Wealth-based equity in maternal, neonatal, and child health services utilization: a cross-sectional study from Ethiopia

Geographical variation and predictors of missing essential newborn care items during the immediate postpartum period in Ethiopia: Spatial and multilevel count analyses

BACKGROUND

Essential Newborn care (ENC) is a High-quality universal newborn health care devised by the World Health Organization for the provision of prompt interventions rendered to newborns during the postpartum period. Even though conducting comprehensive studies could provide a data-driven approach to tackling barriers to service adoption, there was a dearth of studies in Ethiopia that assess the geographical variation and predictors of missing ENC. Hence, this study aimed to identify geographical, individual, and community-level predictors of missing ENC messages at the national level.

METHODS

This study used the 2016 Ethiopian Demographic and Health Survey, by using a weighted sample of 7,590 women who gave birth within two years prior to the survey. The spatial analysis was carried out using Arc-GIS version 10.7 and SaTScan version 9.6 statistical software. Spatial autocorrelation (Moran's I) was checked to figure out the non-randomness of the spatial variation of missing ENC in Ethiopia. Six items of care used to construct a composite index.0of ENC uptake were cord examination, temperature measurement, counselling on danger signs, counselling on breastfeeding, observation of breastfeeding, and measurement of birth weight. To assess the presence of significant differences in the mean number of ENC items across covariates, independent t-tests and one-way ANOVA were performed. Finally, a multilevel multivariable mixed-effect negative binomial regression was done by using STATA version 16. The adjusted incidence rate ratio (aIRR) with its corresponding 95% CI was used as a measure of association and variables with a p-value<0.05 were identified as significant predictors of ENC.

RESULTS

The overall prevalence of missing ENC was 4,675 (61.6%) (95% CI: 60.5, 62.7) with a significant spatial variation across regions. The majority of Somali, Afar, south Amhara, and SNNPR regions had statistically significant hotspots for missing ENC. The mean (±SD) number of ENC items received was 1.23(±1.74) with a variance of 3.02 indicating over-dispersion. Living in the poorest wealth quintile (aIRR = 0.67, 95%CI: 0.51, 0.87), lack of Antenatal care (aIRR = 0.52, 95%CI: 0.49, 0.71), birth at home (aIRR = 0.27, 95% CI: 0.17, 0.34), living in rural area (aIRR = 0.39, 95% CI: 0.24, 0.57) were significant predictors of ENC uptake.

CONCLUSION

The level of missing ENC was found to be high in Ethiopia with a significant spatial variation across regions. Hence, the government and policymakers should devise strategies for hotspot areas to improve women's economic capabilities, access to education, and health-seeking behaviours for prenatal care and skilled delivery services to improve ENC uptake.

Wealth disparities in maternal health service utilization among women of reproductive age in Ethiopia: findings from the mini-EDHS 2019

BACKGROUND

Ethiopia has made strides in reducing maternal mortality, but significant discrepancies in maternal health service utilization exist across socioeconomic levels. According to studies, women from higher-income households are far more likely to use essential services such as antenatal care, delivery care, and postnatal care than poorer women. This wealth disparity is a primary contributor to persistently high maternal mortality, particularly among poor populations. The study's goal was to assess wealth disparities in maternal health service uptake and identify contributing factors.

METHODS AND MATERIALS

We used the Ethiopian Mini Demographic Health Survey (EMDHS), conducted in 2019 on women aged 15-49 living in selected census areas, with a weighted sample size of 3,909. The Erreygers Concentration Index (ECI) was used to measure wealth inequalities in maternal health care, and the ECI decomposition was used to identify factors contributing to inequality in maternal health services.

RESULTS

Maternal health service utilization was pro-rich among women in Ethiopia. The prevalence of antenatal care service (ANC), delivery, and postnatal care (PNC) service utilization showed a pro-rich distribution among Ethiopian women, with ECI = 0.115 (95% CI: 0.091-0.137), ECI = 0.223 (95% CI: 0.191-0.276), and ECI = 0.121 (95% CI: 0.041-0.200), respectively. The ECI indices were decomposed to examine the contributing factors to disparities in maternal service utilization in Ethiopia. Mother's current age, household family size, region, birth order, and parity were contributors to maternal health service utilization.

CONCLUSION

The ANC service, delivery service and PNC service utilization showed a pro-rich distribution among Ethiopian women. Mother's current age, household family size, region, birth order, and parity are important contributors of maternal health service inequality. To improve access and usage among low-income women, policymakers can develop programs including increasing the number of free or subsidized services and providing transportation.

Barriers to equitable healthcare services for under-five children in Ethiopia: a qualitative exploratory study

BACKGROUND

Disparities in child healthcare service utilization are unacceptably high in Ethiopia. Nevertheless, little is known about underlying barriers to accessing child health services, especially among low socioeconomic subgroups and in remote areas. This study aims to identify barriers to equity in the use of child healthcare services in Ethiopia.

METHODS

Data were obtained from 20 key- informant interviews (KII) and 6 focus group discussions (FGD) with mothers and care givers. This study was conducted in Oromia Region, Arsi Zone, Zuway Dugda District from June 1-30, 2023. The study participants for this research were selected purposively. The information was collected based on the principle of saturation after sixteen consecutives interview were conducted. Both KII and FGD were audio-recorded and complementary notes were taken to record observations about the participants' comments and their interactions. Each interview and FGD data were transcribed word-for-word in the local Afaan Oromo and Amaharic languages and then translated to English language. Finally, the data were analyzed thematically using NVivo 14 software and narrated in the linked pattern of child health service utilization.

RESULTS

This study identified six major themes which emerged as barriers to healthcare utilization equity for caregivers and their -under-five children. Barriers related to equity in low level of awareness regarding need, low socioeconomic status, geographical inaccessibility, barriers related to deficient healthcare system, community perception and cultural restrictions, and barriers of equity related to political instability and conflict. The most commonly recognized barriers of equity at the community level were political instability, conflict, and a tremendous distance to a health facility. Transportation challenges, poor functional services, closure of the health facility in working hours, and lack of proper planning to address the marginalized populations were identified barriers of equity at organizational or policy level.

CONCLUSION

This study showed that inequity in child healthcare utilization is an important challenge confronting Ethiopia. To achieve equity, policy makers and planners need to change health policy and structure to be pro-poor. It is also necessary to improve the healthcare system to increase service utilization and access for impoverished women, individuals with lower levels of education, and residents of isolated rural areas. Furthermore, context specific information pertaining to cultural barriers and political ecology are required.

