Determinants of timeliness in early childhood vaccination among mothers with vaccination cards in Sindh province, Pakistan: a secondary analysis of cross-sectional survey data

OBJECTIVE

Untimely vaccination refers to receiving the given dose before (early) or after (delayed) the recommended time window. The purpose of this study was to assess the extent of timeliness of childhood vaccinations and examine the determinants of vaccination timeliness in Sindh province, Pakistan.

DESIGN

Cross-sectional analysis of data from the 2013 and 2014 Maternal and Child Health Program Indicator Surveys.

SETTING

Community-based maternal and child health surveys.

PARTICIPANTS

Among 10 200 respondents of Maternal and Child Health Program Indicator Surveys, 1143 women who had a live birth in the 2 years preceding the survey were included.

OUTCOMES

At the participants' home, an interviewer asked mothers to show their children's vaccination cards, which contained information regarding vaccinations. Children's vaccination status was categorised into timely or early/delayed compared with vaccination schedule. A logistic regression analysis using Firth's penalised likelihood was performed to identify factors associated with timeliness of vaccinations.

RESULTS

238 children (20.8% of children who received a full set of basic vaccinations) received all vaccinations on schedule among children who received a full set of basic vaccinations. The percentages of timely vaccinations ranged from 2.3% for second measles vaccination to 89.3% for bacillus Calmette-Guérin. Child's age and place of delivery were associated with timely vaccinations. Older child age and institutional delivery were associated with decreased timely vaccination rate.

CONCLUSIONS

Home-based vaccination record is a key tool to improve the timeliness of vaccinations. The redesigned vaccination cards, the new electronic registries for vaccination card information and the vaccination tracking system to remind the second/third vaccination visits may be helpful to improve timely vaccinations for children under 2 years old.

Sacrospinous hysteropexy versus vaginal hysterectomy with uterosacral ligament suspension in women with uterine prolapse stage 2 or higher: observational follow-up of a multicentre randomised trial

OBJECTIVE

To evaluate the effectiveness and success of uterus preserving sacrospinous hysteropexy as an alternative to vaginal hysterectomy with uterosacral ligament suspension in the surgical treatment of uterine prolapse five years after surgery.

DESIGN

Observational follow-up of SAVE U (sacrospinous fixation versus vaginal hysterectomy in treatment of uterine prolapse ≥2) randomised controlled trial.

SETTING

Four non-university teaching hospitals, the Netherlands.

PARTICIPANTS

204 of 208 healthy women in the initial trial (2009-12) with uterine prolapse stage 2 or higher requiring surgery and no history of pelvic floor surgery who had been randomised to sacrospinous hysteropexy or vaginal hysterectomy with uterosacral ligament suspension. The women were followed annually for five years after surgery. This extended trial reports the results at five years.

MAIN OUTCOME MEASURES

Prespecified primary outcome evaluated at five year follow-up was recurrent prolapse of the uterus or vaginal vault (apical compartment) stage 2 or higher evaluated by pelvic organ prolapse quantification system in combination with bothersome bulge symptoms or repeat surgery for recurrent apical prolapse. Secondary outcomes were overall anatomical failure (recurrent prolapse stage 2 or higher in apical, anterior, or posterior compartment), composite outcome of success (defined as no prolapse beyond the hymen, no bothersome bulge symptoms, and no repeat surgery or pessary use for recurrent prolapse), functional outcome, quality of life, repeat surgery, and sexual functioning.

RESULTS

At five years, surgical failure of the apical compartment with bothersome bulge symptoms or repeat surgery occurred in one woman (1%) after sacrospinous hysteropexy compared with eight women (7.8%) after vaginal hysterectomy with uterosacral ligament suspension (difference-6.7%, 95% confidence interval -12.8% to-0.7%). A statistically significant difference was found in composite outcome of success between sacrospinous hysteropexy and vaginal hysterectomy (89/102 (87%) v 77/102 (76%). The other secondary outcomes did not differ. Time-to-event analysis at five years showed no differences between the interventions.

CONCLUSIONS

At five year follow-up significantly less anatomical recurrences of the apical compartment with bothersome bulge symptoms or repeat surgery were found after sacrospinous hysteropexy compared with vaginal hysterectomy with uterosacral ligament suspension. After hysteropexy a higher proportion of women had a composite outcome of success. Time-to-event analysis showed no differences in outcomes between the procedures.

TRIAL REGISTRATION

trialregister.nl NTR1866.

Protocol for a prospective mixed-methods longitudinal study to evaluate the dynamics of contraceptive use, discontinuation, and switching in Kenya

Background

More women are accessing modern contraceptive use in Kenya, however, contraceptive discontinuation has stagnated over the decades. Any further increase in contraceptive use will most likely be from past users, hence understanding the dynamics of discontinuation while addressing quality of family planning services offered at health facilities and communities is critical for increasing the contraceptive prevalence rate and reducing the unmet need of family planning. The paper presents a study protocol that intends to evaluate the dynamics of contraceptive use, discontinuation, and switching among women of reproductive age initiating use of a contraceptive method.

Methods

This longitudinal mixed-methods study is being conducted in Migori and Kitui counties, Kenya. A formative assessment using Interviews with adolescents, older women, heterosexual couples, health care workers, and community health volunteers explored barriers to contraceptive continuation and perspectives on discontinuation utilizing a qualitative cross sectional study design. Following the formative assessment, a client-centered intervention focusing on improving quality of family planning services, including counseling, will be implemented in 10 health facilities. A 24-month prospective cohort study among women of reproductive age initiating contraception with follow-up at 3, 6, 12, and 24 months will then be undertaken to assess the discontinuation rates, examine the dynamics of contraceptive use, discontinuation and switching, and further explore barriers and enablers for contraceptive continuation and switching among the study population.

