Disrespect and abuse during pregnancy, labour and childbirth: a qualitative study from four primary healthcare centres of Amhara and Southern Nations Nationalities and People's Regional States, Ethiopia

Background: In Ethiopia, only 28% of all births occur at health facilities. Disrespect and abuse of women by health providers during pregnancy, labour and immediate postpartum is one of the main reasons that affect health care seeking from health facilities. This study explored disrespect and abuse of women using seven categories (Bowser D. and Hill K) including physical abuse, non-dignified care, non-consented care, non-confidential care, discrimination, abandonment care and detention at health facilities.Methods: We conducted a qualitative research in four health centres of Amhara and Southern Nations Nationalities and Peoples’ regional states between March and April 2014. Data were generated using in-depth interviews involving four midwives, 42 women (22 who delivered at the health facilities and another 20 who delivered at home) and eight focus group discussions involving 63 family members who accompanied labouring women to the health centres in the past three months before the study. The interview guides explored potentially abusive and disrespectful care and the perspectives of the participants towards such occurrences. Key themes were identified using phenomenological approach.Results: This study found that most women faced disrespectful care while few were abused during labour, delivery and immediate postpartum. Women who faced disrespect and abusive care during antenatal care reported to have avoided giving birth at health facilities. However, most women and their accompanying family members were found to have normalized non-dignified care (disrespect) and abuse as indicated by a participant "It is ok if a woman is mistreated, insulted, her consent is not asked or her privacy is violated as far as it is for the wellbeing of the delivering women and the newborn".Conclusion: These findings showed that disrespect and abuse at health facilities have negatively affected women’s care-seeking from health facilities for delivery. Normalization of disrespect and abuse by labouring women could be one reason for the continuation of the practice by providers. Facilitating community dialogue on respectful and compassionate care, improving client-professional relationships and ensuring functional grievance handling systems in health facilities should be given high priority to change the situation. [Ethiop. J. Health Dev. 2017; 31(3):129-137]Keywords: Disrespect and abuse, maternal health, pregnancy, labour, delivery, normalization, women and Ethiopi

Effect of ethiopia's health extension program on maternal and newborn health care practices in 101 rural districts: a dose-response study.

BACKGROUND: Improving newborn survival is essential if Ethiopia is to achieve Millennium Development Goal 4. The national Health Extension Program (HEP) includes community-based newborn survival interventions. We report the effect of these interventions on changes in maternal and newborn health care practices between 2008 and 2010 in 101 districts, comprising 11.6 million people, or 16% of Ethiopia's population. METHODS AND FINDINGS: Using data from cross-sectional surveys in December 2008 and December 2010 from a representative sample of 117 communities (kebeles), we estimated the prevalence of maternal and newborn care practices, and a program intensity score in each community. Women with children aged 0 to 11 months reported care practices for their most recent pregnancy and childbirth. The program intensity score ranged between zero and ten and was derived from four outreach activities of the HEP front-line health workers. Dose-response relationships between changes in program intensity and the changes in maternal and newborn health were investigated using regression methods, controlling for secular trend, respondents' background characteristics, and community-level factors. Between 2008 and 2010, median program intensity score increased 2.4-fold. For every unit increase in the score, the odds of receiving antenatal care increased by 1.13 times (95% CI 1.03-1.23); the odds of birth preparedness increased by 1.31 times (1.19-1.44); the odds of receiving postnatal care increased by 1.60 times (1.34-1.91); and the odds of initiating breastfeeding immediately after birth increased by 1.10 times (1.02-1.20). Program intensity score was not associated with skilled deliveries, nor with some of the other newborn health care indicators. CONCLUSIONS: The results of our analysis suggest that Ethiopia's HEP platform has improved maternal and newborn health care practices at scale. However, implementation research will be required to address the maternal and newborn care practices that were not influenced by the HEP outreach activities

Correlates of the Women's Development Army strategy implementation strength with household reproductive, maternal, newborn and child healthcare practices: a cross-sectional study in four regions of Ethiopia.

