Scaling up of family planning in low-income countries: lessons from Ethiopia

Quality of family planning counseling and associated factors among women attending family planning clinics at selected health centers in Akaki Kality sub-city, Addis Ababa, Ethiopia

Background

Ethiopia has achieved a remarkable improvement in the provision of family planning. The modern contraceptive prevalence rate has shown a fivefold increment in the last two decades, yet the family planning service in the country is still deficient and characterized by poor counseling quality.

Objective

The aim of the study is to assess the quality of family planning counseling provided and the associated factors at selected health centers in Akaki Kality sub-city, Addis Ababa, Ethiopia.

Method

A cross-sectional study was conducted among 678 randomly selected women attending family planning services at health centers in Addis Ababa, Ethiopia. Multivariable logistic regression analysis was performed to identify factors associated with the quality of family planning counseling.

Result

A total of 678 women participated in the study. About 29.1% [95% confidence interval (CI): 25.7%–32.6%] of the respondents were adequately counseled. Age groups 37–49 [adjusted odds ratio (AOR) = 2.7; 95% CI: 1.1–6.6], being in marital union (AOR = 2.8; 95% CI: 1.2–6.7), attaining secondary education (AOR = 1.9; 95% CI: 1.1–3.6) or higher education (AOR = 2.2; 95% CI: 1.2–4.3), and visit status (AOR = 1.6; 95% CI: 1.1–2.4) were significantly associated with good counseling.

Conclusion

Less than one in three women was counseled adequately. Health professionals should give due attention to younger women, single clients, and clients with their first presentation to the health facility. It also indicates that promoting education among Ethiopian women is crucial for a positive outcome of family planning counseling.

The triple burden of communicable and non-communicable diseases and injuries on sex differences in life expectancy in Ethiopia

BACKGROUND

Ethiopia has experienced great improvements in life expectancy (LE) at birth over the last three decades. Despite consistent increases in LE for both males and females in Ethiopia, the country has simultaneously witnessed an increasing discrepancy in LE between males and females.

METHODS

This study used Pollard's actuarial method of decomposing LE to compare age- and cause- specific contributions to changes in sex differences in LE between 1995 and 2015 in Ethiopia.

RESULTS

Life expectancy at birth in Ethiopia increased for both males and females from 48.28 years and 50.12 years in 1995 to 65.59 years and 69.11 years in 2015, respectively. However, the sex differences in LE at birth also increased from 1.85 years in 1995 to 3.51 years in 2015. Decomposition analysis shows that the higher male mortality was consistently due to injuries and respiratory infections, which contributed to 1.57 out of 1.85 years in 1995 and 1.62 out of 3.51 years in 2015 of the sex differences in LE. Increased male mortality from non-communicable diseases (NCDs) also contributed to the increased difference in LE between males and females over the period, accounting for 0.21 out of 1.85 years and 1.05 out of 3.51 years in 1995 and 2015, respectively.

CONCLUSIONS

While injuries and respiratory infections causing male mortality were the most consistent causes of the sex differences in LE in Ethiopia, morality from NCDs is the main cause of the recent increasing differences in LE between males and females. However, unlike the higher exposure of males to death from injuries due to road traffic injuries or interpersonal violence, to what extent sex differences are caused by the higher male mortality compared to female mortality from respiratory infection diseases is unclear. Similarly, despite Ethiopia's weak social security system, an explanation for the increased sex differences after the age of 40 years due to either longer female LE or reduced male LE should be further investigated.

Scaling Up a Strengthened Youth-Friendly Service Delivery Model to Include Long-Acting Reversible Contraceptives in Ethiopia: A Mixed Methods Retrospective Assessment

BACKGROUND

Donor funded projects are small scale and time limited, with gains that soon dissipate when donor funds end. This paper presents findings that sought to understand successes, challenges and barriers that influence the scaling up and sustainability of a tested, strengthened youth-friendly service (YFS) delivery model providing an expanded contraceptive method choice in one location - the YFS unit - with additional units in Amhara and Tigray, Ethiopia.