Discussion

In sub-Saharan Africa, contraceptive discontinuation studies have mainly been based on survey data that is collected retrospectively. By implementing a longitudinal mixed-methods study, we gain deeper insights into the contraceptive dynamics influencing the decision to continue, discontinue, and even switch following implementation of a client-centered intervention that enhances quality of care. Additionally, the study will shed more light on the profile of women discontinuing contractive use and further explore individual and couple-level dynamics influencing decision-making on continuation and discontinuation. The findings of this study will provide information that can be used to develop and implement human-centered interventions that focus on improving quality of family planning services and consequently improved continuation rates and overall satisfaction with method.

Trial registration

The study is registered with the Clinical Trials Registry, NCT03973593.

Quality of essential newborn care and neonatal resuscitation at health facilities in Afghanistan: a cross-sectional assessment

OBJECTIVE

To assess readiness and quality of essential newborn care and neonatal resuscitation practices in public health facilities in Afghanistan.

DESIGN

Cross-sectional assessment.

SETTING

226 public health facilities in Afghanistan, including 77 public health facilities with at least five births per day (high-volume facilities) and 149 of 1736 public health facilities with fewer than five births per day (low-volume facilities).

PARTICIPANTS

Managers of 226 public health facilities, 734 skilled birth attendants (SBAs) working at these facilities, and 643 women and their newborns observed during childbirth at 77 high-volume health facilities.

OUTCOME MEASURES

Availability of knowledgeable SBAs, availability of supplies and compliance with global guidelines for essential newborn care and neonatal resuscitation practices.

RESULTS

At high-volume facilities, 569/636 (87.9%) of babies were dried immediately after birth, 313/636 (49.2%) were placed in skin-to-skin contact with their mother and 581/636 (89.7%) had their umbilical cord cut with a sterile blade or scissors. A total of 87 newborn resuscitation attempts were observed. Twenty-four of the 87 (27.5%) began to breath or cry after simply clearing the airway or on stimulation. In the remaining 63 (72.5%) cases, a healthcare worker began resuscitation with a bag and mask; however, only 54 (62%) used a correct size of mask and three babies died as their resuscitation with bag and mask was unsuccessful.

CONCLUSIONS

The study indicates room for improvement of the quality of neonatal resuscitation practices at public health facilities in Afghanistan, requiring only strengthening of the current best practices in newborn care. Certain basic and effective aspects of essential newborn care that can be improved on with little additional resources were also missing, such as skin-to-skin contact of the babies with their mother. Improvement of compliance with the standard newborn care practices must be ensured to reduce preventable newborn mortality and morbidity in Afghanistan.

Mistreatment of women in public health facilities of Ethiopia

Background

Recent evidence suggests that mistreatment of women during childbirth is a global challenge facing health care systems. This study seeks to explore the prevalence of mistreatment of women in public health facilities of Ethiopia, and identify associated factors.

Methods

A two-stage cross sectional sampling design was used to select institutions and women. The study was conducted in hospitals and health centers across four Ethiopian regions. Quantitative data were collected from postpartum women. Mistreatment was measured using four domains: (1) physical abuse, (2) verbal abuse, (3) failure to meet professional standards of care, and (4) poor rapport between women and providers. Percentages of mistreatment and odds ratios for the association between its presence and institutional and socio demographic characteristics of women were calculated using bivariate and multivariable logistic regression modeling.

Results

A total of 379 women were interviewed, of whom 281 (74%) reported any mistreatment. Physical and verbal abuse were reported by 7 (2%) and 31 (8%) women interviewed respectively. Failure to meet professional standards of care and poor rapport between women and providers were reported by 111 (29%) and 274 (72%) women interviewed respectively.

Multivariable logistic regression analysis revealed that the odds of reporting mistreatment were higher among women with four or more previous births (aOR = 3.36 95%CI 1.22,9.23, p = 0.019) compared to women with no previous childbirth, Muslim women (aOR = 3.30 95%CI 1.4,7.77, p = 0.006) and women interviewed in facilities with less than 17 births per MNH staff in a month (aOR = 3.63 95%CI 1.9,6.93, p < 0.001). However, the odds of reporting mistreatment were lower among women aged 35 and older (aOR = 0.22 95%CI 0.06, 0.73, p = 0.014) and among women interviewed between 8 and 42 days after childbirth (aOR = 0.37 95%CI 0.15, 0.9, p = 0.028).

Conclusion

Mistreatment during childbirth in Ethiopia is commonly reported. Health workers need to consider provision of individualized care for women and monitor their experiences in order to adjust quality of their services.

Electronic supplementary material

The online version of this article (10.1186/s12978-019-0781-y) contains supplementary material, which is available to authorized users.

Factors Affecting Breastfeeding Practices in Sindh Province, Pakistan: A Secondary Analysis of Cross-Sectional Survey Data

Breastfeeding practices are critical for child health and growth. This paper investigates demographic factors, socioeconomic status, and information sources that affect breastfeeding practices in Sindh Province, Pakistan. A secondary analysis was performed of data on 10,028 women with a birth in the preceding two years who had participated in the 2013-14 Maternal and Child Health Program Indicator Survey. Multiple logistic regressions were used to test the association between breastfeeding status (ever breastfed and still breastfeeding) and age, number of living children, residence, education, wealth, information sources about breastfeeding, assistance during delivery, and place of delivery. Of the 9955 women included in the analysis, 97.9% had breastfed and 83.9% were still breastfeeding at the time of the survey. Being in the second, third, or fourth wealth quintiles and receiving breastfeeding information from relatives and friends were associated with ever breastfeeding. Women who were 35 years or older, living in a town/small city, higher maternal education, middle wealth quintile, and receiving breastfeeding information from the media were associated with still breastfeeding. The findings suggest the need to develop interventions considering maternal socioeconomic status and peer counseling interventions. Mass media campaigns to promote breastfeeding practices should be accompanied by governmental restrictions on the marketing of infant formula.