BACKGROUND: To address the shortfall in human resources for health, Ethiopia launched the Health Extension Program (HEP) in 2004, establishing a health post with two female health extension workers (HEWs) in every kebele (community). In 2011, the Women's Development Army (WDA) strategy was added, using networks of neighboring women to increase the efficiency of HEWs in reaching every household, with one WDA team leader for every 30 households. Through the strategy, women in the community, in partnership with HEWs, share and learn about health practices and empower one another. This study assessed the association between the WDA strategy implementation strength and household reproductive, maternal, newborn and child health care behaviors and practices. METHODS: Using cross-sectional household surveys and community-level contextual data from 423 kebeles representing 145 rural districts, an internal comparison group design was applied to assess whether HEP outreach activity and household-level care practices were better in kebeles with a higher WDA density. The density of active WDA leaders was considered as WDA strategy implementation strength; higher WDA density in a kebele indicating relatively high implementation strength. Based on this, kebeles were classified as higher, moderate, or lower. Multilevel logit models, adjusted for respondents' individual, household and contextual characteristics, were used to assess the associations of WDA strategy implementation strength with outcome indicators of interest. RESULTS: Average numbers of households per active WDA team leader in the 25th, 50th and 75th percentiles of the kebeles studied were respectively 41, 50 and 73. WDA density was associated with better service for six of 13 indicators considered (p < 0.05). For example, kebeles with one active WDA team leader for up to 40 households (higher category) had respectively 7 (95% CI, 2, 13), 11 (5, 17) and 9 (1, 17) percentage-points higher contraceptive prevalence rate, coverage of four or more antenatal care visits, and coverage of institutional deliveries respectively, compared with kebeles with one active WDA team leader for 60 or more households (lower category). CONCLUSION: Higher WDA strategy implementation strength was associated with better health care behaviors and practices, suggesting that the WDA strategy supported HEWs in improving health care services delivery

Maternity waiting homes in Rural Health Centers of Ethiop: The situation, women’s experiences and challenges

Background: Maternity waiting homes have been promoted to improve pregnant women’s access to quality obstetric care. The main aim of this study was to assess the situation of maternity waiting homes and the experiences and challenges of mothers using waiting homes.Methods: A cross-sectional study was conducted in 134 health centers in Amhara, Oromia, Southern Nations Nationalities and People (SNNP) and Tigray regions of Ethiopia. The study employed both quantitative and qualitative methods. Data were collected by interviewing the head of the health centers and women staying at the waiting homes during the time of the survey.Results: Ninety-four (70%) health centers had maternity waiting homes at the time of the survey. Typologies of the waiting homes and their capability of holding clients varied from region to region. Protocols for managing the waiting homes and admission and discharge criteria were not available elsewhere. Mothers who used waiting homes faced several challenges: No one was available to care for children at home, mothers were considered as being lazy, food problems and lengthy prenatal stay were among the challenges mothers mentioned of staying at the waiting homes.Conclusions: It is necessary to prepare guidelines for the establishment and management of waiting homes as well as set up admission and discharge criteria and to initiate quality control mechanisms. Keywords: Maternity waiting homes, waiting homes, prenatal care, intention to stay postpartum, postpartum care, Ethiopia, health center, obstetric complication

Effects of family conversation on health care practices in Ethiopia: a propensity score matched analysis.

BACKGROUND: Maternal and newborn mortality rates in Ethiopia are among the highest in sub-Saharan Africa. The majority of deaths take place during childbirth or within the following 48 h. Therefore, ensuring facility deliveries with emergency obstetric and newborn care services available and immediate postnatal follow-up are key strategies to increase survival. In early 2014, the Family Conversation was implemented in 115 rural districts in Ethiopia, covering about 17 million people. It aimed to reduce maternal and newborn mortality by promoting institutional delivery, early postnatal care and immediate newborn care practices. More than 6000 Health Extension Workers were trained to initiate home-based Family Conversations with pregnant women and key household decision-makers. These conversations included discussions on birth preparedness, postpartum and newborn care needs to engage key household stakeholders in supporting women during their pregnancy, labor and postpartum periods. This paper examines the effects of the Family Conversation strategy on maternal and neonatal care practices. METHODS: We used cross-sectional data from a representative sample of 4684 women with children aged 0-11 months from 115 districts collected between December 2014 and January 2015. We compared intrapartum and newborn care practices related to the most recent childbirth, between those who reported having participated in a Family Conversation during pregnancy, and those who had not. Propensity score matched analysis was used to estimate average treatment effects of the Family Conversation strategy on intrapartum and newborn care practices, including institutional delivery, early postnatal and immediate breastfeeding. RESULTS: About 17% of the respondents reported having had a Family Conversation during their last pregnancy. Average treatment effects of 7, 12, 9 and 16 percentage-points respectively were found for institutional deliveries, early postnatal care, clean cord care and thermal care of the newborn (p < 0.05). CONCLUSION: We found evidence that Family Conversation, and specifically the involvement of household members who were major decision-makers, was associated with better intrapartum and newborn care practices. This study adds to the evidence base that involving husbands and mothers-in-law, as well as pregnant women, in behavior change communication interventions could be critical for improving maternal and newborn care and therewith lowering mortality rates

The effect of implementation strength of basic emergency obstetric and newborn care (BEmONC) on facility deliveries and the met need for BEmONC at the primary health care level in Ethiopia.

