS is very prevalent. However, there is a lack of evidence on the recovery rate and predictors at the study site and at large in Ethiopia. Therefore, this study will give some insight into the recovery rate and its predictors among under-nourished HIV-positive adults treated with Ready to Use Therapeutic Food (RUTF) attending at Debre Markos referral hospital. Moreover, the findings of this study will be used by both governmental and non-governmental organizations to allocate more resources to mitigate the nutritional problems for people living with HIV. Methods An institution-based retrospective cohort study was conducted among 453 under-nourished HIV positive adults treated with RUTF at Debre Markos referral Hospital from the 1st of July, 2015 to the 31st of December, 2017. The study participants were selected using a simple random sampling technique. Data were extracted from patient charts using a standardized data extraction checklist. Data were entered into Epi-Data Version 4.2 and analyzed using Stata Version 14. The Kaplan-Meier survival curve was used to estimate the time to recovery. Log-rank test was used to compare the recovery time between different baseline categorical variables. The bivariable and multivariable Cox-proportional hazard regression models were fitted for potential predictors of recovery time. Adjusted hazard Ratios (AHRs) with 95% CIs were used to measure the strength of association and test statistical significance. Results A total of 453 undernourished HIV-positive adults were included in the final analysis. About 201, 44.4% (95%CI: 38.9, 49.0%) patients participating in the RUTF program were recovered based on predetermined exit criteria with incidence of 10.65 (95% CI: 9.28, 12.23) per 100 person-month observations. Being moderately undernourished (AHR: 11.0, 95% CI: 5.3, 23.1), WHO clinical stage (I or II) (AHR:1.8, 95% CI: 1.2, 2.6), and working functional status at baseline (AHR = 2.34, 95%CI: 1.01,5.45) were predictors of recovery time. Conclusion This study concluded that the overall nutritional recovery rate was below the acceptable minimum requirement which at least 75% of patients should recovered. Mild to moderate undernutrition at baseline, WHO clinical stage I or II at enrolment, and working functional status were found to be predictors of recovery time in HIV/AIDS patients treated with the RUTF. As a result, special attention should be paid to severely malnourished patients, WHO clinical stages III or higher, and patients who are bedridden or ambulatory during treatment

Nearly half of preschool children are stunted in Dembia district, Northwest Ethiopia: A community based cross-sectional study

Background Stunting has been the most pressing public health problem throughout the developing countries. It is the major causes of child mortality and global disease burden, where 80 % of this burden is found in developing countries. In the future, stunting alone would result in 22 % of loss in adult income. About 40 % of children under five-years were stunted in Ethiopia. In the country, about 28 % of child mortality is related to undernutrition. Thus, the aim of this study was to determine the prevalence and determinants of stunting among preschool children in Dembia district, Northwest Ethiopia. Methods A community based cross–sectional study was carried out in Dembia district, Northwest Ethiopia from January 01 to February 29, 2015. A multi-stage sampling followed by a systematic sampling technique was employed to reach 681 mother-child pairs. A pretested and structured questionnaire was used to collect data. After exporting anthropometric data to ENA/SMART software version 2012, nutritional status (stunting) of a child was determined using the WHO Multicenter Growth Reference Standard. In binary logistic regression, a multivariable analysis was carried out to identify determinants of stunting. The Adjusted Odds Ratio (AOR) with a 95 % confidence interval was computed to assess the strength of the association, and variables with a P-value of <0.05 in multivariable analysis were considered as statistically significant. Results A total 681 of mother-child pairs were included in the study. The overall prevalence of stunting was 46 % [95 % CI: 38.7, 53.3 %]. In multivariable analysis, the odds of stunting was higher among children whose families had no latrine [AOR = 1.6, 95 % CI: 1.1, 2.2)]. Likewise, children living in household with more than four family size [AOR =1.4, 95 % CI: 1.1, 1.9)] were more likely to be stunted. Conclusions This study confirms that stunting is a very high public health problem in Dembia district. The family size and latrine availability were significantly associated with stunting. Hence, emphasis should be given to improve the latrine coverage and utilization of family planning in the district

Spatial patterns and inequalities in skilled birth attendance and caesarean delivery in sub-Saharan Africa

BackgroundImproved access to and quality obstetric care in health facilities reduces maternal and neonatal morbidity and mortality. We examined spatial patterns, within-country wealth-related inequalities and predictors of inequality in skilled birth attendance and caesarean deliveries in sub-Saharan Africa.MethodsWe analysed the most recent Demographic and Health Survey data from 25 sub-Saharan African countries. We used the concentration index to measure within-country wealth-related inequality in skilled birth attendance and caesarean section. We fitted a multilevel Poisson regression model to identify predictors of inequality in having skilled attendant at birth and caesarean section.ResultsThe rate of skilled birth attendance ranged from 24.3% in Chad to 96.7% in South Africa. The overall coverage of caesarean delivery was 5.4% (95% CI 5.2% to 5.6%), ranging from 1.4% in Chad to 24.2% in South Africa. The overall wealth-related absolute inequality in having a skilled attendant at birth was extremely high, with a difference of 46.2 percentage points between the poorest quintile (44.4%) and the richest quintile (90.6%). In 10 out of 25 countries, the caesarean section rate was less than 1% among the poorest quintile, but the rate was more than 15% among the richest quintile in nine countries. Four or more antenatal care contacts, improved maternal education, higher household wealth status and frequently listening to the radio increased the rates of having skilled attendant at birth and caesarean section. Women who reside in rural areas and those who have to travel long distances to access health facilities were less likely to have skilled attendant at birth or caesarean section.ConclusionsThere were significant within-country wealth-related inequalities in having skilled attendant at birth and caesarean delivery. Efforts to improve access to birth at the facility should begin in areas with low coverage and directly consider the needs and experiences of vulnerable populations.</jats:sec