Association of educational attainment with hypertension and type-2 diabetes: A Mendelian randomization study

BACKGROUNDDue to the long time interval between exposure and outcome, it is difficult to infer the causal relationship between educational attainment (EA) and common chronic diseases. Therefore, we utilized Mendelian randomization (MR) to predict the causal relationships of EA with hypertension and type-2 diabetes (T2DM). METHODSA two-sample MR analysis was conducted using genome-wide association studies (GWASs) combined with inferential measurements. A GWAS meta-analysis including 1,131,881 European individuals was used to identify instruments for EA. Hypertension and T2DM data were obtained from a Finnish database. MR analyses were performed using inverse-variance weighted meta-analysis (IVW), weighted median regression, MR‒Egger regression, simple mode regression, weighted mode regression and the MR-Pleiotropy RESidual Sum and Outlier test. Sensitivity analyses were further performed using the leave-one-out method to test the robustness of our findings. RESULTSUsing the MR approach, our results showed that EA was significantly associated with a reduced risk of hypertension (OR = 0.63; P = 2.94 × 10-47; [95% CI: 0.59, 0.67]) and type-2 diabetes (OR = 0.59; P = 1.25 × 10-16; [95% CI: 0.52, 0.67]). CONCLUSIONSThis study showed that EA is causally linked to the risk of chronic diseases, including high blood pressure and T2DM.

Barriers to healthcare utilization among married women in Afghanistan: the role of asset ownership and women's autonomy

Women face multiple socio-economic, cultural, contextual, and perceived barriers in health service utilization. Moreover, poor autonomy and financial constraints act as crucial factors to their healthcare accessibility. Therefore, the objective of the present study is to study the association between health care utilization barriers and women empowerment, including asset ownership among currently married women in Afghanistan. Data of 28,661 currently married women from Afghanistan demographic health survey (2015) was used to carry out this study. Barriers to access healthcare were computed based on problems related to permission, money, distance, and companionship, whereas women empowerment and asset ownership were computed as potential covariates along with other socio-economic risk factors. Bivariate and logistic analysis was carried out to study the association and odds of explanatory variables. Our results confirm the significant and strong association between the barriers to access healthcare and various explanatory variables. Women having any decision-making autonomy are less likely to face any odds [(AOR = 0.56, p < 0.001), CI: 0.51-0.61] among the currently married women than those who don't have any decision-making authority. Similarly, women who justify their beating for some specific reasons face the greater difficulty of accessing health care [(AOR = 1.76, p < 0.001), CI: 1.61-1.93]. In terms of asset ownership, women having any asset ownership (land or household) are less likely to face any barriers in health services utilization given the lower odds [(AOR = 0.91, p < 0.001), CI: 0.90-0.98]. Accessing maternal health is a crucial policy challenge in Afghanistan. A substantial proportion of women face barriers related to approval, money, distance, and companionship while accessing the health services utilization in Afghanistan. Similarly, women empowerment and asset ownership are significantly associated with health service accessibility. This paper therefore suggests for some policy interventions to strengthen the healthcare needs of women and ensure healthcare accessibility by scaling down these potential barriers like poor autonomy, asset ownership and domestic violence.

Spatial variation and predictors of missing birth preparedness and complication readiness (BPCR) messages in Ethiopia

BACKGROUND

The Birth Preparedness and Complication Readiness (BPCR) message is one of the prenatal care packages targeted at reducing maternal and neonatal mortality by avoiding unnecessary delays during labor and delivery. There is limited evidence in Ethiopia that has looked at the spatial variation of missing BPCR messages and potential predictors. Hence, this study aimed to identify spatial predictors missing BPCR messages at the national level.

METHODS

The study was based on analysis of 2016 Ethiopia Demographic Health Survey data, using a weighted sample of 4771 women. Arc-GIS version 10.7 and SaTScan version 9.6 statistical software were used for the spatial analysis. To explore spatial variation and locate spatial clusters of missing BPCR messages, the Global Moran's I statistic and Bernoulli-based spatial scan (SaTScan) analysis were carried out, respectively. Hotspot (Getis-OrdGi*) analysis was conducted to identify Hotspots and Cold spotsof missing BPCR messages. Finally, spatial regression were carried out via ordinary least squares and geographically weighted regression to identify predictors of hotspots for missing BPCR messages.

RESULTS

The overall prevalence of missing BPCR messages in Ethiopia was found to be 44.0% (95%CI: 42.6, 45.4%), with significant spatial variation across regions (Moran's I = 0.218, p-value<0.001) and seven most likely significant SaTScan clusters. The vast majority of Somali, central Afar, and Gambella regions were identified as statistically significant hotspots. Living in the poorest wealth quintile, having only one ANC visit, lack of access to listening to the radio, facing difficulty in accessing money, not having a mobile phone, and being not covered by health insurance were identified as significant spatial predictors of missing BPCR messages.

CONCLUSION

The level of missing BPCR messages during pregnancy was found to be high in Ethiopia, with significant local variation. As a result, policymakers at the national level and local planners should develop strategies and initiatives that enhance women's economic capacities, health-seeking behavior, and media exposure. Furthermore, the regional authorities should focus on strategies that promote universal health coverage through enrolling citizens in health insurance schemes.

Effect of multiple chronic conditions on family doctor contracting in the elderly in China: the moderating role of socioeconomic status

BACKGROUND

China's family doctor contracting service is an important part of deepening the reform of the healthcare systems, aiming to further develop chronic disease management services, enhance the capacity of primary health care services and improve the health of residents. The purpose of this study was to explore the influence of multiple chronic conditions in the elderly on family doctor contracting and whether socioeconomic status played a moderating role.

METHODS

A cross-sectional survey was conducted in Beijing, China. A total of 1814 elderly people over 60 years old were included in this study using a whole-group sampling method. The univariate analysis and logistic regression analysis was used to analyze the data.

RESULTS

21.72% of the elderly signed up with family doctors. The multiple chronic conditions was a factor influencing the elderly to sign up with family doctors (OR = 1.44, 95%CI = 1.28-1.61), and the higher the degree of multiple chronic conditions, the stronger willingness to sign up. Socioeconomic status positively moderates the effect of multiple chronic conditions on signing. Also, physical activity intensity (OR = 1.25, 95%CI = 1.03-1.54) and willingness to first visit primary care facilities (OR = 1.38, 95%CI = 1.25-1.54) influenced the elderly to sign up with family doctors.

