Causes of maternal death in Ethiopia between 1990 and 2016: systematic review with meta-analysis

AbstractBackground: Even though Ethiopia has achieved the Millennium Development Goal targets for child health set for 2015 by the international community, it has failed to do so with regard to maternal health. Maternal deaths are still high, with an estimated maternal mortality ratio of 412 maternal deaths per 100,000 live births in 2016.The causes of maternal death and individual, environmental and health systems related gaps contributing to maternal death in Ethiopia remain unclear.Objectives: The main aim of this study was to document the causes of maternal deaths and risk factors contributing to deaths aggravated by pregnancy and its management in Ethiopia over the period 1990 to 2016, using a systematic review with meta-analysis.Methods: Manuscripts were reviewed on causes of maternal death that were published in scientific journals and grey literature, including the compendium of abstracts presented in the series of annual conferences of the Ethiopian Public Health Association, masters’ theses in public health from different public universities in Ethiopia, and periodic reports of the Federal Ministry of Health of Ethiopia. A comprehensive and reproducible literature search was used, employing the Cochrane systematic literature review technique. Medical subject heading terms – including maternal deaths, maternal mortality, causes of maternal mortality/death, maternal mortality/death in Ethiopia and etiology of maternal mortality/death in Ethiopia – were used to search the required articles. A total of 146 articles (134 from online sources and 12 hard copies) were identified on the basis of their titles and abstracts. Of these, 24 were found to be suitable for further analysis by applying the review criteria, which were then synthesized to identify the main causes of maternal death, as well as the risk factors affecting the patterns of deaths.Results: The main direct causes of maternal death in Ethiopia include obstetric complications such as hemorrhage (29.9%; 95% CI: 20.28%-39.56%), obstructed labor/ruptured uterus (22.34%; 95% CI: 15.26%-29.42%), pregnancy-induced hypertension (16.9%; 95% CI:11.2%-22.6%), puerperal sepsis (14.68%; 95% CI: 10.56%-18.8%), and unsafe abortion (8.6%; 95% CI: 5.0%-12.18%). In recent years, hemorrhage has been the leading cause of mortality, followed by hypertensive disorders of pregnancy and sepsis, while the contributions of obstructed labor and abortion have decreased over the period. The most reported indirect causes of maternal death were anemia (10.39%; 95% CI: 4.79%-15.98%) and malaria (3.55%; 95% CI: 1.50%-3.30%).Conclusions: The nationwide registration of causes of maternal death should be strengthened to understand the causes in detail, their attributes, as well as the patterns of causes of death. The health sector should sustain its current effort to tackle the diverse causes of maternal death in Ethiopia.  [Ethiop. J. Health Dev. 2018;32(4):225-242]Key words: maternal mortality, systematic review, causes of maternal death, Ethiopi

Causes of maternal death in Ethiopia between 1990 and 2016 : systematic review with meta-analysis

The study documented causes of maternal deaths, and risk factors contributing to deaths aggravated by pregnancy and its management in Ethiopia (1990 to 2016), using a systematic review with meta-analysis. The nationwide registration of causes of maternal death should be strengthened to understand the causes in detail, their attributes, as well as the patterns of causes of death. Findings reveal that the main direct causes of maternal death in Ethiopia include obstetric complications such as hemorrhage, obstructed labor/ruptured uterus, pregnancy-induced hypertension, puerperal sepsis, and unsafe abortion. The health sector should sustain its current effort to tackle the diverse causes of maternal death in Ethiopia

Barriers and enablers to improving integrated primary healthcare for non-communicable diseases and mental health conditions in Ethiopia:a mixed methods study

BACKGROUND: The Ethiopian Primary Healthcare Clinical Guidelines (EPHCG) seek to improve quality of primary health care, while also expanding access to care for people with Non-Communicable Diseases and Mental Health Conditions (NCDs/MHCs). The aim of this study was to identify barriers and enablers to implementation of the EPHCG with a particular focus on NCDs/MHCs.METHODS: A mixed-methods convergent-parallel design was employed after EPHCG implementation in 18 health facilities in southern Ethiopia. Semi-structured interviews were conducted with 10 primary healthcare clinicians and one healthcare administrator. Organisational Readiness for Implementing Change (ORIC) questionnaire was self-completed by 124 health workers and analysed using Kruskal Wallis ranked test to investigate median score differences. Qualitative data were mapped to the Consolidated Framework for Implementation Science (CFIR) and the Theoretical Domains Framework (TDF). Expert Recommendations for Implementing Change (ERIC) were employed to select implementation strategies to address barriers.RESULTS: Four domains were identified: EPHCG training and implementation, awareness and meeting patient needs (demand side), resource constraints/barriers (supply side) and care pathway bottlenecks. The innovative facility-based training to implement EPHCG had a mixed response, especially in busy facilities where teams reported struggling to find protected time to meet. Key barriers to implementation of EPHCG were non-availability of resources (CFIR inner setting), such as laboratory reagents and medications that undermined efforts to follow guideline-based care, the way care was structured and lack of familiarity with providing care for people with NCDs-MHCs. Substantial barriers arose because of socio-economic problems that were interlinked with health but not addressable within the health system (CFIR outer setting). Other factors influencing effective implementation of EPHCG (TDF) included low population awareness about NCDs/MHCs and unaffordable diagnostic and treatment services (TDF). Implementation strategies were identified. ORIC findings indicated high scores of organisational readiness to implement the desired change with likely social desirability bias.CONCLUSION: Although perceived as necessary, practical implementation of EPHCG was constrained by challenges across domains of internal/external determinants. This was especially marked in relation to expansion of care responsibilities to include NCDs/MHCs. Attention to social determinants of health outcomes, community engagement and awareness-raising are needed to maximize population impact.</p