Harmonizing scientific rigor with political urgency: policy learnings for identifying accelerators for scale-up from the safe childbirth checklist programme in Rajasthan, India

BACKGROUND

Quick scaling-up of innovative and promising interventions in health systems of low and middle-income countries to rapidly achieve population level benefits is a key challenge. While there is consensus on the need for rigorous scientific evidence on effectiveness of interventions before considering scale-up, there can be significant time lag for the want of gold-standard evidence. The Safe Childbirth Checklist (SCC) programme in India, demonstrated how an innovation was robustly evaluated and scaled up nationally, within a short span of time. In this narrative review, we describe the strategies discussed in various published scale-up frameworks and map them against the strategies adopted by the SCC programme to identify accelerators which facilitated its rapid scale up.

METHODS

The narrative review - done from May to June 2017 - involved keyword searches of electronic databases of PubMed, Ovid Medline and Google Scholar. It included the key words 'pilot', 'health innovations', 'scale-up', 'replication', 'expansion', 'increased coverage', 'conceptual models for scale-up', 'frame-works for scale-up', 'evidence for scale-up' in the title of publications,. This search was limited to publications in English after the year 1995. We used snowball sampling approach (by referring to bibliographies of shortlisted publications) to identify additional publications related to scale-up. We then screened the identified publications independently and relevant publications that discussed attributes for a conceptual model for scale-up of public health interventions in low and middle-income countries were shortlisted. We then mapped the strategies we used in SCC program scale up against those described in the shortlisted frameworks to identify seven accelerators which facilitated rapid scale up.

RESULTS

The identified accelerators were: testing the intervention in real world, resource constrained settings; using an appropriate and time sensitive research design; testing the intervention at substantial scale and in diverse settings; using an adaptive and iterative prototyping approach for implementation; sharing data and evidence with key stakeholders on an ongoing basis; targeting bridge resources through strategic engagement of stakeholders and timely integration of scale-up plans with annual planning and budgeting cycles and systems.

CONCLUSION

These accelerators will complement current frameworks and provide guidance to future scale-up initiatives in India and elsewhere.

Long-Acting Reversible Contraception Uptake and Associated Factors among Women of Reproductive Age in Rural Kenya

In the last two decades, the use of short-acting methods of contraception has driven the increase of contraceptive use in Kenya. We assessed the factors associated with uptake of long-acting reversible contraception by women seeking family planning services in public health facilities in Kakamega County, Kenya. A mixed methods cross-sectional study through client exit surveys among 423 women seeking family planning services was done at 12 public health facilities in Kakamega County. Twelve in-depth interviews with health care providers from the study facilities further explored practices in provision of long-acting reversible contraception (LARC). Among women initiating contraceptive use, LARC method utilization was 20.6%. Women's tertiary education level, Protestant Christian religion, age at first birth, and having no desire for more children were significantly associated with utilization of LARC. Structural factors including shortage of human resource, provider bias and lack of adequate skills on provision of services were identified as key barriers to uptake of long-acting reversible contraception services.

Factors associated with the use of antenatal care in Sindh province, Pakistan: A population-based study

BACKGROUND

Antenatal care (ANC) is critical to decrease maternal and neonatal mortality. However, little is known about the utilization of ANC services in Pakistan. This study assessed the utilization of ANC in Sindh province, Pakistan, and identified the factors that affect its use.

METHODS

We analysed a subset of data from Maternal and Child Health (MCH) Program Indicator Surveys conducted in Sindh province, Pakistan in 2013 and 2014. Respondents included 10,200 women who had given birth in the past two years. The outcome measure was making at least four ANC visits. Logistic regression models were used to identify demographic, socioeconomic, characteristics of ANC, and informational factors associated with ANC use.

RESULTS

Most women (83.5%) received one or more ANC, mostly by doctors (95%), but only 57.3% of them made the recommended four or more visits, and just 53.7% received their initial ANC care during the first trimester. Making four or more ANC visits was associated with: fewer household occupants (odds ratio [OR] = 0.98; 95% confidence interval [CI] = [0.97, 0.99]), large city residence (OR = 1.92; 95% CI = [1.57, 2.35]), higher women's education (OR = 1.70; 95% CI = [1.33, 2.15]), greater household wealth (OR = 5.66; 95% CI = [4.22, 7.60]), and receiving MCH information from lady health worker (OR = 1.17; 95% CI = [1.00, 1.37]), mother-in-law (OR = 1.17; 95% CI = [1.01, 1.36]), other relatives/friends (OR = 1.19; 95% CI = [1.03, 1.38]), or nurse/midwife (OR = 1.31; 95% CI = [1.06, 1.61]).

CONCLUSIONS

This study demonstrates that both socioeconomic factors and health information sources are associated with women's use of ANC. Therefore, programs should target socially disadvantaged and vulnerable groups, particularly rural, less educated, and poor women, to improve utilization of ANC. In addition, strategies to increase exposure to MCH information sources should be a priority in Sindh, Pakistan.