BACKGROUND: Basic emergency obstetric and newborn care (BEmONC) is a primary health care level initiative promoted in low- and middle-income countries to reduce maternal and newborn mortality. Tailored support, including BEmONC training to providers, mentoring and monitoring through supportive supervision, provision of equipment and supplies, strengthening referral linkages, and improving infection-prevention practice, was provided in a package of interventions to 134 health centers, covering 91 rural districts of Ethiopia to ensure timely BEmONC care. In recent years, there has been a growing interest in measuring program implementation strength to evaluate public health gains. To assess the effectiveness of the BEmONC initiative, this study measures its implementation strength and examines the effect of its variability across intervention health centers on the rate of facility deliveries and the met need for BEmONC. METHODS: Before and after data from 134 intervention health centers were collected in April 2013 and July 2015. A BEmONC implementation strength index was constructed from seven input and five process indicators measured through observation, record review, and provider interview; while facility delivery rate and the met need for expected obstetric complications were measured from service statistics and patient records. We estimated the dose-response relationships between outcome and explanatory variables of interest using regression methods. RESULTS: The BEmONC implementation strength index score, which ranged between zero and 10, increased statistically significantly from 4.3 at baseline to 6.7 at follow-up (p < .05). Correspondingly, the health center delivery rate significantly increased from 24% to 56% (p < .05). There was a dose-response relationship between the explanatory and outcome variables. For every unit increase in BEmONC implementation strength score there was a corresponding average of 4.5 percentage points (95% confidence interval: 2.1-6.9) increase in facility-based deliveries; while a higher score for BEmONC implementation strength of a health facility at follow-up was associated with a higher met need. CONCLUSION: The BEmONC initiative was effective in improving institutional deliveries and may have also improved the met need for BEmONC services. The BEmONC implementation strength index can be potentially used to monitor the implementation of BEmONC interventions

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

Characterising innovations in maternal and newborn health based on a common theory of change: lessons from developing and applying a characterisation framework in Nigeria, Ethiopia and India.

Government leadership is key to enhancing maternal and newborn survival. In low/middle-income countries, donor support is extensive and multiple actors add complexity. For policymakers and others interested in harmonising diverse maternal and newborn health efforts, a coherent description of project components and their intended outcomes, based on a common theory of change, can be a valuable tool. We outline an approach to developing such a tool to describe the work and the intended effect of a portfolio of nine large-scale maternal and newborn health projects in north-east Nigeria, Ethiopia and Uttar Pradesh in India. Teams from these projects developed a framework, the 'characterisation framework', based on a common theory of change. They used this framework to describe their innovations and their intended outcomes. Individual project characterisations were then collated in each geography, to identify what innovations were implemented where, when and at what scale, as well as the expected health benefit of the joint efforts of all projects. Our study had some limitations. It would have been enhanced by a more detailed description and analysis of context and, by framing our work in terms of discrete innovations, we may have missed some synergistic aspects of the combination of those innovations. Our approach can be valuable for building a programme according to a commonly agreed theory of change, as well as for researchers examining the effectiveness of the combined work of a range of actors. The exercise enables policymakers and funders, both within and between countries, to enhance coordination of efforts and to inform decision-making about what to fund, when and where

Additional file 1: Table S1. of Changes in equity of maternal, newborn, and child health care practices in 115 districts of rural Ethiopia: implications for the health extension program

Coverage and concentration indices for HEP outreach activities and MNCH care practice indicators by equity factors; and statistically significant Wald’s statistics for the inequities of those indicators during baseline (December 2008), follow-up (December 2010) periods and for the changes between the survey periods. (DOCX 111 kb

Effectiveness of participatory community solutions strategy on improving household and provider health care behaviors and practices: A mixed-method evaluation.

INTRODUCTION:We implemented a participatory quality improvement strategy in eight primary health care units of Ethiopia to improve use and quality of maternal and newborn health services. METHODS:We evaluated the effects of this strategy using mixed-methods research. We used before-and-after (March 2016 and November 2017) cross-sectional surveys of women who had children 0-11 months to compare changes in maternal and newborn health care indicators in the 39 communities that received the intervention and the 148 communities that did not. We used propensity scores to match the intervention with the comparison communities at baseline and difference-in-difference analyses to estimate intervention effects. The qualitative method included 51 in-depth interviews of community volunteers, health extension workers, health center directors and staff, and project specialists. RESULTS:The difference-in-difference analyses indicated that 7.9 percentage points (95% confidence interval [CI]: 1.8-13.9%) increase in receiving skilled delivery care between baseline and follow-up surveys in the intervention area that is attributable to the strategy. The intervention effect on postnatal care in 48 hours of the mother was 15.3% (95% CI: 7.4-23.2). However, there was no evidence that the strategy affected the seven other maternal and newborn health care indicators considered. Interview participants said that the participatory design and implementation strategy helped them to realize gaps, identify real problems, and design appropriate solutions, and created a sense of ownership and shared responsibility for implementing interventions. CONCLUSIONS:Community participation in planning and monitoring maternal and newborn health service delivery improves use of some high-impact maternal and newborn health services. The study supports the notion that participatory community strategies should be considered to foster community-responsive health systems