Healthcare Access and Quality Index based on mortality from causes amenable to personal health care in 195 countries and territories, 1990-2015 : a novel analysis from the Global Burden of Disease Study 2015

Background National levels of personal health-care access and quality can be approximated by measuring mortality rates from causes that should not be fatal in the presence of effective medical care (ie, amenable mortality). Previous analyses of mortality amenable to health care only focused on high-income countries and faced several methodological challenges. In the present analysis, we use the highly standardised cause of death and risk factor estimates generated through the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) to improve and expand the quantification of personal health-care access and quality for 195 countries and territories from 1990 to 2015. Methods We mapped the most widely used list of causes amenable to personal health care developed by Nolte and McKee to 32 GBD causes. We accounted for variations in cause of death certification and misclassifications through the extensive data standardisation processes and redistribution algorithms developed for GBD. To isolate the effects of personal health-care access and quality, we risk-standardised cause-specific mortality rates for each geography-year by removing the joint effects of local environmental and behavioural risks, and adding back the global levels of risk exposure as estimated for GBD 2015. We employed principal component analysis to create a single, interpretable summary measure-the Healthcare Quality and Access (HAQ) Index-on a scale of 0 to 100. The HAQ Index showed strong convergence validity as compared with other health-system indicators, including health expenditure per capita (r= 0.88), an index of 11 universal health coverage interventions (r= 0.83), and human resources for health per 1000 (r= 0.77). We used free disposal hull analysis with bootstrapping to produce a frontier based on the relationship between the HAQ Index and the Socio-demographic Index (SDI), a measure of overall development consisting of income per capita, average years of education, and total fertility rates. This frontier allowed us to better quantify the maximum levels of personal health-care access and quality achieved across the development spectrum, and pinpoint geographies where gaps between observed and potential levels have narrowed or widened over time. Findings Between 1990 and 2015, nearly all countries and territories saw their HAQ Index values improve; nonetheless, the difference between the highest and lowest observed HAQ Index was larger in 2015 than in 1990, ranging from 28.6 to 94.6. Of 195 geographies, 167 had statistically significant increases in HAQ Index levels since 1990, with South Korea, Turkey, Peru, China, and the Maldives recording among the largest gains by 2015. Performance on the HAQ Index and individual causes showed distinct patterns by region and level of development, yet substantial heterogeneities emerged for several causes, including cancers in highest-SDI countries; chronic kidney disease, diabetes, diarrhoeal diseases, and lower respiratory infections among middle-SDI countries; and measles and tetanus among lowest-SDI countries. While the global HAQ Index average rose from 40.7 (95% uncertainty interval, 39.0-42.8) in 1990 to 53.7 (52.2-55.4) in 2015, far less progress occurred in narrowing the gap between observed HAQ Index values and maximum levels achieved; at the global level, the difference between the observed and frontier HAQ Index only decreased from 21.2 in 1990 to 20.1 in 2015. If every country and territory had achieved the highest observed HAQ Index by their corresponding level of SDI, the global average would have been 73.8 in 2015. Several countries, particularly in eastern and western sub-Saharan Africa, reached HAQ Index values similar to or beyond their development levels, whereas others, namely in southern sub-Saharan Africa, the Middle East, and south Asia, lagged behind what geographies of similar development attained between 1990 and 2015. Interpretation This novel extension of the GBD Study shows the untapped potential for personal health-care access and quality improvement across the development spectrum. Amid substantive advances in personal health care at the national level, heterogeneous patterns for individual causes in given countries or territories suggest that few places have consistently achieved optimal health-care access and quality across health-system functions and therapeutic areas. This is especially evident in middle-SDI countries, many of which have recently undergone or are currently experiencing epidemiological transitions. The HAQ Index, if paired with other measures of health-systemcharacteristics such as intervention coverage, could provide a robust avenue for tracking progress on universal health coverage and identifying local priorities for strengthening personal health-care quality and access throughout the world. Copyright (C) The Author(s). Published by Elsevier Ltd.Peer reviewe