Evaluation of two vaginal, uterus sparing operations for pelvic organ prolapse: modified Manchester operation (MM) and sacrospinous hysteropexy (SSH), a study protocol for a multicentre randomized non-inferiority trial (the SAM study)

BACKGROUND

Pelvic organ prolapse (POP) affects up to 40% of parous women which adversely affects the quality of life. During a life time, 20% of all women will undergo an operation. In general the guidelines advise a vaginal operation in case of uterine descent: hysterectomy with uterosacral ligament plication (VH), sacrospinous hysteropexy (SSH) or a modified Manchester operation (MM). In the last decade, renewed interest in uterus sparing techniques has been observed. Previous studies have shown non-inferiority between SSH and VH. Whether or not SSH and MM are comparable concerning anatomical and functional outcome is still unknown. The practical application of both operations is at least in The Netherlands a known cause of practice pattern variation (PPV). To reveal any difference between both techniques the SAM-study was designed.

METHODS

The SAM-study is a randomized controlled multicentre non-inferiority study which compares SSH and MM. Women with symptomatic POP in any stage, uterine descent and POP-Quantification (POP-Q) point D at ≤ minus 1 cm are eligible. The primary outcome is the composite outcome at two years of absence of prolapse beyond the hymen in any compartment, the absence of bulge symptoms and absence of reoperation for pelvic organ prolapse. Secondary outcomes are hospital parameters, surgery related morbidity/complications, pain perception, further treatments for prolapse or urinary incontinence, POP-Q anatomy in all compartments, quality-of-life, sexual function, and cost-effectiveness. Follow-up takes place at 6 weeks, 12 and 24 months. Additionally at 12 weeks, 6 and 9 months cost-effectiveness will be assessed. Validated questionnaires will be used and gynaecological examination will be performed. Analysis will be performed following the intention-to-treat and per protocol principle. With a non-inferiority margin of 9% and an expected loss to follow-up of 10%, 424 women will be needed to prove non-inferiority with a confidence interval of 95%.

DISCUSSION

This study will evaluate the effectiveness and costs of SSH versus MM in women with primary POP. The evidence will show whether the existing PPV is detrimental and a de-implementation process regarding one of the operations is needed.

TRIAL REGISTRATION

Dutch Trial Register (NTR 6978, http://www.trialregister.nl ). Date of registration: 29 January 2018. Prospectively registered.

Applicability of the WHO maternal near miss tool in sub-Saharan Africa: a systematic review

Background

Applicability of the World Health Organization (WHO) maternal near miss criteria in low-income settings is not systematically addressed in the literature. The objective of this review was to determine the applicability of the WHO maternal near miss tool in sub-Saharan Africa.

Methods

We searched PubMed, Embase, Popline, CINAHL, AJOL, and Google scholar using key words for maternal near miss and sub-Saharan Africa. Studies which applied the WHO maternal near miss criteria, containing clear definitions, and published between January 1st, 2009 and December 31st, 2017 were included. Two authors independently extracted data. Quantitative analysis and narrative synthesis were conducted, and medians with interquartile range (IQR) were calculated for summarizing the findings. Methodological quality of the studies was assessed using the Estabrook’s quality assessment and validity tool.

Results

Fifteen studies from nine countries comprising 227,077 participants were included. Median maternal near miss ratio was 24.2 (IQR: 12.4–35.8) per 1000 live births ranging from 4.4 in a population-based study in South Africa to 198 in a rural private hospital in Nigeria. Eight studies reported challenges in implementing the WHO maternal near miss tool, especially related to the threshold for blood transfusion, and availability of several laboratory-based criteria. In three studies, local adaptations were made.

Conclusion

This review showed that the WHO maternal near miss tool is not uniformly applied in sub-Saharan Africa. Therefore, a common adaptation for the region is required to increase its applicability.

Electronic supplementary material

The online version of this article (10.1186/s12884-019-2225-7) contains supplementary material, which is available to authorized users.

Women's Experience of Facility-Based Childbirth Care and Receipt of an Early Postnatal Check for Herself and Her Newborn in Northwestern Tanzania

Negative experiences of care may act as a deterrent to current and/or future utilization of facility-based health services. To examine the situation in Tanzania, we conducted a sub-analysis of a cross-sectional household survey conducted in April 2016 in the Mara and Kagera regions of Tanzania. The sample included 732 women aged 15–49 years who had given birth in a health facility during the previous two years. Log binomial regression models were used to investigate the association between women’s experiences of care during childbirth and the receipt of early postnatal checks before discharge. Overall, 73.1% of women reported disrespect and abuse, 60.1% were offered a birth companion, 29.1% had a choice of birth position, and 85.5% rated facility cleanliness as good. About half of mothers (46.3%) and newborns (51.4%) received early postnatal checks before discharge. Early postnatal checks for both mothers and newborns were associated with no disrespect and abuse (RR: 1.23 and 1.14, respectively) and facility cleanliness (RR: 1.29 and 1.54, respectively). Early postnatal checks for mothers were also associated with choice of birth position (RR: 1.18). The results suggest that a missed opportunity in providing an early postnatal check is an indication of poor quality of the continuum of care for mothers and newborns. Improved quality of care at one stage can predict better care in subsequent stages.

Quality of care in early detection and management of pre-eclampsia/eclampsia in health facilities in Afghanistan

Background

Afghanistan faces a high burden of maternal and neonatal morbidity and mortality. Hypertensive disorders of pregnancy, including pre-eclampsia and eclampsia (PE/E), are among the most common causes of maternal and neonatal complications. Hypertensive disorders of pregnancy can lead to fatal complications for both the mother and fetus. The 2016 Afghanistan National Maternal and Newborn Health Quality of Care Assessment assessed quality of early detection and management of PE/E in health facilities and skilled birth attendants’ (SBAs) perceptions of their working environment.