CONCLUSIONS

The elderly with a high degree of multiple chronic conditions, high activity intensity, and a strong willingness to first visit primary care facilities were more likely to sign up with family doctors. The health literacy of the elderly should be further improved, and publicity on the family doctor contracting service policies for the elderly with lower socioeconomic status should be strengthened to guide them to sign up with family doctors. At the same time, the service capacity of primary care facilities should be further improved to meet the health needs of the elderly.

Global achievement of maternal health-related sustainable development goals targets among women exposed to intimate partner violence

Health-related Sustainable Development Goal (SDG 3) aims to ensure healthy lives. This study investigates the influence of Intimate Partner Violence (IPV) on achieving maternal health related SDG3 targets among exposed women globally.

METHODOLOGY

This study used secondary data analysis of Domestic Violence Modules from the latest Demographic and Health Surveys (DHS) of 40 countries. IPV was defined by women ever exposed to emotional, physical, severe, or sexual violence from the spouse. Achieving maternal health related SDG3 targets among women was measured by: Proportion of births attended by skilled health personnel; Antenatal care (women received antenatal care eight or more times from any provider); and the need for family planning satisfied with modern methods. The influence of IPV was estimated through adjusted OR after controlling for socioeconomic factors using logistic regression.

RESULTS

Exposure to IPV was among one-third of the women (37%) mainly physical (29%) and emotional (24%). Adjusted OR with 95%CI for the influence of IPV on women's utilization of skilled birth attendants was 0.81 (0.79-0.83)); having eight or more antenatal care visits 0.61 (0.59-0.63); and the needs for family planning with modern methods satisfied was 0.85 (0.83-0.87). Achievement of maternal health services was among 57% of the women. Women exposed to IPV were less to achieve maternal health services (50% VS 61%) with adjusted OR 0.71; 95%CI: 0.70-0.73 and it was not confounded by the positive effect of socioeconomic factors.

CONCLUSION & RECOMMENDATION

Exposure to IPV had a statistically significant negative influence on all the maternal health related SDG3 services among women. Programs working in facilitating the achievement of the SDGs related maternal health targets should include prevention of women's exposure to IPV and support for those who are exposed to it.

Completion of the Continuum of Maternity Care in the Emerging Regions of Ethiopia: Analysis of the 2019 Demographic and Health Survey

Maternal mortality in Ethiopia was estimated to be 267 per 100,000 live births in 2020. A significant number of maternal deaths occur in the emerging regions of the country: Afar, Somali, Gambela, and Benishangul-Gumuz. Achieving the Sustainable Development Goal (SDG) target requires a dramatic increase in maternal healthcare utilisation during pregnancy, childbirth, and the postpartum period. Yet, there is a paucity of evidence on the continuum of maternity care utilisation in Ethiopia, particularly in the emerging regions. Therefore, this study aimed to assess completion and factors associated with the continuum of maternity care in the emerging regions of Ethiopia. This study used the 2019 Ethiopian Demographic and Health Survey data (n = 1431). Bivariable and multivariable logistic regression analyses were carried out to identify factors associated with the completion of the continuum of maternity care. An adjustment was made to the survey design (weight, stratification, and clustering). 9.5% (95% Confidence Interval (CI): 7.0-13.0) of women completed the continuum of maternity care (four or more antenatal care, institutional delivery, and postnatal care within 24 h). Living in Somali (adjusted Odds Ratio (aOR): 0.23, 95%CI: 0.07-0.78) and Benishangul-Gumuz (aOR 3.41, 95%CI: 1.65-7.04) regions, having a secondary and higher educational level (aOR 2.12, 95%CI: 1.13-4.00), and being in the richest wealth quintile (aOR 4.55, 95%CI: 2.04-10.15) were factors associated with completion of the continuum of maternity care. Although nearly half of the women had one antenatal care, fewer than 10% completed the continuum of maternity care. This indicates that women in these regions are not getting the maximum health benefits from maternal healthcare services, and this might contribute to the high maternal death in the regions. Moreover, the completion of the continuum of maternity care was skewed toward women who are more educated (secondary or higher education) and in the richest quintile.

Inequalities of Infant Mortality in Ethiopia

(1) Background: Infant mortality is viewed as a core health indicator of overall community health. Although globally child survival has improved significantly over the years, Sub-Saharan Africa is still the region with the highest infant mortality in the world. In Ethiopia, infant mortality is still high, albeit substantial progress has been made in the last few decades. However, there is significant inequalities in infant mortalities in Ethiopia. Understanding the main sources of inequalities in infant mortalities would help identify disadvantaged groups, and develop equity-directed policies. Thus, the purpose of the study was to provide a diagnosis of inequalities of infant mortalities in Ethiopia from four dimensions of inequalities (sex, residence type, mother's education, and household wealth). (2) Methods: Data disaggregated by infant mortalities and infant mortality inequality dimensions (sex, residence type, mother's education, and household wealth) from the WHO Health Equity Monitor Database were used. Data were based on Ethiopia's Demographic and Health Surveys (EDHS) of 2000 (n = 14,072), 2005 (n = 14,500), 2011 (n = 17,817), and 2016 (n = 16,650) households. We used the WHO Health Equity Assessment Toolkit (HEAT) software to find estimates of infant mortalities along with inequality measures. (3) Results: Inequalities related to sex, residence type, mother's education, and household wealth still exist; however, differences in infant mortalities arising from residence type, mother's education, and household wealth were narrowing with the exception of sex-related inequality where male infants were markedly at a disadvantage. (4) Conclusions: Although inequalities of infant mortalities related to social groups still exist, there is a substantial sex related infant mortality inequality with disproportional deaths of male infants. Efforts directed at reducing infant mortality in Ethiopia should focus on improving the survival of male infants.