Contraceptive use among lactating women in Ganta-Afeshum District, Eastern Tigray, Northern Ethiopia, 2015: a cross sectional study

Abstract Background Women who are not exclusively breastfeeding are at risk of pregnancy after four to six weeks of childbirth. Postpartum contraceptive use is crucial to prevent unintended pregnancy, and to have spaced births. The study was conducted to determine the magnitude of modern contraceptive utilization and factors associated with it among lactating women in Ganta-Afeshum district. Methods A community based cross sectional study was conducted among lactating women with children in the age group of six to twelve months. A total of 605 women were included in the study. The study participants were selected using cluster sampling method. Data were collected using structured interviewer administered Tigrigna version questionnaire. Data were analyzed using SPSS version 21. Multivariable logistic regression was used to control the effect of confounders. Results The magnitude of institutional delivery was 96.5%. The mode of delivery of the participants was spontaneous, instrumental and caesarean section, 95.5%, 2.0%, and 2.5%, respectively. The magnitude of modern contraceptive (MC) utilization was 68.1% (95% CI: 64.4–71.8). The contraceptive method mix was dominated by Depo-Provera (58.8%) followed by implants (31.8%). Almost all the study participants had at least one antenatal care (ANC) visit (99.7%) during the pregnancy of their index child. Participants who had radio and those who delivered their recent child by assisted delivery had higher odds of modern contraceptive use. Conclusions The magnitude of contraceptive utilization among lactating mothers in the study area was higher than the national survey reports. However, significant numbers of women are not using contraceptives in their postpartum period, making them at risk of pregnancy. Mode of delivery of the women and having radio at home were significantly associated with the women’s contraceptive utilization. Family planning information dissemination using radio in rural settings should be encouraged to increase the uptake of contraceptives in the lactating women

Factors Associated with Occupational Needle Stick and Sharps Injuries among Hospital Healthcare Workers in Bale Zone, Southeast Ethiopia.

Needle stick and sharps injuries are occupational hazards to healthcare workers. Every day healthcare workers are exposed to deadly blood borne pathogens through contaminated needles and other sharp objects. About twenty blood borne pathogens can be transmitted through accidental needle stick and sharp injury. The study was conducted to determine the lifetime and past one year prevalence of needle stick and sharps injuries and factors associated with the past one year injuries among hospital healthcare workers in Southeast Ethiopia.An institutional based cross sectional study was conducted in December 2014 among healthcare workers in four hospitals of Bale zone, Southeast of Ethiopia. A total of 362 healthcare workers were selected randomly from each department in the hospitals. Data were collected using self-administered questionnaire. The collected data were entered into Epi-Info version 3.5 and analyzed using SPSS version 20.0. Multivariable logistic regression analysis was used to identify the independent effect of each independent variable on the outcome variable. Written informed consent was secured from the participants.The prevalence of lifetime needle stick and sharp injury was 37.1% with 95% CI of 32.0% to 42.5%. The prevalence of injury within the past one year was 19.1% with 95% CI of 14.9% to 23.3%. Emergency ward was a department with highest needle stick and sharp injury (31.7%). The main cause of injury was syringe needles (69.8%). Participants who practiced needle recapping had higher odds of needle stick and sharp injury within the past 12 months (AOR = 3.23, 95% CI: 1.78, 5.84) compared to their counterparts.Nearly one out of five respondents had experienced needle stick and/or sharp injury at least once within past one year. There were practices and behaviors that put healthcare workers at risk of needle stick and sharp injury at the study area. Needle recapping was key modifiable risk behavior. Health policy makers and hospital administrators should formulate strategies to improve the working condition for healthcare workers and increase their adherence to universal precautions

Determinants of defaulting from completion of child immunization in Laelay Adiabo District, Tigray Region, Northern Ethiopia: A case-control study.