Methods

All accessible public health facilities with an average of at least five births per day (n = 77), a nationally representative sample of public health facilities with less than five births per day (n = 149), and 20 purposively selected private health facilities were assessed. Methods included a facility inventory and record review, interviews with SBAs, and direct clinical observation of antenatal care (ANC), intrapartum care and immediate postnatal care (PNC), as well as severe PE/E case management.

Results

Most facilities had supplies and medicines for early detection and management of PE/E.

At public health facilities, 357 of 414 (86.2%) clients observed during ANC consultations had their blood pressure checked and 159 (38.4%) were asked if they had experienced symptoms of PE/E. Only 553 of 734 (72.6%) SBAs interviewed were able to correctly identify severe pre-eclampsia described in a case scenario. Of 29 PE/E cases observed, 17 women (59%) received the correct loading dose of magnesium sulfate (MgSO4) and 12 women (41%) received the correct maintenance dose of MgSO4.

At private health facilities, 39 of 45 ANC clients had their blood pressure checked and 9 of 45 (20%) were asked about symptoms of PE/E. Fifty-four of 64(84.4%) SBAs in private facilities correctly identified severe pre-eclampsia described in a case scenario.

Conclusion

Notable gaps in SBAs’ knowledge and clinical practices in detection and management of PE/E in various health facilities increase the risk of maternal and perinatal mortality. Continuing education of health care providers and increased investment in focused quality improvement initiatives will be critical to improve the quality of health care services in Afghanistan.

Factors associated with institutional delivery: Findings from a cross-sectional study in Mara and Kagera regions in Tanzania

In Tanzania, maternal mortality has stagnated over the last 10 years, and some of the areas with the worst indicators are in the Lake and Western Zones. This study investigates the factors associated with institutional deliveries among women aged 15-49 years in two regions of the Lake Zone. Data were extracted from a cross-sectional household survey of 1,214 women aged 15-49 years who had given birth in the 2 years preceding the survey in Mara and Kagera regions. Logistic regression analyses were conducted to explore the influence of various factors on giving birth in a facility. About two-thirds (67.3%) of women gave birth at a health facility. After adjusting for possible confounders, six factors were significantly associated with institutional delivery: region (adjusted odds ratio [aOR], 95% confidence interval [CI]: 0.54 [0.41-0.71]), number of children (aOR, 95% CI: 0.61 [0.42-0.91]), household wealth index (aOR, 95% CI: 1.47 [1.09-2.27]), four or more antenatal care visits (aOR, 95% CI: 1.97 [1.12-3.47]), knowing three or more pregnancy danger signs (aOR, 95% CI: 1.87 [1.27-2.76]), and number of birth preparations (aOR, 95% CI: 6.09 [3.32-11.18]). Another three factors related to antenatal care were also significant in the bivariate analysis, but these were not significantly associated with place of delivery after adjusting for all variables in an extended multivariable regression model. Giving birth in a health facility was associated both with socio-demographic factors and women's interactions with the health care system during pregnancy. The findings show that national policies and programs promoting institutional delivery in Tanzania should tailor interventions to specific regions and reach out to low-income and high-parity women. Efforts are needed not just to increase the number of antenatal care visits made by pregnant women, but also to improve the quality and content of the interaction between women and service providers.

Factors affecting complete and timely childhood immunization coverage in Sindh, Pakistan; A secondary analysis of cross-sectional survey data

BACKGROUND

Pakistan has a high burden of newborn mortality, which would be significantly preventable through appropriate routine immunization. The purpose of this study was to measure the basic timely childhood immunization coverage and to identify determinants of factors influencing childhood immunization coverage in Sindh, Pakistan.

METHODS

Data from Maternal and Child Health Program Indicator Survey 2013-2014 which was conducted in Sindh province of Pakistan was used. Outcome measure was full coverage of the basic immunization schedule from child's vaccination card. The association of receiving basic immunization with demographic factors, socioeconomic status, mother and child health information sources, and perinatal care factors were tested by binary logistic regression.

RESULTS

Among 2,253 children, 1,156 (51.3%) received age-based full basic immunization. The basic immunization rates were 69.1% for under five weeks old, 38.3% for six to nine weeks, 18.8% for 10-13 weeks, 44.0% for 14 weeks-eight months, 60.4% for nine to 11 months, and 59.1% for over one year. Child's age, number of living children, parents' education level, wealth, the source of mother and child health information, number of antenatal care, and assistance during delivery were associated with completing basic immunization.

CONCLUSIONS

The overall full basic immunization coverage in Pakistan was still low. Policy makers should identify children at risk of low immunization coverage and obstacles of receiving antenatal care, implement educational interventions targeting on less educated parents, and conduct mass immunization campaigns for timely and complete immunization.

Facilitators for maternity waiting home utilisation at Attat Hospital: a mixed-methods study based on 45 years of experience

OBJECTIVE

To describe facilitators for maternity waiting home (MWH) utilisation from the perspectives of MWH users and health staff.

METHODS

Data collection took place over several time frames between March 2014 and January 2018 at Attat Hospital in Ethiopia, using a mixed-methods design. This included seven in-depth interviews with staff and users, three focus group discussions with 28 users and attendants, a structured questionnaire among 244 users, a 2-week observation period and review of annual facility reports. The MWH was built in 1973; consistent records were kept from 1987. Data analysis was done through content analysis, descriptive statistics and data triangulation.