Investigating Health Inequality Using Trend, Decomposition and Spatial Analyses: A Study of Maternal Health Service Use in Nepal

Objectives: (a) To quantify the level and changes in socioeconomic inequality in the utilization of antenatal care (ANC), institutional delivery (ID) and postnatal care (PNC) in Nepal over a 20-year period; (b) identify key drivers of inequality using decomposition analysis; and (c) identify geographical clusters with low service utilization to inform policy. Methods: Data from the most recent five waves of the Demographic Health Survey were used. All outcomes were defined as binary variables: ANC (=1 if ≥4 visits), ID (=1 if place of delivery was a public or private healthcare facility), and PNC (=1 if ≥1 visits). Indices of inequality were computed at national and provincial-level. Inequality was decomposed into explanatory components using Fairile decomposition. Spatial maps identified clusters of low service utilization. Results: During 1996-2016, socioeconomic inequality in ANC and ID reduced by 10 and 23 percentage points, respectively. For PND, the gap remained unchanged at 40 percentage points. Parity, maternal education, and travel time to health facility were the key drivers of inequality. Clusters of low utilization were displayed on spatial maps, alongside deprivation and travel time to health facility. Conclusion: Inequalities in the utilization of ANC, ID and PNC are significant and persistent. Interventions targeting maternal education and distance to health facilities can significantly reduce the gap.

Is Women's Engagement in Women's Development Groups Associated with Enhanced Utilization of Maternal and Neonatal Health Services? A Cross-Sectional Study in Ethiopia

BACKGROUND

In Ethiopia, the Women Development Group program is a community mobilization initiative aimed at enhancing Universal Health Coverage through supporting the primary healthcare services for mothers and newborns. This study aimed to assess the association between engagement in women's groups and the utilization of maternal and neonatal health services.

METHOD

A cluster-sampled community-based survey was conducted in Oromia, Amhara, Southern Nations, Nationalities and Peoples, and Tigray regions of Ethiopia from mid-December 2018 to mid-February 2019. Descriptive and logistic regression analyses were performed, considering the cluster character of the sample.

RESULTS

A total of 6296 women (13 to 49 years) from 181 clusters were interviewed. Of these, 896 women delivered in the 12 months prior to the survey. Only 79 (9%) of these women including Women Development Group leaders reported contact with Women Development Groups in the last 12 months preceding the survey. Women who had educations and greater economic status had more frequent contact with Women Development Group leaders. Women who had contact with Women Development Groups had better knowledge on pregnancy danger signs. Being a Women Development Group leader or having contact with Women Development Groups in the last 12 months were associated with antenatal care utilization (AOR 2.82, 95% CI (1.23, 6.45)) but not with the use of facility delivery and utilization of postnatal care services.

CONCLUSIONS

There is a need to improve the organization and management of the Women Development Group program as well as a need to strengthen the Women Development Group leaders' engagement in group activities to promote the utilization of maternal and neonatal health services.

Okwaraji Y, Tigabu Z, Persson LÅ, Alemu K. Spatial distribution of common childhood illnesses, healthcare utilisation and associated factors in Ethiopia: Evidence from 2016 Ethiopian Demographic and Health Survey

INTRODUCTION

Childhood illnesses, such as acute respiratory illness, fever, and diarrhoea, continue to be public health problems in low-income countries. Detecting spatial variations of common childhood illnesses and service utilisation is essential for identifying inequities and call for targeted actions. This study aimed to assess the geographical distribution and associated factors for common childhood illnesses and service utilisation across Ethiopia based on the 2016 Demographic and Health Survey.

METHODS

The sample was selected using a two-stage stratified sampling process. A total of 10,417 children under five years were included in this analysis. We linked data on their common illnesses during the last two weeks and healthcare utilisation were linked to Global Positioning System (GPS) information of their local area. The spatial data were created in ArcGIS10.1 for each study cluster. We applied a spatial autocorrelation model with Moran's index to determine the spatial clustering of the prevalence of childhood illnesses and healthcare utilisation. Ordinary Least Square (OLS) analysis was done to assess the association between selected explanatory variables and sick child health services utilisation. Hot and cold spot clusters for high or low utilisation were identified using Getis-Ord Gi*. Kriging interpolation was done to predict sick child healthcare utilisation in areas where study samples were not drawn. All statistical analyses were performed using Excel, STATA, and ArcGIS.

RESULTS

Overall, 23% (95CI: 21, 25) of children under five years had some illness during the last two weeks before the survey. Of these, 38% (95%CI: 34, 41) sought care from an appropriate provider. Illnesses and service utilisation were not randomly distributed across the country with a Moran's index 0.111, Z-score 6.22, P<0.001, and Moran's index = 0.0804, Z-score 4.498, P< 0.001, respectively. Wealth and reported distance to health facilities were associated with service utilisation. Prevalence of common childhood illnesses was higher in the North, while service utilisation was more likely to be on a low level in the Eastern, South-western, and the Northern parts of the country.

CONCLUSION

Our study provided evidence of geographic clustering of common childhood illnesses and health service utilisation when the child was sick. Areas with low service utilisation for childhood illnesses need priority, including actions to counteract barriers such as poverty and long distances to services.

Effect of USAID-funded obstetric ultrasound service interventions on maternal and perinatal health outcomes at primary healthcare facilities in Ethiopia: a propensity score matching analysis

OBJECTIVE

A dimensional shift in the health service delivery in the primary healthcare setting is required to raise maternal and child well-being. This study aimed to evaluate the effect of US Agency for International Development-funded obstetric ultrasound service on maternal and perinatal health outcomes at Ethiopia's primary healthcare facilities.

DESIGN

We employed a quasi-experimental study design.

SETTING

The study was conducted in primary health centres located in four regions of Ethiopia.

PARTICIPANTS

We used 2 years' data of 1568 mothers from 13 intervention and 13 control primary health centres. Data were obtained from Vscan, antenatal care (ANC), delivery and postnatal care registers.

INTERVENTION

Use of portable obstetric ultrasound service during pregnancy.

OUTCOME MEASURES

The primary outcome variables include complete four ANC visits, referral during ANC, delivery in a health facility and having postnatal care and continuum of care. The secondary outcome variable was perinatal death.

RESULTS

With the kernel matching approach, we have found that having four or more ANC visits was decreased after the intervention (average treatment effect (ATE): -0.20; 95% CI: -0.23 to -0.09), and the rest of the indicators, including referral during ANC (ATE: 0.01; 95% CI: 0.15 to 0.34), institutional delivery (ATE: 0.24; 95% CI: 0.15 to 0.34) and postnatal care (ATE: 0.26; 95% CI: 0.10 to 0.37), were significantly raised because of the intervention. Similarly, we have found that perinatal death dropped considerably due to the intervention.