Globally 2.5 million children under five years of age die every year due to vaccine preventable diseases. In Tigray Region in Northern Ethiopia, full vaccination coverage in children is low. However, the determinants of defaulting from completion of immunization have not been studied in depth. This study aimed to identify the determinants of defaulting from child immunization completion among children aged 9-23 months in the Laelay Adiabo District, North Ethiopia.An unmatched community based case-control study design was conducted among children aged 9-23 months in the Laelay Adiabo District from February-March 2015. A survey was conducted to identify the existence of cases and controls. Two hundred and seventy children aged 9-23 months (90 cases and 180 controls) were recruited from 11 kebeles (the smallest administrative units) by a simple random sampling technique using computer based Open Epi software. Cases were children aged 9-23 months who missed at least one dose of the recommended vaccine. Controls were children aged 9-23 months who had received all recommended vaccines. Data were collected from mothers/care givers using structured pretested questionnaire. The data were entered into Epi Info version 3.5.1 and analyzed using Statistical Package for Social Sciences (SPSS) version 21. Bivariate and Multiple logistic regression analysis were used to identify the predictors of the outcome variable. The degree of association was assessed by using odds ratio with 95% Confidence Interval (CI).This study shows that mothers who take >30 minutes to reach the vaccination site (Adjusted Odds Ratio (AOR) = 3.56,95%CI:1.58-8.01); households not visited by health extension workers at least monthly (AOR = 2.68,95%CI:1.30-5.51); poor participation in women's developmental groups (AOR = 3.3,95%CI 1.54-7.08); no postnatal care follow-up (AOR = 5.2,95%CI:2.36-11.46); and poor knowledge of child immunization (AOR = 3.3,95%CI:1.87-7.43) were predictors of defaulting from completion of child immunization.Postnatal care follow-up, household visits by health extension workers and maternal participation in women's development groups are important mediums for disseminating information and increasing knowledge to mothers about child immunization. To reduce the rate of defaulters, health providers should motivate and counsel mothers to attend postnatal care. Health extension workers should visit households at least once per month and strengthen mothers' participation in the women's development groups

Predictors of poor glycemic control among patients with type 2 diabetes on follow-up care at a tertiary healthcare setting in Ethiopia

Abstract Objective Contemporary clinical guidelines endorsed that glycemic control is the ultimate goal in the management patients with diabetes. The aim of this study was to assess the prevalence of glycemic control and to identify predictors of poor glycemic control in patients with type 2 diabetes (T2D). A cross-sectional study was conducted among systematically selected 357 diabetic patients. Data were collected through direct patients’ interviews and medical chart review. Binary logistic regression analyses were performed and analyzed using SPSS version 22.0. Results Participants’ mean age was (± SD) 56.1 ± 11.6 years. Nearly four in five (77.9%) of the participants had comorbidities, mainly of hypertension, and 60.2% had diabetic complications, mainly diabetes neuropathy. Poor glycemic control was found in 68.3% of the participants with a mean (± SD) FBG of 174.1 ± 48.9 mg/dL. Being female gender, having greater body mass index and low medication adherence was significantly associated with poor glycemic control. In conclusion, the overall aspects of glycemic control level of patients were far from the standards. Being female, greater body mass index and poor medication adherence were predictors of poor glycemic control. In response to this finding, an aggressive intervention that targets in improving the glycemic control is required

Perspectives of patients, family members, and health care providers on late diagnosis of breast cancer in Ethiopia: A qualitative study.

BackgroundMost women with breast cancer in Ethiopia are diagnosed at an advanced stage of the disease, but the reasons for this have not been systematically investigated. This study, therefore, aimed to explore the main reasons for diagnosis of advanced stage breast cancer from the perspective of patients, family members, and health care providers.MethodsA qualitative study with in-depth interviews was conducted with 23 selected participants at Tikur Anbessa Specialized Hospital, Oncology Clinic using a semi-structured interview guide. These participants were 13 breast cancer patients, 5 family members, and 5 health care providers. Data were transcribed into English, coded and analyzed using thematic analysis.ResultsAwareness about the causes, risk, initial symptoms, early detection methods, and treatment of breast cancer were uncommon, and misconceptions about the disease prevailed among breast cancer patients and family members. There was a sense of hopelessness and uncertainty about the effectiveness of conventional medicine amongst patients and family members. Consequently, performing spiritual acts (using holy water) or seeking care from traditional healers recurred amongst the interviewees. Not taking initial symptoms of breast cancer seriously by the patients, reliance on traditional medicines, competing priorities, financial hardship, older age, fear of diagnosis of cancer, and weak health systems (e.g., delay in referral and long waiting period for consultation) were noted as the main contributors to late diagnosis. In contrast, persuasion by family members and friends, higher educational attainment, and prior experience of neighboring women with breast cancer were mentioned to be facilitators of early diagnosis of breast cancer.ConclusionsThe causes of late diagnosis of breast cancer in Ethiopia are multi-factorial and include individual, cultural, and health system factors. Interventions targeting these factors could alleviate the misconceptions and knowledge gap about breast cancer in the community, and shorten waiting time between symptom recognition and diagnosis of breast cancer

Circumstances in which needle stick and sharps injury occurrence among hospital workers in Bale zone, December, 2014 (n = 126).

<p>* Each of the percentages does not add up to 100% because respondents could choose several responses which could be more than one reasons</p><p>Circumstances in which needle stick and sharps injury occurrence among hospital workers in Bale zone, December, 2014 (n = 126).</p