A policy analysis of policies and strategic plans on Maternal, Newborn and Child Health in Ethiopia

Evaluating the implementation fidelity of basic emergency obstetrics and neonatal care services in Beyeda District, Northwest Ethiopia: a case study evaluation

Background

Worldwide, nearly 830 women die from complications of pregnancy and childbirth daily. Ninety-nine per cent of these maternal deaths take place in low and middle-income countries. Basic Emergency Obstetric Care (BEmONC) is one method of reducing maternal mortality related to pregnancy and childbirth complications. However, the status of its implementation fidelity has not been investigated. Therefore, this study sought to evaluate the implementation fidelity of BEmONC services in Beyeda District, Northwest Ethiopia.

Evaluation methods

A single case study design with mixed method was employed from June 01 to July 30, 2022. 415 client exit interviews, 14 key informants' interviews and 423 retrospective document reviews were conducted. Adherence, participant responsiveness and quality of delivery dimensions from Carroll's conceptual framework, with a total of 21 indicators were used in this evaluation. The overall implementation fidelity status of BEmONC service was judged based on the pre-seated judgmental criteria as; low, medium, and high fidelity.

Results

The overall degree of implementation fidelity of the BEmONC services was 74.5%. Moreover, the implementation fidelity status of adherence, quality of delivery, and participant responsiveness dimensions were 74.7%, 77.2%, and 71.5% respectively. Uterotonic drugs were not administered as per the recommended protocol. Participants' engagement towards the neonatal resuscitation service delivery was inadequate. Likewise, healthcare providers' respect for the clients was not sufficient. Furthermore, women aged >30 years, being government employed and ANC visits four and above were variables positively associated with the quality of delivery of BEmONC services.

Conclusion

The overall implementation fidelity of the BEmONC services was judged as implemented in medium fidelity. Moreover, the adherence, participant responsiveness and quality of delivery dimensions were found to be implemented in medium fidelity. Therefore, public health sectors at all levels should strive to enhance the implementation fidelity of BEmONC services. Moreover, healthcare providers should adhere to the BEmONC implementation protocol guideline during service delivery. Healthcare managers should facilitate a continuous awareness creation for mothers regarding the merit of neonatal resuscitation for neonatal complications. Furthermore, healthcare providers should give due respect to mothers while delivering the services.

Unequal uptake of skilled maternal health care services in Ethiopia: cross-sectional data analyses informed by the intersectionality theory

OBJECTIVE

To investigate intersectional inequality encompassing socioeconomic, geographical and demographic variables in the use of competent birth and postnatal care services in Ethiopia.

DESIGN

Data for the study came from a series of the Ethiopia Demographic and Health Surveys. Four major surveys were taken place between 2000 and 2016 and all were included in the study. 9867, 9075, 10 592 and 9915 live births born 5 years preceding the surveys that were attended by skilled health workers in 2000, 2005, 2011 and 2016, respectively, were included in the study. For the postnatal care, only the 2016 survey was used due to sample size issues in the other surveys, and 3843 women having live births 2 years preceding the survey had complete data, allowing for fitting of a model. Since the outcome measures are binary, the logit model was used. Intersectionality was analysed by entering interactions into models.

SETTINGS

Population-based representative surveys encompassing all areas of Ethiopia.

PARTICIPANTS

The study subjects are women of reproductive age who had live births 2 years preceding the 2016 survey (for postnatal care) and live births born 5 years preceding the respective surveys (for birth care).

OUTCOME MEASURES

The outcome measures are skilled birth and postnatal care services. The postnatal care was for mothers within the first 2 days of giving birth and did not include care for the newborn. Competent maternal health care services are those that are provided by competent health workers: doctors, nurses, midwives and health officers.

RESULTS

It was observed that women at the crossroads of multiple axes of advantage and disadvantage had better and worse utilisation, respectively. For example, maternal education and residence intersected and predicted coverage of birth care was the highest among secondary schooling women who dwelt in urban settings with the values of 0.255; 95% CI 0.113 to 0.397 in 2000 and 0.589; 95% CI 0.359 to 0.819 in 2016 but was the lowest among non-educated women who lived in rural areas with the values of 0.0236; 95% CI 0.0154 to 0.0317 in 2000 and 0.203; 95% CI 0.177 to 0.229 in 2016.

CONCLUSIONS

It appeared that some women who were at the intersections of multiple axes of disadvantage had the lowest predicted coverage for maternal health care services. The study suggests that targeted interventions be developed for women who are at the intersection of multiple axes of marginalisation and that multiple sectors work in their sphere of resposibility to tackle social determinants of maternity care inequality. Policymakers may consider using intersectionality to inform development of targeted policies and or strategies. Further, future studies include structural drivers in the analysis of intersectionality to gain a better insight into the causes of disparities.