CONCLUSION

The findings show a consistent increase in maternal health service use because of the introduction of obstetric ultrasound services at the primary health centre level. Furthermore, early detection of complications and following referral for specialty care were found to be high. The consistent rise in maternal health service use indicators calls for additional trial to test the effect of obstetric ultrasound service in other locations of the country. Furthermore, evaluating the predictive values, sensitivity and specificity of the obstetric ultrasound service is important.

"If I Was Educated, I Would Call the Ambulance and Give Birth at the Health Facility"-A Qualitative Exploratory Study of Inequities in the Utilization of Maternal, Newborn, and Child Health Services in Northern Ethiopia

In earlier studies, we have shown that the utilization of maternal health services in rural Ethiopia was distributed in a pro-rich fashion, while the coverage of child immunization was equitably distributed. Hence, this study aimed to explore mothers' and primary healthcare workers' perceptions of inequities in maternal, newborn, and child health services in rural Ethiopia, along with the factors that could influence such differentials. A qualitative study was conducted from November to December 2019 in two rural districts in Tigray, Ethiopia. Twenty-two in-depth interviews and three focus group discussions were carried out with mothers who had given birth during the last year before the survey. We also interviewed women's development group leaders, health extension workers, and health workers. The final sample was determined based on the principle of saturation. The interviews and focus group discussions were audiotaped, transcribed, translated, coded, and analyzed using thematic analysis. Two major themes emerged during the analysis that characterized the distribution of the service utilization and perceived causes of inequity. These were: (1) perceptions of the inequity in the use of maternal and child health services, and (2) perceived causes of inequity in maternal and child health service utilization. The mothers perceived antenatal care, facility-based delivery, and care-seeking for sick children to be inequitably distributed, while immunization was recognized as an equitable service. The inequity in the maternal and child health services was linked to poverty, lack of education, lack of access, and poor-quality services. The poor, the uneducated, and women who were distant from health facilities had a low utilization rate of services. The weak implementation of community-based equity-oriented policies, such as community-based health insurance, was perceived to result in health inequities. Mothers and primary healthcare providers in rural Ethiopia experienced weaknesses in delivering equitable services. The narratives could inform efforts to provide universal health coverage for mothers, newborns, and children by improving access and empowering women through poverty alleviation and education.

Prevalence and predictors of mother and newborn skin-to-skin contact at birth in Papua New Guinea

OBJECTIVE

This study examined the prevalence and predictors of maternal and newborn skin-to-skin contact at birth in Papua New Guinea.

DESIGN

Data for the study was extracted from the 2016-18 Papua New Guinea Demographic and Health Survey. We included 6,044 women with birth history before the survey in the analysis. Percentages were used to summarise the prevalence of maternal and newborn skin-to-skin contact. A multivariable multilevel binary logistic regression was adopted to examine the predictors of maternal and newborn skin-to-skin contact. The results were presented using adjusted ORs (aORs), with their respective 95% confidence intervals (CIs). Statistical significance was set at p<0.05.

SETTING

The study was conducted in Papua New Guinea.

PARTICIPANT

Mothers with children under 5 years.

OUTCOME MEASURES

Mother and newborn skin-to-skin contact.

RESULTS

The prevalence of mother and newborn skin-to-skin contact was 45.2% (95% CI=42.4 to 48.0). The odds of mother and newborn skin-to-skin contact was higher among women with primary education (aOR=1.38; 95% CI=1.03 to 1.83), women with four or more antenatal care attendance (aOR=1.27; 95% CI=1.01 to 1.61), those who delivered at the health facility (aOR=1.27; 95% CI=1.01 to 1.61), and women from communities with high socioeconomic status (aOR=1.45; 95% CI=1.11 to 1.90).

CONCLUSION

The study has demonstrated that the prevalence of mother and newborn skin-to-skin contact in Papua New Guinea is low. Factors shown to be associated with mother and newborn skin-to-skin contact were maternal level of education, antenatal care attendance, health facility delivery, and community socioeconomic status. A concerted effort should be placed in improving maternal health service utilisation such as antenatal care attendance and skilled birth delivery, which subsequently lead to the practice of skin-to-skin contact. Also, women should be empowered through education as it has positive impact on their socioeconomic status and health service utilisation.

Home based postpartum care and determinants in Ethiopia: A multilevel analysis

INTRODUCTION

Neonatal mortality remains a persisting public health challenge in Ethiopia. Timely intervention to neonatal morbidity and early neonatal care visit could reduce the burden of mortality. Studies related to home based postnatal care is limited in Ethiopia. Therefore, this study aimed to assess home based postnatal care visits and determinants in Ethiopia.

METHODS

A secondary data analysis using 2016 EDHS data was conducted among 7590 women who had live births two years preceding the survey. A multilevel mixed-effect logistic regression analysis model was used and those variables with a P-value ≤ of 0.05 in multivariable analysis were considered as predictors. Results: Home based postpartum care by health care providers was 6.3% and 67.9% of women gave birth at home. Women perceived that distance is not big problem [AOR = 1.37; 95% CI: 1.06, 1.68], richer wealth index [AOR = 1.69; 95% CI: 1.15, 2.48], attending antenatal care visit [AOR = 2.17; 95% CI:1.57, 2.99], giving birth in health institution [AOR = 2.07; 95% CI:1.53, 2.80], giving birth by cesarean section [AOR = 3.41; 95% CI: 2.33, 4.99], and having awareness about neonatal danger sign [AOR = 3.68; 95% CI: 2.90,4.70] were factors associated with home based postpartum care.

CONCLUSION

Home based care by health care providers was low. Therefore, measures should be taken in increasing the number of nearby health care facility, strengthen the continuum of care on antenatal care follow-up, institutional delivery and improve mother's knowledge about neonatal danger sign.

Vaccine equity in low and middle income countries: a systematic review and meta-analysis

BACKGROUND

Evidence to date has shown that inequality in health, and vaccination coverage in particular, can have ramifications to wider society. However, whilst individual studies have sought to characterise these heterogeneities in immunisation coverage at national level, few have taken a broad and quantitative view of the contributing factors to heterogeneity in immunisation coverage and impact, i.e. the number of cases, deaths, and disability-adjusted life years averted. This systematic review aims to highlight these geographic, demographic, and sociodemographic characteristics through a qualitative and quantitative approach, vital to prioritise and optimise vaccination policies.