METHODS

This retrospective mixed methods study included interviews with key informants (KIs) (qualitative arm) and analysis of family planning (FP) uptake statistics extracted from the sampled health facilities (quantitative arm). A multistage convenience purposive sampling technique was adopted to randomly select 8 health facilities aligned with respective woredas, zones and regional health bureaus (RHBs). A semi-structured interview guide soliciting information on 6 scaling-up elements (stakeholder engagement, roles and responsibility, policy environment, financial resources, quality of voluntary FP services and data availability and use) guided the interviews. Fifty-six KI interviews were conducted with policy-makers, program managers, and clinic staff. Recurring themes were triangulated across administrative levels and implementing partners. Relevant FP data (acceptor status, age and method uptake) were extracted from the 8 sampled health facilities for a thirteen-month period. Qualitative findings triangulated with FP service statistics assessed the influence of the 6 scaling-up elements with trends in long-acting reversible contraceptive (LARC) uptake before and after training.

RESULTS

Our findings depict that respondents were knowledgeable and supportive of an expanded method mix. Statistically significant increases in long-acting contraceptive uptake were noted at 2 of the 8 health centers. Fidelity to the tested model was operationally constrained; respondents frequently mentioned trained staff absences and turnover as obstacles in offering quality FP services.

CONCLUSION

Despite conducive policy environment, supportive stakeholders, favorable environment, and financial support for trainings, statistically significant increases in LARC uptake occurred at only 2 of the 8 health centers; indicating the influence of weak health systems, poor quality of voluntary FP services and a ceiling effect. Scale-up processes must consider potential bottlenecks of weak health systems and availability of financial resources by addressing these as crucial elements in any systematic scale-up framework.

The silencing of political context in health research in Ethiopia: why it should be a concern

In 2004, the Ethiopian government launched what has been called an innovative and groundbreaking solution to the country's public health challenges; the Health Extension Programme (HEP). The positive public health outcomes that have been reported following the implementation of the HEP have led researchers and global health actors to propose it as a model for other countries to emulate. In this systematic review, we point to a potential weakness and methodological bias in the existing research. Despite being implemented within a context of an increasingly authoritarian regime, research conducted following the implementation of HEP reflects a limited discussion of the political context. Following a discussion of why political context is marginalized we provide arguments for why a focus on political context is important: first, political context has an impact on health systems and actualizes questions related to good governance and ethics. While some of the studies we reviewed acknowledge the importance of political factors we contend that the one-sided focus on the positive relationship between political will, political commitment and political leadership on the one hand, and key public health outcomes on the other, reflects a narrow engagement with health system governance frameworks. This leads to a silencing of issues actualized by the authoritarian nature of the Ethiopian regime. Secondly, the political context has methodological implications. More specifically, we contend that the current political situation increases the probability of social desirability bias. In order to balance the overarching positive literature on Ethiopia's health system, research that takes the political context into account is much needed.

Rationale, design, and characteristics of the multimedia family planning campaign for a small, happy, and prosperous family in Ethiopia (SHaPE)

Background

Ethiopia, the second most populous country in Africa, has a total fertility rate of 4.6, a decrease from 5.5 in 2000. However, only 35.3% of women in the reproductive age group use modern family planning (FP) methods, and the 22.3% of them who have an unmet need for family planning is among the highest rates in sub-Saharan African countries. The Small, Happy, and Prosperous family in Ethiopia (SHaPE) is one of the country’s first comprehensive multimedia family planning campaigns. Its purpose is to increase FP-related knowledge, attitude, and practice of Ethiopians, particularly women of reproductive age.

Methods/Design

The SHaPE campaign has multiple components: (1) a nationwide representative survey, which serves as formative research to identify region-specific and culture-appropriate media, messages, and barriers and determinants of family planning; (2) a multimedia communication campaign intervention, including radio dramas and other interpersonal, community-level, and mass media channels; and (3) campaign evaluation, including pre-, process-, and post-evaluation research using both quantitative and qualitative methodologies. The main target population for SHaPE is reproductive age women and men in three regions: Amhara, Oromia, and Somali. These regions take up about 66.6% of the entire country and have distinct ethnicities, cultures, and languages.