RESULTS

The MWH at Attat Hospital has become a well-established intervention for high-risk pregnant women (1987-2017: from 142 users of 777 total attended births [18.3%] to 571 of 3693 [15.5%]; range 142-832 users). From 2008, utilisation stabilised at on average 662 women annually. Between 2014 and 2017, total attended births doubled following government promotion of facility births; MWH utilisation stayed approximately the same. Perceived high quality of care at the health facility was expressed by users to be an important reason for MWH utilisation (114 of 128 MWH users who had previous experience with maternity services at Attat Hospital rated overall services as good). A strong community public health programme and continuous provision of comprehensive emergency obstetric and neonatal care (EmONC) seemed to have contributed to realising community support for the MWH. The qualitative data also revealed that awareness of pregnancy-related complications and supportive husbands (203 of 244 supported the MWH stay financially) were key facilitators. Barriers to utilisation existed (no cooking utensils at the MWH [198/244]; attendant being away from work [190/244]), but users considered these necessary to overcome for the perceived benefit: a healthy mother and baby.

CONCLUSIONS

Facilitators for MWH utilisation according to users and staff were perceived high-quality EmONC, integrated health services, awareness of pregnancy-related complications and the husband's support in overcoming barriers. If providing high-quality EmONC and integrating health services are prioritised, MWHs have the potential to become an accepted intervention in (rural) communities. Only then can MWHs improve access to EmONC.

Comparison of pregnancy outcomes between maternity waiting home users and non-users at hospitals with and without a maternity waiting home: retrospective cohort study

Objective

To examine the impact of a maternity waiting home (MWH) by comparing pregnancy outcomes between users and non-users at hospitals with and without an MWH.

Methods

We conducted a retrospective cohort study in Ethiopia comparing one hospital with an MWH (Attat) to a second hospital without one (Butajira). A structured questionnaire among sampled women in 2014 and hospital records from 2011 to 2014 were used to compare sociodemographic characteristics and pregnancy outcomes between Attat MWH users and non-MWH users, Attat MWH users and Butajira, and Attat non-MWH users and Butajira. χ2 or ORs with 95% CIs were calculated.

Results

Compared with Attat non-MWH users (n=306) and Butajira women (n=153), Attat MWH users (n=244) were more often multiparous (multipara vs primigravida: OR 4.43 [95% CI 2.94 to 6.68] and OR 3.58 [95% CI 2.24 to 5.73]), less educated (no schooling vs secondary school: OR 2.62 [95% CI 1.53 to 4.46] and OR 5.21 [95% CI 2.83 to 9.61], primary vs secondary school: OR 4.84 [95% CI 2.84 to 8.25] and OR 5.19 [95% CI 2.91 to 9.27]), poor (poor vs wealthy: OR 8.94 [95% CI 5.13 to 15.61] and OR 12.34 [95% CI 6.78 to 22.44] and further from the hospital (2 h 27 min vs 1 h 00 min and 1 h 12 min: OR 3.08 [95% CI 2.50 to 3.80] and OR 2.18 [95% CI 1.78 to 2.67]). Comparing hospital records of Attat MWH users (n=2784) with Attat non-users (n=5423) and Butajira women (n=9472), maternal deaths were 0 vs 20 (0.4%; p=0.001) and 31 (0.3%; p=0.003), stillbirths 38 (1.4%) vs 393 (7.2%) (OR 0.18 [95% CI 0.13 to 0.25]) and 717 (7.6%) (OR 0.17 [95% CI 0.12 to 0.24]) and uterine ruptures 2 (0.1%) vs 40 (1.1%) (OR 0.05 [95% CI 0.01 to 0.19]) and 122 (1.8%) (OR 0.04 (95% CI 0.01 to 0.16]). No significant differences were found regarding maternal deaths and stillbirths between Attat non-users and Butajira women.

Conclusions

Attat MWH users had less favourable sociodemographic characteristics but better birth outcomes than Attat non-users and Butajira women.

Factors Predicting Ethiopian Anesthetists' Intention to Leave Their Job

Background

Ethiopia has rapidly expanded training programs for associate clinician anesthetists in order to address shortages of anesthesia providers. However, retaining them in the public health sector has proven challenging. This study aimed to determine anesthetists’ intentions to leave their jobs and identify factors that predict turnover intentions.

Methods

A nationally representative, cross-sectional survey of 251 anesthetists working in public-sector hospitals in Ethiopia was conducted in 2014. Respondents were asked whether they planned to leave the job in the next year and what factors they considered important when making decisions to quit. Bivariate and multivariable logistic regressions were conducted to investigate 16 potential predictors of turnover intentions, including personal and facility characteristics as well as decision-making factors.

Results

Almost half (n = 120; 47.8%) of anesthetists planned to leave their jobs in the next year, and turnover intentions peaked among those with 2–5 years of experience. Turnover intentions were not associated with the compulsory service obligation. Anesthetists rated salary and opportunities for professional development as the most important factors in decisions to quit. Five predictors of turnover intentions were significant in the multivariable model: younger age, working at a district rather than regional or referral hospital, the perceived importance of living conditions, opportunities for professional development, and conditions at the workplace.

Conclusions

Human resources strategies focused on improving living conditions for anesthetists and expanding professional development opportunities may increase retention. Special attention should be focused on younger anesthetists and those posted at district hospitals.

Electronic supplementary material

The online version of this article (doi:10.1007/s00268-017-4318-7) contains supplementary material, which is available to authorized users.

Job satisfaction among anesthetists in Ethiopia-a national cross-sectional study

BACKGROUND

Ethiopia has substantially increased production of associate clinician anesthetists. This study aimed to determine the level of and factors that predict job satisfaction among a national sample of anesthetists.