METHODS

A systematic review of two databases (PubMed and Web of Science) was undertaken using search terms and keywords to identify studies examining factors on immunisation inequality and heterogeneity in vaccination coverage. Inclusion criteria were applied independently by two researchers. Studies including data on key characteristics of interest were further analysed through a meta-analysis to produce a pooled estimate of the risk ratio using a random effects model for that characteristic.

RESULTS

One hundred and eight studies were included in this review. We found that inequalities in wealth, education, and geographic access can affect vaccine impact and vaccination dropout. We estimated those living in rural areas were not significantly different in terms of full vaccination status compared to urban areas but noted considerable heterogeneity between countries. We found that females were 3% (95%CI[1%, 5%]) less likely to be fully vaccinated than males. Additionally, we estimated that children whose mothers had no formal education were 28% (95%CI[18%,47%]) less likely to be fully vaccinated than those whose mother had primary level, or above, education. Finally, we found that individuals in the poorest wealth quintile were 27% (95%CI [16%,37%]) less likely to be fully vaccinated than those in the richest.

CONCLUSIONS

We found a nuanced picture of inequality in vaccination coverage and access with wealth disparity dominating, and likely driving, other disparities. This review highlights the complex landscape of inequity and further need to design vaccination strategies targeting missed subgroups to improve and recover vaccination coverage following the COVID-19 pandemic.

TRIAL REGISTRATION

Prospero, CRD42021261927.

Wealth and Education Inequities in Maternal and Child Health Services Utilization in Rural Ethiopia

As part of the 2030 maternal and child health targets, Ethiopia strives for universal and equitable use of health services. We aimed to examine the association between household wealth, maternal education, and the interplay between these in utilization of maternal and child health services. Data emanating from the evaluation of the Optimizing of Health Extension Program intervention. Women in the reproductive age of 15 to 49 years and children aged 12-23 months were included in the study. We used logistic regression with marginal effects to examine the association between household wealth, women's educational level, four or more antenatal care visits, skilled assistance at delivery, and full immunization of children. Further, we analyzed the interactions between household wealth and education on these outcomes. Household wealth was positively associated with skilled assistance at delivery and full child immunization. Women's education had a positive association only with skilled assistance at delivery. Educated women had skilled attendance at delivery, especially in the better-off households. Our results show the importance of poverty alleviation and girls' education for universal health coverage.

Progress in health among regions of Ethiopia, 1990-2019: a subnational country analysis for the Global Burden of Disease Study 2019

BACKGROUND

Previous Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) studies have reported national health estimates for Ethiopia. Substantial regional variations in socioeconomic status, population, demography, and access to health care within Ethiopia require comparable estimates at the subnational level. The GBD 2019 Ethiopia subnational analysis aimed to measure the progress and disparities in health across nine regions and two chartered cities.

METHODS

We gathered 1057 distinct data sources for Ethiopia and all regions and cities that included census, demographic surveillance, household surveys, disease registry, health service use, disease notifications, and other data for this analysis. Using all available data sources, we estimated the Socio-demographic Index (SDI), total fertility rate (TFR), life expectancy, years of life lost, years lived with disability, disability-adjusted life-years, and risk-factor-attributable health loss with 95% uncertainty intervals (UIs) for Ethiopia's nine regions and two chartered cities from 1990 to 2019. Spatiotemporal Gaussian process regression, cause of death ensemble model, Bayesian meta-regression tool, DisMod-MR 2.1, and other models were used to generate fertility, mortality, cause of death, and disability rates. The risk factor attribution estimations followed the general framework established for comparative risk assessment.

FINDINGS

The SDI steadily improved in all regions and cities from 1990 to 2019, yet the disparity between the highest and lowest SDI increased by 54% during that period. The TFR declined from 6·91 (95% UI 6·59-7·20) in 1990 to 4·43 (4·01-4·92) in 2019, but the magnitude of decline also varied substantially among regions and cities. In 2019, TFR ranged from 6·41 (5·96-6·86) in Somali to 1·50 (1·26-1·80) in Addis Ababa. Life expectancy improved in Ethiopia by 21·93 years (21·79-22·07), from 46·91 years (45·71-48·11) in 1990 to 68·84 years (67·51-70·18) in 2019. Addis Ababa had the highest life expectancy at 70·86 years (68·91-72·65) in 2019; Afar and Benishangul-Gumuz had the lowest at 63·74 years (61·53-66·01) for Afar and 64.28 (61.99-66.63) for Benishangul-Gumuz. The overall increases in life expectancy were driven by declines in under-5 mortality and mortality from common infectious diseases, nutritional deficiency, and war and conflict. In 2019, the age-standardised all-cause death rate was the highest in Afar at 1353·38 per 100 000 population (1195·69-1526·19). The leading causes of premature mortality for all sexes in Ethiopia in 2019 were neonatal disorders, diarrhoeal diseases, lower respiratory infections, tuberculosis, stroke, HIV/AIDS, ischaemic heart disease, cirrhosis, congenital defects, and diabetes. With high SDIs and life expectancy for all sexes, Addis Ababa, Dire Dawa, and Harari had low rates of premature mortality from the five leading causes, whereas regions with low SDIs and life expectancy for all sexes (Afar and Somali) had high rates of premature mortality from the leading causes. In 2019, child and maternal malnutrition; unsafe water, sanitation, and handwashing; air pollution; high systolic blood pressure; alcohol use; and high fasting plasma glucose were the leading risk factors for health loss across regions and cities.

INTERPRETATION

There were substantial improvements in health over the past three decades across regions and chartered cities in Ethiopia. However, the progress, measured in SDI, life expectancy, TFR, premature mortality, disability, and risk factors, was not uniform. Federal and regional health policy makers should match strategies, resources, and interventions to disease burden and risk factors across regions and cities to achieve national and regional plans, Sustainable Development Goals, and universal health coverage targets.

FUNDING

Bill & Melinda Gates Foundation.

Coverage and factors associated with mother and newborn skin-to-skin contact in Nigeria: a multilevel analysis

BACKGROUND

Mother and newborn skin-to-skin contact (SSC) is an immediate postpartum intervention known to improve the health of newborn and mothers alike. Albeit, there is paucity of data that explored the coverage or factors associated with SSC in Nigeria. Therefore, we aimed to explore the coverage and hierarchical nature of the factors associated with SSC among women of reproductive age in Nigeria.