Discussion

SHaPE contributes to existing family planning research and intervention because it is theory- and evidence-based, and it employs integrated marketing communications and entertainment-education approaches with key messages that are tailored to audiences within unique cultures. But even within a country, a nationwide campaign with uniform messages is neither possible nor desirable due to different cultures, norms, and languages across regions. Last, media campaigns in developing and underdeveloped countries require constant monitoring of political situations.

Expanding the population coverage of evidence-based interventions with community health workers to save the lives of mothers and children: an analysis of potential global impact using the Lives Saved Tool (LiST)

Background

Evidence has been accumulating that community health workers (CHWs) providing evidence–based interventions as part of community–based primary health care (CBPHC) can lead to reductions in maternal, neonatal and child mortality. However, investments to strengthen and scale–up CHW programs still remain modest.

Methods

We used the Lives Saved Tool (LiST) to estimate the number of maternal, neonatal and child deaths and stillbirths that could be prevented if 73 countries effectively scaled up the population coverage of 30 evidence–based interventions that CHWs can deliver in these high–burden countries. We set population coverage targets at 50%, 70%, and 90% and summed the country–level results by region and by all 73 high–burden countries combined. We also estimated which specific interventions would save the most lives.

Findings

LiST estimates that a total of 3.0 (sensitivity bounds 1.8–4.0), 4.9 (3.1–6.3) and 6.9 (3.7–8.7) million deaths would be prevented between 2016 and 2020 if CBPHC is gradually scaled up during this period and if coverage of key interventions reaches 50%, 70%, and 90% respectively. There would be 14%, 23%, and 32% fewer deaths in the final year compared to a scenario assuming no intervention coverage scale up. The Africa Region would receive the most benefit by far: 58% of the lives saved at 90% coverage would be in this region. The interventions contributing the greatest impact are nutritional interventions during pregnancy, treatment of malaria with artemisinin compounds, oral rehydration solution for childhood diarrhea, hand washing with soap, and oral antibiotics for pneumonia.

Conclusions

Scaling up CHW programming to increase population–level coverage of life–saving interventions represents a very promising strategy to achieve universal health coverage and end preventable maternal and child deaths by 2030. Numerous practical challenges must be overcome, but there is no better alternative at present. Expanding the coverage of key interventions for maternal nutrition and treatment of childhood illnesses, in particular, may produce the greatest gains. Recognizing the millions of lives of mothers and their young offspring that could be achieved by expanding coverage of evidence–based interventions provided by CHWs and strengthening the CBPHC systems that support them underscores the pressing need for commitment from governments and donors over the next 15 years to prioritize funding, so that robust CHW platforms can be refined, strengthened, and expanded.

Preference in place of delivery among rural Indian women

India accounts for the highest number of maternal and child deaths globally. A large body of empirical research suggests that improvement in the coverage of institutional delivery is essential to reduce the burden of maternal and child death. However the dynamics of choice of place of delivery is poorly understood. Using qualitative survey data consisting of twelve focus group discussions, conducted in a rural setting of West Bengal, India, this study aims to understand the reasons behind preferring home or institution for delivery. Findings reveal that some women who underwent an institutional delivery preferred to deliver their baby at home. On the other hand, of women who delivered their baby at home, 60% wanted to deliver their babies in institutions but could not do so, primarily due to the unwillingness of family members and misreporting of the onset of true labour pain. With the help of Accredited Social Health Activists, the village level health workers, there is need for an intervention that focuses on educating household members (essentially targeting husbands and mother-in-laws) about birth preparedness, and identification of true labour pain.

DO THE SEX COMPOSITION OF LIVING CHILDREN AND THE DESIRE FOR ADDITIONAL CHILDREN AFFECT FUTURE INTENTION TO USE CONTRACEPTION IN ETHIOPIA?