METHODS

A cross-sectional study conducted in 2014 sampled 252 anesthetists. Respondents rated 37 items related to job satisfaction and working and living conditions using a Likert scale, which ranged from 1 (strongly disagree) to 5 (strongly agree). Univariate and multivariable logistic regressions were used to determine factors associated with the main outcome variable, level of job satisfaction. Adjusted odds ratios and 95% confidence intervals were calculated to show the magnitude of associations.

RESULTS

Less than half (n = 107, 42.5%) of anesthetists were satisfied with their job. Work environment (aOR = 1.87, 95% CI = 1.06, 3.31) and more than 10 years of experience working in the public health system (aOR = 4.96, 95% CI = 1.11, 22.13) were predictors of job satisfaction in the multivariable model.

CONCLUSION

Ethiopian anesthetists have low levels of job satisfaction, with work environment and years of experience being factors that predict their satisfaction positively. Motivation and retention of this cadre will require emphasis on creating a safe and conducive work environment, and interventions designed to motivate junior anesthetists.

A cohort of women with ectopic pregnancy: challenges in diagnosis and management in a rural hospital in a low-income country

BACKGROUND

Ectopic pregnancy (EP) is a serious complication of early pregnancy. In low-income countries diagnosis of EP is difficult and it is a major contributor to maternal mortality. We aimed to assess and improve the diagnostic process of women with EP.

METHODS

We conducted a retrospective medical records study of all women with confirmed EP in Ndala Hospital from 2010 to 2012. We used data on demographics, symptoms, diagnostic procedures, surgical findings, treatment and post-operative status.

RESULTS

Six thousand six hundred sixty-two women gave birth in the hospital, and 88 women were diagnosed with EP (incidence 1.3%). Thirty-nine percent of women did not report to be pregnant or to have a history of amenorrhea. On admission in Ndala hospital, a diagnosis of 'suspected EP' was made in less than half (47%) of the cases. Most women had a urine pregnancy test done (sensitivity of 98%). Peritoneal aspiration was done in 42%. The fifty-five women with EP who were diagnosed by ultrasound received a lower mean number of units of blood transfusion and had less often severe anaemia than women who were diagnosed by abdominal aspiration (abdominocentesis). The majority of women (65%) had surgery within 24 h after admission.

CONCLUSIONS

Diagnosing EP in a rural hospital in Tanzania is challenging. Often there is a large doctors' delay before the right diagnosis is made. Abdominal aspiration can be useful for rapid diagnosis. A pelvic ultrasound, when available, allows the diagnosis to be made earlier with less intra-abdominal bleeding.

Analysis of caesarean sections using Robson 10-group classification system in a university hospital in eastern Ethiopia: a cross-sectional study

OBJECTIVE

To analyse caesarean section (CS) using Robson 10-group classification system in an Ethiopian university hospital.

DESIGN

Cross-sectional study.

SETTING

A university hospital in eastern, Ethiopia.

PARTICIPANTS

980 women who underwent CS from January 2016 to April 2017.

MAIN OUTCOME

Robson groups (1-10-based on gestational age, fetal presentation, number of fetus, onset of labour and history of CS) and indications for CS.

RESULTS

Robson group 3 (multiparous women with single cephalic full-term pregnancy in spontaneous labour with no history of CS), group 5 (multiparous women with single cephalic full-term pregnancy with history of CS) and group 1 (single cephalic nulliparous women full-term pregnancy in spontaneous labour) were the major contributors to the overall CS at 21.4%, 21.1% and 19.3%, respectively. The three major indications for CS were fetal compromise (mainly fetal distress), obstructed labour (mainly cephalopelvic disproportion) and previous CS.

CONCLUSION

Robson groups 3, 5 and 1 were the major contributors to the overall CS rate. Fetal compromise, obstructed labour and previous CS were the underlying indications for performing CS. Further study is required to assess the appropriateness of the indications and to reduce CS among the low-risk groups (groups 1 and 3).

Realising the right to sexual and reproductive health: access to essential medicines for medical abortion as a core obligation

BACKGROUND

WHO has a pivotal role to play as the leading international agency promoting good practices in health and human rights. In 2005, mifepristone and misoprostol were added to WHO's Model List of Essential Medicines for combined use to terminate unwanted pregnancies. However, these drugs were considered 'complementary' and qualified for use when in line with national legislation and where 'culturally acceptable'.

DISCUSSION

This article argues that these qualifications, while perhaps appropriate at the time, must now be removed. First, compelling medical evidence justifies their reclassification as a 'core' essential medicine. Second, continuing to subjugate essential medicines for medical abortion to domestic law and cultural practices is incoherent with today's human rights standards in which universal access to these medicines is an inextricable part of the right to sexual and reproductive health, which should be supported and realised through domestic legislation.

CONCLUSION

This article shows that removing such limitations will align WHO's Model List of Essential Medicines with the mounting scientific evidence, human rights standards, and its own more recently developed policy guidance. This measure will send a strong normative message to governments that these medicines should be readily available in a functioning and human-rights-abiding health system.

Factors associated with intended use of a maternity waiting home in Southern Ethiopia: a community-based cross-sectional study

Background

Although Ethiopia is scaling up Maternity Waiting Homes (MWHs) to reduce maternal and perinatal mortality, women’s use of MWHs varies markedly between facilities. To maximize MWH utilization, it is essential that policymakers are aware of supportive and inhibitory factors. This study had the objective to describe factors and perceived barriers associated with potential utilization of an MWH among recently delivered and pregnant women in Southern Ethiopia.