METHODS

The 2018 Nigeria Demographic and Health Survey (NDHS) data was used for this study. Data on 29,992 women who had ever given birth were extracted for analysis. SSC was the outcome variable as determined by women's report. A multivariable multilevel logistic regression model was used to estimate the fixed and random effects of the factors associated with SSC. Statistical significance was determined at p< 0.05.

RESULTS

The coverage of SSC was approximately 12.0%. Educated women had higher odds of SSC, when compared with women with no formal education. Those who delivered through caesarean section (CS) had 88% reduction in SSC, when compared with women who had vaginal delivery (OR= 0.12; 95%CI: 0.07, 0.22). Women who delivered at health facility were 15.58 times as likely to practice SSC, when compared with those who delivered at home (OR= 15.58; 95%CI: 10.64, 22.82). Adequate ANC visits and low birth weight significantly increased the odds of SSC. Women from richest household were 1.70 times as likely to practice SSC, when compared with women from poorest household (OR= 1.70; 95%CI: 1.04, 2.79). There was 65% reduction in SSC among women with high rate of community non-use of media, when compared with women from low rate of community non-use of media (OR= 0.35; 95%CI: 0.20, 0.61).

CONCLUSION

SSC coverage was low in Nigeria. Moreover, individual, household and community level factors were associated with SSC. More enlightenment should be created among women to bring to limelight the importance of SSC specifically to newborn's health.

Equity in newborn care, evidence from national surveys in low- and middle-income countries

BACKGROUND

High coverage of care is essential to improving newborn survival; however, gaps exist in access to timely and appropriate newborn care between and within countries. In high mortality burden settings, health inequities due to social and economic factors may also impact on newborn outcomes. This study aimed to examine equity in co-coverage of newborn care interventions in low- and low middle-income countries in sub-Saharan Africa and South Asia.

METHODS

We analysed secondary data from recent Demographic and Health Surveys in 16 countries. We created a co-coverage index of five newborn care interventions. We examined differences in coverage and co-coverage of newborn care interventions by country, place of birth, and wealth quintile. Using multilevel logistic regression, we examined the association between high co-coverage of newborn care (4 or 5 interventions) and social determinants of health.

RESULTS

Coverage and co-coverage of newborn care showed large between- and within-country gaps for home and facility births, with important inequities based on individual, family, contextual, and structural factors. Wealth-based inequities were smaller amongst facility births compared to non-facility births.

CONCLUSION

This analysis underlines the importance of facility birth for improved and more equitable newborn care. Shifting births to facilities, improving facility-based care, and community-based or pro-poor interventions are important to mitigate wealth-based inequities in newborn care, particularly in countries with large differences between the poorest and richest families and in countries with very low coverage of care.

Inequitable Utilization of Neonatal Health Services in Southwest Ethiopia: The Effects of Socioeconomic Disparities

Low levels of neonatal health services utilization and high neonatal deaths are often concentrated among socially and economically disadvantaged groups, especially in low-income countries. Therefore the aim of this study was to assess inequity in the use of neonatal health services in Southwest Ethiopia. A community-based cross-sectional study was conducted in 8 districts located in Jimma Zone, Southwest Ethiopia from 19 March to 28 April 2018. A total of 835 mothers were included in the study with systematic random sampling. Principal component analysis was conducted to develop wealth quintiles of the households. Equity in neonatal health services was measured using rate-ratio, concentration curve, concentration index, and analyzed by binary logistic regression. Neonates from richer families were 1.25 times more likely to use neonatal health services than the poorer households with a concentration index value of 0.07. Neonates from highly educated mothers have better used the services and the corresponding concentration index value of 0.03. Neonatal service utilization was 1.32 times higher in the highest wealth quintile in rural settings. Similarly, services delivered at health posts and hospitals were used 2.4 and 2 times more by the wealthy, whereas services given at health centers are more utilized by the poorest. Outputs of binary logistic regression analysis indicated that neonates from middle quintile wealth households were found to be better neonatal health service users [AOR_1.72, 95% CI: 1.04, 2.82]. Neonate born from a secondary school attended mother [AOR_3.56, 95% CI: 1.90, 6.69] were more likely to use neonatal health services. Neonatal health service utilization in Southwest Ethiopia is more common among neonates from richer households and more educated mothers. There is a big difference among the wealthy and poorer in a rural setting and among those who used health posts. Working on the social-determinants of health will facilitate eliminating inequity.

Caregivers' and Health Extension Workers' Perceptions and Experiences of Outreach Management of Childhood Illnesses in Ethiopia: A Qualitative Study

INTRODUCTION

Ethiopian Health Extension Workers provide facility-based and outreach services, including home visits to manage sick children, aiming to increase equity in service coverage. Little is known about the scope of the outreach services and caregivers' and health workers' perceptions of these services. We aimed at exploring mothers' and health extension workers' perceptions and experiences of the outreach services provided for the management of childhood illnesses.

METHODS

Four focus groups and eight key informant interviews were conducted. A total of 45 community members participated. Interviews were recorded, transcribed verbatim, and translated into English. We applied thematic content analysis, identified challenges in providing outreach services, and suggestions for improvement. We balanced the data collection by selecting half of the participants for interview and focus group discussions from remote areas and the other half from areas closer to the health posts.

RESULTS

Mothers reported that health extension workers visited their homes for preventive services but not for managing childhood illnesses. They showed lack of trust in the health workers' ability to treat children at home. The health extension workers reported that they provide sick children treatment during outreach services but also stated that in most cases, mothers visit the health posts when their child is sick. On the other hand, mothers considered distance from home to health post not to be a problem if the quality of services improved. Workload, long distances, and lack of incentives were perceived as demotivating factors for outreach services. The health workers called for support, incentives, and capacity development activities.

CONCLUSIONS

Mothers and health extension workers had partly divergent perceptions of whether outreach curative services for children were available. Mothers wanted improvements in the quality of services while health workers requested capacity development and more support for providing effective community-based child health services.

Distance, difference in altitude and socioeconomic determinants of utilisation of maternal and child health services in Ethiopia: a geographic and multilevel modelling analysis

OBJECTIVE

We assessed whether geographic distance and difference in altitude between home to health facility and household socioeconomic status were associated with utilisation of maternal and child health services in rural Ethiopia.