Trends and causes of maternal mortality in Ethiopia during 1990-2013:Findings from the Global Burden of Diseases study 2013

Background: Maternal mortality is noticeably high in sub-Saharan African countries including Ethiopia. Continuous nationwide systematic evaluation and assessment of the problem helps to design appropriate policy and strategy in Ethiopia. This study aimed to investigate the trends and causes of maternal mortality in Ethiopia between 1990 and 2013. Methods: We used the Global Burden of Diseases and Risk factors (GBD) Study 2013 data that was collected from multiple sources at national and subnational levels. Spatio-temporal Gaussian Process Regression (ST-GPR) was applied to generate best estimates of maternal mortality with 95% Uncertainty Intervals (UI). Causes of death were measured using Cause of Death Ensemble modelling (CODEm). The modified UNAIDS EPP/SPECTRUM suite model was used to estimate HIV related maternal deaths. Results: In Ethiopia, a total of 16,740 (95% UI: 14,197, 19,271) maternal deaths occurred in 1990 whereas there were 15,234 (95% UI: 11,378, 19,871) maternal deaths occurred in 2013. This finding shows that Maternal Mortality Ratio (MMR) in Ethiopia was still high in the study period. There was a minimal but insignificant change of MMR over the last 23 years. The results revealed Ethiopia is below the target of Millennium Development Goals (MGDs) related to MMR. The top five causes of maternal mortality in 2013 were other direct maternal causes such as complications of anaesthesia, embolism (air, amniotic fluid, and blood clot), and the condition of peripartum cardiomyopathy (25.7%), complications of abortions (19.6%), maternal haemorrhage (12.2%), hypertensive disorders (10.3%), and maternal sepsis and other maternal infections such as influenza, malaria, tuberculosis, and hepatitis (9.6%). Most of the maternal mortality happened during the postpartum period and majority of the deaths occurred at the age group of 20-29 years. Overall trend showed that there was a decline from 708 per 100,000 live births in 1990 to 497 per 100,000 in 2013. The annual rate of change over these years was-1.6 (95% UI:-2.8 to-0.3). Conclusion: The findings of the study highlight the need for comprehensive efforts using multisectoral collaborations from stakeholders for reducing maternal mortality in Ethiopia. It is worthwhile for policies to focus on postpartum period

Respectful maternity care in Ethiopian public health facilities

Background: Disrespect and abuse of women during institutional childbirth services is one of the deterrents to utilization of maternity care services in Ethiopia and other low- and middle-income countries. This paper describes the prevalence of respectful maternity care (RMC) and mistreatment of women in hospitals and health centers, and identifies factors associated with occurrence of RMC and mistreatment of women during institutional labor and childbirth services. Methods: This study had a cross sectional study design. Trained external observers assessed care provided to 240 women in 28 health centers and hospitals during labor and childbirth using structured observation checklists. The outcome variable, providers' RMC performance, was measured by nine behavioral descriptors. The outcome, any mistreatment, was measured by four items related to mistreatment of women: physical abuse, verbal abuse, absence of privacy during examination and abandonment. We present percentages of the nine RMC indicators, mean score of providers' RMC performance and the adjusted multilevel model regression coefficients to determine the association with a quality improvement program and other facility and provider characteristics. Results: Women on average received 5.9 (66%) of the nine recommended RMC practices. Health centers demonstrated higher RMC performance than hospitals. At least one form of mistreatment of women was committed in 36% of the observations (38% in health centers and 32% in hospitals). Higher likelihood of performing high level of RMC was found among male vs. female providers ((beta) over cap = 0: 65, p = 0.012), midwives vs. other cadres ((beta) over cap = 0: 88, p = 0.002), facilities implementing a quality improvement approach, Standards-based Management and Recognition (SBM-R (c)) ((beta) over cap = 1: 31, p = 0.003), and among laboring women accompanied by a companion (beta) over cap = 0: 99, p = 0.003). No factor was associated with observed mistreatment of women. Conclusion: Quality improvement using SBM-R (c) and having a companion during labor and delivery were associated with RMC. Policy makers need to consider the role of quality improvement approaches and accommodating companions in promoting RMC. More research is needed to identify the reason for superior RMC performance of male providers over female providers and midwives compared to other professional cadre, as are longitudinal studies of quality improvement on RMC and mistreatment of women during labor and childbirth services in public health facilities