Methods

A community-based cross-sectional study was conducted between March and November 2014 among 428 recently delivered and pregnant women in the Eastern Gurage Zone, Southern Ethiopia, where an MWH was established for high-risk pregnant women to await onset of labour. The structured questionnaire contained questions regarding possible determinants and barriers. Logistic regression with 95% Confidence Intervals (CI) was used to examine association of selected variables with potential MWH use.

Results

While only thirty women (7.0%) had heard of MWHs prior to the study, 236 (55.1%), after being explained the concept, indicated that they intended to stay at such a structure in the future. The most important factors associated with intended MWH use in the bivariate analysis were a woman’s education (secondary school or higher vs. no schooling: odds ratio [OR] 6.3 [95% CI 3.46 to 11.37]), her husband’s education (secondary school or higher vs. no schooling: OR 5.4 [95% CI 3.21 to 9.06]) and envisioning relatively few barriers to MWH use (OR 0.32 [95% CI 0.25 to 0.39]). After adjusting for possible confounders, potential users had more frequently suffered complications in previous childbirths (adjusted odds ratio [aOR] 4.0 [95% CI 1.13 to 13.99]) and envisioned fewer barriers to MWH use (aOR 0.3 [95% CI 0.23 to 0.38]). Barriers to utilization included being away from the household (aOR 18.1 [95% CI 5.62 to 58.46]) and having children in the household cared for by the community during a woman’s absence (aOR 9.3 [95% CI 2.67 to 32.65]).

Conclusions

Most respondents had no knowledge about MWHs. Having had complications during past births and envisioning few barriers were factors found to be positively associated with intended MWH use. Unless community awareness of preventive maternity care increases and barriers for women to stay at MWHs are overcome, these facilities will continue to be underutilized, especially among marginalized women.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-1670-z) contains supplementary material, which is available to authorized users.

Adaptation of the WHO maternal near miss tool for use in sub-Saharan Africa: an International Delphi study

Background

Assessments of maternal near miss (MNM) are increasingly used in addition to those of maternal mortality measures. The World Health Organization (WHO) has introduced an MNM tool in 2009, but this tool was previously found to be of limited applicability in several low–resource settings. The aim of this study was to identify adaptations to enhance applicability of the WHO MNM tool in sub–Saharan Africa.

Methods

Using a Delphi consensus methodology, existing MNM tools were rated for applicability in sub-Saharan Africa over a series of three rounds. Maternal health experts from sub-Saharan Africa or with considerable knowledge of the context first rated importance of WHO MNM parameters using Likert scales, and were asked to suggest additional parameters. This was followed by two confirmation rounds. Parameters accepted by at least 70% of the panel members were accepted for use in the region.

Results

Of 58 experts who participated from study onset, 47 (81%) completed all three rounds. Out of the 25 WHO MNM parameters, all 11 clinical, four out of eight laboratory, and four out of six management–based parameters were accepted, while six parameters (PaO2/FiO2 < 200 mmHg, bilirubin >100 μmol/l or >6.0 mg/dl, pH <7.1, lactate >5 μmol/l, dialysis for acute renal failure and use of continuous vasoactive drugs) were deemed to not be applicable. An additional eight parameters (uterine rupture, sepsis/severe systemic infection, eclampsia, laparotomy other than caesarean section, pulmonary edema, severe malaria, severe complications of abortions and severe pre-eclampsia with ICU admission) were suggested for inclusion into an adapted sub-Saharan African MNM tool.

Conclusions

All WHO clinical criteria were accepted for use in the region. Only few of the laboratory- and management based were rated applicable. This study brought forward important suggestions for adaptations in the WHO MNM criteria to enhance its applicability in sub-Saharan Africa and possibly other low–resource settings.

Identifying gaps in the practices of rural health extension workers in Ethiopia: a task analysis study

Background

Health extension workers (HEWs) are the frontline health workers for Ethiopia’s primary health care system. The Federal Ministry of Health is seeking to upgrade and increase the number of HEWs, particularly in remote areas, and address concerns about HEWs’ pre-service education and practices. The aim of this study was to identify gaps in HEWs’ practices and recommend changes in their training and scope of practice.

Methods

A cross-sectional descriptive task analysis was conducted to assess the work of rural HEWs who had been in practice for six months to five years. One hundred participants were invited from 100 health posts in five regions of Ethiopia. HEWs self-reported on 62 tasks on: frequency, criticality (importance), where the task was learned, and ability to perform the task. Descriptive statistics, including frequencies and percentages, were computed for each variable. Task combinations were examined to identify tasks performed infrequently or for which HEWs are inadequately prepared.

Results

A total of 82 rural HEWs participated in the study. Nearly all HEWs rated every task as highly critical to individual and public health outcomes. On average, most HEWs (51.5%–57.4%) reported learning hygiene and environmental sanitation tasks, disease prevention and control tasks, family health tasks, and health education and communication tasks outside of their pre-service education, primarily through in-service and on-the-job training. Over half of HEWs reported performing certain critical tasks infrequently, including management of supplies, stocks and maintenance at the facility and management of the cold chain system. Almost all HEWs (95.7–97.2%) perceived themselves as competent and proficient in performing tasks in all program areas.

Conclusion

HEWs were insufficiently prepared during pre-service education for all tasks that fall within their scope of practice. Many learned tasks through in-service or on-the-job training, and some tasks were not learned at all. Some tasks that are part of expected HEW practice were performed infrequently, potentially reducing the effectiveness of the Health Extension Program to provide preventive and basic curative health care services to communities. Findings should alert policy makers to the need to review HEWs’ scope of practice, update pre-service education curricula and prioritize in-service training modules.