Information on future intention to use contraceptives is a potential programme indicator for family planning services. Using three consecutive rounds of Ethiopian Demographic and Health Survey (EDHS) data collected in 2000, 2005 and 2011, this study examined whether the sex composition of living children and future desire for additional children were associated with the intention to use contraceptives among Ethiopian women aged 15-49 years who were not using any method of contraception at the time of the survey. The pooled multivariate binary logistic regression analysis indicated that between 2000 and 2011, the intentions of non-users to use contraceptives in the future increased significantly. Women who had at least one child (with an equal number of boys and girls, more boys than girls or more girls than boys) who did not want any more children, and those who were unsure about their desire for additional children, showed an increased intention to use contraceptives in the future, compared with those with an equal number of boys and girls who expressed a desire for additional children. Women with no children and who did not want children, or those who were unclear about their future desire, showed a lower intention to use contraceptives, compared with women with an equal number of boys and girls who wanted a child in the future.

Fertility is below replacement in Harar Health and Demographic Surveillance System (Harar HDSS), Harar town, Eastern Ethiopia

Background

Population growth is determined by fertility, mortality and migration rates. Fertility is the prime determinant of population growth, which is highly associated with family planning, literacy, urbanization, and expansion of health system. In many part of Africa, its level is more than twice the replacement level. In Ethiopia, a significant decline in fertility mainly in the urban setting has been reported over the past decade, yet there is a paucity of information on the level of the decline. Therefore, this analysis aims to assess the level of fertility in Harar Health and Demographic Surveillance System (Harar HDSS) Eastern Ethiopia.

Methods

Harar HDSS is an urban HDSS located in the city of Harar, eastern Ethiopia. It was established in 2011. All the population under surveillance are followed regularly and updated every six month for any change in the population demographic characteristics. Data were collected on a face-to-face interview to record demographic and socio-economic characteristics. Data were entered into customized HRS-2 software used for capturing longitudinal data and exported to computational software for analysis. For this analysis fertility data of the year 2013 were used. Fertility levels were analyzed using descriptive statistics.

Results

The total population of Harar HDSS in 2013 was 30,055. Of these, 15,701 (52.2 %) were females and 14, 354 (47.8 %) were males. The crude birth rate and general fertility rate for the year 2013 were 20.3 and 64 births per 1000, respectively. In 2013, the Total Fertility Rate (TFR) was 1.9 births per women of reproductive age. The 25 to 29 age group has the highest age-specific fertility rates (128.1 births per 1000 women), followed by the 20 to 24 year old women (89.3 births per 1000 women).

Conclusion

Total fertility rate was relatively low. However, there were a significant number of births among adolescent women. Improving and sustaining access for reproductive health care for young women is highly recommended.

Integrating population, health, and environment programs with contraceptive distribution in rural Ethiopia: a qualitative case study

In rural Ethiopia, environmental degradation and a shortage of arable land impose a major toll on the population. Population, health, and environment (PHE) programs, such as that of the Ethio-Wetlands and Natural Resources Association (EWNRA), have evolved to address these issues. This article examines the community-based distribution (CBD) of family planning commodities in rural Ethiopia through EWNRA's large, multisectoral PHE program. Participants indicated that the integrated program encouraged acceptance of family planning and reduced geographic barriers to access. Through peer education and collaboration across government ministries, EWNRA leveraged integrated population-environment messages to garner support for its network of CBD providers. These integration strategies are a model for PHE programs worldwide, especially amid the global response to climate change. Because of the complex nature of PHE organizations, researchers often find it difficult to effectively document and evaluate their programs. With this in mind, we propose a framework to assess PHE integration.

Getting family planning and population back on track

After a generation of partial neglect, renewed attention is being paid to population and voluntary family planning. Realistic access to family planning is a prerequisite for women's autonomy. For the individual, family, society, and our fragile planet, family planning has great power.

Taking Exception. Reduced mortality leads to population growth: an inconvenient truth

Reduced mortality has been the predominant cause of the marked global population growth over the last 3/4 of a century. While improved child survival increases motivation to reduce fertility, it comes too little and too late to forestall substantial population growth. And, beyond motivation, couples need effective means to control their fertility. It is an inconvenient truth that reducing child mortality contributes considerably to the population growth destined to compromise the quality of life of many, particularly in sub-Saharan Africa. Vigorous child survival programming is of course imperative. Wide access to voluntary family planning can help mitigate that growth and provide many other benefits.