Explaining changes in educational disparities in competent maternal health care services in urban and rural areas in Ethiopia

Introduction

Aggregate statistics of maternal health care services have improved in Ethiopia. Nevertheless, the country has one of the lowest Universal Health Coverage (UHC) service coverage indices, with slight improvement between 2000 and 2019. There are disparity studies that focus on a single dimension of inequality. However, studies that combine multiple dimensions of inequality simultaneously may have important policy implications for closing inequalities. In this study, we investigated education inequalities in the receipt of maternal health care services in rural and urban areas separately, and we examined whether these inequalities decreased, increased, or remained unchanged.

Methods

The data for the study came from the 2011 and 2016 Ethiopia Demographic and Health Surveys. Using women's education as a dimension of inequality, we separately analyzed inequalities in maternal health care services in urban and rural settings. Inequalities were measured through the Erreygers concentration index, second differences, and Relative Index of Inequality (RII). Whether inequalities changed over time was analyzed by relative and absolute measures. An Oaxaca-type decomposition approach was applied to explain changes in absolute disparities over time.

Results

There were glaring educational disparities in maternal health care services in urban and rural areas, where the services were more concentrated among women with better schooling. The disparities were more severe in urban than in rural areas. In urban areas, skilled birth service was the most unequal in both periods. Disparities in rural places were roughly similar for all services except that in 2011, postnatal care was the least unequal, and in 2016, skilled birth was the most unequal services. Trend analyses revealed that disparities significantly dropped in urban by absolute and relative measures. Conversely, in rural regions, the disparities grew by the concentration index measure for most services. The RII and second differences presented conflicting results regarding whether the gaps were increasing, shrinking, or remaining the same.

Conclusion

Substantial disparities in maternal health care services remained and even increased, as in rural areas. Different and targeted strategies are needed for urban and rural places to close the observed educational inequalities in these areas.

Factors determining antenatal care utilization among mothers of deceased perinates in Ethiopia

Introduction

Receiving adequate antenatal care (ANC) had an integral role in improving maternal and child health outcomes. However, several factors influence the utilization of ANC from the individual level up to the community level factors. Thus, this study aims to investigate factors that determine ANC service utilization among mothers of deceased perinate using the proper count regression model.

Method

Secondary data analysis was performed on perinatal death surveillance data. A total of 3,814 mothers of deceased perinates were included in this study. Hurdle Poisson regression with a random intercept at both count-and zero-part (MHPR.ERE) model was selected as a best-fitted model. The result of the model was presented in two ways, the first part of the count segment of the model was presented using the incidence rate ratio (IRR), while the zero parts of the model utilized the adjusted odds ratio (AOR).

Result

This study revealed that 33.0% of mothers of deceased perinates had four ANC visits. Being in advanced maternal age [IRR = 1.03; 95CI: (1.01-1.09)], attending primary level education [IRR = 1.08; 95 CI: (1.02-1.15)], having an advanced education (secondary and above) [IRR = 1.14; 95 CI: (1.07-1.21)] and being resident of a city administration [IRR = 1.17; 95 CI: (1.05-1.31)] were associated with a significantly higher frequency of ANC visits. On the other hand, women with secondary and above education [AOR = 0.37; 95CI: (0.26-0.53)] and women who live in urban areas [AOR = 0.42; 95 CI: (0.33-0.54)] were less likely to have unbooked ANC visit, while women who resided in pastoralist regions [AOR = 2.63; 95 CI: (1.02-6.81)] were more likely to have no ANC visit.

Conclusion

The uptake of ANC service among mothers having a deceased perinate was determined by both individual (maternal age and educational status) and community (residence and type of region) level factors. Thus, a concerted effort is needed to improve community awareness through various means of communication by targeting younger women. Furthermore, efforts should be intensified to narrow down inequalities observed in ANC service provision due to the residence of the mothers by availing necessary personnel and improving the accessibility of service in rural areas.

Barriers Towards Obstetric Care Service Utilization in Ethiopia: An Explorative Qualitative Study

Background

Obstetric care has been at the center of both global and national agendas. More than 50% of pregnant mothers are still preferring to give birth at home with some even after having full antenatal care. However, a few literatures looked at contributing factors for this problem but they are not conclusive and do not consider different sociocultural context of Ethiopia and different health service related barriers. Hence, the aim of this study was to explore barriers to obstetric care service utilization in Ethiopia using the socio-ecological model.

Methods

Explorative qualitative study was employed involving key-informant interviews, in-depth interviews, and focus group discussions between October and December 2021; Individual, community, health system, and contextual barriers were explored. Atlas ti. Version 9 was used for analysis.

Result

Lack of awareness, unfavorable perception, lack of partner involvement, cultural barrier, shortage of supplies, poor infrastructure, provider-related factors, poor monitoring, and evaluation system, challenging topography, and conflict were the major barriers that hinder mothers from receiving obstetrics service in Ethiopia.

Conclusion

Lack of awareness, unfavorable perception, conflict, problems with health system structure and process, and cultural and geographical conditions were major barriers in Ethiopia. Therefore, packages of intervention is important to avail essential equipment, strengthening follow up system, create awareness, and increase access to health facilities is very important for service improvement by the government and non-governmental organizations. Additionally, implementing conflict resolution mechanism is important for addressing better obstetric service.