DESIGN

Household and health facility surveys were conducted from December 2018 to February 2019.

SETTING

Forty-six districts in the Ethiopian regions: Amhara, Oromia, Tigray and Southern Nations, Nationalities, and Peoples.

PARTICIPANTS

A total of 11 877 women aged 13-49 years and 5786 children aged 2-59 months were included.

OUTCOME MEASURES

The outcomes were four or more antenatal care visits, facility delivery, full child immunisation and utilisation of health services for sick children. A multilevel analysis was carried out with adjustments for potential confounding factors.

RESULTS

Overall, 39% (95% CI: 35 to 42) women had attended four or more antenatal care visits, and 55% (95% CI: 51 to 58) women delivered at health facilities. One in three (36%, 95% CI: 33 to 39) of children had received full immunisations and 35% (95% CI: 31 to 39) of sick children used health services. A long distance (adjusted OR (AOR)=0.57; 95% CI: 0.34 to 0.96) and larger difference in altitude (AOR=0.34; 95% CI: 0.19 to 0.59) were associated with fewer facility deliveries. Larger difference in altitude was associated with a lower proportion of antenatal care visits (AOR=0.46; 95% CI: 0.29 to 0.74). A higher wealth index was associated with a higher proportion of antenatal care visits (AOR=1.67; 95% CI: 1.02 to 2.75) and health facility deliveries (AOR=2.11; 95% CI: 2.11 to 6.48). There was no association between distance, difference in altitude or wealth index and children being fully immunised or seeking care when they were sick.

CONCLUSION

Achieving universal access to maternal and child health services will require not only strategies to increase coverage but also targeted efforts to address the geographic and socioeconomic differentials in care utilisation, especially for maternal health.

TRIAL REGISTRATION NUMBER

ISRCTN12040912.

Prevention and treatment of suspected pneumonia in Ethiopian children less than five years from household to primary care

Aim

Ethiopia has implemented the integrated community case management to reduce mortality in childhood diseases. We analysed prevention, care seeking and treatment of suspected pneumonia from household to health facility in Ethiopia.

Methods

Analyses were based on a survey in four regions that included modules covering 5714 households, 169 health posts with 276 health extension workers and 155 health centres with 175 staff. Caregivers of children aged 2‐59 months responded to questions on awareness of services and care seeking for suspected pneumonia. Pneumonia‐related knowledge of health workers was assessed.

Results

When a child had suspected pneumonia, 46% (95% CI: 25,68) sought care at health facilities, and 27% (95% CI: 12,51) received antibiotics. Forty‐one per cent had received full immunisation. One‐fifth (21%, 95%: 19,22) of the caregivers were aware of pneumonia treatment. Sixty‐four per cent of the health extension workers correctly mentioned fast or difficult breathing as signs of suspected pneumonia, and 88% suggested antibiotics treatment.

Conclusion

The caregivers' awareness of suspected pneumonia treatment and the utilisation of these services were low. Some of the health extension workers were not knowledgeable about suspected pneumonia. Strengthening primary health care, including immunisation, and enhancing the utilisation of services are critical for further reduction of pneumonia mortality.

Does a complex intervention targeting communities, health facilities and district health managers increase the utilisation of community-based child health services? A before and after study in intervention and comparison areas of Ethiopia

INTRODUCTION

Ethiopia successfully reduced mortality in children below 5 years of age during the past few decades, but the utilisation of child health services was still low. Optimising the Health Extension Programme was a 2-year intervention in 26 districts, focusing on community engagement, capacity strengthening of primary care workers and reinforcement of district accountability of child health services. We report the intervention's effectiveness on care utilisation for common childhood illnesses.

METHODS

We included a representative sample of 5773 households with 2874 under-five children at baseline (December 2016 to February 2017) and 10 788 households and 5639 under-five children at endline surveys (December 2018 to February 2019) in intervention and comparison areas. Health facilities were also included. We assessed the effect of the intervention using difference-in-differences analyses.

RESULTS

There were 31 intervention activities; many were one-off and implemented late. In eight districts, activities were interrupted for 4 months. Care-seeking for any illness in the 2 weeks before the survey for children aged 2-59 months at baseline was 58% (95% CI 47 to 68) in intervention and 49% (95% CI 39 to 60) in comparison areas. At end-line it was 39% (95% CI 32 to 45) in intervention and 34% (95% CI 27 to 41) in comparison areas (difference-in-differences -4 percentage points, adjusted OR 0.49, 95% CI 0.12 to 1.95). The intervention neither had an effect on care-seeking among sick neonates, nor on household participation in community engagement forums, supportive supervision of primary care workers, nor on indicators of district accountability for child health services.

CONCLUSION

We found no evidence to suggest that the intervention increased the utilisation of care for sick children. The lack of effect could partly be attributed to the short implementation period of a complex intervention and implementation interruption. Future funding schemes should take into consideration that complex interventions that include behaviour change may need an extended implementation period.

TRIAL REGISTRATION NUMBER

ISRCTN12040912.

Implementation of the 'Optimising the Health Extension Program' Intervention in Ethiopia: A Process Evaluation Using Mixed Methods

An intervention called 'Optimising the Health Extension Program', aiming to increase care-seeking for childhood illnesses in four regions of Ethiopia, was implemented between 2016 and 2018, and it included community engagement, capacity building, and district ownership and accountability. A pragmatic trial comparing 26 districts that received the intervention with 26 districts that did not found no evidence to suggest that the intervention increased utilisation of services. Here we used mixed methods to explore how the intervention was implemented. A fidelity analysis of each 31 intervention activities was performed, separately for the first phase and for the entire implementation period, to assess the extent to which what was planned was carried out. Qualitative interviews were undertaken with 39 implementers, to explore the successes and challenges of the implementation, and were analysed by using thematic analysis. Our findings show that the implementation was delayed, with only 19% (n = 6/31) activities having high fidelity in the first phase. Key challenges that presented barriers to timely implementation included the following: complexity both of the intervention itself and of administrative systems; inconsistent support from district health offices, partly due to competing priorities, such as the management of disease outbreaks; and infrequent supervision of health extension workers at the grassroots level. We conclude that, for sustainability, evidence-based interventions must be aligned with national health priorities and delivered within an existing health system. Strategies to overcome the resulting complexity include a realistic time frame and investment in district health teams, to support implementation at grassroots level.